L\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p incisional hernia repair, small bowel resection POD 20\n REASON FOR THIS EXAMINATION:\n please assess for DVT in RLE\n ______________________________________________________________________________\n FINAL REPORT\n\n EXAMINATION: Right lower extremity venous Doppler, .\n\n COMPARISON: None.\n\n INDICATION: Status post incisional hernia repair and small bowel resection,\n evaluate for DVT in right lower extremity.\n\n FINDINGS: scale, color Doppler, and spectral waveform imaging of the\n right lower extremity deep venous system was performed. There is no evidence\n of intraluminal thrombus within the right common femoral, superficial femoral\n and popliteal veins. These veins demonstrate normal color flow and\n augmentation. Incidental note is made of ill-defined complex fluid collection\n in the popliteal region which most likely represents a ruptured cyst.\n\n IMPRESSION:\n 1. No evidence of deep venous thrombosis in the right lower extremity.\n 2. Ruptured cyst.\n\n"},{"category":"Radiology","chartdate":"2135-07-29 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":920918,"text":" 10:25 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please eval for intraabdominal source of infection\n Admitting Diagnosis: ABD PAIN\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, s/p incarcerated hernia repair and small bowel\n resection. Now with hospital-acquired pna, but WBC still increasing. (+)\n diffuse abdominal pain, no SBP.\n REASON FOR THIS EXAMINATION:\n Please eval for intraabdominal source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT of the abdomen and pelvis dated \n\n COMPARISON: CT of the abdomen and pelvis dated .\n\n INDICATION: 51-year-old male with cirrhosis status post incarcerated hernia\n repair and small bowel resection, now with hospital-acquired pneumonia with\n increasing white count, diffuse abdominal pain, but no SBP. Please evaluate\n for intra-abdominal source of infection.\n\n TECHNIQUE: MDCT axial images are obtained through the abdomen and pelvis\n after the administration of IV and oral contrast. The clinical team was\n aware of the patient's creatinine of 1.7 and used hydration and bicarbonate\n solution before and after the exam to help prevent contrast nephropathy.\n\n FINDINGS FOR CT OF THE ABDOMEN WITH CONTRAST: There is a large right pleural\n effusion and right lower lobe atelectasis, unchanged. There has been interval\n development of a tiny left pleural effusion and left basilar atelectasis.\n\n Again seen is a shrunken liver with nodular contour consistent with cirrhosis.\n The gallbladder is present. The patient is status post splenectomy. The\n pancreas, adrenal glands, and right kidney are unremarkable. Again seen are\n two low density lesions involving the left kidney, the interpolar region and\n at the lower pole, consistent with renal cysts. There has been slight\n interval increase in quantity of ascites within the abdomen since the prior\n exam. Multiple fluid collections are demonstrated within the subcutaneous\n tissues in region of prior hernia repair, the largest of which measures 5.7 cm\n x 2.3 cm, unchanged. Multiple dilated loops of small bowel are seen, which\n have thickened wall, there is no evidence for obstruction since contrast is\n seen within colon. The bowel wall thickening is thickening is likely\n secondary to hypoalbuminemia. There has been interval resolution of the\n diffuse colonic thickening seen on the prior examination. Numerous porta\n splenic collateral vessels are demonstrated. The bones demonstrate no\n suspicious lesions.\n\n FINDINGS FOR CT OF THE PELVIS: There has been slight increase in amount of\n intrapelvic ascites. There has been interval resolution of the colonic wall\n thickening. There is no lymphadenopathy or free intraperitoneal gas.\n\n (Over)\n\n 10:25 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please eval for intraabdominal source of infection\n Admitting Diagnosis: ABD PAIN\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: Multiple old left lower rib fractures are demonstrated. There\n is evidence of old trauma to the left ilium.\n\n\n IMPRESSION:\n 1) Cirrhosis with slight increase in intra-abdominal and intrapelvic ascites.\n Stable large right pleural effusion and right basilar atelectasis. New tiny\n left pleural effusion and left lower lobe atelectasis.\n\n 2) Dilated loops of small bowel without evidence of bowel obstruction. Small\n bowel wall thickening, likely secondary to low protein state.\n\n 3) Interval resolution of the diffuse colonic thickening.\n\n"},{"category":"Radiology","chartdate":"2135-07-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":921076,"text":" 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for pneumothorax (s/p thoracentesis)\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, resolving SBP, now with incr WBC. s/p\n thoracentesis\n REASON FOR THIS EXAMINATION:\n Please eval for pneumothorax (s/p thoracentesis)\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cirrhosis, status post thoracentesis, evaluate for\n pneumothorax.\n\n Small bilateral pleural effusions are present. Neither side shows a\n pneumothorax. No infiltrates are present.\n\n IMPRESSION: No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2135-07-27 00:00:00.000","description":"CHEST (PA & LAT)","row_id":920641,"text":" 1:53 PM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for infiltrate/pneumonia\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, s/p bacteremia and fungemia, now with\n increasing WBC again.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 51-year-old man with cirrhosis status post bacteremia and\n fungemia, now with increasing white cell count.\n\n CHEST, AP AND LATERAL:\n\n Extensive opacification is seen within the right lower lung posteriorly. This\n is associated with right pleural effusion also. The lower lobe opacifications\n are new and probably represent pneumonic consolidation.\n\n Elsewhere, the lung fields appear clear.\n\n IMPRESSION: Persistent right effusion. New right lower lobe infiltrate.\n\n\n"},{"category":"Radiology","chartdate":"2135-08-19 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":923716,"text":" 5:58 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: WITH DUPLEX PLEASE-ASSESS for PV thrombosis\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ESLD/cirrhosis for transplant, ascites with acute rise\n in t. bili.\n REASON FOR THIS EXAMINATION:\n WITH DUPLEX PLEASE-ASSESS for PV thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n 51-year-old male with end-stage liver disease, cirrhosis, awaiting transplant\n with acute rise in bilirubin, and concern for portal vein thrombosis.\n\n LIVER ULTRASOUND WITH DOPPLER: The liver is shrunken and nodular with\n coarsened echogenicity consistent with cirrhosis. No definite focal hepatic\n lesion is identified. No intra- or extra-hepatic biliary ductal dilatation is\n identified. There is moderate amount of ascites around the liver. Doppler\n evaluation demonstrates appropriate directionality and waveform of the main,\n left and right portal veins as well as main, left and right hepatic arteries\n and main and right hepatic veins. The left hepatic vein is not identified,\n due to technical factors. The IVC is patent.\n\n IMPRESSION: No evidence of portal vein thrombosis. Severe cirrhosis with\n moderate ascites. Left hepatic vein not visualized due to technical factors,\n but all other vessels are accounted for with appropriate directionality and\n waveform.\n\n\n"},{"category":"Radiology","chartdate":"2135-08-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":924687,"text":" 3:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p malposition ET tube\n\n REASON FOR THIS EXAMINATION:\n ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, candidemia, MRSA sepsis, ET tube placement.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n The ET tube is in satisfactory position approximately 6.2 cm above the carina.\n An NG tube coils over the left upper quadrant, unchanged. The coil overlies\n the expected course of the left hemidiaphragm and there is no air seen and the\n fundus of the precise position is difficult to confirm radiographically. Right\n IJ central line present, tip over distal SVC, unchanged.\n\n Again seen is cardiomegaly and mild prominence of the superior mediastinum,\n with enlarged pulmonary hila. There is upper zone redistribution, diffuse\n vascular blurring, more confluent opacities at the bases, and small bilateral\n pleural effusions. There is left lower lobe collapse and/or consolidation.\n The right pleural catheter is again noted.\n\n IMPRESSION:\n\n 1) ET tube in satisfactory position. Lines and tubes as described. Clinical\n correlation regarding the NG tube is requested. While it probably does lie\n within the gastric fundus, it is difficult to confirm radiographically.\n\n 2) Findings compatible with CHF with alveolar edema, bilateral effusions and\n left lower lobe collapse and/or consolidation. Allowing for differences in\n technique, this appearance is similar to the film from one day earlier.\n\n 3) No pneumothorax detected.\n\n\n"},{"category":"Radiology","chartdate":"2135-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":924569,"text":" 8:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: patient with drop in pressures s/p pig tail placement in \n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p placement of right pleural\n pig tail\n REASON FOR THIS EXAMINATION:\n patient with drop in pressures s/p pig tail placement in chest. Eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis, candidemia, MRSA, sepsis, status post placement of\n right pleural pigtail. Drop in pressures after pigtail placement. Evaluate\n for pneumothorax.\n\n COMPARISONS: Radiograph obtained approximately four hours earlier.\n\n PORTABLE AP SUPINE RADIOGRAPH OF THE CHEST: An endotracheal tube is seen\n approximately 7 cm above the carina. The tip of the NG tube projects over the\n gastric fundus. A right-sided IJ central venous catheter is in unchanged\n position with the tip projecting over the distal SVC. A pigtail catheter is\n seen projecting over the right lower lung. There is almost complete removal\n of the previously seen right pleural effusion. No pneumothorax is seen. There\n is new bilateral hilar prominence and perihilar haziness. The cardiac\n silhouette appear stable.\n\n IMPRESSION: 1. No evidence of pneumothorax. 1. Successful drainage of a right-\n sided pleural effusion. 3. Evidence of new pulmonary vascular congestion.\n\n"},{"category":"Radiology","chartdate":"2135-08-11 00:00:00.000","description":"CHEST (PA & LAT)","row_id":922682,"text":" 3:17 PM\n CHEST (PA & LAT) Clip # \n Reason: r/u pna\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, candidal peritonitis, now with increasing WBC\n again.\n REASON FOR THIS EXAMINATION:\n r/u pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increased white blood cell in patient with known\n peritonitis.\n\n PA and lateral upright chest radiograph compared to the previous film from\n , and .\n\n The left PICC line was inserted in the meantime interval with its tip\n projecting over the inferior portion of superior vena cava. The heart size is\n normal. There is no mediastinal widening or shifting. The right lower lobe\n consolidation is grossly unchanged with some increase in pleural effusion\n better demonstrated on the lateral exam. The rest of the lungs are\n unremarkable. The healed fractures on the left are again demonstrated.\n\n IMPRESSION: Grossly unchanged right lower lobe consolidation with some\n increase in pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2135-08-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":924628,"text":" 1:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls check ETT position after advancement\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p malposition ET tube\n REASON FOR THIS EXAMINATION:\n pls check ETT position after advancement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, candidemia MRSA sepsis, status post ET tube malposition,\n check ET tube position after advancement.\n\n CHEST, SINGLE AP VIEW.\n\n Lines and tubes are unchanged. The ET tube lies approximately 7 cm above the\n carina at the level of mid clavicle, overall similar to its appearance on the\n film from one day earlier. Radiographically, it is somewhat high but in\n overall satisfactory position. If clinically indicated, it could be advanced\n by 1-3 cm. The right IJ central line tip overlies the distal SVC unchanged.\n Of note, the NG tube is coiled in left upper quadrant and overlies the\n hemidiaphragm itself. I suspect this is within the gastric fundus, but this\n is difficult to confirm on these views.\n\n The pleural and parenchymal findings are unchanged. There is evidence of CHF,\n with bibasilar atelectasis and a small right pleural effusion. The left\n costophrenic angle is excluded from the film. No pneumothorax is detected.\n\n IMPRESSION:\n\n 1. ET tube position essentially unchanged compared with . See\n comment.\n\n 2. Right lung base chest tube, with small effusion, unchanged.\n\n\n\n"},{"category":"Radiology","chartdate":"2135-08-10 00:00:00.000","description":"PICC W/O PORT","row_id":922482,"text":" 12:58 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Attempted PICC x2 by IV nurse. Please attempt via IR. In n\n Admitting Diagnosis: ABD PAIN\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 51 year old man with EtOH/HCV cirrhosis, awaiting transplant, with \n peritonitis, will need long-term IV antifungal therapy\n REASON FOR THIS EXAMINATION:\n Attempted PICC x2 by IV nurse. Please attempt via IR. In need of long term\n abx for fungal peritonitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: peritonitis, needing long-term IV antifungal therapy.\n\n PROCEDURE: This procedure was performed by Dr. , with Dr. , the\n attending physician, and supervising throughout. The patient was\n brought to the angiography suite and placed supine on the table. A\n preprocedure timeout was performed to confirm patient, site, and procedure.\n The left upper arm was prepped and draped in the usual sterile fashion. As no\n suitable veins were visible, ultrasound was used to identify the left brachial\n vein, which was patent and compressible. After administration of\n approximately 4 mL of 1% lidocaine for local anesthesia, a 21-gauge needle was\n introduced into the brachial vein using real time ultrasound guidance. Hard\n copy ultrasound images were obtained before and after venipuncture\n documenting vessel patency.\n\n Then, a 0.018 guidewire was advanced through the needle and into the distal\n SVC under fluoroscopic guidance. The needle was exchanged for a 4-French\n micropuncture sheath. Based on the markers on the guide wire, the PICC was\n trimmed to 45 cm, then after withdrawal of the inner dilator, advanced over\n the wire and into the distal SVC under fluoroscopic guidance. The peel-away\n sheath and wire were removed, the line flushed, capped, Hep-Locked, and stat-\n locked, and a final fluoroscopic image taken to demonstrate the tip of the\n catheter in the distal SVC. The patient tolerated the procedure well. There\n were no immediate complications.\n\n IMPRESSION: Successful placement of single lumen PICC in the distal SVC via\n the left brachial vein. Line is ready for use.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-07-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309088,\n \"text\": \"nsg.progress notes:\\nsee flow sheet for specific:\\nNeuro:AOX3,obeys commands,MAE,PRN morphine for pain,with good effect\\nCV: NSR ,no ectopy,Ivf D5 in 0.45% NS 50ml/hr,BP WNL ,inj.lasix & spirolactone po with good effect,tranplant team wants to discuss with renal team regarding diuretics,\\nResp: spont breath O2 4L via NC,LS clear, O2 sat WNL,coughs out clear sputum,ABG acidotic ,Dr. aware.\\nGI: NPO,NGT to LCS clear drain.abd ascitis,no BS,no bm today.abd dressing dry& intact,with abd binder\\nGU: foley cath draining amber coloured clear urine,adq amt(on Lasix BD).\\nEndo : FS Q6H ,on SSRI.\\nACT: bed fast: turned & positioned changed Q2H,made OOB today on chair for 2hrs.tolerated well,stable VSS.\\nID: afebrile,linezolid added to treatment.\\nSkin: gluteal wound 2x1 cm ,with bleeding mod amt,S/b Wound nurse ,adviced for dressing with aquacel& pad,change PRN.bed changed tp Barimax with ETS per her advice( pt says he had this wound prior adm. & was taking bath for the same)\\nPlan: cont monitoring,pul.hygiene.wound care,lytes & coag profile,?follow up by renal team,? transfer to floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-07-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309089,\n \"text\": \"condition update\\nD: pt alert and oriented. follows commands. moves all extremities. pt medicated with 2mg of morphine with relief of shoulder pain.\\ncardiac: nsr rate in the 90's. sbp 120/60's. cvp in the teens.\\nresp: pt remains on 4l nc with of sat of 98%. breath sounds are clear and pt coughing with raising.\\ngi: ngt patent and draining clear fluid. abd distended with ascities.\\ngu: urine output remains adequate. foley is patent.\\na: assess for pain and medicate as needed. ? transfer to floor today.\\nr: morphine effective in relieving pain. vs remain stable. pt appears ready for transfer to floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-07-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309090,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\nNEURO:ALERT & ORIENTED X2-3, FOLLOWS COMMANDS, MAES, EASILY AGITATED. C/O ABD, BILAT SHLDR, RIGHT HAND PAIN-2MG MORPHINE GIVEN W/RELIEF.\\n\\nCVS:HR 90S-100S, NSR, SBP 90S-110S, A-LINE POSITIONAL, CVP 12-17. AFEBRILE, ALBUMIN GIVEN, CONT 20MG LASIX , HOLD SPIRINOLACTONE PER TRANSPLANT TEAM.\\n\\nRESP: O2 SATS >97% ON 4L N/C, LUNGS CLEAR, NARD.\\n\\nGI/GU: ABD DISTENDED, ABSENT BS, NO FLATUS-TRANSPLANT TEAM AWARE. CONT NPO. NGT PATENT, DRNG SM AMT CLEAR FLUID. HRLY U/O>35CC.\\n\\nINTEG: ABD DSGS C/D/I, JP X1 W/MIN AMT SEROSANG DRNG. COCCYX DUODERM INTACT. PT TURNED FREQUENTLY FOR SKIN CHECKS, NO NEW AREAS BREAKDOWN NOTED.\\n\\nPLAN: CONT DIURESIS W/LASIX, PAIN MGMT, NEURO ASSESSMENT, TRANSFER TO .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-07-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309091,\n \"text\": \"condition update\\nD: pt alert and follows commands. medicated with morphine for pain with good relief. moves all extremities. oob to chair with assist of 2. did well and sat up for approx. 1.1/2 hrs. back to bed and sleeping in short naps.\\ncardiac: nsr rate in the 990's. sbp greater than 100 and aline remains positional.\\nresp: pt remains on 4l nc and breath sounds remain clear.\\ngi: pt remain npo with hypoactive bowel sound.\\ngu: urine output remains adequate\\na: ?transfer to floor today. oob to chair.\\nr: tolerated getting oob to the chair. morphine effective in relieving pain.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309082,\n \"text\": \"Resp. Care Note\\nPt received intubated and vented on AC settings as charted on resp flowshhet. ABG's with improving met. acidosis. FiO2 decreased from 50-40% with sats 99%. No other vent changes made. Plan to cont vent support, eval for ability to wean in AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-06-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309083,\n \"text\": \"Resp Care: Pt continues intubated and on ventilatory support with a/c overnoc maintaining abg wnl; bs coarse, sxn thick clear secretions, rsbi this am 81, placed on sbt per protocol, will attempt wean to extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-06-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309084,\n \"text\": \"NURSING UPDATE\\nCV: NSR. MAP>60. HUO CONSIST 20-25CC (20CC ACCEPTABLE AMOUNT PER TEAM). HCT DOWN TO 25.7 THIS AM. PLAN: TO BE TRANSFUSED WITH 1U PRBC'S, FOLLOWED BY LASIX, PRODUCT NOT READY AT THIS TIME.\\n\\nRESP: BREATH SOUNDS SLIGHTLY COARSE TO CLEAR WITH TRANSIENT INSP WHEEZE IN LUL. FAILED CPAP TRIAL DURING NOC DUE TO PERIODS OF APNEA UP TO 20SECONDS. TOLERATING CPAP THIS AM AT THIS TIME, PROPOFOL VERY LOW DOSE, PLAN: EXTUBATE ON ROUNDS.\\n\\nNEURO: SEDATED ON LOW DOSE PROPOFOL, WEANING OFF THIS AM. SLIGHTLY AGITATED WHEN AWAKE, BUT FOLLOWING COMMANDS, NODDING AND SHAKING HEAD APPROPRIATELY IN RESPONSE TO QUESTIONS.\\n\\nGI: BOWEL SOUNDS RETURNED, HYPOACTIVE AT THIS TIME. NGT DRAINING SLIGHTLY BILE TINGED CLEAR FLUID. JP DRAINING SMALL AMOUNT DARK RED BLOOD. ABDOMINAL INCISION CLEAN AND DRY, NO DRAINAGE.\\n\\nSKIN: PT HAS HEALING DECUBITUS ON LT SIDE OF COCCYX, CLEAN, GRANULATING, NO DRAINAGE. AQUACEL AND TEGADERM APPLIED AT THIS TIME. PLAN: TO BE ASSESSED BY WOUND CARE NURSE TODAY.\\n\\nPT MONITORED CLOSELY.\\nDRS AND IN ATTENDANCE OVERNOC.\\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-06-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309085,\n \"text\": \"Nursing Note 7a-7p:\\nNursing Assessment:\\n\\nPt extubated this morning and currently on 4 liters nasal cannula sating 96% and with good abg's. Alert, orientated to person, place, and reorientated to time. Aware of his surgery and diagnosis. Pt's neice called and will be in to visit today. Lungs clear and strong productive. Bowels hypoactive and NGT with minimal out. Dressing intact and jp with only minimal serous out. Morphine ivp x 1 for pain with good effect. HR NSR to Sinus tachy 105, BP 90s-100 most of day and urine ouput inc. to 40-70cc/hr with lasix (following blood this morning). Will continue to monitor labs, uo, and provide emotional support. Please refer to carevue for all further details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-06-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309086,\n \"text\": \"Resp Care\\nPt successfully extubated and now on nasal 4LPM. Maintaining good Sats, and normal RR. Had one Alb tx, clear Breath sounds.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-07-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309087,\n \"text\": \"NURSING UPDATE\\n UNEVENTFUL NIGHT. AFEBRILE AND NORMOTENSIVE, SLIGHT SINUS TACHY, NO ECTOPY. BREATH SOUNDS CLEAR, SATS 95-97% ON 4L O2 N/PRONGS.\\n MORPHINE PRN FOR C/O ABDOMINAL PAIN WITH GOOD EFFECT, INCISION DRESSISNG DRY AND INTACT. BINDER ON, MORE MOBILE IN BED TURNING WITH MIN ASSIST, REQUESTING TO GET OUT OF BED TODAY.\\n NPO, GLUCOSE STABLE, INSULIN COVERAGE NOT REQUIRED. ALBUMIN INFUSED AS ORDERED. HUO 30-60CC CLEAR AMBER, SPEC SENT FOR UREA AND CREATININE THIS AM.\\n PT MONITORED CONTINUOUSLY. DR IN CLOSE ATTENDANCE OVERNOC. SEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309108,\n \"text\": \"MICU 6 NSG 7A-7PM\\nRESP--PT CONTS ON AC 22 600 PEEP 8 40%, BREATHING OVER SET RATE. SX'D Q3-4 FOR THICK TAN AND BLOOD TINGED SECCRETIONS.\\n\\nNEURO--PT REMAINS MIN RESPONSIVE. GRIMACES TO PAINFUL STIMULI AND OCCAS OPENS EYES. NO SPONT MOVEMENT NOTED. PT REMAINS OFF ALL SEDATIVES.\\n\\nCV--HR 80-90'S SR NO ECTOPY NOTED. BP VIA RIGHT RAD REMAINS STABLE. CONTS WITH (+) EDEMA IN LOWER EXTREMITES AND SCROTUM. RIGHT PIGTAIL PLEURAL CATH REMAINS IN PLACE, WITH SEROSANG DRG VIA TUBE 10-20CC/HR. DRESSING C/DI, NO CREPITUS PALPATED. PLEUR-EVAC CONTS TO LOW WALL SUCTION.\\n\\nGI--ABD DISTENDED DUE TO ASCITES, NO BOWEL SOUNDS AUSCULTATED. OGT CONTS TO LIS, DRAINING BILIOUS AND ? FECAL MATERIAL. OGT INTERMITTENTLY CLOGGING AND NEEDING FLUSHING. NO BM THIS SHIFT. TBILI UP TO ~10 TODAY, INR 4.7 THIS AM. FS SLIGHTLY ELEVATED, BEING COVERED WITH SSREG.\\n\\nRENAL--U/O VIA FOLEY CATH 10-20CC/HR. CREAT INC TO 3.4 TODAY.\\n\\n (PT'S HCP) FOR UPDATES ON PT'S CONDITION, SPOKE WITH THIS RN AND DR FROM HEPATOLOGY. PLANS ON COMING IN THIS EVENING WITH OTHER FAMILY MEMBERS, TO VISIT PT AND MEET WITH LIVER TEAM AND MICU TEAM. SIGNED HCP FORM OBTAINED FROM TRANSPLANT COORDINATOR AND PLACED IN CHART. IS LISTED AS HCP ON FORM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309109,\n \"text\": \"Resp Care\\nPt continues to be intubated on A/C. No vent changes made this shift. BS slightly course, suctioned for sm amt of thick tan secretions. plan at this time is to continue on current settings. Please refer to carevue for all vent settings.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309110,\n \"text\": \"NURSING MICU NOTE 7P-7A\\n\\nPT'S FAMILY ARRIVED AT . MULTIPLE FAMILY MEMBERS SPOKE ON THE PHONE WITH DR.. FAMILY MEETING WITH DR.. PT WAS MADE CMO. PT EXTUBATED AT . FAMILY AT BEDSIDE THOUGHT OUT NIGHT.\\n\\nNEURO: EARLY IN SHIFT PT WOULD WITHDRAW TO PAIN, NO SPONTANEOUS MVT, NOT FOLLOWING COMMANDS. SINCE EXTUBATION PT HAS RECEIVED PRN MORPHINE IVP FOR TOTAL 8MG. PT IS ORDERED FOR MORPHINE GTT, BUT HAS NOT YET REQUIRIED IT. PT WILL OPEN EYES TO PAINFUL STIMULI.\\n\\nRESP: PT IS ON RA WITH O2 SATS 95-100%. LS COARSE, DIMINSHED IN RIGHT BASE. PT HAS NO GAG. RR 6-15.\\n\\nCV: HR 80-110 NSR. SBP 100-120'S. PT WITH GENERALIZED +2 EDEMA.\\n\\nGI/GU: ABD LG, ACITIES. NO BS. OGT LEFT IN PLACE POST EXTUBATION. DRAINING GREEN THICK BILE. OGT FLUSHED WITH 30CC WATER TO PREVENT CLOGGING. FOLEY INTACT DRAINING AMBER URINE WITH SEDIMENT.\\n\\nDISPO: PLAN IS FOR COMFORT. PT STILL APPEARS COMFORTABLE, VSS. TO ASSES COMFORT, START MORPHINE GTT WHEN NEEDED. PT'S FAMILY AND FRIENDS IN AND OUT THROUGH OUT NIGHT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309079,\n \"text\": \"Resp Care\\nPt. received from OR s/p liver transplant. AC mode. Ventilation increased d/t resp. acidosis. Most recent abgs reveals hyperoxygenated mild. resp. acidosis, RR increased.\\nBs:diminished R>L.\\nPlan: wake , wean > extubate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309080,\n \"text\": \"Admission Note\\nAssessment:\\nPlease see carevue for details\\n\\nPt arrived from OR s/p small bowel resection and hernia repair. Pt still paralyzied, intubated and placed on AC, abg's showing resp acidosis, resolving with increasing rate on vent.\\n\\nNeuro: Pt placed on prop gtt once paralytic wore off. Pt able to open eyes to speech and follow command intermittently. Pupils equal and responsive. MAE, withdraws to pain. Recieved morphine 2mg IV x1 for pain with pos effect.\\n\\nCV: Remains in NSR, no ectopy noted. Hyperkalemic to 6.1, recieved calcium, dextrose, insulin, and sodium bicarb with pos response of K 3.4. EKG done, no changes noted MD . SBP wnl, afebrile. Palp dp/pt bilat. CVP elevated 18-20. D51/2NS @ 100cc/hr. Recieved 2 units PRBC's for Hct <30, 2 units FFP and vit K for INR 1.9.\\n\\nResp: LS clear bilat, diminished on R side, Chest x-ray showing whiteout on R side. Remains intubated on AC, rate increased to 18 for resp acidosis with pos effect.\\n\\nGI: Abd soft, distended, absent bs. NGT to LCS, requiring frequent flushing to maintain sumping. JP draining small amounts of sang drainage. ABD binder intact, dsd intact.\\n\\nGU: Adequate amounts of cloudy yellow urine via foley cath.\\n\\nID: ABX for MRSA/VRE\\n\\nPlan:\\n Monitor frequent hct and INR, give PRBC's and FFP per team, wean to extubate, Monitor LFT's, Pain management, provide emotional support to pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309100,\n \"text\": \"Nursing Note--Cotinued\\n\\nResp: Right pigtail CT draining straw blood tinged fluid, approx 200cc this shift. Dsg changed, no further bleeding, site unremarkable. No leakage noted, no crepitus. LS coarse upper fields, significantly decreased to bases. CXR of showed ETT requiring advancement; advanced to 21cm and rotated to right side; awaiting results of repeat CXR. Gm stain with +yeast, cx neg. No changes on vent, remains on AC with SRR of 1-3breaths/min.\\n\\nGI/GU: Abd with lg amt ascites, OGT to LIWS, 200cc this shift, bile; no s/s bleeding; remains on ocreotide SQ. No bowel sounds auscultated -- to hold on po meds of lactulose/midodrine/rifaximin--team aware. Hold on TPN for now. No stool this shift--need specimen for c-diff. Mucous membranes sl dry, moistened prn. Bleeding gums. Remains in ARF prob d/t sepsis. Making approx 20cc/hr, amber, clear. Urine cx neg. Renal following. No CVVHD per request of family.\\n\\nID: ID following. On vanco per levels; flagyl, micafungin, and cefepime--emperically treating. Afebrile, WBC sl improved.\\n\\nSocial: Multiple family members and friends visiting. and sister updated on pt's condition. DNR\\n\\nPlan: present level of vent/pressor support; draw labs and am. Cortrosyn levels. Goal MAP >60 and Hct >30. Consider TEE at later time; await pnd cx. ?Paracentesis for infected abdomen early this week. Emotional support to family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309101,\n \"text\": \"Passively resting on current settings.patient has very poor gag reflex suctioned for copious amount of thick bloody secretion. metabolic acidosis most likely related to kidney failure.% Sat ok,(R) pigtail placement still draining sanguinous fluid.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309102,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with only the rr increased from 20 to 22. Latest results determined a partially compensated metabolic acidemia with excellent oxygenation on the current settings.\\n\\nRSBI = 56.1 on 0-PEEP and 0-PSV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309103,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Initially sedated on 15mcg/kg/min of Propofol...Pt unresponsive to painful stimuli---propofol off since MN, Resp. Rate increased on vent to 22 with improved , Able to wean IV Levophed to 0.03 mcgs/kg/min and pt actually tolerated being off of Levophed for 30 minutes during night.\\n\\nNeuro: Pupils 3mm equal but sluggish, no spontaneous movement and extremities flaccid, no response to painful stimuli, Propofol shut off at MN with no sig. change, Pt is overbreathing vent , + gag, + cough reflex, MICU team aware.\\n\\nCardiac: HR= 90-110 SR/ST with rare PVC noted, Right radial Aline with good waveform and correlation to NBP, BP= 84-106/40's with MAPs= 50-70, IV Levophed titrated to 0.03 mcgs/kg/min, Pt tolerated being off of Levophed for 30 minutes and then BP 80's/40's with MAP <60 so placed back on Levophed, CVP= , Right IJ multilumen cath patent and site C/D/I.\\n\\nResp: Remains intubated , Lungs coarse and diminished at bilat bases, ETtube suctioned for very thick blood tinged sputum, 7.27-40-109 during evening----Pt's rate increased from 20 to 22 with = 7.31-31-138. Current vent settings 600-40%-AC=22 and Peep=8. Pt overbreathing vent by 1-5 breaths while off propofol, MV= , Sats 97-100%, RSBI this am= 56. Right posterior pigtail chestube to 20 cm sx. and draining straw colored fluid with occasional serosang. to pleurovac=220/shift. Chest tube dressing C/D/I and no crepitus noted, Positive fluctuation and no air leak at present time.\\n\\nGI: Abd with large amt ascities, No bowel sounds auscultated, No BM, Remains NPO, OGtube to LIWS draining bilious with brown sediment, no coffee grounds and no evidence of bright red blood.\\n\\nGU: Foley to CD draining scant amts amber urine 10-30ml/hr. BUN= 65 with Creatinine= 2.8 this am. CO2= 14-15.\\n\\nID: Temp spike with Tmax= 100.6---Blood and urine cultures sent. WBC this am = 14.9. Remains on VRE and MRSA Precautions, Lactate= 4.2. Started on IV Hydrocortisone last night, Continues on IV Micfungin, IV Flagyl, and IV Cefepime.\\n\\nEndo: fingersticks WNL--no coverage required.\\n\\nSkin: general anasarca unchanged, No skin breakdown noted, Lower abdomen remains reddened.\\n\\nHeme: Hct down to 27.5 this am, INR up to 4.0, Platelets= 50, Continues on SC Octreotide, minor bleeding of gums and suctioning blood tinged sputum from ETtube.\\n\\nSocial: Family members (sisters) in to visit during evening hours, called and was updated on pt's condition and plan of care.\\n\\nPlan: Monitor for bleeding, ? pot. need for transfusion of FFP or possible platelets, Attempt to wean off of IV Levophed today, Freq. Neuro Checks----? if needs to restart Lactulose, Aggressive pulmonary toiletting, Wean vent as tolerated---CPAP+PS trial today, ? TEE in future, ? Paracentesis this week. Support pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309104,\n \"text\": \"Nursing Note (0700-1900hrs)\\n\\nEvents: Remains off levophed and propofol gtts. Noted to have fecal material draining from OGT this am--prob obstruction. Renal function declining. Prognosis grim.\\n\\nReview of systems:\\nNeuro: Opening eyes to sternal rub since 10am; occ opening eyes with verbal stimuli. No spont movements. +gag/cough reflex, mod strong. PERL, 4mm, brisk. Unable to administer lactulose d/t prob obstruction/NPO.\\n\\nCV: Maintaining HR 90-100's, NSR with rare PVC's. Occasionally hypotensive with MAP's 58-59 however quickly rises with stimuli. CVP decreased to . Hct sl decreased with continued decline in plts; no transfusion at this time. Ascites; +3 pitting edema to ankles; arms/hands much improved with elevation. Draining lg amt serous fluid from small abrasion to left ear. Scrotal/penile edema much improved with scrotal sling.QLCL RIJ, PIV d/c'd. A-line unremarkable, occ positional--coinciding with NIBP> Repeat labs at 1700hrs.\\n\\nResp: LS ess coarse upper, diminished to bases. Left Ct with s/s drng; set at 20cm sx, no crepitus/leak. Continues with mod amts thick blood tinged thick tan sputum. ETT advanced 3cm per CXR in am; 24cm teeth/25 cm lip. SRR 1-4. on AC at same settings in order to better manage metabolic issues.\\n\\nGi/GU: NPO; OGT to LIWS with fecal material noted by appearance and odor. OGT drained >1L since 7am. Abd remains quite distended, large however less tympanic. BS absent. Decrease in hourly u/o since yesterday,; renal has signed off. BUN/Cr increasing. Bladder pressure 12. -700cc at the time of this writing.\\n\\nID: Afebrile. Last pan cx last noc. VRE/MRSA. Fungal peritonitis, asp pna. On cefepime, flagyl, and vanco by level--due for dose today, level 20. Lactate stable ~4.\\n\\nSocial: Mutlipe family members visiting; HCP has called twice and updated. Team would like to be paged when HCP arrives to discuss pt's further decline and ?decision to make CMO>\\n\\nPlan: to support hemodynamics; treat with antibx for multiple infections; cx pnd. with goals for MAP >60. Await return of bowel function to begin lactulose/po meds. ?paracentesis. DNR. Family mtg; emotional support.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309105,\n \"text\": \"Patient less sedated today gag reflex more apparent with bronchial hygien.Has poor renal function,metabolic acidosis.On precaution for VRE,MRSA.Suctioned for moderate amount of thik brown to bloody sputum will continue to follow as per protocol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309106,\n \"text\": \"Resp Care Note:\\n\\nPt intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse suct sm=>mod th tan sput. ABGs metabolic acidosis with good oxygenation; no vent changes required overnoc. mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309107,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Remains off IV Levophed and IV Propofol, NO hypotensive episodes overnight, Remains unresponsive except to painful stimuli, Lactulose on hold d/t probable bowel obstruction.\\n\\nNeuro: No sedation x 30 hours---no spontaneous movement noted, extemities remain flaccid, responds to sternal rub, occasionally will open eyes with turning and repositioning, pupils 4mm bilat and brisk, + gag and + cough reflex, lactulose on hold d/t fecal material via OGtube.\\n\\nCardiac: HR= 88-100 SR/ST with occas. PVC noted, Right radial with good waveform and good correlation to , dressing changed x2 d/t oozing bloody, BP= 100-120/50-60's, IV Levophed off x 24 hours, Right IJ mulitlumen cath site C/D/I and all ports patent, CVP= \\n\\nResp: Remains intubated with no vent changes overnight. No vent weaning at present d/t metabolic acidosis, Lungs coarse bilat and diminished at bilat. bases, ETtube suctioned for mod. amts thick tan and occasionally blood tinged sputum, Oral suction for same, Current vent settings 600-40%-AC=22 and Peep=8. Overbreathing vent with stimulation with RR 1-4 breaths over....otherwise RR=22, MV=, Pips 25-30, Sats= 97-100%, and = 7.34-29-130-16. Right posterior pigtail Chest tube to 20 cm. sx via pleurovac---dressing changed and D/I, No crepitus noted, No air leak, + fluctuation, Tube draining small amts serosanguinous.....significantly decreased amount over last 24-36 hours.\\n\\nGI: Remains NPO. Abd with large amt of ascites, no bowel sounds, no flatus, OGtube placement checked by auscultation and to LIWS and draining large amts bilious with occasional flecks of brown fecal matter.\\n\\nGU: Foley to CD draining scant amts amber clear urine 5-20ml/hr. BUN increased to 80 this am with creatinine up to 3.4. Renal signed off yesterday.\\n\\nID: Afebrile, WBC down to 14.3. Lactate= 3.4 this am, Remains on VRE/MRSA precautions, Continues on IV Hydrocortisone, IV Micafungin, IV Flagyl, and IV Cefepime.\\n\\nEndo: fingersticks 150-160's---required sliding scale coverage for first time overnight.\\n\\nHeme: Hct stable this am at 28.7 . Platelets continue to decrease=48. INR up to 4.7. Continues on SC octreotide. No evidence of bleeding at present time.\\n\\nSkin: Left ear with abrasion and draining small amts serous, Right arm draining serous fluid from old puncture sites, Anasarca unchanged, Scrotal edema increased---continues with scrotal sling.\\n\\nSocial: Large amts of family visiting all evening at bedside. Family reports that they are not ready to initiate CMO measures at this time. Support offered. No phone calls overnight after family left at MN. Remains DNR.\\n\\nPlan: Wean vent as tolerated, ? Paracentesis this week and ? of TEE this week, Prognosis poor with worsening liver and renal failure, Continue aggressive pulmonary toiletting, ? of lactulose via enema?, Support pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309081,\n \"text\": \"Nursing Note 7a-7p:\\nNursing Assessment:\\n\\nNeuro: Propofol gtt cont for comfort and safety. Pt easily awakens and follows commands but often agitated, sitting up and reaching for tubes. Temp 95.1 oral this morning and bair-hugger applied with good effect. Had been off this late morning/early afternoon and current temp maintains at 98F. Pt's neice called for update and ?will be in tommorrow. Morphine for abdominal and leg pain with good effect.\\n\\nCV/GU: HR NSR 80s and SBP 100-120. Urine output 20-30cc /hr adn drk amber, cloudy. 2 units FFP for inr >1.5, currently still 1.5 with no further units ordered at this time. Albumin q8hr. 500cc NS bolus with resulting 30-35cc/hr urine output, second ordered later in afternoon, but d/c'd during transfusion by liver team. 350cc in. K 4.6. Pt c/o right leg pain. Venodyne boot on right leg removed and acceptable per liver team, pulses only dopplerable on right and palpable on left. Liver team evaluated and aware, post tib pulses stronger and popliteal palpable by team Toes warm to touch and wiggles to command. NO further c/o pain, if any futher complaints or concern will work up with ultrasound and vascular studies.\\n\\nGI: NGT to low cont wall suct, straw colored out abdomen distended with ascites and bowel sounds absent. Dressing intact adn JP with minimal serous out\\n\\nREsp: Lungs clear on left, diminished on right. Suctioned infreq. Not breathing enough on CPAP immediately back on assist. Gases improved and o2 decreased to 40%.\\n\\nPlan: wean to extubate in am, cont to monitor urine output, abg's, bp. PLease refer to carevue for details\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309094,\n \"text\": \"7pm to 7am:\\n\\nPt adm to MICU with resp failure and was intubated following vomiting and aspiration in radiology.\\n\\nROS:\\n\\nNeuro)\\nPt remains intubated (OETT) with propofol gtt for sedation with good effect. Pt will occ open eyes to voice, but does not follow any commands.\\n\\nCV)\\nPt was found to be hypothermic (94.5) at 8pm and was placed on \\\"Bair hugger\\\" with good result,- temp is now 98.8 (o). Pt is in NSR-ST (90-104) with no ectopy noted. A-line placed last night and has a good wave form. SBP 96-120's with MAP>60. Levophed gtt started last night D/T SBP in the 70-80's after no effect from fluid bolus. Levophed gtt now at 0.04 mcg/kg/min. (been unable to wean off). Pt given 3 units of FFP last night inr of 6.2--> now 3.8. MD aware of hct drop to 22 (27), will cont to follow. Pt has gen edema with + pitting to lower ext's.\\n\\nID)\\nWBC elevated at 20 (24). night 5.3-> now 3.8. Pt has sputum, urine and blood cx's . Vanco was d/c'd ? restart. TR this am. Pt remains on Cefepime IV. Pt will need a stool sample.\\n\\nResp)\\nNo vent changes made over night. A/C mode at 50/600 x 20/8peep. with no changes at 7.30/38/100/19. pt was deep sx'd for sml amounts of green-yellow scretions in the beginning of the shift-> and now deep sx'd for sml amounts of yellow secretions. Pt had a thoracenthesis done and are going to have another one today (Factor 7 on hold for now!). LS coarse to upper resp area with decreased LS at bases.\\n\\nGI)\\nAbd very dist/round and soft. BS (-) x 2min. OGT in place and to LWS with only scant amounts of green drainage. OGT will need some irrigation. No BM at this time. IVF at KVO. Nutrition c/s re TPN. Alb IV qd. Po pills on hold for now.\\n\\nGU)\\nVery low U/O via foley catheter. Md aware and no treatments for , cont to eval.\\n\\nSOC)\\n HCP called last night and updated.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309095,\n \"text\": \"MICU NSG 7A-7PM\\nRESP--PT REMAINS ORALLY INTUB VENT SETTINGS AC 20 600 PEEP 8 40%. PLEASE SEE CAREVIEW FOR 'S. SX'D Q2-4 FOR SCANT AMOUNTS OF THICK GREEN TINGED SECRETIONS VIA ETT. PLEURAL PIGTAIL CATH PLACED AT BEDSIDE, SO FAR HAS DRAINED ~2400CC SEROSANGUINOUS FLUID.\\n\\nCV--PT CONTS IN ST ~100-118, NO ECTOPY NOTED. REMAINS ON LEVOPHED GTT TITRATED FOR GOAL MAP ~60. PT RECEIVED TOTAL OF 6U FFP FOR INR REVERSAL PRIOR TO THORACENTESIS. PT WITH HCT TRENDING DOWN THIS AM, RECEIVED 2U PC'S. WILL HAVE HCT/COAGS/CHEM CHECKED THIS EVENING. CVP 7-13. CONTS WITH (+) EDEMA IN EXTREMITES. FAMILY IN TO VISIT, HCP MADE PT DNR, BUT WOULD LIKE TO CONT WITH CURRENT TREATMENT.\\n\\nGI--OGT TO LIS AND CLAMPED AT TIMES. PT WITH COFFEE GORUNDS, SM AMOUNTS BRB AND SMALL CLOTES NOTED FROM TUBE. NO BM THIS SHIFT, PT WILL NEED STOOL SPECS WHEN HE HAS BM. ABD REMAINS DISTENDED SEC TO ASCITES.\\n\\nRENAL--PT WITH MIN URINE OUT. RENAL CONSULTED, RENAL US DONE. FAMILY REF HD AT THIS TIME.\\n\\nNEURO--PT CONTS ON PROPAFOL GTT INC TO 30MC/KG/MIN FOR PROCEDURES. PT EYES TO PAIN, AND WITHDRAWS TO PAINFUL STIMULI.\\n\\nSOCIAL--HCP AND OTHER FAMILY MEMBERS IN TO VISIT, UPDATED ON PT'S CONDITION AND SPOKE WITH HOUSESTAFF.\\n\\nPLAN--PM LABS\\n--NO HD AT THIS TIME\\n--PT DNR, BUT CONT CURRENTL TREATMENT\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309096,\n \"text\": \"Patient with hepatic failure remains on mechanical ventilation all day.Fluid on (L) side pleural pig tail placed.Draining sanguinous fluid.Patient constipated with poor urine output also.Ultra-sound done,bs clear diminished bilaterally. DNR suctioned for small amount of thick yellow secretion.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309097,\n \"text\": \"Respiratory Care:\\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning results determined a partially compensated metabolic acidemia with very good oxygenation. SX'd for thick, even pluggy secretions. Active humidification added to the ventilator.\\n\\nNo RSBI measured due to hemodynamic instability.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309098,\n \"text\": \"MICU Nursing Note 1900-0700\\nEvents: Pt with 2 episodes of acute hypotension requiring increased dosages of IV Levophed and fluid boluses. Remains sedated and intubated. Transfused with 2 units pRBC's during night.\\n\\nNeuro: Sedated on IV Propofol at 30 mcgs/kg/min. Pt with no spontaneous movement and does not follow commands, withdraws to painful stimuli, PEARL, bilat soft wrist restraints to prevent from pulling at lines and tubes.\\n\\nCardiac: Pt with episodes of BP decrease to 60-70's/40-50's requiring IV Fluid boluses and IV Levophed increased from 0.13 mcgs/kg/min to 0.5 mcgs/kg/min for short periods and then able to titrate Levophed back after each event. Pt with HR= 80-90's SR ----HR will trend to 50-60's SB with hypotensive episodes. 1 episode of HR= 130's SVT self-limiting and broke without intervention. Occas. PVC's. Right IJ multilumen cath site C/D/I and all ports patent, Right radial Aline with good waveform and correlation to NBP. Hct= 24---received 2 units pRBC's during night with repeat Hct this am = 28.6. Platelets remain low at 61. CVP= . Levophed currently infusing at 0.13 mcgs/kg/min. K= 3.4 during evening---replaced with 20 mEq KCL with am level still .\\n\\nResp: Remains intubated with current vent settings 600-40%-AC20 and Peep=8 with Sats=97-100% and = 7.30-35-110-97. Lungs coarse bilat with RLL diminished. ETtube suctioned for thick green sputum with occasional small plugs. Right posterior pigtail chest tube to 20 cm. suction and draining 30-80ml/hr of serous drainage into pleurovac. No creptius noted and chest tube with + fluctation and negative for air leak. Dressing over chest tube with small amt old bloody.\\n\\nGI: OGtube placement checked by auscultation and remains to LIWS and draining 300ml/shift of green bilious drainage---no coffee grounds and no bright red blood noted during night. Abd remains large with ascites and with + hypoactive and distant bowel sounds. No BM.\\n\\nGU: Foley to CD draining amber clear urine in scant amts...0-22 ml/hr\\n\\nID: Tmax= 99.1 with WBC decreased today to 15.9. Remains on IV Micafungin, IV Cefepime, and IV Flagyl. Lactate increased to 4.2 this am.\\n\\nSkin: Lower abd reddened---unchanged as per report from MD, No breakdown noted. General anasarca continues.\\n\\nSocial: niece was contact by MICU resident and she was updated as to pt's condition following acute hypotensive episode last eve... niece called at MN and was updated as to pt's condition at that time. No other contact from family or friends during the night\\n\\nPlan: Attempt to wean IV Levophed as tolerated, MAP goal is 60, Monitor for evidence of bleeding and transfuse to keep HCT > 30, ? if need to transfuse platelets?, Bleeding precautions,Wean Sedation as tolerated, Aggressive pulmonary toiletting, Support pt and family, pt remains DNR at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309099,\n \"text\": \"Nursing Note (0700-1900hrs)\\n\\nMr. to require pressor and vent support. A right sided pigtail CT placed for large pleural effusion. Received 4units PRBC and 6units FFP ; he has been stable this shift.\\n\\nReview of systems;\\nNeuro: Received on 30 mcg/kg/min propofol, heavily sedated with min response to sternal rub; propofol decreased to 20mcg/kg/min with a small increase in his response to sternal rub. +gag reflex; sluggish pupil response to light; otherwise nonresponsive to stimuli.\\n\\nCV: HR 80-90's, NSR; BP 90-100's with MAP >60 with levophed gtt; presently 0.1mcg/kg/min, was able to titrate down. CVP 10-13. Repeat Hct 29.1, no further s/s bleeding. Continues with ascites and +3 edema to hands/feet. Blood cx pnd ; receiving vanco for MRSA with 8/17 blood cx. Repleted with 20meq KCL this am for hypokalemia.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309092,\n \"text\": \"RESPIRATORY CARE: PT INTUBATED FOR IMPENDING\\nRESPIRATORY FAILURE AND AIRWAY PROTECTION TODAY.\\nTX FROM 10 TO MICU 6. 7.5 ORAL ETT ADVANCED\\nFROM 19-20 TO 22 LIP PER CXR/MD. .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2135-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1309093,\n \"text\": \"NURSING NOTE: 1300-1900 51 year old male with PMH positive for cirrhosis, Hep C, CRF, EGD grade 1 varices, S/P splenectomy from trauma, S/P addpendectomy, incisional hernia, Rt tib/fibfx s/p vehicular trauma . Patient was admitted to hospital on with Incisional hernia repair for incarcerated hernia. Complicated post/op by VRE bacteremia, ARF, MRSA, worsening encephalopathy. Patient no longer on transplant list due to fungal infection. Today patient vomited in radiology during a tagged WBC scan, led to aspiration and transfered to MICU for further management. Patient was intubated on arrival to MICU. Please see review of Systems:\\nNEURO: Patient somulent on arrival before intubation. Currently on Propofol at 20mcg/hr with good effect. Occassional bolus during prcedures. PERRLA, MAEW, Upper extremities in soft wrist restraints for line and tube safty.\\nC/V: NSR rate 80-90's, SBP 80-low 100's/ 40-50's.\\nHEME: INR on floor=6.2, transfused with 3 units FFP.\\nRESP: Intubated please see flow sheet for settings. Lung sounds with bilateral rhonchi. O2 Sat 98-100%. Suctioned thick green bile secretions. Thorocotomy done at bedside samples sent to lab results , CXR .\\nGI: Abd firm and distended, positive bowel sounds. OGT placed 2700cc green bile out. no stools this shift.\\nGU: Foley catheter placed with minimal dark amber output.\\nID: Tmax 95.6 AX, Continues on ABX, Blood cultures, urine cultures, and sputum culture sent.\\nLINES: Two PIV started, Right multilumen also started CXR results .\\nSOCIAL: Niece and other friends visited and updated on patients plan of care.\\nPLAN: Continue to monitor, Aline to be started this evening. Awaiting cultures.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2135-08-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79276,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Endocarditis.\\nHeight: (in) 70\\nWeight (lb): 232\\nBSA (m2): 2.23 m2\\nBP (mm Hg): 106/44\\nHR (bpm): 90\\nStatus: Inpatient\\nDate/Time: at 14:00\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\\n\\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\\nfunction (LVEF>55%). Normal regional LV systolic function. No resting LVOT\\ngradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Moderately dilated aortic root.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased\\ngradient c/w minimal AS. Significant AR, but cannot be quantified.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \\nAHA endocarditis prophylaxis recommendations, the echo findings indicate a\\nmoderate risk (prophylaxis recommended). Clinical decisions regarding the need\\nfor prophylaxis should be based on clinical and echocardiographic data. Left\\npleural effusion. Ascites.\\n\\nConclusions:\\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Regional\\nleft ventricular wall motion is normal. Right ventricular chamber size and\\nfree wall motion are normal. The aortic root is moderately dilated. The aortic\\nvalve leaflets (3) are mildly thickened. There is a minimally increased\\ngradient consistent with minimal aortic valve stenosis. Significant aortic\\nregurgitation is present, but cannot be quantified - ?mild. 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 no pericardial effusion.\\n\\nCompared with the prior study (images reviewed) of , the findings are\\nsimilar. The aortic valve is better defined on the current study and appears\\nto be trileaflet. The morphology and severity of aortic regurgitation appear\\nsimilar.\\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\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2135-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 191882,\n \"text\": \"Sinus rhythm. Modest low amplitude lateral T waves are non-specific and\\nprobably within normal limits. Since the previous tracing of T wave\\namplitude is lower, but there may be no significant change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2135-07-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192118,\n \"text\": \"Sinus rhythm. Within normal limits. Compared to the previous tracing of \\nno significant diagnostic change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2135-06-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192119,\n \"text\": \"Normal sinus rhythm with low amplitude P waves and a P-R interval\\nof approximately 0.18. Compared to the previous tracing of no\\ndiagnostic interval change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2135-06-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192120,\n \"text\": \"Sinus rhythm with low amplitude P waves and P-R interval at about 0.16 seconds.\\nRrelatively low voltage diffusely. Compared to the previous tracing of \\nthe heart rate is not as fast, without diagnostic change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-06-28 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE ONLY)\",\n \"row_id\": 916670,\n \"text\": \" 6:47 AM\\n ABDOMEN (SUPINE ONLY) Clip # \\n Reason: please evaluate po contrast\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man s/p drinking po contrast with failure to pass through the\\n stomach\\n REASON FOR THIS EXAMINATION:\\n please evaluate po contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Contrast failed to pass through stomach. Evaluate contrast for\\n CT scan.\\n\\n COMPARISON: .\\n\\n TWO VIEWS OF THE ABDOMEN.\\n Dilute contrast is noted within the stomach. Again seen are dilated air-\\n filled loops of small bowel, which appear smaller when compared to . Degenerative changes again noted within the spine.\\n\\n IMPRESSION: Dilute contrast only seen within the stomach. Persistent\\n dilatation of small bowel with air-filled loops concerning for obstruction.\\n Please refer to CT performed the same day for further evaluation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-08 00:00:00.000\",\n \"description\": \"L UNILAT UP EXT VEINS US LEFT\",\n \"row_id\": 918190,\n \"text\": \" 1:32 PM\\n UNILAT UP EXT VEINS US LEFT Clip # \\n Reason: swelling in arm following PICC placement 2 days ago\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man s/p hernia reduction, POD 10\\n REASON FOR THIS EXAMINATION:\\n swelling in arm following PICC placement 2 days ago\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Duplex ultrasound of left upper extremity.\\n\\n INDICATION: The patient is status post PICC line insertion. Rule out DVT.\\n\\n TECHNIQUE: Grayscale, color flow and pulse wave Doppler insonation of the\\n deep veins of the left upper extremity were performed using dynamic\\n compression maneuvers where appropriate to assess for vessel patency.\\n\\n COMPARISON: There was a previous left sided duplex ultrasound performed in\\n .\\n\\n REPORT:\\n\\n There is normal compressibility, augmentation, and respiratory variation where\\n appropriate of the deep veins of left upper extremity. The PICC line is\\n identified within the left basilic vein extending proximally into the left\\n subclavian vein. No thrombus is identified in either of these veins and no\\n thrombus or adherent thrombus is identified adjacent to the PICC line.\\n\\n CONCLUSION:\\n\\n Normal examination. No evidence of DVT.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-06-28 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 916766,\n \"text\": \" 3:15 PM\\n CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n -77 BY DIFFERENT PHYSICIAN; CT PELVIS W/O CONTRAST\\n -59 DISTINCT PROCEDURAL SERVICE; -77 BY DIFFERENT PHYSICIAN\\n : already received contrast but ileus present, reimage with co\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with hepC cirrhosis with varices, ascites, with 2d N/V/abd\\n pain,\\n REASON FOR THIS EXAMINATION:\\n already received contrast but ileus present, reimage with contrast movemetn\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old man with hepatitis C cirrhosis, varices, ascites with\\n previous abdominal CT questioning strangulated bowel loop.\\n\\n COMPARISON: at 3:14 a.m.\\n\\n TECHNIQUE: MDCT axial non-contrast images of the abdomen and pelvis were\\n obtained with sagittal and coronal reformatted images.\\n\\n CT ABDOMEN WITHOUT IV CONTRAST: Again seen is a large right-sided pleural\\n effusion with associated atelectasis. There is no pericardial effusion. There\\n is a diffusely nodular liver consistent with the patient's history of\\n cirrhosis. The gallbladder is enlarged but there is no evidence of\\n cholecystitis. There is perihepatic ascites and free fluid seen within the\\n abdomen consistent with the prior study. Allowing for the lack of IV\\n contrast, the adrenal glands, pancreas, and kidneys are unremarkable.\\n\\n Again seen are multiple varices in the anterior abdominal wall.\\n\\n Contrast is seen within the stomach and within loops of small bowel. Compared\\n to the prior examination the contrast has progressed. There is an apparent\\n transition point at a complex anterior abdominal wall defect. Several loops\\n of bowel are seen to pass through this defect and one loop in particular has\\n an appearance worrisome for strangulation with fluid seen surrounding it. Far\\n superiorly there is a suggestion of extraluminal air. No contrast is seen in\\n distally collapsed loops of small bowel.\\n\\n CT PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon, and bladder are\\n unremarkable. Again seen is a small amount of free fluid within the pelvis\\n consistent with ascites.\\n\\n BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic foci.\\n\\n Multiplanar reformatted images confirm the above findings.\\n\\n IMPRESSION: Limited examination secondary to lack of IV contrast. There are\\n multiple dilated loops of small bowel consistent with SBO and an apparent\\n transition point at an anterior wall defect. A single loop of bowel which has\\n (Over)\\n\\n 3:15 PM\\n CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n -77 BY DIFFERENT PHYSICIAN; CT PELVIS W/O CONTRAST\\n -59 DISTINCT PROCEDURAL SERVICE; -77 BY DIFFERENT PHYSICIAN\\n : already received contrast but ileus present, reimage with co\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n passed through this defect is concerning for incarcerated bowel.\\n\\n The findings were discussed with the surgical house staff officer at 8:15 p.m.\\n on .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-06-28 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 916654,\n \"text\": \" 2:39 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess for causes of acute abd pain\\n Field of view: 48\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with hepC cirrhosis with varices, ascites, with 2d N/V/abd\\n pain,\\n REASON FOR THIS EXAMINATION:\\n assess for causes of acute abd pain\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KCLd TUE 7:04 AM\\n again seen is anasarca, right pleural effusion, cirrhois, and ascites\\n\\n contrast only in stomach, limiting evaluation of bowel\\n\\n anterior abdominal wall defects again seen with bowel within, limited\\n assessment secondary to lack of contrast (oral and iv)\\n\\n plan to rescan when oral contrast has passed further, d/w dr. 5am\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Hepatitis C, cirrhosis, ascites, nausea, vomiting, and abdominal\\n pain.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained\\n without IV contrast secondary to elevated creatinine. Multiplanar reformatted\\n images were also displayed.\\n\\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Large right pleural effusion with\\n associated atelectasis is seen. There are also atelectatic changes in the\\n left lung. Oral contrast is seen within the stomach. Evaluation of the\\n abdomen is limited by lack of IV contrast; however there do appear to be\\n distended loops of small bowel. Again seen are multiple varices in the\\n anterior abdominal wall. Also, again seen is a complex anterior abdominal\\n wall defect with several loops of bowel seen passing into these defects. One\\n loop in particular, best seen on series 3, image 54 appears concerning for\\n incarceration. Collapsed loops of distal bowel are noted, especially in the\\n area of the terminal ileum. Findings are concerning for a small-bowel\\n obstruction with an incarcerated loop of bowel.\\n\\n Again seen is a small nodular liver consistent with cirrhosis. There is\\n perihepatic ascites and free fluid seen within the abdomen, similar to prior\\n study. Allowing for limitations of the non-contrast study, the pancreas,\\n adrenal glands, and kidneys appear unremarkable. Again seen is evidence of\\n anasarca.\\n\\n CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid, bladder appear\\n unremarkable. Again seen is evidence of free fluid within the pelvis\\n consistent with ascites.\\n (Over)\\n\\n 2:39 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess for causes of acute abd pain\\n Field of view: 48\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\\n\\n Multiplanar reformatted images confirm the axial findings.\\n\\n IMPRESSION: Limited study secondary to lack of IV contrast, however, multiple\\n dilated loops of small bowel are seen with decompressed distal bowel. There\\n is a loop of bowel within the anterior wall defect concerning for incarcerated\\n bowel. Findings consistent with small bowel obstrution with possible\\n incarceration.\\n\\n Discussed with Dr. at 8:30 a.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-06-29 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 916815,\n \"text\": \" 2:46 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: POST op\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with\\n REASON FOR THIS EXAMINATION:\\n POST op\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Postop.\\n\\n COMPARISON: .\\n\\n AP CHEST RADIOGRAPH.\\n Endotracheal tube placement is standard. Nasogastric tube is coiled in the\\n stomach. New right IJ line tip overlies the SVC.\\n\\n Large right pleural effusion and the cardiac and upper mediastinal diameters\\n have increased since the prior study. Diagnostic considerations include\\n superimposed hemothorax or extravasated fluid from the right central venous\\n line. No pneumothorax. Left lung is clear.\\n\\n IMPRESSION: Increased large right pleural effusion, hemothorax, or\\n extravasation of infusate. Findings were discussed with Dr. 7:45\\n a.m., .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-06-28 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 916663,\n \"text\": \" 6:47 AM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o pleural effusion.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with SOB and ascites\\n REASON FOR THIS EXAMINATION:\\n r/o pleural effusion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Shortness of breath and ascites. Evaluate for effusion.\\n\\n COMPARISON: .\\n\\n PA AND LATERAL CHEST RADIOGRAPHS\\n\\n Cardiac and mediastinal, hilar contours appear unchanged. There is a\\n moderate-to-large right-sided pleural effusion. No focal consolidation is\\n seen within lungs.\\n\\n IMPRESSION: Again seen is a moderate-to-large right-sided pleural effusion,\\n slightly increased compared to .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-13 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 918816,\n \"text\": \" 8:48 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: ASCITES, INCRE. WBCOUNT\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 36\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with hepC cirrhosis with varices, ascites, s/p ventral hernia\\n repair, now s/p paracentesis today w/WBC 1110, likely SBP though question of\\n possible leak/perf\\n REASON FOR THIS EXAMINATION:\\n Please rule out bowel perforation, abscess, with PO contrast\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n 51-year-old male with hepatitis C, cirrhosis. Concern for bowel perforation.\\n\\n COMPARISON: CT abdomen and pelvis, .\\n\\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\\n were obtained with oral but no IV contrast due to the patient's elevated\\n creatinine. Coronal and sagittal reformatted images were also obtained.\\n\\n CT OF THE ABDOMEN WITH IV CONTRAST: The left lung base is clear. Again\\n demonstrated at the visualized portion of the right lung base is a small\\n pleural effusion and atelectasis of the right lower lobe. Evaluation of the\\n solid abdominal organs is limited by the non-contrast technique. The liver is\\n shrunken and nodular consistent with cirrhosis. The patient is status post\\n splenectomy. The gallbladder is not well seen. The pancreas, adrenal glands\\n and right kidney are unremarkable. There has been no change in the left\\n kidney with at least two round hypodense lesions consistent with cysts.\\n\\n There remains a large amount of intraabdominal ascites. The appearance of the\\n bowel is similar to . Again demonstrated are a few dilated loops\\n of small bowel up to approximately 4.8 cm. There is no evidence of\\n obstruction with oral contrast passing through to the rectum. There is\\n generalized wall edema throughout the colon. No inflammatory stranding or\\n mural gas is identified. There is no free intra- abdominal air.\\n\\n CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, prostate gland, seminal\\n vesicles and urinary bladder are unremarkable. Ascites tracks into the\\n pelvis.\\n\\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\\n identified.\\n\\n IMPRESSION:\\n 1. No significant change in appearance of the abdomen and pelvis compared to\\n .\\n 2. No free intraabdominal air or other evidence of bowel perforation.\\n 3. A few loops of mildly dilated small bowel but no evidence of bowel\\n obstruction.\\n 4. Cirrhotic liver with large amount of intraabdominal ascites.\\n (Over)\\n\\n 8:48 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: ASCITES, INCRE. WBCOUNT\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 36\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 5. Diffuse edema of colon may be secondary to liver failure and ascites.\\n\\n This was discussed with Dr. at 11 p.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-10 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 918438,\n \"text\": \" 10:29 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess for perf w/PO contrast only. no IV contrast\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 50\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with hepC cirrhosis with varices, ascites, s/p ventral\\n hernia repair, now s/p paracentesis today w/WBC 1110, likely SBP though\\n question of possible leak/perf\\n REASON FOR THIS EXAMINATION:\\n assess for perf w/PO contrast only. no IV contrast\\n CONTRAINDICATIONS for IV CONTRAST:\\n elevated Cr\\n ______________________________________________________________________________\\n FINAL REPORT\\n 51-year-old male with hepatitis C, cirrhosis and ascites, now with concern for\\n bowel perforation versus spontaneous bacterial peritonitis.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\\n were obtained with oral but no IV contrast at the ordering physician's\\n request. Coronal and sagittal reformatted images were also obtained.\\n\\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized lung bases demonstrate\\n a moderate-to-large right pleural effusion with associated atelectasis of the\\n right lower lobe. The left lung base is grossly clear. There are coronary\\n artery calcifications. Evaluation of the abdomen is limited by the\\n noncontrast technique. The liver is shrunken and nodular consistent with\\n cirrhosis. The gallbladder is not well visualized. The patient is status\\n post splenectomy. The pancreas, adrenal glands and right kidney are\\n unremarkable. There are at least two round hypodense lesions of the left\\n kidney which are consistent with simple cysts.\\n\\n There is a large amount of intra-abdominal ascites. Evaluation of the bowel\\n is somewhat limited by ascites. The stomach is nondistended. There are a few\\n loops of mildly dilated small bowel measuring up to 4.6 cm but no evidence of\\n obstruction with oral contrast passing freely through normal caliber large\\n bowel to the rectum. Patient is status post interval ventral hernia repair.\\n There is generalized wall edema throughout the colon probably secondary to\\n liver failure. No inflammatory stranding or mural gas is identified. There\\n is no free intra-abdominal air.\\n\\n CT OF THE PELVIS WITHOUT IV CONTRAST: Oral contrast extends freely through to\\n the rectum. The prostate, seminal vesicles, and urinary bladder are\\n unremarkable. The pelvic loops of bowel are of normal caliber. Ascites\\n tracks into the pelvis.\\n\\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\\n identified.\\n\\n IMPRESSION:\\n (Over)\\n\\n 10:29 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: assess for perf w/PO contrast only. no IV contrast\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 50\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n 1. No free intra-abdominal air or other evidence of bowel perforation.\\n\\n 2. A few loops of mildly dilated small bowel up to 4.8 cm, however no\\n evidence of obstruction with free passage of oral contrast through to the\\n rectum.\\n\\n 3. Cirrhotic liver with a large amount of intra-abdominal ascites.\\n\\n 4. Status post interval ventral hernia repair.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-06-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 916989,\n \"text\": \" 6:27 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: asses effusion\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with effusion\\n s/p ex-lap, has R whiteout ** please do portable UPRIGHT **\\n REASON FOR THIS EXAMINATION:\\n asses effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of right pleural effusion.\\n\\n Portable AP upright chest radiograph compared to .\\n\\n FINDINGS: The ET tube tip is 5.8 cm above the carina. The right internal\\n jugular line tip is in distal portion of superior vena cava. The NG tube tip\\n is in the stomach. The right pleural effusion covers almost all of the right\\n hemithorax, being grossly unchanged in comparison to the previous film. The\\n left lower lung consolidation most probably due to atelectasis is also\\n unchanged. There is no sizable left pleural effusion. There are no gross\\n abnormalities in the left lung.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-06-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 916841,\n \"text\": \" 8:06 AM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: ? NGt tip ? effusion vs consolidation** please do portable U\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with\\n s/p ex-lap, has R whiteout ** please do portable UPRIGHT **\\n REASON FOR THIS EXAMINATION:\\n ? NGt tip ? effusion vs consolidation** please do portable UPRIGHT **\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ONE VIEW PORTABLE\\n\\n INDICATION: 51-year-old man with effusion and consolidation.\\n\\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\\n compared with the previous study at 3:27 a.m.\\n\\n The tip of the endotracheal tube is identified at the thoracic inlet. A\\n nasogastric tube courses towards the stomach. The right jugular IV catheter\\n terminates in the superior vena cava. No pneumothorax is identified.\\n\\n There is continued mild congestive heart failure with cardiomegaly associated\\n with large right pleural effusion. Atelectasis is seen in the right lung\\n base.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-24 00:00:00.000\",\n \"description\": \"IN-111 WHITE BLOOD CELL STUDY\",\n \"row_id\": 924069,\n \"text\": \"IN-111 WHITE BLOOD CELL STUDY Clip # \\n Reason: KNOWN CIRROHSIS, CANDIDIAL PERITONITIS, PERSISTENT WBC = 20 DESPITE ANTIFUNGAL THERAPY\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n RADIOPHARMECEUTICAL DATA:\\n 455.0 uCi In-111 WBCs;\\n History: 51yo many with candidial peritonitis ? occult infection / abscess\\n\\n REPORT:\\n\\n Following the injection of autologous white blood cells labeled with In-111,\\n images of the whole body were obtained.\\n\\n These images show abnormal, heterogeneous, intense lung uptake with highest\\n uptake in the left lower lobe and right lower lobe.\\n\\n Compared with the prior study of the lung uptake is new. Also the\\n patient's liver is smaller and there is haziness in the abdomen consistent with\\n cirrhosis and ascites.\\n\\n IMPRESSION: Abnormal, intense lung uptake worst in LLL and RLL.\\n\\n\\n , M.D.\\n , M.D. Approved: FRI 3:35 PM\\n\\n\\n\\n\\n RADLINE ; A radiology consult service.\\n To hear preliminary results, prior to transcription, call the\\n Radiology Listen Line .\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-13 00:00:00.000\",\n \"description\": \"MRI PELVIS W/O & W/CONTRAST\",\n \"row_id\": 922932,\n \"text\": \" 2:08 PM\\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \\n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\\n Reason: ? intraabdominal abcessPLEASE PERFORM BOTH ABDOMEN AND PELVI\\n Admitting Diagnosis: ABD PAIN\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, h/o VRE bactermiea, , candidemia, perirectal\\n abscess on exam, increasing white counts\\n REASON FOR THIS EXAMINATION:\\n ? intraabdominal abcessPLEASE PERFORM BOTH ABDOMEN AND PELVIS STUDY to look for\\n abcess\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 51-year-old gentleman with cirrhosis, VRE bacteremia,\\n candidemia, and perirectal abscess on exam.\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\\n Tesla magnet. Dynamic volumetric images were acquired before, during, and\\n following intravenous administration of 0.1 mmol/kg of gadolinium-DTPA.\\n Subtraction images and reformatted images were created on an independent\\n workstation.\\n\\n FINDINGS:\\n\\n A linear tract emerges from the anal verge at approximately the 6 o'clock\\n position. At the anal verge, there is an associated adjacent 13 x 9 mm region\\n of enhancement. T2-weighted images show hypointensity in the region of\\n enhancement on T1-weighted images; therefore, this may represent fibrosis or\\n early organization. No supralevator collections.\\n\\n Note is made of marked free fluid within the pelvis and edema within the\\n subcutaneous fat.\\n\\n Fat-containing inguinal hernias are identified bilaterally.\\n\\n Subtraction images and 2- and 3-dimensional reformatted images were helpful in\\n delineating pathology.\\n\\n IMPRESSIONS:\\n 1. Linear tract with associated area of enhancement adjacent to the anal\\n verge, at approximately the 6 o'clock position. No drainable fluid collection\\n is present. Signal characteristics may represent early organization of\\n inflammation.\\n 2. Ascites and anasarca.\\n\\n\\n\\n (Over)\\n\\n 2:08 PM\\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \\n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\\n Reason: ? intraabdominal abcessPLEASE PERFORM BOTH ABDOMEN AND PELVI\\n Admitting Diagnosis: ABD PAIN\\n Contrast: MAGNEVIST Amt: 20\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 924375,\n \"text\": \" 1:06 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ett and ogt placement\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, ascites w/ , elevated WBC of unclear\\n etiology.\\n REASON FOR THIS EXAMINATION:\\n ett and ogt placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cirrhosis and ascites with and elevated white blood count.\\n Status post endotracheal tube and orogastric tube placement.\\n\\n A supine portable chest radiograph shows endotracheal tube in place with the\\n tip positioned 6-1/2 cm above the carina. The tip and sidehole of the\\n orogastric tube are both below the left hemidiaphragm. Hazy obscuration of\\n the right hemithorax appears to be related to large layering pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-24 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 924259,\n \"text\": \" 3:03 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: eval for evidence of SBO - Upright portable abdomen\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51M ESLD, h/o incarcerated ventral hernia, candidal peritonitis, now acutely\\n nausea and vomiting.\\n REASON FOR THIS EXAMINATION:\\n eval for evidence of SBO - Upright portable abdomen\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old male with end-stage liver disease presenting with\\n nausea and vomiting.\\n\\n COMPARISON: .\\n\\n SUPINE ABDOMEN, FOUR VIEWS: A moderate pleural effusion is seen at the right\\n lung base. Surgical clips project over the left upper abdominal quadrant.\\n There is a paucity of bowel gas. A few nondistended loops of gas filled bowel\\n are seen in the right lower abdominal quadrant. No definite free\\n intraperitoneal air is seen on the supine views. Bulging of the flanks and\\n displacement of the bowel from the peritoneal fat stripe suggest underlying\\n ascites. Deformity of the left iliac bone may represent prior trauma.\\n\\n IMPRESSION: No definite underlying obstruction or free intraperitoneal air.\\n Likely moderate ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-17 00:00:00.000\",\n \"description\": \"R ANKLE/FOOT (AP, LAT & OBL) RIGHT\",\n \"row_id\": 923416,\n \"text\": \" 3:57 PM\\n ANKLE/FOOT (AP, LAT & OBL) RIGHT Clip # \\n Reason: rule out osteomyelitis of prosthetic hardware\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, history of VRE bacteremia, persistent WBC,\\n suspect osteo of tibia hardware\\n REASON FOR THIS EXAMINATION:\\n rule out osteomyelitis of prosthetic hardware\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Bacteremia and previous tibial hardware. Assess osteomyelitis.\\n\\n These two exams consist of three views of the right ankle and distal\\n tibia/fibula as well as three views of the right foot. There is marked\\n generalized soft tissue swelling particularly on the dorsum of the foot.\\n There are healed fracture deformities in the distal diaphysis of both the\\n tibia and fibula with lateral tibial plate and screws. There is relatively\\n smooth bridging cortical new bone present with slight irregularity posterior\\n to the fibular fracture of doubtful significance and unchanged from . There is no evidence of loosening of the plate or screws. Ankle\\n mortise congruent with the talus. The bones of the foot are intact.\\n\\n IMPRESSION: Soft tissue swelling. Sequelae of previous fractures. No\\n evidence of osteomyelitis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 924118,\n \"text\": \" 12:13 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval consolidation, effusion\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, ascites w/ , elevated WBC of unclear\\n etiology.\\n REASON FOR THIS EXAMINATION:\\n eval consolidation, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Evaluate effusion and consolidations. Patient 51-year-old\\n man with cirrhosis, elevated white blood count\\n\\n Comparison is made with prior study dated .\\n\\n FINDINGS:\\n Interval increase in size in the moderate right pleural effusion. There is\\n right lower lobe atelectasis. There is no pneumothorax. Left PICC line with\\n tip in the superior third of the SVC. Right heart border is obscured by the\\n atelectasis and pleural effusion. Mediastinum is midline.\\n\\n IMPRESSION: Enlarging moderate right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-26 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 924535,\n \"text\": \" 2:56 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: Please evaluate pigtail position and rule out pneumothorax.\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p placement of right pleural\\n pig tail\\n REASON FOR THIS EXAMINATION:\\n Please evaluate pigtail position and rule out pneumothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST AT 15:45 HOURS.\\n\\n A single AP upright view of the chest is obtained and compared with the prior\\n radiograph of 03:49 of the same day. Right pleural effusion is again seen and\\n is likely not significantly changed. Patient has had placement of a pigtail\\n catheter which is visualized on the current film. There is no evidence of\\n pneumothorax. Tubes and lines are essentially otherwise unchanged.\\n\\n IMPRESSION:\\n\\n Placement of right-sided pigtail catheter in the pleural space. No evidence\\n of pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-26 00:00:00.000\",\n \"description\": \"P RENAL U.S. PORT\",\n \"row_id\": 924537,\n \"text\": \" 3:20 PM\\n RENAL U.S. PORT Clip # \\n Reason: Evaluate please for hydro or evidence of obstruction\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with renal failure.\\n\\n REASON FOR THIS EXAMINATION:\\n Evaluate please for hydro or evidence of obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Renal failure.\\n\\n COMPARISON: CT scan obtained two days prior.\\n\\n FINDINGS: The left kidney measures 13.3 cm in length. The right kidney\\n measures 12.9 cm in length. There is no hydronephrosis, stones, or masses\\n identified. The bladder is collapsed with a Foley in place. A moderately\\n large amount of ascites is again seen throughout the abdomen with note of\\n multiple septations within the ascites fluid.\\n\\n IMPRESSION:\\n 1. No evidence of hydronephrosis.\\n 2. Persistent ascites contained multiple septations, possibly the\\n sequela of SBP or multiple paracenteses.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-24 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 924240,\n \"text\": \" 11:43 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: r/u recurrent PNA\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, peritonitis, known RLL effusion, with\\n new cough and increasing WBC\\n REASON FOR THIS EXAMINATION:\\n r/u recurrent PNA\\n CONTRAINDICATIONS for IV CONTRAST:\\n chronic renal failure/hepatorenal syndrome\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST\\n\\n REASON FOR EXAM: Question pneumonia in a 51-year-old man with cirrhosis,\\n peritonitis, enlarged right pleural effusion.\\n\\n TECHNIQUE: Multidetector CT through the chest without oral or IV contrast. 5,\\n 1.25 mm collimation images and coronal reformation images were reviewed.\\n\\n Comparison was made to prior study dated .\\n\\n FINDINGS: Mildly enlarging nonhemorrhagic layering right pleural effusion is\\n responsible for relaxation atelectasis in the right lower lobe. There is no\\n pneumonia. There is a new small pericardial effusion. Bullae in the apices\\n are unchanged. The central airways are patent. Heavy calcification of the\\n aortic valve could be hemodinamicaly significant. Heart size is normal.\\n Aside from a stable, 11mm wide juxtacardiac node, there is no\\n pathologic enlargment of mediastinal, hilar or axillary lymph nodes.\\n\\n A large volume of ascites persists. The liver is shrunken and nodular\\n consistent with cirrhosis. The adrenal glands are unremarkable. There is a\\n large fluid-filled distention of the stomach.\\n\\n There are no bone findings of malignancy.\\n\\n IMPRESSION: No pneumonia.\\n\\n Minimally enlarged, large right pleural effusion.\\n\\n Aortic valve calcification. Possible aortic stenosis.\\n\\n New small pericardial effusion.\\n\\n Persistent ascites. Cirrhosis.\\n\\n Severely distended stomach\\n\\n\\n (Over)\\n\\n 11:43 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: r/u recurrent PNA\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-24 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 924285,\n \"text\": \" 5:58 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: eval sbo, perf, abscess\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 50\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, s/p incarcerated hernia repair and small\\n bowel resection. Now with hospital-acquired pna, but WBC still increasing.\\n (+) diffuse abdominal pain, now sbc\\n REASON FOR THIS EXAMINATION:\\n eval sbo, perf, abscess\\n CONTRAINDICATIONS for IV CONTRAST:\\n hepatorenal\\n ______________________________________________________________________________\\n WET READ: KMcd WED 11:51 PM\\n VERY LIMITED STUDY DUE TO ABSENCE OF IV AND ORAL CONTRAST. MASSIVE ASCITES.\\n LARGE RIGHT SIDED PLEURAL EFFUSION WITH COMPRESSIVE ATELECTASIS. NO EVIDENCE\\n OF BOWEL OBSTRUCTION. NO FREE ABDOMINAL AIR. ABSCESS CANNOT BE EXCLUDED GIVEN\\n THE MASSIVE ASCITES. BILATERAL FAT-CONTAINING INGUINAL HERNIAS.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cirrhosis with incarcerated hernia repair and small bowel\\n resection, now with pneumonia and increasing leukocytosis, diffuse abdominal\\n pain. Assess for obstruction, perforation or abscess.\\n\\n TECHNIQUE: MDCT-imaging of the abdomen and pelvis was performed without\\n contrast.\\n\\n COMPARISON: Abdominal CT scan from .\\n\\n CT OF THE ABDOMEN WITHOUT CONTRAST: There is a large right pleural effusion\\n with a loculated component anterior to the major fissure, with near complete\\n collapse of the visualized portions of the right lower lobe and and portions\\n of the right middle lobe. A tiny left pleural effusion and associated left\\n lower lobe and lingular atelectasis is also present. There is a large volume\\n of ascites throughout the abdomen, which has increased since the prior study.\\n There is no free intraperitoneal air or evidence of abscess collection. The\\n liver is small and nodular. Note is made of massive gastric distention which\\n extends into the duodenum and proximal jejunum, but smoothly tapers distally.\\n No frank transition point is identified. The descending and sigmoid colon are\\n largely collapsed. The pancreas, adrenal glands, and kidneys are unchanged\\n since the prior study.\\n\\n CT OF THE PELVIS WITHOUT CONTRAST: There is a large amount of fluid in the\\n pelvis. No pathologically enlarged inguinal or pelvic nodes are identified.\\n Bladder is unremarkable.\\n\\n BONE WINDOWS: There is redemonstration of multiple old left rib fractures and\\n left iliac fracture.\\n\\n IMPRESSION:\\n 1. Marked increase in amount of ascites. Spontaneous bacterial peritonitis\\n (Over)\\n\\n 5:58 PM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: eval sbo, perf, abscess\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 50\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n is of concern given the patient's clinical status.\\n 2. Marked gastric distension with distention of duodenum and proximal\\n jejunum. No frank transition point.\\n 3. No evidence of intra-abdominal abscess.\\n 4. Large right pleural effusion, with possible loculation anteriorly.\\n\\n Results describing the effusion, ascites, and lack of bowel obstruction/free\\n air/abscess was discussed with Dr. on the evening this study was\\n performed.\\n\\n Findings detailing the gastric distention were discussed with Dr. \\n at 9:30 a.m. on .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-14 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 923035,\n \"text\": \" 10:57 PM\\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \\n CT PELVIS W/O CONTRAST\\n Reason: ?occult abcess/assess pneumonia and effusion seen on cxrayCa\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 46\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with hep c/alcoholic cirrhosis, unexplained leukocytosis\\n REASON FOR THIS EXAMINATION:\\n ?occult abcess/assess pneumonia and effusion seen on cxrayCannot get contrast\\n due to renal failure.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: AHPb MON 12:14 AM\\n limited by no iv. there is a large right pleural effusion and an associated\\n right lower lobe opacity (atelectasis most likely, but pna is possible).\\n\\n 5 x 2cm fluid collection in anterior subcutaneous tissue (likely ascites from\\n anterior wall defect, but limited by no iv contrast and poor bowel\\n opacification. there is abundant ascites in abd/pelvis with hallmarks of\\n advanced cirrhosis. focal fluid collections cannot be excluded but not\\n suspected.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Alcoholic cirrhosis with unexplained leukocytosis.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Non-contrast axial CT imaging of the chest, abdomen and pelvis\\n without contrast was reviewed. Coronal and sagittal reformats were obtained\\n and reviewed.\\n\\n CT CHEST WITHOUT CONTRAST: There is a moderate/large right pleural effusion\\n with presumed associated atelectasis that is relatively unchanged from . Bullous changes are present in the apices, and there is minimal left\\n basilar atelectasis. Left subclavian central venous catheter tip terminates\\n in the right atrium. Calcification is present within the mitral annulus. No\\n pathologic adenopathy identified. Note of gynecomastia. A few small lymph\\n nodes are present in the pericardial fat.\\n\\n CT ABDOMEN WITHOUT CONTRAST: The liver is shrunken and nodular, consistent\\n with cirrhosis. Attenuation is decreased within the left hepatic lobe of\\n unclear etiology. There is abundant ascites in the abdomen and pelvis,\\n increased from . There is a small anterior wall defect containing\\n ascites. Multiple collaterals are presentThe gallbladder, pancreas, adrenal\\n glands, and right kidney are unremarkable. The patient is status post\\n splenectomy. Low- density lesions in the left kidney are unchanged. There are\\n a few mildly dilated small bowel loops, but unchanged if not slightly improved\\n from . Bowel wall thickening is likely secondary to ascites.\\n Numerous collaterals are present throughout the abdomen.\\n\\n CT PELVIS WITH CONTRAST: The rectum, sigmoid is unchanged. Note of bilateral\\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: ?occult abcess/assess pneumonia and effusion seen on cxrayCa\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 46\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n fat-containing inguinal hernias. The distal ureters and bladder are normal.\\n Ascites is present in the pelvis. Though evaluation for focal fluid\\n collections is limited per non-contrast CT, no suspicious areas are\\n identified.\\n\\n BONE WINDOWS: No suspicious lesions are identified. Note of multiple poorly\\n healed previous left posterior rib fractures. There is a prior left iliac\\n fracture.\\n\\n IMPRESSION: No marked interval change from with a large right\\n pleural effusion and associated atelectasis, marked ascites, and hallmarks of\\n advanced cirrhosis. Mildly dilated small bowel loops are unchanged.\\n\\n These findings were provided to the ED dashboard at the time of the study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 924286,\n \"text\": \" 5:59 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ENCEPHALOPATHY\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51M endstage liver failure, ?fall, encephalopathy.\\n REASON FOR THIS EXAMINATION:\\n eval for head bleed\\n CONTRAINDICATIONS for IV CONTRAST:\\n hepatorenal\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: End-stage liver failure, possible fall, encephalopathy. Evaluate\\n for head bleed.\\n\\n Comparison is made to .\\n\\n CT HEAD WITHOUT CONTRAST: The study is significantly limited due to patient\\n motion artifact, despite repeat acquisitions. Within these limitations, no\\n definite acute intracranial hemorrhage is seen. A small lacunar infarct in\\n the posterior right thalamus is less conspicuous on today's scan. A focal\\n lacunar area in the right cerebellar hemisphere is stable. No mass effect or\\n shift of normally midline structures is seen. Paranasal sinuses and mastoid\\n air cells are clear.\\n\\n IMPRESSION: Within the limitations of motion artifact, no definite evidence\\n of acute intracranial hemorrhage or cerebral edema is seen. No significant\\n interval change since .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 924464,\n \"text\": \" 3:31 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change, incr effusion, chf\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, ascites w/ , elevated WBC of unclear\\n etiology.\\n REASON FOR THIS EXAMINATION:\\n eval for interval change, incr effusion, chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 3:49 A.M., .\\n\\n HISTORY: Cirrhosis and ascites. Elevated white count.\\n\\n IMPRESSION: AP chest compared to through 17:\\n\\n Large right pleural effusion, which decreased during the day on is\\n stable subsequently. There is no pneumothorax. Consolidation at the base of\\n the right lung, most likely residual atelectasis. Vascular congestion in the\\n lungs and mediastinum is unchanged. Heart size top normal. No pneumothorax.\\n Endotracheal tube tip is in standard placement, cuff distends the tracheal\\n diameter above the thoracic inlet. Tip of the right subclavian line projects\\n over the mid SVC and a nasogastric tube ends in the stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-25 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 924423,\n \"text\": \" 6:44 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: new r ij and s/ , eval for placement and ptx\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, ascites w/ , elevated WBC of unclear\\n etiology.\\n REASON FOR THIS EXAMINATION:\\n new r ij and s/ , eval for placement and ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cirrhosis and ascites with . New right IJ catheter and\\n status post thoracentesis. Evaluate placement and for pneumothorax.\\n\\n COMPARISON: at 13:23.\\n\\n SEMI-UPRIGHT AP CHEST: There is an endotracheal tube in place, with the tip\\n approximately 6.7 cm from the carina. An orogastric tube remains in place.\\n There is a new right internal jugular approach central venous catheter, with\\n the tip overlying the mid to distal superior vena cava. The patient is\\n slightly rotated toward the left. There is unchanged cardiac enlargement and\\n the lung fields are not significantly changed. There is slightly decreased\\n hazy opacity of the right hemithorax, likely related to right thoracentesis. A\\n moderate-to-large amount of right pleural fluid persists, however. There is\\n no evidence of a pneumothorax on this study.\\n\\n Impression: No evidence of pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 920400,\n \"text\": \" 2:51 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for infiltrate/pna\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, resolving SBP, now with incr WBC.\\n REASON FOR THIS EXAMINATION:\\n Please eval for infiltrate/pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE AP FILM\\n\\n History of cirrhosis with leukocytosis.\\n\\n Left-sided PICC line has tip located at proximal SVC close to junction with\\n left brachiocephalic vein. Allowing for technique, heart size is within\\n normal limits. Since the previous study of , there has been a\\n reduction in the size of the right pleural effusion. No definite new lung\\n lesions in this single AP film. Specifically, no evidence for new pneumonia.\\n Surgical clips are present in the left upper abdomen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-02 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 921459,\n \"text\": \" 6:02 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: INCR WBC PLEASE EVAL FOR DVT'S\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man w/ HepC/EtOH cirrhosis, recent fungemia and bacteremia now\\n with incr WBC without definite source.\\n REASON FOR THIS EXAMINATION:\\n Please eval for DVTs\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old man with hepatitis C and cirrhosis with recent\\n fungemia and bacteremia, now with increasing white blood cell count. Evaluate\\n for DVT.\\n\\n COMPARISON: Study from .\\n\\n BILATERAL LOWER EXTREMITY ULTRASOUND: -scale and color Doppler son\\n was performed of the right and left common femoral, superficial femoral, and\\n popliteal veins. Normal flow, compressibility, augmentation, and waveforms\\n are demonstrated. No intraluminal thrombus is identified.\\n\\n IMPRESSION: No DVT.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-10 00:00:00.000\",\n \"description\": \"US ABD LIMIT, SINGLE ORGAN\",\n \"row_id\": 918380,\n \"text\": \" 12:12 PM\\n US ABD LIMIT, SINGLE ORGAN Clip # \\n Reason: needs area marked for paracentesis to be done today\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with ESLD/cirrhosis for transplant, abd distension, n/v/abd\\n pain, increased ascites on exam\\n REASON FOR THIS EXAMINATION:\\n needs area marked for paracentesis to be done today\\n ______________________________________________________________________________\\n WET READ: KMcd SUN 1:03 PM\\n moderate amount of ascites. LLQ pocket marked for para.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: End-stage liver disease with cirrhosis for transplant. Abdominal\\n distention. Nausea, vomiting, abdominal pain, increased ascites. Needs a\\n mark for paracentesis to be done today.\\n\\n FINDINGS: All four quadrants were examined. There is a moderate amount of\\n ascites. A pocket in the left lower quadrant was marked for paracentesis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-02 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 917324,\n \"text\": \" 9:35 AM\\n RENAL U.S. Clip # \\n Reason: Please assess for renal pathology\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with renal failure\\n REASON FOR THIS EXAMINATION:\\n Please assess for renal pathology\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 51-year-old male with renal failure. Assess for renal pathology.\\n\\n COMPARISON: CT abdomen and pelvis , ultrasound paracentesis , .\\n\\n RENAL ULTRASOUND:\\n\\n This exam is limited secondary to limited patient positioning. The right\\n kidney measures 10.5 cm. The left kidney measures 12.3 cm. There is no\\n evidence of hydronephrosis. No evidence of stones. Marked ascites is\\n present. The liver is small and nodular consistent with cirrhosis.\\n\\n IMPRESSION:\\n\\n No evidence of hydronephrosis or stones. Marked ascites. Cirrhosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-05 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 917757,\n \"text\": \" 4:06 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Please place double lumen picc for TPN and ABx.\\n Admitting Diagnosis: ABD PAIN\\n Contrast: OPTIRAY Amt: 10\\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 51 year old man with EtOH/HCV cirrhosis, s/p SB resection for incarcerated\\n hernia. Needs long term nutrition.\\n REASON FOR THIS EXAMINATION:\\n Please place double lumen picc for TPN and ABx.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cirrhosis, status post small bowel resection, needs long-term\\n parenteral nutrition.\\n\\n FINDINGS: The patient was placed supine on the angiography table. Limited\\n ultrasound examination was performed of the left forearm. Using ultrasound\\n guidance, a left brachial vein was accessed using a 21-gauge needle. Hard\\n copy ultrasound images were obtained before and after establishing access. A\\n 0.018 guidewire was then advanced through the needle into the SVC under direct\\n fluoroscopic guidance. Based on the markers of the guidewire, the PICC line\\n was trimmed to a length of 41 cm. The needle was exchanged for introducer\\n sheath and the PICC line was advanced through the sheath under direct\\n fluoroscopic guidance with the tip terminating at the lower SVC. Peel-away\\n sheath and wire were removed. The PICC line was aspirated, flushed, capped,\\n and hep-locked. The line was secured using a StatLock device. There were no\\n immediate post-procedure complications.\\n\\n RADIOLOGISTS: and . The attending radiologist, Dr. \\n was present for the entire procedure.\\n\\n IMPRESSION: Successful placement of a dual-lumen, 4 French PICC via a left\\n brachial vein with the tip terminating within the mid SVC.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-13 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 918744,\n \"text\": \" 11:52 AM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o infiltrate, assess right pleural effusion\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with SOB and ascites s/p small bowel resection with hernia\\n repair\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate, assess right pleural effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post ventral hernia repair with shortness of breath.\\n\\n COMPARISON: .\\n\\n CHEST: AP upright and lateral views. Allowing for differences in patient\\n positioning, the large right pleural effusion is not significantly changed.\\n There is no left pleural effusion. The left lung is clear. The endotracheal\\n tube, nasogastric tube, and the right internal jugular central venous catheter\\n have been removed. There is no pneumothorax. The new left PICC terminates in\\n the upper SVC.\\n\\n IMPRESSION: Large right pleural effusion, not significantly changed.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-18 00:00:00.000\",\n \"description\": \"R UNILAT LOWER EXT VEINS RIGHT\",\n \"row_id\": 919413,\n \"text\": \" 1:50 PM\\n UNILAT LOWER EXT VEINS RIGHT Clip # \\n Reason: PLEASE ASSES FOR DVT IN RLE, R>L\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man s/p incisional hernia repair, small bowel resection POD 20\\n REASON FOR THIS EXAMINATION:\\n please assess for DVT in RLE\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n EXAMINATION: Right lower extremity venous Doppler, .\\n\\n COMPARISON: None.\\n\\n INDICATION: Status post incisional hernia repair and small bowel resection,\\n evaluate for DVT in right lower extremity.\\n\\n FINDINGS: scale, color Doppler, and spectral waveform imaging of the\\n right lower extremity deep venous system was performed. There is no evidence\\n of intraluminal thrombus within the right common femoral, superficial femoral\\n and popliteal veins. These veins demonstrate normal color flow and\\n augmentation. Incidental note is made of ill-defined complex fluid collection\\n in the popliteal region which most likely represents a ruptured cyst.\\n\\n IMPRESSION:\\n 1. No evidence of deep venous thrombosis in the right lower extremity.\\n 2. Ruptured cyst.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-29 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 920918,\n \"text\": \" 10:25 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: Please eval for intraabdominal source of infection\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 38 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, s/p incarcerated hernia repair and small bowel\\n resection. Now with hospital-acquired pna, but WBC still increasing. (+)\\n diffuse abdominal pain, no SBP.\\n REASON FOR THIS EXAMINATION:\\n Please eval for intraabdominal source of infection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAMINATION: CT of the abdomen and pelvis dated \\n\\n COMPARISON: CT of the abdomen and pelvis dated .\\n\\n INDICATION: 51-year-old male with cirrhosis status post incarcerated hernia\\n repair and small bowel resection, now with hospital-acquired pneumonia with\\n increasing white count, diffuse abdominal pain, but no SBP. Please evaluate\\n for intra-abdominal source of infection.\\n\\n TECHNIQUE: MDCT axial images are obtained through the abdomen and pelvis\\n after the administration of IV and oral contrast. The clinical team was\\n aware of the patient's creatinine of 1.7 and used hydration and bicarbonate\\n solution before and after the exam to help prevent contrast nephropathy.\\n\\n FINDINGS FOR CT OF THE ABDOMEN WITH CONTRAST: There is a large right pleural\\n effusion and right lower lobe atelectasis, unchanged. There has been interval\\n development of a tiny left pleural effusion and left basilar atelectasis.\\n\\n Again seen is a shrunken liver with nodular contour consistent with cirrhosis.\\n The gallbladder is present. The patient is status post splenectomy. The\\n pancreas, adrenal glands, and right kidney are unremarkable. Again seen are\\n two low density lesions involving the left kidney, the interpolar region and\\n at the lower pole, consistent with renal cysts. There has been slight\\n interval increase in quantity of ascites within the abdomen since the prior\\n exam. Multiple fluid collections are demonstrated within the subcutaneous\\n tissues in region of prior hernia repair, the largest of which measures 5.7 cm\\n x 2.3 cm, unchanged. Multiple dilated loops of small bowel are seen, which\\n have thickened wall, there is no evidence for obstruction since contrast is\\n seen within colon. The bowel wall thickening is thickening is likely\\n secondary to hypoalbuminemia. There has been interval resolution of the\\n diffuse colonic thickening seen on the prior examination. Numerous porta\\n splenic collateral vessels are demonstrated. The bones demonstrate no\\n suspicious lesions.\\n\\n FINDINGS FOR CT OF THE PELVIS: There has been slight increase in amount of\\n intrapelvic ascites. There has been interval resolution of the colonic wall\\n thickening. There is no lymphadenopathy or free intraperitoneal gas.\\n\\n (Over)\\n\\n 10:25 AM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: Please eval for intraabdominal source of infection\\n Admitting Diagnosis: ABD PAIN\\n Field of view: 38 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n BONE WINDOWS: Multiple old left lower rib fractures are demonstrated. There\\n is evidence of old trauma to the left ilium.\\n\\n\\n IMPRESSION:\\n 1) Cirrhosis with slight increase in intra-abdominal and intrapelvic ascites.\\n Stable large right pleural effusion and right basilar atelectasis. New tiny\\n left pleural effusion and left lower lobe atelectasis.\\n\\n 2) Dilated loops of small bowel without evidence of bowel obstruction. Small\\n bowel wall thickening, likely secondary to low protein state.\\n\\n 3) Interval resolution of the diffuse colonic thickening.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 921076,\n \"text\": \" 5:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please eval for pneumothorax (s/p thoracentesis)\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, resolving SBP, now with incr WBC. s/p\\n thoracentesis\\n REASON FOR THIS EXAMINATION:\\n Please eval for pneumothorax (s/p thoracentesis)\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Cirrhosis, status post thoracentesis, evaluate for\\n pneumothorax.\\n\\n Small bilateral pleural effusions are present. Neither side shows a\\n pneumothorax. No infiltrates are present.\\n\\n IMPRESSION: No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-07-27 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 920641,\n \"text\": \" 1:53 PM\\n CHEST (PA & LAT) Clip # \\n Reason: Please eval for infiltrate/pneumonia\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, s/p bacteremia and fungemia, now with\\n increasing WBC again.\\n REASON FOR THIS EXAMINATION:\\n Please eval for infiltrate/pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 51-year-old man with cirrhosis status post bacteremia and\\n fungemia, now with increasing white cell count.\\n\\n CHEST, AP AND LATERAL:\\n\\n Extensive opacification is seen within the right lower lung posteriorly. This\\n is associated with right pleural effusion also. The lower lobe opacifications\\n are new and probably represent pneumonic consolidation.\\n\\n Elsewhere, the lung fields appear clear.\\n\\n IMPRESSION: Persistent right effusion. New right lower lobe infiltrate.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-19 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 923716,\n \"text\": \" 5:58 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: WITH DUPLEX PLEASE-ASSESS for PV thrombosis\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with ESLD/cirrhosis for transplant, ascites with acute rise\\n in t. bili.\\n REASON FOR THIS EXAMINATION:\\n WITH DUPLEX PLEASE-ASSESS for PV thrombosis\\n ______________________________________________________________________________\\n FINAL REPORT\\n 51-year-old male with end-stage liver disease, cirrhosis, awaiting transplant\\n with acute rise in bilirubin, and concern for portal vein thrombosis.\\n\\n LIVER ULTRASOUND WITH DOPPLER: The liver is shrunken and nodular with\\n coarsened echogenicity consistent with cirrhosis. No definite focal hepatic\\n lesion is identified. No intra- or extra-hepatic biliary ductal dilatation is\\n identified. There is moderate amount of ascites around the liver. Doppler\\n evaluation demonstrates appropriate directionality and waveform of the main,\\n left and right portal veins as well as main, left and right hepatic arteries\\n and main and right hepatic veins. The left hepatic vein is not identified,\\n due to technical factors. The IVC is patent.\\n\\n IMPRESSION: No evidence of portal vein thrombosis. Severe cirrhosis with\\n moderate ascites. Left hepatic vein not visualized due to technical factors,\\n but all other vessels are accounted for with appropriate directionality and\\n waveform.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 924687,\n \"text\": \" 3:15 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ett placement\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p malposition ET tube\\n\\n REASON FOR THIS EXAMINATION:\\n ett placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cirrhosis, candidemia, MRSA sepsis, ET tube placement.\\n\\n CHEST, SINGLE AP PORTABLE VIEW.\\n\\n The ET tube is in satisfactory position approximately 6.2 cm above the carina.\\n An NG tube coils over the left upper quadrant, unchanged. The coil overlies\\n the expected course of the left hemidiaphragm and there is no air seen and the\\n fundus of the precise position is difficult to confirm radiographically. Right\\n IJ central line present, tip over distal SVC, unchanged.\\n\\n Again seen is cardiomegaly and mild prominence of the superior mediastinum,\\n with enlarged pulmonary hila. There is upper zone redistribution, diffuse\\n vascular blurring, more confluent opacities at the bases, and small bilateral\\n pleural effusions. There is left lower lobe collapse and/or consolidation.\\n The right pleural catheter is again noted.\\n\\n IMPRESSION:\\n\\n 1) ET tube in satisfactory position. Lines and tubes as described. Clinical\\n correlation regarding the NG tube is requested. While it probably does lie\\n within the gastric fundus, it is difficult to confirm radiographically.\\n\\n 2) Findings compatible with CHF with alveolar edema, bilateral effusions and\\n left lower lobe collapse and/or consolidation. Allowing for differences in\\n technique, this appearance is similar to the film from one day earlier.\\n\\n 3) No pneumothorax detected.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 924569,\n \"text\": \" 8:08 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: patient with drop in pressures s/p pig tail placement in \\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p placement of right pleural\\n pig tail\\n REASON FOR THIS EXAMINATION:\\n patient with drop in pressures s/p pig tail placement in chest. Eval for PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cirrhosis, candidemia, MRSA, sepsis, status post placement of\\n right pleural pigtail. Drop in pressures after pigtail placement. Evaluate\\n for pneumothorax.\\n\\n COMPARISONS: Radiograph obtained approximately four hours earlier.\\n\\n PORTABLE AP SUPINE RADIOGRAPH OF THE CHEST: An endotracheal tube is seen\\n approximately 7 cm above the carina. The tip of the NG tube projects over the\\n gastric fundus. A right-sided IJ central venous catheter is in unchanged\\n position with the tip projecting over the distal SVC. A pigtail catheter is\\n seen projecting over the right lower lung. There is almost complete removal\\n of the previously seen right pleural effusion. No pneumothorax is seen. There\\n is new bilateral hilar prominence and perihilar haziness. The cardiac\\n silhouette appear stable.\\n\\n IMPRESSION: 1. No evidence of pneumothorax. 1. Successful drainage of a right-\\n sided pleural effusion. 3. Evidence of new pulmonary vascular congestion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-11 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 922682,\n \"text\": \" 3:17 PM\\n CHEST (PA & LAT) Clip # \\n Reason: r/u pna\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 year old man with cirrhosis, candidal peritonitis, now with increasing WBC\\n again.\\n REASON FOR THIS EXAMINATION:\\n r/u pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Increased white blood cell in patient with known\\n peritonitis.\\n\\n PA and lateral upright chest radiograph compared to the previous film from\\n , and .\\n\\n The left PICC line was inserted in the meantime interval with its tip\\n projecting over the inferior portion of superior vena cava. The heart size is\\n normal. There is no mediastinal widening or shifting. The right lower lobe\\n consolidation is grossly unchanged with some increase in pleural effusion\\n better demonstrated on the lateral exam. The rest of the lungs are\\n unremarkable. The healed fractures on the left are again demonstrated.\\n\\n IMPRESSION: Grossly unchanged right lower lobe consolidation with some\\n increase in pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 924628,\n \"text\": \" 1:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pls check ETT position after advancement\\n Admitting Diagnosis: ABD PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p malposition ET tube\\n REASON FOR THIS EXAMINATION:\\n pls check ETT position after advancement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Cirrhosis, candidemia MRSA sepsis, status post ET tube malposition,\\n check ET tube position after advancement.\\n\\n CHEST, SINGLE AP VIEW.\\n\\n Lines and tubes are unchanged. The ET tube lies approximately 7 cm above the\\n carina at the level of mid clavicle, overall similar to its appearance on the\\n film from one day earlier. Radiographically, it is somewhat high but in\\n overall satisfactory position. If clinically indicated, it could be advanced\\n by 1-3 cm. The right IJ central line tip overlies the distal SVC unchanged.\\n Of note, the NG tube is coiled in left upper quadrant and overlies the\\n hemidiaphragm itself. I suspect this is within the gastric fundus, but this\\n is difficult to confirm on these views.\\n\\n The pleural and parenchymal findings are unchanged. There is evidence of CHF,\\n with bibasilar atelectasis and a small right pleural effusion. The left\\n costophrenic angle is excluded from the film. No pneumothorax is detected.\\n\\n IMPRESSION:\\n\\n 1. ET tube position essentially unchanged compared with . See\\n comment.\\n\\n 2. Right lung base chest tube, with small effusion, unchanged.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2135-08-10 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 922482,\n \"text\": \" 12:58 PM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: Attempted PICC x2 by IV nurse. Please attempt via IR. In n\\n Admitting Diagnosis: ABD PAIN\\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 51 year old man with EtOH/HCV cirrhosis, awaiting transplant, with \\n peritonitis, will need long-term IV antifungal therapy\\n REASON FOR THIS EXAMINATION:\\n Attempted PICC x2 by IV nurse. Please attempt via IR. In need of long term\\n abx for fungal peritonitis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: peritonitis, needing long-term IV antifungal therapy.\\n\\n PROCEDURE: This procedure was performed by Dr. , with Dr. , the\\n attending physician, and supervising throughout. The patient was\\n brought to the angiography suite and placed supine on the table. A\\n preprocedure timeout was performed to confirm patient, site, and procedure.\\n The left upper arm was prepped and draped in the usual sterile fashion. As no\\n suitable veins were visible, ultrasound was used to identify the left brachial\\n vein, which was patent and compressible. After administration of\\n approximately 4 mL of 1% lidocaine for local anesthesia, a 21-gauge needle was\\n introduced into the brachial vein using real time ultrasound guidance. Hard\\n copy ultrasound images were obtained before and after venipuncture\\n documenting vessel patency.\\n\\n Then, a 0.018 guidewire was advanced through the needle and into the distal\\n SVC under fluoroscopic guidance. The needle was exchanged for a 4-French\\n micropuncture sheath. Based on the markers on the guide wire, the PICC was\\n trimmed to 45 cm, then after withdrawal of the inner dilator, advanced over\\n the wire and into the distal SVC under fluoroscopic guidance. The peel-away\\n sheath and wire were removed, the line flushed, capped, Hep-Locked, and stat-\\n locked, and a final fluoroscopic image taken to demonstrate the tip of the\\n catheter in the distal SVC. The patient tolerated the procedure well. There\\n were no immediate complications.\\n\\n IMPRESSION: Successful placement of single lumen PICC in the distal SVC via\\n the left brachial vein. Line is ready for use.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":177,"cells":{"subject_id":{"kind":"number","value":12136,"string":"12,136"},"hadm_id":{"kind":"number","value":108671,"string":"108,671"},"target_text":{"kind":"string","value":"72 yo F with intramural hematoma of thoracic aorta. Hospital course by problem: . 1. Chronic TAA: Initially, surgical intervention was not felt to be indicated as it was a type B hematoma. Her BP was managed initially with labetolol and Nipride for goal SBP<140 and >100 given likely hx of chronic elevated BP and risk for hypoperfusion. She was ruled out for an acute MI. Her Hct dropped to 23.9 on and developed acute abdominal pain radiating to her back, so a CTA was repeated and showed possible large intramural hematoma in descending thoracic aneurysm. Vascular Surgery was notified and upon review of the scans w/ Radiology, felt the aneurysm was not significantly changed. We changed her antihypertensives and had good BP control with labetalol (changed to Toprol XL upon dispo), amlodipine, and valsartan. . 2. Intramural hematoma with penetrating ulcer: The etiology was unclear. Initially, the ulcer was thought atherosclerotic disease. However, the patient became febrile during her stay and rheum and ID were consulted. She had a negative workup for infectious cause. Her rheum workup was above and notable for positive , anti-CCP, and RF in the setting of an elevated ESR and CRP. An MRI was obtained and revealed a pattern which was not consistent with aortitis. Thus, her fever and inflammatory response was thought to be rheumatoid arthritis and the patient did not have an underlying aortitis. The patient was discharged with good blood pressure control and plans to return on for surgical intervention of her penetrating aortic ulcer. Additionally, we started atorvastatin for goal LDL<70 and for it's anti-inflammatory activity. She has VNA to assist with medication compliance as well as frequent blood pressure checks. . 3. Fevers: As above. The patient had intermittent fevers and confusions for approx 6 days in the middle of her stay. CSF analysis and head CT showed no pathology. ID workup was negative. The fever was thought inflammatory state. The mental status change was thought ICU delirium and it improved rapidly after she was transferred to the floor. . 4. CHF: EF>55% by ECHO. No evidence of heart failure on chest Xray. No shortness of breath and oxygen saturation in high 90's. We continued lasix low salt diet . 5. Hyponatremia: Labs were consistent with SIADH. The patient had resolution of her hyponatremia prior to discharge. . 6. Osteoporosis: All of her bone films mentioned severe osteopenia. We started the patient on alendronate, calcium, and vitamin D during her admission and continued it upon discharge."},"extractive_notes_summ":{"kind":"string","value":"Normalregional LV systolic function. Normal RVsystolic function.AORTA: Moderately dilated aortic root. Mildly dilated ascending aorta. The ascending aorta is mildlydilated. Mildlydilated aortic arch. Right ventricular systolicfunction is normal.4.The aortic root is moderately dilated. Left ventricular function.Height: (in) 68Weight (lb): 154BSA (m2): 1.83 m2BP (mm Hg): 133/62HR (bpm): 80Status: InpatientDate/Time: at 16:38Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Stable left common iliac artery aneurysm. Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:1. Theinteratrial septum is aneurysmal.2.Left ventricular wall thicknesses are normal. Aneurysmal interatrial septum.LEFT VENTRICLE: Normal LV wall thickness. A posterior penetrating ulcer is again noted at the level of the diaphragmatic hiatus, but unchanged in size and character. The glenohumeral and acromioclavicular articulations are within normal limits. Unchanged appearance of extensive Type B intramural hematoma from the subclavian artery origin to the upper abdominal aorta. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Mild mitral annularcalcification. Aneurysmal dilation of the left common iliac measuring 1.8 cm is unchanged. Stable 4-cm infrarenal abdominal aortic aneurysm. No aortic regurgitationis seen.6.The mitral valve leaflets are mildly thickened. 4-cm infrarenal abdominal aortic aneurysm is unchanged. Mild aneurysmal dilation of the left common iliac artery. The aortic arch is mildly dilated. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Left ventricular hypertrophy.Non-specific ST-T wave changes. The associated posterior penetrating ulcer at the diaphragmatic hiatus is stable. Intraabdominal large and small bowel are normal. Mildly dilated descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Bilateral pleural effusions are unchanged from the prior study. WILL CONTINUE O OBERVEB/S STABLERESP..SATS @ 95% ON 2/ NC, NOT TOLERTAING N/C WITH AGITATION AT TIMES..GI/U..TAKEN SOME FLUIDS, MOUTH LOOKS DRY, NO BOWEL MOTION...FOLEY AS ABOVE, SO PRESENTLY OUT..NEG BALANCE AT MN, ...TO HAVE ONE REPLACED WHEN APPROPRIATE....SKIN..INTACT...LINES..PATENT...SOCIAL..DAUGHETER PHONED ASLT PM AND UPDATED..BUT NOT AWARE OF MENTAL STATUS OVERNIGHT...PLAN..FOLOW MS CLOSELY AND MEDICATE AS REQUIRED, MONITOR B/P AIM < 140 CT CHEST WITH CONTRAST: There has been no marked interval change from , , with again demonstrated type B intramural hematoma extending from the subclavian artery through the diaphragmatic hiatus into the upper abdomen proximal to the celiac axis. Good flow demonstrated within parenchymal branches of the mid and lower poles bilaterally, upper pole is not well visualized secondary to patient respiration. Easily palpable PT's bilaterally weakly palpable DP's right weaker than left.RESP: Lungs with bibasilar crackles otherwise CTA. A posterior penetrating ulcer is seen at the level of the diaphragmatic hiatus is again visualized. Stable appearance of the chest, abdomen and pelvis with type B intramural hematoma and associated penetrating ulcer. Tele SR 70's with a a significant first degree AV block. NPN (cont'd)RESP: Lungs with diminished breath sounds throughout. The descending thoracic aorta ismildly dilated.5.The aortic valve leaflets (3) are mildly thickened. TECHNIQUE: Non-contrast and contrast-enhanced axial CT imaging of the chest, abdomen and pelvis was reviewed. TECHNIQUE: CT of the chest without IV contrast. The heart and pericardium are otherwise unremarkable except for dense coronary artery calcifications. Hct, 4pm, stable, 31.1 Vascular cont to follow; aortic dissection is non-operable at this time; may consider stenting if unstable. A crit was drawn @ 2100 that did not bump appropriately.Pt ordered for a CT angio of her chest which was completed at 0300. MICU Nursing Progress Note 0700-1900Events - Pt's BP extremely labile, crit of 28.7 after 2 units PRBCs.Neuro - Pt A&Ox3, MAE, follows commands. ABP 120-160S/ TRENDS DOWN TO 90S WHILE PT ASLEEP/ 0200 LABETALOL DOSE HELD PER PARAMETER/ TEAM AWARE. goal for bp 120-130. hct 28.7 and this am 29.3, k+ 4.1 mg 1.8. AT OSH PT WAS FOUND TO HAVE B/P 240/120/ CT SUGGESTIVE OF ACUTE ON CHRONIC THORACIC ANEURYSM/ TRANSFERRED TO FOR FURTHER MANAGEMENT. Hct drop initially to 24.7(from 28) and pt received 1UPRBC without appropriate bump. LS clear and diminished at the bases.cv: 1 degree AVB (not a new finding). Hypertension now being managed with po meds. Hrt sounds S1S2 w/ systolic murmur. MICU UPDATE and transfer note:Foley and Right Rad A-line d/c'd this AM. No increase in size of hematoma on CT. Stools were initially guiac positive.PO labetolol was started and gtts were weaned off by . Ruled out for an MI per enzymes. has hx of HTN/CHF/hypercholesterolemia along with hx of thoracic aortic aneurysm.Treated with labetolol and nipride gtts (goal 100-140/syst). pt became nauseous this am at 0200 anzemet 12.5mg ivp given w/ good effect. was incontinent this AM until foley was replaced. Fluid goal is slightly negative to a half a liter negative.Skin: IntactAccess: 2 PIV, right radial A-line.Endo: BS QIDSocial: Family in to visit for much of shift, updated on patient's condition. R radial aline.gi/gu: Pt is now NPO for ? Breathing pattern regular and unlabored.CV - Pt is in first degree AVB. pt denied back and abdominal pain. Will cont to closely monitor.CV: Remains in 1st degree AV block, 60-70's. BP elevated early am d/t infiltrated IV upon assessment. Additionally noted on the current exam is marked delayed crescentic enhancement of the entire aortic wall in the region affected by the intramural hematoma, compatible with associated engorgement of (Over) 10:41 AM MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Please eval for evidence of aortitis. 10:41 AM MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Please eval for evidence of aortitis. Colace and PRN Senna added to medications. PM crit 30.1 up from 29.3GI: Pt advanced to regular diet and tolerating well. pt c/o of head ache early this am at 0300 tylenol 650mg po given w/ good effect."},"n_notes":{"kind":"number","value":28,"string":"28"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2178-11-13 00:00:00.000","description":"Report","row_id":81920,"text":"PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 154\nBSA (m2): 1.83 m2\nBP (mm Hg): 133/62\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 16:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dynamic interatrial\nseptum. Aneurysmal interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Moderately dilated aortic root. Mildly dilated ascending aorta. Mildly\ndilated aortic arch. Mildly dilated descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Physiologic\nTR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size. The left atrium is elongated. The\ninteratrial septum is aneurysmal.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic root is moderately dilated. The ascending aorta is mildly\ndilated. The aortic arch is mildly dilated. The descending thoracic aorta is\nmildly dilated.\n5.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\nis seen.\n6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\n7.The pulmonary artery systolic pressure could not be determined.\n8.There is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2178-11-13 00:00:00.000","description":"Report","row_id":208684,"text":"Sinus rhythm. A-V conduction delay and A-V nodal Wenckebach. Diffuse\nnon-specific ST-T wave flattening.\n\n"},{"category":"ECG","chartdate":"2178-11-13 00:00:00.000","description":"Report","row_id":208685,"text":"Sinus rhythm. A-V nodal Wenckebach block. Left ventricular hypertrophy.\nNon-specific ST-T wave changes. No previous tracing available for comparison.\n\n"},{"category":"Radiology","chartdate":"2178-11-28 00:00:00.000","description":"R HUMERUS (AP & LAT) RIGHT","row_id":932507,"text":" 2:33 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT; HUMERUS (AP & LAT) RIGHTClip # \n Reason: r/o fx\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with right shoulder pain s/p trauma\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT SHOULDER, FOUR VIEWS, RIGHT HUMERUS, TWO VIEWS, AT\n 14:02 HOURS.\n\n HISTORY: Status post trauma.\n\n COMPARISON: None.\n\n FINDINGS: There is severe global osteopenia. There is no fracture or\n dislocation. The glenohumeral and acromioclavicular articulations are within\n normal limits. The coracoclavicular interval is appropriate. The regional\n soft tissues of the upper arm are unremarkable. The visualized adjacent lung\n is clear.\n\n IMPRESSION: Severe diffuse osteopenia, likely secondary to osteoporosis.\n Given the severity of the osteopenia, the sensitivity is decreased for\n detecting subtle nondisplaced fracture.\n\n\n"},{"category":"Radiology","chartdate":"2178-11-17 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":930919,"text":" 5:12 AM\n CT CHEST W&W/O C ; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Eval for evidence of new disection. PLEASE DO WITH MMS \n Admitting Diagnosis: BACK PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hx of thoracic aortic aneurysm with chest pain.\n REASON FOR THIS EXAMINATION:\n Eval for evidence of new disection. PLEASE DO WITH MMS PROTOCOL.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old with history of thoracic aortic aneurysm and chest\n pain. Assess for new dissection.\n\n TECHNIQUE: CT of the chest without IV contrast. CT of the chest, abdomen,\n and pelvis after the administration of 90 cc of Optiray. Coronal and sagittal\n reformatted images were obtained.\n\n COMPARISON: .\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: Again seen is extensive Type B\n intramural hematoma from the origin of the subclavian artery through the\n diaphragmatic hiatus and into the upper abdominal aorta proximal to the celiac\n axis. A posterior penetrating ulcer is seen at the level of the diaphragmatic\n hiatus is again visualized. These findings are unchanged. There is no new\n dissection. There is no pulmonary embolus. The lung fields demonstrate\n diffuse patchy areas of ground-glass opacification and mild septal thickening.\n There is a 5 mm nodule in the right lower lobe. There is no focal\n consolidation. The trachea and bronchi are patent to the segmental level.\n Bilateral pleural effusions are unchanged from the prior study. The heart and\n pericardium are unremarkable other than dense coronary calcifications in the\n right, left anterior descending, and circumflex arteries.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a 3.3 x 4.1 cm cyst in the left\n lobe of liver. No other hepatic lesions are identified. There is vicarious\n excretion of contrast into the gallbladder. The spleen, pancreas, adrenals,\n and kidneys are normal. There is no free air or free fluid in the abdomen.\n There is no pathologic lymphadenopathy. Intraabdominal large and small bowel\n are normal. There is a 4 cm infrarenal abdominal aortic aneurysm.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid are unremarkable.\n There is a small amount of free fluid in the pelvis. The uterus is\n unremarkable. There is no lymphadenopathy. There is aneurysmal dilation of\n the left common iliac artery measuring 1.8 cm.\n\n Degenerative changes are seen throughout the thoracic and lumbar spine. Severe\n facet arthropathy are seen at the L4 and L5 levels. Soft tissues are\n unremarkable.\n\n Coronal and sagittal reformatted images confirm the above findings.\n (Over)\n\n 5:12 AM\n CT CHEST W&W/O C ; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Eval for evidence of new disection. PLEASE DO WITH MMS \n Admitting Diagnosis: BACK PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. Unchanged appearance of extensive Type B intramural hematoma from the\n subclavian artery origin to the upper abdominal aorta. The associated\n posterior penetrating ulcer at the diaphragmatic hiatus is stable. No new\n dissection.\n\n 2. Findings suggestive of congestive failure/volume overload with bilateral\n pleural effusions and septal thickening.\n\n 3. Four-cm infrarenal abdominal aortic aneurysm.\n\n 4. Mild aneurysmal dilation of the left common iliac artery.\n\n 5. Dense coronary vascular calcifications.\n\n"},{"category":"Radiology","chartdate":"2178-11-16 00:00:00.000","description":"DISTINCT PROCEDURAL SERVICE","row_id":930902,"text":" 6:24 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Pls perform Doppler U/S to evaluate for RAST in pt with \n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with thoracic aortic hematoma and HTN requiring IV drips to\n control.\n REASON FOR THIS EXAMINATION:\n Pls perform Doppler U/S to evaluate for RAST in pt with persistent HTN on\n nipride and labetolol drips.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with thoracic aortic hematoma, hypertension.\n Evaluate for renal artery stenosis.\n\n COMPARISON: None.\n\n FINDINGS: Right kidney measures 10.4 cm. Left kidney measures 10.7 cm. No\n evidence of hydronephrosis or stones. Arterial upstrokes with diastolic flow\n are seen within the mid and lower pole parenchymal branches of both kidneys,\n with resistive indices ranging from 0.65 to 0.70. Upper pole branches are not\n definitely seen bilaterally. Study was somewhat limited by the patient's\n respirations. Arterial upstrokes with diastolic flow are seen within the\n renal arteries bilaterally, venous waveforms are identified within the renal\n veins bilaterally.\n\n IMPRESSION: Normal arterial and venous waveforms seen within the main renal\n arteries and veins bilaterally. Good flow demonstrated within parenchymal\n branches of the mid and lower poles bilaterally, upper pole is not well\n visualized secondary to patient respiration.\n\n"},{"category":"Radiology","chartdate":"2178-11-23 00:00:00.000","description":"CTA ABD W&W/O C & RECONS","row_id":931805,"text":" 5:43 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS\n Reason: pt with chronic thoracic AAA / with penetrating ulcer\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with AAA\n REASON FOR THIS EXAMINATION:\n pt with chronic thoracic AAA / with penetrating ulcer\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AAA with penetrating ulcer.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast and contrast-enhanced axial CT imaging of the chest,\n abdomen and pelvis was reviewed.\n\n CT CHEST WITH CONTRAST: There has been no marked interval change from , , with again demonstrated type B intramural hematoma extending from\n the subclavian artery through the diaphragmatic hiatus into the upper abdomen\n proximal to the celiac axis. A posterior penetrating ulcer is again noted at\n the level of the diaphragmatic hiatus, but unchanged in size and character.\n The diffuse patchy areas of ground-glass opacification are again noted within\n the lungs with note of a 5-mm nodule in the right lower lobe. The heart and\n pericardium are otherwise unremarkable except for dense coronary artery\n calcifications.\n\n CT ABDOMEN WITH CONTRAST: A 4-cm cyst in the left lobe of the liver is\n unchanged. Gallbladder, pancreas, spleen, adrenals, and kidneys are\n unremarkable. There is no free air or free fluid. No pathologic adenopathy\n is identified. 4-cm infrarenal abdominal aortic aneurysm is unchanged.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid, and remaining large bowel is\n unremarkable. The uterus and adnexa are only remarkable for a small calcified\n fibroid. No pathologic adenopathy is identified. Aneurysmal dilation of the\n left common iliac measuring 1.8 cm is unchanged.\n\n BONE WINDOWS: Degenerative changes are again seen throughout the thoracic and\n lumbar spine with prominent degenerative changes at L5-S1.\n\n IMPRESSION:\n 1. Stable appearance of the chest, abdomen and pelvis with type B intramural\n hematoma and associated penetrating ulcer.\n 2. Improving ground-glass opacities.\n 3. Stable 4-cm infrarenal abdominal aortic aneurysm.\n 4. Stable left common iliac artery aneurysm.\n (Over)\n\n 5:43 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS\n Reason: pt with chronic thoracic AAA / with penetrating ulcer\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Nursing/other","chartdate":"2178-11-17 00:00:00.000","description":"Report","row_id":1421827,"text":"NPN (cont'd)\n\nRESP: Lungs with diminished breath sounds throughout. Sats of >96% on 2lnc.\n\nGI: Taking po's well. OOB to BSC, moderate amount of soft, brown, guiac negative stool.\n\nSKIN: Intact.\n\nID: Afebrile.\n\nSOCIAL: Daughter called and pt's sister visited.\n\nPLAN: Continue to follow B/P on increased po medications...goal 120-140/syst.\n Follow up on results of head CT.. check with HO re:medicating further with haldol if indicated\n ?transfer to floor if B/P stable tomorrow.\n\n"},{"category":"Nursing/other","chartdate":"2178-11-18 00:00:00.000","description":"Report","row_id":1421828,"text":"NURSING NOTE 1900HRS - 0400HRS\n\n\nEVENTS...INCREASING AGITATION/HALLUCINATING/ANGRY OUTBURSTS REQUIRING PO/IV MEDS FOR CONTROL AS PATIENT DANGER TO SELF...PULLED OUT FOLEY, REPLACED THEN TAKEN OUT BY RN AS PATIENT KEPT PULLING AT CATHETER...SITTER REQUESTED...\n\n\n\nNEURO..INITLALLY REALTIVELY CALM ORIENTATED TO SELF....ZYPREXA GIVEN AS PATIENT STARTED TO BECOME RESTLESS..NO EFFECT, NO SLEEP THEREFORE SEROQUEL GIVEN WITH NO EFFECT..PATIENT INCREASINGLY AGITATED AND OBVIUOS THAT SHE WAS HALLUCINATING, PICKING AT LINES/POINTING AT THINGS IN THE ROOM... AND IN PARTICULAR FOLEY..PULLED OUT FOLEY THEN REPLACED BUT AGAIN KEPT ATTEMPTING TO PULL OUT FOLEY ? HALLUCINATING AT THIS POINT AND CALLING OUT ? ANGRY AT TRYING HER TO STOP HER FROM ATTEMPTING TO DO THIS...IV HALDOL GIVEN [ BUT CONCERN FOR QTC INTERVAL]..CONTINUED TO INCREASE WITH SYMPTOMS, PATIENT ATTEMPTING TO GET OOB..EVENTUALLY PUT PATIENT INTO CHAIR..SEEN AGAIN BY TEAM, LORAZAPAM ORDERED WITH SOME EFFECT,PRESENTLY PATIENT QUIETER BUT CONTINUES TO PULL AT LINES AND APPEARS TO BE TALKING TO SELF...SITTER ORDERED WILL CONTINUE TO FOLLOW CLOSELY.. NO COMPLAINST OF PAIN OVERNIGHT... HEAD CT NEGATIVE TO ACUTE EPISODE TAKEN LAST PM\n\n\nCVS...B/P CONTROLLED ON PO MEDS 130-140 SYSTOLIC..HR 70-75BPM 1ST DEGREE AV BLOCK..\nHCT STABLE LAST PM..K MG RELETED ASLT PM AS @ 3.6 AND 1.5.. ALL AM LABS PENDING...\nBORDERLINE TEMP @ 100. WILL CONTINUE O OBERVE\nB/S STABLE\n\n\nRESP..SATS @ 95% ON 2/ NC, NOT TOLERTAING N/C WITH AGITATION AT TIMES..\n\n\nGI/U..TAKEN SOME FLUIDS, MOUTH LOOKS DRY, NO BOWEL MOTION...FOLEY AS ABOVE, SO PRESENTLY OUT..NEG BALANCE AT MN, ...TO HAVE ONE REPLACED WHEN APPROPRIATE....\n\n\nSKIN..INTACT...\n\nLINES..PATENT...\n\n\nSOCIAL..DAUGHETER PHONED ASLT PM AND UPDATED..BUT NOT AWARE OF MENTAL STATUS OVERNIGHT...\n\n\n\nPLAN..FOLOW MS CLOSELY AND MEDICATE AS REQUIRED, MONITOR B/P AIM < 140\n\n\n\n"},{"category":"Nursing/other","chartdate":"2178-11-12 00:00:00.000","description":"Report","row_id":1421813,"text":"pt is a 73yo woman arrived via from OSH. pt had Chest ct at OSH and showed thoracic abd aneurism. Pts BP was >250. Pt was initiated on labetalol, nipride and received morphine and zofran for nausea at OSH ED. Pt on arrival to unit was on nipride 4mcg/kg/min, labetalol 2mg/min. Bp was 195/89. pt received 10mg of hydralazine. pt had a-line placed without difficulty. pt arrived with 3 perp IV's. labs were obtained, waiting results. pt appears A+Ox1 unable to give full assessment pt does not speak english. sbp goal 120's\n"},{"category":"Nursing/other","chartdate":"2178-11-13 00:00:00.000","description":"Report","row_id":1421814,"text":"Nursing Progress Note 1900-0700\n\n72 year old female with a PMH of HTN, hypercholesterolemia, hx of thoracic aortic aneurysm, and ? CHF. She was transferred from an OSH for further management of an acute on chronic thoracic aortic dissection. Upon arrival she was on a nipride gtt and a labetolol gtt was started for management of her HTN. CT surgery was consulted and recommended medical RX at this time. CT from outside hosptial showing a Intramural hematoma of descending thoracic aorta.\n\nNeuro: A&Ox3 per family, patient is portugese creole speaking only. She is able to make her needs known by nonverbal cues. Good bed mobility moving all 4 extremities. Pt with c/o back pain at , given 2 mg morphine with good effect.\n\nCardio: Nipride & Labetalol gtt's weaned to off. Systolic BP down to high 90's briefly overnoc. Tele SR 70's with a a significant first degree AV block. PR. 28-.32. Easily palpable PT's bilaterally weakly palpable DP's right weaker than left.\n\nRESP: Lungs with bibasilar crackles otherwise CTA. RR 10-14. Sats 95-100 on 2LNC ABG at 1900 7.44/29/111.\n\nGI: Remains NPO, abdomen soft non tender. + BS in 4 quadrents. No BM this shift. Trace guiac positive by rectal exam. Pt had two episodes of N&V at & 2100 with small amounts of clear thick emesis. Treated with Zofran & Phenagran with good effect.\n\nRenal: UOP decreased with Drop in BP to under 110 systolically (down to 10-20 x 4 hrs) UOP increasing with rise in BP. Urine is clear yellow. 0100 BUN/CREAT 15/0.7\n\nFEN: Mag and K repleted AM labs pending. On sodium Bicarb at 100/hr for one liter D/T large dye load from CT at OSH.\n\nHeme: HCT 28 upon arrival down to 25.2 at 1 AM. AM HCT pending\n\nID: afebrile, no issues\n\nSkin: No issues\n\nSocial: Mutiple family members in to see patient including her sister, husband, , nephew and daughter. Daughter () is to be spokesperson and is HCP. and sister speak minimal english. Family oriented to ICU environment and housestaff reviewed disease process and POC.\n\nPlan:\n\n1. Blood pressure control Goal is SBP between 110 and 130.\n2. Repeat CT scan in 24-48 hours\n3. Monitor UOP, fluid balance\n4. Pain & Nausea meds PRN for patient comfort\n5. NPO ?restart of diet if patient remains stable\n6. Monitor resp status Re: H/O CHF\n7. Routine ICU care and monitoring\n8. Emotional support to patient and family\n\n"},{"category":"Nursing/other","chartdate":"2178-11-13 00:00:00.000","description":"Report","row_id":1421815,"text":"NPN addendeum\n\nRN noticed pt to have irregular HR, EKG done. ? Afib house staff aware. BP stable. HR 70's. Will Continue to monitor\n"},{"category":"Nursing/other","chartdate":"2178-11-13 00:00:00.000","description":"Report","row_id":1421816,"text":"NURSING NOTE 0700HRS - 1600HRS\n\nPATIENT ADMIT FROM OSH ...HX OF THORACIC AORTIC ANUERYSM AND CHF...SHE WAS TRANSFERRED FROM OSH FOR FURTHER MANAGEMENT OF ACUTE BACK PAIN ASLTING FOR 12HRS..CT OVER THERE SUGGESTED ACUTE ON CHRONIC THORACIC AORTIC DISSECTION...PATIENT TRANSFERRED ON NIPRIDE/LABETOLOL FOR B/P > 200, FOR FURTHER MANAGEMENT AND CONSULT...\n\n\n\nEVENTS...OF IV MEDS THIS AM BUT NIPRIDE RE-COMMENCED PM FOR >> SYSTOLIC TO 150..PO MEDS COMMENCED FRO B/P CONTROL BUT D/C AS HR VARAIBLE [ SEE BELOW]...\nFOR MEDICAL MANAGEMENT AT PRESENT OF B/P CONTROL/DISSECTION NOT FOR SURGERY AS HIGH RISK...\nFOR REPEAT CT SCAN TOMORROW TO RE-ASSESS AREA OF CONCERN\n\n\n\nNEURO...DOES NOT OFFICIALLY SPEAK ENGLISH BUT UNDERSTANDS A LITTLE..FAMILY HAVE BEEN HERE TODAY AND HAVE HELPED IN UPDATING HERE AS TO CONDITION AND PLAN OF CARE...C/O BACK PAIN AND HAS RECEIVED IV MORPHINE WITH GOOD EFFECT TODAY...MOVEMENT OF ALL 4 LIMBS AND FEET WARM PULSES DOPPLER\n\n\nCVS...B/P WITHIN PARAMETERS THIS AM [ AIM 120-130 SYSTOLIC, NOT LESS THAN 120 BECAUSE U/O AFFECTED]...THIS PM , WITH STIMULTION AND FAMILY VISIT, BP > 140 THEREFORE NIPRIDE DRIP RE- COMMENCED AND PO BBLOCKER GIVEN , TITRATED UP TO 1.5 FOR CONTROL [ TEAM AWARE AND WILL REVIEW PO MEDS FOR CONTROL]...HR OVERNIGHT 1ST DEGREE AV BLOCK TO AF THIS AM BUT B/P NOT COMPROMISED AND RATE CONTROLLED @ 75, ECHO PERFORMED, C/E STABLE..THIS PM RIVERTED BACK TO 1ST DEGREE AV BLOCK, RATE 75 BUT WITH OCCASSIONAL PAUSE, TEAM AWARE AND NUMEROUS EKG'S TAKEN, IN VIEW OF THIS BBLOCKER D/C...AWAITING TEAM TO RE-REVIEW MEDS...\nAFEBRILE...B/S STABLE, WERE RAISED DURING THE NIGHT...\nHCT DROPPING TO 24.5 [ THRESHOLD 25] THEREORE IS PRESENTLY RECEIVING X1UPRBC... ? CAUSE OF HCT DROP [ Q6HRLY HCT]\n\n\nRESP...XR SHOWS MILD CHF..LUNGS SOUND CLEAR, FEW CRACKLES BASES..SATS @ 100% ON N/C...\n\n\nGI..TAKEN SOME PO DIET/FLUIDS PM, ADBO SOFT...TRACE GHUAIC POS LAST PM...\n\n\nGU..SATISFACTORY U/O , COMPLETED BICARB DRIP..GIVEN TO PROTECT KIDNEYS AS RECEIVED DYE LOAD YESTERDAY DURING CT...BUN/CREAT ..PM K @ 3.3 REPLETED WITH PO K\n\n\nSKIN..INTACT..\n\n\nLINES...X3 PERIPHERAL, ART LINE..\n\n\nPLAN..B/P CONTROL [ 120-130] WITH PO/IV MEDS...OBSERVE HR FOR FURTHER ARRYTHMIAS..AWAIT REPEAT CT TOMORROW...MONITOR HCT Q6 MAINTAIN >25]\n"},{"category":"Nursing/other","chartdate":"2178-11-17 00:00:00.000","description":"Report","row_id":1421824,"text":"NEURO...DAUGHTER SAID LAST PM THAT PATIENT HAD BEEN INTERMITTENTLY HALLUCINATING/CONFUSED /DISORIENTED OVER THE COURSE OF THE DAY..PATIENT SETTLED EARLY LAST PM THEN BECAME RESTLESS/AGITATED/HALLUCINATING [ PICKING AT SELF AND THE BED] AT APPROX 0100HRS...REFUSED PO HALDOL THEREFORE GIVEN IV DOSE OF 1MG TOTAL..BECAME CALMER THE PATIENT C/O LEFT SIDED CHEST PAIN, EKG TAKEN S/L NITRATE GIVEN BUT TOTAL 4 MGS MORPHINE TOOK THE PAIN AWAY...PRESENTLY PATIENT PAINFREE AND AWAITING REPEAT CT CHEST...\nUNDERSTANDS SOME ENGLISH, SPEAKS /CREOLE\n\n\n\nCVS...LABETOLOL DRIPS WEANED TO OF WITH INCRESAED DOSE OF PO MEDS...BUT WITH INCRESAING AGITATAION/PAIN B/P INCREASING TO > 140 [ AIM 120-140] THEREFORE LABETOLOL DRIP RE-COMMENCED FOR CONTROL AND BRIEFLT NIPRIDE..PRESENTLY CONTROLLED 2MGS/MIN LABETOLOL HR 65-67 AND B/P @ 130 SYSTOLIC...\nHCT HAS DROPPED FROM 31 TO 28.9 [ ? RELATED TO DISSECTION] HAS HAD PREVIUOS DROP AND REQUIRED BLOOD...FRESH CROSS MATCH SENT...ALL OTHER AM LABS STABLE\nAFEBRILE..B/S STABLE...\n\n\nRESP..IN VIEW OF NEW CHEST PAIN 2LN/S APPLIED SATS >95%\n"},{"category":"Nursing/other","chartdate":"2178-11-17 00:00:00.000","description":"Report","row_id":1421825,"text":"GI...TAKING ONLY SMALL AMOUNTS OF FOOD..FAMILY HAVE REQUESTED TO BRING FOOD IN [ ADVISED NO SALT]..NO BOWEL MOTION FOR 4 DAYS THEREFORE ON REGIME, SOFT WITH B/S..HCT AS ABOVE, NEED TO GHUAIC STOOL , PREVIUOSLY GHUAIC POS ? FOR GI TO BE INVOLVED AT SOME POINT...\n\n\nGU..RECEIVED 20MGS LASIX YESTERDAY FOR MILD CHF WITH GOOD RESPONSE [ NEG BALANCE]...BUT RECEIVED BOLUS BICARB DRIP PLUS INFUSSION NOW IN PROGRESS FOR PROTECTION OF KIDNEYS POST CT WITH CONTRAST...\n\n\nLINES..NEW PERIPHERAL SIGHTED, ART LINE POSTIONAL BUT DRAWS..\n\n\nSOCIAL..DAUGHTER SPEAKS VERY GOOD ENGLISH AND IS HCP..SHE VISITS DAILY\n\n\n\nCVS...HR IS FIRST DEGREE HB, HAS HAD PREVIUOS EPISODE OF AF [ FRIDAY]..HR HAS SLOWED WITH TRANSITIONING FROM IV TO PO LOPRESSOR..PRESENTLY @ 60 SINUS/1ST DEGREE AV BLOCK...LOPRESSOR PO IS TO BE GIVEN WITH PARAMETERS\n"},{"category":"Nursing/other","chartdate":"2178-11-17 00:00:00.000","description":"Report","row_id":1421826,"text":"MICU 6 Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data. Hypertension now being managed with po meds. Hct has been stable. Pt to head CT for increased confusion, agitation and paranoia.\n\nCNS: Pt. initially assessed at being alert and oriented x 3 via interpreter this AM x 2. She did make some statements about last night \"they were trying to give me too much medication\"...\"they stuck needles in me\" and seemed upset. When her daughter called and spoke to her later in the morning, daughter stated her mother was extremely confused, disoriented and angry. HO notified re:? further haldol. Pt. began to cry out, again appearing angry and distressed. Given .5mg haldol with good effect and was taken for head CT...awaiting results. She is cooperative now, yet still seems somewhat angry.\n\nCVS: Pt. denies any back or chest pain today. CTA from last night unchanged per report. B/P has ranged 120-140/syst, except for a brief increase to 170/ during IV placement. Currently receiving labetolol 300mg qid, narvasc 10mg qd and valsartan 80mg qd also started today. Heart rate in the mid 60's without VEA. Pt. received 20mg lasix IV and is 900cc negative at this writing.\n"},{"category":"Nursing/other","chartdate":"2178-11-15 00:00:00.000","description":"Report","row_id":1421820,"text":"MICU Nursing Progress Note 0700-1900\n\nEvents: Attempted to transition patient to PO Labetelol and off Nipride gtt with some success.\n\nNeuro: Pt alert and oriented x 3, OOB to chair for approximately 4 hours with an assist of two. Patient able to stand and pivot. Speaks some english but mostly communicates needs through family and gestures. No complaints of pain this shift.\n\nResp: Lungs clear, diminished at bases. No longer on O2. Sats remain above 95%.\n\nCV: HR 63-68, first degree AVB. Afebrile. Pt remains on Nipride gtt currently running at 0.3mcg/kg/min, Labetalol at 4mg/min as well as 300mg PO Labetalol. BP very labile throughout shift. MICU team goal during AM rounds was to wean off Nipride gtt. During shift able to decrease from 1mcg/kg/min to 0.5mcg/kg/min. Pt very sensitive to changes in gtt rate. Goal BP 130-140 systolic. PM crit 30.1 up from 29.3\n\nGI: Pt advanced to regular diet and tolerating well. No complaints of nausea this shift. Please note that family is bringing in food for patient and was made aware by nurse to make sure food from home is low sodium due to increased BP. Colace and PRN Senna added to medications. No stool this shift.\n\nGU: Foley patent and draining light yellow, clear urine. Given 20mg Lasix with good effect, diuresed approximately 1100cc. Fluid goal is slightly negative to a half a liter negative.\n\nSkin: Intact\n\nAccess: 2 PIV, right radial A-line.\n\nEndo: BS QID\n\nSocial: Family in to visit for much of shift, updated on patient's condition. Daughter (HCP) called and updated, will be in this evening.\n\nPlan: Continue to monitor BP and titrate accordingly, wean Nipride gtt as tolerated by patient. Patient/family teaching regarding BP control, importance of compliance to medication regimen.\n"},{"category":"Nursing/other","chartdate":"2178-11-16 00:00:00.000","description":"Report","row_id":1421821,"text":"cv: 72-60 1st degree avb. sbp 106-155/ attmpts to wean nipride to off. unable to get nipride off but did decrease to 0.1 mics/kg/min. goal sbp 130-140.\n\ngi: positive bowel sounds. abdomen soft. no stool.\n\ngu: foley draining clear yellow urine.uo 25-325cc/hr\n\nneuro: moves all extremities to commands. comprehends some english but responds in portuguese.\n\nintegumentary: skin intact.\n\nPain: pt c/o head ache ..medicated with tylenol 650 mg po and morphine 2 mg sc with good effect.pt slept.\n\nlabs: hct stable.see careview for all lab results.\n"},{"category":"Nursing/other","chartdate":"2178-11-16 00:00:00.000","description":"Report","row_id":1421822,"text":"Nursing Note (0700-1900hrs)\n\nPt cont to require IV nipride and labetalol to maintain SBP 130-140's;cont to increase po antihypertensives. Vasc following--feels aortic hematoma does not explain Hct drop. Prob from GI sources with hx of coffee ground emesis, sm amt and OB+stool on admit.\n\nReview of systems:\nNeuro: A&OX3 per family however appears sl disorientated upon awakening; mentioning to family that she is in her living room then realizes she is wrong; also seeing some ?shadows to daughter's face. Will cont to closely monitor.\n\nCV: Remains in 1st degree AV block, 60-70's. BP elevated early am d/t infiltrated IV upon assessment. Nipride gtt continues to be difficult to wean off completely despite low dose of 0.5mcg/kg/min at this time. Labetalol at 4mg/min. PO labetalol increased to 200mg QID. Amlodipine increased to 10mg. Has right radial aline which is accurate however unable to draw bloods from; site sl tender to touch however discomfort seems r/t position of catheter. PIV to left hand leaking as well, presently has #20 to LLA, site unremarkable. Access good. No ankle edema. Hct, 4pm, stable, 31.1 Vascular cont to follow; aortic dissection is non-operable at this time; may consider stenting if unstable. Mg and potassium repleted this am.\n\nResp; Sl crackles to bases. >95% on RA. Evidence of pulm edema on CXR on admit; given lasix 20mg with fair response; goal of -500 to 1L today.\nGi/GU: NAS/Low chol diet; appetite fair. Some bile/mucous emesis in afternoon--prob r/t po potassium. Abd NTND; complaining of some abd discomfort however pt states LBM 4 days ago; up to commode x2 without results. Senna increased to . Given dose this am. Foley patent for clear yellow urine. GAS.\n\nID: Afebrile. No s/s infection. WBC wnl.\n\nSocial: Daughter and ?sister visiting; updated on condition. Daughter reports that aunt and grandmother both had hx aneurysms that were repaired.\n\nPlan: Cont with wean of nipride gtt first then labetalol gtt as po's increased. Goal for <140. Hct's, GAS; repeat CTA tomorrow. Renal US tonight/tomorrow to assess for renal stenosis. Diuresis. Enc po's--senna this evening. Closely monitor mental status.\n"},{"category":"Nursing/other","chartdate":"2178-11-17 00:00:00.000","description":"Report","row_id":1421823,"text":"NURSING NOTE 1900HRS - 0500HRS\n\nADMIT FROM OSH WITH KNOWN AORTIC DISSECTION , BACK PAIN, CT SHOWED HAEMATOMA ON DISSCETION, NOT CANDIDATE FOR SURGERY [ VASC FOLLOWING] ..BUT BE CANDIDATE FOR STENTING IF PATIENT BECOMES UNSTABLE\n\n\nEVENTS....AGITATED/HALLUCINATING REQUIRED IV HALDOL/... EXPERIENCED SIGNIFICANT LEFT SIDED CHEST PAIN REQUIRING IV MORPHINE AND TO RE-START LABETOLOL DRIP FOR B/P > 140... HCT DROP TO 28.9... IN VIEW OF PAIN/HCT FOR URGENT CT TO REASSESS DISSECTION...\n\n\n"},{"category":"Radiology","chartdate":"2178-12-01 00:00:00.000","description":"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS","row_id":932830,"text":" 10:41 AM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please eval for evidence of aortitis.\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with known thoracic aortic aneurysm with mural wall thrombus\n and ulcer.\n REASON FOR THIS EXAMINATION:\n Please eval for evidence of aortitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for aortitis.\n\n TECHNIQUE: Dedicated thoracic aorta imaging was performed on a 1.5 Tesla\n magnet, including dynamic 3D imaging obtained prior to, during, and after the\n intravenous administration of 0.1 millimole per kilogram of gadolinium-BOPTA.\n\n COMPARISON: Findings are compared with recent prior CT scan dated .\n\n Multiplanar 2D and 3D reformations as well as subtraction images were acquired\n on an independent workstation.\n\n FINDINGS: The abdominal aorta is not included in the current examination.\n\n There is circumferential high T1 signal within the wall of the descending\n aorta that begins after the takeoff of the left subclavian and progresses to\n the inferior most extent of the visualized descending aorta on these images.\n The ascending aorta is noted to be spared. Additionally, post- contrast\n imaging of the aorta demonstrates marked delayed crescentic enhancement of the\n vascular wall surrounding the descending aorta that is involved by this\n intramural hematoma. Findings are compatible with intramural hematoma with\n associated engorgement of the vaso vasorum. Lack of circumferential\n enhancement argues strongly against aortitis.\n There is no evidence for aortic dissection. Evaluation of the aortic hiatus\n again demonstrates a prominent focal penetrating ulcer of the thoracic aorta\n at this level.\n\n Evaluation of the remainder of the visualized viscera is unremarkable except\n for simple liver cyst. No pulmonary emboli are visualized. Scattered\n mediastinal lymphadenopathy is again seen, unchanged.\n\n Multiplanar 2D and 3D reformations as well as subtraction images were\n essential in demonstrating multiple perspectives for this dynamic series.\n\n IMPRESSION:\n\n 1. Again seen is an extensive type B intramural hematoma extending from the\n takeoff of the left subclavian artery through the entire visualized thoracic\n and upper abdominal aorta. Additionally noted on the current exam is marked\n delayed crescentic enhancement of the entire aortic wall in the region\n affected by the intramural hematoma, compatible with associated engorgement of\n (Over)\n\n 10:41 AM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please eval for evidence of aortitis.\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the vaso vasorum. Lack of circumferential enhancement argues strongly against\n aortitis.\n\n 2. Abdominal aortic aneurysm is not included in the images of this study and\n has not evaluated.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2178-11-15 00:00:00.000","description":"Report","row_id":1421819,"text":"Nursing progress notes\nReview of systems:\n\nNeuro: pt alert and oriented per familly (pt speaks creole and some english) she can communicate her needs by using hand gestures and little broken english. mae. pt c/o of head ache early this am at 0300 tylenol 650mg po given w/ good effect. pt denied back and abdominal pain. pt has slept most of shift.\n\nResp: pt ls clear w/ diminished bases o2 on at 2liters sats 99-100%\n\nCv: tele sr 62-80 pt on nipride gtt currently at 1.1mcq/kg/min and labetolol gtt at 4mg/min. her bld pressure has been labile throughout shift. micu resident aware and recommended that staff increase labetolol gtt instead of nipride gtt. goal for bp 120-130. hct 28.7 and this am 29.3, k+ 4.1 mg 1.8. Hrt sounds S1S2 w/ systolic murmur. pedal pulses +3 w/ post tibs +2. per vascular, pt may go to OR for bypass if acutely unstable and pt agrees, if pt remains and off of gtts she may go for a stent sometime this week.\n\nGI: pt is npo however had sips of water w/ meds. pt became nauseous this am at 0200 anzemet 12.5mg ivp given w/ good effect. \u0013no sx planned, pt should be able to take po today as tolerates. abd soft bs+ no stool this shift\n\ngU: foley draining 25-125cc/hr\n\nskin: intact\n\naccess: #14 rfa , #20 left hand , right radial aline, it is positional, but still corolates w/ nibp, however it does not draw bld back.\n\nsocial: daughter and pt's sister stayed until 2200 all questions answered. emotional support given.\n\ncode: full\n\nendo: bs 122 no insulin needed\n\nPlan:\n\ncont to draw q 4hr hcts\ntitrate nipride and labetolol gtts for sbp 120-130\nadminister ms/diludid for pain\nobtain diet order\ngive emotional support to family and pt\nmay need to rewire or resite aline.\n"},{"category":"Nursing/other","chartdate":"2178-11-18 00:00:00.000","description":"Report","row_id":1421829,"text":"MICU 6 Nursing Progress Note (0700-\n\nMrs. is a 72 year old () speaking woman admitted from OSH with sudden onset of back pain, N/V, and HTN (240/120). Pt. has hx of HTN/CHF/hypercholesterolemia along with hx of thoracic aortic aneurysm.\nTreated with labetolol and nipride gtts (goal 100-140/syst). CTA with evidence of intramural hematoma in descending thoracic aorta without evidence of dissection. Not a surgical candidate as spinal circulation would be compromised. Ruled out for an MI per enzymes. Hct drop initially to 24.7(from 28) and pt received 1UPRBC without appropriate bump. No increase in size of hematoma on CT. Stools were initially guiac positive.\nPO labetolol was started and gtts were weaned off by . Pt also received another 2UPRBC's and Hct has been stable since. +CHF, treated with lasix. CT repeated early AM due to chest and back pain...no changes.\nRecent problems have included worsening mental status with hallucinations, agitation and delirium (negative head CT). Pt. did spike a temp to 101 rectally today. BC x 2 and urine cultures sent. Pt. received one dose of vanco and one dose of ceftriaxone. LP done. Sitter and family at the bedside.\n\nCNS: Pt. very confused as to time and place per family. She is hallucinating, pointing and \"picking\" at sheets, etc. She is able to follow simple commands and MAE's. Haldol ordered prn, but has not yet been given as she is much better with family and friends at the bedside. Wrist restraints were initially applied for safety and have been removed with family present.\n\nCVS: Blood pressure under good control on labetolol 300mg qid/norvasc and valsartan. SBP generally 110-140/. Heart rate in the 60's, NSR without VEA. Denies any chest pain or SOB.\n\nRESP: Sats of 98% on room air. Lungs with diminished breath sounds throughout. (difficulty in obtaining consistent sat due to agitation).\n\nID: T max of 101 rectally (?cause for MS changes). BC x 2, urine sent. CXR done along with LP. pt. also received vanco and ceftriaxone x 1. Given tylenol 650mg po also.\n\nF and E: Inaccurate I and O's as pt. was incontinent this AM until foley was replaced. To receive 500cc IVF post LP.\n\nRENAL: Clear, light yellow urine via foley.\n\nGI: Taking po's well, needs to be fed. (soft solids as she will not keep dentures in). Please hold senna and colace due to large, loose stools x 3.\n\nSKIN: Intact.\n\nLINES; ART line present, pt. also has 2 peripheral IV's.\n\nSOCIAL: Multiple family members in...very helpful with translation and in keeping pt. calm.\n\nPLAN: Follow mental status and maintain pt. safety.\n Follow B/P with goal SBP 100-140/.\n Follow for any evidence of bleeding.\n Follow up on LP, culture results.\n"},{"category":"Nursing/other","chartdate":"2178-11-18 00:00:00.000","description":"Report","row_id":1421830,"text":"Addendum: No fluids post LP due to evidence of volume overload on CXR. Surgery in to see pt. and spoke with daughter re:possibility of stenting procedure to aorta on Friday. Pt's daughter understands and is agreeable to procedure.\n"},{"category":"Nursing/other","chartdate":"2178-11-19 00:00:00.000","description":"Report","row_id":1421831,"text":"NSG 7PM-7AM\nPLEASE REFER TO CAREVIEW FOR OTHER OBJECTIVE DATA.\n\n72 YR SPEAKING FEMALE WITH HX OF HTN, HYPERCHOLES, CHRONIC THORACIC AORTIC ANEURYSM, PRESENTS TO OSH WITH ACUTE ONSET OF BACK PAIN ASSOCIATED WITH N/V. AT OSH PT WAS FOUND TO HAVE B/P 240/120/ CT SUGGESTIVE OF ACUTE ON CHRONIC THORACIC ANEURYSM/ TRANSFERRED TO FOR FURTHER MANAGEMENT.\n\n REPORTED ACUTE ONSET OF AGITATION AND HALLUCINATIONS OF UNKNOWN ETIOLOGY ON / RECEIVED ZYPREXA, SEROQUEL, HALDOL. PT RECEIVED MILDLY AGITATED, CONFUSED, DISORIENTED TO TIME, PLACE. REORIENTED AND REASSURED PER STAFF AND FAMILY MEMBER. PRESENTLY PT ASLEEP/ HAS BEEN ASLEEP FOR MOST OF SHIFT. NO EPISODE OF ACUTE AGITATION, HALLUCINATIONS/ THOUGH, PT STILL CONFUSED AND DISORIENTED/ REQUIRES SITTER FOR 1:1 SUPERVISION.\n\nHEART RYTHM SINUS/ 1ST DEGREE AVBLOCK/ HR IN 70S NO ECTOPY. ABP 120-160S/ TRENDS DOWN TO 90S WHILE PT ASLEEP/ 0200 LABETALOL DOSE HELD PER PARAMETER/ TEAM AWARE. CHEST XRAY POS FOR PULM EDEMA/ REMAINS ON LASIX DAILY/ UOP 10-80CC/HR/ 24 HR FLUID BALANCE NEG 575ML AT MN/ WITH LOS POS 1092ML.\n PAN CX/ ANTBX ON . T.MAX: 101.7/ TYLENOL 650MG GIVEN THIS SHIFT. CURRENT T:98.9/ WBC:5.8. BLOOD, URINE, SPINAL FLUID CX PENDING. SPINAL FLUID GRAM STAIN SHOWS NO LEUKOCYTES.\nHEAD CT ON NEG FOR HEMORRHAGE/ CHEST CT POS FOR INTRAMURAL HEMATOMA FROM THE SUBCLAVIAN ARTERY.\n\nRESP EFFORT UNLABORED AND EVEN/ LUNG SOUNDS DIMINISHED THROUGHOUT/ SATO2 92-96% ON RA. NON PRODUCTIVE COUGH AT TIME/ UNABLE TO OBTAIN SPUTUM FOR CX.\n\nABD SOFT POS BS/ SMEAR LBM. SENNA AND COLACE HELD FOR REPORTED LBMS PER PREVIOUS SHIFT. TOLERATES PO/ NO N/V.\n\nFOLEY PATENT DRAINING CLEAR URINE.\n\nSKIN W/D/I. ENCOURAGED REPOS. LP SITE COVERED WITH BANDAID/ NO DRAINAGE. PIVX1/ ALINE INTACT.\n\nFAMILY VISITED/INVOLVED IN HELPING REORIENTATING AND REASSURING PT.\n\nFOLLOW MENT STATUS/ MAINTAIN SAFETY/REMAINS RESTRAINED.\nFOLLOW BP/MAINTAIN GOAL 100-140\nFOLLOW TEMP CURVE/ FOLLOW SF AND OTHER CX.\nCOLLECT SPUTUM FOR CX IF POSS.\nPOSS AORTIC STENTING ON FRIDAY\n\n"},{"category":"Nursing/other","chartdate":"2178-11-19 00:00:00.000","description":"Report","row_id":1421832,"text":"MICU UPDATE and transfer note:\n\nFoley and Right Rad A-line d/c'd this AM. Report given to , RN on VICU at 1545. PT. tx'd to VICU via wheelchair and telementry in stable condition at 1600.\n"},{"category":"Nursing/other","chartdate":"2178-11-14 00:00:00.000","description":"Report","row_id":1421817,"text":"npn 1900-0700\n\n Mrs received a unit of blood that finished early yesterday evening. A crit was drawn @ 2100 that did not bump appropriately.Pt ordered for a CT angio of her chest which was completed at 0300. It showed a hematoma. During this period pt has become very unstable; her BP has been as high as 200/100. Nipride gtt is maxed at 10mcg/kg/min. Labetolol has been initiated at 2mg/min. Crit drawn at 0345 has dropped again to 23.9. Is typed and crossed for 4 units. EKG done. VAscular surgery is at the bedside evaluating the patient. MICU intern and resident at bedside and have spoken with the ICU overnight attending. *** Patient is having a lot of abdominal pain-- a new finding.*** She has received many doses of IV morphine since 0400 and they seem to have little effect.\n\nThis RN called pt daughter at 0410 and requested that she come in. She lives ~90 minutes away and is on her way here.\n\nneuro: Pt is speaking and seems to be oriented, she speaks some English. Is able to folllow commands and MAE on the bed.\n\nresp: 2L nc. LS clear and diminished at the bases.\n\ncv: 1 degree AVB (not a new finding). Hypertensive as described above. Labetolol and nipride gtts. Goal BP 130-140. Very difficult to achieve at this point. Dopplerable pedal pulses.\n\naccess: 3 piv. R radial aline.\n\ngi/gu: Pt is now NPO for ? surgery. Patent foley.\n\nSkin: No issues.\n\nEndo: BS QID.\n\nPlan: Vascular team is evalusting CT images, dtr is on her way in, transfuse with 2 units cells.\n\n\n"},{"category":"Nursing/other","chartdate":"2178-11-14 00:00:00.000","description":"Report","row_id":1421818,"text":"MICU Nursing Progress Note 0700-1900\n\nEvents - Pt's BP extremely labile, crit of 28.7 after 2 units PRBCs.\n\nNeuro - Pt A&Ox3, MAE, follows commands. Complained of moderate/severe headache x2 (pain ranging about ). Given morphine and dilaudid for pain, which was relieved but pt did experience some nausea and vomiting. Consider asking team for Tylenol, pt appears to be sensitive to narcotics. No complaints of abdominal pain.\n\nResp - Pt on 2L NC. Lung sounds clear but diminished in bases. Breathing pattern regular and unlabored.\n\nCV - Pt is in first degree AVB. BP continues to be labile, ranging from 190-90/90-50. Goal BP systolic 130-140's. Pt very sensitive to movement and changes in gtt rate. Nipride currently running at 1mcg/kg/min, Labetalol at 2mg/min. Crit after 2 units PRBCs 28.7. Evaluated by Vascular Surgery team and was determined not to be a candidate for surgery at this time.\n\nGI - Pt still NPO, awaiting okay from MICU team to advance diet if surgery is not planned. Bowel sounds present. No stool this shift.\n\nGU - Foley patent and draining clear, yellow urine.\n\nSkin - Intact.\n\nEndo - BS QID.\n\nAccess - 2 PIV, one changed due to left AC infiltration.\n\nSocial - Daughter and extended family in with patient for most of shift. Updated on patient's condition by Dr. .\n\nPlan - Continue to monitor BP, hematocrit, any s/s of bleeding.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2178-11-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 81920,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Hypertension. Left ventricular function.\\nHeight: (in) 68\\nWeight (lb): 154\\nBSA (m2): 1.83 m2\\nBP (mm Hg): 133/62\\nHR (bpm): 80\\nStatus: Inpatient\\nDate/Time: at 16:38\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size. Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dynamic interatrial\\nseptum. Aneurysmal interatrial septum.\\n\\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\\nregional LV systolic function. Overall normal LVEF (>55%).\\n\\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\\nsystolic function.\\n\\nAORTA: Moderately dilated aortic root. Mildly dilated ascending aorta. Mildly\\ndilated aortic arch. Mildly dilated descending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\\ncalcification. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Physiologic\\nTR. Indeterminate PA systolic pressure.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\n1. The left atrium is normal in size. The left atrium is elongated. The\\ninteratrial septum is aneurysmal.\\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\\nsize is normal. Regional left ventricular wall motion is normal. Overall left\\nventricular systolic function is normal (LVEF>55%).\\n3.Right ventricular chamber size is normal. Right ventricular systolic\\nfunction is normal.\\n4.The aortic root is moderately dilated. The ascending aorta is mildly\\ndilated. The aortic arch is mildly dilated. The descending thoracic aorta is\\nmildly dilated.\\n5.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\\nis seen.\\n6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\\nis seen.\\n7.The pulmonary artery systolic pressure could not be determined.\\n8.There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-11-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208684,\n \"text\": \"Sinus rhythm. A-V conduction delay and A-V nodal Wenckebach. Diffuse\\nnon-specific ST-T wave flattening.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-11-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208685,\n \"text\": \"Sinus rhythm. A-V nodal Wenckebach block. Left ventricular hypertrophy.\\nNon-specific ST-T wave changes. No previous tracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-11-28 00:00:00.000\",\n \"description\": \"R HUMERUS (AP & LAT) RIGHT\",\n \"row_id\": 932507,\n \"text\": \" 2:33 PM\\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT; HUMERUS (AP & LAT) RIGHTClip # \\n Reason: r/o fx\\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with right shoulder pain s/p trauma\\n REASON FOR THIS EXAMINATION:\\n r/o fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n RIGHT SHOULDER, FOUR VIEWS, RIGHT HUMERUS, TWO VIEWS, AT\\n 14:02 HOURS.\\n\\n HISTORY: Status post trauma.\\n\\n COMPARISON: None.\\n\\n FINDINGS: There is severe global osteopenia. There is no fracture or\\n dislocation. The glenohumeral and acromioclavicular articulations are within\\n normal limits. The coracoclavicular interval is appropriate. The regional\\n soft tissues of the upper arm are unremarkable. The visualized adjacent lung\\n is clear.\\n\\n IMPRESSION: Severe diffuse osteopenia, likely secondary to osteoporosis.\\n Given the severity of the osteopenia, the sensitivity is decreased for\\n detecting subtle nondisplaced fracture.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-11-17 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 930919,\n \"text\": \" 5:12 AM\\n CT CHEST W&W/O C ; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: Eval for evidence of new disection. PLEASE DO WITH MMS \\n Admitting Diagnosis: BACK PAIN\\n Field of view: 36 Contrast: OPTIRAY Amt: 110\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with hx of thoracic aortic aneurysm with chest pain.\\n REASON FOR THIS EXAMINATION:\\n Eval for evidence of new disection. PLEASE DO WITH MMS PROTOCOL.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old with history of thoracic aortic aneurysm and chest\\n pain. Assess for new dissection.\\n\\n TECHNIQUE: CT of the chest without IV contrast. CT of the chest, abdomen,\\n and pelvis after the administration of 90 cc of Optiray. Coronal and sagittal\\n reformatted images were obtained.\\n\\n COMPARISON: .\\n\\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: Again seen is extensive Type B\\n intramural hematoma from the origin of the subclavian artery through the\\n diaphragmatic hiatus and into the upper abdominal aorta proximal to the celiac\\n axis. A posterior penetrating ulcer is seen at the level of the diaphragmatic\\n hiatus is again visualized. These findings are unchanged. There is no new\\n dissection. There is no pulmonary embolus. The lung fields demonstrate\\n diffuse patchy areas of ground-glass opacification and mild septal thickening.\\n There is a 5 mm nodule in the right lower lobe. There is no focal\\n consolidation. The trachea and bronchi are patent to the segmental level.\\n Bilateral pleural effusions are unchanged from the prior study. The heart and\\n pericardium are unremarkable other than dense coronary calcifications in the\\n right, left anterior descending, and circumflex arteries.\\n\\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a 3.3 x 4.1 cm cyst in the left\\n lobe of liver. No other hepatic lesions are identified. There is vicarious\\n excretion of contrast into the gallbladder. The spleen, pancreas, adrenals,\\n and kidneys are normal. There is no free air or free fluid in the abdomen.\\n There is no pathologic lymphadenopathy. Intraabdominal large and small bowel\\n are normal. There is a 4 cm infrarenal abdominal aortic aneurysm.\\n\\n CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid are unremarkable.\\n There is a small amount of free fluid in the pelvis. The uterus is\\n unremarkable. There is no lymphadenopathy. There is aneurysmal dilation of\\n the left common iliac artery measuring 1.8 cm.\\n\\n Degenerative changes are seen throughout the thoracic and lumbar spine. Severe\\n facet arthropathy are seen at the L4 and L5 levels. Soft tissues are\\n unremarkable.\\n\\n Coronal and sagittal reformatted images confirm the above findings.\\n (Over)\\n\\n 5:12 AM\\n CT CHEST W&W/O C ; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: Eval for evidence of new disection. PLEASE DO WITH MMS \\n Admitting Diagnosis: BACK PAIN\\n Field of view: 36 Contrast: OPTIRAY Amt: 110\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n IMPRESSION:\\n\\n 1. Unchanged appearance of extensive Type B intramural hematoma from the\\n subclavian artery origin to the upper abdominal aorta. The associated\\n posterior penetrating ulcer at the diaphragmatic hiatus is stable. No new\\n dissection.\\n\\n 2. Findings suggestive of congestive failure/volume overload with bilateral\\n pleural effusions and septal thickening.\\n\\n 3. Four-cm infrarenal abdominal aortic aneurysm.\\n\\n 4. Mild aneurysmal dilation of the left common iliac artery.\\n\\n 5. Dense coronary vascular calcifications.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-11-16 00:00:00.000\",\n \"description\": \"DISTINCT PROCEDURAL SERVICE\",\n \"row_id\": 930902,\n \"text\": \" 6:24 PM\\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \\n DUPLEX DOP ABD/PEL LIMITED\\n Reason: Pls perform Doppler U/S to evaluate for RAST in pt with \\n Admitting Diagnosis: BACK PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with thoracic aortic hematoma and HTN requiring IV drips to\\n control.\\n REASON FOR THIS EXAMINATION:\\n Pls perform Doppler U/S to evaluate for RAST in pt with persistent HTN on\\n nipride and labetolol drips.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 72-year-old woman with thoracic aortic hematoma, hypertension.\\n Evaluate for renal artery stenosis.\\n\\n COMPARISON: None.\\n\\n FINDINGS: Right kidney measures 10.4 cm. Left kidney measures 10.7 cm. No\\n evidence of hydronephrosis or stones. Arterial upstrokes with diastolic flow\\n are seen within the mid and lower pole parenchymal branches of both kidneys,\\n with resistive indices ranging from 0.65 to 0.70. Upper pole branches are not\\n definitely seen bilaterally. Study was somewhat limited by the patient's\\n respirations. Arterial upstrokes with diastolic flow are seen within the\\n renal arteries bilaterally, venous waveforms are identified within the renal\\n veins bilaterally.\\n\\n IMPRESSION: Normal arterial and venous waveforms seen within the main renal\\n arteries and veins bilaterally. Good flow demonstrated within parenchymal\\n branches of the mid and lower poles bilaterally, upper pole is not well\\n visualized secondary to patient respiration.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-11-23 00:00:00.000\",\n \"description\": \"CTA ABD W&W/O C & RECONS\",\n \"row_id\": 931805,\n \"text\": \" 5:43 PM\\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: pt with chronic thoracic AAA / with penetrating ulcer\\n Admitting Diagnosis: BACK PAIN\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with AAA\\n REASON FOR THIS EXAMINATION:\\n pt with chronic thoracic AAA / with penetrating ulcer\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: AAA with penetrating ulcer.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Non-contrast and contrast-enhanced axial CT imaging of the chest,\\n abdomen and pelvis was reviewed.\\n\\n CT CHEST WITH CONTRAST: There has been no marked interval change from , , with again demonstrated type B intramural hematoma extending from\\n the subclavian artery through the diaphragmatic hiatus into the upper abdomen\\n proximal to the celiac axis. A posterior penetrating ulcer is again noted at\\n the level of the diaphragmatic hiatus, but unchanged in size and character.\\n The diffuse patchy areas of ground-glass opacification are again noted within\\n the lungs with note of a 5-mm nodule in the right lower lobe. The heart and\\n pericardium are otherwise unremarkable except for dense coronary artery\\n calcifications.\\n\\n CT ABDOMEN WITH CONTRAST: A 4-cm cyst in the left lobe of the liver is\\n unchanged. Gallbladder, pancreas, spleen, adrenals, and kidneys are\\n unremarkable. There is no free air or free fluid. No pathologic adenopathy\\n is identified. 4-cm infrarenal abdominal aortic aneurysm is unchanged.\\n\\n CT PELVIS WITH CONTRAST: The rectum, sigmoid, and remaining large bowel is\\n unremarkable. The uterus and adnexa are only remarkable for a small calcified\\n fibroid. No pathologic adenopathy is identified. Aneurysmal dilation of the\\n left common iliac measuring 1.8 cm is unchanged.\\n\\n BONE WINDOWS: Degenerative changes are again seen throughout the thoracic and\\n lumbar spine with prominent degenerative changes at L5-S1.\\n\\n IMPRESSION:\\n 1. Stable appearance of the chest, abdomen and pelvis with type B intramural\\n hematoma and associated penetrating ulcer.\\n 2. Improving ground-glass opacities.\\n 3. Stable 4-cm infrarenal abdominal aortic aneurysm.\\n 4. Stable left common iliac artery aneurysm.\\n (Over)\\n\\n 5:43 PM\\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \\n CTA PELVIS W&W/O C & RECONS\\n Reason: pt with chronic thoracic AAA / with penetrating ulcer\\n Admitting Diagnosis: BACK PAIN\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421827,\n \"text\": \"NPN (cont'd)\\n\\nRESP: Lungs with diminished breath sounds throughout. Sats of >96% on 2lnc.\\n\\nGI: Taking po's well. OOB to BSC, moderate amount of soft, brown, guiac negative stool.\\n\\nSKIN: Intact.\\n\\nID: Afebrile.\\n\\nSOCIAL: Daughter called and pt's sister visited.\\n\\nPLAN: Continue to follow B/P on increased po medications...goal 120-140/syst.\\n Follow up on results of head CT.. check with HO re:medicating further with haldol if indicated\\n ?transfer to floor if B/P stable tomorrow.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421828,\n \"text\": \"NURSING NOTE 1900HRS - 0400HRS\\n\\n\\nEVENTS...INCREASING AGITATION/HALLUCINATING/ANGRY OUTBURSTS REQUIRING PO/IV MEDS FOR CONTROL AS PATIENT DANGER TO SELF...PULLED OUT FOLEY, REPLACED THEN TAKEN OUT BY RN AS PATIENT KEPT PULLING AT CATHETER...SITTER REQUESTED...\\n\\n\\n\\nNEURO..INITLALLY REALTIVELY CALM ORIENTATED TO SELF....ZYPREXA GIVEN AS PATIENT STARTED TO BECOME RESTLESS..NO EFFECT, NO SLEEP THEREFORE SEROQUEL GIVEN WITH NO EFFECT..PATIENT INCREASINGLY AGITATED AND OBVIUOS THAT SHE WAS HALLUCINATING, PICKING AT LINES/POINTING AT THINGS IN THE ROOM... AND IN PARTICULAR FOLEY..PULLED OUT FOLEY THEN REPLACED BUT AGAIN KEPT ATTEMPTING TO PULL OUT FOLEY ? HALLUCINATING AT THIS POINT AND CALLING OUT ? ANGRY AT TRYING HER TO STOP HER FROM ATTEMPTING TO DO THIS...IV HALDOL GIVEN [ BUT CONCERN FOR QTC INTERVAL]..CONTINUED TO INCREASE WITH SYMPTOMS, PATIENT ATTEMPTING TO GET OOB..EVENTUALLY PUT PATIENT INTO CHAIR..SEEN AGAIN BY TEAM, LORAZAPAM ORDERED WITH SOME EFFECT,PRESENTLY PATIENT QUIETER BUT CONTINUES TO PULL AT LINES AND APPEARS TO BE TALKING TO SELF...SITTER ORDERED WILL CONTINUE TO FOLLOW CLOSELY.. NO COMPLAINST OF PAIN OVERNIGHT... HEAD CT NEGATIVE TO ACUTE EPISODE TAKEN LAST PM\\n\\n\\nCVS...B/P CONTROLLED ON PO MEDS 130-140 SYSTOLIC..HR 70-75BPM 1ST DEGREE AV BLOCK..\\nHCT STABLE LAST PM..K MG RELETED ASLT PM AS @ 3.6 AND 1.5.. ALL AM LABS PENDING...\\nBORDERLINE TEMP @ 100. WILL CONTINUE O OBERVE\\nB/S STABLE\\n\\n\\nRESP..SATS @ 95% ON 2/ NC, NOT TOLERTAING N/C WITH AGITATION AT TIMES..\\n\\n\\nGI/U..TAKEN SOME FLUIDS, MOUTH LOOKS DRY, NO BOWEL MOTION...FOLEY AS ABOVE, SO PRESENTLY OUT..NEG BALANCE AT MN, ...TO HAVE ONE REPLACED WHEN APPROPRIATE....\\n\\n\\nSKIN..INTACT...\\n\\nLINES..PATENT...\\n\\n\\nSOCIAL..DAUGHETER PHONED ASLT PM AND UPDATED..BUT NOT AWARE OF MENTAL STATUS OVERNIGHT...\\n\\n\\n\\nPLAN..FOLOW MS CLOSELY AND MEDICATE AS REQUIRED, MONITOR B/P AIM < 140\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421813,\n \"text\": \"pt is a 73yo woman arrived via from OSH. pt had Chest ct at OSH and showed thoracic abd aneurism. Pts BP was >250. Pt was initiated on labetalol, nipride and received morphine and zofran for nausea at OSH ED. Pt on arrival to unit was on nipride 4mcg/kg/min, labetalol 2mg/min. Bp was 195/89. pt received 10mg of hydralazine. pt had a-line placed without difficulty. pt arrived with 3 perp IV's. labs were obtained, waiting results. pt appears A+Ox1 unable to give full assessment pt does not speak english. sbp goal 120's\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421814,\n \"text\": \"Nursing Progress Note 1900-0700\\n\\n72 year old female with a PMH of HTN, hypercholesterolemia, hx of thoracic aortic aneurysm, and ? CHF. She was transferred from an OSH for further management of an acute on chronic thoracic aortic dissection. Upon arrival she was on a nipride gtt and a labetolol gtt was started for management of her HTN. CT surgery was consulted and recommended medical RX at this time. CT from outside hosptial showing a Intramural hematoma of descending thoracic aorta.\\n\\nNeuro: A&Ox3 per family, patient is portugese creole speaking only. She is able to make her needs known by nonverbal cues. Good bed mobility moving all 4 extremities. Pt with c/o back pain at , given 2 mg morphine with good effect.\\n\\nCardio: Nipride & Labetalol gtt's weaned to off. Systolic BP down to high 90's briefly overnoc. Tele SR 70's with a a significant first degree AV block. PR. 28-.32. Easily palpable PT's bilaterally weakly palpable DP's right weaker than left.\\n\\nRESP: Lungs with bibasilar crackles otherwise CTA. RR 10-14. Sats 95-100 on 2LNC ABG at 1900 7.44/29/111.\\n\\nGI: Remains NPO, abdomen soft non tender. + BS in 4 quadrents. No BM this shift. Trace guiac positive by rectal exam. Pt had two episodes of N&V at & 2100 with small amounts of clear thick emesis. Treated with Zofran & Phenagran with good effect.\\n\\nRenal: UOP decreased with Drop in BP to under 110 systolically (down to 10-20 x 4 hrs) UOP increasing with rise in BP. Urine is clear yellow. 0100 BUN/CREAT 15/0.7\\n\\nFEN: Mag and K repleted AM labs pending. On sodium Bicarb at 100/hr for one liter D/T large dye load from CT at OSH.\\n\\nHeme: HCT 28 upon arrival down to 25.2 at 1 AM. AM HCT pending\\n\\nID: afebrile, no issues\\n\\nSkin: No issues\\n\\nSocial: Mutiple family members in to see patient including her sister, husband, , nephew and daughter. Daughter () is to be spokesperson and is HCP. and sister speak minimal english. Family oriented to ICU environment and housestaff reviewed disease process and POC.\\n\\nPlan:\\n\\n1. Blood pressure control Goal is SBP between 110 and 130.\\n2. Repeat CT scan in 24-48 hours\\n3. Monitor UOP, fluid balance\\n4. Pain & Nausea meds PRN for patient comfort\\n5. NPO ?restart of diet if patient remains stable\\n6. Monitor resp status Re: H/O CHF\\n7. Routine ICU care and monitoring\\n8. Emotional support to patient and family\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421815,\n \"text\": \"NPN addendeum\\n\\nRN noticed pt to have irregular HR, EKG done. ? Afib house staff aware. BP stable. HR 70's. Will Continue to monitor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421816,\n \"text\": \"NURSING NOTE 0700HRS - 1600HRS\\n\\nPATIENT ADMIT FROM OSH ...HX OF THORACIC AORTIC ANUERYSM AND CHF...SHE WAS TRANSFERRED FROM OSH FOR FURTHER MANAGEMENT OF ACUTE BACK PAIN ASLTING FOR 12HRS..CT OVER THERE SUGGESTED ACUTE ON CHRONIC THORACIC AORTIC DISSECTION...PATIENT TRANSFERRED ON NIPRIDE/LABETOLOL FOR B/P > 200, FOR FURTHER MANAGEMENT AND CONSULT...\\n\\n\\n\\nEVENTS...OF IV MEDS THIS AM BUT NIPRIDE RE-COMMENCED PM FOR >> SYSTOLIC TO 150..PO MEDS COMMENCED FRO B/P CONTROL BUT D/C AS HR VARAIBLE [ SEE BELOW]...\\nFOR MEDICAL MANAGEMENT AT PRESENT OF B/P CONTROL/DISSECTION NOT FOR SURGERY AS HIGH RISK...\\nFOR REPEAT CT SCAN TOMORROW TO RE-ASSESS AREA OF CONCERN\\n\\n\\n\\nNEURO...DOES NOT OFFICIALLY SPEAK ENGLISH BUT UNDERSTANDS A LITTLE..FAMILY HAVE BEEN HERE TODAY AND HAVE HELPED IN UPDATING HERE AS TO CONDITION AND PLAN OF CARE...C/O BACK PAIN AND HAS RECEIVED IV MORPHINE WITH GOOD EFFECT TODAY...MOVEMENT OF ALL 4 LIMBS AND FEET WARM PULSES DOPPLER\\n\\n\\nCVS...B/P WITHIN PARAMETERS THIS AM [ AIM 120-130 SYSTOLIC, NOT LESS THAN 120 BECAUSE U/O AFFECTED]...THIS PM , WITH STIMULTION AND FAMILY VISIT, BP > 140 THEREFORE NIPRIDE DRIP RE- COMMENCED AND PO BBLOCKER GIVEN , TITRATED UP TO 1.5 FOR CONTROL [ TEAM AWARE AND WILL REVIEW PO MEDS FOR CONTROL]...HR OVERNIGHT 1ST DEGREE AV BLOCK TO AF THIS AM BUT B/P NOT COMPROMISED AND RATE CONTROLLED @ 75, ECHO PERFORMED, C/E STABLE..THIS PM RIVERTED BACK TO 1ST DEGREE AV BLOCK, RATE 75 BUT WITH OCCASSIONAL PAUSE, TEAM AWARE AND NUMEROUS EKG'S TAKEN, IN VIEW OF THIS BBLOCKER D/C...AWAITING TEAM TO RE-REVIEW MEDS...\\nAFEBRILE...B/S STABLE, WERE RAISED DURING THE NIGHT...\\nHCT DROPPING TO 24.5 [ THRESHOLD 25] THEREORE IS PRESENTLY RECEIVING X1UPRBC... ? CAUSE OF HCT DROP [ Q6HRLY HCT]\\n\\n\\nRESP...XR SHOWS MILD CHF..LUNGS SOUND CLEAR, FEW CRACKLES BASES..SATS @ 100% ON N/C...\\n\\n\\nGI..TAKEN SOME PO DIET/FLUIDS PM, ADBO SOFT...TRACE GHUAIC POS LAST PM...\\n\\n\\nGU..SATISFACTORY U/O , COMPLETED BICARB DRIP..GIVEN TO PROTECT KIDNEYS AS RECEIVED DYE LOAD YESTERDAY DURING CT...BUN/CREAT ..PM K @ 3.3 REPLETED WITH PO K\\n\\n\\nSKIN..INTACT..\\n\\n\\nLINES...X3 PERIPHERAL, ART LINE..\\n\\n\\nPLAN..B/P CONTROL [ 120-130] WITH PO/IV MEDS...OBSERVE HR FOR FURTHER ARRYTHMIAS..AWAIT REPEAT CT TOMORROW...MONITOR HCT Q6 MAINTAIN >25]\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421824,\n \"text\": \"NEURO...DAUGHTER SAID LAST PM THAT PATIENT HAD BEEN INTERMITTENTLY HALLUCINATING/CONFUSED /DISORIENTED OVER THE COURSE OF THE DAY..PATIENT SETTLED EARLY LAST PM THEN BECAME RESTLESS/AGITATED/HALLUCINATING [ PICKING AT SELF AND THE BED] AT APPROX 0100HRS...REFUSED PO HALDOL THEREFORE GIVEN IV DOSE OF 1MG TOTAL..BECAME CALMER THE PATIENT C/O LEFT SIDED CHEST PAIN, EKG TAKEN S/L NITRATE GIVEN BUT TOTAL 4 MGS MORPHINE TOOK THE PAIN AWAY...PRESENTLY PATIENT PAINFREE AND AWAITING REPEAT CT CHEST...\\nUNDERSTANDS SOME ENGLISH, SPEAKS /CREOLE\\n\\n\\n\\nCVS...LABETOLOL DRIPS WEANED TO OF WITH INCRESAED DOSE OF PO MEDS...BUT WITH INCRESAING AGITATAION/PAIN B/P INCREASING TO > 140 [ AIM 120-140] THEREFORE LABETOLOL DRIP RE-COMMENCED FOR CONTROL AND BRIEFLT NIPRIDE..PRESENTLY CONTROLLED 2MGS/MIN LABETOLOL HR 65-67 AND B/P @ 130 SYSTOLIC...\\nHCT HAS DROPPED FROM 31 TO 28.9 [ ? RELATED TO DISSECTION] HAS HAD PREVIUOS DROP AND REQUIRED BLOOD...FRESH CROSS MATCH SENT...ALL OTHER AM LABS STABLE\\nAFEBRILE..B/S STABLE...\\n\\n\\nRESP..IN VIEW OF NEW CHEST PAIN 2LN/S APPLIED SATS >95%\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421825,\n \"text\": \"GI...TAKING ONLY SMALL AMOUNTS OF FOOD..FAMILY HAVE REQUESTED TO BRING FOOD IN [ ADVISED NO SALT]..NO BOWEL MOTION FOR 4 DAYS THEREFORE ON REGIME, SOFT WITH B/S..HCT AS ABOVE, NEED TO GHUAIC STOOL , PREVIUOSLY GHUAIC POS ? FOR GI TO BE INVOLVED AT SOME POINT...\\n\\n\\nGU..RECEIVED 20MGS LASIX YESTERDAY FOR MILD CHF WITH GOOD RESPONSE [ NEG BALANCE]...BUT RECEIVED BOLUS BICARB DRIP PLUS INFUSSION NOW IN PROGRESS FOR PROTECTION OF KIDNEYS POST CT WITH CONTRAST...\\n\\n\\nLINES..NEW PERIPHERAL SIGHTED, ART LINE POSTIONAL BUT DRAWS..\\n\\n\\nSOCIAL..DAUGHTER SPEAKS VERY GOOD ENGLISH AND IS HCP..SHE VISITS DAILY\\n\\n\\n\\nCVS...HR IS FIRST DEGREE HB, HAS HAD PREVIUOS EPISODE OF AF [ FRIDAY]..HR HAS SLOWED WITH TRANSITIONING FROM IV TO PO LOPRESSOR..PRESENTLY @ 60 SINUS/1ST DEGREE AV BLOCK...LOPRESSOR PO IS TO BE GIVEN WITH PARAMETERS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421826,\n \"text\": \"MICU 6 Nursing Progress Note (0700-1900)\\n\\nPlease see carevue for all objective data. Hypertension now being managed with po meds. Hct has been stable. Pt to head CT for increased confusion, agitation and paranoia.\\n\\nCNS: Pt. initially assessed at being alert and oriented x 3 via interpreter this AM x 2. She did make some statements about last night \\\"they were trying to give me too much medication\\\"...\\\"they stuck needles in me\\\" and seemed upset. When her daughter called and spoke to her later in the morning, daughter stated her mother was extremely confused, disoriented and angry. HO notified re:? further haldol. Pt. began to cry out, again appearing angry and distressed. Given .5mg haldol with good effect and was taken for head CT...awaiting results. She is cooperative now, yet still seems somewhat angry.\\n\\nCVS: Pt. denies any back or chest pain today. CTA from last night unchanged per report. B/P has ranged 120-140/syst, except for a brief increase to 170/ during IV placement. Currently receiving labetolol 300mg qid, narvasc 10mg qd and valsartan 80mg qd also started today. Heart rate in the mid 60's without VEA. Pt. received 20mg lasix IV and is 900cc negative at this writing.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421820,\n \"text\": \"MICU Nursing Progress Note 0700-1900\\n\\nEvents: Attempted to transition patient to PO Labetelol and off Nipride gtt with some success.\\n\\nNeuro: Pt alert and oriented x 3, OOB to chair for approximately 4 hours with an assist of two. Patient able to stand and pivot. Speaks some english but mostly communicates needs through family and gestures. No complaints of pain this shift.\\n\\nResp: Lungs clear, diminished at bases. No longer on O2. Sats remain above 95%.\\n\\nCV: HR 63-68, first degree AVB. Afebrile. Pt remains on Nipride gtt currently running at 0.3mcg/kg/min, Labetalol at 4mg/min as well as 300mg PO Labetalol. BP very labile throughout shift. MICU team goal during AM rounds was to wean off Nipride gtt. During shift able to decrease from 1mcg/kg/min to 0.5mcg/kg/min. Pt very sensitive to changes in gtt rate. Goal BP 130-140 systolic. PM crit 30.1 up from 29.3\\n\\nGI: Pt advanced to regular diet and tolerating well. No complaints of nausea this shift. Please note that family is bringing in food for patient and was made aware by nurse to make sure food from home is low sodium due to increased BP. Colace and PRN Senna added to medications. No stool this shift.\\n\\nGU: Foley patent and draining light yellow, clear urine. Given 20mg Lasix with good effect, diuresed approximately 1100cc. Fluid goal is slightly negative to a half a liter negative.\\n\\nSkin: Intact\\n\\nAccess: 2 PIV, right radial A-line.\\n\\nEndo: BS QID\\n\\nSocial: Family in to visit for much of shift, updated on patient's condition. Daughter (HCP) called and updated, will be in this evening.\\n\\nPlan: Continue to monitor BP and titrate accordingly, wean Nipride gtt as tolerated by patient. Patient/family teaching regarding BP control, importance of compliance to medication regimen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421821,\n \"text\": \"cv: 72-60 1st degree avb. sbp 106-155/ attmpts to wean nipride to off. unable to get nipride off but did decrease to 0.1 mics/kg/min. goal sbp 130-140.\\n\\ngi: positive bowel sounds. abdomen soft. no stool.\\n\\ngu: foley draining clear yellow urine.uo 25-325cc/hr\\n\\nneuro: moves all extremities to commands. comprehends some english but responds in portuguese.\\n\\nintegumentary: skin intact.\\n\\nPain: pt c/o head ache ..medicated with tylenol 650 mg po and morphine 2 mg sc with good effect.pt slept.\\n\\nlabs: hct stable.see careview for all lab results.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421822,\n \"text\": \"Nursing Note (0700-1900hrs)\\n\\nPt cont to require IV nipride and labetalol to maintain SBP 130-140's;cont to increase po antihypertensives. Vasc following--feels aortic hematoma does not explain Hct drop. Prob from GI sources with hx of coffee ground emesis, sm amt and OB+stool on admit.\\n\\nReview of systems:\\nNeuro: A&OX3 per family however appears sl disorientated upon awakening; mentioning to family that she is in her living room then realizes she is wrong; also seeing some ?shadows to daughter's face. Will cont to closely monitor.\\n\\nCV: Remains in 1st degree AV block, 60-70's. BP elevated early am d/t infiltrated IV upon assessment. Nipride gtt continues to be difficult to wean off completely despite low dose of 0.5mcg/kg/min at this time. Labetalol at 4mg/min. PO labetalol increased to 200mg QID. Amlodipine increased to 10mg. Has right radial aline which is accurate however unable to draw bloods from; site sl tender to touch however discomfort seems r/t position of catheter. PIV to left hand leaking as well, presently has #20 to LLA, site unremarkable. Access good. No ankle edema. Hct, 4pm, stable, 31.1 Vascular cont to follow; aortic dissection is non-operable at this time; may consider stenting if unstable. Mg and potassium repleted this am.\\n\\nResp; Sl crackles to bases. >95% on RA. Evidence of pulm edema on CXR on admit; given lasix 20mg with fair response; goal of -500 to 1L today.\\nGi/GU: NAS/Low chol diet; appetite fair. Some bile/mucous emesis in afternoon--prob r/t po potassium. Abd NTND; complaining of some abd discomfort however pt states LBM 4 days ago; up to commode x2 without results. Senna increased to . Given dose this am. Foley patent for clear yellow urine. GAS.\\n\\nID: Afebrile. No s/s infection. WBC wnl.\\n\\nSocial: Daughter and ?sister visiting; updated on condition. Daughter reports that aunt and grandmother both had hx aneurysms that were repaired.\\n\\nPlan: Cont with wean of nipride gtt first then labetalol gtt as po's increased. Goal for <140. Hct's, GAS; repeat CTA tomorrow. Renal US tonight/tomorrow to assess for renal stenosis. Diuresis. Enc po's--senna this evening. Closely monitor mental status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421823,\n \"text\": \"NURSING NOTE 1900HRS - 0500HRS\\n\\nADMIT FROM OSH WITH KNOWN AORTIC DISSECTION , BACK PAIN, CT SHOWED HAEMATOMA ON DISSCETION, NOT CANDIDATE FOR SURGERY [ VASC FOLLOWING] ..BUT BE CANDIDATE FOR STENTING IF PATIENT BECOMES UNSTABLE\\n\\n\\nEVENTS....AGITATED/HALLUCINATING REQUIRED IV HALDOL/... EXPERIENCED SIGNIFICANT LEFT SIDED CHEST PAIN REQUIRING IV MORPHINE AND TO RE-START LABETOLOL DRIP FOR B/P > 140... HCT DROP TO 28.9... IN VIEW OF PAIN/HCT FOR URGENT CT TO REASSESS DISSECTION...\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-12-01 00:00:00.000\",\n \"description\": \"MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\",\n \"row_id\": 932830,\n \"text\": \" 10:41 AM\\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: Please eval for evidence of aortitis.\\n Admitting Diagnosis: BACK PAIN\\n Contrast: MAGNEVIST Amt: 20CC\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 72 year old woman with known thoracic aortic aneurysm with mural wall thrombus\\n and ulcer.\\n REASON FOR THIS EXAMINATION:\\n Please eval for evidence of aortitis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Evaluate for aortitis.\\n\\n TECHNIQUE: Dedicated thoracic aorta imaging was performed on a 1.5 Tesla\\n magnet, including dynamic 3D imaging obtained prior to, during, and after the\\n intravenous administration of 0.1 millimole per kilogram of gadolinium-BOPTA.\\n\\n COMPARISON: Findings are compared with recent prior CT scan dated .\\n\\n Multiplanar 2D and 3D reformations as well as subtraction images were acquired\\n on an independent workstation.\\n\\n FINDINGS: The abdominal aorta is not included in the current examination.\\n\\n There is circumferential high T1 signal within the wall of the descending\\n aorta that begins after the takeoff of the left subclavian and progresses to\\n the inferior most extent of the visualized descending aorta on these images.\\n The ascending aorta is noted to be spared. Additionally, post- contrast\\n imaging of the aorta demonstrates marked delayed crescentic enhancement of the\\n vascular wall surrounding the descending aorta that is involved by this\\n intramural hematoma. Findings are compatible with intramural hematoma with\\n associated engorgement of the vaso vasorum. Lack of circumferential\\n enhancement argues strongly against aortitis.\\n There is no evidence for aortic dissection. Evaluation of the aortic hiatus\\n again demonstrates a prominent focal penetrating ulcer of the thoracic aorta\\n at this level.\\n\\n Evaluation of the remainder of the visualized viscera is unremarkable except\\n for simple liver cyst. No pulmonary emboli are visualized. Scattered\\n mediastinal lymphadenopathy is again seen, unchanged.\\n\\n Multiplanar 2D and 3D reformations as well as subtraction images were\\n essential in demonstrating multiple perspectives for this dynamic series.\\n\\n IMPRESSION:\\n\\n 1. Again seen is an extensive type B intramural hematoma extending from the\\n takeoff of the left subclavian artery through the entire visualized thoracic\\n and upper abdominal aorta. Additionally noted on the current exam is marked\\n delayed crescentic enhancement of the entire aortic wall in the region\\n affected by the intramural hematoma, compatible with associated engorgement of\\n (Over)\\n\\n 10:41 AM\\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: Please eval for evidence of aortitis.\\n Admitting Diagnosis: BACK PAIN\\n Contrast: MAGNEVIST Amt: 20CC\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n the vaso vasorum. Lack of circumferential enhancement argues strongly against\\n aortitis.\\n\\n 2. Abdominal aortic aneurysm is not included in the images of this study and\\n has not evaluated.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421819,\n \"text\": \"Nursing progress notes\\nReview of systems:\\n\\nNeuro: pt alert and oriented per familly (pt speaks creole and some english) she can communicate her needs by using hand gestures and little broken english. mae. pt c/o of head ache early this am at 0300 tylenol 650mg po given w/ good effect. pt denied back and abdominal pain. pt has slept most of shift.\\n\\nResp: pt ls clear w/ diminished bases o2 on at 2liters sats 99-100%\\n\\nCv: tele sr 62-80 pt on nipride gtt currently at 1.1mcq/kg/min and labetolol gtt at 4mg/min. her bld pressure has been labile throughout shift. micu resident aware and recommended that staff increase labetolol gtt instead of nipride gtt. goal for bp 120-130. hct 28.7 and this am 29.3, k+ 4.1 mg 1.8. Hrt sounds S1S2 w/ systolic murmur. pedal pulses +3 w/ post tibs +2. per vascular, pt may go to OR for bypass if acutely unstable and pt agrees, if pt remains and off of gtts she may go for a stent sometime this week.\\n\\nGI: pt is npo however had sips of water w/ meds. pt became nauseous this am at 0200 anzemet 12.5mg ivp given w/ good effect. \\u0013no sx planned, pt should be able to take po today as tolerates. abd soft bs+ no stool this shift\\n\\ngU: foley draining 25-125cc/hr\\n\\nskin: intact\\n\\naccess: #14 rfa , #20 left hand , right radial aline, it is positional, but still corolates w/ nibp, however it does not draw bld back.\\n\\nsocial: daughter and pt's sister stayed until 2200 all questions answered. emotional support given.\\n\\ncode: full\\n\\nendo: bs 122 no insulin needed\\n\\nPlan:\\n\\ncont to draw q 4hr hcts\\ntitrate nipride and labetolol gtts for sbp 120-130\\nadminister ms/diludid for pain\\nobtain diet order\\ngive emotional support to family and pt\\nmay need to rewire or resite aline.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421829,\n \"text\": \"MICU 6 Nursing Progress Note (0700-\\n\\nMrs. is a 72 year old () speaking woman admitted from OSH with sudden onset of back pain, N/V, and HTN (240/120). Pt. has hx of HTN/CHF/hypercholesterolemia along with hx of thoracic aortic aneurysm.\\nTreated with labetolol and nipride gtts (goal 100-140/syst). CTA with evidence of intramural hematoma in descending thoracic aorta without evidence of dissection. Not a surgical candidate as spinal circulation would be compromised. Ruled out for an MI per enzymes. Hct drop initially to 24.7(from 28) and pt received 1UPRBC without appropriate bump. No increase in size of hematoma on CT. Stools were initially guiac positive.\\nPO labetolol was started and gtts were weaned off by . Pt also received another 2UPRBC's and Hct has been stable since. +CHF, treated with lasix. CT repeated early AM due to chest and back pain...no changes.\\nRecent problems have included worsening mental status with hallucinations, agitation and delirium (negative head CT). Pt. did spike a temp to 101 rectally today. BC x 2 and urine cultures sent. Pt. received one dose of vanco and one dose of ceftriaxone. LP done. Sitter and family at the bedside.\\n\\nCNS: Pt. very confused as to time and place per family. She is hallucinating, pointing and \\\"picking\\\" at sheets, etc. She is able to follow simple commands and MAE's. Haldol ordered prn, but has not yet been given as she is much better with family and friends at the bedside. Wrist restraints were initially applied for safety and have been removed with family present.\\n\\nCVS: Blood pressure under good control on labetolol 300mg qid/norvasc and valsartan. SBP generally 110-140/. Heart rate in the 60's, NSR without VEA. Denies any chest pain or SOB.\\n\\nRESP: Sats of 98% on room air. Lungs with diminished breath sounds throughout. (difficulty in obtaining consistent sat due to agitation).\\n\\nID: T max of 101 rectally (?cause for MS changes). BC x 2, urine sent. CXR done along with LP. pt. also received vanco and ceftriaxone x 1. Given tylenol 650mg po also.\\n\\nF and E: Inaccurate I and O's as pt. was incontinent this AM until foley was replaced. To receive 500cc IVF post LP.\\n\\nRENAL: Clear, light yellow urine via foley.\\n\\nGI: Taking po's well, needs to be fed. (soft solids as she will not keep dentures in). Please hold senna and colace due to large, loose stools x 3.\\n\\nSKIN: Intact.\\n\\nLINES; ART line present, pt. also has 2 peripheral IV's.\\n\\nSOCIAL: Multiple family members in...very helpful with translation and in keeping pt. calm.\\n\\nPLAN: Follow mental status and maintain pt. safety.\\n Follow B/P with goal SBP 100-140/.\\n Follow for any evidence of bleeding.\\n Follow up on LP, culture results.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421830,\n \"text\": \"Addendum: No fluids post LP due to evidence of volume overload on CXR. Surgery in to see pt. and spoke with daughter re:possibility of stenting procedure to aorta on Friday. Pt's daughter understands and is agreeable to procedure.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421831,\n \"text\": \"NSG 7PM-7AM\\nPLEASE REFER TO CAREVIEW FOR OTHER OBJECTIVE DATA.\\n\\n72 YR SPEAKING FEMALE WITH HX OF HTN, HYPERCHOLES, CHRONIC THORACIC AORTIC ANEURYSM, PRESENTS TO OSH WITH ACUTE ONSET OF BACK PAIN ASSOCIATED WITH N/V. AT OSH PT WAS FOUND TO HAVE B/P 240/120/ CT SUGGESTIVE OF ACUTE ON CHRONIC THORACIC ANEURYSM/ TRANSFERRED TO FOR FURTHER MANAGEMENT.\\n\\n REPORTED ACUTE ONSET OF AGITATION AND HALLUCINATIONS OF UNKNOWN ETIOLOGY ON / RECEIVED ZYPREXA, SEROQUEL, HALDOL. PT RECEIVED MILDLY AGITATED, CONFUSED, DISORIENTED TO TIME, PLACE. REORIENTED AND REASSURED PER STAFF AND FAMILY MEMBER. PRESENTLY PT ASLEEP/ HAS BEEN ASLEEP FOR MOST OF SHIFT. NO EPISODE OF ACUTE AGITATION, HALLUCINATIONS/ THOUGH, PT STILL CONFUSED AND DISORIENTED/ REQUIRES SITTER FOR 1:1 SUPERVISION.\\n\\nHEART RYTHM SINUS/ 1ST DEGREE AVBLOCK/ HR IN 70S NO ECTOPY. ABP 120-160S/ TRENDS DOWN TO 90S WHILE PT ASLEEP/ 0200 LABETALOL DOSE HELD PER PARAMETER/ TEAM AWARE. CHEST XRAY POS FOR PULM EDEMA/ REMAINS ON LASIX DAILY/ UOP 10-80CC/HR/ 24 HR FLUID BALANCE NEG 575ML AT MN/ WITH LOS POS 1092ML.\\n PAN CX/ ANTBX ON . T.MAX: 101.7/ TYLENOL 650MG GIVEN THIS SHIFT. CURRENT T:98.9/ WBC:5.8. BLOOD, URINE, SPINAL FLUID CX PENDING. SPINAL FLUID GRAM STAIN SHOWS NO LEUKOCYTES.\\nHEAD CT ON NEG FOR HEMORRHAGE/ CHEST CT POS FOR INTRAMURAL HEMATOMA FROM THE SUBCLAVIAN ARTERY.\\n\\nRESP EFFORT UNLABORED AND EVEN/ LUNG SOUNDS DIMINISHED THROUGHOUT/ SATO2 92-96% ON RA. NON PRODUCTIVE COUGH AT TIME/ UNABLE TO OBTAIN SPUTUM FOR CX.\\n\\nABD SOFT POS BS/ SMEAR LBM. SENNA AND COLACE HELD FOR REPORTED LBMS PER PREVIOUS SHIFT. TOLERATES PO/ NO N/V.\\n\\nFOLEY PATENT DRAINING CLEAR URINE.\\n\\nSKIN W/D/I. ENCOURAGED REPOS. LP SITE COVERED WITH BANDAID/ NO DRAINAGE. PIVX1/ ALINE INTACT.\\n\\nFAMILY VISITED/INVOLVED IN HELPING REORIENTATING AND REASSURING PT.\\n\\nFOLLOW MENT STATUS/ MAINTAIN SAFETY/REMAINS RESTRAINED.\\nFOLLOW BP/MAINTAIN GOAL 100-140\\nFOLLOW TEMP CURVE/ FOLLOW SF AND OTHER CX.\\nCOLLECT SPUTUM FOR CX IF POSS.\\nPOSS AORTIC STENTING ON FRIDAY\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421832,\n \"text\": \"MICU UPDATE and transfer note:\\n\\nFoley and Right Rad A-line d/c'd this AM. Report given to , RN on VICU at 1545. PT. tx'd to VICU via wheelchair and telementry in stable condition at 1600.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421817,\n \"text\": \"npn 1900-0700\\n\\n Mrs received a unit of blood that finished early yesterday evening. A crit was drawn @ 2100 that did not bump appropriately.Pt ordered for a CT angio of her chest which was completed at 0300. It showed a hematoma. During this period pt has become very unstable; her BP has been as high as 200/100. Nipride gtt is maxed at 10mcg/kg/min. Labetolol has been initiated at 2mg/min. Crit drawn at 0345 has dropped again to 23.9. Is typed and crossed for 4 units. EKG done. VAscular surgery is at the bedside evaluating the patient. MICU intern and resident at bedside and have spoken with the ICU overnight attending. *** Patient is having a lot of abdominal pain-- a new finding.*** She has received many doses of IV morphine since 0400 and they seem to have little effect.\\n\\nThis RN called pt daughter at 0410 and requested that she come in. She lives ~90 minutes away and is on her way here.\\n\\nneuro: Pt is speaking and seems to be oriented, she speaks some English. Is able to folllow commands and MAE on the bed.\\n\\nresp: 2L nc. LS clear and diminished at the bases.\\n\\ncv: 1 degree AVB (not a new finding). Hypertensive as described above. Labetolol and nipride gtts. Goal BP 130-140. Very difficult to achieve at this point. Dopplerable pedal pulses.\\n\\naccess: 3 piv. R radial aline.\\n\\ngi/gu: Pt is now NPO for ? surgery. Patent foley.\\n\\nSkin: No issues.\\n\\nEndo: BS QID.\\n\\nPlan: Vascular team is evalusting CT images, dtr is on her way in, transfuse with 2 units cells.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-11-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1421818,\n \"text\": \"MICU Nursing Progress Note 0700-1900\\n\\nEvents - Pt's BP extremely labile, crit of 28.7 after 2 units PRBCs.\\n\\nNeuro - Pt A&Ox3, MAE, follows commands. Complained of moderate/severe headache x2 (pain ranging about ). Given morphine and dilaudid for pain, which was relieved but pt did experience some nausea and vomiting. Consider asking team for Tylenol, pt appears to be sensitive to narcotics. No complaints of abdominal pain.\\n\\nResp - Pt on 2L NC. Lung sounds clear but diminished in bases. Breathing pattern regular and unlabored.\\n\\nCV - Pt is in first degree AVB. BP continues to be labile, ranging from 190-90/90-50. Goal BP systolic 130-140's. Pt very sensitive to movement and changes in gtt rate. Nipride currently running at 1mcg/kg/min, Labetalol at 2mg/min. Crit after 2 units PRBCs 28.7. Evaluated by Vascular Surgery team and was determined not to be a candidate for surgery at this time.\\n\\nGI - Pt still NPO, awaiting okay from MICU team to advance diet if surgery is not planned. Bowel sounds present. No stool this shift.\\n\\nGU - Foley patent and draining clear, yellow urine.\\n\\nSkin - Intact.\\n\\nEndo - BS QID.\\n\\nAccess - 2 PIV, one changed due to left AC infiltration.\\n\\nSocial - Daughter and extended family in with patient for most of shift. Updated on patient's condition by Dr. .\\n\\nPlan - Continue to monitor BP, hematocrit, any s/s of bleeding.\\n\"\n }\n]"}}},{"rowIdx":178,"cells":{"subject_id":{"kind":"number","value":31512,"string":"31,512"},"hadm_id":{"kind":"number","value":152600,"string":"152,600"},"target_text":{"kind":"string","value":"At the time of admission, he was toxic appearing with a distended, diffusely tender abdomen. This worsened on repeat examination with signs of peritonitis. CT scan was concerning for internal hernia with concern for the integrity of the bowel as far as ischemia. He was brought to the operating room for laparotomy. The high risks were discussed at length with him. The operative findings included a frozen abdomen with a foreshortened and fibrotic mesentery. He had abdominal wall varices which required control and essentially an intra-abdominal cocoon lining which was unable to be initially entered. Some adhesions were able to be lysed as there was a dilated loop of bowel that was visualized superficially and given these findings as well as the ability to decompress the abdominal contents, the operation was stopped at that juncture and open abdomen was left with a dressing. He was brought back to the operating room over the next few days on several occasions for re-evaluation. Dr. assisted with the operation on . He was found to have a small piece of dead bowel which appeared to be terminal ileum and cecum and this had an associated perforation. The ends of the bowel were left stapled off. I was still unable to round the entirety of it and abdomen was left packed with drains. He continued to require intensive care unit care during this point-in-time. Subsequently, he was brought back to the operating room with leakage of bile. A tube ileostomy was created and again a VAC was placed. During this time, intensive care unit care continued. He continued to be fairly stable but in the intensive care unit setting. Given the extenuating circumstances of his abdomen and the inability to provide definitive care and management, our best case scenario was adequate drainage of the ileostomy; however, he was really unable to achieve any significant parenteral nutrition. Ultimately the patient's family as well as the patient were involved in making decisions regarding his care. He was able to be extubated and was awake during this time for these conversations. Social work and palliative care were also involved. He was maintained on CMO care in the intensive care unit because of his high nursing needs. He continued to have high drainage from his abdominal wounds. He was kept comfortable. The patient and family were in agreement that CMO was appropriate care and he was therefore kept there in the intensive care unit with comfort measures only until his death on . , M.D. Dictated By: MEDQUIST36 D: 14:46:54 T: 15:11:13 Job#: "},"extractive_notes_summ":{"kind":"string","value":"Small-bowel obstruction with a coiled up loop of fecalized distal ileum with mild bowel wall thickening adjacent to collapsed loop of terminal ileum possibly at the site of transition point located in the right lower quadrant. There has been interval development of a coalescent opacity in the right upper lung, limited inferiorly by the minor fissure. This loop is located in the right lower quadrant and there is a relatively collapsed loop of terminal ileum adjacent to it (300b:32) and could likely reflect a transition point. Cardiomediastinal contours appear slightly wider, and there is new minimal perihilar edema. The side hole of the nasogastric tube remains just above the cardioesophageal junction. IMPRESSION: Radiopacity covering the lower abdomen and contrast in tubular structure overlying the right lower quadrant, both of uncertain clinical implication; please correlate clinically and with recent operative procedures. CHEST, SINGLE AP SUPINE VIEW A right subclavian central line is present -- the tip overlies the right atrium. FINDINGS: In comparison with study of , there is now diffuse bilateral pulmonary opacification that has a generally alveolar quality. There is contrast noted in the tubular structure in the right lower quadrant, perhaps bowel. Endotracheal tube has been removed. Right renal hypoattenuation lesions could represent parapelvic cysts or collecting system fullness, the early phase of scanning limits differentiation. Again seen is the right-sided hydronephrosis. interval change PFI REPORT ET tube terminates 8 cm above carina, and right subclavian catheter terminates in proximal right atrium. Peripheral pulses palpable.Resp: LS clear/diminished. Min spont mvmt noted. TPN cont infusing. JP x1 w/serosang drng. Vac dsg with serosang output. 2+ edema to LE. JP self sxn with serosang output. Adequate huo, concentrated. Plan to cont to monitor, transition from fent gtt and maintain saftey and comfort. NGT & wnd#2 to suction w/mod amts serous drng. LR bolus given with good effect, total 1L given. Resp support. Abd wound open with vac dsg intact. TPN infusing as ordered. Respiratory Care:Pt. Condition UpdatePt continues to receive CMO care. AM ABG 7.45/34/189/24. Abd with vac dsg intact. Hct 29.9. MDI given as per order. MDI given as per order. Monitor fluid balance/lytes, goal remains even. Condition updateSee careview for objective data/trends:Remains sedated on fentanyl and versed gtt. Albumin x's 3 doses started.Resp: LS clear/diminished. NPO, NGT to lws. Wnd/drain care. 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. Good u/o after lasix. NPN:Neuro: Arouses to voice throughout day-weaned off midaz and pt extubated. Continued MDI's as ordered. Post-op s/p ex-lap, wash-out and vac dsg placement.Neuro: Received from o.r. BP stable. not reversed, currently sedated with fent./versed. Cont IVAB. Creat .7. Foley draining adequate amounts cyu. Lungs ess CTA with crackles L base. Stable on vent. Jp to bulb suctioned and ileum draining to gravity. HR 90s-100s, NSR/ST-min ectopy noted, SBP 110s-120s. OR Mon/Tues. BS are clear with diminished bases. MD aware, pt resedated lightly on versed gtt and ativan given to maintain. AFEBRILE.NEURO: PT SEDATED. NPN (NOC):CV: PT HAS BEEN HEMODYNAMICALLY STABLE OVERNOC OFF PRESSORS.RESP: PT REMAINS INTUBATED. condition updatePlease see carevue for specifics.Neuro: Sedated with fentynal and versed gtt's. Fentanyl gtt remains for pain.CV:SR to ST associated wtih alertness. +pitting edema bil lower ext. Abg's acceptable.GI: NPO, TPN infusing. NGT is to lws and draining clear to bilious fluid. REPLETED W/ 20 MEQ'S IV KCL. 2+ edema noted to bilat LE. Abd wound to intermittent wall suction - small amounts sero-sang drng. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Plan: Keep pt comfortable; titrate gtts as needed. Team aware that not holding suction at times.GU:foley apatent amber adeq. JP to bulb drainage, resecured with tegaerm. Calcium, mag, and k repleted. Question if consistent enough to use as communication.CV:ST, rare PVC's, maintaining bp off pressors. Lactate stable at 1.2 Cont to monitor hemodynamics, resp status, fluid balance, q4 hct/plt and coags, s/sx etoh witdrawl. BP bolus on way to OR for BP sys 80's.RESP:remains on cmv with abg's wnl.GI:ngt to LWS drng billious. Occlusive pressure confirmed accuracy of a-line. Drainage from jp noted to be brownish opaque, Dr aware and into assess. antibiotics a/o. antibiotics a/o. Transfused with 1 unit prbc and 1 unit ffp, goals hct >28 INR >1.8. +pp/csm. Pt appears comfortable, pain well controlled with fenynal gtt.CV: Sinus 100's - 110's with occasional pvc's. PT/OT consulted.RESP:LS clear, diminished. Generalized edema noted, +DP/PT pulses. Initially frequent runs of bigeminy noted, electrolytes from AM stable. Midaz gtt weaned off and receiving prn ativan with good effect. BS DIMINISHED BIBASILAR,CLEAR UPPER. Dr (sicu) aware and into assess aswell. HCT and INR stable. Resp Care Note:Pt cont intub with OETT as per Carevue. Suctioned x1 for scant clear secretions. CXR done. Lungs coarse occasionally, clear with sxn. NO FURTHER OR/ WILL SPEAK WITH DR.A: STABLE AT PRESENT, ABD PAIN.P: MONITOR COMFORT-FENTANYL, HR AND RYTHYM, SBP, CVP, PP, TEMP, RESP STATUS-PULM TOILET, NEURO STATUS-REORIENTE PRN, I+O-CONTINUE TPN, LABS PENDING. Patient has peripheral pitting edema noted and pulses have remained palpable.R - Patient remains on mechanical ventilation via ETT this shift with adequate ABGs and sats greater than 98%. Right SC TLC intact with CVP monitored as above, CVP between . Lungs mostly coarse but clear after sxn. Asking appropriate questions.PLAN:wean versed as tolerated, ativan prn for sedation. VANCO LEVEL 10-RECEIVED VANCO+ZOSYN. Started on lopressor with good effect, currently SR HR 80-90's no ectopy noted. Given ativan with good effect, given haldol x 1 for questionable delirium with no effect. Continues on A/C ventilation w/ PIP = 18, SpO2 90s, Ve ~6-7L/M. nursing noteneuro: versed weaning with addition of ativan. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Right SC TLC noted to be within the right atrium, pulled by resident and PCXR confirmed correct placement, bigeminy noted to lessen but continue, electrolytes checked later in shift and replaced magnesium and calcium per sliding scale order."},"n_notes":{"kind":"number","value":75,"string":"75"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2150-07-07 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1024858,"text":" 10:26 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? subclavian line in good position\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with subclavian line\n REASON FOR THIS EXAMINATION:\n ? subclavian line in good position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subclavian line placement.\n\n FINDINGS: In comparison with earlier study of this date, the tip of the\n subclavian line lies in the lower portion of the SVC. The heart and lungs are\n unchanged, as is the position of the other tubes.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-15 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1026262,"text":" 2:51 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: PICC placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n ISTORY: PICC placement.\n\n COMPARISON: .\n\n FINDINGS: A new left-sided PICC follows the expected course with tip in the\n mid SVC. A right subclavian catheter is in adequate position. The tip is also\n in the SVC. Nasogastric tube extends into the stomach, but the tip is not\n visualized. Endotracheal tube has been removed. Again noted are substantial\n pleural effusions layering posteriorly with apical capping. There has been\n interval development of a coalescent opacity in the right upper lung, limited\n inferiorly by the minor fissure. This is concerning for developing pneumonia.\n The cardiomediastinal contours are unchanged.\n\n IMPRESSION:\n 1. New left-sided PICC with tip in the mid SVC. Right subclavian catheter\n and nasogastric tubes in standard position. ET has been removed.\n 2. Increased bilateral pleural effusions, moderate to large on the right,\n moderate on the left.\n 3. New right upper lobe opacity, which may be due to aspiration or developing\n infectious pneumonia.\n\n"},{"category":"Radiology","chartdate":"2150-07-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026857,"text":" 10:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SICU. increased O2 requirements\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n SICU. increased O2 requirements\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing oxygen requirement.\n\n FINDINGS: In comparison with study of , there is now diffuse bilateral\n pulmonary opacification that has a generally alveolar quality. Although much\n of this could represent asymmetric pulmonary edema, the possibility of\n superimposed pneumonia must be seriously considered.\n\n The endotracheal tube has been removed.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1025898,"text":" 9:48 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check ng tube position\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n check ng tube position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For nasogastric tube position.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of a nasogastric tube that extends at least to the lower body of the\n stomach where it passes the lower margin of the film. Allowing for\n sub-optimal technique, there is probably little change in the appearance of\n the heart and lungs.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-04 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1024439,"text":" 11:32 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval R subclavian CVL placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man w/ cirrhosis s/p ex lap s/p CVL placement\n REASON FOR THIS EXAMINATION:\n eval R subclavian CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CVL placement.\n\n CHEST, SINGLE AP VIEW. No previous chest x-rays on PACS record for comparison.\n\n Heart size is at the upper limits of normal. The aorta is minimally unfolded.\n No CHF, focal infiltrate, or effusion is identified.\n\n An ET tube is present, tip approximately 4.9 cm above the carina. An NG tube\n is present, tip overlying the gastric fundus. A right subclavian central line\n is present, tip over SVC/RA junction -- clinical correlation to assess for\n slight retraction is requested. No pneumothorax is detected.\n\n There is dense opacification of the right renal collecting system, with\n evidence of hydronephrosis.\n\n\n\n"},{"category":"Radiology","chartdate":"2150-07-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1024807,"text":" 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB TUE 9:36 AM\n ET tube terminates 8 cm above carina, and right subclavian catheter terminates\n in proximal right atrium. New mild pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation.\n\n Endotracheal tube terminates 8 cm above the carina, and right subclavian\n catheter terminates in the right atrium, as communicated by telephone to Dr.\n . Cardiomediastinal contours appear slightly wider, and there is new\n minimal perihilar edema. No pleural effusion or pneumothorax is evident.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1024808,"text":", S. SICU-B 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PFI REPORT\n ET tube terminates 8 cm above carina, and right subclavian catheter terminates\n in proximal right atrium. New mild pulmonary edema.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1025883,"text":" 5:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for effusions, atelectasis, consolidation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 cirrhotic w/SBO s/p ex-lap (); s/p segmental bowel resection, washout\n (); s/p repair of ileal vs. cecal perforation, tube ileostomy ()\n REASON FOR THIS EXAMINATION:\n evaluate for effusions, atelectasis, consolidation\n ______________________________________________________________________________\n WET READ: PXDb MON 7:51 PM\n Small layeing bilateral pleural effusions, retrocardiac atelectasis. No\n Pulmonary edema, NG tube side port at GE junction, advance by 10 cm. ET tube\n relatively high, terminating 7 cm above the clavicle, which could be due to\n hyperextension, Findings relating to NG tube DW Dr.. .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative, to evaluate for pneumonia or atelectasis.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again, there are bilateral layering pleural effusions with some\n retrocardiac atelectasis without definite pulmonary edema. The side hole of\n the nasogastric tube remains just above the cardioesophageal junction. The\n relatively high endotracheal tube tip is above the clavicles, but measures\n only 7 cm above the carina.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-13 00:00:00.000","description":"O ABD (SINGLE VIEW ONLY) IN O.R.","row_id":1025872,"text":" 3:47 PM\n ABD (SINGLE VIEW ONLY) IN O.R. Clip # \n Reason: ABDOMINAL WASHOUT\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 53-year-old male, evaluate for abdominal washout of\n questionable foreign body.\n\n EXAMINATION: Single frontal abdominal radiograph.\n\n COMPARISONS: Comparison to CT of the abdomen and pelvis from .\n\n FINDINGS: Correlation with clinical history indicates that patient is status\n post surgery with possible open abdomen. There is a nasogastric tube in\n place. There is a peritoneal drainage catheter noted. There is a\n large uniform radiopacity projecting over the abdominal lower quadrant and\n pelvis, of uncertain significance, requiring clinical correlation for\n interpretation. There is contrast noted in the tubular structure in the right\n lower quadrant, perhaps bowel. There is a paucity of gas noted in the abdomen.\n The visualized osseous and soft tissue structures are otherwise unremarkable.\n\n IMPRESSION: Radiopacity covering the lower abdomen and contrast in tubular\n structure overlying the right lower quadrant, both of uncertain clinical\n implication; please correlate clinically and with recent operative procedures.\n\n"},{"category":"Radiology","chartdate":"2150-07-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026406,"text":" 10:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: position of trachea\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p wash out abdomen\n REASON FOR THIS EXAMINATION:\n position of trachea\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:33 PM\n PFI: Endotracheal tube 5 cm from the carina. Persistent bilateral pleural\n effusions, cardiomegaly, and pulmonary vasculature cephalization. No\n significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recently reintubated following abdominal washout.\n\n COMPARISON: .\n\n FINDINGS: The endotracheal tube terminates 5 cm from the carina. The\n nasogastric tube and right subclavian line are in adequate position. Again\n noted is marked bilateral veiled opacification, suggesting layering pleural\n effusions. Heart size remains enlarged with cephalization of pulmonary\n vasculature. There is no other significant interval change.\n\n IMPRESSION: Endotracheal tube 5 cm from the carina. Persistent bilateral\n layering pleural effusions, cardiomegaly, and cephalization of pulmonary\n vessels.\n\n"},{"category":"Radiology","chartdate":"2150-07-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026407,"text":", S. SICU-B 10:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: position of trachea\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p wash out abdomen\n REASON FOR THIS EXAMINATION:\n position of trachea\n ______________________________________________________________________________\n PFI REPORT\n PFI: Endotracheal tube 5 cm from the carina. Persistent bilateral pleural\n effusions, cardiomegaly, and pulmonary vasculature cephalization. No\n significant interval change.\n\n"},{"category":"Radiology","chartdate":"2150-07-03 00:00:00.000","description":"P ABD COMPL INCLUDING LAT DECUB PORT","row_id":1024359,"text":" 4:58 PM\n ABD COMPL INCLUDING LAT DECUB PORT Clip # \n Reason: r/o air fluid levels\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with h/o sbo left ama now with distended firm tender abd\n REASON FOR THIS EXAMINATION:\n r/o air fluid levels\n ______________________________________________________________________________\n WET READ: FXKd FRI 5:29 PM\n GAS FILLED DISTENDED LOOPS OF BOWEL WITH MAXIMAL SMALL BOWEL DISTETION OF 45\n MM. GAS IS PRESENT IN THE COLON AND RECTUM\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with history of small-bowel obstruction, now with\n firm, tender abdomen, to rule out bowel obstruction.\n\n TECHNIQUE: Portable AP radiograph of the abdomen was performed.\n\n Comparison was made with examination of .\n\n FINDINGS:\n\n Gas-filled distended loops of small bowel are seen in the mid abdomen. There\n is gas also seen in the colon as well as the rectum. The maximally distended\n loop of small bowel measures 45 mm. There is no evidence of free air. Early\n bowel obstruction cannot be excluded.\n\n There are degenerative changes present at the hip joints.\n\n CONCLUSION:\n\n Multiple gas-filled loops of bowel are seen with the maximal diameter of a\n loop of bowel in the right abdomen measuring 45 mm. Early obstruction cannot\n be excluded. There is no free air.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-04 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1024460,"text":" 3:09 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line adjustment (R subclavian)\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man cirrhosis s/p adjustment of CVL (line withrdrawn 2cm)\n REASON FOR THIS EXAMINATION:\n eval line adjustment (R subclavian)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Adjustment of CVL.\n\n CHEST, SINGLE AP SUPINE VIEW\n\n A right subclavian central line is present -- the tip overlies the right\n atrium. The ET tube and NG tube are grossly unchanged. No acute pulmonary\n process or pneumothorax is identified. Again seen is the right-sided\n hydronephrosis.\n\n The left paravertebral stripe is prominent, but unchanged -- the significance\n of this findin on a supine film is indeterminate. Attention to this finding on\n followup films is recommended.\n\n"},{"category":"Radiology","chartdate":"2150-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1025699,"text":" 4:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: preop CXR\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n preop CXR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preop radiograph\n\n A single portable radiograph of the chest demonstrates no change in the\n support lines seen on . Cardiomediastinal contours are normal.\n There is a persistent left-sided pleural effusion. There is a new right-sided\n pleural effusion. No pneumothorax is evident. The trachea is midline.\n\n IMPRESSION:\n\n Bilateral pleural effusions. No consolidation. Support lines unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2150-07-03 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1024385,"text":" 11:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cirrhosis and h/o partial sbo who left ama here with\n distended abd\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb SAT 2:03 AM\n SBO with dilated bowel loops no passage of contrast beyond the distal ileum,\n fecalized loop of ileum in the deep pelvis, with bowel wall thickening, likely\n transition point in the right lower quadrant, could be due to internal hernia\n or adhesions in the setting of h/o exploratory laparascopy.\n\n DW with surgery team.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with cirrhosis and history of partial small-bowel\n obstruction who left AMA, he have a distended abdomen, rule out obstruction.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical CT acquisitions from lung bases to pubic symphysis after\n administration of intravenous and oral contrast. Multiplanar reformations\n generated.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases are clear without\n focal consolidations, pleural effusions or pneumothorax. There is a moderate-\n sized hiatal hernia with NG tube extending into the stomach. There is a large\n amount of intraperitoneal free fluid. Relative hypertrophy of the left\n hepatic lobe is incidentally noted with cirrhotic morphology of liver. The\n spleen is mildly enlarged measuring 13.7 cm. Right renal hypoattenuation\n lesions could represent parapelvic cysts or collecting system fullness, the\n early phase of scanning limits differentiation. Otherwise the kidneys,\n adrenals, pancreas are unremarkable.\n\n Multiple distended small bowel loops are noted. The contrast passes only up\n to proximal ileum with multiple distended ileal loops measuring up to 4 cm.\n Additionally, there is no passage of contrast into the terminal portion of\n ileum with of fecalization and mild bowel wall thickening (2:57). There is a\n coiled up mass of ileal loops which grossly measures 10.2 x 8.1 cm and the\n transition point is likely within this area. This loop is located in the\n right lower quadrant and there is a relatively collapsed loop of terminal\n ileum adjacent to it (300b:32) and could likely reflect a transition point.\n Overall, findings indicate a small-bowel obstruction possibly due to an\n internal hernia or adhesions considering patient's history of exploratory\n laparoscopy. The right sided colonic loops are mildly distended with no\n passage of contrast into the colon. The rectum and sigmoid colon on the other\n hand are unremarkable. There is fecal material throughout the colon.\n\n (Over)\n\n 11:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS: The bladder is collapsed with the Foley catheter. There is\n moderate amount of intrapelvic free fluid. As described above, coiled up loop\n of ileal loops with fecalization and possible transition point is noted in the\n right lower quadrant.\n\n OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions. The L5-\n S1 vertebral body demonstrates mild degenerative changes with osteophyte\n formation, loss of intervertebral disc space. A single sclerotic T12\n vertebral body focus could represent a bone island.\n\n IMPRESSION:\n\n 1. Small-bowel obstruction with a coiled up loop of fecalized distal ileum\n with mild bowel wall thickening adjacent to collapsed loop of terminal ileum\n possibly at the site of transition point located in the right lower quadrant.\n These could be result of internal hernia or adhesion in the setting of prior\n exploratory laparoscopy.\n\n 2. Right renal hypoattenuating lesions could represent parapevlic cysts or\n collecing system fullness. Early phase of imaging limits differentiation.\n\n\n"},{"category":"Nursing/other","chartdate":"2150-07-06 00:00:00.000","description":"Report","row_id":1663872,"text":"7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nPt remains sedated on propofol and fentanyl. Pt will open eyes and inconsistently perform weak hand grasps when propofol lightened. Pt's HR running 80s-90s in NSR, BP ranging 110s-120s/60s-70s. CVP 10-14. Pt remains ventilated on AC mode, 40% fio2, 400 X 14 and 5 PEEP, no vent changes made as patient planned for OR ?Monday to close abdomen. LS clear bilaterally and Pox 98-100%.\nAt start of shift pt's urine output low at 15cc X 1 hour. Foley has been positional and U/O increased to adequate amounts after pt. repositioned in bed.\nPt's abdomen remains open with dressing intact. Pt also has JP drain intact and connected to suction which is putting out red/brown drainage. Abdomen is firm. Bladder pressures have been 10. NGT also to LWS and puttting out moderae amounts of bilious fluid. Getting TPN for nutrition.\nPLAN: ?OR Monday to close abdomen. Follow GI assessment, bladder pressures every 4 hours.\n\n"},{"category":"Nursing/other","chartdate":"2150-07-06 00:00:00.000","description":"Report","row_id":1663873,"text":"Respiratory Care\nPt remains on vent, on AC settings. Pt presents with clear lung sounds bilaterally, but diminished at the bases. Suctioned as noted. Pt is breathing breathes spontanously, although breathing pattern produces a \"breath stack\" sporadically, but none of these \"breath stack\" act negativly on ventilation. PT to remain on current support.\n"},{"category":"Nursing/other","chartdate":"2150-07-06 00:00:00.000","description":"Report","row_id":1663874,"text":"nursing note\nPt to OR for small bowel resection, + pus and stool in abd. Pt left with open abd, betadine elastoplast covering. BP on arrival quickly dropped to 60 systolic, MD in to eval. IVF wide open, levo gtt started and titrated up to goal sbp >85 and MAP 60. 2 u PRBC given with 2 U FFP with plans to check HCT and coags q4hrs. Bairhugger on to warm, off with temp of 98.6. JP to LWS with dark brownish bloody drainage. NGT with icteric output. Fluc/vanco/zosyn started. placed on kinair bed, wound consult deferred until tomorrow. brother calling for updates, spoke with MD. Daughter who is estranged also called for update and possibly to visit. Uncle told to call duaghter for update.\nPLAN: cont abx a/o. wea levo ast olerated. fent/propofol for comfort and sedation wtih open abd. pulm toilet. kinair bed. wound consult. monitor bladder pressures. follow labs q4. family support.\n"},{"category":"Nursing/other","chartdate":"2150-07-06 00:00:00.000","description":"Report","row_id":1663875,"text":"Patient went to OR for bowel resection,pus and stool found in abdomen.Abdomen still opened with Kentukey patch on.Distended abdomen,sedated on full mechanical ventilation will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2150-07-07 00:00:00.000","description":"Report","row_id":1663876,"text":"Resp: pt on ac 16/500/+5/40%. Ett 7.5 taped @ 20 lip. BS are clear with diminished bases. Suctioned for scant amount of white secretions No changes noc. AM ABG pending (see careview) RSBI=31. Plan: Continue present settings, pt remains with open belly and return trip to OR in future.\n"},{"category":"Nursing/other","chartdate":"2150-07-09 00:00:00.000","description":"Report","row_id":1663887,"text":"Resp: pt on a/c 12/500/+5/40%. Ett 7.5, 21 @ lip. BS are clear bilaterally. Suctioned for no/scant clear secretions. MDI's atrovent administered with no adverse reactions. AM ABG 7.45/34/189/24. RSBI=34 Plan: wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2150-07-09 00:00:00.000","description":"Report","row_id":1663888,"text":"Nursing Note\nPlease see carevue for details\n 1300-1900\n Pt remains sedated on Fentanyl at 75mcg/hr, Versed at 2mg/hr. Opens eyes and grimaces to painful stimuli, but does not follow commands. Min spont mvmt noted. PERRL, 3mm, brisk. HR 90s-100s, NSR/ST-min ectopy noted, SBP 110s-120s. CVP 5-8, BLE edema noted, fluid balance presently neg~100cc/24hr, ok per Dr.. Remains on CMV-500x12/40%, no vent changes made, overbreathing set rate of 12 by 3-7 breaths at times. Lungs clear, diminished at bases. ABD remains open, covered w/modified vac dsg. TPN cont infusing. NGT & wnd#2 to suction w/mod amts serous drng. JP x1 w/serosang drng. Ileal drain to gravity w/serous drainage w/sediment. Adequate huo, concentrated. Family in to visit, inquiring about HCP form, but inappropriate given pt current condition per Social Work.\n\n Plan: Cont hemodynamic monitoring, Fentanyl/Versed for comfort. Resp support. Monitor fluid balance/lytes, goal remains even. Wnd/drain care.\n"},{"category":"Nursing/other","chartdate":"2150-07-09 00:00:00.000","description":"Report","row_id":1663889,"text":"Respiratory Care\nPt remains on mechanical ventilation. No changes on this shift. Pt remains on CPAP-PS 12/5/40%. Last gas done at 1251 7.35/33/88/19/-6. Plan: No plan for extubation, continue mechanical ventilation as ordered.\n"},{"category":"Nursing/other","chartdate":"2150-07-09 00:00:00.000","description":"Report","row_id":1663890,"text":"Respiratory Care\nPt remains on mechanical ventilation AC 500/12/5/40%. Continued MDI's as ordered. Last gas at 1610 7.44/35/196/25/0. Went to IR this afternoon for a dialysis catheter. Plan to continue mechanical ventilation as order.\n"},{"category":"Nursing/other","chartdate":"2150-07-10 00:00:00.000","description":"Report","row_id":1663891,"text":"condition update\nPlease see carevue for details.\nNeuro: Sedated with fentyanl/versed, aroues to voice, does not follow commands. Some spontaneous nonpurposeful movements noted in the lower extremities, no movement noted in the upper extremities. Pupils equal and briskly reactive. Pain seems well controlled at 75mcg/hr fentynal.\nCv: Sinus 90's-100's, no ectopy. Sbp mainly 110's-120's. LR continues at 200cc's/hr. Peripheral pulses palpable.\nResp: LS clear/diminished. Remains mechancially ventilated on a/c, no vent. changes made. Suctioned for small amounts thick white sputum.\nGI: NPO, NGT to lws draining bilious drainage. Ileum drain to gravity draining brown liquid. Jp to bulb suction draining serosang drainage, jp to wall suction draining serosang as well. Abd. is open, packing intact. Bs absent.\nGU: Foley draining adequate amounts clear yellow urine.\nEndo: SSRI, bs 129 and 113.\nSocial: Brother called x's 1 for update.\nPlan: Monitor i/o status, pain management, ? social work consult, monitor hemodynamics, ? return to or.\n\n"},{"category":"Nursing/other","chartdate":"2150-07-10 00:00:00.000","description":"Report","row_id":1663892,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds dim bilat; mod th off white sput. MDI given as per order. ABGs stable; no vent changes required overnoc. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2150-07-13 00:00:00.000","description":"Report","row_id":1663906,"text":"condition update\nPlease see carevue for details. Post-op s/p ex-lap, wash-out and vac dsg placement.\nNeuro: Received from o.r. not reversed, currently sedated with fent./versed. pt was alert or aroused to voice, intermittenly agitated attempted to tongue out e.t. tube, etc.. Pupils equal and briskly reactive.\nCV: Sinus 80's-100's, no ectopy. Requiring post-op levophed briefly for map>65. Lr continues at 75cc's/hr. Albumin x's 3 doses started.\nResp: LS clear/diminished. Suctioned for thick white sputum. No vent. changes made.\nGI: Open abdomen with vac dsg intact to 75mmhg suction. Jp to bulb suctioned and ileum draining to gravity. NPO, NGT to lws. TPN continues.\nGu: Foley draining adequate amounts clear amber urine.\nEndo: bs wnl.\nPlan: Wean fent./versed as tolerated, monitor hemodynamics, prn levophed to keep map >65, continue albumin x's 2 more doses, comfort and support.\n"},{"category":"Nursing/other","chartdate":"2150-07-14 00:00:00.000","description":"Report","row_id":1663907,"text":"Condition update\nSee careview for objective data/trends:\n\nRemains sedated on fentanyl and versed gtt. Intermitantly waking and becoming aggitated. +pain per patient, fentanyl gtt increased from 125 mcg fentanyl to 200 for most of night although currently decreased to 175. Able to wean down versed gtt with better pain control, currently at 1.5mg/hr. Arousable to voice, following commands intermitantly. Able to nod to answer questions, bil weak hand grasps and moves ble spontanously. Tmax 100.1. SR-ST, initially HR 90's although increasing overnight to 100-110. BP trending down with systolic down to 88-92. LR bolus given with good effect, total 1L given. CVP 4-7. Lungs coarse, tolerating CPAP 5/5 with good oxygenation/ventilation. Abd wound open with vac dsg intact. Mesh underneith vac dressing, per HO ok to sit hob up. TPN infusing for nutrition. Adequate u/o. JP self sxn with serosang output. Vac dsg with serosang output. NGT with yellow/bilous drainage. Ileum draing with brown/green clear drainage with sedement. Plan to cont to monitor hemodyanmics, resp status, pain managment and sedation, ?plan for extubation.\n"},{"category":"Nursing/other","chartdate":"2150-07-14 00:00:00.000","description":"Report","row_id":1663908,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs stable; able to switch to PSV; currently on SBT doing well. Cont SBT; ? extub today\n"},{"category":"Nursing/other","chartdate":"2150-07-14 00:00:00.000","description":"Report","row_id":1663909,"text":"NPN:\n\nNeuro: Arouses to voice throughout day-weaned off midaz and pt extubated. Initially slightly confused. Now oriented to self and hospital but not consistent. Moves all extremities and follows commands consistently. Gets slightly agitated-wanting to get OOB and walk. Needs reorientation. ? pt inadvertently dc'd his aline. Ativan prn.\nSocial: Brother and daughter called and updated. Family referred to social worker- who will meet with brother and speak with daughter tomorrow.\nID: Tmax 99.9 orally-now 98.4. Pt c/o being cold and shivering/quivering. WBC 14.8. Vanco level 15.3-dose given this am. Cont on zosyn and fluconazole.\nCV: 95-110's SR-ST without VEA. Initially requiring levo to .03 to keep MAP>60-now off. Lopressor 5mg IV given X1. Palpable pedal pulses with 2-3+ pitting edema. CVP 6-11. Hct 29.9. Pneumoboots on.\nResp: Weaned and extubated at 1230pm to 40% OFT neb with sats>975. Now on 4l nc O2 with sat 98-99%. Lungs ess CTA with crackles L base. Cough fair-productive of small tan secretions.\nGU: Foley with amber colored UO>30cc/hr. Creat .7. Given lasix 10 mg IV X1.\nGI: Abdomen remains firm,round with wound VAC intact draining moderate serosang drainage. JP drain scant output. L ileal tube 300cc thick yellow green liquid with brown sediment. NPO with L nare NGT-100cc yellow bilious drainage. TPN at 63cc/hr. Rec 25% albumin q 6 hrs X4.\nEndocrine: Glucoses 122-135-no treatment needed.\nSkin: Coccyx with allevyn foam intact.\nComfort: Remains on fentanyl gtt weaned to 50 then ^ to 100 with c/o pain. Also started on methadone 5mg IV tid.\nActivity: Bedrest-turned side to side q 2 hrs with 2 assists. Multipodus boots removed this afternoon after pt awake and extubated.\nA: Extubated without difficulty. Stable BP off levo-cont with high volume need. Social work involved.\nP: NPO,TPN. Social work-? family meeting-assess patients awareness of illness. Cont IVAB. Ativan prn for agitation. ?decrease IVF. Discuss diuresis if remains off levo.\n"},{"category":"Nursing/other","chartdate":"2150-07-15 00:00:00.000","description":"Report","row_id":1663910,"text":"Condition update\nSee careview for objective data/trends:\n\nAlert and oriented to person, place and summer although at mildy confused but reorients easily. Following commands and cooperative with care. Ativan prn for anxiety, fent gtt for pain with good effect. Afebrile. HR 90-100 SR-ST. BP stable. Lungs clear but diminished, tolerating room air with sats>94%. Abd with vac dsg intact. Good u/o after lasix. Hct down to 25.2 sicu and primary team aware. Plan to cont to monitor, transition from fent gtt and maintain saftey and comfort.\n"},{"category":"Nursing/other","chartdate":"2150-07-21 00:00:00.000","description":"Report","row_id":1663923,"text":"NURSING UPDATE\n EARLY PM, PT GROANING WITH EACH EXHALATION, WIDE-EYED DURING CARE. WHEN ASKED IF IN PAIN PT \"YUP\" - ANALGESIA AND SEDATION INCREASED TO UPPER PARAMETER DOSAGE WITH GOOD EFFECT. PT SINCE OPENING EYES WHEN REPOSITIONED OR HYGIENE CARE DONE BUT NOT GROANING OR GRIMACING. VITAL SIGNS HAVE REMAINED ESSENTIALLY STABLE ALSO. CONTINUES TO DRAIN LG AMT OF BILIOUS DRAINAGE FROM ABDOMEN, SURGICAL RESIDENT INFORMED THIS NURSE VAC WOULD BE APPLIED THIS AM. ALL COMFORT AND HYGIENE CARE PROVIDED. PT APPEARS TO BE AT OPTIMAL COMFORT LEVEL AT THIS TIME.\nMONITORED CONTINUOUSLY. SEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n\n"},{"category":"Nursing/other","chartdate":"2150-07-21 00:00:00.000","description":"Report","row_id":1663924,"text":"Condition Update\nPt continues to receive CMO care. Receiving fent/ativan gtts continuously along with tid methadone IV. Pt is not responding to any verbal/physical stimulation. RR 15-17 with periods of apnea. THis afternoon respirations with gasping noise so ativan gtt increased from 4 to 6mg/hr. No significant changes noted today in vital signs. O2 sats 60-70 on RA SBP 70-80's. HR 80-90 with no ectopy noted. brother called for update x2. No visitors today. Palliative care involved. No further input today. Current plan to keep patient in ICU for CMO.\n"},{"category":"Nursing/other","chartdate":"2150-07-22 00:00:00.000","description":"Report","row_id":1663925,"text":"post-mortem nursing note\n Comfort measures maintained through shift, pt at optimal comfort status on fentanyl and ativan gtts. vital signs fairly unchanged until 0305, then quickly progressed to asystole. time of death 0307. family notified by dr .\n"},{"category":"Nursing/other","chartdate":"2150-07-05 00:00:00.000","description":"Report","row_id":1663868,"text":"7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO-Pt remains sedated on propofol/fentanyl drips. When propofol decreased to 20mcg/kg/min, pt. opened eyes to verbal stimulation and performed weak hand grasps on command. Pupils at 3mm bilaterally and reactive to light.\nCV/HEME-HR 80s-90s in NSR, no ectopy noted. Pt's BP has ranged 130's-140s/70s. CVP ranging . HCT this AM 23.6, Dr. aware of HCT but prior HCT 24.8 so no intervention done at present time.\nRESP-Pt remains intubated and ventilated on settings: AC mode, 40% fio2, 400 X 18, 5 PEEP. Settings unchanged over night. Pox has remained 98-100%. LS clear bilaterally, suctioned only minimally for scant amount of thick white secretions.\nGI-abdomen is open post-surgery. Abdomen is large, firm. Bladder pressures . Dressing intact to open surgical site and JP bulb drainaige continues to LIWS, putting out serosanquinous drainaige. NGT putting out small to moderate amounts of bilious fluid. Pt started on amino acid with dextrose \"quick mix\" bag this evening\nGU-foley putting out 30-40/hr of slightly amber colored urine.\nPLAN-monitor abdominal exams, blader pressures Q 4 hours. Continue IVF, sedation/pain med as needed with overall plan to return to OR ?Monday.\n"},{"category":"Nursing/other","chartdate":"2150-07-05 00:00:00.000","description":"Report","row_id":1663869,"text":"Respiratory Care:\nPt. remains intubated and on AC/18/400/40%/+5 no changes overnight, alarms on and working. Breath sounds decreased, suctioned for scant amounts of thick white secretions. RSBI 17. Continue current level of support.\n"},{"category":"Nursing/other","chartdate":"2150-07-05 00:00:00.000","description":"Report","row_id":1663870,"text":"Nursing Note\nPlease see carevue for details\n\nSedated on propofol - lightened dose x1 and pt opening eyes spontaneously and lifting bilateral LE off bed. On current dose, opens eyes occasionally to stimuli, but not lifting extremities and appears more comfortable. Fentanyl gtt for pain control. Tmax 100.0. HRRR. BP stable. 2+ edema to LE. LSCTA. Stable on vent. Abd with open wound - patch in place - draining moderate amounts foul-smelling, brick red fluid on LIS (SICU team aware). Bladder pressure . TPN infusing as ordered. No BS. Foley draining adequate amounts cyu. Duoderm to coccyx. Frequent turn and reposition. Brother in to visit and updated on POC.\n\nPlan: Monitor hct. Monitor abdomen closely for changes. OR Mon/Tues. Continue sedation/pain med gtts. Comfort and support.\n"},{"category":"Nursing/other","chartdate":"2150-07-05 00:00:00.000","description":"Report","row_id":1663871,"text":"patient passively resting on mechanical ventilation.Post exp lap abdomen still opened with Kentukey patch on.Compensated Blood gas on rate of 14.Following simple commands @ times will continue to follow.\n"},{"category":"Nursing/other","chartdate":"2150-07-08 00:00:00.000","description":"Report","row_id":1663883,"text":"NPN (NOC):\n\nCV: PT HAS BEEN HEMODYNAMICALLY STABLE OVERNOC OFF PRESSORS.\n\nRESP: PT REMAINS INTUBATED. LATEST ABG: 185/30/7.44/21. VENT SETTINGS CHANGED TO 12X500X40%. PT HAS BEEN OVERBREATHING TO HIGH TEENS, LOW 20'S. WILL REPEAT ABG. BS'S CLEAR. SX'D FOR MINIMAL SECRETIONS. AFEBRILE.\n\nNEURO: PT SEDATED. FENTYNL DRIP INCREASED TO 100 MCG'S D/T OVERBREATHING W/O EFFECT. PT WILL OPEN EYES BUT NOT TRACK. DOES NOT FOLLOW COMMANDS, BUT I HAVE OCCASIONALLY NOTED SPONTANEOUS MOVEMENT W/ TURNING ETC. PERL.\n\nGI: ABD REMAINS OPEN. JP TO LCS PUT OUT 700 CC'S OF STRAW COLORED FLUID OVERNOC. NGT TP LCS PUT OUT 500 CC'S OG BILIOUS MATERIAL. TPN CONT.\n\nF/E: I&O BEGINNING TO RUN NEGATIVE OVERNOC. CVP'S . LE'S REMAIN VERY EDEMATOUS. UO VERY GOOD. REPLETED W/ 20 MEQ'S IV KCL.\n"},{"category":"Nursing/other","chartdate":"2150-07-08 00:00:00.000","description":"Report","row_id":1663884,"text":"Respiratory Care\nPt remains on mechanical ventilation AC 40%/500/12/5. Pt went to OR today to place drain in ileum. Abdomen still open. BS clear bilaterally. Sxn thick amounts of white secretions. MDI's continued as ordered. Plan: Continue mechanical ventilation and MDI's as ordered.\n\n"},{"category":"Nursing/other","chartdate":"2150-07-08 00:00:00.000","description":"Report","row_id":1663885,"text":"nursing note\nNeuro:pt remains sedated on versed gtt, fentanyl for comfort. Pt squueze hands lightly, blinks eyes. Question if consistent enough to use as communication.\nCV:ST, rare PVC's, maintaining bp off pressors. BP bolus on way to OR for BP sys 80's.\nRESP:remains on cmv with abg's wnl.\nGI:ngt to LWS drng billious. JP to bulb suction in pelvis and JP to wound overlay to wall suction. PRe OR, stool leaking from wound. MD aware. Post OR, ileum drain to gravity and draining stool with bile.\nGU:foley patent amber to yellow urine.\nSKIN:allevyn intact. remains on kinair.\nSOCIAL:brother calling for update and spoke with MD post surgery. MD states brother would like patient to remains full code until ne speaks with rest of family. Brother made aware of poor prognosis.\n\nPLAN:Cont versed/fentanyl gtts. Levophed if MAP <60. await post-op labs. TPN. antibiotics a/o. await family decisions.\n"},{"category":"Nursing/other","chartdate":"2150-07-09 00:00:00.000","description":"Report","row_id":1663886,"text":"condition update\nPlease see carevue for specifics.\nNeuro: Sedated with fentynal and versed gtt's. Pt opens eyes to voice, does not follow commands or move extremities --> fentynal and versed weaned down - will continue to monitor. Bilater pupils equal and briskly reactive, +gag, impaired cough. Pt appears comfortable, pain well controlled with fenynal gtt.\nCV: Sinus 100's - 110's with occasional pvc's. Sbp mainly 100's 0- 120's. Peripheral pulses weakly palpable. Received 500cc LR bolus x's 1 as it was noted that wound vac output is large, urine is concentrated and pt is tachycardic. Hct 31 (up from 29). INR 1.7.\nResp: Ls clear/diminished, remains mechancially ventilated, no vent. changes were made, suctioned for nothing. 02 sat 100%. Abg's acceptable.\nGI: NPO, TPN infusing. Abd. is open, 'wound vac' (jp to wall suction) is draining large amounts serosang drainage, jp to bulb suction is draining mod. amounts serosang drainage. Ileum tube is draining brownish/bilious colored liquid to gravity. NGT is to lws and draining clear to bilious fluid. Bowel sounds are absent.\nGU: Foley draining adequate amounts clear amber urine.\nEndo: Sliding scale regular insulin prn.\nSocial: No phone calls/visitors this shift.\nPlan: Monitor hemodynamics, IVF and bolus's prn, replete electrolytes prn, monitor coags, pain management, comfort and support.\n"},{"category":"Nursing/other","chartdate":"2150-07-12 00:00:00.000","description":"Report","row_id":1663902,"text":"nursing note\nNeuro:pt remains sedated on versed and fentanyl. Attempted wean at evrsed gtt, pt opening eyes and following commands consistently, pt agitated and attempting to pull at ETT tube and sit up in bed. MD aware, pt resedated lightly on versed gtt and ativan given to maintain. Fentanyl gtt remains for pain.\nCV:SR to ST associated wtih alertness. neg 1600 thus far today. LR decreased, cvp adequate.\nRESP:LS coarse,thick white secretions. pre op cxr done.\nGI:abd remains packed with wound packing and overlay JP to wall suction draining copious amounts. JP to bulb drainage, resecured with tegaerm. Team aware that not holding suction at times.\nGU:foley apatent amber adeq. amounts.\nSKIN:allevyn intact. on kinair bed.\nSOCIAL:sw consulted for estranged daughter relationship. Daughter visibly upset by fathers health and last time they spoke they foiught. MD also emailed for family meeting at some point this week.\n\nPLAN:OR tomorrow for wash out and closure. fentanyl and versed for sedation/pain. prn ativan. antibiotics a/o. family support and meeting this week with sw consult.\n"},{"category":"Nursing/other","chartdate":"2150-07-13 00:00:00.000","description":"Report","row_id":1663903,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. Pt in NARD on current settings; no vent changes required overnoc. Cont mech vent support.\n\n"},{"category":"Nursing/other","chartdate":"2150-07-13 00:00:00.000","description":"Report","row_id":1663904,"text":"7pm-7am Nursing Note\nSee CareVue for objetive data and trends:\n\nPt remains sedated on versed drip at 2mg/hr and fentanyl at 125 mcg/hr. Pt opens eyes to verbal stimuli through sedation, will follow commands inconsistantly. Performing weak hand grasps and pt moving BLE on bed spontaneously. , pt very agitated when sedation lightened.\nPt noted to have occasional fine tremors and pt given PRN ativan Q 3-4 hours. Pt's HR 70s-80s in NSR with no ectopy and BP 100-130s/60s-80s. Pt's BP noted to increase/decrease depending o level of sedation. Pt remains intubated and on vent settings: AC, 40% fio2, 500 X 12, 5 peep. LS clear to coarse and being suctioned for small amounts of thick white secretions. Pox has maintained 98-100%.\nPt with open abdomen and plan to return to OR today. JP drain to self suction and wound drain to suction putting out yellow colored output.\nTmax 99.8, wbc 7.0 today and pt continues Vancomycin, fluconazole and zosyn for coverage.\nPLAN-Pt planned for OR today for possible closure of abdomen. Follow VS, continue antibiotic coverage. Social work consulted to follow-up with family.\n"},{"category":"Nursing/other","chartdate":"2150-07-13 00:00:00.000","description":"Report","row_id":1663905,"text":"Respiratory therapy\npt received this morning on AC. bs clear but diminished. mdi given as ordered. no respiratory distress noted. plan to continue with current vent settings.\n"},{"category":"Nursing/other","chartdate":"2150-07-16 00:00:00.000","description":"Report","row_id":1663913,"text":"Nursing progress note\nPt returned from OR @ 730am. Paralyzed, vented on prop and Neo. A-line in right radial, triple lumen CVL in RSC, dual lumen picc in LAC. 4 abd drains present w/ packingin place. Sbp 90's-100. Per Surgical team wash out only done. Not able to reconnect bowel or close abd. Unknown if they will be able to close abd. Dr spoke w/ brother on phone in am re: prognosis.\n\nPt started moving around by 10 am. Fent Gtt restarted @ 75mcg's. Goal is to wean Fent, by increasing methadone. Methadone increased in afternoon to 10 mg. Fent down to 50mcg's. Propofol off at noon. Pt more alert. Following commands. MAE on bed. Became restless attempting to sit up and talk over ETT. Ativan 1mg given with good effect, pt more calm.\nLs course to clear by afternoon w/ dim bases L > R. O2 sats 98-100%. Suctioning small amts thick tan sputum from ETT. Weaned to cpap+ps 5/5 per abg's. MV up to 18. Pt c/o pain. Fent bolus given and gtt increased to 75mcg's.\nMV back down to 8-10. By late afternoon pt extubated per SICU team, placed on 4l NC. 02 sats 100%.\nNeo weaned off by noon. SBP per a-line 100-110's. Occlusive pressure confirmed accuracy of a-line. Goal is to keep SBP >100 MAP >60. Hr 70-90's SR no ectopy seen. CVP 7-10 No IVF ordered per fluid balance.\nUrine output 30-100hr concentrated clear urine.\nAbd packed, dist, 4 drains present. No bs. Coccyx has allevyn dsg in place due to be changed . Cream applied to back and heels. TPN infusing.\nBrother called in to obtain phone #. He will be in this evening.\nEthics consult was placed regarding the family's capacity to understand the gravity of the situation\nPlan:\nContinue to monitor abd drains and dsg's for signs of stool leak.\nMonitor temp and resp status potential for sepsis.\nPossible OR tomorrow for washout.\nFamily meeting possibly @ noon tomorrow.\nEthics to be involved along with social services to help support family and pt.\nFent and ativan prn for breakthrough pain and restlessness.\n"},{"category":"Nursing/other","chartdate":"2150-07-16 00:00:00.000","description":"Report","row_id":1663914,"text":"Respiratory Care:\nPt recieved from the OR this AM s/p bowel surgery. He has wakened nicely and over today and was weaned to extubation to a 4L/m NC. Presently doing well. HR = 90; bp = 119/64; RR = 18; O2 Sat = 100%\nHe remains critically ill with surgical issues, will watch over noc.\n"},{"category":"Nursing/other","chartdate":"2150-07-04 00:00:00.000","description":"Report","row_id":1663867,"text":"Nursing Note\nPlease see carevue for details\n\nPt sedated on propofol. Appears comfortable - receiving fentanyl drip for pain control. PERRL, 3mm bilat, briskly reactive. HRRR. BP stable. Bladder pressure 10. TLCL placed in right subclavian. 2+ edema noted to bilat LE. +pp/csm. Calcium, mag, and k repleted. Stable on vent. LSCTA. No gag/weak cough. Abdomen firm with open wound - patch. Abd wound to intermittent wall suction - small amounts sero-sang drng. No BS. NPO. NGT to LCS - draining small amounts bilious drng. Foley draining adequate amounts dark yellow urine. Decubitus (stage 3) noted to coccyx - duoderm placed and freq turn/reposition - skin care consult placed.\n\nPlan: Maintain pt comfort - keep sedated per team. Monitor bladder pressure q4hours. Monitor labs. Monitor open abdomen. Maintain skin integrity.\n"},{"category":"Nursing/other","chartdate":"2150-07-19 00:00:00.000","description":"Report","row_id":1663920,"text":"Nursing Note 7a-7p:\nNursing Assessment:\n\n brother and mother in to visit this morning and to discuss code status with surgery team. MD covering for MD and met with the family. Family feels that pt would not want to return to the OR and would like to make the patient comfort measures only. Pt received large doses of ativan and fent/haldol overnight for agitation and again this morning requiring ativan and increase in fent gtt for attempts OOB/ yelling, pulling at tubes/drains in open abdomen. MD plan is to keep patient in icu today with fent gtt/ativan, etc as needed for comfort and agitation. VAC dressing will be placed on abdomen to contain drainage and tommorrow pt can be called out to the floor/ contact hospice care. Pt becoming very restless, attempting oob, yelling out, and crying mostly disorientated. Medicated with ativan for a total of 4 mg at this time and fent gtt increased periodically up to 200mcq /hr. Pt continued to cry and attempt oob and medicated with 1 mg haldol with good effect. Plan: cont fent gtt, ativan, haldol, methadone as needed and consider switching to morphine gtt if nto reaching adequate level of comfort for pt. emotional support for the patient and the family. Please see carevue for further details.\n"},{"category":"Nursing/other","chartdate":"2150-07-20 00:00:00.000","description":"Report","row_id":1663921,"text":"Condition update\nVery aggitated this evening, crying and yelling out, attempting to sit up and pulling at abd dsg and tubes. Large hole ripped in dressing and small area bowel exposed, Gold surgery and SICU resident aware and dressing reinforced with transparent dressing. Fentanyl gtt increased and ativan gtt started after mult doses ivp ativan to keep pt calm/comfortable. Able to wean down fentanyl gtt after ativan started although cont to require high doses as pt crying out in pain and very aggitated when awake. Pt currently appears very comfortable. Cont with comfort care and provide support. No calls from family overnight.\n"},{"category":"Nursing/other","chartdate":"2150-07-20 00:00:00.000","description":"Report","row_id":1663922,"text":"Nursing Note 7a-7p:\nNursing aSsessment:\n\nPt is comfort measures only and remains sedated on fent gtt and ativan gtt. Increased/ fent bolus for turning d/t moaning and grimacing on turns. Gtts also increased for agonal breathing with good effect. Hospice care into evaluate as well as social work and case managment. All agree that pt is to remain in icu at this time d/t requirements of large amounts of sedation in order to keep comfortable. Reinforcing abdomen d/t large amounts of leakage and still awaiting surgery team to place vac dressing to contain drainage. Plan: Keep pt comfortable; titrate gtts as needed. Please see careuve. Pts brother called and updated by RN and spoke with social work as well.\n"},{"category":"Nursing/other","chartdate":"2150-07-17 00:00:00.000","description":"Report","row_id":1663915,"text":"condition update\nPlease see carevue for specifics.\nNeuro: Alert and oriented x's 2, remains confused but less so than the previous night. More cooperative with care, less agitated. Pain controlled with fentyanl gtt (which was titrated down to 50mcg/hr) and tid iv methadone. Pt sleeping most of the night.\nCV: sinus 80's-90's, no ectopy. Sbp mainly 90's-100's, lopressor held. Peripheral pulses palpable. Hct 23. K+ and Mag repleted x's 1.\nResp: LS clear/diminished, 02 sat 97% on 4 liters n.c. Pt has congested cough, coughing/deepbreathing encouraged.\nGI: NPO. NGT to lws draining bilious drainage. Ileum drain to gravity draining brown liquid stool. Jp to wall suction draining dark serosang drainage, Jp to bulb suction unable to hold suction, and drain #2 to gravity draining small amounts brown liquid. Abd. is packed, dsg is intact.\nGU: Foley draining adequate amounts clear amber urine.\nEndo: BS wnl.\nSocial: brother, sister in law and daughter at bedside visiting earlier in the evening, will return at 12noon today for possible family meeting.\nPlan: Pain management, wean fentynal as tolerated, monitor hemodynamics, encourage coughing and deep breathing, monitor drains' output, continue iv abx, comfort and support.\n"},{"category":"Nursing/other","chartdate":"2150-07-17 00:00:00.000","description":"Report","row_id":1663916,"text":"NEURO; A&OX3, FOLLOWS SIMPLE COMMANDS, C/O ABD DISCOMFORT WHEN REPOSITIONED, METHADONE DOSE INCREASED TO 12.5 MGM IV TID, PTMET WITH SOCIAL WORKER AND HIS BROTHER TODAY AND DISCUSSED HIS WISHES TO DECLINE FURTHER SURGERY, FAMILY IN AGREEMENT WITH PT PER SOCIAL WORKER, PT REMAINS ON FENT GTT AT 50 MCG/HR\n\nCARDIOVASCULAR; HR 90'S, SR, TEMP 99.6, TRIPLE LUMEN AND PIC LINE ACCESS,\n\nRESPIR; LUNGS CLEAR, 02 SAT 95%,\n\nWOUND; OPEN ABD WOUND, PACKED WITH STERILE LINEN PACKING, JP DRAIN TO SELF SX, DRAIN #2 TO LWSX-MODER BROWNISH DGE, ILEOS BAG TO DGE, SMALL AMT LIQUID DARK BROWN DGE,\n\nPLAN; BROTHER WILL BE IN TOMORROW AND WOULD LIKE TO TALK TO MD'S ON DR. SERVICE REGARDING PT'S WISHES TO DECLINE FURTHER SURGERY, AND ? OF ADDRESSNG FUTURE FEEDING ISSUES, ETC., HELP PT ATTAIN COMFORT AND REST, EMOTIONAL SUPPORT TO PT AND FAMILY\n"},{"category":"Nursing/other","chartdate":"2150-07-18 00:00:00.000","description":"Report","row_id":1663917,"text":"Condition update\nSee careview for objective data:\n\nAlert and oriented this evening but became very disoriented and aggitated at 2200, unable to redirect and pt pulling at lines and attempting to get oob, given 2 mg ativan with fair effect. Additional 1 mg ativan given overnight although pt remains calm he is confused and often disoriented. He is currently calm and cooperative. C/o intermitant pain but mostly comfortable on fent gtt, requires 25mcg bolus for repositioning. Tmax 100.4. SR HR 80-90 no ectopy. BP stable. LUngs clear but diminished. ABd remains packed with jp to wall sxn. Drainage from jp noted to be brownish opaque, Dr aware and into assess. Good u/o. Plan to cont to monitor neuro status, resp status, s/sx worsening infection, provide support.\n"},{"category":"Nursing/other","chartdate":"2150-07-07 00:00:00.000","description":"Report","row_id":1663877,"text":"Condition update\nSee careview for objective data/trends:\n\nInitially sedated on propofol with fentanyl gtt for pain managment. On current propofol and fentanyl gtt rates no withdrawl/grimice noted to painful stimuli. Propofol off at MN for neuro exam and although not withdrawing to nailbed +grimice to nailbed pressure x 4 extremities and noted to move ble spont. HR elevated when propofol off and noted to be tremulous, given 1 mg ativan for suspected etoh withdrawl. Attempted to maintain lower propofol gtt rate d/t increase in BP with decreased propofol rate although pt remained tachycardic. Midaz gtt initiated for sedation and propfol off and HR remains <100, normotensive off levophed, and no tremors noted. Afebrile. HR 90's with vent bigemeny noted this evening, resolved with 2 gm mag sulfate (previous mag 1.8) then no ectopy noted until 0200 and pt in and out of vent bigeminy. Lytes wnl, no repleation indicated. EKG and cardiac enzymes done. Dr and Dr aware. Given additional 1000cc LR bolus with minimal effect. CVP remains . BP remains stable with ectopy. Transfused with 1 unit prbc and 1 unit ffp, goals hct >28 INR >1.8. +pitting edema bil lower ext. Lungs clear but diminished. No vent changes made, cont on AC 40% 16x500 5 peep occasionally breathing over set rate. ABG good oxygenation/ventilation. Last ABG 7.4/39/207/0/25. Abd open, packed and covered with occlusive transparent dressing, JP to abd to wall sxn with large amt brown/bloody output. Ngt with icteric output. Bladder pressure 8. Adequate urine output. Tbili 3.8 this am, Dr and Dr aware, direct bili pending. Lactate stable at 1.2 Cont to monitor hemodynamics, resp status, fluid balance, q4 hct/plt and coags, s/sx etoh witdrawl. provide comfort and support.\n"},{"category":"Nursing/other","chartdate":"2150-07-07 00:00:00.000","description":"Report","row_id":1663878,"text":"Respiratory Care\nPt continues on mechanical ventilation. BS clear bilaterally. No changes made to ventilator settings. Atrovent MDI ordered and given in the afternoon. Plan: To continue mechanical ventilation and MDI's.\n"},{"category":"Nursing/other","chartdate":"2150-07-07 00:00:00.000","description":"Report","row_id":1663879,"text":"N - Patient neuro status changed since prior shift. Since propofol gtt discontinued and fentanyl gtt decreased patient will open his eyes to verbal stimuli and will move left lower extremity on bed. He does not follow commands but continuously would open eyes without tracking to verbal stimulation. PERRL at 4mm bilaterally with brisk response. Cough and gag intact, no hand grasp. Fentanyl and versed gtts for sedation and comfort.\n\nCV - HR has been continuously NSR throughout shift in the 80s to 90s. Initially frequent runs of bigeminy noted, electrolytes from AM stable. Right SC TLC noted to be within the right atrium, pulled by resident and PCXR confirmed correct placement, bigeminy noted to lessen but continue, electrolytes checked later in shift and replaced magnesium and calcium per sliding scale order. BP has been stable this shift, levophed has remained off this shift with SBP high 90s-low 100s with MAP well above 60mmHg. Patient has remained afebrile. Patient has peripheral pitting edema noted and pulses have remained palpable.\n\nR - Patient remains on mechanical ventilation via ETT this shift with adequate ABGs and sats greater than 98%. Patient has PMH of smoking for greater than 30 years, lung sounds initially contained inspiratory wheezes, combivent MDI q6h ordered and LS have remained clear and diminished in the bases. ETT suctioned for small thick white secretions. Pt remains in reverse trendelenberg.\n\nGI - Patient's abdomen remains open with ioband dressing and surgical towel intact. Bowel sounds are absent and abdomen is firmly distended. Wound has JP drain to medium wall suction with dark yellow transparent drainage noted in large amounts noted, NGT to LCWS with very similar drainage qualities in amounts documented. No BM this shift though hemorrhoids noted to be edematous.\n\nGU - Foley draining amber clear urine in amounts documented, noted to be marginal at times, overall greater than 30mL/hr. IVF of LR infusing at 125mL/hr.\n\nACCESS - Right radial arterial line has good waveform noted, good blood return, good distal CSM noted and good correlation with NIBP. Right SC TLC intact with CVP monitored as above, CVP between . Left wrist 16G placed this shift after old PIV expired.\n\nENDO - RSSI given for elevated blood glucose, continue to monitor every 6 hours as ordered.\n\nSKIN - Wound nurse in to eval patient. Noted to have stage III ulcer on coccyx, dressed with hydragel and allevyn dressing, plan to change dressing every 3 days with hydragel and allevyn. Skin otherwise noted to be edematous and frail, no further breakdown noted. Patient turned frequently and remains on kinair mattress to alleviate pressure points.\n\nP/S - Brother called earlier this shift and updated on plan of care and patient's condition, no visitors or other calls this shift. All aspects of patient's care have been explained to him prior to performing them.\n\nID - Antibiotics administered as ordered. WBC noted to be increased over the pa\n"},{"category":"Nursing/other","chartdate":"2150-07-07 00:00:00.000","description":"Report","row_id":1663880,"text":"(Continued)\nst shifts, afebrile, lactate 0.8.\n\nPLAN - continue to monitor VS frequently, monitor hct/platelets/coags q4h's and plan to replace blood with PRBCs if less than 28, plan on FFP if coags less than 1.8, frequent turning and kinair mattress, wound dressing changes, monitor abdominal qualities and continue NGT/JP to suction, plan to go to OR for ? closure/resection of bowel, fentanyl/versed for sedation/comfort, replace electrolytes, keep patient/family informed on plan of care.\n"},{"category":"Nursing/other","chartdate":"2150-07-07 00:00:00.000","description":"Report","row_id":1663881,"text":"addendum: IVF changed to LR at 40/hr\n"},{"category":"Nursing/other","chartdate":"2150-07-08 00:00:00.000","description":"Report","row_id":1663882,"text":"Resp: pt on a/c 16/500/+5/40%. BS are clear bilaterally. Suctioned for scant amounts of white secretions. MDI's administered atr as ordered with no adverse reactions. AM ABG 7.44/30/185/21. Decreased rate to 12. RSBI=75. No further changes noted. Continue on present settings.\n"},{"category":"Nursing/other","chartdate":"2150-07-11 00:00:00.000","description":"Report","row_id":1663897,"text":"nursing note\nneuro: versed weaning with addition of ativan. Pt opening eyes and periodically following commands. Moving all extrem spont on bed. Fentanyl gtt remains. low grad temps cont. Vanco held for trough 23. To be rechecked this eve.\nCV:SR to ST, no relief in tachycardia with fentanyl bolus. Lopresoor held secondary to borderline BP at noon.\nRESP:LS coarse to diminished. suctioned for thick white secretions.\nGI: NGT with bilious icteric output. JP with ascites looking output. Wound drain with copious amounts of yellow clear frothy output. Ileum drain remains to gravity with light brown output with specs of dark brown stool. abd remains open with packing intact.\nGU: foley patent draining amber output.\nSKIN: allevyn intact. multipodus boots on.\nSOCIAL:daughter in to visit and emotional. Asking appropriate questions.\n\nPLAN:wean versed as tolerated, ativan prn for sedation. fentanyl gtt for pain. abx a/o. Monitor I+O's, allow to get net negative if BP tolerates. ? OR for monday. skin/wound care.\n"},{"category":"Nursing/other","chartdate":"2150-07-11 00:00:00.000","description":"Report","row_id":1663898,"text":"Resp Care\nPt remains intubated on CMV, no vent changes. Sx small white thick. Plan to continue with current tx, ?? OR for Abd closure next week.\n"},{"category":"Nursing/other","chartdate":"2150-07-12 00:00:00.000","description":"Report","row_id":1663899,"text":"Resp Care Note:\n\nPt cont intub with OETT as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs remain ess unchanged; no vent changes required overnoc. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2150-07-12 00:00:00.000","description":"Report","row_id":1663900,"text":"Condition update\nSee careview for objective data:\n\nAlert overnight, following commands much more consistantly and nodding appropriotly to some questions. Midaz gtt weaned off and receiving prn ativan with good effect. Fent gtt increased d/t pt nodding yes to pain consistantly on exam early am. Tmax 100.6. ST HR 100, decreases breifly to 80's after lopressor dose. Frequency of dose increased with good effect. Lungs coarse occasionally, clear with sxn. No vent changes made, abg shows adequate oxygenation/ventilation. Abd remains open. No change in drain outputs. Adequate u/o. Plan to cont to monitor hemodynamics, resp status, drainage, plan for ?or monday.\n"},{"category":"Nursing/other","chartdate":"2150-07-12 00:00:00.000","description":"Report","row_id":1663901,"text":"Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Continues on A/C ventilation w/ PIP = 18, SpO2 90s, Ve ~6-7L/M. ETT secure/patent. MDI given as documented. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"},{"category":"Nursing/other","chartdate":"2150-07-18 00:00:00.000","description":"Report","row_id":1663918,"text":"ALTERED COMFORT\nS: \"IT HURTS RIGHT THERE\"\nO: CARDIAC: SR 80-70'S IV LOPRESSOR X1. SBP 100-130'S. EXTEMITIES WARM AND DRY. PALP PP. HCT 24.3. CVP <10. K TO BE RECHECKED.\n RESP: O2 @ 4 L NP WITH O2 SAT >95%. BS DIMINISHED BIBASILAR,CLEAR UPPER. NONPRODUCTIVE CONGESTED COUGH. INSTRUCTED ON USE OF HIS COUGH PILLOW.\n NEURO: EASILY AROUSABLE, ORIENTED TO SELF AND DATE , NOT PLACE THEREFORE REORIENTED PRN BY NURSE. PERL AND BRISK, GRASPS EQUAL AND FAIRLY STRONG , CAN LIFT LEGS OFF BED. FOLLOWS COMMANDS. CALM MOST OF DAY, SLIGHTLY ANXIOUS PRIOR TO DAUGHTER ARRIVING. RECEIVED .5 MG IV ATIVAN X 1 WITH GOOD EFFECT.\n GI: NGT + PLACEMENT DRAINING GOLD DRAINAGE 300 ML SO FAR. ABD OPEN ? CLOSE OR APPLY MESH . DRAINS DRAINING -PLEASE SEE I+O, ABSENT BOWEL SOUNDS, NO STOOL FROM RECTUM. TPN CONTINUES.\n GU: ADEQUATE UO- AMBER WITH SEDIMENT.\n ID: CULTURES PENDING, TEMP MAX 100.4. VANCO LEVEL 10-RECEIVED VANCO+ZOSYN.\n ENDO: HAS NOT REQUIRED SSI\n PAIN: CONTINUES ON FENTANYL AT 50 MCQ WITH .25 MCQ BOLUS X 4 PRIOR TO MOVING.\n SOCIAL: DAUGHTER INTO VISIT AND UPDATED. BROTHER TO ARRIVE TO DISCUSS PLAN ? NO FURTHER OR/ WILL SPEAK WITH DR.\nA: STABLE AT PRESENT, ABD PAIN.\nP: MONITOR COMFORT-FENTANYL, HR AND RYTHYM, SBP, CVP, PP, TEMP, RESP STATUS-PULM TOILET, NEURO STATUS-REORIENTE PRN, I+O-CONTINUE TPN, LABS PENDING. DISCUSSION RE: PLAN. AS PER ORDERS.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2150-07-19 00:00:00.000","description":"Report","row_id":1663919,"text":"Condition update\nSee careview for objective data and trends:\n\nDisoriented this evening and worseing overnight. Aggitated and at times combative attempting to hit staff and get oob. Given ativan with good effect, given haldol x 1 for questionable delirium with no effect. Fentanyl gtt increased to keep pt comfortable. Abd dsg no longer occlusive d/t movement and leaking bile from bottom dressing. SXN not working d/t non occlusive dsg. Dr (Gold ) up to assess. Attempted to reinforce with tegaderm but not sucessful. Hob at 15 and attempted to keep pt calm and still d/t open abd with non occlusive dsg. Dr (sicu) aware and into assess aswell. Awaiting surgery resident to speak with Dr re: plan for abd dsg as pt and family has expressed wishes to not return for additional surgeries as pt has poor prognosis. Currently hemodynamically stable, SR 80's, BP stable SBP 100-130's. Temp 101.2, pan cx. WBC stable at 8 this am. Increased o2 requirement overnight, Dr and Dr aware. ABG wnl. LUngs clear. CXR done. Good u/o. Awaiting surgery rounds for plan re: open admomen, cont to monitor hemodynamics, monitor abd drainage for s/sx stool, maintain saftey and comfort.\n"},{"category":"Nursing/other","chartdate":"2150-07-10 00:00:00.000","description":"Report","row_id":1663893,"text":"please see carevue for details of care\n\npt intubated, sedated on 2 mg/hr midazolam. Daily wake up done, pt arouses to voice, does not follow commands. Moves all extremities spontaneously, does not withdrawl to pain, grimaces to nailbed pressure. Pupils 3-4mm equal and reactive. No signs/symptoms of pain, specifically no shaking, no agitation, no grimace, 75 mcg/hr fentanyl infusing as ordered. T max 99.9, HR 90s-100s, SR/ST, no ectopy. BP 120s-140s/60s-70s. Midazolam restarted at 1 mg/hr for HR remaining >100 and SBP 140s. Generalized edema noted, +DP/PT pulses. SCD boots in place. LR changed to LR with 20KCl, awaiting pharmacy delivery. Electrolytes repleted as ordered. Lungs CTA all lobes posteriorly, remains ventilated on AC 40% FiO2, rate 12, PEEP 5. O2 sat=100%. Suctioned x1 for scant clear secretions. Open abdomen with VAC dressing in place, draining large amounts of ascities appearing fluid. BS absent. L nare NG tube to LCS draining bilious fluid. Ileostomy tube to gravity, draining brown fluid. pt remains NPO, TPN infusing @ 64 cc/hr. Pelvic JP draining clear serosanginous fluid. Foley catheter draining approx 60 cc/hr clear amber urine. ABdominal dressing C/D/I. Stage III coccyx ulcer with allevyn dressing. Eye drops/eye lubricant applied q 4 hrs for dry eyes. Family at bedside, updated re: plan of care.\n\nPlan: continue to monitor hemodynamic status, monitor drains s/s infection, assess respiratory status, assess GI status, assess pain level, assess neuro status, maintain pt safety.\n"},{"category":"Nursing/other","chartdate":"2150-07-10 00:00:00.000","description":"Report","row_id":1663894,"text":"Resp Care\nPt remains intubated on CMV, no vent changes. Sx for scant white. Plan to continue with current tx.\n"},{"category":"Nursing/other","chartdate":"2150-07-11 00:00:00.000","description":"Report","row_id":1663895,"text":"Condition update\nPlease see careview for objective data/trends:\n\nAlert initially this evening although not following commands. Moving all extremities spontanously. Pt nodding at times but infrequently but when attempting to communicate is appropriote. Sedation increased after pt attempted to push ETT out with tongue, currently well sedated on midaz and fent gtts. Appears comfortable. Tmax 100.3 ST HR 100-110 this evening with SBP 150's. Started on lopressor with good effect, currently SR HR 80-90's no ectopy noted. Remains normotensive. Lungs mostly coarse but clear after sxn. Remains on AC, no vent changes made. ABG WNL. Abd remains open and packed, covered with occlusive dressing. JP to wall sxn draining +ascities to intra abdominal space. JP to pelvic space draining clear serosang fluid. Ileum tube to gravity with clear amber fluid with some sedement draining. NGT draining light clear yellow fluid. Good u/o. HCT and INR stable. WBC down this am to 9. Plan to cont to monitor s/sx worsening infection, monitor hemodyamics and resp status.\n"},{"category":"Nursing/other","chartdate":"2150-07-11 00:00:00.000","description":"Report","row_id":1663896,"text":"Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs stable; no vent changes required overnoc. Cont mech vent support.\n"},{"category":"Nursing/other","chartdate":"2150-07-15 00:00:00.000","description":"Report","row_id":1663911,"text":"nursing note\nNeuro: Patient alert, confused to course of events with labile mood. Intermittent pain with turns, methadone increased and fentanyl weaned. After dose of increased methadone, patient appears more comfortable and sleepy. Easily arouses to voice. Less complaints of anxiousness after increase in methadone.\nCV:SR to ST, no ectopy. SBP WNL. remains on lopressor q4. PICC placed for long term TPN use. At this time, 3 ports needed so central line left in place. PT/OT consulted.\nRESP:LS clear, diminished. Weak non-prod cough. o2 sats down to 93% on RA when asleep.\nGI: NGT to wall suction drng yellow bilious drng with decrease in output.\nGU:foley patent dark amber icteric urine.\nSKIN: Wound team re-evaluated coccyx wound. duoderm gel with allevyn foam applied, wound healing. Bed changed to first step to facilitate OOB. Wound care signed off at this time.\nSOCIAL: Social work fooliwng and spoke with family re:long term plans of rehab and nursing home. Family expressing inability of patient to retun to home where he lives with his 84 year old mother. Patients also in to visit and spoke with sicial work.\n\nPLAN: Vac change thurs at bedside, OOB, mointor I+O's, wean fentanyl with increase in methadone. rehab screen.\n"},{"category":"Nursing/other","chartdate":"2150-07-16 00:00:00.000","description":"Report","row_id":1663912,"text":"condition updated\nPlease see carevue for specifics.\nNeuro: Pt noted to be increasingly more confused throughout the night. Cooperative at times, agitated at other times. Pain controlled with fentynal gtt and methadone iv atc. Moves all extremities on the bed.\nCV: Sinus 90's-100's, no ectopy. Sbp 100's-140's. Peripheral pulses palpable. LR increased to 100cc's/hr. K+ and Mag repleted. Hct stable at 25.\nResp: LS clear/diminished. 02 sat dropped to 92, 4 liters n.c. applied and sat improved to 97%. Congested cough, pt not able raise sputum, coughing/deep breathing encouraged.\nGI: NGT to lws draining bilious drainage, ileum draining brownish fluid. JP with minimal serosang, and wound vac draining serous/light brownish drainage. It was noted roughly around midnight that wound vac white sponge was stained brown on right side. Dr. notified and at bedside to evaluate just before 1am. Brown fluid appearing like stool was noted to be also leaking outside dsg at ileum tube site and near jp, and also extending to right side of wound vac white sponge. Dr. was notifed per Dr. . Pt will be returning to o.r. at 0530 for re-exploration. Brother notified and spoke with Dr. over the phone.\nGu: Foley draining cloudy urine, dr. aware, u/a and culture sent. Urine output is adequate.\nEndo: No ssri coverage necessary.\nID: Temp spike 101.2 at midnight, urine and blood cultures obtained.\nPlan: Return to or for exploration, washout at 0530. Monitor hemodynamics, monitor neuro status, pain management comfort and support.\n"},{"category":"ECG","chartdate":"2150-07-07 00:00:00.000","description":"Report","row_id":221123,"text":"Sinus tachycardia. No previous tracing available for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1024858,\n \"text\": \" 10:26 AM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: ? subclavian line in good position\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with subclavian line\\n REASON FOR THIS EXAMINATION:\\n ? subclavian line in good position\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Subclavian line placement.\\n\\n FINDINGS: In comparison with earlier study of this date, the tip of the\\n subclavian line lies in the lower portion of the SVC. The heart and lungs are\\n unchanged, as is the position of the other tubes.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-15 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1026262,\n \"text\": \" 2:51 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: PICC placement\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with\\n REASON FOR THIS EXAMINATION:\\n PICC placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n ISTORY: PICC placement.\\n\\n COMPARISON: .\\n\\n FINDINGS: A new left-sided PICC follows the expected course with tip in the\\n mid SVC. A right subclavian catheter is in adequate position. The tip is also\\n in the SVC. Nasogastric tube extends into the stomach, but the tip is not\\n visualized. Endotracheal tube has been removed. Again noted are substantial\\n pleural effusions layering posteriorly with apical capping. There has been\\n interval development of a coalescent opacity in the right upper lung, limited\\n inferiorly by the minor fissure. This is concerning for developing pneumonia.\\n The cardiomediastinal contours are unchanged.\\n\\n IMPRESSION:\\n 1. New left-sided PICC with tip in the mid SVC. Right subclavian catheter\\n and nasogastric tubes in standard position. ET has been removed.\\n 2. Increased bilateral pleural effusions, moderate to large on the right,\\n moderate on the left.\\n 3. New right upper lobe opacity, which may be due to aspiration or developing\\n infectious pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026857,\n \"text\": \" 10:17 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: SICU. increased O2 requirements\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with\\n REASON FOR THIS EXAMINATION:\\n SICU. increased O2 requirements\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Increasing oxygen requirement.\\n\\n FINDINGS: In comparison with study of , there is now diffuse bilateral\\n pulmonary opacification that has a generally alveolar quality. Although much\\n of this could represent asymmetric pulmonary edema, the possibility of\\n superimposed pneumonia must be seriously considered.\\n\\n The endotracheal tube has been removed.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1025898,\n \"text\": \" 9:48 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: check ng tube position\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with\\n REASON FOR THIS EXAMINATION:\\n check ng tube position\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: For nasogastric tube position.\\n\\n FINDINGS: In comparison with earlier study of this date, there has been\\n placement of a nasogastric tube that extends at least to the lower body of the\\n stomach where it passes the lower margin of the film. Allowing for\\n sub-optimal technique, there is probably little change in the appearance of\\n the heart and lungs.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-04 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1024439,\n \"text\": \" 11:32 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: eval R subclavian CVL placement\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man w/ cirrhosis s/p ex lap s/p CVL placement\\n REASON FOR THIS EXAMINATION:\\n eval R subclavian CVL placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post CVL placement.\\n\\n CHEST, SINGLE AP VIEW. No previous chest x-rays on PACS record for comparison.\\n\\n Heart size is at the upper limits of normal. The aorta is minimally unfolded.\\n No CHF, focal infiltrate, or effusion is identified.\\n\\n An ET tube is present, tip approximately 4.9 cm above the carina. An NG tube\\n is present, tip overlying the gastric fundus. A right subclavian central line\\n is present, tip over SVC/RA junction -- clinical correlation to assess for\\n slight retraction is requested. No pneumothorax is detected.\\n\\n There is dense opacification of the right renal collecting system, with\\n evidence of hydronephrosis.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1024807,\n \"text\": \" 5:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man intubated\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB TUE 9:36 AM\\n ET tube terminates 8 cm above carina, and right subclavian catheter terminates\\n in proximal right atrium. New mild pulmonary edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intubation.\\n\\n Endotracheal tube terminates 8 cm above the carina, and right subclavian\\n catheter terminates in the right atrium, as communicated by telephone to Dr.\\n . Cardiomediastinal contours appear slightly wider, and there is new\\n minimal perihilar edema. No pleural effusion or pneumothorax is evident.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1024808,\n \"text\": \", S. SICU-B 5:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? interval change\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man intubated\\n REASON FOR THIS EXAMINATION:\\n ? interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n ET tube terminates 8 cm above carina, and right subclavian catheter terminates\\n in proximal right atrium. New mild pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1025883,\n \"text\": \" 5:10 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for effusions, atelectasis, consolidation\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 cirrhotic w/SBO s/p ex-lap (); s/p segmental bowel resection, washout\\n (); s/p repair of ileal vs. cecal perforation, tube ileostomy ()\\n REASON FOR THIS EXAMINATION:\\n evaluate for effusions, atelectasis, consolidation\\n ______________________________________________________________________________\\n WET READ: PXDb MON 7:51 PM\\n Small layeing bilateral pleural effusions, retrocardiac atelectasis. No\\n Pulmonary edema, NG tube side port at GE junction, advance by 10 cm. ET tube\\n relatively high, terminating 7 cm above the clavicle, which could be due to\\n hyperextension, Findings relating to NG tube DW Dr.. .\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Postoperative, to evaluate for pneumonia or atelectasis.\\n\\n FINDINGS: In comparison with the study of , there is little overall\\n change. Again, there are bilateral layering pleural effusions with some\\n retrocardiac atelectasis without definite pulmonary edema. The side hole of\\n the nasogastric tube remains just above the cardioesophageal junction. The\\n relatively high endotracheal tube tip is above the clavicles, but measures\\n only 7 cm above the carina.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"O ABD (SINGLE VIEW ONLY) IN O.R.\",\n \"row_id\": 1025872,\n \"text\": \" 3:47 PM\\n ABD (SINGLE VIEW ONLY) IN O.R. Clip # \\n Reason: ABDOMINAL WASHOUT\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is a 53-year-old male, evaluate for abdominal washout of\\n questionable foreign body.\\n\\n EXAMINATION: Single frontal abdominal radiograph.\\n\\n COMPARISONS: Comparison to CT of the abdomen and pelvis from .\\n\\n FINDINGS: Correlation with clinical history indicates that patient is status\\n post surgery with possible open abdomen. There is a nasogastric tube in\\n place. There is a peritoneal drainage catheter noted. There is a\\n large uniform radiopacity projecting over the abdominal lower quadrant and\\n pelvis, of uncertain significance, requiring clinical correlation for\\n interpretation. There is contrast noted in the tubular structure in the right\\n lower quadrant, perhaps bowel. There is a paucity of gas noted in the abdomen.\\n The visualized osseous and soft tissue structures are otherwise unremarkable.\\n\\n IMPRESSION: Radiopacity covering the lower abdomen and contrast in tubular\\n structure overlying the right lower quadrant, both of uncertain clinical\\n implication; please correlate clinically and with recent operative procedures.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026406,\n \"text\": \" 10:11 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: position of trachea\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p wash out abdomen\\n REASON FOR THIS EXAMINATION:\\n position of trachea\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:33 PM\\n PFI: Endotracheal tube 5 cm from the carina. Persistent bilateral pleural\\n effusions, cardiomegaly, and pulmonary vasculature cephalization. No\\n significant interval change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Recently reintubated following abdominal washout.\\n\\n COMPARISON: .\\n\\n FINDINGS: The endotracheal tube terminates 5 cm from the carina. The\\n nasogastric tube and right subclavian line are in adequate position. Again\\n noted is marked bilateral veiled opacification, suggesting layering pleural\\n effusions. Heart size remains enlarged with cephalization of pulmonary\\n vasculature. There is no other significant interval change.\\n\\n IMPRESSION: Endotracheal tube 5 cm from the carina. Persistent bilateral\\n layering pleural effusions, cardiomegaly, and cephalization of pulmonary\\n vessels.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026407,\n \"text\": \", S. SICU-B 10:11 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: position of trachea\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man s/p wash out abdomen\\n REASON FOR THIS EXAMINATION:\\n position of trachea\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Endotracheal tube 5 cm from the carina. Persistent bilateral pleural\\n effusions, cardiomegaly, and pulmonary vasculature cephalization. No\\n significant interval change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-03 00:00:00.000\",\n \"description\": \"P ABD COMPL INCLUDING LAT DECUB PORT\",\n \"row_id\": 1024359,\n \"text\": \" 4:58 PM\\n ABD COMPL INCLUDING LAT DECUB PORT Clip # \\n Reason: r/o air fluid levels\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with h/o sbo left ama now with distended firm tender abd\\n REASON FOR THIS EXAMINATION:\\n r/o air fluid levels\\n ______________________________________________________________________________\\n WET READ: FXKd FRI 5:29 PM\\n GAS FILLED DISTENDED LOOPS OF BOWEL WITH MAXIMAL SMALL BOWEL DISTETION OF 45\\n MM. GAS IS PRESENT IN THE COLON AND RECTUM\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 53-year-old male with history of small-bowel obstruction, now with\\n firm, tender abdomen, to rule out bowel obstruction.\\n\\n TECHNIQUE: Portable AP radiograph of the abdomen was performed.\\n\\n Comparison was made with examination of .\\n\\n FINDINGS:\\n\\n Gas-filled distended loops of small bowel are seen in the mid abdomen. There\\n is gas also seen in the colon as well as the rectum. The maximally distended\\n loop of small bowel measures 45 mm. There is no evidence of free air. Early\\n bowel obstruction cannot be excluded.\\n\\n There are degenerative changes present at the hip joints.\\n\\n CONCLUSION:\\n\\n Multiple gas-filled loops of bowel are seen with the maximal diameter of a\\n loop of bowel in the right abdomen measuring 45 mm. Early obstruction cannot\\n be excluded. There is no free air.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-04 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1024460,\n \"text\": \" 3:09 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: eval line adjustment (R subclavian)\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man cirrhosis s/p adjustment of CVL (line withrdrawn 2cm)\\n REASON FOR THIS EXAMINATION:\\n eval line adjustment (R subclavian)\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Adjustment of CVL.\\n\\n CHEST, SINGLE AP SUPINE VIEW\\n\\n A right subclavian central line is present -- the tip overlies the right\\n atrium. The ET tube and NG tube are grossly unchanged. No acute pulmonary\\n process or pneumothorax is identified. Again seen is the right-sided\\n hydronephrosis.\\n\\n The left paravertebral stripe is prominent, but unchanged -- the significance\\n of this findin on a supine film is indeterminate. Attention to this finding on\\n followup films is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1025699,\n \"text\": \" 4:41 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: preop CXR\\n Admitting Diagnosis: ABDOMINAL PAIN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with\\n REASON FOR THIS EXAMINATION:\\n preop CXR\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Preop radiograph\\n\\n A single portable radiograph of the chest demonstrates no change in the\\n support lines seen on . Cardiomediastinal contours are normal.\\n There is a persistent left-sided pleural effusion. There is a new right-sided\\n pleural effusion. No pneumothorax is evident. The trachea is midline.\\n\\n IMPRESSION:\\n\\n Bilateral pleural effusions. No consolidation. Support lines unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2150-07-03 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1024385,\n \"text\": \" 11:16 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: r/o obstruction\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 53 year old man with cirrhosis and h/o partial sbo who left ama here with\\n distended abd\\n REASON FOR THIS EXAMINATION:\\n r/o obstruction\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: PXDb SAT 2:03 AM\\n SBO with dilated bowel loops no passage of contrast beyond the distal ileum,\\n fecalized loop of ileum in the deep pelvis, with bowel wall thickening, likely\\n transition point in the right lower quadrant, could be due to internal hernia\\n or adhesions in the setting of h/o exploratory laparascopy.\\n\\n DW with surgery team.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 53-year-old man with cirrhosis and history of partial small-bowel\\n obstruction who left AMA, he have a distended abdomen, rule out obstruction.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Helical CT acquisitions from lung bases to pubic symphysis after\\n administration of intravenous and oral contrast. Multiplanar reformations\\n generated.\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases are clear without\\n focal consolidations, pleural effusions or pneumothorax. There is a moderate-\\n sized hiatal hernia with NG tube extending into the stomach. There is a large\\n amount of intraperitoneal free fluid. Relative hypertrophy of the left\\n hepatic lobe is incidentally noted with cirrhotic morphology of liver. The\\n spleen is mildly enlarged measuring 13.7 cm. Right renal hypoattenuation\\n lesions could represent parapelvic cysts or collecting system fullness, the\\n early phase of scanning limits differentiation. Otherwise the kidneys,\\n adrenals, pancreas are unremarkable.\\n\\n Multiple distended small bowel loops are noted. The contrast passes only up\\n to proximal ileum with multiple distended ileal loops measuring up to 4 cm.\\n Additionally, there is no passage of contrast into the terminal portion of\\n ileum with of fecalization and mild bowel wall thickening (2:57). There is a\\n coiled up mass of ileal loops which grossly measures 10.2 x 8.1 cm and the\\n transition point is likely within this area. This loop is located in the\\n right lower quadrant and there is a relatively collapsed loop of terminal\\n ileum adjacent to it (300b:32) and could likely reflect a transition point.\\n Overall, findings indicate a small-bowel obstruction possibly due to an\\n internal hernia or adhesions considering patient's history of exploratory\\n laparoscopy. The right sided colonic loops are mildly distended with no\\n passage of contrast into the colon. The rectum and sigmoid colon on the other\\n hand are unremarkable. There is fecal material throughout the colon.\\n\\n (Over)\\n\\n 11:16 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n Reason: r/o obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n CT OF THE PELVIS: The bladder is collapsed with the Foley catheter. There is\\n moderate amount of intrapelvic free fluid. As described above, coiled up loop\\n of ileal loops with fecalization and possible transition point is noted in the\\n right lower quadrant.\\n\\n OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions. The L5-\\n S1 vertebral body demonstrates mild degenerative changes with osteophyte\\n formation, loss of intervertebral disc space. A single sclerotic T12\\n vertebral body focus could represent a bone island.\\n\\n IMPRESSION:\\n\\n 1. Small-bowel obstruction with a coiled up loop of fecalized distal ileum\\n with mild bowel wall thickening adjacent to collapsed loop of terminal ileum\\n possibly at the site of transition point located in the right lower quadrant.\\n These could be result of internal hernia or adhesion in the setting of prior\\n exploratory laparoscopy.\\n\\n 2. Right renal hypoattenuating lesions could represent parapevlic cysts or\\n collecing system fullness. Early phase of imaging limits differentiation.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663872,\n \"text\": \"7pm-7am Nursing Note\\nSee CareVue for objective data and trends:\\nPt remains sedated on propofol and fentanyl. Pt will open eyes and inconsistently perform weak hand grasps when propofol lightened. Pt's HR running 80s-90s in NSR, BP ranging 110s-120s/60s-70s. CVP 10-14. Pt remains ventilated on AC mode, 40% fio2, 400 X 14 and 5 PEEP, no vent changes made as patient planned for OR ?Monday to close abdomen. LS clear bilaterally and Pox 98-100%.\\nAt start of shift pt's urine output low at 15cc X 1 hour. Foley has been positional and U/O increased to adequate amounts after pt. repositioned in bed.\\nPt's abdomen remains open with dressing intact. Pt also has JP drain intact and connected to suction which is putting out red/brown drainage. Abdomen is firm. Bladder pressures have been 10. NGT also to LWS and puttting out moderae amounts of bilious fluid. Getting TPN for nutrition.\\nPLAN: ?OR Monday to close abdomen. Follow GI assessment, bladder pressures every 4 hours.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663873,\n \"text\": \"Respiratory Care\\nPt remains on vent, on AC settings. Pt presents with clear lung sounds bilaterally, but diminished at the bases. Suctioned as noted. Pt is breathing breathes spontanously, although breathing pattern produces a \\\"breath stack\\\" sporadically, but none of these \\\"breath stack\\\" act negativly on ventilation. PT to remain on current support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663874,\n \"text\": \"nursing note\\nPt to OR for small bowel resection, + pus and stool in abd. Pt left with open abd, betadine elastoplast covering. BP on arrival quickly dropped to 60 systolic, MD in to eval. IVF wide open, levo gtt started and titrated up to goal sbp >85 and MAP 60. 2 u PRBC given with 2 U FFP with plans to check HCT and coags q4hrs. Bairhugger on to warm, off with temp of 98.6. JP to LWS with dark brownish bloody drainage. NGT with icteric output. Fluc/vanco/zosyn started. placed on kinair bed, wound consult deferred until tomorrow. brother calling for updates, spoke with MD. Daughter who is estranged also called for update and possibly to visit. Uncle told to call duaghter for update.\\nPLAN: cont abx a/o. wea levo ast olerated. fent/propofol for comfort and sedation wtih open abd. pulm toilet. kinair bed. wound consult. monitor bladder pressures. follow labs q4. family support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663875,\n \"text\": \"Patient went to OR for bowel resection,pus and stool found in abdomen.Abdomen still opened with Kentukey patch on.Distended abdomen,sedated on full mechanical ventilation will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663876,\n \"text\": \"Resp: pt on ac 16/500/+5/40%. Ett 7.5 taped @ 20 lip. BS are clear with diminished bases. Suctioned for scant amount of white secretions No changes noc. AM ABG pending (see careview) RSBI=31. Plan: Continue present settings, pt remains with open belly and return trip to OR in future.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663887,\n \"text\": \"Resp: pt on a/c 12/500/+5/40%. Ett 7.5, 21 @ lip. BS are clear bilaterally. Suctioned for no/scant clear secretions. MDI's atrovent administered with no adverse reactions. AM ABG 7.45/34/189/24. RSBI=34 Plan: wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663888,\n \"text\": \"Nursing Note\\nPlease see carevue for details\\n 1300-1900\\n Pt remains sedated on Fentanyl at 75mcg/hr, Versed at 2mg/hr. Opens eyes and grimaces to painful stimuli, but does not follow commands. Min spont mvmt noted. PERRL, 3mm, brisk. HR 90s-100s, NSR/ST-min ectopy noted, SBP 110s-120s. CVP 5-8, BLE edema noted, fluid balance presently neg~100cc/24hr, ok per Dr.. Remains on CMV-500x12/40%, no vent changes made, overbreathing set rate of 12 by 3-7 breaths at times. Lungs clear, diminished at bases. ABD remains open, covered w/modified vac dsg. TPN cont infusing. NGT & wnd#2 to suction w/mod amts serous drng. JP x1 w/serosang drng. Ileal drain to gravity w/serous drainage w/sediment. Adequate huo, concentrated. Family in to visit, inquiring about HCP form, but inappropriate given pt current condition per Social Work.\\n\\n Plan: Cont hemodynamic monitoring, Fentanyl/Versed for comfort. Resp support. Monitor fluid balance/lytes, goal remains even. Wnd/drain care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663889,\n \"text\": \"Respiratory Care\\nPt remains on mechanical ventilation. No changes on this shift. Pt remains on CPAP-PS 12/5/40%. Last gas done at 1251 7.35/33/88/19/-6. Plan: No plan for extubation, continue mechanical ventilation as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663890,\n \"text\": \"Respiratory Care\\nPt remains on mechanical ventilation AC 500/12/5/40%. Continued MDI's as ordered. Last gas at 1610 7.44/35/196/25/0. Went to IR this afternoon for a dialysis catheter. Plan to continue mechanical ventilation as order.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663891,\n \"text\": \"condition update\\nPlease see carevue for details.\\nNeuro: Sedated with fentyanl/versed, aroues to voice, does not follow commands. Some spontaneous nonpurposeful movements noted in the lower extremities, no movement noted in the upper extremities. Pupils equal and briskly reactive. Pain seems well controlled at 75mcg/hr fentynal.\\nCv: Sinus 90's-100's, no ectopy. Sbp mainly 110's-120's. LR continues at 200cc's/hr. Peripheral pulses palpable.\\nResp: LS clear/diminished. Remains mechancially ventilated on a/c, no vent. changes made. Suctioned for small amounts thick white sputum.\\nGI: NPO, NGT to lws draining bilious drainage. Ileum drain to gravity draining brown liquid. Jp to bulb suction draining serosang drainage, jp to wall suction draining serosang as well. Abd. is open, packing intact. Bs absent.\\nGU: Foley draining adequate amounts clear yellow urine.\\nEndo: SSRI, bs 129 and 113.\\nSocial: Brother called x's 1 for update.\\nPlan: Monitor i/o status, pain management, ? social work consult, monitor hemodynamics, ? return to or.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663892,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds dim bilat; mod th off white sput. MDI given as per order. ABGs stable; no vent changes required overnoc. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663906,\n \"text\": \"condition update\\nPlease see carevue for details. Post-op s/p ex-lap, wash-out and vac dsg placement.\\nNeuro: Received from o.r. not reversed, currently sedated with fent./versed. pt was alert or aroused to voice, intermittenly agitated attempted to tongue out e.t. tube, etc.. Pupils equal and briskly reactive.\\nCV: Sinus 80's-100's, no ectopy. Requiring post-op levophed briefly for map>65. Lr continues at 75cc's/hr. Albumin x's 3 doses started.\\nResp: LS clear/diminished. Suctioned for thick white sputum. No vent. changes made.\\nGI: Open abdomen with vac dsg intact to 75mmhg suction. Jp to bulb suctioned and ileum draining to gravity. NPO, NGT to lws. TPN continues.\\nGu: Foley draining adequate amounts clear amber urine.\\nEndo: bs wnl.\\nPlan: Wean fent./versed as tolerated, monitor hemodynamics, prn levophed to keep map >65, continue albumin x's 2 more doses, comfort and support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663907,\n \"text\": \"Condition update\\nSee careview for objective data/trends:\\n\\nRemains sedated on fentanyl and versed gtt. Intermitantly waking and becoming aggitated. +pain per patient, fentanyl gtt increased from 125 mcg fentanyl to 200 for most of night although currently decreased to 175. Able to wean down versed gtt with better pain control, currently at 1.5mg/hr. Arousable to voice, following commands intermitantly. Able to nod to answer questions, bil weak hand grasps and moves ble spontanously. Tmax 100.1. SR-ST, initially HR 90's although increasing overnight to 100-110. BP trending down with systolic down to 88-92. LR bolus given with good effect, total 1L given. CVP 4-7. Lungs coarse, tolerating CPAP 5/5 with good oxygenation/ventilation. Abd wound open with vac dsg intact. Mesh underneith vac dressing, per HO ok to sit hob up. TPN infusing for nutrition. Adequate u/o. JP self sxn with serosang output. Vac dsg with serosang output. NGT with yellow/bilous drainage. Ileum draing with brown/green clear drainage with sedement. Plan to cont to monitor hemodyanmics, resp status, pain managment and sedation, ?plan for extubation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663908,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs stable; able to switch to PSV; currently on SBT doing well. Cont SBT; ? extub today\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663909,\n \"text\": \"NPN:\\n\\nNeuro: Arouses to voice throughout day-weaned off midaz and pt extubated. Initially slightly confused. Now oriented to self and hospital but not consistent. Moves all extremities and follows commands consistently. Gets slightly agitated-wanting to get OOB and walk. Needs reorientation. ? pt inadvertently dc'd his aline. Ativan prn.\\nSocial: Brother and daughter called and updated. Family referred to social worker- who will meet with brother and speak with daughter tomorrow.\\nID: Tmax 99.9 orally-now 98.4. Pt c/o being cold and shivering/quivering. WBC 14.8. Vanco level 15.3-dose given this am. Cont on zosyn and fluconazole.\\nCV: 95-110's SR-ST without VEA. Initially requiring levo to .03 to keep MAP>60-now off. Lopressor 5mg IV given X1. Palpable pedal pulses with 2-3+ pitting edema. CVP 6-11. Hct 29.9. Pneumoboots on.\\nResp: Weaned and extubated at 1230pm to 40% OFT neb with sats>975. Now on 4l nc O2 with sat 98-99%. Lungs ess CTA with crackles L base. Cough fair-productive of small tan secretions.\\nGU: Foley with amber colored UO>30cc/hr. Creat .7. Given lasix 10 mg IV X1.\\nGI: Abdomen remains firm,round with wound VAC intact draining moderate serosang drainage. JP drain scant output. L ileal tube 300cc thick yellow green liquid with brown sediment. NPO with L nare NGT-100cc yellow bilious drainage. TPN at 63cc/hr. Rec 25% albumin q 6 hrs X4.\\nEndocrine: Glucoses 122-135-no treatment needed.\\nSkin: Coccyx with allevyn foam intact.\\nComfort: Remains on fentanyl gtt weaned to 50 then ^ to 100 with c/o pain. Also started on methadone 5mg IV tid.\\nActivity: Bedrest-turned side to side q 2 hrs with 2 assists. Multipodus boots removed this afternoon after pt awake and extubated.\\nA: Extubated without difficulty. Stable BP off levo-cont with high volume need. Social work involved.\\nP: NPO,TPN. Social work-? family meeting-assess patients awareness of illness. Cont IVAB. Ativan prn for agitation. ?decrease IVF. Discuss diuresis if remains off levo.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663910,\n \"text\": \"Condition update\\nSee careview for objective data/trends:\\n\\nAlert and oriented to person, place and summer although at mildy confused but reorients easily. Following commands and cooperative with care. Ativan prn for anxiety, fent gtt for pain with good effect. Afebrile. HR 90-100 SR-ST. BP stable. Lungs clear but diminished, tolerating room air with sats>94%. Abd with vac dsg intact. Good u/o after lasix. Hct down to 25.2 sicu and primary team aware. Plan to cont to monitor, transition from fent gtt and maintain saftey and comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663923,\n \"text\": \"NURSING UPDATE\\n EARLY PM, PT GROANING WITH EACH EXHALATION, WIDE-EYED DURING CARE. WHEN ASKED IF IN PAIN PT \\\"YUP\\\" - ANALGESIA AND SEDATION INCREASED TO UPPER PARAMETER DOSAGE WITH GOOD EFFECT. PT SINCE OPENING EYES WHEN REPOSITIONED OR HYGIENE CARE DONE BUT NOT GROANING OR GRIMACING. VITAL SIGNS HAVE REMAINED ESSENTIALLY STABLE ALSO. CONTINUES TO DRAIN LG AMT OF BILIOUS DRAINAGE FROM ABDOMEN, SURGICAL RESIDENT INFORMED THIS NURSE VAC WOULD BE APPLIED THIS AM. ALL COMFORT AND HYGIENE CARE PROVIDED. PT APPEARS TO BE AT OPTIMAL COMFORT LEVEL AT THIS TIME.\\nMONITORED CONTINUOUSLY. SEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663924,\n \"text\": \"Condition Update\\nPt continues to receive CMO care. Receiving fent/ativan gtts continuously along with tid methadone IV. Pt is not responding to any verbal/physical stimulation. RR 15-17 with periods of apnea. THis afternoon respirations with gasping noise so ativan gtt increased from 4 to 6mg/hr. No significant changes noted today in vital signs. O2 sats 60-70 on RA SBP 70-80's. HR 80-90 with no ectopy noted. brother called for update x2. No visitors today. Palliative care involved. No further input today. Current plan to keep patient in ICU for CMO.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663925,\n \"text\": \"post-mortem nursing note\\n Comfort measures maintained through shift, pt at optimal comfort status on fentanyl and ativan gtts. vital signs fairly unchanged until 0305, then quickly progressed to asystole. time of death 0307. family notified by dr .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663868,\n \"text\": \"7pm-7am Nursing Note\\nSee CareVue for objective data and trends:\\nNEURO-Pt remains sedated on propofol/fentanyl drips. When propofol decreased to 20mcg/kg/min, pt. opened eyes to verbal stimulation and performed weak hand grasps on command. Pupils at 3mm bilaterally and reactive to light.\\nCV/HEME-HR 80s-90s in NSR, no ectopy noted. Pt's BP has ranged 130's-140s/70s. CVP ranging . HCT this AM 23.6, Dr. aware of HCT but prior HCT 24.8 so no intervention done at present time.\\nRESP-Pt remains intubated and ventilated on settings: AC mode, 40% fio2, 400 X 18, 5 PEEP. Settings unchanged over night. Pox has remained 98-100%. LS clear bilaterally, suctioned only minimally for scant amount of thick white secretions.\\nGI-abdomen is open post-surgery. Abdomen is large, firm. Bladder pressures . Dressing intact to open surgical site and JP bulb drainaige continues to LIWS, putting out serosanquinous drainaige. NGT putting out small to moderate amounts of bilious fluid. Pt started on amino acid with dextrose \\\"quick mix\\\" bag this evening\\nGU-foley putting out 30-40/hr of slightly amber colored urine.\\nPLAN-monitor abdominal exams, blader pressures Q 4 hours. Continue IVF, sedation/pain med as needed with overall plan to return to OR ?Monday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663869,\n \"text\": \"Respiratory Care:\\nPt. remains intubated and on AC/18/400/40%/+5 no changes overnight, alarms on and working. Breath sounds decreased, suctioned for scant amounts of thick white secretions. RSBI 17. Continue current level of support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663870,\n \"text\": \"Nursing Note\\nPlease see carevue for details\\n\\nSedated on propofol - lightened dose x1 and pt opening eyes spontaneously and lifting bilateral LE off bed. On current dose, opens eyes occasionally to stimuli, but not lifting extremities and appears more comfortable. Fentanyl gtt for pain control. Tmax 100.0. HRRR. BP stable. 2+ edema to LE. LSCTA. Stable on vent. Abd with open wound - patch in place - draining moderate amounts foul-smelling, brick red fluid on LIS (SICU team aware). Bladder pressure . TPN infusing as ordered. No BS. Foley draining adequate amounts cyu. Duoderm to coccyx. Frequent turn and reposition. Brother in to visit and updated on POC.\\n\\nPlan: Monitor hct. Monitor abdomen closely for changes. OR Mon/Tues. Continue sedation/pain med gtts. Comfort and support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663871,\n \"text\": \"patient passively resting on mechanical ventilation.Post exp lap abdomen still opened with Kentukey patch on.Compensated Blood gas on rate of 14.Following simple commands @ times will continue to follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663883,\n \"text\": \"NPN (NOC):\\n\\nCV: PT HAS BEEN HEMODYNAMICALLY STABLE OVERNOC OFF PRESSORS.\\n\\nRESP: PT REMAINS INTUBATED. LATEST ABG: 185/30/7.44/21. VENT SETTINGS CHANGED TO 12X500X40%. PT HAS BEEN OVERBREATHING TO HIGH TEENS, LOW 20'S. WILL REPEAT ABG. BS'S CLEAR. SX'D FOR MINIMAL SECRETIONS. AFEBRILE.\\n\\nNEURO: PT SEDATED. FENTYNL DRIP INCREASED TO 100 MCG'S D/T OVERBREATHING W/O EFFECT. PT WILL OPEN EYES BUT NOT TRACK. DOES NOT FOLLOW COMMANDS, BUT I HAVE OCCASIONALLY NOTED SPONTANEOUS MOVEMENT W/ TURNING ETC. PERL.\\n\\nGI: ABD REMAINS OPEN. JP TO LCS PUT OUT 700 CC'S OF STRAW COLORED FLUID OVERNOC. NGT TP LCS PUT OUT 500 CC'S OG BILIOUS MATERIAL. TPN CONT.\\n\\nF/E: I&O BEGINNING TO RUN NEGATIVE OVERNOC. CVP'S . LE'S REMAIN VERY EDEMATOUS. UO VERY GOOD. REPLETED W/ 20 MEQ'S IV KCL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663884,\n \"text\": \"Respiratory Care\\nPt remains on mechanical ventilation AC 40%/500/12/5. Pt went to OR today to place drain in ileum. Abdomen still open. BS clear bilaterally. Sxn thick amounts of white secretions. MDI's continued as ordered. Plan: Continue mechanical ventilation and MDI's as ordered.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663885,\n \"text\": \"nursing note\\nNeuro:pt remains sedated on versed gtt, fentanyl for comfort. Pt squueze hands lightly, blinks eyes. Question if consistent enough to use as communication.\\nCV:ST, rare PVC's, maintaining bp off pressors. BP bolus on way to OR for BP sys 80's.\\nRESP:remains on cmv with abg's wnl.\\nGI:ngt to LWS drng billious. JP to bulb suction in pelvis and JP to wound overlay to wall suction. PRe OR, stool leaking from wound. MD aware. Post OR, ileum drain to gravity and draining stool with bile.\\nGU:foley patent amber to yellow urine.\\nSKIN:allevyn intact. remains on kinair.\\nSOCIAL:brother calling for update and spoke with MD post surgery. MD states brother would like patient to remains full code until ne speaks with rest of family. Brother made aware of poor prognosis.\\n\\nPLAN:Cont versed/fentanyl gtts. Levophed if MAP <60. await post-op labs. TPN. antibiotics a/o. await family decisions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663886,\n \"text\": \"condition update\\nPlease see carevue for specifics.\\nNeuro: Sedated with fentynal and versed gtt's. Pt opens eyes to voice, does not follow commands or move extremities --> fentynal and versed weaned down - will continue to monitor. Bilater pupils equal and briskly reactive, +gag, impaired cough. Pt appears comfortable, pain well controlled with fenynal gtt.\\nCV: Sinus 100's - 110's with occasional pvc's. Sbp mainly 100's 0- 120's. Peripheral pulses weakly palpable. Received 500cc LR bolus x's 1 as it was noted that wound vac output is large, urine is concentrated and pt is tachycardic. Hct 31 (up from 29). INR 1.7.\\nResp: Ls clear/diminished, remains mechancially ventilated, no vent. changes were made, suctioned for nothing. 02 sat 100%. Abg's acceptable.\\nGI: NPO, TPN infusing. Abd. is open, 'wound vac' (jp to wall suction) is draining large amounts serosang drainage, jp to bulb suction is draining mod. amounts serosang drainage. Ileum tube is draining brownish/bilious colored liquid to gravity. NGT is to lws and draining clear to bilious fluid. Bowel sounds are absent.\\nGU: Foley draining adequate amounts clear amber urine.\\nEndo: Sliding scale regular insulin prn.\\nSocial: No phone calls/visitors this shift.\\nPlan: Monitor hemodynamics, IVF and bolus's prn, replete electrolytes prn, monitor coags, pain management, comfort and support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663902,\n \"text\": \"nursing note\\nNeuro:pt remains sedated on versed and fentanyl. Attempted wean at evrsed gtt, pt opening eyes and following commands consistently, pt agitated and attempting to pull at ETT tube and sit up in bed. MD aware, pt resedated lightly on versed gtt and ativan given to maintain. Fentanyl gtt remains for pain.\\nCV:SR to ST associated wtih alertness. neg 1600 thus far today. LR decreased, cvp adequate.\\nRESP:LS coarse,thick white secretions. pre op cxr done.\\nGI:abd remains packed with wound packing and overlay JP to wall suction draining copious amounts. JP to bulb drainage, resecured with tegaerm. Team aware that not holding suction at times.\\nGU:foley apatent amber adeq. amounts.\\nSKIN:allevyn intact. on kinair bed.\\nSOCIAL:sw consulted for estranged daughter relationship. Daughter visibly upset by fathers health and last time they spoke they foiught. MD also emailed for family meeting at some point this week.\\n\\nPLAN:OR tomorrow for wash out and closure. fentanyl and versed for sedation/pain. prn ativan. antibiotics a/o. family support and meeting this week with sw consult.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663903,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. Pt in NARD on current settings; no vent changes required overnoc. Cont mech vent support.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663904,\n \"text\": \"7pm-7am Nursing Note\\nSee CareVue for objetive data and trends:\\n\\nPt remains sedated on versed drip at 2mg/hr and fentanyl at 125 mcg/hr. Pt opens eyes to verbal stimuli through sedation, will follow commands inconsistantly. Performing weak hand grasps and pt moving BLE on bed spontaneously. , pt very agitated when sedation lightened.\\nPt noted to have occasional fine tremors and pt given PRN ativan Q 3-4 hours. Pt's HR 70s-80s in NSR with no ectopy and BP 100-130s/60s-80s. Pt's BP noted to increase/decrease depending o level of sedation. Pt remains intubated and on vent settings: AC, 40% fio2, 500 X 12, 5 peep. LS clear to coarse and being suctioned for small amounts of thick white secretions. Pox has maintained 98-100%.\\nPt with open abdomen and plan to return to OR today. JP drain to self suction and wound drain to suction putting out yellow colored output.\\nTmax 99.8, wbc 7.0 today and pt continues Vancomycin, fluconazole and zosyn for coverage.\\nPLAN-Pt planned for OR today for possible closure of abdomen. Follow VS, continue antibiotic coverage. Social work consulted to follow-up with family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663905,\n \"text\": \"Respiratory therapy\\npt received this morning on AC. bs clear but diminished. mdi given as ordered. no respiratory distress noted. plan to continue with current vent settings.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663913,\n \"text\": \"Nursing progress note\\nPt returned from OR @ 730am. Paralyzed, vented on prop and Neo. A-line in right radial, triple lumen CVL in RSC, dual lumen picc in LAC. 4 abd drains present w/ packingin place. Sbp 90's-100. Per Surgical team wash out only done. Not able to reconnect bowel or close abd. Unknown if they will be able to close abd. Dr spoke w/ brother on phone in am re: prognosis.\\n\\nPt started moving around by 10 am. Fent Gtt restarted @ 75mcg's. Goal is to wean Fent, by increasing methadone. Methadone increased in afternoon to 10 mg. Fent down to 50mcg's. Propofol off at noon. Pt more alert. Following commands. MAE on bed. Became restless attempting to sit up and talk over ETT. Ativan 1mg given with good effect, pt more calm.\\nLs course to clear by afternoon w/ dim bases L > R. O2 sats 98-100%. Suctioning small amts thick tan sputum from ETT. Weaned to cpap+ps 5/5 per abg's. MV up to 18. Pt c/o pain. Fent bolus given and gtt increased to 75mcg's.\\nMV back down to 8-10. By late afternoon pt extubated per SICU team, placed on 4l NC. 02 sats 100%.\\nNeo weaned off by noon. SBP per a-line 100-110's. Occlusive pressure confirmed accuracy of a-line. Goal is to keep SBP >100 MAP >60. Hr 70-90's SR no ectopy seen. CVP 7-10 No IVF ordered per fluid balance.\\nUrine output 30-100hr concentrated clear urine.\\nAbd packed, dist, 4 drains present. No bs. Coccyx has allevyn dsg in place due to be changed . Cream applied to back and heels. TPN infusing.\\nBrother called in to obtain phone #. He will be in this evening.\\nEthics consult was placed regarding the family's capacity to understand the gravity of the situation\\nPlan:\\nContinue to monitor abd drains and dsg's for signs of stool leak.\\nMonitor temp and resp status potential for sepsis.\\nPossible OR tomorrow for washout.\\nFamily meeting possibly @ noon tomorrow.\\nEthics to be involved along with social services to help support family and pt.\\nFent and ativan prn for breakthrough pain and restlessness.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663914,\n \"text\": \"Respiratory Care:\\nPt recieved from the OR this AM s/p bowel surgery. He has wakened nicely and over today and was weaned to extubation to a 4L/m NC. Presently doing well. HR = 90; bp = 119/64; RR = 18; O2 Sat = 100%\\nHe remains critically ill with surgical issues, will watch over noc.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663867,\n \"text\": \"Nursing Note\\nPlease see carevue for details\\n\\nPt sedated on propofol. Appears comfortable - receiving fentanyl drip for pain control. PERRL, 3mm bilat, briskly reactive. HRRR. BP stable. Bladder pressure 10. TLCL placed in right subclavian. 2+ edema noted to bilat LE. +pp/csm. Calcium, mag, and k repleted. Stable on vent. LSCTA. No gag/weak cough. Abdomen firm with open wound - patch. Abd wound to intermittent wall suction - small amounts sero-sang drng. No BS. NPO. NGT to LCS - draining small amounts bilious drng. Foley draining adequate amounts dark yellow urine. Decubitus (stage 3) noted to coccyx - duoderm placed and freq turn/reposition - skin care consult placed.\\n\\nPlan: Maintain pt comfort - keep sedated per team. Monitor bladder pressure q4hours. Monitor labs. Monitor open abdomen. Maintain skin integrity.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663920,\n \"text\": \"Nursing Note 7a-7p:\\nNursing Assessment:\\n\\n brother and mother in to visit this morning and to discuss code status with surgery team. MD covering for MD and met with the family. Family feels that pt would not want to return to the OR and would like to make the patient comfort measures only. Pt received large doses of ativan and fent/haldol overnight for agitation and again this morning requiring ativan and increase in fent gtt for attempts OOB/ yelling, pulling at tubes/drains in open abdomen. MD plan is to keep patient in icu today with fent gtt/ativan, etc as needed for comfort and agitation. VAC dressing will be placed on abdomen to contain drainage and tommorrow pt can be called out to the floor/ contact hospice care. Pt becoming very restless, attempting oob, yelling out, and crying mostly disorientated. Medicated with ativan for a total of 4 mg at this time and fent gtt increased periodically up to 200mcq /hr. Pt continued to cry and attempt oob and medicated with 1 mg haldol with good effect. Plan: cont fent gtt, ativan, haldol, methadone as needed and consider switching to morphine gtt if nto reaching adequate level of comfort for pt. emotional support for the patient and the family. Please see carevue for further details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663921,\n \"text\": \"Condition update\\nVery aggitated this evening, crying and yelling out, attempting to sit up and pulling at abd dsg and tubes. Large hole ripped in dressing and small area bowel exposed, Gold surgery and SICU resident aware and dressing reinforced with transparent dressing. Fentanyl gtt increased and ativan gtt started after mult doses ivp ativan to keep pt calm/comfortable. Able to wean down fentanyl gtt after ativan started although cont to require high doses as pt crying out in pain and very aggitated when awake. Pt currently appears very comfortable. Cont with comfort care and provide support. No calls from family overnight.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663922,\n \"text\": \"Nursing Note 7a-7p:\\nNursing aSsessment:\\n\\nPt is comfort measures only and remains sedated on fent gtt and ativan gtt. Increased/ fent bolus for turning d/t moaning and grimacing on turns. Gtts also increased for agonal breathing with good effect. Hospice care into evaluate as well as social work and case managment. All agree that pt is to remain in icu at this time d/t requirements of large amounts of sedation in order to keep comfortable. Reinforcing abdomen d/t large amounts of leakage and still awaiting surgery team to place vac dressing to contain drainage. Plan: Keep pt comfortable; titrate gtts as needed. Please see careuve. Pts brother called and updated by RN and spoke with social work as well.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663915,\n \"text\": \"condition update\\nPlease see carevue for specifics.\\nNeuro: Alert and oriented x's 2, remains confused but less so than the previous night. More cooperative with care, less agitated. Pain controlled with fentyanl gtt (which was titrated down to 50mcg/hr) and tid iv methadone. Pt sleeping most of the night.\\nCV: sinus 80's-90's, no ectopy. Sbp mainly 90's-100's, lopressor held. Peripheral pulses palpable. Hct 23. K+ and Mag repleted x's 1.\\nResp: LS clear/diminished, 02 sat 97% on 4 liters n.c. Pt has congested cough, coughing/deepbreathing encouraged.\\nGI: NPO. NGT to lws draining bilious drainage. Ileum drain to gravity draining brown liquid stool. Jp to wall suction draining dark serosang drainage, Jp to bulb suction unable to hold suction, and drain #2 to gravity draining small amounts brown liquid. Abd. is packed, dsg is intact.\\nGU: Foley draining adequate amounts clear amber urine.\\nEndo: BS wnl.\\nSocial: brother, sister in law and daughter at bedside visiting earlier in the evening, will return at 12noon today for possible family meeting.\\nPlan: Pain management, wean fentynal as tolerated, monitor hemodynamics, encourage coughing and deep breathing, monitor drains' output, continue iv abx, comfort and support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663916,\n \"text\": \"NEURO; A&OX3, FOLLOWS SIMPLE COMMANDS, C/O ABD DISCOMFORT WHEN REPOSITIONED, METHADONE DOSE INCREASED TO 12.5 MGM IV TID, PTMET WITH SOCIAL WORKER AND HIS BROTHER TODAY AND DISCUSSED HIS WISHES TO DECLINE FURTHER SURGERY, FAMILY IN AGREEMENT WITH PT PER SOCIAL WORKER, PT REMAINS ON FENT GTT AT 50 MCG/HR\\n\\nCARDIOVASCULAR; HR 90'S, SR, TEMP 99.6, TRIPLE LUMEN AND PIC LINE ACCESS,\\n\\nRESPIR; LUNGS CLEAR, 02 SAT 95%,\\n\\nWOUND; OPEN ABD WOUND, PACKED WITH STERILE LINEN PACKING, JP DRAIN TO SELF SX, DRAIN #2 TO LWSX-MODER BROWNISH DGE, ILEOS BAG TO DGE, SMALL AMT LIQUID DARK BROWN DGE,\\n\\nPLAN; BROTHER WILL BE IN TOMORROW AND WOULD LIKE TO TALK TO MD'S ON DR. SERVICE REGARDING PT'S WISHES TO DECLINE FURTHER SURGERY, AND ? OF ADDRESSNG FUTURE FEEDING ISSUES, ETC., HELP PT ATTAIN COMFORT AND REST, EMOTIONAL SUPPORT TO PT AND FAMILY\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663917,\n \"text\": \"Condition update\\nSee careview for objective data:\\n\\nAlert and oriented this evening but became very disoriented and aggitated at 2200, unable to redirect and pt pulling at lines and attempting to get oob, given 2 mg ativan with fair effect. Additional 1 mg ativan given overnight although pt remains calm he is confused and often disoriented. He is currently calm and cooperative. C/o intermitant pain but mostly comfortable on fent gtt, requires 25mcg bolus for repositioning. Tmax 100.4. SR HR 80-90 no ectopy. BP stable. LUngs clear but diminished. ABd remains packed with jp to wall sxn. Drainage from jp noted to be brownish opaque, Dr aware and into assess. Good u/o. Plan to cont to monitor neuro status, resp status, s/sx worsening infection, provide support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663877,\n \"text\": \"Condition update\\nSee careview for objective data/trends:\\n\\nInitially sedated on propofol with fentanyl gtt for pain managment. On current propofol and fentanyl gtt rates no withdrawl/grimice noted to painful stimuli. Propofol off at MN for neuro exam and although not withdrawing to nailbed +grimice to nailbed pressure x 4 extremities and noted to move ble spont. HR elevated when propofol off and noted to be tremulous, given 1 mg ativan for suspected etoh withdrawl. Attempted to maintain lower propofol gtt rate d/t increase in BP with decreased propofol rate although pt remained tachycardic. Midaz gtt initiated for sedation and propfol off and HR remains <100, normotensive off levophed, and no tremors noted. Afebrile. HR 90's with vent bigemeny noted this evening, resolved with 2 gm mag sulfate (previous mag 1.8) then no ectopy noted until 0200 and pt in and out of vent bigeminy. Lytes wnl, no repleation indicated. EKG and cardiac enzymes done. Dr and Dr aware. Given additional 1000cc LR bolus with minimal effect. CVP remains . BP remains stable with ectopy. Transfused with 1 unit prbc and 1 unit ffp, goals hct >28 INR >1.8. +pitting edema bil lower ext. Lungs clear but diminished. No vent changes made, cont on AC 40% 16x500 5 peep occasionally breathing over set rate. ABG good oxygenation/ventilation. Last ABG 7.4/39/207/0/25. Abd open, packed and covered with occlusive transparent dressing, JP to abd to wall sxn with large amt brown/bloody output. Ngt with icteric output. Bladder pressure 8. Adequate urine output. Tbili 3.8 this am, Dr and Dr aware, direct bili pending. Lactate stable at 1.2 Cont to monitor hemodynamics, resp status, fluid balance, q4 hct/plt and coags, s/sx etoh witdrawl. provide comfort and support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663878,\n \"text\": \"Respiratory Care\\nPt continues on mechanical ventilation. BS clear bilaterally. No changes made to ventilator settings. Atrovent MDI ordered and given in the afternoon. Plan: To continue mechanical ventilation and MDI's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663879,\n \"text\": \"N - Patient neuro status changed since prior shift. Since propofol gtt discontinued and fentanyl gtt decreased patient will open his eyes to verbal stimuli and will move left lower extremity on bed. He does not follow commands but continuously would open eyes without tracking to verbal stimulation. PERRL at 4mm bilaterally with brisk response. Cough and gag intact, no hand grasp. Fentanyl and versed gtts for sedation and comfort.\\n\\nCV - HR has been continuously NSR throughout shift in the 80s to 90s. Initially frequent runs of bigeminy noted, electrolytes from AM stable. Right SC TLC noted to be within the right atrium, pulled by resident and PCXR confirmed correct placement, bigeminy noted to lessen but continue, electrolytes checked later in shift and replaced magnesium and calcium per sliding scale order. BP has been stable this shift, levophed has remained off this shift with SBP high 90s-low 100s with MAP well above 60mmHg. Patient has remained afebrile. Patient has peripheral pitting edema noted and pulses have remained palpable.\\n\\nR - Patient remains on mechanical ventilation via ETT this shift with adequate ABGs and sats greater than 98%. Patient has PMH of smoking for greater than 30 years, lung sounds initially contained inspiratory wheezes, combivent MDI q6h ordered and LS have remained clear and diminished in the bases. ETT suctioned for small thick white secretions. Pt remains in reverse trendelenberg.\\n\\nGI - Patient's abdomen remains open with ioband dressing and surgical towel intact. Bowel sounds are absent and abdomen is firmly distended. Wound has JP drain to medium wall suction with dark yellow transparent drainage noted in large amounts noted, NGT to LCWS with very similar drainage qualities in amounts documented. No BM this shift though hemorrhoids noted to be edematous.\\n\\nGU - Foley draining amber clear urine in amounts documented, noted to be marginal at times, overall greater than 30mL/hr. IVF of LR infusing at 125mL/hr.\\n\\nACCESS - Right radial arterial line has good waveform noted, good blood return, good distal CSM noted and good correlation with NIBP. Right SC TLC intact with CVP monitored as above, CVP between . Left wrist 16G placed this shift after old PIV expired.\\n\\nENDO - RSSI given for elevated blood glucose, continue to monitor every 6 hours as ordered.\\n\\nSKIN - Wound nurse in to eval patient. Noted to have stage III ulcer on coccyx, dressed with hydragel and allevyn dressing, plan to change dressing every 3 days with hydragel and allevyn. Skin otherwise noted to be edematous and frail, no further breakdown noted. Patient turned frequently and remains on kinair mattress to alleviate pressure points.\\n\\nP/S - Brother called earlier this shift and updated on plan of care and patient's condition, no visitors or other calls this shift. All aspects of patient's care have been explained to him prior to performing them.\\n\\nID - Antibiotics administered as ordered. WBC noted to be increased over the pa\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663880,\n \"text\": \"(Continued)\\nst shifts, afebrile, lactate 0.8.\\n\\nPLAN - continue to monitor VS frequently, monitor hct/platelets/coags q4h's and plan to replace blood with PRBCs if less than 28, plan on FFP if coags less than 1.8, frequent turning and kinair mattress, wound dressing changes, monitor abdominal qualities and continue NGT/JP to suction, plan to go to OR for ? closure/resection of bowel, fentanyl/versed for sedation/comfort, replace electrolytes, keep patient/family informed on plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663881,\n \"text\": \"addendum: IVF changed to LR at 40/hr\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663882,\n \"text\": \"Resp: pt on a/c 16/500/+5/40%. BS are clear bilaterally. Suctioned for scant amounts of white secretions. MDI's administered atr as ordered with no adverse reactions. AM ABG 7.44/30/185/21. Decreased rate to 12. RSBI=75. No further changes noted. Continue on present settings.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663897,\n \"text\": \"nursing note\\nneuro: versed weaning with addition of ativan. Pt opening eyes and periodically following commands. Moving all extrem spont on bed. Fentanyl gtt remains. low grad temps cont. Vanco held for trough 23. To be rechecked this eve.\\nCV:SR to ST, no relief in tachycardia with fentanyl bolus. Lopresoor held secondary to borderline BP at noon.\\nRESP:LS coarse to diminished. suctioned for thick white secretions.\\nGI: NGT with bilious icteric output. JP with ascites looking output. Wound drain with copious amounts of yellow clear frothy output. Ileum drain remains to gravity with light brown output with specs of dark brown stool. abd remains open with packing intact.\\nGU: foley patent draining amber output.\\nSKIN: allevyn intact. multipodus boots on.\\nSOCIAL:daughter in to visit and emotional. Asking appropriate questions.\\n\\nPLAN:wean versed as tolerated, ativan prn for sedation. fentanyl gtt for pain. abx a/o. Monitor I+O's, allow to get net negative if BP tolerates. ? OR for monday. skin/wound care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663898,\n \"text\": \"Resp Care\\nPt remains intubated on CMV, no vent changes. Sx small white thick. Plan to continue with current tx, ?? OR for Abd closure next week.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663899,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs remain ess unchanged; no vent changes required overnoc. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663900,\n \"text\": \"Condition update\\nSee careview for objective data:\\n\\nAlert overnight, following commands much more consistantly and nodding appropriotly to some questions. Midaz gtt weaned off and receiving prn ativan with good effect. Fent gtt increased d/t pt nodding yes to pain consistantly on exam early am. Tmax 100.6. ST HR 100, decreases breifly to 80's after lopressor dose. Frequency of dose increased with good effect. Lungs coarse occasionally, clear with sxn. No vent changes made, abg shows adequate oxygenation/ventilation. Abd remains open. No change in drain outputs. Adequate u/o. Plan to cont to monitor hemodynamics, resp status, drainage, plan for ?or monday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663901,\n \"text\": \"Respiratory Therapy\\n\\nPt remains orally intubated on full mechanical support. Continues on A/C ventilation w/ PIP = 18, SpO2 90s, Ve ~6-7L/M. ETT secure/patent. MDI given as documented. See resp flowsheet for specific vent settings/data.\\n\\nPlan: maintain support\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663918,\n \"text\": \"ALTERED COMFORT\\nS: \\\"IT HURTS RIGHT THERE\\\"\\nO: CARDIAC: SR 80-70'S IV LOPRESSOR X1. SBP 100-130'S. EXTEMITIES WARM AND DRY. PALP PP. HCT 24.3. CVP <10. K TO BE RECHECKED.\\n RESP: O2 @ 4 L NP WITH O2 SAT >95%. BS DIMINISHED BIBASILAR,CLEAR UPPER. NONPRODUCTIVE CONGESTED COUGH. INSTRUCTED ON USE OF HIS COUGH PILLOW.\\n NEURO: EASILY AROUSABLE, ORIENTED TO SELF AND DATE , NOT PLACE THEREFORE REORIENTED PRN BY NURSE. PERL AND BRISK, GRASPS EQUAL AND FAIRLY STRONG , CAN LIFT LEGS OFF BED. FOLLOWS COMMANDS. CALM MOST OF DAY, SLIGHTLY ANXIOUS PRIOR TO DAUGHTER ARRIVING. RECEIVED .5 MG IV ATIVAN X 1 WITH GOOD EFFECT.\\n GI: NGT + PLACEMENT DRAINING GOLD DRAINAGE 300 ML SO FAR. ABD OPEN ? CLOSE OR APPLY MESH . DRAINS DRAINING -PLEASE SEE I+O, ABSENT BOWEL SOUNDS, NO STOOL FROM RECTUM. TPN CONTINUES.\\n GU: ADEQUATE UO- AMBER WITH SEDIMENT.\\n ID: CULTURES PENDING, TEMP MAX 100.4. VANCO LEVEL 10-RECEIVED VANCO+ZOSYN.\\n ENDO: HAS NOT REQUIRED SSI\\n PAIN: CONTINUES ON FENTANYL AT 50 MCQ WITH .25 MCQ BOLUS X 4 PRIOR TO MOVING.\\n SOCIAL: DAUGHTER INTO VISIT AND UPDATED. BROTHER TO ARRIVE TO DISCUSS PLAN ? NO FURTHER OR/ WILL SPEAK WITH DR.\\nA: STABLE AT PRESENT, ABD PAIN.\\nP: MONITOR COMFORT-FENTANYL, HR AND RYTHYM, SBP, CVP, PP, TEMP, RESP STATUS-PULM TOILET, NEURO STATUS-REORIENTE PRN, I+O-CONTINUE TPN, LABS PENDING. DISCUSSION RE: PLAN. AS PER ORDERS.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663919,\n \"text\": \"Condition update\\nSee careview for objective data and trends:\\n\\nDisoriented this evening and worseing overnight. Aggitated and at times combative attempting to hit staff and get oob. Given ativan with good effect, given haldol x 1 for questionable delirium with no effect. Fentanyl gtt increased to keep pt comfortable. Abd dsg no longer occlusive d/t movement and leaking bile from bottom dressing. SXN not working d/t non occlusive dsg. Dr (Gold ) up to assess. Attempted to reinforce with tegaderm but not sucessful. Hob at 15 and attempted to keep pt calm and still d/t open abd with non occlusive dsg. Dr (sicu) aware and into assess aswell. Awaiting surgery resident to speak with Dr re: plan for abd dsg as pt and family has expressed wishes to not return for additional surgeries as pt has poor prognosis. Currently hemodynamically stable, SR 80's, BP stable SBP 100-130's. Temp 101.2, pan cx. WBC stable at 8 this am. Increased o2 requirement overnight, Dr and Dr aware. ABG wnl. LUngs clear. CXR done. Good u/o. Awaiting surgery rounds for plan re: open admomen, cont to monitor hemodynamics, monitor abd drainage for s/sx stool, maintain saftey and comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663893,\n \"text\": \"please see carevue for details of care\\n\\npt intubated, sedated on 2 mg/hr midazolam. Daily wake up done, pt arouses to voice, does not follow commands. Moves all extremities spontaneously, does not withdrawl to pain, grimaces to nailbed pressure. Pupils 3-4mm equal and reactive. No signs/symptoms of pain, specifically no shaking, no agitation, no grimace, 75 mcg/hr fentanyl infusing as ordered. T max 99.9, HR 90s-100s, SR/ST, no ectopy. BP 120s-140s/60s-70s. Midazolam restarted at 1 mg/hr for HR remaining >100 and SBP 140s. Generalized edema noted, +DP/PT pulses. SCD boots in place. LR changed to LR with 20KCl, awaiting pharmacy delivery. Electrolytes repleted as ordered. Lungs CTA all lobes posteriorly, remains ventilated on AC 40% FiO2, rate 12, PEEP 5. O2 sat=100%. Suctioned x1 for scant clear secretions. Open abdomen with VAC dressing in place, draining large amounts of ascities appearing fluid. BS absent. L nare NG tube to LCS draining bilious fluid. Ileostomy tube to gravity, draining brown fluid. pt remains NPO, TPN infusing @ 64 cc/hr. Pelvic JP draining clear serosanginous fluid. Foley catheter draining approx 60 cc/hr clear amber urine. ABdominal dressing C/D/I. Stage III coccyx ulcer with allevyn dressing. Eye drops/eye lubricant applied q 4 hrs for dry eyes. Family at bedside, updated re: plan of care.\\n\\nPlan: continue to monitor hemodynamic status, monitor drains s/s infection, assess respiratory status, assess GI status, assess pain level, assess neuro status, maintain pt safety.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663894,\n \"text\": \"Resp Care\\nPt remains intubated on CMV, no vent changes. Sx for scant white. Plan to continue with current tx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663895,\n \"text\": \"Condition update\\nPlease see careview for objective data/trends:\\n\\nAlert initially this evening although not following commands. Moving all extremities spontanously. Pt nodding at times but infrequently but when attempting to communicate is appropriote. Sedation increased after pt attempted to push ETT out with tongue, currently well sedated on midaz and fent gtts. Appears comfortable. Tmax 100.3 ST HR 100-110 this evening with SBP 150's. Started on lopressor with good effect, currently SR HR 80-90's no ectopy noted. Remains normotensive. Lungs mostly coarse but clear after sxn. Remains on AC, no vent changes made. ABG WNL. Abd remains open and packed, covered with occlusive dressing. JP to wall sxn draining +ascities to intra abdominal space. JP to pelvic space draining clear serosang fluid. Ileum tube to gravity with clear amber fluid with some sedement draining. NGT draining light clear yellow fluid. Good u/o. HCT and INR stable. WBC down this am to 9. Plan to cont to monitor s/sx worsening infection, monitor hemodyamics and resp status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663896,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs stable; no vent changes required overnoc. Cont mech vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663911,\n \"text\": \"nursing note\\nNeuro: Patient alert, confused to course of events with labile mood. Intermittent pain with turns, methadone increased and fentanyl weaned. After dose of increased methadone, patient appears more comfortable and sleepy. Easily arouses to voice. Less complaints of anxiousness after increase in methadone.\\nCV:SR to ST, no ectopy. SBP WNL. remains on lopressor q4. PICC placed for long term TPN use. At this time, 3 ports needed so central line left in place. PT/OT consulted.\\nRESP:LS clear, diminished. Weak non-prod cough. o2 sats down to 93% on RA when asleep.\\nGI: NGT to wall suction drng yellow bilious drng with decrease in output.\\nGU:foley patent dark amber icteric urine.\\nSKIN: Wound team re-evaluated coccyx wound. duoderm gel with allevyn foam applied, wound healing. Bed changed to first step to facilitate OOB. Wound care signed off at this time.\\nSOCIAL: Social work fooliwng and spoke with family re:long term plans of rehab and nursing home. Family expressing inability of patient to retun to home where he lives with his 84 year old mother. Patients also in to visit and spoke with sicial work.\\n\\nPLAN: Vac change thurs at bedside, OOB, mointor I+O's, wean fentanyl with increase in methadone. rehab screen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2150-07-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1663912,\n \"text\": \"condition updated\\nPlease see carevue for specifics.\\nNeuro: Pt noted to be increasingly more confused throughout the night. Cooperative at times, agitated at other times. Pain controlled with fentynal gtt and methadone iv atc. Moves all extremities on the bed.\\nCV: Sinus 90's-100's, no ectopy. Sbp 100's-140's. Peripheral pulses palpable. LR increased to 100cc's/hr. K+ and Mag repleted. Hct stable at 25.\\nResp: LS clear/diminished. 02 sat dropped to 92, 4 liters n.c. applied and sat improved to 97%. Congested cough, pt not able raise sputum, coughing/deep breathing encouraged.\\nGI: NGT to lws draining bilious drainage, ileum draining brownish fluid. JP with minimal serosang, and wound vac draining serous/light brownish drainage. It was noted roughly around midnight that wound vac white sponge was stained brown on right side. Dr. notified and at bedside to evaluate just before 1am. Brown fluid appearing like stool was noted to be also leaking outside dsg at ileum tube site and near jp, and also extending to right side of wound vac white sponge. Dr. was notifed per Dr. . Pt will be returning to o.r. at 0530 for re-exploration. Brother notified and spoke with Dr. over the phone.\\nGu: Foley draining cloudy urine, dr. aware, u/a and culture sent. Urine output is adequate.\\nEndo: No ssri coverage necessary.\\nID: Temp spike 101.2 at midnight, urine and blood cultures obtained.\\nPlan: Return to or for exploration, washout at 0530. Monitor hemodynamics, monitor neuro status, pain management comfort and support.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2150-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 221123,\n \"text\": \"Sinus tachycardia. No previous tracing available for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":179,"cells":{"subject_id":{"kind":"number","value":73417,"string":"73,417"},"hadm_id":{"kind":"number","value":155561,"string":"155,561"},"target_text":{"kind":"string","value":"Assessment and Plan: 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who presents with dyspnea and vomiting complicated by acute respiratory failure and septic shock. . # Dyspnea/respiratory failure: Admitted with worsening dyspnea on exertion, stable orthopnea. Became acutely SOB requiring intubation in the ED, likely due to metabolic acidosis with respiratory compensation leading to fatigue. Repeat CXR showed increased bilateral opacities suggesting pulmonary edema. Heart failure was considered her BNP elevation and history of orthopnea, although she has no known heart failure and ECHO was not particularly concerning for CHF ( dilated, LVEF > 55%). Viral DFA was negative, pneumonia was less likely in the absence of sputum and change in CXR. She has smoking history, but no wheezing or CO2 retention to suggest COPD. Ischemia was considered given report of chest pain, although EKG negative and cardiac markers negative. ABG showed good oxygenation and patient was switched to PSV 10/5 with FiO2 40%. Pt was stable on pressure support on the vent and sedation was weaned. SBTs starting with intention to extubate were unsuccesful (RR into the 40s, tachycardic), likely secondary to volume overload. She was diuresed with lasix and repeated almost daily SBTs continued to show elevated RR and tachycardia. RSBI was 156 on , but given that she is an elderly female with baseline tachypnea and small TVs, extubation was attempted on and was successful. She was quickly weaned down to 2L NC with O2 sats 95-100%. Of note, RSBI is not likely a good indication of this patients suitability for extubation given her baseline tachypnea and small TV and as she did very well s/p extubation with a pre-extubation RSBI of 156. . # Septic shock: Initial WBC with bandemia, elevated lactate, fever, tachycardia, and pressor requirement. Most likely biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. was done on and showed large amounts of sludge and a sludge ball obstructing flow in the CBD. Sludge ball/stone in CBD is approx 3 cm long, so a 5 cm 10 Fr pigtail stent was placed around the sludge ball to facilitate drainage until a definitive procedure can be attempted, now scheduled for . Blood cultures showed G positive rods and Clostridium species (not perfringens) in anaerobic culture bottles, but have not yet been speciated. She was started on broad spectrum antibiotics including Vanc and Zosyn on , then narrowed to Zosyn with G negative organisms in blood with plan for 14 day course. A PICC was placed on . Pressors were weaned starting and she has maintained her BP off pressors. Metoprolol was started on and uptitrated. . # Atrial fibrillation with RVR. She developed atrial fibrillation on . She was initially started on IV amiodarone with no good response. Her rate remained in 100-120's, and rate control was initiated with metoprolol and diltiazem on . On , diltiazem was discontinued and metoprolol was uptitrated. On , she spontaneously converted back to normal sinus rhythm. . # ARF: Likely related to sepsis (ATN), as well as hypovolemia from vomiting and diarrhea. Baseline creatinine 1.2-1.4. urine lytes: Fena: 0.2, FeUrea: 14.9%. She was rescuscitated with D5 1/2 NS with 3 amps of bicarb followed by NS PRN to maintain CVP > 10. Cr returned to baseline by . . # Anion gap acidosis: Most likely related to elevated lactate, initially 4.5 improved consistently with IVF, now 1.7. No history of ingestion and no clear offenders on med list. Glucose not c/w DKA, BUN not c/w uremia. . FEN: Pt was initially kept NPO then provided with full fibersource tube feeds at 30 ml/hr. In anticipation of extubation and question of whether she would be able to pass speech and swallow immediately, her OG tube was changed to an NG tube on . She was evaluated by speech and swallow and her diet changed to regular full, which she tolerated well. . She was called out of the ICU on . FLOOR COURSE: On the floor, she continued to do well. She spontaneously converted from atrial fibrillation back to NSR on . Her oxygen was weaned, and she was seen by physical therapy, who recommended rehab. The remainder of her blood pressure medications from home were held and should be re-added as an outpatient. She was discharged to rehab on in stable condition, not on oxygen, and tolerating PO. . On the floor, she was noted to have frequent stools (3-4 per day). Per her daughter, this is chronic and has been going on for months. A C. difficile study on was negative, and her abdominal exam is benign. This warrants further workup as an outpatient, and she was instructed to make an appointment to see her primary care doctor as an outpatient once discharged from rehab."},"extractive_notes_summ":{"kind":"string","value":"Improving Plan: Plan to diurese as pts hemodynamics tolerate. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Diltiazem d/c Response: Hr effectively controlled on with po diltiazem and lopressor. Diltiazem d/c Response: Hr effectively controlled on with po diltiazem and lopressor. Plan: Change back to pressure support in am, check RSBI, ?ready for extubation repeat RSBI~157 would like pt negative one liter. Plan: Plan to diurese as pts hemodynamics tolerate. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Tongue was at midline with functional strength and ROM.Palatal elevation and gag deferred.SWALLOWING ASSESSMENT:The pt was seen with thin liquids (tsp, straw, consecutive),purees and regular solids. The U/S showed sludge /sludge baland pt is s/p ERCP and stent. - Leukocytosis is resolvingwhite count almost normalized. Peripheral pulses are palpable; she has a right IJ TL CL with CVP monitoring. - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c vanc as GI infection not likely MRSA. - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c vanc as GI infection not likely MRSA. - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c vanc as GI infection not likely MRSA. - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c vanc as GI infection not likely MRSA. - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb less than 18 or LR if needs resuscitation to prevent further NG acidosis. - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb less than 18 or LR if needs resuscitation to prevent further NG acidosis. She was then transferred to the for further management Atrial fibrillation (Afib) Assessment: Pt remains in afib at a rate of 100-130s, BP has been stable Action: Her amnio was d/ced and lopressor was started Response: Tolerated the lopressor it seemed to lower her HR from the 120s to the 100s Plan: Titrate up the lopressor Respiratory failure, acute (not ARDS/) Assessment: Remains vented, lots of oral and ETT secretions, tachypnic to the 40s with VTs in the 300s Action: Unable to extubate today, to receive lasix this afternoon, restarted TF Response: Not yet ready for extubation Plan: Follow I&Os, lytes, cont to try to wean, cont pulm toilet - Hold sedation for now to optimize mental status prior to extubation - need to place a dobhoff prior to extubation as she may be an aspiration risk - CXR looks stable to slightly worsened this morning - family okay with re-intubation if patient fails extubation # Atrial Fibrillation: First occurred during SBT on , initially rates were in the 110s, then increased to the 130s. - Hold sedation for now to optimize mental status prior to extubation - need to place a dobhoff prior to extubation as she may be an aspiration risk - CXR looks stable to slightly worsened this morning - family okay with re-intubation if patient fails extubation # Atrial Fibrillation: First occurred during SBT on , initially rates were in the 110s, then increased to the 130s. - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb less than 18 or LR if needs resuscitation to prevent further NG acidosis. - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb less than 18 or LR if needs resuscitation to prevent further NG acidosis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. - Leukocytosis is resolvingwhite count almost normalized. - Leukocytosis is resolvingwhite count almost normalized. Compared to the previous tracingof atrial fibrillation has resolved and right bundle-branch block isnew. neo being weaned to off as pts hemodynamics tolerate Response: Hr remains in afib tachy from 100-130s but hemodynamically stable Plan: Plan is to continue infusion of amioderon for 18 hrs and then will consider d/cing gtt. A right internal jugular line ends in the mid SVC. PFI REPORT Left PICC ends in upper superior vena cava. FINDINGS: Left PICC ends in the upper superior vena cava. The right internal jugular central venous catheter tip remains in the mid-to-lower SVC. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: 41cm left picc. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: 41cm left picc. PORTABLE UPRIGHT CHEST RADIOGRAPH: The study is degraded by respiratory motion. FINDINGS: As compared to the previous radiograph, an OG tube has been placed. The right internal jugular line ends in the mid superior vena cava. Peripheral wedge-shaped opacity in the left hemithorax obscuring the lateral pleural sulcus, which developed on , has been stable since 1:39 a.m. today consistent with pulmonary infarction, perhaps related to septic embolus or small loculated pleural fluid collection, also sometimes the result of pulmonary embolus."},"n_notes":{"kind":"number","value":128,"string":"128"},"notes":{"kind":"list like","value":[{"category":"Nutrition","chartdate":"2169-11-24 00:00:00.000","description":"Clinical Nutrition Note","row_id":702478,"text":"Subjective\n Patient with n/v and poor appetite prior to admissoin, now intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 163 cm\n 79 kg\n 83.8 kg ( 04:00 AM)\n 31.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 54.4 kg\n 144%\n 61 kg\n kg\n %\n Diagnosis: sepsis\n PMHx: kidney cancer s/p cyberknife, choledocholelithiasis s/p ERCP\n (), dementia, B12 deficiency, HTN, ostoeporosis, CKD, grave's\n disease, follicular lymphoma of intestine (in remission), chronic\n diarrhea\n Food allergies and intolerances: none noted\n Pertinent medications: 30KPhos, amiodarone, versed, phenylephrine,\n others noted\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 04:18 AM\n Glucose Finger Stick\n 116\n 12:00 PM\n BUN\n 32 mg/dL\n 04:18 AM\n Creatinine\n 1.6 mg/dL\n 04:18 AM\n Sodium\n 140 mEq/L\n 04:18 AM\n Potassium\n 3.4 mEq/L\n 04:18 AM\n Chloride\n 108 mEq/L\n 04:18 AM\n TCO2\n 26 mEq/L\n 04:18 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:18 AM\n Phosphorus\n 1.7 mg/dL\n 04:18 AM\n Magnesium\n 2.4 mg/dL\n 04:18 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft with hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1200-1500 (BEE x or / 20-25 cal/kg)\n Protein: 60-80 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Specifics:\n 85 year old female with history of choledocholithiasis, renal CA, and\n dementia who presents with dyspnea and vomiting complicated by acute\n respiratory failure and septic shock likely secondary to biliary\n source. She is now s/p ERCP and stent. Patient unable to be extubated\n so consult received for tube feeding recommendations. Suggest goal of\n Fibersource HN at 50ml/hr x 24 hours to provide 1440kcal and 64g\n protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n Start Fibersource HN at 20ml/hr, advance by 20ml q6H to goal\n rate of 50ml/hr x 24 hours\n Monitor residuals q4H and hold tube feeding if greater than\n 200ml\n Will follow for possible extubation tomorrow\n 10:50 AM\n"},{"category":"Radiology","chartdate":"2169-11-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1260493,"text":" 6:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman intubated w effusion\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Radiograph of earlier the same date.\n\n INDICATION: Nasogastric tube assessment.\n\n FINDINGS: Nasogastric tube courses below the diaphragm, with tip not included\n on the radiograph. Endotracheal tube tip terminates 2.5 cm above carina with\n neck in a flexed position. Persistent cardiomegaly. Probable unchanged left\n effusion and adjacent basilar atelectasis allowing for slight differences in\n patient positioning. Small right effusion unchanged.\n\n\n"},{"category":"Respiratory ","chartdate":"2169-11-22 00:00:00.000","description":"Respiratory Care Shift Note","row_id":701892,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n 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: /\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Received on vent support; overbreathing. Switch to PSV.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done ~79.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"},{"category":"Physician ","chartdate":"2169-11-22 00:00:00.000","description":"Physician Resident Admission Note","row_id":701890,"text":"Chief Complaint: Dyspnea and vomiting\n HPI:\n This is an 85yo F with a h/o choledocholithiasis, HTN, renal CA, and\n dementia who presented to today with dyspnea and vomiting. History\n is mainly taken from that visit note. The patient had onset of n/v\n yesterday after eating fried shrimp the prior day. She took \"nausea\n relief\" from CVS with improvement, although had anorexia. In addition,\n the patient has had dyspnea with minimal exertion associated with\n nonproductive cough and chronic orthopnea. She has also experienced\n weakness and 2 mild falls (no trauma or LOC). She has had diarrhea four\n to five times a day, although may have chronic diarrhea. Per family\n report, patient also had chest pain, although patient could not\n confirm. She had a fever of 100.9 at home that improved to 97.6. She\n was sent to the ED for eval.\n .\n In the ED, labs showed tbili 9.9 with transaminitis, anion gap\n acidosis, lactate 4.5, bandemia 18% of 4.8 and creat 2.6 from 1.3\n baseline. CXR was clear. Due to report of COPD history, she initially\n received combivent and methylprednisolone, as well as ASA and\n ceftriaxone. Once labs revealed a septic picture, she received vanc and\n pip-tazo. SBP was upper 80s to low 90s and a RIJ was placed and the\n patient received 3L IVF. While undergoing RUQ U/S, she became acutely\n dyspneic with new opacities on CXR. She was tiring on , was\n intubated and sedated. The U/S showed CBD 25mm and sludge/sludge ball\n and GI plans to take for ERCP in the am. Prior to transfer, vitals\n were: 101.3 119 118/103 25 99%. However, after signout, she was started\n on norepinephrine.\n .\n On the floor, the patient is intubated and sedated. She is unable to\n answer questions.\n Patient admitted from: ER\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 Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Home medications:\n ALENDRONATE [FOSAMAX] - 70 mg weekly\n AMLODIPINE [NORVASC] - 10 mg once a day\n CHLORTHALIDONE - 25 mg QAM\n CITALOPRAM - 20 mg at bedtime\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit monthly\n LISINOPRIL - 40 mg once a day\n MEMANTINE [NAMENDA] - 10 mg twice daily\n METOPROLOL SUCCINATE [TOPROL XL] - 100 mg once a day\n POTASSIUM CHLORIDE - 20 mEq twice a day\n ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg once a day\n CYANOCOBALAMIN - 1,000 mcg once a day\n MULTIVITAMINS WITH MINERALS - 1 capsule once a day\n Past medical history:\n Family history:\n Social History:\n Primary kidney CA s/p cyberknife\n Choledocholithiasis s/p ERCP with sphincterotomy in \n Dementia\n B12 deficiency\n Hypertension\n Osteoporosis\n CKD\n disease, s/p RAI\n Follicular lymphoma of the small intestine, in remission\n ?Chronic diarrhea\n unable to obtain.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, lives with husband in . Remote tobacco history\n (one-half pack per day for 20 years), no EtOH.\n Review of systems:\n Flowsheet Data as of 05:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 86 (85 - 97) bpm\n BP: 91/51(61) {86/49(58) - 91/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 64 mL\n PO:\n TF:\n IVF:\n 64 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -86 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 470 (470 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 15 cmH2O\n SpO2: 99%\n ABG: 7.31/37/133//-6\n Ve: 9 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Labs / Radiology\n 140\n 130\n 2.6\n 30\n 16\n 106\n 4.0\n 140\n 37.3\n 4.8\n [image002.jpg]\n N 71, Band 18\n \n 2:33 A10/14/ 02:51 AM\n \n 10:20 P10/14/ 04:57 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 TC02\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Imaging:\n CXR: Study is slightly limited due to patient motion. No gross evidence\n of pneumonia or congestive heart failure.\n .\n CXR (repeat, my read): Mildly increased diffuse fluffy bilateral\n opacities compared to prior film.\n .\n RUQ U/S (prelim): Difficult to compare across modalities. perhaps\n slight increase in size of common duct at liver margin, previously\n ~21mm, currently ~25 mm, in pt with chronic dilatation of intra- and\n extra-hepatic bile ducts. echogenic material seen in distal CBD,\n probably sludge/sludge ball. more focal stone-appearing filling defect\n seen on recent MR (measuring 2.5 cm in longest dimension) not seen.\n also distalmost CBD / panc head not well visualized. clinical\n correlation necessary, and if indicated, ERCP or MRCP could be\n performed for further assessment. no fluid in RUQ. no Rt hydro.\n ECG: sinus rhythm, no ischemic changes\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock.\n .\n # Dyspnea/respiratory failure: Has been having recently worsening\n dyspnea on exertion, stable orthopnea. Became acutely SOB requiring\n intubation in the ED. Repeat CXR shows increased bilateral opacities\n suggesting pulmonary edema. Heart failure is possible with her BNP\n elevation and history of orthopnea, although she has no known heart\n failure. Influenza another possibility given concurrent fever and dry\n cough. Pneumonia less likely as initial CXR was clear and there was no\n sputum. Has smoking history, but no wheezing or CO2 retention to\n suggest COPD. Would also consider ischemia given report of chest pain,\n although EKG reportedly negative and cardiac markers negative x1. ABG\n shows good oxygenation and patient has been switched to PSV 10/5 with\n FiO2 40%.\n - Cont PSV for now and wean as tolerated\n - R/o influenza\n - TTE in am to eval for heart failure\n - Repeat CXR in am\n - Cycle cardiac markers\n .\n # Septic shock: Suggested by bandemia, elevated lactate, fever,\n tachycardia, and pressor requirement. Most likely biliary source given\n CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. UA unremarkable and CXR does not suggest PNA.\n Blood cx obtained in ED. BP currently stable on norepinephrine.\n - Cont broad spectrum abx with vancomycin and pip-tazo\n - ERCP in am for biliary drainage\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx and add on urine cx\n - Cont IVF to keep CVP 8-12 mmHg and good UOP\n - Wean pressors as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n .\n # ARF: Likely related to sepsis, as well as hypovolemia from vomiting\n and diarrhea. Baseline creatinine 1.2-1.4. Expect improvement s/p\n fluids.\n - IVF\n - Urine lytes\n - Avoid nephrotoxins\n - Trend renal function\n .\n # Anion gap acidosis: Most likely related to elevated lactate, now\n improving with IVF. No history of ingestion and no clear offenders on\n med list. Glucose not c/w DKA, BUN not c/w uremia.\n - Cont IVF\n - Repeat lactate, lytes in am\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: not indicated\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Husband/HCP (), hter \n ()\n Code status: Full code (confirm with family in am)\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2169-11-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":702013,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 03:45 AM\n Vent settings were changed to Pressure support and tolerating well\n ECHO this AM\n ERCP today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 79 (79 - 97) bpm\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 6 (6 - 7)mmHg\n Total In:\n 369 mL\n PO:\n TF:\n IVF:\n 369 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 219 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 451 (451 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.31/37/133//-6\n Ve: 9.3 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n TCO2\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock.\n .\n # Dyspnea/respiratory failure:\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\n trying to compensate by respiratory means\n Has been having recently worsening dyspnea on exertion, stable\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\n CXR shows increased bilateral opacities suggesting pulmonary edema.\n Heart failure is possible with her BNP elevation and history of\n orthopnea, although she has no known heart failure. Influenza another\n possibility, though less likely, given concurrent fever and dry cough.\n CXR was not concerning for pneumonia or fluid overload. Consider also\n ischemia given report of chest pain, although EKG reportedly negative\n and cardiac markers negative x2, so not likely ACS. ABG shows good\n oxygenation and patient has been switched to PSV 10/5 with FiO2 40%.\n PE less likely\n - Cont PSV for now and wean as tolerated\n - R/o influenza\n - f/u w TTE from this morning\n .\n # Septic shock:\n Bandemia and lactate improving, still febrile and requiring pressors.\n Sepsis likely secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\n other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo\n - ERCP today for biliary drainage\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n .\n # Anion gap acidosis:\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\n IVF.\n - Cont IVF per sepsis protocol\n - trend lactate\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\n - IVFs for CVP 10-12\n - f/u Urine lytes\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia\n Likely secondary to sepsis.\n - send DIC labs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: pneumoboots, subq heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband\n status: Full (Presumed)\n need to confirm w husband\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 85F a w/ renal ca, dementia,\n choledocolithiasis presents with n/v X 2 days, diarrhea, dyspnea, Fever\n 100.9. In ED CXR clear initially but intubated for ? evolving\n infiltrates and resp distress. RIJ CVL placed for hypotension with IVF\n given, levophed then started. Received vanco/zosyn Labs concerning for\n biliary sepsis with t bili 9.9, transaminitis, AGMA, lactate 4.5, 18%\n bandemia and cr 2.6. RUQ with dil cbd, sludge with ERCP consulted and\n plan for ERCP in am today.\n PE: BP: 90/50 HR90 RR 19 T: 100.8 98% ACV--> PS 12/5 40% Intubated,\n sedated, jaundiced, perrla, CTA, RR, soft + BS, non T at ruq, no edema\n LABS: wbc 25 (4.8), 19-->0 bands, hct 31.6, plt 93 (140), na 137, cr\n 2.4 (2.6), lactate 2.4 (4.5), t bili 6.4 (9.9), ast/alt decreasing, inr\n 1.3, 7.31/37/133, trop 0.02, BNP 5600, u/a neg\n ECG with NSR TWI 3, v1. no ST changes\n Imaging reviewed: cxr appears rotated, pulm vascular fullness, no focal\n infiltrate though would watch r mid zone for possible evolving asp pna\n A/P: Sepsis appears from biliary source/cholangitis, c/b arf and resp\n failure. Resp failure does not appear primary lung process, as CXR\n is rather unimpressive, but suspect in setting of met acidosis she\n fatigued. There is a component of mild demand ischemia by trop without\n frank ecg changes. Agree with plan to manage biliary sepsis with broad\n antibx (vanco, zosyn for now f/u cx data), plan for ercp today to\n relieve obstruction. She does not appear fully tanked from volume\n standpoint. Will continue aggressive IVF (LR given NG as well as AGMA)\n for cvp > 10, weaning pressor off, following u/o, trending lactate,\n lfts, a/l. Will continue current vent support as she is oxygenating\n well and appears comfortable on PS. Follow abgs closely for signs of\n fatigue noting her continued met acidosis. Evidence of mild demand\n ischemia in setting of septic picture--trop are flat and without\n progressive ecg changes. Volume may be an issue in setting of\n extubation. TTE will be helpful. . Her ARF likely vol repletion\n from sepsis, n/v and diarrhea. Aggressive fluids as above, send urine\n lytes. Thrombocytopenia likely in part dilutional and related to\n sepsis, also concerning for DIC. Send dic panel. Low suspicion for\n HIT. ICU prophy. Consider a-line placement if unable to wean off\n pressor. Remainder of plan as outlined in resident note. Need to\n confirm code status w/ family.\n Patient is critically ill\n Total time: 55 min.\n ------ Protected Section Addendum Entered By: , MD\n on: 02:11 PM ------\n"},{"category":"Nursing","chartdate":"2169-11-30 00:00:00.000","description":"Nursing Progress Note","row_id":703511,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent on \n Atrial fibrillation (Afib)\n Assessment:\n Pt intubated on . resp failure initially thought to be due to her\n primary metabolic acidosis which caused her to hyperventilate to\n compensate and fatigued beoming acutely sob and requiring intubation in\n the ed.pt initially unable to wean vent secondary to fluid\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\n 20\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\n Action:\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\n liter. Pt successfully extubated on . ngt in place for tube fdgs\n infusing presently at 30cc\ns/hr until speech and swallow study is\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\n status and fluid balance followed closely. Physical therapy consulted\n to increase pt\ns level of activity and for resp toileting. Speech and\n swallow study completed at bedside\n Response:\n Reps status improved with aggressive diuresis. Pt passed speech and\n swallow study so diet advanced to reg low sodium diet\n Plan:\n Continue to monitor pt\ns resp status and increase pt\ns level of\n activity. Continue to follow fluid balance closely. Continue with resp\n toileting. Pt will benefit from incentive spirometry. Physical therapy\n to evaluate pt. maintain pt on aspiration precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\ns . k+\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\n Action:\n Pt receiving lopressor as ordered . Electrolytres repleted as per\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\n Response:\n Hr effectively controlled on with po diltiazem and lopressor.\n Plan:\n Continue lopressor as ordered. Continue to check electrolytes as\n ordered and replete as needed. Follow hemodynamics closely. If pt\n remains tachycardic in afib will increase dose of lopressor.\n"},{"category":"General","chartdate":"2169-11-22 00:00:00.000","description":"ICU Event Note","row_id":702001,"text":"Clinician: Resident\n An Arterial line was placed in the left radial arterial under sterile\n technique without complication at 930 am. 25 mcg of fentanyl was given\n for increased sedation during the procedure.\n"},{"category":"Physician ","chartdate":"2169-11-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":701982,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 03:45 AM\n Vent settings were changed to Pressure support and tolerating well\n ECHO this AM\n ERCP today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 79 (79 - 97) bpm\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 6 (6 - 7)mmHg\n Total In:\n 369 mL\n PO:\n TF:\n IVF:\n 369 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 219 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 451 (451 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.31/37/133//-6\n Ve: 9.3 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n TCO2\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock.\n .\n # Dyspnea/respiratory failure:\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\n trying to compensate by respiratory means\n Has been having recently worsening dyspnea on exertion, stable\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\n CXR shows increased bilateral opacities suggesting pulmonary edema.\n Heart failure is possible with her BNP elevation and history of\n orthopnea, although she has no known heart failure. Influenza another\n possibility, though less likely, given concurrent fever and dry cough.\n CXR was not concerning for pneumonia or fluid overload. Consider also\n ischemia given report of chest pain, although EKG reportedly negative\n and cardiac markers negative x2, so not likely ACS. ABG shows good\n oxygenation and patient has been switched to PSV 10/5 with FiO2 40%.\n PE less likely\n - Cont PSV for now and wean as tolerated\n - R/o influenza\n - f/u w TTE from this morning\n .\n # Septic shock:\n Bandemia and lactate improving, still febrile and requiring pressors.\n Sepsis likely secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\n other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo\n - ERCP today for biliary drainage\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n .\n # Anion gap acidosis:\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\n IVF.\n - Cont IVF per sepsis protocol\n - trend lactate\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\n - IVFs for CVP 10-12\n - f/u Urine lytes\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia\n Likely secondary to sepsis.\n - send DIC labs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: pneumoboots, subq heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband\n status: Full (Presumed)\n need to confirm w husband\n Disposition:\n"},{"category":"Nursing","chartdate":"2169-11-30 00:00:00.000","description":"Nursing Progress Note","row_id":703365,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent. Respiratory failure initially thought to be due to\n metabolic acidosis which caused her to hyperventilate to compensate.\n She fatigued quickly becoming acutely SOB and required intubation on\n ^th. Since then, unable to wean vent because of pt being\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\n coming off peep becoming very tachypneic with low tidal volumes which\n is more concerning for difficulty with compliance then volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on humidified fact ten s/p extubation @ 40% FiO2. Pt\n tachypneic @ times 30-40\ns but appearing comfortable & settles out on\n own. O2 sat 97-100%. LS clear, diminished @ bases. MN fluid goal\n 1.5\n 2L. Mental status much improved. Pt following commands and actively\n participating in care. Pt requesting food throughout the night.\n Action:\n Pt titrated down to 2LNC. Cough improving O/N. Pt able to produce small\n amts of sputum and allow for suctioning. Q4hr mouthcare. (Dentures @\n bedside) Tubefeeds initiated @ 10cc hr (please see previous order)\n Response:\n Pt -1L @ MN. Improving\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal - 1.5\n 2L @\n this time. Cont to trend lab values and f/u on micro data. As discussed\n w/ daughter (HCP) pt will be reintubated in necessary (but remains DNR)\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n Pt did have 2 smears of stool overnight. Please monitor\n closely. Skin breakdown is of concern, amt of stool was not significant\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\n not benefit from fecal inc. bag)\n"},{"category":"Physician ","chartdate":"2169-11-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":703414,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:22 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\n improved in terms of pulmonary vascular congestion, will trial\n extubation today since patient looks the best she has since admission\n - patient may need Bipap post extubation\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n .\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 90\ns with both medications\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month\n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n"},{"category":"Nursing","chartdate":"2169-11-30 00:00:00.000","description":"Nursing Progress Note","row_id":703415,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on humidified fact tent s/p extubation @ 40% FiO2. Pt less\n tachypneic this evening 20\ns. O2 sat 97-100%. LS clear,\n diminished @ bases. MN fluid goal\n 1.5\n 2L. Mental status much\n improved. Pt following commands and actively participating in care. Pt\n requesting food throughout the night.\n Action:\n Pt titrated down to 2LNC. Cough improving O/N. Pt able to produce small\n amts of sputum and allow for suctioning @ beginning of shift. Q4hr\n mouthcare. (Dentures @ bedside) Tubefeeds initiated @ 10cc hr (please\n see previous order) Atrovent nebs Q6hrs.\n Response:\n Pt -1L @ MN. TF currently running @ 30cc/hr (goal 50cc/hr) Dry, NPC\n this AM.\n Plan:\n Cont to diurese w/ Lasix IVP if warranted. Net goal - 1.5\n 2L @ this\n time. Cont to trend lab values and f/u on micro data. As discussed w/\n daughter (HCP) pt will be reintubated if necessary (but remains DNR)\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in Afib; HR ranging from 90-100\ns. SBP 85-120\ns. Minimal\n ectopy noted. AM K 3.6, Mg 1.9\n Action:\n Pt currently on Lopressor 25mg NG TID & Diltiazem 30mg NG Q6hr. MN Dilt\n was held to low BP. Tolerated Lopressor (HR 90\ns) Magnesium 2gm IV\n & KCL 20mEq IV given this AM per sliding scale orders.\n Response:\n Pt has remained in Afib but rate has significantly improved w/\n administration of Lopressor & Dilt. HR ranging 80\n low 100\ns w/\n minimal ectopy.\n Plan:\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\n Diltiazem as warranted. Follow electrolyte status & replete as needed.\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n Pt did have 2 smears of stool overnight. Please monitor\n closely. Skin breakdown is of concern, amt of stool was not significant\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\n not benefit from fecal inc. bag)\n Will most likely be c/o to medical floor this AM\n"},{"category":"Physician ","chartdate":"2169-11-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":703417,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. status post extubation, doing great, weaned down to 2LNC\n - will c/s speech and swallow prior to advancing diet as patient is\n having some difficulty controlling her oral secretions\n - still on dilt/lopressor, dilt seems to have better HR effects\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\n improved in terms of pulmonary vascular congestion, will trial\n extubation today since patient looks the best she has since admission\n - patient may need Bipap post extubation\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n .\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 90\ns with both medications\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month\n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n"},{"category":"Nursing","chartdate":"2169-11-30 00:00:00.000","description":"Nursing Transfer Note","row_id":703486,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent on \n Atrial fibrillation (Afib)\n Assessment:\n Pt intubated on . resp failure initially thought to be due to her\n primary metabolic acidosis which caused her to hyperventilate to\n compensate and fatigued beoming acutely sob and requiring intubation in\n the ed.pt initially unable to wean vent secondary to fluid\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\n 20\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\n Action:\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\n liter. Pt successfully extubated on . ngt in place for tube fdgs\n infusing presently at 30cc\ns/hr until speech and swallow study is\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\n status and fluid balance followed closely. Physical therapy consulted\n to increase pt\ns level of activity and for resp toileting. Speech and\n swallow study completed at bedside\n Response:\n Reps status improved with aggressive diuresis. Pt passed speech and\n swallow study so diet advanced to reg low sodium diet\n Plan:\n Continue to monitor pt\ns resp status and increase pt\ns level of\n activity. Continue to follow fluid balance closely. Continue with resp\n toileting. Pt will benefit from incentive spirometry. Physical therapy\n to evaluate pt. maintain pt on aspiration precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\ns . k+\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\n Action:\n Pt receiving lopressor as ordered . Electrolytres repleted as per\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\n Response:\n Hr effectively controlled on with po diltiazem and lopressor.\n Plan:\n Continue lopressor as ordered. Continue to check electrolytes as\n ordered and replete as needed. Follow hemodynamics closely. If pt\n remains tachycardic in afib will increase dose of lopressor.\n"},{"category":"Physician ","chartdate":"2169-11-30 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":703488,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. status post extubation, doing great, weaned down to 2LNC\n - passed speech and swallow. Diet advanced to regular\n - still on dilt/lopressor, dilt seems to have better HR effects\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\n Does c/o hoarse voice\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: awake, responsive, follows commands\n HEENT: PERRL, MMM, NG tube in place\n Neck: RIJ in place\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload was seen on CXR. S/p\n extubation.\n - s/p extubation, satting well on 2L NC\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 110\ns with both medications. Some\n tachycardia likely related to intubation and agitation. Episodic BPs\n low on both agents.\n - d/c dilt and monitor BP/tachycardia\n - will need ongoing titration/o/p follow up\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month, scheduled \n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n 12:28\n ------ Protected Section ------\n Agree with excellent medical student note with the following addition:\n The patient was on long acting metoprolol at a dose of 100mg daily\n prior to admission. She would benefit from continuing the beta-blocker\n rather than the calcium channel blocker for coronary artery disease\n history. She will likely need to be titrated up on the metoprolol to\n at least her prior home dose but likely higher.\n The patient is doing well on 2L NC this AM and is ready to be\n transferred to the floor.\n She passed her speech and swallow study. Her NG tube will be pulled\n today, and her diet will be advanced.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:53 ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\n respiratory failure, AF c RVR improved with BBL / CCB. Diuresis\n ongoing, BNP 6K.\n Exam notable for Tm 99.8 BP 116/62 HR 95-105AF RR 12-37 with sat 100 on\n PSV 8/5, -2L / 24h. WD woman, alert, conversant. JVD flat. CTA B, \n at bases c few rales. Irreg s1s2. Soft +BS. 2+ edema. Labs notable for\n WBC 7K, HCT 26, K+ 3.6, Cr 1.4.\n Agree with plan to respiratory failure with CPT / upright positioning,\n PT eval, OOB, hold on lasix. OK to ADAT s/p S+S, d/c NGT. Cholangitis\n improving, will need 14d abx via PICC (day ). Over the long term,\n will need f/u ERCP for large nonobstructive stone - scheduled for\n . For AF c RVR, continue BBL, d/c CCB today, start ASA 81mg. ARF\n has resolved; baseline CRI. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:59 PM ------\n"},{"category":"Physician ","chartdate":"2169-11-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":703475,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. status post extubation, doing great, weaned down to 2LNC\n - passed speech and swallow. Diet advanced to regular\n - still on dilt/lopressor, dilt seems to have better HR effects\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\n Does c/o hoarse voice\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: awake, responsive, follows commands\n HEENT: PERRL, MMM, NG tube in place\n Neck: RIJ in place\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload was seen on CXR. S/p\n extubation.\n - s/p extubation, satting well on 2L NC\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 110\ns with both medications. Some\n tachycardia likely related to intubation and agitation. Episodic BPs\n low on both agents.\n - d/c dilt and monitor BP/tachycardia\n - will need ongoing titration/o/p follow up\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month, scheduled \n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n 12:28\n"},{"category":"Physician ","chartdate":"2169-11-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":703478,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. status post extubation, doing great, weaned down to 2LNC\n - passed speech and swallow. Diet advanced to regular\n - still on dilt/lopressor, dilt seems to have better HR effects\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\n Does c/o hoarse voice\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: awake, responsive, follows commands\n HEENT: PERRL, MMM, NG tube in place\n Neck: RIJ in place\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload was seen on CXR. S/p\n extubation.\n - s/p extubation, satting well on 2L NC\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 110\ns with both medications. Some\n tachycardia likely related to intubation and agitation. Episodic BPs\n low on both agents.\n - d/c dilt and monitor BP/tachycardia\n - will need ongoing titration/o/p follow up\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month, scheduled \n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n 12:28\n ------ Protected Section ------\n Agree with excellent medical student note with the following addition:\n The patient was on long acting metoprolol at a dose of 100mg daily\n prior to admission. She would benefit from continuing the beta-blocker\n rather than the calcium channel blocker for coronary artery disease\n history. She will likely need to be titrated up on the metoprolol to\n at least her prior home dose but likely higher.\n The patient is doing well on 2L NC this AM and is ready to be\n transferred to the floor.\n She passed her speech and swallow study. Her NG tube will be pulled\n today, and her diet will be advanced.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:53 ------\n"},{"category":"Nursing","chartdate":"2169-11-30 00:00:00.000","description":"Nursing Transfer Note","row_id":703536,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent on \n Atrial fibrillation (Afib)\n Assessment:\n Pt intubated on . resp failure initially thought to be due to her\n primary metabolic acidosis which caused her to hyperventilate to\n compensate and fatigued beoming acutely sob and requiring intubation in\n the ed.pt initially unable to wean vent secondary to fluid\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\n 20\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\n Action:\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\n liter. Pt successfully extubated on . ngt in place for tube fdgs\n infusing presently at 30cc\ns/hr until speech and swallow study is\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\n status and fluid balance followed closely. Physical therapy consulted\n to increase pt\ns level of activity and for resp toileting. Speech and\n swallow study completed at bedside\n Response:\n Reps status improved with aggressive diuresis. Pt passed speech and\n swallow study so diet advanced to reg low sodium diet\n Plan:\n Continue to monitor pt\ns resp status and increase pt\ns level of\n activity. Continue to follow fluid balance closely. Continue with resp\n toileting. Pt will benefit from incentive spirometry. Physical therapy\n to evaluate pt. maintain pt on aspiration precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\ns . k+\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\n Action:\n Pt receiving lopressor as ordered . Electrolytres repleted as per\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\n Response:\n Hr effectively controlled on with po diltiazem and lopressor.\n Plan:\n Continue lopressor as ordered. Continue to check electrolytes as\n ordered and replete as needed. Follow hemodynamics closely. If pt\n remains tachycardic in afib will increase dose of lopressor.\n"},{"category":"Nursing","chartdate":"2169-11-30 00:00:00.000","description":"Nursing Transfer Note","row_id":703440,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent on \n Atrial fibrillation (Afib)\n Assessment:\n Pt intubated on . resp failure initially thought to be due to her\n primary metabolic acidosis which caused her to hyperventilate to\n compensate and fatigued beoming acutely sob and requiring intubation in\n the ed.pt initially unable to wean vent secondary to fluid\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\n 20\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\n Action:\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\n liter. Pt successfully extubated on . ngt in place for tube fdgs\n infusing presently at 30cc\ns/hr until speech and swallow study is\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\n status and fluid balance followed closely. Physical therapy consulted\n to increase pt\ns level of activity and for resp toileting.\n Response:\n Reps status improved with aggressive diuresis\n Plan:\n Continue to monitor pt\ns resp status and increase pt\ns level of\n activity. Continue to follow fluid balance closely. Await final\n recommendations of speech and swallow consult. Continue with resp\n toileting. Pt will benefit from incentive spirometry.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\ns . k+\n 3.6 and mg=1.9\n Action:\n Pt receiving lopressor and diltiazem as ordered. Electrolytres repleted\n as per sliding scale. Hemodynamics followed closely.\n Response:\n Hr effectively controlled on with po diltiazem and lopressor.\n Plan:\n Continue diltiazem and lopressor as ordered. Continue to check\n electrolytes as ordered and replete as needed. Follow hemodynamics\n closely.\n"},{"category":"Nutrition","chartdate":"2169-11-30 00:00:00.000","description":"Clinical Nutrition Note","row_id":703461,"text":"Subjective\n happy to pass S & S eval\n Objective\n Pertinent medications: Piperacillin-Tazobactam, Vancomycin, Heparin,\n others noted\n Labs:\n Value\n Date\n Glucose\n 78 mg/dL\n 04:02 AM\n Glucose Finger Stick\n 149\n 06:00 PM\n BUN\n 26 mg/dL\n 04:02 AM\n Creatinine\n 1.4 mg/dL\n 04:02 AM\n Sodium\n 139 mEq/L\n 04:02 AM\n Potassium\n 3.6 mEq/L\n 04:02 AM\n Chloride\n 99 mEq/L\n 04:02 AM\n TCO2\n 30 mEq/L\n 04:02 AM\n PO2 (arterial)\n 124 mm Hg\n 07:32 AM\n PCO2 (arterial)\n 44 mm Hg\n 07:32 AM\n pH (arterial)\n 7.46 units\n 07:32 AM\n pH (urine)\n 5.0 units\n 09:47 AM\n CO2 (Calc) arterial\n 32 mEq/L\n 07:32 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:02 AM\n Phosphorus\n 3.2 mg/dL\n 04:02 AM\n Magnesium\n 1.9 mg/dL\n 04:02 AM\n ALT\n 45 IU/L\n 04:54 AM\n Alkaline Phosphate\n 103 IU/L\n 04:15 AM\n AST\n 23 IU/L\n 04:54 AM\n Amylase\n 16 IU/L\n 07:35 AM\n Total Bilirubin\n 1.5 mg/dL\n 04:15 AM\n WBC\n 7.3 K/uL\n 04:02 AM\n Hgb\n 8.9 g/dL\n 04:02 AM\n Hematocrit\n 26.6 %\n 04:02 AM\n Current diet order / nutrition support: Regular; Cardiac/Heart healthy\n GI: NBS, smear stool x 2 last night\n SKIN: buttocks redden\n Assessment of Nutritional Status\n 85 year old female with h/o choledocholithiasis presented with dyspnea\n and vomiting complicated by acute respiratory failure and septic\n shock. Patient intubated and started on tube feed, tube feed off for\n extubation, patient extubated yesterday, and passed S & S evaluation\n this morning, per discussion with SLP, okay to diet advance, patient\n still has her NGT in place and tube feed is currently at 30ml/hr\n HN, MD just change POE diet to regular and tube feed order\n discontinued.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet is appropriate\n Multivitamin / Mineral supplement: daily\n Check chemistry 10 panel daily, replete prn\n will monitor po as tol\n if has question\n"},{"category":"Rehab Services","chartdate":"2169-11-30 00:00:00.000","description":"Bedside Swallow Evaluation","row_id":703463,"text":"TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 85 y/o female with h/o\ncholedocholithiasis, HTN, renal ca and dementia admitted on\n with dyspnea and vomiting. Pt also with diarrhea and\nfever. CXR was initially clear but pt developed acute dyspnea\nwhile in U/S with new opacities suggestive of pulmonary edema on\nCXR and pt required intubation. The U/S showed sludge /sludge bal\nand pt is s/p ERCP and stent. Pt had difficulty weaning from the\nvent volume overload fluid resuscitation. Pt was\nextubated yesterday around noon and we were consulted to evaluate\nfor oral and pharyngeal dysphagia. She is currently NPO with NG\ntube in place.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the .\nCognition, language, speech, voice:\nThe pt was awake, alert and oriented x 3 with fluent language.\nSpeech and voice were wfl and she was able to follow all basic\ncommands.\nTeeth: edentulous- full set of well fitting dentures put in place\nSecretions: wfl in the oral cavity\nORAL MOTOR EXAM:\nSymmetrical facial appearance with adequate lip seal and buccal\ntone. Tongue was at midline with functional strength and ROM.\nPalatal elevation and gag deferred.\nSWALLOWING ASSESSMENT:\nThe pt was seen with thin liquids (tsp, straw, consecutive),\npurees and regular solids. Pt with mild difficulty biting solids,\nbut mastication was functional without significant residue. Pt\nwithout overt coughing, throat clearing or changes in vocal\nquality and she denied the sensation of aspiration or pharyngeal\nresidue. O2 SATs remained greater than 98%. Laryngeal elevation\nwas timely and wfl to palpation.\nSUMMARY / IMPRESSION:\nThe pt had difficulty self feeding but tolerated thin liquids and\nregular solids without difficulty or signs of aspiration. She can\nbe advanced to a regular diet but will require assistance with\nsetting up her meals and feeding. Pills can be given whole with\nwater. If pt tolerates lunch well, we can remove the NG currently\nin place.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 7.\nRECOMMENDATIONS:\n1. Suggest a PO diet of thin liquids and regular consistency\nsolids.\n2. Supervision during meals to assist with feeding.\n3. Meds whole with thin liquids.\n4. If pt tolerates lunch, suggest removing her NG tube.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 11:00-11:20\nTotal time: 60 minutes\n [BUTTON Input] (not implemented)_____\n 11:24\n"},{"category":"Nursing","chartdate":"2169-11-30 00:00:00.000","description":"Nursing Transfer Note","row_id":703530,"text":"Demographics\n Attending MD:\n F.\n Admit diagnosis:\n SEPSIS\n Code status:\n DNR (do not resuscitate)\n Height:\n 64 Inch\n Admission weight:\n 83.8 kg\n Daily weight:\n 80 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: lymphoma, dementia.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:64\n Temperature:\n 97\n Arterial BP:\n S:123\n D:69\n Respiratory rate:\n 37 insp/min\n Heart Rate:\n 101 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,930 mL\n 24h total out:\n 960 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:02 AM\n Potassium:\n 3.6 mEq/L\n 04:02 AM\n Chloride:\n 99 mEq/L\n 04:02 AM\n CO2:\n 30 mEq/L\n 04:02 AM\n BUN:\n 26 mg/dL\n 04:02 AM\n Creatinine:\n 1.4 mg/dL\n 04:02 AM\n Glucose:\n 78 mg/dL\n 04:02 AM\n Hematocrit:\n 26.6 %\n 04:02 AM\n Finger Stick Glucose:\n 149\n 06:00 PM\n Valuables / Signature\n Patient valuables: upper and lower dentures\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: yellow colored wedding band and yellow colored engagement ring\n with clear colored stones\n Transferred from:\n Transferred to: 408\n Date & time of Transfer: 1830\n"},{"category":"Nursing","chartdate":"2169-11-22 00:00:00.000","description":"Nursing Progress Note","row_id":701925,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management.\n CNS: Patient is now sedated on midazolam at 3mg/hr and fentanyl at\n 50mcg/hr for pain management. Bilateral soft wrist restraints on to\n prevent treatment interference. Patient not able to open eyes or follow\n commands at this time but does grimace to painful stimuli.\n CVS: SR on the monitor with BP being maintained on Levophed at 0.2mkm\n to keep MAP greater than 65mmHg. Peripheral pulses are palpable; she\n has a right IJ TL CL with CVP monitoring. One peripheral IV to the\n right inner wrist.\n RESP: Currently the patient is on PSV with setting and maintaining\n adequate saturations in the upper 90\ns, in no obvious distress at the\n time of reporting.\n GI: Abdomen soft with bowel sounds, OGT placed and to be confirmed.\n GU: Foley with icteric colored urine, urine lytes to be collected.\n"},{"category":"Physician ","chartdate":"2169-11-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":701955,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 03:45 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 79 (79 - 97) bpm\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 6 (6 - 7)mmHg\n Total In:\n 369 mL\n PO:\n TF:\n IVF:\n 369 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 219 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 451 (451 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.31/37/133//-6\n Ve: 9.3 L/min\n PaO2 / FiO2: 332\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 02:51 AM\n 04:57 AM\n TCO2\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock.\n .\n # Dyspnea/respiratory failure:\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\n trying to compensate by respiratory means\n Has been having recently worsening dyspnea on exertion, stable\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\n CXR shows increased bilateral opacities suggesting pulmonary edema.\n Heart failure is possible with her BNP elevation and history of\n orthopnea, although she has no known heart failure. Influenza another\n possibility given concurrent fever and dry cough. Pneumonia less likely\n as initial CXR was clear and there was no sputum. Has smoking history,\n but no wheezing or CO2 retention to suggest COPD. Would also consider\n ischemia given report of chest pain, although EKG reportedly negative\n and cardiac markers negative x1. ABG shows good oxygenation and patient\n has been switched to PSV 10/5 with FiO2 40%.\n - Cont PSV for now and wean as tolerated\n - R/o influenza\n - TTE in am to eval for heart failure\n - Repeat CXR in am\n - Cycle cardiac markers\n .\n # Septic shock:\n Bandemia and lactate improving, still febrile and requiring pressors.\n Sepsis likely secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\n other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo\n - ERCP today for biliary drainage\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n .\n # Anion gap acidosis:\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\n IVF.\n - Cont IVF per sepsis protocol\n - trend lactate\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\n - IVFs for CVP 10-12\n - f/u Urine lytes\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia\n Likely secondary to sepsis.\n - send DIC labs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2169-11-22 00:00:00.000","description":"Physician Resident Progress Note","row_id":701936,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 03:45 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 79 (79 - 97) bpm\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 6 (6 - 7)mmHg\n Total In:\n 369 mL\n PO:\n TF:\n IVF:\n 369 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 219 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 451 (451 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.31/37/133//-6\n Ve: 9.3 L/min\n PaO2 / FiO2: 332\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 02:51 AM\n 04:57 AM\n TCO2\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2169-11-22 00:00:00.000","description":"Nursing Progress Note","row_id":701907,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management.\n CNS: Patient is now sedated on midazolam at 3mg/hr and fentanyl at\n 50mcg/hr for pain management. Bilateral soft wrist restraints on to\n prevent treatment interference. Patient not able to open eyes or follow\n commands at this time but does grimace to painful stimuli.\n CVS: SR on the monitor with BP being maintained on Levophed at 0.2mkm\n to keep MAP greater than 65mmHg. Peripheral pulses are palpable; she\n has a right IJ TL CL with CVP monitoring. One peripheral IV to the\n right inner wrist.\n RESP: Currently the patient is on PSV with setting and maintaining\n adequate saturations in the upper 90\ns, in no obvious distress at the\n time of reporting.\n"},{"category":"Nursing","chartdate":"2169-11-22 00:00:00.000","description":"Nursing Progress Note","row_id":702052,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\n Action:\n Placed on A/C for ERCP.\n Response:\n Remains on AC as she received paralytic for ERCP and remains very\n sedated.\n Plan:\n Return PSV when spontaneous breathing returns. Turn off sedation in\n a.m. and do SBT for possible extubation.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\n WBC up to 25.\n Action:\n Received additional 2L IVBs.\n Response:\n UO increased to ~40cc/hr. CVP 13-15. Levophed weaned to\n 0.1mcg/kg/minute.\n Plan:\n Wean Levophed as tol. Follow CVP and UO. IVBs as per team.\n"},{"category":"Echo","chartdate":"2169-11-22 00:00:00.000","description":"Report","row_id":79089,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypotension. Dyspnea.\nHeight: (in) 64\nWeight (lb): 185\nBSA (m2): 1.89 m2\nBP (mm Hg): 97/50\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 09:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification.\nMild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). The\nestimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. Trace aortic regurgitation is\nseen. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nhigh normal. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the left\nventricle is less dynamic, the velocity across the aortic valve is lower (now\nnormal), and the severity of tricuspid regurgitation and pulmonary artery\nsystolic pressure are lower.\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":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703050,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\n RR up to 34-36 pt volume overloaded, remains on 1 mg Versed IV\n gtt, with prn boluses of 0.5 mg\n Action:\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\n received 10 mg IVP Lasix at 9 pm with good response. Received repeat\n 20 mg IVP Lasix at 4:30 am.\n Response:\n Pt rested overnight on AC.\n Plan:\n Change back to pressure support in am, check RSBI, ?ready for\n extubation repeat RSBI~157 would like pt negative one liter.\n Continue Versed gtt\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in Afib, rate 115-130 bp 100/60\n Action:\n Lopressor increased to 25 mg per NGT tid, also received 2.5 mg IV\n Lopressor at 4:30 am\n Response:\n HR down to 107 Afib\n Plan:\n Continue to monitor HR, bp closely. Lopressor increased to tid (25\n mg)\n GI: OG tube removed, r nare NG tube inserted, confirmed by CXRAY,\n also pulled back bile, and air heard in stomach.\n ID: Afebrile, ERCP showed\n"},{"category":"Nursing","chartdate":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703161,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\ns. afib\n first occurred during sbt on / trialed lopressor 12.5 mg po on\n without affect.\n Action:\n Lopressor dose was increased to 25 mg pot id without any improvement in\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\n hr. hemodynamics followed closely.\n Response:\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\n was d/c\nd. sbp retruned to her baseline once esmalol gtt was d/c\n Plan:\n Continue to follow hemodynamics . Continue to check lytes as ordered\n and replete as needed. Pt now started on lopressor 25 mg pot id and\n diltiazem 30 mg po q 6hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp failure initially thought to be due to metabolic acidosis which\n caused her to hyperventilate to compensate and fatigued becoming\n acutely sob and requiring intubation on ^th.unable to wean\n vent because of pt being fluid overloaded secondary to fluid\n resusitiation. Pt having difficulty coming off peep becoming very\n tachypenic with low tidal volumes which is more concerning for\n difficulty with compliance then volume overload. Cxr c/w lll opacity\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\n tachypenic . lungs clear with crackles noted bil at the bases.\n Suctioned for sm amts of thick white sputum.\n Action:\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\n closely.\n Response:\n Vent settings unchanged. Cxr unchanged\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Will keep on cpap mode\n of ventilation overnoc. Plan is to call anesthesia in the am to change\n #7 ett to o #8 ett over the cook catheter. Once ett is changed will\n then check rsbi and do sbt. Will do bronchoscopy after that and then\n possible extubation with the plan to reintubate if pt fails extubation.\n"},{"category":"Nursing","chartdate":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703162,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\ns. afib\n first occurred during sbt on / trialed lopressor 12.5 mg po on\n without affect.\n Action:\n Lopressor dose was increased to 25 mg pot id without any improvement in\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\n hr. hemodynamics followed closely.\n Response:\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\n was d/c\nd. sbp retruned to her baseline once esmalol gtt was d/c\n Plan:\n Continue to follow hemodynamics . Continue to check lytes as ordered\n and replete as needed. Pt now started on lopressor 25 mg pot id and\n diltiazem 30 mg po q 6hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp failure initially thought to be due to metabolic acidosis which\n caused her to hyperventilate to compensate and fatigued becoming\n acutely sob and requiring intubation on ^th.unable to wean\n vent because of pt being fluid overloaded secondary to fluid\n resusitiation. Pt having difficulty coming off peep becoming very\n tachypenic with low tidal volumes which is more concerning for\n difficulty with compliance then volume overload. Cxr c/w lll opacity\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\n tachypenic . lungs clear with crackles noted bil at the bases.\n Suctioned for sm amts of thick white sputum.\n Action:\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\n closely.\n Response:\n Vent settings unchanged. Cxr unchanged\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal for i&o is to\n be neg 1.5 to 2 liters Will keep on cpap mode of ventilation overnoc.\n Plan is to call anesthesia in the am to change #7 ett to o #8 ett over\n the cook catheter. Once ett is changed will then check rsbi and do sbt.\n Will do bronchoscopy after that and then possible extubation with the\n plan to reintubate if pt fails extubation.\n"},{"category":"Physician ","chartdate":"2169-11-28 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":703163,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - diurese further today to help w possibility of extubation--> Net Goal\n -1.5-2L\n - consider risk of aspiration post-extubation due to mental status\n - NG tube placed\n - patient remains tachycardic so metoprolol was increased to 25mg TID\n - need to address possib of anticoagulation w family and PCP\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\n tolerate 20mg IV)\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\n at 9:30pm to rest, so that she can be ready, better rested for SBT\n tomorrow, esp after diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 04:27 PM\n Heparin Sodium (Prophylaxis) - 04:31 AM\n Furosemide (Lasix) - 04:39 AM\n Metoprolol - 04:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 116 (100 - 125) bpm\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\n RR: 23 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 9 (9 - 272)mmHg\n Total In:\n 2,091 mL\n 206 mL\n PO:\n TF:\n 1,506 mL\n IVF:\n 524 mL\n 206 mL\n Blood products:\n Total out:\n 2,125 mL\n 1,120 mL\n Urine:\n 2,125 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -34 mL\n -915 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): 324 (255 - 463) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 25 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: ///30/\n Ve: 7.1 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 131 K/uL\n 9.1 g/dL\n 109 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 103 mEq/L\n 142 mEq/L\n 27.4 %\n 12.2 K/uL\n [image002.jpg]\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n WBC\n 20.2\n 11.3\n 10.6\n 11.2\n 12.2\n Hct\n 30.7\n 29.7\n 29.3\n 27.9\n 27.4\n Plt\n 52\n 48\n 60\n 84\n 131\n Cr\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n TCO2\n 23\n 26\n 25\n Glucose\n 91\n 128\n 119\n 126\n 143\n 117\n 109\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.6 mg/dL\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\n Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n Imaging:\n Chest X-Ray at 2330 (my read): stable effusion/opacity and\n RLL patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\n having difficulty coming off PEEP, becomes very tachypneic and has low\n tidal volumes, which is more concerning for difficulty with compliance\n and volume overload. Additionally, patient with opacity and\n diaphragm pulled up on the left that has been noted on all x-rays\n during this admission, to better see the anatomy in the , \n bronch the patient this afternoon to look at the .\n - continue with net negative goal, if UOP decreases to less than\n 100cc/hr will give another dose of lasix and readdress possible\n extubation this afternoon.\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\n the 120\ns to 130\ns, so will trial an esmolol drip\n # Septic shock: resolving, patient off pressors, likely secondary to\n cholangitis and infected stone/sludge. ERCP showed significant pusand\n very large stone, she is s/p stent placement. Patient afebrile and\n white count stable. Lactate normal. Initial sepsis secondary to biliary\n source given CBD dilation with sludge and obstructive LFTs in setting\n on known choledocholithiasis.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 48 hours.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\n will place a PICC and pull central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\n to help with further diruesis\n - Monitor UOP\n - Check PM lytes\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition: Tube feeds held o/n for possible extubation, will hold this\n afternoon for possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM, will put patient in for a PICC today\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\n respiratory failure, AF c RVR. Failed SBT this AM, diuresis ongoing.\n Exam notable for Tm 99.2 BP HR 122/80 RR 12-37 with sat 100 on PSV 5/5.\n WD woman, follows intermittent commands. Coarse BS B. Irreg s1s2. Soft\n +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+ 3.9, Cr 1.3.\n Agree with plan to manage respiratory failure ongoing IV lasix for TBB\n negative, will check and trend CVP, continue upright positioning,\n bronch c pedi scope to assess prior to trial of extubation. Will\n f/u sputum cx. Cholangitis improving, will need 14d abx, f/u\n cultures, will change CVL to PICC for long-term IV abx. For AF c RVR,\n continue PO BBL c esmolol gtt, hold off on anticoagulation. ARF has\n resolved. Continue TFs for now. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:36 PM ------\n"},{"category":"Nursing","chartdate":"2169-11-29 00:00:00.000","description":"Nursing Progress Note","row_id":703233,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent. Respiratory failure initially thought to be due to\n metabolic acidosis which caused her to hyperventilate to compensate.\n She fatigued quickly becoming acutely SOB and required intubation on\n ^th. Since then, unable to wean vent because of pt being\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\n coming off peep becoming very tachypneic with low tidal volumes which\n is more concerning for difficulty with compliance then volume overload.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in Afib; HR ranging from 90-130\ns. SBP 85-120\ns. Afib first\n occurred during SBT on . Occasional PVC\ns noted.\n Action:\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\n 20mEq IV given last evening per sliding scale orders.\n Response:\n Pt has remained in Afib but rate has significantly improved w/\n administration of Lopressor & Dilt. HR ranging 80\n low 100\ns w/\n minimal ectopy.\n Plan:\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\n Diltiazem. Follow electrolyte status & replete as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\n 30-40\ns but appearing comfortable & settles out on own. LS clear,\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\n 1.5\n 2L. Mental status much improved. Pt following commands and\n actively participating in care. Remains restless @ times but is easily\n redirected.\n Action:\n Suctioning q2-4 hrs for thick/white sputum. Pt appears to be pooling\n large amts of secretions in the subglottal area. (concern for\n aspiration post extubation)\n Response:\n Pt -2L @ MN.\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal - 1.5\n 2L @\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\n exchange. If all goes as planned, pt will be extubated late morning. As\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\n remains DNR)\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n Pt did have 2 smears of stool overnight. Please monitor\n closely. Skin breakdown is of concern, amt of stool was not significant\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\n not benefit from fecal inc. bag)\n"},{"category":"Nursing","chartdate":"2169-11-29 00:00:00.000","description":"Nursing Progress Note","row_id":703328,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on PSV 40% 8/5. Sedated on midaz\n at 1mg/hr. B/L LS clear diminished at the bases. Tachypneic to high\n 20-30\n Action:\n Lasix 20mg X1 given prior to extubation, extubated.\n Response:\n No s/s of resp distress. Patient denies any SOB when asked. Sats at\n high 90\ns on face tent.\n Plan:\n Continue to monitor patient resp status\n Atrial fibrillation (Afib)\n Assessment:\n Known AFib. HR in 90-low 100\ns. B/P 90-110\ns occasionally when asleep\n b/p down to 80\ns. Peripheral pulses present.\n Action:\n Metoprolol at 25mg TID and Dilt 30mg QID\n Response:\n HR in the 90\n Plan:\n Continue to monitor patient hemodynamic status.\n Neuro: alert, follows commands.\n GI: abd soft non tented, positive for BS. NPO. Ngt for meds\n clamped.\n 3 x smear of golden loose stools during the shift.\n GU: clear yellow urine via foley. Lasix X1 given.\n Skin: reddened buttocks. Critic aid cream applied.\n Social: patient is a DNR. OK to re-intubate if needed. Family in to\n visit. Updated by RN and MD.\n"},{"category":"Physician ","chartdate":"2169-11-29 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":703321,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - f/u VBG 7.48/42/78 in central venous, repeat ABG 7.46/44/124\n - BNP high 5525 c/w volume overload.\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid\n - PICC placed\n - Called micro lab: will try to speciate. will call in AM to confirm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:39 AM\n Heparin Sodium (Prophylaxis) - 04:51 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 99 (86 - 128) bpm\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\n RR: 28 (18 - 41) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 6 (2 - 6)mmHg\n Total In:\n 784 mL\n 256 mL\n PO:\n TF:\n IVF:\n 784 mL\n 196 mL\n Blood products:\n Total out:\n 2,885 mL\n 495 mL\n Urine:\n 2,885 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (260 - 404) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 154\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: ///29/\n Ve: 9.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 174 K/uL\n 9.2 g/dL\n 80 mg/dL\n 1.4 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 101 mEq/L\n 140 mEq/L\n 27.9 %\n 11.3 K/uL\n [image002.jpg]\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n Plt\n 48\n 60\n 84\n 131\n 174\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n TCO2\n 26\n 25\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n Other labs:\n Ca: 8.6, Mg: 2.2, Phos: 3.1\n Mircrobiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n ANAEROBIC GRAM NEGATIVE ROD(S).\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\n Radiology:\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\n vena cava. The patient remains intubated, with the endotracheal tube\n terminating 3.2 cm above the carina. The right internal jugular line\n ends in the mid superior vena cava. Left pleural effusion with\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\n consistent with pulmonary arterial hypertension. The right lung is\n clear. There is no pulmonary edema.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\n improved in terms of pulmonary vascular congestion, will trial\n extubation today since patient looks the best she has since admission\n - patient may need Bipap post extubation\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n .\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 90\ns with both medications\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month\n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition: Tube feeds on hold for possible extubation\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\n respiratory failure, AF c RVR improved with BBL / CCB. Diuresis\n ongoing, BNP 6K.\n Exam notable for Tm 99.8 BP 116/62 HR 95-105AF RR 12-37 with sat 100 on\n PSV 8/5, -2L / 24h. WD woman, follows intermittent commands. Coarse BS\n B. Irreg s1s2. Soft +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+\n 4.1, Cr 1.4. CXR c ?LLL collapse.\n Agree with plan to manage respiratory failure ongoing IV lasix for TBB\n negative (20mg x1 now), will continue upright positioning, SBT and plan\n for trial of extubation. Cholangitis improving, will need 14d abx, f/u\n cultures, will change CVL to PICC for long-term IV abx. Over the long\n term, will need f/u ERCP for large nonobstructive stone. For AF c RVR,\n continue BBL/CCB, hold off on anticoagulation. ARF has resolved;\n baseline CRI. Hold TFs for extubation. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:44 PM ------\n"},{"category":"Respiratory ","chartdate":"2169-11-22 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702096,"text":"Demographics\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Placed on CMV for ERCP. Had been on 12 PSV in am.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Wean to PSV as soon as tolerated. Pt to ? extubate in\n am.\n"},{"category":"Nursing","chartdate":"2169-11-23 00:00:00.000","description":"Nursing Progress Note","row_id":702352,"text":"Atrial fibrillation (Afib)\n Assessment:\n Pt was in NSR without ectopi at about 1030 patient had new onset Atrial\n Fibrillation. Patient was on spontaneous breathing trial did not appear\n to be in res p distress O2 SAT > 95. Patient remained on Levophed at\n 0.07mcg/kg/min with out changed in SBP. Patient Hr 110-120 and\n tolerated. Since 1500 HR up to 130-140 at times.. discussed with ICU\n team .\n Action:\n Patient placed back on ventilator. EKG done and read. Additional fluid\n was given and attempted to wean Levophed without success, labs sent.\n Changed Levophed for Phenylephrine. Levophed off phenylephrine @\n 1.5mcg/kg/.\n Response:\n Pt has remained in A Fibrillation. Hr 110-140. Unable to wean Levophed.\n At present Hr in high 120 to 130\ns slightly lower than on Levophed.\n Plan:\n Continue to monitor patient. Monitor the HR and sbp to evaluate if\n phenylephrine drip is tolerated better shown by decrease in hr.\n Continue to treat sepsis and monitor labs,\n"},{"category":"Nursing","chartdate":"2169-11-22 00:00:00.000","description":"Nursing Progress Note","row_id":702085,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\n Action:\n Placed on A/C for ERCP.\n Response:\n Remains on AC as she received paralytic for ERCP and remains very\n sedated.\n Plan:\n Return PSV when spontaneous breathing returns. Turn off sedation in\n a.m. and do SBT for possible extubation. Monitor O2sats.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\n WBC up to 25 from 4.8. Remains in metabolic acidosis. R/O\nd for\n influenza.\n Action:\n Received additional 2L IVBs.\n Response:\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\n 0.1mcg/kg/minute.\n Plan:\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\n requires more fluids for low CVP. Monitor sodium in light of multiple\n liters of NS. Consider LR.\n"},{"category":"Respiratory ","chartdate":"2169-11-23 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702162,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n 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 / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions; Comments: Pt remains stable on vent,\n with full ventilatory support. Pt has clear lung sounds, with minimal\n secretions. Pt showed strong RSBI trial of 54, showing good\n spontaneous respiratory effort. Pt to be tried on CPAP/PSV trial, and\n to be assessed by MD team for plan of care.\n BEDSIDE RSBI- 54\n"},{"category":"Respiratory ","chartdate":"2169-11-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702558,"text":"Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n 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 Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n"},{"category":"Nursing","chartdate":"2169-11-22 00:00:00.000","description":"Nursing Progress Note","row_id":702083,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\n Action:\n Placed on A/C for ERCP.\n Response:\n Remains on AC as she received paralytic for ERCP and remains very\n sedated.\n Plan:\n Return PSV when spontaneous breathing returns. Turn off sedation in\n a.m. and do SBT for possible extubation. Monitor O2sats.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\n WBC up to 25 from 4.8. Remains in metabolic acidosis. R/O\nd for\n influenza.\n Action:\n Received additional 2L IVBs.\n Response:\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\n 0.1mcg/kg/minute.\n Plan:\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\n requires more fluids for low CVP. Monitor sodium in light of multiple\n liters of NS. Consider LR.\n"},{"category":"Physician ","chartdate":"2169-11-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":702291,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n SBT tried this AM and patient went into afib with RVR. Changed to AC\n for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR (OK to intubate)\n Disposition: ICU for now\n ------ Protected Section ------\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 85F a w/ renal ca, dementia,\n choledocolithiasis in w/ sepsis/shock from cholangitis s/p ERCP\n with stent placement yesterday. Required intermittent neo boluses\n peri-proceudre. Remains on levophed though titrating down. During SBT\n this am developed a-fib, asx with rates 100-115. Now back on ACV.\n PE: Tm 97.8 MAP 62-103 HR 60-80\n100-115 RR 19 Sat 97% on PS 10/5\n 40% rsbi 54\n Intubated, awake, NAD, follows commands, mildly jaundiced, perrla, CTA,\n RR, soft + BS, NT, no edema\n LABS: wbc 17, 4% bands, hct 31, plt 48, na 137, cr 2.1 (2.6),\n lactate 1.4 t bili, ast/alt decreasing, inr 1.1, fibrinogen 500,dd >\n \n ECG reviewed-->new a-fib\n TEE ef > 65%, 1+ MR\n Micro: bl gpr 1, others ngtd\n A/P: Sepsis from cholangitis c/b arf, resp failure and\n thrombocytopenia. Now with new a-fib.\n While a-fib temporally related to SBT, suspect component of increased\n myocardial excitability pressors as well as underlying sepsis\n contributing. She has no underlying lung process as cause of her\n intubation, which seemed mainly related to inability to compensate for\n metabolic acidosis. She has had lots of fluids, though and increased\n WOB during SBT could have contributed. Her TTE yesterday showed good\n bivent fx.\n Agree with plan to repeat CXR and abg, transition back to PSV. Her HR\n is not rapid and BP has not changed. Will check 12 lead and assess for\n ischemia. Continue IVF boluses for cvp and u/o and wean pressor,\n maintaining MAPS > 65. If develops RVR, consider changing pressor to\n neo and adding rate control. Monitor resp and hemodynamic status\n closely and consider repeat SBT later in afternoon. We continue to\n treat biliary sepsis with anitbx. Continue zosyn and can d/c vanco,\n following cx data. Infection parameters are improving with decreasing\n wbc and temp curve. Her cr is down slightly from admit but not at\n baseline. ARF is likely pre-renal + atn from sepsis/hypotension. U/o\n holding with boluses. She continues to have worsening thrombocytopenia.\n No recent heparin exposure to suggest HIT occurring so quiclky.\n Suspect this is infection response or medications. Will hold\n heparin products and monitor, following DIC labs, and keeping t and c.\n ICU prophy. A-line and CVL. DNR\n Remainder of plan as outlined in resident note.\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 02:11 PM ------\n"},{"category":"Respiratory ","chartdate":"2169-11-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702621,"text":"TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 54.4\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\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 / Scant\n Ventilation Assessment\n Level of breathing assistance: PSV 12/5/,4\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: weaning PSV as tol\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: ABG drawn: mild resp alkalosis with good\n oxygenation; RSBI 157\n Comments: Will wean as tol.\n"},{"category":"Physician ","chartdate":"2169-11-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":702265,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n SBT tried this AM and patient went into afib with RVR. Changed to AC\n for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR (OK to intubate)\n Disposition: ICU for now\n"},{"category":"Respiratory ","chartdate":"2169-11-23 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702349,"text":"Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan is to wean to SBT before rounds in \n"},{"category":"Physician ","chartdate":"2169-11-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":702269,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n SBT tried this AM and patient went into afib with RVR. Changed to AC\n for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR (OK to intubate)\n Disposition: ICU for now\n"},{"category":"Physician ","chartdate":"2169-11-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":702270,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n SBT tried this AM and patient went into afib with RVR. Changed to AC\n for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR (OK to intubate)\n Disposition: ICU for now\n"},{"category":"Respiratory ","chartdate":"2169-11-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702404,"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: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n 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: 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: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions;\n Comments: Pt remain on vent, with PSV settings. Pt was tried on RSBI\n trial but became tachypneic with an RR of over 35 bpm. Pt had clear\n lung sounds but with some blood tinge secretions being suctioned. Pt\n remains stable with good expiratory tidal volumes and ABG findings. Pt\n to continue current support and to be assessed by MD team for possible\n extubation.\n"},{"category":"Nutrition","chartdate":"2169-11-27 00:00:00.000","description":"Clinical Nutrition Note","row_id":702943,"text":"Subjective\n Patient intubated\n Objective\n Pertinent medications: 2pkt Neutrophos,others noted\n Labs:\n Value\n Date\n Glucose\n 143 mg/dL\n 04:15 AM\n Glucose Finger Stick\n 149\n 06:00 PM\n BUN\n 24 mg/dL\n 04:15 AM\n Creatinine\n 1.3 mg/dL\n 04:15 AM\n Sodium\n 140 mEq/L\n 04:15 AM\n Potassium\n 3.9 mEq/L\n 04:15 AM\n Chloride\n 104 mEq/L\n 04:15 AM\n TCO2\n 30 mEq/L\n 04:15 AM\n Calcium non-ionized\n 8.0 mg/dL\n 04:54 AM\n Phosphorus\n 2.2 mg/dL\n 04:54 AM\n Magnesium\n 1.6 mg/dL\n 04:15 AM\n Current diet order / nutrition support: Fibersource HN at 50ml/hr x 24\n hours - provides 1440kcal and 64g protein\n GI: Abdomen soft with positive bowel sounds, +large stool\n Assessment of Nutritional Status\n Specifics:\n 85 year old female with history of choledocholithiasis, renal CA, and\n dementia who presents with dyspnea and vomiting complicated by acute\n respiratory failure and septic shock likely secondary to biliary\n source. She is now s/p ERCP and stent. Patient unable to be extubated\n over weekend so tube feedings have been restarted and are running at\n goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with Fibersource HN at goal rate of 50ml/hr x 24\n hours\n Monitor residuals q4H and hold tube feeding if greater than\n 200ml\n Will follow for possible extubation\n 11:22 AM\n"},{"category":"Nursing","chartdate":"2169-11-24 00:00:00.000","description":"Nursing Progress Note","row_id":702547,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Atrial fibrillation (Afib)\n Assessment:\n Hr 100-130\ns afib with sbp ranging from 100-120\ns. k+3.4 and phos=1.7.\n afib first occurred during sbt on . pressors were then changed to\n neo in attempt to drop pt\ns hr but was unsuccessful. Pt was started on\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\n bp support\n Action:\n Pt repleted with 30mmol of kphos. Hemodynamics montitored closely.\n Amioderone gtt decreased to 0.5mg/min after 6 hrs of infusion at\n 1mg/min. neo being weaned to off as pt\ns hemodynamics tolerate\n Response:\n Hr remains in afib tachy from 100-130\ns but hemodynamically stable\n Plan:\n Plan is to continue infusion of amioderon for 18 hrs and then will\n consider d/c\ning gtt. Continue to follow hemodynamics and wean as\n tolerated to keep map> 60 and hourly uo > 30cc\ns/hr. check lytes as\n ordered and replete as needed\n Sepsis without organ dysfunction\n Assessment:\n Pt s/p ercp on . low grade temps but wbc up to 20.2 from yesterday\n count of 16.blood cultures from grew gm pos rods and gm neg rods.\n Septic shock most likely secondary to cholangitis and infected\n stone/sludge.with increase in wbc concern is for a new infection.\n Action:\n Fever curve followed closely. Pt receiving piperacillin as ordered.\n Awaiting final speciation of all culture data. Pan cultured today\n Response:\n Low grade temps and elevated wbc unchanged.\n Plan:\n Await results for all culture data. Administer antibiotics as ordered\n and follow fever curve.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt most likely became fatigued in the setting of metabolic acidosis\n and attempt to hyperventilate to compensate requiring her to be\n intubated. Placed pt on 40% cpap with 5 peep and ps of 5 . lungs\n essentially clear on auscultation. Suctioned for sm amts of thick tan\n sputum.cxr c/w fluid overload which is likely contributing to the\n difficulty in weaning her off the vent.once pt is weaned off pressors\n will then need diuresis and hopefully pt will start to mobilize fluid.\n Action:\n Vent weaned to 40%cpap with 5 peep and ps of 5. resp status monitored\n closely. Antibiotics administered as ordered. Reps toileting continues.\n Decision made not to extubate pt since she became tachypneic ,had lower\n tv\ns and appeared more uncomfortable. Versed gtt increased back up to\n 2mg/hr. vent changed back to ac mode of ventilation. Sputum for c&s\n sent off to microbiology. Ogt placed in order to start tube fdgs until\n pt is extubated.\n Response:\n Resting comfortably on ac mode after not tolerating decrease in vent\n settings.\n Plan:\n Check rsbi in the am and do sbt. Wean pressors to off if possible and\n then will diurese as needed . d/c tube fdgs at midnoc in the hope of\n extubating pt in the am. Continue to monitor pt\ns resp status and\n continue with resp toileting\n"},{"category":"Physician ","chartdate":"2169-11-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":702944,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - will attempt to decrease sedation this evening and do an SBT, if she\n looks good will hold tube feeds, otherwise will continue feeds\n overnight\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\n then urine output was over 1L to the lasix\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\n MV and O2sats but RR in the 40's with small TV's. After about 15min\n became uncomfortable with increased WOB-->improved from prior, has more\n stamina, diuresis seems to be improving her respiratory status\n - per discussion with patient's family she can be reintubated if she\n fails extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:55 AM\n Furosemide (Lasix) - 06:14 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 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: 37.2\nC (99\n HR: 112 (106 - 129) bpm\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\n RR: 12 (12 - 37) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 733 mL\n 452 mL\n PO:\n TF:\n 202 mL\n 264 mL\n IVF:\n 531 mL\n 188 mL\n Blood products:\n Total out:\n 3,345 mL\n 765 mL\n Urine:\n 3,345 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,612 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 296 (241 - 304) mL\n PS : 12 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 166\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 8.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 84 K/uL\n 9.2 g/dL\n 143 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n WBC\n 15.3\n 20.2\n 11.3\n 10.6\n 11.2\n Hct\n 31.4\n 30.7\n 29.7\n 29.3\n 27.9\n Plt\n 59\n 46\n 52\n 48\n 60\n 84\n Cr\n 1.8\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 26\n 25\n Glucose\n 102\n 91\n 128\n 119\n 126\n 143\n Other labs:\n Mg: 1.6\n Alk Phos: 103, T. bili: 1.5\n PT: 12, INR: 1, PTT: 23.7\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n Imaging:\n Chest X-Ray (my read): slightly worsening left effusion and right\n basilar patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR.\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\n about 800 cc\ns in the evening so she was given 20mg IV lasix with a\n brisk urine output response. Will give another dose of lasix since she\n had her best SBT with the increased diuresis, hold tube feeds for now\n in case she is able to be extubated this afternoon. She will likely\n never have an excellent RSBI, but she will need to not tire and\n maintain her sats during her SBT.\n - Hold sedation for now to optimize mental status prior to extubation\n - need to place a dobhoff prior to extubation as she may be an\n aspiration risk\n - CXR looks stable to slightly worsened this morning\n - family okay with re-intubation if patient fails extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Increase metoprolol to 25mg and titrate up to good HR control as\n her BP tolerates\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count stable. Lactate\n normal. Initial sepsis secondary to biliary source given CBD dilation\n with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 24 hours.\n - Cont zosyn pending any further culture data; Day of zosyn.\n Day 1=. Will f/u cutlure data to see if we can narrow our\n coverage, if she needs to be continued on Zosyn will place a PICC and\n pull central line, may be able to transitioned to a po antibiotic\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n - f/u sputum culture\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to her baseline at 1.3 today.\n - Monitor UOP\n - Trend creatinine while diuresing\n - Check PM lytes\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Platelet count stable and increasing\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Heparin SQ, pneumo boots\n Stress ulcer: none while on feeds\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, is intubated, ok to be reintubated post extubation if\n necessary\n Disposition: ICU pending stabilization post extubation\n"},{"category":"Nursing","chartdate":"2169-11-27 00:00:00.000","description":"Nursing Progress Note","row_id":703001,"text":"Atrial fibrillation (Afib)\n Assessment:\n Afib 85-130, hr appears responsive to 25mg lopressor. b/p 90s-110/60s.\n Action:\n Lopressor for rate control, 10mg IV Lasix\n Response:\n Better rate control after Lopressor dose, gentler response to 10mg\n Lasix today than yesterday, no hypotension associated w/diuresis.\n Plan:\n Cont to monitor HR and response to meds.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, PSV 12/5, on 0/8 with increase in RR to 30s. LS:\n crackles t/o. Scant secretions via ETT.\n Action:\n Tube feeds off in anticipation of possible extubation. Sedation off 3\n hours w/improvement in mental status, able to nod, laugh and respond to\n family, currently on 1mg versed and receiving 25mcg bolus of fent PRN\n pain.\n Response:\n Not yet ready for extubation\n Plan:\n Tube feeds off at MN as ordered. Daily wake up to aid w/extubation.\n"},{"category":"Respiratory ","chartdate":"2169-11-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702708,"text":"Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Tube Type\n ETT:\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 Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: PSV level increased this morning; weaned to 10cm at approx.\n 1600; please see flowsheet for details.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"},{"category":"Nursing","chartdate":"2169-11-25 00:00:00.000","description":"Nursing Progress Note","row_id":702713,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on PS 10/5 RR 30\ns , grimacing, visibly uncomfortable\n Action:\n Bolused w/ midaz, put back to PS 12/5\n Response:\n Pt tolerated mech vent support, RR 20\ns TV 300\ns w/ MV \n Plan:\n Will not extubate today will re assess for am extuabtion\n Sepsis without organ dysfunction\n Assessment:\n Off pressors for 24 hrs, ~ 50cc hr, maintaining maps > 60, afebrile\n Action:\n Assessed hemodynamics , following VS\n Response:\n Pt remains off of pressors\n Plan:\n Cont Ab therapy , monitor hemodynamics\n Atrial fibrillation (Afib)\n Assessment:\n Continues in a-fib hr 1teens-130\n Action:\n Amiodorone gtt cont @ .5mg /min\n Response:\n ongoing\n Plan:\n Continue to monitor hr, may wean to po amiodorone\n"},{"category":"Respiratory ","chartdate":"2169-11-26 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702865,"text":"Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\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: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt continues on PSV as charted.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"},{"category":"Physician ","chartdate":"2169-11-27 00:00:00.000","description":"Physician Resident Progress Note","row_id":702919,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - will attempt to decrease sedation this evening and do an SBT, if she\n looks good will hold tube feeds, otherwise will continue feeds\n overnight\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\n then urine output was over 1L to the lasix\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\n MV and O2sats but RR in the 40's with small TV's. After about 15min\n became uncomfortable with increased WOB-->improved from prior, has more\n stamina, diuresis seems to be improving her respiratory status\n - per discussion with patient's family she can be reintubated if she\n fails extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:55 AM\n Furosemide (Lasix) - 06:14 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 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: 37.2\nC (99\n HR: 112 (106 - 129) bpm\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\n RR: 12 (12 - 37) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 733 mL\n 452 mL\n PO:\n TF:\n 202 mL\n 264 mL\n IVF:\n 531 mL\n 188 mL\n Blood products:\n Total out:\n 3,345 mL\n 765 mL\n Urine:\n 3,345 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,612 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 296 (241 - 304) mL\n PS : 12 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 166\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 8.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 84 K/uL\n 9.2 g/dL\n 143 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n WBC\n 15.3\n 20.2\n 11.3\n 10.6\n 11.2\n Hct\n 31.4\n 30.7\n 29.7\n 29.3\n 27.9\n Plt\n 59\n 46\n 52\n 48\n 60\n 84\n Cr\n 1.8\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 26\n 25\n Glucose\n 102\n 91\n 128\n 119\n 126\n 143\n Other labs:\n Mg: 1.6\n Alk Phos: 103, T. bili: 1.5\n PT: 12, INR: 1, PTT: 23.7\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n Imaging:\n Chest X-Ray (my read): slightly worsening left effusion and right\n basilar patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR.\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\n about 800 cc\ns in the evening so she was given 20mg IV lasix with a\n brisk urine output response\n - Wean down vent settings as much as possible, but having difficulty\n due to volume overload\n - CXR looks stable to slightly worsened this morning\n - family okay with re-intubation if patient fails extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Increase metoprolol to 25mg and titrate up to good HR control as\n her BP tolerates\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count stable. Lactate\n normal. Initial sepsis secondary to biliary source given CBD dilation\n with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for 24 hours, this morning with low grade temps.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: . Will f/u cutlure data to see if we can narrow our coverage,\n if she needs to be continued on Zosyn will place a PICC and pull\n central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n - will send sputum cx with new low grade temps, and slightly worsening\n chest x-ray\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to her baseline at 1.3 today.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Will restart SQ heparin as her platelet count has increased and the\n initial drop was not consistent with HIT\n - No signs of active bleeding\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Heparin SQ, pneumo boots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, is intubated\n Disposition: ICU\n"},{"category":"Respiratory ","chartdate":"2169-11-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":703058,"text":"Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Pt initially tachypneic with rr>32. Placed on psv overnight to rest in\n preparation for possible extubation today. Mod amts of thick white\n sput. Weak cough and gag.\n"},{"category":"Respiratory ","chartdate":"2169-11-26 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702767,"text":"TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 54.4\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: PSV 12/5/.4\n Visual assessment of breathing pattern: Occ tachypneic (RR> 35 b/min),\n baseline rr 30\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments: Maintaining Vt 3-400 ml with Ve 8-9 L, sp02 99-100%\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: RSBI 204; heated wire system added for humidity\n Comments: Slow PSV wean as tol.\n"},{"category":"Nursing","chartdate":"2169-11-29 00:00:00.000","description":"Nursing Progress Note","row_id":703241,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent. Respiratory failure initially thought to be due to\n metabolic acidosis which caused her to hyperventilate to compensate.\n She fatigued quickly becoming acutely SOB and required intubation on\n ^th. Since then, unable to wean vent because of pt being\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\n coming off peep becoming very tachypneic with low tidal volumes which\n is more concerning for difficulty with compliance then volume overload.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in Afib; HR ranging from 90-130\ns. SBP 85-120\ns. Afib first\n occurred during SBT on . Occasional PVC\ns noted.\n Action:\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\n 20mEq IV given last evening per sliding scale orders.\n Response:\n Pt has remained in Afib but rate has significantly improved w/\n administration of Lopressor & Dilt. HR ranging 80\n low 100\ns w/\n minimal ectopy. Magnesium & K levels WNL this AM.\n Plan:\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\n Diltiazem. Follow electrolyte status & replete as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\n 30-40\ns but appearing comfortable & settles out on own. LS clear,\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\n 1.5\n 2L. Mental status much improved. Pt following commands and\n actively participating in care. Remains restless @ times but is easily\n redirected.\n Action:\n Suctioning q2-4 hrs for thick/white sputum. Pt appears to be pooling\n large amts of secretions in the subglottal area. (concern for\n aspiration post extubation)\n Response:\n Pt -2L @ MN. AM RSBI 154 (will complete SBT once ETT is exchanged & pt\n is bronched per Dr. \n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal - 1.5\n 2L @\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\n exchange. If all goes as planned, pt will be extubated late morning. As\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\n remains DNR)\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n Pt did have 2 smears of stool overnight. Please monitor\n closely. Skin breakdown is of concern, amt of stool was not significant\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\n not benefit from fecal inc. bag)\n"},{"category":"Nursing","chartdate":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703052,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\n RR up to 34-36 pt volume overloaded, remains on 1 mg Versed IV\n gtt, with prn boluses of 0.5 mg suctioned for sm amts of thick white\n sputum. CXR volume overload ~ needs to be diuresed. CVP~12\n Action:\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\n received 10 mg IVP Lasix at 9 pm with good response. Received repeat\n 20 mg IVP Lasix at 4:30 am.\n Response:\n Pt rested overnight on AC. Pt continues to diurese\n Plan:\n Change back to pressure support in am, check RSBI, ?ready for\n extubation repeat RSBI~157 would like pt negative one liter.\n Continue Versed gtt continue with pulmonary toilet.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in Afib, rate 115-130 bp 100/60\n Action:\n Lopressor increased to 25 mg per NGT tid, also received 2.5 mg IV\n Lopressor at 4:30 am\n Response:\n HR down to 107 Afib\n Plan:\n Continue to monitor HR, bp closely. Lopressor increased to tid (25\n mg)\n GI: OG tube removed, r nare NG tube inserted, confirmed by CXRAY,\n also pulled back bile, and air heard in stomach. Passing loose stool.\n tube feedings off at 12 midnight (will try again today to extubate)\n ID: Afebrile, ERCP on showed significant pus and very large\n stone, pt is s/p stent placement. Pt remains on Zosyn\n NEURO: remains on 1 mg/hr IV Versed gtt opens eyes to command, pt\n agitated at times, moving around in bed, hands restrained for safety,\n pt putting hands on ETT.\n SOCIAL: pt is DNR, if gets extubated would be reintubated. Husband\n and 2 daughters in last evening.\n"},{"category":"Respiratory ","chartdate":"2169-11-29 00:00:00.000","description":"Respiratory Care Shift Note","row_id":703245,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: suctioned frequently\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions, Underlying illness not resolved\n Comments: Pt. remains intubated on IPS overnoc. Suctioned frequently\n for large amounts thick white sputum. Plan to change ET tube this am to\n a larger ET , bronchoscopy prior to extubation. RSBI 154 this am. RR\n 30\ns at baseline.\n"},{"category":"Nursing","chartdate":"2169-11-26 00:00:00.000","description":"Nursing Progress Note","row_id":702849,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib at a rate of 100-130s, BP has been stable\n Action:\n Her amnio was d/ced and lopressor was started\n Response:\n Tolerated the lopressor\n it seemed to lower her HR from the 120s to\n the 100s\n Plan:\n Titrate up the lopressor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented, lots of oral and ETT secretions, tachypnic to the 40s\n with VTs in the 300s\n Action:\n Unable to extubate today, to receive lasix this afternoon, restarted TF\n Response:\n Not yet ready for extubation\n Plan:\n Follow I&Os, lytes, cont to try to wean, cont pulm toilet\n"},{"category":"Nursing","chartdate":"2169-11-23 00:00:00.000","description":"Nursing Progress Note","row_id":702189,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\n versed 3mg/hr.\n Action:\n Suctioned for small amount secretions. Blood gas in the am. Versed\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\n Response:\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/ .am\n RSBI 54 and tolerated well.\n Plan:\n Wean vent / sedations as tolerated further and for possible\n extubation today.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\nS on\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\n /BUN 37,elevated liver enzymes.\n Action:\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\n with NaHCo3 150 meq given for hydration and for PH 7.29 from the\n evening lab\n Response:\n SBP 85-90\ns when tried to titrate Levophed further .so continued on\n 0.07mics. urine output improved with fluid bolus.\n Plan:\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\n"},{"category":"Nursing","chartdate":"2169-11-23 00:00:00.000","description":"Nursing Progress Note","row_id":702188,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\n versed 3mg/hr.\n Action:\n Suctioned for small amount secretions. Blood gas in the am. Versed\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\n Response:\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/\n Plan:\n Wean vent / sedations as tolerated further.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\nS on\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\n /BUN 37,elevated liver enzymes.\n Action:\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\n with NaHCo3 150 meq given for hydration and for PH 7.1 from the\n evening lab\n Response:\n SBP 85-90\ns when tried to titrate Levophed further .so continued on\n 0.07mics. urine output improved with fluid bolus.\n Plan:\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\n"},{"category":"Physician ","chartdate":"2169-11-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":702466,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early this morning\npatient very tahcypneic, unable to be\n extubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n URINE CULTURE (Final ): NO GROWTH.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - early this morning\npatient very tachypneic with lower tidal\n volumes, appeared very uncomfortable during short trial this morning,\n will transition back to A/C and then wean to PSV throughout the day\n -Chest x-ray appeared volume overloaded, which is likely contributing\n to the difficulty weaning her off the ventilator, when patient is able\n to be weaned off pressors will need diuresis. Hopefully patient will\n start to mobilize her extra fluid, however once off pressors if she is\n unable to, will give lasix as needed to help decrease the fluid in her\n lungs\n - Hopeful extubation tomorrow pending ability to diurese\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - With increasing leukocytosis concern for a new infection, will\n reculture blood, urine and sputum, also send a C.diff when patient has\n a bowel movement, if LFT\ns increase, will reimage RUQ due to concern\n for possible blockage of stent\n - Cont zosyn pending any further culture data; f/u speciation and\n sensitivities from prior blood cx\n - Trend CBC/diff, LFTs, especially in the setting on increasing\n leukocytosis, will add on Diff to AM labs\n - Follow up blood cx speciation , urine cx with no growth\n - Wean neo as tolerated by MAP >= 60 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\n baseline creatinine 1.2-1.4.\n - Titrate MAP to greater than 60, unless urine output decreases then\n will titrate to increased MAP\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 26 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: Will place OG tube for tube feeds today and turn them off at\n midnight for hopeful extubation tomorrow\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2169-11-25 00:00:00.000","description":"Nursing Progress Note","row_id":702596,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated , cpap/ps see metavision for vent settings, continues\n lightly sedated with versed 2mg.\n Action:\n Vent settings cpap/ps 10/5 fio2 40%\n Response:\n Am blood gas 7.46/34/27\n Plan:\n possible extubation today. tube feeds off since midnight\n Sepsis without organ dysfunction\n Assessment:\n s/p ERCP, was on pressors after procedure\n Action:\n Neo has been weaned\n Response:\n Maps greater than 60 , following NBP\nS, -a-line that was reinserted\n yesterday had fallen out\n Plan:\n Follow vs\n Atrial fibrillation (Afib)\n Assessment:\n Continues in a-fib hr 120-130\n Action:\n Amiodorone gtt is being cont. passed the 18hours\n Response:\n ongoing\n Plan:\n Continue to monitor hr, may wean to po amiodorone\n"},{"category":"Physician ","chartdate":"2169-11-25 00:00:00.000","description":"Physician Attending Progress Note","row_id":702691,"text":"TITLE:\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\n presents with septic shock and cholangitis, s/p ERCP with stent, and\n respiratory failure. Now with persistent vent requirements.\n 24 Hour Events:\n Arterial line came out.\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 PM\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unable to obtain, patient sedated and intubated.\n Flowsheet Data as of 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.2\nC (97.2\n HR: 128 (114 - 141) bpm\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\n RR: 23 (14 - 30) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 1,682 mL\n 311 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 310 mL\n Blood products:\n Total out:\n 2,045 mL\n 920 mL\n Urine:\n 2,045 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -609 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): 380 (308 - 528) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 16 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.9 L/min\n PaO2 / FiO2: 318\n Physical Examination\n Gen\nl: intubated, sedated\n HEENT: ETT in place, pupils constricted by equal and reactive\n Pulm: diminished, transmitted vent sounds, no wheezing, crackles at\n bases anteriorly\n CV: irregularly irregular, tachycardic, distant and no murmur\n appreciated, no gallop or rubs\n Abdomen: soft, no grimace to palpation, (+) bowel sounds\n Extremities: no edema\n Neurologic: responds to tactile stimuli, non-purposeful movement\n Labs / Radiology\n 9.8 g/dL\n 48 K/uL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory failure\n - now likely secondary to volume overload\n - goal TBB - 1 to -1.5L today and will give prn lasix\n - wean pressure support as tolerated, check CXR\n Septic shock\n - now off pressors, autodiuresing\n - on zosyn, day , leukocytosis improving\n - LFTs improving s/p stenting via ERCP\n - awaiting speciation/sensitivities from cultures\nAtrial fibrillation\n - on amiodarone drip, will continue for now\n - will calculate total dose today\n Thrombocytopenia\n - stable, no signs of active bleeding\n - very low suspicion for HIT\n - will restart SC heparin when plts >50K\n ICU Care\n Nutrition:\n Comments: restart TF as unlikely to be extubated today\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2169-11-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":702692,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - amio gtt started in early AM yesterday--> slow progress\n - Neo stopped at 0000\n - OG + tube feeds today, NPO at midnight with hopes for extubation\n - increasing WBC, send sputum for cx, blood and urine cx;\n - if she starts to spike again, then add back Vancomycin\n - Gm+ and Gm- rods in blood in anaerobic bottle\n - Was on AC for most of day after SBT; switched to PS 12/5-- ABG:\n 7.46/34/127 (at 3:15am) RSBI: couldn\nt tolerate b/c tachypnea:\n UOP 50-180 cc/hour\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 141 (111 - 141) bpm\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\n RR: 25 (14 - 36) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 8 (8 - 8)mmHg\n Total In:\n 1,682 mL\n 197 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 196 mL\n Blood products:\n Total out:\n 2,045 mL\n 520 mL\n Urine:\n 2,045 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -322 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): 482 (308 - 528) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 17 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.1 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 9.8 g/dL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\n Unable to wean effectively; likely secondary to fluid resuscitation; as\n fluid overload is seen on CXR.\n - Monitor UOP as patient is auto-diuresing well. Check i/o\ns this\n evening with TBB 1-1.5 liters\n - Wean down vent settings as much as possible, will likely be more\n effective once\n - CXR today to make sure no other acute process is occuring\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Continue amio gtt as HR has improved, but she is still tachycardic in\n the low 100\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\n be improving.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: .\n - f/u speciation and sensitivities from prior blood cx\n - Trend CBC/diff, LFTs,\n - Follow up blood cx speciation , urine cx with no growth\n - no need for pressors now. Monitor maps > 65.\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\n of HIT as timing does not correlate since patient has not had a prior\n heparin exposure. Vancomycin may also be contributing to her\n thrombocytopenia\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 24 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: OG tube feeds\n Glycemic Control:\n Lines: ( no A-line for now: A line measurement were SBP \n points higher than cuff pressure)\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2169-11-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":702693,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - amio gtt started in early AM yesterday--> slow progress\n - Neo stopped at 0000\n - OG + tube feeds today, NPO at midnight with hopes for extubation\n - increasing WBC, send sputum for cx, blood and urine cx;\n - if she starts to spike again, then add back Vancomycin\n - Gm+ and Gm- rods in blood in anaerobic bottle\n - Was on AC for most of day after SBT; switched to PS 12/5-- ABG:\n 7.46/34/127 (at 3:15am) RSBI: couldn\nt tolerate b/c tachypnea:\n UOP 50-180 cc/hour\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 141 (111 - 141) bpm\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\n RR: 25 (14 - 36) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 8 (8 - 8)mmHg\n Total In:\n 1,682 mL\n 197 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 196 mL\n Blood products:\n Total out:\n 2,045 mL\n 520 mL\n Urine:\n 2,045 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -322 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): 482 (308 - 528) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 17 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.1 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 9.8 g/dL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\n Unable to wean effectively; likely secondary to fluid resuscitation; as\n fluid overload is seen on CXR.\n - Monitor UOP as patient is auto-diuresing well. Check i/o\ns this\n evening with TBB 1-1.5 liters\n - Wean down vent settings as much as possible, will likely be more\n effective once\n - CXR today to make sure no other acute process is occuring\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Continue amio gtt as HR has improved, but she is still tachycardic in\n the low 100\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\n be improving.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: .\n - f/u speciation and sensitivities from prior blood cx\n - Trend CBC/diff, LFTs,\n - Follow up blood cx speciation , urine cx with no growth\n - no need for pressors now. Monitor maps > 65.\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\n of HIT as timing does not correlate since patient has not had a prior\n heparin exposure. Vancomycin may also be contributing to her\n thrombocytopenia\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 24 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: OG tube feeds\n Glycemic Control:\n Lines: ( no A-line for now: A line measurement were SBP \n points higher than cuff pressure)\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n ------ Protected Section ------\n Patient may need a PICC line tomorrow if sensitivities of cultures do\n not return. She may need a full 10 day course of zosyn.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:38 ------\n"},{"category":"Nursing","chartdate":"2169-11-26 00:00:00.000","description":"Nursing Progress Note","row_id":702762,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on PS 12/5 40%, rr 30\n Action:\n Sedation off at 2am for ? extubate this am , tube feeds off also\n Response:\n RSBI 204 this am\n Plan:\n Sedation turned back on at 520 due to pt\ns increased rr rate, plan to\n extubate should be reassed at rounds, if no extubation today tube feeds\n need to be restarted\n Sepsis without organ dysfunction\n Assessment:\n Off pressors for 24 hrs, ~ 50cc hr, maintaining maps > 60, afebrile\n Action:\n Assessed hemodynamics , following VS\n Response:\n Pt remains off of pressors\n Plan:\n Cont Ab therapy , monitor hemodynamics\n Atrial fibrillation (Afib)\n Assessment:\n Continues in a-fib hr 1teens-130\n Action:\n Amiodorone gtt cont @ .5mg /min\n Response:\n ongoing\n Plan:\n Continue to monitor hr, may wean to po amiodorone\n"},{"category":"Nursing","chartdate":"2169-11-23 00:00:00.000","description":"Nursing Progress Note","row_id":702316,"text":"Sepsis without organ dysfunction\n Assessment:\n T max 99.2 oral. Remains on Levophed to maintain sbp > 90. Patient\n alert follows command denies abd pain c/o of mouth pain from ET.RIJ 3\n lumen patent CVP 6-13pt in A Fib. Low PLT\n Action:\n Attempted to wean Levophed without success. Fluid given a total of 2.5\n liters. Blood culture from aline and RIJ sent. Labs sent. Antibiotics\n as ordered. Heparin and vancomycin stopped\n Response:\n CVP up to from 6. Urine changed from amber to yellow. Initially\n able to wean Levophed but then sbp dropped x2 levophed at .07mcg. A\n Fib continues PLT still low.\n Plan:\n Monitor plt, gap and lytes treat as indicated. Monitor urine output.\n Monitor HR and rhythm.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient does not appear in any distress tolerating ET tube though asked\n for it to be removed calm and cooperative. Oxygen saturation\n consistently over 95. RR 20-40. Lungs clear. Sputum clear and thick. No\n fever. Large amt of oral secretions. AT about 1030 Attempted to wean in\n am patient tolerated CPAP and PS on spontaneous breathing trial patient\n did not appear distress o2 SAT >95 but rhythm changed to AFIB\n Action:\n Pt placed back on vent after rhythm changed several hours later placed\n back on CPAP with PS, oral suction frequently. BS checked. Mouth care\n given turned q3-4 hours\n Response:\n Patient tolerating CPAP with PS oxygenation is > 95 patient appears\n comfortable\n Plan:\n Monitor resp. status. wean if able tomorrow. ABG\ns as indicated.\n Monitor continuous O2 saturation. Suction as needed. Check results of\n cultures. Continue antibiotics.\n"},{"category":"Physician ","chartdate":"2169-11-25 00:00:00.000","description":"Physician Attending Progress Note","row_id":702677,"text":"TITLE:\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\n presents with septic shock and cholangitis, s/p ERCP with stent, and\n respiratory failure. Now with persistent vent requirements.\n 24 Hour Events:\n Arterial line\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 PM\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.2\nC (97.2\n HR: 128 (114 - 141) bpm\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\n RR: 23 (14 - 30) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 1,682 mL\n 311 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 310 mL\n Blood products:\n Total out:\n 2,045 mL\n 920 mL\n Urine:\n 2,045 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -609 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): 380 (308 - 528) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 16 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.9 L/min\n PaO2 / FiO2: 318\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.8 g/dL\n 48 K/uL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory failure\n - now likely secondary to volume overload\n - goal TBB - 1 to -1.5L today and will give prn lasix\n - wean pressure support as tolerated, check CXR\n Septic shock\n - now off pressors, autodiuresing\n - on zosyn, day , leukocytosis improving\n - LFTs improving s/p stenting via ERCP\n - awaiting speciation/sensitivities from cultures\nAtrial fibrillation\n - on amiodarone drip, will continue for now\n Thrombocytopenia\n - stable, no signs of active bleeding\n - will restart SC heparin when\n ICU Care\n Nutrition:\n Comments: restart TF as unlikely to be extubated today\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2169-11-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":702462,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early this morning for hopeful extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n URINE CULTURE (Final ): NO GROWTH.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - early this morning, discontinue sedation for hopeful extubation\n this morning\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - With increasing leukocytosis concern for a new infection, will\n reculture blood, urine and sputum, also send a C.diff when patient has\n a bowel movement, if LFT\ns increase, will reimage RUQ due to concern\n for possible blockage of stent\n - Cont zosyn pending any further culture data\n - Trend CBC/diff, LFTs, especially in the setting on increasing\n leukocytosis, will add on Diff to AM labs\n - Follow up blood cx speciation , urine cx with no growth\n - Wean neo as tolerated by MAP >= 60 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\n baseline creatinine 1.2-1.4.\n - Titrate MAP to greater than 60, unless urine output decreases then\n will titrate to increased MAP\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 26 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: Will place OG tube for tube feeds today and turn them off at\n midnight for hopeful extubation tomorrow\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2169-11-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":702438,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early this morning for hopeful extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n URINE CULTURE (Final ): NO GROWTH.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - early this morning, discontinue sedation for hopeful extubation\n this morning\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont zosyn pending any further culture data\n - Trend CBC/diff, LFTs\n - Follow up blood cx speciation , urine cx with no growth\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean neo as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\n baseline creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in\n case she had lasix, FeUrea: 14.9%...\n - IVFs for CVP 10-12: patient bolused large volume of fluid yesterday\n with improvement in CVP to 12\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 26 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: NPO pending hopeful extubation this morning, can restart\n diet post extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2169-11-26 00:00:00.000","description":"MICU Fellow Note","row_id":702825,"text":"TITLE:\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\n found to have cholangitis, now s/p ERCP and stenting, with course\n complicated by respiratory failure.\n 24 Hour Events:\n Decreased sedation overnight but had increasing agitation, had\n increased RR and decreasing tidal volumes so re-sedated and left at PS\n .\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\n RR: 37 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 243 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 239 mL\n Blood products:\n Total out:\n 1,795 mL\n 965 mL\n Urine:\n 1,795 mL\n 965 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -722 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 304 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 18 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: ETT in place, slight icterus\n Pulm: diminished at the bases, transmitted vent sounds, no wheezing\n CV: irregularly irregular, soft SM, no rub or gallop\n Abdomen: soft, non-tender, non-distended, (+) bowel sounds\n Ext: no edema\n Skin: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 60 K/uL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory Failure\n - continues to do poorly with decreased support, possibly due to\n ongoing volume overload\n - will follow TBB as she is autodiuresing, goal TBB -1L\n - low suspicion for underlying pneumonia given improving infectious\n parameters and shock\n - will continue PS today, repeat lightening of sedation and SBT\n tomorrow morning\n Septic shock\n - s/p ERCP with cholangitis\n - called micro for speciation of organisms, narrow abx if able\n - shock resolved, creatinine improved\n - on day Zosyn\n Atrial fibrillation\n - continues to be tachycardic, though improved\n - can try low dose beta-blocker today if BP tolerates\n - consider d'c amiodarone if able to be on beta-blocker\n Acute renal failure\n - improved overall\n - some of urine output now may be post-ATN diuresis\n Thrombocytopenia\n - slightly improved, no evidence of bleeding\n - will restart sc heparin today\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\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: 30 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2169-11-26 00:00:00.000","description":"MICU Fellow Note","row_id":702834,"text":"TITLE:\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\n found to have cholangitis, now s/p ERCP and stenting, with course\n complicated by respiratory failure.\n 24 Hour Events:\n Decreased sedation overnight but had increasing agitation, had\n increased RR and decreasing tidal volumes so re-sedated and left at PS\n .\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\n RR: 37 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 243 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 239 mL\n Blood products:\n Total out:\n 1,795 mL\n 965 mL\n Urine:\n 1,795 mL\n 965 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -722 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 304 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 18 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: ETT in place, slight icterus\n Pulm: diminished at the bases, transmitted vent sounds, no wheezing\n CV: irregularly irregular, soft SM, no rub or gallop\n Abdomen: soft, non-tender, non-distended, (+) bowel sounds\n Ext: no edema\n Skin: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 60 K/uL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory Failure\n - continues to do poorly with decreased support, possibly due to\n ongoing volume overload\n - will follow TBB as she is autodiuresing, goal TBB -1L\n - low suspicion for underlying pneumonia given improving infectious\n parameters and shock\n - will continue PS today, repeat lightening of sedation and SBT\n tomorrow morning\n Septic shock\n - s/p ERCP with cholangitis\n - called micro for speciation of organisms, narrow abx if able\n - shock resolved, creatinine improved\n - on day Zosyn\n Atrial fibrillation\n - continues to be tachycardic, though improved\n - can try low dose beta-blocker today if BP tolerates\n - consider d'c amiodarone if able to be on beta-blocker\n Acute renal failure\n - improved overall\n - some of urine output now may be post-ATN diuresis\n Thrombocytopenia\n - slightly improved, no evidence of bleeding\n - will restart sc heparin today\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\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: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n CRITICAL CARE\n 85 yo with dementia, RCC intubated for resp failure in setting of\n cholangitis. Vent PSV 12/5\n 99.0 112 106/87\n Sedated on ventilator\n Chest\n few mid insp crackles bilat\n CV 2/6 sem\n I&O neg over 1 L yesterday -0.6 L today\n WBC 10.6\n RSBI > 200\n Making some progress with diuresis, but she is some ways from\n extubation. Still > 4L pos LOS. Seems likely that weaning success will\n depend on getting her to dry weight. No known signif cardiac dysfxn\n but has long standing cardiomeg on CXR and I wonder if Echo is\n underestimating MR. CXR remarkable for signif pleaural process on L\n possibly related to pancreatitis but signif vol loss is evident. She\n also has signif emphysema on CXR. Will need aggressive care to\n liberate her from vent and she remains at signif risk for VAP so would\n like to get her off ASAP. Her dementia will also likely complicate\n weaning as she may well become agitated as we taper midazolam.\n Time spent 40 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 15:59 ------\n"},{"category":"Physician ","chartdate":"2169-11-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":702430,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with SBT so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early SBT this morning for hopeful extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO pending hopeful extubation this morning\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703141,"text":"R radial nerve damage from compression\n s/p TAH/USO 8 yrs ago, c/b need for 3 units PRBC due to bleeding\n at a ligation site\n"},{"category":"Nursing","chartdate":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703142,"text":"R radial nerve damage from compression\n s/p TAH/USO 8 yrs ago, c/b need for 3 units PRBC due to bleeding\n at a ligation site\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 14:45 ------\n"},{"category":"Physician ","chartdate":"2169-11-25 00:00:00.000","description":"Physician Resident Progress Note","row_id":702643,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - amio gtt started in early AM yesterday--> slow progress\n - Neo stopped at 0000\n - OG + tube feeds today, NPO at midnight with hopes for extubation\n - increasing WBC, send sputum for cx, blood and urine cx;\n - if she starts to spike again, then add back Vancomycin\n - Gm+ and Gm- rods in blood in anaerobic bottle\n - Was on AC for most of day after ; switched to PS 12/5-- ABG:\n 7.46/34/127 (at 3:15am) RSBI: couldn\nt tolerate b/c tachypnea:\n UOP 50-180 cc/hour\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 141 (111 - 141) bpm\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\n RR: 25 (14 - 36) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 8 (8 - 8)mmHg\n Total In:\n 1,682 mL\n 197 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 196 mL\n Blood products:\n Total out:\n 2,045 mL\n 520 mL\n Urine:\n 2,045 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -322 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): 482 (308 - 528) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 17 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.1 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 9.8 g/dL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - RSBI early this morning\npatient very tachypnei,\n -Chest x-ray appeared volume overloaded, which is likely contributing\n to the difficulty weaning her off the ventilator, when patient is able\n to be weaned off pressors will need diuresis. Hopefully patient will\n start to mobilize her extra fluid, however once off pressors if she is\n unable to, will give lasix as needed to help decrease the fluid in her\n lungs\n - Hopeful extubation today pending ability to diurese\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - With increasing leukocytosis concern for a new infection, will\n reculture blood, urine and sputum, also send a C.diff when patient has\n a bowel movement, if LFT\ns increase, will reimage RUQ due to concern\n for possible blockage of stent\n - Cont zosyn pending any further culture data; f/u speciation and\n sensitivities from prior blood cx\n - Trend CBC/diff, LFTs, especially in the setting on increasing\n leukocytosis, will add on Diff to AM labs\n - Follow up blood cx speciation , urine cx with no growth\n - Wean neo as tolerated by MAP >= 60 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.5 today,\n baseline creatinine 1.2-1.4.\n - Titrate MAP to greater than 60, unless urine output decreases then\n will titrate to increased MAP\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 24 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: OG tube feeds\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2169-11-27 00:00:00.000","description":"Nursing Progress Note","row_id":702884,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on PS 12/5 40%, rr 30\n Action:\n Sedation off last night at 8pm then rsbi was done to decide whether to\n shut tf off at midnight for possible am extubation\n Response:\n RSBI 166 last night will not extubate today\n Plan:\n Continue good pulmonary toileting, midaz. Was increased to 3mg/hr due\n to agitation\n Atrial fibrillation (Afib)\n Assessment:\n Afib conts with hr in the 120\n Action:\n Lopressor was increased to 25mg po tid\n Response:\n ongoing\n Plan:\n Continue to monitor hr, increase lopressor if needed if bp can tolerate\n"},{"category":"Respiratory ","chartdate":"2169-11-27 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702968,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: 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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on the vent changes made tol fairly well. See respiratory page of\n meta vision for more information.\n"},{"category":"Nursing","chartdate":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703143,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703145,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\ns. afib\n first occurred during sbt on / trialed lopressor 12.5 mg po on\n without affect.\n Action:\n Lopressor dose was increased to 25 mg pot id without any improvement in\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\n hr. hemodynamics followed closely.\n Response:\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\n was d/c\nd. sbp retruned to her baseline once esmalol gtt was d/c\n Plan:\n Continue to follow hemodynamics . may need to restart po lopressor.\n Continue to check lytes as ordered and replete as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp failure initially thought to be due to metabolic acidosis which\n caused her to hyperventilate to compensate and fatigued becoming\n acutely sob and requiring intubation on ^th.unable to wean\n vent because of pt being fluid overloaded secondary to fluid\n resusitiation. Pt having difficulty coming off peep becoming very\n tachypenic with low tidal volumes which is more concerning for\n difficulty with compliance then volume overload. Cxr c/w lll opacity\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\n tachypenic . lungs clear with crackles noted bil at the bases.\n Suctioned for sm amts of thick white sputum.\n Action:\n Pt placed on 405 cpap with 5 peep and ps of 8.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2169-11-29 00:00:00.000","description":"Nursing Progress Note","row_id":703221,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent. Respiratory failure initially thought to be due to\n metabolic acidosis which caused her to hyperventilate to compensate.\n She fatigued quickly becoming acutely SOB and required intubation on\n ^th. Since then, unable to wean vent because of pt being\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\n coming off peep becoming very tachypneic with low tidal volumes which\n is more concerning for difficulty with compliance then volume overload.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in Afib; HR ranging from 90-130\ns. SBP 85-120\ns. Afib first\n occurred during SBT on . Occasional PVC\ns noted.\n Action:\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\n 20mEq IV given last evening per sliding scale orders.\n Response:\n Pt has remained in Afib but rate has significantly improved w/\n administration of Lopressor & Dilt. HR ranging 80\n low 100\ns w/\n minimal ectopy.\n Plan:\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\n Diltiazem. Follow electrolyte status & replete as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\n 30-40\ns but appearing comfortable & settles out on own. LS clear,\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\n 1.5\n 2L.\n Action:\n Suctiong q2-4 hrs for thick/white sputum. Pt is pooling secretions @\n back of throat (concern for aspiration post extubation)\n Response:\n Pt -2L @ MN.\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal - 1.5\n 2L @\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\n exchange. If all goes as planned, pt will be extubated late morning. As\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\n remains DNR)\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n"},{"category":"Nursing","chartdate":"2169-11-28 00:00:00.000","description":"Nursing Progress Note","row_id":703025,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\n RR up to 34-36 pt volume overloaded,\n Action:\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\n received 10 mg IVP Lasix at 9 pm with good response.\n Response:\n Pt able to sleep, appeared comfortable, rr 14-16\n Plan:\n Change back to pressure support in am, check RSBI, ?ready for\n extubation\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in Afib, rate 115-130 bp\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2169-11-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":703308,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - f/u VBG 7.48/42/78 in central venous, repeat ABG 7.46/44/124\n - BNP high 5525 c/w volume overload.\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid\n - PICC placed\n - Called micro lab: will try to speciate. will call in AM to confirm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:39 AM\n Heparin Sodium (Prophylaxis) - 04:51 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 99 (86 - 128) bpm\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\n RR: 28 (18 - 41) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 6 (2 - 6)mmHg\n Total In:\n 784 mL\n 256 mL\n PO:\n TF:\n IVF:\n 784 mL\n 196 mL\n Blood products:\n Total out:\n 2,885 mL\n 495 mL\n Urine:\n 2,885 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (260 - 404) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 154\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: ///29/\n Ve: 9.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 174 K/uL\n 9.2 g/dL\n 80 mg/dL\n 1.4 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 101 mEq/L\n 140 mEq/L\n 27.9 %\n 11.3 K/uL\n [image002.jpg]\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n Plt\n 48\n 60\n 84\n 131\n 174\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n TCO2\n 26\n 25\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n Other labs:\n Ca: 8.6, Mg: 2.2, Phos: 3.1\n Mircrobiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n ANAEROBIC GRAM NEGATIVE ROD(S).\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\n Radiology:\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\n vena cava. The patient remains intubated, with the endotracheal tube\n terminating 3.2 cm above the carina. The right internal jugular line\n ends in the mid superior vena cava. Left pleural effusion with\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\n consistent with pulmonary arterial hypertension. The right lung is\n clear. There is no pulmonary edema.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\n improved in terms of pulmonary vascular congestion, will trial\n extubation today since patient looks the best she has since admission\n - patient may need Bipap post extubation\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n .\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 90\ns with both medications\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month\n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition: Tube feeds on hold for possible extubation\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2169-11-26 00:00:00.000","description":"Physician Attending Progress Note","row_id":702804,"text":"TITLE:\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\n found to have cholangitis, now s/p ERCP and stenting, with course\n complicated by respiratory failure.\n 24 Hour Events:\n Decreased sedation overnight but had increasing agitation, had\n increased RR and decreasing tidal volumes so re-sedated and left at PS\n .\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\n RR: 37 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 243 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 239 mL\n Blood products:\n Total out:\n 1,795 mL\n 965 mL\n Urine:\n 1,795 mL\n 965 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -722 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 304 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 18 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: intubated, sedated\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.9 g/dL\n 60 K/uL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory Failure\n - continues to do poorly with decreased support, possibly due to\n ongoing volume overload\n - will follow TBB as she is autodiuresing, goal TBB -1L\n - low suspicion for underlying pneumonia given improving infectious\n parameters and shock\n - will continue PS today, repeat lightening of sedation and SBT\n tomorrow morning\n Septic shock\n - s/p ERCP with cholangitis\n - called micro for speciation of organisms, narrow abx if able\n - shock resolved, creatinine improved\n - on day Zosyn\n Atrial fibrillation\n - continues to be tachycardic, though improved\n - can try low dose beta-blocker today if BP tolerates\n - consider d'c amiodarone if able to be on beta-blocker\n Acute renal failure\n - improved overall\n - some of urine output now may be post-ATN diuresis\n Thrombocytopenia\n - slightly improved, no evidence of bleeding\n - will restart sc heparin today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\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: 30 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2169-11-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":702810,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Goal to decrease sedation overnight to help with extubation hopefully\n Sunday. Her barriers are sedation and fluid overload\n ---> on 2 mg versed...shut off for 2-3 hours and patient agitated\n pulling at tube and moving around. RSBI tried on her during her wakeful\n moment and it was 204..has been tachypnic to the 30's and if go down on\n PS tidal volumes decrease. Kept same pressure support . and turned\n versed back to 2 mg.\n - Goal TBB negative 1-1.5 liters. autodiuresing well, no lasix needed\n - CXR done that did not show much interval change.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 122 (114 - 131) bpm\n BP: 108/50(62) {88/44(55) - 133/80(87)} mmHg\n RR: 29 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 201 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 197 mL\n Blood products:\n Total out:\n 1,795 mL\n 745 mL\n Urine:\n 1,795 mL\n 745 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -544 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 403 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 17 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 60 K/uL\n 9.9 g/dL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\n Unable to wean effectively; likely secondary to fluid resuscitation; as\n fluid overload is seen on CXR.\n - Monitor UOP as patient is auto-diuresing well. Check i/o\ns this\n evening with TBB 1-1.5 liters, if not at goal will trial some lasix if\n her blood pressure can tolerate\n - Wean down vent settings as much as possible, but having difficulty\n due to volume overload\n - CXR tomorrow morning to evaluate for improvement in volume overload\n - will further clarify intubation status with family prior to\n extubation, to see if they would want her to be re-intubated if she has\n difficulty post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Patient has\n remained tachycardic on amio gtt, now that she is off pressors will\n trial a low dose beta blocker,\n - Metoprolol 5mg IV: monitor effect on HR and BP, has been on\n metoprolol at home\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized, has been\n afebrile for over 24hours\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: . Will f/u cutlure data to see if we can narrow our coverage,\n if she needs to be continued on Zosyn will place a PICC and pull\n central line\n - LFT\ns normalized, no longer need to trend daily\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Will restart SQ heparin as her platelet count has increased and the\n initial drop was not consistent with HIT\n - No signs of active bleeding\n ICU Care\n Nutrition: Was npo after midnight for possible extubation, but since\n she will not be extubated will restart tube feeds\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: pneumo boots, SQ heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, pt is intubated\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2169-11-27 00:00:00.000","description":"Physician Resident/Attending Progress Note - MICU","row_id":702962,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - will attempt to decrease sedation this evening and do an SBT, if she\n looks good will hold tube feeds, otherwise will continue feeds\n overnight\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\n then urine output was over 1L to the lasix\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\n MV and O2sats but RR in the 40's with small TV's. After about 15min\n became uncomfortable with increased WOB-->improved from prior, has more\n stamina, diuresis seems to be improving her respiratory status\n - per discussion with patient's family she can be reintubated if she\n fails extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:55 AM\n Furosemide (Lasix) - 06:14 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 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: 37.2\nC (99\n HR: 112 (106 - 129) bpm\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\n RR: 12 (12 - 37) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 733 mL\n 452 mL\n PO:\n TF:\n 202 mL\n 264 mL\n IVF:\n 531 mL\n 188 mL\n Blood products:\n Total out:\n 3,345 mL\n 765 mL\n Urine:\n 3,345 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,612 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 296 (241 - 304) mL\n PS : 12 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 166\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 8.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 84 K/uL\n 9.2 g/dL\n 143 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n WBC\n 15.3\n 20.2\n 11.3\n 10.6\n 11.2\n Hct\n 31.4\n 30.7\n 29.7\n 29.3\n 27.9\n Plt\n 59\n 46\n 52\n 48\n 60\n 84\n Cr\n 1.8\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 26\n 25\n Glucose\n 102\n 91\n 128\n 119\n 126\n 143\n Other labs:\n Mg: 1.6\n Alk Phos: 103, T. bili: 1.5\n PT: 12, INR: 1, PTT: 23.7\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n Imaging:\n Chest X-Ray (my read): slightly worsening left effusion and right\n basilar patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR.\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\n about 800 cc\ns in the evening so she was given 20mg IV lasix with a\n brisk urine output response. Will give another dose of lasix since she\n had her best SBT with the increased diuresis, hold tube feeds for now\n in case she is able to be extubated this afternoon. She will likely\n never have an excellent RSBI, but she will need to not tire and\n maintain her sats during her SBT.\n - Hold sedation for now to optimize mental status prior to extubation\n - need to place a dobhoff prior to extubation as she may be an\n aspiration risk\n - CXR looks stable to slightly worsened this morning\n - family okay with re-intubation if patient fails extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Increase metoprolol to 25mg and titrate up to good HR control as\n her BP tolerates\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count stable. Lactate\n normal. Initial sepsis secondary to biliary source given CBD dilation\n with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 24 hours.\n - Cont zosyn pending any further culture data; Day of zosyn.\n Day 1=. Will f/u cutlure data to see if we can narrow our\n coverage, if she needs to be continued on Zosyn will place a PICC and\n pull central line, may be able to transitioned to a po antibiotic\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n - f/u sputum culture\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to her baseline at 1.3 today.\n - Monitor UOP\n - Trend creatinine while diuresing\n - Check PM lytes\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Platelet count stable and increasing\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Heparin SQ, pneumo boots\n Stress ulcer: none while on feeds\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, is intubated, ok to be reintubated post extubation if\n necessary\n Disposition: ICU pending stabilization post extubation\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\n respiratory failure, AF c RVR. Failed SBT last PM, diuresis ongoing.\n Exam notable for Tm 99.8 BP HR 116/50 RR 12-37 with sat 100 on PSV\n . WD woman, follows intermittent commands. Coarse BS B. Irreg s1s2.\n Soft +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+ 3.9, Cr 1.3.\n Agree with plan to manage respiratory failure with IV lasix now for TBB\n negative, will check and trend CVP, continue upright positioning, and\n consider NGT placement prior to extubation. Cholangitis improving, will\n need 14d abx, f/u cultures, consider change CVL to PICC if she needs\n long-term IV abx. For AF c RVR, continue PO BBL, hold off on\n anticoagulation for now and d/w family / PCP\n appears to be at long\n term risk of falls based on prior history. ARF has resolved. Continue\n TFs for now. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 15:37 ------\n"},{"category":"Physician ","chartdate":"2169-11-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":703140,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - diurese further today to help w possibility of extubation--> Net Goal\n -1.5-2L\n - consider risk of aspiration post-extubation due to mental status\n - NG tube placed\n - patient remains tachycardic so metoprolol was increased to 25mg TID\n - need to address possib of anticoagulation w family and PCP\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\n tolerate 20mg IV)\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\n at 9:30pm to rest, so that she can be ready, better rested for SBT\n tomorrow, esp after diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 04:27 PM\n Heparin Sodium (Prophylaxis) - 04:31 AM\n Furosemide (Lasix) - 04:39 AM\n Metoprolol - 04:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 116 (100 - 125) bpm\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\n RR: 23 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 9 (9 - 272)mmHg\n Total In:\n 2,091 mL\n 206 mL\n PO:\n TF:\n 1,506 mL\n IVF:\n 524 mL\n 206 mL\n Blood products:\n Total out:\n 2,125 mL\n 1,120 mL\n Urine:\n 2,125 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -34 mL\n -915 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): 324 (255 - 463) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 25 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: ///30/\n Ve: 7.1 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 131 K/uL\n 9.1 g/dL\n 109 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 103 mEq/L\n 142 mEq/L\n 27.4 %\n 12.2 K/uL\n [image002.jpg]\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n WBC\n 20.2\n 11.3\n 10.6\n 11.2\n 12.2\n Hct\n 30.7\n 29.7\n 29.3\n 27.9\n 27.4\n Plt\n 52\n 48\n 60\n 84\n 131\n Cr\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n TCO2\n 23\n 26\n 25\n Glucose\n 91\n 128\n 119\n 126\n 143\n 117\n 109\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.6 mg/dL\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\n Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n Imaging:\n Chest X-Ray at 2330 (my read): stable effusion/opacity and\n RLL patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\n having difficulty coming off PEEP, becomes very tachypneic and has low\n tidal volumes, which is more concerning for difficulty with compliance\n and volume overload. Additionally, patient with opacity and\n diaphragm pulled up on the left that has been noted on all x-rays\n during this admission, to better see the anatomy in the , \n bronch the patient this afternoon to look at the .\n - continue with net negative goal, if UOP decreases to less than\n 100cc/hr will give another dose of lasix and readdress possible\n extubation this afternoon.\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\n the 120\ns to 130\ns, so will trial an esmolol drip\n # Septic shock: resolving, patient off pressors, likely secondary to\n cholangitis and infected stone/sludge. ERCP showed significant pusand\n very large stone, she is s/p stent placement. Patient afebrile and\n white count stable. Lactate normal. Initial sepsis secondary to biliary\n source given CBD dilation with sludge and obstructive LFTs in setting\n on known choledocholithiasis.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 48 hours.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\n will place a PICC and pull central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\n to help with further diruesis\n - Monitor UOP\n - Check PM lytes\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition: Tube feeds held o/n for possible extubation, will hold this\n afternoon for possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM, will put patient in for a PICC today\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2169-11-22 00:00:00.000","description":"Nursing Progress Note","row_id":702081,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\n Action:\n Placed on A/C for ERCP.\n Response:\n Remains on AC as she received paralytic for ERCP and remains very\n sedated.\n Plan:\n Return PSV when spontaneous breathing returns. Turn off sedation in\n a.m. and do SBT for possible extubation. Monitor O2sats.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\n WBC up to 25. Remains in metabolic acidosis.\n Action:\n Received additional 2L IVBs.\n Response:\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\n 0.1mcg/kg/minute.\n Plan:\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\n requires more fluids for low CVP.\n"},{"category":"Respiratory ","chartdate":"2169-11-27 00:00:00.000","description":"Respiratory Care Shift Note","row_id":702876,"text":"TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 54.\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: PSV 12/5/.4\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments: Maintaining Vt 2-300\ns with Ve8-10 L, sp02 99%\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: Attempted SBT x1: ~18 minutes with RR 40, appeared\n to have increased WOB, increased HR> back to PSV 12/5; RSBI 166\n Comments: Will cont slow PSV wean as tol.\n"},{"category":"Nursing","chartdate":"2169-11-29 00:00:00.000","description":"Nursing Progress Note","row_id":703214,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\ns. afib\n first occurred during sbt on / trialed lopressor 12.5 mg po on\n without affect.\n Action:\n Lopressor dose was increased to 25 mg pot id without any improvement in\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\n hr. hemodynamics followed closely.\n Response:\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\n was d/c\nd. sbp retruned to her baseline once esmalol gtt was d/c\n Plan:\n Continue to follow hemodynamics . Continue to check lytes as ordered\n and replete as needed. Pt now started on lopressor 25 mg pot id and\n diltiazem 30 mg po q 6hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp failure initially thought to be due to metabolic acidosis which\n caused her to hyperventilate to compensate and fatigued becoming\n acutely sob and requiring intubation on ^th.unable to wean\n vent because of pt being fluid overloaded secondary to fluid\n resusitiation. Pt having difficulty coming off peep becoming very\n tachypenic with low tidal volumes which is more concerning for\n difficulty with compliance then volume overload. Cxr c/w lll opacity\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\n tachypenic . lungs clear with crackles noted bil at the bases.\n Suctioned for sm amts of thick white sputum.\n Action:\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\n closely.\n Response:\n Vent settings unchanged. Cxr unchanged\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal for i&o is to\n be neg 1.5 to 2 liters Will keep on cpap mode of ventilation overnoc.\n Plan is to call anesthesia in the am to change #7 ett to o #8 ett over\n the cook catheter. Once ett is changed will then check rsbi and do sbt.\n Will do bronchoscopy after that and then possible extubation with the\n plan to reintubate if pt fails extubation.\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n"},{"category":"Physician ","chartdate":"2169-11-26 00:00:00.000","description":"Physician Resident Progress Note","row_id":702792,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Goal to decrease sedation overnight to help with extubation hopefully\n Sunday. Her barriers are sedation and fluid overload\n ---> on 2 mg versed...shut off for 2-3 hours and patient agitated\n pulling at tube and moving around. RSBI tried on her during her wakeful\n moment and it was 204..has been tachypnic to the 30's and if go down on\n PS tidal volumes decrease. Kept same pressure support . and turned\n versed back to 2 mg.\n - Goal TBB negative 1-1.5 liters. autodiuresing beautifully and have\n not given lasix as she is -840 cc at .\n - CXR done that did not show much interval change.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 122 (114 - 131) bpm\n BP: 108/50(62) {88/44(55) - 133/80(87)} mmHg\n RR: 29 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 201 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 197 mL\n Blood products:\n Total out:\n 1,795 mL\n 745 mL\n Urine:\n 1,795 mL\n 745 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -544 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 403 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 17 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8 L/min\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 60 K/uL\n 9.9 g/dL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\n Unable to wean effectively; likely secondary to fluid resuscitation; as\n fluid overload is seen on CXR.\n - Monitor UOP as patient is auto-diuresing well. Check i/o\ns this\n evening with TBB 1-1.5 liters\n - Wean down vent settings as much as possible, will likely be more\n effective once\n - CXR today to make sure no other acute process is occuring\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Continue amio gtt as HR has improved, but she is still tachycardic in\n the low 100\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\n be improving.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: .\n - f/u speciation and sensitivities from prior blood cx\n - Trend CBC/diff, LFTs,\n - Follow up blood cx speciation , urine cx with no growth\n - no need for pressors now. Monitor maps > 65.\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\n of HIT as timing does not correlate since patient has not had a prior\n heparin exposure. Vancomycin may also be contributing to her\n thrombocytopenia\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 24 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: Currently NPO for possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: pneumo boots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, pt is intubated\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2169-11-28 00:00:00.000","description":"Physician Resident Progress Note","row_id":703083,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - diurese further today to help w possibility of extubation--> Net Goal\n -1.5-2L\n - consider risk of aspiration post-extubation due to mental status\n - NG tube? prior to extubation\n - consider changing her to PO Abx today\n - amio was stopped yesterday ; on metoprolol 25mg --> incr to\n TID\n - need to address possib of anticoagulation w family and PCP\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\n tolerate 20mg IV)\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\n at 9:30pm to rest, so that she can be ready, better rested for SBT\n tomorrow, esp after diuresis\n - SBT in the AM to figure out if she's ready to be extubated; can\n restart tube feeds in AM if not ready\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 04:27 PM\n Heparin Sodium (Prophylaxis) - 04:31 AM\n Furosemide (Lasix) - 04:39 AM\n Metoprolol - 04:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 116 (100 - 125) bpm\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\n RR: 23 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 9 (9 - 272)mmHg\n Total In:\n 2,091 mL\n 206 mL\n PO:\n TF:\n 1,506 mL\n IVF:\n 524 mL\n 206 mL\n Blood products:\n Total out:\n 2,125 mL\n 1,120 mL\n Urine:\n 2,125 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -34 mL\n -915 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): 324 (255 - 463) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 25 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: ///30/\n Ve: 7.1 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 131 K/uL\n 9.1 g/dL\n 109 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 103 mEq/L\n 142 mEq/L\n 27.4 %\n 12.2 K/uL\n [image002.jpg]\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n WBC\n 20.2\n 11.3\n 10.6\n 11.2\n 12.2\n Hct\n 30.7\n 29.7\n 29.3\n 27.9\n 27.4\n Plt\n 52\n 48\n 60\n 84\n 131\n Cr\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n TCO2\n 23\n 26\n 25\n Glucose\n 91\n 128\n 119\n 126\n 143\n 117\n 109\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.6 mg/dL\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\n Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n Imaging:\n Chest X-Ray at 2330 (my read): stable LLL effusion and RLL patchy\n opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR.\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\n about 800 cc\ns in the evening so she was given 20mg IV lasix with a\n brisk urine output response. Will give another dose of lasix since she\n had her best SBT with the increased diuresis, hold tube feeds for now\n in case she is able to be extubated this afternoon. She will likely\n never have an excellent RSBI, but she will need to not tire and\n maintain her sats during her SBT.\n - Hold sedation for now to optimize mental status prior to extubation\n - need to place a dobhoff prior to extubation as she may be an\n aspiration risk\n - CXR looks stable to slightly worsened this morning\n - family okay with re-intubation if patient fails extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Increase metoprolol to 25mg and titrate up to good HR control as\n her BP tolerates\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count stable. Lactate\n normal. Initial sepsis secondary to biliary source given CBD dilation\n with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 24 hours.\n - Cont zosyn pending any further culture data; Day of zosyn.\n Day 1=. Will f/u cutlure data to see if we can narrow our\n coverage, if she needs to be continued on Zosyn will place a PICC and\n pull central line, may be able to transitioned to a po antibiotic\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n - f/u sputum culture\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to her baseline at 1.3 today.\n - Monitor UOP\n - Trend creatinine while diuresing\n - Check PM lytes\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Platelet count stable and increasing\n ICU Care\n Nutrition: Tube feeds held o/n for possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: ICU\n"},{"category":"Physician ","chartdate":"2169-11-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":703266,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:34 PM\n MULTI LUMEN - STOP 05:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:39 AM\n Heparin Sodium (Prophylaxis) - 04:51 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 99 (86 - 128) bpm\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\n RR: 28 (18 - 41) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 6 (2 - 6)mmHg\n Total In:\n 784 mL\n 256 mL\n PO:\n TF:\n IVF:\n 784 mL\n 196 mL\n Blood products:\n Total out:\n 2,885 mL\n 495 mL\n Urine:\n 2,885 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (260 - 404) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 154\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: ///29/\n Ve: 9.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 174 K/uL\n 9.2 g/dL\n 80 mg/dL\n 1.4 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 101 mEq/L\n 140 mEq/L\n 27.9 %\n 11.3 K/uL\n [image002.jpg]\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n Plt\n 48\n 60\n 84\n 131\n 174\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n TCO2\n 26\n 25\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n Other labs:\n Ca: 8.6, Mg: 2.2, Phos: 3.1\n Mircrobiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n ANAEROBIC GRAM NEGATIVE ROD(S).\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\n Radiology:\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\n vena cava. The patient remains intubated, with the endotracheal tube\n terminating 3.2 cm above the carina. The right internal jugular line\n ends in the mid superior vena cava. Left pleural effusion with\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\n consistent with pulmonary arterial hypertension. The right lung is\n clear. There is no pulmonary edema.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\n having difficulty coming off PEEP, becomes very tachypneic and has low\n tidal volumes, which is more concerning for difficulty with compliance\n and volume overload. Additionally, patient with opacity and\n diaphragm pulled up on the left that has been noted on all x-rays\n during this admission, to better see the anatomy in the , \n bronch the patient this afternoon to look at the .\n - continue with net negative goal, if UOP decreases to less than\n 100cc/hr will give another dose of lasix and readdress possible\n extubation this afternoon.\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\n the 120\ns to 130\ns, so will trial an esmolol drip\n # Septic shock: resolving, patient off pressors, likely secondary to\n cholangitis and infected stone/sludge. ERCP showed significant pusand\n very large stone, she is s/p stent placement. Patient afebrile and\n white count stable. Lactate normal. Initial sepsis secondary to biliary\n source given CBD dilation with sludge and obstructive LFTs in setting\n on known choledocholithiasis.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 48 hours.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\n will place a PICC and pull central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\n to help with further diruesis\n - Monitor UOP\n - Check PM lytes\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2169-11-29 00:00:00.000","description":"Physician Resident Progress Note","row_id":703267,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - f/u VBG 7.48/42/78 in mixed venous, Very weird gas for venous...\n - BNP high 5525 c/w volume overload.\n - still intubated with plan to do bronch Wednesday and change out the\n ET tube to a bigger size\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid...will need\n to clean this up in rounds. not at maximum doses of either and both\n aren't working very well.\n - Upright rsbi to be done in early AM.\n - PICC placed\n - Called micro lab: will try to speciate. will call in AM to confirm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:39 AM\n Heparin Sodium (Prophylaxis) - 04:51 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 99 (86 - 128) bpm\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\n RR: 28 (18 - 41) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 6 (2 - 6)mmHg\n Total In:\n 784 mL\n 256 mL\n PO:\n TF:\n IVF:\n 784 mL\n 196 mL\n Blood products:\n Total out:\n 2,885 mL\n 495 mL\n Urine:\n 2,885 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (260 - 404) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 154\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: ///29/\n Ve: 9.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 174 K/uL\n 9.2 g/dL\n 80 mg/dL\n 1.4 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 101 mEq/L\n 140 mEq/L\n 27.9 %\n 11.3 K/uL\n [image002.jpg]\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n Plt\n 48\n 60\n 84\n 131\n 174\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n TCO2\n 26\n 25\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n Other labs:\n Ca: 8.6, Mg: 2.2, Phos: 3.1\n Mircrobiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n ANAEROBIC GRAM NEGATIVE ROD(S).\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\n Radiology:\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\n vena cava. The patient remains intubated, with the endotracheal tube\n terminating 3.2 cm above the carina. The right internal jugular line\n ends in the mid superior vena cava. Left pleural effusion with\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\n consistent with pulmonary arterial hypertension. The right lung is\n clear. There is no pulmonary edema.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\n having difficulty coming off PEEP, becomes very tachypneic and has low\n tidal volumes, which is more concerning for difficulty with compliance\n and volume overload. Additionally, patient with opacity and\n diaphragm pulled up on the left that has been noted on all x-rays\n during this admission, to better see the anatomy in the , \n bronch the patient this afternoon to look at the .\n - continue with net negative goal, if UOP decreases to less than\n 100cc/hr will give another dose of lasix and readdress possible\n extubation this afternoon.\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\n the 120\ns to 130\ns, so will trial an esmolol drip\n # Septic shock: resolving, patient off pressors, likely secondary to\n cholangitis and infected stone/sludge. ERCP showed significant pusand\n very large stone, she is s/p stent placement. Patient afebrile and\n white count stable. Lactate normal. Initial sepsis secondary to biliary\n source given CBD dilation with sludge and obstructive LFTs in setting\n on known choledocholithiasis.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 48 hours.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\n will place a PICC and pull central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\n to help with further diruesis\n - Monitor UOP\n - Check PM lytes\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition:ICU\n"},{"category":"Physician ","chartdate":"2169-11-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":702212,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP today: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n lactate normalized to 1.4.\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some.\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%.\n - Cont PSV for now and wean as tolerated; consider sbt once patient can\n tolerate no sedation and no pressors\n - goal to extubate patient today\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo until\n sensitivies return\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC labs equivical; low\n suscipicion of HIT as timing does not correlate.\n - Concerning as platelets continuing to decrease. Vancomycin/Zosyn may\n be a possibility as known to cause thrombocytopenia.\n - Repeat DIC labs\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband\n status: DNR\n Disposition: ICU for now\n"},{"category":"Nursing","chartdate":"2169-11-29 00:00:00.000","description":"Nursing Progress Note","row_id":703352,"text":"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on PSV 40% 8/5. Sedated on midaz\n at 1mg/hr. B/L LS clear diminished at the bases. Tachypneic to high\n 20-30\n Action:\n Lasix 20mg X1 given prior to extubation, extubated.\n Response:\n No s/s of resp distress. Patient denies any SOB when asked. Sats at\n high 90\ns on face tent.\n Plan:\n Continue to monitor patient resp status\n Atrial fibrillation (Afib)\n Assessment:\n Known AFib. HR in 90-low 100\ns. B/P 90-110\ns occasionally when asleep\n b/p down to 80\ns. Peripheral pulses present.\n Action:\n Metoprolol at 25mg TID and Dilt 30mg QID\n Response:\n HR in the 90\n Plan:\n Continue to monitor patient hemodynamic status.\n Neuro: alert, follows commands.\n GI: abd soft non tented, positive for BS. NPO. Ngt for meds\n clamped.\n 3 x smear of golden loose stools during the shift.\n GU: clear yellow urine via foley. Lasix X1 given.\n Skin: reddened buttocks. Critic aid cream applied.\n Social: patient is a DNR. OK to re-intubate if needed. Family in to\n visit. Updated by RN and MD.\n"},{"category":"Physician ","chartdate":"2169-11-23 00:00:00.000","description":"Physician Resident Progress Note","row_id":702218,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%.\n - Cont PSV for now and wean as tolerated; consider sbt once patient can\n tolerate no sedation and no pressors\n - goal to extubate patient today\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo until\n sensitivies return\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC labs equivical; low\n suscipicion of HIT as timing does not correlate.\n - Concerning as platelets continuing to decrease. Vancomycin/Zosyn may\n be a possibility as known to cause thrombocytopenia.\n - Repeat DIC labs\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband\n status: DNR\n Disposition: ICU for now\n"},{"category":"Nursing","chartdate":"2169-11-24 00:00:00.000","description":"Nursing Progress Note","row_id":702517,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Atrial fibrillation (Afib)\n Assessment:\n Hr 100-130\ns afib with sbp ranging from 100-120\ns. k+3.4 and phos=1.7.\n afib first occurred during sbt on . pressors were then changed to\n neo in attempt to drop pt\ns hr but was unsuccessful. Pt was started on\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\n bp support\n Action:\n Pt repleted with 30mmol of kphos. Hemodynamics montitored closely.\n Amioderone gtt decreased to 0.5mg/min after 6 hrs of infusion at\n 1mg/min. neo being weaned to off as pt\ns hemodynamics tolerate\n Response:\n Hr remains in afib tachy from 100-130\ns but hemodynamically stable\n Plan:\n Plan is to continue infusion of amioderon for 18 hrs and then will\n consider d/c\ning gtt. Continue to follow hemodynamics and wean as\n tolerated to keep map> 60 and hourly uo > 30cc\ns/hr. check lytes as\n ordered and replete as needed\n Sepsis without organ dysfunction\n Assessment:\n Pt s/p ercp on . low grade temps but wbc up to 20.2 from yesterday\n count of 16.blood cultures from grew gm pos rods and gm neg rods.\n Septic shock most likely secondary to cholangitis and infected\n stone/sludge.with increase in wbc concern is for a new infection.\n Action:\n Fever curve followed closely. Pt receiving piperacillin as ordered.\n Awaiting final speciation of all culture data. Pan cultured today\n Response:\n Low grade temps and elevated wbc unchanged.\n Plan:\n Await results for all culture data. Administer antibiotics as ordered\n and follow fever curve.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt most likely became fatigued in the setting of metabolic acidosis\n and attempt to hyperventilate to compensate requiring her to be\n intubated. Placed pt on 40% cpap with 5 peep and ps of 5 . lungs\n essentially clear on auscultation. Suctioned for sm amts of thick tan\n sputum.cxr c/w fluid overload which is likely contributing to the\n difficulty in weaning her off the vent.once pt is weaned off pressors\n will then need diuresis and hopefully pt will start to mobilize fluid.\n Action:\n Vent weaned to 40%cpap with 5 peep and ps of 5. resp status monitored\n closely. Antibiotics administered as ordered. Reps toileting continues.\n Decision made not to extubate pt since she became tachypneic ,had lower\n tv\ns and appeared more uncomfortable. Versed gtt increased back up to\n 2mg/hr. vent changed back to ac mode of ventilation. Sputum for c&s\n sent off to microbiology. Ogt placed in order to start tube fdgs until\n pt is extubated.\n Response:\n Resting comfortably on ac mode after not tolerating decrease in vent\n settings.\n Plan:\n Check rsbi in the am and do sbt. Wean pressors to off if possible and\n then will diurese as needed . d/c tube fdgs at midnoc in the hope of\n extubating pt in the am. Continue to monitor pt\ns resp status and\n continue with resp toileting\n"},{"category":"Respiratory ","chartdate":"2169-11-28 00:00:00.000","description":"Respiratory Care Shift Note","row_id":703202,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Diminished\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use,\n Tachypneic (RR> 35 b/min)\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 Intolerant of weaning attempts, Pending procedure / OR\n Respiratory Care Shift Procedures\n Planning to change tube size and bronch in am.\n"},{"category":"Nursing","chartdate":"2169-11-23 00:00:00.000","description":"Nursing Progress Note","row_id":702324,"text":"Atrial fibrillation (Afib)\n Assessment:\n Pt was in NSR without ectopi at about 1030 patient had new onset Atrial\n Fibrillation. Patient was on spontaneous breathing trial did not appear\n to be in res p distress O2 SAT > 95. Patient remained on Levophed at\n 0.07mcg/kg/min with out changed in sbp. Patient Hr 110-120 and\n tolerated. Since 1500 HR up to 130-140 at times.\n Action:\n Patient placed back on ventilator. EKG done and read Additional fluid\n was given and attempted to wean Levophed without success, labs sent\n Response:\n Pt has remained in A Fibrillation. Hr 110-140. Unable to wean Levophed.\n Plan:\n Continue to monitor patient. Possibly changed patient to another\n pressor. Continue to treat sepsis and monitor labs,\n"},{"category":"Nursing","chartdate":"2169-11-24 00:00:00.000","description":"Nursing Progress Note","row_id":702396,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\n versed 3mg/hr.\n Action:\n Suctioned for small amount secretions. Blood gas in the am. Versed\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\n Response:\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/ .am\n RSBI 54 and tolerated well.\n Plan:\n Wean vent / sedations as tolerated further and for possible\n extubation today.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\nS on\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\n /BUN 37,elevated liver enzymes.\n Action:\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\n with NaHCo3 150 meq given for hydration and for PH 7.29 from the\n evening lab\n Response:\n SBP 85-90\ns when tried to titrate Levophed further .so continued on\n 0.07mics. urine output improved with fluid bolus.\n Plan:\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\n"},{"category":"Nursing","chartdate":"2169-11-24 00:00:00.000","description":"Nursing Progress Note","row_id":702398,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated , cpap/ps see metavision for vent settings\n Action:\n Weaning sedation lightened fentanyl gtt if off, versed at 2mg/hr easily\n arousable following commands\n Response:\n Am blood gas pending\n Plan:\n possible extubation today.\n Sepsis without organ dysfunction\n Assessment:\n s/p ERCP, switch from levophed to neo yesterday\n Action:\n Weaning neo as tolerated\n Response:\n SBP 85-90\ns neo is at 1mcg//min presently\n Plan:\n Wean neo as tolerated. moniotr urine output / VSS .\n Atrial fibrillation (Afib)\n Assessment:\n Continues in a-fib hr 120-130\n Action:\n 10mg of iv Dilt. given\n Response:\n Hr 10 110-118 for short period of time now back in 120\ns still in\n a-fib\n Plan:\n Continue to monitor patient. Monitor the HR, may start on amiodorone\n today\n"},{"category":"Nursing","chartdate":"2169-11-24 00:00:00.000","description":"Nursing Progress Note","row_id":702511,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Atrial fibrillation (Afib)\n Assessment:\n Hr 100-130\ns afib with sbp ranging from 100-120\ns. k+3.4 and phos=1.7.\n afib first occurred during sbt on . pressors were then changed to\n neo in attempt to drop pt\ns hr but was unsuccessful. Pt was started on\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\n bp\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2169-11-25 00:00:00.000","description":"Physician Attending/Fellow Progress Note - MICU","row_id":702702,"text":"TITLE:\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\n presents with septic shock and cholangitis, s/p ERCP with stent, and\n respiratory failure. Now with persistent vent requirements.\n 24 Hour Events:\n Arterial line came out.\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 PM\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unable to obtain, patient sedated and intubated.\n Flowsheet Data as of 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.2\nC (97.2\n HR: 128 (114 - 141) bpm\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\n RR: 23 (14 - 30) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 1,682 mL\n 311 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 310 mL\n Blood products:\n Total out:\n 2,045 mL\n 920 mL\n Urine:\n 2,045 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -609 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): 380 (308 - 528) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 16 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.9 L/min\n PaO2 / FiO2: 318\n Physical Examination\n Gen\nl: intubated, sedated\n HEENT: ETT in place, pupils constricted by equal and reactive\n Pulm: diminished, transmitted vent sounds, no wheezing, crackles at\n bases anteriorly\n CV: irregularly irregular, tachycardic, distant and no murmur\n appreciated, no gallop or rubs\n Abdomen: soft, no grimace to palpation, (+) bowel sounds\n Neurologic: responds to tactile stimuli, non-purposeful movement\n Labs / Radiology\n 9.8 g/dL\n 48 K/uL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory failure\n - now likely secondary to volume overload\n - goal TBB - 1 to -1.5L today and will give prn lasix\n - wean pressure support as tolerated, check CXR\n Septic shock\n - now off pressors, autodiuresing\n - on zosyn, day , leukocytosis improving\n - LFTs improving s/p stenting via ERCP\n - awaiting speciation/sensitivities from cultures\nAtrial fibrillation\n - on amiodarone drip, will continue for now\n - will calculate total dose today\n Thrombocytopenia\n - stable, no signs of active bleeding\n - very low suspicion for HIT\n - will restart SC heparin when plts >50K\n ICU Care\n Nutrition:\n Comments: restart TF as unlikely to be extubated today\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2169-11-23 00:00:00.000","description":"Nursing Progress Note","row_id":702128,"text":"Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\n versed 3mg/hr.\n Action:\n Suctioned for small amount secretions. Blood gas in the am.\n Response:\n Easily arousable, stable during the shift. RSBI in the morning.\n Plan:\n Wean vent / sedations as tolerated further.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\nS on\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr\n Action:\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min,\n tried to titrate to 0.1 later .1000cc D5 with NaHCo3 150 meq given for\n hydration and for PH 7.1\n Response:\n SBP 85-90\ns when tried to titrate levophed.so continued on 0.12mics.\n SBP >110-110 mm of hg.urine output improved with fluid bolus. Blood gas\n in the am.\n Plan:\n Hydrate and wean levo as tolerated.moniotr urine output / VSS .\n"},{"category":"Physician ","chartdate":"2169-11-24 00:00:00.000","description":"Physician Resident Progress Note","row_id":702505,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early this morning\npatient very tahcypneic, unable to be\n extubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n URINE CULTURE (Final ): NO GROWTH.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - early this morning\npatient very tachypneic with lower tidal\n volumes, appeared very uncomfortable during short trial this morning,\n will transition back to A/C and then wean to PSV throughout the day\n -Chest x-ray appeared volume overloaded, which is likely contributing\n to the difficulty weaning her off the ventilator, when patient is able\n to be weaned off pressors will need diuresis. Hopefully patient will\n start to mobilize her extra fluid, however once off pressors if she is\n unable to, will give lasix as needed to help decrease the fluid in her\n lungs\n - Hopeful extubation tomorrow pending ability to diurese\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - With increasing leukocytosis concern for a new infection, will\n reculture blood, urine and sputum, also send a C.diff when patient has\n a bowel movement, if LFT\ns increase, will reimage RUQ due to concern\n for possible blockage of stent\n - Cont zosyn pending any further culture data; f/u speciation and\n sensitivities from prior blood cx\n - Trend CBC/diff, LFTs, especially in the setting on increasing\n leukocytosis, will add on Diff to AM labs\n - Follow up blood cx speciation , urine cx with no growth\n - Wean neo as tolerated by MAP >= 60 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\n baseline creatinine 1.2-1.4.\n - Titrate MAP to greater than 60, unless urine output decreases then\n will titrate to increased MAP\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 26 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: Will place OG tube for tube feeds today and turn them off at\n midnight for hopeful extubation tomorrow\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 85F a w/ renal ca, dementia,\n choledocolithiasis in w/ sepsis/shock from cholangitis s/p ERCP\n with stent placement. She remains intubated, Course has been c/b\n continued pressor requirements and development of A-fib in setting of\n yesterday now on amio gtt for rate control.\n PE: Tm 99.2 BP 102/56 HR 72-141 RR 20's Sat 97% on PS 10/5 40%\n -->7.41/39/98%\n Intubated, more alert awake, NAD, follows commands, CTA ant, decreased\n bb, , tachy, soft + BS, NT, no ruq tenderness, no pedal edema\n LABS: wbc 20.2, hct 31, plt 52, na 140, cr 1.6 (2.6), lactate 1.7, t\n bili, ast/alt continue to decrease, inr 1.0,\n Micro: bl cx's--> gpr/gnr\n CXR-->w/ sm L effusion and prominent vascular markings\n A/P: Sepsis from cholangitis c/b arf, resp failure, thrombocytopenia.,\n and a-fib. Her WBC is rising. She failed this am, likely related\n to extra volume. She remains on pressors.\n Agree with plan to rest on ACV and trial back on PS later today as she\n tolerates following abg and clinical picture. Her MAPs are adequate and\n we should be able to titrate off pressor support. She remains on amio\n gtt/load for rate control. Her cr continues to improve toward her\n baseline CRI and her urine outpt is excellent. We hope she will\n continue to mobilize fluids, though once BP is stable off pressors, we\n may need diurese prior to and extubation. We continue to treat\n biliary sepsis with zosyn. Given her rising wbc ct, we are concerned\n for new infection. Her lfts are down and her abd exam benign, there is\n no diarrhea or new secretions and she remains AF. Her lines are just a\n few days old. We will repeat pan cxs, check for c diff, and f/u\n pending cx speciation /sensitivities. We keep a low threshold for\n broadened coverage in setting of temp spike or clinical decline. We\n continue to monitor her plts closely and suspect her thrombocytopenia\n is infection response or medications noting no recent heparin\n exposure to support early HIT. Will continue to hold heparin products\n and monitor, following DIC labs, and keeping t and c. A-line and CVL.\n DNR. Start TFs.\n Remainder of plan as outlined in resident note.\n Patient is critically ill\n Total time: 45 min.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:31 PM ------\n"},{"category":"ECG","chartdate":"2169-12-01 00:00:00.000","description":"Report","row_id":192914,"text":"Baseline artifact. Normal sinus rhythm with atrial premature beat.\nIntraventricular conduction delay of right bundle-branch block morphology.\nNon-specific ST-T wave abnormalities. Compared to the previous tracing\nof atrial fibrillation has resolved and right bundle-branch block is\nnew. Clinical correlation and repeat tracing are suggested.\n\n"},{"category":"ECG","chartdate":"2169-11-23 00:00:00.000","description":"Report","row_id":192915,"text":"Atrial fibrillation with rapid ventricular response. Low QRS voltage in the\nprecordial leads. Diffuse non-specific T wave flattening. Compared to the\nprevious tracing of atrial fibrillation is new. Decreased QRS voltage\nis now evident.\n\n"},{"category":"ECG","chartdate":"2169-11-22 00:00:00.000","description":"Report","row_id":192916,"text":"Baseline artifact. Sinus rhythm. Since the previous tracing probably no\nsignificant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2169-11-21 00:00:00.000","description":"Report","row_id":192917,"text":"Sinus rhythm. Leftward axis. Since the previous tracing no significant\nchange.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2169-11-21 00:00:00.000","description":"Report","row_id":192918,"text":"Sinus rhythm. Since the previous tracing of the single beat showing a\nmore leftward axis and right bundle-branch block morphology is no longer\npresent.\n\n"},{"category":"Radiology","chartdate":"2169-11-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1102526,"text":" 9:52 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?fluid overload\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with progressive dyspnea, intubated, septic\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:22 A.M., \n\n HISTORY: Progressive dyspnea and sepsis.\n\n IMPRESSION: AP chest compared to and 14 through 1:09 a.m.\n\n Peripheral wedge-shaped opacity in the left hemithorax obscuring the lateral\n pleural sulcus, which developed on , has been stable since 1:39 a.m.\n today consistent with pulmonary infarction, perhaps related to septic embolus\n or small loculated pleural fluid collection, also sometimes the result of\n pulmonary embolus. Moderate cardiomegaly and enlargement of the pulmonary\n arteries are longstanding. ET tube in standard placement. Right jugular line\n ends in the low SVC, nasogastric tube passes into the stomach and out of view.\n New opacification at the right lung base may be due to mild edema in the\n setting of severe emphysema. No pneumothorax or appreciable layering pleural\n effusion.\n\n\n"},{"category":"Radiology","chartdate":"2169-11-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1102456,"text":" 7:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: Chest radiograph .\n\n UPRIGHT AP VIEW OF THE CHEST: Study is slightly limited due to patient\n motion. The cardiac, mediastinal, and hilar contours are stable, with\n unchanged enlargement of the pulmonary arteries, compatible with underlying\n hypertension. Prominent epicardial fat pad is again noted. The lungs are\n grossly clear without focal consolidation, pleural effusion or pneumothorax.\n There appears to be hyperinflation of the lungs, stable from prior.\n Degenerative changes are seen within the right shoulder. New surgical clips\n are also noted within the epigastric region. Multilevel degenerative changes\n are present in the thoracic spine.\n\n IMPRESSION: Study is slightly limited due to patient motion. No gross\n evidence of pneumonia or congestive heart failure.\n\n\n"},{"category":"Radiology","chartdate":"2169-11-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1102784,"text":" 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with sepsis requiring intubation from a biliary source\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:40 PM\n PFI: Gradual increase in left now moderate pleural effusion with adjacent\n opacity, likely due to compression atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 85-year-old woman with sepsis, requiring intubation. Evaluate\n for interval change.\n\n COMPARISON: Several prior studies, most recent dated .\n\n FINDINGS: The patient remains intubated, with the endotracheal tube in a\n standard position. A nasogastric tube is not present. A right internal\n jugular line ends in the mid SVC. The heart remains mildly enlarged. There\n is a left-sided pleural effusion, slowly increasing over the period of days.\n There is adjacent density, probably due to compression atelectasis.\n\n The pulmonary arteries are enlarged, as before. There is no pneumothorax or\n frank pulmonary edema.\n\n IMPRESSION: Gradual increase in left now moderate pleural effusion with\n adjacent opacity, likely due to compression atelectasis.\n\n"},{"category":"Radiology","chartdate":"2169-11-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1102470,"text":" 11:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new central line\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with new central line placement.\n\n COMPARISON: Chest radiographs of and , 7:38 p.m.\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: A new right internal jugular central\n venous catheter tip is seen in the low SVC. No new pneumothorax, pleural\n effusion, or mediastinal widening is seen. Otherwise, the exam is unchanged,\n with evidence of pulmonary hypertension and top normal heart size.\n\n IMPRESSIONS: No evidence of CHF or consolidation.\n\n\n\n"},{"category":"Radiology","chartdate":"2169-11-22 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":1102472,"text":" 12:16 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please eval liver/gb\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new transamionitis and jaundice\n REASON FOR THIS EXAMINATION:\n please eval liver/gb\n ______________________________________________________________________________\n WET READ: AGLc WED 1:37 AM\n difficult to compare across modalities. perhaps slight increase in size of\n common duct at liver margin, previously ~21mm, currently ~25 mm, in pt with\n chronic dilatation of intra- and extra-hepatic bile ducts. echogenic\n material seen in distal CBD, probably sludge/sludge ball. more focal stone-\n appearing filling defect seen on recent MR (measuring 2.5 cm in longest\n dimension) not seen. also distalmost CBD / panc head not well visualized.\n clinical correlation necessary, and if indicated, ERCP or MRCP could be\n performed for further assessment. no fluid in RUQ. no Rt hydro.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with acute onset of dyspnea and vomiting\n beginning yesterday, with near collapse today. No leukocytosis but total\n bilirubin of 9.9.\n\n COMPARISON: MR abdomen of , CT torso last performed on , and\n lap ultrasound performed of the kidneys on .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The examination of the right upper quadrant\n was terminated prematurely due to patient respiratory difficulty towards the\n end of the exam.\n\n The liver parenchyma appears unremarkable. There is again dilatation of the\n extrahepatic bile ducts and central intrahepatic ducts, similar to that seen\n on MRI of 2 weeks prior. The common bile duct again has dilated and tortuous\n appearance, measuring up to 2.5 cm in diameter. Echogenic debris is seen\n within the distal common bile duct which is non-shadowing, probably\n representing sludge and/or stones. However, the distalmost CBD and pancreatic\n head is not well visualized.\n\n Limited views of the right kidney show no hydronephrosis. There is again\n echogenic appearance to the kidney with cortical thinning. The known lower\n pole renal mass is not assessed as the examination was terminated at this\n point.\n\n No ascites is seen in the visualized right upper quadrant.\n\n IMPRESSION: Dilatation of bile ducts, similar to that seen on recent MRI\n study performed 2 weeks ago. Again with sludge/stones seen in CBD, but\n distal most CBD and pancreatic head not well visualized. In this patient with\n clinical concern for ascending cholangitis,there are no imaging studies\n sensitive for this.\n (Over)\n\n 12:16 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please eval liver/gb\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2169-11-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1102475,"text":" 1:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess cardiopulm status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n Please assess cardiopulm status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with respiratory distress.\n\n COMPARISON: Earlier same evening radiographs of at 07:38 p.m. and\n 11:19 p.m., as well as prior chest radiograph of and PET CT of .\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: The study is degraded by respiratory\n motion. Allowing for this, exam is unchanged from two hours prior, with no\n interval development of pneumothorax, pleural effusion, pulmonary edema or\n consolidation.\n\n\n"},{"category":"Radiology","chartdate":"2169-11-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1102984,"text":" 3:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube placement, thanks\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory distress s/p OG tube placement\n REASON FOR THIS EXAMINATION:\n OG tube placement, thanks\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: OG tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, an OG tube has been placed.\n The tip of the tube projects over the distal parts of the stomach, the course\n of the tube is unremarkable. There is no evidence of complications, notably\n no pneumothorax. The other monitoring and support devices are in unchanged\n position. Overall unchanged appearance of the heart and lungs.\n\n\n"},{"category":"Radiology","chartdate":"2169-11-22 00:00:00.000","description":"ERCP BILIARY&PANCREAS BY GI UNIT","row_id":1102642,"text":" 11:03 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: please evaluate ERCP films from \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with CBD stone, cholangitis. Post double pigtail stent\n placement.\n REASON FOR THIS EXAMINATION:\n please evaluate ERCP films from \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Common bile duct stone and cholangitis.\n\n COMPARISON: MR from .\n\n FINDINGS: 16 spot fluoroscopic images of the right upper quadrant from an\n ERCP obtained without a radiologist present. Images reveal scattered clips in\n the right upper quadrant. Thereafter, note is made of cannulation of the\n common bile ducts with consequent opacification of both the pancreatic and\n common bile ducts. Both ducts are dilated with pronounced dilation of the\n common bile duct as well as the intrahepatic biliary ducts. Final image\n reveals placement of a plastic stent traversing the common bile duct.\n\n IMPRESSION: Dilation of both the pancreatic and common bile ducts, similar to\n that depicted on comparison cross-sectional images. Further details are found\n on ERCP report dated .\n\n"},{"category":"Radiology","chartdate":"2169-11-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1102476,"text":" 1:40 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: tube placement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with recent ett for flash edema\n REASON FOR THIS EXAMINATION:\n tube placement?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with recent intubation for flash edema.\n\n COMPARISON: Chest radiographs performed earlier on the same evening on\n at 07:38 p.m. and 11:19 p.m., as well as on at 01:12 a.m.\n\n PORTABLE SUPINE CHEST RADIOGRAPH: The patient is newly intubated, with the ET\n tube tip terminating 3.2 cm above the carina. The right internal jugular\n central venous catheter tip remains in the mid-to-lower SVC. Allowing for\n rotation of the patient, cardiomediastinal contours are unchanged. No supine\n evidence for large pneumothorax is seen. However, there is now increased\n dense consolidation in the left lateral cardiophrenic angle.\n\n IMPRESSIONS:\n 1. No flash pulmonary edema seen.\n 2. Newly apparent dense consolidation in left lateral costophrenic angle,\n concerning for pulmonary embolism with infarction in this patient with\n respiratory distress. This was discussed with Dr. from the\n Medicine service over the phone at 8 am.\n\n\n"},{"category":"Radiology","chartdate":"2169-11-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1103260,"text":" 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate a change in lung fields.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with acute resp failure on vent, cholangitis, please evaluate\n a change in lung fields.\n REASON FOR THIS EXAMINATION:\n please evaluate a change in lung fields.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for lung fields, cholangitis.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate cardiomegaly with suspicion for left-sided pleural effusion\n on subsequent retrocardiac atelectasis. The monitoring and support devices\n are in unchanged position. The presence of minimal right-sided pleural\n effusion cannot be excluded. Slightly hyperlucent lung structure, consistent\n with the presence of pulmonary emphysema. No focal parenchymal opacities\n suggesting pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2169-11-28 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1103566,"text":", F. MED 2:44 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 41cm left picc. tip?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new picc.\n REASON FOR THIS EXAMINATION:\n 41cm left picc. tip?\n ______________________________________________________________________________\n PFI REPORT\n Left PICC ends in upper superior vena cava.\n\n\n"},{"category":"Radiology","chartdate":"2169-11-28 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1103565,"text":" 2:44 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 41cm left picc. tip?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new picc.\n REASON FOR THIS EXAMINATION:\n 41cm left picc. tip?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 4:46 PM\n Left PICC ends in upper superior vena cava.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 85-year-old woman with new PICC.\n\n COMPARISON: Multiple prior studies, most recent dated .\n\n FINDINGS: Left PICC ends in the upper superior vena cava. The patient\n remains intubated, with the endotracheal tube terminating 3.2 cm above the\n carina. The right internal jugular line ends in the mid superior vena cava.\n Left pleural effusion with atelectasis have not changed. Pulmonary arteries\n are markedly enlarged, consistent with pulmonary arterial hypertension. The\n right lung is clear. There is no pulmonary edema.\n\n\n"},{"category":"Radiology","chartdate":"2169-11-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1102785,"text":", S. MED 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with sepsis requiring intubation from a biliary source\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Gradual increase in left now moderate pleural effusion with adjacent\n opacity, likely due to compression atelectasis.\n\n"},{"category":"Radiology","chartdate":"2169-11-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1103113,"text":" 1:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for change in volume status\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory failure and septic shock\n REASON FOR THIS EXAMINATION:\n Eval for change in volume status\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure and septic shock.\n\n Comparison is made with prior study performed a day earlier.\n\n Small right, moderate left pleural effusions associated with adjacent\n atelectasis are unchanged. The upper lobes are clear. Lines and tubes are in\n unchanged standard position. Cardiomediastinal contours are unchanged.\n\n\n"}],"string":"[\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 702478,\n \"text\": \"Subjective\\n Patient with n/v and poor appetite prior to admissoin, now intubated\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 163 cm\\n 79 kg\\n 83.8 kg ( 04:00 AM)\\n 31.6\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 54.4 kg\\n 144%\\n 61 kg\\n kg\\n %\\n Diagnosis: sepsis\\n PMHx: kidney cancer s/p cyberknife, choledocholelithiasis s/p ERCP\\n (), dementia, B12 deficiency, HTN, ostoeporosis, CKD, grave's\\n disease, follicular lymphoma of intestine (in remission), chronic\\n diarrhea\\n Food allergies and intolerances: none noted\\n Pertinent medications: 30KPhos, amiodarone, versed, phenylephrine,\\n others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 91 mg/dL\\n 04:18 AM\\n Glucose Finger Stick\\n 116\\n 12:00 PM\\n BUN\\n 32 mg/dL\\n 04:18 AM\\n Creatinine\\n 1.6 mg/dL\\n 04:18 AM\\n Sodium\\n 140 mEq/L\\n 04:18 AM\\n Potassium\\n 3.4 mEq/L\\n 04:18 AM\\n Chloride\\n 108 mEq/L\\n 04:18 AM\\n TCO2\\n 26 mEq/L\\n 04:18 AM\\n Calcium non-ionized\\n 7.7 mg/dL\\n 04:18 AM\\n Phosphorus\\n 1.7 mg/dL\\n 04:18 AM\\n Magnesium\\n 2.4 mg/dL\\n 04:18 AM\\n Current diet order / nutrition support: NPO\\n GI: Abdomen soft with hypoactive bowel sounds\\n Assessment of Nutritional Status\\n At risk for malnutrition\\n Patient at risk due to: NPO / hypocaloric diet\\n Estimated Nutritional Needs\\n Calories: 1200-1500 (BEE x or / 20-25 cal/kg)\\n Protein: 60-80 (1-1.3 g/kg)\\n Fluid: per team\\n Calculations based on: Adjusted weight\\n Specifics:\\n 85 year old female with history of choledocholithiasis, renal CA, and\\n dementia who presents with dyspnea and vomiting complicated by acute\\n respiratory failure and septic shock likely secondary to biliary\\n source. She is now s/p ERCP and stent. Patient unable to be extubated\\n so consult received for tube feeding recommendations. Suggest goal of\\n Fibersource HN at 50ml/hr x 24 hours to provide 1440kcal and 64g\\n protein.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Start Fibersource HN at 20ml/hr, advance by 20ml q6H to goal\\n rate of 50ml/hr x 24 hours\\n Monitor residuals q4H and hold tube feeding if greater than\\n 200ml\\n Will follow for possible extubation tomorrow\\n 10:50 AM\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1260493,\n \"text\": \" 6:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: NG tube placement\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman intubated w effusion\\n REASON FOR THIS EXAMINATION:\\n NG tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n COMPARISON: Radiograph of earlier the same date.\\n\\n INDICATION: Nasogastric tube assessment.\\n\\n FINDINGS: Nasogastric tube courses below the diaphragm, with tip not included\\n on the radiograph. Endotracheal tube tip terminates 2.5 cm above carina with\\n neck in a flexed position. Persistent cardiomegaly. Probable unchanged left\\n effusion and adjacent basilar atelectasis allowing for slight differences in\\n patient positioning. Small right effusion unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 701892,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n 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: /\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Received on vent support; overbreathing. Switch to PSV.\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: RSBI done ~79.\\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\\n Underlying illness not resolved\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 701890,\n \"text\": \"Chief Complaint: Dyspnea and vomiting\\n HPI:\\n This is an 85yo F with a h/o choledocholithiasis, HTN, renal CA, and\\n dementia who presented to today with dyspnea and vomiting. History\\n is mainly taken from that visit note. The patient had onset of n/v\\n yesterday after eating fried shrimp the prior day. She took \\\"nausea\\n relief\\\" from CVS with improvement, although had anorexia. In addition,\\n the patient has had dyspnea with minimal exertion associated with\\n nonproductive cough and chronic orthopnea. She has also experienced\\n weakness and 2 mild falls (no trauma or LOC). She has had diarrhea four\\n to five times a day, although may have chronic diarrhea. Per family\\n report, patient also had chest pain, although patient could not\\n confirm. She had a fever of 100.9 at home that improved to 97.6. She\\n was sent to the ED for eval.\\n .\\n In the ED, labs showed tbili 9.9 with transaminitis, anion gap\\n acidosis, lactate 4.5, bandemia 18% of 4.8 and creat 2.6 from 1.3\\n baseline. CXR was clear. Due to report of COPD history, she initially\\n received combivent and methylprednisolone, as well as ASA and\\n ceftriaxone. Once labs revealed a septic picture, she received vanc and\\n pip-tazo. SBP was upper 80s to low 90s and a RIJ was placed and the\\n patient received 3L IVF. While undergoing RUQ U/S, she became acutely\\n dyspneic with new opacities on CXR. She was tiring on , was\\n intubated and sedated. The U/S showed CBD 25mm and sludge/sludge ball\\n and GI plans to take for ERCP in the am. Prior to transfer, vitals\\n were: 101.3 119 118/103 25 99%. However, after signout, she was started\\n on norepinephrine.\\n .\\n On the floor, the patient is intubated and sedated. She is unable to\\n answer questions.\\n Patient admitted from: ER\\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 Norepinephrine - 0.2 mcg/Kg/min\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 50 mcg/hour\\n Other ICU medications:\\n Home medications:\\n ALENDRONATE [FOSAMAX] - 70 mg weekly\\n AMLODIPINE [NORVASC] - 10 mg once a day\\n CHLORTHALIDONE - 25 mg QAM\\n CITALOPRAM - 20 mg at bedtime\\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit monthly\\n LISINOPRIL - 40 mg once a day\\n MEMANTINE [NAMENDA] - 10 mg twice daily\\n METOPROLOL SUCCINATE [TOPROL XL] - 100 mg once a day\\n POTASSIUM CHLORIDE - 20 mEq twice a day\\n ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg once a day\\n CYANOCOBALAMIN - 1,000 mcg once a day\\n MULTIVITAMINS WITH MINERALS - 1 capsule once a day\\n Past medical history:\\n Family history:\\n Social History:\\n Primary kidney CA s/p cyberknife\\n Choledocholithiasis s/p ERCP with sphincterotomy in \\n Dementia\\n B12 deficiency\\n Hypertension\\n Osteoporosis\\n CKD\\n disease, s/p RAI\\n Follicular lymphoma of the small intestine, in remission\\n ?Chronic diarrhea\\n unable to obtain.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Married, lives with husband in . Remote tobacco history\\n (one-half pack per day for 20 years), no EtOH.\\n Review of systems:\\n Flowsheet Data as of 05:26 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 38.2\\nC (100.8\\n HR: 86 (85 - 97) bpm\\n BP: 91/51(61) {86/49(58) - 91/51(149)} mmHg\\n RR: 19 (19 - 26) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 64 mL\\n PO:\\n TF:\\n IVF:\\n 64 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -86 mL\\n Respiratory\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 470 (470 - 470) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 24\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 15 cmH2O\\n SpO2: 99%\\n ABG: 7.31/37/133//-6\\n Ve: 9 L/min\\n PaO2 / FiO2: 332\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Labs / Radiology\\n 140\\n 130\\n 2.6\\n 30\\n 16\\n 106\\n 4.0\\n 140\\n 37.3\\n 4.8\\n [image002.jpg]\\n N 71, Band 18\\n \\n 2:33 A10/14/ 02:51 AM\\n \\n 10:20 P10/14/ 04:57 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 TC02\\n 18\\n 20\\n Other labs: Lactic Acid:2.4 mmol/L\\n Imaging:\\n CXR: Study is slightly limited due to patient motion. No gross evidence\\n of pneumonia or congestive heart failure.\\n .\\n CXR (repeat, my read): Mildly increased diffuse fluffy bilateral\\n opacities compared to prior film.\\n .\\n RUQ U/S (prelim): Difficult to compare across modalities. perhaps\\n slight increase in size of common duct at liver margin, previously\\n ~21mm, currently ~25 mm, in pt with chronic dilatation of intra- and\\n extra-hepatic bile ducts. echogenic material seen in distal CBD,\\n probably sludge/sludge ball. more focal stone-appearing filling defect\\n seen on recent MR (measuring 2.5 cm in longest dimension) not seen.\\n also distalmost CBD / panc head not well visualized. clinical\\n correlation necessary, and if indicated, ERCP or MRCP could be\\n performed for further assessment. no fluid in RUQ. no Rt hydro.\\n ECG: sinus rhythm, no ischemic changes\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock.\\n .\\n # Dyspnea/respiratory failure: Has been having recently worsening\\n dyspnea on exertion, stable orthopnea. Became acutely SOB requiring\\n intubation in the ED. Repeat CXR shows increased bilateral opacities\\n suggesting pulmonary edema. Heart failure is possible with her BNP\\n elevation and history of orthopnea, although she has no known heart\\n failure. Influenza another possibility given concurrent fever and dry\\n cough. Pneumonia less likely as initial CXR was clear and there was no\\n sputum. Has smoking history, but no wheezing or CO2 retention to\\n suggest COPD. Would also consider ischemia given report of chest pain,\\n although EKG reportedly negative and cardiac markers negative x1. ABG\\n shows good oxygenation and patient has been switched to PSV 10/5 with\\n FiO2 40%.\\n - Cont PSV for now and wean as tolerated\\n - R/o influenza\\n - TTE in am to eval for heart failure\\n - Repeat CXR in am\\n - Cycle cardiac markers\\n .\\n # Septic shock: Suggested by bandemia, elevated lactate, fever,\\n tachycardia, and pressor requirement. Most likely biliary source given\\n CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. UA unremarkable and CXR does not suggest PNA.\\n Blood cx obtained in ED. BP currently stable on norepinephrine.\\n - Cont broad spectrum abx with vancomycin and pip-tazo\\n - ERCP in am for biliary drainage\\n - Trend CBC/diff, lactate, LFTs\\n - Follow up blood cx and add on urine cx\\n - Cont IVF to keep CVP 8-12 mmHg and good UOP\\n - Wean pressors as tolerated by MAP >= 65 mmHg\\n - Check ScvO2\\n .\\n # ARF: Likely related to sepsis, as well as hypovolemia from vomiting\\n and diarrhea. Baseline creatinine 1.2-1.4. Expect improvement s/p\\n fluids.\\n - IVF\\n - Urine lytes\\n - Avoid nephrotoxins\\n - Trend renal function\\n .\\n # Anion gap acidosis: Most likely related to elevated lactate, now\\n improving with IVF. No history of ingestion and no clear offenders on\\n med list. Glucose not c/w DKA, BUN not c/w uremia.\\n - Cont IVF\\n - Repeat lactate, lytes in am\\n ICU Care\\n Nutrition: NPO\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: not indicated\\n VAP: HOB elevation, Mouth care\\n Comments:\\n Communication: Husband/HCP (), hter \\n ()\\n Code status: Full code (confirm with family in am)\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702013,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n MULTI LUMEN - START 03:45 AM\\n Vent settings were changed to Pressure support and tolerating well\\n ECHO this AM\\n ERCP today\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Infusions:\\n Norepinephrine - 0.2 mcg/Kg/min\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 50 mcg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 38.2\\nC (100.8\\n HR: 79 (79 - 97) bpm\\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\\n RR: 19 (19 - 26) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 6 (6 - 7)mmHg\\n Total In:\\n 369 mL\\n PO:\\n TF:\\n IVF:\\n 369 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 219 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 451 (451 - 470) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 79\\n PIP: 17 cmH2O\\n SpO2: 100%\\n ABG: 7.31/37/133//-6\\n Ve: 9.3 L/min\\n PaO2 / FiO2: 332\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n [image002.jpg]\\n 02:51 AM\\n 04:57 AM\\n TCO2\\n 18\\n 20\\n Other labs: Lactic Acid:2.4 mmol/L\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock.\\n .\\n # Dyspnea/respiratory failure:\\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\\n trying to compensate by respiratory means\\n Has been having recently worsening dyspnea on exertion, stable\\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\\n CXR shows increased bilateral opacities suggesting pulmonary edema.\\n Heart failure is possible with her BNP elevation and history of\\n orthopnea, although she has no known heart failure. Influenza another\\n possibility, though less likely, given concurrent fever and dry cough.\\n CXR was not concerning for pneumonia or fluid overload. Consider also\\n ischemia given report of chest pain, although EKG reportedly negative\\n and cardiac markers negative x2, so not likely ACS. ABG shows good\\n oxygenation and patient has been switched to PSV 10/5 with FiO2 40%.\\n PE less likely\\n - Cont PSV for now and wean as tolerated\\n - R/o influenza\\n - f/u w TTE from this morning\\n .\\n # Septic shock:\\n Bandemia and lactate improving, still febrile and requiring pressors.\\n Sepsis likely secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\\n other source of infection found.\\n - Cont broad spectrum abx with vancomycin and pip-tazo\\n - ERCP today for biliary drainage\\n - Trend CBC/diff, lactate, LFTs\\n - Follow up blood cx , urine cx\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n - Check ScvO2\\n .\\n # Anion gap acidosis:\\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\\n IVF.\\n - Cont IVF per sepsis protocol\\n - trend lactate\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\\n - IVFs for CVP 10-12\\n - f/u Urine lytes\\n - Avoid nephrotoxins\\n - Trend renal function\\n .\\n #Thrombocytopenia\\n Likely secondary to sepsis.\\n - send DIC labs\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Prophylaxis:\\n DVT: pneumoboots, subq heparin\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband\\n status: Full (Presumed)\\n need to confirm w husband\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING PROGRESS NOTE\\n I saw and examined the patient and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n resident note, including the assessment and plan. I would emphasize and\\n add the following points: 85F a w/ renal ca, dementia,\\n choledocolithiasis presents with n/v X 2 days, diarrhea, dyspnea, Fever\\n 100.9. In ED CXR clear initially but intubated for ? evolving\\n infiltrates and resp distress. RIJ CVL placed for hypotension with IVF\\n given, levophed then started. Received vanco/zosyn Labs concerning for\\n biliary sepsis with t bili 9.9, transaminitis, AGMA, lactate 4.5, 18%\\n bandemia and cr 2.6. RUQ with dil cbd, sludge with ERCP consulted and\\n plan for ERCP in am today.\\n PE: BP: 90/50 HR90 RR 19 T: 100.8 98% ACV--> PS 12/5 40% Intubated,\\n sedated, jaundiced, perrla, CTA, RR, soft + BS, non T at ruq, no edema\\n LABS: wbc 25 (4.8), 19-->0 bands, hct 31.6, plt 93 (140), na 137, cr\\n 2.4 (2.6), lactate 2.4 (4.5), t bili 6.4 (9.9), ast/alt decreasing, inr\\n 1.3, 7.31/37/133, trop 0.02, BNP 5600, u/a neg\\n ECG with NSR TWI 3, v1. no ST changes\\n Imaging reviewed: cxr appears rotated, pulm vascular fullness, no focal\\n infiltrate though would watch r mid zone for possible evolving asp pna\\n A/P: Sepsis appears from biliary source/cholangitis, c/b arf and resp\\n failure. Resp failure does not appear primary lung process, as CXR\\n is rather unimpressive, but suspect in setting of met acidosis she\\n fatigued. There is a component of mild demand ischemia by trop without\\n frank ecg changes. Agree with plan to manage biliary sepsis with broad\\n antibx (vanco, zosyn for now f/u cx data), plan for ercp today to\\n relieve obstruction. She does not appear fully tanked from volume\\n standpoint. Will continue aggressive IVF (LR given NG as well as AGMA)\\n for cvp > 10, weaning pressor off, following u/o, trending lactate,\\n lfts, a/l. Will continue current vent support as she is oxygenating\\n well and appears comfortable on PS. Follow abgs closely for signs of\\n fatigue noting her continued met acidosis. Evidence of mild demand\\n ischemia in setting of septic picture--trop are flat and without\\n progressive ecg changes. Volume may be an issue in setting of\\n extubation. TTE will be helpful. . Her ARF likely vol repletion\\n from sepsis, n/v and diarrhea. Aggressive fluids as above, send urine\\n lytes. Thrombocytopenia likely in part dilutional and related to\\n sepsis, also concerning for DIC. Send dic panel. Low suspicion for\\n HIT. ICU prophy. Consider a-line placement if unable to wean off\\n pressor. Remainder of plan as outlined in resident note. Need to\\n confirm code status w/ family.\\n Patient is critically ill\\n Total time: 55 min.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 02:11 PM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703511,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. Pt is s/p\\n ERCP w/ stent on \\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt intubated on . resp failure initially thought to be due to her\\n primary metabolic acidosis which caused her to hyperventilate to\\n compensate and fatigued beoming acutely sob and requiring intubation in\\n the ed.pt initially unable to wean vent secondary to fluid\\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\\n 20\\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\\n Action:\\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\\n liter. Pt successfully extubated on . ngt in place for tube fdgs\\n infusing presently at 30cc\\ns/hr until speech and swallow study is\\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\\n status and fluid balance followed closely. Physical therapy consulted\\n to increase pt\\ns level of activity and for resp toileting. Speech and\\n swallow study completed at bedside\\n Response:\\n Reps status improved with aggressive diuresis. Pt passed speech and\\n swallow study so diet advanced to reg low sodium diet\\n Plan:\\n Continue to monitor pt\\ns resp status and increase pt\\ns level of\\n activity. Continue to follow fluid balance closely. Continue with resp\\n toileting. Pt will benefit from incentive spirometry. Physical therapy\\n to evaluate pt. maintain pt on aspiration precautions.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\\ns . k+\\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\\n Action:\\n Pt receiving lopressor as ordered . Electrolytres repleted as per\\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\\n Response:\\n Hr effectively controlled on with po diltiazem and lopressor.\\n Plan:\\n Continue lopressor as ordered. Continue to check electrolytes as\\n ordered and replete as needed. Follow hemodynamics closely. If pt\\n remains tachycardic in afib will increase dose of lopressor.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 702001,\n \"text\": \"Clinician: Resident\\n An Arterial line was placed in the left radial arterial under sterile\\n technique without complication at 930 am. 25 mcg of fentanyl was given\\n for increased sedation during the procedure.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 701982,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n MULTI LUMEN - START 03:45 AM\\n Vent settings were changed to Pressure support and tolerating well\\n ECHO this AM\\n ERCP today\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Infusions:\\n Norepinephrine - 0.2 mcg/Kg/min\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 50 mcg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 38.2\\nC (100.8\\n HR: 79 (79 - 97) bpm\\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\\n RR: 19 (19 - 26) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 6 (6 - 7)mmHg\\n Total In:\\n 369 mL\\n PO:\\n TF:\\n IVF:\\n 369 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 219 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 451 (451 - 470) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 79\\n PIP: 17 cmH2O\\n SpO2: 100%\\n ABG: 7.31/37/133//-6\\n Ve: 9.3 L/min\\n PaO2 / FiO2: 332\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n [image002.jpg]\\n 02:51 AM\\n 04:57 AM\\n TCO2\\n 18\\n 20\\n Other labs: Lactic Acid:2.4 mmol/L\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock.\\n .\\n # Dyspnea/respiratory failure:\\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\\n trying to compensate by respiratory means\\n Has been having recently worsening dyspnea on exertion, stable\\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\\n CXR shows increased bilateral opacities suggesting pulmonary edema.\\n Heart failure is possible with her BNP elevation and history of\\n orthopnea, although she has no known heart failure. Influenza another\\n possibility, though less likely, given concurrent fever and dry cough.\\n CXR was not concerning for pneumonia or fluid overload. Consider also\\n ischemia given report of chest pain, although EKG reportedly negative\\n and cardiac markers negative x2, so not likely ACS. ABG shows good\\n oxygenation and patient has been switched to PSV 10/5 with FiO2 40%.\\n PE less likely\\n - Cont PSV for now and wean as tolerated\\n - R/o influenza\\n - f/u w TTE from this morning\\n .\\n # Septic shock:\\n Bandemia and lactate improving, still febrile and requiring pressors.\\n Sepsis likely secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\\n other source of infection found.\\n - Cont broad spectrum abx with vancomycin and pip-tazo\\n - ERCP today for biliary drainage\\n - Trend CBC/diff, lactate, LFTs\\n - Follow up blood cx , urine cx\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n - Check ScvO2\\n .\\n # Anion gap acidosis:\\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\\n IVF.\\n - Cont IVF per sepsis protocol\\n - trend lactate\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\\n - IVFs for CVP 10-12\\n - f/u Urine lytes\\n - Avoid nephrotoxins\\n - Trend renal function\\n .\\n #Thrombocytopenia\\n Likely secondary to sepsis.\\n - send DIC labs\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Prophylaxis:\\n DVT: pneumoboots, subq heparin\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband\\n status: Full (Presumed)\\n need to confirm w husband\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703365,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent. Respiratory failure initially thought to be due to\\n metabolic acidosis which caused her to hyperventilate to compensate.\\n She fatigued quickly becoming acutely SOB and required intubation on\\n ^th. Since then, unable to wean vent because of pt being\\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\\n coming off peep becoming very tachypneic with low tidal volumes which\\n is more concerning for difficulty with compliance then volume overload.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on humidified fact ten s/p extubation @ 40% FiO2. Pt\\n tachypneic @ times 30-40\\ns but appearing comfortable & settles out on\\n own. O2 sat 97-100%. LS clear, diminished @ bases. MN fluid goal\\n 1.5\\n 2L. Mental status much improved. Pt following commands and actively\\n participating in care. Pt requesting food throughout the night.\\n Action:\\n Pt titrated down to 2LNC. Cough improving O/N. Pt able to produce small\\n amts of sputum and allow for suctioning. Q4hr mouthcare. (Dentures @\\n bedside) Tubefeeds initiated @ 10cc hr (please see previous order)\\n Response:\\n Pt -1L @ MN. Improving\\n Plan:\\n Plan to diurese as pt\\ns hemodynamics tolerate. Net goal - 1.5\\n 2L @\\n this time. Cont to trend lab values and f/u on micro data. As discussed\\n w/ daughter (HCP) pt will be reintubated in necessary (but remains DNR)\\n DNR (will reintubate if necessary)\\n L DL PICC\\n Family in to see pt and updated by this RN last evening\\n Pt did have 2 smears of stool overnight. Please monitor\\n closely. Skin breakdown is of concern, amt of stool was not significant\\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\\n not benefit from fecal inc. bag)\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703414,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n INVASIVE VENTILATION - STOP 12:22 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:42 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:57 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: 36.1\\nC (97\\n HR: 108 (87 - 111) bpm\\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\\n RR: 29 (25 - 36) insp/min\\n SpO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 892 mL\\n 666 mL\\n PO:\\n TF:\\n 10 mL\\n 99 mL\\n IVF:\\n 642 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 1,965 mL\\n 260 mL\\n Urine:\\n 1,965 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,073 mL\\n 406 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 310 (236 - 310) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 9 cmH2O\\n SpO2: 93%\\n ABG: 7.46/44/124/30/7\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 354\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Labs / Radiology\\n 206 K/uL\\n 8.9 g/dL\\n 78 mg/dL\\n 1.4 mg/dL\\n 30 mEq/L\\n 3.6 mEq/L\\n 26 mg/dL\\n 99 mEq/L\\n 139 mEq/L\\n 26.6 %\\n 7.3 K/uL\\n [image002.jpg]\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n 07:32 AM\\n 04:02 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n 7.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n 26.6\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n 206\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n 1.4\\n TCO2\\n 32\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n 78\\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\\n PO4:3.2 mg/dL\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\\n improved in terms of pulmonary vascular congestion, will trial\\n extubation today since patient looks the best she has since admission\\n - patient may need Bipap post extubation\\n - Hold sedation for now to optimize mental status prior to extubation\\n - NGT in place for meds/diet post extubation\\n .\\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\\n rate control, rate has been in the 90\\ns with both medications\\n # Septic shock: resolved from initial cholangitis source, patient off\\n pressors, likely secondary to cholangitis and infected stone/sludge.\\n ERCP showed significant pusand very large stone, she is s/p stent\\n placement. Patient afebrile and white count stable. Lactate normal.\\n Initial sepsis secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. PICC placed, will complete a 14 day course of zosyn as the\\n mircolab is currently unable to provide further speciation and she has\\n been improving on zosyn\\n - repeat ERCP in 1 month\\n .\\n # ARF: Improved, back to her baseline.\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition:\\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: family\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition: transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703415,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. Pt is s/p\\n ERCP w/ stent.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on humidified fact tent s/p extubation @ 40% FiO2. Pt less\\n tachypneic this evening 20\\ns. O2 sat 97-100%. LS clear,\\n diminished @ bases. MN fluid goal\\n 1.5\\n 2L. Mental status much\\n improved. Pt following commands and actively participating in care. Pt\\n requesting food throughout the night.\\n Action:\\n Pt titrated down to 2LNC. Cough improving O/N. Pt able to produce small\\n amts of sputum and allow for suctioning @ beginning of shift. Q4hr\\n mouthcare. (Dentures @ bedside) Tubefeeds initiated @ 10cc hr (please\\n see previous order) Atrovent nebs Q6hrs.\\n Response:\\n Pt -1L @ MN. TF currently running @ 30cc/hr (goal 50cc/hr) Dry, NPC\\n this AM.\\n Plan:\\n Cont to diurese w/ Lasix IVP if warranted. Net goal - 1.5\\n 2L @ this\\n time. Cont to trend lab values and f/u on micro data. As discussed w/\\n daughter (HCP) pt will be reintubated if necessary (but remains DNR)\\n Atrial fibrillation (Afib)\\n Assessment:\\n Received pt in Afib; HR ranging from 90-100\\ns. SBP 85-120\\ns. Minimal\\n ectopy noted. AM K 3.6, Mg 1.9\\n Action:\\n Pt currently on Lopressor 25mg NG TID & Diltiazem 30mg NG Q6hr. MN Dilt\\n was held to low BP. Tolerated Lopressor (HR 90\\ns) Magnesium 2gm IV\\n & KCL 20mEq IV given this AM per sliding scale orders.\\n Response:\\n Pt has remained in Afib but rate has significantly improved w/\\n administration of Lopressor & Dilt. HR ranging 80\\n low 100\\ns w/\\n minimal ectopy.\\n Plan:\\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\\n Diltiazem as warranted. Follow electrolyte status & replete as needed.\\n DNR (will reintubate if necessary)\\n L DL PICC\\n Family in to see pt and updated by this RN last evening\\n Pt did have 2 smears of stool overnight. Please monitor\\n closely. Skin breakdown is of concern, amt of stool was not significant\\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\\n not benefit from fecal inc. bag)\\n Will most likely be c/o to medical floor this AM\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703417,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. status post extubation, doing great, weaned down to 2LNC\\n - will c/s speech and swallow prior to advancing diet as patient is\\n having some difficulty controlling her oral secretions\\n - still on dilt/lopressor, dilt seems to have better HR effects\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:42 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 05:57 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: 36.1\\nC (97\\n HR: 108 (87 - 111) bpm\\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\\n RR: 29 (25 - 36) insp/min\\n SpO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 892 mL\\n 666 mL\\n PO:\\n TF:\\n 10 mL\\n 99 mL\\n IVF:\\n 642 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 1,965 mL\\n 260 mL\\n Urine:\\n 1,965 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,073 mL\\n 406 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 310 (236 - 310) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 9 cmH2O\\n SpO2: 93%\\n ABG: 7.46/44/124/30/7\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 354\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Labs / Radiology\\n 206 K/uL\\n 8.9 g/dL\\n 78 mg/dL\\n 1.4 mg/dL\\n 30 mEq/L\\n 3.6 mEq/L\\n 26 mg/dL\\n 99 mEq/L\\n 139 mEq/L\\n 26.6 %\\n 7.3 K/uL\\n [image002.jpg]\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n 07:32 AM\\n 04:02 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n 7.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n 26.6\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n 206\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n 1.4\\n TCO2\\n 32\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n 78\\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\\n PO4:3.2 mg/dL\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\\n improved in terms of pulmonary vascular congestion, will trial\\n extubation today since patient looks the best she has since admission\\n - patient may need Bipap post extubation\\n - Hold sedation for now to optimize mental status prior to extubation\\n - NGT in place for meds/diet post extubation\\n .\\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\\n rate control, rate has been in the 90\\ns with both medications\\n # Septic shock: resolved from initial cholangitis source, patient off\\n pressors, likely secondary to cholangitis and infected stone/sludge.\\n ERCP showed significant pusand very large stone, she is s/p stent\\n placement. Patient afebrile and white count stable. Lactate normal.\\n Initial sepsis secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. PICC placed, will complete a 14 day course of zosyn as the\\n mircolab is currently unable to provide further speciation and she has\\n been improving on zosyn\\n - repeat ERCP in 1 month\\n .\\n # ARF: Improved, back to her baseline.\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition:\\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: family\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition: transfer to floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 703486,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. Pt is s/p\\n ERCP w/ stent on \\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt intubated on . resp failure initially thought to be due to her\\n primary metabolic acidosis which caused her to hyperventilate to\\n compensate and fatigued beoming acutely sob and requiring intubation in\\n the ed.pt initially unable to wean vent secondary to fluid\\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\\n 20\\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\\n Action:\\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\\n liter. Pt successfully extubated on . ngt in place for tube fdgs\\n infusing presently at 30cc\\ns/hr until speech and swallow study is\\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\\n status and fluid balance followed closely. Physical therapy consulted\\n to increase pt\\ns level of activity and for resp toileting. Speech and\\n swallow study completed at bedside\\n Response:\\n Reps status improved with aggressive diuresis. Pt passed speech and\\n swallow study so diet advanced to reg low sodium diet\\n Plan:\\n Continue to monitor pt\\ns resp status and increase pt\\ns level of\\n activity. Continue to follow fluid balance closely. Continue with resp\\n toileting. Pt will benefit from incentive spirometry. Physical therapy\\n to evaluate pt. maintain pt on aspiration precautions.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\\ns . k+\\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\\n Action:\\n Pt receiving lopressor as ordered . Electrolytres repleted as per\\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\\n Response:\\n Hr effectively controlled on with po diltiazem and lopressor.\\n Plan:\\n Continue lopressor as ordered. Continue to check electrolytes as\\n ordered and replete as needed. Follow hemodynamics closely. If pt\\n remains tachycardic in afib will increase dose of lopressor.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 703488,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. status post extubation, doing great, weaned down to 2LNC\\n - passed speech and swallow. Diet advanced to regular\\n - still on dilt/lopressor, dilt seems to have better HR effects\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:42 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\\n Does c/o hoarse voice\\n Flowsheet Data as of 05:57 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: 36.1\\nC (97\\n HR: 108 (87 - 111) bpm\\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\\n RR: 29 (25 - 36) insp/min\\n SpO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 892 mL\\n 666 mL\\n PO:\\n TF:\\n 10 mL\\n 99 mL\\n IVF:\\n 642 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 1,965 mL\\n 260 mL\\n Urine:\\n 1,965 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,073 mL\\n 406 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 310 (236 - 310) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 9 cmH2O\\n SpO2: 93%\\n ABG: 7.46/44/124/30/7\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 354\\n Physical Examination\\n General: awake, responsive, follows commands\\n HEENT: PERRL, MMM, NG tube in place\\n Neck: RIJ in place\\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Labs / Radiology\\n 206 K/uL\\n 8.9 g/dL\\n 78 mg/dL\\n 1.4 mg/dL\\n 30 mEq/L\\n 3.6 mEq/L\\n 26 mg/dL\\n 99 mEq/L\\n 139 mEq/L\\n 26.6 %\\n 7.3 K/uL\\n [image002.jpg]\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n 07:32 AM\\n 04:02 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n 7.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n 26.6\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n 206\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n 1.4\\n TCO2\\n 32\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n 78\\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\\n PO4:3.2 mg/dL\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload was seen on CXR. S/p\\n extubation.\\n - s/p extubation, satting well on 2L NC\\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\\n rate control, rate has been in the 110\\ns with both medications. Some\\n tachycardia likely related to intubation and agitation. Episodic BPs\\n low on both agents.\\n - d/c dilt and monitor BP/tachycardia\\n - will need ongoing titration/o/p follow up\\n # Septic shock: resolved from initial cholangitis source, patient off\\n pressors, likely secondary to cholangitis and infected stone/sludge.\\n ERCP showed significant pusand very large stone, she is s/p stent\\n placement. Patient afebrile and white count stable. Lactate normal.\\n Initial sepsis secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. PICC placed, will complete a 14 day course of zosyn as the\\n mircolab is currently unable to provide further speciation and she has\\n been improving on zosyn\\n - repeat ERCP in 1 month, scheduled \\n .\\n # ARF: Improved, back to her baseline.\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition:\\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: family\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition: transfer to floor\\n 12:28\\n ------ Protected Section ------\\n Agree with excellent medical student note with the following addition:\\n The patient was on long acting metoprolol at a dose of 100mg daily\\n prior to admission. She would benefit from continuing the beta-blocker\\n rather than the calcium channel blocker for coronary artery disease\\n history. She will likely need to be titrated up on the metoprolol to\\n at least her prior home dose but likely higher.\\n The patient is doing well on 2L NC this AM and is ready to be\\n transferred to the floor.\\n She passed her speech and swallow study. Her NG tube will be pulled\\n today, and her diet will be advanced.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 12:53 ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\\n respiratory failure, AF c RVR improved with BBL / CCB. Diuresis\\n ongoing, BNP 6K.\\n Exam notable for Tm 99.8 BP 116/62 HR 95-105AF RR 12-37 with sat 100 on\\n PSV 8/5, -2L / 24h. WD woman, alert, conversant. JVD flat. CTA B, \\n at bases c few rales. Irreg s1s2. Soft +BS. 2+ edema. Labs notable for\\n WBC 7K, HCT 26, K+ 3.6, Cr 1.4.\\n Agree with plan to respiratory failure with CPT / upright positioning,\\n PT eval, OOB, hold on lasix. OK to ADAT s/p S+S, d/c NGT. Cholangitis\\n improving, will need 14d abx via PICC (day ). Over the long term,\\n will need f/u ERCP for large nonobstructive stone - scheduled for\\n . For AF c RVR, continue BBL, d/c CCB today, start ASA 81mg. ARF\\n has resolved; baseline CRI. Remainder of plan as outlined above.\\n Total time: 35 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 01:59 PM ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703475,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. status post extubation, doing great, weaned down to 2LNC\\n - passed speech and swallow. Diet advanced to regular\\n - still on dilt/lopressor, dilt seems to have better HR effects\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:42 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\\n Does c/o hoarse voice\\n Flowsheet Data as of 05:57 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: 36.1\\nC (97\\n HR: 108 (87 - 111) bpm\\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\\n RR: 29 (25 - 36) insp/min\\n SpO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 892 mL\\n 666 mL\\n PO:\\n TF:\\n 10 mL\\n 99 mL\\n IVF:\\n 642 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 1,965 mL\\n 260 mL\\n Urine:\\n 1,965 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,073 mL\\n 406 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 310 (236 - 310) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 9 cmH2O\\n SpO2: 93%\\n ABG: 7.46/44/124/30/7\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 354\\n Physical Examination\\n General: awake, responsive, follows commands\\n HEENT: PERRL, MMM, NG tube in place\\n Neck: RIJ in place\\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Labs / Radiology\\n 206 K/uL\\n 8.9 g/dL\\n 78 mg/dL\\n 1.4 mg/dL\\n 30 mEq/L\\n 3.6 mEq/L\\n 26 mg/dL\\n 99 mEq/L\\n 139 mEq/L\\n 26.6 %\\n 7.3 K/uL\\n [image002.jpg]\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n 07:32 AM\\n 04:02 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n 7.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n 26.6\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n 206\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n 1.4\\n TCO2\\n 32\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n 78\\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\\n PO4:3.2 mg/dL\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload was seen on CXR. S/p\\n extubation.\\n - s/p extubation, satting well on 2L NC\\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\\n rate control, rate has been in the 110\\ns with both medications. Some\\n tachycardia likely related to intubation and agitation. Episodic BPs\\n low on both agents.\\n - d/c dilt and monitor BP/tachycardia\\n - will need ongoing titration/o/p follow up\\n # Septic shock: resolved from initial cholangitis source, patient off\\n pressors, likely secondary to cholangitis and infected stone/sludge.\\n ERCP showed significant pusand very large stone, she is s/p stent\\n placement. Patient afebrile and white count stable. Lactate normal.\\n Initial sepsis secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. PICC placed, will complete a 14 day course of zosyn as the\\n mircolab is currently unable to provide further speciation and she has\\n been improving on zosyn\\n - repeat ERCP in 1 month, scheduled \\n .\\n # ARF: Improved, back to her baseline.\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition:\\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: family\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition: transfer to floor\\n 12:28\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703478,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. status post extubation, doing great, weaned down to 2LNC\\n - passed speech and swallow. Diet advanced to regular\\n - still on dilt/lopressor, dilt seems to have better HR effects\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:42 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\\n Does c/o hoarse voice\\n Flowsheet Data as of 05:57 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: 36.1\\nC (97\\n HR: 108 (87 - 111) bpm\\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\\n RR: 29 (25 - 36) insp/min\\n SpO2: 93%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 892 mL\\n 666 mL\\n PO:\\n TF:\\n 10 mL\\n 99 mL\\n IVF:\\n 642 mL\\n 247 mL\\n Blood products:\\n Total out:\\n 1,965 mL\\n 260 mL\\n Urine:\\n 1,965 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,073 mL\\n 406 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 310 (236 - 310) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 33\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 9 cmH2O\\n SpO2: 93%\\n ABG: 7.46/44/124/30/7\\n Ve: 9.2 L/min\\n PaO2 / FiO2: 354\\n Physical Examination\\n General: awake, responsive, follows commands\\n HEENT: PERRL, MMM, NG tube in place\\n Neck: RIJ in place\\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Labs / Radiology\\n 206 K/uL\\n 8.9 g/dL\\n 78 mg/dL\\n 1.4 mg/dL\\n 30 mEq/L\\n 3.6 mEq/L\\n 26 mg/dL\\n 99 mEq/L\\n 139 mEq/L\\n 26.6 %\\n 7.3 K/uL\\n [image002.jpg]\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n 07:32 AM\\n 04:02 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n 7.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n 26.6\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n 206\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n 1.4\\n TCO2\\n 32\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n 78\\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\\n PO4:3.2 mg/dL\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload was seen on CXR. S/p\\n extubation.\\n - s/p extubation, satting well on 2L NC\\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\\n rate control, rate has been in the 110\\ns with both medications. Some\\n tachycardia likely related to intubation and agitation. Episodic BPs\\n low on both agents.\\n - d/c dilt and monitor BP/tachycardia\\n - will need ongoing titration/o/p follow up\\n # Septic shock: resolved from initial cholangitis source, patient off\\n pressors, likely secondary to cholangitis and infected stone/sludge.\\n ERCP showed significant pusand very large stone, she is s/p stent\\n placement. Patient afebrile and white count stable. Lactate normal.\\n Initial sepsis secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. PICC placed, will complete a 14 day course of zosyn as the\\n mircolab is currently unable to provide further speciation and she has\\n been improving on zosyn\\n - repeat ERCP in 1 month, scheduled \\n .\\n # ARF: Improved, back to her baseline.\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition:\\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: family\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition: transfer to floor\\n 12:28\\n ------ Protected Section ------\\n Agree with excellent medical student note with the following addition:\\n The patient was on long acting metoprolol at a dose of 100mg daily\\n prior to admission. She would benefit from continuing the beta-blocker\\n rather than the calcium channel blocker for coronary artery disease\\n history. She will likely need to be titrated up on the metoprolol to\\n at least her prior home dose but likely higher.\\n The patient is doing well on 2L NC this AM and is ready to be\\n transferred to the floor.\\n She passed her speech and swallow study. Her NG tube will be pulled\\n today, and her diet will be advanced.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 12:53 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 703536,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. Pt is s/p\\n ERCP w/ stent on \\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt intubated on . resp failure initially thought to be due to her\\n primary metabolic acidosis which caused her to hyperventilate to\\n compensate and fatigued beoming acutely sob and requiring intubation in\\n the ed.pt initially unable to wean vent secondary to fluid\\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\\n 20\\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\\n Action:\\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\\n liter. Pt successfully extubated on . ngt in place for tube fdgs\\n infusing presently at 30cc\\ns/hr until speech and swallow study is\\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\\n status and fluid balance followed closely. Physical therapy consulted\\n to increase pt\\ns level of activity and for resp toileting. Speech and\\n swallow study completed at bedside\\n Response:\\n Reps status improved with aggressive diuresis. Pt passed speech and\\n swallow study so diet advanced to reg low sodium diet\\n Plan:\\n Continue to monitor pt\\ns resp status and increase pt\\ns level of\\n activity. Continue to follow fluid balance closely. Continue with resp\\n toileting. Pt will benefit from incentive spirometry. Physical therapy\\n to evaluate pt. maintain pt on aspiration precautions.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\\ns . k+\\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\\n Action:\\n Pt receiving lopressor as ordered . Electrolytres repleted as per\\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\\n Response:\\n Hr effectively controlled on with po diltiazem and lopressor.\\n Plan:\\n Continue lopressor as ordered. Continue to check electrolytes as\\n ordered and replete as needed. Follow hemodynamics closely. If pt\\n remains tachycardic in afib will increase dose of lopressor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 703440,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. Pt is s/p\\n ERCP w/ stent on \\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt intubated on . resp failure initially thought to be due to her\\n primary metabolic acidosis which caused her to hyperventilate to\\n compensate and fatigued beoming acutely sob and requiring intubation in\\n the ed.pt initially unable to wean vent secondary to fluid\\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\\n 20\\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\\n Action:\\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\\n liter. Pt successfully extubated on . ngt in place for tube fdgs\\n infusing presently at 30cc\\ns/hr until speech and swallow study is\\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\\n status and fluid balance followed closely. Physical therapy consulted\\n to increase pt\\ns level of activity and for resp toileting.\\n Response:\\n Reps status improved with aggressive diuresis\\n Plan:\\n Continue to monitor pt\\ns resp status and increase pt\\ns level of\\n activity. Continue to follow fluid balance closely. Await final\\n recommendations of speech and swallow consult. Continue with resp\\n toileting. Pt will benefit from incentive spirometry.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\\ns . k+\\n 3.6 and mg=1.9\\n Action:\\n Pt receiving lopressor and diltiazem as ordered. Electrolytres repleted\\n as per sliding scale. Hemodynamics followed closely.\\n Response:\\n Hr effectively controlled on with po diltiazem and lopressor.\\n Plan:\\n Continue diltiazem and lopressor as ordered. Continue to check\\n electrolytes as ordered and replete as needed. Follow hemodynamics\\n closely.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 703461,\n \"text\": \"Subjective\\n happy to pass S & S eval\\n Objective\\n Pertinent medications: Piperacillin-Tazobactam, Vancomycin, Heparin,\\n others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 78 mg/dL\\n 04:02 AM\\n Glucose Finger Stick\\n 149\\n 06:00 PM\\n BUN\\n 26 mg/dL\\n 04:02 AM\\n Creatinine\\n 1.4 mg/dL\\n 04:02 AM\\n Sodium\\n 139 mEq/L\\n 04:02 AM\\n Potassium\\n 3.6 mEq/L\\n 04:02 AM\\n Chloride\\n 99 mEq/L\\n 04:02 AM\\n TCO2\\n 30 mEq/L\\n 04:02 AM\\n PO2 (arterial)\\n 124 mm Hg\\n 07:32 AM\\n PCO2 (arterial)\\n 44 mm Hg\\n 07:32 AM\\n pH (arterial)\\n 7.46 units\\n 07:32 AM\\n pH (urine)\\n 5.0 units\\n 09:47 AM\\n CO2 (Calc) arterial\\n 32 mEq/L\\n 07:32 AM\\n Calcium non-ionized\\n 8.3 mg/dL\\n 04:02 AM\\n Phosphorus\\n 3.2 mg/dL\\n 04:02 AM\\n Magnesium\\n 1.9 mg/dL\\n 04:02 AM\\n ALT\\n 45 IU/L\\n 04:54 AM\\n Alkaline Phosphate\\n 103 IU/L\\n 04:15 AM\\n AST\\n 23 IU/L\\n 04:54 AM\\n Amylase\\n 16 IU/L\\n 07:35 AM\\n Total Bilirubin\\n 1.5 mg/dL\\n 04:15 AM\\n WBC\\n 7.3 K/uL\\n 04:02 AM\\n Hgb\\n 8.9 g/dL\\n 04:02 AM\\n Hematocrit\\n 26.6 %\\n 04:02 AM\\n Current diet order / nutrition support: Regular; Cardiac/Heart healthy\\n GI: NBS, smear stool x 2 last night\\n SKIN: buttocks redden\\n Assessment of Nutritional Status\\n 85 year old female with h/o choledocholithiasis presented with dyspnea\\n and vomiting complicated by acute respiratory failure and septic\\n shock. Patient intubated and started on tube feed, tube feed off for\\n extubation, patient extubated yesterday, and passed S & S evaluation\\n this morning, per discussion with SLP, okay to diet advance, patient\\n still has her NGT in place and tube feed is currently at 30ml/hr\\n HN, MD just change POE diet to regular and tube feed order\\n discontinued.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Current diet is appropriate\\n Multivitamin / Mineral supplement: daily\\n Check chemistry 10 panel daily, replete prn\\n will monitor po as tol\\n if has question\\n\"\n },\n {\n \"category\": \"Rehab Services\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Bedside Swallow Evaluation\",\n \"row_id\": 703463,\n \"text\": \"TITLE:\\nBEDSIDE SWALLOWING EVALUATION:\\nHISTORY:\\nThank you for consulting on this 85 y/o female with h/o\\ncholedocholithiasis, HTN, renal ca and dementia admitted on\\n with dyspnea and vomiting. Pt also with diarrhea and\\nfever. CXR was initially clear but pt developed acute dyspnea\\nwhile in U/S with new opacities suggestive of pulmonary edema on\\nCXR and pt required intubation. The U/S showed sludge /sludge bal\\nand pt is s/p ERCP and stent. Pt had difficulty weaning from the\\nvent volume overload fluid resuscitation. Pt was\\nextubated yesterday around noon and we were consulted to evaluate\\nfor oral and pharyngeal dysphagia. She is currently NPO with NG\\ntube in place.\\nEVALUATION:\\nThe examination was performed while the patient was seated\\nupright in the bed in the .\\nCognition, language, speech, voice:\\nThe pt was awake, alert and oriented x 3 with fluent language.\\nSpeech and voice were wfl and she was able to follow all basic\\ncommands.\\nTeeth: edentulous- full set of well fitting dentures put in place\\nSecretions: wfl in the oral cavity\\nORAL MOTOR EXAM:\\nSymmetrical facial appearance with adequate lip seal and buccal\\ntone. Tongue was at midline with functional strength and ROM.\\nPalatal elevation and gag deferred.\\nSWALLOWING ASSESSMENT:\\nThe pt was seen with thin liquids (tsp, straw, consecutive),\\npurees and regular solids. Pt with mild difficulty biting solids,\\nbut mastication was functional without significant residue. Pt\\nwithout overt coughing, throat clearing or changes in vocal\\nquality and she denied the sensation of aspiration or pharyngeal\\nresidue. O2 SATs remained greater than 98%. Laryngeal elevation\\nwas timely and wfl to palpation.\\nSUMMARY / IMPRESSION:\\nThe pt had difficulty self feeding but tolerated thin liquids and\\nregular solids without difficulty or signs of aspiration. She can\\nbe advanced to a regular diet but will require assistance with\\nsetting up her meals and feeding. Pills can be given whole with\\nwater. If pt tolerates lunch well, we can remove the NG currently\\nin place.\\nThis swallowing pattern correlates to a Functional Oral Intake\\nScale (FOIS) rating of 7.\\nRECOMMENDATIONS:\\n1. Suggest a PO diet of thin liquids and regular consistency\\nsolids.\\n2. Supervision during meals to assist with feeding.\\n3. Meds whole with thin liquids.\\n4. If pt tolerates lunch, suggest removing her NG tube.\\nThese recommendations were shared with the patient, nurse and\\nmedical team.\\n____________________________________\\n , M.S., CCC-SLP\\nPager #\\nFace time: 11:00-11:20\\nTotal time: 60 minutes\\n [BUTTON Input] (not implemented)_____\\n 11:24\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 703530,\n \"text\": \"Demographics\\n Attending MD:\\n F.\\n Admit diagnosis:\\n SEPSIS\\n Code status:\\n DNR (do not resuscitate)\\n Height:\\n 64 Inch\\n Admission weight:\\n 83.8 kg\\n Daily weight:\\n 80 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: lymphoma, dementia.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:97\\n D:64\\n Temperature:\\n 97\\n Arterial BP:\\n S:123\\n D:69\\n Respiratory rate:\\n 37 insp/min\\n Heart Rate:\\n 101 bpm\\n Heart rhythm:\\n AF (Atrial Fibrillation)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 2 L/min\\n FiO2 set:\\n 35% %\\n 24h total in:\\n 1,930 mL\\n 24h total out:\\n 960 mL\\n Pertinent Lab Results:\\n Sodium:\\n 139 mEq/L\\n 04:02 AM\\n Potassium:\\n 3.6 mEq/L\\n 04:02 AM\\n Chloride:\\n 99 mEq/L\\n 04:02 AM\\n CO2:\\n 30 mEq/L\\n 04:02 AM\\n BUN:\\n 26 mg/dL\\n 04:02 AM\\n Creatinine:\\n 1.4 mg/dL\\n 04:02 AM\\n Glucose:\\n 78 mg/dL\\n 04:02 AM\\n Hematocrit:\\n 26.6 %\\n 04:02 AM\\n Finger Stick Glucose:\\n 149\\n 06:00 PM\\n Valuables / Signature\\n Patient valuables: upper and lower dentures\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: yellow colored wedding band and yellow colored engagement ring\\n with clear colored stones\\n Transferred from:\\n Transferred to: 408\\n Date & time of Transfer: 1830\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 701925,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management.\\n CNS: Patient is now sedated on midazolam at 3mg/hr and fentanyl at\\n 50mcg/hr for pain management. Bilateral soft wrist restraints on to\\n prevent treatment interference. Patient not able to open eyes or follow\\n commands at this time but does grimace to painful stimuli.\\n CVS: SR on the monitor with BP being maintained on Levophed at 0.2mkm\\n to keep MAP greater than 65mmHg. Peripheral pulses are palpable; she\\n has a right IJ TL CL with CVP monitoring. One peripheral IV to the\\n right inner wrist.\\n RESP: Currently the patient is on PSV with setting and maintaining\\n adequate saturations in the upper 90\\ns, in no obvious distress at the\\n time of reporting.\\n GI: Abdomen soft with bowel sounds, OGT placed and to be confirmed.\\n GU: Foley with icteric colored urine, urine lytes to be collected.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 701955,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n MULTI LUMEN - START 03:45 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Infusions:\\n Norepinephrine - 0.2 mcg/Kg/min\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 50 mcg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 38.2\\nC (100.8\\n HR: 79 (79 - 97) bpm\\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\\n RR: 19 (19 - 26) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 6 (6 - 7)mmHg\\n Total In:\\n 369 mL\\n PO:\\n TF:\\n IVF:\\n 369 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 219 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 451 (451 - 470) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 79\\n PIP: 17 cmH2O\\n SpO2: 100%\\n ABG: 7.31/37/133//-6\\n Ve: 9.3 L/min\\n PaO2 / FiO2: 332\\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 02:51 AM\\n 04:57 AM\\n TCO2\\n 18\\n 20\\n Other labs: Lactic Acid:2.4 mmol/L\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock.\\n .\\n # Dyspnea/respiratory failure:\\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\\n trying to compensate by respiratory means\\n Has been having recently worsening dyspnea on exertion, stable\\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\\n CXR shows increased bilateral opacities suggesting pulmonary edema.\\n Heart failure is possible with her BNP elevation and history of\\n orthopnea, although she has no known heart failure. Influenza another\\n possibility given concurrent fever and dry cough. Pneumonia less likely\\n as initial CXR was clear and there was no sputum. Has smoking history,\\n but no wheezing or CO2 retention to suggest COPD. Would also consider\\n ischemia given report of chest pain, although EKG reportedly negative\\n and cardiac markers negative x1. ABG shows good oxygenation and patient\\n has been switched to PSV 10/5 with FiO2 40%.\\n - Cont PSV for now and wean as tolerated\\n - R/o influenza\\n - TTE in am to eval for heart failure\\n - Repeat CXR in am\\n - Cycle cardiac markers\\n .\\n # Septic shock:\\n Bandemia and lactate improving, still febrile and requiring pressors.\\n Sepsis likely secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\\n other source of infection found.\\n - Cont broad spectrum abx with vancomycin and pip-tazo\\n - ERCP today for biliary drainage\\n - Trend CBC/diff, lactate, LFTs\\n - Follow up blood cx , urine cx\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n - Check ScvO2\\n .\\n # Anion gap acidosis:\\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\\n IVF.\\n - Cont IVF per sepsis protocol\\n - trend lactate\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\\n - IVFs for CVP 10-12\\n - f/u Urine lytes\\n - Avoid nephrotoxins\\n - Trend renal function\\n .\\n #Thrombocytopenia\\n Likely secondary to sepsis.\\n - send DIC labs\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 701936,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n MULTI LUMEN - START 03:45 AM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Infusions:\\n Norepinephrine - 0.2 mcg/Kg/min\\n Midazolam (Versed) - 3 mg/hour\\n Fentanyl - 50 mcg/hour\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 08:04 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38.2\\nC (100.8\\n Tcurrent: 38.2\\nC (100.8\\n HR: 79 (79 - 97) bpm\\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\\n RR: 19 (19 - 26) insp/min\\n SpO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 6 (6 - 7)mmHg\\n Total In:\\n 369 mL\\n PO:\\n TF:\\n IVF:\\n 369 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 150 mL\\n Urine:\\n 150 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 219 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 451 (451 - 470) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 19\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 79\\n PIP: 17 cmH2O\\n SpO2: 100%\\n ABG: 7.31/37/133//-6\\n Ve: 9.3 L/min\\n PaO2 / FiO2: 332\\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 02:51 AM\\n 04:57 AM\\n TCO2\\n 18\\n 20\\n Other labs: Lactic Acid:2.4 mmol/L\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 701907,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management.\\n CNS: Patient is now sedated on midazolam at 3mg/hr and fentanyl at\\n 50mcg/hr for pain management. Bilateral soft wrist restraints on to\\n prevent treatment interference. Patient not able to open eyes or follow\\n commands at this time but does grimace to painful stimuli.\\n CVS: SR on the monitor with BP being maintained on Levophed at 0.2mkm\\n to keep MAP greater than 65mmHg. Peripheral pulses are palpable; she\\n has a right IJ TL CL with CVP monitoring. One peripheral IV to the\\n right inner wrist.\\n RESP: Currently the patient is on PSV with setting and maintaining\\n adequate saturations in the upper 90\\ns, in no obvious distress at the\\n time of reporting.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702052,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\\n Action:\\n Placed on A/C for ERCP.\\n Response:\\n Remains on AC as she received paralytic for ERCP and remains very\\n sedated.\\n Plan:\\n Return PSV when spontaneous breathing returns. Turn off sedation in\\n a.m. and do SBT for possible extubation.\\n Sepsis without organ dysfunction\\n Assessment:\\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\\n WBC up to 25.\\n Action:\\n Received additional 2L IVBs.\\n Response:\\n UO increased to ~40cc/hr. CVP 13-15. Levophed weaned to\\n 0.1mcg/kg/minute.\\n Plan:\\n Wean Levophed as tol. Follow CVP and UO. IVBs as per team.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79089,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Hypotension. Dyspnea.\\nHeight: (in) 64\\nWeight (lb): 185\\nBSA (m2): 1.89 m2\\nBP (mm Hg): 97/50\\nHR (bpm): 75\\nStatus: Inpatient\\nDate/Time: at 09:09\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\\nCannot assess RA pressure.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%). Estimated cardiac index is normal\\n(>=2.5L/min/m2). No resting LVOT gradient.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification.\\nMild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\\nsystolic pressure.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nConclusions:\\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\\nsize and regional/global systolic function are normal (LVEF >55%). The\\nestimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber\\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\\nthickened but aortic stenosis is not present. Trace aortic regurgitation is\\nseen. The mitral valve leaflets are structurally normal. Mild (1+) mitral\\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\\nhigh normal. There is a trivial/physiologic pericardial effusion.\\n\\nCompared with the prior study (images reviewed) of , the left\\nventricle is less dynamic, the velocity across the aortic valve is lower (now\\nnormal), and the severity of tricuspid regurgitation and pulmonary artery\\nsystolic pressure are lower.\\n\\nCLINICAL IMPLICATIONS:\\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\\nfor prophylaxis should be based on clinical and echocardiographic data.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703050,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\\n RR up to 34-36 pt volume overloaded, remains on 1 mg Versed IV\\n gtt, with prn boluses of 0.5 mg\\n Action:\\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\\n received 10 mg IVP Lasix at 9 pm with good response. Received repeat\\n 20 mg IVP Lasix at 4:30 am.\\n Response:\\n Pt rested overnight on AC.\\n Plan:\\n Change back to pressure support in am, check RSBI, ?ready for\\n extubation repeat RSBI~157 would like pt negative one liter.\\n Continue Versed gtt\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in Afib, rate 115-130 bp 100/60\\n Action:\\n Lopressor increased to 25 mg per NGT tid, also received 2.5 mg IV\\n Lopressor at 4:30 am\\n Response:\\n HR down to 107 Afib\\n Plan:\\n Continue to monitor HR, bp closely. Lopressor increased to tid (25\\n mg)\\n GI: OG tube removed, r nare NG tube inserted, confirmed by CXRAY,\\n also pulled back bile, and air heard in stomach.\\n ID: Afebrile, ERCP showed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703161,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib with hr ranging from 100-130\\ns.sbp 92-120\\ns. afib\\n first occurred during sbt on / trialed lopressor 12.5 mg po on\\n without affect.\\n Action:\\n Lopressor dose was increased to 25 mg pot id without any improvement in\\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\\n hr. hemodynamics followed closely.\\n Response:\\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\\n was d/c\\nd. sbp retruned to her baseline once esmalol gtt was d/c\\n Plan:\\n Continue to follow hemodynamics . Continue to check lytes as ordered\\n and replete as needed. Pt now started on lopressor 25 mg pot id and\\n diltiazem 30 mg po q 6hrs.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Resp failure initially thought to be due to metabolic acidosis which\\n caused her to hyperventilate to compensate and fatigued becoming\\n acutely sob and requiring intubation on ^th.unable to wean\\n vent because of pt being fluid overloaded secondary to fluid\\n resusitiation. Pt having difficulty coming off peep becoming very\\n tachypenic with low tidal volumes which is more concerning for\\n difficulty with compliance then volume overload. Cxr c/w lll opacity\\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\\n tachypenic . lungs clear with crackles noted bil at the bases.\\n Suctioned for sm amts of thick white sputum.\\n Action:\\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\\n closely.\\n Response:\\n Vent settings unchanged. Cxr unchanged\\n Plan:\\n Plan to diurese as pt\\ns hemodynamics tolerate. Will keep on cpap mode\\n of ventilation overnoc. Plan is to call anesthesia in the am to change\\n #7 ett to o #8 ett over the cook catheter. Once ett is changed will\\n then check rsbi and do sbt. Will do bronchoscopy after that and then\\n possible extubation with the plan to reintubate if pt fails extubation.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703162,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib with hr ranging from 100-130\\ns.sbp 92-120\\ns. afib\\n first occurred during sbt on / trialed lopressor 12.5 mg po on\\n without affect.\\n Action:\\n Lopressor dose was increased to 25 mg pot id without any improvement in\\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\\n hr. hemodynamics followed closely.\\n Response:\\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\\n was d/c\\nd. sbp retruned to her baseline once esmalol gtt was d/c\\n Plan:\\n Continue to follow hemodynamics . Continue to check lytes as ordered\\n and replete as needed. Pt now started on lopressor 25 mg pot id and\\n diltiazem 30 mg po q 6hrs.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Resp failure initially thought to be due to metabolic acidosis which\\n caused her to hyperventilate to compensate and fatigued becoming\\n acutely sob and requiring intubation on ^th.unable to wean\\n vent because of pt being fluid overloaded secondary to fluid\\n resusitiation. Pt having difficulty coming off peep becoming very\\n tachypenic with low tidal volumes which is more concerning for\\n difficulty with compliance then volume overload. Cxr c/w lll opacity\\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\\n tachypenic . lungs clear with crackles noted bil at the bases.\\n Suctioned for sm amts of thick white sputum.\\n Action:\\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\\n closely.\\n Response:\\n Vent settings unchanged. Cxr unchanged\\n Plan:\\n Plan to diurese as pt\\ns hemodynamics tolerate. Net goal for i&o is to\\n be neg 1.5 to 2 liters Will keep on cpap mode of ventilation overnoc.\\n Plan is to call anesthesia in the am to change #7 ett to o #8 ett over\\n the cook catheter. Once ett is changed will then check rsbi and do sbt.\\n Will do bronchoscopy after that and then possible extubation with the\\n plan to reintubate if pt fails extubation.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 703163,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - diurese further today to help w possibility of extubation--> Net Goal\\n -1.5-2L\\n - consider risk of aspiration post-extubation due to mental status\\n - NG tube placed\\n - patient remains tachycardic so metoprolol was increased to 25mg TID\\n - need to address possib of anticoagulation w family and PCP\\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\\n tolerate 20mg IV)\\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\\n at 9:30pm to rest, so that she can be ready, better rested for SBT\\n tomorrow, esp after diuresis\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Fentanyl - 04:27 PM\\n Heparin Sodium (Prophylaxis) - 04:31 AM\\n Furosemide (Lasix) - 04:39 AM\\n Metoprolol - 04:40 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.7\\nC (98\\n HR: 116 (100 - 125) bpm\\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\\n RR: 23 (12 - 36) insp/min\\n SpO2: 100%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 9 (9 - 272)mmHg\\n Total In:\\n 2,091 mL\\n 206 mL\\n PO:\\n TF:\\n 1,506 mL\\n IVF:\\n 524 mL\\n 206 mL\\n Blood products:\\n Total out:\\n 2,125 mL\\n 1,120 mL\\n Urine:\\n 2,125 mL\\n 1,120 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -34 mL\\n -915 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): 324 (255 - 463) mL\\n PS : 12 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 25 cmH2O\\n Plateau: 18 cmH2O\\n Compliance: 38.5 cmH2O/mL\\n SpO2: 100%\\n ABG: ///30/\\n Ve: 7.1 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 131 K/uL\\n 9.1 g/dL\\n 109 mg/dL\\n 1.5 mg/dL\\n 30 mEq/L\\n 4.0 mEq/L\\n 22 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 27.4 %\\n 12.2 K/uL\\n [image002.jpg]\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n WBC\\n 20.2\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n Hct\\n 30.7\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n Plt\\n 52\\n 48\\n 60\\n 84\\n 131\\n Cr\\n 1.6\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n TCO2\\n 23\\n 26\\n 25\\n Glucose\\n 91\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\\n PO4:2.6 mg/dL\\n Microbiology:\\nBlood Culture: Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\\n Source: Endotracheal.\\n GRAM STAIN (Final ):\\n PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\\n Imaging:\\n Chest X-Ray at 2330 (my read): stable effusion/opacity and\\n RLL patchy opacity\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\\n having difficulty coming off PEEP, becomes very tachypneic and has low\\n tidal volumes, which is more concerning for difficulty with compliance\\n and volume overload. Additionally, patient with opacity and\\n diaphragm pulled up on the left that has been noted on all x-rays\\n during this admission, to better see the anatomy in the , \\n bronch the patient this afternoon to look at the .\\n - continue with net negative goal, if UOP decreases to less than\\n 100cc/hr will give another dose of lasix and readdress possible\\n extubation this afternoon.\\n - Hold sedation for now to optimize mental status prior to extubation\\n - NGT in place for meds/diet post extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Trialed\\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\\n 100\\ns and her BP tolerated it well.\\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\\n the 120\\ns to 130\\ns, so will trial an esmolol drip\\n # Septic shock: resolving, patient off pressors, likely secondary to\\n cholangitis and infected stone/sludge. ERCP showed significant pusand\\n very large stone, she is s/p stent placement. Patient afebrile and\\n white count stable. Lactate normal. Initial sepsis secondary to biliary\\n source given CBD dilation with sludge and obstructive LFTs in setting\\n on known choledocholithiasis.\\n - Leukocytosis is resolving\\nwhite count almost normalized. Had been\\n afebrile for over 48 hours.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\\n will place a PICC and pull central line\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\\n to help with further diruesis\\n - Monitor UOP\\n - Check PM lytes\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition: Tube feeds held o/n for possible extubation, will hold this\\n afternoon for possible extubation\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM, will put patient in for a PICC today\\n Prophylaxis:\\n DVT: SQ Heparin\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition: ICU\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\\n respiratory failure, AF c RVR. Failed SBT this AM, diuresis ongoing.\\n Exam notable for Tm 99.2 BP HR 122/80 RR 12-37 with sat 100 on PSV 5/5.\\n WD woman, follows intermittent commands. Coarse BS B. Irreg s1s2. Soft\\n +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+ 3.9, Cr 1.3.\\n Agree with plan to manage respiratory failure ongoing IV lasix for TBB\\n negative, will check and trend CVP, continue upright positioning,\\n bronch c pedi scope to assess prior to trial of extubation. Will\\n f/u sputum cx. Cholangitis improving, will need 14d abx, f/u\\n cultures, will change CVL to PICC for long-term IV abx. For AF c RVR,\\n continue PO BBL c esmolol gtt, hold off on anticoagulation. ARF has\\n resolved. Continue TFs for now. Remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 04:36 PM ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703233,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent. Respiratory failure initially thought to be due to\\n metabolic acidosis which caused her to hyperventilate to compensate.\\n She fatigued quickly becoming acutely SOB and required intubation on\\n ^th. Since then, unable to wean vent because of pt being\\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\\n coming off peep becoming very tachypneic with low tidal volumes which\\n is more concerning for difficulty with compliance then volume overload.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Received pt in Afib; HR ranging from 90-130\\ns. SBP 85-120\\ns. Afib first\\n occurred during SBT on . Occasional PVC\\ns noted.\\n Action:\\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\\n 20mEq IV given last evening per sliding scale orders.\\n Response:\\n Pt has remained in Afib but rate has significantly improved w/\\n administration of Lopressor & Dilt. HR ranging 80\\n low 100\\ns w/\\n minimal ectopy.\\n Plan:\\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\\n Diltiazem. Follow electrolyte status & replete as needed.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\\n 30-40\\ns but appearing comfortable & settles out on own. LS clear,\\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\\n 1.5\\n 2L. Mental status much improved. Pt following commands and\\n actively participating in care. Remains restless @ times but is easily\\n redirected.\\n Action:\\n Suctioning q2-4 hrs for thick/white sputum. Pt appears to be pooling\\n large amts of secretions in the subglottal area. (concern for\\n aspiration post extubation)\\n Response:\\n Pt -2L @ MN.\\n Plan:\\n Plan to diurese as pt\\ns hemodynamics tolerate. Net goal - 1.5\\n 2L @\\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\\n exchange. If all goes as planned, pt will be extubated late morning. As\\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\\n remains DNR)\\n DNR (will reintubate if necessary)\\n L DL PICC\\n Family in to see pt and updated by this RN last evening\\n Pt did have 2 smears of stool overnight. Please monitor\\n closely. Skin breakdown is of concern, amt of stool was not significant\\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\\n not benefit from fecal inc. bag)\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703328,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received patient intubated and vented on PSV 40% 8/5. Sedated on midaz\\n at 1mg/hr. B/L LS clear diminished at the bases. Tachypneic to high\\n 20-30\\n Action:\\n Lasix 20mg X1 given prior to extubation, extubated.\\n Response:\\n No s/s of resp distress. Patient denies any SOB when asked. Sats at\\n high 90\\ns on face tent.\\n Plan:\\n Continue to monitor patient resp status\\n Atrial fibrillation (Afib)\\n Assessment:\\n Known AFib. HR in 90-low 100\\ns. B/P 90-110\\ns occasionally when asleep\\n b/p down to 80\\ns. Peripheral pulses present.\\n Action:\\n Metoprolol at 25mg TID and Dilt 30mg QID\\n Response:\\n HR in the 90\\n Plan:\\n Continue to monitor patient hemodynamic status.\\n Neuro: alert, follows commands.\\n GI: abd soft non tented, positive for BS. NPO. Ngt for meds\\n clamped.\\n 3 x smear of golden loose stools during the shift.\\n GU: clear yellow urine via foley. Lasix X1 given.\\n Skin: reddened buttocks. Critic aid cream applied.\\n Social: patient is a DNR. OK to re-intubate if needed. Family in to\\n visit. Updated by RN and MD.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 703321,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - f/u VBG 7.48/42/78 in central venous, repeat ABG 7.46/44/124\\n - BNP high 5525 c/w volume overload.\\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid\\n - PICC placed\\n - Called micro lab: will try to speciate. will call in AM to confirm\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 08:39 AM\\n Heparin Sodium (Prophylaxis) - 04:51 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.2\\nC (99\\n HR: 99 (86 - 128) bpm\\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\\n RR: 28 (18 - 41) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 6 (2 - 6)mmHg\\n Total In:\\n 784 mL\\n 256 mL\\n PO:\\n TF:\\n IVF:\\n 784 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,885 mL\\n 495 mL\\n Urine:\\n 2,885 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,101 mL\\n -239 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 260 (260 - 404) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 38\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 154\\n PIP: 14 cmH2O\\n SpO2: 99%\\n ABG: ///29/\\n Ve: 9.6 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Labs / Radiology\\n 174 K/uL\\n 9.2 g/dL\\n 80 mg/dL\\n 1.4 mg/dL\\n 29 mEq/L\\n 4.1 mEq/L\\n 22 mg/dL\\n 101 mEq/L\\n 140 mEq/L\\n 27.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n TCO2\\n 26\\n 25\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n Other labs:\\n Ca: 8.6, Mg: 2.2, Phos: 3.1\\n Mircrobiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\\n Anaerobic Bottle Gram Stain (Final ):\\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\\n Radiology:\\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\\n vena cava. The patient remains intubated, with the endotracheal tube\\n terminating 3.2 cm above the carina. The right internal jugular line\\n ends in the mid superior vena cava. Left pleural effusion with\\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\\n consistent with pulmonary arterial hypertension. The right lung is\\n clear. There is no pulmonary edema.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\\n improved in terms of pulmonary vascular congestion, will trial\\n extubation today since patient looks the best she has since admission\\n - patient may need Bipap post extubation\\n - Hold sedation for now to optimize mental status prior to extubation\\n - NGT in place for meds/diet post extubation\\n .\\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\\n rate control, rate has been in the 90\\ns with both medications\\n # Septic shock: resolved from initial cholangitis source, patient off\\n pressors, likely secondary to cholangitis and infected stone/sludge.\\n ERCP showed significant pusand very large stone, she is s/p stent\\n placement. Patient afebrile and white count stable. Lactate normal.\\n Initial sepsis secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. PICC placed, will complete a 14 day course of zosyn as the\\n mircolab is currently unable to provide further speciation and she has\\n been improving on zosyn\\n - repeat ERCP in 1 month\\n .\\n # ARF: Improved, back to her baseline.\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition: Tube feeds on hold for possible extubation\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: family\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition:ICU\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\\n respiratory failure, AF c RVR improved with BBL / CCB. Diuresis\\n ongoing, BNP 6K.\\n Exam notable for Tm 99.8 BP 116/62 HR 95-105AF RR 12-37 with sat 100 on\\n PSV 8/5, -2L / 24h. WD woman, follows intermittent commands. Coarse BS\\n B. Irreg s1s2. Soft +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+\\n 4.1, Cr 1.4. CXR c ?LLL collapse.\\n Agree with plan to manage respiratory failure ongoing IV lasix for TBB\\n negative (20mg x1 now), will continue upright positioning, SBT and plan\\n for trial of extubation. Cholangitis improving, will need 14d abx, f/u\\n cultures, will change CVL to PICC for long-term IV abx. Over the long\\n term, will need f/u ERCP for large nonobstructive stone. For AF c RVR,\\n continue BBL/CCB, hold off on anticoagulation. ARF has resolved;\\n baseline CRI. Hold TFs for extubation. Remainder of plan as outlined\\n above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 04:44 PM ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702096,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 1\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Known difficult intubation: No\\n Procedure location: ED\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Diminished\\n LUL Lung Sounds: Diminished\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Scant\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Placed on CMV for ERCP. Had been on 12 PSV in am.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Wean to PSV as soon as tolerated. Pt to ? extubate in\\n am.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702352,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Pt was in NSR without ectopi at about 1030 patient had new onset Atrial\\n Fibrillation. Patient was on spontaneous breathing trial did not appear\\n to be in res p distress O2 SAT > 95. Patient remained on Levophed at\\n 0.07mcg/kg/min with out changed in SBP. Patient Hr 110-120 and\\n tolerated. Since 1500 HR up to 130-140 at times.. discussed with ICU\\n team .\\n Action:\\n Patient placed back on ventilator. EKG done and read. Additional fluid\\n was given and attempted to wean Levophed without success, labs sent.\\n Changed Levophed for Phenylephrine. Levophed off phenylephrine @\\n 1.5mcg/kg/.\\n Response:\\n Pt has remained in A Fibrillation. Hr 110-140. Unable to wean Levophed.\\n At present Hr in high 120 to 130\\ns slightly lower than on Levophed.\\n Plan:\\n Continue to monitor patient. Monitor the HR and sbp to evaluate if\\n phenylephrine drip is tolerated better shown by decrease in hr.\\n Continue to treat sepsis and monitor labs,\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702085,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\\n Action:\\n Placed on A/C for ERCP.\\n Response:\\n Remains on AC as she received paralytic for ERCP and remains very\\n sedated.\\n Plan:\\n Return PSV when spontaneous breathing returns. Turn off sedation in\\n a.m. and do SBT for possible extubation. Monitor O2sats.\\n Sepsis without organ dysfunction\\n Assessment:\\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\\n WBC up to 25 from 4.8. Remains in metabolic acidosis. R/O\\nd for\\n influenza.\\n Action:\\n Received additional 2L IVBs.\\n Response:\\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\\n 0.1mcg/kg/minute.\\n Plan:\\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\\n requires more fluids for low CVP. Monitor sodium in light of multiple\\n liters of NS. Consider LR.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702162,\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: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 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 / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort:\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Adjust Min. ventilation to control pH\\n Reason for continuing current ventilatory support: Cannot protect\\n airway, Cannot manage secretions; Comments: Pt remains stable on vent,\\n with full ventilatory support. Pt has clear lung sounds, with minimal\\n secretions. Pt showed strong RSBI trial of 54, showing good\\n spontaneous respiratory effort. Pt to be tried on CPAP/PSV trial, and\\n to be assessed by MD team for plan of care.\\n BEDSIDE RSBI- 54\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702558,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 3\\n Ideal body weight: 54.4 None\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Cuff volume: mL /\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n 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 Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702083,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\\n Action:\\n Placed on A/C for ERCP.\\n Response:\\n Remains on AC as she received paralytic for ERCP and remains very\\n sedated.\\n Plan:\\n Return PSV when spontaneous breathing returns. Turn off sedation in\\n a.m. and do SBT for possible extubation. Monitor O2sats.\\n Sepsis without organ dysfunction\\n Assessment:\\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\\n WBC up to 25 from 4.8. Remains in metabolic acidosis. R/O\\nd for\\n influenza.\\n Action:\\n Received additional 2L IVBs.\\n Response:\\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\\n 0.1mcg/kg/minute.\\n Plan:\\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\\n requires more fluids for low CVP. Monitor sodium in light of multiple\\n liters of NS. Consider LR.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702291,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\\n single 2.5-3cm filling defect consistent witha stone or sludge ball\\n that was causing partial obstruction was seen at the mid CBD. A 10FR\\n by 5cm double pigtail biliary stent was placed successfully\\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\\n up some. And bicarb improved\\n - this AM: CVP was 7: gave 1 liter of LR\\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\\n Currently on minimal sedation.\\n Changed from AC to PS: doing well; trying to wean down all sedation and\\n pressors:\\n SBT tried this AM and patient went into afib with RVR. Changed to AC\\n for now.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 50 mcg/hour\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n 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 06:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 71 (61 - 79) bpm\\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\\n RR: 19 (8 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 8 (7 - 344)mmHg\\n Total In:\\n 3,664 mL\\n 1,194 mL\\n PO:\\n TF:\\n IVF:\\n 3,664 mL\\n 1,194 mL\\n Blood products:\\n Total out:\\n 827 mL\\n 330 mL\\n Urine:\\n 827 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,837 mL\\n 864 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): 446 (399 - 470) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 54\\n PIP: 15 cmH2O\\n Plateau: 15 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/38/124/22/-1\\n Ve: 9 L/min\\n PaO2 / FiO2: 310\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 10.7 g/dL\\n 266 mg/dL\\n 2.1 mg/dL\\n 22 mEq/L\\n 3.5 mEq/L\\n 37 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 17.8 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 04:57 AM\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n WBC\\n 25.0\\n 17.8\\n Hct\\n 31.6\\n 30.8\\n Plt\\n 93\\n 48\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n TropT\\n 0.02\\n TCO2\\n 18\\n 20\\n 18\\n 23\\n Glucose\\n 195\\n 151\\n 266\\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\\n D-dimer: :\\n DIC repeat panel:\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n +BCx: : anaerobic bottle: GPR\\n Ucx and BCx pending\\n Radiology: none\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but suspect in setting of\\n met acidosis she fatigued. Has been having recently worsening dyspnea\\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\\n in the ED. Heart failure is less likely as echo and CXR do not show any\\n evidence of this. ABG shows good oxygenation and patient has been\\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\\n during SBT, with afib on AC for now.\\n - Attempt to change back to PSV for now and wean as tolerated; consider\\n sbt once patient can tolerate no sedation\\n - wean pressors as tolerated\\n - goal to extubate patient today\\n # Atrial Fibrillation: Appears to be first episode as no history of\\n this in past. Likely exacerbated by SBT and being on levophed in the\\n setting of infection. Hemodynamically stable for now with rates in the\\n 110\\n - EKG\\n - If fast rate persists or if worsening hemodynamics, consider\\n changing levophed to phenylephrine as to reduce beta agonist activity\\n and worsen afib with RVR.\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\\n placement. Patient afebrile and white count trending down. Lactate now\\n normal. Initial sepsis likely secondary to biliary source given CBD\\n dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\\n vanc as GI infection not likely MRSA.\\n - Trend CBC/diff, LFTs\\n - Follow up blood cx , urine cx; GPR may be contamination, but will\\n continue to cover broadly for now until further speciation.\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\\n to correct very fast, likely a component of ATN as well.\\n - IVFs for CVP 10-12\\n - Avoid nephrotoxins\\n - Trend renal function with PM chem. 10.\\n .\\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\\n equivical; low suscipicion of HIT as timing does not correlate.\\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\\n possibility as known to cause thrombocytopenia.\\n - D/C vanc and heparin today\\n - unlikely DIC at this point\\n - No signs of active bleeding\\n - Re-check cbc at 1500\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\\n less than 18 or LR if needs resuscitation to prevent further NG\\n acidosis.\\n ICU Care\\n Nutrition: NPO for now in expectation of extubation today\\n Glycemic Control: None\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR (OK to intubate)\\n Disposition: ICU for now\\n ------ Protected Section ------\\n MICU ATTENDING PROGRESS NOTE\\n I saw and examined the patient and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n resident note, including the assessment and plan. I would emphasize and\\n add the following points: 85F a w/ renal ca, dementia,\\n choledocolithiasis in w/ sepsis/shock from cholangitis s/p ERCP\\n with stent placement yesterday. Required intermittent neo boluses\\n peri-proceudre. Remains on levophed though titrating down. During SBT\\n this am developed a-fib, asx with rates 100-115. Now back on ACV.\\n PE: Tm 97.8 MAP 62-103 HR 60-80\\n100-115 RR 19 Sat 97% on PS 10/5\\n 40% rsbi 54\\n Intubated, awake, NAD, follows commands, mildly jaundiced, perrla, CTA,\\n RR, soft + BS, NT, no edema\\n LABS: wbc 17, 4% bands, hct 31, plt 48, na 137, cr 2.1 (2.6),\\n lactate 1.4 t bili, ast/alt decreasing, inr 1.1, fibrinogen 500,dd >\\n \\n ECG reviewed-->new a-fib\\n TEE ef > 65%, 1+ MR\\n Micro: bl gpr 1, others ngtd\\n A/P: Sepsis from cholangitis c/b arf, resp failure and\\n thrombocytopenia. Now with new a-fib.\\n While a-fib temporally related to SBT, suspect component of increased\\n myocardial excitability pressors as well as underlying sepsis\\n contributing. She has no underlying lung process as cause of her\\n intubation, which seemed mainly related to inability to compensate for\\n metabolic acidosis. She has had lots of fluids, though and increased\\n WOB during SBT could have contributed. Her TTE yesterday showed good\\n bivent fx.\\n Agree with plan to repeat CXR and abg, transition back to PSV. Her HR\\n is not rapid and BP has not changed. Will check 12 lead and assess for\\n ischemia. Continue IVF boluses for cvp and u/o and wean pressor,\\n maintaining MAPS > 65. If develops RVR, consider changing pressor to\\n neo and adding rate control. Monitor resp and hemodynamic status\\n closely and consider repeat SBT later in afternoon. We continue to\\n treat biliary sepsis with anitbx. Continue zosyn and can d/c vanco,\\n following cx data. Infection parameters are improving with decreasing\\n wbc and temp curve. Her cr is down slightly from admit but not at\\n baseline. ARF is likely pre-renal + atn from sepsis/hypotension. U/o\\n holding with boluses. She continues to have worsening thrombocytopenia.\\n No recent heparin exposure to suggest HIT occurring so quiclky.\\n Suspect this is infection response or medications. Will hold\\n heparin products and monitor, following DIC labs, and keeping t and c.\\n ICU prophy. A-line and CVL. DNR\\n Remainder of plan as outlined in resident note.\\n Patient is critically ill\\n ------ Protected Section Addendum Entered By: , MD\\n on: 02:11 PM ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702621,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 4\\n Ideal body weight: 54.4\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: ICU\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n :\\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 / Scant\\n Ventilation Assessment\\n Level of breathing assistance: PSV 12/5/,4\\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: weaning PSV as tol\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Hemodynimic instability, Underlying illness not\\n resolved\\n Respiratory Care Shift Procedures\\n Bedside Procedures: ABG drawn: mild resp alkalosis with good\\n oxygenation; RSBI 157\\n Comments: Will wean as tol.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702265,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\\n single 2.5-3cm filling defect consistent witha stone or sludge ball\\n that was causing partial obstruction was seen at the mid CBD. A 10FR\\n by 5cm double pigtail biliary stent was placed successfully\\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\\n up some. And bicarb improved\\n - this AM: CVP was 7: gave 1 liter of LR\\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\\n Currently on minimal sedation.\\n Changed from AC to PS: doing well; trying to wean down all sedation and\\n pressors:\\n SBT tried this AM and patient went into afib with RVR. Changed to AC\\n for now.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 50 mcg/hour\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n 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 06:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 71 (61 - 79) bpm\\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\\n RR: 19 (8 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 8 (7 - 344)mmHg\\n Total In:\\n 3,664 mL\\n 1,194 mL\\n PO:\\n TF:\\n IVF:\\n 3,664 mL\\n 1,194 mL\\n Blood products:\\n Total out:\\n 827 mL\\n 330 mL\\n Urine:\\n 827 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,837 mL\\n 864 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): 446 (399 - 470) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 54\\n PIP: 15 cmH2O\\n Plateau: 15 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/38/124/22/-1\\n Ve: 9 L/min\\n PaO2 / FiO2: 310\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 10.7 g/dL\\n 266 mg/dL\\n 2.1 mg/dL\\n 22 mEq/L\\n 3.5 mEq/L\\n 37 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 17.8 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 04:57 AM\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n WBC\\n 25.0\\n 17.8\\n Hct\\n 31.6\\n 30.8\\n Plt\\n 93\\n 48\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n TropT\\n 0.02\\n TCO2\\n 18\\n 20\\n 18\\n 23\\n Glucose\\n 195\\n 151\\n 266\\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\\n D-dimer: :\\n DIC repeat panel:\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n +BCx: : anaerobic bottle: GPR\\n Ucx and BCx pending\\n Radiology: none\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but suspect in setting of\\n met acidosis she fatigued. Has been having recently worsening dyspnea\\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\\n in the ED. Heart failure is less likely as echo and CXR do not show any\\n evidence of this. ABG shows good oxygenation and patient has been\\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\\n during SBT, with afib on AC for now.\\n - Attempt to change back to PSV for now and wean as tolerated; consider\\n sbt once patient can tolerate no sedation\\n - wean pressors as tolerated\\n - goal to extubate patient today\\n # Atrial Fibrillation: Appears to be first episode as no history of\\n this in past. Likely exacerbated by SBT and being on levophed in the\\n setting of infection. Hemodynamically stable for now with rates in the\\n 110\\n - EKG\\n - If fast rate persists or if worsening hemodynamics, consider\\n changing levophed to phenylephrine as to reduce beta agonist activity\\n and worsen afib with RVR.\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\\n placement. Patient afebrile and white count trending down. Lactate now\\n normal. Initial sepsis likely secondary to biliary source given CBD\\n dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\\n vanc as GI infection not likely MRSA.\\n - Trend CBC/diff, LFTs\\n - Follow up blood cx , urine cx; GPR may be contamination, but will\\n continue to cover broadly for now until further speciation.\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\\n to correct very fast, likely a component of ATN as well.\\n - IVFs for CVP 10-12\\n - Avoid nephrotoxins\\n - Trend renal function with PM chem. 10.\\n .\\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\\n equivical; low suscipicion of HIT as timing does not correlate.\\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\\n possibility as known to cause thrombocytopenia.\\n - D/C vanc and heparin today\\n - unlikely DIC at this point\\n - No signs of active bleeding\\n - Re-check cbc at 1500\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\\n less than 18 or LR if needs resuscitation to prevent further NG\\n acidosis.\\n ICU Care\\n Nutrition: NPO for now in expectation of extubation today\\n Glycemic Control: None\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR (OK to intubate)\\n Disposition: ICU for now\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702349,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 2\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: Clear / Thick\\n Sputum source/amount: Suctioned / None\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: Plan is to wean to SBT before rounds in \\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702269,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\\n single 2.5-3cm filling defect consistent witha stone or sludge ball\\n that was causing partial obstruction was seen at the mid CBD. A 10FR\\n by 5cm double pigtail biliary stent was placed successfully\\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\\n up some. And bicarb improved\\n - this AM: CVP was 7: gave 1 liter of LR\\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\\n Currently on minimal sedation.\\n Changed from AC to PS: doing well; trying to wean down all sedation and\\n pressors:\\n SBT tried this AM and patient went into afib with RVR. Changed to AC\\n for now.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 50 mcg/hour\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n 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 06:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 71 (61 - 79) bpm\\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\\n RR: 19 (8 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 8 (7 - 344)mmHg\\n Total In:\\n 3,664 mL\\n 1,194 mL\\n PO:\\n TF:\\n IVF:\\n 3,664 mL\\n 1,194 mL\\n Blood products:\\n Total out:\\n 827 mL\\n 330 mL\\n Urine:\\n 827 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,837 mL\\n 864 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): 446 (399 - 470) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 54\\n PIP: 15 cmH2O\\n Plateau: 15 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/38/124/22/-1\\n Ve: 9 L/min\\n PaO2 / FiO2: 310\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 10.7 g/dL\\n 266 mg/dL\\n 2.1 mg/dL\\n 22 mEq/L\\n 3.5 mEq/L\\n 37 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 17.8 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 04:57 AM\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n WBC\\n 25.0\\n 17.8\\n Hct\\n 31.6\\n 30.8\\n Plt\\n 93\\n 48\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n TropT\\n 0.02\\n TCO2\\n 18\\n 20\\n 18\\n 23\\n Glucose\\n 195\\n 151\\n 266\\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\\n D-dimer: :\\n DIC repeat panel:\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n +BCx: : anaerobic bottle: GPR\\n Ucx and BCx pending\\n Radiology: none\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but suspect in setting of\\n met acidosis she fatigued. Has been having recently worsening dyspnea\\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\\n in the ED. Heart failure is less likely as echo and CXR do not show any\\n evidence of this. ABG shows good oxygenation and patient has been\\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\\n during SBT, with afib on AC for now.\\n - Attempt to change back to PSV for now and wean as tolerated; consider\\n sbt once patient can tolerate no sedation\\n - wean pressors as tolerated\\n - goal to extubate patient today\\n # Atrial Fibrillation: Appears to be first episode as no history of\\n this in past. Likely exacerbated by SBT and being on levophed in the\\n setting of infection. Hemodynamically stable for now with rates in the\\n 110\\n - EKG\\n - If fast rate persists or if worsening hemodynamics, consider\\n changing levophed to phenylephrine as to reduce beta agonist activity\\n and worsen afib with RVR.\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\\n placement. Patient afebrile and white count trending down. Lactate now\\n normal. Initial sepsis likely secondary to biliary source given CBD\\n dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\\n vanc as GI infection not likely MRSA.\\n - Trend CBC/diff, LFTs\\n - Follow up blood cx , urine cx; GPR may be contamination, but will\\n continue to cover broadly for now until further speciation.\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\\n to correct very fast, likely a component of ATN as well.\\n - IVFs for CVP 10-12\\n - Avoid nephrotoxins\\n - Trend renal function with PM chem. 10.\\n .\\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\\n equivical; low suscipicion of HIT as timing does not correlate.\\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\\n possibility as known to cause thrombocytopenia.\\n - D/C vanc and heparin today\\n - unlikely DIC at this point\\n - No signs of active bleeding\\n - Re-check cbc at 1500\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\\n less than 18 or LR if needs resuscitation to prevent further NG\\n acidosis.\\n ICU Care\\n Nutrition: NPO for now in expectation of extubation today\\n Glycemic Control: None\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR (OK to intubate)\\n Disposition: ICU for now\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702270,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\\n single 2.5-3cm filling defect consistent witha stone or sludge ball\\n that was causing partial obstruction was seen at the mid CBD. A 10FR\\n by 5cm double pigtail biliary stent was placed successfully\\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\\n up some. And bicarb improved\\n - this AM: CVP was 7: gave 1 liter of LR\\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\\n Currently on minimal sedation.\\n Changed from AC to PS: doing well; trying to wean down all sedation and\\n pressors:\\n SBT tried this AM and patient went into afib with RVR. Changed to AC\\n for now.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 50 mcg/hour\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n 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 06:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 71 (61 - 79) bpm\\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\\n RR: 19 (8 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 8 (7 - 344)mmHg\\n Total In:\\n 3,664 mL\\n 1,194 mL\\n PO:\\n TF:\\n IVF:\\n 3,664 mL\\n 1,194 mL\\n Blood products:\\n Total out:\\n 827 mL\\n 330 mL\\n Urine:\\n 827 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,837 mL\\n 864 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): 446 (399 - 470) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 54\\n PIP: 15 cmH2O\\n Plateau: 15 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/38/124/22/-1\\n Ve: 9 L/min\\n PaO2 / FiO2: 310\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 10.7 g/dL\\n 266 mg/dL\\n 2.1 mg/dL\\n 22 mEq/L\\n 3.5 mEq/L\\n 37 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 17.8 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 04:57 AM\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n WBC\\n 25.0\\n 17.8\\n Hct\\n 31.6\\n 30.8\\n Plt\\n 93\\n 48\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n TropT\\n 0.02\\n TCO2\\n 18\\n 20\\n 18\\n 23\\n Glucose\\n 195\\n 151\\n 266\\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\\n D-dimer: :\\n DIC repeat panel:\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n +BCx: : anaerobic bottle: GPR\\n Ucx and BCx pending\\n Radiology: none\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but suspect in setting of\\n met acidosis she fatigued. Has been having recently worsening dyspnea\\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\\n in the ED. Heart failure is less likely as echo and CXR do not show any\\n evidence of this. ABG shows good oxygenation and patient has been\\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\\n during SBT, with afib on AC for now.\\n - Attempt to change back to PSV for now and wean as tolerated; consider\\n sbt once patient can tolerate no sedation\\n - wean pressors as tolerated\\n - goal to extubate patient today\\n # Atrial Fibrillation: Appears to be first episode as no history of\\n this in past. Likely exacerbated by SBT and being on levophed in the\\n setting of infection. Hemodynamically stable for now with rates in the\\n 110\\n - EKG\\n - If fast rate persists or if worsening hemodynamics, consider\\n changing levophed to phenylephrine as to reduce beta agonist activity\\n and worsen afib with RVR.\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\\n placement. Patient afebrile and white count trending down. Lactate now\\n normal. Initial sepsis likely secondary to biliary source given CBD\\n dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\\n vanc as GI infection not likely MRSA.\\n - Trend CBC/diff, LFTs\\n - Follow up blood cx , urine cx; GPR may be contamination, but will\\n continue to cover broadly for now until further speciation.\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\\n to correct very fast, likely a component of ATN as well.\\n - IVFs for CVP 10-12\\n - Avoid nephrotoxins\\n - Trend renal function with PM chem. 10.\\n .\\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\\n equivical; low suscipicion of HIT as timing does not correlate.\\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\\n possibility as known to cause thrombocytopenia.\\n - D/C vanc and heparin today\\n - unlikely DIC at this point\\n - No signs of active bleeding\\n - Re-check cbc at 1500\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\\n less than 18 or LR if needs resuscitation to prevent further NG\\n acidosis.\\n ICU Care\\n Nutrition: NPO for now in expectation of extubation today\\n Glycemic Control: None\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR (OK to intubate)\\n Disposition: ICU for now\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702404,\n \"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: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 28 cmH2O\\n 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: 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: Continue with daily RSBI tests & SBT's as tolerated,\\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Cannot protect airway, Cannot manage secretions;\\n Comments: Pt remain on vent, with PSV settings. Pt was tried on RSBI\\n trial but became tachypneic with an RR of over 35 bpm. Pt had clear\\n lung sounds but with some blood tinge secretions being suctioned. Pt\\n remains stable with good expiratory tidal volumes and ABG findings. Pt\\n to continue current support and to be assessed by MD team for possible\\n extubation.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 702943,\n \"text\": \"Subjective\\n Patient intubated\\n Objective\\n Pertinent medications: 2pkt Neutrophos,others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 143 mg/dL\\n 04:15 AM\\n Glucose Finger Stick\\n 149\\n 06:00 PM\\n BUN\\n 24 mg/dL\\n 04:15 AM\\n Creatinine\\n 1.3 mg/dL\\n 04:15 AM\\n Sodium\\n 140 mEq/L\\n 04:15 AM\\n Potassium\\n 3.9 mEq/L\\n 04:15 AM\\n Chloride\\n 104 mEq/L\\n 04:15 AM\\n TCO2\\n 30 mEq/L\\n 04:15 AM\\n Calcium non-ionized\\n 8.0 mg/dL\\n 04:54 AM\\n Phosphorus\\n 2.2 mg/dL\\n 04:54 AM\\n Magnesium\\n 1.6 mg/dL\\n 04:15 AM\\n Current diet order / nutrition support: Fibersource HN at 50ml/hr x 24\\n hours - provides 1440kcal and 64g protein\\n GI: Abdomen soft with positive bowel sounds, +large stool\\n Assessment of Nutritional Status\\n Specifics:\\n 85 year old female with history of choledocholithiasis, renal CA, and\\n dementia who presents with dyspnea and vomiting complicated by acute\\n respiratory failure and septic shock likely secondary to biliary\\n source. She is now s/p ERCP and stent. Patient unable to be extubated\\n over weekend so tube feedings have been restarted and are running at\\n goal.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n Continue with Fibersource HN at goal rate of 50ml/hr x 24\\n hours\\n Monitor residuals q4H and hold tube feeding if greater than\\n 200ml\\n Will follow for possible extubation\\n 11:22 AM\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702547,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Atrial fibrillation (Afib)\\n Assessment:\\n Hr 100-130\\ns afib with sbp ranging from 100-120\\ns. k+3.4 and phos=1.7.\\n afib first occurred during sbt on . pressors were then changed to\\n neo in attempt to drop pt\\ns hr but was unsuccessful. Pt was started on\\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\\n bp support\\n Action:\\n Pt repleted with 30mmol of kphos. Hemodynamics montitored closely.\\n Amioderone gtt decreased to 0.5mg/min after 6 hrs of infusion at\\n 1mg/min. neo being weaned to off as pt\\ns hemodynamics tolerate\\n Response:\\n Hr remains in afib tachy from 100-130\\ns but hemodynamically stable\\n Plan:\\n Plan is to continue infusion of amioderon for 18 hrs and then will\\n consider d/c\\ning gtt. Continue to follow hemodynamics and wean as\\n tolerated to keep map> 60 and hourly uo > 30cc\\ns/hr. check lytes as\\n ordered and replete as needed\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt s/p ercp on . low grade temps but wbc up to 20.2 from yesterday\\n count of 16.blood cultures from grew gm pos rods and gm neg rods.\\n Septic shock most likely secondary to cholangitis and infected\\n stone/sludge.with increase in wbc concern is for a new infection.\\n Action:\\n Fever curve followed closely. Pt receiving piperacillin as ordered.\\n Awaiting final speciation of all culture data. Pan cultured today\\n Response:\\n Low grade temps and elevated wbc unchanged.\\n Plan:\\n Await results for all culture data. Administer antibiotics as ordered\\n and follow fever curve.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt most likely became fatigued in the setting of metabolic acidosis\\n and attempt to hyperventilate to compensate requiring her to be\\n intubated. Placed pt on 40% cpap with 5 peep and ps of 5 . lungs\\n essentially clear on auscultation. Suctioned for sm amts of thick tan\\n sputum.cxr c/w fluid overload which is likely contributing to the\\n difficulty in weaning her off the vent.once pt is weaned off pressors\\n will then need diuresis and hopefully pt will start to mobilize fluid.\\n Action:\\n Vent weaned to 40%cpap with 5 peep and ps of 5. resp status monitored\\n closely. Antibiotics administered as ordered. Reps toileting continues.\\n Decision made not to extubate pt since she became tachypneic ,had lower\\n tv\\ns and appeared more uncomfortable. Versed gtt increased back up to\\n 2mg/hr. vent changed back to ac mode of ventilation. Sputum for c&s\\n sent off to microbiology. Ogt placed in order to start tube fdgs until\\n pt is extubated.\\n Response:\\n Resting comfortably on ac mode after not tolerating decrease in vent\\n settings.\\n Plan:\\n Check rsbi in the am and do sbt. Wean pressors to off if possible and\\n then will diurese as needed . d/c tube fdgs at midnoc in the hope of\\n extubating pt in the am. Continue to monitor pt\\ns resp status and\\n continue with resp toileting\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702944,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - will attempt to decrease sedation this evening and do an SBT, if she\\n looks good will hold tube feeds, otherwise will continue feeds\\n overnight\\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\\n then urine output was over 1L to the lasix\\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\\n MV and O2sats but RR in the 40's with small TV's. After about 15min\\n became uncomfortable with increased WOB-->improved from prior, has more\\n stamina, diuresis seems to be improving her respiratory status\\n - per discussion with patient's family she can be reintubated if she\\n fails extubation\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 11:55 AM\\n Furosemide (Lasix) - 06:14 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:10 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: 37.2\\nC (99\\n HR: 112 (106 - 129) bpm\\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\\n RR: 12 (12 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 733 mL\\n 452 mL\\n PO:\\n TF:\\n 202 mL\\n 264 mL\\n IVF:\\n 531 mL\\n 188 mL\\n Blood products:\\n Total out:\\n 3,345 mL\\n 765 mL\\n Urine:\\n 3,345 mL\\n 765 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,612 mL\\n -313 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 296 (241 - 304) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 166\\n PIP: 18 cmH2O\\n SpO2: 100%\\n ABG: ///30/\\n Ve: 8.6 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 84 K/uL\\n 9.2 g/dL\\n 143 mg/dL\\n 1.3 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 24 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 27.9 %\\n 11.2 K/uL\\n [image002.jpg]\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n WBC\\n 15.3\\n 20.2\\n 11.3\\n 10.6\\n 11.2\\n Hct\\n 31.4\\n 30.7\\n 29.7\\n 29.3\\n 27.9\\n Plt\\n 59\\n 46\\n 52\\n 48\\n 60\\n 84\\n Cr\\n 1.8\\n 1.6\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n TropT\\n 0.02\\n TCO2\\n 23\\n 26\\n 25\\n Glucose\\n 102\\n 91\\n 128\\n 119\\n 126\\n 143\\n Other labs:\\n Mg: 1.6\\n Alk Phos: 103, T. bili: 1.5\\n PT: 12, INR: 1, PTT: 23.7\\n Microbiology:\\nBlood Culture: Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n Imaging:\\n Chest X-Ray (my read): slightly worsening left effusion and right\\n basilar patchy opacity\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR.\\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\\n about 800 cc\\ns in the evening so she was given 20mg IV lasix with a\\n brisk urine output response. Will give another dose of lasix since she\\n had her best SBT with the increased diuresis, hold tube feeds for now\\n in case she is able to be extubated this afternoon. She will likely\\n never have an excellent RSBI, but she will need to not tire and\\n maintain her sats during her SBT.\\n - Hold sedation for now to optimize mental status prior to extubation\\n - need to place a dobhoff prior to extubation as she may be an\\n aspiration risk\\n - CXR looks stable to slightly worsened this morning\\n - family okay with re-intubation if patient fails extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Trialed\\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\\n 100\\ns and her BP tolerated it well.\\n - Increase metoprolol to 25mg and titrate up to good HR control as\\n her BP tolerates\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count stable. Lactate\\n normal. Initial sepsis secondary to biliary source given CBD dilation\\n with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Leukocytosis is resolving\\nwhite count almost normalized. Had been\\n afebrile for over 24 hours.\\n - Cont zosyn pending any further culture data; Day of zosyn.\\n Day 1=. Will f/u cutlure data to see if we can narrow our\\n coverage, if she needs to be continued on Zosyn will place a PICC and\\n pull central line, may be able to transitioned to a po antibiotic\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n - f/u sputum culture\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr back to her baseline at 1.3 today.\\n - Monitor UOP\\n - Trend creatinine while diuresing\\n - Check PM lytes\\n .\\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\\n secondary to sepsis.\\n - Platelet count stable and increasing\\n ICU Care\\n Nutrition:\\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Heparin SQ, pneumo boots\\n Stress ulcer: none while on feeds\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR, is intubated, ok to be reintubated post extubation if\\n necessary\\n Disposition: ICU pending stabilization post extubation\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703001,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Afib 85-130, hr appears responsive to 25mg lopressor. b/p 90s-110/60s.\\n Action:\\n Lopressor for rate control, 10mg IV Lasix\\n Response:\\n Better rate control after Lopressor dose, gentler response to 10mg\\n Lasix today than yesterday, no hypotension associated w/diuresis.\\n Plan:\\n Cont to monitor HR and response to meds.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains intubated, PSV 12/5, on 0/8 with increase in RR to 30s. LS:\\n crackles t/o. Scant secretions via ETT.\\n Action:\\n Tube feeds off in anticipation of possible extubation. Sedation off 3\\n hours w/improvement in mental status, able to nod, laugh and respond to\\n family, currently on 1mg versed and receiving 25mcg bolus of fent PRN\\n pain.\\n Response:\\n Not yet ready for extubation\\n Plan:\\n Tube feeds off at MN as ordered. Daily wake up to aid w/extubation.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702708,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 4\\n Ideal body weight: 54.4 None\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Tube Type\\n ETT:\\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 Secretions\\n Sputum color / consistency: White / Thin\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: PSV level increased this morning; weaned to 10cm at approx.\\n 1600; please see flowsheet for details.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702713,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt on PS 10/5 RR 30\\ns , grimacing, visibly uncomfortable\\n Action:\\n Bolused w/ midaz, put back to PS 12/5\\n Response:\\n Pt tolerated mech vent support, RR 20\\ns TV 300\\ns w/ MV \\n Plan:\\n Will not extubate today will re assess for am extuabtion\\n Sepsis without organ dysfunction\\n Assessment:\\n Off pressors for 24 hrs, ~ 50cc hr, maintaining maps > 60, afebrile\\n Action:\\n Assessed hemodynamics , following VS\\n Response:\\n Pt remains off of pressors\\n Plan:\\n Cont Ab therapy , monitor hemodynamics\\n Atrial fibrillation (Afib)\\n Assessment:\\n Continues in a-fib hr 1teens-130\\n Action:\\n Amiodorone gtt cont @ .5mg /min\\n Response:\\n ongoing\\n Plan:\\n Continue to monitor hr, may wean to po amiodorone\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702865,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 5\\n Ideal body weight: 54.4 None\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\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: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thin\\n Sputum source/amount: Suctioned / Scant\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Pt continues on PSV as charted.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702919,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - will attempt to decrease sedation this evening and do an SBT, if she\\n looks good will hold tube feeds, otherwise will continue feeds\\n overnight\\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\\n then urine output was over 1L to the lasix\\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\\n MV and O2sats but RR in the 40's with small TV's. After about 15min\\n became uncomfortable with increased WOB-->improved from prior, has more\\n stamina, diuresis seems to be improving her respiratory status\\n - per discussion with patient's family she can be reintubated if she\\n fails extubation\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 11:55 AM\\n Furosemide (Lasix) - 06:14 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:10 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: 37.2\\nC (99\\n HR: 112 (106 - 129) bpm\\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\\n RR: 12 (12 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 733 mL\\n 452 mL\\n PO:\\n TF:\\n 202 mL\\n 264 mL\\n IVF:\\n 531 mL\\n 188 mL\\n Blood products:\\n Total out:\\n 3,345 mL\\n 765 mL\\n Urine:\\n 3,345 mL\\n 765 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,612 mL\\n -313 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 296 (241 - 304) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 166\\n PIP: 18 cmH2O\\n SpO2: 100%\\n ABG: ///30/\\n Ve: 8.6 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 84 K/uL\\n 9.2 g/dL\\n 143 mg/dL\\n 1.3 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 24 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 27.9 %\\n 11.2 K/uL\\n [image002.jpg]\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n WBC\\n 15.3\\n 20.2\\n 11.3\\n 10.6\\n 11.2\\n Hct\\n 31.4\\n 30.7\\n 29.7\\n 29.3\\n 27.9\\n Plt\\n 59\\n 46\\n 52\\n 48\\n 60\\n 84\\n Cr\\n 1.8\\n 1.6\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n TropT\\n 0.02\\n TCO2\\n 23\\n 26\\n 25\\n Glucose\\n 102\\n 91\\n 128\\n 119\\n 126\\n 143\\n Other labs:\\n Mg: 1.6\\n Alk Phos: 103, T. bili: 1.5\\n PT: 12, INR: 1, PTT: 23.7\\n Microbiology:\\nBlood Culture: Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n Imaging:\\n Chest X-Ray (my read): slightly worsening left effusion and right\\n basilar patchy opacity\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR.\\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\\n about 800 cc\\ns in the evening so she was given 20mg IV lasix with a\\n brisk urine output response\\n - Wean down vent settings as much as possible, but having difficulty\\n due to volume overload\\n - CXR looks stable to slightly worsened this morning\\n - family okay with re-intubation if patient fails extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Trialed\\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\\n 100\\ns and her BP tolerated it well.\\n - Increase metoprolol to 25mg and titrate up to good HR control as\\n her BP tolerates\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count stable. Lactate\\n normal. Initial sepsis secondary to biliary source given CBD dilation\\n with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Leukocytosis is resolving\\nwhite count almost normalized. Had been\\n afebrile for 24 hours, this morning with low grade temps.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1: . Will f/u cutlure data to see if we can narrow our coverage,\\n if she needs to be continued on Zosyn will place a PICC and pull\\n central line\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n - will send sputum cx with new low grade temps, and slightly worsening\\n chest x-ray\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr back to her baseline at 1.3 today.\\n - Monitor UOP\\n - Trend creatinine\\n .\\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\\n secondary to sepsis.\\n - Will restart SQ heparin as her platelet count has increased and the\\n initial drop was not consistent with HIT\\n - No signs of active bleeding\\n ICU Care\\n Nutrition:\\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Heparin SQ, pneumo boots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR, is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 703058,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 7\\n Ideal body weight: 54.4 None\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Diminished\\n LUL Lung Sounds: Diminished\\n LLL Lung Sounds: Crackles\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea)\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\\n Increase ventilatory support at night\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Underlying illness not resolved\\n Pt initially tachypneic with rr>32. Placed on psv overnight to rest in\\n preparation for possible extubation today. Mod amts of thick white\\n sput. Weak cough and gag.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702767,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 5\\n Ideal body weight: 54.4\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: ICU\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: PSV 12/5/.4\\n Visual assessment of breathing pattern: Occ tachypneic (RR> 35 b/min),\\n baseline rr 30\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Comments: Maintaining Vt 3-400 ml with Ve 8-9 L, sp02 99-100%\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Hemodynimic instability, Underlying illness not\\n resolved\\n Respiratory Care Shift Procedures\\n Bedside Procedures: RSBI 204; heated wire system added for humidity\\n Comments: Slow PSV wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703241,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent. Respiratory failure initially thought to be due to\\n metabolic acidosis which caused her to hyperventilate to compensate.\\n She fatigued quickly becoming acutely SOB and required intubation on\\n ^th. Since then, unable to wean vent because of pt being\\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\\n coming off peep becoming very tachypneic with low tidal volumes which\\n is more concerning for difficulty with compliance then volume overload.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Received pt in Afib; HR ranging from 90-130\\ns. SBP 85-120\\ns. Afib first\\n occurred during SBT on . Occasional PVC\\ns noted.\\n Action:\\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\\n 20mEq IV given last evening per sliding scale orders.\\n Response:\\n Pt has remained in Afib but rate has significantly improved w/\\n administration of Lopressor & Dilt. HR ranging 80\\n low 100\\ns w/\\n minimal ectopy. Magnesium & K levels WNL this AM.\\n Plan:\\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\\n Diltiazem. Follow electrolyte status & replete as needed.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\\n 30-40\\ns but appearing comfortable & settles out on own. LS clear,\\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\\n 1.5\\n 2L. Mental status much improved. Pt following commands and\\n actively participating in care. Remains restless @ times but is easily\\n redirected.\\n Action:\\n Suctioning q2-4 hrs for thick/white sputum. Pt appears to be pooling\\n large amts of secretions in the subglottal area. (concern for\\n aspiration post extubation)\\n Response:\\n Pt -2L @ MN. AM RSBI 154 (will complete SBT once ETT is exchanged & pt\\n is bronched per Dr. \\n Plan:\\n Plan to diurese as pt\\ns hemodynamics tolerate. Net goal - 1.5\\n 2L @\\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\\n exchange. If all goes as planned, pt will be extubated late morning. As\\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\\n remains DNR)\\n DNR (will reintubate if necessary)\\n L DL PICC\\n Family in to see pt and updated by this RN last evening\\n Pt did have 2 smears of stool overnight. Please monitor\\n closely. Skin breakdown is of concern, amt of stool was not significant\\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\\n not benefit from fecal inc. bag)\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703052,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\\n RR up to 34-36 pt volume overloaded, remains on 1 mg Versed IV\\n gtt, with prn boluses of 0.5 mg suctioned for sm amts of thick white\\n sputum. CXR volume overload ~ needs to be diuresed. CVP~12\\n Action:\\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\\n received 10 mg IVP Lasix at 9 pm with good response. Received repeat\\n 20 mg IVP Lasix at 4:30 am.\\n Response:\\n Pt rested overnight on AC. Pt continues to diurese\\n Plan:\\n Change back to pressure support in am, check RSBI, ?ready for\\n extubation repeat RSBI~157 would like pt negative one liter.\\n Continue Versed gtt continue with pulmonary toilet.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in Afib, rate 115-130 bp 100/60\\n Action:\\n Lopressor increased to 25 mg per NGT tid, also received 2.5 mg IV\\n Lopressor at 4:30 am\\n Response:\\n HR down to 107 Afib\\n Plan:\\n Continue to monitor HR, bp closely. Lopressor increased to tid (25\\n mg)\\n GI: OG tube removed, r nare NG tube inserted, confirmed by CXRAY,\\n also pulled back bile, and air heard in stomach. Passing loose stool.\\n tube feedings off at 12 midnight (will try again today to extubate)\\n ID: Afebrile, ERCP on showed significant pus and very large\\n stone, pt is s/p stent placement. Pt remains on Zosyn\\n NEURO: remains on 1 mg/hr IV Versed gtt opens eyes to command, pt\\n agitated at times, moving around in bed, hands restrained for safety,\\n pt putting hands on ETT.\\n SOCIAL: pt is DNR, if gets extubated would be reintubated. Husband\\n and 2 daughters in last evening.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 703245,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 8\\n Ideal body weight: 54.4 None\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments: suctioned frequently\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Cannot manage\\n secretions, Underlying illness not resolved\\n Comments: Pt. remains intubated on IPS overnoc. Suctioned frequently\\n for large amounts thick white sputum. Plan to change ET tube this am to\\n a larger ET , bronchoscopy prior to extubation. RSBI 154 this am. RR\\n 30\\ns at baseline.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702849,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib at a rate of 100-130s, BP has been stable\\n Action:\\n Her amnio was d/ced and lopressor was started\\n Response:\\n Tolerated the lopressor\\n it seemed to lower her HR from the 120s to\\n the 100s\\n Plan:\\n Titrate up the lopressor\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Remains vented, lots of oral and ETT secretions, tachypnic to the 40s\\n with VTs in the 300s\\n Action:\\n Unable to extubate today, to receive lasix this afternoon, restarted TF\\n Response:\\n Not yet ready for extubation\\n Plan:\\n Follow I&Os, lytes, cont to try to wean, cont pulm toilet\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702189,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\\n versed 3mg/hr.\\n Action:\\n Suctioned for small amount secretions. Blood gas in the am. Versed\\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\\n Response:\\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/ .am\\n RSBI 54 and tolerated well.\\n Plan:\\n Wean vent / sedations as tolerated further and for possible\\n extubation today.\\n Sepsis without organ dysfunction\\n Assessment:\\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\\nS on\\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\\n /BUN 37,elevated liver enzymes.\\n Action:\\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\\n with NaHCo3 150 meq given for hydration and for PH 7.29 from the\\n evening lab\\n Response:\\n SBP 85-90\\ns when tried to titrate Levophed further .so continued on\\n 0.07mics. urine output improved with fluid bolus.\\n Plan:\\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702188,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\\n versed 3mg/hr.\\n Action:\\n Suctioned for small amount secretions. Blood gas in the am. Versed\\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\\n Response:\\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/\\n Plan:\\n Wean vent / sedations as tolerated further.\\n Sepsis without organ dysfunction\\n Assessment:\\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\\nS on\\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\\n /BUN 37,elevated liver enzymes.\\n Action:\\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\\n with NaHCo3 150 meq given for hydration and for PH 7.1 from the\\n evening lab\\n Response:\\n SBP 85-90\\ns when tried to titrate Levophed further .so continued on\\n 0.07mics. urine output improved with fluid bolus.\\n Plan:\\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702466,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. s/p ERCP with stent placement\\n - patient became tachycardic with so changed back to A/C--> went\\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\\n which dropped her BP into the 70's systolic and her HR decreased into\\n the 110's. Her heart rate remained elevated in the 130\\ns and she\\n continued to have a pressor requirement, so she was started on\\n amiodarone early this morning.\\n - early this morning\\npatient very tahcypneic, unable to be\\n extubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Phenylephrine - 1 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Diltiazem - 11:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 133 (72 - 141) bpm\\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\\n RR: 31 (10 - 34) insp/min\\n SpO2: 97%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 18 (0 - 325)mmHg\\n Mixed Venous O2% Sat: 79 - 79\\n Total In:\\n 5,376 mL\\n 285 mL\\n PO:\\n TF:\\n IVF:\\n 5,376 mL\\n 285 mL\\n Blood products:\\n Total out:\\n 1,320 mL\\n 555 mL\\n Urine:\\n 1,320 mL\\n 555 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,056 mL\\n -270 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): 317 (308 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: RR >35-had good tidal volumes though\\n PIP: 15 cmH2O\\n SpO2: 97%\\n ABG: 7.41/39/98./26/0\\n Ve: 8.8 L/min\\n PaO2 / FiO2: 245\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 52 K/uL\\n 10.5 g/dL\\n 91 mg/dL\\n 1.6 mg/dL\\n 26 mEq/L\\n 3.4 mEq/L\\n 32 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 20.2 K/uL\\n [image002.jpg]\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n WBC\\n 25.0\\n 17.8\\n 15.3\\n 20.2\\n Hct\\n 31.6\\n 30.8\\n 31.4\\n 30.7\\n Plt\\n 93\\n 48\\n 59\\n 46\\n 52\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n TropT\\n 0.02\\n 0.02\\n TCO2\\n 18\\n 23\\n 23\\n 26\\n Glucose\\n 195\\n 151\\n 266\\n 102\\n 91\\n Other labs:\\n Ca: 7.7, Mg: 2.4, Phos: 1.7\\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\\n PT: 12.2, INR: 1.0\\n Microbiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n GRAM NEGATIVE ROD(S).\\n 11:58 pm BLOOD CULTURE X2.\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n URINE CULTURE (Final ): NO GROWTH.\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\\n been doing well on the ventilator, had hoped to extubate her yesterday,\\n however she went into A.fib with RVR during her , she was\\n intially changed back to A/C, then transitioned back to PSV.\\n - early this morning\\npatient very tachypneic with lower tidal\\n volumes, appeared very uncomfortable during short trial this morning,\\n will transition back to A/C and then wean to PSV throughout the day\\n -Chest x-ray appeared volume overloaded, which is likely contributing\\n to the difficulty weaning her off the ventilator, when patient is able\\n to be weaned off pressors will need diuresis. Hopefully patient will\\n start to mobilize her extra fluid, however once off pressors if she is\\n unable to, will give lasix as needed to help decrease the fluid in her\\n lungs\\n - Hopeful extubation tomorrow pending ability to diurese\\n # Atrial Fibrillation: First occurred during on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns, pressor changed\\n from levophed to neo without any effect, her BP dropped with IV dilt,\\n so started amiodarone morning of due to continued pressor\\n requirement\\n - Monitor for improvement and hopeful d/c of amio once patient is\\n extubated and off sedation\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - With increasing leukocytosis concern for a new infection, will\\n reculture blood, urine and sputum, also send a C.diff when patient has\\n a bowel movement, if LFT\\ns increase, will reimage RUQ due to concern\\n for possible blockage of stent\\n - Cont zosyn pending any further culture data; f/u speciation and\\n sensitivities from prior blood cx\\n - Trend CBC/diff, LFTs, especially in the setting on increasing\\n leukocytosis, will add on Diff to AM labs\\n - Follow up blood cx speciation , urine cx with no growth\\n - Wean neo as tolerated by MAP >= 60 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea, also likely some component of ATN\\n as her renal function has not improved as quickly with fluids as would\\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\\n baseline creatinine 1.2-1.4.\\n - Titrate MAP to greater than 60, unless urine output decreases then\\n will titrate to increased MAP\\n .\\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\\n timing does not correlate since patient has not had a prior heparin\\n exposure. Vancomycin may also be contributing to her\\n thrombocytopenia. Platelets slightly increased today.\\n - Continue to hold vanc/heparin\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n - If platelets remain stable or increase tomorrow would restart heparin\\n as HIT is very unlikely\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Bicarb 26 today, extubation will be facilitated by resolution of\\n acidosis.\\n ICU Care\\n Nutrition: Will place OG tube for tube feeds today and turn them off at\\n midnight for hopeful extubation tomorrow\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR-is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702596,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt intubated , cpap/ps see metavision for vent settings, continues\\n lightly sedated with versed 2mg.\\n Action:\\n Vent settings cpap/ps 10/5 fio2 40%\\n Response:\\n Am blood gas 7.46/34/27\\n Plan:\\n possible extubation today. tube feeds off since midnight\\n Sepsis without organ dysfunction\\n Assessment:\\n s/p ERCP, was on pressors after procedure\\n Action:\\n Neo has been weaned\\n Response:\\n Maps greater than 60 , following NBP\\nS, -a-line that was reinserted\\n yesterday had fallen out\\n Plan:\\n Follow vs\\n Atrial fibrillation (Afib)\\n Assessment:\\n Continues in a-fib hr 120-130\\n Action:\\n Amiodorone gtt is being cont. passed the 18hours\\n Response:\\n ongoing\\n Plan:\\n Continue to monitor hr, may wean to po amiodorone\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 702691,\n \"text\": \"TITLE:\\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\\n presents with septic shock and cholangitis, s/p ERCP with stent, and\\n respiratory failure. Now with persistent vent requirements.\\n 24 Hour Events:\\n Arterial line came out.\\n Patient unable to provide history: Sedated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Fentanyl - 05:00 PM\\n Midazolam (Versed) - 08:11 AM\\n Other medications:\\n Changes to medical and family history: No changes\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: Unable to obtain, patient sedated and intubated.\\n Flowsheet Data as of 11:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 128 (114 - 141) bpm\\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\\n RR: 23 (14 - 30) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 1,682 mL\\n 311 mL\\n PO:\\n TF:\\n 73 mL\\n 1 mL\\n IVF:\\n 1,610 mL\\n 310 mL\\n Blood products:\\n Total out:\\n 2,045 mL\\n 920 mL\\n Urine:\\n 2,045 mL\\n 920 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -363 mL\\n -609 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): 380 (308 - 528) mL\\n PS : 12 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 16 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 31.6 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/34/127/24/1\\n Ve: 9.9 L/min\\n PaO2 / FiO2: 318\\n Physical Examination\\n Gen\\nl: intubated, sedated\\n HEENT: ETT in place, pupils constricted by equal and reactive\\n Pulm: diminished, transmitted vent sounds, no wheezing, crackles at\\n bases anteriorly\\n CV: irregularly irregular, tachycardic, distant and no murmur\\n appreciated, no gallop or rubs\\n Abdomen: soft, no grimace to palpation, (+) bowel sounds\\n Extremities: no edema\\n Neurologic: responds to tactile stimuli, non-purposeful movement\\n Labs / Radiology\\n 9.8 g/dL\\n 48 K/uL\\n 128 mg/dL\\n 1.5 mg/dL\\n 24 mEq/L\\n 4.0 mEq/L\\n 29 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 29.7 %\\n 11.3 K/uL\\n [image002.jpg]\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n Cr\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 151\\n 266\\n 102\\n 91\\n 128\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\\n PO4:2.2 mg/dL\\n Assessment and Plan\\n Respiratory failure\\n - now likely secondary to volume overload\\n - goal TBB - 1 to -1.5L today and will give prn lasix\\n - wean pressure support as tolerated, check CXR\\n Septic shock\\n - now off pressors, autodiuresing\\n - on zosyn, day , leukocytosis improving\\n - LFTs improving s/p stenting via ERCP\\n - awaiting speciation/sensitivities from cultures\\nAtrial fibrillation\\n - on amiodarone drip, will continue for now\\n - will calculate total dose today\\n Thrombocytopenia\\n - stable, no signs of active bleeding\\n - very low suspicion for HIT\\n - will restart SC heparin when plts >50K\\n ICU Care\\n Nutrition:\\n Comments: restart TF as unlikely to be extubated today\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Not indicated\\n VAP: HOB elevation, Mouth care, Daily wake up\\n Comments:\\n Communication: Family meeting held , ICU consent signed\\n Code status: DNR (do not resuscitate)\\n Disposition :ICU\\n Total time spent: 30 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702692,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - amio gtt started in early AM yesterday--> slow progress\\n - Neo stopped at 0000\\n - OG + tube feeds today, NPO at midnight with hopes for extubation\\n - increasing WBC, send sputum for cx, blood and urine cx;\\n - if she starts to spike again, then add back Vancomycin\\n - Gm+ and Gm- rods in blood in anaerobic bottle\\n - Was on AC for most of day after SBT; switched to PS 12/5-- ABG:\\n 7.46/34/127 (at 3:15am) RSBI: couldn\\nt tolerate b/c tachypnea:\\n UOP 50-180 cc/hour\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Fentanyl - 05:00 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 07:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37\\nC (98.6\\n HR: 141 (111 - 141) bpm\\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\\n RR: 25 (14 - 36) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 8 (8 - 8)mmHg\\n Total In:\\n 1,682 mL\\n 197 mL\\n PO:\\n TF:\\n 73 mL\\n 1 mL\\n IVF:\\n 1,610 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,045 mL\\n 520 mL\\n Urine:\\n 2,045 mL\\n 520 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -363 mL\\n -322 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): 482 (308 - 528) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 24\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 17 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 31.6 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/34/127/24/1\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 318\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 9.8 g/dL\\n 128 mg/dL\\n 1.5 mg/dL\\n 24 mEq/L\\n 4.0 mEq/L\\n 29 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 29.7 %\\n 11.3 K/uL\\n [image002.jpg]\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n Cr\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 151\\n 266\\n 102\\n 91\\n 128\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\\n PO4:2.2 mg/dL\\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\\n GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\\n GPR anaerobic bottles\\n GNR in\\n anaerobic bottles\\nPan cultured yesterday: NGTD\\nRadiology: None today\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\\n Unable to wean effectively; likely secondary to fluid resuscitation; as\\n fluid overload is seen on CXR.\\n - Monitor UOP as patient is auto-diuresing well. Check i/o\\ns this\\n evening with TBB 1-1.5 liters\\n - Wean down vent settings as much as possible, will likely be more\\n effective once\\n - CXR today to make sure no other acute process is occuring\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns, pressor changed\\n from levophed to neo without any effect, her BP dropped with IV dilt,\\n so started amiodarone morning of due to continued pressor\\n requirement\\n - Continue amio gtt as HR has improved, but she is still tachycardic in\\n the low 100\\n - Monitor for improvement and hopeful d/c of amio once patient is\\n extubated and off sedation\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\\n be improving.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1: .\\n - f/u speciation and sensitivities from prior blood cx\\n - Trend CBC/diff, LFTs,\\n - Follow up blood cx speciation , urine cx with no growth\\n - no need for pressors now. Monitor maps > 65.\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\\n - Monitor UOP\\n - Trend creatinine\\n .\\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\\n of HIT as timing does not correlate since patient has not had a prior\\n heparin exposure. Vancomycin may also be contributing to her\\n thrombocytopenia\\n - Continue to hold vanc/heparin\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n - If platelets remain stable or increase tomorrow would restart heparin\\n as HIT is very unlikely\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Bicarb 24 today, extubation will be facilitated by resolution of\\n acidosis.\\n ICU Care\\n Nutrition: OG tube feeds\\n Glycemic Control:\\n Lines: ( no A-line for now: A line measurement were SBP \\n points higher than cuff pressure)\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR-is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702693,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - amio gtt started in early AM yesterday--> slow progress\\n - Neo stopped at 0000\\n - OG + tube feeds today, NPO at midnight with hopes for extubation\\n - increasing WBC, send sputum for cx, blood and urine cx;\\n - if she starts to spike again, then add back Vancomycin\\n - Gm+ and Gm- rods in blood in anaerobic bottle\\n - Was on AC for most of day after SBT; switched to PS 12/5-- ABG:\\n 7.46/34/127 (at 3:15am) RSBI: couldn\\nt tolerate b/c tachypnea:\\n UOP 50-180 cc/hour\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Fentanyl - 05:00 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 07:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37\\nC (98.6\\n HR: 141 (111 - 141) bpm\\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\\n RR: 25 (14 - 36) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 8 (8 - 8)mmHg\\n Total In:\\n 1,682 mL\\n 197 mL\\n PO:\\n TF:\\n 73 mL\\n 1 mL\\n IVF:\\n 1,610 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,045 mL\\n 520 mL\\n Urine:\\n 2,045 mL\\n 520 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -363 mL\\n -322 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): 482 (308 - 528) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 24\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 17 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 31.6 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/34/127/24/1\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 318\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 9.8 g/dL\\n 128 mg/dL\\n 1.5 mg/dL\\n 24 mEq/L\\n 4.0 mEq/L\\n 29 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 29.7 %\\n 11.3 K/uL\\n [image002.jpg]\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n Cr\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 151\\n 266\\n 102\\n 91\\n 128\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\\n PO4:2.2 mg/dL\\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\\n GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\\n GPR anaerobic bottles\\n GNR in\\n anaerobic bottles\\nPan cultured yesterday: NGTD\\nRadiology: None today\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\\n Unable to wean effectively; likely secondary to fluid resuscitation; as\\n fluid overload is seen on CXR.\\n - Monitor UOP as patient is auto-diuresing well. Check i/o\\ns this\\n evening with TBB 1-1.5 liters\\n - Wean down vent settings as much as possible, will likely be more\\n effective once\\n - CXR today to make sure no other acute process is occuring\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns, pressor changed\\n from levophed to neo without any effect, her BP dropped with IV dilt,\\n so started amiodarone morning of due to continued pressor\\n requirement\\n - Continue amio gtt as HR has improved, but she is still tachycardic in\\n the low 100\\n - Monitor for improvement and hopeful d/c of amio once patient is\\n extubated and off sedation\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\\n be improving.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1: .\\n - f/u speciation and sensitivities from prior blood cx\\n - Trend CBC/diff, LFTs,\\n - Follow up blood cx speciation , urine cx with no growth\\n - no need for pressors now. Monitor maps > 65.\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\\n - Monitor UOP\\n - Trend creatinine\\n .\\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\\n of HIT as timing does not correlate since patient has not had a prior\\n heparin exposure. Vancomycin may also be contributing to her\\n thrombocytopenia\\n - Continue to hold vanc/heparin\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n - If platelets remain stable or increase tomorrow would restart heparin\\n as HIT is very unlikely\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Bicarb 24 today, extubation will be facilitated by resolution of\\n acidosis.\\n ICU Care\\n Nutrition: OG tube feeds\\n Glycemic Control:\\n Lines: ( no A-line for now: A line measurement were SBP \\n points higher than cuff pressure)\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR-is intubated\\n Disposition: ICU\\n ------ Protected Section ------\\n Patient may need a PICC line tomorrow if sensitivities of cultures do\\n not return. She may need a full 10 day course of zosyn.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 13:38 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702762,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt on PS 12/5 40%, rr 30\\n Action:\\n Sedation off at 2am for ? extubate this am , tube feeds off also\\n Response:\\n RSBI 204 this am\\n Plan:\\n Sedation turned back on at 520 due to pt\\ns increased rr rate, plan to\\n extubate should be reassed at rounds, if no extubation today tube feeds\\n need to be restarted\\n Sepsis without organ dysfunction\\n Assessment:\\n Off pressors for 24 hrs, ~ 50cc hr, maintaining maps > 60, afebrile\\n Action:\\n Assessed hemodynamics , following VS\\n Response:\\n Pt remains off of pressors\\n Plan:\\n Cont Ab therapy , monitor hemodynamics\\n Atrial fibrillation (Afib)\\n Assessment:\\n Continues in a-fib hr 1teens-130\\n Action:\\n Amiodorone gtt cont @ .5mg /min\\n Response:\\n ongoing\\n Plan:\\n Continue to monitor hr, may wean to po amiodorone\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702316,\n \"text\": \"Sepsis without organ dysfunction\\n Assessment:\\n T max 99.2 oral. Remains on Levophed to maintain sbp > 90. Patient\\n alert follows command denies abd pain c/o of mouth pain from ET.RIJ 3\\n lumen patent CVP 6-13pt in A Fib. Low PLT\\n Action:\\n Attempted to wean Levophed without success. Fluid given a total of 2.5\\n liters. Blood culture from aline and RIJ sent. Labs sent. Antibiotics\\n as ordered. Heparin and vancomycin stopped\\n Response:\\n CVP up to from 6. Urine changed from amber to yellow. Initially\\n able to wean Levophed but then sbp dropped x2 levophed at .07mcg. A\\n Fib continues PLT still low.\\n Plan:\\n Monitor plt, gap and lytes treat as indicated. Monitor urine output.\\n Monitor HR and rhythm.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Patient does not appear in any distress tolerating ET tube though asked\\n for it to be removed calm and cooperative. Oxygen saturation\\n consistently over 95. RR 20-40. Lungs clear. Sputum clear and thick. No\\n fever. Large amt of oral secretions. AT about 1030 Attempted to wean in\\n am patient tolerated CPAP and PS on spontaneous breathing trial patient\\n did not appear distress o2 SAT >95 but rhythm changed to AFIB\\n Action:\\n Pt placed back on vent after rhythm changed several hours later placed\\n back on CPAP with PS, oral suction frequently. BS checked. Mouth care\\n given turned q3-4 hours\\n Response:\\n Patient tolerating CPAP with PS oxygenation is > 95 patient appears\\n comfortable\\n Plan:\\n Monitor resp. status. wean if able tomorrow. ABG\\ns as indicated.\\n Monitor continuous O2 saturation. Suction as needed. Check results of\\n cultures. Continue antibiotics.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 702677,\n \"text\": \"TITLE:\\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\\n presents with septic shock and cholangitis, s/p ERCP with stent, and\\n respiratory failure. Now with persistent vent requirements.\\n 24 Hour Events:\\n Arterial line\\n Patient unable to provide history: Sedated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Fentanyl - 05:00 PM\\n Midazolam (Versed) - 08:11 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 128 (114 - 141) bpm\\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\\n RR: 23 (14 - 30) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 1,682 mL\\n 311 mL\\n PO:\\n TF:\\n 73 mL\\n 1 mL\\n IVF:\\n 1,610 mL\\n 310 mL\\n Blood products:\\n Total out:\\n 2,045 mL\\n 920 mL\\n Urine:\\n 2,045 mL\\n 920 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -363 mL\\n -609 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): 380 (308 - 528) mL\\n PS : 12 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 16 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 31.6 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/34/127/24/1\\n Ve: 9.9 L/min\\n PaO2 / FiO2: 318\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 9.8 g/dL\\n 48 K/uL\\n 128 mg/dL\\n 1.5 mg/dL\\n 24 mEq/L\\n 4.0 mEq/L\\n 29 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 29.7 %\\n 11.3 K/uL\\n [image002.jpg]\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n Cr\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 151\\n 266\\n 102\\n 91\\n 128\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\\n PO4:2.2 mg/dL\\n Assessment and Plan\\n Respiratory failure\\n - now likely secondary to volume overload\\n - goal TBB - 1 to -1.5L today and will give prn lasix\\n - wean pressure support as tolerated, check CXR\\n Septic shock\\n - now off pressors, autodiuresing\\n - on zosyn, day , leukocytosis improving\\n - LFTs improving s/p stenting via ERCP\\n - awaiting speciation/sensitivities from cultures\\nAtrial fibrillation\\n - on amiodarone drip, will continue for now\\n Thrombocytopenia\\n - stable, no signs of active bleeding\\n - will restart SC heparin when\\n ICU Care\\n Nutrition:\\n Comments: restart TF as unlikely to be extubated today\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Not indicated\\n VAP: HOB elevation, Mouth care, Daily wake up\\n Comments:\\n Communication: Family meeting held , ICU consent signed Comments:\\n Code status: DNR (do not resuscitate)\\n Disposition :ICU\\n Total time spent: 30 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702462,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. s/p ERCP with stent placement\\n - patient became tachycardic with so changed back to A/C--> went\\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\\n which dropped her BP into the 70's systolic and her HR decreased into\\n the 110's. Her heart rate remained elevated in the 130\\ns and she\\n continued to have a pressor requirement, so she was started on\\n amiodarone early this morning.\\n - early this morning for hopeful extubation\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Phenylephrine - 1 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Diltiazem - 11:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 133 (72 - 141) bpm\\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\\n RR: 31 (10 - 34) insp/min\\n SpO2: 97%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 18 (0 - 325)mmHg\\n Mixed Venous O2% Sat: 79 - 79\\n Total In:\\n 5,376 mL\\n 285 mL\\n PO:\\n TF:\\n IVF:\\n 5,376 mL\\n 285 mL\\n Blood products:\\n Total out:\\n 1,320 mL\\n 555 mL\\n Urine:\\n 1,320 mL\\n 555 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,056 mL\\n -270 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): 317 (308 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: RR >35-had good tidal volumes though\\n PIP: 15 cmH2O\\n SpO2: 97%\\n ABG: 7.41/39/98./26/0\\n Ve: 8.8 L/min\\n PaO2 / FiO2: 245\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 52 K/uL\\n 10.5 g/dL\\n 91 mg/dL\\n 1.6 mg/dL\\n 26 mEq/L\\n 3.4 mEq/L\\n 32 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 20.2 K/uL\\n [image002.jpg]\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n WBC\\n 25.0\\n 17.8\\n 15.3\\n 20.2\\n Hct\\n 31.6\\n 30.8\\n 31.4\\n 30.7\\n Plt\\n 93\\n 48\\n 59\\n 46\\n 52\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n TropT\\n 0.02\\n 0.02\\n TCO2\\n 18\\n 23\\n 23\\n 26\\n Glucose\\n 195\\n 151\\n 266\\n 102\\n 91\\n Other labs:\\n Ca: 7.7, Mg: 2.4, Phos: 1.7\\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\\n PT: 12.2, INR: 1.0\\n Microbiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n GRAM NEGATIVE ROD(S).\\n 11:58 pm BLOOD CULTURE X2.\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n URINE CULTURE (Final ): NO GROWTH.\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\\n been doing well on the ventilator, had hoped to extubate her yesterday,\\n however she went into A.fib with RVR during her , she was\\n intially changed back to A/C, then transitioned back to PSV.\\n - early this morning, discontinue sedation for hopeful extubation\\n this morning\\n # Atrial Fibrillation: First occurred during on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns, pressor changed\\n from levophed to neo without any effect, her BP dropped with IV dilt,\\n so started amiodarone morning of due to continued pressor\\n requirement\\n - Monitor for improvement and hopeful d/c of amio once patient is\\n extubated and off sedation\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - With increasing leukocytosis concern for a new infection, will\\n reculture blood, urine and sputum, also send a C.diff when patient has\\n a bowel movement, if LFT\\ns increase, will reimage RUQ due to concern\\n for possible blockage of stent\\n - Cont zosyn pending any further culture data\\n - Trend CBC/diff, LFTs, especially in the setting on increasing\\n leukocytosis, will add on Diff to AM labs\\n - Follow up blood cx speciation , urine cx with no growth\\n - Wean neo as tolerated by MAP >= 60 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea, also likely some component of ATN\\n as her renal function has not improved as quickly with fluids as would\\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\\n baseline creatinine 1.2-1.4.\\n - Titrate MAP to greater than 60, unless urine output decreases then\\n will titrate to increased MAP\\n .\\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\\n timing does not correlate since patient has not had a prior heparin\\n exposure. Vancomycin may also be contributing to her\\n thrombocytopenia. Platelets slightly increased today.\\n - Continue to hold vanc/heparin\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n - If platelets remain stable or increase tomorrow would restart heparin\\n as HIT is very unlikely\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Bicarb 26 today, extubation will be facilitated by resolution of\\n acidosis.\\n ICU Care\\n Nutrition: Will place OG tube for tube feeds today and turn them off at\\n midnight for hopeful extubation tomorrow\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR-is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702438,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. s/p ERCP with stent placement\\n - patient became tachycardic with so changed back to A/C--> went\\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\\n which dropped her BP into the 70's systolic and her HR decreased into\\n the 110's. Her heart rate remained elevated in the 130\\ns and she\\n continued to have a pressor requirement, so she was started on\\n amiodarone early this morning.\\n - early this morning for hopeful extubation\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Phenylephrine - 1 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Diltiazem - 11:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 133 (72 - 141) bpm\\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\\n RR: 31 (10 - 34) insp/min\\n SpO2: 97%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 18 (0 - 325)mmHg\\n Mixed Venous O2% Sat: 79 - 79\\n Total In:\\n 5,376 mL\\n 285 mL\\n PO:\\n TF:\\n IVF:\\n 5,376 mL\\n 285 mL\\n Blood products:\\n Total out:\\n 1,320 mL\\n 555 mL\\n Urine:\\n 1,320 mL\\n 555 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,056 mL\\n -270 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): 317 (308 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: RR >35-had good tidal volumes though\\n PIP: 15 cmH2O\\n SpO2: 97%\\n ABG: 7.41/39/98./26/0\\n Ve: 8.8 L/min\\n PaO2 / FiO2: 245\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 52 K/uL\\n 10.5 g/dL\\n 91 mg/dL\\n 1.6 mg/dL\\n 26 mEq/L\\n 3.4 mEq/L\\n 32 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 20.2 K/uL\\n [image002.jpg]\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n WBC\\n 25.0\\n 17.8\\n 15.3\\n 20.2\\n Hct\\n 31.6\\n 30.8\\n 31.4\\n 30.7\\n Plt\\n 93\\n 48\\n 59\\n 46\\n 52\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n TropT\\n 0.02\\n 0.02\\n TCO2\\n 18\\n 23\\n 23\\n 26\\n Glucose\\n 195\\n 151\\n 266\\n 102\\n 91\\n Other labs:\\n Ca: 7.7, Mg: 2.4, Phos: 1.7\\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\\n PT: 12.2, INR: 1.0\\n Microbiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n GRAM NEGATIVE ROD(S).\\n 11:58 pm BLOOD CULTURE X2.\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n URINE CULTURE (Final ): NO GROWTH.\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\\n been doing well on the ventilator, had hoped to extubate her yesterday,\\n however she went into A.fib with RVR during her , she was\\n intially changed back to A/C, then transitioned back to PSV.\\n - early this morning, discontinue sedation for hopeful extubation\\n this morning\\n # Atrial Fibrillation: First occurred during on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns, pressor changed\\n from levophed to neo without any effect, her BP dropped with IV dilt,\\n so started amiodarone morning of due to continued pressor\\n requirement\\n - Monitor for improvement and hopeful d/c of amio once patient is\\n extubated and off sedation\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Cont zosyn pending any further culture data\\n - Trend CBC/diff, LFTs\\n - Follow up blood cx speciation , urine cx with no growth\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean neo as tolerated by MAP >= 65 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea, also likely some component of ATN\\n as her renal function has not improved as quickly with fluids as would\\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\\n baseline creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in\\n case she had lasix, FeUrea: 14.9%...\\n - IVFs for CVP 10-12: patient bolused large volume of fluid yesterday\\n with improvement in CVP to 12\\n .\\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\\n timing does not correlate since patient has not had a prior heparin\\n exposure. Vancomycin may also be contributing to her\\n thrombocytopenia. Platelets slightly increased today.\\n - Continue to hold vanc/heparin\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Bicarb 26 today, extubation will be facilitated by resolution of\\n acidosis.\\n ICU Care\\n Nutrition: NPO pending hopeful extubation this morning, can restart\\n diet post extubation\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR-is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"MICU Fellow Note\",\n \"row_id\": 702825,\n \"text\": \"TITLE:\\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\\n found to have cholangitis, now s/p ERCP and stenting, with course\\n complicated by respiratory failure.\\n 24 Hour Events:\\n Decreased sedation overnight but had increasing agitation, had\\n increased RR and decreasing tidal volumes so re-sedated and left at PS\\n .\\n Patient unable to provide history: Sedated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\\n RR: 37 (14 - 38) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 628 mL\\n 243 mL\\n PO:\\n TF:\\n 128 mL\\n 4 mL\\n IVF:\\n 500 mL\\n 239 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 965 mL\\n Urine:\\n 1,795 mL\\n 965 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,167 mL\\n -722 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 304 (260 - 483) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 35\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 204\\n PIP: 18 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 9.5 L/min\\n Physical Examination\\n General Appearance: intubated, sedated\\n HEENT: ETT in place, slight icterus\\n Pulm: diminished at the bases, transmitted vent sounds, no wheezing\\n CV: irregularly irregular, soft SM, no rub or gallop\\n Abdomen: soft, non-tender, non-distended, (+) bowel sounds\\n Ext: no edema\\n Skin: Not assessed\\n Labs / Radiology\\n 9.9 g/dL\\n 60 K/uL\\n 119 mg/dL\\n 1.5 mg/dL\\n 26 mEq/L\\n 4.2 mEq/L\\n 26 mg/dL\\n 107 mEq/L\\n 141 mEq/L\\n 29.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n 10.6\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n 29.3\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n 60\\n Cr\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 266\\n 102\\n 91\\n 128\\n 119\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\\n PO4:2.2 mg/dL\\n Assessment and Plan\\n Respiratory Failure\\n - continues to do poorly with decreased support, possibly due to\\n ongoing volume overload\\n - will follow TBB as she is autodiuresing, goal TBB -1L\\n - low suspicion for underlying pneumonia given improving infectious\\n parameters and shock\\n - will continue PS today, repeat lightening of sedation and SBT\\n tomorrow morning\\n Septic shock\\n - s/p ERCP with cholangitis\\n - called micro for speciation of organisms, narrow abx if able\\n - shock resolved, creatinine improved\\n - on day Zosyn\\n Atrial fibrillation\\n - continues to be tachycardic, though improved\\n - can try low dose beta-blocker today if BP tolerates\\n - consider d'c amiodarone if able to be on beta-blocker\\n Acute renal failure\\n - improved overall\\n - some of urine output now may be post-ATN diuresis\\n Thrombocytopenia\\n - slightly improved, no evidence of bleeding\\n - will restart sc heparin today\\n ICU Care\\n Nutrition: TF\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: Not indicated\\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: 30 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"MICU Fellow Note\",\n \"row_id\": 702834,\n \"text\": \"TITLE:\\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\\n found to have cholangitis, now s/p ERCP and stenting, with course\\n complicated by respiratory failure.\\n 24 Hour Events:\\n Decreased sedation overnight but had increasing agitation, had\\n increased RR and decreasing tidal volumes so re-sedated and left at PS\\n .\\n Patient unable to provide history: Sedated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\\n RR: 37 (14 - 38) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 628 mL\\n 243 mL\\n PO:\\n TF:\\n 128 mL\\n 4 mL\\n IVF:\\n 500 mL\\n 239 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 965 mL\\n Urine:\\n 1,795 mL\\n 965 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,167 mL\\n -722 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 304 (260 - 483) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 35\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 204\\n PIP: 18 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 9.5 L/min\\n Physical Examination\\n General Appearance: intubated, sedated\\n HEENT: ETT in place, slight icterus\\n Pulm: diminished at the bases, transmitted vent sounds, no wheezing\\n CV: irregularly irregular, soft SM, no rub or gallop\\n Abdomen: soft, non-tender, non-distended, (+) bowel sounds\\n Ext: no edema\\n Skin: Not assessed\\n Labs / Radiology\\n 9.9 g/dL\\n 60 K/uL\\n 119 mg/dL\\n 1.5 mg/dL\\n 26 mEq/L\\n 4.2 mEq/L\\n 26 mg/dL\\n 107 mEq/L\\n 141 mEq/L\\n 29.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n 10.6\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n 29.3\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n 60\\n Cr\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 266\\n 102\\n 91\\n 128\\n 119\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\\n PO4:2.2 mg/dL\\n Assessment and Plan\\n Respiratory Failure\\n - continues to do poorly with decreased support, possibly due to\\n ongoing volume overload\\n - will follow TBB as she is autodiuresing, goal TBB -1L\\n - low suspicion for underlying pneumonia given improving infectious\\n parameters and shock\\n - will continue PS today, repeat lightening of sedation and SBT\\n tomorrow morning\\n Septic shock\\n - s/p ERCP with cholangitis\\n - called micro for speciation of organisms, narrow abx if able\\n - shock resolved, creatinine improved\\n - on day Zosyn\\n Atrial fibrillation\\n - continues to be tachycardic, though improved\\n - can try low dose beta-blocker today if BP tolerates\\n - consider d'c amiodarone if able to be on beta-blocker\\n Acute renal failure\\n - improved overall\\n - some of urine output now may be post-ATN diuresis\\n Thrombocytopenia\\n - slightly improved, no evidence of bleeding\\n - will restart sc heparin today\\n ICU Care\\n Nutrition: TF\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: Not indicated\\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: 30 minutes\\n Patient is critically ill\\n ------ Protected Section ------\\n CRITICAL CARE\\n 85 yo with dementia, RCC intubated for resp failure in setting of\\n cholangitis. Vent PSV 12/5\\n 99.0 112 106/87\\n Sedated on ventilator\\n Chest\\n few mid insp crackles bilat\\n CV 2/6 sem\\n I&O neg over 1 L yesterday -0.6 L today\\n WBC 10.6\\n RSBI > 200\\n Making some progress with diuresis, but she is some ways from\\n extubation. Still > 4L pos LOS. Seems likely that weaning success will\\n depend on getting her to dry weight. No known signif cardiac dysfxn\\n but has long standing cardiomeg on CXR and I wonder if Echo is\\n underestimating MR. CXR remarkable for signif pleaural process on L\\n possibly related to pancreatitis but signif vol loss is evident. She\\n also has signif emphysema on CXR. Will need aggressive care to\\n liberate her from vent and she remains at signif risk for VAP so would\\n like to get her off ASAP. Her dementia will also likely complicate\\n weaning as she may well become agitated as we taper midazolam.\\n Time spent 40 min\\n Critically ill\\n ------ Protected Section Addendum Entered By: , MD\\n on: 15:59 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702430,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. s/p ERCP with stent placement\\n - patient became tachycardic with SBT so changed back to A/C--> went\\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\\n which dropped her BP into the 70's systolic and her HR decreased into\\n the 110's. Her heart rate remained elevated in the 130\\ns and she\\n continued to have a pressor requirement, so she was started on\\n amiodarone early this morning.\\n - early SBT this morning for hopeful extubation\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Phenylephrine - 1 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Diltiazem - 11:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 133 (72 - 141) bpm\\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\\n RR: 31 (10 - 34) insp/min\\n SpO2: 97%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 18 (0 - 325)mmHg\\n Mixed Venous O2% Sat: 79 - 79\\n Total In:\\n 5,376 mL\\n 285 mL\\n PO:\\n TF:\\n IVF:\\n 5,376 mL\\n 285 mL\\n Blood products:\\n Total out:\\n 1,320 mL\\n 555 mL\\n Urine:\\n 1,320 mL\\n 555 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,056 mL\\n -270 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): 317 (308 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: RR >35-had good tidal volumes though\\n PIP: 15 cmH2O\\n SpO2: 97%\\n ABG: 7.41/39/98./26/0\\n Ve: 8.8 L/min\\n PaO2 / FiO2: 245\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 52 K/uL\\n 10.5 g/dL\\n 91 mg/dL\\n 1.6 mg/dL\\n 26 mEq/L\\n 3.4 mEq/L\\n 32 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 20.2 K/uL\\n [image002.jpg]\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n WBC\\n 25.0\\n 17.8\\n 15.3\\n 20.2\\n Hct\\n 31.6\\n 30.8\\n 31.4\\n 30.7\\n Plt\\n 93\\n 48\\n 59\\n 46\\n 52\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n TropT\\n 0.02\\n 0.02\\n TCO2\\n 18\\n 23\\n 23\\n 26\\n Glucose\\n 195\\n 151\\n 266\\n 102\\n 91\\n Other labs:\\n Ca: 7.7, Mg: 2.4, Phos: 1.7\\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\\n PT: 12.2, INR: 1.0\\n Microbiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n GRAM NEGATIVE ROD(S).\\n 11:58 pm BLOOD CULTURE X2.\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but suspect in setting of\\n met acidosis she fatigued. Has been having recently worsening dyspnea\\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\\n in the ED. Heart failure is less likely as echo and CXR do not show any\\n evidence of this. ABG shows good oxygenation and patient has been\\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\\n during SBT, with afib on AC for now.\\n - Attempt to change back to PSV for now and wean as tolerated; consider\\n sbt once patient can tolerate no sedation\\n - wean pressors as tolerated\\n - goal to extubate patient today\\n # Atrial Fibrillation: Appears to be first episode as no history of\\n this in past. Likely exacerbated by SBT and being on levophed in the\\n setting of infection. Hemodynamically stable for now with rates in the\\n 110\\n - EKG\\n - If fast rate persists or if worsening hemodynamics, consider\\n changing levophed to phenylephrine as to reduce beta agonist activity\\n and worsen afib with RVR.\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\\n placement. Patient afebrile and white count trending down. Lactate now\\n normal. Initial sepsis likely secondary to biliary source given CBD\\n dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\\n vanc as GI infection not likely MRSA.\\n - Trend CBC/diff, LFTs\\n - Follow up blood cx , urine cx; GPR may be contamination, but will\\n continue to cover broadly for now until further speciation.\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\\n to correct very fast, likely a component of ATN as well.\\n - IVFs for CVP 10-12\\n - Avoid nephrotoxins\\n - Trend renal function with PM chem. 10.\\n .\\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\\n equivical; low suscipicion of HIT as timing does not correlate.\\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\\n possibility as known to cause thrombocytopenia.\\n - D/C vanc and heparin today\\n - unlikely DIC at this point\\n - No signs of active bleeding\\n - Re-check cbc at 1500\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\\n less than 18 or LR if needs resuscitation to prevent further NG\\n acidosis.\\n ICU Care\\n Nutrition: NPO pending hopeful extubation this morning\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR-is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703141,\n \"text\": \"R radial nerve damage from compression\\n s/p TAH/USO 8 yrs ago, c/b need for 3 units PRBC due to bleeding\\n at a ligation site\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703142,\n \"text\": \"R radial nerve damage from compression\\n s/p TAH/USO 8 yrs ago, c/b need for 3 units PRBC due to bleeding\\n at a ligation site\\n ------ Protected Section------\\n ------ Protected Section Error Entered By: , RN\\n on: 14:45 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702643,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - amio gtt started in early AM yesterday--> slow progress\\n - Neo stopped at 0000\\n - OG + tube feeds today, NPO at midnight with hopes for extubation\\n - increasing WBC, send sputum for cx, blood and urine cx;\\n - if she starts to spike again, then add back Vancomycin\\n - Gm+ and Gm- rods in blood in anaerobic bottle\\n - Was on AC for most of day after ; switched to PS 12/5-- ABG:\\n 7.46/34/127 (at 3:15am) RSBI: couldn\\nt tolerate b/c tachypnea:\\n UOP 50-180 cc/hour\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Fentanyl - 05:00 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 07:07 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 37\\nC (98.6\\n HR: 141 (111 - 141) bpm\\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\\n RR: 25 (14 - 36) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 8 (8 - 8)mmHg\\n Total In:\\n 1,682 mL\\n 197 mL\\n PO:\\n TF:\\n 73 mL\\n 1 mL\\n IVF:\\n 1,610 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,045 mL\\n 520 mL\\n Urine:\\n 2,045 mL\\n 520 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -363 mL\\n -322 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): 482 (308 - 528) mL\\n PS : 10 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 24\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 17 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 31.6 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/34/127/24/1\\n Ve: 9.1 L/min\\n PaO2 / FiO2: 318\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 9.8 g/dL\\n 128 mg/dL\\n 1.5 mg/dL\\n 24 mEq/L\\n 4.0 mEq/L\\n 29 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 29.7 %\\n 11.3 K/uL\\n [image002.jpg]\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n Cr\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 151\\n 266\\n 102\\n 91\\n 128\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\\n PO4:2.2 mg/dL\\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\\n GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\\n GPR anaerobic bottles\\n GNR in\\n anaerobic bottles\\nPan cultured yesterday: NGTD\\nRadiology: None today\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\\n been doing well on the ventilator, had hoped to extubate her yesterday,\\n however she went into A.fib with RVR during her , she was\\n intially changed back to A/C, then transitioned back to PSV.\\n - RSBI early this morning\\npatient very tachypnei,\\n -Chest x-ray appeared volume overloaded, which is likely contributing\\n to the difficulty weaning her off the ventilator, when patient is able\\n to be weaned off pressors will need diuresis. Hopefully patient will\\n start to mobilize her extra fluid, however once off pressors if she is\\n unable to, will give lasix as needed to help decrease the fluid in her\\n lungs\\n - Hopeful extubation today pending ability to diurese\\n # Atrial Fibrillation: First occurred during on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns, pressor changed\\n from levophed to neo without any effect, her BP dropped with IV dilt,\\n so started amiodarone morning of due to continued pressor\\n requirement\\n - Monitor for improvement and hopeful d/c of amio once patient is\\n extubated and off sedation\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - With increasing leukocytosis concern for a new infection, will\\n reculture blood, urine and sputum, also send a C.diff when patient has\\n a bowel movement, if LFT\\ns increase, will reimage RUQ due to concern\\n for possible blockage of stent\\n - Cont zosyn pending any further culture data; f/u speciation and\\n sensitivities from prior blood cx\\n - Trend CBC/diff, LFTs, especially in the setting on increasing\\n leukocytosis, will add on Diff to AM labs\\n - Follow up blood cx speciation , urine cx with no growth\\n - Wean neo as tolerated by MAP >= 60 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea, also likely some component of ATN\\n as her renal function has not improved as quickly with fluids as would\\n be expected in a purely pre-renal picture. Cr improving to 1.5 today,\\n baseline creatinine 1.2-1.4.\\n - Titrate MAP to greater than 60, unless urine output decreases then\\n will titrate to increased MAP\\n .\\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\\n timing does not correlate since patient has not had a prior heparin\\n exposure. Vancomycin may also be contributing to her\\n thrombocytopenia. Platelets slightly increased today.\\n - Continue to hold vanc/heparin\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n - If platelets remain stable or increase tomorrow would restart heparin\\n as HIT is very unlikely\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Bicarb 24 today, extubation will be facilitated by resolution of\\n acidosis.\\n ICU Care\\n Nutrition: OG tube feeds\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR-is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702884,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt on PS 12/5 40%, rr 30\\n Action:\\n Sedation off last night at 8pm then rsbi was done to decide whether to\\n shut tf off at midnight for possible am extubation\\n Response:\\n RSBI 166 last night will not extubate today\\n Plan:\\n Continue good pulmonary toileting, midaz. Was increased to 3mg/hr due\\n to agitation\\n Atrial fibrillation (Afib)\\n Assessment:\\n Afib conts with hr in the 120\\n Action:\\n Lopressor was increased to 25mg po tid\\n Response:\\n ongoing\\n Plan:\\n Continue to monitor hr, increase lopressor if needed if bp can tolerate\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702968,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 6\\n Ideal body weight: 54.4 None\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Crackles\\n LUL Lung Sounds: Crackles\\n LLL Lung Sounds: Crackles\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: 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 Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n Bedside Procedures:\\n Comments:\\n Pt on the vent changes made tol fairly well. See respiratory page of\\n meta vision for more information.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703143,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib with hr ranging from 100-130\\ns.sbp 92-120\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703145,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib with hr ranging from 100-130\\ns.sbp 92-120\\ns. afib\\n first occurred during sbt on / trialed lopressor 12.5 mg po on\\n without affect.\\n Action:\\n Lopressor dose was increased to 25 mg pot id without any improvement in\\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\\n hr. hemodynamics followed closely.\\n Response:\\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\\n was d/c\\nd. sbp retruned to her baseline once esmalol gtt was d/c\\n Plan:\\n Continue to follow hemodynamics . may need to restart po lopressor.\\n Continue to check lytes as ordered and replete as needed.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Resp failure initially thought to be due to metabolic acidosis which\\n caused her to hyperventilate to compensate and fatigued becoming\\n acutely sob and requiring intubation on ^th.unable to wean\\n vent because of pt being fluid overloaded secondary to fluid\\n resusitiation. Pt having difficulty coming off peep becoming very\\n tachypenic with low tidal volumes which is more concerning for\\n difficulty with compliance then volume overload. Cxr c/w lll opacity\\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\\n tachypenic . lungs clear with crackles noted bil at the bases.\\n Suctioned for sm amts of thick white sputum.\\n Action:\\n Pt placed on 405 cpap with 5 peep and ps of 8.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703221,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent. Respiratory failure initially thought to be due to\\n metabolic acidosis which caused her to hyperventilate to compensate.\\n She fatigued quickly becoming acutely SOB and required intubation on\\n ^th. Since then, unable to wean vent because of pt being\\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\\n coming off peep becoming very tachypneic with low tidal volumes which\\n is more concerning for difficulty with compliance then volume overload.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Received pt in Afib; HR ranging from 90-130\\ns. SBP 85-120\\ns. Afib first\\n occurred during SBT on . Occasional PVC\\ns noted.\\n Action:\\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\\n 20mEq IV given last evening per sliding scale orders.\\n Response:\\n Pt has remained in Afib but rate has significantly improved w/\\n administration of Lopressor & Dilt. HR ranging 80\\n low 100\\ns w/\\n minimal ectopy.\\n Plan:\\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\\n Diltiazem. Follow electrolyte status & replete as needed.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\\n 30-40\\ns but appearing comfortable & settles out on own. LS clear,\\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\\n 1.5\\n 2L.\\n Action:\\n Suctiong q2-4 hrs for thick/white sputum. Pt is pooling secretions @\\n back of throat (concern for aspiration post extubation)\\n Response:\\n Pt -2L @ MN.\\n Plan:\\n Plan to diurese as pt\\ns hemodynamics tolerate. Net goal - 1.5\\n 2L @\\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\\n exchange. If all goes as planned, pt will be extubated late morning. As\\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\\n remains DNR)\\n DNR (will reintubate if necessary)\\n L DL PICC\\n Family in to see pt and updated by this RN last evening\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703025,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\\n RR up to 34-36 pt volume overloaded,\\n Action:\\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\\n received 10 mg IVP Lasix at 9 pm with good response.\\n Response:\\n Pt able to sleep, appeared comfortable, rr 14-16\\n Plan:\\n Change back to pressure support in am, check RSBI, ?ready for\\n extubation\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in Afib, rate 115-130 bp\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703308,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - f/u VBG 7.48/42/78 in central venous, repeat ABG 7.46/44/124\\n - BNP high 5525 c/w volume overload.\\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid\\n - PICC placed\\n - Called micro lab: will try to speciate. will call in AM to confirm\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 08:39 AM\\n Heparin Sodium (Prophylaxis) - 04:51 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.2\\nC (99\\n HR: 99 (86 - 128) bpm\\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\\n RR: 28 (18 - 41) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 6 (2 - 6)mmHg\\n Total In:\\n 784 mL\\n 256 mL\\n PO:\\n TF:\\n IVF:\\n 784 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,885 mL\\n 495 mL\\n Urine:\\n 2,885 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,101 mL\\n -239 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 260 (260 - 404) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 38\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 154\\n PIP: 14 cmH2O\\n SpO2: 99%\\n ABG: ///29/\\n Ve: 9.6 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Labs / Radiology\\n 174 K/uL\\n 9.2 g/dL\\n 80 mg/dL\\n 1.4 mg/dL\\n 29 mEq/L\\n 4.1 mEq/L\\n 22 mg/dL\\n 101 mEq/L\\n 140 mEq/L\\n 27.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n TCO2\\n 26\\n 25\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n Other labs:\\n Ca: 8.6, Mg: 2.2, Phos: 3.1\\n Mircrobiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\\n Anaerobic Bottle Gram Stain (Final ):\\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\\n Radiology:\\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\\n vena cava. The patient remains intubated, with the endotracheal tube\\n terminating 3.2 cm above the carina. The right internal jugular line\\n ends in the mid superior vena cava. Left pleural effusion with\\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\\n consistent with pulmonary arterial hypertension. The right lung is\\n clear. There is no pulmonary edema.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\\n improved in terms of pulmonary vascular congestion, will trial\\n extubation today since patient looks the best she has since admission\\n - patient may need Bipap post extubation\\n - Hold sedation for now to optimize mental status prior to extubation\\n - NGT in place for meds/diet post extubation\\n .\\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\\n rate control, rate has been in the 90\\ns with both medications\\n # Septic shock: resolved from initial cholangitis source, patient off\\n pressors, likely secondary to cholangitis and infected stone/sludge.\\n ERCP showed significant pusand very large stone, she is s/p stent\\n placement. Patient afebrile and white count stable. Lactate normal.\\n Initial sepsis secondary to biliary source given CBD dilation with\\n sludge and obstructive LFTs in setting on known choledocholithiasis.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. PICC placed, will complete a 14 day course of zosyn as the\\n mircolab is currently unable to provide further speciation and she has\\n been improving on zosyn\\n - repeat ERCP in 1 month\\n .\\n # ARF: Improved, back to her baseline.\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition: Tube feeds on hold for possible extubation\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: family\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 702804,\n \"text\": \"TITLE:\\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\\n found to have cholangitis, now s/p ERCP and stenting, with course\\n complicated by respiratory failure.\\n 24 Hour Events:\\n Decreased sedation overnight but had increasing agitation, had\\n increased RR and decreasing tidal volumes so re-sedated and left at PS\\n .\\n Patient unable to provide history: Sedated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\\n RR: 37 (14 - 38) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 628 mL\\n 243 mL\\n PO:\\n TF:\\n 128 mL\\n 4 mL\\n IVF:\\n 500 mL\\n 239 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 965 mL\\n Urine:\\n 1,795 mL\\n 965 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,167 mL\\n -722 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 304 (260 - 483) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 35\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 204\\n PIP: 18 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 9.5 L/min\\n Physical Examination\\n General Appearance: intubated, sedated\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 9.9 g/dL\\n 60 K/uL\\n 119 mg/dL\\n 1.5 mg/dL\\n 26 mEq/L\\n 4.2 mEq/L\\n 26 mg/dL\\n 107 mEq/L\\n 141 mEq/L\\n 29.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n 10.6\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n 29.3\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n 60\\n Cr\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 266\\n 102\\n 91\\n 128\\n 119\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\\n PO4:2.2 mg/dL\\n Assessment and Plan\\n Respiratory Failure\\n - continues to do poorly with decreased support, possibly due to\\n ongoing volume overload\\n - will follow TBB as she is autodiuresing, goal TBB -1L\\n - low suspicion for underlying pneumonia given improving infectious\\n parameters and shock\\n - will continue PS today, repeat lightening of sedation and SBT\\n tomorrow morning\\n Septic shock\\n - s/p ERCP with cholangitis\\n - called micro for speciation of organisms, narrow abx if able\\n - shock resolved, creatinine improved\\n - on day Zosyn\\n Atrial fibrillation\\n - continues to be tachycardic, though improved\\n - can try low dose beta-blocker today if BP tolerates\\n - consider d'c amiodarone if able to be on beta-blocker\\n Acute renal failure\\n - improved overall\\n - some of urine output now may be post-ATN diuresis\\n Thrombocytopenia\\n - slightly improved, no evidence of bleeding\\n - will restart sc heparin today\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: Not indicated\\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: 30 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702810,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - Goal to decrease sedation overnight to help with extubation hopefully\\n Sunday. Her barriers are sedation and fluid overload\\n ---> on 2 mg versed...shut off for 2-3 hours and patient agitated\\n pulling at tube and moving around. RSBI tried on her during her wakeful\\n moment and it was 204..has been tachypnic to the 30's and if go down on\\n PS tidal volumes decrease. Kept same pressure support . and turned\\n versed back to 2 mg.\\n - Goal TBB negative 1-1.5 liters. autodiuresing well, no lasix needed\\n - CXR done that did not show much interval change.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 08:11 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.8\\nC (98.3\\n HR: 122 (114 - 131) bpm\\n BP: 108/50(62) {88/44(55) - 133/80(87)} mmHg\\n RR: 29 (14 - 38) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 628 mL\\n 201 mL\\n PO:\\n TF:\\n 128 mL\\n 4 mL\\n IVF:\\n 500 mL\\n 197 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 745 mL\\n Urine:\\n 1,795 mL\\n 745 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,167 mL\\n -544 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 403 (260 - 483) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 204\\n PIP: 17 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 8 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 60 K/uL\\n 9.9 g/dL\\n 119 mg/dL\\n 1.5 mg/dL\\n 26 mEq/L\\n 4.2 mEq/L\\n 26 mg/dL\\n 107 mEq/L\\n 141 mEq/L\\n 29.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n 10.6\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n 29.3\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n 60\\n Cr\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 266\\n 102\\n 91\\n 128\\n 119\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\\n PO4:2.2 mg/dL\\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\\n GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\\n GPR anaerobic bottles\\n GNR in\\n anaerobic bottles\\nPan cultured yesterday: NGTD\\nRadiology: None today\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\\n Unable to wean effectively; likely secondary to fluid resuscitation; as\\n fluid overload is seen on CXR.\\n - Monitor UOP as patient is auto-diuresing well. Check i/o\\ns this\\n evening with TBB 1-1.5 liters, if not at goal will trial some lasix if\\n her blood pressure can tolerate\\n - Wean down vent settings as much as possible, but having difficulty\\n due to volume overload\\n - CXR tomorrow morning to evaluate for improvement in volume overload\\n - will further clarify intubation status with family prior to\\n extubation, to see if they would want her to be re-intubated if she has\\n difficulty post extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Patient has\\n remained tachycardic on amio gtt, now that she is off pressors will\\n trial a low dose beta blocker,\\n - Metoprolol 5mg IV: monitor effect on HR and BP, has been on\\n metoprolol at home\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Leukocytosis is resolving\\nwhite count almost normalized, has been\\n afebrile for over 24hours\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1: . Will f/u cutlure data to see if we can narrow our coverage,\\n if she needs to be continued on Zosyn will place a PICC and pull\\n central line\\n - LFT\\ns normalized, no longer need to trend daily\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\\n - Monitor UOP\\n - Trend creatinine\\n .\\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\\n secondary to sepsis.\\n - Will restart SQ heparin as her platelet count has increased and the\\n initial drop was not consistent with HIT\\n - No signs of active bleeding\\n ICU Care\\n Nutrition: Was npo after midnight for possible extubation, but since\\n she will not be extubated will restart tube feeds\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: pneumo boots, SQ heparin\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR, pt is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"Physician Resident/Attending Progress Note - MICU\",\n \"row_id\": 702962,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - will attempt to decrease sedation this evening and do an SBT, if she\\n looks good will hold tube feeds, otherwise will continue feeds\\n overnight\\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\\n then urine output was over 1L to the lasix\\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\\n MV and O2sats but RR in the 40's with small TV's. After about 15min\\n became uncomfortable with increased WOB-->improved from prior, has more\\n stamina, diuresis seems to be improving her respiratory status\\n - per discussion with patient's family she can be reintubated if she\\n fails extubation\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\\n Infusions:\\n Midazolam (Versed) - 3 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 11:55 AM\\n Furosemide (Lasix) - 06:14 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:10 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: 37.2\\nC (99\\n HR: 112 (106 - 129) bpm\\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\\n RR: 12 (12 - 37) insp/min\\n SpO2: 100%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 733 mL\\n 452 mL\\n PO:\\n TF:\\n 202 mL\\n 264 mL\\n IVF:\\n 531 mL\\n 188 mL\\n Blood products:\\n Total out:\\n 3,345 mL\\n 765 mL\\n Urine:\\n 3,345 mL\\n 765 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,612 mL\\n -313 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 296 (241 - 304) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 166\\n PIP: 18 cmH2O\\n SpO2: 100%\\n ABG: ///30/\\n Ve: 8.6 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 84 K/uL\\n 9.2 g/dL\\n 143 mg/dL\\n 1.3 mg/dL\\n 30 mEq/L\\n 3.9 mEq/L\\n 24 mg/dL\\n 104 mEq/L\\n 140 mEq/L\\n 27.9 %\\n 11.2 K/uL\\n [image002.jpg]\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n WBC\\n 15.3\\n 20.2\\n 11.3\\n 10.6\\n 11.2\\n Hct\\n 31.4\\n 30.7\\n 29.7\\n 29.3\\n 27.9\\n Plt\\n 59\\n 46\\n 52\\n 48\\n 60\\n 84\\n Cr\\n 1.8\\n 1.6\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n TropT\\n 0.02\\n TCO2\\n 23\\n 26\\n 25\\n Glucose\\n 102\\n 91\\n 128\\n 119\\n 126\\n 143\\n Other labs:\\n Mg: 1.6\\n Alk Phos: 103, T. bili: 1.5\\n PT: 12, INR: 1, PTT: 23.7\\n Microbiology:\\nBlood Culture: Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n Imaging:\\n Chest X-Ray (my read): slightly worsening left effusion and right\\n basilar patchy opacity\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR.\\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\\n about 800 cc\\ns in the evening so she was given 20mg IV lasix with a\\n brisk urine output response. Will give another dose of lasix since she\\n had her best SBT with the increased diuresis, hold tube feeds for now\\n in case she is able to be extubated this afternoon. She will likely\\n never have an excellent RSBI, but she will need to not tire and\\n maintain her sats during her SBT.\\n - Hold sedation for now to optimize mental status prior to extubation\\n - need to place a dobhoff prior to extubation as she may be an\\n aspiration risk\\n - CXR looks stable to slightly worsened this morning\\n - family okay with re-intubation if patient fails extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Trialed\\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\\n 100\\ns and her BP tolerated it well.\\n - Increase metoprolol to 25mg and titrate up to good HR control as\\n her BP tolerates\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count stable. Lactate\\n normal. Initial sepsis secondary to biliary source given CBD dilation\\n with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Leukocytosis is resolving\\nwhite count almost normalized. Had been\\n afebrile for over 24 hours.\\n - Cont zosyn pending any further culture data; Day of zosyn.\\n Day 1=. Will f/u cutlure data to see if we can narrow our\\n coverage, if she needs to be continued on Zosyn will place a PICC and\\n pull central line, may be able to transitioned to a po antibiotic\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n - f/u sputum culture\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr back to her baseline at 1.3 today.\\n - Monitor UOP\\n - Trend creatinine while diuresing\\n - Check PM lytes\\n .\\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\\n secondary to sepsis.\\n - Platelet count stable and increasing\\n ICU Care\\n Nutrition:\\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Heparin SQ, pneumo boots\\n Stress ulcer: none while on feeds\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR, is intubated, ok to be reintubated post extubation if\\n necessary\\n Disposition: ICU pending stabilization post extubation\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\\n respiratory failure, AF c RVR. Failed SBT last PM, diuresis ongoing.\\n Exam notable for Tm 99.8 BP HR 116/50 RR 12-37 with sat 100 on PSV\\n . WD woman, follows intermittent commands. Coarse BS B. Irreg s1s2.\\n Soft +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+ 3.9, Cr 1.3.\\n Agree with plan to manage respiratory failure with IV lasix now for TBB\\n negative, will check and trend CVP, continue upright positioning, and\\n consider NGT placement prior to extubation. Cholangitis improving, will\\n need 14d abx, f/u cultures, consider change CVL to PICC if she needs\\n long-term IV abx. For AF c RVR, continue PO BBL, hold off on\\n anticoagulation for now and d/w family / PCP\\n appears to be at long\\n term risk of falls based on prior history. ARF has resolved. Continue\\n TFs for now. Remainder of plan as outlined above.\\n Patient is critically ill\\n Total time: 40 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 15:37 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703140,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - diurese further today to help w possibility of extubation--> Net Goal\\n -1.5-2L\\n - consider risk of aspiration post-extubation due to mental status\\n - NG tube placed\\n - patient remains tachycardic so metoprolol was increased to 25mg TID\\n - need to address possib of anticoagulation w family and PCP\\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\\n tolerate 20mg IV)\\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\\n at 9:30pm to rest, so that she can be ready, better rested for SBT\\n tomorrow, esp after diuresis\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Fentanyl - 04:27 PM\\n Heparin Sodium (Prophylaxis) - 04:31 AM\\n Furosemide (Lasix) - 04:39 AM\\n Metoprolol - 04:40 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.7\\nC (98\\n HR: 116 (100 - 125) bpm\\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\\n RR: 23 (12 - 36) insp/min\\n SpO2: 100%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 9 (9 - 272)mmHg\\n Total In:\\n 2,091 mL\\n 206 mL\\n PO:\\n TF:\\n 1,506 mL\\n IVF:\\n 524 mL\\n 206 mL\\n Blood products:\\n Total out:\\n 2,125 mL\\n 1,120 mL\\n Urine:\\n 2,125 mL\\n 1,120 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -34 mL\\n -915 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): 324 (255 - 463) mL\\n PS : 12 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 25 cmH2O\\n Plateau: 18 cmH2O\\n Compliance: 38.5 cmH2O/mL\\n SpO2: 100%\\n ABG: ///30/\\n Ve: 7.1 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 131 K/uL\\n 9.1 g/dL\\n 109 mg/dL\\n 1.5 mg/dL\\n 30 mEq/L\\n 4.0 mEq/L\\n 22 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 27.4 %\\n 12.2 K/uL\\n [image002.jpg]\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n WBC\\n 20.2\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n Hct\\n 30.7\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n Plt\\n 52\\n 48\\n 60\\n 84\\n 131\\n Cr\\n 1.6\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n TCO2\\n 23\\n 26\\n 25\\n Glucose\\n 91\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\\n PO4:2.6 mg/dL\\n Microbiology:\\nBlood Culture: Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\\n Source: Endotracheal.\\n GRAM STAIN (Final ):\\n PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\\n Imaging:\\n Chest X-Ray at 2330 (my read): stable effusion/opacity and\\n RLL patchy opacity\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\\n having difficulty coming off PEEP, becomes very tachypneic and has low\\n tidal volumes, which is more concerning for difficulty with compliance\\n and volume overload. Additionally, patient with opacity and\\n diaphragm pulled up on the left that has been noted on all x-rays\\n during this admission, to better see the anatomy in the , \\n bronch the patient this afternoon to look at the .\\n - continue with net negative goal, if UOP decreases to less than\\n 100cc/hr will give another dose of lasix and readdress possible\\n extubation this afternoon.\\n - Hold sedation for now to optimize mental status prior to extubation\\n - NGT in place for meds/diet post extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Trialed\\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\\n 100\\ns and her BP tolerated it well.\\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\\n the 120\\ns to 130\\ns, so will trial an esmolol drip\\n # Septic shock: resolving, patient off pressors, likely secondary to\\n cholangitis and infected stone/sludge. ERCP showed significant pusand\\n very large stone, she is s/p stent placement. Patient afebrile and\\n white count stable. Lactate normal. Initial sepsis secondary to biliary\\n source given CBD dilation with sludge and obstructive LFTs in setting\\n on known choledocholithiasis.\\n - Leukocytosis is resolving\\nwhite count almost normalized. Had been\\n afebrile for over 48 hours.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\\n will place a PICC and pull central line\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\\n to help with further diruesis\\n - Monitor UOP\\n - Check PM lytes\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition: Tube feeds held o/n for possible extubation, will hold this\\n afternoon for possible extubation\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM, will put patient in for a PICC today\\n Prophylaxis:\\n DVT: SQ Heparin\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702081,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\\n Action:\\n Placed on A/C for ERCP.\\n Response:\\n Remains on AC as she received paralytic for ERCP and remains very\\n sedated.\\n Plan:\\n Return PSV when spontaneous breathing returns. Turn off sedation in\\n a.m. and do SBT for possible extubation. Monitor O2sats.\\n Sepsis without organ dysfunction\\n Assessment:\\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\\n WBC up to 25. Remains in metabolic acidosis.\\n Action:\\n Received additional 2L IVBs.\\n Response:\\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\\n 0.1mcg/kg/minute.\\n Plan:\\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\\n requires more fluids for low CVP.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 702876,\n \"text\": \"TITLE:\\n Demographics\\n Day of intubation: \\n Day of mechanical ventilation: 6\\n Ideal body weight: 54.\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: ICU\\n Reason: Emergent (1st time)\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Ventilation Assessment\\n Level of breathing assistance: PSV 12/5/.4\\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Comments: Maintaining Vt 2-300\\ns with Ve8-10 L, sp02 99%\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Intolerant of\\n weaning attempts, Hemodynimic instability, Underlying illness not\\n resolved\\n Respiratory Care Shift Procedures\\n Bedside Procedures: Attempted SBT x1: ~18 minutes with RR 40, appeared\\n to have increased WOB, increased HR> back to PSV 12/5; RSBI 166\\n Comments: Will cont slow PSV wean as tol.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703214,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt remains in afib with hr ranging from 100-130\\ns.sbp 92-120\\ns. afib\\n first occurred during sbt on / trialed lopressor 12.5 mg po on\\n without affect.\\n Action:\\n Lopressor dose was increased to 25 mg pot id without any improvement in\\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\\n hr. hemodynamics followed closely.\\n Response:\\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\\n was d/c\\nd. sbp retruned to her baseline once esmalol gtt was d/c\\n Plan:\\n Continue to follow hemodynamics . Continue to check lytes as ordered\\n and replete as needed. Pt now started on lopressor 25 mg pot id and\\n diltiazem 30 mg po q 6hrs.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Resp failure initially thought to be due to metabolic acidosis which\\n caused her to hyperventilate to compensate and fatigued becoming\\n acutely sob and requiring intubation on ^th.unable to wean\\n vent because of pt being fluid overloaded secondary to fluid\\n resusitiation. Pt having difficulty coming off peep becoming very\\n tachypenic with low tidal volumes which is more concerning for\\n difficulty with compliance then volume overload. Cxr c/w lll opacity\\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\\n tachypenic . lungs clear with crackles noted bil at the bases.\\n Suctioned for sm amts of thick white sputum.\\n Action:\\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\\n closely.\\n Response:\\n Vent settings unchanged. Cxr unchanged\\n Plan:\\n Plan to diurese as pt\\ns hemodynamics tolerate. Net goal for i&o is to\\n be neg 1.5 to 2 liters Will keep on cpap mode of ventilation overnoc.\\n Plan is to call anesthesia in the am to change #7 ett to o #8 ett over\\n the cook catheter. Once ett is changed will then check rsbi and do sbt.\\n Will do bronchoscopy after that and then possible extubation with the\\n plan to reintubate if pt fails extubation.\\n DNR (will reintubate if necessary)\\n L DL PICC\\n Family in to see pt and updated by this RN last evening\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-26 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702792,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - Goal to decrease sedation overnight to help with extubation hopefully\\n Sunday. Her barriers are sedation and fluid overload\\n ---> on 2 mg versed...shut off for 2-3 hours and patient agitated\\n pulling at tube and moving around. RSBI tried on her during her wakeful\\n moment and it was 204..has been tachypnic to the 30's and if go down on\\n PS tidal volumes decrease. Kept same pressure support . and turned\\n versed back to 2 mg.\\n - Goal TBB negative 1-1.5 liters. autodiuresing beautifully and have\\n not given lasix as she is -840 cc at .\\n - CXR done that did not show much interval change.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Amiodarone - 0.5 mg/min\\n Midazolam (Versed) - 2 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 08:11 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.8\\nC (98.3\\n Tcurrent: 36.8\\nC (98.3\\n HR: 122 (114 - 131) bpm\\n BP: 108/50(62) {88/44(55) - 133/80(87)} mmHg\\n RR: 29 (14 - 38) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 628 mL\\n 201 mL\\n PO:\\n TF:\\n 128 mL\\n 4 mL\\n IVF:\\n 500 mL\\n 197 mL\\n Blood products:\\n Total out:\\n 1,795 mL\\n 745 mL\\n Urine:\\n 1,795 mL\\n 745 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,167 mL\\n -544 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 403 (260 - 483) mL\\n PS : 12 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 204\\n PIP: 17 cmH2O\\n SpO2: 99%\\n ABG: ///26/\\n Ve: 8 L/min\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 60 K/uL\\n 9.9 g/dL\\n 119 mg/dL\\n 1.5 mg/dL\\n 26 mEq/L\\n 4.2 mEq/L\\n 26 mg/dL\\n 107 mEq/L\\n 141 mEq/L\\n 29.3 %\\n 10.6 K/uL\\n [image002.jpg]\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n 10.6\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n 29.3\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n 60\\n Cr\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 266\\n 102\\n 91\\n 128\\n 119\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\\n PO4:2.2 mg/dL\\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\\n GRAM STAIN (Final ):\\n >25 PMNs and <10 epithelial cells/100X field.\\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\\n GPR anaerobic bottles\\n GNR in\\n anaerobic bottles\\nPan cultured yesterday: NGTD\\nRadiology: None today\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\\n Unable to wean effectively; likely secondary to fluid resuscitation; as\\n fluid overload is seen on CXR.\\n - Monitor UOP as patient is auto-diuresing well. Check i/o\\ns this\\n evening with TBB 1-1.5 liters\\n - Wean down vent settings as much as possible, will likely be more\\n effective once\\n - CXR today to make sure no other acute process is occuring\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns, pressor changed\\n from levophed to neo without any effect, her BP dropped with IV dilt,\\n so started amiodarone morning of due to continued pressor\\n requirement\\n - Continue amio gtt as HR has improved, but she is still tachycardic in\\n the low 100\\n - Monitor for improvement and hopeful d/c of amio once patient is\\n extubated and off sedation\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\\n be improving.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1: .\\n - f/u speciation and sensitivities from prior blood cx\\n - Trend CBC/diff, LFTs,\\n - Follow up blood cx speciation , urine cx with no growth\\n - no need for pressors now. Monitor maps > 65.\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\\n - Monitor UOP\\n - Trend creatinine\\n .\\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\\n of HIT as timing does not correlate since patient has not had a prior\\n heparin exposure. Vancomycin may also be contributing to her\\n thrombocytopenia\\n - Continue to hold vanc/heparin\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n - If platelets remain stable or increase tomorrow would restart heparin\\n as HIT is very unlikely\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Bicarb 24 today, extubation will be facilitated by resolution of\\n acidosis.\\n ICU Care\\n Nutrition: Currently NPO for possible extubation\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: pneumo boots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR, pt is intubated\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703083,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - diurese further today to help w possibility of extubation--> Net Goal\\n -1.5-2L\\n - consider risk of aspiration post-extubation due to mental status\\n - NG tube? prior to extubation\\n - consider changing her to PO Abx today\\n - amio was stopped yesterday ; on metoprolol 25mg --> incr to\\n TID\\n - need to address possib of anticoagulation w family and PCP\\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\\n tolerate 20mg IV)\\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\\n at 9:30pm to rest, so that she can be ready, better rested for SBT\\n tomorrow, esp after diuresis\\n - SBT in the AM to figure out if she's ready to be extubated; can\\n restart tube feeds in AM if not ready\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Fentanyl - 04:27 PM\\n Heparin Sodium (Prophylaxis) - 04:31 AM\\n Furosemide (Lasix) - 04:39 AM\\n Metoprolol - 04:40 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 36.7\\nC (98\\n HR: 116 (100 - 125) bpm\\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\\n RR: 23 (12 - 36) insp/min\\n SpO2: 100%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 9 (9 - 272)mmHg\\n Total In:\\n 2,091 mL\\n 206 mL\\n PO:\\n TF:\\n 1,506 mL\\n IVF:\\n 524 mL\\n 206 mL\\n Blood products:\\n Total out:\\n 2,125 mL\\n 1,120 mL\\n Urine:\\n 2,125 mL\\n 1,120 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -34 mL\\n -915 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): 324 (255 - 463) mL\\n PS : 12 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 25 cmH2O\\n Plateau: 18 cmH2O\\n Compliance: 38.5 cmH2O/mL\\n SpO2: 100%\\n ABG: ///30/\\n Ve: 7.1 L/min\\n Physical Examination\\n General: Intubated, awake, responsive, follows some commands\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\\n ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\\n R>L, + edema bilaterally\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 131 K/uL\\n 9.1 g/dL\\n 109 mg/dL\\n 1.5 mg/dL\\n 30 mEq/L\\n 4.0 mEq/L\\n 22 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 27.4 %\\n 12.2 K/uL\\n [image002.jpg]\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n WBC\\n 20.2\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n Hct\\n 30.7\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n Plt\\n 52\\n 48\\n 60\\n 84\\n 131\\n Cr\\n 1.6\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n TCO2\\n 23\\n 26\\n 25\\n Glucose\\n 91\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\\n PO4:2.6 mg/dL\\n Microbiology:\\nBlood Culture: Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\\n Source: Endotracheal.\\n GRAM STAIN (Final ):\\n PMNs and <10 epithelial cells/100X field.\\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\\n Imaging:\\n Chest X-Ray at 2330 (my read): stable LLL effusion and RLL patchy\\n opacity\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR.\\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\\n about 800 cc\\ns in the evening so she was given 20mg IV lasix with a\\n brisk urine output response. Will give another dose of lasix since she\\n had her best SBT with the increased diuresis, hold tube feeds for now\\n in case she is able to be extubated this afternoon. She will likely\\n never have an excellent RSBI, but she will need to not tire and\\n maintain her sats during her SBT.\\n - Hold sedation for now to optimize mental status prior to extubation\\n - need to place a dobhoff prior to extubation as she may be an\\n aspiration risk\\n - CXR looks stable to slightly worsened this morning\\n - family okay with re-intubation if patient fails extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Trialed\\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\\n 100\\ns and her BP tolerated it well.\\n - Increase metoprolol to 25mg and titrate up to good HR control as\\n her BP tolerates\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count stable. Lactate\\n normal. Initial sepsis secondary to biliary source given CBD dilation\\n with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Leukocytosis is resolving\\nwhite count almost normalized. Had been\\n afebrile for over 24 hours.\\n - Cont zosyn pending any further culture data; Day of zosyn.\\n Day 1=. Will f/u cutlure data to see if we can narrow our\\n coverage, if she needs to be continued on Zosyn will place a PICC and\\n pull central line, may be able to transitioned to a po antibiotic\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n - f/u sputum culture\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr back to her baseline at 1.3 today.\\n - Monitor UOP\\n - Trend creatinine while diuresing\\n - Check PM lytes\\n .\\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\\n secondary to sepsis.\\n - Platelet count stable and increasing\\n ICU Care\\n Nutrition: Tube feeds held o/n for possible extubation\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: SQ Heparin\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703266,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n PICC LINE - START 03:34 PM\\n MULTI LUMEN - STOP 05:30 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 08:39 AM\\n Heparin Sodium (Prophylaxis) - 04:51 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.2\\nC (99\\n HR: 99 (86 - 128) bpm\\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\\n RR: 28 (18 - 41) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 6 (2 - 6)mmHg\\n Total In:\\n 784 mL\\n 256 mL\\n PO:\\n TF:\\n IVF:\\n 784 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,885 mL\\n 495 mL\\n Urine:\\n 2,885 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,101 mL\\n -239 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 260 (260 - 404) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 38\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 154\\n PIP: 14 cmH2O\\n SpO2: 99%\\n ABG: ///29/\\n Ve: 9.6 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 174 K/uL\\n 9.2 g/dL\\n 80 mg/dL\\n 1.4 mg/dL\\n 29 mEq/L\\n 4.1 mEq/L\\n 22 mg/dL\\n 101 mEq/L\\n 140 mEq/L\\n 27.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n TCO2\\n 26\\n 25\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n Other labs:\\n Ca: 8.6, Mg: 2.2, Phos: 3.1\\n Mircrobiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\\n Anaerobic Bottle Gram Stain (Final ):\\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\\n Radiology:\\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\\n vena cava. The patient remains intubated, with the endotracheal tube\\n terminating 3.2 cm above the carina. The right internal jugular line\\n ends in the mid superior vena cava. Left pleural effusion with\\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\\n consistent with pulmonary arterial hypertension. The right lung is\\n clear. There is no pulmonary edema.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\\n having difficulty coming off PEEP, becomes very tachypneic and has low\\n tidal volumes, which is more concerning for difficulty with compliance\\n and volume overload. Additionally, patient with opacity and\\n diaphragm pulled up on the left that has been noted on all x-rays\\n during this admission, to better see the anatomy in the , \\n bronch the patient this afternoon to look at the .\\n - continue with net negative goal, if UOP decreases to less than\\n 100cc/hr will give another dose of lasix and readdress possible\\n extubation this afternoon.\\n - Hold sedation for now to optimize mental status prior to extubation\\n - NGT in place for meds/diet post extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Trialed\\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\\n 100\\ns and her BP tolerated it well.\\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\\n the 120\\ns to 130\\ns, so will trial an esmolol drip\\n # Septic shock: resolving, patient off pressors, likely secondary to\\n cholangitis and infected stone/sludge. ERCP showed significant pusand\\n very large stone, she is s/p stent placement. Patient afebrile and\\n white count stable. Lactate normal. Initial sepsis secondary to biliary\\n source given CBD dilation with sludge and obstructive LFTs in setting\\n on known choledocholithiasis.\\n - Leukocytosis is resolving\\nwhite count almost normalized. Had been\\n afebrile for over 48 hours.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\\n will place a PICC and pull central line\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\\n to help with further diruesis\\n - Monitor UOP\\n - Check PM lytes\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 703267,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - f/u VBG 7.48/42/78 in mixed venous, Very weird gas for venous...\\n - BNP high 5525 c/w volume overload.\\n - still intubated with plan to do bronch Wednesday and change out the\\n ET tube to a bigger size\\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid...will need\\n to clean this up in rounds. not at maximum doses of either and both\\n aren't working very well.\\n - Upright rsbi to be done in early AM.\\n - PICC placed\\n - Called micro lab: will try to speciate. will call in AM to confirm\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\\n Infusions:\\n Midazolam (Versed) - 1 mg/hour\\n Other ICU medications:\\n Midazolam (Versed) - 08:39 AM\\n Heparin Sodium (Prophylaxis) - 04:51 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.7\\nC (99.8\\n Tcurrent: 37.2\\nC (99\\n HR: 99 (86 - 128) bpm\\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\\n RR: 28 (18 - 41) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 79.2 kg (admission): 83.8 kg\\n Height: 64 Inch\\n CVP: 6 (2 - 6)mmHg\\n Total In:\\n 784 mL\\n 256 mL\\n PO:\\n TF:\\n IVF:\\n 784 mL\\n 196 mL\\n Blood products:\\n Total out:\\n 2,885 mL\\n 495 mL\\n Urine:\\n 2,885 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,101 mL\\n -239 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 260 (260 - 404) mL\\n PS : 8 cmH2O\\n RR (Spontaneous): 38\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 154\\n PIP: 14 cmH2O\\n SpO2: 99%\\n ABG: ///29/\\n Ve: 9.6 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 174 K/uL\\n 9.2 g/dL\\n 80 mg/dL\\n 1.4 mg/dL\\n 29 mEq/L\\n 4.1 mEq/L\\n 22 mg/dL\\n 101 mEq/L\\n 140 mEq/L\\n 27.9 %\\n 11.3 K/uL\\n [image002.jpg]\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n 04:54 AM\\n 09:30 PM\\n 04:15 AM\\n 03:55 PM\\n 02:50 AM\\n 05:17 PM\\n 03:59 AM\\n WBC\\n 11.3\\n 10.6\\n 11.2\\n 12.2\\n 11.3\\n Hct\\n 29.7\\n 29.3\\n 27.9\\n 27.4\\n 27.9\\n Plt\\n 48\\n 60\\n 84\\n 131\\n 174\\n Cr\\n 1.5\\n 1.5\\n 1.4\\n 1.3\\n 1.4\\n 1.5\\n 1.4\\n 1.4\\n TCO2\\n 26\\n 25\\n Glucose\\n 128\\n 119\\n 126\\n 143\\n 117\\n 109\\n 98\\n 80\\n Other labs:\\n Ca: 8.6, Mg: 2.2, Phos: 3.1\\n Mircrobiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n ANAEROBIC GRAM POSITIVE ROD(S).\\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\\n ANAEROBIC GRAM NEGATIVE ROD(S).\\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\\n Anaerobic Bottle Gram Stain (Final ):\\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\\n Radiology:\\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\\n vena cava. The patient remains intubated, with the endotracheal tube\\n terminating 3.2 cm above the carina. The right internal jugular line\\n ends in the mid superior vena cava. Left pleural effusion with\\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\\n consistent with pulmonary arterial hypertension. The right lung is\\n clear. There is no pulmonary edema.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\\n to her primary metabolic acidosis, which caused her to hyperventilate\\n to compensate and fatigued, becoming acutely SOB and requiring\\n intubation in the ED. Unable to wean effectively; likely secondary to\\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\\n having difficulty coming off PEEP, becomes very tachypneic and has low\\n tidal volumes, which is more concerning for difficulty with compliance\\n and volume overload. Additionally, patient with opacity and\\n diaphragm pulled up on the left that has been noted on all x-rays\\n during this admission, to better see the anatomy in the , \\n bronch the patient this afternoon to look at the .\\n - continue with net negative goal, if UOP decreases to less than\\n 100cc/hr will give another dose of lasix and readdress possible\\n extubation this afternoon.\\n - Hold sedation for now to optimize mental status prior to extubation\\n - NGT in place for meds/diet post extubation\\n # Atrial Fibrillation: First occurred during SBT on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns. Trialed\\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\\n 100\\ns and her BP tolerated it well.\\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\\n the 120\\ns to 130\\ns, so will trial an esmolol drip\\n # Septic shock: resolving, patient off pressors, likely secondary to\\n cholangitis and infected stone/sludge. ERCP showed significant pusand\\n very large stone, she is s/p stent placement. Patient afebrile and\\n white count stable. Lactate normal. Initial sepsis secondary to biliary\\n source given CBD dilation with sludge and obstructive LFTs in setting\\n on known choledocholithiasis.\\n - Leukocytosis is resolving\\nwhite count almost normalized. Had been\\n afebrile for over 48 hours.\\n - Cont zosyn pending any further culture data; Day of zosyn. Day\\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\\n will place a PICC and pull central line\\n - plan for repeat ERCP in one month, after resolution of initial\\n infection for stone break up and removal\\n .\\n # ARF: Improved, near baseline. Likely related to sepsis and\\n intravascular volume depletion secondary to vomiting and diarrhea, also\\n likely some component of ATN as her renal function has not improved as\\n quickly with fluids as would be expected in a purely pre-renal picture.\\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\\n to help with further diruesis\\n - Monitor UOP\\n - Check PM lytes\\n .\\n #Thrombocytopenia: resolved\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n PICC Line - 03:34 PM\\n Prophylaxis:\\n DVT: SQ Heparin, pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments:\\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\\n fails extubation\\n Disposition:ICU\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702212,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - ERCP today: . Pus was seen extruding from the major papilla . A\\n single 2.5-3cm filling defect consistent witha stone or sludge ball\\n that was causing partial obstruction was seen at the mid CBD. A 10FR\\n by 5cm double pigtail biliary stent was placed successfully\\n lactate normalized to 1.4.\\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\\n up some.\\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\\n Changed from AC to PS: doing well; trying to wean down all sedation and\\n pressors:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 50 mcg/hour\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n 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 06:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 71 (61 - 79) bpm\\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\\n RR: 19 (8 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 8 (7 - 344)mmHg\\n Total In:\\n 3,664 mL\\n 1,194 mL\\n PO:\\n TF:\\n IVF:\\n 3,664 mL\\n 1,194 mL\\n Blood products:\\n Total out:\\n 827 mL\\n 330 mL\\n Urine:\\n 827 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,837 mL\\n 864 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): 446 (399 - 470) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 54\\n PIP: 15 cmH2O\\n Plateau: 15 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/38/124/22/-1\\n Ve: 9 L/min\\n PaO2 / FiO2: 310\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 10.7 g/dL\\n 266 mg/dL\\n 2.1 mg/dL\\n 22 mEq/L\\n 3.5 mEq/L\\n 37 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 17.8 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 04:57 AM\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n WBC\\n 25.0\\n 17.8\\n Hct\\n 31.6\\n 30.8\\n Plt\\n 93\\n 48\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n TropT\\n 0.02\\n TCO2\\n 18\\n 20\\n 18\\n 23\\n Glucose\\n 195\\n 151\\n 266\\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\\n D-dimer: :\\n DIC repeat panel:\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n +BCx: : anaerobic bottle: GPR\\n Ucx and BCx pending\\n Radiology: none\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but suspect in setting of\\n met acidosis she fatigued. Has been having recently worsening dyspnea\\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\\n in the ED. Heart failure is less likely as echo and CXR do not show any\\n evidence of this. ABG shows good oxygenation and patient has been\\n switched to PSV 10/5 with FiO2 40%.\\n - Cont PSV for now and wean as tolerated; consider sbt once patient can\\n tolerate no sedation and no pressors\\n - goal to extubate patient today\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\\n placement. Patient afebrile and white count trending down. Lactate now\\n normal. Initial sepsis likely secondary to biliary source given CBD\\n dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Cont broad spectrum abx with vancomycin and pip-tazo until\\n sensitivies return\\n - Trend CBC/diff, lactate, LFTs\\n - Follow up blood cx , urine cx; GPR may be contamination, but will\\n continue to cover broadly for now until further speciation.\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n - Check ScvO2\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\\n had lasix, FeUrea: 14.9%...pre-renal likely.\\n - IVFs for CVP 10-12\\n - Avoid nephrotoxins\\n - Trend renal function\\n .\\n #Thrombocytopenia Likely secondary to sepsis. DIC labs equivical; low\\n suscipicion of HIT as timing does not correlate.\\n - Concerning as platelets continuing to decrease. Vancomycin/Zosyn may\\n be a possibility as known to cause thrombocytopenia.\\n - Repeat DIC labs\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\\n less than 18 or LR if needs resuscitation to prevent further NG\\n acidosis.\\n ICU Care\\n Nutrition: NPO for now in expectation of extubation today\\n Glycemic Control: None\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband\\n status: DNR\\n Disposition: ICU for now\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 703352,\n \"text\": \"85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to cholangitis. She is s/p\\n ERCP and stent.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received patient intubated and vented on PSV 40% 8/5. Sedated on midaz\\n at 1mg/hr. B/L LS clear diminished at the bases. Tachypneic to high\\n 20-30\\n Action:\\n Lasix 20mg X1 given prior to extubation, extubated.\\n Response:\\n No s/s of resp distress. Patient denies any SOB when asked. Sats at\\n high 90\\ns on face tent.\\n Plan:\\n Continue to monitor patient resp status\\n Atrial fibrillation (Afib)\\n Assessment:\\n Known AFib. HR in 90-low 100\\ns. B/P 90-110\\ns occasionally when asleep\\n b/p down to 80\\ns. Peripheral pulses present.\\n Action:\\n Metoprolol at 25mg TID and Dilt 30mg QID\\n Response:\\n HR in the 90\\n Plan:\\n Continue to monitor patient hemodynamic status.\\n Neuro: alert, follows commands.\\n GI: abd soft non tented, positive for BS. NPO. Ngt for meds\\n clamped.\\n 3 x smear of golden loose stools during the shift.\\n GU: clear yellow urine via foley. Lasix X1 given.\\n Skin: reddened buttocks. Critic aid cream applied.\\n Social: patient is a DNR. OK to re-intubate if needed. Family in to\\n visit. Updated by RN and MD.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702218,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\\n single 2.5-3cm filling defect consistent witha stone or sludge ball\\n that was causing partial obstruction was seen at the mid CBD. A 10FR\\n by 5cm double pigtail biliary stent was placed successfully\\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\\n up some. And bicarb improved\\n - this AM: CVP was 7: gave 1 liter of LR\\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\\n Currently on minimal sedation.\\n Changed from AC to PS: doing well; trying to wean down all sedation and\\n pressors:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 50 mcg/hour\\n Norepinephrine - 0.08 mcg/Kg/min\\n Other ICU medications:\\n 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 06:02 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36\\nC (96.8\\n HR: 71 (61 - 79) bpm\\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\\n RR: 19 (8 - 23) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 8 (7 - 344)mmHg\\n Total In:\\n 3,664 mL\\n 1,194 mL\\n PO:\\n TF:\\n IVF:\\n 3,664 mL\\n 1,194 mL\\n Blood products:\\n Total out:\\n 827 mL\\n 330 mL\\n Urine:\\n 827 mL\\n 330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,837 mL\\n 864 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): 446 (399 - 470) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 54\\n PIP: 15 cmH2O\\n Plateau: 15 cmH2O\\n Compliance: 50 cmH2O/mL\\n SpO2: 98%\\n ABG: 7.38/38/124/22/-1\\n Ve: 9 L/min\\n PaO2 / FiO2: 310\\n Physical Examination\\n General: Intubated, sedated, not responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 48 K/uL\\n 10.7 g/dL\\n 266 mg/dL\\n 2.1 mg/dL\\n 22 mEq/L\\n 3.5 mEq/L\\n 37 mg/dL\\n 105 mEq/L\\n 137 mEq/L\\n 30.8 %\\n 17.8 K/uL\\n [image002.jpg]\\n 02:51 AM\\n 04:57 AM\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n WBC\\n 25.0\\n 17.8\\n Hct\\n 31.6\\n 30.8\\n Plt\\n 93\\n 48\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n TropT\\n 0.02\\n TCO2\\n 18\\n 20\\n 18\\n 23\\n Glucose\\n 195\\n 151\\n 266\\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\\n D-dimer: :\\n DIC repeat panel:\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n +BCx: : anaerobic bottle: GPR\\n Ucx and BCx pending\\n Radiology: none\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but suspect in setting of\\n met acidosis she fatigued. Has been having recently worsening dyspnea\\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\\n in the ED. Heart failure is less likely as echo and CXR do not show any\\n evidence of this. ABG shows good oxygenation and patient has been\\n switched to PSV 10/5 with FiO2 40%.\\n - Cont PSV for now and wean as tolerated; consider sbt once patient can\\n tolerate no sedation and no pressors\\n - goal to extubate patient today\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\\n placement. Patient afebrile and white count trending down. Lactate now\\n normal. Initial sepsis likely secondary to biliary source given CBD\\n dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - Cont broad spectrum abx with vancomycin and pip-tazo until\\n sensitivies return\\n - Trend CBC/diff, lactate, LFTs\\n - Follow up blood cx , urine cx; GPR may be contamination, but will\\n continue to cover broadly for now until further speciation.\\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\\n - Check ScvO2\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\\n had lasix, FeUrea: 14.9%...pre-renal likely.\\n - IVFs for CVP 10-12\\n - Avoid nephrotoxins\\n - Trend renal function\\n .\\n #Thrombocytopenia Likely secondary to sepsis. DIC labs equivical; low\\n suscipicion of HIT as timing does not correlate.\\n - Concerning as platelets continuing to decrease. Vancomycin/Zosyn may\\n be a possibility as known to cause thrombocytopenia.\\n - Repeat DIC labs\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\\n less than 18 or LR if needs resuscitation to prevent further NG\\n acidosis.\\n ICU Care\\n Nutrition: NPO for now in expectation of extubation today\\n Glycemic Control: None\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband\\n status: DNR\\n Disposition: ICU for now\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702517,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Atrial fibrillation (Afib)\\n Assessment:\\n Hr 100-130\\ns afib with sbp ranging from 100-120\\ns. k+3.4 and phos=1.7.\\n afib first occurred during sbt on . pressors were then changed to\\n neo in attempt to drop pt\\ns hr but was unsuccessful. Pt was started on\\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\\n bp support\\n Action:\\n Pt repleted with 30mmol of kphos. Hemodynamics montitored closely.\\n Amioderone gtt decreased to 0.5mg/min after 6 hrs of infusion at\\n 1mg/min. neo being weaned to off as pt\\ns hemodynamics tolerate\\n Response:\\n Hr remains in afib tachy from 100-130\\ns but hemodynamically stable\\n Plan:\\n Plan is to continue infusion of amioderon for 18 hrs and then will\\n consider d/c\\ning gtt. Continue to follow hemodynamics and wean as\\n tolerated to keep map> 60 and hourly uo > 30cc\\ns/hr. check lytes as\\n ordered and replete as needed\\n Sepsis without organ dysfunction\\n Assessment:\\n Pt s/p ercp on . low grade temps but wbc up to 20.2 from yesterday\\n count of 16.blood cultures from grew gm pos rods and gm neg rods.\\n Septic shock most likely secondary to cholangitis and infected\\n stone/sludge.with increase in wbc concern is for a new infection.\\n Action:\\n Fever curve followed closely. Pt receiving piperacillin as ordered.\\n Awaiting final speciation of all culture data. Pan cultured today\\n Response:\\n Low grade temps and elevated wbc unchanged.\\n Plan:\\n Await results for all culture data. Administer antibiotics as ordered\\n and follow fever curve.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt most likely became fatigued in the setting of metabolic acidosis\\n and attempt to hyperventilate to compensate requiring her to be\\n intubated. Placed pt on 40% cpap with 5 peep and ps of 5 . lungs\\n essentially clear on auscultation. Suctioned for sm amts of thick tan\\n sputum.cxr c/w fluid overload which is likely contributing to the\\n difficulty in weaning her off the vent.once pt is weaned off pressors\\n will then need diuresis and hopefully pt will start to mobilize fluid.\\n Action:\\n Vent weaned to 40%cpap with 5 peep and ps of 5. resp status monitored\\n closely. Antibiotics administered as ordered. Reps toileting continues.\\n Decision made not to extubate pt since she became tachypneic ,had lower\\n tv\\ns and appeared more uncomfortable. Versed gtt increased back up to\\n 2mg/hr. vent changed back to ac mode of ventilation. Sputum for c&s\\n sent off to microbiology. Ogt placed in order to start tube fdgs until\\n pt is extubated.\\n Response:\\n Resting comfortably on ac mode after not tolerating decrease in vent\\n settings.\\n Plan:\\n Check rsbi in the am and do sbt. Wean pressors to off if possible and\\n then will diurese as needed . d/c tube fdgs at midnoc in the hope of\\n extubating pt in the am. Continue to monitor pt\\ns resp status and\\n continue with resp toileting\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 703202,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 7\\n Ideal body weight: 54.4 None\\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: 20 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 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: Diminished\\n LLL Lung Sounds: Crackles\\n Comments:\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Accessory muscle use,\\n Tachypneic (RR> 35 b/min)\\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 Intolerant of weaning attempts, Pending procedure / OR\\n Respiratory Care Shift Procedures\\n Planning to change tube size and bronch in am.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702324,\n \"text\": \"Atrial fibrillation (Afib)\\n Assessment:\\n Pt was in NSR without ectopi at about 1030 patient had new onset Atrial\\n Fibrillation. Patient was on spontaneous breathing trial did not appear\\n to be in res p distress O2 SAT > 95. Patient remained on Levophed at\\n 0.07mcg/kg/min with out changed in sbp. Patient Hr 110-120 and\\n tolerated. Since 1500 HR up to 130-140 at times.\\n Action:\\n Patient placed back on ventilator. EKG done and read Additional fluid\\n was given and attempted to wean Levophed without success, labs sent\\n Response:\\n Pt has remained in A Fibrillation. Hr 110-140. Unable to wean Levophed.\\n Plan:\\n Continue to monitor patient. Possibly changed patient to another\\n pressor. Continue to treat sepsis and monitor labs,\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702396,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\\n versed 3mg/hr.\\n Action:\\n Suctioned for small amount secretions. Blood gas in the am. Versed\\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\\n Response:\\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/ .am\\n RSBI 54 and tolerated well.\\n Plan:\\n Wean vent / sedations as tolerated further and for possible\\n extubation today.\\n Sepsis without organ dysfunction\\n Assessment:\\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\\nS on\\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\\n /BUN 37,elevated liver enzymes.\\n Action:\\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\\n with NaHCo3 150 meq given for hydration and for PH 7.29 from the\\n evening lab\\n Response:\\n SBP 85-90\\ns when tried to titrate Levophed further .so continued on\\n 0.07mics. urine output improved with fluid bolus.\\n Plan:\\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702398,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt intubated , cpap/ps see metavision for vent settings\\n Action:\\n Weaning sedation lightened fentanyl gtt if off, versed at 2mg/hr easily\\n arousable following commands\\n Response:\\n Am blood gas pending\\n Plan:\\n possible extubation today.\\n Sepsis without organ dysfunction\\n Assessment:\\n s/p ERCP, switch from levophed to neo yesterday\\n Action:\\n Weaning neo as tolerated\\n Response:\\n SBP 85-90\\ns neo is at 1mcg//min presently\\n Plan:\\n Wean neo as tolerated. moniotr urine output / VSS .\\n Atrial fibrillation (Afib)\\n Assessment:\\n Continues in a-fib hr 120-130\\n Action:\\n 10mg of iv Dilt. given\\n Response:\\n Hr 10 110-118 for short period of time now back in 120\\ns still in\\n a-fib\\n Plan:\\n Continue to monitor patient. Monitor the HR, may start on amiodorone\\n today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702511,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Atrial fibrillation (Afib)\\n Assessment:\\n Hr 100-130\\ns afib with sbp ranging from 100-120\\ns. k+3.4 and phos=1.7.\\n afib first occurred during sbt on . pressors were then changed to\\n neo in attempt to drop pt\\ns hr but was unsuccessful. Pt was started on\\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\\n bp\\n Action:\\n Response:\\n Plan:\\n Sepsis without organ dysfunction\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"Physician Attending/Fellow Progress Note - MICU\",\n \"row_id\": 702702,\n \"text\": \"TITLE:\\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\\n presents with septic shock and cholangitis, s/p ERCP with stent, and\\n respiratory failure. Now with persistent vent requirements.\\n 24 Hour Events:\\n Arterial line came out.\\n Patient unable to provide history: Sedated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Amiodarone - 0.5 mg/min\\n Other ICU medications:\\n Fentanyl - 05:00 PM\\n Midazolam (Versed) - 08:11 AM\\n Other medications:\\n Changes to medical and family history: No changes\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: Unable to obtain, patient sedated and intubated.\\n Flowsheet Data as of 11:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 38\\nC (100.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 128 (114 - 141) bpm\\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\\n RR: 23 (14 - 30) insp/min\\n SpO2: 99%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n Height: 64 Inch\\n Total In:\\n 1,682 mL\\n 311 mL\\n PO:\\n TF:\\n 73 mL\\n 1 mL\\n IVF:\\n 1,610 mL\\n 310 mL\\n Blood products:\\n Total out:\\n 2,045 mL\\n 920 mL\\n Urine:\\n 2,045 mL\\n 920 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -363 mL\\n -609 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): 380 (308 - 528) mL\\n PS : 12 cmH2O\\n RR (Set): 0\\n RR (Spontaneous): 26\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 157\\n PIP: 16 cmH2O\\n Plateau: 20 cmH2O\\n Compliance: 31.6 cmH2O/mL\\n SpO2: 99%\\n ABG: 7.46/34/127/24/1\\n Ve: 9.9 L/min\\n PaO2 / FiO2: 318\\n Physical Examination\\n Gen\\nl: intubated, sedated\\n HEENT: ETT in place, pupils constricted by equal and reactive\\n Pulm: diminished, transmitted vent sounds, no wheezing, crackles at\\n bases anteriorly\\n CV: irregularly irregular, tachycardic, distant and no murmur\\n appreciated, no gallop or rubs\\n Abdomen: soft, no grimace to palpation, (+) bowel sounds\\n Neurologic: responds to tactile stimuli, non-purposeful movement\\n Labs / Radiology\\n 9.8 g/dL\\n 48 K/uL\\n 128 mg/dL\\n 1.5 mg/dL\\n 24 mEq/L\\n 4.0 mEq/L\\n 29 mg/dL\\n 107 mEq/L\\n 140 mEq/L\\n 29.7 %\\n 11.3 K/uL\\n [image002.jpg]\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n 03:15 AM\\n 04:02 AM\\n WBC\\n 17.8\\n 15.3\\n 20.2\\n 11.3\\n Hct\\n 30.8\\n 31.4\\n 30.7\\n 29.7\\n Plt\\n 48\\n 59\\n 46\\n 52\\n 48\\n Cr\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n 1.5\\n TropT\\n 0.02\\n TCO2\\n 23\\n 23\\n 26\\n 25\\n Glucose\\n 151\\n 266\\n 102\\n 91\\n 128\\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\\n PO4:2.2 mg/dL\\n Assessment and Plan\\n Respiratory failure\\n - now likely secondary to volume overload\\n - goal TBB - 1 to -1.5L today and will give prn lasix\\n - wean pressure support as tolerated, check CXR\\n Septic shock\\n - now off pressors, autodiuresing\\n - on zosyn, day , leukocytosis improving\\n - LFTs improving s/p stenting via ERCP\\n - awaiting speciation/sensitivities from cultures\\nAtrial fibrillation\\n - on amiodarone drip, will continue for now\\n - will calculate total dose today\\n Thrombocytopenia\\n - stable, no signs of active bleeding\\n - very low suspicion for HIT\\n - will restart SC heparin when plts >50K\\n ICU Care\\n Nutrition:\\n Comments: restart TF as unlikely to be extubated today\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Not indicated\\n VAP: HOB elevation, Mouth care, Daily wake up\\n Comments:\\n Communication: Family meeting held , ICU consent signed\\n Code status: DNR (do not resuscitate)\\n Disposition :ICU\\n Total time spent: 35 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 702128,\n \"text\": \"Patient presented to the ED from the doctor's office on with one\\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\\n alert and aware and communicating verbally. Lab tests revealed elevated\\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\\n vancomycin, zosyn and a central line placed poor access. She was\\n then taken for an abdominal u/s where she was placed in a low lying\\n position. She then got into respiratory difficulty which required\\n intubation and sedation followed by pressor to maintain a perfusing\\n pressure. She was then transferred to the for further management\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\\n versed 3mg/hr.\\n Action:\\n Suctioned for small amount secretions. Blood gas in the am.\\n Response:\\n Easily arousable, stable during the shift. RSBI in the morning.\\n Plan:\\n Wean vent / sedations as tolerated further.\\n Sepsis without organ dysfunction\\n Assessment:\\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\\nS on\\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr\\n Action:\\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min,\\n tried to titrate to 0.1 later .1000cc D5 with NaHCo3 150 meq given for\\n hydration and for PH 7.1\\n Response:\\n SBP 85-90\\ns when tried to titrate levophed.so continued on 0.12mics.\\n SBP >110-110 mm of hg.urine output improved with fluid bolus. Blood gas\\n in the am.\\n Plan:\\n Hydrate and wean levo as tolerated.moniotr urine output / VSS .\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 702505,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - pt. s/p ERCP with stent placement\\n - patient became tachycardic with so changed back to A/C--> went\\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\\n which dropped her BP into the 70's systolic and her HR decreased into\\n the 110's. Her heart rate remained elevated in the 130\\ns and she\\n continued to have a pressor requirement, so she was started on\\n amiodarone early this morning.\\n - early this morning\\npatient very tahcypneic, unable to be\\n extubated\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 06:30 AM\\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Phenylephrine - 1 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Diltiazem - 11:00 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.3\\nC (99.2\\n Tcurrent: 37.3\\nC (99.2\\n HR: 133 (72 - 141) bpm\\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\\n RR: 31 (10 - 34) insp/min\\n SpO2: 97%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 83.8 kg (admission): 83.8 kg\\n CVP: 18 (0 - 325)mmHg\\n Mixed Venous O2% Sat: 79 - 79\\n Total In:\\n 5,376 mL\\n 285 mL\\n PO:\\n TF:\\n IVF:\\n 5,376 mL\\n 285 mL\\n Blood products:\\n Total out:\\n 1,320 mL\\n 555 mL\\n Urine:\\n 1,320 mL\\n 555 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 4,056 mL\\n -270 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): 317 (308 - 415) mL\\n PS : 10 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: RR >35-had good tidal volumes though\\n PIP: 15 cmH2O\\n SpO2: 97%\\n ABG: 7.41/39/98./26/0\\n Ve: 8.8 L/min\\n PaO2 / FiO2: 245\\n Physical Examination\\n General: Intubated, awake, responsive\\n HEENT: PERRL, MMM, ETT in place\\n Neck: RIJ in place\\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\\n rebound tenderness or guarding, no organomegaly\\n Ext: warm, well perfused, 2+ pulses, no edema\\n Skin: somewhat jaundiced\\n Labs / Radiology\\n 52 K/uL\\n 10.5 g/dL\\n 91 mg/dL\\n 1.6 mg/dL\\n 26 mEq/L\\n 3.4 mEq/L\\n 32 mg/dL\\n 108 mEq/L\\n 140 mEq/L\\n 30.7 %\\n 20.2 K/uL\\n [image002.jpg]\\n 07:35 AM\\n 05:45 PM\\n 05:50 PM\\n 03:59 AM\\n 05:12 AM\\n 06:45 AM\\n 03:25 PM\\n 06:19 PM\\n 04:18 AM\\n 04:37 AM\\n WBC\\n 25.0\\n 17.8\\n 15.3\\n 20.2\\n Hct\\n 31.6\\n 30.8\\n 31.4\\n 30.7\\n Plt\\n 93\\n 48\\n 59\\n 46\\n 52\\n Cr\\n 2.4\\n 2.1\\n 2.1\\n 1.8\\n 1.6\\n TropT\\n 0.02\\n 0.02\\n TCO2\\n 18\\n 23\\n 23\\n 26\\n Glucose\\n 195\\n 151\\n 266\\n 102\\n 91\\n Other labs:\\n Ca: 7.7, Mg: 2.4, Phos: 1.7\\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\\n PT: 12.2, INR: 1.0\\n Microbiology:\\n 11:55 pm BLOOD CULTURE\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n GRAM NEGATIVE ROD(S).\\n 11:58 pm BLOOD CULTURE X2.\\n Blood Culture, Routine (Preliminary):\\n GRAM POSITIVE RODS.\\n URINE CULTURE (Final ): NO GROWTH.\\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\\n from the major papilla. An opening draining bile and pus consistent\\n with a choledochoduodenal fistula was seen at the superior portion of\\n the major papilla. Cannulation of the biliary duct was successful and\\n deep with a sphincterotome using a free-hand technique. Contrast medium\\n was injected resulting in complete opacification. A single 2.5-3cm\\n filling defect consistent witha stone or sludge ball that was causing\\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\\n introducer kit.\\n Echo: The left atrium is mildly dilated. Left ventricular wall\\n thickness, cavity size and regional/global systolic function are normal\\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\\n Right ventricular chamber size and free wall motion are normal. The\\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\\n not present. Trace aortic regurgitation is seen. The mitral valve\\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\\n seen. The estimated pulmonary artery systolic pressure is high normal.\\n There is a trivial/physiologic pericardial effusion.\\n Compared with the prior study (images reviewed) of , the left\\n ventricle is less dynamic, the velocity across the aortic valve is\\n lower (now normal), and the severity of tricuspid regurgitation and\\n pulmonary artery systolic pressure are lower.\\n Assessment and Plan\\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\\n presents with dyspnea and vomiting complicated by acute respiratory\\n failure and septic shock likely secondary to biliary source. She is s/p\\n ERCP and stent.\\n .\\n # Dyspnea/respiratory failure: Resp failure does not appear primary\\n lung process, as CXR is rather unimpressive, but in the setting of her\\n metabolic acidosis she was hyperventilating to compensate and\\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\\n been doing well on the ventilator, had hoped to extubate her yesterday,\\n however she went into A.fib with RVR during her , she was\\n intially changed back to A/C, then transitioned back to PSV.\\n - early this morning\\npatient very tachypneic with lower tidal\\n volumes, appeared very uncomfortable during short trial this morning,\\n will transition back to A/C and then wean to PSV throughout the day\\n -Chest x-ray appeared volume overloaded, which is likely contributing\\n to the difficulty weaning her off the ventilator, when patient is able\\n to be weaned off pressors will need diuresis. Hopefully patient will\\n start to mobilize her extra fluid, however once off pressors if she is\\n unable to, will give lasix as needed to help decrease the fluid in her\\n lungs\\n - Hopeful extubation tomorrow pending ability to diurese\\n # Atrial Fibrillation: First occurred during on , initially\\n rates were in the 110\\ns, then increased to the 130\\ns, pressor changed\\n from levophed to neo without any effect, her BP dropped with IV dilt,\\n so started amiodarone morning of due to continued pressor\\n requirement\\n - Monitor for improvement and hopeful d/c of amio once patient is\\n extubated and off sedation\\n # Septic shock: Likely secondary to cholangitis and infected\\n stone/sludge. ERCP showed significant pusand very large stone, she is\\n s/p stent placement. Patient afebrile and white count trending down.\\n Lactate now normal. Initial sepsis likely secondary to biliary source\\n given CBD dilation with sludge and obstructive LFTs in setting on known\\n choledocholithiasis. No other source of infection found.\\n - With increasing leukocytosis concern for a new infection, will\\n reculture blood, urine and sputum, also send a C.diff when patient has\\n a bowel movement, if LFT\\ns increase, will reimage RUQ due to concern\\n for possible blockage of stent\\n - Cont zosyn pending any further culture data; f/u speciation and\\n sensitivities from prior blood cx\\n - Trend CBC/diff, LFTs, especially in the setting on increasing\\n leukocytosis, will add on Diff to AM labs\\n - Follow up blood cx speciation , urine cx with no growth\\n - Wean neo as tolerated by MAP >= 60 mmHg\\n # ARF: Likely related to sepsis and intravascular volume depletion\\n secondary to vomiting and diarrhea, also likely some component of ATN\\n as her renal function has not improved as quickly with fluids as would\\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\\n baseline creatinine 1.2-1.4.\\n - Titrate MAP to greater than 60, unless urine output decreases then\\n will titrate to increased MAP\\n .\\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\\n timing does not correlate since patient has not had a prior heparin\\n exposure. Vancomycin may also be contributing to her\\n thrombocytopenia. Platelets slightly increased today.\\n - Continue to hold vanc/heparin\\n - No signs of active bleeding\\n - Transfuse for less than 10,000 or 30,000 for procedure\\n - If platelets remain stable or increase tomorrow would restart heparin\\n as HIT is very unlikely\\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\\n acidosis: Gap has closed. Lactate normalized.\\n - Bicarb 26 today, extubation will be facilitated by resolution of\\n acidosis.\\n ICU Care\\n Nutrition: Will place OG tube for tube feeds today and turn them off at\\n midnight for hopeful extubation tomorrow\\n Glycemic Control:\\n Lines:\\n Multi Lumen - 03:45 AM\\n 20 Gauge - 03:45 AM\\n Arterial Line - 10:32 AM\\n Prophylaxis:\\n DVT: pneumoboots\\n Stress ulcer:\\n VAP: bundle\\n Comments:\\n Communication: Comments: Husband, (daughter) is HCP.\\n status: DNR-is intubated\\n Disposition: ICU\\n ------ Protected Section ------\\n MICU ATTENDING PROGRESS NOTE\\n I saw and examined the patient and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n resident note, including the assessment and plan. I would emphasize and\\n add the following points: 85F a w/ renal ca, dementia,\\n choledocolithiasis in w/ sepsis/shock from cholangitis s/p ERCP\\n with stent placement. She remains intubated, Course has been c/b\\n continued pressor requirements and development of A-fib in setting of\\n yesterday now on amio gtt for rate control.\\n PE: Tm 99.2 BP 102/56 HR 72-141 RR 20's Sat 97% on PS 10/5 40%\\n -->7.41/39/98%\\n Intubated, more alert awake, NAD, follows commands, CTA ant, decreased\\n bb, , tachy, soft + BS, NT, no ruq tenderness, no pedal edema\\n LABS: wbc 20.2, hct 31, plt 52, na 140, cr 1.6 (2.6), lactate 1.7, t\\n bili, ast/alt continue to decrease, inr 1.0,\\n Micro: bl cx's--> gpr/gnr\\n CXR-->w/ sm L effusion and prominent vascular markings\\n A/P: Sepsis from cholangitis c/b arf, resp failure, thrombocytopenia.,\\n and a-fib. Her WBC is rising. She failed this am, likely related\\n to extra volume. She remains on pressors.\\n Agree with plan to rest on ACV and trial back on PS later today as she\\n tolerates following abg and clinical picture. Her MAPs are adequate and\\n we should be able to titrate off pressor support. She remains on amio\\n gtt/load for rate control. Her cr continues to improve toward her\\n baseline CRI and her urine outpt is excellent. We hope she will\\n continue to mobilize fluids, though once BP is stable off pressors, we\\n may need diurese prior to and extubation. We continue to treat\\n biliary sepsis with zosyn. Given her rising wbc ct, we are concerned\\n for new infection. Her lfts are down and her abd exam benign, there is\\n no diarrhea or new secretions and she remains AF. Her lines are just a\\n few days old. We will repeat pan cxs, check for c diff, and f/u\\n pending cx speciation /sensitivities. We keep a low threshold for\\n broadened coverage in setting of temp spike or clinical decline. We\\n continue to monitor her plts closely and suspect her thrombocytopenia\\n is infection response or medications noting no recent heparin\\n exposure to support early HIT. Will continue to hold heparin products\\n and monitor, following DIC labs, and keeping t and c. A-line and CVL.\\n DNR. Start TFs.\\n Remainder of plan as outlined in resident note.\\n Patient is critically ill\\n Total time: 45 min.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 01:31 PM ------\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-12-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192914,\n \"text\": \"Baseline artifact. Normal sinus rhythm with atrial premature beat.\\nIntraventricular conduction delay of right bundle-branch block morphology.\\nNon-specific ST-T wave abnormalities. Compared to the previous tracing\\nof atrial fibrillation has resolved and right bundle-branch block is\\nnew. Clinical correlation and repeat tracing are suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192915,\n \"text\": \"Atrial fibrillation with rapid ventricular response. Low QRS voltage in the\\nprecordial leads. Diffuse non-specific T wave flattening. Compared to the\\nprevious tracing of atrial fibrillation is new. Decreased QRS voltage\\nis now evident.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192916,\n \"text\": \"Baseline artifact. Sinus rhythm. Since the previous tracing probably no\\nsignificant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192917,\n \"text\": \"Sinus rhythm. Leftward axis. Since the previous tracing no significant\\nchange.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2169-11-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192918,\n \"text\": \"Sinus rhythm. Since the previous tracing of the single beat showing a\\nmore leftward axis and right bundle-branch block morphology is no longer\\npresent.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1102526,\n \"text\": \" 9:52 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: ?fluid overload\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with progressive dyspnea, intubated, septic\\n REASON FOR THIS EXAMINATION:\\n NG tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 10:22 A.M., \\n\\n HISTORY: Progressive dyspnea and sepsis.\\n\\n IMPRESSION: AP chest compared to and 14 through 1:09 a.m.\\n\\n Peripheral wedge-shaped opacity in the left hemithorax obscuring the lateral\\n pleural sulcus, which developed on , has been stable since 1:39 a.m.\\n today consistent with pulmonary infarction, perhaps related to septic embolus\\n or small loculated pleural fluid collection, also sometimes the result of\\n pulmonary embolus. Moderate cardiomegaly and enlargement of the pulmonary\\n arteries are longstanding. ET tube in standard placement. Right jugular line\\n ends in the low SVC, nasogastric tube passes into the stomach and out of view.\\n New opacification at the right lung base may be due to mild edema in the\\n setting of severe emphysema. No pneumothorax or appreciable layering pleural\\n effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1102456,\n \"text\": \" 7:37 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for PNA, CHF\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with shortness of breath\\n REASON FOR THIS EXAMINATION:\\n eval for PNA, CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Shortness of breath.\\n\\n COMPARISON: Chest radiograph .\\n\\n UPRIGHT AP VIEW OF THE CHEST: Study is slightly limited due to patient\\n motion. The cardiac, mediastinal, and hilar contours are stable, with\\n unchanged enlargement of the pulmonary arteries, compatible with underlying\\n hypertension. Prominent epicardial fat pad is again noted. The lungs are\\n grossly clear without focal consolidation, pleural effusion or pneumothorax.\\n There appears to be hyperinflation of the lungs, stable from prior.\\n Degenerative changes are seen within the right shoulder. New surgical clips\\n are also noted within the epigastric region. Multilevel degenerative changes\\n are present in the thoracic spine.\\n\\n IMPRESSION: Study is slightly limited due to patient motion. No gross\\n evidence of pneumonia or congestive heart failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1102784,\n \"text\": \" 3:13 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with sepsis requiring intubation from a biliary source\\n REASON FOR THIS EXAMINATION:\\n Evaluate for interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:40 PM\\n PFI: Gradual increase in left now moderate pleural effusion with adjacent\\n opacity, likely due to compression atelectasis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n FRONTAL CHEST RADIOGRAPH\\n\\n INDICATION: 85-year-old woman with sepsis, requiring intubation. Evaluate\\n for interval change.\\n\\n COMPARISON: Several prior studies, most recent dated .\\n\\n FINDINGS: The patient remains intubated, with the endotracheal tube in a\\n standard position. A nasogastric tube is not present. A right internal\\n jugular line ends in the mid SVC. The heart remains mildly enlarged. There\\n is a left-sided pleural effusion, slowly increasing over the period of days.\\n There is adjacent density, probably due to compression atelectasis.\\n\\n The pulmonary arteries are enlarged, as before. There is no pneumothorax or\\n frank pulmonary edema.\\n\\n IMPRESSION: Gradual increase in left now moderate pleural effusion with\\n adjacent opacity, likely due to compression atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1102470,\n \"text\": \" 11:15 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval for line placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with new central line\\n REASON FOR THIS EXAMINATION:\\n eval for line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 85-year-old female with new central line placement.\\n\\n COMPARISON: Chest radiographs of and , 7:38 p.m.\\n\\n PORTABLE UPRIGHT CHEST RADIOGRAPH: A new right internal jugular central\\n venous catheter tip is seen in the low SVC. No new pneumothorax, pleural\\n effusion, or mediastinal widening is seen. Otherwise, the exam is unchanged,\\n with evidence of pulmonary hypertension and top normal heart size.\\n\\n IMPRESSIONS: No evidence of CHF or consolidation.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 1102472,\n \"text\": \" 12:16 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: please eval liver/gb\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with new transamionitis and jaundice\\n REASON FOR THIS EXAMINATION:\\n please eval liver/gb\\n ______________________________________________________________________________\\n WET READ: AGLc WED 1:37 AM\\n difficult to compare across modalities. perhaps slight increase in size of\\n common duct at liver margin, previously ~21mm, currently ~25 mm, in pt with\\n chronic dilatation of intra- and extra-hepatic bile ducts. echogenic\\n material seen in distal CBD, probably sludge/sludge ball. more focal stone-\\n appearing filling defect seen on recent MR (measuring 2.5 cm in longest\\n dimension) not seen. also distalmost CBD / panc head not well visualized.\\n clinical correlation necessary, and if indicated, ERCP or MRCP could be\\n performed for further assessment. no fluid in RUQ. no Rt hydro.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 85-year-old female with acute onset of dyspnea and vomiting\\n beginning yesterday, with near collapse today. No leukocytosis but total\\n bilirubin of 9.9.\\n\\n COMPARISON: MR abdomen of , CT torso last performed on , and\\n lap ultrasound performed of the kidneys on .\\n\\n RIGHT UPPER QUADRANT ULTRASOUND: The examination of the right upper quadrant\\n was terminated prematurely due to patient respiratory difficulty towards the\\n end of the exam.\\n\\n The liver parenchyma appears unremarkable. There is again dilatation of the\\n extrahepatic bile ducts and central intrahepatic ducts, similar to that seen\\n on MRI of 2 weeks prior. The common bile duct again has dilated and tortuous\\n appearance, measuring up to 2.5 cm in diameter. Echogenic debris is seen\\n within the distal common bile duct which is non-shadowing, probably\\n representing sludge and/or stones. However, the distalmost CBD and pancreatic\\n head is not well visualized.\\n\\n Limited views of the right kidney show no hydronephrosis. There is again\\n echogenic appearance to the kidney with cortical thinning. The known lower\\n pole renal mass is not assessed as the examination was terminated at this\\n point.\\n\\n No ascites is seen in the visualized right upper quadrant.\\n\\n IMPRESSION: Dilatation of bile ducts, similar to that seen on recent MRI\\n study performed 2 weeks ago. Again with sludge/stones seen in CBD, but\\n distal most CBD and pancreatic head not well visualized. In this patient with\\n clinical concern for ascending cholangitis,there are no imaging studies\\n sensitive for this.\\n (Over)\\n\\n 12:16 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \\n Reason: please eval liver/gb\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1102475,\n \"text\": \" 1:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Please assess cardiopulm status\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with respiratory distress\\n REASON FOR THIS EXAMINATION:\\n Please assess cardiopulm status\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 85-year-old female with respiratory distress.\\n\\n COMPARISON: Earlier same evening radiographs of at 07:38 p.m. and\\n 11:19 p.m., as well as prior chest radiograph of and PET CT of .\\n\\n PORTABLE UPRIGHT CHEST RADIOGRAPH: The study is degraded by respiratory\\n motion. Allowing for this, exam is unchanged from two hours prior, with no\\n interval development of pneumothorax, pleural effusion, pulmonary edema or\\n consolidation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1102984,\n \"text\": \" 3:10 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: OG tube placement, thanks\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with respiratory distress s/p OG tube placement\\n REASON FOR THIS EXAMINATION:\\n OG tube placement, thanks\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: OG tube placement.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, an OG tube has been placed.\\n The tip of the tube projects over the distal parts of the stomach, the course\\n of the tube is unremarkable. There is no evidence of complications, notably\\n no pneumothorax. The other monitoring and support devices are in unchanged\\n position. Overall unchanged appearance of the heart and lungs.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"ERCP BILIARY&PANCREAS BY GI UNIT\",\n \"row_id\": 1102642,\n \"text\": \" 11:03 PM\\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \\n Reason: please evaluate ERCP films from \\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with CBD stone, cholangitis. Post double pigtail stent\\n placement.\\n REASON FOR THIS EXAMINATION:\\n please evaluate ERCP films from \\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Common bile duct stone and cholangitis.\\n\\n COMPARISON: MR from .\\n\\n FINDINGS: 16 spot fluoroscopic images of the right upper quadrant from an\\n ERCP obtained without a radiologist present. Images reveal scattered clips in\\n the right upper quadrant. Thereafter, note is made of cannulation of the\\n common bile ducts with consequent opacification of both the pancreatic and\\n common bile ducts. Both ducts are dilated with pronounced dilation of the\\n common bile duct as well as the intrahepatic biliary ducts. Final image\\n reveals placement of a plastic stent traversing the common bile duct.\\n\\n IMPRESSION: Dilation of both the pancreatic and common bile ducts, similar to\\n that depicted on comparison cross-sectional images. Further details are found\\n on ERCP report dated .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1102476,\n \"text\": \" 1:40 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: tube placement?\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with recent ett for flash edema\\n REASON FOR THIS EXAMINATION:\\n tube placement?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 85-year-old female with recent intubation for flash edema.\\n\\n COMPARISON: Chest radiographs performed earlier on the same evening on\\n at 07:38 p.m. and 11:19 p.m., as well as on at 01:12 a.m.\\n\\n PORTABLE SUPINE CHEST RADIOGRAPH: The patient is newly intubated, with the ET\\n tube tip terminating 3.2 cm above the carina. The right internal jugular\\n central venous catheter tip remains in the mid-to-lower SVC. Allowing for\\n rotation of the patient, cardiomediastinal contours are unchanged. No supine\\n evidence for large pneumothorax is seen. However, there is now increased\\n dense consolidation in the left lateral cardiophrenic angle.\\n\\n IMPRESSIONS:\\n 1. No flash pulmonary edema seen.\\n 2. Newly apparent dense consolidation in left lateral costophrenic angle,\\n concerning for pulmonary embolism with infarction in this patient with\\n respiratory distress. This was discussed with Dr. from the\\n Medicine service over the phone at 8 am.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1103260,\n \"text\": \" 4:27 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate a change in lung fields.\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with acute resp failure on vent, cholangitis, please evaluate\\n a change in lung fields.\\n REASON FOR THIS EXAMINATION:\\n please evaluate a change in lung fields.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Evaluation for lung fields, cholangitis.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, there is no relevant\\n change. Moderate cardiomegaly with suspicion for left-sided pleural effusion\\n on subsequent retrocardiac atelectasis. The monitoring and support devices\\n are in unchanged position. The presence of minimal right-sided pleural\\n effusion cannot be excluded. Slightly hyperlucent lung structure, consistent\\n with the presence of pulmonary emphysema. No focal parenchymal opacities\\n suggesting pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1103566,\n \"text\": \", F. MED 2:44 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: 41cm left picc. tip?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with new picc.\\n REASON FOR THIS EXAMINATION:\\n 41cm left picc. tip?\\n ______________________________________________________________________________\\n PFI REPORT\\n Left PICC ends in upper superior vena cava.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-28 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1103565,\n \"text\": \" 2:44 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: 41cm left picc. tip?\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with new picc.\\n REASON FOR THIS EXAMINATION:\\n 41cm left picc. tip?\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 4:46 PM\\n Left PICC ends in upper superior vena cava.\\n ______________________________________________________________________________\\n FINAL REPORT\\n FRONTAL CHEST RADIOGRAPH\\n\\n INDICATION: 85-year-old woman with new PICC.\\n\\n COMPARISON: Multiple prior studies, most recent dated .\\n\\n FINDINGS: Left PICC ends in the upper superior vena cava. The patient\\n remains intubated, with the endotracheal tube terminating 3.2 cm above the\\n carina. The right internal jugular line ends in the mid superior vena cava.\\n Left pleural effusion with atelectasis have not changed. Pulmonary arteries\\n are markedly enlarged, consistent with pulmonary arterial hypertension. The\\n right lung is clear. There is no pulmonary edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1102785,\n \"text\": \", S. MED 3:13 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate for interval change\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with sepsis requiring intubation from a biliary source\\n REASON FOR THIS EXAMINATION:\\n Evaluate for interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Gradual increase in left now moderate pleural effusion with adjacent\\n opacity, likely due to compression atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2169-11-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1103113,\n \"text\": \" 1:47 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for change in volume status\\n Admitting Diagnosis: SEPSIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old woman with respiratory failure and septic shock\\n REASON FOR THIS EXAMINATION:\\n Eval for change in volume status\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Respiratory failure and septic shock.\\n\\n Comparison is made with prior study performed a day earlier.\\n\\n Small right, moderate left pleural effusions associated with adjacent\\n atelectasis are unchanged. The upper lobes are clear. Lines and tubes are in\\n unchanged standard position. Cardiomediastinal contours are unchanged.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":180,"cells":{"subject_id":{"kind":"number","value":27597,"string":"27,597"},"hadm_id":{"kind":"number","value":180160,"string":"180,160"},"target_text":{"kind":"string","value":"60 yo presents w/ dyspnea and peripheral edema, admitted initially to ICU as above with severe anemia, acute renal failure, pulmonary hemorrhage with w/u (as above) consistant with anca+ vasculitis - Wegner's Granulomatosis. Pt with prolonged hospitalization, tx with cytoxan, 7 rounds of plasamphoresis, steroids - pt with slow pulm course (as expected), multiple unit transfusion as noted above in the ICU - required only 2units on floor with h/h remaining stable while in-house. Pt with rare aspergillus on sputum, ID consulted - decision to treat with voriconazole for 3 mo (can truncate treatment course if LFTs increase with plan below). ID also with concern for latent TB - AFBx3 neg as checked prior to d/c - decision to treat with INH/vit b6, LFTs to be monitored as outpt, scheduled staggerred consultant appointments for each medical consultant to follow LFTs with voriconazole/INH plan as below. Consultant f/u as detailed in summary (Rheum, Renal, ID, ENT, and Pulmonary).
1. Wegner's Granulomatosis -presented w/ pulm hemorrhage, severe anemia, and ARF. -Appreciated Rheum and Renal input -s/p 7 treatments of plasmapheresis, completed on . Per Renal, removed pheresis catheter on -Appreciate Rheum input, increased Cyclophosphamide to 125mg QD and prednisone to 50mg QD on - with plan for further changes per outpt, f/u time schedule per rheum and renal services -Dyspnea, cough improved and oxygen requirement stable, with cont need for pulm support (more at night time, though recently relatively stable), overall this will be a process with pt about his expected baseline at this point in his disease process - pulm f/u in 1 month, has VNA set upt and home for o2, nebs, pulm support -Renal function stable, Cr monitored. Continued to make good urine, foley discontnued. Appreciate Renal recs, plan for outpt f/u with Dr. , lytes stable at time of d/c.
2. Hypoxia/Aspergillus infection/concern for tuberculosis. -Initially thought to be from Wegener's disease, and is likely main contributor. Pt significantly improved from initial presentation and continues to have stable oxygen requirement. Is afebrile wnl WBC but also immunosupressed, (WBC relatively stable at time of d/c - 4.9). -Treating w/ voriconazole given rare aspergillus growth in one sputum sample () given significant immunosuppression, plan for 4-6wk treatment course (has clinic f/u this month) -shorter course give neg galactomannan and rare cx initially along with INH/cytoxan regime as well. -Oxygen requirement stable, pt worked w PT w/o increased oxygen requirement. Appreciate pulm recs, but they do not think repeat bronchoscopy is necessary. Overall pt stable with treatment, but exam still with sig wheezing, at this point still with benefit from neb tx prn - has VNA set up for support here -PPD placed on is neg but given exposure to TB (father had tb) and immunosupression, result difficult to interpret, quantiferon study considered, though given difficulty with result interpretation - plan to treat if AFB neg x3 (3rd pending, have to resend due to poor sample , awaiting sample's results). Given this regime will need very close monitoring of LFTs, would appreciate consulting services to also monitor LFTs and to assist coordinating appts (staggering) to keep pt consistantly monitored along with pt's PCP (should be checked q2 wks for next wks. - d/c on INH 300mg qd and B6 25mg qd. -AFB neg x3 at time of d/c. -Pt will be treated for latent TB given hx of exposure to tb and being immunocompromised as above
3. Possible Aspergillus infection - Sputum Cx showed rare Aspergillus. ID consulted given pt is immunosuppresed. Clinically pt was afebrile w/ nl WBC but given abn Chest and sinus CT finding (which can be seen either with Wegner's or aspergillous) and given the fact that pt will be immunosupressed longterm, pt was started on Voriconazole (LFTs wnl). (LFTs remain stable, will check monday again (hold tomorrow) -ENT initially consulted given abn sinus CT. They did rhinoscopy and cultures from nasal region, which have not shown aspergillous. -Discussed w ENT about ID's request for sinus sampling and they strongly feel that he does not have acute invasive sinusitis and will defer on sinus sampling -Per ID, repeated sputm cx and sputum from and neg for fungal cx. Nasal swab by ENT showing no fungal growth. -Serum galactomannan noted negative -Per ID recs, ppd placed given that pt will be on immunosupressives for a longtime, ppd placed on has been neg (no induration noted) -Treat with voriconazole for 4-6wks with possibility of shorter course if change in LFTs (with plan for INH to be held at that point till voriconazole tx completed)
4. Anemia, disease and recent active and losses - combination of ACD and acute blood loss from pulm hemorrhage. S/p 2 units PRBC on as HCT was 18 w appropriate correction to 25. Continue FeSo4 and continue to monitor as outpt, H/H stable at time of d/c.
5. Tachycardia, suprventricular- Pt noted to have Aflutter w/ 2:1 block since admission. Pt is asymptomatic during tachycardia and has no hx of it. Tachycardia exacerbation by pulm disease and deconditioning. TTE this admission showed EF 45-50% w trace MR/TR. TSH wnl. HR under good control w repletion of lytes and combination of metoprolol and diltiazem, will continue. PCP to /u and titrate as indicated, may return to sinus with improvements of pulm status, again to f/u.
6. Longterm immunosupression -Bactrim SS MWF for PCP (changed from initial atorovoquone with renal fx more stable now) -Calcium/VitD and Fosamax for osteoporosis prophylaxis (CaCO3 increased past week to help with repletion) -PPI for ulcer prophylaxis . 7. Hyperglycemia -likely high dose prednisone. Since pt is going to be on longterm steroids and has persistent hyperglycemia,pt started on low dose glyburide on . BS improved, fluctuates, will continue current dose, with note pt will need this monitored once able to be weaned off steroids as outpt. VNA to check BS intermittantly, keep BS log for PCP to /u.
8. Constipation - continue senna and dulcolax in addition to colace, pt instructed to take as needed prn. . FEN - Reg diet. . Code status - Full . Disposition - To home today now that AFB neg x3, with extensive home VNA set up with home 02, resp support long with prn nebs, and home PT along with close family support. Pt given instructions, with close f/u arranged.
"},"extractive_notes_summ":{"kind":"string","value":"Chief Complaint: Respiratory distress, hypoxemia HPI: 24 Hour Events: Remains with high FiO2 requirment. Monitor I/O HEMATURIA -- concern for hemorrhagic cystitis A-FIB -- good rate control COntinue meds. If worsening will get U/A -On Sevelamer, for hyperphos. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Assessment and Plan Wegener's Granulomatosis RESPIRATORY DISTRESS -- slow improvement clincally and radiographically. Confirmed to have c-anca vasculitis. Confirmed to have c-anca vasculitis. Confirmed to have c-anca vasculitis. TITLE: Resp Care Note, Pt rxd with albuterol/ atrovent via mask. #Hypocalcemia: plasmapheresis (containing citrate) and to underlying renal failure -follow ionized Ca, more accurate given citrate used in pheresis. - treating underlying cause (likely Wegener's) - Foley in place , strict I&O, q8 lytes. - Albuterol nebs PRN - CXR daily - F/u on BAL results from OSH - Patient now tolerating PO, though still concern for respiratory status - treating treating the underlying disease (presumed Wegener's): -Plasmapheresis, dose yesterday (QOD) -Prednison po daily, -Cyclophosphamide-dose to be determined after c/s with rheum and renal. Plan: Continue to monitor VSS, ECG changes, continue on lopressor., monitor lytes and replete as needed Renal failure, acute (Acute renal failure, ARF) Assessment: U/O maintaining above 40cc/hr, reveived one unit of red cell yesterday Action: HCT trending up from 20.9 to 22.4 after blood, received cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior to Cytoxan Response: U/O remains wnl, BUN and creatinine trending down from 160 and 8.1 yesterday to 149 and 7.1 early this a.m Plan: Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21), cytoxan as ordered Respiratory failure, acute (not ARDS/) Assessment: Continues on O2 6 liters NC and supplemental O2, sats maintaining above 95%, desats when pt removes O2 in his sleep. If worsening will get U/A -On Sevelamer, for hyperphos. If worsening will get U/A -On Sevelamer, for hyperphos. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Plan: Tachycardia, Other Assessment: Pt remains in ST with hr ranging from Action: Response: Plan: Pt currently clinically tachypneic. RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual improvement. -EKG unchanged # Tachycardia: Aflutter on EKG, in and out of NSR this am. Pt currently clinically tachypneic. Pt currently clinically tachypneic. # LE edema: likely secondary to renal failure above. # LE edema: likely secondary to renal failure above. Assessment and Plan VASCULITIS -- Wegener's Granulomatosis. Marked upper lobe predominant paraseptal and centrilobular emphysema are present. (Over) 5:49 PM CT CHEST W/O CONTRAST Clip # Reason: interval change, worsening consolidations on CXR, compare w Admitting Diagnosis: VASCULITIS FINAL REPORT (Cont) The airways are patent to the level of lobar and segmental bronchi bilaterally except for right lower lobe with occlusion of the apical segment is noted, most liklely due to secretions. The right ventricular cavity is mildly dilated with mild globalfree wall hypokinesis. Mild (1+) aortic regurgitation is seen. Thereis mild regional left ventricular systolic dysfunction with septalhypokinesis. Mild (1+) mitral regurgitation is seen.There is mild pulmonary artery systolic hypertension. Diffuse bilateral consolidations with slight decrease in the right mid lung but are unchanged on the left. Diffuse bilateral consolidations with slight decrease in the right mid lung but are unchanged on the left. There is no pericardialeffusion.IMPRESSION: Mild hypokinesis of the septum along with abnormal septal motion.Mildly dilated and hypokinetic right ventricle. Mild regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; midinferoseptal - hypo; septal apex - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. Pt currently clinically tachypneic. Cyclophosphamide was started after UOP was confirmed to be adequate. HYPOCALCEMIA -- iv replacement Rx, consider constant infusion. Heart-Tachycardic and regular rate suggested on initial exam Extremities--1+ bilateral lower extremity edema. Assessment and Plan 60 yom now with Pulmonary-Renal syndrome. Will await Renal and Rheum recs. Following hct and lytes Q8hr as ordered. Following hct and lytes Q8hr as ordered. Following hct and lytes Q8hr as ordered. U/A there--RBC's and granular casts documented. Plan is for plasmapharesis, K to be rechecked. Nephritic picture with RBC casts. He was given Solumedrol 1g IV x 1. On arrival here, pt appeared mildly tachypneic. Lung sounds RLL Lung Sounds: Crackles RUL Lung Sounds: Clear LUL Lung Sounds: Diminished LLL Lung Sounds: Crackles Comments: Plan Pt presently on 3 lpm n/c and ordered for nebs alb/atr. #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+ binder) -Replace Ca2+ (given 4g this am), check again this PM # Tachycardia: Aflutter on EKG. cystitis while on cytoxan) #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+ binder) -Replace Ca2+ (given 4g this am), -lytes q6hrs -EKG # Tachycardia: Aflutter on EKG. # LE edema: likely secondary to renal failure above. In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. HYPOCALCEMIA -- iv replacement Rx, consider constant infusion. DDx: Wegeners granulomatosis, MPA, Goodpasteurs, lupus, post-strep GN with DIC (less likely). Chief Complaint: Respiratory distress, hypoxemia HPI: 24 Hour Events: Remains with high FiO2 requirment. Monitor I/O HEMATURIA -- concern for hemorrhagic cystitis A-FIB -- good rate control COntinue meds. Pt underwent bronchoscopy on , and was found to have active low grade blood emanating from the RLL and LLL. Assessment and Plan 60 yom now with Pulmonary-Renal syndrome. # LE edema: likely secondary to renal failure above. # LE edema: likely secondary to renal failure above."},"n_notes":{"kind":"number","value":152,"string":"152"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2199-07-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":335302,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n Continues to require supplimental oxygen, desaturates with activity.\n Tolerating net diuresis.\n Hemoptysis resolved.\n Overall, states to feel improved. Dysnpea improved. Able to sleep\n somewhat last PM (improvement).\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.4\n HR: 98 (86 - 128) bpm\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\n RR: 25 (11 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 560 mL\n PO:\n 980 mL\n 360 mL\n TF:\n IVF:\n 319 mL\n 200 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 960 mL\n Urine:\n 4,410 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///31/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 170 K/uL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Imaging: CXR () somewhat improved, esp. right lung field.\n Assessment and Plan\n Wegener's Granulomatosis\n RESPIRATORY DISTRESS -- slow improvement clincally and\n radiographically, although clinically best tody. Continue current\n management. Provide supplemental oxygen, monitor SaO2, maintain >90%.\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\n urine output. No indication for acute dialysis at this time.\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\n Continue steoids, cytoxan, plasmaphoresis (total 7 treatments)\n NUTRITIONAL SUPPORT\n encourage PO.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335452,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding.\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335453,"text":"Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding.\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335455,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Labs obtained in a.m\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335456,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal parameters trending down\n Action:\n Diuresed this p.m with 20 lasix,\n Response:\n Good response to lasix, negative 770 by midnight\n Plan:\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\n"},{"category":"Physician ","chartdate":"2199-07-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":335620,"text":"Chief Complaint:\n 24 Hour Events:\n Patient desats to 85 when FM falls off\n Did well O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 108 (91 - 135) bpm\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\n RR: 19 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 190 mL\n PO:\n 1,220 mL\n 120 mL\n TF:\n IVF:\n 470 mL\n 70 mL\n Blood products:\n Total out:\n 2,465 mL\n 900 mL\n Urine:\n 2,465 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -710 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n Gen- NAD, Aox3\n CV- Tachy but reg rhythm, No M/R/G\n Pulm- Decreased breath sounds at bases, crackles to mid lung fields\n Abd- Soft, NT/ND, BS +\n Extr- No edema, Puleses 2+symmetric\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-14 00:00:00.000","description":"Physician Attending Progress Note","row_id":335606,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n No new events.\n Revieved 1 U PRBC transfusion, tolerated well.\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 Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 122 (97 - 135) bpm\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 477 mL\n PO:\n 1,220 mL\n 360 mL\n TF:\n IVF:\n 470 mL\n 117 mL\n Blood products:\n Total out:\n 2,465 mL\n 1,540 mL\n Urine:\n 2,465 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -1,063 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.2 g/dL\n 200 K/uL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n Respiratory distress and acute renal failure --> Wegener's\n Granulomatosis\n RESPRIATORY DISTRESS -- gradual improvement. Monitor RR, SaO2,\n maintain >90%.\n RENAL FAILURE -- initial good recovery, with good urine output;\n however, now creatitine with minimal decline over past 2-3 days. \n be approaching new baseline. ultimately require dialysis.\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\n cytoxan & plasmaphoresis\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\n disease.\n FLUIDS -- desire net negative if tolerated by BP.\n NUTRITIONAL SUPPORT -- encourage PO.\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335622,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Hx. Of alveolar hemorrhage due to wegener\ns dz. Remain on O2 at 80%\n face tent and 6L NC. LS diminished. Congested non productive cough.\n Action:\n Nebs as ordered. Up to chair for good part of the day.\n Response:\n Tolerated being up well. Pt. coughed while up in a chair but no sputum.\n O2 sat stable >90%. Still will desat to 86% while eating or when mask\n of. CXR improving.\n Plan:\n Cont. current treatment.\n"},{"category":"General","chartdate":"2199-07-15 00:00:00.000","description":"Generic Note","row_id":335701,"text":"TITLE: Resp Care Note, Pt rx\nd with albuterol/ atrovent via mask. BS\n wheezes. Improved after rx. Will cont to monitor resp status.\n"},{"category":"Nursing","chartdate":"2199-07-15 00:00:00.000","description":"Nursing Progress Note","row_id":335681,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Plasma pheresis due tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\n during sleep)\n Action:\n Continues on O2, ( frequently reminded to keep O2 on)\n Response:\n Remains afebrile, no hemoptysis, slept well overnight\n Plan:\n Continue to monitor resp status, wean O2 as tolerated.\n"},{"category":"General","chartdate":"2199-07-15 00:00:00.000","description":"ICU Event Note","row_id":335778,"text":"Clinician: Attending\n Critical Care\n Urine output remains good and we will try to maintain him negative\n again today. Creat is trending down still. Oxygen requirement remains\n high and he still has diffuse bilat infiltrates. Plan for\n plasmapheresis again today. He is feeling better but still is very\n fragile HR 140 simply with exam. Checking ECK before increasing beta\n blocker.\n Total time spent: 35 minutes\n Patient is critically ill.\n"},{"category":"Physician ","chartdate":"2199-07-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":335781,"text":"Chief Complaint: 60 year old male transferred from OSH with repiratory\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis. Kidney function improving steadily, no dialysis was\n needed. Respiratory status stable, continues to require facemask to\n keep 02 sats >90%, no signs of continued bleeding into lungs.\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\n hyperglycemia to steroid use.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar hemoorhave given improving\n respiratory status and no hemoptysis. .\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O, goal -1 liter today (has been\n , no lasix unless needed this pm)\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\n continue for at least one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Continued tachycardia, ? atrial vs. sinus.\n Hemodynamically stable. ECHO showed mild LV septal , \n 45-50%. Possibly secondary to large volume shifts (retaining total\n body fluid with renal failure, with large volume load putting stress on\n atria.)\n -EKG to eval for atrial tach vs. sinus tach. If sinus, will work up\n underlying cause. If atrial, will increase lopressor to 75mg po tid.\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been low in the morning and higher in the afternoon for the\n past 2 days despite no transfusion and no plasmapheresis. Variation\n may be due to lab variability, fluid shifts during the day, or another\n unknown cause. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Transfer Note","row_id":336024,"text":"60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily. On RISS and NPH Q am.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n VASCULITIS\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 68.4 kg\n Daily weight:\n 93.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ? emphysema\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:78\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 24h total in:\n 1,136 mL\n 24h total out:\n 2,220 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:05 AM\n Potassium:\n 3.6 mEq/L\n 04:05 AM\n Chloride:\n 103 mEq/L\n 04:05 AM\n CO2:\n 32 mEq/L\n 04:05 AM\n BUN:\n 135 mg/dL\n 04:05 AM\n Creatinine:\n 4.3 mg/dL\n 04:05 AM\n Glucose:\n 92 mg/dL\n 04:05 AM\n Hematocrit:\n 21.3 %\n 04:05 AM\n Finger Stick Glucose:\n 150\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n pherisis line in R IJ, Foley cath\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 412\n Transferred to:\n Date & time of Transfer:\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Transfer Note","row_id":336032,"text":"60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily. On RISS and NPH Q am. BS well\n controlled.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n VASCULITIS\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 68.4 kg\n Daily weight:\n 93.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ? emphysema\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:78\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 24h total in:\n 1,136 mL\n 24h total out:\n 2,220 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:05 AM\n Potassium:\n 3.6 mEq/L\n 04:05 AM\n Chloride:\n 103 mEq/L\n 04:05 AM\n CO2:\n 32 mEq/L\n 04:05 AM\n BUN:\n 135 mg/dL\n 04:05 AM\n Creatinine:\n 4.3 mg/dL\n 04:05 AM\n Glucose:\n 92 mg/dL\n 04:05 AM\n Hematocrit:\n 21.3 %\n 04:05 AM\n Finger Stick Glucose:\n 150\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n pherisis line in R IJ, Foley cath\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 412\n Transferred to: 1173\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Progress Note","row_id":335921,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output.\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Improving.\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334315,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"},{"category":"Physician ","chartdate":"2199-07-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":335286,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n Continues to require supplimental oxygen, desaturates with activity.\n Tolerating net diuresis.\n Hemoptysis resolved.\n Overall, states to feel improved. Dysnpea improved. Able to sleep\n somewhat last PM (improvement).\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.4\n HR: 98 (86 - 128) bpm\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\n RR: 25 (11 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 560 mL\n PO:\n 980 mL\n 360 mL\n TF:\n IVF:\n 319 mL\n 200 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 960 mL\n Urine:\n 4,410 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///31/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 170 K/uL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Imaging: CXR () somewhat improved, esp. right lung field.\n Assessment and Plan\n Wegener's Granulomatosis\n RESPIRATORY DISTRESS -- slow improvement clincally and\n radiographically. Continue current management.\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\n urine output.\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\n Continue steoids, cytoxan, plasmaphoresis\n NUTRITIONAL SUPPORT --\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":335287,"text":"Chief Complaint:\n 24 Hour Events:\n Did well. No hemoptysis.\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\n diuresis yesterday to goal -2L.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36\nC (96.8\n HR: 86 (86 - 116) bpm\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\n RR: 18 (14 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 340 mL\n PO:\n 980 mL\n 240 mL\n TF:\n IVF:\n 319 mL\n 100 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 470 mL\n Urine:\n 4,410 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 7.8 g/dL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\n the last 3 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500\n1L today. We will also watch\n his urine output and restart IVF if necessary to keep >100cc/hr\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Rate has been well controlled over the past 2 days.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately but his HCT is\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\n will not receive pheresis this weekend, so we can monitor to see if HCT\n stays stable.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Attending Progress Note","row_id":334432,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirment.\n Renal bx consistent with Wegener's Granulomatosis.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.9\nC (96.6\n HR: 99 (87 - 130) bpm\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\n RR: 21 (9 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,477 mL\n 2,103 mL\n PO:\n 60 mL\n TF:\n IVF:\n 2,102 mL\n 2,043 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 1,025 mL\n Urine:\n 1,360 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,117 mL\n 1,078 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 221 K/uL\n 94 mg/dL\n 7.2 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 149 mg/dL\n 105 mEq/L\n 145 mEq/L\n 22.7 %\n 9.0 K/uL\n [image002.jpg]\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n WBC\n 8.1\n 5.4\n 9.0\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n Plt\n 355\n 261\n 221\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n 94\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\n likey due to vasculitis. Radiographically without significant change,\n but hope to see improvement over next several days. Monitor RR, SaO2.\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\n improve.\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\n plts). Monitor Hct, transfuse to > 21\n WEGENER\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\n plasmaphoresis QOD.\n FLUIDS -- euvolemic. Monitor I/O\n HEMATURIA -- concern for hemorrhagic cystitis\n A-FIB -- good rate control COntinue meds. Monitor HR.\n NASAL CONGESTION -- possible related to Wegener's but more likely due\n to high flow O2. Symptomaatic relief.\n HYPOCALCEMIA -- repleted. Monitor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":334434,"text":"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO. Received 1 unit PRBCs yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Gen: Sleeping in bed, NAD\n CV:tachy, irregular. No murmur\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\n Ext: 1+ pedal edema, no rash or petichiae\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR.\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\n appropriately to 1unit PRBCs so likely not currently bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Prednison po daily,\n -Cyclophosphamide-dose to be determined after c/s with rheum and\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\n far.\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: Monitoring for need for dialysis, has line in\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\n signs of platelet dysfunction yet, mental status ok. Renal will give\n his kidneys about 48 more hours to turn around before dialyzing. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -pink tinged urine, stable, but will send daily U/As.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiacc negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334532,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\n has episodes of tachycardia in the 130\ns, typically with exertion or\n desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows with NSR episodes, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.9, BUN 149\n Action:\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\n administration of cyclophosphamide (chemo)\n Response:\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\n since midnight.\n Plan:\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\n HD catheter, may have it . Administer mesna as ordered with chemo\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n weak cough. +1.6L positive. Patient would frequently remove face tent,\n thus dropping O2 sats.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\n 6L NC. Patient encouraged to cough and deep breathe.\n Response:\n Oxygenation has improved throughout the afternoon with patient\ns family\n at the bedside\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing.\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334311,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 6 liters NC and supplemental O2, sats maintaining above\n 95%, desats when pt removes O2 in his sleep. , Moist non productive\n cough remains, LS with rhonchi in both lower lobes more on R.\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-12 00:00:00.000","description":"Nursing Progress Note","row_id":334923,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\n pull the O2 mask and cannula,desats to low 80,s when the mask is\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\n cough.\n Action:\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\n Cytoxan yesterday with mesna/IV as ordered by MD. 3^rd dose of mesna\n due at 1000,pt now only on FM with 80%,sats >97% when mask is on.\n Response:\n Pt was more comfortable last night, but continued to be uncomfortable\n with the mask\n Plan:\n Monitor resp status,meds as ordered,Titrate O2 as needed.\n"},{"category":"Physician ","chartdate":"2199-07-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":335259,"text":"Chief Complaint:\n 24 Hour Events:\n Did well. No hemoptysis.\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\n diuresis yesterday to goal -2L.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36\nC (96.8\n HR: 86 (86 - 116) bpm\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\n RR: 18 (14 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 340 mL\n PO:\n 980 mL\n 240 mL\n TF:\n IVF:\n 319 mL\n 100 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 470 mL\n Urine:\n 4,410 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 7.8 g/dL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2L in the past 24 hours and -4L in the\n last 2 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500 today. We will also watch his\n urine output and restart IVF if necessary\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - Stable crit and no more hemoptysis so pulmonary bleeding unlikely,\n - HCTq12h to monitor for alveolar bleeding.\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n No baseline Crit available.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334307,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":334406,"text":"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 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 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\n will give his kidneys about 48 more hours to turn around before\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\n been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":334409,"text":"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Gen: Sleeping in bed, NAD\n CV:tachy, irregular. No murmur\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\n Ext: 1+ pedal edema, no rash or petichiae\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\n will give his kidneys about 48 more hours to turn around before\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\n been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334385,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx., undervent renal biopsy, awaiting results.\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"},{"category":"Nursing","chartdate":"2199-07-12 00:00:00.000","description":"Nursing Progress Note","row_id":334873,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-12 00:00:00.000","description":"Nursing Progress Note","row_id":334877,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\n pull the O2 mask and cannula,desats to low 80,s when the mask is\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\n cough.\n Action:\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\n Cytoxan yesterday with mesna/IV as ordered by MD.\n Response:\n Pt was more comfortable last night,\n Plan:\n Monitor resp status,meds as ordered,\n"},{"category":"General","chartdate":"2199-07-14 00:00:00.000","description":"Generic Note","row_id":335493,"text":"TITLE: Resp Care Note, Pt given albuterol/atrovent nebs. BS rhonchi. 02\n remains on 80% high flow neb/nc 4lpm. Sat 95%. Pt stable . Will cont ot\n monitor resp status.\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Attending Progress Note","row_id":334716,"text":"Chief Complaint: Hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirement.\n HR varies from A-flutter to NRS.\n Coughing up sputum (swallowing), but more productive cough today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 98 (85 - 131) bpm\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\n RR: 18 (12 - 25) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 1,971 mL\n PO:\n 750 mL\n 160 mL\n TF:\n IVF:\n 3,736 mL\n 1,811 mL\n Blood products:\n Total out:\n 2,400 mL\n 1,235 mL\n Urine:\n 2,400 mL\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 736 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\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, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 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, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 211 K/uL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\n Possible component of pulmonary edema.\n HYPOXEMIA -- attributed to pulmonary infiltrates.\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\n steroids & cytoxan. Plasmaphoresis.\n RENAL FAILURE -- improving.\n NUTRIONAL SUPPORT -- PO\n HEMATURIA -- stable. Monitor.\n ANEMIA -- stable s/p transfusion\n HYPOCALCEMIA -- continue to replete\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 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: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":335036,"text":"Chief Complaint: Respiratory distress, hypoxemia.\n HPI:\n 24 Hour Events:\n Experienced some hemoptysis yesterday PM.\n Appears much more comfortable today, less dyspneic.\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 Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\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, Hematuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\n RR: 26 (18 - 27) insp/min\n SpO2: 88%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 238 mL\n PO:\n 290 mL\n 120 mL\n TF:\n IVF:\n 2,214 mL\n 118 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 2,900 mL\n Urine:\n 3,010 mL\n 2,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -2,663 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 88%\n ABG: ///28/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.3 g/dL\n 185 K/uL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Wegener's Granulomatosis\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\n plasmaphoresis\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\n falling, urine output improving, responding to diuretics.\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\n escalation. Consider dDAVP. need dialysis if continues to\n NUTRITIONAL SUPPORT -- PO\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\n suppression. Transfuse to Hct >25\n FLUID -- continue net negative. Monitor I/O.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"},{"category":"Physician ","chartdate":"2199-07-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":335533,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 108 (91 - 135) bpm\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\n RR: 19 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 190 mL\n PO:\n 1,220 mL\n 120 mL\n TF:\n IVF:\n 470 mL\n 70 mL\n Blood products:\n Total out:\n 2,465 mL\n 900 mL\n Urine:\n 2,465 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -710 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\n the last 3 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500\n1L today. We will also watch\n his urine output and restart IVF if necessary to keep >100cc/hr\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's)\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Rate has been well controlled over the past 2 days.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately but his HCT is\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\n will not receive pheresis this weekend, so we can monitor to see if HCT\n stays stable.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nutrition","chartdate":"2199-07-11 00:00:00.000","description":"Clinical Nutrition Note","row_id":334695,"text":"Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diet: low sodium/heart healthy/Renal.\n Reports no weight loss. Tolerating current diet, says he's hungry. Will\n continue to monitor po intake. Continue to monitor renal function and\n hydration.\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335226,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Followed up with labs overnight.\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"},{"category":"Physician ","chartdate":"2199-07-14 00:00:00.000","description":"Physician Attending Progress Note","row_id":335572,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n No new events.\n Revieved 1 U PRBC transfusion, tolerated well.\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 Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 122 (97 - 135) bpm\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 477 mL\n PO:\n 1,220 mL\n 360 mL\n TF:\n IVF:\n 470 mL\n 117 mL\n Blood products:\n Total out:\n 2,465 mL\n 1,540 mL\n Urine:\n 2,465 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -1,063 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.2 g/dL\n 200 K/uL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n Respiratory distress and acute renal failure --> Wegener's\n Granulomatosis\n RESPRIATORY DISTRESS -- gradual improvement.\n RENAL FAILURE -- initial good recovery, with good urine output;\n however, now creatitine with minimal decline over past 2-3 days. \n be approaching new baseline. ultimately require dialysis.\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\n cytoxan & plasmaphoresis\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\n disease.\n FLUIDS -- desire net negative if tolerated by BP.\n NUTRITIONAL SUPPORT -- encourage PO.\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":333963,"text":"Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335357,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\n to 86% when pt. sleeping and face tent away from Pt.\ns face.\n Action:\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\n in sputum. Nebs as ordered.\n Response:\n Pt. states he is feeling better. No hemoptisis this shift. CXR\n improving.\n Plan:\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335358,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\n to 86% when pt. sleeping and face tent away from Pt.\ns face.\n Action:\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\n in sputum. Nebs as ordered.\n Response:\n Pt. states he is feeling better. No hemoptisis this shift. CXR\n improving.\n Plan:\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\n Repleated Ca+ this shift per Ca+ SS.\n Repeat Hct. 26\n"},{"category":"Nursing","chartdate":"2199-07-15 00:00:00.000","description":"Nursing Progress Note","row_id":335733,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Plasma pheresis due tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\n during sleep),\n Action:\n Continues on O2, ( frequently reminded to keep O2 on), xray chest done\n this a.m\n Response:\n Remains afebrile, no hemoptysis, slept well overnight\n Plan:\n Continue to monitor resp status, wean O2 as tolerated.\n"},{"category":"Physician ","chartdate":"2199-07-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":335748,"text":"Chief Complaint: 60 year old male transferred from OSH with repiratory\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis. Kidney function improving steadily, no dialysis was\n needed. Respiratory status stable, continues to require facemask to\n keep 02 sats >90%, no signs of continued bleeding into lungs.\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\n hyperglycemia to steroid use.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar hemoorhave given improving\n respiratory status and no hemoptysis. Continue to monitor with q12\n HCT.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\n continue for at least one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Progress Note","row_id":335872,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n U/O has been good.\n Plan:\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Progress Note","row_id":335873,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Progress Note","row_id":335874,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output.\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Improving.\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Transfer Note","row_id":336022,"text":"60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily.\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":334074,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - also treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily\n -Cyclophosphamide 140mg\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok.\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\n However, apart from pulmonary association, ddx for acute renal failure\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\n Also consider DIC.\n - Renal biopsy yesterday, awaiting results\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is eating, can D/C D5W.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am), check again this PM\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6, given HCT , likely need blood this pm.\n - Type and screen, cross-matched\n - Blood consent obtained\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-16 00:00:00.000","description":"Physician Attending Progress Note","row_id":336013,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n EKG - At 12:02 PM\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\n Tolerated plasmaphoresis yesterday.\n Continues net diuresis, tolerated well.\n No further hemoptysis.\n Up in chair, excellent spirits. Appropriate. Joking with family.\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 Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, 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 10:38 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\n HR: 114 (100 - 142) bpm\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,534 mL\n 902 mL\n PO:\n 1,220 mL\n 750 mL\n TF:\n IVF:\n 314 mL\n 152 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,690 mL\n Urine:\n 2,565 mL\n 1,690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,031 mL\n -788 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///32/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 200 K/uL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\n Assessment and Plan\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\n steroids, cytoxan. Complete Plasmaphoresis course.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\n oxygen requirement.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\n improvement. Monitor. No acute indication for dialysis.\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\n Monitor.\n TACHYCARDIA -- improved. Monitor.\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\n Transfuse to Hct >21.\n HYPERGLYCEMIA -- contributed by high dose steroids. Monitor, use\n insullin to maintain <150.\n ICU Care\n Nutrition: PO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335526,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal parameters trending down\n Action:\n Diuresed this p.m with 20 lasix,\n Response:\n Good response to lasix, negative 770 by midnight\n Plan:\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\n"},{"category":"Nursing","chartdate":"2199-07-15 00:00:00.000","description":"Nursing Progress Note","row_id":335854,"text":"Vasculitis\n Assessment:\n Tolerating pheresis. Hemodynamically stable.\n Action:\n Plasma pheresis this afternoon. Lopressor increased to 75mg d/t atrial\n tachycardia. Hct 23. pedal edema slowly decreasing. Slept in naps. Ssi\n for bs\ns. mg+ 1.6 and given 2mg mg+ ivpb. Good appetite.\n Response:\n Continues to improve. Good response to lopressor.\n Plan:\n Need to check ionized ca+ at 20pm. Pt. has a ss for his ca+ doses.\n Transfuse if hct drops below 21.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Able to tolerate np only.\n Action:\n Mask off. Presently on 5L np. . Non-productive cough. No hemoptysis. No\n c/o sob.\n Response:\n Sats 98-100%.\n Plan:\n Continue to wean o2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal failure improving.\n Action:\n Creat 4.4. k+ 3.7. /20mg lasix ivp ordered/given by night nurse. Urine\n slightly pink-tinged this am, but not noted this pm. Patent dialysis\n catheter with port.\n Response:\n Autodiuresing.\n Plan:\n Plan for 1L negative.\n"},{"category":"General","chartdate":"2199-07-16 00:00:00.000","description":"ICU Event Note","row_id":335955,"text":"Clinician: Attending\n Critical Care\n 42 yo woman paraplegic after MVA , recently discharged from\n hospital after \"pneumonia\" noted by PCA to be lethargic at home, SaO2\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\n somewhat confused but conversant. Still somewhat lethargic. We are\n continuing Narcan but would have some concern about methadone as\n explanation for her lethargy as no change in methadone dose for 6 weeks\n and not previously sedated by med. Would also have some concern about\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\n presentation. Not clear why she developed PNA. We are continuing O2,\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\n have PFTs before d/c.\n Total time spent: 35 minutes\n Patient is critically ill.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 08:08 ------\n"},{"category":"Physician ","chartdate":"2199-07-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":335974,"text":"Chief Complaint:\n 24 Hour Events:\n Continues with same 02 requirement. EKG yesterday revealed aflutter\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\n 100s all night.\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\n overnight.\n Followed by renal and rheum.\n EKG - At 12:02 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 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: 36.6\nC (97.8\n HR: 106 (100 - 142) bpm\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,530 mL\n 600 mL\n PO:\n 1,220 mL\n 500 mL\n TF:\n IVF:\n 310 mL\n 100 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,200 mL\n Urine:\n 2,565 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,036 mL\n -600 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 7.2 g/dL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Has been stable on 6L NC. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Wean 02 to keep sat >90%.\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\n hemoorhave given improving respiratory status and no hemoptysis.\n Probably due to plasmapheresis and fluid shifting. His respiratory\n status may be marginally helped by an increased HCT, but will check pm\n HCT and transfuse if <21.\n -Continue nystatin mouthwash for + sputum given his high dose\n steroids. Day \n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 yesterday, then tomorrow and Friday.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine continues to trend down, 4.3 this morning, BUN is\n also finally down to 135, and he has maintained good urine output. As\n a note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Foley in place , strict I&O,we have been diuresing him well, with ?\n liters off in the past 5 days. We will continue to diurese with goal\n -500cc to -1L, using Lasix 20 IV prn.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\n one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Received 4gIV overnight, will re-check PM ionized Calcium and replete\n as needed. On days when he has pheresis, ionized CA needs to be drawn\n 4 hours after the end of pheresis to be accurate.\n -on SS replacement.\n -EKGs have been unchanged.\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\n stable. ECHO showed mild LV septal , 45-50%. Possibly\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n -Increased lopressor to 75mg po tid yesterday. Will continue to\n monitor on tele. If needed, could start a second rate controlling\n .\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been variable over the weekend despite no transfusion.\n Variation may be due to lab variability, or to fluid shifts with\n plasmapheresis. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\n unit if <21.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units, well controlled.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n #Dispo: to floor if it is possible to do pheresis outside of the ICU.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":335016,"text":"Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \n C-ANCA vasculitis. This morning, he breathing more easily, with stable\n lung exam though his CXR looks unchanged. This is likely due to\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\n 2+ budding yeast on sputum, without signs of candidiasis on\n oropharyngeal exam.\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\n urine output and restart IVF if necessary. We will balance maintaining\n urine output >100/hr for bladder protection with not giving too much\n Lasix due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n -Start nystatin mouthwash\n -Send blood cultures for fungus (though highly unlikely given pt. is\n afebrile, stable, but he is on high dose immunosuppression)\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Given hemoptysis and drop in crit, some concern for pulmonary\n bleeding, though respiratory status improving.\n - HCTq8h to monitor for alveolar bleeding.\n - Will collect sputum to determine whether hemoptysis is tinged, bright\n red or just pink fronthy.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN , some wheezing on exam today\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 today, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n No baseline Crit available.\n -transfuse one unit this morning as HCT is trending down (21.6)\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334319,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx., undervent renal biopsy, awaiting results.\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"},{"category":"Physician ","chartdate":"2199-07-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":335938,"text":"Chief Complaint:\n 24 Hour Events:\n Continues with same 02 requirement. EKG yesterday revealed aflutter\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\n 100s all night.\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\n overnight.\n Followed by renal and rheum.\n EKG - At 12:02 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 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: 36.6\nC (97.8\n HR: 106 (100 - 142) bpm\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,530 mL\n 600 mL\n PO:\n 1,220 mL\n 500 mL\n TF:\n IVF:\n 310 mL\n 100 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,200 mL\n Urine:\n 2,565 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,036 mL\n -600 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 7.2 g/dL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\n hemoorhave given improving respiratory status and no hemoptysis.\n Probably due to plasmapheresis, given with 50% albumin yesterday.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 yesterday, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine up to 4.3 from 4.0 yesterday, BUN down to 135, good\n urine output. As a note, plasmapheresis in cases of severe Wegeners\n has been shown to improve kidney outcomes, though not mortality.\n - Foley in place , strict I&O,we have been diuresing him well, with ?\n liters off in the past 5 days. His creatinine bumped a little bit this\n morning, probably we are at his dry weight and can back off on\n diuresis.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\n one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\n stable. ECHO showed mild LV septal , 45-50%. Possibly\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n -Increased lopressor to 75mg po tid yesterday.\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been low in the morning and higher in the afternoon for the\n past 2 days despite no transfusion and no plasmapheresis. Variation\n may be due to lab variability, fluid shifts during the day, or another\n unknown cause. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\n unit.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units, well controlled.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-08 00:00:00.000","description":"Nursing Progress Note","row_id":333940,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s\n Action:\n Conts on lopressor 50mg TID\n Response:\n Tolerating the lopressor, he did have short periods of a HR in the\n 1teens this afternoon\n Plan:\n Cont with the lopressor, follow VS\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat was 8.6 this morning and 8.0 this afternoon, u/o has been\n 40-50cc/hr\n Action:\n Pt had a renal biopsy this morning under US guidance, given 2 bagsof\n FFP for this, needed Ca gluc this evening as well. He is receiving D5W\n 100cc/hr for 1 liter for a Na of 150\n Response:\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\n Plan:\n Follow HCT\n due tonight, VS, renal bx results, no immediate plans for\n dialysis, follow labs, to receive cytoxan again tonight, 7 \n resourse nurse is aware and some will be down to give this\n he needs\n mesna before and after\n please see \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\n has not been coughing up any blood\n Action:\n He is on scoop mask at 60-70% and this brings his 02 up to the mid 90s\n Response:\n Conts to require a high FI02\n Plan:\n Follow SATs cont to try to wean his FI02\n"},{"category":"Physician ","chartdate":"2199-07-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":335723,"text":"Chief Complaint:\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"General","chartdate":"2199-07-15 00:00:00.000","description":"ICU Event Note","row_id":335851,"text":"Clinician: Attending\n Critical Care\n 42 yo woman paraplegic after MVA , recently discharged from\n hospital after \"pneumonia\" noted by PCA to be lethargic at home, SaO2\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\n somewhat confused but conversant. Still somewhat lethargic. We are\n continuing Narcan but would have some concern about methadone as\n explanation for her lethargy as no change in methadone dose for 6 weeks\n and not previously sedated by med. Would also have some concern about\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\n presentation. Not clear why she developed PNA. We are continuing O2,\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\n have PFTs before d/c.\n Total time spent: 35 minutes\n Patient is critically ill.\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335154,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Followed up with labs overnight.\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334317,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":334996,"text":"Chief Complaint: Respiratory distress, hypoxemia.\n HPI:\n 24 Hour Events:\n Experienced some hemoptysis yesterday PM.\n Appears much more comfortable today, less dyspneic.\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 Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\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, Hematuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\n RR: 26 (18 - 27) insp/min\n SpO2: 88%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 238 mL\n PO:\n 290 mL\n 120 mL\n TF:\n IVF:\n 2,214 mL\n 118 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 2,900 mL\n Urine:\n 3,010 mL\n 2,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -2,663 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 88%\n ABG: ///28/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.3 g/dL\n 185 K/uL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Wegener's Granulomatosis\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\n plasmaphoresis\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\n falling, urine output improving, responding to diuretics.\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\n escalation. Consider dDAVP. need dialysis if continues to\n NUTRITIONAL SUPPORT -- PO\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\n suppression. Transfuse to Hct >25\n FLUID -- continue net negative. Monitor I/O.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"},{"category":"Physician ","chartdate":"2199-07-16 00:00:00.000","description":"Physician Attending Progress Note","row_id":335972,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n EKG - At 12:02 PM\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\n Tolerated plasmaphoresis yesterday.\n Continues net diuresis, tolerated well.\n No further hemoptysis.\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 Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, 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 10:38 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\n HR: 114 (100 - 142) bpm\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,534 mL\n 902 mL\n PO:\n 1,220 mL\n 750 mL\n TF:\n IVF:\n 314 mL\n 152 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,690 mL\n Urine:\n 2,565 mL\n 1,690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,031 mL\n -788 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///32/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 200 K/uL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\n Assessment and Plan\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\n steroids, cytoxan. Complete Plasmaphoresis course.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\n oxygen requirement.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\n improvement. Monitor. No acute indication for dialysis.\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\n Monitor.\n TACHYCARDIA -- improved. Monitor.\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\n Transfuse to Hct >21.\n HYPERGLYCEMIA -- contributed by high dose steroids.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333556,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - Check TSH\n - Surface ECHO in a.m.\n - Will start Lopressor 12.5mg PO daily for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333557,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - F/u on TSH\n - Surface ECHO in a.m. today\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Radiology","chartdate":"2199-07-22 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1030091,"text":" 5:49 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: interval change, worsening consolidations on CXR, compare w\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegner's granulomatosis, pulm hemorrhage, ? aspergillous\n infection, on vori, w worsening dyspnea. On CXR consolidation in R mid lung\n appears worse, needs repeat NON-CONTRAST CHEST CT (renal failure) to evaluate\n the densities further\n REASON FOR THIS EXAMINATION:\n interval change, worsening consolidations on CXR, compare w previous Chest CT\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: ARHb MON 7:50 PM\n Widespread pulmonary abnormalities, including consolidation, ground glass\n change, and nodularity, persist and have worsened at the right lung base.\n Differential continues to include vasculitis/hemorrhage and infection,\n including Aspergillus. Persistent right apical lung nodules. Increased small\n to moderate right pleural effusion. Unchanged left effusion. No significant\n change in mediastinl/hilar adenopathy.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient's Wegener's granulomatosis,\n pulmonary hemorrhage and suspected aspergillus infection with worsening\n dyspnea.\n\n COMPARISON: Chest CT from .\n\n TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to\n upper abdomen with subsequent 1.25 and 5-mm collimation. Axial images\n reviewed in conjunction with coronal and sagittal reformats.\n\n FINDINGS:\n\n Multifocal mediastinal lymphadenopathy is unchanged with enlarged nodes\n present in multiple compartments. Within the left mediastinal lymph nodes\n measure up to 1.4 cm at the shortest access, within the left compartment is up\n to 1.5 cm. The additional conglomerate of the lymph nodes in the subcarinal\n lesion is up to 1.8 cm in diameter so grossly with no significant change since\n the prior study. The bilateral hila are diffusely enlarged with most likely\n present lymph nodes that are difficult to evaluate without injection of\n contrast. Calcifications in the right hilus suggest prior granulomatous\n exposure. There is most likely increase in the size of the right hilar lymph\n node, 2:32 currently 1.3 cm in diameter compared to 7 mm on the prior study.\n The patient is anemic giving the high density of the myocardium compared to\n the blood in the . Diffuse coronary calcifications are seen. There\n is no pericardial effusion. Bilateral pleural effusions are present, still\n small but slightly increased compared to the prior study.\n\n The imaged portion of the upper abdomen is grossly unremarkable with no\n appreciable change since the prior study.\n (Over)\n\n 5:49 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: interval change, worsening consolidations on CXR, compare w\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The airways are patent to the level of lobar and segmental bronchi bilaterally\n except for right lower lobe with occlusion of the apical segment is noted,\n most liklely due to secretions. Widespread pulmonary abnormality has\n slightly progressed since the recent study including areas of consolidation,\n ground- glass opacities and poorly defined nodules. The consolidations and\n ground glass are most pronounced in the mid and lower lungs, namely in the\n posterior segment of left upper lobe, lingula, and both lower lobes, right\n more than left. The previously demonstrated well defined perifissural nodule\n in the right lower lobe anteriorly is unchanged. Extensive bronchial impaction\n is present within the lower lobe bronchi. Marked upper lobe predominantly\n paraseptal and centrilobular emphysema is unchanged. Within the right apex, a\n 2 cm nodular opacity is identified containing calcification. Similar size\n spiculated opacity is seen in the left apex with less prominent spiculated\n appearance.\n\n No suspicious lytic or blastic lesions were demonstrated in the imaged portion\n of the skeleton.\n\n IMPRESSION:\n\n 1. Widespread pulmonary abnormalities including consolidation, ground glass\n in poorly defined lung nodules, slightly worse, but no new areas involved. As\n previously mentioned vasculitis and associated pulmonary hemorrhage are the\n primary diagnosis. Coexisting infection such as bacterial infection or\n aspergillosis cannot be excluded.\n\n 2. Spiculated right apical lesion raise concern for possible primary lung\n cancer especially on a patient with underlying emphysema. It is still\n potentially can be related to diffuse lung abnormalities thus three months\n followup chest CT is highly recommended.\n\n 3. Extensive intrathoracic lymphadenopathy: related to vasculitis and/or\n reactive to infection.\n\n 4. Slightly increased but still small bilateral pleural effusion in minimal\n amount of ascites.\n\n 5. Evidence of anemia.\n\n"},{"category":"Radiology","chartdate":"2199-07-22 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1030021,"text":", V. MED 11R 9:37 PM\n CHEST (PA & LAT) Clip # \n Reason: worsening dyspnea, eval for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\n interval change\n REASON FOR THIS EXAMINATION:\n worsening dyspnea, eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n Dense consolidation right mid and left mid lung zone. Improved aeration in\n lower lung zones.\n\n"},{"category":"Radiology","chartdate":"2199-07-22 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1030020,"text":" 9:37 PM\n CHEST (PA & LAT) Clip # \n Reason: worsening dyspnea, eval for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\n interval change\n REASON FOR THIS EXAMINATION:\n worsening dyspnea, eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 3:42 PM\n Dense consolidation right mid and left mid lung zone. Improved aeration in\n lower lung zones.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL\n\n COMPARISON: .\n\n HISTORY: Wegener's granulomatosis and aspergillosis.\n\n FINDINGS: There has been interval increase in dense consolidation in the\n right mid lung zone and left mid lung zone. The lung bases appear to have\n improved in aeration. Small bilateral pleural effusions are unchanged.\n Emphysematous changes particularly in the apices are noted.\n\n IMPRESSION: More dense consolidations seen in the right mid lung and left mid\n lung zones. Improved aeration in the bilateral lower lung zones.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2199-07-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026997,"text":" 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary renal syndrome\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:49 AM\n PFI: Slight interval improvement in the left lung consolidations.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in a patient with renal failure.\n\n Portable AP chest radiograph was compared to the prior studies obtained on\n .\n\n There is overall slight improvement in the opacities of the left lung with no\n change in the right lower lung consolidation with again demonstrated more\n discrete nodular opacity. There is no pleural effusion. For precise\n characterization of the finding, further evaluation with chest CT might be\n appropriate as the differential diagnosis is broad, including widespread\n infection, hemorrhage or asymmetric edema.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026998,"text":", M. MED 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary renal syndrome\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Slight interval improvement in the left lung consolidations.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-07 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1026946,"text":" 6:32 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please assess dialysis line placement.\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with IJ dialysis line\n REASON FOR THIS EXAMINATION:\n Please assess dialysis line placement.\n ______________________________________________________________________________\n WET READ: SBNa SUN 7:06 PM\n Right IJ line terminates in upper SVC. Unchanged appearance of b/l diffuse\n opacites. No ptx.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the central venous catheter placement.\n\n Portable AP chest was compared to .\n\n The right internal jugular line catheter was inserted with its tip projecting\n at the level of the junction of brachiocephalic vein and superior SVC. The\n heart size is moderately enlarged but stable. There is also no change in the\n mediastinal contour. There is overall no change in the extensive parenchymal\n consolidation compared to the prior study. The differential diagnosis might\n include extensive infection, pulmonary edema in the presence of underlying\n emphysema or pulmonary hemorrhage, clinical correlation in comparison to the\n prior studies is required. Note is made of a more discrete rounded density in\n the right lower lung unchanged since the prior study, which might represent a\n part of a similar process or additional underlying abnormality. Scarring in\n the upper lung is unchanged. No appreciable pleural effusion is demonstrated.\n\n"},{"category":"Radiology","chartdate":"2199-07-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028387,"text":" 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's.\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP:\n\n COMPARISON: One day prior.\n\n HISTORY: 50-year-old man with Wegner's, evaluate for any change.\n\n FINDINGS: There is slightly improved aeration of both lungs. Again seen is\n diffuse areas of consolidation, primarily in the right mid lung zone and left\n mid and lower lung zone. No new consolidations are identified. Biapical\n scarring is unchanged. Cardiomediastinal and hilar contours are unremarkable.\n A right-sided internal jugular catheter sheath is seen terminating in the\n upper SVC. There is no evidence of pneumothorax.\n\n IMPRESSION: Slightly improved aeration of both lungs. Persistent opacities\n seen primarily in the right mid and left mid to lower lung zones.\n\n\n\n"},{"category":"Radiology","chartdate":"2199-07-17 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1028954,"text":" 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\n sx\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB WED 7:17 PM\n Multifocal consolidation, ground-glass attenuation, and poorly defined\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\n lymphadenopathy, and a small amount of ascites.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, \n\n Comparison chest radiographs dating between and .\n\n INDICATION: Wegener's granulomatosis, pulmonary hemorrhage, and Aspergillus\n on recent sputum culture.\n\n TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was\n performed without intravenous or oral contrast. Images are presented for\n display in the axial plane at 5-mm and 1.25-mm collimation. A series of\n multiplanar reformation images were also submitted for review.\n\n FINDINGS: Widespread pulmonary abnormalities are present, including areas of\n consolidation, ground-glass attenuation, and poorly defined nodules. The\n areas of consolidation and ground glass are most pronounced in the mid and\n lower lungs. In addition to poorly defined bronchovascular nodules, one well-\n defined perifissural nodule is identified in the right lower lobe anteriorly\n measuring 8 mm (227, 4A). Extensive bronchial impaction is present within the\n lower lobe bronchi, but the more central airways appear patent. Marked upper\n lobe predominant paraseptal and centrilobular emphysema are present. Within\n the right apex, a spiculated 2.1-cm diameter nodular opacity is identified\n (68, 4A) with an eccentric granuloma. Additional similar-sized spiculated\n opacity is identified higher in the right apex (52, 4A).\n\n Multifocal mediastinal lymphadenopathy is present, with enlarged nodes present\n in multiple compartments. Within the left mediastinum, lymph nodes measure up\n to 1.4 cm in short axis in the lower left paratracheal region and 1.5 cm in\n the left prevascular area. Additional conglomerate lymph nodes are seen in\n the subcarinal region measuring up to approximately 17 mm in short axis. There\n are likely bilateral hilar nodes present, difficult to measure in the absence\n (Over)\n\n 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of intravenous contrast. A few small calcified mediastinal and hilar nodes are\n also evident. No pericardial effusion is identified. Coronary artery\n calcifications are evident. Small dependent simple pleural effusions are\n present bilaterally.\n\n Exam was not tailored to evaluate the subdiaphragmatic region, but note is\n made of a small amount of ascites as well as nonspecific mesenteric stranding.\n Liver appears relatively hyperdense, possibly due to previous transfusions or\n amiodarone therapy.\n\n No suspicious lytic or blastic skeletal lesions are identified.\n\n IMPRESSION:\n 1. Widespread pulmonary abnormalities including consolidation, ground-glass,\n and poorly defined lung nodules. These could be due to the patient's known\n vasculitis with associated pulmonary hemorrhage, but coexisting Aspergillus\n infection is likely given the reported sputum culture results.\n 2. Spiculated right apical nodules raise the concern for possible primary\n lung cancer in this patient with underlying emphysema, but could potentially\n be related to the same process as the diffuse lung abnormalities. 3-month\n chest CT followup is suggested following appropriate therapy to ensure\n resolution.\n 3. Extensive intrathoracic lymphadenopathy, which may be due to Wegener's\n and/or reactive nodes from infection.\n 4. Small bilateral pleural effusions and a small amount of ascites.\n\n"},{"category":"Radiology","chartdate":"2199-07-17 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1028955,"text":", MED 11R 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\n sx\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PFI REPORT\n Multifocal consolidation, ground-glass attenuation, and poorly defined\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\n lymphadenopathy, and a small amount of ascites.\n\n"},{"category":"Radiology","chartdate":"2199-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027858,"text":" 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for worsening infiltrates\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for worsening infiltrates\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 10:07 PM\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\n are unchanged. There is no residual pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMMENTS: 50-year-old man with Wegener and pulmonary hemorrhage.\n\n Since yesterday, bilateral dense consolidation in mid and lower lung zones are\n unchanged. There is no residual pulmonary edema. Pleural effusions, if any,\n are small. Heart size is top normal and unchanged. Right internal jugular\n sheath ends in right brachiocephalic vein.\n\n"},{"category":"Radiology","chartdate":"2199-07-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027200,"text":" 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: looking for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n looking for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 9:50 AM\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\n is unchanged. Right internal jugular is in good position. Left small pleural\n effusion is new with associated atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMMENTS: 60-year-old man with hypoxia. Interval change.\n\n Since , bilateral alveolar opacity with slightly nodular appearance\n is unchanged in this patient with pulmonary renal syndrome.\n\n Small left pleural effusion is new associated with new left lower lobe\n atelectasis. Right internal jugular catheter is in good position.\n\n Findings can be consistent with multifocal infection, bilateral hemorrhage or\n much less likely asymmetric pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2199-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028071,"text":" 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, effusions, edema\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with wegener's and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, effusions, edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NLHa SAT 1:28 PM\n Bilateral opacities unchanged. Right central venous catheter unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable chest x-ray performed at 0515 hours.\n\n Comparison is . There are bilateral opacities involving both lower and\n mid lung fields. The opacity on the left extends to involve the upper lung\n field. Compared to prior exam, there is increasing density in the right\n base. The cardiac silhouette is mildly enlarged.\n\n IMPRESSION: Increasing density in the right base.\n\n"},{"category":"Radiology","chartdate":"2199-07-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027201,"text":", M. MED 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: looking for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n looking for interval change\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\n is unchanged. Right internal jugular is in good position. Left small pleural\n effusion is new with associated atelectasis.\n\n"},{"category":"Radiology","chartdate":"2199-07-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027613,"text":" 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for new infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for new infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:10 AM\n PFI: No change in the bilateral severe predominantly lower lobe opacification\n compared to the prior study.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with pulmonary hemorrhage.\n\n Portable AP chest radiograph was compared to obtained at\n 05:40.\n\n In the interim, there is overall no significant change in the bilateral severe\n predominantly lower lobe consolidations with some involvement of the upper\n lungs, left more than right, consistent with diffuse parenchymal hemorrhage.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027401,"text":", MED 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\n remains normal. Pleural effusion, if any, is small. Right jugular line is\n central. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028562,"text":" 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:21 AM\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\n bilateral consolidations with slight decrease in the right mid lung but are\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\n lesions on the right could be present but are hard to confirm due to\n underlying diffuse consolidation. Chest CT could further characterize lung\n opacities.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n REASON FOR EXAM: 60-year-old man with Wegener. Evaluate for interval change.\n\n Since yesterday, right internal jugular catheter still ends in upper SVC.\n Diffuse bilateral consolidation slightly decreased in the right mid lung but\n are unchanged on the left. Consolidation has a more heterogeneous appearance,\n could be due to underlying cavitary lesions hard to better define. Chest CT\n could further characterize lung opacities if clinically warranted.\n\n Biapical scarring is unchanged.\n\n"},{"category":"Radiology","chartdate":"2199-07-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028563,"text":", MED 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\n bilateral consolidations with slight decrease in the right mid lung but are\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\n lesions on the right could be present but are hard to confirm due to\n underlying diffuse consolidation. Chest CT could further characterize lung\n opacities.\n\n"},{"category":"Radiology","chartdate":"2199-07-08 00:00:00.000","description":"BX-NEEDLE KIDNEY BY NEPHROLOGIST","row_id":1027056,"text":" 10:49 AM\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: ? Gbm disease versus wegeners' granulomatosis\n Admitting Diagnosis: VASCULITIS\n ********************************* CPT Codes ********************************\n * BX-NEEDLE KIDNEY BY NEPHROLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with glomerulonephritis and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n ? Gbm disease versus wegeners' granulomatosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Glomerulonephritis and pulmonary hemorrhage. Questionable GBM\n disease vs. Wegener's.\n\n FINDINGS: Ultrasound guidance was provided for renal biopsy performed by\n nephrology team. Five core biopsy samples were obtained from the lower pole\n of the left kidney. The patient tolerated the procedure well. No immediate\n complications occurred.\n\n IMPRESSION: Successful ultrasound-guided biopsy performed by the nephrology\n team.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-17 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":1028947,"text":" 4:15 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval sinusus (asking for non-contrast study with ARF as belo\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval sinusus (asking for non-contrast study with ARF as below)\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 60-year-old male with newly-diagnosed Wegener's\n granulomatosis with acute renal failure, pulmonary hemorrhage with sputum\n culture noting \"rare aspergillus.\"\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the sinuses. Coronal\n reformatted images were obtained.\n\n FINDINGS: Extensive sinus disease is present with air-fluid levels in both\n maxillary sinuses. The left maxillary sinus is nearly-completely opacified and\n containing hyperdense secretions. The right maxillary, sphenoid and frontal\n sinuses show circumferential mucosal thickening. Dense secretions are also\n identified in the right nasal cavity.\n\n There is diffuse bony remodeling and permeation involving the ethmoid septae,\n maxillary sinus medial walls and ostiomeatal complexes, and the nasal\n turbinates, which in the absence of history or prior surgery, likely relate to\n Wegener's granulomatosis. However, the nasal septum and hard palate remain\n intact. There is no evidence of intracranial or orbital involvement. The\n mastoid air cells remain normally aerated.\n\n IMPRESSION:\n 1. Extensive pansinus soft tissue disease, most severely affecting the left\n maxillary sinus. Note is made of dense secretions in the left maxillary sinus\n and right nasal cavity which may simply represent chronically-inspissated\n secretions; however, fungal colonization (ie. with Aspergillus spp. and their\n metabolic byproducts) can have a similar appearance.\n 2. Extensive bony remodeling and permeation involving the sinuses and nasal\n turbinates which in the absence of prior surgery can be seen with Wegener's\n granulomatosis. The nasal septum remains intact.\n\n These findings were discussed with Dr. (primary hospitalist) at the\n time of interpretation, by Dr. . Evaluation by ENT Service, with\n possible diagnostic aspiration of the left maxillary contents, may be\n warranted.\n\n (Over)\n\n 4:15 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval sinusus (asking for non-contrast study with ARF as belo\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2199-07-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028225,"text":", MED 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n PFI REPORT\n Improved aeration of left mid lung zone.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-08 00:00:00.000","description":"RENAL U.S.","row_id":1027059,"text":" 10:42 AM\n RENAL U.S. Clip # \n Reason: WITH GLOMERULONEPHRITIS\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Glomerulonephritis.\n\n COMPARISON: None.\n\n FINDINGS: The right kidney measures 12.4 cm and the left 12.8 cm. The renal\n parenchymal echogenicity is increased, bilaterally. There are no renal\n calculi or hydronephrosis. Small amount of fluid is seen adjacent to the\n right kidney. The bladder is not distended with a Foley catheter within,\n cannot be assessed accurately.\n\n IMPRESSION: Bilateral increased renal parenchymal echogenicity consistent\n with medical renal disease. Small amount of right perinephric free fluid.\n\n"},{"category":"Radiology","chartdate":"2199-07-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027400,"text":" 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 3:06 PM\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\n remains normal. Pleural effusion, if any, is small. Right jugular line is\n central. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:40 A.M. ON \n\n HISTORY: Pulmonary hemorrhage.\n\n IMPRESSION: AP chest compared to through :\n\n Severe infiltrative pulmonary abnormality responsible for dense consolidation\n in the lower mid and lower lung zones since has not improved and may\n have worsened in the lung bases, now accompanied by progressive vascular\n congestion in the upper lung suggesting volume overload also responsible for\n mild increase in caliber of the azygos vein, although vascular engorgement is\n undoubtedly exaggerated by supine positioning. Pleural effusions, if any, are\n small. Heart size is top normal and unchanged. Right jugular introducer ends\n at the thoracic inlet. No other invasive support devices.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026858,"text":" 10:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for evidence of infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with evidence of diffuse alveolar hemorrhage on bronch and\n renal failure\n REASON FOR THIS EXAMINATION:\n please assess for evidence of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diffuse alveolar hemorrhage.\n\n FINDINGS: No previous images available. There is mild enlargement of the\n cardiac silhouette. Diffuse bilateral asymmetric alveolar opacifications\n involving almost all of both lungs. This would be consistent with diffuse\n alveolar hemorrhage as clinically suspected. Fibrocalcific changes in the\n apices are consistent with old granulomatous disease.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027859,"text":", MED 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for worsening infiltrates\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for worsening infiltrates\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\n are unchanged. There is no residual pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2199-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028072,"text":", MED 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, effusions, edema\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with wegener's and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, effusions, edema\n ______________________________________________________________________________\n PFI REPORT\n Bilateral opacities unchanged. Right central venous catheter unchanged.\n\n"},{"category":"Echo","chartdate":"2199-07-08 00:00:00.000","description":"Report","row_id":87723,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Valvular heart disease.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 112/56\nHR (bpm): 78\nStatus: Outpatient\nDate/Time: at 11:48\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of\nthe interatrial septum. No ASD by 2D or color Doppler.\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\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis. Abnormal septal motion/position.\n\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thicknesses and cavity size are normal. There\nis mild regional left ventricular systolic dysfunction with septal\nhypokinesis. The right ventricular cavity is mildly dilated with mild global\nfree wall hypokinesis. There is abnormal septal motion/position. The aortic\nroot is moderately dilated at the sinus level. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild hypokinesis of the septum along with abnormal septal motion.\nMildly dilated and hypokinetic right ventricle. The interventricular septal\nmotion is abnormal and may be consistent with right ventricular volume\noverload. Mild mitral and tricuspid regurgitation. Dilated aortic sinus and\nascending aorta.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027614,"text":", MED 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for new infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for new infiltrate\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change in the bilateral severe predominantly lower lobe opacification\n compared to the prior study.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028224,"text":" 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 9:18 AM\n Improved aeration of left mid lung zone.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 05:20\n\n INDICATION: Wegener's.\n\n COMPARISON: at 05:09\n\n FINDINGS:\n\n Compared to prior there is improved aeration of the left mid lung zone. The\n remainder of the study is unchanged with continued evidence of previously seen\n airspace disease. No PTX. Right CVL remains in place.\n\n IMPRESSION: Improved aeration of the left mid lung zone.\n\n\n"},{"category":"ECG","chartdate":"2199-07-21 00:00:00.000","description":"Report","row_id":224051,"text":"Atrial flutter with variable block. Non-specific repolarization abnormalities.\nIntraventricular conduction delay of right bundle-branch block type. Compared\nto the previous tracing of there is no significant difference.\n\n"},{"category":"ECG","chartdate":"2199-07-17 00:00:00.000","description":"Report","row_id":224052,"text":"Atrial flutter with rapid ventricular response. Right ventricular conduction\ndelay. Compared to the previous tracing of no diagnostic interim\nchange.\n\n"},{"category":"ECG","chartdate":"2199-07-15 00:00:00.000","description":"Report","row_id":224053,"text":"Atrial flutter\nModest right ventricular conduction delay\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2199-07-10 00:00:00.000","description":"Report","row_id":224054,"text":"Atrial flutter. Modest right ventricular conduction delay. Since the previous\ntracing of no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2199-07-09 00:00:00.000","description":"Report","row_id":224055,"text":"Atrial flutter. Modest right ventricular conduction delay. Since the previous\ntracing of no significant change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2199-07-07 00:00:00.000","description":"Report","row_id":224056,"text":"Atrial flutter with variable block. Incomplete right bundle-branch block.\nCompared to the previous tracing of A-V block is now irregular. The\nunderlying atrial rhythm continues to likely be counterclockwise flutter.\nThe other findings are similar.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2199-07-06 00:00:00.000","description":"Report","row_id":224057,"text":"Counterclockwise atrial flutter with 2:1 A-V block. Diffuse non-specific\nST-T wave changes likely secondary to rate. No previous tracing available for\ncomparison.\nTRACING #1\n\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Attending Progress Note","row_id":333538,"text":"Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. Maculopapular rash resolved.\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent:\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333555,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333655,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in a-flutter (baseline since arrival to OSH per report). RVR\n to 130\ns. BP remains stable.\n Action:\n Monitoring HR, rhythm and hemodynamic status closely. Lopressor\n increased to 25mg PO TID.\n Response:\n HR better controlled on increased lopressor (110-115). Continues in\n a-flutter. BP remains stable.\n Plan:\n Continue to monitor cardiac and hemodynamic status closely. Continue\n lopressor as ordered.\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333454,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\n Action:\n Observing u/o and labs. Will consult renal in am and follow\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\n start sevelamer in the am.\n Response:\n pending\n Plan:\n Renal will consult in the am. Will draw am labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\n Response:\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\n with crackles\n way up.\n Plan:\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\n monitor sao2 and provide o2 as needed.\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333642,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333643,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333496,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 1\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///17/\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 513 K/uL\n 9.0 g/dL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-08 00:00:00.000","description":"Nursing Progress Note","row_id":333711,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx. Pt was adm on .\n Atrial flutter (Aflutter)\n Assessment:\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\n the high 120-130 range during plasmapharesis. B/P has remained stable\n 110/78-132/69.\n Action:\n Lopressor was increased to 50mg tid which was started last evening.\n Response:\n H/R is decreasing from the 100\ns to the 80-90range.\n Plan:\n Cont with tid lopressor. Monitor h/r and pattern.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\n Action:\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\n past 24 hours pt has had 2 doses of Kayexalate.\n Response:\n K+ is 4. U/O improving with urine more yellow. Last creat 8.5 with bun\n 147\n Plan:\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\n lungs have had crackles bil bases with the left lung more dim than the\n right..\n Action:\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\n evening and was given cytoxan after the plasmaphoresis. Pt is also\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\n Response:\n Sao2 drops to the high 80\ns while pt wears only the n/c. pt does not\n like to wear face mask and denies any sob.\n Plan:\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\n plasmaphoresis again on Tues.\n"},{"category":"Physician ","chartdate":"2199-07-08 00:00:00.000","description":"Physician Attending Progress Note","row_id":333805,"text":"Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. MacPap rash resolving\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n MICU Attending Addendum\n Pt seen with fellow and examined. Met with pt and family to review\n situation. Would add and emphasize the following to Dr \ns notes.\n On exam\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\n alos right forearm.\n ABG 7.31/37/67\n BUN 147/ Cr 9.6\n CXR: diffsue bilateral interstitial and alveolar infiltrates\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\n and renal failure quite concerning for vasculitis.\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\n Role of plasmapheresis without clear diagnosis is challenging. Will\n consult with Renal collegues on possibility of a renal biopsy to aid in\n diagnosis. Additionally he is moving towards dialysis, need to closely\n watch K, renally dose all meds. His resp status is tenusous due to\n hypoxemia as well as met acidosis and uremic encephalopathy- may\n require intubation for support\n would likely favor this over NIPPV\n given likely duration.\n Discussed with son who is HCP and updated.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent: Critically Ill 50 min\n ------ Protected Section ------\n MICU Attending Addendum\n Updated note on events from . In the course of the afternoon, I\n spent over 2 hours working with both the renal consultation team and Dr\n and the Plasmapheresis team determining indication and timing of\n pheresis for possible anti GBM. We were able to update family, call in\n pheresis team, and place pheresis catheter all to facilitate. Pt with\n progressive hypoxemia and on NRB\n ongoing frequent labs to assess HCT,\n also borderline indication for HD due to progressive encephalopathy,\n boerdeline hyperK and acidosis.\n Time Spent 120 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:22 ------\n"},{"category":"Physician ","chartdate":"2199-07-08 00:00:00.000","description":"Physician Attending Progress Note","row_id":333807,"text":"Chief Complaint: Respiratory distress/hypoxemia\n HPI:\n 24 Hour Events:\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\n Renal consultation concurred with Pulmonary-Renal syndrome.\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\n anticipating 5 days of treatment. Remains on cortocosteroids.\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\n Denies increased dyspnea, but remains with oxygen requirement.\n History obtained from Patient\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.3\nC (95.5\n HR: 81 (81 - 133) bpm\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\n RR: 24 (22 - 29) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 186 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 186 mL\n Blood products:\n Total out:\n 1,330 mL\n 690 mL\n Urine:\n 1,330 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -504 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\n mildly disshevled\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 355 K/uL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\n predominantly basilar. Right IJ catheter position acceptable. No\n significant overall change compared to .\n Assessment and Plan\n 60 yom now with Pulmonary-Renal syndrome.\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\n diffuse infiltrates and oxygen requirement.\n HYPOXEMIA -- attributed to pulmonary infiltrates.\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\n SaO2.\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\n consult prepared to move to dialysis when indicated. Monitor urine\n output, BUN, Creatitine.\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\n Continue steroids and plasmaphoresis.\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\n FLUIDS -- limit iv fluids intake.\n HYPERPHOSPHATEMIA -- start phosphate binder.\n NUTRITION -- NPO pending evaluation\n ANEMIA -- progressive, attributed to underlying process, and possible\n contribution from RIJ central line placement. Transfuse to Hct >21.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2199-07-08 00:00:00.000","description":"Respiratory Care Shift Note","row_id":333895,"text":"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 Comments:\n Pt currently on 6L NC. Pt ordered for albuterol and Atrovent nebs Q6.\n Nebs given as ordered and pt tolerated them well.\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Admission Note","row_id":333425,"text":"Chief Complaint: Bilateral LE edema, SOB\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy.\n .\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptons started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n .\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\n noted as having mild wheezing and productive cough of white sputum.\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\n Occult blood stool negative. U/A significant for protein 400mg/dl,\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\n microscopy positive for RBCs, granular casts.\n .\n Pt was seen by Renal, who thought there might possibly be a\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\n .\n CXR on admission showed underlying COPD with diffuse bilateral\n pulmonary infiltrates.\n Pt underwent bronchoscopy on , and was found to have active low\n grade blood emanating from the RLL and LLL.\n .\n EKG on admission showed atrial flutter at 2:1 block rate 150.\n .\n On arrival here, pt appeared mildly tachypneic. He reported that LE\n edema had improved, and that pain had resolved in LE. He complained of\n only mild nausea recently without vomiting, and a productive cough.\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\n constipation, melena, hematochezia, chest pain, urinary\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\n no epistaxis. Last BM was yesterday, and was formed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 12:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 107 (107 - 122) bpm\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 48 mL\n PO:\n 230 mL\n TF:\n IVF:\n 48 mL\n Blood products:\n Total out:\n 475 mL\n 100 mL\n Urine:\n 125 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -52 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///16/\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 543 K/uL\n 219 mg/dL\n 9.7 mg/dL\n 144 mg/dL\n 16 mEq/L\n 107 mEq/L\n 6.2 mEq/L\n 143 mEq/L\n 31.0 %\n [image002.jpg]\n \n 2:33 A8/9/ 11:05 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 Hct\n 31.0\n Plt\n 543\n Cr\n 9.7\n Glucose\n 219\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\n mg/dL, PO4:9.6 mg/dL\n Assessment and Plan\n ABG: ///16/\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"General","chartdate":"2199-07-07 00:00:00.000","description":"ICU Event Note","row_id":333422,"text":"Clinician: Attending\n 60 yo male without significant medical history now admit to OSA with\n lower extremity edema x 2 weeks. His presentation there was notable\n for severe acute renal failure and with diffuse alveolar infiltrates.\n The findings at the OSA were consistent with acute GN based upon review\n of the urine sediment. In addition, patient did have bronchoscopy\n revealing a strong suggestion of alveolar hemorrhage with sequential\n lavage showing persistent bloody fluid. There was no hemoptysis noted.\n U/A there--RBC's and granular casts documented.\n There he has had persistent renal failure and alveolar infiltrates and\n now with persistent tachycardia patient to ICU for further\n evaluation and care after solumedrol and cytoxan started at OSH.\n ROS-negative for sinusitis/sinus congestion\n Here patient has persistent sinus tachycardia noted,\n Exam notable for-->\n Patient comfortable by subjective description\n No JVD\n Lungs-Diffuse crackles bilaterally inferiorly and to mid lung zone.\n Heart-Tachycardic and regular rate suggested on initial exam\n Extremities--1+ bilateral lower extremity edema. Diffuse macular rash\n from foot to knee.\n Labs->\n Cr-9.6\n K-5.8\n HCO3-=18\n CXR->Patient with diffuse bilateral alveolar infiltrates--there is a\n suggestion of lower lobe distribution but with the complete absence of\n pleural effusions which is consistent with alveolar hemorrhage.\n ECG-Atrial Flutter seen with atrial rate at approx 300 bpm and\n ventricular rate of 125-150.\n In summary this is a 60 yo male with findings of acute renal failure\n with evidence of diffuse alveolar hemorrhage and active disease with\n ESR >140. No definative diagnostic procedure was preformed and serum\n testing, although sent, is all pending at this time. Patient did start\n Solumedrol and Cytoxan for empiric diagnosis of\n vasculitis with serologies pending. Goodpasteur's and Wegner's and\n microscopic polyangiitis and PAN all are on this list along with\n connective tissue disease.\n 1)Acute Renal Failure-\n -Significant concern for acute vasculitis\n -Given severity of dysfunction certainly intervention is desired in\n timely fashion\n -Would favor biopsy prior to intervention is patient remains stable\n enough to accept.\n -With Solumedrol and Cytoxan 1 dose given is challenging decision to\n consider hold of further treatment prior to biopsy.\n -Will consult renal for consideration of biopsy.\n -Given significant clinical decline and significant pulmonary\n distress--tachypnea and tachycardia--I would favor continuation of\n treatment already started given his subjective improvement over past 24\n hours. Although this will cloud the biopsy results his clinical status\n at this point in time is one that warrants intervention.\n -Continue Solumedrol 1g qd and Cytoxan to continue\n -Renal and Rheum to evaluate patient for aid in diagnosis and treatment\n -C3, C4, , Anti-GBM, ANCA all pending\n 2)Alevolar Hemorrhage--seen on OSH bronchoscopy, no biopsies performed\n -Continue with supportive care at this time\n -Will have to consider diagnostic procedure and consideration of renal\n biopsy may be highest yield\n -Attempt to maintain euvolemia as hydrostatic edema is of concern given\n signficiant volume overload but will be limited by renal failure and\n the distribution of infiltrates.\n 3)Atrial Flutter-\n Hold anticoagulation for bleeding risk\n Rate control as needed\n Will need TSH and ECHO in full evaluation\n 4)Anemia-\n Patient with reasonable stability with transfusion--may well be\n inadequate production with associated blood loss at this time--with the\n blood loss less active at this time.\n -F/u HCT\n -Monitor with OB for stool\n Total time spent: 45 minutes\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333661,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - F/u on TSH\n - Surface ECHO in a.m. today\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n Addendum\n Anti-GBM test sent to Specialty Laboratories, 1, #4 to\n connect to lab. They will run this particular study on Tuesday, ^th, and result may become available ^th-15^th.\n PGY-1\n ------ Protected Section Addendum Entered By: , MD\n on: 19:28 ------\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"ICU Event Note","row_id":333670,"text":"Clinician: Attending\n Patient seen and examined. Plasmapharesis initiated this evening.\n Appears to be tolerating it well with no new complaints. Currently BP\n 130/70, HR 134, sat 94-97% on full face mask. No respiratory distress.\n Fine crackles heard laterally but otherwise lungs are relatively clear.\n Plan is for plasmapharesis, K to be rechecked. If necessary to be\n dialysed, renal will consider tonight. Cytoxan to be redosed at 140 mg\n IV, weight based at ~2 mg/kg for 67 kg. On Solumedrol 1 gm q24h x 3\n days. 30 min of CC time spent with patient.\n Total time spent: 30 minutes\n Patient is critically ill.\n"},{"category":"Respiratory ","chartdate":"2199-07-08 00:00:00.000","description":"Respiratory Care Shift Note","row_id":333725,"text":"Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Crackles\n Comments:\n Plan\n Pt presently on 3 lpm n/c and ordered for nebs alb/atr. Nebs\n administered as ordered with no adverse reactions.\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":335004,"text":"Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \n C-ANCA vasculitis. This morning, he breathing more easily, with stable\n lung exam though his CXR looks unchanged. This is likely due to\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\n 2+ budding yeast on sputum, without signs of candidiasis on\n oropharyngeal exam.\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\n urine output and restart IVF if necessary. We will balance maintaining\n urine output >100/hr for bladder protection with not giving too much\n Lasix due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n -Start nystatin mouthwash\n -Send blood cultures for fungus (though highly unlikely given pt. is\n afebrile, stable, but he is on high dose immunosuppression)\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - HCTq8h to monitor for alveolar bleeding. Given\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335152,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Attending Progress Note","row_id":334768,"text":"Chief Complaint: Hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirement.\n HR varies from A-flutter to NRS.\n Coughing up sputum (swallowing), but more productive cough today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 98 (85 - 131) bpm\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\n RR: 18 (12 - 25) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 1,971 mL\n PO:\n 750 mL\n 160 mL\n TF:\n IVF:\n 3,736 mL\n 1,811 mL\n Blood products:\n Total out:\n 2,400 mL\n 1,235 mL\n Urine:\n 2,400 mL\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 736 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\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, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 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, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 211 K/uL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\n Possible component of pulmonary edema.\n HYPOXEMIA -- attributed to pulmonary infiltrates. Continue\n supplemental oxygen, monitor RR, SaO2.\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\n steroids & cytoxan. Plasmaphoresis.\n RENAL FAILURE -- improving. Monitor uo, BUN, creatinine.\n FLUIDS\n desire to allow net diuresis. Consider Lasix dose.\n NUTRIONAL SUPPORT -- PO\n HEMATURIA -- stable. Monitor.\n ANEMIA -- stable s/p transfusion.\n HYPOCALCEMIA -- continue to replete.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 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: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":334958,"text":"Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\n of breathing, with worsening lung exam and desating to the 70s without\n the facemask on. This is unlikely due to hemorrhage as his crit has\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\n and chest Xray appears to have signs of pulmonary edema, making volume\n overload the most likely cause of worsening pulmonary status.\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\n output >100/hr for bladder protection with not giving too much Lasix\n due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n Will examine his septum today as this could worsen his repiratory\n status and make him feel nasal congestion (which he has been\n complaining of)\n -CT of sinus has been recommended, will consider when patient more\n stable.\n - HCT has been stable, follow HCT q8h to monitor for alveolar\n bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335153,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334748,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Dx: Wegener\ns Granulomatosis confirmed by renal biopsy\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\n frequent episodes of tachycardia in the 130\ns, typically with exertion,\n stimulation and desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows to the 80-90\ns with rest, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered. Encourage rest periods\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.5, BUN 153\n Action:\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\n Creatinine is trending down. Hct drawn at 1530, results pending.\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\n with meals. Lunch held due to respiratory distress.\n Response:\n Labs to be drawn 4 hours after plasmaphoresis and tonight at 2200.\n Fluid balance remains positive. Good urine output response to lasix.\n Tolerated plasmaphoresis with episodes of tachycardia.\n Plan:\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\n total of 7 treatments via right IJ HD catheter. Administer mesna as\n ordered with chemo. Chemo to be given after plasmaphoresis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n strong productive cough. Patient\ns O2 requirements increasing\n throughout the day.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 95% and\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\n albuterol changed to prn (may be contributing to tachycardia). Afrin\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\n on.\n Response:\n Oxygenation remains labile. Desats with eating and removal the face\n tent. Recovery time longer each time he desats.\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\n sputum sample. Patient may need a sinus CT scan if stable. Administer\n neb treatments as ordered.\n Patient\ns family at bedside. Updated on plan of care.\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":334749,"text":"Chief Complaint:\n 24 Hour Events:\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\n edema, 2L fluids up. Did not receive cytoxan yesterday. Will receive\n it after pheresis today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\n of breathing, with worsening lung exam and desating to the 70s without\n the facemask on. This is unlikely due to hemorrhage as his crit has\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\n and chest Xray appears to have signs of pulmonary edema, making volume\n overload the most likely cause of worsening pulmonary status.\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\n output >100/hr for bladder protection with not giving too much Lasix\n due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n Will examine his septum today as this could worsen his repiratory\n status and make him feel nasal congestion (which he has been\n complaining of)\n -CT of sinus has been recommended, will consider when patient more\n stable.\n - HCT has been stable, follow HCT q8h to monitor for alveolar\n bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-12 00:00:00.000","description":"Nursing Progress Note","row_id":335073,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with Wegener\ns granulocytosis with Hx. Of pulmonary hemorrhage per\n bronch at OSH. On 80% face tent and 6L NC. LS diminished. Occ congested\n non-productive cough. No hemoptesis this shift.\n Action:\n Plasmapherisis today. Cont. O2 for O2 sat >90%. HOB >45 degrees.\n Atrovent neb as ordered. Started on Nyastatin swish and spit for yeast\n in sputum cx on .\n Response:\n O2 sat 92-98%. Occ will desat to 86% when mask falls down or when\n eating.\n Plan:\n Cont. current treatment. Monitor resp. status and wean O2 as tolerated.\n F/u sputum cx.\n Plasmapherisis today. Nest treatment on Monday. Transfused today with\n one unit of PRBC for Hct. 21.6. Will need serial Hct. Checks starting\n after transfusion.\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Attending Progress Note","row_id":334190,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Blood loss due to pulmonary hemorrhage and\n renal bx likely contributing. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2199-07-09 00:00:00.000","description":"Respiratory Care Shift Note","row_id":334197,"text":"Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Crackles\n Comments:\n Pt currently on 6L NC. Nebs given as ordered with no adverse reaction.\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333491,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\n Action:\n Observing u/o and labs. Will consult renal in am and follow\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\n start sevelamer in the am.\n Response:\n Pending. Creat 9.2 this am\n Plan:\n Renal will consult in the am. Will draw am labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\n Response:\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\n with crackles\n way up.\n Plan:\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\n monitor sao2 and provide o2 as needed.\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":333972,"text":"This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n na.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":333970,"text":"This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":334155,"text":"Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\n for presumed Wegeners.\n 24 Hour Events:\n Continues to have increasing 02 requirement, on 6L and facemask to keep\n 02 >90%. Yesterday he had a renal biopsy, TTE, given d5W for\n hypernatremia and seen by rheumatology.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\n likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily (will change to prednisone tomorrow per\n rheumatology)\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok. BUN continues to increase, but BUN\n often stays elevated in acute renal failure after the kidneys have\n started to improve, also the patient is on high dose steroids which can\n increase BUN. As a note, plasmapheresis in cases of severe Wegeners\n has been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday, awaiting results. Monitor for bleeding at\n site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Will try to maintain\n 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim due to renal function, patient should be\n discharged on Atovaqone.\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is taking PO, D/C D5W.\n -if needed, restart fluids to maintain UOP 100cc/hr (to prevent hem.\n cystitis while on cytoxan)\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am),\n -lytes q6hrs\n -EKG\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT , give 1unit today\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":334025,"text":"This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n Na.\n Response:\n Phos still high,Na 141 this am.BUN and creatinine trending down.\n Plan:\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\n Hct this am 21.1.?for transfusion.\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":334369,"text":"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required ?? 02. Got pheresis yesterday, solumedrom and\n cyclophosphamide. No hematuria. Talked to renal about biopsy, c/w\n Wegners. Has been on IVF to keep uop >100, successfully. Tolerating\n PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 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 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\n likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6,up to 8.1 then back down to 7.1. BUN\n peaked at 160 now, 150. No signs of platelet dysfunction yet, mental\n status ok. Renal will give his kidneys about 48 more hours to turn\n around before dialyzing. As a note, plasmapheresis in cases of severe\n Wegeners has been shown to improve kidney outcomes, though not\n mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":334116,"text":"Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\n for presumed Wegeners.\n 24 Hour Events:\n Continues to have increasing 02 requirement, on 6L and facemask to keep\n 02 >90%. Yesterday he had a renal biopsy, TTE, put on\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - also treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily\n -Cyclophosphamide 140mg\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok.\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\n However, apart from pulmonary association, ddx for acute renal failure\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\n Also consider DIC.\n - Renal biopsy yesterday, awaiting results\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is eating, can D/C D5W.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am), check again this PM\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6, given HCT , likely need blood this pm.\n - Type and screen, cross-matched\n - Blood consent obtained\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Attending Progress Note","row_id":334121,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333431,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Renal will consult in the am.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Admission Note","row_id":333432,"text":"Chief Complaint: Bilateral LE edema, SOB\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy.\n .\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptons started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n .\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\n noted as having mild wheezing and productive cough of white sputum.\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\n Occult blood stool negative. U/A significant for protein 400mg/dl,\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\n microscopy positive for RBCs, granular casts.\n .\n Pt was seen by Renal, who thought there might possibly be a\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\n .\n CXR on admission showed underlying COPD with diffuse bilateral\n pulmonary infiltrates.\n Pt underwent bronchoscopy on , and was found to have active low\n grade blood emanating from the RLL and LLL.\n .\n EKG on admission showed atrial flutter at 2:1 block rate 150.\n .\n On arrival here, pt appeared mildly tachypneic. He reported that LE\n edema had improved, and that pain had resolved in LE. He complained of\n only mild nausea recently without vomiting, and a productive cough.\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\n constipation, melena, hematochezia, chest pain, urinary\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\n no epistaxis. Last BM was yesterday, and was formed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home medications:\n NONE\n Allergies:\n NKDA\n Past medical history:\n Family history:\n Social History:\n ?Nephrolithiasis ()- blood found in urine after workup for lower\n abdominal pain, no stones passed, 24hr protein done whith was normal\n per pt.\n Finger laceration ()\n Mother passed from CVA in 80s. Father passed in 70s from unknown cause.\n Twin brother passed from MI, another brother with hx cardiac artery\n bypass graft. Denies family hx renal or pulmonary disease.\n Pt works full-time as a machine operator. Mostly stationary job.\n Divorced, college-age son lives with wife. Lives alone.\n Smoked 1-1/2 ppd until when he quit (possibly 50 pack year hx\n prior). Drinks ~2 drinks/day, and on social occasions. Denies other\n drug use.\n Review of systems: He complained of only mild nausea recently without\n vomiting, and a productive cough. Otherwise denies sore throat, fevers,\n chills, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, urinary frequency/urgency, dysuria, lightheadedness, vision\n changes, headache, no epistaxis.\n Flowsheet Data as of 12:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 107 (107 - 122) bpm\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 48 mL\n PO:\n 230 mL\n TF:\n IVF:\n 48 mL\n Blood products:\n Total out:\n 475 mL\n 100 mL\n Urine:\n 125 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -52 mL\n Respiratory\n O2 Delivery Device: Nasal cannula 3L\n SpO2: 91%\n Physical Examination\n GEN: Thin, pale, mildly distressed, tachypneic\n HEENT: EOMI, PERRL, sclera anicteric, conjunctiva pale, no epistaxis or\n rhinorrhea, dry MM, OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, shotty anterior cervical\n lymphadenopathy, trachea midline\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: diffuse rhonchi/crackles bilaterally almost to apices\n ABD: Soft, NT, ND, +BS, +hepatomegaly (four finger-breaths below costal\n margin)\n EXT: +1pitting edema lower extremities bilaterally, no palpable cords,\n no cyanosis/clubbing, diffuse faint non-pruritic macular rash from feet\n -> knees\n NEURO: alert, oriented to person, place, and time. CN II\n XII grossly\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\n extremities. Patellar DTR +1. Plantar reflex downgoing. No gait\n disturbance. No cerebellar dysfunction.\n SKIN: Diffuse macular rash in LE bilaterally from feet -> kness,\n scattered telangiectasias in malar area of face\n Labs / Radiology\n 543 K/uL\n 219 mg/dL\n 9.7 mg/dL\n 144 mg/dL\n 16 mEq/L\n 107 mEq/L\n 6.2 mEq/L\n 143 mEq/L\n 31.0 %\n [image002.jpg]\n CXR : bilateral fluffy pulmonary infiltrates, costophrenic angles\n visible (pending read by radiology)\n EKG : similar to prior EKG from OSH, with atrial flutter\n predominantly in limb leads, rate 121\n \n 2:33 A8/9/ 11:05 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 Hct\n 31.0\n Plt\n 543\n Cr\n 9.7\n Glucose\n 219\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\n mg/dL, PO4:9.6** mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - Daily CXR's\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's.\n - Re-check u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - Check TSH\n - Surface ECHO in a.m.\n - Will start Lopressor 12.5mg PO daily for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control: RISS\n Lines: 2 PIVs\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Pantoprazole PO\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":334007,"text":"This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n Na.\n Response:\n Phos still high,Na 141 thos am.\n Plan:\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Attending Progress Note","row_id":334102,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334581,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334584,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continusly pulling the mask off inspite of frequently remainding\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\n mask off,denies any SOB,pain or discomfort.\n Action:\n On nebs and steroids,FM 60 % and additional NC is on,frequent\n reinforcement needed about need for oxygen.\n Response:\n Pt strongly denies for any pain,SOB\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":334644,"text":"Chief Complaint:\n 24 Hour Events:\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\n edema, 2L fluids up.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR.\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\n appropriately to 1unit PRBCs so likely not currently bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Prednison po daily,\n -Cyclophosphamide-dose to be determined after c/s with rheum and\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\n far.\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: Monitoring for need for dialysis, has line in\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\n signs of platelet dysfunction yet, mental status ok. Renal will give\n his kidneys about 48 more hours to turn around before dialyzing. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -pink tinged urine, stable, but will send daily U/As.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiacc negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334799,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Dx: Wegener\ns Granulomatosis confirmed by renal biopsy\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\n frequent episodes of tachycardia in the 130\ns, typically with exertion,\n stimulation and desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows to the 80-90\ns with rest, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered. Encourage rest periods\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.5, BUN 153\n Action:\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\n Creatinine is trending down. Hct drawn at 1530, result 24.\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\n with meals. Lunch held due to respiratory distress.\n Response:\n Labs to be drawn 8pm (4 hours after plasmaphoresis) and tonight at 2200\n (check with team). Fluid balance remains positive. Good urine output\n response to lasix. Tolerated plasmaphoresis with episodes of\n tachycardia.\n Plan:\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\n total of 7 treatments via right IJ HD catheter. Administer mesna as\n ordered with chemo. Chemo to be given after plasmaphoresis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n strong productive cough. Patient\ns O2 requirements increasing\n throughout the day.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 80% and\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\n albuterol changed to prn (may be contributing to tachycardia). Afrin\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\n on.\n Response:\n Oxygenation remains labile. Desats with eating and removal the face\n tent. Recovery time longer each time he desats. Left lung sounds better\n than this am.\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\n sputum sample. Patient may need a sinus CT scan if stable. Administer\n neb treatments as ordered.\n Patient\ns family at bedside. Updated on plan of care.\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Attending Progress Note","row_id":333590,"text":"Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. MacPap rash resolving\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n MICU Attending Addendum\n Pt seen with fellow and examined. Met with pt and family to review\n situation. Would add and emphasize the following to Dr \ns notes.\n On exam\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\n alos right forearm.\n ABG 7.31/37/67\n BUN 147/ Cr 9.6\n CXR: diffsue bilateral interstitial and alveolar infiltrates\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\n and renal failure quite concerning for vasculitis.\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\n Role of plasmapheresis without clear diagnosis is challenging. Will\n consult with Renal collegues on possibility of a renal biopsy to aid in\n diagnosis. Additionally he is moving towards dialysis, need to closely\n watch K, renally dose all meds. His resp status is tenusous due to\n hypoxemia as well as met acidosis and uremic encephalopathy- may\n require intubation for support\n would likely favor this over NIPPV\n given likely duration.\n Discussed with son who is HCP and updated.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent: Critically Ill 50 min\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":334220,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s occationally going to\n the 120s-130s\n Action:\n Conts on lopressor 50mg TID\n Response:\n HR was fairly well controlled though does have episodes of tachycardia\n in the setting of eating or low SATs\n Plan:\n Cont with the lopressor, follow VS, replete lytes\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat remains high, it was 7.6 this morning and 8.0 this afternoon.\n Calcium conts to be low as well as mag\n Action:\n Received 4 gms of calcium this morning and had a repeat ionized Ca of\n .86, he is presently receiving another 4 gms of Ca and 2 gm of MgS04.\n He is also receiving NS at 100cc/hr to try and protect his bladder from\n the cytoxan, to receive cytoxan again tonight\n Response:\n Creat bumped this afternoon, u/o 70-30cc/hr, conts with low Ca with his\n pheresis\n Plan:\n Presently being pheresed, to get cytoxan tonight\n this needs to be\n arranged with the 7Feldberg nurses, follow ionized Ca, creat, f/u on\n the renal biopsy from yest.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi and wheezes, 02 SAT has improved today from yest with\n an 02 SAT ~ 93% on 6 L NC, he states that he feels a little better\n today. Occationally has a wet cough but not bringing anything up.\n Action:\n Tolerating a lower FI02\n Response:\n Plan:\n Cont to follow 02 requirements, decrease the FI02 as he tolerates,\n started on mepron for PCP prophylaxis\n the bactrim was d/ced due to\n his renal failure\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":334640,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334646,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continuesly pulling the mask off inspite of frequently remainding\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\n mask off,denies any SOB,pain or discomfort.\n Action:\n On nebs and steroids,FM 60 % and additional NC is on,frequent\n reinforcement needed about need for oxygen.\n Response:\n Pt strongly denies for any pain,SOB but continued to be uncomfortable\n during night,MD was informed.No meds ordered at this time.\n Plan:\n Continue to monitor resp status,follow up AM lab results,bleeding time\n should be drawn by lab at AM.\n"},{"category":"Nursing","chartdate":"2199-07-08 00:00:00.000","description":"Nursing Progress Note","row_id":333752,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx. Pt was adm on .\n Atrial flutter (Aflutter)\n Assessment:\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\n the high 120-130 range during plasmapharesis. B/P has remained stable\n 110/78-132/69.\n Action:\n Lopressor was increased to 50mg tid which was started last evening.\n Response:\n H/R is decreasing from the 100\ns to the 80-90range.\n Plan:\n Cont with tid lopressor. Monitor h/r and pattern.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\n Action:\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\n past 24 hours pt has had 2 doses of Kayexalate. Will not repleat K+ of\n 3.9 this am as pt rises.\n Response:\n K+ is 4. U/O improving with urine more yellow. Creat 8.6/bun149 this\n am.\n Plan:\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\n lungs have had crackles bil bases with the left lung more dim than the\n right..\n Action:\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\n evening and was given cytoxan after the plasmaphoresis. Pt is also\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\n Response:\n Sao2 drops to the high 80\ns while pt wears only the n/c. pt does not\n like to wear face mask and denies any sob.\n Plan:\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\n plasmaphoresis again on Tues.\n Hct 22.8 this am and team would like to discuss in rounds as to further\n transfusions. Team wants Hct drawn at 0800. pt will also receive\n calcium gluconate 4gm to replenish 5.9. Na+ 150. Phos 9.5\n"},{"category":"Nursing","chartdate":"2199-07-08 00:00:00.000","description":"Nursing Progress Note","row_id":333876,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s\n Action:\n Conts on lopressor 50mg TID\n Response:\n Tolerating the lopressor, he did have short periods of a HR in the\n 1teens this afternoon\n Plan:\n Cont with the lopressor, follow VS\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat was 8.6 this morning, u/o has been 40-50cc/hr\n Action:\n Pt had a renal biopsy this morning under US guidance, receiving D5W\n 100cc/hr for 1 liter for a Na of 150\n Response:\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\n Plan:\n Follow HCT, VS, renal bx results, no immediate plans for dialysis,\n follow labs\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\n has not been coughing up any blood\n Action:\n He is on scoop mask at 60-70% and this brings his 02 up to 93-99%.\n Response:\n Conts to require a high FI02, he wants to eat but is NPO due to his\n tenuous resp status\n Plan:\n Follow SATs cont to try to wean his FI02\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Attending Progress Note","row_id":334483,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirment.\n Renal bx consistent with Wegener's Granulomatosis.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.9\nC (96.6\n HR: 99 (87 - 130) bpm\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\n RR: 21 (9 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,477 mL\n 2,103 mL\n PO:\n 60 mL\n TF:\n IVF:\n 2,102 mL\n 2,043 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 1,025 mL\n Urine:\n 1,360 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,117 mL\n 1,078 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 221 K/uL\n 94 mg/dL\n 7.2 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 149 mg/dL\n 105 mEq/L\n 145 mEq/L\n 22.7 %\n 9.0 K/uL\n [image002.jpg]\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n WBC\n 8.1\n 5.4\n 9.0\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n Plt\n 355\n 261\n 221\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n 94\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\n likey due to vasculitis. Radiographically without significant change,\n but hope to see improvement over next several days. Monitor RR, SaO2.\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\n improve.\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\n plts). Monitor Hct, transfuse to > 21\n WEGENER\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\n plasmaphoresis QOD.\n FLUIDS -- euvolemic. Monitor I/O\n HEMATURIA -- concern for hemorrhagic cystitis\n A-FIB -- good rate control COntinue meds. Monitor HR.\n NASAL CONGESTION -- possible related to Wegener's but more likely due\n to high flow O2. Symptomaatic relief.\n HYPOCALCEMIA -- repleted. Monitor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":333854,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight the patient remained stable, but continuing to require O2 by\n NC and facemask. HR down to 80s with lopressor but remains in\n aflutter. This am patient only c/o hunger.\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\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 01:53 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: 35.2\nC (95.3\n HR: 94 (72 - 133) bpm\n BP: 109/58(70) {104/53(66) - 142/88(102)} mmHg\n RR: 25 (18 - 29) insp/min\n SpO2: 88%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 1,042 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 485 mL\n Blood products:\n 557 mL\n Total out:\n 1,330 mL\n 1,080 mL\n Urine:\n 1,330 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -38 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 88%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No acute distress\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral, almost \n way up lungs posteriorly)\n Extremities: Right: 1+ pitting, Left: 1+ pitting,, diffuse rash below\n knees\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 355 K/uL\n 7.6 g/dL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. Concern given\n recent HCT drop. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Figure out exact 02 requirement (patient on facemask, not always\n wearing it)\n - Albuterol nebs PRN\n - repeat CXR\n - F/u on BAL results from OSH\n - Continue to keep patient NPO due to tentative respiratory status (and\n renal biopsy).\n (see t'ment plan for presumed Wegener's under acute renal failure)\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on was 126/9.6, K 5.8. Nephritic\n picture with RBC casts. However, apart from pulmonary association, ddx\n for acute renal failure with nephritis includes PSGN, lupus nephritis,\n etc. ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - Renal biopsy today, FFP on call due to INR 1.5\n - For presumed Wegeners, started Plasmapheresis (firs tt'ment last\n night, will be QOD x 5 treatments)\n - Continue Solumedrol 1g IV daily\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Continue Sevelemer in a.m. with meals for elevated Phos.\n - Renal c/s recommends also starting Amphagel (phosphate binder) 30cc\n po tid for 2-3 days for elevated Phos.\n #Hypernatremia: NA+ today 150, up from 147, likely lack of access\n to free water\n -Replace w/ D5NS\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+\n # Tachycardia: Aflutter on EKG. Until yesterday, was asymptomatic but\n rate in 120s. Can be secondary to underlying structural heart disease.\n Also may be secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - F/u on TSH\n - TTE today\n - Lopressor titrated up to 50 mg PO tid with good rate control (HR in\n 80s).\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: NPO for worsening respiratory status, anticipating intubation.\n Will replete lytes PRN.\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Case Management ","chartdate":"2199-07-08 00:00:00.000","description":"Case Managment Initial Patient Assessment","row_id":333828,"text":"Insurance information\n Primary insurance: OOS PPO-NON MANAGED CARE\n Secondary insurance: SELF PAY\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None prior to admission\n DME / Home O[2]: None prior to admission\n Functional Status / Home / Family Assessment:\n Pt. Lives alone in . He is divorced . He has a son who\n lives with the patient's ex-wife. PTA he was working and independent\n with all ADL's\n Primary Contact(s): (son) \n Health Care Proxy: .\n Dialysis: No\n Referrals Recommended: Social Work, Physical Therapy\n Current plan: Undetermined\n Unclear what level of services will be required at discharge. Case\n Management will follow for DC needs.\n If VNA services needed can use:\n VNA of SE Mass - \n - \n Centrus Premier Home Care - \n Patient (s) to Discharge:\n Medically unstable\n Patient discussed with multidisciplinary team: No\n"},{"category":"Physician ","chartdate":"2199-07-08 00:00:00.000","description":"Physician Attending Progress Note","row_id":333866,"text":"Chief Complaint: Respiratory distress/hypoxemia\n HPI:\n 24 Hour Events:\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\n Renal consultation concurred with Pulmonary-Renal syndrome.\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\n anticipating 5 days of treatment. Remains on cortocosteroids.\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\n Denies increased dyspnea, but remains with oxygen requirement.\n History obtained from Patient\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.3\nC (95.5\n HR: 81 (81 - 133) bpm\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\n RR: 24 (22 - 29) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 186 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 186 mL\n Blood products:\n Total out:\n 1,330 mL\n 690 mL\n Urine:\n 1,330 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -504 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\n mildly disshevled\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 355 K/uL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\n predominantly basilar. Right IJ catheter position acceptable. No\n significant overall change compared to .\n Assessment and Plan\n 60 yom now with Pulmonary-Renal syndrome.\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\n diffuse infiltrates and oxygen requirement.\n HYPOXEMIA -- attributed to pulmonary infiltrates. Monitor SaO2,\n supplimental O2 to maintain SaO2 >90%.\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\n SaO2.\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\n consult prepared to move to dialysis when indicated. Monitor urine\n output, BUN, Creatitine.\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\n Continue steroids and plasmaphoresis.\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\n FLUIDS -- limit iv fluids intake.\n HYPERPHOSPHATEMIA -- start phosphate binder.\n NUTRITION -- NPO pending evaluation\n ANEMIA -- progressive, attributed to underlying process, and possible\n contribution from RIJ central line placement. Transfuse to Hct >21.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334546,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\n has episodes of tachycardia in the 130\ns, typically with exertion or\n desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows with NSR episodes, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.9, BUN 149\n Action:\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\n administration of cyclophosphamide (chemo)\n Response:\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\n since midnight.\n Plan:\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\n HD catheter, may have it . Administer mesna as ordered with chemo\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n weak cough. +1.6L positive. Patient would frequently remove face tent,\n thus dropping O2 sats.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\n 6L NC. Patient encouraged to cough and deep breathe. Neb treatments as\n ordered\n Response:\n Oxygenation has improved throughout the afternoon with patient\ns family\n at the bedside\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing.\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335302,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n Continues to require supplimental oxygen, desaturates with activity.\\n Tolerating net diuresis.\\n Hemoptysis resolved.\\n Overall, states to feel improved. Dysnpea improved. Able to sleep\\n somewhat last PM (improvement).\\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 11:10 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.3\\nC (97.4\\n HR: 98 (86 - 128) bpm\\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\\n RR: 25 (11 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,945 mL\\n 560 mL\\n PO:\\n 980 mL\\n 360 mL\\n TF:\\n IVF:\\n 319 mL\\n 200 mL\\n Blood products:\\n 646 mL\\n Total out:\\n 4,410 mL\\n 960 mL\\n Urine:\\n 4,410 mL\\n 960 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,465 mL\\n -400 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 94%\\n ABG: ///31/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.8 g/dL\\n 170 K/uL\\n 79 mg/dL\\n 5.2 mg/dL\\n 31 mEq/L\\n 3.5 mEq/L\\n 147 mg/dL\\n 101 mEq/L\\n 144 mEq/L\\n 22.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n 11.0\\n Hct\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n Plt\\n 221\\n 211\\n 185\\n 170\\n Cr\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n Glucose\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\\n Imaging: CXR () somewhat improved, esp. right lung field.\\n Assessment and Plan\\n Wegener's Granulomatosis\\n RESPIRATORY DISTRESS -- slow improvement clincally and\\n radiographically, although clinically best tody. Continue current\\n management. Provide supplemental oxygen, monitor SaO2, maintain >90%.\\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\\n urine output. No indication for acute dialysis at this time.\\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\\n Continue steoids, cytoxan, plasmaphoresis (total 7 treatments)\\n NUTRITIONAL SUPPORT\\n encourage PO.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335452,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding.\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335453,\n \"text\": \"Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding.\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335455,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Labs obtained in a.m\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding. Scheduled nebs given\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.,\\n continue with neb Rx, wean O2 as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335456,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding. Scheduled nebs given\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.,\\n continue with neb Rx, wean O2 as tolerated.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Renal parameters trending down\\n Action:\\n Diuresed this p.m with 20 lasix,\\n Response:\\n Good response to lasix, negative 770 by midnight\\n Plan:\\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335620,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Patient desats to 85 when FM falls off\\n Did well O/N\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 06:10 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.1\\nC (96.9\\n HR: 108 (91 - 135) bpm\\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\\n RR: 19 (11 - 26) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,690 mL\\n 190 mL\\n PO:\\n 1,220 mL\\n 120 mL\\n TF:\\n IVF:\\n 470 mL\\n 70 mL\\n Blood products:\\n Total out:\\n 2,465 mL\\n 900 mL\\n Urine:\\n 2,465 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -775 mL\\n -710 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///29/\\n Physical Examination\\n Gen- NAD, Aox3\\n CV- Tachy but reg rhythm, No M/R/G\\n Pulm- Decreased breath sounds at bases, crackles to mid lung fields\\n Abd- Soft, NT/ND, BS +\\n Extr- No edema, Puleses 2+symmetric\\n Labs / Radiology\\n 200 K/uL\\n 8.2 g/dL\\n 117 mg/dL\\n 5.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 148 mg/dL\\n 100 mEq/L\\n 140 mEq/L\\n 24.0 %\\n 12.2 K/uL\\n [image002.jpg]\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n Hct\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n Plt\\n 00\\n Cr\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n Glucose\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT down today, unlikely due to alveolar imprroving respiratory\\n status, no hemoptysis. Continue to monitor\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Albuterol nebs PRN\\n - CXR daily\\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. As a note,\\n plasmapheresis in cases of severe Wegeners has been shown to improve\\n kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Asymptomatic, rate increases when active/talking,\\n normal when sleeping. ECHO showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n He received 1 unit yesterday and bumped appropriately.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335606,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n No new events.\\n Revieved 1 U PRBC transfusion, tolerated well.\\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 Furosemide (Lasix) - 06:10 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:08 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 122 (97 - 135) bpm\\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,690 mL\\n 477 mL\\n PO:\\n 1,220 mL\\n 360 mL\\n TF:\\n IVF:\\n 470 mL\\n 117 mL\\n Blood products:\\n Total out:\\n 2,465 mL\\n 1,540 mL\\n Urine:\\n 2,465 mL\\n 1,540 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -775 mL\\n -1,063 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, Face tent\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 8.2 g/dL\\n 200 K/uL\\n 117 mg/dL\\n 5.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 148 mg/dL\\n 100 mEq/L\\n 140 mEq/L\\n 24.0 %\\n 12.2 K/uL\\n [image002.jpg]\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n Hct\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n Plt\\n 00\\n Cr\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n Glucose\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\\n Assessment and Plan\\n Respiratory distress and acute renal failure --> Wegener's\\n Granulomatosis\\n RESPRIATORY DISTRESS -- gradual improvement. Monitor RR, SaO2,\\n maintain >90%.\\n RENAL FAILURE -- initial good recovery, with good urine output;\\n however, now creatitine with minimal decline over past 2-3 days. \\n be approaching new baseline. ultimately require dialysis.\\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\\n cytoxan & plasmaphoresis\\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\\n disease.\\n FLUIDS -- desire net negative if tolerated by BP.\\n NUTRITIONAL SUPPORT -- encourage PO.\\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335622,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Hx. Of alveolar hemorrhage due to wegener\\ns dz. Remain on O2 at 80%\\n face tent and 6L NC. LS diminished. Congested non productive cough.\\n Action:\\n Nebs as ordered. Up to chair for good part of the day.\\n Response:\\n Tolerated being up well. Pt. coughed while up in a chair but no sputum.\\n O2 sat stable >90%. Still will desat to 86% while eating or when mask\\n of. CXR improving.\\n Plan:\\n Cont. current treatment.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 335701,\n \"text\": \"TITLE: Resp Care Note, Pt rx\\nd with albuterol/ atrovent via mask. BS\\n wheezes. Improved after rx. Will cont to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335681,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Plasma pheresis due tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\\n during sleep)\\n Action:\\n Continues on O2, ( frequently reminded to keep O2 on)\\n Response:\\n Remains afebrile, no hemoptysis, slept well overnight\\n Plan:\\n Continue to monitor resp status, wean O2 as tolerated.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 335778,\n \"text\": \"Clinician: Attending\\n Critical Care\\n Urine output remains good and we will try to maintain him negative\\n again today. Creat is trending down still. Oxygen requirement remains\\n high and he still has diffuse bilat infiltrates. Plan for\\n plasmapheresis again today. He is feeling better but still is very\\n fragile HR 140 simply with exam. Checking ECK before increasing beta\\n blocker.\\n Total time spent: 35 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335781,\n \"text\": \"Chief Complaint: 60 year old male transferred from OSH with repiratory\\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis. Kidney function improving steadily, no dialysis was\\n needed. Respiratory status stable, continues to require facemask to\\n keep 02 sats >90%, no signs of continued bleeding into lungs.\\n 24 Hour Events:\\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\\n hyperglycemia to steroid use.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 117 (99 - 137) bpm\\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\\n RR: 24 (11 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,510 mL\\n 304 mL\\n PO:\\n 1,340 mL\\n 240 mL\\n TF:\\n IVF:\\n 170 mL\\n 64 mL\\n Blood products:\\n Total out:\\n 2,800 mL\\n 300 mL\\n Urine:\\n 2,800 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,290 mL\\n 4 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 217 K/uL\\n 7.8 g/dL\\n 88 mg/dL\\n 4.4 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 145 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 23.0 %\\n 9.8 K/uL\\n [image002.jpg]\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n Hct\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n Plt\\n 00\\n 217\\n Cr\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n Glucose\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\\n shows interval improvement, patient appears to be responding to\\n diuresis as well.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT down today, unlikely due to alveolar hemoorhave given improving\\n respiratory status and no hemoptysis. .\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\\n - CXR daily\\n -Plasmapheresis, dose 5/7 today, then W/F.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n - f/u Rheum recs\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. As a note,\\n plasmapheresis in cases of severe Wegeners has been shown to improve\\n kidney outcomes, though not mortality.\\n - Foley in place , strict I&O, goal -1 liter today (has been\\n , no lasix unless needed this pm)\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A\\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\\n continue for at least one more day.\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Continued tachycardia, ? atrial vs. sinus.\\n Hemodynamically stable. ECHO showed mild LV septal , \\n 45-50%. Possibly secondary to large volume shifts (retaining total\\n body fluid with renal failure, with large volume load putting stress on\\n atria.)\\n -EKG to eval for atrial tach vs. sinus tach. If sinus, will work up\\n underlying cause. If atrial, will increase lopressor to 75mg po tid.\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n HCT have been low in the morning and higher in the afternoon for the\\n past 2 days despite no transfusion and no plasmapheresis. Variation\\n may be due to lab variability, fluid shifts during the day, or another\\n unknown cause. Will monitor as long as he is hemodynamically stable.\\n -qday HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n #Hyperglycemia- non-diabetic, likely high dose steroids.\\n -SSI plus standing 3units\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 336024,\n \"text\": \"60 year old male transferred from OSH with respiratory distress\\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis.\\n Vasculitis\\n Assessment:\\n Pt. dx. With Wegener\\ns granulomatosis.\\n Action:\\n Has been reciving plasmapherisis , steroids and cytoxin.\\n Response:\\n Two more treatments of plasmapherisis planed for Wed. and Fri.\\n Plan:\\n Remains stable.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\\n 6L NC. Occ. Congested non-productive cough.\\n Action:\\n Cont. Atovaquone for PCP . OOB to chair today.\\n Response:\\n CXR improving. Pt. states breathing feels much better.\\n Plan:\\n Cont. to wean O2.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n In Renal failure when admitted to MICU.\\n Action:\\n Monitoring. Encourage PO fluid intake.\\n Response:\\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\\n Plan:\\n Goal urine output -500 to 1L .\\n On FS QID due to Prednisone daily. On RISS and NPH Q am.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n VASCULITIS\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 68.4 kg\\n Daily weight:\\n 93.3 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: ? emphysema\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:126\\n D:78\\n Temperature:\\n 98.1\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 106 bpm\\n Heart rhythm:\\n AF (Atrial Fibrillation)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 6 L/min\\n FiO2 set:\\n 24h total in:\\n 1,136 mL\\n 24h total out:\\n 2,220 mL\\n Pertinent Lab Results:\\n Sodium:\\n 145 mEq/L\\n 04:05 AM\\n Potassium:\\n 3.6 mEq/L\\n 04:05 AM\\n Chloride:\\n 103 mEq/L\\n 04:05 AM\\n CO2:\\n 32 mEq/L\\n 04:05 AM\\n BUN:\\n 135 mg/dL\\n 04:05 AM\\n Creatinine:\\n 4.3 mg/dL\\n 04:05 AM\\n Glucose:\\n 92 mg/dL\\n 04:05 AM\\n Hematocrit:\\n 21.3 %\\n 04:05 AM\\n Finger Stick Glucose:\\n 150\\n 12:00 PM\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n pherisis line in R IJ, Foley cath\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: MICU 412\\n Transferred to:\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 336032,\n \"text\": \"60 year old male transferred from OSH with respiratory distress\\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis.\\n Vasculitis\\n Assessment:\\n Pt. dx. With Wegener\\ns granulomatosis.\\n Action:\\n Has been reciving plasmapherisis , steroids and cytoxin.\\n Response:\\n Two more treatments of plasmapherisis planed for Wed. and Fri.\\n Plan:\\n Remains stable.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\\n 6L NC. Occ. Congested non-productive cough.\\n Action:\\n Cont. Atovaquone for PCP . OOB to chair today.\\n Response:\\n CXR improving. Pt. states breathing feels much better.\\n Plan:\\n Cont. to wean O2.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n In Renal failure when admitted to MICU.\\n Action:\\n Monitoring. Encourage PO fluid intake.\\n Response:\\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\\n Plan:\\n Goal urine output -500 to 1L .\\n On FS QID due to Prednisone daily. On RISS and NPH Q am. BS well\\n controlled.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n VASCULITIS\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 68.4 kg\\n Daily weight:\\n 93.3 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: ? emphysema\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:126\\n D:78\\n Temperature:\\n 98.1\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 106 bpm\\n Heart rhythm:\\n AF (Atrial Fibrillation)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 6 L/min\\n FiO2 set:\\n 24h total in:\\n 1,136 mL\\n 24h total out:\\n 2,220 mL\\n Pertinent Lab Results:\\n Sodium:\\n 145 mEq/L\\n 04:05 AM\\n Potassium:\\n 3.6 mEq/L\\n 04:05 AM\\n Chloride:\\n 103 mEq/L\\n 04:05 AM\\n CO2:\\n 32 mEq/L\\n 04:05 AM\\n BUN:\\n 135 mg/dL\\n 04:05 AM\\n Creatinine:\\n 4.3 mg/dL\\n 04:05 AM\\n Glucose:\\n 92 mg/dL\\n 04:05 AM\\n Hematocrit:\\n 21.3 %\\n 04:05 AM\\n Finger Stick Glucose:\\n 150\\n 12:00 PM\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n pherisis line in R IJ, Foley cath\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: MICU 412\\n Transferred to: 1173\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335921,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\\n to having no PCP (regular PCP had retired.) He finally presented for\\n care when he could not put his shoes on in the a.m. due to pedal edema.\\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\\n Pt reports that LE symptoms started in the feet, progressing to\\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\\n macular rash in the LE of the same distribution. He also complained of\\n some SOB on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Vasculitis\\n Assessment:\\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output.\\n Action:\\n Pt had plasmapheresis treatment yesterday.\\n Response:\\n Improving.\\n Plan:\\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\\n Action:\\n Pt did receive lasix 40mg this evening.\\n Response:\\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\\n 775cc neg.\\n Plan:\\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\\n Tachycardia, Other\\n Assessment:\\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\\n Action:\\n Pt is on metoprolol 75 mg tid.\\n Response:\\n Pending.\\n Plan:\\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334315,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\\n non productive cough remains, LS diminished at bases\\n Action:\\n Continue with mepron\\n Response:\\n VSS stable, no resp distress noted\\n Plan:\\n Continue to monitor VSS, sats,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335286,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n Continues to require supplimental oxygen, desaturates with activity.\\n Tolerating net diuresis.\\n Hemoptysis resolved.\\n Overall, states to feel improved. Dysnpea improved. Able to sleep\\n somewhat last PM (improvement).\\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 11:10 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.3\\nC (97.4\\n HR: 98 (86 - 128) bpm\\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\\n RR: 25 (11 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,945 mL\\n 560 mL\\n PO:\\n 980 mL\\n 360 mL\\n TF:\\n IVF:\\n 319 mL\\n 200 mL\\n Blood products:\\n 646 mL\\n Total out:\\n 4,410 mL\\n 960 mL\\n Urine:\\n 4,410 mL\\n 960 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,465 mL\\n -400 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 94%\\n ABG: ///31/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.8 g/dL\\n 170 K/uL\\n 79 mg/dL\\n 5.2 mg/dL\\n 31 mEq/L\\n 3.5 mEq/L\\n 147 mg/dL\\n 101 mEq/L\\n 144 mEq/L\\n 22.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n 11.0\\n Hct\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n Plt\\n 221\\n 211\\n 185\\n 170\\n Cr\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n Glucose\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\\n Imaging: CXR () somewhat improved, esp. right lung field.\\n Assessment and Plan\\n Wegener's Granulomatosis\\n RESPIRATORY DISTRESS -- slow improvement clincally and\\n radiographically. Continue current management.\\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\\n urine output.\\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\\n Continue steoids, cytoxan, plasmaphoresis\\n NUTRITIONAL SUPPORT --\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335287,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Did well. No hemoptysis.\\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\\n diuresis yesterday to goal -2L.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36\\nC (96.8\\n HR: 86 (86 - 116) bpm\\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\\n RR: 18 (14 - 27) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,945 mL\\n 340 mL\\n PO:\\n 980 mL\\n 240 mL\\n TF:\\n IVF:\\n 319 mL\\n 100 mL\\n Blood products:\\n 646 mL\\n Total out:\\n 4,410 mL\\n 470 mL\\n Urine:\\n 4,410 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,465 mL\\n -130 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///31/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 170 K/uL\\n 7.8 g/dL\\n 79 mg/dL\\n 5.2 mg/dL\\n 31 mEq/L\\n 3.5 mEq/L\\n 147 mg/dL\\n 101 mEq/L\\n 144 mEq/L\\n 22.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n 11.0\\n Hct\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n Plt\\n 221\\n 211\\n 185\\n 170\\n Cr\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n Glucose\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\\n looks mor comfortable though CXR looks unchanged. This is likely due\\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\\n the last 3 days. Urine output remains high.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n -Will give lasix 40IV for goal of -500\\n1L today. We will also watch\\n his urine output and restart IVF if necessary to keep >100cc/hr\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n - HCT down today, unlikely due to alveolar imprroving respiratory\\n status, no hemoptysis. Continue to monitor\\n - If possible Will collect sputum to determine whether hemoptysis is\\n tinged, bright red or just pink fronthy.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - Albuterol nebs PRN\\n - CXR daily\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n ok. Urine is less pink that previously. Renal function has been\\n steadily improving, likely as a response to Wegeners treatment. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - treating underlying cause (likely Wegener's).\\n - Foley in place , strict I&O, q8 lytes.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -received 4IV CA last night\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Rate has been well controlled over the past 2 days.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n He received 1 unit yesterday and bumped appropriately but his HCT is\\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\\n will not receive pheresis this weekend, so we can monitor to see if HCT\\n stays stable.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334432,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Remains with high FiO2 requirment.\\n Renal bx consistent with Wegener's Granulomatosis.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 35.9\\nC (96.6\\n HR: 99 (87 - 130) bpm\\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\\n RR: 21 (9 - 28) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,477 mL\\n 2,103 mL\\n PO:\\n 60 mL\\n TF:\\n IVF:\\n 2,102 mL\\n 2,043 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 1,025 mL\\n Urine:\\n 1,360 mL\\n 1,025 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,117 mL\\n 1,078 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.6 g/dL\\n 221 K/uL\\n 94 mg/dL\\n 7.2 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 149 mg/dL\\n 105 mEq/L\\n 145 mEq/L\\n 22.7 %\\n 9.0 K/uL\\n [image002.jpg]\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n WBC\\n 8.1\\n 5.4\\n 9.0\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n Plt\\n 355\\n 261\\n 221\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\\n Assessment and Plan\\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\\n likey due to vasculitis. Radiographically without significant change,\\n but hope to see improvement over next several days. Monitor RR, SaO2.\\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\\n improve.\\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\\n plts). Monitor Hct, transfuse to > 21\\n WEGENER\\\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\\n plasmaphoresis QOD.\\n FLUIDS -- euvolemic. Monitor I/O\\n HEMATURIA -- concern for hemorrhagic cystitis\\n A-FIB -- good rate control COntinue meds. Monitor HR.\\n NASAL CONGESTION -- possible related to Wegener's but more likely due\\n to high flow O2. Symptomaatic relief.\\n HYPOCALCEMIA -- repleted. Monitor.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334434,\n \"text\": \"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\\n renal biopsy c/w Wegeners.\\n 24 Hour Events:\\n O/N required 6L 02 with 40%FIo\\\\02 facemask to keep 02 sat >90. Got\\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\\n >100, successfully. Tolerating PO. Received 1 unit PRBCs yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36\\nC (96.8\\n HR: 99 (75 - 130) bpm\\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\\n RR: 20 (18 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,475 mL\\n 650 mL\\n PO:\\n TF:\\n IVF:\\n 2,100 mL\\n 650 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 260 mL\\n Urine:\\n 1,360 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,115 mL\\n 390 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///25/\\n Physical Examination\\n Gen: Sleeping in bed, NAD\\n CV:tachy, irregular. No murmur\\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\\n Ext: 1+ pedal edema, no rash or petichiae\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 172 mg/dL\\n 7.1 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 149 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 22.4 %\\n 5.4 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n WBC\\n 8.1\\n 5.4\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n Plt\\n 355\\n 261\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n TCO2\\n 20\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR.\\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\\n appropriately to 1unit PRBCs so likely not currently bleeding.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Prednison po daily,\\n -Cyclophosphamide-dose to be determined after c/s with rheum and\\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\\n far.\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: Monitoring for need for dialysis, has line in\\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\\n signs of platelet dysfunction yet, mental status ok. Renal will give\\n his kidneys about 48 more hours to turn around before dialyzing. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\\n cryglobulins, ANCA.\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -pink tinged urine, stable, but will send daily U/As.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiacc negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334532,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Atrial flutter (Aflutter)\\n Assessment:\\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\\n has episodes of tachycardia in the 130\\ns, typically with exertion or\\n desats. BP within normal limits.\\n Action:\\n Tolerating metoprolol PO\\n Response:\\n Heart rate slows with NSR episodes, VS WNL\\n Plan:\\n Continue to monitor Heart rate/rhythm, administer metoprolol as\\n ordered.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\\n noted. Creatinine is 6.9, BUN 149\\n Action:\\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\\n administration of cyclophosphamide (chemo)\\n Response:\\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\\n since midnight.\\n Plan:\\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\\n HD catheter, may have it . Administer mesna as ordered with chemo\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\\n weak cough. +1.6L positive. Patient would frequently remove face tent,\\n thus dropping O2 sats.\\n Action:\\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\\n 6L NC. Patient encouraged to cough and deep breathe.\\n Response:\\n Oxygenation has improved throughout the afternoon with patient\\ns family\\n at the bedside\\n Plan:\\n Continue to titrate O2, encourage deep breathing and coughing.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334311,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 6 liters NC and supplemental O2, sats maintaining above\\n 95%, desats when pt removes O2 in his sleep. , Moist non productive\\n cough remains, LS with rhonchi in both lower lobes more on R.\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334923,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\\n pull the O2 mask and cannula,desats to low 80,s when the mask is\\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\\n cough.\\n Action:\\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\\n Cytoxan yesterday with mesna/IV as ordered by MD. 3^rd dose of mesna\\n due at 1000,pt now only on FM with 80%,sats >97% when mask is on.\\n Response:\\n Pt was more comfortable last night, but continued to be uncomfortable\\n with the mask\\n Plan:\\n Monitor resp status,meds as ordered,Titrate O2 as needed.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335259,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Did well. No hemoptysis.\\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\\n diuresis yesterday to goal -2L.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36\\nC (96.8\\n HR: 86 (86 - 116) bpm\\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\\n RR: 18 (14 - 27) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,945 mL\\n 340 mL\\n PO:\\n 980 mL\\n 240 mL\\n TF:\\n IVF:\\n 319 mL\\n 100 mL\\n Blood products:\\n 646 mL\\n Total out:\\n 4,410 mL\\n 470 mL\\n Urine:\\n 4,410 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,465 mL\\n -130 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///31/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 170 K/uL\\n 7.8 g/dL\\n 79 mg/dL\\n 5.2 mg/dL\\n 31 mEq/L\\n 3.5 mEq/L\\n 147 mg/dL\\n 101 mEq/L\\n 144 mEq/L\\n 22.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n 11.0\\n Hct\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n Plt\\n 221\\n 211\\n 185\\n 170\\n Cr\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n Glucose\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\\n looks mor comfortable though CXR looks unchanged. This is likely due\\n to 2 days of diuresis, as he is -2L in the past 24 hours and -4L in the\\n last 2 days. Urine output remains high.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n -Will give lasix 40IV for goal of -500 today. We will also watch his\\n urine output and restart IVF if necessary\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n - Stable crit and no more hemoptysis so pulmonary bleeding unlikely,\\n - HCTq12h to monitor for alveolar bleeding.\\n - If possible Will collect sputum to determine whether hemoptysis is\\n tinged, bright red or just pink fronthy.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - Albuterol nebs PRN\\n - CXR daily\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n ok. Urine is less pink that previously. Renal function has been\\n steadily improving, likely as a response to Wegeners treatment. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - treating underlying cause (likely Wegener's).\\n - Foley in place , strict I&O, q8 lytes.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -received 4IV CA last night\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n No baseline Crit available.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334307,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334406,\n \"text\": \"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\\n renal biopsy c/w Wegeners.\\n 24 Hour Events:\\n O/N required 6L 02 with 40%FIo\\\\02 facemask to keep 02 sat >90. Got\\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\\n >100, successfully. Tolerating PO.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36\\nC (96.8\\n HR: 99 (75 - 130) bpm\\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\\n RR: 20 (18 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,475 mL\\n 650 mL\\n PO:\\n TF:\\n IVF:\\n 2,100 mL\\n 650 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 260 mL\\n Urine:\\n 1,360 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,115 mL\\n 390 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 261 K/uL\\n 6.9 g/dL\\n 172 mg/dL\\n 7.1 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 149 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 22.4 %\\n 5.4 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n WBC\\n 8.1\\n 5.4\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n Plt\\n 355\\n 261\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n TCO2\\n 20\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, but increased with 1unit yesterday.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\\n prednisone dose\\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\\n doses thus far.\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\\n will give his kidneys about 48 more hours to turn around before\\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\\n been shown to improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\\n cryglobulins, ANCA.\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n yesterday with D51/2.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -given 6g IV Ca yesterday, plus more during pheresis\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - given HCT trend, gave 1 unit yesterday with improved HCT.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Guaiac all stools\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334409,\n \"text\": \"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\\n renal biopsy c/w Wegeners.\\n 24 Hour Events:\\n O/N required 6L 02 with 40%FIo\\\\02 facemask to keep 02 sat >90. Got\\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\\n >100, successfully. Tolerating PO.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36\\nC (96.8\\n HR: 99 (75 - 130) bpm\\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\\n RR: 20 (18 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,475 mL\\n 650 mL\\n PO:\\n TF:\\n IVF:\\n 2,100 mL\\n 650 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 260 mL\\n Urine:\\n 1,360 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,115 mL\\n 390 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///25/\\n Physical Examination\\n Gen: Sleeping in bed, NAD\\n CV:tachy, irregular. No murmur\\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\\n Ext: 1+ pedal edema, no rash or petichiae\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 172 mg/dL\\n 7.1 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 149 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 22.4 %\\n 5.4 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n WBC\\n 8.1\\n 5.4\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n Plt\\n 355\\n 261\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n TCO2\\n 20\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, but increased with 1unit yesterday.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\\n prednisone dose\\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\\n doses thus far.\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\\n will give his kidneys about 48 more hours to turn around before\\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\\n been shown to improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\\n cryglobulins, ANCA.\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n yesterday with D51/2.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -given 6g IV Ca yesterday, plus more during pheresis\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - given HCT trend, gave 1 unit yesterday with improved HCT.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Guaiac all stools\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334385,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx., undervent renal biopsy, awaiting results.\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\\n non productive cough remains, LS diminished at bases\\n Action:\\n Continue with mepron\\n Response:\\n VSS stable, no resp distress noted\\n Plan:\\n Continue to monitor VSS, sats,\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334873,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334877,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\\n pull the O2 mask and cannula,desats to low 80,s when the mask is\\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\\n cough.\\n Action:\\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\\n Cytoxan yesterday with mesna/IV as ordered by MD.\\n Response:\\n Pt was more comfortable last night,\\n Plan:\\n Monitor resp status,meds as ordered,\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 335493,\n \"text\": \"TITLE: Resp Care Note, Pt given albuterol/atrovent nebs. BS rhonchi. 02\\n remains on 80% high flow neb/nc 4lpm. Sat 95%. Pt stable . Will cont ot\\n monitor resp status.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334716,\n \"text\": \"Chief Complaint: Hypoxemia\\n HPI:\\n 24 Hour Events:\\n Remains with high FiO2 requirement.\\n HR varies from A-flutter to NRS.\\n Coughing up sputum (swallowing), but more productive cough today.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.2\\n Tcurrent: 36.1\\nC (96.9\\n HR: 98 (85 - 131) bpm\\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\\n RR: 18 (12 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 1,971 mL\\n PO:\\n 750 mL\\n 160 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 1,811 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 1,235 mL\\n Urine:\\n 2,400 mL\\n 1,235 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 736 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 94%\\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, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: 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, No(t) Sedated,\\n No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.8 g/dL\\n 211 K/uL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\\n Possible component of pulmonary edema.\\n HYPOXEMIA -- attributed to pulmonary infiltrates.\\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\\n steroids & cytoxan. Plasmaphoresis.\\n RENAL FAILURE -- improving.\\n NUTRIONAL SUPPORT -- PO\\n HEMATURIA -- stable. Monitor.\\n ANEMIA -- stable s/p transfusion\\n HYPOCALCEMIA -- continue to replete\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 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: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335036,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia.\\n HPI:\\n 24 Hour Events:\\n Experienced some hemoptysis yesterday PM.\\n Appears much more comfortable today, less dyspneic.\\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 Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\\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, Hematuria\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\\n RR: 26 (18 - 27) insp/min\\n SpO2: 88%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 238 mL\\n PO:\\n 290 mL\\n 120 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 118 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 2,900 mL\\n Urine:\\n 3,010 mL\\n 2,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -2,663 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 88%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\\n No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\\n Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.3 g/dL\\n 185 K/uL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Wegener's Granulomatosis\\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\\n plasmaphoresis\\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\\n falling, urine output improving, responding to diuretics.\\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\\n escalation. Consider dDAVP. need dialysis if continues to\\n NUTRITIONAL SUPPORT -- PO\\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\\n suppression. Transfuse to Hct >25\\n FLUID -- continue net negative. Monitor I/O.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335533,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 06:10 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.1\\nC (96.9\\n HR: 108 (91 - 135) bpm\\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\\n RR: 19 (11 - 26) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,690 mL\\n 190 mL\\n PO:\\n 1,220 mL\\n 120 mL\\n TF:\\n IVF:\\n 470 mL\\n 70 mL\\n Blood products:\\n Total out:\\n 2,465 mL\\n 900 mL\\n Urine:\\n 2,465 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -775 mL\\n -710 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///29/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 200 K/uL\\n 8.2 g/dL\\n 117 mg/dL\\n 5.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 148 mg/dL\\n 100 mEq/L\\n 140 mEq/L\\n 24.0 %\\n 12.2 K/uL\\n [image002.jpg]\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n Hct\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n Plt\\n 00\\n Cr\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n Glucose\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\\n looks mor comfortable though CXR looks unchanged. This is likely due\\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\\n the last 3 days. Urine output remains high.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n -Will give lasix 40IV for goal of -500\\n1L today. We will also watch\\n his urine output and restart IVF if necessary to keep >100cc/hr\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n - HCT down today, unlikely due to alveolar imprroving respiratory\\n status, no hemoptysis. Continue to monitor\\n - If possible Will collect sputum to determine whether hemoptysis is\\n tinged, bright red or just pink fronthy.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - Albuterol nebs PRN\\n - CXR daily\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n ok. Urine is less pink that previously. Renal function has been\\n steadily improving, likely as a response to Wegeners treatment. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - treating underlying cause (likely Wegener's)\\n - Foley in place , strict I&O, q8 lytes.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -received 4IV CA last night\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Rate has been well controlled over the past 2 days.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n He received 1 unit yesterday and bumped appropriately but his HCT is\\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\\n will not receive pheresis this weekend, so we can monitor to see if HCT\\n stays stable.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 334695,\n \"text\": \"Potential for nutrition risk. Patient being monitored. Current\\n intervention if any, listed below:\\n Comments:\\n Diet: low sodium/heart healthy/Renal.\\n Reports no weight loss. Tolerating current diet, says he's hungry. Will\\n continue to monitor po intake. Continue to monitor renal function and\\n hydration.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335226,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\\n continues to desat when off O2 ( removes O2 while sleeping on and off)\\n Action:\\n Scheduled neb given , nystatin swish given for yeast in sputum.\\n Response:\\n Good response to neb , Slept well with ambien.\\n Plan:\\n Continue to monitor VSS and follow sats closely.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\\n Action:\\n Followed up with labs overnight.\\n Response:\\n U/O wnl, continued to monitor renal parameters\\n Plan:\\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335572,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n No new events.\\n Revieved 1 U PRBC transfusion, tolerated well.\\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 Furosemide (Lasix) - 06:10 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:08 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 122 (97 - 135) bpm\\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,690 mL\\n 477 mL\\n PO:\\n 1,220 mL\\n 360 mL\\n TF:\\n IVF:\\n 470 mL\\n 117 mL\\n Blood products:\\n Total out:\\n 2,465 mL\\n 1,540 mL\\n Urine:\\n 2,465 mL\\n 1,540 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -775 mL\\n -1,063 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, Face tent\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 8.2 g/dL\\n 200 K/uL\\n 117 mg/dL\\n 5.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 148 mg/dL\\n 100 mEq/L\\n 140 mEq/L\\n 24.0 %\\n 12.2 K/uL\\n [image002.jpg]\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n Hct\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n Plt\\n 00\\n Cr\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n Glucose\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\\n Assessment and Plan\\n Respiratory distress and acute renal failure --> Wegener's\\n Granulomatosis\\n RESPRIATORY DISTRESS -- gradual improvement.\\n RENAL FAILURE -- initial good recovery, with good urine output;\\n however, now creatitine with minimal decline over past 2-3 days. \\n be approaching new baseline. ultimately require dialysis.\\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\\n cytoxan & plasmaphoresis\\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\\n disease.\\n FLUIDS -- desire net negative if tolerated by BP.\\n NUTRITIONAL SUPPORT -- encourage PO.\\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333963,\n \"text\": \"Most likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335357,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\\n to 86% when pt. sleeping and face tent away from Pt.\\ns face.\\n Action:\\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\\n in sputum. Nebs as ordered.\\n Response:\\n Pt. states he is feeling better. No hemoptisis this shift. CXR\\n improving.\\n Plan:\\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335358,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\\n to 86% when pt. sleeping and face tent away from Pt.\\ns face.\\n Action:\\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\\n in sputum. Nebs as ordered.\\n Response:\\n Pt. states he is feeling better. No hemoptisis this shift. CXR\\n improving.\\n Plan:\\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\\n Repleated Ca+ this shift per Ca+ SS.\\n Repeat Hct. 26\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335733,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Plasma pheresis due tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\\n during sleep),\\n Action:\\n Continues on O2, ( frequently reminded to keep O2 on), xray chest done\\n this a.m\\n Response:\\n Remains afebrile, no hemoptysis, slept well overnight\\n Plan:\\n Continue to monitor resp status, wean O2 as tolerated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335748,\n \"text\": \"Chief Complaint: 60 year old male transferred from OSH with repiratory\\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis. Kidney function improving steadily, no dialysis was\\n needed. Respiratory status stable, continues to require facemask to\\n keep 02 sats >90%, no signs of continued bleeding into lungs.\\n 24 Hour Events:\\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\\n hyperglycemia to steroid use.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 117 (99 - 137) bpm\\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\\n RR: 24 (11 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,510 mL\\n 304 mL\\n PO:\\n 1,340 mL\\n 240 mL\\n TF:\\n IVF:\\n 170 mL\\n 64 mL\\n Blood products:\\n Total out:\\n 2,800 mL\\n 300 mL\\n Urine:\\n 2,800 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,290 mL\\n 4 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 217 K/uL\\n 7.8 g/dL\\n 88 mg/dL\\n 4.4 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 145 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 23.0 %\\n 9.8 K/uL\\n [image002.jpg]\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n Hct\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n Plt\\n 00\\n 217\\n Cr\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n Glucose\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT down today, unlikely due to alveolar hemoorhave given improving\\n respiratory status and no hemoptysis. Continue to monitor with q12\\n HCT.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Albuterol nebs PRN\\n - CXR daily\\n -Plasmapheresis, dose 5/7 today, then W/F.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n - f/u Rheum recs\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. As a note,\\n plasmapheresis in cases of severe Wegeners has been shown to improve\\n kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\\n continue for at least one more day.\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Asymptomatic, rate increases when active/talking,\\n normal when sleeping. ECHO showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n #Hyperglycemia- non-diabetic, likely high dose steroids.\\n -SSI plus standing\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335872,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\\n to having no PCP (regular PCP had retired.) He finally presented for\\n care when he could not put his shoes on in the a.m. due to pedal edema.\\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\\n Pt reports that LE symptoms started in the feet, progressing to\\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\\n macular rash in the LE of the same distribution. He also complained of\\n some SOB on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Vasculitis\\n Assessment:\\n Action:\\n Pt had plasmapheresis treatment yesterday.\\n Response:\\n Plan:\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n U/O has been good.\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n Pt remains in ST with hr ranging from\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335873,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\\n to having no PCP (regular PCP had retired.) He finally presented for\\n care when he could not put his shoes on in the a.m. due to pedal edema.\\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\\n Pt reports that LE symptoms started in the feet, progressing to\\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\\n macular rash in the LE of the same distribution. He also complained of\\n some SOB on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Vasculitis\\n Assessment:\\n Action:\\n Pt had plasmapheresis treatment yesterday.\\n Response:\\n Plan:\\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\\n Action:\\n Pt did receive lasix 40mg this evening.\\n Response:\\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\\n 775cc neg.\\n Plan:\\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\\n Tachycardia, Other\\n Assessment:\\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\\n Action:\\n Pt is on metoprolol 75 mg tid.\\n Response:\\n Pending.\\n Plan:\\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335874,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\\n to having no PCP (regular PCP had retired.) He finally presented for\\n care when he could not put his shoes on in the a.m. due to pedal edema.\\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\\n Pt reports that LE symptoms started in the feet, progressing to\\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\\n macular rash in the LE of the same distribution. He also complained of\\n some SOB on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Vasculitis\\n Assessment:\\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output.\\n Action:\\n Pt had plasmapheresis treatment yesterday.\\n Response:\\n Improving.\\n Plan:\\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\\n Action:\\n Pt did receive lasix 40mg this evening.\\n Response:\\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\\n 775cc neg.\\n Plan:\\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\\n Tachycardia, Other\\n Assessment:\\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\\n Action:\\n Pt is on metoprolol 75 mg tid.\\n Response:\\n Pending.\\n Plan:\\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 336022,\n \"text\": \"60 year old male transferred from OSH with respiratory distress\\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis.\\n Vasculitis\\n Assessment:\\n Pt. dx. With Wegener\\ns granulomatosis.\\n Action:\\n Has been reciving plasmapherisis , steroids and cytoxin.\\n Response:\\n Two more treatments of plasmapherisis planed for Wed. and Fri.\\n Plan:\\n Remains stable.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\\n 6L NC. Occ. Congested non-productive cough.\\n Action:\\n Cont. Atovaquone for PCP . OOB to chair today.\\n Response:\\n CXR improving. Pt. states breathing feels much better.\\n Plan:\\n Cont. to wean O2.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n In Renal failure when admitted to MICU.\\n Action:\\n Monitoring. Encourage PO fluid intake.\\n Response:\\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\\n Plan:\\n Goal urine output -500 to 1L .\\n On FS QID due to Prednisone daily.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334074,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 89 (72 - 133) bpm\\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 343 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 343 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 440 mL\\n Urine:\\n 1,405 mL\\n 440 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -97 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - also treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose today (QOD)\\n -Solumedrol 1g IV daily\\n -Cyclophosphamide 140mg\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\\n dysfunction yet, mental status ok.\\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\\n However, apart from pulmonary association, ddx for acute renal failure\\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\\n Also consider DIC.\\n - Renal biopsy yesterday, awaiting results\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\\n serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\\n today 141, down from 150.\\n -Now patient is eating, can D/C D5W.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -Replace Ca2+ (given 4g this am), check again this PM\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6, given HCT , likely need blood this pm.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 336013,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n EKG - At 12:02 PM\\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\\n Tolerated plasmaphoresis yesterday.\\n Continues net diuresis, tolerated well.\\n No further hemoptysis.\\n Up in chair, excellent spirits. Appropriate. Joking with family.\\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 Furosemide (Lasix) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, 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 10:38 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\\n HR: 114 (100 - 142) bpm\\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\\n RR: 21 (12 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 93.3 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,534 mL\\n 902 mL\\n PO:\\n 1,220 mL\\n 750 mL\\n TF:\\n IVF:\\n 314 mL\\n 152 mL\\n Blood products:\\n Total out:\\n 2,565 mL\\n 1,690 mL\\n Urine:\\n 2,565 mL\\n 1,690 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,031 mL\\n -788 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///32/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.2 g/dL\\n 200 K/uL\\n 92 mg/dL\\n 4.3 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 135 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 21.3 %\\n 8.4 K/uL\\n [image002.jpg]\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n 08:17 PM\\n 04:05 AM\\n WBC\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n 8.4\\n Hct\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n 25.1\\n 21.3\\n Plt\\n 185\\n 170\\n 200\\n 217\\n 200\\n Cr\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n 4.2\\n 4.3\\n Glucose\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n 208\\n 92\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\\n Assessment and Plan\\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\\n steroids, cytoxan. Complete Plasmaphoresis course.\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\\n oxygen requirement.\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\\n improvement. Monitor. No acute indication for dialysis.\\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\\n Monitor.\\n TACHYCARDIA -- improved. Monitor.\\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\\n Transfuse to Hct >21.\\n HYPERGLYCEMIA -- contributed by high dose steroids. Monitor, use\\n insullin to maintain <150.\\n ICU Care\\n Nutrition: PO\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335526,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding. Scheduled nebs given\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.,\\n continue with neb Rx, wean O2 as tolerated.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Renal parameters trending down\\n Action:\\n Diuresed this p.m with 20 lasix,\\n Response:\\n Good response to lasix, negative 770 by midnight\\n Plan:\\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335854,\n \"text\": \"Vasculitis\\n Assessment:\\n Tolerating pheresis. Hemodynamically stable.\\n Action:\\n Plasma pheresis this afternoon. Lopressor increased to 75mg d/t atrial\\n tachycardia. Hct 23. pedal edema slowly decreasing. Slept in naps. Ssi\\n for bs\\ns. mg+ 1.6 and given 2mg mg+ ivpb. Good appetite.\\n Response:\\n Continues to improve. Good response to lopressor.\\n Plan:\\n Need to check ionized ca+ at 20pm. Pt. has a ss for his ca+ doses.\\n Transfuse if hct drops below 21.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Able to tolerate np only.\\n Action:\\n Mask off. Presently on 5L np. . Non-productive cough. No hemoptysis. No\\n c/o sob.\\n Response:\\n Sats 98-100%.\\n Plan:\\n Continue to wean o2.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Renal failure improving.\\n Action:\\n Creat 4.4. k+ 3.7. /20mg lasix ivp ordered/given by night nurse. Urine\\n slightly pink-tinged this am, but not noted this pm. Patent dialysis\\n catheter with port.\\n Response:\\n Autodiuresing.\\n Plan:\\n Plan for 1L negative.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 335955,\n \"text\": \"Clinician: Attending\\n Critical Care\\n 42 yo woman paraplegic after MVA , recently discharged from\\n hospital after \\\"pneumonia\\\" noted by PCA to be lethargic at home, SaO2\\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\\n somewhat confused but conversant. Still somewhat lethargic. We are\\n continuing Narcan but would have some concern about methadone as\\n explanation for her lethargy as no change in methadone dose for 6 weeks\\n and not previously sedated by med. Would also have some concern about\\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\\n presentation. Not clear why she developed PNA. We are continuing O2,\\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\\n have PFTs before d/c.\\n Total time spent: 35 minutes\\n Patient is critically ill.\\n ------ Protected Section------\\n ------ Protected Section Error Entered By: , MD\\n on: 08:08 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335974,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Continues with same 02 requirement. EKG yesterday revealed aflutter\\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\\n 100s all night.\\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\\n overnight.\\n Followed by renal and rheum.\\n EKG - At 12:02 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:25 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: 36.6\\nC (97.8\\n HR: 106 (100 - 142) bpm\\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\\n RR: 12 (12 - 26) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 93.3 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,530 mL\\n 600 mL\\n PO:\\n 1,220 mL\\n 500 mL\\n TF:\\n IVF:\\n 310 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 2,565 mL\\n 1,200 mL\\n Urine:\\n 2,565 mL\\n 1,200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,036 mL\\n -600 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 90%\\n ABG: ///32/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 200 K/uL\\n 7.2 g/dL\\n 92 mg/dL\\n 4.3 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 135 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 21.3 %\\n 8.4 K/uL\\n [image002.jpg]\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n 08:17 PM\\n 04:05 AM\\n WBC\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n 8.4\\n Hct\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n 25.1\\n 21.3\\n Plt\\n 185\\n 170\\n 200\\n 217\\n 200\\n Cr\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n 4.2\\n 4.3\\n Glucose\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n 208\\n 92\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Has been stable on 6L NC. Most likely\\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\\n shows interval improvement, patient appears to be responding to\\n diuresis as well.\\n - Wean 02 to keep sat >90%.\\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\\n hemoorhave given improving respiratory status and no hemoptysis.\\n Probably due to plasmapheresis and fluid shifting. His respiratory\\n status may be marginally helped by an increased HCT, but will check pm\\n HCT and transfuse if <21.\\n -Continue nystatin mouthwash for + sputum given his high dose\\n steroids. Day \\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\\n - CXR daily\\n -Plasmapheresis, dose 5/7 yesterday, then tomorrow and Friday.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n - f/u Rheum recs\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine continues to trend down, 4.3 this morning, BUN is\\n also finally down to 135, and he has maintained good urine output. As\\n a note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,we have been diuresing him well, with ?\\n liters off in the past 5 days. We will continue to diurese with goal\\n -500cc to -1L, using Lasix 20 IV prn.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A\\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\\n one more day.\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Received 4gIV overnight, will re-check PM ionized Calcium and replete\\n as needed. On days when he has pheresis, ionized CA needs to be drawn\\n 4 hours after the end of pheresis to be accurate.\\n -on SS replacement.\\n -EKGs have been unchanged.\\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\\n stable. ECHO showed mild LV septal , 45-50%. Possibly\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n -Increased lopressor to 75mg po tid yesterday. Will continue to\\n monitor on tele. If needed, could start a second rate controlling\\n .\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n HCT have been variable over the weekend despite no transfusion.\\n Variation may be due to lab variability, or to fluid shifts with\\n plasmapheresis. Will monitor as long as he is hemodynamically stable.\\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\\n unit if <21.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n #Hyperglycemia- non-diabetic, likely high dose steroids.\\n -SSI plus standing 3units, well controlled.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n #Dispo: to floor if it is possible to do pheresis outside of the ICU.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335016,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\\n Continued to desat into the 80s because his mask falls off, but remains\\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\\n liters. Urine output before midnight=300cc/hr and after MN, continued\\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\\n sent yesterday.\\n HCT remained stable, repleted lytes\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 92 (76 - 130) bpm\\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\\n RR: 26 (12 - 27) insp/min\\n SpO2: 89%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 70 mL\\n PO:\\n 290 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 70 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 1,900 mL\\n Urine:\\n 3,010 mL\\n 1,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -1,830 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 89%\\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 185 K/uL\\n 7.3 g/dL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \\n C-ANCA vasculitis. This morning, he breathing more easily, with stable\\n lung exam though his CXR looks unchanged. This is likely due to\\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\\n 2+ budding yeast on sputum, without signs of candidiasis on\\n oropharyngeal exam.\\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\\n urine output and restart IVF if necessary. We will balance maintaining\\n urine output >100/hr for bladder protection with not giving too much\\n Lasix due to renal failure.\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n -Start nystatin mouthwash\\n -Send blood cultures for fungus (though highly unlikely given pt. is\\n afebrile, stable, but he is on high dose immunosuppression)\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - Given hemoptysis and drop in crit, some concern for pulmonary\\n bleeding, though respiratory status improving.\\n - HCTq8h to monitor for alveolar bleeding.\\n - Will collect sputum to determine whether hemoptysis is tinged, bright\\n red or just pink fronthy.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN , some wheezing on exam today\\n - CXR daily\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 4/7 today, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\\n mesna for cystitis prophylaxis\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n ok. Urine is less pink that previously. Renal function has been\\n steadily improving, likely as a response to Wegeners treatment. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - treating underlying cause (likely Wegener's).\\n - Foley in place , strict I&O, q8 lytes.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n No baseline Crit available.\\n -transfuse one unit this morning as HCT is trending down (21.6)\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334319,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx., undervent renal biopsy, awaiting results.\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\\n non productive cough remains, LS diminished at bases\\n Action:\\n Continue with mepron\\n Response:\\n VSS stable, no resp distress noted\\n Plan:\\n Continue to monitor VSS, sats,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335938,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Continues with same 02 requirement. EKG yesterday revealed aflutter\\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\\n 100s all night.\\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\\n overnight.\\n Followed by renal and rheum.\\n EKG - At 12:02 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:25 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: 36.6\\nC (97.8\\n HR: 106 (100 - 142) bpm\\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\\n RR: 12 (12 - 26) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 93.3 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,530 mL\\n 600 mL\\n PO:\\n 1,220 mL\\n 500 mL\\n TF:\\n IVF:\\n 310 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 2,565 mL\\n 1,200 mL\\n Urine:\\n 2,565 mL\\n 1,200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,036 mL\\n -600 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 90%\\n ABG: ///32/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 200 K/uL\\n 7.2 g/dL\\n 92 mg/dL\\n 4.3 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 135 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 21.3 %\\n 8.4 K/uL\\n [image002.jpg]\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n 08:17 PM\\n 04:05 AM\\n WBC\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n 8.4\\n Hct\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n 25.1\\n 21.3\\n Plt\\n 185\\n 170\\n 200\\n 217\\n 200\\n Cr\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n 4.2\\n 4.3\\n Glucose\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n 208\\n 92\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\\n shows interval improvement, patient appears to be responding to\\n diuresis as well.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\\n hemoorhave given improving respiratory status and no hemoptysis.\\n Probably due to plasmapheresis, given with 50% albumin yesterday.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\\n - CXR daily\\n -Plasmapheresis, dose 5/7 yesterday, then W/F.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n - f/u Rheum recs\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine up to 4.3 from 4.0 yesterday, BUN down to 135, good\\n urine output. As a note, plasmapheresis in cases of severe Wegeners\\n has been shown to improve kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,we have been diuresing him well, with ?\\n liters off in the past 5 days. His creatinine bumped a little bit this\\n morning, probably we are at his dry weight and can back off on\\n diuresis.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A\\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\\n one more day.\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\\n stable. ECHO showed mild LV septal , 45-50%. Possibly\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n -Increased lopressor to 75mg po tid yesterday.\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n HCT have been low in the morning and higher in the afternoon for the\\n past 2 days despite no transfusion and no plasmapheresis. Variation\\n may be due to lab variability, fluid shifts during the day, or another\\n unknown cause. Will monitor as long as he is hemodynamically stable.\\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\\n unit.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n #Hyperglycemia- non-diabetic, likely high dose steroids.\\n -SSI plus standing 3units, well controlled.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333940,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt remains in aflutter at a rate of 70s-low 100s\\n Action:\\n Conts on lopressor 50mg TID\\n Response:\\n Tolerating the lopressor, he did have short periods of a HR in the\\n 1teens this afternoon\\n Plan:\\n Cont with the lopressor, follow VS\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Creat was 8.6 this morning and 8.0 this afternoon, u/o has been\\n 40-50cc/hr\\n Action:\\n Pt had a renal biopsy this morning under US guidance, given 2 bagsof\\n FFP for this, needed Ca gluc this evening as well. He is receiving D5W\\n 100cc/hr for 1 liter for a Na of 150\\n Response:\\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\\n Plan:\\n Follow HCT\\n due tonight, VS, renal bx results, no immediate plans for\\n dialysis, follow labs, to receive cytoxan again tonight, 7 \\n resourse nurse is aware and some will be down to give this\\n he needs\\n mesna before and after\\n please see \\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\\n has not been coughing up any blood\\n Action:\\n He is on scoop mask at 60-70% and this brings his 02 up to the mid 90s\\n Response:\\n Conts to require a high FI02\\n Plan:\\n Follow SATs cont to try to wean his FI02\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335723,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Continued to desat when facemask off. otherwise, stable.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 117 (99 - 137) bpm\\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\\n RR: 24 (11 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,510 mL\\n 304 mL\\n PO:\\n 1,340 mL\\n 240 mL\\n TF:\\n IVF:\\n 170 mL\\n 64 mL\\n Blood products:\\n Total out:\\n 2,800 mL\\n 300 mL\\n Urine:\\n 2,800 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,290 mL\\n 4 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 217 K/uL\\n 7.8 g/dL\\n 88 mg/dL\\n 4.4 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 145 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 23.0 %\\n 9.8 K/uL\\n [image002.jpg]\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n Hct\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n Plt\\n 00\\n 217\\n Cr\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n Glucose\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT down today, unlikely due to alveolar imprroving respiratory\\n status, no hemoptysis. Continue to monitor\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Albuterol nebs PRN\\n - CXR daily\\n -Plasmapheresis, dose 5/7 today, then W/F.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. As a note,\\n plasmapheresis in cases of severe Wegeners has been shown to improve\\n kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Asymptomatic, rate increases when active/talking,\\n normal when sleeping. ECHO showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n He received 1 unit yesterday and bumped appropriately.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 335851,\n \"text\": \"Clinician: Attending\\n Critical Care\\n 42 yo woman paraplegic after MVA , recently discharged from\\n hospital after \\\"pneumonia\\\" noted by PCA to be lethargic at home, SaO2\\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\\n somewhat confused but conversant. Still somewhat lethargic. We are\\n continuing Narcan but would have some concern about methadone as\\n explanation for her lethargy as no change in methadone dose for 6 weeks\\n and not previously sedated by med. Would also have some concern about\\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\\n presentation. Not clear why she developed PNA. We are continuing O2,\\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\\n have PFTs before d/c.\\n Total time spent: 35 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335154,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\\n continues to desat when off O2 ( removes O2 while sleeping on and off)\\n Action:\\n Scheduled neb given , nystatin swish given for yeast in sputum.\\n Response:\\n Good response to neb , Slept well with ambien.\\n Plan:\\n Continue to monitor VSS and follow sats closely.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\\n Action:\\n Followed up with labs overnight.\\n Response:\\n U/O wnl, continued to monitor renal parameters\\n Plan:\\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334317,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\\n non productive cough remains, LS diminished at bases\\n Action:\\n Continue with mepron\\n Response:\\n VSS stable, no resp distress noted\\n Plan:\\n Continue to monitor VSS, sats,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334996,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia.\\n HPI:\\n 24 Hour Events:\\n Experienced some hemoptysis yesterday PM.\\n Appears much more comfortable today, less dyspneic.\\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 Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\\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, Hematuria\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\\n RR: 26 (18 - 27) insp/min\\n SpO2: 88%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 238 mL\\n PO:\\n 290 mL\\n 120 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 118 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 2,900 mL\\n Urine:\\n 3,010 mL\\n 2,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -2,663 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 88%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\\n No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\\n Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.3 g/dL\\n 185 K/uL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Wegener's Granulomatosis\\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\\n plasmaphoresis\\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\\n falling, urine output improving, responding to diuretics.\\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\\n escalation. Consider dDAVP. need dialysis if continues to\\n NUTRITIONAL SUPPORT -- PO\\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\\n suppression. Transfuse to Hct >25\\n FLUID -- continue net negative. Monitor I/O.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335972,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n EKG - At 12:02 PM\\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\\n Tolerated plasmaphoresis yesterday.\\n Continues net diuresis, tolerated well.\\n No further hemoptysis.\\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 Furosemide (Lasix) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, 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 10:38 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\\n HR: 114 (100 - 142) bpm\\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\\n RR: 21 (12 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 93.3 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,534 mL\\n 902 mL\\n PO:\\n 1,220 mL\\n 750 mL\\n TF:\\n IVF:\\n 314 mL\\n 152 mL\\n Blood products:\\n Total out:\\n 2,565 mL\\n 1,690 mL\\n Urine:\\n 2,565 mL\\n 1,690 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,031 mL\\n -788 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///32/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.2 g/dL\\n 200 K/uL\\n 92 mg/dL\\n 4.3 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 135 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 21.3 %\\n 8.4 K/uL\\n [image002.jpg]\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n 08:17 PM\\n 04:05 AM\\n WBC\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n 8.4\\n Hct\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n 25.1\\n 21.3\\n Plt\\n 185\\n 170\\n 200\\n 217\\n 200\\n Cr\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n 4.2\\n 4.3\\n Glucose\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n 208\\n 92\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\\n Assessment and Plan\\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\\n steroids, cytoxan. Complete Plasmaphoresis course.\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\\n oxygen requirement.\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\\n improvement. Monitor. No acute indication for dialysis.\\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\\n Monitor.\\n TACHYCARDIA -- improved. Monitor.\\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\\n Transfuse to Hct >21.\\n HYPERGLYCEMIA -- contributed by high dose steroids.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333556,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics: None\\n Infusions: None\\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: None\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula 4L\\n SpO2: 90%\\n Physical Examination\\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\\n tachypneic, NAD\\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\\n malar area of face\\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\\n lung fields posteriorly\\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\\n (improved today, less erythematous), no cyanosis/ clubbing\\n Labs / Radiology\\n 213 mg/dL\\n 147 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 107 mEq/L\\n 5.5 mEq/L\\n 144 mEq/L\\n 7.4 K/uL\\n 9.0 g/dL\\n 26.6 %\\n 513 K/uL\\n [image002.jpg]\\n Anion Gap = 20\\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\\n symmetrical alveolar opacities, almost in all lung fields, consistent\\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\\n consistent with old granulomatous disease\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL****\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n .\\n Plan:\\n .\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - Continue supplemental O2 PRN\\n - Albuterol nebs PRN\\n - CXR\\ns as needed\\n - Type and screen, cross match x 2 units; threshold to transfuse hct\\n <21, unless clinically unstable\\n - Blood consent\\n - Consult Renal and Rheum in a.m.\\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\\n get renal biopsy\\n - Will continue Solumedrol 1g IV daily\\n - F/u on Renal serology and BAL results from OSH\\n - Will check Crits q8 for now\\n .\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\\n Denies epistaxis. However, apart from pulmonary association, ddx for\\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\\n ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's. Also consider DIC.\\n - F/u on u/a, urine lytes, urine sediment\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Consult Renal here\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Will check q8 lytes for now\\n - Start Sevelemer in a.m. with meals for elevated Phos.\\n .\\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\\n Can be secondary to underlying structural heart disease. Also may be\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n - Check TSH\\n - Surface ECHO in a.m.\\n - Will start Lopressor 12.5mg PO daily for rate control.\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check Crits q8\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\\n respiratory status worsens anticipating intubation. Will replete lytes\\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\\n .\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333557,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics: None\\n Infusions: None\\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: None\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula 4L\\n SpO2: 90%\\n Physical Examination\\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\\n tachypneic, NAD\\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\\n malar area of face\\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\\n lung fields posteriorly\\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\\n (improved today, less erythematous), no cyanosis/ clubbing\\n Labs / Radiology\\n 213 mg/dL\\n 147 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 107 mEq/L\\n 5.5 mEq/L\\n 144 mEq/L\\n 7.4 K/uL\\n 9.0 g/dL\\n 26.6 %\\n 513 K/uL\\n [image002.jpg]\\n Anion Gap = 20\\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\\n symmetrical alveolar opacities, almost in all lung fields, consistent\\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\\n consistent with old granulomatous disease\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL****\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n .\\n Plan:\\n .\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - Continue supplemental O2 PRN\\n - Albuterol nebs PRN\\n - CXR\\ns as needed\\n - Type and screen, cross match x 2 units; threshold to transfuse hct\\n <21, unless clinically unstable\\n - Blood consent\\n - Consult Renal and Rheum in a.m.\\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\\n get renal biopsy\\n - Will continue Solumedrol 1g IV daily\\n - F/u on Renal serology and BAL results from OSH\\n - Will check Crits q8 for now\\n .\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\\n Denies epistaxis. However, apart from pulmonary association, ddx for\\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\\n ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's. Also consider DIC.\\n - F/u on u/a, urine lytes, urine sediment\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Consult Renal here\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Will check q8 lytes for now\\n - Start Sevelemer in a.m. with meals for elevated Phos.\\n .\\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\\n Can be secondary to underlying structural heart disease. Also may be\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n - F/u on TSH\\n - Surface ECHO in a.m. today\\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check Crits q8\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\\n respiratory status worsens anticipating intubation. Will replete lytes\\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\\n .\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-22 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1030091,\n \"text\": \" 5:49 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: interval change, worsening consolidations on CXR, compare w\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegner's granulomatosis, pulm hemorrhage, ? aspergillous\\n infection, on vori, w worsening dyspnea. On CXR consolidation in R mid lung\\n appears worse, needs repeat NON-CONTRAST CHEST CT (renal failure) to evaluate\\n the densities further\\n REASON FOR THIS EXAMINATION:\\n interval change, worsening consolidations on CXR, compare w previous Chest CT\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n WET READ: ARHb MON 7:50 PM\\n Widespread pulmonary abnormalities, including consolidation, ground glass\\n change, and nodularity, persist and have worsened at the right lung base.\\n Differential continues to include vasculitis/hemorrhage and infection,\\n including Aspergillus. Persistent right apical lung nodules. Increased small\\n to moderate right pleural effusion. Unchanged left effusion. No significant\\n change in mediastinl/hilar adenopathy.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient's Wegener's granulomatosis,\\n pulmonary hemorrhage and suspected aspergillus infection with worsening\\n dyspnea.\\n\\n COMPARISON: Chest CT from .\\n\\n TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to\\n upper abdomen with subsequent 1.25 and 5-mm collimation. Axial images\\n reviewed in conjunction with coronal and sagittal reformats.\\n\\n FINDINGS:\\n\\n Multifocal mediastinal lymphadenopathy is unchanged with enlarged nodes\\n present in multiple compartments. Within the left mediastinal lymph nodes\\n measure up to 1.4 cm at the shortest access, within the left compartment is up\\n to 1.5 cm. The additional conglomerate of the lymph nodes in the subcarinal\\n lesion is up to 1.8 cm in diameter so grossly with no significant change since\\n the prior study. The bilateral hila are diffusely enlarged with most likely\\n present lymph nodes that are difficult to evaluate without injection of\\n contrast. Calcifications in the right hilus suggest prior granulomatous\\n exposure. There is most likely increase in the size of the right hilar lymph\\n node, 2:32 currently 1.3 cm in diameter compared to 7 mm on the prior study.\\n The patient is anemic giving the high density of the myocardium compared to\\n the blood in the . Diffuse coronary calcifications are seen. There\\n is no pericardial effusion. Bilateral pleural effusions are present, still\\n small but slightly increased compared to the prior study.\\n\\n The imaged portion of the upper abdomen is grossly unremarkable with no\\n appreciable change since the prior study.\\n (Over)\\n\\n 5:49 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: interval change, worsening consolidations on CXR, compare w\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n The airways are patent to the level of lobar and segmental bronchi bilaterally\\n except for right lower lobe with occlusion of the apical segment is noted,\\n most liklely due to secretions. Widespread pulmonary abnormality has\\n slightly progressed since the recent study including areas of consolidation,\\n ground- glass opacities and poorly defined nodules. The consolidations and\\n ground glass are most pronounced in the mid and lower lungs, namely in the\\n posterior segment of left upper lobe, lingula, and both lower lobes, right\\n more than left. The previously demonstrated well defined perifissural nodule\\n in the right lower lobe anteriorly is unchanged. Extensive bronchial impaction\\n is present within the lower lobe bronchi. Marked upper lobe predominantly\\n paraseptal and centrilobular emphysema is unchanged. Within the right apex, a\\n 2 cm nodular opacity is identified containing calcification. Similar size\\n spiculated opacity is seen in the left apex with less prominent spiculated\\n appearance.\\n\\n No suspicious lytic or blastic lesions were demonstrated in the imaged portion\\n of the skeleton.\\n\\n IMPRESSION:\\n\\n 1. Widespread pulmonary abnormalities including consolidation, ground glass\\n in poorly defined lung nodules, slightly worse, but no new areas involved. As\\n previously mentioned vasculitis and associated pulmonary hemorrhage are the\\n primary diagnosis. Coexisting infection such as bacterial infection or\\n aspergillosis cannot be excluded.\\n\\n 2. Spiculated right apical lesion raise concern for possible primary lung\\n cancer especially on a patient with underlying emphysema. It is still\\n potentially can be related to diffuse lung abnormalities thus three months\\n followup chest CT is highly recommended.\\n\\n 3. Extensive intrathoracic lymphadenopathy: related to vasculitis and/or\\n reactive to infection.\\n\\n 4. Slightly increased but still small bilateral pleural effusion in minimal\\n amount of ascites.\\n\\n 5. Evidence of anemia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-22 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1030021,\n \"text\": \", V. MED 11R 9:37 PM\\n CHEST (PA & LAT) Clip # \\n Reason: worsening dyspnea, eval for interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\\n interval change\\n REASON FOR THIS EXAMINATION:\\n worsening dyspnea, eval for interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Dense consolidation right mid and left mid lung zone. Improved aeration in\\n lower lung zones.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-22 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1030020,\n \"text\": \" 9:37 PM\\n CHEST (PA & LAT) Clip # \\n Reason: worsening dyspnea, eval for interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\\n interval change\\n REASON FOR THIS EXAMINATION:\\n worsening dyspnea, eval for interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 3:42 PM\\n Dense consolidation right mid and left mid lung zone. Improved aeration in\\n lower lung zones.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PA AND LATERAL\\n\\n COMPARISON: .\\n\\n HISTORY: Wegener's granulomatosis and aspergillosis.\\n\\n FINDINGS: There has been interval increase in dense consolidation in the\\n right mid lung zone and left mid lung zone. The lung bases appear to have\\n improved in aeration. Small bilateral pleural effusions are unchanged.\\n Emphysematous changes particularly in the apices are noted.\\n\\n IMPRESSION: More dense consolidations seen in the right mid lung and left mid\\n lung zones. Improved aeration in the bilateral lower lung zones.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026997,\n \"text\": \" 6:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary renal syndrome\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:49 AM\\n PFI: Slight interval improvement in the left lung consolidations.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Interval change in a patient with renal failure.\\n\\n Portable AP chest radiograph was compared to the prior studies obtained on\\n .\\n\\n There is overall slight improvement in the opacities of the left lung with no\\n change in the right lower lung consolidation with again demonstrated more\\n discrete nodular opacity. There is no pleural effusion. For precise\\n characterization of the finding, further evaluation with chest CT might be\\n appropriate as the differential diagnosis is broad, including widespread\\n infection, hemorrhage or asymmetric edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026998,\n \"text\": \", M. MED 6:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary renal syndrome\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Slight interval improvement in the left lung consolidations.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1026946,\n \"text\": \" 6:32 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Please assess dialysis line placement.\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with IJ dialysis line\\n REASON FOR THIS EXAMINATION:\\n Please assess dialysis line placement.\\n ______________________________________________________________________________\\n WET READ: SBNa SUN 7:06 PM\\n Right IJ line terminates in upper SVC. Unchanged appearance of b/l diffuse\\n opacites. No ptx.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the central venous catheter placement.\\n\\n Portable AP chest was compared to .\\n\\n The right internal jugular line catheter was inserted with its tip projecting\\n at the level of the junction of brachiocephalic vein and superior SVC. The\\n heart size is moderately enlarged but stable. There is also no change in the\\n mediastinal contour. There is overall no change in the extensive parenchymal\\n consolidation compared to the prior study. The differential diagnosis might\\n include extensive infection, pulmonary edema in the presence of underlying\\n emphysema or pulmonary hemorrhage, clinical correlation in comparison to the\\n prior studies is required. Note is made of a more discrete rounded density in\\n the right lower lung unchanged since the prior study, which might represent a\\n part of a similar process or additional underlying abnormality. Scarring in\\n the upper lung is unchanged. No appreciable pleural effusion is demonstrated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028387,\n \"text\": \" 5:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval pulm change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's.\\n REASON FOR THIS EXAMINATION:\\n interval pulm change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, PORTABLE AP:\\n\\n COMPARISON: One day prior.\\n\\n HISTORY: 50-year-old man with Wegner's, evaluate for any change.\\n\\n FINDINGS: There is slightly improved aeration of both lungs. Again seen is\\n diffuse areas of consolidation, primarily in the right mid lung zone and left\\n mid and lower lung zone. No new consolidations are identified. Biapical\\n scarring is unchanged. Cardiomediastinal and hilar contours are unremarkable.\\n A right-sided internal jugular catheter sheath is seen terminating in the\\n upper SVC. There is no evidence of pneumothorax.\\n\\n IMPRESSION: Slightly improved aeration of both lungs. Persistent opacities\\n seen primarily in the right mid and left mid to lower lung zones.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-17 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1028954,\n \"text\": \" 4:27 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: eval of this currently immunocompromised pt with rare asperg\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\\n noted sputum cx noting rare aspergillis\\n REASON FOR THIS EXAMINATION:\\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\\n sx\\n CONTRAINDICATIONS for IV CONTRAST:\\n ARF\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB WED 7:17 PM\\n Multifocal consolidation, ground-glass attenuation, and poorly defined\\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\\n lymphadenopathy, and a small amount of ascites.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST, \\n\\n Comparison chest radiographs dating between and .\\n\\n INDICATION: Wegener's granulomatosis, pulmonary hemorrhage, and Aspergillus\\n on recent sputum culture.\\n\\n TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was\\n performed without intravenous or oral contrast. Images are presented for\\n display in the axial plane at 5-mm and 1.25-mm collimation. A series of\\n multiplanar reformation images were also submitted for review.\\n\\n FINDINGS: Widespread pulmonary abnormalities are present, including areas of\\n consolidation, ground-glass attenuation, and poorly defined nodules. The\\n areas of consolidation and ground glass are most pronounced in the mid and\\n lower lungs. In addition to poorly defined bronchovascular nodules, one well-\\n defined perifissural nodule is identified in the right lower lobe anteriorly\\n measuring 8 mm (227, 4A). Extensive bronchial impaction is present within the\\n lower lobe bronchi, but the more central airways appear patent. Marked upper\\n lobe predominant paraseptal and centrilobular emphysema are present. Within\\n the right apex, a spiculated 2.1-cm diameter nodular opacity is identified\\n (68, 4A) with an eccentric granuloma. Additional similar-sized spiculated\\n opacity is identified higher in the right apex (52, 4A).\\n\\n Multifocal mediastinal lymphadenopathy is present, with enlarged nodes present\\n in multiple compartments. Within the left mediastinum, lymph nodes measure up\\n to 1.4 cm in short axis in the lower left paratracheal region and 1.5 cm in\\n the left prevascular area. Additional conglomerate lymph nodes are seen in\\n the subcarinal region measuring up to approximately 17 mm in short axis. There\\n are likely bilateral hilar nodes present, difficult to measure in the absence\\n (Over)\\n\\n 4:27 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: eval of this currently immunocompromised pt with rare asperg\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n of intravenous contrast. A few small calcified mediastinal and hilar nodes are\\n also evident. No pericardial effusion is identified. Coronary artery\\n calcifications are evident. Small dependent simple pleural effusions are\\n present bilaterally.\\n\\n Exam was not tailored to evaluate the subdiaphragmatic region, but note is\\n made of a small amount of ascites as well as nonspecific mesenteric stranding.\\n Liver appears relatively hyperdense, possibly due to previous transfusions or\\n amiodarone therapy.\\n\\n No suspicious lytic or blastic skeletal lesions are identified.\\n\\n IMPRESSION:\\n 1. Widespread pulmonary abnormalities including consolidation, ground-glass,\\n and poorly defined lung nodules. These could be due to the patient's known\\n vasculitis with associated pulmonary hemorrhage, but coexisting Aspergillus\\n infection is likely given the reported sputum culture results.\\n 2. Spiculated right apical nodules raise the concern for possible primary\\n lung cancer in this patient with underlying emphysema, but could potentially\\n be related to the same process as the diffuse lung abnormalities. 3-month\\n chest CT followup is suggested following appropriate therapy to ensure\\n resolution.\\n 3. Extensive intrathoracic lymphadenopathy, which may be due to Wegener's\\n and/or reactive nodes from infection.\\n 4. Small bilateral pleural effusions and a small amount of ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-17 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1028955,\n \"text\": \", MED 11R 4:27 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: eval of this currently immunocompromised pt with rare asperg\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\\n noted sputum cx noting rare aspergillis\\n REASON FOR THIS EXAMINATION:\\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\\n sx\\n CONTRAINDICATIONS for IV CONTRAST:\\n ARF\\n ______________________________________________________________________________\\n PFI REPORT\\n Multifocal consolidation, ground-glass attenuation, and poorly defined\\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\\n lymphadenopathy, and a small amount of ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027858,\n \"text\": \" 3:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for worsening infiltrates\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegeners and pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Eval for worsening infiltrates\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 10:07 PM\\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\\n are unchanged. There is no residual pulmonary edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PORTABLE AP\\n\\n COMMENTS: 50-year-old man with Wegener and pulmonary hemorrhage.\\n\\n Since yesterday, bilateral dense consolidation in mid and lower lung zones are\\n unchanged. There is no residual pulmonary edema. Pleural effusions, if any,\\n are small. Heart size is top normal and unchanged. Right internal jugular\\n sheath ends in right brachiocephalic vein.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027200,\n \"text\": \" 4:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: looking for interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with hypoxia\\n REASON FOR THIS EXAMINATION:\\n looking for interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 9:50 AM\\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\\n is unchanged. Right internal jugular is in good position. Left small pleural\\n effusion is new with associated atelectasis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PORTABLE AP\\n\\n COMMENTS: 60-year-old man with hypoxia. Interval change.\\n\\n Since , bilateral alveolar opacity with slightly nodular appearance\\n is unchanged in this patient with pulmonary renal syndrome.\\n\\n Small left pleural effusion is new associated with new left lower lobe\\n atelectasis. Right internal jugular catheter is in good position.\\n\\n Findings can be consistent with multifocal infection, bilateral hemorrhage or\\n much less likely asymmetric pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028071,\n \"text\": \" 4:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for infiltrates, effusions, edema\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with wegener's and cough\\n REASON FOR THIS EXAMINATION:\\n evaluate for infiltrates, effusions, edema\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): NLHa SAT 1:28 PM\\n Bilateral opacities unchanged. Right central venous catheter unchanged.\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Portable chest x-ray performed at 0515 hours.\\n\\n Comparison is . There are bilateral opacities involving both lower and\\n mid lung fields. The opacity on the left extends to involve the upper lung\\n field. Compared to prior exam, there is increasing density in the right\\n base. The cardiac silhouette is mildly enlarged.\\n\\n IMPRESSION: Increasing density in the right base.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027201,\n \"text\": \", M. MED 4:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: looking for interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with hypoxia\\n REASON FOR THIS EXAMINATION:\\n looking for interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\\n is unchanged. Right internal jugular is in good position. Left small pleural\\n effusion is new with associated atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027613,\n \"text\": \" 5:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for new infiltrate\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Eval for new infiltrate\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:10 AM\\n PFI: No change in the bilateral severe predominantly lower lobe opacification\\n compared to the prior study.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient with pulmonary hemorrhage.\\n\\n Portable AP chest radiograph was compared to obtained at\\n 05:40.\\n\\n In the interim, there is overall no significant change in the bilateral severe\\n predominantly lower lobe consolidations with some involvement of the upper\\n lungs, left more than right, consistent with diffuse parenchymal hemorrhage.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027401,\n \"text\": \", MED 5:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\\n remains normal. Pleural effusion, if any, is small. Right jugular line is\\n central. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028562,\n \"text\": \" 5:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegeners\\n REASON FOR THIS EXAMINATION:\\n eval interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:21 AM\\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\\n bilateral consolidations with slight decrease in the right mid lung but are\\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\\n lesions on the right could be present but are hard to confirm due to\\n underlying diffuse consolidation. Chest CT could further characterize lung\\n opacities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, PORTABLE AP\\n\\n REASON FOR EXAM: 60-year-old man with Wegener. Evaluate for interval change.\\n\\n Since yesterday, right internal jugular catheter still ends in upper SVC.\\n Diffuse bilateral consolidation slightly decreased in the right mid lung but\\n are unchanged on the left. Consolidation has a more heterogeneous appearance,\\n could be due to underlying cavitary lesions hard to better define. Chest CT\\n could further characterize lung opacities if clinically warranted.\\n\\n Biapical scarring is unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028563,\n \"text\": \", MED 5:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegeners\\n REASON FOR THIS EXAMINATION:\\n eval interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\\n bilateral consolidations with slight decrease in the right mid lung but are\\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\\n lesions on the right could be present but are hard to confirm due to\\n underlying diffuse consolidation. Chest CT could further characterize lung\\n opacities.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"BX-NEEDLE KIDNEY BY NEPHROLOGIST\",\n \"row_id\": 1027056,\n \"text\": \" 10:49 AM\\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \\n Reason: ? Gbm disease versus wegeners' granulomatosis\\n Admitting Diagnosis: VASCULITIS\\n ********************************* CPT Codes ********************************\\n * BX-NEEDLE KIDNEY BY NEPHROLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with glomerulonephritis and pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n ? Gbm disease versus wegeners' granulomatosis\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Glomerulonephritis and pulmonary hemorrhage. Questionable GBM\\n disease vs. Wegener's.\\n\\n FINDINGS: Ultrasound guidance was provided for renal biopsy performed by\\n nephrology team. Five core biopsy samples were obtained from the lower pole\\n of the left kidney. The patient tolerated the procedure well. No immediate\\n complications occurred.\\n\\n IMPRESSION: Successful ultrasound-guided biopsy performed by the nephrology\\n team.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-17 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 1028947,\n \"text\": \" 4:15 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: eval sinusus (asking for non-contrast study with ARF as belo\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\\n noted sputum cx noting rare aspergillis\\n REASON FOR THIS EXAMINATION:\\n eval sinusus (asking for non-contrast study with ARF as below)\\n CONTRAINDICATIONS for IV CONTRAST:\\n acute renal failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 60-year-old male with newly-diagnosed Wegener's\\n granulomatosis with acute renal failure, pulmonary hemorrhage with sputum\\n culture noting \\\"rare aspergillus.\\\"\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the sinuses. Coronal\\n reformatted images were obtained.\\n\\n FINDINGS: Extensive sinus disease is present with air-fluid levels in both\\n maxillary sinuses. The left maxillary sinus is nearly-completely opacified and\\n containing hyperdense secretions. The right maxillary, sphenoid and frontal\\n sinuses show circumferential mucosal thickening. Dense secretions are also\\n identified in the right nasal cavity.\\n\\n There is diffuse bony remodeling and permeation involving the ethmoid septae,\\n maxillary sinus medial walls and ostiomeatal complexes, and the nasal\\n turbinates, which in the absence of history or prior surgery, likely relate to\\n Wegener's granulomatosis. However, the nasal septum and hard palate remain\\n intact. There is no evidence of intracranial or orbital involvement. The\\n mastoid air cells remain normally aerated.\\n\\n IMPRESSION:\\n 1. Extensive pansinus soft tissue disease, most severely affecting the left\\n maxillary sinus. Note is made of dense secretions in the left maxillary sinus\\n and right nasal cavity which may simply represent chronically-inspissated\\n secretions; however, fungal colonization (ie. with Aspergillus spp. and their\\n metabolic byproducts) can have a similar appearance.\\n 2. Extensive bony remodeling and permeation involving the sinuses and nasal\\n turbinates which in the absence of prior surgery can be seen with Wegener's\\n granulomatosis. The nasal septum remains intact.\\n\\n These findings were discussed with Dr. (primary hospitalist) at the\\n time of interpretation, by Dr. . Evaluation by ENT Service, with\\n possible diagnostic aspiration of the left maxillary contents, may be\\n warranted.\\n\\n (Over)\\n\\n 4:15 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: eval sinusus (asking for non-contrast study with ARF as belo\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028225,\n \"text\": \", MED 4:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval pulm change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's\\n REASON FOR THIS EXAMINATION:\\n interval pulm change\\n ______________________________________________________________________________\\n PFI REPORT\\n Improved aeration of left mid lung zone.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 1027059,\n \"text\": \" 10:42 AM\\n RENAL U.S. Clip # \\n Reason: WITH GLOMERULONEPHRITIS\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Glomerulonephritis.\\n\\n COMPARISON: None.\\n\\n FINDINGS: The right kidney measures 12.4 cm and the left 12.8 cm. The renal\\n parenchymal echogenicity is increased, bilaterally. There are no renal\\n calculi or hydronephrosis. Small amount of fluid is seen adjacent to the\\n right kidney. The bladder is not distended with a Foley catheter within,\\n cannot be assessed accurately.\\n\\n IMPRESSION: Bilateral increased renal parenchymal echogenicity consistent\\n with medical renal disease. Small amount of right perinephric free fluid.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027400,\n \"text\": \" 5:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 3:06 PM\\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\\n remains normal. Pleural effusion, if any, is small. Right jugular line is\\n central. No pneumothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 5:40 A.M. ON \\n\\n HISTORY: Pulmonary hemorrhage.\\n\\n IMPRESSION: AP chest compared to through :\\n\\n Severe infiltrative pulmonary abnormality responsible for dense consolidation\\n in the lower mid and lower lung zones since has not improved and may\\n have worsened in the lung bases, now accompanied by progressive vascular\\n congestion in the upper lung suggesting volume overload also responsible for\\n mild increase in caliber of the azygos vein, although vascular engorgement is\\n undoubtedly exaggerated by supine positioning. Pleural effusions, if any, are\\n small. Heart size is top normal and unchanged. Right jugular introducer ends\\n at the thoracic inlet. No other invasive support devices.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026858,\n \"text\": \" 10:30 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please assess for evidence of infiltrate\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with evidence of diffuse alveolar hemorrhage on bronch and\\n renal failure\\n REASON FOR THIS EXAMINATION:\\n please assess for evidence of infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Diffuse alveolar hemorrhage.\\n\\n FINDINGS: No previous images available. There is mild enlargement of the\\n cardiac silhouette. Diffuse bilateral asymmetric alveolar opacifications\\n involving almost all of both lungs. This would be consistent with diffuse\\n alveolar hemorrhage as clinically suspected. Fibrocalcific changes in the\\n apices are consistent with old granulomatous disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027859,\n \"text\": \", MED 3:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for worsening infiltrates\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegeners and pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Eval for worsening infiltrates\\n ______________________________________________________________________________\\n PFI REPORT\\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\\n are unchanged. There is no residual pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028072,\n \"text\": \", MED 4:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for infiltrates, effusions, edema\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with wegener's and cough\\n REASON FOR THIS EXAMINATION:\\n evaluate for infiltrates, effusions, edema\\n ______________________________________________________________________________\\n PFI REPORT\\n Bilateral opacities unchanged. Right central venous catheter unchanged.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 87723,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Right ventricular function. Valvular heart disease.\\nHeight: (in) 69\\nWeight (lb): 150\\nBSA (m2): 1.83 m2\\nBP (mm Hg): 112/56\\nHR (bpm): 78\\nStatus: Outpatient\\nDate/Time: at 11:48\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of\\nthe interatrial septum. No ASD by 2D or color Doppler.\\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\\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\\ninferoseptal - hypo; septal apex - hypo;\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\\nhypokinesis. Abnormal septal motion/position.\\n\\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\\nmitral valve chordae. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\\nDoppler. Left ventricular wall thicknesses and cavity size are normal. There\\nis mild regional left ventricular systolic dysfunction with septal\\nhypokinesis. The right ventricular cavity is mildly dilated with mild global\\nfree wall hypokinesis. There is abnormal septal motion/position. The aortic\\nroot is moderately dilated at the sinus level. The ascending aorta is mildly\\ndilated. The aortic valve leaflets (3) are mildly thickened but aortic\\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\\neffusion.\\n\\nIMPRESSION: Mild hypokinesis of the septum along with abnormal septal motion.\\nMildly dilated and hypokinetic right ventricle. The interventricular septal\\nmotion is abnormal and may be consistent with right ventricular volume\\noverload. Mild mitral and tricuspid regurgitation. Dilated aortic sinus and\\nascending aorta.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027614,\n \"text\": \", MED 5:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for new infiltrate\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Eval for new infiltrate\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: No change in the bilateral severe predominantly lower lobe opacification\\n compared to the prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028224,\n \"text\": \" 4:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval pulm change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's\\n REASON FOR THIS EXAMINATION:\\n interval pulm change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 9:18 AM\\n Improved aeration of left mid lung zone.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST AT 05:20\\n\\n INDICATION: Wegener's.\\n\\n COMPARISON: at 05:09\\n\\n FINDINGS:\\n\\n Compared to prior there is improved aeration of the left mid lung zone. The\\n remainder of the study is unchanged with continued evidence of previously seen\\n airspace disease. No PTX. Right CVL remains in place.\\n\\n IMPRESSION: Improved aeration of the left mid lung zone.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224051,\n \"text\": \"Atrial flutter with variable block. Non-specific repolarization abnormalities.\\nIntraventricular conduction delay of right bundle-branch block type. Compared\\nto the previous tracing of there is no significant difference.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224052,\n \"text\": \"Atrial flutter with rapid ventricular response. Right ventricular conduction\\ndelay. Compared to the previous tracing of no diagnostic interim\\nchange.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224053,\n \"text\": \"Atrial flutter\\nModest right ventricular conduction delay\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224054,\n \"text\": \"Atrial flutter. Modest right ventricular conduction delay. Since the previous\\ntracing of no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224055,\n \"text\": \"Atrial flutter. Modest right ventricular conduction delay. Since the previous\\ntracing of no significant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224056,\n \"text\": \"Atrial flutter with variable block. Incomplete right bundle-branch block.\\nCompared to the previous tracing of A-V block is now irregular. The\\nunderlying atrial rhythm continues to likely be counterclockwise flutter.\\nThe other findings are similar.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224057,\n \"text\": \"Counterclockwise atrial flutter with 2:1 A-V block. Diffuse non-specific\\nST-T wave changes likely secondary to rate. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333538,\n \"text\": \"Chief Complaint: ARF, alveolar hemorrhage\\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\\n cytoxan 120 mg there. He was transferred for consideration of\\n plasmapheresis.\\n 24 Hour Events:\\n EKG - At 10:48 PM\\n -Tachycardic to low 100s with EKG concerning for A.flutter\\n -Hyperkalemic requiring kayexalate\\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 RISS\\n Solumedrol 1 g daily\\n Albuterol Q6H\\n Atrovent Q6H\\n Protonix\\n Colace\\n Lopressor 12.5 mg \\n Renagel\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Tachycardia\\n Respiratory: Cough, No hemoptysis\\n Gastrointestinal: Nausea\\n Genitourinary: Foley\\n Integumentary (skin): Rash, Diffuse maculopapular\\n Heme / Lymph: Anemia\\n Flowsheet Data as of 09:15 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.3\\nC (95.6\\n HR: 109 (106 - 123) bpm\\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\\n RR: 30 (16 - 31) insp/min\\n SpO2: 93%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 426 mL\\n PO:\\n 230 mL\\n 240 mL\\n TF:\\n IVF:\\n 186 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 495 mL\\n Urine:\\n 125 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -69 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n FiO2: 4 L\\n SpO2: 91%\\n Physical Examination\\n General Appearance: No acute distress, Tachypneic\\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\\n Bilateral )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: None.\\n Skin: Few petechiae at feet. Maculopapular rash resolved.\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.0 g/dL\\n 513 K/uL\\n 213 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 5.5 mEq/L\\n 147 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 26.6 %\\n 7.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL\\n Fluid analysis / Other labs: AG 20\\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\\n interstitial components. Normal cardiomediastinal contours. Minimal\\n bilateral costophrenic blunting.\\n Microbiology: None.\\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\\n Wegener\\ns granulomatosis, MPA, Goodpasteur\\ns, lupus, post-strep GN with\\n DIC (less likely). He is currently clinically stable and has been\\n started on solumedrol and cytoxan.\\n 1) Pulmonary-renal syndrome\\n ANCA, anti-GBM, , anti-dsDNA,\\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\\n serologies pending. Will consult renal for cytoxan dosing,\\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\\n 2) Anemia\\n Likely alveolar hemorrhage. Will rule out\\n hemolysis. Trend Q8H until stable.\\n 3) Renal failure\\n No acute indication for RRT at this point.\\n Does have an AG metabolic acidosis. Hyperkalemia currently\\n controllable with medications. No EKG changes. Renagel. Follow\\n electrolytes.\\n 4) Atrial flutter\\n Start low-dose beta-blockade. TSH pending.\\n TTE pending.\\n ICU Care\\n Nutrition: Renal, cardiac\\n Glycemic Control: Regular insulin sliding scale\\n Lines: Peripheral IVs\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Protonix\\n VAP: N/A\\n Comments:\\n Communication: Comments:\\n Code status: Full code. Son, , is HCP.\\n Disposition :Remains in ICU.\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333555,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics: None\\n Infusions: None\\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: None\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula 4L\\n SpO2: 90%\\n Physical Examination\\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\\n tachypneic, NAD\\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\\n malar area of face\\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\\n lung fields posteriorly\\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\\n (improved today, less erythematous), no cyanosis/ clubbing\\n Labs / Radiology\\n 213 mg/dL\\n 147 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 107 mEq/L\\n 5.5 mEq/L\\n 144 mEq/L\\n 7.4 K/uL\\n 9.0 g/dL\\n 26.6 %\\n 513 K/uL\\n [image002.jpg]\\n Anion Gap = 20\\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\\n symmetrical alveolar opacities, almost in all lung fields, consistent\\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\\n consistent with old granulomatous disease\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL****\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333655,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\\ns, SpO2 low\\n 90\\ns trending down to 87 on 4L via NC.\\n Action:\\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\\n assessment closely. Following ABG as ordered. Encouraging C+DB\\n exercises.\\n Response:\\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\\n of accessory muscles; however, pt able to speak in full sentences and\\n reports breathing is\\nbetter\\n as compared to yesterday. ABG 7.31/37/67.\\n Plan:\\n Continue to monitor respiratory assessment closely. Follow ABG as\\n ordered. Titrated FiO2 as ordered and indicated\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt presented to OSH w/ Creatanine >9.\\n Action:\\n Following labs as ordered. Monitoring fluid status closely. Pt given\\n kayexalate X 2 doses since admission\\n see . Renal fellow currently\\n placing HD line.\\n Response:\\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\\n 30-100ml/hr. Hct remains stable at 27.\\n Plan:\\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\\n in am. Following hct and lytes Q8hr as ordered.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt remains in a-flutter (baseline since arrival to OSH per report). RVR\\n to 130\\ns. BP remains stable.\\n Action:\\n Monitoring HR, rhythm and hemodynamic status closely. Lopressor\\n increased to 25mg PO TID.\\n Response:\\n HR better controlled on increased lopressor (110-115). Continues in\\n a-flutter. BP remains stable.\\n Plan:\\n Continue to monitor cardiac and hemodynamic status closely. Continue\\n lopressor as ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333454,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\\n Action:\\n Observing u/o and labs. Will consult renal in am and follow\\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\\n start sevelamer in the am.\\n Response:\\n pending\\n Plan:\\n Renal will consult in the am. Will draw am labs.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\\n lungs with crackles\\n way up. Also some mild exp wheezes.\\n Action:\\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\\n Response:\\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\\n with crackles\\n way up.\\n Plan:\\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\\n monitor sao2 and provide o2 as needed.\\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333642,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\\ns, SpO2 low\\n 90\\ns trending down to 87 on 4L via NC.\\n Action:\\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\\n assessment closely. Following ABG as ordered. Encouraging C+DB\\n exercises.\\n Response:\\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\\n of accessory muscles; however, pt able to speak in full sentences and\\n reports breathing is\\nbetter\\n as compared to yesterday. ABG 7.31/37/67.\\n Plan:\\n Continue to monitor respiratory assessment closely. Follow ABG as\\n ordered. Titrated FiO2 as ordered and indicated\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt presented to OSH w/ Creatanine >9.\\n Action:\\n Following labs as ordered. Monitoring fluid status closely. Pt given\\n kayexalate X 2 doses since admission\\n see . Renal fellow currently\\n placing HD line.\\n Response:\\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\\n 30-100ml/hr. Hct remains stable at 27.\\n Plan:\\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\\n in am. Following hct and lytes Q8hr as ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333643,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\\ns, SpO2 low\\n 90\\ns trending down to 87 on 4L via NC.\\n Action:\\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\\n assessment closely. Following ABG as ordered. Encouraging C+DB\\n exercises.\\n Response:\\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\\n of accessory muscles; however, pt able to speak in full sentences and\\n reports breathing is\\nbetter\\n as compared to yesterday. ABG 7.31/37/67.\\n Plan:\\n Continue to monitor respiratory assessment closely. Follow ABG as\\n ordered. Titrated FiO2 as ordered and indicated\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt presented to OSH w/ Creatanine >9.\\n Action:\\n Following labs as ordered. Monitoring fluid status closely. Pt given\\n kayexalate X 2 doses since admission\\n see . Renal fellow currently\\n placing HD line.\\n Response:\\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\\n 30-100ml/hr. Hct remains stable at 27.\\n Plan:\\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\\n in am. Following hct and lytes Q8hr as ordered.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333496,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 1\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 90%\\n ABG: ///17/\\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 513 K/uL\\n 9.0 g/dL\\n 213 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 5.5 mEq/L\\n 147 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 26.6 %\\n 7.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333711,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx. Pt was adm on .\\n Atrial flutter (Aflutter)\\n Assessment:\\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\\n the high 120-130 range during plasmapharesis. B/P has remained stable\\n 110/78-132/69.\\n Action:\\n Lopressor was increased to 50mg tid which was started last evening.\\n Response:\\n H/R is decreasing from the 100\\ns to the 80-90range.\\n Plan:\\n Cont with tid lopressor. Monitor h/r and pattern.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\\n Action:\\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\\n past 24 hours pt has had 2 doses of Kayexalate.\\n Response:\\n K+ is 4. U/O improving with urine more yellow. Last creat 8.5 with bun\\n 147\\n Plan:\\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\\n lungs have had crackles bil bases with the left lung more dim than the\\n right..\\n Action:\\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\\n evening and was given cytoxan after the plasmaphoresis. Pt is also\\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\\n Response:\\n Sao2 drops to the high 80\\ns while pt wears only the n/c. pt does not\\n like to wear face mask and denies any sob.\\n Plan:\\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\\n plasmaphoresis again on Tues.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333805,\n \"text\": \"Chief Complaint: ARF, alveolar hemorrhage\\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\\n cytoxan 120 mg there. He was transferred for consideration of\\n plasmapheresis.\\n 24 Hour Events:\\n EKG - At 10:48 PM\\n -Tachycardic to low 100s with EKG concerning for A.flutter\\n -Hyperkalemic requiring kayexalate\\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 RISS\\n Solumedrol 1 g daily\\n Albuterol Q6H\\n Atrovent Q6H\\n Protonix\\n Colace\\n Lopressor 12.5 mg \\n Renagel\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Tachycardia\\n Respiratory: Cough, No hemoptysis\\n Gastrointestinal: Nausea\\n Genitourinary: Foley\\n Integumentary (skin): Rash, Diffuse maculopapular\\n Heme / Lymph: Anemia\\n Flowsheet Data as of 09:15 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.3\\nC (95.6\\n HR: 109 (106 - 123) bpm\\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\\n RR: 30 (16 - 31) insp/min\\n SpO2: 93%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 426 mL\\n PO:\\n 230 mL\\n 240 mL\\n TF:\\n IVF:\\n 186 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 495 mL\\n Urine:\\n 125 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -69 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n FiO2: 4 L\\n SpO2: 91%\\n Physical Examination\\n General Appearance: No acute distress, Tachypneic\\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\\n Bilateral )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: None.\\n Skin: Few petechiae at feet. MacPap rash resolving\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.0 g/dL\\n 513 K/uL\\n 213 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 5.5 mEq/L\\n 147 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 26.6 %\\n 7.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL\\n Fluid analysis / Other labs: AG 20\\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\\n interstitial components. Normal cardiomediastinal contours. Minimal\\n bilateral costophrenic blunting.\\n Microbiology: None.\\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\\n Wegener\\ns granulomatosis, MPA, Goodpasteur\\ns, lupus, post-strep GN with\\n DIC (less likely). He is currently clinically stable and has been\\n started on solumedrol and cytoxan.\\n 1) Pulmonary-renal syndrome\\n ANCA, anti-GBM, , anti-dsDNA,\\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\\n serologies pending. Will consult renal for cytoxan dosing,\\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\\n 2) Anemia\\n Likely alveolar hemorrhage. Will rule out\\n hemolysis. Trend Q8H until stable.\\n 3) Renal failure\\n No acute indication for RRT at this point.\\n Does have an AG metabolic acidosis. Hyperkalemia currently\\n controllable with medications. No EKG changes. Renagel. Follow\\n electrolytes.\\n 4) Atrial flutter\\n Start low-dose beta-blockade. TSH pending.\\n TTE pending.\\n MICU Attending Addendum\\n Pt seen with fellow and examined. Met with pt and family to review\\n situation. Would add and emphasize the following to Dr \\ns notes.\\n On exam\\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\\n alos right forearm.\\n ABG 7.31/37/67\\n BUN 147/ Cr 9.6\\n CXR: diffsue bilateral interstitial and alveolar infiltrates\\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\\n and renal failure quite concerning for vasculitis.\\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\\n Role of plasmapheresis without clear diagnosis is challenging. Will\\n consult with Renal collegues on possibility of a renal biopsy to aid in\\n diagnosis. Additionally he is moving towards dialysis, need to closely\\n watch K, renally dose all meds. His resp status is tenusous due to\\n hypoxemia as well as met acidosis and uremic encephalopathy- may\\n require intubation for support\\n would likely favor this over NIPPV\\n given likely duration.\\n Discussed with son who is HCP and updated.\\n ICU Care\\n Nutrition: Renal, cardiac\\n Glycemic Control: Regular insulin sliding scale\\n Lines: Peripheral IVs\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Protonix\\n VAP: N/A\\n Comments:\\n Communication: Comments:\\n Code status: Full code. Son, , is HCP.\\n Disposition :Remains in ICU.\\n Total time spent: Critically Ill 50 min\\n ------ Protected Section ------\\n MICU Attending Addendum\\n Updated note on events from . In the course of the afternoon, I\\n spent over 2 hours working with both the renal consultation team and Dr\\n and the Plasmapheresis team determining indication and timing of\\n pheresis for possible anti GBM. We were able to update family, call in\\n pheresis team, and place pheresis catheter all to facilitate. Pt with\\n progressive hypoxemia and on NRB\\n ongoing frequent labs to assess HCT,\\n also borderline indication for HD due to progressive encephalopathy,\\n boerdeline hyperK and acidosis.\\n Time Spent 120 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 08:22 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333807,\n \"text\": \"Chief Complaint: Respiratory distress/hypoxemia\\n HPI:\\n 24 Hour Events:\\n EKG - At 02:00 PM\\n DIALYSIS CATHETER - START 06:48 PM\\n Renal consultation concurred with Pulmonary-Renal syndrome.\\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\\n anticipating 5 days of treatment. Remains on cortocosteroids.\\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\\n Denies increased dyspnea, but remains with oxygen requirement.\\n History obtained from Patient\\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 09:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.3\\nC (95.5\\n HR: 81 (81 - 133) bpm\\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\\n RR: 24 (22 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 902 mL\\n 186 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 662 mL\\n 186 mL\\n Blood products:\\n Total out:\\n 1,330 mL\\n 690 mL\\n Urine:\\n 1,330 mL\\n 690 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -429 mL\\n -504 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: 7.31/37/67/22/-6\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\\n mildly disshevled\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.6 g/dL\\n 355 K/uL\\n 176 mg/dL\\n 8.6 mg/dL\\n 22 mEq/L\\n 3.9 mEq/L\\n 149 mg/dL\\n 108 mEq/L\\n 150 mEq/L\\n 22.6 %\\n 8.1 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n WBC\\n 7.4\\n 8.1\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n Plt\\n 543\\n 513\\n 355\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\\n predominantly basilar. Right IJ catheter position acceptable. No\\n significant overall change compared to .\\n Assessment and Plan\\n 60 yom now with Pulmonary-Renal syndrome.\\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\\n diffuse infiltrates and oxygen requirement.\\n HYPOXEMIA -- attributed to pulmonary infiltrates.\\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\\n SaO2.\\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\\n consult prepared to move to dialysis when indicated. Monitor urine\\n output, BUN, Creatitine.\\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\\n Continue steroids and plasmaphoresis.\\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\\n FLUIDS -- limit iv fluids intake.\\n HYPERPHOSPHATEMIA -- start phosphate binder.\\n NUTRITION -- NPO pending evaluation\\n ANEMIA -- progressive, attributed to underlying process, and possible\\n contribution from RIJ central line placement. Transfuse to Hct >21.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 333895,\n \"text\": \"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 Comments:\\n Pt currently on 6L NC. Pt ordered for albuterol and Atrovent nebs Q6.\\n Nebs given as ordered and pt tolerated them well.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 333425,\n \"text\": \"Chief Complaint: Bilateral LE edema, SOB\\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy.\\n .\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptons started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n .\\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\\n noted as having mild wheezing and productive cough of white sputum.\\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\\n Occult blood stool negative. U/A significant for protein 400mg/dl,\\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\\n microscopy positive for RBCs, granular casts.\\n .\\n Pt was seen by Renal, who thought there might possibly be a\\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\\n .\\n CXR on admission showed underlying COPD with diffuse bilateral\\n pulmonary infiltrates.\\n Pt underwent bronchoscopy on , and was found to have active low\\n grade blood emanating from the RLL and LLL.\\n .\\n EKG on admission showed atrial flutter at 2:1 block rate 150.\\n .\\n On arrival here, pt appeared mildly tachypneic. He reported that LE\\n edema had improved, and that pain had resolved in LE. He complained of\\n only mild nausea recently without vomiting, and a productive cough.\\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\\n constipation, melena, hematochezia, chest pain, urinary\\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\\n no epistaxis. Last BM was yesterday, and was formed.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other:\\n Review of systems:\\n Flowsheet Data as of 12:49 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.5\\nC (95.9\\n HR: 107 (107 - 122) bpm\\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\\n RR: 27 (16 - 27) insp/min\\n SpO2: 91%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 48 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 48 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 100 mL\\n Urine:\\n 125 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -52 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 91%\\n ABG: ///16/\\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 543 K/uL\\n 219 mg/dL\\n 9.7 mg/dL\\n 144 mg/dL\\n 16 mEq/L\\n 107 mEq/L\\n 6.2 mEq/L\\n 143 mEq/L\\n 31.0 %\\n [image002.jpg]\\n \\n 2:33 A8/9/ 11:05 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 Hct\\n 31.0\\n Plt\\n 543\\n Cr\\n 9.7\\n Glucose\\n 219\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.6 mg/dL\\n Assessment and Plan\\n ABG: ///16/\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 333422,\n \"text\": \"Clinician: Attending\\n 60 yo male without significant medical history now admit to OSA with\\n lower extremity edema x 2 weeks. His presentation there was notable\\n for severe acute renal failure and with diffuse alveolar infiltrates.\\n The findings at the OSA were consistent with acute GN based upon review\\n of the urine sediment. In addition, patient did have bronchoscopy\\n revealing a strong suggestion of alveolar hemorrhage with sequential\\n lavage showing persistent bloody fluid. There was no hemoptysis noted.\\n U/A there--RBC's and granular casts documented.\\n There he has had persistent renal failure and alveolar infiltrates and\\n now with persistent tachycardia patient to ICU for further\\n evaluation and care after solumedrol and cytoxan started at OSH.\\n ROS-negative for sinusitis/sinus congestion\\n Here patient has persistent sinus tachycardia noted,\\n Exam notable for-->\\n Patient comfortable by subjective description\\n No JVD\\n Lungs-Diffuse crackles bilaterally inferiorly and to mid lung zone.\\n Heart-Tachycardic and regular rate suggested on initial exam\\n Extremities--1+ bilateral lower extremity edema. Diffuse macular rash\\n from foot to knee.\\n Labs->\\n Cr-9.6\\n K-5.8\\n HCO3-=18\\n CXR->Patient with diffuse bilateral alveolar infiltrates--there is a\\n suggestion of lower lobe distribution but with the complete absence of\\n pleural effusions which is consistent with alveolar hemorrhage.\\n ECG-Atrial Flutter seen with atrial rate at approx 300 bpm and\\n ventricular rate of 125-150.\\n In summary this is a 60 yo male with findings of acute renal failure\\n with evidence of diffuse alveolar hemorrhage and active disease with\\n ESR >140. No definative diagnostic procedure was preformed and serum\\n testing, although sent, is all pending at this time. Patient did start\\n Solumedrol and Cytoxan for empiric diagnosis of\\n vasculitis with serologies pending. Goodpasteur's and Wegner's and\\n microscopic polyangiitis and PAN all are on this list along with\\n connective tissue disease.\\n 1)Acute Renal Failure-\\n -Significant concern for acute vasculitis\\n -Given severity of dysfunction certainly intervention is desired in\\n timely fashion\\n -Would favor biopsy prior to intervention is patient remains stable\\n enough to accept.\\n -With Solumedrol and Cytoxan 1 dose given is challenging decision to\\n consider hold of further treatment prior to biopsy.\\n -Will consult renal for consideration of biopsy.\\n -Given significant clinical decline and significant pulmonary\\n distress--tachypnea and tachycardia--I would favor continuation of\\n treatment already started given his subjective improvement over past 24\\n hours. Although this will cloud the biopsy results his clinical status\\n at this point in time is one that warrants intervention.\\n -Continue Solumedrol 1g qd and Cytoxan to continue\\n -Renal and Rheum to evaluate patient for aid in diagnosis and treatment\\n -C3, C4, , Anti-GBM, ANCA all pending\\n 2)Alevolar Hemorrhage--seen on OSH bronchoscopy, no biopsies performed\\n -Continue with supportive care at this time\\n -Will have to consider diagnostic procedure and consideration of renal\\n biopsy may be highest yield\\n -Attempt to maintain euvolemia as hydrostatic edema is of concern given\\n signficiant volume overload but will be limited by renal failure and\\n the distribution of infiltrates.\\n 3)Atrial Flutter-\\n Hold anticoagulation for bleeding risk\\n Rate control as needed\\n Will need TSH and ECHO in full evaluation\\n 4)Anemia-\\n Patient with reasonable stability with transfusion--may well be\\n inadequate production with associated blood loss at this time--with the\\n blood loss less active at this time.\\n -F/u HCT\\n -Monitor with OB for stool\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333661,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics: None\\n Infusions: None\\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: None\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula 4L\\n SpO2: 90%\\n Physical Examination\\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\\n tachypneic, NAD\\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\\n malar area of face\\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\\n lung fields posteriorly\\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\\n (improved today, less erythematous), no cyanosis/ clubbing\\n Labs / Radiology\\n 213 mg/dL\\n 147 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 107 mEq/L\\n 5.5 mEq/L\\n 144 mEq/L\\n 7.4 K/uL\\n 9.0 g/dL\\n 26.6 %\\n 513 K/uL\\n [image002.jpg]\\n Anion Gap = 20\\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\\n symmetrical alveolar opacities, almost in all lung fields, consistent\\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\\n consistent with old granulomatous disease\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL****\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n .\\n Plan:\\n .\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - Continue supplemental O2 PRN\\n - Albuterol nebs PRN\\n - CXR\\ns as needed\\n - Type and screen, cross match x 2 units; threshold to transfuse hct\\n <21, unless clinically unstable\\n - Blood consent\\n - Consult Renal and Rheum in a.m.\\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\\n get renal biopsy\\n - Will continue Solumedrol 1g IV daily\\n - F/u on Renal serology and BAL results from OSH\\n - Will check Crits q8 for now\\n .\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\\n Denies epistaxis. However, apart from pulmonary association, ddx for\\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\\n ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's. Also consider DIC.\\n - F/u on u/a, urine lytes, urine sediment\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Consult Renal here\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Will check q8 lytes for now\\n - Start Sevelemer in a.m. with meals for elevated Phos.\\n .\\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\\n Can be secondary to underlying structural heart disease. Also may be\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n - F/u on TSH\\n - Surface ECHO in a.m. today\\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check Crits q8\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\\n respiratory status worsens anticipating intubation. Will replete lytes\\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\\n .\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n ------ Protected Section ------\\n Addendum\\n Anti-GBM test sent to Specialty Laboratories, 1, #4 to\\n connect to lab. They will run this particular study on Tuesday, ^th, and result may become available ^th-15^th.\\n PGY-1\\n ------ Protected Section Addendum Entered By: , MD\\n on: 19:28 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 333670,\n \"text\": \"Clinician: Attending\\n Patient seen and examined. Plasmapharesis initiated this evening.\\n Appears to be tolerating it well with no new complaints. Currently BP\\n 130/70, HR 134, sat 94-97% on full face mask. No respiratory distress.\\n Fine crackles heard laterally but otherwise lungs are relatively clear.\\n Plan is for plasmapharesis, K to be rechecked. If necessary to be\\n dialysed, renal will consider tonight. Cytoxan to be redosed at 140 mg\\n IV, weight based at ~2 mg/kg for 67 kg. On Solumedrol 1 gm q24h x 3\\n days. 30 min of CC time spent with patient.\\n Total time spent: 30 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 333725,\n \"text\": \"Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Diminished\\n LLL Lung Sounds: Crackles\\n Comments:\\n Plan\\n Pt presently on 3 lpm n/c and ordered for nebs alb/atr. Nebs\\n administered as ordered with no adverse reactions.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335004,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\\n Continued to desat into the 80s because his mask falls off, but remains\\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\\n liters. Urine output before midnight=300cc/hr and after MN, continued\\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\\n sent yesterday.\\n HCT remained stable, repleted lytes\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 92 (76 - 130) bpm\\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\\n RR: 26 (12 - 27) insp/min\\n SpO2: 89%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 70 mL\\n PO:\\n 290 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 70 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 1,900 mL\\n Urine:\\n 3,010 mL\\n 1,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -1,830 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 89%\\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 185 K/uL\\n 7.3 g/dL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \\n C-ANCA vasculitis. This morning, he breathing more easily, with stable\\n lung exam though his CXR looks unchanged. This is likely due to\\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\\n 2+ budding yeast on sputum, without signs of candidiasis on\\n oropharyngeal exam.\\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\\n urine output and restart IVF if necessary. We will balance maintaining\\n urine output >100/hr for bladder protection with not giving too much\\n Lasix due to renal failure.\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n -Start nystatin mouthwash\\n -Send blood cultures for fungus (though highly unlikely given pt. is\\n afebrile, stable, but he is on high dose immunosuppression)\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - HCTq8h to monitor for alveolar bleeding. Given\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient desats while eating, if he continues will make him NPO\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\\n mesna for cystitis prophylaxis\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\\n to improve kidney outcomes, though not mortality.\\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\\n but more cellular glomeruli than sclerotic giving hope for return on.\\n Monitor for bleeding at site given possible platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\\n ANCA P.\\n - Foley in place , strict I&O, q8 lytes .\\n -pink tinged urine, stable. Urine has been tinged nephritic\\n picture, but if worsening, concern for hemorrhagic cystitis. Will\\n monitor for increasing blood in urine and can irrigate the bladder if\\n hemorrhagic cystitis is suspected.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 4gIV in last 24 hours.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335152,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\\n continues to desat when off O2 ( removes O2 while sleeping on and off)\\n Action:\\n Scheduled neb given , nystatin swish given for yeast in sputum.\\n Response:\\n Good response to neb , Slept well with ambien.\\n Plan:\\n Continue to monitor VSS and follow sats closely.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334768,\n \"text\": \"Chief Complaint: Hypoxemia\\n HPI:\\n 24 Hour Events:\\n Remains with high FiO2 requirement.\\n HR varies from A-flutter to NRS.\\n Coughing up sputum (swallowing), but more productive cough today.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.2\\n Tcurrent: 36.1\\nC (96.9\\n HR: 98 (85 - 131) bpm\\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\\n RR: 18 (12 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 1,971 mL\\n PO:\\n 750 mL\\n 160 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 1,811 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 1,235 mL\\n Urine:\\n 2,400 mL\\n 1,235 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 736 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 94%\\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, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: 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, No(t) Sedated,\\n No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.8 g/dL\\n 211 K/uL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\\n Possible component of pulmonary edema.\\n HYPOXEMIA -- attributed to pulmonary infiltrates. Continue\\n supplemental oxygen, monitor RR, SaO2.\\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\\n steroids & cytoxan. Plasmaphoresis.\\n RENAL FAILURE -- improving. Monitor uo, BUN, creatinine.\\n FLUIDS\\n desire to allow net diuresis. Consider Lasix dose.\\n NUTRIONAL SUPPORT -- PO\\n HEMATURIA -- stable. Monitor.\\n ANEMIA -- stable s/p transfusion.\\n HYPOCALCEMIA -- continue to replete.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 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: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334958,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\\n Continued to desat into the 80s because his mask falls off, but remains\\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\\n liters. Urine output before midnight=300cc/hr and after MN, continued\\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\\n sent yesterday.\\n HCT remained stable, repleted lytes\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 92 (76 - 130) bpm\\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\\n RR: 26 (12 - 27) insp/min\\n SpO2: 89%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 70 mL\\n PO:\\n 290 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 70 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 1,900 mL\\n Urine:\\n 3,010 mL\\n 1,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -1,830 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 89%\\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 185 K/uL\\n 7.3 g/dL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\\n of breathing, with worsening lung exam and desating to the 70s without\\n the facemask on. This is unlikely due to hemorrhage as his crit has\\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\\n and chest Xray appears to have signs of pulmonary edema, making volume\\n overload the most likely cause of worsening pulmonary status.\\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\\n output >100/hr for bladder protection with not giving too much Lasix\\n due to renal failure.\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n Will examine his septum today as this could worsen his repiratory\\n status and make him feel nasal congestion (which he has been\\n complaining of)\\n -CT of sinus has been recommended, will consider when patient more\\n stable.\\n - HCT has been stable, follow HCT q8h to monitor for alveolar\\n bleeding.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient desats while eating, if he continues will make him NPO\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\\n mesna for cystitis prophylaxis\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\\n to improve kidney outcomes, though not mortality.\\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\\n but more cellular glomeruli than sclerotic giving hope for return on.\\n Monitor for bleeding at site given possible platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\\n ANCA P.\\n - Foley in place , strict I&O, q8 lytes .\\n -pink tinged urine, stable. Urine has been tinged nephritic\\n picture, but if worsening, concern for hemorrhagic cystitis. Will\\n monitor for increasing blood in urine and can irrigate the bladder if\\n hemorrhagic cystitis is suspected.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 4gIV in last 24 hours.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335153,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\\n continues to desat when off O2 ( removes O2 while sleeping on and off)\\n Action:\\n Scheduled neb given , nystatin swish given for yeast in sputum.\\n Response:\\n Good response to neb , Slept well with ambien.\\n Plan:\\n Continue to monitor VSS and follow sats closely.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\\n Action:\\n Response:\\n U/O wnl, continued to monitor renal parameters\\n Plan:\\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334748,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Dx: Wegener\\ns Granulomatosis confirmed by renal biopsy\\n Atrial flutter (Aflutter)\\n Assessment:\\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\\n frequent episodes of tachycardia in the 130\\ns, typically with exertion,\\n stimulation and desats. BP within normal limits.\\n Action:\\n Tolerating metoprolol PO\\n Response:\\n Heart rate slows to the 80-90\\ns with rest, VS WNL\\n Plan:\\n Continue to monitor Heart rate/rhythm, administer metoprolol as\\n ordered. Encourage rest periods\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\\n noted. Creatinine is 6.5, BUN 153\\n Action:\\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\\n Creatinine is trending down. Hct drawn at 1530, results pending.\\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\\n with meals. Lunch held due to respiratory distress.\\n Response:\\n Labs to be drawn 4 hours after plasmaphoresis and tonight at 2200.\\n Fluid balance remains positive. Good urine output response to lasix.\\n Tolerated plasmaphoresis with episodes of tachycardia.\\n Plan:\\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\\n total of 7 treatments via right IJ HD catheter. Administer mesna as\\n ordered with chemo. Chemo to be given after plasmaphoresis.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\\n strong productive cough. Patient\\ns O2 requirements increasing\\n throughout the day.\\n Action:\\n O2 titrated accordingly. Face tent increased/decreased, now at 95% and\\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\\n albuterol changed to prn (may be contributing to tachycardia). Afrin\\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\\n on.\\n Response:\\n Oxygenation remains labile. Desats with eating and removal the face\\n tent. Recovery time longer each time he desats.\\n Plan:\\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\\n sputum sample. Patient may need a sinus CT scan if stable. Administer\\n neb treatments as ordered.\\n Patient\\ns family at bedside. Updated on plan of care.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334749,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\\n edema, 2L fluids up. Did not receive cytoxan yesterday. Will receive\\n it after pheresis today.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\\n RR: 23 (9 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 979 mL\\n PO:\\n 750 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 979 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 640 mL\\n Urine:\\n 2,400 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 339 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 211 K/uL\\n 7.8 g/dL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\\n of breathing, with worsening lung exam and desating to the 70s without\\n the facemask on. This is unlikely due to hemorrhage as his crit has\\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\\n and chest Xray appears to have signs of pulmonary edema, making volume\\n overload the most likely cause of worsening pulmonary status.\\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\\n output >100/hr for bladder protection with not giving too much Lasix\\n due to renal failure.\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n Will examine his septum today as this could worsen his repiratory\\n status and make him feel nasal congestion (which he has been\\n complaining of)\\n -CT of sinus has been recommended, will consider when patient more\\n stable.\\n - HCT has been stable, follow HCT q8h to monitor for alveolar\\n bleeding.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient desats while eating, if he continues will make him NPO\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\\n mesna for cystitis prophylaxis\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\\n to improve kidney outcomes, though not mortality.\\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\\n but more cellular glomeruli than sclerotic giving hope for return on.\\n Monitor for bleeding at site given possible platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\\n ANCA P.\\n - Foley in place , strict I&O, q8 lytes .\\n -pink tinged urine, stable. Urine has been tinged nephritic\\n picture, but if worsening, concern for hemorrhagic cystitis. Will\\n monitor for increasing blood in urine and can irrigate the bladder if\\n hemorrhagic cystitis is suspected.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 4gIV in last 24 hours.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335073,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt. with Wegener\\ns granulocytosis with Hx. Of pulmonary hemorrhage per\\n bronch at OSH. On 80% face tent and 6L NC. LS diminished. Occ congested\\n non-productive cough. No hemoptesis this shift.\\n Action:\\n Plasmapherisis today. Cont. O2 for O2 sat >90%. HOB >45 degrees.\\n Atrovent neb as ordered. Started on Nyastatin swish and spit for yeast\\n in sputum cx on .\\n Response:\\n O2 sat 92-98%. Occ will desat to 86% when mask falls down or when\\n eating.\\n Plan:\\n Cont. current treatment. Monitor resp. status and wean O2 as tolerated.\\n F/u sputum cx.\\n Plasmapherisis today. Nest treatment on Monday. Transfused today with\\n one unit of PRBC for Hct. 21.6. Will need serial Hct. Checks starting\\n after transfusion.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334190,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Overall, no significant change in supplimental oxygen requirement.\\n Overall, appears much more comfortable.\\n Able to eat.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.2\\nC (95.4\\n HR: 90 (72 - 133) bpm\\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\\n RR: 22 (19 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 443 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 443 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 485 mL\\n Urine:\\n 1,405 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -42 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, High flow neb\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Well nourished, No(t) No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\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, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 6.9 g/dL\\n 261 K/uL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\\n bibasilar, unchanged.\\n Assessment and Plan\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\\n Await renal Bx results and serologies.\\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\\n BUN, creatitine, UO.\\n NUTRITIONAL SUPPORT -- advance PO.\\n FLUIDS -- provide adequate urine output (cytoxan)\\n HYPERGLYCEMIA -- promoted by steroids.\\n A-FLUTTER -- good rate control. Continue meds.\\n ANEMIA -- slow reduction. Blood loss due to pulmonary hemorrhage and\\n renal bx likely contributing. Transfuse to >21\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 334197,\n \"text\": \"Lung sounds\\n RLL Lung Sounds: Exp Wheeze\\n RUL Lung Sounds: Exp Wheeze\\n LUL Lung Sounds: Exp Wheeze\\n LLL Lung Sounds: Crackles\\n Comments:\\n Pt currently on 6L NC. Nebs given as ordered with no adverse reaction.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333491,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\\n Action:\\n Observing u/o and labs. Will consult renal in am and follow\\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\\n start sevelamer in the am.\\n Response:\\n Pending. Creat 9.2 this am\\n Plan:\\n Renal will consult in the am. Will draw am labs.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\\n lungs with crackles\\n way up. Also some mild exp wheezes.\\n Action:\\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\\n Response:\\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\\n with crackles\\n way up.\\n Plan:\\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\\n monitor sao2 and provide o2 as needed.\\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333972,\n \"text\": \"This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\\n syndrome.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\\n activities.But when resting and sleeping in 80\\ns-90\\ns.NBP within\\n limits.No drop in BP with high HR.\\n Action:\\n Pt is on metoprolol for rate control.\\n Response:\\n HR in 80\\ns 90\\ns while at rest.\\n Plan:\\n Cont monitoring.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\\n with diminished base.Pt has got strong productive cough.\\n Action:\\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\\n is on high dose of steroids and had chemo.And pt is getting\\n plasmapheresis every other day.\\n Response:\\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\\n Plan:\\n Cont monitoring resp status.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\\n yesterday.Pt has got elevated phos and sodium.\\n Action:\\n Renal failure most likely due to vasculitis. Pt is getting treated by\\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\\n na.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333970,\n \"text\": \"This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\\n syndrome.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\\n activities.But when resting and sleeping in 80\\ns-90\\ns.NBP within\\n limits.No drop in BP with high HR.\\n Action:\\n Pt is on metoprolol for rate control.\\n Response:\\n HR in 80\\ns 90\\ns while at rest.\\n Plan:\\n Cont monitoring.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\\n with diminished base.Pt has got strong productive cough.\\n Action:\\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\\n is on high dose of steroids and had chemo.And pt is getting\\n plasmapheresis every other day.\\n Response:\\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\\n Plan:\\n Cont monitoring resp status.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334155,\n \"text\": \"Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\\n for presumed Wegeners.\\n 24 Hour Events:\\n Continues to have increasing 02 requirement, on 6L and facemask to keep\\n 02 >90%. Yesterday he had a renal biopsy, TTE, given d5W for\\n hypernatremia and seen by rheumatology.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 89 (72 - 133) bpm\\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 343 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 343 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 440 mL\\n Urine:\\n 1,405 mL\\n 440 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -97 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\\n likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, likely a slow bleed.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose today (QOD)\\n -Solumedrol 1g IV daily (will change to prednisone tomorrow per\\n rheumatology)\\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\\n dysfunction yet, mental status ok. BUN continues to increase, but BUN\\n often stays elevated in acute renal failure after the kidneys have\\n started to improve, also the patient is on high dose steroids which can\\n increase BUN. As a note, plasmapheresis in cases of severe Wegeners\\n has been shown to improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday, awaiting results. Monitor for bleeding at\\n site given possible platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\\n serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes . Will try to maintain\\n 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim due to renal function, patient should be\\n discharged on Atovaqone.\\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\\n today 141, down from 150.\\n -Now patient is taking PO, D/C D5W.\\n -if needed, restart fluids to maintain UOP 100cc/hr (to prevent hem.\\n cystitis while on cytoxan)\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -Replace Ca2+ (given 4g this am),\\n -lytes q6hrs\\n -EKG\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - given HCT , give 1unit today\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Guaiac all stools\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334025,\n \"text\": \"This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\\n syndrome.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\\n activities.But when resting and sleeping in 80\\ns-90\\ns.NBP within\\n limits.No drop in BP with high HR.\\n Action:\\n Pt is on metoprolol for rate control.\\n Response:\\n HR in 80\\ns 90\\ns while at rest.\\n Plan:\\n Cont monitoring.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\\n with diminished base.Pt has got strong productive cough.\\n Action:\\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\\n is on high dose of steroids and had chemo.And pt is getting\\n plasmapheresis every other day.\\n Response:\\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\\n Plan:\\n Cont monitoring resp status.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\\n Action:\\n Renal failure most likely due to vasculitis. Pt is getting treated by\\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\\n Na.\\n Response:\\n Phos still high,Na 141 this am.BUN and creatinine trending down.\\n Plan:\\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\\n Hct this am 21.1.?for transfusion.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334369,\n \"text\": \"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\\n renal biopsy c/w Wegeners.\\n 24 Hour Events:\\n O/N required ?? 02. Got pheresis yesterday, solumedrom and\\n cyclophosphamide. No hematuria. Talked to renal about biopsy, c/w\\n Wegners. Has been on IVF to keep uop >100, successfully. Tolerating\\n PO.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36\\nC (96.8\\n HR: 99 (75 - 130) bpm\\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\\n RR: 20 (18 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,475 mL\\n 650 mL\\n PO:\\n TF:\\n IVF:\\n 2,100 mL\\n 650 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 260 mL\\n Urine:\\n 1,360 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,115 mL\\n 390 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 261 K/uL\\n 6.9 g/dL\\n 172 mg/dL\\n 7.1 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 149 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 22.4 %\\n 5.4 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n WBC\\n 8.1\\n 5.4\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n Plt\\n 355\\n 261\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n TCO2\\n 20\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\\n likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, but increased with 1unit yesterday.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\\n prednisone dose\\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\\n doses thus far.\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7.6,up to 8.1 then back down to 7.1. BUN\\n peaked at 160 now, 150. No signs of platelet dysfunction yet, mental\\n status ok. Renal will give his kidneys about 48 more hours to turn\\n around before dialyzing. As a note, plasmapheresis in cases of severe\\n Wegeners has been shown to improve kidney outcomes, though not\\n mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\\n serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n yesterday with D51/2.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -given 6g IV Ca yesterday, plus more during pheresis\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - given HCT trend, gave 1 unit yesterday with improved HCT.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Guaiac all stools\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334116,\n \"text\": \"Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\\n for presumed Wegeners.\\n 24 Hour Events:\\n Continues to have increasing 02 requirement, on 6L and facemask to keep\\n 02 >90%. Yesterday he had a renal biopsy, TTE, put on\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 89 (72 - 133) bpm\\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 343 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 343 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 440 mL\\n Urine:\\n 1,405 mL\\n 440 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -97 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - also treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose today (QOD)\\n -Solumedrol 1g IV daily\\n -Cyclophosphamide 140mg\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\\n dysfunction yet, mental status ok.\\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\\n However, apart from pulmonary association, ddx for acute renal failure\\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\\n Also consider DIC.\\n - Renal biopsy yesterday, awaiting results\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\\n serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\\n today 141, down from 150.\\n -Now patient is eating, can D/C D5W.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -Replace Ca2+ (given 4g this am), check again this PM\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6, given HCT , likely need blood this pm.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334121,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Overall, no significant change in supplimental oxygen requirement.\\n Overall, appears much more comfortable.\\n Able to eat.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.2\\nC (95.4\\n HR: 90 (72 - 133) bpm\\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\\n RR: 22 (19 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 443 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 443 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 485 mL\\n Urine:\\n 1,405 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -42 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, High flow neb\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Well nourished, No(t) No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\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, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 6.9 g/dL\\n 261 K/uL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\\n bibasilar, unchanged.\\n Assessment and Plan\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\\n Await renal Bx results and serologies.\\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\\n BUN, creatitine, UO.\\n NUTRITIONAL SUPPORT -- advance PO.\\n FLUIDS -- provide adequate urine output (cytoxan)\\n HYPERGLYCEMIA -- promoted by steroids.\\n A-FLUTTER -- good rate control. Continue meds.\\n ANEMIA -- slow reduction. Transfuse to >21\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333431,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal will consult in the am.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\\n lungs with crackles\\n way up. Also some mild exp wheezes.\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 333432,\n \"text\": \"Chief Complaint: Bilateral LE edema, SOB\\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy.\\n .\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptons started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n .\\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\\n noted as having mild wheezing and productive cough of white sputum.\\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\\n Occult blood stool negative. U/A significant for protein 400mg/dl,\\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\\n microscopy positive for RBCs, granular casts.\\n .\\n Pt was seen by Renal, who thought there might possibly be a\\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\\n .\\n CXR on admission showed underlying COPD with diffuse bilateral\\n pulmonary infiltrates.\\n Pt underwent bronchoscopy on , and was found to have active low\\n grade blood emanating from the RLL and LLL.\\n .\\n EKG on admission showed atrial flutter at 2:1 block rate 150.\\n .\\n On arrival here, pt appeared mildly tachypneic. He reported that LE\\n edema had improved, and that pain had resolved in LE. He complained of\\n only mild nausea recently without vomiting, and a productive cough.\\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\\n constipation, melena, hematochezia, chest pain, urinary\\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\\n no epistaxis. Last BM was yesterday, and was formed.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Home medications:\\n NONE\\n Allergies:\\n NKDA\\n Past medical history:\\n Family history:\\n Social History:\\n ?Nephrolithiasis ()- blood found in urine after workup for lower\\n abdominal pain, no stones passed, 24hr protein done whith was normal\\n per pt.\\n Finger laceration ()\\n Mother passed from CVA in 80s. Father passed in 70s from unknown cause.\\n Twin brother passed from MI, another brother with hx cardiac artery\\n bypass graft. Denies family hx renal or pulmonary disease.\\n Pt works full-time as a machine operator. Mostly stationary job.\\n Divorced, college-age son lives with wife. Lives alone.\\n Smoked 1-1/2 ppd until when he quit (possibly 50 pack year hx\\n prior). Drinks ~2 drinks/day, and on social occasions. Denies other\\n drug use.\\n Review of systems: He complained of only mild nausea recently without\\n vomiting, and a productive cough. Otherwise denies sore throat, fevers,\\n chills, abdominal pain, diarrhea, constipation, melena, hematochezia,\\n chest pain, urinary frequency/urgency, dysuria, lightheadedness, vision\\n changes, headache, no epistaxis.\\n Flowsheet Data as of 12:49 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.5\\nC (95.9\\n HR: 107 (107 - 122) bpm\\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\\n RR: 27 (16 - 27) insp/min\\n SpO2: 91%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 48 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 48 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 100 mL\\n Urine:\\n 125 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -52 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula 3L\\n SpO2: 91%\\n Physical Examination\\n GEN: Thin, pale, mildly distressed, tachypneic\\n HEENT: EOMI, PERRL, sclera anicteric, conjunctiva pale, no epistaxis or\\n rhinorrhea, dry MM, OP Clear\\n NECK: No JVD, carotid pulses brisk, no bruits, shotty anterior cervical\\n lymphadenopathy, trachea midline\\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\\n PULM: diffuse rhonchi/crackles bilaterally almost to apices\\n ABD: Soft, NT, ND, +BS, +hepatomegaly (four finger-breaths below costal\\n margin)\\n EXT: +1pitting edema lower extremities bilaterally, no palpable cords,\\n no cyanosis/clubbing, diffuse faint non-pruritic macular rash from feet\\n -> knees\\n NEURO: alert, oriented to person, place, and time. CN II\\n XII grossly\\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\\n extremities. Patellar DTR +1. Plantar reflex downgoing. No gait\\n disturbance. No cerebellar dysfunction.\\n SKIN: Diffuse macular rash in LE bilaterally from feet -> kness,\\n scattered telangiectasias in malar area of face\\n Labs / Radiology\\n 543 K/uL\\n 219 mg/dL\\n 9.7 mg/dL\\n 144 mg/dL\\n 16 mEq/L\\n 107 mEq/L\\n 6.2 mEq/L\\n 143 mEq/L\\n 31.0 %\\n [image002.jpg]\\n CXR : bilateral fluffy pulmonary infiltrates, costophrenic angles\\n visible (pending read by radiology)\\n EKG : similar to prior EKG from OSH, with atrial flutter\\n predominantly in limb leads, rate 121\\n \\n 2:33 A8/9/ 11:05 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 Hct\\n 31.0\\n Plt\\n 543\\n Cr\\n 9.7\\n Glucose\\n 219\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.6** mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n .\\n Plan:\\n .\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - Continue supplemental O2 PRN\\n - Albuterol nebs PRN\\n - Daily CXR's\\n - Type and screen, cross match x 2 units; threshold to transfuse hct\\n <21, unless clinically unstable\\n - Blood consent\\n - Consult Renal and Rheum in a.m.\\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\\n get renal biopsy\\n - Will continue Solumedrol 1g IV daily\\n - F/u on Renal serology and BAL results from OSH\\n - Will check Crits q8\\n .\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\\n Denies epistaxis. However, apart from pulmonary association, ddx for\\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\\n ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's.\\n - Re-check u/a, urine lytes, urine sediment\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Consult Renal here\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Start Sevelemer in a.m. with meals for elevated Phos.\\n .\\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\\n Can be secondary to underlying structural heart disease. Also may be\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n - Check TSH\\n - Surface ECHO in a.m.\\n - Will start Lopressor 12.5mg PO daily for rate control.\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check Crits q8\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\\n respiratory status worsens anticipating intubation. Will replete lytes\\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\\n .\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control: RISS\\n Lines: 2 PIVs\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: Pantoprazole PO\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334007,\n \"text\": \"This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\\n syndrome.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\\n activities.But when resting and sleeping in 80\\ns-90\\ns.NBP within\\n limits.No drop in BP with high HR.\\n Action:\\n Pt is on metoprolol for rate control.\\n Response:\\n HR in 80\\ns 90\\ns while at rest.\\n Plan:\\n Cont monitoring.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\\n with diminished base.Pt has got strong productive cough.\\n Action:\\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\\n is on high dose of steroids and had chemo.And pt is getting\\n plasmapheresis every other day.\\n Response:\\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\\n Plan:\\n Cont monitoring resp status.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\\n Action:\\n Renal failure most likely due to vasculitis. Pt is getting treated by\\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\\n Na.\\n Response:\\n Phos still high,Na 141 thos am.\\n Plan:\\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334102,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Overall, no significant change in supplimental oxygen requirement.\\n Overall, appears much more comfortable.\\n Able to eat.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.2\\nC (95.4\\n HR: 90 (72 - 133) bpm\\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\\n RR: 22 (19 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 443 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 443 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 485 mL\\n Urine:\\n 1,405 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -42 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, High flow neb\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Well nourished, No(t) No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\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, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 6.9 g/dL\\n 261 K/uL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\\n bibasilar, unchanged.\\n Assessment and Plan\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\\n Await renal Bx results and serologies.\\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\\n BUN, creatitine, UO.\\n NUTRITIONAL SUPPORT -- advance PO.\\n FLUIDS -- provide adequate urine output (cytoxan)\\n HYPERGLYCEMIA -- promoted by steroids.\\n A-FLUTTER -- good rate control. Continue meds.\\n ANEMIA -- slow reduction. Transfuse to >21\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334581,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334584,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt continusly pulling the mask off inspite of frequently remainding\\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\\n mask off,denies any SOB,pain or discomfort.\\n Action:\\n On nebs and steroids,FM 60 % and additional NC is on,frequent\\n reinforcement needed about need for oxygen.\\n Response:\\n Pt strongly denies for any pain,SOB\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334644,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\\n edema, 2L fluids up.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\\n RR: 23 (9 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 979 mL\\n PO:\\n 750 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 979 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 640 mL\\n Urine:\\n 2,400 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 339 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 211 K/uL\\n 7.8 g/dL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR.\\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\\n appropriately to 1unit PRBCs so likely not currently bleeding.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Prednison po daily,\\n -Cyclophosphamide-dose to be determined after c/s with rheum and\\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\\n far.\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: Monitoring for need for dialysis, has line in\\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\\n signs of platelet dysfunction yet, mental status ok. Renal will give\\n his kidneys about 48 more hours to turn around before dialyzing. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\\n cryglobulins, ANCA.\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -pink tinged urine, stable, but will send daily U/As.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiacc negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334799,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Dx: Wegener\\ns Granulomatosis confirmed by renal biopsy\\n Atrial flutter (Aflutter)\\n Assessment:\\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\\n frequent episodes of tachycardia in the 130\\ns, typically with exertion,\\n stimulation and desats. BP within normal limits.\\n Action:\\n Tolerating metoprolol PO\\n Response:\\n Heart rate slows to the 80-90\\ns with rest, VS WNL\\n Plan:\\n Continue to monitor Heart rate/rhythm, administer metoprolol as\\n ordered. Encourage rest periods\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\\n noted. Creatinine is 6.5, BUN 153\\n Action:\\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\\n Creatinine is trending down. Hct drawn at 1530, result 24.\\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\\n with meals. Lunch held due to respiratory distress.\\n Response:\\n Labs to be drawn 8pm (4 hours after plasmaphoresis) and tonight at 2200\\n (check with team). Fluid balance remains positive. Good urine output\\n response to lasix. Tolerated plasmaphoresis with episodes of\\n tachycardia.\\n Plan:\\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\\n total of 7 treatments via right IJ HD catheter. Administer mesna as\\n ordered with chemo. Chemo to be given after plasmaphoresis.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\\n strong productive cough. Patient\\ns O2 requirements increasing\\n throughout the day.\\n Action:\\n O2 titrated accordingly. Face tent increased/decreased, now at 80% and\\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\\n albuterol changed to prn (may be contributing to tachycardia). Afrin\\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\\n on.\\n Response:\\n Oxygenation remains labile. Desats with eating and removal the face\\n tent. Recovery time longer each time he desats. Left lung sounds better\\n than this am.\\n Plan:\\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\\n sputum sample. Patient may need a sinus CT scan if stable. Administer\\n neb treatments as ordered.\\n Patient\\ns family at bedside. Updated on plan of care.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333590,\n \"text\": \"Chief Complaint: ARF, alveolar hemorrhage\\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\\n cytoxan 120 mg there. He was transferred for consideration of\\n plasmapheresis.\\n 24 Hour Events:\\n EKG - At 10:48 PM\\n -Tachycardic to low 100s with EKG concerning for A.flutter\\n -Hyperkalemic requiring kayexalate\\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 RISS\\n Solumedrol 1 g daily\\n Albuterol Q6H\\n Atrovent Q6H\\n Protonix\\n Colace\\n Lopressor 12.5 mg \\n Renagel\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Tachycardia\\n Respiratory: Cough, No hemoptysis\\n Gastrointestinal: Nausea\\n Genitourinary: Foley\\n Integumentary (skin): Rash, Diffuse maculopapular\\n Heme / Lymph: Anemia\\n Flowsheet Data as of 09:15 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.3\\nC (95.6\\n HR: 109 (106 - 123) bpm\\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\\n RR: 30 (16 - 31) insp/min\\n SpO2: 93%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 426 mL\\n PO:\\n 230 mL\\n 240 mL\\n TF:\\n IVF:\\n 186 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 495 mL\\n Urine:\\n 125 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -69 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n FiO2: 4 L\\n SpO2: 91%\\n Physical Examination\\n General Appearance: No acute distress, Tachypneic\\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\\n Bilateral )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: None.\\n Skin: Few petechiae at feet. MacPap rash resolving\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.0 g/dL\\n 513 K/uL\\n 213 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 5.5 mEq/L\\n 147 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 26.6 %\\n 7.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL\\n Fluid analysis / Other labs: AG 20\\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\\n interstitial components. Normal cardiomediastinal contours. Minimal\\n bilateral costophrenic blunting.\\n Microbiology: None.\\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\\n Wegener\\ns granulomatosis, MPA, Goodpasteur\\ns, lupus, post-strep GN with\\n DIC (less likely). He is currently clinically stable and has been\\n started on solumedrol and cytoxan.\\n 1) Pulmonary-renal syndrome\\n ANCA, anti-GBM, , anti-dsDNA,\\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\\n serologies pending. Will consult renal for cytoxan dosing,\\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\\n 2) Anemia\\n Likely alveolar hemorrhage. Will rule out\\n hemolysis. Trend Q8H until stable.\\n 3) Renal failure\\n No acute indication for RRT at this point.\\n Does have an AG metabolic acidosis. Hyperkalemia currently\\n controllable with medications. No EKG changes. Renagel. Follow\\n electrolytes.\\n 4) Atrial flutter\\n Start low-dose beta-blockade. TSH pending.\\n TTE pending.\\n MICU Attending Addendum\\n Pt seen with fellow and examined. Met with pt and family to review\\n situation. Would add and emphasize the following to Dr \\ns notes.\\n On exam\\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\\n alos right forearm.\\n ABG 7.31/37/67\\n BUN 147/ Cr 9.6\\n CXR: diffsue bilateral interstitial and alveolar infiltrates\\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\\n and renal failure quite concerning for vasculitis.\\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\\n Role of plasmapheresis without clear diagnosis is challenging. Will\\n consult with Renal collegues on possibility of a renal biopsy to aid in\\n diagnosis. Additionally he is moving towards dialysis, need to closely\\n watch K, renally dose all meds. His resp status is tenusous due to\\n hypoxemia as well as met acidosis and uremic encephalopathy- may\\n require intubation for support\\n would likely favor this over NIPPV\\n given likely duration.\\n Discussed with son who is HCP and updated.\\n ICU Care\\n Nutrition: Renal, cardiac\\n Glycemic Control: Regular insulin sliding scale\\n Lines: Peripheral IVs\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Protonix\\n VAP: N/A\\n Comments:\\n Communication: Comments:\\n Code status: Full code. Son, , is HCP.\\n Disposition :Remains in ICU.\\n Total time spent: Critically Ill 50 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334220,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt remains in aflutter at a rate of 70s-low 100s occationally going to\\n the 120s-130s\\n Action:\\n Conts on lopressor 50mg TID\\n Response:\\n HR was fairly well controlled though does have episodes of tachycardia\\n in the setting of eating or low SATs\\n Plan:\\n Cont with the lopressor, follow VS, replete lytes\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Creat remains high, it was 7.6 this morning and 8.0 this afternoon.\\n Calcium conts to be low as well as mag\\n Action:\\n Received 4 gms of calcium this morning and had a repeat ionized Ca of\\n .86, he is presently receiving another 4 gms of Ca and 2 gm of MgS04.\\n He is also receiving NS at 100cc/hr to try and protect his bladder from\\n the cytoxan, to receive cytoxan again tonight\\n Response:\\n Creat bumped this afternoon, u/o 70-30cc/hr, conts with low Ca with his\\n pheresis\\n Plan:\\n Presently being pheresed, to get cytoxan tonight\\n this needs to be\\n arranged with the 7Feldberg nurses, follow ionized Ca, creat, f/u on\\n the renal biopsy from yest.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi and wheezes, 02 SAT has improved today from yest with\\n an 02 SAT ~ 93% on 6 L NC, he states that he feels a little better\\n today. Occationally has a wet cough but not bringing anything up.\\n Action:\\n Tolerating a lower FI02\\n Response:\\n Plan:\\n Cont to follow 02 requirements, decrease the FI02 as he tolerates,\\n started on mepron for PCP prophylaxis\\n the bactrim was d/ced due to\\n his renal failure\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334640,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\\n RR: 23 (9 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 979 mL\\n PO:\\n 750 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 979 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 640 mL\\n Urine:\\n 2,400 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 339 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 211 K/uL\\n 7.8 g/dL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334646,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt continuesly pulling the mask off inspite of frequently remainding\\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\\n mask off,denies any SOB,pain or discomfort.\\n Action:\\n On nebs and steroids,FM 60 % and additional NC is on,frequent\\n reinforcement needed about need for oxygen.\\n Response:\\n Pt strongly denies for any pain,SOB but continued to be uncomfortable\\n during night,MD was informed.No meds ordered at this time.\\n Plan:\\n Continue to monitor resp status,follow up AM lab results,bleeding time\\n should be drawn by lab at AM.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333752,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx. Pt was adm on .\\n Atrial flutter (Aflutter)\\n Assessment:\\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\\n the high 120-130 range during plasmapharesis. B/P has remained stable\\n 110/78-132/69.\\n Action:\\n Lopressor was increased to 50mg tid which was started last evening.\\n Response:\\n H/R is decreasing from the 100\\ns to the 80-90range.\\n Plan:\\n Cont with tid lopressor. Monitor h/r and pattern.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\\n Action:\\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\\n past 24 hours pt has had 2 doses of Kayexalate. Will not repleat K+ of\\n 3.9 this am as pt rises.\\n Response:\\n K+ is 4. U/O improving with urine more yellow. Creat 8.6/bun149 this\\n am.\\n Plan:\\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\\n lungs have had crackles bil bases with the left lung more dim than the\\n right..\\n Action:\\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\\n evening and was given cytoxan after the plasmaphoresis. Pt is also\\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\\n Response:\\n Sao2 drops to the high 80\\ns while pt wears only the n/c. pt does not\\n like to wear face mask and denies any sob.\\n Plan:\\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\\n plasmaphoresis again on Tues.\\n Hct 22.8 this am and team would like to discuss in rounds as to further\\n transfusions. Team wants Hct drawn at 0800. pt will also receive\\n calcium gluconate 4gm to replenish 5.9. Na+ 150. Phos 9.5\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333876,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt remains in aflutter at a rate of 70s-low 100s\\n Action:\\n Conts on lopressor 50mg TID\\n Response:\\n Tolerating the lopressor, he did have short periods of a HR in the\\n 1teens this afternoon\\n Plan:\\n Cont with the lopressor, follow VS\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Creat was 8.6 this morning, u/o has been 40-50cc/hr\\n Action:\\n Pt had a renal biopsy this morning under US guidance, receiving D5W\\n 100cc/hr for 1 liter for a Na of 150\\n Response:\\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\\n Plan:\\n Follow HCT, VS, renal bx results, no immediate plans for dialysis,\\n follow labs\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\\n has not been coughing up any blood\\n Action:\\n He is on scoop mask at 60-70% and this brings his 02 up to 93-99%.\\n Response:\\n Conts to require a high FI02, he wants to eat but is NPO due to his\\n tenuous resp status\\n Plan:\\n Follow SATs cont to try to wean his FI02\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334483,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Remains with high FiO2 requirment.\\n Renal bx consistent with Wegener's Granulomatosis.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 35.9\\nC (96.6\\n HR: 99 (87 - 130) bpm\\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\\n RR: 21 (9 - 28) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,477 mL\\n 2,103 mL\\n PO:\\n 60 mL\\n TF:\\n IVF:\\n 2,102 mL\\n 2,043 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 1,025 mL\\n Urine:\\n 1,360 mL\\n 1,025 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,117 mL\\n 1,078 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.6 g/dL\\n 221 K/uL\\n 94 mg/dL\\n 7.2 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 149 mg/dL\\n 105 mEq/L\\n 145 mEq/L\\n 22.7 %\\n 9.0 K/uL\\n [image002.jpg]\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n WBC\\n 8.1\\n 5.4\\n 9.0\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n Plt\\n 355\\n 261\\n 221\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\\n Assessment and Plan\\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\\n likey due to vasculitis. Radiographically without significant change,\\n but hope to see improvement over next several days. Monitor RR, SaO2.\\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\\n improve.\\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\\n plts). Monitor Hct, transfuse to > 21\\n WEGENER\\\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\\n plasmaphoresis QOD.\\n FLUIDS -- euvolemic. Monitor I/O\\n HEMATURIA -- concern for hemorrhagic cystitis\\n A-FIB -- good rate control COntinue meds. Monitor HR.\\n NASAL CONGESTION -- possible related to Wegener's but more likely due\\n to high flow O2. Symptomaatic relief.\\n HYPOCALCEMIA -- repleted. Monitor.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333854,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight the patient remained stable, but continuing to require O2 by\\n NC and facemask. HR down to 80s with lopressor but remains in\\n aflutter. This am patient only c/o hunger.\\n EKG - At 02:00 PM\\n DIALYSIS CATHETER - START 06:48 PM\\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 01:53 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: 35.2\\nC (95.3\\n HR: 94 (72 - 133) bpm\\n BP: 109/58(70) {104/53(66) - 142/88(102)} mmHg\\n RR: 25 (18 - 29) insp/min\\n SpO2: 88%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 902 mL\\n 1,042 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 662 mL\\n 485 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,330 mL\\n 1,080 mL\\n Urine:\\n 1,330 mL\\n 1,080 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -429 mL\\n -38 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 88%\\n ABG: 7.31/37/67/22/-6\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: No acute distress\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral, almost \\n way up lungs posteriorly)\\n Extremities: Right: 1+ pitting, Left: 1+ pitting,, diffuse rash below\\n knees\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 355 K/uL\\n 7.6 g/dL\\n 176 mg/dL\\n 8.6 mg/dL\\n 22 mEq/L\\n 3.9 mEq/L\\n 149 mg/dL\\n 108 mEq/L\\n 150 mEq/L\\n 22.6 %\\n 8.1 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n WBC\\n 7.4\\n 8.1\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n Plt\\n 543\\n 513\\n 355\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - follow HCT q6h to monitor for alveolar bleeding. Concern given\\n recent HCT drop. Transfusion threshold is HCT<21\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Figure out exact 02 requirement (patient on facemask, not always\\n wearing it)\\n - Albuterol nebs PRN\\n - repeat CXR\\n - F/u on BAL results from OSH\\n - Continue to keep patient NPO due to tentative respiratory status (and\\n renal biopsy).\\n (see t'ment plan for presumed Wegener's under acute renal failure)\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on was 126/9.6, K 5.8. Nephritic\\n picture with RBC casts. However, apart from pulmonary association, ddx\\n for acute renal failure with nephritis includes PSGN, lupus nephritis,\\n etc. ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's. Also consider DIC.\\n - Renal biopsy today, FFP on call due to INR 1.5\\n - For presumed Wegeners, started Plasmapheresis (firs tt'ment last\\n night, will be QOD x 5 treatments)\\n - Continue Solumedrol 1g IV daily\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Will check q8 lytes for now\\n - Continue Sevelemer in a.m. with meals for elevated Phos.\\n - Renal c/s recommends also starting Amphagel (phosphate binder) 30cc\\n po tid for 2-3 days for elevated Phos.\\n #Hypernatremia: NA+ today 150, up from 147, likely lack of access\\n to free water\\n -Replace w/ D5NS\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -Replace Ca2+\\n # Tachycardia: Aflutter on EKG. Until yesterday, was asymptomatic but\\n rate in 120s. Can be secondary to underlying structural heart disease.\\n Also may be secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - F/u on TSH\\n - TTE today\\n - Lopressor titrated up to 50 mg PO tid with good rate control (HR in\\n 80s).\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: NPO for worsening respiratory status, anticipating intubation.\\n Will replete lytes PRN.\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Case Management \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Case Managment Initial Patient Assessment\",\n \"row_id\": 333828,\n \"text\": \"Insurance information\\n Primary insurance: OOS PPO-NON MANAGED CARE\\n Secondary insurance: SELF PAY\\n Insurance reviewer::\\n Free Care application: N/A\\n Status:\\n Medicaid application: N/A\\n Pre-Hospitalization services: None prior to admission\\n DME / Home O[2]: None prior to admission\\n Functional Status / Home / Family Assessment:\\n Pt. Lives alone in . He is divorced . He has a son who\\n lives with the patient's ex-wife. PTA he was working and independent\\n with all ADL's\\n Primary Contact(s): (son) \\n Health Care Proxy: .\\n Dialysis: No\\n Referrals Recommended: Social Work, Physical Therapy\\n Current plan: Undetermined\\n Unclear what level of services will be required at discharge. Case\\n Management will follow for DC needs.\\n If VNA services needed can use:\\n VNA of SE Mass - \\n - \\n Centrus Premier Home Care - \\n Patient (s) to Discharge:\\n Medically unstable\\n Patient discussed with multidisciplinary team: No\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333866,\n \"text\": \"Chief Complaint: Respiratory distress/hypoxemia\\n HPI:\\n 24 Hour Events:\\n EKG - At 02:00 PM\\n DIALYSIS CATHETER - START 06:48 PM\\n Renal consultation concurred with Pulmonary-Renal syndrome.\\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\\n anticipating 5 days of treatment. Remains on cortocosteroids.\\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\\n Denies increased dyspnea, but remains with oxygen requirement.\\n History obtained from Patient\\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 09:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.3\\nC (95.5\\n HR: 81 (81 - 133) bpm\\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\\n RR: 24 (22 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 902 mL\\n 186 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 662 mL\\n 186 mL\\n Blood products:\\n Total out:\\n 1,330 mL\\n 690 mL\\n Urine:\\n 1,330 mL\\n 690 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -429 mL\\n -504 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: 7.31/37/67/22/-6\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\\n mildly disshevled\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.6 g/dL\\n 355 K/uL\\n 176 mg/dL\\n 8.6 mg/dL\\n 22 mEq/L\\n 3.9 mEq/L\\n 149 mg/dL\\n 108 mEq/L\\n 150 mEq/L\\n 22.6 %\\n 8.1 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n WBC\\n 7.4\\n 8.1\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n Plt\\n 543\\n 513\\n 355\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\\n predominantly basilar. Right IJ catheter position acceptable. No\\n significant overall change compared to .\\n Assessment and Plan\\n 60 yom now with Pulmonary-Renal syndrome.\\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\\n diffuse infiltrates and oxygen requirement.\\n HYPOXEMIA -- attributed to pulmonary infiltrates. Monitor SaO2,\\n supplimental O2 to maintain SaO2 >90%.\\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\\n SaO2.\\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\\n consult prepared to move to dialysis when indicated. Monitor urine\\n output, BUN, Creatitine.\\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\\n Continue steroids and plasmaphoresis.\\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\\n FLUIDS -- limit iv fluids intake.\\n HYPERPHOSPHATEMIA -- start phosphate binder.\\n NUTRITION -- NPO pending evaluation\\n ANEMIA -- progressive, attributed to underlying process, and possible\\n contribution from RIJ central line placement. Transfuse to Hct >21.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334546,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Atrial flutter (Aflutter)\\n Assessment:\\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\\n has episodes of tachycardia in the 130\\ns, typically with exertion or\\n desats. BP within normal limits.\\n Action:\\n Tolerating metoprolol PO\\n Response:\\n Heart rate slows with NSR episodes, VS WNL\\n Plan:\\n Continue to monitor Heart rate/rhythm, administer metoprolol as\\n ordered.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\\n noted. Creatinine is 6.9, BUN 149\\n Action:\\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\\n administration of cyclophosphamide (chemo)\\n Response:\\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\\n since midnight.\\n Plan:\\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\\n HD catheter, may have it . Administer mesna as ordered with chemo\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\\n weak cough. +1.6L positive. Patient would frequently remove face tent,\\n thus dropping O2 sats.\\n Action:\\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\\n 6L NC. Patient encouraged to cough and deep breathe. Neb treatments as\\n ordered\\n Response:\\n Oxygenation has improved throughout the afternoon with patient\\ns family\\n at the bedside\\n Plan:\\n Continue to titrate O2, encourage deep breathing and coughing.\\n\"\n }\n]"}}},{"rowIdx":181,"cells":{"subject_id":{"kind":"number","value":26083,"string":"26,083"},"hadm_id":{"kind":"number","value":120427,"string":"120,427"},"target_text":{"kind":"string","value":"A/P: 84 y/ with h/o HTN, severe MR, and transferred to the ICU for abdominal pain and rising lactate/wbc. Please HPI for details of admission prior to ICU: . 1. Abdominal pain- on transfer, ddx includes perforated viscus and mesenteric ischemia. recent CTA showed no evidence of AAA. possible gastritis/ulcer dz w/ high dose steroids and hospitalization. surgery following and KUB w/out evidence of colonic obstruction or free air. lactate continued to rise following ICU transfer, despite elevated CVP and lack of respiratory variation, both indicative of volume repletion. patient continued to have minimal abdominal pain but did have other signs of poor cardiac output including a mixed venous sat of 42%. on the day of the patient's demise, his lactate was 8.6. . . 2. crpytogenic organizing pna- seen on prior needle biopsy and some improvementon high dose steroids (radiographic). O2 sats stable on NC but significant desaturation with any activity. on in the process of being rolled, the patient became acutely SOB and subsequently became apneic. per his family's documented request, a Code was not called. he subsequently expired. . 3. pt /w baseline creatinine of ~1.4 but elevated to 2.7 on micu admission. renal ultrasound today w/out evidence of obstruction/hydronephrosis. continued to worsen in the setting of poor cardiac output. . 4. Severe MR: pt in the process of preparing for a MVR prior to this admission. major contributor to the patient's poor forward flow. . 5. Coagulopathy: Initially likely poor nutritional status but now concern for DIC in setting of mesenteric ischemia ."},"extractive_notes_summ":{"kind":"string","value":"Just returned from abd CT ruling out ischemic bowel. The pt then became bradycardic, remained apneic c no BP measurable. CxR showing worsenig PNACaridac: SR with no ectopy since arrival. Sinus tachycardiaPossible left atrial abnormalityModest nonspecific ST-T wave changesSince previous tracing of , ventricular ectopy absent PO lopressor on hold as b/p is hypotensive 90's/30's. Sinus rhythmIndeterminate axisLow limb lead QRs voltagesModest right ventricular conduction delay patternFindings are nonspecific but clinical correlation is suggested for possiblechronic pulmonary diseaseSince previous tracing of , sinus tachycardia rate slower Nursing Progress Note.Pt functional status progressively worsened over the coarse of the day, pt code status subsequently changed from DNR -- CPR not indicated to full DNR/DNI by team this AM c likely CMO as status waranted. infectious process Admitting Diagnosis: SHORTNESS OF BREATH FINAL REPORT (Cont) Sinus tachycardiaSlight ST-T wave changes - are nonspecific and may be within normal limitsSince previous tracing of , right precordial ST-T wave changes slightlyless prominent Pt has severe mvr and was in process of workup for mitral valve repair when MD suggested he visit ED.GU: Abd soft with positive bowel sounds. Perihperal pulses weakly palpable.ID: Afebrile. Since the previous tracing of the rate isincreased and ventricular ectopy is new. (Over) 11:47 AM CT CHEST W/O CONTRAST Clip # Reason: ? Did have period where he had some confusion while hypotensive, but resolved after fluid boluses. B/P droping as low as 70's/20's prior to fluid boluses. chf.resp remains on 2to3 l nc, ls clear with crackles in bases in am to cracles thru out after line placemnt and receving 2 units of ffp. 11:47 AM CT CHEST W/O CONTRAST Clip # Reason: ? Moderate non-hemorrhagic layering left pleural effusion is new. Events: Bolused with 250cc NS x3 for low u/o and hypotension. Pt states breathing is easier than previous but rr remains tachypneic (30's) at times.Cardiac: SR with no ectopy throughout shift. Unfortunately, the pt became apneic following a routine position change, ETS was attempted but unsuccessful. Left perihilar consolidation is the most significant region of abnormality followed by the right lung base and these areas have not cleared. K+5.8 Phos 9.1 Mg 3.2 BUN 97 and Cr3.8Heme: HCT down to 25.8 (28.5) INR up to 2.3 (2.5) received 2uffp prior to TLC placement yesterday.Derm: Grossly intact. Some minimal presacral fluid and some minimal fluid in the pelvis of unknown etiology. Below the diaphragm, given that this is a non-contrast CT, note is made of a low-attenuation lesion measuring 11 mm in the dome of the liver which is unchanged when compared to the previous CT from . FINDINGS: A right internal jugular vein approach central venous line is present seen to terminate overlying the SVC at the level 2 cm below the carina. Left pleural effusion. UPRIGHT AP CHEST: No free air is visualized beneath the hemidiaphragm. Sigmoid diverticula. There is a left pleural effusion. Scarring right base and bilateral effusions. There is a possible tiny right pleural effusion. While the right pleural effusion has nearly resolved, the moderate left pleural effusion has not. CT OF PELVIS: Note is made of some sigmoid diverticula. The left pleural effusion appears slightly decreased. HISTORY: Dyspnea and tachycardia. Grayscale and Doppler son of the left and right common femoral, superficial femoral, and popliteal veins were performed. 2:41 AM PORTABLE ABDOMEN Clip # Reason: Signs of perforation? INDICATION: Right internal jugular central venous line placement. Signs of ischemia? Note is made of some coronary artery calcification. The lung bases reveal a small right pleural effusion and a moderate-sized left pleural effusion. A subcentimeter lesion is seen in segment VII and is unchanged. IMPRESSION: No free air beneath the hemidiaphragm is visualized. Right upper lobe patchy opacities are also again seen. There is some right- sided linear atelectasis. A granuloma is noted in the right base. Just anterior to the sacrum, note is also made of some minimal fluid. A subcentimeter lesion is seen in segment and is unchanged. Cardiac silhouette is slightly enlarged, and there is persistence of vascular engorgement in the superior mediastinum suggesting cardiac decompensation and/or volume overload. The sequence of changes suggests the persistence of asymmetric edema, and clearing of the inflammatory process in the right upper lobe and improvement, but persistence of what is likely the same process in the right lower lobe. Rule out hydronephrosis or other blockage. A Foley catheter is in the urinary bladder, which is decompressed. The appearances suggest failure with probable pneumonia. Comparison made to CTA of the abdomen dated . Some vascular calcification is noted in relation to the aorta. No contraindications for IV contrast FINAL REPORT CT ABDOMEN INDICATION: Cryptogenic pneumonia, acute renal failure, abdominal pain. This patient is status post cholecystectomy."},"n_notes":{"kind":"number","value":22,"string":"22"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2200-08-28 00:00:00.000","description":"Report","row_id":1601651,"text":"Pt is a 84 y/o who presented to our ED on recomendation from his PCP after CxR as outpt showed new infiltrate. Pt was being worked up for a mitral valve repair due to severe MVR. Admitted to 2 where sputum cx grew out yeast, urine also noted to be cloudy and was cultured . On floor pt was having increasing O2 requirements and some shortness of breath. Also, pt was having increasing abd pain ( on arrival to MICU). Lab values INR 2.3 K 6 WBC 24 Lactic Acid 5. CxR done showing worsening PNA and pt's urine output had diminished to 50cc for entire night shift. Decision made to tx to MICU for increased monitoring and treatment. ABD CT done to r/o ischemic bowel.\n\nNeuro: Pt a+ox3, following commands consistently. MAE, drowsy as he has not had sleep in >24hrs. C/O abd pain \n\nResp: lung sounds with crackles. O2 sats mid 90's on 2L via n/c. Breathing somewhat labored but pt reports no difficulty breathing. CxR showing worsenig PNA\n\nCaridac: SR with no ectopy since arrival. PO lopressor on hold as b/p is hypotensive 90's/30's. Pt has severe mvr and was in process of workup for mitral valve repair when MD suggested he visit ED.\n\nGU: Abd soft with positive bowel sounds. C/O pain. No bm in spite of enemas on floor. Just returned from abd CT ruling out ischemic bowel. Surgery following. NPO.\n\nGU: No urine output since arrival on MICU. Due for labs at 0800.\n\nDerm: Grossly intact. PIV x1 20G intact. Perihperal pulses weakly palpable.\n\nID: Afebrile. On IV zosyn.\n\nPlan: Follow up on abd Ct, to surgery if positive, Lytes at 0800, monitor fluid status, and hemodynamic status.\n\nGU\n"},{"category":"Nursing/other","chartdate":"2200-08-29 00:00:00.000","description":"Report","row_id":1601654,"text":"Nursing Progress Note.\n\nPt functional status progressively worsened over the coarse of the day, pt code status subsequently changed from DNR -- CPR not indicated to full DNR/DNI by team this AM c likely CMO as status waranted. Family members (wife, two , -in-law) @ BS all AM and kept up to date c POC/pt status throughout shift. IVP 0.5mg Morphine provided this afternoon times two for pt discomfort c fair affect noted. Unfortunately, the pt became apneic following a routine position change, ETS was attempted but unsuccessful. The pt then became bradycardic, remained apneic c no BP measurable. Team notified and pt declared deceased @ approx 16:05. Please see CareVue for additional pt care data/comments. Family notified of event, verbal and non-verbal support provided by team.\n"},{"category":"Nursing/other","chartdate":"2200-08-28 00:00:00.000","description":"Report","row_id":1601652,"text":"npn\nevents central line placed, mri on hold until \n\nneuro:aox3, sleeping off and on, pt stating he is very tired.\npain: denies pain. exp. general discomfort from lying in bed. pain med given with line placement which pt tolerated well.\n\ncad hr sr 80 to 90's, nbp 80 systolic in am with two 250cc ns boluses given with nbp up to the 100 to 90's systolic , again dropped to the high 80's at 1730 to 1830 md aware, cvp 12 with some fluctuating noted to 18, pt given lasix 20 mg ivp at 1845 for ? chf.\n\nresp remains on 2to3 l nc, ls clear with crackles in bases in am to cracles thru out after line placemnt and receving 2 units of ffp. sats 91 to 975 rr teens to high 20 to bursts to 30 to 40's.\n\ngi: abd soft slight distended. bs+ no bm this shfit, no c/o abd pain, ? c/o nausea with md was ordered and given in afternoon. mri held at pt's request.\n\ngu: urine output increased to 10cc/hr after multiple boluses and antibiotics given. now 5cc/hr pt given lasix 20 mg ivp at 1845. last 6 pt given kayexlate po at 1600 awaiting results.\n\nendo: bs 108 to 172 las t bs not covered due to pooor po intake.\n\nid: afebrile, antibiotics given.\n\nplan: mri tomorrow am, cont to be full code, cont to moniotr vs, labs resp and fluid status.\n"},{"category":"Nursing/other","chartdate":"2200-08-29 00:00:00.000","description":"Report","row_id":1601653,"text":"Events: Bolused with 250cc NS x3 for low u/o and hypotension. Family in and decision made to change code status to CPR not indicated. Pt can be intubated if need be however.\n\nNeuro: A+Ox3 and following commnads. Did have period where he had some confusion while hypotensive, but resolved after fluid boluses. No complaints of pain this shift. Slept throughout shift but arousable to verbal stimuli.\n\nResp: Lung sounds with wheezes throughout and crackles in bases. O2 sats maintained in high 90's on 70% humidified O2 via face tent. Alb/atr nebs q4. Pt states breathing is easier than previous but rr remains tachypneic (30's) at times.\n\nCardiac: SR with no ectopy throughout shift. CVP 11-16. Bolused with total of 750cc NS to keep MAP's >60. B/P droping as low as 70's/20's prior to fluid boluses. B/P largely 90's/40's since midnight. Team has been reluctant to start pressors as pt has 4+MR.\n\nGI: Abd soft and nontender this shift. No c/o pain which had been yesterday. medicated with 0.5mg morphine prior to start of this shift. No BM this shift either. Pt may go for MRI later today to assess for ischemic bowel.\n\nGU: Pt given 20mg IV lasix, with no effect. Then 40mg IV lasix with similar results, then 80mg with approx 100cc's amber urine output. Renal is following. Pt's electrolytes remain increasingly out of balance. K+5.8 Phos 9.1 Mg 3.2 BUN 97 and Cr3.8\n\nHeme: HCT down to 25.8 (28.5) INR up to 2.3 (2.5) received 2uffp prior to TLC placement yesterday.\n\nDerm: Grossly intact. PIV x1 patent. TLC in RIJ placed yesterday patent with good blood return. Small hematoma at site unchanged.\n\nPlan: Family in today to meet with attending to discuss prognosis and plan of care, may go for MRI if decided to fully treat, Monitor lab data (?HD), monitor hemodynamic status, may start levophed if b/p cannot be maintained with small boluses. Pt is currently CPR not indicated but will be intubated if need be.\n"},{"category":"ECG","chartdate":"2200-08-28 00:00:00.000","description":"Report","row_id":197667,"text":"Sinus rhythm\nIndeterminate axis\nLow limb lead QRs voltages\nModest right ventricular conduction delay pattern\nFindings are nonspecific but clinical correlation is suggested for possible\nchronic pulmonary disease\nSince previous tracing of , sinus tachycardia rate slower\n\n"},{"category":"ECG","chartdate":"2200-08-26 00:00:00.000","description":"Report","row_id":197668,"text":"Sinus tachycardia\nSlight ST-T wave changes - are nonspecific and may be within normal limits\nSince previous tracing of , right precordial ST-T wave changes slightly\nless prominent\n\n"},{"category":"ECG","chartdate":"2200-08-25 00:00:00.000","description":"Report","row_id":197669,"text":"Sinus tachycardia\nPossible left atrial abnormality\nModest nonspecific ST-T wave changes\nSince previous tracing of , ventricular ectopy absent\n\n"},{"category":"ECG","chartdate":"2200-08-22 00:00:00.000","description":"Report","row_id":197670,"text":"Sinus tachycardia with ventricular ectopy. Ventricular rate 114 beats per\nminute. P-R interval 0.16. Since the previous tracing of the rate is\nincreased and ventricular ectopy is new. No other diagnostic changes have\noccurred.\n\n"},{"category":"ECG","chartdate":"2200-08-18 00:00:00.000","description":"Report","row_id":197914,"text":"Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\n\n"},{"category":"Radiology","chartdate":"2200-08-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926604,"text":" 9:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for progression of volume overload\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam\n REASON FOR THIS EXAMINATION:\n please evaluate for progression of volume overload\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:12 P.M., .\n\n HISTORY: Dyspnea and tachycardia.\n\n IMPRESSION: AP chest compared to through .\n\n There has been substantial improvement in pulmonary edema, particularly in the\n right lung. Left perihilar consolidation is the most significant region of\n abnormality followed by the right lung base and these areas have not cleared.\n Small bilateral pleural effusion has increased slightly on the left and\n decreased on the right. Heart is normal size. Mediastinal vascular\n engorgement is unchanged. Left-sided skinfold and overlying tubing should not\n be mistaken for pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-19 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":925836,"text":" 11:47 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? infectious process\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with new oxygen requirement, previous COP on biopsy, hemoptysis\n following CT guided biopsy on .\n REASON FOR THIS EXAMINATION:\n ? infectious process\n CONTRAINDICATIONS for IV CONTRAST:\n increased creatinine\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n REASON FOR EXAM: 84-year-old man with increased oxygen with history of\n organizing pneumonia\n\n COMPARISON: Comparison is made with prior study dated .\n\n TECHNIQUE: Multidetector CT through the chest performed in full inspiration\n and expiration. 2.5 and 1.25 mm collimation images were reviewed.\n\n FINDINGS:\n Extensive peripheral consolidations in the apico- posterior segments of the\n left upper lobe, posterior segment of the right upper lobe and right basal\n posterior and lateral segments have worsened\n New bilateral apical ground-glass opacities, and increase in the interstitial\n abnormality with peribronchial infiltration that is continuous with the\n consolidations, are either worsening of the preexistingpneumonia\n or superimposed pulmonary edema.\n\n The airways are patent to segmental level. Multiple prevascular,\n paratracheal, and subcarinal lymph nodes have increased in number and size,\n for instance the largest in the left lower paratracheal region (2:53)\n measuring 11 mm, was 6 mm, and a 10 mm right lower paratracheal lymph node was\n 6 mm. Many of the paratracheal and right hilar lymph nodes are calcified.\n Moderate non-hemorrhagic layering left pleural effusion is new. A small amount\n of pleural effusion in the right side is loculated in the major fissure. There\n is no pericardial effusion. The LAD is mildly calcified; otherwise, the heart\n and great vessels are unremarkable.\n\n There are no bone findings of malignancy.\n\n In the upper abdomen, sub-cm hypodense lesions in the liver, too small to be\n characterized are likely cysts. Patient is post-cholecystectomy.\n\n IMPRESSION:\n\n 1. Worsening multifocal pneumonia, not hemorrhagic. Multifocal interstitial\n abnormalities are either progression of organizing pneumonia or edema.\n 2. New bilateral pleural effusions, larger in the left side.\n (Over)\n\n 11:47 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? infectious process\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2200-08-28 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":927008,"text":" 4:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: RIJ placement postprocedure\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pna, s/p RIJ placement\n REASON FOR THIS EXAMINATION:\n RIJ placement postprocedure\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Right internal jugular central venous line placement. History of\n cryptogenic pneumonia. Check for line position.\n\n FINDINGS: A right internal jugular vein approach central venous line is\n present seen to terminate overlying the SVC at the level 2 cm below the\n carina. No pneumothorax has developed, no other placement related\n complications are identified. Pulmonary and pleural abnormalities remain\n unchanged as described on previous study obtained 12 hours earlier during the\n same date.\n\n"},{"category":"Radiology","chartdate":"2200-08-27 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":926885,"text":" 9:15 PM\n PORTABLE ABDOMEN Clip # \n Reason: Signs of obstruction or perforation?\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with severe MR, BOOP and new diffuse abdominal pain with\n nausea.\n REASON FOR THIS EXAMINATION:\n Signs of obstruction or perforation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 84-year-old man with severe mitral regurgitation, BOOP, and\n abdominal pain.\n\n ABDOMEN, SINGLE SUPINE PORTABLE: No prior radiographs for comparison. The\n bowel gas pattern is unremarkable, without dilatation of the small or large\n bowel. There is stool in the ascending colon and rectum. Air is present\n within the rectum. There are cholecystectomy clips in the right upper\n quadrant.\n\n IMPRESSION: No evidence of obstruction.\n\n"},{"category":"Radiology","chartdate":"2200-08-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926300,"text":" 9:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulmonary edema, effusion\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia\n REASON FOR THIS EXAMINATION:\n eval pulmonary edema, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dyspnea, tachycardia.\n\n CHEST AP:\n\n Comparison is made with the prior chest from . There has been an\n increase in the size of the left pleural effusion. Some clearing of the\n opacities in the left upper lobe is seen. Patchy opacities are seen in all\n other parts of the lung. The appearances suggest failure with probable\n pneumonia.\n\n IMPRESSION: Increasing left effusion, some clearing of left upper lobe.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926347,"text":" 9:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? edema\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam.\n\n REASON FOR THIS EXAMINATION:\n ? edema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dyspnea, tachypnea. Evaluate failure.\n\n Since the prior chest x-ray of , there has been an increase in the\n size of the right pleural effusion, which now extends towards the apex.\n\n The interstitial is also somewhat more pronounced. These findings\n indicate worsening failure.\n\n IMPRESSION: Worsening failure.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926651,"text":" 9:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam\n\n REASON FOR THIS EXAMINATION:\n ? worsening failure\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:43 A.M .\n\n HISTORY: Dyspnea and tachycardia. Question worsening failure.\n\n IMPRESSION: AP chest compared to through .\n\n Previous heterogeneous opacification in the right upper lobe has largely\n cleared over the past two weeks and pulmonary edema in the right lung has\n largely resolved since . There is persistent severe\n perihilar opacification in the left lung and a slowly resolving heterogeneous\n region of opacity at the right lung base.\n\n While the right pleural effusion has nearly resolved, the moderate left\n pleural effusion has not.\n\n The sequence of changes suggests the persistence of asymmetric edema, and\n clearing of the inflammatory process in the right upper lobe and improvement,\n but persistence of what is likely the same process in the right lower lobe.\n Pleural effusions are probably secondary to pulmonary pathology. Cardiac\n silhouette is slightly enlarged, and there is persistence of vascular\n engorgement in the superior mediastinum suggesting cardiac decompensation\n and/or volume overload.\n\n Left skinfold should not be mistaken for pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-18 00:00:00.000","description":"CHEST (PA & LAT)","row_id":925757,"text":" 7:25 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with recent treatment for PNA\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of recent treatment for pneumonia.\n\n COMPARISON: Radiograph dated and CT scan dated and\n radiograph dated .\n\n PA AND LATERAL VIEWS OF THE CHEST: There is increased confluent opacity in\n the left upper lobe. The area of opacity in the right lower lobe appears\n increased compared to the previous exam, however, the most densely opacified\n area is slightly smaller. Right upper lobe patchy opacities are also again\n seen. There is no evidence of pneumothorax. There is a possible tiny right\n pleural effusion.\n\n IMPRESSION: Interval worsening of left upper lobe airspace opacity with\n possible interval increase in extent of opacity also in the right lower lobe.\n This may represent an infectious process.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-28 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":926899,"text":" 2:41 AM\n PORTABLE ABDOMEN Clip # \n Reason: Signs of perforation?\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pna, acute renal failure on high dose steroids\n with new abdominal pain.\n REASON FOR THIS EXAMINATION:\n Please do upright chest film. Signs of free air?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cryptogenic pneumonia and acute renal failure, now with 9 out of\n 10 abdominal pain. Evaluate for signs of free air.\n\n There are no prior studies for comparison.\n\n SUPINE ABDOMEN: There is no evidence of free air on the supine views. The\n bowel gas pattern is nonspecific, with air seen within non-dilated loops of\n small bowel and throughout the colon to the rectum. No evidence of\n obstruction. There are surgical clips in the right upper quadrant, likely\n related to cholecystectomy.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926900,"text":" 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ABDOMINAL PAIN/ CHECK FOR FREE AIR// ALSO SOB\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Patient with BOOP who is short of breath. Also, 9 out of 10\n abdominal pain. Evaluate for free air.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: No free air is visualized beneath the hemidiaphragm. Air\n space opacity within the left upper lobe has slightly improved compared to\n . The right upper lobe and right lower lung appear not\n significantly changed in the interim. Cardiomegaly and the aortic contours\n are unchanged. The left pleural effusion appears slightly decreased. No\n pneumothorax.\n\n IMPRESSION: No free air beneath the hemidiaphragm is visualized. Improved\n left upper lobe parenchymal opacification.\n\n"},{"category":"Radiology","chartdate":"2200-08-28 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":926901,"text":" 5:31 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please do abdominal CT scan with PO contrast (renal failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pneumonia, acute renal failure, new \n abdominal pain out of proportion to exam with elevated lactate.\n\n REASON FOR THIS EXAMINATION:\n Please do abdominal CT scan with PO contrast (renal failure precludes IV\n contrast). Signs of ischemia?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN\n\n INDICATION: Cryptogenic pneumonia, acute renal failure, abdominal pain.\n\n FINDINGS:\n\n A CT of abdomen and pelvis was performed with axial images taken from the lung\n bases to the symphysis pubis.\n\n Oral contrast only was administered because of the patient's renal failure.\n\n Multiplanar reconstructions in the coronal and sagittal planes were obtained.\n\n The lung bases reveal a small right pleural effusion and a moderate-sized left\n pleural effusion. A granuloma is noted in the right base. There is some right-\n sided linear atelectasis.\n\n Note is made of some coronary artery calcification.\n\n Below the diaphragm, given that this is a non-contrast CT, note is made of a\n low-attenuation lesion measuring 11 mm in the dome of the liver which is\n unchanged when compared to the previous CT from .\n\n A subcentimeter lesion is seen in segment VII and is unchanged.\n\n A subcentimeter lesion is seen in segment and is unchanged.\n\n The fourth lesion which was identified on the previous study is difficult to\n visualize on this study due to artifact from overlying skin markers.\n\n This patient is status post cholecystectomy.\n\n The spleen, adrenals, kidneys and pancreas are normal.\n\n No evidence of any significant lymphadenopathy.\n\n Some vascular calcification is noted in relation to the aorta.\n (Over)\n\n 5:31 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please do abdominal CT scan with PO contrast (renal failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The bowel where visualized is normal.\n\n CT OF PELVIS:\n\n Note is made of some sigmoid diverticula.\n\n The bladder is catheterized with a significant amount of air secondary to\n instrumentation.\n\n In the pelvis, a tiny amount of fluid is seen which measures approximately 2 x\n 1.3 cm. It is of unknown etiology.\n\n Just anterior to the sacrum, note is also made of some minimal fluid. Again,\n this is of unknown etiology.\n\n BONY WINDOWS:\n\n Note is made of degenerative change\n\n IMPRESSION:\n\n No evidence of any ischemic bowel given that this is a non-contrast CT.\n\n Multiple lesions in the liver which are unchanged.\n\n Some minimal presacral fluid and some minimal fluid in the pelvis of unknown\n etiology.\n\n Sigmoid diverticula.\n\n Scarring right base and bilateral effusions.\n\n\n\n"},{"category":"Radiology","chartdate":"2200-08-27 00:00:00.000","description":"RENAL U.S.","row_id":926851,"text":" 2:54 PM\n RENAL U.S. Clip # \n Reason: EVAL FOR HYDRONEPHROSIS OR OTHER BLOCKAGE\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with increasing creatinine with some urinary retention\n yesterday now s/p foley.\n REASON FOR THIS EXAMINATION:\n ? hydronephrosis or other blockage\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Renal ultrasound.\n\n CLINICAL HISTORY: 84-year-old man with increasing creatinine with some\n urinary retention yesterday. Now status post Foley. Rule out hydronephrosis\n or other blockage.\n\n FINDINGS: Renal ultrasound was performed on . No prior ultrasound\n studies available for comparison. Comparison made to CTA of the abdomen dated\n .\n\n The kidneys are normal in size, without evidence of hydronephrosis or solid\n renal masses. There is a small crystal in the renal cortex of the midpole of\n the left kidney. No perinephric fluid collections are seen.\n\n There is a left pleural effusion.\n\n A Foley catheter is in the urinary bladder, which is decompressed.\n\n IMPRESSION:\n 1. No evidence of hydronephrosis.\n 2. Left pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2200-08-26 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":926681,"text":" 12:48 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with hypoxia, tachypnea\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY ULTRASOUND\n\n HISTORY: 84-year-old male with hypoxia and tachypnea. Please evaluate for\n DVT.\n\n FINDINGS: No prior study is available for comparison. Grayscale and Doppler\n son of the left and right common femoral, superficial femoral, and\n popliteal veins were performed. Normal flow, augmentation, compressibility,\n and waveforms are demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1601651,\n \"text\": \"Pt is a 84 y/o who presented to our ED on recomendation from his PCP after CxR as outpt showed new infiltrate. Pt was being worked up for a mitral valve repair due to severe MVR. Admitted to 2 where sputum cx grew out yeast, urine also noted to be cloudy and was cultured . On floor pt was having increasing O2 requirements and some shortness of breath. Also, pt was having increasing abd pain ( on arrival to MICU). Lab values INR 2.3 K 6 WBC 24 Lactic Acid 5. CxR done showing worsening PNA and pt's urine output had diminished to 50cc for entire night shift. Decision made to tx to MICU for increased monitoring and treatment. ABD CT done to r/o ischemic bowel.\\n\\nNeuro: Pt a+ox3, following commands consistently. MAE, drowsy as he has not had sleep in >24hrs. C/O abd pain \\n\\nResp: lung sounds with crackles. O2 sats mid 90's on 2L via n/c. Breathing somewhat labored but pt reports no difficulty breathing. CxR showing worsenig PNA\\n\\nCaridac: SR with no ectopy since arrival. PO lopressor on hold as b/p is hypotensive 90's/30's. Pt has severe mvr and was in process of workup for mitral valve repair when MD suggested he visit ED.\\n\\nGU: Abd soft with positive bowel sounds. C/O pain. No bm in spite of enemas on floor. Just returned from abd CT ruling out ischemic bowel. Surgery following. NPO.\\n\\nGU: No urine output since arrival on MICU. Due for labs at 0800.\\n\\nDerm: Grossly intact. PIV x1 20G intact. Perihperal pulses weakly palpable.\\n\\nID: Afebrile. On IV zosyn.\\n\\nPlan: Follow up on abd Ct, to surgery if positive, Lytes at 0800, monitor fluid status, and hemodynamic status.\\n\\nGU\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1601654,\n \"text\": \"Nursing Progress Note.\\n\\nPt functional status progressively worsened over the coarse of the day, pt code status subsequently changed from DNR -- CPR not indicated to full DNR/DNI by team this AM c likely CMO as status waranted. Family members (wife, two , -in-law) @ BS all AM and kept up to date c POC/pt status throughout shift. IVP 0.5mg Morphine provided this afternoon times two for pt discomfort c fair affect noted. Unfortunately, the pt became apneic following a routine position change, ETS was attempted but unsuccessful. The pt then became bradycardic, remained apneic c no BP measurable. Team notified and pt declared deceased @ approx 16:05. Please see CareVue for additional pt care data/comments. Family notified of event, verbal and non-verbal support provided by team.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1601652,\n \"text\": \"npn\\nevents central line placed, mri on hold until \\n\\nneuro:aox3, sleeping off and on, pt stating he is very tired.\\npain: denies pain. exp. general discomfort from lying in bed. pain med given with line placement which pt tolerated well.\\n\\ncad hr sr 80 to 90's, nbp 80 systolic in am with two 250cc ns boluses given with nbp up to the 100 to 90's systolic , again dropped to the high 80's at 1730 to 1830 md aware, cvp 12 with some fluctuating noted to 18, pt given lasix 20 mg ivp at 1845 for ? chf.\\n\\nresp remains on 2to3 l nc, ls clear with crackles in bases in am to cracles thru out after line placemnt and receving 2 units of ffp. sats 91 to 975 rr teens to high 20 to bursts to 30 to 40's.\\n\\ngi: abd soft slight distended. bs+ no bm this shfit, no c/o abd pain, ? c/o nausea with md was ordered and given in afternoon. mri held at pt's request.\\n\\ngu: urine output increased to 10cc/hr after multiple boluses and antibiotics given. now 5cc/hr pt given lasix 20 mg ivp at 1845. last 6 pt given kayexlate po at 1600 awaiting results.\\n\\nendo: bs 108 to 172 las t bs not covered due to pooor po intake.\\n\\nid: afebrile, antibiotics given.\\n\\nplan: mri tomorrow am, cont to be full code, cont to moniotr vs, labs resp and fluid status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1601653,\n \"text\": \"Events: Bolused with 250cc NS x3 for low u/o and hypotension. Family in and decision made to change code status to CPR not indicated. Pt can be intubated if need be however.\\n\\nNeuro: A+Ox3 and following commnads. Did have period where he had some confusion while hypotensive, but resolved after fluid boluses. No complaints of pain this shift. Slept throughout shift but arousable to verbal stimuli.\\n\\nResp: Lung sounds with wheezes throughout and crackles in bases. O2 sats maintained in high 90's on 70% humidified O2 via face tent. Alb/atr nebs q4. Pt states breathing is easier than previous but rr remains tachypneic (30's) at times.\\n\\nCardiac: SR with no ectopy throughout shift. CVP 11-16. Bolused with total of 750cc NS to keep MAP's >60. B/P droping as low as 70's/20's prior to fluid boluses. B/P largely 90's/40's since midnight. Team has been reluctant to start pressors as pt has 4+MR.\\n\\nGI: Abd soft and nontender this shift. No c/o pain which had been yesterday. medicated with 0.5mg morphine prior to start of this shift. No BM this shift either. Pt may go for MRI later today to assess for ischemic bowel.\\n\\nGU: Pt given 20mg IV lasix, with no effect. Then 40mg IV lasix with similar results, then 80mg with approx 100cc's amber urine output. Renal is following. Pt's electrolytes remain increasingly out of balance. K+5.8 Phos 9.1 Mg 3.2 BUN 97 and Cr3.8\\n\\nHeme: HCT down to 25.8 (28.5) INR up to 2.3 (2.5) received 2uffp prior to TLC placement yesterday.\\n\\nDerm: Grossly intact. PIV x1 patent. TLC in RIJ placed yesterday patent with good blood return. Small hematoma at site unchanged.\\n\\nPlan: Family in today to meet with attending to discuss prognosis and plan of care, may go for MRI if decided to fully treat, Monitor lab data (?HD), monitor hemodynamic status, may start levophed if b/p cannot be maintained with small boluses. Pt is currently CPR not indicated but will be intubated if need be.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197667,\n \"text\": \"Sinus rhythm\\nIndeterminate axis\\nLow limb lead QRs voltages\\nModest right ventricular conduction delay pattern\\nFindings are nonspecific but clinical correlation is suggested for possible\\nchronic pulmonary disease\\nSince previous tracing of , sinus tachycardia rate slower\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197668,\n \"text\": \"Sinus tachycardia\\nSlight ST-T wave changes - are nonspecific and may be within normal limits\\nSince previous tracing of , right precordial ST-T wave changes slightly\\nless prominent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197669,\n \"text\": \"Sinus tachycardia\\nPossible left atrial abnormality\\nModest nonspecific ST-T wave changes\\nSince previous tracing of , ventricular ectopy absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197670,\n \"text\": \"Sinus tachycardia with ventricular ectopy. Ventricular rate 114 beats per\\nminute. P-R interval 0.16. Since the previous tracing of the rate is\\nincreased and ventricular ectopy is new. No other diagnostic changes have\\noccurred.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197914,\n \"text\": \"Sinus rhythm\\nNormal ECG\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926604,\n \"text\": \" 9:56 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for progression of volume overload\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with dyspnea, tachycardia, crackles on exam\\n REASON FOR THIS EXAMINATION:\\n please evaluate for progression of volume overload\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 10:12 P.M., .\\n\\n HISTORY: Dyspnea and tachycardia.\\n\\n IMPRESSION: AP chest compared to through .\\n\\n There has been substantial improvement in pulmonary edema, particularly in the\\n right lung. Left perihilar consolidation is the most significant region of\\n abnormality followed by the right lung base and these areas have not cleared.\\n Small bilateral pleural effusion has increased slightly on the left and\\n decreased on the right. Heart is normal size. Mediastinal vascular\\n engorgement is unchanged. Left-sided skinfold and overlying tubing should not\\n be mistaken for pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-19 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 925836,\n \"text\": \" 11:47 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ? infectious process\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with new oxygen requirement, previous COP on biopsy, hemoptysis\\n following CT guided biopsy on .\\n REASON FOR THIS EXAMINATION:\\n ? infectious process\\n CONTRAINDICATIONS for IV CONTRAST:\\n increased creatinine\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST\\n\\n REASON FOR EXAM: 84-year-old man with increased oxygen with history of\\n organizing pneumonia\\n\\n COMPARISON: Comparison is made with prior study dated .\\n\\n TECHNIQUE: Multidetector CT through the chest performed in full inspiration\\n and expiration. 2.5 and 1.25 mm collimation images were reviewed.\\n\\n FINDINGS:\\n Extensive peripheral consolidations in the apico- posterior segments of the\\n left upper lobe, posterior segment of the right upper lobe and right basal\\n posterior and lateral segments have worsened\\n New bilateral apical ground-glass opacities, and increase in the interstitial\\n abnormality with peribronchial infiltration that is continuous with the\\n consolidations, are either worsening of the preexistingpneumonia\\n or superimposed pulmonary edema.\\n\\n The airways are patent to segmental level. Multiple prevascular,\\n paratracheal, and subcarinal lymph nodes have increased in number and size,\\n for instance the largest in the left lower paratracheal region (2:53)\\n measuring 11 mm, was 6 mm, and a 10 mm right lower paratracheal lymph node was\\n 6 mm. Many of the paratracheal and right hilar lymph nodes are calcified.\\n Moderate non-hemorrhagic layering left pleural effusion is new. A small amount\\n of pleural effusion in the right side is loculated in the major fissure. There\\n is no pericardial effusion. The LAD is mildly calcified; otherwise, the heart\\n and great vessels are unremarkable.\\n\\n There are no bone findings of malignancy.\\n\\n In the upper abdomen, sub-cm hypodense lesions in the liver, too small to be\\n characterized are likely cysts. Patient is post-cholecystectomy.\\n\\n IMPRESSION:\\n\\n 1. Worsening multifocal pneumonia, not hemorrhagic. Multifocal interstitial\\n abnormalities are either progression of organizing pneumonia or edema.\\n 2. New bilateral pleural effusions, larger in the left side.\\n (Over)\\n\\n 11:47 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ? infectious process\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 927008,\n \"text\": \" 4:13 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: RIJ placement postprocedure\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with cryptogenic pna, s/p RIJ placement\\n REASON FOR THIS EXAMINATION:\\n RIJ placement postprocedure\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: Right internal jugular central venous line placement. History of\\n cryptogenic pneumonia. Check for line position.\\n\\n FINDINGS: A right internal jugular vein approach central venous line is\\n present seen to terminate overlying the SVC at the level 2 cm below the\\n carina. No pneumothorax has developed, no other placement related\\n complications are identified. Pulmonary and pleural abnormalities remain\\n unchanged as described on previous study obtained 12 hours earlier during the\\n same date.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-27 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 926885,\n \"text\": \" 9:15 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: Signs of obstruction or perforation?\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with severe MR, BOOP and new diffuse abdominal pain with\\n nausea.\\n REASON FOR THIS EXAMINATION:\\n Signs of obstruction or perforation?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 84-year-old man with severe mitral regurgitation, BOOP, and\\n abdominal pain.\\n\\n ABDOMEN, SINGLE SUPINE PORTABLE: No prior radiographs for comparison. The\\n bowel gas pattern is unremarkable, without dilatation of the small or large\\n bowel. There is stool in the ascending colon and rectum. Air is present\\n within the rectum. There are cholecystectomy clips in the right upper\\n quadrant.\\n\\n IMPRESSION: No evidence of obstruction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926300,\n \"text\": \" 9:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval pulmonary edema, effusion\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with dyspnea, tachycardia\\n REASON FOR THIS EXAMINATION:\\n eval pulmonary edema, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Dyspnea, tachycardia.\\n\\n CHEST AP:\\n\\n Comparison is made with the prior chest from . There has been an\\n increase in the size of the left pleural effusion. Some clearing of the\\n opacities in the left upper lobe is seen. Patchy opacities are seen in all\\n other parts of the lung. The appearances suggest failure with probable\\n pneumonia.\\n\\n IMPRESSION: Increasing left effusion, some clearing of left upper lobe.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926347,\n \"text\": \" 9:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? edema\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with dyspnea, tachycardia, crackles on exam.\\n\\n REASON FOR THIS EXAMINATION:\\n ? edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Dyspnea, tachypnea. Evaluate failure.\\n\\n Since the prior chest x-ray of , there has been an increase in the\\n size of the right pleural effusion, which now extends towards the apex.\\n\\n The interstitial is also somewhat more pronounced. These findings\\n indicate worsening failure.\\n\\n IMPRESSION: Worsening failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926651,\n \"text\": \" 9:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? worsening failure\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with dyspnea, tachycardia, crackles on exam\\n\\n REASON FOR THIS EXAMINATION:\\n ? worsening failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 9:43 A.M .\\n\\n HISTORY: Dyspnea and tachycardia. Question worsening failure.\\n\\n IMPRESSION: AP chest compared to through .\\n\\n Previous heterogeneous opacification in the right upper lobe has largely\\n cleared over the past two weeks and pulmonary edema in the right lung has\\n largely resolved since . There is persistent severe\\n perihilar opacification in the left lung and a slowly resolving heterogeneous\\n region of opacity at the right lung base.\\n\\n While the right pleural effusion has nearly resolved, the moderate left\\n pleural effusion has not.\\n\\n The sequence of changes suggests the persistence of asymmetric edema, and\\n clearing of the inflammatory process in the right upper lobe and improvement,\\n but persistence of what is likely the same process in the right lower lobe.\\n Pleural effusions are probably secondary to pulmonary pathology. Cardiac\\n silhouette is slightly enlarged, and there is persistence of vascular\\n engorgement in the superior mediastinum suggesting cardiac decompensation\\n and/or volume overload.\\n\\n Left skinfold should not be mistaken for pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-18 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 925757,\n \"text\": \" 7:25 PM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for pulmonary process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with recent treatment for PNA\\n REASON FOR THIS EXAMINATION:\\n evaluate for pulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of recent treatment for pneumonia.\\n\\n COMPARISON: Radiograph dated and CT scan dated and\\n radiograph dated .\\n\\n PA AND LATERAL VIEWS OF THE CHEST: There is increased confluent opacity in\\n the left upper lobe. The area of opacity in the right lower lobe appears\\n increased compared to the previous exam, however, the most densely opacified\\n area is slightly smaller. Right upper lobe patchy opacities are also again\\n seen. There is no evidence of pneumothorax. There is a possible tiny right\\n pleural effusion.\\n\\n IMPRESSION: Interval worsening of left upper lobe airspace opacity with\\n possible interval increase in extent of opacity also in the right lower lobe.\\n This may represent an infectious process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 926899,\n \"text\": \" 2:41 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: Signs of perforation?\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with cryptogenic pna, acute renal failure on high dose steroids\\n with new abdominal pain.\\n REASON FOR THIS EXAMINATION:\\n Please do upright chest film. Signs of free air?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cryptogenic pneumonia and acute renal failure, now with 9 out of\\n 10 abdominal pain. Evaluate for signs of free air.\\n\\n There are no prior studies for comparison.\\n\\n SUPINE ABDOMEN: There is no evidence of free air on the supine views. The\\n bowel gas pattern is nonspecific, with air seen within non-dilated loops of\\n small bowel and throughout the colon to the rectum. No evidence of\\n obstruction. There are surgical clips in the right upper quadrant, likely\\n related to cholecystectomy.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926900,\n \"text\": \" 3:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ABDOMINAL PAIN/ CHECK FOR FREE AIR// ALSO SOB\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Patient with BOOP who is short of breath. Also, 9 out of 10\\n abdominal pain. Evaluate for free air.\\n\\n COMPARISON: .\\n\\n UPRIGHT AP CHEST: No free air is visualized beneath the hemidiaphragm. Air\\n space opacity within the left upper lobe has slightly improved compared to\\n . The right upper lobe and right lower lung appear not\\n significantly changed in the interim. Cardiomegaly and the aortic contours\\n are unchanged. The left pleural effusion appears slightly decreased. No\\n pneumothorax.\\n\\n IMPRESSION: No free air beneath the hemidiaphragm is visualized. Improved\\n left upper lobe parenchymal opacification.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 926901,\n \"text\": \" 5:31 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: Please do abdominal CT scan with PO contrast (renal failure\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n Field of view: 38\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with cryptogenic pneumonia, acute renal failure, new \\n abdominal pain out of proportion to exam with elevated lactate.\\n\\n REASON FOR THIS EXAMINATION:\\n Please do abdominal CT scan with PO contrast (renal failure precludes IV\\n contrast). Signs of ischemia?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT ABDOMEN\\n\\n INDICATION: Cryptogenic pneumonia, acute renal failure, abdominal pain.\\n\\n FINDINGS:\\n\\n A CT of abdomen and pelvis was performed with axial images taken from the lung\\n bases to the symphysis pubis.\\n\\n Oral contrast only was administered because of the patient's renal failure.\\n\\n Multiplanar reconstructions in the coronal and sagittal planes were obtained.\\n\\n The lung bases reveal a small right pleural effusion and a moderate-sized left\\n pleural effusion. A granuloma is noted in the right base. There is some right-\\n sided linear atelectasis.\\n\\n Note is made of some coronary artery calcification.\\n\\n Below the diaphragm, given that this is a non-contrast CT, note is made of a\\n low-attenuation lesion measuring 11 mm in the dome of the liver which is\\n unchanged when compared to the previous CT from .\\n\\n A subcentimeter lesion is seen in segment VII and is unchanged.\\n\\n A subcentimeter lesion is seen in segment and is unchanged.\\n\\n The fourth lesion which was identified on the previous study is difficult to\\n visualize on this study due to artifact from overlying skin markers.\\n\\n This patient is status post cholecystectomy.\\n\\n The spleen, adrenals, kidneys and pancreas are normal.\\n\\n No evidence of any significant lymphadenopathy.\\n\\n Some vascular calcification is noted in relation to the aorta.\\n (Over)\\n\\n 5:31 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: Please do abdominal CT scan with PO contrast (renal failure\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n Field of view: 38\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n The bowel where visualized is normal.\\n\\n CT OF PELVIS:\\n\\n Note is made of some sigmoid diverticula.\\n\\n The bladder is catheterized with a significant amount of air secondary to\\n instrumentation.\\n\\n In the pelvis, a tiny amount of fluid is seen which measures approximately 2 x\\n 1.3 cm. It is of unknown etiology.\\n\\n Just anterior to the sacrum, note is also made of some minimal fluid. Again,\\n this is of unknown etiology.\\n\\n BONY WINDOWS:\\n\\n Note is made of degenerative change\\n\\n IMPRESSION:\\n\\n No evidence of any ischemic bowel given that this is a non-contrast CT.\\n\\n Multiple lesions in the liver which are unchanged.\\n\\n Some minimal presacral fluid and some minimal fluid in the pelvis of unknown\\n etiology.\\n\\n Sigmoid diverticula.\\n\\n Scarring right base and bilateral effusions.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-27 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 926851,\n \"text\": \" 2:54 PM\\n RENAL U.S. Clip # \\n Reason: EVAL FOR HYDRONEPHROSIS OR OTHER BLOCKAGE\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with increasing creatinine with some urinary retention\\n yesterday now s/p foley.\\n REASON FOR THIS EXAMINATION:\\n ? hydronephrosis or other blockage\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Renal ultrasound.\\n\\n CLINICAL HISTORY: 84-year-old man with increasing creatinine with some\\n urinary retention yesterday. Now status post Foley. Rule out hydronephrosis\\n or other blockage.\\n\\n FINDINGS: Renal ultrasound was performed on . No prior ultrasound\\n studies available for comparison. Comparison made to CTA of the abdomen dated\\n .\\n\\n The kidneys are normal in size, without evidence of hydronephrosis or solid\\n renal masses. There is a small crystal in the renal cortex of the midpole of\\n the left kidney. No perinephric fluid collections are seen.\\n\\n There is a left pleural effusion.\\n\\n A Foley catheter is in the urinary bladder, which is decompressed.\\n\\n IMPRESSION:\\n 1. No evidence of hydronephrosis.\\n 2. Left pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-26 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 926681,\n \"text\": \" 12:48 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: ? DVT\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with hypoxia, tachypnea\\n REASON FOR THIS EXAMINATION:\\n ? DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n BILATERAL LOWER EXTREMITY ULTRASOUND\\n\\n HISTORY: 84-year-old male with hypoxia and tachypnea. Please evaluate for\\n DVT.\\n\\n FINDINGS: No prior study is available for comparison. Grayscale and Doppler\\n son of the left and right common femoral, superficial femoral, and\\n popliteal veins were performed. Normal flow, augmentation, compressibility,\\n and waveforms are demonstrated. Intraluminal thrombus is not identified.\\n\\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":182,"cells":{"subject_id":{"kind":"number","value":47758,"string":"47,758"},"hadm_id":{"kind":"number","value":135647,"string":"135,647"},"target_text":{"kind":"string","value":"64 year old female admitted to the acute care service with dehydration, elevated creatinine, and leakage around the g-tube site. Upon admission, she was fluid resusitated and her electrolytes were repleted. A foley catheter was replaced in the gastro-cutaneoous fistula to decrease leakge. Despite placment of a larger tube, she continued to leak around the G-tube site and an additional was placed and she was maintained NPO. During her hospitalization, her creatinine slowly decreased and her fluid status improved. She was started on clear liquids with gradual advancement to a regular diet. She continued to leak gastric contents around the drain. Recommendations for skin care were outlined by the ostomy/wound nurse. She has been reluctant to participate in physical therapy, but they have provided daily visits. Her vital signs are stable and she is afebrile. Her electrolytes have normalized and her creatinine as decreased to 2.0. She is preparing for discharge to her daughter's home with VNA assistance. She will follow-up with the acute care service in 2 weeks. She can have her foley catheter removed at the rehab facility Medications on Admission: : simvastatin 20 qhs, citalopram 40', singulair 10 qhs, advair 250/50\", proair prn , albuterol prn, protonix 40', mvi, oxycodone prn, ativan prn"},"extractive_notes_summ":{"kind":"string","value":"Left retrocardiac opacity that is unchanged since the previous examination and is likely to represent atelectasis. Moderate cardiomegaly without overt pulmonary edema. FINDINGS: As compared to the previous radiograph, the left PICC line has been removed. Normal aspect of the hilar and mediastinal structures. Coexisting pneumonia however, cannot be excluded. No other focal parenchymal opacities. No pneumothorax. 3:52 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for consolidation. report of LLL opacity on OSH films FINAL REPORT CHEST RADIOGRAPH INDICATION: Renal failure, evaluation for consolidation, report of left lower lobe opacity from an outside hospital film. COMPARISON: ."},"n_notes":{"kind":"number","value":1,"string":"1"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2124-08-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1200882,"text":" 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for consolidation. report of LLL opacity on\n Admitting Diagnosis: RENAL FAILURE, GASTROCUTANEOUS FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with poor PO intake and renal failure\n REASON FOR THIS EXAMINATION:\n please evaluate for consolidation. report of LLL opacity on OSH films\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Renal failure, evaluation for consolidation, report of left lower\n lobe opacity from an outside hospital film.\n\n COMPARISON: .\n\n FINDINGS:\n\n As compared to the previous radiograph, the left PICC line has been removed.\n Moderate cardiomegaly without overt pulmonary edema. Left retrocardiac\n opacity that is unchanged since the previous examination and is likely to\n represent atelectasis. Coexisting pneumonia however, cannot be excluded. No\n other focal parenchymal opacities. Normal aspect of the hilar and mediastinal\n structures. No pneumothorax.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-08-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1200882,\n \"text\": \" 3:52 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for consolidation. report of LLL opacity on\\n Admitting Diagnosis: RENAL FAILURE, GASTROCUTANEOUS FISTULA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old woman with poor PO intake and renal failure\\n REASON FOR THIS EXAMINATION:\\n please evaluate for consolidation. report of LLL opacity on OSH films\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Renal failure, evaluation for consolidation, report of left lower\\n lobe opacity from an outside hospital film.\\n\\n COMPARISON: .\\n\\n FINDINGS:\\n\\n As compared to the previous radiograph, the left PICC line has been removed.\\n Moderate cardiomegaly without overt pulmonary edema. Left retrocardiac\\n opacity that is unchanged since the previous examination and is likely to\\n represent atelectasis. Coexisting pneumonia however, cannot be excluded. No\\n other focal parenchymal opacities. Normal aspect of the hilar and mediastinal\\n structures. No pneumothorax.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":183,"cells":{"subject_id":{"kind":"number","value":2378,"string":"2,378"},"hadm_id":{"kind":"number","value":157554,"string":"157,554"},"target_text":{"kind":"string","value":"# Pneumonia - On admission, pneumonia was felt less likely given lack of clear evidence on chest x-ray and low grade temperature. Treated for COPD exacerbation with Levaquin and high dose pulse steroids with plan for quick taper. Shortness of breath remained at baseline for 48 hours after admission. On hospitaly day 2, repeat chest x-ray obtained in setting of hypotension showed worsening RLL opacity and Vancomycin and Cefepime were started due to history of MRSA and Pseudomonnal pneumonia. On hospital day 3, patient complained of increased dyspnea, was not hypoxic. She was also persistently hypotensive unresponsive to fluids and was transferred to the ICU for further management. In the ICU a central line was placed and CVP monitoring revealed low values indicative of hypovolemia. She was resuscitated with IV fluids and her blood pressure was initially responsive. She was continued on IV Vancomycin, IV Cefepime and IV Levofloxacin for double coverage given her recent hospitalization and history of Pseudomonal pneumonia, and she completed an eight day course of these antibiotics. Her respiratory status improved slowly with decreased work of breathing. She required only minimal oxygen supplemenation intermittently. # Sepsis - Likely secondary to pneumonia and C. diff diagnosed on hospital day 1. Initially normotensive on admission, Mrs. was hypotensive to SBP 80's on hospital day 2 with adequate response to 2L fluid bolus. Anti-hypertensives held. On hospital day 3, patient became hypotensive to 70-80's with little improvement after 3.5L bolus. Due to persistant hypotension, transferred to ICU and continued Vancomycin and Cefepime for pneumonia as well as PO Vancomycin for C. Diff. In the ICU a central line was placed and CVP monitoring revealed low values indicative of hypovolemia. She was resuscitated with IV fluids and her blood pressure was initially responsive. Presumedly she was hypovolemic due to massive GI losses from C.diff. She was continued on IV boluses PRN. Although he blood pressure did not improve greatly and she remained modestly hypotensive with SBP 90s, on gentle diuresis was started given her history of diastolic CHF as well as anasarca from worsened hypoalbuminemia. She tolerated this well without worsening of her blood pressures. After completing an eight day course of antibiotics for pneumonia, the plan is to complete an additional 6 week taper of PO vancomycin for recurrent C. diff infection. Central line was pulled on day of discharge without complication. # C. Difficile - Patient was admitted with leukocytosis, diarrhea and low grade fevers. C. Diff assay was positive. Vancomycin PO and IV flagyl were started due to recurrent C. Diff infections. Diarrhea was monitored. As above, she was volume resuscitated. Her course appears to have been complicated by a protein losing enteropathy causing a worsening of hypoalbuminemia (3. --> 2.2 now). This has worsened her anasarca and made diuresis more difficult. Repeat KUBs, including one on day before discharge, showed no evidence of significant bowel dilation but did indicate ongoing gut edema. Plan to extend C.diff treatment (oral vancomycin) an additional 6 week taper after completion of her pneumonia antibiotics given recurrent, severe C. diff infection."},"extractive_notes_summ":{"kind":"string","value":"Moderate narrowing of right mainstem bronchus. Mild colonic wall thickening particularly in the right hemicolon is noted. A right IJ catheter terminates in superior vena cava. The bilateral lower lobe consolidations are unchanged noting some non-enhancing lung in the right lower lobe. Right upper lobe calcified granulomas are again noted. There is mild atelectasis at the right lung base. Normal sinus rhythm with ventricular premature beats. Mild degenerative changes are in the thoracic spine. A separate area of consolidation is in the right upper lobe in a perifissural distribution(4.140). FINDINGS: There is stable severe emphysema. Linear atelectasis is mild in the lower lobes bilaterally and partially due to a new nonhemorrhagic small right pleural effusion. Bibasilar opacity is larger on the right side are unchanged. A hiatal hernia is small. Heart and mediastinum are probably within normal limits. 4)New intraabdominal ascites and new small right pleural effusion. A right upper lobe calcified granuloma is redemonstrated. Moderate ascites. FINDINGS: Single abdomen radiograph compared to the prior study from demonstrates a dilated colonic segment. There is mild colonic wall thickening seen particularly along the right hemicolon consistent with known C. diff colitis. There is mild cardiomegaly. The right heart border is obscured by opacity in the right lower lung. Stable bilateral lower lobe consolidation. There is a slightly increasing right pleural effusion and new small left pleural effusion. There is a small left-sided pleural effusion with left lower lobe atelectasis. Centrilobular emphysema is worse in the upper lobes bilaterally and stable since the prior CT. No pathologically enlarged mediastinal or axillary lymph nodes by CT size criteria. IMPRESSION: Improved right lower lobe atelectasis. Scattered phleboliths are noted. Additionally, there is retrocardiac opacity. Right IJ catheter tip is in the mid SVC. Right IJ catheter tip is in the mid SVC. There is a hiatal hernia. Diffuse non-specific ST-T waveabnormalities. Left lower lobe opacity has minimally improved. There is moderate amount of ascites seen in the abdomen. The caliber of the aorta and pulmonary artery is normal. IMPRESSION: 1)Multifocal consolidation which has improved in the left lower lobe and is slightly worse in the right lower and upper lobes since recent conventional CXRs. Compared to the previous tracing of no change. Cardiomediastinal contours are unchanged. Right lower lobe consolidation is stable. Sinus tachycardia with ventricular premature beat. Multiple calcified granulomas are again noted. Decreased oxygen saturation and hypotension. H/o CHF, COPD. Sinus tachycardia. Opacities in the left lower lobe are unchanged. Mild cardiomegaly is stable. Mild cardiomegaly is stable. FINDINGS: The cardiomediastinal silhouette appears unremarkable. BIBASILAR OPACITIES STABLE. Delayed R wave progression with late precordial QRS transitionis non-specific but cannot exclude possible prior anterior myocardialinfarction. There is a left-sided femoral prosthesis partially imaged. Dependent secretions in the right main stem bronchus are new. Heart size normal. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Persistent hypotension. Very little change from the prior study. There is calcification at the mitral annulus. Opacities in the left lower lobe are stable. The heart size is normal with no pericardial effusion. The hila are normal appearing bilaterally. Poor R wave progressionin leads V1-V4 of uncertain significance. Consider left atrialabnormality. There is calcification of the mitral valve. Increasing right greater than left bilateral pleural effusions. The lungs are hyperinflated and there is relative lucency within the lung apices suggestive of underlying emphysema. REASON FOR THIS EXAMINATION: assess for PE No contraindications for IV contrast FINAL REPORT HISTORY: Chest pain, worsening O2 saturations and history of PE with subtherapeutic INR. Upper lung zones are clear. Since the previous tracingof ST-T wave changes appear less prominent but baseline artifacton both tracings makes comparison difficult. Right lower lobe opacity has improved consistent with improving atelectasis. IMPRESSION: Patchy bibasilar opacities which could reflect pneumonia or aspiration in the appropriate clinical setting. IMPRESSION: AP chest compared to : Right basal opacification has worsened, consistent with progressive pneumonia or atelectasis superimposed. 5-mm and 1.25-mm axial slices were acquired with coronal and sagittal reformats. Patient is status post left total hip arthroplasty. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess line. Atherosclerotic plaque is moderately severe in the aortic arch and extends into the origin of the left common carotid and subclavian arteries. No frank dilatation of the small bowel identified. FINDINGS: Single portable chest radiograph is compared to the prior study from . FINDINGS: Consolidation in the left lower lobe has improved and is slightly worse in the right lower lobe since the recent chest radiographs over the preceeding week. Contrast is identified within the bladder. ST-T wave changes are non-specific. IMPRESSION: No dilated loops of small bowel. COMPARISON: Previous CT and most numerous recent chest radiographs. Although this examination was not designed for subdiaphragmatic evaluation, there is new intra-abdominal ascites and diffuse vascular calcification of the suprarenal aorta. IMPRESSION: 1. REASON FOR EXAM: Evaluate for pneumonia TECHNIQUE: MDCT chest was performed without IV contrast. Calcification is severe in the mitral annulus and moderately severe in the aortic valve and coronary arteries. HISTORY: C. diff infection. Multiple calcified granulomas are seen in the lungs. IMPRESSION: No evidence of obstruction. AS before this could represent pneumonia or aspiration. There are degenerative changes in the spine. STUDY: AP portable upright chest radiograph. Some air is present in the descending colon. Extensive vascular calcifications are noted. There are extensive atherosclerotic calcifications of the aorta and coronary arteries. FINDINGS: There are no dilated loops of small bowel to suggest obstruction. Multiplanar reformats were performed. NO PTX OR ADDITIONAL INTERVAL CHANGE. COMPARISON: CT of the abdomen and pelvis from ."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2142-07-18 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":1137626,"text":" 2:50 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for colonic distention\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with acute C. diff infection\n REASON FOR THIS EXAMINATION:\n eval for colonic distention\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, FOUR VIEWS.\n\n COMPARISON: .\n\n HISTORY: C. diff infection.\n\n FINDINGS: There are no dilated loops of small bowel to suggest obstruction.\n There is no evidence of free air. There is mild colonic wall thickening seen\n particularly along the right hemicolon consistent with known C. diff colitis.\n Contrast is identified within the bladder. Scattered phleboliths are noted.\n Extensive vascular calcifications are noted. Patient is status post left\n total hip arthroplasty.\n\n IMPRESSION: No evidence of obstruction. Mild colonic wall thickening\n particularly in the right hemicolon is noted.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-16 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1137332,"text":" 3:14 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: assess for PE\n Admitting Diagnosis: COPD EXACERBATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with right chest pain, worsening O2 saturations, history of\n PE and subtherapeutic INR.\n REASON FOR THIS EXAMINATION:\n assess for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain, worsening O2 saturations and history of PE with\n subtherapeutic INR.\n\n COMPARISON: .\n\n TECHNIQUE: CT of the chest was performed before and after administration of\n IV contrast. Multiplanar reformats were performed.\n\n FINDINGS:\n\n There is stable severe emphysema. The bilateral lower lobe consolidations are\n unchanged noting some non-enhancing lung in the right lower lobe. Moderate\n narrowing of right mainstem bronchus. There is a slightly increasing right\n pleural effusion and new small left pleural effusion. There is moderate\n amount of ascites seen in the abdomen. There are extensive atherosclerotic\n calcifications of the aorta and coronary arteries. Multiple calcified\n granulomas are seen in the lungs. There is no evidence of pulmonary embolism.\n There is mild cardiomegaly. There is a hiatal hernia.\n\n There are degenerative changes in the spine.\n\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n\n 2. Stable bilateral lower lobe consolidation.\n\n 3. Increasing right greater than left bilateral pleural effusions.\n\n 4. Moderate ascites.\n\n"},{"category":"Radiology","chartdate":"2142-07-12 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1136684,"text":" 9:10 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with sepsis, pulmonary disease\n REASON FOR THIS EXAMINATION:\n Evaluate pneumonia versus evolving lesion in right lower lobe\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast.\n\n REASON FOR EXAM: Evaluate for pneumonia\n\n TECHNIQUE: MDCT chest was performed without IV contrast. 5-mm and 1.25-mm\n axial slices were acquired with coronal and sagittal reformats.\n\n COMPARISON: Previous CT and most numerous recent chest\n radiographs.\n\n FINDINGS:\n\n Consolidation in the left lower lobe has improved and is slightly worse in the\n right lower lobe since the recent chest radiographs over the preceeding week.\n A separate area of consolidation is in the right upper lobe in a perifissural\n distribution(4.140). Dependent secretions in the right main stem bronchus are\n new. Linear atelectasis is mild in the lower lobes bilaterally and partially\n due to a new nonhemorrhagic small right pleural effusion. Several calcified\n granulomata are scattered throughout the lungs. Centrilobular emphysema is\n worse in the upper lobes bilaterally and stable since the prior CT.\n\n No pathologically enlarged mediastinal or axillary lymph nodes by CT size\n criteria. Atherosclerotic plaque is moderately severe in the aortic arch and\n extends into the origin of the left common carotid and subclavian arteries.\n The caliber of the aorta and pulmonary artery is normal. The heart size is\n normal with no pericardial effusion. Calcification is severe in the mitral\n annulus and moderately severe in the aortic valve and coronary arteries.\n\n Although this examination was not designed for subdiaphragmatic evaluation,\n there is new intra-abdominal ascites and diffuse vascular calcification of the\n suprarenal aorta. A hiatal hernia is small.\n\n No destructive or sclerotic bone lesions are concerning for malignancy.\n\n IMPRESSION:\n\n 1)Multifocal consolidation which has improved in the left lower lobe and is\n slightly worse in the right lower and upper lobes since recent conventional\n CXRs.\n\n 2)Moderately severe diffuse centrilobular emphysema\n (Over)\n\n 9:10 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3)Diffuse atherosclerotic calcification in the coronary arteries, aorta, in\n the mitral annulus and aortic valve.\n\n 4)New intraabdominal ascites and new small right pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2142-07-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1136612,"text":" 4:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Etiology of SOB\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with persisten hypotension, PNA and C.diff\n REASON FOR THIS EXAMINATION:\n Etiology of SOB\n ______________________________________________________________________________\n WET READ: MBue WED 7:28 PM\n NO SIGNIFICANT CHANGE. BIBASILAR OPACITIES STABLE.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Persistent hypotension.\n\n Comparison is made with prior study .\n\n Mild cardiomegaly is stable. There is calcification at the mitral annulus.\n Bibasilar opacity is larger on the right side are unchanged. This could be\n due to atelectasis and/or pneumonia. Right upper lobe calcified granulomas\n are again noted. There is no pneumothorax or pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-12 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1136700,"text":" 10:59 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess colon distension, other intraabdominal pathology\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cdiff and abd distension, pna, hypotension\n REASON FOR THIS EXAMINATION:\n assess colon distension, other intraabdominal pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Woman with C. diff and abdominal distention.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n Single view of the abdomen shows no dilated loops of small or large bowel.\n Air is noted within the colon. The visible osseous structures are\n unremarkable. There is a left-sided femoral prosthesis partially imaged.\n\n IMPRESSION:\n\n No dilated loops of small bowel.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1137104,"text":" 3:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent PNA, cdiff, some hypotension\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Recent pneumonia, hypotension.\n\n FINDINGS:\n\n Single portable chest radiograph is compared to the prior study from\n . A right IJ catheter terminates in superior vena cava. There is a\n small left-sided pleural effusion with left lower lobe atelectasis. There is\n mild atelectasis at the right lung base. Heart and mediastinum are probably\n within normal limits. Upper lung zones are clear. Very little change from\n the prior study.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-14 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1137105,"text":" 3:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: Colonic distension\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent PNA, cdiff, some hypotension\n REASON FOR THIS EXAMINATION:\n Colonic distension\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, \n\n CLINICAL INFORMATION: Chronic distention.\n\n FINDINGS:\n\n Single abdomen radiograph compared to the prior study from \n demonstrates a dilated colonic segment. No frank dilatation of the small\n bowel identified. Some air is present in the descending colon.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-09 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1136254,"text":" 3:41 PM\n CHEST (PA & LAT) Clip # \n Reason: Assess for edema, infiltrate\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with COPD and hx of pneumonia.\n REASON FOR THIS EXAMINATION:\n Assess for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: COPD and history of pneumonia.\n\n Comparison is made with prior study, .\n\n Cardiomediastinal contours are unchanged. Right lower lobe opacity has\n improved consistent with improving atelectasis. Opacities in the left lower\n lobe are unchanged. Multiple calcified granulomas are again noted. There is\n calcification of the mitral valve. There is no pneumothorax or pleural\n effusion. Mild degenerative changes are in the thoracic spine.\n\n IMPRESSION: Improved right lower lobe atelectasis. Opacities in the left\n lower lobe are stable. AS before this could represent pneumonia or\n aspiration.\n\n"},{"category":"Radiology","chartdate":"2142-07-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1136043,"text":" 9:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with dyspnea, fevers. H/o CHF, COPD.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old female with dyspnea and fevers.\n\n STUDY: AP portable upright chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The cardiomediastinal silhouette appears unremarkable. The hila\n are normal appearing bilaterally. The right heart border is obscured by\n opacity in the right lower lung. Additionally, there is retrocardiac opacity.\n A right upper lobe calcified granuloma is redemonstrated. There is no evidence\n for large pleural effusion or pneumothorax. The lungs are hyperinflated and\n there is relative lucency within the lung apices suggestive of underlying\n emphysema.\n\n IMPRESSION: Patchy bibasilar opacities which could reflect pneumonia or\n aspiration in the appropriate clinical setting.\n DFDdp\n\n"},{"category":"Radiology","chartdate":"2142-07-11 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1136628,"text":" 7:08 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: MBue WED 11:21 PM\n RT CVC TERMINATING IN MID TO DISTAL SVC. NO PTX OR ADDITIONAL INTERVAL\n CHANGE.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study performed two hours earlier.\n\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax. No other\n interval change.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1136382,"text":" 12:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna/interval change\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with COPD, recurrent pneumonia with decreased O2 sat and\n hypotension\n REASON FOR THIS EXAMINATION:\n eval for pna/interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:54 P.M. ON \n\n HISTORY: Recurrent pneumonia. Decreased oxygen saturation and hypotension.\n\n IMPRESSION: AP chest compared to :\n\n Right basal opacification has worsened, consistent with progressive pneumonia\n or atelectasis superimposed. There is no pulmonary edema or pleural effusion.\n Heart size normal. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1136666,"text":" 6:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evidence of worsened pulmonary process\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with pneumonia, sepsis\n REASON FOR THIS EXAMINATION:\n Evidence of worsened pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Pneumonia.\n\n Comparison is made with prior study performed the day earlier.\n\n Mild cardiomegaly is stable. Right IJ catheter tip is in the mid SVC. There\n is no pneumothorax. Left lower lobe opacity has minimally improved. Right\n lower lobe consolidation is stable.\n\n"},{"category":"ECG","chartdate":"2142-07-12 00:00:00.000","description":"Report","row_id":111179,"text":"Sinus tachycardia. Compared to the previous tracing of no change.\n\n"},{"category":"ECG","chartdate":"2142-07-11 00:00:00.000","description":"Report","row_id":111180,"text":"Sinus tachycardia with ventricular premature beat. Consider left atrial\nabnormality. Delayed R wave progression with late precordial QRS transition\nis non-specific but cannot exclude possible prior anterior myocardial\ninfarction. ST-T wave changes are non-specific. Since the previous tracing\nof ST-T wave changes appear less prominent but baseline artifact\non both tracings makes comparison difficult.\n\n"},{"category":"ECG","chartdate":"2142-07-08 00:00:00.000","description":"Report","row_id":111181,"text":"Normal sinus rhythm with ventricular premature beats. Poor R wave progression\nin leads V1-V4 of uncertain significance. Diffuse non-specific ST-T wave\nabnormalities. Compared to the previous tracing of ventricular premature\nbeats are new and heart rate has increased.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-18 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 1137626,\n \"text\": \" 2:50 PM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: eval for colonic distention\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with acute C. diff infection\\n REASON FOR THIS EXAMINATION:\\n eval for colonic distention\\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMEN, FOUR VIEWS.\\n\\n COMPARISON: .\\n\\n HISTORY: C. diff infection.\\n\\n FINDINGS: There are no dilated loops of small bowel to suggest obstruction.\\n There is no evidence of free air. There is mild colonic wall thickening seen\\n particularly along the right hemicolon consistent with known C. diff colitis.\\n Contrast is identified within the bladder. Scattered phleboliths are noted.\\n Extensive vascular calcifications are noted. Patient is status post left\\n total hip arthroplasty.\\n\\n IMPRESSION: No evidence of obstruction. Mild colonic wall thickening\\n particularly in the right hemicolon is noted.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-16 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1137332,\n \"text\": \" 3:14 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: assess for PE\\n Admitting Diagnosis: COPD EXACERBATION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with right chest pain, worsening O2 saturations, history of\\n PE and subtherapeutic INR.\\n REASON FOR THIS EXAMINATION:\\n assess for PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Chest pain, worsening O2 saturations and history of PE with\\n subtherapeutic INR.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: CT of the chest was performed before and after administration of\\n IV contrast. Multiplanar reformats were performed.\\n\\n FINDINGS:\\n\\n There is stable severe emphysema. The bilateral lower lobe consolidations are\\n unchanged noting some non-enhancing lung in the right lower lobe. Moderate\\n narrowing of right mainstem bronchus. There is a slightly increasing right\\n pleural effusion and new small left pleural effusion. There is moderate\\n amount of ascites seen in the abdomen. There are extensive atherosclerotic\\n calcifications of the aorta and coronary arteries. Multiple calcified\\n granulomas are seen in the lungs. There is no evidence of pulmonary embolism.\\n There is mild cardiomegaly. There is a hiatal hernia.\\n\\n There are degenerative changes in the spine.\\n\\n\\n IMPRESSION:\\n 1. No evidence of pulmonary embolism.\\n\\n 2. Stable bilateral lower lobe consolidation.\\n\\n 3. Increasing right greater than left bilateral pleural effusions.\\n\\n 4. Moderate ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-12 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1136684,\n \"text\": \" 9:10 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with sepsis, pulmonary disease\\n REASON FOR THIS EXAMINATION:\\n Evaluate pneumonia versus evolving lesion in right lower lobe\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: CT chest without contrast.\\n\\n REASON FOR EXAM: Evaluate for pneumonia\\n\\n TECHNIQUE: MDCT chest was performed without IV contrast. 5-mm and 1.25-mm\\n axial slices were acquired with coronal and sagittal reformats.\\n\\n COMPARISON: Previous CT and most numerous recent chest\\n radiographs.\\n\\n FINDINGS:\\n\\n Consolidation in the left lower lobe has improved and is slightly worse in the\\n right lower lobe since the recent chest radiographs over the preceeding week.\\n A separate area of consolidation is in the right upper lobe in a perifissural\\n distribution(4.140). Dependent secretions in the right main stem bronchus are\\n new. Linear atelectasis is mild in the lower lobes bilaterally and partially\\n due to a new nonhemorrhagic small right pleural effusion. Several calcified\\n granulomata are scattered throughout the lungs. Centrilobular emphysema is\\n worse in the upper lobes bilaterally and stable since the prior CT.\\n\\n No pathologically enlarged mediastinal or axillary lymph nodes by CT size\\n criteria. Atherosclerotic plaque is moderately severe in the aortic arch and\\n extends into the origin of the left common carotid and subclavian arteries.\\n The caliber of the aorta and pulmonary artery is normal. The heart size is\\n normal with no pericardial effusion. Calcification is severe in the mitral\\n annulus and moderately severe in the aortic valve and coronary arteries.\\n\\n Although this examination was not designed for subdiaphragmatic evaluation,\\n there is new intra-abdominal ascites and diffuse vascular calcification of the\\n suprarenal aorta. A hiatal hernia is small.\\n\\n No destructive or sclerotic bone lesions are concerning for malignancy.\\n\\n IMPRESSION:\\n\\n 1)Multifocal consolidation which has improved in the left lower lobe and is\\n slightly worse in the right lower and upper lobes since recent conventional\\n CXRs.\\n\\n 2)Moderately severe diffuse centrilobular emphysema\\n (Over)\\n\\n 9:10 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n 3)Diffuse atherosclerotic calcification in the coronary arteries, aorta, in\\n the mitral annulus and aortic valve.\\n\\n 4)New intraabdominal ascites and new small right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1136612,\n \"text\": \" 4:36 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Etiology of SOB\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with persisten hypotension, PNA and C.diff\\n REASON FOR THIS EXAMINATION:\\n Etiology of SOB\\n ______________________________________________________________________________\\n WET READ: MBue WED 7:28 PM\\n NO SIGNIFICANT CHANGE. BIBASILAR OPACITIES STABLE.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Persistent hypotension.\\n\\n Comparison is made with prior study .\\n\\n Mild cardiomegaly is stable. There is calcification at the mitral annulus.\\n Bibasilar opacity is larger on the right side are unchanged. This could be\\n due to atelectasis and/or pneumonia. Right upper lobe calcified granulomas\\n are again noted. There is no pneumothorax or pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-12 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1136700,\n \"text\": \" 10:59 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: assess colon distension, other intraabdominal pathology\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with cdiff and abd distension, pna, hypotension\\n REASON FOR THIS EXAMINATION:\\n assess colon distension, other intraabdominal pathology\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Woman with C. diff and abdominal distention.\\n\\n COMPARISON: CT of the abdomen and pelvis from .\\n\\n Single view of the abdomen shows no dilated loops of small or large bowel.\\n Air is noted within the colon. The visible osseous structures are\\n unremarkable. There is a left-sided femoral prosthesis partially imaged.\\n\\n IMPRESSION:\\n\\n No dilated loops of small bowel.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1137104,\n \"text\": \" 3:20 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with recent PNA, cdiff, some hypotension\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n CLINICAL INFORMATION: Recent pneumonia, hypotension.\\n\\n FINDINGS:\\n\\n Single portable chest radiograph is compared to the prior study from\\n . A right IJ catheter terminates in superior vena cava. There is a\\n small left-sided pleural effusion with left lower lobe atelectasis. There is\\n mild atelectasis at the right lung base. Heart and mediastinum are probably\\n within normal limits. Upper lung zones are clear. Very little change from\\n the prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-14 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1137105,\n \"text\": \" 3:20 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: Colonic distension\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with recent PNA, cdiff, some hypotension\\n REASON FOR THIS EXAMINATION:\\n Colonic distension\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE ABDOMEN, \\n\\n CLINICAL INFORMATION: Chronic distention.\\n\\n FINDINGS:\\n\\n Single abdomen radiograph compared to the prior study from \\n demonstrates a dilated colonic segment. No frank dilatation of the small\\n bowel identified. Some air is present in the descending colon.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-09 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1136254,\n \"text\": \" 3:41 PM\\n CHEST (PA & LAT) Clip # \\n Reason: Assess for edema, infiltrate\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with COPD and hx of pneumonia.\\n REASON FOR THIS EXAMINATION:\\n Assess for edema, infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL VIEWS OF THE CHEST\\n\\n REASON FOR EXAM: COPD and history of pneumonia.\\n\\n Comparison is made with prior study, .\\n\\n Cardiomediastinal contours are unchanged. Right lower lobe opacity has\\n improved consistent with improving atelectasis. Opacities in the left lower\\n lobe are unchanged. Multiple calcified granulomas are again noted. There is\\n calcification of the mitral valve. There is no pneumothorax or pleural\\n effusion. Mild degenerative changes are in the thoracic spine.\\n\\n IMPRESSION: Improved right lower lobe atelectasis. Opacities in the left\\n lower lobe are stable. AS before this could represent pneumonia or\\n aspiration.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1136043,\n \"text\": \" 9:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with dyspnea, fevers. H/o CHF, COPD.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 82-year-old female with dyspnea and fevers.\\n\\n STUDY: AP portable upright chest radiograph.\\n\\n COMPARISON: .\\n\\n FINDINGS: The cardiomediastinal silhouette appears unremarkable. The hila\\n are normal appearing bilaterally. The right heart border is obscured by\\n opacity in the right lower lung. Additionally, there is retrocardiac opacity.\\n A right upper lobe calcified granuloma is redemonstrated. There is no evidence\\n for large pleural effusion or pneumothorax. The lungs are hyperinflated and\\n there is relative lucency within the lung apices suggestive of underlying\\n emphysema.\\n\\n IMPRESSION: Patchy bibasilar opacities which could reflect pneumonia or\\n aspiration in the appropriate clinical setting.\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-11 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1136628,\n \"text\": \" 7:08 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: line placement\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with hypotension\\n REASON FOR THIS EXAMINATION:\\n line placement\\n ______________________________________________________________________________\\n WET READ: MBue WED 11:21 PM\\n RT CVC TERMINATING IN MID TO DISTAL SVC. NO PTX OR ADDITIONAL INTERVAL\\n CHANGE.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Assess line.\\n\\n Comparison is made with prior study performed two hours earlier.\\n\\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax. No other\\n interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1136382,\n \"text\": \" 12:39 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for pna/interval change\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with COPD, recurrent pneumonia with decreased O2 sat and\\n hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for pna/interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 12:54 P.M. ON \\n\\n HISTORY: Recurrent pneumonia. Decreased oxygen saturation and hypotension.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Right basal opacification has worsened, consistent with progressive pneumonia\\n or atelectasis superimposed. There is no pulmonary edema or pleural effusion.\\n Heart size normal. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1136666,\n \"text\": \" 6:42 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evidence of worsened pulmonary process\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with pneumonia, sepsis\\n REASON FOR THIS EXAMINATION:\\n Evidence of worsened pulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST:\\n\\n REASON FOR EXAM: Pneumonia.\\n\\n Comparison is made with prior study performed the day earlier.\\n\\n Mild cardiomegaly is stable. Right IJ catheter tip is in the mid SVC. There\\n is no pneumothorax. Left lower lobe opacity has minimally improved. Right\\n lower lobe consolidation is stable.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2142-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 111179,\n \"text\": \"Sinus tachycardia. Compared to the previous tracing of no change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2142-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 111180,\n \"text\": \"Sinus tachycardia with ventricular premature beat. Consider left atrial\\nabnormality. Delayed R wave progression with late precordial QRS transition\\nis non-specific but cannot exclude possible prior anterior myocardial\\ninfarction. ST-T wave changes are non-specific. Since the previous tracing\\nof ST-T wave changes appear less prominent but baseline artifact\\non both tracings makes comparison difficult.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2142-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 111181,\n \"text\": \"Normal sinus rhythm with ventricular premature beats. Poor R wave progression\\nin leads V1-V4 of uncertain significance. Diffuse non-specific ST-T wave\\nabnormalities. Compared to the previous tracing of ventricular premature\\nbeats are new and heart rate has increased.\\n\\n\"\n }\n]"}}},{"rowIdx":184,"cells":{"subject_id":{"kind":"number","value":28386,"string":"28,386"},"hadm_id":{"kind":"number","value":186255,"string":"186,255"},"target_text":{"kind":"string","value":"81F EF 45% inf HK, afib/C, DVT, dm2, copd p/w rapid afib and in setting of rapid rate has angina and CHF . 1. Cardiac: a. Rhythm: Pt was in rapid afib on admission. Initially ther was poor rate control in house and the patient went to ICU. She was on atenolol 12.5 daily that uptitrated gradually and rate control improved. Pt's coumadin was held on admission for a supratherapeutic level, though it was restarted. . b. Coronaries: The patient did have anginal symptoms in the setting of rapid heart rate. There was no known h/o CAD, though there is EF 45% with inf HK which suggests CAD. The chest pain was likely related to the rapid afib. The ECG showed only non-specific changes. Enzymes showed trop t 0.03 with negative CK and MB. Pt was rate controlled as described and continued with aspirin, beta blocker, and statin. c. Pt presented in acute CHF with pulmonary edema. LVEF 45%. The patient was diuresed. She was continued on beta blocker and we started an ace inhibitor as well. 2. Confusion: Pt has h/o dementia and was hospitalized with mutliple sedatives and psych meds. Pt's sedating medications were held in house. Confusion resolved and patient oriented again to person, place, and time by hospital day 4. 3. Pleural effusions: There were bilateral, moderate on the left and small on the right. This is unlikely contributing to SOB. The plan was to diurese and treat CHF. . 4. Leukocytosis: Pt had WBC of 16 on admission, but this resolved over hospital course down to 11.1. Likely stress response. Pt is afebrile, UA is negative. CXR is c/w CHF. 5. Diabetes Mellitus Patient c/w metformin and SSI in-house. . Access - PIV . Prophylaxis: anticoagulated for afib, PPI, bowel regimen, per home regimen"},"extractive_notes_summ":{"kind":"string","value":"Left ventricular function.Weight (lb): 180BP (mm Hg): 142/83HR (bpm): 93Status: InpatientDate/Time: at 15:01Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Left pleural effusion is present.LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Trivial mitral regurgitation isseen. Mild regional LVsystolic dysfunction. left basilar opacity likele reflects compression atelectasis. Cover BS c RISS. There is mild regional left ventricularsystolic dysfunction with inferior hypokinesis. Haziness is noted in the right lung base which mauy reflect edema. -5oo @ mdght, -260 current.Id-afebrile.Endo-SSI, metformin PO. Left apices clear, base diminished. She had some expiratory wheezes, more on L than R and benefited from atrovent neb. There is mild symmetric left ventricular hypertrophy. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. She continues to receive atrovent nebs.GI: Pt has excellent apetite. PMHx significant for HTN, AFib, CHF, DVT, COPD, dementia, DM.N-a/ox1, however and cooperative c care. The mitral valve leaflets are mildlythickened. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Captopril 6.25mg as ordered-tolerated well.Resp-Nebs doesd Q4 c increased in diffuse I/E wheeze-improvement post nebs. INR elevated-holding coumadin. CXR shows failure and bilateraly pleural effusions. No echocardiographic signs oftamponade.Conclusions:The left atrium is mildly dilated. She c/o of constipation and colace was increased to . Pt is asymptomatic. Reorient pt as needed. Reorient pt as needed. RR wnl.GI-no difficulties c pills. Early dementia c anxiety-responds well to reoriention/reassurance. However Right LS diminished throughout > than Left. HR therafter 70s-80s c occasional PVC, SBP 115-130. piv x1. Mild [1+] TR.Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: Small pericardial effusion. Right axis deviation. Right axis deviation. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Atrial fibrillation with slowing of the ventricular response as compared withtracing of . possible echo today to evaluate pump function.Resp-bilateral pleural effusions per cxray L>R. She did not aspirate with liquids or soft solids.ENDO: Blood sugars quite elevated. The estimatedpulmonary artery systolic pressure is normal. There is a small pericardialeffusion without tamponade. Bilateral pleural effusions are noted, left greater than right. CCU NSG NOTE: ALT IN CV/RESPS: \"I feel so anxious. 81y.o female c COPD exacerbation admitted from Rehab. Normal LV cavity size. Bilateral pleural effusions, moderate on the left and small on the right with probable underlying mild congestive failure. She has very decreased BS bilaterally. CCU NSG NOTE: ALT IN RESP/CVS: \"It bothers me that I'm confused\".O: For complete VS see CCU flow sheet. 1 piv. SBP 120s-140s, pulses palpable. Diffuse non-specificST-T wave changes. Dosed colace plus senna. coumadin currently on hold c increased INR. Captopril was also added at 6.25mg tid with bp now in 120-130/70-80s.She was KCL replaced this am with repeat K+ pending.RESP: She has more audible breath sounds today, though some crackles were heard. HR is 70-90s afib, much better controlled with 25mg lopressor.She has occasional single pvcs. abd obese, +BS. Theaortic valve leaflets are mildly thickened. afebrile. Continues on ASA, statin. Perhaps dulcolax tab tonight.RENAL: Pt still has foley draining clear urine, now in small amts. The leftventricular cavity size is normal. WBC last trending down.Skin-intact.endo-pm BS 135, no coverage per sliding scale.social/dispo-supportive children. hr now in mid 80s with bp 171/82. f/u am labs (monitor hyponatremia 129/132). IMPRESSION: 1. RR wnl c some DOE. She was symptom free and transfered to CCU on MICU service for further care.ID: WBCs down to 10.3 (16.9). follows commands consistenly. pulses palpable. Requires soft diet (no teeth).GU-foley c adequate CYU. Monitor resp status and nebs as needed. transfer note complete. Normal IVC diameter (1.5-2.5cm) with <50%decrease during respiration (estimated RAP 11-15mmHg).LEFT VENTRICLE: Mild symmetric LVH. HO notified and she received 12.5mg. Possible increase in Lopressor as BP tolerates. Right ventricular chamber size and free wall motion are normal. Monitor BP c increased lopressor. Clinical correlation of theright axis deviation is suggested. I want to go home\".O: For complete VS see CCU flow sheet.ID: PT remains afebrile with decreasing WBCs.CV: PT has no c/o of chest or neck discomfort. CYU.ID-bld/urine cxs pending. The tricuspid valve leaflets are mildly thickened. -BM.GU-dosed 10mg IV lasix for low UO c effect. PT consult was called.A: Some improvement in MS/continued 02 requirement/walking with assistP: Monitor bp with new and increased meds. Known COPD/heart failure history. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. She was transfered to EW where she c/o of chest pressure in addition to her other symptoms. She received lasix 20mg IV at 1130 with good response. HR was 120af with bp in 170/80s. She was treated with sl nitro X 3, solumedrol for supposed copd exacerbation, nebs and dose of levofloxacin. no coverage last night.skin-pressure areas intact.plan-transfer to 6. (baseline while here). No further ABX, cultures pending.CV: HR creeping up to 110-120af when pt received 12.5 lopressor at 11am. Last dosed Lasix @ 1130 (10-20mg).GI-+BS, -BM since admit. \"O-see flowsheet/admit note for additional details. f/u am labs. Support pt and her fears of being in a new place. Sugars were 228 and 245 and she received 4 and 5u of regular insulin.MS: Pt initially was quite lethargic and oriented only X 1. Please note evaluation was limited due to portable technique and marked patient rotation. She becomes anxious about what is happening, but responds well to reassurance.A: Decreasing WBCs, imcomplete control with 12.5 lopressor,improved msP: Continue to reassure pt that she is safe, and review todays event. By 1800 her sugar was 129 and no further reg insulin was required.MS/ACTIVITY: Pt continues to be A & 0 X . Ck peak 104. Faint basalar crackles. She received lasix 20mg iv at 11am with fair diaresis. Clinical correlation of the rightaxis deviation is suggested.TRACING #2 in short pt 81y.o female admitted from rehab c CP, SOB, hypoxia COPD Exacerbation. \"O-see flowsheet/transfer notes for details. Keep careful I & O. Keep careful I & O. She has strong non-productive cough.RENAL: Pt has foley draining clear urine."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2184-10-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":983497,"text":" 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, CHF, p/w chest pain and SOB.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain and shortness of breath. Known COPD/heart failure\n history.\n\n No prior exams are available.\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS: Patient is rotated to the left. Bilateral pleural effusions\n are noted, left greater than right. left basilar opacity likele reflects\n compression atelectasis. Haziness is noted in the right lung base which\n mauy reflect edema. Upper lobe lucency likely related to emphysema in\n this patient with known COPD. The heart appears enlarged. No evidence of\n pneumothorax.\n\n IMPRESSION:\n\n 1. Bilateral pleural effusions, moderate on the left and small on the right\n with probable underlying mild congestive failure.\n\n 2. Please note evaluation was limited due to portable technique and marked\n patient rotation. Dedicated PA and lateral radiographs would be helpful to\n further delineate.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2184-10-25 00:00:00.000","description":"Report","row_id":1632702,"text":"CCU NSG NOTE: ALT IN RESP/CV\nS: \"It bothers me that I'm confused\".\nO: For complete VS see CCU flow sheet. This 81y old Rehab resident with pmh of CHF, af on coumadin, htn, aodm, COPD, and mild dementia awoke ~0200 with SOB & jaw pain. Her 02 sat was 70% that increased to 92% on 3L NP. She was transfered to EW where she c/o of chest pressure in addition to her other symptoms. HR was 120af with bp in 170/80s. She was treated with sl nitro X 3, solumedrol for supposed copd exacerbation, nebs and dose of levofloxacin. She also received 2.5IV lopressor which brought her hr down to 80s and bp to 120s/70s. She was symptom free and transfered to CCU on MICU service for further care.\nID: WBCs down to 10.3 (16.9). No further ABX, cultures pending.\nCV: HR creeping up to 110-120af when pt received 12.5 lopressor at 11am. \rByy 600 hr up to 100-125 again. HO notified and she received 12.5mg. hr now in mid 80s with bp 171/82. No further meds ordered. Pt is asymptomatic. CKs are 104 down to 86 at noon. Troponin .01.\nRESP: RR 18 up to high 20s later in the day. She has very decreased BS bilaterally. CXR shows failure and bilateraly pleural effusions. She had some expiratory wheezes, more on L than R and benefited from atrovent neb. She is now sating 98% on 4L NP. She has strong non-productive cough.\nRENAL: Pt has foley draining clear urine. She received lasix 20mg IV at 1130 with good response. She is now 600cc neg for the day.\nGI: Pt has excellent apetite, but needs soft food as she has no teeth. Mental status is improving, but pt should still be monitored while eating as she does not attend well and may need to be prompted to swallow. She did not aspirate with liquids or soft solids.\nENDO: Blood sugars quite elevated. Pt did not receive po today. Sugars were 228 and 245 and she received 4 and 5u of regular insulin.\nMS: Pt initially was quite lethargic and oriented only X 1. She slept when left alone, but was easily rouseable. By the afternoon she was more awake and aware that she was confused. She could not recall events earlier in the day. She becomes anxious about what is happening, but responds well to reassurance.\nA: Decreasing WBCs, imcomplete control with 12.5 lopressor,improved ms\nP: Continue to reassure pt that she is safe, and review todays event. Keep careful I & O. Notify HO if HR jumps up again. Monitor finger sticks to better control sugars.\n\n\n"},{"category":"Nursing/other","chartdate":"2184-10-27 00:00:00.000","description":"Report","row_id":1632705,"text":"CCU Nursing note\nS-\"I hope my family is ok. I don't know where I am.\"\nO-see flowsheet/transfer notes for details. 81y.o female c COPD exacerbation admitted from Rehab. C/O to floor, 6. Transfer when ready.\n\nN-a/ox1-2 during night. (baseline while here). Early dementia c anxiety-responds well to reoriention/reassurance. follows commands consistenly. OOB to chair last shift and ambulating in room c walker.\nDenies any pain.\n\nCV-Chronic afib. coumadin currently on hold c increased INR. HR 80s-110 responding to 25mg PO Lopressor. SBP 120s-140s, pulses palpable. 1 piv. Captopril 6.25mg as ordered-tolerated well.\n\nResp-Nebs doesd Q4 c increased in diffuse I/E wheeze-improvement post nebs. Faint basalar crackles. RR wnl c some DOE. Last dosed Lasix @ 1130 (10-20mg).\n\nGI-+BS, -BM since admit. Dosed colace plus senna. No difficulties swallowing pills/eating. however some times requires reminders to swallow. Requires soft diet (no teeth).\n\nGU-foley c adequate CYU. Fluid restriction 1500cc/day. -5oo @ mdght, -260 current.\n\nId-afebrile.\n\nEndo-SSI, metformin PO. no coverage last night.\n\nskin-pressure areas intact.\n\nplan-transfer to 6. Monitor resp status and nebs as needed. Possible increase in Lopressor as BP tolerates. Reorient pt as needed. transfer note complete.\n"},{"category":"Nursing/other","chartdate":"2184-10-26 00:00:00.000","description":"Report","row_id":1632703,"text":"CCU Nursing note\nS-\"I don't know where I'm at. Is it the ? As long as my family knows I'm here.\"\nO-see flowsheet/admit note for additional details. in short pt 81y.o female admitted from rehab c CP, SOB, hypoxia COPD Exacerbation. PMHx significant for HTN, AFib, CHF, DVT, COPD, dementia, DM.\n\nN-a/ox1, however and cooperative c care. Anxious at times, Responds well to orientation and reassurance. Dosed 650mg tylenol @ HS for back discomfort c effect. bilateral strength equal, PERRL, no other focal deficits.\n\nCV-Lopressor increased to 25mg TID c better rate control in afib. HR therafter 70s-80s c occasional PVC, SBP 115-130. piv x1. pulses palpable. Continues on ASA, statin. Ck peak 104. INR elevated-holding coumadin. f/u am labs (monitor hyponatremia 129/132). possible echo today to evaluate pump function.\n\nResp-bilateral pleural effusions per cxray L>R. However Right LS diminished throughout > than Left. Left apices clear, base diminished. Continues on 4L NC 96-99%. RR wnl.\n\nGI-no difficulties c pills. abd obese, +BS. -BM.\nGU-dosed 10mg IV lasix for low UO c effect. CYU.\n\nID-bld/urine cxs pending. afebrile. WBC last trending down.\nSkin-intact.\n\nendo-pm BS 135, no coverage per sliding scale.\nsocial/dispo-supportive children. Full code. c/o to floor when bed available.\n\nplan-echo today? f/u am labs. Monitor BP c increased lopressor. Cover BS c RISS. Reorient pt as needed. bed low/locked c alarm on.\n\n\n"},{"category":"Nursing/other","chartdate":"2184-10-26 00:00:00.000","description":"Report","row_id":1632704,"text":"CCU NSG NOTE: ALT IN CV/RESP\nS: \"I feel so anxious. I want to go home\".\nO: For complete VS see CCU flow sheet.\nID: PT remains afebrile with decreasing WBCs.\nCV: PT has no c/o of chest or neck discomfort. HR is 70-90s afib, much better controlled with 25mg lopressor.She has occasional single pvcs. Captopril was also added at 6.25mg tid with bp now in 120-130/70-80s.She was KCL replaced this am with repeat K+ pending.\nRESP: She has more audible breath sounds today, though some crackles were heard. She is now sating 95-96% on 2L NP. On RA she sats 89-91%. She continues to receive atrovent nebs.\nGI: Pt has excellent apetite. She c/o of constipation and colace was increased to . She has attempted bm multiple times, but has not been able to. Perhaps dulcolax tab tonight.\nRENAL: Pt still has foley draining clear urine, now in small amts. She received lasix 20mg iv at 11am with fair diaresis. She is presently negative ~500cc for the day and ~1 liter LOS.\nENDO: Finger stick at noon was 199 and she received 4u reg insulin for that. She had received metformin 1000mg at 11. By 1800 her sugar was 129 and no further reg insulin was required.\nMS/ACTIVITY: Pt continues to be A & 0 X . By the late afternoon she became anxious, after her family left feeling she was unsure of where she was. She was up in the chair and perhaps fatigued. Once back in bed she went to sleep. She took a walk with assist and did well. She walks with walker at rehab. PT consult was called.\nA: Some improvement in MS/continued 02 requirement/walking with assist\nP: Monitor bp with new and increased meds. Support pt and her fears of being in a new place. Keep careful I & O. Increase activity as tolerated.\n\n"},{"category":"Echo","chartdate":"2184-10-25 00:00:00.000","description":"Report","row_id":96031,"text":"PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nWeight (lb): 180\nBP (mm Hg): 142/83\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 15:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLeft pleural effusion is present.\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (1.5-2.5cm) with <50%\ndecrease during respiration (estimated RAP 11-15mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction with inferior hypokinesis. There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets are mildly thickened. There is no aortic valve stenosis.\nNo 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. The estimated\npulmonary artery systolic pressure is normal. There is a small pericardial\neffusion without tamponade.\n\n\n"},{"category":"ECG","chartdate":"2184-10-25 00:00:00.000","description":"Report","row_id":260971,"text":"Atrial fibrillation with slowing of the ventricular response as compared with\ntracing of . Right axis deviation. Clinical correlation of the right\naxis deviation is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2184-10-25 00:00:00.000","description":"Report","row_id":260972,"text":"Atrial fibrillation with rapid ventricular response. Diffuse non-specific\nST-T wave changes. Right axis deviation. Clinical correlation of the\nright axis deviation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 983497,\n \"text\": \" 4:40 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, edema\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with COPD, CHF, p/w chest pain and SOB.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Chest pain and shortness of breath. Known COPD/heart failure\\n history.\\n\\n No prior exams are available.\\n\\n UPRIGHT PORTABLE CHEST RADIOGRAPH\\n\\n FINDINGS: Patient is rotated to the left. Bilateral pleural effusions\\n are noted, left greater than right. left basilar opacity likele reflects\\n compression atelectasis. Haziness is noted in the right lung base which\\n mauy reflect edema. Upper lobe lucency likely related to emphysema in\\n this patient with known COPD. The heart appears enlarged. No evidence of\\n pneumothorax.\\n\\n IMPRESSION:\\n\\n 1. Bilateral pleural effusions, moderate on the left and small on the right\\n with probable underlying mild congestive failure.\\n\\n 2. Please note evaluation was limited due to portable technique and marked\\n patient rotation. Dedicated PA and lateral radiographs would be helpful to\\n further delineate.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1632702,\n \"text\": \"CCU NSG NOTE: ALT IN RESP/CV\\nS: \\\"It bothers me that I'm confused\\\".\\nO: For complete VS see CCU flow sheet. This 81y old Rehab resident with pmh of CHF, af on coumadin, htn, aodm, COPD, and mild dementia awoke ~0200 with SOB & jaw pain. Her 02 sat was 70% that increased to 92% on 3L NP. She was transfered to EW where she c/o of chest pressure in addition to her other symptoms. HR was 120af with bp in 170/80s. She was treated with sl nitro X 3, solumedrol for supposed copd exacerbation, nebs and dose of levofloxacin. She also received 2.5IV lopressor which brought her hr down to 80s and bp to 120s/70s. She was symptom free and transfered to CCU on MICU service for further care.\\nID: WBCs down to 10.3 (16.9). No further ABX, cultures pending.\\nCV: HR creeping up to 110-120af when pt received 12.5 lopressor at 11am. \\rByy 600 hr up to 100-125 again. HO notified and she received 12.5mg. hr now in mid 80s with bp 171/82. No further meds ordered. Pt is asymptomatic. CKs are 104 down to 86 at noon. Troponin .01.\\nRESP: RR 18 up to high 20s later in the day. She has very decreased BS bilaterally. CXR shows failure and bilateraly pleural effusions. She had some expiratory wheezes, more on L than R and benefited from atrovent neb. She is now sating 98% on 4L NP. She has strong non-productive cough.\\nRENAL: Pt has foley draining clear urine. She received lasix 20mg IV at 1130 with good response. She is now 600cc neg for the day.\\nGI: Pt has excellent apetite, but needs soft food as she has no teeth. Mental status is improving, but pt should still be monitored while eating as she does not attend well and may need to be prompted to swallow. She did not aspirate with liquids or soft solids.\\nENDO: Blood sugars quite elevated. Pt did not receive po today. Sugars were 228 and 245 and she received 4 and 5u of regular insulin.\\nMS: Pt initially was quite lethargic and oriented only X 1. She slept when left alone, but was easily rouseable. By the afternoon she was more awake and aware that she was confused. She could not recall events earlier in the day. She becomes anxious about what is happening, but responds well to reassurance.\\nA: Decreasing WBCs, imcomplete control with 12.5 lopressor,improved ms\\nP: Continue to reassure pt that she is safe, and review todays event. Keep careful I & O. Notify HO if HR jumps up again. Monitor finger sticks to better control sugars.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2184-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1632705,\n \"text\": \"CCU Nursing note\\nS-\\\"I hope my family is ok. I don't know where I am.\\\"\\nO-see flowsheet/transfer notes for details. 81y.o female c COPD exacerbation admitted from Rehab. C/O to floor, 6. Transfer when ready.\\n\\nN-a/ox1-2 during night. (baseline while here). Early dementia c anxiety-responds well to reoriention/reassurance. follows commands consistenly. OOB to chair last shift and ambulating in room c walker.\\nDenies any pain.\\n\\nCV-Chronic afib. coumadin currently on hold c increased INR. HR 80s-110 responding to 25mg PO Lopressor. SBP 120s-140s, pulses palpable. 1 piv. Captopril 6.25mg as ordered-tolerated well.\\n\\nResp-Nebs doesd Q4 c increased in diffuse I/E wheeze-improvement post nebs. Faint basalar crackles. RR wnl c some DOE. Last dosed Lasix @ 1130 (10-20mg).\\n\\nGI-+BS, -BM since admit. Dosed colace plus senna. No difficulties swallowing pills/eating. however some times requires reminders to swallow. Requires soft diet (no teeth).\\n\\nGU-foley c adequate CYU. Fluid restriction 1500cc/day. -5oo @ mdght, -260 current.\\n\\nId-afebrile.\\n\\nEndo-SSI, metformin PO. no coverage last night.\\n\\nskin-pressure areas intact.\\n\\nplan-transfer to 6. Monitor resp status and nebs as needed. Possible increase in Lopressor as BP tolerates. Reorient pt as needed. transfer note complete.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2184-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1632703,\n \"text\": \"CCU Nursing note\\nS-\\\"I don't know where I'm at. Is it the ? As long as my family knows I'm here.\\\"\\nO-see flowsheet/admit note for additional details. in short pt 81y.o female admitted from rehab c CP, SOB, hypoxia COPD Exacerbation. PMHx significant for HTN, AFib, CHF, DVT, COPD, dementia, DM.\\n\\nN-a/ox1, however and cooperative c care. Anxious at times, Responds well to orientation and reassurance. Dosed 650mg tylenol @ HS for back discomfort c effect. bilateral strength equal, PERRL, no other focal deficits.\\n\\nCV-Lopressor increased to 25mg TID c better rate control in afib. HR therafter 70s-80s c occasional PVC, SBP 115-130. piv x1. pulses palpable. Continues on ASA, statin. Ck peak 104. INR elevated-holding coumadin. f/u am labs (monitor hyponatremia 129/132). possible echo today to evaluate pump function.\\n\\nResp-bilateral pleural effusions per cxray L>R. However Right LS diminished throughout > than Left. Left apices clear, base diminished. Continues on 4L NC 96-99%. RR wnl.\\n\\nGI-no difficulties c pills. abd obese, +BS. -BM.\\nGU-dosed 10mg IV lasix for low UO c effect. CYU.\\n\\nID-bld/urine cxs pending. afebrile. WBC last trending down.\\nSkin-intact.\\n\\nendo-pm BS 135, no coverage per sliding scale.\\nsocial/dispo-supportive children. Full code. c/o to floor when bed available.\\n\\nplan-echo today? f/u am labs. Monitor BP c increased lopressor. Cover BS c RISS. Reorient pt as needed. bed low/locked c alarm on.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2184-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1632704,\n \"text\": \"CCU NSG NOTE: ALT IN CV/RESP\\nS: \\\"I feel so anxious. I want to go home\\\".\\nO: For complete VS see CCU flow sheet.\\nID: PT remains afebrile with decreasing WBCs.\\nCV: PT has no c/o of chest or neck discomfort. HR is 70-90s afib, much better controlled with 25mg lopressor.She has occasional single pvcs. Captopril was also added at 6.25mg tid with bp now in 120-130/70-80s.She was KCL replaced this am with repeat K+ pending.\\nRESP: She has more audible breath sounds today, though some crackles were heard. She is now sating 95-96% on 2L NP. On RA she sats 89-91%. She continues to receive atrovent nebs.\\nGI: Pt has excellent apetite. She c/o of constipation and colace was increased to . She has attempted bm multiple times, but has not been able to. Perhaps dulcolax tab tonight.\\nRENAL: Pt still has foley draining clear urine, now in small amts. She received lasix 20mg iv at 11am with fair diaresis. She is presently negative ~500cc for the day and ~1 liter LOS.\\nENDO: Finger stick at noon was 199 and she received 4u reg insulin for that. She had received metformin 1000mg at 11. By 1800 her sugar was 129 and no further reg insulin was required.\\nMS/ACTIVITY: Pt continues to be A & 0 X . By the late afternoon she became anxious, after her family left feeling she was unsure of where she was. She was up in the chair and perhaps fatigued. Once back in bed she went to sleep. She took a walk with assist and did well. She walks with walker at rehab. PT consult was called.\\nA: Some improvement in MS/continued 02 requirement/walking with assist\\nP: Monitor bp with new and increased meds. Support pt and her fears of being in a new place. Keep careful I & O. Increase activity as tolerated.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 96031,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Congestive heart failure. Left ventricular function.\\nWeight (lb): 180\\nBP (mm Hg): 142/83\\nHR (bpm): 93\\nStatus: Inpatient\\nDate/Time: at 15:01\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLeft pleural effusion is present.\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\\nNo ASD by 2D or color Doppler. Normal IVC diameter (1.5-2.5cm) with <50%\\ndecrease during respiration (estimated RAP 11-15mmHg).\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\\nsystolic dysfunction. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\\nNormal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\\n\\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\\ntamponade.\\n\\nConclusions:\\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\\nventricular cavity size is normal. There is mild regional left ventricular\\nsystolic dysfunction with inferior hypokinesis. There is no ventricular septal\\ndefect. Right ventricular chamber size and free wall motion are normal. The\\naortic valve leaflets are mildly thickened. There is no aortic valve stenosis.\\nNo 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. The estimated\\npulmonary artery systolic pressure is normal. There is a small pericardial\\neffusion without tamponade.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 260971,\n \"text\": \"Atrial fibrillation with slowing of the ventricular response as compared with\\ntracing of . Right axis deviation. Clinical correlation of the right\\naxis deviation is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 260972,\n \"text\": \"Atrial fibrillation with rapid ventricular response. Diffuse non-specific\\nST-T wave changes. Right axis deviation. Clinical correlation of the\\nright axis deviation is suggested. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":185,"cells":{"subject_id":{"kind":"number","value":60653,"string":"60,653"},"hadm_id":{"kind":"number","value":181064,"string":"181,064"},"target_text":{"kind":"string","value":"The pt is a 44 year-old left handed man with PMH significant for tobacco and alcohol abuse plus untreated HTN who presents as a transfer from Hospital for management of a right basal ganglia hemorrhage. Etiology of the hemorrhage is somewhat uncertain. HTN is likely given the history of untreated high blood pressures. Patient was initially admitted to Neuro ICU service with neurosurgery following. Overnight, he required frequent Valium for EtOH withdrawal (severe diaphoresis and tachycardia). Patient became more somnolent the next morning which may have been due to Vailum but repeat CT/CTA showed increased hemorrhage with midline shift 13~14mm to the left. Patient was emergently taken to OR per neurosurgery where he underwent right-sided frontotemporal craniotomy for decompression, evacuation, partial frontal lobe resection. He was successfully extubated the next mornind and repeat CT showed no new hemorrhage with stable midline shoft ~9mm to the left as was seen in post-operative imaging. He was continued on CIWA for EtOH withdrawal with tapering standing Ativan plus as needed Ativan. Also, given hemorhage and surgical evacuation, he was empirically loaded with phenytoic for seizure prophylaxis and was continued on 100mg TID for maintenance. He gradually became more arousable but remains L hemiplegic with some withdrawal of LLE to noxious stimuli but no movement on LUE even with noxious stimuli. He started to speak more on POD #3 but his speech remained heavily dysarthric. Since transfer to the neurology floor, his speech has continued to improve. In addition, his awareness regarding his left hemiparesis has improved. On the floor, he no longer needed the Ativan, and his anti-hypertensive medication doses were optimized. He has been evaluated by speech and swallow and is on the appropriate diet as follows: 1. Continue po diet of ground solids, nectar thick liquids. 2. PO meds: crushed in puree 3. 1:1 supervision with all PO. Maintain aspiration precautions including: a) feed only when awake/alert b) sit fully upright for all PO c) alternate bites and sips d) provide verbal cues to clear L side of oral cavity e) if presents with fatigue, cease meal. Consider 6 small meals instead of 3 large ones as needed. He has had a Regular Low sodium / Heart healthy Consistency: Ground; Nectar prethickened liquids Supplement: Ensure Pudding breakfast, lunch, dinner Crush po meds, give 6 small meals, and 1:1 supervision with meals on the Neurology Floor. He has been evaluated by PT and OT and he needs close supervision and appropriate precautions when he is mobilised due to his left hemiparesis and left sided neglect."},"extractive_notes_summ":{"kind":"string","value":"Phenytoin 23. Metoprolol Tartrate 19. Tylenol for HA per primary service. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Metoprolol Tartrate 18. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Subjective: Pt just extubated. Famotidine 7. Famotidine 7. Nicotine Patch 17. Nicotine Patch 17. Morphine Sulfate 18. Morphine Sulfate 18. Lorazepam 14. Lorazepam 14. Phenytoin 21. Phenytoin 21. Phenytoin 21. Phenytoin 21. Current medications: 1. Ativan atc and prn. Ativan atc and prn. Lorazepam 17. Phenytoin 20. Phenytoin 20. Action: Freq neuro checks. Action: Freq neuro checks. Action: Freq neuro checks. Famotidine 10. Famotidine 10. Famotidine 10. HTN. On Ativan atc. On Ativan atc. On Ativan atc. Nicotine Patch 19. Nicotine Patch 19. FoLIC Acid 11. Nicotine Patch 21. Has prn hydral and lopressor. Has prn hydral and lopressor. Has prn hydral and lopressor. Docusate Sodium 9. Docusate Sodium 9. Docusate Sodium 9. Docusate Sodium 6. Docusate Sodium 6. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Lorazepam 15. Lorazepam 15. Current medications: . Current medications: . Morphine Sulfate 20. Lisinopril 13. Lisinopril 13. HydrALAzine 11. HydrALAzine 11. Ondansetron 19. Ondansetron 19. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Remains on ativan atc. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Remains on ativan atc. Addictions consult. Addictions consult. Metoprolol Tartrate 16. Metoprolol Tartrate 16. Action: Ativan atc. Action: Ativan atc. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. TITLE: Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. .H/O respiratory failure, acute (not ARDS/) Assessment: Pt extubated today. Metoprolol Tartrate 19. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Nicotine Patch 17. Nicotine Patch 17. Metoprolol Tartrate 18. Has prn hydral and lopressor. Has prn hydral and lopressor. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt continues with ciwa scale. hydralazine prn. Morphine Sulfate 16. Morphine Sulfate 16. Right Basal Ganglia Hemorrhage Assessment: c/o constant R sided HA upon initial exam, +tremors/sweats- please see metavision for neuron and CIWA assessment. Morphine Sulfate 20. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Hourly CIWA scale 17-27 Action: Response: Plan: Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage Assessment: Action: Response: Plan: Nicotine Patch 21. Phenytoin 19. Phenytoin 19. Current medications: 1. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. Action: Freq neuro checks. Action: Freq neuro checks. Action: Freq neuro checks. Phenytoin 23. Ordered morphine 1mg IVB x1 dose. Ordered morphine 1mg IVB x1 dose. IV labetelol drip restarted with goal SBP 140-160. Lorazepam 14. Lorazepam 14. Addictions consult. Sodium Chloride 0.9% Flush 27. FINDINGS: Post-operative change of a right craniotomy status post evacuation of an intraparenchymal bleed is again noted. A small amount of residual hemorrhage and extensive pneumocephalus within the right basal ganglia is identified. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. ( series 401b/7) (Over) 10:52 AM CTA HEAD W&W/O C & RECONS Clip # Reason: Hemorrhage follow-up Admitting Diagnosis: INTRACRANIAL HEMORRHAGE FINAL REPORT (Cont) There is evidence of scleral band, with ocular implant on the left side, unchanged. Subarachnoid hemorrhage (SAH) Assessment: Neuro assessment done q2hrs. Sinus rhythmProminent precordial lead QRS voltage suggests left ventricular hypertrophy butmay be nondiagnostic given ageModest nonspecific inferior ST-T wave changesNo previous tracing available for comparison FINAL REPORT HISTORY: Known intracranial hemorrhage. FINDINGS: Patient is status post right frontoparietal craniotomy with evacuation of putaminal and temporal lobe hematoma. A few small hypodense foci, noted in the left internal capsule, may represent perivascular spaces or chronic lacunar infarcts are unchanged. Interval decrease in right basal ganglia hemorrhage. This location is most suggestive of a hypertensive etiology, although underlying mass lesion/metastasis is not completely excluded."},"n_notes":{"kind":"number","value":52,"string":"52"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2186-08-28 00:00:00.000","description":"Nursing Transfer Note","row_id":417678,"text":"Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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":"2186-08-28 00:00:00.000","description":"Nursing Transfer Note","row_id":417679,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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":"Physician ","chartdate":"2186-08-27 00:00:00.000","description":"Intensivist Note","row_id":417538,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\n ETOH abuse, h/o illicit drug use\n : none\n .\n Current medications:\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. FoLIC Acid 11. Heparin\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\n 17. Metoprolol Tartrate\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\n Ondansetron 22. Phenytoin 23. Potassium Chloride\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\n 27. Thiamine\n 24 Hour Events:\n TF placed and tF started yesterday\n Post operative day:\n POD#3 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:41 AM\n Lorazepam (Ativan) - 06:00 PM\n Famotidine (Pepcid) - 08:13 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Hydralazine - 02:14 AM\n Metoprolol - 06:18 AM\n Other medications:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.1\nC (100.5\n HR: 119 (86 - 119) bpm\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\n RR: 18 (9 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,828 mL\n 776 mL\n PO:\n Tube feeding:\n 190 mL\n 129 mL\n IV Fluid:\n 2,518 mL\n 647 mL\n Blood products:\n Total out:\n 2,735 mL\n 700 mL\n Urine:\n 2,735 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 93 mL\n 76 mL\n Respiratory support\n SPO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 220 K/uL\n 13.6 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 38.0 %\n 16.5 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n Plt\n 20\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\n to PO\n Cardiovascular: Lopressor 75 TID PO\n HYDRALAZYN prn\n Pulmonary: Stable\n Gastrointestinal / Abdomen: Advance to goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Lasix 20mg \n Hematology: Stable\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Nephrology\n Billing Diagnosis: Other: Basal ganglia Bleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Progress Note","row_id":417605,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Remains on ativan atc. Tachy at times and occ attempting to pull at\n lines, otherwise no s/s withdrawal noted.\n Action:\n Ativan atc, but dose decreased\n Response:\n No need for prn ativan and no s/s withdrawal noted\n Plan:\n Con\nt to monitor. Ativan atc and prn.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Opens eyes to stim . right pupil round and reactive. Left pupil at\n baseline. Follows commands on right. Moves right spont. No spont\n movement on left. Withdraws on left to pain. Oriented to person and\n president and month. Only says few words and speech grarbled.\n Action:\n Neuro checks.\n Response:\n Neuro status unchanged.\n Plan:\n Con\nt neuro checks\n"},{"category":"Physician ","chartdate":"2186-08-25 00:00:00.000","description":"Intensivist Note","row_id":417181,"text":"SICU\n HPI:\n 44yo male presented to an outside hospital with acute onset\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\n right cranimtomy hemmhorrage evacuation\n Chief complaint:\n acute onset left sided plegia\n PMHx:\n left eye injury-screwdriver with surgical correction with\n noted visula impairment since, ETOH abuse, prior hx on illicit\n drug use.\n Current medications:\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\n Acid/Multivitamin/Thiamine-1000mL NS\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\n 17. NiCARdipine 18. Ondansetron\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\n 25. Vancomycin\n 24 Hour Events:\n OR SENT - At 03:00 PM\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\n INTUBATION - At 03:15 PM\n intubated in OR\n INVASIVE VENTILATION - START 03:15 PM\n intubated in OR\n ARTERIAL LINE - START 03:30 PM\n OR RECEIVED - At 05:45 PM\n Post operative day:\n POD#1 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Gentamicin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Diazepam (Valium) - 11:00 AM\n Midazolam (Versed) - 06:05 PM\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.3\nC (97.4\n HR: 88 (73 - 95) bpm\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\n RR: 13 (12 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,980 mL\n 1,228 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,780 mL\n 1,228 mL\n Blood products:\n 200 mL\n Total out:\n 3,800 mL\n 435 mL\n Urine:\n 1,690 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 180 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SPO2: 100%\n ABG: 7.44/40/198/28/3\n Ve: 6.9 L/min\n PaO2 / FiO2: 495\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, No(t) Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\n Weakness)\n Labs / Radiology\n 251 K/uL\n 13.2 g/dL\n 168 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 105 mEq/L\n 142 mEq/L\n 37.6 %\n 18.7 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n WBC\n 9.7\n 18.7\n Hct\n 43.2\n 37.6\n Plt\n 231\n 251\n Creatinine\n 0.8\n 1.0\n TCO2\n 26\n 28\n Glucose\n 134\n 146\n 168\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 44yo male presented to an outside hospital with\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\n evacuation\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\n MEDAZOLEM,\n Cardiovascular: D/C Nocrdipine, Start Lopressor\n Pulmonary: Extubate today, Spontaneous breathing trial\n Gastrointestinal / Abdomen: assess Swallow\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable Ht\n Endocrine: RISS, Start RISS start at 120 mg/dl\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CT scan head today\n Fluids:\n Consults:\n Billing Diagnosis: Other: Left Side weakness\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2186-08-25 00:00:00.000","description":"Intensivist Note","row_id":417183,"text":"SICU\n HPI:\n 44yo male presented to an outside hospital with acute onset\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\n right cranimtomy hemmhorrage evacuation\n Chief complaint:\n acute onset left sided plegia\n PMHx:\n left eye injury-screwdriver with surgical correction with\n noted visula impairment since, ETOH abuse, prior hx on illicit\n drug use.\n Current medications:\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\n Acid/Multivitamin/Thiamine-1000mL NS\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\n 17. NiCARdipine 18. Ondansetron\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\n 25. Vancomycin\n 24 Hour Events:\n OR SENT - At 03:00 PM\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\n INTUBATION - At 03:15 PM\n intubated in OR\n INVASIVE VENTILATION - START 03:15 PM\n intubated in OR\n ARTERIAL LINE - START 03:30 PM\n OR RECEIVED - At 05:45 PM\n Post operative day:\n POD#1 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Gentamicin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Diazepam (Valium) - 11:00 AM\n Midazolam (Versed) - 06:05 PM\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.3\nC (97.4\n HR: 88 (73 - 95) bpm\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\n RR: 13 (12 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,980 mL\n 1,228 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,780 mL\n 1,228 mL\n Blood products:\n 200 mL\n Total out:\n 3,800 mL\n 435 mL\n Urine:\n 1,690 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 180 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SPO2: 100%\n ABG: 7.44/40/198/28/3\n Ve: 6.9 L/min\n PaO2 / FiO2: 495\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, No(t) Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\n Weakness)\n Labs / Radiology\n 251 K/uL\n 13.2 g/dL\n 168 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 105 mEq/L\n 142 mEq/L\n 37.6 %\n 18.7 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n WBC\n 9.7\n 18.7\n Hct\n 43.2\n 37.6\n Plt\n 231\n 251\n Creatinine\n 0.8\n 1.0\n TCO2\n 26\n 28\n Glucose\n 134\n 146\n 168\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 44yo male presented to an outside hospital with\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\n evacuation\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\n MEDAZOLEM,\n Cardiovascular: D/C Nocrdipine, Start Lopressor\n Pulmonary: Extubate today, Spontaneous breathing trial\n Gastrointestinal / Abdomen: assess Swallow\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable Ht\n Endocrine: RISS, Start RISS start at 120 mg/dl\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CT scan head today\n Fluids:\n Consults:\n Billing Diagnosis: Other: Left Side weakness\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-28 00:00:00.000","description":"Nursing Progress Note","row_id":417730,"text":"Subarachnoid hemorrhage (SAH)\n Assessment:\n Moves right arm and leg off the bed. No spontaneous movement in left\n arm or left leg. Opens eyes to stimuli. Right pupil equal and reactive.\n Left pupil non reactive due to prior eye trauma. Speech garbled and at\n times difficult to understand. Pt able to state name and year. Becomes\n confused to month and place. Pt able to stick tongue upon command and\n squeeze hand to command.\n Action:\n Neuro check q2hrs. ativan 0.5mg iv as ordered.\n Response:\n Neuron status stable\n Plan:\n Continue to monitor neuron status.\n"},{"category":"Nursing","chartdate":"2186-08-28 00:00:00.000","description":"Nursing Transfer Note","row_id":417733,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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":"Physician ","chartdate":"2186-08-28 00:00:00.000","description":"Intensivist Note","row_id":417743,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\n Acid 8. Furosemide\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\n Lorazepam 15. Metoprolol Tartrate\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\n Ondansetron 20. Phenytoin 21. Potassium Chloride\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\n Sodium Chloride 0.9% Flush\n 26. Thiamine\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:48 AM\n Post operative day:\n POD#4 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:19 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 110 (94 - 125) bpm\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\n RR: 19 (18 - 26) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,758 mL\n 686 mL\n PO:\n Tube feeding:\n 1,218 mL\n 647 mL\n IV Fluid:\n 1,059 mL\n 39 mL\n Blood products:\n Total out:\n 3,148 mL\n 275 mL\n Urine:\n 3,148 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -390 mL\n 411 mL\n Respiratory support\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n No movement), (LLE: No movement)\n Labs / Radiology\n 266 K/uL\n 14.4 g/dL\n 142 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 101 mEq/L\n 138 mEq/L\n 39.4 %\n 12.9 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n 03:31 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n 12.9\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n 39.4\n Plt\n 20\n 266\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n 0.9\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n 142\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\n controlled\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\n Pulmonary: cont pulm toilet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: stable\n Lines:\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2186-08-28 00:00:00.000","description":"Intensivist Note","row_id":417745,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\n Acid 8. Furosemide\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\n Lorazepam 15. Metoprolol Tartrate\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\n Ondansetron 20. Phenytoin 21. Potassium Chloride\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\n Sodium Chloride 0.9% Flush\n 26. Thiamine\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:48 AM\n Post operative day:\n POD#4 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:19 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 110 (94 - 125) bpm\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\n RR: 19 (18 - 26) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,758 mL\n 686 mL\n PO:\n Tube feeding:\n 1,218 mL\n 647 mL\n IV Fluid:\n 1,059 mL\n 39 mL\n Blood products:\n Total out:\n 3,148 mL\n 275 mL\n Urine:\n 3,148 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -390 mL\n 411 mL\n Respiratory support\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n No movement), (LLE: No movement)\n Labs / Radiology\n 266 K/uL\n 14.4 g/dL\n 142 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 101 mEq/L\n 138 mEq/L\n 39.4 %\n 12.9 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n 03:31 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n 12.9\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n 39.4\n Plt\n 20\n 266\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n 0.9\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n 142\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\n controlled\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\n Pulmonary: cont pulm toilet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: stable\n Lines:\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Progress Note","row_id":417634,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Remains on ativan atc. Tachy at times and occ attempting to pull at\n lines, otherwise no s/s withdrawal noted.\n Action:\n Ativan atc, but dose decreased\n Response:\n No need for prn ativan and no s/s withdrawal noted\n Plan:\n Con\nt to monitor. Ativan atc and prn.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Opens eyes to stim . right pupil round and reactive. Left pupil at\n baseline. Follows commands on right. Moves right spont. No spont\n movement on left. Withdraws on left to pain. Oriented to person and\n president and month at times. Only says few words and speech grarbled.\n Action:\n Neuro checks.\n Response:\n Neuro status unchanged.\n Plan:\n Con\nt neuro checks\n To tx to SDU when bed avail.\n"},{"category":"Physician ","chartdate":"2186-08-24 00:00:00.000","description":"Physician Resident Admission Note","row_id":416935,"text":"Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Labetalol - 2 mg/min\n Other ICU medications:\n Diazepam (Valium) - 01:13 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN untreated, alcohol abuse, tobacco use, remote left eye penetrating\n injury\n Occupation: unemployed\n Drugs:\n Tobacco: +\n Alcohol: admits to alcohol abuse, last drink @ 1pm, avg 6\n drinks/day\n Other:\n Review of systems:\n Eyes: hx left eye injury, impaired vision\n Neurologic: Numbness / tingling, Headache\n Psychiatric / Sleep: Agitated\n Flowsheet Data as of 03:32 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: 35.6\nC (96.1\n HR: 80 (78 - 117) bpm\n BP: 123/94(100) {90/68(69) - 162/106(120)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 120 mL\n 135 mL\n PO:\n TF:\n IVF:\n 120 mL\n 135 mL\n Blood products:\n Total out:\n 800 mL\n 0 mL\n Urine:\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n 135 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: right pupil reactive, left surgical pupil\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\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, Oriented (to): person,\n place. Motor 0/5 left side, right side. Sensory\n light touch,\n decreased on left.\n Labs / Radiology\n head CT:\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\n with\n mild mass effect but no midline shift, presumed to be Htn induced.\n [image002.jpg]\n Assessment and Plan\n ASSESSMENT/PLAN:\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\n hemorrhage, with left leg weakness, left neglect (unable to sense left\n arm without guidance of RUE), and LUE numbness.\n NEURO: neuro check q1hr; neurosurgery consult appreciated and to\n follow; MRI/MRA pending; STAT head CT for acute mental changes. Tylenol\n for HA per primary service. HOB >30 degrees.\n CV: Maintain SB 140-160, MAP <130.\n Pulm/Endo/Heme/Renal/ID: no issues\n GI/ABD/FEN: NPO until S/S eval\n ICU Care\n Nutrition:\n Comments: NPO except meds until S/S eval\n Glycemic Control:\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":417048,"text":"Subarachnoid hemorrhage (SAH)\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed- revealed increased bleed with NEW midline shift.\n Discussion re: elective intubation for airway protection between\n physicians- decided to wait temporarily. 50mg IV mannitol given at\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\n positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":417049,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\n at 15:00.\n Right Basal Ganglia Hemorrhage\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed- revealed increased bleed with NEW midline shift.\n Discussion re: elective intubation for airway protection between\n physicians- decided to wait temporarily. 50mg IV mannitol given at\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\n positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"},{"category":"Nursing","chartdate":"2186-08-28 00:00:00.000","description":"Nursing Progress Note","row_id":417802,"text":"Hypertension, benign\n Assessment:\n Pt slightly hypertensive in 140s; tachycardic to 120s\n Action:\n Administered metoprolol\n Response:\n Patient tolerated dose, heart to 90s and BP 120s/80s\n Plan:\n Continue beta blockade, hydral PRN\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n At times patient appeared restless, diaphoretic though afebrile,\n tachycardic\n Action:\n Ativan, attempted to reduce stimuli in room\n Response:\n Patient settled; less diaphoretic, less restless\n Plan:\n Continue to monitor, administer ativan\n"},{"category":"Physician ","chartdate":"2186-08-24 00:00:00.000","description":"Intensivist Note","row_id":417012,"text":"TSICU\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Chief complaint:\n CC: left sided weakness\n ISSUES:\n 1. Intracranial hemorrhage with left sided plegia/paresthesia.\n 2. HTN.\n 3. EtOH abuse\n PMHx:\n Current medications:\n 24 Hour Events:\n - labetalol gtt started in evening for SBP>160, goal per neuro\n MAP<130, SBP 140s-160s. Await MRI/MRA. Increased valium dose for\n tremors.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Diazepam (Valium) - 08:50 AM\n Other medications:\n Flowsheet Data as of 11:06 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: 36.3\nC (97.3\n HR: 85 (78 - 117) bpm\n BP: 137/89(102) {90/68(69) - 162/106(120)} mmHg\n RR: 20 (15 - 24) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 120 mL\n 346 mL\n PO:\n Tube feeding:\n IV Fluid:\n 120 mL\n 346 mL\n Blood products:\n Total out:\n 800 mL\n 270 mL\n Urine:\n 800 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n 76 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: Somnolent\n HEENT: Left pupil dilated, Right Pupil Equal and reactive\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No(t) Weakness), (LUE: No movement), (RLE: No(t) Weakness), (LLE: No\n movement)\n Labs / Radiology\n 231 K/uL\n 15.2 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 102 mEq/L\n 141 mEq/L\n 43.2 %\n 9.7 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.7\n Hct\n 43.2\n Plt\n 231\n Creatinine\n 0.8\n Glucose\n 134\n Other labs: PT / PTT / INR:13.2/30.9/1.1, Ca:9.2 mg/dL, Mg:2.2 mg/dL,\n PO4:3.3 mg/dL\n Imaging: head CT:\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\n with\n mild mass effect but no midline shift, presumed to be Htn induced.\n Assessment and Plan\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\n hemorrhage.\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, f/u Head CT\n Cardiovascular: Labetalol gtt for SBP < 160 & MAP < 130 (PER PRIMARY\n TEAM REC'S) --> will clarify these goals after f/u head ct. Will need\n a-line.\n Pulmonary: need intubated.\n Gastrointestinal / Abdomen: Will need S&S eval --> will most likely\n need dobhoff and TF\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: No issues\n Endocrine: RISS\n Infectious Disease: No issues\n Lines / Tubes / Drains: Foley, PIV; For a-line.\n Wounds: none\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS), CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Needs ICU consent\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2186-08-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":417129,"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 Known difficult intubation: No\n Procedure location: OR\n Reason: Intubated for procedure\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Plan to switch to CPAP/PS and extubate this AM.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan for extubation today. RSBI completed on PS 5=28.\n Reason for continuing current ventilatory support:\n"},{"category":"Nutrition","chartdate":"2186-08-25 00:00:00.000","description":"Clinical Nutrition Note","row_id":417253,"text":"Subjective: Pt just extubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 70.5 kg\n 68.1 kg ( 12:00 AM)\n 22.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 97%\n Diagnosis: ICH\n PMH : poorly controlled HTN, ETOH abuse (12-18 beers/day), +tobacco,\n remote R eye injury c/ screw driver\n Food allergies and intolerances: NKFA\n Pertinent medications: Famotidine, Abx, Colace, Senna, Bisacodyl, HISS,\n NS c/ Thiamine, Folic Acid & Mvit, others noted\n Labs:\n Value\n Date\n Glucose\n 168 mg/dL\n 02:24 AM\n Glucose Finger Stick\n 167\n 10:00 AM\n BUN\n 9 mg/dL\n 02:24 AM\n Creatinine\n 1.0 mg/dL\n 02:24 AM\n Sodium\n 142 mEq/L\n 02:24 AM\n Potassium\n 3.2 mEq/L\n 01:37 PM\n Chloride\n 105 mEq/L\n 02:24 AM\n Albumin\n 4.0 g/dL\n 02:24 AM\n Calcium non-ionized\n 9.4 mg/dL\n 02:24 AM\n Phosphorus\n 3.7 mg/dL\n 02:24 AM\n Ionized Calcium\n 1.09 mmol/L\n 01:37 PM\n Magnesium\n 2.1 mg/dL\n 02:24 AM\n Current diet order / nutrition support: NPO\n GI: Soft, +BS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: chronic ETOH abuse, possible permanent AMS head\n bleed\n Estimated Nutritional Needs\n Calories: 1760-2115 (BEE x or / 25-30 cal/kg)\n Protein: 84-99 (1.2-1.4 g/kg)\n Fluid: team\n Estimation of previous intake: unknown, possibly inadequate\n Estimation of current intake: Inadequate\n Specifics: 44 y.o. M adm with R basal ganglia hemorrhage, POD #1 of\n crani & hematoma evacuation. Pt recently extubated and remains\n agitated and confused. If pt unable to take po\ns in the next 2-3days,\n rec place feeding tube for start of enteral nutrition. Will use admit\n wt for feeding wt. Noted K is low.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If pt\ns MS doesn\nt clear, rec evaluation by SLP.\n 2) If pt unsafe for po\ns, rec place FT and start TF with goal of\n Fibersource @ 65cc/hr (1872kcals, 84g protein).\n 3) Multivitamin / Mineral supplement: Mvit, 100mg Thiamine & 1mg\n Folic Acid given daily\n 4) Check chemistry 10 panel daily, relplete lytes as needed (namely\n K).\n Please page if ?\ns \n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416960,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\n +family history,. Father also alcoholic When admitted to OSH ETOH level\n 145. Pt still with strong smell of alcohol on breath admits to \n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\n through out the night, trying to get OOB, at times completely drenched\n with new tremors noted at 0300. Neuro med resident called. Pt\n required constant bedside safety observations. Pt is also heavy smoker\n 1-1.5 packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\n restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\n and quickly weaned off. Every 1hr neuro checks remain stable without\n much change. Pt does not suffer from neglect has he frequently rubs his\n left arm and tries to straighten his left hand. c/o right sided\n headache frequently rubbing right side of head. As stated\n above pt a developed lower leg tremor when awake lasting 10-20seconds\n then legs relax. Intermittent periods of clear speech and able to pick\n up left leg 3 inches off bed then fell back. MRI check sheet filled\n out and faxed to MRI.\n Action:\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\n dose. Did not receive because had received valium recently. Received\n Tylenol 650mg PR .\n Response:\n Headache is somewhat improved per patient.\n Plan:\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\n infusion for SBP >160 or MAP >130\n Scheduled for MRI today. Remove nicotine patch before scan. One time\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\n IVB right before scan.\n Continue to keep pt and family aware of POC as discussed in multi\n disciplinary rounds.\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416961,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\n +family history,. Father also alcoholic When admitted to OSH ETOH level\n 145. Pt still with strong smell of alcohol on breath admits to \n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\n through out the night, trying to get OOB, at times completely drenched\n with new tremors noted at 0300. Neuro med resident called. Pt\n required constant bedside safety observations. Pt is also heavy smoker\n 1-1.5 packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\n restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\n and quickly weaned off. Every 1hr neuro checks remain stable without\n much change. Pt does not suffer from neglect has he frequently rubs his\n left arm and tries to straighten his left hand. c/o right sided\n headache frequently rubbing right side of head. As stated\n above pt a developed lower leg tremor when awake lasting 10-20seconds\n then legs relax. Intermittent periods of clear speech and able to pick\n up left leg 3 inches off bed then fell back. MRI check sheet filled\n out and faxed to MRI.\n Action:\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\n dose. Did not receive because had received valium recently. Received\n Tylenol 650mg PR .\n Response:\n Headache is somewhat improved per patient.\n Plan:\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\n infusion for SBP >160 or MAP >130\n Scheduled for MRI today. Remove nicotine patch before scan. One time\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\n IVB right before scan.\n Continue to keep pt and family aware of POC as discussed in multi\n disciplinary rounds.\n"},{"category":"Nursing","chartdate":"2186-08-25 00:00:00.000","description":"Nursing Progress Note","row_id":417294,"text":"Subarachnoid hemorrhage (SAH)\n Assessment:\n - pt off sedation\n - arousable to voice but rarely opens eyes. Shows effort by\n raising eyebrows but eyes are swollen\n - R pupil 3mm and reactive, L eye dilated and unreactive due\n to traumatic injury with screwdriver in the past.\n - lifts and holds , squeeze hand when asked\n - wiggles toes and moves RLE on bed\n - no movement of LUE, does not respond to nail bed stimuli\n - will withdraw LLE to pain\n - dry sterile dressing on R side of head post craniotomy \n not yet removed\n - will cough with turning and stimulation, and secretions\n suctioned out\n - on nicardipine gtt sbp paramters <140\n - on fentanyl and versed\n - K 3.2\n - Ionized Ca 0.94\n Action:\n - cool tea bags applied over R eye\n - q1h neuro checks\n - turn and reposition to stimulate cough\n - Dilantin to prevent sz\n - Fentanyl, and versed gtts off\n - Morphine 2-4mg prn\n - Nicardipine gtt off spb parameter changed from <140 to <160\n - NS with 40meq KCL at 85ml/hr initiated\n - Keep HOB>30\n - Calcium gluconate 2gm given\n Response:\n - swelling of R eye reduced\n - unchanged neuro status\n - cough stimulated with turning\n - no sz activity noted\n - pt more arousable\n - pain adequately controlled assessed by changes in vital\n signs\n - sbps 135-153\n - awaiting K level\n - Ionized ca 1.09\n -\n Plan:\n - continue using cool tea bags to reduce swelling\n - q1h neuro checks\n - turn and reposition with chest pt frequently\n - continue antiseizure therapy\n - treat pain adequately with prn morphine\n - lopressor 10mg q4h\n - monitor sbps with parameter <160\n - monitor and treat hypokalemia and hypocalcemia\n - keep HOB >30\n -\n Respiratory (intubated in OR)\n Assessment:\n - On CMV adequate ABG levels\n - SPO2 98-100%\n - Minimal secretions\n Action:\n - Changed to CPAP, Spontaneous breathing trial, followed by\n Extubation at 1100\n - 3L nasal cannula\n Response:\n - ABG levels within normal limits\n - SPO2 98-100%\n - Lungs sound rhonchorous\n - Normal and regular respiratory pattern\n Plan:\n - Nasal cannula at 3L\n - Chest pt\n - Turn and reposition frequently\n - Encourage pt to cough and suction out secretions when\n necessary\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n - hx smoking\n - alcoholism; takes 12-18 beers/day\n - level elevated on admission to OSH\n Action:\n - monitored for s/s of DTs\n - banana bag given\n - nicotine patch on R arm\n Response:\n - no sz or tremors, or other signs of DTs noted\n - unable to fully assess for CIWA scale due to neurological\n deficits\n Plan:\n - continue to monitor and assess for s/s of DTs\n - continue with nicotine patch\n - assess swallow/gag and start feeding either PO or NG if\n failure to pass swallow\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Nursing Transfer Note","row_id":417417,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Nursing Transfer Note","row_id":417418,"text":"Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"},{"category":"Physician ","chartdate":"2186-08-26 00:00:00.000","description":"Intensivist Note","row_id":417371,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\n Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\n Morphine Sulfate 16. Nicotine Patch\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EXTUBATION - At 11:10 AM\n INVASIVE VENTILATION - STOP 11:10 AM\n intubated in OR\n Post operative day:\n POD#2 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Famotidine (Pepcid) - 08:01 PM\n Morphine Sulfate - 01:00 AM\n Hydralazine - 02:20 AM\n Insulin - Humalog - 02:30 AM\n Lorazepam (Ativan) - 03:09 AM\n Metoprolol - 04:03 AM\n Other medications:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.5\nC (99.5\n HR: 98 (78 - 104) bpm\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\n RR: 19 (13 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,000 mL\n 555 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,000 mL\n 555 mL\n Blood products:\n Total out:\n 2,115 mL\n 765 mL\n Urine:\n 2,115 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 885 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\n PC : 0 cmH2O\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SPO2: 98%\n ABG: 7.45/35/81./25/0\n Ve: 9.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n Weakness, No movement), (LLE: Weakness, No movement)\n Labs / Radiology\n 198 K/uL\n 13.1 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 101 mEq/L\n 136 mEq/L\n 36.1 %\n 16.2 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n WBC\n 9.7\n 18.7\n 16.2\n Hct\n 43.2\n 37.6\n 36.1\n Plt\n \n Creatinine\n 0.8\n 1.0\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\n pain\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\n ?withdrawl- 1 q6 ativan, will start PO metoprolol 50 tid\n Pulmonary: chest pt\n Gastrointestinal / Abdomen:\n Nutrition: dobhoff and will start tube feeding, thiamine/folate, banana\n bag\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS, start tube feeds\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-25 00:00:00.000","description":"Nursing Progress Note","row_id":417287,"text":"Subarachnoid hemorrhage (SAH)\n Assessment:\n - pt off sedation\n - arousable to voice but rarely opens eyes. Shows effort by\n raising eyebrows but eyes are swollen\n - R pupil 3mm and reactive, L eye dilated and unreactive due\n to traumatic injury with screwdriver in the past.\n - lifts and holds , squeeze hand when asked\n - wiggles toes and moves RLE on bed\n - no movement of LUE, does not respond to nail bed stimuli\n - will withdraw LLE to pain\n - dry sterile dressing on R side of head post craniotomy \n not yet removed\n - will cough with turning and stimulation, and secretions\n suctioned out\n - on nicardipine gtt sbp paramters <140\n - on fentanyl and versed\n - K 3.2\n - Ionized Ca 0.94\n Action:\n - cool tea bags applied over R eye\n - q1h neuro checks\n - turn and reposition to stimulate cough\n - Dilantin to prevent sz\n - Fentanyl, and versed gtts off\n - Morphine 2-4mg prn\n - Nicardipine gtt off spb parameter changed from <140 to <160\n - NS with 40meq KCL at 85ml/hr initiated\n - Keep HOB>30\n - Calcium gluconate 2gm given\n Response:\n - swelling of R eye reduced\n - unchanged neuro status\n - cough stimulated with turning\n - no sz activity noted\n - pt more arousable\n - pain adequately controlled assessed by changes in vital\n signs\n - sbps 135-153\n - awaiting K level\n - Ionized ca 1.09\n -\n Plan:\n - continue using cool tea bags to reduce swelling\n - q1h neuro checks\n - turn and reposition with chest pt frequently\n - continue antiseizure therapy\n - treat pain adequately with prn morphine\n - lopressor 10mg q4h\n - monitor sbps with parameter <160\n - monitor and treat hypokalemia and hypocalcemia\n - keep HOB >30\n -\n Respiratory (intubated in OR)\n Assessment:\n - On CMV adequate ABG levels\n - SPO2 98-100%\n - Minimal secretions\n Action:\n - Changed to CPAP, Spontaneous breathing trial, followed by\n Extubation at 1100\n - 3L nasal cannula\n Response:\n - ABG levels within normal limits\n - SPO2 98-100%\n - Lungs sound rhonchorous\n - Normal and regular respiratory pattern\n Plan:\n - Nasal cannula at 3L\n - Chest pt\n - Turn and reposition frequently\n - Encourage pt to cough and suction out secretions when\n necessary\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n - hx smoking\n - alcoholism; takes 12-18 beers/day\n - level elevated on admission to OSH\n Action:\n - monitored for s/s of DTs\n - banana bag given\n - nicotine patch on R arm\n Response:\n - no sz or tremors, or other signs of DTs noted\n - unable to fully assess for CIWA scale due to neurological\n deficits\n Plan:\n - continue to monitor and assess for s/s of DTs\n - continue with nicotine patch\n - assess swallow/gag and start feeding either PO or NG if\n failure to pass swallow\n"},{"category":"Physician ","chartdate":"2186-08-26 00:00:00.000","description":"Intensivist Note","row_id":417369,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\n Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\n Morphine Sulfate 16. Nicotine Patch\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EXTUBATION - At 11:10 AM\n INVASIVE VENTILATION - STOP 11:10 AM\n intubated in OR\n Post operative day:\n POD#2 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Famotidine (Pepcid) - 08:01 PM\n Morphine Sulfate - 01:00 AM\n Hydralazine - 02:20 AM\n Insulin - Humalog - 02:30 AM\n Lorazepam (Ativan) - 03:09 AM\n Metoprolol - 04:03 AM\n Other medications:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.5\nC (99.5\n HR: 98 (78 - 104) bpm\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\n RR: 19 (13 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,000 mL\n 555 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,000 mL\n 555 mL\n Blood products:\n Total out:\n 2,115 mL\n 765 mL\n Urine:\n 2,115 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 885 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\n PC : 0 cmH2O\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SPO2: 98%\n ABG: 7.45/35/81./25/0\n Ve: 9.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n Weakness, No movement), (LLE: Weakness, No movement)\n Labs / Radiology\n 198 K/uL\n 13.1 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 101 mEq/L\n 136 mEq/L\n 36.1 %\n 16.2 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n WBC\n 9.7\n 18.7\n 16.2\n Hct\n 43.2\n 37.6\n 36.1\n Plt\n \n Creatinine\n 0.8\n 1.0\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\n pain\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\n ?withdrawel 1 q6 ativan, will start PO metoprolol 50 tid\n Pulmonary: chest pt\n Gastrointestinal / Abdomen:\n Nutrition: dobhoff and will start tube feeding, thiamine/folate bannana\n bag\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS, d/c nml saline start tube feeds\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2186-08-27 00:00:00.000","description":"Intensivist Note","row_id":417534,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\n ETOH abuse, h/o illicit drug use\n : none\n .\n Current medications:\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. FoLIC Acid 11. Heparin\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\n 17. Metoprolol Tartrate\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\n Ondansetron 22. Phenytoin 23. Potassium Chloride\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\n 27. Thiamine\n 24 Hour Events:\n TF placed and tF started yesterday\n Post operative day:\n POD#3 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:41 AM\n Lorazepam (Ativan) - 06:00 PM\n Famotidine (Pepcid) - 08:13 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Hydralazine - 02:14 AM\n Metoprolol - 06:18 AM\n Other medications:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.1\nC (100.5\n HR: 119 (86 - 119) bpm\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\n RR: 18 (9 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,828 mL\n 776 mL\n PO:\n Tube feeding:\n 190 mL\n 129 mL\n IV Fluid:\n 2,518 mL\n 647 mL\n Blood products:\n Total out:\n 2,735 mL\n 700 mL\n Urine:\n 2,735 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 93 mL\n 76 mL\n Respiratory support\n SPO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 220 K/uL\n 13.6 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 38.0 %\n 16.5 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n Plt\n 20\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\n to PO\n Cardiovascular: Lopressor 75 TID PO\n HYDRALAZYN prn\n Pulmonary: Stable\n Gastrointestinal / Abdomen: Adnance to goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Lasix 20mg \n Hematology: Stable\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Nephrology\n Billing Diagnosis: Other: Basal ganglia Bleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416951,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Hourly CIWA scale 17-27\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416945,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416946,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Nursing Progress Note","row_id":417343,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt continues with ciwa scale. Pt more restless pulling off gown and\n pulling at foley and taking off oxygen. Neuro exam is unchanged hr up\n to 106 and sbp 160\ns/80\n Action:\n Ativan .5mg iv x2 for total of 1mg. pt less restless and sbp down to\n 158/70.\n Response:\n Pt less restless after Ativan.\n Plan:\n Continue with neuro checks and ciwa scale. Assess for Ativan as\n needed.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Neuro exam is unchanged. Pt follows commands on right side. Withdrawal\n on left foot, none on left arm. Right pupil is reactive to light. Rt\n eye is swollen. Pt opens eyes to name. Speech very soft and slightly\n garbled. Goal sbp less than 160. lopressor increased to 20mg q4 and\n hydralazine prn, given x2. Dr. aware of sbp greater than 160.\n does not want to restart nicardipine and increased lopressor.\n Action:\n Lopressor increased to 20mg. hydralazine prn. Continue with q1 neuro\n checks, ? repeat ct today.\n Response:\n Neuro is unchanged. Pt restless at times but responded to ativan\n Plan:\n Continue with neuro exam. Treat bp as needed. Continue with ciwa scale.\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Nursing Progress Note","row_id":417346,"text":".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated today. Pt resp rate 16-20. o2 sat on room air 98%. Breath\n sounds are clear and diminished in the bases. Pt coughing and\n swallowing.\n Action:\n Encourage pt to cough and deep breath.\n Response:\n Doing well extubated.\n Plan:\n Continue to cough and deep breathe. Frequent position changes.\n"},{"category":"Nursing","chartdate":"2186-08-25 00:00:00.000","description":"Nursing Progress Note","row_id":417147,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt responds to name and stimulation with jerking movements, attempts\n to sit up, and tremulous motion of right side, less motion on left\n side. Pt does not nod or shake head to communicate, so assessment of\n hallucinations, pain, etc is difficult.\n Action:\n Midazolam and fentanyl drips started and titrated up as needed to\n control tremulous movement\n Response:\n Tremors are quieter, although still existent with medications at higher\n dosage. Midaz returned to 2 mg/hr from 4 mg/hr when he became more\n difficult to arouse. He is now arousable but with fewer tremors than\n before midazolam and fentanyl were started.\n Plan:\n Titrate drips as needed, monitor for increase tremors, seizures,\n increase in heart rate and bp.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Pt post op evacuation of SDH. Head dressing is dry and intact. Pt\n arouses to name, as above, follows commands with right side, but does\n not nod or shake his head when asked to do so. He is intubated on CMV ,\n sx for thick yellow secretios Right pupil is and reacts briskly.\n Left pupil is damaged from a screwdriver injury. Pt is sedated for\n onset of DT\ns, and responding more slowly with midazolam and fentanyl\n on.\n Action:\n Midazolam decreased to 2 mg when pt very slow to respond to name and\n stimulation\n Response:\n Pt responding again when name called.\n Plan:\n Continue with q 1 hour neuro checks to evaluate neuro status\n complicated by alcohol withdrawal.\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":417053,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\n at 15:00.\n Right Basal Ganglia Hemorrhage\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed revealed increased bleed, cerebral edema, and NEW 1.3\n cm midline shift to left. Discussion re: elective intubation for\n airway protection between physicians- decided to wait temporarily.\n 50mg IV mannitol given at 13:00 over 30minuntes to decrease ICP. HOB at\n 30 degrees. Head positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"},{"category":"Respiratory ","chartdate":"2186-08-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":417263,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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 CT\n without incident\n Bedside Procedures:\n Comments:\n Pt received intubated and vented on AC settings as charted. RSBI 28\n today. Placed on PSV 5 peep 5 with TV 500 and RR 12-16. Pt transported\n to CT scan and placed on SBT after transport. Pt extubated without\n incident and is currently on 3L NP and stable from resp standpoint.\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Generic Note","row_id":417428,"text":"TITLE:\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain but otherwise sleeping most of day. Right pupil\n reactive, round. Left pupil unreactive and odd shaped at baseline.\n Moves right side purposefully and attempts to pull at tubes/lines.\n Withdraws on left to pain. No spont movement on left. Said name once,\n otherwise only groans occ. Follows commands on right inconsistently. No\n sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Progress Note","row_id":417495,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt has a known history of drinking > 8-12 beers/day. Brother states ?\n more than 12 beers. Attempting to pull off bed clothes. Pt does not\n focus on you when speaking to him.\n Action:\n Ativan 1 mg iv q6hrs. nictone patch as ordered.\n Response:\n Pt is less agitated after the ativan iv.\n Plan:\n Continue with ativan iv and prn. Monitor closely.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Neuro assessment done q2hrs. strong hand grasp on right side and moves\n right leg off the bed. Withdraws to pain on left foot but no actual\n movement in left arm. Withdraws slightly to painful stimuli. Speech is\n garbled and pt very diffiulct to understand. Right pupil reactive to\n light and left eye no reaction due to old eye injury. Bp at times >\n 160. operative site on head intact with staples present and no drainage\n noted.\n Action:\n Neuro signs q2hrs. ? head ct today. Incision inspected\n Response:\n No neuro changes\n Plan:\n Cont with neuro exam.\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Progress Note","row_id":417497,"text":"Hypertension, benign\n Assessment:\n Bp mostly > 160 shift\n Action:\n Lopresssor 50mg via tube given as ordered. Hydralazine 10mg iv given\n linsopril 5mg via tube given as ordered.\n Response:\n Bp < 160 for short time after meds given but quickly returns to > 160.\n Plan:\n Monitor closely.\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Transfer Note","row_id":417574,"text":"Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416954,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n ETOH level 145 at OSH with strong smell of alcohol on breath, admits to\n 12-18 beers a day. Hourly CIWA scores 20-27 becoming Increasingly\n restless through out the night, trying to get OOB, at times completely\n drenched with new tremors noted at 0300. Pt required bedside safety\n observations. Neuro med resident called. Pt is also heavy smoker 1-1.5\n packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Initially only decrease in restlessness for 45 minutes after valium 5mg\n IVB. However by am CIWA scale decreasing to 17 by 0500 and becoming\n less restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n Every 1hr neuro checks remain stable without much change. As stated\n above pt developed lower leg tremors mostly when awake lasting\n 10-20seconds then muscle relaxes.\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2186-08-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":417069,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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 arrived from O.R. and taken to C.T. Plan to extubated when awake.\n"},{"category":"Radiology","chartdate":"2186-09-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039777,"text":", NMED FA11 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Querying aspiration pneumonitis\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with left hemiparesis, s/p crani after an ICH\n REASON FOR THIS EXAMINATION:\n Querying aspiration pneumonitis\n ______________________________________________________________________________\n PFI REPORT\n No evidence of acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2186-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037849,"text":" 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Dobhoff placemnet eval plse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Dobhoff placemnet eval plse\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 5:06 PM\n Dobbhoff tube is in the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess Dobbhoff catheter.\n\n Dobbhoff tip is in the stomach. There is mild cardiomegaly. The lungs are\n clear. There is no pleural effusion.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2186-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037850,"text":", H. NMED SICU-A 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Dobhoff placemnet eval plse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Dobhoff placemnet eval plse\n ______________________________________________________________________________\n PFI REPORT\n Dobbhoff tube is in the stomach.\n\n\n"},{"category":"Radiology","chartdate":"2186-09-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039776,"text":" 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Querying aspiration pneumonitis\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with left hemiparesis, s/p crani after an ICH\n REASON FOR THIS EXAMINATION:\n Querying aspiration pneumonitis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 3:52 PM\n No evidence of acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Suspected aspiration pneumonia.\n\n Portable AP chest radiograph was compared to prior study from .\n\n The heart size is normal. Mediastinal position, contour and width are\n unremarkable. Lungs are clear. No pleural effusion or pneumothorax is\n present. Potential old rib fracture is seen on the left\n\n\n"},{"category":"Radiology","chartdate":"2186-08-24 00:00:00.000","description":"ORBITS (WATERS, CALDWELL & LAT)","row_id":1037401,"text":" 11:18 AM\n ORBITS (WATERS, & LAT) Clip # \n Reason: bilateral orbital xray to rule out metal pre-mri\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm), untreated HTN\n presented to OSH with change in gait on left side after alcohol use. Pt noted\n difficulty moving left leg, left facial weakness, left sided numbness, and left\n facial droop. CT @ OSH --> right BG hemorrhage 3cm, transferred to for\n further care. On transfer EMS noted pt has \"worsening symptoms\" from the\n initial transport to OSH (same EMS team). @ repeat head CT showed right\n BG hemorrhage at 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n REASON FOR THIS EXAMINATION:\n bilateral orbital xray to rule out metal pre-mri\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Orbit series .\n\n HISTORY: 44-year-old man with facial droop and needs MRI. Evaluate for metal\n in orbits.\n\n FINDINGS: Comparison is made to the CT scan from .\n\n There are no radiopaque densities in the left orbital prosthesis. Visualized\n paranasal sinuses are within normal limits.\n\n IMPRESSION: No radiopaque densities within the orbits to exclude the patient\n from having MRI.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2186-08-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037478,"text":" 5:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hemorrhage\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:10 PM\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\n pneumocephalus and intraventricular hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: Nine hours prior.\n\n HISTORY: Evaluate for hemorrhage.\n\n FINDINGS: Patient is status post right frontoparietal craniotomy with\n evacuation of putaminal and temporal lobe hematoma. Extensive pneumocephalus\n is identified along the right cerebral convexity. There is a leftward shift of\n normally midline structures by approximately 10 mm, slightly decreased when\n compared to prior exam. Intraventricular hemorrhage in the right frontal \n of the lateral ventricle and bilateral posterior horns of the lateral\n ventricle is not significantly changed. A small amount of residual hemorrhage\n and extensive pneumocephalus within the right basal ganglia is identified.\n Dilated temporal horns, left greater than right, are unchanged. The basilar\n cisterns are patent.\n\n IMPRESSION: Patient status post craniotomy with evacuation of hematoma.\n Extensive pneumocephalus over the right cerebral hemisphere and within the\n right basal ganglia. Interval decrease in right basal ganglia hemorrhage.\n Persistent intraventricular hemorrhage and leftward shift of midline\n structures as described above.\n\n\n\n"},{"category":"Radiology","chartdate":"2186-08-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037479,"text":", H. NMED SICU-A 5:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hemorrhage\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\n pneumocephalus and intraventricular hemorrhage.\n\n"},{"category":"Radiology","chartdate":"2186-08-24 00:00:00.000","description":"CTA HEAD W&W/O C & RECONS","row_id":1037390,"text":" 10:52 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Hemorrhage follow-up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with R basal ganglia hemorrhage\n REASON FOR THIS EXAMINATION:\n Hemorrhage follow-up\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:13 PM\n\n Moderate increas ein the right basal ganglia hematoma with new areas and new\n itnraventricular hemorrhage and mass effect and cerbral edema on the right.\n Patent major arteries; no abnormal vascularity around the hematoma- however,\n lesions within the hematoma are not assessed.\n d/w Dr. . by Dr. on at 2pm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old male patient with right basal ganglial hemorrhage,\n followup.\n\n COMPARISON: CT of the head done on at 4:19 p.m.\n\n TECHNIQUE: Non-contrast CT of the head, followed by CT angiogram of the head\n with IV contrast was performed. Volume rendered and 2D MIP reformations of\n the major arteries were obtained.\n\n FINDINGS:\n\n NON-CONTRAST CT OF THE HEAD:\n\n There is interval moderate increase in the size of the right basal ganglia\n hematoma, 7.6x3.6cm in the AP and transverse dimensions with significant\n mass effect on the adjacent structures, along with cerebral edema on the right\n side. There is 1.3 cm shift of the midline structures to the left side, which\n is increased, which is new. Some of the new areas that have developed are\n less dense in attenuation representing active bleeding/ due to anemia. There\n is also extension of the hemorrhage into the right lateral ventricle as well\n as the third ventricle. A few small hypodense foci, noted in the left\n internal capsule, may represent perivascular spaces or chronic lacunar\n infarcts are unchanged. No osseous lytic or sclerotic lesions of concern are\n noted.\n\n CT ANGIOGRAM OF THE HEAD:\n\n The major intracranial arteries, of the anterior and posterior circulation are\n patent without flow limiting stenosis, occlusion, or aneurysm. No abnormal\n vascularity is noted surrounding the large right basal ganglial hematoma.\n However, the vascular lesion, located within the area of hematoma itself is\n not excluded on the present study. A small prominent vein int he right vertex\n can relate to a small developmental venous anomaly. ( series 401b/7)\n (Over)\n\n 10:52 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Hemorrhage follow-up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is evidence of scleral band, with ocular implant on the left side,\n unchanged.\n\n IMPRESSION:\n\n 1. Moderate increase in the size of the right basal ganglial hematoma with\n new areas of hemorrhage, which are less dense than expected, raising the\n possibility of active bleeding, ? bleeding disorders/anemia.\n\n 2. Development of new intraventricular hemorrhage, in the right lateral\n ventricle and third ventricle.\n\n 3. Significant mass effect, with cerebral edema on the right side, with 1.3\n cm shift of the midline structures to the left side.\n\n 4. Patent major intracranial arteries. No obvious abnormal vascularity noted\n around the hematoma. However, the vascular lesion, within the hematoma itself\n cannot be excluded on the present study. To consider followup evaluation for\n vascular lesions after resolution of the hematoma. In addition,\n MRI/conventional angiogram or close followup CT head can be considered.\n\n Findings were discussed with Dr. . for Dr. on at 2 p.m.\n\n\n\n"},{"category":"Radiology","chartdate":"2186-08-25 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037566,"text":" 8:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change. Please this this am\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change. Please this this am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 44-year-old with intracranial bleed status post surgery, please\n evaluate for change.\n\n COMPARISON: .\n\n FINDINGS: Post-operative change of a right craniotomy status post evacuation\n of an intraparenchymal bleed is again noted. There is decrease in the overall\n amount of pneumocephalus. The degree of mass effect and intracranial\n hemorrhage is not overall changed from prior study. The degree of\n intraventricular hemorrhage is also stable without evidence of hydrocephalus.\n Prominence of the left temporal is stable. The suprasellar cistern\n remains patent. Scleral band over the left orbit is grossly unchanged.\n\n IMPRESSION: Decrease in overall degree of post-operative pneumocephalus. No\n new hemorrhage is identified. Degree of mass effect appears little changed.\n\n\n"},{"category":"Radiology","chartdate":"2186-08-23 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037261,"text":" 4:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with know bleed\n REASON FOR THIS EXAMINATION:\n eval for progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe WED 4:45 PM\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging, with\n mild mass effect but no midline shift, presumed to be Htn induced.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known intracranial hemorrhage.\n\n NON-CONTRAST HEAD CT\n\n FINDINGS: Comparison is made to outside scan from same date. Again\n identified is slightly heterogeneous hyperdense hemorrhage predominantly\n centered within the right basal ganglia with mass effect on the posterior limb\n of the right-sided internal capsule and adjacent parenchyma including the\n right frontal . The hemorrhage appears to have increased in size from\n outside examination, currently measuring 2.6 x 4.9 cm with prior measurement\n at similar level of approximately 2.3 x 3.6 cm. No other regions of\n intraparenchymal or intraventricular hemorrhage are identified. There is no\n significant midline shift. -white matter differentiation is otherwise\n well preserved. An old lacunar-type infarct is noted within the left internal\n capsule anterior limb. An apparent left globe prosthesis is noted. No soft\n tissue irregularity is present. Mastoid air cells and paranasal sinuses are\n well aerated.\n\n IMPRESSION:\n\n Interval increase in size to right intraparenchymal basal ganglia hemorrhage\n which displays mild mass effect on the adjacent brain parenchyma and right\n frontal with no significant midline shift. This location is most\n suggestive of a hypertensive etiology, although underlying mass\n lesion/metastasis is not completely excluded.\n\n Further evaluation with dedicated contrast-enhanced MRI may be obtained once\n the hemorrhage partially resolved for further characterization.\n\n"},{"category":"ECG","chartdate":"2186-08-23 00:00:00.000","description":"Report","row_id":223395,"text":"Sinus rhythm\nProminent precordial lead QRS voltage suggests left ventricular hypertrophy but\nmay be nondiagnostic given age\nModest nonspecific inferior ST-T wave changes\nNo previous tracing available for comparison\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417678,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Demographics\\n Attending MD:\\n H.\\n Admit diagnosis:\\n INTRACRANIAL HEMORRHAGE\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 70.5 kg\\n Daily weight:\\n 67.6 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: He had been told he needed to control HTN but no\\n follow up with this recomendation.\\n ETOH abuse\\n Surgery / Procedure and date: S/P Right craniotomy admitted to\\n SICU-A 692\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:139\\n D:89\\n Temperature:\\n 100.6\\n Arterial BP:\\n S:155\\n D:89\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 94 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 0 L/min\\n FiO2 set:\\n 35% %\\n 24h total in:\\n 164 mL\\n 24h total out:\\n 30 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 03:27 AM\\n Potassium:\\n 3.4 mEq/L\\n 03:27 AM\\n Chloride:\\n 103 mEq/L\\n 03:27 AM\\n CO2:\\n 23 mEq/L\\n 03:27 AM\\n BUN:\\n 8 mg/dL\\n 03:27 AM\\n Creatinine:\\n 0.7 mg/dL\\n 03:27 AM\\n Glucose:\\n 94 mg/dL\\n 03:27 AM\\n Hematocrit:\\n 38.0 %\\n 03:27 AM\\n Finger Stick Glucose:\\n 147\\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\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417679,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Chief Complaint: left leg weakness\\n HPI:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\\n untreated HTN presented to OSH with change in gait on left side after\\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\\n left sided numbness, and left facial droop. CT @ OSH --> right BG\\n hemorrhage 3cm, transferred to for further care. On transfer EMS\\n noted pt has \\\"worsening symptoms\\\" from the initial transport to OSH\\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n Demographics\\n Attending MD:\\n H.\\n Admit diagnosis:\\n INTRACRANIAL HEMORRHAGE\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 70.5 kg\\n Daily weight:\\n 67.6 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: He had been told he needed to control HTN but no\\n follow up with this recomendation.\\n ETOH abuse\\n Surgery / Procedure and date: S/P Right craniotomy admitted to\\n SICU-A 692\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:139\\n D:89\\n Temperature:\\n 100.6\\n Arterial BP:\\n S:155\\n D:89\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 94 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 0 L/min\\n FiO2 set:\\n 35% %\\n 24h total in:\\n 164 mL\\n 24h total out:\\n 30 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 03:27 AM\\n Potassium:\\n 3.4 mEq/L\\n 03:27 AM\\n Chloride:\\n 103 mEq/L\\n 03:27 AM\\n CO2:\\n 23 mEq/L\\n 03:27 AM\\n BUN:\\n 8 mg/dL\\n 03:27 AM\\n Creatinine:\\n 0.7 mg/dL\\n 03:27 AM\\n Glucose:\\n 94 mg/dL\\n 03:27 AM\\n Hematocrit:\\n 38.0 %\\n 03:27 AM\\n Finger Stick Glucose:\\n 147\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417538,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n BG hemorrhage\\n PMHx:\\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\\n ETOH abuse, h/o illicit drug use\\n : none\\n .\\n Current medications:\\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\\n Bisacodyl 6. Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\\n Famotidine 10. FoLIC Acid 11. Heparin\\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\\n 17. Metoprolol Tartrate\\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\\n Ondansetron 22. Phenytoin 23. Potassium Chloride\\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\\n 27. Thiamine\\n 24 Hour Events:\\n TF placed and tF started yesterday\\n Post operative day:\\n POD#3 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:41 AM\\n Lorazepam (Ativan) - 06:00 PM\\n Famotidine (Pepcid) - 08:13 PM\\n Heparin Sodium (Prophylaxis) - 08:15 PM\\n Hydralazine - 02:14 AM\\n Metoprolol - 06:18 AM\\n Other medications:\\n Flowsheet Data as of 06:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.2\\nC (100.7\\n T current: 38.1\\nC (100.5\\n HR: 119 (86 - 119) bpm\\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\\n RR: 18 (9 - 25) insp/min\\n SPO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 67.6 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 2,828 mL\\n 776 mL\\n PO:\\n Tube feeding:\\n 190 mL\\n 129 mL\\n IV Fluid:\\n 2,518 mL\\n 647 mL\\n Blood products:\\n Total out:\\n 2,735 mL\\n 700 mL\\n Urine:\\n 2,735 mL\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 93 mL\\n 76 mL\\n Respiratory support\\n SPO2: 96%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\\n Labs / Radiology\\n 220 K/uL\\n 13.6 g/dL\\n 94 mg/dL\\n 0.7 mg/dL\\n 23 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 38.0 %\\n 16.5 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n 06:00 AM\\n 03:27 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n 16.5\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n 38.0\\n Plt\\n 20\\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n 118\\n 94\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\\n hemorrhage, now s/p R craniotomy, evac \\n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\\n to PO\\n Cardiovascular: Lopressor 75 TID PO\\n HYDRALAZYN prn\\n Pulmonary: Stable\\n Gastrointestinal / Abdomen: Advance to goal\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Lasix 20mg \\n Hematology: Stable\\n Endocrine:\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley\\n Wounds:\\n Imaging:\\n Fluids:\\n Consults: Nephrology\\n Billing Diagnosis: Other: Basal ganglia Bleed\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\\n Glycemic Control:\\n Lines:\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417605,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Remains on ativan atc. Tachy at times and occ attempting to pull at\\n lines, otherwise no s/s withdrawal noted.\\n Action:\\n Ativan atc, but dose decreased\\n Response:\\n No need for prn ativan and no s/s withdrawal noted\\n Plan:\\n Con\\nt to monitor. Ativan atc and prn.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Opens eyes to stim . right pupil round and reactive. Left pupil at\\n baseline. Follows commands on right. Moves right spont. No spont\\n movement on left. Withdraws on left to pain. Oriented to person and\\n president and month. Only says few words and speech grarbled.\\n Action:\\n Neuro checks.\\n Response:\\n Neuro status unchanged.\\n Plan:\\n Con\\nt neuro checks\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417181,\n \"text\": \"SICU\\n HPI:\\n 44yo male presented to an outside hospital with acute onset\\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\\n right cranimtomy hemmhorrage evacuation\\n Chief complaint:\\n acute onset left sided plegia\\n PMHx:\\n left eye injury-screwdriver with surgical correction with\\n noted visula impairment since, ETOH abuse, prior hx on illicit\\n drug use.\\n Current medications:\\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\\n Acid/Multivitamin/Thiamine-1000mL NS\\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\\n 17. NiCARdipine 18. Ondansetron\\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\\n 25. Vancomycin\\n 24 Hour Events:\\n OR SENT - At 03:00 PM\\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\\n INTUBATION - At 03:15 PM\\n intubated in OR\\n INVASIVE VENTILATION - START 03:15 PM\\n intubated in OR\\n ARTERIAL LINE - START 03:30 PM\\n OR RECEIVED - At 05:45 PM\\n Post operative day:\\n POD#1 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:30 PM\\n Gentamicin - 04:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 25 mcg/hour\\n Nicardipine - 1 mcg/Kg/min\\n Other ICU medications:\\n Diazepam (Valium) - 11:00 AM\\n Midazolam (Versed) - 06:05 PM\\n Famotidine (Pepcid) - 09:00 PM\\n Other medications:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 36.3\\nC (97.4\\n HR: 88 (73 - 95) bpm\\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\\n RR: 13 (12 - 29) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.1 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 3,980 mL\\n 1,228 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,780 mL\\n 1,228 mL\\n Blood products:\\n 200 mL\\n Total out:\\n 3,800 mL\\n 435 mL\\n Urine:\\n 1,690 mL\\n 435 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 180 mL\\n 793 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 600 (600 - 600) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 28\\n PIP: 18 cmH2O\\n Plateau: 13 cmH2O\\n SPO2: 100%\\n ABG: 7.44/40/198/28/3\\n Ve: 6.9 L/min\\n PaO2 / FiO2: 495\\n Physical Examination\\n General Appearance: intubated and sedated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\\n Abdominal: Soft, Non-distended, No(t) Non-tender\\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\\n tibial: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\\n Weakness)\\n Labs / Radiology\\n 251 K/uL\\n 13.2 g/dL\\n 168 mg/dL\\n 1.0 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 37.6 %\\n 18.7 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n WBC\\n 9.7\\n 18.7\\n Hct\\n 43.2\\n 37.6\\n Plt\\n 231\\n 251\\n Creatinine\\n 0.8\\n 1.0\\n TCO2\\n 26\\n 28\\n Glucose\\n 134\\n 146\\n 168\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44yo male presented to an outside hospital with\\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\\n evacuation\\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\\n MEDAZOLEM,\\n Cardiovascular: D/C Nocrdipine, Start Lopressor\\n Pulmonary: Extubate today, Spontaneous breathing trial\\n Gastrointestinal / Abdomen: assess Swallow\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: Stable Ht\\n Endocrine: RISS, Start RISS start at 120 mg/dl\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley, NGT\\n Wounds:\\n Imaging: CT scan head today\\n Fluids:\\n Consults:\\n Billing Diagnosis: Other: Left Side weakness\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:45 PM\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417183,\n \"text\": \"SICU\\n HPI:\\n 44yo male presented to an outside hospital with acute onset\\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\\n right cranimtomy hemmhorrage evacuation\\n Chief complaint:\\n acute onset left sided plegia\\n PMHx:\\n left eye injury-screwdriver with surgical correction with\\n noted visula impairment since, ETOH abuse, prior hx on illicit\\n drug use.\\n Current medications:\\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\\n Acid/Multivitamin/Thiamine-1000mL NS\\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\\n 17. NiCARdipine 18. Ondansetron\\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\\n 25. Vancomycin\\n 24 Hour Events:\\n OR SENT - At 03:00 PM\\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\\n INTUBATION - At 03:15 PM\\n intubated in OR\\n INVASIVE VENTILATION - START 03:15 PM\\n intubated in OR\\n ARTERIAL LINE - START 03:30 PM\\n OR RECEIVED - At 05:45 PM\\n Post operative day:\\n POD#1 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:30 PM\\n Gentamicin - 04:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 25 mcg/hour\\n Nicardipine - 1 mcg/Kg/min\\n Other ICU medications:\\n Diazepam (Valium) - 11:00 AM\\n Midazolam (Versed) - 06:05 PM\\n Famotidine (Pepcid) - 09:00 PM\\n Other medications:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 36.3\\nC (97.4\\n HR: 88 (73 - 95) bpm\\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\\n RR: 13 (12 - 29) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.1 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 3,980 mL\\n 1,228 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,780 mL\\n 1,228 mL\\n Blood products:\\n 200 mL\\n Total out:\\n 3,800 mL\\n 435 mL\\n Urine:\\n 1,690 mL\\n 435 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 180 mL\\n 793 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 600 (600 - 600) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 28\\n PIP: 18 cmH2O\\n Plateau: 13 cmH2O\\n SPO2: 100%\\n ABG: 7.44/40/198/28/3\\n Ve: 6.9 L/min\\n PaO2 / FiO2: 495\\n Physical Examination\\n General Appearance: intubated and sedated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\\n Abdominal: Soft, Non-distended, No(t) Non-tender\\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\\n tibial: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\\n Weakness)\\n Labs / Radiology\\n 251 K/uL\\n 13.2 g/dL\\n 168 mg/dL\\n 1.0 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 37.6 %\\n 18.7 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n WBC\\n 9.7\\n 18.7\\n Hct\\n 43.2\\n 37.6\\n Plt\\n 231\\n 251\\n Creatinine\\n 0.8\\n 1.0\\n TCO2\\n 26\\n 28\\n Glucose\\n 134\\n 146\\n 168\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44yo male presented to an outside hospital with\\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\\n evacuation\\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\\n MEDAZOLEM,\\n Cardiovascular: D/C Nocrdipine, Start Lopressor\\n Pulmonary: Extubate today, Spontaneous breathing trial\\n Gastrointestinal / Abdomen: assess Swallow\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: Stable Ht\\n Endocrine: RISS, Start RISS start at 120 mg/dl\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley, NGT\\n Wounds:\\n Imaging: CT scan head today\\n Fluids:\\n Consults:\\n Billing Diagnosis: Other: Left Side weakness\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:45 PM\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417730,\n \"text\": \"Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Moves right arm and leg off the bed. No spontaneous movement in left\\n arm or left leg. Opens eyes to stimuli. Right pupil equal and reactive.\\n Left pupil non reactive due to prior eye trauma. Speech garbled and at\\n times difficult to understand. Pt able to state name and year. Becomes\\n confused to month and place. Pt able to stick tongue upon command and\\n squeeze hand to command.\\n Action:\\n Neuro check q2hrs. ativan 0.5mg iv as ordered.\\n Response:\\n Neuron status stable\\n Plan:\\n Continue to monitor neuron status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417733,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Chief Complaint: left leg weakness\\n HPI:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\\n untreated HTN presented to OSH with change in gait on left side after\\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\\n left sided numbness, and left facial droop. CT @ OSH --> right BG\\n hemorrhage 3cm, transferred to for further care. On transfer EMS\\n noted pt has \\\"worsening symptoms\\\" from the initial transport to OSH\\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n Demographics\\n Attending MD:\\n H.\\n Admit diagnosis:\\n INTRACRANIAL HEMORRHAGE\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 70.5 kg\\n Daily weight:\\n 67.6 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: He had been told he needed to control HTN but no\\n follow up with this recomendation.\\n ETOH abuse\\n Surgery / Procedure and date: S/P Right craniotomy admitted to\\n SICU-A 692\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:139\\n D:89\\n Temperature:\\n 100.6\\n Arterial BP:\\n S:155\\n D:89\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 94 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 0 L/min\\n FiO2 set:\\n 35% %\\n 24h total in:\\n 164 mL\\n 24h total out:\\n 30 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 03:27 AM\\n Potassium:\\n 3.4 mEq/L\\n 03:27 AM\\n Chloride:\\n 103 mEq/L\\n 03:27 AM\\n CO2:\\n 23 mEq/L\\n 03:27 AM\\n BUN:\\n 8 mg/dL\\n 03:27 AM\\n Creatinine:\\n 0.7 mg/dL\\n 03:27 AM\\n Glucose:\\n 94 mg/dL\\n 03:27 AM\\n Hematocrit:\\n 38.0 %\\n 03:27 AM\\n Finger Stick Glucose:\\n 147\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417743,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n PMHx:\\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\\n abuse, h/o illicit drug use\\n Current medications:\\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\\n Acid 8. Furosemide\\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\\n Lorazepam 15. Metoprolol Tartrate\\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\\n Ondansetron 20. Phenytoin 21. Potassium Chloride\\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\\n Sodium Chloride 0.9% Flush\\n 26. Thiamine\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 09:48 AM\\n Post operative day:\\n POD#4 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:19 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 07:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.7\\nC (99.8\\n HR: 110 (94 - 125) bpm\\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\\n RR: 19 (18 - 26) insp/min\\n SPO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 67.6 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 2,758 mL\\n 686 mL\\n PO:\\n Tube feeding:\\n 1,218 mL\\n 647 mL\\n IV Fluid:\\n 1,059 mL\\n 39 mL\\n Blood products:\\n Total out:\\n 3,148 mL\\n 275 mL\\n Urine:\\n 3,148 mL\\n 275 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -390 mL\\n 411 mL\\n Respiratory support\\n SPO2: 96%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent)\\n Right Extremities: (Edema: Absent)\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\\n No movement), (LLE: No movement)\\n Labs / Radiology\\n 266 K/uL\\n 14.4 g/dL\\n 142 mg/dL\\n 0.9 mg/dL\\n 27 mEq/L\\n 3.6 mEq/L\\n 18 mg/dL\\n 101 mEq/L\\n 138 mEq/L\\n 39.4 %\\n 12.9 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n 06:00 AM\\n 03:27 AM\\n 03:31 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n 16.5\\n 12.9\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n 38.0\\n 39.4\\n Plt\\n 20\\n 266\\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.9\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n 118\\n 94\\n 142\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\\n hemorrhage, now s/p R craniotomy, evac \\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\\n controlled\\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\\n Pulmonary: cont pulm toilet\\n Gastrointestinal / Abdomen:\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO\\n Hematology: Serial Hct, stable\\n Endocrine: RISS\\n Infectious Disease: stable\\n Lines / Tubes / Drains: Foley, Dobhoff\\n Wounds: Dry dressings\\n Imaging:\\n Fluids: KVO\\n Consults: Neurology\\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale, Comments: stable\\n Lines:\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417745,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n PMHx:\\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\\n abuse, h/o illicit drug use\\n Current medications:\\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\\n Acid 8. Furosemide\\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\\n Lorazepam 15. Metoprolol Tartrate\\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\\n Ondansetron 20. Phenytoin 21. Potassium Chloride\\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\\n Sodium Chloride 0.9% Flush\\n 26. Thiamine\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 09:48 AM\\n Post operative day:\\n POD#4 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:19 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 07:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.7\\nC (99.8\\n HR: 110 (94 - 125) bpm\\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\\n RR: 19 (18 - 26) insp/min\\n SPO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 67.6 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 2,758 mL\\n 686 mL\\n PO:\\n Tube feeding:\\n 1,218 mL\\n 647 mL\\n IV Fluid:\\n 1,059 mL\\n 39 mL\\n Blood products:\\n Total out:\\n 3,148 mL\\n 275 mL\\n Urine:\\n 3,148 mL\\n 275 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -390 mL\\n 411 mL\\n Respiratory support\\n SPO2: 96%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent)\\n Right Extremities: (Edema: Absent)\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\\n No movement), (LLE: No movement)\\n Labs / Radiology\\n 266 K/uL\\n 14.4 g/dL\\n 142 mg/dL\\n 0.9 mg/dL\\n 27 mEq/L\\n 3.6 mEq/L\\n 18 mg/dL\\n 101 mEq/L\\n 138 mEq/L\\n 39.4 %\\n 12.9 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n 06:00 AM\\n 03:27 AM\\n 03:31 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n 16.5\\n 12.9\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n 38.0\\n 39.4\\n Plt\\n 20\\n 266\\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.9\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n 118\\n 94\\n 142\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\\n hemorrhage, now s/p R craniotomy, evac \\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\\n controlled\\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\\n Pulmonary: cont pulm toilet\\n Gastrointestinal / Abdomen:\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO\\n Hematology: Serial Hct, stable\\n Endocrine: RISS\\n Infectious Disease: stable\\n Lines / Tubes / Drains: Foley, Dobhoff\\n Wounds: Dry dressings\\n Imaging:\\n Fluids: KVO\\n Consults: Neurology\\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale, Comments: stable\\n Lines:\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417634,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Remains on ativan atc. Tachy at times and occ attempting to pull at\\n lines, otherwise no s/s withdrawal noted.\\n Action:\\n Ativan atc, but dose decreased\\n Response:\\n No need for prn ativan and no s/s withdrawal noted\\n Plan:\\n Con\\nt to monitor. Ativan atc and prn.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Opens eyes to stim . right pupil round and reactive. Left pupil at\\n baseline. Follows commands on right. Moves right spont. No spont\\n movement on left. Withdraws on left to pain. Oriented to person and\\n president and month at times. Only says few words and speech grarbled.\\n Action:\\n Neuro checks.\\n Response:\\n Neuro status unchanged.\\n Plan:\\n Con\\nt neuro checks\\n To tx to SDU when bed avail.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 416935,\n \"text\": \"Chief Complaint: left leg weakness\\n HPI:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\\n untreated HTN presented to OSH with change in gait on left side after\\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\\n left sided numbness, and left facial droop. CT @ OSH --> right BG\\n hemorrhage 3cm, transferred to for further care. On transfer EMS\\n noted pt has \\\"worsening symptoms\\\" from the initial transport to OSH\\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Labetalol - 2 mg/min\\n Other ICU medications:\\n Diazepam (Valium) - 01:13 AM\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n HTN untreated, alcohol abuse, tobacco use, remote left eye penetrating\\n injury\\n Occupation: unemployed\\n Drugs:\\n Tobacco: +\\n Alcohol: admits to alcohol abuse, last drink @ 1pm, avg 6\\n drinks/day\\n Other:\\n Review of systems:\\n Eyes: hx left eye injury, impaired vision\\n Neurologic: Numbness / tingling, Headache\\n Psychiatric / Sleep: Agitated\\n Flowsheet Data as of 03:32 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: 35.6\\nC (96.1\\n HR: 80 (78 - 117) bpm\\n BP: 123/94(100) {90/68(69) - 162/106(120)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 120 mL\\n 135 mL\\n PO:\\n TF:\\n IVF:\\n 120 mL\\n 135 mL\\n Blood products:\\n Total out:\\n 800 mL\\n 0 mL\\n Urine:\\n 800 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -680 mL\\n 135 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Well nourished, Anxious\\n Eyes / Conjunctiva: right pupil reactive, left surgical pupil\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\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, Oriented (to): person,\\n place. Motor 0/5 left side, right side. Sensory\\n light touch,\\n decreased on left.\\n Labs / Radiology\\n head CT:\\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\\n with\\n mild mass effect but no midline shift, presumed to be Htn induced.\\n [image002.jpg]\\n Assessment and Plan\\n ASSESSMENT/PLAN:\\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\\n hemorrhage, with left leg weakness, left neglect (unable to sense left\\n arm without guidance of RUE), and LUE numbness.\\n NEURO: neuro check q1hr; neurosurgery consult appreciated and to\\n follow; MRI/MRA pending; STAT head CT for acute mental changes. Tylenol\\n for HA per primary service. HOB >30 degrees.\\n CV: Maintain SB 140-160, MAP <130.\\n Pulm/Endo/Heme/Renal/ID: no issues\\n GI/ABD/FEN: NPO until S/S eval\\n ICU Care\\n Nutrition:\\n Comments: NPO except meds until S/S eval\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:45 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417048,\n \"text\": \"Subarachnoid hemorrhage (SAH)\\n Assessment:\\n c/o constant R sided HA upon initial exam, +tremors/sweats-\\n please see metavision for neuron and CIWA assessment. Initially, pt\\n able to verbally communicate w/ slurred speech and follow\\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\\n BP 166/110, dramatic decrease in mental responsiveness- only\\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\\n position changes.\\n Action:\\n TSICU and Neuro teams notified immediately of above and in to assess\\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\\n reassess bleed- revealed increased bleed with NEW midline shift.\\n Discussion re: elective intubation for airway protection between\\n physicians- decided to wait temporarily. 50mg IV mannitol given at\\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\\n positioned at midline.\\n Response:\\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\\n mannitol.\\n Plan:\\n Emergently to OR at 15:00 for likely ventriculostomy.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\\n Last drink prior to admission. ETOH 143 in ED.\\n Action:\\n Given 2.5mg valium x 2.\\n Response:\\n Temporary decrease in symptoms.\\n Plan:\\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\\n ordered. Addictions consult.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417049,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\\n at 15:00.\\n Right Basal Ganglia Hemorrhage\\n Assessment:\\n c/o constant R sided HA upon initial exam, +tremors/sweats-\\n please see metavision for neuron and CIWA assessment. Initially, pt\\n able to verbally communicate w/ slurred speech and follow\\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\\n BP 166/110, dramatic decrease in mental responsiveness- only\\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\\n position changes.\\n Action:\\n TSICU and Neuro teams notified immediately of above and in to assess\\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\\n reassess bleed- revealed increased bleed with NEW midline shift.\\n Discussion re: elective intubation for airway protection between\\n physicians- decided to wait temporarily. 50mg IV mannitol given at\\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\\n positioned at midline.\\n Response:\\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\\n mannitol.\\n Plan:\\n Emergently to OR at 15:00 for likely ventriculostomy.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\\n Last drink prior to admission. ETOH 143 in ED.\\n Action:\\n Given 2.5mg valium x 2.\\n Response:\\n Temporary decrease in symptoms.\\n Plan:\\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\\n ordered. Addictions consult.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417802,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Pt slightly hypertensive in 140s; tachycardic to 120s\\n Action:\\n Administered metoprolol\\n Response:\\n Patient tolerated dose, heart to 90s and BP 120s/80s\\n Plan:\\n Continue beta blockade, hydral PRN\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n At times patient appeared restless, diaphoretic though afebrile,\\n tachycardic\\n Action:\\n Ativan, attempted to reduce stimuli in room\\n Response:\\n Patient settled; less diaphoretic, less restless\\n Plan:\\n Continue to monitor, administer ativan\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417012,\n \"text\": \"TSICU\\n HPI:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\\n untreated HTN presented to OSH with change in gait on left side after\\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\\n left sided numbness, and left facial droop. CT @ OSH --> right BG\\n hemorrhage 3cm, transferred to for further care. On transfer EMS\\n noted pt has \\\"worsening symptoms\\\" from the initial transport to OSH\\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n Chief complaint:\\n CC: left sided weakness\\n ISSUES:\\n 1. Intracranial hemorrhage with left sided plegia/paresthesia.\\n 2. HTN.\\n 3. EtOH abuse\\n PMHx:\\n Current medications:\\n 24 Hour Events:\\n - labetalol gtt started in evening for SBP>160, goal per neuro\\n MAP<130, SBP 140s-160s. Await MRI/MRA. Increased valium dose for\\n tremors.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:00 AM\\n Diazepam (Valium) - 08:50 AM\\n Other medications:\\n Flowsheet Data as of 11:06 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: 36.3\\nC (97.3\\n HR: 85 (78 - 117) bpm\\n BP: 137/89(102) {90/68(69) - 162/106(120)} mmHg\\n RR: 20 (15 - 24) insp/min\\n SPO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 120 mL\\n 346 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 120 mL\\n 346 mL\\n Blood products:\\n Total out:\\n 800 mL\\n 270 mL\\n Urine:\\n 800 mL\\n 270 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -680 mL\\n 76 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SPO2: 97%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: Somnolent\\n HEENT: Left pupil dilated, Right Pupil Equal and reactive\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\\n No(t) Weakness), (LUE: No movement), (RLE: No(t) Weakness), (LLE: No\\n movement)\\n Labs / Radiology\\n 231 K/uL\\n 15.2 g/dL\\n 134 mg/dL\\n 0.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 9 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 43.2 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:35 AM\\n WBC\\n 9.7\\n Hct\\n 43.2\\n Plt\\n 231\\n Creatinine\\n 0.8\\n Glucose\\n 134\\n Other labs: PT / PTT / INR:13.2/30.9/1.1, Ca:9.2 mg/dL, Mg:2.2 mg/dL,\\n PO4:3.3 mg/dL\\n Imaging: head CT:\\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\\n with\\n mild mass effect but no midline shift, presumed to be Htn induced.\\n Assessment and Plan\\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\\n hemorrhage.\\n Assessment and Plan:\\n Neurologic: Neuro checks Q: 1 hr, f/u Head CT\\n Cardiovascular: Labetalol gtt for SBP < 160 & MAP < 130 (PER PRIMARY\\n TEAM REC'S) --> will clarify these goals after f/u head ct. Will need\\n a-line.\\n Pulmonary: need intubated.\\n Gastrointestinal / Abdomen: Will need S&S eval --> will most likely\\n need dobhoff and TF\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: No issues\\n Endocrine: RISS\\n Infectious Disease: No issues\\n Lines / Tubes / Drains: Foley, PIV; For a-line.\\n Wounds: none\\n Imaging: CT scan head today\\n Fluids: KVO\\n Consults: Neuro surgery, Neurology\\n Billing Diagnosis: (Hemorrhage, NOS), CVA\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:45 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Needs ICU consent\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 35 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 417129,\n \"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 Known difficult intubation: No\\n Procedure location: OR\\n Reason: Intubated for procedure\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Plan to switch to CPAP/PS and extubate this AM.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: Plan for extubation today. RSBI completed on PS 5=28.\\n Reason for continuing current ventilatory support:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 417253,\n \"text\": \"Subjective: Pt just extubated.\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 175 cm\\n 70.5 kg\\n 68.1 kg ( 12:00 AM)\\n 22.9\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 72.6 kg\\n 97%\\n Diagnosis: ICH\\n PMH : poorly controlled HTN, ETOH abuse (12-18 beers/day), +tobacco,\\n remote R eye injury c/ screw driver\\n Food allergies and intolerances: NKFA\\n Pertinent medications: Famotidine, Abx, Colace, Senna, Bisacodyl, HISS,\\n NS c/ Thiamine, Folic Acid & Mvit, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 168 mg/dL\\n 02:24 AM\\n Glucose Finger Stick\\n 167\\n 10:00 AM\\n BUN\\n 9 mg/dL\\n 02:24 AM\\n Creatinine\\n 1.0 mg/dL\\n 02:24 AM\\n Sodium\\n 142 mEq/L\\n 02:24 AM\\n Potassium\\n 3.2 mEq/L\\n 01:37 PM\\n Chloride\\n 105 mEq/L\\n 02:24 AM\\n Albumin\\n 4.0 g/dL\\n 02:24 AM\\n Calcium non-ionized\\n 9.4 mg/dL\\n 02:24 AM\\n Phosphorus\\n 3.7 mg/dL\\n 02:24 AM\\n Ionized Calcium\\n 1.09 mmol/L\\n 01:37 PM\\n Magnesium\\n 2.1 mg/dL\\n 02:24 AM\\n Current diet order / nutrition support: NPO\\n GI: Soft, +BS\\n Assessment of Nutritional Status\\n At risk for malnutrition\\n Pt at risk due to: chronic ETOH abuse, possible permanent AMS head\\n bleed\\n Estimated Nutritional Needs\\n Calories: 1760-2115 (BEE x or / 25-30 cal/kg)\\n Protein: 84-99 (1.2-1.4 g/kg)\\n Fluid: team\\n Estimation of previous intake: unknown, possibly inadequate\\n Estimation of current intake: Inadequate\\n Specifics: 44 y.o. M adm with R basal ganglia hemorrhage, POD #1 of\\n crani & hematoma evacuation. Pt recently extubated and remains\\n agitated and confused. If pt unable to take po\\ns in the next 2-3days,\\n rec place feeding tube for start of enteral nutrition. Will use admit\\n wt for feeding wt. Noted K is low.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1) If pt\\ns MS doesn\\nt clear, rec evaluation by SLP.\\n 2) If pt unsafe for po\\ns, rec place FT and start TF with goal of\\n Fibersource @ 65cc/hr (1872kcals, 84g protein).\\n 3) Multivitamin / Mineral supplement: Mvit, 100mg Thiamine & 1mg\\n Folic Acid given daily\\n 4) Check chemistry 10 panel daily, relplete lytes as needed (namely\\n K).\\n Please page if ?\\ns \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416960,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\\n +family history,. Father also alcoholic When admitted to OSH ETOH level\\n 145. Pt still with strong smell of alcohol on breath admits to \\n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\\n through out the night, trying to get OOB, at times completely drenched\\n with new tremors noted at 0300. Neuro med resident called. Pt\\n required constant bedside safety observations. Pt is also heavy smoker\\n 1-1.5 packs a day for 25years.\\n Action:\\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\\n right upper arm.\\n Response:\\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\\n restless.\\n Plan:\\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\\n q4hrs. Remove nicotine patch before MRI.\\n Right basal ganglia hemorrhage\\n Assessment:\\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\\n and quickly weaned off. Every 1hr neuro checks remain stable without\\n much change. Pt does not suffer from neglect has he frequently rubs his\\n left arm and tries to straighten his left hand. c/o right sided\\n headache frequently rubbing right side of head. As stated\\n above pt a developed lower leg tremor when awake lasting 10-20seconds\\n then legs relax. Intermittent periods of clear speech and able to pick\\n up left leg 3 inches off bed then fell back. MRI check sheet filled\\n out and faxed to MRI.\\n Action:\\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\\n dose. Did not receive because had received valium recently. Received\\n Tylenol 650mg PR .\\n Response:\\n Headache is somewhat improved per patient.\\n Plan:\\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\\n infusion for SBP >160 or MAP >130\\n Scheduled for MRI today. Remove nicotine patch before scan. One time\\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\\n IVB right before scan.\\n Continue to keep pt and family aware of POC as discussed in multi\\n disciplinary rounds.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416961,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\\n +family history,. Father also alcoholic When admitted to OSH ETOH level\\n 145. Pt still with strong smell of alcohol on breath admits to \\n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\\n through out the night, trying to get OOB, at times completely drenched\\n with new tremors noted at 0300. Neuro med resident called. Pt\\n required constant bedside safety observations. Pt is also heavy smoker\\n 1-1.5 packs a day for 25years.\\n Action:\\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\\n right upper arm.\\n Response:\\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\\n restless.\\n Plan:\\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\\n q4hrs. Remove nicotine patch before MRI.\\n Right basal ganglia hemorrhage\\n Assessment:\\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\\n and quickly weaned off. Every 1hr neuro checks remain stable without\\n much change. Pt does not suffer from neglect has he frequently rubs his\\n left arm and tries to straighten his left hand. c/o right sided\\n headache frequently rubbing right side of head. As stated\\n above pt a developed lower leg tremor when awake lasting 10-20seconds\\n then legs relax. Intermittent periods of clear speech and able to pick\\n up left leg 3 inches off bed then fell back. MRI check sheet filled\\n out and faxed to MRI.\\n Action:\\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\\n dose. Did not receive because had received valium recently. Received\\n Tylenol 650mg PR .\\n Response:\\n Headache is somewhat improved per patient.\\n Plan:\\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\\n infusion for SBP >160 or MAP >130\\n Scheduled for MRI today. Remove nicotine patch before scan. One time\\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\\n IVB right before scan.\\n Continue to keep pt and family aware of POC as discussed in multi\\n disciplinary rounds.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417294,\n \"text\": \"Subarachnoid hemorrhage (SAH)\\n Assessment:\\n - pt off sedation\\n - arousable to voice but rarely opens eyes. Shows effort by\\n raising eyebrows but eyes are swollen\\n - R pupil 3mm and reactive, L eye dilated and unreactive due\\n to traumatic injury with screwdriver in the past.\\n - lifts and holds , squeeze hand when asked\\n - wiggles toes and moves RLE on bed\\n - no movement of LUE, does not respond to nail bed stimuli\\n - will withdraw LLE to pain\\n - dry sterile dressing on R side of head post craniotomy \\n not yet removed\\n - will cough with turning and stimulation, and secretions\\n suctioned out\\n - on nicardipine gtt sbp paramters <140\\n - on fentanyl and versed\\n - K 3.2\\n - Ionized Ca 0.94\\n Action:\\n - cool tea bags applied over R eye\\n - q1h neuro checks\\n - turn and reposition to stimulate cough\\n - Dilantin to prevent sz\\n - Fentanyl, and versed gtts off\\n - Morphine 2-4mg prn\\n - Nicardipine gtt off spb parameter changed from <140 to <160\\n - NS with 40meq KCL at 85ml/hr initiated\\n - Keep HOB>30\\n - Calcium gluconate 2gm given\\n Response:\\n - swelling of R eye reduced\\n - unchanged neuro status\\n - cough stimulated with turning\\n - no sz activity noted\\n - pt more arousable\\n - pain adequately controlled assessed by changes in vital\\n signs\\n - sbps 135-153\\n - awaiting K level\\n - Ionized ca 1.09\\n -\\n Plan:\\n - continue using cool tea bags to reduce swelling\\n - q1h neuro checks\\n - turn and reposition with chest pt frequently\\n - continue antiseizure therapy\\n - treat pain adequately with prn morphine\\n - lopressor 10mg q4h\\n - monitor sbps with parameter <160\\n - monitor and treat hypokalemia and hypocalcemia\\n - keep HOB >30\\n -\\n Respiratory (intubated in OR)\\n Assessment:\\n - On CMV adequate ABG levels\\n - SPO2 98-100%\\n - Minimal secretions\\n Action:\\n - Changed to CPAP, Spontaneous breathing trial, followed by\\n Extubation at 1100\\n - 3L nasal cannula\\n Response:\\n - ABG levels within normal limits\\n - SPO2 98-100%\\n - Lungs sound rhonchorous\\n - Normal and regular respiratory pattern\\n Plan:\\n - Nasal cannula at 3L\\n - Chest pt\\n - Turn and reposition frequently\\n - Encourage pt to cough and suction out secretions when\\n necessary\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n - hx smoking\\n - alcoholism; takes 12-18 beers/day\\n - level elevated on admission to OSH\\n Action:\\n - monitored for s/s of DTs\\n - banana bag given\\n - nicotine patch on R arm\\n Response:\\n - no sz or tremors, or other signs of DTs noted\\n - unable to fully assess for CIWA scale due to neurological\\n deficits\\n Plan:\\n - continue to monitor and assess for s/s of DTs\\n - continue with nicotine patch\\n - assess swallow/gag and start feeding either PO or NG if\\n failure to pass swallow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417417,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417418,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Demographics\\n Attending MD:\\n Admit diagnosis:\\n Code status:\\n Height:\\n Admission weight:\\n Daily weight:\\n Allergies/Reactions:\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history:\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:\\n D:\\n Temperature:\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n Heart Rate:\\n Heart rhythm:\\n O2 delivery device:\\n O2 saturation:\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 24h total out:\\n Pacer Data\\n Pertinent Lab Results:\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes:\\n Wallet / Money:\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from:\\n Transferred to:\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417371,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n BG hemorrhage\\n PMHx:\\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\\n abuse, h/o illicit drug use\\n Current medications:\\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\\n Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\\n Morphine Sulfate 16. Nicotine Patch\\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n EXTUBATION - At 11:10 AM\\n INVASIVE VENTILATION - STOP 11:10 AM\\n intubated in OR\\n Post operative day:\\n POD#2 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Famotidine (Pepcid) - 08:01 PM\\n Morphine Sulfate - 01:00 AM\\n Hydralazine - 02:20 AM\\n Insulin - Humalog - 02:30 AM\\n Lorazepam (Ativan) - 03:09 AM\\n Metoprolol - 04:03 AM\\n Other medications:\\n Flowsheet Data as of 06:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.8\\n T current: 37.5\\nC (99.5\\n HR: 98 (78 - 104) bpm\\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\\n RR: 19 (13 - 23) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.1 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 3,000 mL\\n 555 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,000 mL\\n 555 mL\\n Blood products:\\n Total out:\\n 2,115 mL\\n 765 mL\\n Urine:\\n 2,115 mL\\n 765 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 885 mL\\n -207 mL\\n Respiratory support\\n O2 Delivery Device: None\\n Ventilator mode: Standby\\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\\n PC : 0 cmH2O\\n PS : 5 cmH2O\\n RR (Spontaneous): 0\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 0 cmH2O\\n SPO2: 98%\\n ABG: 7.45/35/81./25/0\\n Ve: 9.3 L/min\\n PaO2 / FiO2: 205\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular), tachy\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\\n Weakness, No movement), (LLE: Weakness, No movement)\\n Labs / Radiology\\n 198 K/uL\\n 13.1 g/dL\\n 135 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.4 mEq/L\\n 5 mg/dL\\n 101 mEq/L\\n 136 mEq/L\\n 36.1 %\\n 16.2 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n Plt\\n \\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\\n Assessment and Plan\\n Assessment and Plan:\\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\\n pain\\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\\n ?withdrawl- 1 q6 ativan, will start PO metoprolol 50 tid\\n Pulmonary: chest pt\\n Gastrointestinal / Abdomen:\\n Nutrition: dobhoff and will start tube feeding, thiamine/folate, banana\\n bag\\n Renal: Foley, Adequate UO\\n Hematology:\\n Endocrine: RISS\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley\\n Wounds:\\n Imaging:\\n Fluids: NS, start tube feeds\\n Consults:\\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417287,\n \"text\": \"Subarachnoid hemorrhage (SAH)\\n Assessment:\\n - pt off sedation\\n - arousable to voice but rarely opens eyes. Shows effort by\\n raising eyebrows but eyes are swollen\\n - R pupil 3mm and reactive, L eye dilated and unreactive due\\n to traumatic injury with screwdriver in the past.\\n - lifts and holds , squeeze hand when asked\\n - wiggles toes and moves RLE on bed\\n - no movement of LUE, does not respond to nail bed stimuli\\n - will withdraw LLE to pain\\n - dry sterile dressing on R side of head post craniotomy \\n not yet removed\\n - will cough with turning and stimulation, and secretions\\n suctioned out\\n - on nicardipine gtt sbp paramters <140\\n - on fentanyl and versed\\n - K 3.2\\n - Ionized Ca 0.94\\n Action:\\n - cool tea bags applied over R eye\\n - q1h neuro checks\\n - turn and reposition to stimulate cough\\n - Dilantin to prevent sz\\n - Fentanyl, and versed gtts off\\n - Morphine 2-4mg prn\\n - Nicardipine gtt off spb parameter changed from <140 to <160\\n - NS with 40meq KCL at 85ml/hr initiated\\n - Keep HOB>30\\n - Calcium gluconate 2gm given\\n Response:\\n - swelling of R eye reduced\\n - unchanged neuro status\\n - cough stimulated with turning\\n - no sz activity noted\\n - pt more arousable\\n - pain adequately controlled assessed by changes in vital\\n signs\\n - sbps 135-153\\n - awaiting K level\\n - Ionized ca 1.09\\n -\\n Plan:\\n - continue using cool tea bags to reduce swelling\\n - q1h neuro checks\\n - turn and reposition with chest pt frequently\\n - continue antiseizure therapy\\n - treat pain adequately with prn morphine\\n - lopressor 10mg q4h\\n - monitor sbps with parameter <160\\n - monitor and treat hypokalemia and hypocalcemia\\n - keep HOB >30\\n -\\n Respiratory (intubated in OR)\\n Assessment:\\n - On CMV adequate ABG levels\\n - SPO2 98-100%\\n - Minimal secretions\\n Action:\\n - Changed to CPAP, Spontaneous breathing trial, followed by\\n Extubation at 1100\\n - 3L nasal cannula\\n Response:\\n - ABG levels within normal limits\\n - SPO2 98-100%\\n - Lungs sound rhonchorous\\n - Normal and regular respiratory pattern\\n Plan:\\n - Nasal cannula at 3L\\n - Chest pt\\n - Turn and reposition frequently\\n - Encourage pt to cough and suction out secretions when\\n necessary\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n - hx smoking\\n - alcoholism; takes 12-18 beers/day\\n - level elevated on admission to OSH\\n Action:\\n - monitored for s/s of DTs\\n - banana bag given\\n - nicotine patch on R arm\\n Response:\\n - no sz or tremors, or other signs of DTs noted\\n - unable to fully assess for CIWA scale due to neurological\\n deficits\\n Plan:\\n - continue to monitor and assess for s/s of DTs\\n - continue with nicotine patch\\n - assess swallow/gag and start feeding either PO or NG if\\n failure to pass swallow\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417369,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n BG hemorrhage\\n PMHx:\\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\\n abuse, h/o illicit drug use\\n Current medications:\\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\\n Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\\n Morphine Sulfate 16. Nicotine Patch\\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n EXTUBATION - At 11:10 AM\\n INVASIVE VENTILATION - STOP 11:10 AM\\n intubated in OR\\n Post operative day:\\n POD#2 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Famotidine (Pepcid) - 08:01 PM\\n Morphine Sulfate - 01:00 AM\\n Hydralazine - 02:20 AM\\n Insulin - Humalog - 02:30 AM\\n Lorazepam (Ativan) - 03:09 AM\\n Metoprolol - 04:03 AM\\n Other medications:\\n Flowsheet Data as of 06:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.8\\n T current: 37.5\\nC (99.5\\n HR: 98 (78 - 104) bpm\\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\\n RR: 19 (13 - 23) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.1 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 3,000 mL\\n 555 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,000 mL\\n 555 mL\\n Blood products:\\n Total out:\\n 2,115 mL\\n 765 mL\\n Urine:\\n 2,115 mL\\n 765 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 885 mL\\n -207 mL\\n Respiratory support\\n O2 Delivery Device: None\\n Ventilator mode: Standby\\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\\n PC : 0 cmH2O\\n PS : 5 cmH2O\\n RR (Spontaneous): 0\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 0 cmH2O\\n SPO2: 98%\\n ABG: 7.45/35/81./25/0\\n Ve: 9.3 L/min\\n PaO2 / FiO2: 205\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular), tachy\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\\n Weakness, No movement), (LLE: Weakness, No movement)\\n Labs / Radiology\\n 198 K/uL\\n 13.1 g/dL\\n 135 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.4 mEq/L\\n 5 mg/dL\\n 101 mEq/L\\n 136 mEq/L\\n 36.1 %\\n 16.2 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n Plt\\n \\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\\n Assessment and Plan\\n Assessment and Plan:\\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\\n pain\\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\\n ?withdrawel 1 q6 ativan, will start PO metoprolol 50 tid\\n Pulmonary: chest pt\\n Gastrointestinal / Abdomen:\\n Nutrition: dobhoff and will start tube feeding, thiamine/folate bannana\\n bag\\n Renal: Foley, Adequate UO\\n Hematology:\\n Endocrine: RISS\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley\\n Wounds:\\n Imaging:\\n Fluids: NS, d/c nml saline start tube feeds\\n Consults:\\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417534,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n BG hemorrhage\\n PMHx:\\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\\n ETOH abuse, h/o illicit drug use\\n : none\\n .\\n Current medications:\\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\\n Bisacodyl 6. Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\\n Famotidine 10. FoLIC Acid 11. Heparin\\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\\n 17. Metoprolol Tartrate\\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\\n Ondansetron 22. Phenytoin 23. Potassium Chloride\\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\\n 27. Thiamine\\n 24 Hour Events:\\n TF placed and tF started yesterday\\n Post operative day:\\n POD#3 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:41 AM\\n Lorazepam (Ativan) - 06:00 PM\\n Famotidine (Pepcid) - 08:13 PM\\n Heparin Sodium (Prophylaxis) - 08:15 PM\\n Hydralazine - 02:14 AM\\n Metoprolol - 06:18 AM\\n Other medications:\\n Flowsheet Data as of 06:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.2\\nC (100.7\\n T current: 38.1\\nC (100.5\\n HR: 119 (86 - 119) bpm\\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\\n RR: 18 (9 - 25) insp/min\\n SPO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 67.6 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 2,828 mL\\n 776 mL\\n PO:\\n Tube feeding:\\n 190 mL\\n 129 mL\\n IV Fluid:\\n 2,518 mL\\n 647 mL\\n Blood products:\\n Total out:\\n 2,735 mL\\n 700 mL\\n Urine:\\n 2,735 mL\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 93 mL\\n 76 mL\\n Respiratory support\\n SPO2: 96%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\\n Labs / Radiology\\n 220 K/uL\\n 13.6 g/dL\\n 94 mg/dL\\n 0.7 mg/dL\\n 23 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 38.0 %\\n 16.5 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n 06:00 AM\\n 03:27 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n 16.5\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n 38.0\\n Plt\\n 20\\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n 118\\n 94\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\\n hemorrhage, now s/p R craniotomy, evac \\n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\\n to PO\\n Cardiovascular: Lopressor 75 TID PO\\n HYDRALAZYN prn\\n Pulmonary: Stable\\n Gastrointestinal / Abdomen: Adnance to goal\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Lasix 20mg \\n Hematology: Stable\\n Endocrine:\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley\\n Wounds:\\n Imaging:\\n Fluids:\\n Consults: Nephrology\\n Billing Diagnosis: Other: Basal ganglia Bleed\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\\n Glycemic Control:\\n Lines:\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416951,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Hourly CIWA scale 17-27\\n Action:\\n Response:\\n Plan:\\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416945,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416946,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417343,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt continues with ciwa scale. Pt more restless pulling off gown and\\n pulling at foley and taking off oxygen. Neuro exam is unchanged hr up\\n to 106 and sbp 160\\ns/80\\n Action:\\n Ativan .5mg iv x2 for total of 1mg. pt less restless and sbp down to\\n 158/70.\\n Response:\\n Pt less restless after Ativan.\\n Plan:\\n Continue with neuro checks and ciwa scale. Assess for Ativan as\\n needed.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Neuro exam is unchanged. Pt follows commands on right side. Withdrawal\\n on left foot, none on left arm. Right pupil is reactive to light. Rt\\n eye is swollen. Pt opens eyes to name. Speech very soft and slightly\\n garbled. Goal sbp less than 160. lopressor increased to 20mg q4 and\\n hydralazine prn, given x2. Dr. aware of sbp greater than 160.\\n does not want to restart nicardipine and increased lopressor.\\n Action:\\n Lopressor increased to 20mg. hydralazine prn. Continue with q1 neuro\\n checks, ? repeat ct today.\\n Response:\\n Neuro is unchanged. Pt restless at times but responded to ativan\\n Plan:\\n Continue with neuro exam. Treat bp as needed. Continue with ciwa scale.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417346,\n \"text\": \".H/O respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt extubated today. Pt resp rate 16-20. o2 sat on room air 98%. Breath\\n sounds are clear and diminished in the bases. Pt coughing and\\n swallowing.\\n Action:\\n Encourage pt to cough and deep breath.\\n Response:\\n Doing well extubated.\\n Plan:\\n Continue to cough and deep breathe. Frequent position changes.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417147,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt responds to name and stimulation with jerking movements, attempts\\n to sit up, and tremulous motion of right side, less motion on left\\n side. Pt does not nod or shake head to communicate, so assessment of\\n hallucinations, pain, etc is difficult.\\n Action:\\n Midazolam and fentanyl drips started and titrated up as needed to\\n control tremulous movement\\n Response:\\n Tremors are quieter, although still existent with medications at higher\\n dosage. Midaz returned to 2 mg/hr from 4 mg/hr when he became more\\n difficult to arouse. He is now arousable but with fewer tremors than\\n before midazolam and fentanyl were started.\\n Plan:\\n Titrate drips as needed, monitor for increase tremors, seizures,\\n increase in heart rate and bp.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Pt post op evacuation of SDH. Head dressing is dry and intact. Pt\\n arouses to name, as above, follows commands with right side, but does\\n not nod or shake his head when asked to do so. He is intubated on CMV ,\\n sx for thick yellow secretios Right pupil is and reacts briskly.\\n Left pupil is damaged from a screwdriver injury. Pt is sedated for\\n onset of DT\\ns, and responding more slowly with midazolam and fentanyl\\n on.\\n Action:\\n Midazolam decreased to 2 mg when pt very slow to respond to name and\\n stimulation\\n Response:\\n Pt responding again when name called.\\n Plan:\\n Continue with q 1 hour neuro checks to evaluate neuro status\\n complicated by alcohol withdrawal.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417053,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\\n at 15:00.\\n Right Basal Ganglia Hemorrhage\\n Assessment:\\n c/o constant R sided HA upon initial exam, +tremors/sweats-\\n please see metavision for neuron and CIWA assessment. Initially, pt\\n able to verbally communicate w/ slurred speech and follow\\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\\n BP 166/110, dramatic decrease in mental responsiveness- only\\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\\n position changes.\\n Action:\\n TSICU and Neuro teams notified immediately of above and in to assess\\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\\n reassess bleed revealed increased bleed, cerebral edema, and NEW 1.3\\n cm midline shift to left. Discussion re: elective intubation for\\n airway protection between physicians- decided to wait temporarily.\\n 50mg IV mannitol given at 13:00 over 30minuntes to decrease ICP. HOB at\\n 30 degrees. Head positioned at midline.\\n Response:\\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\\n mannitol.\\n Plan:\\n Emergently to OR at 15:00 for likely ventriculostomy.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\\n Last drink prior to admission. ETOH 143 in ED.\\n Action:\\n Given 2.5mg valium x 2.\\n Response:\\n Temporary decrease in symptoms.\\n Plan:\\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\\n ordered. Addictions consult.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 417263,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 72.6 None\\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Not applicable\\n Size: Not applicable\\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: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: /\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\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 CT\\n without incident\\n Bedside Procedures:\\n Comments:\\n Pt received intubated and vented on AC settings as charted. RSBI 28\\n today. Placed on PSV 5 peep 5 with TV 500 and RR 12-16. Pt transported\\n to CT scan and placed on SBT after transport. Pt extubated without\\n incident and is currently on 3L NP and stable from resp standpoint.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 417428,\n \"text\": \"TITLE:\\n Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain but otherwise sleeping most of day. Right pupil\\n reactive, round. Left pupil unreactive and odd shaped at baseline.\\n Moves right side purposefully and attempts to pull at tubes/lines.\\n Withdraws on left to pain. No spont movement on left. Said name once,\\n otherwise only groans occ. Follows commands on right inconsistently. No\\n sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417495,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt has a known history of drinking > 8-12 beers/day. Brother states ?\\n more than 12 beers. Attempting to pull off bed clothes. Pt does not\\n focus on you when speaking to him.\\n Action:\\n Ativan 1 mg iv q6hrs. nictone patch as ordered.\\n Response:\\n Pt is less agitated after the ativan iv.\\n Plan:\\n Continue with ativan iv and prn. Monitor closely.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Neuro assessment done q2hrs. strong hand grasp on right side and moves\\n right leg off the bed. Withdraws to pain on left foot but no actual\\n movement in left arm. Withdraws slightly to painful stimuli. Speech is\\n garbled and pt very diffiulct to understand. Right pupil reactive to\\n light and left eye no reaction due to old eye injury. Bp at times >\\n 160. operative site on head intact with staples present and no drainage\\n noted.\\n Action:\\n Neuro signs q2hrs. ? head ct today. Incision inspected\\n Response:\\n No neuro changes\\n Plan:\\n Cont with neuro exam.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417497,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Bp mostly > 160 shift\\n Action:\\n Lopresssor 50mg via tube given as ordered. Hydralazine 10mg iv given\\n linsopril 5mg via tube given as ordered.\\n Response:\\n Bp < 160 for short time after meds given but quickly returns to > 160.\\n Plan:\\n Monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417574,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Demographics\\n Attending MD:\\n Admit diagnosis:\\n Code status:\\n Height:\\n Admission weight:\\n Daily weight:\\n Allergies/Reactions:\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history:\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:\\n D:\\n Temperature:\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n Heart Rate:\\n Heart rhythm:\\n O2 delivery device:\\n O2 saturation:\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 24h total out:\\n Pacer Data\\n Pertinent Lab Results:\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes:\\n Wallet / Money:\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from:\\n Transferred to:\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416954,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n ETOH level 145 at OSH with strong smell of alcohol on breath, admits to\\n 12-18 beers a day. Hourly CIWA scores 20-27 becoming Increasingly\\n restless through out the night, trying to get OOB, at times completely\\n drenched with new tremors noted at 0300. Pt required bedside safety\\n observations. Neuro med resident called. Pt is also heavy smoker 1-1.5\\n packs a day for 25years.\\n Action:\\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\\n right upper arm.\\n Response:\\n Initially only decrease in restlessness for 45 minutes after valium 5mg\\n IVB. However by am CIWA scale decreasing to 17 by 0500 and becoming\\n less restless.\\n Plan:\\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\\n q4hrs. Remove nicotine patch before MRI.\\n Right basal ganglia hemorrhage\\n Assessment:\\n Every 1hr neuro checks remain stable without much change. As stated\\n above pt developed lower leg tremors mostly when awake lasting\\n 10-20seconds then muscle relaxes.\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 417069,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 72.6 None\\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\\n Airway\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: /\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\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 arrived from O.R. and taken to C.T. Plan to extubated when awake.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-09-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039777,\n \"text\": \", NMED FA11 11:50 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Querying aspiration pneumonitis\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with left hemiparesis, s/p crani after an ICH\\n REASON FOR THIS EXAMINATION:\\n Querying aspiration pneumonitis\\n ______________________________________________________________________________\\n PFI REPORT\\n No evidence of acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037849,\n \"text\": \" 12:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p Dobhoff placemnet eval plse\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p Dobhoff placemnet eval plse\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 5:06 PM\\n Dobbhoff tube is in the stomach.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Assess Dobbhoff catheter.\\n\\n Dobbhoff tip is in the stomach. There is mild cardiomegaly. The lungs are\\n clear. There is no pleural effusion.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037850,\n \"text\": \", H. NMED SICU-A 12:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p Dobhoff placemnet eval plse\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p Dobhoff placemnet eval plse\\n ______________________________________________________________________________\\n PFI REPORT\\n Dobbhoff tube is in the stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-09-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039776,\n \"text\": \" 11:50 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Querying aspiration pneumonitis\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with left hemiparesis, s/p crani after an ICH\\n REASON FOR THIS EXAMINATION:\\n Querying aspiration pneumonitis\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 3:52 PM\\n No evidence of acute cardiopulmonary process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Suspected aspiration pneumonia.\\n\\n Portable AP chest radiograph was compared to prior study from .\\n\\n The heart size is normal. Mediastinal position, contour and width are\\n unremarkable. Lungs are clear. No pleural effusion or pneumothorax is\\n present. Potential old rib fracture is seen on the left\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"ORBITS (WATERS, CALDWELL & LAT)\",\n \"row_id\": 1037401,\n \"text\": \" 11:18 AM\\n ORBITS (WATERS, & LAT) Clip # \\n Reason: bilateral orbital xray to rule out metal pre-mri\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm), untreated HTN\\n presented to OSH with change in gait on left side after alcohol use. Pt noted\\n difficulty moving left leg, left facial weakness, left sided numbness, and left\\n facial droop. CT @ OSH --> right BG hemorrhage 3cm, transferred to for\\n further care. On transfer EMS noted pt has \\\"worsening symptoms\\\" from the\\n initial transport to OSH (same EMS team). @ repeat head CT showed right\\n BG hemorrhage at 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n REASON FOR THIS EXAMINATION:\\n bilateral orbital xray to rule out metal pre-mri\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Orbit series .\\n\\n HISTORY: 44-year-old man with facial droop and needs MRI. Evaluate for metal\\n in orbits.\\n\\n FINDINGS: Comparison is made to the CT scan from .\\n\\n There are no radiopaque densities in the left orbital prosthesis. Visualized\\n paranasal sinuses are within normal limits.\\n\\n IMPRESSION: No radiopaque densities within the orbits to exclude the patient\\n from having MRI.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037478,\n \"text\": \" 5:50 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate for hemorrhage\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:10 PM\\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\\n pneumocephalus and intraventricular hemorrhage.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT HEAD WITHOUT CONTRAST.\\n\\n COMPARISON: Nine hours prior.\\n\\n HISTORY: Evaluate for hemorrhage.\\n\\n FINDINGS: Patient is status post right frontoparietal craniotomy with\\n evacuation of putaminal and temporal lobe hematoma. Extensive pneumocephalus\\n is identified along the right cerebral convexity. There is a leftward shift of\\n normally midline structures by approximately 10 mm, slightly decreased when\\n compared to prior exam. Intraventricular hemorrhage in the right frontal \\n of the lateral ventricle and bilateral posterior horns of the lateral\\n ventricle is not significantly changed. A small amount of residual hemorrhage\\n and extensive pneumocephalus within the right basal ganglia is identified.\\n Dilated temporal horns, left greater than right, are unchanged. The basilar\\n cisterns are patent.\\n\\n IMPRESSION: Patient status post craniotomy with evacuation of hematoma.\\n Extensive pneumocephalus over the right cerebral hemisphere and within the\\n right basal ganglia. Interval decrease in right basal ganglia hemorrhage.\\n Persistent intraventricular hemorrhage and leftward shift of midline\\n structures as described above.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037479,\n \"text\": \", H. NMED SICU-A 5:50 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate for hemorrhage\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\\n pneumocephalus and intraventricular hemorrhage.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"CTA HEAD W&W/O C & RECONS\",\n \"row_id\": 1037390,\n \"text\": \" 10:52 AM\\n CTA HEAD W&W/O C & RECONS Clip # \\n Reason: Hemorrhage follow-up\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with R basal ganglia hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Hemorrhage follow-up\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 2:13 PM\\n\\n Moderate increas ein the right basal ganglia hematoma with new areas and new\\n itnraventricular hemorrhage and mass effect and cerbral edema on the right.\\n Patent major arteries; no abnormal vascularity around the hematoma- however,\\n lesions within the hematoma are not assessed.\\n d/w Dr. . by Dr. on at 2pm.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 44-year-old male patient with right basal ganglial hemorrhage,\\n followup.\\n\\n COMPARISON: CT of the head done on at 4:19 p.m.\\n\\n TECHNIQUE: Non-contrast CT of the head, followed by CT angiogram of the head\\n with IV contrast was performed. Volume rendered and 2D MIP reformations of\\n the major arteries were obtained.\\n\\n FINDINGS:\\n\\n NON-CONTRAST CT OF THE HEAD:\\n\\n There is interval moderate increase in the size of the right basal ganglia\\n hematoma, 7.6x3.6cm in the AP and transverse dimensions with significant\\n mass effect on the adjacent structures, along with cerebral edema on the right\\n side. There is 1.3 cm shift of the midline structures to the left side, which\\n is increased, which is new. Some of the new areas that have developed are\\n less dense in attenuation representing active bleeding/ due to anemia. There\\n is also extension of the hemorrhage into the right lateral ventricle as well\\n as the third ventricle. A few small hypodense foci, noted in the left\\n internal capsule, may represent perivascular spaces or chronic lacunar\\n infarcts are unchanged. No osseous lytic or sclerotic lesions of concern are\\n noted.\\n\\n CT ANGIOGRAM OF THE HEAD:\\n\\n The major intracranial arteries, of the anterior and posterior circulation are\\n patent without flow limiting stenosis, occlusion, or aneurysm. No abnormal\\n vascularity is noted surrounding the large right basal ganglial hematoma.\\n However, the vascular lesion, located within the area of hematoma itself is\\n not excluded on the present study. A small prominent vein int he right vertex\\n can relate to a small developmental venous anomaly. ( series 401b/7)\\n (Over)\\n\\n 10:52 AM\\n CTA HEAD W&W/O C & RECONS Clip # \\n Reason: Hemorrhage follow-up\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n There is evidence of scleral band, with ocular implant on the left side,\\n unchanged.\\n\\n IMPRESSION:\\n\\n 1. Moderate increase in the size of the right basal ganglial hematoma with\\n new areas of hemorrhage, which are less dense than expected, raising the\\n possibility of active bleeding, ? bleeding disorders/anemia.\\n\\n 2. Development of new intraventricular hemorrhage, in the right lateral\\n ventricle and third ventricle.\\n\\n 3. Significant mass effect, with cerebral edema on the right side, with 1.3\\n cm shift of the midline structures to the left side.\\n\\n 4. Patent major intracranial arteries. No obvious abnormal vascularity noted\\n around the hematoma. However, the vascular lesion, within the hematoma itself\\n cannot be excluded on the present study. To consider followup evaluation for\\n vascular lesions after resolution of the hematoma. In addition,\\n MRI/conventional angiogram or close followup CT head can be considered.\\n\\n Findings were discussed with Dr. . for Dr. on at 2 p.m.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037566,\n \"text\": \" 8:25 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate for interval change. Please this this am\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change. Please this this am\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: CT head without contrast.\\n\\n INDICATION: 44-year-old with intracranial bleed status post surgery, please\\n evaluate for change.\\n\\n COMPARISON: .\\n\\n FINDINGS: Post-operative change of a right craniotomy status post evacuation\\n of an intraparenchymal bleed is again noted. There is decrease in the overall\\n amount of pneumocephalus. The degree of mass effect and intracranial\\n hemorrhage is not overall changed from prior study. The degree of\\n intraventricular hemorrhage is also stable without evidence of hydrocephalus.\\n Prominence of the left temporal is stable. The suprasellar cistern\\n remains patent. Scleral band over the left orbit is grossly unchanged.\\n\\n IMPRESSION: Decrease in overall degree of post-operative pneumocephalus. No\\n new hemorrhage is identified. Degree of mass effect appears little changed.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-23 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037261,\n \"text\": \" 4:12 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for progression\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with know bleed\\n REASON FOR THIS EXAMINATION:\\n eval for progression\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JKPe WED 4:45 PM\\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging, with\\n mild mass effect but no midline shift, presumed to be Htn induced.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Known intracranial hemorrhage.\\n\\n NON-CONTRAST HEAD CT\\n\\n FINDINGS: Comparison is made to outside scan from same date. Again\\n identified is slightly heterogeneous hyperdense hemorrhage predominantly\\n centered within the right basal ganglia with mass effect on the posterior limb\\n of the right-sided internal capsule and adjacent parenchyma including the\\n right frontal . The hemorrhage appears to have increased in size from\\n outside examination, currently measuring 2.6 x 4.9 cm with prior measurement\\n at similar level of approximately 2.3 x 3.6 cm. No other regions of\\n intraparenchymal or intraventricular hemorrhage are identified. There is no\\n significant midline shift. -white matter differentiation is otherwise\\n well preserved. An old lacunar-type infarct is noted within the left internal\\n capsule anterior limb. An apparent left globe prosthesis is noted. No soft\\n tissue irregularity is present. Mastoid air cells and paranasal sinuses are\\n well aerated.\\n\\n IMPRESSION:\\n\\n Interval increase in size to right intraparenchymal basal ganglia hemorrhage\\n which displays mild mass effect on the adjacent brain parenchyma and right\\n frontal with no significant midline shift. This location is most\\n suggestive of a hypertensive etiology, although underlying mass\\n lesion/metastasis is not completely excluded.\\n\\n Further evaluation with dedicated contrast-enhanced MRI may be obtained once\\n the hemorrhage partially resolved for further characterization.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 223395,\n \"text\": \"Sinus rhythm\\nProminent precordial lead QRS voltage suggests left ventricular hypertrophy but\\nmay be nondiagnostic given age\\nModest nonspecific inferior ST-T wave changes\\nNo previous tracing available for comparison\\n\\n\"\n }\n]"}}},{"rowIdx":186,"cells":{"subject_id":{"kind":"number","value":17440,"string":"17,440"},"hadm_id":{"kind":"number","value":169094,"string":"169,094"},"target_text":{"kind":"string","value":"1. Cardiac: The patient is status post ventricular fibrillation arrest, likely secondary to ischemia given the EKG changes, with ST elevations in the inferior leads. The patient was taken for an emergent catheterization. Pressures in the catheterization laboratory revealed right ventricle 42/17, PA 42/19, wedge of 20, cardiac output 8.2, cardiac index 3.7, SVR 1112. The patient's catheterization revealed an right coronary artery with a proximal 70% diffuse, mid-90% diffuse; left main was normal. Left anterior descending showed a 40% D2 lesion. Mid-LAD had a 90% lesion. Distal circumflex had a 30% lesion. The mid-LAD 90% lesion was successfully percutaneous transluminal coronary angioplasty and stented. The patient transferred to the Cardiac Care Unit. In the Cardiac Care Unit the patient was continued on aspirin, Plavix, Integrilin for 18 hours, started on Lipitor. The patient's enzymes were cycled with a maximum CK of 1300, ruling positive troponin. However, CK's trended down to normal by the time of discharge. The patient also had an echocardiogram which showed an ejection fraction of 35 to 40% with multiple regional wall motion abnormalities. The patient was diuresed aggressively throughout his stay. The patient with a ventricular fibrillation arrest, was continued on Lidocaine drip until the following morning, however, at which point Lidocaine was discontinued. The patient remained on Telemetry without any evidence of ventricular tachycardia or ventricular fibrillation after his stent was placed, due to a Staphylococcus aureus blood infection. The patient will be overturned for a defibrillator placement after his antibiotic course is finished. The patient's Captopril and Lopressor were titrated up as tolerated; see final Medicine List. 2. Pulmonary: The patient initially intubated with left lower lobe collapse, question of aspiration. The patient was started on Levaquin and Flagyl for aspiration pneumonia with aggressive deep suctioning and chest Physical Therapy. The patient was able to extubated successfully on hospital day three. The patient maintained excellent saturations for the rest of his stay off the ventilation. While intubated, the patient had a bronchoscopy which showed evidence of left lower lobe secretions consistent with aspiration pneumonia. 3. Infectious Disease: The patient with likely aspiration event. He was started on intravenous Levaquin and Flagyl which was switched over to p.o. when tolerating. The patient to finish a ten day course of p.o. Levaquin and Flagyl. Methicillin resistant Staphylococcus aureus: The patient with four out of four positive blood cultures with Staphylococcus aureus. Final sensitivities showed that Staphylococcus aureus was resistant to Oxacillin but sensitive to Vancomycin. Given Methicillin resistant Staphylococcus aureus the patient was placed on contact precautions and will be discharged to complete a 14 day course of Vancomycin. The patient had a PICC placed prior to discharge. The patient is starting Vancomycin on , to continue until . 4. Endocrine: The patient with history of diabetes mellitus. Was put on an insulin drip initially and switched over to NPH and insulin sliding scale; to restart his oral medications, Avandia 4 mg with an insulin sliding scale for tight control. Avandia can be increased as tolerated. 5. Renal: The patient with initial creatinine of 1.3, which improved with fluid resuscitation and remained in the normal limits with diuresis. 6. Fluids, Electrolytes and Nutrition: The patient was initially NPO and was receiving tube feeds. However, after the patient was extubated, he was able to tolerate clears and advancing diet as tolerated. The patient will be discharged with a mechanical soft diet to be increased to a full diet as tolerated. 7. Orthopedics: The patient initially in a cervical spine collar status post fall. The patient had an x-ray which revealed no evidence of cervical spine fractures. Cervical spine was cleared, the collar was removed and the patient to resume full activities as tolerated. 8. Gastrointestinal: The patient continued on Protonix for GI prophylaxis. 9. Neurologic: The patient with a question of mental status changes given his four minutes of hypoxia. Initial CT scan showed questionable white matter changes consistent with possible early anoxic encephalopathy. However, after sedation was weaned and the patient was extubated, the patient's neurologically mental status was returned to per wife; however, the patient will need aggressive physical therapy to improve his strength and coordination prior to resuming full activities."},"extractive_notes_summ":{"kind":"string","value":"There is moderateregional left ventricular systolic dysfunction.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -hypokinetic; anterior apex - hypokinetic; septal apex - hypokinetic; inferiorapex - hypokinetic; apex - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. Q waves in leads III and aVF suggest inferior myocardialinfarction. T wave flattening in leads III, aVF and V4-V6 suggestpossible inferolateral ischemia. The right cephalic vein is occluded with thrombus. Sinus rhythm- premature ventricular contractionsOld inferior infarctAnterior T wave changes are nonspecificRhythm strip shows normal sinus rhythmSince previous tracing, , ventricular premature complex seen There has been interval removal of the ET tube. AP PORTABLE UPRIGHT CHEST: The left costophrenic angle is excluded. 3) Nasogastric tube side port above the level of the diaphragm. REASON FOR THIS EXAMINATION: r/o infiltrate, worsening CHF FINAL REPORT INDICATIONS: V fib at rest. There is an NG tube with tip in the stomach and sideport just below the level of the diaphragm. RSR' pattern in leads V1-V2.ST segment depressions in the anterior leads suggest possible anteriorischemia. There is opacification of the left retrocardiac space. Evaluation of the mediastinum and lungs is somewhat limited secondary to the overlying trauma board, patient motion and a cardiac pacer seen overlying the left lateral/lower hemithorax. Replaced NG tube. Atelectasis and diffuse parenchymal opacification are seen at the right lower lobe and posterior right middle lobe, findings consistent with aspiration. Sinus tachycardia. The tip of a nasogastric tube is seen just distal to the GE junction, with the side port likely within the distal esophagus. Evaluate for abscess. The ascending aorta is mildly dilated. The mitral valve leaflets are mildlythickened. The left ventricular cavity size is normal.There is moderate regional left ventricular systolic dysfunction. There is persistent opacification of the left lower lobe with a small left pleural effusion. New pulmonary edema. The ST segment depressions in the anterior leads has resolved.TRACING #2 The nasogastric tube overlies the stomach but the side port is above the diaphragm. PATIENT/TEST INFORMATION:Indication: s/p VF arrest, LAD stent, hypotensionHeight: (in) 73Weight (lb): 209BSA (m2): 2.19 m2BP (mm Hg): 127/90HR (bpm): 101Status: InpatientDate/Time: at 11:34Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. Physiologicmitral regurgitation is seen (within normal limits).TRICUSPID VALVE: The tricuspid valve leaflets are normal.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. Compared to tracing #1, the Q waves in the inferior leads are nowapparent. Nasogastric tube tip overlies the proximal stomach with the side port at the level of the diaphgram. and LMCA normal.ID: Febrile. remained 95-120/60-70 via r rad aline.tol lopressor later in am.r fem aline pulled. CPKs trending down.GI: Pt with minimal OG aspirates. NTG WEANED & DCED. Tolerating BB and ACEI titration. ADEQ SEDATION. Abd firm and distended with normoactive BS's. CV=HEMODY STABLE. CV=HEMODY STABLE. min aspirates. Am abg 105/36/7.42/24/0. GI=SELF DCED NGT. tol lopressor and captopril w/ ^'ing doses. good uop.id: on flagyl and levo for aspiration. CONTS ON REGLAN. paps 30s/.sm soft hematoma. lido dc'd this am. bp low this am and req 500ccns bolus this am to stabilize. Occ dry NPC.ID afebrile 99.7R WBC 6.9 on triple abx.GI- NGT replaced for meds and tube feedings. Keep pt negative.Start reglan. TOLERATING CAPTO/LOPRESSOR. advance tf as tol. cont w/ r fem venous/pa line. am K+ pnd. U/O adequate prior to low BP's. Fentanyl and Ativan weaned today. cont on levo and flagyl.neuro: ativan weaned down this am, pt became more active, mae with good strength but nonpurposeful. Resp. U/O adequate, > 40cc/hr.GI: Abd soft and distended with normoactive BS's. resp exam. NSR WO ECTO. Continue to advance as tolerated and guiac stools.ENDO: Insuling gtt decreased to 2u/hr. sxn'd for mod amt drk tan sputum. PERL R>L. Pt then transferred to ER where started on Lido gtt and given occasional Versed and Ativan. Tm 101.1 and Tc 99.6. Started on Reglan QID for ? Given AM dose of NPH.ID: Low grade temps. cont with cspine precautions. anoxia. lobe was found to be inflated and lavaged for mod purulent sputum.gi: abd soft, +bs. Recieved NS bolus total of 1.5L and BP recovering. FOLLOW BS-ADJUST/DC GTT AS INDICATED. residuals. FS ranging 187-267.Following FS q1h. ENDO=BL SUGARS TRENDING DOWN. remains +3l since admit. GI=TF @ 10ML/HR W MINIMAL RESIDUALS. cpt as tol. wean o2 as tol. will req eps, poss device prior to d/c. Tmax 102.6 rectal given Tylenol time two. Breathing unlabored overnoc. Abg's within normal limits. BS PRESENT. BREATH SOUNDS=COURSE THROUGHOUT. borderline oxygenation. Since 0300 pt somolent. home for eve now.a: bp stable s/p fluid this am. Resp Careremains intub/vented ac mode. LIMITED STM, NEEDING FREQUENT REMINDING/ RE ORIENTATION. +BS. Given Tylenol ATC. ADEQ UO. pt remains sedated currently on 1mg ativan/hr. BP when recieved from CL hypertensive. 4.77. right groin swan dc'd and tip sent for cx. was previously on oral .gu: foley. HR 88-110 NSR with occ isolated PVC's K+ 40meq KCL po x1 repeat 3.2. \"O: MS: Lethargic and oriented to self and place. pulses 2+/ bilat.integrillin cont at 16cc/hr. 10.6/C.I. ABG: 88/35/7.45. Good abgs as per flow. cont w/ low grade temps. PERL. CO/CI/MV 3.0/1.67/57. to adding additional antihypertensive on board.RESP:LS course on left and clear on right. PAD 12-24 overnoc. Integ at 16mls at to dc at 2200.K and Mg repleted.NEURO: Sedated and intubated. ota. delayed gastric emptying. Draining CYU. Attempted to wean Nitro. Fentanyl further weaned to 65ugs. ccu npn 11p-7aS: intubated and sedatedO: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 70-80 NSR, no vea noted."},"n_notes":{"kind":"number","value":39,"string":"39"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":70951,"text":"PATIENT/TEST INFORMATION:\nIndication: s/p VF arrest, LAD stent, hypotension\nHeight: (in) 73\nWeight (lb): 209\nBSA (m2): 2.19 m2\nBP (mm Hg): 127/90\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 11:34\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. 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. There is moderate\nregional left ventricular systolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -\nhypokinetic; anterior apex - hypokinetic; septal apex - hypokinetic; inferior\napex - hypokinetic; apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\nmitral regurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nThere is moderate regional left ventricular systolic dysfunction. Resting\nregional wall motion abnormalities include severe hypokinesis of the mid and\ndistal septum and apical segments. Right ventricular chamber size and free\nwall motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are mildly thickened. The mitral valve leaflets are mildly\nthickened. There is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2144-04-08 00:00:00.000","description":"Report","row_id":160019,"text":"Normal sinus rhythm. Q waves in leads III and aVF suggest inferior myocardial\ninfarction. Compared to tracing #1, the Q waves in the inferior leads are now\napparent. The ST segment depressions in the anterior leads has resolved.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2144-04-08 00:00:00.000","description":"Report","row_id":160020,"text":"Sinus tachycardia. Low limb lead voltage. RSR' pattern in leads V1-V2.\nST segment depressions in the anterior leads suggest possible anterior\nischemia. No previous tracing available for comparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2144-04-15 00:00:00.000","description":"Report","row_id":160013,"text":"Sinus rhythm\nProbable old inferior infarct\nAnteroseptal T wave changes may be due to myocardial ischemia\nLow QRS voltages in precordial leads\nSince previous tracing, , no ventricular premature complex\n\n"},{"category":"ECG","chartdate":"2144-04-14 00:00:00.000","description":"Report","row_id":160014,"text":"Sinus rhythm\n- premature ventricular contractions\nOld inferior infarct\nAnterior T wave changes are nonspecific\nRhythm strip shows normal sinus rhythm\nSince previous tracing, , ventricular premature complex seen\n\n"},{"category":"ECG","chartdate":"2144-04-13 00:00:00.000","description":"Report","row_id":160015,"text":"Sinus rhythm\nPossible old inferior infarct\nSince previous tracing, , no significant change\n\n"},{"category":"ECG","chartdate":"2144-04-12 00:00:00.000","description":"Report","row_id":160016,"text":"Sinus rhythm, rate 77. Since the previous tracing of the heart rate has\nslowed somewhat. Technical artifacts are seen. Increased ST-T wave\nabnormalities are noted, particularly over the anterolateral leads.\n\n"},{"category":"ECG","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":160017,"text":"Normal sinus rhythm. T wave flattening in leads III, aVF and V4-V6 suggest\npossible inferolateral ischemia. Compared to tracing #3, the inferolateral\nT wave flattening is new.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2144-04-08 00:00:00.000","description":"Report","row_id":160018,"text":"Normal sinus rhythm. Compared to tracing #2, the Q waves in the inferior leads\nare no longer present.\nTRACING #2\n\n"},{"category":"Radiology","chartdate":"2144-04-09 00:00:00.000","description":"C-SPINE (PORTABLE)","row_id":756196,"text":" 2:38 PM\n C-SPINE (PORTABLE) Clip # \n Reason: please r/o fracture; please focus on c7/t1 as previuos films\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p vfib arrest and fall with head and face trauma\n REASON FOR THIS EXAMINATION:\n please r/o fracture; please focus on c7/t1 as previuos films missed this\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57 y/o man status post V-fib arrest and fall with head trauma.\n\n Single lateral swimmer's view of the cervical spine is read in conjunction\n with AP and lateral cervical spine from earlier the same day. The cervical\n spine is normal in alignment through C7 without evidence of fracture. C7-T1 is\n not adequately visualized.\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756136,"text":" 11:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. ch\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest, now intubated and stable\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. check for ETT\n placement and PAC placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P pulmonary artery catheter placement and ventricular\n fibrillation arrest.\n\n COMPARISONS: .\n\n CHEST, SINGLE: The heart size is within the upper limits of normal. The\n mediastinal and hilar contours are stable in appearance. There is increased\n bilateral perihilar haziness and alveolar opacities. The left costophrenic\n angle has been excluded from this study. There is opacification of the left\n retrocardiac space. An endotracheal tube it is approximately 5 cm above the\n carina. The nasogastric tube tip distended below the field of view. The\n apparent Swan-Ganz catheter tip lies in the right ventricular outflow tract.\n The osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. New pulmonary edema.\n\n 2. Swan-Ganz catheter in right ventricular outflow tract.\n\n 3. Left lower lobe consolidation.\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"C-SPINE (PORTABLE)","row_id":756137,"text":" 11:44 PM\n C-SPINE (PORTABLE) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. Fo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Found down, in\n cervical collar, need to clear c-spine.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unconscious, evaluate cervical spine.\n\n AP AND LATERAL CERVICAL SPINE: Vertebral bodies C1 through C6 are visualized.\n There is normal alignment and vertebral body and disc heights. The\n prevertebral soft tissues cannot be evaluated due to intubation and NG tube\n placement. No fractures or dislocations identified. The frontal view is\n unremarkable.\n\n IMPRESSION: C1 through C6 in normal alignment without evidence of fracture.\n C7 is not visualized on the study.\n\n"},{"category":"Radiology","chartdate":"2144-04-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756164,"text":" 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. As\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Assess for PAC\n placement, ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P V-fib arrest with pulmonary artery catheter and\n endotracheal tube placement.\n\n COMPARISONS: at \n\n CHEST, SINGLE: The cardiac, mediastinal and hilar contours are stable in\n appearance. There has been slight interval improvement in the perhilar and\n predominantly central pulmonary alveolar opacities. There is persistent\n opacification of the left lower lobe with a small left pleural effusion. The\n endotracheal tube tip is approximately 5 cm above the carina. The Swan-Ganz\n catheter tip is in the right ventricular outflow tract. Nasogastric tube tip\n overlies the proximal stomach with the side port at the level of the\n diaphgram. The soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Slight improvement in the pulmonary edema.\n\n Nasogastric tube side port at the level of the diaphragm, recommend advancing\n this by several cm.\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"CHEST CTA WITH CONTRAST","row_id":756122,"text":" 7:52 PM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o pe\n Field of view: 47 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cardiac arrest, ? pe\n REASON FOR THIS EXAMINATION:\n r/o pe\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac arrest, ? of PE\n\n TECHNIQUE: Multiple axial images were obtained from the thoracic inlet from\n the lung basis after the administration of intravenous contrast.\n\n CONTRAST: 100cc of Optiray were administered due to the fast bolus\n requirements: There were no complications.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The heart and great vessels are grossly\n normal in appearance. No intraluminal filling defects are seen within the\n pulmonary circulation. An NG tube is seen passing into the esophagus. There\n is complete collapse of the left lower lobe. Atelectasis and diffuse\n parenchymal opacification are seen at the right lower lobe and posterior right\n middle lobe, findings consistent with aspiration. There is a high attenuation\n nodular density in the peripheral right middle lobe, which may represent a\n granuloma versus a small enhancing nodule. There are no pleural effusions. No\n pneumothoraces are identified. An ET tube is seen terminating in the trachea\n just below the thoracic inlet. A few scattered mediastinal lymph nodes do not\n meet CT criteria for pathologic enlargement.\n\n Multiplanar reformatted images confirm the above findings.\n\n The soft tissues and osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n 2. Total collapse of left lower lobe.\n 3. Multifocal areas of atelectasis and probable aspiration.\n 4. Nodule or granuloma of right middle lobe.\n\n"},{"category":"Radiology","chartdate":"2144-04-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756351,"text":" 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate NG placement before starting TF/PO meds\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 yo male a/w VF arrest, now extubated, replaced NGT. Need to start TF.\n REASON FOR THIS EXAMINATION:\n evaluate NG placement before starting TF/PO meds\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: V-fib arrest. Now extubated. Replaced NG tube. Assess NG tube\n placement before starting tube feeds.\n\n PORTABLE AP CHEST: Comparison . The patient is rotated. There has been\n interval removal of the ET tube. There is an NG tube with tip in the stomach\n and sideport just below the level of the diaphragm. The heart is enlarged.\n There are bilateral patchy alveolar opacities throughout the lungs, without\n significant change. This likely reflects edema, although multifocal infection\n could also have this appearance.\n\n\n"},{"category":"Radiology","chartdate":"2144-04-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756245,"text":" 10:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate ETT placement and lung parenchyma for state of CHF.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n Evaluate ETT placement and lung parenchyma for state of CHF.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate endotracheal tube placement and CHF.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: Allowing for technique and patient rotation, the\n bilateral diffuse pulmonary alveolar opacities are unchanged. The\n cardiomediastinal and hilar contours are unremarkable. The endotracheal tube\n tip is approximately 8 cm above the carina. The nasogastric tube overlies the\n stomach but the side port is above the diaphragm. The soft-tissue and osseous\n structures are unremarkable.\n\n IMPRESSION:\n\n 1) High-lying endotracheal tube, terminating 8 cm above carina.\n\n 2) No significant change in CHF.\n\n 3) Nasogastric tube side port above the level of the diaphragm.\n\n"},{"category":"Radiology","chartdate":"2144-04-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756469,"text":" 2:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, worsening CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 yo male a/w VF arrest, ? aspiration, now extubated, spiking fevers on\n levo/flagyl. r/o worsening infiltrates.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, worsening CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: V fib at rest. Extubated and spiking fevers.\n\n COMPARISONS: .\n\n AP PORTABLE UPRIGHT CHEST: The left costophrenic angle is excluded. Lung\n volumes appear slightly improved and the left lung has nearly completely\n cleared in the interval. There is persistent, though lessened, patchy opacity\n in the right perihilar region compatible with resolving pneumonia. The NG\n tube may have been retracted in the interval and the side port is not well\n visualized and may sit above the GE junction. Cardiac and mediastinal\n contours are unchanged.\n\n IMPRESSION: Improving multifocal pneumonia. NG tube probable malpositioned.\n\n"},{"category":"Radiology","chartdate":"2144-04-17 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":756781,"text":" 1:34 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pt had a left sided picc placed and needs tip confimation, p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p cardiac arrest, bacterimia who needs picc for iv\n vanco.\n REASON FOR THIS EXAMINATION:\n pt had a left sided picc placed and needs tip confimation, please page \n with wet, read,asap because they would like to d/c pt. to rehab., thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac arrest, PICC line placement.\n\n TECHNIQUE: Single view chest: This film is dated and it now\n comes to the radiology list for dictation. There has been a PICC line placed\n and is seen at the lower SVC. There is basilar atelectasis on the left.\n\n No pneumothorax is present.\n\n PICC line seen at the lower SVC. No pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2144-04-18 00:00:00.000","description":"R US EXTREMITY NONVASCULAR RIGHT","row_id":756858,"text":" 2:42 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: SWOLLEN RED RT ANTECUB FOSSA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p VF arrest, with MRSA bacteremia likely 2' to infection in\n right anticubital fossa, ruled out abscess.\n REASON FOR THIS EXAMINATION:\n r/o abscesss in right antecubital fossa\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA bacteremia with infection in right antecubital fossa.\n Evaluate for abscess.\n\n Targeted scale, Doppler and color images were obtained within the\n antecubital fossa. There is no evidence of a discrete fluid collection. The\n right cephalic vein is occluded with thrombus. There is no evidence of\n Doppler flow.\n\n IMPRESSION:\n 1. No discrete fluid collection to suggest abscess formation. There are soft\n tissue changes consistent with cellulitis.\n 2. Thrombus within the superficial cephalic vein.\n\n These findings were directly communicated to the physician caring for the\n patient.\n\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756114,"text":" 6:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest, now intubated and stable\n REASON FOR THIS EXAMINATION:\n eval for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post cardiac arrest, now intubated and stable. Evaluate tube\n placement.\n\n FINDINGS: The tip of the endotracheal tube is seen at the level of the\n thoracic inlet, approximately 7 cm above the carina. The tip of a nasogastric\n tube is seen just distal to the GE junction, with the side port likely within\n the distal esophagus. Evaluation of the mediastinum and lungs is somewhat\n limited secondary to the overlying trauma board, patient motion and a cardiac\n pacer seen overlying the left lateral/lower hemithorax. The cardiac and\n mediastinal contours appear within normal limits. There are no focal\n consolidations or pleural effusions. The visualized soft-tissue and osseous\n structures are unremarkable.\n\n IMPRESSION: Endotracheal tube can be further advanced, with the tip now\n approximately 7 cm above the carina. Nasogastric tube can also be advanced,\n as the side port is now within the distal esophagus.\n\n\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":756117,"text":" 7:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p fall, with head trauma and bleeding\n REASON FOR THIS EXAMINATION:\n s/p trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Head trauma.\n\n TECHNIQUE: Multiple axial images were obtained from the foramen magnum to the\n cranial vertex without intravenous contrast.\n\n FINDINGS: There is some streak artifact from the underlying stiffener board.\n No intraaxial or extraaxial fluid collections or hemorrhages are identified.\n There is no shift of the normally midline structures, or mass effect. The CSF\n spaces are normal. No definite sulcal effacement is seen.\n\n Some mucoperiosteal thickening is seen within the visualized portions of the\n ethmoid sinuses. The orbits, soft tissues and osseous structures of the head\n are unremarkable.\n\n IMPRESSION:\n\n 1. No evidence of acute intracranial hemorrhage.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2144-04-14 00:00:00.000","description":"Report","row_id":1490840,"text":"CCU NSG PROGRESS NOTE.\nO:NEURO=A&O X2. COOPERATIVE. APPROPRIATE. VERY WEAK-ALL EXTREMETIES.\n PULM=BREATH SOUNDS=DEMINISHED/CLEAR THROUGHOUT. SATS MID 90'S.\n CV=HEMODY STABLE. NTG WEANED & DCED. TOLERATING CAPTO/LOPRESSOR.\n GI=SELF DCED NGT. TOLERATING CL LIQ-ABLE TO TAKE PO MEDS.\n GU=FOLEY. ADEQ UO.\n ID=LOW GRADE T. R-ANTECUB NOTE TO REDDENED/WARM/HARD TO TOUCH-WO CO DISCOMFORT.\n LABS=AM SENT.\n\nA:IMPROVING.\n\nP:CALL-OUT. CONTIN PRESENT MED MANAGEMENT.\n\n\n"},{"category":"Nursing/other","chartdate":"2144-04-14 00:00:00.000","description":"Report","row_id":1490841,"text":"ccu nursing progress note\ns: i had a heart attack\no: pls see carevue flowsheet for complete vs/data/events.\npls see transfer note from for complete details.\nneuro: improving. not agitated or confused. ox , cooperative. has poor stm. haldol dc'd.\nremains weak in arms and legs req 2 person pivot/transfer. req assistance w/ feeding. also needs monitoring for aspiration but appears to be doing well with pills, jello, liquids when sitiing up.\ncv: hr 80-90s sr, bp 120-160/70. tol lopressor and captopril w/ ^'ing doses. not on antiarrhythmics. will req eps, poss device prior to d/c. no vea since admit.\nresp: ra sat 93-95%, rr 24-30. bs coarse/dim at bases.\ngi: tol diet, to advance. aspiration precautions. no stool.\nendo: covered per ss and nph. was previously on oral .\ngu: foley. good uop.\nid: on flagyl and levo for aspiration. cont w/ low grade temps. also has mild cellulitus at r antecub.\nsocial: married, 3 children. lives on . works for health care/home care co.\na: s/p arrest c/b anoxic brain injury and aspiration pneumonia. s/p stent to lad.\np: cont to follow rhythm, response to cardiac meds. resp exam. advance diet. follow bs. follow ms. pt and ot. may need rehab stay. support to pt and family. transfer to 2 when bed avail.\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490824,"text":"Respiratory Care: Pt recieved from cath lab put on AC 750*16 100% 10 PEEP. Pt had likely aspirated pao2 was poor ( 83 on 100% and 10 peep). Pao2 improved( see careview) Fio2 weaned to 60%. EET advanced from 22 to 25 MD verbal order. Bs equal bilat. Will continue to follow and wean Fio2 as tollerated.\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490825,"text":"CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\nHPI/CC: 57 year old male with limited medical history available found down , flat on face. According to friends he was feeling well during the day, no c/o nausea, CP, and SOB. Was then walking and suddenly collapsed, no convulsions noted. When EMT's arrived, police officer doing CPR and pt unconscious, pulseless, and agonal respirations and blood from mouth and nares. Pt shocked with 200J in AIVR without pulses. Intubated in field. Atropine given and pt in CHB with a ventricular rate of at 150. EKG in field showing changes in lateral leads. Pt then transferred to ER where started on Lido gtt and given occasional Versed and Ativan. Moving all extremeties and coughing while intubated. Prior to passing OGT pt vomitted large amount dark brown material and chunks of food. During assessment by house staff O2Sats marginal at 88-90% on 100% Fio2. Pt was suctioned numerous time for copious amounts of food particles from ETT. Pt then taken for Head CT which was (-) for intracranial hemmorhage but showing some white and matter.? anoxia. Chest CT also done in addition which was (-) for PE and showing LLL consolidation. Post pt taken for Cath.\n\nCATH LAB: Cath procedure performed without difficulty with the following findings. LHC: RA 26, PA, 42/19, PA 20, CO 8.19 and CI 3.65\nLAD mod calcified, 90% mid occlusion involving moderate DZ. LAD stented times two. TIMI flow of 3 prior to intervention and post. RCA with diffuse dz 70%. and LMCA normal.\n\nID: Febrile. Tmax 102.6 rectal given Tylenol time two. Last given at 0600. Called for cooling blanket. Levo and Flagyl started this AM\nWBC from MN labs down from admission to 3(11).\n\nCV: HR 100's to 110's with rare PVC's. Given total of 10mg of Lopressor in Cath Lab. Repeat doses given aroung MN of 5mg x two and 25mg PO. HR maintaining 88 to low 90's. In addition Lidocaine continuing at 2mg/hr. BP when recieved from CL hypertensive. Given Versed and Verc in transit to floor shortly after pt awakening. Given 2 of Ativan and 50 of Fentanyl and BP bottoming. Recieved NS bolus total of 1.5L and BP recovering. Since has been labile and recieving additional numerous boluses. SBP 80-90's with map > 65. A-V sheath in place with femoral swan at venous site. PAD 12-24 overnoc. Swan unable to wedge. Recv'd 20mg of Lasix post boluses and numbers repeated 1-2hours post. CO/CI/MV 3.0/1.67/57. ? validity of swan because could not visualize in . Femoral site with small ooze and no noted hematoma. Pulses palpable distal. Integ at 16mls at to dc at 2200.\nK and Mg repleted.\n\nNEURO: Sedated and intubated. Ativan at 2mg/hr. Currently unresponsive. Earlier durin night began to awake and moving right extremety only. PERL. 3mm bilaterally. Corneal reflex (+) in left eye only. Right pupil less sluggish than left. Not moving any extremeties.\nFentanyl gtt off due to labile BP's\n\nRESP: Current vent setting at AC 750 x 16 .50 and 7.5 PEEP. When recieved from CL suctioning for copious amounts\n"},{"category":"Nursing/other","chartdate":"2144-04-10 00:00:00.000","description":"Report","row_id":1490829,"text":"CCU NSG PROGRESS NOTE.\nO:NEURO=SEDATED W FENTANYL @ 50MCG & ATIVAN @ 1MG CONTIN W GD EFFECT. AROUSABLE, BUT DOES NOT FOLLOW COMMANDS. WHEN STIM MOVEMENT OF UPPER BODY-SHOULDERS, NECK, & HEAD-ONLY!.\n PULM=INTUBATED & VENTED W SETTINGS-AC/50%/750X16/+7.5 W AM ABG-7.50/31/71/25/1 W SATS 97-98. RR DECREASED FROM 16 TO 12. BREATH SOUNDS=COURSE THROUGHOUT. SX-SCANT THICK TAN/BROWN SECRETIONS.\n CV=HEMODY STABLE. NSR WO ECTO. MAPS 70-80'S. PADS 16-18. CKS SENT @ 0000 & 0500.\n GI=TF @ 10ML/HR W MINIMAL RESIDUALS. WO STOOL.\n ID=FOLEY. LASIX 80MG @ 0000 W EXCELLENT RESPONSE.\n ENDO=BL SUGARS TRENDING DOWN. INSULIN GTT DECREASED TO 1U/HR W BL SUGAR 102.\n MISC=COLLAR/NECK CARE DONE.\n LABS=AM SENT.\n\nA:COMFORTABLE THROUGHOUT NIGHT.\n\nP:CONTIN PRESENT MED RX. ADEQ SEDATION. INCREASE TF AS TOLERATED. FOLLOW BS-ADJUST/DC GTT AS INDICATED. CK AM LABS-REPLACE AS NEEDED.\nSUPPORT PT/FAMILY.\n"},{"category":"Nursing/other","chartdate":"2144-04-10 00:00:00.000","description":"Report","row_id":1490830,"text":"Resp Care\nremains intub/vented ac mode. resp alkalosis thus vent changed to rate 12 ...settings 750x12x.5/7.5 peep. borderline oxygenation. small amts secretions..orangey/brown. stable plateaus. ?increase peep. c/w vent support.\n"},{"category":"Nursing/other","chartdate":"2144-04-10 00:00:00.000","description":"Report","row_id":1490831,"text":"CCU NURSING PROGRESS NOTE 7A-3P\n\nNEURO: Pt sedated on fentanyl and ativan gtts. PERL 3mm. Pt intermittently able to open eyes and wiggle toes to command; no purposeful movements noted of upper extremities. Ativan gtt dc'd at 1pm. Will cont to assess neuro status for changes. C-spine collar in place.\n\nRESP: Intubated on AC 750x12 with peep weaned to 5 and Fio2 weaned to 40%. ABG: 88/35/7.45. Suctioned for minimal amt thin tan secretions.\nPlan is to begin weaning sedation today and based on neuro status, aiming for vent weaning/extubation tomorrow.\n\nCARDIAC: Hemodynamically stable. No VEA. C.O. 10.6/C.I. 4.77. right groin swan dc'd and tip sent for cx. Pt started on 12.5mg captopril TID. CPKs trending down.\n\nGI: Pt with minimal OG aspirates. Tube feeds advanced to 30cc/hr with goal rate of 80cc/hr. +BS. No stool this shift.\n\nGU: foley draining cloudy yellow urine with sediment. Pt is -1200cc at this time. No plans for further diuresis at this time.\n\nENDO: FS range 138-180. Conts on insulin gtt 1-3u/hr.\n\nID: afebrile all shift on RTC tylenol. Conts on IV abx for presumed aspiration pnx.\n\nACCESS; Right a-line and 3 peripheral IVs intact and working well.\n\nFAMILY: Pt's 2 daughters and wife in and out most of afternoon. Appear to be asking appropriate questions. Pt's oldest daughter, has agreed to be spokesperson for all phone calls. Cardiology fellow has spoken to family and informed them of pt's progress and present status.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2144-04-11 00:00:00.000","description":"Report","row_id":1490832,"text":"CCU Nursing Note 1500-2300: Vfib Arrest, Aspirat PNA\nID: Low grade temps. Recieving Tylenol ATC with fair effect and continues on IV Abx for aspiration PNA.\n\nMS: Sedated and intubated. Fentanyl and Ativan weaned today. Recieved at 1500 with Ativan off and Fentanyl at 75ugs. Fentanyl further weaned to 65ugs. Pt now flailing in bed. MAE's. Not obeying or following commands. Moving neck from side to side. Started on Propofol at 10ugs and increased to 20ugs with excellent effect.\n\nCV: VSS. transiently dropping BP to high 90's with sedation titration.\nHR 80's. NSR with no ectopy. SBP 99-mid 100's. Hypertensive when aroused. Right femoral site with small hematoma and slight ooze but has decreased further into night. Pulses palpable distal. Skin clamy and warm to touch.\n\nRESP: LS course with occasional rhoncerous sounds throughout. O2Sats high 90's. Vent settings at AC 750/12/50/5 PEEP. No ABGs' done this shift due to the prior being WNL. Suctioning for moderate to large amounts of thick dark tan sputum, ? food particles. During period of flaling pt found not to be recieving TV's. Resp notified and pt biting on tube. Sedation administerd.\n\nGU: Foley patent, intact and draining golden colored urine. Received pt with sediment on walls of the foley tubing but not draining urine with sediment. U/O adequate, > 40cc/hr.\n\nGI: Abd soft and distended with normoactive BS's. TF increased to 40cc/hr but shut off when pt found not to be recieving volumes and since have not been shut back on. When increased found to have residual of 10cc. OGT intact and in place. Passing flatus but no BM's this shift.\n\nENDO: Insulin gtt continues at 3u/hr. FS ordered Q1H but have been checking 1-3hrs. FS range from 120-140's. No adjustments made this shift.\n\nSKIN: Facial and knee lacerations open to air. Cleansed this shift with NS and applied bactroban to wounds. Upper back area where C-collar rested are red and open abrasions. No drainage. Cleansed with NS and left open to air.\n\nDISPO: 57 year-old man who is S/P VF arrest with a guestimated time out of 4 minutes prior to EMS intervention who had emergent PTCA and stented x two the LAD. Pt course then c/b aspiration pna where he remains vented and sedated.\n\nPLAN:\nTitrate sedation to keep pt comfortable\nPossible re-trial of weaning sedation in AM to assess MS further\nContinue BB and ACE as tolerated\nMonitor skin\nDiscuss possible anticoagulation\nContinue to monitor hemodynamics\n\n"},{"category":"Nursing/other","chartdate":"2144-04-11 00:00:00.000","description":"Report","row_id":1490833,"text":"Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 750, A/C 12, Fio2 40%, and Peep 5. PAP/Plateau 22/19. Bs slightly coarse L Lung, R Lung clear. Sx'd/lavaged for sm amounts of thick tan sputum. Abg's within normal limits. Pt. remains sedated. ETT retaped at 26cm. No further changes made. Continue with mechanical support.\n"},{"category":"Nursing/other","chartdate":"2144-04-12 00:00:00.000","description":"Report","row_id":1490836,"text":"CCU Nursing Note 1900-0700: S/P VFib Arrest/ Aspir P\nSee carevue for VSS and all objective data:\nS: Pt moaning and groaning.\n\nID: Afebrile. Given Tylenol ATC. Continues on IV Flagyl and Levo.\n\nMS: Still not obeying and following commands. Moving head from side to side and moving all extremeties in bed. Opened eyes once during shift but not to command. Neck and limbs remain flacid while on Propofol. Propofol attempted to wean but pt very restless. Given Haldol 5mg at HS and QID ATC. Since 0300 pt somolent. Needed emotional support and positive re-inforcement.\n\nCV: NSR-ST. Hypertensive and tachycardic when restless. Given Captopril and Lopressor with good effect. Nitro off due to low BP. QT interval checked at 0.16. Since 0300 has been NSR, HR 70's and BP 120-130's. Continue to BB and ACE-I as needed.\n\n\nRESP: LS course. FM weaned to .50 Fio2. CPT. Deep oral suctioned for blood-tan colored sputum. O2Sats 97-99%. Breathing unlabored. Continue CPT and sx as needed.\n\nGU/GI: Urine outputs adequate, >/= 60cc/hr. TF restarted at 0400 at 30cc/hr. Prior to residual 5cc. No residual checked since started.\nLarge BM tonoc. Soft-paste like consistency, brown in color. Guiac not checked. Continue to advance as tolerated and guiac stools.\n\nENDO: Insuling gtt decreased to 2u/hr. FS ranging from 77-98. Continue to monitor FS.\n\nSKIN: Cut and bruises open to air. Healing well. Continue to monitor.\n\nSOCIAL: Family into visit earlier during shift. No phone call overnoc.\n\nDISPO: 57 year-old male who s/p vfib arrest who arrest was c/b aspiration pna. Intubated and now extubated with new concern post extubation of anoxia.\n\nContinue to monitor.\n\n"},{"category":"Nursing/other","chartdate":"2144-04-12 00:00:00.000","description":"Report","row_id":1490837,"text":"CCU Nursing Progress Note\nS-\"I have a little headache\"\nO-Neuro becoming more awake during the day. Following commands , . Talking to family and staff. Mumbling most of the time, speech is not clear but understandable. Propofol weaned and d/c'd and haldol increased to 5mg QID. Family with pt mst of time but occ restlessness treated with IV haldol prn.\nCV-VSS IV NTG restarted with SBP 170's but weaned to 40mcg when captopril increased to 50mg TID BP 124-138/58-70 HR 79-90 NSR\nResp-O2 weaned to 5l NP with O2 sats 96% ABG 7.45/38/55 but O2 sats improved to 99-100% later in the am. LS coarse Occ NPC.\nID temp 101 IV abx changed over to po flagyl and levo.\nGU-urine output improved 100cc/hr and received lasix 40mg IVB with transfusion.\nGI-NGT in place tube feeds on hold d/t high residuals which remained most of the day. Possibly start reglan for gastricparesis. Incontinent of moderate amt of soft brown stool OB+. HCT 28 receiving 2nd unit of PRBC over 4hrs.\nEndo- Insulin 2u/hr gtt d/c'd adn started NPH 10u FS 121-156\nSOcial-family all in and aware of POC. Happy pt is conversant.\nA/P-Continue to adjust meds as tolerated. Keep pt negative.\nStart reglan. Follow electrolytes closely.\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490826,"text":"CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\n(Continued)\nof food particles. Now not raising anything from ETT. ETT tube advanced 4cm by resp. ABG improved. LS course. O2Sat 99-100%\n\nGU/GI:Foley patent and intact. Draining CYU. U/O adequate prior to low BP's. Currently making 30-500cc/hr for past 2hrs. HO aware. Abd firm and distended with normoactive BS's. OGT in place.\n\nENDO: Insulin gtt at 4u/hr per sliding scale. FS ranging 187-267.\nFollowing FS q1h.\n\n: Collar in place. Cspine film done at bedside last night. No injuries noted.\nCollar in place until pt awake or till trauma team clears\n\nPLAN:\nPossible removal of swans\nIntegrillin to dc at 2200\nContinue to follow neuro status\nContinue to monitor\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490827,"text":"Resp. Note\nPt remains on AC 16/750/7.5/50% No changes made today. Bronchoscopy done-poss food/foreign body aspiration. No particles found. Pt was sx today for brownish secretions throughtout the day. Will cont support.\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490828,"text":"ccu nursing progress note\ns: orally intubated\no: pls see carevue flowsheet for complete vs/data/events\nid: low grade temp. wbc nml. cont on levo and flagyl.\nneuro: ativan weaned down this am, pt became more active, mae with good strength but nonpurposeful. not able to open eyes or follow commands, did appear to respond to stimuli. in afternoon pt underwent bronch req ^'d sedation w/ fent and ativan. pt remains sedated currently on 1mg ativan/hr. no evidence of sz activity.\ncv: in sr rate 75-90s sr, no vea. lido dc'd this am. bp low this am and req 500ccns bolus this am to stabilize. remained 95-120/60-70 via r rad aline.\ntol lopressor later in am.\nr fem aline pulled. cont w/ r fem venous/pa line. paps 30s/.\nsm soft hematoma. pulses 2+/ bilat.\nintegrillin cont at 16cc/hr. to complete at 11pm.\nck up 1300, mb 19. will cont to cycle.\nresp: cont on a/c 750 x16. 50% and 7.5 peep. sats >95%. sxn'd for mod amt drk tan sputum. bronch'd this afternoon to eval ?collapse for lll. lobe was found to be inflated and lavaged for mod purulent sputum.\ngi: abd soft, +bs. no stool. min aspirates. tf started via ogt, promote w/ fiber at 10cc/hr. awaiting nutrition consult to confirm and set goal.\ngu: uop 30-50cc/hr. remains +3l since admit. will dose w/ lasix this eve. cr 1.4.\nskin: abrasion on face/chin. ota. some bruising underarms.\nremains w collar. cspine film taken this afternoon. has yet to be cleared.\nsocial: wife and children in today. updated. home for eve now.\na: bp stable s/p fluid this am. rhythm stable. neuro improving.\np: cont to monitor cv and neuro status. wean o2 as tol. cpt as tol. cont with cspine precautions. advance tf as tol. monitor fever and await cultures. support to pt and family.\n\n"},{"category":"Nursing/other","chartdate":"2144-04-11 00:00:00.000","description":"Report","row_id":1490834,"text":"ccu npn 11p-7a\nS: intubated and sedated\n\nO: Please see carevue for VS and objective data\n\nCVS: Hemodynamically stable with HR 70-80 NSR, no vea noted. K+ 3.6 repleted with 40meq po KCL. am K+ pnd. BP 107-150/50-60. Tolerated po Captopril and Lopressor.\n\nResp; Remains intubated and mechanically ventilated on A/C 750x12 40%/5 peep. Good abgs as per flow. Am abg 105/36/7.42/24/0. Suctioned q 3-4 hours for small-mod. amounts of tan sputum. Lungs coarse. Rare spont. breathe over vent. impaired gag and cough.\n\nID: low grade on IV Flaggyl and Levo.\n\nEndo: Regular Insulin drip titrated 3u-4u/hour for glucose ranges 118-192.\n\nGI:GU: TF Promote with fiber at 30cc/hour increased to 40cc/hour without sign. residuals. Abdomen soft and distended with active bowel sounds. No stool. Foley to drainage with dark yellow urine with sediment. I/O neg 700cc at MN, positive 400cc this am.\n\nNeuro: Remains sedated on IV Propofol, increased to 40mcg/kg/min. for restlessness. with good effect. MAE, moving head side to side. Not opening eyes or following commands. PERL R>L. 3mm. Soft hand restraints intact. Poor gag and weak cough.\n\nA: Hemodynamically stable s/p arrest. Remains sedated and intubated.\n\nP: Cont to assess hemodynamics. Cont aggressive pulmonary toileting. Sedation as needed. Cont. insulin drip with tube feedings. Assess neuro status. Comfort and emotional support to Pt. and family. Follow up with am labs.\n"},{"category":"Nursing/other","chartdate":"2144-04-11 00:00:00.000","description":"Report","row_id":1490835,"text":"CCU Nursing PRogress Note\nS-Delirious\nO-Neuro weaned off propofol by 1030 and added haldol 5mg x2 1 hr apart for persistant delirium with good effect. ALthough when IV haldol wore off (4hours) aggitation returned 1400 and required low dose propofol for pt saftey. Started po haldol 2.5mg QID started at 1800. Still requiring prn Haldol 2.5-5mg IVB. MAE very strong arms requiring wrist restraints. Opening eyes but not focusing or following commands.\nCV- hypertensive 160-180 with aggitation requiring IV NTG 200-300mcg. Lopessor increased to 50mg TID and captopril increased to 37.5mg TID.\nPlan to increase with each dose until desired effect. HR 88-110 NSR with occ isolated PVC's K+ 40meq KCL po x1 repeat 3.2. Radial aline replaced over a wire d/t brisk bleeding at site.\nResp-Vent changed over to PS 15/PEEP 5 with spont VT 500-800 rr 20-28. PS/PEEP weaned down to 5/5 and quicikly extubated by 1200 to 100% neb with O2 sats 92-100% Last ABG 7.41/42/81 at 1630 on 100% face tent.\nLS coarse with occ exp wheeze. Occ dry NPC.\nID afebrile 99.7R WBC 6.9 on triple abx.\nGI- NGT replaced for meds and tube feedings. Initial asp bile but after extubation coffee grounds OB+. Soft brown BM OB+. HCT 27.5 receiving 1uPRBC over 4 hours. Protonix\nTube feeds stopped for extubation and to be restarted this evening.\nGU-foley draining amber colored urine. Received lasix 40mg IVB with ~1200cc diuresis.\nSKin- pressure sores from neck immobilizer neck, shoulder blades and head cleansed and left open to air\nSocial- family all in and very supportive. Understanding POC\nA/P-succ extubated, s/p AMI stent\nPRN haldol for excessive aggitation, plan to wean off propofol when possible. CT scan Monday if MS unchanged.\nLAsix 40mg IVB PRN for low urine output.\nFollow electrolytes closely\n"},{"category":"Nursing/other","chartdate":"2144-04-13 00:00:00.000","description":"Report","row_id":1490838,"text":"CCU Nursing Note 1900-700: Vfib arrest, Aspir PNA\nS: \"I need to go to bathroom, I need to get up.\"\nO: MS: Lethargic and oriented to self and place. Speech less garbled and voices needs appropriately. Obeying and following simple commands.\nRestless and agitated overnoc needing repeative cues. Sleeping in spurts. Given 5mg every 2hr since MN with limited effect.\n\nCV:VSS stable overnoc. Still remains moderately hypertensive. Attempted to wean Nitro. High as 100ugs currently at 60ugs. Tolerating BB and ACEI titration. ? to adding additional antihypertensive on board.\n\nRESP:LS course on left and clear on right. O2Satt 95-99%/5l NC. Occasionally O2Sat dropping to 90-91& increased to 5L at 033O and has since remained > 95%. Breathing unlabored overnoc. (+) cough but nonproductive and assisted blowing nose with old blood secretions. NC changed over to humidified air.\n\nGU/GI: Foley draining amber colored urine. Urine outputs fair, >50cc/hr. Abd soft and distended. Moderate BM, guiac (+) soft and brown in appearance. TF up at MN at 10cc/hr prior to residual 50cc residual of bilious. Started on Reglan QID for ? delayed gastric emptying. At 0400 residual less that 5cc and TF advance to 20cc/hr. Next residual check at 0800. Given ice H2O overnoc for comfort.\n\nENDO: FS QID. Overnoc FS 125 and 136. Given AM dose of NPH.\n\nID: Low grade temps. Tm 101.1 and Tc 99.6. Given Tylenol 650mg x 2. Last at 0400.\n\nHEME: HCT 35 this AM.\n\nA/P:\nConsider possible PT/OT consult as MS continues to improve\nContinue repeative cues and emotional support\nConsider adding additonal antihypertensive in addition to ACE and BB\nContinue to monitor pulmonary status continue to wean O2\nAdvance TF's as tolerated.\nPossible transfer to floor. Transfer note in blue book.\n\n"},{"category":"Nursing/other","chartdate":"2144-04-13 00:00:00.000","description":"Report","row_id":1490839,"text":"CCU NURSING PROGRESS NOTE 3P- 11P\nS: WHEN CAN I GO HOME?\nO:\nCV: FOR A COMPLETE SET OF VS AND OBJECTIVE DATA PLEASE REFER TO CARE VUE FLOWSHEET. DENIES CP/ SOB WHEN ASKED. REMAINS IN SR , NO VEA NOTED. NITRO DECREASED TO 40 MCG AFTER 4 PM CATOPRIL DOSE. GIVEN LOPRESSOR DOSE EARLY AT 9 PM FOR HR OF 85 AND SBP 160. AWAITING RESULTS.\nRESP: LUNGS WITH CLEAR UPPER LOBES AND CKLS AT LOWER BASES. SATS 91 - 96%. CONTS ON 4L O2.\nGI/ GU: TF AT 20 CC/HOUR INITALLY. THEN RESIDUALS AT 8 PM NOTED TO BE >120. TF HELD AT PRESENT. PT IS ABLE TO SWALLOW PILLS WITH SIPS OF WATER. ? ABSORPTION. CONTS ON REGLAN. BS PRESENT. TWO SMALL SOFT GUIAC POS STOOLS NTED.\nMS: PT IS A&O TO PERSON AND PLACE. HE IS PLEASANT AND COOPERATIVE. LIMITED STM, NEEDING FREQUENT REMINDING/ RE ORIENTATION. DAUGHTERS IN ALL EVE. FAMILY VERY HELPFUL WITH CALMING/ REORIENTATION.\nA: APPEARS STABLE , BUT ? ABSORPTION OF MEDS OR NEED TO INCREASE DOSES, TRANSFER TO THE FLOOR\nP: CONT OT MONITOR, ? INCREASE DOSING OF LOPRESSOR/ CAROPRIL, AWAIT BED.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70951,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: s/p VF arrest, LAD stent, hypotension\\nHeight: (in) 73\\nWeight (lb): 209\\nBSA (m2): 2.19 m2\\nBP (mm Hg): 127/90\\nHR (bpm): 101\\nStatus: Inpatient\\nDate/Time: at 11:34\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. 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. There is moderate\\nregional left ventricular systolic dysfunction.\\n\\nLV WALL MOTION: The following resting regional left ventricular wall motion\\nabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -\\nhypokinetic; anterior apex - hypokinetic; septal apex - hypokinetic; inferior\\napex - hypokinetic; apex - hypokinetic;\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\\ndilated.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\\nmitral regurgitation is seen (within normal limits).\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\nThe left atrium is normal in size. The left ventricular cavity size is normal.\\nThere is moderate regional left ventricular systolic dysfunction. Resting\\nregional wall motion abnormalities include severe hypokinesis of the mid and\\ndistal septum and apical segments. Right ventricular chamber size and free\\nwall motion are normal. The ascending aorta is mildly dilated. The aortic\\nvalve leaflets are mildly thickened. The mitral valve leaflets are mildly\\nthickened. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160019,\n \"text\": \"Normal sinus rhythm. Q waves in leads III and aVF suggest inferior myocardial\\ninfarction. Compared to tracing #1, the Q waves in the inferior leads are now\\napparent. The ST segment depressions in the anterior leads has resolved.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160020,\n \"text\": \"Sinus tachycardia. Low limb lead voltage. RSR' pattern in leads V1-V2.\\nST segment depressions in the anterior leads suggest possible anterior\\nischemia. No previous tracing available for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160013,\n \"text\": \"Sinus rhythm\\nProbable old inferior infarct\\nAnteroseptal T wave changes may be due to myocardial ischemia\\nLow QRS voltages in precordial leads\\nSince previous tracing, , no ventricular premature complex\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160014,\n \"text\": \"Sinus rhythm\\n- premature ventricular contractions\\nOld inferior infarct\\nAnterior T wave changes are nonspecific\\nRhythm strip shows normal sinus rhythm\\nSince previous tracing, , ventricular premature complex seen\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160015,\n \"text\": \"Sinus rhythm\\nPossible old inferior infarct\\nSince previous tracing, , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160016,\n \"text\": \"Sinus rhythm, rate 77. Since the previous tracing of the heart rate has\\nslowed somewhat. Technical artifacts are seen. Increased ST-T wave\\nabnormalities are noted, particularly over the anterolateral leads.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160017,\n \"text\": \"Normal sinus rhythm. T wave flattening in leads III, aVF and V4-V6 suggest\\npossible inferolateral ischemia. Compared to tracing #3, the inferolateral\\nT wave flattening is new.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160018,\n \"text\": \"Normal sinus rhythm. Compared to tracing #2, the Q waves in the inferior leads\\nare no longer present.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"C-SPINE (PORTABLE)\",\n \"row_id\": 756196,\n \"text\": \" 2:38 PM\\n C-SPINE (PORTABLE) Clip # \\n Reason: please r/o fracture; please focus on c7/t1 as previuos films\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p vfib arrest and fall with head and face trauma\\n REASON FOR THIS EXAMINATION:\\n please r/o fracture; please focus on c7/t1 as previuos films missed this\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 57 y/o man status post V-fib arrest and fall with head trauma.\\n\\n Single lateral swimmer's view of the cervical spine is read in conjunction\\n with AP and lateral cervical spine from earlier the same day. The cervical\\n spine is normal in alignment through C7 without evidence of fracture. C7-T1 is\\n not adequately visualized.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756136,\n \"text\": \" 11:44 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. ch\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest, now intubated and stable\\n REASON FOR THIS EXAMINATION:\\n 57 y/o man intubated with PAC in place s/p v-fib arrest. check for ETT\\n placement and PAC placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: S/P pulmonary artery catheter placement and ventricular\\n fibrillation arrest.\\n\\n COMPARISONS: .\\n\\n CHEST, SINGLE: The heart size is within the upper limits of normal. The\\n mediastinal and hilar contours are stable in appearance. There is increased\\n bilateral perihilar haziness and alveolar opacities. The left costophrenic\\n angle has been excluded from this study. There is opacification of the left\\n retrocardiac space. An endotracheal tube it is approximately 5 cm above the\\n carina. The nasogastric tube tip distended below the field of view. The\\n apparent Swan-Ganz catheter tip lies in the right ventricular outflow tract.\\n The osseous structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. New pulmonary edema.\\n\\n 2. Swan-Ganz catheter in right ventricular outflow tract.\\n\\n 3. Left lower lobe consolidation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"C-SPINE (PORTABLE)\",\n \"row_id\": 756137,\n \"text\": \" 11:44 PM\\n C-SPINE (PORTABLE) Clip # \\n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. Fo\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest.\\n REASON FOR THIS EXAMINATION:\\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Found down, in\\n cervical collar, need to clear c-spine.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Found unconscious, evaluate cervical spine.\\n\\n AP AND LATERAL CERVICAL SPINE: Vertebral bodies C1 through C6 are visualized.\\n There is normal alignment and vertebral body and disc heights. The\\n prevertebral soft tissues cannot be evaluated due to intubation and NG tube\\n placement. No fractures or dislocations identified. The frontal view is\\n unremarkable.\\n\\n IMPRESSION: C1 through C6 in normal alignment without evidence of fracture.\\n C7 is not visualized on the study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756164,\n \"text\": \" 8:08 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. As\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest.\\n REASON FOR THIS EXAMINATION:\\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Assess for PAC\\n placement, ETT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: S/P V-fib arrest with pulmonary artery catheter and\\n endotracheal tube placement.\\n\\n COMPARISONS: at \\n\\n CHEST, SINGLE: The cardiac, mediastinal and hilar contours are stable in\\n appearance. There has been slight interval improvement in the perhilar and\\n predominantly central pulmonary alveolar opacities. There is persistent\\n opacification of the left lower lobe with a small left pleural effusion. The\\n endotracheal tube tip is approximately 5 cm above the carina. The Swan-Ganz\\n catheter tip is in the right ventricular outflow tract. Nasogastric tube tip\\n overlies the proximal stomach with the side port at the level of the\\n diaphgram. The soft tissue and osseous structures are unremarkable.\\n\\n IMPRESSION: Slight improvement in the pulmonary edema.\\n\\n Nasogastric tube side port at the level of the diaphragm, recommend advancing\\n this by several cm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"CHEST CTA WITH CONTRAST\",\n \"row_id\": 756122,\n \"text\": \" 7:52 PM\\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \\n Reason: r/o pe\\n Field of view: 47 Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with cardiac arrest, ? pe\\n REASON FOR THIS EXAMINATION:\\n r/o pe\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cardiac arrest, ? of PE\\n\\n TECHNIQUE: Multiple axial images were obtained from the thoracic inlet from\\n the lung basis after the administration of intravenous contrast.\\n\\n CONTRAST: 100cc of Optiray were administered due to the fast bolus\\n requirements: There were no complications.\\n\\n CT CHEST WITH INTRAVENOUS CONTRAST: The heart and great vessels are grossly\\n normal in appearance. No intraluminal filling defects are seen within the\\n pulmonary circulation. An NG tube is seen passing into the esophagus. There\\n is complete collapse of the left lower lobe. Atelectasis and diffuse\\n parenchymal opacification are seen at the right lower lobe and posterior right\\n middle lobe, findings consistent with aspiration. There is a high attenuation\\n nodular density in the peripheral right middle lobe, which may represent a\\n granuloma versus a small enhancing nodule. There are no pleural effusions. No\\n pneumothoraces are identified. An ET tube is seen terminating in the trachea\\n just below the thoracic inlet. A few scattered mediastinal lymph nodes do not\\n meet CT criteria for pathologic enlargement.\\n\\n Multiplanar reformatted images confirm the above findings.\\n\\n The soft tissues and osseous structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. No evidence of pulmonary embolism.\\n 2. Total collapse of left lower lobe.\\n 3. Multifocal areas of atelectasis and probable aspiration.\\n 4. Nodule or granuloma of right middle lobe.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756351,\n \"text\": \" 4:49 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate NG placement before starting TF/PO meds\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 yo male a/w VF arrest, now extubated, replaced NGT. Need to start TF.\\n REASON FOR THIS EXAMINATION:\\n evaluate NG placement before starting TF/PO meds\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: V-fib arrest. Now extubated. Replaced NG tube. Assess NG tube\\n placement before starting tube feeds.\\n\\n PORTABLE AP CHEST: Comparison . The patient is rotated. There has been\\n interval removal of the ET tube. There is an NG tube with tip in the stomach\\n and sideport just below the level of the diaphragm. The heart is enlarged.\\n There are bilateral patchy alveolar opacities throughout the lungs, without\\n significant change. This likely reflects edema, although multifocal infection\\n could also have this appearance.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756245,\n \"text\": \" 10:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate ETT placement and lung parenchyma for state of CHF.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest.\\n REASON FOR THIS EXAMINATION:\\n Evaluate ETT placement and lung parenchyma for state of CHF.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Evaluate endotracheal tube placement and CHF.\\n\\n COMPARISON: .\\n\\n CHEST, PA AND LATERAL: Allowing for technique and patient rotation, the\\n bilateral diffuse pulmonary alveolar opacities are unchanged. The\\n cardiomediastinal and hilar contours are unremarkable. The endotracheal tube\\n tip is approximately 8 cm above the carina. The nasogastric tube overlies the\\n stomach but the side port is above the diaphragm. The soft-tissue and osseous\\n structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1) High-lying endotracheal tube, terminating 8 cm above carina.\\n\\n 2) No significant change in CHF.\\n\\n 3) Nasogastric tube side port above the level of the diaphragm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756469,\n \"text\": \" 2:25 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate, worsening CHF\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 yo male a/w VF arrest, ? aspiration, now extubated, spiking fevers on\\n levo/flagyl. r/o worsening infiltrates.\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate, worsening CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: V fib at rest. Extubated and spiking fevers.\\n\\n COMPARISONS: .\\n\\n AP PORTABLE UPRIGHT CHEST: The left costophrenic angle is excluded. Lung\\n volumes appear slightly improved and the left lung has nearly completely\\n cleared in the interval. There is persistent, though lessened, patchy opacity\\n in the right perihilar region compatible with resolving pneumonia. The NG\\n tube may have been retracted in the interval and the side port is not well\\n visualized and may sit above the GE junction. Cardiac and mediastinal\\n contours are unchanged.\\n\\n IMPRESSION: Improving multifocal pneumonia. NG tube probable malpositioned.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-17 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 756781,\n \"text\": \" 1:34 PM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: pt had a left sided picc placed and needs tip confimation, p\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with s/p cardiac arrest, bacterimia who needs picc for iv\\n vanco.\\n REASON FOR THIS EXAMINATION:\\n pt had a left sided picc placed and needs tip confimation, please page \\n with wet, read,asap because they would like to d/c pt. to rehab., thanks.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cardiac arrest, PICC line placement.\\n\\n TECHNIQUE: Single view chest: This film is dated and it now\\n comes to the radiology list for dictation. There has been a PICC line placed\\n and is seen at the lower SVC. There is basilar atelectasis on the left.\\n\\n No pneumothorax is present.\\n\\n PICC line seen at the lower SVC. No pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-18 00:00:00.000\",\n \"description\": \"R US EXTREMITY NONVASCULAR RIGHT\",\n \"row_id\": 756858,\n \"text\": \" 2:42 PM\\n US EXTREMITY NONVASCULAR RIGHT Clip # \\n Reason: SWOLLEN RED RT ANTECUB FOSSA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p VF arrest, with MRSA bacteremia likely 2' to infection in\\n right anticubital fossa, ruled out abscess.\\n REASON FOR THIS EXAMINATION:\\n r/o abscesss in right antecubital fossa\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: MRSA bacteremia with infection in right antecubital fossa.\\n Evaluate for abscess.\\n\\n Targeted scale, Doppler and color images were obtained within the\\n antecubital fossa. There is no evidence of a discrete fluid collection. The\\n right cephalic vein is occluded with thrombus. There is no evidence of\\n Doppler flow.\\n\\n IMPRESSION:\\n 1. No discrete fluid collection to suggest abscess formation. There are soft\\n tissue changes consistent with cellulitis.\\n 2. Thrombus within the superficial cephalic vein.\\n\\n These findings were directly communicated to the physician caring for the\\n patient.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756114,\n \"text\": \" 6:13 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for tube placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest, now intubated and stable\\n REASON FOR THIS EXAMINATION:\\n eval for tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post cardiac arrest, now intubated and stable. Evaluate tube\\n placement.\\n\\n FINDINGS: The tip of the endotracheal tube is seen at the level of the\\n thoracic inlet, approximately 7 cm above the carina. The tip of a nasogastric\\n tube is seen just distal to the GE junction, with the side port likely within\\n the distal esophagus. Evaluation of the mediastinum and lungs is somewhat\\n limited secondary to the overlying trauma board, patient motion and a cardiac\\n pacer seen overlying the left lateral/lower hemithorax. The cardiac and\\n mediastinal contours appear within normal limits. There are no focal\\n consolidations or pleural effusions. The visualized soft-tissue and osseous\\n structures are unremarkable.\\n\\n IMPRESSION: Endotracheal tube can be further advanced, with the tip now\\n approximately 7 cm above the carina. Nasogastric tube can also be advanced,\\n as the side port is now within the distal esophagus.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 756117,\n \"text\": \" 7:00 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: s/p trauma\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p fall, with head trauma and bleeding\\n REASON FOR THIS EXAMINATION:\\n s/p trauma\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Head trauma.\\n\\n TECHNIQUE: Multiple axial images were obtained from the foramen magnum to the\\n cranial vertex without intravenous contrast.\\n\\n FINDINGS: There is some streak artifact from the underlying stiffener board.\\n No intraaxial or extraaxial fluid collections or hemorrhages are identified.\\n There is no shift of the normally midline structures, or mass effect. The CSF\\n spaces are normal. No definite sulcal effacement is seen.\\n\\n Some mucoperiosteal thickening is seen within the visualized portions of the\\n ethmoid sinuses. The orbits, soft tissues and osseous structures of the head\\n are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. No evidence of acute intracranial hemorrhage.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490840,\n \"text\": \"CCU NSG PROGRESS NOTE.\\nO:NEURO=A&O X2. COOPERATIVE. APPROPRIATE. VERY WEAK-ALL EXTREMETIES.\\n PULM=BREATH SOUNDS=DEMINISHED/CLEAR THROUGHOUT. SATS MID 90'S.\\n CV=HEMODY STABLE. NTG WEANED & DCED. TOLERATING CAPTO/LOPRESSOR.\\n GI=SELF DCED NGT. TOLERATING CL LIQ-ABLE TO TAKE PO MEDS.\\n GU=FOLEY. ADEQ UO.\\n ID=LOW GRADE T. R-ANTECUB NOTE TO REDDENED/WARM/HARD TO TOUCH-WO CO DISCOMFORT.\\n LABS=AM SENT.\\n\\nA:IMPROVING.\\n\\nP:CALL-OUT. CONTIN PRESENT MED MANAGEMENT.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490841,\n \"text\": \"ccu nursing progress note\\ns: i had a heart attack\\no: pls see carevue flowsheet for complete vs/data/events.\\npls see transfer note from for complete details.\\nneuro: improving. not agitated or confused. ox , cooperative. has poor stm. haldol dc'd.\\nremains weak in arms and legs req 2 person pivot/transfer. req assistance w/ feeding. also needs monitoring for aspiration but appears to be doing well with pills, jello, liquids when sitiing up.\\ncv: hr 80-90s sr, bp 120-160/70. tol lopressor and captopril w/ ^'ing doses. not on antiarrhythmics. will req eps, poss device prior to d/c. no vea since admit.\\nresp: ra sat 93-95%, rr 24-30. bs coarse/dim at bases.\\ngi: tol diet, to advance. aspiration precautions. no stool.\\nendo: covered per ss and nph. was previously on oral .\\ngu: foley. good uop.\\nid: on flagyl and levo for aspiration. cont w/ low grade temps. also has mild cellulitus at r antecub.\\nsocial: married, 3 children. lives on . works for health care/home care co.\\na: s/p arrest c/b anoxic brain injury and aspiration pneumonia. s/p stent to lad.\\np: cont to follow rhythm, response to cardiac meds. resp exam. advance diet. follow bs. follow ms. pt and ot. may need rehab stay. support to pt and family. transfer to 2 when bed avail.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490824,\n \"text\": \"Respiratory Care: Pt recieved from cath lab put on AC 750*16 100% 10 PEEP. Pt had likely aspirated pao2 was poor ( 83 on 100% and 10 peep). Pao2 improved( see careview) Fio2 weaned to 60%. EET advanced from 22 to 25 MD verbal order. Bs equal bilat. Will continue to follow and wean Fio2 as tollerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490825,\n \"text\": \"CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\\nHPI/CC: 57 year old male with limited medical history available found down , flat on face. According to friends he was feeling well during the day, no c/o nausea, CP, and SOB. Was then walking and suddenly collapsed, no convulsions noted. When EMT's arrived, police officer doing CPR and pt unconscious, pulseless, and agonal respirations and blood from mouth and nares. Pt shocked with 200J in AIVR without pulses. Intubated in field. Atropine given and pt in CHB with a ventricular rate of at 150. EKG in field showing changes in lateral leads. Pt then transferred to ER where started on Lido gtt and given occasional Versed and Ativan. Moving all extremeties and coughing while intubated. Prior to passing OGT pt vomitted large amount dark brown material and chunks of food. During assessment by house staff O2Sats marginal at 88-90% on 100% Fio2. Pt was suctioned numerous time for copious amounts of food particles from ETT. Pt then taken for Head CT which was (-) for intracranial hemmorhage but showing some white and matter.? anoxia. Chest CT also done in addition which was (-) for PE and showing LLL consolidation. Post pt taken for Cath.\\n\\nCATH LAB: Cath procedure performed without difficulty with the following findings. LHC: RA 26, PA, 42/19, PA 20, CO 8.19 and CI 3.65\\nLAD mod calcified, 90% mid occlusion involving moderate DZ. LAD stented times two. TIMI flow of 3 prior to intervention and post. RCA with diffuse dz 70%. and LMCA normal.\\n\\nID: Febrile. Tmax 102.6 rectal given Tylenol time two. Last given at 0600. Called for cooling blanket. Levo and Flagyl started this AM\\nWBC from MN labs down from admission to 3(11).\\n\\nCV: HR 100's to 110's with rare PVC's. Given total of 10mg of Lopressor in Cath Lab. Repeat doses given aroung MN of 5mg x two and 25mg PO. HR maintaining 88 to low 90's. In addition Lidocaine continuing at 2mg/hr. BP when recieved from CL hypertensive. Given Versed and Verc in transit to floor shortly after pt awakening. Given 2 of Ativan and 50 of Fentanyl and BP bottoming. Recieved NS bolus total of 1.5L and BP recovering. Since has been labile and recieving additional numerous boluses. SBP 80-90's with map > 65. A-V sheath in place with femoral swan at venous site. PAD 12-24 overnoc. Swan unable to wedge. Recv'd 20mg of Lasix post boluses and numbers repeated 1-2hours post. CO/CI/MV 3.0/1.67/57. ? validity of swan because could not visualize in . Femoral site with small ooze and no noted hematoma. Pulses palpable distal. Integ at 16mls at to dc at 2200.\\nK and Mg repleted.\\n\\nNEURO: Sedated and intubated. Ativan at 2mg/hr. Currently unresponsive. Earlier durin night began to awake and moving right extremety only. PERL. 3mm bilaterally. Corneal reflex (+) in left eye only. Right pupil less sluggish than left. Not moving any extremeties.\\nFentanyl gtt off due to labile BP's\\n\\nRESP: Current vent setting at AC 750 x 16 .50 and 7.5 PEEP. When recieved from CL suctioning for copious amounts\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490829,\n \"text\": \"CCU NSG PROGRESS NOTE.\\nO:NEURO=SEDATED W FENTANYL @ 50MCG & ATIVAN @ 1MG CONTIN W GD EFFECT. AROUSABLE, BUT DOES NOT FOLLOW COMMANDS. WHEN STIM MOVEMENT OF UPPER BODY-SHOULDERS, NECK, & HEAD-ONLY!.\\n PULM=INTUBATED & VENTED W SETTINGS-AC/50%/750X16/+7.5 W AM ABG-7.50/31/71/25/1 W SATS 97-98. RR DECREASED FROM 16 TO 12. BREATH SOUNDS=COURSE THROUGHOUT. SX-SCANT THICK TAN/BROWN SECRETIONS.\\n CV=HEMODY STABLE. NSR WO ECTO. MAPS 70-80'S. PADS 16-18. CKS SENT @ 0000 & 0500.\\n GI=TF @ 10ML/HR W MINIMAL RESIDUALS. WO STOOL.\\n ID=FOLEY. LASIX 80MG @ 0000 W EXCELLENT RESPONSE.\\n ENDO=BL SUGARS TRENDING DOWN. INSULIN GTT DECREASED TO 1U/HR W BL SUGAR 102.\\n MISC=COLLAR/NECK CARE DONE.\\n LABS=AM SENT.\\n\\nA:COMFORTABLE THROUGHOUT NIGHT.\\n\\nP:CONTIN PRESENT MED RX. ADEQ SEDATION. INCREASE TF AS TOLERATED. FOLLOW BS-ADJUST/DC GTT AS INDICATED. CK AM LABS-REPLACE AS NEEDED.\\nSUPPORT PT/FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490830,\n \"text\": \"Resp Care\\nremains intub/vented ac mode. resp alkalosis thus vent changed to rate 12 ...settings 750x12x.5/7.5 peep. borderline oxygenation. small amts secretions..orangey/brown. stable plateaus. ?increase peep. c/w vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490831,\n \"text\": \"CCU NURSING PROGRESS NOTE 7A-3P\\n\\nNEURO: Pt sedated on fentanyl and ativan gtts. PERL 3mm. Pt intermittently able to open eyes and wiggle toes to command; no purposeful movements noted of upper extremities. Ativan gtt dc'd at 1pm. Will cont to assess neuro status for changes. C-spine collar in place.\\n\\nRESP: Intubated on AC 750x12 with peep weaned to 5 and Fio2 weaned to 40%. ABG: 88/35/7.45. Suctioned for minimal amt thin tan secretions.\\nPlan is to begin weaning sedation today and based on neuro status, aiming for vent weaning/extubation tomorrow.\\n\\nCARDIAC: Hemodynamically stable. No VEA. C.O. 10.6/C.I. 4.77. right groin swan dc'd and tip sent for cx. Pt started on 12.5mg captopril TID. CPKs trending down.\\n\\nGI: Pt with minimal OG aspirates. Tube feeds advanced to 30cc/hr with goal rate of 80cc/hr. +BS. No stool this shift.\\n\\nGU: foley draining cloudy yellow urine with sediment. Pt is -1200cc at this time. No plans for further diuresis at this time.\\n\\nENDO: FS range 138-180. Conts on insulin gtt 1-3u/hr.\\n\\nID: afebrile all shift on RTC tylenol. Conts on IV abx for presumed aspiration pnx.\\n\\nACCESS; Right a-line and 3 peripheral IVs intact and working well.\\n\\nFAMILY: Pt's 2 daughters and wife in and out most of afternoon. Appear to be asking appropriate questions. Pt's oldest daughter, has agreed to be spokesperson for all phone calls. Cardiology fellow has spoken to family and informed them of pt's progress and present status.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490832,\n \"text\": \"CCU Nursing Note 1500-2300: Vfib Arrest, Aspirat PNA\\nID: Low grade temps. Recieving Tylenol ATC with fair effect and continues on IV Abx for aspiration PNA.\\n\\nMS: Sedated and intubated. Fentanyl and Ativan weaned today. Recieved at 1500 with Ativan off and Fentanyl at 75ugs. Fentanyl further weaned to 65ugs. Pt now flailing in bed. MAE's. Not obeying or following commands. Moving neck from side to side. Started on Propofol at 10ugs and increased to 20ugs with excellent effect.\\n\\nCV: VSS. transiently dropping BP to high 90's with sedation titration.\\nHR 80's. NSR with no ectopy. SBP 99-mid 100's. Hypertensive when aroused. Right femoral site with small hematoma and slight ooze but has decreased further into night. Pulses palpable distal. Skin clamy and warm to touch.\\n\\nRESP: LS course with occasional rhoncerous sounds throughout. O2Sats high 90's. Vent settings at AC 750/12/50/5 PEEP. No ABGs' done this shift due to the prior being WNL. Suctioning for moderate to large amounts of thick dark tan sputum, ? food particles. During period of flaling pt found not to be recieving TV's. Resp notified and pt biting on tube. Sedation administerd.\\n\\nGU: Foley patent, intact and draining golden colored urine. Received pt with sediment on walls of the foley tubing but not draining urine with sediment. U/O adequate, > 40cc/hr.\\n\\nGI: Abd soft and distended with normoactive BS's. TF increased to 40cc/hr but shut off when pt found not to be recieving volumes and since have not been shut back on. When increased found to have residual of 10cc. OGT intact and in place. Passing flatus but no BM's this shift.\\n\\nENDO: Insulin gtt continues at 3u/hr. FS ordered Q1H but have been checking 1-3hrs. FS range from 120-140's. No adjustments made this shift.\\n\\nSKIN: Facial and knee lacerations open to air. Cleansed this shift with NS and applied bactroban to wounds. Upper back area where C-collar rested are red and open abrasions. No drainage. Cleansed with NS and left open to air.\\n\\nDISPO: 57 year-old man who is S/P VF arrest with a guestimated time out of 4 minutes prior to EMS intervention who had emergent PTCA and stented x two the LAD. Pt course then c/b aspiration pna where he remains vented and sedated.\\n\\nPLAN:\\nTitrate sedation to keep pt comfortable\\nPossible re-trial of weaning sedation in AM to assess MS further\\nContinue BB and ACE as tolerated\\nMonitor skin\\nDiscuss possible anticoagulation\\nContinue to monitor hemodynamics\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490833,\n \"text\": \"Respiratory Care:\\n\\nPatient remains intubated on mechanical support. Vent settings Vt 750, A/C 12, Fio2 40%, and Peep 5. PAP/Plateau 22/19. Bs slightly coarse L Lung, R Lung clear. Sx'd/lavaged for sm amounts of thick tan sputum. Abg's within normal limits. Pt. remains sedated. ETT retaped at 26cm. No further changes made. Continue with mechanical support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490836,\n \"text\": \"CCU Nursing Note 1900-0700: S/P VFib Arrest/ Aspir P\\nSee carevue for VSS and all objective data:\\nS: Pt moaning and groaning.\\n\\nID: Afebrile. Given Tylenol ATC. Continues on IV Flagyl and Levo.\\n\\nMS: Still not obeying and following commands. Moving head from side to side and moving all extremeties in bed. Opened eyes once during shift but not to command. Neck and limbs remain flacid while on Propofol. Propofol attempted to wean but pt very restless. Given Haldol 5mg at HS and QID ATC. Since 0300 pt somolent. Needed emotional support and positive re-inforcement.\\n\\nCV: NSR-ST. Hypertensive and tachycardic when restless. Given Captopril and Lopressor with good effect. Nitro off due to low BP. QT interval checked at 0.16. Since 0300 has been NSR, HR 70's and BP 120-130's. Continue to BB and ACE-I as needed.\\n\\n\\nRESP: LS course. FM weaned to .50 Fio2. CPT. Deep oral suctioned for blood-tan colored sputum. O2Sats 97-99%. Breathing unlabored. Continue CPT and sx as needed.\\n\\nGU/GI: Urine outputs adequate, >/= 60cc/hr. TF restarted at 0400 at 30cc/hr. Prior to residual 5cc. No residual checked since started.\\nLarge BM tonoc. Soft-paste like consistency, brown in color. Guiac not checked. Continue to advance as tolerated and guiac stools.\\n\\nENDO: Insuling gtt decreased to 2u/hr. FS ranging from 77-98. Continue to monitor FS.\\n\\nSKIN: Cut and bruises open to air. Healing well. Continue to monitor.\\n\\nSOCIAL: Family into visit earlier during shift. No phone call overnoc.\\n\\nDISPO: 57 year-old male who s/p vfib arrest who arrest was c/b aspiration pna. Intubated and now extubated with new concern post extubation of anoxia.\\n\\nContinue to monitor.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490837,\n \"text\": \"CCU Nursing Progress Note\\nS-\\\"I have a little headache\\\"\\nO-Neuro becoming more awake during the day. Following commands , . Talking to family and staff. Mumbling most of the time, speech is not clear but understandable. Propofol weaned and d/c'd and haldol increased to 5mg QID. Family with pt mst of time but occ restlessness treated with IV haldol prn.\\nCV-VSS IV NTG restarted with SBP 170's but weaned to 40mcg when captopril increased to 50mg TID BP 124-138/58-70 HR 79-90 NSR\\nResp-O2 weaned to 5l NP with O2 sats 96% ABG 7.45/38/55 but O2 sats improved to 99-100% later in the am. LS coarse Occ NPC.\\nID temp 101 IV abx changed over to po flagyl and levo.\\nGU-urine output improved 100cc/hr and received lasix 40mg IVB with transfusion.\\nGI-NGT in place tube feeds on hold d/t high residuals which remained most of the day. Possibly start reglan for gastricparesis. Incontinent of moderate amt of soft brown stool OB+. HCT 28 receiving 2nd unit of PRBC over 4hrs.\\nEndo- Insulin 2u/hr gtt d/c'd adn started NPH 10u FS 121-156\\nSOcial-family all in and aware of POC. Happy pt is conversant.\\nA/P-Continue to adjust meds as tolerated. Keep pt negative.\\nStart reglan. Follow electrolytes closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490826,\n \"text\": \"CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\\n(Continued)\\nof food particles. Now not raising anything from ETT. ETT tube advanced 4cm by resp. ABG improved. LS course. O2Sat 99-100%\\n\\nGU/GI:Foley patent and intact. Draining CYU. U/O adequate prior to low BP's. Currently making 30-500cc/hr for past 2hrs. HO aware. Abd firm and distended with normoactive BS's. OGT in place.\\n\\nENDO: Insulin gtt at 4u/hr per sliding scale. FS ranging 187-267.\\nFollowing FS q1h.\\n\\n: Collar in place. Cspine film done at bedside last night. No injuries noted.\\nCollar in place until pt awake or till trauma team clears\\n\\nPLAN:\\nPossible removal of swans\\nIntegrillin to dc at 2200\\nContinue to follow neuro status\\nContinue to monitor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490827,\n \"text\": \"Resp. Note\\nPt remains on AC 16/750/7.5/50% No changes made today. Bronchoscopy done-poss food/foreign body aspiration. No particles found. Pt was sx today for brownish secretions throughtout the day. Will cont support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490828,\n \"text\": \"ccu nursing progress note\\ns: orally intubated\\no: pls see carevue flowsheet for complete vs/data/events\\nid: low grade temp. wbc nml. cont on levo and flagyl.\\nneuro: ativan weaned down this am, pt became more active, mae with good strength but nonpurposeful. not able to open eyes or follow commands, did appear to respond to stimuli. in afternoon pt underwent bronch req ^'d sedation w/ fent and ativan. pt remains sedated currently on 1mg ativan/hr. no evidence of sz activity.\\ncv: in sr rate 75-90s sr, no vea. lido dc'd this am. bp low this am and req 500ccns bolus this am to stabilize. remained 95-120/60-70 via r rad aline.\\ntol lopressor later in am.\\nr fem aline pulled. cont w/ r fem venous/pa line. paps 30s/.\\nsm soft hematoma. pulses 2+/ bilat.\\nintegrillin cont at 16cc/hr. to complete at 11pm.\\nck up 1300, mb 19. will cont to cycle.\\nresp: cont on a/c 750 x16. 50% and 7.5 peep. sats >95%. sxn'd for mod amt drk tan sputum. bronch'd this afternoon to eval ?collapse for lll. lobe was found to be inflated and lavaged for mod purulent sputum.\\ngi: abd soft, +bs. no stool. min aspirates. tf started via ogt, promote w/ fiber at 10cc/hr. awaiting nutrition consult to confirm and set goal.\\ngu: uop 30-50cc/hr. remains +3l since admit. will dose w/ lasix this eve. cr 1.4.\\nskin: abrasion on face/chin. ota. some bruising underarms.\\nremains w collar. cspine film taken this afternoon. has yet to be cleared.\\nsocial: wife and children in today. updated. home for eve now.\\na: bp stable s/p fluid this am. rhythm stable. neuro improving.\\np: cont to monitor cv and neuro status. wean o2 as tol. cpt as tol. cont with cspine precautions. advance tf as tol. monitor fever and await cultures. support to pt and family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490834,\n \"text\": \"ccu npn 11p-7a\\nS: intubated and sedated\\n\\nO: Please see carevue for VS and objective data\\n\\nCVS: Hemodynamically stable with HR 70-80 NSR, no vea noted. K+ 3.6 repleted with 40meq po KCL. am K+ pnd. BP 107-150/50-60. Tolerated po Captopril and Lopressor.\\n\\nResp; Remains intubated and mechanically ventilated on A/C 750x12 40%/5 peep. Good abgs as per flow. Am abg 105/36/7.42/24/0. Suctioned q 3-4 hours for small-mod. amounts of tan sputum. Lungs coarse. Rare spont. breathe over vent. impaired gag and cough.\\n\\nID: low grade on IV Flaggyl and Levo.\\n\\nEndo: Regular Insulin drip titrated 3u-4u/hour for glucose ranges 118-192.\\n\\nGI:GU: TF Promote with fiber at 30cc/hour increased to 40cc/hour without sign. residuals. Abdomen soft and distended with active bowel sounds. No stool. Foley to drainage with dark yellow urine with sediment. I/O neg 700cc at MN, positive 400cc this am.\\n\\nNeuro: Remains sedated on IV Propofol, increased to 40mcg/kg/min. for restlessness. with good effect. MAE, moving head side to side. Not opening eyes or following commands. PERL R>L. 3mm. Soft hand restraints intact. Poor gag and weak cough.\\n\\nA: Hemodynamically stable s/p arrest. Remains sedated and intubated.\\n\\nP: Cont to assess hemodynamics. Cont aggressive pulmonary toileting. Sedation as needed. Cont. insulin drip with tube feedings. Assess neuro status. Comfort and emotional support to Pt. and family. Follow up with am labs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490835,\n \"text\": \"CCU Nursing PRogress Note\\nS-Delirious\\nO-Neuro weaned off propofol by 1030 and added haldol 5mg x2 1 hr apart for persistant delirium with good effect. ALthough when IV haldol wore off (4hours) aggitation returned 1400 and required low dose propofol for pt saftey. Started po haldol 2.5mg QID started at 1800. Still requiring prn Haldol 2.5-5mg IVB. MAE very strong arms requiring wrist restraints. Opening eyes but not focusing or following commands.\\nCV- hypertensive 160-180 with aggitation requiring IV NTG 200-300mcg. Lopessor increased to 50mg TID and captopril increased to 37.5mg TID.\\nPlan to increase with each dose until desired effect. HR 88-110 NSR with occ isolated PVC's K+ 40meq KCL po x1 repeat 3.2. Radial aline replaced over a wire d/t brisk bleeding at site.\\nResp-Vent changed over to PS 15/PEEP 5 with spont VT 500-800 rr 20-28. PS/PEEP weaned down to 5/5 and quicikly extubated by 1200 to 100% neb with O2 sats 92-100% Last ABG 7.41/42/81 at 1630 on 100% face tent.\\nLS coarse with occ exp wheeze. Occ dry NPC.\\nID afebrile 99.7R WBC 6.9 on triple abx.\\nGI- NGT replaced for meds and tube feedings. Initial asp bile but after extubation coffee grounds OB+. Soft brown BM OB+. HCT 27.5 receiving 1uPRBC over 4 hours. Protonix\\nTube feeds stopped for extubation and to be restarted this evening.\\nGU-foley draining amber colored urine. Received lasix 40mg IVB with ~1200cc diuresis.\\nSKin- pressure sores from neck immobilizer neck, shoulder blades and head cleansed and left open to air\\nSocial- family all in and very supportive. Understanding POC\\nA/P-succ extubated, s/p AMI stent\\nPRN haldol for excessive aggitation, plan to wean off propofol when possible. CT scan Monday if MS unchanged.\\nLAsix 40mg IVB PRN for low urine output.\\nFollow electrolytes closely\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490838,\n \"text\": \"CCU Nursing Note 1900-700: Vfib arrest, Aspir PNA\\nS: \\\"I need to go to bathroom, I need to get up.\\\"\\nO: MS: Lethargic and oriented to self and place. Speech less garbled and voices needs appropriately. Obeying and following simple commands.\\nRestless and agitated overnoc needing repeative cues. Sleeping in spurts. Given 5mg every 2hr since MN with limited effect.\\n\\nCV:VSS stable overnoc. Still remains moderately hypertensive. Attempted to wean Nitro. High as 100ugs currently at 60ugs. Tolerating BB and ACEI titration. ? to adding additional antihypertensive on board.\\n\\nRESP:LS course on left and clear on right. O2Satt 95-99%/5l NC. Occasionally O2Sat dropping to 90-91& increased to 5L at 033O and has since remained > 95%. Breathing unlabored overnoc. (+) cough but nonproductive and assisted blowing nose with old blood secretions. NC changed over to humidified air.\\n\\nGU/GI: Foley draining amber colored urine. Urine outputs fair, >50cc/hr. Abd soft and distended. Moderate BM, guiac (+) soft and brown in appearance. TF up at MN at 10cc/hr prior to residual 50cc residual of bilious. Started on Reglan QID for ? delayed gastric emptying. At 0400 residual less that 5cc and TF advance to 20cc/hr. Next residual check at 0800. Given ice H2O overnoc for comfort.\\n\\nENDO: FS QID. Overnoc FS 125 and 136. Given AM dose of NPH.\\n\\nID: Low grade temps. Tm 101.1 and Tc 99.6. Given Tylenol 650mg x 2. Last at 0400.\\n\\nHEME: HCT 35 this AM.\\n\\nA/P:\\nConsider possible PT/OT consult as MS continues to improve\\nContinue repeative cues and emotional support\\nConsider adding additonal antihypertensive in addition to ACE and BB\\nContinue to monitor pulmonary status continue to wean O2\\nAdvance TF's as tolerated.\\nPossible transfer to floor. Transfer note in blue book.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490839,\n \"text\": \"CCU NURSING PROGRESS NOTE 3P- 11P\\nS: WHEN CAN I GO HOME?\\nO:\\nCV: FOR A COMPLETE SET OF VS AND OBJECTIVE DATA PLEASE REFER TO CARE VUE FLOWSHEET. DENIES CP/ SOB WHEN ASKED. REMAINS IN SR , NO VEA NOTED. NITRO DECREASED TO 40 MCG AFTER 4 PM CATOPRIL DOSE. GIVEN LOPRESSOR DOSE EARLY AT 9 PM FOR HR OF 85 AND SBP 160. AWAITING RESULTS.\\nRESP: LUNGS WITH CLEAR UPPER LOBES AND CKLS AT LOWER BASES. SATS 91 - 96%. CONTS ON 4L O2.\\nGI/ GU: TF AT 20 CC/HOUR INITALLY. THEN RESIDUALS AT 8 PM NOTED TO BE >120. TF HELD AT PRESENT. PT IS ABLE TO SWALLOW PILLS WITH SIPS OF WATER. ? ABSORPTION. CONTS ON REGLAN. BS PRESENT. TWO SMALL SOFT GUIAC POS STOOLS NTED.\\nMS: PT IS A&O TO PERSON AND PLACE. HE IS PLEASANT AND COOPERATIVE. LIMITED STM, NEEDING FREQUENT REMINDING/ RE ORIENTATION. DAUGHTERS IN ALL EVE. FAMILY VERY HELPFUL WITH CALMING/ REORIENTATION.\\nA: APPEARS STABLE , BUT ? ABSORPTION OF MEDS OR NEED TO INCREASE DOSES, TRANSFER TO THE FLOOR\\nP: CONT OT MONITOR, ? INCREASE DOSING OF LOPRESSOR/ CAROPRIL, AWAIT BED.\\n\"\n }\n]"}}},{"rowIdx":187,"cells":{"subject_id":{"kind":"number","value":4313,"string":"4,313"},"hadm_id":{"kind":"number","value":148275,"string":"148,275"},"target_text":{"kind":"string","value":"31 year-old male with ESRD on HD, DMI, HTN presented with hyperkalemia in context of missing hemodialysis. He was section 12. Initially went to MICU for HD, then transferred to floor for continued HD. Had return to MICU later in hospital course for more intensive HD treatment secondary to hypoxia and fluid overload."},"extractive_notes_summ":{"kind":"string","value":"During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. Pt unable/pt refuse and PO medication. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. During pt's most recent admission/ED visit pt reported LLE swelling, LENIS negative and pt was given IV ABX. Noaortic regurgitation is seen. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . - Monitor for withdrawal # Anemia: Likely ACD. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. # Hypertension: Continue outpt meds and uptitrate prn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIS negative and pt was given IV ABX. Fragmentation of medial patella consistent with nondisplaced, comminuted fracture. FINAL REPORT HISTORY: Left lower extremity swelling. nonacute fracture vs post- traumatic heterotopic ossificaiton in adjoining medial retinaculum. IMPRESSION: 1) Findings consistent with medial tibial plateau fracture likely subcaute or chronic . Sinus rhythm with non-diagnostic repolarization abnormalities. There is an ossific fragment along the medial border of the patella, which appears well corticated, and which could represent a either fracture fragment or heterotopic ossification in the medial retinaculum. Sinus rhythm upper normal rateNormal ECGSince previous tracing of , ST-T wave abnormalities are less EXAMINATION: Unilateral left lower extremity DVT study. This again demonstrates a depressed medial tibial plateau fracture, similar to that seen on . FINDINGS: Grayscale and color Doppler son of the left common femoral, superficial femoral and popliteal veins were performed. Medial patellar fracture. 2) Ossicle along medial patella -- ? Compared to the previous tracing there is nosignificant change.TRACING #1 There is a small fracture through the medial aspect of the patella. Tibial and patellar fractures. Moderate joint effusion. Lateral T wave abnormalities. Compared to the previous tracing there is nosignificant change.TRACING #2 Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Depressed, impacted medial tibial plateau fracture which also extends to the intercondylar eminence and medial tibial spine. Clinical correlation and repeat tracing aresuggested. Possible subacute fracture along the medial patella. Compared to the previoustracing of lateral T wave abnormalities are new. Additionally, comminuted fractures of the medial and lateral tibial spines. The prior tracing was consistent with right atrial abnormality.Otherwise, no diagnostic interim change. Sinus rhythmNormal ECGSince previous tracing of , the heart rate is slower Delayed precordial R wave transition. Non-specific ST-T wave changes. Compared to the previoustracing of previous non-specific ST-T wave abnormalities have resolved.Otherwise, no important change. Compared to the previous tracing of no change.TRACING #1 There is evidence of diffuse vascular calcification. Please do delayed phase for better visualization of veins."},"n_notes":{"kind":"number","value":60,"string":"60"},"notes":{"kind":"list like","value":[{"category":"Social Work","chartdate":"2176-06-07 00:00:00.000","description":"Social Work Progress Note","row_id":373800,"text":"SOCIAL WORK:\n SW met with pt, brother (cell ), and mother\n . Pt reviewing his history of betrayal of his family and\n stating his intention to follow recommendations and change his\n behaviors. He would like his care centralized at . Mother spoke\n of how pt has always been self-centered\npt agrees\nto the point of not\n respecting the rights of others. Brother enforced how he still and\n always will love his brother, but that he does not like their\n relationship right now. All agreed that pt will have to earn back\n their respect and trust through hard work and behavior change. While\n pt is stating he would like to change his ways, he still provides many\n excuses for his behaviors (e.g.\n I may have stolen the credit card, but\n I wasn\nt going to use it just yet.\n Mother, brother, and psychiatrist Dr. , and this writer met\n separately from pt. Family reviewed h/o behavior, including\ndeviant\n behavior dating back to pt\ns childhood, but erratic mood swings and\n bizarre behavior (e.g. walking around family home undressed) only in\n recent months. Brother reports he has seen intoxicated on\n etoh and MJ lately, and reports pt\ns substance abuse is real. Mother\n and brother state pt reports he has been\nsnorting dope\n lately, and\n that he does hang around with an addict friend, but they are unclear\n re: history of this. Family notes that while many themes of pt\n reports are true, he does make up some stories.\n After Dr. left, questions were placed re: guardianship and\n capacity\nlargely deferred to meeting next week. Reviewed pt\ns h/o poor\n self-esteem. While pt did not feel he could learn like his brothers,\n pt had been physically skilled when he was young\nplanned to be a boxer,\n played football until dx with DM. Perhaps part of pt\ns long-term plan\n could involve boxing to alleviate physical aggression if medically\n able. Perhaps he could relate to ex-gang members in reform programs.\n Clearly he needs extensive psychiatric support.\n Am following case and waiting to see what floor pt is called out to\n before arranging family meeting for next week. Please page me at \n with any questions/concerns.\n -, LICSW\n PM\n"},{"category":"Physician ","chartdate":"2176-06-01 00:00:00.000","description":"Physician Attending/Resident Progress Note - MICU","row_id":373124,"text":"Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotic positioning.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n - On EKG this AM QTc was 450 ms\n ROS:\n Unable to obtain due to patient sedation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97% on room air\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Physical Examination\n GEN: Sedated and sleeping.\n HEENT: PERRL, oral mucosa moist\n NECK: no LAD, JVP flat\n PULM: CTAB with overlying son upper respiratory sounds\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\n ABD: BS+, soft, non-distended\n EXT: Left > right lower extremity edema with no differential warmth\n NEURO: Somnolent\n Labs from \n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n MICRO:\n URINE URINE CULTURE-PENDING NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n # Chronic renal failure-secondary to ESRD/DM:\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\n hyperkalemia, and hyperphosphatemia.\n - HD today in the ICU\n # Left lower extremity edema:\n Acute within last week. Patient denies pain with ambulation or knee\n joint manipulation. Has had two negative sets of lower-extremity\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\n other obstructive process to cause differential swelling. Patient was\n on antibiotics at presentation, but this is not entirely consistent\n with a cellulitis.\n - Consider pelvic venous imaging to rule out pelvic DVT\n # Psychiatric:\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\n have decided to section 12 pt. Psychiatry aware and suggests that the\n pt does not have capacity and the medical team should consider\n guardianship. had two episodes of threatening to leave hospital\n overnight requiring security to assist in giving patient chemical\n restraints (5 mg haldol and 2 mg lorazepam each episode)\n - Follow-up psychiatry recs\n - Will need 1:1 observation and cannot leave hospital\n # Increase in size of cardiac silhouette by CXR on :\n Was ruled out for pericardial effusion by ECHO. Most likely\n projectional artifact.\n # Hypertension:\n Continue outpt meds and uptitrate prn. HD this AM.\n - As mental status allows will add back on amlodipine, lisinopril,\n metoprolol, labetolol.\n - Will have to reeval outpt regimen\n # Diabetes mellitus type 1:\n Insulin 75/25 at half of home doses and conservative sliding scale\n insulin given that patient is taking little orally.\n # Reported ETOH:\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\n admission. No history of withdrawal symptoms.\n - Monitor for withdrawal\n # Anemia:\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\n today.\n - Epoetin at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n ------ Protected Section ------\n CRITICAL CARE ADDENDUM\n Mr. was seen, examined and evaluated with Dr. and the ICU\n team with whose detailed note above I agree. Mr. is a 31 yo man\n with psychiatric illness, DM I, ESRD on HD who was brought in Section\n 12 because he was not compliant with HD. Getting hemodialysis for\n hyperkalemia. Agitated overnight requiring benzodiazepines and haldol.\n Left leg is edematous and LENIS negative. Overnight, CXR w/?widened\n mediastinum - echo w/o abnormality - ?fat pad or positioning.\n Somnolent throughout the day and agitated over night - restrained by\n security and given haldol. QTc stable at 450.\n Currently somnolent, but arousable and answering questions with\n curses. HR 90, 166/75, Neg 5.4L yesterday. 97% RA, Lungs clear to\n auscultation. RRR w/o murmur. Abd benign. Thrill palpable UE. Left\n LE edematous - no labs today (await w/HD).\n Plan includes hemodialysis today. Continue to use haldol and\n benzodiazepines as needed for agitation and sedation. We are awaiting\n guardianship. Evaluate Left LE with ?pelvic vein imaging and will d/w\n dr . Agitation control. Needs 1:1 sitter. be called out if\n stable following HD today.\n , MD\n Critical Care Attending\n 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 11:04 ------\n"},{"category":"Nursing","chartdate":"2176-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":373628,"text":"HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt admitted to the micu from 2. on 100% non rebreather o2sat\n 92-99%. Creat 7.8\n Action:\n Hemodyiaylsis nurse in and dialysis begun at 0430 am.\n Response:\n Diaylysis intiated and tolerating . bp 160-170\ns. very cooperative;\n sitter at the bedside.\n Plan:\n Continue dialysis till 0830am. Check creat level in late am.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K upon arrival to the unit .8 repeat 7.2.\n Action:\n Postassium level being monitored. Hemodyamics being monitored. Ekg\n monitored.\n Response:\n Dialysis being done and tolerating well\n Plan:\n Monitor potassium level closely.\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373786,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373791,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor, hopefully to 2\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373792,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor, hopefully to 2\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: hyperlipedemia, diabetes type I on insulin end\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\n pressured,racing thoughts decreased sleep consistent with possible\n mania. lower left extremitiy swelling dopplerable. neg for clots.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:136\n D:113\n Temperature:\n 96.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,100 mL\n 24h total out:\n 5,000 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 10:30 AM\n Potassium:\n 4.8 mEq/L\n 10:30 AM\n Chloride:\n 95 mEq/L\n 10:30 AM\n CO2:\n 31 mEq/L\n 10:30 AM\n BUN:\n 28 mg/dL\n 10:30 AM\n Creatinine:\n 4.6 mg/dL\n 10:30 AM\n Glucose:\n 326 mg/dL\n 10:30 AM\n Hematocrit:\n 26.4 %\n 10:30 AM\n Finger Stick Glucose:\n 351\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Micu 687\n Transferred to:\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2176-06-01 00:00:00.000","description":"Nursing Progress Note","row_id":373106,"text":"Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\n w/o complaint until 0500- awake, initially pleasant, engaging in\n conversation- allowed off monitors to wash self , @ 05:30 stating\n wanted to leave to go to dialysis- attempted to talk down pt, pt\n reviewing care and accepting Insulin but not PO anti-hypertensives-\n moderate agitation just persisting on leaving- security called and pt\n accepting IV chemical restraint- 5mg IVP Haldol, 2mg IV Ativan and\n lying down in bed. Pt unable/pt refuse and PO medication. Section 12-\n pt may not leave AMA.\n Impaired Health Maintenance\n Assessment:\n Pt stating\nI had dialysis yesterday, I need to go to my dialysis\n today\n, unable to review dialysis plans, pt focused on leaving\n hospital, refusing medications\n Action:\n Emotional support, reviewing POC\n Response:\n Attempting to leave x1\n Plan:\n not leave AMA, IV Haldol for restraint, reviewing POC ? social work\n and psych to follow up\n"},{"category":"Physician ","chartdate":"2176-06-01 00:00:00.000","description":"Physician Resident Progress Note","row_id":373109,"text":"Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotically positioned.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GEN:\n HEENT:\n NECK:\n PULM:\n CARD:\n ABD:\n EXT:\n NEURO:\n Labs / Radiology\n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:45 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":"2176-06-01 00:00:00.000","description":"Physician Resident Progress Note","row_id":373111,"text":"Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotically positioned.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GEN:\n HEENT:\n NECK:\n PULM:\n CARD:\n ABD:\n EXT:\n NEURO:\n Labs / Radiology\n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n"},{"category":"Nursing","chartdate":"2176-06-01 00:00:00.000","description":"Nursing Progress Note","row_id":373079,"text":"Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\n w/o complaint until 0500- awake.\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373784,"text":"Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372913,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui.\n Action:\n HD for / hrs at bedside.\n Response:\n Plan:\n Follow up with renal,,cont HD\n"},{"category":"Physician ","chartdate":"2176-05-31 00:00:00.000","description":"Physician Resident Admission Note","row_id":372907,"text":"Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n"},{"category":"Physician ","chartdate":"2176-05-31 00:00:00.000","description":"Physician Resident Admission Note","row_id":372908,"text":"Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n ------ Protected Section ------\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\n DVT. Will give unasyn for now for presumed cellulitis.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:50 ------\n"},{"category":"Physician ","chartdate":"2176-05-31 00:00:00.000","description":"Physician Resident Admission Note","row_id":372911,"text":"Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n ------ Protected Section ------\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\n DVT. Will give unasyn for now for presumed cellulitis.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:50 ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: receiving HD currently, psych evaluation and\n treatment of cellulitis as described above. Unable to obtain complete\n ROS due to altered mental status. Labs reviewed and notable for\n hyperkalemia but otherwise stable.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:31 ------\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372914,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372965,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\n of Dextrose foe hypoglycemia.\n"},{"category":"Physician ","chartdate":"2176-05-31 00:00:00.000","description":"Physician Attending Progress Note","row_id":373000,"text":"Chief Complaint: hyperkalemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 31 yo ESRD secondary to DM I on tranplant list. Presenting with\n hyperkalemia after missing HD. Was brought in ?unclear how. In ED was\n agitated. Was eval by psych who felt he did not have capacity to make\n decisions. Got 5mg haldol and 2mg of ativan. K was 6.4. refused\n kayexalate. Came to MICU for urgent HD. BP 192/92 sat 100% on RAn in\n ED. Overnight required D50x3 for hypoglycemia after getting dosed\n with SSI.\n 24 Hour Events:\n NASAL SWAB - At 12:14 AM\n MRSA screen\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 AM\n Hydralazine - 06:10 AM\n Other medications:\n nephrocaps\n calcium acetate\n norvasc\n lisinopril\n EPO\n lipitor\n pepcid\n hep s/q\n toprol\n labetolol\n lanthenum\n SSI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 87 (75 - 98) bpm\n BP: 162/81(99) {137/57(77) - 201/106(128)} mmHg\n RR: 13 (11 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 2,500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -2,400 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: 3+\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 400 K/uL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n ECG: slightly peaked Tw\n Assessment and Plan\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD): Got\n emergent HD overnight. K now normalized.\n Section 12: will need psych admission after medical issues are cleared\n RLE: swelling and redness. Has had this for at least a few days with\n no worsening. No clear evidence of cellulitis,\n DM I: will start half dose NPH and cut back on sliding scale as he was\n hypoglycemic today.\n agitation: Currently sedated, but will need sitter and haldol prn.\n has right effusion in knee: will tap.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU can go to floor after HD\n Total time spent: 35 minutes\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372960,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\n of Dextrose foe hypoglycemia.\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":373062,"text":"31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, dialyzed overnight upon admission to\n unit .5L removed.\n Received pt very lethargic, arousable only to simulation,\n unable to give most PO meds due to lethargy.\n Action:\n Dialyzed again this afternoon per renal orders, 3L removed.\n Pt becoming more arousable during dialysis, alert and\n oriented x 3, very talkative at times becoming agitated however easily\n redirected.\n Response:\n Pt tolerated dialysis well, SBP >100\n Received IV Ativan 1mg x 2 with some effect, also ordered\n for but did not receive any Haldol.\n Plan:\n Pt to have dialysis again tomorrow.\n PRN Ativan and Haldol as needed.\n Pt noted to have larger heart on CXR, MDs questioning pericardial\n effusion, bedside ECHO performed, results pending. Pt called out to\n floor, awaiting bed placement.\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372955,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/\n"},{"category":"Physician ","chartdate":"2176-06-01 00:00:00.000","description":"Physician Resident Progress Note","row_id":373120,"text":"Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotic positioning.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n - On EKG this AM QTc was 450 ms\n ROS:\n Unable to obtain due to patient sedation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97% on room air\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Physical Examination\n GEN: Sedated and sleeping.\n HEENT: PERRL, oral mucosa moist\n NECK: no LAD, JVP flat\n PULM: CTAB with overlying son upper respiratory sounds\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\n ABD: BS+, soft, non-distended\n EXT: Left > right lower extremity edema with no differential warmth\n NEURO: Somnolent\n Labs from \n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n MICRO:\n URINE URINE CULTURE-PENDING NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n # Chronic renal failure-secondary to ESRD/DM:\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\n hyperkalemia, and hyperphosphatemia.\n - HD today in the ICU\n # Left lower extremity edema:\n Acute within last week. Patient denies pain with ambulation or knee\n joint manipulation. Has had two negative sets of lower-extremity\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\n other obstructive process to cause differential swelling. Patient was\n on antibiotics at presentation, but this is not entirely consistent\n with a cellulitis.\n - Consider pelvic venous imaging to rule out pelvic DVT\n # Psychiatric:\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\n have decided to section 12 pt. Psychiatry aware and suggests that the\n pt does not have capacity and the medical team should consider\n guardianship. had two episodes of threatening to leave hospital\n overnight requiring security to assist in giving patient chemical\n restraints (5 mg haldol and 2 mg lorazepam each episode)\n - Follow-up psychiatry recs\n - Will need 1:1 observation and cannot leave hospital\n # Increase in size of cardiac silhouette by CXR on :\n Was ruled out for pericardial effusion by ECHO. Most likely\n projectional artifact.\n # Hypertension:\n Continue outpt meds and uptitrate prn. HD this AM.\n - As mental status allows will add back on amlodipine, lisinopril,\n metoprolol, labetolol.\n - Will have to reeval outpt regimen\n # Diabetes mellitus type 1:\n Insulin 75/25 at half of home doses and conservative sliding scale\n insulin given that patient is taking little orally.\n # Reported ETOH:\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\n admission. No history of withdrawal symptoms.\n - Monitor for withdrawal\n # Anemia:\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\n today.\n - Epoetin at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n"},{"category":"General","chartdate":"2176-06-07 00:00:00.000","description":"Generic Note","row_id":373765,"text":"TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined. This am he is\n manic\n euphoric, pressured speech, flights of ideas. Denies SOB but\n oxygenation still not normal. Seems to be improving with aggressive\n dialysis but CXR being read as c/w pneumonic process. Needs CXR\n tomorrow and may need CT if he fails to clear but clinically this is\n CHF rather than infection.\n Time spent 30 min\n"},{"category":"Physician ","chartdate":"2176-06-06 00:00:00.000","description":"Physician Resident Admission Note","row_id":373601,"text":"Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\n HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: not willing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n **Patient unable to provide. Per discharge summary on ...\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\n Sensipar 30mg Tablet, 1 Tablet PO once a day\n Lanthanum Oral\n .\n Medications on transfer:\n Haloperidol 1.5 mg PO Q 12H\n Acetaminophen 325-650 mg PO Q6H:PRN pain\n Haloperidol 2 mg IM ONCE\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\n Duration: 1 Doses Order date: @ 1614\n amlodipine 5 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Aspirin 325 mg PO DAILY\n Insulin SC (per Insulin Flowsheet)\n Atorvastatin 40 mg PO DAILY\n Insulin Regular 10 UNIT IV ONCE\n Monitor Q1H for 6 Order date: @ 0044\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Lanthanum 1000 mg PO QID\n Calcium Acetate 1334 mg PO TID W/MEALS\n Labetalol 300 mg PO TID\n Calcium Gluconate 2 g IV ONCE\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\n Cinacalcet 30 mg PO DAILY\n Multivitamins 1 TAB PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nephrocaps 1 CAP PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nicotine Patch 21 mg TD DAILY\n DiphenhydrAMINE 25 mg PO HS:PRN\n Senna 1 TAB PO BID:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Epoetin Alfa\n To be administered during dialysis and dosed according to the \n Epoetin Alfa P&T Guidelines.\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\n Famotidine 20 mg PO Q24H\n Thiamine 100 mg PO DAILY\n FoLIC Acid 1 mg PO DAILY\n Valsartan 160 mg PO DAILY\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\n d1= Order date: @ 0044\n Haloperidol 0.5 mg PO Q2H:PRN agitation\n MD if giving Order date: @ 1301\n Past medical history:\n Family history:\n Social History:\n Type I DM (diagnosed 13 years ago), managed by Dr. \n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \n Diabetic retinopathy (diagnosed 2 years ago)\n Diabetic neuropathy\n Diabetic myonecrosis ()\n Chronic ulcer at right foot\n Hypertension\n Concern for psychiatric disorder, possibly bipolar\n :\n Per reveiw of records, Type II diabetes mellitus in mother and father.\n Type I diabetes mellitus in sisters and brothers.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is followed by a social worker because of concern about his\n competence. Reported alcohol use, illicit drug use.\n Review of systems: ROS\n Flowsheet Data as of 03:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 92 (92 - 92) bpm\n BP: 169/75() {169/75() - 169/75()} mmHg\n RR: 5 (5 - 5) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 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: Non-rebreather\n Physical Examination\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\n +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\n ABG, and hypoxia.\n .\n Studies:\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \n 8:11, TWI is more pronounced and STE is unchanged.\n - TTE (): The left atrium is normal in size. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Left ventricular systolic function is hyperdynamic (EF\n 80%). There is no ventricular septal defect. Right ventricular chamber\n size and free wall motion are normal. There are focal calcifications in\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is mild mitral valve\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\n artery systolic pressure is normal. There is no pericardial effusion.\n There is an anterior space which most likely represents a fat pad.\n Compared with the findings of the prior study (images unavailable) of\n , the left ventricular wall thickening has progressed.\n - CXR 2V (): Final read pending\n - LENI (): No evidence of DVT of the left lower extremity.\n Assessment and Plan\n Assessment and plan:\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2176-06-06 00:00:00.000","description":"Physician Resident Admission Note","row_id":373606,"text":"Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\n HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: not willing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n **Patient unable to provide. Per discharge summary on ...\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\n Sensipar 30mg Tablet, 1 Tablet PO once a day\n Lanthanum Oral\n .\n Medications on transfer:\n Haloperidol 1.5 mg PO Q 12H\n Acetaminophen 325-650 mg PO Q6H:PRN pain\n Haloperidol 2 mg IM ONCE\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\n Duration: 1 Doses Order date: @ 1614\n amlodipine 5 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Aspirin 325 mg PO DAILY\n Insulin SC (per Insulin Flowsheet)\n Atorvastatin 40 mg PO DAILY\n Insulin Regular 10 UNIT IV ONCE\n Monitor Q1H for 6 Order date: @ 0044\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Lanthanum 1000 mg PO QID\n Calcium Acetate 1334 mg PO TID W/MEALS\n Labetalol 300 mg PO TID\n Calcium Gluconate 2 g IV ONCE\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\n Cinacalcet 30 mg PO DAILY\n Multivitamins 1 TAB PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nephrocaps 1 CAP PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nicotine Patch 21 mg TD DAILY\n DiphenhydrAMINE 25 mg PO HS:PRN\n Senna 1 TAB PO BID:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Epoetin Alfa\n To be administered during dialysis and dosed according to the \n Epoetin Alfa P&T Guidelines.\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\n Famotidine 20 mg PO Q24H\n Thiamine 100 mg PO DAILY\n FoLIC Acid 1 mg PO DAILY\n Valsartan 160 mg PO DAILY\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\n d1= Order date: @ 0044\n Haloperidol 0.5 mg PO Q2H:PRN agitation\n MD if giving Order date: @ 1301\n Past medical history:\n Family history:\n Social History:\n Type I DM (diagnosed 13 years ago), managed by Dr. \n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \n Diabetic retinopathy (diagnosed 2 years ago)\n Diabetic neuropathy\n Diabetic myonecrosis ()\n Chronic ulcer at right foot\n Hypertension\n Concern for psychiatric disorder, possibly bipolar\n :\n Per reveiw of records, Type II diabetes mellitus in mother and father.\n Type I diabetes mellitus in sisters and brothers.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is followed by a social worker because of concern about his\n competence. Reported alcohol use, illicit drug use.\n Review of systems: ROS\n Flowsheet Data as of 03:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 92 (92 - 92) bpm\n BP: 169/75() {169/75() - 169/75()} mmHg\n RR: 5 (5 - 5) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 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: Non-rebreather\n Physical Examination\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\n +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\n ABG, and hypoxia.\n .\n Studies:\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \n 8:11, TWI is more pronounced and STE is unchanged.\n - TTE (): The left atrium is normal in size. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Left ventricular systolic function is hyperdynamic (EF\n 80%). There is no ventricular septal defect. Right ventricular chamber\n size and free wall motion are normal. There are focal calcifications in\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is mild mitral valve\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\n artery systolic pressure is normal. There is no pericardial effusion.\n There is an anterior space which most likely represents a fat pad.\n Compared with the findings of the prior study (images unavailable) of\n , the left ventricular wall thickening has progressed.\n - CXR 2V (): Final read pending\n - LENI (): No evidence of DVT of the left lower extremity.\n Assessment and Plan\n Assessment and plan:\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n Worsening hypoxemia this eve with new bilateral infiltrates\n presumption is that this represents pulmonary edema and he was\n transferred to ICU for urgent dialysis. He was placed on a 100% NRB\n facemask to maintain adequate saturations.\n Exam notable for Tm afebrile HR 94 BP 156/70 RR 19 with 97 sat on\n 100% NRB\n No distress\n HEENT unremarkable\n Neck supple\n Lungs crackles\n Her rrr\n Abd benign\n Extreme RUE fistula, mild LLE edema\n Labs notable for K+ 6.3 yesterday morning\n Imaging: CXR with new bilateral patchy infiltrates\n EKG with peaked T\n Problems: respiratory distress, hypoxemia, pulmonary edema, ESRD, LLE\n edema, hyperkalemia, DM\n Agree with plan for urgent HD, wean O2 as tolerates, will continue\n antibiotics and let floor team sort out LLE, continue current DM\n regimen\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 36 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:31 ------\n"},{"category":"Nursing","chartdate":"2176-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":373673,"text":" MD H+P:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Today\ns Events\n HD today, removed 4.9kilo\n L leg remains swollen and tender to touch\n CXR revealed pneumonia, received vanco X1\n Pt desatuating on RA to 70\ns, productive cough\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2176-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":373676,"text":" MD H+P:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Today\ns Events\n HD today, removed 4.9kilo\n L leg remains swollen and tender to touch\n CXR revealed pneumonia, received vanco X1\n Pt desatuating on RA to 70\ns, productive cough\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, non-compliant with medical care . K+ 6.8\n overnight with worsening resp distress and desaturation to the 70\n Action:\n Renal ordered HD overnight.\n Response:\n HD removed 4.9kilo\n Plan:\n Monitor fluid balance, pt is refusing to abide by fluid restriction.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Known non-compliance with medical regimen. ? untreated Bipolar\n disease. History of leaving AMA, pt is Currently under Section 12 and\n has 1:1 sitter and can NOT leave.\n Action:\n Pt is on Haldol and can receive PRN doses\n Response:\n Pt has been cooperative with care, 1:1 sitter\n Plan:\n Psych and SW attempting to get medical guardianship, meeting friday\n"},{"category":"Physician ","chartdate":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373734,"text":"24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373735,"text":"24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373737,"text":"24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373742,"text":"24 Hour Events:\n -3.5L O/N\n -No episodes of hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Bcx (): PND\n Bcx (): PND\n UCx (): Negative\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Renal\n following, given dialysis yesterday early AM, continues to be fluid\n overloaded. Will continue to diureses as per renal recommendations and\n fluid restrict (1L per day, 80mg lasix QD).\n -bcx and ucx\n -cxr\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source.\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: As per admission note, patient is Section 12.\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\n has been long standing issue. Per psych notes, has had \"agitation,\n pressured speech, loose and tangential, racing thoughts and decreased\n sleep consistent with possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor\n"},{"category":"Physician ","chartdate":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373826,"text":"24 Hour Events:\n -3.5L O/N\n -No episodes of hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Bcx (): PND\n Bcx (): PND\n UCx (): Negative\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Renal\n following, given dialysis yesterday early AM, continues to be fluid\n overloaded. Will continue to diureses as per renal recommendations and\n fluid restrict (1L per day, 80mg lasix QD).\n -bcx and ucx\n -cxr\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source.\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: As per admission note, patient is Section 12.\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\n has been long standing issue. Per psych notes, has had \"agitation,\n pressured speech, loose and tangential, racing thoughts and decreased\n sleep consistent with possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Progress Note","row_id":373709,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Overnight Events\n L leg remains swollen and tender to touch\n Pt desatuating on RA to80\ns, productive cough\n Pt compliant with meds and no periods of agitation, remains\n on 1:1 sitter\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, non-compliant with medical care prior to admit HD\n done , tol well.\n Action:\n 1000ml fluid restriction maintained.\n Response:\n Pt compliant with meds, and fluid restriction\n Plan:\n Monitor fluid balance, ?HD today\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Known non-compliance with medical regimen. ? untreated Bipolar\n disease. History of leaving AMA, pt is Currently under Section 12 and\n has 1:1 sitter and can NOT leave.\n Action:\n Pt is on Haldol and received PRN dose x1 a/o\n Response:\n Pt has been cooperative with care, 1:1 sitter\n Plan:\n Psych and SW attempting to get medical guardianship, meeting today\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373809,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor,\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: hyperlipedemia, diabetes type I on insulin end\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\n pressured,racing thoughts decreased sleep consistent with possible\n mania. lower left extremitiy swelling dopplerable. neg for clots.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:136\n D:113\n Temperature:\n 96.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,100 mL\n 24h total out:\n 5,000 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 10:30 AM\n Potassium:\n 4.8 mEq/L\n 10:30 AM\n Chloride:\n 95 mEq/L\n 10:30 AM\n CO2:\n 31 mEq/L\n 10:30 AM\n BUN:\n 28 mg/dL\n 10:30 AM\n Creatinine:\n 4.6 mg/dL\n 10:30 AM\n Glucose:\n 326 mg/dL\n 10:30 AM\n Hematocrit:\n 26.4 %\n 10:30 AM\n Finger Stick Glucose:\n 351\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Micu 687\n Transferred to: 201\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372931,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":373010,"text":"31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2176-06-01 00:00:00.000","description":"Nursing Transfer Note","row_id":373152,"text":"TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\n treatment. Unfortunately pt became agitated, angry and appeared\n threatening early this afternoon. Feelings validated and pt given\n ample time to voice his displeasure to no avail. Stat security called\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\n admin. Pt now more cooperative and is not agitated. Pt seems to last\n 8 to 12 hours between outbursts.\n Impaired Health Maintenance\n Assessment:\n As noted above, the pt was more or less cooperative with care this AM\n (though refused all AM meds). Unfortunately pt impulsively became\n angry/agitated/beligerant this afternoon requiring stat security @ BS.\n Stable QTi on EKG this AM. Soft wrist restraints in place. 1:1 Sitter\n @ BS.\n Action:\n With security @ BS and a supportive sitter whom the pt trusted the pt\n relented and allowed 5mg IVP Haldol to be admin @ BS.\n Response:\n Pt now more cooperative with no agitation issues @ this time.\n Plan:\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\n becoming acutely agitated. Follow serial EKG QTi as long as IV Haldol\n treatment in place.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt received his third HD in three days today. AM potassium value of\n 4.3 noted.\n Action:\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\n Response:\n Pt without significant issues surrounding HD treatment.\n Plan:\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\n for Mon vs Tues.\n Demographics: The pt is appearantly estranged from his mother and has\n issues with some of his siblings. Pt also appears to have issues of\n homelessness. Pt with multiple recent hospital admits s/p missed HD\n treatments with significant hyperkalemia.\n Attending MD:\n R.\n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Anemia, Diabetes - Insulin, Renal Failure, Smoker\n CV-PMH: Hypertension\n Additional history: Diabetic retinopathy. Anemia. Recent LLE swelling\n (Leni's negative times two). diabetic neuropathy\n Diabetic myonecrosis. Chronic ulcer right foot\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:155\n D:65\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 380 mL\n 24h total out:\n 1,200 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 10:05 AM\n Potassium:\n 4.8 mEq/L\n 10:05 AM\n Chloride:\n 96 mEq/L\n 10:05 AM\n CO2:\n 29 mEq/L\n 10:05 AM\n BUN:\n 29 mg/dL\n 10:05 AM\n Creatinine:\n 7.2 mg/dL\n 10:05 AM\n Glucose:\n 83 mg/dL\n 10:05 AM\n Hematocrit:\n 29.2 %\n 10:05 AM\n Finger Stick Glucose:\n 147\n 10:05 AM\n Valuables / Signature: All of the pts personal property (5 bags) have\n been moved to a holding area on CC2.\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6 West.\n Transferred to: 226\n Date & time of Transfer:\n"},{"category":"Nursing","chartdate":"2176-06-01 00:00:00.000","description":"Nursing Progress Note","row_id":373149,"text":"TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\n treatment. Unfortunately pt became agitated, angry and appeared\n threatening early this afternoon. Feelings validated and pt given\n ample time to voice his displeasure to no avail. Stat security called\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\n admin. Pt now more cooperative and is not agitated. Pt seems to last\n 8 to 12 hours between outbursts.\n Impaired Health Maintenance\n Assessment:\n As noted above, the pt more or less cooperative with care this AM.\n Unfortunately pt became angry/agitated/ beligerant this afternoon\n requiring stat security @ BS. Stable QTi on EKG this AM.\n Action:\n With security @ BS and a supportive sitter whom the pt trusted the pt\n relented and allowed 5mg IVP Haldol to be admin @ BS.\n Response:\n Pt now more cooperative with no agitation issues @ this time.\n Plan:\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\n becoming agitated. Follow serial EKG QTi as long as IV Haldol\n treatment in place.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt received his third HD in three days today.\n Action:\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\n Response:\n Pt without significant issues surrounding HD treatment.\n Plan:\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\n for Mon vs Tues.\n"},{"category":"Echo","chartdate":"2176-05-31 00:00:00.000","description":"Report","row_id":83971,"text":"PATIENT/TEST INFORMATION:\nIndication: Enlarged cardiac size on CXR. Evaluate for effusion\nHeight: (in) 69\nWeight (lb): 156\nBSA (m2): 1.86 m2\nBP (mm Hg): 128/66\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 16:46\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: Moderate symmetric LVH. Small LV cavity. Hyperdynamic LVEF\n>75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal aortic arch diameter. Focal calcifications in aortic arch.\nNo 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: 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\nConclusions:\nThe left atrium is normal in size. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity is unusually small. Left\nventricular systolic function is hyperdynamic (EF 80%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. There are focal calcifications in the aortic arch. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is mild mitral valve prolapse. Trivial mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion. There is an anterior space which most likely represents\na fat pad.\n\nCompared with the findings of the prior study (images unavailable) of , the left ventricular wall thickening has progressed.\n\n\n"},{"category":"Radiology","chartdate":"2176-06-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1075959,"text":" 12:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, edema\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with h/o DM and ESRD on HD who had desat to 60% on RA.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Diabetes mellitus, desaturation.\n\n FINDINGS: As compared to the previous radiograph, there is a newly appeared\n extensive opacity in the middle and basal parts of the right lung and in the\n retrocardiac lung areas. The opacity is of alveolar morphology, multiple\n subtle air bronchograms are seen. The opacities tend to spare in the\n uppermost parts of the lung. In the region of the right hilus, subtle\n peribronchial cuffing is seen. However, all other signs indicative of\n overhydration are missing. In the light, they are much more likely to\n represent pneumonia rather than edema.\n Unchanged size of the cardiac silhouette, unchanged mediastinal contours.\n\n was notified by telephone at the time of dictation and informed\n about the abnormalities.\n\n"},{"category":"Radiology","chartdate":"2176-06-08 00:00:00.000","description":"L KNEE (AP, LAT & OBLIQUE) LEFT","row_id":1076429,"text":" 10:24 PM\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: Any fracture or other left knee pathology evident on plain f\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with leg lower extremity swelling and new left knee pain.\n REASON FOR THIS EXAMINATION:\n Any fracture or other left knee pathology evident on plain film?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left lower extremity swelling. New left knee pain.\n\n LEFT KNEE, THREE VIEWS\n\n There is deformity and increased density in the right tibial plateau\n consistent with a tibial plateau fracture, with depression. There is a\n probable joint effusion. There is minimal spurring about the patella. There\n is an ossific fragment along the medial border of the patella, which appears\n well corticated, and which could represent a either fracture fragment or\n heterotopic ossification in the medial retinaculum. No dislocation is\n identified. Dense vascular calcification is noted.\n\n IMPRESSION:\n\n 1) Findings consistent with medial tibial plateau fracture likely subcaute or\n chronic .\n\n 2) Ossicle along medial patella -- ? nonacute fracture vs post- traumatic\n heterotopic ossificaiton in adjoining medial retinaculum. Possible subacute\n fracture along the medial patella.\n\n 3. Joint effusion.\n\n Findings discussed with covering house officer Dr. at\n approximately 13:18 p.m. on the day of the exam.\n\n\n"},{"category":"Radiology","chartdate":"2176-06-08 00:00:00.000","description":"L UNILAT LOWER EXT VEINS LEFT","row_id":1076405,"text":" 4:59 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LLE SWELLING EVAL FOR DVT\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with possible DVT, dialysis patient\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: DLrc SAT 6:47 PM\n No evidence of left lower extremity DVT. Prominent lymph nodes in the left\n groin.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 31-year-old male with possible deep venous thrombus.\n Evaluate for deep venous thrombus.\n\n EXAMINATION: Unilateral left lower extremity DVT study.\n\n COMPARISONS: Comparison to ultrasound examination from .\n\n FINDINGS: Grayscale and color Doppler son of the left common femoral,\n superficial femoral and popliteal veins were performed. There is normal\n compressibility, flow, augmentation. There is symmetric respiratory\n variability in the right and left common femoral veins.\n\n IMPRESSION: No evidence of left lower extremity DVT.\n SESHa\n\n"},{"category":"Radiology","chartdate":"2176-06-10 00:00:00.000","description":"L CT LOW EXT W/O C LEFT","row_id":1076744,"text":" 6:12 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: to evaluate knee fracture\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with hx of ESRD on HD, now with knee injury 2 weeks ago, now\n with plain films showing tibial and patellar fractures.\n REASON FOR THIS EXAMINATION:\n to evaluate knee fracture\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD\n ______________________________________________________________________________\n WET READ: CXWc MON 8:46 PM\n Impacted right medial tibial plateau fracture extending to the articular\n surface, with pleateau depression of approximately 8mm. Bony sclerosis\n consistent with subacute fracture. Tiny intra-articular bony fragment\n posteriorly. Additionally, comminuted fractures of the medial and lateral\n tibial spines. Moderate joint effusion. Fragmentation of medial patella\n consistent with nondisplaced, comminuted fracture. Extensive vascular\n calcifications.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF LEFT KNEE\n\n INDICATION: Knee injury. Tibial and patellar fractures.\n\n TECHNIQUE: Non-contrast multidetector CT of the left knee was performed.\n Multiplanar reformations were carried out.\n\n COMPARISON: Radiograph of left knee .\n\n FINDINGS:\n\n There is an impacted fracture of the left medial tibial plateau with at least\n 5 mm of depression of the medial tibial plateau. Comminution is evident with\n small fracture fragments at the medial aspect of the medial plateau (series\n 500B, image 31). Extension of the fracture line into the intercondylar\n eminence and into the medial tibial spine is evident.\n\n The lateral tibial plateau is intact. The proximal tibial and fibular shafts\n are intact. The distal femur demonstrates no evidence of focal bone lesion or\n fracture.\n\n There is a small fracture through the medial aspect of the patella. The\n fracture is minimally displaced, with approximately 2 mm of medial\n displacement of the smaller medial component of the fracture.\n\n Assessment of the internal structures of the knee is limited on CT, but no\n gross ligament abnormality is demonstrated.\n\n There is a moderate to large knee joint effusion. There is evidence of\n diffuse vascular calcification. The bones appear demineralized.\n (Over)\n\n 6:12 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: to evaluate knee fracture\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Depressed, impacted medial tibial plateau fracture which also extends to\n the intercondylar eminence and medial tibial spine.\n 2. Medial patellar fracture.\n 3. Moderate to large knee joint effusion.\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2176-06-11 00:00:00.000","description":"OL KNEE( (SINGLE VIEW) IN O.R. LEFT","row_id":1076811,"text":" 8:06 AM\n KNEE( (SINGLE VIEW) IN O.R. LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. LEFTClip # \n Reason: ORIF LEFT TIBIAL PLATEAU FX\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Tibial plateau fracture.\n\n A single intraoperative fluoroscopic view of the left knee was obtained\n without a radiologist present. This again demonstrates a depressed medial\n tibial plateau fracture, similar to that seen on . For additional\n details, please consult the operative report.\n\n"},{"category":"ECG","chartdate":"2176-06-12 00:00:00.000","description":"Report","row_id":209357,"text":"Normal sinus rhythm. Lateral T wave abnormalities. Compared to the previous\ntracing of lateral T wave abnormalities are new. Some of these\nabnormalities have been seen on previous tracings but now they are increased\nin leads V5-V6.\n\n"},{"category":"ECG","chartdate":"2176-06-09 00:00:00.000","description":"Report","row_id":209358,"text":"Normal sinus rhythm. J point elevation consistent with normal early\nrepolarization. Otherwise, within normal limits. Compared to the previous\ntracing of previous non-specific ST-T wave abnormalities have resolved.\nOtherwise, no important change. Clinical correlation and repeat tracing are\nsuggested.\n\n"},{"category":"ECG","chartdate":"2176-06-06 00:00:00.000","description":"Report","row_id":205615,"text":"Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of no major change.\n\n"},{"category":"ECG","chartdate":"2176-06-05 00:00:00.000","description":"Report","row_id":205616,"text":"Sinus rhythm\nNormal ECG\nSince previous tracing of , the heart rate is slower\n\n"},{"category":"ECG","chartdate":"2176-06-04 00:00:00.000","description":"Report","row_id":205617,"text":"Sinus rhythm upper normal rate\nNormal ECG\nSince previous tracing of , ST-T wave abnormalities are less\n\n"},{"category":"ECG","chartdate":"2176-06-01 00:00:00.000","description":"Report","row_id":205618,"text":"Sinus rhythm. Compared to the previous tracing of there is\nT wave inversion in lead I and more prominent T wave inversion in\nlead aVL as well as new T wave inversion in leads V4-V6. Active\nlateral ischemic process cannot be excluded. Followup and clinical correlation\nare suggested.\n\n"},{"category":"ECG","chartdate":"2176-06-02 00:00:00.000","description":"Report","row_id":205619,"text":"Sinus rhythm. Compared to the previous tracing no change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2176-05-31 00:00:00.000","description":"Report","row_id":205620,"text":"Sinus rhythm. Compared to the previous tracing of no change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2176-05-31 00:00:00.000","description":"Report","row_id":205621,"text":"Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\nsignificant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2176-05-30 00:00:00.000","description":"Report","row_id":205622,"text":"Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\nsignificant change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2176-05-27 00:00:00.000","description":"Report","row_id":205623,"text":"Sinus rhythm. Baseline artifact. Delayed precordial R wave transition. The\nP wave morphology appears less prominent while the P wave axis remains\nrightward. The prior tracing was consistent with right atrial abnormality.\nOtherwise, no diagnostic interim change. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2176-06-07 00:00:00.000","description":"Report","row_id":205614,"text":"Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of ST-T wave changes are new.\n\n"},{"category":"Radiology","chartdate":"2176-06-03 00:00:00.000","description":"CT PELVIS W&W/O C","row_id":1075475,"text":" 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with left lower extremity swelling, negative LENI, concern for\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\n better visualization of veins.\n REASON FOR THIS EXAMINATION:\n eval for venous thrombosis\n CONTRAINDICATIONS for IV CONTRAST:\n Has ESRD and will get dialyzed Tuesday.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 8:10 PM\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\n Extensive vascular calcifications _____, likely reflecting the patient's\n history of diabetes. There is no acute pelvic pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old male with left lower extremity swelling and negative\n LENI. Evaluate for proximal clot in the iliac veins or IVC. The patient has\n a history of hypertension, diabetes, and end-stage renal disease.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the pelvis prior to\n and following administration of intravenous contrast, and three-minute delayed\n phase protocol. Multiplanar reformats were prepared and reviewed.\n\n FINDINGS: Within limits of non-contrast and delayed phase imaging, visualized\n portion of the liver, gallbladder, pancreas, and kidneys are normal. There is\n no evidence for biliary dilatation, cholelithiasis, or hydronephrosis.\n Visualized pelvic loops of small and large bowel are unremarkable. There is\n high-density material within the colon, likely reflecting magnesium-containing\n laxative or antacid use. There is no bowel distention or bowel wall\n thickening. There is no free fluid or free air. There is no lymphadenopathy\n appreciated.\n\n Vascular calcifications are noted in the pelvic vessels, greater than expected\n for a patient of this age, likely due to the patient's history of diabetes.\n There is normal appearance and opacification of the bilateral iliac veins and\n IVC, with no evidence for venous thrombosis.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. No evidence for venous thrombosis in the bilateral iliac vessels or IVC.\n 2. Vascular calcifications, greater than expected for a patient of this age,\n likely reflecting history of diabetes.\n 3. Within the limits of non-contrast and delayed phase imaging, no acute\n pelvic pathology.\n (Over)\n\n 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2176-06-03 00:00:00.000","description":"CT PELVIS W&W/O C","row_id":1075476,"text":", R. MED FA2 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with left lower extremity swelling, negative LENI, concern for\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\n better visualization of veins.\n REASON FOR THIS EXAMINATION:\n eval for venous thrombosis\n CONTRAINDICATIONS for IV CONTRAST:\n Has ESRD and will get dialyzed Tuesday.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\n Extensive vascular calcifications _____, likely reflecting the patient's\n history of diabetes. There is no acute pelvic pathology.\n\n"},{"category":"Radiology","chartdate":"2176-05-30 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1074872,"text":" 11:16 PM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with hx esrd\n REASON FOR THIS EXAMINATION:\n eval effusion, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old with history of end-stage renal disease.\n\n COMPARISON: \n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: The lateral view is limited due to\n inability of the patient to raise her arms. The lungs are grossly clear. The\n cardiac silhouette is increasing in size, even despite the lordotic\n positioning of the film, raising the possibility of pericardial effusion in\n this end- stage renal disease patient. The mediastinal contours are normal.\n There is no effusion or pneumothorax.\n\n IMPRESSION: Enlarging cardiac silouette, raising the possibility of\n pericardial effusion.\n\n Dr. was paged with these findings at 11:30 AM on .\n\n\n\n"},{"category":"Radiology","chartdate":"2176-06-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1076037,"text":" 9:52 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls eval for infiltrate, consolidation, effusion\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with ESRD, hypoxia\n REASON FOR THIS EXAMINATION:\n pls eval for infiltrate, consolidation, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n As compared to the previous radiograph, the lung volumes have increased.\n Despite the resulting overall decrease in lung parenchymal transparency,\n subtle areas of parenchymal opacities, notably in the left basal and\n retrocardiac areas and at the right lung bases persist, so that the suspicion\n of pneumonia cannot be discarded. No evidence of pleural effusions.\n Unchanged mediastinal contours. The size of the cardiac silhouette is smaller\n than before.\n\n\n"}],"string":"[\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 373800,\n \"text\": \"SOCIAL WORK:\\n SW met with pt, brother (cell ), and mother\\n . Pt reviewing his history of betrayal of his family and\\n stating his intention to follow recommendations and change his\\n behaviors. He would like his care centralized at . Mother spoke\\n of how pt has always been self-centered\\npt agrees\\nto the point of not\\n respecting the rights of others. Brother enforced how he still and\\n always will love his brother, but that he does not like their\\n relationship right now. All agreed that pt will have to earn back\\n their respect and trust through hard work and behavior change. While\\n pt is stating he would like to change his ways, he still provides many\\n excuses for his behaviors (e.g.\\n I may have stolen the credit card, but\\n I wasn\\nt going to use it just yet.\\n Mother, brother, and psychiatrist Dr. , and this writer met\\n separately from pt. Family reviewed h/o behavior, including\\ndeviant\\n behavior dating back to pt\\ns childhood, but erratic mood swings and\\n bizarre behavior (e.g. walking around family home undressed) only in\\n recent months. Brother reports he has seen intoxicated on\\n etoh and MJ lately, and reports pt\\ns substance abuse is real. Mother\\n and brother state pt reports he has been\\nsnorting dope\\n lately, and\\n that he does hang around with an addict friend, but they are unclear\\n re: history of this. Family notes that while many themes of pt\\n reports are true, he does make up some stories.\\n After Dr. left, questions were placed re: guardianship and\\n capacity\\nlargely deferred to meeting next week. Reviewed pt\\ns h/o poor\\n self-esteem. While pt did not feel he could learn like his brothers,\\n pt had been physically skilled when he was young\\nplanned to be a boxer,\\n played football until dx with DM. Perhaps part of pt\\ns long-term plan\\n could involve boxing to alleviate physical aggression if medically\\n able. Perhaps he could relate to ex-gang members in reform programs.\\n Clearly he needs extensive psychiatric support.\\n Am following case and waiting to see what floor pt is called out to\\n before arranging family meeting for next week. Please page me at \\n with any questions/concerns.\\n -, LICSW\\n PM\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Physician Attending/Resident Progress Note - MICU\",\n \"row_id\": 373124,\n \"text\": \"Chief Complaint: Section 12 due to non-compliance with dialysis\\n 24 Hour Events:\\n - Read of CXR concerning for pericardial effusion given enlarged\\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\\n more lordotic positioning.\\n - Clinically without hypotension or tachycardia. JVP flat.\\n - ECHO revealed no pericardial effusion and slight increase in left\\n ventricular size since \\n - Was somnolent throughout day and awoke brief during dialysis and was\\n agitated and threatening leave briefly, received 1 mg lorazepam and\\n subsequently slept for several hours.\\n - Was sitting up eating at ~ and suddenly anounced that he was\\n going to leave. Talked to several heathcare personnel and became\\n escalated to the point that he required security to help restrain him\\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\\n 0500 on when had repeat episode and could not be talked down and\\n again security called and was restrained and given 5 mg IV haldol and 2\\n mg IV lorazepam.\\n - On EKG this AM QTc was 450 ms\\n ROS:\\n Unable to obtain due to patient sedation.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 10:15 AM\\n Insulin - Humalog - 05:00 AM\\n Lorazepam (Ativan) - 05:30 AM\\n Haloperidol (Haldol) - 05:30 AM\\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: 37.4\\nC (99.3\\n Tcurrent: 36.4\\nC (97.6\\n HR: 87 (85 - 102) bpm\\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\\n RR: 12 (10 - 21) insp/min\\n SpO2: 97% on room air\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n 280 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 5,500 mL\\n 0 mL\\n Balance:\\n -5,400 mL\\n 280 mL\\n Physical Examination\\n GEN: Sedated and sleeping.\\n HEENT: PERRL, oral mucosa moist\\n NECK: no LAD, JVP flat\\n PULM: CTAB with overlying son upper respiratory sounds\\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\\n ABD: BS+, soft, non-distended\\n EXT: Left > right lower extremity edema with no differential warmth\\n NEURO: Somnolent\\n Labs from \\n 400 K/uL\\n 10.6 g/dL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n MICRO:\\n URINE URINE CULTURE-PENDING NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n Assessment and Plan:\\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n # Chronic renal failure-secondary to ESRD/DM:\\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\\n hyperkalemia, and hyperphosphatemia.\\n - HD today in the ICU\\n # Left lower extremity edema:\\n Acute within last week. Patient denies pain with ambulation or knee\\n joint manipulation. Has had two negative sets of lower-extremity\\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\\n other obstructive process to cause differential swelling. Patient was\\n on antibiotics at presentation, but this is not entirely consistent\\n with a cellulitis.\\n - Consider pelvic venous imaging to rule out pelvic DVT\\n # Psychiatric:\\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\\n have decided to section 12 pt. Psychiatry aware and suggests that the\\n pt does not have capacity and the medical team should consider\\n guardianship. had two episodes of threatening to leave hospital\\n overnight requiring security to assist in giving patient chemical\\n restraints (5 mg haldol and 2 mg lorazepam each episode)\\n - Follow-up psychiatry recs\\n - Will need 1:1 observation and cannot leave hospital\\n # Increase in size of cardiac silhouette by CXR on :\\n Was ruled out for pericardial effusion by ECHO. Most likely\\n projectional artifact.\\n # Hypertension:\\n Continue outpt meds and uptitrate prn. HD this AM.\\n - As mental status allows will add back on amlodipine, lisinopril,\\n metoprolol, labetolol.\\n - Will have to reeval outpt regimen\\n # Diabetes mellitus type 1:\\n Insulin 75/25 at half of home doses and conservative sliding scale\\n insulin given that patient is taking little orally.\\n # Reported ETOH:\\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\\n admission. No history of withdrawal symptoms.\\n - Monitor for withdrawal\\n # Anemia:\\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\\n today.\\n - Epoetin at HD\\n ICU Care\\n Nutrition: Renal, diabetic diet\\n Glycemic Control: Minimal glargine dose and conservative humalog\\n sliding scale\\n Lines: PIV\\n Prophylaxis:\\n DVT: Heparin subcutaneous\\n Stress ulcer: H2 blocker as home medication\\n Communication: Working with psychiatry and liason in determining if\\n guardianship should be obtained. Patient not competent to make own\\n medical decisions at this time.\\n Code status: Presumed FULL\\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\\n leave hospital without psychiatric clearance. Likely discharge to\\n psychiatric facility.\\n ------ Protected Section ------\\n CRITICAL CARE ADDENDUM\\n Mr. was seen, examined and evaluated with Dr. and the ICU\\n team with whose detailed note above I agree. Mr. is a 31 yo man\\n with psychiatric illness, DM I, ESRD on HD who was brought in Section\\n 12 because he was not compliant with HD. Getting hemodialysis for\\n hyperkalemia. Agitated overnight requiring benzodiazepines and haldol.\\n Left leg is edematous and LENIS negative. Overnight, CXR w/?widened\\n mediastinum - echo w/o abnormality - ?fat pad or positioning.\\n Somnolent throughout the day and agitated over night - restrained by\\n security and given haldol. QTc stable at 450.\\n Currently somnolent, but arousable and answering questions with\\n curses. HR 90, 166/75, Neg 5.4L yesterday. 97% RA, Lungs clear to\\n auscultation. RRR w/o murmur. Abd benign. Thrill palpable UE. Left\\n LE edematous - no labs today (await w/HD).\\n Plan includes hemodialysis today. Continue to use haldol and\\n benzodiazepines as needed for agitation and sedation. We are awaiting\\n guardianship. Evaluate Left LE with ?pelvic vein imaging and will d/w\\n dr . Agitation control. Needs 1:1 sitter. be called out if\\n stable following HD today.\\n , MD\\n Critical Care Attending\\n 40 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 11:04 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373628,\n \"text\": \"HPI:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was , during his previous admssion. His normal HD schedule is\\n T/Th/Sat.\\n .\\n He was seen by psychiatry in the ED and admitted under section 12\\n because he was not deemed competent to decline medical care. He\\n received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .\\n He was noted to have an enlarged heart shadow on his CXR concerning for\\n effusion. TTE did not show evidence of effusion.\\n .\\n His left leg was noted to be bigger than his right. LENIs were negative\\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\\n remained afebrile and did not have a leukocytosis.\\n .\\n In addition to above management, in the MICU the patient also received\\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\\n required security involvment for agitation on two separate occasions.\\n .\\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco. Given pt's current respiratory status, the renal\\n fellow made the decision the urgently dialyze the pt and he was\\n therefore transferred to the MICU.\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt admitted to the micu from 2. on 100% non rebreather o2sat\\n 92-99%. Creat 7.8\\n Action:\\n Hemodyiaylsis nurse in and dialysis begun at 0430 am.\\n Response:\\n Diaylysis intiated and tolerating . bp 160-170\\ns. very cooperative;\\n sitter at the bedside.\\n Plan:\\n Continue dialysis till 0830am. Check creat level in late am.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n K upon arrival to the unit .8 repeat 7.2.\\n Action:\\n Postassium level being monitored. Hemodyamics being monitored. Ekg\\n monitored.\\n Response:\\n Dialysis being done and tolerating well\\n Plan:\\n Monitor potassium level closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373786,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373791,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Pt\\ns K+ has been dropping with dialysis.\\n Action:\\n last K+ level was 4.4 at 1030 \\n Response:\\n Pt responding to dialysis.\\n Plan:\\n Continue dialysis according to his schedule.\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Since admission to the MICU pt has been had two sessions of diaylsis\\n Action:\\n Last dialysis was today with the removal of 5l of fluid.\\n Yesterday they also removed 5l of fluid\\n Response:\\n With the total removal of 10 liters of fluid in the last 2 days his O2\\n requirement dropped from NRB to room air. O2 sats are 96-100%.\\n Plan:\\n Continue with fliud restriction, continue with dialysis treatments.\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Pt has been very manic today, He is in a good mood, talking almost\\n constantly day. The family meeting with social services and Psych was\\n cancelled but an informal family meeting was held at 1500.\\n Action:\\n Haldol 1.5 mg continues to be given q12h\\n Response:\\n Behavior in control today.\\n Plan:\\n Pt called out to the floor, hopefully to 2\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373792,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Pt\\ns K+ has been dropping with dialysis.\\n Action:\\n last K+ level was 4.4 at 1030 \\n Response:\\n Pt responding to dialysis.\\n Plan:\\n Continue dialysis according to his schedule.\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Since admission to the MICU pt has been had two sessions of diaylsis\\n Action:\\n Last dialysis was today with the removal of 5l of fluid.\\n Yesterday they also removed 5l of fluid\\n Response:\\n With the total removal of 10 liters of fluid in the last 2 days his O2\\n requirement dropped from NRB to room air. O2 sats are 96-100%.\\n Plan:\\n Continue with fliud restriction, continue with dialysis treatments.\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Pt has been very manic today, He is in a good mood, talking almost\\n constantly day. The family meeting with social services and Psych was\\n cancelled but an informal family meeting was held at 1500.\\n Action:\\n Haldol 1.5 mg continues to be given q12h\\n Response:\\n Behavior in control today.\\n Plan:\\n Pt called out to the floor, hopefully to 2\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n HYPERKALEMIA\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 71.2 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: Anemia, Diabetes - Insulin\\n CV-PMH: Hypertension\\n Additional history: hyperlipedemia, diabetes type I on insulin end\\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\\n pressured,racing thoughts decreased sleep consistent with possible\\n mania. lower left extremitiy swelling dopplerable. neg for clots.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:136\\n D:113\\n Temperature:\\n 96.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 20 insp/min\\n Heart Rate:\\n 89 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 100% %\\n 24h total in:\\n 1,100 mL\\n 24h total out:\\n 5,000 mL\\n Pertinent Lab Results:\\n Sodium:\\n 135 mEq/L\\n 10:30 AM\\n Potassium:\\n 4.8 mEq/L\\n 10:30 AM\\n Chloride:\\n 95 mEq/L\\n 10:30 AM\\n CO2:\\n 31 mEq/L\\n 10:30 AM\\n BUN:\\n 28 mg/dL\\n 10:30 AM\\n Creatinine:\\n 4.6 mg/dL\\n 10:30 AM\\n Glucose:\\n 326 mg/dL\\n 10:30 AM\\n Hematocrit:\\n 26.4 %\\n 10:30 AM\\n Finger Stick Glucose:\\n 351\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables: None\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: Micu 687\\n Transferred to:\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373106,\n \"text\": \"Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\\n w/o complaint until 0500- awake, initially pleasant, engaging in\\n conversation- allowed off monitors to wash self , @ 05:30 stating\\n wanted to leave to go to dialysis- attempted to talk down pt, pt\\n reviewing care and accepting Insulin but not PO anti-hypertensives-\\n moderate agitation just persisting on leaving- security called and pt\\n accepting IV chemical restraint- 5mg IVP Haldol, 2mg IV Ativan and\\n lying down in bed. Pt unable/pt refuse and PO medication. Section 12-\\n pt may not leave AMA.\\n Impaired Health Maintenance\\n Assessment:\\n Pt stating\\nI had dialysis yesterday, I need to go to my dialysis\\n today\\n, unable to review dialysis plans, pt focused on leaving\\n hospital, refusing medications\\n Action:\\n Emotional support, reviewing POC\\n Response:\\n Attempting to leave x1\\n Plan:\\n not leave AMA, IV Haldol for restraint, reviewing POC ? social work\\n and psych to follow up\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373109,\n \"text\": \"Chief Complaint: Section 12 due to non-compliance with dialysis\\n 24 Hour Events:\\n - Read of CXR concerning for pericardial effusion given enlarged\\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\\n more lordotically positioned.\\n - Clinically without hypotension or tachycardia. JVP flat.\\n - ECHO revealed no pericardial effusion and slight increase in left\\n ventricular size since \\n - Was somnolent throughout day and awoke brief during dialysis and was\\n agitated and threatening leave briefly, received 1 mg lorazepam and\\n subsequently slept for several hours.\\n - Was sitting up eating at ~ and suddenly anounced that he was\\n going to leave. Talked to several heathcare personnel and became\\n escalated to the point that he required security to help restrain him\\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\\n 0500 on when had repeat episode and could not be talked down and\\n again security called and was restrained and given 5 mg IV haldol and 2\\n mg IV lorazepam.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 10:15 AM\\n Insulin - Humalog - 05:00 AM\\n Lorazepam (Ativan) - 05:30 AM\\n Haloperidol (Haldol) - 05:30 AM\\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: 37.4\\nC (99.3\\n Tcurrent: 36.4\\nC (97.6\\n HR: 87 (85 - 102) bpm\\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\\n RR: 12 (10 - 21) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n 280 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 5,500 mL\\n 0 mL\\n Balance:\\n -5,400 mL\\n 280 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n GEN:\\n HEENT:\\n NECK:\\n PULM:\\n CARD:\\n ABD:\\n EXT:\\n NEURO:\\n Labs / Radiology\\n 400 K/uL\\n 10.6 g/dL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n Assessment and Plan\\n IMPAIRED HEALTH MAINTENANCE\\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:45 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373111,\n \"text\": \"Chief Complaint: Section 12 due to non-compliance with dialysis\\n 24 Hour Events:\\n - Read of CXR concerning for pericardial effusion given enlarged\\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\\n more lordotically positioned.\\n - Clinically without hypotension or tachycardia. JVP flat.\\n - ECHO revealed no pericardial effusion and slight increase in left\\n ventricular size since \\n - Was somnolent throughout day and awoke brief during dialysis and was\\n agitated and threatening leave briefly, received 1 mg lorazepam and\\n subsequently slept for several hours.\\n - Was sitting up eating at ~ and suddenly anounced that he was\\n going to leave. Talked to several heathcare personnel and became\\n escalated to the point that he required security to help restrain him\\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\\n 0500 on when had repeat episode and could not be talked down and\\n again security called and was restrained and given 5 mg IV haldol and 2\\n mg IV lorazepam.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 10:15 AM\\n Insulin - Humalog - 05:00 AM\\n Lorazepam (Ativan) - 05:30 AM\\n Haloperidol (Haldol) - 05:30 AM\\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: 37.4\\nC (99.3\\n Tcurrent: 36.4\\nC (97.6\\n HR: 87 (85 - 102) bpm\\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\\n RR: 12 (10 - 21) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n 280 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 5,500 mL\\n 0 mL\\n Balance:\\n -5,400 mL\\n 280 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n GEN:\\n HEENT:\\n NECK:\\n PULM:\\n CARD:\\n ABD:\\n EXT:\\n NEURO:\\n Labs / Radiology\\n 400 K/uL\\n 10.6 g/dL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n Assessment and Plan:\\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\\n again missed HD sessions.\\n -renal aware\\n -plan for HD tonight\\n -monitor lytes\\n -continue outpt calcium acetate, sensipar, lanthanum\\n -u/a and Cx\\n -consider renal u/s.\\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\\n HD.\\n -plan for HD tonight\\n -monitor lytes\\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\\n -amlodipine, lisinopril, metoprolol, labetolol.\\n -will have to reeval outpt regimen\\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\\n #psychiatric-PT with persistent pattern of non-compliance with HD,\\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\\n large quantities of ETOH and takes illicit substances, then withdraws,\\n but all screens have been negative. At this time, SW and pt's outpt\\n nephrologist have decided to section 12 pt. Psychiatry aware and\\n suggests that the pt does not have capacity and the medical team should\\n consider guardianship.\\n - screens negative\\n -SW consult\\n -f/u psych recs.\\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\\n monitor for signs of w/d.\\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\\n -epogen at HD\\n ICU Care\\n Nutrition: Renal, diabetic diet\\n Glycemic Control: Minimal glargine dose and conservative humalog\\n sliding scale\\n Lines: PIV\\n Prophylaxis:\\n DVT: Heparin subcutaneous\\n Stress ulcer: H2 blocker as home medication\\n Communication: Working with psychiatry and liason in determining if\\n guardianship should be obtained. Patient not competent to make own\\n medical decisions at this time.\\n Code status: Presumed FULL\\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\\n leave hospital without psychiatric clearance. Likely discharge to\\n psychiatric facility.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373079,\n \"text\": \"Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\\n w/o complaint until 0500- awake.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373784,\n \"text\": \"Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372913,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Plan:\\n Follow up with renal,,cont HD\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 372907,\n \"text\": \"Chief Complaint: Nephrology: Dr. \\n CC: section 12 for HD/hyperkalemia.\\n HPI:\\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn.\\n .\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship. In addition, pt often states that he is\\n taking drugs and drinking large quantities of ETOH and withdrawing in\\n the hospital, but screens are negative.\\n .\\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\\n given plan for HD.\\n .\\n Time Pain Temp HR BP RR Pox\\n 17:43 9 99.6 106 192/92 18 100\\n states drinking a liter of ETOH daily.\\n Patient admitted from: ER\\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 Other ICU medications:\\n Other medications:\\n Epogen 3,000 unit/mL Injection\\n given in dialysis three times a day\\n Lipitor 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\\n 10 units q am and 8 units q pm\\n Sensipar 90 mg Tab\\n 1 Tablet(s) by mouth daily\\n FOSRENOL 1,000 mg Chewable Tab\\n 1 Tablet(s) by mouth 4 times daily with meals and snack\\n Lisinopril 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Colace 100 mg Cap\\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\\n Amlodipine 5 mg Tab\\n 1 Tablet(s) by mouth once a day\\n PhosLo 667 mg Cap\\n 2 Capsule(s) by mouth three times a day\\n Labetalol 300 mg Tab\\n 1 Tablet(s) by mouth three times a day\\n Metoprolol SR 25 mg 24 hr Tab\\n 1 Tablet(s) by mouth twice a day\\n Nephrocaps 1 mg Cap\\n 1 Capsule(s) by mouth once a day\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \\n \\n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\\n Recently, he has been mostly dialyzed in\\n hospital, but usually gets his HD at in \\n T,Th,Sat.\\n 3. Diabetic retinopathy (diagnosed 2 years ago)\\n 4. Diabetic neuropathy\\n 5. Diabetic myonecrosis ()\\n 6. Chronic ulcer at right foot\\n 7. Hypertension\\n 8.?psychiatric disorder-bipolar\\n .\\n Social History:\\n Recent social situation complicated, in that patient used to\\n live with his mother, but due to a disagreement, has moved out.\\n His FH is significant for diabetes. His mother and his father\\n are in the 50's both suffering from DMII. He has 2 sisters at\\n the age of 20 and 26 both suffering from DMI. He has four\\n brothers at the age of 16, 19, 28, and 30. His both older\\n brothers suffer from DMI. All his grandparents had DM. Pt. says\\n there is no h/o of heart disease, HTN, cancer or bleeding\\n disorders in the family.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: worked as cleaner until 7 years ago. Since than he has been\\n living on disability. He is living with his mother, his 16 y/o\\n brother and his 26 y/o sister in a house in . He was\\n recently asked to leave his older brother's house as result of\\n stealing form the brother. The patient now reports being\\n homeless for the last 48 hours.\\n Review of systems: see above\\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\\n RR: 14 (13 - 14) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\\n HEENT-PERRLA, EOMI, anicteric,MMM,\\n neck-unable to assess for JVP, no LAD\\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\\n heart-s1s2 RRR no m/r/g\\n abd-+bs, soft, Nt, ND\\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\\n neuro-somnolent but moving all 4 extremities.\\n Labs / Radiology see OMR.\\n [image002.jpg]\\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\\n prior EKG.\\n .\\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\\n transition. The P wave morphology appears less prominent while the P\\n wave axis remains rightward. The prior tracing was consistent with\\n right atrial abnormality. Otherwise, no diagnostic interim change.\\n Clinical correlation is suggested.\\n .\\n ECHO -The left atrium is mildly dilated. No atrial septal defect\\n is seen by 2D or color Doppler. There is mild symmetric left\\n ventricular hypertrophy with normal cavity size. Regional left\\n ventricular wall motion is normal. Overall left ventricular systolic\\n function is normal (LVEF>55%). Right ventricular chamber size and free\\n wall motion are normal. The aortic valve leaflets (3) appear\\n structurally normal with good leaflet excursion. No masses or\\n vegetations are seen on the aortic valve. There is no aortic valve\\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\\n are structurally normal. There is no mitral valve prolapse. No mass or\\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\\n is seen. There is mild pulmonary artery systolic hypertension. No\\n masses or vegetations are seen on the pulmonic valve, but cannot be\\n fully excluded due to suboptimal image quality. There is no pericardial\\n effusion.\\n CXR\\n LENI -IMPRESSION: No left leg DVT.\\n Assessment and Plan\\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n .\\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\\n again missed HD sessions.\\n -renal aware\\n -plan for HD tonight\\n -monitor lytes\\n -continue outpt calcium acetate, sensipar, lanthanum\\n -u/a and Cx\\n -consider renal u/s.\\n .\\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\\n HD.\\n -plan for HD tonight\\n -monitor lytes\\n .\\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\\n -amlodipine, lisinopril, metoprolol, labetolol.\\n -will have to reeval outpt regimen\\n .\\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\\n .\\n #psychiatric-PT with persistent pattern of non-compliance with HD,\\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\\n large quantities of ETOH and takes illicit substances, then withdraws,\\n but all screens have been negative. At this time, SW and pt's outpt\\n nephrologist have decided to section 12 pt. Psychiatry aware and\\n suggests that the pt does not have capacity and the medical team should\\n consider guardianship.\\n - screens negative\\n -SW consult\\n -f/u psych recs.\\n .\\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\\n monitor for signs of w/d.\\n .\\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\\n -epogen at HD\\n .\\n #FEN-renal/DM\\n .\\n #PPx-bowel regimen, Hep SC\\n #access-HD fistula, pt refusing IV\\n .\\n #Code-presumed full\\n #dispo-pending completion of HD session.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: HISS/ 75/25 at home.\\n Lines: PIV\\n Prophylaxis:\\n DVT: hep SC\\n Stress ulcer: h2\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: presumed full\\n Disposition: ICU overnight.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 372908,\n \"text\": \"Chief Complaint: Nephrology: Dr. \\n CC: section 12 for HD/hyperkalemia.\\n HPI:\\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn.\\n .\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship. In addition, pt often states that he is\\n taking drugs and drinking large quantities of ETOH and withdrawing in\\n the hospital, but screens are negative.\\n .\\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\\n given plan for HD.\\n .\\n Time Pain Temp HR BP RR Pox\\n 17:43 9 99.6 106 192/92 18 100\\n states drinking a liter of ETOH daily.\\n Patient admitted from: ER\\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 Other ICU medications:\\n Other medications:\\n Epogen 3,000 unit/mL Injection\\n given in dialysis three times a day\\n Lipitor 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\\n 10 units q am and 8 units q pm\\n Sensipar 90 mg Tab\\n 1 Tablet(s) by mouth daily\\n FOSRENOL 1,000 mg Chewable Tab\\n 1 Tablet(s) by mouth 4 times daily with meals and snack\\n Lisinopril 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Colace 100 mg Cap\\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\\n Amlodipine 5 mg Tab\\n 1 Tablet(s) by mouth once a day\\n PhosLo 667 mg Cap\\n 2 Capsule(s) by mouth three times a day\\n Labetalol 300 mg Tab\\n 1 Tablet(s) by mouth three times a day\\n Metoprolol SR 25 mg 24 hr Tab\\n 1 Tablet(s) by mouth twice a day\\n Nephrocaps 1 mg Cap\\n 1 Capsule(s) by mouth once a day\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \\n \\n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\\n Recently, he has been mostly dialyzed in\\n hospital, but usually gets his HD at in \\n T,Th,Sat.\\n 3. Diabetic retinopathy (diagnosed 2 years ago)\\n 4. Diabetic neuropathy\\n 5. Diabetic myonecrosis ()\\n 6. Chronic ulcer at right foot\\n 7. Hypertension\\n 8.?psychiatric disorder-bipolar\\n .\\n Social History:\\n Recent social situation complicated, in that patient used to\\n live with his mother, but due to a disagreement, has moved out.\\n His FH is significant for diabetes. His mother and his father\\n are in the 50's both suffering from DMII. He has 2 sisters at\\n the age of 20 and 26 both suffering from DMI. He has four\\n brothers at the age of 16, 19, 28, and 30. His both older\\n brothers suffer from DMI. All his grandparents had DM. Pt. says\\n there is no h/o of heart disease, HTN, cancer or bleeding\\n disorders in the family.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: worked as cleaner until 7 years ago. Since than he has been\\n living on disability. He is living with his mother, his 16 y/o\\n brother and his 26 y/o sister in a house in . He was\\n recently asked to leave his older brother's house as result of\\n stealing form the brother. The patient now reports being\\n homeless for the last 48 hours.\\n Review of systems: see above\\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\\n RR: 14 (13 - 14) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\\n HEENT-PERRLA, EOMI, anicteric,MMM,\\n neck-unable to assess for JVP, no LAD\\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\\n heart-s1s2 RRR no m/r/g\\n abd-+bs, soft, Nt, ND\\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\\n neuro-somnolent but moving all 4 extremities.\\n Labs / Radiology see OMR.\\n [image002.jpg]\\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\\n prior EKG.\\n .\\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\\n transition. The P wave morphology appears less prominent while the P\\n wave axis remains rightward. The prior tracing was consistent with\\n right atrial abnormality. Otherwise, no diagnostic interim change.\\n Clinical correlation is suggested.\\n .\\n ECHO -The left atrium is mildly dilated. No atrial septal defect\\n is seen by 2D or color Doppler. There is mild symmetric left\\n ventricular hypertrophy with normal cavity size. Regional left\\n ventricular wall motion is normal. Overall left ventricular systolic\\n function is normal (LVEF>55%). Right ventricular chamber size and free\\n wall motion are normal. The aortic valve leaflets (3) appear\\n structurally normal with good leaflet excursion. No masses or\\n vegetations are seen on the aortic valve. There is no aortic valve\\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\\n are structurally normal. There is no mitral valve prolapse. No mass or\\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\\n is seen. There is mild pulmonary artery systolic hypertension. No\\n masses or vegetations are seen on the pulmonic valve, but cannot be\\n fully excluded due to suboptimal image quality. There is no pericardial\\n effusion.\\n CXR\\n LENI -IMPRESSION: No left leg DVT.\\n Assessment and Plan\\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n .\\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\\n again missed HD sessions.\\n -renal aware\\n -plan for HD tonight\\n -monitor lytes\\n -continue outpt calcium acetate, sensipar, lanthanum\\n -u/a and Cx\\n -consider renal u/s.\\n .\\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\\n HD.\\n -plan for HD tonight\\n -monitor lytes\\n .\\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\\n -amlodipine, lisinopril, metoprolol, labetolol.\\n -will have to reeval outpt regimen\\n .\\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\\n .\\n #psychiatric-PT with persistent pattern of non-compliance with HD,\\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\\n large quantities of ETOH and takes illicit substances, then withdraws,\\n but all screens have been negative. At this time, SW and pt's outpt\\n nephrologist have decided to section 12 pt. Psychiatry aware and\\n suggests that the pt does not have capacity and the medical team should\\n consider guardianship.\\n - screens negative\\n -SW consult\\n -f/u psych recs.\\n .\\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\\n monitor for signs of w/d.\\n .\\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\\n -epogen at HD\\n .\\n #FEN-renal/DM\\n .\\n #PPx-bowel regimen, Hep SC\\n #access-HD fistula, pt refusing IV\\n .\\n #Code-presumed full\\n #dispo-pending completion of HD session.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: HISS/ 75/25 at home.\\n Lines: PIV\\n Prophylaxis:\\n DVT: hep SC\\n Stress ulcer: h2\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: presumed full\\n Disposition: ICU overnight.\\n ------ Protected Section ------\\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\\n DVT. Will give unasyn for now for presumed cellulitis.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 00:50 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 372911,\n \"text\": \"Chief Complaint: Nephrology: Dr. \\n CC: section 12 for HD/hyperkalemia.\\n HPI:\\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn.\\n .\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship. In addition, pt often states that he is\\n taking drugs and drinking large quantities of ETOH and withdrawing in\\n the hospital, but screens are negative.\\n .\\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\\n given plan for HD.\\n .\\n Time Pain Temp HR BP RR Pox\\n 17:43 9 99.6 106 192/92 18 100\\n states drinking a liter of ETOH daily.\\n Patient admitted from: ER\\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 Other ICU medications:\\n Other medications:\\n Epogen 3,000 unit/mL Injection\\n given in dialysis three times a day\\n Lipitor 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\\n 10 units q am and 8 units q pm\\n Sensipar 90 mg Tab\\n 1 Tablet(s) by mouth daily\\n FOSRENOL 1,000 mg Chewable Tab\\n 1 Tablet(s) by mouth 4 times daily with meals and snack\\n Lisinopril 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Colace 100 mg Cap\\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\\n Amlodipine 5 mg Tab\\n 1 Tablet(s) by mouth once a day\\n PhosLo 667 mg Cap\\n 2 Capsule(s) by mouth three times a day\\n Labetalol 300 mg Tab\\n 1 Tablet(s) by mouth three times a day\\n Metoprolol SR 25 mg 24 hr Tab\\n 1 Tablet(s) by mouth twice a day\\n Nephrocaps 1 mg Cap\\n 1 Capsule(s) by mouth once a day\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \\n \\n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\\n Recently, he has been mostly dialyzed in\\n hospital, but usually gets his HD at in \\n T,Th,Sat.\\n 3. Diabetic retinopathy (diagnosed 2 years ago)\\n 4. Diabetic neuropathy\\n 5. Diabetic myonecrosis ()\\n 6. Chronic ulcer at right foot\\n 7. Hypertension\\n 8.?psychiatric disorder-bipolar\\n .\\n Social History:\\n Recent social situation complicated, in that patient used to\\n live with his mother, but due to a disagreement, has moved out.\\n His FH is significant for diabetes. His mother and his father\\n are in the 50's both suffering from DMII. He has 2 sisters at\\n the age of 20 and 26 both suffering from DMI. He has four\\n brothers at the age of 16, 19, 28, and 30. His both older\\n brothers suffer from DMI. All his grandparents had DM. Pt. says\\n there is no h/o of heart disease, HTN, cancer or bleeding\\n disorders in the family.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: worked as cleaner until 7 years ago. Since than he has been\\n living on disability. He is living with his mother, his 16 y/o\\n brother and his 26 y/o sister in a house in . He was\\n recently asked to leave his older brother's house as result of\\n stealing form the brother. The patient now reports being\\n homeless for the last 48 hours.\\n Review of systems: see above\\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\\n RR: 14 (13 - 14) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\\n HEENT-PERRLA, EOMI, anicteric,MMM,\\n neck-unable to assess for JVP, no LAD\\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\\n heart-s1s2 RRR no m/r/g\\n abd-+bs, soft, Nt, ND\\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\\n neuro-somnolent but moving all 4 extremities.\\n Labs / Radiology see OMR.\\n [image002.jpg]\\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\\n prior EKG.\\n .\\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\\n transition. The P wave morphology appears less prominent while the P\\n wave axis remains rightward. The prior tracing was consistent with\\n right atrial abnormality. Otherwise, no diagnostic interim change.\\n Clinical correlation is suggested.\\n .\\n ECHO -The left atrium is mildly dilated. No atrial septal defect\\n is seen by 2D or color Doppler. There is mild symmetric left\\n ventricular hypertrophy with normal cavity size. Regional left\\n ventricular wall motion is normal. Overall left ventricular systolic\\n function is normal (LVEF>55%). Right ventricular chamber size and free\\n wall motion are normal. The aortic valve leaflets (3) appear\\n structurally normal with good leaflet excursion. No masses or\\n vegetations are seen on the aortic valve. There is no aortic valve\\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\\n are structurally normal. There is no mitral valve prolapse. No mass or\\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\\n is seen. There is mild pulmonary artery systolic hypertension. No\\n masses or vegetations are seen on the pulmonic valve, but cannot be\\n fully excluded due to suboptimal image quality. There is no pericardial\\n effusion.\\n CXR\\n LENI -IMPRESSION: No left leg DVT.\\n Assessment and Plan\\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n .\\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\\n again missed HD sessions.\\n -renal aware\\n -plan for HD tonight\\n -monitor lytes\\n -continue outpt calcium acetate, sensipar, lanthanum\\n -u/a and Cx\\n -consider renal u/s.\\n .\\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\\n HD.\\n -plan for HD tonight\\n -monitor lytes\\n .\\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\\n -amlodipine, lisinopril, metoprolol, labetolol.\\n -will have to reeval outpt regimen\\n .\\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\\n .\\n #psychiatric-PT with persistent pattern of non-compliance with HD,\\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\\n large quantities of ETOH and takes illicit substances, then withdraws,\\n but all screens have been negative. At this time, SW and pt's outpt\\n nephrologist have decided to section 12 pt. Psychiatry aware and\\n suggests that the pt does not have capacity and the medical team should\\n consider guardianship.\\n - screens negative\\n -SW consult\\n -f/u psych recs.\\n .\\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\\n monitor for signs of w/d.\\n .\\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\\n -epogen at HD\\n .\\n #FEN-renal/DM\\n .\\n #PPx-bowel regimen, Hep SC\\n #access-HD fistula, pt refusing IV\\n .\\n #Code-presumed full\\n #dispo-pending completion of HD session.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: HISS/ 75/25 at home.\\n Lines: PIV\\n Prophylaxis:\\n DVT: hep SC\\n Stress ulcer: h2\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: presumed full\\n Disposition: ICU overnight.\\n ------ Protected Section ------\\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\\n DVT. Will give unasyn for now for presumed cellulitis.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 00:50 ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: receiving HD currently, psych evaluation and\\n treatment of cellulitis as described above. Unable to obtain complete\\n ROS due to altered mental status. Labs reviewed and notable for\\n hyperkalemia but otherwise stable.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 01:31 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372914,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372965,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\\n of Dextrose foe hypoglycemia.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 373000,\n \"text\": \"Chief Complaint: hyperkalemia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 31 yo ESRD secondary to DM I on tranplant list. Presenting with\\n hyperkalemia after missing HD. Was brought in ?unclear how. In ED was\\n agitated. Was eval by psych who felt he did not have capacity to make\\n decisions. Got 5mg haldol and 2mg of ativan. K was 6.4. refused\\n kayexalate. Came to MICU for urgent HD. BP 192/92 sat 100% on RAn in\\n ED. Overnight required D50x3 for hypoglycemia after getting dosed\\n with SSI.\\n 24 Hour Events:\\n NASAL SWAB - At 12:14 AM\\n MRSA screen\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 06:00 AM\\n Hydralazine - 06:10 AM\\n Other medications:\\n nephrocaps\\n calcium acetate\\n norvasc\\n lisinopril\\n EPO\\n lipitor\\n pepcid\\n hep s/q\\n toprol\\n labetolol\\n lanthenum\\n SSI\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.9\\n HR: 87 (75 - 98) bpm\\n BP: 162/81(99) {137/57(77) - 201/106(128)} mmHg\\n RR: 13 (11 - 17) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n PO:\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,500 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -2,400 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///29/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender\\n Extremities: Right: Absent, Left: 3+\\n Skin: Not assessed\\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 10.6 g/dL\\n 400 K/uL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n ECG: slightly peaked Tw\\n Assessment and Plan\\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD): Got\\n emergent HD overnight. K now normalized.\\n Section 12: will need psych admission after medical issues are cleared\\n RLE: swelling and redness. Has had this for at least a few days with\\n no worsening. No clear evidence of cellulitis,\\n DM I: will start half dose NPH and cut back on sliding scale as he was\\n hypoglycemic today.\\n agitation: Currently sedated, but will need sitter and haldol prn.\\n has right effusion in knee: will tap.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:45 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU can go to floor after HD\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372960,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\\n of Dextrose foe hypoglycemia.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373062,\n \"text\": \"31M with DM1, ESRD on HD, reportedly on the transplant list who\\n presents again with hyperkalemia after missing HD. Pt reportedly not\\n cooperative in the ED and agitated. Of note, pt has had several\\n admissions for hyperkalemia/missing HD sessions and left the hospital\\n AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\\n ativan IV. Renal fellow aware that pt is here and HD planned for\\n tonight. No intervention for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW) was to\\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt with known ESRD, dialyzed overnight upon admission to\\n unit .5L removed.\\n Received pt very lethargic, arousable only to simulation,\\n unable to give most PO meds due to lethargy.\\n Action:\\n Dialyzed again this afternoon per renal orders, 3L removed.\\n Pt becoming more arousable during dialysis, alert and\\n oriented x 3, very talkative at times becoming agitated however easily\\n redirected.\\n Response:\\n Pt tolerated dialysis well, SBP >100\\n Received IV Ativan 1mg x 2 with some effect, also ordered\\n for but did not receive any Haldol.\\n Plan:\\n Pt to have dialysis again tomorrow.\\n PRN Ativan and Haldol as needed.\\n Pt noted to have larger heart on CXR, MDs questioning pericardial\\n effusion, bedside ECHO performed, results pending. Pt called out to\\n floor, awaiting bed placement.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372955,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n Pt received 10 mg Hydralasinr for BP of 190/\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373120,\n \"text\": \"Chief Complaint: Section 12 due to non-compliance with dialysis\\n 24 Hour Events:\\n - Read of CXR concerning for pericardial effusion given enlarged\\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\\n more lordotic positioning.\\n - Clinically without hypotension or tachycardia. JVP flat.\\n - ECHO revealed no pericardial effusion and slight increase in left\\n ventricular size since \\n - Was somnolent throughout day and awoke brief during dialysis and was\\n agitated and threatening leave briefly, received 1 mg lorazepam and\\n subsequently slept for several hours.\\n - Was sitting up eating at ~ and suddenly anounced that he was\\n going to leave. Talked to several heathcare personnel and became\\n escalated to the point that he required security to help restrain him\\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\\n 0500 on when had repeat episode and could not be talked down and\\n again security called and was restrained and given 5 mg IV haldol and 2\\n mg IV lorazepam.\\n - On EKG this AM QTc was 450 ms\\n ROS:\\n Unable to obtain due to patient sedation.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 10:15 AM\\n Insulin - Humalog - 05:00 AM\\n Lorazepam (Ativan) - 05:30 AM\\n Haloperidol (Haldol) - 05:30 AM\\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: 37.4\\nC (99.3\\n Tcurrent: 36.4\\nC (97.6\\n HR: 87 (85 - 102) bpm\\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\\n RR: 12 (10 - 21) insp/min\\n SpO2: 97% on room air\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n 280 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 5,500 mL\\n 0 mL\\n Balance:\\n -5,400 mL\\n 280 mL\\n Physical Examination\\n GEN: Sedated and sleeping.\\n HEENT: PERRL, oral mucosa moist\\n NECK: no LAD, JVP flat\\n PULM: CTAB with overlying son upper respiratory sounds\\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\\n ABD: BS+, soft, non-distended\\n EXT: Left > right lower extremity edema with no differential warmth\\n NEURO: Somnolent\\n Labs from \\n 400 K/uL\\n 10.6 g/dL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n MICRO:\\n URINE URINE CULTURE-PENDING NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n Assessment and Plan:\\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n # Chronic renal failure-secondary to ESRD/DM:\\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\\n hyperkalemia, and hyperphosphatemia.\\n - HD today in the ICU\\n # Left lower extremity edema:\\n Acute within last week. Patient denies pain with ambulation or knee\\n joint manipulation. Has had two negative sets of lower-extremity\\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\\n other obstructive process to cause differential swelling. Patient was\\n on antibiotics at presentation, but this is not entirely consistent\\n with a cellulitis.\\n - Consider pelvic venous imaging to rule out pelvic DVT\\n # Psychiatric:\\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\\n have decided to section 12 pt. Psychiatry aware and suggests that the\\n pt does not have capacity and the medical team should consider\\n guardianship. had two episodes of threatening to leave hospital\\n overnight requiring security to assist in giving patient chemical\\n restraints (5 mg haldol and 2 mg lorazepam each episode)\\n - Follow-up psychiatry recs\\n - Will need 1:1 observation and cannot leave hospital\\n # Increase in size of cardiac silhouette by CXR on :\\n Was ruled out for pericardial effusion by ECHO. Most likely\\n projectional artifact.\\n # Hypertension:\\n Continue outpt meds and uptitrate prn. HD this AM.\\n - As mental status allows will add back on amlodipine, lisinopril,\\n metoprolol, labetolol.\\n - Will have to reeval outpt regimen\\n # Diabetes mellitus type 1:\\n Insulin 75/25 at half of home doses and conservative sliding scale\\n insulin given that patient is taking little orally.\\n # Reported ETOH:\\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\\n admission. No history of withdrawal symptoms.\\n - Monitor for withdrawal\\n # Anemia:\\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\\n today.\\n - Epoetin at HD\\n ICU Care\\n Nutrition: Renal, diabetic diet\\n Glycemic Control: Minimal glargine dose and conservative humalog\\n sliding scale\\n Lines: PIV\\n Prophylaxis:\\n DVT: Heparin subcutaneous\\n Stress ulcer: H2 blocker as home medication\\n Communication: Working with psychiatry and liason in determining if\\n guardianship should be obtained. Patient not competent to make own\\n medical decisions at this time.\\n Code status: Presumed FULL\\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\\n leave hospital without psychiatric clearance. Likely discharge to\\n psychiatric facility.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 373765,\n \"text\": \"TITLE: Critical Care\\n Present for the key portions of the resident\\ns history and exam. Agree\\n substantially with assessment and plan as outlined. This am he is\\n manic\\n euphoric, pressured speech, flights of ideas. Denies SOB but\\n oxygenation still not normal. Seems to be improving with aggressive\\n dialysis but CXR being read as c/w pneumonic process. Needs CXR\\n tomorrow and may need CT if he fails to clear but clinically this is\\n CHF rather than infection.\\n Time spent 30 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 373601,\n \"text\": \"Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\\n HPI:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was , during his previous admssion. His normal HD schedule is\\n T/Th/Sat.\\n .\\n He was seen by psychiatry in the ED and admitted under section 12\\n because he was not deemed competent to decline medical care. He\\n received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .\\n He was noted to have an enlarged heart shadow on his CXR concerning for\\n effusion. TTE did not show evidence of effusion.\\n .\\n His left leg was noted to be bigger than his right. LENIs were negative\\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\\n remained afebrile and did not have a leukocytosis.\\n .\\n In addition to above management, in the MICU the patient also received\\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\\n required security involvment for agitation on two separate occasions.\\n .\\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco. Given pt's current respiratory status, the renal\\n fellow made the decision the urgently dialyze the pt and he was\\n therefore transferred to the MICU.\\n Patient admitted from: \\n History obtained from Medical records\\n Patient unable to provide history: not willing\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n **Patient unable to provide. Per discharge summary on ...\\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\\n Sensipar 30mg Tablet, 1 Tablet PO once a day\\n Lanthanum Oral\\n .\\n Medications on transfer:\\n Haloperidol 1.5 mg PO Q 12H\\n Acetaminophen 325-650 mg PO Q6H:PRN pain\\n Haloperidol 2 mg IM ONCE\\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\\n Duration: 1 Doses Order date: @ 1614\\n amlodipine 5 mg PO DAILY\\n Heparin 5000 UNIT SC TID\\n Aspirin 325 mg PO DAILY\\n Insulin SC (per Insulin Flowsheet)\\n Atorvastatin 40 mg PO DAILY\\n Insulin Regular 10 UNIT IV ONCE\\n Monitor Q1H for 6 Order date: @ 0044\\n Bisacodyl 10 mg PO/PR DAILY:PRN\\n Lanthanum 1000 mg PO QID\\n Calcium Acetate 1334 mg PO TID W/MEALS\\n Labetalol 300 mg PO TID\\n Calcium Gluconate 2 g IV ONCE\\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\\n Cinacalcet 30 mg PO DAILY\\n Multivitamins 1 TAB PO DAILY\\n Dextrose 50% 25 gm IV ONCE\\n Nephrocaps 1 CAP PO DAILY\\n Dextrose 50% 25 gm IV ONCE\\n Nicotine Patch 21 mg TD DAILY\\n DiphenhydrAMINE 25 mg PO HS:PRN\\n Senna 1 TAB PO BID:PRN\\n Docusate Sodium (Liquid) 100 mg PO BID\\n Epoetin Alfa\\n To be administered during dialysis and dosed according to the \\n Epoetin Alfa P&T Guidelines.\\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\\n Famotidine 20 mg PO Q24H\\n Thiamine 100 mg PO DAILY\\n FoLIC Acid 1 mg PO DAILY\\n Valsartan 160 mg PO DAILY\\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\\n d1= Order date: @ 0044\\n Haloperidol 0.5 mg PO Q2H:PRN agitation\\n MD if giving Order date: @ 1301\\n Past medical history:\\n Family history:\\n Social History:\\n Type I DM (diagnosed 13 years ago), managed by Dr. \\n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \\n Diabetic retinopathy (diagnosed 2 years ago)\\n Diabetic neuropathy\\n Diabetic myonecrosis ()\\n Chronic ulcer at right foot\\n Hypertension\\n Concern for psychiatric disorder, possibly bipolar\\n :\\n Per reveiw of records, Type II diabetes mellitus in mother and father.\\n Type I diabetes mellitus in sisters and brothers.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: He is followed by a social worker because of concern about his\\n competence. Reported alcohol use, illicit drug use.\\n Review of systems: ROS\\n Flowsheet Data as of 03:55 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100\\n Tcurrent: 37.8\\nC (100\\n HR: 92 (92 - 92) bpm\\n BP: 169/75() {169/75() - 169/75()} mmHg\\n RR: 5 (5 - 5) insp/min\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 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: Non-rebreather\\n Physical Examination\\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\\n +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\\n ABG, and hypoxia.\\n .\\n Studies:\\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \\n 8:11, TWI is more pronounced and STE is unchanged.\\n - TTE (): The left atrium is normal in size. There is moderate\\n symmetric left ventricular hypertrophy. The left ventricular cavity is\\n unusually small. Left ventricular systolic function is hyperdynamic (EF\\n 80%). There is no ventricular septal defect. Right ventricular chamber\\n size and free wall motion are normal. There are focal calcifications in\\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\\n aortic stenosis is not present. No aortic regurgitation is seen. The\\n mitral valve leaflets are mildly thickened. There is mild mitral valve\\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\\n artery systolic pressure is normal. There is no pericardial effusion.\\n There is an anterior space which most likely represents a fat pad.\\n Compared with the findings of the prior study (images unavailable) of\\n , the left ventricular wall thickening has progressed.\\n - CXR 2V (): Final read pending\\n - LENI (): No evidence of DVT of the left lower extremity.\\n Assessment and Plan\\n Assessment and plan:\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Pt\\n sat's improved after being given 80mg IV lasix. Appears, pt last\\n dialyzed . However, infection such as from PNA, ACS/cardiac\\n etiology, medication effect from anti-psychotics, or other illicit\\n substance could be involved. Other possibility to consider is PE.\\n -bcx and ucx\\n -cxr\\n -urgent HD per renal fellow\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source. Improved slightly, but now\\n stable. Had temp of 100.8 on .\\n - initially abx were stoped, but now keflex restarted with fever,\\n even though this would be a odd presentation of cellulitis\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - Repeat EKG, daily while haldol dose is adjusted\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\\n disorder component. Poor compliance has been long standing issue. Per\\n psych notes, has had \\\"agitation, pressured speech, loose and\\n tangential, racing thoughts and decreased sleep consistent with\\n possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition: DM/RENal\\n Glycemic Control: HISS\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT: h2, HSC\\n Stress ulcer:\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 373606,\n \"text\": \"Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\\n HPI:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was , during his previous admssion. His normal HD schedule is\\n T/Th/Sat.\\n .\\n He was seen by psychiatry in the ED and admitted under section 12\\n because he was not deemed competent to decline medical care. He\\n received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .\\n He was noted to have an enlarged heart shadow on his CXR concerning for\\n effusion. TTE did not show evidence of effusion.\\n .\\n His left leg was noted to be bigger than his right. LENIs were negative\\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\\n remained afebrile and did not have a leukocytosis.\\n .\\n In addition to above management, in the MICU the patient also received\\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\\n required security involvment for agitation on two separate occasions.\\n .\\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco. Given pt's current respiratory status, the renal\\n fellow made the decision the urgently dialyze the pt and he was\\n therefore transferred to the MICU.\\n Patient admitted from: \\n History obtained from Medical records\\n Patient unable to provide history: not willing\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n **Patient unable to provide. Per discharge summary on ...\\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\\n Sensipar 30mg Tablet, 1 Tablet PO once a day\\n Lanthanum Oral\\n .\\n Medications on transfer:\\n Haloperidol 1.5 mg PO Q 12H\\n Acetaminophen 325-650 mg PO Q6H:PRN pain\\n Haloperidol 2 mg IM ONCE\\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\\n Duration: 1 Doses Order date: @ 1614\\n amlodipine 5 mg PO DAILY\\n Heparin 5000 UNIT SC TID\\n Aspirin 325 mg PO DAILY\\n Insulin SC (per Insulin Flowsheet)\\n Atorvastatin 40 mg PO DAILY\\n Insulin Regular 10 UNIT IV ONCE\\n Monitor Q1H for 6 Order date: @ 0044\\n Bisacodyl 10 mg PO/PR DAILY:PRN\\n Lanthanum 1000 mg PO QID\\n Calcium Acetate 1334 mg PO TID W/MEALS\\n Labetalol 300 mg PO TID\\n Calcium Gluconate 2 g IV ONCE\\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\\n Cinacalcet 30 mg PO DAILY\\n Multivitamins 1 TAB PO DAILY\\n Dextrose 50% 25 gm IV ONCE\\n Nephrocaps 1 CAP PO DAILY\\n Dextrose 50% 25 gm IV ONCE\\n Nicotine Patch 21 mg TD DAILY\\n DiphenhydrAMINE 25 mg PO HS:PRN\\n Senna 1 TAB PO BID:PRN\\n Docusate Sodium (Liquid) 100 mg PO BID\\n Epoetin Alfa\\n To be administered during dialysis and dosed according to the \\n Epoetin Alfa P&T Guidelines.\\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\\n Famotidine 20 mg PO Q24H\\n Thiamine 100 mg PO DAILY\\n FoLIC Acid 1 mg PO DAILY\\n Valsartan 160 mg PO DAILY\\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\\n d1= Order date: @ 0044\\n Haloperidol 0.5 mg PO Q2H:PRN agitation\\n MD if giving Order date: @ 1301\\n Past medical history:\\n Family history:\\n Social History:\\n Type I DM (diagnosed 13 years ago), managed by Dr. \\n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \\n Diabetic retinopathy (diagnosed 2 years ago)\\n Diabetic neuropathy\\n Diabetic myonecrosis ()\\n Chronic ulcer at right foot\\n Hypertension\\n Concern for psychiatric disorder, possibly bipolar\\n :\\n Per reveiw of records, Type II diabetes mellitus in mother and father.\\n Type I diabetes mellitus in sisters and brothers.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: He is followed by a social worker because of concern about his\\n competence. Reported alcohol use, illicit drug use.\\n Review of systems: ROS\\n Flowsheet Data as of 03:55 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100\\n Tcurrent: 37.8\\nC (100\\n HR: 92 (92 - 92) bpm\\n BP: 169/75() {169/75() - 169/75()} mmHg\\n RR: 5 (5 - 5) insp/min\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 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: Non-rebreather\\n Physical Examination\\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\\n +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\\n ABG, and hypoxia.\\n .\\n Studies:\\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \\n 8:11, TWI is more pronounced and STE is unchanged.\\n - TTE (): The left atrium is normal in size. There is moderate\\n symmetric left ventricular hypertrophy. The left ventricular cavity is\\n unusually small. Left ventricular systolic function is hyperdynamic (EF\\n 80%). There is no ventricular septal defect. Right ventricular chamber\\n size and free wall motion are normal. There are focal calcifications in\\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\\n aortic stenosis is not present. No aortic regurgitation is seen. The\\n mitral valve leaflets are mildly thickened. There is mild mitral valve\\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\\n artery systolic pressure is normal. There is no pericardial effusion.\\n There is an anterior space which most likely represents a fat pad.\\n Compared with the findings of the prior study (images unavailable) of\\n , the left ventricular wall thickening has progressed.\\n - CXR 2V (): Final read pending\\n - LENI (): No evidence of DVT of the left lower extremity.\\n Assessment and Plan\\n Assessment and plan:\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Pt\\n sat's improved after being given 80mg IV lasix. Appears, pt last\\n dialyzed . However, infection such as from PNA, ACS/cardiac\\n etiology, medication effect from anti-psychotics, or other illicit\\n substance could be involved. Other possibility to consider is PE.\\n -bcx and ucx\\n -cxr\\n -urgent HD per renal fellow\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source. Improved slightly, but now\\n stable. Had temp of 100.8 on .\\n - initially abx were stoped, but now keflex restarted with fever,\\n even though this would be a odd presentation of cellulitis\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - Repeat EKG, daily while haldol dose is adjusted\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\\n disorder component. Poor compliance has been long standing issue. Per\\n psych notes, has had \\\"agitation, pressured speech, loose and\\n tangential, racing thoughts and decreased sleep consistent with\\n possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition: DM/RENal\\n Glycemic Control: HISS\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT: h2, HSC\\n Stress ulcer:\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points:\\n Worsening hypoxemia this eve with new bilateral infiltrates\\n presumption is that this represents pulmonary edema and he was\\n transferred to ICU for urgent dialysis. He was placed on a 100% NRB\\n facemask to maintain adequate saturations.\\n Exam notable for Tm afebrile HR 94 BP 156/70 RR 19 with 97 sat on\\n 100% NRB\\n No distress\\n HEENT unremarkable\\n Neck supple\\n Lungs crackles\\n Her rrr\\n Abd benign\\n Extreme RUE fistula, mild LLE edema\\n Labs notable for K+ 6.3 yesterday morning\\n Imaging: CXR with new bilateral patchy infiltrates\\n EKG with peaked T\\n Problems: respiratory distress, hypoxemia, pulmonary edema, ESRD, LLE\\n edema, hyperkalemia, DM\\n Agree with plan for urgent HD, wean O2 as tolerates, will continue\\n antibiotics and let floor team sort out LLE, continue current DM\\n regimen\\n Remainder of plan as outlined above.\\n Patient is critically ill.\\n Total time: 36 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 04:31 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373673,\n \"text\": \" MD H+P:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Today\\ns Events\\n HD today, removed 4.9kilo\\n L leg remains swollen and tender to touch\\n CXR revealed pneumonia, received vanco X1\\n Pt desatuating on RA to 70\\ns, productive cough\\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373676,\n \"text\": \" MD H+P:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Today\\ns Events\\n HD today, removed 4.9kilo\\n L leg remains swollen and tender to touch\\n CXR revealed pneumonia, received vanco X1\\n Pt desatuating on RA to 70\\ns, productive cough\\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt with known ESRD, non-compliant with medical care . K+ 6.8\\n overnight with worsening resp distress and desaturation to the 70\\n Action:\\n Renal ordered HD overnight.\\n Response:\\n HD removed 4.9kilo\\n Plan:\\n Monitor fluid balance, pt is refusing to abide by fluid restriction.\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Known non-compliance with medical regimen. ? untreated Bipolar\\n disease. History of leaving AMA, pt is Currently under Section 12 and\\n has 1:1 sitter and can NOT leave.\\n Action:\\n Pt is on Haldol and can receive PRN doses\\n Response:\\n Pt has been cooperative with care, 1:1 sitter\\n Plan:\\n Psych and SW attempting to get medical guardianship, meeting friday\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373734,\n \"text\": \"24 Hour Events:\\n -3.5L at O/N\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373735,\n \"text\": \"24 Hour Events:\\n -3.5L at O/N\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373737,\n \"text\": \"24 Hour Events:\\n -3.5L at O/N\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Assessment and Plan\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Pt\\n sat's improved after being given 80mg IV lasix. Appears, pt last\\n dialyzed . However, infection such as from PNA, ACS/cardiac\\n etiology, medication effect from anti-psychotics, or other illicit\\n substance could be involved. Other possibility to consider is PE.\\n -bcx and ucx\\n -cxr\\n -urgent HD per renal fellow\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source. Improved slightly, but now\\n stable. Had temp of 100.8 on .\\n - initially abx were stoped, but now keflex restarted with fever,\\n even though this would be a odd presentation of cellulitis\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - Repeat EKG, daily while haldol dose is adjusted\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\\n disorder component. Poor compliance has been long standing issue. Per\\n psych notes, has had \\\"agitation, pressured speech, loose and\\n tangential, racing thoughts and decreased sleep consistent with\\n possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373742,\n \"text\": \"24 Hour Events:\\n -3.5L O/N\\n -No episodes of hypotension\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Bcx (): PND\\n Bcx (): PND\\n UCx (): Negative\\n Assessment and Plan\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Renal\\n following, given dialysis yesterday early AM, continues to be fluid\\n overloaded. Will continue to diureses as per renal recommendations and\\n fluid restrict (1L per day, 80mg lasix QD).\\n -bcx and ucx\\n -cxr\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source.\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: As per admission note, patient is Section 12.\\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\\n has been long standing issue. Per psych notes, has had \\\"agitation,\\n pressured speech, loose and tangential, racing thoughts and decreased\\n sleep consistent with possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition: DM/RENal\\n Glycemic Control: HISS\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT: h2, HSC\\n Stress ulcer:\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373826,\n \"text\": \"24 Hour Events:\\n -3.5L O/N\\n -No episodes of hypotension\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Bcx (): PND\\n Bcx (): PND\\n UCx (): Negative\\n Assessment and Plan\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Renal\\n following, given dialysis yesterday early AM, continues to be fluid\\n overloaded. Will continue to diureses as per renal recommendations and\\n fluid restrict (1L per day, 80mg lasix QD).\\n -bcx and ucx\\n -cxr\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source.\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: As per admission note, patient is Section 12.\\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\\n has been long standing issue. Per psych notes, has had \\\"agitation,\\n pressured speech, loose and tangential, racing thoughts and decreased\\n sleep consistent with possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition: DM/RENal\\n Glycemic Control: HISS\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT: h2, HSC\\n Stress ulcer:\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373709,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Overnight Events\\n L leg remains swollen and tender to touch\\n Pt desatuating on RA to80\\ns, productive cough\\n Pt compliant with meds and no periods of agitation, remains\\n on 1:1 sitter\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt with known ESRD, non-compliant with medical care prior to admit HD\\n done , tol well.\\n Action:\\n 1000ml fluid restriction maintained.\\n Response:\\n Pt compliant with meds, and fluid restriction\\n Plan:\\n Monitor fluid balance, ?HD today\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Known non-compliance with medical regimen. ? untreated Bipolar\\n disease. History of leaving AMA, pt is Currently under Section 12 and\\n has 1:1 sitter and can NOT leave.\\n Action:\\n Pt is on Haldol and received PRN dose x1 a/o\\n Response:\\n Pt has been cooperative with care, 1:1 sitter\\n Plan:\\n Psych and SW attempting to get medical guardianship, meeting today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373809,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Pt\\ns K+ has been dropping with dialysis.\\n Action:\\n last K+ level was 4.4 at 1030 \\n Response:\\n Pt responding to dialysis.\\n Plan:\\n Continue dialysis according to his schedule.\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Since admission to the MICU pt has been had two sessions of diaylsis\\n Action:\\n Last dialysis was today with the removal of 5l of fluid.\\n Yesterday they also removed 5l of fluid\\n Response:\\n With the total removal of 10 liters of fluid in the last 2 days his O2\\n requirement dropped from NRB to room air. O2 sats are 96-100%.\\n Plan:\\n Continue with fliud restriction, continue with dialysis treatments.\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Pt has been very manic today, He is in a good mood, talking almost\\n constantly day. The family meeting with social services and Psych was\\n cancelled but an informal family meeting was held at 1500.\\n Action:\\n Haldol 1.5 mg continues to be given q12h\\n Response:\\n Behavior in control today.\\n Plan:\\n Pt called out to the floor,\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n HYPERKALEMIA\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 71.2 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: Anemia, Diabetes - Insulin\\n CV-PMH: Hypertension\\n Additional history: hyperlipedemia, diabetes type I on insulin end\\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\\n pressured,racing thoughts decreased sleep consistent with possible\\n mania. lower left extremitiy swelling dopplerable. neg for clots.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:136\\n D:113\\n Temperature:\\n 96.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 20 insp/min\\n Heart Rate:\\n 89 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 100% %\\n 24h total in:\\n 1,100 mL\\n 24h total out:\\n 5,000 mL\\n Pertinent Lab Results:\\n Sodium:\\n 135 mEq/L\\n 10:30 AM\\n Potassium:\\n 4.8 mEq/L\\n 10:30 AM\\n Chloride:\\n 95 mEq/L\\n 10:30 AM\\n CO2:\\n 31 mEq/L\\n 10:30 AM\\n BUN:\\n 28 mg/dL\\n 10:30 AM\\n Creatinine:\\n 4.6 mg/dL\\n 10:30 AM\\n Glucose:\\n 326 mg/dL\\n 10:30 AM\\n Hematocrit:\\n 26.4 %\\n 10:30 AM\\n Finger Stick Glucose:\\n 351\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables: None\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: Micu 687\\n Transferred to: 201\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372931,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373010,\n \"text\": \"31M with DM1, ESRD on HD, reportedly on the transplant list who\\n presents again with hyperkalemia after missing HD. Pt reportedly not\\n cooperative in the ED and agitated. Of note, pt has had several\\n admissions for hyperkalemia/missing HD sessions and left the hospital\\n AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\\n ativan IV. Renal fellow aware that pt is here and HD planned for\\n tonight. No intervention for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW) was to\\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373152,\n \"text\": \"TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\\n presents again with hyperkalemia after missing HD. Pt reportedly not\\n cooperative in the ED and agitated. Of note, pt has had several\\n admissions for hyperkalemia/missing HD sessions and left the hospital\\n AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\\n ativan IV. Renal fellow aware that pt is here and HD planned for\\n tonight. No intervention for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW) was to\\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\\n treatment. Unfortunately pt became agitated, angry and appeared\\n threatening early this afternoon. Feelings validated and pt given\\n ample time to voice his displeasure to no avail. Stat security called\\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\\n admin. Pt now more cooperative and is not agitated. Pt seems to last\\n 8 to 12 hours between outbursts.\\n Impaired Health Maintenance\\n Assessment:\\n As noted above, the pt was more or less cooperative with care this AM\\n (though refused all AM meds). Unfortunately pt impulsively became\\n angry/agitated/beligerant this afternoon requiring stat security @ BS.\\n Stable QTi on EKG this AM. Soft wrist restraints in place. 1:1 Sitter\\n @ BS.\\n Action:\\n With security @ BS and a supportive sitter whom the pt trusted the pt\\n relented and allowed 5mg IVP Haldol to be admin @ BS.\\n Response:\\n Pt now more cooperative with no agitation issues @ this time.\\n Plan:\\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\\n becoming acutely agitated. Follow serial EKG QTi as long as IV Haldol\\n treatment in place.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt received his third HD in three days today. AM potassium value of\\n 4.3 noted.\\n Action:\\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\\n Response:\\n Pt without significant issues surrounding HD treatment.\\n Plan:\\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\\n for Mon vs Tues.\\n Demographics: The pt is appearantly estranged from his mother and has\\n issues with some of his siblings. Pt also appears to have issues of\\n homelessness. Pt with multiple recent hospital admits s/p missed HD\\n treatments with significant hyperkalemia.\\n Attending MD:\\n R.\\n Admit diagnosis:\\n HYPERKALEMIA\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 71.2 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH: Anemia, Diabetes - Insulin, Renal Failure, Smoker\\n CV-PMH: Hypertension\\n Additional history: Diabetic retinopathy. Anemia. Recent LLE swelling\\n (Leni's negative times two). diabetic neuropathy\\n Diabetic myonecrosis. Chronic ulcer right foot\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:155\\n D:65\\n Temperature:\\n 97.4\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 18 insp/min\\n Heart Rate:\\n 96 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 96% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 380 mL\\n 24h total out:\\n 1,200 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 10:05 AM\\n Potassium:\\n 4.8 mEq/L\\n 10:05 AM\\n Chloride:\\n 96 mEq/L\\n 10:05 AM\\n CO2:\\n 29 mEq/L\\n 10:05 AM\\n BUN:\\n 29 mg/dL\\n 10:05 AM\\n Creatinine:\\n 7.2 mg/dL\\n 10:05 AM\\n Glucose:\\n 83 mg/dL\\n 10:05 AM\\n Hematocrit:\\n 29.2 %\\n 10:05 AM\\n Finger Stick Glucose:\\n 147\\n 10:05 AM\\n Valuables / Signature: All of the pts personal property (5 bags) have\\n been moved to a holding area on CC2.\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: MICU 6 West.\\n Transferred to: 226\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373149,\n \"text\": \"TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\\n presents again with hyperkalemia after missing HD. Pt reportedly not\\n cooperative in the ED and agitated. Of note, pt has had several\\n admissions for hyperkalemia/missing HD sessions and left the hospital\\n AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\\n ativan IV. Renal fellow aware that pt is here and HD planned for\\n tonight. No intervention for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW) was to\\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\\n treatment. Unfortunately pt became agitated, angry and appeared\\n threatening early this afternoon. Feelings validated and pt given\\n ample time to voice his displeasure to no avail. Stat security called\\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\\n admin. Pt now more cooperative and is not agitated. Pt seems to last\\n 8 to 12 hours between outbursts.\\n Impaired Health Maintenance\\n Assessment:\\n As noted above, the pt more or less cooperative with care this AM.\\n Unfortunately pt became angry/agitated/ beligerant this afternoon\\n requiring stat security @ BS. Stable QTi on EKG this AM.\\n Action:\\n With security @ BS and a supportive sitter whom the pt trusted the pt\\n relented and allowed 5mg IVP Haldol to be admin @ BS.\\n Response:\\n Pt now more cooperative with no agitation issues @ this time.\\n Plan:\\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\\n becoming agitated. Follow serial EKG QTi as long as IV Haldol\\n treatment in place.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt received his third HD in three days today.\\n Action:\\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\\n Response:\\n Pt without significant issues surrounding HD treatment.\\n Plan:\\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\\n for Mon vs Tues.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 83971,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Enlarged cardiac size on CXR. Evaluate for effusion\\nHeight: (in) 69\\nWeight (lb): 156\\nBSA (m2): 1.86 m2\\nBP (mm Hg): 128/66\\nHR (bpm): 101\\nStatus: Inpatient\\nDate/Time: at 16:46\\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: Moderate symmetric LVH. Small LV cavity. Hyperdynamic LVEF\\n>75%. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root. Normal aortic arch diameter. Focal calcifications in aortic arch.\\nNo 2D or Doppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\\nof papillary muscles. No MS. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: 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\\nConclusions:\\nThe left atrium is normal in size. There is moderate symmetric left\\nventricular hypertrophy. The left ventricular cavity is unusually small. Left\\nventricular systolic function is hyperdynamic (EF 80%). There is no\\nventricular septal defect. Right ventricular chamber size and free wall motion\\nare normal. There are focal calcifications in the aortic arch. The aortic\\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\\nThere is mild mitral valve prolapse. Trivial mitral regurgitation is seen. The\\nestimated pulmonary artery systolic pressure is normal. There is no\\npericardial effusion. There is an anterior space which most likely represents\\na fat pad.\\n\\nCompared with the findings of the prior study (images unavailable) of , the left ventricular wall thickening has progressed.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1075959,\n \"text\": \" 12:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, edema\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with h/o DM and ESRD on HD who had desat to 60% on RA.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Diabetes mellitus, desaturation.\\n\\n FINDINGS: As compared to the previous radiograph, there is a newly appeared\\n extensive opacity in the middle and basal parts of the right lung and in the\\n retrocardiac lung areas. The opacity is of alveolar morphology, multiple\\n subtle air bronchograms are seen. The opacities tend to spare in the\\n uppermost parts of the lung. In the region of the right hilus, subtle\\n peribronchial cuffing is seen. However, all other signs indicative of\\n overhydration are missing. In the light, they are much more likely to\\n represent pneumonia rather than edema.\\n Unchanged size of the cardiac silhouette, unchanged mediastinal contours.\\n\\n was notified by telephone at the time of dictation and informed\\n about the abnormalities.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-08 00:00:00.000\",\n \"description\": \"L KNEE (AP, LAT & OBLIQUE) LEFT\",\n \"row_id\": 1076429,\n \"text\": \" 10:24 PM\\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \\n Reason: Any fracture or other left knee pathology evident on plain f\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with leg lower extremity swelling and new left knee pain.\\n REASON FOR THIS EXAMINATION:\\n Any fracture or other left knee pathology evident on plain film?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Left lower extremity swelling. New left knee pain.\\n\\n LEFT KNEE, THREE VIEWS\\n\\n There is deformity and increased density in the right tibial plateau\\n consistent with a tibial plateau fracture, with depression. There is a\\n probable joint effusion. There is minimal spurring about the patella. There\\n is an ossific fragment along the medial border of the patella, which appears\\n well corticated, and which could represent a either fracture fragment or\\n heterotopic ossification in the medial retinaculum. No dislocation is\\n identified. Dense vascular calcification is noted.\\n\\n IMPRESSION:\\n\\n 1) Findings consistent with medial tibial plateau fracture likely subcaute or\\n chronic .\\n\\n 2) Ossicle along medial patella -- ? nonacute fracture vs post- traumatic\\n heterotopic ossificaiton in adjoining medial retinaculum. Possible subacute\\n fracture along the medial patella.\\n\\n 3. Joint effusion.\\n\\n Findings discussed with covering house officer Dr. at\\n approximately 13:18 p.m. on the day of the exam.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-08 00:00:00.000\",\n \"description\": \"L UNILAT LOWER EXT VEINS LEFT\",\n \"row_id\": 1076405,\n \"text\": \" 4:59 PM\\n UNILAT LOWER EXT VEINS LEFT Clip # \\n Reason: LLE SWELLING EVAL FOR DVT\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with possible DVT, dialysis patient\\n REASON FOR THIS EXAMINATION:\\n r/o DVT\\n ______________________________________________________________________________\\n WET READ: DLrc SAT 6:47 PM\\n No evidence of left lower extremity DVT. Prominent lymph nodes in the left\\n groin.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is a 31-year-old male with possible deep venous thrombus.\\n Evaluate for deep venous thrombus.\\n\\n EXAMINATION: Unilateral left lower extremity DVT study.\\n\\n COMPARISONS: Comparison to ultrasound examination from .\\n\\n FINDINGS: Grayscale and color Doppler son of the left common femoral,\\n superficial femoral and popliteal veins were performed. There is normal\\n compressibility, flow, augmentation. There is symmetric respiratory\\n variability in the right and left common femoral veins.\\n\\n IMPRESSION: No evidence of left lower extremity DVT.\\n SESHa\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-10 00:00:00.000\",\n \"description\": \"L CT LOW EXT W/O C LEFT\",\n \"row_id\": 1076744,\n \"text\": \" 6:12 PM\\n CT LOW EXT W/O C LEFT Clip # \\n Reason: to evaluate knee fracture\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with hx of ESRD on HD, now with knee injury 2 weeks ago, now\\n with plain films showing tibial and patellar fractures.\\n REASON FOR THIS EXAMINATION:\\n to evaluate knee fracture\\n CONTRAINDICATIONS for IV CONTRAST:\\n ESRD\\n ______________________________________________________________________________\\n WET READ: CXWc MON 8:46 PM\\n Impacted right medial tibial plateau fracture extending to the articular\\n surface, with pleateau depression of approximately 8mm. Bony sclerosis\\n consistent with subacute fracture. Tiny intra-articular bony fragment\\n posteriorly. Additionally, comminuted fractures of the medial and lateral\\n tibial spines. Moderate joint effusion. Fragmentation of medial patella\\n consistent with nondisplaced, comminuted fracture. Extensive vascular\\n calcifications.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF LEFT KNEE\\n\\n INDICATION: Knee injury. Tibial and patellar fractures.\\n\\n TECHNIQUE: Non-contrast multidetector CT of the left knee was performed.\\n Multiplanar reformations were carried out.\\n\\n COMPARISON: Radiograph of left knee .\\n\\n FINDINGS:\\n\\n There is an impacted fracture of the left medial tibial plateau with at least\\n 5 mm of depression of the medial tibial plateau. Comminution is evident with\\n small fracture fragments at the medial aspect of the medial plateau (series\\n 500B, image 31). Extension of the fracture line into the intercondylar\\n eminence and into the medial tibial spine is evident.\\n\\n The lateral tibial plateau is intact. The proximal tibial and fibular shafts\\n are intact. The distal femur demonstrates no evidence of focal bone lesion or\\n fracture.\\n\\n There is a small fracture through the medial aspect of the patella. The\\n fracture is minimally displaced, with approximately 2 mm of medial\\n displacement of the smaller medial component of the fracture.\\n\\n Assessment of the internal structures of the knee is limited on CT, but no\\n gross ligament abnormality is demonstrated.\\n\\n There is a moderate to large knee joint effusion. There is evidence of\\n diffuse vascular calcification. The bones appear demineralized.\\n (Over)\\n\\n 6:12 PM\\n CT LOW EXT W/O C LEFT Clip # \\n Reason: to evaluate knee fracture\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n IMPRESSION:\\n 1. Depressed, impacted medial tibial plateau fracture which also extends to\\n the intercondylar eminence and medial tibial spine.\\n 2. Medial patellar fracture.\\n 3. Moderate to large knee joint effusion.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-11 00:00:00.000\",\n \"description\": \"OL KNEE( (SINGLE VIEW) IN O.R. LEFT\",\n \"row_id\": 1076811,\n \"text\": \" 8:06 AM\\n KNEE( (SINGLE VIEW) IN O.R. LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. LEFTClip # \\n Reason: ORIF LEFT TIBIAL PLATEAU FX\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n HISTORY: Tibial plateau fracture.\\n\\n A single intraoperative fluoroscopic view of the left knee was obtained\\n without a radiologist present. This again demonstrates a depressed medial\\n tibial plateau fracture, similar to that seen on . For additional\\n details, please consult the operative report.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209357,\n \"text\": \"Normal sinus rhythm. Lateral T wave abnormalities. Compared to the previous\\ntracing of lateral T wave abnormalities are new. Some of these\\nabnormalities have been seen on previous tracings but now they are increased\\nin leads V5-V6.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209358,\n \"text\": \"Normal sinus rhythm. J point elevation consistent with normal early\\nrepolarization. Otherwise, within normal limits. Compared to the previous\\ntracing of previous non-specific ST-T wave abnormalities have resolved.\\nOtherwise, no important change. Clinical correlation and repeat tracing are\\nsuggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205615,\n \"text\": \"Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the\\nprevious tracing of no major change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205616,\n \"text\": \"Sinus rhythm\\nNormal ECG\\nSince previous tracing of , the heart rate is slower\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205617,\n \"text\": \"Sinus rhythm upper normal rate\\nNormal ECG\\nSince previous tracing of , ST-T wave abnormalities are less\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205618,\n \"text\": \"Sinus rhythm. Compared to the previous tracing of there is\\nT wave inversion in lead I and more prominent T wave inversion in\\nlead aVL as well as new T wave inversion in leads V4-V6. Active\\nlateral ischemic process cannot be excluded. Followup and clinical correlation\\nare suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205619,\n \"text\": \"Sinus rhythm. Compared to the previous tracing no change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205620,\n \"text\": \"Sinus rhythm. Compared to the previous tracing of no change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205621,\n \"text\": \"Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\\nsignificant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-05-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205622,\n \"text\": \"Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\\nsignificant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-05-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205623,\n \"text\": \"Sinus rhythm. Baseline artifact. Delayed precordial R wave transition. The\\nP wave morphology appears less prominent while the P wave axis remains\\nrightward. The prior tracing was consistent with right atrial abnormality.\\nOtherwise, no diagnostic interim change. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205614,\n \"text\": \"Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\\ntracing of ST-T wave changes are new.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-03 00:00:00.000\",\n \"description\": \"CT PELVIS W&W/O C\",\n \"row_id\": 1075475,\n \"text\": \" 4:12 PM\\n CT PELVIS W&W/O C Clip # \\n Reason: eval for venous thrombosis\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with left lower extremity swelling, negative LENI, concern for\\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\\n better visualization of veins.\\n REASON FOR THIS EXAMINATION:\\n eval for venous thrombosis\\n CONTRAINDICATIONS for IV CONTRAST:\\n Has ESRD and will get dialyzed Tuesday.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 8:10 PM\\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\\n Extensive vascular calcifications _____, likely reflecting the patient's\\n history of diabetes. There is no acute pelvic pathology.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 31-year-old male with left lower extremity swelling and negative\\n LENI. Evaluate for proximal clot in the iliac veins or IVC. The patient has\\n a history of hypertension, diabetes, and end-stage renal disease.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: Contiguous axial images were obtained through the pelvis prior to\\n and following administration of intravenous contrast, and three-minute delayed\\n phase protocol. Multiplanar reformats were prepared and reviewed.\\n\\n FINDINGS: Within limits of non-contrast and delayed phase imaging, visualized\\n portion of the liver, gallbladder, pancreas, and kidneys are normal. There is\\n no evidence for biliary dilatation, cholelithiasis, or hydronephrosis.\\n Visualized pelvic loops of small and large bowel are unremarkable. There is\\n high-density material within the colon, likely reflecting magnesium-containing\\n laxative or antacid use. There is no bowel distention or bowel wall\\n thickening. There is no free fluid or free air. There is no lymphadenopathy\\n appreciated.\\n\\n Vascular calcifications are noted in the pelvic vessels, greater than expected\\n for a patient of this age, likely due to the patient's history of diabetes.\\n There is normal appearance and opacification of the bilateral iliac veins and\\n IVC, with no evidence for venous thrombosis.\\n\\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\\n\\n IMPRESSION:\\n 1. No evidence for venous thrombosis in the bilateral iliac vessels or IVC.\\n 2. Vascular calcifications, greater than expected for a patient of this age,\\n likely reflecting history of diabetes.\\n 3. Within the limits of non-contrast and delayed phase imaging, no acute\\n pelvic pathology.\\n (Over)\\n\\n 4:12 PM\\n CT PELVIS W&W/O C Clip # \\n Reason: eval for venous thrombosis\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-03 00:00:00.000\",\n \"description\": \"CT PELVIS W&W/O C\",\n \"row_id\": 1075476,\n \"text\": \", R. MED FA2 4:12 PM\\n CT PELVIS W&W/O C Clip # \\n Reason: eval for venous thrombosis\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with left lower extremity swelling, negative LENI, concern for\\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\\n better visualization of veins.\\n REASON FOR THIS EXAMINATION:\\n eval for venous thrombosis\\n CONTRAINDICATIONS for IV CONTRAST:\\n Has ESRD and will get dialyzed Tuesday.\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\\n Extensive vascular calcifications _____, likely reflecting the patient's\\n history of diabetes. There is no acute pelvic pathology.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-05-30 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1074872,\n \"text\": \" 11:16 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval effusion, pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with hx esrd\\n REASON FOR THIS EXAMINATION:\\n eval effusion, pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 31-year-old with history of end-stage renal disease.\\n\\n COMPARISON: \\n\\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: The lateral view is limited due to\\n inability of the patient to raise her arms. The lungs are grossly clear. The\\n cardiac silhouette is increasing in size, even despite the lordotic\\n positioning of the film, raising the possibility of pericardial effusion in\\n this end- stage renal disease patient. The mediastinal contours are normal.\\n There is no effusion or pneumothorax.\\n\\n IMPRESSION: Enlarging cardiac silouette, raising the possibility of\\n pericardial effusion.\\n\\n Dr. was paged with these findings at 11:30 AM on .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1076037,\n \"text\": \" 9:52 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: pls eval for infiltrate, consolidation, effusion\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with ESRD, hypoxia\\n REASON FOR THIS EXAMINATION:\\n pls eval for infiltrate, consolidation, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Followup.\\n\\n COMPARISON: .\\n\\n As compared to the previous radiograph, the lung volumes have increased.\\n Despite the resulting overall decrease in lung parenchymal transparency,\\n subtle areas of parenchymal opacities, notably in the left basal and\\n retrocardiac areas and at the right lung bases persist, so that the suspicion\\n of pneumonia cannot be discarded. No evidence of pleural effusions.\\n Unchanged mediastinal contours. The size of the cardiac silhouette is smaller\\n than before.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":188,"cells":{"subject_id":{"kind":"number","value":85444,"string":"85,444"},"hadm_id":{"kind":"number","value":152754,"string":"152,754"},"target_text":{"kind":"string","value":"58 y/o male who is admitted from home for liver . He received a DCD liver and the patient was taken to the OR with Dr after a careful discussion with the patient. The patient tolerated the procedure without difficulty, and the procedure was undertaken without significant complication. The donor liver appeared well perfused at the end of the case. The patient received routine immunosuppression induction to include cellcept, solumedrol intra-op with taper and started prograf on the evening of POD 1. The patient did require multiple transfusions in the ICU per the bleeding pathway, but was never hemodynamically unstable as a result of his bleeding, and by POD his HCT had stabilized. The liver did very well in the post op period. LFTs declined daily and T bili was 2.3 at the time of DC. The remainder of his post operative course was unremarkable. He successfully demonstrated adequate knowledge of his medications and at the time of discharge was sent home on tacrolimus, cellcept and the remainder of his prednisone taper. He was sent home with VNA for lab draws and with plan for close follow up in the clinic. Medications on Admission: : Entacavir 1 mg daily, Tenofavir 300 mg daily, Furosemide 20 mg daily, Spironolactone 100 mg daily, Clotramazole 10 mg troche (intermittent use)"},"extractive_notes_summ":{"kind":"string","value":"small right pleural effusion. Small right pleural effusion. There is a small right pleural effusion. New small left pleural effusion. Left anterior fascicular block. Unchanged minimal right basal atelectasis. Upper abdominal drains in place. No larger pleural effusions. NG tube is in nondistended stomach. Sinus rhythm with left anterior fascicular block. A Swan-Ganz catheter appears to end in the proximal right pulmonary artery. New small left pleural effusion is present. Hilar, mediastinal and cardiac silhouettes are stable. The right, middle, and left hepatic veins are patent with appropriate waveforms. Extreme right lateral abdomen not fully included on the images. Sinus rhythm. Right IJ catheter tip projects over cavoatrial junction. The main hepatic artery and intrahepatic right and left hepatic arteries are patent, with appropriate waveforms demonstrating sharp systolic upstroke and preserved flow through diastole. NG tube ends within the stomach. patent MHA, RHA, LHA with appropriate waveforms. Swan-Ganz catheter has been removed. FINDINGS: Right IJ tip projects over cavoatrial junction. Upper abdominal drains are in place. patent RHV, MHV, LHV with appropriate waveforms. The right and left portal veins are patent, with forward flow. IMPRESSION: 1. IMPRESSION: 1. Unchanged moderate cardiomegaly without overt pulmonary edema. FINDINGS: As compared to the previous radiograph, the patient has been extubated. Pleural surfaces are normal. Left axis deviation. IMPRESSION: AP chest compared to preoperative study, : ET tube, nasogastric tube, Swan-Ganz catheter, in standard placements. IMPRESSION: Needle driver not seen within the imaged abdomen. COMPARISONS: Chest x-ray from . Compared tothe previous tracing of there is no diagnostic change.TRACING #1 Heart size normal. IMPRESSION: No acute cardiopulmonary process. Intraoperative films. The main portal vein is patent, with forward flow. patent MPV, RPV, LPV with forward flow. Two abdominal drains within the right abdomen. PA AND LATERAL VIEW, CHEST: Lungs are clear. 10:03 PM ABDOMEN (SUPINE ONLY); CHEST (SINGLE VIEW) Clip # Reason: MISSING NEEDLE HOLDER. Hilar contours and heart size is normal. INTRA-OP FILMS. Compared to the previoustracing there is no diagnostic change.TRACING #2 Left retrocardiac opacity, which may represent atelectasis, pleural fluid or infection in the right clinical setting. Lungs clear. Endotracheal tube ends 2.5 cm above the carina. No pneumothorax. No pneumothorax. IJ line placement. Normal liver transplant ultrasound with patent hepatic vasculature. Lung volumes are low. No pneumothorax or pleural effusion. COMPARISON: . COMPARISON: . SUPINE ABDOMINAL RADIOGRAPHS AND RADIOGRAPH OF NEEDLE DRIVER: Image of the needle holder/driver indicates the appearance of the missing intra-operative foreign body. Turbulent flow in the main portal vein may be related to the surgical anastomosis, with no definite stenosis identified. Retrocardiac opacity silhouetting left hemidiaphragm may represent pleural fluid, atelectasis or infection in the right clinical setting. 2. 2. There is no pulmonary edema. Allowing for this limitation, there is no intra- or extra-hepatic biliary ductal dilation. 2:19 PM CHEST PORT. COMPARISON: None. The other monitoring and support devices are unchanged. 10:58 PM CHEST PORT. 3. Multiple skin staples overlie the abdomen. The common duct measures 2 mm. No needle driver is noted projected within the imaged abdominal cavity. No evidence of focal parenchymal opacity suggesting pneumonia. ET tube is 5 cm from the carina. turbulent flow in MPV may be due to surgical anastamosis. Turbulent flow in the main portal vein may be due to the surgical anastomosis. Admitting Diagnosis: PRE-OP LIVER TRANSPLANT FINAL REPORT INDICATION: 46-year-old man with missing needle holder. FINAL REPORT HISTORY: 46-year-old male, operative day #1, status post liver transplant. TRANSPLANT LIVER ULTRASOUND: Imaging of the transplanted liver is limited due to the skin bandage and inability of the patient to hold his breath. 4:19 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man POD1 liver tx REASON FOR THIS EXAMINATION: interval change FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post liver transplant, assessment for interval change. 9:50 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: liver transplant u/s, POD 1 Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man with new liver REASON FOR THIS EXAMINATION: liver transplant u/s, POD 1 WET READ: JXRl TUE 12:10 PM no intra or extrahepatic biliary ductal dilation. LINE PLACEMENT Clip # Reason: Please eval for appropriate line placement/PTX Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man with ESLD s/p liver transplant, with swan/cordis switched to triple lumen CVL REASON FOR THIS EXAMINATION: Please eval for appropriate line placement/PTX FINAL REPORT INDICATION: Patient is status post liver transplant."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2184-08-03 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1151372,"text":" 2:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval for appropriate line placement/PTX\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESLD s/p liver transplant, with swan/cordis switched to\n triple lumen CVL\n REASON FOR THIS EXAMINATION:\n Please eval for appropriate line placement/PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is status post liver transplant. IJ line placement.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n Right IJ tip projects over cavoatrial junction. No pneumothorax.\n\n New small left pleural effusion is present. Retrocardiac opacity silhouetting\n left hemidiaphragm may represent pleural fluid, atelectasis or infection in\n the right clinical setting. Hilar, mediastinal and cardiac silhouettes are\n stable.\n\n ET tube is 5 cm from the carina. NG tube is in nondistended stomach.\n Swan-Ganz catheter has been removed. Upper abdominal drains are in place.\n\n IMPRESSION:\n\n 1. Right IJ catheter tip projects over cavoatrial junction. No pneumothorax.\n\n 2. New small left pleural effusion.\n\n 3. Left retrocardiac opacity, which may represent atelectasis, pleural fluid\n or infection in the right clinical setting.\n\n"},{"category":"Radiology","chartdate":"2184-08-02 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1151181,"text":" 1:11 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PRE-OP LIVER TRANSPLANT\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man here for liver transplant\n REASON FOR THIS EXAMINATION:\n assess cardiopulmonary status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver transplant and assess cardiopulmonary status.\n\n COMPARISON: .\n\n PA AND LATERAL VIEW, CHEST: Lungs are clear. Pleural surfaces are normal.\n Hilar contours and heart size is normal. There is no pulmonary edema.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2184-08-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1151473,"text":" 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man POD1 liver tx\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post liver transplant, assessment for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated. The other monitoring and support devices are unchanged. Unchanged\n minimal right basal atelectasis. Unchanged moderate cardiomegaly without\n overt pulmonary edema. No larger pleural effusions. No evidence of focal\n parenchymal opacity suggesting pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2184-08-02 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1151271,"text":" 10:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: RIJ, swan, ETT line placement\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with s/p OLT with new lines\n REASON FOR THIS EXAMINATION:\n RIJ, swan, ETT line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, :06 P.M.\n\n HISTORY: Liver transplant.\n\n IMPRESSION: AP chest compared to preoperative study, :\n\n ET tube, nasogastric tube, Swan-Ganz catheter, in standard placements. Upper\n abdominal drains in place. Lungs clear. No pneumothorax or pleural effusion.\n Heart size normal.\n\n\n"},{"category":"Radiology","chartdate":"2184-08-02 00:00:00.000","description":"ABDOMEN (SUPINE ONLY)","row_id":1151270,"text":" 10:03 PM\n ABDOMEN (SUPINE ONLY); CHEST (SINGLE VIEW) Clip # \n Reason: MISSING NEEDLE HOLDER. INTRA-OP FILMS.\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man with missing needle holder. Intraoperative\n films.\n\n SUPINE ABDOMINAL RADIOGRAPHS AND RADIOGRAPH OF NEEDLE DRIVER: Image of the\n needle holder/driver indicates the appearance of the missing intra-operative\n foreign body. Extreme right lateral abdomen not fully included on the images.\n No needle driver is noted projected within the imaged abdominal cavity. NG\n tube ends within the stomach. A Swan-Ganz catheter appears to end in the\n proximal right pulmonary artery. Endotracheal tube ends 2.5 cm above the\n carina. Two abdominal drains within the right abdomen. Multiple skin staples\n overlie the abdomen. Lung volumes are low.\n\n IMPRESSION: Needle driver not seen within the imaged abdomen. Findings were\n discussed with Dr. at 10:15 p.m. on .\n\n"},{"category":"Radiology","chartdate":"2184-08-03 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1151316,"text":" 9:50 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: liver transplant u/s, POD 1\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with new liver\n REASON FOR THIS EXAMINATION:\n liver transplant u/s, POD 1\n ______________________________________________________________________________\n WET READ: JXRl TUE 12:10 PM\n no intra or extrahepatic biliary ductal dilation. small right pleural\n effusion. patent MPV, RPV, LPV with forward flow. turbulent flow in MPV may\n be due to surgical anastamosis. patent RHV, MHV, LHV with appropriate\n waveforms. patent MHA, RHA, LHA with appropriate waveforms.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old male, operative day #1, status post liver transplant.\n\n COMPARISON: None.\n\n TRANSPLANT LIVER ULTRASOUND: Imaging of the transplanted liver is limited due\n to the skin bandage and inability of the patient to hold his breath. Allowing\n for this limitation, there is no intra- or extra-hepatic biliary ductal\n dilation. The common duct measures 2 mm. There is a small right pleural\n effusion.\n\n The main portal vein is patent, with forward flow. Turbulent flow in the main\n portal vein may be due to the surgical anastomosis. The right and left portal\n veins are patent, with forward flow. The right, middle, and left hepatic\n veins are patent with appropriate waveforms. The main hepatic artery and\n intrahepatic right and left hepatic arteries are patent, with appropriate\n waveforms demonstrating sharp systolic upstroke and preserved flow through\n diastole.\n\n IMPRESSION:\n 1. Normal liver transplant ultrasound with patent hepatic vasculature.\n Turbulent flow in the main portal vein may be related to the surgical\n anastomosis, with no definite stenosis identified.\n 2. Small right pleural effusion.\n\n"},{"category":"ECG","chartdate":"2184-08-03 00:00:00.000","description":"Report","row_id":234952,"text":"Sinus rhythm with left anterior fascicular block. Compared to the previous\ntracing there is no diagnostic change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2184-08-02 00:00:00.000","description":"Report","row_id":234953,"text":"Sinus rhythm. Left axis deviation. Left anterior fascicular block. Compared to\nthe previous tracing of there is no diagnostic change.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-03 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1151372,\n \"text\": \" 2:19 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Please eval for appropriate line placement/PTX\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with ESLD s/p liver transplant, with swan/cordis switched to\\n triple lumen CVL\\n REASON FOR THIS EXAMINATION:\\n Please eval for appropriate line placement/PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is status post liver transplant. IJ line placement.\\n\\n COMPARISONS: Chest x-ray from .\\n\\n FINDINGS:\\n\\n Right IJ tip projects over cavoatrial junction. No pneumothorax.\\n\\n New small left pleural effusion is present. Retrocardiac opacity silhouetting\\n left hemidiaphragm may represent pleural fluid, atelectasis or infection in\\n the right clinical setting. Hilar, mediastinal and cardiac silhouettes are\\n stable.\\n\\n ET tube is 5 cm from the carina. NG tube is in nondistended stomach.\\n Swan-Ganz catheter has been removed. Upper abdominal drains are in place.\\n\\n IMPRESSION:\\n\\n 1. Right IJ catheter tip projects over cavoatrial junction. No pneumothorax.\\n\\n 2. New small left pleural effusion.\\n\\n 3. Left retrocardiac opacity, which may represent atelectasis, pleural fluid\\n or infection in the right clinical setting.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-02 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1151181,\n \"text\": \" 1:11 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: PRE-OP LIVER TRANSPLANT\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man here for liver transplant\\n REASON FOR THIS EXAMINATION:\\n assess cardiopulmonary status\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Liver transplant and assess cardiopulmonary status.\\n\\n COMPARISON: .\\n\\n PA AND LATERAL VIEW, CHEST: Lungs are clear. Pleural surfaces are normal.\\n Hilar contours and heart size is normal. There is no pulmonary edema.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1151473,\n \"text\": \" 4:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man POD1 liver tx\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post liver transplant, assessment for interval change.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the patient has been\\n extubated. The other monitoring and support devices are unchanged. Unchanged\\n minimal right basal atelectasis. Unchanged moderate cardiomegaly without\\n overt pulmonary edema. No larger pleural effusions. No evidence of focal\\n parenchymal opacity suggesting pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-02 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1151271,\n \"text\": \" 10:58 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: RIJ, swan, ETT line placement\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with s/p OLT with new lines\\n REASON FOR THIS EXAMINATION:\\n RIJ, swan, ETT line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, :06 P.M.\\n\\n HISTORY: Liver transplant.\\n\\n IMPRESSION: AP chest compared to preoperative study, :\\n\\n ET tube, nasogastric tube, Swan-Ganz catheter, in standard placements. Upper\\n abdominal drains in place. Lungs clear. No pneumothorax or pleural effusion.\\n Heart size normal.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-02 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE ONLY)\",\n \"row_id\": 1151270,\n \"text\": \" 10:03 PM\\n ABDOMEN (SUPINE ONLY); CHEST (SINGLE VIEW) Clip # \\n Reason: MISSING NEEDLE HOLDER. INTRA-OP FILMS.\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old man with missing needle holder. Intraoperative\\n films.\\n\\n SUPINE ABDOMINAL RADIOGRAPHS AND RADIOGRAPH OF NEEDLE DRIVER: Image of the\\n needle holder/driver indicates the appearance of the missing intra-operative\\n foreign body. Extreme right lateral abdomen not fully included on the images.\\n No needle driver is noted projected within the imaged abdominal cavity. NG\\n tube ends within the stomach. A Swan-Ganz catheter appears to end in the\\n proximal right pulmonary artery. Endotracheal tube ends 2.5 cm above the\\n carina. Two abdominal drains within the right abdomen. Multiple skin staples\\n overlie the abdomen. Lung volumes are low.\\n\\n IMPRESSION: Needle driver not seen within the imaged abdomen. Findings were\\n discussed with Dr. at 10:15 p.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-03 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1151316,\n \"text\": \" 9:50 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \\n Reason: liver transplant u/s, POD 1\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with new liver\\n REASON FOR THIS EXAMINATION:\\n liver transplant u/s, POD 1\\n ______________________________________________________________________________\\n WET READ: JXRl TUE 12:10 PM\\n no intra or extrahepatic biliary ductal dilation. small right pleural\\n effusion. patent MPV, RPV, LPV with forward flow. turbulent flow in MPV may\\n be due to surgical anastamosis. patent RHV, MHV, LHV with appropriate\\n waveforms. patent MHA, RHA, LHA with appropriate waveforms.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 46-year-old male, operative day #1, status post liver transplant.\\n\\n COMPARISON: None.\\n\\n TRANSPLANT LIVER ULTRASOUND: Imaging of the transplanted liver is limited due\\n to the skin bandage and inability of the patient to hold his breath. Allowing\\n for this limitation, there is no intra- or extra-hepatic biliary ductal\\n dilation. The common duct measures 2 mm. There is a small right pleural\\n effusion.\\n\\n The main portal vein is patent, with forward flow. Turbulent flow in the main\\n portal vein may be due to the surgical anastomosis. The right and left portal\\n veins are patent, with forward flow. The right, middle, and left hepatic\\n veins are patent with appropriate waveforms. The main hepatic artery and\\n intrahepatic right and left hepatic arteries are patent, with appropriate\\n waveforms demonstrating sharp systolic upstroke and preserved flow through\\n diastole.\\n\\n IMPRESSION:\\n 1. Normal liver transplant ultrasound with patent hepatic vasculature.\\n Turbulent flow in the main portal vein may be related to the surgical\\n anastomosis, with no definite stenosis identified.\\n 2. Small right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2184-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 234952,\n \"text\": \"Sinus rhythm with left anterior fascicular block. Compared to the previous\\ntracing there is no diagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2184-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 234953,\n \"text\": \"Sinus rhythm. Left axis deviation. Left anterior fascicular block. Compared to\\nthe previous tracing of there is no diagnostic change.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":189,"cells":{"subject_id":{"kind":"number","value":16492,"string":"16,492"},"hadm_id":{"kind":"number","value":104892,"string":"104,892"},"target_text":{"kind":"string","value":"Pt was admitted on for ecxision of Pancoast tumor in RUL. Pain control w/ epidrual is at T6/T7 14/5. She is split receiving both bupivicaine .1% thru epidural and dilaudid PCA because she has a wide incision on multiple dermatomes and a neck incision. She was supported w/ low dose neo while on epidural. Briefly intubated in ICU and, successfully extubated. POD#2 AFIB despite IV lopressor. Treated w/ IV amiodarone bolus, gtt, 2nd bolus and 2 doses of diltiazem. Pain control w/ Epidural- bupivicaine + Dil PCA. 2 chest tubes to suction. Activity OOB > chair, PT, IS. POD#3 Transition to po amiodarone w/ recurrent Afib alt w/ NSR. Re-bolused amiodarone iv and placed back on gtt. Lopressor cont po. CT 1&2 to water seal w/o ptx. Drainage #1<200cc and d/c w/o complication, #2 remained to w/s w/ moderate drainage. Incision anterior and posterior clean and dry, staples intact. POD#4-Amiod po started, lopressor ^50mgBID. Overnight pt had episodes of HR 40 SB-150 Afib, treated with IV lopresssor and Dilt IV with fair rate control. Cardiology consulted.Lopressor 'd 25 .NSR resumed during day. CT #2 d/c w/o complication. PT, IS, ambulation cont w/ high compliance. BS course, very good airation. Inhalers cont. Remains on L O2. Pt R/O'd for MI by enzymes and EKG. POD#5- Per Cardiology rec- Amiod 400 BIDpo; Epid d/c, PCA cont. Lovenox started for anticoagulation in setting of intermittent Afib post epidural d/c. Evidence of left antecubital phlebitis(red, swollen, min discomfort) at old IV site present, Keflex po x10 days started, warm soaks locally w/ small improvement. Chest tube drainge moderate from CT site. Dressing changed prn. POD#6-Remains NSR on Amiod ; PCA weaned, PO Dilaudid started w/ fair effect. Coumadin 5mg dose #1 @1800. Activity/IS compliance excellent. Staples removed and steri-strips applied. Incision- no erythema, small amount serous drainage superior posterior incision. BS course- good airation, inhalers cont. O2 weaned to off w/ good sat at rest and w/ ambulation- 95%RA. POD#7- Cont in NSR,Amiod 400BIDpo, lopresor increased to 50 , restart Imdur 30 mg (1/2 dose), lisinopril 2.5 mg ( daily dose); Coumadin 5mg dose #2 @1800, lovenox ocnt. Pain med changed to percocet w/ very good effect. BM- occurred. Plan for discharge in am POD#8. Discharge plans arranged for anticoagulation follow-up with: VNA for blood draw and post op nursing care, Cardiology clinic short term, then coumadin clinic as of . Follow-up appointments w/ , Cardiology made. PCP, NP, Cardiology NP and Cardiologist informed of plans.Discharge instructions, new medication regimen and instructions reviewed with patient POD#8-Patient discharged to home in stable condition in company of family. Discharge instructions given and reviewed w/ patient and family."},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: There has been interval removal of two right apical chest tubes. IMPRESSION: Interval removal of right apical pleural drains. Respiratory CarePt.received from PACU,intubated BBS+diminished on right,and coarse t/o.Placed on vent. 2) Right apical and hilar densities and postoperative changes right lung. Two chest tubes remain in place in the right hemithorax, and there is a persistent right apical pneumothorax. Since the previoustracing of atrial fibrillation has reverted to sinus with atrialpremature beats. Again seen is a right apical and hilar mass, two right-sided chest tubes, and skin staples. There is stable appearance of a persistent right apical pneumothorax. IMPRESSION: Possible small right apical pneumothorax, which in retrospect is probably unchanged. PT REMAINS TACHYCARDIC TO 120- LOPRESSOR RESTARTED. Right chest tubes x2 to 20 cm suction with small air leak.GI - NPO. There is volume loss of the right hemithorax with persistent elevation of the right hemidiaphragm and mediastinal shift to the right. R CT x2 ot H20 seal w/ serous drainage. DR AWARE OF ABOVE.ENDO: SLIDING SCALE INCREASED TO REFLECT BS 140-210.A: NEO WEANED TO OFF, PROPOFOL WEANED OFF, WEANED AND EXTUBATED, EPIDURAL FOR PAIN CONTROL WITH GOOD RELIEFR: TOL EXTUBATION WELL, HEMODYNAMICALLY STABLE, ENCOURAGE PULM TOILET, OOB TO CHAIR IN AM neo gtt to maintain a map> 60, LR at 75cc/hr, epidural at T5 with bupivicaine only.currently, afebrile, heart rate 90s, lopressor held- pt on neo gtt to keep map > 60.resp: vented, lsc with intermittent wheezes, treated with albuterol/atrovent, chest tubes X 2pain: epidural, but pt has sensation at t5, above and below t5. Abdomen benign.GU - Adequate UOP via foley. SBP 120-150 POST-EXTUBATION.RESP: PT WEANED AND EXTUBATED. CT PATENT WITH + AIR LEAK, NO CREPITUS NOTED.GI: ABD SOFT, HYPOACTIVE BS. Respiratory CarePt.remains on full vent.support,sedated with propofol.BBS reveal some exp wheezes t/o treated with Albuterol and atrovent.Abg's adequate. FINDINGS: There remain 2 apical right-sided pleural drains in unchanged position. Right perihilar and paramediastinal opacities are unchanged and attributed to postoperative changes. There are post-surgical changes at the right apex including signs of volume loss of the right hemithorax with persistent elevation of the right hemidiaphragm and mediastinal shift to the right. There is stable postoperative volume loss. Peripheral pulses palpable.Resp - Lungs essentialy clear. Interval decrease in right lung opacity consistent with postsurgical atelectasis. Compared with earlier the same day, the ET tube has been retracted. +periph pulses, sl edema, extrems warm.Resp: on 5l n/p w/ 02 sat 95-98%. DILT IF RATE IS NOT CONTROLLED.R: RAPID RATE UNCONTROLLED BY LOPRESSOR, AMIODARONE GTT INFUSING WITH POOR RATE CONTROL, START DILT IF RATE UNCHANGED IN HR. On the right, there are skin staples and a right chest tube. Foley cath w/ dark, conc yellow uine.Skin: R CT, R flank incision, R neck incision intactPain: Bupivicaine epidural at 6cc/hr - intact. FINAL REPORT PORTABLE CHEST X-RAY , AT 19:06. condition updateD: PLEASE SEE CAREVUE FOR SPECIFICSNEURO: PROPOFOL WEANED TO OFF. A chest tube remains in place, terminating at the extreme right lung apex. PT HAD MULTIPLE SHORT RUNS OF SVT WITH STABLE BP ALL AM. Surgical changes at the right apex with associated volume loss of the right hemithorax. The right hemidiaphragm is elevated. CT DRESSING CHANGED FOR MOD AMT SEROSANG. There has been slight interval increase in patchy opacity at the right apex, which may be due to atelectasis or aspiration. There has been interval decrease in opacity of the remaining right lung consistent with postoperative atelectasis and surgical change. Pneumothorax effusion. Sinus rhythm with bigeminal atrial premature beats. D:Pt treated for rapid afib without response to amiodarone bolus and diltiazem. ET tube with tip over left proximal main stem bronchus. chest, single vw An ET tube is present. 4:06 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: now both chest tubes with leaks. BS DIMINSHED IN RIGHT BASES. 0600 Metoprolol given early, ectopy continued. INDICATION: Status post right lung cancer resection. Heart size and cardiomediastinal contours are stable given differences and patient rotation. The left lung is slightly overinflated, but grossly clear. HO notified, PRN metoprolol given, Mg repleted with good effect. EKG DONE= RAPID AFIB, AMIODARONE BOLUS STARTED AND PT PLACED ON GTT AT 1MG/MIN. CHEST, SINGLE AP VIEW: A tiny right apical pneumothorax may be present, but is not distinctly seen. MAE WITH EQUAL STRENGTHCV: T MAX 100.9- DR AWARE, NO CX ORDERED, NEO GTT WEANED TO OFF THIS AM. TECHNIQUE: A portable AP upright chest radiograph was obtained. The right lung base and the left lung are grossly clear. The left lung is grossly clear. There is atelectasis in both lungs, slightly more pronounced in the left lung. BY 1600, HR UP TO 120-140, REPEAT BOLUS GIVEN.RESP: BS COARSE. No significant change compared with the film from , except for interval removal of the ET tube. Please evaluate for pneumothorax. IMPRESSION: No change since the prior chest x-ray. COMPARISON: AP portable upright chest radiograph . CXR obtained late morning.GI/GU: abd soft/distended. The tip overlies the proximal left main stem bronchus and should be retracted. There is postoperative volume loss in the right hemithorax, and there is increasing pulmonary opacification within the right lung with relative sparing of the right lung base. Taking clear liqs well. No change in persistent right apical pneumothorax. INDICATION: Pancoast tumor excision. lopressor given with pt converting to SR rate 70-80.P:Manage meds for a-fib. There are surgical staples overlying the right upper hemithorax. 7:02 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: worsening pneumo? Sinus rhythm. Please assess for change in pneumothorax. (A subsequent film currently on PACs demonstrates retraction of the ETT to an appropriate position.)"},"n_notes":{"kind":"number","value":20,"string":"20"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2171-10-23 00:00:00.000","description":"Report","row_id":137430,"text":"Sinus rhythm with bigeminal atrial premature beats. Since the previous\ntracing of atrial fibrillation has reverted to sinus with atrial\npremature beats.\n\n"},{"category":"ECG","chartdate":"2171-10-20 00:00:00.000","description":"Report","row_id":137431,"text":"Atrial fibrillation with a rapid ventricular response. Borderline low\nvoltage. Diffuse non-specific ST-T wave abnormalities. Compared to the previous\ntracing of rhythm is now atrial fibrillation and rate is faster.\n\n"},{"category":"ECG","chartdate":"2171-10-14 00:00:00.000","description":"Report","row_id":137432,"text":"Sinus rhythm. Findings are within normal limits. Compared to the previous\ntracing of no significant diagnostic change.\n\n"},{"category":"Radiology","chartdate":"2171-10-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887462,"text":" 11:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx, interval change\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excisionw/ 2 CT in\n place, no leak at present leaks\n REASON FOR THIS EXAMINATION:\n eval for ptx, interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman with lung cancer status post resection of Pancoast\n tumor. Please assess for change in pneumothorax.\n\n TECHNIQUE: A portable AP upright chest radiograph was obtained.\n\n COMPARISON: AP portable upright chest radiograph .\n\n FINDINGS: There remain 2 apical right-sided pleural drains in unchanged\n position. There is stable appearance of a persistent right apical\n pneumothorax. There is volume loss of the right hemithorax with persistent\n elevation of the right hemidiaphragm and mediastinal shift to the right. There\n has been interval decrease in opacity of the remaining right lung consistent\n with postoperative atelectasis and surgical change. The left lung is grossly\n clear. There are surgical staples overlying the right upper hemithorax.\n\n IMPRESSION: 1. No change in persistent right apical pneumothorax.\n\n 2. Interval decrease in right lung opacity consistent with postsurgical\n atelectasis.\n\n"},{"category":"Radiology","chartdate":"2171-10-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887141,"text":" 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX, effusion\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n REASON FOR THIS EXAMINATION:\n PTX, effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung CA. Pneumothorax effusion.\n\n CHEST, SINGLE AP VIEW:\n\n A tiny right apical pneumothorax may be present, but is not distinctly seen.\n The appearances are not significantly different from the film obtained on\n . Again seen is a right apical and hilar mass, two right-sided chest\n tubes, and skin staples. Changes in the differences of the appearance of the\n right hemidiaphragm likely relate to lordotic positioning on today's films.\n\n Prominence of markings in the left upper zone is noted, of uncertain\n significance. Attention to this area and followup films is recommended. The\n left lung is otherwise clear, without chf, focal infiltrate, or effusion.\n\n IMPRESSION: Possible small right apical pneumothorax, which in retrospect is\n probably unchanged. No significant change compared with the film from\n , except for interval removal of the ET tube.\n\n"},{"category":"Radiology","chartdate":"2171-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887351,"text":" 4:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: now both chest tubes with leaks. R/o larger pneumo.\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\n leaks\n REASON FOR THIS EXAMINATION:\n now both chest tubes with leaks. R/o larger pneumo.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post excision of right Pancoast tumor leaking from\n chest tubes.\n\n CHEST AP: Since the prior chest x-ray, there has been no significant change.\n Two chest tubes are seen in the left apical region with associated rib\n resections. Left lung remains clear. The right perihilar opacification\n persists unchanged.\n\n IMPRESSION: No change since the prior chest x-ray.\n\n"},{"category":"Radiology","chartdate":"2171-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887291,"text":" 10:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change on water seal-eval for PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision\n\n REASON FOR THIS EXAMINATION:\n interval change on water seal-eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST OF \n\n COMPARISON: .\n\n INDICATION: Status post right lung cancer resection. Chest tube on\n water-seal.\n\n A chest tube remains in place, terminating at the extreme right lung apex. An\n apical pneumothorax on the right is not significantly changed allowing for\n technical differences between the studies. There is stable postoperative\n volume loss. There has been slight interval increase in patchy opacity at the\n right apex, which may be due to atelectasis or aspiration. Right perihilar\n and paramediastinal opacities are unchanged and attributed to postoperative\n changes. The left lung is slightly overinflated, but grossly clear.\n\n\n"},{"category":"Radiology","chartdate":"2171-10-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":887789,"text":" 11:29 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA post CT pull\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman with lung cancer status post surgical resection.\n Please evaluate for pneumothorax.\n\n TECHNIQUE: PA and lateral views of the chest were obtained and compared to\n .\n\n FINDINGS: There has been interval removal of two right apical chest tubes.\n No definite pneumothorax identified. There are post-surgical changes at the\n right apex including signs of volume loss of the right hemithorax with\n persistent elevation of the right hemidiaphragm and mediastinal shift to the\n right. Again noted are multiple surgical rib defects at the right apex. The\n right lung base and the left lung are grossly clear. Heart size and\n cardiomediastinal contours are stable given differences and patient rotation.\n\n IMPRESSION: Interval removal of right apical pleural drains. No definite\n pneumothorax. Surgical changes at the right apex with associated volume loss\n of the right hemithorax.\n\n"},{"category":"Radiology","chartdate":"2171-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":886968,"text":" 5:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n REASON FOR THIS EXAMINATION:\n eval PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung CA, question pneumothorax.\n\n chest, single vw\n\n An ET tube is present. The tip overlies the proximal left main stem bronchus\n and should be retracted. The left lung is grossly clear, without CHF,\n infiltrate, or effusion. On the right, there are skin staples and a right\n chest tube. The right hemidiaphragm is elevated. There is increased opacity\n in the right upper zone, confluent with the hilum. The right base is grossly\n clear.\n\n IMPRESSION:\n\n 1. ET tube with tip over left proximal main stem bronchus. This should be\n retracted approximately 4.2 cm. (A subsequent film currently on PACs\n demonstrates retraction of the ETT to an appropriate position.)\n\n 2) Right apical and hilar densities and postoperative changes right lung.\n\n 3) No pneumothorax detected.\n\n"},{"category":"Radiology","chartdate":"2171-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":886985,"text":" 9:13 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube placement.\n\n CHEST, SINGLE AP VIEW SUPINE.\n\n Compared with earlier the same day, the ET tube has been retracted. The tip\n now lies in satisfactory position approximately 2.3 cm above the carina. There\n is atelectasis in both lungs, slightly more pronounced in the left lung.\n Otherwise, no significant change is detected.\n\n"},{"category":"Radiology","chartdate":"2171-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887366,"text":" 7:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: worsening pneumo?\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\n leaks\n REASON FOR THIS EXAMINATION:\n worsening pneumo?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY , AT 19:06.\n\n COMPARISON: Previous study of earlier the same date at 16:22.\n\n INDICATION: Pancoast tumor excision. Chest tube leak.\n\n Two chest tubes remain in place in the right hemithorax, and there is a\n persistent right apical pneumothorax. There is postoperative volume loss in\n the right hemithorax, and there is increasing pulmonary opacification within\n the right lung with relative sparing of the right lung base. This may\n represent worsening postoperative atelectasis, but is difficult to exclude\n superimposed process such as aspiration. Within the left lung, no confluent\n areas of consolidation or pleural effusion are observed.\n\n\n"},{"category":"Nursing/other","chartdate":"2171-10-18 00:00:00.000","description":"Report","row_id":1477987,"text":"Respiratory Care\nPt.received from PACU,intubated BBS+diminished on right,and coarse t/o.Placed on vent. as documented.See CareVue for details.\n"},{"category":"Nursing/other","chartdate":"2171-10-19 00:00:00.000","description":"Report","row_id":1477988,"text":"admit note\nplease see flowsheet for details. pt came from at 1800 to pacu s/p flex bronch, superclavicular scalene fat pad and lymph node disection, cervical mobilization of pancose tumor, right thoractomy, with right upper lobectomy and chest wall excision for right upper lobe mass. She came to SICU from pacu at 2300. at that time she was intubated, sedated on 30 mcq/kg/min propofol but able to nod head to questions and follow commands moving all extremities. neo gtt to maintain a map> 60, LR at 75cc/hr, epidural at T5 with bupivicaine only.\n\ncurrently, afebrile, heart rate 90s, lopressor held- pt on neo gtt to keep map > 60.\n\nresp: vented, lsc with intermittent wheezes, treated with albuterol/atrovent, chest tubes X 2\n\npain: epidural, but pt has sensation at t5, above and below t5. minimal c/o pain, 50 mcq fentanyl given during aline placement\n\nneuro: alert, following commands briskly, mae+, despite propofol gtt at 30 mcq/kg/min,\n\nsurgical dressings c/d/i\n\nplan: wean vent as tolerated, cont to control pain, chest tubes and epidural.\n"},{"category":"Nursing/other","chartdate":"2171-10-19 00:00:00.000","description":"Report","row_id":1477989,"text":"Respiratory Care\nPt.remains on full vent.support,sedated with propofol.BBS reveal some exp wheezes t/o treated with Albuterol and atrovent.Abg's adequate.\n"},{"category":"Nursing/other","chartdate":"2171-10-19 00:00:00.000","description":"Report","row_id":1477990,"text":"Pt woke up well with a good RSBI,VC,NIF & air leak past deflated cuff\nwas extubated and placed on AFM 40% She has a good cough and is productive of thick yellow-green sputum\n"},{"category":"Nursing/other","chartdate":"2171-10-19 00:00:00.000","description":"Report","row_id":1477991,"text":"condition update\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: PROPOFOL WEANED TO OFF. PT IS ALERT, ORIENTED X3, COOPERATIVE, FOLLOWS COMMANDS. MAE WITH EQUAL STRENGTH\nCV: T MAX 100.9- DR AWARE, NO CX ORDERED, NEO GTT WEANED TO OFF THIS AM. PT REMAINS TACHYCARDIC TO 120- LOPRESSOR RESTARTED. SBP 120-150 POST-EXTUBATION.\nRESP: PT WEANED AND EXTUBATED. CURRENTLY ON NP AT 4LITERS WITH SAT 96%. BS DIMINSHED IN RIGHT BASES. COUGHING AND RAISING THICK YELLOW SECRETIONS. CHEST DRESSING DRY AND INTACT. CT DRESSING CHANGED FOR MOD AMT SEROSANG. CT PATENT WITH + AIR LEAK, NO CREPITUS NOTED.\nGI: ABD SOFT, HYPOACTIVE BS. NPO.\nGU: UO DRIFTING OFF THIS AFTERNOON. DR AND DR NOTIFIED. FOLEY THEN IRRIGATED AT 1730 WITH MOD AMT OF SEDIMENT REMOVED AND PT THEN DRAINED 200CC CLOUDY YELLOW URINE. DR AWARE OF ABOVE.\nENDO: SLIDING SCALE INCREASED TO REFLECT BS 140-210.\nA: NEO WEANED TO OFF, PROPOFOL WEANED OFF, WEANED AND EXTUBATED, EPIDURAL FOR PAIN CONTROL WITH GOOD RELIEF\nR: TOL EXTUBATION WELL, HEMODYNAMICALLY STABLE, ENCOURAGE PULM TOILET, OOB TO CHAIR IN AM\n\n"},{"category":"Nursing/other","chartdate":"2171-10-20 00:00:00.000","description":"Report","row_id":1477992,"text":"NSICU Nursing Progress Note\nNeuro - Pt x3. Able to make needs known.\n\nCV - SR to ST with occ PCVs, multifocal PVCs. Pt began having runs of SVT ~0530 AM. 0600 Metoprolol given early, ectopy continued. HO notified, PRN metoprolol given, Mg repleted with good effect. MBP 90's by arterial line. Peripheral pulses palpable.\n\nResp - Lungs essentialy clear. O2 sat > 96% on 4 L NC. Strong cough productive of thick yellow sputum. Right chest tubes x2 to 20 cm suction with small air leak.\n\nGI - NPO. Abdomen benign.\n\nGU - Adequate UOP via foley. Large amount sediment. Sent for UA, cx.\n\nEndo - Regular insulin per sliding scale.\n\nA - Increasing ectopy this AM, resolved with metoprolol, MgSO4.\n\nP - continue to monitor. Contsider tx to floor.\n"},{"category":"Nursing/other","chartdate":"2171-10-20 00:00:00.000","description":"Report","row_id":1477993,"text":"CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: ALERT AND ORIENTED X3. EPIDURAL AT 6CC/HR FOR PAIN, DILAUDID PCA ALSO STARTED THIS AFTERNOON.\nCV: AFEBRILE. PT HAD MULTIPLE SHORT RUNS OF SVT WITH STABLE BP ALL AM. AT 1145, PT WENT INTO SUSTAINED RAPID RHTHTYM WITH DROP IN BP TO 90. EKG DONE= RAPID AFIB, AMIODARONE BOLUS STARTED AND PT PLACED ON GTT AT 1MG/MIN. RATE DID DROP TO 110 FOR A SHORT WHILE. BY 1600, HR UP TO 120-140, REPEAT BOLUS GIVEN.\nRESP: BS COARSE. COUGHING AND RAISING COPIOUS AMTS OF THICK YELLOW-GREEN SPUTUM. CT TO WATER SEAL WITH SEROUS DRAINAGE.\nGI: TAKING CLEAR LIQUIDS SLOWLY, ABD SOFT AND NON-TENDER.\nGU: YELLOW URINE WITH SEDIMENT.\nA: OOB TO CHAIR WITH ASSISTANCE OF 2- TOL GOOD. RHYTHM MONITORED, AMIODARONE GTT STARTED, ? DILT IF RATE IS NOT CONTROLLED.\nR: RAPID RATE UNCONTROLLED BY LOPRESSOR, AMIODARONE GTT INFUSING WITH POOR RATE CONTROL, START DILT IF RATE UNCHANGED IN HR.\n"},{"category":"Nursing/other","chartdate":"2171-10-21 00:00:00.000","description":"Report","row_id":1477994,"text":"D:Pt treated for rapid afib without response to amiodarone bolus and diltiazem. lopressor given with pt converting to SR rate 70-80.\nP:Manage meds for a-fib.\n\n"},{"category":"Nursing/other","chartdate":"2171-10-21 00:00:00.000","description":"Report","row_id":1477995,"text":"FULL CODE Universal precautions Allergy: codeine\n\n\nNeuro: AAOx3, MAEx4. OOB in chair at beginning of shift - BTB at 1200 - walks well - fairly steady on her feet, required minimal assistance.\n\nCV: HR=80-90s, NSR w/ rare to freq PVCs. Prior to am lopressor dose, HR up to 140-160 for a few seconds, then returned to 90-100s. Given 25mg lopressor po dose and additional 5mg IV - HR down to 50s for about 1hour, then has returned to 80s w/ no increase in HR and ectopy has signif decreased as well. Amiodarone gtt at .5mg/min. BP=120-130s/50-60s. +periph pulses, sl edema, extrems warm.\n\nResp: on 5l n/p w/ 02 sat 95-98%. Lungs coarse bilat, decreased in R fields. Excellent cough effort produding thick white secretions - using yankar to clear oral secretions. using IS 750-1000cc. R CT x2 ot H20 seal w/ serous drainage. CXR obtained late morning.\n\nGI/GU: abd soft/distended. +BS, no BM. Taking clear liqs well. Foley cath w/ dark, conc yellow uine.\n\nSkin: R CT, R flank incision, R neck incision intact\n\nPain: Bupivicaine epidural at 6cc/hr - intact. PCA Dialudid .12/6/1.2. Using well.\n\nID: T=98.9 no antibx.\n\nAccess: L piv x2.\n\nSocial: Sister and daughter-in-law visiting - Supportive.\n\nPlan: Tx to 2.\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 137430,\n \"text\": \"Sinus rhythm with bigeminal atrial premature beats. Since the previous\\ntracing of atrial fibrillation has reverted to sinus with atrial\\npremature beats.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 137431,\n \"text\": \"Atrial fibrillation with a rapid ventricular response. Borderline low\\nvoltage. Diffuse non-specific ST-T wave abnormalities. Compared to the previous\\ntracing of rhythm is now atrial fibrillation and rate is faster.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 137432,\n \"text\": \"Sinus rhythm. Findings are within normal limits. Compared to the previous\\ntracing of no significant diagnostic change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887462,\n \"text\": \" 11:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for ptx, interval change\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA s/p right pancoast tumor excisionw/ 2 CT in\\n place, no leak at present leaks\\n REASON FOR THIS EXAMINATION:\\n eval for ptx, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 62-year-old woman with lung cancer status post resection of Pancoast\\n tumor. Please assess for change in pneumothorax.\\n\\n TECHNIQUE: A portable AP upright chest radiograph was obtained.\\n\\n COMPARISON: AP portable upright chest radiograph .\\n\\n FINDINGS: There remain 2 apical right-sided pleural drains in unchanged\\n position. There is stable appearance of a persistent right apical\\n pneumothorax. There is volume loss of the right hemithorax with persistent\\n elevation of the right hemidiaphragm and mediastinal shift to the right. There\\n has been interval decrease in opacity of the remaining right lung consistent\\n with postoperative atelectasis and surgical change. The left lung is grossly\\n clear. There are surgical staples overlying the right upper hemithorax.\\n\\n IMPRESSION: 1. No change in persistent right apical pneumothorax.\\n\\n 2. Interval decrease in right lung opacity consistent with postsurgical\\n atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887141,\n \"text\": \" 7:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PTX, effusion\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA\\n REASON FOR THIS EXAMINATION:\\n PTX, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Lung CA. Pneumothorax effusion.\\n\\n CHEST, SINGLE AP VIEW:\\n\\n A tiny right apical pneumothorax may be present, but is not distinctly seen.\\n The appearances are not significantly different from the film obtained on\\n . Again seen is a right apical and hilar mass, two right-sided chest\\n tubes, and skin staples. Changes in the differences of the appearance of the\\n right hemidiaphragm likely relate to lordotic positioning on today's films.\\n\\n Prominence of markings in the left upper zone is noted, of uncertain\\n significance. Attention to this area and followup films is recommended. The\\n left lung is otherwise clear, without chf, focal infiltrate, or effusion.\\n\\n IMPRESSION: Possible small right apical pneumothorax, which in retrospect is\\n probably unchanged. No significant change compared with the film from\\n , except for interval removal of the ET tube.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887351,\n \"text\": \" 4:06 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: now both chest tubes with leaks. R/o larger pneumo.\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\\n leaks\\n REASON FOR THIS EXAMINATION:\\n now both chest tubes with leaks. R/o larger pneumo.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Status post excision of right Pancoast tumor leaking from\\n chest tubes.\\n\\n CHEST AP: Since the prior chest x-ray, there has been no significant change.\\n Two chest tubes are seen in the left apical region with associated rib\\n resections. Left lung remains clear. The right perihilar opacification\\n persists unchanged.\\n\\n IMPRESSION: No change since the prior chest x-ray.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887291,\n \"text\": \" 10:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change on water seal-eval for PTX\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA s/p right pancoast tumor excision\\n\\n REASON FOR THIS EXAMINATION:\\n interval change on water seal-eval for PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE UPRIGHT CHEST OF \\n\\n COMPARISON: .\\n\\n INDICATION: Status post right lung cancer resection. Chest tube on\\n water-seal.\\n\\n A chest tube remains in place, terminating at the extreme right lung apex. An\\n apical pneumothorax on the right is not significantly changed allowing for\\n technical differences between the studies. There is stable postoperative\\n volume loss. There has been slight interval increase in patchy opacity at the\\n right apex, which may be due to atelectasis or aspiration. Right perihilar\\n and paramediastinal opacities are unchanged and attributed to postoperative\\n changes. The left lung is slightly overinflated, but grossly clear.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 887789,\n \"text\": \" 11:29 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for PTX\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA post CT pull\\n REASON FOR THIS EXAMINATION:\\n eval for PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 62-year-old woman with lung cancer status post surgical resection.\\n Please evaluate for pneumothorax.\\n\\n TECHNIQUE: PA and lateral views of the chest were obtained and compared to\\n .\\n\\n FINDINGS: There has been interval removal of two right apical chest tubes.\\n No definite pneumothorax identified. There are post-surgical changes at the\\n right apex including signs of volume loss of the right hemithorax with\\n persistent elevation of the right hemidiaphragm and mediastinal shift to the\\n right. Again noted are multiple surgical rib defects at the right apex. The\\n right lung base and the left lung are grossly clear. Heart size and\\n cardiomediastinal contours are stable given differences and patient rotation.\\n\\n IMPRESSION: Interval removal of right apical pleural drains. No definite\\n pneumothorax. Surgical changes at the right apex with associated volume loss\\n of the right hemithorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 886968,\n \"text\": \" 5:54 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval PTX\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA\\n REASON FOR THIS EXAMINATION:\\n eval PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Lung CA, question pneumothorax.\\n\\n chest, single vw\\n\\n An ET tube is present. The tip overlies the proximal left main stem bronchus\\n and should be retracted. The left lung is grossly clear, without CHF,\\n infiltrate, or effusion. On the right, there are skin staples and a right\\n chest tube. The right hemidiaphragm is elevated. There is increased opacity\\n in the right upper zone, confluent with the hilum. The right base is grossly\\n clear.\\n\\n IMPRESSION:\\n\\n 1. ET tube with tip over left proximal main stem bronchus. This should be\\n retracted approximately 4.2 cm. (A subsequent film currently on PACs\\n demonstrates retraction of the ETT to an appropriate position.)\\n\\n 2) Right apical and hilar densities and postoperative changes right lung.\\n\\n 3) No pneumothorax detected.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 886985,\n \"text\": \" 9:13 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: ETT placement\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA\\n\\n REASON FOR THIS EXAMINATION:\\n ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ET tube placement.\\n\\n CHEST, SINGLE AP VIEW SUPINE.\\n\\n Compared with earlier the same day, the ET tube has been retracted. The tip\\n now lies in satisfactory position approximately 2.3 cm above the carina. There\\n is atelectasis in both lungs, slightly more pronounced in the left lung.\\n Otherwise, no significant change is detected.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887366,\n \"text\": \" 7:02 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: worsening pneumo?\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\\n leaks\\n REASON FOR THIS EXAMINATION:\\n worsening pneumo?\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST X-RAY , AT 19:06.\\n\\n COMPARISON: Previous study of earlier the same date at 16:22.\\n\\n INDICATION: Pancoast tumor excision. Chest tube leak.\\n\\n Two chest tubes remain in place in the right hemithorax, and there is a\\n persistent right apical pneumothorax. There is postoperative volume loss in\\n the right hemithorax, and there is increasing pulmonary opacification within\\n the right lung with relative sparing of the right lung base. This may\\n represent worsening postoperative atelectasis, but is difficult to exclude\\n superimposed process such as aspiration. Within the left lung, no confluent\\n areas of consolidation or pleural effusion are observed.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477987,\n \"text\": \"Respiratory Care\\nPt.received from PACU,intubated BBS+diminished on right,and coarse t/o.Placed on vent. as documented.See CareVue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477988,\n \"text\": \"admit note\\nplease see flowsheet for details. pt came from at 1800 to pacu s/p flex bronch, superclavicular scalene fat pad and lymph node disection, cervical mobilization of pancose tumor, right thoractomy, with right upper lobectomy and chest wall excision for right upper lobe mass. She came to SICU from pacu at 2300. at that time she was intubated, sedated on 30 mcq/kg/min propofol but able to nod head to questions and follow commands moving all extremities. neo gtt to maintain a map> 60, LR at 75cc/hr, epidural at T5 with bupivicaine only.\\n\\ncurrently, afebrile, heart rate 90s, lopressor held- pt on neo gtt to keep map > 60.\\n\\nresp: vented, lsc with intermittent wheezes, treated with albuterol/atrovent, chest tubes X 2\\n\\npain: epidural, but pt has sensation at t5, above and below t5. minimal c/o pain, 50 mcq fentanyl given during aline placement\\n\\nneuro: alert, following commands briskly, mae+, despite propofol gtt at 30 mcq/kg/min,\\n\\nsurgical dressings c/d/i\\n\\nplan: wean vent as tolerated, cont to control pain, chest tubes and epidural.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477989,\n \"text\": \"Respiratory Care\\nPt.remains on full vent.support,sedated with propofol.BBS reveal some exp wheezes t/o treated with Albuterol and atrovent.Abg's adequate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477990,\n \"text\": \"Pt woke up well with a good RSBI,VC,NIF & air leak past deflated cuff\\nwas extubated and placed on AFM 40% She has a good cough and is productive of thick yellow-green sputum\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477991,\n \"text\": \"condition update\\nD: PLEASE SEE CAREVUE FOR SPECIFICS\\nNEURO: PROPOFOL WEANED TO OFF. PT IS ALERT, ORIENTED X3, COOPERATIVE, FOLLOWS COMMANDS. MAE WITH EQUAL STRENGTH\\nCV: T MAX 100.9- DR AWARE, NO CX ORDERED, NEO GTT WEANED TO OFF THIS AM. PT REMAINS TACHYCARDIC TO 120- LOPRESSOR RESTARTED. SBP 120-150 POST-EXTUBATION.\\nRESP: PT WEANED AND EXTUBATED. CURRENTLY ON NP AT 4LITERS WITH SAT 96%. BS DIMINSHED IN RIGHT BASES. COUGHING AND RAISING THICK YELLOW SECRETIONS. CHEST DRESSING DRY AND INTACT. CT DRESSING CHANGED FOR MOD AMT SEROSANG. CT PATENT WITH + AIR LEAK, NO CREPITUS NOTED.\\nGI: ABD SOFT, HYPOACTIVE BS. NPO.\\nGU: UO DRIFTING OFF THIS AFTERNOON. DR AND DR NOTIFIED. FOLEY THEN IRRIGATED AT 1730 WITH MOD AMT OF SEDIMENT REMOVED AND PT THEN DRAINED 200CC CLOUDY YELLOW URINE. DR AWARE OF ABOVE.\\nENDO: SLIDING SCALE INCREASED TO REFLECT BS 140-210.\\nA: NEO WEANED TO OFF, PROPOFOL WEANED OFF, WEANED AND EXTUBATED, EPIDURAL FOR PAIN CONTROL WITH GOOD RELIEF\\nR: TOL EXTUBATION WELL, HEMODYNAMICALLY STABLE, ENCOURAGE PULM TOILET, OOB TO CHAIR IN AM\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477992,\n \"text\": \"NSICU Nursing Progress Note\\nNeuro - Pt x3. Able to make needs known.\\n\\nCV - SR to ST with occ PCVs, multifocal PVCs. Pt began having runs of SVT ~0530 AM. 0600 Metoprolol given early, ectopy continued. HO notified, PRN metoprolol given, Mg repleted with good effect. MBP 90's by arterial line. Peripheral pulses palpable.\\n\\nResp - Lungs essentialy clear. O2 sat > 96% on 4 L NC. Strong cough productive of thick yellow sputum. Right chest tubes x2 to 20 cm suction with small air leak.\\n\\nGI - NPO. Abdomen benign.\\n\\nGU - Adequate UOP via foley. Large amount sediment. Sent for UA, cx.\\n\\nEndo - Regular insulin per sliding scale.\\n\\nA - Increasing ectopy this AM, resolved with metoprolol, MgSO4.\\n\\nP - continue to monitor. Contsider tx to floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477993,\n \"text\": \"CONDITION UPDATE\\nD: PLEASE SEE CAREVUE FOR SPECIFICS\\nNEURO: ALERT AND ORIENTED X3. EPIDURAL AT 6CC/HR FOR PAIN, DILAUDID PCA ALSO STARTED THIS AFTERNOON.\\nCV: AFEBRILE. PT HAD MULTIPLE SHORT RUNS OF SVT WITH STABLE BP ALL AM. AT 1145, PT WENT INTO SUSTAINED RAPID RHTHTYM WITH DROP IN BP TO 90. EKG DONE= RAPID AFIB, AMIODARONE BOLUS STARTED AND PT PLACED ON GTT AT 1MG/MIN. RATE DID DROP TO 110 FOR A SHORT WHILE. BY 1600, HR UP TO 120-140, REPEAT BOLUS GIVEN.\\nRESP: BS COARSE. COUGHING AND RAISING COPIOUS AMTS OF THICK YELLOW-GREEN SPUTUM. CT TO WATER SEAL WITH SEROUS DRAINAGE.\\nGI: TAKING CLEAR LIQUIDS SLOWLY, ABD SOFT AND NON-TENDER.\\nGU: YELLOW URINE WITH SEDIMENT.\\nA: OOB TO CHAIR WITH ASSISTANCE OF 2- TOL GOOD. RHYTHM MONITORED, AMIODARONE GTT STARTED, ? DILT IF RATE IS NOT CONTROLLED.\\nR: RAPID RATE UNCONTROLLED BY LOPRESSOR, AMIODARONE GTT INFUSING WITH POOR RATE CONTROL, START DILT IF RATE UNCHANGED IN HR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477994,\n \"text\": \"D:Pt treated for rapid afib without response to amiodarone bolus and diltiazem. lopressor given with pt converting to SR rate 70-80.\\nP:Manage meds for a-fib.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477995,\n \"text\": \"FULL CODE Universal precautions Allergy: codeine\\n\\n\\nNeuro: AAOx3, MAEx4. OOB in chair at beginning of shift - BTB at 1200 - walks well - fairly steady on her feet, required minimal assistance.\\n\\nCV: HR=80-90s, NSR w/ rare to freq PVCs. Prior to am lopressor dose, HR up to 140-160 for a few seconds, then returned to 90-100s. Given 25mg lopressor po dose and additional 5mg IV - HR down to 50s for about 1hour, then has returned to 80s w/ no increase in HR and ectopy has signif decreased as well. Amiodarone gtt at .5mg/min. BP=120-130s/50-60s. +periph pulses, sl edema, extrems warm.\\n\\nResp: on 5l n/p w/ 02 sat 95-98%. Lungs coarse bilat, decreased in R fields. Excellent cough effort produding thick white secretions - using yankar to clear oral secretions. using IS 750-1000cc. R CT x2 ot H20 seal w/ serous drainage. CXR obtained late morning.\\n\\nGI/GU: abd soft/distended. +BS, no BM. Taking clear liqs well. Foley cath w/ dark, conc yellow uine.\\n\\nSkin: R CT, R flank incision, R neck incision intact\\n\\nPain: Bupivicaine epidural at 6cc/hr - intact. PCA Dialudid .12/6/1.2. Using well.\\n\\nID: T=98.9 no antibx.\\n\\nAccess: L piv x2.\\n\\nSocial: Sister and daughter-in-law visiting - Supportive.\\n\\nPlan: Tx to 2.\\n\"\n }\n]"}}},{"rowIdx":190,"cells":{"subject_id":{"kind":"number","value":9702,"string":"9,702"},"hadm_id":{"kind":"number","value":177827,"string":"177,827"},"target_text":{"kind":"string","value":"The patient was left intubated post operation due to some concerns of hypotenstion. This resoled quickly and he was extubated. He was extubated by the AM of POD1. He did well postoperativly. He had epidural anesthesia, which provided good pain control. He was moved to the VICU on POD1. His diet was held until flatus was passed. His INR was revered with Vit K. A bleeding time was done to assess coagulation, which was normal. His swan catheter was changed to cvl on POD 3 due to stable cardiac function. In the OR, a stomach mass was found, so Dr. service was consulted, he will f/u as an outpt. He was found to have a weak left deltoid, and neurology was consulted. After extensive radiological study, no definate cause for his weakness was found, but it had almost complealty resolved by the time of discharge. Otherwise his diet advanced without incident and he did well from a PT persepective. He was d/c'ed on POD 7 on coumadin to be followed by his PCP."},"extractive_notes_summ":{"kind":"string","value":"MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES: FINDINGS: There is slight irregularity of the proximal basilar artery without evidence of high-grade stenosis. IMPRESSION: Mild irregularity of the proximal basilar artery. Finally, asymmetrical right apical predominantly pleural opacity is noted and is stable compared to the recent radiograph. There has been interval removal of an endotracheal tube and nasogastric tube. The vertebral bodies demonstrate decreased T1 signal throughout. The distal right vertebral artery appears to end in a PICA. As noted in the cervical spine, there is diffuse decreased T1 signal throughout the vertebral bodies. There is diffuse bilateral carotid calcification seen as well as calcification within the aorta. Also, a mild degree of compression atelectasis at the right lung base is noted unchanged. Decreased T1 signal in the thoracic spine as in the cervical spine. IMPRESSION: 1) Free intraperitoneal air, most likely related to recent abdominal surgery. There are arteriosclerotic changes involving thoracic aorta, left ventricular enlargement, and postoperative changes from prior sternotomy. FINDINGS: A right internal jugular catheter has been placed and terminates in the superior vena cava. 4) Asymmetrical right apical opacity. Decreased T1 signal throughout the cervical spine. FINDINGS: The exam is somewhat limited by patient motion. Small bilateral pleural effusions are present. There is a remote lacunar infarct in the anterior aspect of the right thalamus, as identified on the patient's CT scan. Ventricles and sulci are mildly prominent consistent with mild brain atrophy. Note is made of moderate calcifications of both internal carotid arteries. Free intraperitoneal air is noted within the abdomen. 2) Central venous catheter in good position with no pneumothorax. FINDINGS: CERVICAL SPINE: The visualization of the cervical spine is limited by motion. also had a thoracic epidural, pulled today. Low densities in the right caudate head, the anterior limbs of the internal capsule and the right thalamus are probably remote infarcts but there are no comparison studies. most likely asymmetrical pleural thickening but attention to this region on a dedicated PA and lateral chest radiograph is recommended when the patient's condition permits. 3) Vascular calcifications within the bilateral carotids and aorta. Mild elevation of the left hemidiaphragm is seen. There are small lacunar infarcts, either in the anterior putamina or the anterior limbs of the internal capsules bilaterally, also consistent with CT scan findings. This could be seen in hematopoietic or neoplastic disorders. This could be seen in hematopoietic or neoplastic disorders. Status post sternotomy. Cardiac and mediastinal contours are stable. THORACIC SPINE: There is motion artifact present. 2) Persistent free intraperitoneal air due to the recent abdominal surgery. TECHNIQUE: Axial and sagittal T1, T2 and inversion recovery images of the thoracic and cervical spine were obtained. Free intraperitoneal air under both hemidiaphragms again noted due to recent abdominal surgery. C-spine nontrauma: There is a 2-mm focus of density in the subcutaneous tissues of the anterior neck around the level of C6. TECHNIQUE: Non-contrast CT of the head was obtained without comparisons. There are bibasilar opacities predominantly in the retrocardiac region which have worsened in the interval, and there are also small pleural effusions, left greater than right. INDICATION: Patient with status post catheter placement. The visualized spinal cord is unremarkable. Evaluate for infarction. Evaluate for epidural hematoma. although T-spine is ordered and patient had a Thoracic epidural, it should be noted that his deficit is of the C5 root and thus this area should be included in the study please FINAL REPORT INDICATION: Left deltoid paralysis, history of thoracic epidural. Some asymmetrical thickening in the right apex is seen. The osseous and soft-tissue structures appear unremarkable. Postoperative changes in the abdomen. The visualized paranasal sinuses have a normal signal. CLINICAL INDICATION: Line change. Pt had screening form done recently, and had MR this AM REASON FOR THIS EXAMINATION: Please do diffusion sequences, this was not available at initial MRI FINAL REPORT CLINICAL INFORMATION: Isolated deltoid weakness. The tip is in the mid superior vena cava. REASON FOR THIS EXAMINATION: evaluate for epidural hematoma. Again, the changes appear to be chronic. IMPRESSION: 1) There has been improvement in the magnitude of the left lower lobe partial atelectasis. This is a nonspecific finding. Probable chronic interstitial lung change. IMPRESSION: No evidence of acute mass or hemorrhage. Swan-Ganz catheter is identified with its tip in the right pulmonary artery. REPORT: The patient is intubated. 2) Degenerative changes of the C-spine with anterolisthesis, disk space narrowing, and osteophytosis as described above. No evidence of acute infarction. Areas of severe calcification along the left vertebral artery are also seen. The ventricles, cisterns, and sulci are within normal limits. 3) The remainder of the lungs are clear at this time. Note that MRI with diffusion-weighted imaging is a more sensitive evaluation for infarction. FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of normally midline structures. There is probably free air present on the previous supine study as well but the distribution has changed related to the patient's current upright positioning. 3) Worsening bibasilar opacities predominantly in the retrocardiac area, most likely due to atelectasis, although aspiration should also be considered. Some midline sutures are identified in the abdomen, and there are some apparent bowel loops also seen. IMPRESSION: No evidence of intracranial hemorrhage or gross infarction. Extensive parenchymal lung disease is identified. Anterior osteophytes are seen on C6 and C7."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2138-12-29 00:00:00.000","description":"C-SPINE NON-TRAUMA 2-3 VIEWS","row_id":854973,"text":" 10:20 PM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: eval prior to MRI of Cspine/Tspine\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with possible epidural bleed after epidural catheter removal\n with hx of metal imbedded in neck\n REASON FOR THIS EXAMINATION:\n eval prior to MRI of Cspine/Tspine\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 78-year-old man with possible epidural bleed after epidural\n catheter removal with history of metal imbedded in neck. Please evaluate neck\n for metal.\n\n C-spine nontrauma: There is a 2-mm focus of density in the subcutaneous\n tissues of the anterior neck around the level of C6. This may be a small\n piece of metal. No fractures are identified within the C-spine. There is\n grade I anterolisthesis of C5 on C6. There is disk space narrowing at C4-C5,\n C5-C6, and C6-C7. The most severe disk space narrowing is at C6-C7. Anterior\n osteophytes are seen on C6 and C7. There are increased interstitial markings\n within the lungs. There is diffuse bilateral carotid calcification seen as\n well as calcification within the aorta.\n\n IMPRESSION:\n\n 1) A 2-mm focus of density, likely metal in the subcutaneous tissues of the\n anterior neck.\n\n 2) Degenerative changes of the C-spine with anterolisthesis, disk space\n narrowing, and osteophytosis as described above.\n\n 3) Vascular calcifications within the bilateral carotids and aorta.\n\n\n"},{"category":"Radiology","chartdate":"2138-12-30 00:00:00.000","description":"CHEST (PA & LAT)","row_id":855008,"text":" 8:00 AM\n CHEST (PA & LAT) Clip # \n Reason: surveillance CXR\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p aorto-bifem bypass on \n REASON FOR THIS EXAMINATION:\n surveillance CXR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 78-year-old status post aorto-bifem bypass. Evaluate the chest.\n\n FINDINGS:\n\n Comparison is made to the prior study of a day earlier. Free intraperitoneal\n air under both hemidiaphragms again noted due to recent abdominal surgery.\n The right IJ line is in place. The tip is in the mid superior vena cava.\n There is no evidence of pneumothorax. Minimal degree of partial atelectasis\n involving the left lower lobe is noted, which has improved since the prior\n study. Also, a mild degree of compression atelectasis at the right lung base\n is noted unchanged. The remainder of the lungs are clear. There are\n arteriosclerotic changes involving thoracic aorta, left ventricular\n enlargement, and postoperative changes from prior sternotomy.\n\n IMPRESSION:\n\n 1) There has been improvement in the magnitude of the left lower lobe partial\n atelectasis.\n\n 2) Persistent free intraperitoneal air due to the recent abdominal surgery.\n\n 3) The remainder of the lungs are clear at this time.\n\n\n\n"},{"category":"Radiology","chartdate":"2138-12-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":854900,"text":" 11:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check central line placement\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p right IJ cordis to triple lumen change over guidwire\n\n REASON FOR THIS EXAMINATION:\n check central line placement\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable upright chest that is dated .\n\n CLINICAL INDICATION: Line change.\n\n FINDINGS:\n\n A right internal jugular catheter has been placed and terminates in the\n superior vena cava. There has been interval removal of an endotracheal tube\n and nasogastric tube. There is no pneumothorax. Cardiac and mediastinal\n contours are stable. There are bibasilar opacities predominantly in the\n retrocardiac region which have worsened in the interval, and there are also\n small pleural effusions, left greater than right. Free intraperitoneal air is\n noted within the abdomen. There is probably free air present on the previous\n supine study as well but the distribution has changed related to the patient's\n current upright positioning. Finally, asymmetrical right apical predominantly\n pleural opacity is noted and is stable compared to the recent radiograph.\n\n IMPRESSION:\n\n 1) Free intraperitoneal air, most likely related to recent abdominal surgery.\n\n 2) Central venous catheter in good position with no pneumothorax.\n\n 3) Worsening bibasilar opacities predominantly in the retrocardiac area, most\n likely due to atelectasis, although aspiration should also be considered.\n\n 4) Asymmetrical right apical opacity. most likely asymmetrical pleural\n thickening but attention to this region on a dedicated PA and lateral chest\n radiograph is recommended when the patient's condition permits.\n\n"},{"category":"Radiology","chartdate":"2138-12-30 00:00:00.000","description":"MR CERVICAL SPINE","row_id":854998,"text":" 6:47 AM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n Reason: evaluate for epidural hematoma. although T-spine is ordered\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with vasculopath, s/p aortobifem, with new Left deltoid\n paralysis. also had a thoracic epidural, pulled today.\n REASON FOR THIS EXAMINATION:\n evaluate for epidural hematoma. although T-spine is ordered and patient had a\n Thoracic epidural, it should be noted that his deficit is of the C5 root and\n thus this area should be included in the study please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left deltoid paralysis, history of thoracic epidural. Evaluate\n for epidural hematoma.\n\n TECHNIQUE: Axial and sagittal T1, T2 and inversion recovery images of the\n thoracic and cervical spine were obtained.\n\n FINDINGS:\n\n CERVICAL SPINE: The visualization of the cervical spine is limited by motion.\n There is no spinal cord or paraspinal pathology visualized. There is no disc\n herniation noted. There is no evidence of spinal stenosis or subluxation of\n the component vertebra. The vertebral bodies demonstrate decreased T1 signal\n throughout. Small bilateral pleural effusions are present.\n\n IMPRESSION:\n 1. Decreased T1 signal throughout the cervical spine. This could be seen in\n hematopoietic or neoplastic disorders.\n 2. No evidence of cord compression.\n\n THORACIC SPINE: There is motion artifact present. There is no disc, vertebral\n or intraspinal pathology visualized. There is no evidence of spinal stenosis\n or spondylolisthesis. The visualized spinal cord is unremarkable. As noted in\n the cervical spine, there is diffuse decreased T1 signal throughout the\n vertebral bodies.\n\n IMPRESSION:\n 1. Decreased T1 signal in the thoracic spine as in the cervical spine. This\n could be seen in hematopoietic or neoplastic disorders.\n 2. No evidence of spinal cord compression.\n\n\n"},{"category":"Radiology","chartdate":"2138-12-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":854648,"text":" 7:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PA cath placement\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with s/p AoBF\n REASON FOR THIS EXAMINATION:\n PA cath placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Patient with status post catheter placement. Evaluate.\n\n COMPARISON: No study available for comparison.\n\n REPORT: The patient is intubated. The T-tube lies 5.5 cm above the carina.\n Status post sternotomy. A LIMA graft has also been performed. Swan-Ganz\n catheter is identified with its tip in the right pulmonary artery. It could\n be retracted slightly. NG tube is seen coursing through the mediastinum with\n its tip in the region of the stomach. Mild elevation of the left\n hemidiaphragm is seen. No studies are available for comparison. Some midline\n sutures are identified in the abdomen, and there are some apparent bowel loops\n also seen.\n\n Extensive parenchymal lung disease is identified. This is mostly interstitial\n in nature, the changes are likely longstanding, though no studies available\n for comparison. Some asymmetrical thickening in the right apex is seen. This\n is a nonspecific finding. Again, the changes appear to be chronic.\n\n CONCLUSION:\n\n Good position of the line. Probable chronic interstitial lung change.\n Postoperative changes in the abdomen.\n\n\n\n"},{"category":"Radiology","chartdate":"2138-12-31 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":855123,"text":" 12:42 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Please do diffusion sequences, this was not available at ini\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with isolated deltoid weakness, ? stroke. Pt had screening\n form done recently, and had MR this AM\n REASON FOR THIS EXAMINATION:\n Please do diffusion sequences, this was not available at initial MRI\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Isolated deltoid weakness. ? stroke.\n\n MRI OF THE BRAIN:\n\n Exam compared to the patient's CT scan of .\n\n FINDINGS: The exam is somewhat limited by patient motion. There is a remote\n lacunar infarct in the anterior aspect of the right thalamus, as identified on\n the patient's CT scan. There are small lacunar infarcts, either in the\n anterior putamina or the anterior limbs of the internal capsules bilaterally,\n also consistent with CT scan findings. There is no evidence of abnormal\n diffusion to suggest the presence of acute infarction. There is no evidence\n of mass effect or hemorrhage. Ventricles and sulci are mildly prominent\n consistent with mild brain atrophy. The visualized paranasal sinuses have a\n normal signal.\n\n IMPRESSION: No evidence of acute mass or hemorrhage. No evidence of acute\n infarction.\n\n MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES:\n\n FINDINGS: There is slight irregularity of the proximal basilar artery without\n evidence of high-grade stenosis. The distal right vertebral artery appears to\n end in a PICA. There is no evidence of aneurysm. There is no evidence of\n flow abnormality in the carotid circuits.\n\n IMPRESSION: Mild irregularity of the proximal basilar artery.\n\n"},{"category":"Radiology","chartdate":"2138-12-29 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":854957,"text":" 5:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ACUTE ASYMMETRICAL LEFT UPPER EXTREMITY WEAKNESS, EVAL FOR INFARCT\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with acut asymmetrical left upper extremity weakness\n REASON FOR THIS EXAMINATION:\n r/o infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute asymmetric upper extremity weakness. Evaluate for\n infarction.\n\n TECHNIQUE: Non-contrast CT of the head was obtained without comparisons.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of\n normally midline structures. The ventricles, cisterns, and sulci are within\n normal limits. -white matter differentiation is preserved. Low densities\n in the right caudate head, the anterior limbs of the internal capsule and\n the right thalamus are probably remote infarcts but there are no\n comparison studies. Note is made of moderate calcifications of both internal\n carotid arteries. Areas of severe calcification along the left vertebral\n artery are also seen. The osseous and soft-tissue structures appear\n unremarkable.\n\n IMPRESSION: No evidence of intracranial hemorrhage or gross infarction. Note\n that MRI with diffusion-weighted imaging is a more sensitive evaluation for\n infarction.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-29 00:00:00.000\",\n \"description\": \"C-SPINE NON-TRAUMA 2-3 VIEWS\",\n \"row_id\": 854973,\n \"text\": \" 10:20 PM\\n C-SPINE NON-TRAUMA VIEWS Clip # \\n Reason: eval prior to MRI of Cspine/Tspine\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with possible epidural bleed after epidural catheter removal\\n with hx of metal imbedded in neck\\n REASON FOR THIS EXAMINATION:\\n eval prior to MRI of Cspine/Tspine\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 78-year-old man with possible epidural bleed after epidural\\n catheter removal with history of metal imbedded in neck. Please evaluate neck\\n for metal.\\n\\n C-spine nontrauma: There is a 2-mm focus of density in the subcutaneous\\n tissues of the anterior neck around the level of C6. This may be a small\\n piece of metal. No fractures are identified within the C-spine. There is\\n grade I anterolisthesis of C5 on C6. There is disk space narrowing at C4-C5,\\n C5-C6, and C6-C7. The most severe disk space narrowing is at C6-C7. Anterior\\n osteophytes are seen on C6 and C7. There are increased interstitial markings\\n within the lungs. There is diffuse bilateral carotid calcification seen as\\n well as calcification within the aorta.\\n\\n IMPRESSION:\\n\\n 1) A 2-mm focus of density, likely metal in the subcutaneous tissues of the\\n anterior neck.\\n\\n 2) Degenerative changes of the C-spine with anterolisthesis, disk space\\n narrowing, and osteophytosis as described above.\\n\\n 3) Vascular calcifications within the bilateral carotids and aorta.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-30 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 855008,\n \"text\": \" 8:00 AM\\n CHEST (PA & LAT) Clip # \\n Reason: surveillance CXR\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man s/p aorto-bifem bypass on \\n REASON FOR THIS EXAMINATION:\\n surveillance CXR\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 78-year-old status post aorto-bifem bypass. Evaluate the chest.\\n\\n FINDINGS:\\n\\n Comparison is made to the prior study of a day earlier. Free intraperitoneal\\n air under both hemidiaphragms again noted due to recent abdominal surgery.\\n The right IJ line is in place. The tip is in the mid superior vena cava.\\n There is no evidence of pneumothorax. Minimal degree of partial atelectasis\\n involving the left lower lobe is noted, which has improved since the prior\\n study. Also, a mild degree of compression atelectasis at the right lung base\\n is noted unchanged. The remainder of the lungs are clear. There are\\n arteriosclerotic changes involving thoracic aorta, left ventricular\\n enlargement, and postoperative changes from prior sternotomy.\\n\\n IMPRESSION:\\n\\n 1) There has been improvement in the magnitude of the left lower lobe partial\\n atelectasis.\\n\\n 2) Persistent free intraperitoneal air due to the recent abdominal surgery.\\n\\n 3) The remainder of the lungs are clear at this time.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 854900,\n \"text\": \" 11:34 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: check central line placement\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man s/p right IJ cordis to triple lumen change over guidwire\\n\\n REASON FOR THIS EXAMINATION:\\n check central line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n This is a portable upright chest that is dated .\\n\\n CLINICAL INDICATION: Line change.\\n\\n FINDINGS:\\n\\n A right internal jugular catheter has been placed and terminates in the\\n superior vena cava. There has been interval removal of an endotracheal tube\\n and nasogastric tube. There is no pneumothorax. Cardiac and mediastinal\\n contours are stable. There are bibasilar opacities predominantly in the\\n retrocardiac region which have worsened in the interval, and there are also\\n small pleural effusions, left greater than right. Free intraperitoneal air is\\n noted within the abdomen. There is probably free air present on the previous\\n supine study as well but the distribution has changed related to the patient's\\n current upright positioning. Finally, asymmetrical right apical predominantly\\n pleural opacity is noted and is stable compared to the recent radiograph.\\n\\n IMPRESSION:\\n\\n 1) Free intraperitoneal air, most likely related to recent abdominal surgery.\\n\\n 2) Central venous catheter in good position with no pneumothorax.\\n\\n 3) Worsening bibasilar opacities predominantly in the retrocardiac area, most\\n likely due to atelectasis, although aspiration should also be considered.\\n\\n 4) Asymmetrical right apical opacity. most likely asymmetrical pleural\\n thickening but attention to this region on a dedicated PA and lateral chest\\n radiograph is recommended when the patient's condition permits.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-30 00:00:00.000\",\n \"description\": \"MR CERVICAL SPINE\",\n \"row_id\": 854998,\n \"text\": \" 6:47 AM\\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \\n Reason: evaluate for epidural hematoma. although T-spine is ordered\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with vasculopath, s/p aortobifem, with new Left deltoid\\n paralysis. also had a thoracic epidural, pulled today.\\n REASON FOR THIS EXAMINATION:\\n evaluate for epidural hematoma. although T-spine is ordered and patient had a\\n Thoracic epidural, it should be noted that his deficit is of the C5 root and\\n thus this area should be included in the study please\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Left deltoid paralysis, history of thoracic epidural. Evaluate\\n for epidural hematoma.\\n\\n TECHNIQUE: Axial and sagittal T1, T2 and inversion recovery images of the\\n thoracic and cervical spine were obtained.\\n\\n FINDINGS:\\n\\n CERVICAL SPINE: The visualization of the cervical spine is limited by motion.\\n There is no spinal cord or paraspinal pathology visualized. There is no disc\\n herniation noted. There is no evidence of spinal stenosis or subluxation of\\n the component vertebra. The vertebral bodies demonstrate decreased T1 signal\\n throughout. Small bilateral pleural effusions are present.\\n\\n IMPRESSION:\\n 1. Decreased T1 signal throughout the cervical spine. This could be seen in\\n hematopoietic or neoplastic disorders.\\n 2. No evidence of cord compression.\\n\\n THORACIC SPINE: There is motion artifact present. There is no disc, vertebral\\n or intraspinal pathology visualized. There is no evidence of spinal stenosis\\n or spondylolisthesis. The visualized spinal cord is unremarkable. As noted in\\n the cervical spine, there is diffuse decreased T1 signal throughout the\\n vertebral bodies.\\n\\n IMPRESSION:\\n 1. Decreased T1 signal in the thoracic spine as in the cervical spine. This\\n could be seen in hematopoietic or neoplastic disorders.\\n 2. No evidence of spinal cord compression.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 854648,\n \"text\": \" 7:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PA cath placement\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with s/p AoBF\\n REASON FOR THIS EXAMINATION:\\n PA cath placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Chest radiograph.\\n\\n INDICATION: Patient with status post catheter placement. Evaluate.\\n\\n COMPARISON: No study available for comparison.\\n\\n REPORT: The patient is intubated. The T-tube lies 5.5 cm above the carina.\\n Status post sternotomy. A LIMA graft has also been performed. Swan-Ganz\\n catheter is identified with its tip in the right pulmonary artery. It could\\n be retracted slightly. NG tube is seen coursing through the mediastinum with\\n its tip in the region of the stomach. Mild elevation of the left\\n hemidiaphragm is seen. No studies are available for comparison. Some midline\\n sutures are identified in the abdomen, and there are some apparent bowel loops\\n also seen.\\n\\n Extensive parenchymal lung disease is identified. This is mostly interstitial\\n in nature, the changes are likely longstanding, though no studies available\\n for comparison. Some asymmetrical thickening in the right apex is seen. This\\n is a nonspecific finding. Again, the changes appear to be chronic.\\n\\n CONCLUSION:\\n\\n Good position of the line. Probable chronic interstitial lung change.\\n Postoperative changes in the abdomen.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-31 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 855123,\n \"text\": \" 12:42 AM\\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n Reason: Please do diffusion sequences, this was not available at ini\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with isolated deltoid weakness, ? stroke. Pt had screening\\n form done recently, and had MR this AM\\n REASON FOR THIS EXAMINATION:\\n Please do diffusion sequences, this was not available at initial MRI\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: Isolated deltoid weakness. ? stroke.\\n\\n MRI OF THE BRAIN:\\n\\n Exam compared to the patient's CT scan of .\\n\\n FINDINGS: The exam is somewhat limited by patient motion. There is a remote\\n lacunar infarct in the anterior aspect of the right thalamus, as identified on\\n the patient's CT scan. There are small lacunar infarcts, either in the\\n anterior putamina or the anterior limbs of the internal capsules bilaterally,\\n also consistent with CT scan findings. There is no evidence of abnormal\\n diffusion to suggest the presence of acute infarction. There is no evidence\\n of mass effect or hemorrhage. Ventricles and sulci are mildly prominent\\n consistent with mild brain atrophy. The visualized paranasal sinuses have a\\n normal signal.\\n\\n IMPRESSION: No evidence of acute mass or hemorrhage. No evidence of acute\\n infarction.\\n\\n MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES:\\n\\n FINDINGS: There is slight irregularity of the proximal basilar artery without\\n evidence of high-grade stenosis. The distal right vertebral artery appears to\\n end in a PICA. There is no evidence of aneurysm. There is no evidence of\\n flow abnormality in the carotid circuits.\\n\\n IMPRESSION: Mild irregularity of the proximal basilar artery.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-29 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 854957,\n \"text\": \" 5:45 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ACUTE ASYMMETRICAL LEFT UPPER EXTREMITY WEAKNESS, EVAL FOR INFARCT\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with acut asymmetrical left upper extremity weakness\\n REASON FOR THIS EXAMINATION:\\n r/o infarct\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Acute asymmetric upper extremity weakness. Evaluate for\\n infarction.\\n\\n TECHNIQUE: Non-contrast CT of the head was obtained without comparisons.\\n\\n FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of\\n normally midline structures. The ventricles, cisterns, and sulci are within\\n normal limits. -white matter differentiation is preserved. Low densities\\n in the right caudate head, the anterior limbs of the internal capsule and\\n the right thalamus are probably remote infarcts but there are no\\n comparison studies. Note is made of moderate calcifications of both internal\\n carotid arteries. Areas of severe calcification along the left vertebral\\n artery are also seen. The osseous and soft-tissue structures appear\\n unremarkable.\\n\\n IMPRESSION: No evidence of intracranial hemorrhage or gross infarction. Note\\n that MRI with diffusion-weighted imaging is a more sensitive evaluation for\\n infarction.\\n\\n\"\n }\n]"}}},{"rowIdx":191,"cells":{"subject_id":{"kind":"number","value":55263,"string":"55,263"},"hadm_id":{"kind":"number","value":101045,"string":"101,045"},"target_text":{"kind":"string","value":"Patient was admitted on for an electively planned left sided craniotomy for mass resection. He had an uneventfull post-operative course in which he stayed in PACU overnight then transferred to floor. He ambulated without difficulty, pain well controlled. Did have some nausea/vomiting on however well controlled with medication. On he tolerated PO intake and feeling well. He was evaluated by OT who recommended outpt treatment. Incisional site c/d/i and exam non-focal except for tingling in fingers with sl. dexterity deficits in which he will have OT follow-up."},"extractive_notes_summ":{"kind":"string","value":"Chief complaint: Left Brain Mas PMHx: Left brain mass Current medications: 1. IMPRESSION: Extra-axial enhancing mass, as described above, with stable surrounding edema and thin supratentorial pachymeningeal enhancement. Please have completed within 36hrs post-op No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 10:27 AM Post-operative changes and expected post-operative findings are seen on MRI. Plan: Q1hr neuro checks. Please have completed within 36hrs post-op No contraindications for IV contrast PFI REPORT Post-operative changes and expected post-operative findings are seen on MRI. COMPARISON: CTA of the head with and without contrast, and MRI head (), . T1 axial and MP-RAGE sagittal images were obtained following gadolinium. A faint area of increased signal within the pons with subtle enhancement is consistent with an incidental capillary telangiectasia which is unchanged from previous study. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. FINDINGS: Since the previous MRI of the patient has undergone resection of left frontoparietal extra-axial mass. Initially evaluated at NWH CT/MRI + for Left parietal mass. IMPRESSION: Expected postoperative changes, with a small amount of pneumocephalus overlying the left frontal lobe, as well as tiny foci of pneumocephalus and postoperative hemorrhage within the surgical bed. Chest pain Assessment: Pt c/o left lung pain Pt nauseous Denies sob All vital signs stable Neurologically intact Action: Dr. notified Ekg done Cardiac enzymes sent Zofran given Protonix given Response: Pt verbalizes relief of pain and nausea Ekg normal Enzymes normal Plan: Continue to monitor Visualized paranasal sinuses and mastoid air cells are normally aerated. TB as child vs PNA (per Pt he said he meant PNA when giving his FHP) Surgery / Procedure and date: Left Crani for excision of mass Latest Vital Signs and I/O Non-invasive BP: S:127 D:69 Temperature: 99.1 Arterial BP: S:127 D:56 Respiratory rate: 23 insp/min Heart Rate: 88 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 98% % O2 flow: 1 L/min FiO2 set: 24h total in: 1,982 mL 24h total out: 685 mL Pertinent Lab Results: Sodium: 140 mEq/L 02:01 AM Potassium: 4.0 mEq/L 02:01 AM Chloride: 102 mEq/L 02:01 AM CO2: 30 mEq/L 02:01 AM BUN: 15 mg/dL 02:01 AM Creatinine: 1.0 mg/dL 02:01 AM Glucose: 116 mg/dL 02:01 AM Hematocrit: 40.4 % 02:01 AM Finger Stick Glucose: 127 10:00 AM Valuables / Signature Patient valuables: Other valuables: Clothes: Sent home with: Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: sicu a Transferred to: 1114 Date & time of Transfer: TB as child vs PNA (per Pt he said he meant PNA when giving his FHP) Surgery / Procedure and date: Left Crani for excision of mass Latest Vital Signs and I/O Non-invasive BP: S:127 D:69 Temperature: 99.1 Arterial BP: S:127 D:56 Respiratory rate: 23 insp/min Heart Rate: 88 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 98% % O2 flow: 1 L/min FiO2 set: 24h total in: 1,982 mL 24h total out: 685 mL Pertinent Lab Results: Sodium: 140 mEq/L 02:01 AM Potassium: 4.0 mEq/L 02:01 AM Chloride: 102 mEq/L 02:01 AM CO2: 30 mEq/L 02:01 AM BUN: 15 mg/dL 02:01 AM Creatinine: 1.0 mg/dL 02:01 AM Glucose: 116 mg/dL 02:01 AM Hematocrit: 40.4 % 02:01 AM Finger Stick Glucose: 127 10:00 AM Valuables / Signature Patient valuables: Other valuables: Clothes: Sent home with: Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: sicu a Transferred to: 1114 Date & time of Transfer:"},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420806,"text":"63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n"},{"category":"Physician ","chartdate":"2161-11-12 00:00:00.000","description":"Intensivist Note","row_id":420789,"text":"SICU\n HPI:\n 63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation.\n Chief complaint:\n Left Brain Mas\n PMHx:\n Left brain mass\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5. Dexamethasone 6.\n Docusate Sodium 7. Gentamicin\n 8. HYDROmorphone (Dilaudid) 9. Heparin 10. HydrALAzine 11. Influenza\n Virus Vaccine 12. Insulin 13. NiCARdipine\n 14. Ondansetron 15. Pantoprazole 16. Phenytoin 17. Sodium Chloride 0.9%\n Flush 18. Vancomycin\n 24 Hour Events:\n OR RECEIVED - At 05:00 PM\n ARTERIAL LINE - START 05:11 PM\n EKG - At 02:21 AM\n CHEST PAIN - At 02:21 AM\n FEVER - 209.1\nC - 05:41 PM\n Post operative day:\n POD#1 - S/P L Crani\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 05:57 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 02:31 AM\n Other medications:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 98.4\nC (209.1\n T current: 37.2\nC (98.9\n HR: 83 (73 - 106) bpm\n BP: 144/62(87) {111/48(66) - 156/62(87)} mmHg\n RR: 26 (8 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,622 mL\n 1,039 mL\n PO:\n 200 mL\n 100 mL\n Tube feeding:\n IV Fluid:\n 2,422 mL\n 939 mL\n Blood products:\n Total out:\n 4,070 mL\n 520 mL\n Urine:\n 1,470 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,448 mL\n 519 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (RUE: Weakness)\n Labs / Radiology\n 316 K/uL\n 14.9 g/dL\n 116 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 102 mEq/L\n 140 mEq/L\n 40.4 %\n 20.7 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 20.7\n Hct\n 40.4\n Plt\n 316\n Creatinine\n 1.0\n Troponin T\n <0.01\n Glucose\n 116\n Other labs: PT / PTT / INR:13.2/22.0/1.1, CK / CK-MB / Troponin\n T:31//<0.01, Albumin:3.7 g/dL, Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.5\n mg/dL\n ECG: ECG --> no change from prior; SR with non-specific Q wave\n inferiorly.\n Assessment and Plan\n Assessment and Plan: 63M elective admission for crani who presented\n earlier in the week for ascending paraesthesia of the RUE.\n Neurologic: Neuro checks Q: 4 hr, Phenytoin - therapeutic, MRI of the\n head , check Albumin and Phenytoin\n Cardiovascular: Post op HTN --> weaned off nicardipine overnight to\n Keep SBP<140;\n Pulmonary: Chest PT, OOB; Phys therapy and occupational Therapy.\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, D/C Foley\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Periop Vancomycin\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: MRI of the head\n Fluids: NS\n Consults: Neuro surgery, P.T., O.T.\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:11 PM\n 18 Gauge - 05:13 PM\n 20 Gauge - 08:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2161-11-11 00:00:00.000","description":"Nursing Progress Note","row_id":420740,"text":"Above pt with 2month Hx of intermittent R hand numbness/tingling now\n presents with tingling extending up the medial aspect of the right arm\n to the right shoulder and neck. Initially evaluated at NWH CT/MRI +\n for Left parietal mass. Pt referred to to for further\n evaluation. Pt to OR for Left craniotomy of Left parietal lesion.\n Assessment: Pt arrived from OR extubated. Neuro intact. A+O X3. No\n noted Neuro deficits noted. Pt crani incision clean dry and\n intact. Goal SBP 100-140. Pt arrived with SBP 160\n Action: Pt given 10mg hydral on arrival X2 with little effect.\n Nicardipine gtt started. Pt with mild c/o pain given 2mg PO dilaudid.\n Response: SBP now 125-139 with nicardipine at 3mcgs. Pt with good\n relief from PO dilaudid.\n Plan: Q1hr neuro checks. Cont to maintain SBP within paramenter. CT\n scan tonight MRI within 36hrs post op. Cont with current plan of care.\n"},{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420828,"text":"63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n BRAIN TUMOR/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 81 kg\n Daily weight:\n 81.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Hx of central vision loss OS-Dx macular\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\n he meant PNA when giving his FHP)\n Surgery / Procedure and date: Left Crani for excision of mass\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:69\n Temperature:\n 99.1\n Arterial BP:\n S:127\n D:56\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 1,982 mL\n 24h total out:\n 685 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:01 AM\n Potassium:\n 4.0 mEq/L\n 02:01 AM\n Chloride:\n 102 mEq/L\n 02:01 AM\n CO2:\n 30 mEq/L\n 02:01 AM\n BUN:\n 15 mg/dL\n 02:01 AM\n Creatinine:\n 1.0 mg/dL\n 02:01 AM\n Glucose:\n 116 mg/dL\n 02:01 AM\n Hematocrit:\n 40.4 %\n 02:01 AM\n Finger Stick Glucose:\n 127\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu a\n Transferred to: 1114\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420834,"text":"63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n BRAIN TUMOR/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 81 kg\n Daily weight:\n 81.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Hx of central vision loss OS-Dx macular\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\n he meant PNA when giving his FHP)\n Surgery / Procedure and date: Left Crani for excision of mass\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:69\n Temperature:\n 99.1\n Arterial BP:\n S:127\n D:56\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 1,982 mL\n 24h total out:\n 685 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:01 AM\n Potassium:\n 4.0 mEq/L\n 02:01 AM\n Chloride:\n 102 mEq/L\n 02:01 AM\n CO2:\n 30 mEq/L\n 02:01 AM\n BUN:\n 15 mg/dL\n 02:01 AM\n Creatinine:\n 1.0 mg/dL\n 02:01 AM\n Glucose:\n 116 mg/dL\n 02:01 AM\n Hematocrit:\n 40.4 %\n 02:01 AM\n Finger Stick Glucose:\n 127\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu a\n Transferred to: 1114\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420765,"text":"Chest pain\n Assessment:\n Pt c/o left lung pain\n Pt nauseous\n Denies sob\n All vital signs stable\n Action:\n Dr. notified\n Ekg done\n Cardiac enzymes sent\n Zofran given\n Protonix given\n Response:\n Pt verbalizes relief of pain and nausea\n Ekg normal\n Enzymes normal\n Plan:\n Continue to monitor\n"},{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420767,"text":"Chest pain\n Assessment:\n Pt c/o left lung pain\n Pt nauseous\n Denies sob\n All vital signs stable\n Neurologically intact\n Action:\n Dr. notified\n Ekg done\n Cardiac enzymes sent\n Zofran given\n Protonix given\n Response:\n Pt verbalizes relief of pain and nausea\n Ekg normal\n Enzymes normal\n Plan:\n Continue to monitor\n"},{"category":"Radiology","chartdate":"2161-11-11 00:00:00.000","description":"MR HEAD W/ CONTRAST","row_id":1041347,"text":" 5:25 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: Wand protocol for placement of markers for surgery immediate\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with brain tumor.\n REASON FOR THIS EXAMINATION:\n Wand protocol for placement of markers for surgery immediately after.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male patient with history of a mass.\n\n TECHNIQUE: MRI of the brain was performed with IV contrast as per\n departmental protocol.\n\n COMPARISON: CTA of the head with and without contrast, and MRI\n head (), . The CT demonstrates no\n calcification within the mass, and no reactive change in the overlying skull.\n\n FINDINGS:\n\n There is a 2.9 (TRV) x 2.8 (AP) x 2.3 cm (CC), well-defined and lobulated,\n heterogeneously-enhancing mass that is T2-isointense-to- matter and\n demonstrates restricted diffusion. The mass also demonstrates a broad-based\n attachment to the left parietal dura, and causes mild enlargement of the\n surrounding subarachnoid spaces and buckling of the subjacent matter and\n is, therefore, likely extra-axial. There is vasogenic edema involving the\n adjacent subcortical white matter of the occipital, parietal, and posterior\n frontal lobes including the left precentral gyrus, with mass effect on and\n effacement of the overlying gyri of the left parietal lobe, but no evidence\n for midline shift or herniation. Minimal mass effect on the atrium of the left\n lateral ventricle, but no hydrocephalus. There is diffuse but smooth and thin\n pachymeningeal enhancement in the supratentorial compartment, but no evidence\n for leptomeningeal or subependymal enhancement, and no other focus of abnormal\n enhancement is noted.\n\n The visualized portions of the orbits are within normal limits. The paranasal\n sinuses are clear. The major vascular flow voids are normal.\n\n IMPRESSION: Extra-axial enhancing mass, as described above, with stable\n surrounding edema and thin supratentorial pachymeningeal enhancement. Given\n the constellation of findings, particularly its signal, diffusion and\n enhancement characteristics, this mass likely represents a meningioma. Much\n more remote differential diagnostic considerations also include dural- based\n metastasis (eg. from prostate cancer, in this patient with known nodule),\n lymphoma or granulomatous disease (eg. sarcoidosis).\n (Over)\n\n 5:25 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: Wand protocol for placement of markers for surgery immediate\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2161-11-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1041525,"text":", M. NSURG SICU-A 8:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulmonary process\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p craniectomy and chest pain\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n PFI REPORT\n No acute cardiopulmonary abnormalities.\n\n\n"},{"category":"Radiology","chartdate":"2161-11-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1041524,"text":" 8:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulmonary process\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p craniectomy and chest pain\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:50 AM\n No acute cardiopulmonary abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Chest pain, S/P craniectomy.\n\n Cardiomediastinal contours are normal. The lungs are grossly clear aside from\n linear atelectasis in the left base. There is no pleural effusion or\n pneumothorax.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2161-11-12 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1041641,"text":" 5:00 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual tumor burden. Please have compl\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for residual tumor burden. Please have completed within 36hrs\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 10:27 AM\n Post-operative changes and expected post-operative findings are seen on MRI.\n No residual enhancement. No acute infarct or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient is status post surgery.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired. T1 axial and MP-RAGE sagittal images\n were obtained following gadolinium.\n\n FINDINGS: Since the previous MRI of the patient has undergone\n resection of left frontoparietal extra-axial mass. Small amount of blood\n products are seen in the region. The edema seen in the left frontoparietal\n region has unchanged. Following gadolinium subtle marginal enhancement is\n seen which appears to be due to vascular and meningeal enhancement. No\n definite nodular, extra-axial or intra-axial area of residual enhancement\n identified. There are no acute infarcts seen. There is no midline shift or\n hydrocephalus. A faint area of increased signal within the pons with subtle\n enhancement is consistent with an incidental capillary telangiectasia which is\n unchanged from previous study.\n\n IMPRESSION: Status post resection of left-sided frontoparietal extra-axial\n mass. Small amount of blood products are seen in the region with expected\n post-surgical changes. No definite residual enhancement is seen.\n\n\n"},{"category":"Radiology","chartdate":"2161-11-12 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1041642,"text":", M. NSURG SICU-A 5:00 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual tumor burden. Please have compl\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for residual tumor burden. Please have completed within 36hrs\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Post-operative changes and expected post-operative findings are seen on MRI.\n No residual enhancement. No acute infarct or mass effect.\n\n\n"},{"category":"Radiology","chartdate":"2161-11-11 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1041473,"text":", M. NSURG SICU-A 8:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post operative changes\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p left crainotomy\n REASON FOR THIS EXAMINATION:\n post operative changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\n No other short interval change, with residual vasogenic edema involving the\n left parietal lobe.\n\n"},{"category":"Radiology","chartdate":"2161-11-11 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1041472,"text":" 8:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post operative changes\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p left crainotomy\n REASON FOR THIS EXAMINATION:\n post operative changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:10 AM\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\n No other short interval change, with residual vasogenic edema involving the\n left parietal lobe.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male status post left craniotomy, evaluate for\n postoperative changes.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There are post-surgical changes following a left frontal and\n parietal craniotomy, with a small amount of expected pneumocephalus overlying\n the left frontal lobe, as well as a small amount of pneumocephalus and tiny\n foci of hemorrhage seen within the surgical bed. No additional foci of\n hemorrhage are identified. There continues to be a residual vasogenic edema\n predominantly involving the left parietal lobe. Minimal rightward shift of\n midline is unchanged from . There is no evidence for acute\n major vascular territorial infarction. The caliber of the ventricular system\n is unchanged without hydrocephalus. Visualized paranasal sinuses and mastoid\n air cells are normally aerated. Osseous structures reveal a craniotomy defect.\n\n IMPRESSION: Expected postoperative changes, with a small amount of\n pneumocephalus overlying the left frontal lobe, as well as tiny foci of\n pneumocephalus and postoperative hemorrhage within the surgical bed.\n\n\n\n"},{"category":"ECG","chartdate":"2161-11-12 00:00:00.000","description":"Report","row_id":221980,"text":"Sinus rhythm\nEarly precordial QRS transition is nonspecific\nProlonged Q-Tc interval\nModest ST-T wave changes\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/metabolic/electrolyte effect\nSince previous tracing of , QT-c interval appears prolonged but may be\nno significant change\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420806,\n \"text\": \"63yo RHM with 2 month hx of intermittent R hand\\n numbness/tingling, restricted to 4th and fifth digits. Today\\n tingling extended up the medial aspect of the right arm to the R\\n posterolateral aspect of the neck and ear. Therefore Pt went to\\n ED where neuroimaging (MRI/CT) revealed a L\\n parietal lesion. Pt xferred to for further evaluation. S/p left\\n crani on .\\n Note: Foley was d/c\\nd at 0900, pt is dtv at 1700.\\n Problem\\n parietal brain tumor, s/p craniectomy\\n Assessment:\\n Alert and oriented x\\ns 3, pleasant and cooperative. Pupils equal and\\n briskly reactive. Normal strength in all extremities except right arm\\n in which very mild weakness is noted. Pt also c/o of decreased\\n sensation in right hand, sensation intact in all other extremities. Pt\\n c/o of mild headache, treated with po Tylenol with good effect.\\n Action:\\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\\n oob to chair today, advanced to regular diet (tolerating).\\n Response:\\n Neuro status remains stable\\n Plan:\\n MRI today, transfer to floor with q 4 hour neuro checks, continue\\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\\n planning.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 420789,\n \"text\": \"SICU\\n HPI:\\n 63yo RHM with 2 month hx of intermittent R hand\\n numbness/tingling, restricted to 4th and fifth digits. Today\\n tingling extended up the medial aspect of the right arm to the R\\n posterolateral aspect of the neck and ear. Therefore Pt went to\\n ED where neuroimaging (MRI/CT) revealed a L\\n parietal lesion. Pt xferred to for further evaluation.\\n Chief complaint:\\n Left Brain Mas\\n PMHx:\\n Left brain mass\\n Current medications:\\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5. Dexamethasone 6.\\n Docusate Sodium 7. Gentamicin\\n 8. HYDROmorphone (Dilaudid) 9. Heparin 10. HydrALAzine 11. Influenza\\n Virus Vaccine 12. Insulin 13. NiCARdipine\\n 14. Ondansetron 15. Pantoprazole 16. Phenytoin 17. Sodium Chloride 0.9%\\n Flush 18. Vancomycin\\n 24 Hour Events:\\n OR RECEIVED - At 05:00 PM\\n ARTERIAL LINE - START 05:11 PM\\n EKG - At 02:21 AM\\n CHEST PAIN - At 02:21 AM\\n FEVER - 209.1\\nC - 05:41 PM\\n Post operative day:\\n POD#1 - S/P L Crani\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Gentamicin - 05:57 AM\\n Vancomycin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 02:31 AM\\n Other medications:\\n Flowsheet Data as of 08:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 98.4\\nC (209.1\\n T current: 37.2\\nC (98.9\\n HR: 83 (73 - 106) bpm\\n BP: 144/62(87) {111/48(66) - 156/62(87)} mmHg\\n RR: 26 (8 - 26) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 2,622 mL\\n 1,039 mL\\n PO:\\n 200 mL\\n 100 mL\\n Tube feeding:\\n IV Fluid:\\n 2,422 mL\\n 939 mL\\n Blood products:\\n Total out:\\n 4,070 mL\\n 520 mL\\n Urine:\\n 1,470 mL\\n 520 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,448 mL\\n 519 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 98%\\n ABG: ///30/\\n Physical Examination\\n General Appearance: No acute distress, Cachectic\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Murmur: Systolic)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: No(t) Present)\\n Right Extremities: (Edema: Absent)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n No(t) Moves all extremities, (RUE: Weakness)\\n Labs / Radiology\\n 316 K/uL\\n 14.9 g/dL\\n 116 mg/dL\\n 1.0 mg/dL\\n 30 mEq/L\\n 4.0 mEq/L\\n 15 mg/dL\\n 102 mEq/L\\n 140 mEq/L\\n 40.4 %\\n 20.7 K/uL\\n [image002.jpg]\\n 02:01 AM\\n WBC\\n 20.7\\n Hct\\n 40.4\\n Plt\\n 316\\n Creatinine\\n 1.0\\n Troponin T\\n <0.01\\n Glucose\\n 116\\n Other labs: PT / PTT / INR:13.2/22.0/1.1, CK / CK-MB / Troponin\\n T:31//<0.01, Albumin:3.7 g/dL, Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.5\\n mg/dL\\n ECG: ECG --> no change from prior; SR with non-specific Q wave\\n inferiorly.\\n Assessment and Plan\\n Assessment and Plan: 63M elective admission for crani who presented\\n earlier in the week for ascending paraesthesia of the RUE.\\n Neurologic: Neuro checks Q: 4 hr, Phenytoin - therapeutic, MRI of the\\n head , check Albumin and Phenytoin\\n Cardiovascular: Post op HTN --> weaned off nicardipine overnight to\\n Keep SBP<140;\\n Pulmonary: Chest PT, OOB; Phys therapy and occupational Therapy.\\n Gastrointestinal / Abdomen:\\n Nutrition: Advance diet as tolerated\\n Renal: Foley, Adequate UO, D/C Foley\\n Hematology: Hct stable\\n Endocrine: RISS\\n Infectious Disease: Periop Vancomycin\\n Lines / Tubes / Drains: Foley\\n Wounds: Dry dressings\\n Imaging: MRI of the head\\n Fluids: NS\\n Consults: Neuro surgery, P.T., O.T.\\n Billing Diagnosis: Post-op hypertension\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 05:11 PM\\n 18 Gauge - 05:13 PM\\n 20 Gauge - 08:07 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420740,\n \"text\": \"Above pt with 2month Hx of intermittent R hand numbness/tingling now\\n presents with tingling extending up the medial aspect of the right arm\\n to the right shoulder and neck. Initially evaluated at NWH CT/MRI +\\n for Left parietal mass. Pt referred to to for further\\n evaluation. Pt to OR for Left craniotomy of Left parietal lesion.\\n Assessment: Pt arrived from OR extubated. Neuro intact. A+O X3. No\\n noted Neuro deficits noted. Pt crani incision clean dry and\\n intact. Goal SBP 100-140. Pt arrived with SBP 160\\n Action: Pt given 10mg hydral on arrival X2 with little effect.\\n Nicardipine gtt started. Pt with mild c/o pain given 2mg PO dilaudid.\\n Response: SBP now 125-139 with nicardipine at 3mcgs. Pt with good\\n relief from PO dilaudid.\\n Plan: Q1hr neuro checks. Cont to maintain SBP within paramenter. CT\\n scan tonight MRI within 36hrs post op. Cont with current plan of care.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420828,\n \"text\": \"63yo RHM with 2 month hx of intermittent R hand\\n numbness/tingling, restricted to 4th and fifth digits. Today\\n tingling extended up the medial aspect of the right arm to the R\\n posterolateral aspect of the neck and ear. Therefore Pt went to\\n ED where neuroimaging (MRI/CT) revealed a L\\n parietal lesion. Pt xferred to for further evaluation. S/p left\\n crani on .\\n Note: Foley was d/c\\nd at 0900, pt is dtv at 1700.\\n Problem\\n parietal brain tumor, s/p craniectomy\\n Assessment:\\n Alert and oriented x\\ns 3, pleasant and cooperative. Pupils equal and\\n briskly reactive. Normal strength in all extremities except right arm\\n in which very mild weakness is noted. Pt also c/o of decreased\\n sensation in right hand, sensation intact in all other extremities. Pt\\n c/o of mild headache, treated with po Tylenol with good effect.\\n Action:\\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\\n oob to chair today, advanced to regular diet (tolerating).\\n Response:\\n Neuro status remains stable\\n Plan:\\n MRI today, transfer to floor with q 4 hour neuro checks, continue\\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\\n planning.\\n Demographics\\n Attending MD:\\n M.\\n Admit diagnosis:\\n BRAIN TUMOR/SDA\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 81 kg\\n Daily weight:\\n 81.5 kg\\n Allergies/Reactions:\\n Penicillins\\n Unknown;\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH:\\n Additional history: Hx of central vision loss OS-Dx macular\\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\\n he meant PNA when giving his FHP)\\n Surgery / Procedure and date: Left Crani for excision of mass\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:127\\n D:69\\n Temperature:\\n 99.1\\n Arterial BP:\\n S:127\\n D:56\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 88 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 1 L/min\\n FiO2 set:\\n 24h total in:\\n 1,982 mL\\n 24h total out:\\n 685 mL\\n Pertinent Lab Results:\\n Sodium:\\n 140 mEq/L\\n 02:01 AM\\n Potassium:\\n 4.0 mEq/L\\n 02:01 AM\\n Chloride:\\n 102 mEq/L\\n 02:01 AM\\n CO2:\\n 30 mEq/L\\n 02:01 AM\\n BUN:\\n 15 mg/dL\\n 02:01 AM\\n Creatinine:\\n 1.0 mg/dL\\n 02:01 AM\\n Glucose:\\n 116 mg/dL\\n 02:01 AM\\n Hematocrit:\\n 40.4 %\\n 02:01 AM\\n Finger Stick Glucose:\\n 127\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: sicu a\\n Transferred to: 1114\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420834,\n \"text\": \"63yo RHM with 2 month hx of intermittent R hand\\n numbness/tingling, restricted to 4th and fifth digits. Today\\n tingling extended up the medial aspect of the right arm to the R\\n posterolateral aspect of the neck and ear. Therefore Pt went to\\n ED where neuroimaging (MRI/CT) revealed a L\\n parietal lesion. Pt xferred to for further evaluation. S/p left\\n crani on .\\n Note: Foley was d/c\\nd at 0900, pt is dtv at 1700.\\n Problem\\n parietal brain tumor, s/p craniectomy\\n Assessment:\\n Alert and oriented x\\ns 3, pleasant and cooperative. Pupils equal and\\n briskly reactive. Normal strength in all extremities except right arm\\n in which very mild weakness is noted. Pt also c/o of decreased\\n sensation in right hand, sensation intact in all other extremities. Pt\\n c/o of mild headache, treated with po Tylenol with good effect.\\n Action:\\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\\n oob to chair today, advanced to regular diet (tolerating).\\n Response:\\n Neuro status remains stable\\n Plan:\\n MRI today, transfer to floor with q 4 hour neuro checks, continue\\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\\n planning.\\n Demographics\\n Attending MD:\\n M.\\n Admit diagnosis:\\n BRAIN TUMOR/SDA\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 81 kg\\n Daily weight:\\n 81.5 kg\\n Allergies/Reactions:\\n Penicillins\\n Unknown;\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH:\\n Additional history: Hx of central vision loss OS-Dx macular\\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\\n he meant PNA when giving his FHP)\\n Surgery / Procedure and date: Left Crani for excision of mass\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:127\\n D:69\\n Temperature:\\n 99.1\\n Arterial BP:\\n S:127\\n D:56\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 88 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 1 L/min\\n FiO2 set:\\n 24h total in:\\n 1,982 mL\\n 24h total out:\\n 685 mL\\n Pertinent Lab Results:\\n Sodium:\\n 140 mEq/L\\n 02:01 AM\\n Potassium:\\n 4.0 mEq/L\\n 02:01 AM\\n Chloride:\\n 102 mEq/L\\n 02:01 AM\\n CO2:\\n 30 mEq/L\\n 02:01 AM\\n BUN:\\n 15 mg/dL\\n 02:01 AM\\n Creatinine:\\n 1.0 mg/dL\\n 02:01 AM\\n Glucose:\\n 116 mg/dL\\n 02:01 AM\\n Hematocrit:\\n 40.4 %\\n 02:01 AM\\n Finger Stick Glucose:\\n 127\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: sicu a\\n Transferred to: 1114\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420765,\n \"text\": \"Chest pain\\n Assessment:\\n Pt c/o left lung pain\\n Pt nauseous\\n Denies sob\\n All vital signs stable\\n Action:\\n Dr. notified\\n Ekg done\\n Cardiac enzymes sent\\n Zofran given\\n Protonix given\\n Response:\\n Pt verbalizes relief of pain and nausea\\n Ekg normal\\n Enzymes normal\\n Plan:\\n Continue to monitor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420767,\n \"text\": \"Chest pain\\n Assessment:\\n Pt c/o left lung pain\\n Pt nauseous\\n Denies sob\\n All vital signs stable\\n Neurologically intact\\n Action:\\n Dr. notified\\n Ekg done\\n Cardiac enzymes sent\\n Zofran given\\n Protonix given\\n Response:\\n Pt verbalizes relief of pain and nausea\\n Ekg normal\\n Enzymes normal\\n Plan:\\n Continue to monitor\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-11 00:00:00.000\",\n \"description\": \"MR HEAD W/ CONTRAST\",\n \"row_id\": 1041347,\n \"text\": \" 5:25 AM\\n MR HEAD W/ CONTRAST Clip # \\n Reason: Wand protocol for placement of markers for surgery immediate\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with brain tumor.\\n REASON FOR THIS EXAMINATION:\\n Wand protocol for placement of markers for surgery immediately after.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 63-year-old male patient with history of a mass.\\n\\n TECHNIQUE: MRI of the brain was performed with IV contrast as per\\n departmental protocol.\\n\\n COMPARISON: CTA of the head with and without contrast, and MRI\\n head (), . The CT demonstrates no\\n calcification within the mass, and no reactive change in the overlying skull.\\n\\n FINDINGS:\\n\\n There is a 2.9 (TRV) x 2.8 (AP) x 2.3 cm (CC), well-defined and lobulated,\\n heterogeneously-enhancing mass that is T2-isointense-to- matter and\\n demonstrates restricted diffusion. The mass also demonstrates a broad-based\\n attachment to the left parietal dura, and causes mild enlargement of the\\n surrounding subarachnoid spaces and buckling of the subjacent matter and\\n is, therefore, likely extra-axial. There is vasogenic edema involving the\\n adjacent subcortical white matter of the occipital, parietal, and posterior\\n frontal lobes including the left precentral gyrus, with mass effect on and\\n effacement of the overlying gyri of the left parietal lobe, but no evidence\\n for midline shift or herniation. Minimal mass effect on the atrium of the left\\n lateral ventricle, but no hydrocephalus. There is diffuse but smooth and thin\\n pachymeningeal enhancement in the supratentorial compartment, but no evidence\\n for leptomeningeal or subependymal enhancement, and no other focus of abnormal\\n enhancement is noted.\\n\\n The visualized portions of the orbits are within normal limits. The paranasal\\n sinuses are clear. The major vascular flow voids are normal.\\n\\n IMPRESSION: Extra-axial enhancing mass, as described above, with stable\\n surrounding edema and thin supratentorial pachymeningeal enhancement. Given\\n the constellation of findings, particularly its signal, diffusion and\\n enhancement characteristics, this mass likely represents a meningioma. Much\\n more remote differential diagnostic considerations also include dural- based\\n metastasis (eg. from prostate cancer, in this patient with known nodule),\\n lymphoma or granulomatous disease (eg. sarcoidosis).\\n (Over)\\n\\n 5:25 AM\\n MR HEAD W/ CONTRAST Clip # \\n Reason: Wand protocol for placement of markers for surgery immediate\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1041525,\n \"text\": \", M. NSURG SICU-A 8:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for cardiopulmonary process\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with s/p craniectomy and chest pain\\n REASON FOR THIS EXAMINATION:\\n eval for cardiopulmonary process\\n ______________________________________________________________________________\\n PFI REPORT\\n No acute cardiopulmonary abnormalities.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1041524,\n \"text\": \" 8:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for cardiopulmonary process\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with s/p craniectomy and chest pain\\n REASON FOR THIS EXAMINATION:\\n eval for cardiopulmonary process\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:50 AM\\n No acute cardiopulmonary abnormalities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Chest pain, S/P craniectomy.\\n\\n Cardiomediastinal contours are normal. The lungs are grossly clear aside from\\n linear atelectasis in the left base. There is no pleural effusion or\\n pneumothorax.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1041641,\n \"text\": \" 5:00 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: please evaluate for residual tumor burden. Please have compl\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for residual tumor burden. Please have completed within 36hrs\\n post-op\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 10:27 AM\\n Post-operative changes and expected post-operative findings are seen on MRI.\\n No residual enhancement. No acute infarct or mass effect.\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRI of the brain.\\n\\n CLINICAL INFORMATION: Patient is status post surgery.\\n\\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\\n axial images of the brain were acquired. T1 axial and MP-RAGE sagittal images\\n were obtained following gadolinium.\\n\\n FINDINGS: Since the previous MRI of the patient has undergone\\n resection of left frontoparietal extra-axial mass. Small amount of blood\\n products are seen in the region. The edema seen in the left frontoparietal\\n region has unchanged. Following gadolinium subtle marginal enhancement is\\n seen which appears to be due to vascular and meningeal enhancement. No\\n definite nodular, extra-axial or intra-axial area of residual enhancement\\n identified. There are no acute infarcts seen. There is no midline shift or\\n hydrocephalus. A faint area of increased signal within the pons with subtle\\n enhancement is consistent with an incidental capillary telangiectasia which is\\n unchanged from previous study.\\n\\n IMPRESSION: Status post resection of left-sided frontoparietal extra-axial\\n mass. Small amount of blood products are seen in the region with expected\\n post-surgical changes. No definite residual enhancement is seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1041642,\n \"text\": \", M. NSURG SICU-A 5:00 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: please evaluate for residual tumor burden. Please have compl\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for residual tumor burden. Please have completed within 36hrs\\n post-op\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Post-operative changes and expected post-operative findings are seen on MRI.\\n No residual enhancement. No acute infarct or mass effect.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-11 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1041473,\n \"text\": \", M. NSURG SICU-A 8:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: post operative changes\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with s/p left crainotomy\\n REASON FOR THIS EXAMINATION:\\n post operative changes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\\n No other short interval change, with residual vasogenic edema involving the\\n left parietal lobe.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-11 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1041472,\n \"text\": \" 8:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: post operative changes\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with s/p left crainotomy\\n REASON FOR THIS EXAMINATION:\\n post operative changes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:10 AM\\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\\n No other short interval change, with residual vasogenic edema involving the\\n left parietal lobe.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 63-year-old male status post left craniotomy, evaluate for\\n postoperative changes.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\\n contrast.\\n\\n FINDINGS: There are post-surgical changes following a left frontal and\\n parietal craniotomy, with a small amount of expected pneumocephalus overlying\\n the left frontal lobe, as well as a small amount of pneumocephalus and tiny\\n foci of hemorrhage seen within the surgical bed. No additional foci of\\n hemorrhage are identified. There continues to be a residual vasogenic edema\\n predominantly involving the left parietal lobe. Minimal rightward shift of\\n midline is unchanged from . There is no evidence for acute\\n major vascular territorial infarction. The caliber of the ventricular system\\n is unchanged without hydrocephalus. Visualized paranasal sinuses and mastoid\\n air cells are normally aerated. Osseous structures reveal a craniotomy defect.\\n\\n IMPRESSION: Expected postoperative changes, with a small amount of\\n pneumocephalus overlying the left frontal lobe, as well as tiny foci of\\n pneumocephalus and postoperative hemorrhage within the surgical bed.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 221980,\n \"text\": \"Sinus rhythm\\nEarly precordial QRS transition is nonspecific\\nProlonged Q-Tc interval\\nModest ST-T wave changes\\nFindings are nonspecific but clinical correlation is suggested for possible in\\npart drug/metabolic/electrolyte effect\\nSince previous tracing of , QT-c interval appears prolonged but may be\\nno significant change\\n\\n\"\n }\n]"}}},{"rowIdx":192,"cells":{"subject_id":{"kind":"number","value":70561,"string":"70,561"},"hadm_id":{"kind":"number","value":117086,"string":"117,086"},"target_text":{"kind":"string","value":"The patient is a 49 year old male with a history of severe scoliosis, restrictive lung disease, OSA, who presented to an OSH with worsening dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent tacheostomy placement, now transfered for evaluation of posterior wall erosion."},"extractive_notes_summ":{"kind":"string","value":"Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Assessment and Plan RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: Assessment and Plan RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: Will ask IP if we can change to non-adjustable trach as position of trach has moved overnight -speaking without using , keep off for now -decrease lasix to dosingPulmonary hypertension likely due to restrictive lung disease -continue lasix ADDENDUM Trach changed to 110mm, size 7. Will ask IP if we can change to non-adjustable trach as position of trach has moved overnight -speaking without using , keep off for now -decrease lasix to dosingPulmonary hypertension likely due to restrictive lung disease -continue lasix ICU Care Nutrition: regular diet Glycemic Control: RISS Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: heparin SQ Stress ulcer: Protonix VAP: Comments: Communication: Comments: Code status: full Disposition :Transfer to hospital after IP evaluates whether we should change to non-adjustable trach Total time spent: Demographics Day of intubation: Day of mechanical ventilation: 4 Ideal body weight: 0 None Ideal tidal volume: 0 / 0 / 0 mL/kg Airway Airway Placement Data Known difficult intubation: Procedure location: Reason: : Tracheostomy tube: Type: Adjustable Neck Flange Manufacturer: Size: 7.0mm PMV: Yes Cuff Management: Vol/Press: Cuff pressure: 25 cmH2O Cuff volume: mL / Airway problems: Comments: Lung sounds RLL Lung Sounds: Clear RUL Lung Sounds: Rhonchi LUL Lung Sounds: Rhonchi LLL Lung Sounds: Rhonchi Comments: Secretions Sputum color / consistency: Blood Tinged / Thick Sputum source/amount: Suctioned / Moderate Comments: Ventilation Assessment Level of breathing assistance: Intermittent invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Assessment of breathing comfort: No claim of dyspnea) Plan Next 24-48 hours: Reason for continuing current ventilatory support: Underlying illness not resolved Respiratory Care Shift Procedures Comments: Patient had been off the ventilator most of day on a 50% trach collar. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. Reflux: - cont tx scoliosis 3. pain: - minimal, holding narcotic 4. pHTN: - cont lasix for diuresis Remainder of plan per resident note. Reflux: - cont tx scoliosis 3. pain: - minimal, holding narcotic 4. pHTN: - cont lasix for diuresis Remainder of plan per resident note. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Demographics Day of intubation: Day of mechanical ventilation: 2 Ideal body weight: 0 None Ideal tidal volume: 0 / 0 / 0 mL/kg Airway Airway Placement Data Known difficult intubation: Tube Type Tracheostomy tube: Type: Cuffed, Adjustable Neck Flange Manufacturer: Size: 7.0mm PMV: Yes Cuff Management: Vol/Press: Cuff pressure: cmH2O Cuff volume: mL / Airway problems: Positional leak around cuff, adjustable trach advanced to 12 cm just below flange via bronchoscopic evaluation."},"n_notes":{"kind":"number","value":38,"string":"38"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":615795,"text":"Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-03 00:00:00.000","description":"Physician Resident Progress Note","row_id":615616,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - bronched in morning by IP: supraglottic edema -> started PPI.\n occlusion of airway during expiration by posterior larynx ->\n tracheostomy tube was advanced by 1 cm with better airway patency\n established.\n - put on PS 10/5 while sleeping during day. overnight on vent from 12\n am to 4 am, then on trach collar\n - case mmgnt: should return to OSH vs begin screening for rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 11:13 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 92 (71 - 115) bpm\n BP: 124/88(96) {103/62(71) - 150/123(126)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 720 mL\n PO:\n 720 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 3,820 mL\n 275 mL\n Urine:\n 3,820 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,100 mL\n -275 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 323 (323 - 325) mL\n PS : 10 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///41/\n Ve: 9.7 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:10 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"},{"category":"Respiratory ","chartdate":"2156-12-04 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615755,"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:\n Procedure location:\n Reason:\n :\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\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: 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: 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:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Comments: Patient had been off the ventilator most of day on a 50%\n trach collar. Good vocalization using the passy muir valve. Pt had\n periods of dyspnea relieved with suctioning and neb treatments. Pt and\n wife anxious about handling trach care when home but anxious to get\n started with rehab.\n"},{"category":"Nursing","chartdate":"2156-12-04 00:00:00.000","description":"Nursing Progress Note","row_id":615756,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt alert and sitting on the commode as chair. On trach\n mask.\n Action:\n Suctioned for blood tinged secretion, C/O chest pain around 0200 EKG\n done no changes and he claimed no more chest pain. Received ambien as\n per pt request, Cont PO lasix.\n Response:\n Pt passing 200 cc hr, lung sound less wet sounding\n Plan:\n Continue with lasix tid, nebs and suction as needed, plan to transfere\n back to osh tomorrow\n"},{"category":"Nursing","chartdate":"2156-12-04 00:00:00.000","description":"Nursing Progress Note","row_id":615840,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\n trach site doe have some old blood around trach.\n Action:\n Pt given 40 mg po lasix and albuternal neb x1 this am\n Response:\n Pt states breathing feels better, pt passing 300 cc hr urine\n Plan:\n To transfere to back to osh where he came from,\n Pt had bronch this afternoon, trach changed to #12 boviena, pt received\n 1 mg iv versed and 50 mcgs of iv Fentanyl for procedure, pt states this\n trach more comfortable, also not swelling above trach and bleeding in\n nasal area, pt to be transferred back to osh this afternoon.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615362,"text":"The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615364,"text":"The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\n comfortably in a chair. When in bed pt must lie flat and needs to be on\n full vent status. Lung sounds clear and rhonchorus but will clear once\n suctioned. O2 sat\ns in high 90\n Action:\n Once examined and assessed by resident pt got oob to chair with minimal\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\n mod amt\ns of thick bloody secretions,\n Response:\n Pt tolerated sitting in chair and maintained good o2 sat\ns on 40% trach\n collar. Pt able to eat some ice cream and drank some gingerale without\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\n and then got back to bed and placed on vent with originale settings. Pt\n slept for about 4hrs and when awoke c/o back pain again.\n Plan:\n plan for pt is to schedule him for a permanent trach.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615486,"text":"hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP service consulted, to do FOB to assess trache and exclude\n posterior membrane erosion\n - npo for proc\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615358,"text":"The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n"},{"category":"Respiratory ","chartdate":"2156-12-02 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615361,"text":"Airway\n Tube Type\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Airway problems: Positional leak around cuff\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\n ventilatory support in supine position, due to severe scoliosis.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615357,"text":"The patinet is a deaf 58 year old gentleman with a history of likely\n hypertensive dialated cardiomyopathy (EF 50%,) poorly controlled blood\n pressure, DM2, OSA, deaf and mute who presented to the ED with\n complains of sudden onset SOB. The patient has had prior\n hospitalizations for acute pulmonary edema in the setting of\n hypertensive urgency. He was seen by his PCP one day prior to\n presentation with complaints of 3 days of conjunctivitis and rhinorhea\n with a slight, non-productive cough, which was felt to be a viral\n syndrome, but he was prescribed erythromycin ointment.\n .\n On the day of presentation, the patient was waking and became markedly\n short of breath. EMS was activated, and the patient was placed on a\n NRB. On arrival to the ED, he was markedly hypertensive 242/110/ HR\n 106, and afebrile. The patient was placed on BIPAP, was started on a\n nitro gtt, given ASA 325mg, and was 100mg IV lasix, to which he put out\n 400cc of urine. Cardiology was consulted in the ED, but felt that\n given recent URI symptoms, a MICU admission would be more appropriate.\n The patient was admitted to the MICU for further management.\n .\n The patient denies any fevers/chills, abdominal pain, diahrea, or\n dysuria. He has not had any worsening LE swelling, orthopnea, or PND.\n He reports to be compliant with home medication regimen. He complaints\n of b/l chest pain currently, similar to prior chest pain. Worse with\n palpation and deep inspiration.\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Attending Progress Note","row_id":615827,"text":"Chief Complaint: Trach occlusion\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above.\n HPI: 49 yo man with severe scoliosis. Initially admitted to \n hospital with increasing dyspnea, with hypercarbic respiratory\n failure requiring semi-urgent tracheostomy. Transferred to for\n trach occlusion, now sp advancement of trach 1cm.\n 24 Hour Events:\n -no further issues with occlusion of tracheostomy\n - currently, on AC overnight and TCM with intermittent\n use of during the day\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lasix 40 IV TID\n Protonix\n ASA\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.8\n HR: 98 (79 - 103) bpm\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\n RR: 18 (16 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 930 mL\n PO:\n 790 mL\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Thin. Severe scoliosis.\n Peripheral 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: inspiratory and expiratory wheezing\n Extremities: 2+ symmetrical LE edema\n Skin: Not assessed\n Neurologic: alert and oriented x3\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: CXR:\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n -still has adjustable , doing well during the day and requires\n ventilator at night. Will ask IP if we can change to non-adjustable\n trach as position of trach has moved overnight\n -speaking without using , keep off for now\n -decrease lasix to dosing\nPulmonary hypertension likely due to restrictive lung disease\n -continue lasix\n ADDENDUM\n Trach changed to 110mm, size 7. Tip approximately 1cm above the\n carina. Uncomplicated. Severe subglottic edema noted. Pt indicated that\n he felt much more comfortable with the new trach in place. Doing well\n on trach collar for > 1 hour.\n ICU Care\n Nutrition: regular diet\n Glycemic Control: RISS\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: Protonix\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition :Transfer to hospital. F/U as outpatient with\n Interventional Pulmonary service, Dr .\n Total time spent:\n"},{"category":"Nursing","chartdate":"2156-12-03 00:00:00.000","description":"Nursing Progress Note","row_id":615690,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\n to clear secreations, lungs course\n Action:\n Pt given lasix this am and then lasix increased to tid\n Response:\n Pt passing 200 cc hr, lung sound less wet sounding\n Plan:\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\n tomorrow\n"},{"category":"Nursing","chartdate":"2156-12-03 00:00:00.000","description":"Nursing Progress Note","row_id":615680,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\n to clear secreations, lungs course\n Action:\n Pt given lasix this am and then lasix increased to tid\n Response:\n Pt passing 200 cc hr, lung sound less wet\n Plan:\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\n tomorrow\n"},{"category":"Nursing","chartdate":"2156-12-04 00:00:00.000","description":"Nursing Progress Note","row_id":615804,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\n trach site doe have some old blood around trach.\n Action:\n Pt given 40 mg po lasix and albuternal neb x1 this am\n Response:\n Pt states breathing feels better, pt passing 300 cc hr urine\n Plan:\n To transfere to back to osh where he came from,\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Attending Progress Note","row_id":615808,"text":"Chief Complaint: 49 yo man with severe scoliosis. Initially admitted to\n hospital with increasing dyspnea, with hypercarbic\n respiratory failure requiring semi-urgent tracheostomy. Transferred to\n for trach occlusion, now sp advancement of trach 1cm.\n HPI:\n 24 Hour Events:\n -no further issues with occlusion of tracheostomy\n - currently, on AC overnight and TCM with intermittent\n use of during the day\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lasix 40 IV TID\n Protonix\n ASA\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.8\n HR: 98 (79 - 103) bpm\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\n RR: 18 (16 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 930 mL\n PO:\n 790 mL\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Thin. Severe scoliosis.\n Peripheral 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: inspiratory and expiratory wheezing\n Extremities: 2+ symmetrical LE edema\n Skin: Not assessed\n Neurologic: alert and oriented x3\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: CXR:\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n -still has adjustable , doing well during the day and requires\n ventilator at night. Will ask IP if we can change to non-adjustable\n trach as position of trach has moved overnight\n -speaking without using , keep off for now\n -decrease lasix to dosing\nPulmonary hypertension likely due to restrictive lung disease\n -continue lasix\n ICU Care\n Nutrition: regular diet\n Glycemic Control: RISS\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: Protonix\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition :Transfer to hospital after IP evaluates whether we\n should change to non-adjustable trach\n Total time spent:\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":615809,"text":"Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion, trach repositioned b IP.\n - continue vent settings over night, w/ valve during the day. Although\n pt can talk around valve, which may portend need for trach replacement.\n - discourange ambient use\n - will d/w IP switch to non-flexible valve\n - cont guafenisin and duoneb\n - reduce lasix to \n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":615794,"text":"Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":615796,"text":"Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-02 00:00:00.000","description":"Physician Attending Progress Note","row_id":615423,"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 seen by interventional pulmonary\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa 81\n lasix 40 qday\n heparin 5000 tid\n albuterol\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 09:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 99 (76 - 112) bpm\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\n RR: 21 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 200 mL\n PO:\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 175 mL\n 795 mL\n Urine:\n 175 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n -175 mL\n -595 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 0 cmH2O\n SpO2: 95%\n ABG: ///45/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: Well nourished, scoliosis\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 11.9 g/dL\n 277 K/uL\n 119 mg/dL\n 0.4 mg/dL\n 45 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 91 mEq/L\n 141 mEq/L\n 38.0 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n WBC\n 5.4\n Hct\n 38.0\n Plt\n 277\n Cr\n 0.4\n Glucose\n 119\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n 1./ hypercarbic respiratory failure:\n - IP service following\n - likely bronch this morning, with potential replacement of trach\n - will cont to follow\n - cont albuterol nebs as needed\n - npo for now\n 2. Reflux: cont scoliosis\n 3. pain: minimal, holding narcotic\n 4. pHTN: cont lasix for diuresis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615390,"text":"The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\n comfortably in a chair. When in bed pt must lie flat and needs to be on\n full vent status. Lung sounds clear and rhonchorus but will clear once\n suctioned. O2 sat\ns in high 90\ns. will desat to low 90\ns when need to\n be sx\nd, afebrile. Foley cath with good urine output,\n Action:\n Once examined and assessed by resident pt got oob to chair with minimal\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\n mod amt\ns of thick bloody secretions,\n Response:\n Pt tolerated sitting in chair and maintained good o2 sat\ns on 40% trach\n collar. Pt able to eat some ice cream and drank some gingerale without\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\n and then got back to bed and placed on vent with originale settings. Pt\n slept for about 4hrs and when awoke c/o back pain again. Resident d/d\n oxycodone and ordered Tylenol. Pt received 650mg this am.\n Plan:\n plan for pt is to schedule him for a permanent trach. pt is currently\n npo.\n"},{"category":"Respiratory ","chartdate":"2156-12-02 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615396,"text":"Airway\n Tube Type\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Airway problems: Positional leak around cuff\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\n ventilatory support in supine position, due to severe scoliosis.\n"},{"category":"Respiratory ","chartdate":"2156-12-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615577,"text":"Demographics\n Day of mechanical ventilation: 3\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: when off vent.\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Increase ventilatory support at night\n"},{"category":"Physician ","chartdate":"2156-12-01 00:00:00.000","description":"Physician Resident Admission Note","row_id":615315,"text":"Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. On\n presentation to the ED, the he was found to be hypoxemic (80s) and\n hypercapnic (ABG 7.29 / 89 / 83 / 42,) with episodes of bradycardia\n with 3-4 sec pauses, and was admitted to the ICU. He was started on\n BIPAP at night, with intermitent use during the day due to his severe\n hypercapnic respiratory failure, but did not have good tolerance of\n non-invasive ventilation. His respiratory status continud to worsen,\n and the patient was found somnolent and difficult to arouse at night.\n PCO2 was found during to be 130. Due to his severe scoliosis, and\n failed nasal intubation, and ENT was consulted for a semi-emergent\n tracheostomy. A #6 LTC cuffed Shiley trach was placed, but started on\n Passy-Muir valve during the day time. On , the patient occluded\n the tracheostomy with severe hypoxia, requiring CPR, but resolved with\n trach manipulation to restablish the airway. A similar episode occured\n on , and a #7 Bavrona hyperflexible tracheostomy was placed. He\n has remained on mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - IP vs. ENT c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-01 00:00:00.000","description":"Physician Resident Admission Note","row_id":615316,"text":"Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. Of note, he\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\n to the ICU. He was started on BIPAP at night, with intermitent use\n during the day due to his severe hypercapnic respiratory failure, but\n did not have good tolerance of non-invasive ventilation. His\n respiratory status continud to worsen, and the patient was found\n somnolent and difficult to arouse at night. PCO2 was found during to\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\n Shiley trach was placed, but started on Passy-Muir valve during the day\n time. On , the patient occluded the tracheostomy with severe\n hypoxia, requiring CPR, but resolved with trach manipulation to\n restablish the airway. A similar episode occured on , and a #7\n Bavrona hyperflexible tracheostomy was placed. He has remained on\n mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL CODE\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-02 00:00:00.000","description":"Physician Resident Admission Note","row_id":615319,"text":"Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. Of note, he\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\n to the ICU. He was started on BIPAP at night, with intermitent use\n during the day due to his severe hypercapnic respiratory failure, but\n did not have good tolerance of non-invasive ventilation. His\n respiratory status continud to worsen, and the patient was found\n somnolent and difficult to arouse at night. PCO2 was found during to\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\n Shiley trach was placed, but started on Passy-Muir valve during the day\n time. On , the patient occluded the tracheostomy with severe\n hypoxia, requiring CPR, but resolved with trach manipulation to\n restablish the airway. A similar episode occured on , and a #7\n Bavrona hyperflexible tracheostomy was placed. He has remained on\n mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL CODE\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU Overnight Attending Coverage\n I saw and examined the patient with Dr. . The assessment and plan\n was discussed in detail.\n I would emphasize the following. 49 y.o. man with severe scoliosis,\n OSA, and 30 pound weight gain over past approximately two years with\n progressive dyspnea, hypercapneic and hypoxic respiratory failure\n requiring urgent tracheostomy at the outside hospital. Trach changes\n as noted above, using vent at night, off most of the day, minimal\n suctioning required except when trach first placed. Now concern for\n posterior tracheal erosion. No hemoptysis, minimizing suctioning.\n Appears comfortable on trach collar sitting straight up in chair.\n Severe scoliosis poor air movement on right, occ. crackle on left, no\n wheeze\n RRR, no murmurs\n + bipedal edema Erythema on right forearm, no cord/fluctulence\n Alert and oriented x 3 Ventral and umbilical hernia\n Hypercapneic/hypoxic respiratory failure secondary to restrictive lung\n disease in setting of severe scoliosis and OSA exacerbated in setting\n of significant weight gain. require customized trach, IP to\n evaluate in the morning. NPO after midnight. Minimize suctioning.\n Plan as noted above.\n Patient is critically ill given tenuous respiratory status\n Full code\n Time spent 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 00:32 ------\n"},{"category":"Nursing","chartdate":"2156-12-03 00:00:00.000","description":"Nursing Progress Note","row_id":615568,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Stable overnight, no issues\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"},{"category":"Nursing","chartdate":"2156-12-03 00:00:00.000","description":"Nursing Progress Note","row_id":615570,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Stable overnight, no issues\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"},{"category":"Nutrition","chartdate":"2156-12-03 00:00:00.000","description":"Clinical Nutrition Note","row_id":615664,"text":"Ht: unavailable to assess due to severe scolosis\n Wt: 89 kg\n Diet: Soft, thin liquids\n Labs: noted\n Abdomen: soft/distended, positive bowel sounds\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n 49 year old male with a history of severe scoliosis, restrictive lung\n disease, obstructive sleep apnea, who presented to an outside hosptial\n with worsening dyspnea, who developed hypercapnic respiratory failure\n w/ semi-emergent tacheostomy placement, now transfered for evaluation\n of posterior wall erosion. Now status post tracheostomy placement with\n revision due to hypoxemia with trach blockage.\n Tolerating soft diet, good appetite. Eats soft diet at home. Thinks\n his current weight is\nhigh\n, but stable recently. Per chart, patient\n with 30 lb weight gain x 2 years.\n Noted plan for transfer to .\n Will follow to check po\ns if remains in house, page if questions *\n PM\n"},{"category":"Physician ","chartdate":"2156-12-03 00:00:00.000","description":"Physician Attending Progress Note","row_id":615648,"text":"TITLE:\n Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -IP performed FOB, evaluation of trache\n -Ventilated overnight\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 Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 07:50 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.3\nC (99.1\n HR: 92 (71 - 115) bpm\n BP: 128/80(87) {103/62(71) - 150/123(126)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 720 mL\n 100 mL\n PO:\n 720 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 3,820 mL\n 1,075 mL\n Urine:\n 3,820 mL\n 1,075 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,100 mL\n -975 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 323 (323 - 325) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: ///41/\n Ve: 9.7 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache 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: No(t) Symmetric), (Breath Sounds:\n Diminished: ), severe kyphoscoliosis\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 1. hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP performed FOB/airway evaluation\n -no posterior membrane erosion\n -trache adjusted\n - nocturnal ventilation ongoing\n 2. Reflux:\n - cont tx scoliosis\n 3. pain:\n - minimal, holding narcotic\n 4. pHTN:\n - cont lasix for diuresis\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :Transfer to other facility\n Total time spent:\n"},{"category":"Respiratory ","chartdate":"2156-12-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615711,"text":"Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Airway\n Airway Placement Data\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt on and off Trach Collar .50 today using PMV occasionally\n for short periods of time.\n"},{"category":"Case Management ","chartdate":"2156-12-03 00:00:00.000","description":"Case Management Continued Stay Review","row_id":615657,"text":"Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer:\n Hospital days authorized to:\n Current Discharge Plan: Hospital, NH\n Narrative / Plan (Multidisciplinary team):\n Case discussed w/ team. Pt with new trach/vented on CPAP at times,\n would need hospital level rehab not . Pt with NH medicaid only. No\n LTACs in NH. No NH medicaid contracts at LTACs in MA. Plan is for pt to\n return to Hospital. MICU team has made contact with \n Physician to start arranging for transfer back.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615494,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Pt tolerated procedure well. No erosion noted of trache, some\n irritation though. PPI started for this. sitting in chair and\n maintained good o2 sat\ns on 40% trach collar. To fully supported on\n vent. Diet advanced back to his soft solids, tolerated well.\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"},{"category":"Physician ","chartdate":"2156-12-02 00:00:00.000","description":"Physician Attending Progress Note","row_id":615453,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n - seen by interventional pulmonary\n Allergies:\n No Known Drug Allergies\n Other medications:\n asa 81\n lasix 40 qday\n heparin 5000 tid\n albuterol\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 09:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 99 (76 - 112) bpm\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\n RR: 21 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 200 mL\n PO:\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 175 mL\n 795 mL\n Urine:\n 175 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n -175 mL\n -595 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 0 cmH2O\n SpO2: 95%\n ABG: ///45/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: Well nourished, scoliosis\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: poor air mvmt on right\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive\n Labs / Radiology\n 11.9 g/dL\n 277 K/uL\n 119 mg/dL\n 0.4 mg/dL\n 45 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 91 mEq/L\n 141 mEq/L\n 38.0 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n WBC\n 5.4\n Hct\n 38.0\n Plt\n 277\n Cr\n 0.4\n Glucose\n 119\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n 1. hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP service consulted, to do FOB to assess trache and exclude\n posterior membrane erosion\n - npo for proc\n 2. Reflux:\n - cont tx scoliosis\n 3. pain:\n - minimal, holding narcotic\n 4. pHTN:\n - cont lasix for diuresis\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition :ICU\n Total time spent:\n"},{"category":"Respiratory ","chartdate":"2156-12-02 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615454,"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 Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems: Positional leak around cuff,\n adjustable trach advanced to 12 cm just below flange via bronchoscopic\n evaluation.\n Comments: deflated while off ventilator\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments: expriratory wheezes T/O clear after albuterol adm via\n nebulizer.\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Expectorated / None\n Ventilation Assessment\n Level of breathing assistance: Off ventilator during the day\n Visual assessment of breathing pattern: occasional dyspnea with\n increased congestion and expiratory wheezes, relieved with coughing and\n nebulized albuterol.\n Plan\n Next 24-48 hours: Increase ventilatory support at night; Comments:\n placed on ventilator at night for management of CO2\n Reason for continuing current ventilatory support:\n Bedside Procedures:\n Bronchoscopy (12:00)\n Comments:\n"},{"category":"ECG","chartdate":"2156-12-04 00:00:00.000","description":"Report","row_id":230766,"text":"Sinus rhythm. Consider right atrial abnormality. Right axis deviation.\nProminent lateral lead Q waves. Findings raise consideration of possible\nright ventricular overload. Possible prior lateral myocardial infarction\nof left posterior fascicular block. Clinical correlation is suggested.\nNo previous tracing available for comparison.\n\n"},{"category":"Radiology","chartdate":"2156-12-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1116684,"text":" 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with trach c/o dyspnea.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:39 A.M. \n\n HISTORY: Tracheostomy. Complains of dyspnea.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes have decreased and opacification particularly in the right lung\n has increased since . Given the marked anatomic distortion of the\n chest precise diagnosis is difficult, but since there is vascular engorgement\n in the left lung I suspect cardiac decompensation is playing a role. There is\n also the suggestion of retained secretions in the bronchial tree, particularly\n the right. Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No pneumothorax is\n present.\n\n\n"},{"category":"Radiology","chartdate":"2156-12-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1116480,"text":" 11:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate lung fields\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with severe scoliosis s/p trach\n REASON FOR THIS EXAMINATION:\n pls evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate tracheostomy.\n\n The interpretation of this radiograph is very limited due to the severe\n scoliosis and deformity of the thoracic cage. Tracheostomy tube tip is 5.5 cm\n above the carina. Cardiomediastinal contours cannot be evaluated. There is\n no evident pneumothorax. If any, there is a small right pleural effusion.\n The main central pulmonary arteries appear to be enlarged. There are no prior\n studies available for comparison. The asymmetric increased density in the\n right hemithorax could be due to pleural effusion or lung opacities in the\n right lower lobe, I suspect that also is due to the deformity of the thoracic\n cage. If prior studies were available , comparison could be performed to\n assess new abnormality.\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615795,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - attempted transfer back to ; no beds available so will call in\\n AM, they will take him back there\\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\\n - c/o in chest pain in the middle of the night, checked ECG, no acute\\n changes. CP resolved on its own\\n - did not use the vent overnight; only trach collar\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.8\\nC (98.2\\n HR: 100 (79 - 103) bpm\\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\\n RR: 26 (16 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 450 mL\\n PO:\\n 790 mL\\n 450 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -880 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: Lung volumes have decreased and opacification particularly in\\n the right lung has increased since . Given the marked\\n anatomic distortion of the chest precise diagnosis is difficult, but\\n since there is vascular engorgement in the left lung I suspect cardiac\\n decompensation is playing a role. There is also the suggestion of\\n retained secretions in the bronchial tree, particularly the right.\\n Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No\\n pneumothorax is\\n present.\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615616,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - bronched in morning by IP: supraglottic edema -> started PPI.\\n occlusion of airway during expiration by posterior larynx ->\\n tracheostomy tube was advanced by 1 cm with better airway patency\\n established.\\n - put on PS 10/5 while sleeping during day. overnight on vent from 12\\n am to 4 am, then on trach collar\\n - case mmgnt: should return to OSH vs begin screening for rehab\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:18 PM\\n Heparin Sodium (Prophylaxis) - 11:13 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.3\\n Tcurrent: 37.2\\nC (98.9\\n HR: 92 (71 - 115) bpm\\n BP: 124/88(96) {103/62(71) - 150/123(126)} mmHg\\n RR: 22 (17 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 720 mL\\n PO:\\n 720 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 3,820 mL\\n 275 mL\\n Urine:\\n 3,820 mL\\n 275 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,100 mL\\n -275 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 323 (323 - 325) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 16 cmH2O\\n SpO2: 99%\\n ABG: ///41/\\n Ve: 9.7 L/min\\n Physical Examination\\n Trached, on trach mask, sitting in a chair\\n Severe scoliosis, slgith erosis on neck from trach\\n Abnormal resioatory movements\\n Distant heart sounds, tachycardic, no m/r/g\\n Abdominal ventral, soft, ntnd\\n 1+ LE b/l\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Assessment and Plan\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both\\n restrictive lung process due to severe scoliosis with additonal OSA.\\n Now status post tracheostomy placement with revision due to hypoxemia\\n with trach blockage. Patient has been using trach valve during the day\\n and CMV at night. Transfered for evaluation of posterior trach\\n erosion.\\n - continue vent settings as per \\n - discourange ambient use\\n - IP c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n - encourage weight loss and ? pulm rehab on discharge.\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 06:10 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\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615755,\n \"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:\\n Procedure location:\\n Reason:\\n :\\n Tracheostomy tube:\\n Type: Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n PMV: Yes\\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: 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: 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:\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Comments: Patient had been off the ventilator most of day on a 50%\\n trach collar. Good vocalization using the passy muir valve. Pt had\\n periods of dyspnea relieved with suctioning and neb treatments. Pt and\\n wife anxious about handling trach care when home but anxious to get\\n started with rehab.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615756,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received the pt alert and sitting on the commode as chair. On trach\\n mask.\\n Action:\\n Suctioned for blood tinged secretion, C/O chest pain around 0200 EKG\\n done no changes and he claimed no more chest pain. Received ambien as\\n per pt request, Cont PO lasix.\\n Response:\\n Pt passing 200 cc hr, lung sound less wet sounding\\n Plan:\\n Continue with lasix tid, nebs and suction as needed, plan to transfere\\n back to osh tomorrow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615840,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\\n trach site doe have some old blood around trach.\\n Action:\\n Pt given 40 mg po lasix and albuternal neb x1 this am\\n Response:\\n Pt states breathing feels better, pt passing 300 cc hr urine\\n Plan:\\n To transfere to back to osh where he came from,\\n Pt had bronch this afternoon, trach changed to #12 boviena, pt received\\n 1 mg iv versed and 50 mcgs of iv Fentanyl for procedure, pt states this\\n trach more comfortable, also not swelling above trach and bleeding in\\n nasal area, pt to be transferred back to osh this afternoon.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615362,\n \"text\": \"The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615364,\n \"text\": \"The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\\n comfortably in a chair. When in bed pt must lie flat and needs to be on\\n full vent status. Lung sounds clear and rhonchorus but will clear once\\n suctioned. O2 sat\\ns in high 90\\n Action:\\n Once examined and assessed by resident pt got oob to chair with minimal\\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\\n mod amt\\ns of thick bloody secretions,\\n Response:\\n Pt tolerated sitting in chair and maintained good o2 sat\\ns on 40% trach\\n collar. Pt able to eat some ice cream and drank some gingerale without\\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\\n and then got back to bed and placed on vent with originale settings. Pt\\n slept for about 4hrs and when awoke c/o back pain again.\\n Plan:\\n plan for pt is to schedule him for a permanent trach.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615486,\n \"text\": \"hypercarbic respiratory failure:\\n - restrictive lung disease in setting of severe scoliosis and OSA\\n - likely exacerbated with recent significant weight gain\\n - IP service consulted, to do FOB to assess trache and exclude\\n posterior membrane erosion\\n - npo for proc\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615358,\n \"text\": \"The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615361,\n \"text\": \"Airway\\n Tube Type\\n Tracheostomy tube:\\n Type: Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Airway problems: Positional leak around cuff\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\\n ventilatory support in supine position, due to severe scoliosis.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615357,\n \"text\": \"The patinet is a deaf 58 year old gentleman with a history of likely\\n hypertensive dialated cardiomyopathy (EF 50%,) poorly controlled blood\\n pressure, DM2, OSA, deaf and mute who presented to the ED with\\n complains of sudden onset SOB. The patient has had prior\\n hospitalizations for acute pulmonary edema in the setting of\\n hypertensive urgency. He was seen by his PCP one day prior to\\n presentation with complaints of 3 days of conjunctivitis and rhinorhea\\n with a slight, non-productive cough, which was felt to be a viral\\n syndrome, but he was prescribed erythromycin ointment.\\n .\\n On the day of presentation, the patient was waking and became markedly\\n short of breath. EMS was activated, and the patient was placed on a\\n NRB. On arrival to the ED, he was markedly hypertensive 242/110/ HR\\n 106, and afebrile. The patient was placed on BIPAP, was started on a\\n nitro gtt, given ASA 325mg, and was 100mg IV lasix, to which he put out\\n 400cc of urine. Cardiology was consulted in the ED, but felt that\\n given recent URI symptoms, a MICU admission would be more appropriate.\\n The patient was admitted to the MICU for further management.\\n .\\n The patient denies any fevers/chills, abdominal pain, diahrea, or\\n dysuria. He has not had any worsening LE swelling, orthopnea, or PND.\\n He reports to be compliant with home medication regimen. He complaints\\n of b/l chest pain currently, similar to prior chest pain. Worse with\\n palpation and deep inspiration.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615827,\n \"text\": \"Chief Complaint: Trach occlusion\\n I saw and examined the patient, and was physically present with the ICU\\n resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan. PMH, SH, FH and ROS are\\n unchanged from admission except where noted above.\\n HPI: 49 yo man with severe scoliosis. Initially admitted to \\n hospital with increasing dyspnea, with hypercarbic respiratory\\n failure requiring semi-urgent tracheostomy. Transferred to for\\n trach occlusion, now sp advancement of trach 1cm.\\n 24 Hour Events:\\n -no further issues with occlusion of tracheostomy\\n - currently, on AC overnight and TCM with intermittent\\n use of during the day\\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Lasix 40 IV TID\\n Protonix\\n ASA\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.6\\nC (97.8\\n HR: 98 (79 - 103) bpm\\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\\n RR: 18 (16 - 27) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 930 mL\\n PO:\\n 790 mL\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -400 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 97%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n General Appearance: Thin. Severe scoliosis.\\n Peripheral 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: inspiratory and expiratory wheezing\\n Extremities: 2+ symmetrical LE edema\\n Skin: Not assessed\\n Neurologic: alert and oriented x3\\n Labs / Radiology\\n 12.1 g/dL\\n 308 K/uL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: CXR:\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n -still has adjustable , doing well during the day and requires\\n ventilator at night. Will ask IP if we can change to non-adjustable\\n trach as position of trach has moved overnight\\n -speaking without using , keep off for now\\n -decrease lasix to dosing\\nPulmonary hypertension likely due to restrictive lung disease\\n -continue lasix\\n ADDENDUM\\n Trach changed to 110mm, size 7. Tip approximately 1cm above the\\n carina. Uncomplicated. Severe subglottic edema noted. Pt indicated that\\n he felt much more comfortable with the new trach in place. Doing well\\n on trach collar for > 1 hour.\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control: RISS\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: heparin SQ\\n Stress ulcer: Protonix\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: full\\n Disposition :Transfer to hospital. F/U as outpatient with\\n Interventional Pulmonary service, Dr .\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615690,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\\n to clear secreations, lungs course\\n Action:\\n Pt given lasix this am and then lasix increased to tid\\n Response:\\n Pt passing 200 cc hr, lung sound less wet sounding\\n Plan:\\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\\n tomorrow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615680,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\\n to clear secreations, lungs course\\n Action:\\n Pt given lasix this am and then lasix increased to tid\\n Response:\\n Pt passing 200 cc hr, lung sound less wet\\n Plan:\\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\\n tomorrow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615804,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\\n trach site doe have some old blood around trach.\\n Action:\\n Pt given 40 mg po lasix and albuternal neb x1 this am\\n Response:\\n Pt states breathing feels better, pt passing 300 cc hr urine\\n Plan:\\n To transfere to back to osh where he came from,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615808,\n \"text\": \"Chief Complaint: 49 yo man with severe scoliosis. Initially admitted to\\n hospital with increasing dyspnea, with hypercarbic\\n respiratory failure requiring semi-urgent tracheostomy. Transferred to\\n for trach occlusion, now sp advancement of trach 1cm.\\n HPI:\\n 24 Hour Events:\\n -no further issues with occlusion of tracheostomy\\n - currently, on AC overnight and TCM with intermittent\\n use of during the day\\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Lasix 40 IV TID\\n Protonix\\n ASA\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.6\\nC (97.8\\n HR: 98 (79 - 103) bpm\\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\\n RR: 18 (16 - 27) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 930 mL\\n PO:\\n 790 mL\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -400 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 97%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n General Appearance: Thin. Severe scoliosis.\\n Peripheral 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: inspiratory and expiratory wheezing\\n Extremities: 2+ symmetrical LE edema\\n Skin: Not assessed\\n Neurologic: alert and oriented x3\\n Labs / Radiology\\n 12.1 g/dL\\n 308 K/uL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: CXR:\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n -still has adjustable , doing well during the day and requires\\n ventilator at night. Will ask IP if we can change to non-adjustable\\n trach as position of trach has moved overnight\\n -speaking without using , keep off for now\\n -decrease lasix to dosing\\nPulmonary hypertension likely due to restrictive lung disease\\n -continue lasix\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control: RISS\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: heparin SQ\\n Stress ulcer: Protonix\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: full\\n Disposition :Transfer to hospital after IP evaluates whether we\\n should change to non-adjustable trach\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615809,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - attempted transfer back to ; no beds available so will call in\\n AM, they will take him back there\\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\\n - c/o in chest pain in the middle of the night, checked ECG, no acute\\n changes. CP resolved on its own\\n - did not use the vent overnight; only trach collar\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.8\\nC (98.2\\n HR: 100 (79 - 103) bpm\\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\\n RR: 26 (16 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 450 mL\\n PO:\\n 790 mL\\n 450 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -880 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: Lung volumes have decreased and opacification particularly in\\n the right lung has increased since . Given the marked\\n anatomic distortion of the chest precise diagnosis is difficult, but\\n since there is vascular engorgement in the left lung I suspect cardiac\\n decompensation is playing a role. There is also the suggestion of\\n retained secretions in the bronchial tree, particularly the right.\\n Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No\\n pneumothorax is\\n present.\\n Assessment and Plan\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both\\n restrictive lung process due to severe scoliosis with additonal OSA.\\n Now status post tracheostomy placement with revision due to hypoxemia\\n with trach blockage. Patient has been using trach valve during the day\\n and CMV at night. Transfered for evaluation of posterior trach\\n erosion, trach repositioned b IP.\\n - continue vent settings over night, w/ valve during the day. Although\\n pt can talk around valve, which may portend need for trach replacement.\\n - discourange ambient use\\n - will d/w IP switch to non-flexible valve\\n - cont guafenisin and duoneb\\n - reduce lasix to \\n - encourage weight loss and ? pulm rehab on discharge.\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615794,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - attempted transfer back to ; no beds available so will call in\\n AM, they will take him back there\\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\\n - c/o in chest pain in the middle of the night, checked ECG, no acute\\n changes. CP resolved on its own\\n - did not use the vent overnight; only trach collar\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.8\\nC (98.2\\n HR: 100 (79 - 103) bpm\\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\\n RR: 26 (16 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 450 mL\\n PO:\\n 790 mL\\n 450 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -880 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: Lung volumes have decreased and opacification particularly in\\n the right lung has increased since . Given the marked\\n anatomic distortion of the chest precise diagnosis is difficult, but\\n since there is vascular engorgement in the left lung I suspect cardiac\\n decompensation is playing a role. There is also the suggestion of\\n retained secretions in the bronchial tree, particularly the right.\\n Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No\\n pneumothorax is\\n present.\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615796,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - attempted transfer back to ; no beds available so will call in\\n AM, they will take him back there\\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\\n - c/o in chest pain in the middle of the night, checked ECG, no acute\\n changes. CP resolved on its own\\n - did not use the vent overnight; only trach collar\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.8\\nC (98.2\\n HR: 100 (79 - 103) bpm\\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\\n RR: 26 (16 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 450 mL\\n PO:\\n 790 mL\\n 450 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -880 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: Lung volumes have decreased and opacification particularly in\\n the right lung has increased since . Given the marked\\n anatomic distortion of the chest precise diagnosis is difficult, but\\n since there is vascular engorgement in the left lung I suspect cardiac\\n decompensation is playing a role. There is also the suggestion of\\n retained secretions in the bronchial tree, particularly the right.\\n Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No\\n pneumothorax is\\n present.\\n Assessment and Plan\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both\\n restrictive lung process due to severe scoliosis with additonal OSA.\\n Now status post tracheostomy placement with revision due to hypoxemia\\n with trach blockage. Patient has been using trach valve during the day\\n and CMV at night. Transfered for evaluation of posterior trach\\n erosion.\\n - continue vent settings as per \\n - discourange ambient use\\n - IP c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n - encourage weight loss and ? pulm rehab on discharge.\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615423,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n seen by interventional pulmonary\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n asa 81\\n lasix 40 qday\\n heparin 5000 tid\\n albuterol\\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 09:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 36.7\\nC (98\\n HR: 99 (76 - 112) bpm\\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\\n RR: 21 (14 - 25) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 200 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 175 mL\\n 795 mL\\n Urine:\\n 175 mL\\n 795 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -175 mL\\n -595 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: Unstable Airway\\n PIP: 0 cmH2O\\n SpO2: 95%\\n ABG: ///45/\\n Ve: 4.2 L/min\\n Physical Examination\\n General Appearance: Well nourished, scoliosis\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Musculoskeletal: Muscle wasting\\n Skin: Warm\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\\n Movement: Purposeful, Tone: Not assessed\\n Labs / Radiology\\n 11.9 g/dL\\n 277 K/uL\\n 119 mg/dL\\n 0.4 mg/dL\\n 45 mEq/L\\n 3.7 mEq/L\\n 7 mg/dL\\n 91 mEq/L\\n 141 mEq/L\\n 38.0 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n WBC\\n 5.4\\n Hct\\n 38.0\\n Plt\\n 277\\n Cr\\n 0.4\\n Glucose\\n 119\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\\n PO4:4.2 mg/dL\\n Assessment and Plan\\n 1./ hypercarbic respiratory failure:\\n - IP service following\\n - likely bronch this morning, with potential replacement of trach\\n - will cont to follow\\n - cont albuterol nebs as needed\\n - npo for now\\n 2. Reflux: cont scoliosis\\n 3. pain: minimal, holding narcotic\\n 4. pHTN: cont lasix for diuresis\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 06:10 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: Mouth care\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status:\\n Disposition :ICU\\n Total time spent: 60 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615390,\n \"text\": \"The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\\n comfortably in a chair. When in bed pt must lie flat and needs to be on\\n full vent status. Lung sounds clear and rhonchorus but will clear once\\n suctioned. O2 sat\\ns in high 90\\ns. will desat to low 90\\ns when need to\\n be sx\\nd, afebrile. Foley cath with good urine output,\\n Action:\\n Once examined and assessed by resident pt got oob to chair with minimal\\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\\n mod amt\\ns of thick bloody secretions,\\n Response:\\n Pt tolerated sitting in chair and maintained good o2 sat\\ns on 40% trach\\n collar. Pt able to eat some ice cream and drank some gingerale without\\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\\n and then got back to bed and placed on vent with originale settings. Pt\\n slept for about 4hrs and when awoke c/o back pain again. Resident d/d\\n oxycodone and ordered Tylenol. Pt received 650mg this am.\\n Plan:\\n plan for pt is to schedule him for a permanent trach. pt is currently\\n npo.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615396,\n \"text\": \"Airway\\n Tube Type\\n Tracheostomy tube:\\n Type: Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Airway problems: Positional leak around cuff\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\\n ventilatory support in supine position, due to severe scoliosis.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615577,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 3\\n Airway\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed, Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n PMV: when off vent.\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Increase ventilatory support at night\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-01 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 615315,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: DOE\\n REASON FOR MICU ADMISSION: Vent Dependent on trach\\n HPI:\\n The patinet is a 49 year old male with a history of sever scoliosis\\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\\n OSA who presented to an OSH on with complaints of progressive\\n dyspnea.\\n .\\n The patient has had worsening shortness of breath at rest over the last\\n year. OSH records also indicate the patient dozing off throughotu the\\n day, raising concerns of him falling alseep while driving. On\\n presentation to the ED, the he was found to be hypoxemic (80s) and\\n hypercapnic (ABG 7.29 / 89 / 83 / 42,) with episodes of bradycardia\\n with 3-4 sec pauses, and was admitted to the ICU. He was started on\\n BIPAP at night, with intermitent use during the day due to his severe\\n hypercapnic respiratory failure, but did not have good tolerance of\\n non-invasive ventilation. His respiratory status continud to worsen,\\n and the patient was found somnolent and difficult to arouse at night.\\n PCO2 was found during to be 130. Due to his severe scoliosis, and\\n failed nasal intubation, and ENT was consulted for a semi-emergent\\n tracheostomy. A #6 LTC cuffed Shiley trach was placed, but started on\\n Passy-Muir valve during the day time. On , the patient occluded\\n the tracheostomy with severe hypoxia, requiring CPR, but resolved with\\n trach manipulation to restablish the airway. A similar episode occured\\n on , and a #7 Bavrona hyperflexible tracheostomy was placed. He\\n has remained on mechanic ventialation at night, AC, 400/14/5.\\n .\\n Per OSH records, there were concerns that the tracheostomy tube tip\\n appeard to be eroding at the posterior wall of the trachea due to the\\n patients baseline abnormal antatomy. The patient was transfered to\\n for evaluation of a potential customized tracheostomy vs other\\n intervention.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n ASA 81mg daily\\n Lasix 80mg daily\\n Rozerem PRN\\n .\\n Medications at Transfer-\\n Ambien 5mg HS PRN\\n Morphine 4-6mg q4h PRN pain\\n Percocet tab q4H PRN pain\\n Claritin 10mg daily\\n Magnesium oxide 400mg \\n DuoNeb PRN\\n Protonix 40mg daily\\n Lorazepam 45mg q4 PRN\\n Colace 100mg \\n Humibid 1200mg \\n Lasix 40mg daily\\n Arixtra 2.5mg daily\\n ASA 81mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n Severe scoliosis\\n Prior pneumothoraces\\n Restrictive Lung Disease\\n Chronic respiroatyr failure\\n Cholecystectomy\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: The patient is currently married, no alcohol, or tobacco. On\\n disability due to scoliosis.\\n Review of systems:\\n Flowsheet Data as of 11:06 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n HR: 103 (101 - 103) bpm\\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\\n RR: 25 (20 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 175 mL\\n Urine:\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -175 mL\\n Respiratory\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 36 cmH2O\\n SpO2: 99%\\n Ve: 4.9 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: :\\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\\n the right lung. Opacification of the right heithorax suggesting\\n pulmonary consolidation and a large pleural effusion with pulmonary\\n vascular congestion.\\n .\\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\\n function.\\n .\\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\\n Assessment and Plan\\n ASSESSMENT & PLAN:\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both restrictive\\n lung process due to severe scoliosis with additonal OSA. Now status\\n post tracheostomy placement with revision due to hypoxemia with trach\\n blockage. Patient has been using trach valve during the day and CMV at\\n night. Transfered for evaluation of posterior trach erosion.\\n - continue vent settings as per \\n - IP vs. ENT c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n .\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n .\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n .\\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\\n # PPX: PPI, heparin SQ, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: The patients wife\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-01 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 615316,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: DOE\\n REASON FOR MICU ADMISSION: Vent Dependent on trach\\n HPI:\\n The patinet is a 49 year old male with a history of sever scoliosis\\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\\n OSA who presented to an OSH on with complaints of progressive\\n dyspnea.\\n .\\n The patient has had worsening shortness of breath at rest over the last\\n year. OSH records also indicate the patient dozing off throughotu the\\n day, raising concerns of him falling alseep while driving. Of note, he\\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\\n to the ICU. He was started on BIPAP at night, with intermitent use\\n during the day due to his severe hypercapnic respiratory failure, but\\n did not have good tolerance of non-invasive ventilation. His\\n respiratory status continud to worsen, and the patient was found\\n somnolent and difficult to arouse at night. PCO2 was found during to\\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\\n Shiley trach was placed, but started on Passy-Muir valve during the day\\n time. On , the patient occluded the tracheostomy with severe\\n hypoxia, requiring CPR, but resolved with trach manipulation to\\n restablish the airway. A similar episode occured on , and a #7\\n Bavrona hyperflexible tracheostomy was placed. He has remained on\\n mechanic ventialation at night, AC, 400/14/5.\\n .\\n Per OSH records, there were concerns that the tracheostomy tube tip\\n appeard to be eroding at the posterior wall of the trachea due to the\\n patients baseline abnormal antatomy. The patient was transfered to\\n for evaluation of a potential customized tracheostomy vs other\\n intervention.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n ASA 81mg daily\\n Lasix 80mg daily\\n Rozerem PRN\\n .\\n Medications at Transfer-\\n Ambien 5mg HS PRN\\n Morphine 4-6mg q4h PRN pain\\n Percocet tab q4H PRN pain\\n Claritin 10mg daily\\n Magnesium oxide 400mg \\n DuoNeb PRN\\n Protonix 40mg daily\\n Lorazepam 45mg q4 PRN\\n Colace 100mg \\n Humibid 1200mg \\n Lasix 40mg daily\\n Arixtra 2.5mg daily\\n ASA 81mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n Severe scoliosis\\n Prior pneumothoraces\\n Restrictive Lung Disease\\n Chronic respiroatyr failure\\n Cholecystectomy\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: The patient is currently married, no alcohol, or tobacco. On\\n disability due to scoliosis.\\n Review of systems:\\n Flowsheet Data as of 11:06 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n HR: 103 (101 - 103) bpm\\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\\n RR: 25 (20 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 175 mL\\n Urine:\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -175 mL\\n Respiratory\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 36 cmH2O\\n SpO2: 99%\\n Ve: 4.9 L/min\\n Physical Examination\\n Trached, on trach mask, sitting in a chair\\n Severe scoliosis, slgith erosis on neck from trach\\n Abnormal resioatory movements\\n Distant heart sounds, tachycardic, no m/r/g\\n Abdominal ventral, soft, ntnd\\n 1+ LE b/l\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: :\\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\\n the right lung. Opacification of the right heithorax suggesting\\n pulmonary consolidation and a large pleural effusion with pulmonary\\n vascular congestion.\\n .\\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\\n function.\\n .\\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\\n Assessment and Plan\\n ASSESSMENT & PLAN:\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both restrictive\\n lung process due to severe scoliosis with additonal OSA. Now status\\n post tracheostomy placement with revision due to hypoxemia with trach\\n blockage. Patient has been using trach valve during the day and CMV at\\n night. Transfered for evaluation of posterior trach erosion.\\n - continue vent settings as per \\n - discourange ambient use\\n - IP c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n - encourage weight loss and ? pulm rehab on discharge.\\n .\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n .\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n .\\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\\n # PPX: PPI, heparin SQ, bowel regimen\\n # ACCESS: PIV\\n # CODE: FULL CODE\\n # CONTACT: The patients wife\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 615319,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: DOE\\n REASON FOR MICU ADMISSION: Vent Dependent on trach\\n HPI:\\n The patinet is a 49 year old male with a history of sever scoliosis\\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\\n OSA who presented to an OSH on with complaints of progressive\\n dyspnea.\\n .\\n The patient has had worsening shortness of breath at rest over the last\\n year. OSH records also indicate the patient dozing off throughotu the\\n day, raising concerns of him falling alseep while driving. Of note, he\\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\\n to the ICU. He was started on BIPAP at night, with intermitent use\\n during the day due to his severe hypercapnic respiratory failure, but\\n did not have good tolerance of non-invasive ventilation. His\\n respiratory status continud to worsen, and the patient was found\\n somnolent and difficult to arouse at night. PCO2 was found during to\\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\\n Shiley trach was placed, but started on Passy-Muir valve during the day\\n time. On , the patient occluded the tracheostomy with severe\\n hypoxia, requiring CPR, but resolved with trach manipulation to\\n restablish the airway. A similar episode occured on , and a #7\\n Bavrona hyperflexible tracheostomy was placed. He has remained on\\n mechanic ventialation at night, AC, 400/14/5.\\n .\\n Per OSH records, there were concerns that the tracheostomy tube tip\\n appeard to be eroding at the posterior wall of the trachea due to the\\n patients baseline abnormal antatomy. The patient was transfered to\\n for evaluation of a potential customized tracheostomy vs other\\n intervention.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n ASA 81mg daily\\n Lasix 80mg daily\\n Rozerem PRN\\n .\\n Medications at Transfer-\\n Ambien 5mg HS PRN\\n Morphine 4-6mg q4h PRN pain\\n Percocet tab q4H PRN pain\\n Claritin 10mg daily\\n Magnesium oxide 400mg \\n DuoNeb PRN\\n Protonix 40mg daily\\n Lorazepam 45mg q4 PRN\\n Colace 100mg \\n Humibid 1200mg \\n Lasix 40mg daily\\n Arixtra 2.5mg daily\\n ASA 81mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n Severe scoliosis\\n Prior pneumothoraces\\n Restrictive Lung Disease\\n Chronic respiroatyr failure\\n Cholecystectomy\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: The patient is currently married, no alcohol, or tobacco. On\\n disability due to scoliosis.\\n Review of systems:\\n Flowsheet Data as of 11:06 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n HR: 103 (101 - 103) bpm\\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\\n RR: 25 (20 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 175 mL\\n Urine:\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -175 mL\\n Respiratory\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 36 cmH2O\\n SpO2: 99%\\n Ve: 4.9 L/min\\n Physical Examination\\n Trached, on trach mask, sitting in a chair\\n Severe scoliosis, slgith erosis on neck from trach\\n Abnormal resioatory movements\\n Distant heart sounds, tachycardic, no m/r/g\\n Abdominal ventral, soft, ntnd\\n 1+ LE b/l\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: :\\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\\n the right lung. Opacification of the right heithorax suggesting\\n pulmonary consolidation and a large pleural effusion with pulmonary\\n vascular congestion.\\n .\\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\\n function.\\n .\\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\\n Assessment and Plan\\n ASSESSMENT & PLAN:\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both restrictive\\n lung process due to severe scoliosis with additonal OSA. Now status\\n post tracheostomy placement with revision due to hypoxemia with trach\\n blockage. Patient has been using trach valve during the day and CMV at\\n night. Transfered for evaluation of posterior trach erosion.\\n - continue vent settings as per \\n - discourange ambient use\\n - IP c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n - encourage weight loss and ? pulm rehab on discharge.\\n .\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n .\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n .\\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\\n # PPX: PPI, heparin SQ, bowel regimen\\n # ACCESS: PIV\\n # CODE: FULL CODE\\n # CONTACT: The patients wife\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n ------ Protected Section ------\\n MICU Overnight Attending Coverage\\n I saw and examined the patient with Dr. . The assessment and plan\\n was discussed in detail.\\n I would emphasize the following. 49 y.o. man with severe scoliosis,\\n OSA, and 30 pound weight gain over past approximately two years with\\n progressive dyspnea, hypercapneic and hypoxic respiratory failure\\n requiring urgent tracheostomy at the outside hospital. Trach changes\\n as noted above, using vent at night, off most of the day, minimal\\n suctioning required except when trach first placed. Now concern for\\n posterior tracheal erosion. No hemoptysis, minimizing suctioning.\\n Appears comfortable on trach collar sitting straight up in chair.\\n Severe scoliosis poor air movement on right, occ. crackle on left, no\\n wheeze\\n RRR, no murmurs\\n + bipedal edema Erythema on right forearm, no cord/fluctulence\\n Alert and oriented x 3 Ventral and umbilical hernia\\n Hypercapneic/hypoxic respiratory failure secondary to restrictive lung\\n disease in setting of severe scoliosis and OSA exacerbated in setting\\n of significant weight gain. require customized trach, IP to\\n evaluate in the morning. NPO after midnight. Minimize suctioning.\\n Plan as noted above.\\n Patient is critically ill given tenuous respiratory status\\n Full code\\n Time spent 40 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 00:32 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615568,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n pt alert and oriented x 3 and is able to speak around trach. pt with\\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\\n able to sit comfortably in a chair. When in bed pt must lie flat and\\n needs to be on full vent status. Lung sounds clear and rhonchorus with\\n wheezes throughout, responds very well to neb treatments. Hands and\\n feet puffy from recent weight gain and fluid. Here for IP consult\\n Action:\\n TEDS stockings applied. IP bronched pt this pm, advanced his \\n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\\n signif. Wt gain, also scholiosis and OSA\\n Response:\\n Stable overnight, no issues\\n Plan:\\n plan for pt to hopefully be transferred back to Hospital\\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\\n his Medicaid insurance\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615570,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n pt alert and oriented x 3 and is able to speak around trach. pt with\\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\\n able to sit comfortably in a chair. When in bed pt must lie flat and\\n needs to be on full vent status. Lung sounds clear and rhonchorus with\\n wheezes throughout, responds very well to neb treatments. Hands and\\n feet puffy from recent weight gain and fluid. Here for IP consult\\n Action:\\n TEDS stockings applied. IP bronched pt this pm, advanced his \\n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\\n signif. Wt gain, also scholiosis and OSA\\n Response:\\n Stable overnight, no issues\\n Plan:\\n plan for pt to hopefully be transferred back to Hospital\\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\\n his Medicaid insurance\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 615664,\n \"text\": \"Ht: unavailable to assess due to severe scolosis\\n Wt: 89 kg\\n Diet: Soft, thin liquids\\n Labs: noted\\n Abdomen: soft/distended, positive bowel sounds\\n Potential for nutrition risk. Patient being monitored. Current\\n intervention if any, listed below:\\n 49 year old male with a history of severe scoliosis, restrictive lung\\n disease, obstructive sleep apnea, who presented to an outside hosptial\\n with worsening dyspnea, who developed hypercapnic respiratory failure\\n w/ semi-emergent tacheostomy placement, now transfered for evaluation\\n of posterior wall erosion. Now status post tracheostomy placement with\\n revision due to hypoxemia with trach blockage.\\n Tolerating soft diet, good appetite. Eats soft diet at home. Thinks\\n his current weight is\\nhigh\\n, but stable recently. Per chart, patient\\n with 30 lb weight gain x 2 years.\\n Noted plan for transfer to .\\n Will follow to check po\\ns if remains in house, page if questions *\\n PM\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615648,\n \"text\": \"TITLE:\\n Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n -IP performed FOB, evaluation of trache\\n -Ventilated overnight\\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 Pantoprazole (Protonix) - 08:18 PM\\n Heparin Sodium (Prophylaxis) - 07:50 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.3\\n Tcurrent: 37.3\\nC (99.1\\n HR: 92 (71 - 115) bpm\\n BP: 128/80(87) {103/62(71) - 150/123(126)} mmHg\\n RR: 20 (17 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 720 mL\\n 100 mL\\n PO:\\n 720 mL\\n 100 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 3,820 mL\\n 1,075 mL\\n Urine:\\n 3,820 mL\\n 1,075 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,100 mL\\n -975 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 323 (323 - 325) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 16 cmH2O\\n SpO2: 97%\\n ABG: ///41/\\n Ve: 9.7 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Head, Ears, Nose, Throat: Normocephalic, trache 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: No(t) Symmetric), (Breath Sounds:\\n Diminished: ), severe kyphoscoliosis\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 12.1 g/dL\\n 308 K/uL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Assessment and Plan\\n 1. hypercarbic respiratory failure:\\n - restrictive lung disease in setting of severe scoliosis and OSA\\n - likely exacerbated with recent significant weight gain\\n - IP performed FOB/airway evaluation\\n -no posterior membrane erosion\\n -trache adjusted\\n - nocturnal ventilation ongoing\\n 2. Reflux:\\n - cont tx scoliosis\\n 3. pain:\\n - minimal, holding narcotic\\n 4. pHTN:\\n - cont lasix for diuresis\\n Remainder of plan per resident note.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition :Transfer to other facility\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615711,\n \"text\": \"Demographics\\n Day of intubation: 3\\n Day of mechanical ventilation: 3\\n Airway\\n Airway Placement Data\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed, Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n PMV: Yes\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments: Pt on and off Trach Collar .50 today using PMV occasionally\\n for short periods of time.\\n\"\n },\n {\n \"category\": \"Case Management \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Case Management Continued Stay Review\",\n \"row_id\": 615657,\n \"text\": \"Planned Discharge Date: \\n Insurance Update\\n Primary insurance / reviewer:\\n Hospital days authorized to:\\n Current Discharge Plan: Hospital, NH\\n Narrative / Plan (Multidisciplinary team):\\n Case discussed w/ team. Pt with new trach/vented on CPAP at times,\\n would need hospital level rehab not . Pt with NH medicaid only. No\\n LTACs in NH. No NH medicaid contracts at LTACs in MA. Plan is for pt to\\n return to Hospital. MICU team has made contact with \\n Physician to start arranging for transfer back.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615494,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n pt alert and oriented x 3 and is able to speak around trach. pt with\\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\\n able to sit comfortably in a chair. When in bed pt must lie flat and\\n needs to be on full vent status. Lung sounds clear and rhonchorus with\\n wheezes throughout, responds very well to neb treatments. Hands and\\n feet puffy from recent weight gain and fluid. Here for IP consult\\n Action:\\n TEDS stockings applied. IP bronched pt this pm, advanced his \\n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\\n signif. Wt gain, also scholiosis and OSA\\n Response:\\n Pt tolerated procedure well. No erosion noted of trache, some\\n irritation though. PPI started for this. sitting in chair and\\n maintained good o2 sat\\ns on 40% trach collar. To fully supported on\\n vent. Diet advanced back to his soft solids, tolerated well.\\n Plan:\\n plan for pt to hopefully be transferred back to Hospital\\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\\n his Medicaid insurance\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615453,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n 24 Hour Events:\\n - seen by interventional pulmonary\\n Allergies:\\n No Known Drug Allergies\\n Other medications:\\n asa 81\\n lasix 40 qday\\n heparin 5000 tid\\n albuterol\\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 09:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 36.7\\nC (98\\n HR: 99 (76 - 112) bpm\\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\\n RR: 21 (14 - 25) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 200 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 175 mL\\n 795 mL\\n Urine:\\n 175 mL\\n 795 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -175 mL\\n -595 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: Unstable Airway\\n PIP: 0 cmH2O\\n SpO2: 95%\\n ABG: ///45/\\n Ve: 4.2 L/min\\n Physical Examination\\n General Appearance: Well nourished, scoliosis\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: poor air mvmt on right\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Musculoskeletal: Muscle wasting\\n Skin: Warm\\n Neurologic: Attentive\\n Labs / Radiology\\n 11.9 g/dL\\n 277 K/uL\\n 119 mg/dL\\n 0.4 mg/dL\\n 45 mEq/L\\n 3.7 mEq/L\\n 7 mg/dL\\n 91 mEq/L\\n 141 mEq/L\\n 38.0 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n WBC\\n 5.4\\n Hct\\n 38.0\\n Plt\\n 277\\n Cr\\n 0.4\\n Glucose\\n 119\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\\n PO4:4.2 mg/dL\\n Assessment and Plan\\n 1. hypercarbic respiratory failure:\\n - restrictive lung disease in setting of severe scoliosis and OSA\\n - likely exacerbated with recent significant weight gain\\n - IP service consulted, to do FOB to assess trache and exclude\\n posterior membrane erosion\\n - npo for proc\\n 2. Reflux:\\n - cont tx scoliosis\\n 3. pain:\\n - minimal, holding narcotic\\n 4. pHTN:\\n - cont lasix for diuresis\\n Remainder of plan per resident note.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 06:10 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: Mouth care\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status:\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615454,\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 Tube Type\\n Tracheostomy tube:\\n Type: Cuffed, Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n PMV: Yes\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems: Positional leak around cuff,\\n adjustable trach advanced to 12 cm just below flange via bronchoscopic\\n evaluation.\\n Comments: deflated while off ventilator\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments: expriratory wheezes T/O clear after albuterol adm via\\n nebulizer.\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Expectorated / None\\n Ventilation Assessment\\n Level of breathing assistance: Off ventilator during the day\\n Visual assessment of breathing pattern: occasional dyspnea with\\n increased congestion and expiratory wheezes, relieved with coughing and\\n nebulized albuterol.\\n Plan\\n Next 24-48 hours: Increase ventilatory support at night; Comments:\\n placed on ventilator at night for management of CO2\\n Reason for continuing current ventilatory support:\\n Bedside Procedures:\\n Bronchoscopy (12:00)\\n Comments:\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 230766,\n \"text\": \"Sinus rhythm. Consider right atrial abnormality. Right axis deviation.\\nProminent lateral lead Q waves. Findings raise consideration of possible\\nright ventricular overload. Possible prior lateral myocardial infarction\\nof left posterior fascicular block. Clinical correlation is suggested.\\nNo previous tracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1116684,\n \"text\": \" 9:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old man with trach c/o dyspnea.\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 9:39 A.M. \\n\\n HISTORY: Tracheostomy. Complains of dyspnea.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Lung volumes have decreased and opacification particularly in the right lung\\n has increased since . Given the marked anatomic distortion of the\\n chest precise diagnosis is difficult, but since there is vascular engorgement\\n in the left lung I suspect cardiac decompensation is playing a role. There is\\n also the suggestion of retained secretions in the bronchial tree, particularly\\n the right. Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No pneumothorax is\\n present.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-12-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1116480,\n \"text\": \" 11:14 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pls evaluate lung fields\\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old man with severe scoliosis s/p trach\\n REASON FOR THIS EXAMINATION:\\n pls evaluate lung fields\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Evaluate tracheostomy.\\n\\n The interpretation of this radiograph is very limited due to the severe\\n scoliosis and deformity of the thoracic cage. Tracheostomy tube tip is 5.5 cm\\n above the carina. Cardiomediastinal contours cannot be evaluated. There is\\n no evident pneumothorax. If any, there is a small right pleural effusion.\\n The main central pulmonary arteries appear to be enlarged. There are no prior\\n studies available for comparison. The asymmetric increased density in the\\n right hemithorax could be due to pleural effusion or lung opacities in the\\n right lower lobe, I suspect that also is due to the deformity of the thoracic\\n cage. If prior studies were available , comparison could be performed to\\n assess new abnormality.\\n\\n\"\n }\n]"}}},{"rowIdx":193,"cells":{"subject_id":{"kind":"number","value":369,"string":"369"},"hadm_id":{"kind":"number","value":145787,"string":"145,787"},"target_text":{"kind":"string","value":"Pt under went an unremarkable hospital course. Pt was tolerating a regular diet with good pain control on PO pain medications. Pt was ambulating on her own and working with physical therapy. On , pt's CXR showed R pleural effusion. Pt's O2 saturation were 95% on RA. On discharge, the pt was 6 kg over her pre operative weight and was DC'd on 1 week on lasix 40mg for continued diuresis. CXR pending. An addendum will be added regarding results."},"extractive_notes_summ":{"kind":"string","value":"BS DIMINISHED BIBASILAR COURSE UPPER CLEARS WITH SX. Since the previoustracing of atrial ectopy, right bundle-branch block and prolongedQTc interval are seen. REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade. RX X 1 WITH REGLAN. The approximately 1 cm nodular opacity in the left lower lung zone periphery is again noted, which may represent loculated fluid vs. an unusual atelectatic pattern. is still in OR, please perfo Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? EXTUBATED AT MIDNOC. The patient is status post AVR and median sternotomy. CALCIUM AND MAG REPLACED. IMPRESSION: Residual bilateral pleural effusions. Residual left lower lobe atelectasis. CSRU UPDATES/P AVR TISSUE VALVE. Atrial premature beats. Evaluate for pleural effusion. There are residual bilateral pleural effusions, with residual left lower lobe atelectasis. 1:46 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade. MIN CT DRAINAGE. SBP LABILE 88- 130 PRESENTLY NIPRIDE @ .7 MCQ TO KEEP SBP 90-120.CI > 2.5. 11:31 AM CHEST (PA & LAT) Clip # Reason: re-eval right effusion Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? NEO TITRATED OFF.NEURO: LETHARGIC. NEO ON TRANSIENTLY FOR LOW BP. Pt s/p AVR. Sinus rhythm. The right jugular Swan-Ganz catheter terminates in the right main PA. NIPRIDE OFF TRANSIENT NEO HOWEVER PRESENTLY OFF BOTH WITH SBP 100'S. There is bilateral lower lobe atelectasis. TMAX 37.7. ADDITONAL K AND CALCIUM GIVEN. DILAUDID FOR PAIN. CLINICAL INDICATION: Status post aortic valve replacement. FINDINGS: PA and lateral views of the chest show interval removal of the endotracheal tube and Swan-Ganz catheter. Mildly increased moderate right pleural effusion, with stable left pleural effusion. Unusual nodular opacity over left lower lung zone peripherally, possibly representing possibly loculated fluid vs. unusual pattern of atelectasis. C/O STIFFNESS LEFT ARM. Small left and moderate right pleural effusions are noted with slight worsening of the right effusion. Pt. Pt. VENT SETTINGS PER FLOW WITH GOOD ABG. Midline sternotomy wires and a prosthetic aortic valve are again seen. CI REMAINS > 2. ID: VANCO @ . Midline sternotomy wires and prosthestic aortic valve are seen. Stable small left pleural effusion and improving left lower lobe atelectasis. GIVEN 1L LR THROUGHOUT SHIFT. is still in OR, please perform when pt is in CSRU. NEURO: REVERSED AND AWOKE CALM, PERL, MAE, GRASPS STRONG AND EQUAL. IMPRESSION: 1. IMPRESSION: 1. AMIODARONE BOLUS AND GTT @ 1 MG DUE TO RUNS OF AF. DC CORDIS/SWAN. 10:49 AM CHEST (PRE-OP PA & LAT) Clip # Reason: r/o effusion Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? Low limb lead voltage is non-specific.Right bundle-branch block. CURRENT O2 SETTINGS .7 O2 FACE TENT/ 4L NC. NEO CURRENTLY OFF. HCT 34. Cardiac and mediastinal contours are stable in the postoperative. COMPARISON: . COMPARISON: . S/P AVRO: CARDIAC: CONTINUES TO REQUIRE LR, SR 80'S PRESENTLY. ?TX TO FLOOR. See resp flowsheet for vent data. LS CLEAR, DECREASED IN THE BASES. Mediastinal drains are in place. 3:01 PM CHEST (PA & LAT) Clip # Reason: s/p chest tube removal-r/o PTX Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? FICK CO 3.86, THERMODILUTION 3.0. The patient is status post median sternotomy and aortic valve replacement procedure. An old compression fracture of a mid thoracic vertebra is again noted. FINDINGS: PA & lateral views of the chest show bilateral pleural effusions; the right appears somewhat greater, while the left is stable. Clinical correlation is suggested. Attention to this region on followup CXR is recommended. There are bibasilar atelectatic changes which have improved at the left base and are unchanged at the right lung base. An old compression fracture of a mid- thoracic vertebra is seen. HCT PENDING FEBRILE RECIEVED 650 MG TYLENOL PR. Finally, there is an apparent small nodular opacity in the periphery of the left lower lung zone, possibly due to an overlying structure external to the patient based on the lateral view findings. GI: OGT + PLACEMENT, CARAFATE X2, ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS. Slight increase in right pleural effusion, moderate in size. REQUIRING LR 2 L TO KEEP HR <100, CT MINIMAL DRAINAGE SINCE INITIAL 200ML, DSGS D+I. There is mild congestive heart failure with cardiomegaly and small bilateral pleural effusions. AS PER ORDERS. MAE. The tip of the endotracheal tube is identified 3 cm above the carina. 3. 2. 2. SX FOR A SMALL AMOUNT OF TAN SPUTUM. Prolonged QTc interval - cannot excludemetabolic/drug effect. HYPOACTIVE BS.GU: URINE OUTPUT HAS SLOWED OVN TO 30-40CC/HR.PLAN: OOB TO CHAIR. Respiratory TherapyPt remains orally intubated and on full vent support. SR 80-90'S. DENIES PAIN OR DISCOMFORT WHEN MOANING.CV: NSR 67. COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with the previous study of . Questionable nodular opacity in left lower lobe, possibly external to the patient. A nasogastric tube courses towards the stomach."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2142-10-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":839984,"text":" 1:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perfo\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with AS/AI s/p AVR.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perform when pt is in\n CSRU.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 75-year-old woman with status post AVR.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study of .\n\n The patient is status post AVR and median sternotomy. There is mild\n congestive heart failure with cardiomegaly and small bilateral pleural\n effusions. The right jugular Swan-Ganz catheter terminates in the right main\n PA. The tip of the endotracheal tube is identified 3 cm above the carina. A\n nasogastric tube courses towards the stomach. Mediastinal drains are in\n place. No pneumothorax is identified.\n\n\n"},{"category":"Radiology","chartdate":"2142-10-15 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":840646,"text":" 10:49 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n Compared to earlier study of , and .\n\n CLINICAL INDICATION: Status post aortic valve replacement. Evaluate for\n pleural effusion.\n\n The patient is status post median sternotomy and aortic valve replacement\n procedure. Cardiac and mediastinal contours are stable in the postoperative.\n There is no evidence of cardiac failure. There are bibasilar atelectatic\n changes which have improved at the left base and are unchanged at the right\n lung base. Small left and moderate right pleural effusions are noted with\n slight worsening of the right effusion. There is no evidence of pneumothorax.\n Finally, there is an apparent small nodular opacity in the periphery of the\n left lower lung zone, possibly due to an overlying structure external to the\n patient based on the lateral view findings.\n\n IMPRESSION:\n 1. Stable small left pleural effusion and improving left lower lobe\n atelectasis.\n 2. Slight increase in right pleural effusion, moderate in size.\n 3. Questionable nodular opacity in left lower lobe, possibly external to the\n patient. Repeat radiograph following removal of external EKG lead devices\n would be helpful to fully exclude a lung nodule.\n\n"},{"category":"Radiology","chartdate":"2142-10-16 00:00:00.000","description":"CHEST (PA & LAT)","row_id":840798,"text":" 11:31 AM\n CHEST (PA & LAT) Clip # \n Reason: re-eval right effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n re-eval right effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative for aortic valve replacement.\n\n COMPARISON: .\n\n FINDINGS: PA & lateral views of the chest show bilateral pleural effusions;\n the right appears somewhat greater, while the left is stable. There is\n bilateral lower lobe atelectasis. The approximately 1 cm nodular opacity in\n the left lower lung zone periphery is again noted, which may represent\n loculated fluid vs. an unusual atelectatic pattern. It is also seen on the\n lateral radiograph and does not appear to be due to a structure external to\n the patient, as was considered on the prior report. Midline sternotomy wires\n and a prosthetic aortic valve are again seen. An old compression fracture of a\n mid thoracic vertebra is again noted.\n\n IMPRESSION: 1. Mildly increased moderate right pleural effusion, with stable\n left pleural effusion.\n\n 2. Unusual nodular opacity over left lower lung zone peripherally, possibly\n representing possibly loculated fluid vs. unusual pattern of atelectasis.\n Attention to this region on followup CXR is recommended.\n\n"},{"category":"Radiology","chartdate":"2142-10-11 00:00:00.000","description":"CHEST (PA & LAT)","row_id":840223,"text":" 3:01 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p chest tube removal-r/o PTX\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic valve replacement.\n\n COMPARISON: .\n\n FINDINGS: PA and lateral views of the chest show interval removal of the\n endotracheal tube and Swan-Ganz catheter. There are residual bilateral\n pleural effusions, with residual left lower lobe atelectasis. There is no\n evidence of congestive heart failure. An old compression fracture of a mid-\n thoracic vertebra is seen. Midline sternotomy wires and prosthestic aortic\n valve are seen.\n\n IMPRESSION: Residual bilateral pleural effusions. Residual left lower lobe\n atelectasis.\n\n\n"},{"category":"ECG","chartdate":"2142-10-09 00:00:00.000","description":"Report","row_id":134536,"text":"Sinus rhythm. Atrial premature beats. Low limb lead voltage is non-specific.\nRight bundle-branch block. Prolonged QTc interval - cannot exclude\nmetabolic/drug effect. Clinical correlation is suggested. Since the previous\ntracing of atrial ectopy, right bundle-branch block and prolonged\nQTc interval are seen.\n\n"},{"category":"Nursing/other","chartdate":"2142-10-09 00:00:00.000","description":"Report","row_id":1265625,"text":"S/P AVR\nO: CARDIAC: CONTINUES TO REQUIRE LR, SR 80'S PRESENTLY. AMIODARONE BOLUS AND GTT @ 1 MG DUE TO RUNS OF AF. NIPRIDE OFF TRANSIENT NEO HOWEVER PRESENTLY OFF BOTH WITH SBP 100'S. CI REMAINS > 2. HCT PENDING FEBRILE RECIEVED 650 MG TYLENOL PR. PAD'S LO TWENTIES WITH CVP 15. MIN CT DRAINAGE. ADDITONAL K AND CALCIUM GIVEN.\n RESP: FAILED CPAP WEAN TO ATTEMPT AGAIN, UNABLE TO LIFT HEAD OFF PILLOW. VENT SETTINGS PER FLOW WITH GOOD ABG. O2 SAT >97%. BS DIMINISHED BIBASILAR COURSE UPPER CLEARS WITH SX. SX FOR A SMALL AMOUNT OF TAN SPUTUM. NOT OVERBREATHING THE VENT. NO CHEST TUBE LEAK.\n NEURO: REVERSED AND AWOKE CALM, PERL, MAE, GRASPS STRONG AND EQUAL.\n GI: OGT + PLACEMENT, CARAFATE X2, ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS.\n GU: AUTODIURESED POST OP,\n ENDO: INSULIN GTT PRESENTLY AT 2 UNITS/HR.\n ID: VANCO @ .\n PAIN: RECIEVED .5 MG DILAUDID X 2 WITH GOOD EFFECT, DENIES PAIN AT PRESENT.\n SOCIAL: HUSBAND AND CHILDREN INTO VISIT AND UPDATED\nA: LARGE VOLUME REQUIREMENTS, AMIODARONE DUE TO INCREASED ATRIAL ACTIVITY,FEBRILE, FAILED INITIAL WEAN, LARGE DIURESIS.\nP: MONITOR COMFORT, HR AND RYTHYM-CONTINUE AMIODARONE, KEEP SBP BETWEEN 90-120, CI, CT DRAINAGE, RESP STATUS-WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS PENDING. AS PER ORDERS.\n"},{"category":"Nursing/other","chartdate":"2142-10-10 00:00:00.000","description":"Report","row_id":1265626,"text":"CSRU UPDATE\nS/P AVR TISSUE VALVE. EXTUBATED AT MIDNOC. NEO TITRATED OFF.\nNEURO: LETHARGIC. MAE. C/O STIFFNESS LEFT ARM. DILAUDID FOR PAIN. MOANING THROUGHOUT NIGHT. STATES IT \"MAKES ME FEEL BETTER TO MOAN.\" DENIES PAIN OR DISCOMFORT WHEN MOANING.\nCV: NSR 67. PLACED ON ADEMAND AT 80 TO INCREASE BP. TMAX 37.7. NEO ON TRANSIENTLY FOR LOW BP. GIVEN 1L LR THROUGHOUT SHIFT. NEO CURRENTLY OFF. FICK CO 3.86, THERMODILUTION 3.0. 3+ PEDAL PULSES.\nPULM: NEEDING A LOT OF ENCOURAGEMENT FOR COUGHING AND DEEP BREATHING. CURRENT O2 SETTINGS .7 O2 FACE TENT/ 4L NC. LS CLEAR, DECREASED IN THE BASES. ?START LASIX THIS AM.\nGI: CONTINUES ON INSULIN GTT AT 1U/HR. RX X 1 WITH REGLAN. HYPOACTIVE BS.\nGU: URINE OUTPUT HAS SLOWED OVN TO 30-40CC/HR.\nPLAN: OOB TO CHAIR. DC CORDIS/SWAN. ?TX TO FLOOR.\n"},{"category":"Nursing/other","chartdate":"2142-10-09 00:00:00.000","description":"Report","row_id":1265623,"text":"Respiratory Therapy\nPt remains orally intubated and on full vent support. Pt s/p AVR. See resp flowsheet for vent data. Will follow.\n"},{"category":"Nursing/other","chartdate":"2142-10-09 00:00:00.000","description":"Report","row_id":1265624,"text":"S/P AVR\nO: ARRIVED ON NTG AND NIPRIDE TO KEEP SBP <125 PER DR. , 200 ML CT. 80 MCQ OF PROPOFOL. SR 80-90'S.\n CARDIAC: SR WITH PAC'S NOTED, 6 BEAT RUN VT WITH K 4.5 HAD RECIEVED 40 MEQ KCL X 1. SBP LABILE 88- 130 PRESENTLY NIPRIDE @ .7 MCQ TO KEEP SBP 90-120.CI > 2.5. REQUIRING LR 2 L TO KEEP HR <100, CT MINIMAL DRAINAGE SINCE INITIAL 200ML, DSGS D+I. HCT 34. CALCIUM AND MAG REPLACED.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 839984,\n \"text\": \" 1:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perfo\\n Admitting Diagnosis: AORTIC STENOSIS\\\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with AS/AI s/p AVR.\\n REASON FOR THIS EXAMINATION:\\n r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perform when pt is in\\n CSRU.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 75-year-old woman with status post AVR.\\n\\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\\n the previous study of .\\n\\n The patient is status post AVR and median sternotomy. There is mild\\n congestive heart failure with cardiomegaly and small bilateral pleural\\n effusions. The right jugular Swan-Ganz catheter terminates in the right main\\n PA. The tip of the endotracheal tube is identified 3 cm above the carina. A\\n nasogastric tube courses towards the stomach. Mediastinal drains are in\\n place. No pneumothorax is identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-10-15 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 840646,\n \"text\": \" 10:49 AM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: r/o effusion\\n Admitting Diagnosis: AORTIC STENOSIS\\\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with severe aortic stenosis, pre op for AVR\\n\\n REASON FOR THIS EXAMINATION:\\n r/o effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n Compared to earlier study of , and .\\n\\n CLINICAL INDICATION: Status post aortic valve replacement. Evaluate for\\n pleural effusion.\\n\\n The patient is status post median sternotomy and aortic valve replacement\\n procedure. Cardiac and mediastinal contours are stable in the postoperative.\\n There is no evidence of cardiac failure. There are bibasilar atelectatic\\n changes which have improved at the left base and are unchanged at the right\\n lung base. Small left and moderate right pleural effusions are noted with\\n slight worsening of the right effusion. There is no evidence of pneumothorax.\\n Finally, there is an apparent small nodular opacity in the periphery of the\\n left lower lung zone, possibly due to an overlying structure external to the\\n patient based on the lateral view findings.\\n\\n IMPRESSION:\\n 1. Stable small left pleural effusion and improving left lower lobe\\n atelectasis.\\n 2. Slight increase in right pleural effusion, moderate in size.\\n 3. Questionable nodular opacity in left lower lobe, possibly external to the\\n patient. Repeat radiograph following removal of external EKG lead devices\\n would be helpful to fully exclude a lung nodule.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-10-16 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 840798,\n \"text\": \" 11:31 AM\\n CHEST (PA & LAT) Clip # \\n Reason: re-eval right effusion\\n Admitting Diagnosis: AORTIC STENOSIS\\\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with severe aortic stenosis, pre op for AVR\\n\\n REASON FOR THIS EXAMINATION:\\n re-eval right effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Preoperative for aortic valve replacement.\\n\\n COMPARISON: .\\n\\n FINDINGS: PA & lateral views of the chest show bilateral pleural effusions;\\n the right appears somewhat greater, while the left is stable. There is\\n bilateral lower lobe atelectasis. The approximately 1 cm nodular opacity in\\n the left lower lung zone periphery is again noted, which may represent\\n loculated fluid vs. an unusual atelectatic pattern. It is also seen on the\\n lateral radiograph and does not appear to be due to a structure external to\\n the patient, as was considered on the prior report. Midline sternotomy wires\\n and a prosthetic aortic valve are again seen. An old compression fracture of a\\n mid thoracic vertebra is again noted.\\n\\n IMPRESSION: 1. Mildly increased moderate right pleural effusion, with stable\\n left pleural effusion.\\n\\n 2. Unusual nodular opacity over left lower lung zone peripherally, possibly\\n representing possibly loculated fluid vs. unusual pattern of atelectasis.\\n Attention to this region on followup CXR is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-10-11 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 840223,\n \"text\": \" 3:01 PM\\n CHEST (PA & LAT) Clip # \\n Reason: s/p chest tube removal-r/o PTX\\n Admitting Diagnosis: AORTIC STENOSIS\\\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with severe aortic stenosis, pre op for AVR\\n\\n REASON FOR THIS EXAMINATION:\\n s/p chest tube removal-r/o PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Aortic valve replacement.\\n\\n COMPARISON: .\\n\\n FINDINGS: PA and lateral views of the chest show interval removal of the\\n endotracheal tube and Swan-Ganz catheter. There are residual bilateral\\n pleural effusions, with residual left lower lobe atelectasis. There is no\\n evidence of congestive heart failure. An old compression fracture of a mid-\\n thoracic vertebra is seen. Midline sternotomy wires and prosthestic aortic\\n valve are seen.\\n\\n IMPRESSION: Residual bilateral pleural effusions. Residual left lower lobe\\n atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134536,\n \"text\": \"Sinus rhythm. Atrial premature beats. Low limb lead voltage is non-specific.\\nRight bundle-branch block. Prolonged QTc interval - cannot exclude\\nmetabolic/drug effect. Clinical correlation is suggested. Since the previous\\ntracing of atrial ectopy, right bundle-branch block and prolonged\\nQTc interval are seen.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265625,\n \"text\": \"S/P AVR\\nO: CARDIAC: CONTINUES TO REQUIRE LR, SR 80'S PRESENTLY. AMIODARONE BOLUS AND GTT @ 1 MG DUE TO RUNS OF AF. NIPRIDE OFF TRANSIENT NEO HOWEVER PRESENTLY OFF BOTH WITH SBP 100'S. CI REMAINS > 2. HCT PENDING FEBRILE RECIEVED 650 MG TYLENOL PR. PAD'S LO TWENTIES WITH CVP 15. MIN CT DRAINAGE. ADDITONAL K AND CALCIUM GIVEN.\\n RESP: FAILED CPAP WEAN TO ATTEMPT AGAIN, UNABLE TO LIFT HEAD OFF PILLOW. VENT SETTINGS PER FLOW WITH GOOD ABG. O2 SAT >97%. BS DIMINISHED BIBASILAR COURSE UPPER CLEARS WITH SX. SX FOR A SMALL AMOUNT OF TAN SPUTUM. NOT OVERBREATHING THE VENT. NO CHEST TUBE LEAK.\\n NEURO: REVERSED AND AWOKE CALM, PERL, MAE, GRASPS STRONG AND EQUAL.\\n GI: OGT + PLACEMENT, CARAFATE X2, ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS.\\n GU: AUTODIURESED POST OP,\\n ENDO: INSULIN GTT PRESENTLY AT 2 UNITS/HR.\\n ID: VANCO @ .\\n PAIN: RECIEVED .5 MG DILAUDID X 2 WITH GOOD EFFECT, DENIES PAIN AT PRESENT.\\n SOCIAL: HUSBAND AND CHILDREN INTO VISIT AND UPDATED\\nA: LARGE VOLUME REQUIREMENTS, AMIODARONE DUE TO INCREASED ATRIAL ACTIVITY,FEBRILE, FAILED INITIAL WEAN, LARGE DIURESIS.\\nP: MONITOR COMFORT, HR AND RYTHYM-CONTINUE AMIODARONE, KEEP SBP BETWEEN 90-120, CI, CT DRAINAGE, RESP STATUS-WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS PENDING. AS PER ORDERS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265626,\n \"text\": \"CSRU UPDATE\\nS/P AVR TISSUE VALVE. EXTUBATED AT MIDNOC. NEO TITRATED OFF.\\nNEURO: LETHARGIC. MAE. C/O STIFFNESS LEFT ARM. DILAUDID FOR PAIN. MOANING THROUGHOUT NIGHT. STATES IT \\\"MAKES ME FEEL BETTER TO MOAN.\\\" DENIES PAIN OR DISCOMFORT WHEN MOANING.\\nCV: NSR 67. PLACED ON ADEMAND AT 80 TO INCREASE BP. TMAX 37.7. NEO ON TRANSIENTLY FOR LOW BP. GIVEN 1L LR THROUGHOUT SHIFT. NEO CURRENTLY OFF. FICK CO 3.86, THERMODILUTION 3.0. 3+ PEDAL PULSES.\\nPULM: NEEDING A LOT OF ENCOURAGEMENT FOR COUGHING AND DEEP BREATHING. CURRENT O2 SETTINGS .7 O2 FACE TENT/ 4L NC. LS CLEAR, DECREASED IN THE BASES. ?START LASIX THIS AM.\\nGI: CONTINUES ON INSULIN GTT AT 1U/HR. RX X 1 WITH REGLAN. HYPOACTIVE BS.\\nGU: URINE OUTPUT HAS SLOWED OVN TO 30-40CC/HR.\\nPLAN: OOB TO CHAIR. DC CORDIS/SWAN. ?TX TO FLOOR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265623,\n \"text\": \"Respiratory Therapy\\nPt remains orally intubated and on full vent support. Pt s/p AVR. See resp flowsheet for vent data. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265624,\n \"text\": \"S/P AVR\\nO: ARRIVED ON NTG AND NIPRIDE TO KEEP SBP <125 PER DR. , 200 ML CT. 80 MCQ OF PROPOFOL. SR 80-90'S.\\n CARDIAC: SR WITH PAC'S NOTED, 6 BEAT RUN VT WITH K 4.5 HAD RECIEVED 40 MEQ KCL X 1. SBP LABILE 88- 130 PRESENTLY NIPRIDE @ .7 MCQ TO KEEP SBP 90-120.CI > 2.5. REQUIRING LR 2 L TO KEEP HR <100, CT MINIMAL DRAINAGE SINCE INITIAL 200ML, DSGS D+I. HCT 34. CALCIUM AND MAG REPLACED.\\n\"\n }\n]"}}},{"rowIdx":194,"cells":{"subject_id":{"kind":"number","value":61825,"string":"61,825"},"hadm_id":{"kind":"number","value":163976,"string":"163,976"},"target_text":{"kind":"string","value":"The patinet is a 66 year old man with severe COPD, AAA and HTN who presented with right-sided chest pain and worsening shortness of breath, and was found the have a pulmonary embolus and pneumonia."},"extractive_notes_summ":{"kind":"string","value":"Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Check sputum cx. - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . Echo and LENIs today PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. - ipratropium nebs and albuterol nebs . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . Continue albuterol and atrovent nebs. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. Treat with anticoagulation. Treat with anticoagulation. Treat with anticoagulation. Will eval area of hyperdensity seen on CTA with non-con abd CT. Will eval area of hyperdensity seen on CTA with non-con abd CT. Will eval area of hyperdensity seen on CTA with non-con abd CT. PE, PERINEPHRIC ABSCESS OTHER PATH Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) enhancement. Echo and LENIs today PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. Check sputum cx. Cholelithiasis. Cholelithiasis. The aortic knob is calcified. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. Hepatic vasculature and portal vein are patent. Continue heparin drip PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. Correlation with endoscopy. Prior inferior myocardial infarction. Follow up CT as outpt to eval. The right posterior tibial and peroneal veins are patent. Coronal and sagittal reformats were performed. FINAL REPORT CT TORSO COMPARISON: and . Treat with anticoagulation. Treat with anticoagulation. Switch back to spiriva and prn albuterol inhaler when back to baseline. Rec: MRCP. Rec: MRCP. Rec: MRCP. Rec: MRCP. Continue albuterol and atrovent nebs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. There is trace ascites. Severe emphysema is noted. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Clinical concern for lower extremity DVT. IV contrast was administered. Reasonable to treat with Vanc/Cefepim/Levoflox given history of GNRs in sputum. 5:06 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? IMPRESSION:Hyperdensity noted on recent CTA torso is unchanged and likely corresponds to calcification. MRCP or ERCP should be performed. Sinus tachycardia. Would follow up CT. Strep PNA in sputum. Trace ascites. Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in sputum. Post-surgical changes from left lateral fusion hardware are present. Monitor Hct. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. Sinus tachycardia with ventricular premature beats. COMPARISON: CT abdomen and ; ct chest . Prelim showing left DVT. Severe emphysema is demonstrated as well as nonspecific scarring at the right apex. There is mild pancreatic ductal prominence. Has LLL consolidation on CXR. There mild antral wall thickening and mucosal (Over) 5:06 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ?"},"n_notes":{"kind":"number","value":34,"string":"34"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Progress Note","row_id":619882,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\n heparin to 800units/hr\n Plan:\n Next PTT at 1200. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":619890,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\n use heparin gtt\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\n need repeat CT in 3 months to re-eval.\n -- LFT/lipase/amylase unremarkable\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 325 mL\n PO:\n TF:\n IVF:\n 361 mL\n 325 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n 225 K/uL\n 10.5 g/dL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\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:Transfer to floor\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619896,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\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 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619897,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\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 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\n sputum cx.\n COPD: seems stable, not need for steroids.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619900,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen:\n HEENT:\n Neck:\n CV:\n Pulm:\n Abd:\n Extrem:\n Neuro:\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Cipro given history of GNRs in sputum. Check sputum\n cx\n COPD: seems stable, not need for steroids.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":619901,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\n use heparin gtt\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\n need repeat CT in 3 months to re-eval.\n -- LFT/lipase/amylase unremarkable\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 325 mL\n PO:\n TF:\n IVF:\n 361 mL\n 325 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, mild expiratory\n wheeze\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n 225 K/uL\n 10.5 g/dL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. The patient was\n started on a heparin gtt in the ED. ECG showed no evidence of RV\n strain, troponin wnl. Overnight pt did well on 3L NC and remains\n hemodynamically stable. Troponins have been flat. Pt with no recent\n surgerys, immobilization, known malignancy, family history of\n hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Start Coumadin 5mg; monitor INR\n - follow up TTE to evaluate for right heart strain\n - LENI pending\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - Continue Vanco/Cefepime and d/c cipro given negative urine legionella\n - sputum cx\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . There was mention of a hyperdensity seen on CTA\n and a non-contrast CT abdomen showed AAA stable Spoke with vascular\n surgery who felt there was no evidence of a leak.\n -Monitor Hct closely given heparin/coumadin\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.. LFTs wnl\n - f/u final CTA read\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\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:Transfer to floor\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619902,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Albuterol nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen:\n HEENT:\n Neck:\n CV:\n Pulm:\n Abd:\n Extrem:\n Neuro:\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\n resolution since could also represent malignancy.\n Continue heparin drip. Start coumadin today. Echo and LENI\ns today\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignancy. Follow up CT as outpt to eval.\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\n sputum. Check sputum cx\n COPD: seems stable, not need for steroids. Continue albuterol and\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\n back to baseline.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon. Guaiac stools.\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\n awaiting final read. LFT\ns and /lipase normal. need MRCP as\n outpt.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n ICU Care\n Nutrition: regular diet\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: heparin gtt\n Code status: Full code\n Disposition : call out to floor\n Total time spent: 30 min\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619977,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Patient started on Coumadin today. Given first dose of 5mg.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Monitor Hct.\n AAA increased in size from , but per MICU team is currently\n stable. Hct 34 at 12pm, stable from 33 with am labs. Patient needs\n bedside echo tomorrow.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables: Clothes, shoes\n Other valuables:\n Clothes:\n Wallet / Money: Patient has wallet, but he sent his credit cards and\n cash to security. Wallet contains only ID card and other cards that\n are not credit cards.\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: CC701\n Date & time of Transfer: 1800\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619952,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs. Patient needs bedside echo.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619945,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\n heparin to 800units/hr\n Plan:\n Next PTT at 1200. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619951,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Progress Note","row_id":619828,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT at 1000\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619817,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs q6 and albuterol\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619818,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs q6 and albuterol\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619819,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs and albuterol nebs\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619821,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619822,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":619823,"text":"Chief Complaint: Right sided pleuritic CP/ PE and PNA\n I saw and examined the patient, and was physically present with the 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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n admitted to MICU for COPD exacerbation and PNA. Strep PNA in\n sputum.\n Meds:\n allopurinol\n atorvastatin\n albuterol/tiatropium\n vitamin D\n percocet\n cough suppressant\n noncontributory for PE\n Occupation:\n Drugs:\n Tobacco: long smoking history. - ppD currently\n Alcohol: h/o ETOH abuse - drinks few per night. No recent withdrawl\n Other: lives by self, on disability at home in apartment.\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: Chest pain\n Respiratory: Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Allergy / Immunology: No(t) Immunocompromised\n Pain: Moderate\n Flowsheet Data as of 10:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 125 mL\n PO:\n TF:\n IVF:\n 125 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 221\n 39\n 141\n 0.8\n 10\n 26\n 93\n 3.6\n 133\n 22.0\n [image002.jpg]\n Other labs: Lactic Acid:2.9\n Fluid analysis / Other labs: negative U/A\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\n sputum cx.\n COPD: seems stable, not need for steroids.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2131-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":619825,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Progress Note","row_id":619829,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT at 1000. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco. ABD CT done\n Response:\n Plan:\n Cont ABX, follow CT result.\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619982,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Albuterol nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen: alert, oriented, NAD\n HEENT: PERRL\n Neck:supple\n CV: S1S2 tachy\n Pulm: clear ant/lat\n Abd: soft, nt\n Extrem: no edema\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\n resolution since could also represent malignancy.\n Continue heparin drip. Start coumadin today. Echo and LENI\ns today\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignancy. Follow up CT as outpt to eval.\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\n sputum. Check sputum cx\n COPD: seems stable, not need for steroids. Continue albuterol and\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\n back to baseline.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon. Guaiac stools.\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\n awaiting final read. LFT\ns and /lipase normal. need MRCP as\n outpt.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n ICU Care\n Nutrition: regular diet\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: heparin gtt\n Code status: Full code\n Disposition : call out to floor\n Total time spent: 30 min\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619949,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift.\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"},{"category":"ECG","chartdate":"2132-01-03 00:00:00.000","description":"Report","row_id":252938,"text":"Sinus tachycardia. Prior inferior myocardial infarction. Low limb lead\nvoltage. Non-specific inferolateral ST-T wave flattening. Compared to the\nprevious tracing of the rate has increased. The Q waves are more\nevident in the inferior leads. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2131-12-30 00:00:00.000","description":"Report","row_id":252939,"text":"Sinus rhythm. Baseline artifact. Non-specific ST-T wave changes. Compared to\ntracing #1 the rate has decreased and the ventricular premature beats are no\nlonger seen.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2131-12-29 00:00:00.000","description":"Report","row_id":252940,"text":"Sinus tachycardia with ventricular premature beats. Non-specific ST-T wave\nchanges. Compared to the previous tracing of the ventricular premature\nbeats are new.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2131-12-29 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1120181,"text":" 5:06 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with severe R lower chest wall TTP and flank TTP, sob\n REASON FOR THIS EXAMINATION:\n eval for PE, perineprhic abscess, other acute path\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa SAT 6:44 PM\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n COMPARISON: and .\n\n HISTORY: Right lower chest wall tenderness to palpation, shortness of breath,\n evaluate for PE, perinephric abscess or other acute pathology.\n\n TECHNIQUE: MDCT axially acquired images through the chest, abdomen and pelvis\n were obtained. IV contrast was administered. Coronal and sagittal reformats\n were performed.\n\n FINDINGS: Within the right lower lobe segmental pulmonary artery, there are\n filling defects extending into the subsegmental branches. There is\n consolidation in the right lower lobe which may represent pulmonary infarct\n versus infection. There are severe emphysematous changes identified. In the\n left lower lobe (3A, 58) there is peripheral consolidation with the suggestion\n of an air bronchogram concerning for infection. There is no pleural or\n pericardial effusion. There is no axillary, hilar or mediastinal\n lymphadenopathy. Debris within the trachea is identified (3A, 10). While\n most of this appears aerosolized, underlying endobronchial lesion cannot be\n entirely excluded particularly within the right main stem bronchus (3A, 21).\n\n Atherosclerotic plaque is identified along the thoracic aorta and extending\n into the abdominal aorta.\n\n CT ABDOMEN: There is a large abdominal aortic aneurysm measuring\n approximately 4.2 x 4.0 x 7.5 cm. This has increased in size when compared to\n . More prominent hyperdensity along the periphery likely represents\n calcification (3b, 137). Streak artifact from the posterior spinal hardware\n slightly limits evaluation of the abdomen. Within this limitation, the\n spleen, kidneys, adrenal glands,and small bowel are unremarkable. The liver\n appears nodular. The gallbladder contains tiny gallstones. There is mild\n pancreatic ductal prominence. The commone bile duct is dilated, measuring up\n to 1.5 cm in diameter, new. There mild antral wall thickening and mucosal\n (Over)\n\n 5:06 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n enhancement. There is no mesenteric or retroperitoneal lymphadenopathy. There\n is no free fluid or free air.\n\n CT OF THE PELVIS: The bladder, rectum and sigmoid colon are unremarkable.\n The prostate contains coarse calcifications. There is no pelvic or inguinal\n lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n Compression fracture of L3 is stable.\n\n IMPRESSION:\n 1. Right lower lobe segmental pulmonary artery embolus with possible right\n lower lobe pulmonary infarct vs infection.\n 2. Focal consolidation in the left lower lobe concerning for infection.\n 3. Debris within the trachea; while most appears aerosolized, underlying\n endobronchial lesion cannot be entirely excluded particularly within the right\n main stem bronchus.\n 5. Cholelithiasis. Dilated common bile duct and prominent pancreatic duct.\n MRCP or ERCP should be performed.\n 6. Infrarenal abdominal aortic aneurysm as described above, with interval\n increase in size when compared to .\n 7. Mild antral wall thickening and enhancement, may in part relate to\n underdistention or gastritis. Correlation with endoscopy.\n 8. New hyperdensity within the aortic aneurysm which is likely calcification.\n Noncontrast CT scan of this area is recommended to confirm.\n\n Findings were discussed with Dr. at approximately 6:40\n p.m. via telephone. Recommendations were conveyed to Dr. at 9 pm\n via telephone.\n\n"},{"category":"Radiology","chartdate":"2131-12-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1120222,"text":" 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD presents with pneumonia and PE\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Pneumonia. Pulmonary embolism.\n\n FINDINGS: Ill-defined opacities at the right lung base have progressed since\n the recent chest radiograph, and correspond to an area of suspected hemorrhage\n and/or evolving infarction on recent CT in the setting of an adjacent\n pulmonary embolism. Poorly defined opacities in periphery of left lung base\n could be related to either pulmonary embolism or infection. Severe emphysema\n is demonstrated as well as nonspecific scarring at the right apex.\n\n"},{"category":"Radiology","chartdate":"2131-12-29 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1120204,"text":" 9:46 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\n hyperdensity radiology recommended non-contrast eval\n REASON FOR THIS EXAMINATION:\n eval AAA given radiology concern for hyperdensity seen on prior CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SUN 12:35 AM\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\n torso, demonstrating the likely etiology to the mural calcification.\n 2. No other short-term interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, AAA, presents with PE, pneumonia. On the prior CTA\n performed earlier today, there was a questionable hyperdensity in the\n abdominal aorta, for further evaluation.\n\n TECHNIQUE: Non-contrast CT acquisition through the abdomen at the level of\n the kidneys with multiplanar reformations.\n\n FINDINGS: Focused evaluation was performed for assessing the region of\n interest in the abdominal aorta (2:19) at the site of the abdominal aortic\n aneurysm. The previously noted linear hyperdensity is again present on the\n non-contrast sequences (2:19, 25), unchanged, and therefore likely reflects\n calcification. Please refer to the concurrent CT for further details of the\n remainder of the findings.\n\n Residual contrast is seen in the kidneys from the prior study. Gallstones are\n present. Again is noted the calcified infrarenal abdominal aortic aneurysm\n measuring 4 x 4.2 cm. There is patchy opacity at the base of the right lung\n could represent atelectasis, aspiration, superimposed pneumonia cannot be\n excluded. Post-surgical changes from left lateral fusion hardware are\n present.\n\n IMPRESSION:Hyperdensity noted on recent CTA torso is unchanged and likely\n corresponds to calcification. No other short-term interval change.\n\n"},{"category":"Radiology","chartdate":"2131-12-29 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1120205,"text":", A. MED MICU-7 9:46 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\n hyperdensity radiology recommended non-contrast eval\n REASON FOR THIS EXAMINATION:\n eval AAA given radiology concern for hyperdensity seen on prior CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\n torso, demonstrating the likely etiology to the mural calcification.\n 2. No other short-term interval changes.\n\n"},{"category":"Radiology","chartdate":"2132-01-01 00:00:00.000","description":"MRCP (MR ABD W&W/OC)","row_id":1120550,"text":" 8:36 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\n Admitting Diagnosis: PULMONARY EMBOLIS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with PE, PNA, COPD, recent weight loss found to have dilated\n pancreatic duct on abdominal CT.\n REASON FOR THIS EXAMINATION:\n Please evaluate for causes of pancreatic duct dilatation, specifically\n malignancy.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRCP obtained .\n\n COMPARISON: CT abdomen and ; ct chest .\n\n HISTORY: A 66-year-old male with recent weight loss and dilated pancreatic\n duct on recent abdominal CT, evaluate for etiology.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet, including dynamic 2D T1-weighted GRE images obtained prior to,\n during, and after the uneventful intravenous administration of 17 mL of\n Magnevist. Additionally, the patient drank a combination of Gastromark and\n Redicat.\n\n The study is limited secondary to poor breathhold and therefore non-breath\n hold 2D images were performed for the dynamic series rather than 3D images.\n\n FINDINGS:\n There is pleural thickening along the left lateral chest wall, seen on recent\n CT chest of , and consistent with pleural scarring/chronic changes.\n Additionally, soft tissue density in the right hilum correlates with\n lymphadenopathy per chest CT. Fibrotic changes are stable within the right\n lung base. There are small bilateral pleural effusions.\n\n The liver demonstrates a nodular contour, morphology consistent with\n cirrhosis. There is normal signal intensity. There is homogeneous post-\n contrast enhancement within the liver. No abnormal enhancing are noted within\n the liver. There is no intrahepatic biliary ductal dilatation. Hepatic\n vasculature and portal vein are patent. There is trace ascites.\n\n There is mild dilatation of the common bile duct, which tapers normally at the\n ampulla. Additionally, there is mild dilatation of the pancreatic duct, which\n is smooth and tapers normally to the level of the papilla. There is no\n obstructing lesion or abnormal enhancement identified.\n\n The pancreas, spleen, and adrenal glands are unremarkable in appearance.\n Kidneys demonstrate prompt and symmetric uptake and excretion of contrast.\n Gallstones are identified within the gallbladder. There is no pericholecystic\n fluid or GB wall edema.\n (Over)\n\n 8:36 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\n Admitting Diagnosis: PULMONARY EMBOLIS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is aneurysmal dilatation of the descending abdominal aorta, in an\n infrarenal distribution, measuring approximately 4.2 x 3.7 cm in dimension.\n This is stable in appearance when compared to the recent abdominal CT and has\n a large partially thrombosed lumen, again unchanged when compared to the\n recent CT.\n\n No enlarged intraabdominal lymphadenopathy is identified.\n\n Bone marrow signal is grossly unremarkable. Hardware is noted within the\n spine.\n\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\n dynamic series.\n\n IMPRESSION:\n 1. Mild dilatation of the common bile duct and pancreatic duct which taper\n normally at the ampulla and are smooth in contour. This is most likely from\n papillary stenosis versus sphincter of Oddi dysfunction as no obstructing\n lesion is seen, however, a subtle lesion could be missed given limited\n evaluation secondary to patientinability to breath hold. If concern persists,\n ERCP could be performed for further evaluation.\n\n 2. Cirrhosis. Trace ascites.\n\n 3. Cholelithiasis.\n\n 4. Infrarenal abdominal aortic aneurysm, which is partially thrombosed, and\n unchanged in appearance when compared to the recent CT, and better evaluated\n on that CT.\n\n 5. Fibrosis at the right lung base with scarring involving the left lateral\n pleura as well as right hilar lymphadenopathy, findings unchanged from recent\n chest CT.\n\n"},{"category":"Radiology","chartdate":"2131-12-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1120169,"text":" 3:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with hx of copd recent pneumonia now right flank/?back pain\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 56-year-old male with history of COPD and recent\n pneumonia, now with right flank and back pain.\n\n COMPARISON: .\n\n FINDINGS: The lungs again are hyperinflated with flattening of the diaphragms\n and prominence of the interstitial markings with relative lucency of the upper\n lobes, suggesting chronic obstructive pulmonary disease. Scattered\n parenchymal scarring is again noted, most pronounced in the bilateral apical\n region, right greater than left, where biapical thickening is seen. Mild\n opacities along the peripheral left lung base are without significant interval\n change to mildly decreased since the prior study. Interstitial opacities are\n seen along the right lung base. No discrete focal consolidation or pleural\n effusion is seen. The heart is not enlarged. The aortic knob is calcified.\n Partially visualized spinal metallic hardware is again noted.\n\n"},{"category":"Radiology","chartdate":"2131-12-30 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1120268,"text":" 12:00 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE,EVAL FOR DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo M with COPD, AAA, presents with PE and pneumonia\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd SUN 2:33 PM\n IMPRESSION:\n\n Extensive thrombus within the left superficial femoral vein, popliteal vein\n and peroneal veins.\n\n No right lower extremity deep venous thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: A 66-year-old male with COPD, abdominal aortic aneurysm, PE\n and pneumonia. Clinical concern for lower extremity DVT.\n\n TECHNIQUE: Grayscale and Doppler ultrasound images of bilateral lower\n extremity veins were obtained.\n\n FINDINGS: The left common and superficial femoral veins are thrombosed with\n clot extending into the left popliteal vein and peroneal veins. The clot is\n not entirely occlusive in the common femoral vein but its proximal extent is\n not delineated on this study. The left posterior tibial vein demonstrates\n normal color flow. The right common femoral, superficial femoral, popliteal\n veins demonstrate normal compression, flow, and augmentation. The right\n posterior tibial and peroneal veins are patent.\n\n IMPRESSION: Extensive thrombus within the left common and superficial\n femoral, popliteal and peroneal veins. No right lower extremity deep venous\n thrombosis.\n\n"},{"category":"Radiology","chartdate":"2131-12-30 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1120269,"text":", A. MED MICU-7 12:00 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE,EVAL FOR DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo M with COPD, AAA, presents with PE and pneumonia\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION:\n\n Extensive thrombus within the left superficial femoral vein, popliteal vein\n and peroneal veins.\n\n No right lower extremity deep venous thrombosis.\n\n"},{"category":"Radiology","chartdate":"2131-12-31 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1120388,"text":" 10:13 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 42cm\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with P/E\n REASON FOR THIS EXAMINATION:\n r picc 42cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with new right-sided PICC placement. Evaluate\n for PICC placement.\n\n COMPARISON: Multiple priors, the most recent portable AP chest radiograph\n ; CT chest, abdomen and pelvis .\n\n TECHNIQUE: Portable chest radiograph.\n\n FINDINGS: The cardiac, mediastinal and hila contours are normal and unchanged\n from . The right-sided PICC terminates at the cavoatrial\n junction. Lung opacity is worsened since . Worsened bibasilar\n opacities are noted compared to , worrisome for pneumonia.\n Severe emphysema is noted. Spinal hardware is unchanged compared to most\n recent priors.\n\n IMPRESSION:\n 1. Right-sided PICC line at the cavoatrial junction.\n 2. Worsening bibasilar opacities compared to , worrisome for\n pneumonia.\n 3. Severe emphysema, unchanged since prior.\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 619882,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\\n heparin to 800units/hr\\n Plan:\\n Next PTT at 1200. Leni\\ns in the morning.\\n Pneumonia, other\\n Assessment:\\n Afebrile, upon arrival to unit tachypnic to high 20\\ns mid 30\\ns, sat\\n 96-98%, on NC 3L.\\n Action:\\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\\n Response:\\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\\n Plan:\\n Cont ABX, follow CT result.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 619890,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:05 PM\\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\\n use heparin gtt\\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\\n need repeat CT in 3 months to re-eval.\\n -- LFT/lipase/amylase unremarkable\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Heparin Sodium - 06:21 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 325 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 325 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 125 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n 225 K/uL\\n 10.5 g/dL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PNEUMONIA, OTHER\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evaluation if needed\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium and albuterol nebs prn\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs prn/ replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\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:Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619896,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification.\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:05 PM\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Heparin Sodium - 06:21 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\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 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 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 Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619897,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification.\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:05 PM\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Heparin Sodium - 06:21 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\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 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant.\\n Continue heparin drip\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignacy. Would follow up CT. Reasonable to treat\\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\\n sputum cx.\\n COPD: seems stable, not need for steroids.\\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\\n stabilized.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n Percocet for pain.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 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 Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619900,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification. Abd CT\\n showed no leak\\n 24 Hour Events:\\n heparin gtt started for PE\\n Stable overnight\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefepime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Heparin Sodium - 800 units/hour\\n Atrovent nebs\\n Allopirinol\\n Lipitor\\n Nicotine patch\\n Vit D\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Gen:\\n HEENT:\\n Neck:\\n CV:\\n Pulm:\\n Abd:\\n Extrem:\\n Neuro:\\n Labs / Radiology\\n 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant.\\n Continue heparin drip\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignacy. Would follow up CT. Reasonable to treat\\n with Vanc/Cefepim/Cipro given history of GNRs in sputum. Check sputum\\n cx\\n COPD: seems stable, not need for steroids.\\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\\n will watch carefully in light of anticoagulation. Recheck Hct this\\n afternoon.\\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\\n stabilized.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n Percocet for pain.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 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 Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 619901,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:05 PM\\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\\n use heparin gtt\\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\\n need repeat CT in 3 months to re-eval.\\n -- LFT/lipase/amylase unremarkable\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Heparin Sodium - 06:21 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 325 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 325 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 125 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, mild expiratory\\n wheeze\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n 225 K/uL\\n 10.5 g/dL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PNEUMONIA, OTHER\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. The patient was\\n started on a heparin gtt in the ED. ECG showed no evidence of RV\\n strain, troponin wnl. Overnight pt did well on 3L NC and remains\\n hemodynamically stable. Troponins have been flat. Pt with no recent\\n surgerys, immobilization, known malignancy, family history of\\n hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Start Coumadin 5mg; monitor INR\\n - follow up TTE to evaluate for right heart strain\\n - LENI pending\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - Continue Vanco/Cefepime and d/c cipro given negative urine legionella\\n - sputum cx\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . There was mention of a hyperdensity seen on CTA\\n and a non-contrast CT abdomen showed AAA stable Spoke with vascular\\n surgery who felt there was no evidence of a leak.\\n -Monitor Hct closely given heparin/coumadin\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.. LFTs wnl\\n - f/u final CTA read\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium and albuterol nebs prn\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs prn/ replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\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:Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619902,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification. Abd CT\\n showed no leak\\n 24 Hour Events:\\n heparin gtt started for PE\\n Stable overnight\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefepime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Heparin Sodium - 800 units/hour\\n Atrovent nebs\\n Albuterol nebs\\n Allopirinol\\n Lipitor\\n Nicotine patch\\n Vit D\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Gen:\\n HEENT:\\n Neck:\\n CV:\\n Pulm:\\n Abd:\\n Extrem:\\n Neuro:\\n Labs / Radiology\\n 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\\n resolution since could also represent malignancy.\\n Continue heparin drip. Start coumadin today. Echo and LENI\\ns today\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignancy. Follow up CT as outpt to eval.\\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\\n sputum. Check sputum cx\\n COPD: seems stable, not need for steroids. Continue albuterol and\\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\\n back to baseline.\\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\\n will watch carefully in light of anticoagulation. Recheck Hct this\\n afternoon. Guaiac stools.\\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\\n awaiting final read. LFT\\ns and /lipase normal. need MRCP as\\n outpt.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n ICU Care\\n Nutrition: regular diet\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Prophylaxis:\\n DVT: heparin gtt\\n Code status: Full code\\n Disposition : call out to floor\\n Total time spent: 30 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619977,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\\n and flank pain with cough and movement. Patient tachypnic with\\n movement/exertion.\\n Action:\\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\\n increased to 900units/hr. Next PTT due at . Patient had LENI\\n today. Prelim showing left DVT. Received 2 Percocet for pain\\n associated with coughing.\\n Response:\\n Remains on NC 3L. Patient states he has relief from Percocets.\\n Patient started on Coumadin today. Given first dose of 5mg.\\n Plan:\\n Next PTT at . Continue Heparin gtt per protocol. Monitor Hct.\\n AAA increased in size from , but per MICU team is currently\\n stable. Hct 34 at 12pm, stable from 33 with am labs. Patient needs\\n bedside echo tomorrow.\\n Pneumonia, other\\n Assessment:\\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\\n consolidation on CXR.\\n Action:\\n Patient with weak cough. Encouraged to cough up secretions and\\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\\n Response:\\n Remains afebrile, continues to be tachynic with exertion, but O2\\n requirement remains the same.\\n Plan:\\n Cont ABX. Encourage pulmonary toilet.\\n Demographics\\n Attending MD:\\n Admit diagnosis:\\n Code status:\\n Height:\\n Admission weight:\\n Daily weight:\\n Allergies/Reactions:\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history:\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:\\n D:\\n Temperature:\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n Heart Rate:\\n Heart rhythm:\\n O2 delivery device:\\n O2 saturation:\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 24h total out:\\n Pacer Data\\n Pertinent Lab Results:\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n Valuables / Signature\\n Patient valuables: Clothes, shoes\\n Other valuables:\\n Clothes:\\n Wallet / Money: Patient has wallet, but he sent his credit cards and\\n cash to security. Wallet contains only ID card and other cards that\\n are not credit cards.\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: MICU 7\\n Transferred to: CC701\\n Date & time of Transfer: 1800\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619952,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\\n and flank pain with cough and movement. Patient tachypnic with\\n movement/exertion.\\n Action:\\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\\n increased to 900units/hr. Next PTT due at . Patient had LENI\\n today. Prelim showing left DVT. Received 2 Percocet for pain\\n associated with coughing.\\n Response:\\n Remains on NC 3L. Patient states he has relief from Percocets.\\n Plan:\\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\\n from 33 with am labs. Patient needs bedside echo.\\n Pneumonia, other\\n Assessment:\\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\\n consolidation on CXR.\\n Action:\\n Patient with weak cough. Encouraged to cough up secretions and\\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\\n Response:\\n Remains afebrile, continues to be tachynic with exertion, but O2\\n requirement remains the same.\\n Plan:\\n Cont ABX. Encourage pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619945,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\\n heparin to 800units/hr\\n Plan:\\n Next PTT at 1200. Leni\\ns in the morning.\\n Pneumonia, other\\n Assessment:\\n Afebrile, upon arrival to unit tachypnic to high 20\\ns mid 30\\ns, sat\\n 96-98%, on NC 3L.\\n Action:\\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\\n Response:\\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\\n Plan:\\n Cont ABX, follow CT result.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619951,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\\n and flank pain with cough and movement. Patient tachypnic with\\n movement/exertion.\\n Action:\\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\\n increased to 900units/hr. Next PTT due at . Patient had LENI\\n today. Prelim showing left DVT. Received 2 Percocet for pain\\n associated with coughing.\\n Response:\\n Remains on NC 3L. Patient states he has relief from Percocets.\\n Plan:\\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\\n from 33 with am labs.\\n Pneumonia, other\\n Assessment:\\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\\n consolidation on CXR.\\n Action:\\n Patient with weak cough. Encouraged to cough up secretions and\\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\\n Response:\\n Remains afebrile, continues to be tachynic with exertion, but O2\\n requirement remains the same.\\n Plan:\\n Cont ABX. Encourage pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 619828,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L\\n Plan:\\n next PTT at 1000\\n Pneumonia, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619817,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evalution\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium nebs q6 and albuterol\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs / replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619818,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evalution\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium nebs q6 and albuterol\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs / replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619819,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evalution\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium nebs and albuterol nebs\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs / replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619821,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evaluation if needed\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium and albuterol nebs prn\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs prn/ replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619822,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evaluation if needed\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium and albuterol nebs prn\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs prn/ replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 619823,\n \"text\": \"Chief Complaint: Right sided pleuritic CP/ PE and PNA\\n I saw and examined the patient, and was physically present with the 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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification.\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n admitted to MICU for COPD exacerbation and PNA. Strep PNA in\\n sputum.\\n Meds:\\n allopurinol\\n atorvastatin\\n albuterol/tiatropium\\n vitamin D\\n percocet\\n cough suppressant\\n noncontributory for PE\\n Occupation:\\n Drugs:\\n Tobacco: long smoking history. - ppD currently\\n Alcohol: h/o ETOH abuse - drinks few per night. No recent withdrawl\\n Other: lives by self, on disability at home in apartment.\\n Review of systems:\\n Constitutional: Fatigue\\n Ear, Nose, Throat: No(t) Dry mouth\\n Cardiovascular: Chest pain\\n Respiratory: Dyspnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\\n Genitourinary: No(t) Dysuria\\n Endocrine: No(t) Hyperglycemia\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia\\n Neurologic: No(t) Headache\\n Psychiatric / Sleep: No(t) Agitated\\n Allergy / Immunology: No(t) Immunocompromised\\n Pain: Moderate\\n Flowsheet Data as of 10:28 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 125 mL\\n PO:\\n TF:\\n IVF:\\n 125 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -175 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ////\\n Physical Examination\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Diminished: b/l)\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 221\\n 39\\n 141\\n 0.8\\n 10\\n 26\\n 93\\n 3.6\\n 133\\n 22.0\\n [image002.jpg]\\n Other labs: Lactic Acid:2.9\\n Fluid analysis / Other labs: negative U/A\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant.\\n Continue heparin drip\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignacy. Would follow up CT. Reasonable to treat\\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\\n sputum cx.\\n COPD: seems stable, not need for steroids.\\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\\n stabilized.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n Percocet for pain.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Comments:\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 619825,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L\\n Plan:\\n next PTT\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 619829,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L\\n Plan:\\n next PTT at 1000. Leni\\ns in the morning.\\n Pneumonia, other\\n Assessment:\\n Afebrile, upon arrival to unit tachypnic to high 20\\ns mid 30\\ns, sat\\n 96-98%, on NC 3L.\\n Action:\\n Start on Cipro Iv, cefepime, cont Vanco. ABD CT done\\n Response:\\n Plan:\\n Cont ABX, follow CT result.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619982,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification. Abd CT\\n showed no leak\\n 24 Hour Events:\\n heparin gtt started for PE\\n Stable overnight\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefepime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Heparin Sodium - 800 units/hour\\n Atrovent nebs\\n Albuterol nebs\\n Allopirinol\\n Lipitor\\n Nicotine patch\\n Vit D\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Gen: alert, oriented, NAD\\n HEENT: PERRL\\n Neck:supple\\n CV: S1S2 tachy\\n Pulm: clear ant/lat\\n Abd: soft, nt\\n Extrem: no edema\\n Labs / Radiology\\n 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\\n resolution since could also represent malignancy.\\n Continue heparin drip. Start coumadin today. Echo and LENI\\ns today\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignancy. Follow up CT as outpt to eval.\\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\\n sputum. Check sputum cx\\n COPD: seems stable, not need for steroids. Continue albuterol and\\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\\n back to baseline.\\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\\n will watch carefully in light of anticoagulation. Recheck Hct this\\n afternoon. Guaiac stools.\\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\\n awaiting final read. LFT\\ns and /lipase normal. need MRCP as\\n outpt.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n ICU Care\\n Nutrition: regular diet\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Prophylaxis:\\n DVT: heparin gtt\\n Code status: Full code\\n Disposition : call out to floor\\n Total time spent: 30 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619949,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\\n and flank pain with cough and movement. Patient tachypnic with\\n movement/exertion.\\n Action:\\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\\n increased to 900units/hr. Next PTT due at . Patient had LENI\\n today. Prelim showing left DVT. Received 2 Percocet for pain\\n associated with coughing.\\n Response:\\n Remains on NC 3L. Patient states he has relief from Percocets.\\n Plan:\\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\\n from 33 with am labs.\\n Pneumonia, other\\n Assessment:\\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\\n consolidation on CXR.\\n Action:\\n Patient with weak cough. Encouraged to cough up secretions and\\n pulmonary toilet. Sputum sample sent this shift.\\n Response:\\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\\n Plan:\\n Cont ABX, follow CT result.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 252938,\n \"text\": \"Sinus tachycardia. Prior inferior myocardial infarction. Low limb lead\\nvoltage. Non-specific inferolateral ST-T wave flattening. Compared to the\\nprevious tracing of the rate has increased. The Q waves are more\\nevident in the inferior leads. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 252939,\n \"text\": \"Sinus rhythm. Baseline artifact. Non-specific ST-T wave changes. Compared to\\ntracing #1 the rate has decreased and the ventricular premature beats are no\\nlonger seen.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 252940,\n \"text\": \"Sinus tachycardia with ventricular premature beats. Non-specific ST-T wave\\nchanges. Compared to the previous tracing of the ventricular premature\\nbeats are new.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1120181,\n \"text\": \" 5:06 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with severe R lower chest wall TTP and flank TTP, sob\\n REASON FOR THIS EXAMINATION:\\n eval for PE, perineprhic abscess, other acute path\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SBNa SAT 6:44 PM\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT TORSO\\n\\n COMPARISON: and .\\n\\n HISTORY: Right lower chest wall tenderness to palpation, shortness of breath,\\n evaluate for PE, perinephric abscess or other acute pathology.\\n\\n TECHNIQUE: MDCT axially acquired images through the chest, abdomen and pelvis\\n were obtained. IV contrast was administered. Coronal and sagittal reformats\\n were performed.\\n\\n FINDINGS: Within the right lower lobe segmental pulmonary artery, there are\\n filling defects extending into the subsegmental branches. There is\\n consolidation in the right lower lobe which may represent pulmonary infarct\\n versus infection. There are severe emphysematous changes identified. In the\\n left lower lobe (3A, 58) there is peripheral consolidation with the suggestion\\n of an air bronchogram concerning for infection. There is no pleural or\\n pericardial effusion. There is no axillary, hilar or mediastinal\\n lymphadenopathy. Debris within the trachea is identified (3A, 10). While\\n most of this appears aerosolized, underlying endobronchial lesion cannot be\\n entirely excluded particularly within the right main stem bronchus (3A, 21).\\n\\n Atherosclerotic plaque is identified along the thoracic aorta and extending\\n into the abdominal aorta.\\n\\n CT ABDOMEN: There is a large abdominal aortic aneurysm measuring\\n approximately 4.2 x 4.0 x 7.5 cm. This has increased in size when compared to\\n . More prominent hyperdensity along the periphery likely represents\\n calcification (3b, 137). Streak artifact from the posterior spinal hardware\\n slightly limits evaluation of the abdomen. Within this limitation, the\\n spleen, kidneys, adrenal glands,and small bowel are unremarkable. The liver\\n appears nodular. The gallbladder contains tiny gallstones. There is mild\\n pancreatic ductal prominence. The commone bile duct is dilated, measuring up\\n to 1.5 cm in diameter, new. There mild antral wall thickening and mucosal\\n (Over)\\n\\n 5:06 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n enhancement. There is no mesenteric or retroperitoneal lymphadenopathy. There\\n is no free fluid or free air.\\n\\n CT OF THE PELVIS: The bladder, rectum and sigmoid colon are unremarkable.\\n The prostate contains coarse calcifications. There is no pelvic or inguinal\\n lymphadenopathy.\\n\\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\\n Compression fracture of L3 is stable.\\n\\n IMPRESSION:\\n 1. Right lower lobe segmental pulmonary artery embolus with possible right\\n lower lobe pulmonary infarct vs infection.\\n 2. Focal consolidation in the left lower lobe concerning for infection.\\n 3. Debris within the trachea; while most appears aerosolized, underlying\\n endobronchial lesion cannot be entirely excluded particularly within the right\\n main stem bronchus.\\n 5. Cholelithiasis. Dilated common bile duct and prominent pancreatic duct.\\n MRCP or ERCP should be performed.\\n 6. Infrarenal abdominal aortic aneurysm as described above, with interval\\n increase in size when compared to .\\n 7. Mild antral wall thickening and enhancement, may in part relate to\\n underdistention or gastritis. Correlation with endoscopy.\\n 8. New hyperdensity within the aortic aneurysm which is likely calcification.\\n Noncontrast CT scan of this area is recommended to confirm.\\n\\n Findings were discussed with Dr. at approximately 6:40\\n p.m. via telephone. Recommendations were conveyed to Dr. at 9 pm\\n via telephone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1120222,\n \"text\": \" 4:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with COPD presents with pneumonia and PE\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n COMPARISON: .\\n\\n INDICATION: Pneumonia. Pulmonary embolism.\\n\\n FINDINGS: Ill-defined opacities at the right lung base have progressed since\\n the recent chest radiograph, and correspond to an area of suspected hemorrhage\\n and/or evolving infarction on recent CT in the setting of an adjacent\\n pulmonary embolism. Poorly defined opacities in periphery of left lung base\\n could be related to either pulmonary embolism or infection. Severe emphysema\\n is demonstrated as well as nonspecific scarring at the right apex.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1120204,\n \"text\": \" 9:46 PM\\n CT ABDOMEN W/O CONTRAST Clip # \\n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\\n hyperdensity radiology recommended non-contrast eval\\n REASON FOR THIS EXAMINATION:\\n eval AAA given radiology concern for hyperdensity seen on prior CTA\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SUN 12:35 AM\\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\\n torso, demonstrating the likely etiology to the mural calcification.\\n 2. No other short-term interval changes.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: COPD, AAA, presents with PE, pneumonia. On the prior CTA\\n performed earlier today, there was a questionable hyperdensity in the\\n abdominal aorta, for further evaluation.\\n\\n TECHNIQUE: Non-contrast CT acquisition through the abdomen at the level of\\n the kidneys with multiplanar reformations.\\n\\n FINDINGS: Focused evaluation was performed for assessing the region of\\n interest in the abdominal aorta (2:19) at the site of the abdominal aortic\\n aneurysm. The previously noted linear hyperdensity is again present on the\\n non-contrast sequences (2:19, 25), unchanged, and therefore likely reflects\\n calcification. Please refer to the concurrent CT for further details of the\\n remainder of the findings.\\n\\n Residual contrast is seen in the kidneys from the prior study. Gallstones are\\n present. Again is noted the calcified infrarenal abdominal aortic aneurysm\\n measuring 4 x 4.2 cm. There is patchy opacity at the base of the right lung\\n could represent atelectasis, aspiration, superimposed pneumonia cannot be\\n excluded. Post-surgical changes from left lateral fusion hardware are\\n present.\\n\\n IMPRESSION:Hyperdensity noted on recent CTA torso is unchanged and likely\\n corresponds to calcification. No other short-term interval change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1120205,\n \"text\": \", A. MED MICU-7 9:46 PM\\n CT ABDOMEN W/O CONTRAST Clip # \\n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\\n hyperdensity radiology recommended non-contrast eval\\n REASON FOR THIS EXAMINATION:\\n eval AAA given radiology concern for hyperdensity seen on prior CTA\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\\n torso, demonstrating the likely etiology to the mural calcification.\\n 2. No other short-term interval changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-01-01 00:00:00.000\",\n \"description\": \"MRCP (MR ABD W&W/OC)\",\n \"row_id\": 1120550,\n \"text\": \" 8:36 AM\\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with PE, PNA, COPD, recent weight loss found to have dilated\\n pancreatic duct on abdominal CT.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for causes of pancreatic duct dilatation, specifically\\n malignancy.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRCP obtained .\\n\\n COMPARISON: CT abdomen and ; ct chest .\\n\\n HISTORY: A 66-year-old male with recent weight loss and dilated pancreatic\\n duct on recent abdominal CT, evaluate for etiology.\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\\n Tesla magnet, including dynamic 2D T1-weighted GRE images obtained prior to,\\n during, and after the uneventful intravenous administration of 17 mL of\\n Magnevist. Additionally, the patient drank a combination of Gastromark and\\n Redicat.\\n\\n The study is limited secondary to poor breathhold and therefore non-breath\\n hold 2D images were performed for the dynamic series rather than 3D images.\\n\\n FINDINGS:\\n There is pleural thickening along the left lateral chest wall, seen on recent\\n CT chest of , and consistent with pleural scarring/chronic changes.\\n Additionally, soft tissue density in the right hilum correlates with\\n lymphadenopathy per chest CT. Fibrotic changes are stable within the right\\n lung base. There are small bilateral pleural effusions.\\n\\n The liver demonstrates a nodular contour, morphology consistent with\\n cirrhosis. There is normal signal intensity. There is homogeneous post-\\n contrast enhancement within the liver. No abnormal enhancing are noted within\\n the liver. There is no intrahepatic biliary ductal dilatation. Hepatic\\n vasculature and portal vein are patent. There is trace ascites.\\n\\n There is mild dilatation of the common bile duct, which tapers normally at the\\n ampulla. Additionally, there is mild dilatation of the pancreatic duct, which\\n is smooth and tapers normally to the level of the papilla. There is no\\n obstructing lesion or abnormal enhancement identified.\\n\\n The pancreas, spleen, and adrenal glands are unremarkable in appearance.\\n Kidneys demonstrate prompt and symmetric uptake and excretion of contrast.\\n Gallstones are identified within the gallbladder. There is no pericholecystic\\n fluid or GB wall edema.\\n (Over)\\n\\n 8:36 AM\\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n There is aneurysmal dilatation of the descending abdominal aorta, in an\\n infrarenal distribution, measuring approximately 4.2 x 3.7 cm in dimension.\\n This is stable in appearance when compared to the recent abdominal CT and has\\n a large partially thrombosed lumen, again unchanged when compared to the\\n recent CT.\\n\\n No enlarged intraabdominal lymphadenopathy is identified.\\n\\n Bone marrow signal is grossly unremarkable. Hardware is noted within the\\n spine.\\n\\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\\n dynamic series.\\n\\n IMPRESSION:\\n 1. Mild dilatation of the common bile duct and pancreatic duct which taper\\n normally at the ampulla and are smooth in contour. This is most likely from\\n papillary stenosis versus sphincter of Oddi dysfunction as no obstructing\\n lesion is seen, however, a subtle lesion could be missed given limited\\n evaluation secondary to patientinability to breath hold. If concern persists,\\n ERCP could be performed for further evaluation.\\n\\n 2. Cirrhosis. Trace ascites.\\n\\n 3. Cholelithiasis.\\n\\n 4. Infrarenal abdominal aortic aneurysm, which is partially thrombosed, and\\n unchanged in appearance when compared to the recent CT, and better evaluated\\n on that CT.\\n\\n 5. Fibrosis at the right lung base with scarring involving the left lateral\\n pleura as well as right hilar lymphadenopathy, findings unchanged from recent\\n chest CT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1120169,\n \"text\": \" 3:08 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with hx of copd recent pneumonia now right flank/?back pain\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: Chest, single AP upright portable view.\\n\\n CLINICAL INFORMATION: 56-year-old male with history of COPD and recent\\n pneumonia, now with right flank and back pain.\\n\\n COMPARISON: .\\n\\n FINDINGS: The lungs again are hyperinflated with flattening of the diaphragms\\n and prominence of the interstitial markings with relative lucency of the upper\\n lobes, suggesting chronic obstructive pulmonary disease. Scattered\\n parenchymal scarring is again noted, most pronounced in the bilateral apical\\n region, right greater than left, where biapical thickening is seen. Mild\\n opacities along the peripheral left lung base are without significant interval\\n change to mildly decreased since the prior study. Interstitial opacities are\\n seen along the right lung base. No discrete focal consolidation or pleural\\n effusion is seen. The heart is not enlarged. The aortic knob is calcified.\\n Partially visualized spinal metallic hardware is again noted.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1120268,\n \"text\": \" 12:00 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: PE,EVAL FOR DVT\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 yo M with COPD, AAA, presents with PE and pneumonia\\n REASON FOR THIS EXAMINATION:\\n eval for DVT\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd SUN 2:33 PM\\n IMPRESSION:\\n\\n Extensive thrombus within the left superficial femoral vein, popliteal vein\\n and peroneal veins.\\n\\n No right lower extremity deep venous thrombosis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: A 66-year-old male with COPD, abdominal aortic aneurysm, PE\\n and pneumonia. Clinical concern for lower extremity DVT.\\n\\n TECHNIQUE: Grayscale and Doppler ultrasound images of bilateral lower\\n extremity veins were obtained.\\n\\n FINDINGS: The left common and superficial femoral veins are thrombosed with\\n clot extending into the left popliteal vein and peroneal veins. The clot is\\n not entirely occlusive in the common femoral vein but its proximal extent is\\n not delineated on this study. The left posterior tibial vein demonstrates\\n normal color flow. The right common femoral, superficial femoral, popliteal\\n veins demonstrate normal compression, flow, and augmentation. The right\\n posterior tibial and peroneal veins are patent.\\n\\n IMPRESSION: Extensive thrombus within the left common and superficial\\n femoral, popliteal and peroneal veins. No right lower extremity deep venous\\n thrombosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1120269,\n \"text\": \", A. MED MICU-7 12:00 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: PE,EVAL FOR DVT\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 yo M with COPD, AAA, presents with PE and pneumonia\\n REASON FOR THIS EXAMINATION:\\n eval for DVT\\n ______________________________________________________________________________\\n PFI REPORT\\n IMPRESSION:\\n\\n Extensive thrombus within the left superficial femoral vein, popliteal vein\\n and peroneal veins.\\n\\n No right lower extremity deep venous thrombosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-31 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1120388,\n \"text\": \" 10:13 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r picc 42cm\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with P/E\\n REASON FOR THIS EXAMINATION:\\n r picc 42cm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old man with new right-sided PICC placement. Evaluate\\n for PICC placement.\\n\\n COMPARISON: Multiple priors, the most recent portable AP chest radiograph\\n ; CT chest, abdomen and pelvis .\\n\\n TECHNIQUE: Portable chest radiograph.\\n\\n FINDINGS: The cardiac, mediastinal and hila contours are normal and unchanged\\n from . The right-sided PICC terminates at the cavoatrial\\n junction. Lung opacity is worsened since . Worsened bibasilar\\n opacities are noted compared to , worrisome for pneumonia.\\n Severe emphysema is noted. Spinal hardware is unchanged compared to most\\n recent priors.\\n\\n IMPRESSION:\\n 1. Right-sided PICC line at the cavoatrial junction.\\n 2. Worsening bibasilar opacities compared to , worrisome for\\n pneumonia.\\n 3. Severe emphysema, unchanged since prior.\\n\\n\"\n }\n]"}}},{"rowIdx":195,"cells":{"subject_id":{"kind":"number","value":16436,"string":"16,436"},"hadm_id":{"kind":"number","value":140997,"string":"140,997"},"target_text":{"kind":"string","value":"This is a 68-year-old female with morbid obesity, admitted for line sepsis, methicillin-resistant Staphylococcus aureus with a transient decrease in urinary output, and atrial fibrillation, now controlled, who is now re-admitted to the Medical Intensive Care Unit with an upper gastrointestinal bleed. There was blood seen in her lower esophagus by esophagogastroduodenoscopy with a large amount of clots and oozing red blood in the fundus. The patient was not able to protect airway herself, and she was do not intubate (per her sister who was her health care proxy). An nasogastric tube was placed, and the patient did not clear after 8 liters of fluid. A blood transfusion was initiated. The patient was given Protonix intravenously. Per, the Gastrointestinal Service, the patient was unable to be re-scoped without intubation. However, since she was refusing intubation because the patient wanted to be do not intubate even for temporary measures. The patient understood that this eliminated the possibility of gaining control of bleed via esophagogastroduodenoscopy. The Interventional Radiology Service was consulted, but they were unable to take the patient to angiography for possible embolization secondary to the patient's weight and difficulty in accessing groin and problems of ascites. The patient also received 2 units of fresh frozen plasma to correct coagulation. The team had a conversation with her sister regarding limited options at this point. We reiterated that esophagogastroduodenoscopy with intubation might be her last hope. The sister did understand the situation, but reported that the patient repeatedly expressed the desire to be do not resuscitate/do not intubate. Meanwhile, the patient was receiving blood transfusions and fluid resuscitation. The team was called at 6:30 in the morning by bedside and found the patient having no respirations. The patient subsequently passed away at that time. The patient was pronounced dead at 6:30 in the morning on . , M.D. Dictated By: MEDQUIST36 D: 13:50 T: 10:15 JOB#: "},"extractive_notes_summ":{"kind":"string","value":"She has had a non productive cough.Cardiac: HR 68-78 SR with frequent PAC's. PT DOES HAVE CPAP AT THE BEDSIDE.CV: PT'S HR 80-90'S NSR WITH OCCASIONAL PAC'S AND SBP 110-130'S.GI: ABD TIGHT AND UNABLE TO AUSCULTATE BOWEL SOUNDS. No bowel sounds noted.G-U - Foley draining well, u/o approx 50cc/hr.Skin - + MRSA from old pic line. She was placed back on bipap and she immediately fell asleep with sats 94-96%. Began agonal breathing with decreased pulse Dr. pronounced pt dead at 1830. CALLING OUT TO PEOPLE NOT THERE AND MAKING STATEMENTS THAT ARE DIFFICULT TO UNDERSTAND OR INCOMPREHENSIBLE.RESP: PRESENTLY ON O2 AT 2L/M NC WITH O2 SATS>94%. MAX TEMP=99.2 AND WBC=19.9.SOCIAL PT'S SISTER IS AT BEDSIDE AND AWARE OF PRESENT SITUATION. EMS activated, found to be cyanotic, apneic. SISTER HAS BEEN UPDATED BY MEDICAL TEAM.REVIEW OF SYSTEMS:NEURO: PT AND IS ORIENTED TO PESON AND PLACE BUT STATES IT'S . Pmicu Nursing Progress NoteResp: Pt on biPap with nose mask but around 9am she took off the mask. INSP/EXP WHEEZES BIL BUT DIMINSIHED AT THE BASES. If she moves the NC at all her O2 sats drop very quickly to the 80's. Sinus rhythm - premature ventricular contractionsAnteroseptal infarct - age undeterminedInferior/lateral ST-T changes may be due to myocardial ischemiaGeneralized low QRS voltages PT NEEDS CL ACCESS.INTEGUMENTARY : SKIN VERY THIN WITH AREAS OF ABRASIONS- SKIN TEARS TO ARMS. PT VERY OBESE.ID: PT NOW WITH MRSA FROM OLD PICC SITE AND STAPH LLE CELLULITIS SWAB. Q waves in leads V1-V4 suggest previous anteriormyocardial infarction. She is allergic to Percocet.At , pt was felt to be septic, with acute on chronic renal failure. She was D/C'd , was doing well until when she was noted to have MS changes, fever to 105. Overnight , developed SVT to 160's, given Adenosine 6mg IV with brief response, additional 12mg IV with HR down to 100-120 ? She was ambu'd briefly, brought to , given IV Vanco, blood cx off PICC line grew Gm+ cocci, transferred to per pt/family request. Lungs with inspiratory and expiratory wheezing.GI- Passed small amount maroon stoolx 1. 7p to 7a Micu Progress NoteNeuro - Pt only responding to painful stimuli. update to the above note: pt not a candidate for ir intervention and pt continues with brb output from ogt.discussion held with pt's siste decision made for no further intervention and comfort measures only. BIL LOWER EXTREMTIY DRSGS D&I WITHOUT DRAINAGE. Given Ativan 1mg IV x2 overnight with fair effect, slept only in short naps Per pt's sister, this has been her baseline MS recentlyResp: Sats >95% on BiPAP mask with 3l O2 bled through, drop to 86% with mask off BS diminished throughoutCV: Given Lopressor 12.5mg PO, 2nd dose Digoxin IV (for total .25mg) with HR down to 70's SR with occasional-frequent PAC's. She had a recent prolonged hospitalization for CHF, bilat LE cellulitis, for which a PICC line was placed for home IV Lasix w/ VNA. IV fluid NS begun at 100ml/hr per medical residentGI: NPO except for meds with sips water + bowel sounds, no stool overnightGU: Approx 30ml/hr amber urine with sediment via Foley cath, has not increased with IV fluidsSkin: Dsgs intact at both LE's, no drainageSocial: sister at bedside until 2100, telephone update given this AM Pt remains DNR/DNI. Morphine drip being titrated. PT IS A DNR/DNI SO AFTER DISCUSSION WITH FAMILY PT WAS NOT INTUBATED. TRANSFUSED WITH 2 U FFP AND HCT UPON ARRIVAL=26.5. When asked if she's having pain, she says \"No\". Last rights administered yest pm by chaplain. PT WAS TO GI UNIT BUT UNABLE TO VISULAIZE SOURCE OF BLEEDING SO PT WAS THEN TO MICU FOR FURTHER MANAGEMENT. WETHER PT WILL GO TO IR FOR ANGIOGRAPHY AND POSSIBLE COIL PLACEMENTRENAL: ADEQUATE UO VIA FOLEY CATH WHICH IS AMBER IN COLOR.IV ACCESS: PT HAS 1 18G SL TO R LOWER ARM AND 20G IN L LOWER ARM. Became cyanotic and stopped breathing. Nursing Admission NotePt is a 60yr old woman with complex PMH: CAD, S/P MI '; CHF EF 25-35% last echo ; OSA chronic BiPAP since ; IDDM; Morbid Obesity; elevated cholesterol; Hx GI bleed. She was placed on 1.5L NC with O2 sats 90-92%. Arrived with HR 130's SVT with frequent PAC's, BP stable 120-130/ On her baseline BiPAP, her sats are 93-96% Sister at bedside. PT TO FLOOR LAST EVENING AFTER 24 HR STAY IN MICU FOR CONTROL OF SVT WITH ADENOSINE AND DIGOXIN. LLE cellulitus.Status - Pt is DNR/DNI and CMO. She has had 2 small smears of brown stool.GU: foley draining amber urine with U/O ~40cc/hr.Neuro: Pt oriented to person and place. The toe was cleaned with soap and water, antibotic ointment applied and DSD applied.Social: Her sister in to visit around 11am who helped with her orientation. chaplain at bedside and sacrament of the sick administered. OGT PLACED AND PT CONTINUOUSLY LAVAGED AND HAVE BEEN UNABLE TO CLEAR. Small non-diagnostic Q waves in leads III and aVF.Diffuse low QRS voltage. Addendum- At 1825 pt passing large amount of melanotic stool. admssion note to micu for gi bleedd: SEE ADMISSION NOTE FROM YESTERDAY FOR PT'S PMH AND ORIGINAL REASON FOR ADMISSION. 02 sat 92 - 97 on 4lnc. Adaptic was placed on both areas with some antibotic put on the left leg. The right area is almost healed ulcerated area. will start mso4 gtt and keep titrate to keep pt comfortable Given Vanco, Ceftaz, given fluid. Pt is transferred to MICU for further care. OCCASIONAL DRY NONPRODUCTIVE COUGH. Atrial fibrillation with rapid ventricular response of 123Old anterior myocardial infarctDiffuse ST-T abnormalitiesAbnormal ECG She tolerated the chair until 2pm when she wasd put back to bed with a total lift (10 people helped). Pulling off BiPAP mask, removing johhnie despite continuous reinforcement to not do this. OVERNOC ON CC7 PT HAD 5 EPISODES OF MELANOTIC STOOL AND THIS AM WAS HAVING BRB STOOL OUTPUT APPROXIMATELY EVERY 20 MIN."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2166-10-29 00:00:00.000","description":"Report","row_id":246785,"text":"Normal sinus rhythm. Q waves in leads V1-V4 suggest previous anterior\nmyocardial infarction. Small non-diagnostic Q waves in leads III and aVF.\nDiffuse low QRS voltage. Compared to the previous tracing of there has\nbeen no diagnostic interval change.\n\n"},{"category":"ECG","chartdate":"2166-10-28 00:00:00.000","description":"Report","row_id":246786,"text":"Sinus rhythm\n - premature ventricular contractions\nAnteroseptal infarct - age undetermined\nInferior/lateral ST-T changes may be due to myocardial ischemia\nGeneralized low QRS voltages\n\n"},{"category":"ECG","chartdate":"2166-10-27 00:00:00.000","description":"Report","row_id":246787,"text":"Atrial fibrillation with rapid ventricular response of 123\nOld anterior myocardial infarct\nDiffuse ST-T abnormalities\nAbnormal ECG\n\n"},{"category":"Nursing/other","chartdate":"2166-10-28 00:00:00.000","description":"Report","row_id":1477156,"text":"Pmicu Nursing Progress Note\nResp: Pt on biPap with nose mask but around 9am she took off the mask. She was placed on 1.5L NC with O2 sats 90-92%. If she moves the NC at all her O2 sats drop very quickly to the 80's. She was put in the chair with 4 people helping her but she did not help very much. She tolerated the chair until 2pm when she wasd put back to bed with a total lift (10 people helped). She was placed back on bipap and she immediately fell asleep with sats 94-96%. She has had a non productive cough.\n\nCardiac: HR 68-78 SR with frequent PAC's. B/P 104-110/50's.\n\nGI: Pt has no appetite just drinking apple juice and water. She has had 2 small smears of brown stool.\n\nGU: foley draining amber urine with U/O ~40cc/hr.\n\nNeuro: Pt oriented to person and place. She occasionally will talk to people who are not in the room but quickly reoientes. She was able to stand to transfer to the chair but she was unable to turn into the chair.\n\nSkin: She has an area in the front of her tibias on both legs. The right area is almost healed ulcerated area. On the left the ulcerated area has several small ulcers, reddened around the whole area. Adaptic was placed on both areas with some antibotic put on the left leg. Also on her left great toe the toe nail was lifted up during the transfer to the chair and it started to bleed. The toe was cleaned with soap and water, antibotic ointment applied and DSD applied.\n\nSocial: Her sister in to visit around 11am who helped with her orientation.\n"},{"category":"Nursing/other","chartdate":"2166-10-29 00:00:00.000","description":"Report","row_id":1477157,"text":"admssion note to micu for gi bleed\nd: SEE ADMISSION NOTE FROM YESTERDAY FOR PT'S PMH AND ORIGINAL REASON FOR ADMISSION. PT TO FLOOR LAST EVENING AFTER 24 HR STAY IN MICU FOR CONTROL OF SVT WITH ADENOSINE AND DIGOXIN. OVERNOC ON CC7 PT HAD 5 EPISODES OF MELANOTIC STOOL AND THIS AM WAS HAVING BRB STOOL OUTPUT APPROXIMATELY EVERY 20 MIN. HCT THIS AM=28 AND VSS WERE STABLE WITH SBP 100-110. PT WAS TO GI UNIT BUT UNABLE TO VISULAIZE SOURCE OF BLEEDING SO PT WAS THEN TO MICU FOR FURTHER MANAGEMENT. PT IS A DNR/DNI SO AFTER DISCUSSION WITH FAMILY PT WAS NOT INTUBATED. OGT PLACED AND PT CONTINUOUSLY LAVAGED AND HAVE BEEN UNABLE TO CLEAR. TRANSFUSED WITH 2 U FFP AND HCT UPON ARRIVAL=26.5. SISTER HAS BEEN UPDATED BY MEDICAL TEAM.\n\nREVIEW OF SYSTEMS:\nNEURO: PT AND IS ORIENTED TO PESON AND PLACE BUT STATES IT'S . CALLING OUT TO PEOPLE NOT THERE AND MAKING STATEMENTS THAT ARE DIFFICULT TO UNDERSTAND OR INCOMPREHENSIBLE.\n\nRESP: PRESENTLY ON O2 AT 2L/M NC WITH O2 SATS>94%. OCCASIONAL DRY NONPRODUCTIVE COUGH. INSP/EXP WHEEZES BIL BUT DIMINSIHED AT THE BASES. PT DOES HAVE CPAP AT THE BEDSIDE.\n\nCV: PT'S HR 80-90'S NSR WITH OCCASIONAL PAC'S AND SBP 110-130'S.\n\nGI: ABD TIGHT AND UNABLE TO AUSCULTATE BOWEL SOUNDS. NO STOOL AT PRESENT. OGT IN PALCE WITH BRB OUTPUT AND WILL NEED TO TRANSFUSE BLOOD AS NEEDED. NO C/O N/V. ? WETHER PT WILL GO TO IR FOR ANGIOGRAPHY AND POSSIBLE COIL PLACEMENT\n\nRENAL: ADEQUATE UO VIA FOLEY CATH WHICH IS AMBER IN COLOR.\n\nIV ACCESS: PT HAS 1 18G SL TO R LOWER ARM AND 20G IN L LOWER ARM. PT NEEDS CL ACCESS.\n\nINTEGUMENTARY : SKIN VERY THIN WITH AREAS OF ABRASIONS- SKIN TEARS TO ARMS. BIL LOWER EXTREMTIY DRSGS D&I WITHOUT DRAINAGE. PT VERY OBESE.\n\nID: PT NOW WITH MRSA FROM OLD PICC SITE AND STAPH LLE CELLULITIS SWAB. MAX TEMP=99.2 AND WBC=19.9.\n\nSOCIAL PT'S SISTER IS AT BEDSIDE AND AWARE OF PRESENT SITUATION. WILL GET PHONE NUMBER WHERE SHE CAN BE REACHED.\n\nCODE STATUS : PT IS A DNR/DNI\n"},{"category":"Nursing/other","chartdate":"2166-10-29 00:00:00.000","description":"Report","row_id":1477158,"text":"update to the above note: pt not a candidate for ir intervention and pt continues with brb output from ogt.discussion held with pt's siste decision made for no further intervention and comfort measures only. chaplain at bedside and sacrament of the sick administered. will start mso4 gtt and keep titrate to keep pt comfortable\n"},{"category":"Nursing/other","chartdate":"2166-10-30 00:00:00.000","description":"Report","row_id":1477159,"text":"7p to 7a Micu Progress Note\n\nNeuro - Pt only responding to painful stimuli. No spontaneous eye opening. Morphine drip being titrated. Pt not restless, sleeping most of evening and night.\n\nResp - RR 12 - 20. 02 sat 92 - 97 on 4lnc. Lungs with inspiratory and expiratory wheezing.\n\nGI- Passed small amount maroon stoolx 1. No further drainage noted from og tube. No bowel sounds noted.\n\nG-U - Foley draining well, u/o approx 50cc/hr.\n\nSkin - + MRSA from old pic line. LLE cellulitus.\n\nStatus - Pt is DNR/DNI and CMO. Sister with pt constantly in room. Other family members visiting throughout the evening. Last rights administered yest pm by chaplain.\n"},{"category":"Nursing/other","chartdate":"2166-10-30 00:00:00.000","description":"Report","row_id":1477160,"text":"Addendum- At 1825 pt passing large amount of melanotic stool. Became cyanotic and stopped breathing. Began agonal breathing with decreased pulse Dr. pronounced pt dead at 1830. Sister at bedside. Friends of sister called to come in.\n"},{"category":"Nursing/other","chartdate":"2166-10-28 00:00:00.000","description":"Report","row_id":1477154,"text":"Nursing Admission Note\nPt is a 60yr old woman with complex PMH: CAD, S/P MI '; CHF EF 25-35% last echo ; OSA chronic BiPAP since ; IDDM; Morbid Obesity; elevated cholesterol; Hx GI bleed. She had a recent prolonged hospitalization for CHF, bilat LE cellulitis, for which a PICC line was placed for home IV Lasix w/ VNA. She was D/C'd , was doing well until when she was noted to have MS changes, fever to 105. EMS activated, found to be cyanotic, apneic. She was ambu'd briefly, brought to , given IV Vanco, blood cx off PICC line grew Gm+ cocci, transferred to per pt/family request. She lives with her sister in . She is allergic to Percocet.\nAt , pt was felt to be septic, with acute on chronic renal failure. Given Vanco, Ceftaz, given fluid. Overnight , developed SVT to 160's, given Adenosine 6mg IV with brief response, additional 12mg IV with HR down to 100-120 ? Afib. Pt is transferred to MICU for further care. Arrived with HR 130's SVT with frequent PAC's, BP stable 120-130/ On her baseline BiPAP, her sats are 93-96%\n\n"},{"category":"Nursing/other","chartdate":"2166-10-28 00:00:00.000","description":"Report","row_id":1477155,"text":"Nursing Progres Note\nNeuro: Pt calling out for her sister, yelling \"!\" When asked if she's having pain, she says \"No\". Pulling off BiPAP mask, removing johhnie despite continuous reinforcement to not do this. Soft restraints on bilat. Given Ativan 1mg IV x2 overnight with fair effect, slept only in short naps Per pt's sister, this has been her baseline MS recently\nResp: Sats >95% on BiPAP mask with 3l O2 bled through, drop to 86% with mask off BS diminished throughout\nCV: Given Lopressor 12.5mg PO, 2nd dose Digoxin IV (for total .25mg) with HR down to 70's SR with occasional-frequent PAC's. SBP remains > 110. IV fluid NS begun at 100ml/hr per medical resident\nGI: NPO except for meds with sips water + bowel sounds, no stool overnight\nGU: Approx 30ml/hr amber urine with sediment via Foley cath, has not increased with IV fluids\nSkin: Dsgs intact at both LE's, no drainage\nSocial: sister at bedside until 2100, telephone update given this AM Pt remains DNR/DNI. ? call out to floor later this morning\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-10-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 246785,\n \"text\": \"Normal sinus rhythm. Q waves in leads V1-V4 suggest previous anterior\\nmyocardial infarction. Small non-diagnostic Q waves in leads III and aVF.\\nDiffuse low QRS voltage. Compared to the previous tracing of there has\\nbeen no diagnostic interval change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 246786,\n \"text\": \"Sinus rhythm\\n - premature ventricular contractions\\nAnteroseptal infarct - age undetermined\\nInferior/lateral ST-T changes may be due to myocardial ischemia\\nGeneralized low QRS voltages\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 246787,\n \"text\": \"Atrial fibrillation with rapid ventricular response of 123\\nOld anterior myocardial infarct\\nDiffuse ST-T abnormalities\\nAbnormal ECG\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477156,\n \"text\": \"Pmicu Nursing Progress Note\\nResp: Pt on biPap with nose mask but around 9am she took off the mask. She was placed on 1.5L NC with O2 sats 90-92%. If she moves the NC at all her O2 sats drop very quickly to the 80's. She was put in the chair with 4 people helping her but she did not help very much. She tolerated the chair until 2pm when she wasd put back to bed with a total lift (10 people helped). She was placed back on bipap and she immediately fell asleep with sats 94-96%. She has had a non productive cough.\\n\\nCardiac: HR 68-78 SR with frequent PAC's. B/P 104-110/50's.\\n\\nGI: Pt has no appetite just drinking apple juice and water. She has had 2 small smears of brown stool.\\n\\nGU: foley draining amber urine with U/O ~40cc/hr.\\n\\nNeuro: Pt oriented to person and place. She occasionally will talk to people who are not in the room but quickly reoientes. She was able to stand to transfer to the chair but she was unable to turn into the chair.\\n\\nSkin: She has an area in the front of her tibias on both legs. The right area is almost healed ulcerated area. On the left the ulcerated area has several small ulcers, reddened around the whole area. Adaptic was placed on both areas with some antibotic put on the left leg. Also on her left great toe the toe nail was lifted up during the transfer to the chair and it started to bleed. The toe was cleaned with soap and water, antibotic ointment applied and DSD applied.\\n\\nSocial: Her sister in to visit around 11am who helped with her orientation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477157,\n \"text\": \"admssion note to micu for gi bleed\\nd: SEE ADMISSION NOTE FROM YESTERDAY FOR PT'S PMH AND ORIGINAL REASON FOR ADMISSION. PT TO FLOOR LAST EVENING AFTER 24 HR STAY IN MICU FOR CONTROL OF SVT WITH ADENOSINE AND DIGOXIN. OVERNOC ON CC7 PT HAD 5 EPISODES OF MELANOTIC STOOL AND THIS AM WAS HAVING BRB STOOL OUTPUT APPROXIMATELY EVERY 20 MIN. HCT THIS AM=28 AND VSS WERE STABLE WITH SBP 100-110. PT WAS TO GI UNIT BUT UNABLE TO VISULAIZE SOURCE OF BLEEDING SO PT WAS THEN TO MICU FOR FURTHER MANAGEMENT. PT IS A DNR/DNI SO AFTER DISCUSSION WITH FAMILY PT WAS NOT INTUBATED. OGT PLACED AND PT CONTINUOUSLY LAVAGED AND HAVE BEEN UNABLE TO CLEAR. TRANSFUSED WITH 2 U FFP AND HCT UPON ARRIVAL=26.5. SISTER HAS BEEN UPDATED BY MEDICAL TEAM.\\n\\nREVIEW OF SYSTEMS:\\nNEURO: PT AND IS ORIENTED TO PESON AND PLACE BUT STATES IT'S . CALLING OUT TO PEOPLE NOT THERE AND MAKING STATEMENTS THAT ARE DIFFICULT TO UNDERSTAND OR INCOMPREHENSIBLE.\\n\\nRESP: PRESENTLY ON O2 AT 2L/M NC WITH O2 SATS>94%. OCCASIONAL DRY NONPRODUCTIVE COUGH. INSP/EXP WHEEZES BIL BUT DIMINSIHED AT THE BASES. PT DOES HAVE CPAP AT THE BEDSIDE.\\n\\nCV: PT'S HR 80-90'S NSR WITH OCCASIONAL PAC'S AND SBP 110-130'S.\\n\\nGI: ABD TIGHT AND UNABLE TO AUSCULTATE BOWEL SOUNDS. NO STOOL AT PRESENT. OGT IN PALCE WITH BRB OUTPUT AND WILL NEED TO TRANSFUSE BLOOD AS NEEDED. NO C/O N/V. ? WETHER PT WILL GO TO IR FOR ANGIOGRAPHY AND POSSIBLE COIL PLACEMENT\\n\\nRENAL: ADEQUATE UO VIA FOLEY CATH WHICH IS AMBER IN COLOR.\\n\\nIV ACCESS: PT HAS 1 18G SL TO R LOWER ARM AND 20G IN L LOWER ARM. PT NEEDS CL ACCESS.\\n\\nINTEGUMENTARY : SKIN VERY THIN WITH AREAS OF ABRASIONS- SKIN TEARS TO ARMS. BIL LOWER EXTREMTIY DRSGS D&I WITHOUT DRAINAGE. PT VERY OBESE.\\n\\nID: PT NOW WITH MRSA FROM OLD PICC SITE AND STAPH LLE CELLULITIS SWAB. MAX TEMP=99.2 AND WBC=19.9.\\n\\nSOCIAL PT'S SISTER IS AT BEDSIDE AND AWARE OF PRESENT SITUATION. WILL GET PHONE NUMBER WHERE SHE CAN BE REACHED.\\n\\nCODE STATUS : PT IS A DNR/DNI\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477158,\n \"text\": \"update to the above note: pt not a candidate for ir intervention and pt continues with brb output from ogt.discussion held with pt's siste decision made for no further intervention and comfort measures only. chaplain at bedside and sacrament of the sick administered. will start mso4 gtt and keep titrate to keep pt comfortable\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477159,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nNeuro - Pt only responding to painful stimuli. No spontaneous eye opening. Morphine drip being titrated. Pt not restless, sleeping most of evening and night.\\n\\nResp - RR 12 - 20. 02 sat 92 - 97 on 4lnc. Lungs with inspiratory and expiratory wheezing.\\n\\nGI- Passed small amount maroon stoolx 1. No further drainage noted from og tube. No bowel sounds noted.\\n\\nG-U - Foley draining well, u/o approx 50cc/hr.\\n\\nSkin - + MRSA from old pic line. LLE cellulitus.\\n\\nStatus - Pt is DNR/DNI and CMO. Sister with pt constantly in room. Other family members visiting throughout the evening. Last rights administered yest pm by chaplain.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477160,\n \"text\": \"Addendum- At 1825 pt passing large amount of melanotic stool. Became cyanotic and stopped breathing. Began agonal breathing with decreased pulse Dr. pronounced pt dead at 1830. Sister at bedside. Friends of sister called to come in.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477154,\n \"text\": \"Nursing Admission Note\\nPt is a 60yr old woman with complex PMH: CAD, S/P MI '; CHF EF 25-35% last echo ; OSA chronic BiPAP since ; IDDM; Morbid Obesity; elevated cholesterol; Hx GI bleed. She had a recent prolonged hospitalization for CHF, bilat LE cellulitis, for which a PICC line was placed for home IV Lasix w/ VNA. She was D/C'd , was doing well until when she was noted to have MS changes, fever to 105. EMS activated, found to be cyanotic, apneic. She was ambu'd briefly, brought to , given IV Vanco, blood cx off PICC line grew Gm+ cocci, transferred to per pt/family request. She lives with her sister in . She is allergic to Percocet.\\nAt , pt was felt to be septic, with acute on chronic renal failure. Given Vanco, Ceftaz, given fluid. Overnight , developed SVT to 160's, given Adenosine 6mg IV with brief response, additional 12mg IV with HR down to 100-120 ? Afib. Pt is transferred to MICU for further care. Arrived with HR 130's SVT with frequent PAC's, BP stable 120-130/ On her baseline BiPAP, her sats are 93-96%\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477155,\n \"text\": \"Nursing Progres Note\\nNeuro: Pt calling out for her sister, yelling \\\"!\\\" When asked if she's having pain, she says \\\"No\\\". Pulling off BiPAP mask, removing johhnie despite continuous reinforcement to not do this. Soft restraints on bilat. Given Ativan 1mg IV x2 overnight with fair effect, slept only in short naps Per pt's sister, this has been her baseline MS recently\\nResp: Sats >95% on BiPAP mask with 3l O2 bled through, drop to 86% with mask off BS diminished throughout\\nCV: Given Lopressor 12.5mg PO, 2nd dose Digoxin IV (for total .25mg) with HR down to 70's SR with occasional-frequent PAC's. SBP remains > 110. IV fluid NS begun at 100ml/hr per medical resident\\nGI: NPO except for meds with sips water + bowel sounds, no stool overnight\\nGU: Approx 30ml/hr amber urine with sediment via Foley cath, has not increased with IV fluids\\nSkin: Dsgs intact at both LE's, no drainage\\nSocial: sister at bedside until 2100, telephone update given this AM Pt remains DNR/DNI. ? call out to floor later this morning\\n\"\n }\n]"}}},{"rowIdx":196,"cells":{"subject_id":{"kind":"number","value":29867,"string":"29,867"},"hadm_id":{"kind":"number","value":138500,"string":"138,500"},"target_text":{"kind":"string","value":"This is a 57 year old woman with history of CAD s/p MI and stent () presenting with BRBPR due to diverticulosis. Brief hospital course presented below by problem. . Briefly, this is a 57 year old female with history of MI s/p stent in on aspirin/plavix presented on with single episode of lower GI bleed. She had acute onset of lower abdominal cramping, then was incontinent of a large volume of bright red blood and diarrhea. The pain resolved after the BRBPR. She denied any other preceeding symptoms: fever, chills, chest pain, shortness of breath, nausea, preceeding diarrhea or constipation. In the ED she was hemodynamically stable with BP 107-113/71-83, HR 90s and her hematocrit was 38. She was given 1 liter Normal saline, NG lavage negative. The patient was evaluated by GI who recommended ICU monitoring for lower GI bleed. . In the ICU, patient was continued on her PPI, given IVF, kept NPO for EGD and colonoscopy. No ischemic changes on EKG. The patient's beta blocker was held to not mask tachycardia. She received 1 unit of PRBC. On , her tagged RBC scan was negative, her EGD was shown to be normal, and colonoscopy on showed diverticulosis as likely cause of GIB. Also showed multiple non-bleeding diverticula. During the whole hospital course, the patient was continued on asprin and plavix for recent drug eluting stent . She was also continued on her statin for hyperlipidemia. Patient's Hct remained stable after the colonoscopy and patient was transferred to the general medicine floor for continued care in the evening of . On the day of discharge, the patient tolerated regular diet, had no more episodes of bleeding, and had a stable hematocrit. Patient was discharged on all her home medications including restarting her coreg CR for hypertension. She will need follow up with her primary care physician, . , within 1-2 weeks of discharge from the hospital. Also, she will need follow up with a local GI specialist for a full screening colonoscopy with better prep in the future to look for polyps and other colonic morphology."},"extractive_notes_summ":{"kind":"string","value":"adequate amount.IVF's 1L of .9 done-no new orders for more fluid.Plan: follow hct's q 6 hours cont. BP 100's-1teens/70's, tmax 99.0 po.Resp: LS clear, o2 sat's high 90'sGI/GU: +bs, no bm since 8am, u/o wnl.Access: PIV x2, wnl.plan: hct 18:00, ?c/o to floor Repeat HCT down to 30.9. Received total of PRBC's 1unit, most recent Hct @1200 30.6. Golytley started for colonoscopy prep. No active bleeding since this am, next hct due at 18:00. 4mg zofran given with good effect.No BM yet.GU: voids on the commode. No edema + 3 pt/dp bilaterallyGI: On clear liquids, to start golytely this evening. Nursing Progress NOtereview of systems: 7p-11pSkin: intactNeuro: intact. WBC up with last labs. In the EW her HCT was stable at 36, a NG lavage was done which was negative. Needs U/A sent with next voidID: afebrile, + WBC needs blood cultures with next blood drawSkin: Intact no issuesFEN: getting NS x 1 liter.Heme: HCT 30.9, next HCT due at Social: Son drove down from VT, she lives in PA with daughter and her family works as a medical assistant and in medical researchPlan1. RR mid teensCardiac: Hemodynamically stable. Early precordial R wave transition.Non-diagnostic Q waves in leads II, III and aVF. NPN 07:00Please refer to Carevue for additional patient information*Full CodeShift Events: Las bm at ~8am, liquid/watery stool. Approved: TUE 4:32 PM RADLINE ; A radiology consult service. Red TAG study done this am, no active bldg found. clear liquid diet until midnight and then NPO. nsg notes contd....Pt had large after 0400hrs,total 900ml ( blood + urine) crit sent,report 26,informed team,vital signs stable ,HR 70's,so Dr ti draw next crit at 0800hrs and if it is less than 25 ,then will do further management. Tele SR 70-80's without ectopy. ls clear bilat and throughout.GI: abd soft, nondistended. next due @ 0200.Resp: RA with sats> 95%, RR wnl. GI BLEEDING STUDY Clip # Reason: CAD S/O DES ON ASPIRIN/PLAVIS PRESENTING W/ BRBPR S/ EPISODES FINAL REPORT RADIOPHARMECEUTICAL DATA: 15.5 mCi Tc-m RBC (); GI BLEEDING STUDY. Prep for colonoscopy2. sats 94-96 on RA. No further epiodes of BRBPR or stoolRenal: Voiding clear yellow via commode. with golytely another set of blood cx with next hct draw Colonoscopy done this afternoon, md's probable cause of bleed is Diverticulosis. HCT q 6 hours-stable. Denies painResp: Lungs CTA bilaterally, respirations even and unlabored. VSS, she was transferred to the MICU for an emergent EGD and closer montioring. ST-T wave flattening in lead I. T wave inversion in lead aVL.ST-T wave flattening in leads V5-V6. , M.D. one set of blood cultures and urine culture sent. Nsg.notes 2300-0700hrsAllergies:NKDAEvents: 57YO lady admitted on with H/O BRBPR ,On admission crit 36,susequently down to 30 ,but no PRB till midnight.had an episode of BRBPR at midnight,300ml,vital signs stable,crit sent-28.7,team aware,informed GI team,per GI team,if continuous bleeding and crit lower than 27.5,may need to do red tag study.had one more episode at 0230,100ml.crit at 4am.Neuro:alert and oriented well,having mild abdominal cramping,using commode, on feet.CVS:HR 70-90's,NSR,No ectopics noted,BP 85-110/55-70 mm of hg.crit Q4h.next draw at 0800hrs.bloos c/s 2nd sample sent.Resp:LS clear,Sats 93-95% on RA.gu/gi:Abdomen soft,BS present.had 2 maleana.voided,using commode,yellow clear urine.on oral liquids.for colonosopy today,colon preparation with golytely,drinking not very adequately.Integu:skin intact,mild redness on sacrum.afebrileIV access:18g PIV'S one on each hand.patent.social:calm and co operative.DNR,but she wish to intubate.Plan:serial crit,and follow up with results.watch for PR bleed,and monitor vital signs. + BS in 4 quadrents. VSS through MICU course. She is to be prepped tonight for a colonoscopy in AMNeuro: A&Ox3, OOB to commode with supervision. To hear preliminary results, prior to transcription, call the Radiology Listen Line . EGD was done which was negative (total of 75 mcg fentanyl 2 mg versed given for procedure). Serial HCTS3. FINDINGS: Following intravenous injection of autologous red blood cells labeled with technetium-m, blood flow and dynamic images of the abdomen were obtained for 120 minutes. Routine ICU monitoring and care Sinus rhythm. ?c/o to floor (patient does not have insurance and is very concerned regarding her \"stay\" in hospital) Family at bedside most of day, updated on plan of care.ROS:Neuro: a/o x3, very pleasant, no c/o pain,dizziness.CV: HR 80's, NSR, no ectopy. afebrile. IMPRESSION: No evidence of GI bleeding. No previous tracingavailable for comparison. pt has nausea after starting the prep. pt very cooperative and pleasantCV: VS stable. pt steady on feet. yellow, clear urine. The obtained images demonstrate no evidence of tracer extravasation. Nursing Progress Note 0700-1900This is a 57 year old female with a PMH of HTN, CAD (s/ 5 months ago) who was at a conference this am when she had sudden onset of abdominal cramping and then passed a large amount of BRBPR."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2180-10-28 00:00:00.000","description":"GI BLEEDING STUDY","row_id":978569,"text":"GI BLEEDING STUDY Clip # \n Reason: CAD S/O DES ON ASPIRIN/PLAVIS PRESENTING W/ BRBPR S/ EPISODES\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 15.5 mCi Tc-m RBC ();\n GI BLEEDING STUDY.\n\n INDICATION: Bright red blood per rectum.\n\n FINDINGS: Following intravenous injection of autologous red blood cells labeled\n with technetium-m, blood flow and dynamic images of the abdomen were obtained\n for 120 minutes.\n\n The obtained images demonstrate no evidence of tracer extravasation.\n\n IMPRESSION: No evidence of GI bleeding.\n\n\n , M.D. Approved: TUE 4:32 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"},{"category":"Nursing/other","chartdate":"2180-10-28 00:00:00.000","description":"Report","row_id":1648225,"text":"nsg notes contd....\n\nPt had large after 0400hrs,total 900ml ( blood + urine) crit sent,report 26,informed team,vital signs stable ,HR 70's,so Dr ti draw next crit at 0800hrs and if it is less than 25 ,then will do further management.\n"},{"category":"Nursing/other","chartdate":"2180-10-28 00:00:00.000","description":"Report","row_id":1648226,"text":"NPN 07:00\nPlease refer to Carevue for additional patient information\n*Full Code\n\nShift Events: Las bm at ~8am, liquid/watery stool. Received total of PRBC's 1unit, most recent Hct @1200 30.6. Red TAG study done this am, no active bldg found. Colonoscopy done this afternoon, md's probable cause of bleed is Diverticulosis. No active bleeding since this am, next hct due at 18:00. ?c/o to floor (patient does not have insurance and is very concerned regarding her \"stay\" in hospital) Family at bedside most of day, updated on plan of care.\n\nROS:\nNeuro: a/o x3, very pleasant, no c/o pain,dizziness.\nCV: HR 80's, NSR, no ectopy. BP 100's-1teens/70's, tmax 99.0 po.\nResp: LS clear, o2 sat's high 90's\nGI/GU: +bs, no bm since 8am, u/o wnl.\nAccess: PIV x2, wnl.\nplan: hct 18:00, ?c/o to floor\n"},{"category":"Nursing/other","chartdate":"2180-10-27 00:00:00.000","description":"Report","row_id":1648222,"text":"Nursing Progress Note 0700-1900\n\nThis is a 57 year old female with a PMH of HTN, CAD (s/ 5 months ago) who was at a conference this am when she had sudden onset of abdominal cramping and then passed a large amount of BRBPR. In the EW her HCT was stable at 36, a NG lavage was done which was negative. VSS, she was transferred to the MICU for an emergent EGD and closer montioring. VSS through MICU course. Repeat HCT down to 30.9. EGD was done which was negative (total of 75 mcg fentanyl 2 mg versed given for procedure). She is to be prepped tonight for a colonoscopy in AM\n\nNeuro: A&Ox3, OOB to commode with supervision. Denies pain\n\nResp: Lungs CTA bilaterally, respirations even and unlabored. sats 94-96 on RA. RR mid teens\n\nCardiac: Hemodynamically stable. Tele SR 70-80's without ectopy. No edema + 3 pt/dp bilaterally\n\nGI: On clear liquids, to start golytely this evening. + BS in 4 quadrents. No further epiodes of BRBPR or stool\n\nRenal: Voiding clear yellow via commode. Needs U/A sent with next void\n\nID: afebrile, + WBC needs blood cultures with next blood draw\n\nSkin: Intact no issues\n\nFEN: getting NS x 1 liter.\n\nHeme: HCT 30.9, next HCT due at \n\nSocial: Son drove down from VT, she lives in PA with daughter and her family works as a medical assistant and in medical research\n\nPlan\n\n1. Prep for colonoscopy\n2. Serial HCTS\n3. Routine ICU monitoring and care\n\n"},{"category":"Nursing/other","chartdate":"2180-10-27 00:00:00.000","description":"Report","row_id":1648223,"text":"Nursing Progress NOte\nreview of systems: 7p-11p\n\nSkin: intact\n\nNeuro: intact. pt very cooperative and pleasant\n\nCV: VS stable. afebrile. WBC up with last labs. one set of blood cultures and urine culture sent. HCT q 6 hours-stable. next due @ 0200.\n\nResp: RA with sats> 95%, RR wnl. ls clear bilat and throughout.\n\nGI: abd soft, nondistended. clear liquid diet until midnight and then NPO. Golytley started for colonoscopy prep. pt has nausea after starting the prep. 4mg zofran given with good effect.No BM yet.\n\nGU: voids on the commode. pt steady on feet. yellow, clear urine. adequate amount.\n\nIVF's 1L of .9 done-no new orders for more fluid.\n\nPlan: follow hct's q 6 hours\n cont. with golytely\n another set of blood cx with next hct draw\n"},{"category":"Nursing/other","chartdate":"2180-10-28 00:00:00.000","description":"Report","row_id":1648224,"text":"Nsg.notes 2300-0700hrs\n\nAllergies:NKDA\n\nEvents: 57YO lady admitted on with H/O BRBPR ,On admission crit 36,susequently down to 30 ,but no PRB till midnight.had an episode of BRBPR at midnight,300ml,vital signs stable,crit sent-28.7,team aware,informed GI team,per GI team,if continuous bleeding and crit lower than 27.5,may need to do red tag study.had one more episode at 0230,100ml.crit at 4am.\n\nNeuro:alert and oriented well,having mild abdominal cramping,using commode, on feet.\n\nCVS:HR 70-90's,NSR,No ectopics noted,BP 85-110/55-70 mm of hg.crit Q4h.next draw at 0800hrs.bloos c/s 2nd sample sent.\n\nResp:LS clear,Sats 93-95% on RA.\n\ngu/gi:Abdomen soft,BS present.had 2 maleana.voided,using commode,yellow clear urine.on oral liquids.for colonosopy today,colon preparation with golytely,drinking not very adequately.\n\nIntegu:skin intact,mild redness on sacrum.afebrile\n\nIV access:18g PIV'S one on each hand.patent.\n\nsocial:calm and co operative.DNR,but she wish to intubate.\n\nPlan:serial crit,and follow up with results.watch for PR bleed,and monitor vital signs.\n\n"},{"category":"ECG","chartdate":"2180-10-27 00:00:00.000","description":"Report","row_id":220411,"text":"Sinus rhythm. ST-T wave flattening in lead I. T wave inversion in lead aVL.\nST-T wave flattening in leads V5-V6. Early precordial R wave transition.\nNon-diagnostic Q waves in leads II, III and aVF. No previous tracing\navailable for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2180-10-28 00:00:00.000\",\n \"description\": \"GI BLEEDING STUDY\",\n \"row_id\": 978569,\n \"text\": \"GI BLEEDING STUDY Clip # \\n Reason: CAD S/O DES ON ASPIRIN/PLAVIS PRESENTING W/ BRBPR S/ EPISODES\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n RADIOPHARMECEUTICAL DATA:\\n 15.5 mCi Tc-m RBC ();\\n GI BLEEDING STUDY.\\n\\n INDICATION: Bright red blood per rectum.\\n\\n FINDINGS: Following intravenous injection of autologous red blood cells labeled\\n with technetium-m, blood flow and dynamic images of the abdomen were obtained\\n for 120 minutes.\\n\\n The obtained images demonstrate no evidence of tracer extravasation.\\n\\n IMPRESSION: No evidence of GI bleeding.\\n\\n\\n , M.D. Approved: TUE 4:32 PM\\n\\n\\n\\n\\n RADLINE ; A radiology consult service.\\n To hear preliminary results, prior to transcription, call the\\n Radiology Listen Line .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648225,\n \"text\": \"nsg notes contd....\\n\\nPt had large after 0400hrs,total 900ml ( blood + urine) crit sent,report 26,informed team,vital signs stable ,HR 70's,so Dr ti draw next crit at 0800hrs and if it is less than 25 ,then will do further management.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648226,\n \"text\": \"NPN 07:00\\nPlease refer to Carevue for additional patient information\\n*Full Code\\n\\nShift Events: Las bm at ~8am, liquid/watery stool. Received total of PRBC's 1unit, most recent Hct @1200 30.6. Red TAG study done this am, no active bldg found. Colonoscopy done this afternoon, md's probable cause of bleed is Diverticulosis. No active bleeding since this am, next hct due at 18:00. ?c/o to floor (patient does not have insurance and is very concerned regarding her \\\"stay\\\" in hospital) Family at bedside most of day, updated on plan of care.\\n\\nROS:\\nNeuro: a/o x3, very pleasant, no c/o pain,dizziness.\\nCV: HR 80's, NSR, no ectopy. BP 100's-1teens/70's, tmax 99.0 po.\\nResp: LS clear, o2 sat's high 90's\\nGI/GU: +bs, no bm since 8am, u/o wnl.\\nAccess: PIV x2, wnl.\\nplan: hct 18:00, ?c/o to floor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648222,\n \"text\": \"Nursing Progress Note 0700-1900\\n\\nThis is a 57 year old female with a PMH of HTN, CAD (s/ 5 months ago) who was at a conference this am when she had sudden onset of abdominal cramping and then passed a large amount of BRBPR. In the EW her HCT was stable at 36, a NG lavage was done which was negative. VSS, she was transferred to the MICU for an emergent EGD and closer montioring. VSS through MICU course. Repeat HCT down to 30.9. EGD was done which was negative (total of 75 mcg fentanyl 2 mg versed given for procedure). She is to be prepped tonight for a colonoscopy in AM\\n\\nNeuro: A&Ox3, OOB to commode with supervision. Denies pain\\n\\nResp: Lungs CTA bilaterally, respirations even and unlabored. sats 94-96 on RA. RR mid teens\\n\\nCardiac: Hemodynamically stable. Tele SR 70-80's without ectopy. No edema + 3 pt/dp bilaterally\\n\\nGI: On clear liquids, to start golytely this evening. + BS in 4 quadrents. No further epiodes of BRBPR or stool\\n\\nRenal: Voiding clear yellow via commode. Needs U/A sent with next void\\n\\nID: afebrile, + WBC needs blood cultures with next blood draw\\n\\nSkin: Intact no issues\\n\\nFEN: getting NS x 1 liter.\\n\\nHeme: HCT 30.9, next HCT due at \\n\\nSocial: Son drove down from VT, she lives in PA with daughter and her family works as a medical assistant and in medical research\\n\\nPlan\\n\\n1. Prep for colonoscopy\\n2. Serial HCTS\\n3. Routine ICU monitoring and care\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648223,\n \"text\": \"Nursing Progress NOte\\nreview of systems: 7p-11p\\n\\nSkin: intact\\n\\nNeuro: intact. pt very cooperative and pleasant\\n\\nCV: VS stable. afebrile. WBC up with last labs. one set of blood cultures and urine culture sent. HCT q 6 hours-stable. next due @ 0200.\\n\\nResp: RA with sats> 95%, RR wnl. ls clear bilat and throughout.\\n\\nGI: abd soft, nondistended. clear liquid diet until midnight and then NPO. Golytley started for colonoscopy prep. pt has nausea after starting the prep. 4mg zofran given with good effect.No BM yet.\\n\\nGU: voids on the commode. pt steady on feet. yellow, clear urine. adequate amount.\\n\\nIVF's 1L of .9 done-no new orders for more fluid.\\n\\nPlan: follow hct's q 6 hours\\n cont. with golytely\\n another set of blood cx with next hct draw\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648224,\n \"text\": \"Nsg.notes 2300-0700hrs\\n\\nAllergies:NKDA\\n\\nEvents: 57YO lady admitted on with H/O BRBPR ,On admission crit 36,susequently down to 30 ,but no PRB till midnight.had an episode of BRBPR at midnight,300ml,vital signs stable,crit sent-28.7,team aware,informed GI team,per GI team,if continuous bleeding and crit lower than 27.5,may need to do red tag study.had one more episode at 0230,100ml.crit at 4am.\\n\\nNeuro:alert and oriented well,having mild abdominal cramping,using commode, on feet.\\n\\nCVS:HR 70-90's,NSR,No ectopics noted,BP 85-110/55-70 mm of hg.crit Q4h.next draw at 0800hrs.bloos c/s 2nd sample sent.\\n\\nResp:LS clear,Sats 93-95% on RA.\\n\\ngu/gi:Abdomen soft,BS present.had 2 maleana.voided,using commode,yellow clear urine.on oral liquids.for colonosopy today,colon preparation with golytely,drinking not very adequately.\\n\\nIntegu:skin intact,mild redness on sacrum.afebrile\\n\\nIV access:18g PIV'S one on each hand.patent.\\n\\nsocial:calm and co operative.DNR,but she wish to intubate.\\n\\nPlan:serial crit,and follow up with results.watch for PR bleed,and monitor vital signs.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2180-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220411,\n \"text\": \"Sinus rhythm. ST-T wave flattening in lead I. T wave inversion in lead aVL.\\nST-T wave flattening in leads V5-V6. Early precordial R wave transition.\\nNon-diagnostic Q waves in leads II, III and aVF. No previous tracing\\navailable for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":197,"cells":{"subject_id":{"kind":"number","value":14666,"string":"14,666"},"hadm_id":{"kind":"number","value":136758,"string":"136,758"},"target_text":{"kind":"string","value":"1. Respiratory: The patient was on CPAP of 6 until day of life 3 at which point he transitioned to room air without any supplemental oxygen required after that point. Comfortable on room air at this time, with last bradycardiac spell at 7 p.m. on . The patient will complete a 5-day spell count at 5 p.m. on prior to discharge. 2. Cardiovascular: No issues, no murmur, no history of hypotension. 3. Fluids, electrolytes, nutrition: The patient initially on D10W, transitioned to full enteral feeds by day of life 4 and increased to 24 kilocalories on day of life 11 under which the patient has been undergoing adequate weight gain. At this time, he is on breast milk 24 supplemented with Similac powder. He is taking ad lib p.o. on top of breast feed. No gavage necessary. Discharge weight 2725g. 4. GI: Maximum bilirubin 12.3 on day of life 9, with phototherapy discontinued on day of life 11, with a rebound of 6.5. 5. Hematology: Initial hematocrit 51, white count 16, platelets 322. 6. Infectious disease: The patient is status post 48 hours of ampicillin and gentamicin during initial blood culture, which was negative. Since that time, the patient has had antibiotic ointment with Telfa dressing to the right foot for an IV infiltrate which was discontinued approximately 4 to 5 days before discharge with resolution of infiltrate and healing of skin. 7. Neurology: Not applicable. Sensory hearing screening was performed on with automated auditory brain-stem responses and the patient passed. 8. Ophthalmology: Not applicable."},"extractive_notes_summ":{"kind":"string","value":"Reb bili 10.6/0.2. Sm amtyellow/serous drainage noted. Tripleabx and tefla applied. Swaddled, withboundaries. #1RespLungs clear with mild sc retractions. G/D: Temps stable swaddled in off-isolette. G/D: Temps stable swaddled in off-isolette. BS clear and =; mild sc ret. MildSCR noted. MildSCR noted. to monitor resp. to monitor resp. TEMP STABLE IN AN OFFISOLETTE.#4PARENTMOM X 1 FOR AN UPDATE#6BILIBILI WAS 10.6/.2. A: Resolving P: Check biliMon. NNP INFORMED. Bili thisam was 9.6/0.3. mild subcostal retractions. Cl and = BS. Cl and = BS. Mild rtxns. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Mild retractions. Mild sc rtxns. Updated re statusand plan. Tol well. Tol well. Mild desats-sr. HR 130-140s. infant colorjaundiced. both helping changediaper and do temp. AGA. AGA. Infant breastfed well x 1. TF 100 BM/SC20. Infant isalert/active with cares. Infant isalert/active with cares. REMAINS SL JAUNDICED#7SKINDSG TO R FOOT CHANGED, AREA PINK AND CLEAN. TF 120 BM20/SC20. Tolerating feedingswell; abd exam benign, no spits, min asp. LC gave Momnipple . Infant is a&awith cares. Brady x1, needing mild stim torecover. Parents updated bythis R.N. Small amt of serous drainage noted on dsg x1from that area. Ferinsol and Multivit. Infant can be fiestyat times. LS cl/=.Mild SC retractions. Willalso settle with pacifier, containment and holding. Pedi is . Desitin applied todiaper area.A. Rest well inbetween cares. Stool heme neg. Abd benign, AG 26,V/S, mec stooling. Both held infanttoday. NPN Noc#1 Resp: RA, 30-60's, c/=, mild SC retrac. Updated on infant'scondition and plan of care by this RN. NPN discharge noteVSS, exam benign; see flowsheet for details. AGA.Tripple abx oint TID to right foot infiltrate. Both updated. NPN 0700-2. NPN#1 S. O. BBS cl/=. Abd soft, +, noloops. Will update pediatrician. Mom and this am. A: stable in RA P:Cont to monitor and providesupport as needed.#2: TF's ^'ed to 100cc/k/d. Infant passed trace mec stool. and active duringcares, resting well in between. Eagerbottler and breastfeeder. Fontssoft/flat. Follow wt and exam.#3: Temps stable in an air isolette. NPN Daysaddendum: Pt passed hearing screen. Min asp. A: Toleratingfeeds. P: Cont tosupport and update. Cont to receive BM24.A. Onesmall wet burp. updates given. #1RespLungs clear with mild retractions. On ad lib demand. V/S. sucking onpacifier. abd benign. Abd benign. Plan to recheck bili am. Passed hearing screen. A: AGA. Passing heme negative stool. Passing heme negative stool. MAE/AFOF.AGA. D/C OT. Abdomen round and softwith + BS. Placed in RA. Asking appropriatequestions. Feeding tube out. Tempsstable. BM24 with powder. Took 70cc this am and BF well while werevisiting. Pt day of spell count down. Cont. Discussed SIDS precautions and EI qualifications. Voiding and stooling normally (heme negative). Maturing breathing control. exambenign. Abd soft, active bowel sounds. P- Will cont to monitor resp status.#2 Pt ad lib demand. Sucks on pacifier. BS clear. voiding and stooling. Voiding and stooling. Abd. Benign abdomen. Appearscomfortable#2FENWt 2.615 up 30g. Rehab/OTMet at the bedside. Interested inbottling#4Parentno contact so far. P: Cont to support development.#4 O: Both in to visit. remainder of volume gavaged. P: Cont tomonitor bili status PRN. P: Cont to supp and update. Infant isjaundice. Cl and = BS. continue with currentplan of care. Respiratory CarePt cont on prong CPAP. Updatedat bedside by RN. Fio2 .24-.27. bs clear, rr 50-70 with mild retractions. +murmur. Lytes this am were143/4.6/108/22. CBG: 7.28/47/45/23/-4. A: Independent andappropriate w/cares. sucks vigorously onpacifier. A: AGA. BPP was . d/c photot and check reb bili in AM. AG 27. u/o1.2cc/kg/hr thus far. Infant bottled 52 cc @ 0900 cares w/remainingvolume gavaged. Plan to recheck bili in the am. Mild SC retractions. At delivery, twin A emerged with moderate tone and good cry, with Apgars . aga. AGA. AGA. mild subcostal retractions. BP 67/37, 47. 6.5/0.2 (reb). LS clear/equal, oximetry d/c'dthis morning. Infant GFR on arrival to NICU. CL and =. Tol well. Persistant grunting on CPAP, subcostal retractions. TF 150 BM24. TF 150 BM24. TF 150 BM24. sent this shiftpending. po/pg. Po/pg. PO/PG. Otherwise, AFSFO, oropharynx clear, NGT w/o breakdownCV - RRR, nl s1+s2 no murmurPULM - CTABABD - soft, NT, ND, no massEXT - wwp, R foot c/d/i, cr < 2 secNEURO - reactive, MAE in REsp status. Stable on CPAP cont to follow. ; P/Cont. REsp. O/Anitbiotics d/c. Restswell inbetween cares. Updates given. P/Cont. P/Cont. P/Cont. toleratingfeeds well. Murmur notedand reported to NNP. Updated by RN. Updated re status andplan. remains under neoblue lights with eye shieldsin place. Bili to be rechecked in am. BS clear and =, mild sc ret. NPN 07p-07aRESPRA, LS clear & equal with mild subc. BF well.uop and stool wnl, heme neg.abd wnl. NG d/c. noincreased wob noted. Wakes occassionally for cares. Abd benign. Triple antx ointment applied as ordered.Cont. A/Completion of 48hr r/O. BS active. Nospells so far this shift, last one on . Pt. Pt. Pt. Pt. mild subcostal retractions. Please refer toflowsheet. retractions. Abd exam benign, VQS, smyellow stool x2. VS stable.Alert & active with cares. Stable on CPAP cont to follow closely. Remains NPO.Intermittently sucking on pacifier.3. Occ sat drifts, one spell so far this shift,resolved with mild stim and increased 02. monitorPO/PG feeding tolerance & weight.G&DIn air isolette, temps stable. G/D: Temps stable swaddled in off-isolette. MildSCR noted. NPN DAYS#1 Pt received and cont in RA. updated re: pt spells and DCdate pushed back. A: Independent andappropriate w/cares. Lytes 135/4.0/19. LS C+=. mild subcostal retractions. Abd benign. Keeping NPO. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Pt voiding and stooling hemneg. CBG 7.28/47. NPN:RESP: RA. IV placed in R hand with D10W infusing, initial DS 47, after IVF infusing, DS 74. BBS =/clear. Voiding qs and stoolingheme neg. Bilirubin 1.7. SATSIMPROVED ON BELLY.#2 NPO. received infant in an offisolette. Infant isalert/active with cares. asking approp ques. A: AGA. FeS04. Lung sounds cl/= and mild SC retractions. minimal aspirates. Settlesvery well with pacifier and boundaries. to suppot developmentalneeds. LS sl coarse and diminished, color good, cont with GFR through shift. B.S. AGA. Lung sounds clear/=. Attempted to BFx 2 thus far - latched well. abd benign.all po feeds. ess. Independent withcares and handling infants. lung sounds clear andequal. LS ARE CLEAR,SLIGHTLY DIMINISHED."},"n_notes":{"kind":"number","value":107,"string":"107"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2197-12-16 00:00:00.000","description":"Report","row_id":1884793,"text":"Neonatology Attending\nDOL 7 / PMA 35-3/7 weeks\n\nRemains in room air with no distress. Occasional drifting saturations but no bradycardias.\n\nNo murmur.\n\nOff phototherapy with bilirubin 10.6 yesterday.\n\nWt 2385 (+35) on TFI 140 cc/kg/day BM20, tolerating well. Bottling up to of feeds. Voiding and stooling (guiac negative). Abd benign.\n\nTemp stable in off isolette.\n\nRIght foot infiltrate improved.\n\nA&P\n34-3/7 week GA infant with respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Repeat bilirubin on Monday\n-No changes in management as detailed above\n"},{"category":"Nursing/other","chartdate":"2197-12-16 00:00:00.000","description":"Report","row_id":1884794,"text":"NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 90%. Lung sounds clear/=. RR 30-50's. Mild\nSCR noted. No bradys noted. Occ drifts to high 80's noted.\nP: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempting to\nPO when awake and alert. Infant breastfed x 2 thus far -\nlatched well. Tolerating NGT feedings well; abd exam\nbenign, no spits ,min asp. Voiding qs and stooling heme\nneg. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/active with cares. Settles well in betwen cares.\nAppropriatley brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support developmental\nneeds.\n\n4. : Mom in for 2 set of cares today. Independent\nwith cares and handling. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved . P: Cont. to support and update\n.\n\n5. Bili: Rebound bili fri am was 10.6. Infant remains sl.\njaundiced. Will follow bili on mon am.\n\n6. Skin: Dressing changed no right foot infiltrate. Triple\nabx and tefla applied. No drainage, redness or swelling\nnoted. P: Cont. to monitor skin.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-17 00:00:00.000","description":"Report","row_id":1884795,"text":"Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 96-99%.RR 30-60's.LS\nremain clear and equal with sc retractions.No A's and B's or\ndesats thus far.\n\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\nq 4 hrs gavaged over 45 min.Infant attempted to bottle with\nthe Playtex Nurser and took 25-44cc's.Appeared well\ncoordinated;remainder gavaged.Weight=2.410 up 25 grams.Abd\nsoft with pos bs,no loops or spits,minimal aspirates.Voiding\nand stooling heme negative.\n\nG/D:AF soft and flat.Alert and active with cares.Sleeping\nwell b/t.MAE.Bringing hands to face and mouth.Infant remains\nin off isolette;swaddled with nested boundaries.Temp.\nmaintained.\n\nParenting:Mom called x 1.Updated by this RN.Asking\nappropriate questions very loving and invested.\n\nBili:Infant cont's jaundice but well perfused.Stooling.To\nhave bili checked on .\n\nSkin:R foot appears pink with serous drainage on old\ndressing.Applied triple antibiotics;healing well.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-17 00:00:00.000","description":"Report","row_id":1884796,"text":"Neonatology Attending\n\nDOL 8 PMA 35 4/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 78/33 mean 50\n\nOn 140 ml/kg/d BM 20 po/pg. Voiding. Stooling. Wt 2410 grams (up 25).\n\nR foot infiltrate being treated with triple antibiotics.\n\n in and up to date.\n\nA: Stable. No spells. Tolerating feeds and learning to po. Infiltrate healing.\n\nP: Monitor\n pos as tolerated\n Continue care for infiltrate\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":1884789,"text":"Nursing Progress note\n\n\n#1 Resp-- O: RR 30s-60s; HR 140s-160s; Sats 96-99. No\ndesats, no spells. BS clear and =; mild sc ret. Pink/jaund.\nNo murmer. A: Rare desats in RA P; Cont to monitor\nsats/vitals/spells\n\n#2 Nutrition-- O: Enteral feeds advanced to 140cc/kg/d= 60cc\nBM20 q4h. BF great x2 with good latch and suck 5-10 min-\nthen drowsy. Tol full volume after BF over 45 min. tol well-\nno spits, no asp. NG #5 placed in rt nare after baby pulled\ntube. Abd exam benign, AG 25cm, +BS. VQS, Yellow x2\nguiacneg. A: Stable, tol adv feeds with wt gain P: Monitor\ntol and growth\n\n#3 Development-- O: Alert and active with cares, social with\nmom. stable in off islolette. Swaddled, with\nboundaries. Hands to mouth. A: AGA P: Cont to support\ndevelopment\n\n#4 Parenting-- O: Mom in for 0900 and 1300 feeds.\nIndependent with babies, handling well. Updated re status\nand plan. Will be back for 1700 feed. A: Involved. loving P:\nCont to support and keep informed\n\n#6 ^Bili-- O: rebound bili stable off og photo Rx. Color sl\njaund, VQS, stooling, full feeds. A: Resolving P: Check bili\nMon. am\n\n#7 Skin-- O: Rt foot lesion drsg . Sm amt\nyellow/serous drainage noted. Area cleansed with sterile\nH2O, triple antibx ointment applied with Telpha and gauze\nwrap. A: Improving P: Monitor and change drsg \n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":1884790,"text":"Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl external male genit, no rash\nEXT - wwp, cr < 2, R foot wound c/d/i with normal granulation tissue and no pus or erythema\nNEURO - MAE, reactive\n"},{"category":"Nursing/other","chartdate":"2197-12-16 00:00:00.000","description":"Report","row_id":1884791,"text":"Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 97-100%.RR 30-60's.LS\nremain clear and equal with sc retractions.No A's and B's\nthus far.Occ. will drift in sats to high 80's QSR.\n\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\nq 4 hrs gavaged over 45 min.Infant bottled x 2 with Playtex\nbottle and took 17-47cc the remainder gavaged.Weight=2.385\nup 35.Abd. soft with pos bs,no loops or spits,minimal\naspirates.Voiding and stooling heme negative.\n\nG/D:AF soft and flat.Alert and active with cares.Stirring\nprior to feeds.MAE.Bringing hands to face and mouth and\nintermitently sucking on pacifier.Infant remains in off\nisolette swaddled with nested boundaries.Temp. stable.\n\nParenting:No contact from so far.\n\nBili:Infant cont's slightly jaundice.To recheck Bili .\n\nSkin:R foot appears to be healing well.Cont's slightly pink\nwith healing tissue.No drainage or foul odor\npresent.Dressing changed per protocol.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-16 00:00:00.000","description":"Report","row_id":1884792,"text":"Neonatology NP note\nPE\nswaddled in open crib, cobedding with twin\nAFOf\nminimal subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884786,"text":"NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 93%. Lung sounds clear/=. RR 40-60's. Mild\nSCR noted. Few drifts to high 90s noted. No apnea noted\nthus far. P: Cont. to monitor resp. status.\n\n2. FEN: TF were increased to 120 cc/kg/day of BM/SC20.\nInfant is attempting to PO/breastfeed when awake and\ninterested. Infant breastfed well x 1. Tolerating feedings\nwell; abd exam benign, no spits, min asp. Voiding qs and\nstooling trans stools. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/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. Parents: Mom in for cares this shift. Independent with\ncares and handling infants. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved parents. P: Cont. to support and update\nparents.\n\n5. Bili: Single phototherapy was d/c'd at 1000. Bili this\nam was 9.6/0.3. Plan is to check rebound in am.\n\n6. Skin: Dressing was changed x 1. Tefla and gauze and\ntriple abx ointment placed on infiltrate. No drainage noted\nfrom site. P: Cont. to monitor and change dressings as\nordered.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":1884787,"text":"#1Resp\nLungs clear with mild sc retractions. Baby has had one spell\ntonight which required mild stim.RR 40-60 with sat in high\n90's.\nP. Cont to monitor\n#2FEN\nWt 2.35 up 25g. Baby cont to receive 150cc/kg BM20 52 cc q4.\nAbd round but soft active bowel sounds. Min asp No spits,\nSleepy at 2100 and feed gavaged. At 0130 awake and alert but\nnot that interested and took 15cc. At 0500, bottled 22.\\\nA. Tol feed and learnung to feed\nP> CONT TO MONITOR TOL TO FEEDS AS WELL AS WEIGHT GAIN AND\nFEED ABILITY\n#3DEV\nAWAKE AND ALERT WITH CARES BUT TIRES. TEMP STABLE IN AN OFF\nISOLETTE.\n#4PARENT\nMOM X 1 FOR AN UPDATE\n#6BILI\nBILI WAS 10.6/.2. NNP INFORMED. REMAINS SL JAUNDICED\n#7SKIN\nDSG TO R FOOT CHANGED, AREA PINK AND CLEAN. NO DRAINAGE.\nGOOD PERFUSION TO THE TOES. DIAPER AREA SL PINK. DESITIN\nAPPLIED\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":1884788,"text":"Neonatology Attending Note\nDay 6, PMA 35 2\n\nRA. RR40-60s. Mild sc rtxns. Cl and = BS. Mild desats-sr. HR 130-140s. BP 85/43, 56. Reb bili 10.6/0.2. Wt 2350, up 25. TF 120 BM20/SC20. PO/PG. Tol well. Nl voiding and stooling. Desitin to diaper dermatitis. In off isolette.\n\nA/P:\nGrowing preterm infant learning how to po feed. Adv TF to 140. Follow jaundice clinically, check another Monday.\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884782,"text":"npn 1900-0700\n\n\n1: resp\nremains in ra. one spell with breastfeeding, qsr, see flow\nsheet. rr 30-70's. mild subcostal retractions. no increased\nwob noted. sats 93-100%. lung sounds clear and equal.\nconitnue to monitor for changes in respiratory status.\n\n2; fen\ncurrent weight 2325gms down 50. total fluids remain at\n100cc/kilo/day of bm 20/sc 20. tolerating feeds well. no\nspits. minimal aspirates. voiding and stooling. abd soft\nwith no loops. girth stable. mom breastfed at 2100 and at\n0100, with first care infant latched on and took a few\nsucks, at 0100 care infant latched on and nursed well for\n5-10 minutes. continue to support mom with breastfeeding.\nfull gavage feed given following breastfeeding. continue\nwith current feeding plan.\n\n3: growth and development:\ntemps stable in an air heated isolette. alert and active\nwith cares. sleeps well inbetween. brings hands to face.\nsucks vigorously on pacier. irritable at times. unswaddled\nwith boundaries for phototherapy. continue with current\nfeeding plan.\n\n4; parenting\nmom and dad in for 2100 care. both involved with cares.\nloving and asking appropriate questions. both helping change\ndiaper and do temp. continue to support family while in the\nnicu environment.\n\n6: bili\ninfant remains under single phototherapy. eye shields in\nplace. bili drawn this shift 9.6/0.3/9.4. infant color\njaundiced. continue to monitor for change.\n\n7: skin:\ninfant with newborn rash. infant also with right foot lesion\n\nwith multiple small scabs and open area that is pink. small\namount of serous draingae noted on gauze. dressing changed\nand triple antibiotic ointment applied. no active bleeding\nand no edema noted. continue with dressing changes.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884783,"text":"Neonatology Attending Note\nDay 5, PMA 35 1\n\nRA. RR30-70s. Cl and = BS. Mild rtxns. Occass sat drifts. +2 A&Bs past 24h. HR 130-150s. No murmur.\n\nJaundice, Bili 9.6/0.3, under single photot.\n\nWt 2325, down 50. TF 100 BM/SC20. Tol well. Nl voiding and stooling. Tr mec.\n\nIn air isolette.\n\nA/P:\nCont to monitor mild AOP off caffeine. d/c photot and monitor bili levels in AM. Adv TF to 120.\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884784,"text":"Exam Note\nGEN - asleep in isolette\nHEENT - AFSFO, oropharynx clear, nares patent\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl ext genit\nEXT - wwp, cr < 2s\nNEURO - reactive, MAE\n\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884785,"text":"Exam Addendum\nEXT - RLE wound examined under bandage, c/d/i with appropriate eschar and no signs of infection.\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884775,"text":"Neonatology Attending\n\nDay 4 PMA 35 0/7 wks\n\nRemains in RA. RR 30-60s. Mild retractions. Had four bradycardia episodes over last 24 hours- one with feeding. No murmur. HR 120-160s. BP mean 56. Bilirubin 9/0.4 on phototherapy. Weight 2375g (-30). TF at 80 ml/kg/d. Now on full feeds BM/SC 20. Put to breast daily. Latched. Minimal aspirates. Stable girth. Passing heme negative stool. Stable temperature in air-controlled incubator. Foot infiltrate clean with crust. Treated with triple antibiotic and Telfa. Family meeting yesterday.\n\nDoing well overall with mild breathing control immaturity. Will continue to monitor. Increasing to 100 ml/kg/d today. Monitoring feeding tolerance. Will speak with family today.\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884776,"text":"Lactation Consult\nMet w/ mom/babies this AM to assist w/ latch and assess milk supply. Infants are 4 day old 34 wks, 35 wks corrected today. Infant remains under single phototx and has an ng tube for feeds. Baby went to breast w/o nipple shield first and demonstrated difficulty in latching, and was then trialed w/ nipple shield and did very well. Baby had frequent audible swallows and milk in nipple shield, nursing X 10mins. He was then ng fed for full vol.\nReviewed risks and benefits of using a nipple shield w/ mother, emphasized need to pump 8-12X per 24hrs. Gave mom written material to assess 24 hr milk supply. Will follow this family.\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884777,"text":"Social Work\n\nFamily meeting yesterday, parents doing well, many good questions. Will follow assess need for any additional support.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884778,"text":"Exam Note\nGEN - awake,alert\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl ext genit\nEXT - wwp, cr < 2\nNEURO - reactive, MAE\n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884779,"text":"NPN 7a-7p\n\n\n#1: remains in RA, sating >/= 94%. Rare drift to high\n80's noted with QSR. Brady x1, needing mild stim to\nrecover. RR stable. BBS cl/=. Breathing with mild\nretractions. A: stable in RA P:Cont to monitor and provide\nsupport as needed.\n\n#2: TF's ^'ed to 100cc/k/d. Infant now receiving 43cc q4hrs\ngavaged over 50mins. D/S stable. No spits. Max asp 1.8cc\nslightly green tint. Fellow assessed. Abd soft, +, no\nloops. AG stable. Refed asp and cont'ed with feeds. Infant\nwent to breast x2 today. 1st attempt did well for ~10mins,\nmore consistent latch and suck. 2nd attempt infant was more\ninterested in snuggling with Mom. Latched briefly. Voiding\nqs. Stooled x2 heme negative. A: tol'ing feeds P:Cont to\nmonitor tol to feeds. Follow wt and exam.\n\n#3: Temps stable in an air isolette. Infant can be fiesty\nat times. Sleeps best when nested within boundaries. Will\nalso settle with pacifier, containment and holding. Fonts\nsoft/flat. Brings hands to face. Loves to kangaroo. MAE. A:\nAGA P:Cont to support dev needs.\n\n#4: Parents in for both cares thus far. Mom and\n this am. Better this afternoon. Mom has been d/c'ed\ntoday, but parents are staying in Parent Room overnight. Mom\nmet with LC this am and worked on breastfeeding. LC gave Mom\nnipple . See LC note for details. Parents\nparticipating in cares. Both updated. Both held infant\ntoday. A: Involved, loving family P:Cont to support and\neducate.\n\n#6: Jaundice. Tol'ing full feeds. Voiding and stooling.\nConts under single phototherapy with eye shields on. A:\nhyperbili P:Cont with phototherapy as ordered. Check bili\nlevel in am.\n\n#7: NB rash noted over trunk, face and extremities. Team\nassessed. Right foot noted to have several lesions on it.\nLesion on top of foot has opened pink center with scabbed\nyellow edges. Small amt of serous drainage noted on dsg x1\nfrom that area. No bleeding noted. No edema noted. Other\nscabs intact. Triple antibiotic ointment applied and covered\nwith Telfa dsg.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884780,"text":"NPN 7a-7p cont'ed\n\n7 Skin:\n\n#7cont'ed: Team assessed lesions today. Foot warm to touch\nwith nml pulses. A: healing skin lesions P:Cont with dsg\nchange 3 times a day. Monitor.\n\nREVISIONS TO PATHWAY:\n\n 7 Skin:; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884781,"text":"NICU Infant CPR Class Note\n\nO: Both parents present for infant CPR class at 1800. Watched video and demostration of infant CPR and relieving choking maneuvers by this RN. Both parents practiced on the manikin and were able to demonstrate proper techniques. Reviewed \"Back to Sleep\" brochure and gave to parents. Also gave CPR poster and handout. All questions answered. Both parents stated that they understood all teaching and had no further questions. Class concluded at 1900.\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884769,"text":"NPN 0700-1900\n\n\nResp: Infant received on CPAP 6 with FiO2 21%, weaned\ninfant to RA at 1130. SpO2 89-98%. RR 30s-60s. LS cl/=.\nMild SC retractions. 2 bradys thus far (see flowsheet for\ndetails). P: Cont to monitor resp status.\n\nFEN: TF increased today to 80cc/kg/day. D10W with 2&1\ninfusing at 20cc/kg/day via PIV in left hand without\nincidence. Enteral feeds increased to 60cc/kg/day of\nBM/SC20 = 26cc q4hrs. Plan to advance enteral feeds by\n15cc/kg/day . Will check DS at 1700. Abd soft, full,\n+BS, no loops. AG stable. 3.6 bilious asp at 0900, NNP\naware, discarded asp. No spits. Voiding (see flowsheet for\nu/o this shift). Lg mec stool x1. P: Cont to support\nnutritional needs.\n\nG/D: Temps stable, nested on servo warmer. Infant is a&a\nwith cares. Irritable at times. Appropriately brings hands\nto face and sucks pacifier to comfort self. AFSF. AGA.\nTripple abx oint TID to right foot infiltrate. P: Cont to\nsupport dev needs.\n\nSocial: Mom in for all cares today. Updated on infant's\ncondition and plan of care by this RN. Loving, invested\nparents. Asking appropriate questions. Family meeting\ntoday at 4pm. P: Cont to update & support NICU family.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884770,"text":"Family Meeting\nMet with parents in the family room today. Mother to be discharged home tomorrow. See family meeting checklist for issues discussed. Parents asked many questions that were answered to their apparent satisfaction. Seemed to have a good understanding of the issues. Pedi is .\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884844,"text":"1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\nequal, no retractions seen. No oximetry. Currently on spell\ncountdown, possible discharge tomorrow on day . Continue\nto monitor respiratory status.\n\n2. FEN-Infant is on adlib po demand schedule of BM 24 with\n powder. Infant bottling 45cc's this morning with Playtex\nnurser and breastfeeding with mom this afternoon. Eager\nbottler and breastfeeder. Abd soft. Voiding and stooling\nheme negative. No spits. Destitin applied to bottom with\neach diaper change. Continue to encourage po feeds.\n\n3. DEV-Infant has stable temperatures swaddled in OAC.\nWaking q3-3.5 hours to be feed. and active during\ncares, resting well in between. Continue to support\ndevelopmental needs.\n\n4. PARENT-Mom and dad in this afternoon. Loving towards\ninfant and independent with cares. Made pedi appt for \non Monday due to holiday. Excited for possible discharge\ntomorrow. Continue to educate and support .\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884845,"text":"NPN\n\n\nI have examined the infant and agree with the above note\nwritten by PCA.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884846,"text":"#2FEN\nWt 2.725 up 20g. Baby waking q4h to bottle. Bottled 70/75cc\nwith playtex bottle. Void and stooling. Stool heme neg. No\nspits. Abd soft, active bowel sounds. Desitin applied to\ndiaper area.\nA. Tol feed and gaining weight\nP. Cont to monitor tol to feed\n#3Dev\nTemp stable in an open crib. Waking for feeds\n#4Parent\nNo contact this shift\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884847,"text":"Neonatology Attending\n\nDay 18 PMA 37 0/7 WKS\n\nRemains in RA. RR 30-60s. Had 6.5 seconds heart rate drop seen on pneumocardiogram yesterday that was quickly self-resolved. No murmur. HR 140-170s. BP mean 46. Pink. Weight 2725g (+20). On BM 24 with formula powder. Took 124 ml/kg. Occasional choking with feeds. Benign abdomen. Passing heme negative stools. Waking every 4 hours. Passed hearing screen and car seat position study.\n\nDoing well overall. Feeding well and gaining weight. Heart rate drop not clinically significant so ready for discharge. Appointment with primary pediatrician on Monday. Discharge summary pending. Will update pediatrician.\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884848,"text":"Exam Note\nGEN - NAD, active\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+S2, no M\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2 sec\nNEURO - MAE, reactive, +grasp/suck/moro,\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884849,"text":"NPN 0700-\n\n\n2. Infant on ad lib demand feeds of BM24 with powder.\nWaking Q3-4hr and taking 50cc and 80cc thus far. Bottles\nwith playtex fast flow nipple. Abdomen benign. Voiding and\nstooling; heme negative. Ferinsol and Multivit. given.\nTolerating all bottles without spits. Plan to D/C home this\nafternoon.\n\n3. Temp stable swaddled in open crib. Waking for feeds as\nnoted above. Rest well inbetween cares. MAE, brings hands\nto face and mouth. Suckles well on pacifier. AGA. To be\nd/c'd later today.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884850,"text":"NPN discharge note\nVSS, exam benign; see flowsheet for details. Reviewed NICU D/C instruction form with . Infant D/C home with in car seat. Breast milk given to .\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884763,"text":"NPN\n\n#1 S. O. Received infant on a cpap of 6 with fio2 21% to\n23%. Breath sounds clear and equal with subcostal\nretractions noted. R.R.30's to 70's. O2 sats 94 to\n98%.There have been no a's or b's noted at this time. A.\nInfant with a hx of respiratory distress. P. Discuss with\nteam in the am regarding plan for trial off of cpap.\n\n#2 S. o. Weight down 45 grams. Voiding with 24 hour urine\noutput 1.6cc/kg/hr. Infant passed trace mec stool. Piv of\nd10w with lytes infusing well via left hand piv. Total\nfluids = 60cc/kg/day. Right foot infiltrate site pink/red\nwith no drainage noted.Right foot elevated. Infant had a\n1.4cc bilious aspirant at the 0100 care. Abdomen softly\ndistended with good bowel sounds and no loops. NNP\nnotified.Aspriant discarded. Feeds not advanced at that\ntime. A. ? bilious aspriant related to slow gastric\nmotility. P. Monitor closely. Assess for advancemnet on\nfeeds at the next care.\n\n#4 S. O. Parents in for the 2100 care. Parents updated by\nthis R.N. at the bedside. A. Loving parents. P. Support\nand keep updated.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884764,"text":"5 ID\n\nREVISIONS TO PATHWAY:\n\n 5 ID; resolved\n\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884765,"text":"Neonatology Note\n3 d.o\non CPAP + 6 this am and wean to RA now\n2 spells this am, self resolved.\nwt= 2405 gm -45\nTF at 60 ml/kg/d with IV and feeding at 45 ml/kg/d with EBM/SC 20, 2 aspirates noted\nvoiding(+), bm(+)\n141/6.4/110/21\nbili=9, under phototherapy\n\nA: twin #1, ex 34 wks GA, resolving RDS, hyperbilirubinemia, R foot infiltration resolving\nP: continue advancing feeding and monitor tolerance, monitor spell, f/u bilirubin\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884771,"text":"NPN Noc\n\n\n#1 Resp: RA, 30-60's, c/=, mild SC retrac. No spells so far\nthis shift. P: Cont to monitor resp status.\n#2 FEN: TF=80cc/kg, infant currently on full feeds, BM/SC20.\nPo/pg feeding, infant took 14cc po x 1. Abd benign, AG 26,\nV/S, mec stooling. P: Cont to monitor FEN status.\n#3 G&d: Temp stable in air isolette, nested. Alert, active,\nand sl irritable with cares. Enjoys his pacifier, MAE, opens\neyes, AFSF. IV infiltrate to right foot, triple abx ointment\napplied and wrapped in sterile gauze. Area is sl swollen,\nsmall scabs surrounding small open area on top of foot. P:\nCont to monitor and support G&D, cont with triple abx to\nright foot breakdown.\n#4 Parents: Parents in for eve caretimes. Mom participated\nin cares, briefly held infant. Asking appropriate questions.\nP: cont to encourage parental calls and visits.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884772,"text":"NPN Noc\n#6 Bili: Infant appears jaundiced, cont on single spotlight phototherapy. P: Cont phototherapy, will check bili on Thurs AM.\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884773,"text":"6 Alt in Bili\n\nREVISIONS TO PATHWAY:\n\n 6 Alt in Bili; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884774,"text":"NNP Physical Exam\nPE: pink, AFOF, breath sounds clear/equal with easy WOB, no murmur, well perfused, abd soft, full, + bowel sounds, e tox rash, right foot wound from IV infiltrate with moist scab, does not look infected, active with good tone.\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884837,"text":"NPN 0700-1500\n\n\n#2 O: Infant remains feeding ad lib amounts of BM24 made\nwith similac powder. Bottling 60cc's. Abdomen round and soft\nwith + BS. Voiding and stooling. No spits. A: Tolerating\nfeeds. P: Cont to monitor.\n\n#3 O: Maintaining temp in oac; cobedding with twin. Awake\nand with cares; sleeping well between. AFSF. Swaddled\nin blanket; brings hands to face for comfort and sucks on\npacifier. A: AGA. P: Cont to support development.\n\n#4 O: Both in to visit. Asking appropriate\nquestions. Reviewing d/c teaching for sibling. Mom\nbreastfeeding while here and pumping. Plan to take other\ninfant home this afternoon. A: Involved, loving. P: Cont to\nsupport and update.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884838,"text":"Rehab/OT\n\nMet at the bedside. Reviewed back to sleep protocol and activities birth through one worksheet. Discussed SIDS precautions and EI qualifications. No further in house needs. D/C OT.\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884839,"text":"Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no M\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2\nNEURO - MAE, reactive\n\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884840,"text":"Nursing Progress Note 1900-0700\n\n\nF/E/N:Infant cont's on Ad lib demand schedule waking q 4\nhrs.TF over 24 hrs 122cc's/kg/day.Infant bottling with a\nPlaytex nipple and taking 70-90cc's q time.Weight=2.705 up\n25 grams.Abd. soft with pos bs,no loops or spits.Voiding and\nstooling heme negative stool.\n\nG/D:AF soft and flat. and active with cares.Sleeping\nwell b/t.MAE.Bringing hands to face and mouth.Sucking\nintermitently on pacifier.Infant presently swaddled in open\ncrib.Temp. stable.\n\nParenting:Mom called x 1.Updated by this RN.Asking\nappropriate questions very loving and invested.Other twin at\nhome per mom and doing well.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884766,"text":"NNP Physical Exam\nPE: exam this am while on CPAP. pink, jaundiced, AFOF, CPAP prongs in place, breath sounds clear/equal with easy WoB, no grunting, good air entry, no murmur, well perfusion, abd soft, non distended, non tender, active bowel sounds, IV infiltrate right foot with superficial scabs on dorsum of the foot, no redness or drainage, active with good tone.\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884767,"text":"NPN 0700-1900\nBili: Bili this am was 9.0/0.4, down from 9.6/0.3. Infant remains under single phototherapy wtih eye shields on. Plan to recheck bili am.\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884768,"text":"Respiratory Care Note\nBbay Boy I was weaned from +6 to +5 prong CPAP this am and then was taken off CPAP at noon. Placed in RA. BS clear. RR 30's-60's. No bradys noted since he has been off CPAP.\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884832,"text":"NPN Days\n\n\n#1 Pt has had no spells so far this shift. Pt day \nof spell count down. P- Will cont to monitor resp status.\n#2 Pt ad lib demand. BM24 with powder. all po\nfeeds. Took 70cc this am and BF well while were\nvisiting. abd benign. voiding and stooling. no spits. P-\nWill cont to monitor FEN.\n#3 G&D- Temp stable in open crib. cobedding with sibling.\n and active with cares. irritable at times. sucking on\npacifier. using playtex bottle with fast flow nipple to\nfeed. P- Will cont to monitor G&D.\n#4 Mom called x1 this am. updates given. Both\n visiting @1300. Participating in cares. feeding pt.\nDC teaching done with both re: carseat safety,\nfeeding, bowel and bladder, back to sleep. declined\ncirc. P- Will cont DC teaching.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884833,"text":"NPN Days\naddendum:\n Pt passed hearing screen.\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884834,"text":"Neonatology Attending\nDOL 15 / PMA 36-4/7 weeks\n\nIn room air with no apneas/bradycardias in 2 days.\n\nNo murmur. BP 68/41 (51).\n\nWt 2655 (+35) on ad lib with intake 119 fcc/kg/day BM24 in addition to breastfeeding well. Abd benign. Voiding and stooling normally (heme negative). On iron.\n\nTEmp stable in open crib. Hepatitis B immunization administered.\n\nA&P\n34-3/7 week GA infant with resolving respiratory immaturity\n-Continue to monitor until free of apnea/bradycardia for at least 5 days prior to discharge home\n-Discharge planning in progress\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884835,"text":"NPN/1900-0700\n\n\n#2 FEN: Wt 2680, ^25gms. Ad libe demand feeding, BM24.\nTaking all po's; bottled 149cc/k + breastfeeding this\nprevious 24hrs. Taking 60-80cc Q4hrs. No spits. Abd. exam\nbenign. V/S. Cont. to support nutritional needs.\n#3 DEVELOPMENT: Swaddled in oac; cobedding with twin. Temps\nstable. Active/ w/ cares; sleeps well b/t. Wakes on\nhis own Q3.5-4hrs to feeds. Sucks on pacifier. MAE/AFOF.\nAGA. Support developmental needs.\n#4 : visiting during the day shift; no\ncontact over .\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884841,"text":"Neonatology Attending\n\nDay 17 PMA 36 wks\n\nRemains in RA. RR 50-70s. Clear breath sounds. Day without bradycardia. No murmur. HR 140-160s. BP mean 54. Weight 2705 g (+25). On ad lib demand. On BM 24 with formula powder. Benign abdomen. Passing heme negative stool. On iron. Waking for feeds. Stable temperature in open crib. Passed hearing screen and car seat study.\n\nDoing well overall. Will continue to monitor closely. Feeding well and gaining weight. Will be ready for discharge tomorrow if remains spell-free.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884842,"text":"Lactation Consult\nMet w/ family @ 1pm to assess infant latch. Baby latched on beautifully w/ nipple having frequent audible swallows and milk present in . Mom held infant by football hold and is pleased w/ feeding. plan to nurse infants at home following up w/ bottles of 24cal breast milk. Advised to monitor baby's voids and stools at home and assess for swallows at the breast.\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884843,"text":"Exam Note\nGEN - NAD, active and \nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no M, fem pulses 2+ bilat\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash, stool present\nNEURO - MAE, reactive\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884836,"text":"Neonatology Attending\n\nDay 16 PMA 36 wks\n\nRemains in RA. RR 40-70s. Clear breath sounds. No bradycardia- day . No murmur. HR 150-160s. Pink. BP mean 59. Weight 2680g (+25). Ad lib BM 24 with formula powder. Taking 60-80 ml per feed- 149 ml/kg total- and breast feeding. Passing heme negative stool. Feeding tube out. No spits. Stable temperature in open crib. independent with care.\n\nDoing well overall. Maturing breathing control. Will continue to monitor closely. Needs 2 more days spell-free. Received hepatitis B vaccine. Passed hearing screen. Will speak with mother this morning.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884819,"text":"#1Resp\nLungs clear with mild retractions. No spells. Appears\ncomfortable\n#2FEN\nWt 2.615 up 30g. Baby has bottled entire volume at 2100 and\n0100. Abd soft, active bowel sounds. Void and stooling. One\nsmall wet burp. Min asp. Cont to receive BM24.\nA. Tol feed and gaining weight\nP. Cont to monitor tol to feeds as well as weight gain.\nEncourage po feed ability\n#3Dev\nWaking for feeds. Maintaining temp in crib. Interested in\nbottling\n#4Parent\nno contact so far.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884820,"text":"Cafe spot noted on R side of forehead.\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884821,"text":"Neonatology Attending Note\nDay 13, PMA 36 2\n\nRA. RR40-60s. Mild intermittent sc retractions. No A&Bs. No murmur. HR 130-150s. BP 86/44, 56. Wt 2615, up 40 gms. TF 150 BM24. Just transitioned to all PO last night. Nl voiding and stooling. In open crib.\n\nA/P:\nGrowing preterm infant with improving PO skills. If continues to do well with PO feedings will plan for discharge Monday. PO feedings q other BF. Monitor weight with this suppl plan.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884822,"text":"Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear, NGT out of nose, nares intact\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no M\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2 sec, dorsum c/d/i\nNEURO - MAE, reactive\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884823,"text":"Case Management Note\nReferral called to Care Group VNA today (/fax ) and have made home visit for Wednesday . Team anticipates home d'c Monday . If this date needs to be chnaged, please call VNA to reschedule. All in agreement w/plan.\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884745,"text":"Admission Note\nNeonatology Admission H&P\n\nBaby is a newborn 34 wk twin infant admitted to the NICU with prematurity and respiratory distress.\n\nHe was born at 12:30 am this morning as the 2575 gram product of a 34 wk twin gestation pregnancy to a 28 y.o. G1 P0-2 mother with . Prenatal labs included BT A+/Ab- and GBS unknown; remainder were unavailable at time of delivery but were reportedly negative. Pregnancy was IVF-assisted di/di twin gestation, and was reportedly unremarkable until when mother presented to PMD for evaluation of URI symptoms and was found to be hypertensive. She was sent to , and was also found to have proteinuria and elevated uric acid, consistent with preeclampsia. BPP was . With relatively advanced gestational age, delivery was recommended. Last EFW on was 2289; concordant growth was noted throughout pregnancy.\n\nFamily history and social history are otherwise non-contributory.\n\nInfant was born via c-section for twin gestation. At delivery, twin A emerged with moderate tone and good cry, with Apgars . He required blow-by oxygen for duskiness with gradual improvement, and was brought to NICU with moderate work of breathing noted.\n\nPhysical Exam:\nWt 2575 gm (75-90%) HC 32 cm (50-75%) L 48 cm (75-90%).\nVS: T 97.7, HR 160s, RR 50s, O2sat 80s in RA, 90s with O2, BP pending.\nGen: WD premature infant, moderate resp distress, active and vigorous, overall appearance consistent with EGA.\nSkin: warm, dry, pink with oxygen, no rash.\nHEENT: fontanelles soft and flat, ears/nares normal, palate intact with mildly high arch, +RR bilaterally.\nNeck: supple, no lesions.\nChest: coarse, poorly aerated, + g/f/r.\nCardiac: RRR, no m, femoral pulses 2+.\nAbdomen: soft, quiet BS, no mass, no HSM, 3VC.\nGU: normal male, testes palpable bilaterally, anus patent.\nExt: hips/back normal, no lesions.\nNeuro: appropriate tone, activity, intact moro/grasp.\n\nIMP: Newborn 34 wk twin, delivered secondary to maternal preeclampsia, currently with moderate respiratory distress likely secondary to RDS. Low risk of sepsis given circumstances of delivery.\n\nPLANS:\n- Admit NICU.\n- Monitor resp status closely, likely will need CPAP.\n- O2 as needed.\n- CXR, ABG if resp status worsens.\n- Consider intubation/surfactant if FiO2 high or worsening respiratory distress or hypercarbia.\n- Monitor hemodynamics.\n- NPO, maintenance IVF.\n- Periodic monitoring of dstiks, lytes, bilirubin.\n- CBC with diff, blood cx.\n- Low threshold for abx as pneumonia cannot be ruled out given respiratory distress.\n- Thermoregulatory support on warmer.\n\nParents updated in delivery room.\n\nPMD: , .\nOB: , delivered by .\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884746,"text":"Admission Note\nHep B: Maternal HBsAg resent. Will give HBV if results not available by 12 hrs of life.\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884747,"text":"Respiratory Care\nSee attending and nursing admit notes for hx and further details. Infant GFR on arrival to NICU. Given facial CPAP then placed on prong CPAP 6. BS diminished. 02 req on CPAP 26-30%. CXR done to assess lung fields. Persistant grunting on CPAP, subcostal retractions. CBG: 7.28/47/45/23/-4. RR 30's-60's. Grunting significantly improved, presently intermittent. Will cont to follow closely, support as indicated.\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884813,"text":"npn 1900-0700\n\n\n1: resp\nremains in ra. no spells and no dsats. lung sounds clear and\nequal. mild subcostal retractions. no increased wob noted.\nrr 40-70's. sats >97%. continue to monitor for changes in\nrespiratory status.\n\n2; fen\ncurrent weight 2560 gms up 20. total fluids remain at\n150cc/kilo/day of bm24 cals tolerating feeds well. no spits,\nminimal aspirates. voiding and stooling. stool hem negative.\n\nabd soft with no loops. infant continues on iron. infant\npo'd 20cc's at 2100 and then 50cc at 0100. infant waking\nfor both cares. remainder of volume gavaged. continue with\ncurrent feeding plan.\n\n3: growth and development\ntemps stable in an oac. alert and active with cares. sleeps\nwell inbetween. brings hands to face. sucks vigorously on\npacifier. wakes for feedings. aga. continue to monitor for\ndevelopmental milestones.\n\n4; \nno contact thus far this shift from \n\n6: \ninfant currently off of phototherapy. sent this shift\npending. continues to be jaundiced in color. continue to\nfollow .\n\n7: skin\ninfant continues on triple antibiotic ointment to right\nfoot. infant's right foot with scabbing from old infiltrate\nsite. no drainage or bleeding noted. continue with current\nplan of care.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884809,"text":"I have examined and agree with the above note.\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884810,"text":"Neonatology Attending Note\nDay 11, PMA 36\n\nRA. Cl and = BS. No A&Bs. +murmur. HR 140-160s. BP 67/37, 47. Under photot. Bili 6.5/0.2. Wt 2540, up 70. TF 150 BM24. PO/PG. Tol well. Nl voiding and stooling. In air isolette.\n\nA/P:\nGrowing preterm infant learning how to po feed. Will begin Fe. d/c photot and check reb bili in AM.\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884814,"text":"Neonatology Attending Note\nDay 12, PMA 36 1\n\nRA. RR40-70s. CL and =. No A&Bs. No murmur. HR 130-150s. BP 67/45, 53. 6.5/0.2 (reb). Wt 2560, up 20 gms. TF 150 BM24. po/pg. Nl voiding and stooling. On Fe. Co-beeding in open crib.\n\nA/P:\nGrowing preterm infant awaiting maturation of feeding abilities.\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884815,"text":"PCA Progress Note \nI agree with the above PCA note and have assessed the pt. see flowsheet for further details.\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884816,"text":"PCA Progress Note \n\n\n#1 RESP: Infant remains in room air breathing 50-60s with\nmild subcostal retractions. LS clear/equal, oximetry d/c'd\nthis morning. No spells this shift. Breathing comfortably in\nroom air. Continue to monitor respiratory status.\n\n#2 FEN: TF 150cc/kg/day BM24. 64cc q4hours. Infant finished\nwhole bottle this morning, then breast fed with mom at \ncares and half volume bottle. Uses Playtex\nbottle/nipple. Abd benign, no loops, +BS. No spits, minimal\naspirates. Voiding and stooling heme neg. Tolerating feeds.\nContinue to encourage POs.\n\n#3 DEV: Stable temps swaddled cobedding with twin brother.\n and active with cares, sleeping well between and\noccasionally waking early. MAE. AFSF. Brings hands to face,\nenjoys pacifier. AGA. Continue to support developmental\nneeds.\n\n#4 SOC: Mom in for cares. Independent with son. Updated\nat bedside by RN. Asking appropriate questions. Loving\nfamily. Continue to update and support.\n\n#6 : Photo tx has been off since morning of 15th. \nfrom last night 6.5/0.3, remaining the same as the day\nbefore. Infant slightly jaundiced/well perfused. Continue to\nmonitor.\n\n#7 SKIN: Scab on right foot from IV infiltration healing\nwell. Triple antibiotic applied, then d/c'd this morning.\nContinue to monitor.\n\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884811,"text":"NPN 7a-7p\n\n\n#1 Resp: Infant in room air w/resp rate 40s-70s and sat\n97-100%. Lung sounds cl/= and mild SC retractions. No spells\nso far this shift. A: Infant stable in room air w/no spells.\nP: Cont to monitor.\n\n#2 FEN: TF 150 cc/kg of BM 24 (64 cc q4h gavaged over 50\nmin). Po/pg. Infant bottled 52 cc @ 0900 cares w/remaining\nvolume gavaged. BF well for 20 min @ 1300 cares and was\nsupplemented with half volume gavage. No spits, min asp.\nAbdomen round, pink, and soft w/active bowel sounds and no\nloops. Voiding and stooling heme neg. Now on iron. A: Infant\nimproving with po feedings and is well coordinated. P: Cont\nw/current plan and encourage po feedings as tol.\n\n#3 Dev: Received infant nested in air isolette. Infant now\nswaddled in an open crib, cobedding with brother. \nstable. Alert and active during cares and sleeps well in\nbetween. Wakes early for most feedings. Periods of quiet\nalert. A: AGA. P: Cont to supp dev needs.\n\n#4 : Mom in @ 1300 and was updated. Mom took temp,\nchanged diaper, and BF infant. A: Independent and\nappropriate w/cares. P: Cont to supp and update. Plan to\nprovide bath and teaching @ 1700 cares.\n\n#6 : Photo rx d/c @ 1030. A: Infant appears jaund. P:\nCont off photo rx and plan to check am.\n\n#7 Skin: Infant cont triple antibiotic ointment to scabbed\narea on R foot on old IV infiltrate site. No redness or\ndrainage noted.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884812,"text":"Exam Note\nGEN - calm, NAD\nHEENT - 15-20 blanchable erythematous macules 3-5mm in diameter on face, no excoriation or secondary infection, c/w erythema toxicum. Otherwise, AFSFO, oropharynx clear, NGT w/o breakdown\nCV - RRR, nl s1+s2 no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nEXT - wwp, R foot c/d/i, cr < 2 sec\nNEURO - reactive, MAE\n\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884759,"text":"NPN 0700-1900\n\n\nResp: Infant remains on CPAP 6, FiO2 24-27%. RR 30s-50s.\nLS cl/=. Mild SC retractions. No A's or B's thus far. P:\nCont to support/monitor resp status.\n\nFEN: TF 60cc/kg/day. D10 with 2Na & 1K infusing via left\nhand PIV at 30cc/kg/day. Right foot PIV infiltrated at 0900\nwith excoriated skin d/t tape noted; NNP aware & right foot\nelevated and left OTA. Enteral feeds started today at\n30cc/kg/day of BM/SC20 = 13cc q4hrs. Plan to increase\nenteral feeds by 15cc/kg/day at 1a &1p. DS 74 at 1100.\nAbd full, soft, +BS, no loops; no spits. AG 27. u/o\n1.2cc/kg/hr thus far. No stool. Lytes this am were\n143/4.6/108/22. P: Cont to support nutritional needs.\n\nG/D: Temps stable, nested on sheepskin with boundaries in\nplace on open warmer. Infant is a&a with cares. Irritable\nat times, settles well when left alone. Appropriately\nbrings hands to face & sucks pacifier to comfort self.\nAFSF. AGA. P: Cont to support dev needs.\n\nParents: Mom in for 0900 cares. Speaking lovingly to\ninfant. Updated on infant's condition and plan of care.\nAsking appropriate questions. P: Cont to update & support\nNICU family & plan for family meeting tomorrow at 4pm.\n\nID: IV abx d/c'd. Problem resolved at this time.\n\nBili: Bili this am was 9.6/0.3, up from 1.7/0.3 Infant\nplaced under phototherapy lights at 1130. Infant is\njaundice. Plan to recheck bili in the am. P: Cont to\nmonitor bili status PRN.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884760,"text":"NP NOTE\nPE: well developed preterm infant swaddled in open warmer. PInk, jaundiced in RA CPAP. Edematous.\nAFOF sutures approximated, eyes clear, puffy, nares patent with prongs in place, MMMP, white, frothy secretions\nChest is clear, fair exchaneg, mild SCR. Fair exchange, shallow.\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs cord dry\nGU: testes ins crotum\nEXT: PIV in left hand, right foot edematous with IV infiltrate.\nNeuro: active, responsive. Flexed posture, good tone, symmetric reflexes.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884761,"text":"Respiratory Care\nPt cont on prong CPAP. Fio2 .24-.27. bs clear, rr 50-70 with mild retractions. On caffeine. No spells. Plan to support as needed. Consider trial off in near future. Will follow.\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884762,"text":"RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 21-24%. RR 30-70's Breath sounds are clear. Stable on CPAP cont to follow. Plan to wean off CPAP soon.\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884827,"text":"Neo Attending note\nday 14, now 36.3 wk pma\nwt 2620, up 5 gm.\nCV: no murmur, hr 150s, bp 63/40, 48j\nrespr: ra, rr 3040s, clear=bs, 1qsr brady with apnea / periodic breathing. Thus countdown restarts today = D 0/5.\nTF: 150 cc/kg/day. BM24 all po + BFx2 per day. BF well.\nuop and stool wnl, heme neg.\nabd wnl. 7.5 stable. no spits.\ntemp stable in crib. State Newborn screen sent. HepB immunization today.\nCar seat: wait until bradycardia have continued to improve.\nhearing screen pending, pending.\n\nassessment: due to brady/apnea/periodic breathing, infant will continue CVR monitoring with oximeter.\notherwise assement is as noted above.\nPlan: as noted above.\n\nPt evaluated and discussed with team.\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884807,"text":"1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\nequal, mild subcostal retractions seen. O2 sats are >97%. No\nspells so far this shift, last one on . Continue to\nmonitor respiratory status.\n\n2. FEN-TF=150cc/kg of BM/SC now 24 or 64cc q4hrs PO/PG.\nInfant offered bottle at 0900 care, bottled 18cc's using\nPlaytex bottles. Eager bottler at first but tires easily.\nMom put infant to breast at 1300, infant latched and\nbreastfed for about 10 minutes. Infant asleep for third care\nand mom was unable to put to breast. Full feed gavaged\nafterward over 50 minutes. Abd benign. Voiding and stooling\nheme negative. No spits. Minimal aspirates. Continue to\nencourage po feeds as tolerated by infant.\n\n3. DEV-Temperatures stable in air isolette under neoblue\nlight. Wakes occassionally for cares. Alert and active\nduring first two cares, asleep with last care. Continue to\nsupport developmental needs.\n\n4. PARENT-Mom in afternoon. Updated by RN. Loving towards\ninfant, independent with care. Continue to educate and\nsupport .\n\n6. BILI-Infant remains under neoblue with eye shields in\nplace and slighly jaundiced in color. Yesterdays bili was\n12.3 (0.3). Bili to be rechecked in am. Continue to monitor\nbili.\n\n7. SKIN-Infants right foot continues to heal, small scab\npresent. Triple antibiotic ointment applied as ordered by\nRN. Continue to monitor skin integrity.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884808,"text":"PCA Progress Note 1900-0700\n\n\n#1 RESP: Pt. remains in RA breathing in the 40-60s with\nmild subcostal retractions. Lung sounds cl+= bilaterally.\nNo episodes of apnea or bradycardia so far this shift. P:\nContinue to monitor respiratory status.\n\n#2 FEN: Weight: 2540g ^ 70g. Total fluids: 150cc/kg/d of\nBM/SC 24= 64cc Q4hrs PO/PG. Pt. was put to breast @ 2100\nwith +latch and good coordination for > 10minutes, full\nfeeding gavaged. Pt. took 20cc using the playtex nurser @\n0100. Abd soft and round, +BS, no loops. No spits.\nMinimal aspirates. Pt. is voiding, stooling heme neg. P:\nContinue to encourage po feedings as tolerated.\n\n#3 G&D: Temps stable nested in air isolette. Alert and\nactive during cares. Sometimes waking for feedings. Rests\nwell inbetween cares. MAE. AFSF. P: Continue to support\ndevelopmental needs.\n\n#4 Parenting: Mom and Dad in @ 2100. Mom independent with\ncares and breastfeeding. Mom called X 1. Very loving and\ninvolved. Updates given. P: Continue to support and update\nfamily.\n\n#6 BILI: Pt. remains under neoblue lights with eye shields\nin place. Pt. is sl jaundice. Stooling. Last bili:\n12.3/0.3. Bili was drawn this morning, results pending. P:\nContinue to monitor.\n\n#7 Skin: Scab noted on right foot. Healing, no drainage or\nredness noted. Triple antibiotic applied as ordered. P:\nContinue to monitor.\n\nPlease see flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884802,"text":"Exam Note\nGEN - alert, fussy in air crib under bili lights\nHEENT - AFSFO, oropharynx clear, eye covers intact, NGT w/o breakdown\nCV - RRR, nl s1+s2, no murmur\nABD - soft, NT, NT, no mass\nGU - nl ext genit, no rash\nEXT - wwp, cr < 2 sec\nNEURO - MAE< reactive\n\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884803,"text":"NPN 07p-07a\n\n\nRESP\nRA, LS clear & equal with mild subc. retractions. RR30-60's.\nNo spells or desats this shift thus far. Cont. monitor resp.\nstatus.\nFEN\nCurrent weight 2470g (^50). TF 150cc/kg/day, BM/SSC20.\nTolerating well. Gavaged q4hrs/bottled x1 this shift thus\nfar 20cc (coordinated, quickly tiring). BS active. Abd.\nsoft, round. Voiding, stooling heme negative. Cont. monitor\nPO/PG feeding tolerance & weight.\nG&D\nIn air isolette, temps stable. Nested. Alert & active with\ncares. Resting comfortably inbetween. Fontanels soft, flat.\nMAEs. PPPx4ext. Cont. monitor growth & developm. patterns.\n\nMOB updated over phone x1. Loving & caring. Cont. support &\neducate.\nBili\nCont. under neoblue bank, eye shields in place. VS stable.\nAlert & active with cares. Voiding, stooling. Cont. monitor\nfor changes.\nSkin\nCont. with scabbed area on right foot, no redness, drainage\nor swelling noted. Triple antx ointment applied as ordered.\nCont. monitor for changes.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884804,"text":"Neonatology Attending\n\nAdvancing to 24 cals/oz feed. Will discontinue phototherapy.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884805,"text":"Neonatology Attending\n\nDay 10 PMA 35 wks\n\nRemains in RA. Clear breath sounds. No bradycardia. No murmur. BP mean 45. Weight 2470g (+50). TF at 150 ml/kg/d- BM/SC 20. Bottling 20-30ml per feed. Passing heme negative stool. Stable temperature in air-controlled incubator. Stable temperature.\n\nDoing well overall. Monitoring for apnea. Tolerating feeds well. Gaining weight well. Encouraging po feeds.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884806,"text":"I have examined baby boy I and agree with the above note written by , PCA.\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884754,"text":"NPN Days\n\n\n#1 Resp: CPAP 6 26-32%. 40-80's with occ increased\ntachypnea, mild SC retrac, LS c/=, with intermittent\ngrunting noted. Occ sat drifts, one spell so far this shift,\nresolved with mild stim and increased 02. P: Cont to monitor\nresp status, will check CBG this eve.\n#2 FEN: TF=60cc/kg D10W infusing via PIV without diff. Abd\nbenign, infant cont to be NPO, V/S, mec stooling. P: COnt to\nmonitor FEN status, check lytes and bili in AM.\n#3 G&D: Temp stable on off warmer, swaddled. Alert and\nactive with cares, occ irritable, given sucrose. Sleeps well\nin between cares. P: Cont to monitor and support G&D.\n#4 Parents: Parents in for cares, participated where able.\nAsking appropriate questions, updated frequently by this RN.\nAppear very loving towards infant. P: Cont to encourage\nparental calls and visits.\n#5 ID: Temp stable, infant acting appropriately. Bld cx NTD,\non Amp and Gent. P: F/u with cxs, d/c'd abx at 48hrs.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884755,"text":"Respiratory Care Note\nInfant remains on NCPAP +6, 26-32% - BS sl. diminished, RR's 40's-70 with some intermittant grunting - no spells thus far - occasional saturation drifts - continue to monitor - blood gas this afternoon.\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884756,"text":"RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 23-32%. Breath sounds are clear. RR 40-80's occasional grunting. Stable on CPAP cont to follow closely.\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884757,"text":"Nursing NICU Note\n\n\n1. REsp. O/ Intermittent grunting noted. Remains on Nasal\nProng CPAP of 6, 21-30% primarily. Please refer to\nflowsheet. NO A/B noted. A/Alt. in REsp status. P/Cont. to\nmonitor resp status and intervene as needed. Murmur noted\nand reported to NNP. A/Resp status remains stable at this\ntime on CPAP. P/Cont. to monitor for evidence of resp\ndistress.\n\n2.F/N. O/ Tf remain at 60cc/k/d of IVF D10 with 2 NaCl/dl\nand 1meq KCL/dl via new PIV. Please refer to flowsheet for\nexaminations of pt from this shift. Remains NPO.\nIntermittently sucking on pacifier.\n\n3. G/D. O/TEmp remains stable swaddled on a warmer. AWake\nand alert at care times and sleeping well in between. A/Alt.\nin G/D. P/Cont. to support pt's growth and dev. needs.\n\n4. Parents. O/Parents into visit last night. Parents updated\non pt's status and plan of care. Father held infant\nswaddled. A/Parents are involved in pt's care.; P/Cont. to\nsupport and educate parents.\n\n5. ID. O/Anitbiotics d/c. NNP stated that she corrected lab\nerror. A/Completion of 48hr r/O. Cont. to monitor for s/s of\n infection.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884758,"text":"Neonatology Note\n2 d.o\non CPAP+6, RA-30%O2, no caffeine\nbili= 9.6\nwt= 2450 gm -50\nTF at 60 ml/kg/d, NPO\nvoiding(+), bm(+)\nlytes: 143/4.6/108/22\n\nA: twin #1, 34 wks GA, RDS, sepsis evaluation, hyperbilirubinemia\nP: monitor respiratory staus on CPAP, wean O2 as tolerated, start feeding, start phototherapy, f/u bili.\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884824,"text":"Nursing Progress Note\n\n\n#1 Resp-- O: RA. No spells. HR 160s; HR 50s-60s. Color\npink/sl jaund. BS clear and =, mild sc ret. A: Day 4 of 5 P:\nCont to monitor vitals, document spells\n\n#2 Nutrition-- O: 150cc/kg/d= 65cc BM24- HMF d/c- powder\n4cal/oz started. Po fed well at 0900 taking 70cc., tol well.\nBF x20 min at 1300 well- no supplement after breast. wakeful\nfor long period after feed. NG d/c. Abd exam benign, VQS, sm\nyellow stool x2. Desitin to reddened butoocks (skin intact).\nOn iron. A: Adequate growth, all po x 24h. P: Cont to\nmonitor intake and growth. Plan to supplement BF every other\nBF session with bottle. Switch to pwder 4cal/oz. repeat\nPKU and in am.\n\n#3 Development-- O: and active, waking for feeds.\nHands to mouth, and sucking on pacifier. Temp stable,\nco-bedding with twin. All po feeds. Social with Mom. A: AGA\nP: Cont to support development; Hep B vaccine tonight\n\n#4 Parenting-- O: Mom in at 1300. Updated re status and\nplan. pleased with progress. Mom upset about baby taking\nfeeding by regular nipple overnight and prefers the Playtex\nNurser. Will bring in car seat ; will decide about\ncirc with dad by called, referral to Caregroup\nwith tentative visit next Wed. Mom to make pedi appt\ntentatively for next Tues with tentative discharge date Mon.\nA: Nearing discharge P: Cont to support and keep informed;\ncont discharge planning- car seat test ; Hep B,\nPKU, & over night.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884825,"text":"NNP Physical Exam\nAwake and . AFOF with good tone. Breaht sounds clear and equal on RA without retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded wiht active BS, no HSM or masses. Normal GU.\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884826,"text":"npn 1900-0700\n\n\n1: resp\nremains in ra. infant has had one spell thus far this shift.\ninfant brady was to 74, apneic, qsr. see flow sheet. lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. rr 30-40's. continue to monitor for\nchanges in respiratory status.\n\n2; fen\ncurrent weight 2620gms up 5gms. total fluids remain at\n150cc/kilo/day of bm 24 cals with powder. tolerating\nfeeds well. taking all po feeds. infant taking 50cc at 2100\ncare and then 70 with 0100 care. infant tolerating feeds\nwell. no spits. abd soft with no loops. voiding and\nstooling. desitin applied to buttocks. using platex nurser.\ncontinue with current feeding plan.\n\n3: g/d\ntemps stable in an oac. co-bedded with brother. and\nactive with cares. sleeps well inbetween. brings hands to\nface. sucks vigorously on pacifier. wakes for feedings.\naga. continue to monitor for developmental milestones.\n\n4: \nno contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884799,"text":"Neonatology Attending\n\nDay 9 PMA 35 wks\n\nRemains in RA. RR 30-50s. Sats 92-100%. Clear breath sounds. had one bradycardia episode over last 24 hours. No murmur. HR 130-160s. No murmur. BP mean 57. Bilirubin 12.3 (rebound) so palced back under phototherapy. Weight 2420g (+10). TF at 140 ml/kg/d- SC 20. Bottled one feed. Breast feeding for 5-10 minutes. No spits. Minimal aspirates. Stable temperature in air-controlled incubator. Family up to date.\n\nDoing well overall. Minimal respiratory immaturity. Will continue to monitor. Advancing feeds to 150 ml/kg/d. Exaggerated physiologic hyperbilirubinemia. Will continue on phototherapy.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884800,"text":"Social Work\n\n\nMet with mother while in visiting with babies today.\nMother feeling overwhelmed today. She states that she gets here in the morning and styas for the whole day as she wants to be here for all of the babies feedings.\nTalked with her about cutting back on the amount of time she is here each day, and the importance of having some time for her to rest and pump. Really encouraged her to only come in in early afternoon and she can stay until her husband comes in from work and then they can go home together.\nMother states that she has good supports, a lot of help from members of her church who have been bringing in dinners for them. Also a friend has been driving them in to the hospital each day, as the couple do not have a car they live closby in , but public transportation is not direct to the hospital.\nMother's sister will be visiting from over , and her mother in law will come in mid . All extended family members are in State.\nWill plan to check in with mother tomorrow, continue to encourage her to take car of herself and not to be spending the entire day at the hospital.\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884801,"text":"NPN 7a-7p\n\n\n#1 Resp: Infant in room air w/resp rate 20s-50s and sat\n93-100%. Lung sounds cl/= and mild SC retractions. No spells\nso far this shift. A: Infant stable in room air w/no spells.\nP: Cont to monitor.\n\n#2 FEN: TF inc from 140 to 150 cc/kg of BM 20 (64 cc q4h\ngavaged over 50 min). Po/pg. Infant breast feeding w/Mom q\ncares and receiving full gavage volume. Infant BF for 5 min\n@ 0900 but was sleepy with weak suck. Infant awake and eager\nand breast fed for 10 min with good latch and suck @ 1300\ncares. No spits, min asp. Abdomen round, pink, and soft\nw/active bowel sounds and no loops. Voiding and stooling\nheme negative. A: Infant coordinated w/breast feeding when\nawake and eager. P: Cont w/current plan and encourage po\nfeedings as tol.\n\n#3 Dev: Infant nested in air isolette, temp stable. Alert\nand active during cares and sl irritable in between. Settles\nvery well with pacifier and boundaries. A: AGA. P: Cont to\nsupp dev needs.\n\n#4 : Mom in q cares and updated. Mom took temp,\nchanged diaper, and breast fed infant. A: Independent and\nappropriate w/cares. P: Cont to support and update.\n\n#6 Bili: Infant cont neoblue photo rx with eye shields for\nbili of 12.3/0.3 this am. A: Infant appears jaund. P: Cont\nphoto rx and check bili .\n\n#7 Skin: Triple antibiotic ointment applied to old\ninfiltrate/scabbed area on right foot @ 0900 cares.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-17 00:00:00.000","description":"Report","row_id":1884797,"text":"NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 96%. Lung sounds clear/=. RR 30-50's. Mild\nSCR noted. No A's or B's noted. P: Cont. to monitor resp.\nstatus.\n\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempted to BF\nx 2 thus far - latched well. Tolerating NGT feedings well;\nabd exam benign, no spits, min asp. Voiding qs and stooling\nheme neg. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/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 suppot developmental\nneeds. P: Cont. to support developmental needs.\n\n4. : in throughout day. Independent with\ncares and handling infants. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved . P: Cont. to support and update\n.\n\n5. Bili: Photo was d/c'd on thurs at 10 am for a bili of\n10.6. P: Repeat bili to be drawn in am.\n\n6. Skin - Rt foot infiltrate left open to air. Healing well\nwith triple abx ointment q 12 hours. No drainage, swelling,\nor redness noted. P: Cont. to monitor skin.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884798,"text":"npn 1900-0700\n\n\n1: resp\nremains in ra. no spells and no dsats. lung sounds clear and\nequal. mild subcostal retractions. no increased wob noted.\nrr 30-50's. sats .925. continue to monitor for changes in\nrespiratory status.\n\n2: fen\ncurrent weight 2420gms up 10. total fluids remain at\n140cc/kilo/day of bm 20 cals. tolerating feeds well. no\nspits. minimal aspirates. voiding and stooling. abd soft\nwith no loops. infant po'd 20cc at 0100. infant po fed based\non feeding cues. continue to encourage po feeds as\ntolerated.\n\n3: growth and development. received infant in an off\nisolette. infant currently co-bedding in a crib with\nsibbling. temps remain stable. alert and active with cares.\nsleeps well inbetween. brings hands to face. sucks\nvigorously on pacifier. brings hands to face. aga.continue\nto monitor for developmental milestones.\n\n6; bili\ninfant color slighlty jaundiced. infant currently off of\nphototherapy. rebound bili sent this shift. will continue to\nmonitor bili closely.\n\n7: skin\ninfant right foot old infiltrate sight with multiple small\nscabs. no drainage noted and no bleeding. triple antibiotic\nointment applied at 2100. continue to monitor for changes.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884748,"text":"Admission Note\nBB admitted to NICU following C/S delivery for PIH. Infant emerged with good cry, dusky and retracting, requiring stim and BBO2 in DR. . on admission, GFR with RA SaO2 mid 80's, placed on CPAP 6 in 26-30% FiO2 to maintain SaO2 89-95. LS sl coarse and diminished, color good, cont with GFR through shift. Cap gas 7.27/45/47. No murmur audible, BP 75/35 mean 45. Labs sent for Bld cx and CBC, antibiotics begun. IV placed in R hand with D10W infusing, initial DS 47, after IVF infusing, DS 74. Abd benign, soft, round, +BS, has voided, no stool, NPO for now. Stable on open warmer, sl irritable with cares, little interest in pacifer. Dad visited briefly, told weights/measures and equipment explained, spoke softly with the babies. A: 34 week infant w/RDS P: cont CPAP/O2 as needed, maintain IVF NPO for now, cont antibiotics as ordered, monitor\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884749,"text":"Respiratory Care Note\nPt continues on Prong CPAP +6 FIO2 26-28%. B.S. ess. clear with good air entry. Mild retractions and grunting noted. Without apnea or bradys as of this note.\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884750,"text":"1 Alt in Resp\n2 Alt in FEN\n3 Alt in G&D\n4 Alt in Parenting\n5 ID\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in Resp; added\n Start date: \n 2 Alt in FEN; added\n Start date: \n 3 Alt in G&D; added\n Start date: \n 4 Alt in Parenting; added\n Start date: \n 5 ID; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884751,"text":"#1 PT CONT ON CPAP OF 6, MOSTLY 25-30% FI02. LS ARE CLEAR,\nSLIGHTLY DIMINISHED. RR 40-80 WITH OCC GRUNTING. SATS\nIMPROVED ON BELLY.\n#2 NPO. TF 60/KG D10W INFUSING WELL VIA PIV. WEIGHT DECREASE\n75GM. VOIDING AND STOOLING. DSTIX 113. BELLY FULL AND SOFT\nWITH ACTIVE BS.\n#3 TEMPS ARE STABLE NESTED ON SERVO WARMER. ALERT AND\nIRRITABLE.\n#4 DAD IN TO VISIT IN EVENING. DAD UPDATED AT BEDSIDE.\n#5 PT CONT ON AMP AND GENT AS ORDERED.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884752,"text":"RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 25-30%. Occasional grunting RR 40-80's. Breath sounds are clear. Stable on CPAP will cont to follow closely.\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884753,"text":"Neonatology Attending\n\nDay 1 PMA 34 wks\n\nRemains on CPAP 6 with fio2 0.28. RR 50-80s. Intermittent grunting. CBG 7.28/47. No apnea, bradycardia. No murmur. HR 130-160s. BP mean 47. Weight 2500g (-75). NPO. IV dextrose at 60 ml/kg/d. Blood glucose 103. Benign abdomen. Lytes 135/4.0/19. Bilirubin 1.7. Stable temperature on off warmer. Parents in earlier this morning. On ampicillin and gentamicin. Blood culture no growth.\n\nMild hyaline membrane disease. Will continue to monitor closely. Keeping NPO. Will continue to follow blood glucose. Ruling out on antibiotics.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884817,"text":"Exam Note\nGEN - , active\nHEENT - AFSFO, facial macules almost completely resolved from yesterday, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash, stool present\nEXT - wwp, cr < 2\nNEURO - MAE, reactive\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884818,"text":"6 Alt in \n7 Skin:\n\nREVISIONS TO PATHWAY:\n\n 6 Alt in ; resolved\n 7 Skin:; resolved\n\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884828,"text":"NPN DAYS\n\n\n#1 Pt received and cont in RA. LS C+=. no spells so\nfar this shift. Pt day of spell count down. P- Will cont\nto monitor resp status.\n#2 FEN- TF=150cc/kg/d of BM24 with powder. abd benign.\nall po feeds. po 35-50cc +BFx2. Pt voiding and stooling hem\nneg. no spits. waking q2.5-4hrs. P- Will cont to monitor\nFEN.\n#3 G&D- Temp stable in open crib. cobedding with sibling.\n and active with cares. sucking on pacifier. P- Will\ncont to monitor G&D.\n#4 Mom and Dad visiting this shift. Loving and\ncaring towards pt. asking approp ques. updates given.\nhelping with cares. updated re: pt spells and DC\ndate pushed back. P- Will cont to support and educate\n.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884829,"text":"NPN DAYS\naddendum: Hep B immunization given @ 1800.\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884830,"text":"NPN:\n\nRESP: RA. RR=40-50s w/SC retraction. BBS =/clear. Last A&B on ; day of brady count.\n\nCV: No murmur. HR=140-160. BP=68/41 (51). Color pink w/slight jaundice. Perfusion good.\n\nFEN: Wt=2655g (+ 35g). Ad Lib feeds of BM-24. Intake yesterday 119cc/kg/d + breast fdgs x 2. Bottled slowly x 1 for 10cc; 60cc taken well at following feeding. No spits. Abd benign. Voiding qs; small yellow stool. FeS04. Mother has appt w/lactation consultant on (13:00).\n\nG&D: CGA=36-4/7 wk. Temp stable in crib. Co-bedding w/sibling. Active and w/good tone. Swaddled and resting well. Discharge preparations in progress; hearing screen and carseat test need to be done.\n\nSOCIAL: Mother called x 1 for update.\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884831,"text":"NNP ON-Call\nPhysical Exam\nGeneral: infant in open crib, room air,co-bedding with twin\nSkin; warm and dry; color pink/jaundiced; cafe spot on forehead\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds; cord healed\nExt: moving all\nneuro: appropriate tone and reflexes; alerts\n"},{"category":"Radiology","chartdate":"2197-12-09 00:00:00.000","description":"BABYGRAM (CHEST ONLY)","row_id":934419,"text":" 1:36 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate for rds vs retained fetal lung fluid\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, on CPAP\n REASON FOR THIS EXAMINATION:\n evaluate for rds vs retained fetal lung fluid\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest x-ray.\n\n DATE OF EXAM: .\n\n TIME OF EXAM: 1:46.\n\n CLINICAL HISTORY: This is a newborn infant on day of life 1 with respiratory\n distress.\n\n FINDINGS: A single, portable view of the chest was obtained. I have no prior\n films available for comparison. The heart size is normal. The pulmonary\n vasculature is within range of normal limits. There is some increased\n interstitial fluid suggesting the diagnosis of TTN, perhaps with a component\n of mild hyaline membrane disease. There is no focal lung opacification.\n\n Abdominal situs is normal. The visualized bony structures are normal.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884793,\n \"text\": \"Neonatology Attending\\nDOL 7 / PMA 35-3/7 weeks\\n\\nRemains in room air with no distress. Occasional drifting saturations but no bradycardias.\\n\\nNo murmur.\\n\\nOff phototherapy with bilirubin 10.6 yesterday.\\n\\nWt 2385 (+35) on TFI 140 cc/kg/day BM20, tolerating well. Bottling up to of feeds. Voiding and stooling (guiac negative). Abd benign.\\n\\nTemp stable in off isolette.\\n\\nRIght foot infiltrate improved.\\n\\nA&P\\n34-3/7 week GA infant with respiratory and feeding immaturity\\n-Continue to await maturation of oral feeding skills and respiratory drive\\n-Repeat bilirubin on Monday\\n-No changes in management as detailed above\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884794,\n \"text\": \"NPN 0700-1900\\n\\n\\n1. Resp: Infant remains in RA, maintaining his O2 sats\\ngreater than 90%. Lung sounds clear/=. RR 30-50's. Mild\\nSCR noted. No bradys noted. Occ drifts to high 80's noted.\\nP: Cont. to monitor resp. status.\\n\\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempting to\\nPO when awake and alert. Infant breastfed x 2 thus far -\\nlatched well. Tolerating NGT feedings well; abd exam\\nbenign, no spits ,min asp. Voiding qs and stooling heme\\nneg. P: Cont. to support nutritional needs.\\n\\n3. G/D: Temps stable swaddled in off-isolette. Infant is\\nalert/active with cares. Settles well in betwen cares.\\nAppropriatley brings hands to face and sucks on pacifier to\\ncomfort self. AFSF. AGA. P: Cont. to support developmental\\nneeds.\\n\\n4. : Mom in for 2 set of cares today. Independent\\nwith cares and handling. Updated at bedside on infant's\\ncondition and plan of care. Asking appropriate questions.\\nLoving, involved . P: Cont. to support and update\\n.\\n\\n5. Bili: Rebound bili fri am was 10.6. Infant remains sl.\\njaundiced. Will follow bili on mon am.\\n\\n6. Skin: Dressing changed no right foot infiltrate. Triple\\nabx and tefla applied. No drainage, redness or swelling\\nnoted. P: Cont. to monitor skin.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884795,\n \"text\": \"Nursing Progress Note 1900-0700\\n\\n\\nResp:Infant remains in RA saturating 96-99%.RR 30-60's.LS\\nremain clear and equal with sc retractions.No A's and B's or\\ndesats thus far.\\n\\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\\nq 4 hrs gavaged over 45 min.Infant attempted to bottle with\\nthe Playtex Nurser and took 25-44cc's.Appeared well\\ncoordinated;remainder gavaged.Weight=2.410 up 25 grams.Abd\\nsoft with pos bs,no loops or spits,minimal aspirates.Voiding\\nand stooling heme negative.\\n\\nG/D:AF soft and flat.Alert and active with cares.Sleeping\\nwell b/t.MAE.Bringing hands to face and mouth.Infant remains\\nin off isolette;swaddled with nested boundaries.Temp.\\nmaintained.\\n\\nParenting:Mom called x 1.Updated by this RN.Asking\\nappropriate questions very loving and invested.\\n\\nBili:Infant cont's jaundice but well perfused.Stooling.To\\nhave bili checked on .\\n\\nSkin:R foot appears pink with serous drainage on old\\ndressing.Applied triple antibiotics;healing well.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884796,\n \"text\": \"Neonatology Attending\\n\\nDOL 8 PMA 35 4/7 weeks\\n\\nStable in RA. No A/B.\\n\\nNo murmur. BP 78/33 mean 50\\n\\nOn 140 ml/kg/d BM 20 po/pg. Voiding. Stooling. Wt 2410 grams (up 25).\\n\\nR foot infiltrate being treated with triple antibiotics.\\n\\n in and up to date.\\n\\nA: Stable. No spells. Tolerating feeds and learning to po. Infiltrate healing.\\n\\nP: Monitor\\n pos as tolerated\\n Continue care for infiltrate\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884789,\n \"text\": \"Nursing Progress note\\n\\n\\n#1 Resp-- O: RR 30s-60s; HR 140s-160s; Sats 96-99. No\\ndesats, no spells. BS clear and =; mild sc ret. Pink/jaund.\\nNo murmer. A: Rare desats in RA P; Cont to monitor\\nsats/vitals/spells\\n\\n#2 Nutrition-- O: Enteral feeds advanced to 140cc/kg/d= 60cc\\nBM20 q4h. BF great x2 with good latch and suck 5-10 min-\\nthen drowsy. Tol full volume after BF over 45 min. tol well-\\nno spits, no asp. NG #5 placed in rt nare after baby pulled\\ntube. Abd exam benign, AG 25cm, +BS. VQS, Yellow x2\\nguiacneg. A: Stable, tol adv feeds with wt gain P: Monitor\\ntol and growth\\n\\n#3 Development-- O: Alert and active with cares, social with\\nmom. stable in off islolette. Swaddled, with\\nboundaries. Hands to mouth. A: AGA P: Cont to support\\ndevelopment\\n\\n#4 Parenting-- O: Mom in for 0900 and 1300 feeds.\\nIndependent with babies, handling well. Updated re status\\nand plan. Will be back for 1700 feed. A: Involved. loving P:\\nCont to support and keep informed\\n\\n#6 ^Bili-- O: rebound bili stable off og photo Rx. Color sl\\njaund, VQS, stooling, full feeds. A: Resolving P: Check bili\\nMon. am\\n\\n#7 Skin-- O: Rt foot lesion drsg . Sm amt\\nyellow/serous drainage noted. Area cleansed with sterile\\nH2O, triple antibx ointment applied with Telpha and gauze\\nwrap. A: Improving P: Monitor and change drsg \\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884790,\n \"text\": \"Exam Note\\nGEN - calm, NAD\\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl external male genit, no rash\\nEXT - wwp, cr < 2, R foot wound c/d/i with normal granulation tissue and no pus or erythema\\nNEURO - MAE, reactive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884791,\n \"text\": \"Nursing Progress Note 1900-0700\\n\\n\\nResp:Infant remains in RA saturating 97-100%.RR 30-60's.LS\\nremain clear and equal with sc retractions.No A's and B's\\nthus far.Occ. will drift in sats to high 80's QSR.\\n\\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\\nq 4 hrs gavaged over 45 min.Infant bottled x 2 with Playtex\\nbottle and took 17-47cc the remainder gavaged.Weight=2.385\\nup 35.Abd. soft with pos bs,no loops or spits,minimal\\naspirates.Voiding and stooling heme negative.\\n\\nG/D:AF soft and flat.Alert and active with cares.Stirring\\nprior to feeds.MAE.Bringing hands to face and mouth and\\nintermitently sucking on pacifier.Infant remains in off\\nisolette swaddled with nested boundaries.Temp. stable.\\n\\nParenting:No contact from so far.\\n\\nBili:Infant cont's slightly jaundice.To recheck Bili .\\n\\nSkin:R foot appears to be healing well.Cont's slightly pink\\nwith healing tissue.No drainage or foul odor\\npresent.Dressing changed per protocol.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884792,\n \"text\": \"Neonatology NP note\\nPE\\nswaddled in open crib, cobedding with twin\\nAFOf\\nminimal subcostal retractions in room air, lungs clear/=\\nRRR, no murmur, pink and well perfused\\nabdomen soft, nontender and nondistended, active bowel sounds\\nactive with good tone\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884786,\n \"text\": \"NPN 0700-1900\\n\\n\\n1. Resp: Infant remains in RA, maintaining his O2 sats\\ngreater than 93%. Lung sounds clear/=. RR 40-60's. Mild\\nSCR noted. Few drifts to high 90s noted. No apnea noted\\nthus far. P: Cont. to monitor resp. status.\\n\\n2. FEN: TF were increased to 120 cc/kg/day of BM/SC20.\\nInfant is attempting to PO/breastfeed when awake and\\ninterested. Infant breastfed well x 1. Tolerating feedings\\nwell; abd exam benign, no spits, min asp. Voiding qs and\\nstooling trans stools. P: Cont. to support nutritional\\nneeds.\\n\\n3. G/D: Temps stable swaddled in off-isolette. Infant is\\nalert/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. Parents: Mom in for cares this shift. Independent with\\ncares and handling infants. Updated at bedside on infant's\\ncondition and plan of care. Asking appropriate questions.\\nLoving, involved parents. P: Cont. to support and update\\nparents.\\n\\n5. Bili: Single phototherapy was d/c'd at 1000. Bili this\\nam was 9.6/0.3. Plan is to check rebound in am.\\n\\n6. Skin: Dressing was changed x 1. Tefla and gauze and\\ntriple abx ointment placed on infiltrate. No drainage noted\\nfrom site. P: Cont. to monitor and change dressings as\\nordered.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884787,\n \"text\": \"#1Resp\\nLungs clear with mild sc retractions. Baby has had one spell\\ntonight which required mild stim.RR 40-60 with sat in high\\n90's.\\nP. Cont to monitor\\n#2FEN\\nWt 2.35 up 25g. Baby cont to receive 150cc/kg BM20 52 cc q4.\\nAbd round but soft active bowel sounds. Min asp No spits,\\nSleepy at 2100 and feed gavaged. At 0130 awake and alert but\\nnot that interested and took 15cc. At 0500, bottled 22.\\\\\\nA. Tol feed and learnung to feed\\nP> CONT TO MONITOR TOL TO FEEDS AS WELL AS WEIGHT GAIN AND\\nFEED ABILITY\\n#3DEV\\nAWAKE AND ALERT WITH CARES BUT TIRES. TEMP STABLE IN AN OFF\\nISOLETTE.\\n#4PARENT\\nMOM X 1 FOR AN UPDATE\\n#6BILI\\nBILI WAS 10.6/.2. NNP INFORMED. REMAINS SL JAUNDICED\\n#7SKIN\\nDSG TO R FOOT CHANGED, AREA PINK AND CLEAN. NO DRAINAGE.\\nGOOD PERFUSION TO THE TOES. DIAPER AREA SL PINK. DESITIN\\nAPPLIED\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884788,\n \"text\": \"Neonatology Attending Note\\nDay 6, PMA 35 2\\n\\nRA. RR40-60s. Mild sc rtxns. Cl and = BS. Mild desats-sr. HR 130-140s. BP 85/43, 56. Reb bili 10.6/0.2. Wt 2350, up 25. TF 120 BM20/SC20. PO/PG. Tol well. Nl voiding and stooling. Desitin to diaper dermatitis. In off isolette.\\n\\nA/P:\\nGrowing preterm infant learning how to po feed. Adv TF to 140. Follow jaundice clinically, check another Monday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884782,\n \"text\": \"npn 1900-0700\\n\\n\\n1: resp\\nremains in ra. one spell with breastfeeding, qsr, see flow\\nsheet. rr 30-70's. mild subcostal retractions. no increased\\nwob noted. sats 93-100%. lung sounds clear and equal.\\nconitnue to monitor for changes in respiratory status.\\n\\n2; fen\\ncurrent weight 2325gms down 50. total fluids remain at\\n100cc/kilo/day of bm 20/sc 20. tolerating feeds well. no\\nspits. minimal aspirates. voiding and stooling. abd soft\\nwith no loops. girth stable. mom breastfed at 2100 and at\\n0100, with first care infant latched on and took a few\\nsucks, at 0100 care infant latched on and nursed well for\\n5-10 minutes. continue to support mom with breastfeeding.\\nfull gavage feed given following breastfeeding. continue\\nwith current feeding plan.\\n\\n3: growth and development:\\ntemps stable in an air heated isolette. alert and active\\nwith cares. sleeps well inbetween. brings hands to face.\\nsucks vigorously on pacier. irritable at times. unswaddled\\nwith boundaries for phototherapy. continue with current\\nfeeding plan.\\n\\n4; parenting\\nmom and dad in for 2100 care. both involved with cares.\\nloving and asking appropriate questions. both helping change\\ndiaper and do temp. continue to support family while in the\\nnicu environment.\\n\\n6: bili\\ninfant remains under single phototherapy. eye shields in\\nplace. bili drawn this shift 9.6/0.3/9.4. infant color\\njaundiced. continue to monitor for change.\\n\\n7: skin:\\ninfant with newborn rash. infant also with right foot lesion\\n\\nwith multiple small scabs and open area that is pink. small\\namount of serous draingae noted on gauze. dressing changed\\nand triple antibiotic ointment applied. no active bleeding\\nand no edema noted. continue with dressing changes.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884783,\n \"text\": \"Neonatology Attending Note\\nDay 5, PMA 35 1\\n\\nRA. RR30-70s. Cl and = BS. Mild rtxns. Occass sat drifts. +2 A&Bs past 24h. HR 130-150s. No murmur.\\n\\nJaundice, Bili 9.6/0.3, under single photot.\\n\\nWt 2325, down 50. TF 100 BM/SC20. Tol well. Nl voiding and stooling. Tr mec.\\n\\nIn air isolette.\\n\\nA/P:\\nCont to monitor mild AOP off caffeine. d/c photot and monitor bili levels in AM. Adv TF to 120.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884784,\n \"text\": \"Exam Note\\nGEN - asleep in isolette\\nHEENT - AFSFO, oropharynx clear, nares patent\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl ext genit\\nEXT - wwp, cr < 2s\\nNEURO - reactive, MAE\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884785,\n \"text\": \"Exam Addendum\\nEXT - RLE wound examined under bandage, c/d/i with appropriate eschar and no signs of infection.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884775,\n \"text\": \"Neonatology Attending\\n\\nDay 4 PMA 35 0/7 wks\\n\\nRemains in RA. RR 30-60s. Mild retractions. Had four bradycardia episodes over last 24 hours- one with feeding. No murmur. HR 120-160s. BP mean 56. Bilirubin 9/0.4 on phototherapy. Weight 2375g (-30). TF at 80 ml/kg/d. Now on full feeds BM/SC 20. Put to breast daily. Latched. Minimal aspirates. Stable girth. Passing heme negative stool. Stable temperature in air-controlled incubator. Foot infiltrate clean with crust. Treated with triple antibiotic and Telfa. Family meeting yesterday.\\n\\nDoing well overall with mild breathing control immaturity. Will continue to monitor. Increasing to 100 ml/kg/d today. Monitoring feeding tolerance. Will speak with family today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884776,\n \"text\": \"Lactation Consult\\nMet w/ mom/babies this AM to assist w/ latch and assess milk supply. Infants are 4 day old 34 wks, 35 wks corrected today. Infant remains under single phototx and has an ng tube for feeds. Baby went to breast w/o nipple shield first and demonstrated difficulty in latching, and was then trialed w/ nipple shield and did very well. Baby had frequent audible swallows and milk in nipple shield, nursing X 10mins. He was then ng fed for full vol.\\nReviewed risks and benefits of using a nipple shield w/ mother, emphasized need to pump 8-12X per 24hrs. Gave mom written material to assess 24 hr milk supply. Will follow this family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884777,\n \"text\": \"Social Work\\n\\nFamily meeting yesterday, parents doing well, many good questions. Will follow assess need for any additional support.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884778,\n \"text\": \"Exam Note\\nGEN - awake,alert\\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl ext genit\\nEXT - wwp, cr < 2\\nNEURO - reactive, MAE\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884779,\n \"text\": \"NPN 7a-7p\\n\\n\\n#1: remains in RA, sating >/= 94%. Rare drift to high\\n80's noted with QSR. Brady x1, needing mild stim to\\nrecover. RR stable. BBS cl/=. Breathing with mild\\nretractions. A: stable in RA P:Cont to monitor and provide\\nsupport as needed.\\n\\n#2: TF's ^'ed to 100cc/k/d. Infant now receiving 43cc q4hrs\\ngavaged over 50mins. D/S stable. No spits. Max asp 1.8cc\\nslightly green tint. Fellow assessed. Abd soft, +, no\\nloops. AG stable. Refed asp and cont'ed with feeds. Infant\\nwent to breast x2 today. 1st attempt did well for ~10mins,\\nmore consistent latch and suck. 2nd attempt infant was more\\ninterested in snuggling with Mom. Latched briefly. Voiding\\nqs. Stooled x2 heme negative. A: tol'ing feeds P:Cont to\\nmonitor tol to feeds. Follow wt and exam.\\n\\n#3: Temps stable in an air isolette. Infant can be fiesty\\nat times. Sleeps best when nested within boundaries. Will\\nalso settle with pacifier, containment and holding. Fonts\\nsoft/flat. Brings hands to face. Loves to kangaroo. MAE. A:\\nAGA P:Cont to support dev needs.\\n\\n#4: Parents in for both cares thus far. Mom and\\n this am. Better this afternoon. Mom has been d/c'ed\\ntoday, but parents are staying in Parent Room overnight. Mom\\nmet with LC this am and worked on breastfeeding. LC gave Mom\\nnipple . See LC note for details. Parents\\nparticipating in cares. Both updated. Both held infant\\ntoday. A: Involved, loving family P:Cont to support and\\neducate.\\n\\n#6: Jaundice. Tol'ing full feeds. Voiding and stooling.\\nConts under single phototherapy with eye shields on. A:\\nhyperbili P:Cont with phototherapy as ordered. Check bili\\nlevel in am.\\n\\n#7: NB rash noted over trunk, face and extremities. Team\\nassessed. Right foot noted to have several lesions on it.\\nLesion on top of foot has opened pink center with scabbed\\nyellow edges. Small amt of serous drainage noted on dsg x1\\nfrom that area. No bleeding noted. No edema noted. Other\\nscabs intact. Triple antibiotic ointment applied and covered\\nwith Telfa dsg.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884780,\n \"text\": \"NPN 7a-7p cont'ed\\n\\n7 Skin:\\n\\n#7cont'ed: Team assessed lesions today. Foot warm to touch\\nwith nml pulses. A: healing skin lesions P:Cont with dsg\\nchange 3 times a day. Monitor.\\n\\nREVISIONS TO PATHWAY:\\n\\n 7 Skin:; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884781,\n \"text\": \"NICU Infant CPR Class Note\\n\\nO: Both parents present for infant CPR class at 1800. Watched video and demostration of infant CPR and relieving choking maneuvers by this RN. Both parents practiced on the manikin and were able to demonstrate proper techniques. Reviewed \\\"Back to Sleep\\\" brochure and gave to parents. Also gave CPR poster and handout. All questions answered. Both parents stated that they understood all teaching and had no further questions. Class concluded at 1900.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884769,\n \"text\": \"NPN 0700-1900\\n\\n\\nResp: Infant received on CPAP 6 with FiO2 21%, weaned\\ninfant to RA at 1130. SpO2 89-98%. RR 30s-60s. LS cl/=.\\nMild SC retractions. 2 bradys thus far (see flowsheet for\\ndetails). P: Cont to monitor resp status.\\n\\nFEN: TF increased today to 80cc/kg/day. D10W with 2&1\\ninfusing at 20cc/kg/day via PIV in left hand without\\nincidence. Enteral feeds increased to 60cc/kg/day of\\nBM/SC20 = 26cc q4hrs. Plan to advance enteral feeds by\\n15cc/kg/day . Will check DS at 1700. Abd soft, full,\\n+BS, no loops. AG stable. 3.6 bilious asp at 0900, NNP\\naware, discarded asp. No spits. Voiding (see flowsheet for\\nu/o this shift). Lg mec stool x1. P: Cont to support\\nnutritional needs.\\n\\nG/D: Temps stable, nested on servo warmer. Infant is a&a\\nwith cares. Irritable at times. Appropriately brings hands\\nto face and sucks pacifier to comfort self. AFSF. AGA.\\nTripple abx oint TID to right foot infiltrate. P: Cont to\\nsupport dev needs.\\n\\nSocial: Mom in for all cares today. Updated on infant's\\ncondition and plan of care by this RN. Loving, invested\\nparents. Asking appropriate questions. Family meeting\\ntoday at 4pm. P: Cont to update & support NICU family.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884770,\n \"text\": \"Family Meeting\\nMet with parents in the family room today. Mother to be discharged home tomorrow. See family meeting checklist for issues discussed. Parents asked many questions that were answered to their apparent satisfaction. Seemed to have a good understanding of the issues. Pedi is .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884844,\n \"text\": \"1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\\nequal, no retractions seen. No oximetry. Currently on spell\\ncountdown, possible discharge tomorrow on day . Continue\\nto monitor respiratory status.\\n\\n2. FEN-Infant is on adlib po demand schedule of BM 24 with\\n powder. Infant bottling 45cc's this morning with Playtex\\nnurser and breastfeeding with mom this afternoon. Eager\\nbottler and breastfeeder. Abd soft. Voiding and stooling\\nheme negative. No spits. Destitin applied to bottom with\\neach diaper change. Continue to encourage po feeds.\\n\\n3. DEV-Infant has stable temperatures swaddled in OAC.\\nWaking q3-3.5 hours to be feed. and active during\\ncares, resting well in between. Continue to support\\ndevelopmental needs.\\n\\n4. PARENT-Mom and dad in this afternoon. Loving towards\\ninfant and independent with cares. Made pedi appt for \\non Monday due to holiday. Excited for possible discharge\\ntomorrow. Continue to educate and support .\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884845,\n \"text\": \"NPN\\n\\n\\nI have examined the infant and agree with the above note\\nwritten by PCA.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884846,\n \"text\": \"#2FEN\\nWt 2.725 up 20g. Baby waking q4h to bottle. Bottled 70/75cc\\nwith playtex bottle. Void and stooling. Stool heme neg. No\\nspits. Abd soft, active bowel sounds. Desitin applied to\\ndiaper area.\\nA. Tol feed and gaining weight\\nP. Cont to monitor tol to feed\\n#3Dev\\nTemp stable in an open crib. Waking for feeds\\n#4Parent\\nNo contact this shift\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884847,\n \"text\": \"Neonatology Attending\\n\\nDay 18 PMA 37 0/7 WKS\\n\\nRemains in RA. RR 30-60s. Had 6.5 seconds heart rate drop seen on pneumocardiogram yesterday that was quickly self-resolved. No murmur. HR 140-170s. BP mean 46. Pink. Weight 2725g (+20). On BM 24 with formula powder. Took 124 ml/kg. Occasional choking with feeds. Benign abdomen. Passing heme negative stools. Waking every 4 hours. Passed hearing screen and car seat position study.\\n\\nDoing well overall. Feeding well and gaining weight. Heart rate drop not clinically significant so ready for discharge. Appointment with primary pediatrician on Monday. Discharge summary pending. Will update pediatrician.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884848,\n \"text\": \"Exam Note\\nGEN - NAD, active\\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+S2, no M\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl male ext genit, no rash\\nEXT - wwp, cr < 2 sec\\nNEURO - MAE, reactive, +grasp/suck/moro,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884849,\n \"text\": \"NPN 0700-\\n\\n\\n2. Infant on ad lib demand feeds of BM24 with powder.\\nWaking Q3-4hr and taking 50cc and 80cc thus far. Bottles\\nwith playtex fast flow nipple. Abdomen benign. Voiding and\\nstooling; heme negative. Ferinsol and Multivit. given.\\nTolerating all bottles without spits. Plan to D/C home this\\nafternoon.\\n\\n3. Temp stable swaddled in open crib. Waking for feeds as\\nnoted above. Rest well inbetween cares. MAE, brings hands\\nto face and mouth. Suckles well on pacifier. AGA. To be\\nd/c'd later today.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884850,\n \"text\": \"NPN discharge note\\nVSS, exam benign; see flowsheet for details. Reviewed NICU D/C instruction form with . Infant D/C home with in car seat. Breast milk given to .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884763,\n \"text\": \"NPN\\n\\n#1 S. O. Received infant on a cpap of 6 with fio2 21% to\\n23%. Breath sounds clear and equal with subcostal\\nretractions noted. R.R.30's to 70's. O2 sats 94 to\\n98%.There have been no a's or b's noted at this time. A.\\nInfant with a hx of respiratory distress. P. Discuss with\\nteam in the am regarding plan for trial off of cpap.\\n\\n#2 S. o. Weight down 45 grams. Voiding with 24 hour urine\\noutput 1.6cc/kg/hr. Infant passed trace mec stool. Piv of\\nd10w with lytes infusing well via left hand piv. Total\\nfluids = 60cc/kg/day. Right foot infiltrate site pink/red\\nwith no drainage noted.Right foot elevated. Infant had a\\n1.4cc bilious aspirant at the 0100 care. Abdomen softly\\ndistended with good bowel sounds and no loops. NNP\\nnotified.Aspriant discarded. Feeds not advanced at that\\ntime. A. ? bilious aspriant related to slow gastric\\nmotility. P. Monitor closely. Assess for advancemnet on\\nfeeds at the next care.\\n\\n#4 S. O. Parents in for the 2100 care. Parents updated by\\nthis R.N. at the bedside. A. Loving parents. P. Support\\nand keep updated.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884764,\n \"text\": \"5 ID\\n\\nREVISIONS TO PATHWAY:\\n\\n 5 ID; resolved\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884765,\n \"text\": \"Neonatology Note\\n3 d.o\\non CPAP + 6 this am and wean to RA now\\n2 spells this am, self resolved.\\nwt= 2405 gm -45\\nTF at 60 ml/kg/d with IV and feeding at 45 ml/kg/d with EBM/SC 20, 2 aspirates noted\\nvoiding(+), bm(+)\\n141/6.4/110/21\\nbili=9, under phototherapy\\n\\nA: twin #1, ex 34 wks GA, resolving RDS, hyperbilirubinemia, R foot infiltration resolving\\nP: continue advancing feeding and monitor tolerance, monitor spell, f/u bilirubin\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884771,\n \"text\": \"NPN Noc\\n\\n\\n#1 Resp: RA, 30-60's, c/=, mild SC retrac. No spells so far\\nthis shift. P: Cont to monitor resp status.\\n#2 FEN: TF=80cc/kg, infant currently on full feeds, BM/SC20.\\nPo/pg feeding, infant took 14cc po x 1. Abd benign, AG 26,\\nV/S, mec stooling. P: Cont to monitor FEN status.\\n#3 G&d: Temp stable in air isolette, nested. Alert, active,\\nand sl irritable with cares. Enjoys his pacifier, MAE, opens\\neyes, AFSF. IV infiltrate to right foot, triple abx ointment\\napplied and wrapped in sterile gauze. Area is sl swollen,\\nsmall scabs surrounding small open area on top of foot. P:\\nCont to monitor and support G&D, cont with triple abx to\\nright foot breakdown.\\n#4 Parents: Parents in for eve caretimes. Mom participated\\nin cares, briefly held infant. Asking appropriate questions.\\nP: cont to encourage parental calls and visits.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884772,\n \"text\": \"NPN Noc\\n#6 Bili: Infant appears jaundiced, cont on single spotlight phototherapy. P: Cont phototherapy, will check bili on Thurs AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884773,\n \"text\": \"6 Alt in Bili\\n\\nREVISIONS TO PATHWAY:\\n\\n 6 Alt in Bili; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884774,\n \"text\": \"NNP Physical Exam\\nPE: pink, AFOF, breath sounds clear/equal with easy WOB, no murmur, well perfused, abd soft, full, + bowel sounds, e tox rash, right foot wound from IV infiltrate with moist scab, does not look infected, active with good tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884837,\n \"text\": \"NPN 0700-1500\\n\\n\\n#2 O: Infant remains feeding ad lib amounts of BM24 made\\nwith similac powder. Bottling 60cc's. Abdomen round and soft\\nwith + BS. Voiding and stooling. No spits. A: Tolerating\\nfeeds. P: Cont to monitor.\\n\\n#3 O: Maintaining temp in oac; cobedding with twin. Awake\\nand with cares; sleeping well between. AFSF. Swaddled\\nin blanket; brings hands to face for comfort and sucks on\\npacifier. A: AGA. P: Cont to support development.\\n\\n#4 O: Both in to visit. Asking appropriate\\nquestions. Reviewing d/c teaching for sibling. Mom\\nbreastfeeding while here and pumping. Plan to take other\\ninfant home this afternoon. A: Involved, loving. P: Cont to\\nsupport and update.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884838,\n \"text\": \"Rehab/OT\\n\\nMet at the bedside. Reviewed back to sleep protocol and activities birth through one worksheet. Discussed SIDS precautions and EI qualifications. No further in house needs. D/C OT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884839,\n \"text\": \"Exam Note\\nGEN - calm, NAD\\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+s2, no M\\nABD - soft, NT, ND, no mass\\nGU - nl male ext genit, no rash\\nEXT - wwp, cr < 2\\nNEURO - MAE, reactive\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884840,\n \"text\": \"Nursing Progress Note 1900-0700\\n\\n\\nF/E/N:Infant cont's on Ad lib demand schedule waking q 4\\nhrs.TF over 24 hrs 122cc's/kg/day.Infant bottling with a\\nPlaytex nipple and taking 70-90cc's q time.Weight=2.705 up\\n25 grams.Abd. soft with pos bs,no loops or spits.Voiding and\\nstooling heme negative stool.\\n\\nG/D:AF soft and flat. and active with cares.Sleeping\\nwell b/t.MAE.Bringing hands to face and mouth.Sucking\\nintermitently on pacifier.Infant presently swaddled in open\\ncrib.Temp. stable.\\n\\nParenting:Mom called x 1.Updated by this RN.Asking\\nappropriate questions very loving and invested.Other twin at\\nhome per mom and doing well.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884766,\n \"text\": \"NNP Physical Exam\\nPE: exam this am while on CPAP. pink, jaundiced, AFOF, CPAP prongs in place, breath sounds clear/equal with easy WoB, no grunting, good air entry, no murmur, well perfusion, abd soft, non distended, non tender, active bowel sounds, IV infiltrate right foot with superficial scabs on dorsum of the foot, no redness or drainage, active with good tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884767,\n \"text\": \"NPN 0700-1900\\nBili: Bili this am was 9.0/0.4, down from 9.6/0.3. Infant remains under single phototherapy wtih eye shields on. Plan to recheck bili am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884768,\n \"text\": \"Respiratory Care Note\\nBbay Boy I was weaned from +6 to +5 prong CPAP this am and then was taken off CPAP at noon. Placed in RA. BS clear. RR 30's-60's. No bradys noted since he has been off CPAP.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884832,\n \"text\": \"NPN Days\\n\\n\\n#1 Pt has had no spells so far this shift. Pt day \\nof spell count down. P- Will cont to monitor resp status.\\n#2 Pt ad lib demand. BM24 with powder. all po\\nfeeds. Took 70cc this am and BF well while were\\nvisiting. abd benign. voiding and stooling. no spits. P-\\nWill cont to monitor FEN.\\n#3 G&D- Temp stable in open crib. cobedding with sibling.\\n and active with cares. irritable at times. sucking on\\npacifier. using playtex bottle with fast flow nipple to\\nfeed. P- Will cont to monitor G&D.\\n#4 Mom called x1 this am. updates given. Both\\n visiting @1300. Participating in cares. feeding pt.\\nDC teaching done with both re: carseat safety,\\nfeeding, bowel and bladder, back to sleep. declined\\ncirc. P- Will cont DC teaching.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884833,\n \"text\": \"NPN Days\\naddendum:\\n Pt passed hearing screen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884834,\n \"text\": \"Neonatology Attending\\nDOL 15 / PMA 36-4/7 weeks\\n\\nIn room air with no apneas/bradycardias in 2 days.\\n\\nNo murmur. BP 68/41 (51).\\n\\nWt 2655 (+35) on ad lib with intake 119 fcc/kg/day BM24 in addition to breastfeeding well. Abd benign. Voiding and stooling normally (heme negative). On iron.\\n\\nTEmp stable in open crib. Hepatitis B immunization administered.\\n\\nA&P\\n34-3/7 week GA infant with resolving respiratory immaturity\\n-Continue to monitor until free of apnea/bradycardia for at least 5 days prior to discharge home\\n-Discharge planning in progress\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884835,\n \"text\": \"NPN/1900-0700\\n\\n\\n#2 FEN: Wt 2680, ^25gms. Ad libe demand feeding, BM24.\\nTaking all po's; bottled 149cc/k + breastfeeding this\\nprevious 24hrs. Taking 60-80cc Q4hrs. No spits. Abd. exam\\nbenign. V/S. Cont. to support nutritional needs.\\n#3 DEVELOPMENT: Swaddled in oac; cobedding with twin. Temps\\nstable. Active/ w/ cares; sleeps well b/t. Wakes on\\nhis own Q3.5-4hrs to feeds. Sucks on pacifier. MAE/AFOF.\\nAGA. Support developmental needs.\\n#4 : visiting during the day shift; no\\ncontact over .\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884841,\n \"text\": \"Neonatology Attending\\n\\nDay 17 PMA 36 wks\\n\\nRemains in RA. RR 50-70s. Clear breath sounds. Day without bradycardia. No murmur. HR 140-160s. BP mean 54. Weight 2705 g (+25). On ad lib demand. On BM 24 with formula powder. Benign abdomen. Passing heme negative stool. On iron. Waking for feeds. Stable temperature in open crib. Passed hearing screen and car seat study.\\n\\nDoing well overall. Will continue to monitor closely. Feeding well and gaining weight. Will be ready for discharge tomorrow if remains spell-free.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884842,\n \"text\": \"Lactation Consult\\nMet w/ family @ 1pm to assess infant latch. Baby latched on beautifully w/ nipple having frequent audible swallows and milk present in . Mom held infant by football hold and is pleased w/ feeding. plan to nurse infants at home following up w/ bottles of 24cal breast milk. Advised to monitor baby's voids and stools at home and assess for swallows at the breast.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884843,\n \"text\": \"Exam Note\\nGEN - NAD, active and \\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+s2, no M, fem pulses 2+ bilat\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl male ext genit, no rash, stool present\\nNEURO - MAE, reactive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884836,\n \"text\": \"Neonatology Attending\\n\\nDay 16 PMA 36 wks\\n\\nRemains in RA. RR 40-70s. Clear breath sounds. No bradycardia- day . No murmur. HR 150-160s. Pink. BP mean 59. Weight 2680g (+25). Ad lib BM 24 with formula powder. Taking 60-80 ml per feed- 149 ml/kg total- and breast feeding. Passing heme negative stool. Feeding tube out. No spits. Stable temperature in open crib. independent with care.\\n\\nDoing well overall. Maturing breathing control. Will continue to monitor closely. Needs 2 more days spell-free. Received hepatitis B vaccine. Passed hearing screen. Will speak with mother this morning.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884819,\n \"text\": \"#1Resp\\nLungs clear with mild retractions. No spells. Appears\\ncomfortable\\n#2FEN\\nWt 2.615 up 30g. Baby has bottled entire volume at 2100 and\\n0100. Abd soft, active bowel sounds. Void and stooling. One\\nsmall wet burp. Min asp. Cont to receive BM24.\\nA. Tol feed and gaining weight\\nP. Cont to monitor tol to feeds as well as weight gain.\\nEncourage po feed ability\\n#3Dev\\nWaking for feeds. Maintaining temp in crib. Interested in\\nbottling\\n#4Parent\\nno contact so far.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884820,\n \"text\": \"Cafe spot noted on R side of forehead.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884821,\n \"text\": \"Neonatology Attending Note\\nDay 13, PMA 36 2\\n\\nRA. RR40-60s. Mild intermittent sc retractions. No A&Bs. No murmur. HR 130-150s. BP 86/44, 56. Wt 2615, up 40 gms. TF 150 BM24. Just transitioned to all PO last night. Nl voiding and stooling. In open crib.\\n\\nA/P:\\nGrowing preterm infant with improving PO skills. If continues to do well with PO feedings will plan for discharge Monday. PO feedings q other BF. Monitor weight with this suppl plan.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884822,\n \"text\": \"Exam Note\\nGEN - calm, NAD\\nHEENT - AFSFO, oropharynx clear, NGT out of nose, nares intact\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no M\\nGU - nl male ext genit, no rash\\nEXT - wwp, cr < 2 sec, dorsum c/d/i\\nNEURO - MAE, reactive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884823,\n \"text\": \"Case Management Note\\nReferral called to Care Group VNA today (/fax ) and have made home visit for Wednesday . Team anticipates home d'c Monday . If this date needs to be chnaged, please call VNA to reschedule. All in agreement w/plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884745,\n \"text\": \"Admission Note\\nNeonatology Admission H&P\\n\\nBaby is a newborn 34 wk twin infant admitted to the NICU with prematurity and respiratory distress.\\n\\nHe was born at 12:30 am this morning as the 2575 gram product of a 34 wk twin gestation pregnancy to a 28 y.o. G1 P0-2 mother with . Prenatal labs included BT A+/Ab- and GBS unknown; remainder were unavailable at time of delivery but were reportedly negative. Pregnancy was IVF-assisted di/di twin gestation, and was reportedly unremarkable until when mother presented to PMD for evaluation of URI symptoms and was found to be hypertensive. She was sent to , and was also found to have proteinuria and elevated uric acid, consistent with preeclampsia. BPP was . With relatively advanced gestational age, delivery was recommended. Last EFW on was 2289; concordant growth was noted throughout pregnancy.\\n\\nFamily history and social history are otherwise non-contributory.\\n\\nInfant was born via c-section for twin gestation. At delivery, twin A emerged with moderate tone and good cry, with Apgars . He required blow-by oxygen for duskiness with gradual improvement, and was brought to NICU with moderate work of breathing noted.\\n\\nPhysical Exam:\\nWt 2575 gm (75-90%) HC 32 cm (50-75%) L 48 cm (75-90%).\\nVS: T 97.7, HR 160s, RR 50s, O2sat 80s in RA, 90s with O2, BP pending.\\nGen: WD premature infant, moderate resp distress, active and vigorous, overall appearance consistent with EGA.\\nSkin: warm, dry, pink with oxygen, no rash.\\nHEENT: fontanelles soft and flat, ears/nares normal, palate intact with mildly high arch, +RR bilaterally.\\nNeck: supple, no lesions.\\nChest: coarse, poorly aerated, + g/f/r.\\nCardiac: RRR, no m, femoral pulses 2+.\\nAbdomen: soft, quiet BS, no mass, no HSM, 3VC.\\nGU: normal male, testes palpable bilaterally, anus patent.\\nExt: hips/back normal, no lesions.\\nNeuro: appropriate tone, activity, intact moro/grasp.\\n\\nIMP: Newborn 34 wk twin, delivered secondary to maternal preeclampsia, currently with moderate respiratory distress likely secondary to RDS. Low risk of sepsis given circumstances of delivery.\\n\\nPLANS:\\n- Admit NICU.\\n- Monitor resp status closely, likely will need CPAP.\\n- O2 as needed.\\n- CXR, ABG if resp status worsens.\\n- Consider intubation/surfactant if FiO2 high or worsening respiratory distress or hypercarbia.\\n- Monitor hemodynamics.\\n- NPO, maintenance IVF.\\n- Periodic monitoring of dstiks, lytes, bilirubin.\\n- CBC with diff, blood cx.\\n- Low threshold for abx as pneumonia cannot be ruled out given respiratory distress.\\n- Thermoregulatory support on warmer.\\n\\nParents updated in delivery room.\\n\\nPMD: , .\\nOB: , delivered by .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884746,\n \"text\": \"Admission Note\\nHep B: Maternal HBsAg resent. Will give HBV if results not available by 12 hrs of life.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884747,\n \"text\": \"Respiratory Care\\nSee attending and nursing admit notes for hx and further details. Infant GFR on arrival to NICU. Given facial CPAP then placed on prong CPAP 6. BS diminished. 02 req on CPAP 26-30%. CXR done to assess lung fields. Persistant grunting on CPAP, subcostal retractions. CBG: 7.28/47/45/23/-4. RR 30's-60's. Grunting significantly improved, presently intermittent. Will cont to follow closely, support as indicated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884813,\n \"text\": \"npn 1900-0700\\n\\n\\n1: resp\\nremains in ra. no spells and no dsats. lung sounds clear and\\nequal. mild subcostal retractions. no increased wob noted.\\nrr 40-70's. sats >97%. continue to monitor for changes in\\nrespiratory status.\\n\\n2; fen\\ncurrent weight 2560 gms up 20. total fluids remain at\\n150cc/kilo/day of bm24 cals tolerating feeds well. no spits,\\nminimal aspirates. voiding and stooling. stool hem negative.\\n\\nabd soft with no loops. infant continues on iron. infant\\npo'd 20cc's at 2100 and then 50cc at 0100. infant waking\\nfor both cares. remainder of volume gavaged. continue with\\ncurrent feeding plan.\\n\\n3: growth and development\\ntemps stable in an oac. alert and active with cares. sleeps\\nwell inbetween. brings hands to face. sucks vigorously on\\npacifier. wakes for feedings. aga. continue to monitor for\\ndevelopmental milestones.\\n\\n4; \\nno contact thus far this shift from \\n\\n6: \\ninfant currently off of phototherapy. sent this shift\\npending. continues to be jaundiced in color. continue to\\nfollow .\\n\\n7: skin\\ninfant continues on triple antibiotic ointment to right\\nfoot. infant's right foot with scabbing from old infiltrate\\nsite. no drainage or bleeding noted. continue with current\\nplan of care.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884809,\n \"text\": \"I have examined and agree with the above note.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884810,\n \"text\": \"Neonatology Attending Note\\nDay 11, PMA 36\\n\\nRA. Cl and = BS. No A&Bs. +murmur. HR 140-160s. BP 67/37, 47. Under photot. Bili 6.5/0.2. Wt 2540, up 70. TF 150 BM24. PO/PG. Tol well. Nl voiding and stooling. In air isolette.\\n\\nA/P:\\nGrowing preterm infant learning how to po feed. Will begin Fe. d/c photot and check reb bili in AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884814,\n \"text\": \"Neonatology Attending Note\\nDay 12, PMA 36 1\\n\\nRA. RR40-70s. CL and =. No A&Bs. No murmur. HR 130-150s. BP 67/45, 53. 6.5/0.2 (reb). Wt 2560, up 20 gms. TF 150 BM24. po/pg. Nl voiding and stooling. On Fe. Co-beeding in open crib.\\n\\nA/P:\\nGrowing preterm infant awaiting maturation of feeding abilities.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884815,\n \"text\": \"PCA Progress Note \\nI agree with the above PCA note and have assessed the pt. see flowsheet for further details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884816,\n \"text\": \"PCA Progress Note \\n\\n\\n#1 RESP: Infant remains in room air breathing 50-60s with\\nmild subcostal retractions. LS clear/equal, oximetry d/c'd\\nthis morning. No spells this shift. Breathing comfortably in\\nroom air. Continue to monitor respiratory status.\\n\\n#2 FEN: TF 150cc/kg/day BM24. 64cc q4hours. Infant finished\\nwhole bottle this morning, then breast fed with mom at \\ncares and half volume bottle. Uses Playtex\\nbottle/nipple. Abd benign, no loops, +BS. No spits, minimal\\naspirates. Voiding and stooling heme neg. Tolerating feeds.\\nContinue to encourage POs.\\n\\n#3 DEV: Stable temps swaddled cobedding with twin brother.\\n and active with cares, sleeping well between and\\noccasionally waking early. MAE. AFSF. Brings hands to face,\\nenjoys pacifier. AGA. Continue to support developmental\\nneeds.\\n\\n#4 SOC: Mom in for cares. Independent with son. Updated\\nat bedside by RN. Asking appropriate questions. Loving\\nfamily. Continue to update and support.\\n\\n#6 : Photo tx has been off since morning of 15th. \\nfrom last night 6.5/0.3, remaining the same as the day\\nbefore. Infant slightly jaundiced/well perfused. Continue to\\nmonitor.\\n\\n#7 SKIN: Scab on right foot from IV infiltration healing\\nwell. Triple antibiotic applied, then d/c'd this morning.\\nContinue to monitor.\\n\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884811,\n \"text\": \"NPN 7a-7p\\n\\n\\n#1 Resp: Infant in room air w/resp rate 40s-70s and sat\\n97-100%. Lung sounds cl/= and mild SC retractions. No spells\\nso far this shift. A: Infant stable in room air w/no spells.\\nP: Cont to monitor.\\n\\n#2 FEN: TF 150 cc/kg of BM 24 (64 cc q4h gavaged over 50\\nmin). Po/pg. Infant bottled 52 cc @ 0900 cares w/remaining\\nvolume gavaged. BF well for 20 min @ 1300 cares and was\\nsupplemented with half volume gavage. No spits, min asp.\\nAbdomen round, pink, and soft w/active bowel sounds and no\\nloops. Voiding and stooling heme neg. Now on iron. A: Infant\\nimproving with po feedings and is well coordinated. P: Cont\\nw/current plan and encourage po feedings as tol.\\n\\n#3 Dev: Received infant nested in air isolette. Infant now\\nswaddled in an open crib, cobedding with brother. \\nstable. Alert and active during cares and sleeps well in\\nbetween. Wakes early for most feedings. Periods of quiet\\nalert. A: AGA. P: Cont to supp dev needs.\\n\\n#4 : Mom in @ 1300 and was updated. Mom took temp,\\nchanged diaper, and BF infant. A: Independent and\\nappropriate w/cares. P: Cont to supp and update. Plan to\\nprovide bath and teaching @ 1700 cares.\\n\\n#6 : Photo rx d/c @ 1030. A: Infant appears jaund. P:\\nCont off photo rx and plan to check am.\\n\\n#7 Skin: Infant cont triple antibiotic ointment to scabbed\\narea on R foot on old IV infiltrate site. No redness or\\ndrainage noted.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884812,\n \"text\": \"Exam Note\\nGEN - calm, NAD\\nHEENT - 15-20 blanchable erythematous macules 3-5mm in diameter on face, no excoriation or secondary infection, c/w erythema toxicum. Otherwise, AFSFO, oropharynx clear, NGT w/o breakdown\\nCV - RRR, nl s1+s2 no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nEXT - wwp, R foot c/d/i, cr < 2 sec\\nNEURO - reactive, MAE\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884759,\n \"text\": \"NPN 0700-1900\\n\\n\\nResp: Infant remains on CPAP 6, FiO2 24-27%. RR 30s-50s.\\nLS cl/=. Mild SC retractions. No A's or B's thus far. P:\\nCont to support/monitor resp status.\\n\\nFEN: TF 60cc/kg/day. D10 with 2Na & 1K infusing via left\\nhand PIV at 30cc/kg/day. Right foot PIV infiltrated at 0900\\nwith excoriated skin d/t tape noted; NNP aware & right foot\\nelevated and left OTA. Enteral feeds started today at\\n30cc/kg/day of BM/SC20 = 13cc q4hrs. Plan to increase\\nenteral feeds by 15cc/kg/day at 1a &1p. DS 74 at 1100.\\nAbd full, soft, +BS, no loops; no spits. AG 27. u/o\\n1.2cc/kg/hr thus far. No stool. Lytes this am were\\n143/4.6/108/22. P: Cont to support nutritional needs.\\n\\nG/D: Temps stable, nested on sheepskin with boundaries in\\nplace on open warmer. Infant is a&a with cares. Irritable\\nat times, settles well when left alone. Appropriately\\nbrings hands to face & sucks pacifier to comfort self.\\nAFSF. AGA. P: Cont to support dev needs.\\n\\nParents: Mom in for 0900 cares. Speaking lovingly to\\ninfant. Updated on infant's condition and plan of care.\\nAsking appropriate questions. P: Cont to update & support\\nNICU family & plan for family meeting tomorrow at 4pm.\\n\\nID: IV abx d/c'd. Problem resolved at this time.\\n\\nBili: Bili this am was 9.6/0.3, up from 1.7/0.3 Infant\\nplaced under phototherapy lights at 1130. Infant is\\njaundice. Plan to recheck bili in the am. P: Cont to\\nmonitor bili status PRN.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884760,\n \"text\": \"NP NOTE\\nPE: well developed preterm infant swaddled in open warmer. PInk, jaundiced in RA CPAP. Edematous.\\nAFOF sutures approximated, eyes clear, puffy, nares patent with prongs in place, MMMP, white, frothy secretions\\nChest is clear, fair exchaneg, mild SCR. Fair exchange, shallow.\\nCV: RRR, no murmur, pulses+2=\\nAbd: soft, active bs cord dry\\nGU: testes ins crotum\\nEXT: PIV in left hand, right foot edematous with IV infiltrate.\\nNeuro: active, responsive. Flexed posture, good tone, symmetric reflexes.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884761,\n \"text\": \"Respiratory Care\\nPt cont on prong CPAP. Fio2 .24-.27. bs clear, rr 50-70 with mild retractions. On caffeine. No spells. Plan to support as needed. Consider trial off in near future. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884762,\n \"text\": \"RESPIRATORY CARE NOTE\\nBaby #1 remains on Prong CPAP 6 FiO2 21-24%. RR 30-70's Breath sounds are clear. Stable on CPAP cont to follow. Plan to wean off CPAP soon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884827,\n \"text\": \"Neo Attending note\\nday 14, now 36.3 wk pma\\nwt 2620, up 5 gm.\\nCV: no murmur, hr 150s, bp 63/40, 48j\\nrespr: ra, rr 3040s, clear=bs, 1qsr brady with apnea / periodic breathing. Thus countdown restarts today = D 0/5.\\nTF: 150 cc/kg/day. BM24 all po + BFx2 per day. BF well.\\nuop and stool wnl, heme neg.\\nabd wnl. 7.5 stable. no spits.\\ntemp stable in crib. State Newborn screen sent. HepB immunization today.\\nCar seat: wait until bradycardia have continued to improve.\\nhearing screen pending, pending.\\n\\nassessment: due to brady/apnea/periodic breathing, infant will continue CVR monitoring with oximeter.\\notherwise assement is as noted above.\\nPlan: as noted above.\\n\\nPt evaluated and discussed with team.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884807,\n \"text\": \"1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\\nequal, mild subcostal retractions seen. O2 sats are >97%. No\\nspells so far this shift, last one on . Continue to\\nmonitor respiratory status.\\n\\n2. FEN-TF=150cc/kg of BM/SC now 24 or 64cc q4hrs PO/PG.\\nInfant offered bottle at 0900 care, bottled 18cc's using\\nPlaytex bottles. Eager bottler at first but tires easily.\\nMom put infant to breast at 1300, infant latched and\\nbreastfed for about 10 minutes. Infant asleep for third care\\nand mom was unable to put to breast. Full feed gavaged\\nafterward over 50 minutes. Abd benign. Voiding and stooling\\nheme negative. No spits. Minimal aspirates. Continue to\\nencourage po feeds as tolerated by infant.\\n\\n3. DEV-Temperatures stable in air isolette under neoblue\\nlight. Wakes occassionally for cares. Alert and active\\nduring first two cares, asleep with last care. Continue to\\nsupport developmental needs.\\n\\n4. PARENT-Mom in afternoon. Updated by RN. Loving towards\\ninfant, independent with care. Continue to educate and\\nsupport .\\n\\n6. BILI-Infant remains under neoblue with eye shields in\\nplace and slighly jaundiced in color. Yesterdays bili was\\n12.3 (0.3). Bili to be rechecked in am. Continue to monitor\\nbili.\\n\\n7. SKIN-Infants right foot continues to heal, small scab\\npresent. Triple antibiotic ointment applied as ordered by\\nRN. Continue to monitor skin integrity.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884808,\n \"text\": \"PCA Progress Note 1900-0700\\n\\n\\n#1 RESP: Pt. remains in RA breathing in the 40-60s with\\nmild subcostal retractions. Lung sounds cl+= bilaterally.\\nNo episodes of apnea or bradycardia so far this shift. P:\\nContinue to monitor respiratory status.\\n\\n#2 FEN: Weight: 2540g ^ 70g. Total fluids: 150cc/kg/d of\\nBM/SC 24= 64cc Q4hrs PO/PG. Pt. was put to breast @ 2100\\nwith +latch and good coordination for > 10minutes, full\\nfeeding gavaged. Pt. took 20cc using the playtex nurser @\\n0100. Abd soft and round, +BS, no loops. No spits.\\nMinimal aspirates. Pt. is voiding, stooling heme neg. P:\\nContinue to encourage po feedings as tolerated.\\n\\n#3 G&D: Temps stable nested in air isolette. Alert and\\nactive during cares. Sometimes waking for feedings. Rests\\nwell inbetween cares. MAE. AFSF. P: Continue to support\\ndevelopmental needs.\\n\\n#4 Parenting: Mom and Dad in @ 2100. Mom independent with\\ncares and breastfeeding. Mom called X 1. Very loving and\\ninvolved. Updates given. P: Continue to support and update\\nfamily.\\n\\n#6 BILI: Pt. remains under neoblue lights with eye shields\\nin place. Pt. is sl jaundice. Stooling. Last bili:\\n12.3/0.3. Bili was drawn this morning, results pending. P:\\nContinue to monitor.\\n\\n#7 Skin: Scab noted on right foot. Healing, no drainage or\\nredness noted. Triple antibiotic applied as ordered. P:\\nContinue to monitor.\\n\\nPlease see flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884802,\n \"text\": \"Exam Note\\nGEN - alert, fussy in air crib under bili lights\\nHEENT - AFSFO, oropharynx clear, eye covers intact, NGT w/o breakdown\\nCV - RRR, nl s1+s2, no murmur\\nABD - soft, NT, NT, no mass\\nGU - nl ext genit, no rash\\nEXT - wwp, cr < 2 sec\\nNEURO - MAE< reactive\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884803,\n \"text\": \"NPN 07p-07a\\n\\n\\nRESP\\nRA, LS clear & equal with mild subc. retractions. RR30-60's.\\nNo spells or desats this shift thus far. Cont. monitor resp.\\nstatus.\\nFEN\\nCurrent weight 2470g (^50). TF 150cc/kg/day, BM/SSC20.\\nTolerating well. Gavaged q4hrs/bottled x1 this shift thus\\nfar 20cc (coordinated, quickly tiring). BS active. Abd.\\nsoft, round. Voiding, stooling heme negative. Cont. monitor\\nPO/PG feeding tolerance & weight.\\nG&D\\nIn air isolette, temps stable. Nested. Alert & active with\\ncares. Resting comfortably inbetween. Fontanels soft, flat.\\nMAEs. PPPx4ext. Cont. monitor growth & developm. patterns.\\n\\nMOB updated over phone x1. Loving & caring. Cont. support &\\neducate.\\nBili\\nCont. under neoblue bank, eye shields in place. VS stable.\\nAlert & active with cares. Voiding, stooling. Cont. monitor\\nfor changes.\\nSkin\\nCont. with scabbed area on right foot, no redness, drainage\\nor swelling noted. Triple antx ointment applied as ordered.\\nCont. monitor for changes.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884804,\n \"text\": \"Neonatology Attending\\n\\nAdvancing to 24 cals/oz feed. Will discontinue phototherapy.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884805,\n \"text\": \"Neonatology Attending\\n\\nDay 10 PMA 35 wks\\n\\nRemains in RA. Clear breath sounds. No bradycardia. No murmur. BP mean 45. Weight 2470g (+50). TF at 150 ml/kg/d- BM/SC 20. Bottling 20-30ml per feed. Passing heme negative stool. Stable temperature in air-controlled incubator. Stable temperature.\\n\\nDoing well overall. Monitoring for apnea. Tolerating feeds well. Gaining weight well. Encouraging po feeds.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884806,\n \"text\": \"I have examined baby boy I and agree with the above note written by , PCA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884754,\n \"text\": \"NPN Days\\n\\n\\n#1 Resp: CPAP 6 26-32%. 40-80's with occ increased\\ntachypnea, mild SC retrac, LS c/=, with intermittent\\ngrunting noted. Occ sat drifts, one spell so far this shift,\\nresolved with mild stim and increased 02. P: Cont to monitor\\nresp status, will check CBG this eve.\\n#2 FEN: TF=60cc/kg D10W infusing via PIV without diff. Abd\\nbenign, infant cont to be NPO, V/S, mec stooling. P: COnt to\\nmonitor FEN status, check lytes and bili in AM.\\n#3 G&D: Temp stable on off warmer, swaddled. Alert and\\nactive with cares, occ irritable, given sucrose. Sleeps well\\nin between cares. P: Cont to monitor and support G&D.\\n#4 Parents: Parents in for cares, participated where able.\\nAsking appropriate questions, updated frequently by this RN.\\nAppear very loving towards infant. P: Cont to encourage\\nparental calls and visits.\\n#5 ID: Temp stable, infant acting appropriately. Bld cx NTD,\\non Amp and Gent. P: F/u with cxs, d/c'd abx at 48hrs.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884755,\n \"text\": \"Respiratory Care Note\\nInfant remains on NCPAP +6, 26-32% - BS sl. diminished, RR's 40's-70 with some intermittant grunting - no spells thus far - occasional saturation drifts - continue to monitor - blood gas this afternoon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884756,\n \"text\": \"RESPIRATORY CARE NOTE\\nBaby #1 remains on Prong CPAP 6 FiO2 23-32%. Breath sounds are clear. RR 40-80's occasional grunting. Stable on CPAP cont to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884757,\n \"text\": \"Nursing NICU Note\\n\\n\\n1. REsp. O/ Intermittent grunting noted. Remains on Nasal\\nProng CPAP of 6, 21-30% primarily. Please refer to\\nflowsheet. NO A/B noted. A/Alt. in REsp status. P/Cont. to\\nmonitor resp status and intervene as needed. Murmur noted\\nand reported to NNP. A/Resp status remains stable at this\\ntime on CPAP. P/Cont. to monitor for evidence of resp\\ndistress.\\n\\n2.F/N. O/ Tf remain at 60cc/k/d of IVF D10 with 2 NaCl/dl\\nand 1meq KCL/dl via new PIV. Please refer to flowsheet for\\nexaminations of pt from this shift. Remains NPO.\\nIntermittently sucking on pacifier.\\n\\n3. G/D. O/TEmp remains stable swaddled on a warmer. AWake\\nand alert at care times and sleeping well in between. A/Alt.\\nin G/D. P/Cont. to support pt's growth and dev. needs.\\n\\n4. Parents. O/Parents into visit last night. Parents updated\\non pt's status and plan of care. Father held infant\\nswaddled. A/Parents are involved in pt's care.; P/Cont. to\\nsupport and educate parents.\\n\\n5. ID. O/Anitbiotics d/c. NNP stated that she corrected lab\\nerror. A/Completion of 48hr r/O. Cont. to monitor for s/s of\\n infection.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884758,\n \"text\": \"Neonatology Note\\n2 d.o\\non CPAP+6, RA-30%O2, no caffeine\\nbili= 9.6\\nwt= 2450 gm -50\\nTF at 60 ml/kg/d, NPO\\nvoiding(+), bm(+)\\nlytes: 143/4.6/108/22\\n\\nA: twin #1, 34 wks GA, RDS, sepsis evaluation, hyperbilirubinemia\\nP: monitor respiratory staus on CPAP, wean O2 as tolerated, start feeding, start phototherapy, f/u bili.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884824,\n \"text\": \"Nursing Progress Note\\n\\n\\n#1 Resp-- O: RA. No spells. HR 160s; HR 50s-60s. Color\\npink/sl jaund. BS clear and =, mild sc ret. A: Day 4 of 5 P:\\nCont to monitor vitals, document spells\\n\\n#2 Nutrition-- O: 150cc/kg/d= 65cc BM24- HMF d/c- powder\\n4cal/oz started. Po fed well at 0900 taking 70cc., tol well.\\nBF x20 min at 1300 well- no supplement after breast. wakeful\\nfor long period after feed. NG d/c. Abd exam benign, VQS, sm\\nyellow stool x2. Desitin to reddened butoocks (skin intact).\\nOn iron. A: Adequate growth, all po x 24h. P: Cont to\\nmonitor intake and growth. Plan to supplement BF every other\\nBF session with bottle. Switch to pwder 4cal/oz. repeat\\nPKU and in am.\\n\\n#3 Development-- O: and active, waking for feeds.\\nHands to mouth, and sucking on pacifier. Temp stable,\\nco-bedding with twin. All po feeds. Social with Mom. A: AGA\\nP: Cont to support development; Hep B vaccine tonight\\n\\n#4 Parenting-- O: Mom in at 1300. Updated re status and\\nplan. pleased with progress. Mom upset about baby taking\\nfeeding by regular nipple overnight and prefers the Playtex\\nNurser. Will bring in car seat ; will decide about\\ncirc with dad by called, referral to Caregroup\\nwith tentative visit next Wed. Mom to make pedi appt\\ntentatively for next Tues with tentative discharge date Mon.\\nA: Nearing discharge P: Cont to support and keep informed;\\ncont discharge planning- car seat test ; Hep B,\\nPKU, & over night.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884825,\n \"text\": \"NNP Physical Exam\\nAwake and . AFOF with good tone. Breaht sounds clear and equal on RA without retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded wiht active BS, no HSM or masses. Normal GU.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884826,\n \"text\": \"npn 1900-0700\\n\\n\\n1: resp\\nremains in ra. infant has had one spell thus far this shift.\\ninfant brady was to 74, apneic, qsr. see flow sheet. lung\\nsounds clear and equal. mild subcostal retractions. no\\nincreased wob noted. rr 30-40's. continue to monitor for\\nchanges in respiratory status.\\n\\n2; fen\\ncurrent weight 2620gms up 5gms. total fluids remain at\\n150cc/kilo/day of bm 24 cals with powder. tolerating\\nfeeds well. taking all po feeds. infant taking 50cc at 2100\\ncare and then 70 with 0100 care. infant tolerating feeds\\nwell. no spits. abd soft with no loops. voiding and\\nstooling. desitin applied to buttocks. using platex nurser.\\ncontinue with current feeding plan.\\n\\n3: g/d\\ntemps stable in an oac. co-bedded with brother. and\\nactive with cares. sleeps well inbetween. brings hands to\\nface. sucks vigorously on pacifier. wakes for feedings.\\naga. continue to monitor for developmental milestones.\\n\\n4: \\nno contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884799,\n \"text\": \"Neonatology Attending\\n\\nDay 9 PMA 35 wks\\n\\nRemains in RA. RR 30-50s. Sats 92-100%. Clear breath sounds. had one bradycardia episode over last 24 hours. No murmur. HR 130-160s. No murmur. BP mean 57. Bilirubin 12.3 (rebound) so palced back under phototherapy. Weight 2420g (+10). TF at 140 ml/kg/d- SC 20. Bottled one feed. Breast feeding for 5-10 minutes. No spits. Minimal aspirates. Stable temperature in air-controlled incubator. Family up to date.\\n\\nDoing well overall. Minimal respiratory immaturity. Will continue to monitor. Advancing feeds to 150 ml/kg/d. Exaggerated physiologic hyperbilirubinemia. Will continue on phototherapy.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884800,\n \"text\": \"Social Work\\n\\n\\nMet with mother while in visiting with babies today.\\nMother feeling overwhelmed today. She states that she gets here in the morning and styas for the whole day as she wants to be here for all of the babies feedings.\\nTalked with her about cutting back on the amount of time she is here each day, and the importance of having some time for her to rest and pump. Really encouraged her to only come in in early afternoon and she can stay until her husband comes in from work and then they can go home together.\\nMother states that she has good supports, a lot of help from members of her church who have been bringing in dinners for them. Also a friend has been driving them in to the hospital each day, as the couple do not have a car they live closby in , but public transportation is not direct to the hospital.\\nMother's sister will be visiting from over , and her mother in law will come in mid . All extended family members are in State.\\nWill plan to check in with mother tomorrow, continue to encourage her to take car of herself and not to be spending the entire day at the hospital.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884801,\n \"text\": \"NPN 7a-7p\\n\\n\\n#1 Resp: Infant in room air w/resp rate 20s-50s and sat\\n93-100%. Lung sounds cl/= and mild SC retractions. No spells\\nso far this shift. A: Infant stable in room air w/no spells.\\nP: Cont to monitor.\\n\\n#2 FEN: TF inc from 140 to 150 cc/kg of BM 20 (64 cc q4h\\ngavaged over 50 min). Po/pg. Infant breast feeding w/Mom q\\ncares and receiving full gavage volume. Infant BF for 5 min\\n@ 0900 but was sleepy with weak suck. Infant awake and eager\\nand breast fed for 10 min with good latch and suck @ 1300\\ncares. No spits, min asp. Abdomen round, pink, and soft\\nw/active bowel sounds and no loops. Voiding and stooling\\nheme negative. A: Infant coordinated w/breast feeding when\\nawake and eager. P: Cont w/current plan and encourage po\\nfeedings as tol.\\n\\n#3 Dev: Infant nested in air isolette, temp stable. Alert\\nand active during cares and sl irritable in between. Settles\\nvery well with pacifier and boundaries. A: AGA. P: Cont to\\nsupp dev needs.\\n\\n#4 : Mom in q cares and updated. Mom took temp,\\nchanged diaper, and breast fed infant. A: Independent and\\nappropriate w/cares. P: Cont to support and update.\\n\\n#6 Bili: Infant cont neoblue photo rx with eye shields for\\nbili of 12.3/0.3 this am. A: Infant appears jaund. P: Cont\\nphoto rx and check bili .\\n\\n#7 Skin: Triple antibiotic ointment applied to old\\ninfiltrate/scabbed area on right foot @ 0900 cares.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884797,\n \"text\": \"NPN 0700-1900\\n\\n\\n1. Resp: Infant remains in RA, maintaining his O2 sats\\ngreater than 96%. Lung sounds clear/=. RR 30-50's. Mild\\nSCR noted. No A's or B's noted. P: Cont. to monitor resp.\\nstatus.\\n\\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempted to BF\\nx 2 thus far - latched well. Tolerating NGT feedings well;\\nabd exam benign, no spits, min asp. Voiding qs and stooling\\nheme neg. P: Cont. to support nutritional needs.\\n\\n3. G/D: Temps stable swaddled in off-isolette. Infant is\\nalert/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 suppot developmental\\nneeds. P: Cont. to support developmental needs.\\n\\n4. : in throughout day. Independent with\\ncares and handling infants. Updated at bedside on infant's\\ncondition and plan of care. Asking appropriate questions.\\nLoving, involved . P: Cont. to support and update\\n.\\n\\n5. Bili: Photo was d/c'd on thurs at 10 am for a bili of\\n10.6. P: Repeat bili to be drawn in am.\\n\\n6. Skin - Rt foot infiltrate left open to air. Healing well\\nwith triple abx ointment q 12 hours. No drainage, swelling,\\nor redness noted. P: Cont. to monitor skin.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884798,\n \"text\": \"npn 1900-0700\\n\\n\\n1: resp\\nremains in ra. no spells and no dsats. lung sounds clear and\\nequal. mild subcostal retractions. no increased wob noted.\\nrr 30-50's. sats .925. continue to monitor for changes in\\nrespiratory status.\\n\\n2: fen\\ncurrent weight 2420gms up 10. total fluids remain at\\n140cc/kilo/day of bm 20 cals. tolerating feeds well. no\\nspits. minimal aspirates. voiding and stooling. abd soft\\nwith no loops. infant po'd 20cc at 0100. infant po fed based\\non feeding cues. continue to encourage po feeds as\\ntolerated.\\n\\n3: growth and development. received infant in an off\\nisolette. infant currently co-bedding in a crib with\\nsibbling. temps remain stable. alert and active with cares.\\nsleeps well inbetween. brings hands to face. sucks\\nvigorously on pacifier. brings hands to face. aga.continue\\nto monitor for developmental milestones.\\n\\n6; bili\\ninfant color slighlty jaundiced. infant currently off of\\nphototherapy. rebound bili sent this shift. will continue to\\nmonitor bili closely.\\n\\n7: skin\\ninfant right foot old infiltrate sight with multiple small\\nscabs. no drainage noted and no bleeding. triple antibiotic\\nointment applied at 2100. continue to monitor for changes.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884748,\n \"text\": \"Admission Note\\nBB admitted to NICU following C/S delivery for PIH. Infant emerged with good cry, dusky and retracting, requiring stim and BBO2 in DR. . on admission, GFR with RA SaO2 mid 80's, placed on CPAP 6 in 26-30% FiO2 to maintain SaO2 89-95. LS sl coarse and diminished, color good, cont with GFR through shift. Cap gas 7.27/45/47. No murmur audible, BP 75/35 mean 45. Labs sent for Bld cx and CBC, antibiotics begun. IV placed in R hand with D10W infusing, initial DS 47, after IVF infusing, DS 74. Abd benign, soft, round, +BS, has voided, no stool, NPO for now. Stable on open warmer, sl irritable with cares, little interest in pacifer. Dad visited briefly, told weights/measures and equipment explained, spoke softly with the babies. A: 34 week infant w/RDS P: cont CPAP/O2 as needed, maintain IVF NPO for now, cont antibiotics as ordered, monitor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884749,\n \"text\": \"Respiratory Care Note\\nPt continues on Prong CPAP +6 FIO2 26-28%. B.S. ess. clear with good air entry. Mild retractions and grunting noted. Without apnea or bradys as of this note.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884750,\n \"text\": \"1 Alt in Resp\\n2 Alt in FEN\\n3 Alt in G&D\\n4 Alt in Parenting\\n5 ID\\n\\nREVISIONS TO PATHWAY:\\n\\n 1 Alt in Resp; added\\n Start date: \\n 2 Alt in FEN; added\\n Start date: \\n 3 Alt in G&D; added\\n Start date: \\n 4 Alt in Parenting; added\\n Start date: \\n 5 ID; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884751,\n \"text\": \"#1 PT CONT ON CPAP OF 6, MOSTLY 25-30% FI02. LS ARE CLEAR,\\nSLIGHTLY DIMINISHED. RR 40-80 WITH OCC GRUNTING. SATS\\nIMPROVED ON BELLY.\\n#2 NPO. TF 60/KG D10W INFUSING WELL VIA PIV. WEIGHT DECREASE\\n75GM. VOIDING AND STOOLING. DSTIX 113. BELLY FULL AND SOFT\\nWITH ACTIVE BS.\\n#3 TEMPS ARE STABLE NESTED ON SERVO WARMER. ALERT AND\\nIRRITABLE.\\n#4 DAD IN TO VISIT IN EVENING. DAD UPDATED AT BEDSIDE.\\n#5 PT CONT ON AMP AND GENT AS ORDERED.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884752,\n \"text\": \"RESPIRATORY CARE NOTE\\nBaby #1 remains on Prong CPAP 6 FiO2 25-30%. Occasional grunting RR 40-80's. Breath sounds are clear. Stable on CPAP will cont to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884753,\n \"text\": \"Neonatology Attending\\n\\nDay 1 PMA 34 wks\\n\\nRemains on CPAP 6 with fio2 0.28. RR 50-80s. Intermittent grunting. CBG 7.28/47. No apnea, bradycardia. No murmur. HR 130-160s. BP mean 47. Weight 2500g (-75). NPO. IV dextrose at 60 ml/kg/d. Blood glucose 103. Benign abdomen. Lytes 135/4.0/19. Bilirubin 1.7. Stable temperature on off warmer. Parents in earlier this morning. On ampicillin and gentamicin. Blood culture no growth.\\n\\nMild hyaline membrane disease. Will continue to monitor closely. Keeping NPO. Will continue to follow blood glucose. Ruling out on antibiotics.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884817,\n \"text\": \"Exam Note\\nGEN - , active\\nHEENT - AFSFO, facial macules almost completely resolved from yesterday, oropharynx clear\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl male ext genit, no rash, stool present\\nEXT - wwp, cr < 2\\nNEURO - MAE, reactive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884818,\n \"text\": \"6 Alt in \\n7 Skin:\\n\\nREVISIONS TO PATHWAY:\\n\\n 6 Alt in ; resolved\\n 7 Skin:; resolved\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884828,\n \"text\": \"NPN DAYS\\n\\n\\n#1 Pt received and cont in RA. LS C+=. no spells so\\nfar this shift. Pt day of spell count down. P- Will cont\\nto monitor resp status.\\n#2 FEN- TF=150cc/kg/d of BM24 with powder. abd benign.\\nall po feeds. po 35-50cc +BFx2. Pt voiding and stooling hem\\nneg. no spits. waking q2.5-4hrs. P- Will cont to monitor\\nFEN.\\n#3 G&D- Temp stable in open crib. cobedding with sibling.\\n and active with cares. sucking on pacifier. P- Will\\ncont to monitor G&D.\\n#4 Mom and Dad visiting this shift. Loving and\\ncaring towards pt. asking approp ques. updates given.\\nhelping with cares. updated re: pt spells and DC\\ndate pushed back. P- Will cont to support and educate\\n.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884829,\n \"text\": \"NPN DAYS\\naddendum: Hep B immunization given @ 1800.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884830,\n \"text\": \"NPN:\\n\\nRESP: RA. RR=40-50s w/SC retraction. BBS =/clear. Last A&B on ; day of brady count.\\n\\nCV: No murmur. HR=140-160. BP=68/41 (51). Color pink w/slight jaundice. Perfusion good.\\n\\nFEN: Wt=2655g (+ 35g). Ad Lib feeds of BM-24. Intake yesterday 119cc/kg/d + breast fdgs x 2. Bottled slowly x 1 for 10cc; 60cc taken well at following feeding. No spits. Abd benign. Voiding qs; small yellow stool. FeS04. Mother has appt w/lactation consultant on (13:00).\\n\\nG&D: CGA=36-4/7 wk. Temp stable in crib. Co-bedding w/sibling. Active and w/good tone. Swaddled and resting well. Discharge preparations in progress; hearing screen and carseat test need to be done.\\n\\nSOCIAL: Mother called x 1 for update.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884831,\n \"text\": \"NNP ON-Call\\nPhysical Exam\\nGeneral: infant in open crib, room air,co-bedding with twin\\nSkin; warm and dry; color pink/jaundiced; cafe spot on forehead\\nHEENT: anterior fontanel open, level; sutures opposed\\nChest: breath sounds clear/=\\nCV: RRR, no murmur; normal S1 S2; pulses +2\\nAbd: soft; no masses; + bowel sounds; cord healed\\nExt: moving all\\nneuro: appropriate tone and reflexes; alerts\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"BABYGRAM (CHEST ONLY)\",\n \"row_id\": 934419,\n \"text\": \" 1:36 AM\\n BABYGRAM (CHEST ONLY) Clip # \\n Reason: evaluate for rds vs retained fetal lung fluid\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant with prematurity, on CPAP\\n REASON FOR THIS EXAMINATION:\\n evaluate for rds vs retained fetal lung fluid\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Chest x-ray.\\n\\n DATE OF EXAM: .\\n\\n TIME OF EXAM: 1:46.\\n\\n CLINICAL HISTORY: This is a newborn infant on day of life 1 with respiratory\\n distress.\\n\\n FINDINGS: A single, portable view of the chest was obtained. I have no prior\\n films available for comparison. The heart size is normal. The pulmonary\\n vasculature is within range of normal limits. There is some increased\\n interstitial fluid suggesting the diagnosis of TTN, perhaps with a component\\n of mild hyaline membrane disease. There is no focal lung opacification.\\n\\n Abdominal situs is normal. The visualized bony structures are normal.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":198,"cells":{"subject_id":{"kind":"number","value":81662,"string":"81,662"},"hadm_id":{"kind":"number","value":124697,"string":"124,697"},"target_text":{"kind":"string","value":"46 y/o w/ depression and prior suicide attempts and MAOI overdose/toxicity, presents after being found unresponsive concerning for medication overdose."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: No acute intracranial abnormality. COMPARISON: CT head without contrast . The cardiomediastinal and hilar contours are normal. Minimal fluid is seen within the left mastoid air cell. The ventricles and sulci are normal in caliber and configuration. Sinustachycardia persists. No acute fractures are identified. Minimal hypodensity in the right frontal region suggests small vessel ischemic disease. No right pleural effusion or pneumothorax is seen. Non-specific ST-T wave changes.Compared to the previous tracing of no diagnostic interim change. TECHNIQUE: Contiguous axial images were acquired through the head without intravenous contrast. Endotracheal tube in good position. Lungs are clear with the previously noted infiltrate at the left lung base resolved. The basal cisterns are normal. Heart size and vascularity are normal. PORTABLE SEMI-ERECT CHEST RADIOGRAPH: Endotracheal tube is low in position terminating in the proximal left main bronchus. The imaged paranasal sinuses are clear. IMPRESSION: 1. IMPRESSION: 1. The -white matter differentiation is well preserved. The lung volumes are low, with bibasal opacities, could represent atelectasis or aspiration. FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses or mass effect. There is no evidence of pneumothorax. There is an NG tube passing beyond the stomach. Low lung volumes with bibasal opacities, could represent atelectasis or aspiration. Endotracheal tube in the proximal left main bronchus. An endotracheal tube is present with the tip at the T3 level. ICH No contraindications for IV contrast WET READ: KKgc SAT 5:55 PM No acute intracranial abnormality. No evidence for active cardiopulmonary disease. Sinus tachycardia. 2. 2. Sagittal and coronal reformats were generated and reviewed. Early R wave transition. 4:59 PM CT HEAD W/O CONTRAST Clip # Reason: ? The findings were discussed with Dr. on . ICH MEDICAL CONDITION: 46 year old woman unresponsive REASON FOR THIS EXAMINATION: ? WET READ VERSION #1 FINAL REPORT INDICATION: 46-year-old woman, unresponsive, to rule out intracranial hemorrhage. 3:16 PM CHEST (PORTABLE AP) Clip # Reason: please eval tube MEDICAL CONDITION: 46 year old woman unresponsive, intubated REASON FOR THIS EXAMINATION: please eval tube FINAL REPORT INDICATION: 46-year-old woman who is unresponsive and is intubated. 9:35 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please evaluate for ET tube placement Admitting Diagnosis: UNRESPONSIVE MEDICAL CONDITION: 46 year old woman presented unresponsive, s/p ET adjustment REASON FOR THIS EXAMINATION: please evaluate for ET tube placement FINAL REPORT PORTABLE CHEST HISTORY: Unresponsive, ET tube placement."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2109-09-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1210749,"text":" 9:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for ET tube placement\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman presented unresponsive, s/p ET adjustment\n REASON FOR THIS EXAMINATION:\n please evaluate for ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Unresponsive, ET tube placement.\n\n COMPARISON: at 1524 hours.\n\n An endotracheal tube is present with the tip at the T3 level. There is an NG\n tube passing beyond the stomach. Heart size and vascularity are normal.\n Lungs are clear with the previously noted infiltrate at the left lung base\n resolved. There is no evidence of pneumothorax.\n\n IMPRESSION:\n 1. Endotracheal tube in good position.\n 2. No evidence for active cardiopulmonary disease.\n\n\n"},{"category":"Radiology","chartdate":"2109-09-21 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1210729,"text":" 4:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman unresponsive\n REASON FOR THIS EXAMINATION:\n ? ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc SAT 5:55 PM\n No acute intracranial abnormality.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old woman, unresponsive, to rule out intracranial\n hemorrhage.\n\n COMPARISON: CT head without contrast .\n\n TECHNIQUE: Contiguous axial images were acquired through the head without\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses or\n mass effect. The -white matter differentiation is well preserved. The\n ventricles and sulci are normal in caliber and configuration. Minimal\n hypodensity in the right frontal region suggests small vessel ischemic\n disease. The basal cisterns are normal. No acute fractures are identified.\n The imaged paranasal sinuses are clear. Minimal fluid is seen within the left\n mastoid air cell.\n\n IMPRESSION: No acute intracranial abnormality.\n\n"},{"category":"Radiology","chartdate":"2109-09-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1210716,"text":" 3:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman unresponsive, intubated\n REASON FOR THIS EXAMINATION:\n please eval tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old woman who is unresponsive and is intubated.\n\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH: Endotracheal tube is low in position\n terminating in the proximal left main bronchus. The lung volumes are low,\n with bibasal opacities, could represent atelectasis or aspiration. The\n cardiomediastinal and hilar contours are normal. No right pleural effusion or\n pneumothorax is seen.\n\n IMPRESSION:\n 1. Endotracheal tube in the proximal left main bronchus. The findings were\n discussed with Dr. on .\n 2. Low lung volumes with bibasal opacities, could represent atelectasis or\n aspiration.\n\n"},{"category":"ECG","chartdate":"2109-09-21 00:00:00.000","description":"Report","row_id":164267,"text":"Sinus tachycardia. Early R wave transition. Non-specific ST-T wave changes.\nCompared to the previous tracing of no diagnostic interim change. Sinus\ntachycardia persists.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-09-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210749,\n \"text\": \" 9:35 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: please evaluate for ET tube placement\\n Admitting Diagnosis: UNRESPONSIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old woman presented unresponsive, s/p ET adjustment\\n REASON FOR THIS EXAMINATION:\\n please evaluate for ET tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST\\n\\n HISTORY: Unresponsive, ET tube placement.\\n\\n COMPARISON: at 1524 hours.\\n\\n An endotracheal tube is present with the tip at the T3 level. There is an NG\\n tube passing beyond the stomach. Heart size and vascularity are normal.\\n Lungs are clear with the previously noted infiltrate at the left lung base\\n resolved. There is no evidence of pneumothorax.\\n\\n IMPRESSION:\\n 1. Endotracheal tube in good position.\\n 2. No evidence for active cardiopulmonary disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-09-21 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1210729,\n \"text\": \" 4:59 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? ICH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old woman unresponsive\\n REASON FOR THIS EXAMINATION:\\n ? ICH\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KKgc SAT 5:55 PM\\n No acute intracranial abnormality.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old woman, unresponsive, to rule out intracranial\\n hemorrhage.\\n\\n COMPARISON: CT head without contrast .\\n\\n TECHNIQUE: Contiguous axial images were acquired through the head without\\n intravenous contrast. Sagittal and coronal reformats were generated and\\n reviewed.\\n\\n FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses or\\n mass effect. The -white matter differentiation is well preserved. The\\n ventricles and sulci are normal in caliber and configuration. Minimal\\n hypodensity in the right frontal region suggests small vessel ischemic\\n disease. The basal cisterns are normal. No acute fractures are identified.\\n The imaged paranasal sinuses are clear. Minimal fluid is seen within the left\\n mastoid air cell.\\n\\n IMPRESSION: No acute intracranial abnormality.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-09-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210716,\n \"text\": \" 3:16 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval tube\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old woman unresponsive, intubated\\n REASON FOR THIS EXAMINATION:\\n please eval tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old woman who is unresponsive and is intubated.\\n\\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH: Endotracheal tube is low in position\\n terminating in the proximal left main bronchus. The lung volumes are low,\\n with bibasal opacities, could represent atelectasis or aspiration. The\\n cardiomediastinal and hilar contours are normal. No right pleural effusion or\\n pneumothorax is seen.\\n\\n IMPRESSION:\\n 1. Endotracheal tube in the proximal left main bronchus. The findings were\\n discussed with Dr. on .\\n 2. Low lung volumes with bibasal opacities, could represent atelectasis or\\n aspiration.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 164267,\n \"text\": \"Sinus tachycardia. Early R wave transition. Non-specific ST-T wave changes.\\nCompared to the previous tracing of no diagnostic interim change. Sinus\\ntachycardia persists.\\n\\n\"\n }\n]"}}},{"rowIdx":199,"cells":{"subject_id":{"kind":"number","value":3018,"string":"3,018"},"hadm_id":{"kind":"number","value":160704,"string":"160,704"},"target_text":{"kind":"string","value":"Patient admitted to the trauma service. Plastic Surgery was immediately consulted for his facial fractures; Ophthalmology was also consulted for his orbital fractures. He was taken to the operating room on by Plastics for repair of his facial fractures. He was prophylaxed with IV antibiotics for meningitis. Ophthalmology recommended follow up in Eye Clinic for his diabetic retinopathy. Neurosurgery was consulted for his head injuries and recommended repeat imaging and Dilantin. His Dilantin was weaned per recommendation by Neurosurgery starting on with a d/c date of . Diabetes was also consulted because of his elevated blood sugars. Patient started on 75/25 insulin . He has agreed to follow up in the Clinic after discharge. Because of his ETOH history patient was placed on CIWA protocol; there were no clinical signs of delirium tremors during his hospitalization. Physical and Occupational therapy were consulted. Social work consulted because of patient's home situation and his refusal of home services and complying with his medication regimen after his discharge; reportedly patient does not have a permanent home address and no family in this country or his home land of . Psychiatry was consulted to assess patient's capacity and felt that he did possess the capacity to make his health decisions. Pt. discharged to home."},"extractive_notes_summ":{"kind":"string","value":"Right subdural hematoma. RIght subdural hematoma. Stable appearance of tiny focus of probable intraparenchymal hemorrhage within the right temporal lobe. Again seen is a right subdural hematoma extending along the convexity, which appears approximately unchanged in size. There is proptosis of the right globe and intraorbital hematoma within the superolateral aspect of the right orbit. There is a moderate right subdural hematoma layering adjacent to the right frontoparietal convexity and extending inferiorly to the right temporal lobe. Subdural hemorrhage, right temporal lobe hemorrhage approx unchanged. Probable left subarachnoid hemorrhage. There is air within the right orbit, and along the superolateral aspect of the orbit, there is a hematoma displacing the extraocular muscles medially. Right frontal and parietal subgaleal hematoma. further access today.Resp: LS clear, diminished at bases; suctioned for sm. Marked gastric distention. Possible small focus of right temoral intraparenchymal hemorrhage. PB's for DVT prophylaxis. PB's for DVT prophylaxis. A right frontal fracture line extends anteriorly and inferiorly to the right frontal sinus, where there is marked comminution with displaced fragments involving the anterior and posterior walls of the frontal sinus. A small focus of hyperdensity along the medial aspect of the right frontal lobe likely represents a small amount of subarachnoid hemorrhage at this location. Note is made of heterogeneity within the clivus, a finding that may indicate clival hemangioma. Additional linear opacity within the right middle and right lower lobe laterally is consistent with scarring versus atelectasis. There is diffuse narrowing of the sulci of the right frontal and parietal lobes. The celiac trunk, superior mesenteric artery, and inferior mesenteric artery appear patent. Injuries: non-depressed R skull fx, traumatic R frontal parietal SDH/SAH with complex orbital/midface fx with sm. on ciwa scale (score ).Resp: LS clear, diminished at bases, denies shortness of breath or difficulty breathing. The appearance of a rounded focus of hemorrhage within the posterior aspect of the right temporal lobe, possibly representing an intraparenchymal hemorrhage, is stable. Right frontal and parietal scalp hematoma. There has been slight interval new hypodensity within the inferior right frontal lobe, which could be consistent with a contusion. TECHNIQUE: Non-contrast head CT. A large right frontal scalp hematoma appears approximately unchanged. The lateral ventricles are symmetric and nondilated, and the basilar cisterns appear patent. Additional tiny focus of hemorrhage within the right temporal lobe may represent subarachnoid or intraparenchymal hemorrhage. Within the right lobe of the liver anteriorly, there is a triangular area of hypodensity. The cardiac, mediastinal, and hilar contours are within normal limits. Proptosis of right globe with intraorbital hematoma on right. There is a punctate density superficially within the area of the right frontoparietal hemorrhage, which may possibly represent a foreign body versus structure on the surface of the patient. Respiratory Therapy60 y.o. Questionable subarachnoid hemorrhage within the left parietal region. Evaluate for solid organ injury. MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate a triangular area of hypodensity within the right lobe of the liver anteriorly. Right frontal skull fracture, displaced. There is a small amount of fluid and mucosal thickening within the left ethmoid air cells and left frontal sinus. Right subdural hematoma is approximately unchanged in size. There are comminuted fractures of the right zygomatic arch and of the anterior and lateral walls of the right maxillary sinus. R side of forehead/next to eye with sm. The visualized portions of the heart and pericardium appear unremarkable. Additional incidental finding of possibly left lung abnormality - please see report. Subarachnoid blood is again seen medially adjacent to the right frontal lobe. Note is made of a small amount of intraventricular hemorrhage which is seen layering in the left lateral ventricle slightly more conspicuous than the prior study. A rounded focus of hemorrhage within the posterior aspect of the right temporal lobe may represent a small focus of subarachnoid blood versus an intraparenchymal hemorrhage. unasyn as ordered.Skin: back/buttocks intact; R sided facial abrasion with sm. FINAL REPORT INDICATION: Facial trauma, found down. Wedge configuration of L1 vertebra, a finding that likely represents old trauma versus normal variant. There is an appearance of proptosis of the right globe, although no large retrobulbar hematoma is identified. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are dependent changes within the lower lobes bilaterally. Right inferior frontal lobe contusion is more apparent on the current study. Coronal and sagittal reformations are provided. FINDINGS: The previously identified right subdural hematoma is not significantly changed. Old right rib fracture and wedge configuration of L1 that could represent prior compression deformity or normal variant; see report. Lytes repleted.Endo: BS 132->195, covered per ss.ID: tmax 100.3; wbc 7.5,conts. Subarachnoid hemorrhage centered in the suprasellar cistern and involving the right frontal lobe inferolaterally and medially. There is decreased conspicuity of subarachnoid hemorrhage along the course of the right middle cerebral artery. There is soft tissue stranding and swelling within the right frontal scalp and preorbital soft tissues. There are multiple comminuted fractures involving the anterior and posterior walls of the right frontal sinus with posterior displacement of a fracture fragment into the intracranial space and with a tiny focus of pneumocephalus. There is an additional comminuted fracture of the posterior aspect of a right ethmoid air cell with displacement of a fracture fragment into the intracranial space. (+) ETOH Intubated in ED for deteriorating GCS. A right frontal skull fracture with triangular configuration demonstrates mild displacement. Kcl repleted.Endo: BS 216->covered per SS.ID; tmax 99.2; conts. IMPRESSION: Bibasilar linear atelectases. The prevertebral soft tissues appear unremarkable. In the setting of trauma, this could represent a hepatic laceration, although no perihepatic fluid collections are identified. There is degenerative change of the thoracolumbar and lumbosacral spine. Dilantin loaded in ER. Comminuted fracture of the anterior wall of the right orbit and of the right zygomatic arch. The ventricles are symmetric and nondilated. Questionable hyperdensity at the left insula is suggestive of possible subarachnoid hemorrhage."},"n_notes":{"kind":"number","value":16,"string":"16"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2128-08-18 00:00:00.000","description":"Report","row_id":209871,"text":"Normal sinus rhythm. Tracing is within normal limits. No previous tracing\navailable for comparison.\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":881656,"text":" 4:10 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: r/o injueries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man found btwen curb and car\n REASON FOR THIS EXAMINATION:\n r/o injueries\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n COMPARISON: None.\n\n AP CHEST X-RAY: The cardiac silhouette, mediastinal, and hilar contours are\n normal. No pneumothorax is seen bilaterally on this supine radiograph. Both\n lungs are clear without consolidations or effusions. The surrounding soft\n tissue and osseous structures are unremarkable.\n\n AP PELVIS: Bilateral sacroiliac joints, pubic symphysis, and partially imaged\n bilateral hips are unremarkable. There is normal bony mineralization, without\n malalignment. The surrounding soft tissues are unremarkable.\n\n IMPRESSION: No evidence of intrathoracic or intrapelvic trauma.\n\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":881657,"text":" 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with found unresp btwn car and curb\n REASON FOR THIS EXAMINATION:\n r/o injur\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 5:22 PM\n Subarachnoid hemorrhage in basal cisterns and extending along right frontal\n and parietal lobes. RIght subdural hematoma. Possible small focus of right\n temoral intraparenchymal hemorrhage. Probable left subarachnoid hemorrhage.\n Multiple facial and skull fractures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: There is subarachnoid blood\n within the suprasellar cistern and lateral to the pons on the right, with\n extension to the Sylvian fissure and to the inferolateral aspect of the right\n frontal lobe. A small focus of hyperdensity along the medial aspect of the\n right frontal lobe likely represents a small amount of subarachnoid hemorrhage\n at this location.\n There is a moderate right subdural hematoma layering adjacent to the right\n frontoparietal convexity and extending inferiorly to the right temporal lobe.\n A rounded focus of hemorrhage within the posterior aspect of the right\n temporal lobe may represent a small focus of subarachnoid blood versus an\n intraparenchymal hemorrhage. Questionable hyperdensity at the left insula is\n suggestive of possible subarachnoid hemorrhage.\n\n The lateral ventricles are symmetric and nondilated, and the basilar cisterns\n appear patent. There is diffuse narrowing of the sulci of the right frontal\n and parietal lobes. There is no shift of normally midline structures. The\n - white differentiation appears preserved.\n\n Bone windows demonstrate numerous fractures of the skull and facial bones.\n There is a coronally oriented fracture extending through the right and left\n frontal bones originating near the vertex. A right frontal fracture line\n extends anteriorly and inferiorly to the right frontal sinus, where there is\n marked comminution with displaced fragments involving the anterior and\n posterior walls of the frontal sinus. There are multiple comminuted fractures\n of the roof of the orbit and of the right lamina papyracea. There are\n comminuted fractures of the right zygomatic arch and of the anterior and\n lateral walls of the right maxillary sinus. There is blood layering within\n the right maxillary sinus, ethmoid sinuses, and frontal sinus and air within\n the orbit. There is an appearance of proptosis of the right globe, although\n no large retrobulbar hematoma is identified. The mastoid air cells are\n (Over)\n\n 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n normally pneumatized. There is extensive soft tissue swelling and hematoma\n within the right frontal scalp. There is a punctate density superficially\n within the area of the right frontoparietal hemorrhage, which may possibly\n represent a foreign body versus structure on the surface of the patient.\n\n IMPRESSION:\n 1. Subarachnoid hemorrhage centered in the suprasellar cistern and involving\n the right frontal lobe inferolaterally and medially.\n 2. Right subdural hematoma.\n 3. Additional tiny focus of hemorrhage within the right temporal lobe may\n represent subarachnoid or intraparenchymal hemorrhage.\n 4. Questionable subarachnoid hemorrhage within the left parietal region.\n 5. Numerous comminuted facial and skull fractures.\n 6. Right frontal and parietal subgaleal hematoma.\n\n Facial fractures will be further assessed with facial bone CT of same date.\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":881658,"text":" 4:25 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with found unresp btwn car and curb\n REASON FOR THIS EXAMINATION:\n r/o injur\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 5:46 PM\n No fracture of cervical spine.\n Slight exaggeration of cervical lordosis may be positional. Please see\n dictated report for further recommendations. Additional incidental finding of\n possibly left lung abnormality - please see report.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained through the cervical spine without\n intravenous contrast. Coronal and sagittal reformations are provided.\n\n CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is\n imaged from C1 through the upper portion of T3. No fracture is identified in\n the cervical spine. There is multilevel degenerative change of the cervical\n spine with anterior osteophytosis, most prominent at C3-4, C5-6, and C6-7.\n There is slight exaggeration of the normal cervical lordosis that may be\n positional in nature. There is a suggestion of widening of the intervertebral\n disc spaces anteriorly, a finding that is predominantly diffuse to the C4-5\n through C6-7 intervertebral disc spaces. The prevertebral soft tissues appear\n unremarkable. The visualized outlines of the thecal sac demonstrate posterior\n probable disc bulges at C4-5 and C5-6 with indentation of the thecal sac. CT\n is limited in its ability to provide intrathecal detail.\n\n The visualized portions of the lung apices demonstrate emphysematous change.\n In addition, there is an ill-defined opacity at the left lung apex with\n irregular margins that is incompletely imaged. There are several small\n projections from the tracheal wall, which may represent adherent secretions.\n The mastoid air cells are normally pneumatized.\n\n IMPRESSION:\n 1. No fracture of the cervical spine.\n 2. Exaggeration of the cervical lordosis with diffuse widening of several\n intervertebral disc spaces anteriorly may be positional in nature. If there\n is clinical concern for ligamentous injury, MR is a more sensitive test.\n 3. Suggestion of disc bulges at C4-5 and C5-6. CT is limited in its\n evaluation of the spinal canal and its contents.\n 4. Emphysematous changes in the visualized portions of the lungs and\n additional irregular opacity at the left lung apex, a finding that may be\n further evaluated with dedicated chest CT once the patient is clinically able.\n\n (Over)\n\n 4:25 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":881659,"text":" 4:28 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/out fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with facial trauma\n REASON FOR THIS EXAMINATION:\n r/out fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 6:54 PM\n Multiple facial and skull fractures. please see report.\n Proptosis of right globe with intraorbital hematoma on right.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down with facial trauma, evaluate fractures.\n\n COMPARISON: Head CT of same date.\n\n TECHNIQUE: Axial MDCT images were obtained through the facial bones. Coronal\n reformations are provided.\n\n CT OF THE FACIAL BONES WITHOUT INTRAVENOUS CONTRAST: There are numerous skull\n and facial fractures. A right frontal skull fracture with triangular\n configuration demonstrates mild displacement.\n\n There are multiple comminuted fractures involving the anterior and posterior\n walls of the right frontal sinus with posterior displacement of a fracture\n fragment into the intracranial space and with a tiny focus of pneumocephalus.\n There is an additional comminuted fracture of the posterior aspect of a right\n ethmoid air cell with displacement of a fracture fragment into the\n intracranial space.\n\n Additional comminuted fractures are present within the roof of the right orbit\n with displacement of a fracture fragment into the superior aspect of the right\n orbit. There is air within the right orbit, and along the superolateral\n aspect of the orbit, there is a hematoma displacing the extraocular muscles\n medially. The fracture fragments do not appear to impinge directly upon the\n optic nerve, although there is proptosis of the right globe.\n\n There are additional linear fractures of the lamina papyracea on the right.\n Comminuted fracture of the anterior wall of the right orbit and of the right\n zygomatic arch. There is blood layering within the right maxillary sinus,\n ethmoid sinuses, and frontal sinus. There is a small amount of fluid and\n mucosal thickening within the left ethmoid air cells and left frontal sinus.\n The left maxillary sinus is normally pneumatized and no fractures are\n identified within the left maxillary sinus or orbit. The mastoid air cells\n are normally pneumatized. Note is made of heterogeneity within the clivus, a\n finding that may indicate clival hemangioma. There is soft tissue stranding\n and swelling within the right frontal scalp and preorbital soft tissues.\n\n IMPRESSION:\n 1. Right frontal skull fracture, displaced.\n (Over)\n\n 4:28 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/out fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Extensive comminuted fractures of the right frontal sinus, maxillary\n sinus, orbit, and zygomatic arch.\n 3. There is proptosis of the right globe and intraorbital hematoma within the\n superolateral aspect of the right orbit.\n 4. There are displaced comminuted fracture fragments protruding into the\n right orbit without direct evidence of impingement upon the optic nerve.\n\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":881660,"text":" 4:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/out solid organ injury\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with facial trauma found down\n REASON FOR THIS EXAMINATION:\n r/out solid organ injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 6:09 PM\n Triangular hypodensity in right lobe of liver without perihepatic fluid\n collection could possibly represent small liver laceration versus other liver\n lesion.\n\n No fractures identified. Old right rib fracture and wedge configuration of L1\n that could represent prior compression deformity or normal variant; see\n report.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Facial trauma, found down. Evaluate for solid organ injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\n symphysis following the administration of 150 cc of intravenous Optiray.\n Additional coronal and sagittal reformations are provided.\n\n CONTRAST: Intravenous non-ionic contrast was administered due to the rapid\n rate of bolus injection required for this examination.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are dependent changes\n within the lower lobes bilaterally. Additional linear opacity within the\n right middle and right lower lobe laterally is consistent with scarring versus\n atelectasis. The visualized portions of the heart and pericardium appear\n unremarkable. There is marked distension of the stomach containing air and\n fluid.\n\n Within the right lobe of the liver anteriorly, there is a triangular area of\n hypodensity. There is no perihepatic fluid collection at this location. There\n is an additional questionable hypodensity within the left lobe of the liver\n superiorly (series 2, image 9), possibly representing partial volume\n averaging. The spleen, pancreas, gallbladder, and adrenal glands appear\n unremarkable. There are no perinephric fluid collections. There are symmetric\n nephrograms bilaterally without evidence of masses or hydronephrosis in either\n kidney. The ureters are nondilated. The aorta is normal in caliber. The\n celiac trunk, superior mesenteric artery, and inferior mesenteric artery\n appear patent. The large and small bowel loops are normal in caliber. The\n appendix is normal. There is no free fluid and no free air within the\n abdomen.\n\n (Over)\n\n 4:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/out solid organ injury\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley\n catheter and contrast. The bladder, distal ureters, prostate and seminal\n vesicles, rectum, and sigmoid colon appear unremarkable. There is no\n pathologic-appearing pelvic or inguinal lymphadenopathy. There is no free\n fluid and no free air within the pelvis.\n\n BONE WINDOWS: Bone windows demonstrate anterior wedge deformity of L1, a\n finding that is of uncertain significance. This could represent prior\n compression deformity versus normal variant. There is additional lucency\n within the superior endplates of T12 and L1 that is suggestive of Schmorl's\n node. There is degenerative change of the thoracolumbar and lumbosacral\n spine. There is deformity of the right iliac bone with sclerotic margins\n suggestive of prior trauma. No suspicious lytic or sclerotic osseous lesions\n are identified. There is an old healed right-sided rib fracture.\n\n MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate a\n triangular area of hypodensity within the right lobe of the liver anteriorly.\n\n IMPRESSION:\n 1. Triangular area of hypodensity in the right lobe of the liver. In the\n setting of trauma, this could represent a hepatic laceration, although no\n perihepatic fluid collections are identified. Additional questionable\n hypodense lesion in the left lobe of the liver may represent artifact.\n 2. Marked gastric distention.\n 3. Wedge configuration of L1 vertebra, a finding that likely represents old\n trauma versus normal variant. No acute fractures are identified.\n\n Results were called to the trauma resident caring for the patient at the time\n of interpretation.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2128-08-23 00:00:00.000","description":"CHEST (PA & LAT)","row_id":882768,"text":" 10:34 AM\n CHEST (PA & LAT) Clip # \n Reason: consolidation?\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p repair for skull fracture, SAH, SDH now spiking fevers\n\n REASON FOR THIS EXAMINATION:\n consolidation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of subarachnoid and subdural hemorrhages, fever.\n\n COMPARISON: Chest x-ray from .\n\n PA AND LATERAL CHEST RADIOGRAPHS: The lungs are clear. The cardiac,\n mediastinal, and hilar contours are within normal limits. Bilateral healed\n rib fractures are noted.\n\n IMPRESSION: No evidence of pneumonia.\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":881671,"text":" 6:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: HEAD TRAUMA\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Head trauma.\n\n FINDINGS: There is an endotracheal tube with tip 3 cm above the carina. The\n lungs are clear without effusion. There is some pleural thickening or\n scarring in the right lateral lower lung. An NG tube is in the stomach.\n Despite the NG tube in the stomach, there is a large collection of air seen in\n the mid abdomen. Compared to the CT from a few hours earlier, this is seen to\n represent a markedly distended stomach. This finding was called to the floor\n at the time of the CT .\n\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":881672,"text":" 6:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression of bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ICH\n REASON FOR THIS EXAMINATION:\n eval for progression of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 7:46 PM\n Increase in subarachnoid hemorrhage with local mass effect (sulcal narrowing\n but no shift of normally midline structures).\n Subdural hemorrhage, right temporal lobe hemorrhage approx unchanged.\n No hydrocephalus\n Please see report\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage, evaluate for progression of bleed.\n\n COMPARISON: Same date at 16:19 hours.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: In comparison with the\n examination of several hours earlier, there is a similar extent of\n subarachnoid hemorrhage within the basilar cisterns as well as within the\n sulci of the right frontal, parietal, and temporal lobes. Again seen is a\n right subdural hematoma extending along the convexity, which appears\n approximately unchanged in size. The appearance of a rounded focus of\n hemorrhage within the posterior aspect of the right temporal lobe, possibly\n representing an intraparenchymal hemorrhage, is stable. The subarachnoid\n blood within the left parietal sulciappears stable overall. The ventricles\n are symmetric and nondilated. The ventricles appear unchanged in size in\n comparison with the previous examination. There is no shift of normally\n midline structures. The basilar cisterns are patent. Subarachnoid blood is\n again seen medially adjacent to the right frontal lobe. A large right frontal\n scalp hematoma appears approximately unchanged.\n\n Bone windows again disclose numerous facial and skull fractures. There is\n increased density within the right maxillary, ethmoid, and frontal sinuses.\n\n IMPRESSION:\n 1. Some redistribution in subarachnoid hemorrhage within the basilar\n cisterns, layering within the sulci of the right frontal, parietal, and\n temporal lobes, and within the sulci of the left parietal lobe. There is no\n definite increase in the amount of subarachnoid blood.\n 2. Right subdural hematoma is approximately unchanged in size.\n 3. Stable appearance of tiny focus of probable intraparenchymal hemorrhage\n within the right temporal lobe.\n 4. No hydrocephalus and no shift of normally midline structures.\n 5. Right frontal and parietal scalp hematoma.\n (Over)\n\n 6:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression of bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 6. Multiple facial fractures.\n\n"},{"category":"Radiology","chartdate":"2128-08-15 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":881720,"text":" 10:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, SDH, intraparenchymal s/p trauma -- repeat head CT in\n AM\n REASON FOR THIS EXAMINATION:\n eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD\n\n INDICATION: Trauma, followup of hemorrhages.\n\n Comparison is made to the CT scan performed one day prior.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The previously identified right subdural hematoma is not\n significantly changed. There is again demonstrated bilateral areas of\n subarachnoid hemorrhage which is again seen layering in the interpeduncular\n cistern. Note is made of a small amount of intraventricular hemorrhage which\n is seen layering in the left lateral ventricle slightly more conspicuous than\n the prior study. There has been slight interval new hypodensity within the\n inferior right frontal lobe, which could be consistent with a contusion. There\n is decreased conspicuity of subarachnoid hemorrhage along the course of the\n right middle cerebral artery. The previously identified tiny focus of\n hemorrhage along the posterior aspect of the right temporal lobe is not\n significantly changed. No new areas of hemorrhage are identified. There is\n no shift of normally midline structures, mass effect or hydrocephalus. The\n previously described paranasal sinuses and osseous structures are not\n significantly changed with redemonstration of numerous facial and skull\n fractures.\n\n IMPRESSION: No new areas of hemorrhage identified. Right inferior frontal\n lobe contusion is more apparent on the current study.\n\n\n"},{"category":"Radiology","chartdate":"2128-08-18 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":882170,"text":" 2:54 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: INTRACRANIAL BLEED\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man pre-op for for skull fracture, SAH, SDH.\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS PA AND LATERAL\n\n Preop subdural hematoma.\n\n Heart size is normal. Apart from bibasilar linear atelectases the lungs are\n clear. No pleural effusions and no pneumothorax.\n\n IMPRESSION: Bibasilar linear atelectases.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-08-15 00:00:00.000","description":"Report","row_id":1301104,"text":"T-SICU admission note -0700\n60yo male found down between 2 parked cars, +ETOH. Arrived in ER with GCS 13, decreased MS , intubated. Injuries: non-depressed R skull fx, traumatic R frontal parietal SDH/SAH with complex orbital/midface fx with sm. L SAH. ?Spanish speaking per chart; appears to understand some English over course of noc. A-line placed by HO. ER RN, ER SW was working on location family/next of ; no contact .\n:\nNeuro: Lightly sedated on propofol gtt; easily lightened for neuro exams (at times neuro exam consistent with propofol on). Pupils dilated in EW; initially both pupils 8mm, NR, slowly improving over noc, currently R5mm, L 4mm, reactive. +corneals, gag and cough. MAE's; follows commands when asked in Spanish by Dr. ; cont. to follow commands throughout night in few Spanish words with this RN (squeezes hands, wiggles toes, sticks out tongue, opens eyes). Dilantin loaded in ER. Logroll c/spine precautions maintained.\n\nCV: HR 70-80'sSR, BP 100-130's/50-60's. Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\nAccess: a-line placed last noc; PIV x2 wnl, ? further access today.\n\nResp: LS clear, diminished at bases; suctioned for sm. amts. blood tinged sputum. Suctioned for sm. amts. blood tinged oral secretions. See carevue for labs/resp. notes.\n\nGI: abd soft, BS hypoactive, no stool, NPO. OGT to LCWS for sm. amts. brown drainage. Protonix for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in adequate amts. Kcl repleted.\n\nEndo: BS 216->covered per SS.\n\nID; tmax 99.2; conts. unasyn as ordered.\n\nSkin: back/buttocks intact; R sided facial abrasion with sm. amt. sang. drainage. R eye with red/purple hematoma, +scleral edema; iced NS gauze applied .\n\npsych/social: no contact from family/next of ; follow up with SW today.\n\nA: pt found down +SAH/SDH, hemodynamically stable\n\nP: Monitor VS, I/O, labs, neuro checks. Follow up CT results, ?d/c logroll, repeat head CT, ? further access today. Follow up with SW regarding next of . Maintain sedation/comfort/support to pt.\n"},{"category":"Nursing/other","chartdate":"2128-08-15 00:00:00.000","description":"Report","row_id":1301105,"text":"Respiratory Therapy\n60 y.o. M found down btwn 2 cars MOI unknown. (+) ETOH Intubated in ED for deteriorating GCS. Pt remains orally intubated on full ventilatory support at this time. BS clear Sx for sml amts thick blood tinged secretions. FiO2 weaned to .4. Plan: wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2128-08-15 00:00:00.000","description":"Report","row_id":1301106,"text":"T/SICU NPN: 0700-1900\nS:\n\nO: SYSTEM REVIEW:\n\nNEURO: FOLLOW UP HEAD CT THIS MORNING ALERT TO OPENS EYES TO VOICE\nORIENTED TO PERSON ONLY PT THINKS HE IS IN AND THE YEAR ABLE TO SPEAK ENGLISH SPEECH AT TIMES DIFFICULT TO UNDERSTAND D/T ACCENT AND LACK OF TEETH ANSWERS MOST QUESTIONS APPROPIATELY PUPILS REACTIVE TO LIGHT R=5MM WITH NO TO SLUGGISH REACTION L=4 WITH BRISK REACTION CORNEAL REFLEXES WEAKER ON RIGHT INTACT COUGH/GAG\nMAE WITH GOOD STRENGTH SPONTANEOUSLY AND TO COMMAND CONTINUES ON DILANTIN 100MG TID LEVEL 10.1 TODAY C-COLLAR INTACT AND REMAINS ON\nTLS CLEARED LOGROLL PRECAUTIONS D/C'D\n\nCVS: HR 70-80'S WITH NO>>RARE>>OFTEN UNIFOCAL PVC'S WITH COMPENSATORY PAUSE ELECTROLYTES REPLETED GOAL TO KEEP SBP < 140 RECEIVED TOTAL OF 5MG IV LABETOLOL X 3 SBP 120-130'S SKIN WARM/DRY PALPABLE PEDAL PULSES\n\nRESPIRATORY: SELF EXTUBATED TODAY AT 1440 RR 10-14 SAO2 100% ON 50% FACE TENT LUNGS CLEAR, DECREASED AT BASES NONPRODUCTIVE COUGH\n\nRENAL: FOLEY PATENT AND DRAINING CLEAR YELLOW URINE 10-200CC/HR\nNS AT 125CC/HR K+ 3.5 CURRENTLY RECEIVING TOTAL OF 40MEQ KCL OVER 5HRS FOR REPLETION MG++ 1.7 REPLETED WITH 2GMS MGSO4\nIVF TO CHANGE TO NS WITH 20MEQ KCL IV 125CC/HR\n\nGI: ABDOMEN: SOFT HYPOACTIVE BS REMAINS NPO ON IVF NO N/V ON PROTONIX OGT PULLED WITH EXTUBATION\n\nENDOCRINE: SS TIGHTENED 0800 179 COVERED WITH 6UNITS REGULAR INSULIN SQ 1400 FS 141 COVERED WITH 4UNITS OF REGULAR INSULIN\n\nHEME: CONTINUES ON PNEUMOBOOTS FOR DVT PROPHYALAXIS\n\nID: TMAX 99.6 ANTBX CHANGED TO FLAGYL/OXACILLIN/CEFTRIAXONE FOR OMF\n\nSKIN: BACK AND BUTTOCKS INTACT WITH NO REDNESS RIGHT EYE WITH ECCHYMOSIS SMALL ABRASION---PINK WITH NO OBVIOUS DRAINAGE SMALL RIGHT FRONTAL HEMATOMA\n\nCOMFORT: DENIES ANY PAIN\n\nPSYCHOSOCIAL: STATES LIVES ALONE IN NO FAMILY NEVER BEEN MARRIED WORKS PART-TIME AS LABORER ALTHOUGH UNABLE TO ELABORATE ABOUT JOB DENIES ANY PMH/PSH/MEDICATIONS STATES NO ALLERGIES\nADMITS TO ETOH USE--STATES THAT DRINKS A BOTTLE OF VODKA A DAY\n\nA: STABLE S/P HEAD INJURY\n\nP: CONTINUE TO MONITOR ABOVE PARAMETERS\n"},{"category":"Nursing/other","chartdate":"2128-08-16 00:00:00.000","description":"Report","row_id":1301107,"text":"T-SICU NPN 1900-0700\nSee carevue for specifics.\n:\nNeuro: Sleeping most of noc; arousable to voice, opens eyes spontaneously, MAE's, follows commands consistently. Oriented to self only; states he is in (also states this is where he lives); does not know date, remember incident, or that he is in hospital. +corneals,gag, and cough. R pupil 5mm, L pupil 4mm both reactive. C-collar in place. Conts. dilantin.\nCV: HR 60-70'sSR with occ. PVC's, BP 120-150's/60-70's. Started 100mg po labetalol last eve, SBP cont. 140-150's; additional 100mg po labetalol given, SBP now 130-140 (goal <140). Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\nAccess: R rad. a-line and PIV'x 2 wnl. conts. on ciwa scale (score ).\nResp: LS clear, diminished at bases, denies shortness of breath or difficulty breathing. O2sats 99-100% on 50% face tent which pt. continually removed, sats 98% ra. Enc. C+DB; pt with productive cough, swallowing secretions.\nGI: abd soft, NT/D, BS hypoactive, no stool. Tol sips water, denies n/v. Protonix for GI prophylaxis.\nGU: foley patent draining large amts. light yellow clear urine. Lytes repleted.\nEndo: BS 132->195, covered per ss.\nID: tmax 100.3; wbc 7.5,conts. cefazolin/flagyl/oxacillin as ordered.\nSkin: back/buttocks intact. R eye with red/purple hematoma, +scleral edema, eye gtt applied as ordered. R side of forehead/next to eye with sm. abrasion, OTA.\nPsych/social: pt states he lives alone, no family in area.\nA: labetolol po increased, hemodynamically stable with SBP<140; confusion conts.\nP: Monitor VS,I/O, labs, neuro checks, CIWA scale. Enc. pulmonary hygiene, increase po's as tolerated. Re-orient prn. Cont. ongoing comfort/support to pt. ?transfer to floor today.\n"},{"category":"Nursing/other","chartdate":"2128-08-16 00:00:00.000","description":"Report","row_id":1301108,"text":"See nursing transfer note.\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2128-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209871,\n \"text\": \"Normal sinus rhythm. Tracing is within normal limits. No previous tracing\\navailable for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 881656,\n \"text\": \" 4:10 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: r/o injueries\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man found btwen curb and car\\n REASON FOR THIS EXAMINATION:\\n r/o injueries\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post fall.\\n\\n COMPARISON: None.\\n\\n AP CHEST X-RAY: The cardiac silhouette, mediastinal, and hilar contours are\\n normal. No pneumothorax is seen bilaterally on this supine radiograph. Both\\n lungs are clear without consolidations or effusions. The surrounding soft\\n tissue and osseous structures are unremarkable.\\n\\n AP PELVIS: Bilateral sacroiliac joints, pubic symphysis, and partially imaged\\n bilateral hips are unremarkable. There is normal bony mineralization, without\\n malalignment. The surrounding soft tissues are unremarkable.\\n\\n IMPRESSION: No evidence of intrathoracic or intrapelvic trauma.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 881657,\n \"text\": \" 4:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o injur\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with found unresp btwn car and curb\\n REASON FOR THIS EXAMINATION:\\n r/o injur\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 5:22 PM\\n Subarachnoid hemorrhage in basal cisterns and extending along right frontal\\n and parietal lobes. RIght subdural hematoma. Possible small focus of right\\n temoral intraparenchymal hemorrhage. Probable left subarachnoid hemorrhage.\\n Multiple facial and skull fractures.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: There is subarachnoid blood\\n within the suprasellar cistern and lateral to the pons on the right, with\\n extension to the Sylvian fissure and to the inferolateral aspect of the right\\n frontal lobe. A small focus of hyperdensity along the medial aspect of the\\n right frontal lobe likely represents a small amount of subarachnoid hemorrhage\\n at this location.\\n There is a moderate right subdural hematoma layering adjacent to the right\\n frontoparietal convexity and extending inferiorly to the right temporal lobe.\\n A rounded focus of hemorrhage within the posterior aspect of the right\\n temporal lobe may represent a small focus of subarachnoid blood versus an\\n intraparenchymal hemorrhage. Questionable hyperdensity at the left insula is\\n suggestive of possible subarachnoid hemorrhage.\\n\\n The lateral ventricles are symmetric and nondilated, and the basilar cisterns\\n appear patent. There is diffuse narrowing of the sulci of the right frontal\\n and parietal lobes. There is no shift of normally midline structures. The\\n - white differentiation appears preserved.\\n\\n Bone windows demonstrate numerous fractures of the skull and facial bones.\\n There is a coronally oriented fracture extending through the right and left\\n frontal bones originating near the vertex. A right frontal fracture line\\n extends anteriorly and inferiorly to the right frontal sinus, where there is\\n marked comminution with displaced fragments involving the anterior and\\n posterior walls of the frontal sinus. There are multiple comminuted fractures\\n of the roof of the orbit and of the right lamina papyracea. There are\\n comminuted fractures of the right zygomatic arch and of the anterior and\\n lateral walls of the right maxillary sinus. There is blood layering within\\n the right maxillary sinus, ethmoid sinuses, and frontal sinus and air within\\n the orbit. There is an appearance of proptosis of the right globe, although\\n no large retrobulbar hematoma is identified. The mastoid air cells are\\n (Over)\\n\\n 4:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o injur\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n normally pneumatized. There is extensive soft tissue swelling and hematoma\\n within the right frontal scalp. There is a punctate density superficially\\n within the area of the right frontoparietal hemorrhage, which may possibly\\n represent a foreign body versus structure on the surface of the patient.\\n\\n IMPRESSION:\\n 1. Subarachnoid hemorrhage centered in the suprasellar cistern and involving\\n the right frontal lobe inferolaterally and medially.\\n 2. Right subdural hematoma.\\n 3. Additional tiny focus of hemorrhage within the right temporal lobe may\\n represent subarachnoid or intraparenchymal hemorrhage.\\n 4. Questionable subarachnoid hemorrhage within the left parietal region.\\n 5. Numerous comminuted facial and skull fractures.\\n 6. Right frontal and parietal subgaleal hematoma.\\n\\n Facial fractures will be further assessed with facial bone CT of same date.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 881658,\n \"text\": \" 4:25 PM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/o injur\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with found unresp btwn car and curb\\n REASON FOR THIS EXAMINATION:\\n r/o injur\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 5:46 PM\\n No fracture of cervical spine.\\n Slight exaggeration of cervical lordosis may be positional. Please see\\n dictated report for further recommendations. Additional incidental finding of\\n possibly left lung abnormality - please see report.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Axial MDCT images were obtained through the cervical spine without\\n intravenous contrast. Coronal and sagittal reformations are provided.\\n\\n CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is\\n imaged from C1 through the upper portion of T3. No fracture is identified in\\n the cervical spine. There is multilevel degenerative change of the cervical\\n spine with anterior osteophytosis, most prominent at C3-4, C5-6, and C6-7.\\n There is slight exaggeration of the normal cervical lordosis that may be\\n positional in nature. There is a suggestion of widening of the intervertebral\\n disc spaces anteriorly, a finding that is predominantly diffuse to the C4-5\\n through C6-7 intervertebral disc spaces. The prevertebral soft tissues appear\\n unremarkable. The visualized outlines of the thecal sac demonstrate posterior\\n probable disc bulges at C4-5 and C5-6 with indentation of the thecal sac. CT\\n is limited in its ability to provide intrathecal detail.\\n\\n The visualized portions of the lung apices demonstrate emphysematous change.\\n In addition, there is an ill-defined opacity at the left lung apex with\\n irregular margins that is incompletely imaged. There are several small\\n projections from the tracheal wall, which may represent adherent secretions.\\n The mastoid air cells are normally pneumatized.\\n\\n IMPRESSION:\\n 1. No fracture of the cervical spine.\\n 2. Exaggeration of the cervical lordosis with diffuse widening of several\\n intervertebral disc spaces anteriorly may be positional in nature. If there\\n is clinical concern for ligamentous injury, MR is a more sensitive test.\\n 3. Suggestion of disc bulges at C4-5 and C5-6. CT is limited in its\\n evaluation of the spinal canal and its contents.\\n 4. Emphysematous changes in the visualized portions of the lungs and\\n additional irregular opacity at the left lung apex, a finding that may be\\n further evaluated with dedicated chest CT once the patient is clinically able.\\n\\n (Over)\\n\\n 4:25 PM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/o injur\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 881659,\n \"text\": \" 4:28 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/out fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with facial trauma\\n REASON FOR THIS EXAMINATION:\\n r/out fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 6:54 PM\\n Multiple facial and skull fractures. please see report.\\n Proptosis of right globe with intraorbital hematoma on right.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Found down with facial trauma, evaluate fractures.\\n\\n COMPARISON: Head CT of same date.\\n\\n TECHNIQUE: Axial MDCT images were obtained through the facial bones. Coronal\\n reformations are provided.\\n\\n CT OF THE FACIAL BONES WITHOUT INTRAVENOUS CONTRAST: There are numerous skull\\n and facial fractures. A right frontal skull fracture with triangular\\n configuration demonstrates mild displacement.\\n\\n There are multiple comminuted fractures involving the anterior and posterior\\n walls of the right frontal sinus with posterior displacement of a fracture\\n fragment into the intracranial space and with a tiny focus of pneumocephalus.\\n There is an additional comminuted fracture of the posterior aspect of a right\\n ethmoid air cell with displacement of a fracture fragment into the\\n intracranial space.\\n\\n Additional comminuted fractures are present within the roof of the right orbit\\n with displacement of a fracture fragment into the superior aspect of the right\\n orbit. There is air within the right orbit, and along the superolateral\\n aspect of the orbit, there is a hematoma displacing the extraocular muscles\\n medially. The fracture fragments do not appear to impinge directly upon the\\n optic nerve, although there is proptosis of the right globe.\\n\\n There are additional linear fractures of the lamina papyracea on the right.\\n Comminuted fracture of the anterior wall of the right orbit and of the right\\n zygomatic arch. There is blood layering within the right maxillary sinus,\\n ethmoid sinuses, and frontal sinus. There is a small amount of fluid and\\n mucosal thickening within the left ethmoid air cells and left frontal sinus.\\n The left maxillary sinus is normally pneumatized and no fractures are\\n identified within the left maxillary sinus or orbit. The mastoid air cells\\n are normally pneumatized. Note is made of heterogeneity within the clivus, a\\n finding that may indicate clival hemangioma. There is soft tissue stranding\\n and swelling within the right frontal scalp and preorbital soft tissues.\\n\\n IMPRESSION:\\n 1. Right frontal skull fracture, displaced.\\n (Over)\\n\\n 4:28 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/out fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. Extensive comminuted fractures of the right frontal sinus, maxillary\\n sinus, orbit, and zygomatic arch.\\n 3. There is proptosis of the right globe and intraorbital hematoma within the\\n superolateral aspect of the right orbit.\\n 4. There are displaced comminuted fracture fragments protruding into the\\n right orbit without direct evidence of impingement upon the optic nerve.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 881660,\n \"text\": \" 4:29 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\\n Reason: r/out solid organ injury\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with facial trauma found down\\n REASON FOR THIS EXAMINATION:\\n r/out solid organ injury\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 6:09 PM\\n Triangular hypodensity in right lobe of liver without perihepatic fluid\\n collection could possibly represent small liver laceration versus other liver\\n lesion.\\n\\n No fractures identified. Old right rib fracture and wedge configuration of L1\\n that could represent prior compression deformity or normal variant; see\\n report.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Facial trauma, found down. Evaluate for solid organ injury.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\\n symphysis following the administration of 150 cc of intravenous Optiray.\\n Additional coronal and sagittal reformations are provided.\\n\\n CONTRAST: Intravenous non-ionic contrast was administered due to the rapid\\n rate of bolus injection required for this examination.\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are dependent changes\\n within the lower lobes bilaterally. Additional linear opacity within the\\n right middle and right lower lobe laterally is consistent with scarring versus\\n atelectasis. The visualized portions of the heart and pericardium appear\\n unremarkable. There is marked distension of the stomach containing air and\\n fluid.\\n\\n Within the right lobe of the liver anteriorly, there is a triangular area of\\n hypodensity. There is no perihepatic fluid collection at this location. There\\n is an additional questionable hypodensity within the left lobe of the liver\\n superiorly (series 2, image 9), possibly representing partial volume\\n averaging. The spleen, pancreas, gallbladder, and adrenal glands appear\\n unremarkable. There are no perinephric fluid collections. There are symmetric\\n nephrograms bilaterally without evidence of masses or hydronephrosis in either\\n kidney. The ureters are nondilated. The aorta is normal in caliber. The\\n celiac trunk, superior mesenteric artery, and inferior mesenteric artery\\n appear patent. The large and small bowel loops are normal in caliber. The\\n appendix is normal. There is no free fluid and no free air within the\\n abdomen.\\n\\n (Over)\\n\\n 4:29 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\\n Reason: r/out solid organ injury\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley\\n catheter and contrast. The bladder, distal ureters, prostate and seminal\\n vesicles, rectum, and sigmoid colon appear unremarkable. There is no\\n pathologic-appearing pelvic or inguinal lymphadenopathy. There is no free\\n fluid and no free air within the pelvis.\\n\\n BONE WINDOWS: Bone windows demonstrate anterior wedge deformity of L1, a\\n finding that is of uncertain significance. This could represent prior\\n compression deformity versus normal variant. There is additional lucency\\n within the superior endplates of T12 and L1 that is suggestive of Schmorl's\\n node. There is degenerative change of the thoracolumbar and lumbosacral\\n spine. There is deformity of the right iliac bone with sclerotic margins\\n suggestive of prior trauma. No suspicious lytic or sclerotic osseous lesions\\n are identified. There is an old healed right-sided rib fracture.\\n\\n MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate a\\n triangular area of hypodensity within the right lobe of the liver anteriorly.\\n\\n IMPRESSION:\\n 1. Triangular area of hypodensity in the right lobe of the liver. In the\\n setting of trauma, this could represent a hepatic laceration, although no\\n perihepatic fluid collections are identified. Additional questionable\\n hypodense lesion in the left lobe of the liver may represent artifact.\\n 2. Marked gastric distention.\\n 3. Wedge configuration of L1 vertebra, a finding that likely represents old\\n trauma versus normal variant. No acute fractures are identified.\\n\\n Results were called to the trauma resident caring for the patient at the time\\n of interpretation.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-23 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 882768,\n \"text\": \" 10:34 AM\\n CHEST (PA & LAT) Clip # \\n Reason: consolidation?\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man s/p repair for skull fracture, SAH, SDH now spiking fevers\\n\\n REASON FOR THIS EXAMINATION:\\n consolidation?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of subarachnoid and subdural hemorrhages, fever.\\n\\n COMPARISON: Chest x-ray from .\\n\\n PA AND LATERAL CHEST RADIOGRAPHS: The lungs are clear. The cardiac,\\n mediastinal, and hilar contours are within normal limits. Bilateral healed\\n rib fractures are noted.\\n\\n IMPRESSION: No evidence of pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 881671,\n \"text\": \" 6:29 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: HEAD TRAUMA\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE VIEW ON \\n\\n HISTORY: Head trauma.\\n\\n FINDINGS: There is an endotracheal tube with tip 3 cm above the carina. The\\n lungs are clear without effusion. There is some pleural thickening or\\n scarring in the right lateral lower lung. An NG tube is in the stomach.\\n Despite the NG tube in the stomach, there is a large collection of air seen in\\n the mid abdomen. Compared to the CT from a few hours earlier, this is seen to\\n represent a markedly distended stomach. This finding was called to the floor\\n at the time of the CT .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 881672,\n \"text\": \" 6:36 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for progression of bleed\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with ICH\\n REASON FOR THIS EXAMINATION:\\n eval for progression of bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 7:46 PM\\n Increase in subarachnoid hemorrhage with local mass effect (sulcal narrowing\\n but no shift of normally midline structures).\\n Subdural hemorrhage, right temporal lobe hemorrhage approx unchanged.\\n No hydrocephalus\\n Please see report\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intracranial hemorrhage, evaluate for progression of bleed.\\n\\n COMPARISON: Same date at 16:19 hours.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: In comparison with the\\n examination of several hours earlier, there is a similar extent of\\n subarachnoid hemorrhage within the basilar cisterns as well as within the\\n sulci of the right frontal, parietal, and temporal lobes. Again seen is a\\n right subdural hematoma extending along the convexity, which appears\\n approximately unchanged in size. The appearance of a rounded focus of\\n hemorrhage within the posterior aspect of the right temporal lobe, possibly\\n representing an intraparenchymal hemorrhage, is stable. The subarachnoid\\n blood within the left parietal sulciappears stable overall. The ventricles\\n are symmetric and nondilated. The ventricles appear unchanged in size in\\n comparison with the previous examination. There is no shift of normally\\n midline structures. The basilar cisterns are patent. Subarachnoid blood is\\n again seen medially adjacent to the right frontal lobe. A large right frontal\\n scalp hematoma appears approximately unchanged.\\n\\n Bone windows again disclose numerous facial and skull fractures. There is\\n increased density within the right maxillary, ethmoid, and frontal sinuses.\\n\\n IMPRESSION:\\n 1. Some redistribution in subarachnoid hemorrhage within the basilar\\n cisterns, layering within the sulci of the right frontal, parietal, and\\n temporal lobes, and within the sulci of the left parietal lobe. There is no\\n definite increase in the amount of subarachnoid blood.\\n 2. Right subdural hematoma is approximately unchanged in size.\\n 3. Stable appearance of tiny focus of probable intraparenchymal hemorrhage\\n within the right temporal lobe.\\n 4. No hydrocephalus and no shift of normally midline structures.\\n 5. Right frontal and parietal scalp hematoma.\\n (Over)\\n\\n 6:36 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for progression of bleed\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 6. Multiple facial fractures.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-15 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 881720,\n \"text\": \" 10:12 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval bleed\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with SAH, SDH, intraparenchymal s/p trauma -- repeat head CT in\\n AM\\n REASON FOR THIS EXAMINATION:\\n eval bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT HEAD\\n\\n INDICATION: Trauma, followup of hemorrhages.\\n\\n Comparison is made to the CT scan performed one day prior.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: The previously identified right subdural hematoma is not\\n significantly changed. There is again demonstrated bilateral areas of\\n subarachnoid hemorrhage which is again seen layering in the interpeduncular\\n cistern. Note is made of a small amount of intraventricular hemorrhage which\\n is seen layering in the left lateral ventricle slightly more conspicuous than\\n the prior study. There has been slight interval new hypodensity within the\\n inferior right frontal lobe, which could be consistent with a contusion. There\\n is decreased conspicuity of subarachnoid hemorrhage along the course of the\\n right middle cerebral artery. The previously identified tiny focus of\\n hemorrhage along the posterior aspect of the right temporal lobe is not\\n significantly changed. No new areas of hemorrhage are identified. There is\\n no shift of normally midline structures, mass effect or hydrocephalus. The\\n previously described paranasal sinuses and osseous structures are not\\n significantly changed with redemonstration of numerous facial and skull\\n fractures.\\n\\n IMPRESSION: No new areas of hemorrhage identified. Right inferior frontal\\n lobe contusion is more apparent on the current study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-18 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 882170,\n \"text\": \" 2:54 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: INTRACRANIAL BLEED\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man pre-op for for skull fracture, SAH, SDH.\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST TWO VIEWS PA AND LATERAL\\n\\n Preop subdural hematoma.\\n\\n Heart size is normal. Apart from bibasilar linear atelectases the lungs are\\n clear. No pleural effusions and no pneumothorax.\\n\\n IMPRESSION: Bibasilar linear atelectases.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301104,\n \"text\": \"T-SICU admission note -0700\\n60yo male found down between 2 parked cars, +ETOH. Arrived in ER with GCS 13, decreased MS , intubated. Injuries: non-depressed R skull fx, traumatic R frontal parietal SDH/SAH with complex orbital/midface fx with sm. L SAH. ?Spanish speaking per chart; appears to understand some English over course of noc. A-line placed by HO. ER RN, ER SW was working on location family/next of ; no contact .\\n:\\nNeuro: Lightly sedated on propofol gtt; easily lightened for neuro exams (at times neuro exam consistent with propofol on). Pupils dilated in EW; initially both pupils 8mm, NR, slowly improving over noc, currently R5mm, L 4mm, reactive. +corneals, gag and cough. MAE's; follows commands when asked in Spanish by Dr. ; cont. to follow commands throughout night in few Spanish words with this RN (squeezes hands, wiggles toes, sticks out tongue, opens eyes). Dilantin loaded in ER. Logroll c/spine precautions maintained.\\n\\nCV: HR 70-80'sSR, BP 100-130's/50-60's. Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\\nAccess: a-line placed last noc; PIV x2 wnl, ? further access today.\\n\\nResp: LS clear, diminished at bases; suctioned for sm. amts. blood tinged sputum. Suctioned for sm. amts. blood tinged oral secretions. See carevue for labs/resp. notes.\\n\\nGI: abd soft, BS hypoactive, no stool, NPO. OGT to LCWS for sm. amts. brown drainage. Protonix for GI prophylaxis.\\n\\nGU: foley patent draining clear yellow urine in adequate amts. Kcl repleted.\\n\\nEndo: BS 216->covered per SS.\\n\\nID; tmax 99.2; conts. unasyn as ordered.\\n\\nSkin: back/buttocks intact; R sided facial abrasion with sm. amt. sang. drainage. R eye with red/purple hematoma, +scleral edema; iced NS gauze applied .\\n\\npsych/social: no contact from family/next of ; follow up with SW today.\\n\\nA: pt found down +SAH/SDH, hemodynamically stable\\n\\nP: Monitor VS, I/O, labs, neuro checks. Follow up CT results, ?d/c logroll, repeat head CT, ? further access today. Follow up with SW regarding next of . Maintain sedation/comfort/support to pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301105,\n \"text\": \"Respiratory Therapy\\n60 y.o. M found down btwn 2 cars MOI unknown. (+) ETOH Intubated in ED for deteriorating GCS. Pt remains orally intubated on full ventilatory support at this time. BS clear Sx for sml amts thick blood tinged secretions. FiO2 weaned to .4. Plan: wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301106,\n \"text\": \"T/SICU NPN: 0700-1900\\nS:\\n\\nO: SYSTEM REVIEW:\\n\\nNEURO: FOLLOW UP HEAD CT THIS MORNING ALERT TO OPENS EYES TO VOICE\\nORIENTED TO PERSON ONLY PT THINKS HE IS IN AND THE YEAR ABLE TO SPEAK ENGLISH SPEECH AT TIMES DIFFICULT TO UNDERSTAND D/T ACCENT AND LACK OF TEETH ANSWERS MOST QUESTIONS APPROPIATELY PUPILS REACTIVE TO LIGHT R=5MM WITH NO TO SLUGGISH REACTION L=4 WITH BRISK REACTION CORNEAL REFLEXES WEAKER ON RIGHT INTACT COUGH/GAG\\nMAE WITH GOOD STRENGTH SPONTANEOUSLY AND TO COMMAND CONTINUES ON DILANTIN 100MG TID LEVEL 10.1 TODAY C-COLLAR INTACT AND REMAINS ON\\nTLS CLEARED LOGROLL PRECAUTIONS D/C'D\\n\\nCVS: HR 70-80'S WITH NO>>RARE>>OFTEN UNIFOCAL PVC'S WITH COMPENSATORY PAUSE ELECTROLYTES REPLETED GOAL TO KEEP SBP < 140 RECEIVED TOTAL OF 5MG IV LABETOLOL X 3 SBP 120-130'S SKIN WARM/DRY PALPABLE PEDAL PULSES\\n\\nRESPIRATORY: SELF EXTUBATED TODAY AT 1440 RR 10-14 SAO2 100% ON 50% FACE TENT LUNGS CLEAR, DECREASED AT BASES NONPRODUCTIVE COUGH\\n\\nRENAL: FOLEY PATENT AND DRAINING CLEAR YELLOW URINE 10-200CC/HR\\nNS AT 125CC/HR K+ 3.5 CURRENTLY RECEIVING TOTAL OF 40MEQ KCL OVER 5HRS FOR REPLETION MG++ 1.7 REPLETED WITH 2GMS MGSO4\\nIVF TO CHANGE TO NS WITH 20MEQ KCL IV 125CC/HR\\n\\nGI: ABDOMEN: SOFT HYPOACTIVE BS REMAINS NPO ON IVF NO N/V ON PROTONIX OGT PULLED WITH EXTUBATION\\n\\nENDOCRINE: SS TIGHTENED 0800 179 COVERED WITH 6UNITS REGULAR INSULIN SQ 1400 FS 141 COVERED WITH 4UNITS OF REGULAR INSULIN\\n\\nHEME: CONTINUES ON PNEUMOBOOTS FOR DVT PROPHYALAXIS\\n\\nID: TMAX 99.6 ANTBX CHANGED TO FLAGYL/OXACILLIN/CEFTRIAXONE FOR OMF\\n\\nSKIN: BACK AND BUTTOCKS INTACT WITH NO REDNESS RIGHT EYE WITH ECCHYMOSIS SMALL ABRASION---PINK WITH NO OBVIOUS DRAINAGE SMALL RIGHT FRONTAL HEMATOMA\\n\\nCOMFORT: DENIES ANY PAIN\\n\\nPSYCHOSOCIAL: STATES LIVES ALONE IN NO FAMILY NEVER BEEN MARRIED WORKS PART-TIME AS LABORER ALTHOUGH UNABLE TO ELABORATE ABOUT JOB DENIES ANY PMH/PSH/MEDICATIONS STATES NO ALLERGIES\\nADMITS TO ETOH USE--STATES THAT DRINKS A BOTTLE OF VODKA A DAY\\n\\nA: STABLE S/P HEAD INJURY\\n\\nP: CONTINUE TO MONITOR ABOVE PARAMETERS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301107,\n \"text\": \"T-SICU NPN 1900-0700\\nSee carevue for specifics.\\n:\\nNeuro: Sleeping most of noc; arousable to voice, opens eyes spontaneously, MAE's, follows commands consistently. Oriented to self only; states he is in (also states this is where he lives); does not know date, remember incident, or that he is in hospital. +corneals,gag, and cough. R pupil 5mm, L pupil 4mm both reactive. C-collar in place. Conts. dilantin.\\nCV: HR 60-70'sSR with occ. PVC's, BP 120-150's/60-70's. Started 100mg po labetalol last eve, SBP cont. 140-150's; additional 100mg po labetalol given, SBP now 130-140 (goal <140). Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\\nAccess: R rad. a-line and PIV'x 2 wnl. conts. on ciwa scale (score ).\\nResp: LS clear, diminished at bases, denies shortness of breath or difficulty breathing. O2sats 99-100% on 50% face tent which pt. continually removed, sats 98% ra. Enc. C+DB; pt with productive cough, swallowing secretions.\\nGI: abd soft, NT/D, BS hypoactive, no stool. Tol sips water, denies n/v. Protonix for GI prophylaxis.\\nGU: foley patent draining large amts. light yellow clear urine. Lytes repleted.\\nEndo: BS 132->195, covered per ss.\\nID: tmax 100.3; wbc 7.5,conts. cefazolin/flagyl/oxacillin as ordered.\\nSkin: back/buttocks intact. R eye with red/purple hematoma, +scleral edema, eye gtt applied as ordered. R side of forehead/next to eye with sm. abrasion, OTA.\\nPsych/social: pt states he lives alone, no family in area.\\nA: labetolol po increased, hemodynamically stable with SBP<140; confusion conts.\\nP: Monitor VS,I/O, labs, neuro checks, CIWA scale. Enc. pulmonary hygiene, increase po's as tolerated. Re-orient prn. Cont. ongoing comfort/support to pt. ?transfer to floor today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301108,\n \"text\": \"See nursing transfer note.\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":1,"numItemsPerPage":100,"numTotalItems":24993,"offset":100,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMTg0MDE3MCwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMTg0Mzc3MCwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.OlivPA4_VegVdhU3PZsaBxcgmW7BUziDbk14zXJFb6DkQY4IuxCTg5Ncxl2Sk3ZMZ9343WhZ6o7975hhqB93Cw","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
1. Wegner's Granulomatosis -presented w/ pulm hemorrhage, severe anemia, and ARF. -Appreciated Rheum and Renal input -s/p 7 treatments of plasmapheresis, completed on . Per Renal, removed pheresis catheter on -Appreciate Rheum input, increased Cyclophosphamide to 125mg QD and prednisone to 50mg QD on - with plan for further changes per outpt, f/u time schedule per rheum and renal services -Dyspnea, cough improved and oxygen requirement stable, with cont need for pulm support (more at night time, though recently relatively stable), overall this will be a process with pt about his expected baseline at this point in his disease process - pulm f/u in 1 month, has VNA set upt and home for o2, nebs, pulm support -Renal function stable, Cr monitored. Continued to make good urine, foley discontnued. Appreciate Renal recs, plan for outpt f/u with Dr. , lytes stable at time of d/c.
2. Hypoxia/Aspergillus infection/concern for tuberculosis. -Initially thought to be from Wegener's disease, and is likely main contributor. Pt significantly improved from initial presentation and continues to have stable oxygen requirement. Is afebrile wnl WBC but also immunosupressed, (WBC relatively stable at time of d/c - 4.9). -Treating w/ voriconazole given rare aspergillus growth in one sputum sample () given significant immunosuppression, plan for 4-6wk treatment course (has clinic f/u this month) -shorter course give neg galactomannan and rare cx initially along with INH/cytoxan regime as well. -Oxygen requirement stable, pt worked w PT w/o increased oxygen requirement. Appreciate pulm recs, but they do not think repeat bronchoscopy is necessary. Overall pt stable with treatment, but exam still with sig wheezing, at this point still with benefit from neb tx prn - has VNA set up for support here -PPD placed on is neg but given exposure to TB (father had tb) and immunosupression, result difficult to interpret, quantiferon study considered, though given difficulty with result interpretation - plan to treat if AFB neg x3 (3rd pending, have to resend due to poor sample , awaiting sample's results). Given this regime will need very close monitoring of LFTs, would appreciate consulting services to also monitor LFTs and to assist coordinating appts (staggering) to keep pt consistantly monitored along with pt's PCP (should be checked q2 wks for next wks. - d/c on INH 300mg qd and B6 25mg qd. -AFB neg x3 at time of d/c. -Pt will be treated for latent TB given hx of exposure to tb and being immunocompromised as above
3. Possible Aspergillus infection - Sputum Cx showed rare Aspergillus. ID consulted given pt is immunosuppresed. Clinically pt was afebrile w/ nl WBC but given abn Chest and sinus CT finding (which can be seen either with Wegner's or aspergillous) and given the fact that pt will be immunosupressed longterm, pt was started on Voriconazole (LFTs wnl). (LFTs remain stable, will check monday again (hold tomorrow) -ENT initially consulted given abn sinus CT. They did rhinoscopy and cultures from nasal region, which have not shown aspergillous. -Discussed w ENT about ID's request for sinus sampling and they strongly feel that he does not have acute invasive sinusitis and will defer on sinus sampling -Per ID, repeated sputm cx and sputum from and neg for fungal cx. Nasal swab by ENT showing no fungal growth. -Serum galactomannan noted negative -Per ID recs, ppd placed given that pt will be on immunosupressives for a longtime, ppd placed on has been neg (no induration noted) -Treat with voriconazole for 4-6wks with possibility of shorter course if change in LFTs (with plan for INH to be held at that point till voriconazole tx completed)
4. Anemia, disease and recent active and losses - combination of ACD and acute blood loss from pulm hemorrhage. S/p 2 units PRBC on as HCT was 18 w appropriate correction to 25. Continue FeSo4 and continue to monitor as outpt, H/H stable at time of d/c.
5. Tachycardia, suprventricular- Pt noted to have Aflutter w/ 2:1 block since admission. Pt is asymptomatic during tachycardia and has no hx of it. Tachycardia exacerbation by pulm disease and deconditioning. TTE this admission showed EF 45-50% w trace MR/TR. TSH wnl. HR under good control w repletion of lytes and combination of metoprolol and diltiazem, will continue. PCP to /u and titrate as indicated, may return to sinus with improvements of pulm status, again to f/u.
6. Longterm immunosupression -Bactrim SS MWF for PCP (changed from initial atorovoquone with renal fx more stable now) -Calcium/VitD and Fosamax for osteoporosis prophylaxis (CaCO3 increased past week to help with repletion) -PPI for ulcer prophylaxis . 7. Hyperglycemia -likely high dose prednisone. Since pt is going to be on longterm steroids and has persistent hyperglycemia,pt started on low dose glyburide on . BS improved, fluctuates, will continue current dose, with note pt will need this monitored once able to be weaned off steroids as outpt. VNA to check BS intermittantly, keep BS log for PCP to /u.
8. Constipation - continue senna and dulcolax in addition to colace, pt instructed to take as needed prn. . FEN - Reg diet. . Code status - Full . Disposition - To home today now that AFB neg x3, with extensive home VNA set up with home 02, resp support long with prn nebs, and home PT along with close family support. Pt given instructions, with close f/u arranged.
"},"extractive_notes_summ":{"kind":"string","value":"Chief Complaint: Respiratory distress, hypoxemia HPI: 24 Hour Events: Remains with high FiO2 requirment. Monitor I/O HEMATURIA -- concern for hemorrhagic cystitis A-FIB -- good rate control COntinue meds. If worsening will get U/A -On Sevelamer, for hyperphos. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Assessment and Plan Wegener's Granulomatosis RESPIRATORY DISTRESS -- slow improvement clincally and radiographically. Confirmed to have c-anca vasculitis. Confirmed to have c-anca vasculitis. Confirmed to have c-anca vasculitis. TITLE: Resp Care Note, Pt rxd with albuterol/ atrovent via mask. #Hypocalcemia: plasmapheresis (containing citrate) and to underlying renal failure -follow ionized Ca, more accurate given citrate used in pheresis. - treating underlying cause (likely Wegener's) - Foley in place , strict I&O, q8 lytes. - Albuterol nebs PRN - CXR daily - F/u on BAL results from OSH - Patient now tolerating PO, though still concern for respiratory status - treating treating the underlying disease (presumed Wegener's): -Plasmapheresis, dose yesterday (QOD) -Prednison po daily, -Cyclophosphamide-dose to be determined after c/s with rheum and renal. Plan: Continue to monitor VSS, ECG changes, continue on lopressor., monitor lytes and replete as needed Renal failure, acute (Acute renal failure, ARF) Assessment: U/O maintaining above 40cc/hr, reveived one unit of red cell yesterday Action: HCT trending up from 20.9 to 22.4 after blood, received cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior to Cytoxan Response: U/O remains wnl, BUN and creatinine trending down from 160 and 8.1 yesterday to 149 and 7.1 early this a.m Plan: Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21), cytoxan as ordered Respiratory failure, acute (not ARDS/) Assessment: Continues on O2 6 liters NC and supplemental O2, sats maintaining above 95%, desats when pt removes O2 in his sleep. If worsening will get U/A -On Sevelamer, for hyperphos. If worsening will get U/A -On Sevelamer, for hyperphos. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Plan: Tachycardia, Other Assessment: Pt remains in ST with hr ranging from Action: Response: Plan: Pt currently clinically tachypneic. RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual improvement. -EKG unchanged # Tachycardia: Aflutter on EKG, in and out of NSR this am. Pt currently clinically tachypneic. Pt currently clinically tachypneic. # LE edema: likely secondary to renal failure above. # LE edema: likely secondary to renal failure above. Assessment and Plan VASCULITIS -- Wegener's Granulomatosis. Marked upper lobe predominant paraseptal and centrilobular emphysema are present. (Over) 5:49 PM CT CHEST W/O CONTRAST Clip # Reason: interval change, worsening consolidations on CXR, compare w Admitting Diagnosis: VASCULITIS FINAL REPORT (Cont) The airways are patent to the level of lobar and segmental bronchi bilaterally except for right lower lobe with occlusion of the apical segment is noted, most liklely due to secretions. The right ventricular cavity is mildly dilated with mild globalfree wall hypokinesis. Mild (1+) aortic regurgitation is seen. Thereis mild regional left ventricular systolic dysfunction with septalhypokinesis. Mild (1+) mitral regurgitation is seen.There is mild pulmonary artery systolic hypertension. Diffuse bilateral consolidations with slight decrease in the right mid lung but are unchanged on the left. Diffuse bilateral consolidations with slight decrease in the right mid lung but are unchanged on the left. There is no pericardialeffusion.IMPRESSION: Mild hypokinesis of the septum along with abnormal septal motion.Mildly dilated and hypokinetic right ventricle. Mild regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; midinferoseptal - hypo; septal apex - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. Pt currently clinically tachypneic. Cyclophosphamide was started after UOP was confirmed to be adequate. HYPOCALCEMIA -- iv replacement Rx, consider constant infusion. Heart-Tachycardic and regular rate suggested on initial exam Extremities--1+ bilateral lower extremity edema. Assessment and Plan 60 yom now with Pulmonary-Renal syndrome. Will await Renal and Rheum recs. Following hct and lytes Q8hr as ordered. Following hct and lytes Q8hr as ordered. Following hct and lytes Q8hr as ordered. U/A there--RBC's and granular casts documented. Plan is for plasmapharesis, K to be rechecked. Nephritic picture with RBC casts. He was given Solumedrol 1g IV x 1. On arrival here, pt appeared mildly tachypneic. Lung sounds RLL Lung Sounds: Crackles RUL Lung Sounds: Clear LUL Lung Sounds: Diminished LLL Lung Sounds: Crackles Comments: Plan Pt presently on 3 lpm n/c and ordered for nebs alb/atr. #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+ binder) -Replace Ca2+ (given 4g this am), check again this PM # Tachycardia: Aflutter on EKG. cystitis while on cytoxan) #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+ binder) -Replace Ca2+ (given 4g this am), -lytes q6hrs -EKG # Tachycardia: Aflutter on EKG. # LE edema: likely secondary to renal failure above. In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. HYPOCALCEMIA -- iv replacement Rx, consider constant infusion. DDx: Wegeners granulomatosis, MPA, Goodpasteurs, lupus, post-strep GN with DIC (less likely). Chief Complaint: Respiratory distress, hypoxemia HPI: 24 Hour Events: Remains with high FiO2 requirment. Monitor I/O HEMATURIA -- concern for hemorrhagic cystitis A-FIB -- good rate control COntinue meds. Pt underwent bronchoscopy on , and was found to have active low grade blood emanating from the RLL and LLL. Assessment and Plan 60 yom now with Pulmonary-Renal syndrome. # LE edema: likely secondary to renal failure above. # LE edema: likely secondary to renal failure above."},"n_notes":{"kind":"number","value":152,"string":"152"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2199-07-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":335302,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n Continues to require supplimental oxygen, desaturates with activity.\n Tolerating net diuresis.\n Hemoptysis resolved.\n Overall, states to feel improved. Dysnpea improved. Able to sleep\n somewhat last PM (improvement).\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.4\n HR: 98 (86 - 128) bpm\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\n RR: 25 (11 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 560 mL\n PO:\n 980 mL\n 360 mL\n TF:\n IVF:\n 319 mL\n 200 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 960 mL\n Urine:\n 4,410 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///31/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 170 K/uL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Imaging: CXR () somewhat improved, esp. right lung field.\n Assessment and Plan\n Wegener's Granulomatosis\n RESPIRATORY DISTRESS -- slow improvement clincally and\n radiographically, although clinically best tody. Continue current\n management. Provide supplemental oxygen, monitor SaO2, maintain >90%.\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\n urine output. No indication for acute dialysis at this time.\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\n Continue steoids, cytoxan, plasmaphoresis (total 7 treatments)\n NUTRITIONAL SUPPORT\n encourage PO.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335452,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding.\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335453,"text":"Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding.\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335455,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Labs obtained in a.m\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335456,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal parameters trending down\n Action:\n Diuresed this p.m with 20 lasix,\n Response:\n Good response to lasix, negative 770 by midnight\n Plan:\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\n"},{"category":"Physician ","chartdate":"2199-07-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":335620,"text":"Chief Complaint:\n 24 Hour Events:\n Patient desats to 85 when FM falls off\n Did well O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 108 (91 - 135) bpm\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\n RR: 19 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 190 mL\n PO:\n 1,220 mL\n 120 mL\n TF:\n IVF:\n 470 mL\n 70 mL\n Blood products:\n Total out:\n 2,465 mL\n 900 mL\n Urine:\n 2,465 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -710 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n Gen- NAD, Aox3\n CV- Tachy but reg rhythm, No M/R/G\n Pulm- Decreased breath sounds at bases, crackles to mid lung fields\n Abd- Soft, NT/ND, BS +\n Extr- No edema, Puleses 2+symmetric\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-14 00:00:00.000","description":"Physician Attending Progress Note","row_id":335606,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n No new events.\n Revieved 1 U PRBC transfusion, tolerated well.\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 Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 122 (97 - 135) bpm\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 477 mL\n PO:\n 1,220 mL\n 360 mL\n TF:\n IVF:\n 470 mL\n 117 mL\n Blood products:\n Total out:\n 2,465 mL\n 1,540 mL\n Urine:\n 2,465 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -1,063 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.2 g/dL\n 200 K/uL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n Respiratory distress and acute renal failure --> Wegener's\n Granulomatosis\n RESPRIATORY DISTRESS -- gradual improvement. Monitor RR, SaO2,\n maintain >90%.\n RENAL FAILURE -- initial good recovery, with good urine output;\n however, now creatitine with minimal decline over past 2-3 days. \n be approaching new baseline. ultimately require dialysis.\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\n cytoxan & plasmaphoresis\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\n disease.\n FLUIDS -- desire net negative if tolerated by BP.\n NUTRITIONAL SUPPORT -- encourage PO.\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335622,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Hx. Of alveolar hemorrhage due to wegener\ns dz. Remain on O2 at 80%\n face tent and 6L NC. LS diminished. Congested non productive cough.\n Action:\n Nebs as ordered. Up to chair for good part of the day.\n Response:\n Tolerated being up well. Pt. coughed while up in a chair but no sputum.\n O2 sat stable >90%. Still will desat to 86% while eating or when mask\n of. CXR improving.\n Plan:\n Cont. current treatment.\n"},{"category":"General","chartdate":"2199-07-15 00:00:00.000","description":"Generic Note","row_id":335701,"text":"TITLE: Resp Care Note, Pt rx\nd with albuterol/ atrovent via mask. BS\n wheezes. Improved after rx. Will cont to monitor resp status.\n"},{"category":"Nursing","chartdate":"2199-07-15 00:00:00.000","description":"Nursing Progress Note","row_id":335681,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Plasma pheresis due tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\n during sleep)\n Action:\n Continues on O2, ( frequently reminded to keep O2 on)\n Response:\n Remains afebrile, no hemoptysis, slept well overnight\n Plan:\n Continue to monitor resp status, wean O2 as tolerated.\n"},{"category":"General","chartdate":"2199-07-15 00:00:00.000","description":"ICU Event Note","row_id":335778,"text":"Clinician: Attending\n Critical Care\n Urine output remains good and we will try to maintain him negative\n again today. Creat is trending down still. Oxygen requirement remains\n high and he still has diffuse bilat infiltrates. Plan for\n plasmapheresis again today. He is feeling better but still is very\n fragile HR 140 simply with exam. Checking ECK before increasing beta\n blocker.\n Total time spent: 35 minutes\n Patient is critically ill.\n"},{"category":"Physician ","chartdate":"2199-07-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":335781,"text":"Chief Complaint: 60 year old male transferred from OSH with repiratory\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis. Kidney function improving steadily, no dialysis was\n needed. Respiratory status stable, continues to require facemask to\n keep 02 sats >90%, no signs of continued bleeding into lungs.\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\n hyperglycemia to steroid use.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar hemoorhave given improving\n respiratory status and no hemoptysis. .\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O, goal -1 liter today (has been\n , no lasix unless needed this pm)\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\n continue for at least one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Continued tachycardia, ? atrial vs. sinus.\n Hemodynamically stable. ECHO showed mild LV septal , \n 45-50%. Possibly secondary to large volume shifts (retaining total\n body fluid with renal failure, with large volume load putting stress on\n atria.)\n -EKG to eval for atrial tach vs. sinus tach. If sinus, will work up\n underlying cause. If atrial, will increase lopressor to 75mg po tid.\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been low in the morning and higher in the afternoon for the\n past 2 days despite no transfusion and no plasmapheresis. Variation\n may be due to lab variability, fluid shifts during the day, or another\n unknown cause. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Transfer Note","row_id":336024,"text":"60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily. On RISS and NPH Q am.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n VASCULITIS\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 68.4 kg\n Daily weight:\n 93.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ? emphysema\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:78\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 24h total in:\n 1,136 mL\n 24h total out:\n 2,220 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:05 AM\n Potassium:\n 3.6 mEq/L\n 04:05 AM\n Chloride:\n 103 mEq/L\n 04:05 AM\n CO2:\n 32 mEq/L\n 04:05 AM\n BUN:\n 135 mg/dL\n 04:05 AM\n Creatinine:\n 4.3 mg/dL\n 04:05 AM\n Glucose:\n 92 mg/dL\n 04:05 AM\n Hematocrit:\n 21.3 %\n 04:05 AM\n Finger Stick Glucose:\n 150\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n pherisis line in R IJ, Foley cath\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 412\n Transferred to:\n Date & time of Transfer:\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Transfer Note","row_id":336032,"text":"60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily. On RISS and NPH Q am. BS well\n controlled.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n VASCULITIS\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 68.4 kg\n Daily weight:\n 93.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ? emphysema\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:78\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 24h total in:\n 1,136 mL\n 24h total out:\n 2,220 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:05 AM\n Potassium:\n 3.6 mEq/L\n 04:05 AM\n Chloride:\n 103 mEq/L\n 04:05 AM\n CO2:\n 32 mEq/L\n 04:05 AM\n BUN:\n 135 mg/dL\n 04:05 AM\n Creatinine:\n 4.3 mg/dL\n 04:05 AM\n Glucose:\n 92 mg/dL\n 04:05 AM\n Hematocrit:\n 21.3 %\n 04:05 AM\n Finger Stick Glucose:\n 150\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n pherisis line in R IJ, Foley cath\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 412\n Transferred to: 1173\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Progress Note","row_id":335921,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output.\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Improving.\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334315,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"},{"category":"Physician ","chartdate":"2199-07-13 00:00:00.000","description":"Physician Attending Progress Note","row_id":335286,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n Continues to require supplimental oxygen, desaturates with activity.\n Tolerating net diuresis.\n Hemoptysis resolved.\n Overall, states to feel improved. Dysnpea improved. Able to sleep\n somewhat last PM (improvement).\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.4\n HR: 98 (86 - 128) bpm\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\n RR: 25 (11 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 560 mL\n PO:\n 980 mL\n 360 mL\n TF:\n IVF:\n 319 mL\n 200 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 960 mL\n Urine:\n 4,410 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///31/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 170 K/uL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Imaging: CXR () somewhat improved, esp. right lung field.\n Assessment and Plan\n Wegener's Granulomatosis\n RESPIRATORY DISTRESS -- slow improvement clincally and\n radiographically. Continue current management.\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\n urine output.\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\n Continue steoids, cytoxan, plasmaphoresis\n NUTRITIONAL SUPPORT --\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":335287,"text":"Chief Complaint:\n 24 Hour Events:\n Did well. No hemoptysis.\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\n diuresis yesterday to goal -2L.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36\nC (96.8\n HR: 86 (86 - 116) bpm\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\n RR: 18 (14 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 340 mL\n PO:\n 980 mL\n 240 mL\n TF:\n IVF:\n 319 mL\n 100 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 470 mL\n Urine:\n 4,410 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 7.8 g/dL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\n the last 3 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500\n1L today. We will also watch\n his urine output and restart IVF if necessary to keep >100cc/hr\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Rate has been well controlled over the past 2 days.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately but his HCT is\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\n will not receive pheresis this weekend, so we can monitor to see if HCT\n stays stable.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Attending Progress Note","row_id":334432,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirment.\n Renal bx consistent with Wegener's Granulomatosis.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.9\nC (96.6\n HR: 99 (87 - 130) bpm\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\n RR: 21 (9 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,477 mL\n 2,103 mL\n PO:\n 60 mL\n TF:\n IVF:\n 2,102 mL\n 2,043 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 1,025 mL\n Urine:\n 1,360 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,117 mL\n 1,078 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 221 K/uL\n 94 mg/dL\n 7.2 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 149 mg/dL\n 105 mEq/L\n 145 mEq/L\n 22.7 %\n 9.0 K/uL\n [image002.jpg]\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n WBC\n 8.1\n 5.4\n 9.0\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n Plt\n 355\n 261\n 221\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n 94\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\n likey due to vasculitis. Radiographically without significant change,\n but hope to see improvement over next several days. Monitor RR, SaO2.\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\n improve.\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\n plts). Monitor Hct, transfuse to > 21\n WEGENER\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\n plasmaphoresis QOD.\n FLUIDS -- euvolemic. Monitor I/O\n HEMATURIA -- concern for hemorrhagic cystitis\n A-FIB -- good rate control COntinue meds. Monitor HR.\n NASAL CONGESTION -- possible related to Wegener's but more likely due\n to high flow O2. Symptomaatic relief.\n HYPOCALCEMIA -- repleted. Monitor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":334434,"text":"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO. Received 1 unit PRBCs yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Gen: Sleeping in bed, NAD\n CV:tachy, irregular. No murmur\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\n Ext: 1+ pedal edema, no rash or petichiae\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR.\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\n appropriately to 1unit PRBCs so likely not currently bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Prednison po daily,\n -Cyclophosphamide-dose to be determined after c/s with rheum and\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\n far.\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: Monitoring for need for dialysis, has line in\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\n signs of platelet dysfunction yet, mental status ok. Renal will give\n his kidneys about 48 more hours to turn around before dialyzing. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -pink tinged urine, stable, but will send daily U/As.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiacc negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334532,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\n has episodes of tachycardia in the 130\ns, typically with exertion or\n desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows with NSR episodes, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.9, BUN 149\n Action:\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\n administration of cyclophosphamide (chemo)\n Response:\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\n since midnight.\n Plan:\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\n HD catheter, may have it . Administer mesna as ordered with chemo\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n weak cough. +1.6L positive. Patient would frequently remove face tent,\n thus dropping O2 sats.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\n 6L NC. Patient encouraged to cough and deep breathe.\n Response:\n Oxygenation has improved throughout the afternoon with patient\ns family\n at the bedside\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing.\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334311,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 6 liters NC and supplemental O2, sats maintaining above\n 95%, desats when pt removes O2 in his sleep. , Moist non productive\n cough remains, LS with rhonchi in both lower lobes more on R.\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-12 00:00:00.000","description":"Nursing Progress Note","row_id":334923,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\n pull the O2 mask and cannula,desats to low 80,s when the mask is\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\n cough.\n Action:\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\n Cytoxan yesterday with mesna/IV as ordered by MD. 3^rd dose of mesna\n due at 1000,pt now only on FM with 80%,sats >97% when mask is on.\n Response:\n Pt was more comfortable last night, but continued to be uncomfortable\n with the mask\n Plan:\n Monitor resp status,meds as ordered,Titrate O2 as needed.\n"},{"category":"Physician ","chartdate":"2199-07-13 00:00:00.000","description":"Physician Resident Progress Note","row_id":335259,"text":"Chief Complaint:\n 24 Hour Events:\n Did well. No hemoptysis.\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\n diuresis yesterday to goal -2L.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36\nC (96.8\n HR: 86 (86 - 116) bpm\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\n RR: 18 (14 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 340 mL\n PO:\n 980 mL\n 240 mL\n TF:\n IVF:\n 319 mL\n 100 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 470 mL\n Urine:\n 4,410 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 7.8 g/dL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2L in the past 24 hours and -4L in the\n last 2 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500 today. We will also watch his\n urine output and restart IVF if necessary\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - Stable crit and no more hemoptysis so pulmonary bleeding unlikely,\n - HCTq12h to monitor for alveolar bleeding.\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n No baseline Crit available.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334307,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":334406,"text":"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 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 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\n will give his kidneys about 48 more hours to turn around before\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\n been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":334409,"text":"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Gen: Sleeping in bed, NAD\n CV:tachy, irregular. No murmur\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\n Ext: 1+ pedal edema, no rash or petichiae\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\n will give his kidneys about 48 more hours to turn around before\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\n been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334385,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx., undervent renal biopsy, awaiting results.\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"},{"category":"Nursing","chartdate":"2199-07-12 00:00:00.000","description":"Nursing Progress Note","row_id":334873,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-12 00:00:00.000","description":"Nursing Progress Note","row_id":334877,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\n pull the O2 mask and cannula,desats to low 80,s when the mask is\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\n cough.\n Action:\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\n Cytoxan yesterday with mesna/IV as ordered by MD.\n Response:\n Pt was more comfortable last night,\n Plan:\n Monitor resp status,meds as ordered,\n"},{"category":"General","chartdate":"2199-07-14 00:00:00.000","description":"Generic Note","row_id":335493,"text":"TITLE: Resp Care Note, Pt given albuterol/atrovent nebs. BS rhonchi. 02\n remains on 80% high flow neb/nc 4lpm. Sat 95%. Pt stable . Will cont ot\n monitor resp status.\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Attending Progress Note","row_id":334716,"text":"Chief Complaint: Hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirement.\n HR varies from A-flutter to NRS.\n Coughing up sputum (swallowing), but more productive cough today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 98 (85 - 131) bpm\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\n RR: 18 (12 - 25) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 1,971 mL\n PO:\n 750 mL\n 160 mL\n TF:\n IVF:\n 3,736 mL\n 1,811 mL\n Blood products:\n Total out:\n 2,400 mL\n 1,235 mL\n Urine:\n 2,400 mL\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 736 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\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, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 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, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 211 K/uL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\n Possible component of pulmonary edema.\n HYPOXEMIA -- attributed to pulmonary infiltrates.\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\n steroids & cytoxan. Plasmaphoresis.\n RENAL FAILURE -- improving.\n NUTRIONAL SUPPORT -- PO\n HEMATURIA -- stable. Monitor.\n ANEMIA -- stable s/p transfusion\n HYPOCALCEMIA -- continue to replete\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 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: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":335036,"text":"Chief Complaint: Respiratory distress, hypoxemia.\n HPI:\n 24 Hour Events:\n Experienced some hemoptysis yesterday PM.\n Appears much more comfortable today, less dyspneic.\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 Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\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, Hematuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\n RR: 26 (18 - 27) insp/min\n SpO2: 88%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 238 mL\n PO:\n 290 mL\n 120 mL\n TF:\n IVF:\n 2,214 mL\n 118 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 2,900 mL\n Urine:\n 3,010 mL\n 2,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -2,663 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 88%\n ABG: ///28/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.3 g/dL\n 185 K/uL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Wegener's Granulomatosis\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\n plasmaphoresis\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\n falling, urine output improving, responding to diuretics.\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\n escalation. Consider dDAVP. need dialysis if continues to\n NUTRITIONAL SUPPORT -- PO\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\n suppression. Transfuse to Hct >25\n FLUID -- continue net negative. Monitor I/O.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"},{"category":"Physician ","chartdate":"2199-07-14 00:00:00.000","description":"Physician Resident Progress Note","row_id":335533,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 108 (91 - 135) bpm\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\n RR: 19 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 190 mL\n PO:\n 1,220 mL\n 120 mL\n TF:\n IVF:\n 470 mL\n 70 mL\n Blood products:\n Total out:\n 2,465 mL\n 900 mL\n Urine:\n 2,465 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -710 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\n the last 3 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500\n1L today. We will also watch\n his urine output and restart IVF if necessary to keep >100cc/hr\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's)\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Rate has been well controlled over the past 2 days.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately but his HCT is\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\n will not receive pheresis this weekend, so we can monitor to see if HCT\n stays stable.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nutrition","chartdate":"2199-07-11 00:00:00.000","description":"Clinical Nutrition Note","row_id":334695,"text":"Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diet: low sodium/heart healthy/Renal.\n Reports no weight loss. Tolerating current diet, says he's hungry. Will\n continue to monitor po intake. Continue to monitor renal function and\n hydration.\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335226,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Followed up with labs overnight.\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"},{"category":"Physician ","chartdate":"2199-07-14 00:00:00.000","description":"Physician Attending Progress Note","row_id":335572,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n No new events.\n Revieved 1 U PRBC transfusion, tolerated well.\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 Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 122 (97 - 135) bpm\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 477 mL\n PO:\n 1,220 mL\n 360 mL\n TF:\n IVF:\n 470 mL\n 117 mL\n Blood products:\n Total out:\n 2,465 mL\n 1,540 mL\n Urine:\n 2,465 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -1,063 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.2 g/dL\n 200 K/uL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n Respiratory distress and acute renal failure --> Wegener's\n Granulomatosis\n RESPRIATORY DISTRESS -- gradual improvement.\n RENAL FAILURE -- initial good recovery, with good urine output;\n however, now creatitine with minimal decline over past 2-3 days. \n be approaching new baseline. ultimately require dialysis.\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\n cytoxan & plasmaphoresis\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\n disease.\n FLUIDS -- desire net negative if tolerated by BP.\n NUTRITIONAL SUPPORT -- encourage PO.\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":333963,"text":"Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335357,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\n to 86% when pt. sleeping and face tent away from Pt.\ns face.\n Action:\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\n in sputum. Nebs as ordered.\n Response:\n Pt. states he is feeling better. No hemoptisis this shift. CXR\n improving.\n Plan:\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335358,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\n to 86% when pt. sleeping and face tent away from Pt.\ns face.\n Action:\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\n in sputum. Nebs as ordered.\n Response:\n Pt. states he is feeling better. No hemoptisis this shift. CXR\n improving.\n Plan:\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\n Repleated Ca+ this shift per Ca+ SS.\n Repeat Hct. 26\n"},{"category":"Nursing","chartdate":"2199-07-15 00:00:00.000","description":"Nursing Progress Note","row_id":335733,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Plasma pheresis due tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\n during sleep),\n Action:\n Continues on O2, ( frequently reminded to keep O2 on), xray chest done\n this a.m\n Response:\n Remains afebrile, no hemoptysis, slept well overnight\n Plan:\n Continue to monitor resp status, wean O2 as tolerated.\n"},{"category":"Physician ","chartdate":"2199-07-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":335748,"text":"Chief Complaint: 60 year old male transferred from OSH with repiratory\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis. Kidney function improving steadily, no dialysis was\n needed. Respiratory status stable, continues to require facemask to\n keep 02 sats >90%, no signs of continued bleeding into lungs.\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\n hyperglycemia to steroid use.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar hemoorhave given improving\n respiratory status and no hemoptysis. Continue to monitor with q12\n HCT.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\n continue for at least one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Progress Note","row_id":335872,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n U/O has been good.\n Plan:\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Progress Note","row_id":335873,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Progress Note","row_id":335874,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output.\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Improving.\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"},{"category":"Nursing","chartdate":"2199-07-16 00:00:00.000","description":"Nursing Transfer Note","row_id":336022,"text":"60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily.\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":334074,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - also treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily\n -Cyclophosphamide 140mg\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok.\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\n However, apart from pulmonary association, ddx for acute renal failure\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\n Also consider DIC.\n - Renal biopsy yesterday, awaiting results\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is eating, can D/C D5W.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am), check again this PM\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6, given HCT , likely need blood this pm.\n - Type and screen, cross-matched\n - Blood consent obtained\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-16 00:00:00.000","description":"Physician Attending Progress Note","row_id":336013,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n EKG - At 12:02 PM\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\n Tolerated plasmaphoresis yesterday.\n Continues net diuresis, tolerated well.\n No further hemoptysis.\n Up in chair, excellent spirits. Appropriate. Joking with family.\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 Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, 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 10:38 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\n HR: 114 (100 - 142) bpm\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,534 mL\n 902 mL\n PO:\n 1,220 mL\n 750 mL\n TF:\n IVF:\n 314 mL\n 152 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,690 mL\n Urine:\n 2,565 mL\n 1,690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,031 mL\n -788 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///32/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 200 K/uL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\n Assessment and Plan\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\n steroids, cytoxan. Complete Plasmaphoresis course.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\n oxygen requirement.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\n improvement. Monitor. No acute indication for dialysis.\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\n Monitor.\n TACHYCARDIA -- improved. Monitor.\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\n Transfuse to Hct >21.\n HYPERGLYCEMIA -- contributed by high dose steroids. Monitor, use\n insullin to maintain <150.\n ICU Care\n Nutrition: PO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"},{"category":"Nursing","chartdate":"2199-07-14 00:00:00.000","description":"Nursing Progress Note","row_id":335526,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal parameters trending down\n Action:\n Diuresed this p.m with 20 lasix,\n Response:\n Good response to lasix, negative 770 by midnight\n Plan:\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\n"},{"category":"Nursing","chartdate":"2199-07-15 00:00:00.000","description":"Nursing Progress Note","row_id":335854,"text":"Vasculitis\n Assessment:\n Tolerating pheresis. Hemodynamically stable.\n Action:\n Plasma pheresis this afternoon. Lopressor increased to 75mg d/t atrial\n tachycardia. Hct 23. pedal edema slowly decreasing. Slept in naps. Ssi\n for bs\ns. mg+ 1.6 and given 2mg mg+ ivpb. Good appetite.\n Response:\n Continues to improve. Good response to lopressor.\n Plan:\n Need to check ionized ca+ at 20pm. Pt. has a ss for his ca+ doses.\n Transfuse if hct drops below 21.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Able to tolerate np only.\n Action:\n Mask off. Presently on 5L np. . Non-productive cough. No hemoptysis. No\n c/o sob.\n Response:\n Sats 98-100%.\n Plan:\n Continue to wean o2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal failure improving.\n Action:\n Creat 4.4. k+ 3.7. /20mg lasix ivp ordered/given by night nurse. Urine\n slightly pink-tinged this am, but not noted this pm. Patent dialysis\n catheter with port.\n Response:\n Autodiuresing.\n Plan:\n Plan for 1L negative.\n"},{"category":"General","chartdate":"2199-07-16 00:00:00.000","description":"ICU Event Note","row_id":335955,"text":"Clinician: Attending\n Critical Care\n 42 yo woman paraplegic after MVA , recently discharged from\n hospital after \"pneumonia\" noted by PCA to be lethargic at home, SaO2\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\n somewhat confused but conversant. Still somewhat lethargic. We are\n continuing Narcan but would have some concern about methadone as\n explanation for her lethargy as no change in methadone dose for 6 weeks\n and not previously sedated by med. Would also have some concern about\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\n presentation. Not clear why she developed PNA. We are continuing O2,\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\n have PFTs before d/c.\n Total time spent: 35 minutes\n Patient is critically ill.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 08:08 ------\n"},{"category":"Physician ","chartdate":"2199-07-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":335974,"text":"Chief Complaint:\n 24 Hour Events:\n Continues with same 02 requirement. EKG yesterday revealed aflutter\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\n 100s all night.\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\n overnight.\n Followed by renal and rheum.\n EKG - At 12:02 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 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: 36.6\nC (97.8\n HR: 106 (100 - 142) bpm\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,530 mL\n 600 mL\n PO:\n 1,220 mL\n 500 mL\n TF:\n IVF:\n 310 mL\n 100 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,200 mL\n Urine:\n 2,565 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,036 mL\n -600 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 7.2 g/dL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Has been stable on 6L NC. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Wean 02 to keep sat >90%.\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\n hemoorhave given improving respiratory status and no hemoptysis.\n Probably due to plasmapheresis and fluid shifting. His respiratory\n status may be marginally helped by an increased HCT, but will check pm\n HCT and transfuse if <21.\n -Continue nystatin mouthwash for + sputum given his high dose\n steroids. Day \n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 yesterday, then tomorrow and Friday.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine continues to trend down, 4.3 this morning, BUN is\n also finally down to 135, and he has maintained good urine output. As\n a note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Foley in place , strict I&O,we have been diuresing him well, with ?\n liters off in the past 5 days. We will continue to diurese with goal\n -500cc to -1L, using Lasix 20 IV prn.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\n one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Received 4gIV overnight, will re-check PM ionized Calcium and replete\n as needed. On days when he has pheresis, ionized CA needs to be drawn\n 4 hours after the end of pheresis to be accurate.\n -on SS replacement.\n -EKGs have been unchanged.\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\n stable. ECHO showed mild LV septal , 45-50%. Possibly\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n -Increased lopressor to 75mg po tid yesterday. Will continue to\n monitor on tele. If needed, could start a second rate controlling\n .\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been variable over the weekend despite no transfusion.\n Variation may be due to lab variability, or to fluid shifts with\n plasmapheresis. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\n unit if <21.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units, well controlled.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n #Dispo: to floor if it is possible to do pheresis outside of the ICU.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":335016,"text":"Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \n C-ANCA vasculitis. This morning, he breathing more easily, with stable\n lung exam though his CXR looks unchanged. This is likely due to\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\n 2+ budding yeast on sputum, without signs of candidiasis on\n oropharyngeal exam.\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\n urine output and restart IVF if necessary. We will balance maintaining\n urine output >100/hr for bladder protection with not giving too much\n Lasix due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n -Start nystatin mouthwash\n -Send blood cultures for fungus (though highly unlikely given pt. is\n afebrile, stable, but he is on high dose immunosuppression)\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Given hemoptysis and drop in crit, some concern for pulmonary\n bleeding, though respiratory status improving.\n - HCTq8h to monitor for alveolar bleeding.\n - Will collect sputum to determine whether hemoptysis is tinged, bright\n red or just pink fronthy.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN , some wheezing on exam today\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 today, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n No baseline Crit available.\n -transfuse one unit this morning as HCT is trending down (21.6)\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334319,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx., undervent renal biopsy, awaiting results.\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"},{"category":"Physician ","chartdate":"2199-07-16 00:00:00.000","description":"Physician Resident Progress Note","row_id":335938,"text":"Chief Complaint:\n 24 Hour Events:\n Continues with same 02 requirement. EKG yesterday revealed aflutter\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\n 100s all night.\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\n overnight.\n Followed by renal and rheum.\n EKG - At 12:02 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 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: 36.6\nC (97.8\n HR: 106 (100 - 142) bpm\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,530 mL\n 600 mL\n PO:\n 1,220 mL\n 500 mL\n TF:\n IVF:\n 310 mL\n 100 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,200 mL\n Urine:\n 2,565 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,036 mL\n -600 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 7.2 g/dL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\n hemoorhave given improving respiratory status and no hemoptysis.\n Probably due to plasmapheresis, given with 50% albumin yesterday.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 yesterday, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine up to 4.3 from 4.0 yesterday, BUN down to 135, good\n urine output. As a note, plasmapheresis in cases of severe Wegeners\n has been shown to improve kidney outcomes, though not mortality.\n - Foley in place , strict I&O,we have been diuresing him well, with ?\n liters off in the past 5 days. His creatinine bumped a little bit this\n morning, probably we are at his dry weight and can back off on\n diuresis.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\n one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\n stable. ECHO showed mild LV septal , 45-50%. Possibly\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n -Increased lopressor to 75mg po tid yesterday.\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been low in the morning and higher in the afternoon for the\n past 2 days despite no transfusion and no plasmapheresis. Variation\n may be due to lab variability, fluid shifts during the day, or another\n unknown cause. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\n unit.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units, well controlled.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-08 00:00:00.000","description":"Nursing Progress Note","row_id":333940,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s\n Action:\n Conts on lopressor 50mg TID\n Response:\n Tolerating the lopressor, he did have short periods of a HR in the\n 1teens this afternoon\n Plan:\n Cont with the lopressor, follow VS\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat was 8.6 this morning and 8.0 this afternoon, u/o has been\n 40-50cc/hr\n Action:\n Pt had a renal biopsy this morning under US guidance, given 2 bagsof\n FFP for this, needed Ca gluc this evening as well. He is receiving D5W\n 100cc/hr for 1 liter for a Na of 150\n Response:\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\n Plan:\n Follow HCT\n due tonight, VS, renal bx results, no immediate plans for\n dialysis, follow labs, to receive cytoxan again tonight, 7 \n resourse nurse is aware and some will be down to give this\n he needs\n mesna before and after\n please see \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\n has not been coughing up any blood\n Action:\n He is on scoop mask at 60-70% and this brings his 02 up to the mid 90s\n Response:\n Conts to require a high FI02\n Plan:\n Follow SATs cont to try to wean his FI02\n"},{"category":"Physician ","chartdate":"2199-07-15 00:00:00.000","description":"Physician Resident Progress Note","row_id":335723,"text":"Chief Complaint:\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"General","chartdate":"2199-07-15 00:00:00.000","description":"ICU Event Note","row_id":335851,"text":"Clinician: Attending\n Critical Care\n 42 yo woman paraplegic after MVA , recently discharged from\n hospital after \"pneumonia\" noted by PCA to be lethargic at home, SaO2\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\n somewhat confused but conversant. Still somewhat lethargic. We are\n continuing Narcan but would have some concern about methadone as\n explanation for her lethargy as no change in methadone dose for 6 weeks\n and not previously sedated by med. Would also have some concern about\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\n presentation. Not clear why she developed PNA. We are continuing O2,\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\n have PFTs before d/c.\n Total time spent: 35 minutes\n Patient is critically ill.\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335154,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Followed up with labs overnight.\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334317,"text":": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Attending Progress Note","row_id":334996,"text":"Chief Complaint: Respiratory distress, hypoxemia.\n HPI:\n 24 Hour Events:\n Experienced some hemoptysis yesterday PM.\n Appears much more comfortable today, less dyspneic.\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 Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\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, Hematuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\n RR: 26 (18 - 27) insp/min\n SpO2: 88%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 238 mL\n PO:\n 290 mL\n 120 mL\n TF:\n IVF:\n 2,214 mL\n 118 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 2,900 mL\n Urine:\n 3,010 mL\n 2,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -2,663 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 88%\n ABG: ///28/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.3 g/dL\n 185 K/uL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Wegener's Granulomatosis\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\n plasmaphoresis\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\n falling, urine output improving, responding to diuretics.\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\n escalation. Consider dDAVP. need dialysis if continues to\n NUTRITIONAL SUPPORT -- PO\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\n suppression. Transfuse to Hct >25\n FLUID -- continue net negative. Monitor I/O.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"},{"category":"Physician ","chartdate":"2199-07-16 00:00:00.000","description":"Physician Attending Progress Note","row_id":335972,"text":"Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n EKG - At 12:02 PM\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\n Tolerated plasmaphoresis yesterday.\n Continues net diuresis, tolerated well.\n No further hemoptysis.\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 Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, 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 10:38 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\n HR: 114 (100 - 142) bpm\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,534 mL\n 902 mL\n PO:\n 1,220 mL\n 750 mL\n TF:\n IVF:\n 314 mL\n 152 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,690 mL\n Urine:\n 2,565 mL\n 1,690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,031 mL\n -788 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///32/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 200 K/uL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\n Assessment and Plan\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\n steroids, cytoxan. Complete Plasmaphoresis course.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\n oxygen requirement.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\n improvement. Monitor. No acute indication for dialysis.\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\n Monitor.\n TACHYCARDIA -- improved. Monitor.\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\n Transfuse to Hct >21.\n HYPERGLYCEMIA -- contributed by high dose steroids.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333556,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - Check TSH\n - Surface ECHO in a.m.\n - Will start Lopressor 12.5mg PO daily for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333557,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - F/u on TSH\n - Surface ECHO in a.m. today\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Radiology","chartdate":"2199-07-22 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1030091,"text":" 5:49 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: interval change, worsening consolidations on CXR, compare w\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegner's granulomatosis, pulm hemorrhage, ? aspergillous\n infection, on vori, w worsening dyspnea. On CXR consolidation in R mid lung\n appears worse, needs repeat NON-CONTRAST CHEST CT (renal failure) to evaluate\n the densities further\n REASON FOR THIS EXAMINATION:\n interval change, worsening consolidations on CXR, compare w previous Chest CT\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: ARHb MON 7:50 PM\n Widespread pulmonary abnormalities, including consolidation, ground glass\n change, and nodularity, persist and have worsened at the right lung base.\n Differential continues to include vasculitis/hemorrhage and infection,\n including Aspergillus. Persistent right apical lung nodules. Increased small\n to moderate right pleural effusion. Unchanged left effusion. No significant\n change in mediastinl/hilar adenopathy.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient's Wegener's granulomatosis,\n pulmonary hemorrhage and suspected aspergillus infection with worsening\n dyspnea.\n\n COMPARISON: Chest CT from .\n\n TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to\n upper abdomen with subsequent 1.25 and 5-mm collimation. Axial images\n reviewed in conjunction with coronal and sagittal reformats.\n\n FINDINGS:\n\n Multifocal mediastinal lymphadenopathy is unchanged with enlarged nodes\n present in multiple compartments. Within the left mediastinal lymph nodes\n measure up to 1.4 cm at the shortest access, within the left compartment is up\n to 1.5 cm. The additional conglomerate of the lymph nodes in the subcarinal\n lesion is up to 1.8 cm in diameter so grossly with no significant change since\n the prior study. The bilateral hila are diffusely enlarged with most likely\n present lymph nodes that are difficult to evaluate without injection of\n contrast. Calcifications in the right hilus suggest prior granulomatous\n exposure. There is most likely increase in the size of the right hilar lymph\n node, 2:32 currently 1.3 cm in diameter compared to 7 mm on the prior study.\n The patient is anemic giving the high density of the myocardium compared to\n the blood in the . Diffuse coronary calcifications are seen. There\n is no pericardial effusion. Bilateral pleural effusions are present, still\n small but slightly increased compared to the prior study.\n\n The imaged portion of the upper abdomen is grossly unremarkable with no\n appreciable change since the prior study.\n (Over)\n\n 5:49 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: interval change, worsening consolidations on CXR, compare w\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The airways are patent to the level of lobar and segmental bronchi bilaterally\n except for right lower lobe with occlusion of the apical segment is noted,\n most liklely due to secretions. Widespread pulmonary abnormality has\n slightly progressed since the recent study including areas of consolidation,\n ground- glass opacities and poorly defined nodules. The consolidations and\n ground glass are most pronounced in the mid and lower lungs, namely in the\n posterior segment of left upper lobe, lingula, and both lower lobes, right\n more than left. The previously demonstrated well defined perifissural nodule\n in the right lower lobe anteriorly is unchanged. Extensive bronchial impaction\n is present within the lower lobe bronchi. Marked upper lobe predominantly\n paraseptal and centrilobular emphysema is unchanged. Within the right apex, a\n 2 cm nodular opacity is identified containing calcification. Similar size\n spiculated opacity is seen in the left apex with less prominent spiculated\n appearance.\n\n No suspicious lytic or blastic lesions were demonstrated in the imaged portion\n of the skeleton.\n\n IMPRESSION:\n\n 1. Widespread pulmonary abnormalities including consolidation, ground glass\n in poorly defined lung nodules, slightly worse, but no new areas involved. As\n previously mentioned vasculitis and associated pulmonary hemorrhage are the\n primary diagnosis. Coexisting infection such as bacterial infection or\n aspergillosis cannot be excluded.\n\n 2. Spiculated right apical lesion raise concern for possible primary lung\n cancer especially on a patient with underlying emphysema. It is still\n potentially can be related to diffuse lung abnormalities thus three months\n followup chest CT is highly recommended.\n\n 3. Extensive intrathoracic lymphadenopathy: related to vasculitis and/or\n reactive to infection.\n\n 4. Slightly increased but still small bilateral pleural effusion in minimal\n amount of ascites.\n\n 5. Evidence of anemia.\n\n"},{"category":"Radiology","chartdate":"2199-07-22 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1030021,"text":", V. MED 11R 9:37 PM\n CHEST (PA & LAT) Clip # \n Reason: worsening dyspnea, eval for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\n interval change\n REASON FOR THIS EXAMINATION:\n worsening dyspnea, eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n Dense consolidation right mid and left mid lung zone. Improved aeration in\n lower lung zones.\n\n"},{"category":"Radiology","chartdate":"2199-07-22 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1030020,"text":" 9:37 PM\n CHEST (PA & LAT) Clip # \n Reason: worsening dyspnea, eval for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\n interval change\n REASON FOR THIS EXAMINATION:\n worsening dyspnea, eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 3:42 PM\n Dense consolidation right mid and left mid lung zone. Improved aeration in\n lower lung zones.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL\n\n COMPARISON: .\n\n HISTORY: Wegener's granulomatosis and aspergillosis.\n\n FINDINGS: There has been interval increase in dense consolidation in the\n right mid lung zone and left mid lung zone. The lung bases appear to have\n improved in aeration. Small bilateral pleural effusions are unchanged.\n Emphysematous changes particularly in the apices are noted.\n\n IMPRESSION: More dense consolidations seen in the right mid lung and left mid\n lung zones. Improved aeration in the bilateral lower lung zones.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2199-07-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026997,"text":" 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary renal syndrome\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:49 AM\n PFI: Slight interval improvement in the left lung consolidations.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in a patient with renal failure.\n\n Portable AP chest radiograph was compared to the prior studies obtained on\n .\n\n There is overall slight improvement in the opacities of the left lung with no\n change in the right lower lung consolidation with again demonstrated more\n discrete nodular opacity. There is no pleural effusion. For precise\n characterization of the finding, further evaluation with chest CT might be\n appropriate as the differential diagnosis is broad, including widespread\n infection, hemorrhage or asymmetric edema.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026998,"text":", M. MED 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary renal syndrome\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Slight interval improvement in the left lung consolidations.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-07 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1026946,"text":" 6:32 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please assess dialysis line placement.\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with IJ dialysis line\n REASON FOR THIS EXAMINATION:\n Please assess dialysis line placement.\n ______________________________________________________________________________\n WET READ: SBNa SUN 7:06 PM\n Right IJ line terminates in upper SVC. Unchanged appearance of b/l diffuse\n opacites. No ptx.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the central venous catheter placement.\n\n Portable AP chest was compared to .\n\n The right internal jugular line catheter was inserted with its tip projecting\n at the level of the junction of brachiocephalic vein and superior SVC. The\n heart size is moderately enlarged but stable. There is also no change in the\n mediastinal contour. There is overall no change in the extensive parenchymal\n consolidation compared to the prior study. The differential diagnosis might\n include extensive infection, pulmonary edema in the presence of underlying\n emphysema or pulmonary hemorrhage, clinical correlation in comparison to the\n prior studies is required. Note is made of a more discrete rounded density in\n the right lower lung unchanged since the prior study, which might represent a\n part of a similar process or additional underlying abnormality. Scarring in\n the upper lung is unchanged. No appreciable pleural effusion is demonstrated.\n\n"},{"category":"Radiology","chartdate":"2199-07-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028387,"text":" 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's.\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP:\n\n COMPARISON: One day prior.\n\n HISTORY: 50-year-old man with Wegner's, evaluate for any change.\n\n FINDINGS: There is slightly improved aeration of both lungs. Again seen is\n diffuse areas of consolidation, primarily in the right mid lung zone and left\n mid and lower lung zone. No new consolidations are identified. Biapical\n scarring is unchanged. Cardiomediastinal and hilar contours are unremarkable.\n A right-sided internal jugular catheter sheath is seen terminating in the\n upper SVC. There is no evidence of pneumothorax.\n\n IMPRESSION: Slightly improved aeration of both lungs. Persistent opacities\n seen primarily in the right mid and left mid to lower lung zones.\n\n\n\n"},{"category":"Radiology","chartdate":"2199-07-17 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1028954,"text":" 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\n sx\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB WED 7:17 PM\n Multifocal consolidation, ground-glass attenuation, and poorly defined\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\n lymphadenopathy, and a small amount of ascites.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, \n\n Comparison chest radiographs dating between and .\n\n INDICATION: Wegener's granulomatosis, pulmonary hemorrhage, and Aspergillus\n on recent sputum culture.\n\n TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was\n performed without intravenous or oral contrast. Images are presented for\n display in the axial plane at 5-mm and 1.25-mm collimation. A series of\n multiplanar reformation images were also submitted for review.\n\n FINDINGS: Widespread pulmonary abnormalities are present, including areas of\n consolidation, ground-glass attenuation, and poorly defined nodules. The\n areas of consolidation and ground glass are most pronounced in the mid and\n lower lungs. In addition to poorly defined bronchovascular nodules, one well-\n defined perifissural nodule is identified in the right lower lobe anteriorly\n measuring 8 mm (227, 4A). Extensive bronchial impaction is present within the\n lower lobe bronchi, but the more central airways appear patent. Marked upper\n lobe predominant paraseptal and centrilobular emphysema are present. Within\n the right apex, a spiculated 2.1-cm diameter nodular opacity is identified\n (68, 4A) with an eccentric granuloma. Additional similar-sized spiculated\n opacity is identified higher in the right apex (52, 4A).\n\n Multifocal mediastinal lymphadenopathy is present, with enlarged nodes present\n in multiple compartments. Within the left mediastinum, lymph nodes measure up\n to 1.4 cm in short axis in the lower left paratracheal region and 1.5 cm in\n the left prevascular area. Additional conglomerate lymph nodes are seen in\n the subcarinal region measuring up to approximately 17 mm in short axis. There\n are likely bilateral hilar nodes present, difficult to measure in the absence\n (Over)\n\n 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of intravenous contrast. A few small calcified mediastinal and hilar nodes are\n also evident. No pericardial effusion is identified. Coronary artery\n calcifications are evident. Small dependent simple pleural effusions are\n present bilaterally.\n\n Exam was not tailored to evaluate the subdiaphragmatic region, but note is\n made of a small amount of ascites as well as nonspecific mesenteric stranding.\n Liver appears relatively hyperdense, possibly due to previous transfusions or\n amiodarone therapy.\n\n No suspicious lytic or blastic skeletal lesions are identified.\n\n IMPRESSION:\n 1. Widespread pulmonary abnormalities including consolidation, ground-glass,\n and poorly defined lung nodules. These could be due to the patient's known\n vasculitis with associated pulmonary hemorrhage, but coexisting Aspergillus\n infection is likely given the reported sputum culture results.\n 2. Spiculated right apical nodules raise the concern for possible primary\n lung cancer in this patient with underlying emphysema, but could potentially\n be related to the same process as the diffuse lung abnormalities. 3-month\n chest CT followup is suggested following appropriate therapy to ensure\n resolution.\n 3. Extensive intrathoracic lymphadenopathy, which may be due to Wegener's\n and/or reactive nodes from infection.\n 4. Small bilateral pleural effusions and a small amount of ascites.\n\n"},{"category":"Radiology","chartdate":"2199-07-17 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1028955,"text":", MED 11R 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\n sx\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PFI REPORT\n Multifocal consolidation, ground-glass attenuation, and poorly defined\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\n lymphadenopathy, and a small amount of ascites.\n\n"},{"category":"Radiology","chartdate":"2199-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027858,"text":" 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for worsening infiltrates\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for worsening infiltrates\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 10:07 PM\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\n are unchanged. There is no residual pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMMENTS: 50-year-old man with Wegener and pulmonary hemorrhage.\n\n Since yesterday, bilateral dense consolidation in mid and lower lung zones are\n unchanged. There is no residual pulmonary edema. Pleural effusions, if any,\n are small. Heart size is top normal and unchanged. Right internal jugular\n sheath ends in right brachiocephalic vein.\n\n"},{"category":"Radiology","chartdate":"2199-07-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027200,"text":" 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: looking for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n looking for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 9:50 AM\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\n is unchanged. Right internal jugular is in good position. Left small pleural\n effusion is new with associated atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMMENTS: 60-year-old man with hypoxia. Interval change.\n\n Since , bilateral alveolar opacity with slightly nodular appearance\n is unchanged in this patient with pulmonary renal syndrome.\n\n Small left pleural effusion is new associated with new left lower lobe\n atelectasis. Right internal jugular catheter is in good position.\n\n Findings can be consistent with multifocal infection, bilateral hemorrhage or\n much less likely asymmetric pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2199-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028071,"text":" 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, effusions, edema\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with wegener's and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, effusions, edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NLHa SAT 1:28 PM\n Bilateral opacities unchanged. Right central venous catheter unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable chest x-ray performed at 0515 hours.\n\n Comparison is . There are bilateral opacities involving both lower and\n mid lung fields. The opacity on the left extends to involve the upper lung\n field. Compared to prior exam, there is increasing density in the right\n base. The cardiac silhouette is mildly enlarged.\n\n IMPRESSION: Increasing density in the right base.\n\n"},{"category":"Radiology","chartdate":"2199-07-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027201,"text":", M. MED 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: looking for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n looking for interval change\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\n is unchanged. Right internal jugular is in good position. Left small pleural\n effusion is new with associated atelectasis.\n\n"},{"category":"Radiology","chartdate":"2199-07-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027613,"text":" 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for new infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for new infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:10 AM\n PFI: No change in the bilateral severe predominantly lower lobe opacification\n compared to the prior study.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with pulmonary hemorrhage.\n\n Portable AP chest radiograph was compared to obtained at\n 05:40.\n\n In the interim, there is overall no significant change in the bilateral severe\n predominantly lower lobe consolidations with some involvement of the upper\n lungs, left more than right, consistent with diffuse parenchymal hemorrhage.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027401,"text":", MED 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\n remains normal. Pleural effusion, if any, is small. Right jugular line is\n central. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028562,"text":" 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:21 AM\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\n bilateral consolidations with slight decrease in the right mid lung but are\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\n lesions on the right could be present but are hard to confirm due to\n underlying diffuse consolidation. Chest CT could further characterize lung\n opacities.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n REASON FOR EXAM: 60-year-old man with Wegener. Evaluate for interval change.\n\n Since yesterday, right internal jugular catheter still ends in upper SVC.\n Diffuse bilateral consolidation slightly decreased in the right mid lung but\n are unchanged on the left. Consolidation has a more heterogeneous appearance,\n could be due to underlying cavitary lesions hard to better define. Chest CT\n could further characterize lung opacities if clinically warranted.\n\n Biapical scarring is unchanged.\n\n"},{"category":"Radiology","chartdate":"2199-07-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028563,"text":", MED 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\n bilateral consolidations with slight decrease in the right mid lung but are\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\n lesions on the right could be present but are hard to confirm due to\n underlying diffuse consolidation. Chest CT could further characterize lung\n opacities.\n\n"},{"category":"Radiology","chartdate":"2199-07-08 00:00:00.000","description":"BX-NEEDLE KIDNEY BY NEPHROLOGIST","row_id":1027056,"text":" 10:49 AM\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: ? Gbm disease versus wegeners' granulomatosis\n Admitting Diagnosis: VASCULITIS\n ********************************* CPT Codes ********************************\n * BX-NEEDLE KIDNEY BY NEPHROLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with glomerulonephritis and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n ? Gbm disease versus wegeners' granulomatosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Glomerulonephritis and pulmonary hemorrhage. Questionable GBM\n disease vs. Wegener's.\n\n FINDINGS: Ultrasound guidance was provided for renal biopsy performed by\n nephrology team. Five core biopsy samples were obtained from the lower pole\n of the left kidney. The patient tolerated the procedure well. No immediate\n complications occurred.\n\n IMPRESSION: Successful ultrasound-guided biopsy performed by the nephrology\n team.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-17 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":1028947,"text":" 4:15 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval sinusus (asking for non-contrast study with ARF as belo\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval sinusus (asking for non-contrast study with ARF as below)\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 60-year-old male with newly-diagnosed Wegener's\n granulomatosis with acute renal failure, pulmonary hemorrhage with sputum\n culture noting \"rare aspergillus.\"\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the sinuses. Coronal\n reformatted images were obtained.\n\n FINDINGS: Extensive sinus disease is present with air-fluid levels in both\n maxillary sinuses. The left maxillary sinus is nearly-completely opacified and\n containing hyperdense secretions. The right maxillary, sphenoid and frontal\n sinuses show circumferential mucosal thickening. Dense secretions are also\n identified in the right nasal cavity.\n\n There is diffuse bony remodeling and permeation involving the ethmoid septae,\n maxillary sinus medial walls and ostiomeatal complexes, and the nasal\n turbinates, which in the absence of history or prior surgery, likely relate to\n Wegener's granulomatosis. However, the nasal septum and hard palate remain\n intact. There is no evidence of intracranial or orbital involvement. The\n mastoid air cells remain normally aerated.\n\n IMPRESSION:\n 1. Extensive pansinus soft tissue disease, most severely affecting the left\n maxillary sinus. Note is made of dense secretions in the left maxillary sinus\n and right nasal cavity which may simply represent chronically-inspissated\n secretions; however, fungal colonization (ie. with Aspergillus spp. and their\n metabolic byproducts) can have a similar appearance.\n 2. Extensive bony remodeling and permeation involving the sinuses and nasal\n turbinates which in the absence of prior surgery can be seen with Wegener's\n granulomatosis. The nasal septum remains intact.\n\n These findings were discussed with Dr. (primary hospitalist) at the\n time of interpretation, by Dr. . Evaluation by ENT Service, with\n possible diagnostic aspiration of the left maxillary contents, may be\n warranted.\n\n (Over)\n\n 4:15 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval sinusus (asking for non-contrast study with ARF as belo\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2199-07-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028225,"text":", MED 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n PFI REPORT\n Improved aeration of left mid lung zone.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-08 00:00:00.000","description":"RENAL U.S.","row_id":1027059,"text":" 10:42 AM\n RENAL U.S. Clip # \n Reason: WITH GLOMERULONEPHRITIS\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Glomerulonephritis.\n\n COMPARISON: None.\n\n FINDINGS: The right kidney measures 12.4 cm and the left 12.8 cm. The renal\n parenchymal echogenicity is increased, bilaterally. There are no renal\n calculi or hydronephrosis. Small amount of fluid is seen adjacent to the\n right kidney. The bladder is not distended with a Foley catheter within,\n cannot be assessed accurately.\n\n IMPRESSION: Bilateral increased renal parenchymal echogenicity consistent\n with medical renal disease. Small amount of right perinephric free fluid.\n\n"},{"category":"Radiology","chartdate":"2199-07-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027400,"text":" 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 3:06 PM\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\n remains normal. Pleural effusion, if any, is small. Right jugular line is\n central. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:40 A.M. ON \n\n HISTORY: Pulmonary hemorrhage.\n\n IMPRESSION: AP chest compared to through :\n\n Severe infiltrative pulmonary abnormality responsible for dense consolidation\n in the lower mid and lower lung zones since has not improved and may\n have worsened in the lung bases, now accompanied by progressive vascular\n congestion in the upper lung suggesting volume overload also responsible for\n mild increase in caliber of the azygos vein, although vascular engorgement is\n undoubtedly exaggerated by supine positioning. Pleural effusions, if any, are\n small. Heart size is top normal and unchanged. Right jugular introducer ends\n at the thoracic inlet. No other invasive support devices.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1026858,"text":" 10:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for evidence of infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with evidence of diffuse alveolar hemorrhage on bronch and\n renal failure\n REASON FOR THIS EXAMINATION:\n please assess for evidence of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diffuse alveolar hemorrhage.\n\n FINDINGS: No previous images available. There is mild enlargement of the\n cardiac silhouette. Diffuse bilateral asymmetric alveolar opacifications\n involving almost all of both lungs. This would be consistent with diffuse\n alveolar hemorrhage as clinically suspected. Fibrocalcific changes in the\n apices are consistent with old granulomatous disease.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027859,"text":", MED 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for worsening infiltrates\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for worsening infiltrates\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\n are unchanged. There is no residual pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2199-07-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028072,"text":", MED 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, effusions, edema\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with wegener's and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, effusions, edema\n ______________________________________________________________________________\n PFI REPORT\n Bilateral opacities unchanged. Right central venous catheter unchanged.\n\n"},{"category":"Echo","chartdate":"2199-07-08 00:00:00.000","description":"Report","row_id":87723,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Valvular heart disease.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 112/56\nHR (bpm): 78\nStatus: Outpatient\nDate/Time: at 11:48\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of\nthe interatrial septum. No ASD by 2D or color Doppler.\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\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis. Abnormal septal motion/position.\n\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thicknesses and cavity size are normal. There\nis mild regional left ventricular systolic dysfunction with septal\nhypokinesis. The right ventricular cavity is mildly dilated with mild global\nfree wall hypokinesis. There is abnormal septal motion/position. The aortic\nroot is moderately dilated at the sinus level. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild hypokinesis of the septum along with abnormal septal motion.\nMildly dilated and hypokinetic right ventricle. The interventricular septal\nmotion is abnormal and may be consistent with right ventricular volume\noverload. Mild mitral and tricuspid regurgitation. Dilated aortic sinus and\nascending aorta.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1027614,"text":", MED 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for new infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for new infiltrate\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change in the bilateral severe predominantly lower lobe opacification\n compared to the prior study.\n\n\n"},{"category":"Radiology","chartdate":"2199-07-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1028224,"text":" 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 9:18 AM\n Improved aeration of left mid lung zone.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 05:20\n\n INDICATION: Wegener's.\n\n COMPARISON: at 05:09\n\n FINDINGS:\n\n Compared to prior there is improved aeration of the left mid lung zone. The\n remainder of the study is unchanged with continued evidence of previously seen\n airspace disease. No PTX. Right CVL remains in place.\n\n IMPRESSION: Improved aeration of the left mid lung zone.\n\n\n"},{"category":"ECG","chartdate":"2199-07-21 00:00:00.000","description":"Report","row_id":224051,"text":"Atrial flutter with variable block. Non-specific repolarization abnormalities.\nIntraventricular conduction delay of right bundle-branch block type. Compared\nto the previous tracing of there is no significant difference.\n\n"},{"category":"ECG","chartdate":"2199-07-17 00:00:00.000","description":"Report","row_id":224052,"text":"Atrial flutter with rapid ventricular response. Right ventricular conduction\ndelay. Compared to the previous tracing of no diagnostic interim\nchange.\n\n"},{"category":"ECG","chartdate":"2199-07-15 00:00:00.000","description":"Report","row_id":224053,"text":"Atrial flutter\nModest right ventricular conduction delay\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2199-07-10 00:00:00.000","description":"Report","row_id":224054,"text":"Atrial flutter. Modest right ventricular conduction delay. Since the previous\ntracing of no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2199-07-09 00:00:00.000","description":"Report","row_id":224055,"text":"Atrial flutter. Modest right ventricular conduction delay. Since the previous\ntracing of no significant change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2199-07-07 00:00:00.000","description":"Report","row_id":224056,"text":"Atrial flutter with variable block. Incomplete right bundle-branch block.\nCompared to the previous tracing of A-V block is now irregular. The\nunderlying atrial rhythm continues to likely be counterclockwise flutter.\nThe other findings are similar.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2199-07-06 00:00:00.000","description":"Report","row_id":224057,"text":"Counterclockwise atrial flutter with 2:1 A-V block. Diffuse non-specific\nST-T wave changes likely secondary to rate. No previous tracing available for\ncomparison.\nTRACING #1\n\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Attending Progress Note","row_id":333538,"text":"Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. Maculopapular rash resolved.\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent:\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333555,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333655,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in a-flutter (baseline since arrival to OSH per report). RVR\n to 130\ns. BP remains stable.\n Action:\n Monitoring HR, rhythm and hemodynamic status closely. Lopressor\n increased to 25mg PO TID.\n Response:\n HR better controlled on increased lopressor (110-115). Continues in\n a-flutter. BP remains stable.\n Plan:\n Continue to monitor cardiac and hemodynamic status closely. Continue\n lopressor as ordered.\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333454,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\n Action:\n Observing u/o and labs. Will consult renal in am and follow\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\n start sevelamer in the am.\n Response:\n pending\n Plan:\n Renal will consult in the am. Will draw am labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\n Response:\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\n with crackles\n way up.\n Plan:\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\n monitor sao2 and provide o2 as needed.\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333642,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333643,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333496,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 1\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///17/\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 513 K/uL\n 9.0 g/dL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-08 00:00:00.000","description":"Nursing Progress Note","row_id":333711,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx. Pt was adm on .\n Atrial flutter (Aflutter)\n Assessment:\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\n the high 120-130 range during plasmapharesis. B/P has remained stable\n 110/78-132/69.\n Action:\n Lopressor was increased to 50mg tid which was started last evening.\n Response:\n H/R is decreasing from the 100\ns to the 80-90range.\n Plan:\n Cont with tid lopressor. Monitor h/r and pattern.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\n Action:\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\n past 24 hours pt has had 2 doses of Kayexalate.\n Response:\n K+ is 4. U/O improving with urine more yellow. Last creat 8.5 with bun\n 147\n Plan:\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\n lungs have had crackles bil bases with the left lung more dim than the\n right..\n Action:\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\n evening and was given cytoxan after the plasmaphoresis. Pt is also\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\n Response:\n Sao2 drops to the high 80\ns while pt wears only the n/c. pt does not\n like to wear face mask and denies any sob.\n Plan:\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\n plasmaphoresis again on Tues.\n"},{"category":"Physician ","chartdate":"2199-07-08 00:00:00.000","description":"Physician Attending Progress Note","row_id":333805,"text":"Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. MacPap rash resolving\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n MICU Attending Addendum\n Pt seen with fellow and examined. Met with pt and family to review\n situation. Would add and emphasize the following to Dr \ns notes.\n On exam\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\n alos right forearm.\n ABG 7.31/37/67\n BUN 147/ Cr 9.6\n CXR: diffsue bilateral interstitial and alveolar infiltrates\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\n and renal failure quite concerning for vasculitis.\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\n Role of plasmapheresis without clear diagnosis is challenging. Will\n consult with Renal collegues on possibility of a renal biopsy to aid in\n diagnosis. Additionally he is moving towards dialysis, need to closely\n watch K, renally dose all meds. His resp status is tenusous due to\n hypoxemia as well as met acidosis and uremic encephalopathy- may\n require intubation for support\n would likely favor this over NIPPV\n given likely duration.\n Discussed with son who is HCP and updated.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent: Critically Ill 50 min\n ------ Protected Section ------\n MICU Attending Addendum\n Updated note on events from . In the course of the afternoon, I\n spent over 2 hours working with both the renal consultation team and Dr\n and the Plasmapheresis team determining indication and timing of\n pheresis for possible anti GBM. We were able to update family, call in\n pheresis team, and place pheresis catheter all to facilitate. Pt with\n progressive hypoxemia and on NRB\n ongoing frequent labs to assess HCT,\n also borderline indication for HD due to progressive encephalopathy,\n boerdeline hyperK and acidosis.\n Time Spent 120 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:22 ------\n"},{"category":"Physician ","chartdate":"2199-07-08 00:00:00.000","description":"Physician Attending Progress Note","row_id":333807,"text":"Chief Complaint: Respiratory distress/hypoxemia\n HPI:\n 24 Hour Events:\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\n Renal consultation concurred with Pulmonary-Renal syndrome.\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\n anticipating 5 days of treatment. Remains on cortocosteroids.\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\n Denies increased dyspnea, but remains with oxygen requirement.\n History obtained from Patient\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.3\nC (95.5\n HR: 81 (81 - 133) bpm\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\n RR: 24 (22 - 29) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 186 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 186 mL\n Blood products:\n Total out:\n 1,330 mL\n 690 mL\n Urine:\n 1,330 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -504 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\n mildly disshevled\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 355 K/uL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\n predominantly basilar. Right IJ catheter position acceptable. No\n significant overall change compared to .\n Assessment and Plan\n 60 yom now with Pulmonary-Renal syndrome.\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\n diffuse infiltrates and oxygen requirement.\n HYPOXEMIA -- attributed to pulmonary infiltrates.\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\n SaO2.\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\n consult prepared to move to dialysis when indicated. Monitor urine\n output, BUN, Creatitine.\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\n Continue steroids and plasmaphoresis.\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\n FLUIDS -- limit iv fluids intake.\n HYPERPHOSPHATEMIA -- start phosphate binder.\n NUTRITION -- NPO pending evaluation\n ANEMIA -- progressive, attributed to underlying process, and possible\n contribution from RIJ central line placement. Transfuse to Hct >21.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2199-07-08 00:00:00.000","description":"Respiratory Care Shift Note","row_id":333895,"text":"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 Comments:\n Pt currently on 6L NC. Pt ordered for albuterol and Atrovent nebs Q6.\n Nebs given as ordered and pt tolerated them well.\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Admission Note","row_id":333425,"text":"Chief Complaint: Bilateral LE edema, SOB\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy.\n .\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptons started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n .\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\n noted as having mild wheezing and productive cough of white sputum.\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\n Occult blood stool negative. U/A significant for protein 400mg/dl,\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\n microscopy positive for RBCs, granular casts.\n .\n Pt was seen by Renal, who thought there might possibly be a\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\n .\n CXR on admission showed underlying COPD with diffuse bilateral\n pulmonary infiltrates.\n Pt underwent bronchoscopy on , and was found to have active low\n grade blood emanating from the RLL and LLL.\n .\n EKG on admission showed atrial flutter at 2:1 block rate 150.\n .\n On arrival here, pt appeared mildly tachypneic. He reported that LE\n edema had improved, and that pain had resolved in LE. He complained of\n only mild nausea recently without vomiting, and a productive cough.\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\n constipation, melena, hematochezia, chest pain, urinary\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\n no epistaxis. Last BM was yesterday, and was formed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 12:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 107 (107 - 122) bpm\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 48 mL\n PO:\n 230 mL\n TF:\n IVF:\n 48 mL\n Blood products:\n Total out:\n 475 mL\n 100 mL\n Urine:\n 125 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -52 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///16/\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 543 K/uL\n 219 mg/dL\n 9.7 mg/dL\n 144 mg/dL\n 16 mEq/L\n 107 mEq/L\n 6.2 mEq/L\n 143 mEq/L\n 31.0 %\n [image002.jpg]\n \n 2:33 A8/9/ 11:05 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 Hct\n 31.0\n Plt\n 543\n Cr\n 9.7\n Glucose\n 219\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\n mg/dL, PO4:9.6 mg/dL\n Assessment and Plan\n ABG: ///16/\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"General","chartdate":"2199-07-07 00:00:00.000","description":"ICU Event Note","row_id":333422,"text":"Clinician: Attending\n 60 yo male without significant medical history now admit to OSA with\n lower extremity edema x 2 weeks. His presentation there was notable\n for severe acute renal failure and with diffuse alveolar infiltrates.\n The findings at the OSA were consistent with acute GN based upon review\n of the urine sediment. In addition, patient did have bronchoscopy\n revealing a strong suggestion of alveolar hemorrhage with sequential\n lavage showing persistent bloody fluid. There was no hemoptysis noted.\n U/A there--RBC's and granular casts documented.\n There he has had persistent renal failure and alveolar infiltrates and\n now with persistent tachycardia patient to ICU for further\n evaluation and care after solumedrol and cytoxan started at OSH.\n ROS-negative for sinusitis/sinus congestion\n Here patient has persistent sinus tachycardia noted,\n Exam notable for-->\n Patient comfortable by subjective description\n No JVD\n Lungs-Diffuse crackles bilaterally inferiorly and to mid lung zone.\n Heart-Tachycardic and regular rate suggested on initial exam\n Extremities--1+ bilateral lower extremity edema. Diffuse macular rash\n from foot to knee.\n Labs->\n Cr-9.6\n K-5.8\n HCO3-=18\n CXR->Patient with diffuse bilateral alveolar infiltrates--there is a\n suggestion of lower lobe distribution but with the complete absence of\n pleural effusions which is consistent with alveolar hemorrhage.\n ECG-Atrial Flutter seen with atrial rate at approx 300 bpm and\n ventricular rate of 125-150.\n In summary this is a 60 yo male with findings of acute renal failure\n with evidence of diffuse alveolar hemorrhage and active disease with\n ESR >140. No definative diagnostic procedure was preformed and serum\n testing, although sent, is all pending at this time. Patient did start\n Solumedrol and Cytoxan for empiric diagnosis of\n vasculitis with serologies pending. Goodpasteur's and Wegner's and\n microscopic polyangiitis and PAN all are on this list along with\n connective tissue disease.\n 1)Acute Renal Failure-\n -Significant concern for acute vasculitis\n -Given severity of dysfunction certainly intervention is desired in\n timely fashion\n -Would favor biopsy prior to intervention is patient remains stable\n enough to accept.\n -With Solumedrol and Cytoxan 1 dose given is challenging decision to\n consider hold of further treatment prior to biopsy.\n -Will consult renal for consideration of biopsy.\n -Given significant clinical decline and significant pulmonary\n distress--tachypnea and tachycardia--I would favor continuation of\n treatment already started given his subjective improvement over past 24\n hours. Although this will cloud the biopsy results his clinical status\n at this point in time is one that warrants intervention.\n -Continue Solumedrol 1g qd and Cytoxan to continue\n -Renal and Rheum to evaluate patient for aid in diagnosis and treatment\n -C3, C4, , Anti-GBM, ANCA all pending\n 2)Alevolar Hemorrhage--seen on OSH bronchoscopy, no biopsies performed\n -Continue with supportive care at this time\n -Will have to consider diagnostic procedure and consideration of renal\n biopsy may be highest yield\n -Attempt to maintain euvolemia as hydrostatic edema is of concern given\n signficiant volume overload but will be limited by renal failure and\n the distribution of infiltrates.\n 3)Atrial Flutter-\n Hold anticoagulation for bleeding risk\n Rate control as needed\n Will need TSH and ECHO in full evaluation\n 4)Anemia-\n Patient with reasonable stability with transfusion--may well be\n inadequate production with associated blood loss at this time--with the\n blood loss less active at this time.\n -F/u HCT\n -Monitor with OB for stool\n Total time spent: 45 minutes\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":333661,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - F/u on TSH\n - Surface ECHO in a.m. today\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n Addendum\n Anti-GBM test sent to Specialty Laboratories, 1, #4 to\n connect to lab. They will run this particular study on Tuesday, ^th, and result may become available ^th-15^th.\n PGY-1\n ------ Protected Section Addendum Entered By: , MD\n on: 19:28 ------\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"ICU Event Note","row_id":333670,"text":"Clinician: Attending\n Patient seen and examined. Plasmapharesis initiated this evening.\n Appears to be tolerating it well with no new complaints. Currently BP\n 130/70, HR 134, sat 94-97% on full face mask. No respiratory distress.\n Fine crackles heard laterally but otherwise lungs are relatively clear.\n Plan is for plasmapharesis, K to be rechecked. If necessary to be\n dialysed, renal will consider tonight. Cytoxan to be redosed at 140 mg\n IV, weight based at ~2 mg/kg for 67 kg. On Solumedrol 1 gm q24h x 3\n days. 30 min of CC time spent with patient.\n Total time spent: 30 minutes\n Patient is critically ill.\n"},{"category":"Respiratory ","chartdate":"2199-07-08 00:00:00.000","description":"Respiratory Care Shift Note","row_id":333725,"text":"Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Crackles\n Comments:\n Plan\n Pt presently on 3 lpm n/c and ordered for nebs alb/atr. Nebs\n administered as ordered with no adverse reactions.\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":335004,"text":"Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \n C-ANCA vasculitis. This morning, he breathing more easily, with stable\n lung exam though his CXR looks unchanged. This is likely due to\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\n 2+ budding yeast on sputum, without signs of candidiasis on\n oropharyngeal exam.\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\n urine output and restart IVF if necessary. We will balance maintaining\n urine output >100/hr for bladder protection with not giving too much\n Lasix due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n -Start nystatin mouthwash\n -Send blood cultures for fungus (though highly unlikely given pt. is\n afebrile, stable, but he is on high dose immunosuppression)\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - HCTq8h to monitor for alveolar bleeding. Given\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335152,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Attending Progress Note","row_id":334768,"text":"Chief Complaint: Hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirement.\n HR varies from A-flutter to NRS.\n Coughing up sputum (swallowing), but more productive cough today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 98 (85 - 131) bpm\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\n RR: 18 (12 - 25) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 1,971 mL\n PO:\n 750 mL\n 160 mL\n TF:\n IVF:\n 3,736 mL\n 1,811 mL\n Blood products:\n Total out:\n 2,400 mL\n 1,235 mL\n Urine:\n 2,400 mL\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 736 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\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, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 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, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 211 K/uL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\n Possible component of pulmonary edema.\n HYPOXEMIA -- attributed to pulmonary infiltrates. Continue\n supplemental oxygen, monitor RR, SaO2.\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\n steroids & cytoxan. Plasmaphoresis.\n RENAL FAILURE -- improving. Monitor uo, BUN, creatinine.\n FLUIDS\n desire to allow net diuresis. Consider Lasix dose.\n NUTRIONAL SUPPORT -- PO\n HEMATURIA -- stable. Monitor.\n ANEMIA -- stable s/p transfusion.\n HYPOCALCEMIA -- continue to replete.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 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: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-12 00:00:00.000","description":"Physician Resident Progress Note","row_id":334958,"text":"Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\n of breathing, with worsening lung exam and desating to the 70s without\n the facemask on. This is unlikely due to hemorrhage as his crit has\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\n and chest Xray appears to have signs of pulmonary edema, making volume\n overload the most likely cause of worsening pulmonary status.\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\n output >100/hr for bladder protection with not giving too much Lasix\n due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n Will examine his septum today as this could worsen his repiratory\n status and make him feel nasal congestion (which he has been\n complaining of)\n -CT of sinus has been recommended, will consider when patient more\n stable.\n - HCT has been stable, follow HCT q8h to monitor for alveolar\n bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-13 00:00:00.000","description":"Nursing Progress Note","row_id":335153,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334748,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Dx: Wegener\ns Granulomatosis confirmed by renal biopsy\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\n frequent episodes of tachycardia in the 130\ns, typically with exertion,\n stimulation and desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows to the 80-90\ns with rest, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered. Encourage rest periods\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.5, BUN 153\n Action:\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\n Creatinine is trending down. Hct drawn at 1530, results pending.\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\n with meals. Lunch held due to respiratory distress.\n Response:\n Labs to be drawn 4 hours after plasmaphoresis and tonight at 2200.\n Fluid balance remains positive. Good urine output response to lasix.\n Tolerated plasmaphoresis with episodes of tachycardia.\n Plan:\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\n total of 7 treatments via right IJ HD catheter. Administer mesna as\n ordered with chemo. Chemo to be given after plasmaphoresis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n strong productive cough. Patient\ns O2 requirements increasing\n throughout the day.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 95% and\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\n albuterol changed to prn (may be contributing to tachycardia). Afrin\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\n on.\n Response:\n Oxygenation remains labile. Desats with eating and removal the face\n tent. Recovery time longer each time he desats.\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\n sputum sample. Patient may need a sinus CT scan if stable. Administer\n neb treatments as ordered.\n Patient\ns family at bedside. Updated on plan of care.\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":334749,"text":"Chief Complaint:\n 24 Hour Events:\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\n edema, 2L fluids up. Did not receive cytoxan yesterday. Will receive\n it after pheresis today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\n of breathing, with worsening lung exam and desating to the 70s without\n the facemask on. This is unlikely due to hemorrhage as his crit has\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\n and chest Xray appears to have signs of pulmonary edema, making volume\n overload the most likely cause of worsening pulmonary status.\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\n output >100/hr for bladder protection with not giving too much Lasix\n due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n Will examine his septum today as this could worsen his repiratory\n status and make him feel nasal congestion (which he has been\n complaining of)\n -CT of sinus has been recommended, will consider when patient more\n stable.\n - HCT has been stable, follow HCT q8h to monitor for alveolar\n bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-12 00:00:00.000","description":"Nursing Progress Note","row_id":335073,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with Wegener\ns granulocytosis with Hx. Of pulmonary hemorrhage per\n bronch at OSH. On 80% face tent and 6L NC. LS diminished. Occ congested\n non-productive cough. No hemoptesis this shift.\n Action:\n Plasmapherisis today. Cont. O2 for O2 sat >90%. HOB >45 degrees.\n Atrovent neb as ordered. Started on Nyastatin swish and spit for yeast\n in sputum cx on .\n Response:\n O2 sat 92-98%. Occ will desat to 86% when mask falls down or when\n eating.\n Plan:\n Cont. current treatment. Monitor resp. status and wean O2 as tolerated.\n F/u sputum cx.\n Plasmapherisis today. Nest treatment on Monday. Transfused today with\n one unit of PRBC for Hct. 21.6. Will need serial Hct. Checks starting\n after transfusion.\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Attending Progress Note","row_id":334190,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Blood loss due to pulmonary hemorrhage and\n renal bx likely contributing. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2199-07-09 00:00:00.000","description":"Respiratory Care Shift Note","row_id":334197,"text":"Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Crackles\n Comments:\n Pt currently on 6L NC. Nebs given as ordered with no adverse reaction.\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333491,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\n Action:\n Observing u/o and labs. Will consult renal in am and follow\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\n start sevelamer in the am.\n Response:\n Pending. Creat 9.2 this am\n Plan:\n Renal will consult in the am. Will draw am labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\n Response:\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\n with crackles\n way up.\n Plan:\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\n monitor sao2 and provide o2 as needed.\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":333972,"text":"This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n na.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":333970,"text":"This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":334155,"text":"Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\n for presumed Wegeners.\n 24 Hour Events:\n Continues to have increasing 02 requirement, on 6L and facemask to keep\n 02 >90%. Yesterday he had a renal biopsy, TTE, given d5W for\n hypernatremia and seen by rheumatology.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\n likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily (will change to prednisone tomorrow per\n rheumatology)\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok. BUN continues to increase, but BUN\n often stays elevated in acute renal failure after the kidneys have\n started to improve, also the patient is on high dose steroids which can\n increase BUN. As a note, plasmapheresis in cases of severe Wegeners\n has been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday, awaiting results. Monitor for bleeding at\n site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Will try to maintain\n 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim due to renal function, patient should be\n discharged on Atovaqone.\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is taking PO, D/C D5W.\n -if needed, restart fluids to maintain UOP 100cc/hr (to prevent hem.\n cystitis while on cytoxan)\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am),\n -lytes q6hrs\n -EKG\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT , give 1unit today\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":334025,"text":"This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n Na.\n Response:\n Phos still high,Na 141 this am.BUN and creatinine trending down.\n Plan:\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\n Hct this am 21.1.?for transfusion.\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Resident Progress Note","row_id":334369,"text":"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required ?? 02. Got pheresis yesterday, solumedrom and\n cyclophosphamide. No hematuria. Talked to renal about biopsy, c/w\n Wegners. Has been on IVF to keep uop >100, successfully. Tolerating\n PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 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 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\n likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6,up to 8.1 then back down to 7.1. BUN\n peaked at 160 now, 150. No signs of platelet dysfunction yet, mental\n status ok. Renal will give his kidneys about 48 more hours to turn\n around before dialyzing. As a note, plasmapheresis in cases of severe\n Wegeners has been shown to improve kidney outcomes, though not\n mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Resident Progress Note","row_id":334116,"text":"Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\n for presumed Wegeners.\n 24 Hour Events:\n Continues to have increasing 02 requirement, on 6L and facemask to keep\n 02 >90%. Yesterday he had a renal biopsy, TTE, put on\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - also treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily\n -Cyclophosphamide 140mg\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok.\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\n However, apart from pulmonary association, ddx for acute renal failure\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\n Also consider DIC.\n - Renal biopsy yesterday, awaiting results\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is eating, can D/C D5W.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am), check again this PM\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6, given HCT , likely need blood this pm.\n - Type and screen, cross-matched\n - Blood consent obtained\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Attending Progress Note","row_id":334121,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-07 00:00:00.000","description":"Nursing Progress Note","row_id":333431,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Renal will consult in the am.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Resident Admission Note","row_id":333432,"text":"Chief Complaint: Bilateral LE edema, SOB\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy.\n .\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptons started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n .\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\n noted as having mild wheezing and productive cough of white sputum.\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\n Occult blood stool negative. U/A significant for protein 400mg/dl,\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\n microscopy positive for RBCs, granular casts.\n .\n Pt was seen by Renal, who thought there might possibly be a\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\n .\n CXR on admission showed underlying COPD with diffuse bilateral\n pulmonary infiltrates.\n Pt underwent bronchoscopy on , and was found to have active low\n grade blood emanating from the RLL and LLL.\n .\n EKG on admission showed atrial flutter at 2:1 block rate 150.\n .\n On arrival here, pt appeared mildly tachypneic. He reported that LE\n edema had improved, and that pain had resolved in LE. He complained of\n only mild nausea recently without vomiting, and a productive cough.\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\n constipation, melena, hematochezia, chest pain, urinary\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\n no epistaxis. Last BM was yesterday, and was formed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home medications:\n NONE\n Allergies:\n NKDA\n Past medical history:\n Family history:\n Social History:\n ?Nephrolithiasis ()- blood found in urine after workup for lower\n abdominal pain, no stones passed, 24hr protein done whith was normal\n per pt.\n Finger laceration ()\n Mother passed from CVA in 80s. Father passed in 70s from unknown cause.\n Twin brother passed from MI, another brother with hx cardiac artery\n bypass graft. Denies family hx renal or pulmonary disease.\n Pt works full-time as a machine operator. Mostly stationary job.\n Divorced, college-age son lives with wife. Lives alone.\n Smoked 1-1/2 ppd until when he quit (possibly 50 pack year hx\n prior). Drinks ~2 drinks/day, and on social occasions. Denies other\n drug use.\n Review of systems: He complained of only mild nausea recently without\n vomiting, and a productive cough. Otherwise denies sore throat, fevers,\n chills, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, urinary frequency/urgency, dysuria, lightheadedness, vision\n changes, headache, no epistaxis.\n Flowsheet Data as of 12:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 107 (107 - 122) bpm\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 48 mL\n PO:\n 230 mL\n TF:\n IVF:\n 48 mL\n Blood products:\n Total out:\n 475 mL\n 100 mL\n Urine:\n 125 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -52 mL\n Respiratory\n O2 Delivery Device: Nasal cannula 3L\n SpO2: 91%\n Physical Examination\n GEN: Thin, pale, mildly distressed, tachypneic\n HEENT: EOMI, PERRL, sclera anicteric, conjunctiva pale, no epistaxis or\n rhinorrhea, dry MM, OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, shotty anterior cervical\n lymphadenopathy, trachea midline\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: diffuse rhonchi/crackles bilaterally almost to apices\n ABD: Soft, NT, ND, +BS, +hepatomegaly (four finger-breaths below costal\n margin)\n EXT: +1pitting edema lower extremities bilaterally, no palpable cords,\n no cyanosis/clubbing, diffuse faint non-pruritic macular rash from feet\n -> knees\n NEURO: alert, oriented to person, place, and time. CN II\n XII grossly\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\n extremities. Patellar DTR +1. Plantar reflex downgoing. No gait\n disturbance. No cerebellar dysfunction.\n SKIN: Diffuse macular rash in LE bilaterally from feet -> kness,\n scattered telangiectasias in malar area of face\n Labs / Radiology\n 543 K/uL\n 219 mg/dL\n 9.7 mg/dL\n 144 mg/dL\n 16 mEq/L\n 107 mEq/L\n 6.2 mEq/L\n 143 mEq/L\n 31.0 %\n [image002.jpg]\n CXR : bilateral fluffy pulmonary infiltrates, costophrenic angles\n visible (pending read by radiology)\n EKG : similar to prior EKG from OSH, with atrial flutter\n predominantly in limb leads, rate 121\n \n 2:33 A8/9/ 11:05 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 Hct\n 31.0\n Plt\n 543\n Cr\n 9.7\n Glucose\n 219\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\n mg/dL, PO4:9.6** mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - Daily CXR's\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's.\n - Re-check u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - Check TSH\n - Surface ECHO in a.m.\n - Will start Lopressor 12.5mg PO daily for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control: RISS\n Lines: 2 PIVs\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Pantoprazole PO\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":334007,"text":"This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n Na.\n Response:\n Phos still high,Na 141 thos am.\n Plan:\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\n"},{"category":"Physician ","chartdate":"2199-07-09 00:00:00.000","description":"Physician Attending Progress Note","row_id":334102,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334581,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334584,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continusly pulling the mask off inspite of frequently remainding\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\n mask off,denies any SOB,pain or discomfort.\n Action:\n On nebs and steroids,FM 60 % and additional NC is on,frequent\n reinforcement needed about need for oxygen.\n Response:\n Pt strongly denies for any pain,SOB\n Plan:\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":334644,"text":"Chief Complaint:\n 24 Hour Events:\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\n edema, 2L fluids up.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR.\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\n appropriately to 1unit PRBCs so likely not currently bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Prednison po daily,\n -Cyclophosphamide-dose to be determined after c/s with rheum and\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\n far.\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: Monitoring for need for dialysis, has line in\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\n signs of platelet dysfunction yet, mental status ok. Renal will give\n his kidneys about 48 more hours to turn around before dialyzing. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -pink tinged urine, stable, but will send daily U/As.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiacc negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334799,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Dx: Wegener\ns Granulomatosis confirmed by renal biopsy\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\n frequent episodes of tachycardia in the 130\ns, typically with exertion,\n stimulation and desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows to the 80-90\ns with rest, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered. Encourage rest periods\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.5, BUN 153\n Action:\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\n Creatinine is trending down. Hct drawn at 1530, result 24.\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\n with meals. Lunch held due to respiratory distress.\n Response:\n Labs to be drawn 8pm (4 hours after plasmaphoresis) and tonight at 2200\n (check with team). Fluid balance remains positive. Good urine output\n response to lasix. Tolerated plasmaphoresis with episodes of\n tachycardia.\n Plan:\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\n total of 7 treatments via right IJ HD catheter. Administer mesna as\n ordered with chemo. Chemo to be given after plasmaphoresis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n strong productive cough. Patient\ns O2 requirements increasing\n throughout the day.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 80% and\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\n albuterol changed to prn (may be contributing to tachycardia). Afrin\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\n on.\n Response:\n Oxygenation remains labile. Desats with eating and removal the face\n tent. Recovery time longer each time he desats. Left lung sounds better\n than this am.\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\n sputum sample. Patient may need a sinus CT scan if stable. Administer\n neb treatments as ordered.\n Patient\ns family at bedside. Updated on plan of care.\n"},{"category":"Physician ","chartdate":"2199-07-07 00:00:00.000","description":"Physician Attending Progress Note","row_id":333590,"text":"Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. MacPap rash resolving\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n MICU Attending Addendum\n Pt seen with fellow and examined. Met with pt and family to review\n situation. Would add and emphasize the following to Dr \ns notes.\n On exam\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\n alos right forearm.\n ABG 7.31/37/67\n BUN 147/ Cr 9.6\n CXR: diffsue bilateral interstitial and alveolar infiltrates\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\n and renal failure quite concerning for vasculitis.\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\n Role of plasmapheresis without clear diagnosis is challenging. Will\n consult with Renal collegues on possibility of a renal biopsy to aid in\n diagnosis. Additionally he is moving towards dialysis, need to closely\n watch K, renally dose all meds. His resp status is tenusous due to\n hypoxemia as well as met acidosis and uremic encephalopathy- may\n require intubation for support\n would likely favor this over NIPPV\n given likely duration.\n Discussed with son who is HCP and updated.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent: Critically Ill 50 min\n"},{"category":"Nursing","chartdate":"2199-07-09 00:00:00.000","description":"Nursing Progress Note","row_id":334220,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s occationally going to\n the 120s-130s\n Action:\n Conts on lopressor 50mg TID\n Response:\n HR was fairly well controlled though does have episodes of tachycardia\n in the setting of eating or low SATs\n Plan:\n Cont with the lopressor, follow VS, replete lytes\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat remains high, it was 7.6 this morning and 8.0 this afternoon.\n Calcium conts to be low as well as mag\n Action:\n Received 4 gms of calcium this morning and had a repeat ionized Ca of\n .86, he is presently receiving another 4 gms of Ca and 2 gm of MgS04.\n He is also receiving NS at 100cc/hr to try and protect his bladder from\n the cytoxan, to receive cytoxan again tonight\n Response:\n Creat bumped this afternoon, u/o 70-30cc/hr, conts with low Ca with his\n pheresis\n Plan:\n Presently being pheresed, to get cytoxan tonight\n this needs to be\n arranged with the 7Feldberg nurses, follow ionized Ca, creat, f/u on\n the renal biopsy from yest.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi and wheezes, 02 SAT has improved today from yest with\n an 02 SAT ~ 93% on 6 L NC, he states that he feels a little better\n today. Occationally has a wet cough but not bringing anything up.\n Action:\n Tolerating a lower FI02\n Response:\n Plan:\n Cont to follow 02 requirements, decrease the FI02 as he tolerates,\n started on mepron for PCP prophylaxis\n the bactrim was d/ced due to\n his renal failure\n"},{"category":"Physician ","chartdate":"2199-07-11 00:00:00.000","description":"Physician Resident Progress Note","row_id":334640,"text":"Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Nursing","chartdate":"2199-07-11 00:00:00.000","description":"Nursing Progress Note","row_id":334646,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continuesly pulling the mask off inspite of frequently remainding\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\n mask off,denies any SOB,pain or discomfort.\n Action:\n On nebs and steroids,FM 60 % and additional NC is on,frequent\n reinforcement needed about need for oxygen.\n Response:\n Pt strongly denies for any pain,SOB but continued to be uncomfortable\n during night,MD was informed.No meds ordered at this time.\n Plan:\n Continue to monitor resp status,follow up AM lab results,bleeding time\n should be drawn by lab at AM.\n"},{"category":"Nursing","chartdate":"2199-07-08 00:00:00.000","description":"Nursing Progress Note","row_id":333752,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx. Pt was adm on .\n Atrial flutter (Aflutter)\n Assessment:\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\n the high 120-130 range during plasmapharesis. B/P has remained stable\n 110/78-132/69.\n Action:\n Lopressor was increased to 50mg tid which was started last evening.\n Response:\n H/R is decreasing from the 100\ns to the 80-90range.\n Plan:\n Cont with tid lopressor. Monitor h/r and pattern.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\n Action:\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\n past 24 hours pt has had 2 doses of Kayexalate. Will not repleat K+ of\n 3.9 this am as pt rises.\n Response:\n K+ is 4. U/O improving with urine more yellow. Creat 8.6/bun149 this\n am.\n Plan:\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\n lungs have had crackles bil bases with the left lung more dim than the\n right..\n Action:\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\n evening and was given cytoxan after the plasmaphoresis. Pt is also\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\n Response:\n Sao2 drops to the high 80\ns while pt wears only the n/c. pt does not\n like to wear face mask and denies any sob.\n Plan:\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\n plasmaphoresis again on Tues.\n Hct 22.8 this am and team would like to discuss in rounds as to further\n transfusions. Team wants Hct drawn at 0800. pt will also receive\n calcium gluconate 4gm to replenish 5.9. Na+ 150. Phos 9.5\n"},{"category":"Nursing","chartdate":"2199-07-08 00:00:00.000","description":"Nursing Progress Note","row_id":333876,"text":"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s\n Action:\n Conts on lopressor 50mg TID\n Response:\n Tolerating the lopressor, he did have short periods of a HR in the\n 1teens this afternoon\n Plan:\n Cont with the lopressor, follow VS\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat was 8.6 this morning, u/o has been 40-50cc/hr\n Action:\n Pt had a renal biopsy this morning under US guidance, receiving D5W\n 100cc/hr for 1 liter for a Na of 150\n Response:\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\n Plan:\n Follow HCT, VS, renal bx results, no immediate plans for dialysis,\n follow labs\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\n has not been coughing up any blood\n Action:\n He is on scoop mask at 60-70% and this brings his 02 up to 93-99%.\n Response:\n Conts to require a high FI02, he wants to eat but is NPO due to his\n tenuous resp status\n Plan:\n Follow SATs cont to try to wean his FI02\n"},{"category":"Physician ","chartdate":"2199-07-10 00:00:00.000","description":"Physician Attending Progress Note","row_id":334483,"text":"Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirment.\n Renal bx consistent with Wegener's Granulomatosis.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.9\nC (96.6\n HR: 99 (87 - 130) bpm\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\n RR: 21 (9 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,477 mL\n 2,103 mL\n PO:\n 60 mL\n TF:\n IVF:\n 2,102 mL\n 2,043 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 1,025 mL\n Urine:\n 1,360 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,117 mL\n 1,078 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 221 K/uL\n 94 mg/dL\n 7.2 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 149 mg/dL\n 105 mEq/L\n 145 mEq/L\n 22.7 %\n 9.0 K/uL\n [image002.jpg]\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n WBC\n 8.1\n 5.4\n 9.0\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n Plt\n 355\n 261\n 221\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n 94\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\n likey due to vasculitis. Radiographically without significant change,\n but hope to see improvement over next several days. Monitor RR, SaO2.\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\n improve.\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\n plts). Monitor Hct, transfuse to > 21\n WEGENER\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\n plasmaphoresis QOD.\n FLUIDS -- euvolemic. Monitor I/O\n HEMATURIA -- concern for hemorrhagic cystitis\n A-FIB -- good rate control COntinue meds. Monitor HR.\n NASAL CONGESTION -- possible related to Wegener's but more likely due\n to high flow O2. Symptomaatic relief.\n HYPOCALCEMIA -- repleted. Monitor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Physician ","chartdate":"2199-07-08 00:00:00.000","description":"Physician Resident Progress Note","row_id":333854,"text":"Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight the patient remained stable, but continuing to require O2 by\n NC and facemask. HR down to 80s with lopressor but remains in\n aflutter. This am patient only c/o hunger.\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\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 01:53 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: 35.2\nC (95.3\n HR: 94 (72 - 133) bpm\n BP: 109/58(70) {104/53(66) - 142/88(102)} mmHg\n RR: 25 (18 - 29) insp/min\n SpO2: 88%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 1,042 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 485 mL\n Blood products:\n 557 mL\n Total out:\n 1,330 mL\n 1,080 mL\n Urine:\n 1,330 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -38 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 88%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No acute distress\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral, almost \n way up lungs posteriorly)\n Extremities: Right: 1+ pitting, Left: 1+ pitting,, diffuse rash below\n knees\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 355 K/uL\n 7.6 g/dL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. Concern given\n recent HCT drop. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Figure out exact 02 requirement (patient on facemask, not always\n wearing it)\n - Albuterol nebs PRN\n - repeat CXR\n - F/u on BAL results from OSH\n - Continue to keep patient NPO due to tentative respiratory status (and\n renal biopsy).\n (see t'ment plan for presumed Wegener's under acute renal failure)\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on was 126/9.6, K 5.8. Nephritic\n picture with RBC casts. However, apart from pulmonary association, ddx\n for acute renal failure with nephritis includes PSGN, lupus nephritis,\n etc. ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - Renal biopsy today, FFP on call due to INR 1.5\n - For presumed Wegeners, started Plasmapheresis (firs tt'ment last\n night, will be QOD x 5 treatments)\n - Continue Solumedrol 1g IV daily\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Continue Sevelemer in a.m. with meals for elevated Phos.\n - Renal c/s recommends also starting Amphagel (phosphate binder) 30cc\n po tid for 2-3 days for elevated Phos.\n #Hypernatremia: NA+ today 150, up from 147, likely lack of access\n to free water\n -Replace w/ D5NS\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+\n # Tachycardia: Aflutter on EKG. Until yesterday, was asymptomatic but\n rate in 120s. Can be secondary to underlying structural heart disease.\n Also may be secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - F/u on TSH\n - TTE today\n - Lopressor titrated up to 50 mg PO tid with good rate control (HR in\n 80s).\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: NPO for worsening respiratory status, anticipating intubation.\n Will replete lytes PRN.\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Case Management ","chartdate":"2199-07-08 00:00:00.000","description":"Case Managment Initial Patient Assessment","row_id":333828,"text":"Insurance information\n Primary insurance: OOS PPO-NON MANAGED CARE\n Secondary insurance: SELF PAY\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None prior to admission\n DME / Home O[2]: None prior to admission\n Functional Status / Home / Family Assessment:\n Pt. Lives alone in . He is divorced . He has a son who\n lives with the patient's ex-wife. PTA he was working and independent\n with all ADL's\n Primary Contact(s): (son) \n Health Care Proxy: .\n Dialysis: No\n Referrals Recommended: Social Work, Physical Therapy\n Current plan: Undetermined\n Unclear what level of services will be required at discharge. Case\n Management will follow for DC needs.\n If VNA services needed can use:\n VNA of SE Mass - \n - \n Centrus Premier Home Care - \n Patient (s) to Discharge:\n Medically unstable\n Patient discussed with multidisciplinary team: No\n"},{"category":"Physician ","chartdate":"2199-07-08 00:00:00.000","description":"Physician Attending Progress Note","row_id":333866,"text":"Chief Complaint: Respiratory distress/hypoxemia\n HPI:\n 24 Hour Events:\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\n Renal consultation concurred with Pulmonary-Renal syndrome.\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\n anticipating 5 days of treatment. Remains on cortocosteroids.\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\n Denies increased dyspnea, but remains with oxygen requirement.\n History obtained from Patient\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.3\nC (95.5\n HR: 81 (81 - 133) bpm\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\n RR: 24 (22 - 29) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 186 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 186 mL\n Blood products:\n Total out:\n 1,330 mL\n 690 mL\n Urine:\n 1,330 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -504 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\n mildly disshevled\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 355 K/uL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\n predominantly basilar. Right IJ catheter position acceptable. No\n significant overall change compared to .\n Assessment and Plan\n 60 yom now with Pulmonary-Renal syndrome.\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\n diffuse infiltrates and oxygen requirement.\n HYPOXEMIA -- attributed to pulmonary infiltrates. Monitor SaO2,\n supplimental O2 to maintain SaO2 >90%.\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\n SaO2.\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\n consult prepared to move to dialysis when indicated. Monitor urine\n output, BUN, Creatitine.\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\n Continue steroids and plasmaphoresis.\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\n FLUIDS -- limit iv fluids intake.\n HYPERPHOSPHATEMIA -- start phosphate binder.\n NUTRITION -- NPO pending evaluation\n ANEMIA -- progressive, attributed to underlying process, and possible\n contribution from RIJ central line placement. Transfuse to Hct >21.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2199-07-10 00:00:00.000","description":"Nursing Progress Note","row_id":334546,"text":"This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\n has episodes of tachycardia in the 130\ns, typically with exertion or\n desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows with NSR episodes, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.9, BUN 149\n Action:\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\n administration of cyclophosphamide (chemo)\n Response:\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\n since midnight.\n Plan:\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\n HD catheter, may have it . Administer mesna as ordered with chemo\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n weak cough. +1.6L positive. Patient would frequently remove face tent,\n thus dropping O2 sats.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\n 6L NC. Patient encouraged to cough and deep breathe. Neb treatments as\n ordered\n Response:\n Oxygenation has improved throughout the afternoon with patient\ns family\n at the bedside\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing.\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335302,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n Continues to require supplimental oxygen, desaturates with activity.\\n Tolerating net diuresis.\\n Hemoptysis resolved.\\n Overall, states to feel improved. Dysnpea improved. Able to sleep\\n somewhat last PM (improvement).\\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 11:10 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.3\\nC (97.4\\n HR: 98 (86 - 128) bpm\\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\\n RR: 25 (11 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,945 mL\\n 560 mL\\n PO:\\n 980 mL\\n 360 mL\\n TF:\\n IVF:\\n 319 mL\\n 200 mL\\n Blood products:\\n 646 mL\\n Total out:\\n 4,410 mL\\n 960 mL\\n Urine:\\n 4,410 mL\\n 960 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,465 mL\\n -400 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 94%\\n ABG: ///31/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.8 g/dL\\n 170 K/uL\\n 79 mg/dL\\n 5.2 mg/dL\\n 31 mEq/L\\n 3.5 mEq/L\\n 147 mg/dL\\n 101 mEq/L\\n 144 mEq/L\\n 22.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n 11.0\\n Hct\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n Plt\\n 221\\n 211\\n 185\\n 170\\n Cr\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n Glucose\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\\n Imaging: CXR () somewhat improved, esp. right lung field.\\n Assessment and Plan\\n Wegener's Granulomatosis\\n RESPIRATORY DISTRESS -- slow improvement clincally and\\n radiographically, although clinically best tody. Continue current\\n management. Provide supplemental oxygen, monitor SaO2, maintain >90%.\\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\\n urine output. No indication for acute dialysis at this time.\\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\\n Continue steoids, cytoxan, plasmaphoresis (total 7 treatments)\\n NUTRITIONAL SUPPORT\\n encourage PO.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335452,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding.\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335453,\n \"text\": \"Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding.\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335455,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Labs obtained in a.m\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding. Scheduled nebs given\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.,\\n continue with neb Rx, wean O2 as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335456,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding. Scheduled nebs given\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.,\\n continue with neb Rx, wean O2 as tolerated.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Renal parameters trending down\\n Action:\\n Diuresed this p.m with 20 lasix,\\n Response:\\n Good response to lasix, negative 770 by midnight\\n Plan:\\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335620,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Patient desats to 85 when FM falls off\\n Did well O/N\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 06:10 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.1\\nC (96.9\\n HR: 108 (91 - 135) bpm\\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\\n RR: 19 (11 - 26) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,690 mL\\n 190 mL\\n PO:\\n 1,220 mL\\n 120 mL\\n TF:\\n IVF:\\n 470 mL\\n 70 mL\\n Blood products:\\n Total out:\\n 2,465 mL\\n 900 mL\\n Urine:\\n 2,465 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -775 mL\\n -710 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///29/\\n Physical Examination\\n Gen- NAD, Aox3\\n CV- Tachy but reg rhythm, No M/R/G\\n Pulm- Decreased breath sounds at bases, crackles to mid lung fields\\n Abd- Soft, NT/ND, BS +\\n Extr- No edema, Puleses 2+symmetric\\n Labs / Radiology\\n 200 K/uL\\n 8.2 g/dL\\n 117 mg/dL\\n 5.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 148 mg/dL\\n 100 mEq/L\\n 140 mEq/L\\n 24.0 %\\n 12.2 K/uL\\n [image002.jpg]\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n Hct\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n Plt\\n 00\\n Cr\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n Glucose\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT down today, unlikely due to alveolar imprroving respiratory\\n status, no hemoptysis. Continue to monitor\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Albuterol nebs PRN\\n - CXR daily\\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. As a note,\\n plasmapheresis in cases of severe Wegeners has been shown to improve\\n kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Asymptomatic, rate increases when active/talking,\\n normal when sleeping. ECHO showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n He received 1 unit yesterday and bumped appropriately.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335606,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n No new events.\\n Revieved 1 U PRBC transfusion, tolerated well.\\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 Furosemide (Lasix) - 06:10 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:08 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 122 (97 - 135) bpm\\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,690 mL\\n 477 mL\\n PO:\\n 1,220 mL\\n 360 mL\\n TF:\\n IVF:\\n 470 mL\\n 117 mL\\n Blood products:\\n Total out:\\n 2,465 mL\\n 1,540 mL\\n Urine:\\n 2,465 mL\\n 1,540 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -775 mL\\n -1,063 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, Face tent\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 8.2 g/dL\\n 200 K/uL\\n 117 mg/dL\\n 5.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 148 mg/dL\\n 100 mEq/L\\n 140 mEq/L\\n 24.0 %\\n 12.2 K/uL\\n [image002.jpg]\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n Hct\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n Plt\\n 00\\n Cr\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n Glucose\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\\n Assessment and Plan\\n Respiratory distress and acute renal failure --> Wegener's\\n Granulomatosis\\n RESPRIATORY DISTRESS -- gradual improvement. Monitor RR, SaO2,\\n maintain >90%.\\n RENAL FAILURE -- initial good recovery, with good urine output;\\n however, now creatitine with minimal decline over past 2-3 days. \\n be approaching new baseline. ultimately require dialysis.\\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\\n cytoxan & plasmaphoresis\\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\\n disease.\\n FLUIDS -- desire net negative if tolerated by BP.\\n NUTRITIONAL SUPPORT -- encourage PO.\\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335622,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Hx. Of alveolar hemorrhage due to wegener\\ns dz. Remain on O2 at 80%\\n face tent and 6L NC. LS diminished. Congested non productive cough.\\n Action:\\n Nebs as ordered. Up to chair for good part of the day.\\n Response:\\n Tolerated being up well. Pt. coughed while up in a chair but no sputum.\\n O2 sat stable >90%. Still will desat to 86% while eating or when mask\\n of. CXR improving.\\n Plan:\\n Cont. current treatment.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 335701,\n \"text\": \"TITLE: Resp Care Note, Pt rx\\nd with albuterol/ atrovent via mask. BS\\n wheezes. Improved after rx. Will cont to monitor resp status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335681,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Plasma pheresis due tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\\n during sleep)\\n Action:\\n Continues on O2, ( frequently reminded to keep O2 on)\\n Response:\\n Remains afebrile, no hemoptysis, slept well overnight\\n Plan:\\n Continue to monitor resp status, wean O2 as tolerated.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 335778,\n \"text\": \"Clinician: Attending\\n Critical Care\\n Urine output remains good and we will try to maintain him negative\\n again today. Creat is trending down still. Oxygen requirement remains\\n high and he still has diffuse bilat infiltrates. Plan for\\n plasmapheresis again today. He is feeling better but still is very\\n fragile HR 140 simply with exam. Checking ECK before increasing beta\\n blocker.\\n Total time spent: 35 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335781,\n \"text\": \"Chief Complaint: 60 year old male transferred from OSH with repiratory\\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis. Kidney function improving steadily, no dialysis was\\n needed. Respiratory status stable, continues to require facemask to\\n keep 02 sats >90%, no signs of continued bleeding into lungs.\\n 24 Hour Events:\\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\\n hyperglycemia to steroid use.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 117 (99 - 137) bpm\\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\\n RR: 24 (11 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,510 mL\\n 304 mL\\n PO:\\n 1,340 mL\\n 240 mL\\n TF:\\n IVF:\\n 170 mL\\n 64 mL\\n Blood products:\\n Total out:\\n 2,800 mL\\n 300 mL\\n Urine:\\n 2,800 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,290 mL\\n 4 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 217 K/uL\\n 7.8 g/dL\\n 88 mg/dL\\n 4.4 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 145 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 23.0 %\\n 9.8 K/uL\\n [image002.jpg]\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n Hct\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n Plt\\n 00\\n 217\\n Cr\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n Glucose\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\\n shows interval improvement, patient appears to be responding to\\n diuresis as well.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT down today, unlikely due to alveolar hemoorhave given improving\\n respiratory status and no hemoptysis. .\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\\n - CXR daily\\n -Plasmapheresis, dose 5/7 today, then W/F.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n - f/u Rheum recs\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. As a note,\\n plasmapheresis in cases of severe Wegeners has been shown to improve\\n kidney outcomes, though not mortality.\\n - Foley in place , strict I&O, goal -1 liter today (has been\\n , no lasix unless needed this pm)\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A\\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\\n continue for at least one more day.\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Continued tachycardia, ? atrial vs. sinus.\\n Hemodynamically stable. ECHO showed mild LV septal , \\n 45-50%. Possibly secondary to large volume shifts (retaining total\\n body fluid with renal failure, with large volume load putting stress on\\n atria.)\\n -EKG to eval for atrial tach vs. sinus tach. If sinus, will work up\\n underlying cause. If atrial, will increase lopressor to 75mg po tid.\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n HCT have been low in the morning and higher in the afternoon for the\\n past 2 days despite no transfusion and no plasmapheresis. Variation\\n may be due to lab variability, fluid shifts during the day, or another\\n unknown cause. Will monitor as long as he is hemodynamically stable.\\n -qday HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n #Hyperglycemia- non-diabetic, likely high dose steroids.\\n -SSI plus standing 3units\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 336024,\n \"text\": \"60 year old male transferred from OSH with respiratory distress\\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis.\\n Vasculitis\\n Assessment:\\n Pt. dx. With Wegener\\ns granulomatosis.\\n Action:\\n Has been reciving plasmapherisis , steroids and cytoxin.\\n Response:\\n Two more treatments of plasmapherisis planed for Wed. and Fri.\\n Plan:\\n Remains stable.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\\n 6L NC. Occ. Congested non-productive cough.\\n Action:\\n Cont. Atovaquone for PCP . OOB to chair today.\\n Response:\\n CXR improving. Pt. states breathing feels much better.\\n Plan:\\n Cont. to wean O2.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n In Renal failure when admitted to MICU.\\n Action:\\n Monitoring. Encourage PO fluid intake.\\n Response:\\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\\n Plan:\\n Goal urine output -500 to 1L .\\n On FS QID due to Prednisone daily. On RISS and NPH Q am.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n VASCULITIS\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 68.4 kg\\n Daily weight:\\n 93.3 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: ? emphysema\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:126\\n D:78\\n Temperature:\\n 98.1\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 106 bpm\\n Heart rhythm:\\n AF (Atrial Fibrillation)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 6 L/min\\n FiO2 set:\\n 24h total in:\\n 1,136 mL\\n 24h total out:\\n 2,220 mL\\n Pertinent Lab Results:\\n Sodium:\\n 145 mEq/L\\n 04:05 AM\\n Potassium:\\n 3.6 mEq/L\\n 04:05 AM\\n Chloride:\\n 103 mEq/L\\n 04:05 AM\\n CO2:\\n 32 mEq/L\\n 04:05 AM\\n BUN:\\n 135 mg/dL\\n 04:05 AM\\n Creatinine:\\n 4.3 mg/dL\\n 04:05 AM\\n Glucose:\\n 92 mg/dL\\n 04:05 AM\\n Hematocrit:\\n 21.3 %\\n 04:05 AM\\n Finger Stick Glucose:\\n 150\\n 12:00 PM\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n pherisis line in R IJ, Foley cath\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: MICU 412\\n Transferred to:\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 336032,\n \"text\": \"60 year old male transferred from OSH with respiratory distress\\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis.\\n Vasculitis\\n Assessment:\\n Pt. dx. With Wegener\\ns granulomatosis.\\n Action:\\n Has been reciving plasmapherisis , steroids and cytoxin.\\n Response:\\n Two more treatments of plasmapherisis planed for Wed. and Fri.\\n Plan:\\n Remains stable.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\\n 6L NC. Occ. Congested non-productive cough.\\n Action:\\n Cont. Atovaquone for PCP . OOB to chair today.\\n Response:\\n CXR improving. Pt. states breathing feels much better.\\n Plan:\\n Cont. to wean O2.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n In Renal failure when admitted to MICU.\\n Action:\\n Monitoring. Encourage PO fluid intake.\\n Response:\\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\\n Plan:\\n Goal urine output -500 to 1L .\\n On FS QID due to Prednisone daily. On RISS and NPH Q am. BS well\\n controlled.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n VASCULITIS\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 68.4 kg\\n Daily weight:\\n 93.3 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: ? emphysema\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:126\\n D:78\\n Temperature:\\n 98.1\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 106 bpm\\n Heart rhythm:\\n AF (Atrial Fibrillation)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 6 L/min\\n FiO2 set:\\n 24h total in:\\n 1,136 mL\\n 24h total out:\\n 2,220 mL\\n Pertinent Lab Results:\\n Sodium:\\n 145 mEq/L\\n 04:05 AM\\n Potassium:\\n 3.6 mEq/L\\n 04:05 AM\\n Chloride:\\n 103 mEq/L\\n 04:05 AM\\n CO2:\\n 32 mEq/L\\n 04:05 AM\\n BUN:\\n 135 mg/dL\\n 04:05 AM\\n Creatinine:\\n 4.3 mg/dL\\n 04:05 AM\\n Glucose:\\n 92 mg/dL\\n 04:05 AM\\n Hematocrit:\\n 21.3 %\\n 04:05 AM\\n Finger Stick Glucose:\\n 150\\n 12:00 PM\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n pherisis line in R IJ, Foley cath\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry: none\\n Transferred from: MICU 412\\n Transferred to: 1173\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335921,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\\n to having no PCP (regular PCP had retired.) He finally presented for\\n care when he could not put his shoes on in the a.m. due to pedal edema.\\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\\n Pt reports that LE symptoms started in the feet, progressing to\\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\\n macular rash in the LE of the same distribution. He also complained of\\n some SOB on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Vasculitis\\n Assessment:\\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output.\\n Action:\\n Pt had plasmapheresis treatment yesterday.\\n Response:\\n Improving.\\n Plan:\\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\\n Action:\\n Pt did receive lasix 40mg this evening.\\n Response:\\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\\n 775cc neg.\\n Plan:\\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\\n Tachycardia, Other\\n Assessment:\\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\\n Action:\\n Pt is on metoprolol 75 mg tid.\\n Response:\\n Pending.\\n Plan:\\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334315,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\\n non productive cough remains, LS diminished at bases\\n Action:\\n Continue with mepron\\n Response:\\n VSS stable, no resp distress noted\\n Plan:\\n Continue to monitor VSS, sats,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335286,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n Continues to require supplimental oxygen, desaturates with activity.\\n Tolerating net diuresis.\\n Hemoptysis resolved.\\n Overall, states to feel improved. Dysnpea improved. Able to sleep\\n somewhat last PM (improvement).\\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 11:10 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.3\\nC (97.4\\n HR: 98 (86 - 128) bpm\\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\\n RR: 25 (11 - 27) insp/min\\n SpO2: 94%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,945 mL\\n 560 mL\\n PO:\\n 980 mL\\n 360 mL\\n TF:\\n IVF:\\n 319 mL\\n 200 mL\\n Blood products:\\n 646 mL\\n Total out:\\n 4,410 mL\\n 960 mL\\n Urine:\\n 4,410 mL\\n 960 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,465 mL\\n -400 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 94%\\n ABG: ///31/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.8 g/dL\\n 170 K/uL\\n 79 mg/dL\\n 5.2 mg/dL\\n 31 mEq/L\\n 3.5 mEq/L\\n 147 mg/dL\\n 101 mEq/L\\n 144 mEq/L\\n 22.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n 11.0\\n Hct\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n Plt\\n 221\\n 211\\n 185\\n 170\\n Cr\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n Glucose\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\\n Imaging: CXR () somewhat improved, esp. right lung field.\\n Assessment and Plan\\n Wegener's Granulomatosis\\n RESPIRATORY DISTRESS -- slow improvement clincally and\\n radiographically. Continue current management.\\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\\n urine output.\\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\\n Continue steoids, cytoxan, plasmaphoresis\\n NUTRITIONAL SUPPORT --\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335287,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Did well. No hemoptysis.\\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\\n diuresis yesterday to goal -2L.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36\\nC (96.8\\n HR: 86 (86 - 116) bpm\\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\\n RR: 18 (14 - 27) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,945 mL\\n 340 mL\\n PO:\\n 980 mL\\n 240 mL\\n TF:\\n IVF:\\n 319 mL\\n 100 mL\\n Blood products:\\n 646 mL\\n Total out:\\n 4,410 mL\\n 470 mL\\n Urine:\\n 4,410 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,465 mL\\n -130 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///31/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 170 K/uL\\n 7.8 g/dL\\n 79 mg/dL\\n 5.2 mg/dL\\n 31 mEq/L\\n 3.5 mEq/L\\n 147 mg/dL\\n 101 mEq/L\\n 144 mEq/L\\n 22.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n 11.0\\n Hct\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n Plt\\n 221\\n 211\\n 185\\n 170\\n Cr\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n Glucose\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\\n looks mor comfortable though CXR looks unchanged. This is likely due\\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\\n the last 3 days. Urine output remains high.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n -Will give lasix 40IV for goal of -500\\n1L today. We will also watch\\n his urine output and restart IVF if necessary to keep >100cc/hr\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n - HCT down today, unlikely due to alveolar imprroving respiratory\\n status, no hemoptysis. Continue to monitor\\n - If possible Will collect sputum to determine whether hemoptysis is\\n tinged, bright red or just pink fronthy.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - Albuterol nebs PRN\\n - CXR daily\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n ok. Urine is less pink that previously. Renal function has been\\n steadily improving, likely as a response to Wegeners treatment. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - treating underlying cause (likely Wegener's).\\n - Foley in place , strict I&O, q8 lytes.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -received 4IV CA last night\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Rate has been well controlled over the past 2 days.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n He received 1 unit yesterday and bumped appropriately but his HCT is\\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\\n will not receive pheresis this weekend, so we can monitor to see if HCT\\n stays stable.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334432,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Remains with high FiO2 requirment.\\n Renal bx consistent with Wegener's Granulomatosis.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 35.9\\nC (96.6\\n HR: 99 (87 - 130) bpm\\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\\n RR: 21 (9 - 28) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,477 mL\\n 2,103 mL\\n PO:\\n 60 mL\\n TF:\\n IVF:\\n 2,102 mL\\n 2,043 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 1,025 mL\\n Urine:\\n 1,360 mL\\n 1,025 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,117 mL\\n 1,078 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.6 g/dL\\n 221 K/uL\\n 94 mg/dL\\n 7.2 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 149 mg/dL\\n 105 mEq/L\\n 145 mEq/L\\n 22.7 %\\n 9.0 K/uL\\n [image002.jpg]\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n WBC\\n 8.1\\n 5.4\\n 9.0\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n Plt\\n 355\\n 261\\n 221\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\\n Assessment and Plan\\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\\n likey due to vasculitis. Radiographically without significant change,\\n but hope to see improvement over next several days. Monitor RR, SaO2.\\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\\n improve.\\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\\n plts). Monitor Hct, transfuse to > 21\\n WEGENER\\\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\\n plasmaphoresis QOD.\\n FLUIDS -- euvolemic. Monitor I/O\\n HEMATURIA -- concern for hemorrhagic cystitis\\n A-FIB -- good rate control COntinue meds. Monitor HR.\\n NASAL CONGESTION -- possible related to Wegener's but more likely due\\n to high flow O2. Symptomaatic relief.\\n HYPOCALCEMIA -- repleted. Monitor.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334434,\n \"text\": \"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\\n renal biopsy c/w Wegeners.\\n 24 Hour Events:\\n O/N required 6L 02 with 40%FIo\\\\02 facemask to keep 02 sat >90. Got\\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\\n >100, successfully. Tolerating PO. Received 1 unit PRBCs yesterday\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36\\nC (96.8\\n HR: 99 (75 - 130) bpm\\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\\n RR: 20 (18 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,475 mL\\n 650 mL\\n PO:\\n TF:\\n IVF:\\n 2,100 mL\\n 650 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 260 mL\\n Urine:\\n 1,360 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,115 mL\\n 390 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///25/\\n Physical Examination\\n Gen: Sleeping in bed, NAD\\n CV:tachy, irregular. No murmur\\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\\n Ext: 1+ pedal edema, no rash or petichiae\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 172 mg/dL\\n 7.1 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 149 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 22.4 %\\n 5.4 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n WBC\\n 8.1\\n 5.4\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n Plt\\n 355\\n 261\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n TCO2\\n 20\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR.\\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\\n appropriately to 1unit PRBCs so likely not currently bleeding.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Prednison po daily,\\n -Cyclophosphamide-dose to be determined after c/s with rheum and\\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\\n far.\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: Monitoring for need for dialysis, has line in\\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\\n signs of platelet dysfunction yet, mental status ok. Renal will give\\n his kidneys about 48 more hours to turn around before dialyzing. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\\n cryglobulins, ANCA.\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -pink tinged urine, stable, but will send daily U/As.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiacc negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334532,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Atrial flutter (Aflutter)\\n Assessment:\\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\\n has episodes of tachycardia in the 130\\ns, typically with exertion or\\n desats. BP within normal limits.\\n Action:\\n Tolerating metoprolol PO\\n Response:\\n Heart rate slows with NSR episodes, VS WNL\\n Plan:\\n Continue to monitor Heart rate/rhythm, administer metoprolol as\\n ordered.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\\n noted. Creatinine is 6.9, BUN 149\\n Action:\\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\\n administration of cyclophosphamide (chemo)\\n Response:\\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\\n since midnight.\\n Plan:\\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\\n HD catheter, may have it . Administer mesna as ordered with chemo\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\\n weak cough. +1.6L positive. Patient would frequently remove face tent,\\n thus dropping O2 sats.\\n Action:\\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\\n 6L NC. Patient encouraged to cough and deep breathe.\\n Response:\\n Oxygenation has improved throughout the afternoon with patient\\ns family\\n at the bedside\\n Plan:\\n Continue to titrate O2, encourage deep breathing and coughing.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334311,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 6 liters NC and supplemental O2, sats maintaining above\\n 95%, desats when pt removes O2 in his sleep. , Moist non productive\\n cough remains, LS with rhonchi in both lower lobes more on R.\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334923,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\\n pull the O2 mask and cannula,desats to low 80,s when the mask is\\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\\n cough.\\n Action:\\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\\n Cytoxan yesterday with mesna/IV as ordered by MD. 3^rd dose of mesna\\n due at 1000,pt now only on FM with 80%,sats >97% when mask is on.\\n Response:\\n Pt was more comfortable last night, but continued to be uncomfortable\\n with the mask\\n Plan:\\n Monitor resp status,meds as ordered,Titrate O2 as needed.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335259,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Did well. No hemoptysis.\\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\\n diuresis yesterday to goal -2L.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36\\nC (96.8\\n HR: 86 (86 - 116) bpm\\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\\n RR: 18 (14 - 27) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,945 mL\\n 340 mL\\n PO:\\n 980 mL\\n 240 mL\\n TF:\\n IVF:\\n 319 mL\\n 100 mL\\n Blood products:\\n 646 mL\\n Total out:\\n 4,410 mL\\n 470 mL\\n Urine:\\n 4,410 mL\\n 470 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -2,465 mL\\n -130 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///31/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 170 K/uL\\n 7.8 g/dL\\n 79 mg/dL\\n 5.2 mg/dL\\n 31 mEq/L\\n 3.5 mEq/L\\n 147 mg/dL\\n 101 mEq/L\\n 144 mEq/L\\n 22.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n 11.0\\n Hct\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n Plt\\n 221\\n 211\\n 185\\n 170\\n Cr\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n Glucose\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\\n looks mor comfortable though CXR looks unchanged. This is likely due\\n to 2 days of diuresis, as he is -2L in the past 24 hours and -4L in the\\n last 2 days. Urine output remains high.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n -Will give lasix 40IV for goal of -500 today. We will also watch his\\n urine output and restart IVF if necessary\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n - Stable crit and no more hemoptysis so pulmonary bleeding unlikely,\\n - HCTq12h to monitor for alveolar bleeding.\\n - If possible Will collect sputum to determine whether hemoptysis is\\n tinged, bright red or just pink fronthy.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - Albuterol nebs PRN\\n - CXR daily\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n ok. Urine is less pink that previously. Renal function has been\\n steadily improving, likely as a response to Wegeners treatment. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - treating underlying cause (likely Wegener's).\\n - Foley in place , strict I&O, q8 lytes.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -received 4IV CA last night\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n No baseline Crit available.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334307,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to\\n Response:\\n Plan:\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334406,\n \"text\": \"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\\n renal biopsy c/w Wegeners.\\n 24 Hour Events:\\n O/N required 6L 02 with 40%FIo\\\\02 facemask to keep 02 sat >90. Got\\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\\n >100, successfully. Tolerating PO.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36\\nC (96.8\\n HR: 99 (75 - 130) bpm\\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\\n RR: 20 (18 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,475 mL\\n 650 mL\\n PO:\\n TF:\\n IVF:\\n 2,100 mL\\n 650 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 260 mL\\n Urine:\\n 1,360 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,115 mL\\n 390 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 261 K/uL\\n 6.9 g/dL\\n 172 mg/dL\\n 7.1 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 149 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 22.4 %\\n 5.4 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n WBC\\n 8.1\\n 5.4\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n Plt\\n 355\\n 261\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n TCO2\\n 20\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, but increased with 1unit yesterday.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\\n prednisone dose\\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\\n doses thus far.\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\\n will give his kidneys about 48 more hours to turn around before\\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\\n been shown to improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\\n cryglobulins, ANCA.\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n yesterday with D51/2.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -given 6g IV Ca yesterday, plus more during pheresis\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - given HCT trend, gave 1 unit yesterday with improved HCT.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Guaiac all stools\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334409,\n \"text\": \"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\\n renal biopsy c/w Wegeners.\\n 24 Hour Events:\\n O/N required 6L 02 with 40%FIo\\\\02 facemask to keep 02 sat >90. Got\\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\\n >100, successfully. Tolerating PO.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36\\nC (96.8\\n HR: 99 (75 - 130) bpm\\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\\n RR: 20 (18 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,475 mL\\n 650 mL\\n PO:\\n TF:\\n IVF:\\n 2,100 mL\\n 650 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 260 mL\\n Urine:\\n 1,360 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,115 mL\\n 390 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///25/\\n Physical Examination\\n Gen: Sleeping in bed, NAD\\n CV:tachy, irregular. No murmur\\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\\n Ext: 1+ pedal edema, no rash or petichiae\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 172 mg/dL\\n 7.1 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 149 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 22.4 %\\n 5.4 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n WBC\\n 8.1\\n 5.4\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n Plt\\n 355\\n 261\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n TCO2\\n 20\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, but increased with 1unit yesterday.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\\n prednisone dose\\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\\n doses thus far.\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\\n will give his kidneys about 48 more hours to turn around before\\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\\n been shown to improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\\n cryglobulins, ANCA.\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n yesterday with D51/2.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -given 6g IV Ca yesterday, plus more during pheresis\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - given HCT trend, gave 1 unit yesterday with improved HCT.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Guaiac all stools\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334385,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx., undervent renal biopsy, awaiting results.\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\\n non productive cough remains, LS diminished at bases\\n Action:\\n Continue with mepron\\n Response:\\n VSS stable, no resp distress noted\\n Plan:\\n Continue to monitor VSS, sats,\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334873,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334877,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\\n pull the O2 mask and cannula,desats to low 80,s when the mask is\\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\\n cough.\\n Action:\\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\\n Cytoxan yesterday with mesna/IV as ordered by MD.\\n Response:\\n Pt was more comfortable last night,\\n Plan:\\n Monitor resp status,meds as ordered,\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 335493,\n \"text\": \"TITLE: Resp Care Note, Pt given albuterol/atrovent nebs. BS rhonchi. 02\\n remains on 80% high flow neb/nc 4lpm. Sat 95%. Pt stable . Will cont ot\\n monitor resp status.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334716,\n \"text\": \"Chief Complaint: Hypoxemia\\n HPI:\\n 24 Hour Events:\\n Remains with high FiO2 requirement.\\n HR varies from A-flutter to NRS.\\n Coughing up sputum (swallowing), but more productive cough today.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.2\\n Tcurrent: 36.1\\nC (96.9\\n HR: 98 (85 - 131) bpm\\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\\n RR: 18 (12 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 1,971 mL\\n PO:\\n 750 mL\\n 160 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 1,811 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 1,235 mL\\n Urine:\\n 2,400 mL\\n 1,235 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 736 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 94%\\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, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: 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, No(t) Sedated,\\n No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.8 g/dL\\n 211 K/uL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\\n Possible component of pulmonary edema.\\n HYPOXEMIA -- attributed to pulmonary infiltrates.\\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\\n steroids & cytoxan. Plasmaphoresis.\\n RENAL FAILURE -- improving.\\n NUTRIONAL SUPPORT -- PO\\n HEMATURIA -- stable. Monitor.\\n ANEMIA -- stable s/p transfusion\\n HYPOCALCEMIA -- continue to replete\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 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: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335036,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia.\\n HPI:\\n 24 Hour Events:\\n Experienced some hemoptysis yesterday PM.\\n Appears much more comfortable today, less dyspneic.\\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 Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\\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, Hematuria\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\\n RR: 26 (18 - 27) insp/min\\n SpO2: 88%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 238 mL\\n PO:\\n 290 mL\\n 120 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 118 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 2,900 mL\\n Urine:\\n 3,010 mL\\n 2,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -2,663 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 88%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\\n No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\\n Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.3 g/dL\\n 185 K/uL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Wegener's Granulomatosis\\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\\n plasmaphoresis\\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\\n falling, urine output improving, responding to diuretics.\\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\\n escalation. Consider dDAVP. need dialysis if continues to\\n NUTRITIONAL SUPPORT -- PO\\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\\n suppression. Transfuse to Hct >25\\n FLUID -- continue net negative. Monitor I/O.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335533,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 06:10 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:03 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.1\\nC (96.9\\n HR: 108 (91 - 135) bpm\\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\\n RR: 19 (11 - 26) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,690 mL\\n 190 mL\\n PO:\\n 1,220 mL\\n 120 mL\\n TF:\\n IVF:\\n 470 mL\\n 70 mL\\n Blood products:\\n Total out:\\n 2,465 mL\\n 900 mL\\n Urine:\\n 2,465 mL\\n 900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -775 mL\\n -710 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 100%\\n ABG: ///29/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 200 K/uL\\n 8.2 g/dL\\n 117 mg/dL\\n 5.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 148 mg/dL\\n 100 mEq/L\\n 140 mEq/L\\n 24.0 %\\n 12.2 K/uL\\n [image002.jpg]\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n Hct\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n Plt\\n 00\\n Cr\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n Glucose\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\\n looks mor comfortable though CXR looks unchanged. This is likely due\\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\\n the last 3 days. Urine output remains high.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n -Will give lasix 40IV for goal of -500\\n1L today. We will also watch\\n his urine output and restart IVF if necessary to keep >100cc/hr\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n - HCT down today, unlikely due to alveolar imprroving respiratory\\n status, no hemoptysis. Continue to monitor\\n - If possible Will collect sputum to determine whether hemoptysis is\\n tinged, bright red or just pink fronthy.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - Albuterol nebs PRN\\n - CXR daily\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n ok. Urine is less pink that previously. Renal function has been\\n steadily improving, likely as a response to Wegeners treatment. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - treating underlying cause (likely Wegener's)\\n - Foley in place , strict I&O, q8 lytes.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -received 4IV CA last night\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Rate has been well controlled over the past 2 days.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n He received 1 unit yesterday and bumped appropriately but his HCT is\\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\\n will not receive pheresis this weekend, so we can monitor to see if HCT\\n stays stable.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 334695,\n \"text\": \"Potential for nutrition risk. Patient being monitored. Current\\n intervention if any, listed below:\\n Comments:\\n Diet: low sodium/heart healthy/Renal.\\n Reports no weight loss. Tolerating current diet, says he's hungry. Will\\n continue to monitor po intake. Continue to monitor renal function and\\n hydration.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335226,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\\n continues to desat when off O2 ( removes O2 while sleeping on and off)\\n Action:\\n Scheduled neb given , nystatin swish given for yeast in sputum.\\n Response:\\n Good response to neb , Slept well with ambien.\\n Plan:\\n Continue to monitor VSS and follow sats closely.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\\n Action:\\n Followed up with labs overnight.\\n Response:\\n U/O wnl, continued to monitor renal parameters\\n Plan:\\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335572,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n No new events.\\n Revieved 1 U PRBC transfusion, tolerated well.\\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 Furosemide (Lasix) - 06:10 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:08 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 122 (97 - 135) bpm\\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,690 mL\\n 477 mL\\n PO:\\n 1,220 mL\\n 360 mL\\n TF:\\n IVF:\\n 470 mL\\n 117 mL\\n Blood products:\\n Total out:\\n 2,465 mL\\n 1,540 mL\\n Urine:\\n 2,465 mL\\n 1,540 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -775 mL\\n -1,063 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, Face tent\\n SpO2: 94%\\n ABG: ///29/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\\n Paralyzed, Tone: Normal\\n Labs / Radiology\\n 8.2 g/dL\\n 200 K/uL\\n 117 mg/dL\\n 5.0 mg/dL\\n 29 mEq/L\\n 3.5 mEq/L\\n 148 mg/dL\\n 100 mEq/L\\n 140 mEq/L\\n 24.0 %\\n 12.2 K/uL\\n [image002.jpg]\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n Hct\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n Plt\\n 00\\n Cr\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n Glucose\\n 144\\n 208\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\\n Assessment and Plan\\n Respiratory distress and acute renal failure --> Wegener's\\n Granulomatosis\\n RESPRIATORY DISTRESS -- gradual improvement.\\n RENAL FAILURE -- initial good recovery, with good urine output;\\n however, now creatitine with minimal decline over past 2-3 days. \\n be approaching new baseline. ultimately require dialysis.\\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\\n cytoxan & plasmaphoresis\\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\\n disease.\\n FLUIDS -- desire net negative if tolerated by BP.\\n NUTRITIONAL SUPPORT -- encourage PO.\\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 40 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333963,\n \"text\": \"Most likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335357,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\\n to 86% when pt. sleeping and face tent away from Pt.\\ns face.\\n Action:\\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\\n in sputum. Nebs as ordered.\\n Response:\\n Pt. states he is feeling better. No hemoptisis this shift. CXR\\n improving.\\n Plan:\\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335358,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\\n to 86% when pt. sleeping and face tent away from Pt.\\ns face.\\n Action:\\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\\n in sputum. Nebs as ordered.\\n Response:\\n Pt. states he is feeling better. No hemoptisis this shift. CXR\\n improving.\\n Plan:\\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\\n Repleated Ca+ this shift per Ca+ SS.\\n Repeat Hct. 26\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335733,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Plasma pheresis due tomorrow.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\\n during sleep),\\n Action:\\n Continues on O2, ( frequently reminded to keep O2 on), xray chest done\\n this a.m\\n Response:\\n Remains afebrile, no hemoptysis, slept well overnight\\n Plan:\\n Continue to monitor resp status, wean O2 as tolerated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335748,\n \"text\": \"Chief Complaint: 60 year old male transferred from OSH with repiratory\\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis. Kidney function improving steadily, no dialysis was\\n needed. Respiratory status stable, continues to require facemask to\\n keep 02 sats >90%, no signs of continued bleeding into lungs.\\n 24 Hour Events:\\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\\n hyperglycemia to steroid use.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 117 (99 - 137) bpm\\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\\n RR: 24 (11 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,510 mL\\n 304 mL\\n PO:\\n 1,340 mL\\n 240 mL\\n TF:\\n IVF:\\n 170 mL\\n 64 mL\\n Blood products:\\n Total out:\\n 2,800 mL\\n 300 mL\\n Urine:\\n 2,800 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,290 mL\\n 4 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 217 K/uL\\n 7.8 g/dL\\n 88 mg/dL\\n 4.4 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 145 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 23.0 %\\n 9.8 K/uL\\n [image002.jpg]\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n Hct\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n Plt\\n 00\\n 217\\n Cr\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n Glucose\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT down today, unlikely due to alveolar hemoorhave given improving\\n respiratory status and no hemoptysis. Continue to monitor with q12\\n HCT.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Albuterol nebs PRN\\n - CXR daily\\n -Plasmapheresis, dose 5/7 today, then W/F.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n - f/u Rheum recs\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. As a note,\\n plasmapheresis in cases of severe Wegeners has been shown to improve\\n kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\\n continue for at least one more day.\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Asymptomatic, rate increases when active/talking,\\n normal when sleeping. ECHO showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n #Hyperglycemia- non-diabetic, likely high dose steroids.\\n -SSI plus standing\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335872,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\\n to having no PCP (regular PCP had retired.) He finally presented for\\n care when he could not put his shoes on in the a.m. due to pedal edema.\\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\\n Pt reports that LE symptoms started in the feet, progressing to\\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\\n macular rash in the LE of the same distribution. He also complained of\\n some SOB on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Vasculitis\\n Assessment:\\n Action:\\n Pt had plasmapheresis treatment yesterday.\\n Response:\\n Plan:\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n U/O has been good.\\n Plan:\\n Tachycardia, Other\\n Assessment:\\n Pt remains in ST with hr ranging from\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335873,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\\n to having no PCP (regular PCP had retired.) He finally presented for\\n care when he could not put his shoes on in the a.m. due to pedal edema.\\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\\n Pt reports that LE symptoms started in the feet, progressing to\\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\\n macular rash in the LE of the same distribution. He also complained of\\n some SOB on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Vasculitis\\n Assessment:\\n Action:\\n Pt had plasmapheresis treatment yesterday.\\n Response:\\n Plan:\\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\\n Action:\\n Pt did receive lasix 40mg this evening.\\n Response:\\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\\n 775cc neg.\\n Plan:\\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\\n Tachycardia, Other\\n Assessment:\\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\\n Action:\\n Pt is on metoprolol 75 mg tid.\\n Response:\\n Pending.\\n Plan:\\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335874,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\\n to having no PCP (regular PCP had retired.) He finally presented for\\n care when he could not put his shoes on in the a.m. due to pedal edema.\\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\\n Pt reports that LE symptoms started in the feet, progressing to\\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\\n macular rash in the LE of the same distribution. He also complained of\\n some SOB on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Vasculitis\\n Assessment:\\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output.\\n Action:\\n Pt had plasmapheresis treatment yesterday.\\n Response:\\n Improving.\\n Plan:\\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\\n Action:\\n Pt did receive lasix 40mg this evening.\\n Response:\\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\\n 775cc neg.\\n Plan:\\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\\n Tachycardia, Other\\n Assessment:\\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\\n Action:\\n Pt is on metoprolol 75 mg tid.\\n Response:\\n Pending.\\n Plan:\\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 336022,\n \"text\": \"60 year old male transferred from OSH with respiratory distress\\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\\n plasmapheresis.\\n Vasculitis\\n Assessment:\\n Pt. dx. With Wegener\\ns granulomatosis.\\n Action:\\n Has been reciving plasmapherisis , steroids and cytoxin.\\n Response:\\n Two more treatments of plasmapherisis planed for Wed. and Fri.\\n Plan:\\n Remains stable.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\\n 6L NC. Occ. Congested non-productive cough.\\n Action:\\n Cont. Atovaquone for PCP . OOB to chair today.\\n Response:\\n CXR improving. Pt. states breathing feels much better.\\n Plan:\\n Cont. to wean O2.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n In Renal failure when admitted to MICU.\\n Action:\\n Monitoring. Encourage PO fluid intake.\\n Response:\\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\\n Plan:\\n Goal urine output -500 to 1L .\\n On FS QID due to Prednisone daily.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334074,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 89 (72 - 133) bpm\\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 343 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 343 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 440 mL\\n Urine:\\n 1,405 mL\\n 440 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -97 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - also treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose today (QOD)\\n -Solumedrol 1g IV daily\\n -Cyclophosphamide 140mg\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\\n dysfunction yet, mental status ok.\\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\\n However, apart from pulmonary association, ddx for acute renal failure\\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\\n Also consider DIC.\\n - Renal biopsy yesterday, awaiting results\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\\n serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\\n today 141, down from 150.\\n -Now patient is eating, can D/C D5W.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -Replace Ca2+ (given 4g this am), check again this PM\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6, given HCT , likely need blood this pm.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 336013,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n EKG - At 12:02 PM\\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\\n Tolerated plasmaphoresis yesterday.\\n Continues net diuresis, tolerated well.\\n No further hemoptysis.\\n Up in chair, excellent spirits. Appropriate. Joking with family.\\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 Furosemide (Lasix) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, 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 10:38 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\\n HR: 114 (100 - 142) bpm\\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\\n RR: 21 (12 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 93.3 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,534 mL\\n 902 mL\\n PO:\\n 1,220 mL\\n 750 mL\\n TF:\\n IVF:\\n 314 mL\\n 152 mL\\n Blood products:\\n Total out:\\n 2,565 mL\\n 1,690 mL\\n Urine:\\n 2,565 mL\\n 1,690 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,031 mL\\n -788 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///32/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.2 g/dL\\n 200 K/uL\\n 92 mg/dL\\n 4.3 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 135 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 21.3 %\\n 8.4 K/uL\\n [image002.jpg]\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n 08:17 PM\\n 04:05 AM\\n WBC\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n 8.4\\n Hct\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n 25.1\\n 21.3\\n Plt\\n 185\\n 170\\n 200\\n 217\\n 200\\n Cr\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n 4.2\\n 4.3\\n Glucose\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n 208\\n 92\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\\n Assessment and Plan\\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\\n steroids, cytoxan. Complete Plasmaphoresis course.\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\\n oxygen requirement.\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\\n improvement. Monitor. No acute indication for dialysis.\\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\\n Monitor.\\n TACHYCARDIA -- improved. Monitor.\\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\\n Transfuse to Hct >21.\\n HYPERGLYCEMIA -- contributed by high dose steroids. Monitor, use\\n insullin to maintain <150.\\n ICU Care\\n Nutrition: PO\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335526,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\\n off O2( removes O2 during sleep)\\n Action:\\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\\n sputum, pt requires repeated reinforcement for O2 compliance with\\n understanding. Scheduled nebs given\\n Response:\\n Remains afebrile, no hemoptysis this shift,\\n Plan:\\n Continue to monitor hemodynamic status, follow up on culture reports.,\\n continue with neb Rx, wean O2 as tolerated.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Renal parameters trending down\\n Action:\\n Diuresed this p.m with 20 lasix,\\n Response:\\n Good response to lasix, negative 770 by midnight\\n Plan:\\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335854,\n \"text\": \"Vasculitis\\n Assessment:\\n Tolerating pheresis. Hemodynamically stable.\\n Action:\\n Plasma pheresis this afternoon. Lopressor increased to 75mg d/t atrial\\n tachycardia. Hct 23. pedal edema slowly decreasing. Slept in naps. Ssi\\n for bs\\ns. mg+ 1.6 and given 2mg mg+ ivpb. Good appetite.\\n Response:\\n Continues to improve. Good response to lopressor.\\n Plan:\\n Need to check ionized ca+ at 20pm. Pt. has a ss for his ca+ doses.\\n Transfuse if hct drops below 21.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Able to tolerate np only.\\n Action:\\n Mask off. Presently on 5L np. . Non-productive cough. No hemoptysis. No\\n c/o sob.\\n Response:\\n Sats 98-100%.\\n Plan:\\n Continue to wean o2.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Renal failure improving.\\n Action:\\n Creat 4.4. k+ 3.7. /20mg lasix ivp ordered/given by night nurse. Urine\\n slightly pink-tinged this am, but not noted this pm. Patent dialysis\\n catheter with port.\\n Response:\\n Autodiuresing.\\n Plan:\\n Plan for 1L negative.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 335955,\n \"text\": \"Clinician: Attending\\n Critical Care\\n 42 yo woman paraplegic after MVA , recently discharged from\\n hospital after \\\"pneumonia\\\" noted by PCA to be lethargic at home, SaO2\\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\\n somewhat confused but conversant. Still somewhat lethargic. We are\\n continuing Narcan but would have some concern about methadone as\\n explanation for her lethargy as no change in methadone dose for 6 weeks\\n and not previously sedated by med. Would also have some concern about\\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\\n presentation. Not clear why she developed PNA. We are continuing O2,\\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\\n have PFTs before d/c.\\n Total time spent: 35 minutes\\n Patient is critically ill.\\n ------ Protected Section------\\n ------ Protected Section Error Entered By: , MD\\n on: 08:08 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335974,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Continues with same 02 requirement. EKG yesterday revealed aflutter\\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\\n 100s all night.\\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\\n overnight.\\n Followed by renal and rheum.\\n EKG - At 12:02 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:25 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: 36.6\\nC (97.8\\n HR: 106 (100 - 142) bpm\\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\\n RR: 12 (12 - 26) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 93.3 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,530 mL\\n 600 mL\\n PO:\\n 1,220 mL\\n 500 mL\\n TF:\\n IVF:\\n 310 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 2,565 mL\\n 1,200 mL\\n Urine:\\n 2,565 mL\\n 1,200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,036 mL\\n -600 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 90%\\n ABG: ///32/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 200 K/uL\\n 7.2 g/dL\\n 92 mg/dL\\n 4.3 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 135 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 21.3 %\\n 8.4 K/uL\\n [image002.jpg]\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n 08:17 PM\\n 04:05 AM\\n WBC\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n 8.4\\n Hct\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n 25.1\\n 21.3\\n Plt\\n 185\\n 170\\n 200\\n 217\\n 200\\n Cr\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n 4.2\\n 4.3\\n Glucose\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n 208\\n 92\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Has been stable on 6L NC. Most likely\\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\\n shows interval improvement, patient appears to be responding to\\n diuresis as well.\\n - Wean 02 to keep sat >90%.\\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\\n hemoorhave given improving respiratory status and no hemoptysis.\\n Probably due to plasmapheresis and fluid shifting. His respiratory\\n status may be marginally helped by an increased HCT, but will check pm\\n HCT and transfuse if <21.\\n -Continue nystatin mouthwash for + sputum given his high dose\\n steroids. Day \\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\\n - CXR daily\\n -Plasmapheresis, dose 5/7 yesterday, then tomorrow and Friday.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n - f/u Rheum recs\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine continues to trend down, 4.3 this morning, BUN is\\n also finally down to 135, and he has maintained good urine output. As\\n a note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,we have been diuresing him well, with ?\\n liters off in the past 5 days. We will continue to diurese with goal\\n -500cc to -1L, using Lasix 20 IV prn.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A\\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\\n one more day.\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Received 4gIV overnight, will re-check PM ionized Calcium and replete\\n as needed. On days when he has pheresis, ionized CA needs to be drawn\\n 4 hours after the end of pheresis to be accurate.\\n -on SS replacement.\\n -EKGs have been unchanged.\\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\\n stable. ECHO showed mild LV septal , 45-50%. Possibly\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n -Increased lopressor to 75mg po tid yesterday. Will continue to\\n monitor on tele. If needed, could start a second rate controlling\\n .\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n HCT have been variable over the weekend despite no transfusion.\\n Variation may be due to lab variability, or to fluid shifts with\\n plasmapheresis. Will monitor as long as he is hemodynamically stable.\\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\\n unit if <21.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n #Hyperglycemia- non-diabetic, likely high dose steroids.\\n -SSI plus standing 3units, well controlled.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n #Dispo: to floor if it is possible to do pheresis outside of the ICU.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335016,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\\n Continued to desat into the 80s because his mask falls off, but remains\\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\\n liters. Urine output before midnight=300cc/hr and after MN, continued\\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\\n sent yesterday.\\n HCT remained stable, repleted lytes\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 92 (76 - 130) bpm\\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\\n RR: 26 (12 - 27) insp/min\\n SpO2: 89%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 70 mL\\n PO:\\n 290 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 70 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 1,900 mL\\n Urine:\\n 3,010 mL\\n 1,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -1,830 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 89%\\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 185 K/uL\\n 7.3 g/dL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \\n C-ANCA vasculitis. This morning, he breathing more easily, with stable\\n lung exam though his CXR looks unchanged. This is likely due to\\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\\n 2+ budding yeast on sputum, without signs of candidiasis on\\n oropharyngeal exam.\\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\\n urine output and restart IVF if necessary. We will balance maintaining\\n urine output >100/hr for bladder protection with not giving too much\\n Lasix due to renal failure.\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n -Start nystatin mouthwash\\n -Send blood cultures for fungus (though highly unlikely given pt. is\\n afebrile, stable, but he is on high dose immunosuppression)\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - Given hemoptysis and drop in crit, some concern for pulmonary\\n bleeding, though respiratory status improving.\\n - HCTq8h to monitor for alveolar bleeding.\\n - Will collect sputum to determine whether hemoptysis is tinged, bright\\n red or just pink fronthy.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN , some wheezing on exam today\\n - CXR daily\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 4/7 today, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\\n mesna for cystitis prophylaxis\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n ok. Urine is less pink that previously. Renal function has been\\n steadily improving, likely as a response to Wegeners treatment. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - treating underlying cause (likely Wegener's).\\n - Foley in place , strict I&O, q8 lytes.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n No baseline Crit available.\\n -transfuse one unit this morning as HCT is trending down (21.6)\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative yesterday, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334319,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx., undervent renal biopsy, awaiting results.\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\\n non productive cough remains, LS diminished at bases\\n Action:\\n Continue with mepron\\n Response:\\n VSS stable, no resp distress noted\\n Plan:\\n Continue to monitor VSS, sats,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335938,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Continues with same 02 requirement. EKG yesterday revealed aflutter\\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\\n 100s all night.\\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\\n overnight.\\n Followed by renal and rheum.\\n EKG - At 12:02 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:25 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: 36.6\\nC (97.8\\n HR: 106 (100 - 142) bpm\\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\\n RR: 12 (12 - 26) insp/min\\n SpO2: 90%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 93.3 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,530 mL\\n 600 mL\\n PO:\\n 1,220 mL\\n 500 mL\\n TF:\\n IVF:\\n 310 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 2,565 mL\\n 1,200 mL\\n Urine:\\n 2,565 mL\\n 1,200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,036 mL\\n -600 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 90%\\n ABG: ///32/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 200 K/uL\\n 7.2 g/dL\\n 92 mg/dL\\n 4.3 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 135 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 21.3 %\\n 8.4 K/uL\\n [image002.jpg]\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n 08:17 PM\\n 04:05 AM\\n WBC\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n 8.4\\n Hct\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n 25.1\\n 21.3\\n Plt\\n 185\\n 170\\n 200\\n 217\\n 200\\n Cr\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n 4.2\\n 4.3\\n Glucose\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n 208\\n 92\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\\n shows interval improvement, patient appears to be responding to\\n diuresis as well.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\\n hemoorhave given improving respiratory status and no hemoptysis.\\n Probably due to plasmapheresis, given with 50% albumin yesterday.\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\\n - CXR daily\\n -Plasmapheresis, dose 5/7 yesterday, then W/F.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n - f/u Rheum recs\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine up to 4.3 from 4.0 yesterday, BUN down to 135, good\\n urine output. As a note, plasmapheresis in cases of severe Wegeners\\n has been shown to improve kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,we have been diuresing him well, with ?\\n liters off in the past 5 days. His creatinine bumped a little bit this\\n morning, probably we are at his dry weight and can back off on\\n diuresis.\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A\\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\\n one more day.\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\\n stable. ECHO showed mild LV septal , 45-50%. Possibly\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n -Increased lopressor to 75mg po tid yesterday.\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n HCT have been low in the morning and higher in the afternoon for the\\n past 2 days despite no transfusion and no plasmapheresis. Variation\\n may be due to lab variability, fluid shifts during the day, or another\\n unknown cause. Will monitor as long as he is hemodynamically stable.\\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\\n unit.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n #Hyperglycemia- non-diabetic, likely high dose steroids.\\n -SSI plus standing 3units, well controlled.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333940,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt remains in aflutter at a rate of 70s-low 100s\\n Action:\\n Conts on lopressor 50mg TID\\n Response:\\n Tolerating the lopressor, he did have short periods of a HR in the\\n 1teens this afternoon\\n Plan:\\n Cont with the lopressor, follow VS\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Creat was 8.6 this morning and 8.0 this afternoon, u/o has been\\n 40-50cc/hr\\n Action:\\n Pt had a renal biopsy this morning under US guidance, given 2 bagsof\\n FFP for this, needed Ca gluc this evening as well. He is receiving D5W\\n 100cc/hr for 1 liter for a Na of 150\\n Response:\\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\\n Plan:\\n Follow HCT\\n due tonight, VS, renal bx results, no immediate plans for\\n dialysis, follow labs, to receive cytoxan again tonight, 7 \\n resourse nurse is aware and some will be down to give this\\n he needs\\n mesna before and after\\n please see \\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\\n has not been coughing up any blood\\n Action:\\n He is on scoop mask at 60-70% and this brings his 02 up to the mid 90s\\n Response:\\n Conts to require a high FI02\\n Plan:\\n Follow SATs cont to try to wean his FI02\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335723,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Continued to desat when facemask off. otherwise, stable.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:24 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 36.3\\nC (97.4\\n HR: 117 (99 - 137) bpm\\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\\n RR: 24 (11 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,510 mL\\n 304 mL\\n PO:\\n 1,340 mL\\n 240 mL\\n TF:\\n IVF:\\n 170 mL\\n 64 mL\\n Blood products:\\n Total out:\\n 2,800 mL\\n 300 mL\\n Urine:\\n 2,800 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,290 mL\\n 4 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 217 K/uL\\n 7.8 g/dL\\n 88 mg/dL\\n 4.4 mg/dL\\n 30 mEq/L\\n 3.7 mEq/L\\n 145 mg/dL\\n 103 mEq/L\\n 144 mEq/L\\n 23.0 %\\n 9.8 K/uL\\n [image002.jpg]\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n WBC\\n 10.3\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n Hct\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n Plt\\n 00\\n 217\\n Cr\\n 6.5\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n Glucose\\n 95\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\\n Assessment and Plan\\n This is a 60 year-old male with a distant history of nephrolithiasis,\\n no other chronic medical problems who presents with lower extremity\\n edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\\n Continues to desat to 80s when mask comes off. Most likely secondary\\n to diffuse alveolar hemorrhage C-ANCA vasculitis\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - HCT down today, unlikely due to alveolar imprroving respiratory\\n status, no hemoptysis. Continue to monitor\\n -Continue nystatin mouthwash for + sputum, though no sign of\\n thrush.\\n - Albuterol nebs PRN\\n - CXR daily\\n -Plasmapheresis, dose 5/7 today, then W/F.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\\n needed, will give po H20 before dose\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. As a note,\\n plasmapheresis in cases of severe Wegeners has been shown to improve\\n kidney outcomes, though not mortality.\\n - Foley in place , strict I&O,\\n -pink tinged urine, improved. Will continue to monitor visually. If\\n worsening will get U/A. It is also possible that his HCT is due to\\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\\n signs of increasing hematuria at present.\\n -On Sevelamer, for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n # Tachycardia: Asymptomatic, rate increases when active/talking,\\n normal when sleeping. ECHO showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\\n He received 1 unit yesterday and bumped appropriately.\\n -q12 HCT, transfuse if <21\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative thus far, continue to check all stools.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 335851,\n \"text\": \"Clinician: Attending\\n Critical Care\\n 42 yo woman paraplegic after MVA , recently discharged from\\n hospital after \\\"pneumonia\\\" noted by PCA to be lethargic at home, SaO2\\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\\n somewhat confused but conversant. Still somewhat lethargic. We are\\n continuing Narcan but would have some concern about methadone as\\n explanation for her lethargy as no change in methadone dose for 6 weeks\\n and not previously sedated by med. Would also have some concern about\\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\\n presentation. Not clear why she developed PNA. We are continuing O2,\\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\\n have PFTs before d/c.\\n Total time spent: 35 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335154,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\\n continues to desat when off O2 ( removes O2 while sleeping on and off)\\n Action:\\n Scheduled neb given , nystatin swish given for yeast in sputum.\\n Response:\\n Good response to neb , Slept well with ambien.\\n Plan:\\n Continue to monitor VSS and follow sats closely.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\\n Action:\\n Followed up with labs overnight.\\n Response:\\n U/O wnl, continued to monitor renal parameters\\n Plan:\\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334317,\n \"text\": \": This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt in atrial flutter when awake , rate in mid 130\\ns, BP remaining\\n stable at 130\\ns systolic. When sleeping NSR, rate in 90\\ns, Calcium\\n level remains low , less than 1.1 ( ionized calcium)\\n Action:\\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\\n this shift\\n Response:\\n Positive effect to lopressor.\\n Plan:\\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\\n lytes and replete as needed\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n U/O maintaining above 40cc/hr, reveived one unit of red cell\\n yesterday\\n Action:\\n HCT trending up from 20.9 to 22.4 after blood, received\\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\\n to Cytoxan\\n Response:\\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\\n yesterday to 149 and 7.1 early this a.m\\n Plan:\\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\\n cytoxan as ordered\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\\n non productive cough remains, LS diminished at bases\\n Action:\\n Continue with mepron\\n Response:\\n VSS stable, no resp distress noted\\n Plan:\\n Continue to monitor VSS, sats,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334996,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia.\\n HPI:\\n 24 Hour Events:\\n Experienced some hemoptysis yesterday PM.\\n Appears much more comfortable today, less dyspneic.\\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 Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\\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, Hematuria\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\\n RR: 26 (18 - 27) insp/min\\n SpO2: 88%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 238 mL\\n PO:\\n 290 mL\\n 120 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 118 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 2,900 mL\\n Urine:\\n 3,010 mL\\n 2,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -2,663 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 88%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\\n No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\\n Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.3 g/dL\\n 185 K/uL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Wegener's Granulomatosis\\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\\n plasmaphoresis\\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\\n falling, urine output improving, responding to diuretics.\\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\\n escalation. Consider dDAVP. need dialysis if continues to\\n NUTRITIONAL SUPPORT -- PO\\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\\n suppression. Transfuse to Hct >25\\n FLUID -- continue net negative. Monitor I/O.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 335972,\n \"text\": \"Chief Complaint: Respiratory distress\\n HPI:\\n 24 Hour Events:\\n EKG - At 12:02 PM\\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\\n Tolerated plasmaphoresis yesterday.\\n Continues net diuresis, tolerated well.\\n No further hemoptysis.\\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 Furosemide (Lasix) - 07:30 PM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, 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 10:38 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\\n HR: 114 (100 - 142) bpm\\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\\n RR: 21 (12 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 93.3 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 1,534 mL\\n 902 mL\\n PO:\\n 1,220 mL\\n 750 mL\\n TF:\\n IVF:\\n 314 mL\\n 152 mL\\n Blood products:\\n Total out:\\n 2,565 mL\\n 1,690 mL\\n Urine:\\n 2,565 mL\\n 1,690 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,031 mL\\n -788 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///32/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.2 g/dL\\n 200 K/uL\\n 92 mg/dL\\n 4.3 mg/dL\\n 32 mEq/L\\n 3.6 mEq/L\\n 135 mg/dL\\n 103 mEq/L\\n 145 mEq/L\\n 21.3 %\\n 8.4 K/uL\\n [image002.jpg]\\n 09:59 PM\\n 04:37 AM\\n 07:41 PM\\n 05:22 AM\\n 04:05 PM\\n 04:00 AM\\n 03:55 PM\\n 04:07 AM\\n 08:17 PM\\n 04:05 AM\\n WBC\\n 11.0\\n 11.0\\n 12.2\\n 9.8\\n 8.4\\n Hct\\n 23.7\\n 21.6\\n 25.0\\n 22.6\\n 26.7\\n 24.0\\n 27.0\\n 23.0\\n 25.1\\n 21.3\\n Plt\\n 185\\n 170\\n 200\\n 217\\n 200\\n Cr\\n 6.2\\n 6.1\\n 5.6\\n 5.2\\n 5.1\\n 5.0\\n 4.4\\n 4.2\\n 4.3\\n Glucose\\n 146\\n 82\\n 145\\n 79\\n 237\\n 117\\n 88\\n 208\\n 92\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\\n Assessment and Plan\\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\\n steroids, cytoxan. Complete Plasmaphoresis course.\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\\n oxygen requirement.\\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\\n improvement. Monitor. No acute indication for dialysis.\\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\\n Monitor.\\n TACHYCARDIA -- improved. Monitor.\\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\\n Transfuse to Hct >21.\\n HYPERGLYCEMIA -- contributed by high dose steroids.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :Transfer to floor\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333556,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics: None\\n Infusions: None\\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: None\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula 4L\\n SpO2: 90%\\n Physical Examination\\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\\n tachypneic, NAD\\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\\n malar area of face\\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\\n lung fields posteriorly\\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\\n (improved today, less erythematous), no cyanosis/ clubbing\\n Labs / Radiology\\n 213 mg/dL\\n 147 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 107 mEq/L\\n 5.5 mEq/L\\n 144 mEq/L\\n 7.4 K/uL\\n 9.0 g/dL\\n 26.6 %\\n 513 K/uL\\n [image002.jpg]\\n Anion Gap = 20\\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\\n symmetrical alveolar opacities, almost in all lung fields, consistent\\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\\n consistent with old granulomatous disease\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL****\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n .\\n Plan:\\n .\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - Continue supplemental O2 PRN\\n - Albuterol nebs PRN\\n - CXR\\ns as needed\\n - Type and screen, cross match x 2 units; threshold to transfuse hct\\n <21, unless clinically unstable\\n - Blood consent\\n - Consult Renal and Rheum in a.m.\\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\\n get renal biopsy\\n - Will continue Solumedrol 1g IV daily\\n - F/u on Renal serology and BAL results from OSH\\n - Will check Crits q8 for now\\n .\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\\n Denies epistaxis. However, apart from pulmonary association, ddx for\\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\\n ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's. Also consider DIC.\\n - F/u on u/a, urine lytes, urine sediment\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Consult Renal here\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Will check q8 lytes for now\\n - Start Sevelemer in a.m. with meals for elevated Phos.\\n .\\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\\n Can be secondary to underlying structural heart disease. Also may be\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n - Check TSH\\n - Surface ECHO in a.m.\\n - Will start Lopressor 12.5mg PO daily for rate control.\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check Crits q8\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\\n respiratory status worsens anticipating intubation. Will replete lytes\\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\\n .\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333557,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics: None\\n Infusions: None\\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: None\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula 4L\\n SpO2: 90%\\n Physical Examination\\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\\n tachypneic, NAD\\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\\n malar area of face\\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\\n lung fields posteriorly\\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\\n (improved today, less erythematous), no cyanosis/ clubbing\\n Labs / Radiology\\n 213 mg/dL\\n 147 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 107 mEq/L\\n 5.5 mEq/L\\n 144 mEq/L\\n 7.4 K/uL\\n 9.0 g/dL\\n 26.6 %\\n 513 K/uL\\n [image002.jpg]\\n Anion Gap = 20\\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\\n symmetrical alveolar opacities, almost in all lung fields, consistent\\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\\n consistent with old granulomatous disease\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL****\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n .\\n Plan:\\n .\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - Continue supplemental O2 PRN\\n - Albuterol nebs PRN\\n - CXR\\ns as needed\\n - Type and screen, cross match x 2 units; threshold to transfuse hct\\n <21, unless clinically unstable\\n - Blood consent\\n - Consult Renal and Rheum in a.m.\\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\\n get renal biopsy\\n - Will continue Solumedrol 1g IV daily\\n - F/u on Renal serology and BAL results from OSH\\n - Will check Crits q8 for now\\n .\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\\n Denies epistaxis. However, apart from pulmonary association, ddx for\\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\\n ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's. Also consider DIC.\\n - F/u on u/a, urine lytes, urine sediment\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Consult Renal here\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Will check q8 lytes for now\\n - Start Sevelemer in a.m. with meals for elevated Phos.\\n .\\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\\n Can be secondary to underlying structural heart disease. Also may be\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n - F/u on TSH\\n - Surface ECHO in a.m. today\\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check Crits q8\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\\n respiratory status worsens anticipating intubation. Will replete lytes\\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\\n .\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-22 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1030091,\n \"text\": \" 5:49 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: interval change, worsening consolidations on CXR, compare w\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegner's granulomatosis, pulm hemorrhage, ? aspergillous\\n infection, on vori, w worsening dyspnea. On CXR consolidation in R mid lung\\n appears worse, needs repeat NON-CONTRAST CHEST CT (renal failure) to evaluate\\n the densities further\\n REASON FOR THIS EXAMINATION:\\n interval change, worsening consolidations on CXR, compare w previous Chest CT\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n WET READ: ARHb MON 7:50 PM\\n Widespread pulmonary abnormalities, including consolidation, ground glass\\n change, and nodularity, persist and have worsened at the right lung base.\\n Differential continues to include vasculitis/hemorrhage and infection,\\n including Aspergillus. Persistent right apical lung nodules. Increased small\\n to moderate right pleural effusion. Unchanged left effusion. No significant\\n change in mediastinl/hilar adenopathy.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient's Wegener's granulomatosis,\\n pulmonary hemorrhage and suspected aspergillus infection with worsening\\n dyspnea.\\n\\n COMPARISON: Chest CT from .\\n\\n TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to\\n upper abdomen with subsequent 1.25 and 5-mm collimation. Axial images\\n reviewed in conjunction with coronal and sagittal reformats.\\n\\n FINDINGS:\\n\\n Multifocal mediastinal lymphadenopathy is unchanged with enlarged nodes\\n present in multiple compartments. Within the left mediastinal lymph nodes\\n measure up to 1.4 cm at the shortest access, within the left compartment is up\\n to 1.5 cm. The additional conglomerate of the lymph nodes in the subcarinal\\n lesion is up to 1.8 cm in diameter so grossly with no significant change since\\n the prior study. The bilateral hila are diffusely enlarged with most likely\\n present lymph nodes that are difficult to evaluate without injection of\\n contrast. Calcifications in the right hilus suggest prior granulomatous\\n exposure. There is most likely increase in the size of the right hilar lymph\\n node, 2:32 currently 1.3 cm in diameter compared to 7 mm on the prior study.\\n The patient is anemic giving the high density of the myocardium compared to\\n the blood in the . Diffuse coronary calcifications are seen. There\\n is no pericardial effusion. Bilateral pleural effusions are present, still\\n small but slightly increased compared to the prior study.\\n\\n The imaged portion of the upper abdomen is grossly unremarkable with no\\n appreciable change since the prior study.\\n (Over)\\n\\n 5:49 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: interval change, worsening consolidations on CXR, compare w\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n The airways are patent to the level of lobar and segmental bronchi bilaterally\\n except for right lower lobe with occlusion of the apical segment is noted,\\n most liklely due to secretions. Widespread pulmonary abnormality has\\n slightly progressed since the recent study including areas of consolidation,\\n ground- glass opacities and poorly defined nodules. The consolidations and\\n ground glass are most pronounced in the mid and lower lungs, namely in the\\n posterior segment of left upper lobe, lingula, and both lower lobes, right\\n more than left. The previously demonstrated well defined perifissural nodule\\n in the right lower lobe anteriorly is unchanged. Extensive bronchial impaction\\n is present within the lower lobe bronchi. Marked upper lobe predominantly\\n paraseptal and centrilobular emphysema is unchanged. Within the right apex, a\\n 2 cm nodular opacity is identified containing calcification. Similar size\\n spiculated opacity is seen in the left apex with less prominent spiculated\\n appearance.\\n\\n No suspicious lytic or blastic lesions were demonstrated in the imaged portion\\n of the skeleton.\\n\\n IMPRESSION:\\n\\n 1. Widespread pulmonary abnormalities including consolidation, ground glass\\n in poorly defined lung nodules, slightly worse, but no new areas involved. As\\n previously mentioned vasculitis and associated pulmonary hemorrhage are the\\n primary diagnosis. Coexisting infection such as bacterial infection or\\n aspergillosis cannot be excluded.\\n\\n 2. Spiculated right apical lesion raise concern for possible primary lung\\n cancer especially on a patient with underlying emphysema. It is still\\n potentially can be related to diffuse lung abnormalities thus three months\\n followup chest CT is highly recommended.\\n\\n 3. Extensive intrathoracic lymphadenopathy: related to vasculitis and/or\\n reactive to infection.\\n\\n 4. Slightly increased but still small bilateral pleural effusion in minimal\\n amount of ascites.\\n\\n 5. Evidence of anemia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-22 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1030021,\n \"text\": \", V. MED 11R 9:37 PM\\n CHEST (PA & LAT) Clip # \\n Reason: worsening dyspnea, eval for interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\\n interval change\\n REASON FOR THIS EXAMINATION:\\n worsening dyspnea, eval for interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Dense consolidation right mid and left mid lung zone. Improved aeration in\\n lower lung zones.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-22 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1030020,\n \"text\": \" 9:37 PM\\n CHEST (PA & LAT) Clip # \\n Reason: worsening dyspnea, eval for interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\\n interval change\\n REASON FOR THIS EXAMINATION:\\n worsening dyspnea, eval for interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 3:42 PM\\n Dense consolidation right mid and left mid lung zone. Improved aeration in\\n lower lung zones.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PA AND LATERAL\\n\\n COMPARISON: .\\n\\n HISTORY: Wegener's granulomatosis and aspergillosis.\\n\\n FINDINGS: There has been interval increase in dense consolidation in the\\n right mid lung zone and left mid lung zone. The lung bases appear to have\\n improved in aeration. Small bilateral pleural effusions are unchanged.\\n Emphysematous changes particularly in the apices are noted.\\n\\n IMPRESSION: More dense consolidations seen in the right mid lung and left mid\\n lung zones. Improved aeration in the bilateral lower lung zones.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026997,\n \"text\": \" 6:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary renal syndrome\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:49 AM\\n PFI: Slight interval improvement in the left lung consolidations.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Interval change in a patient with renal failure.\\n\\n Portable AP chest radiograph was compared to the prior studies obtained on\\n .\\n\\n There is overall slight improvement in the opacities of the left lung with no\\n change in the right lower lung consolidation with again demonstrated more\\n discrete nodular opacity. There is no pleural effusion. For precise\\n characterization of the finding, further evaluation with chest CT might be\\n appropriate as the differential diagnosis is broad, including widespread\\n infection, hemorrhage or asymmetric edema.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026998,\n \"text\": \", M. MED 6:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary renal syndrome\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Slight interval improvement in the left lung consolidations.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1026946,\n \"text\": \" 6:32 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Please assess dialysis line placement.\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with IJ dialysis line\\n REASON FOR THIS EXAMINATION:\\n Please assess dialysis line placement.\\n ______________________________________________________________________________\\n WET READ: SBNa SUN 7:06 PM\\n Right IJ line terminates in upper SVC. Unchanged appearance of b/l diffuse\\n opacites. No ptx.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Evaluation of the central venous catheter placement.\\n\\n Portable AP chest was compared to .\\n\\n The right internal jugular line catheter was inserted with its tip projecting\\n at the level of the junction of brachiocephalic vein and superior SVC. The\\n heart size is moderately enlarged but stable. There is also no change in the\\n mediastinal contour. There is overall no change in the extensive parenchymal\\n consolidation compared to the prior study. The differential diagnosis might\\n include extensive infection, pulmonary edema in the presence of underlying\\n emphysema or pulmonary hemorrhage, clinical correlation in comparison to the\\n prior studies is required. Note is made of a more discrete rounded density in\\n the right lower lung unchanged since the prior study, which might represent a\\n part of a similar process or additional underlying abnormality. Scarring in\\n the upper lung is unchanged. No appreciable pleural effusion is demonstrated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028387,\n \"text\": \" 5:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval pulm change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's.\\n REASON FOR THIS EXAMINATION:\\n interval pulm change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, PORTABLE AP:\\n\\n COMPARISON: One day prior.\\n\\n HISTORY: 50-year-old man with Wegner's, evaluate for any change.\\n\\n FINDINGS: There is slightly improved aeration of both lungs. Again seen is\\n diffuse areas of consolidation, primarily in the right mid lung zone and left\\n mid and lower lung zone. No new consolidations are identified. Biapical\\n scarring is unchanged. Cardiomediastinal and hilar contours are unremarkable.\\n A right-sided internal jugular catheter sheath is seen terminating in the\\n upper SVC. There is no evidence of pneumothorax.\\n\\n IMPRESSION: Slightly improved aeration of both lungs. Persistent opacities\\n seen primarily in the right mid and left mid to lower lung zones.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-17 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1028954,\n \"text\": \" 4:27 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: eval of this currently immunocompromised pt with rare asperg\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\\n noted sputum cx noting rare aspergillis\\n REASON FOR THIS EXAMINATION:\\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\\n sx\\n CONTRAINDICATIONS for IV CONTRAST:\\n ARF\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB WED 7:17 PM\\n Multifocal consolidation, ground-glass attenuation, and poorly defined\\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\\n lymphadenopathy, and a small amount of ascites.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST, \\n\\n Comparison chest radiographs dating between and .\\n\\n INDICATION: Wegener's granulomatosis, pulmonary hemorrhage, and Aspergillus\\n on recent sputum culture.\\n\\n TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was\\n performed without intravenous or oral contrast. Images are presented for\\n display in the axial plane at 5-mm and 1.25-mm collimation. A series of\\n multiplanar reformation images were also submitted for review.\\n\\n FINDINGS: Widespread pulmonary abnormalities are present, including areas of\\n consolidation, ground-glass attenuation, and poorly defined nodules. The\\n areas of consolidation and ground glass are most pronounced in the mid and\\n lower lungs. In addition to poorly defined bronchovascular nodules, one well-\\n defined perifissural nodule is identified in the right lower lobe anteriorly\\n measuring 8 mm (227, 4A). Extensive bronchial impaction is present within the\\n lower lobe bronchi, but the more central airways appear patent. Marked upper\\n lobe predominant paraseptal and centrilobular emphysema are present. Within\\n the right apex, a spiculated 2.1-cm diameter nodular opacity is identified\\n (68, 4A) with an eccentric granuloma. Additional similar-sized spiculated\\n opacity is identified higher in the right apex (52, 4A).\\n\\n Multifocal mediastinal lymphadenopathy is present, with enlarged nodes present\\n in multiple compartments. Within the left mediastinum, lymph nodes measure up\\n to 1.4 cm in short axis in the lower left paratracheal region and 1.5 cm in\\n the left prevascular area. Additional conglomerate lymph nodes are seen in\\n the subcarinal region measuring up to approximately 17 mm in short axis. There\\n are likely bilateral hilar nodes present, difficult to measure in the absence\\n (Over)\\n\\n 4:27 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: eval of this currently immunocompromised pt with rare asperg\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n of intravenous contrast. A few small calcified mediastinal and hilar nodes are\\n also evident. No pericardial effusion is identified. Coronary artery\\n calcifications are evident. Small dependent simple pleural effusions are\\n present bilaterally.\\n\\n Exam was not tailored to evaluate the subdiaphragmatic region, but note is\\n made of a small amount of ascites as well as nonspecific mesenteric stranding.\\n Liver appears relatively hyperdense, possibly due to previous transfusions or\\n amiodarone therapy.\\n\\n No suspicious lytic or blastic skeletal lesions are identified.\\n\\n IMPRESSION:\\n 1. Widespread pulmonary abnormalities including consolidation, ground-glass,\\n and poorly defined lung nodules. These could be due to the patient's known\\n vasculitis with associated pulmonary hemorrhage, but coexisting Aspergillus\\n infection is likely given the reported sputum culture results.\\n 2. Spiculated right apical nodules raise the concern for possible primary\\n lung cancer in this patient with underlying emphysema, but could potentially\\n be related to the same process as the diffuse lung abnormalities. 3-month\\n chest CT followup is suggested following appropriate therapy to ensure\\n resolution.\\n 3. Extensive intrathoracic lymphadenopathy, which may be due to Wegener's\\n and/or reactive nodes from infection.\\n 4. Small bilateral pleural effusions and a small amount of ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-17 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1028955,\n \"text\": \", MED 11R 4:27 PM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: eval of this currently immunocompromised pt with rare asperg\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\\n noted sputum cx noting rare aspergillis\\n REASON FOR THIS EXAMINATION:\\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\\n sx\\n CONTRAINDICATIONS for IV CONTRAST:\\n ARF\\n ______________________________________________________________________________\\n PFI REPORT\\n Multifocal consolidation, ground-glass attenuation, and poorly defined\\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\\n lymphadenopathy, and a small amount of ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027858,\n \"text\": \" 3:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for worsening infiltrates\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegeners and pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Eval for worsening infiltrates\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 10:07 PM\\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\\n are unchanged. There is no residual pulmonary edema.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PORTABLE AP\\n\\n COMMENTS: 50-year-old man with Wegener and pulmonary hemorrhage.\\n\\n Since yesterday, bilateral dense consolidation in mid and lower lung zones are\\n unchanged. There is no residual pulmonary edema. Pleural effusions, if any,\\n are small. Heart size is top normal and unchanged. Right internal jugular\\n sheath ends in right brachiocephalic vein.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027200,\n \"text\": \" 4:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: looking for interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with hypoxia\\n REASON FOR THIS EXAMINATION:\\n looking for interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 9:50 AM\\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\\n is unchanged. Right internal jugular is in good position. Left small pleural\\n effusion is new with associated atelectasis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST PORTABLE AP\\n\\n COMMENTS: 60-year-old man with hypoxia. Interval change.\\n\\n Since , bilateral alveolar opacity with slightly nodular appearance\\n is unchanged in this patient with pulmonary renal syndrome.\\n\\n Small left pleural effusion is new associated with new left lower lobe\\n atelectasis. Right internal jugular catheter is in good position.\\n\\n Findings can be consistent with multifocal infection, bilateral hemorrhage or\\n much less likely asymmetric pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028071,\n \"text\": \" 4:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for infiltrates, effusions, edema\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with wegener's and cough\\n REASON FOR THIS EXAMINATION:\\n evaluate for infiltrates, effusions, edema\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): NLHa SAT 1:28 PM\\n Bilateral opacities unchanged. Right central venous catheter unchanged.\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Portable chest x-ray performed at 0515 hours.\\n\\n Comparison is . There are bilateral opacities involving both lower and\\n mid lung fields. The opacity on the left extends to involve the upper lung\\n field. Compared to prior exam, there is increasing density in the right\\n base. The cardiac silhouette is mildly enlarged.\\n\\n IMPRESSION: Increasing density in the right base.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027201,\n \"text\": \", M. MED 4:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: looking for interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with hypoxia\\n REASON FOR THIS EXAMINATION:\\n looking for interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\\n is unchanged. Right internal jugular is in good position. Left small pleural\\n effusion is new with associated atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027613,\n \"text\": \" 5:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for new infiltrate\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Eval for new infiltrate\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:10 AM\\n PFI: No change in the bilateral severe predominantly lower lobe opacification\\n compared to the prior study.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient with pulmonary hemorrhage.\\n\\n Portable AP chest radiograph was compared to obtained at\\n 05:40.\\n\\n In the interim, there is overall no significant change in the bilateral severe\\n predominantly lower lobe consolidations with some involvement of the upper\\n lungs, left more than right, consistent with diffuse parenchymal hemorrhage.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027401,\n \"text\": \", MED 5:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\\n remains normal. Pleural effusion, if any, is small. Right jugular line is\\n central. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028562,\n \"text\": \" 5:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegeners\\n REASON FOR THIS EXAMINATION:\\n eval interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:21 AM\\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\\n bilateral consolidations with slight decrease in the right mid lung but are\\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\\n lesions on the right could be present but are hard to confirm due to\\n underlying diffuse consolidation. Chest CT could further characterize lung\\n opacities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, PORTABLE AP\\n\\n REASON FOR EXAM: 60-year-old man with Wegener. Evaluate for interval change.\\n\\n Since yesterday, right internal jugular catheter still ends in upper SVC.\\n Diffuse bilateral consolidation slightly decreased in the right mid lung but\\n are unchanged on the left. Consolidation has a more heterogeneous appearance,\\n could be due to underlying cavitary lesions hard to better define. Chest CT\\n could further characterize lung opacities if clinically warranted.\\n\\n Biapical scarring is unchanged.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028563,\n \"text\": \", MED 5:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegeners\\n REASON FOR THIS EXAMINATION:\\n eval interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\\n bilateral consolidations with slight decrease in the right mid lung but are\\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\\n lesions on the right could be present but are hard to confirm due to\\n underlying diffuse consolidation. Chest CT could further characterize lung\\n opacities.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"BX-NEEDLE KIDNEY BY NEPHROLOGIST\",\n \"row_id\": 1027056,\n \"text\": \" 10:49 AM\\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \\n Reason: ? Gbm disease versus wegeners' granulomatosis\\n Admitting Diagnosis: VASCULITIS\\n ********************************* CPT Codes ********************************\\n * BX-NEEDLE KIDNEY BY NEPHROLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with glomerulonephritis and pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n ? Gbm disease versus wegeners' granulomatosis\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Glomerulonephritis and pulmonary hemorrhage. Questionable GBM\\n disease vs. Wegener's.\\n\\n FINDINGS: Ultrasound guidance was provided for renal biopsy performed by\\n nephrology team. Five core biopsy samples were obtained from the lower pole\\n of the left kidney. The patient tolerated the procedure well. No immediate\\n complications occurred.\\n\\n IMPRESSION: Successful ultrasound-guided biopsy performed by the nephrology\\n team.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-17 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 1028947,\n \"text\": \" 4:15 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: eval sinusus (asking for non-contrast study with ARF as belo\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\\n noted sputum cx noting rare aspergillis\\n REASON FOR THIS EXAMINATION:\\n eval sinusus (asking for non-contrast study with ARF as below)\\n CONTRAINDICATIONS for IV CONTRAST:\\n acute renal failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 60-year-old male with newly-diagnosed Wegener's\\n granulomatosis with acute renal failure, pulmonary hemorrhage with sputum\\n culture noting \\\"rare aspergillus.\\\"\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the sinuses. Coronal\\n reformatted images were obtained.\\n\\n FINDINGS: Extensive sinus disease is present with air-fluid levels in both\\n maxillary sinuses. The left maxillary sinus is nearly-completely opacified and\\n containing hyperdense secretions. The right maxillary, sphenoid and frontal\\n sinuses show circumferential mucosal thickening. Dense secretions are also\\n identified in the right nasal cavity.\\n\\n There is diffuse bony remodeling and permeation involving the ethmoid septae,\\n maxillary sinus medial walls and ostiomeatal complexes, and the nasal\\n turbinates, which in the absence of history or prior surgery, likely relate to\\n Wegener's granulomatosis. However, the nasal septum and hard palate remain\\n intact. There is no evidence of intracranial or orbital involvement. The\\n mastoid air cells remain normally aerated.\\n\\n IMPRESSION:\\n 1. Extensive pansinus soft tissue disease, most severely affecting the left\\n maxillary sinus. Note is made of dense secretions in the left maxillary sinus\\n and right nasal cavity which may simply represent chronically-inspissated\\n secretions; however, fungal colonization (ie. with Aspergillus spp. and their\\n metabolic byproducts) can have a similar appearance.\\n 2. Extensive bony remodeling and permeation involving the sinuses and nasal\\n turbinates which in the absence of prior surgery can be seen with Wegener's\\n granulomatosis. The nasal septum remains intact.\\n\\n These findings were discussed with Dr. (primary hospitalist) at the\\n time of interpretation, by Dr. . Evaluation by ENT Service, with\\n possible diagnostic aspiration of the left maxillary contents, may be\\n warranted.\\n\\n (Over)\\n\\n 4:15 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \\n Reason: eval sinusus (asking for non-contrast study with ARF as belo\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028225,\n \"text\": \", MED 4:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval pulm change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's\\n REASON FOR THIS EXAMINATION:\\n interval pulm change\\n ______________________________________________________________________________\\n PFI REPORT\\n Improved aeration of left mid lung zone.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 1027059,\n \"text\": \" 10:42 AM\\n RENAL U.S. Clip # \\n Reason: WITH GLOMERULONEPHRITIS\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Glomerulonephritis.\\n\\n COMPARISON: None.\\n\\n FINDINGS: The right kidney measures 12.4 cm and the left 12.8 cm. The renal\\n parenchymal echogenicity is increased, bilaterally. There are no renal\\n calculi or hydronephrosis. Small amount of fluid is seen adjacent to the\\n right kidney. The bladder is not distended with a Foley catheter within,\\n cannot be assessed accurately.\\n\\n IMPRESSION: Bilateral increased renal parenchymal echogenicity consistent\\n with medical renal disease. Small amount of right perinephric free fluid.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027400,\n \"text\": \" 5:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 3:06 PM\\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\\n remains normal. Pleural effusion, if any, is small. Right jugular line is\\n central. No pneumothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 5:40 A.M. ON \\n\\n HISTORY: Pulmonary hemorrhage.\\n\\n IMPRESSION: AP chest compared to through :\\n\\n Severe infiltrative pulmonary abnormality responsible for dense consolidation\\n in the lower mid and lower lung zones since has not improved and may\\n have worsened in the lung bases, now accompanied by progressive vascular\\n congestion in the upper lung suggesting volume overload also responsible for\\n mild increase in caliber of the azygos vein, although vascular engorgement is\\n undoubtedly exaggerated by supine positioning. Pleural effusions, if any, are\\n small. Heart size is top normal and unchanged. Right jugular introducer ends\\n at the thoracic inlet. No other invasive support devices.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1026858,\n \"text\": \" 10:30 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please assess for evidence of infiltrate\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with evidence of diffuse alveolar hemorrhage on bronch and\\n renal failure\\n REASON FOR THIS EXAMINATION:\\n please assess for evidence of infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Diffuse alveolar hemorrhage.\\n\\n FINDINGS: No previous images available. There is mild enlargement of the\\n cardiac silhouette. Diffuse bilateral asymmetric alveolar opacifications\\n involving almost all of both lungs. This would be consistent with diffuse\\n alveolar hemorrhage as clinically suspected. Fibrocalcific changes in the\\n apices are consistent with old granulomatous disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027859,\n \"text\": \", MED 3:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for worsening infiltrates\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegeners and pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Eval for worsening infiltrates\\n ______________________________________________________________________________\\n PFI REPORT\\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\\n are unchanged. There is no residual pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028072,\n \"text\": \", MED 4:14 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for infiltrates, effusions, edema\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with wegener's and cough\\n REASON FOR THIS EXAMINATION:\\n evaluate for infiltrates, effusions, edema\\n ______________________________________________________________________________\\n PFI REPORT\\n Bilateral opacities unchanged. Right central venous catheter unchanged.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 87723,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Right ventricular function. Valvular heart disease.\\nHeight: (in) 69\\nWeight (lb): 150\\nBSA (m2): 1.83 m2\\nBP (mm Hg): 112/56\\nHR (bpm): 78\\nStatus: Outpatient\\nDate/Time: at 11:48\\nTest: TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Elongated LA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of\\nthe interatrial septum. No ASD by 2D or color Doppler.\\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\\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\\ninferoseptal - hypo; septal apex - hypo;\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\\nhypokinesis. Abnormal septal motion/position.\\n\\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\\nmitral valve chordae. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\\nPhysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nConclusions:\\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\\nDoppler. Left ventricular wall thicknesses and cavity size are normal. There\\nis mild regional left ventricular systolic dysfunction with septal\\nhypokinesis. The right ventricular cavity is mildly dilated with mild global\\nfree wall hypokinesis. There is abnormal septal motion/position. The aortic\\nroot is moderately dilated at the sinus level. The ascending aorta is mildly\\ndilated. The aortic valve leaflets (3) are mildly thickened but aortic\\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\\neffusion.\\n\\nIMPRESSION: Mild hypokinesis of the septum along with abnormal septal motion.\\nMildly dilated and hypokinetic right ventricle. The interventricular septal\\nmotion is abnormal and may be consistent with right ventricular volume\\noverload. Mild mitral and tricuspid regurgitation. Dilated aortic sinus and\\nascending aorta.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1027614,\n \"text\": \", MED 5:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for new infiltrate\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with pulmonary hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Eval for new infiltrate\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: No change in the bilateral severe predominantly lower lobe opacification\\n compared to the prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2199-07-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1028224,\n \"text\": \" 4:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval pulm change\\n Admitting Diagnosis: VASCULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with Wegener's\\n REASON FOR THIS EXAMINATION:\\n interval pulm change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 9:18 AM\\n Improved aeration of left mid lung zone.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST AT 05:20\\n\\n INDICATION: Wegener's.\\n\\n COMPARISON: at 05:09\\n\\n FINDINGS:\\n\\n Compared to prior there is improved aeration of the left mid lung zone. The\\n remainder of the study is unchanged with continued evidence of previously seen\\n airspace disease. No PTX. Right CVL remains in place.\\n\\n IMPRESSION: Improved aeration of the left mid lung zone.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224051,\n \"text\": \"Atrial flutter with variable block. Non-specific repolarization abnormalities.\\nIntraventricular conduction delay of right bundle-branch block type. Compared\\nto the previous tracing of there is no significant difference.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224052,\n \"text\": \"Atrial flutter with rapid ventricular response. Right ventricular conduction\\ndelay. Compared to the previous tracing of no diagnostic interim\\nchange.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224053,\n \"text\": \"Atrial flutter\\nModest right ventricular conduction delay\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224054,\n \"text\": \"Atrial flutter. Modest right ventricular conduction delay. Since the previous\\ntracing of no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224055,\n \"text\": \"Atrial flutter. Modest right ventricular conduction delay. Since the previous\\ntracing of no significant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224056,\n \"text\": \"Atrial flutter with variable block. Incomplete right bundle-branch block.\\nCompared to the previous tracing of A-V block is now irregular. The\\nunderlying atrial rhythm continues to likely be counterclockwise flutter.\\nThe other findings are similar.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2199-07-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 224057,\n \"text\": \"Counterclockwise atrial flutter with 2:1 A-V block. Diffuse non-specific\\nST-T wave changes likely secondary to rate. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333538,\n \"text\": \"Chief Complaint: ARF, alveolar hemorrhage\\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\\n cytoxan 120 mg there. He was transferred for consideration of\\n plasmapheresis.\\n 24 Hour Events:\\n EKG - At 10:48 PM\\n -Tachycardic to low 100s with EKG concerning for A.flutter\\n -Hyperkalemic requiring kayexalate\\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 RISS\\n Solumedrol 1 g daily\\n Albuterol Q6H\\n Atrovent Q6H\\n Protonix\\n Colace\\n Lopressor 12.5 mg \\n Renagel\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Tachycardia\\n Respiratory: Cough, No hemoptysis\\n Gastrointestinal: Nausea\\n Genitourinary: Foley\\n Integumentary (skin): Rash, Diffuse maculopapular\\n Heme / Lymph: Anemia\\n Flowsheet Data as of 09:15 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.3\\nC (95.6\\n HR: 109 (106 - 123) bpm\\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\\n RR: 30 (16 - 31) insp/min\\n SpO2: 93%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 426 mL\\n PO:\\n 230 mL\\n 240 mL\\n TF:\\n IVF:\\n 186 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 495 mL\\n Urine:\\n 125 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -69 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n FiO2: 4 L\\n SpO2: 91%\\n Physical Examination\\n General Appearance: No acute distress, Tachypneic\\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\\n Bilateral )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: None.\\n Skin: Few petechiae at feet. Maculopapular rash resolved.\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.0 g/dL\\n 513 K/uL\\n 213 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 5.5 mEq/L\\n 147 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 26.6 %\\n 7.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL\\n Fluid analysis / Other labs: AG 20\\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\\n interstitial components. Normal cardiomediastinal contours. Minimal\\n bilateral costophrenic blunting.\\n Microbiology: None.\\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\\n Wegener\\ns granulomatosis, MPA, Goodpasteur\\ns, lupus, post-strep GN with\\n DIC (less likely). He is currently clinically stable and has been\\n started on solumedrol and cytoxan.\\n 1) Pulmonary-renal syndrome\\n ANCA, anti-GBM, , anti-dsDNA,\\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\\n serologies pending. Will consult renal for cytoxan dosing,\\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\\n 2) Anemia\\n Likely alveolar hemorrhage. Will rule out\\n hemolysis. Trend Q8H until stable.\\n 3) Renal failure\\n No acute indication for RRT at this point.\\n Does have an AG metabolic acidosis. Hyperkalemia currently\\n controllable with medications. No EKG changes. Renagel. Follow\\n electrolytes.\\n 4) Atrial flutter\\n Start low-dose beta-blockade. TSH pending.\\n TTE pending.\\n ICU Care\\n Nutrition: Renal, cardiac\\n Glycemic Control: Regular insulin sliding scale\\n Lines: Peripheral IVs\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Protonix\\n VAP: N/A\\n Comments:\\n Communication: Comments:\\n Code status: Full code. Son, , is HCP.\\n Disposition :Remains in ICU.\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333555,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics: None\\n Infusions: None\\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: None\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula 4L\\n SpO2: 90%\\n Physical Examination\\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\\n tachypneic, NAD\\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\\n malar area of face\\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\\n lung fields posteriorly\\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\\n (improved today, less erythematous), no cyanosis/ clubbing\\n Labs / Radiology\\n 213 mg/dL\\n 147 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 107 mEq/L\\n 5.5 mEq/L\\n 144 mEq/L\\n 7.4 K/uL\\n 9.0 g/dL\\n 26.6 %\\n 513 K/uL\\n [image002.jpg]\\n Anion Gap = 20\\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\\n symmetrical alveolar opacities, almost in all lung fields, consistent\\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\\n consistent with old granulomatous disease\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL****\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333655,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\\ns, SpO2 low\\n 90\\ns trending down to 87 on 4L via NC.\\n Action:\\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\\n assessment closely. Following ABG as ordered. Encouraging C+DB\\n exercises.\\n Response:\\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\\n of accessory muscles; however, pt able to speak in full sentences and\\n reports breathing is\\nbetter\\n as compared to yesterday. ABG 7.31/37/67.\\n Plan:\\n Continue to monitor respiratory assessment closely. Follow ABG as\\n ordered. Titrated FiO2 as ordered and indicated\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt presented to OSH w/ Creatanine >9.\\n Action:\\n Following labs as ordered. Monitoring fluid status closely. Pt given\\n kayexalate X 2 doses since admission\\n see . Renal fellow currently\\n placing HD line.\\n Response:\\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\\n 30-100ml/hr. Hct remains stable at 27.\\n Plan:\\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\\n in am. Following hct and lytes Q8hr as ordered.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt remains in a-flutter (baseline since arrival to OSH per report). RVR\\n to 130\\ns. BP remains stable.\\n Action:\\n Monitoring HR, rhythm and hemodynamic status closely. Lopressor\\n increased to 25mg PO TID.\\n Response:\\n HR better controlled on increased lopressor (110-115). Continues in\\n a-flutter. BP remains stable.\\n Plan:\\n Continue to monitor cardiac and hemodynamic status closely. Continue\\n lopressor as ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333454,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\\n Action:\\n Observing u/o and labs. Will consult renal in am and follow\\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\\n start sevelamer in the am.\\n Response:\\n pending\\n Plan:\\n Renal will consult in the am. Will draw am labs.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\\n lungs with crackles\\n way up. Also some mild exp wheezes.\\n Action:\\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\\n Response:\\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\\n with crackles\\n way up.\\n Plan:\\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\\n monitor sao2 and provide o2 as needed.\\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333642,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\\ns, SpO2 low\\n 90\\ns trending down to 87 on 4L via NC.\\n Action:\\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\\n assessment closely. Following ABG as ordered. Encouraging C+DB\\n exercises.\\n Response:\\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\\n of accessory muscles; however, pt able to speak in full sentences and\\n reports breathing is\\nbetter\\n as compared to yesterday. ABG 7.31/37/67.\\n Plan:\\n Continue to monitor respiratory assessment closely. Follow ABG as\\n ordered. Titrated FiO2 as ordered and indicated\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt presented to OSH w/ Creatanine >9.\\n Action:\\n Following labs as ordered. Monitoring fluid status closely. Pt given\\n kayexalate X 2 doses since admission\\n see . Renal fellow currently\\n placing HD line.\\n Response:\\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\\n 30-100ml/hr. Hct remains stable at 27.\\n Plan:\\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\\n in am. Following hct and lytes Q8hr as ordered.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333643,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\\ns, SpO2 low\\n 90\\ns trending down to 87 on 4L via NC.\\n Action:\\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\\n assessment closely. Following ABG as ordered. Encouraging C+DB\\n exercises.\\n Response:\\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\\n of accessory muscles; however, pt able to speak in full sentences and\\n reports breathing is\\nbetter\\n as compared to yesterday. ABG 7.31/37/67.\\n Plan:\\n Continue to monitor respiratory assessment closely. Follow ABG as\\n ordered. Titrated FiO2 as ordered and indicated\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt presented to OSH w/ Creatanine >9.\\n Action:\\n Following labs as ordered. Monitoring fluid status closely. Pt given\\n kayexalate X 2 doses since admission\\n see . Renal fellow currently\\n placing HD line.\\n Response:\\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\\n 30-100ml/hr. Hct remains stable at 27.\\n Plan:\\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\\n in am. Following hct and lytes Q8hr as ordered.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333496,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 1\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 90%\\n ABG: ///17/\\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 513 K/uL\\n 9.0 g/dL\\n 213 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 5.5 mEq/L\\n 147 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 26.6 %\\n 7.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333711,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx. Pt was adm on .\\n Atrial flutter (Aflutter)\\n Assessment:\\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\\n the high 120-130 range during plasmapharesis. B/P has remained stable\\n 110/78-132/69.\\n Action:\\n Lopressor was increased to 50mg tid which was started last evening.\\n Response:\\n H/R is decreasing from the 100\\ns to the 80-90range.\\n Plan:\\n Cont with tid lopressor. Monitor h/r and pattern.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\\n Action:\\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\\n past 24 hours pt has had 2 doses of Kayexalate.\\n Response:\\n K+ is 4. U/O improving with urine more yellow. Last creat 8.5 with bun\\n 147\\n Plan:\\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\\n lungs have had crackles bil bases with the left lung more dim than the\\n right..\\n Action:\\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\\n evening and was given cytoxan after the plasmaphoresis. Pt is also\\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\\n Response:\\n Sao2 drops to the high 80\\ns while pt wears only the n/c. pt does not\\n like to wear face mask and denies any sob.\\n Plan:\\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\\n plasmaphoresis again on Tues.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333805,\n \"text\": \"Chief Complaint: ARF, alveolar hemorrhage\\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\\n cytoxan 120 mg there. He was transferred for consideration of\\n plasmapheresis.\\n 24 Hour Events:\\n EKG - At 10:48 PM\\n -Tachycardic to low 100s with EKG concerning for A.flutter\\n -Hyperkalemic requiring kayexalate\\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 RISS\\n Solumedrol 1 g daily\\n Albuterol Q6H\\n Atrovent Q6H\\n Protonix\\n Colace\\n Lopressor 12.5 mg \\n Renagel\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Tachycardia\\n Respiratory: Cough, No hemoptysis\\n Gastrointestinal: Nausea\\n Genitourinary: Foley\\n Integumentary (skin): Rash, Diffuse maculopapular\\n Heme / Lymph: Anemia\\n Flowsheet Data as of 09:15 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.3\\nC (95.6\\n HR: 109 (106 - 123) bpm\\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\\n RR: 30 (16 - 31) insp/min\\n SpO2: 93%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 426 mL\\n PO:\\n 230 mL\\n 240 mL\\n TF:\\n IVF:\\n 186 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 495 mL\\n Urine:\\n 125 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -69 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n FiO2: 4 L\\n SpO2: 91%\\n Physical Examination\\n General Appearance: No acute distress, Tachypneic\\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\\n Bilateral )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: None.\\n Skin: Few petechiae at feet. MacPap rash resolving\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.0 g/dL\\n 513 K/uL\\n 213 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 5.5 mEq/L\\n 147 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 26.6 %\\n 7.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL\\n Fluid analysis / Other labs: AG 20\\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\\n interstitial components. Normal cardiomediastinal contours. Minimal\\n bilateral costophrenic blunting.\\n Microbiology: None.\\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\\n Wegener\\ns granulomatosis, MPA, Goodpasteur\\ns, lupus, post-strep GN with\\n DIC (less likely). He is currently clinically stable and has been\\n started on solumedrol and cytoxan.\\n 1) Pulmonary-renal syndrome\\n ANCA, anti-GBM, , anti-dsDNA,\\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\\n serologies pending. Will consult renal for cytoxan dosing,\\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\\n 2) Anemia\\n Likely alveolar hemorrhage. Will rule out\\n hemolysis. Trend Q8H until stable.\\n 3) Renal failure\\n No acute indication for RRT at this point.\\n Does have an AG metabolic acidosis. Hyperkalemia currently\\n controllable with medications. No EKG changes. Renagel. Follow\\n electrolytes.\\n 4) Atrial flutter\\n Start low-dose beta-blockade. TSH pending.\\n TTE pending.\\n MICU Attending Addendum\\n Pt seen with fellow and examined. Met with pt and family to review\\n situation. Would add and emphasize the following to Dr \\ns notes.\\n On exam\\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\\n alos right forearm.\\n ABG 7.31/37/67\\n BUN 147/ Cr 9.6\\n CXR: diffsue bilateral interstitial and alveolar infiltrates\\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\\n and renal failure quite concerning for vasculitis.\\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\\n Role of plasmapheresis without clear diagnosis is challenging. Will\\n consult with Renal collegues on possibility of a renal biopsy to aid in\\n diagnosis. Additionally he is moving towards dialysis, need to closely\\n watch K, renally dose all meds. His resp status is tenusous due to\\n hypoxemia as well as met acidosis and uremic encephalopathy- may\\n require intubation for support\\n would likely favor this over NIPPV\\n given likely duration.\\n Discussed with son who is HCP and updated.\\n ICU Care\\n Nutrition: Renal, cardiac\\n Glycemic Control: Regular insulin sliding scale\\n Lines: Peripheral IVs\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Protonix\\n VAP: N/A\\n Comments:\\n Communication: Comments:\\n Code status: Full code. Son, , is HCP.\\n Disposition :Remains in ICU.\\n Total time spent: Critically Ill 50 min\\n ------ Protected Section ------\\n MICU Attending Addendum\\n Updated note on events from . In the course of the afternoon, I\\n spent over 2 hours working with both the renal consultation team and Dr\\n and the Plasmapheresis team determining indication and timing of\\n pheresis for possible anti GBM. We were able to update family, call in\\n pheresis team, and place pheresis catheter all to facilitate. Pt with\\n progressive hypoxemia and on NRB\\n ongoing frequent labs to assess HCT,\\n also borderline indication for HD due to progressive encephalopathy,\\n boerdeline hyperK and acidosis.\\n Time Spent 120 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 08:22 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333807,\n \"text\": \"Chief Complaint: Respiratory distress/hypoxemia\\n HPI:\\n 24 Hour Events:\\n EKG - At 02:00 PM\\n DIALYSIS CATHETER - START 06:48 PM\\n Renal consultation concurred with Pulmonary-Renal syndrome.\\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\\n anticipating 5 days of treatment. Remains on cortocosteroids.\\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\\n Denies increased dyspnea, but remains with oxygen requirement.\\n History obtained from Patient\\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 09:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.3\\nC (95.5\\n HR: 81 (81 - 133) bpm\\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\\n RR: 24 (22 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 902 mL\\n 186 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 662 mL\\n 186 mL\\n Blood products:\\n Total out:\\n 1,330 mL\\n 690 mL\\n Urine:\\n 1,330 mL\\n 690 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -429 mL\\n -504 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: 7.31/37/67/22/-6\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\\n mildly disshevled\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.6 g/dL\\n 355 K/uL\\n 176 mg/dL\\n 8.6 mg/dL\\n 22 mEq/L\\n 3.9 mEq/L\\n 149 mg/dL\\n 108 mEq/L\\n 150 mEq/L\\n 22.6 %\\n 8.1 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n WBC\\n 7.4\\n 8.1\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n Plt\\n 543\\n 513\\n 355\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\\n predominantly basilar. Right IJ catheter position acceptable. No\\n significant overall change compared to .\\n Assessment and Plan\\n 60 yom now with Pulmonary-Renal syndrome.\\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\\n diffuse infiltrates and oxygen requirement.\\n HYPOXEMIA -- attributed to pulmonary infiltrates.\\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\\n SaO2.\\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\\n consult prepared to move to dialysis when indicated. Monitor urine\\n output, BUN, Creatitine.\\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\\n Continue steroids and plasmaphoresis.\\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\\n FLUIDS -- limit iv fluids intake.\\n HYPERPHOSPHATEMIA -- start phosphate binder.\\n NUTRITION -- NPO pending evaluation\\n ANEMIA -- progressive, attributed to underlying process, and possible\\n contribution from RIJ central line placement. Transfuse to Hct >21.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 333895,\n \"text\": \"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 Comments:\\n Pt currently on 6L NC. Pt ordered for albuterol and Atrovent nebs Q6.\\n Nebs given as ordered and pt tolerated them well.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 333425,\n \"text\": \"Chief Complaint: Bilateral LE edema, SOB\\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy.\\n .\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptons started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n .\\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\\n noted as having mild wheezing and productive cough of white sputum.\\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\\n Occult blood stool negative. U/A significant for protein 400mg/dl,\\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\\n microscopy positive for RBCs, granular casts.\\n .\\n Pt was seen by Renal, who thought there might possibly be a\\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\\n .\\n CXR on admission showed underlying COPD with diffuse bilateral\\n pulmonary infiltrates.\\n Pt underwent bronchoscopy on , and was found to have active low\\n grade blood emanating from the RLL and LLL.\\n .\\n EKG on admission showed atrial flutter at 2:1 block rate 150.\\n .\\n On arrival here, pt appeared mildly tachypneic. He reported that LE\\n edema had improved, and that pain had resolved in LE. He complained of\\n only mild nausea recently without vomiting, and a productive cough.\\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\\n constipation, melena, hematochezia, chest pain, urinary\\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\\n no epistaxis. Last BM was yesterday, and was formed.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other:\\n Review of systems:\\n Flowsheet Data as of 12:49 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.5\\nC (95.9\\n HR: 107 (107 - 122) bpm\\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\\n RR: 27 (16 - 27) insp/min\\n SpO2: 91%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 48 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 48 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 100 mL\\n Urine:\\n 125 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -52 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 91%\\n ABG: ///16/\\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 543 K/uL\\n 219 mg/dL\\n 9.7 mg/dL\\n 144 mg/dL\\n 16 mEq/L\\n 107 mEq/L\\n 6.2 mEq/L\\n 143 mEq/L\\n 31.0 %\\n [image002.jpg]\\n \\n 2:33 A8/9/ 11:05 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 Hct\\n 31.0\\n Plt\\n 543\\n Cr\\n 9.7\\n Glucose\\n 219\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.6 mg/dL\\n Assessment and Plan\\n ABG: ///16/\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 333422,\n \"text\": \"Clinician: Attending\\n 60 yo male without significant medical history now admit to OSA with\\n lower extremity edema x 2 weeks. His presentation there was notable\\n for severe acute renal failure and with diffuse alveolar infiltrates.\\n The findings at the OSA were consistent with acute GN based upon review\\n of the urine sediment. In addition, patient did have bronchoscopy\\n revealing a strong suggestion of alveolar hemorrhage with sequential\\n lavage showing persistent bloody fluid. There was no hemoptysis noted.\\n U/A there--RBC's and granular casts documented.\\n There he has had persistent renal failure and alveolar infiltrates and\\n now with persistent tachycardia patient to ICU for further\\n evaluation and care after solumedrol and cytoxan started at OSH.\\n ROS-negative for sinusitis/sinus congestion\\n Here patient has persistent sinus tachycardia noted,\\n Exam notable for-->\\n Patient comfortable by subjective description\\n No JVD\\n Lungs-Diffuse crackles bilaterally inferiorly and to mid lung zone.\\n Heart-Tachycardic and regular rate suggested on initial exam\\n Extremities--1+ bilateral lower extremity edema. Diffuse macular rash\\n from foot to knee.\\n Labs->\\n Cr-9.6\\n K-5.8\\n HCO3-=18\\n CXR->Patient with diffuse bilateral alveolar infiltrates--there is a\\n suggestion of lower lobe distribution but with the complete absence of\\n pleural effusions which is consistent with alveolar hemorrhage.\\n ECG-Atrial Flutter seen with atrial rate at approx 300 bpm and\\n ventricular rate of 125-150.\\n In summary this is a 60 yo male with findings of acute renal failure\\n with evidence of diffuse alveolar hemorrhage and active disease with\\n ESR >140. No definative diagnostic procedure was preformed and serum\\n testing, although sent, is all pending at this time. Patient did start\\n Solumedrol and Cytoxan for empiric diagnosis of\\n vasculitis with serologies pending. Goodpasteur's and Wegner's and\\n microscopic polyangiitis and PAN all are on this list along with\\n connective tissue disease.\\n 1)Acute Renal Failure-\\n -Significant concern for acute vasculitis\\n -Given severity of dysfunction certainly intervention is desired in\\n timely fashion\\n -Would favor biopsy prior to intervention is patient remains stable\\n enough to accept.\\n -With Solumedrol and Cytoxan 1 dose given is challenging decision to\\n consider hold of further treatment prior to biopsy.\\n -Will consult renal for consideration of biopsy.\\n -Given significant clinical decline and significant pulmonary\\n distress--tachypnea and tachycardia--I would favor continuation of\\n treatment already started given his subjective improvement over past 24\\n hours. Although this will cloud the biopsy results his clinical status\\n at this point in time is one that warrants intervention.\\n -Continue Solumedrol 1g qd and Cytoxan to continue\\n -Renal and Rheum to evaluate patient for aid in diagnosis and treatment\\n -C3, C4, , Anti-GBM, ANCA all pending\\n 2)Alevolar Hemorrhage--seen on OSH bronchoscopy, no biopsies performed\\n -Continue with supportive care at this time\\n -Will have to consider diagnostic procedure and consideration of renal\\n biopsy may be highest yield\\n -Attempt to maintain euvolemia as hydrostatic edema is of concern given\\n signficiant volume overload but will be limited by renal failure and\\n the distribution of infiltrates.\\n 3)Atrial Flutter-\\n Hold anticoagulation for bleeding risk\\n Rate control as needed\\n Will need TSH and ECHO in full evaluation\\n 4)Anemia-\\n Patient with reasonable stability with transfusion--may well be\\n inadequate production with associated blood loss at this time--with the\\n blood loss less active at this time.\\n -F/u HCT\\n -Monitor with OB for stool\\n Total time spent: 45 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333661,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\\n for elevated K.\\n EKG - At 10:48 PM\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics: None\\n Infusions: None\\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\\n Other medications:\\n Changes to medical and family history: None\\n Review of systems is unchanged from admission except as noted below\\n Review of systems: None\\n Flowsheet Data as of 06:25 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.4\\nC (95.8\\n HR: 109 (107 - 123) bpm\\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\\n RR: 26 (16 - 31) insp/min\\n SpO2: 90%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 161 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 161 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 415 mL\\n Urine:\\n 125 mL\\n 415 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -255 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula 4L\\n SpO2: 90%\\n Physical Examination\\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\\n tachypneic, NAD\\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\\n malar area of face\\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\\n lung fields posteriorly\\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\\n (improved today, less erythematous), no cyanosis/ clubbing\\n Labs / Radiology\\n 213 mg/dL\\n 147 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 107 mEq/L\\n 5.5 mEq/L\\n 144 mEq/L\\n 7.4 K/uL\\n 9.0 g/dL\\n 26.6 %\\n 513 K/uL\\n [image002.jpg]\\n Anion Gap = 20\\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\\n symmetrical alveolar opacities, almost in all lung fields, consistent\\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\\n consistent with old granulomatous disease\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL****\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n .\\n Plan:\\n .\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - Continue supplemental O2 PRN\\n - Albuterol nebs PRN\\n - CXR\\ns as needed\\n - Type and screen, cross match x 2 units; threshold to transfuse hct\\n <21, unless clinically unstable\\n - Blood consent\\n - Consult Renal and Rheum in a.m.\\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\\n get renal biopsy\\n - Will continue Solumedrol 1g IV daily\\n - F/u on Renal serology and BAL results from OSH\\n - Will check Crits q8 for now\\n .\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\\n Denies epistaxis. However, apart from pulmonary association, ddx for\\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\\n ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's. Also consider DIC.\\n - F/u on u/a, urine lytes, urine sediment\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Consult Renal here\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Will check q8 lytes for now\\n - Start Sevelemer in a.m. with meals for elevated Phos.\\n .\\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\\n Can be secondary to underlying structural heart disease. Also may be\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n - F/u on TSH\\n - Surface ECHO in a.m. today\\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check Crits q8\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\\n respiratory status worsens anticipating intubation. Will replete lytes\\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\\n .\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n ------ Protected Section ------\\n Addendum\\n Anti-GBM test sent to Specialty Laboratories, 1, #4 to\\n connect to lab. They will run this particular study on Tuesday, ^th, and result may become available ^th-15^th.\\n PGY-1\\n ------ Protected Section Addendum Entered By: , MD\\n on: 19:28 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 333670,\n \"text\": \"Clinician: Attending\\n Patient seen and examined. Plasmapharesis initiated this evening.\\n Appears to be tolerating it well with no new complaints. Currently BP\\n 130/70, HR 134, sat 94-97% on full face mask. No respiratory distress.\\n Fine crackles heard laterally but otherwise lungs are relatively clear.\\n Plan is for plasmapharesis, K to be rechecked. If necessary to be\\n dialysed, renal will consider tonight. Cytoxan to be redosed at 140 mg\\n IV, weight based at ~2 mg/kg for 67 kg. On Solumedrol 1 gm q24h x 3\\n days. 30 min of CC time spent with patient.\\n Total time spent: 30 minutes\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 333725,\n \"text\": \"Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Diminished\\n LLL Lung Sounds: Crackles\\n Comments:\\n Plan\\n Pt presently on 3 lpm n/c and ordered for nebs alb/atr. Nebs\\n administered as ordered with no adverse reactions.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 335004,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\\n Continued to desat into the 80s because his mask falls off, but remains\\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\\n liters. Urine output before midnight=300cc/hr and after MN, continued\\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\\n sent yesterday.\\n HCT remained stable, repleted lytes\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 92 (76 - 130) bpm\\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\\n RR: 26 (12 - 27) insp/min\\n SpO2: 89%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 70 mL\\n PO:\\n 290 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 70 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 1,900 mL\\n Urine:\\n 3,010 mL\\n 1,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -1,830 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 89%\\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 185 K/uL\\n 7.3 g/dL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \\n C-ANCA vasculitis. This morning, he breathing more easily, with stable\\n lung exam though his CXR looks unchanged. This is likely due to\\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\\n 2+ budding yeast on sputum, without signs of candidiasis on\\n oropharyngeal exam.\\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\\n urine output and restart IVF if necessary. We will balance maintaining\\n urine output >100/hr for bladder protection with not giving too much\\n Lasix due to renal failure.\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n His septum is intact this am. Will continue to check daily.\\n -Start nystatin mouthwash\\n -Send blood cultures for fungus (though highly unlikely given pt. is\\n afebrile, stable, but he is on high dose immunosuppression)\\n -CT of sinus has been recommended, but will not likely change\\n management so we will not order it at this time.\\n - HCTq8h to monitor for alveolar bleeding. Given\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient desats while eating, if he continues will make him NPO\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\\n mesna for cystitis prophylaxis\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\\n to improve kidney outcomes, though not mortality.\\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\\n but more cellular glomeruli than sclerotic giving hope for return on.\\n Monitor for bleeding at site given possible platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\\n ANCA P.\\n - Foley in place , strict I&O, q8 lytes .\\n -pink tinged urine, stable. Urine has been tinged nephritic\\n picture, but if worsening, concern for hemorrhagic cystitis. Will\\n monitor for increasing blood in urine and can irrigate the bladder if\\n hemorrhagic cystitis is suspected.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 4gIV in last 24 hours.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335152,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\\n continues to desat when off O2 ( removes O2 while sleeping on and off)\\n Action:\\n Scheduled neb given , nystatin swish given for yeast in sputum.\\n Response:\\n Good response to neb , Slept well with ambien.\\n Plan:\\n Continue to monitor VSS and follow sats closely.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334768,\n \"text\": \"Chief Complaint: Hypoxemia\\n HPI:\\n 24 Hour Events:\\n Remains with high FiO2 requirement.\\n HR varies from A-flutter to NRS.\\n Coughing up sputum (swallowing), but more productive cough today.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.2\\n Tcurrent: 36.1\\nC (96.9\\n HR: 98 (85 - 131) bpm\\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\\n RR: 18 (12 - 25) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 1,971 mL\\n PO:\\n 750 mL\\n 160 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 1,811 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 1,235 mL\\n Urine:\\n 2,400 mL\\n 1,235 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 736 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 94%\\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, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: 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, No(t) Sedated,\\n No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.8 g/dL\\n 211 K/uL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\\n Possible component of pulmonary edema.\\n HYPOXEMIA -- attributed to pulmonary infiltrates. Continue\\n supplemental oxygen, monitor RR, SaO2.\\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\\n steroids & cytoxan. Plasmaphoresis.\\n RENAL FAILURE -- improving. Monitor uo, BUN, creatinine.\\n FLUIDS\\n desire to allow net diuresis. Consider Lasix dose.\\n NUTRIONAL SUPPORT -- PO\\n HEMATURIA -- stable. Monitor.\\n ANEMIA -- stable s/p transfusion.\\n HYPOCALCEMIA -- continue to replete.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 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: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334958,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\\n Continued to desat into the 80s because his mask falls off, but remains\\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\\n liters. Urine output before midnight=300cc/hr and after MN, continued\\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\\n sent yesterday.\\n HCT remained stable, repleted lytes\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Furosemide (Lasix) - 12:30 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:05 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36.2\\nC (97.2\\n HR: 92 (76 - 130) bpm\\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\\n RR: 26 (12 - 27) insp/min\\n SpO2: 89%\\n Heart rhythm: AF (Atrial Fibrillation)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,660 mL\\n 70 mL\\n PO:\\n 290 mL\\n TF:\\n IVF:\\n 2,214 mL\\n 70 mL\\n Blood products:\\n 156 mL\\n Total out:\\n 3,010 mL\\n 1,900 mL\\n Urine:\\n 3,010 mL\\n 1,900 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -350 mL\\n -1,830 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 89%\\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 185 K/uL\\n 7.3 g/dL\\n 82 mg/dL\\n 6.1 mg/dL\\n 28 mEq/L\\n 3.6 mEq/L\\n 152 mg/dL\\n 104 mEq/L\\n 143 mEq/L\\n 21.6 %\\n 11.0 K/uL\\n [image002.jpg]\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n 03:17 PM\\n 09:59 PM\\n 04:37 AM\\n WBC\\n 9.0\\n 10.3\\n 11.0\\n Hct\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n 24.0\\n 23.7\\n 21.6\\n Plt\\n 221\\n 211\\n 185\\n Cr\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n 6.2\\n 6.1\\n Glucose\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n 146\\n 82\\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\\n of breathing, with worsening lung exam and desating to the 70s without\\n the facemask on. This is unlikely due to hemorrhage as his crit has\\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\\n and chest Xray appears to have signs of pulmonary edema, making volume\\n overload the most likely cause of worsening pulmonary status.\\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\\n output >100/hr for bladder protection with not giving too much Lasix\\n due to renal failure.\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n Will examine his septum today as this could worsen his repiratory\\n status and make him feel nasal congestion (which he has been\\n complaining of)\\n -CT of sinus has been recommended, will consider when patient more\\n stable.\\n - HCT has been stable, follow HCT q8h to monitor for alveolar\\n bleeding.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient desats while eating, if he continues will make him NPO\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\\n mesna for cystitis prophylaxis\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\\n to improve kidney outcomes, though not mortality.\\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\\n but more cellular glomeruli than sclerotic giving hope for return on.\\n Monitor for bleeding at site given possible platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\\n ANCA P.\\n - Foley in place , strict I&O, q8 lytes .\\n -pink tinged urine, stable. Urine has been tinged nephritic\\n picture, but if worsening, concern for hemorrhagic cystitis. Will\\n monitor for increasing blood in urine and can irrigate the bladder if\\n hemorrhagic cystitis is suspected.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 4gIV in last 24 hours.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-13 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335153,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\\n continues to desat when off O2 ( removes O2 while sleeping on and off)\\n Action:\\n Scheduled neb given , nystatin swish given for yeast in sputum.\\n Response:\\n Good response to neb , Slept well with ambien.\\n Plan:\\n Continue to monitor VSS and follow sats closely.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\\n Action:\\n Response:\\n U/O wnl, continued to monitor renal parameters\\n Plan:\\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334748,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Dx: Wegener\\ns Granulomatosis confirmed by renal biopsy\\n Atrial flutter (Aflutter)\\n Assessment:\\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\\n frequent episodes of tachycardia in the 130\\ns, typically with exertion,\\n stimulation and desats. BP within normal limits.\\n Action:\\n Tolerating metoprolol PO\\n Response:\\n Heart rate slows to the 80-90\\ns with rest, VS WNL\\n Plan:\\n Continue to monitor Heart rate/rhythm, administer metoprolol as\\n ordered. Encourage rest periods\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\\n noted. Creatinine is 6.5, BUN 153\\n Action:\\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\\n Creatinine is trending down. Hct drawn at 1530, results pending.\\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\\n with meals. Lunch held due to respiratory distress.\\n Response:\\n Labs to be drawn 4 hours after plasmaphoresis and tonight at 2200.\\n Fluid balance remains positive. Good urine output response to lasix.\\n Tolerated plasmaphoresis with episodes of tachycardia.\\n Plan:\\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\\n total of 7 treatments via right IJ HD catheter. Administer mesna as\\n ordered with chemo. Chemo to be given after plasmaphoresis.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\\n strong productive cough. Patient\\ns O2 requirements increasing\\n throughout the day.\\n Action:\\n O2 titrated accordingly. Face tent increased/decreased, now at 95% and\\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\\n albuterol changed to prn (may be contributing to tachycardia). Afrin\\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\\n on.\\n Response:\\n Oxygenation remains labile. Desats with eating and removal the face\\n tent. Recovery time longer each time he desats.\\n Plan:\\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\\n sputum sample. Patient may need a sinus CT scan if stable. Administer\\n neb treatments as ordered.\\n Patient\\ns family at bedside. Updated on plan of care.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334749,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\\n edema, 2L fluids up. Did not receive cytoxan yesterday. Will receive\\n it after pheresis today.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\\n RR: 23 (9 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 979 mL\\n PO:\\n 750 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 979 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 640 mL\\n Urine:\\n 2,400 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 339 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 211 K/uL\\n 7.8 g/dL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\\n of breathing, with worsening lung exam and desating to the 70s without\\n the facemask on. This is unlikely due to hemorrhage as his crit has\\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\\n and chest Xray appears to have signs of pulmonary edema, making volume\\n overload the most likely cause of worsening pulmonary status.\\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\\n output >100/hr for bladder protection with not giving too much Lasix\\n due to renal failure.\\n -Patients at Wegener\\ns are at increased risk for septal perforation.\\n Will examine his septum today as this could worsen his repiratory\\n status and make him feel nasal congestion (which he has been\\n complaining of)\\n -CT of sinus has been recommended, will consider when patient more\\n stable.\\n - HCT has been stable, follow HCT q8h to monitor for alveolar\\n bleeding.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient desats while eating, if he continues will make him NPO\\n - treating the underlying disease-Wegeners:\\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\\n -Prednisone 60mg po daily,\\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\\n mesna for cystitis prophylaxis\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\\n biopsy. Creatinine trending down, good urine output. BUN still high\\n but not increasing, no signs of platelet dysfunction yet, mental status\\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\\n to improve kidney outcomes, though not mortality.\\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\\n but more cellular glomeruli than sclerotic giving hope for return on.\\n Monitor for bleeding at site given possible platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\\n ANCA P.\\n - Foley in place , strict I&O, q8 lytes .\\n -pink tinged urine, stable. Urine has been tinged nephritic\\n picture, but if worsening, concern for hemorrhagic cystitis. Will\\n monitor for increasing blood in urine and can irrigate the bladder if\\n hemorrhagic cystitis is suspected.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\\n renal toxicity.\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 4gIV in last 24 hours.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n Waiting at least 4 hours after pheresis for accurate .\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\\n septal , 45-50%. Likely secondary to large volume shifts\\n (retaining total body fluid with renal failure, with large volume load\\n putting stress on atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiac negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: Dialysis line in his neck, with pigtail.\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 335073,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis on\\n plasmapheresis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt. with Wegener\\ns granulocytosis with Hx. Of pulmonary hemorrhage per\\n bronch at OSH. On 80% face tent and 6L NC. LS diminished. Occ congested\\n non-productive cough. No hemoptesis this shift.\\n Action:\\n Plasmapherisis today. Cont. O2 for O2 sat >90%. HOB >45 degrees.\\n Atrovent neb as ordered. Started on Nyastatin swish and spit for yeast\\n in sputum cx on .\\n Response:\\n O2 sat 92-98%. Occ will desat to 86% when mask falls down or when\\n eating.\\n Plan:\\n Cont. current treatment. Monitor resp. status and wean O2 as tolerated.\\n F/u sputum cx.\\n Plasmapherisis today. Nest treatment on Monday. Transfused today with\\n one unit of PRBC for Hct. 21.6. Will need serial Hct. Checks starting\\n after transfusion.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334190,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Overall, no significant change in supplimental oxygen requirement.\\n Overall, appears much more comfortable.\\n Able to eat.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.2\\nC (95.4\\n HR: 90 (72 - 133) bpm\\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\\n RR: 22 (19 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 443 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 443 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 485 mL\\n Urine:\\n 1,405 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -42 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, High flow neb\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Well nourished, No(t) No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\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, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 6.9 g/dL\\n 261 K/uL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\\n bibasilar, unchanged.\\n Assessment and Plan\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\\n Await renal Bx results and serologies.\\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\\n BUN, creatitine, UO.\\n NUTRITIONAL SUPPORT -- advance PO.\\n FLUIDS -- provide adequate urine output (cytoxan)\\n HYPERGLYCEMIA -- promoted by steroids.\\n A-FLUTTER -- good rate control. Continue meds.\\n ANEMIA -- slow reduction. Blood loss due to pulmonary hemorrhage and\\n renal bx likely contributing. Transfuse to >21\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 334197,\n \"text\": \"Lung sounds\\n RLL Lung Sounds: Exp Wheeze\\n RUL Lung Sounds: Exp Wheeze\\n LUL Lung Sounds: Exp Wheeze\\n LLL Lung Sounds: Crackles\\n Comments:\\n Pt currently on 6L NC. Nebs given as ordered with no adverse reaction.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333491,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\\n Action:\\n Observing u/o and labs. Will consult renal in am and follow\\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\\n start sevelamer in the am.\\n Response:\\n Pending. Creat 9.2 this am\\n Plan:\\n Renal will consult in the am. Will draw am labs.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\\n lungs with crackles\\n way up. Also some mild exp wheezes.\\n Action:\\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\\n Response:\\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\\n with crackles\\n way up.\\n Plan:\\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\\n monitor sao2 and provide o2 as needed.\\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333972,\n \"text\": \"This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\\n syndrome.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\\n activities.But when resting and sleeping in 80\\ns-90\\ns.NBP within\\n limits.No drop in BP with high HR.\\n Action:\\n Pt is on metoprolol for rate control.\\n Response:\\n HR in 80\\ns 90\\ns while at rest.\\n Plan:\\n Cont monitoring.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\\n with diminished base.Pt has got strong productive cough.\\n Action:\\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\\n is on high dose of steroids and had chemo.And pt is getting\\n plasmapheresis every other day.\\n Response:\\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\\n Plan:\\n Cont monitoring resp status.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\\n yesterday.Pt has got elevated phos and sodium.\\n Action:\\n Renal failure most likely due to vasculitis. Pt is getting treated by\\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\\n na.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333970,\n \"text\": \"This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\\n syndrome.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\\n activities.But when resting and sleeping in 80\\ns-90\\ns.NBP within\\n limits.No drop in BP with high HR.\\n Action:\\n Pt is on metoprolol for rate control.\\n Response:\\n HR in 80\\ns 90\\ns while at rest.\\n Plan:\\n Cont monitoring.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\\n with diminished base.Pt has got strong productive cough.\\n Action:\\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\\n is on high dose of steroids and had chemo.And pt is getting\\n plasmapheresis every other day.\\n Response:\\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\\n Plan:\\n Cont monitoring resp status.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334155,\n \"text\": \"Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\\n for presumed Wegeners.\\n 24 Hour Events:\\n Continues to have increasing 02 requirement, on 6L and facemask to keep\\n 02 >90%. Yesterday he had a renal biopsy, TTE, given d5W for\\n hypernatremia and seen by rheumatology.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 89 (72 - 133) bpm\\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 343 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 343 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 440 mL\\n Urine:\\n 1,405 mL\\n 440 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -97 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\\n likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, likely a slow bleed.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose today (QOD)\\n -Solumedrol 1g IV daily (will change to prednisone tomorrow per\\n rheumatology)\\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\\n dysfunction yet, mental status ok. BUN continues to increase, but BUN\\n often stays elevated in acute renal failure after the kidneys have\\n started to improve, also the patient is on high dose steroids which can\\n increase BUN. As a note, plasmapheresis in cases of severe Wegeners\\n has been shown to improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday, awaiting results. Monitor for bleeding at\\n site given possible platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\\n serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes . Will try to maintain\\n 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim due to renal function, patient should be\\n discharged on Atovaqone.\\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\\n today 141, down from 150.\\n -Now patient is taking PO, D/C D5W.\\n -if needed, restart fluids to maintain UOP 100cc/hr (to prevent hem.\\n cystitis while on cytoxan)\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -Replace Ca2+ (given 4g this am),\\n -lytes q6hrs\\n -EKG\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - given HCT , give 1unit today\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Guaiac all stools\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334025,\n \"text\": \"This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\\n syndrome.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\\n activities.But when resting and sleeping in 80\\ns-90\\ns.NBP within\\n limits.No drop in BP with high HR.\\n Action:\\n Pt is on metoprolol for rate control.\\n Response:\\n HR in 80\\ns 90\\ns while at rest.\\n Plan:\\n Cont monitoring.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\\n with diminished base.Pt has got strong productive cough.\\n Action:\\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\\n is on high dose of steroids and had chemo.And pt is getting\\n plasmapheresis every other day.\\n Response:\\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\\n Plan:\\n Cont monitoring resp status.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\\n Action:\\n Renal failure most likely due to vasculitis. Pt is getting treated by\\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\\n Na.\\n Response:\\n Phos still high,Na 141 this am.BUN and creatinine trending down.\\n Plan:\\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\\n Hct this am 21.1.?for transfusion.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334369,\n \"text\": \"Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\\n renal biopsy c/w Wegeners.\\n 24 Hour Events:\\n O/N required ?? 02. Got pheresis yesterday, solumedrom and\\n cyclophosphamide. No hematuria. Talked to renal about biopsy, c/w\\n Wegners. Has been on IVF to keep uop >100, successfully. Tolerating\\n PO.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 36\\nC (96.8\\n HR: 99 (75 - 130) bpm\\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\\n RR: 20 (18 - 28) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,475 mL\\n 650 mL\\n PO:\\n TF:\\n IVF:\\n 2,100 mL\\n 650 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 260 mL\\n Urine:\\n 1,360 mL\\n 260 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,115 mL\\n 390 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 261 K/uL\\n 6.9 g/dL\\n 172 mg/dL\\n 7.1 mg/dL\\n 25 mEq/L\\n 3.6 mEq/L\\n 149 mg/dL\\n 101 mEq/L\\n 145 mEq/L\\n 22.4 %\\n 5.4 K/uL\\n [image002.jpg]\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n WBC\\n 8.1\\n 5.4\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n Plt\\n 355\\n 261\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n TCO2\\n 20\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\\n likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, but increased with 1unit yesterday.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\\n prednisone dose\\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\\n doses thus far.\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7.6,up to 8.1 then back down to 7.1. BUN\\n peaked at 160 now, 150. No signs of platelet dysfunction yet, mental\\n status ok. Renal will give his kidneys about 48 more hours to turn\\n around before dialyzing. As a note, plasmapheresis in cases of severe\\n Wegeners has been shown to improve kidney outcomes, though not\\n mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\\n serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n yesterday with D51/2.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -given 6g IV Ca yesterday, plus more during pheresis\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - given HCT trend, gave 1 unit yesterday with improved HCT.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Guaiac all stools\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334116,\n \"text\": \"Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\\n for presumed Wegeners.\\n 24 Hour Events:\\n Continues to have increasing 02 requirement, on 6L and facemask to keep\\n 02 >90%. Yesterday he had a renal biopsy, TTE, put on\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:39 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.6\\nC (96.1\\n HR: 89 (72 - 133) bpm\\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\\n RR: 23 (18 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 343 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 343 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 440 mL\\n Urine:\\n 1,405 mL\\n 440 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -97 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ///21/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 261 K/uL\\n 6.9 g/dL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\\n bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - also treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose today (QOD)\\n -Solumedrol 1g IV daily\\n -Cyclophosphamide 140mg\\n # Acute renal failure: Monitoring for need for dialysis, has line just\\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\\n dysfunction yet, mental status ok.\\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\\n However, apart from pulmonary association, ddx for acute renal failure\\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\\n Also consider DIC.\\n - Renal biopsy yesterday, awaiting results\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\\n serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place , strict I&O, q8 lytes\\n -On Sevelamer, Amphagel (day ) for hyperphos\\n - Avoid nephrotoxic agents\\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\\n today 141, down from 150.\\n -Now patient is eating, can D/C D5W.\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -Replace Ca2+ (given 4g this am), check again this PM\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6, given HCT , likely need blood this pm.\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334121,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Overall, no significant change in supplimental oxygen requirement.\\n Overall, appears much more comfortable.\\n Able to eat.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.2\\nC (95.4\\n HR: 90 (72 - 133) bpm\\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\\n RR: 22 (19 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 443 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 443 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 485 mL\\n Urine:\\n 1,405 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -42 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, High flow neb\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Well nourished, No(t) No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\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, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 6.9 g/dL\\n 261 K/uL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\\n bibasilar, unchanged.\\n Assessment and Plan\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\\n Await renal Bx results and serologies.\\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\\n BUN, creatitine, UO.\\n NUTRITIONAL SUPPORT -- advance PO.\\n FLUIDS -- provide adequate urine output (cytoxan)\\n HYPERGLYCEMIA -- promoted by steroids.\\n A-FLUTTER -- good rate control. Continue meds.\\n ANEMIA -- slow reduction. Transfuse to >21\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333431,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Renal will consult in the am.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\\n lungs with crackles\\n way up. Also some mild exp wheezes.\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 333432,\n \"text\": \"Chief Complaint: Bilateral LE edema, SOB\\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy.\\n .\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptons started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n .\\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\\n noted as having mild wheezing and productive cough of white sputum.\\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\\n Occult blood stool negative. U/A significant for protein 400mg/dl,\\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\\n microscopy positive for RBCs, granular casts.\\n .\\n Pt was seen by Renal, who thought there might possibly be a\\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\\n .\\n CXR on admission showed underlying COPD with diffuse bilateral\\n pulmonary infiltrates.\\n Pt underwent bronchoscopy on , and was found to have active low\\n grade blood emanating from the RLL and LLL.\\n .\\n EKG on admission showed atrial flutter at 2:1 block rate 150.\\n .\\n On arrival here, pt appeared mildly tachypneic. He reported that LE\\n edema had improved, and that pain had resolved in LE. He complained of\\n only mild nausea recently without vomiting, and a productive cough.\\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\\n constipation, melena, hematochezia, chest pain, urinary\\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\\n no epistaxis. Last BM was yesterday, and was formed.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Home medications:\\n NONE\\n Allergies:\\n NKDA\\n Past medical history:\\n Family history:\\n Social History:\\n ?Nephrolithiasis ()- blood found in urine after workup for lower\\n abdominal pain, no stones passed, 24hr protein done whith was normal\\n per pt.\\n Finger laceration ()\\n Mother passed from CVA in 80s. Father passed in 70s from unknown cause.\\n Twin brother passed from MI, another brother with hx cardiac artery\\n bypass graft. Denies family hx renal or pulmonary disease.\\n Pt works full-time as a machine operator. Mostly stationary job.\\n Divorced, college-age son lives with wife. Lives alone.\\n Smoked 1-1/2 ppd until when he quit (possibly 50 pack year hx\\n prior). Drinks ~2 drinks/day, and on social occasions. Denies other\\n drug use.\\n Review of systems: He complained of only mild nausea recently without\\n vomiting, and a productive cough. Otherwise denies sore throat, fevers,\\n chills, abdominal pain, diarrhea, constipation, melena, hematochezia,\\n chest pain, urinary frequency/urgency, dysuria, lightheadedness, vision\\n changes, headache, no epistaxis.\\n Flowsheet Data as of 12:49 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.5\\nC (95.9\\n HR: 107 (107 - 122) bpm\\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\\n RR: 27 (16 - 27) insp/min\\n SpO2: 91%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 48 mL\\n PO:\\n 230 mL\\n TF:\\n IVF:\\n 48 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 100 mL\\n Urine:\\n 125 mL\\n 100 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -52 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula 3L\\n SpO2: 91%\\n Physical Examination\\n GEN: Thin, pale, mildly distressed, tachypneic\\n HEENT: EOMI, PERRL, sclera anicteric, conjunctiva pale, no epistaxis or\\n rhinorrhea, dry MM, OP Clear\\n NECK: No JVD, carotid pulses brisk, no bruits, shotty anterior cervical\\n lymphadenopathy, trachea midline\\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\\n PULM: diffuse rhonchi/crackles bilaterally almost to apices\\n ABD: Soft, NT, ND, +BS, +hepatomegaly (four finger-breaths below costal\\n margin)\\n EXT: +1pitting edema lower extremities bilaterally, no palpable cords,\\n no cyanosis/clubbing, diffuse faint non-pruritic macular rash from feet\\n -> knees\\n NEURO: alert, oriented to person, place, and time. CN II\\n XII grossly\\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\\n extremities. Patellar DTR +1. Plantar reflex downgoing. No gait\\n disturbance. No cerebellar dysfunction.\\n SKIN: Diffuse macular rash in LE bilaterally from feet -> kness,\\n scattered telangiectasias in malar area of face\\n Labs / Radiology\\n 543 K/uL\\n 219 mg/dL\\n 9.7 mg/dL\\n 144 mg/dL\\n 16 mEq/L\\n 107 mEq/L\\n 6.2 mEq/L\\n 143 mEq/L\\n 31.0 %\\n [image002.jpg]\\n CXR : bilateral fluffy pulmonary infiltrates, costophrenic angles\\n visible (pending read by radiology)\\n EKG : similar to prior EKG from OSH, with atrial flutter\\n predominantly in limb leads, rate 121\\n \\n 2:33 A8/9/ 11:05 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 Hct\\n 31.0\\n Plt\\n 543\\n Cr\\n 9.7\\n Glucose\\n 219\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.6** mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n .\\n Plan:\\n .\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - Continue supplemental O2 PRN\\n - Albuterol nebs PRN\\n - Daily CXR's\\n - Type and screen, cross match x 2 units; threshold to transfuse hct\\n <21, unless clinically unstable\\n - Blood consent\\n - Consult Renal and Rheum in a.m.\\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\\n get renal biopsy\\n - Will continue Solumedrol 1g IV daily\\n - F/u on Renal serology and BAL results from OSH\\n - Will check Crits q8\\n .\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\\n Denies epistaxis. However, apart from pulmonary association, ddx for\\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\\n ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's.\\n - Re-check u/a, urine lytes, urine sediment\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Consult Renal here\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Start Sevelemer in a.m. with meals for elevated Phos.\\n .\\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\\n Can be secondary to underlying structural heart disease. Also may be\\n secondary to large volume shifts (retaining total body fluid with renal\\n failure, with large volume load putting stress on atria.)\\n - Check TSH\\n - Surface ECHO in a.m.\\n - Will start Lopressor 12.5mg PO daily for rate control.\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check Crits q8\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\\n respiratory status worsens anticipating intubation. Will replete lytes\\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\\n .\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control: RISS\\n Lines: 2 PIVs\\n Prophylaxis:\\n DVT: Pneumoboots\\n Stress ulcer: Pantoprazole PO\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full\\n Disposition: ICU\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334007,\n \"text\": \"This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\\n syndrome.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\\n activities.But when resting and sleeping in 80\\ns-90\\ns.NBP within\\n limits.No drop in BP with high HR.\\n Action:\\n Pt is on metoprolol for rate control.\\n Response:\\n HR in 80\\ns 90\\ns while at rest.\\n Plan:\\n Cont monitoring.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\\n with diminished base.Pt has got strong productive cough.\\n Action:\\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\\n is on high dose of steroids and had chemo.And pt is getting\\n plasmapheresis every other day.\\n Response:\\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\\n Plan:\\n Cont monitoring resp status.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\\n Action:\\n Renal failure most likely due to vasculitis. Pt is getting treated by\\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\\n Na.\\n Response:\\n Phos still high,Na 141 thos am.\\n Plan:\\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334102,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Overall, no significant change in supplimental oxygen requirement.\\n Overall, appears much more comfortable.\\n Able to eat.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 10:57 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.2\\nC (97.1\\n Tcurrent: 35.2\\nC (95.4\\n HR: 90 (72 - 133) bpm\\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\\n RR: 22 (19 - 26) insp/min\\n SpO2: 94%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,462 mL\\n 443 mL\\n PO:\\n TF:\\n IVF:\\n 1,905 mL\\n 443 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,405 mL\\n 485 mL\\n Urine:\\n 1,405 mL\\n 485 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,057 mL\\n -42 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula, High flow neb\\n SpO2: 94%\\n ABG: ///21/\\n Physical Examination\\n General Appearance: Well nourished, No(t) No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\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, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 6.9 g/dL\\n 261 K/uL\\n 223 mg/dL\\n 7.6 mg/dL\\n 21 mEq/L\\n 3.9 mEq/L\\n 155 mg/dL\\n 101 mEq/L\\n 141 mEq/L\\n 21.1 %\\n 5.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n WBC\\n 7.4\\n 8.1\\n 5.4\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n Plt\\n 543\\n 513\\n 355\\n 261\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n 156\\n 223\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\\n bibasilar, unchanged.\\n Assessment and Plan\\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\\n Await renal Bx results and serologies.\\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\\n BUN, creatitine, UO.\\n NUTRITIONAL SUPPORT -- advance PO.\\n FLUIDS -- provide adequate urine output (cytoxan)\\n HYPERGLYCEMIA -- promoted by steroids.\\n A-FLUTTER -- good rate control. Continue meds.\\n ANEMIA -- slow reduction. Transfuse to >21\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334581,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334584,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt continusly pulling the mask off inspite of frequently remainding\\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\\n mask off,denies any SOB,pain or discomfort.\\n Action:\\n On nebs and steroids,FM 60 % and additional NC is on,frequent\\n reinforcement needed about need for oxygen.\\n Response:\\n Pt strongly denies for any pain,SOB\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334644,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\\n edema, 2L fluids up.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\\n RR: 23 (9 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 979 mL\\n PO:\\n 750 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 979 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 640 mL\\n Urine:\\n 2,400 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 339 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 211 K/uL\\n 7.8 g/dL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\\n on bronchoscopy . Vasculitis is suspected, particularly a\\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\\n microscopic polyangiitis, lupus, PAN) given associated acute renal\\n failure. However, lower on the differential are ARDS, TRALI with\\n bilateral pulmonary infiltrates on CXR.\\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\\n appropriately to 1unit PRBCs so likely not currently bleeding.\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Albuterol nebs PRN\\n - CXR daily\\n - F/u on BAL results from OSH\\n - Patient now tolerating PO, though still concern for respiratory\\n status\\n - treating treating the underlying disease (presumed Wegener's):\\n -Plasmapheresis, dose yesterday (QOD)\\n -Prednison po daily,\\n -Cyclophosphamide-dose to be determined after c/s with rheum and\\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\\n far.\\n -affrin nasal spray day for nasal congestion\\n # Acute renal failure: Monitoring for need for dialysis, has line in\\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\\n signs of platelet dysfunction yet, mental status ok. Renal will give\\n his kidneys about 48 more hours to turn around before dialyzing. As a\\n note, plasmapheresis in cases of severe Wegeners has been shown to\\n improve kidney outcomes, though not mortality.\\n - Renal biopsy yesterday: per renal, patient with cresenteric\\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\\n hope for return on. Monitor for bleeding at site given possible\\n platelet dysfunction.\\n - treating underlying cause (likely Wegener's).\\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\\n cryglobulins, ANCA.\\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\\n -pink tinged urine, stable, but will send daily U/As.\\n -On Sevelamer, Amphagel (today is day ) for hyperphos\\n - Avoid nephrotoxic agents\\n - D/C Bactrim yesterday due to renal function, patient now on\\n Atovaqone for PCP .\\n #Hypernatremia:likely secondary to lack of access to water,resolved\\n with D51/2.\\n #Hypocalcemia: plasmapheresis (containing citrate) and to\\n underlying renal failure\\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\\n -follow ionized Ca, more accurate given citrate used in pheresis.\\n -on SS replacement.\\n -EKG unchanged\\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\\n overnight. ECHO yesterday showed mild LV septal , \\n 45-50%. Likely secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\\n (HR in 80s).\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q8\\n - will transfuse for HCT<21 or symptomatic anemia\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n - Stool guaiacc negative today, continue to check.\\n # FEN: Taking PO. Will replete lytes PRN.\\n # Access: 2 PIVs\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n # Code: FULL, confirmed with pt with son present ()\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334799,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Dx: Wegener\\ns Granulomatosis confirmed by renal biopsy\\n Atrial flutter (Aflutter)\\n Assessment:\\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\\n frequent episodes of tachycardia in the 130\\ns, typically with exertion,\\n stimulation and desats. BP within normal limits.\\n Action:\\n Tolerating metoprolol PO\\n Response:\\n Heart rate slows to the 80-90\\ns with rest, VS WNL\\n Plan:\\n Continue to monitor Heart rate/rhythm, administer metoprolol as\\n ordered. Encourage rest periods\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\\n noted. Creatinine is 6.5, BUN 153\\n Action:\\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\\n Creatinine is trending down. Hct drawn at 1530, result 24.\\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\\n with meals. Lunch held due to respiratory distress.\\n Response:\\n Labs to be drawn 8pm (4 hours after plasmaphoresis) and tonight at 2200\\n (check with team). Fluid balance remains positive. Good urine output\\n response to lasix. Tolerated plasmaphoresis with episodes of\\n tachycardia.\\n Plan:\\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\\n total of 7 treatments via right IJ HD catheter. Administer mesna as\\n ordered with chemo. Chemo to be given after plasmaphoresis.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\\n strong productive cough. Patient\\ns O2 requirements increasing\\n throughout the day.\\n Action:\\n O2 titrated accordingly. Face tent increased/decreased, now at 80% and\\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\\n albuterol changed to prn (may be contributing to tachycardia). Afrin\\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\\n on.\\n Response:\\n Oxygenation remains labile. Desats with eating and removal the face\\n tent. Recovery time longer each time he desats. Left lung sounds better\\n than this am.\\n Plan:\\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\\n sputum sample. Patient may need a sinus CT scan if stable. Administer\\n neb treatments as ordered.\\n Patient\\ns family at bedside. Updated on plan of care.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-07 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333590,\n \"text\": \"Chief Complaint: ARF, alveolar hemorrhage\\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\\n cytoxan 120 mg there. He was transferred for consideration of\\n plasmapheresis.\\n 24 Hour Events:\\n EKG - At 10:48 PM\\n -Tachycardic to low 100s with EKG concerning for A.flutter\\n -Hyperkalemic requiring kayexalate\\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 RISS\\n Solumedrol 1 g daily\\n Albuterol Q6H\\n Atrovent Q6H\\n Protonix\\n Colace\\n Lopressor 12.5 mg \\n Renagel\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Tachycardia\\n Respiratory: Cough, No hemoptysis\\n Gastrointestinal: Nausea\\n Genitourinary: Foley\\n Integumentary (skin): Rash, Diffuse maculopapular\\n Heme / Lymph: Anemia\\n Flowsheet Data as of 09:15 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 35.5\\nC (95.9\\n Tcurrent: 35.3\\nC (95.6\\n HR: 109 (106 - 123) bpm\\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\\n RR: 30 (16 - 31) insp/min\\n SpO2: 93%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 2,105 mL\\n 426 mL\\n PO:\\n 230 mL\\n 240 mL\\n TF:\\n IVF:\\n 186 mL\\n Blood products:\\n Total out:\\n 475 mL\\n 495 mL\\n Urine:\\n 125 mL\\n 495 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,630 mL\\n -69 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n FiO2: 4 L\\n SpO2: 91%\\n Physical Examination\\n General Appearance: No acute distress, Tachypneic\\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\\n Bilateral )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: None.\\n Skin: Few petechiae at feet. MacPap rash resolving\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 9.0 g/dL\\n 513 K/uL\\n 213 mg/dL\\n 9.2 mg/dL\\n 17 mEq/L\\n 5.5 mEq/L\\n 147 mg/dL\\n 107 mEq/L\\n 144 mEq/L\\n 26.6 %\\n 7.4 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n WBC\\n 7.4\\n Hct\\n 31.0\\n 26.6\\n Plt\\n 543\\n 513\\n Cr\\n 9.7\\n 9.2\\n Glucose\\n 219\\n 213\\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\\n mg/dL, PO4:9.9 mg/dL\\n Fluid analysis / Other labs: AG 20\\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\\n interstitial components. Normal cardiomediastinal contours. Minimal\\n bilateral costophrenic blunting.\\n Microbiology: None.\\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\\n Wegener\\ns granulomatosis, MPA, Goodpasteur\\ns, lupus, post-strep GN with\\n DIC (less likely). He is currently clinically stable and has been\\n started on solumedrol and cytoxan.\\n 1) Pulmonary-renal syndrome\\n ANCA, anti-GBM, , anti-dsDNA,\\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\\n serologies pending. Will consult renal for cytoxan dosing,\\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\\n 2) Anemia\\n Likely alveolar hemorrhage. Will rule out\\n hemolysis. Trend Q8H until stable.\\n 3) Renal failure\\n No acute indication for RRT at this point.\\n Does have an AG metabolic acidosis. Hyperkalemia currently\\n controllable with medications. No EKG changes. Renagel. Follow\\n electrolytes.\\n 4) Atrial flutter\\n Start low-dose beta-blockade. TSH pending.\\n TTE pending.\\n MICU Attending Addendum\\n Pt seen with fellow and examined. Met with pt and family to review\\n situation. Would add and emphasize the following to Dr \\ns notes.\\n On exam\\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\\n alos right forearm.\\n ABG 7.31/37/67\\n BUN 147/ Cr 9.6\\n CXR: diffsue bilateral interstitial and alveolar infiltrates\\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\\n and renal failure quite concerning for vasculitis.\\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\\n Role of plasmapheresis without clear diagnosis is challenging. Will\\n consult with Renal collegues on possibility of a renal biopsy to aid in\\n diagnosis. Additionally he is moving towards dialysis, need to closely\\n watch K, renally dose all meds. His resp status is tenusous due to\\n hypoxemia as well as met acidosis and uremic encephalopathy- may\\n require intubation for support\\n would likely favor this over NIPPV\\n given likely duration.\\n Discussed with son who is HCP and updated.\\n ICU Care\\n Nutrition: Renal, cardiac\\n Glycemic Control: Regular insulin sliding scale\\n Lines: Peripheral IVs\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: Protonix\\n VAP: N/A\\n Comments:\\n Communication: Comments:\\n Code status: Full code. Son, , is HCP.\\n Disposition :Remains in ICU.\\n Total time spent: Critically Ill 50 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-09 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334220,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt remains in aflutter at a rate of 70s-low 100s occationally going to\\n the 120s-130s\\n Action:\\n Conts on lopressor 50mg TID\\n Response:\\n HR was fairly well controlled though does have episodes of tachycardia\\n in the setting of eating or low SATs\\n Plan:\\n Cont with the lopressor, follow VS, replete lytes\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Creat remains high, it was 7.6 this morning and 8.0 this afternoon.\\n Calcium conts to be low as well as mag\\n Action:\\n Received 4 gms of calcium this morning and had a repeat ionized Ca of\\n .86, he is presently receiving another 4 gms of Ca and 2 gm of MgS04.\\n He is also receiving NS at 100cc/hr to try and protect his bladder from\\n the cytoxan, to receive cytoxan again tonight\\n Response:\\n Creat bumped this afternoon, u/o 70-30cc/hr, conts with low Ca with his\\n pheresis\\n Plan:\\n Presently being pheresed, to get cytoxan tonight\\n this needs to be\\n arranged with the 7Feldberg nurses, follow ionized Ca, creat, f/u on\\n the renal biopsy from yest.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n LS with rhonchi and wheezes, 02 SAT has improved today from yest with\\n an 02 SAT ~ 93% on 6 L NC, he states that he feels a little better\\n today. Occationally has a wet cough but not bringing anything up.\\n Action:\\n Tolerating a lower FI02\\n Response:\\n Plan:\\n Cont to follow 02 requirements, decrease the FI02 as he tolerates,\\n started on mepron for PCP prophylaxis\\n the bactrim was d/ced due to\\n his renal failure\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 334640,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\\n RR: 23 (9 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 4,486 mL\\n 979 mL\\n PO:\\n 750 mL\\n TF:\\n IVF:\\n 3,736 mL\\n 979 mL\\n Blood products:\\n Total out:\\n 2,400 mL\\n 640 mL\\n Urine:\\n 2,400 mL\\n 640 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,086 mL\\n 339 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 99%\\n ABG: ///23/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 211 K/uL\\n 7.8 g/dL\\n 95 mg/dL\\n 6.5 mg/dL\\n 23 mEq/L\\n 3.9 mEq/L\\n 153 mg/dL\\n 103 mEq/L\\n 142 mEq/L\\n 23.9 %\\n 10.3 K/uL\\n [image002.jpg]\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n 01:54 PM\\n 11:04 PM\\n 05:08 AM\\n WBC\\n 5.4\\n 9.0\\n 10.3\\n Hct\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n 25.5\\n 23.9\\n Plt\\n 261\\n 221\\n 211\\n Cr\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n 6.9\\n 6.8\\n 6.5\\n Glucose\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n 144\\n 208\\n 95\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334646,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt continuesly pulling the mask off inspite of frequently remainding\\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\\n mask off,denies any SOB,pain or discomfort.\\n Action:\\n On nebs and steroids,FM 60 % and additional NC is on,frequent\\n reinforcement needed about need for oxygen.\\n Response:\\n Pt strongly denies for any pain,SOB but continued to be uncomfortable\\n during night,MD was informed.No meds ordered at this time.\\n Plan:\\n Continue to monitor resp status,follow up AM lab results,bleeding time\\n should be drawn by lab at AM.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333752,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx. Pt was adm on .\\n Atrial flutter (Aflutter)\\n Assessment:\\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\\n the high 120-130 range during plasmapharesis. B/P has remained stable\\n 110/78-132/69.\\n Action:\\n Lopressor was increased to 50mg tid which was started last evening.\\n Response:\\n H/R is decreasing from the 100\\ns to the 80-90range.\\n Plan:\\n Cont with tid lopressor. Monitor h/r and pattern.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\\n Action:\\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\\n past 24 hours pt has had 2 doses of Kayexalate. Will not repleat K+ of\\n 3.9 this am as pt rises.\\n Response:\\n K+ is 4. U/O improving with urine more yellow. Creat 8.6/bun149 this\\n am.\\n Plan:\\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\\n lungs have had crackles bil bases with the left lung more dim than the\\n right..\\n Action:\\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\\n evening and was given cytoxan after the plasmaphoresis. Pt is also\\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\\n Response:\\n Sao2 drops to the high 80\\ns while pt wears only the n/c. pt does not\\n like to wear face mask and denies any sob.\\n Plan:\\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\\n plasmaphoresis again on Tues.\\n Hct 22.8 this am and team would like to discuss in rounds as to further\\n transfusions. Team wants Hct drawn at 0800. pt will also receive\\n calcium gluconate 4gm to replenish 5.9. Na+ 150. Phos 9.5\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 333876,\n \"text\": \"HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\\n medical hx.\\n Atrial flutter (Aflutter)\\n Assessment:\\n Pt remains in aflutter at a rate of 70s-low 100s\\n Action:\\n Conts on lopressor 50mg TID\\n Response:\\n Tolerating the lopressor, he did have short periods of a HR in the\\n 1teens this afternoon\\n Plan:\\n Cont with the lopressor, follow VS\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Creat was 8.6 this morning, u/o has been 40-50cc/hr\\n Action:\\n Pt had a renal biopsy this morning under US guidance, receiving D5W\\n 100cc/hr for 1 liter for a Na of 150\\n Response:\\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\\n Plan:\\n Follow HCT, VS, renal bx results, no immediate plans for dialysis,\\n follow labs\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\\n has not been coughing up any blood\\n Action:\\n He is on scoop mask at 60-70% and this brings his 02 up to 93-99%.\\n Response:\\n Conts to require a high FI02, he wants to eat but is NPO due to his\\n tenuous resp status\\n Plan:\\n Follow SATs cont to try to wean his FI02\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 334483,\n \"text\": \"Chief Complaint: Respiratory distress, hypoxemia\\n HPI:\\n 24 Hour Events:\\n Remains with high FiO2 requirment.\\n Renal bx consistent with Wegener's Granulomatosis.\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Bactrim (SMX/TMP) - 10:03 PM\\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: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n No(t) Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.3\\nC (97.4\\n Tcurrent: 35.9\\nC (96.6\\n HR: 99 (87 - 130) bpm\\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\\n RR: 21 (9 - 28) insp/min\\n SpO2: 93%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.4 kg (admission): 68.4 kg\\n Height: 69 Inch\\n Total In:\\n 2,477 mL\\n 2,103 mL\\n PO:\\n 60 mL\\n TF:\\n IVF:\\n 2,102 mL\\n 2,043 mL\\n Blood products:\\n 375 mL\\n Total out:\\n 1,360 mL\\n 1,025 mL\\n Urine:\\n 1,360 mL\\n 1,025 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,117 mL\\n 1,078 mL\\n Respiratory support\\n O2 Delivery Device: Face tent\\n SpO2: 93%\\n ABG: ///25/\\n Physical Examination\\n General Appearance: No(t) Well nourished, No acute distress, No(t)\\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\\n Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\\n Rhonchorous: )\\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\\n No(t) Tender: , No(t) Obese\\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.6 g/dL\\n 221 K/uL\\n 94 mg/dL\\n 7.2 mg/dL\\n 25 mEq/L\\n 3.5 mEq/L\\n 149 mg/dL\\n 105 mEq/L\\n 145 mEq/L\\n 22.7 %\\n 9.0 K/uL\\n [image002.jpg]\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n 02:46 PM\\n 09:30 PM\\n 04:25 AM\\n 01:17 PM\\n 09:20 PM\\n 01:30 AM\\n 08:05 AM\\n WBC\\n 8.1\\n 5.4\\n 9.0\\n Hct\\n 24.4\\n 22.8\\n 22.6\\n 22.0\\n 21.9\\n 21.1\\n 20.9\\n 22.7\\n 22.4\\n 22.7\\n Plt\\n 355\\n 261\\n 221\\n Cr\\n 8.5\\n 8.6\\n 8.1\\n 7.6\\n 8.1\\n 7.4\\n 7.1\\n 7.2\\n Glucose\\n 293\\n 176\\n 156\\n 223\\n 195\\n 229\\n 172\\n 94\\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\\n Assessment and Plan\\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\\n likey due to vasculitis. Radiographically without significant change,\\n but hope to see improvement over next several days. Monitor RR, SaO2.\\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\\n improve.\\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\\n plts). Monitor Hct, transfuse to > 21\\n WEGENER\\\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\\n plasmaphoresis QOD.\\n FLUIDS -- euvolemic. Monitor I/O\\n HEMATURIA -- concern for hemorrhagic cystitis\\n A-FIB -- good rate control COntinue meds. Monitor HR.\\n NASAL CONGESTION -- possible related to Wegener's but more likely due\\n to high flow O2. Symptomaatic relief.\\n HYPOCALCEMIA -- repleted. Monitor.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer: PPI\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 333854,\n \"text\": \"Chief Complaint: LE edema, SOB\\n 24 Hour Events:\\n Overnight the patient remained stable, but continuing to require O2 by\\n NC and facemask. HR down to 80s with lopressor but remains in\\n aflutter. This am patient only c/o hunger.\\n EKG - At 02:00 PM\\n DIALYSIS CATHETER - START 06:48 PM\\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 01:53 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: 35.2\\nC (95.3\\n HR: 94 (72 - 133) bpm\\n BP: 109/58(70) {104/53(66) - 142/88(102)} mmHg\\n RR: 25 (18 - 29) insp/min\\n SpO2: 88%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 902 mL\\n 1,042 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 662 mL\\n 485 mL\\n Blood products:\\n 557 mL\\n Total out:\\n 1,330 mL\\n 1,080 mL\\n Urine:\\n 1,330 mL\\n 1,080 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -429 mL\\n -38 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 88%\\n ABG: 7.31/37/67/22/-6\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: No acute distress\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral, almost \\n way up lungs posteriorly)\\n Extremities: Right: 1+ pitting, Left: 1+ pitting,, diffuse rash below\\n knees\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 355 K/uL\\n 7.6 g/dL\\n 176 mg/dL\\n 8.6 mg/dL\\n 22 mEq/L\\n 3.9 mEq/L\\n 149 mg/dL\\n 108 mEq/L\\n 150 mEq/L\\n 22.6 %\\n 8.1 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n WBC\\n 7.4\\n 8.1\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n Plt\\n 543\\n 513\\n 355\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\\n Assessment and Plan\\n Assessment: This is a 60 year-old male with a distant history of\\n nephrolithiasis, no other chronic medical problems who presents with\\n lower extremity edema and SOB.\\n Plan:\\n # Respiratory distress: Most likely secondary to diffuse alveolar\\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\\n acute renal failure. However, lower on the differential are ARDS, TRALI\\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\\n - follow HCT q6h to monitor for alveolar bleeding. Concern given\\n recent HCT drop. Transfusion threshold is HCT<21\\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\\n - Figure out exact 02 requirement (patient on facemask, not always\\n wearing it)\\n - Albuterol nebs PRN\\n - repeat CXR\\n - F/u on BAL results from OSH\\n - Continue to keep patient NPO due to tentative respiratory status (and\\n renal biopsy).\\n (see t'ment plan for presumed Wegener's under acute renal failure)\\n # Acute renal failure: Ddx includes most likely pulmonary renal\\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\\n polyangiitis, lupus, PAN. BUN/Cr on was 126/9.6, K 5.8. Nephritic\\n picture with RBC casts. However, apart from pulmonary association, ddx\\n for acute renal failure with nephritis includes PSGN, lupus nephritis,\\n etc. ESR elevated >140, consistent with an autoimmune disorder.\\n Age-appropriate for Wegener's. Also consider DIC.\\n - Renal biopsy today, FFP on call due to INR 1.5\\n - For presumed Wegeners, started Plasmapheresis (firs tt'ment last\\n night, will be QOD x 5 treatments)\\n - Continue Solumedrol 1g IV daily\\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\\n cryglobulins, ANCA, HepB/C serology\\n - Will re-check renal labs above here as well (C3, C4, etc.)\\n - Foley in place\\n - Avoid nephrotoxic agents\\n - Replete lytes PRN\\n - Will check q8 lytes for now\\n - Continue Sevelemer in a.m. with meals for elevated Phos.\\n - Renal c/s recommends also starting Amphagel (phosphate binder) 30cc\\n po tid for 2-3 days for elevated Phos.\\n #Hypernatremia: NA+ today 150, up from 147, likely lack of access\\n to free water\\n -Replace w/ D5NS\\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\\n binder)\\n -Replace Ca2+\\n # Tachycardia: Aflutter on EKG. Until yesterday, was asymptomatic but\\n rate in 120s. Can be secondary to underlying structural heart disease.\\n Also may be secondary to large volume shifts (retaining total body\\n fluid with renal failure, with large volume load putting stress on\\n atria.)\\n - F/u on TSH\\n - TTE today\\n - Lopressor titrated up to 50 mg PO tid with good rate control (HR in\\n 80s).\\n .\\n # LE edema: likely secondary to renal failure above. Would hold off on\\n diuresis given ARF.\\n .\\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\\n combination of chronic inflammatory disease, renal failure, and diffuse\\n alveolar hemorrhage. No baseline Crit available.\\n - Check HCT q6\\n - Type and screen, cross-matched\\n - Blood consent obtained\\n .\\n # FEN: NPO for worsening respiratory status, anticipating intubation.\\n Will replete lytes PRN.\\n # Access: 2 PIVs\\n .\\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\\n .\\n # Code: FULL, confirmed with pt with son present ()\\n .\\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\\n pulmonary status.\\n .\\n # Comm: HCP , ; \\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Case Management \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Case Managment Initial Patient Assessment\",\n \"row_id\": 333828,\n \"text\": \"Insurance information\\n Primary insurance: OOS PPO-NON MANAGED CARE\\n Secondary insurance: SELF PAY\\n Insurance reviewer::\\n Free Care application: N/A\\n Status:\\n Medicaid application: N/A\\n Pre-Hospitalization services: None prior to admission\\n DME / Home O[2]: None prior to admission\\n Functional Status / Home / Family Assessment:\\n Pt. Lives alone in . He is divorced . He has a son who\\n lives with the patient's ex-wife. PTA he was working and independent\\n with all ADL's\\n Primary Contact(s): (son) \\n Health Care Proxy: .\\n Dialysis: No\\n Referrals Recommended: Social Work, Physical Therapy\\n Current plan: Undetermined\\n Unclear what level of services will be required at discharge. Case\\n Management will follow for DC needs.\\n If VNA services needed can use:\\n VNA of SE Mass - \\n - \\n Centrus Premier Home Care - \\n Patient (s) to Discharge:\\n Medically unstable\\n Patient discussed with multidisciplinary team: No\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2199-07-08 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 333866,\n \"text\": \"Chief Complaint: Respiratory distress/hypoxemia\\n HPI:\\n 24 Hour Events:\\n EKG - At 02:00 PM\\n DIALYSIS CATHETER - START 06:48 PM\\n Renal consultation concurred with Pulmonary-Renal syndrome.\\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\\n anticipating 5 days of treatment. Remains on cortocosteroids.\\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\\n Denies increased dyspnea, but remains with oxygen requirement.\\n History obtained from Patient\\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\\n Tachycardia, No(t) Orthopnea\\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\\n nutrition\\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\\n No(t) Diarrhea, No(t) Constipation\\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\\n Integumentary (skin): No(t) Jaundice, No(t) Rash\\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\\n Signs or concerns for abuse : No\\n Pain: No pain / appears comfortable\\n Flowsheet Data as of 09:14 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.8\\n Tcurrent: 35.3\\nC (95.5\\n HR: 81 (81 - 133) bpm\\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\\n RR: 24 (22 - 29) insp/min\\n SpO2: 97%\\n Heart rhythm: A Flut (Atrial Flutter)\\n Height: 59 Inch\\n Total In:\\n 902 mL\\n 186 mL\\n PO:\\n 240 mL\\n TF:\\n IVF:\\n 662 mL\\n 186 mL\\n Blood products:\\n Total out:\\n 1,330 mL\\n 690 mL\\n Urine:\\n 1,330 mL\\n 690 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -429 mL\\n -504 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: 7.31/37/67/22/-6\\n PaO2 / FiO2: 134\\n Physical Examination\\n General Appearance: No(t) Well nourished, No(t) No acute distress,\\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\\n mildly disshevled\\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\\n pale, No(t) Sclera edema\\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\\n Endotracheal tube, No(t) NG tube, No(t) OG tube\\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\\n Cervical adenopathy\\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\\n No(t) Diastolic)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\\n Labs / Radiology\\n 7.6 g/dL\\n 355 K/uL\\n 176 mg/dL\\n 8.6 mg/dL\\n 22 mEq/L\\n 3.9 mEq/L\\n 149 mg/dL\\n 108 mEq/L\\n 150 mEq/L\\n 22.6 %\\n 8.1 K/uL\\n [image002.jpg]\\n 11:05 PM\\n 04:46 AM\\n 12:46 PM\\n 01:36 PM\\n 11:04 PM\\n 04:02 AM\\n 08:13 AM\\n WBC\\n 7.4\\n 8.1\\n Hct\\n 31.0\\n 26.6\\n 27.1\\n 24.4\\n 22.8\\n 22.6\\n Plt\\n 543\\n 513\\n 355\\n Cr\\n 9.7\\n 9.2\\n 9.6\\n 8.5\\n 8.6\\n TCO2\\n 20\\n Glucose\\n 93\\n 176\\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\\n predominantly basilar. Right IJ catheter position acceptable. No\\n significant overall change compared to .\\n Assessment and Plan\\n 60 yom now with Pulmonary-Renal syndrome.\\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\\n diffuse infiltrates and oxygen requirement.\\n HYPOXEMIA -- attributed to pulmonary infiltrates. Monitor SaO2,\\n supplimental O2 to maintain SaO2 >90%.\\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\\n SaO2.\\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\\n consult prepared to move to dialysis when indicated. Monitor urine\\n output, BUN, Creatitine.\\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\\n Continue steroids and plasmaphoresis.\\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\\n FLUIDS -- limit iv fluids intake.\\n HYPERPHOSPHATEMIA -- start phosphate binder.\\n NUTRITION -- NPO pending evaluation\\n ANEMIA -- progressive, attributed to underlying process, and possible\\n contribution from RIJ central line placement. Transfuse to Hct >21.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:00 AM\\n 18 Gauge - 08:32 AM\\n Dialysis Catheter - 06:48 PM\\n Prophylaxis:\\n DVT: Boots(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: HOB elevation\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU\\n Total time spent: 55 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2199-07-10 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 334546,\n \"text\": \"This is a 60 year-old male with distant hx nephrolithiasis who presents\\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\\n bronchoscopy.\\n OSH course:\\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\\n having no PCP (regular PCP had retired.) He finally presented for care\\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\\n reports that LE symptoms started in the feet, progressing to swelling\\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\\n rash in the LE of the same distribution. He also complained of some SOB\\n on exertion and decreased appetite.\\n Patient is being worked up for Wegener\\ns Granulomatosis\\n Atrial flutter (Aflutter)\\n Assessment:\\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\\n has episodes of tachycardia in the 130\\ns, typically with exertion or\\n desats. BP within normal limits.\\n Action:\\n Tolerating metoprolol PO\\n Response:\\n Heart rate slows with NSR episodes, VS WNL\\n Plan:\\n Continue to monitor Heart rate/rhythm, administer metoprolol as\\n ordered.\\n Renal failure, acute (Acute renal failure, ARF)\\n Assessment:\\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\\n noted. Creatinine is 6.9, BUN 149\\n Action:\\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\\n administration of cyclophosphamide (chemo)\\n Response:\\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\\n since midnight.\\n Plan:\\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\\n HD catheter, may have it . Administer mesna as ordered with chemo\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\\n weak cough. +1.6L positive. Patient would frequently remove face tent,\\n thus dropping O2 sats.\\n Action:\\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\\n 6L NC. Patient encouraged to cough and deep breathe. Neb treatments as\\n ordered\\n Response:\\n Oxygenation has improved throughout the afternoon with patient\\ns family\\n at the bedside\\n Plan:\\n Continue to titrate O2, encourage deep breathing and coughing.\\n\"\n }\n]"}}},{"rowIdx":181,"cells":{"subject_id":{"kind":"number","value":26083,"string":"26,083"},"hadm_id":{"kind":"number","value":120427,"string":"120,427"},"target_text":{"kind":"string","value":"A/P: 84 y/ with h/o HTN, severe MR, and transferred to the ICU for abdominal pain and rising lactate/wbc. Please HPI for details of admission prior to ICU: . 1. Abdominal pain- on transfer, ddx includes perforated viscus and mesenteric ischemia. recent CTA showed no evidence of AAA. possible gastritis/ulcer dz w/ high dose steroids and hospitalization. surgery following and KUB w/out evidence of colonic obstruction or free air. lactate continued to rise following ICU transfer, despite elevated CVP and lack of respiratory variation, both indicative of volume repletion. patient continued to have minimal abdominal pain but did have other signs of poor cardiac output including a mixed venous sat of 42%. on the day of the patient's demise, his lactate was 8.6. . . 2. crpytogenic organizing pna- seen on prior needle biopsy and some improvementon high dose steroids (radiographic). O2 sats stable on NC but significant desaturation with any activity. on in the process of being rolled, the patient became acutely SOB and subsequently became apneic. per his family's documented request, a Code was not called. he subsequently expired. . 3. pt /w baseline creatinine of ~1.4 but elevated to 2.7 on micu admission. renal ultrasound today w/out evidence of obstruction/hydronephrosis. continued to worsen in the setting of poor cardiac output. . 4. Severe MR: pt in the process of preparing for a MVR prior to this admission. major contributor to the patient's poor forward flow. . 5. Coagulopathy: Initially likely poor nutritional status but now concern for DIC in setting of mesenteric ischemia ."},"extractive_notes_summ":{"kind":"string","value":"Just returned from abd CT ruling out ischemic bowel. The pt then became bradycardic, remained apneic c no BP measurable. CxR showing worsenig PNACaridac: SR with no ectopy since arrival. Sinus tachycardiaPossible left atrial abnormalityModest nonspecific ST-T wave changesSince previous tracing of , ventricular ectopy absent PO lopressor on hold as b/p is hypotensive 90's/30's. Sinus rhythmIndeterminate axisLow limb lead QRs voltagesModest right ventricular conduction delay patternFindings are nonspecific but clinical correlation is suggested for possiblechronic pulmonary diseaseSince previous tracing of , sinus tachycardia rate slower Nursing Progress Note.Pt functional status progressively worsened over the coarse of the day, pt code status subsequently changed from DNR -- CPR not indicated to full DNR/DNI by team this AM c likely CMO as status waranted. infectious process Admitting Diagnosis: SHORTNESS OF BREATH FINAL REPORT (Cont) Sinus tachycardiaSlight ST-T wave changes - are nonspecific and may be within normal limitsSince previous tracing of , right precordial ST-T wave changes slightlyless prominent Pt has severe mvr and was in process of workup for mitral valve repair when MD suggested he visit ED.GU: Abd soft with positive bowel sounds. Perihperal pulses weakly palpable.ID: Afebrile. Since the previous tracing of the rate isincreased and ventricular ectopy is new. (Over) 11:47 AM CT CHEST W/O CONTRAST Clip # Reason: ? Did have period where he had some confusion while hypotensive, but resolved after fluid boluses. B/P droping as low as 70's/20's prior to fluid boluses. chf.resp remains on 2to3 l nc, ls clear with crackles in bases in am to cracles thru out after line placemnt and receving 2 units of ffp. 11:47 AM CT CHEST W/O CONTRAST Clip # Reason: ? Moderate non-hemorrhagic layering left pleural effusion is new. Events: Bolused with 250cc NS x3 for low u/o and hypotension. Pt states breathing is easier than previous but rr remains tachypneic (30's) at times.Cardiac: SR with no ectopy throughout shift. Unfortunately, the pt became apneic following a routine position change, ETS was attempted but unsuccessful. Left perihilar consolidation is the most significant region of abnormality followed by the right lung base and these areas have not cleared. K+5.8 Phos 9.1 Mg 3.2 BUN 97 and Cr3.8Heme: HCT down to 25.8 (28.5) INR up to 2.3 (2.5) received 2uffp prior to TLC placement yesterday.Derm: Grossly intact. Some minimal presacral fluid and some minimal fluid in the pelvis of unknown etiology. Below the diaphragm, given that this is a non-contrast CT, note is made of a low-attenuation lesion measuring 11 mm in the dome of the liver which is unchanged when compared to the previous CT from . FINDINGS: A right internal jugular vein approach central venous line is present seen to terminate overlying the SVC at the level 2 cm below the carina. Left pleural effusion. UPRIGHT AP CHEST: No free air is visualized beneath the hemidiaphragm. Sigmoid diverticula. There is a left pleural effusion. Scarring right base and bilateral effusions. There is a possible tiny right pleural effusion. While the right pleural effusion has nearly resolved, the moderate left pleural effusion has not. CT OF PELVIS: Note is made of some sigmoid diverticula. The left pleural effusion appears slightly decreased. HISTORY: Dyspnea and tachycardia. Grayscale and Doppler son of the left and right common femoral, superficial femoral, and popliteal veins were performed. 2:41 AM PORTABLE ABDOMEN Clip # Reason: Signs of perforation? INDICATION: Right internal jugular central venous line placement. Signs of ischemia? Note is made of some coronary artery calcification. The lung bases reveal a small right pleural effusion and a moderate-sized left pleural effusion. A subcentimeter lesion is seen in segment VII and is unchanged. IMPRESSION: No free air beneath the hemidiaphragm is visualized. Right upper lobe patchy opacities are also again seen. There is some right- sided linear atelectasis. A granuloma is noted in the right base. Just anterior to the sacrum, note is also made of some minimal fluid. A subcentimeter lesion is seen in segment and is unchanged. Cardiac silhouette is slightly enlarged, and there is persistence of vascular engorgement in the superior mediastinum suggesting cardiac decompensation and/or volume overload. The sequence of changes suggests the persistence of asymmetric edema, and clearing of the inflammatory process in the right upper lobe and improvement, but persistence of what is likely the same process in the right lower lobe. Rule out hydronephrosis or other blockage. A Foley catheter is in the urinary bladder, which is decompressed. The appearances suggest failure with probable pneumonia. Comparison made to CTA of the abdomen dated . Some vascular calcification is noted in relation to the aorta. No contraindications for IV contrast FINAL REPORT CT ABDOMEN INDICATION: Cryptogenic pneumonia, acute renal failure, abdominal pain. This patient is status post cholecystectomy."},"n_notes":{"kind":"number","value":22,"string":"22"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2200-08-28 00:00:00.000","description":"Report","row_id":1601651,"text":"Pt is a 84 y/o who presented to our ED on recomendation from his PCP after CxR as outpt showed new infiltrate. Pt was being worked up for a mitral valve repair due to severe MVR. Admitted to 2 where sputum cx grew out yeast, urine also noted to be cloudy and was cultured . On floor pt was having increasing O2 requirements and some shortness of breath. Also, pt was having increasing abd pain ( on arrival to MICU). Lab values INR 2.3 K 6 WBC 24 Lactic Acid 5. CxR done showing worsening PNA and pt's urine output had diminished to 50cc for entire night shift. Decision made to tx to MICU for increased monitoring and treatment. ABD CT done to r/o ischemic bowel.\n\nNeuro: Pt a+ox3, following commands consistently. MAE, drowsy as he has not had sleep in >24hrs. C/O abd pain \n\nResp: lung sounds with crackles. O2 sats mid 90's on 2L via n/c. Breathing somewhat labored but pt reports no difficulty breathing. CxR showing worsenig PNA\n\nCaridac: SR with no ectopy since arrival. PO lopressor on hold as b/p is hypotensive 90's/30's. Pt has severe mvr and was in process of workup for mitral valve repair when MD suggested he visit ED.\n\nGU: Abd soft with positive bowel sounds. C/O pain. No bm in spite of enemas on floor. Just returned from abd CT ruling out ischemic bowel. Surgery following. NPO.\n\nGU: No urine output since arrival on MICU. Due for labs at 0800.\n\nDerm: Grossly intact. PIV x1 20G intact. Perihperal pulses weakly palpable.\n\nID: Afebrile. On IV zosyn.\n\nPlan: Follow up on abd Ct, to surgery if positive, Lytes at 0800, monitor fluid status, and hemodynamic status.\n\nGU\n"},{"category":"Nursing/other","chartdate":"2200-08-29 00:00:00.000","description":"Report","row_id":1601654,"text":"Nursing Progress Note.\n\nPt functional status progressively worsened over the coarse of the day, pt code status subsequently changed from DNR -- CPR not indicated to full DNR/DNI by team this AM c likely CMO as status waranted. Family members (wife, two , -in-law) @ BS all AM and kept up to date c POC/pt status throughout shift. IVP 0.5mg Morphine provided this afternoon times two for pt discomfort c fair affect noted. Unfortunately, the pt became apneic following a routine position change, ETS was attempted but unsuccessful. The pt then became bradycardic, remained apneic c no BP measurable. Team notified and pt declared deceased @ approx 16:05. Please see CareVue for additional pt care data/comments. Family notified of event, verbal and non-verbal support provided by team.\n"},{"category":"Nursing/other","chartdate":"2200-08-28 00:00:00.000","description":"Report","row_id":1601652,"text":"npn\nevents central line placed, mri on hold until \n\nneuro:aox3, sleeping off and on, pt stating he is very tired.\npain: denies pain. exp. general discomfort from lying in bed. pain med given with line placement which pt tolerated well.\n\ncad hr sr 80 to 90's, nbp 80 systolic in am with two 250cc ns boluses given with nbp up to the 100 to 90's systolic , again dropped to the high 80's at 1730 to 1830 md aware, cvp 12 with some fluctuating noted to 18, pt given lasix 20 mg ivp at 1845 for ? chf.\n\nresp remains on 2to3 l nc, ls clear with crackles in bases in am to cracles thru out after line placemnt and receving 2 units of ffp. sats 91 to 975 rr teens to high 20 to bursts to 30 to 40's.\n\ngi: abd soft slight distended. bs+ no bm this shfit, no c/o abd pain, ? c/o nausea with md was ordered and given in afternoon. mri held at pt's request.\n\ngu: urine output increased to 10cc/hr after multiple boluses and antibiotics given. now 5cc/hr pt given lasix 20 mg ivp at 1845. last 6 pt given kayexlate po at 1600 awaiting results.\n\nendo: bs 108 to 172 las t bs not covered due to pooor po intake.\n\nid: afebrile, antibiotics given.\n\nplan: mri tomorrow am, cont to be full code, cont to moniotr vs, labs resp and fluid status.\n"},{"category":"Nursing/other","chartdate":"2200-08-29 00:00:00.000","description":"Report","row_id":1601653,"text":"Events: Bolused with 250cc NS x3 for low u/o and hypotension. Family in and decision made to change code status to CPR not indicated. Pt can be intubated if need be however.\n\nNeuro: A+Ox3 and following commnads. Did have period where he had some confusion while hypotensive, but resolved after fluid boluses. No complaints of pain this shift. Slept throughout shift but arousable to verbal stimuli.\n\nResp: Lung sounds with wheezes throughout and crackles in bases. O2 sats maintained in high 90's on 70% humidified O2 via face tent. Alb/atr nebs q4. Pt states breathing is easier than previous but rr remains tachypneic (30's) at times.\n\nCardiac: SR with no ectopy throughout shift. CVP 11-16. Bolused with total of 750cc NS to keep MAP's >60. B/P droping as low as 70's/20's prior to fluid boluses. B/P largely 90's/40's since midnight. Team has been reluctant to start pressors as pt has 4+MR.\n\nGI: Abd soft and nontender this shift. No c/o pain which had been yesterday. medicated with 0.5mg morphine prior to start of this shift. No BM this shift either. Pt may go for MRI later today to assess for ischemic bowel.\n\nGU: Pt given 20mg IV lasix, with no effect. Then 40mg IV lasix with similar results, then 80mg with approx 100cc's amber urine output. Renal is following. Pt's electrolytes remain increasingly out of balance. K+5.8 Phos 9.1 Mg 3.2 BUN 97 and Cr3.8\n\nHeme: HCT down to 25.8 (28.5) INR up to 2.3 (2.5) received 2uffp prior to TLC placement yesterday.\n\nDerm: Grossly intact. PIV x1 patent. TLC in RIJ placed yesterday patent with good blood return. Small hematoma at site unchanged.\n\nPlan: Family in today to meet with attending to discuss prognosis and plan of care, may go for MRI if decided to fully treat, Monitor lab data (?HD), monitor hemodynamic status, may start levophed if b/p cannot be maintained with small boluses. Pt is currently CPR not indicated but will be intubated if need be.\n"},{"category":"ECG","chartdate":"2200-08-28 00:00:00.000","description":"Report","row_id":197667,"text":"Sinus rhythm\nIndeterminate axis\nLow limb lead QRs voltages\nModest right ventricular conduction delay pattern\nFindings are nonspecific but clinical correlation is suggested for possible\nchronic pulmonary disease\nSince previous tracing of , sinus tachycardia rate slower\n\n"},{"category":"ECG","chartdate":"2200-08-26 00:00:00.000","description":"Report","row_id":197668,"text":"Sinus tachycardia\nSlight ST-T wave changes - are nonspecific and may be within normal limits\nSince previous tracing of , right precordial ST-T wave changes slightly\nless prominent\n\n"},{"category":"ECG","chartdate":"2200-08-25 00:00:00.000","description":"Report","row_id":197669,"text":"Sinus tachycardia\nPossible left atrial abnormality\nModest nonspecific ST-T wave changes\nSince previous tracing of , ventricular ectopy absent\n\n"},{"category":"ECG","chartdate":"2200-08-22 00:00:00.000","description":"Report","row_id":197670,"text":"Sinus tachycardia with ventricular ectopy. Ventricular rate 114 beats per\nminute. P-R interval 0.16. Since the previous tracing of the rate is\nincreased and ventricular ectopy is new. No other diagnostic changes have\noccurred.\n\n"},{"category":"ECG","chartdate":"2200-08-18 00:00:00.000","description":"Report","row_id":197914,"text":"Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\n\n"},{"category":"Radiology","chartdate":"2200-08-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926604,"text":" 9:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for progression of volume overload\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam\n REASON FOR THIS EXAMINATION:\n please evaluate for progression of volume overload\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:12 P.M., .\n\n HISTORY: Dyspnea and tachycardia.\n\n IMPRESSION: AP chest compared to through .\n\n There has been substantial improvement in pulmonary edema, particularly in the\n right lung. Left perihilar consolidation is the most significant region of\n abnormality followed by the right lung base and these areas have not cleared.\n Small bilateral pleural effusion has increased slightly on the left and\n decreased on the right. Heart is normal size. Mediastinal vascular\n engorgement is unchanged. Left-sided skinfold and overlying tubing should not\n be mistaken for pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-19 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":925836,"text":" 11:47 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? infectious process\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with new oxygen requirement, previous COP on biopsy, hemoptysis\n following CT guided biopsy on .\n REASON FOR THIS EXAMINATION:\n ? infectious process\n CONTRAINDICATIONS for IV CONTRAST:\n increased creatinine\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n REASON FOR EXAM: 84-year-old man with increased oxygen with history of\n organizing pneumonia\n\n COMPARISON: Comparison is made with prior study dated .\n\n TECHNIQUE: Multidetector CT through the chest performed in full inspiration\n and expiration. 2.5 and 1.25 mm collimation images were reviewed.\n\n FINDINGS:\n Extensive peripheral consolidations in the apico- posterior segments of the\n left upper lobe, posterior segment of the right upper lobe and right basal\n posterior and lateral segments have worsened\n New bilateral apical ground-glass opacities, and increase in the interstitial\n abnormality with peribronchial infiltration that is continuous with the\n consolidations, are either worsening of the preexistingpneumonia\n or superimposed pulmonary edema.\n\n The airways are patent to segmental level. Multiple prevascular,\n paratracheal, and subcarinal lymph nodes have increased in number and size,\n for instance the largest in the left lower paratracheal region (2:53)\n measuring 11 mm, was 6 mm, and a 10 mm right lower paratracheal lymph node was\n 6 mm. Many of the paratracheal and right hilar lymph nodes are calcified.\n Moderate non-hemorrhagic layering left pleural effusion is new. A small amount\n of pleural effusion in the right side is loculated in the major fissure. There\n is no pericardial effusion. The LAD is mildly calcified; otherwise, the heart\n and great vessels are unremarkable.\n\n There are no bone findings of malignancy.\n\n In the upper abdomen, sub-cm hypodense lesions in the liver, too small to be\n characterized are likely cysts. Patient is post-cholecystectomy.\n\n IMPRESSION:\n\n 1. Worsening multifocal pneumonia, not hemorrhagic. Multifocal interstitial\n abnormalities are either progression of organizing pneumonia or edema.\n 2. New bilateral pleural effusions, larger in the left side.\n (Over)\n\n 11:47 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? infectious process\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2200-08-28 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":927008,"text":" 4:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: RIJ placement postprocedure\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pna, s/p RIJ placement\n REASON FOR THIS EXAMINATION:\n RIJ placement postprocedure\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Right internal jugular central venous line placement. History of\n cryptogenic pneumonia. Check for line position.\n\n FINDINGS: A right internal jugular vein approach central venous line is\n present seen to terminate overlying the SVC at the level 2 cm below the\n carina. No pneumothorax has developed, no other placement related\n complications are identified. Pulmonary and pleural abnormalities remain\n unchanged as described on previous study obtained 12 hours earlier during the\n same date.\n\n"},{"category":"Radiology","chartdate":"2200-08-27 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":926885,"text":" 9:15 PM\n PORTABLE ABDOMEN Clip # \n Reason: Signs of obstruction or perforation?\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with severe MR, BOOP and new diffuse abdominal pain with\n nausea.\n REASON FOR THIS EXAMINATION:\n Signs of obstruction or perforation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 84-year-old man with severe mitral regurgitation, BOOP, and\n abdominal pain.\n\n ABDOMEN, SINGLE SUPINE PORTABLE: No prior radiographs for comparison. The\n bowel gas pattern is unremarkable, without dilatation of the small or large\n bowel. There is stool in the ascending colon and rectum. Air is present\n within the rectum. There are cholecystectomy clips in the right upper\n quadrant.\n\n IMPRESSION: No evidence of obstruction.\n\n"},{"category":"Radiology","chartdate":"2200-08-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926300,"text":" 9:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulmonary edema, effusion\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia\n REASON FOR THIS EXAMINATION:\n eval pulmonary edema, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dyspnea, tachycardia.\n\n CHEST AP:\n\n Comparison is made with the prior chest from . There has been an\n increase in the size of the left pleural effusion. Some clearing of the\n opacities in the left upper lobe is seen. Patchy opacities are seen in all\n other parts of the lung. The appearances suggest failure with probable\n pneumonia.\n\n IMPRESSION: Increasing left effusion, some clearing of left upper lobe.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926347,"text":" 9:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? edema\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam.\n\n REASON FOR THIS EXAMINATION:\n ? edema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dyspnea, tachypnea. Evaluate failure.\n\n Since the prior chest x-ray of , there has been an increase in the\n size of the right pleural effusion, which now extends towards the apex.\n\n The interstitial is also somewhat more pronounced. These findings\n indicate worsening failure.\n\n IMPRESSION: Worsening failure.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926651,"text":" 9:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam\n\n REASON FOR THIS EXAMINATION:\n ? worsening failure\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:43 A.M .\n\n HISTORY: Dyspnea and tachycardia. Question worsening failure.\n\n IMPRESSION: AP chest compared to through .\n\n Previous heterogeneous opacification in the right upper lobe has largely\n cleared over the past two weeks and pulmonary edema in the right lung has\n largely resolved since . There is persistent severe\n perihilar opacification in the left lung and a slowly resolving heterogeneous\n region of opacity at the right lung base.\n\n While the right pleural effusion has nearly resolved, the moderate left\n pleural effusion has not.\n\n The sequence of changes suggests the persistence of asymmetric edema, and\n clearing of the inflammatory process in the right upper lobe and improvement,\n but persistence of what is likely the same process in the right lower lobe.\n Pleural effusions are probably secondary to pulmonary pathology. Cardiac\n silhouette is slightly enlarged, and there is persistence of vascular\n engorgement in the superior mediastinum suggesting cardiac decompensation\n and/or volume overload.\n\n Left skinfold should not be mistaken for pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-18 00:00:00.000","description":"CHEST (PA & LAT)","row_id":925757,"text":" 7:25 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with recent treatment for PNA\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of recent treatment for pneumonia.\n\n COMPARISON: Radiograph dated and CT scan dated and\n radiograph dated .\n\n PA AND LATERAL VIEWS OF THE CHEST: There is increased confluent opacity in\n the left upper lobe. The area of opacity in the right lower lobe appears\n increased compared to the previous exam, however, the most densely opacified\n area is slightly smaller. Right upper lobe patchy opacities are also again\n seen. There is no evidence of pneumothorax. There is a possible tiny right\n pleural effusion.\n\n IMPRESSION: Interval worsening of left upper lobe airspace opacity with\n possible interval increase in extent of opacity also in the right lower lobe.\n This may represent an infectious process.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-28 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":926899,"text":" 2:41 AM\n PORTABLE ABDOMEN Clip # \n Reason: Signs of perforation?\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pna, acute renal failure on high dose steroids\n with new abdominal pain.\n REASON FOR THIS EXAMINATION:\n Please do upright chest film. Signs of free air?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cryptogenic pneumonia and acute renal failure, now with 9 out of\n 10 abdominal pain. Evaluate for signs of free air.\n\n There are no prior studies for comparison.\n\n SUPINE ABDOMEN: There is no evidence of free air on the supine views. The\n bowel gas pattern is nonspecific, with air seen within non-dilated loops of\n small bowel and throughout the colon to the rectum. No evidence of\n obstruction. There are surgical clips in the right upper quadrant, likely\n related to cholecystectomy.\n\n\n"},{"category":"Radiology","chartdate":"2200-08-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":926900,"text":" 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ABDOMINAL PAIN/ CHECK FOR FREE AIR// ALSO SOB\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Patient with BOOP who is short of breath. Also, 9 out of 10\n abdominal pain. Evaluate for free air.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: No free air is visualized beneath the hemidiaphragm. Air\n space opacity within the left upper lobe has slightly improved compared to\n . The right upper lobe and right lower lung appear not\n significantly changed in the interim. Cardiomegaly and the aortic contours\n are unchanged. The left pleural effusion appears slightly decreased. No\n pneumothorax.\n\n IMPRESSION: No free air beneath the hemidiaphragm is visualized. Improved\n left upper lobe parenchymal opacification.\n\n"},{"category":"Radiology","chartdate":"2200-08-28 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":926901,"text":" 5:31 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please do abdominal CT scan with PO contrast (renal failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pneumonia, acute renal failure, new \n abdominal pain out of proportion to exam with elevated lactate.\n\n REASON FOR THIS EXAMINATION:\n Please do abdominal CT scan with PO contrast (renal failure precludes IV\n contrast). Signs of ischemia?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN\n\n INDICATION: Cryptogenic pneumonia, acute renal failure, abdominal pain.\n\n FINDINGS:\n\n A CT of abdomen and pelvis was performed with axial images taken from the lung\n bases to the symphysis pubis.\n\n Oral contrast only was administered because of the patient's renal failure.\n\n Multiplanar reconstructions in the coronal and sagittal planes were obtained.\n\n The lung bases reveal a small right pleural effusion and a moderate-sized left\n pleural effusion. A granuloma is noted in the right base. There is some right-\n sided linear atelectasis.\n\n Note is made of some coronary artery calcification.\n\n Below the diaphragm, given that this is a non-contrast CT, note is made of a\n low-attenuation lesion measuring 11 mm in the dome of the liver which is\n unchanged when compared to the previous CT from .\n\n A subcentimeter lesion is seen in segment VII and is unchanged.\n\n A subcentimeter lesion is seen in segment and is unchanged.\n\n The fourth lesion which was identified on the previous study is difficult to\n visualize on this study due to artifact from overlying skin markers.\n\n This patient is status post cholecystectomy.\n\n The spleen, adrenals, kidneys and pancreas are normal.\n\n No evidence of any significant lymphadenopathy.\n\n Some vascular calcification is noted in relation to the aorta.\n (Over)\n\n 5:31 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please do abdominal CT scan with PO contrast (renal failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The bowel where visualized is normal.\n\n CT OF PELVIS:\n\n Note is made of some sigmoid diverticula.\n\n The bladder is catheterized with a significant amount of air secondary to\n instrumentation.\n\n In the pelvis, a tiny amount of fluid is seen which measures approximately 2 x\n 1.3 cm. It is of unknown etiology.\n\n Just anterior to the sacrum, note is also made of some minimal fluid. Again,\n this is of unknown etiology.\n\n BONY WINDOWS:\n\n Note is made of degenerative change\n\n IMPRESSION:\n\n No evidence of any ischemic bowel given that this is a non-contrast CT.\n\n Multiple lesions in the liver which are unchanged.\n\n Some minimal presacral fluid and some minimal fluid in the pelvis of unknown\n etiology.\n\n Sigmoid diverticula.\n\n Scarring right base and bilateral effusions.\n\n\n\n"},{"category":"Radiology","chartdate":"2200-08-27 00:00:00.000","description":"RENAL U.S.","row_id":926851,"text":" 2:54 PM\n RENAL U.S. Clip # \n Reason: EVAL FOR HYDRONEPHROSIS OR OTHER BLOCKAGE\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with increasing creatinine with some urinary retention\n yesterday now s/p foley.\n REASON FOR THIS EXAMINATION:\n ? hydronephrosis or other blockage\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Renal ultrasound.\n\n CLINICAL HISTORY: 84-year-old man with increasing creatinine with some\n urinary retention yesterday. Now status post Foley. Rule out hydronephrosis\n or other blockage.\n\n FINDINGS: Renal ultrasound was performed on . No prior ultrasound\n studies available for comparison. Comparison made to CTA of the abdomen dated\n .\n\n The kidneys are normal in size, without evidence of hydronephrosis or solid\n renal masses. There is a small crystal in the renal cortex of the midpole of\n the left kidney. No perinephric fluid collections are seen.\n\n There is a left pleural effusion.\n\n A Foley catheter is in the urinary bladder, which is decompressed.\n\n IMPRESSION:\n 1. No evidence of hydronephrosis.\n 2. Left pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2200-08-26 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":926681,"text":" 12:48 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with hypoxia, tachypnea\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY ULTRASOUND\n\n HISTORY: 84-year-old male with hypoxia and tachypnea. Please evaluate for\n DVT.\n\n FINDINGS: No prior study is available for comparison. Grayscale and Doppler\n son of the left and right common femoral, superficial femoral, and\n popliteal veins were performed. Normal flow, augmentation, compressibility,\n and waveforms are demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1601651,\n \"text\": \"Pt is a 84 y/o who presented to our ED on recomendation from his PCP after CxR as outpt showed new infiltrate. Pt was being worked up for a mitral valve repair due to severe MVR. Admitted to 2 where sputum cx grew out yeast, urine also noted to be cloudy and was cultured . On floor pt was having increasing O2 requirements and some shortness of breath. Also, pt was having increasing abd pain ( on arrival to MICU). Lab values INR 2.3 K 6 WBC 24 Lactic Acid 5. CxR done showing worsening PNA and pt's urine output had diminished to 50cc for entire night shift. Decision made to tx to MICU for increased monitoring and treatment. ABD CT done to r/o ischemic bowel.\\n\\nNeuro: Pt a+ox3, following commands consistently. MAE, drowsy as he has not had sleep in >24hrs. C/O abd pain \\n\\nResp: lung sounds with crackles. O2 sats mid 90's on 2L via n/c. Breathing somewhat labored but pt reports no difficulty breathing. CxR showing worsenig PNA\\n\\nCaridac: SR with no ectopy since arrival. PO lopressor on hold as b/p is hypotensive 90's/30's. Pt has severe mvr and was in process of workup for mitral valve repair when MD suggested he visit ED.\\n\\nGU: Abd soft with positive bowel sounds. C/O pain. No bm in spite of enemas on floor. Just returned from abd CT ruling out ischemic bowel. Surgery following. NPO.\\n\\nGU: No urine output since arrival on MICU. Due for labs at 0800.\\n\\nDerm: Grossly intact. PIV x1 20G intact. Perihperal pulses weakly palpable.\\n\\nID: Afebrile. On IV zosyn.\\n\\nPlan: Follow up on abd Ct, to surgery if positive, Lytes at 0800, monitor fluid status, and hemodynamic status.\\n\\nGU\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1601654,\n \"text\": \"Nursing Progress Note.\\n\\nPt functional status progressively worsened over the coarse of the day, pt code status subsequently changed from DNR -- CPR not indicated to full DNR/DNI by team this AM c likely CMO as status waranted. Family members (wife, two , -in-law) @ BS all AM and kept up to date c POC/pt status throughout shift. IVP 0.5mg Morphine provided this afternoon times two for pt discomfort c fair affect noted. Unfortunately, the pt became apneic following a routine position change, ETS was attempted but unsuccessful. The pt then became bradycardic, remained apneic c no BP measurable. Team notified and pt declared deceased @ approx 16:05. Please see CareVue for additional pt care data/comments. Family notified of event, verbal and non-verbal support provided by team.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1601652,\n \"text\": \"npn\\nevents central line placed, mri on hold until \\n\\nneuro:aox3, sleeping off and on, pt stating he is very tired.\\npain: denies pain. exp. general discomfort from lying in bed. pain med given with line placement which pt tolerated well.\\n\\ncad hr sr 80 to 90's, nbp 80 systolic in am with two 250cc ns boluses given with nbp up to the 100 to 90's systolic , again dropped to the high 80's at 1730 to 1830 md aware, cvp 12 with some fluctuating noted to 18, pt given lasix 20 mg ivp at 1845 for ? chf.\\n\\nresp remains on 2to3 l nc, ls clear with crackles in bases in am to cracles thru out after line placemnt and receving 2 units of ffp. sats 91 to 975 rr teens to high 20 to bursts to 30 to 40's.\\n\\ngi: abd soft slight distended. bs+ no bm this shfit, no c/o abd pain, ? c/o nausea with md was ordered and given in afternoon. mri held at pt's request.\\n\\ngu: urine output increased to 10cc/hr after multiple boluses and antibiotics given. now 5cc/hr pt given lasix 20 mg ivp at 1845. last 6 pt given kayexlate po at 1600 awaiting results.\\n\\nendo: bs 108 to 172 las t bs not covered due to pooor po intake.\\n\\nid: afebrile, antibiotics given.\\n\\nplan: mri tomorrow am, cont to be full code, cont to moniotr vs, labs resp and fluid status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2200-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1601653,\n \"text\": \"Events: Bolused with 250cc NS x3 for low u/o and hypotension. Family in and decision made to change code status to CPR not indicated. Pt can be intubated if need be however.\\n\\nNeuro: A+Ox3 and following commnads. Did have period where he had some confusion while hypotensive, but resolved after fluid boluses. No complaints of pain this shift. Slept throughout shift but arousable to verbal stimuli.\\n\\nResp: Lung sounds with wheezes throughout and crackles in bases. O2 sats maintained in high 90's on 70% humidified O2 via face tent. Alb/atr nebs q4. Pt states breathing is easier than previous but rr remains tachypneic (30's) at times.\\n\\nCardiac: SR with no ectopy throughout shift. CVP 11-16. Bolused with total of 750cc NS to keep MAP's >60. B/P droping as low as 70's/20's prior to fluid boluses. B/P largely 90's/40's since midnight. Team has been reluctant to start pressors as pt has 4+MR.\\n\\nGI: Abd soft and nontender this shift. No c/o pain which had been yesterday. medicated with 0.5mg morphine prior to start of this shift. No BM this shift either. Pt may go for MRI later today to assess for ischemic bowel.\\n\\nGU: Pt given 20mg IV lasix, with no effect. Then 40mg IV lasix with similar results, then 80mg with approx 100cc's amber urine output. Renal is following. Pt's electrolytes remain increasingly out of balance. K+5.8 Phos 9.1 Mg 3.2 BUN 97 and Cr3.8\\n\\nHeme: HCT down to 25.8 (28.5) INR up to 2.3 (2.5) received 2uffp prior to TLC placement yesterday.\\n\\nDerm: Grossly intact. PIV x1 patent. TLC in RIJ placed yesterday patent with good blood return. Small hematoma at site unchanged.\\n\\nPlan: Family in today to meet with attending to discuss prognosis and plan of care, may go for MRI if decided to fully treat, Monitor lab data (?HD), monitor hemodynamic status, may start levophed if b/p cannot be maintained with small boluses. Pt is currently CPR not indicated but will be intubated if need be.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197667,\n \"text\": \"Sinus rhythm\\nIndeterminate axis\\nLow limb lead QRs voltages\\nModest right ventricular conduction delay pattern\\nFindings are nonspecific but clinical correlation is suggested for possible\\nchronic pulmonary disease\\nSince previous tracing of , sinus tachycardia rate slower\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197668,\n \"text\": \"Sinus tachycardia\\nSlight ST-T wave changes - are nonspecific and may be within normal limits\\nSince previous tracing of , right precordial ST-T wave changes slightly\\nless prominent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197669,\n \"text\": \"Sinus tachycardia\\nPossible left atrial abnormality\\nModest nonspecific ST-T wave changes\\nSince previous tracing of , ventricular ectopy absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197670,\n \"text\": \"Sinus tachycardia with ventricular ectopy. Ventricular rate 114 beats per\\nminute. P-R interval 0.16. Since the previous tracing of the rate is\\nincreased and ventricular ectopy is new. No other diagnostic changes have\\noccurred.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2200-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 197914,\n \"text\": \"Sinus rhythm\\nNormal ECG\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926604,\n \"text\": \" 9:56 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for progression of volume overload\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with dyspnea, tachycardia, crackles on exam\\n REASON FOR THIS EXAMINATION:\\n please evaluate for progression of volume overload\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 10:12 P.M., .\\n\\n HISTORY: Dyspnea and tachycardia.\\n\\n IMPRESSION: AP chest compared to through .\\n\\n There has been substantial improvement in pulmonary edema, particularly in the\\n right lung. Left perihilar consolidation is the most significant region of\\n abnormality followed by the right lung base and these areas have not cleared.\\n Small bilateral pleural effusion has increased slightly on the left and\\n decreased on the right. Heart is normal size. Mediastinal vascular\\n engorgement is unchanged. Left-sided skinfold and overlying tubing should not\\n be mistaken for pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-19 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 925836,\n \"text\": \" 11:47 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ? infectious process\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with new oxygen requirement, previous COP on biopsy, hemoptysis\\n following CT guided biopsy on .\\n REASON FOR THIS EXAMINATION:\\n ? infectious process\\n CONTRAINDICATIONS for IV CONTRAST:\\n increased creatinine\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT CHEST\\n\\n REASON FOR EXAM: 84-year-old man with increased oxygen with history of\\n organizing pneumonia\\n\\n COMPARISON: Comparison is made with prior study dated .\\n\\n TECHNIQUE: Multidetector CT through the chest performed in full inspiration\\n and expiration. 2.5 and 1.25 mm collimation images were reviewed.\\n\\n FINDINGS:\\n Extensive peripheral consolidations in the apico- posterior segments of the\\n left upper lobe, posterior segment of the right upper lobe and right basal\\n posterior and lateral segments have worsened\\n New bilateral apical ground-glass opacities, and increase in the interstitial\\n abnormality with peribronchial infiltration that is continuous with the\\n consolidations, are either worsening of the preexistingpneumonia\\n or superimposed pulmonary edema.\\n\\n The airways are patent to segmental level. Multiple prevascular,\\n paratracheal, and subcarinal lymph nodes have increased in number and size,\\n for instance the largest in the left lower paratracheal region (2:53)\\n measuring 11 mm, was 6 mm, and a 10 mm right lower paratracheal lymph node was\\n 6 mm. Many of the paratracheal and right hilar lymph nodes are calcified.\\n Moderate non-hemorrhagic layering left pleural effusion is new. A small amount\\n of pleural effusion in the right side is loculated in the major fissure. There\\n is no pericardial effusion. The LAD is mildly calcified; otherwise, the heart\\n and great vessels are unremarkable.\\n\\n There are no bone findings of malignancy.\\n\\n In the upper abdomen, sub-cm hypodense lesions in the liver, too small to be\\n characterized are likely cysts. Patient is post-cholecystectomy.\\n\\n IMPRESSION:\\n\\n 1. Worsening multifocal pneumonia, not hemorrhagic. Multifocal interstitial\\n abnormalities are either progression of organizing pneumonia or edema.\\n 2. New bilateral pleural effusions, larger in the left side.\\n (Over)\\n\\n 11:47 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: ? infectious process\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 927008,\n \"text\": \" 4:13 PM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: RIJ placement postprocedure\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with cryptogenic pna, s/p RIJ placement\\n REASON FOR THIS EXAMINATION:\\n RIJ placement postprocedure\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: Right internal jugular central venous line placement. History of\\n cryptogenic pneumonia. Check for line position.\\n\\n FINDINGS: A right internal jugular vein approach central venous line is\\n present seen to terminate overlying the SVC at the level 2 cm below the\\n carina. No pneumothorax has developed, no other placement related\\n complications are identified. Pulmonary and pleural abnormalities remain\\n unchanged as described on previous study obtained 12 hours earlier during the\\n same date.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-27 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 926885,\n \"text\": \" 9:15 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: Signs of obstruction or perforation?\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with severe MR, BOOP and new diffuse abdominal pain with\\n nausea.\\n REASON FOR THIS EXAMINATION:\\n Signs of obstruction or perforation?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 84-year-old man with severe mitral regurgitation, BOOP, and\\n abdominal pain.\\n\\n ABDOMEN, SINGLE SUPINE PORTABLE: No prior radiographs for comparison. The\\n bowel gas pattern is unremarkable, without dilatation of the small or large\\n bowel. There is stool in the ascending colon and rectum. Air is present\\n within the rectum. There are cholecystectomy clips in the right upper\\n quadrant.\\n\\n IMPRESSION: No evidence of obstruction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926300,\n \"text\": \" 9:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval pulmonary edema, effusion\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with dyspnea, tachycardia\\n REASON FOR THIS EXAMINATION:\\n eval pulmonary edema, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Dyspnea, tachycardia.\\n\\n CHEST AP:\\n\\n Comparison is made with the prior chest from . There has been an\\n increase in the size of the left pleural effusion. Some clearing of the\\n opacities in the left upper lobe is seen. Patchy opacities are seen in all\\n other parts of the lung. The appearances suggest failure with probable\\n pneumonia.\\n\\n IMPRESSION: Increasing left effusion, some clearing of left upper lobe.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926347,\n \"text\": \" 9:03 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? edema\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with dyspnea, tachycardia, crackles on exam.\\n\\n REASON FOR THIS EXAMINATION:\\n ? edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Dyspnea, tachypnea. Evaluate failure.\\n\\n Since the prior chest x-ray of , there has been an increase in the\\n size of the right pleural effusion, which now extends towards the apex.\\n\\n The interstitial is also somewhat more pronounced. These findings\\n indicate worsening failure.\\n\\n IMPRESSION: Worsening failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926651,\n \"text\": \" 9:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ? worsening failure\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with dyspnea, tachycardia, crackles on exam\\n\\n REASON FOR THIS EXAMINATION:\\n ? worsening failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 9:43 A.M .\\n\\n HISTORY: Dyspnea and tachycardia. Question worsening failure.\\n\\n IMPRESSION: AP chest compared to through .\\n\\n Previous heterogeneous opacification in the right upper lobe has largely\\n cleared over the past two weeks and pulmonary edema in the right lung has\\n largely resolved since . There is persistent severe\\n perihilar opacification in the left lung and a slowly resolving heterogeneous\\n region of opacity at the right lung base.\\n\\n While the right pleural effusion has nearly resolved, the moderate left\\n pleural effusion has not.\\n\\n The sequence of changes suggests the persistence of asymmetric edema, and\\n clearing of the inflammatory process in the right upper lobe and improvement,\\n but persistence of what is likely the same process in the right lower lobe.\\n Pleural effusions are probably secondary to pulmonary pathology. Cardiac\\n silhouette is slightly enlarged, and there is persistence of vascular\\n engorgement in the superior mediastinum suggesting cardiac decompensation\\n and/or volume overload.\\n\\n Left skinfold should not be mistaken for pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-18 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 925757,\n \"text\": \" 7:25 PM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for pulmonary process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with recent treatment for PNA\\n REASON FOR THIS EXAMINATION:\\n evaluate for pulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of recent treatment for pneumonia.\\n\\n COMPARISON: Radiograph dated and CT scan dated and\\n radiograph dated .\\n\\n PA AND LATERAL VIEWS OF THE CHEST: There is increased confluent opacity in\\n the left upper lobe. The area of opacity in the right lower lobe appears\\n increased compared to the previous exam, however, the most densely opacified\\n area is slightly smaller. Right upper lobe patchy opacities are also again\\n seen. There is no evidence of pneumothorax. There is a possible tiny right\\n pleural effusion.\\n\\n IMPRESSION: Interval worsening of left upper lobe airspace opacity with\\n possible interval increase in extent of opacity also in the right lower lobe.\\n This may represent an infectious process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 926899,\n \"text\": \" 2:41 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: Signs of perforation?\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with cryptogenic pna, acute renal failure on high dose steroids\\n with new abdominal pain.\\n REASON FOR THIS EXAMINATION:\\n Please do upright chest film. Signs of free air?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cryptogenic pneumonia and acute renal failure, now with 9 out of\\n 10 abdominal pain. Evaluate for signs of free air.\\n\\n There are no prior studies for comparison.\\n\\n SUPINE ABDOMEN: There is no evidence of free air on the supine views. The\\n bowel gas pattern is nonspecific, with air seen within non-dilated loops of\\n small bowel and throughout the colon to the rectum. No evidence of\\n obstruction. There are surgical clips in the right upper quadrant, likely\\n related to cholecystectomy.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 926900,\n \"text\": \" 3:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ABDOMINAL PAIN/ CHECK FOR FREE AIR// ALSO SOB\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Patient with BOOP who is short of breath. Also, 9 out of 10\\n abdominal pain. Evaluate for free air.\\n\\n COMPARISON: .\\n\\n UPRIGHT AP CHEST: No free air is visualized beneath the hemidiaphragm. Air\\n space opacity within the left upper lobe has slightly improved compared to\\n . The right upper lobe and right lower lung appear not\\n significantly changed in the interim. Cardiomegaly and the aortic contours\\n are unchanged. The left pleural effusion appears slightly decreased. No\\n pneumothorax.\\n\\n IMPRESSION: No free air beneath the hemidiaphragm is visualized. Improved\\n left upper lobe parenchymal opacification.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-28 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 926901,\n \"text\": \" 5:31 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: Please do abdominal CT scan with PO contrast (renal failure\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n Field of view: 38\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with cryptogenic pneumonia, acute renal failure, new \\n abdominal pain out of proportion to exam with elevated lactate.\\n\\n REASON FOR THIS EXAMINATION:\\n Please do abdominal CT scan with PO contrast (renal failure precludes IV\\n contrast). Signs of ischemia?\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT ABDOMEN\\n\\n INDICATION: Cryptogenic pneumonia, acute renal failure, abdominal pain.\\n\\n FINDINGS:\\n\\n A CT of abdomen and pelvis was performed with axial images taken from the lung\\n bases to the symphysis pubis.\\n\\n Oral contrast only was administered because of the patient's renal failure.\\n\\n Multiplanar reconstructions in the coronal and sagittal planes were obtained.\\n\\n The lung bases reveal a small right pleural effusion and a moderate-sized left\\n pleural effusion. A granuloma is noted in the right base. There is some right-\\n sided linear atelectasis.\\n\\n Note is made of some coronary artery calcification.\\n\\n Below the diaphragm, given that this is a non-contrast CT, note is made of a\\n low-attenuation lesion measuring 11 mm in the dome of the liver which is\\n unchanged when compared to the previous CT from .\\n\\n A subcentimeter lesion is seen in segment VII and is unchanged.\\n\\n A subcentimeter lesion is seen in segment and is unchanged.\\n\\n The fourth lesion which was identified on the previous study is difficult to\\n visualize on this study due to artifact from overlying skin markers.\\n\\n This patient is status post cholecystectomy.\\n\\n The spleen, adrenals, kidneys and pancreas are normal.\\n\\n No evidence of any significant lymphadenopathy.\\n\\n Some vascular calcification is noted in relation to the aorta.\\n (Over)\\n\\n 5:31 AM\\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \\n Reason: Please do abdominal CT scan with PO contrast (renal failure\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n Field of view: 38\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n The bowel where visualized is normal.\\n\\n CT OF PELVIS:\\n\\n Note is made of some sigmoid diverticula.\\n\\n The bladder is catheterized with a significant amount of air secondary to\\n instrumentation.\\n\\n In the pelvis, a tiny amount of fluid is seen which measures approximately 2 x\\n 1.3 cm. It is of unknown etiology.\\n\\n Just anterior to the sacrum, note is also made of some minimal fluid. Again,\\n this is of unknown etiology.\\n\\n BONY WINDOWS:\\n\\n Note is made of degenerative change\\n\\n IMPRESSION:\\n\\n No evidence of any ischemic bowel given that this is a non-contrast CT.\\n\\n Multiple lesions in the liver which are unchanged.\\n\\n Some minimal presacral fluid and some minimal fluid in the pelvis of unknown\\n etiology.\\n\\n Sigmoid diverticula.\\n\\n Scarring right base and bilateral effusions.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-27 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 926851,\n \"text\": \" 2:54 PM\\n RENAL U.S. Clip # \\n Reason: EVAL FOR HYDRONEPHROSIS OR OTHER BLOCKAGE\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with increasing creatinine with some urinary retention\\n yesterday now s/p foley.\\n REASON FOR THIS EXAMINATION:\\n ? hydronephrosis or other blockage\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Renal ultrasound.\\n\\n CLINICAL HISTORY: 84-year-old man with increasing creatinine with some\\n urinary retention yesterday. Now status post Foley. Rule out hydronephrosis\\n or other blockage.\\n\\n FINDINGS: Renal ultrasound was performed on . No prior ultrasound\\n studies available for comparison. Comparison made to CTA of the abdomen dated\\n .\\n\\n The kidneys are normal in size, without evidence of hydronephrosis or solid\\n renal masses. There is a small crystal in the renal cortex of the midpole of\\n the left kidney. No perinephric fluid collections are seen.\\n\\n There is a left pleural effusion.\\n\\n A Foley catheter is in the urinary bladder, which is decompressed.\\n\\n IMPRESSION:\\n 1. No evidence of hydronephrosis.\\n 2. Left pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2200-08-26 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 926681,\n \"text\": \" 12:48 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: ? DVT\\n Admitting Diagnosis: SHORTNESS OF BREATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old man with hypoxia, tachypnea\\n REASON FOR THIS EXAMINATION:\\n ? DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n BILATERAL LOWER EXTREMITY ULTRASOUND\\n\\n HISTORY: 84-year-old male with hypoxia and tachypnea. Please evaluate for\\n DVT.\\n\\n FINDINGS: No prior study is available for comparison. Grayscale and Doppler\\n son of the left and right common femoral, superficial femoral, and\\n popliteal veins were performed. Normal flow, augmentation, compressibility,\\n and waveforms are demonstrated. Intraluminal thrombus is not identified.\\n\\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":182,"cells":{"subject_id":{"kind":"number","value":47758,"string":"47,758"},"hadm_id":{"kind":"number","value":135647,"string":"135,647"},"target_text":{"kind":"string","value":"64 year old female admitted to the acute care service with dehydration, elevated creatinine, and leakage around the g-tube site. Upon admission, she was fluid resusitated and her electrolytes were repleted. A foley catheter was replaced in the gastro-cutaneoous fistula to decrease leakge. Despite placment of a larger tube, she continued to leak around the G-tube site and an additional was placed and she was maintained NPO. During her hospitalization, her creatinine slowly decreased and her fluid status improved. She was started on clear liquids with gradual advancement to a regular diet. She continued to leak gastric contents around the drain. Recommendations for skin care were outlined by the ostomy/wound nurse. She has been reluctant to participate in physical therapy, but they have provided daily visits. Her vital signs are stable and she is afebrile. Her electrolytes have normalized and her creatinine as decreased to 2.0. She is preparing for discharge to her daughter's home with VNA assistance. She will follow-up with the acute care service in 2 weeks. She can have her foley catheter removed at the rehab facility Medications on Admission: : simvastatin 20 qhs, citalopram 40', singulair 10 qhs, advair 250/50\", proair prn , albuterol prn, protonix 40', mvi, oxycodone prn, ativan prn"},"extractive_notes_summ":{"kind":"string","value":"Left retrocardiac opacity that is unchanged since the previous examination and is likely to represent atelectasis. Moderate cardiomegaly without overt pulmonary edema. FINDINGS: As compared to the previous radiograph, the left PICC line has been removed. Normal aspect of the hilar and mediastinal structures. Coexisting pneumonia however, cannot be excluded. No other focal parenchymal opacities. No pneumothorax. 3:52 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for consolidation. report of LLL opacity on OSH films FINAL REPORT CHEST RADIOGRAPH INDICATION: Renal failure, evaluation for consolidation, report of left lower lobe opacity from an outside hospital film. COMPARISON: ."},"n_notes":{"kind":"number","value":1,"string":"1"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2124-08-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1200882,"text":" 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for consolidation. report of LLL opacity on\n Admitting Diagnosis: RENAL FAILURE, GASTROCUTANEOUS FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with poor PO intake and renal failure\n REASON FOR THIS EXAMINATION:\n please evaluate for consolidation. report of LLL opacity on OSH films\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Renal failure, evaluation for consolidation, report of left lower\n lobe opacity from an outside hospital film.\n\n COMPARISON: .\n\n FINDINGS:\n\n As compared to the previous radiograph, the left PICC line has been removed.\n Moderate cardiomegaly without overt pulmonary edema. Left retrocardiac\n opacity that is unchanged since the previous examination and is likely to\n represent atelectasis. Coexisting pneumonia however, cannot be excluded. No\n other focal parenchymal opacities. Normal aspect of the hilar and mediastinal\n structures. No pneumothorax.\n\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2124-08-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1200882,\n \"text\": \" 3:52 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for consolidation. report of LLL opacity on\\n Admitting Diagnosis: RENAL FAILURE, GASTROCUTANEOUS FISTULA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old woman with poor PO intake and renal failure\\n REASON FOR THIS EXAMINATION:\\n please evaluate for consolidation. report of LLL opacity on OSH films\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Renal failure, evaluation for consolidation, report of left lower\\n lobe opacity from an outside hospital film.\\n\\n COMPARISON: .\\n\\n FINDINGS:\\n\\n As compared to the previous radiograph, the left PICC line has been removed.\\n Moderate cardiomegaly without overt pulmonary edema. Left retrocardiac\\n opacity that is unchanged since the previous examination and is likely to\\n represent atelectasis. Coexisting pneumonia however, cannot be excluded. No\\n other focal parenchymal opacities. Normal aspect of the hilar and mediastinal\\n structures. No pneumothorax.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":183,"cells":{"subject_id":{"kind":"number","value":2378,"string":"2,378"},"hadm_id":{"kind":"number","value":157554,"string":"157,554"},"target_text":{"kind":"string","value":"# Pneumonia - On admission, pneumonia was felt less likely given lack of clear evidence on chest x-ray and low grade temperature. Treated for COPD exacerbation with Levaquin and high dose pulse steroids with plan for quick taper. Shortness of breath remained at baseline for 48 hours after admission. On hospitaly day 2, repeat chest x-ray obtained in setting of hypotension showed worsening RLL opacity and Vancomycin and Cefepime were started due to history of MRSA and Pseudomonnal pneumonia. On hospital day 3, patient complained of increased dyspnea, was not hypoxic. She was also persistently hypotensive unresponsive to fluids and was transferred to the ICU for further management. In the ICU a central line was placed and CVP monitoring revealed low values indicative of hypovolemia. She was resuscitated with IV fluids and her blood pressure was initially responsive. She was continued on IV Vancomycin, IV Cefepime and IV Levofloxacin for double coverage given her recent hospitalization and history of Pseudomonal pneumonia, and she completed an eight day course of these antibiotics. Her respiratory status improved slowly with decreased work of breathing. She required only minimal oxygen supplemenation intermittently. # Sepsis - Likely secondary to pneumonia and C. diff diagnosed on hospital day 1. Initially normotensive on admission, Mrs. was hypotensive to SBP 80's on hospital day 2 with adequate response to 2L fluid bolus. Anti-hypertensives held. On hospital day 3, patient became hypotensive to 70-80's with little improvement after 3.5L bolus. Due to persistant hypotension, transferred to ICU and continued Vancomycin and Cefepime for pneumonia as well as PO Vancomycin for C. Diff. In the ICU a central line was placed and CVP monitoring revealed low values indicative of hypovolemia. She was resuscitated with IV fluids and her blood pressure was initially responsive. Presumedly she was hypovolemic due to massive GI losses from C.diff. She was continued on IV boluses PRN. Although he blood pressure did not improve greatly and she remained modestly hypotensive with SBP 90s, on gentle diuresis was started given her history of diastolic CHF as well as anasarca from worsened hypoalbuminemia. She tolerated this well without worsening of her blood pressures. After completing an eight day course of antibiotics for pneumonia, the plan is to complete an additional 6 week taper of PO vancomycin for recurrent C. diff infection. Central line was pulled on day of discharge without complication. # C. Difficile - Patient was admitted with leukocytosis, diarrhea and low grade fevers. C. Diff assay was positive. Vancomycin PO and IV flagyl were started due to recurrent C. Diff infections. Diarrhea was monitored. As above, she was volume resuscitated. Her course appears to have been complicated by a protein losing enteropathy causing a worsening of hypoalbuminemia (3. --> 2.2 now). This has worsened her anasarca and made diuresis more difficult. Repeat KUBs, including one on day before discharge, showed no evidence of significant bowel dilation but did indicate ongoing gut edema. Plan to extend C.diff treatment (oral vancomycin) an additional 6 week taper after completion of her pneumonia antibiotics given recurrent, severe C. diff infection."},"extractive_notes_summ":{"kind":"string","value":"Moderate narrowing of right mainstem bronchus. Mild colonic wall thickening particularly in the right hemicolon is noted. A right IJ catheter terminates in superior vena cava. The bilateral lower lobe consolidations are unchanged noting some non-enhancing lung in the right lower lobe. Right upper lobe calcified granulomas are again noted. There is mild atelectasis at the right lung base. Normal sinus rhythm with ventricular premature beats. Mild degenerative changes are in the thoracic spine. A separate area of consolidation is in the right upper lobe in a perifissural distribution(4.140). FINDINGS: There is stable severe emphysema. Linear atelectasis is mild in the lower lobes bilaterally and partially due to a new nonhemorrhagic small right pleural effusion. Bibasilar opacity is larger on the right side are unchanged. A hiatal hernia is small. Heart and mediastinum are probably within normal limits. 4)New intraabdominal ascites and new small right pleural effusion. A right upper lobe calcified granuloma is redemonstrated. Moderate ascites. FINDINGS: Single abdomen radiograph compared to the prior study from demonstrates a dilated colonic segment. There is mild colonic wall thickening seen particularly along the right hemicolon consistent with known C. diff colitis. There is mild cardiomegaly. The right heart border is obscured by opacity in the right lower lung. Stable bilateral lower lobe consolidation. There is a slightly increasing right pleural effusion and new small left pleural effusion. There is a small left-sided pleural effusion with left lower lobe atelectasis. Centrilobular emphysema is worse in the upper lobes bilaterally and stable since the prior CT. No pathologically enlarged mediastinal or axillary lymph nodes by CT size criteria. IMPRESSION: Improved right lower lobe atelectasis. Scattered phleboliths are noted. Additionally, there is retrocardiac opacity. Right IJ catheter tip is in the mid SVC. Right IJ catheter tip is in the mid SVC. There is a hiatal hernia. Diffuse non-specific ST-T waveabnormalities. Left lower lobe opacity has minimally improved. There is moderate amount of ascites seen in the abdomen. The caliber of the aorta and pulmonary artery is normal. IMPRESSION: 1)Multifocal consolidation which has improved in the left lower lobe and is slightly worse in the right lower and upper lobes since recent conventional CXRs. Compared to the previous tracing of no change. Cardiomediastinal contours are unchanged. Right lower lobe consolidation is stable. Sinus tachycardia with ventricular premature beat. Multiple calcified granulomas are again noted. Decreased oxygen saturation and hypotension. H/o CHF, COPD. Sinus tachycardia. Opacities in the left lower lobe are unchanged. Mild cardiomegaly is stable. Mild cardiomegaly is stable. FINDINGS: The cardiomediastinal silhouette appears unremarkable. BIBASILAR OPACITIES STABLE. Delayed R wave progression with late precordial QRS transitionis non-specific but cannot exclude possible prior anterior myocardialinfarction. There is a left-sided femoral prosthesis partially imaged. Dependent secretions in the right main stem bronchus are new. Heart size normal. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Persistent hypotension. Very little change from the prior study. There is calcification at the mitral annulus. Opacities in the left lower lobe are stable. The heart size is normal with no pericardial effusion. The hila are normal appearing bilaterally. Poor R wave progressionin leads V1-V4 of uncertain significance. Consider left atrialabnormality. There is calcification of the mitral valve. Increasing right greater than left bilateral pleural effusions. The lungs are hyperinflated and there is relative lucency within the lung apices suggestive of underlying emphysema. REASON FOR THIS EXAMINATION: assess for PE No contraindications for IV contrast FINAL REPORT HISTORY: Chest pain, worsening O2 saturations and history of PE with subtherapeutic INR. Upper lung zones are clear. Since the previous tracingof ST-T wave changes appear less prominent but baseline artifacton both tracings makes comparison difficult. Right lower lobe opacity has improved consistent with improving atelectasis. IMPRESSION: Patchy bibasilar opacities which could reflect pneumonia or aspiration in the appropriate clinical setting. IMPRESSION: AP chest compared to : Right basal opacification has worsened, consistent with progressive pneumonia or atelectasis superimposed. 5-mm and 1.25-mm axial slices were acquired with coronal and sagittal reformats. Patient is status post left total hip arthroplasty. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess line. Atherosclerotic plaque is moderately severe in the aortic arch and extends into the origin of the left common carotid and subclavian arteries. No frank dilatation of the small bowel identified. FINDINGS: Single portable chest radiograph is compared to the prior study from . FINDINGS: Consolidation in the left lower lobe has improved and is slightly worse in the right lower lobe since the recent chest radiographs over the preceeding week. Contrast is identified within the bladder. ST-T wave changes are non-specific. IMPRESSION: No dilated loops of small bowel. COMPARISON: Previous CT and most numerous recent chest radiographs. Although this examination was not designed for subdiaphragmatic evaluation, there is new intra-abdominal ascites and diffuse vascular calcification of the suprarenal aorta. IMPRESSION: 1. REASON FOR EXAM: Evaluate for pneumonia TECHNIQUE: MDCT chest was performed without IV contrast. Calcification is severe in the mitral annulus and moderately severe in the aortic valve and coronary arteries. HISTORY: C. diff infection. Multiple calcified granulomas are seen in the lungs. IMPRESSION: No evidence of obstruction. AS before this could represent pneumonia or aspiration. There are degenerative changes in the spine. STUDY: AP portable upright chest radiograph. Some air is present in the descending colon. Extensive vascular calcifications are noted. There are extensive atherosclerotic calcifications of the aorta and coronary arteries. FINDINGS: There are no dilated loops of small bowel to suggest obstruction. Multiplanar reformats were performed. NO PTX OR ADDITIONAL INTERVAL CHANGE. COMPARISON: CT of the abdomen and pelvis from ."},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2142-07-18 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":1137626,"text":" 2:50 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for colonic distention\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with acute C. diff infection\n REASON FOR THIS EXAMINATION:\n eval for colonic distention\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, FOUR VIEWS.\n\n COMPARISON: .\n\n HISTORY: C. diff infection.\n\n FINDINGS: There are no dilated loops of small bowel to suggest obstruction.\n There is no evidence of free air. There is mild colonic wall thickening seen\n particularly along the right hemicolon consistent with known C. diff colitis.\n Contrast is identified within the bladder. Scattered phleboliths are noted.\n Extensive vascular calcifications are noted. Patient is status post left\n total hip arthroplasty.\n\n IMPRESSION: No evidence of obstruction. Mild colonic wall thickening\n particularly in the right hemicolon is noted.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-16 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1137332,"text":" 3:14 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: assess for PE\n Admitting Diagnosis: COPD EXACERBATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with right chest pain, worsening O2 saturations, history of\n PE and subtherapeutic INR.\n REASON FOR THIS EXAMINATION:\n assess for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain, worsening O2 saturations and history of PE with\n subtherapeutic INR.\n\n COMPARISON: .\n\n TECHNIQUE: CT of the chest was performed before and after administration of\n IV contrast. Multiplanar reformats were performed.\n\n FINDINGS:\n\n There is stable severe emphysema. The bilateral lower lobe consolidations are\n unchanged noting some non-enhancing lung in the right lower lobe. Moderate\n narrowing of right mainstem bronchus. There is a slightly increasing right\n pleural effusion and new small left pleural effusion. There is moderate\n amount of ascites seen in the abdomen. There are extensive atherosclerotic\n calcifications of the aorta and coronary arteries. Multiple calcified\n granulomas are seen in the lungs. There is no evidence of pulmonary embolism.\n There is mild cardiomegaly. There is a hiatal hernia.\n\n There are degenerative changes in the spine.\n\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n\n 2. Stable bilateral lower lobe consolidation.\n\n 3. Increasing right greater than left bilateral pleural effusions.\n\n 4. Moderate ascites.\n\n"},{"category":"Radiology","chartdate":"2142-07-12 00:00:00.000","description":"CT CHEST W/O CONTRAST","row_id":1136684,"text":" 9:10 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with sepsis, pulmonary disease\n REASON FOR THIS EXAMINATION:\n Evaluate pneumonia versus evolving lesion in right lower lobe\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast.\n\n REASON FOR EXAM: Evaluate for pneumonia\n\n TECHNIQUE: MDCT chest was performed without IV contrast. 5-mm and 1.25-mm\n axial slices were acquired with coronal and sagittal reformats.\n\n COMPARISON: Previous CT and most numerous recent chest\n radiographs.\n\n FINDINGS:\n\n Consolidation in the left lower lobe has improved and is slightly worse in the\n right lower lobe since the recent chest radiographs over the preceeding week.\n A separate area of consolidation is in the right upper lobe in a perifissural\n distribution(4.140). Dependent secretions in the right main stem bronchus are\n new. Linear atelectasis is mild in the lower lobes bilaterally and partially\n due to a new nonhemorrhagic small right pleural effusion. Several calcified\n granulomata are scattered throughout the lungs. Centrilobular emphysema is\n worse in the upper lobes bilaterally and stable since the prior CT.\n\n No pathologically enlarged mediastinal or axillary lymph nodes by CT size\n criteria. Atherosclerotic plaque is moderately severe in the aortic arch and\n extends into the origin of the left common carotid and subclavian arteries.\n The caliber of the aorta and pulmonary artery is normal. The heart size is\n normal with no pericardial effusion. Calcification is severe in the mitral\n annulus and moderately severe in the aortic valve and coronary arteries.\n\n Although this examination was not designed for subdiaphragmatic evaluation,\n there is new intra-abdominal ascites and diffuse vascular calcification of the\n suprarenal aorta. A hiatal hernia is small.\n\n No destructive or sclerotic bone lesions are concerning for malignancy.\n\n IMPRESSION:\n\n 1)Multifocal consolidation which has improved in the left lower lobe and is\n slightly worse in the right lower and upper lobes since recent conventional\n CXRs.\n\n 2)Moderately severe diffuse centrilobular emphysema\n (Over)\n\n 9:10 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3)Diffuse atherosclerotic calcification in the coronary arteries, aorta, in\n the mitral annulus and aortic valve.\n\n 4)New intraabdominal ascites and new small right pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2142-07-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1136612,"text":" 4:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Etiology of SOB\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with persisten hypotension, PNA and C.diff\n REASON FOR THIS EXAMINATION:\n Etiology of SOB\n ______________________________________________________________________________\n WET READ: MBue WED 7:28 PM\n NO SIGNIFICANT CHANGE. BIBASILAR OPACITIES STABLE.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Persistent hypotension.\n\n Comparison is made with prior study .\n\n Mild cardiomegaly is stable. There is calcification at the mitral annulus.\n Bibasilar opacity is larger on the right side are unchanged. This could be\n due to atelectasis and/or pneumonia. Right upper lobe calcified granulomas\n are again noted. There is no pneumothorax or pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-12 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1136700,"text":" 10:59 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess colon distension, other intraabdominal pathology\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cdiff and abd distension, pna, hypotension\n REASON FOR THIS EXAMINATION:\n assess colon distension, other intraabdominal pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Woman with C. diff and abdominal distention.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n Single view of the abdomen shows no dilated loops of small or large bowel.\n Air is noted within the colon. The visible osseous structures are\n unremarkable. There is a left-sided femoral prosthesis partially imaged.\n\n IMPRESSION:\n\n No dilated loops of small bowel.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1137104,"text":" 3:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent PNA, cdiff, some hypotension\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Recent pneumonia, hypotension.\n\n FINDINGS:\n\n Single portable chest radiograph is compared to the prior study from\n . A right IJ catheter terminates in superior vena cava. There is a\n small left-sided pleural effusion with left lower lobe atelectasis. There is\n mild atelectasis at the right lung base. Heart and mediastinum are probably\n within normal limits. Upper lung zones are clear. Very little change from\n the prior study.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-14 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1137105,"text":" 3:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: Colonic distension\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent PNA, cdiff, some hypotension\n REASON FOR THIS EXAMINATION:\n Colonic distension\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, \n\n CLINICAL INFORMATION: Chronic distention.\n\n FINDINGS:\n\n Single abdomen radiograph compared to the prior study from \n demonstrates a dilated colonic segment. No frank dilatation of the small\n bowel identified. Some air is present in the descending colon.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-09 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1136254,"text":" 3:41 PM\n CHEST (PA & LAT) Clip # \n Reason: Assess for edema, infiltrate\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with COPD and hx of pneumonia.\n REASON FOR THIS EXAMINATION:\n Assess for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: COPD and history of pneumonia.\n\n Comparison is made with prior study, .\n\n Cardiomediastinal contours are unchanged. Right lower lobe opacity has\n improved consistent with improving atelectasis. Opacities in the left lower\n lobe are unchanged. Multiple calcified granulomas are again noted. There is\n calcification of the mitral valve. There is no pneumothorax or pleural\n effusion. Mild degenerative changes are in the thoracic spine.\n\n IMPRESSION: Improved right lower lobe atelectasis. Opacities in the left\n lower lobe are stable. AS before this could represent pneumonia or\n aspiration.\n\n"},{"category":"Radiology","chartdate":"2142-07-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1136043,"text":" 9:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with dyspnea, fevers. H/o CHF, COPD.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old female with dyspnea and fevers.\n\n STUDY: AP portable upright chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The cardiomediastinal silhouette appears unremarkable. The hila\n are normal appearing bilaterally. The right heart border is obscured by\n opacity in the right lower lung. Additionally, there is retrocardiac opacity.\n A right upper lobe calcified granuloma is redemonstrated. There is no evidence\n for large pleural effusion or pneumothorax. The lungs are hyperinflated and\n there is relative lucency within the lung apices suggestive of underlying\n emphysema.\n\n IMPRESSION: Patchy bibasilar opacities which could reflect pneumonia or\n aspiration in the appropriate clinical setting.\n DFDdp\n\n"},{"category":"Radiology","chartdate":"2142-07-11 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1136628,"text":" 7:08 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: MBue WED 11:21 PM\n RT CVC TERMINATING IN MID TO DISTAL SVC. NO PTX OR ADDITIONAL INTERVAL\n CHANGE.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study performed two hours earlier.\n\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax. No other\n interval change.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1136382,"text":" 12:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna/interval change\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with COPD, recurrent pneumonia with decreased O2 sat and\n hypotension\n REASON FOR THIS EXAMINATION:\n eval for pna/interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:54 P.M. ON \n\n HISTORY: Recurrent pneumonia. Decreased oxygen saturation and hypotension.\n\n IMPRESSION: AP chest compared to :\n\n Right basal opacification has worsened, consistent with progressive pneumonia\n or atelectasis superimposed. There is no pulmonary edema or pleural effusion.\n Heart size normal. No pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2142-07-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1136666,"text":" 6:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evidence of worsened pulmonary process\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with pneumonia, sepsis\n REASON FOR THIS EXAMINATION:\n Evidence of worsened pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Pneumonia.\n\n Comparison is made with prior study performed the day earlier.\n\n Mild cardiomegaly is stable. Right IJ catheter tip is in the mid SVC. There\n is no pneumothorax. Left lower lobe opacity has minimally improved. Right\n lower lobe consolidation is stable.\n\n"},{"category":"ECG","chartdate":"2142-07-12 00:00:00.000","description":"Report","row_id":111179,"text":"Sinus tachycardia. Compared to the previous tracing of no change.\n\n"},{"category":"ECG","chartdate":"2142-07-11 00:00:00.000","description":"Report","row_id":111180,"text":"Sinus tachycardia with ventricular premature beat. Consider left atrial\nabnormality. Delayed R wave progression with late precordial QRS transition\nis non-specific but cannot exclude possible prior anterior myocardial\ninfarction. ST-T wave changes are non-specific. Since the previous tracing\nof ST-T wave changes appear less prominent but baseline artifact\non both tracings makes comparison difficult.\n\n"},{"category":"ECG","chartdate":"2142-07-08 00:00:00.000","description":"Report","row_id":111181,"text":"Normal sinus rhythm with ventricular premature beats. Poor R wave progression\nin leads V1-V4 of uncertain significance. Diffuse non-specific ST-T wave\nabnormalities. Compared to the previous tracing of ventricular premature\nbeats are new and heart rate has increased.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-18 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 1137626,\n \"text\": \" 2:50 PM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: eval for colonic distention\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with acute C. diff infection\\n REASON FOR THIS EXAMINATION:\\n eval for colonic distention\\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMEN, FOUR VIEWS.\\n\\n COMPARISON: .\\n\\n HISTORY: C. diff infection.\\n\\n FINDINGS: There are no dilated loops of small bowel to suggest obstruction.\\n There is no evidence of free air. There is mild colonic wall thickening seen\\n particularly along the right hemicolon consistent with known C. diff colitis.\\n Contrast is identified within the bladder. Scattered phleboliths are noted.\\n Extensive vascular calcifications are noted. Patient is status post left\\n total hip arthroplasty.\\n\\n IMPRESSION: No evidence of obstruction. Mild colonic wall thickening\\n particularly in the right hemicolon is noted.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-16 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1137332,\n \"text\": \" 3:14 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \\n Reason: assess for PE\\n Admitting Diagnosis: COPD EXACERBATION\\n Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with right chest pain, worsening O2 saturations, history of\\n PE and subtherapeutic INR.\\n REASON FOR THIS EXAMINATION:\\n assess for PE\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Chest pain, worsening O2 saturations and history of PE with\\n subtherapeutic INR.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: CT of the chest was performed before and after administration of\\n IV contrast. Multiplanar reformats were performed.\\n\\n FINDINGS:\\n\\n There is stable severe emphysema. The bilateral lower lobe consolidations are\\n unchanged noting some non-enhancing lung in the right lower lobe. Moderate\\n narrowing of right mainstem bronchus. There is a slightly increasing right\\n pleural effusion and new small left pleural effusion. There is moderate\\n amount of ascites seen in the abdomen. There are extensive atherosclerotic\\n calcifications of the aorta and coronary arteries. Multiple calcified\\n granulomas are seen in the lungs. There is no evidence of pulmonary embolism.\\n There is mild cardiomegaly. There is a hiatal hernia.\\n\\n There are degenerative changes in the spine.\\n\\n\\n IMPRESSION:\\n 1. No evidence of pulmonary embolism.\\n\\n 2. Stable bilateral lower lobe consolidation.\\n\\n 3. Increasing right greater than left bilateral pleural effusions.\\n\\n 4. Moderate ascites.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-12 00:00:00.000\",\n \"description\": \"CT CHEST W/O CONTRAST\",\n \"row_id\": 1136684,\n \"text\": \" 9:10 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with sepsis, pulmonary disease\\n REASON FOR THIS EXAMINATION:\\n Evaluate pneumonia versus evolving lesion in right lower lobe\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: CT chest without contrast.\\n\\n REASON FOR EXAM: Evaluate for pneumonia\\n\\n TECHNIQUE: MDCT chest was performed without IV contrast. 5-mm and 1.25-mm\\n axial slices were acquired with coronal and sagittal reformats.\\n\\n COMPARISON: Previous CT and most numerous recent chest\\n radiographs.\\n\\n FINDINGS:\\n\\n Consolidation in the left lower lobe has improved and is slightly worse in the\\n right lower lobe since the recent chest radiographs over the preceeding week.\\n A separate area of consolidation is in the right upper lobe in a perifissural\\n distribution(4.140). Dependent secretions in the right main stem bronchus are\\n new. Linear atelectasis is mild in the lower lobes bilaterally and partially\\n due to a new nonhemorrhagic small right pleural effusion. Several calcified\\n granulomata are scattered throughout the lungs. Centrilobular emphysema is\\n worse in the upper lobes bilaterally and stable since the prior CT.\\n\\n No pathologically enlarged mediastinal or axillary lymph nodes by CT size\\n criteria. Atherosclerotic plaque is moderately severe in the aortic arch and\\n extends into the origin of the left common carotid and subclavian arteries.\\n The caliber of the aorta and pulmonary artery is normal. The heart size is\\n normal with no pericardial effusion. Calcification is severe in the mitral\\n annulus and moderately severe in the aortic valve and coronary arteries.\\n\\n Although this examination was not designed for subdiaphragmatic evaluation,\\n there is new intra-abdominal ascites and diffuse vascular calcification of the\\n suprarenal aorta. A hiatal hernia is small.\\n\\n No destructive or sclerotic bone lesions are concerning for malignancy.\\n\\n IMPRESSION:\\n\\n 1)Multifocal consolidation which has improved in the left lower lobe and is\\n slightly worse in the right lower and upper lobes since recent conventional\\n CXRs.\\n\\n 2)Moderately severe diffuse centrilobular emphysema\\n (Over)\\n\\n 9:10 AM\\n CT CHEST W/O CONTRAST Clip # \\n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n 3)Diffuse atherosclerotic calcification in the coronary arteries, aorta, in\\n the mitral annulus and aortic valve.\\n\\n 4)New intraabdominal ascites and new small right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1136612,\n \"text\": \" 4:36 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Etiology of SOB\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with persisten hypotension, PNA and C.diff\\n REASON FOR THIS EXAMINATION:\\n Etiology of SOB\\n ______________________________________________________________________________\\n WET READ: MBue WED 7:28 PM\\n NO SIGNIFICANT CHANGE. BIBASILAR OPACITIES STABLE.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Persistent hypotension.\\n\\n Comparison is made with prior study .\\n\\n Mild cardiomegaly is stable. There is calcification at the mitral annulus.\\n Bibasilar opacity is larger on the right side are unchanged. This could be\\n due to atelectasis and/or pneumonia. Right upper lobe calcified granulomas\\n are again noted. There is no pneumothorax or pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-12 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1136700,\n \"text\": \" 10:59 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: assess colon distension, other intraabdominal pathology\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with cdiff and abd distension, pna, hypotension\\n REASON FOR THIS EXAMINATION:\\n assess colon distension, other intraabdominal pathology\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Woman with C. diff and abdominal distention.\\n\\n COMPARISON: CT of the abdomen and pelvis from .\\n\\n Single view of the abdomen shows no dilated loops of small or large bowel.\\n Air is noted within the colon. The visible osseous structures are\\n unremarkable. There is a left-sided femoral prosthesis partially imaged.\\n\\n IMPRESSION:\\n\\n No dilated loops of small bowel.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1137104,\n \"text\": \" 3:20 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with recent PNA, cdiff, some hypotension\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n CLINICAL INFORMATION: Recent pneumonia, hypotension.\\n\\n FINDINGS:\\n\\n Single portable chest radiograph is compared to the prior study from\\n . A right IJ catheter terminates in superior vena cava. There is a\\n small left-sided pleural effusion with left lower lobe atelectasis. There is\\n mild atelectasis at the right lung base. Heart and mediastinum are probably\\n within normal limits. Upper lung zones are clear. Very little change from\\n the prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-14 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1137105,\n \"text\": \" 3:20 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: Colonic distension\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with recent PNA, cdiff, some hypotension\\n REASON FOR THIS EXAMINATION:\\n Colonic distension\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE ABDOMEN, \\n\\n CLINICAL INFORMATION: Chronic distention.\\n\\n FINDINGS:\\n\\n Single abdomen radiograph compared to the prior study from \\n demonstrates a dilated colonic segment. No frank dilatation of the small\\n bowel identified. Some air is present in the descending colon.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-09 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1136254,\n \"text\": \" 3:41 PM\\n CHEST (PA & LAT) Clip # \\n Reason: Assess for edema, infiltrate\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with COPD and hx of pneumonia.\\n REASON FOR THIS EXAMINATION:\\n Assess for edema, infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n PA AND LATERAL VIEWS OF THE CHEST\\n\\n REASON FOR EXAM: COPD and history of pneumonia.\\n\\n Comparison is made with prior study, .\\n\\n Cardiomediastinal contours are unchanged. Right lower lobe opacity has\\n improved consistent with improving atelectasis. Opacities in the left lower\\n lobe are unchanged. Multiple calcified granulomas are again noted. There is\\n calcification of the mitral valve. There is no pneumothorax or pleural\\n effusion. Mild degenerative changes are in the thoracic spine.\\n\\n IMPRESSION: Improved right lower lobe atelectasis. Opacities in the left\\n lower lobe are stable. AS before this could represent pneumonia or\\n aspiration.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1136043,\n \"text\": \" 9:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with dyspnea, fevers. H/o CHF, COPD.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 82-year-old female with dyspnea and fevers.\\n\\n STUDY: AP portable upright chest radiograph.\\n\\n COMPARISON: .\\n\\n FINDINGS: The cardiomediastinal silhouette appears unremarkable. The hila\\n are normal appearing bilaterally. The right heart border is obscured by\\n opacity in the right lower lung. Additionally, there is retrocardiac opacity.\\n A right upper lobe calcified granuloma is redemonstrated. There is no evidence\\n for large pleural effusion or pneumothorax. The lungs are hyperinflated and\\n there is relative lucency within the lung apices suggestive of underlying\\n emphysema.\\n\\n IMPRESSION: Patchy bibasilar opacities which could reflect pneumonia or\\n aspiration in the appropriate clinical setting.\\n DFDdp\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-11 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1136628,\n \"text\": \" 7:08 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: line placement\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with hypotension\\n REASON FOR THIS EXAMINATION:\\n line placement\\n ______________________________________________________________________________\\n WET READ: MBue WED 11:21 PM\\n RT CVC TERMINATING IN MID TO DISTAL SVC. NO PTX OR ADDITIONAL INTERVAL\\n CHANGE.\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Assess line.\\n\\n Comparison is made with prior study performed two hours earlier.\\n\\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax. No other\\n interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1136382,\n \"text\": \" 12:39 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for pna/interval change\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with COPD, recurrent pneumonia with decreased O2 sat and\\n hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for pna/interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 12:54 P.M. ON \\n\\n HISTORY: Recurrent pneumonia. Decreased oxygen saturation and hypotension.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Right basal opacification has worsened, consistent with progressive pneumonia\\n or atelectasis superimposed. There is no pulmonary edema or pleural effusion.\\n Heart size normal. No pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-07-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1136666,\n \"text\": \" 6:42 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evidence of worsened pulmonary process\\n Admitting Diagnosis: COPD EXACERBATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 82 year old woman with pneumonia, sepsis\\n REASON FOR THIS EXAMINATION:\\n Evidence of worsened pulmonary process\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST:\\n\\n REASON FOR EXAM: Pneumonia.\\n\\n Comparison is made with prior study performed the day earlier.\\n\\n Mild cardiomegaly is stable. Right IJ catheter tip is in the mid SVC. There\\n is no pneumothorax. Left lower lobe opacity has minimally improved. Right\\n lower lobe consolidation is stable.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2142-07-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 111179,\n \"text\": \"Sinus tachycardia. Compared to the previous tracing of no change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2142-07-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 111180,\n \"text\": \"Sinus tachycardia with ventricular premature beat. Consider left atrial\\nabnormality. Delayed R wave progression with late precordial QRS transition\\nis non-specific but cannot exclude possible prior anterior myocardial\\ninfarction. ST-T wave changes are non-specific. Since the previous tracing\\nof ST-T wave changes appear less prominent but baseline artifact\\non both tracings makes comparison difficult.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2142-07-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 111181,\n \"text\": \"Normal sinus rhythm with ventricular premature beats. Poor R wave progression\\nin leads V1-V4 of uncertain significance. Diffuse non-specific ST-T wave\\nabnormalities. Compared to the previous tracing of ventricular premature\\nbeats are new and heart rate has increased.\\n\\n\"\n }\n]"}}},{"rowIdx":184,"cells":{"subject_id":{"kind":"number","value":28386,"string":"28,386"},"hadm_id":{"kind":"number","value":186255,"string":"186,255"},"target_text":{"kind":"string","value":"81F EF 45% inf HK, afib/C, DVT, dm2, copd p/w rapid afib and in setting of rapid rate has angina and CHF . 1. Cardiac: a. Rhythm: Pt was in rapid afib on admission. Initially ther was poor rate control in house and the patient went to ICU. She was on atenolol 12.5 daily that uptitrated gradually and rate control improved. Pt's coumadin was held on admission for a supratherapeutic level, though it was restarted. . b. Coronaries: The patient did have anginal symptoms in the setting of rapid heart rate. There was no known h/o CAD, though there is EF 45% with inf HK which suggests CAD. The chest pain was likely related to the rapid afib. The ECG showed only non-specific changes. Enzymes showed trop t 0.03 with negative CK and MB. Pt was rate controlled as described and continued with aspirin, beta blocker, and statin. c. Pt presented in acute CHF with pulmonary edema. LVEF 45%. The patient was diuresed. She was continued on beta blocker and we started an ace inhibitor as well. 2. Confusion: Pt has h/o dementia and was hospitalized with mutliple sedatives and psych meds. Pt's sedating medications were held in house. Confusion resolved and patient oriented again to person, place, and time by hospital day 4. 3. Pleural effusions: There were bilateral, moderate on the left and small on the right. This is unlikely contributing to SOB. The plan was to diurese and treat CHF. . 4. Leukocytosis: Pt had WBC of 16 on admission, but this resolved over hospital course down to 11.1. Likely stress response. Pt is afebrile, UA is negative. CXR is c/w CHF. 5. Diabetes Mellitus Patient c/w metformin and SSI in-house. . Access - PIV . Prophylaxis: anticoagulated for afib, PPI, bowel regimen, per home regimen"},"extractive_notes_summ":{"kind":"string","value":"Left ventricular function.Weight (lb): 180BP (mm Hg): 142/83HR (bpm): 93Status: InpatientDate/Time: at 15:01Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Left pleural effusion is present.LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Trivial mitral regurgitation isseen. Mild regional LVsystolic dysfunction. left basilar opacity likele reflects compression atelectasis. Cover BS c RISS. There is mild regional left ventricularsystolic dysfunction with inferior hypokinesis. Haziness is noted in the right lung base which mauy reflect edema. -5oo @ mdght, -260 current.Id-afebrile.Endo-SSI, metformin PO. Left apices clear, base diminished. She had some expiratory wheezes, more on L than R and benefited from atrovent neb. There is mild symmetric left ventricular hypertrophy. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. She continues to receive atrovent nebs.GI: Pt has excellent apetite. PMHx significant for HTN, AFib, CHF, DVT, COPD, dementia, DM.N-a/ox1, however and cooperative c care. The mitral valve leaflets are mildlythickened. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Captopril 6.25mg as ordered-tolerated well.Resp-Nebs doesd Q4 c increased in diffuse I/E wheeze-improvement post nebs. INR elevated-holding coumadin. CXR shows failure and bilateraly pleural effusions. No echocardiographic signs oftamponade.Conclusions:The left atrium is mildly dilated. She c/o of constipation and colace was increased to . Pt is asymptomatic. Reorient pt as needed. Reorient pt as needed. RR wnl.GI-no difficulties c pills. Early dementia c anxiety-responds well to reoriention/reassurance. However Right LS diminished throughout > than Left. HR therafter 70s-80s c occasional PVC, SBP 115-130. piv x1. Mild [1+] TR.Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: Small pericardial effusion. Right axis deviation. Right axis deviation. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Atrial fibrillation with slowing of the ventricular response as compared withtracing of . possible echo today to evaluate pump function.Resp-bilateral pleural effusions per cxray L>R. She did not aspirate with liquids or soft solids.ENDO: Blood sugars quite elevated. The estimatedpulmonary artery systolic pressure is normal. There is a small pericardialeffusion without tamponade. Bilateral pleural effusions are noted, left greater than right. CCU NSG NOTE: ALT IN CV/RESPS: \"I feel so anxious. 81y.o female c COPD exacerbation admitted from Rehab. Normal LV cavity size. Bilateral pleural effusions, moderate on the left and small on the right with probable underlying mild congestive failure. She has very decreased BS bilaterally. CCU NSG NOTE: ALT IN RESP/CVS: \"It bothers me that I'm confused\".O: For complete VS see CCU flow sheet. 1 piv. SBP 120s-140s, pulses palpable. Diffuse non-specificST-T wave changes. Dosed colace plus senna. coumadin currently on hold c increased INR. Captopril was also added at 6.25mg tid with bp now in 120-130/70-80s.She was KCL replaced this am with repeat K+ pending.RESP: She has more audible breath sounds today, though some crackles were heard. HR is 70-90s afib, much better controlled with 25mg lopressor.She has occasional single pvcs. abd obese, +BS. Theaortic valve leaflets are mildly thickened. afebrile. Continues on ASA, statin. Perhaps dulcolax tab tonight.RENAL: Pt still has foley draining clear urine, now in small amts. The leftventricular cavity size is normal. WBC last trending down.Skin-intact.endo-pm BS 135, no coverage per sliding scale.social/dispo-supportive children. hr now in mid 80s with bp 171/82. f/u am labs (monitor hyponatremia 129/132). IMPRESSION: 1. RR wnl c some DOE. She was symptom free and transfered to CCU on MICU service for further care.ID: WBCs down to 10.3 (16.9). follows commands consistenly. pulses palpable. Requires soft diet (no teeth).GU-foley c adequate CYU. Monitor resp status and nebs as needed. transfer note complete. Normal IVC diameter (1.5-2.5cm) with <50%decrease during respiration (estimated RAP 11-15mmHg).LEFT VENTRICLE: Mild symmetric LVH. HO notified and she received 12.5mg. Possible increase in Lopressor as BP tolerates. Right ventricular chamber size and free wall motion are normal. Monitor BP c increased lopressor. Clinical correlation of theright axis deviation is suggested. I want to go home\".O: For complete VS see CCU flow sheet.ID: PT remains afebrile with decreasing WBCs.CV: PT has no c/o of chest or neck discomfort. CYU.ID-bld/urine cxs pending. The tricuspid valve leaflets are mildly thickened. -BM.GU-dosed 10mg IV lasix for low UO c effect. PT consult was called.A: Some improvement in MS/continued 02 requirement/walking with assistP: Monitor bp with new and increased meds. Known COPD/heart failure history. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. She was transfered to EW where she c/o of chest pressure in addition to her other symptoms. She received lasix 20mg IV at 1130 with good response. HR was 120af with bp in 170/80s. She was treated with sl nitro X 3, solumedrol for supposed copd exacerbation, nebs and dose of levofloxacin. no coverage last night.skin-pressure areas intact.plan-transfer to 6. (baseline while here). No further ABX, cultures pending.CV: HR creeping up to 110-120af when pt received 12.5 lopressor at 11am. Last dosed Lasix @ 1130 (10-20mg).GI-+BS, -BM since admit. \"O-see flowsheet/admit note for additional details. f/u am labs. Support pt and her fears of being in a new place. Sugars were 228 and 245 and she received 4 and 5u of regular insulin.MS: Pt initially was quite lethargic and oriented only X 1. Please note evaluation was limited due to portable technique and marked patient rotation. She becomes anxious about what is happening, but responds well to reassurance.A: Decreasing WBCs, imcomplete control with 12.5 lopressor,improved msP: Continue to reassure pt that she is safe, and review todays event. By 1800 her sugar was 129 and no further reg insulin was required.MS/ACTIVITY: Pt continues to be A & 0 X . Ck peak 104. Faint basalar crackles. She received lasix 20mg iv at 11am with fair diaresis. Clinical correlation of the rightaxis deviation is suggested.TRACING #2 in short pt 81y.o female admitted from rehab c CP, SOB, hypoxia COPD Exacerbation. \"O-see flowsheet/transfer notes for details. Keep careful I & O. Keep careful I & O. She has strong non-productive cough.RENAL: Pt has foley draining clear urine."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2184-10-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":983497,"text":" 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, CHF, p/w chest pain and SOB.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain and shortness of breath. Known COPD/heart failure\n history.\n\n No prior exams are available.\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS: Patient is rotated to the left. Bilateral pleural effusions\n are noted, left greater than right. left basilar opacity likele reflects\n compression atelectasis. Haziness is noted in the right lung base which\n mauy reflect edema. Upper lobe lucency likely related to emphysema in\n this patient with known COPD. The heart appears enlarged. No evidence of\n pneumothorax.\n\n IMPRESSION:\n\n 1. Bilateral pleural effusions, moderate on the left and small on the right\n with probable underlying mild congestive failure.\n\n 2. Please note evaluation was limited due to portable technique and marked\n patient rotation. Dedicated PA and lateral radiographs would be helpful to\n further delineate.\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2184-10-25 00:00:00.000","description":"Report","row_id":1632702,"text":"CCU NSG NOTE: ALT IN RESP/CV\nS: \"It bothers me that I'm confused\".\nO: For complete VS see CCU flow sheet. This 81y old Rehab resident with pmh of CHF, af on coumadin, htn, aodm, COPD, and mild dementia awoke ~0200 with SOB & jaw pain. Her 02 sat was 70% that increased to 92% on 3L NP. She was transfered to EW where she c/o of chest pressure in addition to her other symptoms. HR was 120af with bp in 170/80s. She was treated with sl nitro X 3, solumedrol for supposed copd exacerbation, nebs and dose of levofloxacin. She also received 2.5IV lopressor which brought her hr down to 80s and bp to 120s/70s. She was symptom free and transfered to CCU on MICU service for further care.\nID: WBCs down to 10.3 (16.9). No further ABX, cultures pending.\nCV: HR creeping up to 110-120af when pt received 12.5 lopressor at 11am. \rByy 600 hr up to 100-125 again. HO notified and she received 12.5mg. hr now in mid 80s with bp 171/82. No further meds ordered. Pt is asymptomatic. CKs are 104 down to 86 at noon. Troponin .01.\nRESP: RR 18 up to high 20s later in the day. She has very decreased BS bilaterally. CXR shows failure and bilateraly pleural effusions. She had some expiratory wheezes, more on L than R and benefited from atrovent neb. She is now sating 98% on 4L NP. She has strong non-productive cough.\nRENAL: Pt has foley draining clear urine. She received lasix 20mg IV at 1130 with good response. She is now 600cc neg for the day.\nGI: Pt has excellent apetite, but needs soft food as she has no teeth. Mental status is improving, but pt should still be monitored while eating as she does not attend well and may need to be prompted to swallow. She did not aspirate with liquids or soft solids.\nENDO: Blood sugars quite elevated. Pt did not receive po today. Sugars were 228 and 245 and she received 4 and 5u of regular insulin.\nMS: Pt initially was quite lethargic and oriented only X 1. She slept when left alone, but was easily rouseable. By the afternoon she was more awake and aware that she was confused. She could not recall events earlier in the day. She becomes anxious about what is happening, but responds well to reassurance.\nA: Decreasing WBCs, imcomplete control with 12.5 lopressor,improved ms\nP: Continue to reassure pt that she is safe, and review todays event. Keep careful I & O. Notify HO if HR jumps up again. Monitor finger sticks to better control sugars.\n\n\n"},{"category":"Nursing/other","chartdate":"2184-10-27 00:00:00.000","description":"Report","row_id":1632705,"text":"CCU Nursing note\nS-\"I hope my family is ok. I don't know where I am.\"\nO-see flowsheet/transfer notes for details. 81y.o female c COPD exacerbation admitted from Rehab. C/O to floor, 6. Transfer when ready.\n\nN-a/ox1-2 during night. (baseline while here). Early dementia c anxiety-responds well to reoriention/reassurance. follows commands consistenly. OOB to chair last shift and ambulating in room c walker.\nDenies any pain.\n\nCV-Chronic afib. coumadin currently on hold c increased INR. HR 80s-110 responding to 25mg PO Lopressor. SBP 120s-140s, pulses palpable. 1 piv. Captopril 6.25mg as ordered-tolerated well.\n\nResp-Nebs doesd Q4 c increased in diffuse I/E wheeze-improvement post nebs. Faint basalar crackles. RR wnl c some DOE. Last dosed Lasix @ 1130 (10-20mg).\n\nGI-+BS, -BM since admit. Dosed colace plus senna. No difficulties swallowing pills/eating. however some times requires reminders to swallow. Requires soft diet (no teeth).\n\nGU-foley c adequate CYU. Fluid restriction 1500cc/day. -5oo @ mdght, -260 current.\n\nId-afebrile.\n\nEndo-SSI, metformin PO. no coverage last night.\n\nskin-pressure areas intact.\n\nplan-transfer to 6. Monitor resp status and nebs as needed. Possible increase in Lopressor as BP tolerates. Reorient pt as needed. transfer note complete.\n"},{"category":"Nursing/other","chartdate":"2184-10-26 00:00:00.000","description":"Report","row_id":1632703,"text":"CCU Nursing note\nS-\"I don't know where I'm at. Is it the ? As long as my family knows I'm here.\"\nO-see flowsheet/admit note for additional details. in short pt 81y.o female admitted from rehab c CP, SOB, hypoxia COPD Exacerbation. PMHx significant for HTN, AFib, CHF, DVT, COPD, dementia, DM.\n\nN-a/ox1, however and cooperative c care. Anxious at times, Responds well to orientation and reassurance. Dosed 650mg tylenol @ HS for back discomfort c effect. bilateral strength equal, PERRL, no other focal deficits.\n\nCV-Lopressor increased to 25mg TID c better rate control in afib. HR therafter 70s-80s c occasional PVC, SBP 115-130. piv x1. pulses palpable. Continues on ASA, statin. Ck peak 104. INR elevated-holding coumadin. f/u am labs (monitor hyponatremia 129/132). possible echo today to evaluate pump function.\n\nResp-bilateral pleural effusions per cxray L>R. However Right LS diminished throughout > than Left. Left apices clear, base diminished. Continues on 4L NC 96-99%. RR wnl.\n\nGI-no difficulties c pills. abd obese, +BS. -BM.\nGU-dosed 10mg IV lasix for low UO c effect. CYU.\n\nID-bld/urine cxs pending. afebrile. WBC last trending down.\nSkin-intact.\n\nendo-pm BS 135, no coverage per sliding scale.\nsocial/dispo-supportive children. Full code. c/o to floor when bed available.\n\nplan-echo today? f/u am labs. Monitor BP c increased lopressor. Cover BS c RISS. Reorient pt as needed. bed low/locked c alarm on.\n\n\n"},{"category":"Nursing/other","chartdate":"2184-10-26 00:00:00.000","description":"Report","row_id":1632704,"text":"CCU NSG NOTE: ALT IN CV/RESP\nS: \"I feel so anxious. I want to go home\".\nO: For complete VS see CCU flow sheet.\nID: PT remains afebrile with decreasing WBCs.\nCV: PT has no c/o of chest or neck discomfort. HR is 70-90s afib, much better controlled with 25mg lopressor.She has occasional single pvcs. Captopril was also added at 6.25mg tid with bp now in 120-130/70-80s.She was KCL replaced this am with repeat K+ pending.\nRESP: She has more audible breath sounds today, though some crackles were heard. She is now sating 95-96% on 2L NP. On RA she sats 89-91%. She continues to receive atrovent nebs.\nGI: Pt has excellent apetite. She c/o of constipation and colace was increased to . She has attempted bm multiple times, but has not been able to. Perhaps dulcolax tab tonight.\nRENAL: Pt still has foley draining clear urine, now in small amts. She received lasix 20mg iv at 11am with fair diaresis. She is presently negative ~500cc for the day and ~1 liter LOS.\nENDO: Finger stick at noon was 199 and she received 4u reg insulin for that. She had received metformin 1000mg at 11. By 1800 her sugar was 129 and no further reg insulin was required.\nMS/ACTIVITY: Pt continues to be A & 0 X . By the late afternoon she became anxious, after her family left feeling she was unsure of where she was. She was up in the chair and perhaps fatigued. Once back in bed she went to sleep. She took a walk with assist and did well. She walks with walker at rehab. PT consult was called.\nA: Some improvement in MS/continued 02 requirement/walking with assist\nP: Monitor bp with new and increased meds. Support pt and her fears of being in a new place. Keep careful I & O. Increase activity as tolerated.\n\n"},{"category":"Echo","chartdate":"2184-10-25 00:00:00.000","description":"Report","row_id":96031,"text":"PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nWeight (lb): 180\nBP (mm Hg): 142/83\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 15:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLeft pleural effusion is present.\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (1.5-2.5cm) with <50%\ndecrease during respiration (estimated RAP 11-15mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction with inferior hypokinesis. There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets are mildly thickened. There is no aortic valve stenosis.\nNo 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. The estimated\npulmonary artery systolic pressure is normal. There is a small pericardial\neffusion without tamponade.\n\n\n"},{"category":"ECG","chartdate":"2184-10-25 00:00:00.000","description":"Report","row_id":260971,"text":"Atrial fibrillation with slowing of the ventricular response as compared with\ntracing of . Right axis deviation. Clinical correlation of the right\naxis deviation is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2184-10-25 00:00:00.000","description":"Report","row_id":260972,"text":"Atrial fibrillation with rapid ventricular response. Diffuse non-specific\nST-T wave changes. Right axis deviation. Clinical correlation of the\nright axis deviation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 983497,\n \"text\": \" 4:40 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, edema\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with COPD, CHF, p/w chest pain and SOB.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Chest pain and shortness of breath. Known COPD/heart failure\\n history.\\n\\n No prior exams are available.\\n\\n UPRIGHT PORTABLE CHEST RADIOGRAPH\\n\\n FINDINGS: Patient is rotated to the left. Bilateral pleural effusions\\n are noted, left greater than right. left basilar opacity likele reflects\\n compression atelectasis. Haziness is noted in the right lung base which\\n mauy reflect edema. Upper lobe lucency likely related to emphysema in\\n this patient with known COPD. The heart appears enlarged. No evidence of\\n pneumothorax.\\n\\n IMPRESSION:\\n\\n 1. Bilateral pleural effusions, moderate on the left and small on the right\\n with probable underlying mild congestive failure.\\n\\n 2. Please note evaluation was limited due to portable technique and marked\\n patient rotation. Dedicated PA and lateral radiographs would be helpful to\\n further delineate.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1632702,\n \"text\": \"CCU NSG NOTE: ALT IN RESP/CV\\nS: \\\"It bothers me that I'm confused\\\".\\nO: For complete VS see CCU flow sheet. This 81y old Rehab resident with pmh of CHF, af on coumadin, htn, aodm, COPD, and mild dementia awoke ~0200 with SOB & jaw pain. Her 02 sat was 70% that increased to 92% on 3L NP. She was transfered to EW where she c/o of chest pressure in addition to her other symptoms. HR was 120af with bp in 170/80s. She was treated with sl nitro X 3, solumedrol for supposed copd exacerbation, nebs and dose of levofloxacin. She also received 2.5IV lopressor which brought her hr down to 80s and bp to 120s/70s. She was symptom free and transfered to CCU on MICU service for further care.\\nID: WBCs down to 10.3 (16.9). No further ABX, cultures pending.\\nCV: HR creeping up to 110-120af when pt received 12.5 lopressor at 11am. \\rByy 600 hr up to 100-125 again. HO notified and she received 12.5mg. hr now in mid 80s with bp 171/82. No further meds ordered. Pt is asymptomatic. CKs are 104 down to 86 at noon. Troponin .01.\\nRESP: RR 18 up to high 20s later in the day. She has very decreased BS bilaterally. CXR shows failure and bilateraly pleural effusions. She had some expiratory wheezes, more on L than R and benefited from atrovent neb. She is now sating 98% on 4L NP. She has strong non-productive cough.\\nRENAL: Pt has foley draining clear urine. She received lasix 20mg IV at 1130 with good response. She is now 600cc neg for the day.\\nGI: Pt has excellent apetite, but needs soft food as she has no teeth. Mental status is improving, but pt should still be monitored while eating as she does not attend well and may need to be prompted to swallow. She did not aspirate with liquids or soft solids.\\nENDO: Blood sugars quite elevated. Pt did not receive po today. Sugars were 228 and 245 and she received 4 and 5u of regular insulin.\\nMS: Pt initially was quite lethargic and oriented only X 1. She slept when left alone, but was easily rouseable. By the afternoon she was more awake and aware that she was confused. She could not recall events earlier in the day. She becomes anxious about what is happening, but responds well to reassurance.\\nA: Decreasing WBCs, imcomplete control with 12.5 lopressor,improved ms\\nP: Continue to reassure pt that she is safe, and review todays event. Keep careful I & O. Notify HO if HR jumps up again. Monitor finger sticks to better control sugars.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2184-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1632705,\n \"text\": \"CCU Nursing note\\nS-\\\"I hope my family is ok. I don't know where I am.\\\"\\nO-see flowsheet/transfer notes for details. 81y.o female c COPD exacerbation admitted from Rehab. C/O to floor, 6. Transfer when ready.\\n\\nN-a/ox1-2 during night. (baseline while here). Early dementia c anxiety-responds well to reoriention/reassurance. follows commands consistenly. OOB to chair last shift and ambulating in room c walker.\\nDenies any pain.\\n\\nCV-Chronic afib. coumadin currently on hold c increased INR. HR 80s-110 responding to 25mg PO Lopressor. SBP 120s-140s, pulses palpable. 1 piv. Captopril 6.25mg as ordered-tolerated well.\\n\\nResp-Nebs doesd Q4 c increased in diffuse I/E wheeze-improvement post nebs. Faint basalar crackles. RR wnl c some DOE. Last dosed Lasix @ 1130 (10-20mg).\\n\\nGI-+BS, -BM since admit. Dosed colace plus senna. No difficulties swallowing pills/eating. however some times requires reminders to swallow. Requires soft diet (no teeth).\\n\\nGU-foley c adequate CYU. Fluid restriction 1500cc/day. -5oo @ mdght, -260 current.\\n\\nId-afebrile.\\n\\nEndo-SSI, metformin PO. no coverage last night.\\n\\nskin-pressure areas intact.\\n\\nplan-transfer to 6. Monitor resp status and nebs as needed. Possible increase in Lopressor as BP tolerates. Reorient pt as needed. transfer note complete.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2184-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1632703,\n \"text\": \"CCU Nursing note\\nS-\\\"I don't know where I'm at. Is it the ? As long as my family knows I'm here.\\\"\\nO-see flowsheet/admit note for additional details. in short pt 81y.o female admitted from rehab c CP, SOB, hypoxia COPD Exacerbation. PMHx significant for HTN, AFib, CHF, DVT, COPD, dementia, DM.\\n\\nN-a/ox1, however and cooperative c care. Anxious at times, Responds well to orientation and reassurance. Dosed 650mg tylenol @ HS for back discomfort c effect. bilateral strength equal, PERRL, no other focal deficits.\\n\\nCV-Lopressor increased to 25mg TID c better rate control in afib. HR therafter 70s-80s c occasional PVC, SBP 115-130. piv x1. pulses palpable. Continues on ASA, statin. Ck peak 104. INR elevated-holding coumadin. f/u am labs (monitor hyponatremia 129/132). possible echo today to evaluate pump function.\\n\\nResp-bilateral pleural effusions per cxray L>R. However Right LS diminished throughout > than Left. Left apices clear, base diminished. Continues on 4L NC 96-99%. RR wnl.\\n\\nGI-no difficulties c pills. abd obese, +BS. -BM.\\nGU-dosed 10mg IV lasix for low UO c effect. CYU.\\n\\nID-bld/urine cxs pending. afebrile. WBC last trending down.\\nSkin-intact.\\n\\nendo-pm BS 135, no coverage per sliding scale.\\nsocial/dispo-supportive children. Full code. c/o to floor when bed available.\\n\\nplan-echo today? f/u am labs. Monitor BP c increased lopressor. Cover BS c RISS. Reorient pt as needed. bed low/locked c alarm on.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2184-10-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1632704,\n \"text\": \"CCU NSG NOTE: ALT IN CV/RESP\\nS: \\\"I feel so anxious. I want to go home\\\".\\nO: For complete VS see CCU flow sheet.\\nID: PT remains afebrile with decreasing WBCs.\\nCV: PT has no c/o of chest or neck discomfort. HR is 70-90s afib, much better controlled with 25mg lopressor.She has occasional single pvcs. Captopril was also added at 6.25mg tid with bp now in 120-130/70-80s.She was KCL replaced this am with repeat K+ pending.\\nRESP: She has more audible breath sounds today, though some crackles were heard. She is now sating 95-96% on 2L NP. On RA she sats 89-91%. She continues to receive atrovent nebs.\\nGI: Pt has excellent apetite. She c/o of constipation and colace was increased to . She has attempted bm multiple times, but has not been able to. Perhaps dulcolax tab tonight.\\nRENAL: Pt still has foley draining clear urine, now in small amts. She received lasix 20mg iv at 11am with fair diaresis. She is presently negative ~500cc for the day and ~1 liter LOS.\\nENDO: Finger stick at noon was 199 and she received 4u reg insulin for that. She had received metformin 1000mg at 11. By 1800 her sugar was 129 and no further reg insulin was required.\\nMS/ACTIVITY: Pt continues to be A & 0 X . By the late afternoon she became anxious, after her family left feeling she was unsure of where she was. She was up in the chair and perhaps fatigued. Once back in bed she went to sleep. She took a walk with assist and did well. She walks with walker at rehab. PT consult was called.\\nA: Some improvement in MS/continued 02 requirement/walking with assist\\nP: Monitor bp with new and increased meds. Support pt and her fears of being in a new place. Keep careful I & O. Increase activity as tolerated.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 96031,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Congestive heart failure. Left ventricular function.\\nWeight (lb): 180\\nBP (mm Hg): 142/83\\nHR (bpm): 93\\nStatus: Inpatient\\nDate/Time: at 15:01\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLeft pleural effusion is present.\\nLEFT ATRIUM: Mild LA enlargement.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\\nNo ASD by 2D or color Doppler. Normal IVC diameter (1.5-2.5cm) with <50%\\ndecrease during respiration (estimated RAP 11-15mmHg).\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\\nsystolic dysfunction. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\\nNormal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\\n\\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\\ntamponade.\\n\\nConclusions:\\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\\nventricular cavity size is normal. There is mild regional left ventricular\\nsystolic dysfunction with inferior hypokinesis. There is no ventricular septal\\ndefect. Right ventricular chamber size and free wall motion are normal. The\\naortic valve leaflets are mildly thickened. There is no aortic valve stenosis.\\nNo 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. The estimated\\npulmonary artery systolic pressure is normal. There is a small pericardial\\neffusion without tamponade.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 260971,\n \"text\": \"Atrial fibrillation with slowing of the ventricular response as compared with\\ntracing of . Right axis deviation. Clinical correlation of the right\\naxis deviation is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2184-10-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 260972,\n \"text\": \"Atrial fibrillation with rapid ventricular response. Diffuse non-specific\\nST-T wave changes. Right axis deviation. Clinical correlation of the\\nright axis deviation is suggested. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":185,"cells":{"subject_id":{"kind":"number","value":60653,"string":"60,653"},"hadm_id":{"kind":"number","value":181064,"string":"181,064"},"target_text":{"kind":"string","value":"The pt is a 44 year-old left handed man with PMH significant for tobacco and alcohol abuse plus untreated HTN who presents as a transfer from Hospital for management of a right basal ganglia hemorrhage. Etiology of the hemorrhage is somewhat uncertain. HTN is likely given the history of untreated high blood pressures. Patient was initially admitted to Neuro ICU service with neurosurgery following. Overnight, he required frequent Valium for EtOH withdrawal (severe diaphoresis and tachycardia). Patient became more somnolent the next morning which may have been due to Vailum but repeat CT/CTA showed increased hemorrhage with midline shift 13~14mm to the left. Patient was emergently taken to OR per neurosurgery where he underwent right-sided frontotemporal craniotomy for decompression, evacuation, partial frontal lobe resection. He was successfully extubated the next mornind and repeat CT showed no new hemorrhage with stable midline shoft ~9mm to the left as was seen in post-operative imaging. He was continued on CIWA for EtOH withdrawal with tapering standing Ativan plus as needed Ativan. Also, given hemorhage and surgical evacuation, he was empirically loaded with phenytoic for seizure prophylaxis and was continued on 100mg TID for maintenance. He gradually became more arousable but remains L hemiplegic with some withdrawal of LLE to noxious stimuli but no movement on LUE even with noxious stimuli. He started to speak more on POD #3 but his speech remained heavily dysarthric. Since transfer to the neurology floor, his speech has continued to improve. In addition, his awareness regarding his left hemiparesis has improved. On the floor, he no longer needed the Ativan, and his anti-hypertensive medication doses were optimized. He has been evaluated by speech and swallow and is on the appropriate diet as follows: 1. Continue po diet of ground solids, nectar thick liquids. 2. PO meds: crushed in puree 3. 1:1 supervision with all PO. Maintain aspiration precautions including: a) feed only when awake/alert b) sit fully upright for all PO c) alternate bites and sips d) provide verbal cues to clear L side of oral cavity e) if presents with fatigue, cease meal. Consider 6 small meals instead of 3 large ones as needed. He has had a Regular Low sodium / Heart healthy Consistency: Ground; Nectar prethickened liquids Supplement: Ensure Pudding breakfast, lunch, dinner Crush po meds, give 6 small meals, and 1:1 supervision with meals on the Neurology Floor. He has been evaluated by PT and OT and he needs close supervision and appropriate precautions when he is mobilised due to his left hemiparesis and left sided neglect."},"extractive_notes_summ":{"kind":"string","value":"Phenytoin 23. Metoprolol Tartrate 19. Tylenol for HA per primary service. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Metoprolol Tartrate 18. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Subjective: Pt just extubated. Famotidine 7. Famotidine 7. Nicotine Patch 17. Nicotine Patch 17. Morphine Sulfate 18. Morphine Sulfate 18. Lorazepam 14. Lorazepam 14. Phenytoin 21. Phenytoin 21. Phenytoin 21. Phenytoin 21. Current medications: 1. Ativan atc and prn. Ativan atc and prn. Lorazepam 17. Phenytoin 20. Phenytoin 20. Action: Freq neuro checks. Action: Freq neuro checks. Action: Freq neuro checks. Famotidine 10. Famotidine 10. Famotidine 10. HTN. On Ativan atc. On Ativan atc. On Ativan atc. Nicotine Patch 19. Nicotine Patch 19. FoLIC Acid 11. Nicotine Patch 21. Has prn hydral and lopressor. Has prn hydral and lopressor. Has prn hydral and lopressor. Docusate Sodium 9. Docusate Sodium 9. Docusate Sodium 9. Docusate Sodium 6. Docusate Sodium 6. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Lorazepam 15. Lorazepam 15. Current medications: . Current medications: . Morphine Sulfate 20. Lisinopril 13. Lisinopril 13. HydrALAzine 11. HydrALAzine 11. Ondansetron 19. Ondansetron 19. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Remains on ativan atc. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Remains on ativan atc. Addictions consult. Addictions consult. Metoprolol Tartrate 16. Metoprolol Tartrate 16. Action: Ativan atc. Action: Ativan atc. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. TITLE: Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. .H/O respiratory failure, acute (not ARDS/) Assessment: Pt extubated today. Metoprolol Tartrate 19. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Nicotine Patch 17. Nicotine Patch 17. Metoprolol Tartrate 18. Has prn hydral and lopressor. Has prn hydral and lopressor. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt continues with ciwa scale. hydralazine prn. Morphine Sulfate 16. Morphine Sulfate 16. Right Basal Ganglia Hemorrhage Assessment: c/o constant R sided HA upon initial exam, +tremors/sweats- please see metavision for neuron and CIWA assessment. Morphine Sulfate 20. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Hourly CIWA scale 17-27 Action: Response: Plan: Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage Assessment: Action: Response: Plan: Nicotine Patch 21. Phenytoin 19. Phenytoin 19. Current medications: 1. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. Action: Freq neuro checks. Action: Freq neuro checks. Action: Freq neuro checks. Phenytoin 23. Ordered morphine 1mg IVB x1 dose. Ordered morphine 1mg IVB x1 dose. IV labetelol drip restarted with goal SBP 140-160. Lorazepam 14. Lorazepam 14. Addictions consult. Sodium Chloride 0.9% Flush 27. FINDINGS: Post-operative change of a right craniotomy status post evacuation of an intraparenchymal bleed is again noted. A small amount of residual hemorrhage and extensive pneumocephalus within the right basal ganglia is identified. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. ( series 401b/7) (Over) 10:52 AM CTA HEAD W&W/O C & RECONS Clip # Reason: Hemorrhage follow-up Admitting Diagnosis: INTRACRANIAL HEMORRHAGE FINAL REPORT (Cont) There is evidence of scleral band, with ocular implant on the left side, unchanged. Subarachnoid hemorrhage (SAH) Assessment: Neuro assessment done q2hrs. Sinus rhythmProminent precordial lead QRS voltage suggests left ventricular hypertrophy butmay be nondiagnostic given ageModest nonspecific inferior ST-T wave changesNo previous tracing available for comparison FINAL REPORT HISTORY: Known intracranial hemorrhage. FINDINGS: Patient is status post right frontoparietal craniotomy with evacuation of putaminal and temporal lobe hematoma. A few small hypodense foci, noted in the left internal capsule, may represent perivascular spaces or chronic lacunar infarcts are unchanged. Interval decrease in right basal ganglia hemorrhage. This location is most suggestive of a hypertensive etiology, although underlying mass lesion/metastasis is not completely excluded."},"n_notes":{"kind":"number","value":52,"string":"52"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2186-08-28 00:00:00.000","description":"Nursing Transfer Note","row_id":417678,"text":"Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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":"2186-08-28 00:00:00.000","description":"Nursing Transfer Note","row_id":417679,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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":"Physician ","chartdate":"2186-08-27 00:00:00.000","description":"Intensivist Note","row_id":417538,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\n ETOH abuse, h/o illicit drug use\n : none\n .\n Current medications:\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. FoLIC Acid 11. Heparin\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\n 17. Metoprolol Tartrate\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\n Ondansetron 22. Phenytoin 23. Potassium Chloride\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\n 27. Thiamine\n 24 Hour Events:\n TF placed and tF started yesterday\n Post operative day:\n POD#3 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:41 AM\n Lorazepam (Ativan) - 06:00 PM\n Famotidine (Pepcid) - 08:13 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Hydralazine - 02:14 AM\n Metoprolol - 06:18 AM\n Other medications:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.1\nC (100.5\n HR: 119 (86 - 119) bpm\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\n RR: 18 (9 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,828 mL\n 776 mL\n PO:\n Tube feeding:\n 190 mL\n 129 mL\n IV Fluid:\n 2,518 mL\n 647 mL\n Blood products:\n Total out:\n 2,735 mL\n 700 mL\n Urine:\n 2,735 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 93 mL\n 76 mL\n Respiratory support\n SPO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 220 K/uL\n 13.6 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 38.0 %\n 16.5 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n Plt\n 20\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\n to PO\n Cardiovascular: Lopressor 75 TID PO\n HYDRALAZYN prn\n Pulmonary: Stable\n Gastrointestinal / Abdomen: Advance to goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Lasix 20mg \n Hematology: Stable\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Nephrology\n Billing Diagnosis: Other: Basal ganglia Bleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Progress Note","row_id":417605,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Remains on ativan atc. Tachy at times and occ attempting to pull at\n lines, otherwise no s/s withdrawal noted.\n Action:\n Ativan atc, but dose decreased\n Response:\n No need for prn ativan and no s/s withdrawal noted\n Plan:\n Con\nt to monitor. Ativan atc and prn.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Opens eyes to stim . right pupil round and reactive. Left pupil at\n baseline. Follows commands on right. Moves right spont. No spont\n movement on left. Withdraws on left to pain. Oriented to person and\n president and month. Only says few words and speech grarbled.\n Action:\n Neuro checks.\n Response:\n Neuro status unchanged.\n Plan:\n Con\nt neuro checks\n"},{"category":"Physician ","chartdate":"2186-08-25 00:00:00.000","description":"Intensivist Note","row_id":417181,"text":"SICU\n HPI:\n 44yo male presented to an outside hospital with acute onset\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\n right cranimtomy hemmhorrage evacuation\n Chief complaint:\n acute onset left sided plegia\n PMHx:\n left eye injury-screwdriver with surgical correction with\n noted visula impairment since, ETOH abuse, prior hx on illicit\n drug use.\n Current medications:\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\n Acid/Multivitamin/Thiamine-1000mL NS\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\n 17. NiCARdipine 18. Ondansetron\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\n 25. Vancomycin\n 24 Hour Events:\n OR SENT - At 03:00 PM\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\n INTUBATION - At 03:15 PM\n intubated in OR\n INVASIVE VENTILATION - START 03:15 PM\n intubated in OR\n ARTERIAL LINE - START 03:30 PM\n OR RECEIVED - At 05:45 PM\n Post operative day:\n POD#1 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Gentamicin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Diazepam (Valium) - 11:00 AM\n Midazolam (Versed) - 06:05 PM\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.3\nC (97.4\n HR: 88 (73 - 95) bpm\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\n RR: 13 (12 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,980 mL\n 1,228 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,780 mL\n 1,228 mL\n Blood products:\n 200 mL\n Total out:\n 3,800 mL\n 435 mL\n Urine:\n 1,690 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 180 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SPO2: 100%\n ABG: 7.44/40/198/28/3\n Ve: 6.9 L/min\n PaO2 / FiO2: 495\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, No(t) Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\n Weakness)\n Labs / Radiology\n 251 K/uL\n 13.2 g/dL\n 168 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 105 mEq/L\n 142 mEq/L\n 37.6 %\n 18.7 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n WBC\n 9.7\n 18.7\n Hct\n 43.2\n 37.6\n Plt\n 231\n 251\n Creatinine\n 0.8\n 1.0\n TCO2\n 26\n 28\n Glucose\n 134\n 146\n 168\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 44yo male presented to an outside hospital with\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\n evacuation\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\n MEDAZOLEM,\n Cardiovascular: D/C Nocrdipine, Start Lopressor\n Pulmonary: Extubate today, Spontaneous breathing trial\n Gastrointestinal / Abdomen: assess Swallow\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable Ht\n Endocrine: RISS, Start RISS start at 120 mg/dl\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CT scan head today\n Fluids:\n Consults:\n Billing Diagnosis: Other: Left Side weakness\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2186-08-25 00:00:00.000","description":"Intensivist Note","row_id":417183,"text":"SICU\n HPI:\n 44yo male presented to an outside hospital with acute onset\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\n right cranimtomy hemmhorrage evacuation\n Chief complaint:\n acute onset left sided plegia\n PMHx:\n left eye injury-screwdriver with surgical correction with\n noted visula impairment since, ETOH abuse, prior hx on illicit\n drug use.\n Current medications:\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\n Acid/Multivitamin/Thiamine-1000mL NS\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\n 17. NiCARdipine 18. Ondansetron\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\n 25. Vancomycin\n 24 Hour Events:\n OR SENT - At 03:00 PM\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\n INTUBATION - At 03:15 PM\n intubated in OR\n INVASIVE VENTILATION - START 03:15 PM\n intubated in OR\n ARTERIAL LINE - START 03:30 PM\n OR RECEIVED - At 05:45 PM\n Post operative day:\n POD#1 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Gentamicin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Diazepam (Valium) - 11:00 AM\n Midazolam (Versed) - 06:05 PM\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.3\nC (97.4\n HR: 88 (73 - 95) bpm\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\n RR: 13 (12 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,980 mL\n 1,228 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,780 mL\n 1,228 mL\n Blood products:\n 200 mL\n Total out:\n 3,800 mL\n 435 mL\n Urine:\n 1,690 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 180 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SPO2: 100%\n ABG: 7.44/40/198/28/3\n Ve: 6.9 L/min\n PaO2 / FiO2: 495\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, No(t) Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\n Weakness)\n Labs / Radiology\n 251 K/uL\n 13.2 g/dL\n 168 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 105 mEq/L\n 142 mEq/L\n 37.6 %\n 18.7 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n WBC\n 9.7\n 18.7\n Hct\n 43.2\n 37.6\n Plt\n 231\n 251\n Creatinine\n 0.8\n 1.0\n TCO2\n 26\n 28\n Glucose\n 134\n 146\n 168\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 44yo male presented to an outside hospital with\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\n evacuation\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\n MEDAZOLEM,\n Cardiovascular: D/C Nocrdipine, Start Lopressor\n Pulmonary: Extubate today, Spontaneous breathing trial\n Gastrointestinal / Abdomen: assess Swallow\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable Ht\n Endocrine: RISS, Start RISS start at 120 mg/dl\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CT scan head today\n Fluids:\n Consults:\n Billing Diagnosis: Other: Left Side weakness\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-28 00:00:00.000","description":"Nursing Progress Note","row_id":417730,"text":"Subarachnoid hemorrhage (SAH)\n Assessment:\n Moves right arm and leg off the bed. No spontaneous movement in left\n arm or left leg. Opens eyes to stimuli. Right pupil equal and reactive.\n Left pupil non reactive due to prior eye trauma. Speech garbled and at\n times difficult to understand. Pt able to state name and year. Becomes\n confused to month and place. Pt able to stick tongue upon command and\n squeeze hand to command.\n Action:\n Neuro check q2hrs. ativan 0.5mg iv as ordered.\n Response:\n Neuron status stable\n Plan:\n Continue to monitor neuron status.\n"},{"category":"Nursing","chartdate":"2186-08-28 00:00:00.000","description":"Nursing Transfer Note","row_id":417733,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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":"Physician ","chartdate":"2186-08-28 00:00:00.000","description":"Intensivist Note","row_id":417743,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\n Acid 8. Furosemide\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\n Lorazepam 15. Metoprolol Tartrate\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\n Ondansetron 20. Phenytoin 21. Potassium Chloride\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\n Sodium Chloride 0.9% Flush\n 26. Thiamine\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:48 AM\n Post operative day:\n POD#4 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:19 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 110 (94 - 125) bpm\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\n RR: 19 (18 - 26) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,758 mL\n 686 mL\n PO:\n Tube feeding:\n 1,218 mL\n 647 mL\n IV Fluid:\n 1,059 mL\n 39 mL\n Blood products:\n Total out:\n 3,148 mL\n 275 mL\n Urine:\n 3,148 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -390 mL\n 411 mL\n Respiratory support\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n No movement), (LLE: No movement)\n Labs / Radiology\n 266 K/uL\n 14.4 g/dL\n 142 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 101 mEq/L\n 138 mEq/L\n 39.4 %\n 12.9 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n 03:31 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n 12.9\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n 39.4\n Plt\n 20\n 266\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n 0.9\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n 142\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\n controlled\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\n Pulmonary: cont pulm toilet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: stable\n Lines:\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2186-08-28 00:00:00.000","description":"Intensivist Note","row_id":417745,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\n Acid 8. Furosemide\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\n Lorazepam 15. Metoprolol Tartrate\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\n Ondansetron 20. Phenytoin 21. Potassium Chloride\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\n Sodium Chloride 0.9% Flush\n 26. Thiamine\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:48 AM\n Post operative day:\n POD#4 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:19 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 110 (94 - 125) bpm\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\n RR: 19 (18 - 26) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,758 mL\n 686 mL\n PO:\n Tube feeding:\n 1,218 mL\n 647 mL\n IV Fluid:\n 1,059 mL\n 39 mL\n Blood products:\n Total out:\n 3,148 mL\n 275 mL\n Urine:\n 3,148 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -390 mL\n 411 mL\n Respiratory support\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n No movement), (LLE: No movement)\n Labs / Radiology\n 266 K/uL\n 14.4 g/dL\n 142 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 101 mEq/L\n 138 mEq/L\n 39.4 %\n 12.9 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n 03:31 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n 12.9\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n 39.4\n Plt\n 20\n 266\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n 0.9\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n 142\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\n controlled\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\n Pulmonary: cont pulm toilet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: stable\n Lines:\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Progress Note","row_id":417634,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Remains on ativan atc. Tachy at times and occ attempting to pull at\n lines, otherwise no s/s withdrawal noted.\n Action:\n Ativan atc, but dose decreased\n Response:\n No need for prn ativan and no s/s withdrawal noted\n Plan:\n Con\nt to monitor. Ativan atc and prn.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Opens eyes to stim . right pupil round and reactive. Left pupil at\n baseline. Follows commands on right. Moves right spont. No spont\n movement on left. Withdraws on left to pain. Oriented to person and\n president and month at times. Only says few words and speech grarbled.\n Action:\n Neuro checks.\n Response:\n Neuro status unchanged.\n Plan:\n Con\nt neuro checks\n To tx to SDU when bed avail.\n"},{"category":"Physician ","chartdate":"2186-08-24 00:00:00.000","description":"Physician Resident Admission Note","row_id":416935,"text":"Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Labetalol - 2 mg/min\n Other ICU medications:\n Diazepam (Valium) - 01:13 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN untreated, alcohol abuse, tobacco use, remote left eye penetrating\n injury\n Occupation: unemployed\n Drugs:\n Tobacco: +\n Alcohol: admits to alcohol abuse, last drink @ 1pm, avg 6\n drinks/day\n Other:\n Review of systems:\n Eyes: hx left eye injury, impaired vision\n Neurologic: Numbness / tingling, Headache\n Psychiatric / Sleep: Agitated\n Flowsheet Data as of 03:32 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: 35.6\nC (96.1\n HR: 80 (78 - 117) bpm\n BP: 123/94(100) {90/68(69) - 162/106(120)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 120 mL\n 135 mL\n PO:\n TF:\n IVF:\n 120 mL\n 135 mL\n Blood products:\n Total out:\n 800 mL\n 0 mL\n Urine:\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n 135 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: right pupil reactive, left surgical pupil\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\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, Oriented (to): person,\n place. Motor 0/5 left side, right side. Sensory\n light touch,\n decreased on left.\n Labs / Radiology\n head CT:\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\n with\n mild mass effect but no midline shift, presumed to be Htn induced.\n [image002.jpg]\n Assessment and Plan\n ASSESSMENT/PLAN:\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\n hemorrhage, with left leg weakness, left neglect (unable to sense left\n arm without guidance of RUE), and LUE numbness.\n NEURO: neuro check q1hr; neurosurgery consult appreciated and to\n follow; MRI/MRA pending; STAT head CT for acute mental changes. Tylenol\n for HA per primary service. HOB >30 degrees.\n CV: Maintain SB 140-160, MAP <130.\n Pulm/Endo/Heme/Renal/ID: no issues\n GI/ABD/FEN: NPO until S/S eval\n ICU Care\n Nutrition:\n Comments: NPO except meds until S/S eval\n Glycemic Control:\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":417048,"text":"Subarachnoid hemorrhage (SAH)\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed- revealed increased bleed with NEW midline shift.\n Discussion re: elective intubation for airway protection between\n physicians- decided to wait temporarily. 50mg IV mannitol given at\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\n positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":417049,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\n at 15:00.\n Right Basal Ganglia Hemorrhage\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed- revealed increased bleed with NEW midline shift.\n Discussion re: elective intubation for airway protection between\n physicians- decided to wait temporarily. 50mg IV mannitol given at\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\n positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"},{"category":"Nursing","chartdate":"2186-08-28 00:00:00.000","description":"Nursing Progress Note","row_id":417802,"text":"Hypertension, benign\n Assessment:\n Pt slightly hypertensive in 140s; tachycardic to 120s\n Action:\n Administered metoprolol\n Response:\n Patient tolerated dose, heart to 90s and BP 120s/80s\n Plan:\n Continue beta blockade, hydral PRN\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n At times patient appeared restless, diaphoretic though afebrile,\n tachycardic\n Action:\n Ativan, attempted to reduce stimuli in room\n Response:\n Patient settled; less diaphoretic, less restless\n Plan:\n Continue to monitor, administer ativan\n"},{"category":"Physician ","chartdate":"2186-08-24 00:00:00.000","description":"Intensivist Note","row_id":417012,"text":"TSICU\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Chief complaint:\n CC: left sided weakness\n ISSUES:\n 1. Intracranial hemorrhage with left sided plegia/paresthesia.\n 2. HTN.\n 3. EtOH abuse\n PMHx:\n Current medications:\n 24 Hour Events:\n - labetalol gtt started in evening for SBP>160, goal per neuro\n MAP<130, SBP 140s-160s. Await MRI/MRA. Increased valium dose for\n tremors.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Diazepam (Valium) - 08:50 AM\n Other medications:\n Flowsheet Data as of 11:06 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: 36.3\nC (97.3\n HR: 85 (78 - 117) bpm\n BP: 137/89(102) {90/68(69) - 162/106(120)} mmHg\n RR: 20 (15 - 24) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 120 mL\n 346 mL\n PO:\n Tube feeding:\n IV Fluid:\n 120 mL\n 346 mL\n Blood products:\n Total out:\n 800 mL\n 270 mL\n Urine:\n 800 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n 76 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: Somnolent\n HEENT: Left pupil dilated, Right Pupil Equal and reactive\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No(t) Weakness), (LUE: No movement), (RLE: No(t) Weakness), (LLE: No\n movement)\n Labs / Radiology\n 231 K/uL\n 15.2 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 102 mEq/L\n 141 mEq/L\n 43.2 %\n 9.7 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.7\n Hct\n 43.2\n Plt\n 231\n Creatinine\n 0.8\n Glucose\n 134\n Other labs: PT / PTT / INR:13.2/30.9/1.1, Ca:9.2 mg/dL, Mg:2.2 mg/dL,\n PO4:3.3 mg/dL\n Imaging: head CT:\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\n with\n mild mass effect but no midline shift, presumed to be Htn induced.\n Assessment and Plan\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\n hemorrhage.\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, f/u Head CT\n Cardiovascular: Labetalol gtt for SBP < 160 & MAP < 130 (PER PRIMARY\n TEAM REC'S) --> will clarify these goals after f/u head ct. Will need\n a-line.\n Pulmonary: need intubated.\n Gastrointestinal / Abdomen: Will need S&S eval --> will most likely\n need dobhoff and TF\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: No issues\n Endocrine: RISS\n Infectious Disease: No issues\n Lines / Tubes / Drains: Foley, PIV; For a-line.\n Wounds: none\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS), CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Needs ICU consent\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"},{"category":"Respiratory ","chartdate":"2186-08-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":417129,"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 Known difficult intubation: No\n Procedure location: OR\n Reason: Intubated for procedure\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Plan to switch to CPAP/PS and extubate this AM.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan for extubation today. RSBI completed on PS 5=28.\n Reason for continuing current ventilatory support:\n"},{"category":"Nutrition","chartdate":"2186-08-25 00:00:00.000","description":"Clinical Nutrition Note","row_id":417253,"text":"Subjective: Pt just extubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 70.5 kg\n 68.1 kg ( 12:00 AM)\n 22.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 97%\n Diagnosis: ICH\n PMH : poorly controlled HTN, ETOH abuse (12-18 beers/day), +tobacco,\n remote R eye injury c/ screw driver\n Food allergies and intolerances: NKFA\n Pertinent medications: Famotidine, Abx, Colace, Senna, Bisacodyl, HISS,\n NS c/ Thiamine, Folic Acid & Mvit, others noted\n Labs:\n Value\n Date\n Glucose\n 168 mg/dL\n 02:24 AM\n Glucose Finger Stick\n 167\n 10:00 AM\n BUN\n 9 mg/dL\n 02:24 AM\n Creatinine\n 1.0 mg/dL\n 02:24 AM\n Sodium\n 142 mEq/L\n 02:24 AM\n Potassium\n 3.2 mEq/L\n 01:37 PM\n Chloride\n 105 mEq/L\n 02:24 AM\n Albumin\n 4.0 g/dL\n 02:24 AM\n Calcium non-ionized\n 9.4 mg/dL\n 02:24 AM\n Phosphorus\n 3.7 mg/dL\n 02:24 AM\n Ionized Calcium\n 1.09 mmol/L\n 01:37 PM\n Magnesium\n 2.1 mg/dL\n 02:24 AM\n Current diet order / nutrition support: NPO\n GI: Soft, +BS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: chronic ETOH abuse, possible permanent AMS head\n bleed\n Estimated Nutritional Needs\n Calories: 1760-2115 (BEE x or / 25-30 cal/kg)\n Protein: 84-99 (1.2-1.4 g/kg)\n Fluid: team\n Estimation of previous intake: unknown, possibly inadequate\n Estimation of current intake: Inadequate\n Specifics: 44 y.o. M adm with R basal ganglia hemorrhage, POD #1 of\n crani & hematoma evacuation. Pt recently extubated and remains\n agitated and confused. If pt unable to take po\ns in the next 2-3days,\n rec place feeding tube for start of enteral nutrition. Will use admit\n wt for feeding wt. Noted K is low.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If pt\ns MS doesn\nt clear, rec evaluation by SLP.\n 2) If pt unsafe for po\ns, rec place FT and start TF with goal of\n Fibersource @ 65cc/hr (1872kcals, 84g protein).\n 3) Multivitamin / Mineral supplement: Mvit, 100mg Thiamine & 1mg\n Folic Acid given daily\n 4) Check chemistry 10 panel daily, relplete lytes as needed (namely\n K).\n Please page if ?\ns \n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416960,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\n +family history,. Father also alcoholic When admitted to OSH ETOH level\n 145. Pt still with strong smell of alcohol on breath admits to \n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\n through out the night, trying to get OOB, at times completely drenched\n with new tremors noted at 0300. Neuro med resident called. Pt\n required constant bedside safety observations. Pt is also heavy smoker\n 1-1.5 packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\n restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\n and quickly weaned off. Every 1hr neuro checks remain stable without\n much change. Pt does not suffer from neglect has he frequently rubs his\n left arm and tries to straighten his left hand. c/o right sided\n headache frequently rubbing right side of head. As stated\n above pt a developed lower leg tremor when awake lasting 10-20seconds\n then legs relax. Intermittent periods of clear speech and able to pick\n up left leg 3 inches off bed then fell back. MRI check sheet filled\n out and faxed to MRI.\n Action:\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\n dose. Did not receive because had received valium recently. Received\n Tylenol 650mg PR .\n Response:\n Headache is somewhat improved per patient.\n Plan:\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\n infusion for SBP >160 or MAP >130\n Scheduled for MRI today. Remove nicotine patch before scan. One time\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\n IVB right before scan.\n Continue to keep pt and family aware of POC as discussed in multi\n disciplinary rounds.\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416961,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\n +family history,. Father also alcoholic When admitted to OSH ETOH level\n 145. Pt still with strong smell of alcohol on breath admits to \n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\n through out the night, trying to get OOB, at times completely drenched\n with new tremors noted at 0300. Neuro med resident called. Pt\n required constant bedside safety observations. Pt is also heavy smoker\n 1-1.5 packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\n restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\n and quickly weaned off. Every 1hr neuro checks remain stable without\n much change. Pt does not suffer from neglect has he frequently rubs his\n left arm and tries to straighten his left hand. c/o right sided\n headache frequently rubbing right side of head. As stated\n above pt a developed lower leg tremor when awake lasting 10-20seconds\n then legs relax. Intermittent periods of clear speech and able to pick\n up left leg 3 inches off bed then fell back. MRI check sheet filled\n out and faxed to MRI.\n Action:\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\n dose. Did not receive because had received valium recently. Received\n Tylenol 650mg PR .\n Response:\n Headache is somewhat improved per patient.\n Plan:\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\n infusion for SBP >160 or MAP >130\n Scheduled for MRI today. Remove nicotine patch before scan. One time\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\n IVB right before scan.\n Continue to keep pt and family aware of POC as discussed in multi\n disciplinary rounds.\n"},{"category":"Nursing","chartdate":"2186-08-25 00:00:00.000","description":"Nursing Progress Note","row_id":417294,"text":"Subarachnoid hemorrhage (SAH)\n Assessment:\n - pt off sedation\n - arousable to voice but rarely opens eyes. Shows effort by\n raising eyebrows but eyes are swollen\n - R pupil 3mm and reactive, L eye dilated and unreactive due\n to traumatic injury with screwdriver in the past.\n - lifts and holds , squeeze hand when asked\n - wiggles toes and moves RLE on bed\n - no movement of LUE, does not respond to nail bed stimuli\n - will withdraw LLE to pain\n - dry sterile dressing on R side of head post craniotomy \n not yet removed\n - will cough with turning and stimulation, and secretions\n suctioned out\n - on nicardipine gtt sbp paramters <140\n - on fentanyl and versed\n - K 3.2\n - Ionized Ca 0.94\n Action:\n - cool tea bags applied over R eye\n - q1h neuro checks\n - turn and reposition to stimulate cough\n - Dilantin to prevent sz\n - Fentanyl, and versed gtts off\n - Morphine 2-4mg prn\n - Nicardipine gtt off spb parameter changed from <140 to <160\n - NS with 40meq KCL at 85ml/hr initiated\n - Keep HOB>30\n - Calcium gluconate 2gm given\n Response:\n - swelling of R eye reduced\n - unchanged neuro status\n - cough stimulated with turning\n - no sz activity noted\n - pt more arousable\n - pain adequately controlled assessed by changes in vital\n signs\n - sbps 135-153\n - awaiting K level\n - Ionized ca 1.09\n -\n Plan:\n - continue using cool tea bags to reduce swelling\n - q1h neuro checks\n - turn and reposition with chest pt frequently\n - continue antiseizure therapy\n - treat pain adequately with prn morphine\n - lopressor 10mg q4h\n - monitor sbps with parameter <160\n - monitor and treat hypokalemia and hypocalcemia\n - keep HOB >30\n -\n Respiratory (intubated in OR)\n Assessment:\n - On CMV adequate ABG levels\n - SPO2 98-100%\n - Minimal secretions\n Action:\n - Changed to CPAP, Spontaneous breathing trial, followed by\n Extubation at 1100\n - 3L nasal cannula\n Response:\n - ABG levels within normal limits\n - SPO2 98-100%\n - Lungs sound rhonchorous\n - Normal and regular respiratory pattern\n Plan:\n - Nasal cannula at 3L\n - Chest pt\n - Turn and reposition frequently\n - Encourage pt to cough and suction out secretions when\n necessary\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n - hx smoking\n - alcoholism; takes 12-18 beers/day\n - level elevated on admission to OSH\n Action:\n - monitored for s/s of DTs\n - banana bag given\n - nicotine patch on R arm\n Response:\n - no sz or tremors, or other signs of DTs noted\n - unable to fully assess for CIWA scale due to neurological\n deficits\n Plan:\n - continue to monitor and assess for s/s of DTs\n - continue with nicotine patch\n - assess swallow/gag and start feeding either PO or NG if\n failure to pass swallow\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Nursing Transfer Note","row_id":417417,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Nursing Transfer Note","row_id":417418,"text":"Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"},{"category":"Physician ","chartdate":"2186-08-26 00:00:00.000","description":"Intensivist Note","row_id":417371,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\n Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\n Morphine Sulfate 16. Nicotine Patch\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EXTUBATION - At 11:10 AM\n INVASIVE VENTILATION - STOP 11:10 AM\n intubated in OR\n Post operative day:\n POD#2 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Famotidine (Pepcid) - 08:01 PM\n Morphine Sulfate - 01:00 AM\n Hydralazine - 02:20 AM\n Insulin - Humalog - 02:30 AM\n Lorazepam (Ativan) - 03:09 AM\n Metoprolol - 04:03 AM\n Other medications:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.5\nC (99.5\n HR: 98 (78 - 104) bpm\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\n RR: 19 (13 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,000 mL\n 555 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,000 mL\n 555 mL\n Blood products:\n Total out:\n 2,115 mL\n 765 mL\n Urine:\n 2,115 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 885 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\n PC : 0 cmH2O\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SPO2: 98%\n ABG: 7.45/35/81./25/0\n Ve: 9.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n Weakness, No movement), (LLE: Weakness, No movement)\n Labs / Radiology\n 198 K/uL\n 13.1 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 101 mEq/L\n 136 mEq/L\n 36.1 %\n 16.2 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n WBC\n 9.7\n 18.7\n 16.2\n Hct\n 43.2\n 37.6\n 36.1\n Plt\n \n Creatinine\n 0.8\n 1.0\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\n pain\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\n ?withdrawl- 1 q6 ativan, will start PO metoprolol 50 tid\n Pulmonary: chest pt\n Gastrointestinal / Abdomen:\n Nutrition: dobhoff and will start tube feeding, thiamine/folate, banana\n bag\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS, start tube feeds\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-25 00:00:00.000","description":"Nursing Progress Note","row_id":417287,"text":"Subarachnoid hemorrhage (SAH)\n Assessment:\n - pt off sedation\n - arousable to voice but rarely opens eyes. Shows effort by\n raising eyebrows but eyes are swollen\n - R pupil 3mm and reactive, L eye dilated and unreactive due\n to traumatic injury with screwdriver in the past.\n - lifts and holds , squeeze hand when asked\n - wiggles toes and moves RLE on bed\n - no movement of LUE, does not respond to nail bed stimuli\n - will withdraw LLE to pain\n - dry sterile dressing on R side of head post craniotomy \n not yet removed\n - will cough with turning and stimulation, and secretions\n suctioned out\n - on nicardipine gtt sbp paramters <140\n - on fentanyl and versed\n - K 3.2\n - Ionized Ca 0.94\n Action:\n - cool tea bags applied over R eye\n - q1h neuro checks\n - turn and reposition to stimulate cough\n - Dilantin to prevent sz\n - Fentanyl, and versed gtts off\n - Morphine 2-4mg prn\n - Nicardipine gtt off spb parameter changed from <140 to <160\n - NS with 40meq KCL at 85ml/hr initiated\n - Keep HOB>30\n - Calcium gluconate 2gm given\n Response:\n - swelling of R eye reduced\n - unchanged neuro status\n - cough stimulated with turning\n - no sz activity noted\n - pt more arousable\n - pain adequately controlled assessed by changes in vital\n signs\n - sbps 135-153\n - awaiting K level\n - Ionized ca 1.09\n -\n Plan:\n - continue using cool tea bags to reduce swelling\n - q1h neuro checks\n - turn and reposition with chest pt frequently\n - continue antiseizure therapy\n - treat pain adequately with prn morphine\n - lopressor 10mg q4h\n - monitor sbps with parameter <160\n - monitor and treat hypokalemia and hypocalcemia\n - keep HOB >30\n -\n Respiratory (intubated in OR)\n Assessment:\n - On CMV adequate ABG levels\n - SPO2 98-100%\n - Minimal secretions\n Action:\n - Changed to CPAP, Spontaneous breathing trial, followed by\n Extubation at 1100\n - 3L nasal cannula\n Response:\n - ABG levels within normal limits\n - SPO2 98-100%\n - Lungs sound rhonchorous\n - Normal and regular respiratory pattern\n Plan:\n - Nasal cannula at 3L\n - Chest pt\n - Turn and reposition frequently\n - Encourage pt to cough and suction out secretions when\n necessary\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n - hx smoking\n - alcoholism; takes 12-18 beers/day\n - level elevated on admission to OSH\n Action:\n - monitored for s/s of DTs\n - banana bag given\n - nicotine patch on R arm\n Response:\n - no sz or tremors, or other signs of DTs noted\n - unable to fully assess for CIWA scale due to neurological\n deficits\n Plan:\n - continue to monitor and assess for s/s of DTs\n - continue with nicotine patch\n - assess swallow/gag and start feeding either PO or NG if\n failure to pass swallow\n"},{"category":"Physician ","chartdate":"2186-08-26 00:00:00.000","description":"Intensivist Note","row_id":417369,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\n Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\n Morphine Sulfate 16. Nicotine Patch\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EXTUBATION - At 11:10 AM\n INVASIVE VENTILATION - STOP 11:10 AM\n intubated in OR\n Post operative day:\n POD#2 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Famotidine (Pepcid) - 08:01 PM\n Morphine Sulfate - 01:00 AM\n Hydralazine - 02:20 AM\n Insulin - Humalog - 02:30 AM\n Lorazepam (Ativan) - 03:09 AM\n Metoprolol - 04:03 AM\n Other medications:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.5\nC (99.5\n HR: 98 (78 - 104) bpm\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\n RR: 19 (13 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,000 mL\n 555 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,000 mL\n 555 mL\n Blood products:\n Total out:\n 2,115 mL\n 765 mL\n Urine:\n 2,115 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 885 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\n PC : 0 cmH2O\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SPO2: 98%\n ABG: 7.45/35/81./25/0\n Ve: 9.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n Weakness, No movement), (LLE: Weakness, No movement)\n Labs / Radiology\n 198 K/uL\n 13.1 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 101 mEq/L\n 136 mEq/L\n 36.1 %\n 16.2 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n WBC\n 9.7\n 18.7\n 16.2\n Hct\n 43.2\n 37.6\n 36.1\n Plt\n \n Creatinine\n 0.8\n 1.0\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\n pain\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\n ?withdrawel 1 q6 ativan, will start PO metoprolol 50 tid\n Pulmonary: chest pt\n Gastrointestinal / Abdomen:\n Nutrition: dobhoff and will start tube feeding, thiamine/folate bannana\n bag\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS, d/c nml saline start tube feeds\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"},{"category":"Physician ","chartdate":"2186-08-27 00:00:00.000","description":"Intensivist Note","row_id":417534,"text":"SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\n ETOH abuse, h/o illicit drug use\n : none\n .\n Current medications:\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. FoLIC Acid 11. Heparin\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\n 17. Metoprolol Tartrate\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\n Ondansetron 22. Phenytoin 23. Potassium Chloride\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\n 27. Thiamine\n 24 Hour Events:\n TF placed and tF started yesterday\n Post operative day:\n POD#3 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:41 AM\n Lorazepam (Ativan) - 06:00 PM\n Famotidine (Pepcid) - 08:13 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Hydralazine - 02:14 AM\n Metoprolol - 06:18 AM\n Other medications:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.1\nC (100.5\n HR: 119 (86 - 119) bpm\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\n RR: 18 (9 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,828 mL\n 776 mL\n PO:\n Tube feeding:\n 190 mL\n 129 mL\n IV Fluid:\n 2,518 mL\n 647 mL\n Blood products:\n Total out:\n 2,735 mL\n 700 mL\n Urine:\n 2,735 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 93 mL\n 76 mL\n Respiratory support\n SPO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 220 K/uL\n 13.6 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 38.0 %\n 16.5 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n Plt\n 20\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\n to PO\n Cardiovascular: Lopressor 75 TID PO\n HYDRALAZYN prn\n Pulmonary: Stable\n Gastrointestinal / Abdomen: Adnance to goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Lasix 20mg \n Hematology: Stable\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Nephrology\n Billing Diagnosis: Other: Basal ganglia Bleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416951,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Hourly CIWA scale 17-27\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416945,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416946,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Nursing Progress Note","row_id":417343,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt continues with ciwa scale. Pt more restless pulling off gown and\n pulling at foley and taking off oxygen. Neuro exam is unchanged hr up\n to 106 and sbp 160\ns/80\n Action:\n Ativan .5mg iv x2 for total of 1mg. pt less restless and sbp down to\n 158/70.\n Response:\n Pt less restless after Ativan.\n Plan:\n Continue with neuro checks and ciwa scale. Assess for Ativan as\n needed.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Neuro exam is unchanged. Pt follows commands on right side. Withdrawal\n on left foot, none on left arm. Right pupil is reactive to light. Rt\n eye is swollen. Pt opens eyes to name. Speech very soft and slightly\n garbled. Goal sbp less than 160. lopressor increased to 20mg q4 and\n hydralazine prn, given x2. Dr. aware of sbp greater than 160.\n does not want to restart nicardipine and increased lopressor.\n Action:\n Lopressor increased to 20mg. hydralazine prn. Continue with q1 neuro\n checks, ? repeat ct today.\n Response:\n Neuro is unchanged. Pt restless at times but responded to ativan\n Plan:\n Continue with neuro exam. Treat bp as needed. Continue with ciwa scale.\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Nursing Progress Note","row_id":417346,"text":".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated today. Pt resp rate 16-20. o2 sat on room air 98%. Breath\n sounds are clear and diminished in the bases. Pt coughing and\n swallowing.\n Action:\n Encourage pt to cough and deep breath.\n Response:\n Doing well extubated.\n Plan:\n Continue to cough and deep breathe. Frequent position changes.\n"},{"category":"Nursing","chartdate":"2186-08-25 00:00:00.000","description":"Nursing Progress Note","row_id":417147,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt responds to name and stimulation with jerking movements, attempts\n to sit up, and tremulous motion of right side, less motion on left\n side. Pt does not nod or shake head to communicate, so assessment of\n hallucinations, pain, etc is difficult.\n Action:\n Midazolam and fentanyl drips started and titrated up as needed to\n control tremulous movement\n Response:\n Tremors are quieter, although still existent with medications at higher\n dosage. Midaz returned to 2 mg/hr from 4 mg/hr when he became more\n difficult to arouse. He is now arousable but with fewer tremors than\n before midazolam and fentanyl were started.\n Plan:\n Titrate drips as needed, monitor for increase tremors, seizures,\n increase in heart rate and bp.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Pt post op evacuation of SDH. Head dressing is dry and intact. Pt\n arouses to name, as above, follows commands with right side, but does\n not nod or shake his head when asked to do so. He is intubated on CMV ,\n sx for thick yellow secretios Right pupil is and reacts briskly.\n Left pupil is damaged from a screwdriver injury. Pt is sedated for\n onset of DT\ns, and responding more slowly with midazolam and fentanyl\n on.\n Action:\n Midazolam decreased to 2 mg when pt very slow to respond to name and\n stimulation\n Response:\n Pt responding again when name called.\n Plan:\n Continue with q 1 hour neuro checks to evaluate neuro status\n complicated by alcohol withdrawal.\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":417053,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\n at 15:00.\n Right Basal Ganglia Hemorrhage\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed revealed increased bleed, cerebral edema, and NEW 1.3\n cm midline shift to left. Discussion re: elective intubation for\n airway protection between physicians- decided to wait temporarily.\n 50mg IV mannitol given at 13:00 over 30minuntes to decrease ICP. HOB at\n 30 degrees. Head positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"},{"category":"Respiratory ","chartdate":"2186-08-25 00:00:00.000","description":"Respiratory Care Shift Note","row_id":417263,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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 CT\n without incident\n Bedside Procedures:\n Comments:\n Pt received intubated and vented on AC settings as charted. RSBI 28\n today. Placed on PSV 5 peep 5 with TV 500 and RR 12-16. Pt transported\n to CT scan and placed on SBT after transport. Pt extubated without\n incident and is currently on 3L NP and stable from resp standpoint.\n"},{"category":"Nursing","chartdate":"2186-08-26 00:00:00.000","description":"Generic Note","row_id":417428,"text":"TITLE:\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain but otherwise sleeping most of day. Right pupil\n reactive, round. Left pupil unreactive and odd shaped at baseline.\n Moves right side purposefully and attempts to pull at tubes/lines.\n Withdraws on left to pain. No spont movement on left. Said name once,\n otherwise only groans occ. Follows commands on right inconsistently. No\n sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Progress Note","row_id":417495,"text":".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt has a known history of drinking > 8-12 beers/day. Brother states ?\n more than 12 beers. Attempting to pull off bed clothes. Pt does not\n focus on you when speaking to him.\n Action:\n Ativan 1 mg iv q6hrs. nictone patch as ordered.\n Response:\n Pt is less agitated after the ativan iv.\n Plan:\n Continue with ativan iv and prn. Monitor closely.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Neuro assessment done q2hrs. strong hand grasp on right side and moves\n right leg off the bed. Withdraws to pain on left foot but no actual\n movement in left arm. Withdraws slightly to painful stimuli. Speech is\n garbled and pt very diffiulct to understand. Right pupil reactive to\n light and left eye no reaction due to old eye injury. Bp at times >\n 160. operative site on head intact with staples present and no drainage\n noted.\n Action:\n Neuro signs q2hrs. ? head ct today. Incision inspected\n Response:\n No neuro changes\n Plan:\n Cont with neuro exam.\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Progress Note","row_id":417497,"text":"Hypertension, benign\n Assessment:\n Bp mostly > 160 shift\n Action:\n Lopresssor 50mg via tube given as ordered. Hydralazine 10mg iv given\n linsopril 5mg via tube given as ordered.\n Response:\n Bp < 160 for short time after meds given but quickly returns to > 160.\n Plan:\n Monitor closely.\n"},{"category":"Nursing","chartdate":"2186-08-27 00:00:00.000","description":"Nursing Transfer Note","row_id":417574,"text":"Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"},{"category":"Nursing","chartdate":"2186-08-24 00:00:00.000","description":"Nursing Progress Note","row_id":416954,"text":"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n ETOH level 145 at OSH with strong smell of alcohol on breath, admits to\n 12-18 beers a day. Hourly CIWA scores 20-27 becoming Increasingly\n restless through out the night, trying to get OOB, at times completely\n drenched with new tremors noted at 0300. Pt required bedside safety\n observations. Neuro med resident called. Pt is also heavy smoker 1-1.5\n packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Initially only decrease in restlessness for 45 minutes after valium 5mg\n IVB. However by am CIWA scale decreasing to 17 by 0500 and becoming\n less restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n Every 1hr neuro checks remain stable without much change. As stated\n above pt developed lower leg tremors mostly when awake lasting\n 10-20seconds then muscle relaxes.\n Action:\n Response:\n Plan:\n"},{"category":"Respiratory ","chartdate":"2186-08-24 00:00:00.000","description":"Respiratory Care Shift Note","row_id":417069,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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 arrived from O.R. and taken to C.T. Plan to extubated when awake.\n"},{"category":"Radiology","chartdate":"2186-09-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039777,"text":", NMED FA11 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Querying aspiration pneumonitis\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with left hemiparesis, s/p crani after an ICH\n REASON FOR THIS EXAMINATION:\n Querying aspiration pneumonitis\n ______________________________________________________________________________\n PFI REPORT\n No evidence of acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2186-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037849,"text":" 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Dobhoff placemnet eval plse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Dobhoff placemnet eval plse\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 5:06 PM\n Dobbhoff tube is in the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess Dobbhoff catheter.\n\n Dobbhoff tip is in the stomach. There is mild cardiomegaly. The lungs are\n clear. There is no pleural effusion.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2186-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1037850,"text":", H. NMED SICU-A 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Dobhoff placemnet eval plse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Dobhoff placemnet eval plse\n ______________________________________________________________________________\n PFI REPORT\n Dobbhoff tube is in the stomach.\n\n\n"},{"category":"Radiology","chartdate":"2186-09-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1039776,"text":" 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Querying aspiration pneumonitis\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with left hemiparesis, s/p crani after an ICH\n REASON FOR THIS EXAMINATION:\n Querying aspiration pneumonitis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 3:52 PM\n No evidence of acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Suspected aspiration pneumonia.\n\n Portable AP chest radiograph was compared to prior study from .\n\n The heart size is normal. Mediastinal position, contour and width are\n unremarkable. Lungs are clear. No pleural effusion or pneumothorax is\n present. Potential old rib fracture is seen on the left\n\n\n"},{"category":"Radiology","chartdate":"2186-08-24 00:00:00.000","description":"ORBITS (WATERS, CALDWELL & LAT)","row_id":1037401,"text":" 11:18 AM\n ORBITS (WATERS, & LAT) Clip # \n Reason: bilateral orbital xray to rule out metal pre-mri\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm), untreated HTN\n presented to OSH with change in gait on left side after alcohol use. Pt noted\n difficulty moving left leg, left facial weakness, left sided numbness, and left\n facial droop. CT @ OSH --> right BG hemorrhage 3cm, transferred to for\n further care. On transfer EMS noted pt has \"worsening symptoms\" from the\n initial transport to OSH (same EMS team). @ repeat head CT showed right\n BG hemorrhage at 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n REASON FOR THIS EXAMINATION:\n bilateral orbital xray to rule out metal pre-mri\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Orbit series .\n\n HISTORY: 44-year-old man with facial droop and needs MRI. Evaluate for metal\n in orbits.\n\n FINDINGS: Comparison is made to the CT scan from .\n\n There are no radiopaque densities in the left orbital prosthesis. Visualized\n paranasal sinuses are within normal limits.\n\n IMPRESSION: No radiopaque densities within the orbits to exclude the patient\n from having MRI.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2186-08-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037478,"text":" 5:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hemorrhage\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:10 PM\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\n pneumocephalus and intraventricular hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: Nine hours prior.\n\n HISTORY: Evaluate for hemorrhage.\n\n FINDINGS: Patient is status post right frontoparietal craniotomy with\n evacuation of putaminal and temporal lobe hematoma. Extensive pneumocephalus\n is identified along the right cerebral convexity. There is a leftward shift of\n normally midline structures by approximately 10 mm, slightly decreased when\n compared to prior exam. Intraventricular hemorrhage in the right frontal \n of the lateral ventricle and bilateral posterior horns of the lateral\n ventricle is not significantly changed. A small amount of residual hemorrhage\n and extensive pneumocephalus within the right basal ganglia is identified.\n Dilated temporal horns, left greater than right, are unchanged. The basilar\n cisterns are patent.\n\n IMPRESSION: Patient status post craniotomy with evacuation of hematoma.\n Extensive pneumocephalus over the right cerebral hemisphere and within the\n right basal ganglia. Interval decrease in right basal ganglia hemorrhage.\n Persistent intraventricular hemorrhage and leftward shift of midline\n structures as described above.\n\n\n\n"},{"category":"Radiology","chartdate":"2186-08-24 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037479,"text":", H. NMED SICU-A 5:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hemorrhage\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\n pneumocephalus and intraventricular hemorrhage.\n\n"},{"category":"Radiology","chartdate":"2186-08-24 00:00:00.000","description":"CTA HEAD W&W/O C & RECONS","row_id":1037390,"text":" 10:52 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Hemorrhage follow-up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with R basal ganglia hemorrhage\n REASON FOR THIS EXAMINATION:\n Hemorrhage follow-up\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:13 PM\n\n Moderate increas ein the right basal ganglia hematoma with new areas and new\n itnraventricular hemorrhage and mass effect and cerbral edema on the right.\n Patent major arteries; no abnormal vascularity around the hematoma- however,\n lesions within the hematoma are not assessed.\n d/w Dr. . by Dr. on at 2pm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old male patient with right basal ganglial hemorrhage,\n followup.\n\n COMPARISON: CT of the head done on at 4:19 p.m.\n\n TECHNIQUE: Non-contrast CT of the head, followed by CT angiogram of the head\n with IV contrast was performed. Volume rendered and 2D MIP reformations of\n the major arteries were obtained.\n\n FINDINGS:\n\n NON-CONTRAST CT OF THE HEAD:\n\n There is interval moderate increase in the size of the right basal ganglia\n hematoma, 7.6x3.6cm in the AP and transverse dimensions with significant\n mass effect on the adjacent structures, along with cerebral edema on the right\n side. There is 1.3 cm shift of the midline structures to the left side, which\n is increased, which is new. Some of the new areas that have developed are\n less dense in attenuation representing active bleeding/ due to anemia. There\n is also extension of the hemorrhage into the right lateral ventricle as well\n as the third ventricle. A few small hypodense foci, noted in the left\n internal capsule, may represent perivascular spaces or chronic lacunar\n infarcts are unchanged. No osseous lytic or sclerotic lesions of concern are\n noted.\n\n CT ANGIOGRAM OF THE HEAD:\n\n The major intracranial arteries, of the anterior and posterior circulation are\n patent without flow limiting stenosis, occlusion, or aneurysm. No abnormal\n vascularity is noted surrounding the large right basal ganglial hematoma.\n However, the vascular lesion, located within the area of hematoma itself is\n not excluded on the present study. A small prominent vein int he right vertex\n can relate to a small developmental venous anomaly. ( series 401b/7)\n (Over)\n\n 10:52 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Hemorrhage follow-up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is evidence of scleral band, with ocular implant on the left side,\n unchanged.\n\n IMPRESSION:\n\n 1. Moderate increase in the size of the right basal ganglial hematoma with\n new areas of hemorrhage, which are less dense than expected, raising the\n possibility of active bleeding, ? bleeding disorders/anemia.\n\n 2. Development of new intraventricular hemorrhage, in the right lateral\n ventricle and third ventricle.\n\n 3. Significant mass effect, with cerebral edema on the right side, with 1.3\n cm shift of the midline structures to the left side.\n\n 4. Patent major intracranial arteries. No obvious abnormal vascularity noted\n around the hematoma. However, the vascular lesion, within the hematoma itself\n cannot be excluded on the present study. To consider followup evaluation for\n vascular lesions after resolution of the hematoma. In addition,\n MRI/conventional angiogram or close followup CT head can be considered.\n\n Findings were discussed with Dr. . for Dr. on at 2 p.m.\n\n\n\n"},{"category":"Radiology","chartdate":"2186-08-25 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037566,"text":" 8:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change. Please this this am\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change. Please this this am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 44-year-old with intracranial bleed status post surgery, please\n evaluate for change.\n\n COMPARISON: .\n\n FINDINGS: Post-operative change of a right craniotomy status post evacuation\n of an intraparenchymal bleed is again noted. There is decrease in the overall\n amount of pneumocephalus. The degree of mass effect and intracranial\n hemorrhage is not overall changed from prior study. The degree of\n intraventricular hemorrhage is also stable without evidence of hydrocephalus.\n Prominence of the left temporal is stable. The suprasellar cistern\n remains patent. Scleral band over the left orbit is grossly unchanged.\n\n IMPRESSION: Decrease in overall degree of post-operative pneumocephalus. No\n new hemorrhage is identified. Degree of mass effect appears little changed.\n\n\n"},{"category":"Radiology","chartdate":"2186-08-23 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1037261,"text":" 4:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with know bleed\n REASON FOR THIS EXAMINATION:\n eval for progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe WED 4:45 PM\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging, with\n mild mass effect but no midline shift, presumed to be Htn induced.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known intracranial hemorrhage.\n\n NON-CONTRAST HEAD CT\n\n FINDINGS: Comparison is made to outside scan from same date. Again\n identified is slightly heterogeneous hyperdense hemorrhage predominantly\n centered within the right basal ganglia with mass effect on the posterior limb\n of the right-sided internal capsule and adjacent parenchyma including the\n right frontal . The hemorrhage appears to have increased in size from\n outside examination, currently measuring 2.6 x 4.9 cm with prior measurement\n at similar level of approximately 2.3 x 3.6 cm. No other regions of\n intraparenchymal or intraventricular hemorrhage are identified. There is no\n significant midline shift. -white matter differentiation is otherwise\n well preserved. An old lacunar-type infarct is noted within the left internal\n capsule anterior limb. An apparent left globe prosthesis is noted. No soft\n tissue irregularity is present. Mastoid air cells and paranasal sinuses are\n well aerated.\n\n IMPRESSION:\n\n Interval increase in size to right intraparenchymal basal ganglia hemorrhage\n which displays mild mass effect on the adjacent brain parenchyma and right\n frontal with no significant midline shift. This location is most\n suggestive of a hypertensive etiology, although underlying mass\n lesion/metastasis is not completely excluded.\n\n Further evaluation with dedicated contrast-enhanced MRI may be obtained once\n the hemorrhage partially resolved for further characterization.\n\n"},{"category":"ECG","chartdate":"2186-08-23 00:00:00.000","description":"Report","row_id":223395,"text":"Sinus rhythm\nProminent precordial lead QRS voltage suggests left ventricular hypertrophy but\nmay be nondiagnostic given age\nModest nonspecific inferior ST-T wave changes\nNo previous tracing available for comparison\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417678,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Demographics\\n Attending MD:\\n H.\\n Admit diagnosis:\\n INTRACRANIAL HEMORRHAGE\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 70.5 kg\\n Daily weight:\\n 67.6 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: He had been told he needed to control HTN but no\\n follow up with this recomendation.\\n ETOH abuse\\n Surgery / Procedure and date: S/P Right craniotomy admitted to\\n SICU-A 692\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:139\\n D:89\\n Temperature:\\n 100.6\\n Arterial BP:\\n S:155\\n D:89\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 94 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 0 L/min\\n FiO2 set:\\n 35% %\\n 24h total in:\\n 164 mL\\n 24h total out:\\n 30 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 03:27 AM\\n Potassium:\\n 3.4 mEq/L\\n 03:27 AM\\n Chloride:\\n 103 mEq/L\\n 03:27 AM\\n CO2:\\n 23 mEq/L\\n 03:27 AM\\n BUN:\\n 8 mg/dL\\n 03:27 AM\\n Creatinine:\\n 0.7 mg/dL\\n 03:27 AM\\n Glucose:\\n 94 mg/dL\\n 03:27 AM\\n Hematocrit:\\n 38.0 %\\n 03:27 AM\\n Finger Stick Glucose:\\n 147\\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\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417679,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Chief Complaint: left leg weakness\\n HPI:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\\n untreated HTN presented to OSH with change in gait on left side after\\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\\n left sided numbness, and left facial droop. CT @ OSH --> right BG\\n hemorrhage 3cm, transferred to for further care. On transfer EMS\\n noted pt has \\\"worsening symptoms\\\" from the initial transport to OSH\\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n Demographics\\n Attending MD:\\n H.\\n Admit diagnosis:\\n INTRACRANIAL HEMORRHAGE\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 70.5 kg\\n Daily weight:\\n 67.6 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: He had been told he needed to control HTN but no\\n follow up with this recomendation.\\n ETOH abuse\\n Surgery / Procedure and date: S/P Right craniotomy admitted to\\n SICU-A 692\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:139\\n D:89\\n Temperature:\\n 100.6\\n Arterial BP:\\n S:155\\n D:89\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 94 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 0 L/min\\n FiO2 set:\\n 35% %\\n 24h total in:\\n 164 mL\\n 24h total out:\\n 30 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 03:27 AM\\n Potassium:\\n 3.4 mEq/L\\n 03:27 AM\\n Chloride:\\n 103 mEq/L\\n 03:27 AM\\n CO2:\\n 23 mEq/L\\n 03:27 AM\\n BUN:\\n 8 mg/dL\\n 03:27 AM\\n Creatinine:\\n 0.7 mg/dL\\n 03:27 AM\\n Glucose:\\n 94 mg/dL\\n 03:27 AM\\n Hematocrit:\\n 38.0 %\\n 03:27 AM\\n Finger Stick Glucose:\\n 147\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417538,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n BG hemorrhage\\n PMHx:\\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\\n ETOH abuse, h/o illicit drug use\\n : none\\n .\\n Current medications:\\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\\n Bisacodyl 6. Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\\n Famotidine 10. FoLIC Acid 11. Heparin\\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\\n 17. Metoprolol Tartrate\\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\\n Ondansetron 22. Phenytoin 23. Potassium Chloride\\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\\n 27. Thiamine\\n 24 Hour Events:\\n TF placed and tF started yesterday\\n Post operative day:\\n POD#3 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:41 AM\\n Lorazepam (Ativan) - 06:00 PM\\n Famotidine (Pepcid) - 08:13 PM\\n Heparin Sodium (Prophylaxis) - 08:15 PM\\n Hydralazine - 02:14 AM\\n Metoprolol - 06:18 AM\\n Other medications:\\n Flowsheet Data as of 06:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.2\\nC (100.7\\n T current: 38.1\\nC (100.5\\n HR: 119 (86 - 119) bpm\\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\\n RR: 18 (9 - 25) insp/min\\n SPO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 67.6 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 2,828 mL\\n 776 mL\\n PO:\\n Tube feeding:\\n 190 mL\\n 129 mL\\n IV Fluid:\\n 2,518 mL\\n 647 mL\\n Blood products:\\n Total out:\\n 2,735 mL\\n 700 mL\\n Urine:\\n 2,735 mL\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 93 mL\\n 76 mL\\n Respiratory support\\n SPO2: 96%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\\n Labs / Radiology\\n 220 K/uL\\n 13.6 g/dL\\n 94 mg/dL\\n 0.7 mg/dL\\n 23 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 38.0 %\\n 16.5 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n 06:00 AM\\n 03:27 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n 16.5\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n 38.0\\n Plt\\n 20\\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n 118\\n 94\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\\n hemorrhage, now s/p R craniotomy, evac \\n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\\n to PO\\n Cardiovascular: Lopressor 75 TID PO\\n HYDRALAZYN prn\\n Pulmonary: Stable\\n Gastrointestinal / Abdomen: Advance to goal\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Lasix 20mg \\n Hematology: Stable\\n Endocrine:\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley\\n Wounds:\\n Imaging:\\n Fluids:\\n Consults: Nephrology\\n Billing Diagnosis: Other: Basal ganglia Bleed\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\\n Glycemic Control:\\n Lines:\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417605,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Remains on ativan atc. Tachy at times and occ attempting to pull at\\n lines, otherwise no s/s withdrawal noted.\\n Action:\\n Ativan atc, but dose decreased\\n Response:\\n No need for prn ativan and no s/s withdrawal noted\\n Plan:\\n Con\\nt to monitor. Ativan atc and prn.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Opens eyes to stim . right pupil round and reactive. Left pupil at\\n baseline. Follows commands on right. Moves right spont. No spont\\n movement on left. Withdraws on left to pain. Oriented to person and\\n president and month. Only says few words and speech grarbled.\\n Action:\\n Neuro checks.\\n Response:\\n Neuro status unchanged.\\n Plan:\\n Con\\nt neuro checks\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417181,\n \"text\": \"SICU\\n HPI:\\n 44yo male presented to an outside hospital with acute onset\\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\\n right cranimtomy hemmhorrage evacuation\\n Chief complaint:\\n acute onset left sided plegia\\n PMHx:\\n left eye injury-screwdriver with surgical correction with\\n noted visula impairment since, ETOH abuse, prior hx on illicit\\n drug use.\\n Current medications:\\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\\n Acid/Multivitamin/Thiamine-1000mL NS\\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\\n 17. NiCARdipine 18. Ondansetron\\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\\n 25. Vancomycin\\n 24 Hour Events:\\n OR SENT - At 03:00 PM\\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\\n INTUBATION - At 03:15 PM\\n intubated in OR\\n INVASIVE VENTILATION - START 03:15 PM\\n intubated in OR\\n ARTERIAL LINE - START 03:30 PM\\n OR RECEIVED - At 05:45 PM\\n Post operative day:\\n POD#1 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:30 PM\\n Gentamicin - 04:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 25 mcg/hour\\n Nicardipine - 1 mcg/Kg/min\\n Other ICU medications:\\n Diazepam (Valium) - 11:00 AM\\n Midazolam (Versed) - 06:05 PM\\n Famotidine (Pepcid) - 09:00 PM\\n Other medications:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 36.3\\nC (97.4\\n HR: 88 (73 - 95) bpm\\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\\n RR: 13 (12 - 29) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.1 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 3,980 mL\\n 1,228 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,780 mL\\n 1,228 mL\\n Blood products:\\n 200 mL\\n Total out:\\n 3,800 mL\\n 435 mL\\n Urine:\\n 1,690 mL\\n 435 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 180 mL\\n 793 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 600 (600 - 600) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 28\\n PIP: 18 cmH2O\\n Plateau: 13 cmH2O\\n SPO2: 100%\\n ABG: 7.44/40/198/28/3\\n Ve: 6.9 L/min\\n PaO2 / FiO2: 495\\n Physical Examination\\n General Appearance: intubated and sedated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\\n Abdominal: Soft, Non-distended, No(t) Non-tender\\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\\n tibial: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\\n Weakness)\\n Labs / Radiology\\n 251 K/uL\\n 13.2 g/dL\\n 168 mg/dL\\n 1.0 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 37.6 %\\n 18.7 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n WBC\\n 9.7\\n 18.7\\n Hct\\n 43.2\\n 37.6\\n Plt\\n 231\\n 251\\n Creatinine\\n 0.8\\n 1.0\\n TCO2\\n 26\\n 28\\n Glucose\\n 134\\n 146\\n 168\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44yo male presented to an outside hospital with\\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\\n evacuation\\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\\n MEDAZOLEM,\\n Cardiovascular: D/C Nocrdipine, Start Lopressor\\n Pulmonary: Extubate today, Spontaneous breathing trial\\n Gastrointestinal / Abdomen: assess Swallow\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: Stable Ht\\n Endocrine: RISS, Start RISS start at 120 mg/dl\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley, NGT\\n Wounds:\\n Imaging: CT scan head today\\n Fluids:\\n Consults:\\n Billing Diagnosis: Other: Left Side weakness\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:45 PM\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417183,\n \"text\": \"SICU\\n HPI:\\n 44yo male presented to an outside hospital with acute onset\\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\\n right cranimtomy hemmhorrage evacuation\\n Chief complaint:\\n acute onset left sided plegia\\n PMHx:\\n left eye injury-screwdriver with surgical correction with\\n noted visula impairment since, ETOH abuse, prior hx on illicit\\n drug use.\\n Current medications:\\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\\n Acid/Multivitamin/Thiamine-1000mL NS\\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\\n 17. NiCARdipine 18. Ondansetron\\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\\n 25. Vancomycin\\n 24 Hour Events:\\n OR SENT - At 03:00 PM\\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\\n INTUBATION - At 03:15 PM\\n intubated in OR\\n INVASIVE VENTILATION - START 03:15 PM\\n intubated in OR\\n ARTERIAL LINE - START 03:30 PM\\n OR RECEIVED - At 05:45 PM\\n Post operative day:\\n POD#1 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:30 PM\\n Gentamicin - 04:00 AM\\n Infusions:\\n Midazolam (Versed) - 2 mg/hour\\n Fentanyl - 25 mcg/hour\\n Nicardipine - 1 mcg/Kg/min\\n Other ICU medications:\\n Diazepam (Valium) - 11:00 AM\\n Midazolam (Versed) - 06:05 PM\\n Famotidine (Pepcid) - 09:00 PM\\n Other medications:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.3\\nC (99.2\\n T current: 36.3\\nC (97.4\\n HR: 88 (73 - 95) bpm\\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\\n RR: 13 (12 - 29) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.1 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 3,980 mL\\n 1,228 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,780 mL\\n 1,228 mL\\n Blood products:\\n 200 mL\\n Total out:\\n 3,800 mL\\n 435 mL\\n Urine:\\n 1,690 mL\\n 435 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 180 mL\\n 793 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: CMV/ASSIST/AutoFlow\\n Vt (Set): 600 (600 - 600) mL\\n RR (Set): 12\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 28\\n PIP: 18 cmH2O\\n Plateau: 13 cmH2O\\n SPO2: 100%\\n ABG: 7.44/40/198/28/3\\n Ve: 6.9 L/min\\n PaO2 / FiO2: 495\\n Physical Examination\\n General Appearance: intubated and sedated\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\\n Abdominal: Soft, Non-distended, No(t) Non-tender\\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\\n tibial: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\\n Weakness)\\n Labs / Radiology\\n 251 K/uL\\n 13.2 g/dL\\n 168 mg/dL\\n 1.0 mg/dL\\n 28 mEq/L\\n 3.7 mEq/L\\n 9 mg/dL\\n 105 mEq/L\\n 142 mEq/L\\n 37.6 %\\n 18.7 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n WBC\\n 9.7\\n 18.7\\n Hct\\n 43.2\\n 37.6\\n Plt\\n 231\\n 251\\n Creatinine\\n 0.8\\n 1.0\\n TCO2\\n 26\\n 28\\n Glucose\\n 134\\n 146\\n 168\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44yo male presented to an outside hospital with\\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\\n evacuation\\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\\n MEDAZOLEM,\\n Cardiovascular: D/C Nocrdipine, Start Lopressor\\n Pulmonary: Extubate today, Spontaneous breathing trial\\n Gastrointestinal / Abdomen: assess Swallow\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: Stable Ht\\n Endocrine: RISS, Start RISS start at 120 mg/dl\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley, NGT\\n Wounds:\\n Imaging: CT scan head today\\n Fluids:\\n Consults:\\n Billing Diagnosis: Other: Left Side weakness\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:45 PM\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417730,\n \"text\": \"Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Moves right arm and leg off the bed. No spontaneous movement in left\\n arm or left leg. Opens eyes to stimuli. Right pupil equal and reactive.\\n Left pupil non reactive due to prior eye trauma. Speech garbled and at\\n times difficult to understand. Pt able to state name and year. Becomes\\n confused to month and place. Pt able to stick tongue upon command and\\n squeeze hand to command.\\n Action:\\n Neuro check q2hrs. ativan 0.5mg iv as ordered.\\n Response:\\n Neuron status stable\\n Plan:\\n Continue to monitor neuron status.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417733,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Chief Complaint: left leg weakness\\n HPI:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\\n untreated HTN presented to OSH with change in gait on left side after\\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\\n left sided numbness, and left facial droop. CT @ OSH --> right BG\\n hemorrhage 3cm, transferred to for further care. On transfer EMS\\n noted pt has \\\"worsening symptoms\\\" from the initial transport to OSH\\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n Demographics\\n Attending MD:\\n H.\\n Admit diagnosis:\\n INTRACRANIAL HEMORRHAGE\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 70.5 kg\\n Daily weight:\\n 67.6 kg\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: He had been told he needed to control HTN but no\\n follow up with this recomendation.\\n ETOH abuse\\n Surgery / Procedure and date: S/P Right craniotomy admitted to\\n SICU-A 692\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:139\\n D:89\\n Temperature:\\n 100.6\\n Arterial BP:\\n S:155\\n D:89\\n Respiratory rate:\\n 22 insp/min\\n Heart Rate:\\n 94 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 0 L/min\\n FiO2 set:\\n 35% %\\n 24h total in:\\n 164 mL\\n 24h total out:\\n 30 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 03:27 AM\\n Potassium:\\n 3.4 mEq/L\\n 03:27 AM\\n Chloride:\\n 103 mEq/L\\n 03:27 AM\\n CO2:\\n 23 mEq/L\\n 03:27 AM\\n BUN:\\n 8 mg/dL\\n 03:27 AM\\n Creatinine:\\n 0.7 mg/dL\\n 03:27 AM\\n Glucose:\\n 94 mg/dL\\n 03:27 AM\\n Hematocrit:\\n 38.0 %\\n 03:27 AM\\n Finger Stick Glucose:\\n 147\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417743,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n PMHx:\\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\\n abuse, h/o illicit drug use\\n Current medications:\\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\\n Acid 8. Furosemide\\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\\n Lorazepam 15. Metoprolol Tartrate\\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\\n Ondansetron 20. Phenytoin 21. Potassium Chloride\\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\\n Sodium Chloride 0.9% Flush\\n 26. Thiamine\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 09:48 AM\\n Post operative day:\\n POD#4 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:19 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 07:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.7\\nC (99.8\\n HR: 110 (94 - 125) bpm\\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\\n RR: 19 (18 - 26) insp/min\\n SPO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 67.6 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 2,758 mL\\n 686 mL\\n PO:\\n Tube feeding:\\n 1,218 mL\\n 647 mL\\n IV Fluid:\\n 1,059 mL\\n 39 mL\\n Blood products:\\n Total out:\\n 3,148 mL\\n 275 mL\\n Urine:\\n 3,148 mL\\n 275 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -390 mL\\n 411 mL\\n Respiratory support\\n SPO2: 96%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent)\\n Right Extremities: (Edema: Absent)\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\\n No movement), (LLE: No movement)\\n Labs / Radiology\\n 266 K/uL\\n 14.4 g/dL\\n 142 mg/dL\\n 0.9 mg/dL\\n 27 mEq/L\\n 3.6 mEq/L\\n 18 mg/dL\\n 101 mEq/L\\n 138 mEq/L\\n 39.4 %\\n 12.9 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n 06:00 AM\\n 03:27 AM\\n 03:31 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n 16.5\\n 12.9\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n 38.0\\n 39.4\\n Plt\\n 20\\n 266\\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.9\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n 118\\n 94\\n 142\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\\n hemorrhage, now s/p R craniotomy, evac \\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\\n controlled\\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\\n Pulmonary: cont pulm toilet\\n Gastrointestinal / Abdomen:\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO\\n Hematology: Serial Hct, stable\\n Endocrine: RISS\\n Infectious Disease: stable\\n Lines / Tubes / Drains: Foley, Dobhoff\\n Wounds: Dry dressings\\n Imaging:\\n Fluids: KVO\\n Consults: Neurology\\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale, Comments: stable\\n Lines:\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417745,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n PMHx:\\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\\n abuse, h/o illicit drug use\\n Current medications:\\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\\n Acid 8. Furosemide\\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\\n Lorazepam 15. Metoprolol Tartrate\\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\\n Ondansetron 20. Phenytoin 21. Potassium Chloride\\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\\n Sodium Chloride 0.9% Flush\\n 26. Thiamine\\n 24 Hour Events:\\n ARTERIAL LINE - STOP 09:48 AM\\n Post operative day:\\n POD#4 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:19 PM\\n Heparin Sodium (Prophylaxis) - 04:00 AM\\n Other medications:\\n Flowsheet Data as of 07:56 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.1\\nC (100.6\\n T current: 37.7\\nC (99.8\\n HR: 110 (94 - 125) bpm\\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\\n RR: 19 (18 - 26) insp/min\\n SPO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 67.6 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 2,758 mL\\n 686 mL\\n PO:\\n Tube feeding:\\n 1,218 mL\\n 647 mL\\n IV Fluid:\\n 1,059 mL\\n 39 mL\\n Blood products:\\n Total out:\\n 3,148 mL\\n 275 mL\\n Urine:\\n 3,148 mL\\n 275 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -390 mL\\n 411 mL\\n Respiratory support\\n SPO2: 96%\\n ABG: ///27/\\n Physical Examination\\n General Appearance: No acute distress\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft\\n Left Extremities: (Edema: Absent)\\n Right Extremities: (Edema: Absent)\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\\n No movement), (LLE: No movement)\\n Labs / Radiology\\n 266 K/uL\\n 14.4 g/dL\\n 142 mg/dL\\n 0.9 mg/dL\\n 27 mEq/L\\n 3.6 mEq/L\\n 18 mg/dL\\n 101 mEq/L\\n 138 mEq/L\\n 39.4 %\\n 12.9 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n 06:00 AM\\n 03:27 AM\\n 03:31 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n 16.5\\n 12.9\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n 38.0\\n 39.4\\n Plt\\n 20\\n 266\\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n 0.9\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n 118\\n 94\\n 142\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\\n hemorrhage, now s/p R craniotomy, evac \\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\\n controlled\\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\\n Pulmonary: cont pulm toilet\\n Gastrointestinal / Abdomen:\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO\\n Hematology: Serial Hct, stable\\n Endocrine: RISS\\n Infectious Disease: stable\\n Lines / Tubes / Drains: Foley, Dobhoff\\n Wounds: Dry dressings\\n Imaging:\\n Fluids: KVO\\n Consults: Neurology\\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\\n Glycemic Control: Regular insulin sliding scale, Comments: stable\\n Lines:\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417634,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Remains on ativan atc. Tachy at times and occ attempting to pull at\\n lines, otherwise no s/s withdrawal noted.\\n Action:\\n Ativan atc, but dose decreased\\n Response:\\n No need for prn ativan and no s/s withdrawal noted\\n Plan:\\n Con\\nt to monitor. Ativan atc and prn.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Opens eyes to stim . right pupil round and reactive. Left pupil at\\n baseline. Follows commands on right. Moves right spont. No spont\\n movement on left. Withdraws on left to pain. Oriented to person and\\n president and month at times. Only says few words and speech grarbled.\\n Action:\\n Neuro checks.\\n Response:\\n Neuro status unchanged.\\n Plan:\\n Con\\nt neuro checks\\n To tx to SDU when bed avail.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 416935,\n \"text\": \"Chief Complaint: left leg weakness\\n HPI:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\\n untreated HTN presented to OSH with change in gait on left side after\\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\\n left sided numbness, and left facial droop. CT @ OSH --> right BG\\n hemorrhage 3cm, transferred to for further care. On transfer EMS\\n noted pt has \\\"worsening symptoms\\\" from the initial transport to OSH\\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Labetalol - 2 mg/min\\n Other ICU medications:\\n Diazepam (Valium) - 01:13 AM\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n HTN untreated, alcohol abuse, tobacco use, remote left eye penetrating\\n injury\\n Occupation: unemployed\\n Drugs:\\n Tobacco: +\\n Alcohol: admits to alcohol abuse, last drink @ 1pm, avg 6\\n drinks/day\\n Other:\\n Review of systems:\\n Eyes: hx left eye injury, impaired vision\\n Neurologic: Numbness / tingling, Headache\\n Psychiatric / Sleep: Agitated\\n Flowsheet Data as of 03:32 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: 35.6\\nC (96.1\\n HR: 80 (78 - 117) bpm\\n BP: 123/94(100) {90/68(69) - 162/106(120)} mmHg\\n RR: 18 (15 - 24) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 120 mL\\n 135 mL\\n PO:\\n TF:\\n IVF:\\n 120 mL\\n 135 mL\\n Blood products:\\n Total out:\\n 800 mL\\n 0 mL\\n Urine:\\n 800 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -680 mL\\n 135 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Well nourished, Anxious\\n Eyes / Conjunctiva: right pupil reactive, left surgical pupil\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\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, Oriented (to): person,\\n place. Motor 0/5 left side, right side. Sensory\\n light touch,\\n decreased on left.\\n Labs / Radiology\\n head CT:\\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\\n with\\n mild mass effect but no midline shift, presumed to be Htn induced.\\n [image002.jpg]\\n Assessment and Plan\\n ASSESSMENT/PLAN:\\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\\n hemorrhage, with left leg weakness, left neglect (unable to sense left\\n arm without guidance of RUE), and LUE numbness.\\n NEURO: neuro check q1hr; neurosurgery consult appreciated and to\\n follow; MRI/MRA pending; STAT head CT for acute mental changes. Tylenol\\n for HA per primary service. HOB >30 degrees.\\n CV: Maintain SB 140-160, MAP <130.\\n Pulm/Endo/Heme/Renal/ID: no issues\\n GI/ABD/FEN: NPO until S/S eval\\n ICU Care\\n Nutrition:\\n Comments: NPO except meds until S/S eval\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 06:45 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417048,\n \"text\": \"Subarachnoid hemorrhage (SAH)\\n Assessment:\\n c/o constant R sided HA upon initial exam, +tremors/sweats-\\n please see metavision for neuron and CIWA assessment. Initially, pt\\n able to verbally communicate w/ slurred speech and follow\\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\\n BP 166/110, dramatic decrease in mental responsiveness- only\\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\\n position changes.\\n Action:\\n TSICU and Neuro teams notified immediately of above and in to assess\\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\\n reassess bleed- revealed increased bleed with NEW midline shift.\\n Discussion re: elective intubation for airway protection between\\n physicians- decided to wait temporarily. 50mg IV mannitol given at\\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\\n positioned at midline.\\n Response:\\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\\n mannitol.\\n Plan:\\n Emergently to OR at 15:00 for likely ventriculostomy.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\\n Last drink prior to admission. ETOH 143 in ED.\\n Action:\\n Given 2.5mg valium x 2.\\n Response:\\n Temporary decrease in symptoms.\\n Plan:\\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\\n ordered. Addictions consult.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417049,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\\n at 15:00.\\n Right Basal Ganglia Hemorrhage\\n Assessment:\\n c/o constant R sided HA upon initial exam, +tremors/sweats-\\n please see metavision for neuron and CIWA assessment. Initially, pt\\n able to verbally communicate w/ slurred speech and follow\\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\\n BP 166/110, dramatic decrease in mental responsiveness- only\\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\\n position changes.\\n Action:\\n TSICU and Neuro teams notified immediately of above and in to assess\\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\\n reassess bleed- revealed increased bleed with NEW midline shift.\\n Discussion re: elective intubation for airway protection between\\n physicians- decided to wait temporarily. 50mg IV mannitol given at\\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\\n positioned at midline.\\n Response:\\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\\n mannitol.\\n Plan:\\n Emergently to OR at 15:00 for likely ventriculostomy.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\\n Last drink prior to admission. ETOH 143 in ED.\\n Action:\\n Given 2.5mg valium x 2.\\n Response:\\n Temporary decrease in symptoms.\\n Plan:\\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\\n ordered. Addictions consult.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-28 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417802,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Pt slightly hypertensive in 140s; tachycardic to 120s\\n Action:\\n Administered metoprolol\\n Response:\\n Patient tolerated dose, heart to 90s and BP 120s/80s\\n Plan:\\n Continue beta blockade, hydral PRN\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n At times patient appeared restless, diaphoretic though afebrile,\\n tachycardic\\n Action:\\n Ativan, attempted to reduce stimuli in room\\n Response:\\n Patient settled; less diaphoretic, less restless\\n Plan:\\n Continue to monitor, administer ativan\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417012,\n \"text\": \"TSICU\\n HPI:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\\n untreated HTN presented to OSH with change in gait on left side after\\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\\n left sided numbness, and left facial droop. CT @ OSH --> right BG\\n hemorrhage 3cm, transferred to for further care. On transfer EMS\\n noted pt has \\\"worsening symptoms\\\" from the initial transport to OSH\\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n Chief complaint:\\n CC: left sided weakness\\n ISSUES:\\n 1. Intracranial hemorrhage with left sided plegia/paresthesia.\\n 2. HTN.\\n 3. EtOH abuse\\n PMHx:\\n Current medications:\\n 24 Hour Events:\\n - labetalol gtt started in evening for SBP>160, goal per neuro\\n MAP<130, SBP 140s-160s. Await MRI/MRA. Increased valium dose for\\n tremors.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 08:00 AM\\n Diazepam (Valium) - 08:50 AM\\n Other medications:\\n Flowsheet Data as of 11:06 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: 36.3\\nC (97.3\\n HR: 85 (78 - 117) bpm\\n BP: 137/89(102) {90/68(69) - 162/106(120)} mmHg\\n RR: 20 (15 - 24) insp/min\\n SPO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 120 mL\\n 346 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 120 mL\\n 346 mL\\n Blood products:\\n Total out:\\n 800 mL\\n 270 mL\\n Urine:\\n 800 mL\\n 270 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -680 mL\\n 76 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SPO2: 97%\\n ABG: ///28/\\n Physical Examination\\n General Appearance: Somnolent\\n HEENT: Left pupil dilated, Right Pupil Equal and reactive\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\\n No(t) Weakness), (LUE: No movement), (RLE: No(t) Weakness), (LLE: No\\n movement)\\n Labs / Radiology\\n 231 K/uL\\n 15.2 g/dL\\n 134 mg/dL\\n 0.8 mg/dL\\n 28 mEq/L\\n 4.2 mEq/L\\n 9 mg/dL\\n 102 mEq/L\\n 141 mEq/L\\n 43.2 %\\n 9.7 K/uL\\n [image002.jpg]\\n 03:35 AM\\n WBC\\n 9.7\\n Hct\\n 43.2\\n Plt\\n 231\\n Creatinine\\n 0.8\\n Glucose\\n 134\\n Other labs: PT / PTT / INR:13.2/30.9/1.1, Ca:9.2 mg/dL, Mg:2.2 mg/dL,\\n PO4:3.3 mg/dL\\n Imaging: head CT:\\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\\n with\\n mild mass effect but no midline shift, presumed to be Htn induced.\\n Assessment and Plan\\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\\n hemorrhage.\\n Assessment and Plan:\\n Neurologic: Neuro checks Q: 1 hr, f/u Head CT\\n Cardiovascular: Labetalol gtt for SBP < 160 & MAP < 130 (PER PRIMARY\\n TEAM REC'S) --> will clarify these goals after f/u head ct. Will need\\n a-line.\\n Pulmonary: need intubated.\\n Gastrointestinal / Abdomen: Will need S&S eval --> will most likely\\n need dobhoff and TF\\n Nutrition: NPO\\n Renal: Foley, Adequate UO\\n Hematology: No issues\\n Endocrine: RISS\\n Infectious Disease: No issues\\n Lines / Tubes / Drains: Foley, PIV; For a-line.\\n Wounds: none\\n Imaging: CT scan head today\\n Fluids: KVO\\n Consults: Neuro surgery, Neurology\\n Billing Diagnosis: (Hemorrhage, NOS), CVA\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 06:45 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Needs ICU consent\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 35 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 417129,\n \"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 Known difficult intubation: No\\n Procedure location: OR\\n Reason: Intubated for procedure\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route: Oral\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Small\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing;\\n Comments: Plan to switch to CPAP/PS and extubate this AM.\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Invasive ventilation assessment:\\n Trigger work assessment: Not triggering\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\\n Comments: Plan for extubation today. RSBI completed on PS 5=28.\\n Reason for continuing current ventilatory support:\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 417253,\n \"text\": \"Subjective: Pt just extubated.\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 175 cm\\n 70.5 kg\\n 68.1 kg ( 12:00 AM)\\n 22.9\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 72.6 kg\\n 97%\\n Diagnosis: ICH\\n PMH : poorly controlled HTN, ETOH abuse (12-18 beers/day), +tobacco,\\n remote R eye injury c/ screw driver\\n Food allergies and intolerances: NKFA\\n Pertinent medications: Famotidine, Abx, Colace, Senna, Bisacodyl, HISS,\\n NS c/ Thiamine, Folic Acid & Mvit, others noted\\n Labs:\\n Value\\n Date\\n Glucose\\n 168 mg/dL\\n 02:24 AM\\n Glucose Finger Stick\\n 167\\n 10:00 AM\\n BUN\\n 9 mg/dL\\n 02:24 AM\\n Creatinine\\n 1.0 mg/dL\\n 02:24 AM\\n Sodium\\n 142 mEq/L\\n 02:24 AM\\n Potassium\\n 3.2 mEq/L\\n 01:37 PM\\n Chloride\\n 105 mEq/L\\n 02:24 AM\\n Albumin\\n 4.0 g/dL\\n 02:24 AM\\n Calcium non-ionized\\n 9.4 mg/dL\\n 02:24 AM\\n Phosphorus\\n 3.7 mg/dL\\n 02:24 AM\\n Ionized Calcium\\n 1.09 mmol/L\\n 01:37 PM\\n Magnesium\\n 2.1 mg/dL\\n 02:24 AM\\n Current diet order / nutrition support: NPO\\n GI: Soft, +BS\\n Assessment of Nutritional Status\\n At risk for malnutrition\\n Pt at risk due to: chronic ETOH abuse, possible permanent AMS head\\n bleed\\n Estimated Nutritional Needs\\n Calories: 1760-2115 (BEE x or / 25-30 cal/kg)\\n Protein: 84-99 (1.2-1.4 g/kg)\\n Fluid: team\\n Estimation of previous intake: unknown, possibly inadequate\\n Estimation of current intake: Inadequate\\n Specifics: 44 y.o. M adm with R basal ganglia hemorrhage, POD #1 of\\n crani & hematoma evacuation. Pt recently extubated and remains\\n agitated and confused. If pt unable to take po\\ns in the next 2-3days,\\n rec place feeding tube for start of enteral nutrition. Will use admit\\n wt for feeding wt. Noted K is low.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1) If pt\\ns MS doesn\\nt clear, rec evaluation by SLP.\\n 2) If pt unsafe for po\\ns, rec place FT and start TF with goal of\\n Fibersource @ 65cc/hr (1872kcals, 84g protein).\\n 3) Multivitamin / Mineral supplement: Mvit, 100mg Thiamine & 1mg\\n Folic Acid given daily\\n 4) Check chemistry 10 panel daily, relplete lytes as needed (namely\\n K).\\n Please page if ?\\ns \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416960,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\\n +family history,. Father also alcoholic When admitted to OSH ETOH level\\n 145. Pt still with strong smell of alcohol on breath admits to \\n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\\n through out the night, trying to get OOB, at times completely drenched\\n with new tremors noted at 0300. Neuro med resident called. Pt\\n required constant bedside safety observations. Pt is also heavy smoker\\n 1-1.5 packs a day for 25years.\\n Action:\\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\\n right upper arm.\\n Response:\\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\\n restless.\\n Plan:\\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\\n q4hrs. Remove nicotine patch before MRI.\\n Right basal ganglia hemorrhage\\n Assessment:\\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\\n and quickly weaned off. Every 1hr neuro checks remain stable without\\n much change. Pt does not suffer from neglect has he frequently rubs his\\n left arm and tries to straighten his left hand. c/o right sided\\n headache frequently rubbing right side of head. As stated\\n above pt a developed lower leg tremor when awake lasting 10-20seconds\\n then legs relax. Intermittent periods of clear speech and able to pick\\n up left leg 3 inches off bed then fell back. MRI check sheet filled\\n out and faxed to MRI.\\n Action:\\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\\n dose. Did not receive because had received valium recently. Received\\n Tylenol 650mg PR .\\n Response:\\n Headache is somewhat improved per patient.\\n Plan:\\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\\n infusion for SBP >160 or MAP >130\\n Scheduled for MRI today. Remove nicotine patch before scan. One time\\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\\n IVB right before scan.\\n Continue to keep pt and family aware of POC as discussed in multi\\n disciplinary rounds.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416961,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\\n +family history,. Father also alcoholic When admitted to OSH ETOH level\\n 145. Pt still with strong smell of alcohol on breath admits to \\n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\\n through out the night, trying to get OOB, at times completely drenched\\n with new tremors noted at 0300. Neuro med resident called. Pt\\n required constant bedside safety observations. Pt is also heavy smoker\\n 1-1.5 packs a day for 25years.\\n Action:\\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\\n right upper arm.\\n Response:\\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\\n restless.\\n Plan:\\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\\n q4hrs. Remove nicotine patch before MRI.\\n Right basal ganglia hemorrhage\\n Assessment:\\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\\n and quickly weaned off. Every 1hr neuro checks remain stable without\\n much change. Pt does not suffer from neglect has he frequently rubs his\\n left arm and tries to straighten his left hand. c/o right sided\\n headache frequently rubbing right side of head. As stated\\n above pt a developed lower leg tremor when awake lasting 10-20seconds\\n then legs relax. Intermittent periods of clear speech and able to pick\\n up left leg 3 inches off bed then fell back. MRI check sheet filled\\n out and faxed to MRI.\\n Action:\\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\\n dose. Did not receive because had received valium recently. Received\\n Tylenol 650mg PR .\\n Response:\\n Headache is somewhat improved per patient.\\n Plan:\\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\\n infusion for SBP >160 or MAP >130\\n Scheduled for MRI today. Remove nicotine patch before scan. One time\\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\\n IVB right before scan.\\n Continue to keep pt and family aware of POC as discussed in multi\\n disciplinary rounds.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417294,\n \"text\": \"Subarachnoid hemorrhage (SAH)\\n Assessment:\\n - pt off sedation\\n - arousable to voice but rarely opens eyes. Shows effort by\\n raising eyebrows but eyes are swollen\\n - R pupil 3mm and reactive, L eye dilated and unreactive due\\n to traumatic injury with screwdriver in the past.\\n - lifts and holds , squeeze hand when asked\\n - wiggles toes and moves RLE on bed\\n - no movement of LUE, does not respond to nail bed stimuli\\n - will withdraw LLE to pain\\n - dry sterile dressing on R side of head post craniotomy \\n not yet removed\\n - will cough with turning and stimulation, and secretions\\n suctioned out\\n - on nicardipine gtt sbp paramters <140\\n - on fentanyl and versed\\n - K 3.2\\n - Ionized Ca 0.94\\n Action:\\n - cool tea bags applied over R eye\\n - q1h neuro checks\\n - turn and reposition to stimulate cough\\n - Dilantin to prevent sz\\n - Fentanyl, and versed gtts off\\n - Morphine 2-4mg prn\\n - Nicardipine gtt off spb parameter changed from <140 to <160\\n - NS with 40meq KCL at 85ml/hr initiated\\n - Keep HOB>30\\n - Calcium gluconate 2gm given\\n Response:\\n - swelling of R eye reduced\\n - unchanged neuro status\\n - cough stimulated with turning\\n - no sz activity noted\\n - pt more arousable\\n - pain adequately controlled assessed by changes in vital\\n signs\\n - sbps 135-153\\n - awaiting K level\\n - Ionized ca 1.09\\n -\\n Plan:\\n - continue using cool tea bags to reduce swelling\\n - q1h neuro checks\\n - turn and reposition with chest pt frequently\\n - continue antiseizure therapy\\n - treat pain adequately with prn morphine\\n - lopressor 10mg q4h\\n - monitor sbps with parameter <160\\n - monitor and treat hypokalemia and hypocalcemia\\n - keep HOB >30\\n -\\n Respiratory (intubated in OR)\\n Assessment:\\n - On CMV adequate ABG levels\\n - SPO2 98-100%\\n - Minimal secretions\\n Action:\\n - Changed to CPAP, Spontaneous breathing trial, followed by\\n Extubation at 1100\\n - 3L nasal cannula\\n Response:\\n - ABG levels within normal limits\\n - SPO2 98-100%\\n - Lungs sound rhonchorous\\n - Normal and regular respiratory pattern\\n Plan:\\n - Nasal cannula at 3L\\n - Chest pt\\n - Turn and reposition frequently\\n - Encourage pt to cough and suction out secretions when\\n necessary\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n - hx smoking\\n - alcoholism; takes 12-18 beers/day\\n - level elevated on admission to OSH\\n Action:\\n - monitored for s/s of DTs\\n - banana bag given\\n - nicotine patch on R arm\\n Response:\\n - no sz or tremors, or other signs of DTs noted\\n - unable to fully assess for CIWA scale due to neurological\\n deficits\\n Plan:\\n - continue to monitor and assess for s/s of DTs\\n - continue with nicotine patch\\n - assess swallow/gag and start feeding either PO or NG if\\n failure to pass swallow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417417,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417418,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Demographics\\n Attending MD:\\n Admit diagnosis:\\n Code status:\\n Height:\\n Admission weight:\\n Daily weight:\\n Allergies/Reactions:\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history:\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:\\n D:\\n Temperature:\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n Heart Rate:\\n Heart rhythm:\\n O2 delivery device:\\n O2 saturation:\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 24h total out:\\n Pacer Data\\n Pertinent Lab Results:\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes:\\n Wallet / Money:\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from:\\n Transferred to:\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417371,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n BG hemorrhage\\n PMHx:\\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\\n abuse, h/o illicit drug use\\n Current medications:\\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\\n Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\\n Morphine Sulfate 16. Nicotine Patch\\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n EXTUBATION - At 11:10 AM\\n INVASIVE VENTILATION - STOP 11:10 AM\\n intubated in OR\\n Post operative day:\\n POD#2 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Famotidine (Pepcid) - 08:01 PM\\n Morphine Sulfate - 01:00 AM\\n Hydralazine - 02:20 AM\\n Insulin - Humalog - 02:30 AM\\n Lorazepam (Ativan) - 03:09 AM\\n Metoprolol - 04:03 AM\\n Other medications:\\n Flowsheet Data as of 06:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.8\\n T current: 37.5\\nC (99.5\\n HR: 98 (78 - 104) bpm\\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\\n RR: 19 (13 - 23) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.1 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 3,000 mL\\n 555 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,000 mL\\n 555 mL\\n Blood products:\\n Total out:\\n 2,115 mL\\n 765 mL\\n Urine:\\n 2,115 mL\\n 765 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 885 mL\\n -207 mL\\n Respiratory support\\n O2 Delivery Device: None\\n Ventilator mode: Standby\\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\\n PC : 0 cmH2O\\n PS : 5 cmH2O\\n RR (Spontaneous): 0\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 0 cmH2O\\n SPO2: 98%\\n ABG: 7.45/35/81./25/0\\n Ve: 9.3 L/min\\n PaO2 / FiO2: 205\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular), tachy\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\\n Weakness, No movement), (LLE: Weakness, No movement)\\n Labs / Radiology\\n 198 K/uL\\n 13.1 g/dL\\n 135 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.4 mEq/L\\n 5 mg/dL\\n 101 mEq/L\\n 136 mEq/L\\n 36.1 %\\n 16.2 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n Plt\\n \\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\\n Assessment and Plan\\n Assessment and Plan:\\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\\n pain\\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\\n ?withdrawl- 1 q6 ativan, will start PO metoprolol 50 tid\\n Pulmonary: chest pt\\n Gastrointestinal / Abdomen:\\n Nutrition: dobhoff and will start tube feeding, thiamine/folate, banana\\n bag\\n Renal: Foley, Adequate UO\\n Hematology:\\n Endocrine: RISS\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley\\n Wounds:\\n Imaging:\\n Fluids: NS, start tube feeds\\n Consults:\\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417287,\n \"text\": \"Subarachnoid hemorrhage (SAH)\\n Assessment:\\n - pt off sedation\\n - arousable to voice but rarely opens eyes. Shows effort by\\n raising eyebrows but eyes are swollen\\n - R pupil 3mm and reactive, L eye dilated and unreactive due\\n to traumatic injury with screwdriver in the past.\\n - lifts and holds , squeeze hand when asked\\n - wiggles toes and moves RLE on bed\\n - no movement of LUE, does not respond to nail bed stimuli\\n - will withdraw LLE to pain\\n - dry sterile dressing on R side of head post craniotomy \\n not yet removed\\n - will cough with turning and stimulation, and secretions\\n suctioned out\\n - on nicardipine gtt sbp paramters <140\\n - on fentanyl and versed\\n - K 3.2\\n - Ionized Ca 0.94\\n Action:\\n - cool tea bags applied over R eye\\n - q1h neuro checks\\n - turn and reposition to stimulate cough\\n - Dilantin to prevent sz\\n - Fentanyl, and versed gtts off\\n - Morphine 2-4mg prn\\n - Nicardipine gtt off spb parameter changed from <140 to <160\\n - NS with 40meq KCL at 85ml/hr initiated\\n - Keep HOB>30\\n - Calcium gluconate 2gm given\\n Response:\\n - swelling of R eye reduced\\n - unchanged neuro status\\n - cough stimulated with turning\\n - no sz activity noted\\n - pt more arousable\\n - pain adequately controlled assessed by changes in vital\\n signs\\n - sbps 135-153\\n - awaiting K level\\n - Ionized ca 1.09\\n -\\n Plan:\\n - continue using cool tea bags to reduce swelling\\n - q1h neuro checks\\n - turn and reposition with chest pt frequently\\n - continue antiseizure therapy\\n - treat pain adequately with prn morphine\\n - lopressor 10mg q4h\\n - monitor sbps with parameter <160\\n - monitor and treat hypokalemia and hypocalcemia\\n - keep HOB >30\\n -\\n Respiratory (intubated in OR)\\n Assessment:\\n - On CMV adequate ABG levels\\n - SPO2 98-100%\\n - Minimal secretions\\n Action:\\n - Changed to CPAP, Spontaneous breathing trial, followed by\\n Extubation at 1100\\n - 3L nasal cannula\\n Response:\\n - ABG levels within normal limits\\n - SPO2 98-100%\\n - Lungs sound rhonchorous\\n - Normal and regular respiratory pattern\\n Plan:\\n - Nasal cannula at 3L\\n - Chest pt\\n - Turn and reposition frequently\\n - Encourage pt to cough and suction out secretions when\\n necessary\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n - hx smoking\\n - alcoholism; takes 12-18 beers/day\\n - level elevated on admission to OSH\\n Action:\\n - monitored for s/s of DTs\\n - banana bag given\\n - nicotine patch on R arm\\n Response:\\n - no sz or tremors, or other signs of DTs noted\\n - unable to fully assess for CIWA scale due to neurological\\n deficits\\n Plan:\\n - continue to monitor and assess for s/s of DTs\\n - continue with nicotine patch\\n - assess swallow/gag and start feeding either PO or NG if\\n failure to pass swallow\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417369,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n BG hemorrhage\\n PMHx:\\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\\n abuse, h/o illicit drug use\\n Current medications:\\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\\n Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\\n Morphine Sulfate 16. Nicotine Patch\\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n EXTUBATION - At 11:10 AM\\n INVASIVE VENTILATION - STOP 11:10 AM\\n intubated in OR\\n Post operative day:\\n POD#2 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 08:00 AM\\n Famotidine (Pepcid) - 08:01 PM\\n Morphine Sulfate - 01:00 AM\\n Hydralazine - 02:20 AM\\n Insulin - Humalog - 02:30 AM\\n Lorazepam (Ativan) - 03:09 AM\\n Metoprolol - 04:03 AM\\n Other medications:\\n Flowsheet Data as of 06:22 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.7\\nC (99.8\\n T current: 37.5\\nC (99.5\\n HR: 98 (78 - 104) bpm\\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\\n RR: 19 (13 - 23) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 68.1 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 3,000 mL\\n 555 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,000 mL\\n 555 mL\\n Blood products:\\n Total out:\\n 2,115 mL\\n 765 mL\\n Urine:\\n 2,115 mL\\n 765 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 885 mL\\n -207 mL\\n Respiratory support\\n O2 Delivery Device: None\\n Ventilator mode: Standby\\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\\n PC : 0 cmH2O\\n PS : 5 cmH2O\\n RR (Spontaneous): 0\\n PEEP: 0 cmH2O\\n FiO2: 35%\\n PIP: 0 cmH2O\\n SPO2: 98%\\n ABG: 7.45/35/81./25/0\\n Ve: 9.3 L/min\\n PaO2 / FiO2: 205\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular), tachy\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft\\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\\n Weakness, No movement), (LLE: Weakness, No movement)\\n Labs / Radiology\\n 198 K/uL\\n 13.1 g/dL\\n 135 mg/dL\\n 0.7 mg/dL\\n 25 mEq/L\\n 3.4 mEq/L\\n 5 mg/dL\\n 101 mEq/L\\n 136 mEq/L\\n 36.1 %\\n 16.2 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n Plt\\n \\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\\n Assessment and Plan\\n Assessment and Plan:\\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\\n pain\\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\\n ?withdrawel 1 q6 ativan, will start PO metoprolol 50 tid\\n Pulmonary: chest pt\\n Gastrointestinal / Abdomen:\\n Nutrition: dobhoff and will start tube feeding, thiamine/folate bannana\\n bag\\n Renal: Foley, Adequate UO\\n Hematology:\\n Endocrine: RISS\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley\\n Wounds:\\n Imaging:\\n Fluids: NS, d/c nml saline start tube feeds\\n Consults:\\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Patient discussed on interdisciplinary rounds Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 417534,\n \"text\": \"SICU\\n HPI:\\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\\n craniotomy, evac \\n Chief complaint:\\n BG hemorrhage\\n PMHx:\\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\\n ETOH abuse, h/o illicit drug use\\n : none\\n .\\n Current medications:\\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\\n Bisacodyl 6. Calcium Gluconate\\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\\n Famotidine 10. FoLIC Acid 11. Heparin\\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\\n 17. Metoprolol Tartrate\\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\\n Ondansetron 22. Phenytoin 23. Potassium Chloride\\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\\n 27. Thiamine\\n 24 Hour Events:\\n TF placed and tF started yesterday\\n Post operative day:\\n POD#3 - S/P right crani\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Vancomycin - 09:00 AM\\n Gentamicin - 12:34 PM\\n Infusions:\\n Other ICU medications:\\n Morphine Sulfate - 06:41 AM\\n Lorazepam (Ativan) - 06:00 PM\\n Famotidine (Pepcid) - 08:13 PM\\n Heparin Sodium (Prophylaxis) - 08:15 PM\\n Hydralazine - 02:14 AM\\n Metoprolol - 06:18 AM\\n Other medications:\\n Flowsheet Data as of 06:35 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 38.2\\nC (100.7\\n T current: 38.1\\nC (100.5\\n HR: 119 (86 - 119) bpm\\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\\n RR: 18 (9 - 25) insp/min\\n SPO2: 96%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 67.6 kg (admission): 70.5 kg\\n Height: 69 Inch\\n Total In:\\n 2,828 mL\\n 776 mL\\n PO:\\n Tube feeding:\\n 190 mL\\n 129 mL\\n IV Fluid:\\n 2,518 mL\\n 647 mL\\n Blood products:\\n Total out:\\n 2,735 mL\\n 700 mL\\n Urine:\\n 2,735 mL\\n 700 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 93 mL\\n 76 mL\\n Respiratory support\\n SPO2: 96%\\n ABG: ///23/\\n Physical Examination\\n General Appearance: No acute distress\\n HEENT: PERRL\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\\n Labs / Radiology\\n 220 K/uL\\n 13.6 g/dL\\n 94 mg/dL\\n 0.7 mg/dL\\n 23 mEq/L\\n 3.4 mEq/L\\n 8 mg/dL\\n 103 mEq/L\\n 138 mEq/L\\n 38.0 %\\n 16.5 K/uL\\n [image002.jpg]\\n 03:35 AM\\n 03:40 PM\\n 02:24 AM\\n 02:33 AM\\n 09:48 AM\\n 01:37 PM\\n 02:44 AM\\n 06:00 AM\\n 03:27 AM\\n WBC\\n 9.7\\n 18.7\\n 16.2\\n 16.5\\n Hct\\n 43.2\\n 37.6\\n 36.1\\n 38.0\\n Plt\\n 20\\n Creatinine\\n 0.8\\n 1.0\\n 0.7\\n 0.7\\n TCO2\\n 26\\n 28\\n 22\\n 25\\n Glucose\\n 134\\n 146\\n 168\\n 135\\n 118\\n 94\\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\\n Assessment and Plan\\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\\n hemorrhage, now s/p R craniotomy, evac \\n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\\n to PO\\n Cardiovascular: Lopressor 75 TID PO\\n HYDRALAZYN prn\\n Pulmonary: Stable\\n Gastrointestinal / Abdomen: Adnance to goal\\n Nutrition: Tube feeding\\n Renal: Foley, Adequate UO, Lasix 20mg \\n Hematology: Stable\\n Endocrine:\\n Infectious Disease:\\n Lines / Tubes / Drains: Foley\\n Wounds:\\n Imaging:\\n Fluids:\\n Consults: Nephrology\\n Billing Diagnosis: Other: Basal ganglia Bleed\\n ICU Care\\n Nutrition:\\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\\n Glycemic Control:\\n Lines:\\n Arterial Line - 03:30 PM\\n 14 Gauge - 06:00 PM\\n 18 Gauge - 12:15 PM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416951,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Hourly CIWA scale 17-27\\n Action:\\n Response:\\n Plan:\\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416945,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416946,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417343,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt continues with ciwa scale. Pt more restless pulling off gown and\\n pulling at foley and taking off oxygen. Neuro exam is unchanged hr up\\n to 106 and sbp 160\\ns/80\\n Action:\\n Ativan .5mg iv x2 for total of 1mg. pt less restless and sbp down to\\n 158/70.\\n Response:\\n Pt less restless after Ativan.\\n Plan:\\n Continue with neuro checks and ciwa scale. Assess for Ativan as\\n needed.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Neuro exam is unchanged. Pt follows commands on right side. Withdrawal\\n on left foot, none on left arm. Right pupil is reactive to light. Rt\\n eye is swollen. Pt opens eyes to name. Speech very soft and slightly\\n garbled. Goal sbp less than 160. lopressor increased to 20mg q4 and\\n hydralazine prn, given x2. Dr. aware of sbp greater than 160.\\n does not want to restart nicardipine and increased lopressor.\\n Action:\\n Lopressor increased to 20mg. hydralazine prn. Continue with q1 neuro\\n checks, ? repeat ct today.\\n Response:\\n Neuro is unchanged. Pt restless at times but responded to ativan\\n Plan:\\n Continue with neuro exam. Treat bp as needed. Continue with ciwa scale.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417346,\n \"text\": \".H/O respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt extubated today. Pt resp rate 16-20. o2 sat on room air 98%. Breath\\n sounds are clear and diminished in the bases. Pt coughing and\\n swallowing.\\n Action:\\n Encourage pt to cough and deep breath.\\n Response:\\n Doing well extubated.\\n Plan:\\n Continue to cough and deep breathe. Frequent position changes.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417147,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt responds to name and stimulation with jerking movements, attempts\\n to sit up, and tremulous motion of right side, less motion on left\\n side. Pt does not nod or shake head to communicate, so assessment of\\n hallucinations, pain, etc is difficult.\\n Action:\\n Midazolam and fentanyl drips started and titrated up as needed to\\n control tremulous movement\\n Response:\\n Tremors are quieter, although still existent with medications at higher\\n dosage. Midaz returned to 2 mg/hr from 4 mg/hr when he became more\\n difficult to arouse. He is now arousable but with fewer tremors than\\n before midazolam and fentanyl were started.\\n Plan:\\n Titrate drips as needed, monitor for increase tremors, seizures,\\n increase in heart rate and bp.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Pt post op evacuation of SDH. Head dressing is dry and intact. Pt\\n arouses to name, as above, follows commands with right side, but does\\n not nod or shake his head when asked to do so. He is intubated on CMV ,\\n sx for thick yellow secretios Right pupil is and reacts briskly.\\n Left pupil is damaged from a screwdriver injury. Pt is sedated for\\n onset of DT\\ns, and responding more slowly with midazolam and fentanyl\\n on.\\n Action:\\n Midazolam decreased to 2 mg when pt very slow to respond to name and\\n stimulation\\n Response:\\n Pt responding again when name called.\\n Plan:\\n Continue with q 1 hour neuro checks to evaluate neuro status\\n complicated by alcohol withdrawal.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417053,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\\n at 15:00.\\n Right Basal Ganglia Hemorrhage\\n Assessment:\\n c/o constant R sided HA upon initial exam, +tremors/sweats-\\n please see metavision for neuron and CIWA assessment. Initially, pt\\n able to verbally communicate w/ slurred speech and follow\\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\\n BP 166/110, dramatic decrease in mental responsiveness- only\\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\\n position changes.\\n Action:\\n TSICU and Neuro teams notified immediately of above and in to assess\\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\\n reassess bleed revealed increased bleed, cerebral edema, and NEW 1.3\\n cm midline shift to left. Discussion re: elective intubation for\\n airway protection between physicians- decided to wait temporarily.\\n 50mg IV mannitol given at 13:00 over 30minuntes to decrease ICP. HOB at\\n 30 degrees. Head positioned at midline.\\n Response:\\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\\n mannitol.\\n Plan:\\n Emergently to OR at 15:00 for likely ventriculostomy.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\\n Last drink prior to admission. ETOH 143 in ED.\\n Action:\\n Given 2.5mg valium x 2.\\n Response:\\n Temporary decrease in symptoms.\\n Plan:\\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\\n ordered. Addictions consult.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 417263,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 72.6 None\\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Not applicable\\n Size: Not applicable\\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: Rhonchi\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: /\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\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 CT\\n without incident\\n Bedside Procedures:\\n Comments:\\n Pt received intubated and vented on AC settings as charted. RSBI 28\\n today. Placed on PSV 5 peep 5 with TV 500 and RR 12-16. Pt transported\\n to CT scan and placed on SBT after transport. Pt extubated without\\n incident and is currently on 3L NP and stable from resp standpoint.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 417428,\n \"text\": \"TITLE:\\n Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain but otherwise sleeping most of day. Right pupil\\n reactive, round. Left pupil unreactive and odd shaped at baseline.\\n Moves right side purposefully and attempts to pull at tubes/lines.\\n Withdraws on left to pain. No spont movement on left. Said name once,\\n otherwise only groans occ. Follows commands on right inconsistently. No\\n sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417495,\n \"text\": \".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt has a known history of drinking > 8-12 beers/day. Brother states ?\\n more than 12 beers. Attempting to pull off bed clothes. Pt does not\\n focus on you when speaking to him.\\n Action:\\n Ativan 1 mg iv q6hrs. nictone patch as ordered.\\n Response:\\n Pt is less agitated after the ativan iv.\\n Plan:\\n Continue with ativan iv and prn. Monitor closely.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Neuro assessment done q2hrs. strong hand grasp on right side and moves\\n right leg off the bed. Withdraws to pain on left foot but no actual\\n movement in left arm. Withdraws slightly to painful stimuli. Speech is\\n garbled and pt very diffiulct to understand. Right pupil reactive to\\n light and left eye no reaction due to old eye injury. Bp at times >\\n 160. operative site on head intact with staples present and no drainage\\n noted.\\n Action:\\n Neuro signs q2hrs. ? head ct today. Incision inspected\\n Response:\\n No neuro changes\\n Plan:\\n Cont with neuro exam.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 417497,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Bp mostly > 160 shift\\n Action:\\n Lopresssor 50mg via tube given as ordered. Hydralazine 10mg iv given\\n linsopril 5mg via tube given as ordered.\\n Response:\\n Bp < 160 for short time after meds given but quickly returns to > 160.\\n Plan:\\n Monitor closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-27 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 417574,\n \"text\": \"Hypertension, benign\\n Assessment:\\n Sbp >160\\n Action:\\n Lopressor dose changed to po. Lisinopril started. Hydral given\\n Response:\\n Sbp now <160\\n Plan:\\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\\n neuro status.\\n Action:\\n Ativan atc.\\n Response:\\n No s/s DT at this time. get Ativan prn as well.\\n Plan:\\n Con\\nt Ativan atc and monitor for s/s withdrawal.\\n Subarachnoid hemorrhage (SAH)\\n Assessment:\\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\\n odd shaped at baseline. Moves right side purposefully and attempts to\\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\\n left. Said name once, otherwise only groans occ. Follows commands on\\n right inconsistently. No sz.\\n Action:\\n Freq neuro checks.\\n Response:\\n No neuro changes.\\n Plan:\\n Con\\nt to monitor closely.\\n Demographics\\n Attending MD:\\n Admit diagnosis:\\n Code status:\\n Height:\\n Admission weight:\\n Daily weight:\\n Allergies/Reactions:\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history:\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:\\n D:\\n Temperature:\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n Heart Rate:\\n Heart rhythm:\\n O2 delivery device:\\n O2 saturation:\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 24h total out:\\n Pacer Data\\n Pertinent Lab Results:\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes:\\n Wallet / Money:\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from:\\n Transferred to:\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 416954,\n \"text\": \"44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\\n state of health until 1300 when developed acute onset of left\\n sided weakness, unable to hold phone with mild headache. Called 911\\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\\n surgical consult found no midline shift at his time presumed to be HTN\\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\\n Assessment:\\n ETOH level 145 at OSH with strong smell of alcohol on breath, admits to\\n 12-18 beers a day. Hourly CIWA scores 20-27 becoming Increasingly\\n restless through out the night, trying to get OOB, at times completely\\n drenched with new tremors noted at 0300. Pt required bedside safety\\n observations. Neuro med resident called. Pt is also heavy smoker 1-1.5\\n packs a day for 25years.\\n Action:\\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\\n right upper arm.\\n Response:\\n Initially only decrease in restlessness for 45 minutes after valium 5mg\\n IVB. However by am CIWA scale decreasing to 17 by 0500 and becoming\\n less restless.\\n Plan:\\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\\n q4hrs. Remove nicotine patch before MRI.\\n Right basal ganglia hemorrhage\\n Assessment:\\n Every 1hr neuro checks remain stable without much change. As stated\\n above pt developed lower leg tremors mostly when awake lasting\\n 10-20seconds then muscle relaxes.\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 417069,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 0\\n Ideal body weight: 72.6 None\\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\\n Airway\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments:\\n Secretions\\n Sputum color / consistency: /\\n Sputum source/amount: /\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance:\\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 arrived from O.R. and taken to C.T. Plan to extubated when awake.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-09-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039777,\n \"text\": \", NMED FA11 11:50 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Querying aspiration pneumonitis\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with left hemiparesis, s/p crani after an ICH\\n REASON FOR THIS EXAMINATION:\\n Querying aspiration pneumonitis\\n ______________________________________________________________________________\\n PFI REPORT\\n No evidence of acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037849,\n \"text\": \" 12:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p Dobhoff placemnet eval plse\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p Dobhoff placemnet eval plse\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 5:06 PM\\n Dobbhoff tube is in the stomach.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Assess Dobbhoff catheter.\\n\\n Dobbhoff tip is in the stomach. There is mild cardiomegaly. The lungs are\\n clear. There is no pleural effusion.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1037850,\n \"text\": \", H. NMED SICU-A 12:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p Dobhoff placemnet eval plse\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n s/p Dobhoff placemnet eval plse\\n ______________________________________________________________________________\\n PFI REPORT\\n Dobbhoff tube is in the stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-09-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1039776,\n \"text\": \" 11:50 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Querying aspiration pneumonitis\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with left hemiparesis, s/p crani after an ICH\\n REASON FOR THIS EXAMINATION:\\n Querying aspiration pneumonitis\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 3:52 PM\\n No evidence of acute cardiopulmonary process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Suspected aspiration pneumonia.\\n\\n Portable AP chest radiograph was compared to prior study from .\\n\\n The heart size is normal. Mediastinal position, contour and width are\\n unremarkable. Lungs are clear. No pleural effusion or pneumothorax is\\n present. Potential old rib fracture is seen on the left\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"ORBITS (WATERS, CALDWELL & LAT)\",\n \"row_id\": 1037401,\n \"text\": \" 11:18 AM\\n ORBITS (WATERS, & LAT) Clip # \\n Reason: bilateral orbital xray to rule out metal pre-mri\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm), untreated HTN\\n presented to OSH with change in gait on left side after alcohol use. Pt noted\\n difficulty moving left leg, left facial weakness, left sided numbness, and left\\n facial droop. CT @ OSH --> right BG hemorrhage 3cm, transferred to for\\n further care. On transfer EMS noted pt has \\\"worsening symptoms\\\" from the\\n initial transport to OSH (same EMS team). @ repeat head CT showed right\\n BG hemorrhage at 4.7cm. Admit to ICU for BP control and neuro check q1hr.\\n REASON FOR THIS EXAMINATION:\\n bilateral orbital xray to rule out metal pre-mri\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Orbit series .\\n\\n HISTORY: 44-year-old man with facial droop and needs MRI. Evaluate for metal\\n in orbits.\\n\\n FINDINGS: Comparison is made to the CT scan from .\\n\\n There are no radiopaque densities in the left orbital prosthesis. Visualized\\n paranasal sinuses are within normal limits.\\n\\n IMPRESSION: No radiopaque densities within the orbits to exclude the patient\\n from having MRI.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037478,\n \"text\": \" 5:50 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate for hemorrhage\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:10 PM\\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\\n pneumocephalus and intraventricular hemorrhage.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT HEAD WITHOUT CONTRAST.\\n\\n COMPARISON: Nine hours prior.\\n\\n HISTORY: Evaluate for hemorrhage.\\n\\n FINDINGS: Patient is status post right frontoparietal craniotomy with\\n evacuation of putaminal and temporal lobe hematoma. Extensive pneumocephalus\\n is identified along the right cerebral convexity. There is a leftward shift of\\n normally midline structures by approximately 10 mm, slightly decreased when\\n compared to prior exam. Intraventricular hemorrhage in the right frontal \\n of the lateral ventricle and bilateral posterior horns of the lateral\\n ventricle is not significantly changed. A small amount of residual hemorrhage\\n and extensive pneumocephalus within the right basal ganglia is identified.\\n Dilated temporal horns, left greater than right, are unchanged. The basilar\\n cisterns are patent.\\n\\n IMPRESSION: Patient status post craniotomy with evacuation of hematoma.\\n Extensive pneumocephalus over the right cerebral hemisphere and within the\\n right basal ganglia. Interval decrease in right basal ganglia hemorrhage.\\n Persistent intraventricular hemorrhage and leftward shift of midline\\n structures as described above.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037479,\n \"text\": \", H. NMED SICU-A 5:50 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate for hemorrhage\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\\n pneumocephalus and intraventricular hemorrhage.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-24 00:00:00.000\",\n \"description\": \"CTA HEAD W&W/O C & RECONS\",\n \"row_id\": 1037390,\n \"text\": \" 10:52 AM\\n CTA HEAD W&W/O C & RECONS Clip # \\n Reason: Hemorrhage follow-up\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with R basal ganglia hemorrhage\\n REASON FOR THIS EXAMINATION:\\n Hemorrhage follow-up\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: 2:13 PM\\n\\n Moderate increas ein the right basal ganglia hematoma with new areas and new\\n itnraventricular hemorrhage and mass effect and cerbral edema on the right.\\n Patent major arteries; no abnormal vascularity around the hematoma- however,\\n lesions within the hematoma are not assessed.\\n d/w Dr. . by Dr. on at 2pm.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 44-year-old male patient with right basal ganglial hemorrhage,\\n followup.\\n\\n COMPARISON: CT of the head done on at 4:19 p.m.\\n\\n TECHNIQUE: Non-contrast CT of the head, followed by CT angiogram of the head\\n with IV contrast was performed. Volume rendered and 2D MIP reformations of\\n the major arteries were obtained.\\n\\n FINDINGS:\\n\\n NON-CONTRAST CT OF THE HEAD:\\n\\n There is interval moderate increase in the size of the right basal ganglia\\n hematoma, 7.6x3.6cm in the AP and transverse dimensions with significant\\n mass effect on the adjacent structures, along with cerebral edema on the right\\n side. There is 1.3 cm shift of the midline structures to the left side, which\\n is increased, which is new. Some of the new areas that have developed are\\n less dense in attenuation representing active bleeding/ due to anemia. There\\n is also extension of the hemorrhage into the right lateral ventricle as well\\n as the third ventricle. A few small hypodense foci, noted in the left\\n internal capsule, may represent perivascular spaces or chronic lacunar\\n infarcts are unchanged. No osseous lytic or sclerotic lesions of concern are\\n noted.\\n\\n CT ANGIOGRAM OF THE HEAD:\\n\\n The major intracranial arteries, of the anterior and posterior circulation are\\n patent without flow limiting stenosis, occlusion, or aneurysm. No abnormal\\n vascularity is noted surrounding the large right basal ganglial hematoma.\\n However, the vascular lesion, located within the area of hematoma itself is\\n not excluded on the present study. A small prominent vein int he right vertex\\n can relate to a small developmental venous anomaly. ( series 401b/7)\\n (Over)\\n\\n 10:52 AM\\n CTA HEAD W&W/O C & RECONS Clip # \\n Reason: Hemorrhage follow-up\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n There is evidence of scleral band, with ocular implant on the left side,\\n unchanged.\\n\\n IMPRESSION:\\n\\n 1. Moderate increase in the size of the right basal ganglial hematoma with\\n new areas of hemorrhage, which are less dense than expected, raising the\\n possibility of active bleeding, ? bleeding disorders/anemia.\\n\\n 2. Development of new intraventricular hemorrhage, in the right lateral\\n ventricle and third ventricle.\\n\\n 3. Significant mass effect, with cerebral edema on the right side, with 1.3\\n cm shift of the midline structures to the left side.\\n\\n 4. Patent major intracranial arteries. No obvious abnormal vascularity noted\\n around the hematoma. However, the vascular lesion, within the hematoma itself\\n cannot be excluded on the present study. To consider followup evaluation for\\n vascular lesions after resolution of the hematoma. In addition,\\n MRI/conventional angiogram or close followup CT head can be considered.\\n\\n Findings were discussed with Dr. . for Dr. on at 2 p.m.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-25 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037566,\n \"text\": \" 8:25 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: please evaluate for interval change. Please this this am\\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change. Please this this am\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: CT head without contrast.\\n\\n INDICATION: 44-year-old with intracranial bleed status post surgery, please\\n evaluate for change.\\n\\n COMPARISON: .\\n\\n FINDINGS: Post-operative change of a right craniotomy status post evacuation\\n of an intraparenchymal bleed is again noted. There is decrease in the overall\\n amount of pneumocephalus. The degree of mass effect and intracranial\\n hemorrhage is not overall changed from prior study. The degree of\\n intraventricular hemorrhage is also stable without evidence of hydrocephalus.\\n Prominence of the left temporal is stable. The suprasellar cistern\\n remains patent. Scleral band over the left orbit is grossly unchanged.\\n\\n IMPRESSION: Decrease in overall degree of post-operative pneumocephalus. No\\n new hemorrhage is identified. Degree of mass effect appears little changed.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-08-23 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1037261,\n \"text\": \" 4:12 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for progression\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 year old man with know bleed\\n REASON FOR THIS EXAMINATION:\\n eval for progression\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: JKPe WED 4:45 PM\\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging, with\\n mild mass effect but no midline shift, presumed to be Htn induced.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Known intracranial hemorrhage.\\n\\n NON-CONTRAST HEAD CT\\n\\n FINDINGS: Comparison is made to outside scan from same date. Again\\n identified is slightly heterogeneous hyperdense hemorrhage predominantly\\n centered within the right basal ganglia with mass effect on the posterior limb\\n of the right-sided internal capsule and adjacent parenchyma including the\\n right frontal . The hemorrhage appears to have increased in size from\\n outside examination, currently measuring 2.6 x 4.9 cm with prior measurement\\n at similar level of approximately 2.3 x 3.6 cm. No other regions of\\n intraparenchymal or intraventricular hemorrhage are identified. There is no\\n significant midline shift. -white matter differentiation is otherwise\\n well preserved. An old lacunar-type infarct is noted within the left internal\\n capsule anterior limb. An apparent left globe prosthesis is noted. No soft\\n tissue irregularity is present. Mastoid air cells and paranasal sinuses are\\n well aerated.\\n\\n IMPRESSION:\\n\\n Interval increase in size to right intraparenchymal basal ganglia hemorrhage\\n which displays mild mass effect on the adjacent brain parenchyma and right\\n frontal with no significant midline shift. This location is most\\n suggestive of a hypertensive etiology, although underlying mass\\n lesion/metastasis is not completely excluded.\\n\\n Further evaluation with dedicated contrast-enhanced MRI may be obtained once\\n the hemorrhage partially resolved for further characterization.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 223395,\n \"text\": \"Sinus rhythm\\nProminent precordial lead QRS voltage suggests left ventricular hypertrophy but\\nmay be nondiagnostic given age\\nModest nonspecific inferior ST-T wave changes\\nNo previous tracing available for comparison\\n\\n\"\n }\n]"}}},{"rowIdx":186,"cells":{"subject_id":{"kind":"number","value":17440,"string":"17,440"},"hadm_id":{"kind":"number","value":169094,"string":"169,094"},"target_text":{"kind":"string","value":"1. Cardiac: The patient is status post ventricular fibrillation arrest, likely secondary to ischemia given the EKG changes, with ST elevations in the inferior leads. The patient was taken for an emergent catheterization. Pressures in the catheterization laboratory revealed right ventricle 42/17, PA 42/19, wedge of 20, cardiac output 8.2, cardiac index 3.7, SVR 1112. The patient's catheterization revealed an right coronary artery with a proximal 70% diffuse, mid-90% diffuse; left main was normal. Left anterior descending showed a 40% D2 lesion. Mid-LAD had a 90% lesion. Distal circumflex had a 30% lesion. The mid-LAD 90% lesion was successfully percutaneous transluminal coronary angioplasty and stented. The patient transferred to the Cardiac Care Unit. In the Cardiac Care Unit the patient was continued on aspirin, Plavix, Integrilin for 18 hours, started on Lipitor. The patient's enzymes were cycled with a maximum CK of 1300, ruling positive troponin. However, CK's trended down to normal by the time of discharge. The patient also had an echocardiogram which showed an ejection fraction of 35 to 40% with multiple regional wall motion abnormalities. The patient was diuresed aggressively throughout his stay. The patient with a ventricular fibrillation arrest, was continued on Lidocaine drip until the following morning, however, at which point Lidocaine was discontinued. The patient remained on Telemetry without any evidence of ventricular tachycardia or ventricular fibrillation after his stent was placed, due to a Staphylococcus aureus blood infection. The patient will be overturned for a defibrillator placement after his antibiotic course is finished. The patient's Captopril and Lopressor were titrated up as tolerated; see final Medicine List. 2. Pulmonary: The patient initially intubated with left lower lobe collapse, question of aspiration. The patient was started on Levaquin and Flagyl for aspiration pneumonia with aggressive deep suctioning and chest Physical Therapy. The patient was able to extubated successfully on hospital day three. The patient maintained excellent saturations for the rest of his stay off the ventilation. While intubated, the patient had a bronchoscopy which showed evidence of left lower lobe secretions consistent with aspiration pneumonia. 3. Infectious Disease: The patient with likely aspiration event. He was started on intravenous Levaquin and Flagyl which was switched over to p.o. when tolerating. The patient to finish a ten day course of p.o. Levaquin and Flagyl. Methicillin resistant Staphylococcus aureus: The patient with four out of four positive blood cultures with Staphylococcus aureus. Final sensitivities showed that Staphylococcus aureus was resistant to Oxacillin but sensitive to Vancomycin. Given Methicillin resistant Staphylococcus aureus the patient was placed on contact precautions and will be discharged to complete a 14 day course of Vancomycin. The patient had a PICC placed prior to discharge. The patient is starting Vancomycin on , to continue until . 4. Endocrine: The patient with history of diabetes mellitus. Was put on an insulin drip initially and switched over to NPH and insulin sliding scale; to restart his oral medications, Avandia 4 mg with an insulin sliding scale for tight control. Avandia can be increased as tolerated. 5. Renal: The patient with initial creatinine of 1.3, which improved with fluid resuscitation and remained in the normal limits with diuresis. 6. Fluids, Electrolytes and Nutrition: The patient was initially NPO and was receiving tube feeds. However, after the patient was extubated, he was able to tolerate clears and advancing diet as tolerated. The patient will be discharged with a mechanical soft diet to be increased to a full diet as tolerated. 7. Orthopedics: The patient initially in a cervical spine collar status post fall. The patient had an x-ray which revealed no evidence of cervical spine fractures. Cervical spine was cleared, the collar was removed and the patient to resume full activities as tolerated. 8. Gastrointestinal: The patient continued on Protonix for GI prophylaxis. 9. Neurologic: The patient with a question of mental status changes given his four minutes of hypoxia. Initial CT scan showed questionable white matter changes consistent with possible early anoxic encephalopathy. However, after sedation was weaned and the patient was extubated, the patient's neurologically mental status was returned to per wife; however, the patient will need aggressive physical therapy to improve his strength and coordination prior to resuming full activities."},"extractive_notes_summ":{"kind":"string","value":"There is moderateregional left ventricular systolic dysfunction.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -hypokinetic; anterior apex - hypokinetic; septal apex - hypokinetic; inferiorapex - hypokinetic; apex - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. Q waves in leads III and aVF suggest inferior myocardialinfarction. T wave flattening in leads III, aVF and V4-V6 suggestpossible inferolateral ischemia. The right cephalic vein is occluded with thrombus. Sinus rhythm- premature ventricular contractionsOld inferior infarctAnterior T wave changes are nonspecificRhythm strip shows normal sinus rhythmSince previous tracing, , ventricular premature complex seen There has been interval removal of the ET tube. AP PORTABLE UPRIGHT CHEST: The left costophrenic angle is excluded. 3) Nasogastric tube side port above the level of the diaphragm. REASON FOR THIS EXAMINATION: r/o infiltrate, worsening CHF FINAL REPORT INDICATIONS: V fib at rest. There is an NG tube with tip in the stomach and sideport just below the level of the diaphragm. RSR' pattern in leads V1-V2.ST segment depressions in the anterior leads suggest possible anteriorischemia. There is opacification of the left retrocardiac space. Evaluation of the mediastinum and lungs is somewhat limited secondary to the overlying trauma board, patient motion and a cardiac pacer seen overlying the left lateral/lower hemithorax. Replaced NG tube. Atelectasis and diffuse parenchymal opacification are seen at the right lower lobe and posterior right middle lobe, findings consistent with aspiration. Sinus tachycardia. The tip of a nasogastric tube is seen just distal to the GE junction, with the side port likely within the distal esophagus. Evaluate for abscess. The ascending aorta is mildly dilated. The mitral valve leaflets are mildlythickened. The left ventricular cavity size is normal.There is moderate regional left ventricular systolic dysfunction. There is persistent opacification of the left lower lobe with a small left pleural effusion. New pulmonary edema. The ST segment depressions in the anterior leads has resolved.TRACING #2 The nasogastric tube overlies the stomach but the side port is above the diaphragm. PATIENT/TEST INFORMATION:Indication: s/p VF arrest, LAD stent, hypotensionHeight: (in) 73Weight (lb): 209BSA (m2): 2.19 m2BP (mm Hg): 127/90HR (bpm): 101Status: InpatientDate/Time: at 11:34Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. Physiologicmitral regurgitation is seen (within normal limits).TRICUSPID VALVE: The tricuspid valve leaflets are normal.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. Compared to tracing #1, the Q waves in the inferior leads are nowapparent. Nasogastric tube tip overlies the proximal stomach with the side port at the level of the diaphgram. and LMCA normal.ID: Febrile. remained 95-120/60-70 via r rad aline.tol lopressor later in am.r fem aline pulled. CPKs trending down.GI: Pt with minimal OG aspirates. NTG WEANED & DCED. Tolerating BB and ACEI titration. ADEQ SEDATION. Abd firm and distended with normoactive BS's. CV=HEMODY STABLE. CV=HEMODY STABLE. min aspirates. Am abg 105/36/7.42/24/0. GI=SELF DCED NGT. tol lopressor and captopril w/ ^'ing doses. good uop.id: on flagyl and levo for aspiration. CONTS ON REGLAN. paps 30s/.sm soft hematoma. lido dc'd this am. bp low this am and req 500ccns bolus this am to stabilize. Occ dry NPC.ID afebrile 99.7R WBC 6.9 on triple abx.GI- NGT replaced for meds and tube feedings. Keep pt negative.Start reglan. TOLERATING CAPTO/LOPRESSOR. advance tf as tol. cont w/ r fem venous/pa line. am K+ pnd. U/O adequate prior to low BP's. Fentanyl and Ativan weaned today. cont on levo and flagyl.neuro: ativan weaned down this am, pt became more active, mae with good strength but nonpurposeful. Resp. U/O adequate, > 40cc/hr.GI: Abd soft and distended with normoactive BS's. resp exam. NSR WO ECTO. Continue to advance as tolerated and guiac stools.ENDO: Insuling gtt decreased to 2u/hr. sxn'd for mod amt drk tan sputum. PERL R>L. Pt then transferred to ER where started on Lido gtt and given occasional Versed and Ativan. Tm 101.1 and Tc 99.6. Started on Reglan QID for ? Given AM dose of NPH.ID: Low grade temps. cont with cspine precautions. anoxia. lobe was found to be inflated and lavaged for mod purulent sputum.gi: abd soft, +bs. Recieved NS bolus total of 1.5L and BP recovering. FOLLOW BS-ADJUST/DC GTT AS INDICATED. residuals. FS ranging 187-267.Following FS q1h. ENDO=BL SUGARS TRENDING DOWN. remains +3l since admit. GI=TF @ 10ML/HR W MINIMAL RESIDUALS. cpt as tol. wean o2 as tol. will req eps, poss device prior to d/c. Tmax 102.6 rectal given Tylenol time two. Breathing unlabored overnoc. Abg's within normal limits. BS PRESENT. BREATH SOUNDS=COURSE THROUGHOUT. borderline oxygenation. Since 0300 pt somolent. home for eve now.a: bp stable s/p fluid this am. Resp Careremains intub/vented ac mode. LIMITED STM, NEEDING FREQUENT REMINDING/ RE ORIENTATION. +BS. Given Tylenol ATC. ADEQ UO. pt remains sedated currently on 1mg ativan/hr. BP when recieved from CL hypertensive. 4.77. right groin swan dc'd and tip sent for cx. was previously on oral .gu: foley. HR 88-110 NSR with occ isolated PVC's K+ 40meq KCL po x1 repeat 3.2. \"O: MS: Lethargic and oriented to self and place. pulses 2+/ bilat.integrillin cont at 16cc/hr. 10.6/C.I. ABG: 88/35/7.45. Good abgs as per flow. cont w/ low grade temps. PERL. CO/CI/MV 3.0/1.67/57. to adding additional antihypertensive on board.RESP:LS course on left and clear on right. PAD 12-24 overnoc. Integ at 16mls at to dc at 2200.K and Mg repleted.NEURO: Sedated and intubated. ota. delayed gastric emptying. Draining CYU. Attempted to wean Nitro. Fentanyl further weaned to 65ugs. ccu npn 11p-7aS: intubated and sedatedO: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 70-80 NSR, no vea noted."},"n_notes":{"kind":"number","value":39,"string":"39"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":70951,"text":"PATIENT/TEST INFORMATION:\nIndication: s/p VF arrest, LAD stent, hypotension\nHeight: (in) 73\nWeight (lb): 209\nBSA (m2): 2.19 m2\nBP (mm Hg): 127/90\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 11:34\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. 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. There is moderate\nregional left ventricular systolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -\nhypokinetic; anterior apex - hypokinetic; septal apex - hypokinetic; inferior\napex - hypokinetic; apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\nmitral regurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nThere is moderate regional left ventricular systolic dysfunction. Resting\nregional wall motion abnormalities include severe hypokinesis of the mid and\ndistal septum and apical segments. Right ventricular chamber size and free\nwall motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are mildly thickened. The mitral valve leaflets are mildly\nthickened. There is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2144-04-08 00:00:00.000","description":"Report","row_id":160019,"text":"Normal sinus rhythm. Q waves in leads III and aVF suggest inferior myocardial\ninfarction. Compared to tracing #1, the Q waves in the inferior leads are now\napparent. The ST segment depressions in the anterior leads has resolved.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2144-04-08 00:00:00.000","description":"Report","row_id":160020,"text":"Sinus tachycardia. Low limb lead voltage. RSR' pattern in leads V1-V2.\nST segment depressions in the anterior leads suggest possible anterior\nischemia. No previous tracing available for comparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2144-04-15 00:00:00.000","description":"Report","row_id":160013,"text":"Sinus rhythm\nProbable old inferior infarct\nAnteroseptal T wave changes may be due to myocardial ischemia\nLow QRS voltages in precordial leads\nSince previous tracing, , no ventricular premature complex\n\n"},{"category":"ECG","chartdate":"2144-04-14 00:00:00.000","description":"Report","row_id":160014,"text":"Sinus rhythm\n- premature ventricular contractions\nOld inferior infarct\nAnterior T wave changes are nonspecific\nRhythm strip shows normal sinus rhythm\nSince previous tracing, , ventricular premature complex seen\n\n"},{"category":"ECG","chartdate":"2144-04-13 00:00:00.000","description":"Report","row_id":160015,"text":"Sinus rhythm\nPossible old inferior infarct\nSince previous tracing, , no significant change\n\n"},{"category":"ECG","chartdate":"2144-04-12 00:00:00.000","description":"Report","row_id":160016,"text":"Sinus rhythm, rate 77. Since the previous tracing of the heart rate has\nslowed somewhat. Technical artifacts are seen. Increased ST-T wave\nabnormalities are noted, particularly over the anterolateral leads.\n\n"},{"category":"ECG","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":160017,"text":"Normal sinus rhythm. T wave flattening in leads III, aVF and V4-V6 suggest\npossible inferolateral ischemia. Compared to tracing #3, the inferolateral\nT wave flattening is new.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2144-04-08 00:00:00.000","description":"Report","row_id":160018,"text":"Normal sinus rhythm. Compared to tracing #2, the Q waves in the inferior leads\nare no longer present.\nTRACING #2\n\n"},{"category":"Radiology","chartdate":"2144-04-09 00:00:00.000","description":"C-SPINE (PORTABLE)","row_id":756196,"text":" 2:38 PM\n C-SPINE (PORTABLE) Clip # \n Reason: please r/o fracture; please focus on c7/t1 as previuos films\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p vfib arrest and fall with head and face trauma\n REASON FOR THIS EXAMINATION:\n please r/o fracture; please focus on c7/t1 as previuos films missed this\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57 y/o man status post V-fib arrest and fall with head trauma.\n\n Single lateral swimmer's view of the cervical spine is read in conjunction\n with AP and lateral cervical spine from earlier the same day. The cervical\n spine is normal in alignment through C7 without evidence of fracture. C7-T1 is\n not adequately visualized.\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756136,"text":" 11:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. ch\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest, now intubated and stable\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. check for ETT\n placement and PAC placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P pulmonary artery catheter placement and ventricular\n fibrillation arrest.\n\n COMPARISONS: .\n\n CHEST, SINGLE: The heart size is within the upper limits of normal. The\n mediastinal and hilar contours are stable in appearance. There is increased\n bilateral perihilar haziness and alveolar opacities. The left costophrenic\n angle has been excluded from this study. There is opacification of the left\n retrocardiac space. An endotracheal tube it is approximately 5 cm above the\n carina. The nasogastric tube tip distended below the field of view. The\n apparent Swan-Ganz catheter tip lies in the right ventricular outflow tract.\n The osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. New pulmonary edema.\n\n 2. Swan-Ganz catheter in right ventricular outflow tract.\n\n 3. Left lower lobe consolidation.\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"C-SPINE (PORTABLE)","row_id":756137,"text":" 11:44 PM\n C-SPINE (PORTABLE) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. Fo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Found down, in\n cervical collar, need to clear c-spine.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unconscious, evaluate cervical spine.\n\n AP AND LATERAL CERVICAL SPINE: Vertebral bodies C1 through C6 are visualized.\n There is normal alignment and vertebral body and disc heights. The\n prevertebral soft tissues cannot be evaluated due to intubation and NG tube\n placement. No fractures or dislocations identified. The frontal view is\n unremarkable.\n\n IMPRESSION: C1 through C6 in normal alignment without evidence of fracture.\n C7 is not visualized on the study.\n\n"},{"category":"Radiology","chartdate":"2144-04-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756164,"text":" 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. As\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Assess for PAC\n placement, ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P V-fib arrest with pulmonary artery catheter and\n endotracheal tube placement.\n\n COMPARISONS: at \n\n CHEST, SINGLE: The cardiac, mediastinal and hilar contours are stable in\n appearance. There has been slight interval improvement in the perhilar and\n predominantly central pulmonary alveolar opacities. There is persistent\n opacification of the left lower lobe with a small left pleural effusion. The\n endotracheal tube tip is approximately 5 cm above the carina. The Swan-Ganz\n catheter tip is in the right ventricular outflow tract. Nasogastric tube tip\n overlies the proximal stomach with the side port at the level of the\n diaphgram. The soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Slight improvement in the pulmonary edema.\n\n Nasogastric tube side port at the level of the diaphragm, recommend advancing\n this by several cm.\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"CHEST CTA WITH CONTRAST","row_id":756122,"text":" 7:52 PM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o pe\n Field of view: 47 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cardiac arrest, ? pe\n REASON FOR THIS EXAMINATION:\n r/o pe\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac arrest, ? of PE\n\n TECHNIQUE: Multiple axial images were obtained from the thoracic inlet from\n the lung basis after the administration of intravenous contrast.\n\n CONTRAST: 100cc of Optiray were administered due to the fast bolus\n requirements: There were no complications.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The heart and great vessels are grossly\n normal in appearance. No intraluminal filling defects are seen within the\n pulmonary circulation. An NG tube is seen passing into the esophagus. There\n is complete collapse of the left lower lobe. Atelectasis and diffuse\n parenchymal opacification are seen at the right lower lobe and posterior right\n middle lobe, findings consistent with aspiration. There is a high attenuation\n nodular density in the peripheral right middle lobe, which may represent a\n granuloma versus a small enhancing nodule. There are no pleural effusions. No\n pneumothoraces are identified. An ET tube is seen terminating in the trachea\n just below the thoracic inlet. A few scattered mediastinal lymph nodes do not\n meet CT criteria for pathologic enlargement.\n\n Multiplanar reformatted images confirm the above findings.\n\n The soft tissues and osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n 2. Total collapse of left lower lobe.\n 3. Multifocal areas of atelectasis and probable aspiration.\n 4. Nodule or granuloma of right middle lobe.\n\n"},{"category":"Radiology","chartdate":"2144-04-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756351,"text":" 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate NG placement before starting TF/PO meds\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 yo male a/w VF arrest, now extubated, replaced NGT. Need to start TF.\n REASON FOR THIS EXAMINATION:\n evaluate NG placement before starting TF/PO meds\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: V-fib arrest. Now extubated. Replaced NG tube. Assess NG tube\n placement before starting tube feeds.\n\n PORTABLE AP CHEST: Comparison . The patient is rotated. There has been\n interval removal of the ET tube. There is an NG tube with tip in the stomach\n and sideport just below the level of the diaphragm. The heart is enlarged.\n There are bilateral patchy alveolar opacities throughout the lungs, without\n significant change. This likely reflects edema, although multifocal infection\n could also have this appearance.\n\n\n"},{"category":"Radiology","chartdate":"2144-04-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756245,"text":" 10:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate ETT placement and lung parenchyma for state of CHF.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n Evaluate ETT placement and lung parenchyma for state of CHF.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate endotracheal tube placement and CHF.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: Allowing for technique and patient rotation, the\n bilateral diffuse pulmonary alveolar opacities are unchanged. The\n cardiomediastinal and hilar contours are unremarkable. The endotracheal tube\n tip is approximately 8 cm above the carina. The nasogastric tube overlies the\n stomach but the side port is above the diaphragm. The soft-tissue and osseous\n structures are unremarkable.\n\n IMPRESSION:\n\n 1) High-lying endotracheal tube, terminating 8 cm above carina.\n\n 2) No significant change in CHF.\n\n 3) Nasogastric tube side port above the level of the diaphragm.\n\n"},{"category":"Radiology","chartdate":"2144-04-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756469,"text":" 2:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, worsening CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 yo male a/w VF arrest, ? aspiration, now extubated, spiking fevers on\n levo/flagyl. r/o worsening infiltrates.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, worsening CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: V fib at rest. Extubated and spiking fevers.\n\n COMPARISONS: .\n\n AP PORTABLE UPRIGHT CHEST: The left costophrenic angle is excluded. Lung\n volumes appear slightly improved and the left lung has nearly completely\n cleared in the interval. There is persistent, though lessened, patchy opacity\n in the right perihilar region compatible with resolving pneumonia. The NG\n tube may have been retracted in the interval and the side port is not well\n visualized and may sit above the GE junction. Cardiac and mediastinal\n contours are unchanged.\n\n IMPRESSION: Improving multifocal pneumonia. NG tube probable malpositioned.\n\n"},{"category":"Radiology","chartdate":"2144-04-17 00:00:00.000","description":"CHEST (SINGLE VIEW)","row_id":756781,"text":" 1:34 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pt had a left sided picc placed and needs tip confimation, p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p cardiac arrest, bacterimia who needs picc for iv\n vanco.\n REASON FOR THIS EXAMINATION:\n pt had a left sided picc placed and needs tip confimation, please page \n with wet, read,asap because they would like to d/c pt. to rehab., thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac arrest, PICC line placement.\n\n TECHNIQUE: Single view chest: This film is dated and it now\n comes to the radiology list for dictation. There has been a PICC line placed\n and is seen at the lower SVC. There is basilar atelectasis on the left.\n\n No pneumothorax is present.\n\n PICC line seen at the lower SVC. No pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2144-04-18 00:00:00.000","description":"R US EXTREMITY NONVASCULAR RIGHT","row_id":756858,"text":" 2:42 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: SWOLLEN RED RT ANTECUB FOSSA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p VF arrest, with MRSA bacteremia likely 2' to infection in\n right anticubital fossa, ruled out abscess.\n REASON FOR THIS EXAMINATION:\n r/o abscesss in right antecubital fossa\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA bacteremia with infection in right antecubital fossa.\n Evaluate for abscess.\n\n Targeted scale, Doppler and color images were obtained within the\n antecubital fossa. There is no evidence of a discrete fluid collection. The\n right cephalic vein is occluded with thrombus. There is no evidence of\n Doppler flow.\n\n IMPRESSION:\n 1. No discrete fluid collection to suggest abscess formation. There are soft\n tissue changes consistent with cellulitis.\n 2. Thrombus within the superficial cephalic vein.\n\n These findings were directly communicated to the physician caring for the\n patient.\n\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":756114,"text":" 6:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest, now intubated and stable\n REASON FOR THIS EXAMINATION:\n eval for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post cardiac arrest, now intubated and stable. Evaluate tube\n placement.\n\n FINDINGS: The tip of the endotracheal tube is seen at the level of the\n thoracic inlet, approximately 7 cm above the carina. The tip of a nasogastric\n tube is seen just distal to the GE junction, with the side port likely within\n the distal esophagus. Evaluation of the mediastinum and lungs is somewhat\n limited secondary to the overlying trauma board, patient motion and a cardiac\n pacer seen overlying the left lateral/lower hemithorax. The cardiac and\n mediastinal contours appear within normal limits. There are no focal\n consolidations or pleural effusions. The visualized soft-tissue and osseous\n structures are unremarkable.\n\n IMPRESSION: Endotracheal tube can be further advanced, with the tip now\n approximately 7 cm above the carina. Nasogastric tube can also be advanced,\n as the side port is now within the distal esophagus.\n\n\n\n"},{"category":"Radiology","chartdate":"2144-04-08 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":756117,"text":" 7:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p fall, with head trauma and bleeding\n REASON FOR THIS EXAMINATION:\n s/p trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Head trauma.\n\n TECHNIQUE: Multiple axial images were obtained from the foramen magnum to the\n cranial vertex without intravenous contrast.\n\n FINDINGS: There is some streak artifact from the underlying stiffener board.\n No intraaxial or extraaxial fluid collections or hemorrhages are identified.\n There is no shift of the normally midline structures, or mass effect. The CSF\n spaces are normal. No definite sulcal effacement is seen.\n\n Some mucoperiosteal thickening is seen within the visualized portions of the\n ethmoid sinuses. The orbits, soft tissues and osseous structures of the head\n are unremarkable.\n\n IMPRESSION:\n\n 1. No evidence of acute intracranial hemorrhage.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2144-04-14 00:00:00.000","description":"Report","row_id":1490840,"text":"CCU NSG PROGRESS NOTE.\nO:NEURO=A&O X2. COOPERATIVE. APPROPRIATE. VERY WEAK-ALL EXTREMETIES.\n PULM=BREATH SOUNDS=DEMINISHED/CLEAR THROUGHOUT. SATS MID 90'S.\n CV=HEMODY STABLE. NTG WEANED & DCED. TOLERATING CAPTO/LOPRESSOR.\n GI=SELF DCED NGT. TOLERATING CL LIQ-ABLE TO TAKE PO MEDS.\n GU=FOLEY. ADEQ UO.\n ID=LOW GRADE T. R-ANTECUB NOTE TO REDDENED/WARM/HARD TO TOUCH-WO CO DISCOMFORT.\n LABS=AM SENT.\n\nA:IMPROVING.\n\nP:CALL-OUT. CONTIN PRESENT MED MANAGEMENT.\n\n\n"},{"category":"Nursing/other","chartdate":"2144-04-14 00:00:00.000","description":"Report","row_id":1490841,"text":"ccu nursing progress note\ns: i had a heart attack\no: pls see carevue flowsheet for complete vs/data/events.\npls see transfer note from for complete details.\nneuro: improving. not agitated or confused. ox , cooperative. has poor stm. haldol dc'd.\nremains weak in arms and legs req 2 person pivot/transfer. req assistance w/ feeding. also needs monitoring for aspiration but appears to be doing well with pills, jello, liquids when sitiing up.\ncv: hr 80-90s sr, bp 120-160/70. tol lopressor and captopril w/ ^'ing doses. not on antiarrhythmics. will req eps, poss device prior to d/c. no vea since admit.\nresp: ra sat 93-95%, rr 24-30. bs coarse/dim at bases.\ngi: tol diet, to advance. aspiration precautions. no stool.\nendo: covered per ss and nph. was previously on oral .\ngu: foley. good uop.\nid: on flagyl and levo for aspiration. cont w/ low grade temps. also has mild cellulitus at r antecub.\nsocial: married, 3 children. lives on . works for health care/home care co.\na: s/p arrest c/b anoxic brain injury and aspiration pneumonia. s/p stent to lad.\np: cont to follow rhythm, response to cardiac meds. resp exam. advance diet. follow bs. follow ms. pt and ot. may need rehab stay. support to pt and family. transfer to 2 when bed avail.\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490824,"text":"Respiratory Care: Pt recieved from cath lab put on AC 750*16 100% 10 PEEP. Pt had likely aspirated pao2 was poor ( 83 on 100% and 10 peep). Pao2 improved( see careview) Fio2 weaned to 60%. EET advanced from 22 to 25 MD verbal order. Bs equal bilat. Will continue to follow and wean Fio2 as tollerated.\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490825,"text":"CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\nHPI/CC: 57 year old male with limited medical history available found down , flat on face. According to friends he was feeling well during the day, no c/o nausea, CP, and SOB. Was then walking and suddenly collapsed, no convulsions noted. When EMT's arrived, police officer doing CPR and pt unconscious, pulseless, and agonal respirations and blood from mouth and nares. Pt shocked with 200J in AIVR without pulses. Intubated in field. Atropine given and pt in CHB with a ventricular rate of at 150. EKG in field showing changes in lateral leads. Pt then transferred to ER where started on Lido gtt and given occasional Versed and Ativan. Moving all extremeties and coughing while intubated. Prior to passing OGT pt vomitted large amount dark brown material and chunks of food. During assessment by house staff O2Sats marginal at 88-90% on 100% Fio2. Pt was suctioned numerous time for copious amounts of food particles from ETT. Pt then taken for Head CT which was (-) for intracranial hemmorhage but showing some white and matter.? anoxia. Chest CT also done in addition which was (-) for PE and showing LLL consolidation. Post pt taken for Cath.\n\nCATH LAB: Cath procedure performed without difficulty with the following findings. LHC: RA 26, PA, 42/19, PA 20, CO 8.19 and CI 3.65\nLAD mod calcified, 90% mid occlusion involving moderate DZ. LAD stented times two. TIMI flow of 3 prior to intervention and post. RCA with diffuse dz 70%. and LMCA normal.\n\nID: Febrile. Tmax 102.6 rectal given Tylenol time two. Last given at 0600. Called for cooling blanket. Levo and Flagyl started this AM\nWBC from MN labs down from admission to 3(11).\n\nCV: HR 100's to 110's with rare PVC's. Given total of 10mg of Lopressor in Cath Lab. Repeat doses given aroung MN of 5mg x two and 25mg PO. HR maintaining 88 to low 90's. In addition Lidocaine continuing at 2mg/hr. BP when recieved from CL hypertensive. Given Versed and Verc in transit to floor shortly after pt awakening. Given 2 of Ativan and 50 of Fentanyl and BP bottoming. Recieved NS bolus total of 1.5L and BP recovering. Since has been labile and recieving additional numerous boluses. SBP 80-90's with map > 65. A-V sheath in place with femoral swan at venous site. PAD 12-24 overnoc. Swan unable to wedge. Recv'd 20mg of Lasix post boluses and numbers repeated 1-2hours post. CO/CI/MV 3.0/1.67/57. ? validity of swan because could not visualize in . Femoral site with small ooze and no noted hematoma. Pulses palpable distal. Integ at 16mls at to dc at 2200.\nK and Mg repleted.\n\nNEURO: Sedated and intubated. Ativan at 2mg/hr. Currently unresponsive. Earlier durin night began to awake and moving right extremety only. PERL. 3mm bilaterally. Corneal reflex (+) in left eye only. Right pupil less sluggish than left. Not moving any extremeties.\nFentanyl gtt off due to labile BP's\n\nRESP: Current vent setting at AC 750 x 16 .50 and 7.5 PEEP. When recieved from CL suctioning for copious amounts\n"},{"category":"Nursing/other","chartdate":"2144-04-10 00:00:00.000","description":"Report","row_id":1490829,"text":"CCU NSG PROGRESS NOTE.\nO:NEURO=SEDATED W FENTANYL @ 50MCG & ATIVAN @ 1MG CONTIN W GD EFFECT. AROUSABLE, BUT DOES NOT FOLLOW COMMANDS. WHEN STIM MOVEMENT OF UPPER BODY-SHOULDERS, NECK, & HEAD-ONLY!.\n PULM=INTUBATED & VENTED W SETTINGS-AC/50%/750X16/+7.5 W AM ABG-7.50/31/71/25/1 W SATS 97-98. RR DECREASED FROM 16 TO 12. BREATH SOUNDS=COURSE THROUGHOUT. SX-SCANT THICK TAN/BROWN SECRETIONS.\n CV=HEMODY STABLE. NSR WO ECTO. MAPS 70-80'S. PADS 16-18. CKS SENT @ 0000 & 0500.\n GI=TF @ 10ML/HR W MINIMAL RESIDUALS. WO STOOL.\n ID=FOLEY. LASIX 80MG @ 0000 W EXCELLENT RESPONSE.\n ENDO=BL SUGARS TRENDING DOWN. INSULIN GTT DECREASED TO 1U/HR W BL SUGAR 102.\n MISC=COLLAR/NECK CARE DONE.\n LABS=AM SENT.\n\nA:COMFORTABLE THROUGHOUT NIGHT.\n\nP:CONTIN PRESENT MED RX. ADEQ SEDATION. INCREASE TF AS TOLERATED. FOLLOW BS-ADJUST/DC GTT AS INDICATED. CK AM LABS-REPLACE AS NEEDED.\nSUPPORT PT/FAMILY.\n"},{"category":"Nursing/other","chartdate":"2144-04-10 00:00:00.000","description":"Report","row_id":1490830,"text":"Resp Care\nremains intub/vented ac mode. resp alkalosis thus vent changed to rate 12 ...settings 750x12x.5/7.5 peep. borderline oxygenation. small amts secretions..orangey/brown. stable plateaus. ?increase peep. c/w vent support.\n"},{"category":"Nursing/other","chartdate":"2144-04-10 00:00:00.000","description":"Report","row_id":1490831,"text":"CCU NURSING PROGRESS NOTE 7A-3P\n\nNEURO: Pt sedated on fentanyl and ativan gtts. PERL 3mm. Pt intermittently able to open eyes and wiggle toes to command; no purposeful movements noted of upper extremities. Ativan gtt dc'd at 1pm. Will cont to assess neuro status for changes. C-spine collar in place.\n\nRESP: Intubated on AC 750x12 with peep weaned to 5 and Fio2 weaned to 40%. ABG: 88/35/7.45. Suctioned for minimal amt thin tan secretions.\nPlan is to begin weaning sedation today and based on neuro status, aiming for vent weaning/extubation tomorrow.\n\nCARDIAC: Hemodynamically stable. No VEA. C.O. 10.6/C.I. 4.77. right groin swan dc'd and tip sent for cx. Pt started on 12.5mg captopril TID. CPKs trending down.\n\nGI: Pt with minimal OG aspirates. Tube feeds advanced to 30cc/hr with goal rate of 80cc/hr. +BS. No stool this shift.\n\nGU: foley draining cloudy yellow urine with sediment. Pt is -1200cc at this time. No plans for further diuresis at this time.\n\nENDO: FS range 138-180. Conts on insulin gtt 1-3u/hr.\n\nID: afebrile all shift on RTC tylenol. Conts on IV abx for presumed aspiration pnx.\n\nACCESS; Right a-line and 3 peripheral IVs intact and working well.\n\nFAMILY: Pt's 2 daughters and wife in and out most of afternoon. Appear to be asking appropriate questions. Pt's oldest daughter, has agreed to be spokesperson for all phone calls. Cardiology fellow has spoken to family and informed them of pt's progress and present status.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2144-04-11 00:00:00.000","description":"Report","row_id":1490832,"text":"CCU Nursing Note 1500-2300: Vfib Arrest, Aspirat PNA\nID: Low grade temps. Recieving Tylenol ATC with fair effect and continues on IV Abx for aspiration PNA.\n\nMS: Sedated and intubated. Fentanyl and Ativan weaned today. Recieved at 1500 with Ativan off and Fentanyl at 75ugs. Fentanyl further weaned to 65ugs. Pt now flailing in bed. MAE's. Not obeying or following commands. Moving neck from side to side. Started on Propofol at 10ugs and increased to 20ugs with excellent effect.\n\nCV: VSS. transiently dropping BP to high 90's with sedation titration.\nHR 80's. NSR with no ectopy. SBP 99-mid 100's. Hypertensive when aroused. Right femoral site with small hematoma and slight ooze but has decreased further into night. Pulses palpable distal. Skin clamy and warm to touch.\n\nRESP: LS course with occasional rhoncerous sounds throughout. O2Sats high 90's. Vent settings at AC 750/12/50/5 PEEP. No ABGs' done this shift due to the prior being WNL. Suctioning for moderate to large amounts of thick dark tan sputum, ? food particles. During period of flaling pt found not to be recieving TV's. Resp notified and pt biting on tube. Sedation administerd.\n\nGU: Foley patent, intact and draining golden colored urine. Received pt with sediment on walls of the foley tubing but not draining urine with sediment. U/O adequate, > 40cc/hr.\n\nGI: Abd soft and distended with normoactive BS's. TF increased to 40cc/hr but shut off when pt found not to be recieving volumes and since have not been shut back on. When increased found to have residual of 10cc. OGT intact and in place. Passing flatus but no BM's this shift.\n\nENDO: Insulin gtt continues at 3u/hr. FS ordered Q1H but have been checking 1-3hrs. FS range from 120-140's. No adjustments made this shift.\n\nSKIN: Facial and knee lacerations open to air. Cleansed this shift with NS and applied bactroban to wounds. Upper back area where C-collar rested are red and open abrasions. No drainage. Cleansed with NS and left open to air.\n\nDISPO: 57 year-old man who is S/P VF arrest with a guestimated time out of 4 minutes prior to EMS intervention who had emergent PTCA and stented x two the LAD. Pt course then c/b aspiration pna where he remains vented and sedated.\n\nPLAN:\nTitrate sedation to keep pt comfortable\nPossible re-trial of weaning sedation in AM to assess MS further\nContinue BB and ACE as tolerated\nMonitor skin\nDiscuss possible anticoagulation\nContinue to monitor hemodynamics\n\n"},{"category":"Nursing/other","chartdate":"2144-04-11 00:00:00.000","description":"Report","row_id":1490833,"text":"Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 750, A/C 12, Fio2 40%, and Peep 5. PAP/Plateau 22/19. Bs slightly coarse L Lung, R Lung clear. Sx'd/lavaged for sm amounts of thick tan sputum. Abg's within normal limits. Pt. remains sedated. ETT retaped at 26cm. No further changes made. Continue with mechanical support.\n"},{"category":"Nursing/other","chartdate":"2144-04-12 00:00:00.000","description":"Report","row_id":1490836,"text":"CCU Nursing Note 1900-0700: S/P VFib Arrest/ Aspir P\nSee carevue for VSS and all objective data:\nS: Pt moaning and groaning.\n\nID: Afebrile. Given Tylenol ATC. Continues on IV Flagyl and Levo.\n\nMS: Still not obeying and following commands. Moving head from side to side and moving all extremeties in bed. Opened eyes once during shift but not to command. Neck and limbs remain flacid while on Propofol. Propofol attempted to wean but pt very restless. Given Haldol 5mg at HS and QID ATC. Since 0300 pt somolent. Needed emotional support and positive re-inforcement.\n\nCV: NSR-ST. Hypertensive and tachycardic when restless. Given Captopril and Lopressor with good effect. Nitro off due to low BP. QT interval checked at 0.16. Since 0300 has been NSR, HR 70's and BP 120-130's. Continue to BB and ACE-I as needed.\n\n\nRESP: LS course. FM weaned to .50 Fio2. CPT. Deep oral suctioned for blood-tan colored sputum. O2Sats 97-99%. Breathing unlabored. Continue CPT and sx as needed.\n\nGU/GI: Urine outputs adequate, >/= 60cc/hr. TF restarted at 0400 at 30cc/hr. Prior to residual 5cc. No residual checked since started.\nLarge BM tonoc. Soft-paste like consistency, brown in color. Guiac not checked. Continue to advance as tolerated and guiac stools.\n\nENDO: Insuling gtt decreased to 2u/hr. FS ranging from 77-98. Continue to monitor FS.\n\nSKIN: Cut and bruises open to air. Healing well. Continue to monitor.\n\nSOCIAL: Family into visit earlier during shift. No phone call overnoc.\n\nDISPO: 57 year-old male who s/p vfib arrest who arrest was c/b aspiration pna. Intubated and now extubated with new concern post extubation of anoxia.\n\nContinue to monitor.\n\n"},{"category":"Nursing/other","chartdate":"2144-04-12 00:00:00.000","description":"Report","row_id":1490837,"text":"CCU Nursing Progress Note\nS-\"I have a little headache\"\nO-Neuro becoming more awake during the day. Following commands , . Talking to family and staff. Mumbling most of the time, speech is not clear but understandable. Propofol weaned and d/c'd and haldol increased to 5mg QID. Family with pt mst of time but occ restlessness treated with IV haldol prn.\nCV-VSS IV NTG restarted with SBP 170's but weaned to 40mcg when captopril increased to 50mg TID BP 124-138/58-70 HR 79-90 NSR\nResp-O2 weaned to 5l NP with O2 sats 96% ABG 7.45/38/55 but O2 sats improved to 99-100% later in the am. LS coarse Occ NPC.\nID temp 101 IV abx changed over to po flagyl and levo.\nGU-urine output improved 100cc/hr and received lasix 40mg IVB with transfusion.\nGI-NGT in place tube feeds on hold d/t high residuals which remained most of the day. Possibly start reglan for gastricparesis. Incontinent of moderate amt of soft brown stool OB+. HCT 28 receiving 2nd unit of PRBC over 4hrs.\nEndo- Insulin 2u/hr gtt d/c'd adn started NPH 10u FS 121-156\nSOcial-family all in and aware of POC. Happy pt is conversant.\nA/P-Continue to adjust meds as tolerated. Keep pt negative.\nStart reglan. Follow electrolytes closely.\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490826,"text":"CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\n(Continued)\nof food particles. Now not raising anything from ETT. ETT tube advanced 4cm by resp. ABG improved. LS course. O2Sat 99-100%\n\nGU/GI:Foley patent and intact. Draining CYU. U/O adequate prior to low BP's. Currently making 30-500cc/hr for past 2hrs. HO aware. Abd firm and distended with normoactive BS's. OGT in place.\n\nENDO: Insulin gtt at 4u/hr per sliding scale. FS ranging 187-267.\nFollowing FS q1h.\n\n: Collar in place. Cspine film done at bedside last night. No injuries noted.\nCollar in place until pt awake or till trauma team clears\n\nPLAN:\nPossible removal of swans\nIntegrillin to dc at 2200\nContinue to follow neuro status\nContinue to monitor\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490827,"text":"Resp. Note\nPt remains on AC 16/750/7.5/50% No changes made today. Bronchoscopy done-poss food/foreign body aspiration. No particles found. Pt was sx today for brownish secretions throughtout the day. Will cont support.\n"},{"category":"Nursing/other","chartdate":"2144-04-09 00:00:00.000","description":"Report","row_id":1490828,"text":"ccu nursing progress note\ns: orally intubated\no: pls see carevue flowsheet for complete vs/data/events\nid: low grade temp. wbc nml. cont on levo and flagyl.\nneuro: ativan weaned down this am, pt became more active, mae with good strength but nonpurposeful. not able to open eyes or follow commands, did appear to respond to stimuli. in afternoon pt underwent bronch req ^'d sedation w/ fent and ativan. pt remains sedated currently on 1mg ativan/hr. no evidence of sz activity.\ncv: in sr rate 75-90s sr, no vea. lido dc'd this am. bp low this am and req 500ccns bolus this am to stabilize. remained 95-120/60-70 via r rad aline.\ntol lopressor later in am.\nr fem aline pulled. cont w/ r fem venous/pa line. paps 30s/.\nsm soft hematoma. pulses 2+/ bilat.\nintegrillin cont at 16cc/hr. to complete at 11pm.\nck up 1300, mb 19. will cont to cycle.\nresp: cont on a/c 750 x16. 50% and 7.5 peep. sats >95%. sxn'd for mod amt drk tan sputum. bronch'd this afternoon to eval ?collapse for lll. lobe was found to be inflated and lavaged for mod purulent sputum.\ngi: abd soft, +bs. no stool. min aspirates. tf started via ogt, promote w/ fiber at 10cc/hr. awaiting nutrition consult to confirm and set goal.\ngu: uop 30-50cc/hr. remains +3l since admit. will dose w/ lasix this eve. cr 1.4.\nskin: abrasion on face/chin. ota. some bruising underarms.\nremains w collar. cspine film taken this afternoon. has yet to be cleared.\nsocial: wife and children in today. updated. home for eve now.\na: bp stable s/p fluid this am. rhythm stable. neuro improving.\np: cont to monitor cv and neuro status. wean o2 as tol. cpt as tol. cont with cspine precautions. advance tf as tol. monitor fever and await cultures. support to pt and family.\n\n"},{"category":"Nursing/other","chartdate":"2144-04-11 00:00:00.000","description":"Report","row_id":1490834,"text":"ccu npn 11p-7a\nS: intubated and sedated\n\nO: Please see carevue for VS and objective data\n\nCVS: Hemodynamically stable with HR 70-80 NSR, no vea noted. K+ 3.6 repleted with 40meq po KCL. am K+ pnd. BP 107-150/50-60. Tolerated po Captopril and Lopressor.\n\nResp; Remains intubated and mechanically ventilated on A/C 750x12 40%/5 peep. Good abgs as per flow. Am abg 105/36/7.42/24/0. Suctioned q 3-4 hours for small-mod. amounts of tan sputum. Lungs coarse. Rare spont. breathe over vent. impaired gag and cough.\n\nID: low grade on IV Flaggyl and Levo.\n\nEndo: Regular Insulin drip titrated 3u-4u/hour for glucose ranges 118-192.\n\nGI:GU: TF Promote with fiber at 30cc/hour increased to 40cc/hour without sign. residuals. Abdomen soft and distended with active bowel sounds. No stool. Foley to drainage with dark yellow urine with sediment. I/O neg 700cc at MN, positive 400cc this am.\n\nNeuro: Remains sedated on IV Propofol, increased to 40mcg/kg/min. for restlessness. with good effect. MAE, moving head side to side. Not opening eyes or following commands. PERL R>L. 3mm. Soft hand restraints intact. Poor gag and weak cough.\n\nA: Hemodynamically stable s/p arrest. Remains sedated and intubated.\n\nP: Cont to assess hemodynamics. Cont aggressive pulmonary toileting. Sedation as needed. Cont. insulin drip with tube feedings. Assess neuro status. Comfort and emotional support to Pt. and family. Follow up with am labs.\n"},{"category":"Nursing/other","chartdate":"2144-04-11 00:00:00.000","description":"Report","row_id":1490835,"text":"CCU Nursing PRogress Note\nS-Delirious\nO-Neuro weaned off propofol by 1030 and added haldol 5mg x2 1 hr apart for persistant delirium with good effect. ALthough when IV haldol wore off (4hours) aggitation returned 1400 and required low dose propofol for pt saftey. Started po haldol 2.5mg QID started at 1800. Still requiring prn Haldol 2.5-5mg IVB. MAE very strong arms requiring wrist restraints. Opening eyes but not focusing or following commands.\nCV- hypertensive 160-180 with aggitation requiring IV NTG 200-300mcg. Lopessor increased to 50mg TID and captopril increased to 37.5mg TID.\nPlan to increase with each dose until desired effect. HR 88-110 NSR with occ isolated PVC's K+ 40meq KCL po x1 repeat 3.2. Radial aline replaced over a wire d/t brisk bleeding at site.\nResp-Vent changed over to PS 15/PEEP 5 with spont VT 500-800 rr 20-28. PS/PEEP weaned down to 5/5 and quicikly extubated by 1200 to 100% neb with O2 sats 92-100% Last ABG 7.41/42/81 at 1630 on 100% face tent.\nLS coarse with occ exp wheeze. Occ dry NPC.\nID afebrile 99.7R WBC 6.9 on triple abx.\nGI- NGT replaced for meds and tube feedings. Initial asp bile but after extubation coffee grounds OB+. Soft brown BM OB+. HCT 27.5 receiving 1uPRBC over 4 hours. Protonix\nTube feeds stopped for extubation and to be restarted this evening.\nGU-foley draining amber colored urine. Received lasix 40mg IVB with ~1200cc diuresis.\nSKin- pressure sores from neck immobilizer neck, shoulder blades and head cleansed and left open to air\nSocial- family all in and very supportive. Understanding POC\nA/P-succ extubated, s/p AMI stent\nPRN haldol for excessive aggitation, plan to wean off propofol when possible. CT scan Monday if MS unchanged.\nLAsix 40mg IVB PRN for low urine output.\nFollow electrolytes closely\n"},{"category":"Nursing/other","chartdate":"2144-04-13 00:00:00.000","description":"Report","row_id":1490838,"text":"CCU Nursing Note 1900-700: Vfib arrest, Aspir PNA\nS: \"I need to go to bathroom, I need to get up.\"\nO: MS: Lethargic and oriented to self and place. Speech less garbled and voices needs appropriately. Obeying and following simple commands.\nRestless and agitated overnoc needing repeative cues. Sleeping in spurts. Given 5mg every 2hr since MN with limited effect.\n\nCV:VSS stable overnoc. Still remains moderately hypertensive. Attempted to wean Nitro. High as 100ugs currently at 60ugs. Tolerating BB and ACEI titration. ? to adding additional antihypertensive on board.\n\nRESP:LS course on left and clear on right. O2Satt 95-99%/5l NC. Occasionally O2Sat dropping to 90-91& increased to 5L at 033O and has since remained > 95%. Breathing unlabored overnoc. (+) cough but nonproductive and assisted blowing nose with old blood secretions. NC changed over to humidified air.\n\nGU/GI: Foley draining amber colored urine. Urine outputs fair, >50cc/hr. Abd soft and distended. Moderate BM, guiac (+) soft and brown in appearance. TF up at MN at 10cc/hr prior to residual 50cc residual of bilious. Started on Reglan QID for ? delayed gastric emptying. At 0400 residual less that 5cc and TF advance to 20cc/hr. Next residual check at 0800. Given ice H2O overnoc for comfort.\n\nENDO: FS QID. Overnoc FS 125 and 136. Given AM dose of NPH.\n\nID: Low grade temps. Tm 101.1 and Tc 99.6. Given Tylenol 650mg x 2. Last at 0400.\n\nHEME: HCT 35 this AM.\n\nA/P:\nConsider possible PT/OT consult as MS continues to improve\nContinue repeative cues and emotional support\nConsider adding additonal antihypertensive in addition to ACE and BB\nContinue to monitor pulmonary status continue to wean O2\nAdvance TF's as tolerated.\nPossible transfer to floor. Transfer note in blue book.\n\n"},{"category":"Nursing/other","chartdate":"2144-04-13 00:00:00.000","description":"Report","row_id":1490839,"text":"CCU NURSING PROGRESS NOTE 3P- 11P\nS: WHEN CAN I GO HOME?\nO:\nCV: FOR A COMPLETE SET OF VS AND OBJECTIVE DATA PLEASE REFER TO CARE VUE FLOWSHEET. DENIES CP/ SOB WHEN ASKED. REMAINS IN SR , NO VEA NOTED. NITRO DECREASED TO 40 MCG AFTER 4 PM CATOPRIL DOSE. GIVEN LOPRESSOR DOSE EARLY AT 9 PM FOR HR OF 85 AND SBP 160. AWAITING RESULTS.\nRESP: LUNGS WITH CLEAR UPPER LOBES AND CKLS AT LOWER BASES. SATS 91 - 96%. CONTS ON 4L O2.\nGI/ GU: TF AT 20 CC/HOUR INITALLY. THEN RESIDUALS AT 8 PM NOTED TO BE >120. TF HELD AT PRESENT. PT IS ABLE TO SWALLOW PILLS WITH SIPS OF WATER. ? ABSORPTION. CONTS ON REGLAN. BS PRESENT. TWO SMALL SOFT GUIAC POS STOOLS NTED.\nMS: PT IS A&O TO PERSON AND PLACE. HE IS PLEASANT AND COOPERATIVE. LIMITED STM, NEEDING FREQUENT REMINDING/ RE ORIENTATION. DAUGHTERS IN ALL EVE. FAMILY VERY HELPFUL WITH CALMING/ REORIENTATION.\nA: APPEARS STABLE , BUT ? ABSORPTION OF MEDS OR NEED TO INCREASE DOSES, TRANSFER TO THE FLOOR\nP: CONT OT MONITOR, ? INCREASE DOSING OF LOPRESSOR/ CAROPRIL, AWAIT BED.\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70951,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: s/p VF arrest, LAD stent, hypotension\\nHeight: (in) 73\\nWeight (lb): 209\\nBSA (m2): 2.19 m2\\nBP (mm Hg): 127/90\\nHR (bpm): 101\\nStatus: Inpatient\\nDate/Time: at 11:34\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is normal in size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. 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. There is moderate\\nregional left ventricular systolic dysfunction.\\n\\nLV WALL MOTION: The following resting regional left ventricular wall motion\\nabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -\\nhypokinetic; anterior apex - hypokinetic; septal apex - hypokinetic; inferior\\napex - hypokinetic; apex - hypokinetic;\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\\ndilated.\\n\\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\\nmitral regurgitation is seen (within normal limits).\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\nThe left atrium is normal in size. The left ventricular cavity size is normal.\\nThere is moderate regional left ventricular systolic dysfunction. Resting\\nregional wall motion abnormalities include severe hypokinesis of the mid and\\ndistal septum and apical segments. Right ventricular chamber size and free\\nwall motion are normal. The ascending aorta is mildly dilated. The aortic\\nvalve leaflets are mildly thickened. The mitral valve leaflets are mildly\\nthickened. There is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160019,\n \"text\": \"Normal sinus rhythm. Q waves in leads III and aVF suggest inferior myocardial\\ninfarction. Compared to tracing #1, the Q waves in the inferior leads are now\\napparent. The ST segment depressions in the anterior leads has resolved.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160020,\n \"text\": \"Sinus tachycardia. Low limb lead voltage. RSR' pattern in leads V1-V2.\\nST segment depressions in the anterior leads suggest possible anterior\\nischemia. No previous tracing available for comparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160013,\n \"text\": \"Sinus rhythm\\nProbable old inferior infarct\\nAnteroseptal T wave changes may be due to myocardial ischemia\\nLow QRS voltages in precordial leads\\nSince previous tracing, , no ventricular premature complex\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160014,\n \"text\": \"Sinus rhythm\\n- premature ventricular contractions\\nOld inferior infarct\\nAnterior T wave changes are nonspecific\\nRhythm strip shows normal sinus rhythm\\nSince previous tracing, , ventricular premature complex seen\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160015,\n \"text\": \"Sinus rhythm\\nPossible old inferior infarct\\nSince previous tracing, , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160016,\n \"text\": \"Sinus rhythm, rate 77. Since the previous tracing of the heart rate has\\nslowed somewhat. Technical artifacts are seen. Increased ST-T wave\\nabnormalities are noted, particularly over the anterolateral leads.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160017,\n \"text\": \"Normal sinus rhythm. T wave flattening in leads III, aVF and V4-V6 suggest\\npossible inferolateral ischemia. Compared to tracing #3, the inferolateral\\nT wave flattening is new.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 160018,\n \"text\": \"Normal sinus rhythm. Compared to tracing #2, the Q waves in the inferior leads\\nare no longer present.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"C-SPINE (PORTABLE)\",\n \"row_id\": 756196,\n \"text\": \" 2:38 PM\\n C-SPINE (PORTABLE) Clip # \\n Reason: please r/o fracture; please focus on c7/t1 as previuos films\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p vfib arrest and fall with head and face trauma\\n REASON FOR THIS EXAMINATION:\\n please r/o fracture; please focus on c7/t1 as previuos films missed this\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 57 y/o man status post V-fib arrest and fall with head trauma.\\n\\n Single lateral swimmer's view of the cervical spine is read in conjunction\\n with AP and lateral cervical spine from earlier the same day. The cervical\\n spine is normal in alignment through C7 without evidence of fracture. C7-T1 is\\n not adequately visualized.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756136,\n \"text\": \" 11:44 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. ch\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest, now intubated and stable\\n REASON FOR THIS EXAMINATION:\\n 57 y/o man intubated with PAC in place s/p v-fib arrest. check for ETT\\n placement and PAC placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: S/P pulmonary artery catheter placement and ventricular\\n fibrillation arrest.\\n\\n COMPARISONS: .\\n\\n CHEST, SINGLE: The heart size is within the upper limits of normal. The\\n mediastinal and hilar contours are stable in appearance. There is increased\\n bilateral perihilar haziness and alveolar opacities. The left costophrenic\\n angle has been excluded from this study. There is opacification of the left\\n retrocardiac space. An endotracheal tube it is approximately 5 cm above the\\n carina. The nasogastric tube tip distended below the field of view. The\\n apparent Swan-Ganz catheter tip lies in the right ventricular outflow tract.\\n The osseous structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. New pulmonary edema.\\n\\n 2. Swan-Ganz catheter in right ventricular outflow tract.\\n\\n 3. Left lower lobe consolidation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"C-SPINE (PORTABLE)\",\n \"row_id\": 756137,\n \"text\": \" 11:44 PM\\n C-SPINE (PORTABLE) Clip # \\n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. Fo\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest.\\n REASON FOR THIS EXAMINATION:\\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Found down, in\\n cervical collar, need to clear c-spine.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Found unconscious, evaluate cervical spine.\\n\\n AP AND LATERAL CERVICAL SPINE: Vertebral bodies C1 through C6 are visualized.\\n There is normal alignment and vertebral body and disc heights. The\\n prevertebral soft tissues cannot be evaluated due to intubation and NG tube\\n placement. No fractures or dislocations identified. The frontal view is\\n unremarkable.\\n\\n IMPRESSION: C1 through C6 in normal alignment without evidence of fracture.\\n C7 is not visualized on the study.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756164,\n \"text\": \" 8:08 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. As\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest.\\n REASON FOR THIS EXAMINATION:\\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Assess for PAC\\n placement, ETT placement.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: S/P V-fib arrest with pulmonary artery catheter and\\n endotracheal tube placement.\\n\\n COMPARISONS: at \\n\\n CHEST, SINGLE: The cardiac, mediastinal and hilar contours are stable in\\n appearance. There has been slight interval improvement in the perhilar and\\n predominantly central pulmonary alveolar opacities. There is persistent\\n opacification of the left lower lobe with a small left pleural effusion. The\\n endotracheal tube tip is approximately 5 cm above the carina. The Swan-Ganz\\n catheter tip is in the right ventricular outflow tract. Nasogastric tube tip\\n overlies the proximal stomach with the side port at the level of the\\n diaphgram. The soft tissue and osseous structures are unremarkable.\\n\\n IMPRESSION: Slight improvement in the pulmonary edema.\\n\\n Nasogastric tube side port at the level of the diaphragm, recommend advancing\\n this by several cm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"CHEST CTA WITH CONTRAST\",\n \"row_id\": 756122,\n \"text\": \" 7:52 PM\\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \\n Reason: r/o pe\\n Field of view: 47 Contrast: OPTIRAY Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with cardiac arrest, ? pe\\n REASON FOR THIS EXAMINATION:\\n r/o pe\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cardiac arrest, ? of PE\\n\\n TECHNIQUE: Multiple axial images were obtained from the thoracic inlet from\\n the lung basis after the administration of intravenous contrast.\\n\\n CONTRAST: 100cc of Optiray were administered due to the fast bolus\\n requirements: There were no complications.\\n\\n CT CHEST WITH INTRAVENOUS CONTRAST: The heart and great vessels are grossly\\n normal in appearance. No intraluminal filling defects are seen within the\\n pulmonary circulation. An NG tube is seen passing into the esophagus. There\\n is complete collapse of the left lower lobe. Atelectasis and diffuse\\n parenchymal opacification are seen at the right lower lobe and posterior right\\n middle lobe, findings consistent with aspiration. There is a high attenuation\\n nodular density in the peripheral right middle lobe, which may represent a\\n granuloma versus a small enhancing nodule. There are no pleural effusions. No\\n pneumothoraces are identified. An ET tube is seen terminating in the trachea\\n just below the thoracic inlet. A few scattered mediastinal lymph nodes do not\\n meet CT criteria for pathologic enlargement.\\n\\n Multiplanar reformatted images confirm the above findings.\\n\\n The soft tissues and osseous structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. No evidence of pulmonary embolism.\\n 2. Total collapse of left lower lobe.\\n 3. Multifocal areas of atelectasis and probable aspiration.\\n 4. Nodule or granuloma of right middle lobe.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756351,\n \"text\": \" 4:49 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate NG placement before starting TF/PO meds\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 yo male a/w VF arrest, now extubated, replaced NGT. Need to start TF.\\n REASON FOR THIS EXAMINATION:\\n evaluate NG placement before starting TF/PO meds\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: V-fib arrest. Now extubated. Replaced NG tube. Assess NG tube\\n placement before starting tube feeds.\\n\\n PORTABLE AP CHEST: Comparison . The patient is rotated. There has been\\n interval removal of the ET tube. There is an NG tube with tip in the stomach\\n and sideport just below the level of the diaphragm. The heart is enlarged.\\n There are bilateral patchy alveolar opacities throughout the lungs, without\\n significant change. This likely reflects edema, although multifocal infection\\n could also have this appearance.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756245,\n \"text\": \" 10:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate ETT placement and lung parenchyma for state of CHF.\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest.\\n REASON FOR THIS EXAMINATION:\\n Evaluate ETT placement and lung parenchyma for state of CHF.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Evaluate endotracheal tube placement and CHF.\\n\\n COMPARISON: .\\n\\n CHEST, PA AND LATERAL: Allowing for technique and patient rotation, the\\n bilateral diffuse pulmonary alveolar opacities are unchanged. The\\n cardiomediastinal and hilar contours are unremarkable. The endotracheal tube\\n tip is approximately 8 cm above the carina. The nasogastric tube overlies the\\n stomach but the side port is above the diaphragm. The soft-tissue and osseous\\n structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1) High-lying endotracheal tube, terminating 8 cm above carina.\\n\\n 2) No significant change in CHF.\\n\\n 3) Nasogastric tube side port above the level of the diaphragm.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756469,\n \"text\": \" 2:25 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate, worsening CHF\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 yo male a/w VF arrest, ? aspiration, now extubated, spiking fevers on\\n levo/flagyl. r/o worsening infiltrates.\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate, worsening CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: V fib at rest. Extubated and spiking fevers.\\n\\n COMPARISONS: .\\n\\n AP PORTABLE UPRIGHT CHEST: The left costophrenic angle is excluded. Lung\\n volumes appear slightly improved and the left lung has nearly completely\\n cleared in the interval. There is persistent, though lessened, patchy opacity\\n in the right perihilar region compatible with resolving pneumonia. The NG\\n tube may have been retracted in the interval and the side port is not well\\n visualized and may sit above the GE junction. Cardiac and mediastinal\\n contours are unchanged.\\n\\n IMPRESSION: Improving multifocal pneumonia. NG tube probable malpositioned.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-17 00:00:00.000\",\n \"description\": \"CHEST (SINGLE VIEW)\",\n \"row_id\": 756781,\n \"text\": \" 1:34 PM\\n CHEST (SINGLE VIEW) Clip # \\n Reason: pt had a left sided picc placed and needs tip confimation, p\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man with s/p cardiac arrest, bacterimia who needs picc for iv\\n vanco.\\n REASON FOR THIS EXAMINATION:\\n pt had a left sided picc placed and needs tip confimation, please page \\n with wet, read,asap because they would like to d/c pt. to rehab., thanks.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cardiac arrest, PICC line placement.\\n\\n TECHNIQUE: Single view chest: This film is dated and it now\\n comes to the radiology list for dictation. There has been a PICC line placed\\n and is seen at the lower SVC. There is basilar atelectasis on the left.\\n\\n No pneumothorax is present.\\n\\n PICC line seen at the lower SVC. No pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-18 00:00:00.000\",\n \"description\": \"R US EXTREMITY NONVASCULAR RIGHT\",\n \"row_id\": 756858,\n \"text\": \" 2:42 PM\\n US EXTREMITY NONVASCULAR RIGHT Clip # \\n Reason: SWOLLEN RED RT ANTECUB FOSSA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p VF arrest, with MRSA bacteremia likely 2' to infection in\\n right anticubital fossa, ruled out abscess.\\n REASON FOR THIS EXAMINATION:\\n r/o abscesss in right antecubital fossa\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: MRSA bacteremia with infection in right antecubital fossa.\\n Evaluate for abscess.\\n\\n Targeted scale, Doppler and color images were obtained within the\\n antecubital fossa. There is no evidence of a discrete fluid collection. The\\n right cephalic vein is occluded with thrombus. There is no evidence of\\n Doppler flow.\\n\\n IMPRESSION:\\n 1. No discrete fluid collection to suggest abscess formation. There are soft\\n tissue changes consistent with cellulitis.\\n 2. Thrombus within the superficial cephalic vein.\\n\\n These findings were directly communicated to the physician caring for the\\n patient.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 756114,\n \"text\": \" 6:13 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for tube placement\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 30 year old man with s/p out of hospital arrest, now intubated and stable\\n REASON FOR THIS EXAMINATION:\\n eval for tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Status post cardiac arrest, now intubated and stable. Evaluate tube\\n placement.\\n\\n FINDINGS: The tip of the endotracheal tube is seen at the level of the\\n thoracic inlet, approximately 7 cm above the carina. The tip of a nasogastric\\n tube is seen just distal to the GE junction, with the side port likely within\\n the distal esophagus. Evaluation of the mediastinum and lungs is somewhat\\n limited secondary to the overlying trauma board, patient motion and a cardiac\\n pacer seen overlying the left lateral/lower hemithorax. The cardiac and\\n mediastinal contours appear within normal limits. There are no focal\\n consolidations or pleural effusions. The visualized soft-tissue and osseous\\n structures are unremarkable.\\n\\n IMPRESSION: Endotracheal tube can be further advanced, with the tip now\\n approximately 7 cm above the carina. Nasogastric tube can also be advanced,\\n as the side port is now within the distal esophagus.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2144-04-08 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 756117,\n \"text\": \" 7:00 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: s/p trauma\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 57 year old man s/p fall, with head trauma and bleeding\\n REASON FOR THIS EXAMINATION:\\n s/p trauma\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Head trauma.\\n\\n TECHNIQUE: Multiple axial images were obtained from the foramen magnum to the\\n cranial vertex without intravenous contrast.\\n\\n FINDINGS: There is some streak artifact from the underlying stiffener board.\\n No intraaxial or extraaxial fluid collections or hemorrhages are identified.\\n There is no shift of the normally midline structures, or mass effect. The CSF\\n spaces are normal. No definite sulcal effacement is seen.\\n\\n Some mucoperiosteal thickening is seen within the visualized portions of the\\n ethmoid sinuses. The orbits, soft tissues and osseous structures of the head\\n are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. No evidence of acute intracranial hemorrhage.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490840,\n \"text\": \"CCU NSG PROGRESS NOTE.\\nO:NEURO=A&O X2. COOPERATIVE. APPROPRIATE. VERY WEAK-ALL EXTREMETIES.\\n PULM=BREATH SOUNDS=DEMINISHED/CLEAR THROUGHOUT. SATS MID 90'S.\\n CV=HEMODY STABLE. NTG WEANED & DCED. TOLERATING CAPTO/LOPRESSOR.\\n GI=SELF DCED NGT. TOLERATING CL LIQ-ABLE TO TAKE PO MEDS.\\n GU=FOLEY. ADEQ UO.\\n ID=LOW GRADE T. R-ANTECUB NOTE TO REDDENED/WARM/HARD TO TOUCH-WO CO DISCOMFORT.\\n LABS=AM SENT.\\n\\nA:IMPROVING.\\n\\nP:CALL-OUT. CONTIN PRESENT MED MANAGEMENT.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490841,\n \"text\": \"ccu nursing progress note\\ns: i had a heart attack\\no: pls see carevue flowsheet for complete vs/data/events.\\npls see transfer note from for complete details.\\nneuro: improving. not agitated or confused. ox , cooperative. has poor stm. haldol dc'd.\\nremains weak in arms and legs req 2 person pivot/transfer. req assistance w/ feeding. also needs monitoring for aspiration but appears to be doing well with pills, jello, liquids when sitiing up.\\ncv: hr 80-90s sr, bp 120-160/70. tol lopressor and captopril w/ ^'ing doses. not on antiarrhythmics. will req eps, poss device prior to d/c. no vea since admit.\\nresp: ra sat 93-95%, rr 24-30. bs coarse/dim at bases.\\ngi: tol diet, to advance. aspiration precautions. no stool.\\nendo: covered per ss and nph. was previously on oral .\\ngu: foley. good uop.\\nid: on flagyl and levo for aspiration. cont w/ low grade temps. also has mild cellulitus at r antecub.\\nsocial: married, 3 children. lives on . works for health care/home care co.\\na: s/p arrest c/b anoxic brain injury and aspiration pneumonia. s/p stent to lad.\\np: cont to follow rhythm, response to cardiac meds. resp exam. advance diet. follow bs. follow ms. pt and ot. may need rehab stay. support to pt and family. transfer to 2 when bed avail.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490824,\n \"text\": \"Respiratory Care: Pt recieved from cath lab put on AC 750*16 100% 10 PEEP. Pt had likely aspirated pao2 was poor ( 83 on 100% and 10 peep). Pao2 improved( see careview) Fio2 weaned to 60%. EET advanced from 22 to 25 MD verbal order. Bs equal bilat. Will continue to follow and wean Fio2 as tollerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490825,\n \"text\": \"CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\\nHPI/CC: 57 year old male with limited medical history available found down , flat on face. According to friends he was feeling well during the day, no c/o nausea, CP, and SOB. Was then walking and suddenly collapsed, no convulsions noted. When EMT's arrived, police officer doing CPR and pt unconscious, pulseless, and agonal respirations and blood from mouth and nares. Pt shocked with 200J in AIVR without pulses. Intubated in field. Atropine given and pt in CHB with a ventricular rate of at 150. EKG in field showing changes in lateral leads. Pt then transferred to ER where started on Lido gtt and given occasional Versed and Ativan. Moving all extremeties and coughing while intubated. Prior to passing OGT pt vomitted large amount dark brown material and chunks of food. During assessment by house staff O2Sats marginal at 88-90% on 100% Fio2. Pt was suctioned numerous time for copious amounts of food particles from ETT. Pt then taken for Head CT which was (-) for intracranial hemmorhage but showing some white and matter.? anoxia. Chest CT also done in addition which was (-) for PE and showing LLL consolidation. Post pt taken for Cath.\\n\\nCATH LAB: Cath procedure performed without difficulty with the following findings. LHC: RA 26, PA, 42/19, PA 20, CO 8.19 and CI 3.65\\nLAD mod calcified, 90% mid occlusion involving moderate DZ. LAD stented times two. TIMI flow of 3 prior to intervention and post. RCA with diffuse dz 70%. and LMCA normal.\\n\\nID: Febrile. Tmax 102.6 rectal given Tylenol time two. Last given at 0600. Called for cooling blanket. Levo and Flagyl started this AM\\nWBC from MN labs down from admission to 3(11).\\n\\nCV: HR 100's to 110's with rare PVC's. Given total of 10mg of Lopressor in Cath Lab. Repeat doses given aroung MN of 5mg x two and 25mg PO. HR maintaining 88 to low 90's. In addition Lidocaine continuing at 2mg/hr. BP when recieved from CL hypertensive. Given Versed and Verc in transit to floor shortly after pt awakening. Given 2 of Ativan and 50 of Fentanyl and BP bottoming. Recieved NS bolus total of 1.5L and BP recovering. Since has been labile and recieving additional numerous boluses. SBP 80-90's with map > 65. A-V sheath in place with femoral swan at venous site. PAD 12-24 overnoc. Swan unable to wedge. Recv'd 20mg of Lasix post boluses and numbers repeated 1-2hours post. CO/CI/MV 3.0/1.67/57. ? validity of swan because could not visualize in . Femoral site with small ooze and no noted hematoma. Pulses palpable distal. Integ at 16mls at to dc at 2200.\\nK and Mg repleted.\\n\\nNEURO: Sedated and intubated. Ativan at 2mg/hr. Currently unresponsive. Earlier durin night began to awake and moving right extremety only. PERL. 3mm bilaterally. Corneal reflex (+) in left eye only. Right pupil less sluggish than left. Not moving any extremeties.\\nFentanyl gtt off due to labile BP's\\n\\nRESP: Current vent setting at AC 750 x 16 .50 and 7.5 PEEP. When recieved from CL suctioning for copious amounts\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490829,\n \"text\": \"CCU NSG PROGRESS NOTE.\\nO:NEURO=SEDATED W FENTANYL @ 50MCG & ATIVAN @ 1MG CONTIN W GD EFFECT. AROUSABLE, BUT DOES NOT FOLLOW COMMANDS. WHEN STIM MOVEMENT OF UPPER BODY-SHOULDERS, NECK, & HEAD-ONLY!.\\n PULM=INTUBATED & VENTED W SETTINGS-AC/50%/750X16/+7.5 W AM ABG-7.50/31/71/25/1 W SATS 97-98. RR DECREASED FROM 16 TO 12. BREATH SOUNDS=COURSE THROUGHOUT. SX-SCANT THICK TAN/BROWN SECRETIONS.\\n CV=HEMODY STABLE. NSR WO ECTO. MAPS 70-80'S. PADS 16-18. CKS SENT @ 0000 & 0500.\\n GI=TF @ 10ML/HR W MINIMAL RESIDUALS. WO STOOL.\\n ID=FOLEY. LASIX 80MG @ 0000 W EXCELLENT RESPONSE.\\n ENDO=BL SUGARS TRENDING DOWN. INSULIN GTT DECREASED TO 1U/HR W BL SUGAR 102.\\n MISC=COLLAR/NECK CARE DONE.\\n LABS=AM SENT.\\n\\nA:COMFORTABLE THROUGHOUT NIGHT.\\n\\nP:CONTIN PRESENT MED RX. ADEQ SEDATION. INCREASE TF AS TOLERATED. FOLLOW BS-ADJUST/DC GTT AS INDICATED. CK AM LABS-REPLACE AS NEEDED.\\nSUPPORT PT/FAMILY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490830,\n \"text\": \"Resp Care\\nremains intub/vented ac mode. resp alkalosis thus vent changed to rate 12 ...settings 750x12x.5/7.5 peep. borderline oxygenation. small amts secretions..orangey/brown. stable plateaus. ?increase peep. c/w vent support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490831,\n \"text\": \"CCU NURSING PROGRESS NOTE 7A-3P\\n\\nNEURO: Pt sedated on fentanyl and ativan gtts. PERL 3mm. Pt intermittently able to open eyes and wiggle toes to command; no purposeful movements noted of upper extremities. Ativan gtt dc'd at 1pm. Will cont to assess neuro status for changes. C-spine collar in place.\\n\\nRESP: Intubated on AC 750x12 with peep weaned to 5 and Fio2 weaned to 40%. ABG: 88/35/7.45. Suctioned for minimal amt thin tan secretions.\\nPlan is to begin weaning sedation today and based on neuro status, aiming for vent weaning/extubation tomorrow.\\n\\nCARDIAC: Hemodynamically stable. No VEA. C.O. 10.6/C.I. 4.77. right groin swan dc'd and tip sent for cx. Pt started on 12.5mg captopril TID. CPKs trending down.\\n\\nGI: Pt with minimal OG aspirates. Tube feeds advanced to 30cc/hr with goal rate of 80cc/hr. +BS. No stool this shift.\\n\\nGU: foley draining cloudy yellow urine with sediment. Pt is -1200cc at this time. No plans for further diuresis at this time.\\n\\nENDO: FS range 138-180. Conts on insulin gtt 1-3u/hr.\\n\\nID: afebrile all shift on RTC tylenol. Conts on IV abx for presumed aspiration pnx.\\n\\nACCESS; Right a-line and 3 peripheral IVs intact and working well.\\n\\nFAMILY: Pt's 2 daughters and wife in and out most of afternoon. Appear to be asking appropriate questions. Pt's oldest daughter, has agreed to be spokesperson for all phone calls. Cardiology fellow has spoken to family and informed them of pt's progress and present status.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490832,\n \"text\": \"CCU Nursing Note 1500-2300: Vfib Arrest, Aspirat PNA\\nID: Low grade temps. Recieving Tylenol ATC with fair effect and continues on IV Abx for aspiration PNA.\\n\\nMS: Sedated and intubated. Fentanyl and Ativan weaned today. Recieved at 1500 with Ativan off and Fentanyl at 75ugs. Fentanyl further weaned to 65ugs. Pt now flailing in bed. MAE's. Not obeying or following commands. Moving neck from side to side. Started on Propofol at 10ugs and increased to 20ugs with excellent effect.\\n\\nCV: VSS. transiently dropping BP to high 90's with sedation titration.\\nHR 80's. NSR with no ectopy. SBP 99-mid 100's. Hypertensive when aroused. Right femoral site with small hematoma and slight ooze but has decreased further into night. Pulses palpable distal. Skin clamy and warm to touch.\\n\\nRESP: LS course with occasional rhoncerous sounds throughout. O2Sats high 90's. Vent settings at AC 750/12/50/5 PEEP. No ABGs' done this shift due to the prior being WNL. Suctioning for moderate to large amounts of thick dark tan sputum, ? food particles. During period of flaling pt found not to be recieving TV's. Resp notified and pt biting on tube. Sedation administerd.\\n\\nGU: Foley patent, intact and draining golden colored urine. Received pt with sediment on walls of the foley tubing but not draining urine with sediment. U/O adequate, > 40cc/hr.\\n\\nGI: Abd soft and distended with normoactive BS's. TF increased to 40cc/hr but shut off when pt found not to be recieving volumes and since have not been shut back on. When increased found to have residual of 10cc. OGT intact and in place. Passing flatus but no BM's this shift.\\n\\nENDO: Insulin gtt continues at 3u/hr. FS ordered Q1H but have been checking 1-3hrs. FS range from 120-140's. No adjustments made this shift.\\n\\nSKIN: Facial and knee lacerations open to air. Cleansed this shift with NS and applied bactroban to wounds. Upper back area where C-collar rested are red and open abrasions. No drainage. Cleansed with NS and left open to air.\\n\\nDISPO: 57 year-old man who is S/P VF arrest with a guestimated time out of 4 minutes prior to EMS intervention who had emergent PTCA and stented x two the LAD. Pt course then c/b aspiration pna where he remains vented and sedated.\\n\\nPLAN:\\nTitrate sedation to keep pt comfortable\\nPossible re-trial of weaning sedation in AM to assess MS further\\nContinue BB and ACE as tolerated\\nMonitor skin\\nDiscuss possible anticoagulation\\nContinue to monitor hemodynamics\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490833,\n \"text\": \"Respiratory Care:\\n\\nPatient remains intubated on mechanical support. Vent settings Vt 750, A/C 12, Fio2 40%, and Peep 5. PAP/Plateau 22/19. Bs slightly coarse L Lung, R Lung clear. Sx'd/lavaged for sm amounts of thick tan sputum. Abg's within normal limits. Pt. remains sedated. ETT retaped at 26cm. No further changes made. Continue with mechanical support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490836,\n \"text\": \"CCU Nursing Note 1900-0700: S/P VFib Arrest/ Aspir P\\nSee carevue for VSS and all objective data:\\nS: Pt moaning and groaning.\\n\\nID: Afebrile. Given Tylenol ATC. Continues on IV Flagyl and Levo.\\n\\nMS: Still not obeying and following commands. Moving head from side to side and moving all extremeties in bed. Opened eyes once during shift but not to command. Neck and limbs remain flacid while on Propofol. Propofol attempted to wean but pt very restless. Given Haldol 5mg at HS and QID ATC. Since 0300 pt somolent. Needed emotional support and positive re-inforcement.\\n\\nCV: NSR-ST. Hypertensive and tachycardic when restless. Given Captopril and Lopressor with good effect. Nitro off due to low BP. QT interval checked at 0.16. Since 0300 has been NSR, HR 70's and BP 120-130's. Continue to BB and ACE-I as needed.\\n\\n\\nRESP: LS course. FM weaned to .50 Fio2. CPT. Deep oral suctioned for blood-tan colored sputum. O2Sats 97-99%. Breathing unlabored. Continue CPT and sx as needed.\\n\\nGU/GI: Urine outputs adequate, >/= 60cc/hr. TF restarted at 0400 at 30cc/hr. Prior to residual 5cc. No residual checked since started.\\nLarge BM tonoc. Soft-paste like consistency, brown in color. Guiac not checked. Continue to advance as tolerated and guiac stools.\\n\\nENDO: Insuling gtt decreased to 2u/hr. FS ranging from 77-98. Continue to monitor FS.\\n\\nSKIN: Cut and bruises open to air. Healing well. Continue to monitor.\\n\\nSOCIAL: Family into visit earlier during shift. No phone call overnoc.\\n\\nDISPO: 57 year-old male who s/p vfib arrest who arrest was c/b aspiration pna. Intubated and now extubated with new concern post extubation of anoxia.\\n\\nContinue to monitor.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490837,\n \"text\": \"CCU Nursing Progress Note\\nS-\\\"I have a little headache\\\"\\nO-Neuro becoming more awake during the day. Following commands , . Talking to family and staff. Mumbling most of the time, speech is not clear but understandable. Propofol weaned and d/c'd and haldol increased to 5mg QID. Family with pt mst of time but occ restlessness treated with IV haldol prn.\\nCV-VSS IV NTG restarted with SBP 170's but weaned to 40mcg when captopril increased to 50mg TID BP 124-138/58-70 HR 79-90 NSR\\nResp-O2 weaned to 5l NP with O2 sats 96% ABG 7.45/38/55 but O2 sats improved to 99-100% later in the am. LS coarse Occ NPC.\\nID temp 101 IV abx changed over to po flagyl and levo.\\nGU-urine output improved 100cc/hr and received lasix 40mg IVB with transfusion.\\nGI-NGT in place tube feeds on hold d/t high residuals which remained most of the day. Possibly start reglan for gastricparesis. Incontinent of moderate amt of soft brown stool OB+. HCT 28 receiving 2nd unit of PRBC over 4hrs.\\nEndo- Insulin 2u/hr gtt d/c'd adn started NPH 10u FS 121-156\\nSOcial-family all in and aware of POC. Happy pt is conversant.\\nA/P-Continue to adjust meds as tolerated. Keep pt negative.\\nStart reglan. Follow electrolytes closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490826,\n \"text\": \"CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\\n(Continued)\\nof food particles. Now not raising anything from ETT. ETT tube advanced 4cm by resp. ABG improved. LS course. O2Sat 99-100%\\n\\nGU/GI:Foley patent and intact. Draining CYU. U/O adequate prior to low BP's. Currently making 30-500cc/hr for past 2hrs. HO aware. Abd firm and distended with normoactive BS's. OGT in place.\\n\\nENDO: Insulin gtt at 4u/hr per sliding scale. FS ranging 187-267.\\nFollowing FS q1h.\\n\\n: Collar in place. Cspine film done at bedside last night. No injuries noted.\\nCollar in place until pt awake or till trauma team clears\\n\\nPLAN:\\nPossible removal of swans\\nIntegrillin to dc at 2200\\nContinue to follow neuro status\\nContinue to monitor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490827,\n \"text\": \"Resp. Note\\nPt remains on AC 16/750/7.5/50% No changes made today. Bronchoscopy done-poss food/foreign body aspiration. No particles found. Pt was sx today for brownish secretions throughtout the day. Will cont support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490828,\n \"text\": \"ccu nursing progress note\\ns: orally intubated\\no: pls see carevue flowsheet for complete vs/data/events\\nid: low grade temp. wbc nml. cont on levo and flagyl.\\nneuro: ativan weaned down this am, pt became more active, mae with good strength but nonpurposeful. not able to open eyes or follow commands, did appear to respond to stimuli. in afternoon pt underwent bronch req ^'d sedation w/ fent and ativan. pt remains sedated currently on 1mg ativan/hr. no evidence of sz activity.\\ncv: in sr rate 75-90s sr, no vea. lido dc'd this am. bp low this am and req 500ccns bolus this am to stabilize. remained 95-120/60-70 via r rad aline.\\ntol lopressor later in am.\\nr fem aline pulled. cont w/ r fem venous/pa line. paps 30s/.\\nsm soft hematoma. pulses 2+/ bilat.\\nintegrillin cont at 16cc/hr. to complete at 11pm.\\nck up 1300, mb 19. will cont to cycle.\\nresp: cont on a/c 750 x16. 50% and 7.5 peep. sats >95%. sxn'd for mod amt drk tan sputum. bronch'd this afternoon to eval ?collapse for lll. lobe was found to be inflated and lavaged for mod purulent sputum.\\ngi: abd soft, +bs. no stool. min aspirates. tf started via ogt, promote w/ fiber at 10cc/hr. awaiting nutrition consult to confirm and set goal.\\ngu: uop 30-50cc/hr. remains +3l since admit. will dose w/ lasix this eve. cr 1.4.\\nskin: abrasion on face/chin. ota. some bruising underarms.\\nremains w collar. cspine film taken this afternoon. has yet to be cleared.\\nsocial: wife and children in today. updated. home for eve now.\\na: bp stable s/p fluid this am. rhythm stable. neuro improving.\\np: cont to monitor cv and neuro status. wean o2 as tol. cpt as tol. cont with cspine precautions. advance tf as tol. monitor fever and await cultures. support to pt and family.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490834,\n \"text\": \"ccu npn 11p-7a\\nS: intubated and sedated\\n\\nO: Please see carevue for VS and objective data\\n\\nCVS: Hemodynamically stable with HR 70-80 NSR, no vea noted. K+ 3.6 repleted with 40meq po KCL. am K+ pnd. BP 107-150/50-60. Tolerated po Captopril and Lopressor.\\n\\nResp; Remains intubated and mechanically ventilated on A/C 750x12 40%/5 peep. Good abgs as per flow. Am abg 105/36/7.42/24/0. Suctioned q 3-4 hours for small-mod. amounts of tan sputum. Lungs coarse. Rare spont. breathe over vent. impaired gag and cough.\\n\\nID: low grade on IV Flaggyl and Levo.\\n\\nEndo: Regular Insulin drip titrated 3u-4u/hour for glucose ranges 118-192.\\n\\nGI:GU: TF Promote with fiber at 30cc/hour increased to 40cc/hour without sign. residuals. Abdomen soft and distended with active bowel sounds. No stool. Foley to drainage with dark yellow urine with sediment. I/O neg 700cc at MN, positive 400cc this am.\\n\\nNeuro: Remains sedated on IV Propofol, increased to 40mcg/kg/min. for restlessness. with good effect. MAE, moving head side to side. Not opening eyes or following commands. PERL R>L. 3mm. Soft hand restraints intact. Poor gag and weak cough.\\n\\nA: Hemodynamically stable s/p arrest. Remains sedated and intubated.\\n\\nP: Cont to assess hemodynamics. Cont aggressive pulmonary toileting. Sedation as needed. Cont. insulin drip with tube feedings. Assess neuro status. Comfort and emotional support to Pt. and family. Follow up with am labs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490835,\n \"text\": \"CCU Nursing PRogress Note\\nS-Delirious\\nO-Neuro weaned off propofol by 1030 and added haldol 5mg x2 1 hr apart for persistant delirium with good effect. ALthough when IV haldol wore off (4hours) aggitation returned 1400 and required low dose propofol for pt saftey. Started po haldol 2.5mg QID started at 1800. Still requiring prn Haldol 2.5-5mg IVB. MAE very strong arms requiring wrist restraints. Opening eyes but not focusing or following commands.\\nCV- hypertensive 160-180 with aggitation requiring IV NTG 200-300mcg. Lopessor increased to 50mg TID and captopril increased to 37.5mg TID.\\nPlan to increase with each dose until desired effect. HR 88-110 NSR with occ isolated PVC's K+ 40meq KCL po x1 repeat 3.2. Radial aline replaced over a wire d/t brisk bleeding at site.\\nResp-Vent changed over to PS 15/PEEP 5 with spont VT 500-800 rr 20-28. PS/PEEP weaned down to 5/5 and quicikly extubated by 1200 to 100% neb with O2 sats 92-100% Last ABG 7.41/42/81 at 1630 on 100% face tent.\\nLS coarse with occ exp wheeze. Occ dry NPC.\\nID afebrile 99.7R WBC 6.9 on triple abx.\\nGI- NGT replaced for meds and tube feedings. Initial asp bile but after extubation coffee grounds OB+. Soft brown BM OB+. HCT 27.5 receiving 1uPRBC over 4 hours. Protonix\\nTube feeds stopped for extubation and to be restarted this evening.\\nGU-foley draining amber colored urine. Received lasix 40mg IVB with ~1200cc diuresis.\\nSKin- pressure sores from neck immobilizer neck, shoulder blades and head cleansed and left open to air\\nSocial- family all in and very supportive. Understanding POC\\nA/P-succ extubated, s/p AMI stent\\nPRN haldol for excessive aggitation, plan to wean off propofol when possible. CT scan Monday if MS unchanged.\\nLAsix 40mg IVB PRN for low urine output.\\nFollow electrolytes closely\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490838,\n \"text\": \"CCU Nursing Note 1900-700: Vfib arrest, Aspir PNA\\nS: \\\"I need to go to bathroom, I need to get up.\\\"\\nO: MS: Lethargic and oriented to self and place. Speech less garbled and voices needs appropriately. Obeying and following simple commands.\\nRestless and agitated overnoc needing repeative cues. Sleeping in spurts. Given 5mg every 2hr since MN with limited effect.\\n\\nCV:VSS stable overnoc. Still remains moderately hypertensive. Attempted to wean Nitro. High as 100ugs currently at 60ugs. Tolerating BB and ACEI titration. ? to adding additional antihypertensive on board.\\n\\nRESP:LS course on left and clear on right. O2Satt 95-99%/5l NC. Occasionally O2Sat dropping to 90-91& increased to 5L at 033O and has since remained > 95%. Breathing unlabored overnoc. (+) cough but nonproductive and assisted blowing nose with old blood secretions. NC changed over to humidified air.\\n\\nGU/GI: Foley draining amber colored urine. Urine outputs fair, >50cc/hr. Abd soft and distended. Moderate BM, guiac (+) soft and brown in appearance. TF up at MN at 10cc/hr prior to residual 50cc residual of bilious. Started on Reglan QID for ? delayed gastric emptying. At 0400 residual less that 5cc and TF advance to 20cc/hr. Next residual check at 0800. Given ice H2O overnoc for comfort.\\n\\nENDO: FS QID. Overnoc FS 125 and 136. Given AM dose of NPH.\\n\\nID: Low grade temps. Tm 101.1 and Tc 99.6. Given Tylenol 650mg x 2. Last at 0400.\\n\\nHEME: HCT 35 this AM.\\n\\nA/P:\\nConsider possible PT/OT consult as MS continues to improve\\nContinue repeative cues and emotional support\\nConsider adding additonal antihypertensive in addition to ACE and BB\\nContinue to monitor pulmonary status continue to wean O2\\nAdvance TF's as tolerated.\\nPossible transfer to floor. Transfer note in blue book.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2144-04-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1490839,\n \"text\": \"CCU NURSING PROGRESS NOTE 3P- 11P\\nS: WHEN CAN I GO HOME?\\nO:\\nCV: FOR A COMPLETE SET OF VS AND OBJECTIVE DATA PLEASE REFER TO CARE VUE FLOWSHEET. DENIES CP/ SOB WHEN ASKED. REMAINS IN SR , NO VEA NOTED. NITRO DECREASED TO 40 MCG AFTER 4 PM CATOPRIL DOSE. GIVEN LOPRESSOR DOSE EARLY AT 9 PM FOR HR OF 85 AND SBP 160. AWAITING RESULTS.\\nRESP: LUNGS WITH CLEAR UPPER LOBES AND CKLS AT LOWER BASES. SATS 91 - 96%. CONTS ON 4L O2.\\nGI/ GU: TF AT 20 CC/HOUR INITALLY. THEN RESIDUALS AT 8 PM NOTED TO BE >120. TF HELD AT PRESENT. PT IS ABLE TO SWALLOW PILLS WITH SIPS OF WATER. ? ABSORPTION. CONTS ON REGLAN. BS PRESENT. TWO SMALL SOFT GUIAC POS STOOLS NTED.\\nMS: PT IS A&O TO PERSON AND PLACE. HE IS PLEASANT AND COOPERATIVE. LIMITED STM, NEEDING FREQUENT REMINDING/ RE ORIENTATION. DAUGHTERS IN ALL EVE. FAMILY VERY HELPFUL WITH CALMING/ REORIENTATION.\\nA: APPEARS STABLE , BUT ? ABSORPTION OF MEDS OR NEED TO INCREASE DOSES, TRANSFER TO THE FLOOR\\nP: CONT OT MONITOR, ? INCREASE DOSING OF LOPRESSOR/ CAROPRIL, AWAIT BED.\\n\"\n }\n]"}}},{"rowIdx":187,"cells":{"subject_id":{"kind":"number","value":4313,"string":"4,313"},"hadm_id":{"kind":"number","value":148275,"string":"148,275"},"target_text":{"kind":"string","value":"31 year-old male with ESRD on HD, DMI, HTN presented with hyperkalemia in context of missing hemodialysis. He was section 12. Initially went to MICU for HD, then transferred to floor for continued HD. Had return to MICU later in hospital course for more intensive HD treatment secondary to hypoxia and fluid overload."},"extractive_notes_summ":{"kind":"string","value":"During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. Pt unable/pt refuse and PO medication. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. During pt's most recent admission/ED visit pt reported LLE swelling, LENIS negative and pt was given IV ABX. Noaortic regurgitation is seen. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . - Monitor for withdrawal # Anemia: Likely ACD. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. # Hypertension: Continue outpt meds and uptitrate prn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIS negative and pt was given IV ABX. Fragmentation of medial patella consistent with nondisplaced, comminuted fracture. FINAL REPORT HISTORY: Left lower extremity swelling. nonacute fracture vs post- traumatic heterotopic ossificaiton in adjoining medial retinaculum. IMPRESSION: 1) Findings consistent with medial tibial plateau fracture likely subcaute or chronic . Sinus rhythm with non-diagnostic repolarization abnormalities. There is an ossific fragment along the medial border of the patella, which appears well corticated, and which could represent a either fracture fragment or heterotopic ossification in the medial retinaculum. Sinus rhythm upper normal rateNormal ECGSince previous tracing of , ST-T wave abnormalities are less EXAMINATION: Unilateral left lower extremity DVT study. This again demonstrates a depressed medial tibial plateau fracture, similar to that seen on . FINDINGS: Grayscale and color Doppler son of the left common femoral, superficial femoral and popliteal veins were performed. Medial patellar fracture. 2) Ossicle along medial patella -- ? Compared to the previous tracing there is nosignificant change.TRACING #1 There is a small fracture through the medial aspect of the patella. Tibial and patellar fractures. Moderate joint effusion. Lateral T wave abnormalities. Compared to the previous tracing there is nosignificant change.TRACING #2 Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Depressed, impacted medial tibial plateau fracture which also extends to the intercondylar eminence and medial tibial spine. Clinical correlation and repeat tracing aresuggested. Possible subacute fracture along the medial patella. Compared to the previoustracing of lateral T wave abnormalities are new. Additionally, comminuted fractures of the medial and lateral tibial spines. The prior tracing was consistent with right atrial abnormality.Otherwise, no diagnostic interim change. Sinus rhythmNormal ECGSince previous tracing of , the heart rate is slower Delayed precordial R wave transition. Non-specific ST-T wave changes. Compared to the previoustracing of previous non-specific ST-T wave abnormalities have resolved.Otherwise, no important change. Compared to the previous tracing of no change.TRACING #1 There is evidence of diffuse vascular calcification. Please do delayed phase for better visualization of veins."},"n_notes":{"kind":"number","value":60,"string":"60"},"notes":{"kind":"list like","value":[{"category":"Social Work","chartdate":"2176-06-07 00:00:00.000","description":"Social Work Progress Note","row_id":373800,"text":"SOCIAL WORK:\n SW met with pt, brother (cell ), and mother\n . Pt reviewing his history of betrayal of his family and\n stating his intention to follow recommendations and change his\n behaviors. He would like his care centralized at . Mother spoke\n of how pt has always been self-centered\npt agrees\nto the point of not\n respecting the rights of others. Brother enforced how he still and\n always will love his brother, but that he does not like their\n relationship right now. All agreed that pt will have to earn back\n their respect and trust through hard work and behavior change. While\n pt is stating he would like to change his ways, he still provides many\n excuses for his behaviors (e.g.\n I may have stolen the credit card, but\n I wasn\nt going to use it just yet.\n Mother, brother, and psychiatrist Dr. , and this writer met\n separately from pt. Family reviewed h/o behavior, including\ndeviant\n behavior dating back to pt\ns childhood, but erratic mood swings and\n bizarre behavior (e.g. walking around family home undressed) only in\n recent months. Brother reports he has seen intoxicated on\n etoh and MJ lately, and reports pt\ns substance abuse is real. Mother\n and brother state pt reports he has been\nsnorting dope\n lately, and\n that he does hang around with an addict friend, but they are unclear\n re: history of this. Family notes that while many themes of pt\n reports are true, he does make up some stories.\n After Dr. left, questions were placed re: guardianship and\n capacity\nlargely deferred to meeting next week. Reviewed pt\ns h/o poor\n self-esteem. While pt did not feel he could learn like his brothers,\n pt had been physically skilled when he was young\nplanned to be a boxer,\n played football until dx with DM. Perhaps part of pt\ns long-term plan\n could involve boxing to alleviate physical aggression if medically\n able. Perhaps he could relate to ex-gang members in reform programs.\n Clearly he needs extensive psychiatric support.\n Am following case and waiting to see what floor pt is called out to\n before arranging family meeting for next week. Please page me at \n with any questions/concerns.\n -, LICSW\n PM\n"},{"category":"Physician ","chartdate":"2176-06-01 00:00:00.000","description":"Physician Attending/Resident Progress Note - MICU","row_id":373124,"text":"Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotic positioning.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n - On EKG this AM QTc was 450 ms\n ROS:\n Unable to obtain due to patient sedation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97% on room air\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Physical Examination\n GEN: Sedated and sleeping.\n HEENT: PERRL, oral mucosa moist\n NECK: no LAD, JVP flat\n PULM: CTAB with overlying son upper respiratory sounds\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\n ABD: BS+, soft, non-distended\n EXT: Left > right lower extremity edema with no differential warmth\n NEURO: Somnolent\n Labs from \n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n MICRO:\n URINE URINE CULTURE-PENDING NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n # Chronic renal failure-secondary to ESRD/DM:\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\n hyperkalemia, and hyperphosphatemia.\n - HD today in the ICU\n # Left lower extremity edema:\n Acute within last week. Patient denies pain with ambulation or knee\n joint manipulation. Has had two negative sets of lower-extremity\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\n other obstructive process to cause differential swelling. Patient was\n on antibiotics at presentation, but this is not entirely consistent\n with a cellulitis.\n - Consider pelvic venous imaging to rule out pelvic DVT\n # Psychiatric:\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\n have decided to section 12 pt. Psychiatry aware and suggests that the\n pt does not have capacity and the medical team should consider\n guardianship. had two episodes of threatening to leave hospital\n overnight requiring security to assist in giving patient chemical\n restraints (5 mg haldol and 2 mg lorazepam each episode)\n - Follow-up psychiatry recs\n - Will need 1:1 observation and cannot leave hospital\n # Increase in size of cardiac silhouette by CXR on :\n Was ruled out for pericardial effusion by ECHO. Most likely\n projectional artifact.\n # Hypertension:\n Continue outpt meds and uptitrate prn. HD this AM.\n - As mental status allows will add back on amlodipine, lisinopril,\n metoprolol, labetolol.\n - Will have to reeval outpt regimen\n # Diabetes mellitus type 1:\n Insulin 75/25 at half of home doses and conservative sliding scale\n insulin given that patient is taking little orally.\n # Reported ETOH:\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\n admission. No history of withdrawal symptoms.\n - Monitor for withdrawal\n # Anemia:\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\n today.\n - Epoetin at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n ------ Protected Section ------\n CRITICAL CARE ADDENDUM\n Mr. was seen, examined and evaluated with Dr. and the ICU\n team with whose detailed note above I agree. Mr. is a 31 yo man\n with psychiatric illness, DM I, ESRD on HD who was brought in Section\n 12 because he was not compliant with HD. Getting hemodialysis for\n hyperkalemia. Agitated overnight requiring benzodiazepines and haldol.\n Left leg is edematous and LENIS negative. Overnight, CXR w/?widened\n mediastinum - echo w/o abnormality - ?fat pad or positioning.\n Somnolent throughout the day and agitated over night - restrained by\n security and given haldol. QTc stable at 450.\n Currently somnolent, but arousable and answering questions with\n curses. HR 90, 166/75, Neg 5.4L yesterday. 97% RA, Lungs clear to\n auscultation. RRR w/o murmur. Abd benign. Thrill palpable UE. Left\n LE edematous - no labs today (await w/HD).\n Plan includes hemodialysis today. Continue to use haldol and\n benzodiazepines as needed for agitation and sedation. We are awaiting\n guardianship. Evaluate Left LE with ?pelvic vein imaging and will d/w\n dr . Agitation control. Needs 1:1 sitter. be called out if\n stable following HD today.\n , MD\n Critical Care Attending\n 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 11:04 ------\n"},{"category":"Nursing","chartdate":"2176-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":373628,"text":"HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt admitted to the micu from 2. on 100% non rebreather o2sat\n 92-99%. Creat 7.8\n Action:\n Hemodyiaylsis nurse in and dialysis begun at 0430 am.\n Response:\n Diaylysis intiated and tolerating . bp 160-170\ns. very cooperative;\n sitter at the bedside.\n Plan:\n Continue dialysis till 0830am. Check creat level in late am.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K upon arrival to the unit .8 repeat 7.2.\n Action:\n Postassium level being monitored. Hemodyamics being monitored. Ekg\n monitored.\n Response:\n Dialysis being done and tolerating well\n Plan:\n Monitor potassium level closely.\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373786,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373791,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor, hopefully to 2\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373792,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor, hopefully to 2\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: hyperlipedemia, diabetes type I on insulin end\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\n pressured,racing thoughts decreased sleep consistent with possible\n mania. lower left extremitiy swelling dopplerable. neg for clots.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:136\n D:113\n Temperature:\n 96.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,100 mL\n 24h total out:\n 5,000 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 10:30 AM\n Potassium:\n 4.8 mEq/L\n 10:30 AM\n Chloride:\n 95 mEq/L\n 10:30 AM\n CO2:\n 31 mEq/L\n 10:30 AM\n BUN:\n 28 mg/dL\n 10:30 AM\n Creatinine:\n 4.6 mg/dL\n 10:30 AM\n Glucose:\n 326 mg/dL\n 10:30 AM\n Hematocrit:\n 26.4 %\n 10:30 AM\n Finger Stick Glucose:\n 351\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Micu 687\n Transferred to:\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2176-06-01 00:00:00.000","description":"Nursing Progress Note","row_id":373106,"text":"Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\n w/o complaint until 0500- awake, initially pleasant, engaging in\n conversation- allowed off monitors to wash self , @ 05:30 stating\n wanted to leave to go to dialysis- attempted to talk down pt, pt\n reviewing care and accepting Insulin but not PO anti-hypertensives-\n moderate agitation just persisting on leaving- security called and pt\n accepting IV chemical restraint- 5mg IVP Haldol, 2mg IV Ativan and\n lying down in bed. Pt unable/pt refuse and PO medication. Section 12-\n pt may not leave AMA.\n Impaired Health Maintenance\n Assessment:\n Pt stating\nI had dialysis yesterday, I need to go to my dialysis\n today\n, unable to review dialysis plans, pt focused on leaving\n hospital, refusing medications\n Action:\n Emotional support, reviewing POC\n Response:\n Attempting to leave x1\n Plan:\n not leave AMA, IV Haldol for restraint, reviewing POC ? social work\n and psych to follow up\n"},{"category":"Physician ","chartdate":"2176-06-01 00:00:00.000","description":"Physician Resident Progress Note","row_id":373109,"text":"Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotically positioned.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GEN:\n HEENT:\n NECK:\n PULM:\n CARD:\n ABD:\n EXT:\n NEURO:\n Labs / Radiology\n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:45 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":"2176-06-01 00:00:00.000","description":"Physician Resident Progress Note","row_id":373111,"text":"Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotically positioned.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GEN:\n HEENT:\n NECK:\n PULM:\n CARD:\n ABD:\n EXT:\n NEURO:\n Labs / Radiology\n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n"},{"category":"Nursing","chartdate":"2176-06-01 00:00:00.000","description":"Nursing Progress Note","row_id":373079,"text":"Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\n w/o complaint until 0500- awake.\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373784,"text":"Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372913,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui.\n Action:\n HD for / hrs at bedside.\n Response:\n Plan:\n Follow up with renal,,cont HD\n"},{"category":"Physician ","chartdate":"2176-05-31 00:00:00.000","description":"Physician Resident Admission Note","row_id":372907,"text":"Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n"},{"category":"Physician ","chartdate":"2176-05-31 00:00:00.000","description":"Physician Resident Admission Note","row_id":372908,"text":"Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n ------ Protected Section ------\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\n DVT. Will give unasyn for now for presumed cellulitis.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:50 ------\n"},{"category":"Physician ","chartdate":"2176-05-31 00:00:00.000","description":"Physician Resident Admission Note","row_id":372911,"text":"Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n ------ Protected Section ------\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\n DVT. Will give unasyn for now for presumed cellulitis.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:50 ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: receiving HD currently, psych evaluation and\n treatment of cellulitis as described above. Unable to obtain complete\n ROS due to altered mental status. Labs reviewed and notable for\n hyperkalemia but otherwise stable.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:31 ------\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372914,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372965,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\n of Dextrose foe hypoglycemia.\n"},{"category":"Physician ","chartdate":"2176-05-31 00:00:00.000","description":"Physician Attending Progress Note","row_id":373000,"text":"Chief Complaint: hyperkalemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 31 yo ESRD secondary to DM I on tranplant list. Presenting with\n hyperkalemia after missing HD. Was brought in ?unclear how. In ED was\n agitated. Was eval by psych who felt he did not have capacity to make\n decisions. Got 5mg haldol and 2mg of ativan. K was 6.4. refused\n kayexalate. Came to MICU for urgent HD. BP 192/92 sat 100% on RAn in\n ED. Overnight required D50x3 for hypoglycemia after getting dosed\n with SSI.\n 24 Hour Events:\n NASAL SWAB - At 12:14 AM\n MRSA screen\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 AM\n Hydralazine - 06:10 AM\n Other medications:\n nephrocaps\n calcium acetate\n norvasc\n lisinopril\n EPO\n lipitor\n pepcid\n hep s/q\n toprol\n labetolol\n lanthenum\n SSI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 87 (75 - 98) bpm\n BP: 162/81(99) {137/57(77) - 201/106(128)} mmHg\n RR: 13 (11 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 2,500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -2,400 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: 3+\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 400 K/uL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n ECG: slightly peaked Tw\n Assessment and Plan\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD): Got\n emergent HD overnight. K now normalized.\n Section 12: will need psych admission after medical issues are cleared\n RLE: swelling and redness. Has had this for at least a few days with\n no worsening. No clear evidence of cellulitis,\n DM I: will start half dose NPH and cut back on sliding scale as he was\n hypoglycemic today.\n agitation: Currently sedated, but will need sitter and haldol prn.\n has right effusion in knee: will tap.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU can go to floor after HD\n Total time spent: 35 minutes\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372960,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\n of Dextrose foe hypoglycemia.\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":373062,"text":"31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, dialyzed overnight upon admission to\n unit .5L removed.\n Received pt very lethargic, arousable only to simulation,\n unable to give most PO meds due to lethargy.\n Action:\n Dialyzed again this afternoon per renal orders, 3L removed.\n Pt becoming more arousable during dialysis, alert and\n oriented x 3, very talkative at times becoming agitated however easily\n redirected.\n Response:\n Pt tolerated dialysis well, SBP >100\n Received IV Ativan 1mg x 2 with some effect, also ordered\n for but did not receive any Haldol.\n Plan:\n Pt to have dialysis again tomorrow.\n PRN Ativan and Haldol as needed.\n Pt noted to have larger heart on CXR, MDs questioning pericardial\n effusion, bedside ECHO performed, results pending. Pt called out to\n floor, awaiting bed placement.\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372955,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/\n"},{"category":"Physician ","chartdate":"2176-06-01 00:00:00.000","description":"Physician Resident Progress Note","row_id":373120,"text":"Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotic positioning.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n - On EKG this AM QTc was 450 ms\n ROS:\n Unable to obtain due to patient sedation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97% on room air\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Physical Examination\n GEN: Sedated and sleeping.\n HEENT: PERRL, oral mucosa moist\n NECK: no LAD, JVP flat\n PULM: CTAB with overlying son upper respiratory sounds\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\n ABD: BS+, soft, non-distended\n EXT: Left > right lower extremity edema with no differential warmth\n NEURO: Somnolent\n Labs from \n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n MICRO:\n URINE URINE CULTURE-PENDING NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n # Chronic renal failure-secondary to ESRD/DM:\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\n hyperkalemia, and hyperphosphatemia.\n - HD today in the ICU\n # Left lower extremity edema:\n Acute within last week. Patient denies pain with ambulation or knee\n joint manipulation. Has had two negative sets of lower-extremity\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\n other obstructive process to cause differential swelling. Patient was\n on antibiotics at presentation, but this is not entirely consistent\n with a cellulitis.\n - Consider pelvic venous imaging to rule out pelvic DVT\n # Psychiatric:\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\n have decided to section 12 pt. Psychiatry aware and suggests that the\n pt does not have capacity and the medical team should consider\n guardianship. had two episodes of threatening to leave hospital\n overnight requiring security to assist in giving patient chemical\n restraints (5 mg haldol and 2 mg lorazepam each episode)\n - Follow-up psychiatry recs\n - Will need 1:1 observation and cannot leave hospital\n # Increase in size of cardiac silhouette by CXR on :\n Was ruled out for pericardial effusion by ECHO. Most likely\n projectional artifact.\n # Hypertension:\n Continue outpt meds and uptitrate prn. HD this AM.\n - As mental status allows will add back on amlodipine, lisinopril,\n metoprolol, labetolol.\n - Will have to reeval outpt regimen\n # Diabetes mellitus type 1:\n Insulin 75/25 at half of home doses and conservative sliding scale\n insulin given that patient is taking little orally.\n # Reported ETOH:\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\n admission. No history of withdrawal symptoms.\n - Monitor for withdrawal\n # Anemia:\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\n today.\n - Epoetin at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n"},{"category":"General","chartdate":"2176-06-07 00:00:00.000","description":"Generic Note","row_id":373765,"text":"TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined. This am he is\n manic\n euphoric, pressured speech, flights of ideas. Denies SOB but\n oxygenation still not normal. Seems to be improving with aggressive\n dialysis but CXR being read as c/w pneumonic process. Needs CXR\n tomorrow and may need CT if he fails to clear but clinically this is\n CHF rather than infection.\n Time spent 30 min\n"},{"category":"Physician ","chartdate":"2176-06-06 00:00:00.000","description":"Physician Resident Admission Note","row_id":373601,"text":"Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\n HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: not willing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n **Patient unable to provide. Per discharge summary on ...\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\n Sensipar 30mg Tablet, 1 Tablet PO once a day\n Lanthanum Oral\n .\n Medications on transfer:\n Haloperidol 1.5 mg PO Q 12H\n Acetaminophen 325-650 mg PO Q6H:PRN pain\n Haloperidol 2 mg IM ONCE\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\n Duration: 1 Doses Order date: @ 1614\n amlodipine 5 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Aspirin 325 mg PO DAILY\n Insulin SC (per Insulin Flowsheet)\n Atorvastatin 40 mg PO DAILY\n Insulin Regular 10 UNIT IV ONCE\n Monitor Q1H for 6 Order date: @ 0044\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Lanthanum 1000 mg PO QID\n Calcium Acetate 1334 mg PO TID W/MEALS\n Labetalol 300 mg PO TID\n Calcium Gluconate 2 g IV ONCE\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\n Cinacalcet 30 mg PO DAILY\n Multivitamins 1 TAB PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nephrocaps 1 CAP PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nicotine Patch 21 mg TD DAILY\n DiphenhydrAMINE 25 mg PO HS:PRN\n Senna 1 TAB PO BID:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Epoetin Alfa\n To be administered during dialysis and dosed according to the \n Epoetin Alfa P&T Guidelines.\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\n Famotidine 20 mg PO Q24H\n Thiamine 100 mg PO DAILY\n FoLIC Acid 1 mg PO DAILY\n Valsartan 160 mg PO DAILY\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\n d1= Order date: @ 0044\n Haloperidol 0.5 mg PO Q2H:PRN agitation\n MD if giving Order date: @ 1301\n Past medical history:\n Family history:\n Social History:\n Type I DM (diagnosed 13 years ago), managed by Dr. \n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \n Diabetic retinopathy (diagnosed 2 years ago)\n Diabetic neuropathy\n Diabetic myonecrosis ()\n Chronic ulcer at right foot\n Hypertension\n Concern for psychiatric disorder, possibly bipolar\n :\n Per reveiw of records, Type II diabetes mellitus in mother and father.\n Type I diabetes mellitus in sisters and brothers.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is followed by a social worker because of concern about his\n competence. Reported alcohol use, illicit drug use.\n Review of systems: ROS\n Flowsheet Data as of 03:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 92 (92 - 92) bpm\n BP: 169/75() {169/75() - 169/75()} mmHg\n RR: 5 (5 - 5) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 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: Non-rebreather\n Physical Examination\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\n +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\n ABG, and hypoxia.\n .\n Studies:\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \n 8:11, TWI is more pronounced and STE is unchanged.\n - TTE (): The left atrium is normal in size. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Left ventricular systolic function is hyperdynamic (EF\n 80%). There is no ventricular septal defect. Right ventricular chamber\n size and free wall motion are normal. There are focal calcifications in\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is mild mitral valve\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\n artery systolic pressure is normal. There is no pericardial effusion.\n There is an anterior space which most likely represents a fat pad.\n Compared with the findings of the prior study (images unavailable) of\n , the left ventricular wall thickening has progressed.\n - CXR 2V (): Final read pending\n - LENI (): No evidence of DVT of the left lower extremity.\n Assessment and Plan\n Assessment and plan:\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2176-06-06 00:00:00.000","description":"Physician Resident Admission Note","row_id":373606,"text":"Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\n HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: not willing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n **Patient unable to provide. Per discharge summary on ...\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\n Sensipar 30mg Tablet, 1 Tablet PO once a day\n Lanthanum Oral\n .\n Medications on transfer:\n Haloperidol 1.5 mg PO Q 12H\n Acetaminophen 325-650 mg PO Q6H:PRN pain\n Haloperidol 2 mg IM ONCE\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\n Duration: 1 Doses Order date: @ 1614\n amlodipine 5 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Aspirin 325 mg PO DAILY\n Insulin SC (per Insulin Flowsheet)\n Atorvastatin 40 mg PO DAILY\n Insulin Regular 10 UNIT IV ONCE\n Monitor Q1H for 6 Order date: @ 0044\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Lanthanum 1000 mg PO QID\n Calcium Acetate 1334 mg PO TID W/MEALS\n Labetalol 300 mg PO TID\n Calcium Gluconate 2 g IV ONCE\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\n Cinacalcet 30 mg PO DAILY\n Multivitamins 1 TAB PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nephrocaps 1 CAP PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nicotine Patch 21 mg TD DAILY\n DiphenhydrAMINE 25 mg PO HS:PRN\n Senna 1 TAB PO BID:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Epoetin Alfa\n To be administered during dialysis and dosed according to the \n Epoetin Alfa P&T Guidelines.\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\n Famotidine 20 mg PO Q24H\n Thiamine 100 mg PO DAILY\n FoLIC Acid 1 mg PO DAILY\n Valsartan 160 mg PO DAILY\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\n d1= Order date: @ 0044\n Haloperidol 0.5 mg PO Q2H:PRN agitation\n MD if giving Order date: @ 1301\n Past medical history:\n Family history:\n Social History:\n Type I DM (diagnosed 13 years ago), managed by Dr. \n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \n Diabetic retinopathy (diagnosed 2 years ago)\n Diabetic neuropathy\n Diabetic myonecrosis ()\n Chronic ulcer at right foot\n Hypertension\n Concern for psychiatric disorder, possibly bipolar\n :\n Per reveiw of records, Type II diabetes mellitus in mother and father.\n Type I diabetes mellitus in sisters and brothers.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is followed by a social worker because of concern about his\n competence. Reported alcohol use, illicit drug use.\n Review of systems: ROS\n Flowsheet Data as of 03:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 92 (92 - 92) bpm\n BP: 169/75() {169/75() - 169/75()} mmHg\n RR: 5 (5 - 5) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 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: Non-rebreather\n Physical Examination\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\n +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\n ABG, and hypoxia.\n .\n Studies:\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \n 8:11, TWI is more pronounced and STE is unchanged.\n - TTE (): The left atrium is normal in size. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Left ventricular systolic function is hyperdynamic (EF\n 80%). There is no ventricular septal defect. Right ventricular chamber\n size and free wall motion are normal. There are focal calcifications in\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is mild mitral valve\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\n artery systolic pressure is normal. There is no pericardial effusion.\n There is an anterior space which most likely represents a fat pad.\n Compared with the findings of the prior study (images unavailable) of\n , the left ventricular wall thickening has progressed.\n - CXR 2V (): Final read pending\n - LENI (): No evidence of DVT of the left lower extremity.\n Assessment and Plan\n Assessment and plan:\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n Worsening hypoxemia this eve with new bilateral infiltrates\n presumption is that this represents pulmonary edema and he was\n transferred to ICU for urgent dialysis. He was placed on a 100% NRB\n facemask to maintain adequate saturations.\n Exam notable for Tm afebrile HR 94 BP 156/70 RR 19 with 97 sat on\n 100% NRB\n No distress\n HEENT unremarkable\n Neck supple\n Lungs crackles\n Her rrr\n Abd benign\n Extreme RUE fistula, mild LLE edema\n Labs notable for K+ 6.3 yesterday morning\n Imaging: CXR with new bilateral patchy infiltrates\n EKG with peaked T\n Problems: respiratory distress, hypoxemia, pulmonary edema, ESRD, LLE\n edema, hyperkalemia, DM\n Agree with plan for urgent HD, wean O2 as tolerates, will continue\n antibiotics and let floor team sort out LLE, continue current DM\n regimen\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 36 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:31 ------\n"},{"category":"Nursing","chartdate":"2176-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":373673,"text":" MD H+P:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Today\ns Events\n HD today, removed 4.9kilo\n L leg remains swollen and tender to touch\n CXR revealed pneumonia, received vanco X1\n Pt desatuating on RA to 70\ns, productive cough\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2176-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":373676,"text":" MD H+P:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Today\ns Events\n HD today, removed 4.9kilo\n L leg remains swollen and tender to touch\n CXR revealed pneumonia, received vanco X1\n Pt desatuating on RA to 70\ns, productive cough\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, non-compliant with medical care . K+ 6.8\n overnight with worsening resp distress and desaturation to the 70\n Action:\n Renal ordered HD overnight.\n Response:\n HD removed 4.9kilo\n Plan:\n Monitor fluid balance, pt is refusing to abide by fluid restriction.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Known non-compliance with medical regimen. ? untreated Bipolar\n disease. History of leaving AMA, pt is Currently under Section 12 and\n has 1:1 sitter and can NOT leave.\n Action:\n Pt is on Haldol and can receive PRN doses\n Response:\n Pt has been cooperative with care, 1:1 sitter\n Plan:\n Psych and SW attempting to get medical guardianship, meeting friday\n"},{"category":"Physician ","chartdate":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373734,"text":"24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373735,"text":"24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373737,"text":"24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373742,"text":"24 Hour Events:\n -3.5L O/N\n -No episodes of hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Bcx (): PND\n Bcx (): PND\n UCx (): Negative\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Renal\n following, given dialysis yesterday early AM, continues to be fluid\n overloaded. Will continue to diureses as per renal recommendations and\n fluid restrict (1L per day, 80mg lasix QD).\n -bcx and ucx\n -cxr\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source.\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: As per admission note, patient is Section 12.\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\n has been long standing issue. Per psych notes, has had \"agitation,\n pressured speech, loose and tangential, racing thoughts and decreased\n sleep consistent with possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor\n"},{"category":"Physician ","chartdate":"2176-06-07 00:00:00.000","description":"Physician Resident Progress Note","row_id":373826,"text":"24 Hour Events:\n -3.5L O/N\n -No episodes of hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Bcx (): PND\n Bcx (): PND\n UCx (): Negative\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Renal\n following, given dialysis yesterday early AM, continues to be fluid\n overloaded. Will continue to diureses as per renal recommendations and\n fluid restrict (1L per day, 80mg lasix QD).\n -bcx and ucx\n -cxr\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source.\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: As per admission note, patient is Section 12.\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\n has been long standing issue. Per psych notes, has had \"agitation,\n pressured speech, loose and tangential, racing thoughts and decreased\n sleep consistent with possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Progress Note","row_id":373709,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Overnight Events\n L leg remains swollen and tender to touch\n Pt desatuating on RA to80\ns, productive cough\n Pt compliant with meds and no periods of agitation, remains\n on 1:1 sitter\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, non-compliant with medical care prior to admit HD\n done , tol well.\n Action:\n 1000ml fluid restriction maintained.\n Response:\n Pt compliant with meds, and fluid restriction\n Plan:\n Monitor fluid balance, ?HD today\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Known non-compliance with medical regimen. ? untreated Bipolar\n disease. History of leaving AMA, pt is Currently under Section 12 and\n has 1:1 sitter and can NOT leave.\n Action:\n Pt is on Haldol and received PRN dose x1 a/o\n Response:\n Pt has been cooperative with care, 1:1 sitter\n Plan:\n Psych and SW attempting to get medical guardianship, meeting today\n"},{"category":"Nursing","chartdate":"2176-06-07 00:00:00.000","description":"Nursing Transfer Note","row_id":373809,"text":"Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor,\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: hyperlipedemia, diabetes type I on insulin end\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\n pressured,racing thoughts decreased sleep consistent with possible\n mania. lower left extremitiy swelling dopplerable. neg for clots.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:136\n D:113\n Temperature:\n 96.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,100 mL\n 24h total out:\n 5,000 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 10:30 AM\n Potassium:\n 4.8 mEq/L\n 10:30 AM\n Chloride:\n 95 mEq/L\n 10:30 AM\n CO2:\n 31 mEq/L\n 10:30 AM\n BUN:\n 28 mg/dL\n 10:30 AM\n Creatinine:\n 4.6 mg/dL\n 10:30 AM\n Glucose:\n 326 mg/dL\n 10:30 AM\n Hematocrit:\n 26.4 %\n 10:30 AM\n Finger Stick Glucose:\n 351\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Micu 687\n Transferred to: 201\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":372931,"text":"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n"},{"category":"Nursing","chartdate":"2176-05-31 00:00:00.000","description":"Nursing Progress Note","row_id":373010,"text":"31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2176-06-01 00:00:00.000","description":"Nursing Transfer Note","row_id":373152,"text":"TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\n treatment. Unfortunately pt became agitated, angry and appeared\n threatening early this afternoon. Feelings validated and pt given\n ample time to voice his displeasure to no avail. Stat security called\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\n admin. Pt now more cooperative and is not agitated. Pt seems to last\n 8 to 12 hours between outbursts.\n Impaired Health Maintenance\n Assessment:\n As noted above, the pt was more or less cooperative with care this AM\n (though refused all AM meds). Unfortunately pt impulsively became\n angry/agitated/beligerant this afternoon requiring stat security @ BS.\n Stable QTi on EKG this AM. Soft wrist restraints in place. 1:1 Sitter\n @ BS.\n Action:\n With security @ BS and a supportive sitter whom the pt trusted the pt\n relented and allowed 5mg IVP Haldol to be admin @ BS.\n Response:\n Pt now more cooperative with no agitation issues @ this time.\n Plan:\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\n becoming acutely agitated. Follow serial EKG QTi as long as IV Haldol\n treatment in place.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt received his third HD in three days today. AM potassium value of\n 4.3 noted.\n Action:\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\n Response:\n Pt without significant issues surrounding HD treatment.\n Plan:\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\n for Mon vs Tues.\n Demographics: The pt is appearantly estranged from his mother and has\n issues with some of his siblings. Pt also appears to have issues of\n homelessness. Pt with multiple recent hospital admits s/p missed HD\n treatments with significant hyperkalemia.\n Attending MD:\n R.\n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Anemia, Diabetes - Insulin, Renal Failure, Smoker\n CV-PMH: Hypertension\n Additional history: Diabetic retinopathy. Anemia. Recent LLE swelling\n (Leni's negative times two). diabetic neuropathy\n Diabetic myonecrosis. Chronic ulcer right foot\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:155\n D:65\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 380 mL\n 24h total out:\n 1,200 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 10:05 AM\n Potassium:\n 4.8 mEq/L\n 10:05 AM\n Chloride:\n 96 mEq/L\n 10:05 AM\n CO2:\n 29 mEq/L\n 10:05 AM\n BUN:\n 29 mg/dL\n 10:05 AM\n Creatinine:\n 7.2 mg/dL\n 10:05 AM\n Glucose:\n 83 mg/dL\n 10:05 AM\n Hematocrit:\n 29.2 %\n 10:05 AM\n Finger Stick Glucose:\n 147\n 10:05 AM\n Valuables / Signature: All of the pts personal property (5 bags) have\n been moved to a holding area on CC2.\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6 West.\n Transferred to: 226\n Date & time of Transfer:\n"},{"category":"Nursing","chartdate":"2176-06-01 00:00:00.000","description":"Nursing Progress Note","row_id":373149,"text":"TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\n treatment. Unfortunately pt became agitated, angry and appeared\n threatening early this afternoon. Feelings validated and pt given\n ample time to voice his displeasure to no avail. Stat security called\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\n admin. Pt now more cooperative and is not agitated. Pt seems to last\n 8 to 12 hours between outbursts.\n Impaired Health Maintenance\n Assessment:\n As noted above, the pt more or less cooperative with care this AM.\n Unfortunately pt became angry/agitated/ beligerant this afternoon\n requiring stat security @ BS. Stable QTi on EKG this AM.\n Action:\n With security @ BS and a supportive sitter whom the pt trusted the pt\n relented and allowed 5mg IVP Haldol to be admin @ BS.\n Response:\n Pt now more cooperative with no agitation issues @ this time.\n Plan:\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\n becoming agitated. Follow serial EKG QTi as long as IV Haldol\n treatment in place.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt received his third HD in three days today.\n Action:\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\n Response:\n Pt without significant issues surrounding HD treatment.\n Plan:\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\n for Mon vs Tues.\n"},{"category":"Echo","chartdate":"2176-05-31 00:00:00.000","description":"Report","row_id":83971,"text":"PATIENT/TEST INFORMATION:\nIndication: Enlarged cardiac size on CXR. Evaluate for effusion\nHeight: (in) 69\nWeight (lb): 156\nBSA (m2): 1.86 m2\nBP (mm Hg): 128/66\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 16:46\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: Moderate symmetric LVH. Small LV cavity. Hyperdynamic LVEF\n>75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal aortic arch diameter. Focal calcifications in aortic arch.\nNo 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: 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\nConclusions:\nThe left atrium is normal in size. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity is unusually small. Left\nventricular systolic function is hyperdynamic (EF 80%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. There are focal calcifications in the aortic arch. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is mild mitral valve prolapse. Trivial mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion. There is an anterior space which most likely represents\na fat pad.\n\nCompared with the findings of the prior study (images unavailable) of , the left ventricular wall thickening has progressed.\n\n\n"},{"category":"Radiology","chartdate":"2176-06-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1075959,"text":" 12:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, edema\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with h/o DM and ESRD on HD who had desat to 60% on RA.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Diabetes mellitus, desaturation.\n\n FINDINGS: As compared to the previous radiograph, there is a newly appeared\n extensive opacity in the middle and basal parts of the right lung and in the\n retrocardiac lung areas. The opacity is of alveolar morphology, multiple\n subtle air bronchograms are seen. The opacities tend to spare in the\n uppermost parts of the lung. In the region of the right hilus, subtle\n peribronchial cuffing is seen. However, all other signs indicative of\n overhydration are missing. In the light, they are much more likely to\n represent pneumonia rather than edema.\n Unchanged size of the cardiac silhouette, unchanged mediastinal contours.\n\n was notified by telephone at the time of dictation and informed\n about the abnormalities.\n\n"},{"category":"Radiology","chartdate":"2176-06-08 00:00:00.000","description":"L KNEE (AP, LAT & OBLIQUE) LEFT","row_id":1076429,"text":" 10:24 PM\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: Any fracture or other left knee pathology evident on plain f\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with leg lower extremity swelling and new left knee pain.\n REASON FOR THIS EXAMINATION:\n Any fracture or other left knee pathology evident on plain film?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left lower extremity swelling. New left knee pain.\n\n LEFT KNEE, THREE VIEWS\n\n There is deformity and increased density in the right tibial plateau\n consistent with a tibial plateau fracture, with depression. There is a\n probable joint effusion. There is minimal spurring about the patella. There\n is an ossific fragment along the medial border of the patella, which appears\n well corticated, and which could represent a either fracture fragment or\n heterotopic ossification in the medial retinaculum. No dislocation is\n identified. Dense vascular calcification is noted.\n\n IMPRESSION:\n\n 1) Findings consistent with medial tibial plateau fracture likely subcaute or\n chronic .\n\n 2) Ossicle along medial patella -- ? nonacute fracture vs post- traumatic\n heterotopic ossificaiton in adjoining medial retinaculum. Possible subacute\n fracture along the medial patella.\n\n 3. Joint effusion.\n\n Findings discussed with covering house officer Dr. at\n approximately 13:18 p.m. on the day of the exam.\n\n\n"},{"category":"Radiology","chartdate":"2176-06-08 00:00:00.000","description":"L UNILAT LOWER EXT VEINS LEFT","row_id":1076405,"text":" 4:59 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LLE SWELLING EVAL FOR DVT\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with possible DVT, dialysis patient\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: DLrc SAT 6:47 PM\n No evidence of left lower extremity DVT. Prominent lymph nodes in the left\n groin.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 31-year-old male with possible deep venous thrombus.\n Evaluate for deep venous thrombus.\n\n EXAMINATION: Unilateral left lower extremity DVT study.\n\n COMPARISONS: Comparison to ultrasound examination from .\n\n FINDINGS: Grayscale and color Doppler son of the left common femoral,\n superficial femoral and popliteal veins were performed. There is normal\n compressibility, flow, augmentation. There is symmetric respiratory\n variability in the right and left common femoral veins.\n\n IMPRESSION: No evidence of left lower extremity DVT.\n SESHa\n\n"},{"category":"Radiology","chartdate":"2176-06-10 00:00:00.000","description":"L CT LOW EXT W/O C LEFT","row_id":1076744,"text":" 6:12 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: to evaluate knee fracture\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with hx of ESRD on HD, now with knee injury 2 weeks ago, now\n with plain films showing tibial and patellar fractures.\n REASON FOR THIS EXAMINATION:\n to evaluate knee fracture\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD\n ______________________________________________________________________________\n WET READ: CXWc MON 8:46 PM\n Impacted right medial tibial plateau fracture extending to the articular\n surface, with pleateau depression of approximately 8mm. Bony sclerosis\n consistent with subacute fracture. Tiny intra-articular bony fragment\n posteriorly. Additionally, comminuted fractures of the medial and lateral\n tibial spines. Moderate joint effusion. Fragmentation of medial patella\n consistent with nondisplaced, comminuted fracture. Extensive vascular\n calcifications.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF LEFT KNEE\n\n INDICATION: Knee injury. Tibial and patellar fractures.\n\n TECHNIQUE: Non-contrast multidetector CT of the left knee was performed.\n Multiplanar reformations were carried out.\n\n COMPARISON: Radiograph of left knee .\n\n FINDINGS:\n\n There is an impacted fracture of the left medial tibial plateau with at least\n 5 mm of depression of the medial tibial plateau. Comminution is evident with\n small fracture fragments at the medial aspect of the medial plateau (series\n 500B, image 31). Extension of the fracture line into the intercondylar\n eminence and into the medial tibial spine is evident.\n\n The lateral tibial plateau is intact. The proximal tibial and fibular shafts\n are intact. The distal femur demonstrates no evidence of focal bone lesion or\n fracture.\n\n There is a small fracture through the medial aspect of the patella. The\n fracture is minimally displaced, with approximately 2 mm of medial\n displacement of the smaller medial component of the fracture.\n\n Assessment of the internal structures of the knee is limited on CT, but no\n gross ligament abnormality is demonstrated.\n\n There is a moderate to large knee joint effusion. There is evidence of\n diffuse vascular calcification. The bones appear demineralized.\n (Over)\n\n 6:12 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: to evaluate knee fracture\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Depressed, impacted medial tibial plateau fracture which also extends to\n the intercondylar eminence and medial tibial spine.\n 2. Medial patellar fracture.\n 3. Moderate to large knee joint effusion.\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2176-06-11 00:00:00.000","description":"OL KNEE( (SINGLE VIEW) IN O.R. LEFT","row_id":1076811,"text":" 8:06 AM\n KNEE( (SINGLE VIEW) IN O.R. LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. LEFTClip # \n Reason: ORIF LEFT TIBIAL PLATEAU FX\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Tibial plateau fracture.\n\n A single intraoperative fluoroscopic view of the left knee was obtained\n without a radiologist present. This again demonstrates a depressed medial\n tibial plateau fracture, similar to that seen on . For additional\n details, please consult the operative report.\n\n"},{"category":"ECG","chartdate":"2176-06-12 00:00:00.000","description":"Report","row_id":209357,"text":"Normal sinus rhythm. Lateral T wave abnormalities. Compared to the previous\ntracing of lateral T wave abnormalities are new. Some of these\nabnormalities have been seen on previous tracings but now they are increased\nin leads V5-V6.\n\n"},{"category":"ECG","chartdate":"2176-06-09 00:00:00.000","description":"Report","row_id":209358,"text":"Normal sinus rhythm. J point elevation consistent with normal early\nrepolarization. Otherwise, within normal limits. Compared to the previous\ntracing of previous non-specific ST-T wave abnormalities have resolved.\nOtherwise, no important change. Clinical correlation and repeat tracing are\nsuggested.\n\n"},{"category":"ECG","chartdate":"2176-06-06 00:00:00.000","description":"Report","row_id":205615,"text":"Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of no major change.\n\n"},{"category":"ECG","chartdate":"2176-06-05 00:00:00.000","description":"Report","row_id":205616,"text":"Sinus rhythm\nNormal ECG\nSince previous tracing of , the heart rate is slower\n\n"},{"category":"ECG","chartdate":"2176-06-04 00:00:00.000","description":"Report","row_id":205617,"text":"Sinus rhythm upper normal rate\nNormal ECG\nSince previous tracing of , ST-T wave abnormalities are less\n\n"},{"category":"ECG","chartdate":"2176-06-01 00:00:00.000","description":"Report","row_id":205618,"text":"Sinus rhythm. Compared to the previous tracing of there is\nT wave inversion in lead I and more prominent T wave inversion in\nlead aVL as well as new T wave inversion in leads V4-V6. Active\nlateral ischemic process cannot be excluded. Followup and clinical correlation\nare suggested.\n\n"},{"category":"ECG","chartdate":"2176-06-02 00:00:00.000","description":"Report","row_id":205619,"text":"Sinus rhythm. Compared to the previous tracing no change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2176-05-31 00:00:00.000","description":"Report","row_id":205620,"text":"Sinus rhythm. Compared to the previous tracing of no change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2176-05-31 00:00:00.000","description":"Report","row_id":205621,"text":"Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\nsignificant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2176-05-30 00:00:00.000","description":"Report","row_id":205622,"text":"Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\nsignificant change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2176-05-27 00:00:00.000","description":"Report","row_id":205623,"text":"Sinus rhythm. Baseline artifact. Delayed precordial R wave transition. The\nP wave morphology appears less prominent while the P wave axis remains\nrightward. The prior tracing was consistent with right atrial abnormality.\nOtherwise, no diagnostic interim change. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2176-06-07 00:00:00.000","description":"Report","row_id":205614,"text":"Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of ST-T wave changes are new.\n\n"},{"category":"Radiology","chartdate":"2176-06-03 00:00:00.000","description":"CT PELVIS W&W/O C","row_id":1075475,"text":" 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with left lower extremity swelling, negative LENI, concern for\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\n better visualization of veins.\n REASON FOR THIS EXAMINATION:\n eval for venous thrombosis\n CONTRAINDICATIONS for IV CONTRAST:\n Has ESRD and will get dialyzed Tuesday.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 8:10 PM\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\n Extensive vascular calcifications _____, likely reflecting the patient's\n history of diabetes. There is no acute pelvic pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old male with left lower extremity swelling and negative\n LENI. Evaluate for proximal clot in the iliac veins or IVC. The patient has\n a history of hypertension, diabetes, and end-stage renal disease.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the pelvis prior to\n and following administration of intravenous contrast, and three-minute delayed\n phase protocol. Multiplanar reformats were prepared and reviewed.\n\n FINDINGS: Within limits of non-contrast and delayed phase imaging, visualized\n portion of the liver, gallbladder, pancreas, and kidneys are normal. There is\n no evidence for biliary dilatation, cholelithiasis, or hydronephrosis.\n Visualized pelvic loops of small and large bowel are unremarkable. There is\n high-density material within the colon, likely reflecting magnesium-containing\n laxative or antacid use. There is no bowel distention or bowel wall\n thickening. There is no free fluid or free air. There is no lymphadenopathy\n appreciated.\n\n Vascular calcifications are noted in the pelvic vessels, greater than expected\n for a patient of this age, likely due to the patient's history of diabetes.\n There is normal appearance and opacification of the bilateral iliac veins and\n IVC, with no evidence for venous thrombosis.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. No evidence for venous thrombosis in the bilateral iliac vessels or IVC.\n 2. Vascular calcifications, greater than expected for a patient of this age,\n likely reflecting history of diabetes.\n 3. Within the limits of non-contrast and delayed phase imaging, no acute\n pelvic pathology.\n (Over)\n\n 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2176-06-03 00:00:00.000","description":"CT PELVIS W&W/O C","row_id":1075476,"text":", R. MED FA2 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with left lower extremity swelling, negative LENI, concern for\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\n better visualization of veins.\n REASON FOR THIS EXAMINATION:\n eval for venous thrombosis\n CONTRAINDICATIONS for IV CONTRAST:\n Has ESRD and will get dialyzed Tuesday.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\n Extensive vascular calcifications _____, likely reflecting the patient's\n history of diabetes. There is no acute pelvic pathology.\n\n"},{"category":"Radiology","chartdate":"2176-05-30 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1074872,"text":" 11:16 PM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with hx esrd\n REASON FOR THIS EXAMINATION:\n eval effusion, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old with history of end-stage renal disease.\n\n COMPARISON: \n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: The lateral view is limited due to\n inability of the patient to raise her arms. The lungs are grossly clear. The\n cardiac silhouette is increasing in size, even despite the lordotic\n positioning of the film, raising the possibility of pericardial effusion in\n this end- stage renal disease patient. The mediastinal contours are normal.\n There is no effusion or pneumothorax.\n\n IMPRESSION: Enlarging cardiac silouette, raising the possibility of\n pericardial effusion.\n\n Dr. was paged with these findings at 11:30 AM on .\n\n\n\n"},{"category":"Radiology","chartdate":"2176-06-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1076037,"text":" 9:52 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls eval for infiltrate, consolidation, effusion\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with ESRD, hypoxia\n REASON FOR THIS EXAMINATION:\n pls eval for infiltrate, consolidation, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n As compared to the previous radiograph, the lung volumes have increased.\n Despite the resulting overall decrease in lung parenchymal transparency,\n subtle areas of parenchymal opacities, notably in the left basal and\n retrocardiac areas and at the right lung bases persist, so that the suspicion\n of pneumonia cannot be discarded. No evidence of pleural effusions.\n Unchanged mediastinal contours. The size of the cardiac silhouette is smaller\n than before.\n\n\n"}],"string":"[\n {\n \"category\": \"Social Work\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Social Work Progress Note\",\n \"row_id\": 373800,\n \"text\": \"SOCIAL WORK:\\n SW met with pt, brother (cell ), and mother\\n . Pt reviewing his history of betrayal of his family and\\n stating his intention to follow recommendations and change his\\n behaviors. He would like his care centralized at . Mother spoke\\n of how pt has always been self-centered\\npt agrees\\nto the point of not\\n respecting the rights of others. Brother enforced how he still and\\n always will love his brother, but that he does not like their\\n relationship right now. All agreed that pt will have to earn back\\n their respect and trust through hard work and behavior change. While\\n pt is stating he would like to change his ways, he still provides many\\n excuses for his behaviors (e.g.\\n I may have stolen the credit card, but\\n I wasn\\nt going to use it just yet.\\n Mother, brother, and psychiatrist Dr. , and this writer met\\n separately from pt. Family reviewed h/o behavior, including\\ndeviant\\n behavior dating back to pt\\ns childhood, but erratic mood swings and\\n bizarre behavior (e.g. walking around family home undressed) only in\\n recent months. Brother reports he has seen intoxicated on\\n etoh and MJ lately, and reports pt\\ns substance abuse is real. Mother\\n and brother state pt reports he has been\\nsnorting dope\\n lately, and\\n that he does hang around with an addict friend, but they are unclear\\n re: history of this. Family notes that while many themes of pt\\n reports are true, he does make up some stories.\\n After Dr. left, questions were placed re: guardianship and\\n capacity\\nlargely deferred to meeting next week. Reviewed pt\\ns h/o poor\\n self-esteem. While pt did not feel he could learn like his brothers,\\n pt had been physically skilled when he was young\\nplanned to be a boxer,\\n played football until dx with DM. Perhaps part of pt\\ns long-term plan\\n could involve boxing to alleviate physical aggression if medically\\n able. Perhaps he could relate to ex-gang members in reform programs.\\n Clearly he needs extensive psychiatric support.\\n Am following case and waiting to see what floor pt is called out to\\n before arranging family meeting for next week. Please page me at \\n with any questions/concerns.\\n -, LICSW\\n PM\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Physician Attending/Resident Progress Note - MICU\",\n \"row_id\": 373124,\n \"text\": \"Chief Complaint: Section 12 due to non-compliance with dialysis\\n 24 Hour Events:\\n - Read of CXR concerning for pericardial effusion given enlarged\\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\\n more lordotic positioning.\\n - Clinically without hypotension or tachycardia. JVP flat.\\n - ECHO revealed no pericardial effusion and slight increase in left\\n ventricular size since \\n - Was somnolent throughout day and awoke brief during dialysis and was\\n agitated and threatening leave briefly, received 1 mg lorazepam and\\n subsequently slept for several hours.\\n - Was sitting up eating at ~ and suddenly anounced that he was\\n going to leave. Talked to several heathcare personnel and became\\n escalated to the point that he required security to help restrain him\\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\\n 0500 on when had repeat episode and could not be talked down and\\n again security called and was restrained and given 5 mg IV haldol and 2\\n mg IV lorazepam.\\n - On EKG this AM QTc was 450 ms\\n ROS:\\n Unable to obtain due to patient sedation.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 10:15 AM\\n Insulin - Humalog - 05:00 AM\\n Lorazepam (Ativan) - 05:30 AM\\n Haloperidol (Haldol) - 05:30 AM\\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: 37.4\\nC (99.3\\n Tcurrent: 36.4\\nC (97.6\\n HR: 87 (85 - 102) bpm\\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\\n RR: 12 (10 - 21) insp/min\\n SpO2: 97% on room air\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n 280 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 5,500 mL\\n 0 mL\\n Balance:\\n -5,400 mL\\n 280 mL\\n Physical Examination\\n GEN: Sedated and sleeping.\\n HEENT: PERRL, oral mucosa moist\\n NECK: no LAD, JVP flat\\n PULM: CTAB with overlying son upper respiratory sounds\\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\\n ABD: BS+, soft, non-distended\\n EXT: Left > right lower extremity edema with no differential warmth\\n NEURO: Somnolent\\n Labs from \\n 400 K/uL\\n 10.6 g/dL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n MICRO:\\n URINE URINE CULTURE-PENDING NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n Assessment and Plan:\\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n # Chronic renal failure-secondary to ESRD/DM:\\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\\n hyperkalemia, and hyperphosphatemia.\\n - HD today in the ICU\\n # Left lower extremity edema:\\n Acute within last week. Patient denies pain with ambulation or knee\\n joint manipulation. Has had two negative sets of lower-extremity\\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\\n other obstructive process to cause differential swelling. Patient was\\n on antibiotics at presentation, but this is not entirely consistent\\n with a cellulitis.\\n - Consider pelvic venous imaging to rule out pelvic DVT\\n # Psychiatric:\\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\\n have decided to section 12 pt. Psychiatry aware and suggests that the\\n pt does not have capacity and the medical team should consider\\n guardianship. had two episodes of threatening to leave hospital\\n overnight requiring security to assist in giving patient chemical\\n restraints (5 mg haldol and 2 mg lorazepam each episode)\\n - Follow-up psychiatry recs\\n - Will need 1:1 observation and cannot leave hospital\\n # Increase in size of cardiac silhouette by CXR on :\\n Was ruled out for pericardial effusion by ECHO. Most likely\\n projectional artifact.\\n # Hypertension:\\n Continue outpt meds and uptitrate prn. HD this AM.\\n - As mental status allows will add back on amlodipine, lisinopril,\\n metoprolol, labetolol.\\n - Will have to reeval outpt regimen\\n # Diabetes mellitus type 1:\\n Insulin 75/25 at half of home doses and conservative sliding scale\\n insulin given that patient is taking little orally.\\n # Reported ETOH:\\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\\n admission. No history of withdrawal symptoms.\\n - Monitor for withdrawal\\n # Anemia:\\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\\n today.\\n - Epoetin at HD\\n ICU Care\\n Nutrition: Renal, diabetic diet\\n Glycemic Control: Minimal glargine dose and conservative humalog\\n sliding scale\\n Lines: PIV\\n Prophylaxis:\\n DVT: Heparin subcutaneous\\n Stress ulcer: H2 blocker as home medication\\n Communication: Working with psychiatry and liason in determining if\\n guardianship should be obtained. Patient not competent to make own\\n medical decisions at this time.\\n Code status: Presumed FULL\\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\\n leave hospital without psychiatric clearance. Likely discharge to\\n psychiatric facility.\\n ------ Protected Section ------\\n CRITICAL CARE ADDENDUM\\n Mr. was seen, examined and evaluated with Dr. and the ICU\\n team with whose detailed note above I agree. Mr. is a 31 yo man\\n with psychiatric illness, DM I, ESRD on HD who was brought in Section\\n 12 because he was not compliant with HD. Getting hemodialysis for\\n hyperkalemia. Agitated overnight requiring benzodiazepines and haldol.\\n Left leg is edematous and LENIS negative. Overnight, CXR w/?widened\\n mediastinum - echo w/o abnormality - ?fat pad or positioning.\\n Somnolent throughout the day and agitated over night - restrained by\\n security and given haldol. QTc stable at 450.\\n Currently somnolent, but arousable and answering questions with\\n curses. HR 90, 166/75, Neg 5.4L yesterday. 97% RA, Lungs clear to\\n auscultation. RRR w/o murmur. Abd benign. Thrill palpable UE. Left\\n LE edematous - no labs today (await w/HD).\\n Plan includes hemodialysis today. Continue to use haldol and\\n benzodiazepines as needed for agitation and sedation. We are awaiting\\n guardianship. Evaluate Left LE with ?pelvic vein imaging and will d/w\\n dr . Agitation control. Needs 1:1 sitter. be called out if\\n stable following HD today.\\n , MD\\n Critical Care Attending\\n 40 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 11:04 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373628,\n \"text\": \"HPI:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was , during his previous admssion. His normal HD schedule is\\n T/Th/Sat.\\n .\\n He was seen by psychiatry in the ED and admitted under section 12\\n because he was not deemed competent to decline medical care. He\\n received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .\\n He was noted to have an enlarged heart shadow on his CXR concerning for\\n effusion. TTE did not show evidence of effusion.\\n .\\n His left leg was noted to be bigger than his right. LENIs were negative\\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\\n remained afebrile and did not have a leukocytosis.\\n .\\n In addition to above management, in the MICU the patient also received\\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\\n required security involvment for agitation on two separate occasions.\\n .\\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco. Given pt's current respiratory status, the renal\\n fellow made the decision the urgently dialyze the pt and he was\\n therefore transferred to the MICU.\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt admitted to the micu from 2. on 100% non rebreather o2sat\\n 92-99%. Creat 7.8\\n Action:\\n Hemodyiaylsis nurse in and dialysis begun at 0430 am.\\n Response:\\n Diaylysis intiated and tolerating . bp 160-170\\ns. very cooperative;\\n sitter at the bedside.\\n Plan:\\n Continue dialysis till 0830am. Check creat level in late am.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n K upon arrival to the unit .8 repeat 7.2.\\n Action:\\n Postassium level being monitored. Hemodyamics being monitored. Ekg\\n monitored.\\n Response:\\n Dialysis being done and tolerating well\\n Plan:\\n Monitor potassium level closely.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373786,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373791,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Pt\\ns K+ has been dropping with dialysis.\\n Action:\\n last K+ level was 4.4 at 1030 \\n Response:\\n Pt responding to dialysis.\\n Plan:\\n Continue dialysis according to his schedule.\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Since admission to the MICU pt has been had two sessions of diaylsis\\n Action:\\n Last dialysis was today with the removal of 5l of fluid.\\n Yesterday they also removed 5l of fluid\\n Response:\\n With the total removal of 10 liters of fluid in the last 2 days his O2\\n requirement dropped from NRB to room air. O2 sats are 96-100%.\\n Plan:\\n Continue with fliud restriction, continue with dialysis treatments.\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Pt has been very manic today, He is in a good mood, talking almost\\n constantly day. The family meeting with social services and Psych was\\n cancelled but an informal family meeting was held at 1500.\\n Action:\\n Haldol 1.5 mg continues to be given q12h\\n Response:\\n Behavior in control today.\\n Plan:\\n Pt called out to the floor, hopefully to 2\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373792,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Pt\\ns K+ has been dropping with dialysis.\\n Action:\\n last K+ level was 4.4 at 1030 \\n Response:\\n Pt responding to dialysis.\\n Plan:\\n Continue dialysis according to his schedule.\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Since admission to the MICU pt has been had two sessions of diaylsis\\n Action:\\n Last dialysis was today with the removal of 5l of fluid.\\n Yesterday they also removed 5l of fluid\\n Response:\\n With the total removal of 10 liters of fluid in the last 2 days his O2\\n requirement dropped from NRB to room air. O2 sats are 96-100%.\\n Plan:\\n Continue with fliud restriction, continue with dialysis treatments.\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Pt has been very manic today, He is in a good mood, talking almost\\n constantly day. The family meeting with social services and Psych was\\n cancelled but an informal family meeting was held at 1500.\\n Action:\\n Haldol 1.5 mg continues to be given q12h\\n Response:\\n Behavior in control today.\\n Plan:\\n Pt called out to the floor, hopefully to 2\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n HYPERKALEMIA\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 71.2 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: Anemia, Diabetes - Insulin\\n CV-PMH: Hypertension\\n Additional history: hyperlipedemia, diabetes type I on insulin end\\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\\n pressured,racing thoughts decreased sleep consistent with possible\\n mania. lower left extremitiy swelling dopplerable. neg for clots.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:136\\n D:113\\n Temperature:\\n 96.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 20 insp/min\\n Heart Rate:\\n 89 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 100% %\\n 24h total in:\\n 1,100 mL\\n 24h total out:\\n 5,000 mL\\n Pertinent Lab Results:\\n Sodium:\\n 135 mEq/L\\n 10:30 AM\\n Potassium:\\n 4.8 mEq/L\\n 10:30 AM\\n Chloride:\\n 95 mEq/L\\n 10:30 AM\\n CO2:\\n 31 mEq/L\\n 10:30 AM\\n BUN:\\n 28 mg/dL\\n 10:30 AM\\n Creatinine:\\n 4.6 mg/dL\\n 10:30 AM\\n Glucose:\\n 326 mg/dL\\n 10:30 AM\\n Hematocrit:\\n 26.4 %\\n 10:30 AM\\n Finger Stick Glucose:\\n 351\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables: None\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: Micu 687\\n Transferred to:\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373106,\n \"text\": \"Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\\n w/o complaint until 0500- awake, initially pleasant, engaging in\\n conversation- allowed off monitors to wash self , @ 05:30 stating\\n wanted to leave to go to dialysis- attempted to talk down pt, pt\\n reviewing care and accepting Insulin but not PO anti-hypertensives-\\n moderate agitation just persisting on leaving- security called and pt\\n accepting IV chemical restraint- 5mg IVP Haldol, 2mg IV Ativan and\\n lying down in bed. Pt unable/pt refuse and PO medication. Section 12-\\n pt may not leave AMA.\\n Impaired Health Maintenance\\n Assessment:\\n Pt stating\\nI had dialysis yesterday, I need to go to my dialysis\\n today\\n, unable to review dialysis plans, pt focused on leaving\\n hospital, refusing medications\\n Action:\\n Emotional support, reviewing POC\\n Response:\\n Attempting to leave x1\\n Plan:\\n not leave AMA, IV Haldol for restraint, reviewing POC ? social work\\n and psych to follow up\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373109,\n \"text\": \"Chief Complaint: Section 12 due to non-compliance with dialysis\\n 24 Hour Events:\\n - Read of CXR concerning for pericardial effusion given enlarged\\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\\n more lordotically positioned.\\n - Clinically without hypotension or tachycardia. JVP flat.\\n - ECHO revealed no pericardial effusion and slight increase in left\\n ventricular size since \\n - Was somnolent throughout day and awoke brief during dialysis and was\\n agitated and threatening leave briefly, received 1 mg lorazepam and\\n subsequently slept for several hours.\\n - Was sitting up eating at ~ and suddenly anounced that he was\\n going to leave. Talked to several heathcare personnel and became\\n escalated to the point that he required security to help restrain him\\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\\n 0500 on when had repeat episode and could not be talked down and\\n again security called and was restrained and given 5 mg IV haldol and 2\\n mg IV lorazepam.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 10:15 AM\\n Insulin - Humalog - 05:00 AM\\n Lorazepam (Ativan) - 05:30 AM\\n Haloperidol (Haldol) - 05:30 AM\\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: 37.4\\nC (99.3\\n Tcurrent: 36.4\\nC (97.6\\n HR: 87 (85 - 102) bpm\\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\\n RR: 12 (10 - 21) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n 280 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 5,500 mL\\n 0 mL\\n Balance:\\n -5,400 mL\\n 280 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n GEN:\\n HEENT:\\n NECK:\\n PULM:\\n CARD:\\n ABD:\\n EXT:\\n NEURO:\\n Labs / Radiology\\n 400 K/uL\\n 10.6 g/dL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n Assessment and Plan\\n IMPAIRED HEALTH MAINTENANCE\\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:45 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373111,\n \"text\": \"Chief Complaint: Section 12 due to non-compliance with dialysis\\n 24 Hour Events:\\n - Read of CXR concerning for pericardial effusion given enlarged\\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\\n more lordotically positioned.\\n - Clinically without hypotension or tachycardia. JVP flat.\\n - ECHO revealed no pericardial effusion and slight increase in left\\n ventricular size since \\n - Was somnolent throughout day and awoke brief during dialysis and was\\n agitated and threatening leave briefly, received 1 mg lorazepam and\\n subsequently slept for several hours.\\n - Was sitting up eating at ~ and suddenly anounced that he was\\n going to leave. Talked to several heathcare personnel and became\\n escalated to the point that he required security to help restrain him\\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\\n 0500 on when had repeat episode and could not be talked down and\\n again security called and was restrained and given 5 mg IV haldol and 2\\n mg IV lorazepam.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 10:15 AM\\n Insulin - Humalog - 05:00 AM\\n Lorazepam (Ativan) - 05:30 AM\\n Haloperidol (Haldol) - 05:30 AM\\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: 37.4\\nC (99.3\\n Tcurrent: 36.4\\nC (97.6\\n HR: 87 (85 - 102) bpm\\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\\n RR: 12 (10 - 21) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n 280 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 5,500 mL\\n 0 mL\\n Balance:\\n -5,400 mL\\n 280 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n GEN:\\n HEENT:\\n NECK:\\n PULM:\\n CARD:\\n ABD:\\n EXT:\\n NEURO:\\n Labs / Radiology\\n 400 K/uL\\n 10.6 g/dL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n Assessment and Plan:\\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\\n again missed HD sessions.\\n -renal aware\\n -plan for HD tonight\\n -monitor lytes\\n -continue outpt calcium acetate, sensipar, lanthanum\\n -u/a and Cx\\n -consider renal u/s.\\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\\n HD.\\n -plan for HD tonight\\n -monitor lytes\\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\\n -amlodipine, lisinopril, metoprolol, labetolol.\\n -will have to reeval outpt regimen\\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\\n #psychiatric-PT with persistent pattern of non-compliance with HD,\\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\\n large quantities of ETOH and takes illicit substances, then withdraws,\\n but all screens have been negative. At this time, SW and pt's outpt\\n nephrologist have decided to section 12 pt. Psychiatry aware and\\n suggests that the pt does not have capacity and the medical team should\\n consider guardianship.\\n - screens negative\\n -SW consult\\n -f/u psych recs.\\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\\n monitor for signs of w/d.\\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\\n -epogen at HD\\n ICU Care\\n Nutrition: Renal, diabetic diet\\n Glycemic Control: Minimal glargine dose and conservative humalog\\n sliding scale\\n Lines: PIV\\n Prophylaxis:\\n DVT: Heparin subcutaneous\\n Stress ulcer: H2 blocker as home medication\\n Communication: Working with psychiatry and liason in determining if\\n guardianship should be obtained. Patient not competent to make own\\n medical decisions at this time.\\n Code status: Presumed FULL\\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\\n leave hospital without psychiatric clearance. Likely discharge to\\n psychiatric facility.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373079,\n \"text\": \"Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\\n w/o complaint until 0500- awake.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373784,\n \"text\": \"Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372913,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Plan:\\n Follow up with renal,,cont HD\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 372907,\n \"text\": \"Chief Complaint: Nephrology: Dr. \\n CC: section 12 for HD/hyperkalemia.\\n HPI:\\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn.\\n .\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship. In addition, pt often states that he is\\n taking drugs and drinking large quantities of ETOH and withdrawing in\\n the hospital, but screens are negative.\\n .\\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\\n given plan for HD.\\n .\\n Time Pain Temp HR BP RR Pox\\n 17:43 9 99.6 106 192/92 18 100\\n states drinking a liter of ETOH daily.\\n Patient admitted from: ER\\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 Other ICU medications:\\n Other medications:\\n Epogen 3,000 unit/mL Injection\\n given in dialysis three times a day\\n Lipitor 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\\n 10 units q am and 8 units q pm\\n Sensipar 90 mg Tab\\n 1 Tablet(s) by mouth daily\\n FOSRENOL 1,000 mg Chewable Tab\\n 1 Tablet(s) by mouth 4 times daily with meals and snack\\n Lisinopril 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Colace 100 mg Cap\\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\\n Amlodipine 5 mg Tab\\n 1 Tablet(s) by mouth once a day\\n PhosLo 667 mg Cap\\n 2 Capsule(s) by mouth three times a day\\n Labetalol 300 mg Tab\\n 1 Tablet(s) by mouth three times a day\\n Metoprolol SR 25 mg 24 hr Tab\\n 1 Tablet(s) by mouth twice a day\\n Nephrocaps 1 mg Cap\\n 1 Capsule(s) by mouth once a day\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \\n \\n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\\n Recently, he has been mostly dialyzed in\\n hospital, but usually gets his HD at in \\n T,Th,Sat.\\n 3. Diabetic retinopathy (diagnosed 2 years ago)\\n 4. Diabetic neuropathy\\n 5. Diabetic myonecrosis ()\\n 6. Chronic ulcer at right foot\\n 7. Hypertension\\n 8.?psychiatric disorder-bipolar\\n .\\n Social History:\\n Recent social situation complicated, in that patient used to\\n live with his mother, but due to a disagreement, has moved out.\\n His FH is significant for diabetes. His mother and his father\\n are in the 50's both suffering from DMII. He has 2 sisters at\\n the age of 20 and 26 both suffering from DMI. He has four\\n brothers at the age of 16, 19, 28, and 30. His both older\\n brothers suffer from DMI. All his grandparents had DM. Pt. says\\n there is no h/o of heart disease, HTN, cancer or bleeding\\n disorders in the family.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: worked as cleaner until 7 years ago. Since than he has been\\n living on disability. He is living with his mother, his 16 y/o\\n brother and his 26 y/o sister in a house in . He was\\n recently asked to leave his older brother's house as result of\\n stealing form the brother. The patient now reports being\\n homeless for the last 48 hours.\\n Review of systems: see above\\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\\n RR: 14 (13 - 14) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\\n HEENT-PERRLA, EOMI, anicteric,MMM,\\n neck-unable to assess for JVP, no LAD\\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\\n heart-s1s2 RRR no m/r/g\\n abd-+bs, soft, Nt, ND\\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\\n neuro-somnolent but moving all 4 extremities.\\n Labs / Radiology see OMR.\\n [image002.jpg]\\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\\n prior EKG.\\n .\\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\\n transition. The P wave morphology appears less prominent while the P\\n wave axis remains rightward. The prior tracing was consistent with\\n right atrial abnormality. Otherwise, no diagnostic interim change.\\n Clinical correlation is suggested.\\n .\\n ECHO -The left atrium is mildly dilated. No atrial septal defect\\n is seen by 2D or color Doppler. There is mild symmetric left\\n ventricular hypertrophy with normal cavity size. Regional left\\n ventricular wall motion is normal. Overall left ventricular systolic\\n function is normal (LVEF>55%). Right ventricular chamber size and free\\n wall motion are normal. The aortic valve leaflets (3) appear\\n structurally normal with good leaflet excursion. No masses or\\n vegetations are seen on the aortic valve. There is no aortic valve\\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\\n are structurally normal. There is no mitral valve prolapse. No mass or\\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\\n is seen. There is mild pulmonary artery systolic hypertension. No\\n masses or vegetations are seen on the pulmonic valve, but cannot be\\n fully excluded due to suboptimal image quality. There is no pericardial\\n effusion.\\n CXR\\n LENI -IMPRESSION: No left leg DVT.\\n Assessment and Plan\\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n .\\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\\n again missed HD sessions.\\n -renal aware\\n -plan for HD tonight\\n -monitor lytes\\n -continue outpt calcium acetate, sensipar, lanthanum\\n -u/a and Cx\\n -consider renal u/s.\\n .\\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\\n HD.\\n -plan for HD tonight\\n -monitor lytes\\n .\\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\\n -amlodipine, lisinopril, metoprolol, labetolol.\\n -will have to reeval outpt regimen\\n .\\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\\n .\\n #psychiatric-PT with persistent pattern of non-compliance with HD,\\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\\n large quantities of ETOH and takes illicit substances, then withdraws,\\n but all screens have been negative. At this time, SW and pt's outpt\\n nephrologist have decided to section 12 pt. Psychiatry aware and\\n suggests that the pt does not have capacity and the medical team should\\n consider guardianship.\\n - screens negative\\n -SW consult\\n -f/u psych recs.\\n .\\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\\n monitor for signs of w/d.\\n .\\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\\n -epogen at HD\\n .\\n #FEN-renal/DM\\n .\\n #PPx-bowel regimen, Hep SC\\n #access-HD fistula, pt refusing IV\\n .\\n #Code-presumed full\\n #dispo-pending completion of HD session.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: HISS/ 75/25 at home.\\n Lines: PIV\\n Prophylaxis:\\n DVT: hep SC\\n Stress ulcer: h2\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: presumed full\\n Disposition: ICU overnight.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 372908,\n \"text\": \"Chief Complaint: Nephrology: Dr. \\n CC: section 12 for HD/hyperkalemia.\\n HPI:\\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn.\\n .\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship. In addition, pt often states that he is\\n taking drugs and drinking large quantities of ETOH and withdrawing in\\n the hospital, but screens are negative.\\n .\\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\\n given plan for HD.\\n .\\n Time Pain Temp HR BP RR Pox\\n 17:43 9 99.6 106 192/92 18 100\\n states drinking a liter of ETOH daily.\\n Patient admitted from: ER\\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 Other ICU medications:\\n Other medications:\\n Epogen 3,000 unit/mL Injection\\n given in dialysis three times a day\\n Lipitor 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\\n 10 units q am and 8 units q pm\\n Sensipar 90 mg Tab\\n 1 Tablet(s) by mouth daily\\n FOSRENOL 1,000 mg Chewable Tab\\n 1 Tablet(s) by mouth 4 times daily with meals and snack\\n Lisinopril 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Colace 100 mg Cap\\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\\n Amlodipine 5 mg Tab\\n 1 Tablet(s) by mouth once a day\\n PhosLo 667 mg Cap\\n 2 Capsule(s) by mouth three times a day\\n Labetalol 300 mg Tab\\n 1 Tablet(s) by mouth three times a day\\n Metoprolol SR 25 mg 24 hr Tab\\n 1 Tablet(s) by mouth twice a day\\n Nephrocaps 1 mg Cap\\n 1 Capsule(s) by mouth once a day\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \\n \\n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\\n Recently, he has been mostly dialyzed in\\n hospital, but usually gets his HD at in \\n T,Th,Sat.\\n 3. Diabetic retinopathy (diagnosed 2 years ago)\\n 4. Diabetic neuropathy\\n 5. Diabetic myonecrosis ()\\n 6. Chronic ulcer at right foot\\n 7. Hypertension\\n 8.?psychiatric disorder-bipolar\\n .\\n Social History:\\n Recent social situation complicated, in that patient used to\\n live with his mother, but due to a disagreement, has moved out.\\n His FH is significant for diabetes. His mother and his father\\n are in the 50's both suffering from DMII. He has 2 sisters at\\n the age of 20 and 26 both suffering from DMI. He has four\\n brothers at the age of 16, 19, 28, and 30. His both older\\n brothers suffer from DMI. All his grandparents had DM. Pt. says\\n there is no h/o of heart disease, HTN, cancer or bleeding\\n disorders in the family.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: worked as cleaner until 7 years ago. Since than he has been\\n living on disability. He is living with his mother, his 16 y/o\\n brother and his 26 y/o sister in a house in . He was\\n recently asked to leave his older brother's house as result of\\n stealing form the brother. The patient now reports being\\n homeless for the last 48 hours.\\n Review of systems: see above\\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\\n RR: 14 (13 - 14) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\\n HEENT-PERRLA, EOMI, anicteric,MMM,\\n neck-unable to assess for JVP, no LAD\\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\\n heart-s1s2 RRR no m/r/g\\n abd-+bs, soft, Nt, ND\\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\\n neuro-somnolent but moving all 4 extremities.\\n Labs / Radiology see OMR.\\n [image002.jpg]\\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\\n prior EKG.\\n .\\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\\n transition. The P wave morphology appears less prominent while the P\\n wave axis remains rightward. The prior tracing was consistent with\\n right atrial abnormality. Otherwise, no diagnostic interim change.\\n Clinical correlation is suggested.\\n .\\n ECHO -The left atrium is mildly dilated. No atrial septal defect\\n is seen by 2D or color Doppler. There is mild symmetric left\\n ventricular hypertrophy with normal cavity size. Regional left\\n ventricular wall motion is normal. Overall left ventricular systolic\\n function is normal (LVEF>55%). Right ventricular chamber size and free\\n wall motion are normal. The aortic valve leaflets (3) appear\\n structurally normal with good leaflet excursion. No masses or\\n vegetations are seen on the aortic valve. There is no aortic valve\\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\\n are structurally normal. There is no mitral valve prolapse. No mass or\\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\\n is seen. There is mild pulmonary artery systolic hypertension. No\\n masses or vegetations are seen on the pulmonic valve, but cannot be\\n fully excluded due to suboptimal image quality. There is no pericardial\\n effusion.\\n CXR\\n LENI -IMPRESSION: No left leg DVT.\\n Assessment and Plan\\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n .\\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\\n again missed HD sessions.\\n -renal aware\\n -plan for HD tonight\\n -monitor lytes\\n -continue outpt calcium acetate, sensipar, lanthanum\\n -u/a and Cx\\n -consider renal u/s.\\n .\\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\\n HD.\\n -plan for HD tonight\\n -monitor lytes\\n .\\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\\n -amlodipine, lisinopril, metoprolol, labetolol.\\n -will have to reeval outpt regimen\\n .\\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\\n .\\n #psychiatric-PT with persistent pattern of non-compliance with HD,\\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\\n large quantities of ETOH and takes illicit substances, then withdraws,\\n but all screens have been negative. At this time, SW and pt's outpt\\n nephrologist have decided to section 12 pt. Psychiatry aware and\\n suggests that the pt does not have capacity and the medical team should\\n consider guardianship.\\n - screens negative\\n -SW consult\\n -f/u psych recs.\\n .\\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\\n monitor for signs of w/d.\\n .\\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\\n -epogen at HD\\n .\\n #FEN-renal/DM\\n .\\n #PPx-bowel regimen, Hep SC\\n #access-HD fistula, pt refusing IV\\n .\\n #Code-presumed full\\n #dispo-pending completion of HD session.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: HISS/ 75/25 at home.\\n Lines: PIV\\n Prophylaxis:\\n DVT: hep SC\\n Stress ulcer: h2\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: presumed full\\n Disposition: ICU overnight.\\n ------ Protected Section ------\\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\\n DVT. Will give unasyn for now for presumed cellulitis.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 00:50 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 372911,\n \"text\": \"Chief Complaint: Nephrology: Dr. \\n CC: section 12 for HD/hyperkalemia.\\n HPI:\\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn.\\n .\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship. In addition, pt often states that he is\\n taking drugs and drinking large quantities of ETOH and withdrawing in\\n the hospital, but screens are negative.\\n .\\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\\n given plan for HD.\\n .\\n Time Pain Temp HR BP RR Pox\\n 17:43 9 99.6 106 192/92 18 100\\n states drinking a liter of ETOH daily.\\n Patient admitted from: ER\\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 Other ICU medications:\\n Other medications:\\n Epogen 3,000 unit/mL Injection\\n given in dialysis three times a day\\n Lipitor 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\\n 10 units q am and 8 units q pm\\n Sensipar 90 mg Tab\\n 1 Tablet(s) by mouth daily\\n FOSRENOL 1,000 mg Chewable Tab\\n 1 Tablet(s) by mouth 4 times daily with meals and snack\\n Lisinopril 40 mg Tab\\n 1 Tablet(s) by mouth once a day\\n Colace 100 mg Cap\\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\\n Amlodipine 5 mg Tab\\n 1 Tablet(s) by mouth once a day\\n PhosLo 667 mg Cap\\n 2 Capsule(s) by mouth three times a day\\n Labetalol 300 mg Tab\\n 1 Tablet(s) by mouth three times a day\\n Metoprolol SR 25 mg 24 hr Tab\\n 1 Tablet(s) by mouth twice a day\\n Nephrocaps 1 mg Cap\\n 1 Capsule(s) by mouth once a day\\n Past medical history:\\n Family history:\\n Social History:\\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \\n \\n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\\n Recently, he has been mostly dialyzed in\\n hospital, but usually gets his HD at in \\n T,Th,Sat.\\n 3. Diabetic retinopathy (diagnosed 2 years ago)\\n 4. Diabetic neuropathy\\n 5. Diabetic myonecrosis ()\\n 6. Chronic ulcer at right foot\\n 7. Hypertension\\n 8.?psychiatric disorder-bipolar\\n .\\n Social History:\\n Recent social situation complicated, in that patient used to\\n live with his mother, but due to a disagreement, has moved out.\\n His FH is significant for diabetes. His mother and his father\\n are in the 50's both suffering from DMII. He has 2 sisters at\\n the age of 20 and 26 both suffering from DMI. He has four\\n brothers at the age of 16, 19, 28, and 30. His both older\\n brothers suffer from DMI. All his grandparents had DM. Pt. says\\n there is no h/o of heart disease, HTN, cancer or bleeding\\n disorders in the family.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: worked as cleaner until 7 years ago. Since than he has been\\n living on disability. He is living with his mother, his 16 y/o\\n brother and his 26 y/o sister in a house in . He was\\n recently asked to leave his older brother's house as result of\\n stealing form the brother. The patient now reports being\\n homeless for the last 48 hours.\\n Review of systems: see above\\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\\n RR: 14 (13 - 14) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 0 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 97%\\n Physical Examination\\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\\n HEENT-PERRLA, EOMI, anicteric,MMM,\\n neck-unable to assess for JVP, no LAD\\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\\n heart-s1s2 RRR no m/r/g\\n abd-+bs, soft, Nt, ND\\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\\n neuro-somnolent but moving all 4 extremities.\\n Labs / Radiology see OMR.\\n [image002.jpg]\\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\\n prior EKG.\\n .\\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\\n transition. The P wave morphology appears less prominent while the P\\n wave axis remains rightward. The prior tracing was consistent with\\n right atrial abnormality. Otherwise, no diagnostic interim change.\\n Clinical correlation is suggested.\\n .\\n ECHO -The left atrium is mildly dilated. No atrial septal defect\\n is seen by 2D or color Doppler. There is mild symmetric left\\n ventricular hypertrophy with normal cavity size. Regional left\\n ventricular wall motion is normal. Overall left ventricular systolic\\n function is normal (LVEF>55%). Right ventricular chamber size and free\\n wall motion are normal. The aortic valve leaflets (3) appear\\n structurally normal with good leaflet excursion. No masses or\\n vegetations are seen on the aortic valve. There is no aortic valve\\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\\n are structurally normal. There is no mitral valve prolapse. No mass or\\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\\n is seen. There is mild pulmonary artery systolic hypertension. No\\n masses or vegetations are seen on the pulmonic valve, but cannot be\\n fully excluded due to suboptimal image quality. There is no pericardial\\n effusion.\\n CXR\\n LENI -IMPRESSION: No left leg DVT.\\n Assessment and Plan\\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n .\\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\\n again missed HD sessions.\\n -renal aware\\n -plan for HD tonight\\n -monitor lytes\\n -continue outpt calcium acetate, sensipar, lanthanum\\n -u/a and Cx\\n -consider renal u/s.\\n .\\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\\n HD.\\n -plan for HD tonight\\n -monitor lytes\\n .\\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\\n -amlodipine, lisinopril, metoprolol, labetolol.\\n -will have to reeval outpt regimen\\n .\\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\\n .\\n #psychiatric-PT with persistent pattern of non-compliance with HD,\\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\\n large quantities of ETOH and takes illicit substances, then withdraws,\\n but all screens have been negative. At this time, SW and pt's outpt\\n nephrologist have decided to section 12 pt. Psychiatry aware and\\n suggests that the pt does not have capacity and the medical team should\\n consider guardianship.\\n - screens negative\\n -SW consult\\n -f/u psych recs.\\n .\\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\\n monitor for signs of w/d.\\n .\\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\\n -epogen at HD\\n .\\n #FEN-renal/DM\\n .\\n #PPx-bowel regimen, Hep SC\\n #access-HD fistula, pt refusing IV\\n .\\n #Code-presumed full\\n #dispo-pending completion of HD session.\\n ICU Care\\n Nutrition: NPO for now\\n Glycemic Control: HISS/ 75/25 at home.\\n Lines: PIV\\n Prophylaxis:\\n DVT: hep SC\\n Stress ulcer: h2\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: presumed full\\n Disposition: ICU overnight.\\n ------ Protected Section ------\\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\\n DVT. Will give unasyn for now for presumed cellulitis.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 00:50 ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points: receiving HD currently, psych evaluation and\\n treatment of cellulitis as described above. Unable to obtain complete\\n ROS due to altered mental status. Labs reviewed and notable for\\n hyperkalemia but otherwise stable.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 01:31 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372914,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372965,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\\n of Dextrose foe hypoglycemia.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 373000,\n \"text\": \"Chief Complaint: hyperkalemia\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 31 yo ESRD secondary to DM I on tranplant list. Presenting with\\n hyperkalemia after missing HD. Was brought in ?unclear how. In ED was\\n agitated. Was eval by psych who felt he did not have capacity to make\\n decisions. Got 5mg haldol and 2mg of ativan. K was 6.4. refused\\n kayexalate. Came to MICU for urgent HD. BP 192/92 sat 100% on RAn in\\n ED. Overnight required D50x3 for hypoglycemia after getting dosed\\n with SSI.\\n 24 Hour Events:\\n NASAL SWAB - At 12:14 AM\\n MRSA screen\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\\n Infusions:\\n Other ICU medications:\\n Lorazepam (Ativan) - 06:00 AM\\n Hydralazine - 06:10 AM\\n Other medications:\\n nephrocaps\\n calcium acetate\\n norvasc\\n lisinopril\\n EPO\\n lipitor\\n pepcid\\n hep s/q\\n toprol\\n labetolol\\n lanthenum\\n SSI\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:06 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.9\\n HR: 87 (75 - 98) bpm\\n BP: 162/81(99) {137/57(77) - 201/106(128)} mmHg\\n RR: 13 (11 - 17) insp/min\\n SpO2: 97%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n PO:\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 2,500 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -2,400 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 97%\\n ABG: ///29/\\n Physical Examination\\n General Appearance: Well nourished, No acute distress\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Lymphatic: Cervical WNL\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\\n Present)\\n Respiratory / Chest: (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender\\n Extremities: Right: Absent, Left: 3+\\n Skin: Not assessed\\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 10.6 g/dL\\n 400 K/uL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n ECG: slightly peaked Tw\\n Assessment and Plan\\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD): Got\\n emergent HD overnight. K now normalized.\\n Section 12: will need psych admission after medical issues are cleared\\n RLE: swelling and redness. Has had this for at least a few days with\\n no worsening. No clear evidence of cellulitis,\\n DM I: will start half dose NPH and cut back on sliding scale as he was\\n hypoglycemic today.\\n agitation: Currently sedated, but will need sitter and haldol prn.\\n has right effusion in knee: will tap.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 12:45 AM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition :ICU can go to floor after HD\\n Total time spent: 35 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372960,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\\n of Dextrose foe hypoglycemia.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373062,\n \"text\": \"31M with DM1, ESRD on HD, reportedly on the transplant list who\\n presents again with hyperkalemia after missing HD. Pt reportedly not\\n cooperative in the ED and agitated. Of note, pt has had several\\n admissions for hyperkalemia/missing HD sessions and left the hospital\\n AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\\n ativan IV. Renal fellow aware that pt is here and HD planned for\\n tonight. No intervention for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW) was to\\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt with known ESRD, dialyzed overnight upon admission to\\n unit .5L removed.\\n Received pt very lethargic, arousable only to simulation,\\n unable to give most PO meds due to lethargy.\\n Action:\\n Dialyzed again this afternoon per renal orders, 3L removed.\\n Pt becoming more arousable during dialysis, alert and\\n oriented x 3, very talkative at times becoming agitated however easily\\n redirected.\\n Response:\\n Pt tolerated dialysis well, SBP >100\\n Received IV Ativan 1mg x 2 with some effect, also ordered\\n for but did not receive any Haldol.\\n Plan:\\n Pt to have dialysis again tomorrow.\\n PRN Ativan and Haldol as needed.\\n Pt noted to have larger heart on CXR, MDs questioning pericardial\\n effusion, bedside ECHO performed, results pending. Pt called out to\\n floor, awaiting bed placement.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372955,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n Pt received 10 mg Hydralasinr for BP of 190/\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373120,\n \"text\": \"Chief Complaint: Section 12 due to non-compliance with dialysis\\n 24 Hour Events:\\n - Read of CXR concerning for pericardial effusion given enlarged\\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\\n more lordotic positioning.\\n - Clinically without hypotension or tachycardia. JVP flat.\\n - ECHO revealed no pericardial effusion and slight increase in left\\n ventricular size since \\n - Was somnolent throughout day and awoke brief during dialysis and was\\n agitated and threatening leave briefly, received 1 mg lorazepam and\\n subsequently slept for several hours.\\n - Was sitting up eating at ~ and suddenly anounced that he was\\n going to leave. Talked to several heathcare personnel and became\\n escalated to the point that he required security to help restrain him\\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\\n 0500 on when had repeat episode and could not be talked down and\\n again security called and was restrained and given 5 mg IV haldol and 2\\n mg IV lorazepam.\\n - On EKG this AM QTc was 450 ms\\n ROS:\\n Unable to obtain due to patient sedation.\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\\n Infusions:\\n Other ICU medications:\\n Metoprolol - 10:15 AM\\n Insulin - Humalog - 05:00 AM\\n Lorazepam (Ativan) - 05:30 AM\\n Haloperidol (Haldol) - 05:30 AM\\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: 37.4\\nC (99.3\\n Tcurrent: 36.4\\nC (97.6\\n HR: 87 (85 - 102) bpm\\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\\n RR: 12 (10 - 21) insp/min\\n SpO2: 97% on room air\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 100 mL\\n 280 mL\\n PO:\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n 100 mL\\n Blood products:\\n Total out:\\n 5,500 mL\\n 0 mL\\n Balance:\\n -5,400 mL\\n 280 mL\\n Physical Examination\\n GEN: Sedated and sleeping.\\n HEENT: PERRL, oral mucosa moist\\n NECK: no LAD, JVP flat\\n PULM: CTAB with overlying son upper respiratory sounds\\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\\n ABD: BS+, soft, non-distended\\n EXT: Left > right lower extremity edema with no differential warmth\\n NEURO: Somnolent\\n Labs from \\n 400 K/uL\\n 10.6 g/dL\\n 38 mg/dL\\n 8.5 mg/dL\\n 29 mEq/L\\n 4.7 mEq/L\\n 44 mg/dL\\n 99 mEq/L\\n 142 mEq/L\\n 32.6 %\\n 7.1 K/uL\\n [image002.jpg]\\n 06:07 AM\\n WBC\\n 7.1\\n Hct\\n 32.6\\n Plt\\n 400\\n Cr\\n 8.5\\n Glucose\\n 38\\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\\n mg/dL, PO4:5.9 mg/dL\\n MICRO:\\n URINE URINE CULTURE-PENDING NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\\n Assessment and Plan:\\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\\n hyperkalemia, now section 12.\\n # Chronic renal failure-secondary to ESRD/DM:\\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\\n hyperkalemia, and hyperphosphatemia.\\n - HD today in the ICU\\n # Left lower extremity edema:\\n Acute within last week. Patient denies pain with ambulation or knee\\n joint manipulation. Has had two negative sets of lower-extremity\\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\\n other obstructive process to cause differential swelling. Patient was\\n on antibiotics at presentation, but this is not entirely consistent\\n with a cellulitis.\\n - Consider pelvic venous imaging to rule out pelvic DVT\\n # Psychiatric:\\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\\n have decided to section 12 pt. Psychiatry aware and suggests that the\\n pt does not have capacity and the medical team should consider\\n guardianship. had two episodes of threatening to leave hospital\\n overnight requiring security to assist in giving patient chemical\\n restraints (5 mg haldol and 2 mg lorazepam each episode)\\n - Follow-up psychiatry recs\\n - Will need 1:1 observation and cannot leave hospital\\n # Increase in size of cardiac silhouette by CXR on :\\n Was ruled out for pericardial effusion by ECHO. Most likely\\n projectional artifact.\\n # Hypertension:\\n Continue outpt meds and uptitrate prn. HD this AM.\\n - As mental status allows will add back on amlodipine, lisinopril,\\n metoprolol, labetolol.\\n - Will have to reeval outpt regimen\\n # Diabetes mellitus type 1:\\n Insulin 75/25 at half of home doses and conservative sliding scale\\n insulin given that patient is taking little orally.\\n # Reported ETOH:\\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\\n admission. No history of withdrawal symptoms.\\n - Monitor for withdrawal\\n # Anemia:\\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\\n today.\\n - Epoetin at HD\\n ICU Care\\n Nutrition: Renal, diabetic diet\\n Glycemic Control: Minimal glargine dose and conservative humalog\\n sliding scale\\n Lines: PIV\\n Prophylaxis:\\n DVT: Heparin subcutaneous\\n Stress ulcer: H2 blocker as home medication\\n Communication: Working with psychiatry and liason in determining if\\n guardianship should be obtained. Patient not competent to make own\\n medical decisions at this time.\\n Code status: Presumed FULL\\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\\n leave hospital without psychiatric clearance. Likely discharge to\\n psychiatric facility.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Generic Note\",\n \"row_id\": 373765,\n \"text\": \"TITLE: Critical Care\\n Present for the key portions of the resident\\ns history and exam. Agree\\n substantially with assessment and plan as outlined. This am he is\\n manic\\n euphoric, pressured speech, flights of ideas. Denies SOB but\\n oxygenation still not normal. Seems to be improving with aggressive\\n dialysis but CXR being read as c/w pneumonic process. Needs CXR\\n tomorrow and may need CT if he fails to clear but clinically this is\\n CHF rather than infection.\\n Time spent 30 min\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 373601,\n \"text\": \"Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\\n HPI:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was , during his previous admssion. His normal HD schedule is\\n T/Th/Sat.\\n .\\n He was seen by psychiatry in the ED and admitted under section 12\\n because he was not deemed competent to decline medical care. He\\n received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .\\n He was noted to have an enlarged heart shadow on his CXR concerning for\\n effusion. TTE did not show evidence of effusion.\\n .\\n His left leg was noted to be bigger than his right. LENIs were negative\\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\\n remained afebrile and did not have a leukocytosis.\\n .\\n In addition to above management, in the MICU the patient also received\\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\\n required security involvment for agitation on two separate occasions.\\n .\\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco. Given pt's current respiratory status, the renal\\n fellow made the decision the urgently dialyze the pt and he was\\n therefore transferred to the MICU.\\n Patient admitted from: \\n History obtained from Medical records\\n Patient unable to provide history: not willing\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n **Patient unable to provide. Per discharge summary on ...\\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\\n Sensipar 30mg Tablet, 1 Tablet PO once a day\\n Lanthanum Oral\\n .\\n Medications on transfer:\\n Haloperidol 1.5 mg PO Q 12H\\n Acetaminophen 325-650 mg PO Q6H:PRN pain\\n Haloperidol 2 mg IM ONCE\\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\\n Duration: 1 Doses Order date: @ 1614\\n amlodipine 5 mg PO DAILY\\n Heparin 5000 UNIT SC TID\\n Aspirin 325 mg PO DAILY\\n Insulin SC (per Insulin Flowsheet)\\n Atorvastatin 40 mg PO DAILY\\n Insulin Regular 10 UNIT IV ONCE\\n Monitor Q1H for 6 Order date: @ 0044\\n Bisacodyl 10 mg PO/PR DAILY:PRN\\n Lanthanum 1000 mg PO QID\\n Calcium Acetate 1334 mg PO TID W/MEALS\\n Labetalol 300 mg PO TID\\n Calcium Gluconate 2 g IV ONCE\\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\\n Cinacalcet 30 mg PO DAILY\\n Multivitamins 1 TAB PO DAILY\\n Dextrose 50% 25 gm IV ONCE\\n Nephrocaps 1 CAP PO DAILY\\n Dextrose 50% 25 gm IV ONCE\\n Nicotine Patch 21 mg TD DAILY\\n DiphenhydrAMINE 25 mg PO HS:PRN\\n Senna 1 TAB PO BID:PRN\\n Docusate Sodium (Liquid) 100 mg PO BID\\n Epoetin Alfa\\n To be administered during dialysis and dosed according to the \\n Epoetin Alfa P&T Guidelines.\\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\\n Famotidine 20 mg PO Q24H\\n Thiamine 100 mg PO DAILY\\n FoLIC Acid 1 mg PO DAILY\\n Valsartan 160 mg PO DAILY\\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\\n d1= Order date: @ 0044\\n Haloperidol 0.5 mg PO Q2H:PRN agitation\\n MD if giving Order date: @ 1301\\n Past medical history:\\n Family history:\\n Social History:\\n Type I DM (diagnosed 13 years ago), managed by Dr. \\n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \\n Diabetic retinopathy (diagnosed 2 years ago)\\n Diabetic neuropathy\\n Diabetic myonecrosis ()\\n Chronic ulcer at right foot\\n Hypertension\\n Concern for psychiatric disorder, possibly bipolar\\n :\\n Per reveiw of records, Type II diabetes mellitus in mother and father.\\n Type I diabetes mellitus in sisters and brothers.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: He is followed by a social worker because of concern about his\\n competence. Reported alcohol use, illicit drug use.\\n Review of systems: ROS\\n Flowsheet Data as of 03:55 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100\\n Tcurrent: 37.8\\nC (100\\n HR: 92 (92 - 92) bpm\\n BP: 169/75() {169/75() - 169/75()} mmHg\\n RR: 5 (5 - 5) insp/min\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 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: Non-rebreather\\n Physical Examination\\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\\n +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\\n ABG, and hypoxia.\\n .\\n Studies:\\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \\n 8:11, TWI is more pronounced and STE is unchanged.\\n - TTE (): The left atrium is normal in size. There is moderate\\n symmetric left ventricular hypertrophy. The left ventricular cavity is\\n unusually small. Left ventricular systolic function is hyperdynamic (EF\\n 80%). There is no ventricular septal defect. Right ventricular chamber\\n size and free wall motion are normal. There are focal calcifications in\\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\\n aortic stenosis is not present. No aortic regurgitation is seen. The\\n mitral valve leaflets are mildly thickened. There is mild mitral valve\\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\\n artery systolic pressure is normal. There is no pericardial effusion.\\n There is an anterior space which most likely represents a fat pad.\\n Compared with the findings of the prior study (images unavailable) of\\n , the left ventricular wall thickening has progressed.\\n - CXR 2V (): Final read pending\\n - LENI (): No evidence of DVT of the left lower extremity.\\n Assessment and Plan\\n Assessment and plan:\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Pt\\n sat's improved after being given 80mg IV lasix. Appears, pt last\\n dialyzed . However, infection such as from PNA, ACS/cardiac\\n etiology, medication effect from anti-psychotics, or other illicit\\n substance could be involved. Other possibility to consider is PE.\\n -bcx and ucx\\n -cxr\\n -urgent HD per renal fellow\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source. Improved slightly, but now\\n stable. Had temp of 100.8 on .\\n - initially abx were stoped, but now keflex restarted with fever,\\n even though this would be a odd presentation of cellulitis\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - Repeat EKG, daily while haldol dose is adjusted\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\\n disorder component. Poor compliance has been long standing issue. Per\\n psych notes, has had \\\"agitation, pressured speech, loose and\\n tangential, racing thoughts and decreased sleep consistent with\\n possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition: DM/RENal\\n Glycemic Control: HISS\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT: h2, HSC\\n Stress ulcer:\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 373606,\n \"text\": \"Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\\n HPI:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was , during his previous admssion. His normal HD schedule is\\n T/Th/Sat.\\n .\\n He was seen by psychiatry in the ED and admitted under section 12\\n because he was not deemed competent to decline medical care. He\\n received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .\\n He was noted to have an enlarged heart shadow on his CXR concerning for\\n effusion. TTE did not show evidence of effusion.\\n .\\n His left leg was noted to be bigger than his right. LENIs were negative\\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\\n remained afebrile and did not have a leukocytosis.\\n .\\n In addition to above management, in the MICU the patient also received\\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\\n required security involvment for agitation on two separate occasions.\\n .\\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco. Given pt's current respiratory status, the renal\\n fellow made the decision the urgently dialyze the pt and he was\\n therefore transferred to the MICU.\\n Patient admitted from: \\n History obtained from Medical records\\n Patient unable to provide history: not willing\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n **Patient unable to provide. Per discharge summary on ...\\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\\n Sensipar 30mg Tablet, 1 Tablet PO once a day\\n Lanthanum Oral\\n .\\n Medications on transfer:\\n Haloperidol 1.5 mg PO Q 12H\\n Acetaminophen 325-650 mg PO Q6H:PRN pain\\n Haloperidol 2 mg IM ONCE\\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\\n Duration: 1 Doses Order date: @ 1614\\n amlodipine 5 mg PO DAILY\\n Heparin 5000 UNIT SC TID\\n Aspirin 325 mg PO DAILY\\n Insulin SC (per Insulin Flowsheet)\\n Atorvastatin 40 mg PO DAILY\\n Insulin Regular 10 UNIT IV ONCE\\n Monitor Q1H for 6 Order date: @ 0044\\n Bisacodyl 10 mg PO/PR DAILY:PRN\\n Lanthanum 1000 mg PO QID\\n Calcium Acetate 1334 mg PO TID W/MEALS\\n Labetalol 300 mg PO TID\\n Calcium Gluconate 2 g IV ONCE\\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\\n Cinacalcet 30 mg PO DAILY\\n Multivitamins 1 TAB PO DAILY\\n Dextrose 50% 25 gm IV ONCE\\n Nephrocaps 1 CAP PO DAILY\\n Dextrose 50% 25 gm IV ONCE\\n Nicotine Patch 21 mg TD DAILY\\n DiphenhydrAMINE 25 mg PO HS:PRN\\n Senna 1 TAB PO BID:PRN\\n Docusate Sodium (Liquid) 100 mg PO BID\\n Epoetin Alfa\\n To be administered during dialysis and dosed according to the \\n Epoetin Alfa P&T Guidelines.\\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\\n Famotidine 20 mg PO Q24H\\n Thiamine 100 mg PO DAILY\\n FoLIC Acid 1 mg PO DAILY\\n Valsartan 160 mg PO DAILY\\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\\n d1= Order date: @ 0044\\n Haloperidol 0.5 mg PO Q2H:PRN agitation\\n MD if giving Order date: @ 1301\\n Past medical history:\\n Family history:\\n Social History:\\n Type I DM (diagnosed 13 years ago), managed by Dr. \\n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \\n Diabetic retinopathy (diagnosed 2 years ago)\\n Diabetic neuropathy\\n Diabetic myonecrosis ()\\n Chronic ulcer at right foot\\n Hypertension\\n Concern for psychiatric disorder, possibly bipolar\\n :\\n Per reveiw of records, Type II diabetes mellitus in mother and father.\\n Type I diabetes mellitus in sisters and brothers.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: He is followed by a social worker because of concern about his\\n competence. Reported alcohol use, illicit drug use.\\n Review of systems: ROS\\n Flowsheet Data as of 03:55 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.8\\nC (100\\n Tcurrent: 37.8\\nC (100\\n HR: 92 (92 - 92) bpm\\n BP: 169/75() {169/75() - 169/75()} mmHg\\n RR: 5 (5 - 5) insp/min\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 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: Non-rebreather\\n Physical Examination\\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\\n +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\\n ABG, and hypoxia.\\n .\\n Studies:\\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \\n 8:11, TWI is more pronounced and STE is unchanged.\\n - TTE (): The left atrium is normal in size. There is moderate\\n symmetric left ventricular hypertrophy. The left ventricular cavity is\\n unusually small. Left ventricular systolic function is hyperdynamic (EF\\n 80%). There is no ventricular septal defect. Right ventricular chamber\\n size and free wall motion are normal. There are focal calcifications in\\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\\n aortic stenosis is not present. No aortic regurgitation is seen. The\\n mitral valve leaflets are mildly thickened. There is mild mitral valve\\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\\n artery systolic pressure is normal. There is no pericardial effusion.\\n There is an anterior space which most likely represents a fat pad.\\n Compared with the findings of the prior study (images unavailable) of\\n , the left ventricular wall thickening has progressed.\\n - CXR 2V (): Final read pending\\n - LENI (): No evidence of DVT of the left lower extremity.\\n Assessment and Plan\\n Assessment and plan:\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Pt\\n sat's improved after being given 80mg IV lasix. Appears, pt last\\n dialyzed . However, infection such as from PNA, ACS/cardiac\\n etiology, medication effect from anti-psychotics, or other illicit\\n substance could be involved. Other possibility to consider is PE.\\n -bcx and ucx\\n -cxr\\n -urgent HD per renal fellow\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source. Improved slightly, but now\\n stable. Had temp of 100.8 on .\\n - initially abx were stoped, but now keflex restarted with fever,\\n even though this would be a odd presentation of cellulitis\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - Repeat EKG, daily while haldol dose is adjusted\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\\n disorder component. Poor compliance has been long standing issue. Per\\n psych notes, has had \\\"agitation, pressured speech, loose and\\n tangential, racing thoughts and decreased sleep consistent with\\n possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition: DM/RENal\\n Glycemic Control: HISS\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT: h2, HSC\\n Stress ulcer:\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n ------ Protected Section ------\\n MICU ATTENDING ADDENDUM\\n I saw and examined the patient, and was physically present with the ICU\\n team for the key portions of the services provided. I agree with the\\n note above, including the assessment and plan. I would emphasize and\\n add the following points:\\n Worsening hypoxemia this eve with new bilateral infiltrates\\n presumption is that this represents pulmonary edema and he was\\n transferred to ICU for urgent dialysis. He was placed on a 100% NRB\\n facemask to maintain adequate saturations.\\n Exam notable for Tm afebrile HR 94 BP 156/70 RR 19 with 97 sat on\\n 100% NRB\\n No distress\\n HEENT unremarkable\\n Neck supple\\n Lungs crackles\\n Her rrr\\n Abd benign\\n Extreme RUE fistula, mild LLE edema\\n Labs notable for K+ 6.3 yesterday morning\\n Imaging: CXR with new bilateral patchy infiltrates\\n EKG with peaked T\\n Problems: respiratory distress, hypoxemia, pulmonary edema, ESRD, LLE\\n edema, hyperkalemia, DM\\n Agree with plan for urgent HD, wean O2 as tolerates, will continue\\n antibiotics and let floor team sort out LLE, continue current DM\\n regimen\\n Remainder of plan as outlined above.\\n Patient is critically ill.\\n Total time: 36 min\\n ------ Protected Section Addendum Entered By: , MD\\n on: 04:31 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373673,\n \"text\": \" MD H+P:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Today\\ns Events\\n HD today, removed 4.9kilo\\n L leg remains swollen and tender to touch\\n CXR revealed pneumonia, received vanco X1\\n Pt desatuating on RA to 70\\ns, productive cough\\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373676,\n \"text\": \" MD H+P:\\n Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Today\\ns Events\\n HD today, removed 4.9kilo\\n L leg remains swollen and tender to touch\\n CXR revealed pneumonia, received vanco X1\\n Pt desatuating on RA to 70\\ns, productive cough\\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt with known ESRD, non-compliant with medical care . K+ 6.8\\n overnight with worsening resp distress and desaturation to the 70\\n Action:\\n Renal ordered HD overnight.\\n Response:\\n HD removed 4.9kilo\\n Plan:\\n Monitor fluid balance, pt is refusing to abide by fluid restriction.\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Known non-compliance with medical regimen. ? untreated Bipolar\\n disease. History of leaving AMA, pt is Currently under Section 12 and\\n has 1:1 sitter and can NOT leave.\\n Action:\\n Pt is on Haldol and can receive PRN doses\\n Response:\\n Pt has been cooperative with care, 1:1 sitter\\n Plan:\\n Psych and SW attempting to get medical guardianship, meeting friday\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373734,\n \"text\": \"24 Hour Events:\\n -3.5L at O/N\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373735,\n \"text\": \"24 Hour Events:\\n -3.5L at O/N\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373737,\n \"text\": \"24 Hour Events:\\n -3.5L at O/N\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Assessment and Plan\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Pt\\n sat's improved after being given 80mg IV lasix. Appears, pt last\\n dialyzed . However, infection such as from PNA, ACS/cardiac\\n etiology, medication effect from anti-psychotics, or other illicit\\n substance could be involved. Other possibility to consider is PE.\\n -bcx and ucx\\n -cxr\\n -urgent HD per renal fellow\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source. Improved slightly, but now\\n stable. Had temp of 100.8 on .\\n - initially abx were stoped, but now keflex restarted with fever,\\n even though this would be a odd presentation of cellulitis\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - Repeat EKG, daily while haldol dose is adjusted\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\\n disorder component. Poor compliance has been long standing issue. Per\\n psych notes, has had \\\"agitation, pressured speech, loose and\\n tangential, racing thoughts and decreased sleep consistent with\\n possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373742,\n \"text\": \"24 Hour Events:\\n -3.5L O/N\\n -No episodes of hypotension\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Bcx (): PND\\n Bcx (): PND\\n UCx (): Negative\\n Assessment and Plan\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Renal\\n following, given dialysis yesterday early AM, continues to be fluid\\n overloaded. Will continue to diureses as per renal recommendations and\\n fluid restrict (1L per day, 80mg lasix QD).\\n -bcx and ucx\\n -cxr\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source.\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: As per admission note, patient is Section 12.\\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\\n has been long standing issue. Per psych notes, has had \\\"agitation,\\n pressured speech, loose and tangential, racing thoughts and decreased\\n sleep consistent with possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition: DM/RENal\\n Glycemic Control: HISS\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT: h2, HSC\\n Stress ulcer:\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 373826,\n \"text\": \"24 Hour Events:\\n -3.5L O/N\\n -No episodes of hypotension\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since 12 AM\\n Tmax: 37.5\\nC (99.5\\n Tcurrent: 37.1\\nC (98.8\\n HR: 88 (86 - 106) bpm\\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\\n RR: 18 (0 - 24) insp/min\\n SpO2: 96%\\n Heart rhythm: SR (Sinus Rhythm)\\n Height: 69 Inch\\n Total In:\\n 1,550 mL\\n 180 mL\\n PO:\\n 1,450 mL\\n 180 mL\\n TF:\\n IVF:\\n 100 mL\\n Blood products:\\n Total out:\\n 4,900 mL\\n 0 mL\\n Urine:\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,350 mL\\n 180 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 96%\\n ABG: ///30/\\n Physical Examination\\n General - Resting comfortably in bed, no acute distress. No audible\\n wheezing, head nods and answers yes/no to questioning.\\n HEENT - Sclera anicteric, dry mucous membranes\\n Neck - Supple,\\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\\n bilaterally; LLE with swelling extending above knee, trace pitting\\n edema to shin without obvious erythema\\n Neuro - Moves all extremities; unable to do exam given somnolence\\n Labs / Radiology\\n 457 K/uL\\n 8.3 g/dL\\n 296 mg/dL\\n 5.1 mg/dL\\n 30 mEq/L\\n 5.4 mEq/L\\n 29 mg/dL\\n 93 mEq/L\\n 132 mEq/L\\n 26.6 %\\n 15.1 K/uL\\n [image002.jpg]\\n 03:53 AM\\n 03:17 PM\\n WBC\\n 14.7\\n 15.1\\n Hct\\n 27.6\\n 26.6\\n Plt\\n 550\\n 457\\n Cr\\n 7.8\\n 5.1\\n TropT\\n 0.27\\n Glucose\\n 74\\n 296\\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\\n mg/dL\\n Bcx (): PND\\n Bcx (): PND\\n UCx (): Negative\\n Assessment and Plan\\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\\n Section 12 for hyperkalemia in context of missed HD. Transferred to\\n medicine service on for further management of lower extremity\\n swelling and placement in psychiatric facility. transferred to the\\n MICU for hypoxia.\\n .\\n #hypoxia-likely secondary to volume overload from renal failure. Renal\\n following, given dialysis yesterday early AM, continues to be fluid\\n overloaded. Will continue to diureses as per renal recommendations and\\n fluid restrict (1L per day, 80mg lasix QD).\\n -bcx and ucx\\n -cxr\\n -has had several LENI's that have been neg for PE.\\n -tele\\n -EKG\\n -CE's.\\n .\\n #. Lower extremity swelling: Patient has clear asymmetry of lower\\n extremities, L>R extending above knee. Lower extremity dopplers x2\\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\\n Differential diagnosis for unilateral extremity swelling includes\\n thrombosis, obstruction of venous return by extravascular source,\\n cellulitis. Patient is on calcium-channel blocker, but would expect\\n bilateral edema if this were the source.\\n - Continue DVT prophylaxis as below\\n -vanco started by floor team.\\n .\\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\\n had perstantine MIBI stress test in which was normal but with\\n suboptimal heart rate. Several risk factors for CAD. At time of writing\\n this note, patient more responsive; denies chest pain, shortness of\\n breath, palpitations, back pain.\\n - Aspirin 325mg PO daily\\n - cardiac enzymes- negative\\n - Continue beta-blocker\\n .\\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\\n outpatient, although missed sessions prior to admission to MICU.\\n Previously evaluated for transplantation by Dr. . Still with\\n hyperphosphatemia; improving. Hyperkalemia recurrent.\\n - Continue HD per home regimen (T/Th/Sat)\\n - Renal diet\\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\\n - Renal recs\\n .\\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\\n Secondary to ESRD and likely anemia of chronic disease (iron studies\\n last checked .\\n - Continue Epo at HD\\n - Guaiac stools\\n .\\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\\n unclear at this time\\n - Changed to , due to concern for edema\\n - Continue amlodipine\\n - Patient currently on metoprolol, no longer on atenolol\\n .\\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\\n so on , insulin changed to once a day lantus at night.\\n - humalog SSI\\n - QID fingersticks\\n .\\n #. Psychiatric history: As per admission note, patient is Section 12.\\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\\n has been long standing issue. Per psych notes, has had \\\"agitation,\\n pressured speech, loose and tangential, racing thoughts and decreased\\n sleep consistent with possible mania.\\\"\\n - One to one sitter\\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\\n dose given sedation with 5mg IV\\n - follow QTc if giving frequent doses of Haldol\\n - Code purple if tries to leave AMA\\n - possible psychiatry admission after medically stable for\\n \\\"stabilization of mood and behavior that might then allow for more\\n optimal medical mgmt\\\"\\n - Psychiatry recs\\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\\n extra doses as needed, will uptitrate standing dose\\n .\\n #. Hyperlipidemia:\\n - Continue statin per home regimen\\n .\\n #. Increase in size of cardiac silhouette by CXR on : Concern for\\n pericardial effusion ruled out with TTE.\\n .\\n #. FEN/GI:\\n - Renal, diabetic diet\\n - Replete lytes as needed\\n .\\n #. Prophylaxis:\\n - DVT - Heparin SC TID\\n - Bowel - As needed\\n - PPI - Not indicated at this time\\n .\\n #access-AV fistula, PIV\\n .\\n #. Contact: does not wish for his medical care to be discussed\\n with family members.\\n .\\n #. Code status: FULL CODE\\n .\\n #. Disposition: Patient may not leave hospital without psychiatric\\n clearance. Likely discharge to psychiatric facility after medically\\n stable.\\n ICU Care\\n Nutrition: DM/RENal\\n Glycemic Control: HISS\\n Lines:\\n 20 Gauge - 03:34 AM\\n Prophylaxis:\\n DVT: h2, HSC\\n Stress ulcer:\\n VAP: n/a\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: Floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373709,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Overnight Events\\n L leg remains swollen and tender to touch\\n Pt desatuating on RA to80\\ns, productive cough\\n Pt compliant with meds and no periods of agitation, remains\\n on 1:1 sitter\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt with known ESRD, non-compliant with medical care prior to admit HD\\n done , tol well.\\n Action:\\n 1000ml fluid restriction maintained.\\n Response:\\n Pt compliant with meds, and fluid restriction\\n Plan:\\n Monitor fluid balance, ?HD today\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Known non-compliance with medical regimen. ? untreated Bipolar\\n disease. History of leaving AMA, pt is Currently under Section 12 and\\n has 1:1 sitter and can NOT leave.\\n Action:\\n Pt is on Haldol and received PRN dose x1 a/o\\n Response:\\n Pt has been cooperative with care, 1:1 sitter\\n Plan:\\n Psych and SW attempting to get medical guardianship, meeting today\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373809,\n \"text\": \"Mr. is a 31 year-old male initially admitted to the MICU \\n for hyperkalemia. He has a long history of poor compliance with\\n dialysis and medical care. He was sent to the ED after his nephrologist\\n found he was hyperkalemic. His last dialysis session prior to admission\\n was .. He was seen by psychiatry in the ED and admitted under\\n section 12 because he was not deemed competent to decline medical care.\\n He received haldol and ativan, and was sent to the MICU because of\\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\\n was some concern for peaked T waves. He never accepted kayexalate but\\n he has had two dialysis prior to transfer to the floor.\\n .His left leg was noted to be bigger than his right. LENIs were\\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\\n note, he remained afebrile and did not have a leukocytosis.\\n .\\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\\n dextrose. He was initially given keflex for LLE cellulitis, then\\n changed to vanco(last dose 4/30 at 0200). Given pt's current\\n respiratory status, the renal fellow made the decision the urgently\\n dialyze the pt and he was therefore transferred to the MICU.\\n Hyperkalemia (high Potassium, Hyperpotassemia)\\n Assessment:\\n Pt\\ns K+ has been dropping with dialysis.\\n Action:\\n last K+ level was 4.4 at 1030 \\n Response:\\n Pt responding to dialysis.\\n Plan:\\n Continue dialysis according to his schedule.\\n .H/O renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Since admission to the MICU pt has been had two sessions of diaylsis\\n Action:\\n Last dialysis was today with the removal of 5l of fluid.\\n Yesterday they also removed 5l of fluid\\n Response:\\n With the total removal of 10 liters of fluid in the last 2 days his O2\\n requirement dropped from NRB to room air. O2 sats are 96-100%.\\n Plan:\\n Continue with fliud restriction, continue with dialysis treatments.\\n Psychiatric Disease, Other (including Schizophrenia, Personality\\n Disorders)\\n Assessment:\\n Pt has been very manic today, He is in a good mood, talking almost\\n constantly day. The family meeting with social services and Psych was\\n cancelled but an informal family meeting was held at 1500.\\n Action:\\n Haldol 1.5 mg continues to be given q12h\\n Response:\\n Behavior in control today.\\n Plan:\\n Pt called out to the floor,\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n HYPERKALEMIA\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 71.2 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: Anemia, Diabetes - Insulin\\n CV-PMH: Hypertension\\n Additional history: hyperlipedemia, diabetes type I on insulin end\\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\\n pressured,racing thoughts decreased sleep consistent with possible\\n mania. lower left extremitiy swelling dopplerable. neg for clots.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:136\\n D:113\\n Temperature:\\n 96.2\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 20 insp/min\\n Heart Rate:\\n 89 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 95% %\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 100% %\\n 24h total in:\\n 1,100 mL\\n 24h total out:\\n 5,000 mL\\n Pertinent Lab Results:\\n Sodium:\\n 135 mEq/L\\n 10:30 AM\\n Potassium:\\n 4.8 mEq/L\\n 10:30 AM\\n Chloride:\\n 95 mEq/L\\n 10:30 AM\\n CO2:\\n 31 mEq/L\\n 10:30 AM\\n BUN:\\n 28 mg/dL\\n 10:30 AM\\n Creatinine:\\n 4.6 mg/dL\\n 10:30 AM\\n Glucose:\\n 326 mg/dL\\n 10:30 AM\\n Hematocrit:\\n 26.4 %\\n 10:30 AM\\n Finger Stick Glucose:\\n 351\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables: None\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: Micu 687\\n Transferred to: 201\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 372931,\n \"text\": \"Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\\n list who presents again with hyperkalemia after missing HD. Pt\\n reportedly not cooperative in the ED and agitated. Of note, pt has had\\n several admissions for hyperkalemia/missing HD sessions and left the\\n hospital AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\\n for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW)was to\\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\\n thrill and brui. K was 6.4 in the ED.\\n Action:\\n HD for / hrs at bedside.\\n Response:\\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\\n Plan:\\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\\n If stable.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373010,\n \"text\": \"31M with DM1, ESRD on HD, reportedly on the transplant list who\\n presents again with hyperkalemia after missing HD. Pt reportedly not\\n cooperative in the ED and agitated. Of note, pt has had several\\n admissions for hyperkalemia/missing HD sessions and left the hospital\\n AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\\n ativan IV. Renal fellow aware that pt is here and HD planned for\\n tonight. No intervention for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW) was to\\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 373152,\n \"text\": \"TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\\n presents again with hyperkalemia after missing HD. Pt reportedly not\\n cooperative in the ED and agitated. Of note, pt has had several\\n admissions for hyperkalemia/missing HD sessions and left the hospital\\n AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\\n ativan IV. Renal fellow aware that pt is here and HD planned for\\n tonight. No intervention for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW) was to\\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\\n treatment. Unfortunately pt became agitated, angry and appeared\\n threatening early this afternoon. Feelings validated and pt given\\n ample time to voice his displeasure to no avail. Stat security called\\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\\n admin. Pt now more cooperative and is not agitated. Pt seems to last\\n 8 to 12 hours between outbursts.\\n Impaired Health Maintenance\\n Assessment:\\n As noted above, the pt was more or less cooperative with care this AM\\n (though refused all AM meds). Unfortunately pt impulsively became\\n angry/agitated/beligerant this afternoon requiring stat security @ BS.\\n Stable QTi on EKG this AM. Soft wrist restraints in place. 1:1 Sitter\\n @ BS.\\n Action:\\n With security @ BS and a supportive sitter whom the pt trusted the pt\\n relented and allowed 5mg IVP Haldol to be admin @ BS.\\n Response:\\n Pt now more cooperative with no agitation issues @ this time.\\n Plan:\\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\\n becoming acutely agitated. Follow serial EKG QTi as long as IV Haldol\\n treatment in place.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt received his third HD in three days today. AM potassium value of\\n 4.3 noted.\\n Action:\\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\\n Response:\\n Pt without significant issues surrounding HD treatment.\\n Plan:\\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\\n for Mon vs Tues.\\n Demographics: The pt is appearantly estranged from his mother and has\\n issues with some of his siblings. Pt also appears to have issues of\\n homelessness. Pt with multiple recent hospital admits s/p missed HD\\n treatments with significant hyperkalemia.\\n Attending MD:\\n R.\\n Admit diagnosis:\\n HYPERKALEMIA\\n Code status:\\n Full code\\n Height:\\n 69 Inch\\n Admission weight:\\n 71.2 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions: No Additional Precautions\\n PMH: Anemia, Diabetes - Insulin, Renal Failure, Smoker\\n CV-PMH: Hypertension\\n Additional history: Diabetic retinopathy. Anemia. Recent LLE swelling\\n (Leni's negative times two). diabetic neuropathy\\n Diabetic myonecrosis. Chronic ulcer right foot\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:155\\n D:65\\n Temperature:\\n 97.4\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 18 insp/min\\n Heart Rate:\\n 96 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 96% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 380 mL\\n 24h total out:\\n 1,200 mL\\n Pertinent Lab Results:\\n Sodium:\\n 138 mEq/L\\n 10:05 AM\\n Potassium:\\n 4.8 mEq/L\\n 10:05 AM\\n Chloride:\\n 96 mEq/L\\n 10:05 AM\\n CO2:\\n 29 mEq/L\\n 10:05 AM\\n BUN:\\n 29 mg/dL\\n 10:05 AM\\n Creatinine:\\n 7.2 mg/dL\\n 10:05 AM\\n Glucose:\\n 83 mg/dL\\n 10:05 AM\\n Hematocrit:\\n 29.2 %\\n 10:05 AM\\n Finger Stick Glucose:\\n 147\\n 10:05 AM\\n Valuables / Signature: All of the pts personal property (5 bags) have\\n been moved to a holding area on CC2.\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: MICU 6 West.\\n Transferred to: 226\\n Date & time of Transfer:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 373149,\n \"text\": \"TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\\n presents again with hyperkalemia after missing HD. Pt reportedly not\\n cooperative in the ED and agitated. Of note, pt has had several\\n admissions for hyperkalemia/missing HD sessions and left the hospital\\n AMA including most recently on . During pt's most recent\\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\\n ativan IV. Renal fellow aware that pt is here and HD planned for\\n tonight. No intervention for hyperkalemia given plan for HD.\\n Given pts multiple AMA's and noncompliance with HD and medical\\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\\n disorder that makes him incompetent to make medical decisions.\\n Therefore, plan (developed by outpt renal Dr. and SW) was to\\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\\n ED, feels that he lacks competency and suggests that the medical team\\n pursue legal guardianship.\\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\\n treatment. Unfortunately pt became agitated, angry and appeared\\n threatening early this afternoon. Feelings validated and pt given\\n ample time to voice his displeasure to no avail. Stat security called\\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\\n admin. Pt now more cooperative and is not agitated. Pt seems to last\\n 8 to 12 hours between outbursts.\\n Impaired Health Maintenance\\n Assessment:\\n As noted above, the pt more or less cooperative with care this AM.\\n Unfortunately pt became angry/agitated/ beligerant this afternoon\\n requiring stat security @ BS. Stable QTi on EKG this AM.\\n Action:\\n With security @ BS and a supportive sitter whom the pt trusted the pt\\n relented and allowed 5mg IVP Haldol to be admin @ BS.\\n Response:\\n Pt now more cooperative with no agitation issues @ this time.\\n Plan:\\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\\n becoming agitated. Follow serial EKG QTi as long as IV Haldol\\n treatment in place.\\n Renal failure, End stage (End stage renal disease, ESRD)\\n Assessment:\\n Pt received his third HD in three days today.\\n Action:\\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\\n Response:\\n Pt without significant issues surrounding HD treatment.\\n Plan:\\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\\n for Mon vs Tues.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 83971,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Enlarged cardiac size on CXR. Evaluate for effusion\\nHeight: (in) 69\\nWeight (lb): 156\\nBSA (m2): 1.86 m2\\nBP (mm Hg): 128/66\\nHR (bpm): 101\\nStatus: Inpatient\\nDate/Time: at 16:46\\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: Moderate symmetric LVH. Small LV cavity. Hyperdynamic LVEF\\n>75%. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root. Normal aortic arch diameter. Focal calcifications in aortic arch.\\nNo 2D or Doppler evidence of distal arch coarctation.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\\nof papillary muscles. No MS. Trivial MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: 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\\nConclusions:\\nThe left atrium is normal in size. There is moderate symmetric left\\nventricular hypertrophy. The left ventricular cavity is unusually small. Left\\nventricular systolic function is hyperdynamic (EF 80%). There is no\\nventricular septal defect. Right ventricular chamber size and free wall motion\\nare normal. There are focal calcifications in the aortic arch. The aortic\\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\\nThere is mild mitral valve prolapse. Trivial mitral regurgitation is seen. The\\nestimated pulmonary artery systolic pressure is normal. There is no\\npericardial effusion. There is an anterior space which most likely represents\\na fat pad.\\n\\nCompared with the findings of the prior study (images unavailable) of , the left ventricular wall thickening has progressed.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1075959,\n \"text\": \" 12:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, edema\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with h/o DM and ESRD on HD who had desat to 60% on RA.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Diabetes mellitus, desaturation.\\n\\n FINDINGS: As compared to the previous radiograph, there is a newly appeared\\n extensive opacity in the middle and basal parts of the right lung and in the\\n retrocardiac lung areas. The opacity is of alveolar morphology, multiple\\n subtle air bronchograms are seen. The opacities tend to spare in the\\n uppermost parts of the lung. In the region of the right hilus, subtle\\n peribronchial cuffing is seen. However, all other signs indicative of\\n overhydration are missing. In the light, they are much more likely to\\n represent pneumonia rather than edema.\\n Unchanged size of the cardiac silhouette, unchanged mediastinal contours.\\n\\n was notified by telephone at the time of dictation and informed\\n about the abnormalities.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-08 00:00:00.000\",\n \"description\": \"L KNEE (AP, LAT & OBLIQUE) LEFT\",\n \"row_id\": 1076429,\n \"text\": \" 10:24 PM\\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \\n Reason: Any fracture or other left knee pathology evident on plain f\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with leg lower extremity swelling and new left knee pain.\\n REASON FOR THIS EXAMINATION:\\n Any fracture or other left knee pathology evident on plain film?\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Left lower extremity swelling. New left knee pain.\\n\\n LEFT KNEE, THREE VIEWS\\n\\n There is deformity and increased density in the right tibial plateau\\n consistent with a tibial plateau fracture, with depression. There is a\\n probable joint effusion. There is minimal spurring about the patella. There\\n is an ossific fragment along the medial border of the patella, which appears\\n well corticated, and which could represent a either fracture fragment or\\n heterotopic ossification in the medial retinaculum. No dislocation is\\n identified. Dense vascular calcification is noted.\\n\\n IMPRESSION:\\n\\n 1) Findings consistent with medial tibial plateau fracture likely subcaute or\\n chronic .\\n\\n 2) Ossicle along medial patella -- ? nonacute fracture vs post- traumatic\\n heterotopic ossificaiton in adjoining medial retinaculum. Possible subacute\\n fracture along the medial patella.\\n\\n 3. Joint effusion.\\n\\n Findings discussed with covering house officer Dr. at\\n approximately 13:18 p.m. on the day of the exam.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-08 00:00:00.000\",\n \"description\": \"L UNILAT LOWER EXT VEINS LEFT\",\n \"row_id\": 1076405,\n \"text\": \" 4:59 PM\\n UNILAT LOWER EXT VEINS LEFT Clip # \\n Reason: LLE SWELLING EVAL FOR DVT\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with possible DVT, dialysis patient\\n REASON FOR THIS EXAMINATION:\\n r/o DVT\\n ______________________________________________________________________________\\n WET READ: DLrc SAT 6:47 PM\\n No evidence of left lower extremity DVT. Prominent lymph nodes in the left\\n groin.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is a 31-year-old male with possible deep venous thrombus.\\n Evaluate for deep venous thrombus.\\n\\n EXAMINATION: Unilateral left lower extremity DVT study.\\n\\n COMPARISONS: Comparison to ultrasound examination from .\\n\\n FINDINGS: Grayscale and color Doppler son of the left common femoral,\\n superficial femoral and popliteal veins were performed. There is normal\\n compressibility, flow, augmentation. There is symmetric respiratory\\n variability in the right and left common femoral veins.\\n\\n IMPRESSION: No evidence of left lower extremity DVT.\\n SESHa\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-10 00:00:00.000\",\n \"description\": \"L CT LOW EXT W/O C LEFT\",\n \"row_id\": 1076744,\n \"text\": \" 6:12 PM\\n CT LOW EXT W/O C LEFT Clip # \\n Reason: to evaluate knee fracture\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with hx of ESRD on HD, now with knee injury 2 weeks ago, now\\n with plain films showing tibial and patellar fractures.\\n REASON FOR THIS EXAMINATION:\\n to evaluate knee fracture\\n CONTRAINDICATIONS for IV CONTRAST:\\n ESRD\\n ______________________________________________________________________________\\n WET READ: CXWc MON 8:46 PM\\n Impacted right medial tibial plateau fracture extending to the articular\\n surface, with pleateau depression of approximately 8mm. Bony sclerosis\\n consistent with subacute fracture. Tiny intra-articular bony fragment\\n posteriorly. Additionally, comminuted fractures of the medial and lateral\\n tibial spines. Moderate joint effusion. Fragmentation of medial patella\\n consistent with nondisplaced, comminuted fracture. Extensive vascular\\n calcifications.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF LEFT KNEE\\n\\n INDICATION: Knee injury. Tibial and patellar fractures.\\n\\n TECHNIQUE: Non-contrast multidetector CT of the left knee was performed.\\n Multiplanar reformations were carried out.\\n\\n COMPARISON: Radiograph of left knee .\\n\\n FINDINGS:\\n\\n There is an impacted fracture of the left medial tibial plateau with at least\\n 5 mm of depression of the medial tibial plateau. Comminution is evident with\\n small fracture fragments at the medial aspect of the medial plateau (series\\n 500B, image 31). Extension of the fracture line into the intercondylar\\n eminence and into the medial tibial spine is evident.\\n\\n The lateral tibial plateau is intact. The proximal tibial and fibular shafts\\n are intact. The distal femur demonstrates no evidence of focal bone lesion or\\n fracture.\\n\\n There is a small fracture through the medial aspect of the patella. The\\n fracture is minimally displaced, with approximately 2 mm of medial\\n displacement of the smaller medial component of the fracture.\\n\\n Assessment of the internal structures of the knee is limited on CT, but no\\n gross ligament abnormality is demonstrated.\\n\\n There is a moderate to large knee joint effusion. There is evidence of\\n diffuse vascular calcification. The bones appear demineralized.\\n (Over)\\n\\n 6:12 PM\\n CT LOW EXT W/O C LEFT Clip # \\n Reason: to evaluate knee fracture\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n IMPRESSION:\\n 1. Depressed, impacted medial tibial plateau fracture which also extends to\\n the intercondylar eminence and medial tibial spine.\\n 2. Medial patellar fracture.\\n 3. Moderate to large knee joint effusion.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-11 00:00:00.000\",\n \"description\": \"OL KNEE( (SINGLE VIEW) IN O.R. LEFT\",\n \"row_id\": 1076811,\n \"text\": \" 8:06 AM\\n KNEE( (SINGLE VIEW) IN O.R. LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. LEFTClip # \\n Reason: ORIF LEFT TIBIAL PLATEAU FX\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n HISTORY: Tibial plateau fracture.\\n\\n A single intraoperative fluoroscopic view of the left knee was obtained\\n without a radiologist present. This again demonstrates a depressed medial\\n tibial plateau fracture, similar to that seen on . For additional\\n details, please consult the operative report.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209357,\n \"text\": \"Normal sinus rhythm. Lateral T wave abnormalities. Compared to the previous\\ntracing of lateral T wave abnormalities are new. Some of these\\nabnormalities have been seen on previous tracings but now they are increased\\nin leads V5-V6.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209358,\n \"text\": \"Normal sinus rhythm. J point elevation consistent with normal early\\nrepolarization. Otherwise, within normal limits. Compared to the previous\\ntracing of previous non-specific ST-T wave abnormalities have resolved.\\nOtherwise, no important change. Clinical correlation and repeat tracing are\\nsuggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205615,\n \"text\": \"Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the\\nprevious tracing of no major change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205616,\n \"text\": \"Sinus rhythm\\nNormal ECG\\nSince previous tracing of , the heart rate is slower\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205617,\n \"text\": \"Sinus rhythm upper normal rate\\nNormal ECG\\nSince previous tracing of , ST-T wave abnormalities are less\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205618,\n \"text\": \"Sinus rhythm. Compared to the previous tracing of there is\\nT wave inversion in lead I and more prominent T wave inversion in\\nlead aVL as well as new T wave inversion in leads V4-V6. Active\\nlateral ischemic process cannot be excluded. Followup and clinical correlation\\nare suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205619,\n \"text\": \"Sinus rhythm. Compared to the previous tracing no change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205620,\n \"text\": \"Sinus rhythm. Compared to the previous tracing of no change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-05-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205621,\n \"text\": \"Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\\nsignificant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-05-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205622,\n \"text\": \"Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\\nsignificant change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-05-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205623,\n \"text\": \"Sinus rhythm. Baseline artifact. Delayed precordial R wave transition. The\\nP wave morphology appears less prominent while the P wave axis remains\\nrightward. The prior tracing was consistent with right atrial abnormality.\\nOtherwise, no diagnostic interim change. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 205614,\n \"text\": \"Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\\ntracing of ST-T wave changes are new.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-03 00:00:00.000\",\n \"description\": \"CT PELVIS W&W/O C\",\n \"row_id\": 1075475,\n \"text\": \" 4:12 PM\\n CT PELVIS W&W/O C Clip # \\n Reason: eval for venous thrombosis\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with left lower extremity swelling, negative LENI, concern for\\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\\n better visualization of veins.\\n REASON FOR THIS EXAMINATION:\\n eval for venous thrombosis\\n CONTRAINDICATIONS for IV CONTRAST:\\n Has ESRD and will get dialyzed Tuesday.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 8:10 PM\\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\\n Extensive vascular calcifications _____, likely reflecting the patient's\\n history of diabetes. There is no acute pelvic pathology.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 31-year-old male with left lower extremity swelling and negative\\n LENI. Evaluate for proximal clot in the iliac veins or IVC. The patient has\\n a history of hypertension, diabetes, and end-stage renal disease.\\n\\n COMPARISON: None available.\\n\\n TECHNIQUE: Contiguous axial images were obtained through the pelvis prior to\\n and following administration of intravenous contrast, and three-minute delayed\\n phase protocol. Multiplanar reformats were prepared and reviewed.\\n\\n FINDINGS: Within limits of non-contrast and delayed phase imaging, visualized\\n portion of the liver, gallbladder, pancreas, and kidneys are normal. There is\\n no evidence for biliary dilatation, cholelithiasis, or hydronephrosis.\\n Visualized pelvic loops of small and large bowel are unremarkable. There is\\n high-density material within the colon, likely reflecting magnesium-containing\\n laxative or antacid use. There is no bowel distention or bowel wall\\n thickening. There is no free fluid or free air. There is no lymphadenopathy\\n appreciated.\\n\\n Vascular calcifications are noted in the pelvic vessels, greater than expected\\n for a patient of this age, likely due to the patient's history of diabetes.\\n There is normal appearance and opacification of the bilateral iliac veins and\\n IVC, with no evidence for venous thrombosis.\\n\\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\\n\\n IMPRESSION:\\n 1. No evidence for venous thrombosis in the bilateral iliac vessels or IVC.\\n 2. Vascular calcifications, greater than expected for a patient of this age,\\n likely reflecting history of diabetes.\\n 3. Within the limits of non-contrast and delayed phase imaging, no acute\\n pelvic pathology.\\n (Over)\\n\\n 4:12 PM\\n CT PELVIS W&W/O C Clip # \\n Reason: eval for venous thrombosis\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-03 00:00:00.000\",\n \"description\": \"CT PELVIS W&W/O C\",\n \"row_id\": 1075476,\n \"text\": \", R. MED FA2 4:12 PM\\n CT PELVIS W&W/O C Clip # \\n Reason: eval for venous thrombosis\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with left lower extremity swelling, negative LENI, concern for\\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\\n better visualization of veins.\\n REASON FOR THIS EXAMINATION:\\n eval for venous thrombosis\\n CONTRAINDICATIONS for IV CONTRAST:\\n Has ESRD and will get dialyzed Tuesday.\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\\n Extensive vascular calcifications _____, likely reflecting the patient's\\n history of diabetes. There is no acute pelvic pathology.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-05-30 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1074872,\n \"text\": \" 11:16 PM\\n CHEST (PA & LAT) Clip # \\n Reason: eval effusion, pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with hx esrd\\n REASON FOR THIS EXAMINATION:\\n eval effusion, pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 31-year-old with history of end-stage renal disease.\\n\\n COMPARISON: \\n\\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: The lateral view is limited due to\\n inability of the patient to raise her arms. The lungs are grossly clear. The\\n cardiac silhouette is increasing in size, even despite the lordotic\\n positioning of the film, raising the possibility of pericardial effusion in\\n this end- stage renal disease patient. The mediastinal contours are normal.\\n There is no effusion or pneumothorax.\\n\\n IMPRESSION: Enlarging cardiac silouette, raising the possibility of\\n pericardial effusion.\\n\\n Dr. was paged with these findings at 11:30 AM on .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-06-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1076037,\n \"text\": \" 9:52 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: pls eval for infiltrate, consolidation, effusion\\n Admitting Diagnosis: HYPERKALEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 31 year old man with ESRD, hypoxia\\n REASON FOR THIS EXAMINATION:\\n pls eval for infiltrate, consolidation, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Followup.\\n\\n COMPARISON: .\\n\\n As compared to the previous radiograph, the lung volumes have increased.\\n Despite the resulting overall decrease in lung parenchymal transparency,\\n subtle areas of parenchymal opacities, notably in the left basal and\\n retrocardiac areas and at the right lung bases persist, so that the suspicion\\n of pneumonia cannot be discarded. No evidence of pleural effusions.\\n Unchanged mediastinal contours. The size of the cardiac silhouette is smaller\\n than before.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":188,"cells":{"subject_id":{"kind":"number","value":85444,"string":"85,444"},"hadm_id":{"kind":"number","value":152754,"string":"152,754"},"target_text":{"kind":"string","value":"58 y/o male who is admitted from home for liver . He received a DCD liver and the patient was taken to the OR with Dr after a careful discussion with the patient. The patient tolerated the procedure without difficulty, and the procedure was undertaken without significant complication. The donor liver appeared well perfused at the end of the case. The patient received routine immunosuppression induction to include cellcept, solumedrol intra-op with taper and started prograf on the evening of POD 1. The patient did require multiple transfusions in the ICU per the bleeding pathway, but was never hemodynamically unstable as a result of his bleeding, and by POD his HCT had stabilized. The liver did very well in the post op period. LFTs declined daily and T bili was 2.3 at the time of DC. The remainder of his post operative course was unremarkable. He successfully demonstrated adequate knowledge of his medications and at the time of discharge was sent home on tacrolimus, cellcept and the remainder of his prednisone taper. He was sent home with VNA for lab draws and with plan for close follow up in the clinic. Medications on Admission: : Entacavir 1 mg daily, Tenofavir 300 mg daily, Furosemide 20 mg daily, Spironolactone 100 mg daily, Clotramazole 10 mg troche (intermittent use)"},"extractive_notes_summ":{"kind":"string","value":"small right pleural effusion. Small right pleural effusion. There is a small right pleural effusion. New small left pleural effusion. Left anterior fascicular block. Unchanged minimal right basal atelectasis. Upper abdominal drains in place. No larger pleural effusions. NG tube is in nondistended stomach. Sinus rhythm with left anterior fascicular block. A Swan-Ganz catheter appears to end in the proximal right pulmonary artery. New small left pleural effusion is present. Hilar, mediastinal and cardiac silhouettes are stable. The right, middle, and left hepatic veins are patent with appropriate waveforms. Extreme right lateral abdomen not fully included on the images. Sinus rhythm. Right IJ catheter tip projects over cavoatrial junction. The main hepatic artery and intrahepatic right and left hepatic arteries are patent, with appropriate waveforms demonstrating sharp systolic upstroke and preserved flow through diastole. NG tube ends within the stomach. patent MHA, RHA, LHA with appropriate waveforms. Swan-Ganz catheter has been removed. FINDINGS: Right IJ tip projects over cavoatrial junction. Upper abdominal drains are in place. patent RHV, MHV, LHV with appropriate waveforms. The right and left portal veins are patent, with forward flow. IMPRESSION: 1. IMPRESSION: 1. Unchanged moderate cardiomegaly without overt pulmonary edema. FINDINGS: As compared to the previous radiograph, the patient has been extubated. Pleural surfaces are normal. Left axis deviation. IMPRESSION: AP chest compared to preoperative study, : ET tube, nasogastric tube, Swan-Ganz catheter, in standard placements. IMPRESSION: Needle driver not seen within the imaged abdomen. COMPARISONS: Chest x-ray from . Compared tothe previous tracing of there is no diagnostic change.TRACING #1 Heart size normal. IMPRESSION: No acute cardiopulmonary process. Intraoperative films. The main portal vein is patent, with forward flow. patent MPV, RPV, LPV with forward flow. Two abdominal drains within the right abdomen. PA AND LATERAL VIEW, CHEST: Lungs are clear. 10:03 PM ABDOMEN (SUPINE ONLY); CHEST (SINGLE VIEW) Clip # Reason: MISSING NEEDLE HOLDER. Hilar contours and heart size is normal. INTRA-OP FILMS. Compared to the previoustracing there is no diagnostic change.TRACING #2 Left retrocardiac opacity, which may represent atelectasis, pleural fluid or infection in the right clinical setting. Lungs clear. Endotracheal tube ends 2.5 cm above the carina. No pneumothorax. No pneumothorax. IJ line placement. Normal liver transplant ultrasound with patent hepatic vasculature. Lung volumes are low. No pneumothorax or pleural effusion. COMPARISON: . COMPARISON: . SUPINE ABDOMINAL RADIOGRAPHS AND RADIOGRAPH OF NEEDLE DRIVER: Image of the needle holder/driver indicates the appearance of the missing intra-operative foreign body. Turbulent flow in the main portal vein may be related to the surgical anastomosis, with no definite stenosis identified. Retrocardiac opacity silhouetting left hemidiaphragm may represent pleural fluid, atelectasis or infection in the right clinical setting. 2. 2. There is no pulmonary edema. Allowing for this limitation, there is no intra- or extra-hepatic biliary ductal dilation. 2:19 PM CHEST PORT. COMPARISON: None. The other monitoring and support devices are unchanged. 10:58 PM CHEST PORT. 3. Multiple skin staples overlie the abdomen. The common duct measures 2 mm. No needle driver is noted projected within the imaged abdominal cavity. No evidence of focal parenchymal opacity suggesting pneumonia. ET tube is 5 cm from the carina. turbulent flow in MPV may be due to surgical anastamosis. Turbulent flow in the main portal vein may be due to the surgical anastomosis. Admitting Diagnosis: PRE-OP LIVER TRANSPLANT FINAL REPORT INDICATION: 46-year-old man with missing needle holder. FINAL REPORT HISTORY: 46-year-old male, operative day #1, status post liver transplant. TRANSPLANT LIVER ULTRASOUND: Imaging of the transplanted liver is limited due to the skin bandage and inability of the patient to hold his breath. 4:19 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man POD1 liver tx REASON FOR THIS EXAMINATION: interval change FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post liver transplant, assessment for interval change. 9:50 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: liver transplant u/s, POD 1 Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man with new liver REASON FOR THIS EXAMINATION: liver transplant u/s, POD 1 WET READ: JXRl TUE 12:10 PM no intra or extrahepatic biliary ductal dilation. LINE PLACEMENT Clip # Reason: Please eval for appropriate line placement/PTX Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man with ESLD s/p liver transplant, with swan/cordis switched to triple lumen CVL REASON FOR THIS EXAMINATION: Please eval for appropriate line placement/PTX FINAL REPORT INDICATION: Patient is status post liver transplant."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2184-08-03 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1151372,"text":" 2:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval for appropriate line placement/PTX\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESLD s/p liver transplant, with swan/cordis switched to\n triple lumen CVL\n REASON FOR THIS EXAMINATION:\n Please eval for appropriate line placement/PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is status post liver transplant. IJ line placement.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n Right IJ tip projects over cavoatrial junction. No pneumothorax.\n\n New small left pleural effusion is present. Retrocardiac opacity silhouetting\n left hemidiaphragm may represent pleural fluid, atelectasis or infection in\n the right clinical setting. Hilar, mediastinal and cardiac silhouettes are\n stable.\n\n ET tube is 5 cm from the carina. NG tube is in nondistended stomach.\n Swan-Ganz catheter has been removed. Upper abdominal drains are in place.\n\n IMPRESSION:\n\n 1. Right IJ catheter tip projects over cavoatrial junction. No pneumothorax.\n\n 2. New small left pleural effusion.\n\n 3. Left retrocardiac opacity, which may represent atelectasis, pleural fluid\n or infection in the right clinical setting.\n\n"},{"category":"Radiology","chartdate":"2184-08-02 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":1151181,"text":" 1:11 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PRE-OP LIVER TRANSPLANT\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man here for liver transplant\n REASON FOR THIS EXAMINATION:\n assess cardiopulmonary status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver transplant and assess cardiopulmonary status.\n\n COMPARISON: .\n\n PA AND LATERAL VIEW, CHEST: Lungs are clear. Pleural surfaces are normal.\n Hilar contours and heart size is normal. There is no pulmonary edema.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2184-08-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1151473,"text":" 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man POD1 liver tx\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post liver transplant, assessment for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated. The other monitoring and support devices are unchanged. Unchanged\n minimal right basal atelectasis. Unchanged moderate cardiomegaly without\n overt pulmonary edema. No larger pleural effusions. No evidence of focal\n parenchymal opacity suggesting pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2184-08-02 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1151271,"text":" 10:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: RIJ, swan, ETT line placement\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with s/p OLT with new lines\n REASON FOR THIS EXAMINATION:\n RIJ, swan, ETT line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, :06 P.M.\n\n HISTORY: Liver transplant.\n\n IMPRESSION: AP chest compared to preoperative study, :\n\n ET tube, nasogastric tube, Swan-Ganz catheter, in standard placements. Upper\n abdominal drains in place. Lungs clear. No pneumothorax or pleural effusion.\n Heart size normal.\n\n\n"},{"category":"Radiology","chartdate":"2184-08-02 00:00:00.000","description":"ABDOMEN (SUPINE ONLY)","row_id":1151270,"text":" 10:03 PM\n ABDOMEN (SUPINE ONLY); CHEST (SINGLE VIEW) Clip # \n Reason: MISSING NEEDLE HOLDER. INTRA-OP FILMS.\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man with missing needle holder. Intraoperative\n films.\n\n SUPINE ABDOMINAL RADIOGRAPHS AND RADIOGRAPH OF NEEDLE DRIVER: Image of the\n needle holder/driver indicates the appearance of the missing intra-operative\n foreign body. Extreme right lateral abdomen not fully included on the images.\n No needle driver is noted projected within the imaged abdominal cavity. NG\n tube ends within the stomach. A Swan-Ganz catheter appears to end in the\n proximal right pulmonary artery. Endotracheal tube ends 2.5 cm above the\n carina. Two abdominal drains within the right abdomen. Multiple skin staples\n overlie the abdomen. Lung volumes are low.\n\n IMPRESSION: Needle driver not seen within the imaged abdomen. Findings were\n discussed with Dr. at 10:15 p.m. on .\n\n"},{"category":"Radiology","chartdate":"2184-08-03 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1151316,"text":" 9:50 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: liver transplant u/s, POD 1\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with new liver\n REASON FOR THIS EXAMINATION:\n liver transplant u/s, POD 1\n ______________________________________________________________________________\n WET READ: JXRl TUE 12:10 PM\n no intra or extrahepatic biliary ductal dilation. small right pleural\n effusion. patent MPV, RPV, LPV with forward flow. turbulent flow in MPV may\n be due to surgical anastamosis. patent RHV, MHV, LHV with appropriate\n waveforms. patent MHA, RHA, LHA with appropriate waveforms.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old male, operative day #1, status post liver transplant.\n\n COMPARISON: None.\n\n TRANSPLANT LIVER ULTRASOUND: Imaging of the transplanted liver is limited due\n to the skin bandage and inability of the patient to hold his breath. Allowing\n for this limitation, there is no intra- or extra-hepatic biliary ductal\n dilation. The common duct measures 2 mm. There is a small right pleural\n effusion.\n\n The main portal vein is patent, with forward flow. Turbulent flow in the main\n portal vein may be due to the surgical anastomosis. The right and left portal\n veins are patent, with forward flow. The right, middle, and left hepatic\n veins are patent with appropriate waveforms. The main hepatic artery and\n intrahepatic right and left hepatic arteries are patent, with appropriate\n waveforms demonstrating sharp systolic upstroke and preserved flow through\n diastole.\n\n IMPRESSION:\n 1. Normal liver transplant ultrasound with patent hepatic vasculature.\n Turbulent flow in the main portal vein may be related to the surgical\n anastomosis, with no definite stenosis identified.\n 2. Small right pleural effusion.\n\n"},{"category":"ECG","chartdate":"2184-08-03 00:00:00.000","description":"Report","row_id":234952,"text":"Sinus rhythm with left anterior fascicular block. Compared to the previous\ntracing there is no diagnostic change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2184-08-02 00:00:00.000","description":"Report","row_id":234953,"text":"Sinus rhythm. Left axis deviation. Left anterior fascicular block. Compared to\nthe previous tracing of there is no diagnostic change.\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-03 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1151372,\n \"text\": \" 2:19 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: Please eval for appropriate line placement/PTX\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with ESLD s/p liver transplant, with swan/cordis switched to\\n triple lumen CVL\\n REASON FOR THIS EXAMINATION:\\n Please eval for appropriate line placement/PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Patient is status post liver transplant. IJ line placement.\\n\\n COMPARISONS: Chest x-ray from .\\n\\n FINDINGS:\\n\\n Right IJ tip projects over cavoatrial junction. No pneumothorax.\\n\\n New small left pleural effusion is present. Retrocardiac opacity silhouetting\\n left hemidiaphragm may represent pleural fluid, atelectasis or infection in\\n the right clinical setting. Hilar, mediastinal and cardiac silhouettes are\\n stable.\\n\\n ET tube is 5 cm from the carina. NG tube is in nondistended stomach.\\n Swan-Ganz catheter has been removed. Upper abdominal drains are in place.\\n\\n IMPRESSION:\\n\\n 1. Right IJ catheter tip projects over cavoatrial junction. No pneumothorax.\\n\\n 2. New small left pleural effusion.\\n\\n 3. Left retrocardiac opacity, which may represent atelectasis, pleural fluid\\n or infection in the right clinical setting.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-02 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 1151181,\n \"text\": \" 1:11 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: PRE-OP LIVER TRANSPLANT\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man here for liver transplant\\n REASON FOR THIS EXAMINATION:\\n assess cardiopulmonary status\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Liver transplant and assess cardiopulmonary status.\\n\\n COMPARISON: .\\n\\n PA AND LATERAL VIEW, CHEST: Lungs are clear. Pleural surfaces are normal.\\n Hilar contours and heart size is normal. There is no pulmonary edema.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1151473,\n \"text\": \" 4:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man POD1 liver tx\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Status post liver transplant, assessment for interval change.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the patient has been\\n extubated. The other monitoring and support devices are unchanged. Unchanged\\n minimal right basal atelectasis. Unchanged moderate cardiomegaly without\\n overt pulmonary edema. No larger pleural effusions. No evidence of focal\\n parenchymal opacity suggesting pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-02 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1151271,\n \"text\": \" 10:58 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: RIJ, swan, ETT line placement\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with s/p OLT with new lines\\n REASON FOR THIS EXAMINATION:\\n RIJ, swan, ETT line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, :06 P.M.\\n\\n HISTORY: Liver transplant.\\n\\n IMPRESSION: AP chest compared to preoperative study, :\\n\\n ET tube, nasogastric tube, Swan-Ganz catheter, in standard placements. Upper\\n abdominal drains in place. Lungs clear. No pneumothorax or pleural effusion.\\n Heart size normal.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-02 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE ONLY)\",\n \"row_id\": 1151270,\n \"text\": \" 10:03 PM\\n ABDOMEN (SUPINE ONLY); CHEST (SINGLE VIEW) Clip # \\n Reason: MISSING NEEDLE HOLDER. INTRA-OP FILMS.\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old man with missing needle holder. Intraoperative\\n films.\\n\\n SUPINE ABDOMINAL RADIOGRAPHS AND RADIOGRAPH OF NEEDLE DRIVER: Image of the\\n needle holder/driver indicates the appearance of the missing intra-operative\\n foreign body. Extreme right lateral abdomen not fully included on the images.\\n No needle driver is noted projected within the imaged abdominal cavity. NG\\n tube ends within the stomach. A Swan-Ganz catheter appears to end in the\\n proximal right pulmonary artery. Endotracheal tube ends 2.5 cm above the\\n carina. Two abdominal drains within the right abdomen. Multiple skin staples\\n overlie the abdomen. Lung volumes are low.\\n\\n IMPRESSION: Needle driver not seen within the imaged abdomen. Findings were\\n discussed with Dr. at 10:15 p.m. on .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2184-08-03 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1151316,\n \"text\": \" 9:50 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \\n Reason: liver transplant u/s, POD 1\\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old man with new liver\\n REASON FOR THIS EXAMINATION:\\n liver transplant u/s, POD 1\\n ______________________________________________________________________________\\n WET READ: JXRl TUE 12:10 PM\\n no intra or extrahepatic biliary ductal dilation. small right pleural\\n effusion. patent MPV, RPV, LPV with forward flow. turbulent flow in MPV may\\n be due to surgical anastamosis. patent RHV, MHV, LHV with appropriate\\n waveforms. patent MHA, RHA, LHA with appropriate waveforms.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 46-year-old male, operative day #1, status post liver transplant.\\n\\n COMPARISON: None.\\n\\n TRANSPLANT LIVER ULTRASOUND: Imaging of the transplanted liver is limited due\\n to the skin bandage and inability of the patient to hold his breath. Allowing\\n for this limitation, there is no intra- or extra-hepatic biliary ductal\\n dilation. The common duct measures 2 mm. There is a small right pleural\\n effusion.\\n\\n The main portal vein is patent, with forward flow. Turbulent flow in the main\\n portal vein may be due to the surgical anastomosis. The right and left portal\\n veins are patent, with forward flow. The right, middle, and left hepatic\\n veins are patent with appropriate waveforms. The main hepatic artery and\\n intrahepatic right and left hepatic arteries are patent, with appropriate\\n waveforms demonstrating sharp systolic upstroke and preserved flow through\\n diastole.\\n\\n IMPRESSION:\\n 1. Normal liver transplant ultrasound with patent hepatic vasculature.\\n Turbulent flow in the main portal vein may be related to the surgical\\n anastomosis, with no definite stenosis identified.\\n 2. Small right pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2184-08-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 234952,\n \"text\": \"Sinus rhythm with left anterior fascicular block. Compared to the previous\\ntracing there is no diagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2184-08-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 234953,\n \"text\": \"Sinus rhythm. Left axis deviation. Left anterior fascicular block. Compared to\\nthe previous tracing of there is no diagnostic change.\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":189,"cells":{"subject_id":{"kind":"number","value":16492,"string":"16,492"},"hadm_id":{"kind":"number","value":104892,"string":"104,892"},"target_text":{"kind":"string","value":"Pt was admitted on for ecxision of Pancoast tumor in RUL. Pain control w/ epidrual is at T6/T7 14/5. She is split receiving both bupivicaine .1% thru epidural and dilaudid PCA because she has a wide incision on multiple dermatomes and a neck incision. She was supported w/ low dose neo while on epidural. Briefly intubated in ICU and, successfully extubated. POD#2 AFIB despite IV lopressor. Treated w/ IV amiodarone bolus, gtt, 2nd bolus and 2 doses of diltiazem. Pain control w/ Epidural- bupivicaine + Dil PCA. 2 chest tubes to suction. Activity OOB > chair, PT, IS. POD#3 Transition to po amiodarone w/ recurrent Afib alt w/ NSR. Re-bolused amiodarone iv and placed back on gtt. Lopressor cont po. CT 1&2 to water seal w/o ptx. Drainage #1<200cc and d/c w/o complication, #2 remained to w/s w/ moderate drainage. Incision anterior and posterior clean and dry, staples intact. POD#4-Amiod po started, lopressor ^50mgBID. Overnight pt had episodes of HR 40 SB-150 Afib, treated with IV lopresssor and Dilt IV with fair rate control. Cardiology consulted.Lopressor 'd 25 .NSR resumed during day. CT #2 d/c w/o complication. PT, IS, ambulation cont w/ high compliance. BS course, very good airation. Inhalers cont. Remains on L O2. Pt R/O'd for MI by enzymes and EKG. POD#5- Per Cardiology rec- Amiod 400 BIDpo; Epid d/c, PCA cont. Lovenox started for anticoagulation in setting of intermittent Afib post epidural d/c. Evidence of left antecubital phlebitis(red, swollen, min discomfort) at old IV site present, Keflex po x10 days started, warm soaks locally w/ small improvement. Chest tube drainge moderate from CT site. Dressing changed prn. POD#6-Remains NSR on Amiod ; PCA weaned, PO Dilaudid started w/ fair effect. Coumadin 5mg dose #1 @1800. Activity/IS compliance excellent. Staples removed and steri-strips applied. Incision- no erythema, small amount serous drainage superior posterior incision. BS course- good airation, inhalers cont. O2 weaned to off w/ good sat at rest and w/ ambulation- 95%RA. POD#7- Cont in NSR,Amiod 400BIDpo, lopresor increased to 50 , restart Imdur 30 mg (1/2 dose), lisinopril 2.5 mg ( daily dose); Coumadin 5mg dose #2 @1800, lovenox ocnt. Pain med changed to percocet w/ very good effect. BM- occurred. Plan for discharge in am POD#8. Discharge plans arranged for anticoagulation follow-up with: VNA for blood draw and post op nursing care, Cardiology clinic short term, then coumadin clinic as of . Follow-up appointments w/ , Cardiology made. PCP, NP, Cardiology NP and Cardiologist informed of plans.Discharge instructions, new medication regimen and instructions reviewed with patient POD#8-Patient discharged to home in stable condition in company of family. Discharge instructions given and reviewed w/ patient and family."},"extractive_notes_summ":{"kind":"string","value":"FINDINGS: There has been interval removal of two right apical chest tubes. IMPRESSION: Interval removal of right apical pleural drains. Respiratory CarePt.received from PACU,intubated BBS+diminished on right,and coarse t/o.Placed on vent. 2) Right apical and hilar densities and postoperative changes right lung. Two chest tubes remain in place in the right hemithorax, and there is a persistent right apical pneumothorax. Since the previoustracing of atrial fibrillation has reverted to sinus with atrialpremature beats. Again seen is a right apical and hilar mass, two right-sided chest tubes, and skin staples. There is stable appearance of a persistent right apical pneumothorax. IMPRESSION: Possible small right apical pneumothorax, which in retrospect is probably unchanged. PT REMAINS TACHYCARDIC TO 120- LOPRESSOR RESTARTED. Right chest tubes x2 to 20 cm suction with small air leak.GI - NPO. There is volume loss of the right hemithorax with persistent elevation of the right hemidiaphragm and mediastinal shift to the right. R CT x2 ot H20 seal w/ serous drainage. DR AWARE OF ABOVE.ENDO: SLIDING SCALE INCREASED TO REFLECT BS 140-210.A: NEO WEANED TO OFF, PROPOFOL WEANED OFF, WEANED AND EXTUBATED, EPIDURAL FOR PAIN CONTROL WITH GOOD RELIEFR: TOL EXTUBATION WELL, HEMODYNAMICALLY STABLE, ENCOURAGE PULM TOILET, OOB TO CHAIR IN AM neo gtt to maintain a map> 60, LR at 75cc/hr, epidural at T5 with bupivicaine only.currently, afebrile, heart rate 90s, lopressor held- pt on neo gtt to keep map > 60.resp: vented, lsc with intermittent wheezes, treated with albuterol/atrovent, chest tubes X 2pain: epidural, but pt has sensation at t5, above and below t5. Abdomen benign.GU - Adequate UOP via foley. SBP 120-150 POST-EXTUBATION.RESP: PT WEANED AND EXTUBATED. CT PATENT WITH + AIR LEAK, NO CREPITUS NOTED.GI: ABD SOFT, HYPOACTIVE BS. Respiratory CarePt.remains on full vent.support,sedated with propofol.BBS reveal some exp wheezes t/o treated with Albuterol and atrovent.Abg's adequate. FINDINGS: There remain 2 apical right-sided pleural drains in unchanged position. Right perihilar and paramediastinal opacities are unchanged and attributed to postoperative changes. There are post-surgical changes at the right apex including signs of volume loss of the right hemithorax with persistent elevation of the right hemidiaphragm and mediastinal shift to the right. There is stable postoperative volume loss. Peripheral pulses palpable.Resp - Lungs essentialy clear. Interval decrease in right lung opacity consistent with postsurgical atelectasis. Compared with earlier the same day, the ET tube has been retracted. +periph pulses, sl edema, extrems warm.Resp: on 5l n/p w/ 02 sat 95-98%. DILT IF RATE IS NOT CONTROLLED.R: RAPID RATE UNCONTROLLED BY LOPRESSOR, AMIODARONE GTT INFUSING WITH POOR RATE CONTROL, START DILT IF RATE UNCHANGED IN HR. On the right, there are skin staples and a right chest tube. Foley cath w/ dark, conc yellow uine.Skin: R CT, R flank incision, R neck incision intactPain: Bupivicaine epidural at 6cc/hr - intact. FINAL REPORT PORTABLE CHEST X-RAY , AT 19:06. condition updateD: PLEASE SEE CAREVUE FOR SPECIFICSNEURO: PROPOFOL WEANED TO OFF. A chest tube remains in place, terminating at the extreme right lung apex. PT HAD MULTIPLE SHORT RUNS OF SVT WITH STABLE BP ALL AM. Surgical changes at the right apex with associated volume loss of the right hemithorax. The right hemidiaphragm is elevated. CT DRESSING CHANGED FOR MOD AMT SEROSANG. There has been slight interval increase in patchy opacity at the right apex, which may be due to atelectasis or aspiration. There has been interval decrease in opacity of the remaining right lung consistent with postoperative atelectasis and surgical change. Pneumothorax effusion. Sinus rhythm with bigeminal atrial premature beats. D:Pt treated for rapid afib without response to amiodarone bolus and diltiazem. ET tube with tip over left proximal main stem bronchus. chest, single vw An ET tube is present. 4:06 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: now both chest tubes with leaks. BS DIMINSHED IN RIGHT BASES. 0600 Metoprolol given early, ectopy continued. INDICATION: Status post right lung cancer resection. Heart size and cardiomediastinal contours are stable given differences and patient rotation. The left lung is slightly overinflated, but grossly clear. HO notified, PRN metoprolol given, Mg repleted with good effect. EKG DONE= RAPID AFIB, AMIODARONE BOLUS STARTED AND PT PLACED ON GTT AT 1MG/MIN. CHEST, SINGLE AP VIEW: A tiny right apical pneumothorax may be present, but is not distinctly seen. MAE WITH EQUAL STRENGTHCV: T MAX 100.9- DR AWARE, NO CX ORDERED, NEO GTT WEANED TO OFF THIS AM. TECHNIQUE: A portable AP upright chest radiograph was obtained. The right lung base and the left lung are grossly clear. The left lung is grossly clear. There is atelectasis in both lungs, slightly more pronounced in the left lung. BY 1600, HR UP TO 120-140, REPEAT BOLUS GIVEN.RESP: BS COARSE. No significant change compared with the film from , except for interval removal of the ET tube. Please evaluate for pneumothorax. IMPRESSION: No change since the prior chest x-ray. COMPARISON: AP portable upright chest radiograph . CXR obtained late morning.GI/GU: abd soft/distended. The tip overlies the proximal left main stem bronchus and should be retracted. There is postoperative volume loss in the right hemithorax, and there is increasing pulmonary opacification within the right lung with relative sparing of the right lung base. Taking clear liqs well. No change in persistent right apical pneumothorax. INDICATION: Pancoast tumor excision. lopressor given with pt converting to SR rate 70-80.P:Manage meds for a-fib. There are surgical staples overlying the right upper hemithorax. 7:02 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: worsening pneumo? Sinus rhythm. Please assess for change in pneumothorax. (A subsequent film currently on PACs demonstrates retraction of the ETT to an appropriate position.)"},"n_notes":{"kind":"number","value":20,"string":"20"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2171-10-23 00:00:00.000","description":"Report","row_id":137430,"text":"Sinus rhythm with bigeminal atrial premature beats. Since the previous\ntracing of atrial fibrillation has reverted to sinus with atrial\npremature beats.\n\n"},{"category":"ECG","chartdate":"2171-10-20 00:00:00.000","description":"Report","row_id":137431,"text":"Atrial fibrillation with a rapid ventricular response. Borderline low\nvoltage. Diffuse non-specific ST-T wave abnormalities. Compared to the previous\ntracing of rhythm is now atrial fibrillation and rate is faster.\n\n"},{"category":"ECG","chartdate":"2171-10-14 00:00:00.000","description":"Report","row_id":137432,"text":"Sinus rhythm. Findings are within normal limits. Compared to the previous\ntracing of no significant diagnostic change.\n\n"},{"category":"Radiology","chartdate":"2171-10-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887462,"text":" 11:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx, interval change\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excisionw/ 2 CT in\n place, no leak at present leaks\n REASON FOR THIS EXAMINATION:\n eval for ptx, interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman with lung cancer status post resection of Pancoast\n tumor. Please assess for change in pneumothorax.\n\n TECHNIQUE: A portable AP upright chest radiograph was obtained.\n\n COMPARISON: AP portable upright chest radiograph .\n\n FINDINGS: There remain 2 apical right-sided pleural drains in unchanged\n position. There is stable appearance of a persistent right apical\n pneumothorax. There is volume loss of the right hemithorax with persistent\n elevation of the right hemidiaphragm and mediastinal shift to the right. There\n has been interval decrease in opacity of the remaining right lung consistent\n with postoperative atelectasis and surgical change. The left lung is grossly\n clear. There are surgical staples overlying the right upper hemithorax.\n\n IMPRESSION: 1. No change in persistent right apical pneumothorax.\n\n 2. Interval decrease in right lung opacity consistent with postsurgical\n atelectasis.\n\n"},{"category":"Radiology","chartdate":"2171-10-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887141,"text":" 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX, effusion\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n REASON FOR THIS EXAMINATION:\n PTX, effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung CA. Pneumothorax effusion.\n\n CHEST, SINGLE AP VIEW:\n\n A tiny right apical pneumothorax may be present, but is not distinctly seen.\n The appearances are not significantly different from the film obtained on\n . Again seen is a right apical and hilar mass, two right-sided chest\n tubes, and skin staples. Changes in the differences of the appearance of the\n right hemidiaphragm likely relate to lordotic positioning on today's films.\n\n Prominence of markings in the left upper zone is noted, of uncertain\n significance. Attention to this area and followup films is recommended. The\n left lung is otherwise clear, without chf, focal infiltrate, or effusion.\n\n IMPRESSION: Possible small right apical pneumothorax, which in retrospect is\n probably unchanged. No significant change compared with the film from\n , except for interval removal of the ET tube.\n\n"},{"category":"Radiology","chartdate":"2171-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887351,"text":" 4:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: now both chest tubes with leaks. R/o larger pneumo.\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\n leaks\n REASON FOR THIS EXAMINATION:\n now both chest tubes with leaks. R/o larger pneumo.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post excision of right Pancoast tumor leaking from\n chest tubes.\n\n CHEST AP: Since the prior chest x-ray, there has been no significant change.\n Two chest tubes are seen in the left apical region with associated rib\n resections. Left lung remains clear. The right perihilar opacification\n persists unchanged.\n\n IMPRESSION: No change since the prior chest x-ray.\n\n"},{"category":"Radiology","chartdate":"2171-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887291,"text":" 10:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change on water seal-eval for PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision\n\n REASON FOR THIS EXAMINATION:\n interval change on water seal-eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST OF \n\n COMPARISON: .\n\n INDICATION: Status post right lung cancer resection. Chest tube on\n water-seal.\n\n A chest tube remains in place, terminating at the extreme right lung apex. An\n apical pneumothorax on the right is not significantly changed allowing for\n technical differences between the studies. There is stable postoperative\n volume loss. There has been slight interval increase in patchy opacity at the\n right apex, which may be due to atelectasis or aspiration. Right perihilar\n and paramediastinal opacities are unchanged and attributed to postoperative\n changes. The left lung is slightly overinflated, but grossly clear.\n\n\n"},{"category":"Radiology","chartdate":"2171-10-24 00:00:00.000","description":"CHEST (PA & LAT)","row_id":887789,"text":" 11:29 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA post CT pull\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman with lung cancer status post surgical resection.\n Please evaluate for pneumothorax.\n\n TECHNIQUE: PA and lateral views of the chest were obtained and compared to\n .\n\n FINDINGS: There has been interval removal of two right apical chest tubes.\n No definite pneumothorax identified. There are post-surgical changes at the\n right apex including signs of volume loss of the right hemithorax with\n persistent elevation of the right hemidiaphragm and mediastinal shift to the\n right. Again noted are multiple surgical rib defects at the right apex. The\n right lung base and the left lung are grossly clear. Heart size and\n cardiomediastinal contours are stable given differences and patient rotation.\n\n IMPRESSION: Interval removal of right apical pleural drains. No definite\n pneumothorax. Surgical changes at the right apex with associated volume loss\n of the right hemithorax.\n\n"},{"category":"Radiology","chartdate":"2171-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":886968,"text":" 5:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n REASON FOR THIS EXAMINATION:\n eval PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung CA, question pneumothorax.\n\n chest, single vw\n\n An ET tube is present. The tip overlies the proximal left main stem bronchus\n and should be retracted. The left lung is grossly clear, without CHF,\n infiltrate, or effusion. On the right, there are skin staples and a right\n chest tube. The right hemidiaphragm is elevated. There is increased opacity\n in the right upper zone, confluent with the hilum. The right base is grossly\n clear.\n\n IMPRESSION:\n\n 1. ET tube with tip over left proximal main stem bronchus. This should be\n retracted approximately 4.2 cm. (A subsequent film currently on PACs\n demonstrates retraction of the ETT to an appropriate position.)\n\n 2) Right apical and hilar densities and postoperative changes right lung.\n\n 3) No pneumothorax detected.\n\n"},{"category":"Radiology","chartdate":"2171-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":886985,"text":" 9:13 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube placement.\n\n CHEST, SINGLE AP VIEW SUPINE.\n\n Compared with earlier the same day, the ET tube has been retracted. The tip\n now lies in satisfactory position approximately 2.3 cm above the carina. There\n is atelectasis in both lungs, slightly more pronounced in the left lung.\n Otherwise, no significant change is detected.\n\n"},{"category":"Radiology","chartdate":"2171-10-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":887366,"text":" 7:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: worsening pneumo?\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\n leaks\n REASON FOR THIS EXAMINATION:\n worsening pneumo?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY , AT 19:06.\n\n COMPARISON: Previous study of earlier the same date at 16:22.\n\n INDICATION: Pancoast tumor excision. Chest tube leak.\n\n Two chest tubes remain in place in the right hemithorax, and there is a\n persistent right apical pneumothorax. There is postoperative volume loss in\n the right hemithorax, and there is increasing pulmonary opacification within\n the right lung with relative sparing of the right lung base. This may\n represent worsening postoperative atelectasis, but is difficult to exclude\n superimposed process such as aspiration. Within the left lung, no confluent\n areas of consolidation or pleural effusion are observed.\n\n\n"},{"category":"Nursing/other","chartdate":"2171-10-18 00:00:00.000","description":"Report","row_id":1477987,"text":"Respiratory Care\nPt.received from PACU,intubated BBS+diminished on right,and coarse t/o.Placed on vent. as documented.See CareVue for details.\n"},{"category":"Nursing/other","chartdate":"2171-10-19 00:00:00.000","description":"Report","row_id":1477988,"text":"admit note\nplease see flowsheet for details. pt came from at 1800 to pacu s/p flex bronch, superclavicular scalene fat pad and lymph node disection, cervical mobilization of pancose tumor, right thoractomy, with right upper lobectomy and chest wall excision for right upper lobe mass. She came to SICU from pacu at 2300. at that time she was intubated, sedated on 30 mcq/kg/min propofol but able to nod head to questions and follow commands moving all extremities. neo gtt to maintain a map> 60, LR at 75cc/hr, epidural at T5 with bupivicaine only.\n\ncurrently, afebrile, heart rate 90s, lopressor held- pt on neo gtt to keep map > 60.\n\nresp: vented, lsc with intermittent wheezes, treated with albuterol/atrovent, chest tubes X 2\n\npain: epidural, but pt has sensation at t5, above and below t5. minimal c/o pain, 50 mcq fentanyl given during aline placement\n\nneuro: alert, following commands briskly, mae+, despite propofol gtt at 30 mcq/kg/min,\n\nsurgical dressings c/d/i\n\nplan: wean vent as tolerated, cont to control pain, chest tubes and epidural.\n"},{"category":"Nursing/other","chartdate":"2171-10-19 00:00:00.000","description":"Report","row_id":1477989,"text":"Respiratory Care\nPt.remains on full vent.support,sedated with propofol.BBS reveal some exp wheezes t/o treated with Albuterol and atrovent.Abg's adequate.\n"},{"category":"Nursing/other","chartdate":"2171-10-19 00:00:00.000","description":"Report","row_id":1477990,"text":"Pt woke up well with a good RSBI,VC,NIF & air leak past deflated cuff\nwas extubated and placed on AFM 40% She has a good cough and is productive of thick yellow-green sputum\n"},{"category":"Nursing/other","chartdate":"2171-10-19 00:00:00.000","description":"Report","row_id":1477991,"text":"condition update\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: PROPOFOL WEANED TO OFF. PT IS ALERT, ORIENTED X3, COOPERATIVE, FOLLOWS COMMANDS. MAE WITH EQUAL STRENGTH\nCV: T MAX 100.9- DR AWARE, NO CX ORDERED, NEO GTT WEANED TO OFF THIS AM. PT REMAINS TACHYCARDIC TO 120- LOPRESSOR RESTARTED. SBP 120-150 POST-EXTUBATION.\nRESP: PT WEANED AND EXTUBATED. CURRENTLY ON NP AT 4LITERS WITH SAT 96%. BS DIMINSHED IN RIGHT BASES. COUGHING AND RAISING THICK YELLOW SECRETIONS. CHEST DRESSING DRY AND INTACT. CT DRESSING CHANGED FOR MOD AMT SEROSANG. CT PATENT WITH + AIR LEAK, NO CREPITUS NOTED.\nGI: ABD SOFT, HYPOACTIVE BS. NPO.\nGU: UO DRIFTING OFF THIS AFTERNOON. DR AND DR NOTIFIED. FOLEY THEN IRRIGATED AT 1730 WITH MOD AMT OF SEDIMENT REMOVED AND PT THEN DRAINED 200CC CLOUDY YELLOW URINE. DR AWARE OF ABOVE.\nENDO: SLIDING SCALE INCREASED TO REFLECT BS 140-210.\nA: NEO WEANED TO OFF, PROPOFOL WEANED OFF, WEANED AND EXTUBATED, EPIDURAL FOR PAIN CONTROL WITH GOOD RELIEF\nR: TOL EXTUBATION WELL, HEMODYNAMICALLY STABLE, ENCOURAGE PULM TOILET, OOB TO CHAIR IN AM\n\n"},{"category":"Nursing/other","chartdate":"2171-10-20 00:00:00.000","description":"Report","row_id":1477992,"text":"NSICU Nursing Progress Note\nNeuro - Pt x3. Able to make needs known.\n\nCV - SR to ST with occ PCVs, multifocal PVCs. Pt began having runs of SVT ~0530 AM. 0600 Metoprolol given early, ectopy continued. HO notified, PRN metoprolol given, Mg repleted with good effect. MBP 90's by arterial line. Peripheral pulses palpable.\n\nResp - Lungs essentialy clear. O2 sat > 96% on 4 L NC. Strong cough productive of thick yellow sputum. Right chest tubes x2 to 20 cm suction with small air leak.\n\nGI - NPO. Abdomen benign.\n\nGU - Adequate UOP via foley. Large amount sediment. Sent for UA, cx.\n\nEndo - Regular insulin per sliding scale.\n\nA - Increasing ectopy this AM, resolved with metoprolol, MgSO4.\n\nP - continue to monitor. Contsider tx to floor.\n"},{"category":"Nursing/other","chartdate":"2171-10-20 00:00:00.000","description":"Report","row_id":1477993,"text":"CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: ALERT AND ORIENTED X3. EPIDURAL AT 6CC/HR FOR PAIN, DILAUDID PCA ALSO STARTED THIS AFTERNOON.\nCV: AFEBRILE. PT HAD MULTIPLE SHORT RUNS OF SVT WITH STABLE BP ALL AM. AT 1145, PT WENT INTO SUSTAINED RAPID RHTHTYM WITH DROP IN BP TO 90. EKG DONE= RAPID AFIB, AMIODARONE BOLUS STARTED AND PT PLACED ON GTT AT 1MG/MIN. RATE DID DROP TO 110 FOR A SHORT WHILE. BY 1600, HR UP TO 120-140, REPEAT BOLUS GIVEN.\nRESP: BS COARSE. COUGHING AND RAISING COPIOUS AMTS OF THICK YELLOW-GREEN SPUTUM. CT TO WATER SEAL WITH SEROUS DRAINAGE.\nGI: TAKING CLEAR LIQUIDS SLOWLY, ABD SOFT AND NON-TENDER.\nGU: YELLOW URINE WITH SEDIMENT.\nA: OOB TO CHAIR WITH ASSISTANCE OF 2- TOL GOOD. RHYTHM MONITORED, AMIODARONE GTT STARTED, ? DILT IF RATE IS NOT CONTROLLED.\nR: RAPID RATE UNCONTROLLED BY LOPRESSOR, AMIODARONE GTT INFUSING WITH POOR RATE CONTROL, START DILT IF RATE UNCHANGED IN HR.\n"},{"category":"Nursing/other","chartdate":"2171-10-21 00:00:00.000","description":"Report","row_id":1477994,"text":"D:Pt treated for rapid afib without response to amiodarone bolus and diltiazem. lopressor given with pt converting to SR rate 70-80.\nP:Manage meds for a-fib.\n\n"},{"category":"Nursing/other","chartdate":"2171-10-21 00:00:00.000","description":"Report","row_id":1477995,"text":"FULL CODE Universal precautions Allergy: codeine\n\n\nNeuro: AAOx3, MAEx4. OOB in chair at beginning of shift - BTB at 1200 - walks well - fairly steady on her feet, required minimal assistance.\n\nCV: HR=80-90s, NSR w/ rare to freq PVCs. Prior to am lopressor dose, HR up to 140-160 for a few seconds, then returned to 90-100s. Given 25mg lopressor po dose and additional 5mg IV - HR down to 50s for about 1hour, then has returned to 80s w/ no increase in HR and ectopy has signif decreased as well. Amiodarone gtt at .5mg/min. BP=120-130s/50-60s. +periph pulses, sl edema, extrems warm.\n\nResp: on 5l n/p w/ 02 sat 95-98%. Lungs coarse bilat, decreased in R fields. Excellent cough effort produding thick white secretions - using yankar to clear oral secretions. using IS 750-1000cc. R CT x2 ot H20 seal w/ serous drainage. CXR obtained late morning.\n\nGI/GU: abd soft/distended. +BS, no BM. Taking clear liqs well. Foley cath w/ dark, conc yellow uine.\n\nSkin: R CT, R flank incision, R neck incision intact\n\nPain: Bupivicaine epidural at 6cc/hr - intact. PCA Dialudid .12/6/1.2. Using well.\n\nID: T=98.9 no antibx.\n\nAccess: L piv x2.\n\nSocial: Sister and daughter-in-law visiting - Supportive.\n\nPlan: Tx to 2.\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-10-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 137430,\n \"text\": \"Sinus rhythm with bigeminal atrial premature beats. Since the previous\\ntracing of atrial fibrillation has reverted to sinus with atrial\\npremature beats.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 137431,\n \"text\": \"Atrial fibrillation with a rapid ventricular response. Borderline low\\nvoltage. Diffuse non-specific ST-T wave abnormalities. Compared to the previous\\ntracing of rhythm is now atrial fibrillation and rate is faster.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2171-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 137432,\n \"text\": \"Sinus rhythm. Findings are within normal limits. Compared to the previous\\ntracing of no significant diagnostic change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887462,\n \"text\": \" 11:13 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for ptx, interval change\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA s/p right pancoast tumor excisionw/ 2 CT in\\n place, no leak at present leaks\\n REASON FOR THIS EXAMINATION:\\n eval for ptx, interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 62-year-old woman with lung cancer status post resection of Pancoast\\n tumor. Please assess for change in pneumothorax.\\n\\n TECHNIQUE: A portable AP upright chest radiograph was obtained.\\n\\n COMPARISON: AP portable upright chest radiograph .\\n\\n FINDINGS: There remain 2 apical right-sided pleural drains in unchanged\\n position. There is stable appearance of a persistent right apical\\n pneumothorax. There is volume loss of the right hemithorax with persistent\\n elevation of the right hemidiaphragm and mediastinal shift to the right. There\\n has been interval decrease in opacity of the remaining right lung consistent\\n with postoperative atelectasis and surgical change. The left lung is grossly\\n clear. There are surgical staples overlying the right upper hemithorax.\\n\\n IMPRESSION: 1. No change in persistent right apical pneumothorax.\\n\\n 2. Interval decrease in right lung opacity consistent with postsurgical\\n atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887141,\n \"text\": \" 7:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PTX, effusion\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA\\n REASON FOR THIS EXAMINATION:\\n PTX, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Lung CA. Pneumothorax effusion.\\n\\n CHEST, SINGLE AP VIEW:\\n\\n A tiny right apical pneumothorax may be present, but is not distinctly seen.\\n The appearances are not significantly different from the film obtained on\\n . Again seen is a right apical and hilar mass, two right-sided chest\\n tubes, and skin staples. Changes in the differences of the appearance of the\\n right hemidiaphragm likely relate to lordotic positioning on today's films.\\n\\n Prominence of markings in the left upper zone is noted, of uncertain\\n significance. Attention to this area and followup films is recommended. The\\n left lung is otherwise clear, without chf, focal infiltrate, or effusion.\\n\\n IMPRESSION: Possible small right apical pneumothorax, which in retrospect is\\n probably unchanged. No significant change compared with the film from\\n , except for interval removal of the ET tube.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887351,\n \"text\": \" 4:06 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: now both chest tubes with leaks. R/o larger pneumo.\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\\n leaks\\n REASON FOR THIS EXAMINATION:\\n now both chest tubes with leaks. R/o larger pneumo.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Status post excision of right Pancoast tumor leaking from\\n chest tubes.\\n\\n CHEST AP: Since the prior chest x-ray, there has been no significant change.\\n Two chest tubes are seen in the left apical region with associated rib\\n resections. Left lung remains clear. The right perihilar opacification\\n persists unchanged.\\n\\n IMPRESSION: No change since the prior chest x-ray.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887291,\n \"text\": \" 10:12 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change on water seal-eval for PTX\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA s/p right pancoast tumor excision\\n\\n REASON FOR THIS EXAMINATION:\\n interval change on water seal-eval for PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE UPRIGHT CHEST OF \\n\\n COMPARISON: .\\n\\n INDICATION: Status post right lung cancer resection. Chest tube on\\n water-seal.\\n\\n A chest tube remains in place, terminating at the extreme right lung apex. An\\n apical pneumothorax on the right is not significantly changed allowing for\\n technical differences between the studies. There is stable postoperative\\n volume loss. There has been slight interval increase in patchy opacity at the\\n right apex, which may be due to atelectasis or aspiration. Right perihilar\\n and paramediastinal opacities are unchanged and attributed to postoperative\\n changes. The left lung is slightly overinflated, but grossly clear.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-24 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 887789,\n \"text\": \" 11:29 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval for PTX\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA post CT pull\\n REASON FOR THIS EXAMINATION:\\n eval for PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 62-year-old woman with lung cancer status post surgical resection.\\n Please evaluate for pneumothorax.\\n\\n TECHNIQUE: PA and lateral views of the chest were obtained and compared to\\n .\\n\\n FINDINGS: There has been interval removal of two right apical chest tubes.\\n No definite pneumothorax identified. There are post-surgical changes at the\\n right apex including signs of volume loss of the right hemithorax with\\n persistent elevation of the right hemidiaphragm and mediastinal shift to the\\n right. Again noted are multiple surgical rib defects at the right apex. The\\n right lung base and the left lung are grossly clear. Heart size and\\n cardiomediastinal contours are stable given differences and patient rotation.\\n\\n IMPRESSION: Interval removal of right apical pleural drains. No definite\\n pneumothorax. Surgical changes at the right apex with associated volume loss\\n of the right hemithorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 886968,\n \"text\": \" 5:54 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval PTX\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA\\n REASON FOR THIS EXAMINATION:\\n eval PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Lung CA, question pneumothorax.\\n\\n chest, single vw\\n\\n An ET tube is present. The tip overlies the proximal left main stem bronchus\\n and should be retracted. The left lung is grossly clear, without CHF,\\n infiltrate, or effusion. On the right, there are skin staples and a right\\n chest tube. The right hemidiaphragm is elevated. There is increased opacity\\n in the right upper zone, confluent with the hilum. The right base is grossly\\n clear.\\n\\n IMPRESSION:\\n\\n 1. ET tube with tip over left proximal main stem bronchus. This should be\\n retracted approximately 4.2 cm. (A subsequent film currently on PACs\\n demonstrates retraction of the ETT to an appropriate position.)\\n\\n 2) Right apical and hilar densities and postoperative changes right lung.\\n\\n 3) No pneumothorax detected.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 886985,\n \"text\": \" 9:13 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: ETT placement\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA\\n\\n REASON FOR THIS EXAMINATION:\\n ETT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ET tube placement.\\n\\n CHEST, SINGLE AP VIEW SUPINE.\\n\\n Compared with earlier the same day, the ET tube has been retracted. The tip\\n now lies in satisfactory position approximately 2.3 cm above the carina. There\\n is atelectasis in both lungs, slightly more pronounced in the left lung.\\n Otherwise, no significant change is detected.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 887366,\n \"text\": \" 7:02 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: worsening pneumo?\\n Admitting Diagnosis: RIGHT LUNG CA/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\\n leaks\\n REASON FOR THIS EXAMINATION:\\n worsening pneumo?\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST X-RAY , AT 19:06.\\n\\n COMPARISON: Previous study of earlier the same date at 16:22.\\n\\n INDICATION: Pancoast tumor excision. Chest tube leak.\\n\\n Two chest tubes remain in place in the right hemithorax, and there is a\\n persistent right apical pneumothorax. There is postoperative volume loss in\\n the right hemithorax, and there is increasing pulmonary opacification within\\n the right lung with relative sparing of the right lung base. This may\\n represent worsening postoperative atelectasis, but is difficult to exclude\\n superimposed process such as aspiration. Within the left lung, no confluent\\n areas of consolidation or pleural effusion are observed.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477987,\n \"text\": \"Respiratory Care\\nPt.received from PACU,intubated BBS+diminished on right,and coarse t/o.Placed on vent. as documented.See CareVue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477988,\n \"text\": \"admit note\\nplease see flowsheet for details. pt came from at 1800 to pacu s/p flex bronch, superclavicular scalene fat pad and lymph node disection, cervical mobilization of pancose tumor, right thoractomy, with right upper lobectomy and chest wall excision for right upper lobe mass. She came to SICU from pacu at 2300. at that time she was intubated, sedated on 30 mcq/kg/min propofol but able to nod head to questions and follow commands moving all extremities. neo gtt to maintain a map> 60, LR at 75cc/hr, epidural at T5 with bupivicaine only.\\n\\ncurrently, afebrile, heart rate 90s, lopressor held- pt on neo gtt to keep map > 60.\\n\\nresp: vented, lsc with intermittent wheezes, treated with albuterol/atrovent, chest tubes X 2\\n\\npain: epidural, but pt has sensation at t5, above and below t5. minimal c/o pain, 50 mcq fentanyl given during aline placement\\n\\nneuro: alert, following commands briskly, mae+, despite propofol gtt at 30 mcq/kg/min,\\n\\nsurgical dressings c/d/i\\n\\nplan: wean vent as tolerated, cont to control pain, chest tubes and epidural.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477989,\n \"text\": \"Respiratory Care\\nPt.remains on full vent.support,sedated with propofol.BBS reveal some exp wheezes t/o treated with Albuterol and atrovent.Abg's adequate.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477990,\n \"text\": \"Pt woke up well with a good RSBI,VC,NIF & air leak past deflated cuff\\nwas extubated and placed on AFM 40% She has a good cough and is productive of thick yellow-green sputum\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477991,\n \"text\": \"condition update\\nD: PLEASE SEE CAREVUE FOR SPECIFICS\\nNEURO: PROPOFOL WEANED TO OFF. PT IS ALERT, ORIENTED X3, COOPERATIVE, FOLLOWS COMMANDS. MAE WITH EQUAL STRENGTH\\nCV: T MAX 100.9- DR AWARE, NO CX ORDERED, NEO GTT WEANED TO OFF THIS AM. PT REMAINS TACHYCARDIC TO 120- LOPRESSOR RESTARTED. SBP 120-150 POST-EXTUBATION.\\nRESP: PT WEANED AND EXTUBATED. CURRENTLY ON NP AT 4LITERS WITH SAT 96%. BS DIMINSHED IN RIGHT BASES. COUGHING AND RAISING THICK YELLOW SECRETIONS. CHEST DRESSING DRY AND INTACT. CT DRESSING CHANGED FOR MOD AMT SEROSANG. CT PATENT WITH + AIR LEAK, NO CREPITUS NOTED.\\nGI: ABD SOFT, HYPOACTIVE BS. NPO.\\nGU: UO DRIFTING OFF THIS AFTERNOON. DR AND DR NOTIFIED. FOLEY THEN IRRIGATED AT 1730 WITH MOD AMT OF SEDIMENT REMOVED AND PT THEN DRAINED 200CC CLOUDY YELLOW URINE. DR AWARE OF ABOVE.\\nENDO: SLIDING SCALE INCREASED TO REFLECT BS 140-210.\\nA: NEO WEANED TO OFF, PROPOFOL WEANED OFF, WEANED AND EXTUBATED, EPIDURAL FOR PAIN CONTROL WITH GOOD RELIEF\\nR: TOL EXTUBATION WELL, HEMODYNAMICALLY STABLE, ENCOURAGE PULM TOILET, OOB TO CHAIR IN AM\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477992,\n \"text\": \"NSICU Nursing Progress Note\\nNeuro - Pt x3. Able to make needs known.\\n\\nCV - SR to ST with occ PCVs, multifocal PVCs. Pt began having runs of SVT ~0530 AM. 0600 Metoprolol given early, ectopy continued. HO notified, PRN metoprolol given, Mg repleted with good effect. MBP 90's by arterial line. Peripheral pulses palpable.\\n\\nResp - Lungs essentialy clear. O2 sat > 96% on 4 L NC. Strong cough productive of thick yellow sputum. Right chest tubes x2 to 20 cm suction with small air leak.\\n\\nGI - NPO. Abdomen benign.\\n\\nGU - Adequate UOP via foley. Large amount sediment. Sent for UA, cx.\\n\\nEndo - Regular insulin per sliding scale.\\n\\nA - Increasing ectopy this AM, resolved with metoprolol, MgSO4.\\n\\nP - continue to monitor. Contsider tx to floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477993,\n \"text\": \"CONDITION UPDATE\\nD: PLEASE SEE CAREVUE FOR SPECIFICS\\nNEURO: ALERT AND ORIENTED X3. EPIDURAL AT 6CC/HR FOR PAIN, DILAUDID PCA ALSO STARTED THIS AFTERNOON.\\nCV: AFEBRILE. PT HAD MULTIPLE SHORT RUNS OF SVT WITH STABLE BP ALL AM. AT 1145, PT WENT INTO SUSTAINED RAPID RHTHTYM WITH DROP IN BP TO 90. EKG DONE= RAPID AFIB, AMIODARONE BOLUS STARTED AND PT PLACED ON GTT AT 1MG/MIN. RATE DID DROP TO 110 FOR A SHORT WHILE. BY 1600, HR UP TO 120-140, REPEAT BOLUS GIVEN.\\nRESP: BS COARSE. COUGHING AND RAISING COPIOUS AMTS OF THICK YELLOW-GREEN SPUTUM. CT TO WATER SEAL WITH SEROUS DRAINAGE.\\nGI: TAKING CLEAR LIQUIDS SLOWLY, ABD SOFT AND NON-TENDER.\\nGU: YELLOW URINE WITH SEDIMENT.\\nA: OOB TO CHAIR WITH ASSISTANCE OF 2- TOL GOOD. RHYTHM MONITORED, AMIODARONE GTT STARTED, ? DILT IF RATE IS NOT CONTROLLED.\\nR: RAPID RATE UNCONTROLLED BY LOPRESSOR, AMIODARONE GTT INFUSING WITH POOR RATE CONTROL, START DILT IF RATE UNCHANGED IN HR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477994,\n \"text\": \"D:Pt treated for rapid afib without response to amiodarone bolus and diltiazem. lopressor given with pt converting to SR rate 70-80.\\nP:Manage meds for a-fib.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2171-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477995,\n \"text\": \"FULL CODE Universal precautions Allergy: codeine\\n\\n\\nNeuro: AAOx3, MAEx4. OOB in chair at beginning of shift - BTB at 1200 - walks well - fairly steady on her feet, required minimal assistance.\\n\\nCV: HR=80-90s, NSR w/ rare to freq PVCs. Prior to am lopressor dose, HR up to 140-160 for a few seconds, then returned to 90-100s. Given 25mg lopressor po dose and additional 5mg IV - HR down to 50s for about 1hour, then has returned to 80s w/ no increase in HR and ectopy has signif decreased as well. Amiodarone gtt at .5mg/min. BP=120-130s/50-60s. +periph pulses, sl edema, extrems warm.\\n\\nResp: on 5l n/p w/ 02 sat 95-98%. Lungs coarse bilat, decreased in R fields. Excellent cough effort produding thick white secretions - using yankar to clear oral secretions. using IS 750-1000cc. R CT x2 ot H20 seal w/ serous drainage. CXR obtained late morning.\\n\\nGI/GU: abd soft/distended. +BS, no BM. Taking clear liqs well. Foley cath w/ dark, conc yellow uine.\\n\\nSkin: R CT, R flank incision, R neck incision intact\\n\\nPain: Bupivicaine epidural at 6cc/hr - intact. PCA Dialudid .12/6/1.2. Using well.\\n\\nID: T=98.9 no antibx.\\n\\nAccess: L piv x2.\\n\\nSocial: Sister and daughter-in-law visiting - Supportive.\\n\\nPlan: Tx to 2.\\n\"\n }\n]"}}},{"rowIdx":190,"cells":{"subject_id":{"kind":"number","value":9702,"string":"9,702"},"hadm_id":{"kind":"number","value":177827,"string":"177,827"},"target_text":{"kind":"string","value":"The patient was left intubated post operation due to some concerns of hypotenstion. This resoled quickly and he was extubated. He was extubated by the AM of POD1. He did well postoperativly. He had epidural anesthesia, which provided good pain control. He was moved to the VICU on POD1. His diet was held until flatus was passed. His INR was revered with Vit K. A bleeding time was done to assess coagulation, which was normal. His swan catheter was changed to cvl on POD 3 due to stable cardiac function. In the OR, a stomach mass was found, so Dr. service was consulted, he will f/u as an outpt. He was found to have a weak left deltoid, and neurology was consulted. After extensive radiological study, no definate cause for his weakness was found, but it had almost complealty resolved by the time of discharge. Otherwise his diet advanced without incident and he did well from a PT persepective. He was d/c'ed on POD 7 on coumadin to be followed by his PCP."},"extractive_notes_summ":{"kind":"string","value":"MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES: FINDINGS: There is slight irregularity of the proximal basilar artery without evidence of high-grade stenosis. IMPRESSION: Mild irregularity of the proximal basilar artery. Finally, asymmetrical right apical predominantly pleural opacity is noted and is stable compared to the recent radiograph. There has been interval removal of an endotracheal tube and nasogastric tube. The vertebral bodies demonstrate decreased T1 signal throughout. The distal right vertebral artery appears to end in a PICA. As noted in the cervical spine, there is diffuse decreased T1 signal throughout the vertebral bodies. There is diffuse bilateral carotid calcification seen as well as calcification within the aorta. Also, a mild degree of compression atelectasis at the right lung base is noted unchanged. Decreased T1 signal in the thoracic spine as in the cervical spine. IMPRESSION: 1) Free intraperitoneal air, most likely related to recent abdominal surgery. There are arteriosclerotic changes involving thoracic aorta, left ventricular enlargement, and postoperative changes from prior sternotomy. FINDINGS: A right internal jugular catheter has been placed and terminates in the superior vena cava. 4) Asymmetrical right apical opacity. Decreased T1 signal throughout the cervical spine. FINDINGS: The exam is somewhat limited by patient motion. Small bilateral pleural effusions are present. There is a remote lacunar infarct in the anterior aspect of the right thalamus, as identified on the patient's CT scan. Ventricles and sulci are mildly prominent consistent with mild brain atrophy. Note is made of moderate calcifications of both internal carotid arteries. Free intraperitoneal air is noted within the abdomen. 2) Central venous catheter in good position with no pneumothorax. FINDINGS: CERVICAL SPINE: The visualization of the cervical spine is limited by motion. also had a thoracic epidural, pulled today. Low densities in the right caudate head, the anterior limbs of the internal capsule and the right thalamus are probably remote infarcts but there are no comparison studies. most likely asymmetrical pleural thickening but attention to this region on a dedicated PA and lateral chest radiograph is recommended when the patient's condition permits. 3) Vascular calcifications within the bilateral carotids and aorta. Mild elevation of the left hemidiaphragm is seen. There are small lacunar infarcts, either in the anterior putamina or the anterior limbs of the internal capsules bilaterally, also consistent with CT scan findings. This could be seen in hematopoietic or neoplastic disorders. This could be seen in hematopoietic or neoplastic disorders. Status post sternotomy. Cardiac and mediastinal contours are stable. THORACIC SPINE: There is motion artifact present. 2) Persistent free intraperitoneal air due to the recent abdominal surgery. TECHNIQUE: Axial and sagittal T1, T2 and inversion recovery images of the thoracic and cervical spine were obtained. Free intraperitoneal air under both hemidiaphragms again noted due to recent abdominal surgery. C-spine nontrauma: There is a 2-mm focus of density in the subcutaneous tissues of the anterior neck around the level of C6. TECHNIQUE: Non-contrast CT of the head was obtained without comparisons. There are bibasilar opacities predominantly in the retrocardiac region which have worsened in the interval, and there are also small pleural effusions, left greater than right. INDICATION: Patient with status post catheter placement. The visualized spinal cord is unremarkable. Evaluate for infarction. Evaluate for epidural hematoma. although T-spine is ordered and patient had a Thoracic epidural, it should be noted that his deficit is of the C5 root and thus this area should be included in the study please FINAL REPORT INDICATION: Left deltoid paralysis, history of thoracic epidural. Some asymmetrical thickening in the right apex is seen. The osseous and soft-tissue structures appear unremarkable. Postoperative changes in the abdomen. The visualized paranasal sinuses have a normal signal. CLINICAL INDICATION: Line change. Pt had screening form done recently, and had MR this AM REASON FOR THIS EXAMINATION: Please do diffusion sequences, this was not available at initial MRI FINAL REPORT CLINICAL INFORMATION: Isolated deltoid weakness. The tip is in the mid superior vena cava. REASON FOR THIS EXAMINATION: evaluate for epidural hematoma. Again, the changes appear to be chronic. IMPRESSION: 1) There has been improvement in the magnitude of the left lower lobe partial atelectasis. This is a nonspecific finding. Probable chronic interstitial lung change. IMPRESSION: No evidence of acute mass or hemorrhage. Swan-Ganz catheter is identified with its tip in the right pulmonary artery. REPORT: The patient is intubated. 2) Degenerative changes of the C-spine with anterolisthesis, disk space narrowing, and osteophytosis as described above. No evidence of acute infarction. Areas of severe calcification along the left vertebral artery are also seen. The ventricles, cisterns, and sulci are within normal limits. 3) The remainder of the lungs are clear at this time. Note that MRI with diffusion-weighted imaging is a more sensitive evaluation for infarction. FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of normally midline structures. There is probably free air present on the previous supine study as well but the distribution has changed related to the patient's current upright positioning. 3) Worsening bibasilar opacities predominantly in the retrocardiac area, most likely due to atelectasis, although aspiration should also be considered. Some midline sutures are identified in the abdomen, and there are some apparent bowel loops also seen. IMPRESSION: No evidence of intracranial hemorrhage or gross infarction. Extensive parenchymal lung disease is identified. Anterior osteophytes are seen on C6 and C7."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2138-12-29 00:00:00.000","description":"C-SPINE NON-TRAUMA 2-3 VIEWS","row_id":854973,"text":" 10:20 PM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: eval prior to MRI of Cspine/Tspine\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with possible epidural bleed after epidural catheter removal\n with hx of metal imbedded in neck\n REASON FOR THIS EXAMINATION:\n eval prior to MRI of Cspine/Tspine\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 78-year-old man with possible epidural bleed after epidural\n catheter removal with history of metal imbedded in neck. Please evaluate neck\n for metal.\n\n C-spine nontrauma: There is a 2-mm focus of density in the subcutaneous\n tissues of the anterior neck around the level of C6. This may be a small\n piece of metal. No fractures are identified within the C-spine. There is\n grade I anterolisthesis of C5 on C6. There is disk space narrowing at C4-C5,\n C5-C6, and C6-C7. The most severe disk space narrowing is at C6-C7. Anterior\n osteophytes are seen on C6 and C7. There are increased interstitial markings\n within the lungs. There is diffuse bilateral carotid calcification seen as\n well as calcification within the aorta.\n\n IMPRESSION:\n\n 1) A 2-mm focus of density, likely metal in the subcutaneous tissues of the\n anterior neck.\n\n 2) Degenerative changes of the C-spine with anterolisthesis, disk space\n narrowing, and osteophytosis as described above.\n\n 3) Vascular calcifications within the bilateral carotids and aorta.\n\n\n"},{"category":"Radiology","chartdate":"2138-12-30 00:00:00.000","description":"CHEST (PA & LAT)","row_id":855008,"text":" 8:00 AM\n CHEST (PA & LAT) Clip # \n Reason: surveillance CXR\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p aorto-bifem bypass on \n REASON FOR THIS EXAMINATION:\n surveillance CXR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 78-year-old status post aorto-bifem bypass. Evaluate the chest.\n\n FINDINGS:\n\n Comparison is made to the prior study of a day earlier. Free intraperitoneal\n air under both hemidiaphragms again noted due to recent abdominal surgery.\n The right IJ line is in place. The tip is in the mid superior vena cava.\n There is no evidence of pneumothorax. Minimal degree of partial atelectasis\n involving the left lower lobe is noted, which has improved since the prior\n study. Also, a mild degree of compression atelectasis at the right lung base\n is noted unchanged. The remainder of the lungs are clear. There are\n arteriosclerotic changes involving thoracic aorta, left ventricular\n enlargement, and postoperative changes from prior sternotomy.\n\n IMPRESSION:\n\n 1) There has been improvement in the magnitude of the left lower lobe partial\n atelectasis.\n\n 2) Persistent free intraperitoneal air due to the recent abdominal surgery.\n\n 3) The remainder of the lungs are clear at this time.\n\n\n\n"},{"category":"Radiology","chartdate":"2138-12-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":854900,"text":" 11:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check central line placement\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p right IJ cordis to triple lumen change over guidwire\n\n REASON FOR THIS EXAMINATION:\n check central line placement\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable upright chest that is dated .\n\n CLINICAL INDICATION: Line change.\n\n FINDINGS:\n\n A right internal jugular catheter has been placed and terminates in the\n superior vena cava. There has been interval removal of an endotracheal tube\n and nasogastric tube. There is no pneumothorax. Cardiac and mediastinal\n contours are stable. There are bibasilar opacities predominantly in the\n retrocardiac region which have worsened in the interval, and there are also\n small pleural effusions, left greater than right. Free intraperitoneal air is\n noted within the abdomen. There is probably free air present on the previous\n supine study as well but the distribution has changed related to the patient's\n current upright positioning. Finally, asymmetrical right apical predominantly\n pleural opacity is noted and is stable compared to the recent radiograph.\n\n IMPRESSION:\n\n 1) Free intraperitoneal air, most likely related to recent abdominal surgery.\n\n 2) Central venous catheter in good position with no pneumothorax.\n\n 3) Worsening bibasilar opacities predominantly in the retrocardiac area, most\n likely due to atelectasis, although aspiration should also be considered.\n\n 4) Asymmetrical right apical opacity. most likely asymmetrical pleural\n thickening but attention to this region on a dedicated PA and lateral chest\n radiograph is recommended when the patient's condition permits.\n\n"},{"category":"Radiology","chartdate":"2138-12-30 00:00:00.000","description":"MR CERVICAL SPINE","row_id":854998,"text":" 6:47 AM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n Reason: evaluate for epidural hematoma. although T-spine is ordered\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with vasculopath, s/p aortobifem, with new Left deltoid\n paralysis. also had a thoracic epidural, pulled today.\n REASON FOR THIS EXAMINATION:\n evaluate for epidural hematoma. although T-spine is ordered and patient had a\n Thoracic epidural, it should be noted that his deficit is of the C5 root and\n thus this area should be included in the study please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left deltoid paralysis, history of thoracic epidural. Evaluate\n for epidural hematoma.\n\n TECHNIQUE: Axial and sagittal T1, T2 and inversion recovery images of the\n thoracic and cervical spine were obtained.\n\n FINDINGS:\n\n CERVICAL SPINE: The visualization of the cervical spine is limited by motion.\n There is no spinal cord or paraspinal pathology visualized. There is no disc\n herniation noted. There is no evidence of spinal stenosis or subluxation of\n the component vertebra. The vertebral bodies demonstrate decreased T1 signal\n throughout. Small bilateral pleural effusions are present.\n\n IMPRESSION:\n 1. Decreased T1 signal throughout the cervical spine. This could be seen in\n hematopoietic or neoplastic disorders.\n 2. No evidence of cord compression.\n\n THORACIC SPINE: There is motion artifact present. There is no disc, vertebral\n or intraspinal pathology visualized. There is no evidence of spinal stenosis\n or spondylolisthesis. The visualized spinal cord is unremarkable. As noted in\n the cervical spine, there is diffuse decreased T1 signal throughout the\n vertebral bodies.\n\n IMPRESSION:\n 1. Decreased T1 signal in the thoracic spine as in the cervical spine. This\n could be seen in hematopoietic or neoplastic disorders.\n 2. No evidence of spinal cord compression.\n\n\n"},{"category":"Radiology","chartdate":"2138-12-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":854648,"text":" 7:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PA cath placement\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with s/p AoBF\n REASON FOR THIS EXAMINATION:\n PA cath placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Patient with status post catheter placement. Evaluate.\n\n COMPARISON: No study available for comparison.\n\n REPORT: The patient is intubated. The T-tube lies 5.5 cm above the carina.\n Status post sternotomy. A LIMA graft has also been performed. Swan-Ganz\n catheter is identified with its tip in the right pulmonary artery. It could\n be retracted slightly. NG tube is seen coursing through the mediastinum with\n its tip in the region of the stomach. Mild elevation of the left\n hemidiaphragm is seen. No studies are available for comparison. Some midline\n sutures are identified in the abdomen, and there are some apparent bowel loops\n also seen.\n\n Extensive parenchymal lung disease is identified. This is mostly interstitial\n in nature, the changes are likely longstanding, though no studies available\n for comparison. Some asymmetrical thickening in the right apex is seen. This\n is a nonspecific finding. Again, the changes appear to be chronic.\n\n CONCLUSION:\n\n Good position of the line. Probable chronic interstitial lung change.\n Postoperative changes in the abdomen.\n\n\n\n"},{"category":"Radiology","chartdate":"2138-12-31 00:00:00.000","description":"MR HEAD W/O CONTRAST","row_id":855123,"text":" 12:42 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Please do diffusion sequences, this was not available at ini\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with isolated deltoid weakness, ? stroke. Pt had screening\n form done recently, and had MR this AM\n REASON FOR THIS EXAMINATION:\n Please do diffusion sequences, this was not available at initial MRI\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Isolated deltoid weakness. ? stroke.\n\n MRI OF THE BRAIN:\n\n Exam compared to the patient's CT scan of .\n\n FINDINGS: The exam is somewhat limited by patient motion. There is a remote\n lacunar infarct in the anterior aspect of the right thalamus, as identified on\n the patient's CT scan. There are small lacunar infarcts, either in the\n anterior putamina or the anterior limbs of the internal capsules bilaterally,\n also consistent with CT scan findings. There is no evidence of abnormal\n diffusion to suggest the presence of acute infarction. There is no evidence\n of mass effect or hemorrhage. Ventricles and sulci are mildly prominent\n consistent with mild brain atrophy. The visualized paranasal sinuses have a\n normal signal.\n\n IMPRESSION: No evidence of acute mass or hemorrhage. No evidence of acute\n infarction.\n\n MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES:\n\n FINDINGS: There is slight irregularity of the proximal basilar artery without\n evidence of high-grade stenosis. The distal right vertebral artery appears to\n end in a PICA. There is no evidence of aneurysm. There is no evidence of\n flow abnormality in the carotid circuits.\n\n IMPRESSION: Mild irregularity of the proximal basilar artery.\n\n"},{"category":"Radiology","chartdate":"2138-12-29 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":854957,"text":" 5:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ACUTE ASYMMETRICAL LEFT UPPER EXTREMITY WEAKNESS, EVAL FOR INFARCT\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with acut asymmetrical left upper extremity weakness\n REASON FOR THIS EXAMINATION:\n r/o infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute asymmetric upper extremity weakness. Evaluate for\n infarction.\n\n TECHNIQUE: Non-contrast CT of the head was obtained without comparisons.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of\n normally midline structures. The ventricles, cisterns, and sulci are within\n normal limits. -white matter differentiation is preserved. Low densities\n in the right caudate head, the anterior limbs of the internal capsule and\n the right thalamus are probably remote infarcts but there are no\n comparison studies. Note is made of moderate calcifications of both internal\n carotid arteries. Areas of severe calcification along the left vertebral\n artery are also seen. The osseous and soft-tissue structures appear\n unremarkable.\n\n IMPRESSION: No evidence of intracranial hemorrhage or gross infarction. Note\n that MRI with diffusion-weighted imaging is a more sensitive evaluation for\n infarction.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-29 00:00:00.000\",\n \"description\": \"C-SPINE NON-TRAUMA 2-3 VIEWS\",\n \"row_id\": 854973,\n \"text\": \" 10:20 PM\\n C-SPINE NON-TRAUMA VIEWS Clip # \\n Reason: eval prior to MRI of Cspine/Tspine\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with possible epidural bleed after epidural catheter removal\\n with hx of metal imbedded in neck\\n REASON FOR THIS EXAMINATION:\\n eval prior to MRI of Cspine/Tspine\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 78-year-old man with possible epidural bleed after epidural\\n catheter removal with history of metal imbedded in neck. Please evaluate neck\\n for metal.\\n\\n C-spine nontrauma: There is a 2-mm focus of density in the subcutaneous\\n tissues of the anterior neck around the level of C6. This may be a small\\n piece of metal. No fractures are identified within the C-spine. There is\\n grade I anterolisthesis of C5 on C6. There is disk space narrowing at C4-C5,\\n C5-C6, and C6-C7. The most severe disk space narrowing is at C6-C7. Anterior\\n osteophytes are seen on C6 and C7. There are increased interstitial markings\\n within the lungs. There is diffuse bilateral carotid calcification seen as\\n well as calcification within the aorta.\\n\\n IMPRESSION:\\n\\n 1) A 2-mm focus of density, likely metal in the subcutaneous tissues of the\\n anterior neck.\\n\\n 2) Degenerative changes of the C-spine with anterolisthesis, disk space\\n narrowing, and osteophytosis as described above.\\n\\n 3) Vascular calcifications within the bilateral carotids and aorta.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-30 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 855008,\n \"text\": \" 8:00 AM\\n CHEST (PA & LAT) Clip # \\n Reason: surveillance CXR\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man s/p aorto-bifem bypass on \\n REASON FOR THIS EXAMINATION:\\n surveillance CXR\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: A 78-year-old status post aorto-bifem bypass. Evaluate the chest.\\n\\n FINDINGS:\\n\\n Comparison is made to the prior study of a day earlier. Free intraperitoneal\\n air under both hemidiaphragms again noted due to recent abdominal surgery.\\n The right IJ line is in place. The tip is in the mid superior vena cava.\\n There is no evidence of pneumothorax. Minimal degree of partial atelectasis\\n involving the left lower lobe is noted, which has improved since the prior\\n study. Also, a mild degree of compression atelectasis at the right lung base\\n is noted unchanged. The remainder of the lungs are clear. There are\\n arteriosclerotic changes involving thoracic aorta, left ventricular\\n enlargement, and postoperative changes from prior sternotomy.\\n\\n IMPRESSION:\\n\\n 1) There has been improvement in the magnitude of the left lower lobe partial\\n atelectasis.\\n\\n 2) Persistent free intraperitoneal air due to the recent abdominal surgery.\\n\\n 3) The remainder of the lungs are clear at this time.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 854900,\n \"text\": \" 11:34 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: check central line placement\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man s/p right IJ cordis to triple lumen change over guidwire\\n\\n REASON FOR THIS EXAMINATION:\\n check central line placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n This is a portable upright chest that is dated .\\n\\n CLINICAL INDICATION: Line change.\\n\\n FINDINGS:\\n\\n A right internal jugular catheter has been placed and terminates in the\\n superior vena cava. There has been interval removal of an endotracheal tube\\n and nasogastric tube. There is no pneumothorax. Cardiac and mediastinal\\n contours are stable. There are bibasilar opacities predominantly in the\\n retrocardiac region which have worsened in the interval, and there are also\\n small pleural effusions, left greater than right. Free intraperitoneal air is\\n noted within the abdomen. There is probably free air present on the previous\\n supine study as well but the distribution has changed related to the patient's\\n current upright positioning. Finally, asymmetrical right apical predominantly\\n pleural opacity is noted and is stable compared to the recent radiograph.\\n\\n IMPRESSION:\\n\\n 1) Free intraperitoneal air, most likely related to recent abdominal surgery.\\n\\n 2) Central venous catheter in good position with no pneumothorax.\\n\\n 3) Worsening bibasilar opacities predominantly in the retrocardiac area, most\\n likely due to atelectasis, although aspiration should also be considered.\\n\\n 4) Asymmetrical right apical opacity. most likely asymmetrical pleural\\n thickening but attention to this region on a dedicated PA and lateral chest\\n radiograph is recommended when the patient's condition permits.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-30 00:00:00.000\",\n \"description\": \"MR CERVICAL SPINE\",\n \"row_id\": 854998,\n \"text\": \" 6:47 AM\\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \\n Reason: evaluate for epidural hematoma. although T-spine is ordered\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with vasculopath, s/p aortobifem, with new Left deltoid\\n paralysis. also had a thoracic epidural, pulled today.\\n REASON FOR THIS EXAMINATION:\\n evaluate for epidural hematoma. although T-spine is ordered and patient had a\\n Thoracic epidural, it should be noted that his deficit is of the C5 root and\\n thus this area should be included in the study please\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Left deltoid paralysis, history of thoracic epidural. Evaluate\\n for epidural hematoma.\\n\\n TECHNIQUE: Axial and sagittal T1, T2 and inversion recovery images of the\\n thoracic and cervical spine were obtained.\\n\\n FINDINGS:\\n\\n CERVICAL SPINE: The visualization of the cervical spine is limited by motion.\\n There is no spinal cord or paraspinal pathology visualized. There is no disc\\n herniation noted. There is no evidence of spinal stenosis or subluxation of\\n the component vertebra. The vertebral bodies demonstrate decreased T1 signal\\n throughout. Small bilateral pleural effusions are present.\\n\\n IMPRESSION:\\n 1. Decreased T1 signal throughout the cervical spine. This could be seen in\\n hematopoietic or neoplastic disorders.\\n 2. No evidence of cord compression.\\n\\n THORACIC SPINE: There is motion artifact present. There is no disc, vertebral\\n or intraspinal pathology visualized. There is no evidence of spinal stenosis\\n or spondylolisthesis. The visualized spinal cord is unremarkable. As noted in\\n the cervical spine, there is diffuse decreased T1 signal throughout the\\n vertebral bodies.\\n\\n IMPRESSION:\\n 1. Decreased T1 signal in the thoracic spine as in the cervical spine. This\\n could be seen in hematopoietic or neoplastic disorders.\\n 2. No evidence of spinal cord compression.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 854648,\n \"text\": \" 7:27 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: PA cath placement\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with s/p AoBF\\n REASON FOR THIS EXAMINATION:\\n PA cath placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Chest radiograph.\\n\\n INDICATION: Patient with status post catheter placement. Evaluate.\\n\\n COMPARISON: No study available for comparison.\\n\\n REPORT: The patient is intubated. The T-tube lies 5.5 cm above the carina.\\n Status post sternotomy. A LIMA graft has also been performed. Swan-Ganz\\n catheter is identified with its tip in the right pulmonary artery. It could\\n be retracted slightly. NG tube is seen coursing through the mediastinum with\\n its tip in the region of the stomach. Mild elevation of the left\\n hemidiaphragm is seen. No studies are available for comparison. Some midline\\n sutures are identified in the abdomen, and there are some apparent bowel loops\\n also seen.\\n\\n Extensive parenchymal lung disease is identified. This is mostly interstitial\\n in nature, the changes are likely longstanding, though no studies available\\n for comparison. Some asymmetrical thickening in the right apex is seen. This\\n is a nonspecific finding. Again, the changes appear to be chronic.\\n\\n CONCLUSION:\\n\\n Good position of the line. Probable chronic interstitial lung change.\\n Postoperative changes in the abdomen.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-31 00:00:00.000\",\n \"description\": \"MR HEAD W/O CONTRAST\",\n \"row_id\": 855123,\n \"text\": \" 12:42 AM\\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \\n Reason: Please do diffusion sequences, this was not available at ini\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with isolated deltoid weakness, ? stroke. Pt had screening\\n form done recently, and had MR this AM\\n REASON FOR THIS EXAMINATION:\\n Please do diffusion sequences, this was not available at initial MRI\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL INFORMATION: Isolated deltoid weakness. ? stroke.\\n\\n MRI OF THE BRAIN:\\n\\n Exam compared to the patient's CT scan of .\\n\\n FINDINGS: The exam is somewhat limited by patient motion. There is a remote\\n lacunar infarct in the anterior aspect of the right thalamus, as identified on\\n the patient's CT scan. There are small lacunar infarcts, either in the\\n anterior putamina or the anterior limbs of the internal capsules bilaterally,\\n also consistent with CT scan findings. There is no evidence of abnormal\\n diffusion to suggest the presence of acute infarction. There is no evidence\\n of mass effect or hemorrhage. Ventricles and sulci are mildly prominent\\n consistent with mild brain atrophy. The visualized paranasal sinuses have a\\n normal signal.\\n\\n IMPRESSION: No evidence of acute mass or hemorrhage. No evidence of acute\\n infarction.\\n\\n MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES:\\n\\n FINDINGS: There is slight irregularity of the proximal basilar artery without\\n evidence of high-grade stenosis. The distal right vertebral artery appears to\\n end in a PICA. There is no evidence of aneurysm. There is no evidence of\\n flow abnormality in the carotid circuits.\\n\\n IMPRESSION: Mild irregularity of the proximal basilar artery.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2138-12-29 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 854957,\n \"text\": \" 5:45 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ACUTE ASYMMETRICAL LEFT UPPER EXTREMITY WEAKNESS, EVAL FOR INFARCT\\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 78 year old man with acut asymmetrical left upper extremity weakness\\n REASON FOR THIS EXAMINATION:\\n r/o infarct\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Acute asymmetric upper extremity weakness. Evaluate for\\n infarction.\\n\\n TECHNIQUE: Non-contrast CT of the head was obtained without comparisons.\\n\\n FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of\\n normally midline structures. The ventricles, cisterns, and sulci are within\\n normal limits. -white matter differentiation is preserved. Low densities\\n in the right caudate head, the anterior limbs of the internal capsule and\\n the right thalamus are probably remote infarcts but there are no\\n comparison studies. Note is made of moderate calcifications of both internal\\n carotid arteries. Areas of severe calcification along the left vertebral\\n artery are also seen. The osseous and soft-tissue structures appear\\n unremarkable.\\n\\n IMPRESSION: No evidence of intracranial hemorrhage or gross infarction. Note\\n that MRI with diffusion-weighted imaging is a more sensitive evaluation for\\n infarction.\\n\\n\"\n }\n]"}}},{"rowIdx":191,"cells":{"subject_id":{"kind":"number","value":55263,"string":"55,263"},"hadm_id":{"kind":"number","value":101045,"string":"101,045"},"target_text":{"kind":"string","value":"Patient was admitted on for an electively planned left sided craniotomy for mass resection. He had an uneventfull post-operative course in which he stayed in PACU overnight then transferred to floor. He ambulated without difficulty, pain well controlled. Did have some nausea/vomiting on however well controlled with medication. On he tolerated PO intake and feeling well. He was evaluated by OT who recommended outpt treatment. Incisional site c/d/i and exam non-focal except for tingling in fingers with sl. dexterity deficits in which he will have OT follow-up."},"extractive_notes_summ":{"kind":"string","value":"Chief complaint: Left Brain Mas PMHx: Left brain mass Current medications: 1. IMPRESSION: Extra-axial enhancing mass, as described above, with stable surrounding edema and thin supratentorial pachymeningeal enhancement. Please have completed within 36hrs post-op No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 10:27 AM Post-operative changes and expected post-operative findings are seen on MRI. Plan: Q1hr neuro checks. Please have completed within 36hrs post-op No contraindications for IV contrast PFI REPORT Post-operative changes and expected post-operative findings are seen on MRI. COMPARISON: CTA of the head with and without contrast, and MRI head (), . T1 axial and MP-RAGE sagittal images were obtained following gadolinium. A faint area of increased signal within the pons with subtle enhancement is consistent with an incidental capillary telangiectasia which is unchanged from previous study. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. FINDINGS: Since the previous MRI of the patient has undergone resection of left frontoparietal extra-axial mass. Initially evaluated at NWH CT/MRI + for Left parietal mass. IMPRESSION: Expected postoperative changes, with a small amount of pneumocephalus overlying the left frontal lobe, as well as tiny foci of pneumocephalus and postoperative hemorrhage within the surgical bed. Chest pain Assessment: Pt c/o left lung pain Pt nauseous Denies sob All vital signs stable Neurologically intact Action: Dr. notified Ekg done Cardiac enzymes sent Zofran given Protonix given Response: Pt verbalizes relief of pain and nausea Ekg normal Enzymes normal Plan: Continue to monitor Visualized paranasal sinuses and mastoid air cells are normally aerated. TB as child vs PNA (per Pt he said he meant PNA when giving his FHP) Surgery / Procedure and date: Left Crani for excision of mass Latest Vital Signs and I/O Non-invasive BP: S:127 D:69 Temperature: 99.1 Arterial BP: S:127 D:56 Respiratory rate: 23 insp/min Heart Rate: 88 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 98% % O2 flow: 1 L/min FiO2 set: 24h total in: 1,982 mL 24h total out: 685 mL Pertinent Lab Results: Sodium: 140 mEq/L 02:01 AM Potassium: 4.0 mEq/L 02:01 AM Chloride: 102 mEq/L 02:01 AM CO2: 30 mEq/L 02:01 AM BUN: 15 mg/dL 02:01 AM Creatinine: 1.0 mg/dL 02:01 AM Glucose: 116 mg/dL 02:01 AM Hematocrit: 40.4 % 02:01 AM Finger Stick Glucose: 127 10:00 AM Valuables / Signature Patient valuables: Other valuables: Clothes: Sent home with: Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: sicu a Transferred to: 1114 Date & time of Transfer: TB as child vs PNA (per Pt he said he meant PNA when giving his FHP) Surgery / Procedure and date: Left Crani for excision of mass Latest Vital Signs and I/O Non-invasive BP: S:127 D:69 Temperature: 99.1 Arterial BP: S:127 D:56 Respiratory rate: 23 insp/min Heart Rate: 88 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 98% % O2 flow: 1 L/min FiO2 set: 24h total in: 1,982 mL 24h total out: 685 mL Pertinent Lab Results: Sodium: 140 mEq/L 02:01 AM Potassium: 4.0 mEq/L 02:01 AM Chloride: 102 mEq/L 02:01 AM CO2: 30 mEq/L 02:01 AM BUN: 15 mg/dL 02:01 AM Creatinine: 1.0 mg/dL 02:01 AM Glucose: 116 mg/dL 02:01 AM Hematocrit: 40.4 % 02:01 AM Finger Stick Glucose: 127 10:00 AM Valuables / Signature Patient valuables: Other valuables: Clothes: Sent home with: Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: sicu a Transferred to: 1114 Date & time of Transfer:"},"n_notes":{"kind":"number","value":15,"string":"15"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420806,"text":"63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n"},{"category":"Physician ","chartdate":"2161-11-12 00:00:00.000","description":"Intensivist Note","row_id":420789,"text":"SICU\n HPI:\n 63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation.\n Chief complaint:\n Left Brain Mas\n PMHx:\n Left brain mass\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5. Dexamethasone 6.\n Docusate Sodium 7. Gentamicin\n 8. HYDROmorphone (Dilaudid) 9. Heparin 10. HydrALAzine 11. Influenza\n Virus Vaccine 12. Insulin 13. NiCARdipine\n 14. Ondansetron 15. Pantoprazole 16. Phenytoin 17. Sodium Chloride 0.9%\n Flush 18. Vancomycin\n 24 Hour Events:\n OR RECEIVED - At 05:00 PM\n ARTERIAL LINE - START 05:11 PM\n EKG - At 02:21 AM\n CHEST PAIN - At 02:21 AM\n FEVER - 209.1\nC - 05:41 PM\n Post operative day:\n POD#1 - S/P L Crani\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 05:57 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 02:31 AM\n Other medications:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 98.4\nC (209.1\n T current: 37.2\nC (98.9\n HR: 83 (73 - 106) bpm\n BP: 144/62(87) {111/48(66) - 156/62(87)} mmHg\n RR: 26 (8 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,622 mL\n 1,039 mL\n PO:\n 200 mL\n 100 mL\n Tube feeding:\n IV Fluid:\n 2,422 mL\n 939 mL\n Blood products:\n Total out:\n 4,070 mL\n 520 mL\n Urine:\n 1,470 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,448 mL\n 519 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (RUE: Weakness)\n Labs / Radiology\n 316 K/uL\n 14.9 g/dL\n 116 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 102 mEq/L\n 140 mEq/L\n 40.4 %\n 20.7 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 20.7\n Hct\n 40.4\n Plt\n 316\n Creatinine\n 1.0\n Troponin T\n <0.01\n Glucose\n 116\n Other labs: PT / PTT / INR:13.2/22.0/1.1, CK / CK-MB / Troponin\n T:31//<0.01, Albumin:3.7 g/dL, Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.5\n mg/dL\n ECG: ECG --> no change from prior; SR with non-specific Q wave\n inferiorly.\n Assessment and Plan\n Assessment and Plan: 63M elective admission for crani who presented\n earlier in the week for ascending paraesthesia of the RUE.\n Neurologic: Neuro checks Q: 4 hr, Phenytoin - therapeutic, MRI of the\n head , check Albumin and Phenytoin\n Cardiovascular: Post op HTN --> weaned off nicardipine overnight to\n Keep SBP<140;\n Pulmonary: Chest PT, OOB; Phys therapy and occupational Therapy.\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, D/C Foley\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Periop Vancomycin\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: MRI of the head\n Fluids: NS\n Consults: Neuro surgery, P.T., O.T.\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:11 PM\n 18 Gauge - 05:13 PM\n 20 Gauge - 08:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"},{"category":"Nursing","chartdate":"2161-11-11 00:00:00.000","description":"Nursing Progress Note","row_id":420740,"text":"Above pt with 2month Hx of intermittent R hand numbness/tingling now\n presents with tingling extending up the medial aspect of the right arm\n to the right shoulder and neck. Initially evaluated at NWH CT/MRI +\n for Left parietal mass. Pt referred to to for further\n evaluation. Pt to OR for Left craniotomy of Left parietal lesion.\n Assessment: Pt arrived from OR extubated. Neuro intact. A+O X3. No\n noted Neuro deficits noted. Pt crani incision clean dry and\n intact. Goal SBP 100-140. Pt arrived with SBP 160\n Action: Pt given 10mg hydral on arrival X2 with little effect.\n Nicardipine gtt started. Pt with mild c/o pain given 2mg PO dilaudid.\n Response: SBP now 125-139 with nicardipine at 3mcgs. Pt with good\n relief from PO dilaudid.\n Plan: Q1hr neuro checks. Cont to maintain SBP within paramenter. CT\n scan tonight MRI within 36hrs post op. Cont with current plan of care.\n"},{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420828,"text":"63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n BRAIN TUMOR/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 81 kg\n Daily weight:\n 81.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Hx of central vision loss OS-Dx macular\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\n he meant PNA when giving his FHP)\n Surgery / Procedure and date: Left Crani for excision of mass\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:69\n Temperature:\n 99.1\n Arterial BP:\n S:127\n D:56\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 1,982 mL\n 24h total out:\n 685 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:01 AM\n Potassium:\n 4.0 mEq/L\n 02:01 AM\n Chloride:\n 102 mEq/L\n 02:01 AM\n CO2:\n 30 mEq/L\n 02:01 AM\n BUN:\n 15 mg/dL\n 02:01 AM\n Creatinine:\n 1.0 mg/dL\n 02:01 AM\n Glucose:\n 116 mg/dL\n 02:01 AM\n Hematocrit:\n 40.4 %\n 02:01 AM\n Finger Stick Glucose:\n 127\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu a\n Transferred to: 1114\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420834,"text":"63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n BRAIN TUMOR/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 81 kg\n Daily weight:\n 81.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Hx of central vision loss OS-Dx macular\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\n he meant PNA when giving his FHP)\n Surgery / Procedure and date: Left Crani for excision of mass\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:69\n Temperature:\n 99.1\n Arterial BP:\n S:127\n D:56\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 1,982 mL\n 24h total out:\n 685 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:01 AM\n Potassium:\n 4.0 mEq/L\n 02:01 AM\n Chloride:\n 102 mEq/L\n 02:01 AM\n CO2:\n 30 mEq/L\n 02:01 AM\n BUN:\n 15 mg/dL\n 02:01 AM\n Creatinine:\n 1.0 mg/dL\n 02:01 AM\n Glucose:\n 116 mg/dL\n 02:01 AM\n Hematocrit:\n 40.4 %\n 02:01 AM\n Finger Stick Glucose:\n 127\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu a\n Transferred to: 1114\n Date & time of Transfer: \n"},{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420765,"text":"Chest pain\n Assessment:\n Pt c/o left lung pain\n Pt nauseous\n Denies sob\n All vital signs stable\n Action:\n Dr. notified\n Ekg done\n Cardiac enzymes sent\n Zofran given\n Protonix given\n Response:\n Pt verbalizes relief of pain and nausea\n Ekg normal\n Enzymes normal\n Plan:\n Continue to monitor\n"},{"category":"Nursing","chartdate":"2161-11-12 00:00:00.000","description":"Nursing Progress Note","row_id":420767,"text":"Chest pain\n Assessment:\n Pt c/o left lung pain\n Pt nauseous\n Denies sob\n All vital signs stable\n Neurologically intact\n Action:\n Dr. notified\n Ekg done\n Cardiac enzymes sent\n Zofran given\n Protonix given\n Response:\n Pt verbalizes relief of pain and nausea\n Ekg normal\n Enzymes normal\n Plan:\n Continue to monitor\n"},{"category":"Radiology","chartdate":"2161-11-11 00:00:00.000","description":"MR HEAD W/ CONTRAST","row_id":1041347,"text":" 5:25 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: Wand protocol for placement of markers for surgery immediate\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with brain tumor.\n REASON FOR THIS EXAMINATION:\n Wand protocol for placement of markers for surgery immediately after.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male patient with history of a mass.\n\n TECHNIQUE: MRI of the brain was performed with IV contrast as per\n departmental protocol.\n\n COMPARISON: CTA of the head with and without contrast, and MRI\n head (), . The CT demonstrates no\n calcification within the mass, and no reactive change in the overlying skull.\n\n FINDINGS:\n\n There is a 2.9 (TRV) x 2.8 (AP) x 2.3 cm (CC), well-defined and lobulated,\n heterogeneously-enhancing mass that is T2-isointense-to- matter and\n demonstrates restricted diffusion. The mass also demonstrates a broad-based\n attachment to the left parietal dura, and causes mild enlargement of the\n surrounding subarachnoid spaces and buckling of the subjacent matter and\n is, therefore, likely extra-axial. There is vasogenic edema involving the\n adjacent subcortical white matter of the occipital, parietal, and posterior\n frontal lobes including the left precentral gyrus, with mass effect on and\n effacement of the overlying gyri of the left parietal lobe, but no evidence\n for midline shift or herniation. Minimal mass effect on the atrium of the left\n lateral ventricle, but no hydrocephalus. There is diffuse but smooth and thin\n pachymeningeal enhancement in the supratentorial compartment, but no evidence\n for leptomeningeal or subependymal enhancement, and no other focus of abnormal\n enhancement is noted.\n\n The visualized portions of the orbits are within normal limits. The paranasal\n sinuses are clear. The major vascular flow voids are normal.\n\n IMPRESSION: Extra-axial enhancing mass, as described above, with stable\n surrounding edema and thin supratentorial pachymeningeal enhancement. Given\n the constellation of findings, particularly its signal, diffusion and\n enhancement characteristics, this mass likely represents a meningioma. Much\n more remote differential diagnostic considerations also include dural- based\n metastasis (eg. from prostate cancer, in this patient with known nodule),\n lymphoma or granulomatous disease (eg. sarcoidosis).\n (Over)\n\n 5:25 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: Wand protocol for placement of markers for surgery immediate\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2161-11-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1041525,"text":", M. NSURG SICU-A 8:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulmonary process\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p craniectomy and chest pain\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n PFI REPORT\n No acute cardiopulmonary abnormalities.\n\n\n"},{"category":"Radiology","chartdate":"2161-11-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1041524,"text":" 8:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulmonary process\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p craniectomy and chest pain\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:50 AM\n No acute cardiopulmonary abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Chest pain, S/P craniectomy.\n\n Cardiomediastinal contours are normal. The lungs are grossly clear aside from\n linear atelectasis in the left base. There is no pleural effusion or\n pneumothorax.\n\n\n DR. \n"},{"category":"Radiology","chartdate":"2161-11-12 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1041641,"text":" 5:00 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual tumor burden. Please have compl\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for residual tumor burden. Please have completed within 36hrs\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 10:27 AM\n Post-operative changes and expected post-operative findings are seen on MRI.\n No residual enhancement. No acute infarct or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient is status post surgery.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired. T1 axial and MP-RAGE sagittal images\n were obtained following gadolinium.\n\n FINDINGS: Since the previous MRI of the patient has undergone\n resection of left frontoparietal extra-axial mass. Small amount of blood\n products are seen in the region. The edema seen in the left frontoparietal\n region has unchanged. Following gadolinium subtle marginal enhancement is\n seen which appears to be due to vascular and meningeal enhancement. No\n definite nodular, extra-axial or intra-axial area of residual enhancement\n identified. There are no acute infarcts seen. There is no midline shift or\n hydrocephalus. A faint area of increased signal within the pons with subtle\n enhancement is consistent with an incidental capillary telangiectasia which is\n unchanged from previous study.\n\n IMPRESSION: Status post resection of left-sided frontoparietal extra-axial\n mass. Small amount of blood products are seen in the region with expected\n post-surgical changes. No definite residual enhancement is seen.\n\n\n"},{"category":"Radiology","chartdate":"2161-11-12 00:00:00.000","description":"MR HEAD W & W/O CONTRAST","row_id":1041642,"text":", M. NSURG SICU-A 5:00 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual tumor burden. Please have compl\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for residual tumor burden. Please have completed within 36hrs\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Post-operative changes and expected post-operative findings are seen on MRI.\n No residual enhancement. No acute infarct or mass effect.\n\n\n"},{"category":"Radiology","chartdate":"2161-11-11 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1041473,"text":", M. NSURG SICU-A 8:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post operative changes\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p left crainotomy\n REASON FOR THIS EXAMINATION:\n post operative changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\n No other short interval change, with residual vasogenic edema involving the\n left parietal lobe.\n\n"},{"category":"Radiology","chartdate":"2161-11-11 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1041472,"text":" 8:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post operative changes\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p left crainotomy\n REASON FOR THIS EXAMINATION:\n post operative changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:10 AM\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\n No other short interval change, with residual vasogenic edema involving the\n left parietal lobe.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male status post left craniotomy, evaluate for\n postoperative changes.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There are post-surgical changes following a left frontal and\n parietal craniotomy, with a small amount of expected pneumocephalus overlying\n the left frontal lobe, as well as a small amount of pneumocephalus and tiny\n foci of hemorrhage seen within the surgical bed. No additional foci of\n hemorrhage are identified. There continues to be a residual vasogenic edema\n predominantly involving the left parietal lobe. Minimal rightward shift of\n midline is unchanged from . There is no evidence for acute\n major vascular territorial infarction. The caliber of the ventricular system\n is unchanged without hydrocephalus. Visualized paranasal sinuses and mastoid\n air cells are normally aerated. Osseous structures reveal a craniotomy defect.\n\n IMPRESSION: Expected postoperative changes, with a small amount of\n pneumocephalus overlying the left frontal lobe, as well as tiny foci of\n pneumocephalus and postoperative hemorrhage within the surgical bed.\n\n\n\n"},{"category":"ECG","chartdate":"2161-11-12 00:00:00.000","description":"Report","row_id":221980,"text":"Sinus rhythm\nEarly precordial QRS transition is nonspecific\nProlonged Q-Tc interval\nModest ST-T wave changes\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/metabolic/electrolyte effect\nSince previous tracing of , QT-c interval appears prolonged but may be\nno significant change\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420806,\n \"text\": \"63yo RHM with 2 month hx of intermittent R hand\\n numbness/tingling, restricted to 4th and fifth digits. Today\\n tingling extended up the medial aspect of the right arm to the R\\n posterolateral aspect of the neck and ear. Therefore Pt went to\\n ED where neuroimaging (MRI/CT) revealed a L\\n parietal lesion. Pt xferred to for further evaluation. S/p left\\n crani on .\\n Note: Foley was d/c\\nd at 0900, pt is dtv at 1700.\\n Problem\\n parietal brain tumor, s/p craniectomy\\n Assessment:\\n Alert and oriented x\\ns 3, pleasant and cooperative. Pupils equal and\\n briskly reactive. Normal strength in all extremities except right arm\\n in which very mild weakness is noted. Pt also c/o of decreased\\n sensation in right hand, sensation intact in all other extremities. Pt\\n c/o of mild headache, treated with po Tylenol with good effect.\\n Action:\\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\\n oob to chair today, advanced to regular diet (tolerating).\\n Response:\\n Neuro status remains stable\\n Plan:\\n MRI today, transfer to floor with q 4 hour neuro checks, continue\\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\\n planning.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 420789,\n \"text\": \"SICU\\n HPI:\\n 63yo RHM with 2 month hx of intermittent R hand\\n numbness/tingling, restricted to 4th and fifth digits. Today\\n tingling extended up the medial aspect of the right arm to the R\\n posterolateral aspect of the neck and ear. Therefore Pt went to\\n ED where neuroimaging (MRI/CT) revealed a L\\n parietal lesion. Pt xferred to for further evaluation.\\n Chief complaint:\\n Left Brain Mas\\n PMHx:\\n Left brain mass\\n Current medications:\\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5. Dexamethasone 6.\\n Docusate Sodium 7. Gentamicin\\n 8. HYDROmorphone (Dilaudid) 9. Heparin 10. HydrALAzine 11. Influenza\\n Virus Vaccine 12. Insulin 13. NiCARdipine\\n 14. Ondansetron 15. Pantoprazole 16. Phenytoin 17. Sodium Chloride 0.9%\\n Flush 18. Vancomycin\\n 24 Hour Events:\\n OR RECEIVED - At 05:00 PM\\n ARTERIAL LINE - START 05:11 PM\\n EKG - At 02:21 AM\\n CHEST PAIN - At 02:21 AM\\n FEVER - 209.1\\nC - 05:41 PM\\n Post operative day:\\n POD#1 - S/P L Crani\\n Allergies:\\n Penicillins\\n Unknown;\\n Last dose of Antibiotics:\\n Gentamicin - 05:57 AM\\n Vancomycin - 08:00 AM\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 02:31 AM\\n Other medications:\\n Flowsheet Data as of 08:16 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 98.4\\nC (209.1\\n T current: 37.2\\nC (98.9\\n HR: 83 (73 - 106) bpm\\n BP: 144/62(87) {111/48(66) - 156/62(87)} mmHg\\n RR: 26 (8 - 26) insp/min\\n SPO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 2,622 mL\\n 1,039 mL\\n PO:\\n 200 mL\\n 100 mL\\n Tube feeding:\\n IV Fluid:\\n 2,422 mL\\n 939 mL\\n Blood products:\\n Total out:\\n 4,070 mL\\n 520 mL\\n Urine:\\n 1,470 mL\\n 520 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -1,448 mL\\n 519 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SPO2: 98%\\n ABG: ///30/\\n Physical Examination\\n General Appearance: No acute distress, Cachectic\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Murmur: Systolic)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: No(t) Present)\\n Right Extremities: (Edema: Absent)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n No(t) Moves all extremities, (RUE: Weakness)\\n Labs / Radiology\\n 316 K/uL\\n 14.9 g/dL\\n 116 mg/dL\\n 1.0 mg/dL\\n 30 mEq/L\\n 4.0 mEq/L\\n 15 mg/dL\\n 102 mEq/L\\n 140 mEq/L\\n 40.4 %\\n 20.7 K/uL\\n [image002.jpg]\\n 02:01 AM\\n WBC\\n 20.7\\n Hct\\n 40.4\\n Plt\\n 316\\n Creatinine\\n 1.0\\n Troponin T\\n <0.01\\n Glucose\\n 116\\n Other labs: PT / PTT / INR:13.2/22.0/1.1, CK / CK-MB / Troponin\\n T:31//<0.01, Albumin:3.7 g/dL, Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.5\\n mg/dL\\n ECG: ECG --> no change from prior; SR with non-specific Q wave\\n inferiorly.\\n Assessment and Plan\\n Assessment and Plan: 63M elective admission for crani who presented\\n earlier in the week for ascending paraesthesia of the RUE.\\n Neurologic: Neuro checks Q: 4 hr, Phenytoin - therapeutic, MRI of the\\n head , check Albumin and Phenytoin\\n Cardiovascular: Post op HTN --> weaned off nicardipine overnight to\\n Keep SBP<140;\\n Pulmonary: Chest PT, OOB; Phys therapy and occupational Therapy.\\n Gastrointestinal / Abdomen:\\n Nutrition: Advance diet as tolerated\\n Renal: Foley, Adequate UO, D/C Foley\\n Hematology: Hct stable\\n Endocrine: RISS\\n Infectious Disease: Periop Vancomycin\\n Lines / Tubes / Drains: Foley\\n Wounds: Dry dressings\\n Imaging: MRI of the head\\n Fluids: NS\\n Consults: Neuro surgery, P.T., O.T.\\n Billing Diagnosis: Post-op hypertension\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n Arterial Line - 05:11 PM\\n 18 Gauge - 05:13 PM\\n 20 Gauge - 08:07 PM\\n Prophylaxis:\\n DVT: Boots\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition: Transfer to floor\\n Total time spent: 31 minutes\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-11 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420740,\n \"text\": \"Above pt with 2month Hx of intermittent R hand numbness/tingling now\\n presents with tingling extending up the medial aspect of the right arm\\n to the right shoulder and neck. Initially evaluated at NWH CT/MRI +\\n for Left parietal mass. Pt referred to to for further\\n evaluation. Pt to OR for Left craniotomy of Left parietal lesion.\\n Assessment: Pt arrived from OR extubated. Neuro intact. A+O X3. No\\n noted Neuro deficits noted. Pt crani incision clean dry and\\n intact. Goal SBP 100-140. Pt arrived with SBP 160\\n Action: Pt given 10mg hydral on arrival X2 with little effect.\\n Nicardipine gtt started. Pt with mild c/o pain given 2mg PO dilaudid.\\n Response: SBP now 125-139 with nicardipine at 3mcgs. Pt with good\\n relief from PO dilaudid.\\n Plan: Q1hr neuro checks. Cont to maintain SBP within paramenter. CT\\n scan tonight MRI within 36hrs post op. Cont with current plan of care.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420828,\n \"text\": \"63yo RHM with 2 month hx of intermittent R hand\\n numbness/tingling, restricted to 4th and fifth digits. Today\\n tingling extended up the medial aspect of the right arm to the R\\n posterolateral aspect of the neck and ear. Therefore Pt went to\\n ED where neuroimaging (MRI/CT) revealed a L\\n parietal lesion. Pt xferred to for further evaluation. S/p left\\n crani on .\\n Note: Foley was d/c\\nd at 0900, pt is dtv at 1700.\\n Problem\\n parietal brain tumor, s/p craniectomy\\n Assessment:\\n Alert and oriented x\\ns 3, pleasant and cooperative. Pupils equal and\\n briskly reactive. Normal strength in all extremities except right arm\\n in which very mild weakness is noted. Pt also c/o of decreased\\n sensation in right hand, sensation intact in all other extremities. Pt\\n c/o of mild headache, treated with po Tylenol with good effect.\\n Action:\\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\\n oob to chair today, advanced to regular diet (tolerating).\\n Response:\\n Neuro status remains stable\\n Plan:\\n MRI today, transfer to floor with q 4 hour neuro checks, continue\\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\\n planning.\\n Demographics\\n Attending MD:\\n M.\\n Admit diagnosis:\\n BRAIN TUMOR/SDA\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 81 kg\\n Daily weight:\\n 81.5 kg\\n Allergies/Reactions:\\n Penicillins\\n Unknown;\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH:\\n Additional history: Hx of central vision loss OS-Dx macular\\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\\n he meant PNA when giving his FHP)\\n Surgery / Procedure and date: Left Crani for excision of mass\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:127\\n D:69\\n Temperature:\\n 99.1\\n Arterial BP:\\n S:127\\n D:56\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 88 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 1 L/min\\n FiO2 set:\\n 24h total in:\\n 1,982 mL\\n 24h total out:\\n 685 mL\\n Pertinent Lab Results:\\n Sodium:\\n 140 mEq/L\\n 02:01 AM\\n Potassium:\\n 4.0 mEq/L\\n 02:01 AM\\n Chloride:\\n 102 mEq/L\\n 02:01 AM\\n CO2:\\n 30 mEq/L\\n 02:01 AM\\n BUN:\\n 15 mg/dL\\n 02:01 AM\\n Creatinine:\\n 1.0 mg/dL\\n 02:01 AM\\n Glucose:\\n 116 mg/dL\\n 02:01 AM\\n Hematocrit:\\n 40.4 %\\n 02:01 AM\\n Finger Stick Glucose:\\n 127\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: sicu a\\n Transferred to: 1114\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420834,\n \"text\": \"63yo RHM with 2 month hx of intermittent R hand\\n numbness/tingling, restricted to 4th and fifth digits. Today\\n tingling extended up the medial aspect of the right arm to the R\\n posterolateral aspect of the neck and ear. Therefore Pt went to\\n ED where neuroimaging (MRI/CT) revealed a L\\n parietal lesion. Pt xferred to for further evaluation. S/p left\\n crani on .\\n Note: Foley was d/c\\nd at 0900, pt is dtv at 1700.\\n Problem\\n parietal brain tumor, s/p craniectomy\\n Assessment:\\n Alert and oriented x\\ns 3, pleasant and cooperative. Pupils equal and\\n briskly reactive. Normal strength in all extremities except right arm\\n in which very mild weakness is noted. Pt also c/o of decreased\\n sensation in right hand, sensation intact in all other extremities. Pt\\n c/o of mild headache, treated with po Tylenol with good effect.\\n Action:\\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\\n oob to chair today, advanced to regular diet (tolerating).\\n Response:\\n Neuro status remains stable\\n Plan:\\n MRI today, transfer to floor with q 4 hour neuro checks, continue\\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\\n planning.\\n Demographics\\n Attending MD:\\n M.\\n Admit diagnosis:\\n BRAIN TUMOR/SDA\\n Code status:\\n Full code\\n Height:\\n Admission weight:\\n 81 kg\\n Daily weight:\\n 81.5 kg\\n Allergies/Reactions:\\n Penicillins\\n Unknown;\\n Precautions: No Additional Precautions\\n PMH:\\n CV-PMH:\\n Additional history: Hx of central vision loss OS-Dx macular\\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\\n he meant PNA when giving his FHP)\\n Surgery / Procedure and date: Left Crani for excision of mass\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:127\\n D:69\\n Temperature:\\n 99.1\\n Arterial BP:\\n S:127\\n D:56\\n Respiratory rate:\\n 23 insp/min\\n Heart Rate:\\n 88 bpm\\n Heart rhythm:\\n SR (Sinus Rhythm)\\n O2 delivery device:\\n None\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 1 L/min\\n FiO2 set:\\n 24h total in:\\n 1,982 mL\\n 24h total out:\\n 685 mL\\n Pertinent Lab Results:\\n Sodium:\\n 140 mEq/L\\n 02:01 AM\\n Potassium:\\n 4.0 mEq/L\\n 02:01 AM\\n Chloride:\\n 102 mEq/L\\n 02:01 AM\\n CO2:\\n 30 mEq/L\\n 02:01 AM\\n BUN:\\n 15 mg/dL\\n 02:01 AM\\n Creatinine:\\n 1.0 mg/dL\\n 02:01 AM\\n Glucose:\\n 116 mg/dL\\n 02:01 AM\\n Hematocrit:\\n 40.4 %\\n 02:01 AM\\n Finger Stick Glucose:\\n 127\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: sicu a\\n Transferred to: 1114\\n Date & time of Transfer: \\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420765,\n \"text\": \"Chest pain\\n Assessment:\\n Pt c/o left lung pain\\n Pt nauseous\\n Denies sob\\n All vital signs stable\\n Action:\\n Dr. notified\\n Ekg done\\n Cardiac enzymes sent\\n Zofran given\\n Protonix given\\n Response:\\n Pt verbalizes relief of pain and nausea\\n Ekg normal\\n Enzymes normal\\n Plan:\\n Continue to monitor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 420767,\n \"text\": \"Chest pain\\n Assessment:\\n Pt c/o left lung pain\\n Pt nauseous\\n Denies sob\\n All vital signs stable\\n Neurologically intact\\n Action:\\n Dr. notified\\n Ekg done\\n Cardiac enzymes sent\\n Zofran given\\n Protonix given\\n Response:\\n Pt verbalizes relief of pain and nausea\\n Ekg normal\\n Enzymes normal\\n Plan:\\n Continue to monitor\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-11 00:00:00.000\",\n \"description\": \"MR HEAD W/ CONTRAST\",\n \"row_id\": 1041347,\n \"text\": \" 5:25 AM\\n MR HEAD W/ CONTRAST Clip # \\n Reason: Wand protocol for placement of markers for surgery immediate\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with brain tumor.\\n REASON FOR THIS EXAMINATION:\\n Wand protocol for placement of markers for surgery immediately after.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 63-year-old male patient with history of a mass.\\n\\n TECHNIQUE: MRI of the brain was performed with IV contrast as per\\n departmental protocol.\\n\\n COMPARISON: CTA of the head with and without contrast, and MRI\\n head (), . The CT demonstrates no\\n calcification within the mass, and no reactive change in the overlying skull.\\n\\n FINDINGS:\\n\\n There is a 2.9 (TRV) x 2.8 (AP) x 2.3 cm (CC), well-defined and lobulated,\\n heterogeneously-enhancing mass that is T2-isointense-to- matter and\\n demonstrates restricted diffusion. The mass also demonstrates a broad-based\\n attachment to the left parietal dura, and causes mild enlargement of the\\n surrounding subarachnoid spaces and buckling of the subjacent matter and\\n is, therefore, likely extra-axial. There is vasogenic edema involving the\\n adjacent subcortical white matter of the occipital, parietal, and posterior\\n frontal lobes including the left precentral gyrus, with mass effect on and\\n effacement of the overlying gyri of the left parietal lobe, but no evidence\\n for midline shift or herniation. Minimal mass effect on the atrium of the left\\n lateral ventricle, but no hydrocephalus. There is diffuse but smooth and thin\\n pachymeningeal enhancement in the supratentorial compartment, but no evidence\\n for leptomeningeal or subependymal enhancement, and no other focus of abnormal\\n enhancement is noted.\\n\\n The visualized portions of the orbits are within normal limits. The paranasal\\n sinuses are clear. The major vascular flow voids are normal.\\n\\n IMPRESSION: Extra-axial enhancing mass, as described above, with stable\\n surrounding edema and thin supratentorial pachymeningeal enhancement. Given\\n the constellation of findings, particularly its signal, diffusion and\\n enhancement characteristics, this mass likely represents a meningioma. Much\\n more remote differential diagnostic considerations also include dural- based\\n metastasis (eg. from prostate cancer, in this patient with known nodule),\\n lymphoma or granulomatous disease (eg. sarcoidosis).\\n (Over)\\n\\n 5:25 AM\\n MR HEAD W/ CONTRAST Clip # \\n Reason: Wand protocol for placement of markers for surgery immediate\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1041525,\n \"text\": \", M. NSURG SICU-A 8:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for cardiopulmonary process\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with s/p craniectomy and chest pain\\n REASON FOR THIS EXAMINATION:\\n eval for cardiopulmonary process\\n ______________________________________________________________________________\\n PFI REPORT\\n No acute cardiopulmonary abnormalities.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1041524,\n \"text\": \" 8:41 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for cardiopulmonary process\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with s/p craniectomy and chest pain\\n REASON FOR THIS EXAMINATION:\\n eval for cardiopulmonary process\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:50 AM\\n No acute cardiopulmonary abnormalities.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: Chest pain, S/P craniectomy.\\n\\n Cardiomediastinal contours are normal. The lungs are grossly clear aside from\\n linear atelectasis in the left base. There is no pleural effusion or\\n pneumothorax.\\n\\n\\n DR. \\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1041641,\n \"text\": \" 5:00 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: please evaluate for residual tumor burden. Please have compl\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for residual tumor burden. Please have completed within 36hrs\\n post-op\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 10:27 AM\\n Post-operative changes and expected post-operative findings are seen on MRI.\\n No residual enhancement. No acute infarct or mass effect.\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRI of the brain.\\n\\n CLINICAL INFORMATION: Patient is status post surgery.\\n\\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\\n axial images of the brain were acquired. T1 axial and MP-RAGE sagittal images\\n were obtained following gadolinium.\\n\\n FINDINGS: Since the previous MRI of the patient has undergone\\n resection of left frontoparietal extra-axial mass. Small amount of blood\\n products are seen in the region. The edema seen in the left frontoparietal\\n region has unchanged. Following gadolinium subtle marginal enhancement is\\n seen which appears to be due to vascular and meningeal enhancement. No\\n definite nodular, extra-axial or intra-axial area of residual enhancement\\n identified. There are no acute infarcts seen. There is no midline shift or\\n hydrocephalus. A faint area of increased signal within the pons with subtle\\n enhancement is consistent with an incidental capillary telangiectasia which is\\n unchanged from previous study.\\n\\n IMPRESSION: Status post resection of left-sided frontoparietal extra-axial\\n mass. Small amount of blood products are seen in the region with expected\\n post-surgical changes. No definite residual enhancement is seen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"MR HEAD W & W/O CONTRAST\",\n \"row_id\": 1041642,\n \"text\": \", M. NSURG SICU-A 5:00 PM\\n MR HEAD W & W/O CONTRAST Clip # \\n Reason: please evaluate for residual tumor burden. Please have compl\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n Contrast: MAGNEVIST Amt: 15\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with\\n REASON FOR THIS EXAMINATION:\\n please evaluate for residual tumor burden. Please have completed within 36hrs\\n post-op\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Post-operative changes and expected post-operative findings are seen on MRI.\\n No residual enhancement. No acute infarct or mass effect.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-11 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1041473,\n \"text\": \", M. NSURG SICU-A 8:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: post operative changes\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with s/p left crainotomy\\n REASON FOR THIS EXAMINATION:\\n post operative changes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\\n No other short interval change, with residual vasogenic edema involving the\\n left parietal lobe.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2161-11-11 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1041472,\n \"text\": \" 8:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: post operative changes\\n Admitting Diagnosis: BRAIN TUMOR/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 63 year old man with s/p left crainotomy\\n REASON FOR THIS EXAMINATION:\\n post operative changes\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:10 AM\\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\\n No other short interval change, with residual vasogenic edema involving the\\n left parietal lobe.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 63-year-old male status post left craniotomy, evaluate for\\n postoperative changes.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\\n contrast.\\n\\n FINDINGS: There are post-surgical changes following a left frontal and\\n parietal craniotomy, with a small amount of expected pneumocephalus overlying\\n the left frontal lobe, as well as a small amount of pneumocephalus and tiny\\n foci of hemorrhage seen within the surgical bed. No additional foci of\\n hemorrhage are identified. There continues to be a residual vasogenic edema\\n predominantly involving the left parietal lobe. Minimal rightward shift of\\n midline is unchanged from . There is no evidence for acute\\n major vascular territorial infarction. The caliber of the ventricular system\\n is unchanged without hydrocephalus. Visualized paranasal sinuses and mastoid\\n air cells are normally aerated. Osseous structures reveal a craniotomy defect.\\n\\n IMPRESSION: Expected postoperative changes, with a small amount of\\n pneumocephalus overlying the left frontal lobe, as well as tiny foci of\\n pneumocephalus and postoperative hemorrhage within the surgical bed.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2161-11-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 221980,\n \"text\": \"Sinus rhythm\\nEarly precordial QRS transition is nonspecific\\nProlonged Q-Tc interval\\nModest ST-T wave changes\\nFindings are nonspecific but clinical correlation is suggested for possible in\\npart drug/metabolic/electrolyte effect\\nSince previous tracing of , QT-c interval appears prolonged but may be\\nno significant change\\n\\n\"\n }\n]"}}},{"rowIdx":192,"cells":{"subject_id":{"kind":"number","value":70561,"string":"70,561"},"hadm_id":{"kind":"number","value":117086,"string":"117,086"},"target_text":{"kind":"string","value":"The patient is a 49 year old male with a history of severe scoliosis, restrictive lung disease, OSA, who presented to an OSH with worsening dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent tacheostomy placement, now transfered for evaluation of posterior wall erosion."},"extractive_notes_summ":{"kind":"string","value":"Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Assessment and Plan RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: Assessment and Plan RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: Will ask IP if we can change to non-adjustable trach as position of trach has moved overnight -speaking without using , keep off for now -decrease lasix to dosingPulmonary hypertension likely due to restrictive lung disease -continue lasix ADDENDUM Trach changed to 110mm, size 7. Will ask IP if we can change to non-adjustable trach as position of trach has moved overnight -speaking without using , keep off for now -decrease lasix to dosingPulmonary hypertension likely due to restrictive lung disease -continue lasix ICU Care Nutrition: regular diet Glycemic Control: RISS Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: heparin SQ Stress ulcer: Protonix VAP: Comments: Communication: Comments: Code status: full Disposition :Transfer to hospital after IP evaluates whether we should change to non-adjustable trach Total time spent: Demographics Day of intubation: Day of mechanical ventilation: 4 Ideal body weight: 0 None Ideal tidal volume: 0 / 0 / 0 mL/kg Airway Airway Placement Data Known difficult intubation: Procedure location: Reason: : Tracheostomy tube: Type: Adjustable Neck Flange Manufacturer: Size: 7.0mm PMV: Yes Cuff Management: Vol/Press: Cuff pressure: 25 cmH2O Cuff volume: mL / Airway problems: Comments: Lung sounds RLL Lung Sounds: Clear RUL Lung Sounds: Rhonchi LUL Lung Sounds: Rhonchi LLL Lung Sounds: Rhonchi Comments: Secretions Sputum color / consistency: Blood Tinged / Thick Sputum source/amount: Suctioned / Moderate Comments: Ventilation Assessment Level of breathing assistance: Intermittent invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Assessment of breathing comfort: No claim of dyspnea) Plan Next 24-48 hours: Reason for continuing current ventilatory support: Underlying illness not resolved Respiratory Care Shift Procedures Comments: Patient had been off the ventilator most of day on a 50% trach collar. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. Reflux: - cont tx scoliosis 3. pain: - minimal, holding narcotic 4. pHTN: - cont lasix for diuresis Remainder of plan per resident note. Reflux: - cont tx scoliosis 3. pain: - minimal, holding narcotic 4. pHTN: - cont lasix for diuresis Remainder of plan per resident note. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Demographics Day of intubation: Day of mechanical ventilation: 2 Ideal body weight: 0 None Ideal tidal volume: 0 / 0 / 0 mL/kg Airway Airway Placement Data Known difficult intubation: Tube Type Tracheostomy tube: Type: Cuffed, Adjustable Neck Flange Manufacturer: Size: 7.0mm PMV: Yes Cuff Management: Vol/Press: Cuff pressure: cmH2O Cuff volume: mL / Airway problems: Positional leak around cuff, adjustable trach advanced to 12 cm just below flange via bronchoscopic evaluation."},"n_notes":{"kind":"number","value":38,"string":"38"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":615795,"text":"Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-03 00:00:00.000","description":"Physician Resident Progress Note","row_id":615616,"text":"TITLE:\n Chief Complaint:\n 24 Hour Events:\n - bronched in morning by IP: supraglottic edema -> started PPI.\n occlusion of airway during expiration by posterior larynx ->\n tracheostomy tube was advanced by 1 cm with better airway patency\n established.\n - put on PS 10/5 while sleeping during day. overnight on vent from 12\n am to 4 am, then on trach collar\n - case mmgnt: should return to OSH vs begin screening for rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 11:13 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 92 (71 - 115) bpm\n BP: 124/88(96) {103/62(71) - 150/123(126)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 720 mL\n PO:\n 720 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 3,820 mL\n 275 mL\n Urine:\n 3,820 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,100 mL\n -275 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 323 (323 - 325) mL\n PS : 10 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///41/\n Ve: 9.7 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:10 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"},{"category":"Respiratory ","chartdate":"2156-12-04 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615755,"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:\n Procedure location:\n Reason:\n :\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\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: 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: 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:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Comments: Patient had been off the ventilator most of day on a 50%\n trach collar. Good vocalization using the passy muir valve. Pt had\n periods of dyspnea relieved with suctioning and neb treatments. Pt and\n wife anxious about handling trach care when home but anxious to get\n started with rehab.\n"},{"category":"Nursing","chartdate":"2156-12-04 00:00:00.000","description":"Nursing Progress Note","row_id":615756,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt alert and sitting on the commode as chair. On trach\n mask.\n Action:\n Suctioned for blood tinged secretion, C/O chest pain around 0200 EKG\n done no changes and he claimed no more chest pain. Received ambien as\n per pt request, Cont PO lasix.\n Response:\n Pt passing 200 cc hr, lung sound less wet sounding\n Plan:\n Continue with lasix tid, nebs and suction as needed, plan to transfere\n back to osh tomorrow\n"},{"category":"Nursing","chartdate":"2156-12-04 00:00:00.000","description":"Nursing Progress Note","row_id":615840,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\n trach site doe have some old blood around trach.\n Action:\n Pt given 40 mg po lasix and albuternal neb x1 this am\n Response:\n Pt states breathing feels better, pt passing 300 cc hr urine\n Plan:\n To transfere to back to osh where he came from,\n Pt had bronch this afternoon, trach changed to #12 boviena, pt received\n 1 mg iv versed and 50 mcgs of iv Fentanyl for procedure, pt states this\n trach more comfortable, also not swelling above trach and bleeding in\n nasal area, pt to be transferred back to osh this afternoon.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615362,"text":"The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615364,"text":"The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\n comfortably in a chair. When in bed pt must lie flat and needs to be on\n full vent status. Lung sounds clear and rhonchorus but will clear once\n suctioned. O2 sat\ns in high 90\n Action:\n Once examined and assessed by resident pt got oob to chair with minimal\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\n mod amt\ns of thick bloody secretions,\n Response:\n Pt tolerated sitting in chair and maintained good o2 sat\ns on 40% trach\n collar. Pt able to eat some ice cream and drank some gingerale without\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\n and then got back to bed and placed on vent with originale settings. Pt\n slept for about 4hrs and when awoke c/o back pain again.\n Plan:\n plan for pt is to schedule him for a permanent trach.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615486,"text":"hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP service consulted, to do FOB to assess trache and exclude\n posterior membrane erosion\n - npo for proc\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615358,"text":"The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n"},{"category":"Respiratory ","chartdate":"2156-12-02 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615361,"text":"Airway\n Tube Type\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Airway problems: Positional leak around cuff\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\n ventilatory support in supine position, due to severe scoliosis.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615357,"text":"The patinet is a deaf 58 year old gentleman with a history of likely\n hypertensive dialated cardiomyopathy (EF 50%,) poorly controlled blood\n pressure, DM2, OSA, deaf and mute who presented to the ED with\n complains of sudden onset SOB. The patient has had prior\n hospitalizations for acute pulmonary edema in the setting of\n hypertensive urgency. He was seen by his PCP one day prior to\n presentation with complaints of 3 days of conjunctivitis and rhinorhea\n with a slight, non-productive cough, which was felt to be a viral\n syndrome, but he was prescribed erythromycin ointment.\n .\n On the day of presentation, the patient was waking and became markedly\n short of breath. EMS was activated, and the patient was placed on a\n NRB. On arrival to the ED, he was markedly hypertensive 242/110/ HR\n 106, and afebrile. The patient was placed on BIPAP, was started on a\n nitro gtt, given ASA 325mg, and was 100mg IV lasix, to which he put out\n 400cc of urine. Cardiology was consulted in the ED, but felt that\n given recent URI symptoms, a MICU admission would be more appropriate.\n The patient was admitted to the MICU for further management.\n .\n The patient denies any fevers/chills, abdominal pain, diahrea, or\n dysuria. He has not had any worsening LE swelling, orthopnea, or PND.\n He reports to be compliant with home medication regimen. He complaints\n of b/l chest pain currently, similar to prior chest pain. Worse with\n palpation and deep inspiration.\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Attending Progress Note","row_id":615827,"text":"Chief Complaint: Trach occlusion\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above.\n HPI: 49 yo man with severe scoliosis. Initially admitted to \n hospital with increasing dyspnea, with hypercarbic respiratory\n failure requiring semi-urgent tracheostomy. Transferred to for\n trach occlusion, now sp advancement of trach 1cm.\n 24 Hour Events:\n -no further issues with occlusion of tracheostomy\n - currently, on AC overnight and TCM with intermittent\n use of during the day\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lasix 40 IV TID\n Protonix\n ASA\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.8\n HR: 98 (79 - 103) bpm\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\n RR: 18 (16 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 930 mL\n PO:\n 790 mL\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Thin. Severe scoliosis.\n Peripheral 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: inspiratory and expiratory wheezing\n Extremities: 2+ symmetrical LE edema\n Skin: Not assessed\n Neurologic: alert and oriented x3\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: CXR:\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n -still has adjustable , doing well during the day and requires\n ventilator at night. Will ask IP if we can change to non-adjustable\n trach as position of trach has moved overnight\n -speaking without using , keep off for now\n -decrease lasix to dosing\nPulmonary hypertension likely due to restrictive lung disease\n -continue lasix\n ADDENDUM\n Trach changed to 110mm, size 7. Tip approximately 1cm above the\n carina. Uncomplicated. Severe subglottic edema noted. Pt indicated that\n he felt much more comfortable with the new trach in place. Doing well\n on trach collar for > 1 hour.\n ICU Care\n Nutrition: regular diet\n Glycemic Control: RISS\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: Protonix\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition :Transfer to hospital. F/U as outpatient with\n Interventional Pulmonary service, Dr .\n Total time spent:\n"},{"category":"Nursing","chartdate":"2156-12-03 00:00:00.000","description":"Nursing Progress Note","row_id":615690,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\n to clear secreations, lungs course\n Action:\n Pt given lasix this am and then lasix increased to tid\n Response:\n Pt passing 200 cc hr, lung sound less wet sounding\n Plan:\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\n tomorrow\n"},{"category":"Nursing","chartdate":"2156-12-03 00:00:00.000","description":"Nursing Progress Note","row_id":615680,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\n to clear secreations, lungs course\n Action:\n Pt given lasix this am and then lasix increased to tid\n Response:\n Pt passing 200 cc hr, lung sound less wet\n Plan:\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\n tomorrow\n"},{"category":"Nursing","chartdate":"2156-12-04 00:00:00.000","description":"Nursing Progress Note","row_id":615804,"text":"Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\n trach site doe have some old blood around trach.\n Action:\n Pt given 40 mg po lasix and albuternal neb x1 this am\n Response:\n Pt states breathing feels better, pt passing 300 cc hr urine\n Plan:\n To transfere to back to osh where he came from,\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Attending Progress Note","row_id":615808,"text":"Chief Complaint: 49 yo man with severe scoliosis. Initially admitted to\n hospital with increasing dyspnea, with hypercarbic\n respiratory failure requiring semi-urgent tracheostomy. Transferred to\n for trach occlusion, now sp advancement of trach 1cm.\n HPI:\n 24 Hour Events:\n -no further issues with occlusion of tracheostomy\n - currently, on AC overnight and TCM with intermittent\n use of during the day\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lasix 40 IV TID\n Protonix\n ASA\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.8\n HR: 98 (79 - 103) bpm\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\n RR: 18 (16 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 930 mL\n PO:\n 790 mL\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Thin. Severe scoliosis.\n Peripheral 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: inspiratory and expiratory wheezing\n Extremities: 2+ symmetrical LE edema\n Skin: Not assessed\n Neurologic: alert and oriented x3\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: CXR:\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n -still has adjustable , doing well during the day and requires\n ventilator at night. Will ask IP if we can change to non-adjustable\n trach as position of trach has moved overnight\n -speaking without using , keep off for now\n -decrease lasix to dosing\nPulmonary hypertension likely due to restrictive lung disease\n -continue lasix\n ICU Care\n Nutrition: regular diet\n Glycemic Control: RISS\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: Protonix\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition :Transfer to hospital after IP evaluates whether we\n should change to non-adjustable trach\n Total time spent:\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":615809,"text":"Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion, trach repositioned b IP.\n - continue vent settings over night, w/ valve during the day. Although\n pt can talk around valve, which may portend need for trach replacement.\n - discourange ambient use\n - will d/w IP switch to non-flexible valve\n - cont guafenisin and duoneb\n - reduce lasix to \n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":615794,"text":"Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-04 00:00:00.000","description":"Physician Resident Progress Note","row_id":615796,"text":"Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-02 00:00:00.000","description":"Physician Attending Progress Note","row_id":615423,"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 seen by interventional pulmonary\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa 81\n lasix 40 qday\n heparin 5000 tid\n albuterol\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 09:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 99 (76 - 112) bpm\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\n RR: 21 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 200 mL\n PO:\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 175 mL\n 795 mL\n Urine:\n 175 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n -175 mL\n -595 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 0 cmH2O\n SpO2: 95%\n ABG: ///45/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: Well nourished, scoliosis\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 11.9 g/dL\n 277 K/uL\n 119 mg/dL\n 0.4 mg/dL\n 45 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 91 mEq/L\n 141 mEq/L\n 38.0 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n WBC\n 5.4\n Hct\n 38.0\n Plt\n 277\n Cr\n 0.4\n Glucose\n 119\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n 1./ hypercarbic respiratory failure:\n - IP service following\n - likely bronch this morning, with potential replacement of trach\n - will cont to follow\n - cont albuterol nebs as needed\n - npo for now\n 2. Reflux: cont scoliosis\n 3. pain: minimal, holding narcotic\n 4. pHTN: cont lasix for diuresis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615390,"text":"The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\n comfortably in a chair. When in bed pt must lie flat and needs to be on\n full vent status. Lung sounds clear and rhonchorus but will clear once\n suctioned. O2 sat\ns in high 90\ns. will desat to low 90\ns when need to\n be sx\nd, afebrile. Foley cath with good urine output,\n Action:\n Once examined and assessed by resident pt got oob to chair with minimal\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\n mod amt\ns of thick bloody secretions,\n Response:\n Pt tolerated sitting in chair and maintained good o2 sat\ns on 40% trach\n collar. Pt able to eat some ice cream and drank some gingerale without\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\n and then got back to bed and placed on vent with originale settings. Pt\n slept for about 4hrs and when awoke c/o back pain again. Resident d/d\n oxycodone and ordered Tylenol. Pt received 650mg this am.\n Plan:\n plan for pt is to schedule him for a permanent trach. pt is currently\n npo.\n"},{"category":"Respiratory ","chartdate":"2156-12-02 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615396,"text":"Airway\n Tube Type\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Airway problems: Positional leak around cuff\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\n ventilatory support in supine position, due to severe scoliosis.\n"},{"category":"Respiratory ","chartdate":"2156-12-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615577,"text":"Demographics\n Day of mechanical ventilation: 3\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: when off vent.\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Increase ventilatory support at night\n"},{"category":"Physician ","chartdate":"2156-12-01 00:00:00.000","description":"Physician Resident Admission Note","row_id":615315,"text":"Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. On\n presentation to the ED, the he was found to be hypoxemic (80s) and\n hypercapnic (ABG 7.29 / 89 / 83 / 42,) with episodes of bradycardia\n with 3-4 sec pauses, and was admitted to the ICU. He was started on\n BIPAP at night, with intermitent use during the day due to his severe\n hypercapnic respiratory failure, but did not have good tolerance of\n non-invasive ventilation. His respiratory status continud to worsen,\n and the patient was found somnolent and difficult to arouse at night.\n PCO2 was found during to be 130. Due to his severe scoliosis, and\n failed nasal intubation, and ENT was consulted for a semi-emergent\n tracheostomy. A #6 LTC cuffed Shiley trach was placed, but started on\n Passy-Muir valve during the day time. On , the patient occluded\n the tracheostomy with severe hypoxia, requiring CPR, but resolved with\n trach manipulation to restablish the airway. A similar episode occured\n on , and a #7 Bavrona hyperflexible tracheostomy was placed. He\n has remained on mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - IP vs. ENT c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-01 00:00:00.000","description":"Physician Resident Admission Note","row_id":615316,"text":"Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. Of note, he\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\n to the ICU. He was started on BIPAP at night, with intermitent use\n during the day due to his severe hypercapnic respiratory failure, but\n did not have good tolerance of non-invasive ventilation. His\n respiratory status continud to worsen, and the patient was found\n somnolent and difficult to arouse at night. PCO2 was found during to\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\n Shiley trach was placed, but started on Passy-Muir valve during the day\n time. On , the patient occluded the tracheostomy with severe\n hypoxia, requiring CPR, but resolved with trach manipulation to\n restablish the airway. A similar episode occured on , and a #7\n Bavrona hyperflexible tracheostomy was placed. He has remained on\n mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL CODE\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"},{"category":"Physician ","chartdate":"2156-12-02 00:00:00.000","description":"Physician Resident Admission Note","row_id":615319,"text":"Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. Of note, he\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\n to the ICU. He was started on BIPAP at night, with intermitent use\n during the day due to his severe hypercapnic respiratory failure, but\n did not have good tolerance of non-invasive ventilation. His\n respiratory status continud to worsen, and the patient was found\n somnolent and difficult to arouse at night. PCO2 was found during to\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\n Shiley trach was placed, but started on Passy-Muir valve during the day\n time. On , the patient occluded the tracheostomy with severe\n hypoxia, requiring CPR, but resolved with trach manipulation to\n restablish the airway. A similar episode occured on , and a #7\n Bavrona hyperflexible tracheostomy was placed. He has remained on\n mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL CODE\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU Overnight Attending Coverage\n I saw and examined the patient with Dr. . The assessment and plan\n was discussed in detail.\n I would emphasize the following. 49 y.o. man with severe scoliosis,\n OSA, and 30 pound weight gain over past approximately two years with\n progressive dyspnea, hypercapneic and hypoxic respiratory failure\n requiring urgent tracheostomy at the outside hospital. Trach changes\n as noted above, using vent at night, off most of the day, minimal\n suctioning required except when trach first placed. Now concern for\n posterior tracheal erosion. No hemoptysis, minimizing suctioning.\n Appears comfortable on trach collar sitting straight up in chair.\n Severe scoliosis poor air movement on right, occ. crackle on left, no\n wheeze\n RRR, no murmurs\n + bipedal edema Erythema on right forearm, no cord/fluctulence\n Alert and oriented x 3 Ventral and umbilical hernia\n Hypercapneic/hypoxic respiratory failure secondary to restrictive lung\n disease in setting of severe scoliosis and OSA exacerbated in setting\n of significant weight gain. require customized trach, IP to\n evaluate in the morning. NPO after midnight. Minimize suctioning.\n Plan as noted above.\n Patient is critically ill given tenuous respiratory status\n Full code\n Time spent 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 00:32 ------\n"},{"category":"Nursing","chartdate":"2156-12-03 00:00:00.000","description":"Nursing Progress Note","row_id":615568,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Stable overnight, no issues\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"},{"category":"Nursing","chartdate":"2156-12-03 00:00:00.000","description":"Nursing Progress Note","row_id":615570,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Stable overnight, no issues\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"},{"category":"Nutrition","chartdate":"2156-12-03 00:00:00.000","description":"Clinical Nutrition Note","row_id":615664,"text":"Ht: unavailable to assess due to severe scolosis\n Wt: 89 kg\n Diet: Soft, thin liquids\n Labs: noted\n Abdomen: soft/distended, positive bowel sounds\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n 49 year old male with a history of severe scoliosis, restrictive lung\n disease, obstructive sleep apnea, who presented to an outside hosptial\n with worsening dyspnea, who developed hypercapnic respiratory failure\n w/ semi-emergent tacheostomy placement, now transfered for evaluation\n of posterior wall erosion. Now status post tracheostomy placement with\n revision due to hypoxemia with trach blockage.\n Tolerating soft diet, good appetite. Eats soft diet at home. Thinks\n his current weight is\nhigh\n, but stable recently. Per chart, patient\n with 30 lb weight gain x 2 years.\n Noted plan for transfer to .\n Will follow to check po\ns if remains in house, page if questions *\n PM\n"},{"category":"Physician ","chartdate":"2156-12-03 00:00:00.000","description":"Physician Attending Progress Note","row_id":615648,"text":"TITLE:\n Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -IP performed FOB, evaluation of trache\n -Ventilated overnight\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 Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 07:50 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.3\nC (99.1\n HR: 92 (71 - 115) bpm\n BP: 128/80(87) {103/62(71) - 150/123(126)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 720 mL\n 100 mL\n PO:\n 720 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 3,820 mL\n 1,075 mL\n Urine:\n 3,820 mL\n 1,075 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,100 mL\n -975 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 323 (323 - 325) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: ///41/\n Ve: 9.7 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache 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: No(t) Symmetric), (Breath Sounds:\n Diminished: ), severe kyphoscoliosis\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 1. hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP performed FOB/airway evaluation\n -no posterior membrane erosion\n -trache adjusted\n - nocturnal ventilation ongoing\n 2. Reflux:\n - cont tx scoliosis\n 3. pain:\n - minimal, holding narcotic\n 4. pHTN:\n - cont lasix for diuresis\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :Transfer to other facility\n Total time spent:\n"},{"category":"Respiratory ","chartdate":"2156-12-03 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615711,"text":"Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Airway\n Airway Placement Data\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt on and off Trach Collar .50 today using PMV occasionally\n for short periods of time.\n"},{"category":"Case Management ","chartdate":"2156-12-03 00:00:00.000","description":"Case Management Continued Stay Review","row_id":615657,"text":"Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer:\n Hospital days authorized to:\n Current Discharge Plan: Hospital, NH\n Narrative / Plan (Multidisciplinary team):\n Case discussed w/ team. Pt with new trach/vented on CPAP at times,\n would need hospital level rehab not . Pt with NH medicaid only. No\n LTACs in NH. No NH medicaid contracts at LTACs in MA. Plan is for pt to\n return to Hospital. MICU team has made contact with \n Physician to start arranging for transfer back.\n"},{"category":"Nursing","chartdate":"2156-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":615494,"text":"49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Pt tolerated procedure well. No erosion noted of trache, some\n irritation though. PPI started for this. sitting in chair and\n maintained good o2 sat\ns on 40% trach collar. To fully supported on\n vent. Diet advanced back to his soft solids, tolerated well.\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"},{"category":"Physician ","chartdate":"2156-12-02 00:00:00.000","description":"Physician Attending Progress Note","row_id":615453,"text":"Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n - seen by interventional pulmonary\n Allergies:\n No Known Drug Allergies\n Other medications:\n asa 81\n lasix 40 qday\n heparin 5000 tid\n albuterol\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 09:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 99 (76 - 112) bpm\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\n RR: 21 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 200 mL\n PO:\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 175 mL\n 795 mL\n Urine:\n 175 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n -175 mL\n -595 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 0 cmH2O\n SpO2: 95%\n ABG: ///45/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: Well nourished, scoliosis\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: poor air mvmt on right\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive\n Labs / Radiology\n 11.9 g/dL\n 277 K/uL\n 119 mg/dL\n 0.4 mg/dL\n 45 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 91 mEq/L\n 141 mEq/L\n 38.0 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n WBC\n 5.4\n Hct\n 38.0\n Plt\n 277\n Cr\n 0.4\n Glucose\n 119\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n 1. hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP service consulted, to do FOB to assess trache and exclude\n posterior membrane erosion\n - npo for proc\n 2. Reflux:\n - cont tx scoliosis\n 3. pain:\n - minimal, holding narcotic\n 4. pHTN:\n - cont lasix for diuresis\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition :ICU\n Total time spent:\n"},{"category":"Respiratory ","chartdate":"2156-12-02 00:00:00.000","description":"Respiratory Care Shift Note","row_id":615454,"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 Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems: Positional leak around cuff,\n adjustable trach advanced to 12 cm just below flange via bronchoscopic\n evaluation.\n Comments: deflated while off ventilator\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments: expriratory wheezes T/O clear after albuterol adm via\n nebulizer.\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Expectorated / None\n Ventilation Assessment\n Level of breathing assistance: Off ventilator during the day\n Visual assessment of breathing pattern: occasional dyspnea with\n increased congestion and expiratory wheezes, relieved with coughing and\n nebulized albuterol.\n Plan\n Next 24-48 hours: Increase ventilatory support at night; Comments:\n placed on ventilator at night for management of CO2\n Reason for continuing current ventilatory support:\n Bedside Procedures:\n Bronchoscopy (12:00)\n Comments:\n"},{"category":"ECG","chartdate":"2156-12-04 00:00:00.000","description":"Report","row_id":230766,"text":"Sinus rhythm. Consider right atrial abnormality. Right axis deviation.\nProminent lateral lead Q waves. Findings raise consideration of possible\nright ventricular overload. Possible prior lateral myocardial infarction\nof left posterior fascicular block. Clinical correlation is suggested.\nNo previous tracing available for comparison.\n\n"},{"category":"Radiology","chartdate":"2156-12-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1116684,"text":" 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with trach c/o dyspnea.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:39 A.M. \n\n HISTORY: Tracheostomy. Complains of dyspnea.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes have decreased and opacification particularly in the right lung\n has increased since . Given the marked anatomic distortion of the\n chest precise diagnosis is difficult, but since there is vascular engorgement\n in the left lung I suspect cardiac decompensation is playing a role. There is\n also the suggestion of retained secretions in the bronchial tree, particularly\n the right. Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No pneumothorax is\n present.\n\n\n"},{"category":"Radiology","chartdate":"2156-12-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1116480,"text":" 11:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate lung fields\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with severe scoliosis s/p trach\n REASON FOR THIS EXAMINATION:\n pls evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate tracheostomy.\n\n The interpretation of this radiograph is very limited due to the severe\n scoliosis and deformity of the thoracic cage. Tracheostomy tube tip is 5.5 cm\n above the carina. Cardiomediastinal contours cannot be evaluated. There is\n no evident pneumothorax. If any, there is a small right pleural effusion.\n The main central pulmonary arteries appear to be enlarged. There are no prior\n studies available for comparison. The asymmetric increased density in the\n right hemithorax could be due to pleural effusion or lung opacities in the\n right lower lobe, I suspect that also is due to the deformity of the thoracic\n cage. If prior studies were available , comparison could be performed to\n assess new abnormality.\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615795,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - attempted transfer back to ; no beds available so will call in\\n AM, they will take him back there\\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\\n - c/o in chest pain in the middle of the night, checked ECG, no acute\\n changes. CP resolved on its own\\n - did not use the vent overnight; only trach collar\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.8\\nC (98.2\\n HR: 100 (79 - 103) bpm\\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\\n RR: 26 (16 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 450 mL\\n PO:\\n 790 mL\\n 450 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -880 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: Lung volumes have decreased and opacification particularly in\\n the right lung has increased since . Given the marked\\n anatomic distortion of the chest precise diagnosis is difficult, but\\n since there is vascular engorgement in the left lung I suspect cardiac\\n decompensation is playing a role. There is also the suggestion of\\n retained secretions in the bronchial tree, particularly the right.\\n Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No\\n pneumothorax is\\n present.\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615616,\n \"text\": \"TITLE:\\n Chief Complaint:\\n 24 Hour Events:\\n - bronched in morning by IP: supraglottic edema -> started PPI.\\n occlusion of airway during expiration by posterior larynx ->\\n tracheostomy tube was advanced by 1 cm with better airway patency\\n established.\\n - put on PS 10/5 while sleeping during day. overnight on vent from 12\\n am to 4 am, then on trach collar\\n - case mmgnt: should return to OSH vs begin screening for rehab\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Pantoprazole (Protonix) - 08:18 PM\\n Heparin Sodium (Prophylaxis) - 11:13 PM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:48 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.3\\n Tcurrent: 37.2\\nC (98.9\\n HR: 92 (71 - 115) bpm\\n BP: 124/88(96) {103/62(71) - 150/123(126)} mmHg\\n RR: 22 (17 - 29) insp/min\\n SpO2: 99%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 720 mL\\n PO:\\n 720 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 3,820 mL\\n 275 mL\\n Urine:\\n 3,820 mL\\n 275 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,100 mL\\n -275 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 323 (323 - 325) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 16 cmH2O\\n SpO2: 99%\\n ABG: ///41/\\n Ve: 9.7 L/min\\n Physical Examination\\n Trached, on trach mask, sitting in a chair\\n Severe scoliosis, slgith erosis on neck from trach\\n Abnormal resioatory movements\\n Distant heart sounds, tachycardic, no m/r/g\\n Abdominal ventral, soft, ntnd\\n 1+ LE b/l\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Assessment and Plan\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both\\n restrictive lung process due to severe scoliosis with additonal OSA.\\n Now status post tracheostomy placement with revision due to hypoxemia\\n with trach blockage. Patient has been using trach valve during the day\\n and CMV at night. Transfered for evaluation of posterior trach\\n erosion.\\n - continue vent settings as per \\n - discourange ambient use\\n - IP c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n - encourage weight loss and ? pulm rehab on discharge.\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 06:10 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\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615755,\n \"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:\\n Procedure location:\\n Reason:\\n :\\n Tracheostomy tube:\\n Type: Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n PMV: Yes\\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: 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: 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:\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Comments: Patient had been off the ventilator most of day on a 50%\\n trach collar. Good vocalization using the passy muir valve. Pt had\\n periods of dyspnea relieved with suctioning and neb treatments. Pt and\\n wife anxious about handling trach care when home but anxious to get\\n started with rehab.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615756,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Received the pt alert and sitting on the commode as chair. On trach\\n mask.\\n Action:\\n Suctioned for blood tinged secretion, C/O chest pain around 0200 EKG\\n done no changes and he claimed no more chest pain. Received ambien as\\n per pt request, Cont PO lasix.\\n Response:\\n Pt passing 200 cc hr, lung sound less wet sounding\\n Plan:\\n Continue with lasix tid, nebs and suction as needed, plan to transfere\\n back to osh tomorrow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615840,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\\n trach site doe have some old blood around trach.\\n Action:\\n Pt given 40 mg po lasix and albuternal neb x1 this am\\n Response:\\n Pt states breathing feels better, pt passing 300 cc hr urine\\n Plan:\\n To transfere to back to osh where he came from,\\n Pt had bronch this afternoon, trach changed to #12 boviena, pt received\\n 1 mg iv versed and 50 mcgs of iv Fentanyl for procedure, pt states this\\n trach more comfortable, also not swelling above trach and bleeding in\\n nasal area, pt to be transferred back to osh this afternoon.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615362,\n \"text\": \"The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615364,\n \"text\": \"The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\\n comfortably in a chair. When in bed pt must lie flat and needs to be on\\n full vent status. Lung sounds clear and rhonchorus but will clear once\\n suctioned. O2 sat\\ns in high 90\\n Action:\\n Once examined and assessed by resident pt got oob to chair with minimal\\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\\n mod amt\\ns of thick bloody secretions,\\n Response:\\n Pt tolerated sitting in chair and maintained good o2 sat\\ns on 40% trach\\n collar. Pt able to eat some ice cream and drank some gingerale without\\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\\n and then got back to bed and placed on vent with originale settings. Pt\\n slept for about 4hrs and when awoke c/o back pain again.\\n Plan:\\n plan for pt is to schedule him for a permanent trach.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615486,\n \"text\": \"hypercarbic respiratory failure:\\n - restrictive lung disease in setting of severe scoliosis and OSA\\n - likely exacerbated with recent significant weight gain\\n - IP service consulted, to do FOB to assess trache and exclude\\n posterior membrane erosion\\n - npo for proc\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615358,\n \"text\": \"The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615361,\n \"text\": \"Airway\\n Tube Type\\n Tracheostomy tube:\\n Type: Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Airway problems: Positional leak around cuff\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\\n ventilatory support in supine position, due to severe scoliosis.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615357,\n \"text\": \"The patinet is a deaf 58 year old gentleman with a history of likely\\n hypertensive dialated cardiomyopathy (EF 50%,) poorly controlled blood\\n pressure, DM2, OSA, deaf and mute who presented to the ED with\\n complains of sudden onset SOB. The patient has had prior\\n hospitalizations for acute pulmonary edema in the setting of\\n hypertensive urgency. He was seen by his PCP one day prior to\\n presentation with complaints of 3 days of conjunctivitis and rhinorhea\\n with a slight, non-productive cough, which was felt to be a viral\\n syndrome, but he was prescribed erythromycin ointment.\\n .\\n On the day of presentation, the patient was waking and became markedly\\n short of breath. EMS was activated, and the patient was placed on a\\n NRB. On arrival to the ED, he was markedly hypertensive 242/110/ HR\\n 106, and afebrile. The patient was placed on BIPAP, was started on a\\n nitro gtt, given ASA 325mg, and was 100mg IV lasix, to which he put out\\n 400cc of urine. Cardiology was consulted in the ED, but felt that\\n given recent URI symptoms, a MICU admission would be more appropriate.\\n The patient was admitted to the MICU for further management.\\n .\\n The patient denies any fevers/chills, abdominal pain, diahrea, or\\n dysuria. He has not had any worsening LE swelling, orthopnea, or PND.\\n He reports to be compliant with home medication regimen. He complaints\\n of b/l chest pain currently, similar to prior chest pain. Worse with\\n palpation and deep inspiration.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615827,\n \"text\": \"Chief Complaint: Trach occlusion\\n I saw and examined the patient, and was physically present with the ICU\\n resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan. PMH, SH, FH and ROS are\\n unchanged from admission except where noted above.\\n HPI: 49 yo man with severe scoliosis. Initially admitted to \\n hospital with increasing dyspnea, with hypercarbic respiratory\\n failure requiring semi-urgent tracheostomy. Transferred to for\\n trach occlusion, now sp advancement of trach 1cm.\\n 24 Hour Events:\\n -no further issues with occlusion of tracheostomy\\n - currently, on AC overnight and TCM with intermittent\\n use of during the day\\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Lasix 40 IV TID\\n Protonix\\n ASA\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.6\\nC (97.8\\n HR: 98 (79 - 103) bpm\\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\\n RR: 18 (16 - 27) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 930 mL\\n PO:\\n 790 mL\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -400 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 97%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n General Appearance: Thin. Severe scoliosis.\\n Peripheral 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: inspiratory and expiratory wheezing\\n Extremities: 2+ symmetrical LE edema\\n Skin: Not assessed\\n Neurologic: alert and oriented x3\\n Labs / Radiology\\n 12.1 g/dL\\n 308 K/uL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: CXR:\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n -still has adjustable , doing well during the day and requires\\n ventilator at night. Will ask IP if we can change to non-adjustable\\n trach as position of trach has moved overnight\\n -speaking without using , keep off for now\\n -decrease lasix to dosing\\nPulmonary hypertension likely due to restrictive lung disease\\n -continue lasix\\n ADDENDUM\\n Trach changed to 110mm, size 7. Tip approximately 1cm above the\\n carina. Uncomplicated. Severe subglottic edema noted. Pt indicated that\\n he felt much more comfortable with the new trach in place. Doing well\\n on trach collar for > 1 hour.\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control: RISS\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: heparin SQ\\n Stress ulcer: Protonix\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: full\\n Disposition :Transfer to hospital. F/U as outpatient with\\n Interventional Pulmonary service, Dr .\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615690,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\\n to clear secreations, lungs course\\n Action:\\n Pt given lasix this am and then lasix increased to tid\\n Response:\\n Pt passing 200 cc hr, lung sound less wet sounding\\n Plan:\\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\\n tomorrow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615680,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\\n to clear secreations, lungs course\\n Action:\\n Pt given lasix this am and then lasix increased to tid\\n Response:\\n Pt passing 200 cc hr, lung sound less wet\\n Plan:\\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\\n tomorrow\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615804,\n \"text\": \"Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\\n trach site doe have some old blood around trach.\\n Action:\\n Pt given 40 mg po lasix and albuternal neb x1 this am\\n Response:\\n Pt states breathing feels better, pt passing 300 cc hr urine\\n Plan:\\n To transfere to back to osh where he came from,\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615808,\n \"text\": \"Chief Complaint: 49 yo man with severe scoliosis. Initially admitted to\\n hospital with increasing dyspnea, with hypercarbic\\n respiratory failure requiring semi-urgent tracheostomy. Transferred to\\n for trach occlusion, now sp advancement of trach 1cm.\\n HPI:\\n 24 Hour Events:\\n -no further issues with occlusion of tracheostomy\\n - currently, on AC overnight and TCM with intermittent\\n use of during the day\\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n Lasix 40 IV TID\\n Protonix\\n ASA\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 10:11 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.6\\nC (97.8\\n HR: 98 (79 - 103) bpm\\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\\n RR: 18 (16 - 27) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 930 mL\\n PO:\\n 790 mL\\n 930 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -400 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 97%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n General Appearance: Thin. Severe scoliosis.\\n Peripheral 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: inspiratory and expiratory wheezing\\n Extremities: 2+ symmetrical LE edema\\n Skin: Not assessed\\n Neurologic: alert and oriented x3\\n Labs / Radiology\\n 12.1 g/dL\\n 308 K/uL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: CXR:\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n -still has adjustable , doing well during the day and requires\\n ventilator at night. Will ask IP if we can change to non-adjustable\\n trach as position of trach has moved overnight\\n -speaking without using , keep off for now\\n -decrease lasix to dosing\\nPulmonary hypertension likely due to restrictive lung disease\\n -continue lasix\\n ICU Care\\n Nutrition: regular diet\\n Glycemic Control: RISS\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: heparin SQ\\n Stress ulcer: Protonix\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: full\\n Disposition :Transfer to hospital after IP evaluates whether we\\n should change to non-adjustable trach\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615809,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - attempted transfer back to ; no beds available so will call in\\n AM, they will take him back there\\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\\n - c/o in chest pain in the middle of the night, checked ECG, no acute\\n changes. CP resolved on its own\\n - did not use the vent overnight; only trach collar\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.8\\nC (98.2\\n HR: 100 (79 - 103) bpm\\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\\n RR: 26 (16 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 450 mL\\n PO:\\n 790 mL\\n 450 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -880 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: Lung volumes have decreased and opacification particularly in\\n the right lung has increased since . Given the marked\\n anatomic distortion of the chest precise diagnosis is difficult, but\\n since there is vascular engorgement in the left lung I suspect cardiac\\n decompensation is playing a role. There is also the suggestion of\\n retained secretions in the bronchial tree, particularly the right.\\n Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No\\n pneumothorax is\\n present.\\n Assessment and Plan\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both\\n restrictive lung process due to severe scoliosis with additonal OSA.\\n Now status post tracheostomy placement with revision due to hypoxemia\\n with trach blockage. Patient has been using trach valve during the day\\n and CMV at night. Transfered for evaluation of posterior trach\\n erosion, trach repositioned b IP.\\n - continue vent settings over night, w/ valve during the day. Although\\n pt can talk around valve, which may portend need for trach replacement.\\n - discourange ambient use\\n - will d/w IP switch to non-flexible valve\\n - cont guafenisin and duoneb\\n - reduce lasix to \\n - encourage weight loss and ? pulm rehab on discharge.\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615794,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - attempted transfer back to ; no beds available so will call in\\n AM, they will take him back there\\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\\n - c/o in chest pain in the middle of the night, checked ECG, no acute\\n changes. CP resolved on its own\\n - did not use the vent overnight; only trach collar\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.8\\nC (98.2\\n HR: 100 (79 - 103) bpm\\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\\n RR: 26 (16 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 450 mL\\n PO:\\n 790 mL\\n 450 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -880 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: Lung volumes have decreased and opacification particularly in\\n the right lung has increased since . Given the marked\\n anatomic distortion of the chest precise diagnosis is difficult, but\\n since there is vascular engorgement in the left lung I suspect cardiac\\n decompensation is playing a role. There is also the suggestion of\\n retained secretions in the bronchial tree, particularly the right.\\n Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No\\n pneumothorax is\\n present.\\n Assessment and Plan\\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 615796,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n - attempted transfer back to ; no beds available so will call in\\n AM, they will take him back there\\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\\n - c/o in chest pain in the middle of the night, checked ECG, no acute\\n changes. CP resolved on its own\\n - did not use the vent overnight; only trach collar\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.1\\nC (98.7\\n Tcurrent: 36.8\\nC (98.2\\n HR: 100 (79 - 103) bpm\\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\\n RR: 26 (16 - 27) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 790 mL\\n 450 mL\\n PO:\\n 790 mL\\n 450 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 4,390 mL\\n 1,330 mL\\n Urine:\\n 4,390 mL\\n 1,330 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,600 mL\\n -880 mL\\n Respiratory support\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CPAP/PSV\\n Vt (Spontaneous): 230 (230 - 439) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 21\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 12 cmH2O\\n SpO2: 95%\\n ABG: ////\\n Ve: 6.4 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n 308 K/uL\\n 12.1 g/dL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Imaging: Lung volumes have decreased and opacification particularly in\\n the right lung has increased since . Given the marked\\n anatomic distortion of the chest precise diagnosis is difficult, but\\n since there is vascular engorgement in the left lung I suspect cardiac\\n decompensation is playing a role. There is also the suggestion of\\n retained secretions in the bronchial tree, particularly the right.\\n Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No\\n pneumothorax is\\n present.\\n Assessment and Plan\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both\\n restrictive lung process due to severe scoliosis with additonal OSA.\\n Now status post tracheostomy placement with revision due to hypoxemia\\n with trach blockage. Patient has been using trach valve during the day\\n and CMV at night. Transfered for evaluation of posterior trach\\n erosion.\\n - continue vent settings as per \\n - discourange ambient use\\n - IP c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n - encourage weight loss and ? pulm rehab on discharge.\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 01:41 PM\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer: PPI\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615423,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n seen by interventional pulmonary\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n asa 81\\n lasix 40 qday\\n heparin 5000 tid\\n albuterol\\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 09:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 36.7\\nC (98\\n HR: 99 (76 - 112) bpm\\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\\n RR: 21 (14 - 25) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 200 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 175 mL\\n 795 mL\\n Urine:\\n 175 mL\\n 795 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -175 mL\\n -595 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: Unstable Airway\\n PIP: 0 cmH2O\\n SpO2: 95%\\n ABG: ///45/\\n Ve: 4.2 L/min\\n Physical Examination\\n General Appearance: Well nourished, scoliosis\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Musculoskeletal: Muscle wasting\\n Skin: Warm\\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\\n Movement: Purposeful, Tone: Not assessed\\n Labs / Radiology\\n 11.9 g/dL\\n 277 K/uL\\n 119 mg/dL\\n 0.4 mg/dL\\n 45 mEq/L\\n 3.7 mEq/L\\n 7 mg/dL\\n 91 mEq/L\\n 141 mEq/L\\n 38.0 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n WBC\\n 5.4\\n Hct\\n 38.0\\n Plt\\n 277\\n Cr\\n 0.4\\n Glucose\\n 119\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\\n PO4:4.2 mg/dL\\n Assessment and Plan\\n 1./ hypercarbic respiratory failure:\\n - IP service following\\n - likely bronch this morning, with potential replacement of trach\\n - will cont to follow\\n - cont albuterol nebs as needed\\n - npo for now\\n 2. Reflux: cont scoliosis\\n 3. pain: minimal, holding narcotic\\n 4. pHTN: cont lasix for diuresis\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 06:10 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: Mouth care\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status:\\n Disposition :ICU\\n Total time spent: 60 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615390,\n \"text\": \"The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\\n comfortably in a chair. When in bed pt must lie flat and needs to be on\\n full vent status. Lung sounds clear and rhonchorus but will clear once\\n suctioned. O2 sat\\ns in high 90\\ns. will desat to low 90\\ns when need to\\n be sx\\nd, afebrile. Foley cath with good urine output,\\n Action:\\n Once examined and assessed by resident pt got oob to chair with minimal\\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\\n mod amt\\ns of thick bloody secretions,\\n Response:\\n Pt tolerated sitting in chair and maintained good o2 sat\\ns on 40% trach\\n collar. Pt able to eat some ice cream and drank some gingerale without\\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\\n and then got back to bed and placed on vent with originale settings. Pt\\n slept for about 4hrs and when awoke c/o back pain again. Resident d/d\\n oxycodone and ordered Tylenol. Pt received 650mg this am.\\n Plan:\\n plan for pt is to schedule him for a permanent trach. pt is currently\\n npo.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615396,\n \"text\": \"Airway\\n Tube Type\\n Tracheostomy tube:\\n Type: Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Airway problems: Positional leak around cuff\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Clear\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\\n ventilatory support in supine position, due to severe scoliosis.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615577,\n \"text\": \"Demographics\\n Day of mechanical ventilation: 3\\n Airway\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed, Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n PMV: when off vent.\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: Yellow / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Ventilation Assessment\\n Level of breathing assistance: Intermittent invasive ventilation\\n Visual assessment of breathing pattern: Normal quiet breathing\\n Assessment of breathing comfort: No claim of dyspnea\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Increase ventilatory support at night\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-01 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 615315,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: DOE\\n REASON FOR MICU ADMISSION: Vent Dependent on trach\\n HPI:\\n The patinet is a 49 year old male with a history of sever scoliosis\\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\\n OSA who presented to an OSH on with complaints of progressive\\n dyspnea.\\n .\\n The patient has had worsening shortness of breath at rest over the last\\n year. OSH records also indicate the patient dozing off throughotu the\\n day, raising concerns of him falling alseep while driving. On\\n presentation to the ED, the he was found to be hypoxemic (80s) and\\n hypercapnic (ABG 7.29 / 89 / 83 / 42,) with episodes of bradycardia\\n with 3-4 sec pauses, and was admitted to the ICU. He was started on\\n BIPAP at night, with intermitent use during the day due to his severe\\n hypercapnic respiratory failure, but did not have good tolerance of\\n non-invasive ventilation. His respiratory status continud to worsen,\\n and the patient was found somnolent and difficult to arouse at night.\\n PCO2 was found during to be 130. Due to his severe scoliosis, and\\n failed nasal intubation, and ENT was consulted for a semi-emergent\\n tracheostomy. A #6 LTC cuffed Shiley trach was placed, but started on\\n Passy-Muir valve during the day time. On , the patient occluded\\n the tracheostomy with severe hypoxia, requiring CPR, but resolved with\\n trach manipulation to restablish the airway. A similar episode occured\\n on , and a #7 Bavrona hyperflexible tracheostomy was placed. He\\n has remained on mechanic ventialation at night, AC, 400/14/5.\\n .\\n Per OSH records, there were concerns that the tracheostomy tube tip\\n appeard to be eroding at the posterior wall of the trachea due to the\\n patients baseline abnormal antatomy. The patient was transfered to\\n for evaluation of a potential customized tracheostomy vs other\\n intervention.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n ASA 81mg daily\\n Lasix 80mg daily\\n Rozerem PRN\\n .\\n Medications at Transfer-\\n Ambien 5mg HS PRN\\n Morphine 4-6mg q4h PRN pain\\n Percocet tab q4H PRN pain\\n Claritin 10mg daily\\n Magnesium oxide 400mg \\n DuoNeb PRN\\n Protonix 40mg daily\\n Lorazepam 45mg q4 PRN\\n Colace 100mg \\n Humibid 1200mg \\n Lasix 40mg daily\\n Arixtra 2.5mg daily\\n ASA 81mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n Severe scoliosis\\n Prior pneumothoraces\\n Restrictive Lung Disease\\n Chronic respiroatyr failure\\n Cholecystectomy\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: The patient is currently married, no alcohol, or tobacco. On\\n disability due to scoliosis.\\n Review of systems:\\n Flowsheet Data as of 11:06 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n HR: 103 (101 - 103) bpm\\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\\n RR: 25 (20 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 175 mL\\n Urine:\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -175 mL\\n Respiratory\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 36 cmH2O\\n SpO2: 99%\\n Ve: 4.9 L/min\\n Physical Examination\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Skin: Not assessed\\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\\n Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: :\\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\\n the right lung. Opacification of the right heithorax suggesting\\n pulmonary consolidation and a large pleural effusion with pulmonary\\n vascular congestion.\\n .\\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\\n function.\\n .\\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\\n Assessment and Plan\\n ASSESSMENT & PLAN:\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both restrictive\\n lung process due to severe scoliosis with additonal OSA. Now status\\n post tracheostomy placement with revision due to hypoxemia with trach\\n blockage. Patient has been using trach valve during the day and CMV at\\n night. Transfered for evaluation of posterior trach erosion.\\n - continue vent settings as per \\n - IP vs. ENT c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n .\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n .\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n .\\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\\n # PPX: PPI, heparin SQ, bowel regimen\\n # ACCESS: PIV\\n # CODE:\\n # CONTACT: The patients wife\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-01 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 615316,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: DOE\\n REASON FOR MICU ADMISSION: Vent Dependent on trach\\n HPI:\\n The patinet is a 49 year old male with a history of sever scoliosis\\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\\n OSA who presented to an OSH on with complaints of progressive\\n dyspnea.\\n .\\n The patient has had worsening shortness of breath at rest over the last\\n year. OSH records also indicate the patient dozing off throughotu the\\n day, raising concerns of him falling alseep while driving. Of note, he\\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\\n to the ICU. He was started on BIPAP at night, with intermitent use\\n during the day due to his severe hypercapnic respiratory failure, but\\n did not have good tolerance of non-invasive ventilation. His\\n respiratory status continud to worsen, and the patient was found\\n somnolent and difficult to arouse at night. PCO2 was found during to\\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\\n Shiley trach was placed, but started on Passy-Muir valve during the day\\n time. On , the patient occluded the tracheostomy with severe\\n hypoxia, requiring CPR, but resolved with trach manipulation to\\n restablish the airway. A similar episode occured on , and a #7\\n Bavrona hyperflexible tracheostomy was placed. He has remained on\\n mechanic ventialation at night, AC, 400/14/5.\\n .\\n Per OSH records, there were concerns that the tracheostomy tube tip\\n appeard to be eroding at the posterior wall of the trachea due to the\\n patients baseline abnormal antatomy. The patient was transfered to\\n for evaluation of a potential customized tracheostomy vs other\\n intervention.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n ASA 81mg daily\\n Lasix 80mg daily\\n Rozerem PRN\\n .\\n Medications at Transfer-\\n Ambien 5mg HS PRN\\n Morphine 4-6mg q4h PRN pain\\n Percocet tab q4H PRN pain\\n Claritin 10mg daily\\n Magnesium oxide 400mg \\n DuoNeb PRN\\n Protonix 40mg daily\\n Lorazepam 45mg q4 PRN\\n Colace 100mg \\n Humibid 1200mg \\n Lasix 40mg daily\\n Arixtra 2.5mg daily\\n ASA 81mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n Severe scoliosis\\n Prior pneumothoraces\\n Restrictive Lung Disease\\n Chronic respiroatyr failure\\n Cholecystectomy\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: The patient is currently married, no alcohol, or tobacco. On\\n disability due to scoliosis.\\n Review of systems:\\n Flowsheet Data as of 11:06 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n HR: 103 (101 - 103) bpm\\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\\n RR: 25 (20 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 175 mL\\n Urine:\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -175 mL\\n Respiratory\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 36 cmH2O\\n SpO2: 99%\\n Ve: 4.9 L/min\\n Physical Examination\\n Trached, on trach mask, sitting in a chair\\n Severe scoliosis, slgith erosis on neck from trach\\n Abnormal resioatory movements\\n Distant heart sounds, tachycardic, no m/r/g\\n Abdominal ventral, soft, ntnd\\n 1+ LE b/l\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: :\\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\\n the right lung. Opacification of the right heithorax suggesting\\n pulmonary consolidation and a large pleural effusion with pulmonary\\n vascular congestion.\\n .\\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\\n function.\\n .\\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\\n Assessment and Plan\\n ASSESSMENT & PLAN:\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both restrictive\\n lung process due to severe scoliosis with additonal OSA. Now status\\n post tracheostomy placement with revision due to hypoxemia with trach\\n blockage. Patient has been using trach valve during the day and CMV at\\n night. Transfered for evaluation of posterior trach erosion.\\n - continue vent settings as per \\n - discourange ambient use\\n - IP c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n - encourage weight loss and ? pulm rehab on discharge.\\n .\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n .\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n .\\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\\n # PPX: PPI, heparin SQ, bowel regimen\\n # ACCESS: PIV\\n # CODE: FULL CODE\\n # CONTACT: The patients wife\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 615319,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: DOE\\n REASON FOR MICU ADMISSION: Vent Dependent on trach\\n HPI:\\n The patinet is a 49 year old male with a history of sever scoliosis\\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\\n OSA who presented to an OSH on with complaints of progressive\\n dyspnea.\\n .\\n The patient has had worsening shortness of breath at rest over the last\\n year. OSH records also indicate the patient dozing off throughotu the\\n day, raising concerns of him falling alseep while driving. Of note, he\\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\\n to the ICU. He was started on BIPAP at night, with intermitent use\\n during the day due to his severe hypercapnic respiratory failure, but\\n did not have good tolerance of non-invasive ventilation. His\\n respiratory status continud to worsen, and the patient was found\\n somnolent and difficult to arouse at night. PCO2 was found during to\\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\\n Shiley trach was placed, but started on Passy-Muir valve during the day\\n time. On , the patient occluded the tracheostomy with severe\\n hypoxia, requiring CPR, but resolved with trach manipulation to\\n restablish the airway. A similar episode occured on , and a #7\\n Bavrona hyperflexible tracheostomy was placed. He has remained on\\n mechanic ventialation at night, AC, 400/14/5.\\n .\\n Per OSH records, there were concerns that the tracheostomy tube tip\\n appeard to be eroding at the posterior wall of the trachea due to the\\n patients baseline abnormal antatomy. The patient was transfered to\\n for evaluation of a potential customized tracheostomy vs other\\n intervention.\\n Allergies:\\n Last dose of Antibiotics:\\n Infusions:\\n Other ICU medications:\\n Other medications:\\n ASA 81mg daily\\n Lasix 80mg daily\\n Rozerem PRN\\n .\\n Medications at Transfer-\\n Ambien 5mg HS PRN\\n Morphine 4-6mg q4h PRN pain\\n Percocet tab q4H PRN pain\\n Claritin 10mg daily\\n Magnesium oxide 400mg \\n DuoNeb PRN\\n Protonix 40mg daily\\n Lorazepam 45mg q4 PRN\\n Colace 100mg \\n Humibid 1200mg \\n Lasix 40mg daily\\n Arixtra 2.5mg daily\\n ASA 81mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n Severe scoliosis\\n Prior pneumothoraces\\n Restrictive Lung Disease\\n Chronic respiroatyr failure\\n Cholecystectomy\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: The patient is currently married, no alcohol, or tobacco. On\\n disability due to scoliosis.\\n Review of systems:\\n Flowsheet Data as of 11:06 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n HR: 103 (101 - 103) bpm\\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\\n RR: 25 (20 - 25) insp/min\\n SpO2: 99%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 175 mL\\n Urine:\\n 175 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -175 mL\\n Respiratory\\n O2 Delivery Device: Tracheostomy tube\\n Ventilator mode: CMV/ASSIST\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 36 cmH2O\\n SpO2: 99%\\n Ve: 4.9 L/min\\n Physical Examination\\n Trached, on trach mask, sitting in a chair\\n Severe scoliosis, slgith erosis on neck from trach\\n Abnormal resioatory movements\\n Distant heart sounds, tachycardic, no m/r/g\\n Abdominal ventral, soft, ntnd\\n 1+ LE b/l\\n Labs / Radiology\\n [image002.jpg]\\n Imaging: :\\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\\n the right lung. Opacification of the right heithorax suggesting\\n pulmonary consolidation and a large pleural effusion with pulmonary\\n vascular congestion.\\n .\\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\\n function.\\n .\\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\\n Assessment and Plan\\n ASSESSMENT & PLAN:\\n The patient is a 49 year old male with a history of severe scoliosis,\\n restrictive lung disease, OSA, who presented to an OSH with worsening\\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\\n tacheostomy placement, now transfered for evaluation of posterior wall\\n erosion.\\n # Hypercapnic respiratory failure: likely secondary to both restrictive\\n lung process due to severe scoliosis with additonal OSA. Now status\\n post tracheostomy placement with revision due to hypoxemia with trach\\n blockage. Patient has been using trach valve during the day and CMV at\\n night. Transfered for evaluation of posterior trach erosion.\\n - continue vent settings as per \\n - discourange ambient use\\n - IP c/s in am\\n - cont guafenisin and duoneb\\n - check baseline CXR here\\n - encourage weight loss and ? pulm rehab on discharge.\\n .\\n # Severe Scoliosis:\\n - cont protonix\\n - tylenol for pain, holding narcotics from OSH as is not part of home\\n regimen.\\n .\\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\\n Mild reduced RV function.\\n - cont home lasix\\n - TEDS\\n .\\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\\n # PPX: PPI, heparin SQ, bowel regimen\\n # ACCESS: PIV\\n # CODE: FULL CODE\\n # CONTACT: The patients wife\\n # DISPO: ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT: SQ UF Heparin\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition:\\n ------ Protected Section ------\\n MICU Overnight Attending Coverage\\n I saw and examined the patient with Dr. . The assessment and plan\\n was discussed in detail.\\n I would emphasize the following. 49 y.o. man with severe scoliosis,\\n OSA, and 30 pound weight gain over past approximately two years with\\n progressive dyspnea, hypercapneic and hypoxic respiratory failure\\n requiring urgent tracheostomy at the outside hospital. Trach changes\\n as noted above, using vent at night, off most of the day, minimal\\n suctioning required except when trach first placed. Now concern for\\n posterior tracheal erosion. No hemoptysis, minimizing suctioning.\\n Appears comfortable on trach collar sitting straight up in chair.\\n Severe scoliosis poor air movement on right, occ. crackle on left, no\\n wheeze\\n RRR, no murmurs\\n + bipedal edema Erythema on right forearm, no cord/fluctulence\\n Alert and oriented x 3 Ventral and umbilical hernia\\n Hypercapneic/hypoxic respiratory failure secondary to restrictive lung\\n disease in setting of severe scoliosis and OSA exacerbated in setting\\n of significant weight gain. require customized trach, IP to\\n evaluate in the morning. NPO after midnight. Minimize suctioning.\\n Plan as noted above.\\n Patient is critically ill given tenuous respiratory status\\n Full code\\n Time spent 40 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 00:32 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615568,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n pt alert and oriented x 3 and is able to speak around trach. pt with\\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\\n able to sit comfortably in a chair. When in bed pt must lie flat and\\n needs to be on full vent status. Lung sounds clear and rhonchorus with\\n wheezes throughout, responds very well to neb treatments. Hands and\\n feet puffy from recent weight gain and fluid. Here for IP consult\\n Action:\\n TEDS stockings applied. IP bronched pt this pm, advanced his \\n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\\n signif. Wt gain, also scholiosis and OSA\\n Response:\\n Stable overnight, no issues\\n Plan:\\n plan for pt to hopefully be transferred back to Hospital\\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\\n his Medicaid insurance\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615570,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n pt alert and oriented x 3 and is able to speak around trach. pt with\\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\\n able to sit comfortably in a chair. When in bed pt must lie flat and\\n needs to be on full vent status. Lung sounds clear and rhonchorus with\\n wheezes throughout, responds very well to neb treatments. Hands and\\n feet puffy from recent weight gain and fluid. Here for IP consult\\n Action:\\n TEDS stockings applied. IP bronched pt this pm, advanced his \\n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\\n signif. Wt gain, also scholiosis and OSA\\n Response:\\n Stable overnight, no issues\\n Plan:\\n plan for pt to hopefully be transferred back to Hospital\\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\\n his Medicaid insurance\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 615664,\n \"text\": \"Ht: unavailable to assess due to severe scolosis\\n Wt: 89 kg\\n Diet: Soft, thin liquids\\n Labs: noted\\n Abdomen: soft/distended, positive bowel sounds\\n Potential for nutrition risk. Patient being monitored. Current\\n intervention if any, listed below:\\n 49 year old male with a history of severe scoliosis, restrictive lung\\n disease, obstructive sleep apnea, who presented to an outside hosptial\\n with worsening dyspnea, who developed hypercapnic respiratory failure\\n w/ semi-emergent tacheostomy placement, now transfered for evaluation\\n of posterior wall erosion. Now status post tracheostomy placement with\\n revision due to hypoxemia with trach blockage.\\n Tolerating soft diet, good appetite. Eats soft diet at home. Thinks\\n his current weight is\\nhigh\\n, but stable recently. Per chart, patient\\n with 30 lb weight gain x 2 years.\\n Noted plan for transfer to .\\n Will follow to check po\\ns if remains in house, page if questions *\\n PM\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615648,\n \"text\": \"TITLE:\\n Chief Complaint: respiratory failure\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 24 Hour Events:\\n -IP performed FOB, evaluation of trache\\n -Ventilated overnight\\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 Pantoprazole (Protonix) - 08:18 PM\\n Heparin Sodium (Prophylaxis) - 07:50 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 11:19 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.4\\nC (99.3\\n Tcurrent: 37.3\\nC (99.1\\n HR: 92 (71 - 115) bpm\\n BP: 128/80(87) {103/62(71) - 150/123(126)} mmHg\\n RR: 20 (17 - 26) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Total In:\\n 720 mL\\n 100 mL\\n PO:\\n 720 mL\\n 100 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 3,820 mL\\n 1,075 mL\\n Urine:\\n 3,820 mL\\n 1,075 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -3,100 mL\\n -975 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Spontaneous): 323 (323 - 325) mL\\n PS : 10 cmH2O\\n RR (Spontaneous): 28\\n PEEP: 5 cmH2O\\n FiO2: 50%\\n PIP: 16 cmH2O\\n SpO2: 97%\\n ABG: ///41/\\n Ve: 9.7 L/min\\n Physical Examination\\n General Appearance: No acute distress, Overweight / Obese\\n Head, Ears, Nose, Throat: Normocephalic, trache 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: No(t) Symmetric), (Breath Sounds:\\n Diminished: ), severe kyphoscoliosis\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 12.1 g/dL\\n 308 K/uL\\n 103 mg/dL\\n 0.4 mg/dL\\n 41 mEq/L\\n 4.1 mEq/L\\n 7 mg/dL\\n 94 mEq/L\\n 141 mEq/L\\n 38.2 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n 04:45 AM\\n WBC\\n 5.4\\n 5.4\\n Hct\\n 38.0\\n 38.2\\n Plt\\n 277\\n 308\\n Cr\\n 0.4\\n 0.4\\n Glucose\\n 119\\n 103\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\\n PO4:3.6 mg/dL\\n Assessment and Plan\\n 1. hypercarbic respiratory failure:\\n - restrictive lung disease in setting of severe scoliosis and OSA\\n - likely exacerbated with recent significant weight gain\\n - IP performed FOB/airway evaluation\\n -no posterior membrane erosion\\n -trache adjusted\\n - nocturnal ventilation ongoing\\n 2. Reflux:\\n - cont tx scoliosis\\n 3. pain:\\n - minimal, holding narcotic\\n 4. pHTN:\\n - cont lasix for diuresis\\n Remainder of plan per resident note.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n Prophylaxis:\\n DVT:\\n Stress ulcer:\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status:\\n Disposition :Transfer to other facility\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615711,\n \"text\": \"Demographics\\n Day of intubation: 3\\n Day of mechanical ventilation: 3\\n Airway\\n Airway Placement Data\\n Tube Type\\n Tracheostomy tube:\\n Type: Cuffed, Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n PMV: Yes\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: 25 cmH2O\\n Lung sounds\\n RLL Lung Sounds: Rhonchi\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Rhonchi\\n Secretions\\n Sputum color / consistency: White / Thick\\n Sputum source/amount: Suctioned / Moderate\\n Comments: Pt on and off Trach Collar .50 today using PMV occasionally\\n for short periods of time.\\n\"\n },\n {\n \"category\": \"Case Management \",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"Case Management Continued Stay Review\",\n \"row_id\": 615657,\n \"text\": \"Planned Discharge Date: \\n Insurance Update\\n Primary insurance / reviewer:\\n Hospital days authorized to:\\n Current Discharge Plan: Hospital, NH\\n Narrative / Plan (Multidisciplinary team):\\n Case discussed w/ team. Pt with new trach/vented on CPAP at times,\\n would need hospital level rehab not . Pt with NH medicaid only. No\\n LTACs in NH. No NH medicaid contracts at LTACs in MA. Plan is for pt to\\n return to Hospital. MICU team has made contact with \\n Physician to start arranging for transfer back.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 615494,\n \"text\": \"49 year old male with a history of severe scoliosis, restrictive lung\\n disease, OSA, who presented to an OSH with worsening dyspnea, who\\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\\n placement, now transferred for evaluation of posterior wall erosion.\\n Respiratory failure, acute (not ARDS/)\\n Assessment:\\n pt alert and oriented x 3 and is able to speak around trach. pt with\\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\\n able to sit comfortably in a chair. When in bed pt must lie flat and\\n needs to be on full vent status. Lung sounds clear and rhonchorus with\\n wheezes throughout, responds very well to neb treatments. Hands and\\n feet puffy from recent weight gain and fluid. Here for IP consult\\n Action:\\n TEDS stockings applied. IP bronched pt this pm, advanced his \\n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\\n signif. Wt gain, also scholiosis and OSA\\n Response:\\n Pt tolerated procedure well. No erosion noted of trache, some\\n irritation though. PPI started for this. sitting in chair and\\n maintained good o2 sat\\ns on 40% trach collar. To fully supported on\\n vent. Diet advanced back to his soft solids, tolerated well.\\n Plan:\\n plan for pt to hopefully be transferred back to Hospital\\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\\n his Medicaid insurance\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 615453,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n 24 Hour Events:\\n - seen by interventional pulmonary\\n Allergies:\\n No Known Drug Allergies\\n Other medications:\\n asa 81\\n lasix 40 qday\\n heparin 5000 tid\\n albuterol\\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 09:31 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 37.2\\nC (98.9\\n Tcurrent: 36.7\\nC (98\\n HR: 99 (76 - 112) bpm\\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\\n RR: 21 (14 - 25) insp/min\\n SpO2: 95%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 200 mL\\n PO:\\n 200 mL\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 175 mL\\n 795 mL\\n Urine:\\n 175 mL\\n 795 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -175 mL\\n -595 mL\\n Respiratory support\\n O2 Delivery Device: Trach mask\\n Ventilator mode: Standby\\n Vt (Set): 400 (400 - 400) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI Deferred: Unstable Airway\\n PIP: 0 cmH2O\\n SpO2: 95%\\n ABG: ///45/\\n Ve: 4.2 L/min\\n Physical Examination\\n General Appearance: Well nourished, scoliosis\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: poor air mvmt on right\\n Extremities: Right lower extremity edema: Trace, Left lower extremity\\n edema: Trace\\n Musculoskeletal: Muscle wasting\\n Skin: Warm\\n Neurologic: Attentive\\n Labs / Radiology\\n 11.9 g/dL\\n 277 K/uL\\n 119 mg/dL\\n 0.4 mg/dL\\n 45 mEq/L\\n 3.7 mEq/L\\n 7 mg/dL\\n 91 mEq/L\\n 141 mEq/L\\n 38.0 %\\n 5.4 K/uL\\n [image002.jpg]\\n 12:26 AM\\n WBC\\n 5.4\\n Hct\\n 38.0\\n Plt\\n 277\\n Cr\\n 0.4\\n Glucose\\n 119\\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\\n PO4:4.2 mg/dL\\n Assessment and Plan\\n 1. hypercarbic respiratory failure:\\n - restrictive lung disease in setting of severe scoliosis and OSA\\n - likely exacerbated with recent significant weight gain\\n - IP service consulted, to do FOB to assess trache and exclude\\n posterior membrane erosion\\n - npo for proc\\n 2. Reflux:\\n - cont tx scoliosis\\n 3. pain:\\n - minimal, holding narcotic\\n 4. pHTN:\\n - cont lasix for diuresis\\n Remainder of plan per resident note.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 20 Gauge - 06:10 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\\n Stress ulcer:\\n VAP: Mouth care\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status:\\n Disposition :ICU\\n Total time spent:\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2156-12-02 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 615454,\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 Tube Type\\n Tracheostomy tube:\\n Type: Cuffed, Adjustable Neck Flange\\n Manufacturer: \\n Size: 7.0mm\\n PMV: Yes\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems: Positional leak around cuff,\\n adjustable trach advanced to 12 cm just below flange via bronchoscopic\\n evaluation.\\n Comments: deflated while off ventilator\\n Lung sounds\\n RLL Lung Sounds: Crackles\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Clear\\n Comments: expriratory wheezes T/O clear after albuterol adm via\\n nebulizer.\\n Secretions\\n Sputum color / consistency: Blood Tinged / Thick\\n Sputum source/amount: Expectorated / None\\n Ventilation Assessment\\n Level of breathing assistance: Off ventilator during the day\\n Visual assessment of breathing pattern: occasional dyspnea with\\n increased congestion and expiratory wheezes, relieved with coughing and\\n nebulized albuterol.\\n Plan\\n Next 24-48 hours: Increase ventilatory support at night; Comments:\\n placed on ventilator at night for management of CO2\\n Reason for continuing current ventilatory support:\\n Bedside Procedures:\\n Bronchoscopy (12:00)\\n Comments:\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2156-12-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 230766,\n \"text\": \"Sinus rhythm. Consider right atrial abnormality. Right axis deviation.\\nProminent lateral lead Q waves. Findings raise consideration of possible\\nright ventricular overload. Possible prior lateral myocardial infarction\\nof left posterior fascicular block. Clinical correlation is suggested.\\nNo previous tracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-12-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1116684,\n \"text\": \" 9:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old man with trach c/o dyspnea.\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST 9:39 A.M. \\n\\n HISTORY: Tracheostomy. Complains of dyspnea.\\n\\n IMPRESSION: AP chest compared to :\\n\\n Lung volumes have decreased and opacification particularly in the right lung\\n has increased since . Given the marked anatomic distortion of the\\n chest precise diagnosis is difficult, but since there is vascular engorgement\\n in the left lung I suspect cardiac decompensation is playing a role. There is\\n also the suggestion of retained secretions in the bronchial tree, particularly\\n the right. Right pleural effusion has probably developed and whether the\\n right lower lung is atelectatic or consolidated is radiographically\\n indeterminate, as is the extent of presumed cardiomegaly. No pneumothorax is\\n present.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-12-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1116480,\n \"text\": \" 11:14 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pls evaluate lung fields\\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 49 year old man with severe scoliosis s/p trach\\n REASON FOR THIS EXAMINATION:\\n pls evaluate lung fields\\n ______________________________________________________________________________\\n FINAL REPORT\\n SINGLE AP PORTABLE VIEW OF THE CHEST\\n\\n REASON FOR EXAM: Evaluate tracheostomy.\\n\\n The interpretation of this radiograph is very limited due to the severe\\n scoliosis and deformity of the thoracic cage. Tracheostomy tube tip is 5.5 cm\\n above the carina. Cardiomediastinal contours cannot be evaluated. There is\\n no evident pneumothorax. If any, there is a small right pleural effusion.\\n The main central pulmonary arteries appear to be enlarged. There are no prior\\n studies available for comparison. The asymmetric increased density in the\\n right hemithorax could be due to pleural effusion or lung opacities in the\\n right lower lobe, I suspect that also is due to the deformity of the thoracic\\n cage. If prior studies were available , comparison could be performed to\\n assess new abnormality.\\n\\n\"\n }\n]"}}},{"rowIdx":193,"cells":{"subject_id":{"kind":"number","value":369,"string":"369"},"hadm_id":{"kind":"number","value":145787,"string":"145,787"},"target_text":{"kind":"string","value":"Pt under went an unremarkable hospital course. Pt was tolerating a regular diet with good pain control on PO pain medications. Pt was ambulating on her own and working with physical therapy. On , pt's CXR showed R pleural effusion. Pt's O2 saturation were 95% on RA. On discharge, the pt was 6 kg over her pre operative weight and was DC'd on 1 week on lasix 40mg for continued diuresis. CXR pending. An addendum will be added regarding results."},"extractive_notes_summ":{"kind":"string","value":"BS DIMINISHED BIBASILAR COURSE UPPER CLEARS WITH SX. Since the previoustracing of atrial ectopy, right bundle-branch block and prolongedQTc interval are seen. REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade. RX X 1 WITH REGLAN. The approximately 1 cm nodular opacity in the left lower lung zone periphery is again noted, which may represent loculated fluid vs. an unusual atelectatic pattern. is still in OR, please perfo Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? EXTUBATED AT MIDNOC. The patient is status post AVR and median sternotomy. CALCIUM AND MAG REPLACED. IMPRESSION: Residual bilateral pleural effusions. Residual left lower lobe atelectasis. CSRU UPDATES/P AVR TISSUE VALVE. Atrial premature beats. Evaluate for pleural effusion. There are residual bilateral pleural effusions, with residual left lower lobe atelectasis. 1:46 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade. MIN CT DRAINAGE. SBP LABILE 88- 130 PRESENTLY NIPRIDE @ .7 MCQ TO KEEP SBP 90-120.CI > 2.5. 11:31 AM CHEST (PA & LAT) Clip # Reason: re-eval right effusion Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? NEO TITRATED OFF.NEURO: LETHARGIC. NEO ON TRANSIENTLY FOR LOW BP. Pt s/p AVR. Sinus rhythm. The right jugular Swan-Ganz catheter terminates in the right main PA. NIPRIDE OFF TRANSIENT NEO HOWEVER PRESENTLY OFF BOTH WITH SBP 100'S. There is bilateral lower lobe atelectasis. TMAX 37.7. ADDITONAL K AND CALCIUM GIVEN. DILAUDID FOR PAIN. CLINICAL INDICATION: Status post aortic valve replacement. FINDINGS: PA and lateral views of the chest show interval removal of the endotracheal tube and Swan-Ganz catheter. Mildly increased moderate right pleural effusion, with stable left pleural effusion. Unusual nodular opacity over left lower lung zone peripherally, possibly representing possibly loculated fluid vs. unusual pattern of atelectasis. C/O STIFFNESS LEFT ARM. Small left and moderate right pleural effusions are noted with slight worsening of the right effusion. Pt. Pt. VENT SETTINGS PER FLOW WITH GOOD ABG. Midline sternotomy wires and a prosthetic aortic valve are again seen. CI REMAINS > 2. ID: VANCO @ . Midline sternotomy wires and prosthestic aortic valve are seen. Stable small left pleural effusion and improving left lower lobe atelectasis. GIVEN 1L LR THROUGHOUT SHIFT. is still in OR, please perform when pt is in CSRU. NEURO: REVERSED AND AWOKE CALM, PERL, MAE, GRASPS STRONG AND EQUAL. IMPRESSION: 1. IMPRESSION: 1. AMIODARONE BOLUS AND GTT @ 1 MG DUE TO RUNS OF AF. DC CORDIS/SWAN. 10:49 AM CHEST (PRE-OP PA & LAT) Clip # Reason: r/o effusion Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? Low limb lead voltage is non-specific.Right bundle-branch block. CURRENT O2 SETTINGS .7 O2 FACE TENT/ 4L NC. NEO CURRENTLY OFF. HCT 34. Cardiac and mediastinal contours are stable in the postoperative. COMPARISON: . COMPARISON: . S/P AVRO: CARDIAC: CONTINUES TO REQUIRE LR, SR 80'S PRESENTLY. ?TX TO FLOOR. See resp flowsheet for vent data. LS CLEAR, DECREASED IN THE BASES. Mediastinal drains are in place. 3:01 PM CHEST (PA & LAT) Clip # Reason: s/p chest tube removal-r/o PTX Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? FICK CO 3.86, THERMODILUTION 3.0. The patient is status post median sternotomy and aortic valve replacement procedure. An old compression fracture of a mid thoracic vertebra is again noted. FINDINGS: PA & lateral views of the chest show bilateral pleural effusions; the right appears somewhat greater, while the left is stable. Clinical correlation is suggested. Attention to this region on followup CXR is recommended. There are bibasilar atelectatic changes which have improved at the left base and are unchanged at the right lung base. An old compression fracture of a mid- thoracic vertebra is seen. HCT PENDING FEBRILE RECIEVED 650 MG TYLENOL PR. Finally, there is an apparent small nodular opacity in the periphery of the left lower lung zone, possibly due to an overlying structure external to the patient based on the lateral view findings. GI: OGT + PLACEMENT, CARAFATE X2, ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS. Slight increase in right pleural effusion, moderate in size. REQUIRING LR 2 L TO KEEP HR <100, CT MINIMAL DRAINAGE SINCE INITIAL 200ML, DSGS D+I. There is mild congestive heart failure with cardiomegaly and small bilateral pleural effusions. AS PER ORDERS. MAE. The tip of the endotracheal tube is identified 3 cm above the carina. 3. 2. 2. SX FOR A SMALL AMOUNT OF TAN SPUTUM. Prolonged QTc interval - cannot excludemetabolic/drug effect. HYPOACTIVE BS.GU: URINE OUTPUT HAS SLOWED OVN TO 30-40CC/HR.PLAN: OOB TO CHAIR. Respiratory TherapyPt remains orally intubated and on full vent support. SR 80-90'S. DENIES PAIN OR DISCOMFORT WHEN MOANING.CV: NSR 67. COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with the previous study of . Questionable nodular opacity in left lower lobe, possibly external to the patient. A nasogastric tube courses towards the stomach."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2142-10-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":839984,"text":" 1:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perfo\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with AS/AI s/p AVR.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perform when pt is in\n CSRU.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 75-year-old woman with status post AVR.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study of .\n\n The patient is status post AVR and median sternotomy. There is mild\n congestive heart failure with cardiomegaly and small bilateral pleural\n effusions. The right jugular Swan-Ganz catheter terminates in the right main\n PA. The tip of the endotracheal tube is identified 3 cm above the carina. A\n nasogastric tube courses towards the stomach. Mediastinal drains are in\n place. No pneumothorax is identified.\n\n\n"},{"category":"Radiology","chartdate":"2142-10-15 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":840646,"text":" 10:49 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n Compared to earlier study of , and .\n\n CLINICAL INDICATION: Status post aortic valve replacement. Evaluate for\n pleural effusion.\n\n The patient is status post median sternotomy and aortic valve replacement\n procedure. Cardiac and mediastinal contours are stable in the postoperative.\n There is no evidence of cardiac failure. There are bibasilar atelectatic\n changes which have improved at the left base and are unchanged at the right\n lung base. Small left and moderate right pleural effusions are noted with\n slight worsening of the right effusion. There is no evidence of pneumothorax.\n Finally, there is an apparent small nodular opacity in the periphery of the\n left lower lung zone, possibly due to an overlying structure external to the\n patient based on the lateral view findings.\n\n IMPRESSION:\n 1. Stable small left pleural effusion and improving left lower lobe\n atelectasis.\n 2. Slight increase in right pleural effusion, moderate in size.\n 3. Questionable nodular opacity in left lower lobe, possibly external to the\n patient. Repeat radiograph following removal of external EKG lead devices\n would be helpful to fully exclude a lung nodule.\n\n"},{"category":"Radiology","chartdate":"2142-10-16 00:00:00.000","description":"CHEST (PA & LAT)","row_id":840798,"text":" 11:31 AM\n CHEST (PA & LAT) Clip # \n Reason: re-eval right effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n re-eval right effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative for aortic valve replacement.\n\n COMPARISON: .\n\n FINDINGS: PA & lateral views of the chest show bilateral pleural effusions;\n the right appears somewhat greater, while the left is stable. There is\n bilateral lower lobe atelectasis. The approximately 1 cm nodular opacity in\n the left lower lung zone periphery is again noted, which may represent\n loculated fluid vs. an unusual atelectatic pattern. It is also seen on the\n lateral radiograph and does not appear to be due to a structure external to\n the patient, as was considered on the prior report. Midline sternotomy wires\n and a prosthetic aortic valve are again seen. An old compression fracture of a\n mid thoracic vertebra is again noted.\n\n IMPRESSION: 1. Mildly increased moderate right pleural effusion, with stable\n left pleural effusion.\n\n 2. Unusual nodular opacity over left lower lung zone peripherally, possibly\n representing possibly loculated fluid vs. unusual pattern of atelectasis.\n Attention to this region on followup CXR is recommended.\n\n"},{"category":"Radiology","chartdate":"2142-10-11 00:00:00.000","description":"CHEST (PA & LAT)","row_id":840223,"text":" 3:01 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p chest tube removal-r/o PTX\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic valve replacement.\n\n COMPARISON: .\n\n FINDINGS: PA and lateral views of the chest show interval removal of the\n endotracheal tube and Swan-Ganz catheter. There are residual bilateral\n pleural effusions, with residual left lower lobe atelectasis. There is no\n evidence of congestive heart failure. An old compression fracture of a mid-\n thoracic vertebra is seen. Midline sternotomy wires and prosthestic aortic\n valve are seen.\n\n IMPRESSION: Residual bilateral pleural effusions. Residual left lower lobe\n atelectasis.\n\n\n"},{"category":"ECG","chartdate":"2142-10-09 00:00:00.000","description":"Report","row_id":134536,"text":"Sinus rhythm. Atrial premature beats. Low limb lead voltage is non-specific.\nRight bundle-branch block. Prolonged QTc interval - cannot exclude\nmetabolic/drug effect. Clinical correlation is suggested. Since the previous\ntracing of atrial ectopy, right bundle-branch block and prolonged\nQTc interval are seen.\n\n"},{"category":"Nursing/other","chartdate":"2142-10-09 00:00:00.000","description":"Report","row_id":1265625,"text":"S/P AVR\nO: CARDIAC: CONTINUES TO REQUIRE LR, SR 80'S PRESENTLY. AMIODARONE BOLUS AND GTT @ 1 MG DUE TO RUNS OF AF. NIPRIDE OFF TRANSIENT NEO HOWEVER PRESENTLY OFF BOTH WITH SBP 100'S. CI REMAINS > 2. HCT PENDING FEBRILE RECIEVED 650 MG TYLENOL PR. PAD'S LO TWENTIES WITH CVP 15. MIN CT DRAINAGE. ADDITONAL K AND CALCIUM GIVEN.\n RESP: FAILED CPAP WEAN TO ATTEMPT AGAIN, UNABLE TO LIFT HEAD OFF PILLOW. VENT SETTINGS PER FLOW WITH GOOD ABG. O2 SAT >97%. BS DIMINISHED BIBASILAR COURSE UPPER CLEARS WITH SX. SX FOR A SMALL AMOUNT OF TAN SPUTUM. NOT OVERBREATHING THE VENT. NO CHEST TUBE LEAK.\n NEURO: REVERSED AND AWOKE CALM, PERL, MAE, GRASPS STRONG AND EQUAL.\n GI: OGT + PLACEMENT, CARAFATE X2, ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS.\n GU: AUTODIURESED POST OP,\n ENDO: INSULIN GTT PRESENTLY AT 2 UNITS/HR.\n ID: VANCO @ .\n PAIN: RECIEVED .5 MG DILAUDID X 2 WITH GOOD EFFECT, DENIES PAIN AT PRESENT.\n SOCIAL: HUSBAND AND CHILDREN INTO VISIT AND UPDATED\nA: LARGE VOLUME REQUIREMENTS, AMIODARONE DUE TO INCREASED ATRIAL ACTIVITY,FEBRILE, FAILED INITIAL WEAN, LARGE DIURESIS.\nP: MONITOR COMFORT, HR AND RYTHYM-CONTINUE AMIODARONE, KEEP SBP BETWEEN 90-120, CI, CT DRAINAGE, RESP STATUS-WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS PENDING. AS PER ORDERS.\n"},{"category":"Nursing/other","chartdate":"2142-10-10 00:00:00.000","description":"Report","row_id":1265626,"text":"CSRU UPDATE\nS/P AVR TISSUE VALVE. EXTUBATED AT MIDNOC. NEO TITRATED OFF.\nNEURO: LETHARGIC. MAE. C/O STIFFNESS LEFT ARM. DILAUDID FOR PAIN. MOANING THROUGHOUT NIGHT. STATES IT \"MAKES ME FEEL BETTER TO MOAN.\" DENIES PAIN OR DISCOMFORT WHEN MOANING.\nCV: NSR 67. PLACED ON ADEMAND AT 80 TO INCREASE BP. TMAX 37.7. NEO ON TRANSIENTLY FOR LOW BP. GIVEN 1L LR THROUGHOUT SHIFT. NEO CURRENTLY OFF. FICK CO 3.86, THERMODILUTION 3.0. 3+ PEDAL PULSES.\nPULM: NEEDING A LOT OF ENCOURAGEMENT FOR COUGHING AND DEEP BREATHING. CURRENT O2 SETTINGS .7 O2 FACE TENT/ 4L NC. LS CLEAR, DECREASED IN THE BASES. ?START LASIX THIS AM.\nGI: CONTINUES ON INSULIN GTT AT 1U/HR. RX X 1 WITH REGLAN. HYPOACTIVE BS.\nGU: URINE OUTPUT HAS SLOWED OVN TO 30-40CC/HR.\nPLAN: OOB TO CHAIR. DC CORDIS/SWAN. ?TX TO FLOOR.\n"},{"category":"Nursing/other","chartdate":"2142-10-09 00:00:00.000","description":"Report","row_id":1265623,"text":"Respiratory Therapy\nPt remains orally intubated and on full vent support. Pt s/p AVR. See resp flowsheet for vent data. Will follow.\n"},{"category":"Nursing/other","chartdate":"2142-10-09 00:00:00.000","description":"Report","row_id":1265624,"text":"S/P AVR\nO: ARRIVED ON NTG AND NIPRIDE TO KEEP SBP <125 PER DR. , 200 ML CT. 80 MCQ OF PROPOFOL. SR 80-90'S.\n CARDIAC: SR WITH PAC'S NOTED, 6 BEAT RUN VT WITH K 4.5 HAD RECIEVED 40 MEQ KCL X 1. SBP LABILE 88- 130 PRESENTLY NIPRIDE @ .7 MCQ TO KEEP SBP 90-120.CI > 2.5. REQUIRING LR 2 L TO KEEP HR <100, CT MINIMAL DRAINAGE SINCE INITIAL 200ML, DSGS D+I. HCT 34. CALCIUM AND MAG REPLACED.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 839984,\n \"text\": \" 1:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perfo\\n Admitting Diagnosis: AORTIC STENOSIS\\\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with AS/AI s/p AVR.\\n REASON FOR THIS EXAMINATION:\\n r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perform when pt is in\\n CSRU.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 75-year-old woman with status post AVR.\\n\\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\\n the previous study of .\\n\\n The patient is status post AVR and median sternotomy. There is mild\\n congestive heart failure with cardiomegaly and small bilateral pleural\\n effusions. The right jugular Swan-Ganz catheter terminates in the right main\\n PA. The tip of the endotracheal tube is identified 3 cm above the carina. A\\n nasogastric tube courses towards the stomach. Mediastinal drains are in\\n place. No pneumothorax is identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-10-15 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 840646,\n \"text\": \" 10:49 AM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: r/o effusion\\n Admitting Diagnosis: AORTIC STENOSIS\\\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with severe aortic stenosis, pre op for AVR\\n\\n REASON FOR THIS EXAMINATION:\\n r/o effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n Compared to earlier study of , and .\\n\\n CLINICAL INDICATION: Status post aortic valve replacement. Evaluate for\\n pleural effusion.\\n\\n The patient is status post median sternotomy and aortic valve replacement\\n procedure. Cardiac and mediastinal contours are stable in the postoperative.\\n There is no evidence of cardiac failure. There are bibasilar atelectatic\\n changes which have improved at the left base and are unchanged at the right\\n lung base. Small left and moderate right pleural effusions are noted with\\n slight worsening of the right effusion. There is no evidence of pneumothorax.\\n Finally, there is an apparent small nodular opacity in the periphery of the\\n left lower lung zone, possibly due to an overlying structure external to the\\n patient based on the lateral view findings.\\n\\n IMPRESSION:\\n 1. Stable small left pleural effusion and improving left lower lobe\\n atelectasis.\\n 2. Slight increase in right pleural effusion, moderate in size.\\n 3. Questionable nodular opacity in left lower lobe, possibly external to the\\n patient. Repeat radiograph following removal of external EKG lead devices\\n would be helpful to fully exclude a lung nodule.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-10-16 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 840798,\n \"text\": \" 11:31 AM\\n CHEST (PA & LAT) Clip # \\n Reason: re-eval right effusion\\n Admitting Diagnosis: AORTIC STENOSIS\\\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with severe aortic stenosis, pre op for AVR\\n\\n REASON FOR THIS EXAMINATION:\\n re-eval right effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Preoperative for aortic valve replacement.\\n\\n COMPARISON: .\\n\\n FINDINGS: PA & lateral views of the chest show bilateral pleural effusions;\\n the right appears somewhat greater, while the left is stable. There is\\n bilateral lower lobe atelectasis. The approximately 1 cm nodular opacity in\\n the left lower lung zone periphery is again noted, which may represent\\n loculated fluid vs. an unusual atelectatic pattern. It is also seen on the\\n lateral radiograph and does not appear to be due to a structure external to\\n the patient, as was considered on the prior report. Midline sternotomy wires\\n and a prosthetic aortic valve are again seen. An old compression fracture of a\\n mid thoracic vertebra is again noted.\\n\\n IMPRESSION: 1. Mildly increased moderate right pleural effusion, with stable\\n left pleural effusion.\\n\\n 2. Unusual nodular opacity over left lower lung zone peripherally, possibly\\n representing possibly loculated fluid vs. unusual pattern of atelectasis.\\n Attention to this region on followup CXR is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-10-11 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 840223,\n \"text\": \" 3:01 PM\\n CHEST (PA & LAT) Clip # \\n Reason: s/p chest tube removal-r/o PTX\\n Admitting Diagnosis: AORTIC STENOSIS\\\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 75 year old woman with severe aortic stenosis, pre op for AVR\\n\\n REASON FOR THIS EXAMINATION:\\n s/p chest tube removal-r/o PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Aortic valve replacement.\\n\\n COMPARISON: .\\n\\n FINDINGS: PA and lateral views of the chest show interval removal of the\\n endotracheal tube and Swan-Ganz catheter. There are residual bilateral\\n pleural effusions, with residual left lower lobe atelectasis. There is no\\n evidence of congestive heart failure. An old compression fracture of a mid-\\n thoracic vertebra is seen. Midline sternotomy wires and prosthestic aortic\\n valve are seen.\\n\\n IMPRESSION: Residual bilateral pleural effusions. Residual left lower lobe\\n atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 134536,\n \"text\": \"Sinus rhythm. Atrial premature beats. Low limb lead voltage is non-specific.\\nRight bundle-branch block. Prolonged QTc interval - cannot exclude\\nmetabolic/drug effect. Clinical correlation is suggested. Since the previous\\ntracing of atrial ectopy, right bundle-branch block and prolonged\\nQTc interval are seen.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265625,\n \"text\": \"S/P AVR\\nO: CARDIAC: CONTINUES TO REQUIRE LR, SR 80'S PRESENTLY. AMIODARONE BOLUS AND GTT @ 1 MG DUE TO RUNS OF AF. NIPRIDE OFF TRANSIENT NEO HOWEVER PRESENTLY OFF BOTH WITH SBP 100'S. CI REMAINS > 2. HCT PENDING FEBRILE RECIEVED 650 MG TYLENOL PR. PAD'S LO TWENTIES WITH CVP 15. MIN CT DRAINAGE. ADDITONAL K AND CALCIUM GIVEN.\\n RESP: FAILED CPAP WEAN TO ATTEMPT AGAIN, UNABLE TO LIFT HEAD OFF PILLOW. VENT SETTINGS PER FLOW WITH GOOD ABG. O2 SAT >97%. BS DIMINISHED BIBASILAR COURSE UPPER CLEARS WITH SX. SX FOR A SMALL AMOUNT OF TAN SPUTUM. NOT OVERBREATHING THE VENT. NO CHEST TUBE LEAK.\\n NEURO: REVERSED AND AWOKE CALM, PERL, MAE, GRASPS STRONG AND EQUAL.\\n GI: OGT + PLACEMENT, CARAFATE X2, ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS.\\n GU: AUTODIURESED POST OP,\\n ENDO: INSULIN GTT PRESENTLY AT 2 UNITS/HR.\\n ID: VANCO @ .\\n PAIN: RECIEVED .5 MG DILAUDID X 2 WITH GOOD EFFECT, DENIES PAIN AT PRESENT.\\n SOCIAL: HUSBAND AND CHILDREN INTO VISIT AND UPDATED\\nA: LARGE VOLUME REQUIREMENTS, AMIODARONE DUE TO INCREASED ATRIAL ACTIVITY,FEBRILE, FAILED INITIAL WEAN, LARGE DIURESIS.\\nP: MONITOR COMFORT, HR AND RYTHYM-CONTINUE AMIODARONE, KEEP SBP BETWEEN 90-120, CI, CT DRAINAGE, RESP STATUS-WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS PENDING. AS PER ORDERS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-10-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265626,\n \"text\": \"CSRU UPDATE\\nS/P AVR TISSUE VALVE. EXTUBATED AT MIDNOC. NEO TITRATED OFF.\\nNEURO: LETHARGIC. MAE. C/O STIFFNESS LEFT ARM. DILAUDID FOR PAIN. MOANING THROUGHOUT NIGHT. STATES IT \\\"MAKES ME FEEL BETTER TO MOAN.\\\" DENIES PAIN OR DISCOMFORT WHEN MOANING.\\nCV: NSR 67. PLACED ON ADEMAND AT 80 TO INCREASE BP. TMAX 37.7. NEO ON TRANSIENTLY FOR LOW BP. GIVEN 1L LR THROUGHOUT SHIFT. NEO CURRENTLY OFF. FICK CO 3.86, THERMODILUTION 3.0. 3+ PEDAL PULSES.\\nPULM: NEEDING A LOT OF ENCOURAGEMENT FOR COUGHING AND DEEP BREATHING. CURRENT O2 SETTINGS .7 O2 FACE TENT/ 4L NC. LS CLEAR, DECREASED IN THE BASES. ?START LASIX THIS AM.\\nGI: CONTINUES ON INSULIN GTT AT 1U/HR. RX X 1 WITH REGLAN. HYPOACTIVE BS.\\nGU: URINE OUTPUT HAS SLOWED OVN TO 30-40CC/HR.\\nPLAN: OOB TO CHAIR. DC CORDIS/SWAN. ?TX TO FLOOR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265623,\n \"text\": \"Respiratory Therapy\\nPt remains orally intubated and on full vent support. Pt s/p AVR. See resp flowsheet for vent data. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-10-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265624,\n \"text\": \"S/P AVR\\nO: ARRIVED ON NTG AND NIPRIDE TO KEEP SBP <125 PER DR. , 200 ML CT. 80 MCQ OF PROPOFOL. SR 80-90'S.\\n CARDIAC: SR WITH PAC'S NOTED, 6 BEAT RUN VT WITH K 4.5 HAD RECIEVED 40 MEQ KCL X 1. SBP LABILE 88- 130 PRESENTLY NIPRIDE @ .7 MCQ TO KEEP SBP 90-120.CI > 2.5. REQUIRING LR 2 L TO KEEP HR <100, CT MINIMAL DRAINAGE SINCE INITIAL 200ML, DSGS D+I. HCT 34. CALCIUM AND MAG REPLACED.\\n\"\n }\n]"}}},{"rowIdx":194,"cells":{"subject_id":{"kind":"number","value":61825,"string":"61,825"},"hadm_id":{"kind":"number","value":163976,"string":"163,976"},"target_text":{"kind":"string","value":"The patinet is a 66 year old man with severe COPD, AAA and HTN who presented with right-sided chest pain and worsening shortness of breath, and was found the have a pulmonary embolus and pneumonia."},"extractive_notes_summ":{"kind":"string","value":"Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Check sputum cx. - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . Echo and LENIs today PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. - ipratropium nebs and albuterol nebs . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . Continue albuterol and atrovent nebs. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. Treat with anticoagulation. Treat with anticoagulation. Treat with anticoagulation. Will eval area of hyperdensity seen on CTA with non-con abd CT. Will eval area of hyperdensity seen on CTA with non-con abd CT. Will eval area of hyperdensity seen on CTA with non-con abd CT. PE, PERINEPHRIC ABSCESS OTHER PATH Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) enhancement. Echo and LENIs today PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. Check sputum cx. Cholelithiasis. Cholelithiasis. The aortic knob is calcified. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. Hepatic vasculature and portal vein are patent. Continue heparin drip PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. Correlation with endoscopy. Prior inferior myocardial infarction. Follow up CT as outpt to eval. The right posterior tibial and peroneal veins are patent. Coronal and sagittal reformats were performed. FINAL REPORT CT TORSO COMPARISON: and . Treat with anticoagulation. Treat with anticoagulation. Switch back to spiriva and prn albuterol inhaler when back to baseline. Rec: MRCP. Rec: MRCP. Rec: MRCP. Rec: MRCP. Continue albuterol and atrovent nebs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. There is trace ascites. Severe emphysema is noted. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Clinical concern for lower extremity DVT. IV contrast was administered. Reasonable to treat with Vanc/Cefepim/Levoflox given history of GNRs in sputum. 5:06 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? IMPRESSION:Hyperdensity noted on recent CTA torso is unchanged and likely corresponds to calcification. MRCP or ERCP should be performed. Sinus tachycardia. Would follow up CT. Strep PNA in sputum. Trace ascites. Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in sputum. Post-surgical changes from left lateral fusion hardware are present. Monitor Hct. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. Sinus tachycardia with ventricular premature beats. COMPARISON: CT abdomen and ; ct chest . Prelim showing left DVT. Severe emphysema is demonstrated as well as nonspecific scarring at the right apex. There is mild pancreatic ductal prominence. Has LLL consolidation on CXR. There mild antral wall thickening and mucosal (Over) 5:06 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ?"},"n_notes":{"kind":"number","value":34,"string":"34"},"notes":{"kind":"list like","value":[{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Progress Note","row_id":619882,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\n heparin to 800units/hr\n Plan:\n Next PTT at 1200. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":619890,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\n use heparin gtt\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\n need repeat CT in 3 months to re-eval.\n -- LFT/lipase/amylase unremarkable\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 325 mL\n PO:\n TF:\n IVF:\n 361 mL\n 325 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n 225 K/uL\n 10.5 g/dL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\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:Transfer to floor\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619896,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\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 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619897,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\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 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\n sputum cx.\n COPD: seems stable, not need for steroids.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619900,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen:\n HEENT:\n Neck:\n CV:\n Pulm:\n Abd:\n Extrem:\n Neuro:\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Cipro given history of GNRs in sputum. Check sputum\n cx\n COPD: seems stable, not need for steroids.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Resident Progress Note","row_id":619901,"text":"Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\n use heparin gtt\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\n need repeat CT in 3 months to re-eval.\n -- LFT/lipase/amylase unremarkable\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 325 mL\n PO:\n TF:\n IVF:\n 361 mL\n 325 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, mild expiratory\n wheeze\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n 225 K/uL\n 10.5 g/dL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. The patient was\n started on a heparin gtt in the ED. ECG showed no evidence of RV\n strain, troponin wnl. Overnight pt did well on 3L NC and remains\n hemodynamically stable. Troponins have been flat. Pt with no recent\n surgerys, immobilization, known malignancy, family history of\n hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Start Coumadin 5mg; monitor INR\n - follow up TTE to evaluate for right heart strain\n - LENI pending\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - Continue Vanco/Cefepime and d/c cipro given negative urine legionella\n - sputum cx\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . There was mention of a hyperdensity seen on CTA\n and a non-contrast CT abdomen showed AAA stable Spoke with vascular\n surgery who felt there was no evidence of a leak.\n -Monitor Hct closely given heparin/coumadin\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.. LFTs wnl\n - f/u final CTA read\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\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:Transfer to floor\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619902,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Albuterol nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen:\n HEENT:\n Neck:\n CV:\n Pulm:\n Abd:\n Extrem:\n Neuro:\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\n resolution since could also represent malignancy.\n Continue heparin drip. Start coumadin today. Echo and LENI\ns today\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignancy. Follow up CT as outpt to eval.\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\n sputum. Check sputum cx\n COPD: seems stable, not need for steroids. Continue albuterol and\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\n back to baseline.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon. Guaiac stools.\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\n awaiting final read. LFT\ns and /lipase normal. need MRCP as\n outpt.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n ICU Care\n Nutrition: regular diet\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: heparin gtt\n Code status: Full code\n Disposition : call out to floor\n Total time spent: 30 min\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619977,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Patient started on Coumadin today. Given first dose of 5mg.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Monitor Hct.\n AAA increased in size from , but per MICU team is currently\n stable. Hct 34 at 12pm, stable from 33 with am labs. Patient needs\n bedside echo tomorrow.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables: Clothes, shoes\n Other valuables:\n Clothes:\n Wallet / Money: Patient has wallet, but he sent his credit cards and\n cash to security. Wallet contains only ID card and other cards that\n are not credit cards.\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: CC701\n Date & time of Transfer: 1800\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619952,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs. Patient needs bedside echo.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619945,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\n heparin to 800units/hr\n Plan:\n Next PTT at 1200. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619951,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Progress Note","row_id":619828,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT at 1000\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619817,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs q6 and albuterol\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619818,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs q6 and albuterol\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619819,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs and albuterol nebs\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619821,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Resident Admission Note","row_id":619822,"text":"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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":"Physician ","chartdate":"2131-12-29 00:00:00.000","description":"Physician Attending Admission Note - MICU","row_id":619823,"text":"Chief Complaint: Right sided pleuritic CP/ PE and PNA\n I saw and examined the patient, and was physically present with the 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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n admitted to MICU for COPD exacerbation and PNA. Strep PNA in\n sputum.\n Meds:\n allopurinol\n atorvastatin\n albuterol/tiatropium\n vitamin D\n percocet\n cough suppressant\n noncontributory for PE\n Occupation:\n Drugs:\n Tobacco: long smoking history. - ppD currently\n Alcohol: h/o ETOH abuse - drinks few per night. No recent withdrawl\n Other: lives by self, on disability at home in apartment.\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: Chest pain\n Respiratory: Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Allergy / Immunology: No(t) Immunocompromised\n Pain: Moderate\n Flowsheet Data as of 10:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 125 mL\n PO:\n TF:\n IVF:\n 125 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 221\n 39\n 141\n 0.8\n 10\n 26\n 93\n 3.6\n 133\n 22.0\n [image002.jpg]\n Other labs: Lactic Acid:2.9\n Fluid analysis / Other labs: negative U/A\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\n sputum cx.\n COPD: seems stable, not need for steroids.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2131-12-29 00:00:00.000","description":"Nursing Progress Note","row_id":619825,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Progress Note","row_id":619829,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT at 1000. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco. ABD CT done\n Response:\n Plan:\n Cont ABX, follow CT result.\n"},{"category":"Physician ","chartdate":"2131-12-30 00:00:00.000","description":"Physician Attending Progress Note","row_id":619982,"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Albuterol nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen: alert, oriented, NAD\n HEENT: PERRL\n Neck:supple\n CV: S1S2 tachy\n Pulm: clear ant/lat\n Abd: soft, nt\n Extrem: no edema\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\n resolution since could also represent malignancy.\n Continue heparin drip. Start coumadin today. Echo and LENI\ns today\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignancy. Follow up CT as outpt to eval.\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\n sputum. Check sputum cx\n COPD: seems stable, not need for steroids. Continue albuterol and\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\n back to baseline.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon. Guaiac stools.\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\n awaiting final read. LFT\ns and /lipase normal. need MRCP as\n outpt.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n ICU Care\n Nutrition: regular diet\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: heparin gtt\n Code status: Full code\n Disposition : call out to floor\n Total time spent: 30 min\n"},{"category":"Nursing","chartdate":"2131-12-30 00:00:00.000","description":"Nursing Transfer Note","row_id":619949,"text":"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift.\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"},{"category":"ECG","chartdate":"2132-01-03 00:00:00.000","description":"Report","row_id":252938,"text":"Sinus tachycardia. Prior inferior myocardial infarction. Low limb lead\nvoltage. Non-specific inferolateral ST-T wave flattening. Compared to the\nprevious tracing of the rate has increased. The Q waves are more\nevident in the inferior leads. Clinical correlation is suggested.\n\n"},{"category":"ECG","chartdate":"2131-12-30 00:00:00.000","description":"Report","row_id":252939,"text":"Sinus rhythm. Baseline artifact. Non-specific ST-T wave changes. Compared to\ntracing #1 the rate has decreased and the ventricular premature beats are no\nlonger seen.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2131-12-29 00:00:00.000","description":"Report","row_id":252940,"text":"Sinus tachycardia with ventricular premature beats. Non-specific ST-T wave\nchanges. Compared to the previous tracing of the ventricular premature\nbeats are new.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2131-12-29 00:00:00.000","description":"CTA CHEST W&W/O C&RECONS, NON-CORONARY","row_id":1120181,"text":" 5:06 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with severe R lower chest wall TTP and flank TTP, sob\n REASON FOR THIS EXAMINATION:\n eval for PE, perineprhic abscess, other acute path\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa SAT 6:44 PM\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n COMPARISON: and .\n\n HISTORY: Right lower chest wall tenderness to palpation, shortness of breath,\n evaluate for PE, perinephric abscess or other acute pathology.\n\n TECHNIQUE: MDCT axially acquired images through the chest, abdomen and pelvis\n were obtained. IV contrast was administered. Coronal and sagittal reformats\n were performed.\n\n FINDINGS: Within the right lower lobe segmental pulmonary artery, there are\n filling defects extending into the subsegmental branches. There is\n consolidation in the right lower lobe which may represent pulmonary infarct\n versus infection. There are severe emphysematous changes identified. In the\n left lower lobe (3A, 58) there is peripheral consolidation with the suggestion\n of an air bronchogram concerning for infection. There is no pleural or\n pericardial effusion. There is no axillary, hilar or mediastinal\n lymphadenopathy. Debris within the trachea is identified (3A, 10). While\n most of this appears aerosolized, underlying endobronchial lesion cannot be\n entirely excluded particularly within the right main stem bronchus (3A, 21).\n\n Atherosclerotic plaque is identified along the thoracic aorta and extending\n into the abdominal aorta.\n\n CT ABDOMEN: There is a large abdominal aortic aneurysm measuring\n approximately 4.2 x 4.0 x 7.5 cm. This has increased in size when compared to\n . More prominent hyperdensity along the periphery likely represents\n calcification (3b, 137). Streak artifact from the posterior spinal hardware\n slightly limits evaluation of the abdomen. Within this limitation, the\n spleen, kidneys, adrenal glands,and small bowel are unremarkable. The liver\n appears nodular. The gallbladder contains tiny gallstones. There is mild\n pancreatic ductal prominence. The commone bile duct is dilated, measuring up\n to 1.5 cm in diameter, new. There mild antral wall thickening and mucosal\n (Over)\n\n 5:06 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n enhancement. There is no mesenteric or retroperitoneal lymphadenopathy. There\n is no free fluid or free air.\n\n CT OF THE PELVIS: The bladder, rectum and sigmoid colon are unremarkable.\n The prostate contains coarse calcifications. There is no pelvic or inguinal\n lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n Compression fracture of L3 is stable.\n\n IMPRESSION:\n 1. Right lower lobe segmental pulmonary artery embolus with possible right\n lower lobe pulmonary infarct vs infection.\n 2. Focal consolidation in the left lower lobe concerning for infection.\n 3. Debris within the trachea; while most appears aerosolized, underlying\n endobronchial lesion cannot be entirely excluded particularly within the right\n main stem bronchus.\n 5. Cholelithiasis. Dilated common bile duct and prominent pancreatic duct.\n MRCP or ERCP should be performed.\n 6. Infrarenal abdominal aortic aneurysm as described above, with interval\n increase in size when compared to .\n 7. Mild antral wall thickening and enhancement, may in part relate to\n underdistention or gastritis. Correlation with endoscopy.\n 8. New hyperdensity within the aortic aneurysm which is likely calcification.\n Noncontrast CT scan of this area is recommended to confirm.\n\n Findings were discussed with Dr. at approximately 6:40\n p.m. via telephone. Recommendations were conveyed to Dr. at 9 pm\n via telephone.\n\n"},{"category":"Radiology","chartdate":"2131-12-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1120222,"text":" 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD presents with pneumonia and PE\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Pneumonia. Pulmonary embolism.\n\n FINDINGS: Ill-defined opacities at the right lung base have progressed since\n the recent chest radiograph, and correspond to an area of suspected hemorrhage\n and/or evolving infarction on recent CT in the setting of an adjacent\n pulmonary embolism. Poorly defined opacities in periphery of left lung base\n could be related to either pulmonary embolism or infection. Severe emphysema\n is demonstrated as well as nonspecific scarring at the right apex.\n\n"},{"category":"Radiology","chartdate":"2131-12-29 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1120204,"text":" 9:46 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\n hyperdensity radiology recommended non-contrast eval\n REASON FOR THIS EXAMINATION:\n eval AAA given radiology concern for hyperdensity seen on prior CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SUN 12:35 AM\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\n torso, demonstrating the likely etiology to the mural calcification.\n 2. No other short-term interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, AAA, presents with PE, pneumonia. On the prior CTA\n performed earlier today, there was a questionable hyperdensity in the\n abdominal aorta, for further evaluation.\n\n TECHNIQUE: Non-contrast CT acquisition through the abdomen at the level of\n the kidneys with multiplanar reformations.\n\n FINDINGS: Focused evaluation was performed for assessing the region of\n interest in the abdominal aorta (2:19) at the site of the abdominal aortic\n aneurysm. The previously noted linear hyperdensity is again present on the\n non-contrast sequences (2:19, 25), unchanged, and therefore likely reflects\n calcification. Please refer to the concurrent CT for further details of the\n remainder of the findings.\n\n Residual contrast is seen in the kidneys from the prior study. Gallstones are\n present. Again is noted the calcified infrarenal abdominal aortic aneurysm\n measuring 4 x 4.2 cm. There is patchy opacity at the base of the right lung\n could represent atelectasis, aspiration, superimposed pneumonia cannot be\n excluded. Post-surgical changes from left lateral fusion hardware are\n present.\n\n IMPRESSION:Hyperdensity noted on recent CTA torso is unchanged and likely\n corresponds to calcification. No other short-term interval change.\n\n"},{"category":"Radiology","chartdate":"2131-12-29 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":1120205,"text":", A. MED MICU-7 9:46 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\n hyperdensity radiology recommended non-contrast eval\n REASON FOR THIS EXAMINATION:\n eval AAA given radiology concern for hyperdensity seen on prior CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\n torso, demonstrating the likely etiology to the mural calcification.\n 2. No other short-term interval changes.\n\n"},{"category":"Radiology","chartdate":"2132-01-01 00:00:00.000","description":"MRCP (MR ABD W&W/OC)","row_id":1120550,"text":" 8:36 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\n Admitting Diagnosis: PULMONARY EMBOLIS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with PE, PNA, COPD, recent weight loss found to have dilated\n pancreatic duct on abdominal CT.\n REASON FOR THIS EXAMINATION:\n Please evaluate for causes of pancreatic duct dilatation, specifically\n malignancy.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRCP obtained .\n\n COMPARISON: CT abdomen and ; ct chest .\n\n HISTORY: A 66-year-old male with recent weight loss and dilated pancreatic\n duct on recent abdominal CT, evaluate for etiology.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet, including dynamic 2D T1-weighted GRE images obtained prior to,\n during, and after the uneventful intravenous administration of 17 mL of\n Magnevist. Additionally, the patient drank a combination of Gastromark and\n Redicat.\n\n The study is limited secondary to poor breathhold and therefore non-breath\n hold 2D images were performed for the dynamic series rather than 3D images.\n\n FINDINGS:\n There is pleural thickening along the left lateral chest wall, seen on recent\n CT chest of , and consistent with pleural scarring/chronic changes.\n Additionally, soft tissue density in the right hilum correlates with\n lymphadenopathy per chest CT. Fibrotic changes are stable within the right\n lung base. There are small bilateral pleural effusions.\n\n The liver demonstrates a nodular contour, morphology consistent with\n cirrhosis. There is normal signal intensity. There is homogeneous post-\n contrast enhancement within the liver. No abnormal enhancing are noted within\n the liver. There is no intrahepatic biliary ductal dilatation. Hepatic\n vasculature and portal vein are patent. There is trace ascites.\n\n There is mild dilatation of the common bile duct, which tapers normally at the\n ampulla. Additionally, there is mild dilatation of the pancreatic duct, which\n is smooth and tapers normally to the level of the papilla. There is no\n obstructing lesion or abnormal enhancement identified.\n\n The pancreas, spleen, and adrenal glands are unremarkable in appearance.\n Kidneys demonstrate prompt and symmetric uptake and excretion of contrast.\n Gallstones are identified within the gallbladder. There is no pericholecystic\n fluid or GB wall edema.\n (Over)\n\n 8:36 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\n Admitting Diagnosis: PULMONARY EMBOLIS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is aneurysmal dilatation of the descending abdominal aorta, in an\n infrarenal distribution, measuring approximately 4.2 x 3.7 cm in dimension.\n This is stable in appearance when compared to the recent abdominal CT and has\n a large partially thrombosed lumen, again unchanged when compared to the\n recent CT.\n\n No enlarged intraabdominal lymphadenopathy is identified.\n\n Bone marrow signal is grossly unremarkable. Hardware is noted within the\n spine.\n\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\n dynamic series.\n\n IMPRESSION:\n 1. Mild dilatation of the common bile duct and pancreatic duct which taper\n normally at the ampulla and are smooth in contour. This is most likely from\n papillary stenosis versus sphincter of Oddi dysfunction as no obstructing\n lesion is seen, however, a subtle lesion could be missed given limited\n evaluation secondary to patientinability to breath hold. If concern persists,\n ERCP could be performed for further evaluation.\n\n 2. Cirrhosis. Trace ascites.\n\n 3. Cholelithiasis.\n\n 4. Infrarenal abdominal aortic aneurysm, which is partially thrombosed, and\n unchanged in appearance when compared to the recent CT, and better evaluated\n on that CT.\n\n 5. Fibrosis at the right lung base with scarring involving the left lateral\n pleura as well as right hilar lymphadenopathy, findings unchanged from recent\n chest CT.\n\n"},{"category":"Radiology","chartdate":"2131-12-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1120169,"text":" 3:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with hx of copd recent pneumonia now right flank/?back pain\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 56-year-old male with history of COPD and recent\n pneumonia, now with right flank and back pain.\n\n COMPARISON: .\n\n FINDINGS: The lungs again are hyperinflated with flattening of the diaphragms\n and prominence of the interstitial markings with relative lucency of the upper\n lobes, suggesting chronic obstructive pulmonary disease. Scattered\n parenchymal scarring is again noted, most pronounced in the bilateral apical\n region, right greater than left, where biapical thickening is seen. Mild\n opacities along the peripheral left lung base are without significant interval\n change to mildly decreased since the prior study. Interstitial opacities are\n seen along the right lung base. No discrete focal consolidation or pleural\n effusion is seen. The heart is not enlarged. The aortic knob is calcified.\n Partially visualized spinal metallic hardware is again noted.\n\n"},{"category":"Radiology","chartdate":"2131-12-30 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1120268,"text":" 12:00 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE,EVAL FOR DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo M with COPD, AAA, presents with PE and pneumonia\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd SUN 2:33 PM\n IMPRESSION:\n\n Extensive thrombus within the left superficial femoral vein, popliteal vein\n and peroneal veins.\n\n No right lower extremity deep venous thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: A 66-year-old male with COPD, abdominal aortic aneurysm, PE\n and pneumonia. Clinical concern for lower extremity DVT.\n\n TECHNIQUE: Grayscale and Doppler ultrasound images of bilateral lower\n extremity veins were obtained.\n\n FINDINGS: The left common and superficial femoral veins are thrombosed with\n clot extending into the left popliteal vein and peroneal veins. The clot is\n not entirely occlusive in the common femoral vein but its proximal extent is\n not delineated on this study. The left posterior tibial vein demonstrates\n normal color flow. The right common femoral, superficial femoral, popliteal\n veins demonstrate normal compression, flow, and augmentation. The right\n posterior tibial and peroneal veins are patent.\n\n IMPRESSION: Extensive thrombus within the left common and superficial\n femoral, popliteal and peroneal veins. No right lower extremity deep venous\n thrombosis.\n\n"},{"category":"Radiology","chartdate":"2131-12-30 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1120269,"text":", A. MED MICU-7 12:00 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE,EVAL FOR DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo M with COPD, AAA, presents with PE and pneumonia\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION:\n\n Extensive thrombus within the left superficial femoral vein, popliteal vein\n and peroneal veins.\n\n No right lower extremity deep venous thrombosis.\n\n"},{"category":"Radiology","chartdate":"2131-12-31 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1120388,"text":" 10:13 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 42cm\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with P/E\n REASON FOR THIS EXAMINATION:\n r picc 42cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with new right-sided PICC placement. Evaluate\n for PICC placement.\n\n COMPARISON: Multiple priors, the most recent portable AP chest radiograph\n ; CT chest, abdomen and pelvis .\n\n TECHNIQUE: Portable chest radiograph.\n\n FINDINGS: The cardiac, mediastinal and hila contours are normal and unchanged\n from . The right-sided PICC terminates at the cavoatrial\n junction. Lung opacity is worsened since . Worsened bibasilar\n opacities are noted compared to , worrisome for pneumonia.\n Severe emphysema is noted. Spinal hardware is unchanged compared to most\n recent priors.\n\n IMPRESSION:\n 1. Right-sided PICC line at the cavoatrial junction.\n 2. Worsening bibasilar opacities compared to , worrisome for\n pneumonia.\n 3. Severe emphysema, unchanged since prior.\n\n"}],"string":"[\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 619882,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\\n heparin to 800units/hr\\n Plan:\\n Next PTT at 1200. Leni\\ns in the morning.\\n Pneumonia, other\\n Assessment:\\n Afebrile, upon arrival to unit tachypnic to high 20\\ns mid 30\\ns, sat\\n 96-98%, on NC 3L.\\n Action:\\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\\n Response:\\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\\n Plan:\\n Cont ABX, follow CT result.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 619890,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:05 PM\\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\\n use heparin gtt\\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\\n need repeat CT in 3 months to re-eval.\\n -- LFT/lipase/amylase unremarkable\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Heparin Sodium - 06:21 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 325 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 325 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 125 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n 225 K/uL\\n 10.5 g/dL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PNEUMONIA, OTHER\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evaluation if needed\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium and albuterol nebs prn\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs prn/ replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\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:Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619896,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification.\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:05 PM\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Heparin Sodium - 06:21 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\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 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 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 Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619897,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification.\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:05 PM\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Heparin Sodium - 06:21 AM\\n Other medications:\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\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 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant.\\n Continue heparin drip\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignacy. Would follow up CT. Reasonable to treat\\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\\n sputum cx.\\n COPD: seems stable, not need for steroids.\\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\\n stabilized.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n Percocet for pain.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 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 Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619900,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification. Abd CT\\n showed no leak\\n 24 Hour Events:\\n heparin gtt started for PE\\n Stable overnight\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefepime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Heparin Sodium - 800 units/hour\\n Atrovent nebs\\n Allopirinol\\n Lipitor\\n Nicotine patch\\n Vit D\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Gen:\\n HEENT:\\n Neck:\\n CV:\\n Pulm:\\n Abd:\\n Extrem:\\n Neuro:\\n Labs / Radiology\\n 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant.\\n Continue heparin drip\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignacy. Would follow up CT. Reasonable to treat\\n with Vanc/Cefepim/Cipro given history of GNRs in sputum. Check sputum\\n cx\\n COPD: seems stable, not need for steroids.\\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\\n will watch carefully in light of anticoagulation. Recheck Hct this\\n afternoon.\\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\\n stabilized.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n Percocet for pain.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 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 Total time spent:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 619901,\n \"text\": \"Chief Complaint:\\n 24 Hour Events:\\n BLOOD CULTURED - At 11:05 PM\\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\\n use heparin gtt\\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\\n need repeat CT in 3 months to re-eval.\\n -- LFT/lipase/amylase unremarkable\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Heparin Sodium - 06:21 AM\\n Other medications:\\n Changes to medical and family history:\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:26 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 325 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 325 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 125 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, mild expiratory\\n wheeze\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n 225 K/uL\\n 10.5 g/dL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PNEUMONIA, OTHER\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. The patient was\\n started on a heparin gtt in the ED. ECG showed no evidence of RV\\n strain, troponin wnl. Overnight pt did well on 3L NC and remains\\n hemodynamically stable. Troponins have been flat. Pt with no recent\\n surgerys, immobilization, known malignancy, family history of\\n hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Start Coumadin 5mg; monitor INR\\n - follow up TTE to evaluate for right heart strain\\n - LENI pending\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - Continue Vanco/Cefepime and d/c cipro given negative urine legionella\\n - sputum cx\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . There was mention of a hyperdensity seen on CTA\\n and a non-contrast CT abdomen showed AAA stable Spoke with vascular\\n surgery who felt there was no evidence of a leak.\\n -Monitor Hct closely given heparin/coumadin\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.. LFTs wnl\\n - f/u final CTA read\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium and albuterol nebs prn\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs prn/ replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\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:Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619902,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification. Abd CT\\n showed no leak\\n 24 Hour Events:\\n heparin gtt started for PE\\n Stable overnight\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefepime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Heparin Sodium - 800 units/hour\\n Atrovent nebs\\n Albuterol nebs\\n Allopirinol\\n Lipitor\\n Nicotine patch\\n Vit D\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Gen:\\n HEENT:\\n Neck:\\n CV:\\n Pulm:\\n Abd:\\n Extrem:\\n Neuro:\\n Labs / Radiology\\n 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\\n resolution since could also represent malignancy.\\n Continue heparin drip. Start coumadin today. Echo and LENI\\ns today\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignancy. Follow up CT as outpt to eval.\\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\\n sputum. Check sputum cx\\n COPD: seems stable, not need for steroids. Continue albuterol and\\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\\n back to baseline.\\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\\n will watch carefully in light of anticoagulation. Recheck Hct this\\n afternoon. Guaiac stools.\\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\\n awaiting final read. LFT\\ns and /lipase normal. need MRCP as\\n outpt.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n ICU Care\\n Nutrition: regular diet\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Prophylaxis:\\n DVT: heparin gtt\\n Code status: Full code\\n Disposition : call out to floor\\n Total time spent: 30 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619977,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\\n and flank pain with cough and movement. Patient tachypnic with\\n movement/exertion.\\n Action:\\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\\n increased to 900units/hr. Next PTT due at . Patient had LENI\\n today. Prelim showing left DVT. Received 2 Percocet for pain\\n associated with coughing.\\n Response:\\n Remains on NC 3L. Patient states he has relief from Percocets.\\n Patient started on Coumadin today. Given first dose of 5mg.\\n Plan:\\n Next PTT at . Continue Heparin gtt per protocol. Monitor Hct.\\n AAA increased in size from , but per MICU team is currently\\n stable. Hct 34 at 12pm, stable from 33 with am labs. Patient needs\\n bedside echo tomorrow.\\n Pneumonia, other\\n Assessment:\\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\\n consolidation on CXR.\\n Action:\\n Patient with weak cough. Encouraged to cough up secretions and\\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\\n Response:\\n Remains afebrile, continues to be tachynic with exertion, but O2\\n requirement remains the same.\\n Plan:\\n Cont ABX. Encourage pulmonary toilet.\\n Demographics\\n Attending MD:\\n Admit diagnosis:\\n Code status:\\n Height:\\n Admission weight:\\n Daily weight:\\n Allergies/Reactions:\\n Precautions:\\n PMH:\\n CV-PMH:\\n Additional history:\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:\\n D:\\n Temperature:\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n Heart Rate:\\n Heart rhythm:\\n O2 delivery device:\\n O2 saturation:\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 24h total out:\\n Pacer Data\\n Pertinent Lab Results:\\n Additional pertinent labs:\\n Lines / Tubes / Drains:\\n Valuables / Signature\\n Patient valuables: Clothes, shoes\\n Other valuables:\\n Clothes:\\n Wallet / Money: Patient has wallet, but he sent his credit cards and\\n cash to security. Wallet contains only ID card and other cards that\\n are not credit cards.\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: MICU 7\\n Transferred to: CC701\\n Date & time of Transfer: 1800\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619952,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\\n and flank pain with cough and movement. Patient tachypnic with\\n movement/exertion.\\n Action:\\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\\n increased to 900units/hr. Next PTT due at . Patient had LENI\\n today. Prelim showing left DVT. Received 2 Percocet for pain\\n associated with coughing.\\n Response:\\n Remains on NC 3L. Patient states he has relief from Percocets.\\n Plan:\\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\\n from 33 with am labs. Patient needs bedside echo.\\n Pneumonia, other\\n Assessment:\\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\\n consolidation on CXR.\\n Action:\\n Patient with weak cough. Encouraged to cough up secretions and\\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\\n Response:\\n Remains afebrile, continues to be tachynic with exertion, but O2\\n requirement remains the same.\\n Plan:\\n Cont ABX. Encourage pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619945,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\\n heparin to 800units/hr\\n Plan:\\n Next PTT at 1200. Leni\\ns in the morning.\\n Pneumonia, other\\n Assessment:\\n Afebrile, upon arrival to unit tachypnic to high 20\\ns mid 30\\ns, sat\\n 96-98%, on NC 3L.\\n Action:\\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\\n Response:\\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\\n Plan:\\n Cont ABX, follow CT result.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619951,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\\n and flank pain with cough and movement. Patient tachypnic with\\n movement/exertion.\\n Action:\\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\\n increased to 900units/hr. Next PTT due at . Patient had LENI\\n today. Prelim showing left DVT. Received 2 Percocet for pain\\n associated with coughing.\\n Response:\\n Remains on NC 3L. Patient states he has relief from Percocets.\\n Plan:\\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\\n from 33 with am labs.\\n Pneumonia, other\\n Assessment:\\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\\n consolidation on CXR.\\n Action:\\n Patient with weak cough. Encouraged to cough up secretions and\\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\\n Response:\\n Remains afebrile, continues to be tachynic with exertion, but O2\\n requirement remains the same.\\n Plan:\\n Cont ABX. Encourage pulmonary toilet.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 619828,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L\\n Plan:\\n next PTT at 1000\\n Pneumonia, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619817,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evalution\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium nebs q6 and albuterol\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs / replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619818,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evalution\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium nebs q6 and albuterol\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs / replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619819,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evalution\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium nebs and albuterol nebs\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs / replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619821,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evaluation if needed\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium and albuterol nebs prn\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs prn/ replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 619822,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\\n REASON FOR MICU ADMISSION: PE & Pneumonia\\n HPI:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated for pneumonia/COPD\\n exacerbation with levofloxacin and prednisone. His sputum culture grew\\n 2 types of GNR that were not speciated. He was also discharged on\\n after being intubated in the MICU for COPD exacerbation/pneumonia\\n that eventually grew S. pneumonia and treated with levoflox.\\n .\\n The patient reports for the last for days he has been having worsening\\n SOB, cough and sputum production. The patient also developed\\n sharp/pleuritic right lower chest and flank pain. He states that the\\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\\n abdominal pain or N/V.\\n .\\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\\n underwent CTA that showed RLL segmental PE with associated RLL\\n infarct. There was also a LLL consolidation concerning for pnuemonia.\\n Additionally, his AAA had increased in size to 4.2x7.5cm without\\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\\n was also given morphine 2mg x2 for pain. The patient continued to be\\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\\n 100% on 3L.\\n .\\n On the floor the patient is complaining of SOB and pleuritic right\\n sided chest/flank pain. He denied fevers/chills.\\n .\\n Called by radiology regarding CTA . Pancreatic ductal dilation\\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\\n likely represents thrombus, but would recommend non-con CT to better\\n evaluated for possible leak.\\n Patient admitted from: ER\\n History obtained from Medical records\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n MEDICATIONS AT HOME:\\n Bisacodyl 5 mg daily\\n Senna 8.6 mg \\n Docusate Sodium \\n Albuterol Sulfate 0.63 mg/3 mL q6:prn\\n Albuterol Sulfate 90 mcg/Actuation QID\\n Allopurinol 150mg daily\\n Cholecalciferol (Vitamin D3) 800U daily\\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\\n Atorvastatin 10 mg daily\\n Tiotropium Bromide 18 mcg Capsule daily\\n Codeine-Guaifenesin q6prn\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n Hyperlipidemia\\n Gout\\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\\n relief, l3 compresion fracture\\n No history of CAD.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: History of EtOH abuse with beer, no history of illicit drug use.\\n Long history of smoking >40 years of 2 ppd, currently smoking pack\\n per day. Lives by himself, is on disability.\\n Review of systems:\\n Flowsheet Data as of 09:30 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 117 mL\\n PO:\\n TF:\\n IVF:\\n 117 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -183 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n Physical Examination\\n GEN: NAD, tachypneic and purse lip breathing\\n SKIN:No rashes or skin changes noted\\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\\n or supraclavicular chains noted.\\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\\n wheezes\\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\\n ABDOMEN: s/nt/nd\\n EXTREMITIES: no pedal edema bilaterally\\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\\n and BLE both proximally and distally. No pronator drift. Reflexes\\n were symmetric.\\n Labs / Radiology\\n [image002.jpg]\\n STUDIES:\\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\\n significant change when compared to .\\n .\\n CTA: Prelim\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\\n air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\\n 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n .\\n TTE \\n The left atrium and right atrium are normal in cavity size. The\\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\\n thickness, cavity size, and global systolic function are normal\\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\n abnormality cannot be fully excluded. Right ventricular chamber size\\n and free wall motion are normal. The aortic valve leaflets are mildly\\n thickened (?#). There is no aortic valve stenosis. Trace aortic\\n regurgitation is seen. The mitral valve appears structurally normal\\n with trivial mitral regurgitation. The pulmonary artery systolic\\n pressure could not be determined. There is no pericardial effusion.\\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\\n with preserved global biventricular systolic function. Aortic valve\\n sclerosis.\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE\\n ASSESSMENT & PLAN:\\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\\n recently discharged on after being treated in the MICU for COPD\\n exacerbation/pneumonia with levoflox and prednisone presents with PE\\n and pneumonia.\\n .\\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\\n associated tacyhcardia, but stable blood pressure. He is maintaining\\n his sats on 3L, but tachypneic. The patient was started on a heparin\\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\\n Pt with no recent surgerys, immobilization, known malignancy, family\\n history of hypercoagulability.\\n - Cont heparin gtt (active T&S and guaiac stools)\\n - Cont Respiratory Support, stable on room air, but low threshold for\\n intubation\\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\\n but will limit given possibility of worsening RV failure. Maintain MAPS\\n >65. Support with levophed if needed.\\n - check BNP\\n - trend troponin\\n - order TTE to eval for right heart strain\\n - LENI\\n - ECG\\n .\\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\\n evidence of other acute pathology. UA negative Also, likely reactive\\n component in the setting of PE and pulm infarct. Prior admission\\n pt with GNR in sputum and also treated for S. pneumo on \\n both treated with levoflox.\\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\\n and to cover for legionella/ double coverage given GNR in last sputum\\n - sputum cx\\n - legionella antigen\\n - f/u urine and blood cx\\n - trend fever curve and WBC\\n .\\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\\n from U/S on . Will eval area of hyperdensity seen on CTA with\\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\\n abnormal then will further assess patient.\\n .\\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\\n pain likely secondary to pulmonary infarct, however less likely could\\n represent gallbladder/pancreatic pathology.\\n - will check LFT and lipase/amylase\\n - f/u final CTA read\\n - consider MRCP for further evaluation if needed\\n .\\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\\n Current tachypnea and SOB related to PE & pneumonia and not COPD\\n exacerbation.\\n - ipratropium and albuterol nebs prn\\n .\\n # Hyperlipidemia:\\n - continue atorvostatin\\n .\\n #. Gout: Cont allopurinol\\n .\\n # FEN: IVFs prn/ replete lytes prn / regular diet\\n # PPX: PPI, heparin gtt, bowel regimen\\n # ACCESS: PIV\\n # CODE: Full, discussed\\n # CONTACT:\\n # DISPOSITION:\\n [ ] Floor pending further investigation\\n [ ] Floor pending\\n [ ] Stepdown / \\n [x] ICU\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note - MICU\",\n \"row_id\": 619823,\n \"text\": \"Chief Complaint: Right sided pleuritic CP/ PE and PNA\\n I saw and examined the patient, and was physically present with the 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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification.\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefipime - 09:26 PM\\n Infusions:\\n Heparin Sodium - 800 units/hour\\n Other ICU medications:\\n Other medications:\\n Past medical history:\\n Family history:\\n Social History:\\n COPD\\n AAA\\n HTN\\n admitted to MICU for COPD exacerbation and PNA. Strep PNA in\\n sputum.\\n Meds:\\n allopurinol\\n atorvastatin\\n albuterol/tiatropium\\n vitamin D\\n percocet\\n cough suppressant\\n noncontributory for PE\\n Occupation:\\n Drugs:\\n Tobacco: long smoking history. - ppD currently\\n Alcohol: h/o ETOH abuse - drinks few per night. No recent withdrawl\\n Other: lives by self, on disability at home in apartment.\\n Review of systems:\\n Constitutional: Fatigue\\n Ear, Nose, Throat: No(t) Dry mouth\\n Cardiovascular: Chest pain\\n Respiratory: Dyspnea\\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\\n Genitourinary: No(t) Dysuria\\n Endocrine: No(t) Hyperglycemia\\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia\\n Neurologic: No(t) Headache\\n Psychiatric / Sleep: No(t) Agitated\\n Allergy / Immunology: No(t) Immunocompromised\\n Pain: Moderate\\n Flowsheet Data as of 10:28 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.5\\nC (97.7\\n Tcurrent: 36.5\\nC (97.7\\n HR: 108 (108 - 116) bpm\\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\\n RR: 25 (19 - 25) insp/min\\n SpO2: 97%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 125 mL\\n PO:\\n TF:\\n IVF:\\n 125 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -175 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 97%\\n ABG: ////\\n Physical Examination\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\\n Not assessed)\\n Respiratory / Chest: (Breath Sounds: Diminished: b/l)\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Skin: Warm\\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\\n stimuli, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 221\\n 39\\n 141\\n 0.8\\n 10\\n 26\\n 93\\n 3.6\\n 133\\n 22.0\\n [image002.jpg]\\n Other labs: Lactic Acid:2.9\\n Fluid analysis / Other labs: negative U/A\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant.\\n Continue heparin drip\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignacy. Would follow up CT. Reasonable to treat\\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\\n sputum cx.\\n COPD: seems stable, not need for steroids.\\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\\n stabilized.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n Percocet for pain.\\n ICU Care\\n Nutrition:\\n Glycemic Control:\\n Lines / Intubation:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Comments:\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Heparin gtt)\\n Stress ulcer: Not indicated\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 45 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 619825,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L\\n Plan:\\n next PTT\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 619829,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\\n pain and flank pain with cough and movemnt PTT 109\\n Action:\\n decreased Heparin to 700units/hr, given Percoset.\\n Response:\\n remaisn on NC 3L\\n Plan:\\n next PTT at 1000. Leni\\ns in the morning.\\n Pneumonia, other\\n Assessment:\\n Afebrile, upon arrival to unit tachypnic to high 20\\ns mid 30\\ns, sat\\n 96-98%, on NC 3L.\\n Action:\\n Start on Cipro Iv, cefepime, cont Vanco. ABD CT done\\n Response:\\n Plan:\\n Cont ABX, follow CT result.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Physician Attending Progress Note\",\n \"row_id\": 619982,\n \"text\": \"Chief Complaint:\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\\n non-contrast CT to r/o possible leak versus calcification. Abd CT\\n showed no leak\\n 24 Hour Events:\\n heparin gtt started for PE\\n Stable overnight\\n Allergies:\\n Atenolol\\n Wheezing;\\n Ms Contin (Oral) (Morphine Sulfate)\\n Nausea/Vomiting\\n Last dose of Antibiotics:\\n Cefepime - 09:26 PM\\n Ciprofloxacin - 10:53 PM\\n Vancomycin - 06:27 AM\\n Heparin Sodium - 800 units/hour\\n Atrovent nebs\\n Albuterol nebs\\n Allopirinol\\n Lipitor\\n Nicotine patch\\n Vit D\\n Changes to medical and family history:\\n PMH, SH, FH and ROS are unchanged from Admission except where noted\\n above and below\\n Review of systems is unchanged from admission except as noted below\\n Review of systems:\\n Flowsheet Data as of 07:52 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since AM\\n Tmax: 36.8\\nC (98.2\\n Tcurrent: 36.1\\nC (97\\n HR: 83 (83 - 116) bpm\\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\\n RR: 17 (9 - 26) insp/min\\n SpO2: 98%\\n Heart rhythm: SR (Sinus Rhythm)\\n Wgt (current): 42.3 kg (admission): 42.3 kg\\n Total In:\\n 2,361 mL\\n 335 mL\\n PO:\\n TF:\\n IVF:\\n 361 mL\\n 335 mL\\n Blood products:\\n Total out:\\n 1,100 mL\\n 200 mL\\n Urine:\\n 500 mL\\n 200 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,261 mL\\n 135 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n SpO2: 98%\\n ABG: ///27/\\n Physical Examination\\n Gen: alert, oriented, NAD\\n HEENT: PERRL\\n Neck:supple\\n CV: S1S2 tachy\\n Pulm: clear ant/lat\\n Abd: soft, nt\\n Extrem: no edema\\n Labs / Radiology\\n 10.5 g/dL\\n 225 K/uL\\n 130 mg/dL\\n 0.6 mg/dL\\n 27 mEq/L\\n 3.4 mEq/L\\n 7 mg/dL\\n 104 mEq/L\\n 137 mEq/L\\n 33.1 %\\n 15.1 K/uL\\n [image002.jpg]\\n 04:25 AM\\n WBC\\n 15.1\\n Hct\\n 33.1\\n Plt\\n 225\\n Cr\\n 0.6\\n TropT\\n <0.01\\n Glucose\\n 130\\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\\n Hemodynamically stable. Treat with anticoagulation. No clear\\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\\n resolution since could also represent malignancy.\\n Continue heparin drip. Start coumadin today. Echo and LENI\\ns today\\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\\n versus area of bullous emphysema. Await final read of Chest CT, but\\n would worry about malignancy. Follow up CT as outpt to eval.\\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\\n sputum. Check sputum cx\\n COPD: seems stable, not need for steroids. Continue albuterol and\\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\\n back to baseline.\\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\\n will watch carefully in light of anticoagulation. Recheck Hct this\\n afternoon. Guaiac stools.\\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\\n awaiting final read. LFT\\ns and /lipase normal. need MRCP as\\n outpt.\\n As per radiology: abd CT shows stable aneurysm compared to last CT.\\n ICU Care\\n Nutrition: regular diet\\n Lines:\\n 18 Gauge - 08:29 PM\\n 20 Gauge - 08:30 PM\\n Prophylaxis:\\n DVT: heparin gtt\\n Code status: Full code\\n Disposition : call out to floor\\n Total time spent: 30 min\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 619949,\n \"text\": \"66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\\n infarct. LLL consolidation concerning for PNA. AAA was increased in\\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\\n there was also pancreatic ductal dilatation, possible needs\\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\\n calcification\\n Pulmonary Embolism (PE), Acute\\n Assessment:\\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\\n and flank pain with cough and movement. Patient tachypnic with\\n movement/exertion.\\n Action:\\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\\n increased to 900units/hr. Next PTT due at . Patient had LENI\\n today. Prelim showing left DVT. Received 2 Percocet for pain\\n associated with coughing.\\n Response:\\n Remains on NC 3L. Patient states he has relief from Percocets.\\n Plan:\\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\\n from 33 with am labs.\\n Pneumonia, other\\n Assessment:\\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\\n consolidation on CXR.\\n Action:\\n Patient with weak cough. Encouraged to cough up secretions and\\n pulmonary toilet. Sputum sample sent this shift.\\n Response:\\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\\n Plan:\\n Cont ABX, follow CT result.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2132-01-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 252938,\n \"text\": \"Sinus tachycardia. Prior inferior myocardial infarction. Low limb lead\\nvoltage. Non-specific inferolateral ST-T wave flattening. Compared to the\\nprevious tracing of the rate has increased. The Q waves are more\\nevident in the inferior leads. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 252939,\n \"text\": \"Sinus rhythm. Baseline artifact. Non-specific ST-T wave changes. Compared to\\ntracing #1 the rate has decreased and the ventricular premature beats are no\\nlonger seen.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 252940,\n \"text\": \"Sinus tachycardia with ventricular premature beats. Non-specific ST-T wave\\nchanges. Compared to the previous tracing of the ventricular premature\\nbeats are new.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"CTA CHEST W&W/O C&RECONS, NON-CORONARY\",\n \"row_id\": 1120181,\n \"text\": \" 5:06 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with severe R lower chest wall TTP and flank TTP, sob\\n REASON FOR THIS EXAMINATION:\\n eval for PE, perineprhic abscess, other acute path\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: SBNa SAT 6:44 PM\\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with air\\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x 7.5\\n cm increased since . gallstones. Debris in trachea, can't exclude\\n underlying endobronchial lesion.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT TORSO\\n\\n COMPARISON: and .\\n\\n HISTORY: Right lower chest wall tenderness to palpation, shortness of breath,\\n evaluate for PE, perinephric abscess or other acute pathology.\\n\\n TECHNIQUE: MDCT axially acquired images through the chest, abdomen and pelvis\\n were obtained. IV contrast was administered. Coronal and sagittal reformats\\n were performed.\\n\\n FINDINGS: Within the right lower lobe segmental pulmonary artery, there are\\n filling defects extending into the subsegmental branches. There is\\n consolidation in the right lower lobe which may represent pulmonary infarct\\n versus infection. There are severe emphysematous changes identified. In the\\n left lower lobe (3A, 58) there is peripheral consolidation with the suggestion\\n of an air bronchogram concerning for infection. There is no pleural or\\n pericardial effusion. There is no axillary, hilar or mediastinal\\n lymphadenopathy. Debris within the trachea is identified (3A, 10). While\\n most of this appears aerosolized, underlying endobronchial lesion cannot be\\n entirely excluded particularly within the right main stem bronchus (3A, 21).\\n\\n Atherosclerotic plaque is identified along the thoracic aorta and extending\\n into the abdominal aorta.\\n\\n CT ABDOMEN: There is a large abdominal aortic aneurysm measuring\\n approximately 4.2 x 4.0 x 7.5 cm. This has increased in size when compared to\\n . More prominent hyperdensity along the periphery likely represents\\n calcification (3b, 137). Streak artifact from the posterior spinal hardware\\n slightly limits evaluation of the abdomen. Within this limitation, the\\n spleen, kidneys, adrenal glands,and small bowel are unremarkable. The liver\\n appears nodular. The gallbladder contains tiny gallstones. There is mild\\n pancreatic ductal prominence. The commone bile duct is dilated, measuring up\\n to 1.5 cm in diameter, new. There mild antral wall thickening and mucosal\\n (Over)\\n\\n 5:06 PM\\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\\n Contrast: OPTIRAY Amt: 130\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n enhancement. There is no mesenteric or retroperitoneal lymphadenopathy. There\\n is no free fluid or free air.\\n\\n CT OF THE PELVIS: The bladder, rectum and sigmoid colon are unremarkable.\\n The prostate contains coarse calcifications. There is no pelvic or inguinal\\n lymphadenopathy.\\n\\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\\n Compression fracture of L3 is stable.\\n\\n IMPRESSION:\\n 1. Right lower lobe segmental pulmonary artery embolus with possible right\\n lower lobe pulmonary infarct vs infection.\\n 2. Focal consolidation in the left lower lobe concerning for infection.\\n 3. Debris within the trachea; while most appears aerosolized, underlying\\n endobronchial lesion cannot be entirely excluded particularly within the right\\n main stem bronchus.\\n 5. Cholelithiasis. Dilated common bile duct and prominent pancreatic duct.\\n MRCP or ERCP should be performed.\\n 6. Infrarenal abdominal aortic aneurysm as described above, with interval\\n increase in size when compared to .\\n 7. Mild antral wall thickening and enhancement, may in part relate to\\n underdistention or gastritis. Correlation with endoscopy.\\n 8. New hyperdensity within the aortic aneurysm which is likely calcification.\\n Noncontrast CT scan of this area is recommended to confirm.\\n\\n Findings were discussed with Dr. at approximately 6:40\\n p.m. via telephone. Recommendations were conveyed to Dr. at 9 pm\\n via telephone.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1120222,\n \"text\": \" 4:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with COPD presents with pneumonia and PE\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n COMPARISON: .\\n\\n INDICATION: Pneumonia. Pulmonary embolism.\\n\\n FINDINGS: Ill-defined opacities at the right lung base have progressed since\\n the recent chest radiograph, and correspond to an area of suspected hemorrhage\\n and/or evolving infarction on recent CT in the setting of an adjacent\\n pulmonary embolism. Poorly defined opacities in periphery of left lung base\\n could be related to either pulmonary embolism or infection. Severe emphysema\\n is demonstrated as well as nonspecific scarring at the right apex.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1120204,\n \"text\": \" 9:46 PM\\n CT ABDOMEN W/O CONTRAST Clip # \\n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\\n hyperdensity radiology recommended non-contrast eval\\n REASON FOR THIS EXAMINATION:\\n eval AAA given radiology concern for hyperdensity seen on prior CTA\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SUN 12:35 AM\\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\\n torso, demonstrating the likely etiology to the mural calcification.\\n 2. No other short-term interval changes.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: COPD, AAA, presents with PE, pneumonia. On the prior CTA\\n performed earlier today, there was a questionable hyperdensity in the\\n abdominal aorta, for further evaluation.\\n\\n TECHNIQUE: Non-contrast CT acquisition through the abdomen at the level of\\n the kidneys with multiplanar reformations.\\n\\n FINDINGS: Focused evaluation was performed for assessing the region of\\n interest in the abdominal aorta (2:19) at the site of the abdominal aortic\\n aneurysm. The previously noted linear hyperdensity is again present on the\\n non-contrast sequences (2:19, 25), unchanged, and therefore likely reflects\\n calcification. Please refer to the concurrent CT for further details of the\\n remainder of the findings.\\n\\n Residual contrast is seen in the kidneys from the prior study. Gallstones are\\n present. Again is noted the calcified infrarenal abdominal aortic aneurysm\\n measuring 4 x 4.2 cm. There is patchy opacity at the base of the right lung\\n could represent atelectasis, aspiration, superimposed pneumonia cannot be\\n excluded. Post-surgical changes from left lateral fusion hardware are\\n present.\\n\\n IMPRESSION:Hyperdensity noted on recent CTA torso is unchanged and likely\\n corresponds to calcification. No other short-term interval change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 1120205,\n \"text\": \", A. MED MICU-7 9:46 PM\\n CT ABDOMEN W/O CONTRAST Clip # \\n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\\n hyperdensity radiology recommended non-contrast eval\\n REASON FOR THIS EXAMINATION:\\n eval AAA given radiology concern for hyperdensity seen on prior CTA\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n PFI REPORT\\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\\n torso, demonstrating the likely etiology to the mural calcification.\\n 2. No other short-term interval changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2132-01-01 00:00:00.000\",\n \"description\": \"MRCP (MR ABD W&W/OC)\",\n \"row_id\": 1120550,\n \"text\": \" 8:36 AM\\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with PE, PNA, COPD, recent weight loss found to have dilated\\n pancreatic duct on abdominal CT.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for causes of pancreatic duct dilatation, specifically\\n malignancy.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: MRCP obtained .\\n\\n COMPARISON: CT abdomen and ; ct chest .\\n\\n HISTORY: A 66-year-old male with recent weight loss and dilated pancreatic\\n duct on recent abdominal CT, evaluate for etiology.\\n\\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\\n Tesla magnet, including dynamic 2D T1-weighted GRE images obtained prior to,\\n during, and after the uneventful intravenous administration of 17 mL of\\n Magnevist. Additionally, the patient drank a combination of Gastromark and\\n Redicat.\\n\\n The study is limited secondary to poor breathhold and therefore non-breath\\n hold 2D images were performed for the dynamic series rather than 3D images.\\n\\n FINDINGS:\\n There is pleural thickening along the left lateral chest wall, seen on recent\\n CT chest of , and consistent with pleural scarring/chronic changes.\\n Additionally, soft tissue density in the right hilum correlates with\\n lymphadenopathy per chest CT. Fibrotic changes are stable within the right\\n lung base. There are small bilateral pleural effusions.\\n\\n The liver demonstrates a nodular contour, morphology consistent with\\n cirrhosis. There is normal signal intensity. There is homogeneous post-\\n contrast enhancement within the liver. No abnormal enhancing are noted within\\n the liver. There is no intrahepatic biliary ductal dilatation. Hepatic\\n vasculature and portal vein are patent. There is trace ascites.\\n\\n There is mild dilatation of the common bile duct, which tapers normally at the\\n ampulla. Additionally, there is mild dilatation of the pancreatic duct, which\\n is smooth and tapers normally to the level of the papilla. There is no\\n obstructing lesion or abnormal enhancement identified.\\n\\n The pancreas, spleen, and adrenal glands are unremarkable in appearance.\\n Kidneys demonstrate prompt and symmetric uptake and excretion of contrast.\\n Gallstones are identified within the gallbladder. There is no pericholecystic\\n fluid or GB wall edema.\\n (Over)\\n\\n 8:36 AM\\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \\n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n Contrast: MAGNEVIST Amt: 17\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n There is aneurysmal dilatation of the descending abdominal aorta, in an\\n infrarenal distribution, measuring approximately 4.2 x 3.7 cm in dimension.\\n This is stable in appearance when compared to the recent abdominal CT and has\\n a large partially thrombosed lumen, again unchanged when compared to the\\n recent CT.\\n\\n No enlarged intraabdominal lymphadenopathy is identified.\\n\\n Bone marrow signal is grossly unremarkable. Hardware is noted within the\\n spine.\\n\\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\\n dynamic series.\\n\\n IMPRESSION:\\n 1. Mild dilatation of the common bile duct and pancreatic duct which taper\\n normally at the ampulla and are smooth in contour. This is most likely from\\n papillary stenosis versus sphincter of Oddi dysfunction as no obstructing\\n lesion is seen, however, a subtle lesion could be missed given limited\\n evaluation secondary to patientinability to breath hold. If concern persists,\\n ERCP could be performed for further evaluation.\\n\\n 2. Cirrhosis. Trace ascites.\\n\\n 3. Cholelithiasis.\\n\\n 4. Infrarenal abdominal aortic aneurysm, which is partially thrombosed, and\\n unchanged in appearance when compared to the recent CT, and better evaluated\\n on that CT.\\n\\n 5. Fibrosis at the right lung base with scarring involving the left lateral\\n pleura as well as right hilar lymphadenopathy, findings unchanged from recent\\n chest CT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1120169,\n \"text\": \" 3:08 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with hx of copd recent pneumonia now right flank/?back pain\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n EXAM: Chest, single AP upright portable view.\\n\\n CLINICAL INFORMATION: 56-year-old male with history of COPD and recent\\n pneumonia, now with right flank and back pain.\\n\\n COMPARISON: .\\n\\n FINDINGS: The lungs again are hyperinflated with flattening of the diaphragms\\n and prominence of the interstitial markings with relative lucency of the upper\\n lobes, suggesting chronic obstructive pulmonary disease. Scattered\\n parenchymal scarring is again noted, most pronounced in the bilateral apical\\n region, right greater than left, where biapical thickening is seen. Mild\\n opacities along the peripheral left lung base are without significant interval\\n change to mildly decreased since the prior study. Interstitial opacities are\\n seen along the right lung base. No discrete focal consolidation or pleural\\n effusion is seen. The heart is not enlarged. The aortic knob is calcified.\\n Partially visualized spinal metallic hardware is again noted.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1120268,\n \"text\": \" 12:00 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: PE,EVAL FOR DVT\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 yo M with COPD, AAA, presents with PE and pneumonia\\n REASON FOR THIS EXAMINATION:\\n eval for DVT\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd SUN 2:33 PM\\n IMPRESSION:\\n\\n Extensive thrombus within the left superficial femoral vein, popliteal vein\\n and peroneal veins.\\n\\n No right lower extremity deep venous thrombosis.\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAM: A 66-year-old male with COPD, abdominal aortic aneurysm, PE\\n and pneumonia. Clinical concern for lower extremity DVT.\\n\\n TECHNIQUE: Grayscale and Doppler ultrasound images of bilateral lower\\n extremity veins were obtained.\\n\\n FINDINGS: The left common and superficial femoral veins are thrombosed with\\n clot extending into the left popliteal vein and peroneal veins. The clot is\\n not entirely occlusive in the common femoral vein but its proximal extent is\\n not delineated on this study. The left posterior tibial vein demonstrates\\n normal color flow. The right common femoral, superficial femoral, popliteal\\n veins demonstrate normal compression, flow, and augmentation. The right\\n posterior tibial and peroneal veins are patent.\\n\\n IMPRESSION: Extensive thrombus within the left common and superficial\\n femoral, popliteal and peroneal veins. No right lower extremity deep venous\\n thrombosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-30 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1120269,\n \"text\": \", A. MED MICU-7 12:00 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: PE,EVAL FOR DVT\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 yo M with COPD, AAA, presents with PE and pneumonia\\n REASON FOR THIS EXAMINATION:\\n eval for DVT\\n ______________________________________________________________________________\\n PFI REPORT\\n IMPRESSION:\\n\\n Extensive thrombus within the left superficial femoral vein, popliteal vein\\n and peroneal veins.\\n\\n No right lower extremity deep venous thrombosis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2131-12-31 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1120388,\n \"text\": \" 10:13 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: r picc 42cm\\n Admitting Diagnosis: PULMONARY EMBOLIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 66 year old man with P/E\\n REASON FOR THIS EXAMINATION:\\n r picc 42cm\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 66-year-old man with new right-sided PICC placement. Evaluate\\n for PICC placement.\\n\\n COMPARISON: Multiple priors, the most recent portable AP chest radiograph\\n ; CT chest, abdomen and pelvis .\\n\\n TECHNIQUE: Portable chest radiograph.\\n\\n FINDINGS: The cardiac, mediastinal and hila contours are normal and unchanged\\n from . The right-sided PICC terminates at the cavoatrial\\n junction. Lung opacity is worsened since . Worsened bibasilar\\n opacities are noted compared to , worrisome for pneumonia.\\n Severe emphysema is noted. Spinal hardware is unchanged compared to most\\n recent priors.\\n\\n IMPRESSION:\\n 1. Right-sided PICC line at the cavoatrial junction.\\n 2. Worsening bibasilar opacities compared to , worrisome for\\n pneumonia.\\n 3. Severe emphysema, unchanged since prior.\\n\\n\"\n }\n]"}}},{"rowIdx":195,"cells":{"subject_id":{"kind":"number","value":16436,"string":"16,436"},"hadm_id":{"kind":"number","value":140997,"string":"140,997"},"target_text":{"kind":"string","value":"This is a 68-year-old female with morbid obesity, admitted for line sepsis, methicillin-resistant Staphylococcus aureus with a transient decrease in urinary output, and atrial fibrillation, now controlled, who is now re-admitted to the Medical Intensive Care Unit with an upper gastrointestinal bleed. There was blood seen in her lower esophagus by esophagogastroduodenoscopy with a large amount of clots and oozing red blood in the fundus. The patient was not able to protect airway herself, and she was do not intubate (per her sister who was her health care proxy). An nasogastric tube was placed, and the patient did not clear after 8 liters of fluid. A blood transfusion was initiated. The patient was given Protonix intravenously. Per, the Gastrointestinal Service, the patient was unable to be re-scoped without intubation. However, since she was refusing intubation because the patient wanted to be do not intubate even for temporary measures. The patient understood that this eliminated the possibility of gaining control of bleed via esophagogastroduodenoscopy. The Interventional Radiology Service was consulted, but they were unable to take the patient to angiography for possible embolization secondary to the patient's weight and difficulty in accessing groin and problems of ascites. The patient also received 2 units of fresh frozen plasma to correct coagulation. The team had a conversation with her sister regarding limited options at this point. We reiterated that esophagogastroduodenoscopy with intubation might be her last hope. The sister did understand the situation, but reported that the patient repeatedly expressed the desire to be do not resuscitate/do not intubate. Meanwhile, the patient was receiving blood transfusions and fluid resuscitation. The team was called at 6:30 in the morning by bedside and found the patient having no respirations. The patient subsequently passed away at that time. The patient was pronounced dead at 6:30 in the morning on . , M.D. Dictated By: MEDQUIST36 D: 13:50 T: 10:15 JOB#: "},"extractive_notes_summ":{"kind":"string","value":"She has had a non productive cough.Cardiac: HR 68-78 SR with frequent PAC's. PT DOES HAVE CPAP AT THE BEDSIDE.CV: PT'S HR 80-90'S NSR WITH OCCASIONAL PAC'S AND SBP 110-130'S.GI: ABD TIGHT AND UNABLE TO AUSCULTATE BOWEL SOUNDS. No bowel sounds noted.G-U - Foley draining well, u/o approx 50cc/hr.Skin - + MRSA from old pic line. She was placed back on bipap and she immediately fell asleep with sats 94-96%. Began agonal breathing with decreased pulse Dr. pronounced pt dead at 1830. CALLING OUT TO PEOPLE NOT THERE AND MAKING STATEMENTS THAT ARE DIFFICULT TO UNDERSTAND OR INCOMPREHENSIBLE.RESP: PRESENTLY ON O2 AT 2L/M NC WITH O2 SATS>94%. MAX TEMP=99.2 AND WBC=19.9.SOCIAL PT'S SISTER IS AT BEDSIDE AND AWARE OF PRESENT SITUATION. EMS activated, found to be cyanotic, apneic. SISTER HAS BEEN UPDATED BY MEDICAL TEAM.REVIEW OF SYSTEMS:NEURO: PT AND IS ORIENTED TO PESON AND PLACE BUT STATES IT'S . Pmicu Nursing Progress NoteResp: Pt on biPap with nose mask but around 9am she took off the mask. INSP/EXP WHEEZES BIL BUT DIMINSIHED AT THE BASES. If she moves the NC at all her O2 sats drop very quickly to the 80's. Sinus rhythm - premature ventricular contractionsAnteroseptal infarct - age undeterminedInferior/lateral ST-T changes may be due to myocardial ischemiaGeneralized low QRS voltages PT NEEDS CL ACCESS.INTEGUMENTARY : SKIN VERY THIN WITH AREAS OF ABRASIONS- SKIN TEARS TO ARMS. PT VERY OBESE.ID: PT NOW WITH MRSA FROM OLD PICC SITE AND STAPH LLE CELLULITIS SWAB. Q waves in leads V1-V4 suggest previous anteriormyocardial infarction. She is allergic to Percocet.At , pt was felt to be septic, with acute on chronic renal failure. She was D/C'd , was doing well until when she was noted to have MS changes, fever to 105. Overnight , developed SVT to 160's, given Adenosine 6mg IV with brief response, additional 12mg IV with HR down to 100-120 ? She was ambu'd briefly, brought to , given IV Vanco, blood cx off PICC line grew Gm+ cocci, transferred to per pt/family request. Lungs with inspiratory and expiratory wheezing.GI- Passed small amount maroon stoolx 1. 7p to 7a Micu Progress NoteNeuro - Pt only responding to painful stimuli. update to the above note: pt not a candidate for ir intervention and pt continues with brb output from ogt.discussion held with pt's siste decision made for no further intervention and comfort measures only. BIL LOWER EXTREMTIY DRSGS D&I WITHOUT DRAINAGE. Given Ativan 1mg IV x2 overnight with fair effect, slept only in short naps Per pt's sister, this has been her baseline MS recentlyResp: Sats >95% on BiPAP mask with 3l O2 bled through, drop to 86% with mask off BS diminished throughoutCV: Given Lopressor 12.5mg PO, 2nd dose Digoxin IV (for total .25mg) with HR down to 70's SR with occasional-frequent PAC's. She had a recent prolonged hospitalization for CHF, bilat LE cellulitis, for which a PICC line was placed for home IV Lasix w/ VNA. IV fluid NS begun at 100ml/hr per medical residentGI: NPO except for meds with sips water + bowel sounds, no stool overnightGU: Approx 30ml/hr amber urine with sediment via Foley cath, has not increased with IV fluidsSkin: Dsgs intact at both LE's, no drainageSocial: sister at bedside until 2100, telephone update given this AM Pt remains DNR/DNI. Morphine drip being titrated. PT IS A DNR/DNI SO AFTER DISCUSSION WITH FAMILY PT WAS NOT INTUBATED. TRANSFUSED WITH 2 U FFP AND HCT UPON ARRIVAL=26.5. When asked if she's having pain, she says \"No\". Last rights administered yest pm by chaplain. PT WAS TO GI UNIT BUT UNABLE TO VISULAIZE SOURCE OF BLEEDING SO PT WAS THEN TO MICU FOR FURTHER MANAGEMENT. WETHER PT WILL GO TO IR FOR ANGIOGRAPHY AND POSSIBLE COIL PLACEMENTRENAL: ADEQUATE UO VIA FOLEY CATH WHICH IS AMBER IN COLOR.IV ACCESS: PT HAS 1 18G SL TO R LOWER ARM AND 20G IN L LOWER ARM. Became cyanotic and stopped breathing. Nursing Admission NotePt is a 60yr old woman with complex PMH: CAD, S/P MI '; CHF EF 25-35% last echo ; OSA chronic BiPAP since ; IDDM; Morbid Obesity; elevated cholesterol; Hx GI bleed. She was placed on 1.5L NC with O2 sats 90-92%. Arrived with HR 130's SVT with frequent PAC's, BP stable 120-130/ On her baseline BiPAP, her sats are 93-96% Sister at bedside. PT TO FLOOR LAST EVENING AFTER 24 HR STAY IN MICU FOR CONTROL OF SVT WITH ADENOSINE AND DIGOXIN. LLE cellulitus.Status - Pt is DNR/DNI and CMO. She has had 2 small smears of brown stool.GU: foley draining amber urine with U/O ~40cc/hr.Neuro: Pt oriented to person and place. The toe was cleaned with soap and water, antibotic ointment applied and DSD applied.Social: Her sister in to visit around 11am who helped with her orientation. chaplain at bedside and sacrament of the sick administered. OGT PLACED AND PT CONTINUOUSLY LAVAGED AND HAVE BEEN UNABLE TO CLEAR. Small non-diagnostic Q waves in leads III and aVF.Diffuse low QRS voltage. Addendum- At 1825 pt passing large amount of melanotic stool. admssion note to micu for gi bleedd: SEE ADMISSION NOTE FROM YESTERDAY FOR PT'S PMH AND ORIGINAL REASON FOR ADMISSION. 02 sat 92 - 97 on 4lnc. Adaptic was placed on both areas with some antibotic put on the left leg. The right area is almost healed ulcerated area. will start mso4 gtt and keep titrate to keep pt comfortable Given Vanco, Ceftaz, given fluid. Pt is transferred to MICU for further care. OCCASIONAL DRY NONPRODUCTIVE COUGH. Atrial fibrillation with rapid ventricular response of 123Old anterior myocardial infarctDiffuse ST-T abnormalitiesAbnormal ECG She tolerated the chair until 2pm when she wasd put back to bed with a total lift (10 people helped). Pulling off BiPAP mask, removing johhnie despite continuous reinforcement to not do this. OVERNOC ON CC7 PT HAD 5 EPISODES OF MELANOTIC STOOL AND THIS AM WAS HAVING BRB STOOL OUTPUT APPROXIMATELY EVERY 20 MIN."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2166-10-29 00:00:00.000","description":"Report","row_id":246785,"text":"Normal sinus rhythm. Q waves in leads V1-V4 suggest previous anterior\nmyocardial infarction. Small non-diagnostic Q waves in leads III and aVF.\nDiffuse low QRS voltage. Compared to the previous tracing of there has\nbeen no diagnostic interval change.\n\n"},{"category":"ECG","chartdate":"2166-10-28 00:00:00.000","description":"Report","row_id":246786,"text":"Sinus rhythm\n - premature ventricular contractions\nAnteroseptal infarct - age undetermined\nInferior/lateral ST-T changes may be due to myocardial ischemia\nGeneralized low QRS voltages\n\n"},{"category":"ECG","chartdate":"2166-10-27 00:00:00.000","description":"Report","row_id":246787,"text":"Atrial fibrillation with rapid ventricular response of 123\nOld anterior myocardial infarct\nDiffuse ST-T abnormalities\nAbnormal ECG\n\n"},{"category":"Nursing/other","chartdate":"2166-10-28 00:00:00.000","description":"Report","row_id":1477156,"text":"Pmicu Nursing Progress Note\nResp: Pt on biPap with nose mask but around 9am she took off the mask. She was placed on 1.5L NC with O2 sats 90-92%. If she moves the NC at all her O2 sats drop very quickly to the 80's. She was put in the chair with 4 people helping her but she did not help very much. She tolerated the chair until 2pm when she wasd put back to bed with a total lift (10 people helped). She was placed back on bipap and she immediately fell asleep with sats 94-96%. She has had a non productive cough.\n\nCardiac: HR 68-78 SR with frequent PAC's. B/P 104-110/50's.\n\nGI: Pt has no appetite just drinking apple juice and water. She has had 2 small smears of brown stool.\n\nGU: foley draining amber urine with U/O ~40cc/hr.\n\nNeuro: Pt oriented to person and place. She occasionally will talk to people who are not in the room but quickly reoientes. She was able to stand to transfer to the chair but she was unable to turn into the chair.\n\nSkin: She has an area in the front of her tibias on both legs. The right area is almost healed ulcerated area. On the left the ulcerated area has several small ulcers, reddened around the whole area. Adaptic was placed on both areas with some antibotic put on the left leg. Also on her left great toe the toe nail was lifted up during the transfer to the chair and it started to bleed. The toe was cleaned with soap and water, antibotic ointment applied and DSD applied.\n\nSocial: Her sister in to visit around 11am who helped with her orientation.\n"},{"category":"Nursing/other","chartdate":"2166-10-29 00:00:00.000","description":"Report","row_id":1477157,"text":"admssion note to micu for gi bleed\nd: SEE ADMISSION NOTE FROM YESTERDAY FOR PT'S PMH AND ORIGINAL REASON FOR ADMISSION. PT TO FLOOR LAST EVENING AFTER 24 HR STAY IN MICU FOR CONTROL OF SVT WITH ADENOSINE AND DIGOXIN. OVERNOC ON CC7 PT HAD 5 EPISODES OF MELANOTIC STOOL AND THIS AM WAS HAVING BRB STOOL OUTPUT APPROXIMATELY EVERY 20 MIN. HCT THIS AM=28 AND VSS WERE STABLE WITH SBP 100-110. PT WAS TO GI UNIT BUT UNABLE TO VISULAIZE SOURCE OF BLEEDING SO PT WAS THEN TO MICU FOR FURTHER MANAGEMENT. PT IS A DNR/DNI SO AFTER DISCUSSION WITH FAMILY PT WAS NOT INTUBATED. OGT PLACED AND PT CONTINUOUSLY LAVAGED AND HAVE BEEN UNABLE TO CLEAR. TRANSFUSED WITH 2 U FFP AND HCT UPON ARRIVAL=26.5. SISTER HAS BEEN UPDATED BY MEDICAL TEAM.\n\nREVIEW OF SYSTEMS:\nNEURO: PT AND IS ORIENTED TO PESON AND PLACE BUT STATES IT'S . CALLING OUT TO PEOPLE NOT THERE AND MAKING STATEMENTS THAT ARE DIFFICULT TO UNDERSTAND OR INCOMPREHENSIBLE.\n\nRESP: PRESENTLY ON O2 AT 2L/M NC WITH O2 SATS>94%. OCCASIONAL DRY NONPRODUCTIVE COUGH. INSP/EXP WHEEZES BIL BUT DIMINSIHED AT THE BASES. PT DOES HAVE CPAP AT THE BEDSIDE.\n\nCV: PT'S HR 80-90'S NSR WITH OCCASIONAL PAC'S AND SBP 110-130'S.\n\nGI: ABD TIGHT AND UNABLE TO AUSCULTATE BOWEL SOUNDS. NO STOOL AT PRESENT. OGT IN PALCE WITH BRB OUTPUT AND WILL NEED TO TRANSFUSE BLOOD AS NEEDED. NO C/O N/V. ? WETHER PT WILL GO TO IR FOR ANGIOGRAPHY AND POSSIBLE COIL PLACEMENT\n\nRENAL: ADEQUATE UO VIA FOLEY CATH WHICH IS AMBER IN COLOR.\n\nIV ACCESS: PT HAS 1 18G SL TO R LOWER ARM AND 20G IN L LOWER ARM. PT NEEDS CL ACCESS.\n\nINTEGUMENTARY : SKIN VERY THIN WITH AREAS OF ABRASIONS- SKIN TEARS TO ARMS. BIL LOWER EXTREMTIY DRSGS D&I WITHOUT DRAINAGE. PT VERY OBESE.\n\nID: PT NOW WITH MRSA FROM OLD PICC SITE AND STAPH LLE CELLULITIS SWAB. MAX TEMP=99.2 AND WBC=19.9.\n\nSOCIAL PT'S SISTER IS AT BEDSIDE AND AWARE OF PRESENT SITUATION. WILL GET PHONE NUMBER WHERE SHE CAN BE REACHED.\n\nCODE STATUS : PT IS A DNR/DNI\n"},{"category":"Nursing/other","chartdate":"2166-10-29 00:00:00.000","description":"Report","row_id":1477158,"text":"update to the above note: pt not a candidate for ir intervention and pt continues with brb output from ogt.discussion held with pt's siste decision made for no further intervention and comfort measures only. chaplain at bedside and sacrament of the sick administered. will start mso4 gtt and keep titrate to keep pt comfortable\n"},{"category":"Nursing/other","chartdate":"2166-10-30 00:00:00.000","description":"Report","row_id":1477159,"text":"7p to 7a Micu Progress Note\n\nNeuro - Pt only responding to painful stimuli. No spontaneous eye opening. Morphine drip being titrated. Pt not restless, sleeping most of evening and night.\n\nResp - RR 12 - 20. 02 sat 92 - 97 on 4lnc. Lungs with inspiratory and expiratory wheezing.\n\nGI- Passed small amount maroon stoolx 1. No further drainage noted from og tube. No bowel sounds noted.\n\nG-U - Foley draining well, u/o approx 50cc/hr.\n\nSkin - + MRSA from old pic line. LLE cellulitus.\n\nStatus - Pt is DNR/DNI and CMO. Sister with pt constantly in room. Other family members visiting throughout the evening. Last rights administered yest pm by chaplain.\n"},{"category":"Nursing/other","chartdate":"2166-10-30 00:00:00.000","description":"Report","row_id":1477160,"text":"Addendum- At 1825 pt passing large amount of melanotic stool. Became cyanotic and stopped breathing. Began agonal breathing with decreased pulse Dr. pronounced pt dead at 1830. Sister at bedside. Friends of sister called to come in.\n"},{"category":"Nursing/other","chartdate":"2166-10-28 00:00:00.000","description":"Report","row_id":1477154,"text":"Nursing Admission Note\nPt is a 60yr old woman with complex PMH: CAD, S/P MI '; CHF EF 25-35% last echo ; OSA chronic BiPAP since ; IDDM; Morbid Obesity; elevated cholesterol; Hx GI bleed. She had a recent prolonged hospitalization for CHF, bilat LE cellulitis, for which a PICC line was placed for home IV Lasix w/ VNA. She was D/C'd , was doing well until when she was noted to have MS changes, fever to 105. EMS activated, found to be cyanotic, apneic. She was ambu'd briefly, brought to , given IV Vanco, blood cx off PICC line grew Gm+ cocci, transferred to per pt/family request. She lives with her sister in . She is allergic to Percocet.\nAt , pt was felt to be septic, with acute on chronic renal failure. Given Vanco, Ceftaz, given fluid. Overnight , developed SVT to 160's, given Adenosine 6mg IV with brief response, additional 12mg IV with HR down to 100-120 ? Afib. Pt is transferred to MICU for further care. Arrived with HR 130's SVT with frequent PAC's, BP stable 120-130/ On her baseline BiPAP, her sats are 93-96%\n\n"},{"category":"Nursing/other","chartdate":"2166-10-28 00:00:00.000","description":"Report","row_id":1477155,"text":"Nursing Progres Note\nNeuro: Pt calling out for her sister, yelling \"!\" When asked if she's having pain, she says \"No\". Pulling off BiPAP mask, removing johhnie despite continuous reinforcement to not do this. Soft restraints on bilat. Given Ativan 1mg IV x2 overnight with fair effect, slept only in short naps Per pt's sister, this has been her baseline MS recently\nResp: Sats >95% on BiPAP mask with 3l O2 bled through, drop to 86% with mask off BS diminished throughout\nCV: Given Lopressor 12.5mg PO, 2nd dose Digoxin IV (for total .25mg) with HR down to 70's SR with occasional-frequent PAC's. SBP remains > 110. IV fluid NS begun at 100ml/hr per medical resident\nGI: NPO except for meds with sips water + bowel sounds, no stool overnight\nGU: Approx 30ml/hr amber urine with sediment via Foley cath, has not increased with IV fluids\nSkin: Dsgs intact at both LE's, no drainage\nSocial: sister at bedside until 2100, telephone update given this AM Pt remains DNR/DNI. ? call out to floor later this morning\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-10-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 246785,\n \"text\": \"Normal sinus rhythm. Q waves in leads V1-V4 suggest previous anterior\\nmyocardial infarction. Small non-diagnostic Q waves in leads III and aVF.\\nDiffuse low QRS voltage. Compared to the previous tracing of there has\\nbeen no diagnostic interval change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 246786,\n \"text\": \"Sinus rhythm\\n - premature ventricular contractions\\nAnteroseptal infarct - age undetermined\\nInferior/lateral ST-T changes may be due to myocardial ischemia\\nGeneralized low QRS voltages\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2166-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 246787,\n \"text\": \"Atrial fibrillation with rapid ventricular response of 123\\nOld anterior myocardial infarct\\nDiffuse ST-T abnormalities\\nAbnormal ECG\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477156,\n \"text\": \"Pmicu Nursing Progress Note\\nResp: Pt on biPap with nose mask but around 9am she took off the mask. She was placed on 1.5L NC with O2 sats 90-92%. If she moves the NC at all her O2 sats drop very quickly to the 80's. She was put in the chair with 4 people helping her but she did not help very much. She tolerated the chair until 2pm when she wasd put back to bed with a total lift (10 people helped). She was placed back on bipap and she immediately fell asleep with sats 94-96%. She has had a non productive cough.\\n\\nCardiac: HR 68-78 SR with frequent PAC's. B/P 104-110/50's.\\n\\nGI: Pt has no appetite just drinking apple juice and water. She has had 2 small smears of brown stool.\\n\\nGU: foley draining amber urine with U/O ~40cc/hr.\\n\\nNeuro: Pt oriented to person and place. She occasionally will talk to people who are not in the room but quickly reoientes. She was able to stand to transfer to the chair but she was unable to turn into the chair.\\n\\nSkin: She has an area in the front of her tibias on both legs. The right area is almost healed ulcerated area. On the left the ulcerated area has several small ulcers, reddened around the whole area. Adaptic was placed on both areas with some antibotic put on the left leg. Also on her left great toe the toe nail was lifted up during the transfer to the chair and it started to bleed. The toe was cleaned with soap and water, antibotic ointment applied and DSD applied.\\n\\nSocial: Her sister in to visit around 11am who helped with her orientation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477157,\n \"text\": \"admssion note to micu for gi bleed\\nd: SEE ADMISSION NOTE FROM YESTERDAY FOR PT'S PMH AND ORIGINAL REASON FOR ADMISSION. PT TO FLOOR LAST EVENING AFTER 24 HR STAY IN MICU FOR CONTROL OF SVT WITH ADENOSINE AND DIGOXIN. OVERNOC ON CC7 PT HAD 5 EPISODES OF MELANOTIC STOOL AND THIS AM WAS HAVING BRB STOOL OUTPUT APPROXIMATELY EVERY 20 MIN. HCT THIS AM=28 AND VSS WERE STABLE WITH SBP 100-110. PT WAS TO GI UNIT BUT UNABLE TO VISULAIZE SOURCE OF BLEEDING SO PT WAS THEN TO MICU FOR FURTHER MANAGEMENT. PT IS A DNR/DNI SO AFTER DISCUSSION WITH FAMILY PT WAS NOT INTUBATED. OGT PLACED AND PT CONTINUOUSLY LAVAGED AND HAVE BEEN UNABLE TO CLEAR. TRANSFUSED WITH 2 U FFP AND HCT UPON ARRIVAL=26.5. SISTER HAS BEEN UPDATED BY MEDICAL TEAM.\\n\\nREVIEW OF SYSTEMS:\\nNEURO: PT AND IS ORIENTED TO PESON AND PLACE BUT STATES IT'S . CALLING OUT TO PEOPLE NOT THERE AND MAKING STATEMENTS THAT ARE DIFFICULT TO UNDERSTAND OR INCOMPREHENSIBLE.\\n\\nRESP: PRESENTLY ON O2 AT 2L/M NC WITH O2 SATS>94%. OCCASIONAL DRY NONPRODUCTIVE COUGH. INSP/EXP WHEEZES BIL BUT DIMINSIHED AT THE BASES. PT DOES HAVE CPAP AT THE BEDSIDE.\\n\\nCV: PT'S HR 80-90'S NSR WITH OCCASIONAL PAC'S AND SBP 110-130'S.\\n\\nGI: ABD TIGHT AND UNABLE TO AUSCULTATE BOWEL SOUNDS. NO STOOL AT PRESENT. OGT IN PALCE WITH BRB OUTPUT AND WILL NEED TO TRANSFUSE BLOOD AS NEEDED. NO C/O N/V. ? WETHER PT WILL GO TO IR FOR ANGIOGRAPHY AND POSSIBLE COIL PLACEMENT\\n\\nRENAL: ADEQUATE UO VIA FOLEY CATH WHICH IS AMBER IN COLOR.\\n\\nIV ACCESS: PT HAS 1 18G SL TO R LOWER ARM AND 20G IN L LOWER ARM. PT NEEDS CL ACCESS.\\n\\nINTEGUMENTARY : SKIN VERY THIN WITH AREAS OF ABRASIONS- SKIN TEARS TO ARMS. BIL LOWER EXTREMTIY DRSGS D&I WITHOUT DRAINAGE. PT VERY OBESE.\\n\\nID: PT NOW WITH MRSA FROM OLD PICC SITE AND STAPH LLE CELLULITIS SWAB. MAX TEMP=99.2 AND WBC=19.9.\\n\\nSOCIAL PT'S SISTER IS AT BEDSIDE AND AWARE OF PRESENT SITUATION. WILL GET PHONE NUMBER WHERE SHE CAN BE REACHED.\\n\\nCODE STATUS : PT IS A DNR/DNI\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477158,\n \"text\": \"update to the above note: pt not a candidate for ir intervention and pt continues with brb output from ogt.discussion held with pt's siste decision made for no further intervention and comfort measures only. chaplain at bedside and sacrament of the sick administered. will start mso4 gtt and keep titrate to keep pt comfortable\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477159,\n \"text\": \"7p to 7a Micu Progress Note\\n\\nNeuro - Pt only responding to painful stimuli. No spontaneous eye opening. Morphine drip being titrated. Pt not restless, sleeping most of evening and night.\\n\\nResp - RR 12 - 20. 02 sat 92 - 97 on 4lnc. Lungs with inspiratory and expiratory wheezing.\\n\\nGI- Passed small amount maroon stoolx 1. No further drainage noted from og tube. No bowel sounds noted.\\n\\nG-U - Foley draining well, u/o approx 50cc/hr.\\n\\nSkin - + MRSA from old pic line. LLE cellulitus.\\n\\nStatus - Pt is DNR/DNI and CMO. Sister with pt constantly in room. Other family members visiting throughout the evening. Last rights administered yest pm by chaplain.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477160,\n \"text\": \"Addendum- At 1825 pt passing large amount of melanotic stool. Became cyanotic and stopped breathing. Began agonal breathing with decreased pulse Dr. pronounced pt dead at 1830. Sister at bedside. Friends of sister called to come in.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477154,\n \"text\": \"Nursing Admission Note\\nPt is a 60yr old woman with complex PMH: CAD, S/P MI '; CHF EF 25-35% last echo ; OSA chronic BiPAP since ; IDDM; Morbid Obesity; elevated cholesterol; Hx GI bleed. She had a recent prolonged hospitalization for CHF, bilat LE cellulitis, for which a PICC line was placed for home IV Lasix w/ VNA. She was D/C'd , was doing well until when she was noted to have MS changes, fever to 105. EMS activated, found to be cyanotic, apneic. She was ambu'd briefly, brought to , given IV Vanco, blood cx off PICC line grew Gm+ cocci, transferred to per pt/family request. She lives with her sister in . She is allergic to Percocet.\\nAt , pt was felt to be septic, with acute on chronic renal failure. Given Vanco, Ceftaz, given fluid. Overnight , developed SVT to 160's, given Adenosine 6mg IV with brief response, additional 12mg IV with HR down to 100-120 ? Afib. Pt is transferred to MICU for further care. Arrived with HR 130's SVT with frequent PAC's, BP stable 120-130/ On her baseline BiPAP, her sats are 93-96%\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2166-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1477155,\n \"text\": \"Nursing Progres Note\\nNeuro: Pt calling out for her sister, yelling \\\"!\\\" When asked if she's having pain, she says \\\"No\\\". Pulling off BiPAP mask, removing johhnie despite continuous reinforcement to not do this. Soft restraints on bilat. Given Ativan 1mg IV x2 overnight with fair effect, slept only in short naps Per pt's sister, this has been her baseline MS recently\\nResp: Sats >95% on BiPAP mask with 3l O2 bled through, drop to 86% with mask off BS diminished throughout\\nCV: Given Lopressor 12.5mg PO, 2nd dose Digoxin IV (for total .25mg) with HR down to 70's SR with occasional-frequent PAC's. SBP remains > 110. IV fluid NS begun at 100ml/hr per medical resident\\nGI: NPO except for meds with sips water + bowel sounds, no stool overnight\\nGU: Approx 30ml/hr amber urine with sediment via Foley cath, has not increased with IV fluids\\nSkin: Dsgs intact at both LE's, no drainage\\nSocial: sister at bedside until 2100, telephone update given this AM Pt remains DNR/DNI. ? call out to floor later this morning\\n\"\n }\n]"}}},{"rowIdx":196,"cells":{"subject_id":{"kind":"number","value":29867,"string":"29,867"},"hadm_id":{"kind":"number","value":138500,"string":"138,500"},"target_text":{"kind":"string","value":"This is a 57 year old woman with history of CAD s/p MI and stent () presenting with BRBPR due to diverticulosis. Brief hospital course presented below by problem. . Briefly, this is a 57 year old female with history of MI s/p stent in on aspirin/plavix presented on with single episode of lower GI bleed. She had acute onset of lower abdominal cramping, then was incontinent of a large volume of bright red blood and diarrhea. The pain resolved after the BRBPR. She denied any other preceeding symptoms: fever, chills, chest pain, shortness of breath, nausea, preceeding diarrhea or constipation. In the ED she was hemodynamically stable with BP 107-113/71-83, HR 90s and her hematocrit was 38. She was given 1 liter Normal saline, NG lavage negative. The patient was evaluated by GI who recommended ICU monitoring for lower GI bleed. . In the ICU, patient was continued on her PPI, given IVF, kept NPO for EGD and colonoscopy. No ischemic changes on EKG. The patient's beta blocker was held to not mask tachycardia. She received 1 unit of PRBC. On , her tagged RBC scan was negative, her EGD was shown to be normal, and colonoscopy on showed diverticulosis as likely cause of GIB. Also showed multiple non-bleeding diverticula. During the whole hospital course, the patient was continued on asprin and plavix for recent drug eluting stent . She was also continued on her statin for hyperlipidemia. Patient's Hct remained stable after the colonoscopy and patient was transferred to the general medicine floor for continued care in the evening of . On the day of discharge, the patient tolerated regular diet, had no more episodes of bleeding, and had a stable hematocrit. Patient was discharged on all her home medications including restarting her coreg CR for hypertension. She will need follow up with her primary care physician, . , within 1-2 weeks of discharge from the hospital. Also, she will need follow up with a local GI specialist for a full screening colonoscopy with better prep in the future to look for polyps and other colonic morphology."},"extractive_notes_summ":{"kind":"string","value":"adequate amount.IVF's 1L of .9 done-no new orders for more fluid.Plan: follow hct's q 6 hours cont. BP 100's-1teens/70's, tmax 99.0 po.Resp: LS clear, o2 sat's high 90'sGI/GU: +bs, no bm since 8am, u/o wnl.Access: PIV x2, wnl.plan: hct 18:00, ?c/o to floor Repeat HCT down to 30.9. Received total of PRBC's 1unit, most recent Hct @1200 30.6. Golytley started for colonoscopy prep. No active bleeding since this am, next hct due at 18:00. 4mg zofran given with good effect.No BM yet.GU: voids on the commode. No edema + 3 pt/dp bilaterallyGI: On clear liquids, to start golytely this evening. Nursing Progress NOtereview of systems: 7p-11pSkin: intactNeuro: intact. WBC up with last labs. In the EW her HCT was stable at 36, a NG lavage was done which was negative. Needs U/A sent with next voidID: afebrile, + WBC needs blood cultures with next blood drawSkin: Intact no issuesFEN: getting NS x 1 liter.Heme: HCT 30.9, next HCT due at Social: Son drove down from VT, she lives in PA with daughter and her family works as a medical assistant and in medical researchPlan1. RR mid teensCardiac: Hemodynamically stable. Early precordial R wave transition.Non-diagnostic Q waves in leads II, III and aVF. NPN 07:00Please refer to Carevue for additional patient information*Full CodeShift Events: Las bm at ~8am, liquid/watery stool. Approved: TUE 4:32 PM RADLINE ; A radiology consult service. Red TAG study done this am, no active bldg found. clear liquid diet until midnight and then NPO. nsg notes contd....Pt had large after 0400hrs,total 900ml ( blood + urine) crit sent,report 26,informed team,vital signs stable ,HR 70's,so Dr ti draw next crit at 0800hrs and if it is less than 25 ,then will do further management. Tele SR 70-80's without ectopy. ls clear bilat and throughout.GI: abd soft, nondistended. next due @ 0200.Resp: RA with sats> 95%, RR wnl. GI BLEEDING STUDY Clip # Reason: CAD S/O DES ON ASPIRIN/PLAVIS PRESENTING W/ BRBPR S/ EPISODES FINAL REPORT RADIOPHARMECEUTICAL DATA: 15.5 mCi Tc-m RBC (); GI BLEEDING STUDY. Prep for colonoscopy2. sats 94-96 on RA. No further epiodes of BRBPR or stoolRenal: Voiding clear yellow via commode. with golytely another set of blood cx with next hct draw Colonoscopy done this afternoon, md's probable cause of bleed is Diverticulosis. HCT q 6 hours-stable. Denies painResp: Lungs CTA bilaterally, respirations even and unlabored. VSS, she was transferred to the MICU for an emergent EGD and closer montioring. ST-T wave flattening in lead I. T wave inversion in lead aVL.ST-T wave flattening in leads V5-V6. , M.D. one set of blood cultures and urine culture sent. Nsg.notes 2300-0700hrsAllergies:NKDAEvents: 57YO lady admitted on with H/O BRBPR ,On admission crit 36,susequently down to 30 ,but no PRB till midnight.had an episode of BRBPR at midnight,300ml,vital signs stable,crit sent-28.7,team aware,informed GI team,per GI team,if continuous bleeding and crit lower than 27.5,may need to do red tag study.had one more episode at 0230,100ml.crit at 4am.Neuro:alert and oriented well,having mild abdominal cramping,using commode, on feet.CVS:HR 70-90's,NSR,No ectopics noted,BP 85-110/55-70 mm of hg.crit Q4h.next draw at 0800hrs.bloos c/s 2nd sample sent.Resp:LS clear,Sats 93-95% on RA.gu/gi:Abdomen soft,BS present.had 2 maleana.voided,using commode,yellow clear urine.on oral liquids.for colonosopy today,colon preparation with golytely,drinking not very adequately.Integu:skin intact,mild redness on sacrum.afebrileIV access:18g PIV'S one on each hand.patent.social:calm and co operative.DNR,but she wish to intubate.Plan:serial crit,and follow up with results.watch for PR bleed,and monitor vital signs. + BS in 4 quadrents. VSS through MICU course. She is to be prepped tonight for a colonoscopy in AMNeuro: A&Ox3, OOB to commode with supervision. To hear preliminary results, prior to transcription, call the Radiology Listen Line . EGD was done which was negative (total of 75 mcg fentanyl 2 mg versed given for procedure). Serial HCTS3. FINDINGS: Following intravenous injection of autologous red blood cells labeled with technetium-m, blood flow and dynamic images of the abdomen were obtained for 120 minutes. Routine ICU monitoring and care Sinus rhythm. ?c/o to floor (patient does not have insurance and is very concerned regarding her \"stay\" in hospital) Family at bedside most of day, updated on plan of care.ROS:Neuro: a/o x3, very pleasant, no c/o pain,dizziness.CV: HR 80's, NSR, no ectopy. afebrile. IMPRESSION: No evidence of GI bleeding. No previous tracingavailable for comparison. pt has nausea after starting the prep. pt very cooperative and pleasantCV: VS stable. pt steady on feet. yellow, clear urine. The obtained images demonstrate no evidence of tracer extravasation. Nursing Progress Note 0700-1900This is a 57 year old female with a PMH of HTN, CAD (s/ 5 months ago) who was at a conference this am when she had sudden onset of abdominal cramping and then passed a large amount of BRBPR."},"n_notes":{"kind":"number","value":7,"string":"7"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2180-10-28 00:00:00.000","description":"GI BLEEDING STUDY","row_id":978569,"text":"GI BLEEDING STUDY Clip # \n Reason: CAD S/O DES ON ASPIRIN/PLAVIS PRESENTING W/ BRBPR S/ EPISODES\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 15.5 mCi Tc-m RBC ();\n GI BLEEDING STUDY.\n\n INDICATION: Bright red blood per rectum.\n\n FINDINGS: Following intravenous injection of autologous red blood cells labeled\n with technetium-m, blood flow and dynamic images of the abdomen were obtained\n for 120 minutes.\n\n The obtained images demonstrate no evidence of tracer extravasation.\n\n IMPRESSION: No evidence of GI bleeding.\n\n\n , M.D. Approved: TUE 4:32 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"},{"category":"Nursing/other","chartdate":"2180-10-28 00:00:00.000","description":"Report","row_id":1648225,"text":"nsg notes contd....\n\nPt had large after 0400hrs,total 900ml ( blood + urine) crit sent,report 26,informed team,vital signs stable ,HR 70's,so Dr ti draw next crit at 0800hrs and if it is less than 25 ,then will do further management.\n"},{"category":"Nursing/other","chartdate":"2180-10-28 00:00:00.000","description":"Report","row_id":1648226,"text":"NPN 07:00\nPlease refer to Carevue for additional patient information\n*Full Code\n\nShift Events: Las bm at ~8am, liquid/watery stool. Received total of PRBC's 1unit, most recent Hct @1200 30.6. Red TAG study done this am, no active bldg found. Colonoscopy done this afternoon, md's probable cause of bleed is Diverticulosis. No active bleeding since this am, next hct due at 18:00. ?c/o to floor (patient does not have insurance and is very concerned regarding her \"stay\" in hospital) Family at bedside most of day, updated on plan of care.\n\nROS:\nNeuro: a/o x3, very pleasant, no c/o pain,dizziness.\nCV: HR 80's, NSR, no ectopy. BP 100's-1teens/70's, tmax 99.0 po.\nResp: LS clear, o2 sat's high 90's\nGI/GU: +bs, no bm since 8am, u/o wnl.\nAccess: PIV x2, wnl.\nplan: hct 18:00, ?c/o to floor\n"},{"category":"Nursing/other","chartdate":"2180-10-27 00:00:00.000","description":"Report","row_id":1648222,"text":"Nursing Progress Note 0700-1900\n\nThis is a 57 year old female with a PMH of HTN, CAD (s/ 5 months ago) who was at a conference this am when she had sudden onset of abdominal cramping and then passed a large amount of BRBPR. In the EW her HCT was stable at 36, a NG lavage was done which was negative. VSS, she was transferred to the MICU for an emergent EGD and closer montioring. VSS through MICU course. Repeat HCT down to 30.9. EGD was done which was negative (total of 75 mcg fentanyl 2 mg versed given for procedure). She is to be prepped tonight for a colonoscopy in AM\n\nNeuro: A&Ox3, OOB to commode with supervision. Denies pain\n\nResp: Lungs CTA bilaterally, respirations even and unlabored. sats 94-96 on RA. RR mid teens\n\nCardiac: Hemodynamically stable. Tele SR 70-80's without ectopy. No edema + 3 pt/dp bilaterally\n\nGI: On clear liquids, to start golytely this evening. + BS in 4 quadrents. No further epiodes of BRBPR or stool\n\nRenal: Voiding clear yellow via commode. Needs U/A sent with next void\n\nID: afebrile, + WBC needs blood cultures with next blood draw\n\nSkin: Intact no issues\n\nFEN: getting NS x 1 liter.\n\nHeme: HCT 30.9, next HCT due at \n\nSocial: Son drove down from VT, she lives in PA with daughter and her family works as a medical assistant and in medical research\n\nPlan\n\n1. Prep for colonoscopy\n2. Serial HCTS\n3. Routine ICU monitoring and care\n\n"},{"category":"Nursing/other","chartdate":"2180-10-27 00:00:00.000","description":"Report","row_id":1648223,"text":"Nursing Progress NOte\nreview of systems: 7p-11p\n\nSkin: intact\n\nNeuro: intact. pt very cooperative and pleasant\n\nCV: VS stable. afebrile. WBC up with last labs. one set of blood cultures and urine culture sent. HCT q 6 hours-stable. next due @ 0200.\n\nResp: RA with sats> 95%, RR wnl. ls clear bilat and throughout.\n\nGI: abd soft, nondistended. clear liquid diet until midnight and then NPO. Golytley started for colonoscopy prep. pt has nausea after starting the prep. 4mg zofran given with good effect.No BM yet.\n\nGU: voids on the commode. pt steady on feet. yellow, clear urine. adequate amount.\n\nIVF's 1L of .9 done-no new orders for more fluid.\n\nPlan: follow hct's q 6 hours\n cont. with golytely\n another set of blood cx with next hct draw\n"},{"category":"Nursing/other","chartdate":"2180-10-28 00:00:00.000","description":"Report","row_id":1648224,"text":"Nsg.notes 2300-0700hrs\n\nAllergies:NKDA\n\nEvents: 57YO lady admitted on with H/O BRBPR ,On admission crit 36,susequently down to 30 ,but no PRB till midnight.had an episode of BRBPR at midnight,300ml,vital signs stable,crit sent-28.7,team aware,informed GI team,per GI team,if continuous bleeding and crit lower than 27.5,may need to do red tag study.had one more episode at 0230,100ml.crit at 4am.\n\nNeuro:alert and oriented well,having mild abdominal cramping,using commode, on feet.\n\nCVS:HR 70-90's,NSR,No ectopics noted,BP 85-110/55-70 mm of hg.crit Q4h.next draw at 0800hrs.bloos c/s 2nd sample sent.\n\nResp:LS clear,Sats 93-95% on RA.\n\ngu/gi:Abdomen soft,BS present.had 2 maleana.voided,using commode,yellow clear urine.on oral liquids.for colonosopy today,colon preparation with golytely,drinking not very adequately.\n\nIntegu:skin intact,mild redness on sacrum.afebrile\n\nIV access:18g PIV'S one on each hand.patent.\n\nsocial:calm and co operative.DNR,but she wish to intubate.\n\nPlan:serial crit,and follow up with results.watch for PR bleed,and monitor vital signs.\n\n"},{"category":"ECG","chartdate":"2180-10-27 00:00:00.000","description":"Report","row_id":220411,"text":"Sinus rhythm. ST-T wave flattening in lead I. T wave inversion in lead aVL.\nST-T wave flattening in leads V5-V6. Early precordial R wave transition.\nNon-diagnostic Q waves in leads II, III and aVF. No previous tracing\navailable for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2180-10-28 00:00:00.000\",\n \"description\": \"GI BLEEDING STUDY\",\n \"row_id\": 978569,\n \"text\": \"GI BLEEDING STUDY Clip # \\n Reason: CAD S/O DES ON ASPIRIN/PLAVIS PRESENTING W/ BRBPR S/ EPISODES\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n RADIOPHARMECEUTICAL DATA:\\n 15.5 mCi Tc-m RBC ();\\n GI BLEEDING STUDY.\\n\\n INDICATION: Bright red blood per rectum.\\n\\n FINDINGS: Following intravenous injection of autologous red blood cells labeled\\n with technetium-m, blood flow and dynamic images of the abdomen were obtained\\n for 120 minutes.\\n\\n The obtained images demonstrate no evidence of tracer extravasation.\\n\\n IMPRESSION: No evidence of GI bleeding.\\n\\n\\n , M.D. Approved: TUE 4:32 PM\\n\\n\\n\\n\\n RADLINE ; A radiology consult service.\\n To hear preliminary results, prior to transcription, call the\\n Radiology Listen Line .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648225,\n \"text\": \"nsg notes contd....\\n\\nPt had large after 0400hrs,total 900ml ( blood + urine) crit sent,report 26,informed team,vital signs stable ,HR 70's,so Dr ti draw next crit at 0800hrs and if it is less than 25 ,then will do further management.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648226,\n \"text\": \"NPN 07:00\\nPlease refer to Carevue for additional patient information\\n*Full Code\\n\\nShift Events: Las bm at ~8am, liquid/watery stool. Received total of PRBC's 1unit, most recent Hct @1200 30.6. Red TAG study done this am, no active bldg found. Colonoscopy done this afternoon, md's probable cause of bleed is Diverticulosis. No active bleeding since this am, next hct due at 18:00. ?c/o to floor (patient does not have insurance and is very concerned regarding her \\\"stay\\\" in hospital) Family at bedside most of day, updated on plan of care.\\n\\nROS:\\nNeuro: a/o x3, very pleasant, no c/o pain,dizziness.\\nCV: HR 80's, NSR, no ectopy. BP 100's-1teens/70's, tmax 99.0 po.\\nResp: LS clear, o2 sat's high 90's\\nGI/GU: +bs, no bm since 8am, u/o wnl.\\nAccess: PIV x2, wnl.\\nplan: hct 18:00, ?c/o to floor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648222,\n \"text\": \"Nursing Progress Note 0700-1900\\n\\nThis is a 57 year old female with a PMH of HTN, CAD (s/ 5 months ago) who was at a conference this am when she had sudden onset of abdominal cramping and then passed a large amount of BRBPR. In the EW her HCT was stable at 36, a NG lavage was done which was negative. VSS, she was transferred to the MICU for an emergent EGD and closer montioring. VSS through MICU course. Repeat HCT down to 30.9. EGD was done which was negative (total of 75 mcg fentanyl 2 mg versed given for procedure). She is to be prepped tonight for a colonoscopy in AM\\n\\nNeuro: A&Ox3, OOB to commode with supervision. Denies pain\\n\\nResp: Lungs CTA bilaterally, respirations even and unlabored. sats 94-96 on RA. RR mid teens\\n\\nCardiac: Hemodynamically stable. Tele SR 70-80's without ectopy. No edema + 3 pt/dp bilaterally\\n\\nGI: On clear liquids, to start golytely this evening. + BS in 4 quadrents. No further epiodes of BRBPR or stool\\n\\nRenal: Voiding clear yellow via commode. Needs U/A sent with next void\\n\\nID: afebrile, + WBC needs blood cultures with next blood draw\\n\\nSkin: Intact no issues\\n\\nFEN: getting NS x 1 liter.\\n\\nHeme: HCT 30.9, next HCT due at \\n\\nSocial: Son drove down from VT, she lives in PA with daughter and her family works as a medical assistant and in medical research\\n\\nPlan\\n\\n1. Prep for colonoscopy\\n2. Serial HCTS\\n3. Routine ICU monitoring and care\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648223,\n \"text\": \"Nursing Progress NOte\\nreview of systems: 7p-11p\\n\\nSkin: intact\\n\\nNeuro: intact. pt very cooperative and pleasant\\n\\nCV: VS stable. afebrile. WBC up with last labs. one set of blood cultures and urine culture sent. HCT q 6 hours-stable. next due @ 0200.\\n\\nResp: RA with sats> 95%, RR wnl. ls clear bilat and throughout.\\n\\nGI: abd soft, nondistended. clear liquid diet until midnight and then NPO. Golytley started for colonoscopy prep. pt has nausea after starting the prep. 4mg zofran given with good effect.No BM yet.\\n\\nGU: voids on the commode. pt steady on feet. yellow, clear urine. adequate amount.\\n\\nIVF's 1L of .9 done-no new orders for more fluid.\\n\\nPlan: follow hct's q 6 hours\\n cont. with golytely\\n another set of blood cx with next hct draw\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2180-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1648224,\n \"text\": \"Nsg.notes 2300-0700hrs\\n\\nAllergies:NKDA\\n\\nEvents: 57YO lady admitted on with H/O BRBPR ,On admission crit 36,susequently down to 30 ,but no PRB till midnight.had an episode of BRBPR at midnight,300ml,vital signs stable,crit sent-28.7,team aware,informed GI team,per GI team,if continuous bleeding and crit lower than 27.5,may need to do red tag study.had one more episode at 0230,100ml.crit at 4am.\\n\\nNeuro:alert and oriented well,having mild abdominal cramping,using commode, on feet.\\n\\nCVS:HR 70-90's,NSR,No ectopics noted,BP 85-110/55-70 mm of hg.crit Q4h.next draw at 0800hrs.bloos c/s 2nd sample sent.\\n\\nResp:LS clear,Sats 93-95% on RA.\\n\\ngu/gi:Abdomen soft,BS present.had 2 maleana.voided,using commode,yellow clear urine.on oral liquids.for colonosopy today,colon preparation with golytely,drinking not very adequately.\\n\\nIntegu:skin intact,mild redness on sacrum.afebrile\\n\\nIV access:18g PIV'S one on each hand.patent.\\n\\nsocial:calm and co operative.DNR,but she wish to intubate.\\n\\nPlan:serial crit,and follow up with results.watch for PR bleed,and monitor vital signs.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2180-10-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 220411,\n \"text\": \"Sinus rhythm. ST-T wave flattening in lead I. T wave inversion in lead aVL.\\nST-T wave flattening in leads V5-V6. Early precordial R wave transition.\\nNon-diagnostic Q waves in leads II, III and aVF. No previous tracing\\navailable for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":197,"cells":{"subject_id":{"kind":"number","value":14666,"string":"14,666"},"hadm_id":{"kind":"number","value":136758,"string":"136,758"},"target_text":{"kind":"string","value":"1. Respiratory: The patient was on CPAP of 6 until day of life 3 at which point he transitioned to room air without any supplemental oxygen required after that point. Comfortable on room air at this time, with last bradycardiac spell at 7 p.m. on . The patient will complete a 5-day spell count at 5 p.m. on prior to discharge. 2. Cardiovascular: No issues, no murmur, no history of hypotension. 3. Fluids, electrolytes, nutrition: The patient initially on D10W, transitioned to full enteral feeds by day of life 4 and increased to 24 kilocalories on day of life 11 under which the patient has been undergoing adequate weight gain. At this time, he is on breast milk 24 supplemented with Similac powder. He is taking ad lib p.o. on top of breast feed. No gavage necessary. Discharge weight 2725g. 4. GI: Maximum bilirubin 12.3 on day of life 9, with phototherapy discontinued on day of life 11, with a rebound of 6.5. 5. Hematology: Initial hematocrit 51, white count 16, platelets 322. 6. Infectious disease: The patient is status post 48 hours of ampicillin and gentamicin during initial blood culture, which was negative. Since that time, the patient has had antibiotic ointment with Telfa dressing to the right foot for an IV infiltrate which was discontinued approximately 4 to 5 days before discharge with resolution of infiltrate and healing of skin. 7. Neurology: Not applicable. Sensory hearing screening was performed on with automated auditory brain-stem responses and the patient passed. 8. Ophthalmology: Not applicable."},"extractive_notes_summ":{"kind":"string","value":"Reb bili 10.6/0.2. Sm amtyellow/serous drainage noted. Tripleabx and tefla applied. Swaddled, withboundaries. #1RespLungs clear with mild sc retractions. G/D: Temps stable swaddled in off-isolette. G/D: Temps stable swaddled in off-isolette. BS clear and =; mild sc ret. MildSCR noted. MildSCR noted. to monitor resp. to monitor resp. TEMP STABLE IN AN OFFISOLETTE.#4PARENTMOM X 1 FOR AN UPDATE#6BILIBILI WAS 10.6/.2. A: Resolving P: Check biliMon. NNP INFORMED. Bili thisam was 9.6/0.3. mild subcostal retractions. Cl and = BS. Cl and = BS. Mild rtxns. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Mild retractions. Mild sc rtxns. Updated re statusand plan. Tol well. Tol well. Mild desats-sr. HR 130-140s. infant colorjaundiced. both helping changediaper and do temp. AGA. AGA. Infant breastfed well x 1. TF 100 BM/SC20. Infant isalert/active with cares. Infant isalert/active with cares. REMAINS SL JAUNDICED#7SKINDSG TO R FOOT CHANGED, AREA PINK AND CLEAN. TF 120 BM20/SC20. Tolerating feedingswell; abd exam benign, no spits, min asp. LC gave Momnipple . Infant is a&awith cares. Brady x1, needing mild stim torecover. Parents updated bythis R.N. Small amt of serous drainage noted on dsg x1from that area. Ferinsol and Multivit. Infant can be fiestyat times. LS cl/=.Mild SC retractions. Willalso settle with pacifier, containment and holding. Pedi is . Desitin applied todiaper area.A. Rest well inbetween cares. Stool heme neg. Abd benign, AG 26,V/S, mec stooling. Both held infanttoday. NPN Noc#1 Resp: RA, 30-60's, c/=, mild SC retrac. Updated on infant'scondition and plan of care by this RN. NPN discharge noteVSS, exam benign; see flowsheet for details. AGA.Tripple abx oint TID to right foot infiltrate. Both updated. NPN 0700-2. NPN#1 S. O. BBS cl/=. Abd soft, +, noloops. Will update pediatrician. Mom and this am. A: stable in RA P:Cont to monitor and providesupport as needed.#2: TF's ^'ed to 100cc/k/d. Infant passed trace mec stool. and active duringcares, resting well in between. Eagerbottler and breastfeeder. Fontssoft/flat. Follow wt and exam.#3: Temps stable in an air isolette. NPN Daysaddendum: Pt passed hearing screen. Min asp. A: Toleratingfeeds. P: Cont tosupport and update. Cont to receive BM24.A. Onesmall wet burp. updates given. #1RespLungs clear with mild retractions. On ad lib demand. V/S. sucking onpacifier. abd benign. Abd benign. Plan to recheck bili am. Passed hearing screen. A: AGA. Passing heme negative stool. Passing heme negative stool. MAE/AFOF.AGA. D/C OT. Abdomen round and softwith + BS. Placed in RA. Asking appropriatequestions. Feeding tube out. Tempsstable. BM24 with powder. Took 70cc this am and BF well while werevisiting. Pt day of spell count down. Cont. Discussed SIDS precautions and EI qualifications. Voiding and stooling normally (heme negative). Maturing breathing control. exambenign. Abd soft, active bowel sounds. P- Will cont to monitor resp status.#2 Pt ad lib demand. Sucks on pacifier. BS clear. voiding and stooling. Voiding and stooling. Abd. Benign abdomen. Appearscomfortable#2FENWt 2.615 up 30g. Rehab/OTMet at the bedside. Interested inbottling#4Parentno contact so far. P: Cont to support development.#4 O: Both in to visit. remainder of volume gavaged. P: Cont tomonitor bili status PRN. P: Cont to supp and update. Infant isjaundice. Cl and = BS. continue with currentplan of care. Respiratory CarePt cont on prong CPAP. Updatedat bedside by RN. Fio2 .24-.27. bs clear, rr 50-70 with mild retractions. +murmur. Lytes this am were143/4.6/108/22. CBG: 7.28/47/45/23/-4. A: Independent andappropriate w/cares. sucks vigorously onpacifier. A: AGA. BPP was . d/c photot and check reb bili in AM. AG 27. u/o1.2cc/kg/hr thus far. Infant bottled 52 cc @ 0900 cares w/remainingvolume gavaged. Plan to recheck bili in the am. Mild SC retractions. At delivery, twin A emerged with moderate tone and good cry, with Apgars . aga. AGA. AGA. mild subcostal retractions. BP 67/37, 47. 6.5/0.2 (reb). LS clear/equal, oximetry d/c'dthis morning. Infant GFR on arrival to NICU. CL and =. Tol well. Persistant grunting on CPAP, subcostal retractions. TF 150 BM24. TF 150 BM24. TF 150 BM24. sent this shiftpending. po/pg. Po/pg. PO/PG. Otherwise, AFSFO, oropharynx clear, NGT w/o breakdownCV - RRR, nl s1+s2 no murmurPULM - CTABABD - soft, NT, ND, no massEXT - wwp, R foot c/d/i, cr < 2 secNEURO - reactive, MAE in REsp status. Stable on CPAP cont to follow. ; P/Cont. REsp. O/Anitbiotics d/c. Restswell inbetween cares. Updates given. P/Cont. P/Cont. P/Cont. toleratingfeeds well. Murmur notedand reported to NNP. Updated by RN. Updated re status andplan. remains under neoblue lights with eye shieldsin place. Bili to be rechecked in am. BS clear and =, mild sc ret. NPN 07p-07aRESPRA, LS clear & equal with mild subc. BF well.uop and stool wnl, heme neg.abd wnl. NG d/c. noincreased wob noted. Wakes occassionally for cares. Abd benign. Triple antx ointment applied as ordered.Cont. A/Completion of 48hr r/O. BS active. Nospells so far this shift, last one on . Pt. Pt. Pt. Pt. mild subcostal retractions. Please refer toflowsheet. retractions. Abd exam benign, VQS, smyellow stool x2. VS stable.Alert & active with cares. Stable on CPAP cont to follow closely. Remains NPO.Intermittently sucking on pacifier.3. Occ sat drifts, one spell so far this shift,resolved with mild stim and increased 02. monitorPO/PG feeding tolerance & weight.G&DIn air isolette, temps stable. G/D: Temps stable swaddled in off-isolette. MildSCR noted. NPN DAYS#1 Pt received and cont in RA. updated re: pt spells and DCdate pushed back. A: Independent andappropriate w/cares. Lytes 135/4.0/19. LS C+=. mild subcostal retractions. Abd benign. Keeping NPO. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Pt voiding and stooling hemneg. CBG 7.28/47. NPN:RESP: RA. IV placed in R hand with D10W infusing, initial DS 47, after IVF infusing, DS 74. BBS =/clear. Voiding qs and stoolingheme neg. Bilirubin 1.7. SATSIMPROVED ON BELLY.#2 NPO. received infant in an offisolette. Infant isalert/active with cares. asking approp ques. A: AGA. FeS04. Lung sounds cl/= and mild SC retractions. minimal aspirates. Settlesvery well with pacifier and boundaries. to suppot developmentalneeds. LS sl coarse and diminished, color good, cont with GFR through shift. B.S. AGA. Lung sounds clear/=. Attempted to BFx 2 thus far - latched well. abd benign.all po feeds. ess. Independent withcares and handling infants. lung sounds clear andequal. LS ARE CLEAR,SLIGHTLY DIMINISHED."},"n_notes":{"kind":"number","value":107,"string":"107"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2197-12-16 00:00:00.000","description":"Report","row_id":1884793,"text":"Neonatology Attending\nDOL 7 / PMA 35-3/7 weeks\n\nRemains in room air with no distress. Occasional drifting saturations but no bradycardias.\n\nNo murmur.\n\nOff phototherapy with bilirubin 10.6 yesterday.\n\nWt 2385 (+35) on TFI 140 cc/kg/day BM20, tolerating well. Bottling up to of feeds. Voiding and stooling (guiac negative). Abd benign.\n\nTemp stable in off isolette.\n\nRIght foot infiltrate improved.\n\nA&P\n34-3/7 week GA infant with respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Repeat bilirubin on Monday\n-No changes in management as detailed above\n"},{"category":"Nursing/other","chartdate":"2197-12-16 00:00:00.000","description":"Report","row_id":1884794,"text":"NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 90%. Lung sounds clear/=. RR 30-50's. Mild\nSCR noted. No bradys noted. Occ drifts to high 80's noted.\nP: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempting to\nPO when awake and alert. Infant breastfed x 2 thus far -\nlatched well. Tolerating NGT feedings well; abd exam\nbenign, no spits ,min asp. Voiding qs and stooling heme\nneg. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/active with cares. Settles well in betwen cares.\nAppropriatley brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support developmental\nneeds.\n\n4. : Mom in for 2 set of cares today. Independent\nwith cares and handling. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved . P: Cont. to support and update\n.\n\n5. Bili: Rebound bili fri am was 10.6. Infant remains sl.\njaundiced. Will follow bili on mon am.\n\n6. Skin: Dressing changed no right foot infiltrate. Triple\nabx and tefla applied. No drainage, redness or swelling\nnoted. P: Cont. to monitor skin.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-17 00:00:00.000","description":"Report","row_id":1884795,"text":"Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 96-99%.RR 30-60's.LS\nremain clear and equal with sc retractions.No A's and B's or\ndesats thus far.\n\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\nq 4 hrs gavaged over 45 min.Infant attempted to bottle with\nthe Playtex Nurser and took 25-44cc's.Appeared well\ncoordinated;remainder gavaged.Weight=2.410 up 25 grams.Abd\nsoft with pos bs,no loops or spits,minimal aspirates.Voiding\nand stooling heme negative.\n\nG/D:AF soft and flat.Alert and active with cares.Sleeping\nwell b/t.MAE.Bringing hands to face and mouth.Infant remains\nin off isolette;swaddled with nested boundaries.Temp.\nmaintained.\n\nParenting:Mom called x 1.Updated by this RN.Asking\nappropriate questions very loving and invested.\n\nBili:Infant cont's jaundice but well perfused.Stooling.To\nhave bili checked on .\n\nSkin:R foot appears pink with serous drainage on old\ndressing.Applied triple antibiotics;healing well.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-17 00:00:00.000","description":"Report","row_id":1884796,"text":"Neonatology Attending\n\nDOL 8 PMA 35 4/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 78/33 mean 50\n\nOn 140 ml/kg/d BM 20 po/pg. Voiding. Stooling. Wt 2410 grams (up 25).\n\nR foot infiltrate being treated with triple antibiotics.\n\n in and up to date.\n\nA: Stable. No spells. Tolerating feeds and learning to po. Infiltrate healing.\n\nP: Monitor\n pos as tolerated\n Continue care for infiltrate\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":1884789,"text":"Nursing Progress note\n\n\n#1 Resp-- O: RR 30s-60s; HR 140s-160s; Sats 96-99. No\ndesats, no spells. BS clear and =; mild sc ret. Pink/jaund.\nNo murmer. A: Rare desats in RA P; Cont to monitor\nsats/vitals/spells\n\n#2 Nutrition-- O: Enteral feeds advanced to 140cc/kg/d= 60cc\nBM20 q4h. BF great x2 with good latch and suck 5-10 min-\nthen drowsy. Tol full volume after BF over 45 min. tol well-\nno spits, no asp. NG #5 placed in rt nare after baby pulled\ntube. Abd exam benign, AG 25cm, +BS. VQS, Yellow x2\nguiacneg. A: Stable, tol adv feeds with wt gain P: Monitor\ntol and growth\n\n#3 Development-- O: Alert and active with cares, social with\nmom. stable in off islolette. Swaddled, with\nboundaries. Hands to mouth. A: AGA P: Cont to support\ndevelopment\n\n#4 Parenting-- O: Mom in for 0900 and 1300 feeds.\nIndependent with babies, handling well. Updated re status\nand plan. Will be back for 1700 feed. A: Involved. loving P:\nCont to support and keep informed\n\n#6 ^Bili-- O: rebound bili stable off og photo Rx. Color sl\njaund, VQS, stooling, full feeds. A: Resolving P: Check bili\nMon. am\n\n#7 Skin-- O: Rt foot lesion drsg . Sm amt\nyellow/serous drainage noted. Area cleansed with sterile\nH2O, triple antibx ointment applied with Telpha and gauze\nwrap. A: Improving P: Monitor and change drsg \n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":1884790,"text":"Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl external male genit, no rash\nEXT - wwp, cr < 2, R foot wound c/d/i with normal granulation tissue and no pus or erythema\nNEURO - MAE, reactive\n"},{"category":"Nursing/other","chartdate":"2197-12-16 00:00:00.000","description":"Report","row_id":1884791,"text":"Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 97-100%.RR 30-60's.LS\nremain clear and equal with sc retractions.No A's and B's\nthus far.Occ. will drift in sats to high 80's QSR.\n\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\nq 4 hrs gavaged over 45 min.Infant bottled x 2 with Playtex\nbottle and took 17-47cc the remainder gavaged.Weight=2.385\nup 35.Abd. soft with pos bs,no loops or spits,minimal\naspirates.Voiding and stooling heme negative.\n\nG/D:AF soft and flat.Alert and active with cares.Stirring\nprior to feeds.MAE.Bringing hands to face and mouth and\nintermitently sucking on pacifier.Infant remains in off\nisolette swaddled with nested boundaries.Temp. stable.\n\nParenting:No contact from so far.\n\nBili:Infant cont's slightly jaundice.To recheck Bili .\n\nSkin:R foot appears to be healing well.Cont's slightly pink\nwith healing tissue.No drainage or foul odor\npresent.Dressing changed per protocol.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-16 00:00:00.000","description":"Report","row_id":1884792,"text":"Neonatology NP note\nPE\nswaddled in open crib, cobedding with twin\nAFOf\nminimal subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884786,"text":"NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 93%. Lung sounds clear/=. RR 40-60's. Mild\nSCR noted. Few drifts to high 90s noted. No apnea noted\nthus far. P: Cont. to monitor resp. status.\n\n2. FEN: TF were increased to 120 cc/kg/day of BM/SC20.\nInfant is attempting to PO/breastfeed when awake and\ninterested. Infant breastfed well x 1. Tolerating feedings\nwell; abd exam benign, no spits, min asp. Voiding qs and\nstooling trans stools. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/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. Parents: Mom in for cares this shift. Independent with\ncares and handling infants. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved parents. P: Cont. to support and update\nparents.\n\n5. Bili: Single phototherapy was d/c'd at 1000. Bili this\nam was 9.6/0.3. Plan is to check rebound in am.\n\n6. Skin: Dressing was changed x 1. Tefla and gauze and\ntriple abx ointment placed on infiltrate. No drainage noted\nfrom site. P: Cont. to monitor and change dressings as\nordered.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":1884787,"text":"#1Resp\nLungs clear with mild sc retractions. Baby has had one spell\ntonight which required mild stim.RR 40-60 with sat in high\n90's.\nP. Cont to monitor\n#2FEN\nWt 2.35 up 25g. Baby cont to receive 150cc/kg BM20 52 cc q4.\nAbd round but soft active bowel sounds. Min asp No spits,\nSleepy at 2100 and feed gavaged. At 0130 awake and alert but\nnot that interested and took 15cc. At 0500, bottled 22.\\\nA. Tol feed and learnung to feed\nP> CONT TO MONITOR TOL TO FEEDS AS WELL AS WEIGHT GAIN AND\nFEED ABILITY\n#3DEV\nAWAKE AND ALERT WITH CARES BUT TIRES. TEMP STABLE IN AN OFF\nISOLETTE.\n#4PARENT\nMOM X 1 FOR AN UPDATE\n#6BILI\nBILI WAS 10.6/.2. NNP INFORMED. REMAINS SL JAUNDICED\n#7SKIN\nDSG TO R FOOT CHANGED, AREA PINK AND CLEAN. NO DRAINAGE.\nGOOD PERFUSION TO THE TOES. DIAPER AREA SL PINK. DESITIN\nAPPLIED\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-15 00:00:00.000","description":"Report","row_id":1884788,"text":"Neonatology Attending Note\nDay 6, PMA 35 2\n\nRA. RR40-60s. Mild sc rtxns. Cl and = BS. Mild desats-sr. HR 130-140s. BP 85/43, 56. Reb bili 10.6/0.2. Wt 2350, up 25. TF 120 BM20/SC20. PO/PG. Tol well. Nl voiding and stooling. Desitin to diaper dermatitis. In off isolette.\n\nA/P:\nGrowing preterm infant learning how to po feed. Adv TF to 140. Follow jaundice clinically, check another Monday.\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884782,"text":"npn 1900-0700\n\n\n1: resp\nremains in ra. one spell with breastfeeding, qsr, see flow\nsheet. rr 30-70's. mild subcostal retractions. no increased\nwob noted. sats 93-100%. lung sounds clear and equal.\nconitnue to monitor for changes in respiratory status.\n\n2; fen\ncurrent weight 2325gms down 50. total fluids remain at\n100cc/kilo/day of bm 20/sc 20. tolerating feeds well. no\nspits. minimal aspirates. voiding and stooling. abd soft\nwith no loops. girth stable. mom breastfed at 2100 and at\n0100, with first care infant latched on and took a few\nsucks, at 0100 care infant latched on and nursed well for\n5-10 minutes. continue to support mom with breastfeeding.\nfull gavage feed given following breastfeeding. continue\nwith current feeding plan.\n\n3: growth and development:\ntemps stable in an air heated isolette. alert and active\nwith cares. sleeps well inbetween. brings hands to face.\nsucks vigorously on pacier. irritable at times. unswaddled\nwith boundaries for phototherapy. continue with current\nfeeding plan.\n\n4; parenting\nmom and dad in for 2100 care. both involved with cares.\nloving and asking appropriate questions. both helping change\ndiaper and do temp. continue to support family while in the\nnicu environment.\n\n6: bili\ninfant remains under single phototherapy. eye shields in\nplace. bili drawn this shift 9.6/0.3/9.4. infant color\njaundiced. continue to monitor for change.\n\n7: skin:\ninfant with newborn rash. infant also with right foot lesion\n\nwith multiple small scabs and open area that is pink. small\namount of serous draingae noted on gauze. dressing changed\nand triple antibiotic ointment applied. no active bleeding\nand no edema noted. continue with dressing changes.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884783,"text":"Neonatology Attending Note\nDay 5, PMA 35 1\n\nRA. RR30-70s. Cl and = BS. Mild rtxns. Occass sat drifts. +2 A&Bs past 24h. HR 130-150s. No murmur.\n\nJaundice, Bili 9.6/0.3, under single photot.\n\nWt 2325, down 50. TF 100 BM/SC20. Tol well. Nl voiding and stooling. Tr mec.\n\nIn air isolette.\n\nA/P:\nCont to monitor mild AOP off caffeine. d/c photot and monitor bili levels in AM. Adv TF to 120.\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884784,"text":"Exam Note\nGEN - asleep in isolette\nHEENT - AFSFO, oropharynx clear, nares patent\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl ext genit\nEXT - wwp, cr < 2s\nNEURO - reactive, MAE\n\n"},{"category":"Nursing/other","chartdate":"2197-12-14 00:00:00.000","description":"Report","row_id":1884785,"text":"Exam Addendum\nEXT - RLE wound examined under bandage, c/d/i with appropriate eschar and no signs of infection.\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884775,"text":"Neonatology Attending\n\nDay 4 PMA 35 0/7 wks\n\nRemains in RA. RR 30-60s. Mild retractions. Had four bradycardia episodes over last 24 hours- one with feeding. No murmur. HR 120-160s. BP mean 56. Bilirubin 9/0.4 on phototherapy. Weight 2375g (-30). TF at 80 ml/kg/d. Now on full feeds BM/SC 20. Put to breast daily. Latched. Minimal aspirates. Stable girth. Passing heme negative stool. Stable temperature in air-controlled incubator. Foot infiltrate clean with crust. Treated with triple antibiotic and Telfa. Family meeting yesterday.\n\nDoing well overall with mild breathing control immaturity. Will continue to monitor. Increasing to 100 ml/kg/d today. Monitoring feeding tolerance. Will speak with family today.\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884776,"text":"Lactation Consult\nMet w/ mom/babies this AM to assist w/ latch and assess milk supply. Infants are 4 day old 34 wks, 35 wks corrected today. Infant remains under single phototx and has an ng tube for feeds. Baby went to breast w/o nipple shield first and demonstrated difficulty in latching, and was then trialed w/ nipple shield and did very well. Baby had frequent audible swallows and milk in nipple shield, nursing X 10mins. He was then ng fed for full vol.\nReviewed risks and benefits of using a nipple shield w/ mother, emphasized need to pump 8-12X per 24hrs. Gave mom written material to assess 24 hr milk supply. Will follow this family.\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884777,"text":"Social Work\n\nFamily meeting yesterday, parents doing well, many good questions. Will follow assess need for any additional support.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884778,"text":"Exam Note\nGEN - awake,alert\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl ext genit\nEXT - wwp, cr < 2\nNEURO - reactive, MAE\n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884779,"text":"NPN 7a-7p\n\n\n#1: remains in RA, sating >/= 94%. Rare drift to high\n80's noted with QSR. Brady x1, needing mild stim to\nrecover. RR stable. BBS cl/=. Breathing with mild\nretractions. A: stable in RA P:Cont to monitor and provide\nsupport as needed.\n\n#2: TF's ^'ed to 100cc/k/d. Infant now receiving 43cc q4hrs\ngavaged over 50mins. D/S stable. No spits. Max asp 1.8cc\nslightly green tint. Fellow assessed. Abd soft, +, no\nloops. AG stable. Refed asp and cont'ed with feeds. Infant\nwent to breast x2 today. 1st attempt did well for ~10mins,\nmore consistent latch and suck. 2nd attempt infant was more\ninterested in snuggling with Mom. Latched briefly. Voiding\nqs. Stooled x2 heme negative. A: tol'ing feeds P:Cont to\nmonitor tol to feeds. Follow wt and exam.\n\n#3: Temps stable in an air isolette. Infant can be fiesty\nat times. Sleeps best when nested within boundaries. Will\nalso settle with pacifier, containment and holding. Fonts\nsoft/flat. Brings hands to face. Loves to kangaroo. MAE. A:\nAGA P:Cont to support dev needs.\n\n#4: Parents in for both cares thus far. Mom and\n this am. Better this afternoon. Mom has been d/c'ed\ntoday, but parents are staying in Parent Room overnight. Mom\nmet with LC this am and worked on breastfeeding. LC gave Mom\nnipple . See LC note for details. Parents\nparticipating in cares. Both updated. Both held infant\ntoday. A: Involved, loving family P:Cont to support and\neducate.\n\n#6: Jaundice. Tol'ing full feeds. Voiding and stooling.\nConts under single phototherapy with eye shields on. A:\nhyperbili P:Cont with phototherapy as ordered. Check bili\nlevel in am.\n\n#7: NB rash noted over trunk, face and extremities. Team\nassessed. Right foot noted to have several lesions on it.\nLesion on top of foot has opened pink center with scabbed\nyellow edges. Small amt of serous drainage noted on dsg x1\nfrom that area. No bleeding noted. No edema noted. Other\nscabs intact. Triple antibiotic ointment applied and covered\nwith Telfa dsg.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884780,"text":"NPN 7a-7p cont'ed\n\n7 Skin:\n\n#7cont'ed: Team assessed lesions today. Foot warm to touch\nwith nml pulses. A: healing skin lesions P:Cont with dsg\nchange 3 times a day. Monitor.\n\nREVISIONS TO PATHWAY:\n\n 7 Skin:; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884781,"text":"NICU Infant CPR Class Note\n\nO: Both parents present for infant CPR class at 1800. Watched video and demostration of infant CPR and relieving choking maneuvers by this RN. Both parents practiced on the manikin and were able to demonstrate proper techniques. Reviewed \"Back to Sleep\" brochure and gave to parents. Also gave CPR poster and handout. All questions answered. Both parents stated that they understood all teaching and had no further questions. Class concluded at 1900.\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884769,"text":"NPN 0700-1900\n\n\nResp: Infant received on CPAP 6 with FiO2 21%, weaned\ninfant to RA at 1130. SpO2 89-98%. RR 30s-60s. LS cl/=.\nMild SC retractions. 2 bradys thus far (see flowsheet for\ndetails). P: Cont to monitor resp status.\n\nFEN: TF increased today to 80cc/kg/day. D10W with 2&1\ninfusing at 20cc/kg/day via PIV in left hand without\nincidence. Enteral feeds increased to 60cc/kg/day of\nBM/SC20 = 26cc q4hrs. Plan to advance enteral feeds by\n15cc/kg/day . Will check DS at 1700. Abd soft, full,\n+BS, no loops. AG stable. 3.6 bilious asp at 0900, NNP\naware, discarded asp. No spits. Voiding (see flowsheet for\nu/o this shift). Lg mec stool x1. P: Cont to support\nnutritional needs.\n\nG/D: Temps stable, nested on servo warmer. Infant is a&a\nwith cares. Irritable at times. Appropriately brings hands\nto face and sucks pacifier to comfort self. AFSF. AGA.\nTripple abx oint TID to right foot infiltrate. P: Cont to\nsupport dev needs.\n\nSocial: Mom in for all cares today. Updated on infant's\ncondition and plan of care by this RN. Loving, invested\nparents. Asking appropriate questions. Family meeting\ntoday at 4pm. P: Cont to update & support NICU family.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884770,"text":"Family Meeting\nMet with parents in the family room today. Mother to be discharged home tomorrow. See family meeting checklist for issues discussed. Parents asked many questions that were answered to their apparent satisfaction. Seemed to have a good understanding of the issues. Pedi is .\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884844,"text":"1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\nequal, no retractions seen. No oximetry. Currently on spell\ncountdown, possible discharge tomorrow on day . Continue\nto monitor respiratory status.\n\n2. FEN-Infant is on adlib po demand schedule of BM 24 with\n powder. Infant bottling 45cc's this morning with Playtex\nnurser and breastfeeding with mom this afternoon. Eager\nbottler and breastfeeder. Abd soft. Voiding and stooling\nheme negative. No spits. Destitin applied to bottom with\neach diaper change. Continue to encourage po feeds.\n\n3. DEV-Infant has stable temperatures swaddled in OAC.\nWaking q3-3.5 hours to be feed. and active during\ncares, resting well in between. Continue to support\ndevelopmental needs.\n\n4. PARENT-Mom and dad in this afternoon. Loving towards\ninfant and independent with cares. Made pedi appt for \non Monday due to holiday. Excited for possible discharge\ntomorrow. Continue to educate and support .\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884845,"text":"NPN\n\n\nI have examined the infant and agree with the above note\nwritten by PCA.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884846,"text":"#2FEN\nWt 2.725 up 20g. Baby waking q4h to bottle. Bottled 70/75cc\nwith playtex bottle. Void and stooling. Stool heme neg. No\nspits. Abd soft, active bowel sounds. Desitin applied to\ndiaper area.\nA. Tol feed and gaining weight\nP. Cont to monitor tol to feed\n#3Dev\nTemp stable in an open crib. Waking for feeds\n#4Parent\nNo contact this shift\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884847,"text":"Neonatology Attending\n\nDay 18 PMA 37 0/7 WKS\n\nRemains in RA. RR 30-60s. Had 6.5 seconds heart rate drop seen on pneumocardiogram yesterday that was quickly self-resolved. No murmur. HR 140-170s. BP mean 46. Pink. Weight 2725g (+20). On BM 24 with formula powder. Took 124 ml/kg. Occasional choking with feeds. Benign abdomen. Passing heme negative stools. Waking every 4 hours. Passed hearing screen and car seat position study.\n\nDoing well overall. Feeding well and gaining weight. Heart rate drop not clinically significant so ready for discharge. Appointment with primary pediatrician on Monday. Discharge summary pending. Will update pediatrician.\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884848,"text":"Exam Note\nGEN - NAD, active\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+S2, no M\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2 sec\nNEURO - MAE, reactive, +grasp/suck/moro,\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884849,"text":"NPN 0700-\n\n\n2. Infant on ad lib demand feeds of BM24 with powder.\nWaking Q3-4hr and taking 50cc and 80cc thus far. Bottles\nwith playtex fast flow nipple. Abdomen benign. Voiding and\nstooling; heme negative. Ferinsol and Multivit. given.\nTolerating all bottles without spits. Plan to D/C home this\nafternoon.\n\n3. Temp stable swaddled in open crib. Waking for feeds as\nnoted above. Rest well inbetween cares. MAE, brings hands\nto face and mouth. Suckles well on pacifier. AGA. To be\nd/c'd later today.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-27 00:00:00.000","description":"Report","row_id":1884850,"text":"NPN discharge note\nVSS, exam benign; see flowsheet for details. Reviewed NICU D/C instruction form with . Infant D/C home with in car seat. Breast milk given to .\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884763,"text":"NPN\n\n#1 S. O. Received infant on a cpap of 6 with fio2 21% to\n23%. Breath sounds clear and equal with subcostal\nretractions noted. R.R.30's to 70's. O2 sats 94 to\n98%.There have been no a's or b's noted at this time. A.\nInfant with a hx of respiratory distress. P. Discuss with\nteam in the am regarding plan for trial off of cpap.\n\n#2 S. o. Weight down 45 grams. Voiding with 24 hour urine\noutput 1.6cc/kg/hr. Infant passed trace mec stool. Piv of\nd10w with lytes infusing well via left hand piv. Total\nfluids = 60cc/kg/day. Right foot infiltrate site pink/red\nwith no drainage noted.Right foot elevated. Infant had a\n1.4cc bilious aspirant at the 0100 care. Abdomen softly\ndistended with good bowel sounds and no loops. NNP\nnotified.Aspriant discarded. Feeds not advanced at that\ntime. A. ? bilious aspriant related to slow gastric\nmotility. P. Monitor closely. Assess for advancemnet on\nfeeds at the next care.\n\n#4 S. O. Parents in for the 2100 care. Parents updated by\nthis R.N. at the bedside. A. Loving parents. P. Support\nand keep updated.\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884764,"text":"5 ID\n\nREVISIONS TO PATHWAY:\n\n 5 ID; resolved\n\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884765,"text":"Neonatology Note\n3 d.o\non CPAP + 6 this am and wean to RA now\n2 spells this am, self resolved.\nwt= 2405 gm -45\nTF at 60 ml/kg/d with IV and feeding at 45 ml/kg/d with EBM/SC 20, 2 aspirates noted\nvoiding(+), bm(+)\n141/6.4/110/21\nbili=9, under phototherapy\n\nA: twin #1, ex 34 wks GA, resolving RDS, hyperbilirubinemia, R foot infiltration resolving\nP: continue advancing feeding and monitor tolerance, monitor spell, f/u bilirubin\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884771,"text":"NPN Noc\n\n\n#1 Resp: RA, 30-60's, c/=, mild SC retrac. No spells so far\nthis shift. P: Cont to monitor resp status.\n#2 FEN: TF=80cc/kg, infant currently on full feeds, BM/SC20.\nPo/pg feeding, infant took 14cc po x 1. Abd benign, AG 26,\nV/S, mec stooling. P: Cont to monitor FEN status.\n#3 G&d: Temp stable in air isolette, nested. Alert, active,\nand sl irritable with cares. Enjoys his pacifier, MAE, opens\neyes, AFSF. IV infiltrate to right foot, triple abx ointment\napplied and wrapped in sterile gauze. Area is sl swollen,\nsmall scabs surrounding small open area on top of foot. P:\nCont to monitor and support G&D, cont with triple abx to\nright foot breakdown.\n#4 Parents: Parents in for eve caretimes. Mom participated\nin cares, briefly held infant. Asking appropriate questions.\nP: cont to encourage parental calls and visits.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884772,"text":"NPN Noc\n#6 Bili: Infant appears jaundiced, cont on single spotlight phototherapy. P: Cont phototherapy, will check bili on Thurs AM.\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884773,"text":"6 Alt in Bili\n\nREVISIONS TO PATHWAY:\n\n 6 Alt in Bili; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2197-12-13 00:00:00.000","description":"Report","row_id":1884774,"text":"NNP Physical Exam\nPE: pink, AFOF, breath sounds clear/equal with easy WOB, no murmur, well perfused, abd soft, full, + bowel sounds, e tox rash, right foot wound from IV infiltrate with moist scab, does not look infected, active with good tone.\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884837,"text":"NPN 0700-1500\n\n\n#2 O: Infant remains feeding ad lib amounts of BM24 made\nwith similac powder. Bottling 60cc's. Abdomen round and soft\nwith + BS. Voiding and stooling. No spits. A: Tolerating\nfeeds. P: Cont to monitor.\n\n#3 O: Maintaining temp in oac; cobedding with twin. Awake\nand with cares; sleeping well between. AFSF. Swaddled\nin blanket; brings hands to face for comfort and sucks on\npacifier. A: AGA. P: Cont to support development.\n\n#4 O: Both in to visit. Asking appropriate\nquestions. Reviewing d/c teaching for sibling. Mom\nbreastfeeding while here and pumping. Plan to take other\ninfant home this afternoon. A: Involved, loving. P: Cont to\nsupport and update.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884838,"text":"Rehab/OT\n\nMet at the bedside. Reviewed back to sleep protocol and activities birth through one worksheet. Discussed SIDS precautions and EI qualifications. No further in house needs. D/C OT.\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884839,"text":"Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no M\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2\nNEURO - MAE, reactive\n\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884840,"text":"Nursing Progress Note 1900-0700\n\n\nF/E/N:Infant cont's on Ad lib demand schedule waking q 4\nhrs.TF over 24 hrs 122cc's/kg/day.Infant bottling with a\nPlaytex nipple and taking 70-90cc's q time.Weight=2.705 up\n25 grams.Abd. soft with pos bs,no loops or spits.Voiding and\nstooling heme negative stool.\n\nG/D:AF soft and flat. and active with cares.Sleeping\nwell b/t.MAE.Bringing hands to face and mouth.Sucking\nintermitently on pacifier.Infant presently swaddled in open\ncrib.Temp. stable.\n\nParenting:Mom called x 1.Updated by this RN.Asking\nappropriate questions very loving and invested.Other twin at\nhome per mom and doing well.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884766,"text":"NNP Physical Exam\nPE: exam this am while on CPAP. pink, jaundiced, AFOF, CPAP prongs in place, breath sounds clear/equal with easy WoB, no grunting, good air entry, no murmur, well perfusion, abd soft, non distended, non tender, active bowel sounds, IV infiltrate right foot with superficial scabs on dorsum of the foot, no redness or drainage, active with good tone.\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884767,"text":"NPN 0700-1900\nBili: Bili this am was 9.0/0.4, down from 9.6/0.3. Infant remains under single phototherapy wtih eye shields on. Plan to recheck bili am.\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884768,"text":"Respiratory Care Note\nBbay Boy I was weaned from +6 to +5 prong CPAP this am and then was taken off CPAP at noon. Placed in RA. BS clear. RR 30's-60's. No bradys noted since he has been off CPAP.\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884832,"text":"NPN Days\n\n\n#1 Pt has had no spells so far this shift. Pt day \nof spell count down. P- Will cont to monitor resp status.\n#2 Pt ad lib demand. BM24 with powder. all po\nfeeds. Took 70cc this am and BF well while were\nvisiting. abd benign. voiding and stooling. no spits. P-\nWill cont to monitor FEN.\n#3 G&D- Temp stable in open crib. cobedding with sibling.\n and active with cares. irritable at times. sucking on\npacifier. using playtex bottle with fast flow nipple to\nfeed. P- Will cont to monitor G&D.\n#4 Mom called x1 this am. updates given. Both\n visiting @1300. Participating in cares. feeding pt.\nDC teaching done with both re: carseat safety,\nfeeding, bowel and bladder, back to sleep. declined\ncirc. P- Will cont DC teaching.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884833,"text":"NPN Days\naddendum:\n Pt passed hearing screen.\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884834,"text":"Neonatology Attending\nDOL 15 / PMA 36-4/7 weeks\n\nIn room air with no apneas/bradycardias in 2 days.\n\nNo murmur. BP 68/41 (51).\n\nWt 2655 (+35) on ad lib with intake 119 fcc/kg/day BM24 in addition to breastfeeding well. Abd benign. Voiding and stooling normally (heme negative). On iron.\n\nTEmp stable in open crib. Hepatitis B immunization administered.\n\nA&P\n34-3/7 week GA infant with resolving respiratory immaturity\n-Continue to monitor until free of apnea/bradycardia for at least 5 days prior to discharge home\n-Discharge planning in progress\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884835,"text":"NPN/1900-0700\n\n\n#2 FEN: Wt 2680, ^25gms. Ad libe demand feeding, BM24.\nTaking all po's; bottled 149cc/k + breastfeeding this\nprevious 24hrs. Taking 60-80cc Q4hrs. No spits. Abd. exam\nbenign. V/S. Cont. to support nutritional needs.\n#3 DEVELOPMENT: Swaddled in oac; cobedding with twin. Temps\nstable. Active/ w/ cares; sleeps well b/t. Wakes on\nhis own Q3.5-4hrs to feeds. Sucks on pacifier. MAE/AFOF.\nAGA. Support developmental needs.\n#4 : visiting during the day shift; no\ncontact over .\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884841,"text":"Neonatology Attending\n\nDay 17 PMA 36 wks\n\nRemains in RA. RR 50-70s. Clear breath sounds. Day without bradycardia. No murmur. HR 140-160s. BP mean 54. Weight 2705 g (+25). On ad lib demand. On BM 24 with formula powder. Benign abdomen. Passing heme negative stool. On iron. Waking for feeds. Stable temperature in open crib. Passed hearing screen and car seat study.\n\nDoing well overall. Will continue to monitor closely. Feeding well and gaining weight. Will be ready for discharge tomorrow if remains spell-free.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884842,"text":"Lactation Consult\nMet w/ family @ 1pm to assess infant latch. Baby latched on beautifully w/ nipple having frequent audible swallows and milk present in . Mom held infant by football hold and is pleased w/ feeding. plan to nurse infants at home following up w/ bottles of 24cal breast milk. Advised to monitor baby's voids and stools at home and assess for swallows at the breast.\n"},{"category":"Nursing/other","chartdate":"2197-12-26 00:00:00.000","description":"Report","row_id":1884843,"text":"Exam Note\nGEN - NAD, active and \nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no M, fem pulses 2+ bilat\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash, stool present\nNEURO - MAE, reactive\n"},{"category":"Nursing/other","chartdate":"2197-12-25 00:00:00.000","description":"Report","row_id":1884836,"text":"Neonatology Attending\n\nDay 16 PMA 36 wks\n\nRemains in RA. RR 40-70s. Clear breath sounds. No bradycardia- day . No murmur. HR 150-160s. Pink. BP mean 59. Weight 2680g (+25). Ad lib BM 24 with formula powder. Taking 60-80 ml per feed- 149 ml/kg total- and breast feeding. Passing heme negative stool. Feeding tube out. No spits. Stable temperature in open crib. independent with care.\n\nDoing well overall. Maturing breathing control. Will continue to monitor closely. Needs 2 more days spell-free. Received hepatitis B vaccine. Passed hearing screen. Will speak with mother this morning.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884819,"text":"#1Resp\nLungs clear with mild retractions. No spells. Appears\ncomfortable\n#2FEN\nWt 2.615 up 30g. Baby has bottled entire volume at 2100 and\n0100. Abd soft, active bowel sounds. Void and stooling. One\nsmall wet burp. Min asp. Cont to receive BM24.\nA. Tol feed and gaining weight\nP. Cont to monitor tol to feeds as well as weight gain.\nEncourage po feed ability\n#3Dev\nWaking for feeds. Maintaining temp in crib. Interested in\nbottling\n#4Parent\nno contact so far.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884820,"text":"Cafe spot noted on R side of forehead.\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884821,"text":"Neonatology Attending Note\nDay 13, PMA 36 2\n\nRA. RR40-60s. Mild intermittent sc retractions. No A&Bs. No murmur. HR 130-150s. BP 86/44, 56. Wt 2615, up 40 gms. TF 150 BM24. Just transitioned to all PO last night. Nl voiding and stooling. In open crib.\n\nA/P:\nGrowing preterm infant with improving PO skills. If continues to do well with PO feedings will plan for discharge Monday. PO feedings q other BF. Monitor weight with this suppl plan.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884822,"text":"Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear, NGT out of nose, nares intact\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no M\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2 sec, dorsum c/d/i\nNEURO - MAE, reactive\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884823,"text":"Case Management Note\nReferral called to Care Group VNA today (/fax ) and have made home visit for Wednesday . Team anticipates home d'c Monday . If this date needs to be chnaged, please call VNA to reschedule. All in agreement w/plan.\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884745,"text":"Admission Note\nNeonatology Admission H&P\n\nBaby is a newborn 34 wk twin infant admitted to the NICU with prematurity and respiratory distress.\n\nHe was born at 12:30 am this morning as the 2575 gram product of a 34 wk twin gestation pregnancy to a 28 y.o. G1 P0-2 mother with . Prenatal labs included BT A+/Ab- and GBS unknown; remainder were unavailable at time of delivery but were reportedly negative. Pregnancy was IVF-assisted di/di twin gestation, and was reportedly unremarkable until when mother presented to PMD for evaluation of URI symptoms and was found to be hypertensive. She was sent to , and was also found to have proteinuria and elevated uric acid, consistent with preeclampsia. BPP was . With relatively advanced gestational age, delivery was recommended. Last EFW on was 2289; concordant growth was noted throughout pregnancy.\n\nFamily history and social history are otherwise non-contributory.\n\nInfant was born via c-section for twin gestation. At delivery, twin A emerged with moderate tone and good cry, with Apgars . He required blow-by oxygen for duskiness with gradual improvement, and was brought to NICU with moderate work of breathing noted.\n\nPhysical Exam:\nWt 2575 gm (75-90%) HC 32 cm (50-75%) L 48 cm (75-90%).\nVS: T 97.7, HR 160s, RR 50s, O2sat 80s in RA, 90s with O2, BP pending.\nGen: WD premature infant, moderate resp distress, active and vigorous, overall appearance consistent with EGA.\nSkin: warm, dry, pink with oxygen, no rash.\nHEENT: fontanelles soft and flat, ears/nares normal, palate intact with mildly high arch, +RR bilaterally.\nNeck: supple, no lesions.\nChest: coarse, poorly aerated, + g/f/r.\nCardiac: RRR, no m, femoral pulses 2+.\nAbdomen: soft, quiet BS, no mass, no HSM, 3VC.\nGU: normal male, testes palpable bilaterally, anus patent.\nExt: hips/back normal, no lesions.\nNeuro: appropriate tone, activity, intact moro/grasp.\n\nIMP: Newborn 34 wk twin, delivered secondary to maternal preeclampsia, currently with moderate respiratory distress likely secondary to RDS. Low risk of sepsis given circumstances of delivery.\n\nPLANS:\n- Admit NICU.\n- Monitor resp status closely, likely will need CPAP.\n- O2 as needed.\n- CXR, ABG if resp status worsens.\n- Consider intubation/surfactant if FiO2 high or worsening respiratory distress or hypercarbia.\n- Monitor hemodynamics.\n- NPO, maintenance IVF.\n- Periodic monitoring of dstiks, lytes, bilirubin.\n- CBC with diff, blood cx.\n- Low threshold for abx as pneumonia cannot be ruled out given respiratory distress.\n- Thermoregulatory support on warmer.\n\nParents updated in delivery room.\n\nPMD: , .\nOB: , delivered by .\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884746,"text":"Admission Note\nHep B: Maternal HBsAg resent. Will give HBV if results not available by 12 hrs of life.\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884747,"text":"Respiratory Care\nSee attending and nursing admit notes for hx and further details. Infant GFR on arrival to NICU. Given facial CPAP then placed on prong CPAP 6. BS diminished. 02 req on CPAP 26-30%. CXR done to assess lung fields. Persistant grunting on CPAP, subcostal retractions. CBG: 7.28/47/45/23/-4. RR 30's-60's. Grunting significantly improved, presently intermittent. Will cont to follow closely, support as indicated.\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884813,"text":"npn 1900-0700\n\n\n1: resp\nremains in ra. no spells and no dsats. lung sounds clear and\nequal. mild subcostal retractions. no increased wob noted.\nrr 40-70's. sats >97%. continue to monitor for changes in\nrespiratory status.\n\n2; fen\ncurrent weight 2560 gms up 20. total fluids remain at\n150cc/kilo/day of bm24 cals tolerating feeds well. no spits,\nminimal aspirates. voiding and stooling. stool hem negative.\n\nabd soft with no loops. infant continues on iron. infant\npo'd 20cc's at 2100 and then 50cc at 0100. infant waking\nfor both cares. remainder of volume gavaged. continue with\ncurrent feeding plan.\n\n3: growth and development\ntemps stable in an oac. alert and active with cares. sleeps\nwell inbetween. brings hands to face. sucks vigorously on\npacifier. wakes for feedings. aga. continue to monitor for\ndevelopmental milestones.\n\n4; \nno contact thus far this shift from \n\n6: \ninfant currently off of phototherapy. sent this shift\npending. continues to be jaundiced in color. continue to\nfollow .\n\n7: skin\ninfant continues on triple antibiotic ointment to right\nfoot. infant's right foot with scabbing from old infiltrate\nsite. no drainage or bleeding noted. continue with current\nplan of care.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884809,"text":"I have examined and agree with the above note.\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884810,"text":"Neonatology Attending Note\nDay 11, PMA 36\n\nRA. Cl and = BS. No A&Bs. +murmur. HR 140-160s. BP 67/37, 47. Under photot. Bili 6.5/0.2. Wt 2540, up 70. TF 150 BM24. PO/PG. Tol well. Nl voiding and stooling. In air isolette.\n\nA/P:\nGrowing preterm infant learning how to po feed. Will begin Fe. d/c photot and check reb bili in AM.\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884814,"text":"Neonatology Attending Note\nDay 12, PMA 36 1\n\nRA. RR40-70s. CL and =. No A&Bs. No murmur. HR 130-150s. BP 67/45, 53. 6.5/0.2 (reb). Wt 2560, up 20 gms. TF 150 BM24. po/pg. Nl voiding and stooling. On Fe. Co-beeding in open crib.\n\nA/P:\nGrowing preterm infant awaiting maturation of feeding abilities.\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884815,"text":"PCA Progress Note \nI agree with the above PCA note and have assessed the pt. see flowsheet for further details.\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884816,"text":"PCA Progress Note \n\n\n#1 RESP: Infant remains in room air breathing 50-60s with\nmild subcostal retractions. LS clear/equal, oximetry d/c'd\nthis morning. No spells this shift. Breathing comfortably in\nroom air. Continue to monitor respiratory status.\n\n#2 FEN: TF 150cc/kg/day BM24. 64cc q4hours. Infant finished\nwhole bottle this morning, then breast fed with mom at \ncares and half volume bottle. Uses Playtex\nbottle/nipple. Abd benign, no loops, +BS. No spits, minimal\naspirates. Voiding and stooling heme neg. Tolerating feeds.\nContinue to encourage POs.\n\n#3 DEV: Stable temps swaddled cobedding with twin brother.\n and active with cares, sleeping well between and\noccasionally waking early. MAE. AFSF. Brings hands to face,\nenjoys pacifier. AGA. Continue to support developmental\nneeds.\n\n#4 SOC: Mom in for cares. Independent with son. Updated\nat bedside by RN. Asking appropriate questions. Loving\nfamily. Continue to update and support.\n\n#6 : Photo tx has been off since morning of 15th. \nfrom last night 6.5/0.3, remaining the same as the day\nbefore. Infant slightly jaundiced/well perfused. Continue to\nmonitor.\n\n#7 SKIN: Scab on right foot from IV infiltration healing\nwell. Triple antibiotic applied, then d/c'd this morning.\nContinue to monitor.\n\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884811,"text":"NPN 7a-7p\n\n\n#1 Resp: Infant in room air w/resp rate 40s-70s and sat\n97-100%. Lung sounds cl/= and mild SC retractions. No spells\nso far this shift. A: Infant stable in room air w/no spells.\nP: Cont to monitor.\n\n#2 FEN: TF 150 cc/kg of BM 24 (64 cc q4h gavaged over 50\nmin). Po/pg. Infant bottled 52 cc @ 0900 cares w/remaining\nvolume gavaged. BF well for 20 min @ 1300 cares and was\nsupplemented with half volume gavage. No spits, min asp.\nAbdomen round, pink, and soft w/active bowel sounds and no\nloops. Voiding and stooling heme neg. Now on iron. A: Infant\nimproving with po feedings and is well coordinated. P: Cont\nw/current plan and encourage po feedings as tol.\n\n#3 Dev: Received infant nested in air isolette. Infant now\nswaddled in an open crib, cobedding with brother. \nstable. Alert and active during cares and sleeps well in\nbetween. Wakes early for most feedings. Periods of quiet\nalert. A: AGA. P: Cont to supp dev needs.\n\n#4 : Mom in @ 1300 and was updated. Mom took temp,\nchanged diaper, and BF infant. A: Independent and\nappropriate w/cares. P: Cont to supp and update. Plan to\nprovide bath and teaching @ 1700 cares.\n\n#6 : Photo rx d/c @ 1030. A: Infant appears jaund. P:\nCont off photo rx and plan to check am.\n\n#7 Skin: Infant cont triple antibiotic ointment to scabbed\narea on R foot on old IV infiltrate site. No redness or\ndrainage noted.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884812,"text":"Exam Note\nGEN - calm, NAD\nHEENT - 15-20 blanchable erythematous macules 3-5mm in diameter on face, no excoriation or secondary infection, c/w erythema toxicum. Otherwise, AFSFO, oropharynx clear, NGT w/o breakdown\nCV - RRR, nl s1+s2 no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nEXT - wwp, R foot c/d/i, cr < 2 sec\nNEURO - reactive, MAE\n\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884759,"text":"NPN 0700-1900\n\n\nResp: Infant remains on CPAP 6, FiO2 24-27%. RR 30s-50s.\nLS cl/=. Mild SC retractions. No A's or B's thus far. P:\nCont to support/monitor resp status.\n\nFEN: TF 60cc/kg/day. D10 with 2Na & 1K infusing via left\nhand PIV at 30cc/kg/day. Right foot PIV infiltrated at 0900\nwith excoriated skin d/t tape noted; NNP aware & right foot\nelevated and left OTA. Enteral feeds started today at\n30cc/kg/day of BM/SC20 = 13cc q4hrs. Plan to increase\nenteral feeds by 15cc/kg/day at 1a &1p. DS 74 at 1100.\nAbd full, soft, +BS, no loops; no spits. AG 27. u/o\n1.2cc/kg/hr thus far. No stool. Lytes this am were\n143/4.6/108/22. P: Cont to support nutritional needs.\n\nG/D: Temps stable, nested on sheepskin with boundaries in\nplace on open warmer. Infant is a&a with cares. Irritable\nat times, settles well when left alone. Appropriately\nbrings hands to face & sucks pacifier to comfort self.\nAFSF. AGA. P: Cont to support dev needs.\n\nParents: Mom in for 0900 cares. Speaking lovingly to\ninfant. Updated on infant's condition and plan of care.\nAsking appropriate questions. P: Cont to update & support\nNICU family & plan for family meeting tomorrow at 4pm.\n\nID: IV abx d/c'd. Problem resolved at this time.\n\nBili: Bili this am was 9.6/0.3, up from 1.7/0.3 Infant\nplaced under phototherapy lights at 1130. Infant is\njaundice. Plan to recheck bili in the am. P: Cont to\nmonitor bili status PRN.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884760,"text":"NP NOTE\nPE: well developed preterm infant swaddled in open warmer. PInk, jaundiced in RA CPAP. Edematous.\nAFOF sutures approximated, eyes clear, puffy, nares patent with prongs in place, MMMP, white, frothy secretions\nChest is clear, fair exchaneg, mild SCR. Fair exchange, shallow.\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs cord dry\nGU: testes ins crotum\nEXT: PIV in left hand, right foot edematous with IV infiltrate.\nNeuro: active, responsive. Flexed posture, good tone, symmetric reflexes.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884761,"text":"Respiratory Care\nPt cont on prong CPAP. Fio2 .24-.27. bs clear, rr 50-70 with mild retractions. On caffeine. No spells. Plan to support as needed. Consider trial off in near future. Will follow.\n"},{"category":"Nursing/other","chartdate":"2197-12-12 00:00:00.000","description":"Report","row_id":1884762,"text":"RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 21-24%. RR 30-70's Breath sounds are clear. Stable on CPAP cont to follow. Plan to wean off CPAP soon.\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884827,"text":"Neo Attending note\nday 14, now 36.3 wk pma\nwt 2620, up 5 gm.\nCV: no murmur, hr 150s, bp 63/40, 48j\nrespr: ra, rr 3040s, clear=bs, 1qsr brady with apnea / periodic breathing. Thus countdown restarts today = D 0/5.\nTF: 150 cc/kg/day. BM24 all po + BFx2 per day. BF well.\nuop and stool wnl, heme neg.\nabd wnl. 7.5 stable. no spits.\ntemp stable in crib. State Newborn screen sent. HepB immunization today.\nCar seat: wait until bradycardia have continued to improve.\nhearing screen pending, pending.\n\nassessment: due to brady/apnea/periodic breathing, infant will continue CVR monitoring with oximeter.\notherwise assement is as noted above.\nPlan: as noted above.\n\nPt evaluated and discussed with team.\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884807,"text":"1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\nequal, mild subcostal retractions seen. O2 sats are >97%. No\nspells so far this shift, last one on . Continue to\nmonitor respiratory status.\n\n2. FEN-TF=150cc/kg of BM/SC now 24 or 64cc q4hrs PO/PG.\nInfant offered bottle at 0900 care, bottled 18cc's using\nPlaytex bottles. Eager bottler at first but tires easily.\nMom put infant to breast at 1300, infant latched and\nbreastfed for about 10 minutes. Infant asleep for third care\nand mom was unable to put to breast. Full feed gavaged\nafterward over 50 minutes. Abd benign. Voiding and stooling\nheme negative. No spits. Minimal aspirates. Continue to\nencourage po feeds as tolerated by infant.\n\n3. DEV-Temperatures stable in air isolette under neoblue\nlight. Wakes occassionally for cares. Alert and active\nduring first two cares, asleep with last care. Continue to\nsupport developmental needs.\n\n4. PARENT-Mom in afternoon. Updated by RN. Loving towards\ninfant, independent with care. Continue to educate and\nsupport .\n\n6. BILI-Infant remains under neoblue with eye shields in\nplace and slighly jaundiced in color. Yesterdays bili was\n12.3 (0.3). Bili to be rechecked in am. Continue to monitor\nbili.\n\n7. SKIN-Infants right foot continues to heal, small scab\npresent. Triple antibiotic ointment applied as ordered by\nRN. Continue to monitor skin integrity.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-20 00:00:00.000","description":"Report","row_id":1884808,"text":"PCA Progress Note 1900-0700\n\n\n#1 RESP: Pt. remains in RA breathing in the 40-60s with\nmild subcostal retractions. Lung sounds cl+= bilaterally.\nNo episodes of apnea or bradycardia so far this shift. P:\nContinue to monitor respiratory status.\n\n#2 FEN: Weight: 2540g ^ 70g. Total fluids: 150cc/kg/d of\nBM/SC 24= 64cc Q4hrs PO/PG. Pt. was put to breast @ 2100\nwith +latch and good coordination for > 10minutes, full\nfeeding gavaged. Pt. took 20cc using the playtex nurser @\n0100. Abd soft and round, +BS, no loops. No spits.\nMinimal aspirates. Pt. is voiding, stooling heme neg. P:\nContinue to encourage po feedings as tolerated.\n\n#3 G&D: Temps stable nested in air isolette. Alert and\nactive during cares. Sometimes waking for feedings. Rests\nwell inbetween cares. MAE. AFSF. P: Continue to support\ndevelopmental needs.\n\n#4 Parenting: Mom and Dad in @ 2100. Mom independent with\ncares and breastfeeding. Mom called X 1. Very loving and\ninvolved. Updates given. P: Continue to support and update\nfamily.\n\n#6 BILI: Pt. remains under neoblue lights with eye shields\nin place. Pt. is sl jaundice. Stooling. Last bili:\n12.3/0.3. Bili was drawn this morning, results pending. P:\nContinue to monitor.\n\n#7 Skin: Scab noted on right foot. Healing, no drainage or\nredness noted. Triple antibiotic applied as ordered. P:\nContinue to monitor.\n\nPlease see flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884802,"text":"Exam Note\nGEN - alert, fussy in air crib under bili lights\nHEENT - AFSFO, oropharynx clear, eye covers intact, NGT w/o breakdown\nCV - RRR, nl s1+s2, no murmur\nABD - soft, NT, NT, no mass\nGU - nl ext genit, no rash\nEXT - wwp, cr < 2 sec\nNEURO - MAE< reactive\n\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884803,"text":"NPN 07p-07a\n\n\nRESP\nRA, LS clear & equal with mild subc. retractions. RR30-60's.\nNo spells or desats this shift thus far. Cont. monitor resp.\nstatus.\nFEN\nCurrent weight 2470g (^50). TF 150cc/kg/day, BM/SSC20.\nTolerating well. Gavaged q4hrs/bottled x1 this shift thus\nfar 20cc (coordinated, quickly tiring). BS active. Abd.\nsoft, round. Voiding, stooling heme negative. Cont. monitor\nPO/PG feeding tolerance & weight.\nG&D\nIn air isolette, temps stable. Nested. Alert & active with\ncares. Resting comfortably inbetween. Fontanels soft, flat.\nMAEs. PPPx4ext. Cont. monitor growth & developm. patterns.\n\nMOB updated over phone x1. Loving & caring. Cont. support &\neducate.\nBili\nCont. under neoblue bank, eye shields in place. VS stable.\nAlert & active with cares. Voiding, stooling. Cont. monitor\nfor changes.\nSkin\nCont. with scabbed area on right foot, no redness, drainage\nor swelling noted. Triple antx ointment applied as ordered.\nCont. monitor for changes.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884804,"text":"Neonatology Attending\n\nAdvancing to 24 cals/oz feed. Will discontinue phototherapy.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884805,"text":"Neonatology Attending\n\nDay 10 PMA 35 wks\n\nRemains in RA. Clear breath sounds. No bradycardia. No murmur. BP mean 45. Weight 2470g (+50). TF at 150 ml/kg/d- BM/SC 20. Bottling 20-30ml per feed. Passing heme negative stool. Stable temperature in air-controlled incubator. Stable temperature.\n\nDoing well overall. Monitoring for apnea. Tolerating feeds well. Gaining weight well. Encouraging po feeds.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-19 00:00:00.000","description":"Report","row_id":1884806,"text":"I have examined baby boy I and agree with the above note written by , PCA.\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884754,"text":"NPN Days\n\n\n#1 Resp: CPAP 6 26-32%. 40-80's with occ increased\ntachypnea, mild SC retrac, LS c/=, with intermittent\ngrunting noted. Occ sat drifts, one spell so far this shift,\nresolved with mild stim and increased 02. P: Cont to monitor\nresp status, will check CBG this eve.\n#2 FEN: TF=60cc/kg D10W infusing via PIV without diff. Abd\nbenign, infant cont to be NPO, V/S, mec stooling. P: COnt to\nmonitor FEN status, check lytes and bili in AM.\n#3 G&D: Temp stable on off warmer, swaddled. Alert and\nactive with cares, occ irritable, given sucrose. Sleeps well\nin between cares. P: Cont to monitor and support G&D.\n#4 Parents: Parents in for cares, participated where able.\nAsking appropriate questions, updated frequently by this RN.\nAppear very loving towards infant. P: Cont to encourage\nparental calls and visits.\n#5 ID: Temp stable, infant acting appropriately. Bld cx NTD,\non Amp and Gent. P: F/u with cxs, d/c'd abx at 48hrs.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884755,"text":"Respiratory Care Note\nInfant remains on NCPAP +6, 26-32% - BS sl. diminished, RR's 40's-70 with some intermittant grunting - no spells thus far - occasional saturation drifts - continue to monitor - blood gas this afternoon.\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884756,"text":"RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 23-32%. Breath sounds are clear. RR 40-80's occasional grunting. Stable on CPAP cont to follow closely.\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884757,"text":"Nursing NICU Note\n\n\n1. REsp. O/ Intermittent grunting noted. Remains on Nasal\nProng CPAP of 6, 21-30% primarily. Please refer to\nflowsheet. NO A/B noted. A/Alt. in REsp status. P/Cont. to\nmonitor resp status and intervene as needed. Murmur noted\nand reported to NNP. A/Resp status remains stable at this\ntime on CPAP. P/Cont. to monitor for evidence of resp\ndistress.\n\n2.F/N. O/ Tf remain at 60cc/k/d of IVF D10 with 2 NaCl/dl\nand 1meq KCL/dl via new PIV. Please refer to flowsheet for\nexaminations of pt from this shift. Remains NPO.\nIntermittently sucking on pacifier.\n\n3. G/D. O/TEmp remains stable swaddled on a warmer. AWake\nand alert at care times and sleeping well in between. A/Alt.\nin G/D. P/Cont. to support pt's growth and dev. needs.\n\n4. Parents. O/Parents into visit last night. Parents updated\non pt's status and plan of care. Father held infant\nswaddled. A/Parents are involved in pt's care.; P/Cont. to\nsupport and educate parents.\n\n5. ID. O/Anitbiotics d/c. NNP stated that she corrected lab\nerror. A/Completion of 48hr r/O. Cont. to monitor for s/s of\n infection.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-11 00:00:00.000","description":"Report","row_id":1884758,"text":"Neonatology Note\n2 d.o\non CPAP+6, RA-30%O2, no caffeine\nbili= 9.6\nwt= 2450 gm -50\nTF at 60 ml/kg/d, NPO\nvoiding(+), bm(+)\nlytes: 143/4.6/108/22\n\nA: twin #1, 34 wks GA, RDS, sepsis evaluation, hyperbilirubinemia\nP: monitor respiratory staus on CPAP, wean O2 as tolerated, start feeding, start phototherapy, f/u bili.\n"},{"category":"Nursing/other","chartdate":"2197-12-22 00:00:00.000","description":"Report","row_id":1884824,"text":"Nursing Progress Note\n\n\n#1 Resp-- O: RA. No spells. HR 160s; HR 50s-60s. Color\npink/sl jaund. BS clear and =, mild sc ret. A: Day 4 of 5 P:\nCont to monitor vitals, document spells\n\n#2 Nutrition-- O: 150cc/kg/d= 65cc BM24- HMF d/c- powder\n4cal/oz started. Po fed well at 0900 taking 70cc., tol well.\nBF x20 min at 1300 well- no supplement after breast. wakeful\nfor long period after feed. NG d/c. Abd exam benign, VQS, sm\nyellow stool x2. Desitin to reddened butoocks (skin intact).\nOn iron. A: Adequate growth, all po x 24h. P: Cont to\nmonitor intake and growth. Plan to supplement BF every other\nBF session with bottle. Switch to pwder 4cal/oz. repeat\nPKU and in am.\n\n#3 Development-- O: and active, waking for feeds.\nHands to mouth, and sucking on pacifier. Temp stable,\nco-bedding with twin. All po feeds. Social with Mom. A: AGA\nP: Cont to support development; Hep B vaccine tonight\n\n#4 Parenting-- O: Mom in at 1300. Updated re status and\nplan. pleased with progress. Mom upset about baby taking\nfeeding by regular nipple overnight and prefers the Playtex\nNurser. Will bring in car seat ; will decide about\ncirc with dad by called, referral to Caregroup\nwith tentative visit next Wed. Mom to make pedi appt\ntentatively for next Tues with tentative discharge date Mon.\nA: Nearing discharge P: Cont to support and keep informed;\ncont discharge planning- car seat test ; Hep B,\nPKU, & over night.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884825,"text":"NNP Physical Exam\nAwake and . AFOF with good tone. Breaht sounds clear and equal on RA without retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded wiht active BS, no HSM or masses. Normal GU.\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884826,"text":"npn 1900-0700\n\n\n1: resp\nremains in ra. infant has had one spell thus far this shift.\ninfant brady was to 74, apneic, qsr. see flow sheet. lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. rr 30-40's. continue to monitor for\nchanges in respiratory status.\n\n2; fen\ncurrent weight 2620gms up 5gms. total fluids remain at\n150cc/kilo/day of bm 24 cals with powder. tolerating\nfeeds well. taking all po feeds. infant taking 50cc at 2100\ncare and then 70 with 0100 care. infant tolerating feeds\nwell. no spits. abd soft with no loops. voiding and\nstooling. desitin applied to buttocks. using platex nurser.\ncontinue with current feeding plan.\n\n3: g/d\ntemps stable in an oac. co-bedded with brother. and\nactive with cares. sleeps well inbetween. brings hands to\nface. sucks vigorously on pacifier. wakes for feedings.\naga. continue to monitor for developmental milestones.\n\n4: \nno contact thus far this shift.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884799,"text":"Neonatology Attending\n\nDay 9 PMA 35 wks\n\nRemains in RA. RR 30-50s. Sats 92-100%. Clear breath sounds. had one bradycardia episode over last 24 hours. No murmur. HR 130-160s. No murmur. BP mean 57. Bilirubin 12.3 (rebound) so palced back under phototherapy. Weight 2420g (+10). TF at 140 ml/kg/d- SC 20. Bottled one feed. Breast feeding for 5-10 minutes. No spits. Minimal aspirates. Stable temperature in air-controlled incubator. Family up to date.\n\nDoing well overall. Minimal respiratory immaturity. Will continue to monitor. Advancing feeds to 150 ml/kg/d. Exaggerated physiologic hyperbilirubinemia. Will continue on phototherapy.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884800,"text":"Social Work\n\n\nMet with mother while in visiting with babies today.\nMother feeling overwhelmed today. She states that she gets here in the morning and styas for the whole day as she wants to be here for all of the babies feedings.\nTalked with her about cutting back on the amount of time she is here each day, and the importance of having some time for her to rest and pump. Really encouraged her to only come in in early afternoon and she can stay until her husband comes in from work and then they can go home together.\nMother states that she has good supports, a lot of help from members of her church who have been bringing in dinners for them. Also a friend has been driving them in to the hospital each day, as the couple do not have a car they live closby in , but public transportation is not direct to the hospital.\nMother's sister will be visiting from over , and her mother in law will come in mid . All extended family members are in State.\nWill plan to check in with mother tomorrow, continue to encourage her to take car of herself and not to be spending the entire day at the hospital.\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884801,"text":"NPN 7a-7p\n\n\n#1 Resp: Infant in room air w/resp rate 20s-50s and sat\n93-100%. Lung sounds cl/= and mild SC retractions. No spells\nso far this shift. A: Infant stable in room air w/no spells.\nP: Cont to monitor.\n\n#2 FEN: TF inc from 140 to 150 cc/kg of BM 20 (64 cc q4h\ngavaged over 50 min). Po/pg. Infant breast feeding w/Mom q\ncares and receiving full gavage volume. Infant BF for 5 min\n@ 0900 but was sleepy with weak suck. Infant awake and eager\nand breast fed for 10 min with good latch and suck @ 1300\ncares. No spits, min asp. Abdomen round, pink, and soft\nw/active bowel sounds and no loops. Voiding and stooling\nheme negative. A: Infant coordinated w/breast feeding when\nawake and eager. P: Cont w/current plan and encourage po\nfeedings as tol.\n\n#3 Dev: Infant nested in air isolette, temp stable. Alert\nand active during cares and sl irritable in between. Settles\nvery well with pacifier and boundaries. A: AGA. P: Cont to\nsupp dev needs.\n\n#4 : Mom in q cares and updated. Mom took temp,\nchanged diaper, and breast fed infant. A: Independent and\nappropriate w/cares. P: Cont to support and update.\n\n#6 Bili: Infant cont neoblue photo rx with eye shields for\nbili of 12.3/0.3 this am. A: Infant appears jaund. P: Cont\nphoto rx and check bili .\n\n#7 Skin: Triple antibiotic ointment applied to old\ninfiltrate/scabbed area on right foot @ 0900 cares.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-17 00:00:00.000","description":"Report","row_id":1884797,"text":"NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 96%. Lung sounds clear/=. RR 30-50's. Mild\nSCR noted. No A's or B's noted. P: Cont. to monitor resp.\nstatus.\n\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempted to BF\nx 2 thus far - latched well. Tolerating NGT feedings well;\nabd exam benign, no spits, min asp. Voiding qs and stooling\nheme neg. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/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 suppot developmental\nneeds. P: Cont. to support developmental needs.\n\n4. : in throughout day. Independent with\ncares and handling infants. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved . P: Cont. to support and update\n.\n\n5. Bili: Photo was d/c'd on thurs at 10 am for a bili of\n10.6. P: Repeat bili to be drawn in am.\n\n6. Skin - Rt foot infiltrate left open to air. Healing well\nwith triple abx ointment q 12 hours. No drainage, swelling,\nor redness noted. P: Cont. to monitor skin.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-18 00:00:00.000","description":"Report","row_id":1884798,"text":"npn 1900-0700\n\n\n1: resp\nremains in ra. no spells and no dsats. lung sounds clear and\nequal. mild subcostal retractions. no increased wob noted.\nrr 30-50's. sats .925. continue to monitor for changes in\nrespiratory status.\n\n2: fen\ncurrent weight 2420gms up 10. total fluids remain at\n140cc/kilo/day of bm 20 cals. tolerating feeds well. no\nspits. minimal aspirates. voiding and stooling. abd soft\nwith no loops. infant po'd 20cc at 0100. infant po fed based\non feeding cues. continue to encourage po feeds as\ntolerated.\n\n3: growth and development. received infant in an off\nisolette. infant currently co-bedding in a crib with\nsibbling. temps remain stable. alert and active with cares.\nsleeps well inbetween. brings hands to face. sucks\nvigorously on pacifier. brings hands to face. aga.continue\nto monitor for developmental milestones.\n\n6; bili\ninfant color slighlty jaundiced. infant currently off of\nphototherapy. rebound bili sent this shift. will continue to\nmonitor bili closely.\n\n7: skin\ninfant right foot old infiltrate sight with multiple small\nscabs. no drainage noted and no bleeding. triple antibiotic\nointment applied at 2100. continue to monitor for changes.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884748,"text":"Admission Note\nBB admitted to NICU following C/S delivery for PIH. Infant emerged with good cry, dusky and retracting, requiring stim and BBO2 in DR. . on admission, GFR with RA SaO2 mid 80's, placed on CPAP 6 in 26-30% FiO2 to maintain SaO2 89-95. LS sl coarse and diminished, color good, cont with GFR through shift. Cap gas 7.27/45/47. No murmur audible, BP 75/35 mean 45. Labs sent for Bld cx and CBC, antibiotics begun. IV placed in R hand with D10W infusing, initial DS 47, after IVF infusing, DS 74. Abd benign, soft, round, +BS, has voided, no stool, NPO for now. Stable on open warmer, sl irritable with cares, little interest in pacifer. Dad visited briefly, told weights/measures and equipment explained, spoke softly with the babies. A: 34 week infant w/RDS P: cont CPAP/O2 as needed, maintain IVF NPO for now, cont antibiotics as ordered, monitor\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884749,"text":"Respiratory Care Note\nPt continues on Prong CPAP +6 FIO2 26-28%. B.S. ess. clear with good air entry. Mild retractions and grunting noted. Without apnea or bradys as of this note.\n"},{"category":"Nursing/other","chartdate":"2197-12-09 00:00:00.000","description":"Report","row_id":1884750,"text":"1 Alt in Resp\n2 Alt in FEN\n3 Alt in G&D\n4 Alt in Parenting\n5 ID\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in Resp; added\n Start date: \n 2 Alt in FEN; added\n Start date: \n 3 Alt in G&D; added\n Start date: \n 4 Alt in Parenting; added\n Start date: \n 5 ID; added\n Start date: \n\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884751,"text":"#1 PT CONT ON CPAP OF 6, MOSTLY 25-30% FI02. LS ARE CLEAR,\nSLIGHTLY DIMINISHED. RR 40-80 WITH OCC GRUNTING. SATS\nIMPROVED ON BELLY.\n#2 NPO. TF 60/KG D10W INFUSING WELL VIA PIV. WEIGHT DECREASE\n75GM. VOIDING AND STOOLING. DSTIX 113. BELLY FULL AND SOFT\nWITH ACTIVE BS.\n#3 TEMPS ARE STABLE NESTED ON SERVO WARMER. ALERT AND\nIRRITABLE.\n#4 DAD IN TO VISIT IN EVENING. DAD UPDATED AT BEDSIDE.\n#5 PT CONT ON AMP AND GENT AS ORDERED.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884752,"text":"RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 25-30%. Occasional grunting RR 40-80's. Breath sounds are clear. Stable on CPAP will cont to follow closely.\n"},{"category":"Nursing/other","chartdate":"2197-12-10 00:00:00.000","description":"Report","row_id":1884753,"text":"Neonatology Attending\n\nDay 1 PMA 34 wks\n\nRemains on CPAP 6 with fio2 0.28. RR 50-80s. Intermittent grunting. CBG 7.28/47. No apnea, bradycardia. No murmur. HR 130-160s. BP mean 47. Weight 2500g (-75). NPO. IV dextrose at 60 ml/kg/d. Blood glucose 103. Benign abdomen. Lytes 135/4.0/19. Bilirubin 1.7. Stable temperature on off warmer. Parents in earlier this morning. On ampicillin and gentamicin. Blood culture no growth.\n\nMild hyaline membrane disease. Will continue to monitor closely. Keeping NPO. Will continue to follow blood glucose. Ruling out on antibiotics.\n\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884817,"text":"Exam Note\nGEN - , active\nHEENT - AFSFO, facial macules almost completely resolved from yesterday, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash, stool present\nEXT - wwp, cr < 2\nNEURO - MAE, reactive\n"},{"category":"Nursing/other","chartdate":"2197-12-21 00:00:00.000","description":"Report","row_id":1884818,"text":"6 Alt in \n7 Skin:\n\nREVISIONS TO PATHWAY:\n\n 6 Alt in ; resolved\n 7 Skin:; resolved\n\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884828,"text":"NPN DAYS\n\n\n#1 Pt received and cont in RA. LS C+=. no spells so\nfar this shift. Pt day of spell count down. P- Will cont\nto monitor resp status.\n#2 FEN- TF=150cc/kg/d of BM24 with powder. abd benign.\nall po feeds. po 35-50cc +BFx2. Pt voiding and stooling hem\nneg. no spits. waking q2.5-4hrs. P- Will cont to monitor\nFEN.\n#3 G&D- Temp stable in open crib. cobedding with sibling.\n and active with cares. sucking on pacifier. P- Will\ncont to monitor G&D.\n#4 Mom and Dad visiting this shift. Loving and\ncaring towards pt. asking approp ques. updates given.\nhelping with cares. updated re: pt spells and DC\ndate pushed back. P- Will cont to support and educate\n.\nSee flowsheet for further details.\n\n\n"},{"category":"Nursing/other","chartdate":"2197-12-23 00:00:00.000","description":"Report","row_id":1884829,"text":"NPN DAYS\naddendum: Hep B immunization given @ 1800.\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884830,"text":"NPN:\n\nRESP: RA. RR=40-50s w/SC retraction. BBS =/clear. Last A&B on ; day of brady count.\n\nCV: No murmur. HR=140-160. BP=68/41 (51). Color pink w/slight jaundice. Perfusion good.\n\nFEN: Wt=2655g (+ 35g). Ad Lib feeds of BM-24. Intake yesterday 119cc/kg/d + breast fdgs x 2. Bottled slowly x 1 for 10cc; 60cc taken well at following feeding. No spits. Abd benign. Voiding qs; small yellow stool. FeS04. Mother has appt w/lactation consultant on (13:00).\n\nG&D: CGA=36-4/7 wk. Temp stable in crib. Co-bedding w/sibling. Active and w/good tone. Swaddled and resting well. Discharge preparations in progress; hearing screen and carseat test need to be done.\n\nSOCIAL: Mother called x 1 for update.\n"},{"category":"Nursing/other","chartdate":"2197-12-24 00:00:00.000","description":"Report","row_id":1884831,"text":"NNP ON-Call\nPhysical Exam\nGeneral: infant in open crib, room air,co-bedding with twin\nSkin; warm and dry; color pink/jaundiced; cafe spot on forehead\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds; cord healed\nExt: moving all\nneuro: appropriate tone and reflexes; alerts\n"},{"category":"Radiology","chartdate":"2197-12-09 00:00:00.000","description":"BABYGRAM (CHEST ONLY)","row_id":934419,"text":" 1:36 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate for rds vs retained fetal lung fluid\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, on CPAP\n REASON FOR THIS EXAMINATION:\n evaluate for rds vs retained fetal lung fluid\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest x-ray.\n\n DATE OF EXAM: .\n\n TIME OF EXAM: 1:46.\n\n CLINICAL HISTORY: This is a newborn infant on day of life 1 with respiratory\n distress.\n\n FINDINGS: A single, portable view of the chest was obtained. I have no prior\n films available for comparison. The heart size is normal. The pulmonary\n vasculature is within range of normal limits. There is some increased\n interstitial fluid suggesting the diagnosis of TTN, perhaps with a component\n of mild hyaline membrane disease. There is no focal lung opacification.\n\n Abdominal situs is normal. The visualized bony structures are normal.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884793,\n \"text\": \"Neonatology Attending\\nDOL 7 / PMA 35-3/7 weeks\\n\\nRemains in room air with no distress. Occasional drifting saturations but no bradycardias.\\n\\nNo murmur.\\n\\nOff phototherapy with bilirubin 10.6 yesterday.\\n\\nWt 2385 (+35) on TFI 140 cc/kg/day BM20, tolerating well. Bottling up to of feeds. Voiding and stooling (guiac negative). Abd benign.\\n\\nTemp stable in off isolette.\\n\\nRIght foot infiltrate improved.\\n\\nA&P\\n34-3/7 week GA infant with respiratory and feeding immaturity\\n-Continue to await maturation of oral feeding skills and respiratory drive\\n-Repeat bilirubin on Monday\\n-No changes in management as detailed above\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884794,\n \"text\": \"NPN 0700-1900\\n\\n\\n1. Resp: Infant remains in RA, maintaining his O2 sats\\ngreater than 90%. Lung sounds clear/=. RR 30-50's. Mild\\nSCR noted. No bradys noted. Occ drifts to high 80's noted.\\nP: Cont. to monitor resp. status.\\n\\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempting to\\nPO when awake and alert. Infant breastfed x 2 thus far -\\nlatched well. Tolerating NGT feedings well; abd exam\\nbenign, no spits ,min asp. Voiding qs and stooling heme\\nneg. P: Cont. to support nutritional needs.\\n\\n3. G/D: Temps stable swaddled in off-isolette. Infant is\\nalert/active with cares. Settles well in betwen cares.\\nAppropriatley brings hands to face and sucks on pacifier to\\ncomfort self. AFSF. AGA. P: Cont. to support developmental\\nneeds.\\n\\n4. : Mom in for 2 set of cares today. Independent\\nwith cares and handling. Updated at bedside on infant's\\ncondition and plan of care. Asking appropriate questions.\\nLoving, involved . P: Cont. to support and update\\n.\\n\\n5. Bili: Rebound bili fri am was 10.6. Infant remains sl.\\njaundiced. Will follow bili on mon am.\\n\\n6. Skin: Dressing changed no right foot infiltrate. Triple\\nabx and tefla applied. No drainage, redness or swelling\\nnoted. P: Cont. to monitor skin.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884795,\n \"text\": \"Nursing Progress Note 1900-0700\\n\\n\\nResp:Infant remains in RA saturating 96-99%.RR 30-60's.LS\\nremain clear and equal with sc retractions.No A's and B's or\\ndesats thus far.\\n\\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\\nq 4 hrs gavaged over 45 min.Infant attempted to bottle with\\nthe Playtex Nurser and took 25-44cc's.Appeared well\\ncoordinated;remainder gavaged.Weight=2.410 up 25 grams.Abd\\nsoft with pos bs,no loops or spits,minimal aspirates.Voiding\\nand stooling heme negative.\\n\\nG/D:AF soft and flat.Alert and active with cares.Sleeping\\nwell b/t.MAE.Bringing hands to face and mouth.Infant remains\\nin off isolette;swaddled with nested boundaries.Temp.\\nmaintained.\\n\\nParenting:Mom called x 1.Updated by this RN.Asking\\nappropriate questions very loving and invested.\\n\\nBili:Infant cont's jaundice but well perfused.Stooling.To\\nhave bili checked on .\\n\\nSkin:R foot appears pink with serous drainage on old\\ndressing.Applied triple antibiotics;healing well.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884796,\n \"text\": \"Neonatology Attending\\n\\nDOL 8 PMA 35 4/7 weeks\\n\\nStable in RA. No A/B.\\n\\nNo murmur. BP 78/33 mean 50\\n\\nOn 140 ml/kg/d BM 20 po/pg. Voiding. Stooling. Wt 2410 grams (up 25).\\n\\nR foot infiltrate being treated with triple antibiotics.\\n\\n in and up to date.\\n\\nA: Stable. No spells. Tolerating feeds and learning to po. Infiltrate healing.\\n\\nP: Monitor\\n pos as tolerated\\n Continue care for infiltrate\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884789,\n \"text\": \"Nursing Progress note\\n\\n\\n#1 Resp-- O: RR 30s-60s; HR 140s-160s; Sats 96-99. No\\ndesats, no spells. BS clear and =; mild sc ret. Pink/jaund.\\nNo murmer. A: Rare desats in RA P; Cont to monitor\\nsats/vitals/spells\\n\\n#2 Nutrition-- O: Enteral feeds advanced to 140cc/kg/d= 60cc\\nBM20 q4h. BF great x2 with good latch and suck 5-10 min-\\nthen drowsy. Tol full volume after BF over 45 min. tol well-\\nno spits, no asp. NG #5 placed in rt nare after baby pulled\\ntube. Abd exam benign, AG 25cm, +BS. VQS, Yellow x2\\nguiacneg. A: Stable, tol adv feeds with wt gain P: Monitor\\ntol and growth\\n\\n#3 Development-- O: Alert and active with cares, social with\\nmom. stable in off islolette. Swaddled, with\\nboundaries. Hands to mouth. A: AGA P: Cont to support\\ndevelopment\\n\\n#4 Parenting-- O: Mom in for 0900 and 1300 feeds.\\nIndependent with babies, handling well. Updated re status\\nand plan. Will be back for 1700 feed. A: Involved. loving P:\\nCont to support and keep informed\\n\\n#6 ^Bili-- O: rebound bili stable off og photo Rx. Color sl\\njaund, VQS, stooling, full feeds. A: Resolving P: Check bili\\nMon. am\\n\\n#7 Skin-- O: Rt foot lesion drsg . Sm amt\\nyellow/serous drainage noted. Area cleansed with sterile\\nH2O, triple antibx ointment applied with Telpha and gauze\\nwrap. A: Improving P: Monitor and change drsg \\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884790,\n \"text\": \"Exam Note\\nGEN - calm, NAD\\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl external male genit, no rash\\nEXT - wwp, cr < 2, R foot wound c/d/i with normal granulation tissue and no pus or erythema\\nNEURO - MAE, reactive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884791,\n \"text\": \"Nursing Progress Note 1900-0700\\n\\n\\nResp:Infant remains in RA saturating 97-100%.RR 30-60's.LS\\nremain clear and equal with sc retractions.No A's and B's\\nthus far.Occ. will drift in sats to high 80's QSR.\\n\\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\\nq 4 hrs gavaged over 45 min.Infant bottled x 2 with Playtex\\nbottle and took 17-47cc the remainder gavaged.Weight=2.385\\nup 35.Abd. soft with pos bs,no loops or spits,minimal\\naspirates.Voiding and stooling heme negative.\\n\\nG/D:AF soft and flat.Alert and active with cares.Stirring\\nprior to feeds.MAE.Bringing hands to face and mouth and\\nintermitently sucking on pacifier.Infant remains in off\\nisolette swaddled with nested boundaries.Temp. stable.\\n\\nParenting:No contact from so far.\\n\\nBili:Infant cont's slightly jaundice.To recheck Bili .\\n\\nSkin:R foot appears to be healing well.Cont's slightly pink\\nwith healing tissue.No drainage or foul odor\\npresent.Dressing changed per protocol.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884792,\n \"text\": \"Neonatology NP note\\nPE\\nswaddled in open crib, cobedding with twin\\nAFOf\\nminimal subcostal retractions in room air, lungs clear/=\\nRRR, no murmur, pink and well perfused\\nabdomen soft, nontender and nondistended, active bowel sounds\\nactive with good tone\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884786,\n \"text\": \"NPN 0700-1900\\n\\n\\n1. Resp: Infant remains in RA, maintaining his O2 sats\\ngreater than 93%. Lung sounds clear/=. RR 40-60's. Mild\\nSCR noted. Few drifts to high 90s noted. No apnea noted\\nthus far. P: Cont. to monitor resp. status.\\n\\n2. FEN: TF were increased to 120 cc/kg/day of BM/SC20.\\nInfant is attempting to PO/breastfeed when awake and\\ninterested. Infant breastfed well x 1. Tolerating feedings\\nwell; abd exam benign, no spits, min asp. Voiding qs and\\nstooling trans stools. P: Cont. to support nutritional\\nneeds.\\n\\n3. G/D: Temps stable swaddled in off-isolette. Infant is\\nalert/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. Parents: Mom in for cares this shift. Independent with\\ncares and handling infants. Updated at bedside on infant's\\ncondition and plan of care. Asking appropriate questions.\\nLoving, involved parents. P: Cont. to support and update\\nparents.\\n\\n5. Bili: Single phototherapy was d/c'd at 1000. Bili this\\nam was 9.6/0.3. Plan is to check rebound in am.\\n\\n6. Skin: Dressing was changed x 1. Tefla and gauze and\\ntriple abx ointment placed on infiltrate. No drainage noted\\nfrom site. P: Cont. to monitor and change dressings as\\nordered.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884787,\n \"text\": \"#1Resp\\nLungs clear with mild sc retractions. Baby has had one spell\\ntonight which required mild stim.RR 40-60 with sat in high\\n90's.\\nP. Cont to monitor\\n#2FEN\\nWt 2.35 up 25g. Baby cont to receive 150cc/kg BM20 52 cc q4.\\nAbd round but soft active bowel sounds. Min asp No spits,\\nSleepy at 2100 and feed gavaged. At 0130 awake and alert but\\nnot that interested and took 15cc. At 0500, bottled 22.\\\\\\nA. Tol feed and learnung to feed\\nP> CONT TO MONITOR TOL TO FEEDS AS WELL AS WEIGHT GAIN AND\\nFEED ABILITY\\n#3DEV\\nAWAKE AND ALERT WITH CARES BUT TIRES. TEMP STABLE IN AN OFF\\nISOLETTE.\\n#4PARENT\\nMOM X 1 FOR AN UPDATE\\n#6BILI\\nBILI WAS 10.6/.2. NNP INFORMED. REMAINS SL JAUNDICED\\n#7SKIN\\nDSG TO R FOOT CHANGED, AREA PINK AND CLEAN. NO DRAINAGE.\\nGOOD PERFUSION TO THE TOES. DIAPER AREA SL PINK. DESITIN\\nAPPLIED\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884788,\n \"text\": \"Neonatology Attending Note\\nDay 6, PMA 35 2\\n\\nRA. RR40-60s. Mild sc rtxns. Cl and = BS. Mild desats-sr. HR 130-140s. BP 85/43, 56. Reb bili 10.6/0.2. Wt 2350, up 25. TF 120 BM20/SC20. PO/PG. Tol well. Nl voiding and stooling. Desitin to diaper dermatitis. In off isolette.\\n\\nA/P:\\nGrowing preterm infant learning how to po feed. Adv TF to 140. Follow jaundice clinically, check another Monday.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884782,\n \"text\": \"npn 1900-0700\\n\\n\\n1: resp\\nremains in ra. one spell with breastfeeding, qsr, see flow\\nsheet. rr 30-70's. mild subcostal retractions. no increased\\nwob noted. sats 93-100%. lung sounds clear and equal.\\nconitnue to monitor for changes in respiratory status.\\n\\n2; fen\\ncurrent weight 2325gms down 50. total fluids remain at\\n100cc/kilo/day of bm 20/sc 20. tolerating feeds well. no\\nspits. minimal aspirates. voiding and stooling. abd soft\\nwith no loops. girth stable. mom breastfed at 2100 and at\\n0100, with first care infant latched on and took a few\\nsucks, at 0100 care infant latched on and nursed well for\\n5-10 minutes. continue to support mom with breastfeeding.\\nfull gavage feed given following breastfeeding. continue\\nwith current feeding plan.\\n\\n3: growth and development:\\ntemps stable in an air heated isolette. alert and active\\nwith cares. sleeps well inbetween. brings hands to face.\\nsucks vigorously on pacier. irritable at times. unswaddled\\nwith boundaries for phototherapy. continue with current\\nfeeding plan.\\n\\n4; parenting\\nmom and dad in for 2100 care. both involved with cares.\\nloving and asking appropriate questions. both helping change\\ndiaper and do temp. continue to support family while in the\\nnicu environment.\\n\\n6: bili\\ninfant remains under single phototherapy. eye shields in\\nplace. bili drawn this shift 9.6/0.3/9.4. infant color\\njaundiced. continue to monitor for change.\\n\\n7: skin:\\ninfant with newborn rash. infant also with right foot lesion\\n\\nwith multiple small scabs and open area that is pink. small\\namount of serous draingae noted on gauze. dressing changed\\nand triple antibiotic ointment applied. no active bleeding\\nand no edema noted. continue with dressing changes.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884783,\n \"text\": \"Neonatology Attending Note\\nDay 5, PMA 35 1\\n\\nRA. RR30-70s. Cl and = BS. Mild rtxns. Occass sat drifts. +2 A&Bs past 24h. HR 130-150s. No murmur.\\n\\nJaundice, Bili 9.6/0.3, under single photot.\\n\\nWt 2325, down 50. TF 100 BM/SC20. Tol well. Nl voiding and stooling. Tr mec.\\n\\nIn air isolette.\\n\\nA/P:\\nCont to monitor mild AOP off caffeine. d/c photot and monitor bili levels in AM. Adv TF to 120.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884784,\n \"text\": \"Exam Note\\nGEN - asleep in isolette\\nHEENT - AFSFO, oropharynx clear, nares patent\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl ext genit\\nEXT - wwp, cr < 2s\\nNEURO - reactive, MAE\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884785,\n \"text\": \"Exam Addendum\\nEXT - RLE wound examined under bandage, c/d/i with appropriate eschar and no signs of infection.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884775,\n \"text\": \"Neonatology Attending\\n\\nDay 4 PMA 35 0/7 wks\\n\\nRemains in RA. RR 30-60s. Mild retractions. Had four bradycardia episodes over last 24 hours- one with feeding. No murmur. HR 120-160s. BP mean 56. Bilirubin 9/0.4 on phototherapy. Weight 2375g (-30). TF at 80 ml/kg/d. Now on full feeds BM/SC 20. Put to breast daily. Latched. Minimal aspirates. Stable girth. Passing heme negative stool. Stable temperature in air-controlled incubator. Foot infiltrate clean with crust. Treated with triple antibiotic and Telfa. Family meeting yesterday.\\n\\nDoing well overall with mild breathing control immaturity. Will continue to monitor. Increasing to 100 ml/kg/d today. Monitoring feeding tolerance. Will speak with family today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884776,\n \"text\": \"Lactation Consult\\nMet w/ mom/babies this AM to assist w/ latch and assess milk supply. Infants are 4 day old 34 wks, 35 wks corrected today. Infant remains under single phototx and has an ng tube for feeds. Baby went to breast w/o nipple shield first and demonstrated difficulty in latching, and was then trialed w/ nipple shield and did very well. Baby had frequent audible swallows and milk in nipple shield, nursing X 10mins. He was then ng fed for full vol.\\nReviewed risks and benefits of using a nipple shield w/ mother, emphasized need to pump 8-12X per 24hrs. Gave mom written material to assess 24 hr milk supply. Will follow this family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884777,\n \"text\": \"Social Work\\n\\nFamily meeting yesterday, parents doing well, many good questions. Will follow assess need for any additional support.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884778,\n \"text\": \"Exam Note\\nGEN - awake,alert\\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl ext genit\\nEXT - wwp, cr < 2\\nNEURO - reactive, MAE\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884779,\n \"text\": \"NPN 7a-7p\\n\\n\\n#1: remains in RA, sating >/= 94%. Rare drift to high\\n80's noted with QSR. Brady x1, needing mild stim to\\nrecover. RR stable. BBS cl/=. Breathing with mild\\nretractions. A: stable in RA P:Cont to monitor and provide\\nsupport as needed.\\n\\n#2: TF's ^'ed to 100cc/k/d. Infant now receiving 43cc q4hrs\\ngavaged over 50mins. D/S stable. No spits. Max asp 1.8cc\\nslightly green tint. Fellow assessed. Abd soft, +, no\\nloops. AG stable. Refed asp and cont'ed with feeds. Infant\\nwent to breast x2 today. 1st attempt did well for ~10mins,\\nmore consistent latch and suck. 2nd attempt infant was more\\ninterested in snuggling with Mom. Latched briefly. Voiding\\nqs. Stooled x2 heme negative. A: tol'ing feeds P:Cont to\\nmonitor tol to feeds. Follow wt and exam.\\n\\n#3: Temps stable in an air isolette. Infant can be fiesty\\nat times. Sleeps best when nested within boundaries. Will\\nalso settle with pacifier, containment and holding. Fonts\\nsoft/flat. Brings hands to face. Loves to kangaroo. MAE. A:\\nAGA P:Cont to support dev needs.\\n\\n#4: Parents in for both cares thus far. Mom and\\n this am. Better this afternoon. Mom has been d/c'ed\\ntoday, but parents are staying in Parent Room overnight. Mom\\nmet with LC this am and worked on breastfeeding. LC gave Mom\\nnipple . See LC note for details. Parents\\nparticipating in cares. Both updated. Both held infant\\ntoday. A: Involved, loving family P:Cont to support and\\neducate.\\n\\n#6: Jaundice. Tol'ing full feeds. Voiding and stooling.\\nConts under single phototherapy with eye shields on. A:\\nhyperbili P:Cont with phototherapy as ordered. Check bili\\nlevel in am.\\n\\n#7: NB rash noted over trunk, face and extremities. Team\\nassessed. Right foot noted to have several lesions on it.\\nLesion on top of foot has opened pink center with scabbed\\nyellow edges. Small amt of serous drainage noted on dsg x1\\nfrom that area. No bleeding noted. No edema noted. Other\\nscabs intact. Triple antibiotic ointment applied and covered\\nwith Telfa dsg.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884780,\n \"text\": \"NPN 7a-7p cont'ed\\n\\n7 Skin:\\n\\n#7cont'ed: Team assessed lesions today. Foot warm to touch\\nwith nml pulses. A: healing skin lesions P:Cont with dsg\\nchange 3 times a day. Monitor.\\n\\nREVISIONS TO PATHWAY:\\n\\n 7 Skin:; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884781,\n \"text\": \"NICU Infant CPR Class Note\\n\\nO: Both parents present for infant CPR class at 1800. Watched video and demostration of infant CPR and relieving choking maneuvers by this RN. Both parents practiced on the manikin and were able to demonstrate proper techniques. Reviewed \\\"Back to Sleep\\\" brochure and gave to parents. Also gave CPR poster and handout. All questions answered. Both parents stated that they understood all teaching and had no further questions. Class concluded at 1900.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884769,\n \"text\": \"NPN 0700-1900\\n\\n\\nResp: Infant received on CPAP 6 with FiO2 21%, weaned\\ninfant to RA at 1130. SpO2 89-98%. RR 30s-60s. LS cl/=.\\nMild SC retractions. 2 bradys thus far (see flowsheet for\\ndetails). P: Cont to monitor resp status.\\n\\nFEN: TF increased today to 80cc/kg/day. D10W with 2&1\\ninfusing at 20cc/kg/day via PIV in left hand without\\nincidence. Enteral feeds increased to 60cc/kg/day of\\nBM/SC20 = 26cc q4hrs. Plan to advance enteral feeds by\\n15cc/kg/day . Will check DS at 1700. Abd soft, full,\\n+BS, no loops. AG stable. 3.6 bilious asp at 0900, NNP\\naware, discarded asp. No spits. Voiding (see flowsheet for\\nu/o this shift). Lg mec stool x1. P: Cont to support\\nnutritional needs.\\n\\nG/D: Temps stable, nested on servo warmer. Infant is a&a\\nwith cares. Irritable at times. Appropriately brings hands\\nto face and sucks pacifier to comfort self. AFSF. AGA.\\nTripple abx oint TID to right foot infiltrate. P: Cont to\\nsupport dev needs.\\n\\nSocial: Mom in for all cares today. Updated on infant's\\ncondition and plan of care by this RN. Loving, invested\\nparents. Asking appropriate questions. Family meeting\\ntoday at 4pm. P: Cont to update & support NICU family.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884770,\n \"text\": \"Family Meeting\\nMet with parents in the family room today. Mother to be discharged home tomorrow. See family meeting checklist for issues discussed. Parents asked many questions that were answered to their apparent satisfaction. Seemed to have a good understanding of the issues. Pedi is .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884844,\n \"text\": \"1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\\nequal, no retractions seen. No oximetry. Currently on spell\\ncountdown, possible discharge tomorrow on day . Continue\\nto monitor respiratory status.\\n\\n2. FEN-Infant is on adlib po demand schedule of BM 24 with\\n powder. Infant bottling 45cc's this morning with Playtex\\nnurser and breastfeeding with mom this afternoon. Eager\\nbottler and breastfeeder. Abd soft. Voiding and stooling\\nheme negative. No spits. Destitin applied to bottom with\\neach diaper change. Continue to encourage po feeds.\\n\\n3. DEV-Infant has stable temperatures swaddled in OAC.\\nWaking q3-3.5 hours to be feed. and active during\\ncares, resting well in between. Continue to support\\ndevelopmental needs.\\n\\n4. PARENT-Mom and dad in this afternoon. Loving towards\\ninfant and independent with cares. Made pedi appt for \\non Monday due to holiday. Excited for possible discharge\\ntomorrow. Continue to educate and support .\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884845,\n \"text\": \"NPN\\n\\n\\nI have examined the infant and agree with the above note\\nwritten by PCA.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884846,\n \"text\": \"#2FEN\\nWt 2.725 up 20g. Baby waking q4h to bottle. Bottled 70/75cc\\nwith playtex bottle. Void and stooling. Stool heme neg. No\\nspits. Abd soft, active bowel sounds. Desitin applied to\\ndiaper area.\\nA. Tol feed and gaining weight\\nP. Cont to monitor tol to feed\\n#3Dev\\nTemp stable in an open crib. Waking for feeds\\n#4Parent\\nNo contact this shift\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884847,\n \"text\": \"Neonatology Attending\\n\\nDay 18 PMA 37 0/7 WKS\\n\\nRemains in RA. RR 30-60s. Had 6.5 seconds heart rate drop seen on pneumocardiogram yesterday that was quickly self-resolved. No murmur. HR 140-170s. BP mean 46. Pink. Weight 2725g (+20). On BM 24 with formula powder. Took 124 ml/kg. Occasional choking with feeds. Benign abdomen. Passing heme negative stools. Waking every 4 hours. Passed hearing screen and car seat position study.\\n\\nDoing well overall. Feeding well and gaining weight. Heart rate drop not clinically significant so ready for discharge. Appointment with primary pediatrician on Monday. Discharge summary pending. Will update pediatrician.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884848,\n \"text\": \"Exam Note\\nGEN - NAD, active\\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+S2, no M\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl male ext genit, no rash\\nEXT - wwp, cr < 2 sec\\nNEURO - MAE, reactive, +grasp/suck/moro,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884849,\n \"text\": \"NPN 0700-\\n\\n\\n2. Infant on ad lib demand feeds of BM24 with powder.\\nWaking Q3-4hr and taking 50cc and 80cc thus far. Bottles\\nwith playtex fast flow nipple. Abdomen benign. Voiding and\\nstooling; heme negative. Ferinsol and Multivit. given.\\nTolerating all bottles without spits. Plan to D/C home this\\nafternoon.\\n\\n3. Temp stable swaddled in open crib. Waking for feeds as\\nnoted above. Rest well inbetween cares. MAE, brings hands\\nto face and mouth. Suckles well on pacifier. AGA. To be\\nd/c'd later today.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884850,\n \"text\": \"NPN discharge note\\nVSS, exam benign; see flowsheet for details. Reviewed NICU D/C instruction form with . Infant D/C home with in car seat. Breast milk given to .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884763,\n \"text\": \"NPN\\n\\n#1 S. O. Received infant on a cpap of 6 with fio2 21% to\\n23%. Breath sounds clear and equal with subcostal\\nretractions noted. R.R.30's to 70's. O2 sats 94 to\\n98%.There have been no a's or b's noted at this time. A.\\nInfant with a hx of respiratory distress. P. Discuss with\\nteam in the am regarding plan for trial off of cpap.\\n\\n#2 S. o. Weight down 45 grams. Voiding with 24 hour urine\\noutput 1.6cc/kg/hr. Infant passed trace mec stool. Piv of\\nd10w with lytes infusing well via left hand piv. Total\\nfluids = 60cc/kg/day. Right foot infiltrate site pink/red\\nwith no drainage noted.Right foot elevated. Infant had a\\n1.4cc bilious aspirant at the 0100 care. Abdomen softly\\ndistended with good bowel sounds and no loops. NNP\\nnotified.Aspriant discarded. Feeds not advanced at that\\ntime. A. ? bilious aspriant related to slow gastric\\nmotility. P. Monitor closely. Assess for advancemnet on\\nfeeds at the next care.\\n\\n#4 S. O. Parents in for the 2100 care. Parents updated by\\nthis R.N. at the bedside. A. Loving parents. P. Support\\nand keep updated.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884764,\n \"text\": \"5 ID\\n\\nREVISIONS TO PATHWAY:\\n\\n 5 ID; resolved\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884765,\n \"text\": \"Neonatology Note\\n3 d.o\\non CPAP + 6 this am and wean to RA now\\n2 spells this am, self resolved.\\nwt= 2405 gm -45\\nTF at 60 ml/kg/d with IV and feeding at 45 ml/kg/d with EBM/SC 20, 2 aspirates noted\\nvoiding(+), bm(+)\\n141/6.4/110/21\\nbili=9, under phototherapy\\n\\nA: twin #1, ex 34 wks GA, resolving RDS, hyperbilirubinemia, R foot infiltration resolving\\nP: continue advancing feeding and monitor tolerance, monitor spell, f/u bilirubin\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884771,\n \"text\": \"NPN Noc\\n\\n\\n#1 Resp: RA, 30-60's, c/=, mild SC retrac. No spells so far\\nthis shift. P: Cont to monitor resp status.\\n#2 FEN: TF=80cc/kg, infant currently on full feeds, BM/SC20.\\nPo/pg feeding, infant took 14cc po x 1. Abd benign, AG 26,\\nV/S, mec stooling. P: Cont to monitor FEN status.\\n#3 G&d: Temp stable in air isolette, nested. Alert, active,\\nand sl irritable with cares. Enjoys his pacifier, MAE, opens\\neyes, AFSF. IV infiltrate to right foot, triple abx ointment\\napplied and wrapped in sterile gauze. Area is sl swollen,\\nsmall scabs surrounding small open area on top of foot. P:\\nCont to monitor and support G&D, cont with triple abx to\\nright foot breakdown.\\n#4 Parents: Parents in for eve caretimes. Mom participated\\nin cares, briefly held infant. Asking appropriate questions.\\nP: cont to encourage parental calls and visits.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884772,\n \"text\": \"NPN Noc\\n#6 Bili: Infant appears jaundiced, cont on single spotlight phototherapy. P: Cont phototherapy, will check bili on Thurs AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884773,\n \"text\": \"6 Alt in Bili\\n\\nREVISIONS TO PATHWAY:\\n\\n 6 Alt in Bili; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884774,\n \"text\": \"NNP Physical Exam\\nPE: pink, AFOF, breath sounds clear/equal with easy WOB, no murmur, well perfused, abd soft, full, + bowel sounds, e tox rash, right foot wound from IV infiltrate with moist scab, does not look infected, active with good tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884837,\n \"text\": \"NPN 0700-1500\\n\\n\\n#2 O: Infant remains feeding ad lib amounts of BM24 made\\nwith similac powder. Bottling 60cc's. Abdomen round and soft\\nwith + BS. Voiding and stooling. No spits. A: Tolerating\\nfeeds. P: Cont to monitor.\\n\\n#3 O: Maintaining temp in oac; cobedding with twin. Awake\\nand with cares; sleeping well between. AFSF. Swaddled\\nin blanket; brings hands to face for comfort and sucks on\\npacifier. A: AGA. P: Cont to support development.\\n\\n#4 O: Both in to visit. Asking appropriate\\nquestions. Reviewing d/c teaching for sibling. Mom\\nbreastfeeding while here and pumping. Plan to take other\\ninfant home this afternoon. A: Involved, loving. P: Cont to\\nsupport and update.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884838,\n \"text\": \"Rehab/OT\\n\\nMet at the bedside. Reviewed back to sleep protocol and activities birth through one worksheet. Discussed SIDS precautions and EI qualifications. No further in house needs. D/C OT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884839,\n \"text\": \"Exam Note\\nGEN - calm, NAD\\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+s2, no M\\nABD - soft, NT, ND, no mass\\nGU - nl male ext genit, no rash\\nEXT - wwp, cr < 2\\nNEURO - MAE, reactive\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884840,\n \"text\": \"Nursing Progress Note 1900-0700\\n\\n\\nF/E/N:Infant cont's on Ad lib demand schedule waking q 4\\nhrs.TF over 24 hrs 122cc's/kg/day.Infant bottling with a\\nPlaytex nipple and taking 70-90cc's q time.Weight=2.705 up\\n25 grams.Abd. soft with pos bs,no loops or spits.Voiding and\\nstooling heme negative stool.\\n\\nG/D:AF soft and flat. and active with cares.Sleeping\\nwell b/t.MAE.Bringing hands to face and mouth.Sucking\\nintermitently on pacifier.Infant presently swaddled in open\\ncrib.Temp. stable.\\n\\nParenting:Mom called x 1.Updated by this RN.Asking\\nappropriate questions very loving and invested.Other twin at\\nhome per mom and doing well.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884766,\n \"text\": \"NNP Physical Exam\\nPE: exam this am while on CPAP. pink, jaundiced, AFOF, CPAP prongs in place, breath sounds clear/equal with easy WoB, no grunting, good air entry, no murmur, well perfusion, abd soft, non distended, non tender, active bowel sounds, IV infiltrate right foot with superficial scabs on dorsum of the foot, no redness or drainage, active with good tone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884767,\n \"text\": \"NPN 0700-1900\\nBili: Bili this am was 9.0/0.4, down from 9.6/0.3. Infant remains under single phototherapy wtih eye shields on. Plan to recheck bili am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884768,\n \"text\": \"Respiratory Care Note\\nBbay Boy I was weaned from +6 to +5 prong CPAP this am and then was taken off CPAP at noon. Placed in RA. BS clear. RR 30's-60's. No bradys noted since he has been off CPAP.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884832,\n \"text\": \"NPN Days\\n\\n\\n#1 Pt has had no spells so far this shift. Pt day \\nof spell count down. P- Will cont to monitor resp status.\\n#2 Pt ad lib demand. BM24 with powder. all po\\nfeeds. Took 70cc this am and BF well while were\\nvisiting. abd benign. voiding and stooling. no spits. P-\\nWill cont to monitor FEN.\\n#3 G&D- Temp stable in open crib. cobedding with sibling.\\n and active with cares. irritable at times. sucking on\\npacifier. using playtex bottle with fast flow nipple to\\nfeed. P- Will cont to monitor G&D.\\n#4 Mom called x1 this am. updates given. Both\\n visiting @1300. Participating in cares. feeding pt.\\nDC teaching done with both re: carseat safety,\\nfeeding, bowel and bladder, back to sleep. declined\\ncirc. P- Will cont DC teaching.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884833,\n \"text\": \"NPN Days\\naddendum:\\n Pt passed hearing screen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884834,\n \"text\": \"Neonatology Attending\\nDOL 15 / PMA 36-4/7 weeks\\n\\nIn room air with no apneas/bradycardias in 2 days.\\n\\nNo murmur. BP 68/41 (51).\\n\\nWt 2655 (+35) on ad lib with intake 119 fcc/kg/day BM24 in addition to breastfeeding well. Abd benign. Voiding and stooling normally (heme negative). On iron.\\n\\nTEmp stable in open crib. Hepatitis B immunization administered.\\n\\nA&P\\n34-3/7 week GA infant with resolving respiratory immaturity\\n-Continue to monitor until free of apnea/bradycardia for at least 5 days prior to discharge home\\n-Discharge planning in progress\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884835,\n \"text\": \"NPN/1900-0700\\n\\n\\n#2 FEN: Wt 2680, ^25gms. Ad libe demand feeding, BM24.\\nTaking all po's; bottled 149cc/k + breastfeeding this\\nprevious 24hrs. Taking 60-80cc Q4hrs. No spits. Abd. exam\\nbenign. V/S. Cont. to support nutritional needs.\\n#3 DEVELOPMENT: Swaddled in oac; cobedding with twin. Temps\\nstable. Active/ w/ cares; sleeps well b/t. Wakes on\\nhis own Q3.5-4hrs to feeds. Sucks on pacifier. MAE/AFOF.\\nAGA. Support developmental needs.\\n#4 : visiting during the day shift; no\\ncontact over .\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884841,\n \"text\": \"Neonatology Attending\\n\\nDay 17 PMA 36 wks\\n\\nRemains in RA. RR 50-70s. Clear breath sounds. Day without bradycardia. No murmur. HR 140-160s. BP mean 54. Weight 2705 g (+25). On ad lib demand. On BM 24 with formula powder. Benign abdomen. Passing heme negative stool. On iron. Waking for feeds. Stable temperature in open crib. Passed hearing screen and car seat study.\\n\\nDoing well overall. Will continue to monitor closely. Feeding well and gaining weight. Will be ready for discharge tomorrow if remains spell-free.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884842,\n \"text\": \"Lactation Consult\\nMet w/ family @ 1pm to assess infant latch. Baby latched on beautifully w/ nipple having frequent audible swallows and milk present in . Mom held infant by football hold and is pleased w/ feeding. plan to nurse infants at home following up w/ bottles of 24cal breast milk. Advised to monitor baby's voids and stools at home and assess for swallows at the breast.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884843,\n \"text\": \"Exam Note\\nGEN - NAD, active and \\nHEENT - AFSFO, oropharynx clear\\nCV - RRR, nl s1+s2, no M, fem pulses 2+ bilat\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl male ext genit, no rash, stool present\\nNEURO - MAE, reactive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884836,\n \"text\": \"Neonatology Attending\\n\\nDay 16 PMA 36 wks\\n\\nRemains in RA. RR 40-70s. Clear breath sounds. No bradycardia- day . No murmur. HR 150-160s. Pink. BP mean 59. Weight 2680g (+25). Ad lib BM 24 with formula powder. Taking 60-80 ml per feed- 149 ml/kg total- and breast feeding. Passing heme negative stool. Feeding tube out. No spits. Stable temperature in open crib. independent with care.\\n\\nDoing well overall. Maturing breathing control. Will continue to monitor closely. Needs 2 more days spell-free. Received hepatitis B vaccine. Passed hearing screen. Will speak with mother this morning.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884819,\n \"text\": \"#1Resp\\nLungs clear with mild retractions. No spells. Appears\\ncomfortable\\n#2FEN\\nWt 2.615 up 30g. Baby has bottled entire volume at 2100 and\\n0100. Abd soft, active bowel sounds. Void and stooling. One\\nsmall wet burp. Min asp. Cont to receive BM24.\\nA. Tol feed and gaining weight\\nP. Cont to monitor tol to feeds as well as weight gain.\\nEncourage po feed ability\\n#3Dev\\nWaking for feeds. Maintaining temp in crib. Interested in\\nbottling\\n#4Parent\\nno contact so far.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884820,\n \"text\": \"Cafe spot noted on R side of forehead.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884821,\n \"text\": \"Neonatology Attending Note\\nDay 13, PMA 36 2\\n\\nRA. RR40-60s. Mild intermittent sc retractions. No A&Bs. No murmur. HR 130-150s. BP 86/44, 56. Wt 2615, up 40 gms. TF 150 BM24. Just transitioned to all PO last night. Nl voiding and stooling. In open crib.\\n\\nA/P:\\nGrowing preterm infant with improving PO skills. If continues to do well with PO feedings will plan for discharge Monday. PO feedings q other BF. Monitor weight with this suppl plan.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884822,\n \"text\": \"Exam Note\\nGEN - calm, NAD\\nHEENT - AFSFO, oropharynx clear, NGT out of nose, nares intact\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no M\\nGU - nl male ext genit, no rash\\nEXT - wwp, cr < 2 sec, dorsum c/d/i\\nNEURO - MAE, reactive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884823,\n \"text\": \"Case Management Note\\nReferral called to Care Group VNA today (/fax ) and have made home visit for Wednesday . Team anticipates home d'c Monday . If this date needs to be chnaged, please call VNA to reschedule. All in agreement w/plan.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884745,\n \"text\": \"Admission Note\\nNeonatology Admission H&P\\n\\nBaby is a newborn 34 wk twin infant admitted to the NICU with prematurity and respiratory distress.\\n\\nHe was born at 12:30 am this morning as the 2575 gram product of a 34 wk twin gestation pregnancy to a 28 y.o. G1 P0-2 mother with . Prenatal labs included BT A+/Ab- and GBS unknown; remainder were unavailable at time of delivery but were reportedly negative. Pregnancy was IVF-assisted di/di twin gestation, and was reportedly unremarkable until when mother presented to PMD for evaluation of URI symptoms and was found to be hypertensive. She was sent to , and was also found to have proteinuria and elevated uric acid, consistent with preeclampsia. BPP was . With relatively advanced gestational age, delivery was recommended. Last EFW on was 2289; concordant growth was noted throughout pregnancy.\\n\\nFamily history and social history are otherwise non-contributory.\\n\\nInfant was born via c-section for twin gestation. At delivery, twin A emerged with moderate tone and good cry, with Apgars . He required blow-by oxygen for duskiness with gradual improvement, and was brought to NICU with moderate work of breathing noted.\\n\\nPhysical Exam:\\nWt 2575 gm (75-90%) HC 32 cm (50-75%) L 48 cm (75-90%).\\nVS: T 97.7, HR 160s, RR 50s, O2sat 80s in RA, 90s with O2, BP pending.\\nGen: WD premature infant, moderate resp distress, active and vigorous, overall appearance consistent with EGA.\\nSkin: warm, dry, pink with oxygen, no rash.\\nHEENT: fontanelles soft and flat, ears/nares normal, palate intact with mildly high arch, +RR bilaterally.\\nNeck: supple, no lesions.\\nChest: coarse, poorly aerated, + g/f/r.\\nCardiac: RRR, no m, femoral pulses 2+.\\nAbdomen: soft, quiet BS, no mass, no HSM, 3VC.\\nGU: normal male, testes palpable bilaterally, anus patent.\\nExt: hips/back normal, no lesions.\\nNeuro: appropriate tone, activity, intact moro/grasp.\\n\\nIMP: Newborn 34 wk twin, delivered secondary to maternal preeclampsia, currently with moderate respiratory distress likely secondary to RDS. Low risk of sepsis given circumstances of delivery.\\n\\nPLANS:\\n- Admit NICU.\\n- Monitor resp status closely, likely will need CPAP.\\n- O2 as needed.\\n- CXR, ABG if resp status worsens.\\n- Consider intubation/surfactant if FiO2 high or worsening respiratory distress or hypercarbia.\\n- Monitor hemodynamics.\\n- NPO, maintenance IVF.\\n- Periodic monitoring of dstiks, lytes, bilirubin.\\n- CBC with diff, blood cx.\\n- Low threshold for abx as pneumonia cannot be ruled out given respiratory distress.\\n- Thermoregulatory support on warmer.\\n\\nParents updated in delivery room.\\n\\nPMD: , .\\nOB: , delivered by .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884746,\n \"text\": \"Admission Note\\nHep B: Maternal HBsAg resent. Will give HBV if results not available by 12 hrs of life.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884747,\n \"text\": \"Respiratory Care\\nSee attending and nursing admit notes for hx and further details. Infant GFR on arrival to NICU. Given facial CPAP then placed on prong CPAP 6. BS diminished. 02 req on CPAP 26-30%. CXR done to assess lung fields. Persistant grunting on CPAP, subcostal retractions. CBG: 7.28/47/45/23/-4. RR 30's-60's. Grunting significantly improved, presently intermittent. Will cont to follow closely, support as indicated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884813,\n \"text\": \"npn 1900-0700\\n\\n\\n1: resp\\nremains in ra. no spells and no dsats. lung sounds clear and\\nequal. mild subcostal retractions. no increased wob noted.\\nrr 40-70's. sats >97%. continue to monitor for changes in\\nrespiratory status.\\n\\n2; fen\\ncurrent weight 2560 gms up 20. total fluids remain at\\n150cc/kilo/day of bm24 cals tolerating feeds well. no spits,\\nminimal aspirates. voiding and stooling. stool hem negative.\\n\\nabd soft with no loops. infant continues on iron. infant\\npo'd 20cc's at 2100 and then 50cc at 0100. infant waking\\nfor both cares. remainder of volume gavaged. continue with\\ncurrent feeding plan.\\n\\n3: growth and development\\ntemps stable in an oac. alert and active with cares. sleeps\\nwell inbetween. brings hands to face. sucks vigorously on\\npacifier. wakes for feedings. aga. continue to monitor for\\ndevelopmental milestones.\\n\\n4; \\nno contact thus far this shift from \\n\\n6: \\ninfant currently off of phototherapy. sent this shift\\npending. continues to be jaundiced in color. continue to\\nfollow .\\n\\n7: skin\\ninfant continues on triple antibiotic ointment to right\\nfoot. infant's right foot with scabbing from old infiltrate\\nsite. no drainage or bleeding noted. continue with current\\nplan of care.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884809,\n \"text\": \"I have examined and agree with the above note.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884810,\n \"text\": \"Neonatology Attending Note\\nDay 11, PMA 36\\n\\nRA. Cl and = BS. No A&Bs. +murmur. HR 140-160s. BP 67/37, 47. Under photot. Bili 6.5/0.2. Wt 2540, up 70. TF 150 BM24. PO/PG. Tol well. Nl voiding and stooling. In air isolette.\\n\\nA/P:\\nGrowing preterm infant learning how to po feed. Will begin Fe. d/c photot and check reb bili in AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884814,\n \"text\": \"Neonatology Attending Note\\nDay 12, PMA 36 1\\n\\nRA. RR40-70s. CL and =. No A&Bs. No murmur. HR 130-150s. BP 67/45, 53. 6.5/0.2 (reb). Wt 2560, up 20 gms. TF 150 BM24. po/pg. Nl voiding and stooling. On Fe. Co-beeding in open crib.\\n\\nA/P:\\nGrowing preterm infant awaiting maturation of feeding abilities.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884815,\n \"text\": \"PCA Progress Note \\nI agree with the above PCA note and have assessed the pt. see flowsheet for further details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884816,\n \"text\": \"PCA Progress Note \\n\\n\\n#1 RESP: Infant remains in room air breathing 50-60s with\\nmild subcostal retractions. LS clear/equal, oximetry d/c'd\\nthis morning. No spells this shift. Breathing comfortably in\\nroom air. Continue to monitor respiratory status.\\n\\n#2 FEN: TF 150cc/kg/day BM24. 64cc q4hours. Infant finished\\nwhole bottle this morning, then breast fed with mom at \\ncares and half volume bottle. Uses Playtex\\nbottle/nipple. Abd benign, no loops, +BS. No spits, minimal\\naspirates. Voiding and stooling heme neg. Tolerating feeds.\\nContinue to encourage POs.\\n\\n#3 DEV: Stable temps swaddled cobedding with twin brother.\\n and active with cares, sleeping well between and\\noccasionally waking early. MAE. AFSF. Brings hands to face,\\nenjoys pacifier. AGA. Continue to support developmental\\nneeds.\\n\\n#4 SOC: Mom in for cares. Independent with son. Updated\\nat bedside by RN. Asking appropriate questions. Loving\\nfamily. Continue to update and support.\\n\\n#6 : Photo tx has been off since morning of 15th. \\nfrom last night 6.5/0.3, remaining the same as the day\\nbefore. Infant slightly jaundiced/well perfused. Continue to\\nmonitor.\\n\\n#7 SKIN: Scab on right foot from IV infiltration healing\\nwell. Triple antibiotic applied, then d/c'd this morning.\\nContinue to monitor.\\n\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884811,\n \"text\": \"NPN 7a-7p\\n\\n\\n#1 Resp: Infant in room air w/resp rate 40s-70s and sat\\n97-100%. Lung sounds cl/= and mild SC retractions. No spells\\nso far this shift. A: Infant stable in room air w/no spells.\\nP: Cont to monitor.\\n\\n#2 FEN: TF 150 cc/kg of BM 24 (64 cc q4h gavaged over 50\\nmin). Po/pg. Infant bottled 52 cc @ 0900 cares w/remaining\\nvolume gavaged. BF well for 20 min @ 1300 cares and was\\nsupplemented with half volume gavage. No spits, min asp.\\nAbdomen round, pink, and soft w/active bowel sounds and no\\nloops. Voiding and stooling heme neg. Now on iron. A: Infant\\nimproving with po feedings and is well coordinated. P: Cont\\nw/current plan and encourage po feedings as tol.\\n\\n#3 Dev: Received infant nested in air isolette. Infant now\\nswaddled in an open crib, cobedding with brother. \\nstable. Alert and active during cares and sleeps well in\\nbetween. Wakes early for most feedings. Periods of quiet\\nalert. A: AGA. P: Cont to supp dev needs.\\n\\n#4 : Mom in @ 1300 and was updated. Mom took temp,\\nchanged diaper, and BF infant. A: Independent and\\nappropriate w/cares. P: Cont to supp and update. Plan to\\nprovide bath and teaching @ 1700 cares.\\n\\n#6 : Photo rx d/c @ 1030. A: Infant appears jaund. P:\\nCont off photo rx and plan to check am.\\n\\n#7 Skin: Infant cont triple antibiotic ointment to scabbed\\narea on R foot on old IV infiltrate site. No redness or\\ndrainage noted.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884812,\n \"text\": \"Exam Note\\nGEN - calm, NAD\\nHEENT - 15-20 blanchable erythematous macules 3-5mm in diameter on face, no excoriation or secondary infection, c/w erythema toxicum. Otherwise, AFSFO, oropharynx clear, NGT w/o breakdown\\nCV - RRR, nl s1+s2 no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nEXT - wwp, R foot c/d/i, cr < 2 sec\\nNEURO - reactive, MAE\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884759,\n \"text\": \"NPN 0700-1900\\n\\n\\nResp: Infant remains on CPAP 6, FiO2 24-27%. RR 30s-50s.\\nLS cl/=. Mild SC retractions. No A's or B's thus far. P:\\nCont to support/monitor resp status.\\n\\nFEN: TF 60cc/kg/day. D10 with 2Na & 1K infusing via left\\nhand PIV at 30cc/kg/day. Right foot PIV infiltrated at 0900\\nwith excoriated skin d/t tape noted; NNP aware & right foot\\nelevated and left OTA. Enteral feeds started today at\\n30cc/kg/day of BM/SC20 = 13cc q4hrs. Plan to increase\\nenteral feeds by 15cc/kg/day at 1a &1p. DS 74 at 1100.\\nAbd full, soft, +BS, no loops; no spits. AG 27. u/o\\n1.2cc/kg/hr thus far. No stool. Lytes this am were\\n143/4.6/108/22. P: Cont to support nutritional needs.\\n\\nG/D: Temps stable, nested on sheepskin with boundaries in\\nplace on open warmer. Infant is a&a with cares. Irritable\\nat times, settles well when left alone. Appropriately\\nbrings hands to face & sucks pacifier to comfort self.\\nAFSF. AGA. P: Cont to support dev needs.\\n\\nParents: Mom in for 0900 cares. Speaking lovingly to\\ninfant. Updated on infant's condition and plan of care.\\nAsking appropriate questions. P: Cont to update & support\\nNICU family & plan for family meeting tomorrow at 4pm.\\n\\nID: IV abx d/c'd. Problem resolved at this time.\\n\\nBili: Bili this am was 9.6/0.3, up from 1.7/0.3 Infant\\nplaced under phototherapy lights at 1130. Infant is\\njaundice. Plan to recheck bili in the am. P: Cont to\\nmonitor bili status PRN.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884760,\n \"text\": \"NP NOTE\\nPE: well developed preterm infant swaddled in open warmer. PInk, jaundiced in RA CPAP. Edematous.\\nAFOF sutures approximated, eyes clear, puffy, nares patent with prongs in place, MMMP, white, frothy secretions\\nChest is clear, fair exchaneg, mild SCR. Fair exchange, shallow.\\nCV: RRR, no murmur, pulses+2=\\nAbd: soft, active bs cord dry\\nGU: testes ins crotum\\nEXT: PIV in left hand, right foot edematous with IV infiltrate.\\nNeuro: active, responsive. Flexed posture, good tone, symmetric reflexes.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884761,\n \"text\": \"Respiratory Care\\nPt cont on prong CPAP. Fio2 .24-.27. bs clear, rr 50-70 with mild retractions. On caffeine. No spells. Plan to support as needed. Consider trial off in near future. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884762,\n \"text\": \"RESPIRATORY CARE NOTE\\nBaby #1 remains on Prong CPAP 6 FiO2 21-24%. RR 30-70's Breath sounds are clear. Stable on CPAP cont to follow. Plan to wean off CPAP soon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884827,\n \"text\": \"Neo Attending note\\nday 14, now 36.3 wk pma\\nwt 2620, up 5 gm.\\nCV: no murmur, hr 150s, bp 63/40, 48j\\nrespr: ra, rr 3040s, clear=bs, 1qsr brady with apnea / periodic breathing. Thus countdown restarts today = D 0/5.\\nTF: 150 cc/kg/day. BM24 all po + BFx2 per day. BF well.\\nuop and stool wnl, heme neg.\\nabd wnl. 7.5 stable. no spits.\\ntemp stable in crib. State Newborn screen sent. HepB immunization today.\\nCar seat: wait until bradycardia have continued to improve.\\nhearing screen pending, pending.\\n\\nassessment: due to brady/apnea/periodic breathing, infant will continue CVR monitoring with oximeter.\\notherwise assement is as noted above.\\nPlan: as noted above.\\n\\nPt evaluated and discussed with team.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884807,\n \"text\": \"1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\\nequal, mild subcostal retractions seen. O2 sats are >97%. No\\nspells so far this shift, last one on . Continue to\\nmonitor respiratory status.\\n\\n2. FEN-TF=150cc/kg of BM/SC now 24 or 64cc q4hrs PO/PG.\\nInfant offered bottle at 0900 care, bottled 18cc's using\\nPlaytex bottles. Eager bottler at first but tires easily.\\nMom put infant to breast at 1300, infant latched and\\nbreastfed for about 10 minutes. Infant asleep for third care\\nand mom was unable to put to breast. Full feed gavaged\\nafterward over 50 minutes. Abd benign. Voiding and stooling\\nheme negative. No spits. Minimal aspirates. Continue to\\nencourage po feeds as tolerated by infant.\\n\\n3. DEV-Temperatures stable in air isolette under neoblue\\nlight. Wakes occassionally for cares. Alert and active\\nduring first two cares, asleep with last care. Continue to\\nsupport developmental needs.\\n\\n4. PARENT-Mom in afternoon. Updated by RN. Loving towards\\ninfant, independent with care. Continue to educate and\\nsupport .\\n\\n6. BILI-Infant remains under neoblue with eye shields in\\nplace and slighly jaundiced in color. Yesterdays bili was\\n12.3 (0.3). Bili to be rechecked in am. Continue to monitor\\nbili.\\n\\n7. SKIN-Infants right foot continues to heal, small scab\\npresent. Triple antibiotic ointment applied as ordered by\\nRN. Continue to monitor skin integrity.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884808,\n \"text\": \"PCA Progress Note 1900-0700\\n\\n\\n#1 RESP: Pt. remains in RA breathing in the 40-60s with\\nmild subcostal retractions. Lung sounds cl+= bilaterally.\\nNo episodes of apnea or bradycardia so far this shift. P:\\nContinue to monitor respiratory status.\\n\\n#2 FEN: Weight: 2540g ^ 70g. Total fluids: 150cc/kg/d of\\nBM/SC 24= 64cc Q4hrs PO/PG. Pt. was put to breast @ 2100\\nwith +latch and good coordination for > 10minutes, full\\nfeeding gavaged. Pt. took 20cc using the playtex nurser @\\n0100. Abd soft and round, +BS, no loops. No spits.\\nMinimal aspirates. Pt. is voiding, stooling heme neg. P:\\nContinue to encourage po feedings as tolerated.\\n\\n#3 G&D: Temps stable nested in air isolette. Alert and\\nactive during cares. Sometimes waking for feedings. Rests\\nwell inbetween cares. MAE. AFSF. P: Continue to support\\ndevelopmental needs.\\n\\n#4 Parenting: Mom and Dad in @ 2100. Mom independent with\\ncares and breastfeeding. Mom called X 1. Very loving and\\ninvolved. Updates given. P: Continue to support and update\\nfamily.\\n\\n#6 BILI: Pt. remains under neoblue lights with eye shields\\nin place. Pt. is sl jaundice. Stooling. Last bili:\\n12.3/0.3. Bili was drawn this morning, results pending. P:\\nContinue to monitor.\\n\\n#7 Skin: Scab noted on right foot. Healing, no drainage or\\nredness noted. Triple antibiotic applied as ordered. P:\\nContinue to monitor.\\n\\nPlease see flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884802,\n \"text\": \"Exam Note\\nGEN - alert, fussy in air crib under bili lights\\nHEENT - AFSFO, oropharynx clear, eye covers intact, NGT w/o breakdown\\nCV - RRR, nl s1+s2, no murmur\\nABD - soft, NT, NT, no mass\\nGU - nl ext genit, no rash\\nEXT - wwp, cr < 2 sec\\nNEURO - MAE< reactive\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884803,\n \"text\": \"NPN 07p-07a\\n\\n\\nRESP\\nRA, LS clear & equal with mild subc. retractions. RR30-60's.\\nNo spells or desats this shift thus far. Cont. monitor resp.\\nstatus.\\nFEN\\nCurrent weight 2470g (^50). TF 150cc/kg/day, BM/SSC20.\\nTolerating well. Gavaged q4hrs/bottled x1 this shift thus\\nfar 20cc (coordinated, quickly tiring). BS active. Abd.\\nsoft, round. Voiding, stooling heme negative. Cont. monitor\\nPO/PG feeding tolerance & weight.\\nG&D\\nIn air isolette, temps stable. Nested. Alert & active with\\ncares. Resting comfortably inbetween. Fontanels soft, flat.\\nMAEs. PPPx4ext. Cont. monitor growth & developm. patterns.\\n\\nMOB updated over phone x1. Loving & caring. Cont. support &\\neducate.\\nBili\\nCont. under neoblue bank, eye shields in place. VS stable.\\nAlert & active with cares. Voiding, stooling. Cont. monitor\\nfor changes.\\nSkin\\nCont. with scabbed area on right foot, no redness, drainage\\nor swelling noted. Triple antx ointment applied as ordered.\\nCont. monitor for changes.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884804,\n \"text\": \"Neonatology Attending\\n\\nAdvancing to 24 cals/oz feed. Will discontinue phototherapy.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884805,\n \"text\": \"Neonatology Attending\\n\\nDay 10 PMA 35 wks\\n\\nRemains in RA. Clear breath sounds. No bradycardia. No murmur. BP mean 45. Weight 2470g (+50). TF at 150 ml/kg/d- BM/SC 20. Bottling 20-30ml per feed. Passing heme negative stool. Stable temperature in air-controlled incubator. Stable temperature.\\n\\nDoing well overall. Monitoring for apnea. Tolerating feeds well. Gaining weight well. Encouraging po feeds.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884806,\n \"text\": \"I have examined baby boy I and agree with the above note written by , PCA.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884754,\n \"text\": \"NPN Days\\n\\n\\n#1 Resp: CPAP 6 26-32%. 40-80's with occ increased\\ntachypnea, mild SC retrac, LS c/=, with intermittent\\ngrunting noted. Occ sat drifts, one spell so far this shift,\\nresolved with mild stim and increased 02. P: Cont to monitor\\nresp status, will check CBG this eve.\\n#2 FEN: TF=60cc/kg D10W infusing via PIV without diff. Abd\\nbenign, infant cont to be NPO, V/S, mec stooling. P: COnt to\\nmonitor FEN status, check lytes and bili in AM.\\n#3 G&D: Temp stable on off warmer, swaddled. Alert and\\nactive with cares, occ irritable, given sucrose. Sleeps well\\nin between cares. P: Cont to monitor and support G&D.\\n#4 Parents: Parents in for cares, participated where able.\\nAsking appropriate questions, updated frequently by this RN.\\nAppear very loving towards infant. P: Cont to encourage\\nparental calls and visits.\\n#5 ID: Temp stable, infant acting appropriately. Bld cx NTD,\\non Amp and Gent. P: F/u with cxs, d/c'd abx at 48hrs.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884755,\n \"text\": \"Respiratory Care Note\\nInfant remains on NCPAP +6, 26-32% - BS sl. diminished, RR's 40's-70 with some intermittant grunting - no spells thus far - occasional saturation drifts - continue to monitor - blood gas this afternoon.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884756,\n \"text\": \"RESPIRATORY CARE NOTE\\nBaby #1 remains on Prong CPAP 6 FiO2 23-32%. Breath sounds are clear. RR 40-80's occasional grunting. Stable on CPAP cont to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884757,\n \"text\": \"Nursing NICU Note\\n\\n\\n1. REsp. O/ Intermittent grunting noted. Remains on Nasal\\nProng CPAP of 6, 21-30% primarily. Please refer to\\nflowsheet. NO A/B noted. A/Alt. in REsp status. P/Cont. to\\nmonitor resp status and intervene as needed. Murmur noted\\nand reported to NNP. A/Resp status remains stable at this\\ntime on CPAP. P/Cont. to monitor for evidence of resp\\ndistress.\\n\\n2.F/N. O/ Tf remain at 60cc/k/d of IVF D10 with 2 NaCl/dl\\nand 1meq KCL/dl via new PIV. Please refer to flowsheet for\\nexaminations of pt from this shift. Remains NPO.\\nIntermittently sucking on pacifier.\\n\\n3. G/D. O/TEmp remains stable swaddled on a warmer. AWake\\nand alert at care times and sleeping well in between. A/Alt.\\nin G/D. P/Cont. to support pt's growth and dev. needs.\\n\\n4. Parents. O/Parents into visit last night. Parents updated\\non pt's status and plan of care. Father held infant\\nswaddled. A/Parents are involved in pt's care.; P/Cont. to\\nsupport and educate parents.\\n\\n5. ID. O/Anitbiotics d/c. NNP stated that she corrected lab\\nerror. A/Completion of 48hr r/O. Cont. to monitor for s/s of\\n infection.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884758,\n \"text\": \"Neonatology Note\\n2 d.o\\non CPAP+6, RA-30%O2, no caffeine\\nbili= 9.6\\nwt= 2450 gm -50\\nTF at 60 ml/kg/d, NPO\\nvoiding(+), bm(+)\\nlytes: 143/4.6/108/22\\n\\nA: twin #1, 34 wks GA, RDS, sepsis evaluation, hyperbilirubinemia\\nP: monitor respiratory staus on CPAP, wean O2 as tolerated, start feeding, start phototherapy, f/u bili.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884824,\n \"text\": \"Nursing Progress Note\\n\\n\\n#1 Resp-- O: RA. No spells. HR 160s; HR 50s-60s. Color\\npink/sl jaund. BS clear and =, mild sc ret. A: Day 4 of 5 P:\\nCont to monitor vitals, document spells\\n\\n#2 Nutrition-- O: 150cc/kg/d= 65cc BM24- HMF d/c- powder\\n4cal/oz started. Po fed well at 0900 taking 70cc., tol well.\\nBF x20 min at 1300 well- no supplement after breast. wakeful\\nfor long period after feed. NG d/c. Abd exam benign, VQS, sm\\nyellow stool x2. Desitin to reddened butoocks (skin intact).\\nOn iron. A: Adequate growth, all po x 24h. P: Cont to\\nmonitor intake and growth. Plan to supplement BF every other\\nBF session with bottle. Switch to pwder 4cal/oz. repeat\\nPKU and in am.\\n\\n#3 Development-- O: and active, waking for feeds.\\nHands to mouth, and sucking on pacifier. Temp stable,\\nco-bedding with twin. All po feeds. Social with Mom. A: AGA\\nP: Cont to support development; Hep B vaccine tonight\\n\\n#4 Parenting-- O: Mom in at 1300. Updated re status and\\nplan. pleased with progress. Mom upset about baby taking\\nfeeding by regular nipple overnight and prefers the Playtex\\nNurser. Will bring in car seat ; will decide about\\ncirc with dad by called, referral to Caregroup\\nwith tentative visit next Wed. Mom to make pedi appt\\ntentatively for next Tues with tentative discharge date Mon.\\nA: Nearing discharge P: Cont to support and keep informed;\\ncont discharge planning- car seat test ; Hep B,\\nPKU, & over night.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884825,\n \"text\": \"NNP Physical Exam\\nAwake and . AFOF with good tone. Breaht sounds clear and equal on RA without retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded wiht active BS, no HSM or masses. Normal GU.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884826,\n \"text\": \"npn 1900-0700\\n\\n\\n1: resp\\nremains in ra. infant has had one spell thus far this shift.\\ninfant brady was to 74, apneic, qsr. see flow sheet. lung\\nsounds clear and equal. mild subcostal retractions. no\\nincreased wob noted. rr 30-40's. continue to monitor for\\nchanges in respiratory status.\\n\\n2; fen\\ncurrent weight 2620gms up 5gms. total fluids remain at\\n150cc/kilo/day of bm 24 cals with powder. tolerating\\nfeeds well. taking all po feeds. infant taking 50cc at 2100\\ncare and then 70 with 0100 care. infant tolerating feeds\\nwell. no spits. abd soft with no loops. voiding and\\nstooling. desitin applied to buttocks. using platex nurser.\\ncontinue with current feeding plan.\\n\\n3: g/d\\ntemps stable in an oac. co-bedded with brother. and\\nactive with cares. sleeps well inbetween. brings hands to\\nface. sucks vigorously on pacifier. wakes for feedings.\\naga. continue to monitor for developmental milestones.\\n\\n4: \\nno contact thus far this shift.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884799,\n \"text\": \"Neonatology Attending\\n\\nDay 9 PMA 35 wks\\n\\nRemains in RA. RR 30-50s. Sats 92-100%. Clear breath sounds. had one bradycardia episode over last 24 hours. No murmur. HR 130-160s. No murmur. BP mean 57. Bilirubin 12.3 (rebound) so palced back under phototherapy. Weight 2420g (+10). TF at 140 ml/kg/d- SC 20. Bottled one feed. Breast feeding for 5-10 minutes. No spits. Minimal aspirates. Stable temperature in air-controlled incubator. Family up to date.\\n\\nDoing well overall. Minimal respiratory immaturity. Will continue to monitor. Advancing feeds to 150 ml/kg/d. Exaggerated physiologic hyperbilirubinemia. Will continue on phototherapy.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884800,\n \"text\": \"Social Work\\n\\n\\nMet with mother while in visiting with babies today.\\nMother feeling overwhelmed today. She states that she gets here in the morning and styas for the whole day as she wants to be here for all of the babies feedings.\\nTalked with her about cutting back on the amount of time she is here each day, and the importance of having some time for her to rest and pump. Really encouraged her to only come in in early afternoon and she can stay until her husband comes in from work and then they can go home together.\\nMother states that she has good supports, a lot of help from members of her church who have been bringing in dinners for them. Also a friend has been driving them in to the hospital each day, as the couple do not have a car they live closby in , but public transportation is not direct to the hospital.\\nMother's sister will be visiting from over , and her mother in law will come in mid . All extended family members are in State.\\nWill plan to check in with mother tomorrow, continue to encourage her to take car of herself and not to be spending the entire day at the hospital.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884801,\n \"text\": \"NPN 7a-7p\\n\\n\\n#1 Resp: Infant in room air w/resp rate 20s-50s and sat\\n93-100%. Lung sounds cl/= and mild SC retractions. No spells\\nso far this shift. A: Infant stable in room air w/no spells.\\nP: Cont to monitor.\\n\\n#2 FEN: TF inc from 140 to 150 cc/kg of BM 20 (64 cc q4h\\ngavaged over 50 min). Po/pg. Infant breast feeding w/Mom q\\ncares and receiving full gavage volume. Infant BF for 5 min\\n@ 0900 but was sleepy with weak suck. Infant awake and eager\\nand breast fed for 10 min with good latch and suck @ 1300\\ncares. No spits, min asp. Abdomen round, pink, and soft\\nw/active bowel sounds and no loops. Voiding and stooling\\nheme negative. A: Infant coordinated w/breast feeding when\\nawake and eager. P: Cont w/current plan and encourage po\\nfeedings as tol.\\n\\n#3 Dev: Infant nested in air isolette, temp stable. Alert\\nand active during cares and sl irritable in between. Settles\\nvery well with pacifier and boundaries. A: AGA. P: Cont to\\nsupp dev needs.\\n\\n#4 : Mom in q cares and updated. Mom took temp,\\nchanged diaper, and breast fed infant. A: Independent and\\nappropriate w/cares. P: Cont to support and update.\\n\\n#6 Bili: Infant cont neoblue photo rx with eye shields for\\nbili of 12.3/0.3 this am. A: Infant appears jaund. P: Cont\\nphoto rx and check bili .\\n\\n#7 Skin: Triple antibiotic ointment applied to old\\ninfiltrate/scabbed area on right foot @ 0900 cares.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884797,\n \"text\": \"NPN 0700-1900\\n\\n\\n1. Resp: Infant remains in RA, maintaining his O2 sats\\ngreater than 96%. Lung sounds clear/=. RR 30-50's. Mild\\nSCR noted. No A's or B's noted. P: Cont. to monitor resp.\\nstatus.\\n\\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempted to BF\\nx 2 thus far - latched well. Tolerating NGT feedings well;\\nabd exam benign, no spits, min asp. Voiding qs and stooling\\nheme neg. P: Cont. to support nutritional needs.\\n\\n3. G/D: Temps stable swaddled in off-isolette. Infant is\\nalert/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 suppot developmental\\nneeds. P: Cont. to support developmental needs.\\n\\n4. : in throughout day. Independent with\\ncares and handling infants. Updated at bedside on infant's\\ncondition and plan of care. Asking appropriate questions.\\nLoving, involved . P: Cont. to support and update\\n.\\n\\n5. Bili: Photo was d/c'd on thurs at 10 am for a bili of\\n10.6. P: Repeat bili to be drawn in am.\\n\\n6. Skin - Rt foot infiltrate left open to air. Healing well\\nwith triple abx ointment q 12 hours. No drainage, swelling,\\nor redness noted. P: Cont. to monitor skin.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884798,\n \"text\": \"npn 1900-0700\\n\\n\\n1: resp\\nremains in ra. no spells and no dsats. lung sounds clear and\\nequal. mild subcostal retractions. no increased wob noted.\\nrr 30-50's. sats .925. continue to monitor for changes in\\nrespiratory status.\\n\\n2: fen\\ncurrent weight 2420gms up 10. total fluids remain at\\n140cc/kilo/day of bm 20 cals. tolerating feeds well. no\\nspits. minimal aspirates. voiding and stooling. abd soft\\nwith no loops. infant po'd 20cc at 0100. infant po fed based\\non feeding cues. continue to encourage po feeds as\\ntolerated.\\n\\n3: growth and development. received infant in an off\\nisolette. infant currently co-bedding in a crib with\\nsibbling. temps remain stable. alert and active with cares.\\nsleeps well inbetween. brings hands to face. sucks\\nvigorously on pacifier. brings hands to face. aga.continue\\nto monitor for developmental milestones.\\n\\n6; bili\\ninfant color slighlty jaundiced. infant currently off of\\nphototherapy. rebound bili sent this shift. will continue to\\nmonitor bili closely.\\n\\n7: skin\\ninfant right foot old infiltrate sight with multiple small\\nscabs. no drainage noted and no bleeding. triple antibiotic\\nointment applied at 2100. continue to monitor for changes.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884748,\n \"text\": \"Admission Note\\nBB admitted to NICU following C/S delivery for PIH. Infant emerged with good cry, dusky and retracting, requiring stim and BBO2 in DR. . on admission, GFR with RA SaO2 mid 80's, placed on CPAP 6 in 26-30% FiO2 to maintain SaO2 89-95. LS sl coarse and diminished, color good, cont with GFR through shift. Cap gas 7.27/45/47. No murmur audible, BP 75/35 mean 45. Labs sent for Bld cx and CBC, antibiotics begun. IV placed in R hand with D10W infusing, initial DS 47, after IVF infusing, DS 74. Abd benign, soft, round, +BS, has voided, no stool, NPO for now. Stable on open warmer, sl irritable with cares, little interest in pacifer. Dad visited briefly, told weights/measures and equipment explained, spoke softly with the babies. A: 34 week infant w/RDS P: cont CPAP/O2 as needed, maintain IVF NPO for now, cont antibiotics as ordered, monitor\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884749,\n \"text\": \"Respiratory Care Note\\nPt continues on Prong CPAP +6 FIO2 26-28%. B.S. ess. clear with good air entry. Mild retractions and grunting noted. Without apnea or bradys as of this note.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884750,\n \"text\": \"1 Alt in Resp\\n2 Alt in FEN\\n3 Alt in G&D\\n4 Alt in Parenting\\n5 ID\\n\\nREVISIONS TO PATHWAY:\\n\\n 1 Alt in Resp; added\\n Start date: \\n 2 Alt in FEN; added\\n Start date: \\n 3 Alt in G&D; added\\n Start date: \\n 4 Alt in Parenting; added\\n Start date: \\n 5 ID; added\\n Start date: \\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884751,\n \"text\": \"#1 PT CONT ON CPAP OF 6, MOSTLY 25-30% FI02. LS ARE CLEAR,\\nSLIGHTLY DIMINISHED. RR 40-80 WITH OCC GRUNTING. SATS\\nIMPROVED ON BELLY.\\n#2 NPO. TF 60/KG D10W INFUSING WELL VIA PIV. WEIGHT DECREASE\\n75GM. VOIDING AND STOOLING. DSTIX 113. BELLY FULL AND SOFT\\nWITH ACTIVE BS.\\n#3 TEMPS ARE STABLE NESTED ON SERVO WARMER. ALERT AND\\nIRRITABLE.\\n#4 DAD IN TO VISIT IN EVENING. DAD UPDATED AT BEDSIDE.\\n#5 PT CONT ON AMP AND GENT AS ORDERED.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884752,\n \"text\": \"RESPIRATORY CARE NOTE\\nBaby #1 remains on Prong CPAP 6 FiO2 25-30%. Occasional grunting RR 40-80's. Breath sounds are clear. Stable on CPAP will cont to follow closely.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884753,\n \"text\": \"Neonatology Attending\\n\\nDay 1 PMA 34 wks\\n\\nRemains on CPAP 6 with fio2 0.28. RR 50-80s. Intermittent grunting. CBG 7.28/47. No apnea, bradycardia. No murmur. HR 130-160s. BP mean 47. Weight 2500g (-75). NPO. IV dextrose at 60 ml/kg/d. Blood glucose 103. Benign abdomen. Lytes 135/4.0/19. Bilirubin 1.7. Stable temperature on off warmer. Parents in earlier this morning. On ampicillin and gentamicin. Blood culture no growth.\\n\\nMild hyaline membrane disease. Will continue to monitor closely. Keeping NPO. Will continue to follow blood glucose. Ruling out on antibiotics.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884817,\n \"text\": \"Exam Note\\nGEN - , active\\nHEENT - AFSFO, facial macules almost completely resolved from yesterday, oropharynx clear\\nCV - RRR, nl s1+s2, no murmur\\nPULM - CTAB\\nABD - soft, NT, ND, no mass\\nGU - nl male ext genit, no rash, stool present\\nEXT - wwp, cr < 2\\nNEURO - MAE, reactive\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884818,\n \"text\": \"6 Alt in \\n7 Skin:\\n\\nREVISIONS TO PATHWAY:\\n\\n 6 Alt in ; resolved\\n 7 Skin:; resolved\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884828,\n \"text\": \"NPN DAYS\\n\\n\\n#1 Pt received and cont in RA. LS C+=. no spells so\\nfar this shift. Pt day of spell count down. P- Will cont\\nto monitor resp status.\\n#2 FEN- TF=150cc/kg/d of BM24 with powder. abd benign.\\nall po feeds. po 35-50cc +BFx2. Pt voiding and stooling hem\\nneg. no spits. waking q2.5-4hrs. P- Will cont to monitor\\nFEN.\\n#3 G&D- Temp stable in open crib. cobedding with sibling.\\n and active with cares. sucking on pacifier. P- Will\\ncont to monitor G&D.\\n#4 Mom and Dad visiting this shift. Loving and\\ncaring towards pt. asking approp ques. updates given.\\nhelping with cares. updated re: pt spells and DC\\ndate pushed back. P- Will cont to support and educate\\n.\\nSee flowsheet for further details.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884829,\n \"text\": \"NPN DAYS\\naddendum: Hep B immunization given @ 1800.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884830,\n \"text\": \"NPN:\\n\\nRESP: RA. RR=40-50s w/SC retraction. BBS =/clear. Last A&B on ; day of brady count.\\n\\nCV: No murmur. HR=140-160. BP=68/41 (51). Color pink w/slight jaundice. Perfusion good.\\n\\nFEN: Wt=2655g (+ 35g). Ad Lib feeds of BM-24. Intake yesterday 119cc/kg/d + breast fdgs x 2. Bottled slowly x 1 for 10cc; 60cc taken well at following feeding. No spits. Abd benign. Voiding qs; small yellow stool. FeS04. Mother has appt w/lactation consultant on (13:00).\\n\\nG&D: CGA=36-4/7 wk. Temp stable in crib. Co-bedding w/sibling. Active and w/good tone. Swaddled and resting well. Discharge preparations in progress; hearing screen and carseat test need to be done.\\n\\nSOCIAL: Mother called x 1 for update.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2197-12-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1884831,\n \"text\": \"NNP ON-Call\\nPhysical Exam\\nGeneral: infant in open crib, room air,co-bedding with twin\\nSkin; warm and dry; color pink/jaundiced; cafe spot on forehead\\nHEENT: anterior fontanel open, level; sutures opposed\\nChest: breath sounds clear/=\\nCV: RRR, no murmur; normal S1 S2; pulses +2\\nAbd: soft; no masses; + bowel sounds; cord healed\\nExt: moving all\\nneuro: appropriate tone and reflexes; alerts\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2197-12-09 00:00:00.000\",\n \"description\": \"BABYGRAM (CHEST ONLY)\",\n \"row_id\": 934419,\n \"text\": \" 1:36 AM\\n BABYGRAM (CHEST ONLY) Clip # \\n Reason: evaluate for rds vs retained fetal lung fluid\\n Admitting Diagnosis: NEWBORN\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Infant with prematurity, on CPAP\\n REASON FOR THIS EXAMINATION:\\n evaluate for rds vs retained fetal lung fluid\\n ______________________________________________________________________________\\n FINAL REPORT\\n STUDY: Chest x-ray.\\n\\n DATE OF EXAM: .\\n\\n TIME OF EXAM: 1:46.\\n\\n CLINICAL HISTORY: This is a newborn infant on day of life 1 with respiratory\\n distress.\\n\\n FINDINGS: A single, portable view of the chest was obtained. I have no prior\\n films available for comparison. The heart size is normal. The pulmonary\\n vasculature is within range of normal limits. There is some increased\\n interstitial fluid suggesting the diagnosis of TTN, perhaps with a component\\n of mild hyaline membrane disease. There is no focal lung opacification.\\n\\n Abdominal situs is normal. The visualized bony structures are normal.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":198,"cells":{"subject_id":{"kind":"number","value":81662,"string":"81,662"},"hadm_id":{"kind":"number","value":124697,"string":"124,697"},"target_text":{"kind":"string","value":"46 y/o w/ depression and prior suicide attempts and MAOI overdose/toxicity, presents after being found unresponsive concerning for medication overdose."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: No acute intracranial abnormality. COMPARISON: CT head without contrast . The cardiomediastinal and hilar contours are normal. Minimal fluid is seen within the left mastoid air cell. The ventricles and sulci are normal in caliber and configuration. Sinustachycardia persists. No acute fractures are identified. Minimal hypodensity in the right frontal region suggests small vessel ischemic disease. No right pleural effusion or pneumothorax is seen. Non-specific ST-T wave changes.Compared to the previous tracing of no diagnostic interim change. TECHNIQUE: Contiguous axial images were acquired through the head without intravenous contrast. Endotracheal tube in good position. Lungs are clear with the previously noted infiltrate at the left lung base resolved. The basal cisterns are normal. Heart size and vascularity are normal. PORTABLE SEMI-ERECT CHEST RADIOGRAPH: Endotracheal tube is low in position terminating in the proximal left main bronchus. The imaged paranasal sinuses are clear. IMPRESSION: 1. IMPRESSION: 1. The -white matter differentiation is well preserved. The lung volumes are low, with bibasal opacities, could represent atelectasis or aspiration. FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses or mass effect. There is no evidence of pneumothorax. There is an NG tube passing beyond the stomach. Low lung volumes with bibasal opacities, could represent atelectasis or aspiration. Endotracheal tube in the proximal left main bronchus. An endotracheal tube is present with the tip at the T3 level. ICH No contraindications for IV contrast WET READ: KKgc SAT 5:55 PM No acute intracranial abnormality. No evidence for active cardiopulmonary disease. Sinus tachycardia. 2. 2. Sagittal and coronal reformats were generated and reviewed. Early R wave transition. 4:59 PM CT HEAD W/O CONTRAST Clip # Reason: ? The findings were discussed with Dr. on . ICH MEDICAL CONDITION: 46 year old woman unresponsive REASON FOR THIS EXAMINATION: ? WET READ VERSION #1 FINAL REPORT INDICATION: 46-year-old woman, unresponsive, to rule out intracranial hemorrhage. 3:16 PM CHEST (PORTABLE AP) Clip # Reason: please eval tube MEDICAL CONDITION: 46 year old woman unresponsive, intubated REASON FOR THIS EXAMINATION: please eval tube FINAL REPORT INDICATION: 46-year-old woman who is unresponsive and is intubated. 9:35 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please evaluate for ET tube placement Admitting Diagnosis: UNRESPONSIVE MEDICAL CONDITION: 46 year old woman presented unresponsive, s/p ET adjustment REASON FOR THIS EXAMINATION: please evaluate for ET tube placement FINAL REPORT PORTABLE CHEST HISTORY: Unresponsive, ET tube placement."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2109-09-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1210749,"text":" 9:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for ET tube placement\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman presented unresponsive, s/p ET adjustment\n REASON FOR THIS EXAMINATION:\n please evaluate for ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Unresponsive, ET tube placement.\n\n COMPARISON: at 1524 hours.\n\n An endotracheal tube is present with the tip at the T3 level. There is an NG\n tube passing beyond the stomach. Heart size and vascularity are normal.\n Lungs are clear with the previously noted infiltrate at the left lung base\n resolved. There is no evidence of pneumothorax.\n\n IMPRESSION:\n 1. Endotracheal tube in good position.\n 2. No evidence for active cardiopulmonary disease.\n\n\n"},{"category":"Radiology","chartdate":"2109-09-21 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":1210729,"text":" 4:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman unresponsive\n REASON FOR THIS EXAMINATION:\n ? ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc SAT 5:55 PM\n No acute intracranial abnormality.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old woman, unresponsive, to rule out intracranial\n hemorrhage.\n\n COMPARISON: CT head without contrast .\n\n TECHNIQUE: Contiguous axial images were acquired through the head without\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses or\n mass effect. The -white matter differentiation is well preserved. The\n ventricles and sulci are normal in caliber and configuration. Minimal\n hypodensity in the right frontal region suggests small vessel ischemic\n disease. The basal cisterns are normal. No acute fractures are identified.\n The imaged paranasal sinuses are clear. Minimal fluid is seen within the left\n mastoid air cell.\n\n IMPRESSION: No acute intracranial abnormality.\n\n"},{"category":"Radiology","chartdate":"2109-09-21 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1210716,"text":" 3:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman unresponsive, intubated\n REASON FOR THIS EXAMINATION:\n please eval tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old woman who is unresponsive and is intubated.\n\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH: Endotracheal tube is low in position\n terminating in the proximal left main bronchus. The lung volumes are low,\n with bibasal opacities, could represent atelectasis or aspiration. The\n cardiomediastinal and hilar contours are normal. No right pleural effusion or\n pneumothorax is seen.\n\n IMPRESSION:\n 1. Endotracheal tube in the proximal left main bronchus. The findings were\n discussed with Dr. on .\n 2. Low lung volumes with bibasal opacities, could represent atelectasis or\n aspiration.\n\n"},{"category":"ECG","chartdate":"2109-09-21 00:00:00.000","description":"Report","row_id":164267,"text":"Sinus tachycardia. Early R wave transition. Non-specific ST-T wave changes.\nCompared to the previous tracing of no diagnostic interim change. Sinus\ntachycardia persists.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-09-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210749,\n \"text\": \" 9:35 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: please evaluate for ET tube placement\\n Admitting Diagnosis: UNRESPONSIVE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old woman presented unresponsive, s/p ET adjustment\\n REASON FOR THIS EXAMINATION:\\n please evaluate for ET tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST\\n\\n HISTORY: Unresponsive, ET tube placement.\\n\\n COMPARISON: at 1524 hours.\\n\\n An endotracheal tube is present with the tip at the T3 level. There is an NG\\n tube passing beyond the stomach. Heart size and vascularity are normal.\\n Lungs are clear with the previously noted infiltrate at the left lung base\\n resolved. There is no evidence of pneumothorax.\\n\\n IMPRESSION:\\n 1. Endotracheal tube in good position.\\n 2. No evidence for active cardiopulmonary disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-09-21 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 1210729,\n \"text\": \" 4:59 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: ? ICH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old woman unresponsive\\n REASON FOR THIS EXAMINATION:\\n ? ICH\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: KKgc SAT 5:55 PM\\n No acute intracranial abnormality.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old woman, unresponsive, to rule out intracranial\\n hemorrhage.\\n\\n COMPARISON: CT head without contrast .\\n\\n TECHNIQUE: Contiguous axial images were acquired through the head without\\n intravenous contrast. Sagittal and coronal reformats were generated and\\n reviewed.\\n\\n FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses or\\n mass effect. The -white matter differentiation is well preserved. The\\n ventricles and sulci are normal in caliber and configuration. Minimal\\n hypodensity in the right frontal region suggests small vessel ischemic\\n disease. The basal cisterns are normal. No acute fractures are identified.\\n The imaged paranasal sinuses are clear. Minimal fluid is seen within the left\\n mastoid air cell.\\n\\n IMPRESSION: No acute intracranial abnormality.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2109-09-21 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1210716,\n \"text\": \" 3:16 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval tube\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 46 year old woman unresponsive, intubated\\n REASON FOR THIS EXAMINATION:\\n please eval tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 46-year-old woman who is unresponsive and is intubated.\\n\\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH: Endotracheal tube is low in position\\n terminating in the proximal left main bronchus. The lung volumes are low,\\n with bibasal opacities, could represent atelectasis or aspiration. The\\n cardiomediastinal and hilar contours are normal. No right pleural effusion or\\n pneumothorax is seen.\\n\\n IMPRESSION:\\n 1. Endotracheal tube in the proximal left main bronchus. The findings were\\n discussed with Dr. on .\\n 2. Low lung volumes with bibasal opacities, could represent atelectasis or\\n aspiration.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2109-09-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 164267,\n \"text\": \"Sinus tachycardia. Early R wave transition. Non-specific ST-T wave changes.\\nCompared to the previous tracing of no diagnostic interim change. Sinus\\ntachycardia persists.\\n\\n\"\n }\n]"}}},{"rowIdx":199,"cells":{"subject_id":{"kind":"number","value":3018,"string":"3,018"},"hadm_id":{"kind":"number","value":160704,"string":"160,704"},"target_text":{"kind":"string","value":"Patient admitted to the trauma service. Plastic Surgery was immediately consulted for his facial fractures; Ophthalmology was also consulted for his orbital fractures. He was taken to the operating room on by Plastics for repair of his facial fractures. He was prophylaxed with IV antibiotics for meningitis. Ophthalmology recommended follow up in Eye Clinic for his diabetic retinopathy. Neurosurgery was consulted for his head injuries and recommended repeat imaging and Dilantin. His Dilantin was weaned per recommendation by Neurosurgery starting on with a d/c date of . Diabetes was also consulted because of his elevated blood sugars. Patient started on 75/25 insulin . He has agreed to follow up in the Clinic after discharge. Because of his ETOH history patient was placed on CIWA protocol; there were no clinical signs of delirium tremors during his hospitalization. Physical and Occupational therapy were consulted. Social work consulted because of patient's home situation and his refusal of home services and complying with his medication regimen after his discharge; reportedly patient does not have a permanent home address and no family in this country or his home land of . Psychiatry was consulted to assess patient's capacity and felt that he did possess the capacity to make his health decisions. Pt. discharged to home."},"extractive_notes_summ":{"kind":"string","value":"Right subdural hematoma. RIght subdural hematoma. Stable appearance of tiny focus of probable intraparenchymal hemorrhage within the right temporal lobe. Again seen is a right subdural hematoma extending along the convexity, which appears approximately unchanged in size. There is proptosis of the right globe and intraorbital hematoma within the superolateral aspect of the right orbit. There is a moderate right subdural hematoma layering adjacent to the right frontoparietal convexity and extending inferiorly to the right temporal lobe. Subdural hemorrhage, right temporal lobe hemorrhage approx unchanged. Probable left subarachnoid hemorrhage. There is air within the right orbit, and along the superolateral aspect of the orbit, there is a hematoma displacing the extraocular muscles medially. Right frontal and parietal subgaleal hematoma. further access today.Resp: LS clear, diminished at bases; suctioned for sm. Marked gastric distention. Possible small focus of right temoral intraparenchymal hemorrhage. PB's for DVT prophylaxis. PB's for DVT prophylaxis. A right frontal fracture line extends anteriorly and inferiorly to the right frontal sinus, where there is marked comminution with displaced fragments involving the anterior and posterior walls of the frontal sinus. A small focus of hyperdensity along the medial aspect of the right frontal lobe likely represents a small amount of subarachnoid hemorrhage at this location. Note is made of heterogeneity within the clivus, a finding that may indicate clival hemangioma. Additional linear opacity within the right middle and right lower lobe laterally is consistent with scarring versus atelectasis. There is diffuse narrowing of the sulci of the right frontal and parietal lobes. The celiac trunk, superior mesenteric artery, and inferior mesenteric artery appear patent. Injuries: non-depressed R skull fx, traumatic R frontal parietal SDH/SAH with complex orbital/midface fx with sm. on ciwa scale (score ).Resp: LS clear, diminished at bases, denies shortness of breath or difficulty breathing. The appearance of a rounded focus of hemorrhage within the posterior aspect of the right temporal lobe, possibly representing an intraparenchymal hemorrhage, is stable. Right frontal and parietal scalp hematoma. There has been slight interval new hypodensity within the inferior right frontal lobe, which could be consistent with a contusion. TECHNIQUE: Non-contrast head CT. A large right frontal scalp hematoma appears approximately unchanged. The lateral ventricles are symmetric and nondilated, and the basilar cisterns appear patent. Additional tiny focus of hemorrhage within the right temporal lobe may represent subarachnoid or intraparenchymal hemorrhage. Within the right lobe of the liver anteriorly, there is a triangular area of hypodensity. The cardiac, mediastinal, and hilar contours are within normal limits. Proptosis of right globe with intraorbital hematoma on right. There is a punctate density superficially within the area of the right frontoparietal hemorrhage, which may possibly represent a foreign body versus structure on the surface of the patient. Respiratory Therapy60 y.o. Questionable subarachnoid hemorrhage within the left parietal region. Evaluate for solid organ injury. MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate a triangular area of hypodensity within the right lobe of the liver anteriorly. Right frontal skull fracture, displaced. There is a small amount of fluid and mucosal thickening within the left ethmoid air cells and left frontal sinus. Right subdural hematoma is approximately unchanged in size. There are comminuted fractures of the right zygomatic arch and of the anterior and lateral walls of the right maxillary sinus. R side of forehead/next to eye with sm. The visualized portions of the heart and pericardium appear unremarkable. Additional incidental finding of possibly left lung abnormality - please see report. Subarachnoid blood is again seen medially adjacent to the right frontal lobe. Note is made of a small amount of intraventricular hemorrhage which is seen layering in the left lateral ventricle slightly more conspicuous than the prior study. A rounded focus of hemorrhage within the posterior aspect of the right temporal lobe may represent a small focus of subarachnoid blood versus an intraparenchymal hemorrhage. unasyn as ordered.Skin: back/buttocks intact; R sided facial abrasion with sm. FINAL REPORT INDICATION: Facial trauma, found down. Wedge configuration of L1 vertebra, a finding that likely represents old trauma versus normal variant. There is an appearance of proptosis of the right globe, although no large retrobulbar hematoma is identified. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are dependent changes within the lower lobes bilaterally. Right inferior frontal lobe contusion is more apparent on the current study. Coronal and sagittal reformations are provided. FINDINGS: The previously identified right subdural hematoma is not significantly changed. Old right rib fracture and wedge configuration of L1 that could represent prior compression deformity or normal variant; see report. Lytes repleted.Endo: BS 132->195, covered per ss.ID: tmax 100.3; wbc 7.5,conts. Subarachnoid hemorrhage centered in the suprasellar cistern and involving the right frontal lobe inferolaterally and medially. There is decreased conspicuity of subarachnoid hemorrhage along the course of the right middle cerebral artery. There is soft tissue stranding and swelling within the right frontal scalp and preorbital soft tissues. There are multiple comminuted fractures involving the anterior and posterior walls of the right frontal sinus with posterior displacement of a fracture fragment into the intracranial space and with a tiny focus of pneumocephalus. There is an additional comminuted fracture of the posterior aspect of a right ethmoid air cell with displacement of a fracture fragment into the intracranial space. (+) ETOH Intubated in ED for deteriorating GCS. A right frontal skull fracture with triangular configuration demonstrates mild displacement. Kcl repleted.Endo: BS 216->covered per SS.ID; tmax 99.2; conts. IMPRESSION: Bibasilar linear atelectases. The prevertebral soft tissues appear unremarkable. In the setting of trauma, this could represent a hepatic laceration, although no perihepatic fluid collections are identified. There is degenerative change of the thoracolumbar and lumbosacral spine. Dilantin loaded in ER. Comminuted fracture of the anterior wall of the right orbit and of the right zygomatic arch. The ventricles are symmetric and nondilated. Questionable hyperdensity at the left insula is suggestive of possible subarachnoid hemorrhage."},"n_notes":{"kind":"number","value":16,"string":"16"},"notes":{"kind":"list like","value":[{"category":"ECG","chartdate":"2128-08-18 00:00:00.000","description":"Report","row_id":209871,"text":"Normal sinus rhythm. Tracing is within normal limits. No previous tracing\navailable for comparison.\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":881656,"text":" 4:10 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: r/o injueries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man found btwen curb and car\n REASON FOR THIS EXAMINATION:\n r/o injueries\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n COMPARISON: None.\n\n AP CHEST X-RAY: The cardiac silhouette, mediastinal, and hilar contours are\n normal. No pneumothorax is seen bilaterally on this supine radiograph. Both\n lungs are clear without consolidations or effusions. The surrounding soft\n tissue and osseous structures are unremarkable.\n\n AP PELVIS: Bilateral sacroiliac joints, pubic symphysis, and partially imaged\n bilateral hips are unremarkable. There is normal bony mineralization, without\n malalignment. The surrounding soft tissues are unremarkable.\n\n IMPRESSION: No evidence of intrathoracic or intrapelvic trauma.\n\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":881657,"text":" 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with found unresp btwn car and curb\n REASON FOR THIS EXAMINATION:\n r/o injur\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 5:22 PM\n Subarachnoid hemorrhage in basal cisterns and extending along right frontal\n and parietal lobes. RIght subdural hematoma. Possible small focus of right\n temoral intraparenchymal hemorrhage. Probable left subarachnoid hemorrhage.\n Multiple facial and skull fractures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: There is subarachnoid blood\n within the suprasellar cistern and lateral to the pons on the right, with\n extension to the Sylvian fissure and to the inferolateral aspect of the right\n frontal lobe. A small focus of hyperdensity along the medial aspect of the\n right frontal lobe likely represents a small amount of subarachnoid hemorrhage\n at this location.\n There is a moderate right subdural hematoma layering adjacent to the right\n frontoparietal convexity and extending inferiorly to the right temporal lobe.\n A rounded focus of hemorrhage within the posterior aspect of the right\n temporal lobe may represent a small focus of subarachnoid blood versus an\n intraparenchymal hemorrhage. Questionable hyperdensity at the left insula is\n suggestive of possible subarachnoid hemorrhage.\n\n The lateral ventricles are symmetric and nondilated, and the basilar cisterns\n appear patent. There is diffuse narrowing of the sulci of the right frontal\n and parietal lobes. There is no shift of normally midline structures. The\n - white differentiation appears preserved.\n\n Bone windows demonstrate numerous fractures of the skull and facial bones.\n There is a coronally oriented fracture extending through the right and left\n frontal bones originating near the vertex. A right frontal fracture line\n extends anteriorly and inferiorly to the right frontal sinus, where there is\n marked comminution with displaced fragments involving the anterior and\n posterior walls of the frontal sinus. There are multiple comminuted fractures\n of the roof of the orbit and of the right lamina papyracea. There are\n comminuted fractures of the right zygomatic arch and of the anterior and\n lateral walls of the right maxillary sinus. There is blood layering within\n the right maxillary sinus, ethmoid sinuses, and frontal sinus and air within\n the orbit. There is an appearance of proptosis of the right globe, although\n no large retrobulbar hematoma is identified. The mastoid air cells are\n (Over)\n\n 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n normally pneumatized. There is extensive soft tissue swelling and hematoma\n within the right frontal scalp. There is a punctate density superficially\n within the area of the right frontoparietal hemorrhage, which may possibly\n represent a foreign body versus structure on the surface of the patient.\n\n IMPRESSION:\n 1. Subarachnoid hemorrhage centered in the suprasellar cistern and involving\n the right frontal lobe inferolaterally and medially.\n 2. Right subdural hematoma.\n 3. Additional tiny focus of hemorrhage within the right temporal lobe may\n represent subarachnoid or intraparenchymal hemorrhage.\n 4. Questionable subarachnoid hemorrhage within the left parietal region.\n 5. Numerous comminuted facial and skull fractures.\n 6. Right frontal and parietal subgaleal hematoma.\n\n Facial fractures will be further assessed with facial bone CT of same date.\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT C-SPINE W/O CONTRAST","row_id":881658,"text":" 4:25 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with found unresp btwn car and curb\n REASON FOR THIS EXAMINATION:\n r/o injur\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 5:46 PM\n No fracture of cervical spine.\n Slight exaggeration of cervical lordosis may be positional. Please see\n dictated report for further recommendations. Additional incidental finding of\n possibly left lung abnormality - please see report.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained through the cervical spine without\n intravenous contrast. Coronal and sagittal reformations are provided.\n\n CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is\n imaged from C1 through the upper portion of T3. No fracture is identified in\n the cervical spine. There is multilevel degenerative change of the cervical\n spine with anterior osteophytosis, most prominent at C3-4, C5-6, and C6-7.\n There is slight exaggeration of the normal cervical lordosis that may be\n positional in nature. There is a suggestion of widening of the intervertebral\n disc spaces anteriorly, a finding that is predominantly diffuse to the C4-5\n through C6-7 intervertebral disc spaces. The prevertebral soft tissues appear\n unremarkable. The visualized outlines of the thecal sac demonstrate posterior\n probable disc bulges at C4-5 and C5-6 with indentation of the thecal sac. CT\n is limited in its ability to provide intrathecal detail.\n\n The visualized portions of the lung apices demonstrate emphysematous change.\n In addition, there is an ill-defined opacity at the left lung apex with\n irregular margins that is incompletely imaged. There are several small\n projections from the tracheal wall, which may represent adherent secretions.\n The mastoid air cells are normally pneumatized.\n\n IMPRESSION:\n 1. No fracture of the cervical spine.\n 2. Exaggeration of the cervical lordosis with diffuse widening of several\n intervertebral disc spaces anteriorly may be positional in nature. If there\n is clinical concern for ligamentous injury, MR is a more sensitive test.\n 3. Suggestion of disc bulges at C4-5 and C5-6. CT is limited in its\n evaluation of the spinal canal and its contents.\n 4. Emphysematous changes in the visualized portions of the lungs and\n additional irregular opacity at the left lung apex, a finding that may be\n further evaluated with dedicated chest CT once the patient is clinically able.\n\n (Over)\n\n 4:25 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST","row_id":881659,"text":" 4:28 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/out fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with facial trauma\n REASON FOR THIS EXAMINATION:\n r/out fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 6:54 PM\n Multiple facial and skull fractures. please see report.\n Proptosis of right globe with intraorbital hematoma on right.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down with facial trauma, evaluate fractures.\n\n COMPARISON: Head CT of same date.\n\n TECHNIQUE: Axial MDCT images were obtained through the facial bones. Coronal\n reformations are provided.\n\n CT OF THE FACIAL BONES WITHOUT INTRAVENOUS CONTRAST: There are numerous skull\n and facial fractures. A right frontal skull fracture with triangular\n configuration demonstrates mild displacement.\n\n There are multiple comminuted fractures involving the anterior and posterior\n walls of the right frontal sinus with posterior displacement of a fracture\n fragment into the intracranial space and with a tiny focus of pneumocephalus.\n There is an additional comminuted fracture of the posterior aspect of a right\n ethmoid air cell with displacement of a fracture fragment into the\n intracranial space.\n\n Additional comminuted fractures are present within the roof of the right orbit\n with displacement of a fracture fragment into the superior aspect of the right\n orbit. There is air within the right orbit, and along the superolateral\n aspect of the orbit, there is a hematoma displacing the extraocular muscles\n medially. The fracture fragments do not appear to impinge directly upon the\n optic nerve, although there is proptosis of the right globe.\n\n There are additional linear fractures of the lamina papyracea on the right.\n Comminuted fracture of the anterior wall of the right orbit and of the right\n zygomatic arch. There is blood layering within the right maxillary sinus,\n ethmoid sinuses, and frontal sinus. There is a small amount of fluid and\n mucosal thickening within the left ethmoid air cells and left frontal sinus.\n The left maxillary sinus is normally pneumatized and no fractures are\n identified within the left maxillary sinus or orbit. The mastoid air cells\n are normally pneumatized. Note is made of heterogeneity within the clivus, a\n finding that may indicate clival hemangioma. There is soft tissue stranding\n and swelling within the right frontal scalp and preorbital soft tissues.\n\n IMPRESSION:\n 1. Right frontal skull fracture, displaced.\n (Over)\n\n 4:28 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/out fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Extensive comminuted fractures of the right frontal sinus, maxillary\n sinus, orbit, and zygomatic arch.\n 3. There is proptosis of the right globe and intraorbital hematoma within the\n superolateral aspect of the right orbit.\n 4. There are displaced comminuted fracture fragments protruding into the\n right orbit without direct evidence of impingement upon the optic nerve.\n\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":881660,"text":" 4:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/out solid organ injury\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with facial trauma found down\n REASON FOR THIS EXAMINATION:\n r/out solid organ injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 6:09 PM\n Triangular hypodensity in right lobe of liver without perihepatic fluid\n collection could possibly represent small liver laceration versus other liver\n lesion.\n\n No fractures identified. Old right rib fracture and wedge configuration of L1\n that could represent prior compression deformity or normal variant; see\n report.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Facial trauma, found down. Evaluate for solid organ injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\n symphysis following the administration of 150 cc of intravenous Optiray.\n Additional coronal and sagittal reformations are provided.\n\n CONTRAST: Intravenous non-ionic contrast was administered due to the rapid\n rate of bolus injection required for this examination.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are dependent changes\n within the lower lobes bilaterally. Additional linear opacity within the\n right middle and right lower lobe laterally is consistent with scarring versus\n atelectasis. The visualized portions of the heart and pericardium appear\n unremarkable. There is marked distension of the stomach containing air and\n fluid.\n\n Within the right lobe of the liver anteriorly, there is a triangular area of\n hypodensity. There is no perihepatic fluid collection at this location. There\n is an additional questionable hypodensity within the left lobe of the liver\n superiorly (series 2, image 9), possibly representing partial volume\n averaging. The spleen, pancreas, gallbladder, and adrenal glands appear\n unremarkable. There are no perinephric fluid collections. There are symmetric\n nephrograms bilaterally without evidence of masses or hydronephrosis in either\n kidney. The ureters are nondilated. The aorta is normal in caliber. The\n celiac trunk, superior mesenteric artery, and inferior mesenteric artery\n appear patent. The large and small bowel loops are normal in caliber. The\n appendix is normal. There is no free fluid and no free air within the\n abdomen.\n\n (Over)\n\n 4:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/out solid organ injury\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley\n catheter and contrast. The bladder, distal ureters, prostate and seminal\n vesicles, rectum, and sigmoid colon appear unremarkable. There is no\n pathologic-appearing pelvic or inguinal lymphadenopathy. There is no free\n fluid and no free air within the pelvis.\n\n BONE WINDOWS: Bone windows demonstrate anterior wedge deformity of L1, a\n finding that is of uncertain significance. This could represent prior\n compression deformity versus normal variant. There is additional lucency\n within the superior endplates of T12 and L1 that is suggestive of Schmorl's\n node. There is degenerative change of the thoracolumbar and lumbosacral\n spine. There is deformity of the right iliac bone with sclerotic margins\n suggestive of prior trauma. No suspicious lytic or sclerotic osseous lesions\n are identified. There is an old healed right-sided rib fracture.\n\n MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate a\n triangular area of hypodensity within the right lobe of the liver anteriorly.\n\n IMPRESSION:\n 1. Triangular area of hypodensity in the right lobe of the liver. In the\n setting of trauma, this could represent a hepatic laceration, although no\n perihepatic fluid collections are identified. Additional questionable\n hypodense lesion in the left lobe of the liver may represent artifact.\n 2. Marked gastric distention.\n 3. Wedge configuration of L1 vertebra, a finding that likely represents old\n trauma versus normal variant. No acute fractures are identified.\n\n Results were called to the trauma resident caring for the patient at the time\n of interpretation.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2128-08-23 00:00:00.000","description":"CHEST (PA & LAT)","row_id":882768,"text":" 10:34 AM\n CHEST (PA & LAT) Clip # \n Reason: consolidation?\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p repair for skull fracture, SAH, SDH now spiking fevers\n\n REASON FOR THIS EXAMINATION:\n consolidation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of subarachnoid and subdural hemorrhages, fever.\n\n COMPARISON: Chest x-ray from .\n\n PA AND LATERAL CHEST RADIOGRAPHS: The lungs are clear. The cardiac,\n mediastinal, and hilar contours are within normal limits. Bilateral healed\n rib fractures are noted.\n\n IMPRESSION: No evidence of pneumonia.\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":881671,"text":" 6:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: HEAD TRAUMA\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Head trauma.\n\n FINDINGS: There is an endotracheal tube with tip 3 cm above the carina. The\n lungs are clear without effusion. There is some pleural thickening or\n scarring in the right lateral lower lung. An NG tube is in the stomach.\n Despite the NG tube in the stomach, there is a large collection of air seen in\n the mid abdomen. Compared to the CT from a few hours earlier, this is seen to\n represent a markedly distended stomach. This finding was called to the floor\n at the time of the CT .\n\n\n"},{"category":"Radiology","chartdate":"2128-08-14 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":881672,"text":" 6:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression of bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ICH\n REASON FOR THIS EXAMINATION:\n eval for progression of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 7:46 PM\n Increase in subarachnoid hemorrhage with local mass effect (sulcal narrowing\n but no shift of normally midline structures).\n Subdural hemorrhage, right temporal lobe hemorrhage approx unchanged.\n No hydrocephalus\n Please see report\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage, evaluate for progression of bleed.\n\n COMPARISON: Same date at 16:19 hours.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: In comparison with the\n examination of several hours earlier, there is a similar extent of\n subarachnoid hemorrhage within the basilar cisterns as well as within the\n sulci of the right frontal, parietal, and temporal lobes. Again seen is a\n right subdural hematoma extending along the convexity, which appears\n approximately unchanged in size. The appearance of a rounded focus of\n hemorrhage within the posterior aspect of the right temporal lobe, possibly\n representing an intraparenchymal hemorrhage, is stable. The subarachnoid\n blood within the left parietal sulciappears stable overall. The ventricles\n are symmetric and nondilated. The ventricles appear unchanged in size in\n comparison with the previous examination. There is no shift of normally\n midline structures. The basilar cisterns are patent. Subarachnoid blood is\n again seen medially adjacent to the right frontal lobe. A large right frontal\n scalp hematoma appears approximately unchanged.\n\n Bone windows again disclose numerous facial and skull fractures. There is\n increased density within the right maxillary, ethmoid, and frontal sinuses.\n\n IMPRESSION:\n 1. Some redistribution in subarachnoid hemorrhage within the basilar\n cisterns, layering within the sulci of the right frontal, parietal, and\n temporal lobes, and within the sulci of the left parietal lobe. There is no\n definite increase in the amount of subarachnoid blood.\n 2. Right subdural hematoma is approximately unchanged in size.\n 3. Stable appearance of tiny focus of probable intraparenchymal hemorrhage\n within the right temporal lobe.\n 4. No hydrocephalus and no shift of normally midline structures.\n 5. Right frontal and parietal scalp hematoma.\n (Over)\n\n 6:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression of bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 6. Multiple facial fractures.\n\n"},{"category":"Radiology","chartdate":"2128-08-15 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":881720,"text":" 10:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, SDH, intraparenchymal s/p trauma -- repeat head CT in\n AM\n REASON FOR THIS EXAMINATION:\n eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD\n\n INDICATION: Trauma, followup of hemorrhages.\n\n Comparison is made to the CT scan performed one day prior.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The previously identified right subdural hematoma is not\n significantly changed. There is again demonstrated bilateral areas of\n subarachnoid hemorrhage which is again seen layering in the interpeduncular\n cistern. Note is made of a small amount of intraventricular hemorrhage which\n is seen layering in the left lateral ventricle slightly more conspicuous than\n the prior study. There has been slight interval new hypodensity within the\n inferior right frontal lobe, which could be consistent with a contusion. There\n is decreased conspicuity of subarachnoid hemorrhage along the course of the\n right middle cerebral artery. The previously identified tiny focus of\n hemorrhage along the posterior aspect of the right temporal lobe is not\n significantly changed. No new areas of hemorrhage are identified. There is\n no shift of normally midline structures, mass effect or hydrocephalus. The\n previously described paranasal sinuses and osseous structures are not\n significantly changed with redemonstration of numerous facial and skull\n fractures.\n\n IMPRESSION: No new areas of hemorrhage identified. Right inferior frontal\n lobe contusion is more apparent on the current study.\n\n\n"},{"category":"Radiology","chartdate":"2128-08-18 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":882170,"text":" 2:54 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: INTRACRANIAL BLEED\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man pre-op for for skull fracture, SAH, SDH.\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS PA AND LATERAL\n\n Preop subdural hematoma.\n\n Heart size is normal. Apart from bibasilar linear atelectases the lungs are\n clear. No pleural effusions and no pneumothorax.\n\n IMPRESSION: Bibasilar linear atelectases.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-08-15 00:00:00.000","description":"Report","row_id":1301104,"text":"T-SICU admission note -0700\n60yo male found down between 2 parked cars, +ETOH. Arrived in ER with GCS 13, decreased MS , intubated. Injuries: non-depressed R skull fx, traumatic R frontal parietal SDH/SAH with complex orbital/midface fx with sm. L SAH. ?Spanish speaking per chart; appears to understand some English over course of noc. A-line placed by HO. ER RN, ER SW was working on location family/next of ; no contact .\n:\nNeuro: Lightly sedated on propofol gtt; easily lightened for neuro exams (at times neuro exam consistent with propofol on). Pupils dilated in EW; initially both pupils 8mm, NR, slowly improving over noc, currently R5mm, L 4mm, reactive. +corneals, gag and cough. MAE's; follows commands when asked in Spanish by Dr. ; cont. to follow commands throughout night in few Spanish words with this RN (squeezes hands, wiggles toes, sticks out tongue, opens eyes). Dilantin loaded in ER. Logroll c/spine precautions maintained.\n\nCV: HR 70-80'sSR, BP 100-130's/50-60's. Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\nAccess: a-line placed last noc; PIV x2 wnl, ? further access today.\n\nResp: LS clear, diminished at bases; suctioned for sm. amts. blood tinged sputum. Suctioned for sm. amts. blood tinged oral secretions. See carevue for labs/resp. notes.\n\nGI: abd soft, BS hypoactive, no stool, NPO. OGT to LCWS for sm. amts. brown drainage. Protonix for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in adequate amts. Kcl repleted.\n\nEndo: BS 216->covered per SS.\n\nID; tmax 99.2; conts. unasyn as ordered.\n\nSkin: back/buttocks intact; R sided facial abrasion with sm. amt. sang. drainage. R eye with red/purple hematoma, +scleral edema; iced NS gauze applied .\n\npsych/social: no contact from family/next of ; follow up with SW today.\n\nA: pt found down +SAH/SDH, hemodynamically stable\n\nP: Monitor VS, I/O, labs, neuro checks. Follow up CT results, ?d/c logroll, repeat head CT, ? further access today. Follow up with SW regarding next of . Maintain sedation/comfort/support to pt.\n"},{"category":"Nursing/other","chartdate":"2128-08-15 00:00:00.000","description":"Report","row_id":1301105,"text":"Respiratory Therapy\n60 y.o. M found down btwn 2 cars MOI unknown. (+) ETOH Intubated in ED for deteriorating GCS. Pt remains orally intubated on full ventilatory support at this time. BS clear Sx for sml amts thick blood tinged secretions. FiO2 weaned to .4. Plan: wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2128-08-15 00:00:00.000","description":"Report","row_id":1301106,"text":"T/SICU NPN: 0700-1900\nS:\n\nO: SYSTEM REVIEW:\n\nNEURO: FOLLOW UP HEAD CT THIS MORNING ALERT TO OPENS EYES TO VOICE\nORIENTED TO PERSON ONLY PT THINKS HE IS IN AND THE YEAR ABLE TO SPEAK ENGLISH SPEECH AT TIMES DIFFICULT TO UNDERSTAND D/T ACCENT AND LACK OF TEETH ANSWERS MOST QUESTIONS APPROPIATELY PUPILS REACTIVE TO LIGHT R=5MM WITH NO TO SLUGGISH REACTION L=4 WITH BRISK REACTION CORNEAL REFLEXES WEAKER ON RIGHT INTACT COUGH/GAG\nMAE WITH GOOD STRENGTH SPONTANEOUSLY AND TO COMMAND CONTINUES ON DILANTIN 100MG TID LEVEL 10.1 TODAY C-COLLAR INTACT AND REMAINS ON\nTLS CLEARED LOGROLL PRECAUTIONS D/C'D\n\nCVS: HR 70-80'S WITH NO>>RARE>>OFTEN UNIFOCAL PVC'S WITH COMPENSATORY PAUSE ELECTROLYTES REPLETED GOAL TO KEEP SBP < 140 RECEIVED TOTAL OF 5MG IV LABETOLOL X 3 SBP 120-130'S SKIN WARM/DRY PALPABLE PEDAL PULSES\n\nRESPIRATORY: SELF EXTUBATED TODAY AT 1440 RR 10-14 SAO2 100% ON 50% FACE TENT LUNGS CLEAR, DECREASED AT BASES NONPRODUCTIVE COUGH\n\nRENAL: FOLEY PATENT AND DRAINING CLEAR YELLOW URINE 10-200CC/HR\nNS AT 125CC/HR K+ 3.5 CURRENTLY RECEIVING TOTAL OF 40MEQ KCL OVER 5HRS FOR REPLETION MG++ 1.7 REPLETED WITH 2GMS MGSO4\nIVF TO CHANGE TO NS WITH 20MEQ KCL IV 125CC/HR\n\nGI: ABDOMEN: SOFT HYPOACTIVE BS REMAINS NPO ON IVF NO N/V ON PROTONIX OGT PULLED WITH EXTUBATION\n\nENDOCRINE: SS TIGHTENED 0800 179 COVERED WITH 6UNITS REGULAR INSULIN SQ 1400 FS 141 COVERED WITH 4UNITS OF REGULAR INSULIN\n\nHEME: CONTINUES ON PNEUMOBOOTS FOR DVT PROPHYALAXIS\n\nID: TMAX 99.6 ANTBX CHANGED TO FLAGYL/OXACILLIN/CEFTRIAXONE FOR OMF\n\nSKIN: BACK AND BUTTOCKS INTACT WITH NO REDNESS RIGHT EYE WITH ECCHYMOSIS SMALL ABRASION---PINK WITH NO OBVIOUS DRAINAGE SMALL RIGHT FRONTAL HEMATOMA\n\nCOMFORT: DENIES ANY PAIN\n\nPSYCHOSOCIAL: STATES LIVES ALONE IN NO FAMILY NEVER BEEN MARRIED WORKS PART-TIME AS LABORER ALTHOUGH UNABLE TO ELABORATE ABOUT JOB DENIES ANY PMH/PSH/MEDICATIONS STATES NO ALLERGIES\nADMITS TO ETOH USE--STATES THAT DRINKS A BOTTLE OF VODKA A DAY\n\nA: STABLE S/P HEAD INJURY\n\nP: CONTINUE TO MONITOR ABOVE PARAMETERS\n"},{"category":"Nursing/other","chartdate":"2128-08-16 00:00:00.000","description":"Report","row_id":1301107,"text":"T-SICU NPN 1900-0700\nSee carevue for specifics.\n:\nNeuro: Sleeping most of noc; arousable to voice, opens eyes spontaneously, MAE's, follows commands consistently. Oriented to self only; states he is in (also states this is where he lives); does not know date, remember incident, or that he is in hospital. +corneals,gag, and cough. R pupil 5mm, L pupil 4mm both reactive. C-collar in place. Conts. dilantin.\nCV: HR 60-70'sSR with occ. PVC's, BP 120-150's/60-70's. Started 100mg po labetalol last eve, SBP cont. 140-150's; additional 100mg po labetalol given, SBP now 130-140 (goal <140). Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\nAccess: R rad. a-line and PIV'x 2 wnl. conts. on ciwa scale (score ).\nResp: LS clear, diminished at bases, denies shortness of breath or difficulty breathing. O2sats 99-100% on 50% face tent which pt. continually removed, sats 98% ra. Enc. C+DB; pt with productive cough, swallowing secretions.\nGI: abd soft, NT/D, BS hypoactive, no stool. Tol sips water, denies n/v. Protonix for GI prophylaxis.\nGU: foley patent draining large amts. light yellow clear urine. Lytes repleted.\nEndo: BS 132->195, covered per ss.\nID: tmax 100.3; wbc 7.5,conts. cefazolin/flagyl/oxacillin as ordered.\nSkin: back/buttocks intact. R eye with red/purple hematoma, +scleral edema, eye gtt applied as ordered. R side of forehead/next to eye with sm. abrasion, OTA.\nPsych/social: pt states he lives alone, no family in area.\nA: labetolol po increased, hemodynamically stable with SBP<140; confusion conts.\nP: Monitor VS,I/O, labs, neuro checks, CIWA scale. Enc. pulmonary hygiene, increase po's as tolerated. Re-orient prn. Cont. ongoing comfort/support to pt. ?transfer to floor today.\n"},{"category":"Nursing/other","chartdate":"2128-08-16 00:00:00.000","description":"Report","row_id":1301108,"text":"See nursing transfer note.\n"}],"string":"[\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2128-08-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 209871,\n \"text\": \"Normal sinus rhythm. Tracing is within normal limits. No previous tracing\\navailable for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 881656,\n \"text\": \" 4:10 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: r/o injueries\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man found btwen curb and car\\n REASON FOR THIS EXAMINATION:\\n r/o injueries\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post fall.\\n\\n COMPARISON: None.\\n\\n AP CHEST X-RAY: The cardiac silhouette, mediastinal, and hilar contours are\\n normal. No pneumothorax is seen bilaterally on this supine radiograph. Both\\n lungs are clear without consolidations or effusions. The surrounding soft\\n tissue and osseous structures are unremarkable.\\n\\n AP PELVIS: Bilateral sacroiliac joints, pubic symphysis, and partially imaged\\n bilateral hips are unremarkable. There is normal bony mineralization, without\\n malalignment. The surrounding soft tissues are unremarkable.\\n\\n IMPRESSION: No evidence of intrathoracic or intrapelvic trauma.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 881657,\n \"text\": \" 4:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o injur\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with found unresp btwn car and curb\\n REASON FOR THIS EXAMINATION:\\n r/o injur\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 5:22 PM\\n Subarachnoid hemorrhage in basal cisterns and extending along right frontal\\n and parietal lobes. RIght subdural hematoma. Possible small focus of right\\n temoral intraparenchymal hemorrhage. Probable left subarachnoid hemorrhage.\\n Multiple facial and skull fractures.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: There is subarachnoid blood\\n within the suprasellar cistern and lateral to the pons on the right, with\\n extension to the Sylvian fissure and to the inferolateral aspect of the right\\n frontal lobe. A small focus of hyperdensity along the medial aspect of the\\n right frontal lobe likely represents a small amount of subarachnoid hemorrhage\\n at this location.\\n There is a moderate right subdural hematoma layering adjacent to the right\\n frontoparietal convexity and extending inferiorly to the right temporal lobe.\\n A rounded focus of hemorrhage within the posterior aspect of the right\\n temporal lobe may represent a small focus of subarachnoid blood versus an\\n intraparenchymal hemorrhage. Questionable hyperdensity at the left insula is\\n suggestive of possible subarachnoid hemorrhage.\\n\\n The lateral ventricles are symmetric and nondilated, and the basilar cisterns\\n appear patent. There is diffuse narrowing of the sulci of the right frontal\\n and parietal lobes. There is no shift of normally midline structures. The\\n - white differentiation appears preserved.\\n\\n Bone windows demonstrate numerous fractures of the skull and facial bones.\\n There is a coronally oriented fracture extending through the right and left\\n frontal bones originating near the vertex. A right frontal fracture line\\n extends anteriorly and inferiorly to the right frontal sinus, where there is\\n marked comminution with displaced fragments involving the anterior and\\n posterior walls of the frontal sinus. There are multiple comminuted fractures\\n of the roof of the orbit and of the right lamina papyracea. There are\\n comminuted fractures of the right zygomatic arch and of the anterior and\\n lateral walls of the right maxillary sinus. There is blood layering within\\n the right maxillary sinus, ethmoid sinuses, and frontal sinus and air within\\n the orbit. There is an appearance of proptosis of the right globe, although\\n no large retrobulbar hematoma is identified. The mastoid air cells are\\n (Over)\\n\\n 4:25 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o injur\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n normally pneumatized. There is extensive soft tissue swelling and hematoma\\n within the right frontal scalp. There is a punctate density superficially\\n within the area of the right frontoparietal hemorrhage, which may possibly\\n represent a foreign body versus structure on the surface of the patient.\\n\\n IMPRESSION:\\n 1. Subarachnoid hemorrhage centered in the suprasellar cistern and involving\\n the right frontal lobe inferolaterally and medially.\\n 2. Right subdural hematoma.\\n 3. Additional tiny focus of hemorrhage within the right temporal lobe may\\n represent subarachnoid or intraparenchymal hemorrhage.\\n 4. Questionable subarachnoid hemorrhage within the left parietal region.\\n 5. Numerous comminuted facial and skull fractures.\\n 6. Right frontal and parietal subgaleal hematoma.\\n\\n Facial fractures will be further assessed with facial bone CT of same date.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT C-SPINE W/O CONTRAST\",\n \"row_id\": 881658,\n \"text\": \" 4:25 PM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/o injur\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with found unresp btwn car and curb\\n REASON FOR THIS EXAMINATION:\\n r/o injur\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 5:46 PM\\n No fracture of cervical spine.\\n Slight exaggeration of cervical lordosis may be positional. Please see\\n dictated report for further recommendations. Additional incidental finding of\\n possibly left lung abnormality - please see report.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Axial MDCT images were obtained through the cervical spine without\\n intravenous contrast. Coronal and sagittal reformations are provided.\\n\\n CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is\\n imaged from C1 through the upper portion of T3. No fracture is identified in\\n the cervical spine. There is multilevel degenerative change of the cervical\\n spine with anterior osteophytosis, most prominent at C3-4, C5-6, and C6-7.\\n There is slight exaggeration of the normal cervical lordosis that may be\\n positional in nature. There is a suggestion of widening of the intervertebral\\n disc spaces anteriorly, a finding that is predominantly diffuse to the C4-5\\n through C6-7 intervertebral disc spaces. The prevertebral soft tissues appear\\n unremarkable. The visualized outlines of the thecal sac demonstrate posterior\\n probable disc bulges at C4-5 and C5-6 with indentation of the thecal sac. CT\\n is limited in its ability to provide intrathecal detail.\\n\\n The visualized portions of the lung apices demonstrate emphysematous change.\\n In addition, there is an ill-defined opacity at the left lung apex with\\n irregular margins that is incompletely imaged. There are several small\\n projections from the tracheal wall, which may represent adherent secretions.\\n The mastoid air cells are normally pneumatized.\\n\\n IMPRESSION:\\n 1. No fracture of the cervical spine.\\n 2. Exaggeration of the cervical lordosis with diffuse widening of several\\n intervertebral disc spaces anteriorly may be positional in nature. If there\\n is clinical concern for ligamentous injury, MR is a more sensitive test.\\n 3. Suggestion of disc bulges at C4-5 and C5-6. CT is limited in its\\n evaluation of the spinal canal and its contents.\\n 4. Emphysematous changes in the visualized portions of the lungs and\\n additional irregular opacity at the left lung apex, a finding that may be\\n further evaluated with dedicated chest CT once the patient is clinically able.\\n\\n (Over)\\n\\n 4:25 PM\\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/o injur\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST\",\n \"row_id\": 881659,\n \"text\": \" 4:28 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/out fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with facial trauma\\n REASON FOR THIS EXAMINATION:\\n r/out fx\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 6:54 PM\\n Multiple facial and skull fractures. please see report.\\n Proptosis of right globe with intraorbital hematoma on right.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Found down with facial trauma, evaluate fractures.\\n\\n COMPARISON: Head CT of same date.\\n\\n TECHNIQUE: Axial MDCT images were obtained through the facial bones. Coronal\\n reformations are provided.\\n\\n CT OF THE FACIAL BONES WITHOUT INTRAVENOUS CONTRAST: There are numerous skull\\n and facial fractures. A right frontal skull fracture with triangular\\n configuration demonstrates mild displacement.\\n\\n There are multiple comminuted fractures involving the anterior and posterior\\n walls of the right frontal sinus with posterior displacement of a fracture\\n fragment into the intracranial space and with a tiny focus of pneumocephalus.\\n There is an additional comminuted fracture of the posterior aspect of a right\\n ethmoid air cell with displacement of a fracture fragment into the\\n intracranial space.\\n\\n Additional comminuted fractures are present within the roof of the right orbit\\n with displacement of a fracture fragment into the superior aspect of the right\\n orbit. There is air within the right orbit, and along the superolateral\\n aspect of the orbit, there is a hematoma displacing the extraocular muscles\\n medially. The fracture fragments do not appear to impinge directly upon the\\n optic nerve, although there is proptosis of the right globe.\\n\\n There are additional linear fractures of the lamina papyracea on the right.\\n Comminuted fracture of the anterior wall of the right orbit and of the right\\n zygomatic arch. There is blood layering within the right maxillary sinus,\\n ethmoid sinuses, and frontal sinus. There is a small amount of fluid and\\n mucosal thickening within the left ethmoid air cells and left frontal sinus.\\n The left maxillary sinus is normally pneumatized and no fractures are\\n identified within the left maxillary sinus or orbit. The mastoid air cells\\n are normally pneumatized. Note is made of heterogeneity within the clivus, a\\n finding that may indicate clival hemangioma. There is soft tissue stranding\\n and swelling within the right frontal scalp and preorbital soft tissues.\\n\\n IMPRESSION:\\n 1. Right frontal skull fracture, displaced.\\n (Over)\\n\\n 4:28 PM\\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \\n Reason: r/out fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. Extensive comminuted fractures of the right frontal sinus, maxillary\\n sinus, orbit, and zygomatic arch.\\n 3. There is proptosis of the right globe and intraorbital hematoma within the\\n superolateral aspect of the right orbit.\\n 4. There are displaced comminuted fracture fragments protruding into the\\n right orbit without direct evidence of impingement upon the optic nerve.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 881660,\n \"text\": \" 4:29 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\\n Reason: r/out solid organ injury\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with facial trauma found down\\n REASON FOR THIS EXAMINATION:\\n r/out solid organ injury\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 6:09 PM\\n Triangular hypodensity in right lobe of liver without perihepatic fluid\\n collection could possibly represent small liver laceration versus other liver\\n lesion.\\n\\n No fractures identified. Old right rib fracture and wedge configuration of L1\\n that could represent prior compression deformity or normal variant; see\\n report.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Facial trauma, found down. Evaluate for solid organ injury.\\n\\n COMPARISON: None.\\n\\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\\n symphysis following the administration of 150 cc of intravenous Optiray.\\n Additional coronal and sagittal reformations are provided.\\n\\n CONTRAST: Intravenous non-ionic contrast was administered due to the rapid\\n rate of bolus injection required for this examination.\\n\\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are dependent changes\\n within the lower lobes bilaterally. Additional linear opacity within the\\n right middle and right lower lobe laterally is consistent with scarring versus\\n atelectasis. The visualized portions of the heart and pericardium appear\\n unremarkable. There is marked distension of the stomach containing air and\\n fluid.\\n\\n Within the right lobe of the liver anteriorly, there is a triangular area of\\n hypodensity. There is no perihepatic fluid collection at this location. There\\n is an additional questionable hypodensity within the left lobe of the liver\\n superiorly (series 2, image 9), possibly representing partial volume\\n averaging. The spleen, pancreas, gallbladder, and adrenal glands appear\\n unremarkable. There are no perinephric fluid collections. There are symmetric\\n nephrograms bilaterally without evidence of masses or hydronephrosis in either\\n kidney. The ureters are nondilated. The aorta is normal in caliber. The\\n celiac trunk, superior mesenteric artery, and inferior mesenteric artery\\n appear patent. The large and small bowel loops are normal in caliber. The\\n appendix is normal. There is no free fluid and no free air within the\\n abdomen.\\n\\n (Over)\\n\\n 4:29 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\\n Reason: r/out solid organ injury\\n Field of view: 40 Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley\\n catheter and contrast. The bladder, distal ureters, prostate and seminal\\n vesicles, rectum, and sigmoid colon appear unremarkable. There is no\\n pathologic-appearing pelvic or inguinal lymphadenopathy. There is no free\\n fluid and no free air within the pelvis.\\n\\n BONE WINDOWS: Bone windows demonstrate anterior wedge deformity of L1, a\\n finding that is of uncertain significance. This could represent prior\\n compression deformity versus normal variant. There is additional lucency\\n within the superior endplates of T12 and L1 that is suggestive of Schmorl's\\n node. There is degenerative change of the thoracolumbar and lumbosacral\\n spine. There is deformity of the right iliac bone with sclerotic margins\\n suggestive of prior trauma. No suspicious lytic or sclerotic osseous lesions\\n are identified. There is an old healed right-sided rib fracture.\\n\\n MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate a\\n triangular area of hypodensity within the right lobe of the liver anteriorly.\\n\\n IMPRESSION:\\n 1. Triangular area of hypodensity in the right lobe of the liver. In the\\n setting of trauma, this could represent a hepatic laceration, although no\\n perihepatic fluid collections are identified. Additional questionable\\n hypodense lesion in the left lobe of the liver may represent artifact.\\n 2. Marked gastric distention.\\n 3. Wedge configuration of L1 vertebra, a finding that likely represents old\\n trauma versus normal variant. No acute fractures are identified.\\n\\n Results were called to the trauma resident caring for the patient at the time\\n of interpretation.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-23 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 882768,\n \"text\": \" 10:34 AM\\n CHEST (PA & LAT) Clip # \\n Reason: consolidation?\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man s/p repair for skull fracture, SAH, SDH now spiking fevers\\n\\n REASON FOR THIS EXAMINATION:\\n consolidation?\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of subarachnoid and subdural hemorrhages, fever.\\n\\n COMPARISON: Chest x-ray from .\\n\\n PA AND LATERAL CHEST RADIOGRAPHS: The lungs are clear. The cardiac,\\n mediastinal, and hilar contours are within normal limits. Bilateral healed\\n rib fractures are noted.\\n\\n IMPRESSION: No evidence of pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 881671,\n \"text\": \" 6:29 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: HEAD TRAUMA\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST SINGLE VIEW ON \\n\\n HISTORY: Head trauma.\\n\\n FINDINGS: There is an endotracheal tube with tip 3 cm above the carina. The\\n lungs are clear without effusion. There is some pleural thickening or\\n scarring in the right lateral lower lung. An NG tube is in the stomach.\\n Despite the NG tube in the stomach, there is a large collection of air seen in\\n the mid abdomen. Compared to the CT from a few hours earlier, this is seen to\\n represent a markedly distended stomach. This finding was called to the floor\\n at the time of the CT .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-14 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 881672,\n \"text\": \" 6:36 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for progression of bleed\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with ICH\\n REASON FOR THIS EXAMINATION:\\n eval for progression of bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MRSg SAT 7:46 PM\\n Increase in subarachnoid hemorrhage with local mass effect (sulcal narrowing\\n but no shift of normally midline structures).\\n Subdural hemorrhage, right temporal lobe hemorrhage approx unchanged.\\n No hydrocephalus\\n Please see report\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Intracranial hemorrhage, evaluate for progression of bleed.\\n\\n COMPARISON: Same date at 16:19 hours.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: In comparison with the\\n examination of several hours earlier, there is a similar extent of\\n subarachnoid hemorrhage within the basilar cisterns as well as within the\\n sulci of the right frontal, parietal, and temporal lobes. Again seen is a\\n right subdural hematoma extending along the convexity, which appears\\n approximately unchanged in size. The appearance of a rounded focus of\\n hemorrhage within the posterior aspect of the right temporal lobe, possibly\\n representing an intraparenchymal hemorrhage, is stable. The subarachnoid\\n blood within the left parietal sulciappears stable overall. The ventricles\\n are symmetric and nondilated. The ventricles appear unchanged in size in\\n comparison with the previous examination. There is no shift of normally\\n midline structures. The basilar cisterns are patent. Subarachnoid blood is\\n again seen medially adjacent to the right frontal lobe. A large right frontal\\n scalp hematoma appears approximately unchanged.\\n\\n Bone windows again disclose numerous facial and skull fractures. There is\\n increased density within the right maxillary, ethmoid, and frontal sinuses.\\n\\n IMPRESSION:\\n 1. Some redistribution in subarachnoid hemorrhage within the basilar\\n cisterns, layering within the sulci of the right frontal, parietal, and\\n temporal lobes, and within the sulci of the left parietal lobe. There is no\\n definite increase in the amount of subarachnoid blood.\\n 2. Right subdural hematoma is approximately unchanged in size.\\n 3. Stable appearance of tiny focus of probable intraparenchymal hemorrhage\\n within the right temporal lobe.\\n 4. No hydrocephalus and no shift of normally midline structures.\\n 5. Right frontal and parietal scalp hematoma.\\n (Over)\\n\\n 6:36 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval for progression of bleed\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 6. Multiple facial fractures.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-15 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 881720,\n \"text\": \" 10:12 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: eval bleed\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man with SAH, SDH, intraparenchymal s/p trauma -- repeat head CT in\\n AM\\n REASON FOR THIS EXAMINATION:\\n eval bleed\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT HEAD\\n\\n INDICATION: Trauma, followup of hemorrhages.\\n\\n Comparison is made to the CT scan performed one day prior.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: The previously identified right subdural hematoma is not\\n significantly changed. There is again demonstrated bilateral areas of\\n subarachnoid hemorrhage which is again seen layering in the interpeduncular\\n cistern. Note is made of a small amount of intraventricular hemorrhage which\\n is seen layering in the left lateral ventricle slightly more conspicuous than\\n the prior study. There has been slight interval new hypodensity within the\\n inferior right frontal lobe, which could be consistent with a contusion. There\\n is decreased conspicuity of subarachnoid hemorrhage along the course of the\\n right middle cerebral artery. The previously identified tiny focus of\\n hemorrhage along the posterior aspect of the right temporal lobe is not\\n significantly changed. No new areas of hemorrhage are identified. There is\\n no shift of normally midline structures, mass effect or hydrocephalus. The\\n previously described paranasal sinuses and osseous structures are not\\n significantly changed with redemonstration of numerous facial and skull\\n fractures.\\n\\n IMPRESSION: No new areas of hemorrhage identified. Right inferior frontal\\n lobe contusion is more apparent on the current study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-08-18 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 882170,\n \"text\": \" 2:54 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: INTRACRANIAL BLEED\\n Admitting Diagnosis: INTRACRANIAL BLEED\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man pre-op for for skull fracture, SAH, SDH.\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST TWO VIEWS PA AND LATERAL\\n\\n Preop subdural hematoma.\\n\\n Heart size is normal. Apart from bibasilar linear atelectases the lungs are\\n clear. No pleural effusions and no pneumothorax.\\n\\n IMPRESSION: Bibasilar linear atelectases.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301104,\n \"text\": \"T-SICU admission note -0700\\n60yo male found down between 2 parked cars, +ETOH. Arrived in ER with GCS 13, decreased MS , intubated. Injuries: non-depressed R skull fx, traumatic R frontal parietal SDH/SAH with complex orbital/midface fx with sm. L SAH. ?Spanish speaking per chart; appears to understand some English over course of noc. A-line placed by HO. ER RN, ER SW was working on location family/next of ; no contact .\\n:\\nNeuro: Lightly sedated on propofol gtt; easily lightened for neuro exams (at times neuro exam consistent with propofol on). Pupils dilated in EW; initially both pupils 8mm, NR, slowly improving over noc, currently R5mm, L 4mm, reactive. +corneals, gag and cough. MAE's; follows commands when asked in Spanish by Dr. ; cont. to follow commands throughout night in few Spanish words with this RN (squeezes hands, wiggles toes, sticks out tongue, opens eyes). Dilantin loaded in ER. Logroll c/spine precautions maintained.\\n\\nCV: HR 70-80'sSR, BP 100-130's/50-60's. Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\\nAccess: a-line placed last noc; PIV x2 wnl, ? further access today.\\n\\nResp: LS clear, diminished at bases; suctioned for sm. amts. blood tinged sputum. Suctioned for sm. amts. blood tinged oral secretions. See carevue for labs/resp. notes.\\n\\nGI: abd soft, BS hypoactive, no stool, NPO. OGT to LCWS for sm. amts. brown drainage. Protonix for GI prophylaxis.\\n\\nGU: foley patent draining clear yellow urine in adequate amts. Kcl repleted.\\n\\nEndo: BS 216->covered per SS.\\n\\nID; tmax 99.2; conts. unasyn as ordered.\\n\\nSkin: back/buttocks intact; R sided facial abrasion with sm. amt. sang. drainage. R eye with red/purple hematoma, +scleral edema; iced NS gauze applied .\\n\\npsych/social: no contact from family/next of ; follow up with SW today.\\n\\nA: pt found down +SAH/SDH, hemodynamically stable\\n\\nP: Monitor VS, I/O, labs, neuro checks. Follow up CT results, ?d/c logroll, repeat head CT, ? further access today. Follow up with SW regarding next of . Maintain sedation/comfort/support to pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301105,\n \"text\": \"Respiratory Therapy\\n60 y.o. M found down btwn 2 cars MOI unknown. (+) ETOH Intubated in ED for deteriorating GCS. Pt remains orally intubated on full ventilatory support at this time. BS clear Sx for sml amts thick blood tinged secretions. FiO2 weaned to .4. Plan: wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301106,\n \"text\": \"T/SICU NPN: 0700-1900\\nS:\\n\\nO: SYSTEM REVIEW:\\n\\nNEURO: FOLLOW UP HEAD CT THIS MORNING ALERT TO OPENS EYES TO VOICE\\nORIENTED TO PERSON ONLY PT THINKS HE IS IN AND THE YEAR ABLE TO SPEAK ENGLISH SPEECH AT TIMES DIFFICULT TO UNDERSTAND D/T ACCENT AND LACK OF TEETH ANSWERS MOST QUESTIONS APPROPIATELY PUPILS REACTIVE TO LIGHT R=5MM WITH NO TO SLUGGISH REACTION L=4 WITH BRISK REACTION CORNEAL REFLEXES WEAKER ON RIGHT INTACT COUGH/GAG\\nMAE WITH GOOD STRENGTH SPONTANEOUSLY AND TO COMMAND CONTINUES ON DILANTIN 100MG TID LEVEL 10.1 TODAY C-COLLAR INTACT AND REMAINS ON\\nTLS CLEARED LOGROLL PRECAUTIONS D/C'D\\n\\nCVS: HR 70-80'S WITH NO>>RARE>>OFTEN UNIFOCAL PVC'S WITH COMPENSATORY PAUSE ELECTROLYTES REPLETED GOAL TO KEEP SBP < 140 RECEIVED TOTAL OF 5MG IV LABETOLOL X 3 SBP 120-130'S SKIN WARM/DRY PALPABLE PEDAL PULSES\\n\\nRESPIRATORY: SELF EXTUBATED TODAY AT 1440 RR 10-14 SAO2 100% ON 50% FACE TENT LUNGS CLEAR, DECREASED AT BASES NONPRODUCTIVE COUGH\\n\\nRENAL: FOLEY PATENT AND DRAINING CLEAR YELLOW URINE 10-200CC/HR\\nNS AT 125CC/HR K+ 3.5 CURRENTLY RECEIVING TOTAL OF 40MEQ KCL OVER 5HRS FOR REPLETION MG++ 1.7 REPLETED WITH 2GMS MGSO4\\nIVF TO CHANGE TO NS WITH 20MEQ KCL IV 125CC/HR\\n\\nGI: ABDOMEN: SOFT HYPOACTIVE BS REMAINS NPO ON IVF NO N/V ON PROTONIX OGT PULLED WITH EXTUBATION\\n\\nENDOCRINE: SS TIGHTENED 0800 179 COVERED WITH 6UNITS REGULAR INSULIN SQ 1400 FS 141 COVERED WITH 4UNITS OF REGULAR INSULIN\\n\\nHEME: CONTINUES ON PNEUMOBOOTS FOR DVT PROPHYALAXIS\\n\\nID: TMAX 99.6 ANTBX CHANGED TO FLAGYL/OXACILLIN/CEFTRIAXONE FOR OMF\\n\\nSKIN: BACK AND BUTTOCKS INTACT WITH NO REDNESS RIGHT EYE WITH ECCHYMOSIS SMALL ABRASION---PINK WITH NO OBVIOUS DRAINAGE SMALL RIGHT FRONTAL HEMATOMA\\n\\nCOMFORT: DENIES ANY PAIN\\n\\nPSYCHOSOCIAL: STATES LIVES ALONE IN NO FAMILY NEVER BEEN MARRIED WORKS PART-TIME AS LABORER ALTHOUGH UNABLE TO ELABORATE ABOUT JOB DENIES ANY PMH/PSH/MEDICATIONS STATES NO ALLERGIES\\nADMITS TO ETOH USE--STATES THAT DRINKS A BOTTLE OF VODKA A DAY\\n\\nA: STABLE S/P HEAD INJURY\\n\\nP: CONTINUE TO MONITOR ABOVE PARAMETERS\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301107,\n \"text\": \"T-SICU NPN 1900-0700\\nSee carevue for specifics.\\n:\\nNeuro: Sleeping most of noc; arousable to voice, opens eyes spontaneously, MAE's, follows commands consistently. Oriented to self only; states he is in (also states this is where he lives); does not know date, remember incident, or that he is in hospital. +corneals,gag, and cough. R pupil 5mm, L pupil 4mm both reactive. C-collar in place. Conts. dilantin.\\nCV: HR 60-70'sSR with occ. PVC's, BP 120-150's/60-70's. Started 100mg po labetalol last eve, SBP cont. 140-150's; additional 100mg po labetalol given, SBP now 130-140 (goal <140). Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\\nAccess: R rad. a-line and PIV'x 2 wnl. conts. on ciwa scale (score ).\\nResp: LS clear, diminished at bases, denies shortness of breath or difficulty breathing. O2sats 99-100% on 50% face tent which pt. continually removed, sats 98% ra. Enc. C+DB; pt with productive cough, swallowing secretions.\\nGI: abd soft, NT/D, BS hypoactive, no stool. Tol sips water, denies n/v. Protonix for GI prophylaxis.\\nGU: foley patent draining large amts. light yellow clear urine. Lytes repleted.\\nEndo: BS 132->195, covered per ss.\\nID: tmax 100.3; wbc 7.5,conts. cefazolin/flagyl/oxacillin as ordered.\\nSkin: back/buttocks intact. R eye with red/purple hematoma, +scleral edema, eye gtt applied as ordered. R side of forehead/next to eye with sm. abrasion, OTA.\\nPsych/social: pt states he lives alone, no family in area.\\nA: labetolol po increased, hemodynamically stable with SBP<140; confusion conts.\\nP: Monitor VS,I/O, labs, neuro checks, CIWA scale. Enc. pulmonary hygiene, increase po's as tolerated. Re-orient prn. Cont. ongoing comfort/support to pt. ?transfer to floor today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-08-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1301108,\n \"text\": \"See nursing transfer note.\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":1,"numItemsPerPage":100,"numTotalItems":24993,"offset":100,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMTg0MDE3MCwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMTg0Mzc3MCwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.OlivPA4_VegVdhU3PZsaBxcgmW7BUziDbk14zXJFb6DkQY4IuxCTg5Ncxl2Sk3ZMZ9343WhZ6o7975hhqB93Cw","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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6,189 | 145,240 | A/P: 56 y/o female with h/o HTN who presented s/p VFib arrest with large anterior MI s/p cath with POBA. . #Cardiac . a)Ischemia: Pt had a large anterior MI. An IABP was placed in the cath lab due to the size of the infarct as a prophylactic measure, but overall she did well and it was weaned off and the balloon was d/c'd after the 18 hours of integrillin had completed its course. She was started on metoprolol and this was titrated up. Lisinopril was restarted as well as plavix, statin, ASA. . b)Rhythm: s/p VFib and PEA arrest. Pt was monitored on telemetry and had no further events. EP was consulted and obtained a signal average ECG on to determine if a defibrillator might be appropriate in the future. . c)Pump: Echo post-event showed an LVEF of 35-50%. She was restarted on lisinopril. She has been scheduled for a repeat echo in 1 month to determine if an ICD might be indicated given the VFib arrest. . # Infiltrates on CXR with ? of hemoptysis at OSH: She was begun on empiric treatment for PNA at the OSH with ceftriaxone and flagyl. She improved and was changed to levofloxacin PO to complete a 7 day course. (last day ) . # Mental Status: pt was down for many minutes before resuscitation occurred. In the hospital she was noted to have problems with short term memory. She was seen by Dr. with neurology who specializes in memory loss that occurs in the setting of VFib arrests and he felt that the pt would likely recover most function given some time. | Sinus rhythmPoor R wave progression - probable normal variantSince previous tracing of , anterior ST-T wave abnormalities areresolved Since theprevious tracing of ventricular ectopy is absent and further ST-T wavechanges are now seen. PATIENT/TEST INFORMATION:Indication: Hypertension.Height: (in) 61Weight (lb): 210BSA (m2): 1.93 m2BP (mm Hg): 131/75HR (bpm): 89Status: InpatientDate/Time: at 12:12Test: 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: Normal LV cavity size. AM labs pending.Resp: Lungs clear in apices, c crackles about halfway up on L. Sats 94-100 on 2L. PT ARRIVED FROM CATH LAB S/P LAD/DIAG STENT WITH IAPB 1:1 FOR HYPOTENSION/SHOCK STATE.HR- 80-90'S SR, NO RUNS VEA/VT- OFF AMIO GTT FROM CATH LAB. Lopressor 12.5mg started without change in HR Cont on IAPB 1:1 with good augmentation and systolic unloading . Pulses +3/+1 bilat.Resp - ls with dependant rales r base. SOME TACHYPNEA WITH EXERTION BUT OTHERWISE COMFORTABLE.HOLDING OFF DIUIRESIS THIS SHIFT, AS PT DIURESING ON OWN.PAD- 18-22, CVP-. LV inflow pattern c/wimpaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.Conclusions:1. 18G & 20G R PIV'sID: Afebrile. Q-T interval hasprolonged. Poor R wave progression inleads VI-V3. Left atrial abnormality is present..TRACING #1 D/C POST CATH IVF AS WELL. Sinus rhythm with occaional ventricular premature beats. NO DESAT IN SETTING OF FEELING SOB.NO LASIX THIS SHIFT.PT (-)1300CC .DIM BS WITH SOME CX DEP BASE.GU- FOLEY CATH IN PLACE- CLEAR YELLOW TO TEA COLORED URINE.30-50CC/HOUR.GI- SOME NAUSEA LATE AFTERNOON TX ANZIMET. Rec'd Lopressor, Imdur, Spironolactone, and Lasix at same time in AM . T max 99.1CV - HR 70-80's nsr with rare pvc's. PCW SLIGHTLY LOWER IN CATH LAB THAN PAD.CXR CONFIRMING GOOD PLACEMENT OF PA LINE AS WELL AS IABP.GU- 1 LITER OUT FROM CATH LAB ON ARRIVAL.FOLEY CATH IN PLACE.PUTTING OUT 90-140CC/HOUR- TO GIVE LASIX IF DROPS LESS THAN 50CC/HOUR. MG - 1.7- CURRENTLY REPLETING WITH 2 AMPS. ETOH USE.RECEIVED 2 MG ATIVAN ON ARRIVAL FOR 13 SCORE.SLEEPING , RESTFUL BUT EASILY AWAKENED CURRENTLY.A/ PT ADMITTED FOR CV SHOCK/ R/I MI/ S/P VFIB ARREST.CONTINUE TO SUPPORT HEMODYNAMICS WITH IABP/INTEG GTT/ASA- ? PT ALERT, ORIENTED, NORMAL NEURO EXAM.FORGETTING DATE/MONTH- BUT AWARE OF WHY SHE IS HERE AND WHERE WE ARE.SOME SHORT TERM MEMORY DEFICIT, ASKING SIMILAR ? CP FREE.INTEGRILLEN 2 MCG/KG UNTIL 4PM AND STARTED 5AM HEPARIN GTT 1100U NO BOLUS S/P 12:30 AM RT FEMORAL ALINE SHEATH PULL.GROIN SITES REMAIN STABLE, FREE OF BLEED, PULSES (+) BILATERALLY.RT GROIN REMAINS WITH PA LINE IN PLACE, LEFT GROIN WITH IABP.CO/CI ON ADMIT- 4.5/2.2/1742. TO INCREASE TODAY.ASA/PLAVIX- OFF INTEG/HEP GTT.RT GROIN WITH PA LINE INTRODUCER IN PLACE- CLEAN/DRY- NEEDS TO BE REMINDED OF KEEPING THAT LEG STRAIGHT. Heparin stopped at 4:30 for planned IAPB removal at 5:30 and IAPB was placed back to 1:1.CPK #2 7232/152.R groin swan introducer d/i without ooze. Rx with Tylenol 650mg x2.CV - HR 70-80's nsr with rare single pvc. MAPS- 100-110.REMAINS HEMODYNAMICALLY STABLE OFF DOPA AND AMIO GTT. Trace aorticregurgitation is seen.3. Mediastinal and hilar contours within normal limits. T waves are now inverted in leads V4-V6. TEAM TO D/C THAT LINE TODAY.LEFT GROIN S/P IABP REMOVAL WITH PRESSURE HELD 6P- 7:20P. Flat T waves inleads I, aVL, III, aVF and V5-V6 which are non-specific. (+) BOWEL SOUNDS- NO STOOL THIS SHIFT.LINES- 4 PERIPHERALS, 1 RT FEMORAL INTRODUCER IN PLACE.A/ PT S/P LARGE MI, V FIB REQUIRING PTCA LAD AND IABP INSERTION- CURRENTLY DOING WELL S/P IABP D/C.-CONTINUE TO MAXIMIZE GOOD RATE/PRESSURE WITH CV MEDS- INCREASE CAPTOPRIL THIS AM.-REPLETE LYTES AS NEEDED ONCE LABS COME BACK FROM LAB.-CONTINUE TO ASSESS MENTAL STATUS, NEED FOR REORIENTATION.CONTINUE TO ORIENT AS NEEDED.ADVANCE DIET AS SHE TOLERATED- WATCH FOR FURTHER NAUSEA/DRY HEAVES. Possible anterior myocardial infarction - ageundetermined. Pt turned and repositioned as tolerated. REASON FOR THIS EXAMINATION: r/o infection FINAL REPORT CHEST, SINGLE AP FILM History of atrial fibrillation arrest and anterior myocardial infarct. Probable anterior wall myocardial infarction of indeterminateage. On Vanco and Zosyn abx.Neuro/Social: A&O x 3, MAE, turns by self. No LVmass/thrombus.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). BP 115/75 and HR 80's nsr with no vea. MORE LASIX THIS AM.CONSIDER WEANING IABP TODAY- AM ECHO. L groin IAPB with slight ooze at site, covered with modified pressure dsg. PT WITH SHORT TERM MEMORY LOSS- PLEASANT, COOPERATIVE BUT FORGETTING REASON FOR ADMIT OR HAVING TO KEEP LEGS STRAIGHT, AND REASONING BEHIND THAT.ANXIOUS - WANTING TO GET OOB- GIVEN 2 MG ATIVAN 8P AND THEN 1 MG LATER DURING THE NITE. Left atrial abnormality. SENT UA/C/S- CLEAR YELLOW URINE.GI- NO FURTHER N/V AS AT OSH/CATH LAB.TO START PROTONIX QD.HCT STABLE- 40.3. CCU NSG PROGRESS NOTE 7P-7A/ S/P CV ARREST; CADS- " CAN I GET UP? CCU NSG ADMIT/PROGRESS NOTE 12A-7A/ S/P AMI; SHOCKS- " WHERE AM I"?O- SEE NSG FHPA FOR DETAILS R/T HPI/PMH AS WELL AS CCU TEAM ADMISSION NOTE. Abd is soft with +bs, but no stool since admit.GU - Foley intact to clear yellow urine, approx 30-50cc/hr.Activity - Dangle x2 today, and tolerated with no orthostatic changes.Neuro - Cont with short term memory loss. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. SINGLE AP PORTABLE VIEW OF THE CHEST: Interval improvement of mild to moderate pulmonary edema. Compared tothe previous tracing of no change.TRACING #1 Nursing Progress Note 1900-0700S: "No..No pain, good, breathing good"O: Please see carevue for complete objective data.CV: NSR c RBBB, ocass PVC's. WATCH FOR ANY FURTHER ARRYTHMIA/ISCHEMIC SIGNS., MEDICAL MANAGEMENT POST MI.CHECK PTT 11AM- KEEP WITHIN THERAPEUTIC LEVELS.REPLETE LYTES AS NEEDED, CONTINUE TO CYCLE CPK.BACK CARE/COMFORT- MUCH CHANGE POSITION WITH SUPERVISION, FENTANYL AS NEEDED FOR PAIN, CIWA SCALE/ATIVAN AS NEEDED CURRENTLY AT Q 8 HOUR.KEEP PT AND FAMILY AWARE OF PLAN OF CARE, CURRENT PROGRESS.WATCH PAD /UO/ I AND O- AND NEED FOR ? | 18 | [
{
"category": "Echo",
"chartdate": "2169-08-31 00:00:00.000",
"description": "Report",
"row_id": 82863,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension.\nHeight: (in) 61\nWeight (lb): 210\nBSA (m2): 1.93 m2\nBP (mm Hg): 131/75\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 12:12\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Moderately depressed LVEF. No LV\nmass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. LV inflow pattern c/w\nimpaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is moderately depressed. Anterior, distal septal, and apical\nhypokinesis is present. No LV thrombus seen.\n2. The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n3. The mitral valve leaflets are mildly thickened.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-09-01 00:00:00.000",
"description": "Report",
"row_id": 1343863,
"text": "CCU Nursing Progress Note 7am-7pm\nS: My chest is sore when I press on it.\n\nO: Pt c/o above soreness. Rx with Tylenol 650mg x2.\n\nCV - HR 70-80's nsr with rare single pvc. Lopressor dose increased and will rec first dose of 37.5mg at 8pm. BP 110-130/70's. Captopril cont 6.25mg tid.\nR groin introducer dc'd at 10am and site is d/i. Pulses +3/+2 bilat with good csm.\n\nResp - ls are clear with some intermittent coarseness, which clears with cough. O2 remains on at 2ln/p with sats 100%.\n\nGI - Appetite is poor for meals, only wants to take po liqs. Abd is soft with +bs, but no stool since admit.\n\nGU - Foley intact to clear yellow urine, approx 30-50cc/hr.\n\nActivity - Dangle x2 today, and tolerated with no orthostatic changes.\n\nNeuro - Cont with short term memory loss. Does not remember anything past card event on . Requires continual reminders/reinforcement of poc. Family aware. Dr. consulted and is to see pt , per CCU team.\n\nSocial - 2 sisters and 1 son today and have spoken with MD's and are aware of plan.\n\nO: 58yof s/p vf arrest at home, requiring IABP and PTCA of LAD now with short term memory loss\n\nP: cont monitor cv status and increase meds as tolerated, monitor resp status for compromise, increase activity as tolerated with PT consult, encourage po intake of solids, reinforce poc and keep pt informed as possible, cont med/card teaching with pt and family, c/o to 6.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-08-31 00:00:00.000",
"description": "Report",
"row_id": 1343857,
"text": "Nursing Progress Note 1900-0700\nS: \"No..No pain, good, breathing good\"\n\nO: Please see carevue for complete objective data.\n\nCV: NSR c RBBB, ocass PVC's. HR 60-70's. SBP 80-100's, MAP~60. Rec'd 500cc IVFB @ 1800 for MAP less than 60, c minimal effect. AM labs pending.\n\nResp: Lungs clear in apices, c crackles about halfway up on L. Sats 94-100 on 2L. Non productive cough, no c/o SOB.\n\nGI/GU/Endo: Diabetic diet, BS present. Gave colace, no BM. Foley draining CYU. Approx +1.2L for LOS/24 hours. Urine cx pending. Insulin dependent, rec's Lantus 60U and RISS.\n\nSkin/Access: No skin impairments. 18G & 20G R PIV's\n\nID: Afebrile. WBC-23.3. On Vanco and Zosyn abx.\n\nNeuro/Social: A&O x 3, MAE, turns by self. Very cooperative and pleasant. Italian speaking, does understand english. Family translates when visiting. Has 2 sons and 1 dtr (spokesperson) Lives alone but upstairs from one son in same bulding.\n\nA: 80 yo female c h/o IDDM, CHF c EF of 20%, HTN, hypothyroidism, s/p CABG ', followed by occlusion of SVG to RCA in ' c stent to proximal circ artery.\n\nAdmitted for to 3 c 7day h/o of SOB and O2 sat 88%. ? Rec'd Lopressor, Imdur, Spironolactone, and Lasix at same time in AM . SBP dropped to 70's, pt mentating and making urine. Rec'd 1250cc IVFB.\n\nP: Cont to monitor hemodynamics and resp status. Advance activity as tol. Cont abx therapy and follow up c labs. Monitor UO. Keep updated c POC and emotionally support family and pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-08-31 00:00:00.000",
"description": "Report",
"row_id": 1343858,
"text": "CCU NSG ADMIT/PROGRESS NOTE 12A-7A/ S/P AMI; SHOCK\n\nS- \" WHERE AM I\"?\n\nO- SEE NSG FHPA FOR DETAILS R/T HPI/PMH AS WELL AS CCU TEAM ADMISSION NOTE.\n\n PT ARRIVED FROM CATH LAB S/P LAD/DIAG STENT WITH IAPB 1:1 FOR HYPOTENSION/SHOCK STATE.\n\nHR- 80-90'S SR, NO RUNS VEA/VT- OFF AMIO GTT FROM CATH LAB. IABP WITH GOOD TRACING, AUGMENTATION- SEE FLOWSHEET FOR VALUES. MAPS- 100-110.\nREMAINS HEMODYNAMICALLY STABLE OFF DOPA AND AMIO GTT. CP FREE.\nINTEGRILLEN 2 MCG/KG UNTIL 4PM AND STARTED 5AM HEPARIN GTT 1100U NO BOLUS S/P 12:30 AM RT FEMORAL ALINE SHEATH PULL.\nGROIN SITES REMAIN STABLE, FREE OF BLEED, PULSES (+) BILATERALLY.\nRT GROIN REMAINS WITH PA LINE IN PLACE, LEFT GROIN WITH IABP.\nCO/CI ON ADMIT- 4.5/2.2/1742. MG - 1.7- CURRENTLY REPLETING WITH 2 AMPS. OTHER LYTES/HCT/CBC WNL. CPK (+)- 8902/234.\nBILATERAL LEG BRACES, EMPHASIZING NEED FOR IMMOBILITY OF LOWER EXTREMITIES.\n\nRESP - PT ARRIVED ON 100% NR- WEANED DOWN TO 35% COOL NEB/6 L NP.\n100% O2 SATS. RESP RATE MID 20'S WHILE ASLEEP. SOME TACHYPNEA WITH EXERTION BUT OTHERWISE COMFORTABLE.\nHOLDING OFF DIUIRESIS THIS SHIFT, AS PT DIURESING ON OWN.\nPAD- 18-22, CVP-. PCW SLIGHTLY LOWER IN CATH LAB THAN PAD.\nCXR CONFIRMING GOOD PLACEMENT OF PA LINE AS WELL AS IABP.\n\nGU- 1 LITER OUT FROM CATH LAB ON ARRIVAL.\nFOLEY CATH IN PLACE.\nPUTTING OUT 90-140CC/HOUR- TO GIVE LASIX IF DROPS LESS THAN 50CC/HOUR. D/C POST CATH IVF AS WELL. SENT UA/C/S- CLEAR YELLOW URINE.\n\nGI- NO FURTHER N/V AS AT OSH/CATH LAB.\nTO START PROTONIX QD.\nHCT STABLE- 40.3.\n(+) BOWEL SOUNDS, NPO BUT FOR SIPS WATER.\nBLOOD SUGAR HIGH AT OSH BUT SINCE HERE, CATH LAB- UNDER 150.\nON SS REG AS NEEDED OF INSULIN.\nNONE GIVEN HERE CURRENTLY.\n\nLINES- 4 PERIPHERALS, RT FEMORAL PA, LEFT FEMORAL IABP.\n\n PT ALERT, ORIENTED, NORMAL NEURO EXAM.\nFORGETTING DATE/MONTH- BUT AWARE OF WHY SHE IS HERE AND WHERE WE ARE.\nSOME SHORT TERM MEMORY DEFICIT, ASKING SIMILAR ? OVER AND OVER AT TIMES.\nMUCH SUPPORT/TEACHING TO PT AND FAMILY.\nC/O BACK DISCOMFORT WITH NEED FOR STRICT BEDREST- HAS \" BAD BACK\".\nGIVEN TOTAL 50 MCG FENTANYL THIS SHIFT WITH GOOD RELIEF AS WELL AS CHANGING POSITION/BACK RUBS/ETC.\nPT PUT ON CIWA SCALE FOR ? ETOH USE.\nRECEIVED 2 MG ATIVAN ON ARRIVAL FOR 13 SCORE.\nSLEEPING , RESTFUL BUT EASILY AWAKENED CURRENTLY.\n\nA/ PT ADMITTED FOR CV SHOCK/ R/I MI/ S/P VFIB ARREST.\n\nCONTINUE TO SUPPORT HEMODYNAMICS WITH IABP/INTEG GTT/ASA- ? START B BLOCKER AND ACE THIS AM. WATCH FOR ANY FURTHER ARRYTHMIA/ISCHEMIC SIGNS., MEDICAL MANAGEMENT POST MI.\nCHECK PTT 11AM- KEEP WITHIN THERAPEUTIC LEVELS.\nREPLETE LYTES AS NEEDED, CONTINUE TO CYCLE CPK.\nBACK CARE/COMFORT- MUCH CHANGE POSITION WITH SUPERVISION, FENTANYL AS NEEDED FOR PAIN, CIWA SCALE/ATIVAN AS NEEDED CURRENTLY AT Q 8 HOUR.\nKEEP PT AND FAMILY AWARE OF PLAN OF CARE, CURRENT PROGRESS.\nWATCH PAD /UO/ I AND O- AND NEED FOR ? MORE LASIX THIS AM.\nCONSIDER WEANING IABP TODAY- AM ECHO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-08-31 00:00:00.000",
"description": "Report",
"row_id": 1343859,
"text": "Addendum!!\nPlease disregard initial note on . Written on wrong pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-08-31 00:00:00.000",
"description": "Report",
"row_id": 1343860,
"text": "CCU Nursing Progress Note 7am-7pm\nS: What happened to me?\n\nO: Pt alert and oriented x3, very cooperative and conversant. Does however have short term memory loss. Pt asking repeatedly to have hob elevated as well as asking what has happened to her. Instructions and information given and reinforced continually throughout day.\n\nSocial - Pt's family vss (2 sisters and 1 son) and are aware of medical poc as well as pts short term memory loss. Have spoken to cardiologists for update.\n\nID - Treated for lll and rul infiltrates with Ceftriaxone q24 as well as Metronidazole q8hrs. Pt has cough, as she is a smoker, but is unproductive at this point. T max 99.1\n\nCV - HR 70-80's nsr with rare pvc's. K+ 4.2 and Mg 2.8 from 11 am. Lopressor 12.5mg started without change in HR Cont on IAPB 1:1 with good augmentation and systolic unloading . MAP's cont elevated >100. Captopril 6.25mg tid started without change in MAP. PAd's 23-21 and CVP 13-15 CO/CI/SVR 7.8/3.8/923 at 8am. Swan removed at 10am, as was found to be in RV. Pt had increased vea, and decision by team to remove swan. Integrillin dose of 2mcgs/kg/min completed and dc/d at 4pm. Heparin which was started at 5am at 1100u/hr was held for 30min and to 750u/h for PTT of 114. Pt placed on 1:2 at 3:50pm until 4:30pm and tolerated without effect. Heparin stopped at 4:30 for planned IAPB removal at 5:30 and IAPB was placed back to 1:1.\nCPK #2 7232/152.\nR groin swan introducer d/i without ooze. L groin IAPB with slight ooze at site, covered with modified pressure dsg. Pulses +3/+1 bilat.\n\nResp - ls with dependant rales r base. O2 weaned down to 3ln/p with O2 sats 100%. Denies sob. Pt does have cough as above, but unproductive.\n\nGI - Pt states that she is hungry intermittently throughout the day, but only asks for jello. Abd is soft with +bs.\n\nGU - Foley draining tea colored cloudy urine approx 65-90cc/hr. U/O dropped off to 25-30cc/hr at approx 1pm. Team aware. No lasix given.\n\nPain mgnt - Pt rec'd 12.5mg IVP fentanyl x2 for generalized back ache, d/t lying flat. Pt turned and repositioned as tolerated. Pt states that she does experience back pain at home at baseline.\n\nA: Stable hemodynamics s/p vf arrest and R/I\n\nP: IABP removal at 5:30pm. Monitor groins for ooze, Restart heparin at time by MD's, Keep flat in bed x 6hrs post IAPB removal, monitor resp status and send culture if cough becomes productive, turn and position for comfort, med with fentanyl as needed, continue to reinforce and explain all proceedures, monitor pt's short term memory loss, keep family informed of poc per multidisiciplinary rounds.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-08-31 00:00:00.000",
"description": "Report",
"row_id": 1343861,
"text": "CCU nurinsg addendum\n6:02pm - IAPB removed by card fellow. BP 115/75 and HR 80's nsr with no vea. c/o nausea with some dry heaves, rec'd 12.5 anzimet with good effect. c/o back pain and rec'd 12.5 fentanyl with some relief. At present, card fellow cont to hold manual pressure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2169-09-01 00:00:00.000",
"description": "Report",
"row_id": 1343862,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CV ARREST; CAD\n\nS- \" CAN I GET UP?\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE THIS SHIFT, FREE OF CP, VSS.\nHR- 80'S SR, ABLE TO INCREASE LOPRESSOR TO 25 FROM 12.5 - TOLERATED WELL. REMAINS ON 6.25 TID CAPTOPRIL- ? TO INCREASE TODAY.\nASA/PLAVIX- OFF INTEG/HEP GTT.\nRT GROIN WITH PA LINE INTRODUCER IN PLACE- CLEAN/DRY- NEEDS TO BE REMINDED OF KEEPING THAT LEG STRAIGHT. TEAM TO D/C THAT LINE TODAY.\nLEFT GROIN S/P IABP REMOVAL WITH PRESSURE HELD 6P- 7:20P. NO OOZING FROM EITHER SITE. REMAINS ON BEDREST WITH RT LINE IN PLACE- TO D/C TODAY. ASKING APPRORIATE QUESTIONS ABOUT REASON FOR ADMIT TO HOSPITAL, WHAT HAPPENED.\n\n PT WITH SHORT TERM MEMORY LOSS- PLEASANT, COOPERATIVE BUT FORGETTING REASON FOR ADMIT OR HAVING TO KEEP LEGS STRAIGHT, AND REASONING BEHIND THAT.\nANXIOUS - WANTING TO GET OOB- GIVEN 2 MG ATIVAN 8P AND THEN 1 MG LATER DURING THE NITE. ALSO RECEIVING FENTANYL 12.5-25 SEVERAL TIMES FOR BACK PAIN- BETTER WITH BACKRUBS/CHANGE POSITION AND MEDS.\nSISTER CALLED TO CHECK IN.\nPT SLEEPING AFTER MEDS IVP. ONLY COMPLAINT IS BACK PAIN FOR LAYING ON IT FOR \"SO LONG'.\n\nRESP- 02 SATS 98-100% ON 3-6L NP- SOME SUBJECTIVE SOB AND TACHYPNEA WITH TURNING IN BED, PM CARE- GIVEN SOME COOL NEB AT 35% AND WITH THAT AND REST, FEELING BETTER. NO DESAT IN SETTING OF FEELING SOB.\nNO LASIX THIS SHIFT.\nPT (-)1300CC .\nDIM BS WITH SOME CX DEP BASE.\n\nGU- FOLEY CATH IN PLACE- CLEAR YELLOW TO TEA COLORED URINE.\n30-50CC/HOUR.\n\nGI- SOME NAUSEA LATE AFTERNOON TX ANZIMET. REPEAT FEELING WITH ANXIETY- TX WITH CIWA SCALE ATIVAN DOSE OF 2 MG- GOOD RESULT, NO FURHTER NAUSEA- DECLINING LIGHT SNACK- TAKING SIPS WATER.\n(+) BOWEL SOUNDS- NO STOOL THIS SHIFT.\n\nLINES- 4 PERIPHERALS, 1 RT FEMORAL INTRODUCER IN PLACE.\n\nA/ PT S/P LARGE MI, V FIB REQUIRING PTCA LAD AND IABP INSERTION- CURRENTLY DOING WELL S/P IABP D/C.\n\n-CONTINUE TO MAXIMIZE GOOD RATE/PRESSURE WITH CV MEDS- INCREASE CAPTOPRIL THIS AM.\n\n-REPLETE LYTES AS NEEDED ONCE LABS COME BACK FROM LAB.\n\n-CONTINUE TO ASSESS MENTAL STATUS, NEED FOR REORIENTATION.\nCONTINUE TO ORIENT AS NEEDED.\n\nADVANCE DIET AS SHE TOLERATED- WATCH FOR FURTHER NAUSEA/DRY HEAVES. MEDICATION AS NEEDED.\n\nTEAM TO D/C RT FEMORAL LINE.\nONCE TIME HAS PASSED FOR BEDREST NEED- ATTEMPT TO VERY GRADUALLY ADVANCE ACTIVIY- TO DANGLE ON EDGE OF BED.\n\nCONTINUE TO TEACH PT AND FAMILY AND SUPPORT.\nC/O TO 6 ONCE MEDICALLY APPROPRIATE.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2169-09-04 00:00:00.000",
"description": "Report",
"row_id": 199975,
"text": "Sinus rhythm\nPoor R wave progression - probable normal variant\nSince previous tracing of , anterior ST-T wave abnormalities are\nresolved\n\n"
},
{
"category": "ECG",
"chartdate": "2169-09-04 00:00:00.000",
"description": "Report",
"row_id": 199976,
"text": "Sinus rhythm. Probable anterior wall myocardial infarction of indeterminate\nage. ST-T wave abnormalities - cannot exclude anterolateral ischemia. Since the\nprevious tracing of ventricular ectopy is absent and further ST-T wave\nchanges are now seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-09-02 00:00:00.000",
"description": "Report",
"row_id": 199977,
"text": "Sinus rhythm with occaional ventricular premature beats. Compared to the\nprevious tracing of ectopy is new.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2169-09-02 00:00:00.000",
"description": "Report",
"row_id": 199978,
"text": "Sinus rhythm. Compared to the previous tracing of no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-09-01 00:00:00.000",
"description": "Report",
"row_id": 199979,
"text": "Sinus rhythm. Delayed precordial R wave transition is non-specific. Compared to\nthe previous tracing of no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2169-09-01 00:00:00.000",
"description": "Report",
"row_id": 199980,
"text": "Sinus rhythm. Long QTc interval. Possible anterior myocardial infarction - age\nundetermined. Inferior/lateral ST-T wave changes may be due to myocardial\nischemia. Compared to the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-08-31 00:00:00.000",
"description": "Report",
"row_id": 200213,
"text": "Sinus rhythm. T waves are now inverted in leads V4-V6. Q-T interval has\nprolonged. ST segments are elevated in leads VI-V3. Consider current of injury,\nmetabolic abnormality, cardiomyopathy or anterior wall myocardial infarction.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-08-30 00:00:00.000",
"description": "Report",
"row_id": 200214,
"text": "Sinus rhythm. Low voltage. Left atrial abnormality. Poor R wave progression in\nleads VI-V3. Miniature follwwed by S waves in lead V4. Flat T waves in\nleads I, aVL, III, aVF and V5-V6 which are non-specific. Micro R waves in\nlead V4 followed by S waves raise possibility of infarction. Voltage raises\npossibility of infiltrative disease. Left atrial abnormality is present..\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 925167,
"text": " 1:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infection\n Admitting Diagnosis: CHEST PAIN;S/P VENTRICULAR FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 yo F with HTN who presents s/p VFib arrest with large anterior MI s/p cath\n with stents.\n REASON FOR THIS EXAMINATION:\n r/o infection\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of atrial fibrillation arrest and anterior myocardial infarct.\n\n No previous films for comparison. Heart size is within normal limits for\n supine technique. There is tortuosity of the thoracic aorta. There is\n pulmonary vascular engorgement with bilateral predominantly perihilar\n opacities consistent with pulmonary edema. Well presumed Swan-Ganz catheter\n introduced via femoral route overlies the tip located in the region of the\n pulmonic valve but difficult to clearly localize on this film. The\n intra-aortic balloon is approximately 4 cm inferior to the superior margin of\n the aortic arch. No pneumothorax.\n\n IMPRESSION: Pulmonary edema. No pneumothorax. Swan-Ganz catheter in region\n of pulmonary valve. Could revaluate with repeat film as tip not well\n localized.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-08-31 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 925200,
"text": " 9:00 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Swan placement\n Admitting Diagnosis: CHEST PAIN;S/P VENTRICULAR FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 yo F with HTN who presents s/p VFib arrest with large anterior MI s/p cath\n with stents.\n REASON FOR THIS EXAMINATION:\n Swan placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess Swan-Ganz catheter placement.\n\n COMPARISON: Comparison is made with prior study performed eight hours before.\n\n SINGLE AP PORTABLE VIEW OF THE CHEST: Interval improvement of mild to\n moderate pulmonary edema. There is no pneumothorax. Swan-Ganz catheter with\n tip not well localized in the single AP view, lateral view might be helpful\n when clinical condition of the patient improves. There is no pneumothorax or\n sizable pleural effusion. Mediastinal and hilar contours within normal\n limits.\n\n IMPRESSION: Improved mild to moderate pulmonary edema. Swan-Ganz catheter\n introduced via femoral with tip just left of midline is over the region of\n pulmonary valve, but difficult to clearly localize on this single AP view of\n the chest.\n\n"
}
] |
26,953 | 144,365 | The patient is a 70 y F with ESRD on hemodialysis (MWF) who developed fevers to 103 and rigors. | The double-lumen catheter inserted through the right subclavian approach terminates in low SVC. The double-lumen catheter inserted through the right subclavian approach terminates at the level of cavoatrial junction. pus in right shoulder/effusion FINAL REPORT LIMITED UPPER EXTREMITY ULTRASOUND. Possible empty sella, correlate clinically. Endotracheal tube terminates about 1.0 cm above the carina and could be withdrawn a few centimeters for standard positioning. Several small, nonpathologic mesenteric and retroperitoneal lymph nodes are noted. Enlarged and CSF filled sella turcica, possible related to empty sella syndrome. FINDINGS: Tracheostomy tube is within normal limits. Tracheostomy tube in standard placement. right pneumo REASON FOR THIS EXAMINATION: following pneumo/trach placement FINAL REPORT INDICATION: Follow-up right pneumothorax. FINDINGS: In comparison with earlier study of this date, there again is a tiny or resolved pneumothorax in the left apex. now s/p tracheostomy. now s/p tracheostomy. The patient has had repositioning of ET tube. There is bilateral decrease in the pneumothorax, which is tiny in the left apex and resolved on the right. allevyn dsg to trach site changed.endo: remains on fingersticks q6hr with riss.i-d: temp max 99.5. no abx.psy-soc: dtr called x1 and updated on status and plan of care. Needed emergent bronch.Airways had lrg amts of edema. pt was placed on vent sub q air and bilateral pneumothorax. tracheal edema.During the coarse of time pt BP 170-210/ 70-90, HR 50-90 NSR w/ rare ectopics. minimal residuals noted.gu: anuric.skin: allevyn dsg to coccyx c/d/i. AM labs pending.RESP: LS coarse, On trach vent /100%/500/12/10. Received scheduled dose of Lopressor. Responds to painful stimulai.CV: HR 50-90 NSR. DOPPLERABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS- LARGE AMOUNTS OF PITTING EDEMA NOTED TO BILATERAL UPPER EXTREMITIES.GI: ABD IS SOFT, NON-DISTENDED. REMAINS NPO.ID: TMAX 101 PO, MD AWARE, BLD AND SPUTUM CX'S OBTAINED. Trach care performed w/RT.GI/Endo: Obese abd s/nt with +BS. Still on fentanyl gtt..recieved multiple boluses..added Versed gtt..1mgm/hr..with additional boluses. LS: usually CTA, exp wheezes ausc this morning, some cleared w/albuterol neb rx. argatroban restarted and titrated per ss. ID: Afebrile..elevated wbc..on meropenum and vanco..? Pain/sedation management RISS HD today, Gentamicn 80mg IV after HD UE edema 3+ b/l. Pt received HD and able to remove 2600cc. MICU NPN 7P-7ANEURO: RECEIVED PT ON GTTS; FENTANYL 100MCG AND VERSED 2MG. HD today.Skin: CDILines: Art line patent, good waveform, dressing CDI. Appears hypercoaguable ?/ eti.D/C midline.Fent gtt for sedation. Prior to re-intubation pt MAE w/ normal strenght. restated heparin. Team aware, pt has been receiving solumedrol, tolerating SBT extubation planned. Post intubation VS improving w/ decreasing hypotension and tachycardia. Frequent turns.ID: Ceftriaxone for PNA and previous line infxn of enterobacterLines: Midline not d/c'd for now, spoke with Dr re: tenuous state of fem line. Colace and bisacodyl admin @ , awaiting effect. BS coarse bilaterally which clears with suctioning. PICC line in the rt arm.RESP: LS coarse. NGT placed pnd swallow eval and placement confirmed via CXR.Post extubation pt w/ increasing hypertension and tachycardia. Propofol titrated and pt started on fentanyl 25-50mcg IV Q 1hr PRN now w/ better control of sedation and stable SBP. remains intubated/sedated overnight w/o vent changes.BS: coarse sxn'd for minimal thick yellow.Plan:To OR for trach/peg. Updated on pt's condition.HD deferred until tomorrow scheduling conflict with IR.Overall hypertensive most of the shift with SBP 160's-200 with transient response to fentanyl & propofol boluses. Getting heparin.BP labile @ times. Recieved pt off sedation. LS coarse.CVS:HR 80-100/min,NSR.BP 120-160 sys.argatrobin 1.276 mg/kg/min is on progress.GU/GI:abdomen obese,BS present.NPO except meds.KVO on.anuric.Social:agitated at times,slept on and off.sister called and updated.full code.Plan:continue same treatments.watch for orientation.follow up with PTT report EKG w/o change per team.FEN: Pt is HD pt and is anuric. PTT 59.5 2hr after starting argatroban, now will need q6hr PTT checks w/ titration per protocol. CONITNUES ON MEROPENEM AND VANCO ON HD DAYS. sputum cxs show GNRs. Plan to extubate when secretions subside. UE edema b/l clots. BUE remain edematous, CT to r/o SVC syndrome as above - results pnd.FEN: Abd obese, non-tender, BS present. next hd tomorrow .skin: very small coccyx abrasion left ota and aloe vesta applied with every turn.access: r radial aline dampened with difficultly getting blood return. called and given update.plan: continue npo for possible extubation in am, assess gag, cough if improved off propofol. nsg note addendum: 19:00-7:00oral airway was placed at beginning of shift and left in as pt biting down hard on tube and unable to suction-once oral airway in place, able to suction. CURRENTLY ON HEPARIN GTT AT 1150U/HR.RR: RECEIVED VENTED FROM PROCEDURE. remains intubated on A/C overnoc. ABG met alkalosis.Will cont to monitor resp status. PLAN IS TO WEAN TO TRACH MASK AS PT TOLERATES (HAD BEEN ON TRACH MASK PRIOR TO PROCEDURE).GI: ABD IS OBESE, SOFT, DISTENDED. PT RECEIVED HD M,W,F.INTEG: PT HAS DUODERM TO COCCYX. RESP CARE: Pt remains with 6.0 adjustable lenghth/12cm at flange. Resp Care,Pt. RT FEMORAL CVL DC'D BY DR. . Lungs coarse rhonchi, dim on L. Continue to follow per respiratory protocol. Endo: Following bs q6hrs..ssri Access: A-line changed over wire successfully..Midline flushes and draws back. Lungs diminished L>R, few crackles/Pt has a 6.0 adjustable length trach in place, 12cm at flange,trach is sutured. Filamentous strands on the aortic leaflets c/withLambl's excresences (normal variant). Trace aortic regurgitation is noted. Simple atheroma in descending aorta. Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. A stretched patent foramen ovale is present with intermittent rightto left shunting at rest. FINDINGS: A right-sided catheter terminates in the low SVC. Compared to the priortracing evidence of myocardial infarction is now present. Normal ascending aorta diameter. Focally thickened mitral andaortic valves with trivial regurgitation. IMPRESSION: Thrombosed subclavian and brachiocephalic veins bilaterally. Right adrenal myelolipoma. There are tiny R waves in the inferior leadsconsistent with prior myocardial infarction. Nasogastric tube and endotracheal tube are in place. | 177 | [
{
"category": "Radiology",
"chartdate": "2136-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977705,
"text": " 4:50 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please comment on placement of ETT and OGT\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OSA, intubated for apnea, but ETT noted to be too far\n in. Pt. is now s/p repositioning of ETT.\n REASON FOR THIS EXAMINATION:\n Please comment on placement of ETT and OGT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 16:05\n\n COMPARISON: Previous study of the same date.\n\n INDICATION: Endotracheal tube repositioning.\n\n Endotracheal tube has been withdrawn and now terminates about 4 cm above the\n carina. Other devices are unchanged in position. Cardiomediastinal contours\n appear wider than on the previous study, possibly due to accentuation by lower\n lung volumes, but increased volume status of the patient is an additional\n consideration. Small right pleural effusion is new.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978388,
"text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check lines and tubes\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OSA, intubated for apnea. ? interval change.\n\n REASON FOR THIS EXAMINATION:\n check lines and tubes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for interval change in a patient intubated\n for apnea.\n\n The lateral half of the left chest was not included in the field of view that\n the exam was recommended to be repeated. The imaged portion of the chest\n demonstrates ET tube tip located about 4.7 cm proximal to the carina. The NG\n tube passes below the diaphragm with its tip in the stomach. The double-lumen\n catheter inserted through the right subclavian approach terminates at the\n level of cavoatrial junction. No change in the appearance of the\n cardiomediastinal silhouette is noted. No new consolidations in the imaged\n portion of the lungs are demonstrated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-29 00:00:00.000",
"description": "R UNILAT UP EXT VEINS US RIGHT",
"row_id": 977560,
"text": " 1:36 PM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: PLEASE DO ULTRASOUND OF RIGHT SHOULDER--? pus in right shoul\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 y/o with line infection, esrd, bactermia now with increasing delirium, right\n shoulder pain\n REASON FOR THIS EXAMINATION:\n PLEASE DO ULTRASOUND OF RIGHT SHOULDER--? pus in right shoulder/effusion\n ______________________________________________________________________________\n FINAL REPORT\n LIMITED UPPER EXTREMITY ULTRASOUND.\n\n INDICATION: 71-year-old with line infection, end-stage renal disease,\n bacteremia, presenting with delirium and right shoulder pain.\n\n COMPARISON: Not available.\n\n FINDINGS: -scale images of the right shoulder demonstrate a 2.5\n hypoechoic fluid anterior to the glenohumeral joint.\n\n IMPRESSION: A 2.5 cm hypoechoic fluid collection anterior to the glenohumeral\n joint, may represent a bursal fluid collection. Lower echogenicity argues\n against purulent nature of the fluid.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 976800,
"text": " 6:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: rule out bleed\n Admitting Diagnosis: FEVER\n Field of view: 235\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent HIT Ab (questionable diagnosis) and on argatroban\n x 2 days, now with new occipital HA.\n REASON FOR THIS EXAMINATION:\n rule out bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST.\n\n INDICATION: 70-year-old female with recent HIT antibody and on argatroban x2\n days with new occipital headache. Assess for intracranial hemorrhage.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no acute intracranial hemorrhage, shift of normally\n midline structures, hydrocephalus, or major vascular territorial infarction.\n The density values of the brain parenchyma are maintained. Mild\n periventricular white matter is consistent with chronic small vessel ischemia.\n Small amount of fluid is again noted within the sella turcica. Soft tissues,\n osseous structures, and visualized portions of the paranasal sinuses and\n mastoid air cells are unremarkable. Calcifications of the cavernous portions\n of the internal carotid arteries and vertebral arteries is incidentally noted.\n A small ossification in left frontal bone again visualized due to a small\n incidental osteoma.\n\n IMPRESSION: No acute intracranial hemorrhage. Persistent fluid density\n within the sella turcica, unchanged compared to . This most likely\n represent empmty sella.\n\n Findings were discussed with Dr. on at 7:20 p.m. by Dr.\n over the telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977542,
"text": " 11:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? etiology of desats\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent Enterobacter bacteremia secondary to line\n infection, now with increasing WBC, and new desaturation\n REASON FOR THIS EXAMINATION:\n ? etiology of desats\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Increased white blood cell count and oxygen desaturation.\n\n Vascular catheter remains in standard position. Cardiac and mediastinal\n contours are stable in appearance. No focal areas of consolidation are\n identified, but standard PA and lateral views of the chest would be more\n sensitive and may be helpful for more complete evaluation given clinical\n suspicion for infection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-25 00:00:00.000",
"description": "TUNNELED W/O PORT",
"row_id": 976909,
"text": " 12:43 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: needs new tunneled dialysis catheter. Can be either side. H\n Admitting Diagnosis: FEVER\n ********************************* CPT Codes ********************************\n * TUNNELED W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 yo woman with CKD, on dialysis, admitted with line infection, bacteremia\n with removal of line. Surveillance cultures neg, needs new tunneled line.\n\n REASON FOR THIS EXAMINATION:\n needs new tunneled dialysis catheter. Can be either side. Has temporary cath\n on right.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR THE EXAM: 70-year-old woman with end-stage renal disease, on\n dialysis, with temporary dialysis catheter in place.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , with\n Dr. , the attending radiologist, supervising.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiographic table, and a chest fluoroscopic image was obtained\n to document the previously placed temporary dialysis catheter with tip in the\n SVC/right atrium. The right neck and chest of the patient were prepped and\n draped in standard sterile fashion. Aspiration of blood was performed in each\n lumen of the existing catheter. The sutures of the existing catheter to the\n skin were cut and blunt dissection around catheter was done to facilitate the\n release.\n\n Attention was then directed to creation of superficial tunnel along right\n chest. Approximately 15 cc of 1% lidocaine was used to administer local\n anesthesia to the skin and subcutaneous tissues of the pre-determined\n subcutaneous tract. The tract was created using blunt dissection, and the\n line was tunneled.\n\n Now the attention was directed to the existing catheter. A 0.035 Amplatz wire\n was advanced through the existing catheter with the tip into the level of the\n IVC. The existing catheter was removed and the peel-away sheath was advanced\n over the wire into the SVC. The inner dilator and the wire were removed and\n the new HD catheter was advanced through the peel- away sheath into the right\n atrium. The peel-away sheath was removed. The neck incision was closed with\n Dermabond and the catheter was secured to the skin with 2-0 silk sutures, and\n flushed. Final fluoroscopic image of the chest demonstrated the tip of the\n catheter to be located in the right atrium.\n\n The patient tolerated the procedure well. Moderate sedation was provided by\n administering divided doses of 50 mcg of fentanyl and 1 mg of Versed\n throughout the total intraservice time of 30 minutes during which the\n patient's hemodynamic parameters were continuously monitored.\n (Over)\n\n 12:43 PM\n TUNNELLED CATH PLACE SCH Clip # \n Reason: needs new tunneled dialysis catheter. Can be either side. H\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION: Successful conversion of temporary into a tunneled dialysis\n catheter, with successful placement of a 14.5 French double-lumen dialysis\n line with 23-cm tip to cuff length via the right internal jugular vein with\n tip in the right atrium. The line is ready to use.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-21 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 976359,
"text": " 8:54 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Place a temporary HD cath in the neck. PLEASE AVOID THE FE\n Admitting Diagnosis: FEVER\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n MODERATE SEDATION was provided by administering 50 mcg of Fentanyl and 1 mg of\n Versed throughout the intraservice time of 35 minutes during which the\n patient's hemodynamic parameters were continuously monitored.\n\n\n 8:54 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Place a temporary HD cath in the neck. PLEASE AVOID THE FE\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CKD - with fever / rigors\n REASON FOR THIS EXAMINATION:\n Place a temporary HD cath in the neck. PLEASE AVOID THE FEMORAL AREA, if\n possible. Send cath tip of the current line for culture. Thanks\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: This is a 71-year-old woman with end-stage renal disease who\n presents for placement of a temporary hemodialysis line for hemodialysis. She\n had a tunneled hemodialysis line removed yesterday for suspected infection.\n\n Informed consent was obtained. A timeout was performed.\n\n RADIOLOGISTS: , nurse practitioner, and Dr. performed the\n procedure supervised by Dr. , attending radiologist.\n\n TECHNIQUE: The patient was placed supine on the angiography table and the\n right neck was prepped and draped in standard sterile fashion. Using\n ultrasound guidance and after injection of 5 cc of 1% lidocaine, access was\n gained into the right internal jugular vein with a 21 gauge needle. Hard\n copies of ultrasound images were taken before and after the venopuncture was\n obtained. A 0.018 glidewire was then advanced through the needle up to the\n level of the SVC under fluoroscopic guidance and the needle was then exchanged\n for 4.5 French micropuncture sheath. The wire was exchanged for a 0.035 \n wire that was placed with the tip in the inferior vena cava under fluoroscopic\n guidance. The neck incision was progressively dilated with 12 and 14 French\n dilators and a double-lumen dialysis line was placed over the wire with the\n tip in the cavoatrial junction. The wire and the inner dilator were then\n removed. A final fluoroscopic image of the chest demonstrates the tip of the\n catheter to be located in the right atrium. The patient tolerated the\n procedure well.\n\n IMPRESSION: Successful placement of a double-lumen temporary dialysis line\n via the right internal jugular vein with the tip in the right atrium. The\n line is ready to use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 976102,
"text": " 4:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Evaluate for intracranial hemorrhage, mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n Evaluate for intracranial hemorrhage, mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa WED 5:41 PM\n No bleed.\n Possible empty sella, correlate clinically.\n WET READ VERSION #1 MNIa WED 4:42 PM\n No bleed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with altered mental status.\n\n HEAD CT WITHOUT CONTRAST: There is no comparison. There is no acute\n intracranial hemorrhage, mass effect or shift of normally midline structures\n or hydrocephalus. There is small hypodensity in periventricular white matter,\n probably due to chronic small vessel ischemia. There is small prior lacunar\n infarct in the right basal ganglia. The surrounding osseous and soft tissue\n structures are unremarkable. Sella turcica is somewhat expanded and filled\n with CSF; Findings may be due to empty sella syndrome in the correct clinical\n context.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage.\n 2. Chronic small vessel ischemia.\n 3. Enlarged and CSF filled sella turcica, possible related to empty sella\n syndrome. Please correlate clinically.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977399,
"text": " 10:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent Enterobacter bacteremia secondary to line\n infection, now with increasing WBC\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:55 A.M. ON \n\n HISTORY: Bacteremia. Increasing white count. Rule out pneumonia.\n\n IMPRESSION: AP chest compared to through :\n\n Lungs are clear. Heart size is top normal. There is no pleural effusion.\n Dual-channel right supraclavicular central venous line ends in the SVC.\n Azygous distention suggests volume overload. No pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-28 00:00:00.000",
"description": "R KNEE (2 VIEWS) RIGHT",
"row_id": 977400,
"text": " 10:38 AM\n KNEE (2 VIEWS) RIGHT Clip # \n Reason: please evaluate for possible right knee effusion; ddx includ\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent Enterobacter bacteremia secondary to line\n infection, now with increasing WBC, currently on argatrobran gtt for suspected\n HIT, ?right knee pain and effusion\n REASON FOR THIS EXAMINATION:\n please evaluate for possible right knee effusion; ddx includes gout, OA flare,\n septic jt, hemarthrosis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Right knee, two views, .\n\n HISTORY: Evaluate for right knee effusion. Patient with line infection now\n with increasing white count.\n\n FINDINGS: There is extensive end stage degenerative changes of the right knee\n with complete loss of the medial joint space. There is also narrowing of the\n patellofemoral compartment. There is subchondral sclerosis and large\n osteophytes. No acute fractures or dislocations are seen. A small joint\n effusion is seen. There are extensive vascular calcifications.\n\n IMPRESSION:\n\n End-stage osteoarthritic changes involving predominantly the medial\n compartment. No acute bony injury.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978229,
"text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check lines and tubes\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OSA, intubated for apnea. ? interval change.\n\n REASON FOR THIS EXAMINATION:\n check lines and tubes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient intubated for apnea.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 5 cm above the carina. Double-lumen right-side central\n line tip terminates at the level of cavoatrial junction. The NG tube tip\n passes below the diaphragm most likely terminating in the stomach, although\n its tip is below the inferior margin of the film. There is no substantial\n change in the appearance of the mediastinal silhouette and the heart size.\n The lungs are essentially clear. No sizeable pleural effusion is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-20 00:00:00.000",
"description": "FOLLOW-UP,REQUEST BY RAD.",
"row_id": 976275,
"text": " 3:33 PM\n DIALYSIS REMOVE Clip # \n Reason: REMOVAL OF TEMPORARY HD CATH\n Admitting Diagnosis: FEVER\n ********************************* CPT Codes ********************************\n * FOLLOW-UP,REQUEST BY RAD. *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CKD on dialysis and fevers/chills - suspect cath\n infection\n REASON FOR THIS EXAMINATION:\n REMOVAL OF TEMPORARY HD CATH\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION OF EXAM: This is 70-year-old woman with end-stage renal disease\n and temporary dialysis line that is now infected.\n\n RADIOLOGISTS: The exam was performed by Drs. and , the\n attending radiologist, who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: Using aseptic and sterile technique, the left-sided\n temporary dialysis catheter was removed, and manual compression was held for 5\n minutes until hemostasis was achieved. Patient tolerated the procedure well.\n\n IMPRESSION: Successful removal of a temporary dialysis catheter.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977883,
"text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check lines and tubes\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OSA, intubated for apnea.\n REASON FOR THIS EXAMINATION:\n check lines and tubes\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient intubated for apnea.\n\n Portable AP chest radiograph compared to three radiographs from to\n .\n\n The ET tube tip is 4.2 cm above the carina. The double-lumen catheter\n inserted through the right subclavian approach terminates in low SVC.\n\n The cardiomediastinal silhouette is unchanged including the cardiomegaly and\n dilated but stable upper mediastinum.\n\n There are new bilateral consolidations and most likely bilateral small pleural\n effusions, findings suggesting either bilateral aspiration or developing\n infection.\n\n IMPRESSION:\n\n New bibasilar consolidations worrisome for bilateral aspiration or developing\n pneumonia giving their rapid appearance since . Probable\n bilateral small pleural effusions.\n\n Standard position of ET tube and NG tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977629,
"text": " 6:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Verify ETT placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OSA, just intubated for apnea\n REASON FOR THIS EXAMINATION:\n Verify ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Endotracheal tube assessment.\n\n Endotracheal tube terminates about 1.0 cm above the carina and could be\n withdrawn a few centimeters for standard positioning. Flexed position of the\n patient's neck may accentuate the low position. Neutral position of the neck\n on followup radiograph would be helpful. Nasogastric tube is in place\n terminating in the stomach. Cardiomediastinal contours are without change,\n and lungs are grossly clear except for minor discoid atelectasis at the left\n base.\n\n Endotracheal tube position has been communicated by phone with Dr. on\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 976094,
"text": " 3:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with fever, altered mental status\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with fever, altered mental status.\n\n PORTABLE AP CHEST RADIOGRAPH: Comparison is made with the prior chest\n radiograph dated . Again note is made of left subclavian venous\n line, terminating in mid SVC. Angulation of the catheter tip is noted.\n Cardiac and mediastinal contours are unchanged, with tortuous aorta. Heart is\n mildly enlarged. There is mild interstitial prominence which may be due\n to volume overload. No large effusions are seen.\n\n IMPRESSION:\n\n 1. Mild interstitial edema, cardiomegaly.\n\n 2. Dialysis catheter with angulated tip in the SVC. Correlate clinically\n for patency.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 977685,
"text": " 2:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o bleed/CVA\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with HIT on argatroban, mental status changes and apneic\n periods, just intubated\n REASON FOR THIS EXAMINATION:\n r/o bleed/CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the head without contrast.\n\n INDICATION: 71-year-old female with HIT on argatroban with mental status\n changes. Assess for intracranial hemorrhage.\n\n COMPARISONS: \n\n FINDINGS: There is no acute intracranial hemorrhage, shift of normally\n midline structures, hydrocephalus, or major vascular territorial infarction.\n The density values of the brain parenchyma are maintained. Mild ventricular\n white matter change is consistent with chronic small vessel ischemia. A small\n amount of fluid is again noted within the sella turcica. Small ossification\n within the left frontal bone is again visualized and most likely represents a\n small incidental osteoma. Calcifications of the cavernous portions of the\n internal carotid arteries and vertebral arteries are again incidentally noted.\n The soft tissues, osseous structures, and visualized portions of the paranasal\n sinuses and mastoid air cells are otherwise unremarkable.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage.\n 2. Persistent fluid density within the sella turcica, unchanged compared to\n , most likely represents empty sella.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978066,
"text": " 5:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OSA, intubated for apnea. ? interval change.\n\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW CHEST:\n\n REASON FOR EXAM: Follow up intubated for apnea, patient with OSA.\n\n Single AP portable view of the chest compared to prior study performed a day\n earlier.\n\n ETT is in standard position as is a right supraclavicular double lumen\n catheter. NG tube tip is out of view below the diaphragm. Widened mediastinum\n and mild cardiomegaly are stable. There has been improvement of bibasilar\n aeration, this allowing the difference in technique. There is no pneumothorax.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2136-09-30 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 977686,
"text": " 2:14 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abscess, diverticulitis\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with recent bacteremia, now with rising wbc count of unclear\n etiology. Intubated for airway protection in setting of apneic periods\n REASON FOR THIS EXAMINATION:\n r/o abscess, diverticulitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF ABDOMEN AND PELVIS.\n\n INDICATION: 71-year-old female with recent bacteremia, presenting with rising\n white blood cell count of unclear etiology. Assess for\n abscess/diverticulitis.\n\n COMPARISONS: .\n\n TECHNIQUE: Following administration of intravenous Optiray contrast, MDCT\n axial images were acquired from the lung bases to the pubic symphysis. Coronal\n and sagittal reformatted images were then obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is bibasilar dependent atelectasis,\n right greater than left. Extensive coronary and aortic calcifications are\n incidentally noted. The inferior portion of the nasogastric tube can be seen\n coursing within the stomach into the duodenum. Within segment V of the liver,\n there is a large hyperdense triangular shaped peripheral area measuring 5.3 x\n 5.2 cm. The liver is otherwise unremarkable. The gallbladder is normal in\n appearance. There is no intra- or extra-hepatic biliary dilatation. The\n spleen, left adrenal gland, stomach, and abdominal portions of the large and\n small bowel are unremarkable. Calcifications within the splenic artery are\n again noted. The pancreas is unremarkable in appearance. A low attenuation\n lesion of the right adrenal gland measuring approximately 4.1 x 2.8 cm is\n unchanged in appearance compared to . This lesion is noted to contain\n fat density material. Several low-attenuation lesions of the kidneys are\n noted bilaterally, too small to characterize, but mostly likely represent\n simple cysts. Several small, nonpathologic mesenteric and retroperitoneal\n lymph nodes are noted. There is no free fluid or free air within the abdomen.\n\n Multiple vessels are seen throughout the abdominal wall.\n\n CT OF THE PELVIS WITH IV CONTRAST: The uterus, ovaries, rectum, intrapelvic\n loops of large and small bowel are unremarkable. There is no free fluid\n within the pelvis. No inguinal or pelvic lymph nodes are present.\n\n OSSEOUS STRUCTURES: There are mild degenerative changes noted of the lower\n thoracic spine. No lytic or blastic lesions are present.\n\n IMPRESSION:\n\n (Over)\n\n 2:14 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o abscess, diverticulitis\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Geographic hyperdense focus within segment V of the liver, new compared to\n , could reflect underlying occlusion of the superior vena cava.\n\n 2. Unchanged appearance of right adrenal myelolipoma and hypoattenuating\n lesions within the kidneys, most likely representing cysts.\n\n 3. Mild, dependent bibasilar atelectasis.\n\n 4. Prominent bilateral ovaries for a post-menopausal female. A pelvic\n ultrasound is recommended as clinically indicated.\n\n Findings were discussed with Dr. by Dr. over the telephone on the\n afternoon of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-09-27 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 977239,
"text": " 11:43 AM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ESRD, recent Enterbacter bacteremia from dialysis line,\n now with new nausea, no BM in 2 days\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n HISTORY: 70-year-old woman with end-stage renal disease, recent Enterobacter\n bacteremia from dialysis line, now with new nausea, and no bowel movement in\n two days. Evaluate for obstruction.\n\n COMPARISON: CT of the abdomen and pelvis .\n\n ABDOMEN, SUPINE AND UPRIGHT: No dilated loops of small or large bowel or free\n intraperitoneal air is seen.\n\n IMPRESSION: No evidence of obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981396,
"text": " 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u cxr\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD admitted with line sepsis complicated by pna and\n respiratory failure s/p trach.\n REASON FOR THIS EXAMINATION:\n f/u cxr\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW CHEST.\n\n REASON FOR EXAM: ESRD with sepsis.\n\n Comparison is made with prior study including most recent one dated .\n\n There has been no acute interval changes. Tracheostomy tube, subclavian vein\n and right internal jugular vein catheter remain in place. There is no overt\n CHF. No pneumothorax. Left lower lobe retrocardiac opacity likely\n atelectasis. There are small bilateral pleural effusions. Right lower lobe\n opacity due to atelectasis or pneumonia has increased from . Right\n PICC remains in place.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2136-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981243,
"text": " 4:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD admitted with line sepsis complicated by pna and\n respiratory failure s/p trach.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in a patient with tracheostomy.\n\n Portable AP chest radiograph compared to and .\n\n No change in the tracheostomy position, two central lines and superior vena\n cava stent are demonstrated. No pulmonary edema is currently demonstrated and\n there is a unchanged left retrocardiac atelectasis.\n\n IMPRESSION: No significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980262,
"text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pneumonia resolution\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated, new fevers + sputum production. now s/p\n tracheostomy. ? interval change\n REASON FOR THIS EXAMINATION:\n Pneumonia resolution\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Fever and sputum production.\n\n Portable AP chest radiograph compared to .\n\n There is no significant interval change in the appearance of tracheostomy,\n right central venous line, SVC stent, and mild cardiomegaly. There is no\n evidence of consolidation, congestive heart failure or sizable pleural\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978716,
"text": " 12:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Check ET tube placement after advancement of tube.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with PNA s/p extubation then reintubated for respiratory\n distress. s/p ET tube advancement\n REASON FOR THIS EXAMINATION:\n Check ET tube placement after advancement of tube.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Re-positioning of ET tube.\n\n Single AP view of the chest is obtained on at 12:35 hours and compared\n with the prior day's radiograph. The patient has had repositioning of ET\n tube. On the current examination, the tip lies approximately 2.3 cm above the\n carina. The remainder of the examination is essentially unchanged from the\n prior day's study.\n\n IMPRESSION:\n\n ET tube tip now 2.3 cm above the carina. No major change in the appearance of\n the lung fields.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979336,
"text": " 10:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change. NOTE: Film from this AM is not of the co\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with PNA s/p extubation then reintubated for respiratory\n distress. ? interval change (XRAY from this AM rounds ARE NOT of the correct\n patient). Please repeat film on this patient!\n REASON FOR THIS EXAMINATION:\n ? interval change. NOTE: Film from this AM is not of the correct patient.\n Please repeat film of this patient.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON 20 AT 1012\n\n INDICATION: Respiratory distress.\n\n PORTABLE SUPINE CHEST\n\n In comparison with the study of , the patient has taken a somewhat better\n inspiration. The lungs are essentially clear except for a small area at the\n left base medially that could represent a focus of atelectatic change or\n pneumonia. The endotracheal tube, central catheter, and nasogastric tubes\n remain in position.\n\n IMPRESSION: Better inspiration with possible focus of pneumonia or\n atelectasis at the left base medially.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2136-10-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 979132,
"text": " 8:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for cerebral edema.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with ? SVC syndrome, agitation, mental status changes.\n REASON FOR THIS EXAMINATION:\n please evaluate for cerebral edema.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD\n\n HISTORY: 71-year-old woman with question of SVC syndrome, mental status\n changes, assess for cerebral edema.\n\n TECHNIQUE: Contiguous 5 mm axial images were obtained from the skull base to\n the vertex.\n\n FINDINGS: Comparison is made to and .\n\n There is intracranial enhancement, which may be related to IV contrast\n administered for preceding venogram in this patient with end-stage renal\n disease.\n\n There are no intracranial hemorrhages. The /white matter differentiation\n is maintained. The ventricles and sulci are unchanged in size. There is no\n evidence of cerebral edema.\n\n Adjacent to the posterior body of the left lateral ventricle is a small\n hyperdense region which may represent area of enhancement. This was not\n definitively seen on the prior studies.\n\n Again seen are minimal amount of periventricular white matter hypodensities\n consistent with chronic microangiopathic changes. A small lacune of the right\n caudate nucleus is again seen.\n\n The right-sided nasogastric tube is in place. Fluid densities seen within the\n mastoid air cells as well as the sphenoid and ethmoid sinuses. No suspicious\n bony abnormalities are seen.\n\n IMPRESSION: Apparent tiny area of hyperdensity adjacent to the posterior\n portion of the left lateral ventricle which may represent an area of abnormal\n enhancement. This could be further evaluated with an MRI of the head if\n clinically indicated.\n\n No evidence of cerebral edema or hemorrhage.\n\n (Over)\n\n 8:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for cerebral edema.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980791,
"text": " 3:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? is pneumo expanding\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated s/p trach; now with trach replaced.\n right pneumo\n REASON FOR THIS EXAMINATION:\n ? is pneumo expanding\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of patient with pneumothorax.\n\n Portable AP chest radiograph compared to obtained at 5:46\n p.m.\n\n There is bilateral decrease in the pneumothorax, which is tiny in the left\n apex and resolved on the right. The rest of the findings such as\n cardiomegaly, left hilar prominence, tracheostomy position, double lumen\n catheter are unchanged. There is no congestive heart failure or pleural\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981081,
"text": " 4:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change in lung field appearance\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD admitted with line sepsis complicated by pna and\n respiratory failure s/p trach.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change in lung field appearance.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:57 A.M., \n\n HISTORY: End-stage renal disease, line sepsis, and probable pneumonia.\n\n IMPRESSION: AP chest compared to through :\n\n Small-to-moderate left pleural effusion is new. Mild cardiomegaly stable. No\n focal pulmonary findings to suggest pneumonia. Tracheostomy tube in standard\n placement. Dual-channel right supraclavicular central venous catheter ends at\n the superior cavoatrial junction. Heart size top normal. Right lung clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980703,
"text": " 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for interval change in appearance of lungs.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated s/p trach.\n REASON FOR THIS EXAMINATION:\n Please evaluate for interval change in appearance of lungs.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 71-year-old female with end-stage renal disease. Evaluate for\n interval change in the appearance of lungs.\n\n FINDINGS: Comparison is made to the previous study from .\n\n There is a moderate-sized right pneumothorax. There are two central venous\n catheters from the right side. There is a tracheostomy. There has been\n interval development of extensive subcutaneous gas along the neck and left\n axilla and mediastinum. The cardiac silhouette is within normal limits. There\n are developing areas of consolidation within the left suprahilar region and\n the right mid lung zone. No overt pulmonary edema is seen.\n\n These findings have been discussed with Dr. .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979599,
"text": " 7:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube/line placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated, ? pneumonia on yesterday's xray. ?\n interval change\n REASON FOR THIS EXAMINATION:\n ? tube/line placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: 71-year-old female status post line placement.\n\n FINDINGS: Comparison is made to previous study from .\n\n There is a right-sided dialysis catheter with distal lead tip in the distal\n SVC. A nasogastric tube is seen whose distal tip is folded over upon itself\n and near the gastroesophageal junction. This could be readjusted for more\n optimal placement. There is an endotracheal tube whose distal tip is at the\n level of the aortic knob. There is calcification of thoracic aorta. No focal\n consolidation is seen. There is some mild prominence of the pulmonary\n interstitial markings without overt edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-22 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 980884,
"text": " 3:29 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for interval change in ptx\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated s/p trach; now with trach replaced.\n\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ESRD with tracheostomy.\n\n FINDINGS: In comparison with earlier study of this date, there again is a\n tiny or resolved pneumothorax in the left apex. Otherwise, little change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979849,
"text": " 12:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated, new fevers + sputum production. ?\n interval change\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with end-stage renal disease intubated with\n fever and sputum production.\n\n COMPARISON: .\n\n FINDINGS: The cardiac silhouette is mildly enlarged and unchanged.\n Atelectatic changes are noted in the left mid lung zone and left base. There\n is mild blunting of the left costophrenic angle that could represent small\n pleural effusion. There is no pneumothorax. The aorta is elongated. Again\n noted, SVC stent and right-sided central venous catheter, unchanged since\n prior exam. Endotracheal tube is noted with its tip at 3.5 cm above the\n carina. NG tube is again seen the tip is out of the field of view. The\n osseous structures are unchanged.\n\n IMPRESSION: Mild cardiomegaly. No evidence of pneumonia or CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980771,
"text": " 5:40 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? worsening of right pneumo\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated s/p trach; now with trach replaced.\n right pneumo\n REASON FOR THIS EXAMINATION:\n ? worsening of right pneumo\n ______________________________________________________________________________\n WET READ: AKSb SUN 11:27 PM\n Unchanged right PTX. Moderate left PTX, present but not as conspicious on\n prior exam. d/ .\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of pneumothorax.\n\n Portable AP chest radiograph compared to previous study obtained the same day\n earlier at 11:46 p.m.\n\n Right small and left small-to-moderate pneumothorax are demonstrated, grossly\n unchanged in size. The bibasal and bilateral perihilar atelectasis are new\n and most likely related to lung compression by pneumothorax. There is no\n congestive heart failure or bilateral pleural effusions. The fullness in the\n left hilus is most likely due to atelectasis.\n\n Subcutaneous bilateral subcutaneous emphysema has decreased in the meantime\n interval.\n\n Findings were communicated to Dr. at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980719,
"text": " 8:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please confirm placement of trach. Redone at the bedside\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated s/p trach.\n\n REASON FOR THIS EXAMINATION:\n please confirm placement of trach. Redone at the bedside\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest .\n\n HISTORY: Confirm placement of tracheostomy tube done on bedside.\n\n FINDINGS: Tracheostomy tube is within normal limits. There is again seen a\n moderate-sized right pneumothorax. This is unchanged since the previous\n study. A SVC stent, right-sided central venous catheter and dialysis catheter\n are again seen. There is an area of consolidation within the left suprahilar\n region. The subcutaneous gas and mediastinal gas has decreased since the\n previous study.\n\n These findings have been discussed with Dr. .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980736,
"text": " 11:00 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: F/U PTX LIKELY SECONDARY TO VENT OF SQ.PLEASE TAKE FILM AT 11AM\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated s/p trach.\n\n REASON FOR THIS EXAMINATION:\n f/u PTX likely secondary to ventilation of SQ. Please take film at 115PM\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Patient with pneumothorax.\n\n FINDINGS: Study is suboptimal as the right chest wall has been partially\n excluded from the study. There is again seen a moderate-sized right\n pneumothorax. The appearance and size is stable since the previous study;\n however, full evaluation cannot be made as the right lateral wall has been\n excluded. There is again seen a stent in the SVC and a tracheostomy. The\n right- sided central venous catheters are unchanged in position. There is an\n area of consolidation within the left suprahilar region. The subcutaneous\n emphysema has improved.\n\n IMPRESSION:\n\n 1. Unchanged moderate right pneumothorax.\n 2. Limited study as the right chest wall has been cut off from the study.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980924,
"text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: following pneumo/trach placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated s/p trach; now with trach replaced.\n right pneumo\n REASON FOR THIS EXAMINATION:\n following pneumo/trach placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow-up right pneumothorax.\n\n COMPARISON: and .\n\n FINDINGS: The left apical pneumothorax noted on the prior examination is no\n longer apparent, otherwise no significant interval change. The cardiac\n silhouette is at the upper limits of normal. A prominent left hila persists.\n The supporting lines are stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-09 00:00:00.000",
"description": "TRANSCATH PLCMT INTRAVAS STENT",
"row_id": 979042,
"text": " 3:50 PM\n UNILAT SUBCLAV Clip # \n Reason: Please evaluate SVC for clot. Please place SVC stent if poss\n Admitting Diagnosis: FEVER\n ********************************* CPT Codes ********************************\n * TRANSCATH PLCMT INTRAVAS STENT PTA VENOUS *\n * -51 MULTI-PROCEDURE SAME DAY EXCH CENTRAL TUNNELED W/O PORT *\n * -51 MULTI-PROCEDURE SAME DAY INTRO INTRAVASCULAR STENT *\n * PTA VENOUS SVC GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with ESRD on HD with R tunnelled HD cath and R midline\n catheter now with extensive SVC clot seen on CT scan with collaterals.\n REASON FOR THIS EXAMINATION:\n Please evaluate SVC for clot. Please place SVC stent if possible. thanks you.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION OF EXAM: This is a 71-year-old woman with end-stage renal disease\n on hemodialysis that presents with SVC occlusion.\n\n RADIOLOGISTS: The procedure was performed Drs. and , the\n attending radiologist, who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the procedure, the patient was placed supine on the angiographic\n table and the right neck and chest were prepped and draped in standard sterile\n fashion. An initial fluoroscopic image of the chest demonstrates a\n percutaneously placed tunneled dialysis catheter with tip in the right atrium.\n Using ultrasonographic guidance, multiple attempts were made in order to\n catheterize the right internal jugular vein and injection of contrast\n demonstrated complete occlusion of that vein. A guidewire could be advanced\n caudad, but never reached the right atrium, just collateral veins. Then it was\n decided to access the SVC via the tunneled dialysis catheter. A 0.035 \n wire was placed through the catheter with tip in the inferior vena cava. The\n catheter was removed and a 9 French BriteTip sheath was placed over the wire.\n A pullback venogram was performed and demonstrated occlusion of the SVC and a\n patent linear tract of the dialysis catheter. Based on the diagnostic\n findings, it was decided to perform balloon dilation of the SVC with a 20- mm\n balloon. Followup angiogram demonstrated partial angiographic improvement of\n a tight SVC stenosis, and then it was decided to place a 20- mm Wallstent in\n order to treat the SVC stenosis. The vascular sheath was then exchanged for an\n 11 French vascular sheath that was placed with tip in the SVC. A 20 mm x 80\n mm Wallstent was placed over the wire and was deployed from the SVC up to the\n IVC. Followup venogram demonstrates good angiographic results after the stent\n placement with patent SVC. Then vascular sheath was removed and a new 28-cm\n tip-to-cuff tunneled dialysis catheter was placed over the wire with tip of\n the catheter in the right atrium. The patient tolerated the procedure well.\n\n IMPRESSION:\n 1. Venogram demonstrates SVC thrombosis around hemodialysis catheter.\n (Over)\n\n 3:50 PM\n UNILAT SUBCLAV Clip # \n Reason: Please evaluate SVC for clot. Please place SVC stent if poss\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Successful angioplasty of a tight SVC stenosis with 20-mm balloon with\n partial improvement followed by placement of a 20 x 80 mm Wallstent.\n 3. Successful replacement of a 14.5 French 28-cm tip-to-cuff right internal\n jugular tunneled dialysis catheter.\n 4. Patient should remain on anticoagulation to increase inflow into the SVC\n and help resolve extensive jugular/brachiocephalic thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978551,
"text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check lines tubes.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OSA, intubated for apnea. ? interval change.\n\n REASON FOR THIS EXAMINATION:\n check lines tubes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Obstructive sleep apnea, intubated for apnea, evaluate for\n interval change.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable semi-upright chest.\n\n FINDINGS: An endotracheal tube is in unchanged position with tip terminating\n approximately 5 cm from the carina. Nasogastric tube has been removed. A\n right internal jugular venous access catheter with tip in the lower SVC is in\n unchanged position. Since the previous examination there is slight increase\n in lung aeration. The heart size and mediastinal contours are unchanged. The\n right costophrenic angle is excluded from the radiograph and no definite\n pleural effusions are seen. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-13 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 979681,
"text": " 10:39 PM\n PORTABLE ABDOMEN Clip # \n Reason: ng tube placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ESRD, recent Enterbacter bacteremia from dialysis line,\n now with new nausea, no BM in 2 days\n REASON FOR THIS EXAMINATION:\n ng tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: End-stage renal disease, bacteremia, nausea.\n\n ABDOMEN\n\n Film does not include a large amount of the abdomen and the film is\n underpenetrated for the abdomen. Some contrast is seen in the non-distended\n colon, no free air is identified.\n\n IMPRESSION: Very limited film which is not included enough for the abdomen,\n no obvious obstruction or free air.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980101,
"text": " 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated, new fevers + sputum production.\n now s/p tracheostomy. ? interval change\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of interval change in a patient with end-\n stage renal disease.\n\n Portable AP chest radiograph compared to .\n\n The ET tube was removed with an interim insertion of tracheostomy. The\n tracheostomy tip is about 5 cm above the carina. There is no change in the\n appearance of the double-lumen right central venous catheter with its tip\n terminating at the cavoatrial junction. The SVC stent is again noted in\n unchanged position. The cardiomediastinal silhouette is stable. The lung\n volumes are low with no evidence of pulmonary edema. Left small area of\n atelectasis is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979679,
"text": " 10:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: NG tube position after advancement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated, ? pneumonia on yesterday's xray. ?\n interval change\n REASON FOR THIS EXAMINATION:\n NG tube position after advancement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: End-stage renal disease, nasogastric tube placed, check\n position.\n\n The exact lower extension of the nasogastric tube cannot be determined on this\n somewhat underpenetrated film. Does appear to extend below the diaphragm.\n\n The position of the various other stents, lines and tubes is unaltered. No\n gross failure is seen.\n\n IMPRESSION: Correct position of nasogastric tube difficult to determine but\n probably lies below the diaphragm.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-15 00:00:00.000",
"description": "Report",
"row_id": 1614558,
"text": "NURSING PROGRESS NOTE 0700-1900\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT AROUSES VERY EASILY AND IS VERY RAMBUNCTIOUS! DANGER TO HERSELF AS SHE ACTIVELY ATTEMPTS TO PULL OUT LINES. RECEIVED TOTAL OF 450MCG FENTANYL BOLUS IN OR FOR PROCEDURE. CURRENTLY ON 100MCG/HR FENTANYL GTT AND 2MG/HR VERSED GTT WITH THERAPEUTIC RESULTS. PT WILL OPEN EYES SPONTANEOUSLY. DOES NOT FOLLOW COMMANDS- ABLE TO MAE X 4 WITHOUT ANY DIFFICULTY. PERRLA, 2/BRISK. AFEBRILE. BILATERAL WRIST RESTRAINTS APPLIED FOR SAFETY. NO SEIZURE ACTIVITY NOTED.\n\nRR: PT IN OR TODAY. TRACH SITE IS OOZING SMALL AMOUNTS OF BLOOD. OTHERWISE, STOMA IS MIDLINE. NO VENT CHANGES MADE. ABG'S UNREMARKABLE. BBS= ESSENTIALLY COARSE THROUGHOUT ALL LUNG FIELDS. SUCTIONING FOR MODERATE AMOUNTS OF THICK, TAN, BLOOD TINGED SECRETIONS. BILATERAL CHEST EXPANSION NOTED. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR-ST DEPENDING ON AGITAION, HR 80-120'S. NO SIGNS OF ECTOPY NOTED. SBP IS VERY LABILE- AGAIN DEPENDENT ON AGITATION- SBP CAN BE UP TO THE 200'S. PT HAS SECURE AND PATENT RT FEMORAL LINE. RT RADIAL ALINE IS SECURE AND PATENT- POSITIONAL AT TIMES- STABILIZED ON ARM BOARD. PT HAS MIDLINE TO RT FA. DOPPLERABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS- LARGE AMOUNTS OF PITTING EDEMA NOTED TO BILATERAL UPPER EXTREMITIES.\n\nGI: ABD IS SOFT, NON-DISTENDED. PT HAD PEG TUBE PLCMT IN OR TODAY- CURRENTLY DRAINING TO GRAVITY. BS X 4 QUADRANTS. PASSING FLATUS. NO BM THIS SHIFT. NPO AT THIS TIME.\n\nGU: ANURIC. PT DID HAVE COURSE OF HD TODAY- 2.3L REMOVED.\n\nSOCIAL: DAIGHTERS UPDATED VIA TELEPHONE. NO ISSUES.\n\nPLAN: IR TO EVENTUALLY EVALUATE PATENCY OF STENT, POSSIBLE TX BACK TO 4 TOMORROW. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-20 00:00:00.000",
"description": "Report",
"row_id": 1614582,
"text": "71 yo with ESRD on HD, admitted with enterobacter sepsis, c/b VAP, SVC syndrome and delerium.\n\nEVENTS: received 250 cc FB for episode of hypotension.\n\nneuro: Pt restless and agitated attempted to climb oob. prn zypexa and haldol given x1. +facial grimacing noted with ^HR and ^BP-> received morphine 1 mg x2 with fair effect. +mae noted. cough/gag impaired. +perrla noted.\ncv: monitor shows sb-nsr with occ pac noted. held afternoon dose of lopressor 2/2 hr/bp parametes. 250 cc ns bolus given for map <60 with improvement. heparin gtt infusing @ 800 unit/hr.\nresp: ls coarse throughout. initially placed on cpap+ps, changed to MMV low TV's and of apnea. sxn for sm amts thick white secretions via trach. trach care done with mod amt brown crusty drainage at exit site.\ngi: abd soft and obese. +bs noted. no stools this shift. tf's off briefly hypotensive episode with hob decreased. resumed this evening. minimal residuals noted.\ngu: anuric.\nskin: allevyn dsg to coccyx c/d/i. allevyn dsg to trach site changed.\nendo: remains on fingersticks q6hr with riss.\ni-d: temp max 99.5. no abx.\npsy-soc: dtr called x1 and updated on status and plan of care. code status full. cont supportive care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-21 00:00:00.000",
"description": "Report",
"row_id": 1614583,
"text": "Resp Care Note, Pt coughing with lrg air leak. Unable to pass suction cath or ambu bag.Pt started to develop facial sub Q edema. Needed emergent bronch.Airways had lrg amts of edema. Unable to see airways clearly. Pt intubated with # 6.0 ETT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-26 00:00:00.000",
"description": "Report",
"row_id": 1614605,
"text": "Respiratory Care:\nPatient on 35% trach mask to # 6.0 adjustable length trach with cuff deflated and HOB at 30 degrees. Suctioned for med amounts of thick yellowish secretions. Plan for possible dc to rehab soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-26 00:00:00.000",
"description": "Report",
"row_id": 1614606,
"text": "HR 55-85 SB-NSR,ABP labile,on metoprolol no other interventions SBP 140-170.A- removed and pressure dressing applied no bleeding.Double lumen picc line on rt hand and Rt SCV HD line are in place.positive pedal pulses.\non trach mask with 35% FiO2 o2 sats are amintained 97-100%.LS are coarse throughout secretion are much less comapre to previous days.\n\nPt ia alert mainly speaking so unable to asses, interpretor was in AM was nodding haedfor simple questions.pt was agitated by afternoon prn Haldol 2.5mg/IV was given with good effect.\n\nAbdomen obese,with positiv bowel sounds TF via PEG tube at goal,no stools today.\n\non regular HD on MWF,dialysed today with 3 kg wt reduction,next due on monday.Antibiotics and EPO was given by HD staff as HD protocol.\n\nAllevyn dressing at lt side back\n called and given new contact numbers,and hse was updated by this RN and Case manager.\n\nPt is going to Hospital( old hospital) at 1400 with assistance of Ambulance staff.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-21 00:00:00.000",
"description": "Report",
"row_id": 1614584,
"text": "MICU 7 RN REPORT 1900-0700\n\nEVENTS: @ 0300 After giving back care pt found to be coughing w/ loud voice. Suctioned thick yellow sec. Informed and seen by RT able to ventilate the pt in holding the trach in one position resistance noted w/ suctioning. by MD. @ 0320 suddenly pt developed huge facial subq air leak. Anaesthesia team called in emergent bronch done. Unable to see the airways clearly. ? tracheal edema.During the coarse of time pt BP 170-210/ 70-90, HR 50-90 NSR w/ rare ectopics. @ 0355 Oral intubation done ET tube 6. Ventmode changed to AC/70%/400/15/5 and received fentanyl 50mics and versed 1mg IVP and BP dropped to 90- 110. Cardiothoracic team visited.\n\nNEURO: Received the pt alert on trach vent. Trying to hit bite while atempting to give personal care.Primarily speaking does not understand english. According to family she is following commands consistently. MAE. PERLA. Currently on Fentanyl GTT 25 mic/hr and versed GTT 0.5mg/hr. Responds to painful stimulai.\n\nCV: HR 50-90 NSR. Pt is very sensitive to sedations. Received morphine 2mg for neck pain BP dropped to mid 80's and slowly picked up to 110 without any intervention. Heparin GTT 800units/hr cont. Am labs pending. A line sharp. PICC line patent.\n\nRESP: Currently pt is having oral ET Vent AC/ 70%/400/15/5. tracheostomy tube secured in place possible sugical intervention in AM. LS coarse. Suctioned thick sec.\n\nGI: Abd soft BS x4. No BM during this shift. PEG tube clamped in place. Feeding stopped @ 0330. NPO for possible surgical procedure.\n\nGU: Anuric. HD today.\n\nSKIN: Coccyx w/ allevyn dressing.\n\nSOCIAL: Full code.Family visited and updated.\n\nPLAN: Possible surgical intervention to fix tracheostomy tube.\n Cont sedation if SBP drops <90 start neo GTT.\n Psychological support to family.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-22 00:00:00.000",
"description": "Report",
"row_id": 1614587,
"text": "MICU 7 RN REPORT 1900-0700\n\nNEURO: Received the pt alert agitated mouthing words received hs dose zyprexa @ 1900 w/ no effect. @ Pt was grimacing seems to be uncomfortable received morphine 1mg x2 w/ no effect. Received haldol 2.5mg @ 2115 w/ no effect. Multiple repositioning and back rub done but pt was still grimacing and mouthing words. @ 2300 received zyprexa 2.5mg prn. In times she is very resistant and trying to beat and bite while attempting personal care. However around 2400 started to become little quiet and slept intermittently. MAE. PERLA. Primarily spesking does not understand english. According to family she is following commands consistently.\n\nCV: HR 60-90 while awake, NSR. While sleeping bradycardic to 40's. SBP 90-110 during sleep. But when agitated SBP 160-200/ 70-90. Heparin GTT 800units cont. PICC line, A line and HD cath secured in place. INR 2.1 received warfarin 5mg. AM labs pending.\n\nRESP: LS coarse, On trach vent /100%/500/12/10. Pt is brething 16/min. Suctioned thick white sec. SPO2 100%. CXR done to evaluate pneumothorax. Repatedly trach cuff inflated but still she is making .\n\nGI/GU: Abd soft BS x4, Peg in place feeding nutrene renal w/ beneprotein 30cc/hr. No BM. Anuric and HD today.\n\nSKIN: Allevyn intact in coccyx.\n\nENDO: BS q6. Insulin as per sliding scale.\n\nSOCIAL: Full code no contact from family in this shift.\n\nPLAN: HD today possible blood transfusion w/ HD.\n Wean O2\n Tracheal suctioning.\n ? changing trach tube to bigger size.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-22 00:00:00.000",
"description": "Report",
"row_id": 1614588,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick tan secretions. Trach newly changed has positional cuff leak.RSBI done on 0 peep/5 ips 26. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-22 00:00:00.000",
"description": "Report",
"row_id": 1614589,
"text": "npn: 0700-1900\nneuro: pt is alert and speanking. the dialysis rn was speaking and asked pt yes/no questions. pt was able to nod head appropriately to questions regarding pain however when mouthing words or using the alphabet board she was not appropriate. pt moves all ext on bed and continues to scoot herself to the foot of the bed repeatly. pt does not like her rest wrist and fights/shows resistance when being tied. pt has attempted to remove dislysis cath and reach for trach. pt medicated with 4 mg ivp morphine and 5mg one dose of zyprexa.\n\ncv: heparin gtt stopped theraputic level reached. pt was bridge with coumadin. pt hr and bp are very labile. pt will brady into the 40's s/p metoprolol/when comfortable, pt bp has been 99-190's. md's discussed changing the metoprolol to hydralyzine, however, pt is to continue the metoprolol untill further notice. pt has weak but ppp bilaterally. pt recieved 2 units of prbc's during dialysis to low hct.\n\nresp: vented on ps10/80%/peep5. tv are 400-600 which has been acceptable. pt has a huge airleak around cuff. thoracic aware. may need to increase cuff size however nothing has been ordered to change size at this time. pt is sating well 98-100%. pt was recently intubated portex mispositioned, bronchoscopy was done and pt had a number 6 placed. pt was placed on vent sub q air and bilateral pneumothorax. chest tubes were never placed thoracic thought the pnuemothorax's would resolve-- at 1515 pt had cxray whichc showed large improvement of both pnuemothorax's. pt still has crepitus bilaterally but also improving. pt goal for this afternoon is to have fio2 dailed down to 60% and by morning change pt over to trach mask.\n\ngi/gu: pt is anuric. pt had 2.7 liter removed in dialysis. pt has tf at 30cc/hr. abd soft nt. no residuals noted.\n\nid: tmax: 100.2. cont to monitor.\n\nfssq6 hrs\n\naline, dialysis cath, picc line\n\nsocial: daughter called this afternoon and was updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-22 00:00:00.000",
"description": "Report",
"row_id": 1614590,
"text": "Resp Care\nPt remains with #6.0 currently on psv 10/5 with vt 400-600 rr 12-20. PT has positional cuff leak, cuff presssure 25 cm h20 ? change trach to larger size. BLBS diminished suctioned for sm amt thick yellow secretions. will contiue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-23 00:00:00.000",
"description": "Report",
"row_id": 1614591,
"text": "Nursing Note: 1900-0700\nNeuro: Alert/unable to determine orientation. Nods yes to all questions. MAE requiring use of bilat wrist restraints to maintain safety of lines. Follows commands inconsistently. Sleeping on/off throughout shift.\n\nResp: with PSV 10; FiO2 weaned to 50% maintaining sats 98-100%. LS clr/diminished at bases. Suctioned for small amt of thick, wht secretions via trach. Audible cuff leak. RR 10s-20s.\n\nC/V: HR 50s-70s, sinus rhythm. ABP labile 80s-140s correlating with NBP at times. Received scheduled dose of Lopressor. Hct 27; other AM labs pending.\n\nGI/GU: TF at goal rate 30cc/hr via PEG with minimal residual. Small amt stool; anuric.\n\nID: Tmax 100.5 PO.\n\nENDO: Sliding scale coverage.\n\nDISPO: Full code; no contact with family overnight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-24 00:00:00.000",
"description": "Report",
"row_id": 1614597,
"text": "71 y/o female with ESRD on HD(MWF),Delerium,HD catheter infection/PNA and labile BP's.Pt was vented till yesterday and weaned and now remains on trach mask FiO2 50% o2 sats are maintained 97-100%.LS are coarse to diminished at bases.increased productive cough suctioned Q3-4 hrs for thick whitish secretions.Sputum CX are send.\n\nHR 70-90 NSR no ectopy noted,NBP-systolic in 130-140 and ABP 150-170/50-70.Pedal pulses are positive.for access double lumen PICC line on rt hand and RT radial A-Line,Rt SVC are in place.\n\nPt is alert but not oriented,mainly speaking moves in bed,pt was appropriate today no episodes of agitation.\n\nAbdomen obese with positive bowel sounds,PEG tube in place TF @ goal,no bowel movement today.\n\nHaemodialysed with 4 kg wt reduction,EPO and iron given during HD, and blood CX are taken from HD line and one shot of Vanco given since pt was febrile at AM.HD due on friday.\n\nSKIN;Allevyn dressing at the back.\n\nsocial;no contact from family today,if they visit at working hrs,case manager to be paged regarding her update with rehab screening.case manager contact two of her daughters and awaiting to hear from them.\n\nPlan; ? transfer to rehab on friady ( not confirmed about placement)\nfollow up CX,Re-culture in case if she spikes again\nSpeech and swallow evaluation\npulmonary toiletting\nmonitor vital signs.\nAvoid sedating meds in view of her delerium\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-24 00:00:00.000",
"description": "Report",
"row_id": 1614598,
"text": "Addendum...\n\nSpeech and swallow evaluation done with intrepretor,pt tolerated PMV ~ 10 mts but didnot made any attempts to speak.PMV left at can be tried later when pt is more awake.Pt has increased secretions,will be seen by speech therapist later.\n\nDaughter called and updated.Concerned about rehab transfer,should be updated with when descision is taken about transfer.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-11 00:00:00.000",
"description": "Report",
"row_id": 1614540,
"text": "MICU Nursing Progress Note\n 71y/o speaking woman originally admit to on with fever to 103, ?dialysis line infection line changed on On pt became increasingly confused,MS changes, and periods of apnea with bradycardia requiring intubation on (difficult airway)... attempted extubation on however reintubated within 5hours.Developing clots at end of dialysis line,on and off heparin d/t elevated PTT,\n Respiratory: place on PS ventilation this morning. PS 10cm and PEEP of 5cm. minute ventilation is from 4-9liters/min. with TV 300-500cc depending on level of alertness. was on Propofol at 20mcg/kg/min but would wean up and down to BP or agitation... presently is off as of 1500. fentanyl was 25mcg/hr now at 20mcg/hr.suctioning thick tan sputum as times is blood tinged, spec sent for culture as consistency and color changed.\n Cardiac: HR 80-110 ST with rare to occasional PVC, BP ranged from 87-160/50-100's very labile. arterial line is damped, capatpril d/c.\n Renal: dialysis today over 4hours,able to remove 2kg. tolerated well.\n GI: large stool this afternoon. cont on TF of nutregen strenght with 30gm benaprotein.. at 20cc/hr. tolerating well residuals only 10cc\n Heme: restarted heparin IV infusion as IR not taking pt back...no bolus and restarted at 1,000units/hr. labs pnd at 1800. no oozing from catheter insertion sites. midline flushed and triple lumen flushed with heparinized saline as ordered.\n Skin: sm abrasion noted on coccyx area. stage 2 .5cm in width and 1 cm in length.frequent turning.\n Social: daughter called today for update.\n Plan: follow PTT closely as pt sensitive to heparin. adjust accordingly. will cont to wean pt plan is to try one more extubation if possible over weekend... but plan if unsuccessful will trach and PEG pt on monday...will need to go west for procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-14 00:00:00.000",
"description": "Report",
"row_id": 1614550,
"text": "MICU Nursing Progress Note\n Neuro: pt cont to be restless,kicking leg in the air and landing on the bed, difficult to assess level of understanding as pt is speaking ... will calm when hearing commands but only for short period. tried 5mg of zyprexa then ativan 1mg given at 2300 and 4am without much success. Pt moving all over bed, concerned about maintaining airway as pt moves to bottom of bed.. cont on fenanyl at 100mcg/hr.\n Cardiac: Hr 80-120 ST depending on level of agitation... more agitated then higher rate..along with BP will go from 80/ up to 200/90 when agitated.\n Respiratory: cont on the vent with settings of A/C 500x14 PEEP of 5cm, FIO2 40% cont to suction every 3-4 hours for thick yellow sputum. BS coarse upper and diminished at the bases. RISB 112. plan for trach and PEG on Monday.\n ID: received vanco 1gm last night now will go on HD protocol for dosing... next dose will be 500mg on dialysis day.. and meropenum. awaiting culture results.\n GI; on Nutrogen with benaprotein at 30cc/hr. tolerating well. no stool tonight.\n GU: anuric, hemodiaylsis due Monday..\n social: no contact with family tonight.\n Plan: plan to trach and PEg on Monday. cont to attempt to wean though with new temp and secretions ?if successful.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-14 00:00:00.000",
"description": "Report",
"row_id": 1614551,
"text": "Respiratory Care:\nPt has been as restless as ever. Up for trach and peg on Monday\u0013\u0013.no vent changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-24 00:00:00.000",
"description": "Report",
"row_id": 1614599,
"text": "Resp Care\nPt seen for routine airway check. Pt continues with #6.0 cuff inflated on 50% aerosol TM. BLBS diminished, suctioned for sm-mod amt thick white secretions. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-25 00:00:00.000",
"description": "Report",
"row_id": 1614603,
"text": "resp care - Pt remains with #6 trach secured at 12, cuff deflated. 35% TM in use. Pt was suctioned Q1 for small to moderate amounts of thick, yellow/tan secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-26 00:00:00.000",
"description": "Report",
"row_id": 1614604,
"text": "Nursing Progress Note:\nALLERGIES: PCN, HEPARIN\n\nFULL CODE\n\nUNIVERSAL PRECAUTIONS\n\nEVENTS OVERNIGHT: pt requiring much less suctioning as compared to day shift; afebrile; pt continues to appear confused and attempting to get arms and legs out of bed\n\nNEURO: pt alert most of shift, slept very little and attempted to get out of bed as noted above, md aware given prn haldol and zyprexa as well as standing dose with little effect; restraints in place as pt has history of pulling out trach and lines; denies pain; pt speaking; moves all extremities; PERL, pupils 4mm and sluggisg bilaterally with bilateral cataracts\n\nCV: pt cont to have labile ABP from 200's to 100's, with rapid fluctuations without intervention; cont on lopressor tid; HR NSR/SB 50's-70's, no ectopy; am lytes per Careview; daily coumadin stopped now qHD; +PP/RP to palpation; no edema noted\n\nRESP: pt with #6 ; on trach mask at 35%, sats 100%; suctioned q1-2hrs for scant to moderate amt thick tan secretions; repeat sputum spec sent; LS cont coarse at apices, dim at bases; no wheezing SOB\n\nGI/GU: +BS, +flatus, small amt yellow brown stools; abd soft obese; PEG in place; TF Nutren Pulm 3/4 strength with 30 grams beneprotein at goal 30cc/hr, minimal residuals; pt anuric, HD today (MWF)\n\nSKIN: small abrasion at coccyx, pink but skin intact, aloe vesta applied\n\nACCESS: right art line, right DL PICC WNL\n\nID: pt afebrile tongiht, tmax 99.4; abx today with HD; cultures pending\n\n: family to be in to visit tomorrow, should contact CM to discuss rehab planning with family; cont abx follow cultures; HD today; plan to d/c to rehab after weekend pending culture results and improved resp status\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-14 00:00:00.000",
"description": "Report",
"row_id": 1614552,
"text": "respiratory care Addenda:\nPt to go west for dialysis in the AM, then trach and PEG over there; recover and return east post recovery.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-14 00:00:00.000",
"description": "Report",
"row_id": 1614553,
"text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented. AC/500/14/40/5 spont rr 0-10\nSuctioned for mod amts yellow-tan secretions..\nPt is scheduled for trach and peg tomorrow at 1300.\n Cardiac: Hr as high as 130's with agitation..occassional PVCs..bp up to 200's..\n Neuro: Pt awake and thrashing in bed. Bouncing legs off bed and pulling at wrist restraints. Still on fentanyl gtt..recieved multiple boluses..added Versed gtt..1mgm/hr..with additional boluses. Currently fentanyl at 100mic/hr and Versed at 1mgm/hr and pt much more sedate. With bp 100-120/ and hr 55-70.\n ID: Afebrile..elevated wbc..on meropenum and vanco..??check vanco dose in am prior to HD.\n GI: TF needs to be re-evaluated..not on propofol anymore. NPO after 12m. No stool today. Small amt yesterday\n GU: Incontinent of large amt urine this am..apparently pt voids intermittently. Will be dialized in am prior to going to OR.\n Endo: FS q6hrs..bs 170-200 ssi\n Skin: Small skin tear at coccyx..\n Heme: Heparin gtt at 1100units/hr.d/t clots in SVC am PTT 95. Has no bleeding sites.\n Social: Daughter called this am..updated on condition and aware that pt may be transfered to West ICU.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-16 00:00:00.000",
"description": "Report",
"row_id": 1614559,
"text": "Resp Care\nPt. #8 Portex DIC yesterday/PEG also placed. Remained on overnight. No vent changes or abgs.\nBS: diminished with minimal secreations.\nPlan: Return to today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-16 00:00:00.000",
"description": "Report",
"row_id": 1614560,
"text": "MICU NPN 7P-7A\nNEURO: RECEIVED PT ON GTTS; FENTANYL 100MCG AND VERSED 2MG. AT THE TIME QUITE AGITATED, MAE, CAUSING HR ^^120 AND SBP ^^220. WILL ALTERNATE BETWEEN RELAXED/ASLEEP AND AGITATED WITH LABILE HR/BP. SPOKE WITH MD ABOUT INCREASING SEDATION HEMODYNAMICS. INCREASED FENT TO 150MCG AND VERSED TO 4MG WITH GOOD EFFECT BUT CLOSELY WATCHING BP AS SHE HAS BEEN KNOWN TO DROP WITH SEDATION. BP UP/DOWN BUT AT ONE POINT SBP 70'S SO DECREASED FENT TO 75MCG. LATER IN SHIFT NOTED THAT WHEN SHE IS ASLEEP BP 70'S SO EVENTUALLY ALL SEDATION OFF. SEDATION NOT TURNED BACK ON AS NOTED WHEN SHE GETS AGITATED SBP ONLY RISING TO 130-140'S AND HR 100'S. EASILY AROUSABLE, NO INDICATIONS THAT SHE IS AWARE OF SURROUNDINGS. DOES NOT FOLLOW COMMANDS. SOFT WRIST RESTRAINTS IN PLACE FOR SAFETY OF TUBES AND LINES. GAG IMPAIRED. PERL @4-5MM AND BRISK.\n\nCARDIAC: HR 79-120'S SR/ST WITH NO ECTOPY. SBP 70-220. PEDAL PULSES BY DOPPLER. RESTARTED HEPARIN GTT AT 1500UNITS/HR AFTER 6700U BOLUS. NEXT PTT >150 SO GTT HELD X 60MIN THEN RESUMED @1150U/HR. NO SIGNS OF BLLEDING. HCT STABLE @25.\n\nRESP: REMAINS ON A/C 500X14 40% +5. RR 14-24 AND SATS 99-100%. LS COARSE AND SXTED FOR SMALL AMOUNTS OF BLOODTINGED TO YELLOW THICK SPUTUM. TRACH MIDLINE WITH SMALL AMOUNT OF BLOODY DRNG. REMAINS SUTURED IN.\n\nGI/GU: ABD OBESE WITH +BS. NO STOOL BUT WHEN SUPPOSITORY GIVEN, STOOL NOTED IN RECTUM. PEG IN PLACE AND PATENT, TO GRAVITY, WITH BILIOUS DRNG. ESRD ON HD BUT APPEARS TO HAVE HAD A MODERATE AMOUNT OF INCONTINENT URINE X1. CREAT 3.3 S/P HD.\n\nFEN: HELD OFF ON 500CC FLD BOLUS THIS MORNING S/P DECREASED BP WHILE OFF SEDATION AS BP IS NOW STABLIZING. UPPER BODY EDEMA. LYTES PER CAREVUE. FS Q6HRS WITH SS HUMALOG. REMAINS NPO.\n\nID: TMAX 101 PO, MD AWARE, BLD AND SPUTUM CX'S OBTAINED. GIVEN 650MG TYLENOL PR WITH TEMP COMING DOWN TO 100.3. WBC UNCHANGED @11. ON VANCO AND MEROPENEM.\n\nSKIN: DUODERM TO COCCYX/RIGHT BUTTOCK AREA.\n\nACCESS: HD LINE RSC, RIGHT ART LINE, RAC MIDLINE, RIGHT FEM CVL.\n\nSOCIAL/DISPO: FULL CODE. DAUGHTER CALLED FOR UPDATE LAST EVENING.\n\nPLAN: RESTART SEDATION IF HEMODYNAMICS UNSTABLE (^HR/BP) AGITATION...NEXT PTT 1115...?WHEN WILL TRANSITION TO COUMADIN...START TUBE FEEDS VIA PEG...BOWEL MEDS...F/U CX'S...?REMOVING CVL ( FEVERS) IF ABLE TO GET PERIPHERALS...HD TOMORROW...?BACK TO 4 TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-16 00:00:00.000",
"description": "Report",
"row_id": 1614561,
"text": "Nursing Progress Note 0700-1900\n*Full Code\n\n*Allergies: PCN, Heparin ( MD's, was ? of HIT in past but was determined this was not the case and the allergy has not yet been removed from her electronic medical record).\n\n*Access: RSC HD line, Rfem TLC, Rant Mid-line, Rrad A-line, PEG\n\n** Please see admit note/FHP for admit info and hx.\n\nNeuro: pt moving around constantly in bed, appears uncomfortable, ^VS w/ stimulation, not following commands, sedation OFF overnight, attempted to treat w/ disolving Zyprexa, now attempting Haldol IV 2.5mg Q4H PRN w/ fair effect. MAE w/ normal strength, impaired gag, intact cough, PERRL 4mm/brisk.\n\nCardiac: NSR/ST w/ rare PVC's, HR 81-102, SBP 118-164, higher BP and HR w/ aggitation, goes up and down very quickly. Hct stable @ 24.8, lytes stable this AM. Heparin gtt @ 1150 Units/hr, last PTT @ 1100, next @ 1700, results pending. ? start coumadin soon. Afternoon lytes pending as well.\n\nResp: Started shift on A/C, now on trach collar. Fresh trach from yesterday for laryngeal edema. Trach care done. This shift, o2sat 99-100, rr 11-23, ls coarse upper/diminished lower, sxn infrequently for sm amts thick yellow/white secretions.\n\nGI/GU: Fresh PEG, okay to use for meds, can start TF's today. +BS, no stool this shift, abd obese/soft/non-tender. Anuric, HD yesterday, next tomorrow, Creat 3.3 this AM after HD yesterday. FSBG 142, no coverage per Humalog SS.\n\nID: Temp 98.2-99.0, WBC 11.0. Spiked overnight to 101, cx's sent. Vanco (w/ HD) and Meropenem, vanco trough ordered w/ next AM labs. Had BAL w/ yesterdays procedure. Awaiting all recent cx results.\n\nPsychosocial: Daughter called today and updated on and condition. Stated she will visit this evening but I informed her to call ahead to see which unit the pt is in.\n\nDispo: monitor MS (treating aggitation w/ Haldol), awaiting 1700 lab results (PTT for heparin gtt, evening lytes), ? start TF's, vanco trough in AM w/ labs, HD tomorrow, cont med regimen and abx, cont ICU care, to be transferred to 4 M/SICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-16 00:00:00.000",
"description": "Report",
"row_id": 1614562,
"text": "Correction to above note\nFSBG was 161, covered per Humalog SS @ noon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-16 00:00:00.000",
"description": "Report",
"row_id": 1614563,
"text": "Respiratory Care:\nPt., Re-Admitted from west after a trach and peg and replacement of dialysis catheter.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-17 00:00:00.000",
"description": "Report",
"row_id": 1614564,
"text": "Resp: Pt rec'd on 40% t/c. BS are coarse to clear. Suctioned for small amounts of thick bloody tinged secretions. Trach care done. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-02 00:00:00.000",
"description": "Report",
"row_id": 1614499,
"text": " nsg note: 19:00-7:00\nthis is a 71 y.o. woman adm with esrd on hd, adm to floor with temp 103 r/t dialysis line- replaced . pt became confused and combative with periods of apnea and desat to high 80s. pt transferred to and required intubation by 5am for prolonged periods of apnea. pt was a difficult intubation. head ct negative, abd/pelvis ct negative for bleed with likely svc clot. argatroban restarted and titrated per ss. currently at 1.05 mcg/kg/min. next ptt due at 11:20am.\n\nneuro: lightly sedated on propofol at 25mcg/kg/min (was increased from 15mcg/kg/min for agitation). arousing to stimuli with occas hr in 180s with thrashing arms on bed x1 requiring zyprexa x1 with relief. perrla 2mm sluggish. not following commands. bilat wrist restraints maintained as pt attempting to pull at ett when stimulated.\n\ncv: hr ranging 50s-90s sb/sr with no ectopy noted. sbp ranging 100s-150s, up to as high as 180s with agitation. +pp, appears comfortable with no grimacing noted.\n\nresp: remains intubated on psv weaned down to 5 ps , 5 peep , fi02 40%. am abg pending. lungs cta, suctioned x1 for small amt thick white secretions sent for gm stain and cx. sp02 ranging 98-100%.\n\ngi/gu: abd soft, obese, +bs, npo for tee in am. ogt patent and clamped. anuric. last hd for 1.9 liters removed.\n\nskin: dry and intact.\n\nsocial: and visited last pm and updated with plan of care.\n\nplan: continue sedation until closer to extubation and then wean down propofol, monitor mental status, npo, tee in am, titrate argatroban per ss with next ptt check at 11:20am. send stool for cdiff. next hd ? .\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-02 00:00:00.000",
"description": "Report",
"row_id": 1614500,
"text": "Resp Care\nPt. remains intubated/sedated overnight on PSV. Vts 500-600cc with MV . No resp. distress noted.\nBs: coarse bilat. secreations minimal.\nPlan:Changed to 5/5 this morning after passing rsbi. Abg's to be sent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-02 00:00:00.000",
"description": "Report",
"row_id": 1614501,
"text": "resp care - Pt remains intubated and is currently on full vent support. Sedation for TEE required change to AC. Pt had been on minimal settings of PSV for most of the day, however no cuff leak was heard, so pt was put on steroids and will be reevaluated tomorrow morning for extubation. BS were mostly clear and secretions were minimal. Plan to return to PSV when sedation lightens.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-17 00:00:00.000",
"description": "Report",
"row_id": 1614565,
"text": "NPN 1900-0700\nFull code All: PCN speaking\nPt returned to after trach/PEG on .\n\nNeuro: Restless/agitated intermittently throughout shift, not following any commands. PERRL. MAE with RUE weakness noted. Good cough. Morphine 2mg IV x2 for ?pain at new incision sites w/minimal effect. Zyprexa PO x1 minimal effect. Haldol 2.5mg IV x1 w/good effect as pt able to sleep in am hours. Afebrile.\n\nCV: NSR-ST w/occasional PVC's observed. Continues to be hypertensive w/ restlessness and nursing care though no SBP's >170; hypotensive with sleep experiencing low systolic of 88. UE edema 3+ b/l. Remains on Heparin, currently @ 1150units /hr with am PTT pending.\n\nResp: RR in teen's to 20's w/ sats 97-100% on 40% trach mask. Sxn' x for small amts blood tinged, thick white secretions. Trach care performed w/RT.\n\nGI/Endo: Obese abd s/nt with +BS. No BM. Colace and dulcolax administered, awaiting effect. 2units humalog @ . PEG patent, site CDI.\n\nGU: No urine output. HD scheduled today.\n\nSkin: Stage 2 pressures ulcers x2 on coccyx. Cleaned w/ NS, cavillon barrier and fresh duoderm applied.\n\nLines: HD cath R chest, art line patent in R radial, R fem line TLC with blue port not flushing but both other ports flush/draw, single lumen midline in RUE which may d/c today with plan to place double lumen PICC. All dressings CDI\n\nID: Vanc trough pending; pt remains on Vanco w/ HD, Meropenem for 10day course.\n\nSocial: Daughter called, requests that only she and sister receive detailed information, all other family that calls may be told that pt is stable but referred to daughters.\n\nPlan: HD today\n HISS; restart TF\n PICC placement in RUE (LUE being saved for future HD access)\n Monitor/manage agitation\n Heparin gtt, next PTT due at noon\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-17 00:00:00.000",
"description": "Report",
"row_id": 1614566,
"text": "npn 0700-1900\nNeuro: pt intermittantly opens eyes to verbal stim, no eye contact, no tracking and does not nod to yes/no ?s or follow commands when spoken to in . Pt moves legs in bed and appears to flex arms up as high as chest only. Does grasp, not on command. Has good cough, though unable to expectorate secretions via trache and +gag w/mouth care when able to get to back of throat, usually will bite down on anything placed in mouth. Afebrile\nCV: Labile b/p, as high as 200/90 to low of 130/60, hr 80s SR to 100 ST, no VEA. Magsulfate as ordered. Pt received HD and able to remove 2600cc. Pt occasionally appears uncomfortable for which she has received 1mg morphine IV x2 and morphine 2mg x 1. Appears to have lower b/p when people are in room talking. Plan with ICU team is to rx b/p if sustained SBP >200. Trying to avoid haldol as able and use morphine sparingly as trying not to cloud mental status exam.\nPlan for pt tomorrow is to go to IR for SVC clot, will either TPA or angio jet (break up) clot. Consent obtained by Dr. with daughter . Heparin is to be off @ MN and tube feeds off @ midnight in anticipation of procedure. IR control is extension to call in am for time if one not called, resource RN is . Heparin now @ 1000u/hr adjusted according to sliding scale, will need PTT checked @ . Access remains right subclavian tunneled dialysis catheter, dressing changed by dialysis RN, site w/minimal sticky drainage. Right midline site clean. RIght groin triple lumen catheter patent, site w/small drainage. Right a-line patent occasionally positional and wrist board changed but necessary.\nResp: Pt on trache mask 40%, RR 12-22, O2 sats 98%+, FiO2 now 35%. Suctioned approx q2-3hours for thick white, blood tinged secretions. LS: usually CTA, exp wheezes ausc this morning, some cleared w/albuterol neb rx. Trache sutures intact, site cleaned of old blood.\nGI: ABD soft, tube feeds restarted as discussed on rounds this morning, tolerating renal 3/4str w/beneprotein @ 10cc/hr, to increase as tol to 30cc, however, will be NPO @MN.\nGU: dialyis done as above, pt straight cathed for 350cc dark yellow urine which was sent for benzos (to see if contributing to mental status). Pt str cath w/aseptic technique, noticed large amt vaginal drainage, presumed yeast and will start miconazole vaginal cream as ordered.\nSkin: coccyx ulcer covered w/duoderm, unable to assess skin. Laceration on right side of neck appears clean, covered w/tegaderm.\nSocial: daughters and visited as well as brother from and sister from and other extended family. Family met w/social worker, , who reports family appears to be coping appropriately. to f/u w/family tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-17 00:00:00.000",
"description": "Report",
"row_id": 1614567,
"text": "Respiratory care:\nPt seen for routine airway care. Pt on 35% cool aerosol via trach mask. Lung sounds clear most of the time.. Pt was given Alb neb x1 today, for wheezes. Suctioned for moderate bloody/brown thick secretions. Emegency equipment at bed side.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-18 00:00:00.000",
"description": "Report",
"row_id": 1614568,
"text": "Resp: Pt rec'd on 40% t/c. Pt has #8 portex trach. Bs are coarse to clear bilaterally. Suctioned for small amounts of thick white/yellow secretions. 02 sats @ 100%. Titrated 02 to 35%. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-18 00:00:00.000",
"description": "Report",
"row_id": 1614569,
"text": "NPN 1900-0700\nFull code All: PCN, ?previous rxn to heparin speaking\n\nPt is a 71yo ESRD pt who experienced a change in MS at the end of . Pt had a temp of >103. Admitted for line infxn. HD line changed. Pt transferred to MICU and intubated for further decline in MS of apnea. Failed extubation, but was moderately improving MS, following some commands just prior to trach/PEG placement. Pt went to for trach/PEG on then returned to . MS again with of agitation which precipitate hypertension.\n\nNeuro: Agitated early in shift but rested peacefully overnoc. No sedative medications given. MAE with more limited movement of RUE. Opens eyes to speech, PERRL sluggishly. Occasionally will follow command to squeeze hand or open mouth. Agitation results in much nonpurposeful UE movement with hypertension.\nCV: NSR to SB when sleeping this shift. Occasional PVC. Labile BP's, see carevue for objectives. Clots causing UE edema, to go west again today for TPA. Heparin gtt off at midnight. K=3.0, being repleted with 40meQ KCl. See carevue for further objectives/labs.\nResp: 35% trach mask w/ RR in teens and 20's, sats 100%. Sxn'd q2-3hrs for small amts thick yellow secretions.\nGI/Endo: obese abd soft, +BS, smears of soft yellow stool. Rec'd 100mg colace and 30ml Lactulose last noc, awaiting effect. Remains on HISS, am FS=112. TF off at midinight for IR procedure.\nGU: Anuric. HD schedule MWF. Miconazole cream vaginally last noc for 7 day course.\nSkin: Stage 2 pressure ulcers on coccyx, covered with duoderm. wound at neck covered w/ transparent.\nLines: To have midline changed out for (hopefully) PICC today in IR. Art line, femoral TLC, HD cath all patent, CDI.\nSocial: daughter, is point person. She visited last night with other family and called in later. Aware of plan.\nPlan: Replete lytes prn.\n Monitor for HTN>200 systolic\n Monitor/manage pain and agitation.\n bowel regimen\n West for TPA and PICC placement\n HISS\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-03 00:00:00.000",
"description": "Report",
"row_id": 1614504,
"text": "NPN 1900-0700\nFull code All: HEPARIN Spanish-speaking\n\n71yo female originally admitted to for fever r/t HD cath infxn. HD cath replaced . Admitted to after episode of combativeness, desat. Became obtunded on , intubated with difficulty. Unable to extubate on d/t no cuff leak. Started on SoluMedrol for airway edema with goal to extubate .\n\nNeuro: Pt was very agitated early in shift, required increased titration of sedative meds. Currently on Propofol 35mcg/kg/min and Fentanyl @ 25mcg. MAE but less on RUE. ?bursitis of R shoulder joint, Rheumatology to f/u Afebrile.\n\nCV: NSR with rare SB to 58bpm. No ectopy noted. BP 115-210/60-84. BP well controlled once pt more comfortably sedated. Started on Captopril 6.25mg TID. TEE neg for endocarditis, + for mild thickening of valves, ventricular walls, nonmobile plaque. Neg for LE edema.\n\nResp: Placed on MMV overnoc to support resp status while increasing sedation for comfort. 40%/ with 7-16 bpm. LSCTA with some diminishment noted in R base. +cuff leak this am.\n\nGI/GU: Obese abd s/nt. No BM this shift. +BS. follows; RISS, required 2units Humalog x2. Anuric. HD today.\n\nSkin: CDI\nLines: Art line patent, good waveform, dressing CDI. PIV x3 on LUE, x1 on RUE all patent.\n\nPlan: Probable extubation attempt today.\n Pain/sedation management\n RISS\n HD today, \n Gentamicn 80mg IV after HD\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-03 00:00:00.000",
"description": "Report",
"row_id": 1614505,
"text": "Addendum\nPt scheduled for MRI of chest today to r/o SVC clot. Family will have to be called to fill out check list if pt not extubated/A&O/interpreter available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-03 00:00:00.000",
"description": "Report",
"row_id": 1614506,
"text": "Respiratory Care\nPatient remains on ventilatory support. Positioned to extubate per settings. Documented in Carevue. Cuff leak evident. Suctioned for small amount of pale white secreations.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-03 00:00:00.000",
"description": "Report",
"row_id": 1614507,
"text": "Nsg.notes 0700-1900 hrs\n\nAllergies:PCN,Heparin\n\nNeuro:sedated,often agitated,on propofol and fenta gtt.tried to off propofol and wean off and extubate am ,but pt more agitated and needed propofol gtt back,thinking that her shoulder pain may be one cause for her agitation,started on fentanyl patch ,applied at 1300hrs/72hrs.lidocaine patch on at 1600hrs.planned for MRI to r/o SVC clot,but cancelled.\n\nResp:orally intubated,vented,CPAP+PS,peep 10,psup 8,fio2 40%.blood gas done afternoon.7.3/46/64/0/28/ suctioned moderate thick yellow secretions.LS coarse.planned to extubate today with anaethesia ,but later cancelled ?agitation reason.\n\nCVS:HR 80-90'S,NSR.no Ectopics noted.A line on Rt.radial,was not having back flow,hands edematous,showed to Dr,and both A line and peripheral line from Rt hand removed.had HD today,removed 2lit.HD cath intact.received genta and epoetin after HD,and genta trough level sent.vital signs stable.\n\nGU/GI:Abdomen obese,BS present, sump OGT present,feed started neutran renal 10ml/hr ,and held inbetween for possible extubation and restarted at 1600hrs.goal 20ml/hr.no BM this shift.anuric,HD done today.\n\nIntegu: skin intact,afebrile,positioned,all hygenic needs attended.both hands swollen.\n\nIV access:new 20G PIV on Lt wrist done by IV nurse,and 18g PIV on Lt hand.all other lines removed.HD cath on Rt SVC.\n\nSocial:sister called over the phone and updated.full code.\n\nPlan:next HD ?friday.pulmonary toilet.?plan for possible extubation tomorrow.emotional support to family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-19 00:00:00.000",
"description": "Report",
"row_id": 1614576,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS AND PMH\nNEURO: SPEAKING ONLY, PER FAMILY, PT APPEARS TO UNDERSTAND AND DOES FOLLOW SIMPLE COMMANDS. ABLE TO LIFT AND HOLD ALL EXTREMITES. VERY RESTLESS IN BEGINNING OF SHIFT, WEEPY THIS AFTERNOON WHEN FAMILY VISITED.\nCV: T MAX 99.5. HR 60-80'S NSR. SBP 80-90 THIS AM. LOPRESSOR HELD. THIS AFTERNOON, SBP 120- DOSE OF LOPRESSOR GIVEN. EXTREMITES WARM, REMAINS ON HEPARIN GTT AT 1150 UNITS/HR, PTT 60-75 RANGE.\nRESP: BS COARSE. SX FOR SM AMTS THICK TAN SECRETIONS. REMAINS ON CMV WITH RATE OF 10 AND 5 PEEP. ATTEMTED TO CHANGE TO CPAP WITH PS X2 UNSUCESSFUL ( OF APNEA PRESENT)\nGI: ABD SOFT, + BS, MUSHROOM CATH REMOVED (STOOL TOO SOLID), TOL TF AT GOAL WITH MINIMAL RESIDUAL\nGU: HEMODIAYSIS DONE TODAY, 2.5 LITERS REMOVED\nA/P: MONITOR HEMODYNAMICS AND RESP STATUS, ATTEMPT TO CHANGE TO CPAP IF TOLERATED, MEDICATE FOR ANXIETY AS NEEDED, CONT TO UPDATE FAMILY, CHECK PTT Q6HRS WHILE ON HEPARIN GTT\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-19 00:00:00.000",
"description": "Report",
"row_id": 1614577,
"text": "Respiratory Care Note\nPt received on AC as noted. BS coarse, but diminished especially in the bases. Pt suctioned for small amts thick, tan secretions. Attempted PSV trials x 2, but aborted secondary to apnea over 40seconds. AC rate weaned from 14 to 10 according to ABG from previous shift. No ABG's this shift. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-20 00:00:00.000",
"description": "Report",
"row_id": 1614578,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions.RSBI done on 0 peep/ 5 ips 54.Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-20 00:00:00.000",
"description": "Report",
"row_id": 1614579,
"text": "MICU 7 RN REPORT 1900-0700\n\nNEURO: Pt is primarily speaking does not understand english. Alert on trach vent. According to the family members she is following commands consistently. Grimace for painful stimulai. MAE, PERLA. No agitation noted during this shift.\n\nCV: HR 70-80 NSR, No ectopy. Heparin GTT as per protocol. Currently running 800 units/hr. 0200 PTT 98. A line sharp. PICC line in the rt arm.\n\nRESP: LS coarse. SPO2>95%. On trach vent CMV/50%/. Pt breathing 10/min. No vent changes over noc. Suctioned thick tan sec.\n\nGI/GU: Abd soft BS x4, Peg in place feeding nutrene renal 30cc/hr @ goal. No BM during this shift. Anuric. Received HD yesterday removed 2.5lit.\n\nENDO: BS q6. Insulin as per sliding scale.\n\nSKIN: Coccyx w/ allevyn dressing.\n\nID: T max 98.5. No abx.\n\nSOCIAL: Full code. Daughter called and updated.\n\nPLAN: Wean off vent.\n Next PTT due @ 0800.\n Tracheal suctioning.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-20 00:00:00.000",
"description": "Report",
"row_id": 1614580,
"text": "ADDENDUM\n\n@ 0615 Pt grimacing and received morphine 1mg x2 w/ little effect. Rt arm is bigger than the left Rt arm measures 16 inches and lt arm 15 inches. MD aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-20 00:00:00.000",
"description": "Report",
"row_id": 1614581,
"text": "Respiratory Care Note\nPt received on AC as noted. BS coarse bilaterally which clears with suctioning. Pt suctioned for small amt thick, white secretions. Pt weaned to PSV 5/5 - PS increased to 10 for low VT's. Pt having increasing of apnea and was placed on MMV with a minimum MV of 5.0L. Pt tolerating well. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-04 00:00:00.000",
"description": "Report",
"row_id": 1614510,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED AND ON\nPS 8/5 .40. APPEARS REASONABLY COMFORTABLE ON\nPS BUT DID HAVE SOME MILD CO2 RETENTION AND\nMARGINAL OXYGENATION EARLIER ON PS 8/5 .40.\nALSO SX ING FOR THICK TAN SPUTUM. WILL\nHOLD EXTUBATION TODAY AND REEVALUATE IN THE\nAM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-04 00:00:00.000",
"description": "Report",
"row_id": 1614511,
"text": "Nsg.notes 0700-1900hrs\n\nNeuro:more alert than yesterday,understands simple questions and responding with nodding head,and more calm and quiet today,not agitated.pupils 2mm size and reacting to light.understands little english,spanish speaking.denies any pain ,lidocaine patch on Rt shoulder for her chronic pain ,applied 1600hrs,and fentanyl patch on Rt side chest x 72 hrs.both hands swollen.propofol gtt 45 mcg/kg/hr .\n\nResp:orally intubated,ventillated ,CPAP+PS/ PEEP 5/PS 8/FIO2 40%/ Suctioned copious amount thick yellow secretions,no coughing reflex,planned for extubation,in view of her neuro status she was ready but due to thick secretions and no coughing reflex plan changed to extubate her tomorrow.LS clear ,slight diminish on Rt UL.blood gas done am ,7.32/52/86/28/\n\nCVS:HR 80-100'S,NSR,no ectopics noted,BP 110-150/70-80 mm of hg.heparin 5000u s/c started as there is no allergy to heparin now,per team.( and using heparin for HD also)\n\nGU/GI:Abdomen obese,BS present,tube feed neutran renal 10ml/hr started and increased to 20ml/hr,goal rate 20.residual 05ml.no BM this shift.anuric on HD three days in a week.next HD tomorrow.\n\nID :cefipime and genta DC'd,started on ceftriaxone 2gm in view of E coli in sputum,sensitive to ceftriaxone.\n\nIntegu:skin intact,edematous.positioned.Temp max 99.0\n\nSocial:sister called and updated.no visitors today.full code.\n\nIV access:only one PIV on Lt hand 20g,called for IV team,she told she will be coming ,if not succeded ,then plan for PICC or central line.HD perm cath on RT.SVC,dressing inact.\n\nPlan:wean and extubate tomorrow.pulmonary toileting.HD tomorrow.emotional support to pt and family.? stop feed by midnight for possible extubation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 1614515,
"text": "NPN 0700-1900\nEvents: Dialysis today pulled of 2L. To IR for midline placement right side sparing left as rec by renal as want to do fistula in future.\nExtubation aborted d/t high secretions\n\nNeuro: afebrile. Cont on propofol to keep intubated, able to wean down to 20mcg/kg/min and pt easily aroused w/voice, able to nod to yes/no ?s and appears to follow some commands.\n\nResp: moderate amt thick yellow secretions. Anesthesia @ bedside this afternoon to attempt extubation, however, pt w/copious thick yellow secretions that extubation not attempted. Pt resting on PSV 10/10 40%. LS: coarse t/o, has good cough and gag reflex\n\nCV: b/p labile, see flowsheet for details, able to give captopril as ordered given parameters. HD removed 2l.\n\nGI: ABD soft, no bm, BS+. Tube feeds off all day for anticipated extubation.\n\nGU: has not made urine, cont on MWF dialysis schedule\n\nSocial: dtr, , called for update.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-06 00:00:00.000",
"description": "Report",
"row_id": 1614516,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on CPAP/PS settings this AM. Decreased PS and Peep to . Tolerating well. Vt=450-625, Ve=4-7 liters, RR=10. Plan to extubate this AM. RSBI completed on PS 5=31.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-06 00:00:00.000",
"description": "Report",
"row_id": 1614517,
"text": "NPN 1900-0700\nFull code Spanish-speaking\nAll: PCN; note that Heparin SC has been started as pt unlikely to have experienced HIT\n\n71 yo female admitted w/ fever HD catheter infection. HD line changed on . Intubated after periods of apnea and episode of delerium. Has remained intubated esophageal swelling/no cuff leak and increased secretions, as well as continued agitation. Solumedrol q8h for esoph edema.\n\nNeuro: Lightly sedated on 20mcg/kg/min of propofol. Improved neuro status and no agitation this shift. +gag,+cough. MAE with decreased movement in RUE. Able to follow commands. T stable at 99.3.\n\nCV: NSR-ST 70-100 without ectopy. NBP 105-143/45-73. 3+ edema in UE's b/l, +pp b/l without edema. AM labs pending, pt has experienced mod Hct drop but stable now, guaiac stool if she has BM.\n\nResp: Remains intubated on CPAP @ 40/5/8. LS with scattered rhonci, coarse in LLL and diminished at bases. Sats>95%. Small cuff leak auscultated this am.\n\nGI/Endo: Obese abd s/nt with pos bs but again no BM. Rec'd colace as ordered, may require increased bowel regimen. HISS scale tightened, required 4units @ 0000, am pending.\n\nGU: anuric pt w/ ESRD. HD M/W/F, 2l removed on .\n\nPain: R shoulder pain of unknown origin, thought to be bursitis. Lidocaine patch applied at midnight, due off at noon.\n\nID: Gram neg rods in sputum on Ceftriaxone. Rec's Gentamicin at HD for line infxn\n\nSkin: CDI\n\nLines: new midline placed in IR on , flushing well but no blood draw. Dressing CDI.\n\nSocial: daughter called for update. Pt has 2 daughters, and . Their phone #'s are on the white board\n\nPlan: deep sxn prn, diligent w/oropharyngeal sxn before turning\n manage sedation, pain\n bowel regimen; guaiac stool\n HISS\n IV abx as ordered\n HD on Monday\n hope to extubate today\n c/o to floor after extubation and stable for 24h\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-06 00:00:00.000",
"description": "Report",
"row_id": 1614518,
"text": "RESPIRATORY CARE: PT EXTUBATED THIS AM OVER \nCATHETER W/ ANESTHESIA PRESENT. INITIALLY APPEARED\nCOMFORTABLE BUT GRADUALLY BECAME INCREASINGLY\nHYPERCARBIC AND REQUIRED REINTUBATION USING A\nFIBEROPTIC BRONCHOSCOPE BY ANESTHESIA. PLACED\nON THE AC MODE AS PER CV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-06 00:00:00.000",
"description": "Report",
"row_id": 1614519,
"text": "Shift Note: 0700-1900\nEvents: Received pt intubated and lightly sedated - no cuff leak present despite increasing vent settings and venting w/ ambut to elicite cuff leak. Team aware, pt has been receiving solumedrol, tolerating SBT extubation planned. Anesthesia to bedside and extubated over cook catheter, pt able to protect airway and cook removed. NGT placed pnd swallow eval and placement confirmed via CXR.\n\nPost extubation pt w/ increasing hypertension and tachycardia. Given lopressor 5mg IV w/ little effect. Pt then w/ increasing respiratory distress. Dr. to bedside, ABG obtained - 7.19/61/128. RT to bedside and pt given racemic epi neb and heliox, though respiratory distress continued to worsen. Anesthesia paged to bedside stat and pt intubated bronchoscopically w/ 7.0. Pt difficult to intubate w/ airway edema and collapse on inhalation. Pt now vented AC 500/5 X 18 FiO2 40%. ETT placement confirmed via ETCO2, BBS and CXR. Post intubation VS improving w/ decreasing hypotension and tachycardia. Fentanyl and versed sedation up as ordered. Team presently placing a-line.\n\nPlease see flowsheet for all objective data:\n\nROS:\n\nNeuro: Pt intubated and sedated, receiving fentanyl/versed sedation as above. Prior to re-intubation pt MAE w/ normal strenght. Bilat soft wrist restraints in place for pt's safety.\n\nResp: Vent settings as above, BBS CTA. Snx for moderate amounts bloody drainage. SpO2 100%. Team placing a-line and will need repeat ABG. Continues solumedrol as ordered.\n\nCV: HR now 60's to 70's -SR. SBP 140's.\n\nFEN: Pt NPO. Abd soft, non-tender w/ BS present. FSBS covered w/ SSI as ordered. Pt is anuric, HD pt. K+ 4.4.\n\nSocial: Pt's daughter in to visit this afternoon when pt extubated. Pt updated on pt staus and at that time by this RN and Dr. . S/P intubation Dr. called and spoke w/ pt's daughter to update family re: change in pt status.\n\nPlan: Continue to monitor VS and labs. Monitor Respiratory status closely. Continue sedation and Bilat soft wrist restraints for safety. Wean vent settings as able. Continue solu-medrol as ordered. Continue support for pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 1614520,
"text": "NPN 1900-0700\nFull code All: PCN ESRD\n\nNeuro: Currently well sedated on 4mg versed and 75mcg fentanyl. Pt restless and hypertensive on lower doses. Aroused to voice. MAE, afebrile.\n\nCV: NSR-SB with low rate of 48. No ectopy noted. Very hypertensive before sedation successfully titrated. Art line placed 2 2230. See carevue for objectives. AM Hct 31.9, other labs pending. HD due on Mon. Skin warm/dry, +pp's b/l. UE 3+ non pitting edema continues in upper extremities.\n\nResp: Intubed on CMV w RR 2 14, 40%/500/5. Not overbreathing vent at current sedation. AM abg pending, last noc gas improved to 7.47/30/11/22 from day shift acidotic episode. No am RSBI sedation for HTN\n\nGI/GU: Obese abd s. Scant stool output when washed, CDiff spec sent. Colace and bisacodyl admin @ , awaiting effect. Requested TF orders. Remains on HISS which may need to be modified as pt will no longer be getting solumedrol. No urine.\n\nSkin: CDI\n\nLines: HD cath dressing changed, CDI. R midline patent, dressing changed. Art line patent with good waveform.\n\nsocial: Daughter, checked in, stated that she had spoken to MD and was aware of reintubation, .\n\nPlan: manage sedation\n monitor, manage HTN\n probable trach placement in near future\n needs nutrition, may need HISS revisiion\n replete lytes prn\n monitor for skin brkdwn\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 1614521,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support. RR decreased from 18 to 14. Latest abg results on these settings reveal a mild respiratory alkalemia with good oxygenation.\n\nNo RSBI measured due to the level of PEEP required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 1614522,
"text": "resp care - Pt remains intubated and on full vent support. No changes were made this shift. ETT was advanced 3cm per CXR and MD. ETT is now 3cm above the carina. Pt was suctioned for thick, white secretions. BS were coarse t/o. Plan is for trach early this week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 1614523,
"text": "Shift Note: 0700-1900\nNeuro: Pt intubated and sedated. Pt initially lightly sedated on fentanyl/versed, easily arousable to soft voice, though bradycardic to 50's w/ rhythm sinus to junctional. Sedation changed to propofol at 30mcg/kg/min. Pt obtunded at times and hypotensive w/ SBP to 80's, then agitated, pulling against bilat soft wrist restraints and reaching for ETT w/ SBP to 180's. Propofol titrated and pt started on fentanyl 25-50mcg IV Q 1hr PRN now w/ better control of sedation and stable SBP. Pt resting quietly in bed, appears calm and relaxed and remains free of s/s pain.\n\nResp: Vent settings AC 500/5 X 18 FiO2 40%. BBS somewhat course t/o. Snx q2-3hr for small to moderate amounts thick white secretions. Remains afebrile. SpO2 remains 98-100%.\n\nCV: HR 45 has ranged 45 to low 100's w/ episodes juncional escape rhythm w/ versed sedation as above. Rhythm has remained SB to SR since changing versed to propofol. BP labile as above. Captopril held earlier episodes of hypotension. SBP now 1teens to 140's w/ HR mid 40's.\n\nFEN: Pt tolerating TF nutren renal at 20ml/hr. Increasing to goal rate as ordered. Abd soft, non-tender w/ BS present. Pt anuric on HD. FSBS controlled w/ SSI as ordered.\n\nSocial: Daughter has called, updated on pt status and . Team to discuss possiblity of trach this evening when she comes in.\n\nPlan: Continue to monitor VS and labs. Anticipate surgical trach placement early this week. Titrate propofol and fentanyl to achieve optimal sedation. Advance TF as tolerated. Pt to receive HD in am. Continue support for pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1614531,
"text": " 4 ICU NPN 0700-1900\nPS trial of 15. RR down to 6 breaths min with low MV. Switched back to A/C. BS coarse. Suctioned for mod amt, thick, yellow secretions.\nSBP 70's 230's. Usulally with small boluses of fentanyl or propofol.\nCurrently on fentanyl 20 mcg hr.\nHD done X 4hrs. Removed 2 KG. Initially much difficulty aspirating from HD lines despite TPA. Improved towards end of treatment. Lines dwelling with TPA between treatments. Anuric\nAlso much difficult asp from A-line. Unable to asp from blue port as well as midlie catheter. All ports flush without dificulty.\nIn IR to R/O thrombus in chest. Heparin gtt started. Off at present while in IR.\nOn fent gtt with peroids of agitation especially when stimulated. Unable to talk pt down. Pt is speaking.\nDtr phoned. She stated she wil be in to visit today.\nA/P; Unable to tol PS.\nR/O SVC Syndrome. restated heparin. Assess for bleeding. Appears hypercoaguable ?/ eti.\nD/C midline.\nFent gtt for sedation. Add propofol back if necessary & pt tolerates.\nSupport to pt & family\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1614532,
"text": "Respiratory Care\n\n Pt continues on full ventilatory support. Pt placed on PSV 15/5 and tolerated well until she dropped her RR () and was placed back on A/C. B/S ess clear and dim in bases. With cuff down there is NO leak. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1614533,
"text": "Resp Care Note,Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick bld tinged secretions.Oral airway placed,pt biting on ETT. HR-ST with PVC'S.BP labile. Sedated with fentanyl and propofol. to L2 for new HD cath. Unable to place. Pt was stented.Will go back to L2 today.Plan for trach and peg? when. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1614534,
"text": "NPN 1900-0700\nFull code speaking All: PCN\nSVC gram/stent placement/angioplasty in IR for numerous clots (likely old) with collateral circulation\n\nNeuro: Minimally sedated on 10mcg Propofol and 10mcg Fentanyl; rec's occasional boluses prior to nursing care. Oral airway had to be placed pt biting on ETT. MAE though RUE rarely. PERRL sluggishly. Intermittently interactive, nodding appropriately to yes/no ?'s. Afebrile.\n\nCV: NSR to ST 80's to 1teen's. PVC's noted throughout shift. Very labile pressures, appears to be sedation, agitation. Heparin drip currently off as PTT >150, to restart @ 0600 at 800units/hr. Pt was oozing continuously from fem line site which required dressing changes x3. Has slowed somewhat. UE's continue to be edematous to 3+, cool.\n\nResp: LS clear in upper lobes, diminished at bases particularly on L. Intubated with oral airway placed to prevent biting on tube. Assist control at 40%,RR= 14 with overbreathing when agitated, 500/5. Plan for trach and PEG, probably at end of week\n\nGI/Endo: Obese abd s/nt with +BS. Scant amt stool when bathed. Needs additional bowel regimen. HISS, no coverage this shift. TF remains off in case trach can be placed .\n\nGU: anuric. HD M/W/F. New HD cath placed in IR on .\n\nSkin: new stage 2 pressure ulcer at coccyx. Washed, duoderm applied. Frequent turns.\n\nID: Ceftriaxone for PNA and previous line infxn of enterobacter\n\nLines: Midline not d/c'd for now, spoke with Dr re: tenuous state of fem line. Fem line has all lines patent and drawing. Dressing changed and surgicell applied, may require addtional change in am. HD cath dressing changed also for oozing which has since ceased. Art line patent, good wave form. Needs dressing change, plan to do so this shift.\n\nPlan: Manage pressure vs sedation\n Head CT in am\n IV abx\n HISS\n restart TF if no IP trach placement\n Heparin gtt for hypercoagulability --monitor platelets\n Emotional support for pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-09-29 00:00:00.000",
"description": "Report",
"row_id": 1614489,
"text": "71yr old spanish speaking female admitted to floor w/ temp 103 r/t line infection. new dialysis line placed .\nPMH: end stage renal disease, dialysis 3x/wk, HTN, sleep apnea, DM, and arthritis.\n\npt became confused and combative 9/8pm w/ periods of apnea and O2 sat dropping to high 80s-90s. transfered to unit for O2 monitoring and changes in mental status.\n\nneuro: confused, agitated, and combative. in soft limb restraints bilat arms for safety. pulling off NC, pulling at lines, and trying to get OOB. haldol 2mg given with no improvement, QT elongation so haldol D/Ced and ativan started. spanish interpreter called, pt not making sense. CT of head ordered, unable to do b/c of agitation. team did not want to sedate.\n\nresp: RR 20s, 30s when agitated. O2 sat 96-100% on 2L NC.\n\ncv: elevated BP but stable, NSR-ST. refusing PO meds. HIT, on argatraban gtt, PTT w/ AMLs.\n\ngi/gu: pt anuric per floor rpt, no stool this shift. +BS, NPO except ice chips.\n\nplan: poss head CT, U/S R shoulder r/t pain. sitter, full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1614535,
"text": "Respiratory Care\n\n Pt continues on full ventilatory support. Pt traveled to CT and Angio without complication. B/S coarse Sx'd for mod amount teneciously thick yellow secretions. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1614536,
"text": " 4 ICU NPN 0700-1900\nevents. head Ct scan to r/o cerebral edema, unable to TPA SVC clot oozing from HD, CVL sites & increased risk of complications due to bleeding if given TPA. No vent channges.\nOozing blood from HD catheter. Dsd changed x1. Old blood clots noted from insertion site L femerol CVL. Dsg changed x1 . No additional bleeding noted, heamtoma noted around TL inserrtion site when able to visualize groin area. Pt to IR for TPA. Procedure deferred when bleding from HD catheter insertion site noted. Heparin gtt off all day for elevated PTT & for TPA procedure. PTT sent this afternoon for baseline ptt .Plts nml. L upper arm 38 cm. (marked with skin marker)\nPreliminary results of head CT scan negative to R/O cerebral edema. At X's appears to nod & shake head to questions when asked in . Lifts legs in air, moves s LUE, minimal movement from RUE. PEARL 3-4mm\nRemains on A/C 500 X 14 X .4, PEEP. BS Clear to coarse, diminished at bases. ; Fent gtt at 15 mcg hr & propofol 22 mcg/kg.min (based on admit wt of 80 kg)\nTF restarted at 10 cc hr. Abd obese, positive BS. No stool. given colce, bisacodyl.\nSeveral visiters including dtr & sister in to visit. Updated on pt's condition.\nHD deferred until tomorrow scheduling conflict with IR.\nOverall hypertensive most of the shift with SBP 160's-200 with transient response to fentanyl & propofol boluses. On captopril 6.25.\nAwaiting trach & pnd. According to progress note , pt's family has consented to both.\nA/P; Bleeding has sig subsided from HD site & stopped oozing from TL site. Restart heparin gtt with bolus according to baseline PTT (pnd). Will reevaluate for TPA . Assess for bleeding.\n Stable on vent ? PS trial in Am if pt remains stable overnight. Mouth care Q4 hrs\n need to increase propofol/ fentanyl gtts to maintain adequate sedation.\n? increase captopril for HTN.\nHD .\nChange TF to Nutren Renal 3/4 strength with Beneprotein when available. Needs aggressive bowl regime. lactulose added. ? lactulose enema.\nTrach & PEG hopefully this week.\nSupport to pt & family .\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-11 00:00:00.000",
"description": "Report",
"row_id": 1614537,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick bld tinged secretions. Sedated with propofol and fentanyl.No spont resp @ this time. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-12 00:00:00.000",
"description": "Report",
"row_id": 1614541,
"text": " nsg note: 19:00-7:00\n71 y.o. speaking woman adm to with fever to 103, ? r/t dialysis line infection. line was changed . on pt increasingly confused, MS changes, periods of apnea with bradycardia requiring intubation on with difficult airway. an extubation was tried but within 5 hours pt tired with stridor and worsening resp failure. pt then developed clots at the end of the dialysis line, on and off heparin d/t elevated ptt. pt being treated with heparin gtt for clots at end of dialysis line. IR deferred doing TPA. heparin gtt adjusted per ptt sliding scale.\n\nneuro: sedated at times alternating with periods of wakefullness with agitation hitting the bed, attempting to pull at lines. very hypertensive to the 200s when awake and agitated and when grimacing fentanyl gtt was increased as high as 75mcg/hr but pt remained hyertensive and agitated. required propofol intermittently for agitation but very sensitive to even a very low dose of 15mcg/kg/min with sbp as low as 79. perrla 3mm sluggish. bilat wrist restraints maintained to prevent pt from pulling lines out.\n\ncv: hr ranging 70s-90s sr with no ectopy noted. bp ranging 80s-200s depending on level of agitation. arterial line appears dampened when pt hypotensive but appears sharp when hypertensive. +pp. heparin gtt decreased to 800units/hr at 9pm and ptt pending from 3:00am.\n\ngi/gu: abd obese, soft, +bs, moderate brown soft bm- unable to send for cdiff spec as sample smeared in pads. anuric.\n\nskin: coccyx with stage 2 coccyx decub very small pea sized. aloe vesta liberally applied with turns.\n\nplan: monitor and manage sedation and bps. hd as scheduled, attempt extubation over the weekend if possible. trach/peg asap. sw to follow prn. f/u with ptt results and adjust heparin gtt per ss.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-12 00:00:00.000",
"description": "Report",
"row_id": 1614542,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thick bld tinged secretions.RSBI done on 0 peep/5 ips 37.Agitated @ times bites on ETT.Sedated with fentanyl. Getting heparin.BP labile @ times. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-09-30 00:00:00.000",
"description": "Report",
"row_id": 1614490,
"text": "Nsg notes 1900-0700hrs.\n\nAllergies:PCN,heparin.\n\n71yo femaile pt PMH ESRD on HD ,sleep apnea,arthritis,s/p knee replacemnt admitted to in confused and combative stage for close monitoring and further manangement.c/o pain on Rt shoulder,U/S scan done,report fluid collection.\n\nNeuro:alert and oriented x 1 ,denies any pain this shift,receieved total Inj ativan 2mg iv this shift without much good efect.\n\nResp:on RA 2lit/min,sats > 97-100%. LS coarse.\n\nCVS:HR 80-100/min,NSR.BP 120-160 sys.argatrobin 1.276 mg/kg/min is on progress.\n\nGU/GI:abdomen obese,BS present.NPO except meds.KVO on.anuric.\n\nSocial:agitated at times,slept on and off.sister called and updated.full code.\n\nPlan:continue same treatments.watch for orientation.follow up with PTT report\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-09-30 00:00:00.000",
"description": "Report",
"row_id": 1614491,
"text": "Nsg notes contd...\n\nAt around 0515 am pt apnoeic and holding breath for long time,sats 88-90%,started breathing when i called and again stopped ,and having agonal breathing,ambu bag done,sats maintained 95-98%,and called for anaesthesia for intubation,difficult intubation,finally intubated with LMA and cook airway assistance.connected to ventillator.sats 97%,BP maintained 100-110/60-70 mm of hg. sump OGT inserted.cxr done\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-09-30 00:00:00.000",
"description": "Report",
"row_id": 1614492,
"text": "Respiratory Care:\nPt emergently intubated at ~0600 due to apnea, She has a #7.5 OET @ 21cms. Not over breathing the set RR unless stimulated. Went to CT for head and chest this PM..Results pending. The OET was withdrawn 2cms to 19cms today per CXR. On A/C 450 x 14/14 @ 60% w/5peep FiO2 to 40%\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-09-30 00:00:00.000",
"description": "Report",
"row_id": 1614493,
"text": "Respiratory Care:\nADDENDA: CT showed fluid/blood around liver. FiO2 to 40%\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-09-30 00:00:00.000",
"description": "Report",
"row_id": 1614494,
"text": "Shift Note: 0700-1900\nNeuro: Received pt intubated w/ minimal responsiveness - eye twitch noted w/ snx. Recieved pt off sedation. As shift progressed, pt w/ agitation and reaching for tubes and lines w/ stimulation, though quickly becoming obtunded w/ stimulation removed and no overbreathing of vent settings noted. Pt started on propofol briefly to faciliated CT scan, though became hypotensive on small dose of propfol and this drug was D/C'd. BP slowly stabilized, pt to CT ~1400, recieved total dose versed 1mg and fentanyl 50mcg to facilitate CT scan w/o significant change in MS. At rest pt appears calm and relaxed, not overbreathing vent, no guarding, appears comfortable w/ no s/s pain.\n\nResp: Pt intubated and vented - weaning FiO2. ABG continues to improve w/ decreasing acidosis. Current vent settings AC 400/5 X 14 FiO2 weaned to 50%. Current ABG 7.33/46/162. Snx X1 w/ no significant secretions. BBS CTA. Spo2 remains 95-100%.\n\nCV: Pt hypotensive to 80's at start of shift as above. Recieved total IVF bolus 1200ml during peri-intubation period. BP stabilized and IVF stopped. Pt again hypotensive w/ small dose of propofol as above, though resolved w/ D/C of propofol. BP borderline t/o mid to late am w/ SBP 90's to low 100's, now low 100's to 130's. HR 80's to 90's SR w/ no appreciable ectopy. EKG w/o change per team.\n\nFEN: Pt is HD pt and is anuric. RSC tunneled cath in place. Received fluid bolus at start of shift as above. Given IV and PO contrast for CT, and hyperphosphatemia noted. Pt seen by renal fellow though no need for HD today, and plan for HD tomorrow. Abd soft, non-tender, BS present. OGT present and placement confirmed via CXR per team. Pt remains NPO. No BM this shift. Recieved pt on agatroban infusing per protocol. Bleed noted on CT near liver per team and agatroban D/C'd. Hct 29.0 down from 36.8. HR and BP remain stable. Repeat hct due at . Pt w/ PIV #22 X2, #20 X 1 and # 18 X1, no need for central line access at this time MD. Plan to continue to follow VS and labs w/ plan for PRBC transfusion for hct <25 or hemodynamic instability. Team reports bleeding likely loculated and will hopefully self tamponade.\n\nSocial: Pt's daughter has been updated on pt status and by MD. Many family members in to see pt today.\n\nPlan: Continue to monitor VS and labs closely. Monitor for s/s active bleeding and plan for PRBC transfusion as above. Monitor neuro status and respiratory status closely and follow sedation needs. Wean vent settings as able. Continue support for pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-01 00:00:00.000",
"description": "Report",
"row_id": 1614495,
"text": " nsg note: 19:00-7:00\nthis is a 71 y.o. woman adm with esrd on hd, adm to floor with temp 103 r/t dialysis line-replaced . became confused and combative with periods of apnea and desat to high 80s. transferred to and required intubated by 5am for prolonged period of apnea. pt was a difficult intubation. head ct negative, abd/pelvis ct showed ? fluid/blood around liver versus chronic svc clot. argatroban continues to remain on hold per team with q6hr hcts checked and remaining stable.\n\nneuro: opens eyes and thrashing with stimulation. c/o r shoulder pain. given 100mcg fentanyl and 2mg versed with good effect but only seeming to last for 2 hours. per team, will reattempt to sedate with propofol low dose with next period of agitation. propofol was d'cd sec. to sbp dipping into the 90s. perrla 4mm sluggish. bilat wrist restraints maintained as pt attempting to pull at ett.\n\ncv: hr ranging 70s-80s sr with no ectopy noted. sbp ranging 100s when resting and up to 180s when agitated and with r shoulder pain. +pp.\n\nresp: remains intubated with no vent changes made: .4x450x14+5. lungs cta, suctioned for scant amt white sputum. sp02 ranging 99-100%.\n\ngi/gu: abd obese, soft, +bs, no bm, remains npo. ogt patent with minimal bilious residuals. anuric.\n\nskin: clean, dry, and intact.\n\naccess: r radial aline, #22g , #22g r wrist, #18g rla, r radial aline.\n\nplan: continue to check hct q6hrs, try propofol for agitation and monitor bp. hold argatroban for now. ? will be able to extubate later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-12 00:00:00.000",
"description": "Report",
"row_id": 1614543,
"text": " 4 RN REPORT 0700-1900\n\nEVENTS: CAT SCAN HEAD W/ CONTRAST AND NECK W/OUT CONTRAST.\n\nNEURO: Pt is awake on vent. Primarily speaking does not understand english. Follows commands. Moves all four extremities. On fentanyl GTT 50mch/hr. Becomes agitated during activities needs fentanyl bolus to calm her. Pupil 3mm brisk.CT head report pending.\n\nCV: HR 70-80 NSR. Periods of tachycardia noted w/ agitation. No ectopy. PTT @ 1100 51 Heparin 950units GTT. A line dampend but draws blood. SBP 85-120 Hypertensive episodes w/ agitation received fentanyl bolus.\n\nRESP: LS clear dim, On vent PS 10/5/40% No vent changes in this shift.\nSuctioned yellow thick sec. RSBI 37 but no cuff leak.\n\nGI/GU: Abd soft, BS x4, NGT feed nutrene renal 3/4 strength w/ benprotien 30gm 300cc/hr @ goal. Anuric.\n\nID: T max 99.1 Abx cefriaxone.\n\nACCESS: RSC HD cath, Rt fem triple lumen, Rt brachial midline PICC, Rt radial A line dampend.\n\nSOCIAL: Full code. Family visited and updated.\n\nPLAN: SVC gram to schedule routine. No time yet.\n HD tommorrow\n PEG and Tracheostomy on monday. Anaesthesia consult visited telephone consent obtained from daughter .\n PTT @ 2200.\n ? PICC line.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-14 00:00:00.000",
"description": "Report",
"row_id": 1614554,
"text": " to MICU 7 transfer acceptance note\n71 yo speaking woman admitted to w/presumed dialysis line sepsis. Now being transfered from to MICU 7 in anticipation of HD and going to OR for tracheostomy .\nBrief Hosp course: Pt required intubation for worsening mental status, delirium, sleep apnea and eventually bradycardia and resp failure. Pt was a difficult intubation and anethesia recommends their presence if/when extubated. Pt was extubated on and reintubated (with difficulty) 5 hours later for resp failure. Pt had HD line changed over upon admit w/suspected line sepsis, developed right arm swelling and work up revealed SVC clots. There was a question of HIT and Heparin listed on the allergy sheet, however, w/u not + for HIT and is NOT allergic to Heparin. Currently on Heparin gtt @ therapeutic dose for clots, to have heparin off tomorrow 6 hours prior to going to OR for tracheostomy @ 1300. Pt has been difficult to sedate. Has required propofol, fentanyl and is currently on fentanyl and versed. Recent head CT done on to r/o cerebral edema was -. Awaiting patient arrival from via ambulance.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-15 00:00:00.000",
"description": "Report",
"row_id": 1614555,
"text": "Resp Care\nPt. remains intubated/sedated overnight w/o vent changes.\nBS: coarse sxn'd for minimal thick yellow.\nPlan:To OR for trach/peg. Return to -4\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-01 00:00:00.000",
"description": "Report",
"row_id": 1614496,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Latest abg results determined a very mild respiratory acidemia with good oxygenation on the current settings.\n\nNo RSBI measured due to patient's agitation at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-01 00:00:00.000",
"description": "Report",
"row_id": 1614497,
"text": "resp care - Pt remains intubated and is on PSV. ABG is WNL. BS were mostly clear and pt had minimal secretions. No cuff leak is present. Continued weaning planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-01 00:00:00.000",
"description": "Report",
"row_id": 1614498,
"text": "Shift Note: 0700-1900\nNeuro: Pt intubated and sedated. Initially on low doses of propofol and receiving fentanyl boluses 100mcg ~q2hr overnoc as ordered. At start of shift pt agitated, thrashing in bed and reaching for ETT. Pt tachypneic w/ low tital volumes on PS trial in am prior to increasing sedation. Propofol has been titrated, pt started on fentanyl gtt at 25mcg/hr and pt has been started on zyprexa. Pt now adequately sedated, receiving zyprexa PRN as ordered and weaning propofol. Pt occasionally grimacing w/ light palpation of LUE though pain well controlled w/ fentanyl as above. Pt resting quietly in bed, easily arousable to soft voice, appears calm and relaxed, no grimace at rest and appears comfortable.\n\nResp: Vented AC weaned to CPAP/PS 10/5 FiO2 40% w/ obtaining adequate sedation. Pt now w/ RR 14 TV 400 MV 5.2L. Snx q3-4hr for moderate amounts thick tan secretions. BBS CTA, SpO2 98-100%. ABG on current settings 7.37/43/108. Tongue remains somewhat swollen, no cuff leak noted, anticipate order for steroids.\n\nCV: HR 90's to low 100's, SR/ST w/ no appreciable ectopy. BP stable. Team reports radiology report of yesterdays CT now negative for bleeding and indicates likely SVC clot. Argatroban restarted as ordered at 1.05 mcg/kg/min per pharmicist as this was her dose at time of D/C yesterday. PTT 59.5 2hr after starting argatroban, now will need q6hr PTT checks w/ titration per protocol. Plan TEE in am.\n\nFEN: Pt remains NPO. Abd soft, non-tender, BS present. Pt incontinent of scant soft brown stool - guiac negative. Pt remains NPO pnd TEE tomorrow, though TF orders in place. Pt started on PPI. Pt received HD for 1.9L off today. Tolerated well, BP remained stable. Gentamycin given s/p HD and peak level sent per pharmacy as they feel pt may need increased dose.\n\nSocial: Call received from daughter , Updated on pt status and .\n\nPlan: Continue to monitor VS and labs as ordered. Monitor respiratory status closely. Anticipate order for steroids as above. Wean vent settings as able. Plan for TEE tomorrow and also likely MRI to evaluate SVC clot. Pt to remain intubated for these procedures though potential extubation possible pnd ability to wean and airway stability. If pt remains intubated start TF as ordered. Continue support for pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-02 00:00:00.000",
"description": "Report",
"row_id": 1614502,
"text": "nsg.notes 0700-1900hrs\n\n71yo lady with PMH ESRD,sleep apnoea,arthritis,lt knee replacement admittted to on with increased agitation and confusion after HD,for observation,intubated on for prolonged apnoea.\n\nNeuro:sedated with fentanyl 25 and propofol 25,needs bolus dose in between ,when wide awake BP >210/80 mm of hg.tried to dc propofol during am rounds,but restarted because of increased agitation.received zyprexa only one dose at 0700hrs.c/o pain on Rt shoulder,lidocaine patch 5% applied.pupils 2mm size ,sluggish reacting to light,following commands consistently,spanish speaking.\n\nResp:orally intubated,vented,was on CPAP + PS,required more sedation for TEE ,then vent mode changed to AC/14/5/450/40%/ .can be changed back to CPAP when more awake.LS clear,suctioned small thick yellow secretions.sats 98-100%\n\nCVS:HR 46-56/MIN WHEN SLEEPING ,SB,when awake HR >70/min,NSR,no ectopics noted.BP ranging from 150-240/70-110 mm of hg,depending on her agitation.started on captopril.TEE done,report no endocarditis,thick walls.argotroban titrated per PTT.At present running at a rate of 0.800 mcg/kg/min.EKG done for bradycardia.\n\nGU/GI:NPO,except for meds,abdomen obese,BS present.no BM this shift.anuric ,on HD 3days in a week,next HD .\n\nIntegu:skin intact,afebrile,positioned ,all hygenic needs attended.both arms restrained for safety purpose.\n\nSocial:brothers visited and sister called over the phone and updated.\nspanish speaking.full code.\n\nPlan:vent mode back to CPAP +PS when possible,HD tomorrow.monitor BP and HR.Control agitation.next PTT at 2000hrs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-03 00:00:00.000",
"description": "Report",
"row_id": 1614503,
"text": "Resp Care\nPt. remains intubated/sedated overnight. Initally on , however pt. placed on MMV d/t MV 2-3LPM when sedated. This morning rsbi was 20 and a cuff leak was noted @ 0500.(started on steroids yesterday d/t lack of cuff leak)\nBS: dim. bilat. sxn'd for yellow thick mod. amts.\nPlan:Appears to be a good canidate for extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-04 00:00:00.000",
"description": "Report",
"row_id": 1614508,
"text": "Resp Care\n\nPt is breathing spont on PSV mod with 10 of peep. She was given a back up ventilation mode in the form of MMV last night so she could be sedated w/o concern for hypoventilation. SHe has an ABG from this morning that reveals a mostly compensated resp acidosis with somewhat marginally acceptable Po2 for 4-% FiO2 and 10 peep. . Plan today is to attempt wean peep and prepare for extubation. Pt was difficult intubation. She requires sedation due to agitation but this is problm as resp become suppressed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-15 00:00:00.000",
"description": "Report",
"row_id": 1614556,
"text": "MICU NPN 7P-7A\nNEURO: FAMILY AND MD A START OF SHIFT. PT AWAKE AND AGITATED, THRASHING AROUND, ATTEMPTING TO SIT UP. ASKED FAMILY TO DISCONTINUE STIMULATING HER AS IT WAS CAUSING HER BP TO JUMP TO >200'S. WHEN QUESTIONING THE FAMILY THEY STATED THAT PT DENIED PAIN, WAS NODDING APPROPIATELY TO QUESTIONS AND WAS ABLE TO FOLLOW COMMANDS. FAMILY SAID THEIR GOODBYES AND PT WAS . REMAINS ON 100MCG OF FENTANYL AND 1MG VERSED. EASILY AROUSABLE TO VOICE/STIMULUS. REC'D BOLUSES THROUGHOUT THE SHIFT FOR AGITATION WITH EFFECT. PERL @2-4MM AND BRISK. GAG IMPAIRED. SOFT WRIST RESTRAINTS IN PLACE FOR SAFETY OF LINES AND TUBES.\n\nCARDIAC: HR 61-87 SR WITH RARE ECTOPY. BP 83-188/40-82. RECEIVED ON 1100UNITS/HR OF HEPARIN. MORNING PTT 83, WITHIN RANGE, HCT 24, NO SIGNS OF BLEEDING. PEDAL PULSES BY DOPPLER.\n\nRESP: REMAINS ON A/C 500X14 40% +5PEEP. RR 14-24 SATS 100%. LS COARSE, SXTED FOR SMALL AMOUNT OF THICK YELLOW SPUTUM.\n\nGI/GU: ABD OBESE WITH +BS. NO STOOL. NGT IN PLACE AND PATENT. ANURIC, CREAT 4.4.\n\nFEN: UPPER BODY EDEMA. +7L LOS. LYTES PER CAREVUE. FS Q6HRS WITH SS HUMALOG. NPO SINCE MIDNOC.\n\nID: TMAX 99.1 WITH WBC OF 11. BLD CX'S PENDING. CONITNUES ON MEROPENEM AND VANCO ON HD DAYS. TREATING E.COLI PNA.\n\nSKIN: ABRAISED AREA ON COCCYX/RIGHT BUTTOCK. DUODERM THIN APPLIED. RIJ AREA WITH SMALL AOPEN AREA THAT HAVE BEEN PREVIOUS LINE SITE, 2X2 APPLIED.\n\nACCESS: RSC HD LINE, RIGHT ART LINE, RIGHT FEM CVL, RAC MIDLINE.\n\nSOCIAL/DISPO: FULL CODE. DAUGHTERS IN LAST NOC, SPOKE WITH MD. TURN OFF HEPARIN GTT @0700 FOR TRACH/PEG IN OR @1300. WILL HAVE HD THIS MORNING. ?PLAN TO GO BACK TO 4 AFTER PROCEDURES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-04 00:00:00.000",
"description": "Report",
"row_id": 1614509,
"text": "NPN 1900-0700\nEvent: Pt suddenly became extremely agitated @0545 despite being on Propofol 35mcg/kg/min. Pulling at ETT, mouthing words. Given Fentanyl 50mcg IV x1, Propofol increased to 45mcg/kg; daughter had telephoned so she spoke to pt in Spanish in an effort to assess for pain or discomfort other than ETT. Pt is now resting comfortably. Passed RSBI this am, hope to extubate sooner rather than later.\n\nNeuro: Occasional periods of mild agitation other than above episode but slept for 3-4 hrs overnoc. MAE, very strong. PERRL b/l. c/o pain in R shoulder. Fent patch for pain and Lidocaine patch due @ 1600. Inconsistently follows some commands. Spanish speaking.\n\nCV: SR-ST w/ occasional PVC's noted. Experienced hypotension Propofol @ 55mcg/kg (increased for obvious discomfort) but quickly rebounded when Prop shut off. HTN with episodes of agitation. See Carevue. UE's grossly edemetous b/l. No labs obtained this am.\n\nResp: CPAP/PS 40%/. LSCTS b/l slightly diminished in R base. Sxn for small amts thick yellow sputum. Sats 93-100%.\n\nGI: Obese abd, +BS. Very small bm this shift. TF off at midnight for extubation attempt. RISS. AM FS pending.\n\nGU: anuric\n\nLines: PIV x2 on L wrist. HD cath w/ dressing CDI.\n\nSocial: Daughters in to visit last night. called this am and was able to calm pt. Will be going to work. Call first if pt needs to be calmed again. Phone #'s on white board.\n\nPlan: Attempt extubation\n Monitor and manage hypo/hypertension.\n RISS\n Cefepime when approved\n ? sputum cx\n emotional support\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 1614512,
"text": " nsg note: 19:00-7:00\nthis is a 70 y.o. woman with ESRD on hd (mwf) who developed fevers to 103 and rigors. pt intubated for apnea and associated bradycardia in setting of delirium, sleep apnea and benzos. pt also has pna. sputum cxs show GNRs. cefepime and gent dc'd . down to only one peripheral iv (#20 l wrist) d/t poor veins. iv rn unable to place another iv. propofol infusing thru the single iv to keep pt sedated for agitation. pt with increased secretions and poor cough/no gap , thus extubation held off.\n\nneuro: sedated on propofol 45mcg/kg/min. opens eyes to stimuli with repositioning. mae with stimuli but less with rue. appears comfortable with no grimacing noted. perrla 2mm sluggish. bilat wrist restraints maintained to prevent pulling of tubes. no gag, weak cough.\n\ncv: hr ranging 60s-70s sr with no ectopy noted. bp ranging 100s-130s/40s-50s. +pp. trace edema.\n\nresp: remains on psv with no vent changes: fi02 40%, 8 ps, 5 peep. sp02 ranging high 90s-100%. lungs cta and diminished at bases. suctioned for scant to small amts thick tan secretions. maintaining tidal volumes of 400-480.\n\ngi/gu: abd obese, soft, +bs, no bm, tolerated tf with no residual but shut off at midnight for possible extubation in am. anuric.\n\nskin: warm, dry, intact.\n\nid: afebrile. md team aware pt only with one piv #20g in l wrist infusing propofol. iv rn and this rn unable to place another iv. per team, pt given ceftriaxone im x1 dose and team to reevaluate access issue in am. team is hoping pt gets extubated in am and won't need propofol and will start to take pos.\n\nsocial: dtr. called and given update.\n\nplan: continue npo for possible extubation in am, assess gag, cough if improved off propofol. address iv access issue. may need picc line placement in IR as pt not a candidate for bedside picc iv rn team. hd .\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 1614513,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on CPAP/PS settings through night. Vt=385-500, RR=. RSBI completed on PS 5=32. Tan secretions decreasing during shift. Plan to extubate when secretions subside.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 1614514,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED AND ON\nPS AS PER CV. TAKEN TO IR FOR A PICC LINE\nTODAY W/OUT INCIDENT. OTHER DATA AS PER CV. WILL\nC/W PS A0/A0 AS TOLERATED AND REEVALUATE IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 1614524,
"text": "NPN 1900-0700\n70 yo woman w/ESRD on HD had developed fever to 103 and rigors admitted to . Pt rx for pneumonia. Pt intubated for apnea and asociated bradycardia in setting of delirium, sleep apnea and benzos(difficult airway). Pt w/very poor IV access, has single lumen right antecub midline through which propofol in infusing. Tunnel HD catheter (R)subclavian. Attempting to save left arm for fistula in future. Multiple IV attempts by MICU staff as well as IV RNs. Pt extubated and required reintubation within 5hours for resp failure. Pt will need trach and Dr. talked w/pt's evening. Dtr's anticipated to return w/decision re: consent for trache soon after discussion w/in family. Events overnight, continues to have labile b/p, usually appears sedate on propofol, however, wakes up, appears agitated or in pain, occasionally admits to pain.\n\nNeuro: Propofol infusing @ 30mcg/kg/min and usually appears sedate, however, appears to awaken with agitation, pulling at restraints, legs in air, facial grimacing. Occasionally nods to yes/no ?s. Pt medicated w/fentanyl 50mcg four times w/relief of apparent pain/agitation. Medicated once w/5mg olanzipine without good effect. Afebrile. Pt w/good gag and cough reflexes.\n\nResp: No vent changes overnight, remains on AC, occasionally overbreathing vent. Suctioning thick white secretions from ETT.\nLS: coarse t/o, occasionally clrs w/suctioning, no wheezes.\n\nCV: b/p labile as well as HR, see flowsheet.\n\nGI: ABD soft, BS+, tube feeds @ goal 20cc/hr, low to no residuals. No bm this shift.\n\nGU: On HD 3xweek MWF schedule. Does not make urine.\n\nSocial: Pt's and visited, had discussion w/Dr. re: condition and need for tracheostomy.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 1614525,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. No morning abg results at this time.\n\nRSBI = 27 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 1614526,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED AAND ON THE AC MODE\nAS PER CV. TAKEN TO MRI AND CT SCAN TODAY OF CHEST TO R/O\nSVC SYNDROME. BP LABILE DURING TX AND PT DIFFICULT TO SEDATE\nAND MAINTAIN STABLE BP BY RN. SPO2 STABLE WHEN TRACING WAS ADEQUATE.\nPT BACK TO 4 AFTER CT SCAN W/ OUT INCIDENT. WILL C/W AC MODE\nAS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 1614527,
"text": "Shift Note: 0700-1900\nNeuro/events: Obtaining adequate sedation has remained difficult w/ pt lightly sedated at times, easily arousable to soft voice to pt pulling against bilat soft wrist restraints, legs in air. Pt hypotensive w/ SBP to 80's at times w/ adaquate sedation, then SBP to 200's w/ pt agitated. Pt has been started on fentanyl gtt for better control of sedation to faciliate MRI - see flow sheet. Pt transported to MRI in bed at 1530, initially well sedated and normotensive, though pt increasingly agitated w/ SBP to 200's despite propofol increased to 60mcg/kg/min and multiple boluses given. Approximately 45 minutes spent in MRI working towards controlling sedation and hemodynamic status, then despite obtaining appropriate sedation and hemodynamic stability decision was made by MD's to obtain CT in place of MRI. Pt transported to CT and tolerated study well. Pt returned to unit at 1730, now resting quietly in bed, appears calm and relaxed and remains free of distress. Titrating sedation to obtain optimal sedation and hemodynamic stability.\n\nResp: No change in vent settings AC 500/5 X 18 FiO2 40%. BBS somewhat course. SpO2 remains 98-100%.\n\nCV: HR 45-90's SB/SR w/ no appreciable ectopy. BP labile in setting of sedation as above. Capotopril held per Dr. - reassess plan for captopril tonight. BUE remain edematous, CT to r/o SVC syndrome as above - results pnd.\n\nFEN: Abd obese, non-tender, BS present. Tolerating TF at goal rate. FSBS covered w/ SSI as ordered. HD postponed for imaging studies as above. Plan for HD tomorrow.\n\nSocial: call received from this am. Reports that she has discussed plan for trach w/ team last noc and denies questions. Dr. reports . to obtain consent.\n\nPlan: Continue to monitor VS, continue to titrate fentanyl up to faciliate propofol down to obtain adequate sedation and decrease episodes of hypotension. Monitor labs as ordered. Plan for HD tomorrow. Plan for trach early in week. Continue support for pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1614528,
"text": " nsg note: 19:00-7:00\nthis is a 71 y.o. woman adm with ESRD on HD with line sepsis, developed pna, intubated for apnea and associated bradycardia in setting of delirium, sleep apnea, and benzos (difficult airway). pt with very poor access with multiple pivs lost. has r radial aline with sharp waveform but now with no blood return. r midline patent but also with no blood return. r femoral triple lumen central line intact with +blood return-meds infusing thru femoral line.pt also with tunnel HD catheter (rsc). attempting to save l arm for fistula in the future. pt extubated and reintubated in 5hrs for resp failure. pt will need trach-dr. talked with pt's dtr and family in agreement with trach. pt will need consent for procedure from dtr. continues with labile bp-normal when sedated on propofol but very hypertensive with sbp up to 200s when stimulated with any bit of nsg care.\n\nneuro: opens eyes to stimuli, grimaced once when repositioned but unable to tell where pain is, not following commands. moves all ext pulling at restraints when stimulated with nsg care. perrla 3mm sluggish. usually appears sedated on propofol at 30mcg/kg/min but wakes up with agitation. required fentanyl increase to 100mcg/kg/min as appeared to grimace with bp in 200s, relieved with bp in low 100s. pt still remained agitated requiring propofol increase to 45mcg/kg/min.\n\ncv: hr 50s-60s sb/sr with occas pvcs. sbp 90s-200s, down as low as 90s when sedated and 200s with any nsg intervention. captopril was given at mn when hr and bp in parameters.\n\nresp: no vent changes overnight, remains on AC, occasionally overbreathing the vent. suctioned thick yellow secretions from ETT. lungs coarse t/o.\n\ngi/gu: abd soft, +bs, tube feeds were at goal at 20cc/hr with min residuals. tf off by mn in case trach placed today. pt anuric.\n\nskin: warm, dry, intact.\n\naccess: r radial aline with sharp waveform but no blood return, r midline flushing well but with no blood return. r femoral triple lumen central line patent with + blood return.\n\nsocial: dtr. called for update.\n\nplan: trach placement in near future. continue sedation and attempt to wean again if able. hd today. abx as ordered for PNA.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1614529,
"text": "RESPIRATORY CARE:\n\nPt remains intubated, vent supported. No changes made overnight. BS's coarse, sxing thick yellow secretions. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1614530,
"text": " nsg note addendum: 19:00-7:00\noral airway was placed at beginning of shift and left in as pt biting down hard on tube and unable to suction-once oral airway in place, able to suction. am cxr done and results pending. continues to require 45mcg/kg/min for agitation and 100mcg/hr for comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-21 00:00:00.000",
"description": "Report",
"row_id": 1614585,
"text": "NURSING NOTE 0700HRS - 1600HRS\n\n\nEVENTS...SEEN BY THORCIC WHO REPLACED/RE-POSTIONED THE TRACH AND SWITCHED TO BOVONA SIZE 6... SMALL RT PNEUMO NOTED ON POST CXR, PATIENT RECEIVING 100% FIO2 TO HELP WITH RE-ABSORPTION [ AS MD]...HEPARIN RE-COMMENCE, FEED RE-COMMENCE...FOR HD TOMORROW..FAMILY VISITED AND UPDATED..\n\n\nNEURO.. SEDATED THIS AM ON FENT/VERSED FOR PROCEDURE..STOPPED AT 12MD, SINCE THEN PATIENT RELATIVELY CALM,NAPPING BUT EASILY ROUSABLE MOVEMENT OF ALL 4 LIMBS NOTED.. RECEIVED X1 DOSE OF ZYPREXA FOR AGITATION THIS PM WITH GOOD EFFECT...PATIENT DOES NOT SPEAK ANY ENGLISH BUT APPEARS AT TIME TO UNDERSTAND, WHEN FAMILY VISITED SHE WAS ABLE TO LET HER NEEDS KNOWN AND PATIENT AKNOWLEGES HER FAMILY AND THEY SAY SHE KNOWS WHERE SHE IS/DENIES ANY PAIN...CONTINUE TO OBSERVE..\n\n\nRESP...RESP EVENTS AS ABOVE , NOW ON MMV 12 PEEP 5 P/S 10 100% [ FOR PNEUMO RE-ABSORPTION], ABG STABLE..SATS @ 100%..LUNGS SOUND COURSE AND SX FOR THICK TAN..? NEEDS REPEAT CXR THIS EVE TO RE-ASSESS PNEUMO..TRACH SIGHT SUTURED AND STABLE..\n\n\nCVS..B/P RANGES MARKEDLY FROM 95 SYSTOLIC WHEN RESTING TO 180 WHEN AGITATED, ON BBLOCKER BUT HELD FOR PARAMETERS..HR 49-75BPM, AM LABS STABLE..SLIDING SCALE TIGHTENED TODAY , TO OBSERVE Q6..\nAFEBRILE, FOR VANS LEVEL IN THE AM..\n\nHAEM..HCT STABLE AT 24 THIS AM BUT PLAN IS TO RECEIVE X1UPRBC ON HD TOMORROW, NEW TYPE/SCREEN SENT TODAY...HEPARIN RE-COMMNECE @ 1000HRS , CHECK PTT AT 1500HRS @ 86, FOR RE-CHECK AT 1900HRS..RANGE 60-100\n\n\nGI..BELLY SOFT DISTENDED..RECEIVING BOWEL REGIME BUT NOT STOOLED..B/S HYPOACTIVE..FEED RE-COMMENCED AND ADVNACED TO 30..APPERAS TO BE TOLLERTAING..\n\n\nGU..PASSED URINE TODAY, LARGE AMOUNT , REVIWED BY RENAL FOR HD TOMORROW..\n\n\nSKIN..ALLEVYN ON SCARUM, INTACT...\n\n\nLINES DILAYSIS, PICC ART LINE..\n\n\nSOCIAL..FAMILY IN AND UPDATED..\n\n\n\nPLAN... ? REPEAT CXR TONIGHT, ? WHEN TO STOP 100% FIO2 FOR PNEUMO...PTT AT 1900HRS ? GOAL OF INR\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-21 00:00:00.000",
"description": "Report",
"row_id": 1614586,
"text": "Respiratory Care Note\nPt received on AC as noted. Bronchoscopy done to evaluate trach site. #8.0 Portex removed from trach site secondary to false tracking. Adjustable #6.0 inserted and is secured at 12 - good placement on CXR. CXR also reveals small pneumothorax in RUL. After 4hours, pneumothorax is still present. FiO2 increased to 100% at 2p to aid in reabsorption of pneumo - will redo CXR at 6p to check on progress. Pt weaned to - pt having of apnea, but tolerating well - ABG within normal limits with excellent oxygenation. with VT 400-700 and RR mid teens. Plan to continue on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-23 00:00:00.000",
"description": "Report",
"row_id": 1614592,
"text": "RESP CARE: Pt remains with 6.0 adjustable lenghth trach tube at 12cm marking. Leak around trach tube. Vent placed on leak compensation. Pt changed to with low MV set at 4.8 liters at the start of the shift due to prolonged of apnea. Lungs coarse, diminished. Sxd thick white sputum, moderate amounts. AM RSBI-132. Continue to wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-11 00:00:00.000",
"description": "Report",
"row_id": 1614538,
"text": "NPN 1900-0700\nFULL CODE speaking/some English All: PCN\nESRD, DM2\nTrach and PEG on Fri probable\n\n71yo female originally admitted with HD cath infxn/fevers. Experienced change in MS and became apenic requiring intubation (difficult). Attempted extubation over weekend lasted approx 5hrs but extreme hypertension and incrsd WOB required reintubation. Labile BP's. Stent placed in IR on several (probably old clots). To go to IR for TPA admin and possible replacement of HD cath.\n\nNeuro: Sedated on 20mcg/kg Propofol and 25mcg Fentanyl. Rested comfortably most of noc but has begun to experience labile BP's this am req frequent titrations of sedation. See carevue.\n\nCV: NSR w/occ PVC. SBP from 88-230's. UE edema b/l clots. Heparin gtt currently off as PTT @ 02 >150 then hope to get to IR for TPA this am.\n\nGI/Endo: Began to stool overnight, some manual extraction. Lactulose prn started . TF at goal of 20cc/hr w min residual, new formula to be made up by nutrition today. HISS\n\nGU: anuric. HD schedule MWF but not done yesterday so maybe today.\n\nSkin: new stage 2 pressure ulcer on coccyx. Aloe vesta liberally applied.\n\nLines: art line patent, HD cath dressing CDI but cath may be changed out today. TLC at R fem, dressing has some ooze, requires help to change. Midline still in R UE, IR should check placement w/ fluoro\n\nPlan: monitor/manage sedation and BP;s\n to IR for TPA\n HD fri if not today\n trach/peg asap\n TF/HISS\n emotional support for pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-11 00:00:00.000",
"description": "Report",
"row_id": 1614539,
"text": "pt PSV weaned mid-shift and tolerated well. sx'd for moderate amount of thick secretions. plan is for further weaning attempts in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-12 00:00:00.000",
"description": "Report",
"row_id": 1614544,
"text": "Respiratory Care:\nPt remains orally intubated and vented. Pt remians on PS. Pt still does not have cuff leak. Lung sounds clear. SUctioned for moderate thick yellow secretions. Traveled to and from CT without incident, will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-13 00:00:00.000",
"description": "Report",
"row_id": 1614545,
"text": " nsg note: 19:00-7:00\n71 y.o. speaking woman adm to with fever to 103, ? r/t dialysis line infection. line was changed . on pt increasingly confused, MS changes, periods of apnea with bradycardia requiring intubation on with difficult airway. an extubation was tried but within 5 hrs pt tired with stridor and worsening resp failure. pt then developed clots at the end of the dialysis line, on and off heparin d/t elevated ptt. pt currently continuing on the heparin gtt for these clots at the end of the dialysis catheter. am labs ptt pending. IR deferred doing TPA.\n\nneuro: periods of agitation with some grimacing at times controlled with iv fentanyl gtt with occas bolus needed. will sleep for up to 1.5 hour period in b/w periods of agitation. her bp goes as high as 220 with agitation but usually now goes only to 160s-180s. no periods of hypotension detected with noninvasive bp cuff. aline dampened and not accurately. bilat wrist restraints on as pt attempting to pull at lines. also kicking legs out and over the side rails. bed alarm on for safety. perrla 3 mm sluggish. not following commands.\n\ncv: hr ranging 70s-100s- tacycardic to as high as 110s when agitated and back down to 70s-80s when resting. +pp. aline dampened and very difficult to draw abg.\n\nresp: abg: 7.36/50/31. changed from psv to ac: .4x500x14+5. overbreathing the vent with agitation. lungs cta and diminished at bases. suctioned for moderate amts white thin secretions. sp02 high 90s to 100%.\n\ngi/gu: abd softly distended, +bs, tolerating tf at goal rate at 30cc/hr with min. residuals. anuric. next hd tomorrow .\n\nskin: very small coccyx abrasion left ota and aloe vesta applied with every turn.\n\naccess: r radial aline dampened with difficultly getting blood return. rsc hd cathter, r femoral tlcl catheter patent and with good blood return from brown port. also has r midline catheter.\n\nplan: SVC gram to check the stent placed in the near future (? monday), hemodialysis , PEG and Trach on Monday. anesthesia consulted for consent that was obtained from dtr. . ? picc line placement versus l ij tlcl.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-13 00:00:00.000",
"description": "Report",
"row_id": 1614546,
"text": "Resp Care,\nPt. remains intubated on A/C overnoc. Changed to A/C due to PCO2 50. Agitated at times during noc. Suctioned for thin white sputum. RSBI 68 this am. Plan trach on Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-13 00:00:00.000",
"description": "Report",
"row_id": 1614547,
"text": "Respiratory Care\n\n Pt continues on A/C with no changes today. B/S sl coarse sx'ing mod thick white secretions. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-23 00:00:00.000",
"description": "Report",
"row_id": 1614593,
"text": "npn: 0700-1900\nneuro: pt is alert, speaking and oriented to self and occasionally place. the co-worker asked her multiple yes and no questions and discovered pt orientation. pt appearded to follow all commands he asked of her. pt denies pain/no grimacing. pt resting in bed and will be sent to rehab in am.\n\ncv: pt nsr-sb 50'-80's pt will even dip into the 40's when relax or s/p metoprolol. pt abp 120-140's. will occasionally see pt bp in the 190's when aggrevated, tmax 100.1. ppp bilaterally.\n\nresp: pt was weaned off vent to trach mask this afternoon. pt on 50% fio2 trach mask. pt sats remain 100%. pt lungs are coarse to clear and diminshed in bases. pt suctioned q 3-4 hours for thick small to mod amounts of white secertions.\n\ngi/gu: pt is anuric. pt has dialysis mwf. pt has tf at 30cc/hr. abd soft nt. pt had two bm's on shift. guaic negative.\n\nsocial: pt will be headed to rehab tomorrow. pt screened today.\n\nplan: monitor sats. wean trach mask, suction as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-23 00:00:00.000",
"description": "Report",
"row_id": 1614594,
"text": "Resp Care\nPt remains with #6.0 . vent settings weaned to PSV 5/5 40% abg drawn wnl and pt the placed on 50% TM which she has toerated well for the duration of the sift satting >97%. BLBS diminished, suctioned for small amt thick yellow/white secretions. Plan to continue to monitor ? transfer to floow tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-24 00:00:00.000",
"description": "Report",
"row_id": 1614595,
"text": "Nsg.notes 1900-0700 hrs\n\nNeuro:Alert,eye opens spontaneously,responding with nodding head.denies any pain.slept moderately with haldol.agitated at times,BP high when agitated.\n\nResp:trache collar,50%,sats 98-100% .LS coarse UL,base diminshed.suctioned thick secretions.\n\nCVS:HR 60-90's,NSR,no ectopics,BP 130-190'S/50-70'S.\n\nGU/GI:Abdomen obese,BS present,PEG in place,feed neutran pulmonary st 30cc/hr.tolerating well.site looks clean.no BM this shift.anuric,on HD 3/week.\n\nIntegu:skin impaired on coccyx,allevyn dressing.Temp 101.3,tylenol 650mg given with good effect.bath given and positioned.\n\nIV access:RT picc ,Rt svc for HD,and A line on Rt radial,all patent,site looks clean.\n\nsocial:no family contact this shift,slept moderately,full code.\n\nPlan:for rehab screening today.pulmonary toileting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-24 00:00:00.000",
"description": "Report",
"row_id": 1614596,
"text": "RESP CARE: Pt remained on 50% TC all noc. Sxd Q4, small amount bld tinged sputum. Lungs diminished L>R, few crackles/Pt has a 6.0 adjustable length trach in place, 12cm at flange,trach is sutured. Leak noted aroung trach due to small size. Ventilator pulled from room. Will continue to monitor per respiratory protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-13 00:00:00.000",
"description": "Report",
"row_id": 1614548,
"text": " 4 ICU nursing progress note:\n Respiratory: Remains intubated and vented. AC/500/14/5/40%..spont rr 0-6. Suctioned for mod amts tan-yellow thick secretions. Change from 24hrs ago. Pt is scheduled for trach on Monday .\n ID: 1600 spiked temp to 102.2r..cultured..blood and sputum. RT attempting mini-BAL. ??new pneumonia with change in sputum. Per HO will change antibiotics.\n Neuro: Pt very restless, thrashing head back and forth..constantly lifting legs up and down on bed.???restless leg syndrome. Continues on fentanyl gtt at 100mic/hr with frequent boluses 50-100mic. Responds appropriately to yes/no questions when spoken to in .\n Renal: HD done..removed 2300cc..tolerated well.\n Cardiac: Periods of tachycardia with agitation..up to 130s..settles into the 80-90's with sedation. BP up to 160's at times.\n GI: TF at goal..30cc hr..??need to reassess now that pt is off propofol.\n Heme: Heparin gtt at 1100..am PTT therapeutic..no obvious bleeding.\n Endo: Following bs q6hrs..ssri\n Access: A-line changed over wire successfully..Midline flushes and draws back. Femoral line with heparin and fentanyl infusing.\n Social: Daughter called and updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-14 00:00:00.000",
"description": "Report",
"row_id": 1614549,
"text": "Resp Care\nPt remains intubated with #7 ett @ 22, patent and seure. Suctioned for mod amt of thick yellow secretions. No changes made. Rsbi 112. Pt restless. Plan for trach/peg in the futur. will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-15 00:00:00.000",
"description": "Report",
"row_id": 1614557,
"text": "Resp Care\nPt trached today in OR with # 8.o portex. pt remains on a/c no vent changes made. BLBS diminished, suctioned for thick tan/yellow secretions. Plan to contiue on current settings as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-25 00:00:00.000",
"description": "Report",
"row_id": 1614600,
"text": "Nursing Progress Note:\nFULL CODE\n\nUNIVERSAL PRECAUTIONS\n\nALLERGIES: PCN, HEPARIN\n\nNo events overnight.\n\nNEURO: pt speaking, denies pain, follows commands; moves all extremities, agitated at times, rec'd haldol x1 tonight with minimal affect, sleeping off and on throughout the night; unable to assess orientation d/t trach; pupils 4mm and sluggish, bilateral catarcts\n\nCV: HR NSR no ectopy; ABP 180's-90's, SBP fluctuates rapidly with no change in HR; +PP/RP to palpation; no edema noted; no S+S bleeding; HD yesterday with epoetin\n\nRESP: pt with #6 , on trach mask 50%; suctioned for moderate amts thick tan sputum; satting 100%; RR regular in teen's; LS coarse at apices, dim at bases; failed speech/swallow for PMV\n\nGI: +BS, sm amt stool, soft brown; abd soft obese; TF @ goal 30cc/hr, minimal residuals; TF nutren renal 3/4 strength with 30grams beneprotein\n\nGU: pt anuric, HD MWF, 4L removed yesterday; BUN WNL, cr elevated\n\nSKIN: intact, slightly pink at coccyx, aloe vesta applied\n\nACCESS: dl PICC, distal port clotted; right art line WNL\n\nID: re-pan cultured for spike temp yesteray, 100.5, overnight, tmax 101.9, tonight, given tylenol x1 now 98.9; WBC's 9.3; cultures pending\n\n: ? VAP, follow cultures, cont abx; plan to d/c to rehab on Friday if continues stable; limit sedating meds, haldol/zyprexa prn for agitation\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-25 00:00:00.000",
"description": "Report",
"row_id": 1614601,
"text": "RESP CARE: Pt remains with 6.0 adjustable lenghth/12cm at flange. Cuff pressure 30, leak still present. She is on 50% TC continuously. Sxd moderate amounts thick tan sputum. Lungs coarse rhonchi, dim on L. Continue to follow per respiratory protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-25 00:00:00.000",
"description": "Report",
"row_id": 1614602,
"text": "NPN MICU-7 7AM-7PM\nS/O: NEURO: IS alert and responsive, is speaking so is difficult to assess oreintation. Is very restless in bed constantly moving about, @ times has legs over the siderails, but does not appear extremely anxious or agigated, no sedation needed. Able to MAE, PERL.\n\nRespir: Remains on 35% cool neb trach mask, requires suctioning frequ q30min in the AM now q1hr for mod to lrge amts thick yellow/tan secretions. L/S course to diminished @ bases. O2 sats 95-99%. CXR appears a little worse.\n\nC/V: BP 110-170/60-70's with HR 68-75 SR with no ectopy noted.\n\nRenal: To have HD in the AM. BUN/CRe 18/3.4.\n\nGI: Rec'ing TF's Nutren Renal str with 30GM of Beneprotein @ goal rate of 30cc/hr via PEG. HCT-28.1.\n\nID: Temp 99.0 PO max with WBC 9.3, to rec Vanco and Meropenum on HD days. Awaiting culture results from PND cultures taken on . One set of blood cultures sent from PICC line this AM.\n\nSkin: Small red area on coccyx, not open, applying cream to area and turning frequ.\n\nIV: PICC line in R A/C both ports flushing well, no need for TPA.\n\nDispo/Social: Family in late this afternoon, was told to contact Manager in the AM to discuss Rehab facilities. Awaiting culture results and improve respir status before transfer to rehab.\n\nA/P: Continue with aggressive Pulmonary toilet, assess O2 sats, monitor VS's. Provide for pt's safety. Monitor temps and administer IV antibx's with HD. Remind family to discuss rehab's with Case Manager in the AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-18 00:00:00.000",
"description": "Report",
"row_id": 1614570,
"text": "Nursing Transfer Note\n\nThis is a 71 yo female with ESRD - on dialysis, DM, sleep apnea, HTN, and back pain who came to the hosp at the end of for mental status (MS) changes. Her temp was >103, she was admitted for a line infection. Her MS cont to decline and she was transfered to the MICU for of apnea. She required intubation, failed extubation so was and had a PEG placed. Her MS has been improving, today she was able to follow simple commands, she is not able to speak due to her trache. She now has SVC syndrome, she was on a hep gtt but to go to IR for TPA. Hep gtt has been off since midnight. She has a stage 2 bed sore on her coccyx which is covered with a duoderm. Her blood sugars have been covered with SS insulin q6 hrs with fairly good control. She has a wet cough and has not been coughing up and sx for thick yellow sputum. Her potasium was 3.0 this morning, it was repleated with 40 meq of IV K, she is dialysed q MWF. She has a lido patch over her R shoulder. Prior to this admit she was living with her daugter.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-18 00:00:00.000",
"description": "Report",
"row_id": 1614571,
"text": "NURSING PROGRESS NOTE 1700-1900\nREPORT RECEIVED FROM IR. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nTHIS IS A 71 Y/O SPEAKING WOMAN INITIALLY ADMITTED TO W/ PRESUMED DIALYSIS LINE SEPSIS. BRIEF HOSPITAL COURSE: REQUIRED INTUBATION ON FOR WORSENING MENTAL STATUS, DELIRIUM, SLEEP APNEA AS WELL AS BRADYCARDIA AND RESP. FAILURE. PT WAS A DIFFICULT INTUBATION. PT FAILED EXTUBATION ON - REQUIRING RE-INTUBATION. PT ALSO DEVELOPED RT ARM SWELLING- WORK UP REVEALED SVC CLOTS. PT HAD PEG AND TRACH DONE ON . TODAY, - PT RECEIVED FROM IR AFTER HAVING SVC THROMBECTOMY. PT TOLERATED PROCEDURE WELL AND IS CURRENTLY ADMITTED TO MICU 7 FOR OBSERVATION. PLAN IS TO OBSERVE TONIGHT AND WEAN PT BACK TO TRACH COLLAR AND EITHER DISCHARGE TO FLOOR OR TO REHAB.\n\nNEURO: PT OPENS EYES TO STIMULUS. DOES NOT FOLLOW COMMANDS (PRIMARILY SPEAKING). RECEIVED ON PROPOFOL GTT- HAS SINCE BEEN DISCONTINUED. AFEBRILE. PERRLA, 2/SLUGGISH. ABLE TO LIFT AND HOLD ALL HER EXTREMITIES WITHOUT DIFFICULTY. NO SEIZURE ACTIVITY NOTED.\n\nCV: S1 AND S2 AS PER AUSCULTATION. BRADYCARDIC WITH HR IN THE 40-50'S. NO SIGNS OF ECTOPY NOTED. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. SBP IS LABILE DEPENDENT ON AGITATION (THIS IS HER NORM)- ANYWHERE FROM 100-190'S. RT FEMORAL CVL DC'D BY DR. . PT HAS RT SCL HD LINE AND RT PICC LINE. ALL ARE SECURE AND PATENT. CURRENTLY ON HEPARIN GTT AT 1150U/HR.\n\nRR: RECEIVED VENTED FROM PROCEDURE. PT IS . STOMA IS PINK AND MIDLINE. BBS= ESSENTIALLY CLEAR TO COARSE THROUGHOUT ALL LUNG FIELDS. BILATERAL CHEST EXPANSION NOTED. SUCTIONING FOR THICK, YELLOW SECRETIONS. SP02 > OR = TO 95%. PLAN IS TO WEAN TO TRACH MASK AS PT TOLERATES (HAD BEEN ON TRACH MASK PRIOR TO PROCEDURE).\n\nGI: ABD IS OBESE, SOFT, DISTENDED. BS X 4 QUADRANTS. PASSING PT HAVING LARGE AMOUNTS OF LOOSE, BROWN STOOL- MUSHROOM CATHETER INSERTED. PEG TUBE IS SECURE AND PATENT.\n\nGU: ANURIC. PT RECEIVED HD M,W,F.\n\nINTEG: PT HAS DUODERM TO COCCYX. NO OTHER SIGNS OF BREAKDOWN NOTED.\n\nSOCIAL: LARGE FAMILY- DAUGHTER UPDATED ON PHONE.\n\nPLAN: PT TO REMAIN IN UNIT FOR OBSERVATION S/P THROMBECTOMY, WEAN TO TRACH MASK, DISCHARGE TO REHAB OR FLOOR ONCE ABLE. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-18 00:00:00.000",
"description": "Report",
"row_id": 1614572,
"text": "Resp Care\nPt remains #8 Portex. Current vent settings: A/C 500 x 14 5P 50%. Pt went to IR for procedure. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-19 00:00:00.000",
"description": "Report",
"row_id": 1614573,
"text": "1900-0700 rn notes micu\n\n71 y.o f with h/o ESRD, , HTN, DM inittially admitted d/t mental status changed during HD, was intubated for sleep apnea,respiratory failure, failed extubation, pt and PEG at 9/24. underwent bilat SVC thrombectomy, put on heparin gtt.\n\nevents: overnight pt became restless with BP up to 190-200/107 given Halidol 2.5 mg x2 iv and Zyprexa 5mg with some effect,also recieved Hydralazin 10mg x2 IV and start Metoprolol 25mg TID Po.\n\nneuro: pt speaking only, response to voice and pain.does not follow commands,MAE.PERL 2mm/slugish.\n\nresp: remains on Ac 50%/500/RR 14/peep 5, OVB 5-10bpm, suction moderate amount yellow thick secretion, sat 100%, LS coarse clear to suction, dim at bases.\n\ncv: HR 80-90's,NSR, at time HR down to 40-50's SB. after second dose of Hydralazin BP 130-140/70's.cont heparin gtt 1500u/hr, last PTT 73,morning labs pending.\n\ngi/gu: pt on HD, anuric, ABD softy, Bs +, mushroom cath in place drainged brown loose stool, start TF at 30cc/hr goal via PEG.\n\naccess: A-line at time damping, R arm PICC line from . RSC HD cath. R fem line removed by Dr .\n\nid: afebrile,cont Meropenem and Vanco per HD protocol.\n\nskin: abrasion on coccyx area, allevyn dressing apllied.\n\nsocial: full code, pt's daughter called updated by RN.\n\nplan: cont monitoring resp/cardio status\n monitorign BP\n wean vent to trach mask and then to rehab or floor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-19 00:00:00.000",
"description": "Report",
"row_id": 1614574,
"text": "pt can not have benzodiazepines and narcotics, that cause dellirium to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-19 00:00:00.000",
"description": "Report",
"row_id": 1614575,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions.RSBI done on 0 peep/5 ips94.6. ABG met alkalosis.Will cont to monitor resp status.\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978779,
"text": " 5:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for cardiopulmonary process.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with PNA s/p extubation then reintubated for respiratory\n distress.\n REASON FOR THIS EXAMINATION:\n Please evaluate for cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient reintubated for respiratory\n distress.\n\n Portable AP chest radiograph compared to .\n\n The ET tube tip is 3.5 cm above the carina. The double-lumen catheter\n inserted through the right subclavian approach terminates at the level of\n cavoatrial junction. The NG tube tip is in the stomach.\n\n There is no change in the moderate cardiomegaly and prominent bilateral hila\n related to pulmonary artery enlargement and known bilateral hilar lymph nodes.\n The lungs are essentially clear. No sizeable pleural effusion is identified.\n\n IMPRESSION:\n 1. Standard position of tubes and lines.\n\n 2. No evidence of pneumonia.\n\n 3. Bilateral hilar enlargement due to combination of pulmonary hypertension\n and lymph nodes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-18 00:00:00.000",
"description": "EXCH PERPHERAL W/O PORT",
"row_id": 980314,
"text": " 11:04 AM\n UNILAT SUBCLAV Clip # \n Reason: TPA and thrombectomy of SVC\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 100\n ********************************* CPT Codes ********************************\n * EXCH PERPHERAL W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with svc clots and svc syndrome not improving on heparin\n REASON FOR THIS EXAMINATION:\n TPA and thrombectomy of SVC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with SVC syndrome.\n\n RADIOLOGISTS: The procedure was performed by Dr. , Dr. , and\n Dr. , the attending radiologist, who was present and supervising\n throughout.\n\n PROCEDURE AND FINDINGS: Using the previous access into the right basilic\n vein, a peel-away sheath was advanced over the wire. The inner dilator was\n removed and a double-lumen PICC line measuring 35 cm was advanced over the\n wire through the peel-away sheath into the SVC under fluoroscopic guidance.\n The wire and the peel-away sheath were removed. Position of the catheter was\n confirmed by a fluoroscopic spot film of the chest. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well, and there were no immediate\n complications.\n\n IMPRESSION: Uncomplicated fluoroscopically guided double-lumen PICC line\n placement via the right basilic approach. Final internal length is 35 cm,\n with the tip positioned in the SVC. The line is ready to use.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-18 00:00:00.000",
"description": "PERC MECHANICAL THROMBECTOMY INCL LYTIC INJ, VENOUS",
"row_id": 980315,
"text": " 11:05 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Evaluate to place midline\n Admitting Diagnosis: FEVER\n ********************************* CPT Codes ********************************\n * PERC MECHANICAL THROMBECTOMY I 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * PTA VENOUS 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * -51 MULTI-PROCEDURE SAME DAY PTA VENOUS *\n * 79 UNRELATED PROCEDURE/SERVICE DURIN -59 DISTINCT PROCEDURAL SERVICE *\n * PTA VENOUS 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * -59 DISTINCT PROCEDURAL SERVICE PTA VENOUS *\n * 79 UNRELATED PROCEDURE/SERVICE DURIN -59 DISTINCT PROCEDURAL SERVICE *\n * INTRO CATH SVC/IVC -59 DISTINCT PROCEDURAL SERVICE *\n * PTA VENOUS PTA VENOUS *\n * -59 DISTINCT PROCEDURAL SERVICE PTA VENOUS *\n * -59 DISTINCT PROCEDURAL SERVICE PTA VENOUS *\n * -59 DISTINCT PROCEDURAL SERVICE EXTREM BILAT VENOGRAPHY *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CKD on dialysis, SVC syndrome, with PNA. Needs\n prolonged IV access for abx.\n REASON FOR THIS EXAMINATION:\n Evaluate to place midline\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: 71-year-old woman with thrombosed SVC.\n\n RADIOLOGISTS: The procedure was performed by Dr. , Dr. and\n Dr. , the attending radiologist, who was present and supervising\n throughout.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained, the patient was\n placed supine on the angiographic table and both arms were prepped and draped\n in the standard sterile fashion. The previously placed PICC line in the right\n arm was cut and a 0.018 Glidewire was advanced through the catheter into the\n right subclavian vein and the catheter was removed over the wire. A\n micropuncture sheath was advanced over the wire and the wire and the inner\n dilator were removed. A 0.035 Glidewire was advanced through the\n micropuncture sheath into the distal right subclavian vein and the\n micropuncture sheath was exchanged for a 5-French bright tip sheath. Venograms\n were performed through the sheath demonstrating thrombosed right subclavian\n and brachiocephalic veins. Using a combination of Kumpe catheter and\n Glidewire, access was gained into the previously placed SVC stent and both the\n wire and the catheter were advanced under fluoroscopic guidance into the IVC.\n Based on these diagnostic findings, it was decided that the patient would\n benefit from AngioJet thrombectomy and balloon angioplasty. Venograms were\n performed after thrombectomy and angioplasty with good angiographic results.\n\n Using ultrasonographic guidance and local anesthesia, access was gained into\n the left brachial vein with a 21-gauge needle. A 0.018 guidewire was advanced\n through the needle and the needle was exchanged for a micropuncture sheath.\n (Over)\n\n 11:05 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Evaluate to place midline\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The wire and inner dilator were removed and a 0.035 Glidewire was advanced\n through the micropuncture sheath and the sheath was exchanged for a 7-French\n bright tip sheath. A venogram was performed demonstrating thrombosed left\n subclavian and brachiocephalic veins. Based on these diagnostic findings, it\n was decided that the patient would benefit from AngioJet thrombectomy and\n balloon angioplasty. Venogram was performed after the angioplasty with good\n angiographic results.\n\n The wire and sheath were removed and compression was applied until hemostasis\n was achieved. The patient tolerated the procedure well and there were no\n immediate complications.\n\n Moderate sedation was provided by administering divided doses of 75 mcg of\n fentanyl throughout the total intraservice time of 2 hours and 35 minutes\n during which the patient's hemodynamic parameters were continuously monitored.\n\n IMPRESSION: Thrombosed subclavian and brachiocephalic veins bilaterally.\n\n AngioJet thrombectomy and balloon dilatation were performed with good\n angiographic results.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-05 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 978429,
"text": " 2:19 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: RT. PICC, NOT LT.\n Admitting Diagnosis: FEVER\n ********************************* CPT Codes ********************************\n * PICC W/O PORT 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * FLUORO GUID PLCT/REPLCT/REMOVE US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CKD on dialysis with PNA. Needs prolonged IV access for\n abx.\n REASON FOR THIS EXAMINATION:\n please place RIGHT MIDLINE - do NOT touch L side. Pt has a tunneled HD line on\n Right chest\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with CKD needing intravenous access.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist, who was present and supervising throughout.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right brachial\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a single lumen PICC line was placed through the peel-\n away sheath with its tip positioned in the right subclavian vein under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and the guide wire were then removed. The catheter was\n secured to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well and there were no immediate post-\n procedural complications.\n\n IMPRESSION: Successful ultrasonographically-guided single lumen \n midline placement via the right brachial venous approach. Final internal\n length is 23 cm with the tip positioned in the right subclavian vein. The\n line is ready for use.\n\n\n\n\n\n\n\n\n\n\n (Over)\n\n 2:19 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: RT. PICC, NOT LT.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978638,
"text": " 5:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please evaluate ETT placement.\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p extubation, now reintubated for respiratory distress.\n REASON FOR THIS EXAMINATION:\n Please evaluate ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: ET placement.\n\n Single AP view of the chest is obtained on at 17:40 hours and is\n compared with the study performed approximately one hour previously. The\n patient has been intubated. The tip of the ET tube is approximately 6 cm\n above the carina. There is no other change from the prior examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978934,
"text": " 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for aspiration pneumonia/pneumonitis\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with PNA s/p extubation then reintubated for respiratory\n distress. ? aspiration\n REASON FOR THIS EXAMINATION:\n please assess for aspiration pneumonia/pneumonitis\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess for aspiration pneumonia.\n\n Comparison is made to prior study performed at the earlier.\n\n ET tube tip remains low at 1.5 cm above the carina. Right supraclavicular\n vein catheter tip is seen in the cavoatrial junction unchanged in position.\n Cardiomediastinal contour is unchanged aside from mild bibasilar atelectasis.\n The lungs are clear.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2136-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978629,
"text": " 4:17 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Confirm NGT placement\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with OSA, intubated for apnea. ? interval change.\n\n REASON FOR THIS EXAMINATION:\n Confirm NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Nasogastric tube placement.\n\n Single AP view of the chest is obtained at 16:30 hours and is compared\n with the prior radiograph performed the same morning at 05:20 hours. The\n patient has had insertion of a nasogastric tube with its tip in the gastric\n antrum. Residual contrast is seen in the colon. Patchy increased density in\n the retrocardiac area on the left side likely represents some subsegmental\n atelectasis. Right-sided dual-lumen catheter unchanged in position. The\n patient has been extubated.\n\n IMPRESSION:\n\n Placement of nasogastric tube with the tip in the gastric antrum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-12 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 979499,
"text": " 12:07 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? cerebral event/edema/stroke given extensive clots and HTN\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71yo F w/ agitation and alternating mental status, off sedation. ? cerebral\n event given extensive clots and HTN urgency.\n REASON FOR THIS EXAMINATION:\n ? cerebral event/edema/stroke given extensive clots and HTN urgency.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with altered mental status.\n\n Comparison is made to prior CT of head performed on , which\n appeared unremarkable.\n\n TECHNIQUE: Axial MDCT images of the head were obtained with no IV contrast\n administration.\n\n FINDINGS: No edema, masses, mass effect, major vascular territorial infarct,\n intra- or extra-axial hemorrhage is identified. The ventricles and sulci are\n normal in course and configuration. Incidental note is made of large sella\n turcica, consisent with an empty sella. Calcification of the cavernous\n segment of both carotid arteries are also noted.\n\n Both sphenoid sinuses contain hyperdense material consistent with inspissated\n debris or fungal colonization. There is also mucosal thickening of the\n ethmoid sinuses and maxillary sinuses. Opacification of the nasopharynx and\n oropharynx secondary to soft tissue/fluid is noted. Nasogastric tube and\n endotracheal tube are in place. The hyperdense clot of the right internal\n jugular vein is also noted.\n\n IMPRESSION:\n 1.No acute intracranial pathology is identified, including no intracranial\n hemorrhage.\n 2.For further information on findings of the neck, please refer to the CT of\n neck report.\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-12 00:00:00.000",
"description": "CT NECK W/CONTRAST (EG:PAROTIDS)",
"row_id": 979500,
"text": " 12:07 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: ? still with laryngeal edema or neck swelling\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71yo F w/ extensive SVC clot and laryngeal edema. Failed extubation x1. ? still\n with laryngeal edema or neck swelling.\n REASON FOR THIS EXAMINATION:\n ? still with laryngeal edema or neck swelling\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with extensive SVC clot and laryngeal edema.\n\n Comparison is made to the CT of chest performed on .\n\n TECHNIQUE: Axial MDCT images of the neck were obtained after administration\n of 100 cc of Optiray intravenously.\n\n CT OF NECK WITH IV CONTRAST: The epiglottis is enlarged and the piriform\n sinuses are not visualized. The prominent soft tissues of the nasopharynx and\n oropharynx, most likely tonsils, surround nasogastric tube and the\n endotracheal tube. These may all be secondary to intubation.\n\n The thrombosis of the internal jugular vein starts at the level of SVC and\n extends to the base of skull. Thrombus is also seen in the right facial\n vein. There is a dual-lumen catheter as well as a stent in the SVC.\n\n Both sphenoid sinuses contain high-density material most likely representing\n inspissated secretion or fungal colonization. There is opacification of the\n maxillary, ethmoid, and sphenoid sinuses and also both mastoid air cells. The\n sella is elarged. Multiple non-pathologically enlarged nodes are noted within\n the neck. A soft tissue density lesion is noted within the right parotid\n gland, which measures 9 mm. The visualized portions of right upper lungs\n appear normal.\n\n IMPRESSION:\n 1. Epiglottis is enlarged and the piriform sinuses are obliterated. The\n prominent soft tissue of the oropharynx and nasopharynx completely surrounds\n the nasogastric tube and endotracheal tube. These finding might be all\n secondary to intubation.\n\n 2. Unchanged appearance of complete thrombosis of right internal jugular\n vein, which extends to the skull base.\n\n 3. 9-mm round soft tissue of the right parotid gland might represent a node\n or less likely pleomorphic adenoma. Clinical correlation is recommended.\n\n 4. Hyperdense material are noted within the sphenoid sinuses, which are most\n likely related to inspissated secretion or fungal colonization.\n (Over)\n\n 12:07 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: ? still with laryngeal edema or neck swelling\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 979442,
"text": " 5:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: FEVER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old female, ESRD, intubated, ? pneumonia on yesterday's xray. ?\n interval change\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 71-year-old female with end-stage renal disease and respiratory\n failure, evaluate for change.\n\n COMPARISON: Radiographs .\n\n SINGLE PORTABLE SEMI-UPRIGHT SINGLE VIEW OF THE CHEST: Lung volumes remain\n low, the previously identified left basilar opacification is no longer\n appreciated and the hemidiaphragm appears sharp. No pneumothorax or effusion\n is identified. The cardiomediastinal contour is normal. The bony thorax is\n normal.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-08 00:00:00.000",
"description": "CT CHEST W&W/O C",
"row_id": 978885,
"text": " 4:36 PM\n CT CHEST W&W/O C Clip # \n Reason: ? SVC clot\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with ESRD on HD, found to have bilateral UE edema and airway\n edema preventing extubation. Please perform CT venogram to evaluate SVC for\n clot.\n REASON FOR THIS EXAMINATION:\n ? SVC clot\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD on HD\n ______________________________________________________________________________\n FINAL REPORT\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n \n INDICATION: 71-year-old female with end-stage renal disease on hemodialysis\n found to have bilateral upper extremity edema and airway edema preventing\n extubation. Evaluate mediastinal extension of clot.\n\n COMPARISON: Multiple prior chest radiographs dating back to , most\n recently on , CT abdomen and pelvis dated , Chest CTA .\n\n TECHNIQUE: MDCT imaging of the chest was performed before and after the\n administration of 100 cc of intravenous Optiray. Images were obtained with\n 1.25 mm slice thickness and displayed in soft tissue and lung windows. Coronal\n reformatted images were obtained.\n\n FINDINGS: A right-sided catheter terminates in the low SVC. The\n right subclavian and right brachiocephalic veins are expanded and entirely\n occluded by thrombus which extends into and largely occludes the SVC and into\n but not occluding the left brachiocephalic vein; the right axillary vein may\n also be thrombosed. Other thrombus partially fills the left subclavian and\n left brachiocephalic veins. Extensive subcutaneous collateral vessels and\n prominence of the distal azygous vein reflect SVC occlusion. The remaining\n mediastinal vessels are patent.\n\n At the level of the thyroid, the upper airway, probably the glottis, is\n extremely edematous conforming to the caliber of the endotracheal tube. The\n endotracheal tube tip is positioned 1.5 cm above the carina. Bilateral\n axillary lymphadenopathy may reflect underlying venous stasis. The largest\n right axillary lymph node measures 16 mm in short axis. The largest left\n axillary lymph node measures 13 mm in short axis. Subcutaneous edema is\n present only in the upper thorax.\n\n A single precarinal lymph node measures 12 mm in short axis. The aortic valve\n is heavily calcified. Severe calcifications line all three coronary arteries.\n There is no pericardial effusion. Small pleural effusions layer posteriorly\n and appear non-hemorrhagic. There is bibasilar dependent atelectasis.\n Respiratory motion limits evaluation for small pulmonary nodules. No masses\n (Over)\n\n 4:36 PM\n CT CHEST W&W/O C Clip # \n Reason: ? SVC clot\n Admitting Diagnosis: FEVER\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n @@@@@@@@@@@@@@ This is a revision of a previously signed report @@@@@@@@@@@@@@\n\n (Cont)\n are identified.\n\n Limited imaging of the upper abdomen is not sufficient for diagnosis, but\n demonstrates a 41 x 27 mm right adrenal myelolipoma. Abnormal hepatic\n parenchymal enhancement noted on is no longer present. A 9- mm\n exophytic, hypodense, left renal upper pole lesionis stable size since\n , consistent with a simple cyst.\n\n IMPRESSION:\n 1. Extensive venous thrombosis of head and neck drainage, with occlusion of\n SVC, right brachiocephalic, bilateral subclavian and probably right axillary\n veins, due at least in part to indwelling large bore central venous catheter.\n 2. Severe laryngeal edema.\n 3. Bilateral axillary and subcarinal lymphadenopathy.\n 4. Interval resolution of hepatic parenchymal enhancement abnormality.\n 5. Marked coronary atherosclerosis. Probable calcific aortic stenosis.\n 6. Right adrenal myelolipoma.\n\n"
},
{
"category": "Echo",
"chartdate": "2136-10-02 00:00:00.000",
"description": "Report",
"row_id": 82021,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Mitral valve disease. Endocarditis?\nHeight: (in) 60\nWeight (lb): 186\nBSA (m2): 1.81 m2\nBP (mm Hg): 155/67\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 15:21\nTest: Portable TEE (Congenital)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient has been intubated for respiratory failure and has been receiving\nfentanyl and propofol. She was give a single additional bolus of propofol for\nthe TEE.\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: Dynamic interatrial septum. PFO is present.\nRight-to-left shunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: RV not well seen.\n\nAORTA: No atheroma in ascending aorta. Complex (>4mm) atheroma in the aortic\narch. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No masses or\nvegetations on aortic valve. Filamentous strands on the aortic leaflets c/with\nLambl's excresences (normal variant). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or\nvegetation on mitral valve. Mild mitral annular calcification. Mild thickening\nof mitral valve chordae. Calcified tips of papillary muscles. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve. Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. 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). No TEE related complications. Echocardiographic results were\nreviewed with the houseofficer caring for the patient.\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. A stretched patent foramen ovale is present with intermittent right\nto left shunting at rest. Overall left ventricular systolic function is normal\n(LVEF>55%). There are complex (>4mm) non-mobile atheroma in the aortic arch.\nThere are simple atheroma in the descending thoracic aorta. The aortic valve\nleaflets (3) are mildly thickened with focal thickening of the right and left\ncoronary cusps. No masses or vegetations are seen on the aortic valve. There\nis a 2 mm linear density on the non-coronary cusp of the aortic valve which is\nnot independently mobile and is consistent with a Lambl's excrescence (clips\n11, 14). Trace aortic regurgitation is noted. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. No mass or vegetation is\nseen on the mitral valve. Trivial mitral regurgitation is seen. No\nvegetation/mass is seen on the pulmonic valve. There is no pericardial\neffusion.\n\nIMPRESSION: No valvular vegetations identified. Focally thickened mitral and\naortic valves with trivial regurgitation. Dynamic interatrial septum with\nstretched patent foramen ovale. Complex non-mobile atheroma in the aortic\narch. Simple atheroma in descending aorta.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2136-09-25 00:00:00.000",
"description": "Report",
"row_id": 82022,
"text": "PATIENT/TEST INFORMATION:\nIndication: ? Endocarditis.\nHeight: (in) 62\nWeight (lb): 185\nBSA (m2): 1.85 m2\nBP (mm Hg): 123/79\nHR (bpm): 60\nStatus: Outpatient\nDate/Time: at 09:46\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Aortic valve\nvegetation/mass cannot be excluded. Minimally increased gradient c/w minimal\nAS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Cannot exclude\nmass or vegetation on mitral valve. Moderate mitral annular calcification.\nMild thickening of mitral valve chordae. Calcified tips of papillary muscles.\nNo MS. Trivial MR. [Due to acoustic shadowing, the severity of MR may be\nsignificantly UNDERestimated.] Prolonged (>250ms) transmitral E-wave decel\ntime. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No\nDoppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF 60-70%). There is no ventricular\nseptal defect. Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) are mildly thickened, with focal thickening of\nthe right cusp. An aortic valve vegetation/mass cannot be excluded. There is a\nminimally increased gradient consistent with minimal aortic valve stenosis.\nMild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. A mass or vegetation on the\nmitral valve cannot be excluded. Trivial mitral regurgitation is seen. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The left ventricular inflow pattern suggests impaired\nrelaxation. The tricuspid valve leaflets are mildly thickened. The pulmonary\nartery systolic pressure could not be determined. No vegetation/mass is seen\non the pulmonic valve. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the findings appear similar.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-19 00:00:00.000",
"description": "Report",
"row_id": 207862,
"text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. There is an abnormal R wave progression consistent\nwith anterior and anterolateral myocardial infarction. Low voltage in the\nprecordial leads. There are tiny R waves in the inferior leads consistent\nwith possible prior inferior myocardial infarction. Compared to the prior\ntracing evidence of myocardial infarction is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 207863,
"text": "Baseline artifact. Sinus rhythm. Left axis deviation. Probable left anterior\nfascicular block. Intraventricular conduction delay of right bundle-branch\nblock type. Q-T interval prolongation. Since the previous tracing of \nprobably no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-01 00:00:00.000",
"description": "Report",
"row_id": 207864,
"text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. There are tiny R waves in the inferior leads\nconsistent with prior myocardial infarction. There are tiny R waves in the\nanterolateral leads consistent with possible prior myocardial infarction.\nCompared to the prior ECG there is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2136-09-29 00:00:00.000",
"description": "Report",
"row_id": 207865,
"text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. There is a late transition with tiny R waves in the\nanterior and anterolateral leads consistent with prior myocardial infarction.\nThere are tiny R waves in the inferior leads consistent with prior myocardial\ninfarction. Compared to the prior ECG there is no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2136-09-20 00:00:00.000",
"description": "Report",
"row_id": 207866,
"text": "Sinus rhythm with slowing of the rate as compared with tracing of .\nThe previously mentioned multiple abnoralities persist without diagnostic\ninterim change. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2136-09-19 00:00:00.000",
"description": "Report",
"row_id": 207867,
"text": "Sinus tachycardia. Left atrial abnormality. Right bundle-branch block. Left\nanterior fascicular block. Compared to the prior tracing of right\nbundle-branch block has appeared. The rate has increased. Followup and\nclinical correlation are suggested.\nTRACING #1\n\n"
}
] |
14,052 | 194,335 | 1. Chest pain: 48yo man with history of chronic chest pain and Brugada type transferred from outside hospital with chest pain. He ruled out for myocardial infarction by cardiac enzymes. He underwent a p-MIBI stress test, which was significant for a moderate reversible perfusion defect in the inferior wall with no wall motion abnormalities. He subsequently underwent cardiac catheterization, which was only significant for a 30% RCA lesion. This was without complication. He was maintained on his ASA and amlodipine, and the amlodipine was changed to low dose atenolol before discharge. He was given NTG prn for pain. Otherwise, his lipids were significant for LDL at 76. His triglycerides were elevated at 251; this will need to addressed as an outpatient. 2. Pseudoseizures: Has history of pseudoseizures with previous negative EEG studies. He was evaluated by Neurology, who felt that this was pseudoseizure. Psychiatry concurred with this diagnosis. Additionally, he had a 24hour EEG, which captured only a pseudoseizure and no evidence of epileptiform activity. 3. Fever: Hospital course significant for intermittent fevers with no localizing source, and no abnormalities on UA or chest xray. He was systemically well and afebrile upon discharge. 4. HTN: This was well controlled on amlodipine during his hospital course; it was changed to low dose atenolol before discharge. He will f/u with Cardiology for further management. 5. L sided weakness: poor effort on exam but intact strength bilat, concern for malingering, MRI/A negative at OSH, psych consulted for malingering. 6. stuttering/slurred speech: not c/w any neuro lesion as alternates stuttering and slurred speech with intermittent resolution of both, no defect of word finding or repitition or comprehension, pt R handed 7. Dispo: Patient will be discharged to home, no services required. He was to be seen by PT for gait/steadiness, as he had complained of some lightheadedness with ambulating. He was observed by his nurse before discharge, and he had no symptoms of lightheadedness or gait instability. He will f/u with his PCP as well as Dr. in Cardiology for further care. | IMPRESSION: Moderate reversible perfusion defect of the basilar inferior wall. Sinus rhythmBorderline first degree A-V delayConsider left atrial abnormalityprecordial lead/ anteroseptal ST-T wave configuration suggests acuteinjury/ischemia - clinical correlation is suggestedSince previous tracing of , sinus tachycardia absent and further ST-Twave changes in V1 and V2 seen Sinus bradycardiaBorderline first degree A-V delayConsider left axis deviationRSR' pattern in V1 and V2 and modest ST segment elevation in V2 - isnonspecific and could be normal variant but clinical correlation is suggestedfor possible injury/ischemiaSince previous tracing of , no significant change There is a moderately reversible perfusion defect in the base of the inferior wall. Sinus rhythmBorderline first degree A-V delayConsider left atrial abnormalityrsr' pattern in V1 and V2 and modest ST segment elevation in V2 - isnonspecific and could be normal variant but clinical correlation is suggestedfor possible injury/ischemiaSince previous tracing of , no significant change Tc-m sestamibi was administered. RSR' pattern in leads V1-V2 with mild ST segment elevationin leads V1-V3 of uncertain clinical significance. TECHNIQUE: Noncontrast head CT. 12:37 AM CT HEAD W/O CONTRAST Clip # Reason: FOUND DOWN. Since the previous tracing of inferior ST segmentelevation is less.TRACING #4 npn 7p-7a (see also carevuew flownotes for objective data)dx: chest pain; altered LOC s/p procedure d/t medications for symptomsneuro/resp:pt somnulent until about 02:45; per neurology attending note, pt s/p 16 mg IV ativan , d/t symptoms as described in chart; b/p and hrt rate stable; respirations shallow at one point with questionable adequate air exchange; n.c.O2 turned up from 2 l to 3 l.p.m. IMPRESSION: Normal radiographic appearance of the chest. Clinical correlation is suggested.TRACING #1 PMED HX SIG FOR ETOH -6-7DRINKS/DAY, 3-4PPD SMOKER, COPD, BRUGATTA SYNDROME, SLEEP ANPNEA, HTN, NONCARDIAC CP WITH MULTIPLE CARD CATH IN PAST, LAST ONE HERE IN .ALLERGIES--PCN--HIVESROS--NEURO--PT LETHARGIC, ORIENTED X2. Approved: 11:33 AM West RADLINE ; A radiology consult service. Peak blood pressure: 102/70. Baseline artifactSinus tachycardiaST segment elevationin V1 and V2 - clinical correlation is suggested for acuteinjury/ischemia although baseline artifact makes assessment difficultSince previous tracing of , ST segment elevation in V1 and V2 moreprominent INTERPRETATION: Following injection of thallium while the patient was at rest, static and SPECT images were obtained. The mediastinal and hilar contours are normal. Resting perfusion images were obtained with Tl-201. Compared to the previous tracing of ST segments are lesselevated in lead V2 and are newly elevated in lead V3. /nkg , M.D. IMPRESSION: Rest thallium images demonstrate no perfusion defects. Sinus rhythm. Sinus rhythm. Sinus rhythm. T waves are invertedin leads VI and V3. FINDINGS: The cardiac silhouette is normal in size. ST segment elevation inleads VI-V3 with associated T wave inversion. PT ORIGINALLY ADMITTED TO OSH WITH HIS RECURRENT NON-CARDIAC CP AND WAS TRANS HERE FOR FURTHER WORK UP. Sinus bradycardia. Elsewhere there was normal perfusion. Compared to the previous tracing of the rate hasincreased. LV cavity size appears normal. , M.D. , M.D. Poor R wave progression. Images show a mild amount of diaphragmatic attenuation, but no perfusion defects are identified. Since the previous tracing of no significant change.TRACING #3 Imaging protocol: SPECT. DENIES PAIN.GI--LOWER ABD SLIGHTLY DISTENDED, OTHERWISE SOFT, NONTENDER WITH GOOD BS IN ALL 4 QUADS. Consider anteroseptal injurycurrent. On those images, the inferior wall was well visualized. Negative catheterization. NEGATIVE CATHETERIZATION. The ventricles are normal, and the cisterns are patent. Clinical correlation is suggested.TRACING #2 Approved: 10:13 AM West RADLINE ; A radiology consult service. Both costophrenic angles are sharp, with no evidence of pleural effusions. CIWA SCALE STARTED. Since the previous tracingof the rate has decreased. The pulmonary vasculature is normal. The -white matter differentiation is normal. NO FURTHER SZ-LIKE TREMORING NOTED.CV--PT IN SR 70'S, NO SCTOPY NOTED. FINAL REPORT HISTORY: Chronic chest pain. Gated images reveal normal region wall motion. Two minutes after the cessation of infustion, Tc-m sestamibi was administered IV. FINDINGS: Compared with a portable AP chest of two days ago, as well as portable chest from , no consolidating pulmonary infiltrates or definite acute process seen. This may represent lead placement but is also consistentwith evolution of an anteroseptal injury process. NO PERIPHERAL EDEMA NOTED. Surrounding soft tissue and osseous structures are normal. Sinus rhythm, rate 85. A second set of post stress images were obtained after the activity from the liver had washed out. The visualized paranasal sinuses and mastoid air cells are clear. RECEIVED TOTAL OF ATIVAN 14MG IV AND WAS TRANS TO MICU FOR OBSERVATION. Found on floor with left sided weakness and expressive aphasia. PERSANTINE MIBI Clip # Reason: CHRONIC CHEST PAIN. | 17 | [
{
"category": "Radiology",
"chartdate": "2139-12-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 850741,
"text": " 12:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FOUND DOWN.?ACUTE HEMORRHAGIC STROKE\n Admitting Diagnosis: CHAST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with h/o ?pseudoseizure, EtOH abuse admitted for chronic CP\n found on floor with left sided weakness and expressive aphasia\n REASON FOR THIS EXAMINATION:\n acute hemorrhagic stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Alcohol abuse and history of pseudoseizure. Found on floor with\n left sided weakness and expressive aphasia.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: None.\n\n FINDINGS: There is no intracranial hemorrhage, abnormal extraaxial fluid\n collection, mass effect or midline shift. The ventricles are normal, and the\n cisterns are patent. The -white matter differentiation is normal. The\n visualized paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION: No intracranial hemorrhage or mass effect.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-12-21 00:00:00.000",
"description": "REST THALLIUM",
"row_id": 850857,
"text": "REST THALLIUM Clip # \n Reason: CHEST PAIN\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Forty-eight year old with chest pain.\n\n INTERPRETATION: Following injection of thallium while the patient was at rest,\n static and SPECT images were obtained.\n Imaging protocol: SPECT.\n\n Images show a mild amount of diaphragmatic attenuation, but no perfusion defects\n are identified.\n LV cavity size appears normal.\n\n IMPRESSION: Rest thallium images demonstrate no perfusion defects.\n /nkg\n\n\n , M.D.\n , M.D. Approved: 10:13 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": "2139-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 850937,
"text": " 10:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: history of fevers\n Admitting Diagnosis: CHAST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with fevers\n REASON FOR THIS EXAMINATION:\n history of fevers\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old man with fevers. Evaluate for infiltrate.\n\n Comparison is made with a prior study obtained.\n\n FINDINGS:\n\n The cardiac silhouette is normal in size. The mediastinal and hilar contours\n are normal. The pulmonary vasculature is normal. The lungs are clear\n bilaterally. Both costophrenic angles are sharp, with no evidence of pleural\n effusions. Surrounding soft tissue and osseous structures are normal.\n\n IMPRESSION:\n\n Normal radiographic appearance of the chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-12-23 00:00:00.000",
"description": "PERSANTINE MIBI",
"row_id": 850992,
"text": "PERSANTINE MIBI Clip # \n Reason: CHRONIC CHEST PAIN. NEGATIVE CATHETERIZATION.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chronic chest pain. Negative catheterization.\n\n SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:\n Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142\n mg/kg/min.\n Peak heart rate: 85.\n Peak blood pressure: 102/70.\n Symptoms during exercise: no symptoms during exercise.\n\n INTERPRETATION:\n Imaging Protocol: Gated SPECT.\n Resting perfusion images were obtained with Tl-201.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n Two minutes after the cessation of infustion, Tc-m sestamibi was administered\n IV.\n This study was interpreted using the 17-segment myocardial perfusion model.\n\n Initial post dipyhridamole stress images show very high hepatic activity making\n interpretation of the inferior wall difficult. A second set of post stress\n images were obtained after the activity from the liver had washed out. On those\n images, the inferior wall was well visualized.\n There is a moderately reversible perfusion defect in the base of the inferior\n wall. Elsewhere there was normal perfusion.\n\n Gated images reveal normal region wall motion.\n The ejection fraction was 45%. Tc-m sestamibi was administered.\n\n IMPRESSION: Moderate reversible perfusion defect of the basilar inferior wall.\n LVEF of 45% with normal regional wall motion.\n\n\n , M.D. Approved: 11:33 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": "2139-12-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 851252,
"text": " 11:21 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for PNA\n Admitting Diagnosis: CHAST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with fever, evidence of consolidation on exam\n REASON FOR THIS EXAMINATION:\n Please assess for PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever. Assess for pneumonia.\n\n FINDINGS: Compared with a portable AP chest of two days ago, as well as\n portable chest from , no consolidating pulmonary infiltrates or\n definite acute process seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-23 00:00:00.000",
"description": "Report",
"row_id": 123753,
"text": "Sinus rhythm, rate 85. Poor R wave progression. ST segment elevation in\nleads VI-V3 with associated T wave inversion. Consider anteroseptal injury\ncurrent. Compared to the previous tracing of ST segments are less\nelevated in lead V2 and are newly elevated in lead V3. T waves are inverted\nin leads VI and V3. This may represent lead placement but is also consistent\nwith evolution of an anteroseptal injury process.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-23 00:00:00.000",
"description": "Report",
"row_id": 123754,
"text": "Sinus rhythm\nBorderline first degree A-V delay\nConsider left atrial abnormality\nprecordial lead/ anteroseptal ST-T wave configuration suggests acute\ninjury/ischemia - clinical correlation is suggested\nSince previous tracing of , sinus tachycardia absent and further ST-T\nwave changes in V1 and V2 seen\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-22 00:00:00.000",
"description": "Report",
"row_id": 123755,
"text": "Baseline artifact\nSinus tachycardia\nST segment elevationin V1 and V2 - clinical correlation is suggested for acute\ninjury/ischemia although baseline artifact makes assessment difficult\nSince previous tracing of , ST segment elevation in V1 and V2 more\nprominent\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-21 00:00:00.000",
"description": "Report",
"row_id": 123756,
"text": "Sinus rhythm\nBorderline first degree A-V delay\nConsider left atrial abnormality\nrsr' pattern in V1 and V2 and modest ST segment elevation in V2 - is\nnonspecific and could be normal variant but clinical correlation is suggested\nfor possible injury/ischemia\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-20 00:00:00.000",
"description": "Report",
"row_id": 123757,
"text": "Sinus bradycardia\nBorderline first degree A-V delay\nConsider left axis deviation\nRSR' pattern in V1 and V2 and modest ST segment elevation in V2 - is\nnonspecific and could be normal variant but clinical correlation is suggested\nfor possible injury/ischemia\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-19 00:00:00.000",
"description": "Report",
"row_id": 123758,
"text": "Sinus rhythm. Since the previous tracing of inferior ST segment\nelevation is less.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-18 00:00:00.000",
"description": "Report",
"row_id": 123759,
"text": "Sinus rhythm. Since the previous tracing of no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-18 00:00:00.000",
"description": "Report",
"row_id": 123760,
"text": "Sinus rhythm. Compared to the previous tracing of the rate has\nincreased. There may be more prominent ST segment elevation in the inferior\nleads. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-12-17 00:00:00.000",
"description": "Report",
"row_id": 123761,
"text": "Sinus bradycardia. RSR' pattern in leads V1-V2 with mild ST segment elevation\nin leads V1-V3 of uncertain clinical significance. Since the previous tracing\nof the rate has decreased. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-12-22 00:00:00.000",
"description": "Report",
"row_id": 1445540,
"text": "npn 7p-7a addendum: re event 05:40\n\nPt observed to have subtle shaking of all 4 limbs, hands in fists; pt unresponsive, observed to arch back/neck mildly; pupils constricted approx 1 mm, equally; hypertensive during this time (144/92), also tachycardic; O2 was 3 l nc, because of subtle shaking of arms, did not have good pleth for O2 sat probe, so couldn't assess directly if pt was having significant decrease in O2 sat, though did look like consistant drop to 92/03% from 97%; non-rebreather mask placed on pt at 100% O2;\n covering MD paged and present immediately, to assess pt's symptoms of seizure/seizure-like activity; notable is ETOH history, and possibility of DT's; (see MD's notes re exam);\n pt received total of 4 mg IV ativan, slow IVP, in two divided doses; pt's hrt rate and b/p did seem to respond to ativan both by decreasing closer to pt's prior basline (prior to event);\n pt aware of person only this 12 hours; seemed unable to explain to pt the need for him being here (/MICU), repeated a few times that he wanted to go to his \"old room\"; stated at approx 06:00 that he \"wanted to go home\"...\n\n received 2 new periph IV's, one in each arm; one by MICU RN, and one by IV team RN; a.m. labs sent at approx 05:30; 1 set blood cx's obtained at that time also; urine specimen also sent for u/a and cx;\n\nat 06:20, pt observed to have subtle shaking of rt arm and rt leg, no movt of left side; tachycardic to 110's, slightly hypertensive (syst 130's), though pt observed to turn to right and manipulate bed control, returned to back side, glanced at nurse, shut eyes again and started subtle shaking of limbs;\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-12-21 00:00:00.000",
"description": "Report",
"row_id": 1445538,
"text": "MICU A NSG ADMIT\nPT IS A 42 YO MAN WITH WITNESSED SEIZURE TYPE EPISODE IN NUC MED. RECEIVED TOTAL OF ATIVAN 14MG IV AND WAS TRANS TO MICU FOR OBSERVATION. PT ORIGINALLY ADMITTED TO OSH WITH HIS RECURRENT NON-CARDIAC CP AND WAS TRANS HERE FOR FURTHER WORK UP. PT WAS HAVING MIBI SCAN AS HIS CARD ENZYMES WERE NEG. PMED HX SIG FOR ETOH -6-7DRINKS/DAY, 3-4PPD SMOKER, COPD, BRUGATTA SYNDROME, SLEEP ANPNEA, HTN, NONCARDIAC CP WITH MULTIPLE CARD CATH IN PAST, LAST ONE HERE IN .\n\nALLERGIES--PCN--HIVES\n\nROS--NEURO--PT LETHARGIC, ORIENTED X2. SLEEPING WHEN NOT STIMULATED. CIWA SCALE STARTED. PT <10. ABLE TO MAE. PERRL AT 3-4MM AND BRISK. NO FURTHER SZ-LIKE TREMORING NOTED.\n\nCV--PT IN SR 70'S, NO SCTOPY NOTED. BP 90-115/. NO PERIPHERAL EDEMA NOTED. DENIES PAIN.\n\nGI--LOWER ABD SLIGHTLY DISTENDED, OTHERWISE SOFT, NONTENDER WITH GOOD BS IN ALL 4 QUADS. PT ORDERED FOR DIET, BUT HOLDING PO'S TILL MORE AWAKE.\n\nGU--FOLEY CATH PLACED AND DRAINED 900CC URINE IMMEDIATELY.\n\nSOCAIL--SISTER LISTED AS NEXT OF , PT WOULD LIKE HER NOTIFIED IN CASE OF EMERGENCY.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2139-12-22 00:00:00.000",
"description": "Report",
"row_id": 1445539,
"text": "npn 7p-7a (see also carevuew flownotes for objective data)\n\ndx: chest pain; altered LOC s/p procedure d/t medications for symptoms\n\nneuro/resp:\npt somnulent until about 02:45; per neurology attending note, pt s/p 16 mg IV ativan , d/t symptoms as described in chart; b/p and hrt rate stable; respirations shallow at one point with questionable adequate air exchange; n.c.O2 turned up from 2 l to 3 l.p.m.; O2 sats adequate in high 90's overnight;\n at 02:45 pt found standing at bedside, IV lines and b/p cord intact; pt with mild shuttering of arms only; able to answer questions by caregivers, though some stuttering noted; no incontinence occurred, no fall, no LOC; pt assisted back to bed, bed alarm turned on;\n\nc-v:\nb/p and hrt rate wnl's, though b/p on low side at times; NTP dc'd; no c/o chest pain overnight; no ectopy observed overnight;\n nicotine patch applied to prevent w/drawal symptoms from smoking;\n\ng-i:\nabd soft, n-t; + bowel sounds; no stool this night; stated hungry at approx 02:50, asked for something to eat; given bites custard and sips milk at that time, though will be npo following d/t possible continued procedures/tests ;\n\ng-u:\nurine output adequate via patent foley; urine specimen to be sent when able; volume gradually decreasing, likely d/t pt not on IVF's for hydration; KVO increased;\n\nskin:\nIV access Rt a.c.; patent; to SL at 03:30 after meds in, for pt comfort--IV pump kept alarming d/t pt bending Rt arm at elbow;\n\nLABS:\nyesterday's troponin reportedly <0.01; anticipate repeat cardiac enzymes with a.m. labs;\n\nSocial:\npt's sister called during the evening to check on pt's updates;\n\nPLAN:\n1) medical work-up re cardiac symptoms and c/o's\n2) possible EEG a.m.\n3) check results a.m. labs\n4) anticipate tranfer out to telemetry bed\n5) pt w/ hx ETOH; no ETOH intake since hospitalization; watch for w/drawal s/s; nicotine patch to prevent nicotine w/drawal re smoking;\n6) ?psych c/s, psych work-up re etiology stated pseudoseizures\n"
}
] |
42,555 | 151,483 | 62F with a history of chronic hip pain/NSAID, s/p right hip replacement this in who presents with an apparent upper GI bleed. | HCT drifting down today, may reflect hemodilution vs slow downwards drift -- continue IV PPI -- remains NPO -- f/u GI recs re: scope today -- has 2 18g PIVs -- HCTs today . Mild HCT drop this AM, no melena/hematemesis -Maintain 2 large bore IV's -Recheck HCT Q6hr -Continue IV PPI -Check coags -GI to perform EGD this AM. Mild HCT drop this AM, no melena/hematemesis -Maintain 2 large bore IV's -Recheck HCT Q6hr -Continue IV PPI -Check coags -GI to perform EGD this AM. # FEN -- NPO for now -- IVF . # FEN -- NPO for now -- IVF . # HTN -- hold lisinopril given GIB . # Lipids -- continue niacin . # Lipids -- continue niacin . Self d/c'ed NGT. -Maintain 2 large bore IV's -Another NS 1 liter bolus now -Recheck HCT Q6hr, transfuse to keep HCT >27 -Continue IV PPI -Check coags -GI saw patient in ED, plan is for endoscopy tomorrow as long as she remains stable. -Maintain 2 large bore IV's -Another NS 1 liter bolus now -Recheck HCT Q6hr, transfuse to keep HCT >27 -Continue IV PPI -Check coags -GI saw patient in ED, plan is for endoscopy tomorrow as long as she remains stable. HEMODYNAMICS: -Tachycardia improved with IVF -Currently at baseline bp HTN: -Holding antihypertensives ACCESS: -Large bore IV access x 2 Rest of plan per Resident Note ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 05:17 PM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: DNI (do not intubate) Disposition :Transfer to floor Total time spent: 30 minutes HEMODYNAMICS: -Tachycardia improved with IVF -Currently at baseline bp HTN: -Holding antihypertensives ACCESS: -Large bore IV access x 2 Rest of plan per Resident Note ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 05:17 PM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: DNI (do not intubate) Disposition :Transfer to floor Total time spent: 30 minutes There is an RSR' pattern in lead V1 which is probablynormal. NG lavage suggests no brisk bleeding at this time. NG lavage suggests no brisk bleeding at this time. # Dispo -- ICU overnight ICU Care Nutrition: Comments: NPO Glycemic Control: Lines: 18 Gauge - 05:17 PM Comments: 2 18g PIVs Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU Response: PND Plan: Serial HCts with plan for scope in AM. Response: PND Plan: Serial HCts with plan for scope in AM. Response: Pt with small Hct drop in setting of coffee ground emesis, also rec 2L NS in ED - ? Response: Pt with small Hct drop in setting of coffee ground emesis. Has been tachycardic but has remained with her baseline hypertension. Gastrointestinal bleed, other (GI Bleed, GIB) Assessment: Hct 29.3. Gastrointestinal bleed, other (GI Bleed, GIB) Assessment: Hct 29.3. Ongoing Hct checks. Ongoing Hct checks. In ED she had small amount of coffee ground emesis and was NG lavaged for same. In ED she had small amount of coffee ground emesis and was NG lavaged for same. In ED she had small amount of coffee ground emesis and was NG lavaged for same. # Pain -- tylenol instead of NSAIDs . # Pain -- tylenol instead of NSAIDs . # Dispo -- c/o to floor ICU Care Nutrition: Comments: NPO Glycemic Control: Lines: 18 Gauge - 05:17 PM Prophylaxis: DVT: Boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Disposition:Transfer to floor Allergies: Iodine; Iodine Containing CT contrast dye Adhesive Tape (Topical) makes skin red Last dose of Antibiotics: Infusions: Other ICU medications: Pantoprazole (Protonix) - 07:54 PM 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 06:41 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 36.8C (98.3 Tcurrent: 36.3C (97.3 HR: 79 (79 - 107) bpm BP: 103/51(64) {103/51(64) - 153/82(99)} mmHg RR: 14 (13 - 23) insp/min SpO2: 95% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 78.1 kg (admission): 78.1 kg Height: 63 Inch Total In: 2,510 mL PO: TF: IVF: 510 mL Blood products: Total out: 1,600 mL 450 mL Urine: 1,600 mL 450 mL NG: Stool: Drains: Balance: 910 mL -450 mL Respiratory support O2 Delivery Device: None SpO2: 95% ABG: ///27/ Physical Examination Gen: middle aged female in NAD HEENT: conjunctival pallor Cor: RRR, 2/6 systolic murmur LSB Resp: CTAB Abd: obese, S/nt/nd +BS ext: WWP, no c/c/e Labs / Radiology 293 K/uL 9.6 g/dL 94 mg/dL 0.7 mg/dL 27 mEq/L 3.8 mEq/L 23 mg/dL 108 mEq/L 141 mEq/L 26.4 % 9.2 K/uL [image002.jpg] 07:37 PM 03:31 AM WBC 9.2 Hct 29.0 26.4 Plt 293 Cr 0.7 Glucose 94 Other labs: PT / PTT / INR:13.6/20.3/1.2 Imaging: none Microbiology: none Assessment and Plan 62F with extensive recent NSAID use now p/w upper GIB. | 11 | [
{
"category": "Physician ",
"chartdate": "2192-12-27 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 551014,
"text": "Chief Complaint: Syncope\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 yo F with a h/o renal cell carcinoma (s/p partial L nephrectomy in\n , felt to be disease free) who presented to the EW today after\n experiencing dark (but not black) stools x 2 days and lightheadedness\n followed by syncope x \"few seconds\" at work today. Reports taking\n ibuprofen 400mg 1-2x/day for joint pains.\n In the ED, she vomited once-->coffee grounds. Underwent NG lavage\n which revealed more coffee grounds but no BRB. HCT 29 (baseline a few\n years ago was 40). Given 2L NS, no PRBC, IV PPI and 2 18 gauge PIV's\n placed. GI notified -- plan for EGD tomorrow. Has been tachycardic\n but has remained with her baseline hypertension.\n Admitted to the ICU for fluid resuscitation & hemodynamic\n monitoring.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Iodine; Iodine Containing\n CT contrast dye\n Adhesive Tape (Topical)\n makes skin red\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lisinopril, ibuprofen, MVI, Vit D, flaxseed oil\n Past medical history:\n Family history:\n Social History:\n Renal cell carcinoma\n HTN\n Hyperlipidemia\n s/p L THR in \n NC\n Occupation: Former RT, works for lead screening coalition\n Drugs: Denies\n Tobacco: Denies\n Alcohol: rare\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Neurologic: lightheadedness\n Flowsheet Data as of 05:15 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 109 () bpm\n BP: 153/82\n RR: 12 ()\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\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 ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), Tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 246\n 29.3\n 131\n 0.6\n 33\n 25\n 107\n 5.2\n 141\n 10.5\n [image002.jpg]\n Other labs: CK / CKMB / Troponin-T:60//<0.01\n Fluid analysis / Other labs: U/A: neg for infection\n ECG: ST@103 BPM Nml axis No STchanges\n Assessment and Plan\n 62 you F admitted with UGIB resulting in syncope in the setting of\n NSAID use.\n GIB: Likely PUD. Subjectively better with IVF. Still mildly\n tachycardic. NG lavage suggests no brisk bleeding at this time.\n -Maintain 2 large bore IV's\n -Another NS 1 liter bolus now\n -Recheck HCT Q6hr, transfuse to keep HCT >27\n -Continue IV PPI\n -Check coags\n -GI saw patient in ED, plan is for endoscopy tomorrow as long as she\n remains stable.\n HEMODYNAMICS:\n -Tachycardia\n fluid resuscitation crystalloid\n -Currently at baseline bp\n HTN:\n -Holding antihypertensives\n ACCESS:\n -Large bore IV access x 2\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\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 Patient is critically ill.\n Total time spent: 40 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2192-12-27 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 551031,
"text": "TITLE:\n Chief Complaint: GIB\n HPI:\n 62F with PMH of HTN, renal cell CA s/p nephrectomy , who presents\n after syncopizing today at work. She acutely began to feel diaphoretic\n and lightheaded, so she sat down. Per others' reports she then briefly\n syncopized and came to immediately afterwards, with no confusion,\n speech slurring, toic/clonic movements. Endorses associated N/V, but no\n CP or SOB. No recent F/C. She does note that she has been taking motrin\n once or twice daily ever since her total hip replacement in .\n She also reports that her stools have been darker but not frnakly black\n for the last few days\n .\n In the ED, VS were 97.9 95 113/77 16 100%RA. NAD. 2/6 SEM. benign\n belly. Had 1 epidose of coffee ground episodes. EKG showed 1st degree\n block, non ischemic. HCT of 29.3, baseline 40. T+C x 4 units, no blood\n given. NG lavage returned coffee grounds, no bright red blood. Self\n d/c'ed NGT. GI was consulted, will scope tomorrow. Last VS 100 34/74 16\n 99%RA. Access was obtained with 2 18g PIVs. Got 2L NS and admitted to\n ICU for monitoring.\n .\n Currently feels weak and tired but no other complaints.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Iodine; Iodine Containing\n CT contrast dye\n Adhesive Tape (Topical)\n makes skin red\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n lisinopril 20mg daily\n niacin 500 \n flaxseed oil\n MVI\n motrin 400mg prn\n Past medical history:\n Family history:\n Social History:\n HTN\n RCC s/p partial left nephrectomy - disease free since.\n high cholesterol\n s/p total hip replacement \n N/C\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Works as head of lead prevention program. Denies\n EtOH/tobacco/drug use.\n Review of systems:\n Flowsheet Data as of 07:37 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 90 (90 - 107) bpm\n BP: 121/68(81) {121/68(81) - 153/82(99)} mmHg\n RR: 18 (18 - 23) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.1 kg (admission): 78.1 kg\n Height: 63 Inch\n Total In:\n 2,483 mL\n PO:\n TF:\n IVF:\n 483 mL\n Blood products:\n Total out:\n 0 mL\n 800 mL\n Urine:\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,683 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n VS: afeb 103 135-153/80-90s 21 98%RA\n Gen: middle aged female in NAD\n HEENT: conjunctival pallor\n Cor: RRR, 2/6 systolic murmur LSB\n Resp: CTAB\n Abd: obese, S/nt/nd +BS\n ext: WWP, no c/c/e\n Labs / Radiology\n 246\n 131\n 0.6\n 33\n 25\n 107\n 5.2\n 141\n 29.3\n 10.5\n [image002.jpg]\n Imaging: None\n Microbiology: None; U/A clean\n Assessment and Plan\n 62F with extensive recent NSAID use now p/w upper GIB.\n .\n # GIB\n -- IV PPI \n -- NPO\n -- GI to scope in AM\n -- T+C active 4 units\n -- has 2 18g PIVs\n -- q6 HCTs overnight\n .\n # HTN\n -- hold lisinopril given GIB\n .\n # Lipids\n -- continue niacin\n .\n # Pain\n -- tylenol instead of NSAIDs\n .\n # FEN\n -- NPO for now\n -- IVF\n .\n # Ppx\n -- pboots, no heparin, no bowel reigmen given GIB, PPI\n .\n # Access\n - 2 18 PIVs\n .\n # Code\n -- full\n .\n # Dispo\n -- ICU overnight\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 05:17 PM\n Comments: 2 18g PIVs\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2192-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 551021,
"text": "62 yo female was at work when she reported feelling lightheaded. LOC\n for few seconds. EMS called and sent to . In ED she had small\n amount of coffee ground emesis and was NG lavaged for same. Hct stable\n at 29.3. Patient reported dark stool last few days. Has been taking\n Ibuprofen regularly hip replacement. Plan is for scope tomorrow.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct 29.3. NG lavaged in ED for coffee ground material. Did have small\n amt of coffed ground emesis.\n Action:\n Sent to MICU for further monitoring and endoscopy.\n Response:\n PND\n Plan:\n Serial HCts with plan for scope in AM.\n"
},
{
"category": "Physician ",
"chartdate": "2192-12-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 551104,
"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 Remained stable overnight, received NS overnight.\n Refused to sign ICU and Blood consent.\n History obtained from Patient\n Allergies:\n Iodine; Iodine Containing\n CT contrast dye\n Adhesive Tape (Topical)\n makes skin red\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:54 PM\n Other medications:\n niacin, MVI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 86 (79 - 107) bpm\n BP: 128/64(80) {103/51(64) - 153/82(99)} mmHg\n RR: 17 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.1 kg (admission): 78.1 kg\n Height: 63 Inch\n Total In:\n 2,510 mL\n PO:\n TF:\n IVF:\n 510 mL\n Blood products:\n Total out:\n 1,600 mL\n 450 mL\n Urine:\n 1,600 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 910 mL\n -450 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 293 K/uL\n 94 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 108 mEq/L\n 141 mEq/L\n 26.4 %\n 9.2 K/uL\n [image002.jpg]\n 07:37 PM\n 03:31 AM\n WBC\n 9.2\n Hct\n 29.0\n 26.4\n Plt\n 293\n Cr\n 0.7\n Glucose\n 94\n Other labs: PT / PTT / INR:13.6/20.3/1.2\n Assessment and Plan\n 62 you F admitted with UGIB resulting in syncope in the setting of\n NSAID use.\n GIB: Likely PUD. Subjectively better with IVF. NG lavage yesterday\n suggested no brisk bleeding at that time. Mild HCT drop this AM, no\n melena/hematemesis\n -Maintain 2 large bore IV's\n -Recheck HCT Q6hr\n -Continue IV PPI\n -Check coags\n -GI to perform EGD this AM.\n HEMODYNAMICS:\n -Tachycardia improved with IVF\n -Currently at baseline bp\n HTN:\n -Holding antihypertensives\n ACCESS:\n -Large bore IV access x 2\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2192-12-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 551106,
"text": "62 yo female was at work when she reported feelling lightheaded. LOC\n for few seconds. EMS called and sent to . In ED she had small\n amount of coffee ground emesis and was NG lavaged for same. Hct stable\n at 29.3. Patient reported dark stool last few days. Has been taking\n Ibuprofen regularly hip replacement. Plan is for EGD today.\n Dispo: DNI\n Allergies: Iodine; Iodine Containing, CT contrast dye, Adhesive Tape\n (Topical), makes skin red\n Access: 2 18g piv\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct 26.4 from 29.0 NG lavaged in ED for coffee ground material. No\n emesis since arrival to MICU. No melena or stool. No obvious signs of\n bleeding.\n Action:\n Sent to MICU for further monitoring and endoscopy. Pt is .\n Response:\n Pt with small Hct drop in setting of coffee ground emesis, also rec\n 2L NS in ED - ? dilutional. Ongoing Hct checks.\n Plan:\n Serial HCts with plan for scope in AM. Repeat Hct at 1200.\n Demographics\n Attending MD:\n P.\n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Height:\n 63 Inch\n Admission weight:\n 78.1 kg\n Daily weight:\n 78.1 kg\n Allergies/Reactions:\n Iodine; Iodine Containing\n CT contrast dye\n Adhesive Tape (Topical)\n makes skin red\n Precautions:\n PMH:\n CV-PMH:\n Additional history: osteoarthritis with left hip replacement.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:119\n D:71\n Temperature:\n 99.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n 450 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 03:31 AM\n Potassium:\n 3.8 mEq/L\n 03:31 AM\n Chloride:\n 108 mEq/L\n 03:31 AM\n CO2:\n 27 mEq/L\n 03:31 AM\n BUN:\n 23 mg/dL\n 03:31 AM\n Creatinine:\n 0.7 mg/dL\n 03:31 AM\n Glucose:\n 94 mg/dL\n 03:31 AM\n Hematocrit:\n 26.4 %\n 03:31 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: CC701\n Date & time of Transfer: 0930\n"
},
{
"category": "Physician ",
"chartdate": "2192-12-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 551079,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n overnight events:\n none.\n This AM pt with decreased lightheadedness, interviewed while ambulating\n around the room.\n Allergies:\n Iodine; Iodine Containing\n CT contrast dye\n Adhesive Tape (Topical)\n makes skin red\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:54 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 06:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.3\nC (97.3\n HR: 79 (79 - 107) bpm\n BP: 103/51(64) {103/51(64) - 153/82(99)} mmHg\n RR: 14 (13 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.1 kg (admission): 78.1 kg\n Height: 63 Inch\n Total In:\n 2,510 mL\n PO:\n TF:\n IVF:\n 510 mL\n Blood products:\n Total out:\n 1,600 mL\n 450 mL\n Urine:\n 1,600 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 910 mL\n -450 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n Gen: middle aged female in NAD\n HEENT: conjunctival pallor\n Cor: RRR, 2/6 systolic murmur LSB\n Resp: CTAB\n Abd: obese, S/nt/nd +BS\n ext: WWP, no c/c/e\n Labs / Radiology\n 293 K/uL\n 9.6 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 108 mEq/L\n 141 mEq/L\n 26.4 %\n 9.2 K/uL\n [image002.jpg]\n 07:37 PM\n 03:31 AM\n WBC\n 9.2\n Hct\n 29.0\n 26.4\n Plt\n 293\n Cr\n 0.7\n Glucose\n 94\n Other labs: PT / PTT / INR:13.6/20.3/1.2\n Imaging: none\n Microbiology: none\n Assessment and Plan\n 62F with extensive recent NSAID use now p/w upper GIB.\n .\n # GIB\n pt refusing blood transfusions. HCT drifting down today, may\n reflect hemodilution vs slow downwards drift\n -- continue IV PPI \n -- remains NPO\n -- f/u GI recs re: scope today\n -- has 2 18g PIVs\n -- HCTs today\n .\n # HTN\n -- continue to hold lisinopril given GIB\n .\n # Lipids\n -- continue niacin\n .\n # Pain\n -- tylenol instead of NSAIDs\n .\n # FEN\n -- NPO for now\n -- IVF\n .\n # Ppx\n -- pboots, no heparin, no bowel reigmen given GIB, PPI\n .\n # Access\n - 2 18 PIVs\n .\n # Code\n -- full\n .\n # Dispo\n -- c/o to floor\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control:\n Lines:\n 18 Gauge - 05:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2192-12-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 551008,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct 29.3. NG lavaged in ED for coffee ground material. Did have small\n amt of coffed ground emesis.\n Action:\n Sent to MICU for further monitoring and endoscopy.\n Response:\n PND\n Plan:\n Serial HCts with plan for scope in AM.\n"
},
{
"category": "Physician ",
"chartdate": "2192-12-27 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 551006,
"text": "Chief Complaint: Syncope\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 62 yo F with a h/o renal cell carcinoma (s/p partial L nephrectomy in\n , felt to be disease free) who presented to the EW today after\n experiencing dark (but not black) stools x 2 days and lightheadedness\n followed by syncope x \"few seconds\" at work today. Reports taking\n ibuprofen 400mg 1-2x/day for joint pains.\n In the ED, she vomited once-->coffee grounds. Underwent NG lavage\n which revealed more coffee grounds but no BRB. HCT 29 (baseline a few\n years ago was 40). Given 2L NS, no PRBC, IV PPI and 2 18 gauge PIV's\n placed. GI notified who planned for EGD tomorrow.\n Admitted to the ICU for monitoring.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Iodine; Iodine Containing\n CT contrast dye\n Adhesive Tape (Topical)\n makes skin red\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lisinopril, ibuprofen, MVI, Vit D, flaxseed oil\n Past medical history:\n Family history:\n Social History:\n Renal cell carcinoma\n HTN\n Hyperlipidemia\n s/p L THR in \n NC\n Occupation: Former RT, works for lead screening coalition\n Drugs: Denies\n Tobacco: Denies\n Alcohol: rare\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Cough, No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis\n Genitourinary: No(t) Dysuria\n Musculoskeletal: Joint pain\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Neurologic: lightheadedness\n Flowsheet Data as of 05:15 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 109 () bpm\n BP: 153/82\n RR: 12 ()\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\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 ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: Systolic), Tachycardic\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 246\n 29.3\n 131\n 0.6\n 33\n 25\n 107\n 5.2\n 141\n 10.5\n [image002.jpg]\n Other labs: CK / CKMB / Troponin-T:60//<0.01\n Fluid analysis / Other labs: U/A: neg for infection\n ECG: ST@103 BPM Nml axis No STchanges\n Assessment and Plan\n 62 you F admitted with UGIB resulting in syncope in the setting of\n NSAID use.\n GIB: Likely PUD. Subjectively better with IVF. Still mildly\n tachycardic. NG lavage suggests no brisk bleeding at this time.\n -Maintain 2 large bore IV's\n -Another NS 1 liter bolus now\n -Recheck HCT Q6hr, transfuse to keep HCT >27\n -Continue IV PPI\n -Check coags\n -GI saw patient in ED, plan is for endoscopy tomorrow as long as she\n remains stable.\n HTN:\n -Holding antihypertensives\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\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: 30 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2192-12-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 551051,
"text": "62 yo female was at work when she reported feelling lightheaded. LOC\n for few seconds. EMS called and sent to . In ED she had small\n amount of coffee ground emesis and was NG lavaged for same. Hct stable\n at 29.3. Patient reported dark stool last few days. Has been taking\n Ibuprofen regularly hip replacement. Plan is for EGD today.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct 26.4 from 29.0 NG lavaged in ED for coffee ground material. No\n emesis since arrival to MICU. No melena or stool. No obvious signs of\n bleeding.\n Action:\n Sent to MICU for further monitoring and endoscopy. Pt is refusing blood\n products at this time. Pt is . Dr. discussed both issues at\n length the pt.\n Response:\n Pt with small Hct drop in setting of coffee ground emesis. Ongoing Hct\n checks.\n Plan:\n Serial HCts with plan for scope in AM. ? Further discussion regarding\n blood transfusions.\n"
},
{
"category": "Physician ",
"chartdate": "2192-12-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 551148,
"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 Remained stable overnight, received NS overnight.\n Refused to sign ICU and Blood consent.\n History obtained from Patient\n Allergies:\n Iodine; Iodine Containing\n CT contrast dye\n Adhesive Tape (Topical)\n makes skin red\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:54 PM\n Other medications:\n niacin, MVI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 86 (79 - 107) bpm\n BP: 128/64(80) {103/51(64) - 153/82(99)} mmHg\n RR: 17 (13 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 78.1 kg (admission): 78.1 kg\n Height: 63 Inch\n Total In:\n 2,510 mL\n PO:\n TF:\n IVF:\n 510 mL\n Blood products:\n Total out:\n 1,600 mL\n 450 mL\n Urine:\n 1,600 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 910 mL\n -450 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,\n (Murmur: No(t) Systolic, No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.6 g/dL\n 293 K/uL\n 94 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 23 mg/dL\n 108 mEq/L\n 141 mEq/L\n 26.4 %\n 9.2 K/uL\n [image002.jpg]\n 07:37 PM\n 03:31 AM\n WBC\n 9.2\n Hct\n 29.0\n 26.4\n Plt\n 293\n Cr\n 0.7\n Glucose\n 94\n Other labs: PT / PTT / INR:13.6/20.3/1.2\n Assessment and Plan\n 62 you F admitted with UGIB resulting in syncope in the setting of\n NSAID use.\n GIB: Likely PUD. Subjectively better with IVF. NG lavage yesterday\n suggested no brisk bleeding at that time. Mild HCT drop this AM, no\n melena/hematemesis\n -Maintain 2 large bore IV's\n -Recheck HCT Q6hr\n -Continue IV PPI\n -Check coags\n -GI to perform EGD this AM.\n HEMODYNAMICS:\n -Tachycardia improved with IVF\n -Currently at baseline bp\n HTN:\n -Holding antihypertensives\n ACCESS:\n -Large bore IV access x 2\n Rest of plan per Resident Note\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNI (do not intubate)\n Disposition :Transfer to floor\n Total time spent: 30 minutes\n"
},
{
"category": "ECG",
"chartdate": "2192-12-27 00:00:00.000",
"description": "Report",
"row_id": 300464,
"text": "Sinus tachycardia. The P-R interval is short without evidence of\npre-excitation. There is an RSR' pattern in lead V1 which is probably\nnormal. Compared to the previous tracing the rate is faster and the\nP-R interval is shorter.\n\n"
}
] |
9,750 | 119,267 | The patient was admitted to C-Medicine on . He was taken to catheterization on , which found the patient's left ventricular ejection fraction was 45% and the patient had severe apical hypokinesis. The left anterior descending was 99% stenosed, mid after major diagonal with filling of distal left anterior descending via right to left collaterals, left circumflex 70% stenosed mid, 99% second major OM and right coronary artery was 95% occluded. At that time, the patient's anatomy was thought to be best suited for coronary artery bypass graft at which time a cardiothoracic surgical consultation was obtained. The patient was optimized for surgery in subsequent days, and the patient was brought to the operating room on , at which time a coronary artery bypass graft times two vessels was performed. The operation consisted of bringing the left internal mammary artery to the left anterior descending, and reversed saphenous vein graft to the right posterior descending artery. The patient tolerated the procedure well and was brought to the Cardiothoracic Surgical Intensive Care Unit in good condition. The patient remained hemodynamically stable postoperatively and was subsequently transferred to the surgical floor where he continued to do well until postoperative day number two where the patient was found to be in atrial fibrillation. The patient was subsequently treated with intravenous Lopressor, intravenous bolus of Amiodarone and p.o. Amiodarone as well as p.o. Lopressor. The patient converted early in the morning of the next day and was continued on 400 mg three times a day Amiodarone as well as 75 mg p.o. twice a day of Lopressor. The remainder of the hospital stay was uneventful, and throughout, he maintained his blood pressure at approximately 110 to 120 systolic blood pressure. The patient was discharged home in good condition. | Left atrial abnormality. AP and lateral chest radiographs dated . 7P-7A CSRU SHIFT SUMMARY;NEURO; ALERT, ORIENTED, FOLLOWS COMMANDS, AND MAE'S WELL.RESP; LUNGS CLEAR DIM IN THE BASES. QS deflections in leads III and aVFconsistent with prior inferior myocardial infarction. There is opacification of the retrocardiac area. Rule outinfarction. Q-T interval prolongation. PT IN USE OF I.S. 02 SAT'S AND RR WNL ALL NOC ON 4L/NC. AMTS. Atrially paced rhythm, new compared to the previous tracing of .Evidence for inferolasteral ischemia persists. Sinus bradycardia. No previous tracing availablefor comparison.TRACING #1 TO MOD. CHEST TUBES DRAINING MIN. The mediastinal and hilar contours are normal. FINDINGS: The patient has interval sternotomy and CABG, with several mediastinal clips noted. IMPRESSION: The retrocardiac opacity likely represents a combination of atelectasis and pleural effusion given the patient's post-CABG state. MANAGE BP'S AND TRANSFER TO 2 IF REMAINS STABLE. Rule out infarction.Followup and clinical correlation are suggested. BLD SUGARS WNL THIS AM.PLAN; CONT TO MONITOR AND ASSESS. The cardiac silhouette is unchanged in size, slightly enlarged. THIN SEROSANQ DRAINAGE. NTG GTT TITRATED OFF THIS AM WITH SBP UP TO 150'S AND MAP UP TO 90'S. No pneumothorax. No pneumothorax. Osseous structures are unremarkable. T wave inversions inleads II, III and aVF, biphasic to inverted T waves in leads V3-V6 representinglateral ischemia as well. IMPRESSION: No evidence of acute cardiopulmonary disease. The left costophrenic angle is not visualized on this study. Clinical correlation is suggested.TRACING #2 NEURO ARRIVED FROM OR ON 15 OF PROPOFOL UNRESPONSIVE REVERSED AND PROPFOL WEANED WITH FULL RESPONSIVENESS MOVES ALL EXTREMETIES FOLLOWS COMMANDS NO NEURO DEFECITS NOTEDRESP WEANED AND EXTUBATED WITHOUT DIFFICULTY LUNGS CLEAR NC 4L SATS 98% CHEST TUBES INTACT DRAINING MOD SEROSANG NONPRODUCTIVE TAKING DEEP BREATHS EASILYC/V ARRIVED A PACED UNDERLYING HR 60-70 SR NO ECT LOWER B/P WITH HR 60S REMAINS A PACED 90S COUPLET X1 NO OTHER ECTOPY SEEN NP B/P ELEVATED MAP > 90 NTG TITRATED WITH GOOD EFFECT CURRENT 0.3 MCGS WOUNDS NO DRAINAGE DSD INTACTGU/GI OG ON ARRIVAL DC/D WITH ETT REGLAN X1 FOR C/O NAUSEA WITH GOOD EFFECT ABD SOFT ABSENT BOWEL SOUNDS TOL ICE CHIPS WELL GOOD URINE OUTPAIN C/O STERNAL WOUND PAIN MS GIVEN X2 WITH ONLY FAIR EFFECT ADDITIONAL DOSE MORPINE 4MG X1 GIVEN PER PA E NILLSON WITH GOOD EFFECTPLAN CONTINUE TO MONITOR HEMODYNAMIC OVERNOC MAINTAIN NTG FOR B/P AS NEEDED INCREASE FLUIDS AS TOL The osseous structures are unremarkable. CT TEAM AWARE AND PT GIVEN LOPRESSOR 5MG IVP ALONG WITH 25MG PO.GI; BS HYPOACTIVE. There are no pleural effusions. No priors are available for comparison. REASON FOR THIS EXAMINATION: pre-op evaluation for CABG FINAL REPORT INDICATION: Preop, history of hypertension, new onset chest pain. TECHNIQUE: A single portable AP view of the chest is compared with 2 days prior. The heart is moderately enlarged. PT ON NTG GTT AND TITRATED ALL NOC TO MAINTAIN MAP >60 AND <90. AND PT PULLING TV OF 1000 WITHOUT DIFFICULTY.CARDIOVAS; SR 80'S NO ECTOPY. Several metallic objects are seen overlying the left abdomen, which likely represent pacing leads. The lungs are clear. TAKING AND TOLERATING SIPS OF H20 WITH NO C/O'S OF NAUSEA.GU; URINE OP WNL AND NOT AN ISSUE OVER NOC.COMFORT; PT C/O INCISIONAL DISCOMFORT AND MED SEVERAL TIMES WITH MS04 2MG IVP AND STARTED ON PERCOCET 1 TAB X2 WITH GOOD EFFECT.ENDO; INITALLY ON INSULIN GTT AND DC'D FOR BS OF 85 AND TX DURING THE NOC WITH REG INSULIN SQ PER SS. 10:49 AM CHEST (PORTABLE AP) Clip # Reason: r/o ptx MEDICAL CONDITION: 77 year old man s/p cabg and ct removal REASON FOR THIS EXAMINATION: r/o ptx FINAL REPORT CHEST X-RAY: INDICATION: Status post CABG and chest tube removal, question pneumothorax. The rate is increased. | 6 | [
{
"category": "Radiology",
"chartdate": "2165-10-22 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 775543,
"text": " 9:04 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: UNSTABLE ANGINA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with no prior cardiac history, but hx positive for HTN,\n Barrett's esophagitis, prostatectomy ' for prostate CA, lumbar disk\n herniation, renal stone obstruction ' with bilateral renal stents, admitted\n with new onset chest pain 1 day prior to admission, now ruled in for MI, and\n s/p cardiac cath positive for multivessel disease.\n REASON FOR THIS EXAMINATION:\n pre-op evaluation for CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop, history of hypertension, new onset chest pain.\n\n AP and lateral chest radiographs dated . No priors are available for\n comparison.\n\n The heart is moderately enlarged. The mediastinal and hilar contours are\n normal. The lungs are clear. There are no pleural effusions. The osseous\n structures are unremarkable.\n\n IMPRESSION: No evidence of acute cardiopulmonary disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 775686,
"text": " 10:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY:\n\n INDICATION: Status post CABG and chest tube removal, question pneumothorax.\n\n TECHNIQUE: A single portable AP view of the chest is compared with 2 days\n prior.\n\n FINDINGS: The patient has interval sternotomy and CABG, with several\n mediastinal clips noted. There is opacification of the retrocardiac area.\n The left costophrenic angle is not visualized on this study. Several metallic\n objects are seen overlying the left abdomen, which likely represent pacing\n leads. No pneumothorax. The cardiac silhouette is unchanged in size,\n slightly enlarged. Osseous structures are unremarkable.\n\n IMPRESSION: The retrocardiac opacity likely represents a combination of\n atelectasis and pleural effusion given the patient's post-CABG state. No\n pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2165-10-23 00:00:00.000",
"description": "Report",
"row_id": 170662,
"text": "Atrially paced rhythm, new compared to the previous tracing of .\nEvidence for inferolasteral ischemia persists. The rate is increased. Rule out\ninfarction. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2165-10-21 00:00:00.000",
"description": "Report",
"row_id": 170663,
"text": "Sinus bradycardia. Left atrial abnormality. QS deflections in leads III and aVF\nconsistent with prior inferior myocardial infarction. T wave inversions in\nleads II, III and aVF, biphasic to inverted T waves in leads V3-V6 representing\nlateral ischemia as well. Q-T interval prolongation. Rule out infarction.\nFollowup and clinical correlation are suggested. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-10-24 00:00:00.000",
"description": "Report",
"row_id": 1390707,
"text": " 7P-7A CSRU SHIFT SUMMARY;\n\nNEURO; ALERT, ORIENTED, FOLLOWS COMMANDS, AND MAE'S WELL.\n\nRESP; LUNGS CLEAR DIM IN THE BASES. 02 SAT'S AND RR WNL ALL NOC ON 4L/NC. CHEST TUBES DRAINING MIN. TO MOD. AMTS. THIN SEROSANQ DRAINAGE. PT IN USE OF I.S. AND PT PULLING TV OF 1000 WITHOUT DIFFICULTY.\n\nCARDIOVAS; SR 80'S NO ECTOPY. PT ON NTG GTT AND TITRATED ALL NOC TO MAINTAIN MAP >60 AND <90. NTG GTT TITRATED OFF THIS AM WITH SBP UP TO 150'S AND MAP UP TO 90'S. CT TEAM AWARE AND PT GIVEN LOPRESSOR 5MG IVP ALONG WITH 25MG PO.\n\nGI; BS HYPOACTIVE. TAKING AND TOLERATING SIPS OF H20 WITH NO C/O'S OF NAUSEA.\n\nGU; URINE OP WNL AND NOT AN ISSUE OVER NOC.\n\nCOMFORT; PT C/O INCISIONAL DISCOMFORT AND MED SEVERAL TIMES WITH MS04 2MG IVP AND STARTED ON PERCOCET 1 TAB X2 WITH GOOD EFFECT.\n\nENDO; INITALLY ON INSULIN GTT AND DC'D FOR BS OF 85 AND TX DURING THE NOC WITH REG INSULIN SQ PER SS. BLD SUGARS WNL THIS AM.\n\nPLAN; CONT TO MONITOR AND ASSESS. MANAGE BP'S AND TRANSFER TO 2 IF REMAINS STABLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-10-23 00:00:00.000",
"description": "Report",
"row_id": 1390706,
"text": "NEURO ARRIVED FROM OR ON 15 OF PROPOFOL UNRESPONSIVE REVERSED AND PROPFOL WEANED WITH FULL RESPONSIVENESS MOVES ALL EXTREMETIES FOLLOWS COMMANDS NO NEURO DEFECITS NOTED\n\nRESP WEANED AND EXTUBATED WITHOUT DIFFICULTY LUNGS CLEAR NC 4L SATS 98% CHEST TUBES INTACT DRAINING MOD SEROSANG NONPRODUCTIVE TAKING DEEP BREATHS EASILY\n\nC/V ARRIVED A PACED UNDERLYING HR 60-70 SR NO ECT LOWER B/P WITH HR 60S REMAINS A PACED 90S COUPLET X1 NO OTHER ECTOPY SEEN NP B/P ELEVATED MAP > 90 NTG TITRATED WITH GOOD EFFECT CURRENT 0.3 MCGS WOUNDS NO DRAINAGE DSD INTACT\n\nGU/GI OG ON ARRIVAL DC/D WITH ETT REGLAN X1 FOR C/O NAUSEA WITH GOOD EFFECT ABD SOFT ABSENT BOWEL SOUNDS TOL ICE CHIPS WELL GOOD URINE OUT\n\nPAIN C/O STERNAL WOUND PAIN MS GIVEN X2 WITH ONLY FAIR EFFECT ADDITIONAL DOSE MORPINE 4MG X1 GIVEN PER PA E NILLSON WITH GOOD EFFECT\n\nPLAN CONTINUE TO MONITOR HEMODYNAMIC OVERNOC MAINTAIN NTG FOR B/P AS NEEDED INCREASE FLUIDS AS TOL\n"
}
] |
51,750 | 145,131 | Rabbi is a 49 year old man with extensive cardiac history s/p 14 stents, diabetic (no longer on hypoglycemic agents after losing 100 lbs) and seizure history who was witnessed to have several seizures while giving a lecture. He received total of 15mg of Ativan in the ED resulting in respiratory depression warranting intubation. Hence he was initially admitted to the ICU then was successfully extubated the next day. Head CT showed small subdural hematoma likely traumatic from the seizure and MRI showed no infarct or other pathology. Repeat CT on the day of discharge showed mild decrease in the subdural hematoma. Patient was transferred to the neurology floor on then evaluated per physical therapist who found the patient to be safe to be discharged without therapy or assistive device. Patient also had an EEG while in the ICU which did not show any seizure activities. He was already on Keppra 1500 mg for seizure control and given the recent breakthrough seizures, he was started on Lamotrigine 25 mg daily. The plan is to titrate this up to 25 mg in 2 weeks. Our current plan is to further increase the Lamictal to 50 mg 2 weeks after that then to 100 mg 2 weeks later. We are providing a prescription for the first 4 weeks of this titration plan, and will leave the further dose increases up to his outpatient neurologist, Dr. . He also reported pain in both R wrist and ankle with some swelling. X-ray with multiple views of wrist and hand were negative as were X-rays of R ankle. This summary will be provided to the family/patient upon discharge and will also be faxed to Dr. (, fax (. | Minor ST-T wave abnormalities. Small left-sided subdural hematoma. Small left-sided subdural hematoma. Small left-sided subdural hematoma. Slight decrease in size of thin left-sided subdural hematoma. Slight decrease in size of thin left-sided subdural hematoma. Slight decrease in size of thin left-sided subdural hematoma. Again, there is redemonstration of an enlarged empty sella. Noted is an enlarged empty sella. Enlarged empty sella. Enlarged empty sella. Enlarged empty sella. Redemonstration of enlarged empty sella. Redemonstration of enlarged empty sella. Re-demonstrated "empty sella" variant. Prominent posterior and inferior calcaneal spurring is noted. Asymmetric prominence of left cerebellar tentorium - could represent hemorrhage but more likely normal variant, compare with priors and attn on f/u. IMPRESSION: 1) Possible tiny nondisplaced fracture at extreme distakl tip of medial malleolus. The sella is empty and slightly expanded. Empty sella which is hyperexpanded. Cardiomediastinal silhouette is within normal limits. There is a Tornwaldt cyst present within the posterior nasopharynx. Sinus tachycardia. The ventricles and sulci appear unremarkable. This is extra-axial in location and most consistent with an acute/subacute subdural hematoma. FINDINGS: There is redemonstration of a thin subdural hematoma layering along the left parietal and occipital lobes as well as the left leaflet of the tentorium. Mild prominence of the left cerebellar tentorium is present. TECHNIQUE: CT of the head without IV contrast. The mortise is congruent. The subdural hematoma appears slightly decreased in size compared to the prior study performed on , suggesting resorption/redistribution of blood products. IMPRESSION: 1. IMPRESSION: 1. IMPRESSION: 1. COMPARISON: CT of the head without contrast from as well as MR of the head with and without contrast from . Acute on chronic sinus disease as described above. Acute on chronic sinus disease as described above. Correlation is made with prior CT of . TECHNIQUE: Axial images were acquired of the head without contrast. Intubated state with mottled air and soft tissue filling the nasal canals and posterior nasopharynx. Lung volumes are low, limiting evaluation. In the right ankle, there may be a tiny (1.1 x 2.6 mm) non-displaced fracture at the extreme tip of the medial malleolus. Asymmetric density of the left cerebellar tent is likely a normal variant but layering hemorrhage is not excluded. COMPARISON: None available. Allowing for this, there is marked diffuse soft tissue swelling. There is mucosal thickening within the left frontal, ethmoid and sphenoid sinuses. Within this limitation, there is no focal consolidation. FINDINGS: There is a curvilinear confluent area of high signal intensity seen along the left frontal, parietal and temporal convexity. Hilar contours and pulmonary vasculature are normal. The orbits and visualized soft tissues are normal in appearance. There is no significant mass effect. 2. 2. 2. 2. 2. 2. 2. 3. 3. 3. 3. RIGHT HAND, THREE PORTABLE VIEWS. Acute-on-chronic sinus inflammatory disease, as described above. The ventricles and sulci are normal in size and configuration. There is no acute intracranial infarct. Clinical correlation is suggested. Assess for interval change in size of subdural hemorrhage. FINDINGS: There is no mass effect or extra-axial collection. Evaluate ETT placement. The patient is intubated and there is soft tissue and mottled gas filling the bilateral nasal passages as well as the posterior nasopharynx. There is no appreciable pleural effusion or pneumothorax. No previous tracing availablefor comparison. RIGHT ANKLE, THREE PORTABLE VIEWS: Of note, the history refers to right foot injury and images are of the right ankle. Note is made of bifrontal cortical atrophy that is more pronounced than expected, given the patient's age. Otherwise, no fracture or dislocation is detected. There is no abnormal marrow signal. Given the degree of soft tissue swelling, if symptoms persist, repeat radiographs in days would be recommended. COMPARISON: No prior study available for comparison. No localizing history is available and a pulse oximeter obscures the distal phalanx and DIP joint of the index finger. No mass effect or extra-axial collection is seen. -white differentiation is preserved throughout. Recommend comparison with priors and attention on followup. 2) If there is specific concern for an injury to the mid or forefoot, then dedicated foot radiographs would be recommended. No fracture or dislocation is detected. FINAL REPORT HISTORY: Patient with new-onset seizures, for further evaluation. The mastoid air cells are clear. There is extensive mucosal thickening as well as air-fluid levels in the fronto-ethmoidal sinuses, the sphenoid sinuses and the frontal sinuses suggesting acute on chronic sinusitis. AP VIEW OF THE CHEST: The endotracheal tube terminates 5 cm above the carina. If clinically indicated, this could be further evaluated with MRI. The visualized paranasal sinuses are significant for mucosal thickening of the ethmoid air cells. There is no evidence of any new hemorrhage. Findings submitted to critical results dashboard. TECHNIQUE: Multiplanar and multisequence MRI of the brain was performed pre- and post-administration of intravenous contrast. FINAL REPORT INDICATION: 49-year-old male with general tonic-clonic seizure and previous history of subdural hemorrhage seen on MRI. 4:55 PM MR HEAD W & W/O CONTRAST Clip # Reason: Evaluate for underlying mass lesion Admitting Diagnosis: SEIZURE Contrast: MAGNEVIST Amt: 22 MEDICAL CONDITION: 49 year old man with new seizures REASON FOR THIS EXAMINATION: Evaluate for underlying mass lesion No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): FXKd 10:13 AM 1. 8:05 AM CT HEAD W/O CONTRAST Clip # Reason: f/u study for the SDH Admitting Diagnosis: SEIZURE MEDICAL CONDITION: 49 year old man with GTC seizure - 1 mm L SDH on MRI REASON FOR THIS EXAMINATION: f/u study for the SDH No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): SZm WED 11:27 AM 1. | 9 | [
{
"category": "Radiology",
"chartdate": "2140-01-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1172815,
"text": " 10:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man s/p intubation\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old male status post intubation. Evaluate ETT placement.\n\n COMPARISON: No prior study available for comparison.\n\n AP VIEW OF THE CHEST: The endotracheal tube terminates 5 cm above the carina.\n Lung volumes are low, limiting evaluation. Within this limitation, there is\n no focal consolidation. Cardiomediastinal silhouette is within normal limits.\n Hilar contours and pulmonary vasculature are normal. There is no appreciable\n pleural effusion or pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-11 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1172863,
"text": " 4:55 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Evaluate for underlying mass lesion\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with new seizures\n REASON FOR THIS EXAMINATION:\n Evaluate for underlying mass lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FXKd 10:13 AM\n 1. Small left-sided subdural hematoma.\n\n 2. Enlarged empty sella.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Patient with new-onset seizures, for further evaluation.\n\n TECHNIQUE: Multiplanar and multisequence MRI of the brain was performed pre-\n and post-administration of intravenous contrast. Correlation is made with\n prior CT of .\n\n FINDINGS:\n\n There is a curvilinear confluent area of high signal intensity seen along the\n left frontal, parietal and temporal convexity. This is extra-axial in\n location and most consistent with an acute/subacute subdural hematoma. There\n is no significant mass effect. There is no acute intracranial infarct.\n\n Noted is an enlarged empty sella. The ventricles and sulci appear\n unremarkable. There is mucosal thickening within the left frontal, ethmoid\n and sphenoid sinuses. There is a Tornwaldt cyst present within the posterior\n nasopharynx. There is no abnormal marrow signal.\n\n IMPRESSION:\n\n 1. Small left-sided subdural hematoma.\n\n 2. Enlarged empty sella.\n\n Findings were discussed with Dr. by Dr. at 10:00 a.m. on\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-11 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1172864,
"text": ", C. NMED TSICU 4:55 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Evaluate for underlying mass lesion\n Admitting Diagnosis: SEIZURE\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with new seizures\n REASON FOR THIS EXAMINATION:\n Evaluate for underlying mass lesion\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Small left-sided subdural hematoma.\n\n 2. Enlarged empty sella.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1172813,
"text": " 10:50 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for ICH/fx/mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with seizures for few months, here w/ breakthrough seizures and\n agitation\n REASON FOR THIS EXAMINATION:\n please eval for ICH/fx/mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg MON 11:19 AM\n No mass effect, or territorial ischemia.\n Asymmetric prominence of left cerebellar tentorium - could represent\n hemorrhage but more likely normal variant, compare with priors and attn on\n f/u.\n Empty sella\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 49-year-old male with seizures for several months and\n agitation.\n\n TECHNIQUE: Axial images were acquired of the head without contrast.\n\n COMPARISON: None available.\n\n FINDINGS: There is no mass effect or extra-axial collection. Mild prominence\n of the left cerebellar tentorium is present. The ventricles and sulci are\n normal in size and configuration. -white differentiation is preserved\n throughout. The sella is empty and slightly expanded.\n\n The orbits and visualized soft tissues are normal in appearance. The patient\n is intubated and there is soft tissue and mottled gas filling the bilateral\n nasal passages as well as the posterior nasopharynx. The mastoid air cells\n are clear. The visualized paranasal sinuses are significant for mucosal\n thickening of the ethmoid air cells.\n\n IMPRESSION:\n 1. No mass effect or extra-axial collection is seen. Asymmetric density of\n the left cerebellar tent is likely a normal variant but layering hemorrhage is\n not excluded. Recommend comparison with priors and attention on followup.\n 2. Empty sella which is hyperexpanded. If clinically indicated, this could\n be further evaluated with MRI.\n 3. Intubated state with mottled air and soft tissue filling the nasal canals\n and posterior nasopharynx.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-12 00:00:00.000",
"description": "RP HAND (AP, LAT & OBLIQUE) RIGHT PORT",
"row_id": 1172984,
"text": " 1:52 PM\n HAND (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: Is there a fracture\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with GTC seizure and hand injury\n REASON FOR THIS EXAMINATION:\n Is there a fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seizure with hand injury, question fracture.\n\n RIGHT HAND, THREE PORTABLE VIEWS.\n\n No localizing history is available and a pulse oximeter obscures the distal\n phalanx and DIP joint of the index finger. Allowing for this, there is marked\n diffuse soft tissue swelling. No fracture or dislocation is detected. Given\n the degree of soft tissue swelling, if symptoms persist, repeat radiographs in\n days would be recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-12 00:00:00.000",
"description": "RP ANKLE (AP, LAT & OBLIQUE) RIGHT PORT",
"row_id": 1172985,
"text": " 1:52 PM\n ANKLE (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: Is there a fracture\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with GTC seizure and hand injury and right foot injury\n REASON FOR THIS EXAMINATION:\n Is there a fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seizure, right foot injury, question fracture.\n\n RIGHT ANKLE, THREE PORTABLE VIEWS:\n\n Of note, the history refers to right foot injury and images are of the right\n ankle.\n\n In the right ankle, there may be a tiny (1.1 x 2.6 mm) non-displaced fracture\n at the extreme tip of the medial malleolus. Otherwise, no fracture or\n dislocation is detected. The mortise is congruent. Prominent posterior and\n inferior calcaneal spurring is noted.\n\n IMPRESSION:\n 1) Possible tiny nondisplaced fracture at extreme distakl tip of medial\n malleolus.\n 2) If there is specific concern for an injury to the mid or forefoot, then\n dedicated foot radiographs would be recommended.\n\n Findings submitted to critical results dashboard.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1173083,
"text": " 8:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u study for the SDH\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with GTC seizure - 1 mm L SDH on MRI\n REASON FOR THIS EXAMINATION:\n f/u study for the SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SZm WED 11:27 AM\n 1. Slight decrease in size of thin left-sided subdural hematoma.\n\n 2. Acute on chronic sinus disease as described above.\n\n 3. Redemonstration of enlarged empty sella.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old male with general tonic-clonic seizure and previous\n history of subdural hemorrhage seen on MRI. Assess for interval change in\n size of subdural hemorrhage.\n\n COMPARISON: CT of the head without contrast from as well as\n MR of the head with and without contrast from .\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: There is redemonstration of a thin subdural hematoma layering along\n the left parietal and occipital lobes as well as the left leaflet of the\n tentorium. The subdural hematoma appears slightly decreased in size compared\n to the prior study performed on , suggesting\n resorption/redistribution of blood products. There is no evidence of any new\n hemorrhage. Again, there is redemonstration of an enlarged empty sella. Note\n is made of bifrontal cortical atrophy that is more pronounced than expected,\n given the patient's age.\n\n There is extensive mucosal thickening as well as air-fluid levels in the\n fronto-ethmoidal sinuses, the sphenoid sinuses and the frontal sinuses\n suggesting acute on chronic sinusitis.\n\n IMPRESSION:\n 1. Slight decrease in size of thin left-sided subdural hematoma.\n\n 2. Acute-on-chronic sinus inflammatory disease, as described above.\n\n 3. Re-demonstrated \"empty sella\" variant.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-01-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1173084,
"text": ", T. NMED FA11 8:05 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u study for the SDH\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with GTC seizure - 1 mm L SDH on MRI\n REASON FOR THIS EXAMINATION:\n f/u study for the SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Slight decrease in size of thin left-sided subdural hematoma.\n\n 2. Acute on chronic sinus disease as described above.\n\n 3. Redemonstration of enlarged empty sella.\n\n"
},
{
"category": "ECG",
"chartdate": "2140-01-11 00:00:00.000",
"description": "Report",
"row_id": 256728,
"text": "Sinus tachycardia. Minor ST-T wave abnormalities. No previous tracing available\nfor comparison. Clinical correlation is suggested.\n\n"
}
] |
93,623 | 187,232 | 62-year-old right-handed woman with a history of left MCA aneurysm s/p coiling in , prior right occipital infarcts and a subacute left superior frontal infarcts on imaging in with negative workup and started aspirin and simvastatin per OSH records, borderline HTN, HLD and seizure disorder (with somewhat unclear history - please see "additional history" for details) who presented on as an OSH transfer with persistent (initially sudden onset) posterior headache and fluctuating difficulties with right visual field which then became fixed. On presentation to , patient was hypertensive to 180/90 and IV nicardipine was started. On arrival at , neurological exam was significant for right visual field homonymous hemianopia, alexia without clear agraphia, finger confusion, and color errors and acalculia. She was admitted to the stroke service from to . CT showed a large left occipitoparietal intraparenchymal hemorrhage with intraventricular extension and 2 mm rightward midline shift as well as associated left intraventricular, subarachnoid and subdural hemorrhage suggestive of amyloid angiopathy. CTA showed no evidence of underlying arteriovenous malformation, aneurysm or other vascular anomaly. CTV showed no evidence of cerebral venous thrombosis. In addition, there was calcific atherosclerosis involving the both carotid bifurcations and proximal internal carotid arteries, without flow-limiting stenosis. MRI showed several "micro-bleeds" peripherally-located in the posterior aspect of both cerebral hemispheres with only expected early enhancement of the evolving parenchymal hematoma, with no finding to suggest underlying mass lesion. This was again suggestive of underlying cerebral amyloid angiopathy with leptomeningeal vascular involvement. Patient was initially admitted to the ICU and transferred to the floor on . Repeat CT was stable after worsening of word-finding difficulties. She was monitored on telemetry and her examination remained stable thereafter. Hypertension was controlled with uptitrating lisinopril to 40mg qd on discharge in addition to PRN IV hydralazine which was latterly not required. Echo showed EF >55% and mild AR with mild valve sclerosis, mild symmetric LVH with preserved global and regional biventricular systolic function. HA was treated with standing acetaminophen and we continue home levetiracetam 750mg po bid. She had no seizures in house. Patient should discuss with PCP regarding routine screening (colonoscopy, mammography and skin checks etc) and should discuss regarding starting Chantix to aid in smoking cessation. WBCs and platelets were mildly elevated and UA and chest exam were unremarkable and were felt to be likely reactive to her IPH. The most likely aetiology was amyloid angiopathy given the multiple bleeding sources and evidence of microbleeds and other imaging findings suggestive of this. MRI did not show any clear underlying lesion and she had a CT torso which showed no clear evidence of malignancy (This was pursued especially in light of a remote history of melanoma). She will have an interval MRI w and w/o contrast in to assess for underlying mass lesion once the hemorrhage has resolved. Colour naming and finger agnosia resolved and writing (previously described as clumsy but not agraphia) had also improved and patient could spell words but could often not read directly and had striking acalculia (was able to only do one serial seven and had difficulty with simple arithmetic) given her job as an accountant. There were no limb impairments and she was bright and alert while on the floor. She had persistent headache treated with acetaminophen. OT assessed her and felt that she could go home if she had 24 hour supervision, however the patient lives at home alone and given this, she was deemed more appropriate for rehab. Dr was contact and we have arranged for formal visual fields and neuro-ophthalmology review as an outpatient to happen in . She was transferred to rehab on . Patient was still hypertensive on discharge with SBP 140s-160s and she will need uptitration of her anti-hypertensives at rehab. She has stroke, neuro-ophthalmology follow-up and repeat MRI booked. . TRANSITIONAL ISSUES: - Patient will need uptitration of her anti-hypertensives with goal BP <140/90 - Plt increase likely reactive and to be trended at rehab - Patient awaits repeat MRI w and w/o contrast on - Awaits neuro-ophthalmology review and formal visual fields in - Patient should discuss with PCP regarding cancer screening and f/u (Mammogram, Colonoscopy, Pap etc) and Dermatologist follow up due to history of melanoma - Patient to discuss Chantix with PCP to aid in smoking cessation - Pt was counselled to please avoid aspirin and antiplatelet agents | There is extension of hemorrhage into the left lateral ventricle as well as layering along the left tentorium falx suggesting subdural hematoma, unchanged from the prior examination. Stable large left occipitoparietal parenchymal hemorrhage with intraventricular extension, 2 mm rightward midline shift, unchanged from , . Subdural hemorrhage layering along the left tentorium and falx, unchanged from the prior examination. Subdural hemorrhage layering along the left tentorium and falx, unchanged from the prior examination. Mild (1+) aortic regurgitationis seen. No significant short-interval change in the large left parieto-occipital "lobar" hemorrhage, as well as associated left intraventricular and subarachnoid and subdural hemorrhage; the overall appearance is highly suggestive of underlying cerebral amyloid angiopathy (CAA). Diffuse sulcal FLAIR-hyperintensity, likely representing subarachnoid blood, more evident than on the recent CT (this is in a non-aneurysmal pattern). With the exception of mild coronary artery calcifications, the heart, pericardium, and great vessels are unremarkable. Incidental findings: Small left adreal adenoma, diverticulosis, atherosclerotic calcifications, calcified hepatic granulomas. Calcific atherosclerosis involving the both carotid bifurcations and proximal internal carotid arteries, without flow-limiting stenosis. Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK FINAL REPORT (Cont) intraventricular extension, 2 mm rightward midline shift, unchanged from , . There is extensive sigmoid diverticulosis without evidence of diverticulitis. PATIENT/TEST INFORMATION:Indication: Source of embolism.Height: (in) 62Weight (lb): 105BSA (m2): 1.45 m2BP (mm Hg): 188/85HR (bpm): 51Status: InpatientDate/Time: at 10:22Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color Doppler or salinecontrast with maneuvers.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%). A smaller second focus of hemorrhage in the left occipital lobe may represent second smaller parenchymal hemorrhage or focal subdural hematoma, unchanged from the prior examination. A smaller second focus of hemorrhage in the left occipital lobe may represent second smaller parenchymal hemorrhage or focal subdural hematoma, unchanged from the prior examination. There is only faint vascular and, perhaps, early marginal enhancement involving the lobar hematoma, but no discrete peripheral or central nodular or mass-like enhancement to suggest an underlying space-occupying lesion. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.Normal descending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There is no pericardial effusion.IMPRESSION: Mild aortic regurgitation with mild valve sclerosis. Mildsymmetric left ventricular hypertrophy with preserved global and regionalbiventricular systolic function.CLINICAL IMPLICATIONS:Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate prophylaxis is NOT recommended. There is mild asymmetric enlargement of the right ventricle; however, the ventricle size appears similar to . There is associated mass effect with effacement of the overlying sulci and relatively mild rightward shift of the septum pellucidum, measuring up to 4 mm, also unchanged. Stable asymmetric enlargement of the right lateral ventricle. Stable asymmetric enlargement of the right lateral ventricle. The right adrenal gland is within normal limits while the left adrenal gland demonstrates a 7 mm nodularity in its posterior lymph (3:59), which has a average attenuation of 8.3 Hounsfield (Over) 11:31 AM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: Evaluate for malignancy Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK Contrast: OMNIPAQUE Amt: 130 FINAL REPORT (Cont) units in the non-contrast CT, suggesting small adenoma. Mildthickening of mitral valve chordae.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Artifact from left MCA aneurysm coiling is noted. Left atrial abnormality. COMMENT: A preliminary interpretation of "No aneurysm, arteriovenous malformation, or evidence of venous sinus 'injury.' Minimal rightward shift of normally midline structures (2 mm rightward shift) is noted, unchanged from the prior examination. Cardiac and mediastinal contours are within normal limits. In the region of the lobar hemorrhage, the DWI sequence is not interpretable; however, elsewhere, there is no focus of slow diffusion to suggest an acute ischemic event, and the principal intracranial vascular flow-voids, including those of dural venous sinuses are preserved, and these structures enhance normally, corresponding to the findings on the recent CTA. Again demonstrated is the very large left parieto-occipital "lobar" hemorrhage, measuring up to 6.4 (AP) x 3.3 cm with surrounding zone of vasogenic edema, not significantly changed over the interval. Calcified pleural plaques are noted. The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. The kidneys do not demonstrate any focal lesions and show symmetric nephrograms and excretion of contrast. Incomplete right bundle-branch block.Left ventricular hypertrophy. OSSEOUS STRUCTURES: Mild left convex scoliosis centered in the upper lumbar spine is noted. Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK Contrast: GADAVIST Amt: 6 FINAL REPORT (Cont) Incidentally noted is minor mucosal thickening involving the anterior ethmoidal air cells. There is also calcific more than soft plaque involving both carotid bulbs and proximal ICAs; however, again, there is no evidence of flow-limiting stenosis with the Dmin measurements, as follows: On the right, proximal, 6 mm, distal, 4.5 mm; on the left, proximal, 6 mm and distal, 4 mm. | 8 | [
{
"category": "Echo",
"chartdate": "2118-06-06 00:00:00.000",
"description": "Report",
"row_id": 104237,
"text": "PATIENT/TEST INFORMATION:\nIndication: Source of embolism.\nHeight: (in) 62\nWeight (lb): 105\nBSA (m2): 1.45 m2\nBP (mm Hg): 188/85\nHR (bpm): 51\nStatus: Inpatient\nDate/Time: at 10:22\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color Doppler or saline\ncontrast with maneuvers.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\nNormal descending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nthickening of mitral valve chordae.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\nSuboptimal image quality - poor suprasternal views.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. No atrial septal\ndefect or patent foramen ovale is seen by 2D, color Doppler or saline contrast\nwith maneuvers. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and regional/global systolic function (LVEF>55%). The\nestimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber\nsize and free wall motion are normal. 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. Mild (1+) aortic regurgitation\nis seen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. The estimated pulmonary\nartery systolic pressure is high normal. There is no pericardial effusion.\n\nIMPRESSION: Mild aortic regurgitation with mild valve sclerosis. Mild\nsymmetric left ventricular hypertrophy with preserved global and regional\nbiventricular 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": "Radiology",
"chartdate": "2118-06-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1237794,
"text": " 2:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: any worsening in IPH?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with new word finding difficulties and known IPH\n REASON FOR THIS EXAMINATION:\n any worsening in IPH?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SUN 5:55 AM\n 1. Stable large left occipitoparietal parenchymal hemorrhage with\n intraventricular extension, 2 mm rightward midline shift, unchanged from , .\n 2. Stable asymmetric enlargement of the right lateral ventricle.\n 3. Subdural hemorrhage layering along the left tentorium and falx, unchanged\n from the prior examination.\n 4. A smaller second focus of hemorrhage in the left occipital lobe may\n represent second smaller parenchymal hemorrhage or focal subdural hematoma,\n unchanged from the prior examination.\n 5. No new acute foci of hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with new word finding difficulties and known\n IPH, any worse in IPH.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n the administration of IV contrast. Multiplanar reformats were generated and\n reviewed.\n\n FINDINGS: There is a large left occipitoparietal parenchymal hemorrhage\n similar in size and appearance compared to . A second\n hyperdense focus is present just lateral to this (2, 13) which may reflect\n another area of parenchymal hemorrhage or a small focus of subdural hematoma.\n This is unchanged from the most recent prior examination of .\n There is extension of hemorrhage into the left lateral ventricle as well as\n layering along the left tentorium falx suggesting subdural hematoma, unchanged\n from the prior examination. There is mild asymmetric enlargement of the right\n ventricle; however, the ventricle size appears similar to .\n Minimal rightward shift of normally midline structures (2 mm rightward shift)\n is noted, unchanged from the prior examination. Artifact from left MCA\n aneurysm coiling is noted. There is no evidence of acute major vascular\n territory infarction. Periventricular and subcortical low attenuating regions\n appear consistent with sequelae of chronic small vessel ischemic disease.\n\n Bilateral mastoid air cells and visualized paranasal sinuses are clear.\n Globes are intact.\n\n IMPRESSION:\n 1. Stable large left occipitoparietal parenchymal hemorrhage with\n (Over)\n\n 2:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: any worsening in IPH?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n intraventricular extension, 2 mm rightward midline shift, unchanged from , .\n 2. Stable asymmetric enlargement of the right lateral ventricle.\n 3. Subdural hemorrhage layering along the left tentorium and falx, unchanged\n from the prior examination.\n 4. A smaller second focus of hemorrhage in the left occipital lobe may\n represent second smaller parenchymal hemorrhage or focal subdural hematoma,\n unchanged from the prior examination.\n 5. No new acute foci of hemorrhage.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-06-03 00:00:00.000",
"description": "Report",
"row_id": 306676,
"text": "Sinus rhythm. Left atrial abnormality. Incomplete right bundle-branch block.\nLeft ventricular hypertrophy. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-06-03 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1237673,
"text": " 4:39 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: e/f vessels\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OMNIPAQUE Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with h/o large left IPH\n REASON FOR THIS EXAMINATION:\n e/f vessels\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AMLw FRI 5:54 PM\n No aneurysm, arteriovenous malformation, or evidence of venous sinus injury.\n Final results pending reconstructions.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CTA OF THE HEAD AND NECK, \n\n HISTORY: 62-year-old female with large left parenchymal hemorrhage; evaluate\n vessels.\n\n TECHNIQUE: Routine CTA, comprising contiguous 5-mm axial MDCT sections\n from the skull base to the vertex, prior to contrast administration.\n Subsequently, helical 1.25-mm axial MDCT sections were obtained from the main\n pulmonary artery level through the vertex, during dynamic intravenous\n administration of 70 mL Omnipaque-350. \"Venous phase\" images were also\n obtained, with a roughly 45-second delay. Thick-slab axial, sagittal and\n coronal MIP- and rotational curved planar and volume-rendered 3D-reconstructed\n images were obtained and reviewed on a separate workstation.\n\n FINDINGS: The study is compared with the NECT (), obtained\n roughly 9 hours earlier.\n\n Again demonstrated is the very large left parieto-occipital \"lobar\"\n hemorrhage, measuring up to 6.4 (AP) x 3.3 cm with surrounding zone of\n vasogenic edema, not significantly changed over the interval. There is\n associated mass effect with effacement of the overlying sulci and relatively\n mild rightward shift of the septum pellucidum, measuring up to 4 mm, also\n unchanged. There is no definite \"trapping\" of the contralateral lateral\n ventricle or evidence of more central herniation. There is associated\n ventricular hemorrhage with clot occupying the atrium and extending into the\n occipital and temporal horns of the ipsilateral lateral ventricle. There is\n also overlying subarachnoid hemorrhage, as well as subdural blood layering\n along the dorsal aspect of the falx and over the left leaflet of the\n tentorium, all unchanged. No new hemorrhagic focus is identified. Again\n demonstrated is extensive metallic \"star\" artifact originating from coils in\n the region of the left MCA bifurcation, presumably related to previous\n treatment of an aneurysm at this site, limiting the evaluation of adjacent\n structures.\n\n (Over)\n\n 4:39 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: e/f vessels\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OMNIPAQUE Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n No definite peripheral or central CTA \"spot sign\" is identified in association\n with the large parenchymal hematoma to suggest extravasation portending rapid\n expansion. Allowing for the presence of the clot, there is no evidence of\n underlying arteriovenous malformation or other vascular anomaly. No aneurysm\n is identified in the region or elsewhere in the circle of , with\n evaluation of the region of the left MCA bifurcation, limited by the metallic\n artifact. There is normal, symmetric opacification of the major dural venous\n sinuses and principal deep cerebral veins with no evidence of cerebral venous\n thrombosis. There is no significant mural irregularity or steno-occlusive\n disease involving the cerebral vasculature.\n\n There is only minimal calcific atherosclerotic plaque involving the aortic\n arch and great vessel origins, with no flow-limiting stenosis at these sites.\n There is also calcific more than soft plaque involving both carotid bulbs and\n proximal ICAs; however, again, there is no evidence of flow-limiting stenosis\n with the Dmin measurements, as follows: On the right, proximal, 6 mm, distal,\n 4.5 mm; on the left, proximal, 6 mm and distal, 4 mm. Similarly, the\n vertebral arteries are normal in course, caliber, contour and enhancement from\n their origins through the vertebrobasilar confluence; note that the left\n vertebral artery originates directly from the aortic arch, a common normal\n variant.\n\n The remainder of the examination is notable for fairly severe panlobular\n emphysema at the lung apices, without discrete bulla formation. There is also\n biapical calcific pleuroparenchymal scarring, which may relate to old\n granulomatous disease. The thyroid gland is grossly unremarkable and there is\n no cervical lymphadenopathy. The -, oro- and hypopharyngeal mucosal\n surfaces are grossly unremarkable. The included portions of the paranasal\n sinuses, mastoid air cells and middle ear cavities are clear.\n\n There is multilevel, multifactorial degenerative disease involving the\n cervical spine, most marked at the C5-6 and C6-7 levels, where there is both\n central spinal canal and severe left neural foraminal narrowing with possible\n exiting neural impingement. Also, incidentally noted are DISH involving the\n imaged cervicothoracic spine, as well as a congenital fusion anomaly involving\n the posterior neural arch of C1.\n\n IMPRESSION:\n 1. No significant short-interval change in the large left parieto-occipital\n \"lobar\" hemorrhage, as well as associated left intraventricular and\n subarachnoid and subdural hemorrhage; the overall appearance is highly\n suggestive of underlying cerebral amyloid angiopathy (CAA).\n 2. No CTA \"spot sign\" to indicate extravasation portending rapid expansion of\n the hematoma.\n 3. No evidence of underlying arteriovenous malformation, aneurysm or other\n (Over)\n\n 4:39 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: e/f vessels\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OMNIPAQUE Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vascular anomaly.\n 4. No evidence of cerebral venous thrombosis.\n 5. Status post apparent aneurysm coiling at the left MCA bifurcation, with no\n other aneurysm seen to involve the circle of .\n 6. Calcific atherosclerosis involving the both carotid bifurcations and\n proximal internal carotid arteries, without flow-limiting stenosis.\n\n COMMENT: A preliminary interpretation of \"No aneurysm, arteriovenous\n malformation, or evidence of venous sinus 'injury.' (sic) Final results\n pending reconstructions\" was posted to CCC and to PACS by Dr. at 5:54\n p.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-06-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1237674,
"text": " 4:57 PM\n CHEST (PA & LAT) Clip # \n Reason: Baseline, nodes, mass\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with history of smoking, now unexplained lobar hemorrhage\n REASON FOR THIS EXAMINATION:\n Baseline, nodes, mass\n ______________________________________________________________________________\n WET READ: MDAg FRI 9:11 PM\n No nodule or mass identified although part of the lung is obscured by cardiac\n leads. Nipple markers in place.\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FROM AT 1659\n\n CLINICAL INDICATION: 62-year-old with smoking, now unexplained lobar\n hemorrhage, assess for nodes or mass.\n\n Comparison is made to the patient's outside chest film from .\n\n AP upright and lateral views of the chest are submitted at 1659.\n\n IMPRESSION:\n\n 1. Cardiac and mediastinal contours are within normal limits. Streaky linear\n opacities at left base likely reflect subsegmental atelectasis given their\n absence on the comparison study from earlier in the day. Lungs are otherwise\n clear without evidence of pleural effusions, focal airspace consolidation or\n pneumothorax. Overall, there are slightly less vascular markings in the upper\n lungs relative to the lower lungs which suggests a component of underlying\n emphysema given the patient's history of smoking. If a lung primary remains\n of clinical concern, further imaging evaluation with CT should be considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-06-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1237595,
"text": " 9:50 AM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval ct for intraparenchymal hemmhorage reported, no rads re\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with R visual field cut, reported ich on ct, no read from osh\n REASON FOR THIS EXAMINATION:\n eval ct for intraparenchymal hemmhorage reported, no rads report from osh\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMTd FRI 11:01 AM\n 1. Large left parieto-occipital intraparenchymal hemorrhage with\n intraventricular extension and 2 mm of rightward shift of the midline\n structures. Hemorrhage is tracking along the falx. The basal cisterns are\n patent. 2. Evidence of prior left MCA coiling.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right visual field cut.\n\n COMPARISONS: None.\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without the administration of IV contrast. Sagittal and coronal reformats\n were obtained and reviewed. Images were obtained at an outside hospital. A\n second read was requested by the ordering physicians.\n\n FINDINGS: There is a large left occipitoparietal intraparenchymal hemorrhage\n measuring approximately 5.8 x 3.0 cm. A second hyperdense focus is present\n just lateral to this large hemorrhage and measures 7 mm (2, 14). This may\n reflect another region of intraparenchymal hemorrhage or a small focal\n subdural hematoma. Hemorrhagic hyperdense material is layering along the\n tentorium and falx suggesting a component of subdural hematoma. There is\n intraventricular extension with blood in the left lateral ventricle. It is\n predominantly in the posterior but a small amount is present in the left\n frontal (2, 14). A small amount of blood is likely also present in the\n third ventricle (2, 15). There is relative enlargement of the right lateral\n ventricle suggesting some component of compression. There is minimal shift of\n the normal midline structures to the right by 2 mm.\n\n Metallic artifact is present in the region of the left MCA suggesting prior\n aneurysmal coiling. There is no evidence of acute or prior infarction.\n Periventricular white matter hypodensities are consistent with small vessel\n ischemic disease. The basal cisterns are patent. No fracture is identified.\n The visualized paranasal sinuses, mastoid air cells, and middle ear cavities\n are clear.\n\n IMPRESSION:\n 1. Large left occipitoparietal intraparenchymal hemorrhage with\n intraventricular extension, as above. 2 mm rightward midline shift. Relative\n enlargement of the right lateral ventricle suggesting component of\n compression.\n (Over)\n\n 9:50 AM\n CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY Clip # \n Reason: eval ct for intraparenchymal hemmhorage reported, no rads re\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Smaller second focus of hemorrhage in the left occipital lobe may be a\n second small intraparenchymal hemorrhage or focal subdural hemorrhage.\n 3. Subdural hemorrhage layering along the left tentorium and falx.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-06-04 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1237702,
"text": " 2:39 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: source of ICH? mass?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: GADAVIST Amt: 6\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with hx of L MCA aneurysm s/p clipping presents with L ICH.\n REASON FOR THIS EXAMINATION:\n source of ICH? mass?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, \n\n HISTORY: 62-year-old female with history of left MCA aneurysm clipping,\n presents with left intracranial hemorrhage; ? source, including mass.\n\n TECHNIQUE: Routine enhanced MR examination, comprising T1-weighted SE\n and sagittal MP-RAGE sequences, post-contrast administration, the latter with\n axial and coronal reformations.\n\n FINDINGS: The study is compared with the CTA of the head and neck, obtained\n roughly 8 hours earlier. There is expected extensive \"blooming\"\n susceptibility artifact associated with the large left parieto-occipital\n \"lobar\" hemorrhage. There is similar susceptibility artifact related to the\n transependymal dissection with significant left lateral ventricular component,\n as well as the overlying subarachnoid and subdural blood, layering along the\n left lateral aspect of the falx, posteriorly, as well as the left leaflet of\n the tentorium. However, apart from this finding, there are also scattered\n \"micro-bleeds,\" largely peripherally-located at the -white matter junction\n of both cerebral hemispheres, posteriorly. No similar microhemorrhage is\n identified in the basal ganglia or other deep matter structures. These\n findings are consistent with underlying cerebral amyloid angiopathy (CAA).\n\n There is only faint vascular and, perhaps, early marginal enhancement\n involving the lobar hematoma, but no discrete peripheral or central nodular or\n mass-like enhancement to suggest an underlying space-occupying lesion. There\n is no pathologic parenchymal, leptomeningeal or dural focus of enhancement,\n elsewhere.\n\n Apart from the expected zone of vasogenic edema surrounding the large\n parenchymal hematoma, not significantly changed from the CTA, there is also\n more diffuse sulcal FLAIR-hyperintensity suggestive of subarachnoid\n hemorrhage, also likely related to CAA. There are also scattered punctate,\n more ovoid and more confluent T2-/FLAIR-hyperintense foci in bihemispheric\n subcortical and periventricular, as well as central pontine white matter,\n likely the sequelae of chronic small vessel ischemic disease. In the region\n of the lobar hemorrhage, the DWI sequence is not interpretable; however,\n elsewhere, there is no focus of slow diffusion to suggest an acute ischemic\n event, and the principal intracranial vascular flow-voids, including those of\n dural venous sinuses are preserved, and these structures enhance normally,\n corresponding to the findings on the recent CTA.\n (Over)\n\n 2:39 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: source of ICH? mass?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: GADAVIST Amt: 6\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Incidentally noted is minor mucosal thickening involving the anterior\n ethmoidal air cells.\n\n IMPRESSION:\n 1. Expected marked susceptibility artifact associated with the known left\n parieto-occipital lobar hemorrhage and associated intraventricular and\n overlying subdural blood.\n 2. Diffuse sulcal FLAIR-hyperintensity, likely representing subarachnoid\n blood, more evident than on the recent CT (this is in a non-aneurysmal\n pattern).\n 3. Several \"micro-bleeds\" peripherally-located in the posterior aspect of\n both cerebral hemispheres. The overall constellation of findings is highly\n suggestive of underlying cerebral amyloid angiopathy (CAA) with leptomeningeal\n vascular involvement.\n 4. Only expected early enhancement of the evolving parenchymal hematoma, with\n no finding to suggest underlying mass lesion.\n 5. Normal opacification of the cerebral venous system with no evidence of\n thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-06-05 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1237830,
"text": " 11:31 AM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Evaluate for malignancy\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with left pariet-occipital hemorrhage, with distant history\n (20 years ago) of melanoma, and long-standing smoking history\n REASON FOR THIS EXAMINATION:\n Evaluate for malignancy\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRke SUN 12:15 PM\n No evidence of malignancy.\n\n Incidental findings: Small left adreal adenoma, diverticulosis,\n atherosclerotic calcifications, calcified hepatic granulomas.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old female with left parieto-occipital hemorrhage with a\n distant history of melanoma and longstanding smoking history. Evaluate for\n evidence of malignancy.\n\n COMPARISON: PA and lateral chest radiograph on .\n\n TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal\n notch to the pubic symphysis in a multiphasic fashion after administration of\n IV and oral contrast. Coronal and sagittal reformations were generated.\n\n FINDINGS:\n\n CT OF THORAX: The thyroid gland is unremarkable and there is no\n supraclavicular lymphadenopathy. The airways are patent to mental\n level. No mediastinal, hilar, or axillary lymph node enlargement by CT size\n criteria is present. With the exception of mild coronary artery\n calcifications, the heart, pericardium, and great vessels are unremarkable.\n There is no esophageal wall thickening or hiatal hernia.\n\n Lung windows demonstrate moderate diffuse centrilobular emphysema. No focal\n opacities. Biapical consolidations likely represent age-related changes.\n Calcified pleural plaques are noted. There is no pleural effusion or\n pneumothorax.\n\n CT OF THE ABDOMEN: The liver is normal in size without evidence of an\n intrahepatic biliary duct dilatation. Multiple calcifications are noted in\n segments 4A and B. A small focus of focal fatty infiltrate is also noted in\n segment /b along the falciform ligament, likely related to focal perfusion\n abnormalities. The portal vein is patent and the gallbladder is unremarkable.\n The pancreas and spleen are unremarkable. The right adrenal gland is within\n normal limits while the left adrenal gland demonstrates a 7 mm nodularity in\n its posterior lymph (3:59), which has a average attenuation of 8.3 Hounsfield\n (Over)\n\n 11:31 AM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: Evaluate for malignancy\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n units in the non-contrast CT, suggesting small adenoma. The kidneys do not\n demonstrate any focal lesions and show symmetric nephrograms and excretion of\n contrast. There are no perinephric abnormalities or fluid collection.\n\n The stomach, small bowel and colon are within normal limits without evidence\n of wall thickening or obstruction. The appendix is not visualized, but there\n is no evidence of appendicitis. There is extensive sigmoid diverticulosis\n without evidence of diverticulitis.\n\n With the exception of atherosclerotic calcifications of the aorta and main\n abdominal vessels there is no evidence of aneurysm or any other abdominal\n vascular abnormality. There is no mesenteric or retroperitoneal lymph node\n enlargement by CT size criteria. No ascites, free air, abdominal wall hernia\n is present.\n\n CT OF THE PELVIS: The urinary bladder, terminal ureters, uterus and adnexa\n are unremarkable. Two small calcified fibroids are noted in the uterus.\n There is no pelvic free fluid.\n\n OSSEOUS STRUCTURES: Mild left convex scoliosis centered in the upper lumbar\n spine is noted. There are also degenerative changes at the lumbar spine, more\n prominent at the level of L2 on L3, but no lytic or blastic lesions concerning\n for malignancy. Small sclerotic focus in the body of L1 is likely a bone\n island.\n\n Coronal and sagittal images were reviewed, confirming the axial findings.\n\n IMPRESSION:\n 1. No evidence of thoracic, abdominal or pelvic malignancy.\n 2. Multiple calcified foci in the liver likely represents granulomas.\n 3. Chronic conditions including atherosclerotic vascular calcifications,\n clacified pleural plaques, centrilobular emphysema, degenerative changes of\n the spine, and diverticulosis are noted.\n\n DLP: 694.38 mGy-cm.\n\n"
}
] |
29,154 | 177,228 | Pt is a 26 yoM with long history of narcotic abuse who is transferred from an outside hospital after facial/head trauma and evaluated in the emergency department. He was found to have multiple facial fractures and a small subarachnoid hemorrage. He was admitted to trauma surgery. . He had radiologic work-up that revealed: 1) CT head: A small amount of likely subarachnoid hemorrhage present within the right frontal lobe. This finding was followed up with a repeat CT head scan approximately 10 hours later that showed that the bleed was stable, with no evolution. He had no clinical neurological sign changes during his hospital course that would suggest any worsening of his intracranial bleed. On his day of discharge, he had no focal neurological signs suggestive of evolving head bleed. 2) CT SINUS/MANDIBLE/MAXILLA: Multiple right-sided facial fractures including comminuted fractures of the medial, inferior and lateral orbital walls. The globe appears to be relatively intact, however there is an adjacent retrobulbar hematoma. Comminuted fractures involving the right lateral, anterior and medial maxillary sinus wall. Minimally displaced right nasal bone fracture. Comminuted fracture involving the right zygomatic arch. He was evaluated by both the opthalmology service and plastic and reconstructive services regarding these injuries. Both services concluded that he needed no acute intervention. Plastic and reconstructive surgery concluded that surgical repair of his facial fractures were indicated only for cosmetic reasons and given his social issues would be better addressed at a time when his social issues are more stable. Ophthalmology concluded that there were no acute emergent injuries to his globe or optic nerve. The patient was given contact information for both services for follow-up. 3) CT abdomen/chest/pelvis: overall was negative for acute bleed or fracture. 4) CT of cervical spine was negative for fracture or abnormality . Due to his history of narcotic abuse and his positive urine tox screen, he was put on withdrawal scale. He tolerated his withdrawal course well without significant events. He had no hemodynamic instability or seizure activity. On the day of discharge he had no symptoms or signs of acute withdrawal. During his course he had mild headaches that were managed by Tylenol and fioricet. He responded to these well. The patient was seen by social work and case management regarding placement and options for addiction rehabilition. The patient deferred this assistance. . On hospital 4, the patient was discharged in stable condition to via chair ambulance where he arranged to have a friend pick him up. He was discharged with a prescription for dilantin to complete a total of 10 days. He was given information for follow-up with ophthalmology and plastic surgery. | Adequate UO.SKIN: Laceration to right upper eyebrow sutured per plastics this am, scant amount serous sanginous drainage noted. There is rightward deviation of the nasal septum, likely chronic. Occiput with laceration, staples intact. The globe appears to be relatively intact, however there is an adjacent retrobulbar hematoma. Right upper lip laceration sutured this am per plastics, small amt serous sanginous drainage noted. and as revealing "small amount of likely subarachnoid hemorrhage present within the right frontal lobe. CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, prostate, and distal ureters appear within normal limits. Status post endotracheal tube placement in good position. TECHNIQUE: Non-contrast head CT. There is a comminuted fracture involving the right zygomatic arch. Minimally displaced right nasal bone fracture. FINAL REPORT STUDY: CT of the head without contrast. Comminuted fracture involving the right zygomatic arch. FINDINGS: There is negligible change in the minor hyperdensity noted adjacent to the right pterion, suggested as being a tiny quantity of subarachnoid hemorrhage in this locale. Patchy opacities present posteriorly within the lungs, right greater than left, most consistent in appearance with aspiration. CONCLUSION: Stable, abnormal study as noted above. 2:48 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: HEAD TRAUMA, KNOWN SAH FROM OSH. There is diastasis of the frontozygomatic suture on the right. The right globe appears intact, although there is relative proptosis compared to the contralateral side. tiny R frontal SAH stable, mult facial fx's nondisplaced, all lacerations addressed and healing. There is a small nondisplaced fracture of the right nasal bone. hct stable this am, lytes wnl.gi: belly soft/nt/nd. 2:47 AM CT HEAD W/O CONTRAST Clip # Reason: HEAD TRAUMA, KNOWN SAH FROM OSH. There is a comminuted fracture involving the medial orbital wall with displacement medially and associated surrounding hemorrhage There is a comminuted fracture involving the inferior orbital wall with minimal displacement of orbital contents. A small amount of likely subarachnoid hemorrhage present within the right frontal lobe. tls cleared, c spine precautions maintained.neuro- unable to obtain complete neuro assessment d/t pt received vecuronium for safe transport to ICU, RN. Travelled to CT for scan head/neck w/out incident (small head bleed appears unchanged). There is cresentic high attenuation along the posterior-superior aspect of the right globe (3:25) which could represent a small extra-ocular intraconal hematoma. There is a comminuted fracture involving the right lateral maxillary wall with (Over) 2:48 AM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: HEAD TRAUMA, KNOWN SAH FROM OSH. sx sm amts thick tan blood tinged secretions prn.cv: bp stable, nsr, 60s-80s, no ectope. There are prominent, posterior ill-defined patchy opacities present within the lung parenchyma, right greater than left, most consistent with probable aspiration. Right radial arterial ine intact. Multiple, predominantly right-sided, facial fractures are identified. Suctioned for scant amt old thick bloody secretions. Assess for intraabdominal/thoracic trauma. Perihilar diffuse aveolar opacity is noted, right greater than left. TECHNIQUE: Non-contrast MDCT axial images of the facial bones were acquired. (Over) 2:48 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: HEAD TRAUMA. FINDINGS: Along the superior aspect of the right C4 superior articular facet is a semilunar area of somewhat speckled bony density, approximately 1 x 4 mm in diameter seen immediately adjacent to the right C4 superior articular facet, with the facet itself having a contiguous focal depression. There is a fracture involving the superior aspect of the lamina papyracea on the right. Field of view: 38 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) OSSEOUS STRUCTURES: No lytic or blastic lesions are present. TECHNIQUE: Axial non-contrast cervical spine images were obtained with sagittal and coronal reconstructions. TECHNIQUE: Non-contrast head CT scan. lac to occiput w/ few staples, intact. High density material is seen within the right maxillary sinus consistent with hemorrhage. There is a comminuted fracture of the anterior maxillary wall. 2:48 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: HEAD TRAUMA. FINDINGS: Detail is obscured secondary to underlying trauma board. Perhaps some very unusually situated calcification related to the synovium within the joint space could be considered, as opposed to an even more unusual chondromatous neoplastic lesion. sm amt serosanguinous drainage. The patient is noted to be status post intubation. Scattered conchae bullosa noted incidently. IMPRESSION: Detail is limited secondary to underlying trauma board. FINAL REPORT (Cont) displacement of several bony fragments medially within the sinus itself. SpO2 90s, suctioned for scant amounts of thick blood tinged secretions. | 14 | [
{
"category": "Radiology",
"chartdate": "2153-08-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 970866,
"text": " 2:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: HEAD TRAUMA, KNOWN SAH FROM OSH.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with head trauma, known SAH from OHS\n REASON FOR THIS EXAMINATION:\n eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj TUE 3:50 AM\n Diffuse, small amount of subarachnoid hemorrhage within right frontal lobe. No\n mass effect. Multiple right sided facial fractures.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the head without contrast.\n\n INDICATION: 26-year-old male status post assault, transferred from the\n outside hospital with known subarachnoid hemorrhage. Assess for bleed.\n Previous images are unavailable for consultation.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is wispy high attenuation at the right frontotemporal\n junction suspicious for posttraumatic subarachnoid hemorrhage. No other acute\n hemorrhage is identified. There is no shift of normally midline structures,\n hydrocephalus, major or minor vascular territorial infarction. The density\n values of the brain parenchyma are maintained.\n\n There is diffuse swelling of the subcutaneous tissues of the entire cranium\n consistent with mechanism of injury. Multiple staples overlie the left\n parietal bone. There are extensive facial fractures involving predominantly\n the right maxillary sinus, orbit and zygomatic arch which will be described in\n further detail in the associated CT of the facial bones. High density\n material is seen within the right maxillary sinus consistent with hemorrhage.\n High density material is also visualized within the ethmoid sinuses.\n\n IMPRESSION:\n 1. A small amount of likely subarachnoid hemorrhage present within the right\n frontal lobe.\n 2. Extensive subcutaneous tissue swelling and right periorbital edema with\n associated multiple predominantly right-sided facial fractures. These\n findings will be discussed in further detail in the accompanying CT of the\n facial bones.\n\n Findings were discussed with the trauma team including Dr. as well as\n neurosurgery at approximately 3:30 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-08-07 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 970867,
"text": " 2:48 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: HEAD TRAUMA, KNOWN SAH FROM OSH.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with head trauma, known SAH from OHS\n REASON FOR THIS EXAMINATION:\n eval facial fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj TUE 3:52 AM\n Comminuted fractures involving the right medial, lateral and inferior orbital\n walls. Comminuted fracture with inward diplacement of fragments involving the\n right lateral wall of the maxillary sinus. Increased diastassis of rt\n frontozygomatic suture. Multiple fractures involving right zygomatic arch.\n Right globe appears relatively intact.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the facial bones.\n\n INDICATION: 26-year-old male status post head trauma. Assess for facial\n fractures.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast MDCT axial images of the facial bones were acquired.\n Coronal and sagittal reformatted images were then obtained.\n\n FINDINGS: There is extensive periorbital preseptal edema and soft tissue\n subcutaneous swelling, right greater than left. Multiple, predominantly\n right-sided, facial fractures are identified.\n\n There is a comminuted fracture involving the right lateral orbital wall at the\n sphenozygomatic suture with overlap of a 6 mm. There is a comminuted fracture\n involving the medial orbital wall with displacement medially and associated\n surrounding hemorrhage There is a comminuted fracture involving the inferior\n orbital wall with minimal displacement of orbital contents. The inferior\n rectus muscle assumes a rounded configuration suspicious for injury. Correlate\n for clinical evidence of entrapment. The right globe appears intact, although\n there is relative proptosis compared to the contralateral side. There is no\n evidence vitreous hemorrhage. There is cresentic high attenuation along the\n posterior-superior aspect of the right globe (3:25) which could represent a\n small extra-ocular intraconal hematoma.\n\n There is a small nondisplaced fracture of the right nasal bone. There is\n rightward deviation of the nasal septum, likely chronic. Scattered conchae\n bullosa noted incidently.\n\n There is a comminuted fracture involving the right zygomatic arch. There is\n no impingement on the mandibular coronoid process. The left zygomatic arch is\n intact. No fracture of ptyerygoid plates noted.\n\n There is a comminuted fracture involving the right lateral maxillary wall with\n (Over)\n\n 2:48 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: HEAD TRAUMA, KNOWN SAH FROM OSH.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n displacement of several bony fragments medially within the sinus itself. There\n is high density material within the sinus consistent with hemorrhage. There is\n a fracture involving the superior aspect of the lamina papyracea on the right.\n There is a comminuted fracture of the anterior maxillary wall. No left- sided\n maxillary sinus fractures are identified. The patient is noted to be status\n post intubation.\n\n There is diastasis of the frontozygomatic suture on the right.\n\n IMPRESSION: Extensive of subcutaneous swelling and periorbital edema, right\n greater than left. Multiple right-sided facial fractures including comminuted\n fractures of the medial, inferior and lateral orbital walls. The globe\n appears to be relatively intact, however there is an adjacent retrobulbar\n hematoma. Comminuted fractures involving the right lateral, anterior and\n medial maxillary sinus wall. Minimally displaced right nasal bone fracture.\n Comminuted fracture involving the right zygomatic arch.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-08-07 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 970868,
"text": " 2:48 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: HEAD TRAUMA. KNOWN SAH FROM OSH.\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with head trauma, known SAH from OHS\n REASON FOR THIS EXAMINATION:\n r/o TLS fx (please do recons), intraabdominal/thoracic trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DMFj TUE 4:02 AM\n Bilateral posterior patchy opacities, right greater than left, within the\n lungs is c/w probable aspiration. No acute intrathoracic, abdominal or pelvic\n pathology. No fracture or malaignment of the thoracic/lumbar spines.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the chest, abdomen and pelvis.\n\n INDICATION: 26-year-old male with head trauma. Assess for\n intraabdominal/thoracic trauma.\n\n COMPARISONS: None.\n\n TECHNIQUE: Following administration of 130 cc of Optiray intravenous\n contrast, MDCT axial images were acquired from the thoracic inlet to the pubic\n symphysis. Coronal and sagittal reformatted images were then obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: The heart and great vessels are\n unremarkable. The aorta is of normal caliber and there is no evidence of\n dissection. There is no pathologic mediastinal, hilar or axillary lymph\n nodes. There are prominent, posterior ill-defined patchy opacities present\n within the lung parenchyma, right greater than left, most consistent with\n probable aspiration. The anterior portion of the lungs is clear. No\n pulmonary nodules or pleural effusions are present. An endotracheal tube is\n located approximately 5 cm superior to the carina.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: A tiny hypodensity present within the\n dome of the liver is too small to characterize but most likely represents a\n simple liver cyst (2:46). Evaluation of the liver is somewhat limited\n secondary to streak artifact from arm positioning. Overall, the liver is\n unremarkable. The gallbladder, spleen, stomach, pancreas, adrenal glands,\n kidneys, and abdominal portions of the large and small bowel appear within\n normal limits. No acute pathology is identified. There is no free air or\n free fluid within the abdomen. No pathologic mesenteric or retroperitoneal\n lymph nodes are present. Nasogastric tube sideport at least 5 cm superior to\n GE junction.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, prostate, and\n distal ureters appear within normal limits. A Foley balloon is present within\n the decompressed bladder, which is overall unremarkable.\n\n (Over)\n\n 2:48 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: HEAD TRAUMA. KNOWN SAH FROM OSH.\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n OSSEOUS STRUCTURES: No lytic or blastic lesions are present. There is no\n malalignment of the thoracic or lumbar spines respectively. No acute fracture\n is present.\n\n IMPRESSION:\n\n 1. Patchy opacities present posteriorly within the lungs, right greater than\n left, most consistent in appearance with aspiration. Clinical correlation is\n recommended.\n\n 2. No intrathoracic, abdominal or pelvic acute pathology identified.\n\n 3. No acute fractures or malalignment involving the thoracic or lumbar\n spines.\n\n 4. Recommend advancement of NG tube by 10 cm.\n\n Findings reported to the ED dashboard and discussed with the trauma team\n including Dr. by Dr. at the time of the examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 970869,
"text": " 2:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with head trauma, in tubated\n REASON FOR THIS EXAMINATION:\n eval tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST X-RAY\n\n INDICATION: 26-year-old male status post head trauma and intubation.\n\n COMPARISONS: None.\n\n FINDINGS: Detail is obscured secondary to underlying trauma board. An\n endotracheal tube is noted with tip approximately 5 cm superior to the carina.\n The heart is normal in size. The mediastinal and hilar contours are\n unremarkable. Perihilar diffuse aveolar opacity is noted, right greater than\n left. There are no pleural effusions. No fractures are identified. NG tube\n high with side port above GE junction.\n\n IMPRESSION: Detail is limited secondary to underlying trauma board. Status\n post endotracheal tube placement in good position. Alveolar opacities, right\n greater than left, could reflect underlying aspiration. Clinical correlation\n is recommended. Recommend advancement of NG tube by 10 cm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-08-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 970938,
"text": " 12:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for changeNEED SCAN AROUND 11AM\n Admitting Diagnosis: TRAUMATIC SUBARACHNOID HEMORRHAGE\n Field of view: 18\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with with subarachnoidNEED SCAN AROUND 11 AM\n REASON FOR THIS EXAMINATION:\n eval for changeNEED SCAN AROUND 11AM\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old man with subarachnoid hemorrhage. Evaluate for\n change.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n COMPARISON STUDY: Non-contrast head CT scan, obtained 10 hours earlier,\n reported by Drs. and as revealing \"small amount of likely\n subarachnoid hemorrhage present within the right frontal lobe. Extensive\n subcutaneous tissue swelling and right periorbital edema associated with\n multiple predominantly right-sided facial fractures.\"\n\n FINDINGS: There is negligible change in the minor hyperdensity noted adjacent\n to the right pterion, suggested as being a tiny quantity of subarachnoid\n hemorrhage in this locale. There is no new mass effect or shift of normally\n midline structures, or perceptible change in ventricular size. The extensive\n facial soft tissue swelling and accompanying fractures are also noted again as\n is the large air fluid level within the right maxillary sinus.\n\n No other new intracranial abnormalities are seen.\n\n CONCLUSION: Stable, abnormal study as noted above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-08-07 00:00:00.000",
"description": "CT C-SPINE W/CONTRAST",
"row_id": 970939,
"text": " 12:30 PM\n CT C-SPINE W/CONTRAST Clip # \n Reason: thrown from car, multiple facial fractures. Evaluate c-spine\n Admitting Diagnosis: TRAUMATIC SUBARACHNOID HEMORRHAGE\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with\n REASON FOR THIS EXAMINATION:\n thrown from car, multiple facial fractures. Evaluate c-spine for clearance\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE CERVICAL SPINE\n\n HISTORY: Thrown from car. Multiple facial fractures. Evaluate cervical\n spine for clearance.\n\n TECHNIQUE: Axial non-contrast cervical spine images were obtained with\n sagittal and coronal reconstructions.\n\n COMPARISON STUDY: None.\n\n FINDINGS: Along the superior aspect of the right C4 superior articular facet\n is a semilunar area of somewhat speckled bony density, approximately 1 x 4 mm\n in diameter seen immediately adjacent to the right C4 superior articular\n facet, with the facet itself having a contiguous focal depression. Smooth\n margination of the depression suggests that this complex of findings is more\n in keeping with a chronic than an acute abnormality. Perhaps some very\n unusually situated calcification related to the synovium within the joint\n space could be considered, as opposed to an even more unusual chondromatous\n neoplastic lesion. There are no other cervical spine fractures seen. The\n alignment of the spine is also within normal limits. There are no overt\n extraspinal abnormalities discerned, either.\n\n The findings were discussed in detail by telephone with you immediately after\n the performance of the study.\n\n CONCLUSION: No overt cervical spine fracture aside from unusual\n osseous/calcific abnormality involving the right C3-4 facet joint complex.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-08-07 00:00:00.000",
"description": "Report",
"row_id": 1640330,
"text": "t-sicu nsg note:\nPt is a 26y/o male s/p thrown from car, taken to OSH and transferred to for management.Injuries include multiple facial fractures, sm. r frontal SAH, laceration to occiput(stapled)in ED, laceration to r eyebrow and inner lower lip( plastics aware and will suture). sm amt serosanguinous drainage. Pt admitted with the following lines and tubes. Oral ett @ 23cm to the lip advanced to 25cm to the lip MD , # 20angio R antecub, #18 and #16 in L upper anterior forearm. propofol infusing @20mcg/kg/min. foley to gravity and patent for clear light yellow urine. hr 110 and initial sbp 179sys. MD aware. tls cleared, c spine precautions maintained.\n\nneuro- unable to obtain complete neuro assessment d/t pt received vecuronium for safe transport to ICU, RN. no cough, no spont resps above vent, perrla 3mm brisk.\n\nresp- vented on a/c 80% peep of 5cm, 500vt rate of 16, spo2 97-100%, suctioned for scant amt of thick bld tinged secretions. bs coarse bibasilar.\n\ncvs- on 45mcg/kg/min of propofol, hr 70's nsr no ectopy, sbp 120's-140's, tm 98.6po, see flowsheet for all details.\n\ngi- ngt placed on admission, patent for thick browinsh drainage, abd soft/nondistended.\n\ngu- foley patent for clear yellow urine in gd amounts.\n\nskin- mult abrasions over neck, upper chest etc, and lacerations as previously noted.\n\nsocial- unknown at this time.\n\na: stable cvs, unable to obtain complete neuro exam d/t vecuronium.\n\np: monitor cvs/nvs per routine, follow labs as ordered, lighten sedation for neuro checks, plastics to address facial lacerations, provide pain med as needed, follow-up head ct later today, c-spine precautions, collar immobilization continues.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-08-07 00:00:00.000",
"description": "Report",
"row_id": 1640331,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. FiO2 weaned this shift, no other vent changes made. Travelled to CT for scan head/neck w/out incident (small head bleed appears unchanged). Continues on A/C ventilation w/ PIP/Pplat = 18/15. SpO2 90s, suctioned for scant amounts of thick blood tinged secretions. ETT secure/patent. Vent alarms on/functioning. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-08-07 00:00:00.000",
"description": "Report",
"row_id": 1640332,
"text": "TSICU NPN 0700-1900\nEVENTS:\n\n-Arterial line placement\n\n-Plastics sutured eyebrow and lip lacerations\n\n-Head and Neck CT scan, offical results pending at this time\n\n\nSEE CAREVIEW FOR SPECIFIC TRENDS\n\nREVIEW OF SYSTEMS:\n\nNEURO: Pt sedated on Propofol, currently infusing at 50mcg/kg/min. When lightend, pt is very purposeful reaching toward ETT. Localizes and withdraws with all four extremities. RUE noted to be weaker than LUE, neurosurgery aware. Does not follow and commands. Occassionally opens eyes to voice and pain. Pupils equal and reactive, 2-3mm. Strong cough and gag. Fentanyl given PRN for pain. J collar intact.\n\nCV: SR 60-100's, no ectopy noted. SBP ranging 90-120's. PIV X 3. Right radial arterial ine intact. NS infusing at 75cc/hr. P-boots intact. SC Heparin. TMAX 100.4.\n\nRESP: Orally intubated on CMV 500X16, 5 PEEP, 50% FIO2. LS clear throughout. Suctioned for scant amt old thick bloody secretions. ABG stable. SATS >96%.\n\nGI: Abd soft, non-distended. OGT to low wall suction, draining bilious output. +BS. No stool this shift.\n\nGU: Foley draining clear yellow urine. Adequate UO.\n\nSKIN: Laceration to right upper eyebrow sutured per plastics this am, scant amount serous sanginous drainage noted. Right upper lip laceration sutured this am per plastics, small amt serous sanginous drainage noted. Occiput with laceration, staples intact. Backside intact.\n\nSOCIAL: Pt remains Eu Critical at this time. Unaware of pt's real name, no family to identify. Social work aware and following.\n\nPLAN: Continue to montior neuro status, if following commands in am will extubate. Follow lytes, montior hemodynamics, monitor pain. Awaiting final read of neck CT to clear neck.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-08-08 00:00:00.000",
"description": "Report",
"row_id": 1640333,
"text": "nursing progress note\n\nneuro: sedation lightened q2h for exam, does not open eyes, although turns head in direction of voice. perrla, 3-5mm. very strong to all extrem, faintly weaker to R arm. purposeful w/ bue, cough and gag intact. dilantin dosing as ordered.\n\nresp: weaned to cpap+ps overnight, 40%, at present. rsbi 37 this am. abg acceptable. ls clear throughout, slightly dimin to bases. sx sm amts thick tan blood tinged secretions prn.\n\ncv: bp stable, nsr, 60s-80s, no ectope. extrem warm, pulses intact. hct stable this am, lytes wnl.\n\ngi: belly soft/nt/nd. bs present. og w/ mod amts thick old bloody drainage, note facial fx's and likely post nasal drainage.\n\ngu: foley patent clear yellow urine, becoming increasingly darker this am. volume adeq.\n\nid: afebrile, wbc stable. no abx at this time.\n\nendo: glucose levels wnl.\n\nskin: lacs to lips, R eye healing, sutures intact. some edema to surrounding tissue. lac to occiput w/ few staples, intact. scant amts serosang drainage. all wounds cleansed w/ ns, bacitracin applied.\n\nsocial: pt remains , no family found as of this time. social work consult in progress.\n\na/p: young man in early 20s s/p assault vs. fall from moving vehicle. tiny R frontal SAH stable, mult facial fx's nondisplaced, all lacerations addressed and healing. weaned to cpap+ps, plan to extubate this am. ongoing social work to find family, identify patient continued.+\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-08-08 00:00:00.000",
"description": "Report",
"row_id": 1640334,
"text": "addendum nursing progress note\n\nneuro: pt inconsistently following commands throughout shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-08-08 00:00:00.000",
"description": "Report",
"row_id": 1640335,
"text": "Respiratory Care:\nPatient was able to wean from A/C to CPAP/PSV ventilatory support, 40%, . Latest abg results determined a normal acid-base balance with excellent oxygenation.\n\nRSBI = 37 on 0-PEEP and 5 cm PSV.\n\nPlan is to wean to extubation this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-08-08 00:00:00.000",
"description": "Report",
"row_id": 1640336,
"text": "respiratory care\npt was weaned from the vnet to well. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2153-08-08 00:00:00.000",
"description": "Report",
"row_id": 1640337,
"text": "****See Nsg transfer note for day note 7a-7pm****\n"
}
] |
11,061 | 181,367 | 1. Diabetic ketoacidosis: The patient had an anion gap acidosis with trace ketones and hyperglycemia on admission. Although it was not a clear cut diabetic ketoacidosis and we do not know what her arterial blood gas showed the patient has a history of type 1 diabetes as well as decreased insulin use as well as possible infection all of which are consistent with a potential diabetic ketoacidosis. Given the anion gap the patient was transferred to the Intensive Care Unit and treated with an insulin drip. The endocrine service was consulted and they continued to provide recommendations throughout the course of her admission. She was kept on an insulin drip throughout her Intensive Care Unit stay and on the drip was shut off with coverage with long acting insulin prior to stopping the drip. The anion gap had closed over the course of her treatment and the patient was not felt to be in diabetic ketoacidosis. The patient was given two appointments at the Clinic the first of which with an endocrinologist in and a second appointment was with a nutritionist. 2. Pneumonia: Although the patient was afebrile she has a history of immunosuppression on Cyclosporin as well as Imuran and the chest film is convincing enough that she was started in the Emergency Department on Azithromycin, however, given her immunosuppression the patient was given Ceftriaxone over the course of her Intensive Care Unit stay and during her time on the floor her chest film improved over the course of her admission as well as her symptoms of cough as well as fatigue. On the day of discharge the patient was able to walk around the floor without feeling any significant discomfort and her fatigue on exertion had improved significantly. The patient was discharged with a total of a fourteen day course of Azithromycin and Cefpodoxime that will again be completed in a total of fourteen days. 3. Paronychia: The patient has a history of chronic infection and has been treated chronically with Vancomycin. Of note the patient had MRSA at one point growing out of the toe. The patient was wondering why she has been labeled as a MRSA patient. It is likely because of this infection. Podiatry was consulted who did not make any change in management plans. 4. End stage renal disease: The patient as a history of diabetic nephropathy that ultimately resulted in an renal transplant, however, the patient has failed on the renal transplant and is again on the transplant list, but is currently requiring hemodialysis. The Renal Service was consulted as she underwent hemodialysis as an inpatient. The immunosuppressive regimen was changed such that her Imuran was discontinued altogether. Her Cyclosporin was lowered to 50 q.d. and her Prednisone was changed from 10 q.o.d. to 10 q.d. The patient was recommended by the Renal Service to stop her Cyclosporin altogether, however, she was resistant to this, because her transplant surgeon wanted her to stay on Cyclosporin. This will be discussed as an outpatient with her primary care physician and nephrologist. 5. Coronary artery disease: The patient has known severe coronary artery disease status post coronary artery bypass graft in with electrocardiogram changes on admission. It was concerning for active ischemia, however, as the patient was treated for diabetic ketoacidosis, hydrated and her pneumonia treated her electrocardiogram improved significantly. Her CK's were negative. Her troponins were mildly elevated, but trended down and given her renal failure it was not felt to indicate an acute coronary syndrome. The patient was seen by cardiology as an inpatient was to see her outpatient cardiologist after discharge. She was not given intravenous heparin and her beta blocker was continued. The patient was scheduled for an outpatient exercise MIBI in late . | Mild tricuspid [1+]regurgitation is seen. Mild (1+) mitralregurgitation is seen. IMPRESSION: Cardiomegaly with mild CHF. There is moderate pulmonary artery systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Also noted is mild bilateral perihilar haziness. There is moderate pulmonary artery systolichypertension. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are normal. There is mildmitral annular calcification. Noaortic regurgitation is seen. There is mild LV enlargement. The aorta is tortuous, and the pulmonary vascularity is within normal limits. No aortic regurgitation isseen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild mitral regurgitation.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). Regional left ventricularwall motion is normal.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) are mildly thickened but notstenotic. GI/GU: Abdomen soft with + bs. 0500 FS FS 203.C-V: Hemodynamically stable. There is moderate thickening of the mitral valvechordae. Brief apneic periods observed. Left ventricular function.Height: (in) 59Weight (lb): 140BSA (m2): 1.59 m2BP (mm Hg): 160/60Status: InpatientDate/Time: at 14:10Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in theright atrium and/or right ventricle.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy withnormal cavity size and systolic function (LVEF>55%). Sinus rhythmInferior/lateral ST-T changes may be due to myocardial ischemiaSince previous tracing of : no significant change Based on AHA endocarditis prophylaxis recommendations, the echo findings indicatea moderate risk (prophylaxis recommended). The aortic valve leaflets (3) are mildlythickened but not stenotic. Seen by cardiology fellow, who suggests ECHO and stress test when more stable.SKIN: Left great toe dressing changed; area under and around nail is hardened, brown, dry. Regionalleft ventricular wall motion is normal. Respiratory: Lung sounds are clear, diminished in lt base. Id: Azithro and ceftriaxone d/c'd. The skeletal structures reveal diffuse demineralization and mild decreased height of several vertebral bodies, unchanged. CHEST PA & LATERAL: Comparison is made to . There is mild symmetric left ventricularhypertrophy with normal cavity size and systolic function (LVEF>55%). Ekg in ed showed st depression in laterlal leads, 1,2,l, v4-v6, with t wave flattening in 3. ck 42. There is no pericardial effusion.IMPRESSION: Symmetric left ventricular hypertrophy with preserved global andregional biventricular systolic function. Has limited voiding due to dialysis, Awaiting urine for lytes and osmol. The heart is upper limits of normal in size and stable. Right ventricular chamber size andfree wall motion are normal. NPN 1900-0700:RESP: Remains stable on R/A. There are inferior and lateral ST-T wave abnormalities suggestiveof myocardial ischemia. Patient is s/p sternotomy. Able to do MDI independently. There is low lung volume bilaterally. Temperature max 98.6 oral. The mitral valve leaflets are mildly thickened.There is moderate thickening of the mitral valve chordae. Nbp in low 100's to 120's range. Sinus rhythm. The tips of the papillary muscles are calcified. CHEST AP PORTABLE: Comparison is made to the prior study obtained on . Pt has been given Robitussin w/Codeine X 2 as well as Tessalon pearls once with some effect. Pt was instructed in use of albuterol MDI w/spacer by RT. Awaiting results of previous sputum cx. Sinus rhythmST-T changes inferior and anterolaterallySince previous tracing of : ST-T wave abnormalities more marked Denies dizziness or lightheadedness. Denies any sob at this time. if sleep apnea is new vs result of Ambien).A: some difficulty getting sugars under control. Continue MDI's, cough syrup and pearls. Clinical decisions regarding theneed for prophylaxis should be based on clinical and echocardiographic data.Conclusions:The left atrium is mildly dilated. Sinus rhythmInferior/lateral ST-T changes are nonspecificSince previous tracing of : no significant change Pulmonary artery systolichypertension. Given Cepacol lozenges at bedside.ENDO: FS 262; pt given standing 10U dose Lente. Comparison is made to previous chest x-ray of . Reports having some rt shoulder discomfort, ? There are areas of bronchial wall thickening within the lower lobes bilaterally, best seen on the lateral view. Has ruled out for MI. A dialysis catheter remains in place, terminating in the right atrium. The heart is mildly enlarged. Cxr showed lll infiltrate. Clinical correlation is suggested. CV: Sinus rhythm with no ectopy noted, rate 70's to 90's. Is on vancomycin with dialysis, has toe wd that is draining mrsa + fluid. Compared to the previous tracing of inferior andlateral ST-T wave changes are new. Tolerating diet well, taking po's well. Allergy to ciprofloxacin. Need sputum spec. Per pt's home routine, area cleansed with NS, swabbed w/Betadine and allowed to air dry. Additionally, there are very ill-defined small opacities present at the left lung base, best seen on the frontal projection. 0400 FS 365; pt given 4U Humalog. RESPIRATORY CARE:Instructed pt on MDI use with spacer. She demonstrated good technique, and is using the MDI q6 hours with reminder from nursing. RR 16-24 and non labored. The lungs are clear. Hilar and mediastinal contours appear unremarkable. Pt is a diifcult stick reportedly, has 2 peripherals at present. Neuro: Alert and oriented x 3. Pt c/o feeling SOB with coughing jags, but no drop in sats, and sx resolve very quickly. 2400 FS FS 288; pt given 4U Humalog. Pt was started on heparin in ed with bolus but was turned of per orders upon arrival to micu. While sleeping, however, pt was observed to apparently have sleep apnea, with periodic and frequent drops in sats as low as 70's, lasting only a few seconds before returning to baseline. Adjacent ill-defined opacities at the left lung base may reflect a component of developing bronchopneumonia. Denies n/v. Medicated with tylenol 650 mg po for discomfort, team made aware of discomfort and will evaluate. IMPRESSION: Bilateral lower lobe bronchial wall thickening, likely due to acute bronchitis. | 11 | [
{
"category": "Radiology",
"chartdate": "2148-08-13 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 796361,
"text": " 10:51 AM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate progression of infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with productive cough\n REASON FOR THIS EXAMINATION:\n Evaluate progression of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cough.\n\n CHEST PA & LATERAL: Comparison is made to . There is mild LV\n enlargement. Patient is s/p sternotomy. Hilar and mediastinal contours appear\n unremarkable. The lungs are clear.\n\n IMPRESSION: No evidence of acute pneumonia or CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796225,
"text": " 6:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PNA\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with DMI, CAD s/p CABG, ESRD on HD now with DKA and probable\n PNA\n REASON FOR THIS EXAMINATION:\n eval PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG.\n\n CHEST AP PORTABLE: Comparison is made to the prior study obtained on\n . The heart is mildly enlarged. There is upper zone redistribution.\n Also noted is mild bilateral perihilar haziness. There is low lung volume\n bilaterally. There is no definite pleural effusion or focal consolidation.\n\n IMPRESSION: Cardiomegaly with mild CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-08-10 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 796127,
"text": " 6:26 PM\n CHEST (PA & LAT) Clip # \n Reason: 5 days yellow productive cough, now laryngitis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman with productive cough\n REASON FOR THIS EXAMINATION:\n 5 days yellow productive cough, now laryngitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Productive cough.\n\n Comparison is made to previous chest x-ray of .\n\n A dialysis catheter remains in place, terminating in the right atrium. The\n heart is upper limits of normal in size and stable. The aorta is tortuous,\n and the pulmonary vascularity is within normal limits. There are areas of\n bronchial wall thickening within the lower lobes bilaterally, best seen on the\n lateral view. Additionally, there are very ill-defined small opacities\n present at the left lung base, best seen on the frontal projection.\n\n No pleural effusions are evident. The skeletal structures reveal diffuse\n demineralization and mild decreased height of several vertebral bodies,\n unchanged. Vascular calcifications are also noted in both kidneys.\n\n IMPRESSION: Bilateral lower lobe bronchial wall thickening, likely due to\n acute bronchitis. Adjacent ill-defined opacities at the left lung base may\n reflect a component of developing bronchopneumonia.\n\n"
},
{
"category": "Echo",
"chartdate": "2148-08-12 00:00:00.000",
"description": "Report",
"row_id": 65942,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 59\nWeight (lb): 140\nBSA (m2): 1.59 m2\nBP (mm Hg): 160/60\nStatus: Inpatient\nDate/Time: at 14:10\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and systolic function (LVEF>55%). Regional left ventricular\nwall motion is normal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. There is no valvular aortic stenosis. The increased transaortic\ngradient is likely related to high cardiac output. No aortic regurgitation is\nseen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. There is moderate thickening of the mitral valve\nchordae. The tips of the papillary muscles are calcified. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Based on\n AHA endocarditis prophylaxis recommendations, the echo findings indicate\na moderate risk (prophylaxis recommended). Clinical decisions regarding the\nneed for prophylaxis should be based on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Regional\nleft ventricular wall motion is normal. Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but not stenotic. There is no valvular aortic stenosis. The\nincreased transaortic gradient is likely related to high cardiac output. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is moderate thickening of the mitral valve chordae. Mild (1+) mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Symmetric left ventricular hypertrophy with preserved global and\nregional biventricular systolic function. Pulmonary artery systolic\nhypertension. Mild mitral regurgitation.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2148-08-13 00:00:00.000",
"description": "Report",
"row_id": 138424,
"text": "Sinus rhythm\nST-T changes inferior and anterolaterally\nSince previous tracing of : ST-T wave abnormalities more marked\n\n"
},
{
"category": "ECG",
"chartdate": "2148-08-12 00:00:00.000",
"description": "Report",
"row_id": 138425,
"text": "Sinus rhythm\nInferior/lateral ST-T changes are nonspecific\nSince previous tracing of : no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2148-08-11 00:00:00.000",
"description": "Report",
"row_id": 138426,
"text": "Sinus rhythm\nInferior/lateral ST-T changes may be due to myocardial ischemia\nSince previous tracing of : no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2148-08-10 00:00:00.000",
"description": "Report",
"row_id": 138427,
"text": "Sinus rhythm. There are inferior and lateral ST-T wave abnormalities suggestive\nof myocardial ischemia. Compared to the previous tracing of inferior and\nlateral ST-T wave changes are new. Clinical correlation is suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-08-11 00:00:00.000",
"description": "Report",
"row_id": 1407439,
"text": "MICU NURSING PROGESS NOTE 1245-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Alert and oriented x 3. Speach is clear and is able to make needs known verbally. Denies dizziness or lightheadedness. Moving all extrem freely. Reports having some rt shoulder discomfort, ? from position in bed. Medicated with tylenol 650 mg po for discomfort, team made aware of discomfort and will evaluate. Temperature max 98.6 oral.\n\n Respiratory: Lung sounds are clear, diminished in lt base. RR 16-24 and non labored. O2 saturation 98-100% on ra. Denies any sob at this time. Cxr showed lll infiltrate. Need sputum spec. Awaiting results of previous sputum cx.\n\n CV: Sinus rhythm with no ectopy noted, rate 70's to 90's. Nbp in low 100's to 120's range. Pt was started on heparin in ed with bolus but was turned of per orders upon arrival to micu. Ekg in ed showed st depression in laterlal leads, 1,2,l, v4-v6, with t wave flattening in 3. ck 42. Ivf d5ns at 50cc/hr for 250cc/hr. Pt is a diifcult stick reportedly, has 2 peripherals at present.\n\n GI/GU: Abdomen soft with + bs. Tolerating diet well, taking po's well. Denies n/v. Liquid brown stool every 2-3 hrs, reports started last pm. Has limited voiding due to dialysis, Awaiting urine for lytes and osmol.\n\n Id: Azithro and ceftriaxone d/c'd. Allergy to ciprofloxacin. Is on vancomycin with dialysis, has toe wd that is draining mrsa + fluid.\n\n Social: Wife and son were in to visit pt this pm, both also have coughs but were feeling well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-08-11 00:00:00.000",
"description": "Report",
"row_id": 1407440,
"text": "RESPIRATORY CARE:\n\nInstructed pt on MDI use with spacer. Her technique is excellent. Able to do MDI independently. Please call for further RT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-08-12 00:00:00.000",
"description": "Report",
"row_id": 1407441,
"text": "NPN 1900-0700:\nRESP: Remains stable on R/A. RR 16-24, non-labored, sats high 90's while awake. Pt c/o feeling SOB with coughing jags, but no drop in sats, and sx resolve very quickly. While sleeping, however, pt was observed to apparently have sleep apnea, with periodic and frequent drops in sats as low as 70's, lasting only a few seconds before returning to baseline. Brief apneic periods observed. Pt was instructed in use of albuterol MDI w/spacer by RT. She demonstrated good technique, and is using the MDI q6 hours with reminder from nursing. Pt has been given Robitussin w/Codeine X 2 as well as Tessalon pearls once with some effect. She continues to have coughing jags w/occasional upper airway wheezing. Given Cepacol lozenges at bedside.\nENDO: FS 262; pt given standing 10U dose Lente. 2100 FS FS 148; pt given 1U Humalog and gtt was turned off 30 minutes later. 2400 FS FS 288; pt given 4U Humalog. At 0245 pt called RN, asking to have FS checked, saying she felt funny all over; FS 347, and pt was given 6U Humalog. 0400 FS 365; pt given 4U Humalog. 0500 FS FS 203.\nC-V: Hemodynamically stable. Has ruled out for MI. Seen by cardiology fellow, who suggests ECHO and stress test when more stable.\nSKIN: Left great toe dressing changed; area under and around nail is hardened, brown, dry. No drainage. Per pt, toe is improving, and she is seen by podiatry monthly as outpatient. Per pt's home routine, area cleansed with NS, swabbed w/Betadine and allowed to air dry. DSD loosely placed around toe, and \"toe sock\" replaced.\nNEURO: Pt unable to sleep by 0200, so she was given 5mg Ambein with excellent effect (? if sleep apnea is new vs result of Ambien).\n\nA: some difficulty getting sugars under control. Trouble sleeping d/t cough.\n\nP: Continue to follow sugars q2 hours until stable. Continue standing Lente and SS Humalog. Continue MDI's, cough syrup and pearls. ? sleep study.\n\n"
}
] |
19,029 | 117,000 | 43 yo F with encephalitis, seizures, right hemiparesis, aphasia, tracheobronchomalacia, chronic trach, presents with trach that fell out and was replaced, with balloon unable to be inflated. . #Tracheostomy with balloon not functioning: Interventional Pulmonary consulted in ED and replaced prvious trach with new Portex 7mm (6cc air inflation). The patient was monitored in the ICU without issues. Her tube feeds and albuterol/ipratropium can be resumed on discharge. Profound supraglottic edema, redundant tissue and subglottic stenosis/malacia were noted on bronchoscopy suggestive of GERD. IP recommended starting a PPI and GERD precautions (elevating head of bed, monitoring tube feeds etc). - Start Lansoprazole for GERD . # encephalitis/seizure disorder: The patient was continued on phenobarbital, keppra, zonisamide, dilantin. Neurology evaluated the patient and felt there were no acute issues. Initially, recommended EEG given relative hypotension and bradycardia. 20 minute EEG was performed, final read pending -- although Neurology felt the patient's mental status is at baseline and did not need EEG monitoring. Technically, ongoing seizure activity should cause tachycardia, not bradycardia. - Follow-up final EEG read . #Depression: Continued on fluoxetine. . #Hypothyroidism: The patient may actualy be sick euthyroid as patient's hypothyroidism diagnosis was made during acute illness. She was continued on home levothyroxine. . #Access: 22-gauge PIV on right shoulder; patient with very difficult access. . #Communication: HCP is mother , cell phone: . . #Code status: FULL CODE, confirmed with mother . ## TRANSITIONAL CARE: EEG final read pending. Lasix held in-house for relative hypotension. Lansoprazole started for GERD. | Interval improvement in pleural effusion and bibasilar opacities with residual interstitial edema. Tracheostomy tube is appropriately positioned. FINDINGS: Portable semi-upright chest frontal chest radiograph demonstrates interval improvement in pleural effusion and bibasilar opacities, though mild interstitial edema remains. A tracheostomy tube is in place and appears appropriately positioned. Note is again made of S-shaped scoliosis of the thoracolumbar spine. COMPARISON: . A neurostimulator control unit is superimposed over the left lower lung which limits evaluation. IMPRESSION: 1. 2. 3. Vagal nerve stimulator overlies the left lower lung which limits evaluation. Mild cardiomegaly is unchanged. | 1 | [
{
"category": "Radiology",
"chartdate": "2110-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190292,
"text": " 10:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval trach placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 43 year old woman with accident trach removal now s/p replacement\n REASON FOR THIS EXAMINATION:\n eval trach placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 43-year-old female with accidental tracheostomy removal\n status post replacement.\n\n COMPARISON: .\n\n FINDINGS: Portable semi-upright chest frontal chest radiograph demonstrates\n interval improvement in pleural effusion and bibasilar opacities, though mild\n interstitial edema remains. A neurostimulator control unit is superimposed\n over the left lower lung which limits evaluation. Mild cardiomegaly is\n unchanged. A tracheostomy tube is in place and appears appropriately\n positioned. Note is again made of S-shaped scoliosis of the thoracolumbar\n spine.\n\n IMPRESSION:\n\n 1. Interval improvement in pleural effusion and bibasilar opacities with\n residual interstitial edema.\n\n 2. Tracheostomy tube is appropriately positioned.\n\n 3. Vagal nerve stimulator overlies the left lower lung which limits\n evaluation.\n\n"
}
] |
56,186 | 163,457 | Hospital Course: 84F h/o afib on coumadin, s/p recent hip fracture with nailing at 1 month ago and then sent to rehab who developed worsening dysphagia 1d prior to admission. She described having difficulty swallowing pills and her saliva so was sent to ED where EGD showed concern for food impaction that was unable to be cleared with flex endoscopy and also notable for question of zenker's diverticulum. She also had afib with RVR treatedwith IV and BB. She was sent to ICU on for ENT evaluation. She was given FFP and her coumadin was held prior to proceeding with laryngoscope and rigid endoscope with esophageal baloon dilation on that showed a narrow esophagus. A standard post-procedure CXR had a prelim read notable for pneumomediastinum, but she remained clincially stable, and a repeat CXR on did not show any evidence of pneumomediastinum and ENT felt comfortable beginning a PO diet. She tolerated mechanical soft diet on and had no symptoms of dyspnea, cough, vomitting, dysphagia, or neck pain. She has been ambulating with the aide of a walker. | FINDINGS: Previously seen equivocal lucency in the left lower paratracheal region is not evident on the present x-ray. This is concerning for postoperative pneumomediastinum. Comparisons were made with prior chest radiographs dated . IMPRESSION: Since the most recent radiograph from acquired at 5:47 a.m., there are no significant relevant changes in the lung findings. There is otherwise no specific radiographic evidence of pneumomediastinum. Rule out any acute injury to esophagus or the airways. 5:13 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for pneumomediastinum. 5:55 PM CHEST (PA & LAT) Clip # Reason: r/o pneunomediastinum Admitting Diagnosis: DYSPHAGIA MEDICAL CONDITION: s/p esophageal dilatation REASON FOR THIS EXAMINATION: r/o pneunomediastinum WET READ: 6:44 PM Similar or decreased mediastinal width when compared to study on . Non-specific ST-T wave abnormalities. FINDINGS: In comparison with the study of earlier in this date, the prominence of the superior mediastinum is less, probably due to the PA technique. FINAL REPORT HISTORY: Esophageal dilatation, to assess for pneumomediastinum. Heart, mediastinal and hilar contours are unchanged. REASON FOR THIS EXAMINATION: please evaluate for pneumomediastinum. No specific radiographic evidence of pneumomediastinum. COMPARISON: Film from dated FINDINGS: Single portable frontal view of the chest shows an apparent widening of the mediastinum. Heart size and mediastinal contours are unchanged. If the clinical suspicion remains high, and the patient is decompensating, consider CT chest. There is air seen superior to the left main stem bronchus which was also seen in the previous film. Unchanged cardiomegaly. Unchanged cardiomegaly. TECHNIQUE: Frontal and lateral radiographs of the chest. Delayed R wavetransition. A small lucent area in the fifth intercostal space posteriorly is probably contributed from margins of ribs and the vascular structure and is very unlikely to be a true lung cavity. Both lungs are low volume and there are no lung opacities concerning for pneumonic consolidation. Comparisons were made with prior chest radiographs through , with the most recent radiograph from acquired at 5:47 a.m. No previous tracingavailable for comparison. No pneumothorax or pleural effusion. There is no evidence of a pneumomediastinum on the present radiograph. Pleural effusion, if any, is minimal on the left side. There is no evidence of pneumomediastinum/pneumothorax. There is no effusion/pneumothorax REASON FOR THIS EXAMINATION: check for pneumothorax or other complication of procedure FINAL REPORT HISTORY: Evaluation for pneumothorax after endoscopy and balloon dilation of the esophagus. TECHNIQUE: AP upright portable radiograph of the chest. If there is serious concern, CT could be considered. This again could possibly represent pneumomediastinum or represent an artifact from overlying structures. REASON FOR THIS EXAMINATION: stricture of esophagus, pneumomediastinum, acute injury to upper esophagus/airway FINAL REPORT INDICATION: 84-year-old man with achalasia status post rigid endoscopy yesterday. The equivocal lucency just superior to the left main bronchus was similarly noted in the study, likely representing artifacts from overlaying structures. Admitting Diagnosis: DYSPHAGIA MEDICAL CONDITION: 84 year old woman s/p rigid endoscopy with ?pneumomediastinum. Air along the lower left side of the trachea and left main stem bronchus again is seen. No PTX. No PTX. Most recent chest radiograph was done on at 6:04 p.m. 9:25 AM CHEST (PA & LAT); -76 BY SAME PHYSICIAN # Reason: stricture of esophagus, pneumomediastinum, acute injury to u Admitting Diagnosis: DYSPHAGIA MEDICAL CONDITION: 84 year old woman with achalasia, s/p rigid endoscopy yesterday. FINAL REPORT HISTORY: 84-year-old woman status post rigid endoscopy with query pneumomediastinum. Atrial fibrillation with rapid ventricular response. 3:57 PM CHEST (PORTABLE AP) Clip # Reason: check for pneumothorax or other complication of procedure Admitting Diagnosis: DYSPHAGIA MEDICAL CONDITION: 84 year old woman with episode of difficulty swallowing, now post rigid endoscopy and balloon dilation of upper esophagus/crichopharyngeus. WET READ VERSION #1 6:25 PM Similar mediastinal width compared to study on . Followup within one to two hours with a PA and lateral film is recommended. IMPRESSION: Widening of the mediastinum. Please evaluate for interval change. It was probably an artifact. Dr. discussed the findings with the primary team Dr. at 6:20PM, who reports that the patient is asymptomatic and stable. Dr. discussed the findings with the primary team Dr. at 6:20PM, who reports that the patient is asymptomatic and stable. | 5 | [
{
"category": "Radiology",
"chartdate": "2175-09-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1203448,
"text": " 5:55 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneunomediastinum\n Admitting Diagnosis: DYSPHAGIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p esophageal dilatation\n REASON FOR THIS EXAMINATION:\n r/o pneunomediastinum\n ______________________________________________________________________________\n WET READ: 6:44 PM\n Similar or decreased mediastinal width when compared to study on\n . The equivocal lucency just superior to the left main bronchus\n was similarly noted in the study, likely representing artifacts from\n overlaying structures. There is otherwise no specific radiographic evidence\n of pneumomediastinum. No PTX. Unchanged cardiomegaly. If the clinical\n suspicion remains high, and the patient is decompensating, consider CT chest.\n Dr. discussed the findings with the primary team Dr. at\n 6:20PM, who reports that the patient is asymptomatic and stable. Dr. also\n discussed the findings with ENT consult resident at 6:35PM.\n WET READ VERSION #1 6:25 PM\n Similar mediastinal width compared to study on . No\n specific radiographic evidence of pneumomediastinum. No PTX. Unchanged\n cardiomegaly. Dr. discussed the findings with the primary team Dr.\n at 6:20PM, who reports that the patient is asymptomatic and\n stable.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Esophageal dilatation, to assess for pneumomediastinum.\n\n FINDINGS: In comparison with the study of earlier in this date, the\n prominence of the superior mediastinum is less, probably due to the PA\n technique. Air along the lower left side of the trachea and left main stem\n bronchus again is seen. This again could possibly represent pneumomediastinum\n or represent an artifact from overlying structures. If there is serious\n concern, CT could be considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203480,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for pneumomediastinum.\n Admitting Diagnosis: DYSPHAGIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p rigid endoscopy with ?pneumomediastinum.\n REASON FOR THIS EXAMINATION:\n please evaluate for pneumomediastinum.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old woman status post rigid endoscopy with query\n pneumomediastinum. Please evaluate for interval change.\n\n TECHNIQUE: AP upright portable radiograph of the chest.\n\n Comparisons were made with prior chest radiographs dated .\n Most recent chest radiograph was done on at 6:04 p.m.\n\n FINDINGS: Previously seen equivocal lucency in the left lower paratracheal\n region is not evident on the present x-ray. It was probably an artifact.\n There is no evidence of a pneumomediastinum on the present radiograph. Both\n lungs are low volume and there are no lung opacities concerning for pneumonic\n consolidation. A small lucent area in the fifth intercostal space posteriorly\n is probably contributed from margins of ribs and the vascular structure and is\n very unlikely to be a true lung cavity. Heart size and mediastinal contours\n are unchanged. There is no effusion/pneumothorax\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-09-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1203510,
"text": " 9:25 AM\n CHEST (PA & LAT); -76 BY SAME PHYSICIAN # \n Reason: stricture of esophagus, pneumomediastinum, acute injury to u\n Admitting Diagnosis: DYSPHAGIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with achalasia, s/p rigid endoscopy yesterday.\n REASON FOR THIS EXAMINATION:\n stricture of esophagus, pneumomediastinum, acute injury to upper\n esophagus/airway\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old man with achalasia status post rigid endoscopy\n yesterday. Rule out any acute injury to esophagus or the airways.\n\n TECHNIQUE: Frontal and lateral radiographs of the chest.\n\n Comparisons were made with prior chest radiographs through ,\n with the most recent radiograph from acquired at 5:47 a.m.\n\n IMPRESSION: Since the most recent radiograph from acquired at 5:47\n a.m., there are no significant relevant changes in the lung findings. There\n is no evidence of pneumomediastinum/pneumothorax. Pleural effusion, if any,\n is minimal on the left side. Heart, mediastinal and hilar contours are\n unchanged.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203437,
"text": " 3:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check for pneumothorax or other complication of procedure\n Admitting Diagnosis: DYSPHAGIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with episode of difficulty swallowing, now post rigid\n endoscopy and balloon dilation of upper esophagus/crichopharyngeus.\n REASON FOR THIS EXAMINATION:\n check for pneumothorax or other complication of procedure\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluation for pneumothorax after endoscopy and balloon dilation of\n the esophagus.\n\n COMPARISON: Film from dated \n\n FINDINGS: Single portable frontal view of the chest shows an apparent\n widening of the mediastinum. This is concerning for postoperative\n pneumomediastinum. There is air seen superior to the left main stem bronchus\n which was also seen in the previous film. No pneumothorax or pleural\n effusion. Heart size is large.\n\n IMPRESSION: Widening of the mediastinum. Followup within one to two hours\n with a PA and lateral film is recommended.\n\n These findings were discussed with the covering ENT and ICU teams at the time\n of this dictation by telephone.\n\n"
},
{
"category": "ECG",
"chartdate": "2175-09-28 00:00:00.000",
"description": "Report",
"row_id": 250690,
"text": "Atrial fibrillation with rapid ventricular response. Delayed R wave\ntransition. Non-specific ST-T wave abnormalities. No previous tracing\navailable for comparison.\n\n"
}
] |
28,549 | 199,987 | He was admitted to the Trauma Service. Orthopedics was consulted urgently due to his multiple fractures. he was taken to the operating room on for repair of his injuries and placement of an IVC filter because of high for pulmonary embolus because of the long bone fractures. There were no intraoperative complications. The Pain service was also consulted for epidural catheter placement for managing his multiple rib fractures; the catheter was placed without any complications. He also underwent an ECHO and his CK-MB and troponin were cycled and were negative. He remained in the Trauma ICU for several days and was the transferred to the regular nursing unit. Thoracic surgery was consulted given the left hemothorax, he was taken to the operating room on for a VATS procedure. There were no complications. His left chest tube remained in place for several days following this and was eventually removed. Pain control was ongoing throughout his hospital stay. Once the epidural was removed he was placed on long acting narcotics with shorter acting ones for breakthrough pain. Neurontin was also added to his pain regimen. An aggressive bowel routine was initiated. Physical therapy was also consulted and have recommended acute rehab after hospital stay. | There is moderate left apical pleural thickening without appreciable pneumothorax, which was seen on the concurrently obtained CT torso. Size of the left pneumothorax is essentially unchanged and appears to be limited to the apex. 3 X OR DRESSINGS TO HIP AND ABDOMEN INTACT WITHOUT SOAKAGE. Left communinuted acetabular fracture with pelvic free fluid. Left communinuted acetabular fracture with pelvic free fluid. Minimal atherosclerotic calcification of the left coronary artery and aortic annulus is seen. Mild right lower lobe and retrocardiac atelectasis. IMPRESSION: Apical pneumothorax unchanged. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Aortic valve not well seen.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Tricuspid valve not well visualized.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The mitral valve appears grossly normal with trivialmitral regurgitation. Overall normal cavity sizes withexcellent biventricular systolic function. Minimal anterior ethmoidal mucosal thickening is noted. SINGLE PORTABLE TRAUMA VIEW OF THE PELVIS: There is an abnormal appearance of the left hip and acetabulum with a medial position of the femoral head. TECHNIQUE: Non-contrast head CT. Multiple displaced left rib fractures extending the full length of the hemithorax grossly unchanged. Left pleuraleffusion.Conclusions:The left atrium and right atrium are normal in cavity size. There is minimal atelectasis at the right lung base. Left posterior and right mid inferior pubic rami demonstrate minimally displaced fractures with extension of the left sided inferior ramus fracture into the ischium. HAEMOVAC INTACT WITH MODERATE BLOODYT DRAINAGE. Mild periportal edema is noted. Right ventricular function.Height: (in) 75Weight (lb): 185BSA (m2): 2.12 m2BP (mm Hg): 126/68HR (bpm): 54Status: InpatientDate/Time: at 15:09Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:No parasternal views available. There is a small left and moderate right pleural effusion with a fluid level on the right in the setting of right basilar pleural air can not be excluded. Incidental deformity of the left thyroid laminar cartilage is noted. A tiny marginal osteophyte is noted at the medial tibial femoral compartment. The right chest wall is incompletely imaged. The partially visualized right maxillary sinus is completely opacified. Left acetabulum/pelvic fractures. Left lower lobe is probably collapsed, also stable. A comminuted left acetabular fracture is present with some internal displacement of the fractured acetabulum. There is also a right superior ramus and a comminuted left superior ramus fracture without diastasis of the symphysis. no coverage on riss.has bilateral incision on lower quads with hemovac draining mod amounts of sanguinous draininge.a/p continue to encourage pulmonary hygiene . Small right pleural effusion has decreased in size. There is moderate central canal narrowing with a posterior disc osteophyte complex causing mild thecal sac indentation at C4-C5 and to a lesser degree, at C5-C6 level. The aortic contour is well defined without aneurysm or dissection. There is no pericardial effusion.IMPRESSION: Suboptimal image quality. KPHOS TO BE REPLETED THIS AM.RESP: LS REMAIN CLEAR WITH DIMINISHED LLL. Moderate left pleural effusion which is suggestive of hemothorax. The right lung is clear except for linear atelectasis at the base. diluadid x 2mg total for extreme discomfort @ 1200.a: pt hemodynamically stable. EPIDURAL IN PLACE AND PT USING PCA WELL.CV: HR SR 70'S. NO MOVEMENT OVERNIGHT.SKIN: TRACTION TO L LEG. UpdateSee careview for details...Neuro: Pt 3, MAE, epidural in place and using PCA, good pain controlCV: NSR, occas PVC's noted later in the day,AM lytes WNL's, BP stable, afebrile, good CSM to LE'sResp: lungs clear in AM, tol O2 2lnc, at 1400 sats decreased to 80's, no distress noted, alb/atrovent neb given, sats 99% but slowly dropping after Tx, lungs clear with some wheezes noted, Dr notified, CXR done, O2 changed to OFM at 40%, tol well with sats 96-98%, encouraged to cough and deep breath, using IS frequentlyGI: taking ice chips, 1 episode of nausea, no vomiting, Zofran given with good results, no BMGU: amber urine via foley, 15-20cc/hr, Dr notifiedSkin: traction pin area dry, no redness or dng, cleansed with NS and DSD applied10 lbs traction added by Ortho, pelvic x-ray donePlan: Monitor Resp status, pain control, plan for OR Monday, ECHO ordered afebrile 97.2. currently pain free.p: OR tomorrow for lt hip + IVC filter. IMPRESSION: Stable small left pleural effusion. Otherwise, the bilateral common femoral veins, superficial femoral veins, and popliteal veins demonstrate normal compressibility, respiratory variation and augmentation. Abd soft slightly distended since am. Left-sided apically oriented chest tube is in unchanged position. Sensation adequate to lt leg.Resp: noted to have episodes of sleep apnea. Cardiomediastinal silhouette and hilar contours are unchanged. The cardiomediastinal silhouette and hilar contours are unchanged. The femoral head remains displaced inwards. CXR done this amRENAL: LR @ 80cc/hr, urine output adequate, lytes wnlGI: taking sips of water, on protonix, belly with + bowel soundsHeme: hct stable, venodynes in use.ID: temp low, on now antibiotics.musculoskeletal: L leg in 25# of skeletal traction. Has epidural of 0.1%bipuvicaine running @ 8cc/hr and using pca dilaudid for pain control. admission to TSICU for pain mgmt, pulmnary hygiene, epidural catheter placement, and skeletal traction placement.N: Pt remains fully alert and oriented to time, place and situation, PERRLA, symmetrical face, equal strength throughout with exception of L LE (due to injury), PCA with hydromorphone and PCA with bupivicaine infusion.CV: Palp pedal pulses with freq pulse check to L LE, NSR with some mild ventricular ectopy and x 2 bouts of PSVT, stable blp with one episode of hypotension due to epidural infusion, PIV's for access.Resp: Weak cough, limited by pain---> improved after epidural placed at T8, clear breathsounds in the upper lobes and diminished breathsounds in the lower lobes, oxygen saturations > 92% on nasal connular O2.GI: Soft abdomen with active bowel sounds and mild tenderness upon palpation in the R UQ and LQ.GU: foley with adequate urine output and electrolytes WNL's.Endo: Elevated blood sugars, pending insulin sliding scale.Social: Strong family support from wife and children.Skin: Small superficial abrasions remain from accident and L skeletal traction pin sites covered with dry sterile dressing.MS: Bed rest with L LE skeletal traction until surgery is performed.Plan: To OR for fixation of acetabular fracture, pulmonary hygiene and pain mgmt while in ICU, clear neck and d/c cervical collar, d/c traction after fixation. | 33 | [
{
"category": "Echo",
"chartdate": "2175-05-22 00:00:00.000",
"description": "Report",
"row_id": 63301,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 75\nWeight (lb): 185\nBSA (m2): 2.12 m2\nBP (mm Hg): 126/68\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 15:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nNo parasternal views available. Patient in severe pain. Scanned supine.\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Aortic valve not well seen.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Left pleural\neffusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size, and global systolic function are normal\n(LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Right ventricular chamber size and free\nwall motion are normal. The aortic valve is not well seen. No definite aortic\nregurgitation is seen. The mitral valve appears grossly normal with trivial\nmitral regurgitation. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Overall normal cavity sizes with\nexcellent biventricular systolic function. No definite valvular pathology\nidentified (suboptimal views).\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-05-22 00:00:00.000",
"description": "Report",
"row_id": 1634457,
"text": "npn. 1300-1900\n\nreceived back from OR @ 1300 s/p ivc filter placement and repair of acetablular fracture.pt extubated bit sleepy requiring frequent stimulation.to remain awake. recovered from anaesthesia by 2pm approx. placed on tent mask 40% with o2sats 94-98% rr 8-22\nreceived 2500 mls crystalloid hct 24% intraop received prbcx2 with 500 mls cell hct at 4pm 30%.also received 10 mgs decadron intraop required neo for majority of case then received 30 mgs esmolol at end of case.feet warm with palp pulsed and pos sensation.\nepidural remains in place also has hydromorphone pca with tylenol po atc. pain with activity.\n\nros; neuro aoox3 mae to command mae to command lt leg slighly less.than rt.perla 3mm asking appropriate questions.\n\nres; lungs clear to coarse diminshed at bases encouraged to cdb\nrr 15-20 sats 96-100% on 50 5 face tent dropps to 78-85 on r.a.\n\ncvs; tmax 97.6 po nsr 98-110 with isolated pvc's bp 103-120/79\n\ngu; min u/o receiving lr at 80 mls/hr until taking adequate po.\nalso has kphos running over 6 hours will complete around 7 pm. with u/o improved to 60-80 mls/hr. currently.\n\ngi; belly soft pos bs taking small amount of po fluids.no stool no flatus.may advance to regular diet. no coverage on riss.\n\nhas bilateral incision on lower quads with hemovac draining mod amounts of sanguinous draininge.\n\na/p continue to encourage pulmonary hygiene . continue to monitor pain increase activity and diet as ordered.\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-05-23 00:00:00.000",
"description": "Report",
"row_id": 1634458,
"text": "1900-0700\nSEE CAREVUE FOR ASSESSMENT AND VITALS SIGNS.\n\nNEURO: A&O X3. NO NEUROLOGICAL DEFICTS. EPIDURAL/PCA/PO MEDS FOR ANALGESIA WORKING WELL.\n\nCV: HR SR 80-97. SBP 95-130. NO ECTOPY.\n\nRESP: 02 SATS MAINTAINED >95% USING EITHER NC4L OR HUMIDIFIED FACETENT DEPENDENT ON PT PREFERENCE AND ACTIVITY LEVEL. LS CLEAR WITH SLIGHTLY DIMINISHED BASES. NON PRODUCTIVE COUGH. C&DB DONE WELL.\n\nGI/GU: LR CONTINUES @ 80ML/HR. ATE SOME SOUP LAST EVENING AND IS TOLERATING LIQUIDS WELL. REGULAR DIET AS TOLERATED. PT HAS AN APPETITE. FOLEY DRAINING AMBER URINE >40ML/HR.\n\nSKIN: FREQUENT POSITION CHANGES OVERNIGHT FOR SKIN PROTECTION AND PT COMFORT. PINK AREA TO COCCYX INTACT AND UNCHANGED. 3 X OR DRESSINGS TO HIP AND ABDOMEN INTACT WITHOUT SOAKAGE. HAEMOVAC INTACT WITH MODERATE BLOODYT DRAINAGE. REMAINING SKIN INTACT. FOR PT TODAY AND OOB WITH ASSIST.\n\nPAIN: EPIDURAL/PCA/TORADOL/TYLENOL WORKING WELL FOR ANALGESIA. OCCASIONAL BURNING PAIN TO RIB FRACTURE AREA. ABLE TO TAKE DEEP BREATHS WITH MINIMAL DISCOMFORT. HIP ACHE BEARABLE.\n\nSOCIAL: NO CONTACT FROM FAMILY OVERNIGHT.\n\nPLAN: CONTINUE TO MONITOR/TREAT PAIN.\n OOB WITH PT ASSIST.\n ? TX TO FLOOR.\n REHAB SCREENING.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017641,
"text": " 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change in pneumothorax\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with L. pneumothorax and multiple left rib fractures\n REASON FOR THIS EXAMINATION:\n interval change in pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Multiple left rib fractures. No pneumothorax. Evaluate\n for worsening.\n\n CHEST: Right and left rib fractures are again seen. Size of the left\n pneumothorax is essentially unchanged and appears to be limited to the apex.\n\n IMPRESSION: Apical pneumothorax unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-19 00:00:00.000",
"description": "LP KNEE( (SINGLE VIEW) LEFT PORT",
"row_id": 1017488,
"text": " 9:13 PM\n KNEE( (SINGLE VIEW) LEFT PORT; -76 BY SAME PHYSICIAN # \n Reason: s/p pinning for acetabular fracture. confirming appropriate\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with left acetabular fx with recent pinning\n REASON FOR THIS EXAMINATION:\n s/p pinning for acetabular fracture. confirming appropriate placement prior to\n traction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with left acetabular fracture with recent pinning\n status post pinning for acetabular fracture, please confirm placement.\n\n COMPARISON: at 6:56 p.m.\n\n BEDSIDE AP RADIOGRAPH OF THE KNEE AT 9:10 P.M.: There is an interval\n placement of the traction device projected over the distal femoral\n metadiaphysis. No other interval changes.\n\n IMPRESSION: Interval placement of a traction device projecting over the\n distal femoral metadiaphysis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1018336,
"text": " 2:41 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for reaccumulation/chest tube placement/ptx\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p VATS for hemothorax n/w chest tube\n REASON FOR THIS EXAMINATION:\n please evaluate for reaccumulation/chest tube placement/ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB 4:27 PM\n No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST X-RAY :\n\n COMPARISON: .\n\n INDICATION: Chest tube.\n\n Left-sided chest tube is in place with no evidence of pneumothorax. Small\n left pleural effusion is not substantially changed. Small right pleural\n effusion has decreased in size. Cardiomediastinal contours are within normal\n limits. Worsening left basilar atelectasis is present in the retrocardiac\n region. Multiple bilateral rib fractures are again evident.\n\n IMPRESSION: No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-20 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 1017532,
"text": " 8:35 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: acet fx, s/p traction\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with\n REASON FOR THIS EXAMINATION:\n acet fx, s/p traction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acetabular fracture, status post traction.\n\n PELVIS.\n\n There are no previous films available for comparison. A comminuted left\n acetabular fracture is present with some internal displacement of the\n fractured acetabulum. The femoral head is shifted medially.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1017457,
"text": " 4:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb FRI 5:34 PM\n no acute intracranial process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old status post motor vehicle collision, evaluate.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, masses, mass effect\n or shift of normally midline structures. The ventricles and sulci are mildly\n prominent appropriate for age-associated involutionary changes. There are no\n acute major vascular territorial infarcts. The osseous and soft tissue\n structures are unremarkable. Minimal anterior ethmoidal mucosal thickening is\n noted. The partially visualized right maxillary sinus is completely\n opacified.\n\n IMPRESSION: No acute intracranial process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-19 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1017458,
"text": " 4:39 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb FRI 5:42 PM\n No acute fractures of the cervical spine\n non displaced, left second rib posterolateral fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man status post motor vehicle collision, evaluate for\n fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast helical CT acquisition of the cervical spine with\n multiplanar reformations.\n\n FINDINGS: There are no acute fractures or alignment abnormalities of the\n cervical spine. There is a non-displaces hairline fracture of the left second\n posterolateral rib. There is multilevel degenerative disease with exaggerated\n kyphosis and grade 1 retrolistheses of C4 on C5 and C5 on C6. There is\n moderate central canal narrowing with a posterior disc osteophyte complex\n causing mild thecal sac indentation at C4-C5 and to a lesser degree, at C5-C6\n level. There is severe left neural foraminal narrowing at C2-C3, C3-C4, and\n C4- C5 levels.\n\n There is no pre- or paravertebral soft tissue abnormality. Incidental\n deformity of the left thyroid laminar cartilage is noted. There is moderate\n left apical pleural thickening without appreciable pneumothorax, which was\n seen on the concurrently obtained CT torso. The right maxillary sinus is\n completely opacified. The left maxillary sinus is excluded from the field of\n view.\n\n IMPRESSION:\n 1. Nondisplaced second left posterolateral rib fracture.\n 2. No acute fractures or alignment abnormalities of the cervical spine.\n 3. Severe degenerative disease with significant central canal narrowing\n causing thecal sac indentation at C4-C5 and severe left neural foraminal\n narrowing at C2-C3, C3-C4, C4-C5.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-19 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1017459,
"text": " 4:40 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for injury\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p mvc\n REASON FOR THIS EXAMINATION:\n eval for injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb SAT 1:46 AM\n multiple left sided rib fractures many of which are segmental.\n medial small pneumothorax with two other smaller lateral and paramediastinal\n components of small loculations of air.\n\n Left communinuted acetabular fracture with pelvic free fluid.\n\n Multiple other plevic fractures, including bilateral inferior and superior\n pubic rami fractures.\n WET READ VERSION #1 PXDb FRI 5:56 PM\n multiple left sided rib fractures many of which are segmental.\n medial small pneumothorax with two other smaller lateral and paramediastinal\n components of small loculations of air.\n\n Left communinuted acetabular fracture with pelvic free fluid.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man status post motor vehicle collision. Evaluate\n for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical CT acquisitions from the top of the lungs to pubic\n symphysis after administration of intravenous contrast. Multiplanar\n reformations were generated.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There is no axillary or\n mediastinal adenopathy. There is no mediastinal hemorrhage. The aortic\n contour is well defined without aneurysm or dissection. The heart and the\n great vessels are unremarkable, without pericardial effusion. The coronary\n arteries are well opacified with moderate amount of left anterior descending\n artery calcification. There is a calcified right hilar lymph node. Lung\n windows demonstrate a small loculated pneumothorax at the superomedial aspect\n of the left lung with two smaller pockets of loculated air in the lateral and\n paravertebral aspects of the LUL and LLL respectively. Additionally there is\n LLL focal consolidation in subpleural aspects, part of which could be\n atelectasis, however, in the setting of multiple rib fractures, pulmonary\n contusion cannot be excluded. There is minimal atelectasis at the right lung\n base. There is no pleural effusion. The tracheobronchial tree is patent to\n the subsegmental level. Minimal ground-glass opacity at the left lower lobe\n (Over)\n\n 4:40 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for injury\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n (2:35) could reflect focal pneumonitis. There is mild lingular scarring.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There is no intraperitoneal free\n fluid or free air. There is no evidence of traumatic injury to the solid\n visceral organs. Mild periportal edema is noted. Otherwise the liver,\n gallbladder, kidneys, adrenals, spleen, stomach, and intra-abdominal bowel\n loops are within normal limits. There is no mesenteric or retroperitoneal\n adenopathy.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon,\n urinary bladder, intrapelvic bowel loops are unremarkable. There is trace\n amount of pelvic free fluid. No pelvic or inguinal adenopathy.\n\n OSSEOUS STRUCTURES: There are multiple segmental left-sided rib fractures.\n The left second to eleventh ribs demonstrate posterolateral fractures with\n additonal fractures in, at least, the fifth to ninth ribs, anterolaterally.\n There is a markedly comminuted left acetabular fracture involving both the\n anterior and posterior columns with extension into the intervening\n quadrilateral plate. It is markedly distracted with approximately 1.6 cm of\n distraction of the fractured anterior column.\n\n Left posterior and right mid inferior pubic rami demonstrate minimally\n displaced fractures with extension of the left sided inferior ramus fracture\n into the ischium. There is also a right superior ramus and a comminuted left\n superior ramus fracture without diastasis of the symphysis. The remainder of\n bilateral iliac bones are intact. The sacral ala and the sacral arcuate lines\n are intact.\n\n IMPRESSION:\n 1. Multiple left-sided rib fractures, with small multiloculated left\n pneumothorax and LLL subpleural opacity, could reflect pulmonary contusion in\n this setting.\n\n 2. Multiple pelvic fractures and communited left acetabular fracture, as\n described above. Trace amount of pelvic free fluid.\n\n 3. No other solid organ injury.\n\n Findings were discussed with Dr. (Trauma Surgery) and Dr. \n (Orthopedic Surgery).\n (Over)\n\n 4:40 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for injury\n Field of view: 38 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1018660,
"text": " 2:44 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p Left chest tube removal\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n WET READ: PXDb SAT 3:23 PM\n No left pneumothorax, s/p chest tube removal. multiple rib fractures. There is\n a small left and moderate right pleural effusion with a fluid level on the\n right in the setting of right basilar pleural air can not be excluded. Mild\n right lower lobe and retrocardiac atelectasis. Discussed with Dr..\n\n , R1\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, .\n\n COMPARISON: .\n\n INDICATION: Left chest tube removal.\n\n Following left-sided chest tube removal, a small left apicolateral\n pneumothorax has developed, as communicated by phone to Dr. on , , at 5:00 p.m. Improving aeration at both lung bases with some\n residual atelectasis predominantly in the left retrocardiac region. Small\n pleural effusions are present bilaterally, and multiple bilateral rib\n fractures are again demonstrated, left greater than right.\n\n IMPRESSION: New small left apicolateral pneumothorax following left-sided\n chest tube removal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-19 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1017454,
"text": " 4:30 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old male with trauma.\n\n COMPARISON: None available.\n\n SINGLE TRAUMA VIEW OF THE CHEST: Multiple left lateral rib fractures are\n identified. There is no evidence of pneumothorax. The cardiomediastinal\n contour is normal. The heart is not enlarged. The lungs are clear. The\n right chest wall is incompletely imaged. There is an S-shaped scoliosis of\n the thoracolumbar spine, right convex.\n\n SINGLE PORTABLE TRAUMA VIEW OF THE PELVIS: There is an abnormal appearance of\n the left hip and acetabulum with a medial position of the femoral head. There\n are fractures of the left pelvis which are better assessed on CT. Bowel gas\n obscures osseous detail of the sacrum and limits detection for additional\n fractures.\n\n IMPRESSION:\n\n 1. Multiple left lateral rib fractures.\n 2. Left acetabulum/pelvic fractures. Please refer to subsequently performed\n CT torso for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-23 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1017971,
"text": " 1:06 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess L. pleural effusion vs. hemothorax\n Admitting Diagnosis: BLUNT TRAUMA\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with L. pleural effusion vs. L. hemothorax\n REASON FOR THIS EXAMINATION:\n assess L. pleural effusion vs. hemothorax\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast on .\n\n COMPARISON: None similar. Multiple previous chest radiographs between and .\n\n TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to\n the subdiaphragmatic area without contrast. Thinner slice 5 mm and 1.25 mm\n images were reconstructed in the axial plane on different window algorithms.\n Sagittal/coronal reformatted images were also obtained for further evaluation.\n\n HISTORY: 72-year-old man with left pleural effusion versus left hemothorax.\n\n FINDINGS: The patient is status post trauma and multiple fractures involving\n the left rib cage and three fractures involving the right rib cage. There is\n a moderate left hemothorax with Hounsfield unit higher than simple fluid\n indicating breaking blood products. Adjacent ipsilateral left lower lobe\n atelectasis is seen. A small right pleural effusion is also noted. In the\n right upper lobe two focal areas of opacity indicative of pulmonary contusions\n are visualized.\n\n The heart is normal in size. There is no pericardial effusion. Minimal\n atherosclerotic calcification of the left coronary artery and aortic annulus\n is seen. There are no pathologically enlarged lymph nodes in the mediastinum\n or hila according to CT size criteria. There are two calcified right hilar\n lymph nodes.\n\n The limited evaluation of the abdomen shows no abnormality.\n\n IMPRESSION:\n 1. Left moderate hemothorax with adjacent multiple rib fractures, some of\n which are displaced.\n 2. Three right rib fractures with a small right pleural effusion.\n 3. Two focal areas of right upper lobe pulmonary contusions.\n\n\n\n\n\n (Over)\n\n 1:06 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess L. pleural effusion vs. hemothorax\n Admitting Diagnosis: BLUNT TRAUMA\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-19 00:00:00.000",
"description": "L KNEE (2 VIEWS) LEFT",
"row_id": 1017474,
"text": " 7:00 PM\n KNEE (2 VIEWS) LEFT Clip # \n Reason: eval for fracture prior to pinning\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with L acetabular , need traction pin\n REASON FOR THIS EXAMINATION:\n eval for fracture prior to pinning\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with left acetabular fracture, will need traction\n pin, evaluate prior to pinning.\n\n COMPARISON: None.\n\n LEFT KNEE, TWO VIEWS: There are no acute fractures or alignment\n abnormalities. There are no lytic or sclerotic osseous lesions. A tiny\n marginal osteophyte is noted at the medial tibial femoral compartment.\n Atherosclerotic vascular calcifications are noted. The rest of soft tissues\n are unremarkable.\n\n IMPRESSION: No acute fractures or alignment abnormalities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017567,
"text": " 1:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for low o2 sats\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with multiple left rib fx and small ptx, now with worsening o2\n sats\n REASON FOR THIS EXAMINATION:\n eval for low o2 sats\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Multiple rib fractures and small pneumothorax, now with\n worsening sats.\n\n CHEST:\n\n There is no evidence of worsening of the pneumothorax. No evidence of failure\n or other infiltrates present. Multiple rib fractures are again noted.\n\n IMPRESSION: No evidence of increasing pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-22 00:00:00.000",
"description": "L LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT",
"row_id": 1017811,
"text": " 12:15 PM\n PELVIS W/JUDET VIEWS (3V) IN O.R.; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFTClip # \n Reason: ORIF PELVIS\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture.\n\n 16 intraoperative fluoroscopic views of the left hip were obtained without a\n radiologist present. These demonstrate successive steps of left acetabular\n reconstruction. For additional details, please consult the operative report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1017916,
"text": " 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change from \n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with L. pleural effusion s/p MVC and multiple L. rib fx\n REASON FOR THIS EXAMINATION:\n assess for interval change from \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:16 A.M. ON \n\n HISTORY: Left pleural effusion after motor vehicle accident and multiple left\n rib fractures.\n\n IMPRESSION: AP chest compared to and 16:\n\n Moderate-to-large left pleural effusion is probably unchanged since at\n 1:16 p.m., having enlarged since . Multiple displaced left rib\n fractures extending the full length of the hemithorax grossly unchanged. Left\n lower lobe is probably collapsed, also stable. Cardiomediastinal silhouette\n is unremarkable. Right lung is grossly clear. There may be a tiny right\n pleural effusion. No pneumothorax is present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-22 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1017730,
"text": " 12:29 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: FRACTURED PELVIS,R/O DVT, PRE IVC FILTER\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72M s/p mvc with long bone fracture\n REASON FOR THIS EXAMINATION:\n mapping for IVC filter ?DVT\n ______________________________________________________________________________\n WET READ: DXAe MON 3:10 AM\n NO evidence of DVT.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 70-year-old male status post MVC with long bone\n fracture.\n\n COMPARISON: None.\n\n BILATERAL LOWER EXTREMITY DVT: -scale, color flow and Doppler images of\n both lower extremity veins was performed. The left popliteal vein could not\n be evaluated. Otherwise, the bilateral common femoral veins, superficial\n femoral veins, and popliteal veins demonstrate normal compressibility,\n respiratory variation and augmentation. Incidentally noted is duplication of\n the proximal and mid left superficial femoral veins and the right superficial\n femoral vein distally.\n\n IMPRESSION: No evidence of DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1018337,
"text": ", M. CC6A 2:41 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for reaccumulation/chest tube placement/ptx\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p VATS for hemothorax n/w chest tube\n REASON FOR THIS EXAMINATION:\n please evaluate for reaccumulation/chest tube placement/ptx\n ______________________________________________________________________________\n PFI REPORT\n No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018149,
"text": " 1:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for pneumothorax\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with s/p L VATS evacuation of hemothorax, L ct placed\n REASON FOR THIS EXAMINATION:\n please assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with VATS, evacuation of the hemothorax and the\n left chest tube placement.\n\n Comparison is made to the prior chest radiograph of .\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: The patient is status post left\n chest tube placement with interval resolution of the left pleural effusion. No\n pneumothorax. The right lung is clear except for linear atelectasis at the\n base. Cardiomediastinal silhouette and hilar contours are unchanged. Spinal\n epidural device is in place.\n\n IMPRESSION: Status post left chest tube removal with complete resolution of\n the left pleural effusion. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-26 00:00:00.000",
"description": "PELVIS (AP ONLY)",
"row_id": 1018502,
"text": " 1:26 PM\n PELVIS (AP ONLY) Clip # \n Reason: please eval postop\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p left acetabular repair\n REASON FOR THIS EXAMINATION:\n please eval postop PLEASE DO STANDING WITH CRUTCHES\n ______________________________________________________________________________\n FINAL REPORT\n AP PELVIS, \n\n HISTORY: 72-year-old man with acetabular fracture status post repair.\n\n FINDINGS: Comparison is made to intraoperative study from .\n\n There is fracture plate in the left hemipelvis across the iliopectineal line.\n Surgical skin staples are seen projecting over the pubic symphysis and\n laterally over the iliac crest on the left side. Irregularity of the\n acetabulum on the left is also seen. There is a fracture seen of the right\n superior and inferior pubic rami. No hardware related complications are seen.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018441,
"text": " 8:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for reaccumulation of hemothorax or new ptx\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p vats for L hemothorax - CT now to water seal\n REASON FOR THIS EXAMINATION:\n Please evaluate for reaccumulation of hemothorax or new ptx\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 72-year-old male status post VATS for left hemothorax. Chest\n tube now to waterseal.\n\n COMPARISON: .\n\n FINDINGS: There is no significant change to the appearance of the chest. A\n small left effusion is stable. No pneumothorax detected. Cardiomediastinal\n silhouette is stable. Left-sided apically oriented chest tube is in unchanged\n position. Numerous acute left lateral rib fractures are again noted.\n\n IMPRESSION: Stable small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-22 00:00:00.000",
"description": "CHEST FLUORO WITHOUT RADIOLOGIST",
"row_id": 1017771,
"text": " 9:00 AM\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: IVC FILTER PLACEMENT\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: IVC filter placement.\n\n Single view obtained during fluoroscopy was brought to our review,\n demonstrating part of the pelvis most likely on the left. This field of view\n is too narrow for precise delineation. No radiopaque object suggesting\n indwelling devices were demonstrated on the current film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1017817,
"text": " 1:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: check filter\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with IVC filter just placed\n REASON FOR THIS EXAMINATION:\n check filter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with IVC filter placement.\n\n Comparison is made to the prior radiograph of .\n\n Findings: The IVC filter has not been included on this chest radiograph. The\n spinal stimulator device is unchanged in position. The cardiomediastinal\n silhouette and hilar contours are unchanged. There is interval increase in\n the left pleural effusion which is now moderate to severe in degree suggesting\n the presence of hemothorax. Atelectatic changes are noted at the left lung\n base. There are also signs of volume overload. No pneumothorax. Multiple\n bilateral rib fractures are noted.\n\n IMPRESSION:\n 1. The IVC filter has not been included on the radiograph.\n 2. Moderate left pleural effusion which is suggestive of hemothorax.\n 3. Unchanged multiple bilateral rib fractures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-05-20 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 1017574,
"text": " 2:18 PM\n PELVIS (AP ONLY) PORT; -76 BY SAME PHYSICIAN # \n Reason: 25lbs traction\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with\n REASON FOR THIS EXAMINATION:\n 25lbs traction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Fracture of left pelvis on traction, evaluate for change in\n position.\n\n There has been no significant change in the position of the fractured left\n pelvis. The femoral head remains displaced inwards.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-05-20 00:00:00.000",
"description": "Report",
"row_id": 1634452,
"text": "Update\nSee careview for details...\nNeuro: Pt 3, MAE, epidural in place and using PCA, good pain control\n\nCV: NSR, occas PVC's noted later in the day,AM lytes WNL's, BP stable, afebrile, good CSM to LE's\n\nResp: lungs clear in AM, tol O2 2lnc, at 1400 sats decreased to 80's, no distress noted, alb/atrovent neb given, sats 99% but slowly dropping after Tx, lungs clear with some wheezes noted, Dr notified, CXR done, O2 changed to OFM at 40%, tol well with sats 96-98%, encouraged to cough and deep breath, using IS frequently\n\nGI: taking ice chips, 1 episode of nausea, no vomiting, Zofran given with good results, no BM\n\nGU: amber urine via foley, 15-20cc/hr, Dr notified\n\nSkin: traction pin area dry, no redness or dng, cleansed with NS and DSD applied\n\n10 lbs traction added by Ortho, pelvic x-ray done\n\nPlan: Monitor Resp status, pain control, plan for OR Monday, ECHO ordered\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-05-21 00:00:00.000",
"description": "Report",
"row_id": 1634453,
"text": "T/SICU Nursing Progress Note 3am-7am\nS: \"I have a burning pain on the left side of my back\"\nO: Review of systems\nNeuro: pt. sleeping in naps. Oriented X 3. Has epidural of 0.1%bipuvicaine running @ 8cc/hr and using pca dilaudid for pain control. Falls asleep and upon awakening c/o pain in L back and chest. Also c/o L hip pain with turning. Encouraged to use pca more frequently.\nCVS: stable heart rate and rhythm, pulse present\nRESP: on 50% face tent and 4l np with sats 94-99%. At times when asleep has 4-5sec periods of apnea. Lung fields essentially clear. Nonproductive cough. Received atrovent nebs q 6 hours. Coughs with encouragement. CXR done this am\nRENAL: LR @ 80cc/hr, urine output adequate, lytes wnl\nGI: taking sips of water, on protonix, belly with + bowel sounds\nHeme: hct stable, venodynes in use.\nID: temp low, on now antibiotics.\nmusculoskeletal: L leg in 25# of skeletal traction. Pin sites with small amount of bloody drainage.\nSKIN: coccyx reddened, pt having difficulty tolerating side lying positions.\nLInes: pt with 2 peripheral ivs.\nA: 74 year old man s/p mvc with blunt chest injury and multiple broken ribs and fx L hip. Insufficient pain control at present\nP: to or tomorrow for hip repair and ivc filter.\n??adding oxycodone po for pain control\nContinue meticulous pulmonary hygiene\nAdvance diet today.\nAdd bowel regimen\nContinue to offer psychosocial support\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-05-20 00:00:00.000",
"description": "Report",
"row_id": 1634451,
"text": "Admission Note:\n\nPt is 72 yo male admitted via EMS from a MVA in , MA. Pt was struck on the drivers side which resulted in a prolonged extrication, EMS sent pt to , scans performed and revealed L comminuted acetabular fracture, multiple L sided rib fractures, and a small L sided pneumothorax. admission to TSICU for pain mgmt, pulmnary hygiene, epidural catheter placement, and skeletal traction placement.\n\nN: Pt remains fully alert and oriented to time, place and situation, PERRLA, symmetrical face, equal strength throughout with exception of L LE (due to injury), PCA with hydromorphone and PCA with bupivicaine infusion.\n\nCV: Palp pedal pulses with freq pulse check to L LE, NSR with some mild ventricular ectopy and x 2 bouts of PSVT, stable blp with one episode of hypotension due to epidural infusion, PIV's for access.\n\nResp: Weak cough, limited by pain---> improved after epidural placed at T8, clear breathsounds in the upper lobes and diminished breathsounds in the lower lobes, oxygen saturations > 92% on nasal connular O2.\n\nGI: Soft abdomen with active bowel sounds and mild tenderness upon palpation in the R UQ and LQ.\n\nGU: foley with adequate urine output and electrolytes WNL's.\n\nEndo: Elevated blood sugars, pending insulin sliding scale.\n\nSocial: Strong family support from wife and children.\n\nSkin: Small superficial abrasions remain from accident and L skeletal traction pin sites covered with dry sterile dressing.\n\nMS: Bed rest with L LE skeletal traction until surgery is performed.\n\n\nPlan: To OR for fixation of acetabular fracture, pulmonary hygiene and pain mgmt while in ICU, clear neck and d/c cervical collar, d/c traction after fixation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-05-21 00:00:00.000",
"description": "Report",
"row_id": 1634454,
"text": "assessment as noted in carevue\n\n1900-3am\n\npain: c/o l/sided pain in chest wall and hip/l.pelvis, epidural was increased up to 8cc/h, remained on dilodid pca 0.25 and dilodid prn was added for turns. despite that pt still had pain while moving, sensation was intact down to L5/feet, l/leg traction remains intact\n\nvs: stable bp, in nsr with occasional PVCs and a times bigemini, cpk came back 800/700, denies chest pain or sob, on nc and coolmist 50% maintains sats100, having periods of apnea sec while asleep with dropping to 70s and recovering to 90s\n\npt encouraged deep breathing and coughing , and repositined q2h with pain control optimized, pt's care was transferreed to KP due to patient request at 3am\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-05-21 00:00:00.000",
"description": "Report",
"row_id": 1634455,
"text": "7a-7p nursing note\nsee flowsheet for details:\n\nneuro: alert & orientated. strong to all extremties.\n\ncv: sinus rhythm with rare PVC's. heart rate 80-109. Increases with pain. SBP 120-150. Puples palpable to all extremties. Sensation adequate to lt leg.\n\nResp: noted to have episodes of sleep apnea. desats to 85% at with apnea. On 50% fio2 via shuvel mask. Sao2 99% with mask. Lung sounds clear bilaterally. Diminshed to the lt lower base. Using incentive spirmetry.\n\ngi: started on bowel routine this am. No bm no flatus noted. Abd soft slightly distended since am. pt taking PO full fluids fairly well.\n\ngu: foley insitu. LR infusing @ 80ml/hr. urine output 30ml/hr.\n\ninteg: pins to lt leg. site draing scant amt of serousangious drainage. 25lbs of traction. epidural site wnl.\n\nendo: blood sugars 138-187.\n\nsocial: family in to visit.\n\nPain: pain service into see.pt every uncomfortable this am to lt chest and back. c/o burning sensation to lt chest.Epidural bupivacaine 0.1% increased @10ml/hr + bolus 5ml. Tylenol ATC + Ketorolac ATC x 3days. Using pca properly. diluadid x 2mg total for extreme discomfort @ 1200.\n\na: pt hemodynamically stable. afebrile 97.2. currently pain free.\n\np: OR tomorrow for lt hip + IVC filter. awaiting u/s dopplers of legs tonight.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-05-22 00:00:00.000",
"description": "Report",
"row_id": 1634456,
"text": "1900-0700\nSEE CAREVUE FOR ASSESSMENT AND VITAL SIGNS.\n\nEVENTS: BLE USS.\n\nNEURO: A&O X3. EPIDURAL IN PLACE AND PT USING PCA WELL.\n\nCV: HR SR 70'S. SBP 120-130. KPHOS TO BE REPLETED THIS AM.\n\nRESP: LS REMAIN CLEAR WITH DIMINISHED LLL. PT WISHED TO USE HUMIDIFIED FACETENT 02 OVERNIGHT FOR COMFORT. SATS >95% WITH JUST NC4L ON. NON PRODUCTIVE COUGH.\n\nGI/GU: PT TOLERATED DIET WELL. NOW NPO FOR OR THIS AM. FOLEY DRAINING ADEQUATE VOLUMES OF CLEAR AMBER URINE. + BOWEL SOUNDS. ON BOWEL REGIMEN. NO MOVEMENT OVERNIGHT.\n\nSKIN: TRACTION TO L LEG. PIN SITES CLEAN. MINOR BRUISING TO L HIP. COCCYX SLIGHTLY PINK BUT UNCHANGED.\n\nPAIN: BUPIVICAINE EPIDURAL, TORADOL, ACETAMINOPHEN AND DILAUDID PCA WORKING EFFECTIVELY FOR PT.\n\nSOCIAL: PT REQUESTED HIS WIFE BE CALLED T INFORM HER OF HIS OR TIME OF 0730HRS. SHE WILL BE VISITING PRIOR TO PT LEAVING FOR THE OR.\n\nPLAN: FOR OR @ 0730 FOR HIP FIX AND IVC FILTER PLACEMENT.\n REPLETE K PHOS WHEN AVAILABLE FROM PHARMACY.\n ENSURE PTS COMFORT AND SAFETY.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2175-05-24 00:00:00.000",
"description": "Report",
"row_id": 127338,
"text": "Sinus rhythm. Compared to the previous tracing of no change in\npreviously noted findings.\n\n"
},
{
"category": "ECG",
"chartdate": "2175-05-19 00:00:00.000",
"description": "Report",
"row_id": 127339,
"text": "Normal sinus rhythm. RSR' pattern in leads V1-V2. Non-specific ST-T wave\nabnormalities. No previous tracing available for comparison.\n\n"
}
] |
92,787 | 138,967 | This 18 yo M was admitted for increased seizure frequency which we felt was occurring in the context of a lowered seizure threshold secondary to recent GI illness. He was initially treated at an OSH and received a significant amount of ativan there such that he required intubation for airway protection. Thus he was initially monitored in the ICU. He was continued on his home dose lamictal (200 mg ) and started on Keppra 1000 mg , which he will continue as an outpatient at least for the short term. He remained seizure free in the hospital and his neurological exam on discharge was normal save perhaps some mild slowness of mentation/verbal responses. | .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Patient to be extubated as lungs clear, patient orientated able to obey commands. Extubated on and respiratory status wnl. Extubated on and respiratory status wnl. Response: Tolerated extubation. Action: cont EEG monitoring. Action: cont EEG monitoring. Action: cont EEG monitoring. Action: Taking clear liquids and meds po in high fowlers position. Action: Taking clear liquids and meds po in high fowlers position. Action: Taking clear liquids and meds po in high fowlers position. Action: Taking clear liquids and meds po in high fowlers position. Receiving keppra iv and lamotrigine as ordered. Receiving keppra iv and lamotrigine as ordered. Receiving keppra iv and lamotrigine as ordered. Receiving keppra iv and lamotrigine as ordered. Frequent neuro checks. Frequent neuro checks. Frequent neuro checks. .H/O seizure, with status epilepticus Assessment: Neuro no seizure noted. .H/O seizure, with status epilepticus Assessment: Neuro no seizure noted. .H/O seizure, with status epilepticus Assessment: Neuro no seizure noted. .H/O seizure, with status epilepticus Assessment: Neuro no seizure noted. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Lethargic, arousable to stimulation. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Lethargic, arousable to stimulation. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Lethargic, arousable to stimulation. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Lethargic, arousable to stimulation. Neurologically intact though speech slow, slurred and delayed, per pt. Neurologically intact though speech slow, slurred and delayed, per pt. Neurologically intact though speech slow, slurred and delayed, per pt. Patient on cpap tolerating well. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Pt was intubated from OSH for airway protection d/t seizure Action: Remains on CPAP/PS, no vent changes overnight, on propofol gtt , reduced the dose to 30mcg/kg/min Response: Pt is comfortable, sedated well, Good O 2sat, LS clear. .H/O seizure, with status epilepticus Assessment: No seizures noted. lamictal 200'', keppra 1000'', EEG monitoring, ativan for seizures, ativan Cardiovascular: hemodynamically stable Pulmonary: (Ventilator mode: CPAP + PS) Gastrointestinal / Abdomen:. f/u stool cx . Endotracheal tube is unchanged with its tip at the clavicular heads. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Pt was intubated from OSH for airway protection d/t seizure Action: Remains on CPAP/PS, no vent changes overnight, on propofol gtt , reduced the dose to 40mcg/kg/min Response: Pt is comfortable, sedated well, Good O 2sat, LS clear. Pt continues on iv keppra and po lamictal. Pt continues on iv keppra and po lamictal. Placed on NC 2l, lungs clear, weak cough. ET tube in standard location. Pt more awake now, but has slowed speech w/ some slurring Cardiovascular: allow to autoregulate Pulmonary: stable post extubation Gastrointestinal / Abdomen: diet advanced Nutrition: diet advanced Renal: Foley, Adequate UO, no issues Hematology: stable Endocrine: RISS Infectious Disease: p/w GI inf. Pserl at 3mm, lethargic, arousable to loud voice or stimulation, mae to command Action: Continuous eeg monitor in place. Pserl at 3mm, lethargic, arousable to loud voice or stimulation, mae to command Action: Continuous eeg monitor in place. Pserl at 3mm, lethargic, arousable to loud voice or stimulation, mae to command Action: Continuous eeg monitor in place. Pserl at 3mm, lethargic, arousable to loud voice or stimulation, mae to command Action: Continuous eeg monitor in place. Improving leukocytosis. Response: Lethargic, neuro exam otherwise wnl, no signs of seizure activity. Response: Lethargic, neuro exam otherwise wnl, no signs of seizure activity. Response: Lethargic, neuro exam otherwise wnl, no signs of seizure activity. Response: Lethargic, neuro exam otherwise wnl, no signs of seizure activity. Tolerating reg diet well. Tolerating reg diet well. Tolerating reg diet well. He is currently seizure free. He is currently seizure free. He is currently seizure free. He is currently seizure free. He is currently seizure free. He is currently seizure free. He is currently seizure free. These occur in the context of a recent GI infection and possible decreased absorption of lamictal. These occur in the context of a recent GI infection and possible decreased absorption of lamictal. These occur in the context of a recent GI infection and possible decreased absorption of lamictal. These occur in the context of a recent GI infection and possible decreased absorption of lamictal. These occur in the context of a recent GI infection and possible decreased absorption of lamictal. These occur in the context of a recent GI infection and possible decreased absorption of lamictal. These occur in the context of a recent GI infection and possible decreased absorption of lamictal. | 18 | [
{
"category": "Radiology",
"chartdate": "2154-12-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053408,
"text": " 3:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 18 year old man with intubated and xfr from osh\n REASON FOR THIS EXAMINATION:\n please eval for tube placement\n ______________________________________________________________________________\n WET READ: GWp SAT 6:00 PM\n Need to advance ngt 15cm (side hole in d esophagus)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 18-year-old man with intubated and transferred from outside\n hospital, please evaluate for tube placement.\n\n COMPARISON: None available.\n\n CHEST, SINGLE VIEW: An ET tube is in place with its tip 5.2 cm from the\n carina. An NG tube is seen with its tip projecting over the gastric bubble\n with its sidehole located in the distal esophagus. The heart is normal size\n and the mediastinal and hilar contours are normal. There is no focal\n consolidation, pleural effusion or pneumothorax, and pulmonary vasculature is\n normal. Osseous structures are grossly unremarkable.\n\n IMPRESSION:\n 1. Recommend advancement of NG tube by approximately 15 cm so the side hole\n is located in the stomach.\n 2. ET tube in standard location.\n\n"
},
{
"category": "Radiology",
"chartdate": "2154-12-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1053461,
"text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ngt placement\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n .HPI:The pt is an 18 year-old man with a PMH of seizures (either primary\n generalized or secondary generalized) who was transfered after having had\n multiple seizures earlier today. These occur in the context of a recent GI\n infection and possible decreased absorption of lamictal. He is currently\n seizure free. His work-up has shown a significant leukocytosis and anion gap\n which has improved on repeat labs here. He most likely has had seizrues due to\n infection and decreased medication. We will admit him for further monitoring\n and treatment and extubate once stable.\n REASON FOR THIS EXAMINATION:\n ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seizure.\n\n Single portable radiograph of the chest excludes the apices. Lungs are clear.\n No effusion. Trachea is midline. No pneumothorax is detected. Nasogastric\n tube has been repositioned and is now seen within the stomach. Endotracheal\n tube is unchanged with its tip at the clavicular heads. Trachea is midline.\n\n IMPRESSION:\n\n Support lines in place.\n\n No acute cardiopulmonary disease.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 651643,
"text": "The pt is an 18 year-old man with a PMH of seizures (either primary\n generalized or secondary generalized) who was transfered after having\n had multiple seizures on . These occur in the context of a recent\n GI infection and possible decreased absorption of lamictal. He is\n currently seizure free. Intubated in SICU for airway protection.\n Extubated on and respiratory status wnl. LS clear, sats 98-100 on\n RA.\n .H/O seizure, with status epilepticus\n Assessment:\n a&ox3, moving all extremities. Speech slow though clear. PERRL 3-4 mm.\n Neurologically intact though speech slow, slurred and delayed, per pt.\n Action:\n cont EEG monitoring. Frequent neuro checks.\n Response:\n NSS. Remains hemodynamically intact. MAE well. Tolerating reg diet\n well.\n Plan:\n Continue to closely monitor neuro signs and EEG. Provide comfort and\n support. Foley to be discontinued prior to transfer.\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 651644,
"text": "The pt is an 18 year-old man with a PMH of seizures (either primary\n generalized or secondary generalized) who was transfered after having\n had multiple seizures on . These occur in the context of a recent\n GI infection and possible decreased absorption of lamictal. He is\n currently seizure free. Intubated in SICU for airway protection.\n Extubated on and respiratory status wnl. LS clear, sats 98-100 on\n RA.\n .H/O seizure, with status epilepticus\n Assessment:\n a&ox3, moving all extremities. Speech slow though clear. PERRL 3-4 mm.\n Neurologically intact though speech slow, slurred and delayed, per pt.\n Action:\n cont EEG monitoring. Frequent neuro checks.\n Response:\n NSS. Remains hemodynamically intact. MAE well. Tolerating reg diet\n well.\n Plan:\n Continue to closely monitor neuro signs and EEG. Provide comfort and\n support. Foley to be discontinued prior to transfer.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n SEIZURE\n Code status:\n Height:\n Admission weight:\n 55 kg\n Daily weight:\n 59.2 kg\n Allergies/Reactions:\n Penicillins\n Rash;\n Precautions:\n PMH: Seizures\n CV-PMH:\n Additional history: seizures started 3 1/2yrs ago\n frequent ear infections, ear surgery\n tonsillectomy\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:131\n D:74\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 72 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,595 mL\n 24h total out:\n 930 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 03:06 AM\n Potassium:\n 3.7 mEq/L\n 03:06 AM\n Chloride:\n 110 mEq/L\n 03:06 AM\n CO2:\n 24 mEq/L\n 03:06 AM\n BUN:\n 12 mg/dL\n 03:06 AM\n Creatinine:\n 1.1 mg/dL\n 03:06 AM\n Glucose:\n 105 mg/dL\n 03:06 AM\n Hematocrit:\n 32.8 %\n 03:06 AM\n Finger Stick Glucose:\n 118\n 10:00 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: SICU A\n Transferred to: 1126\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651481,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient to be extubated as lungs clear, patient orientated able to obey\n commands.\n Action:\n Sedation turned off, patient extubated and placed on open face mask\n 40%.\n Response:\n Tolerated extubation. Placed on NC 2l, lungs clear, weak cough.\n Plan:\n Deep breathing coughing and incentive spirometer encouraged.\n .H/O seizure, with status epilepticus\n Assessment:\n No seizures noted. Patient sleepy but rouseable to speech, orientated x\n 3. Mae. perrla\n Action:\n will continue to monitor neuro checks q2, continue eeg monitoring\n response:\n Patient remains sleepy but rouseable. No seizures noted.\n Plan:\n Will continue to monitor for seizure activity. As long as patient is\n seizure free patient can transfer to floor tomorrow.\n"
},
{
"category": "Physician ",
"chartdate": "2154-12-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651651,
"text": "SICU\n HPI:\n 18 year-old man with a PMH of seizures p/w multiple seizures in context\n of recent GI illness\n Chief complaint:\n seizure\n PMHx:\n *seizures as above *numerous ear surgeries due to difficult drainage\n of his ears resulting in frequent ear infections\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:08 PM\n EXTUBATION - At 12:12 PM\n Post operative day:\n HD3\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 AM\n Famotidine (Pepcid) - 07:45 PM\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: 37.8\nC (100.1\n T current: 37\nC (98.6\n HR: 53 (52 - 96) bpm\n BP: 108/50(64) {96/40(53) - 141/84(102)} mmHg\n RR: 14 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 59.2 kg (admission): 55 kg\n Total In:\n 2,521 mL\n 509 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 2,281 mL\n 509 mL\n Blood products:\n Total out:\n 2,530 mL\n 510 mL\n Urine:\n 2,530 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n -9 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///24/\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 Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 199 K/uL\n 11.7 g/dL\n 105 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 32.8 %\n 7.3 K/uL\n [image002.jpg]\n 02:52 AM\n 03:06 AM\n WBC\n 12.3\n 7.3\n Hct\n 33.4\n 32.8\n Plt\n 205\n 199\n Creatinine\n 1.1\n 1.1\n Glucose\n 93\n 105\n Other labs: PT / PTT / INR:14.7/41.8/1.3, Ca:9.2 mg/dL, Mg:1.9 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), .H/O SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: 18 year-old man with a PMH of seizures p/w\n multiple seizures in context of recent GI illness\n Neurologic: Seizure: on lamictal 200'', added keppra 1000'', continuous\n EEG monitoring. Pt more awake now, but has slowed speech w/ some\n slurring, no recent seizures\n Cardiovascular: HD stable\n Pulmonary: stable post extubation, room air\n Gastrointestinal / Abdomen: diet advanced\n Nutrition: diet advanced\n Renal: Foley, Adequate UO, no issues\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: p/w GI inf. f/u stool cultures\n Lines / Tubes / Drains: d/c Foley\n Wounds:\n Imaging: EEG monitoring\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:52 PM\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: Transfer to floor\n Total time spent: 26 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651580,
"text": "The pt is an 18 year-old man with a PMH of seizures (either primary\n generalized or secondary generalized) who was transfered after having\n had multiple seizures earlier . These occur in the context of a\n recent GI infection and possible decreased absorption of lamictal. He\n is currently seizure free. His work-up has shown a significant\n leukocytosis and anion gap which has improved on repeat labs here. Pt\n adm to sicu intubated overnight and extubated on at 12pm w/o\n incident. Continuous eeg monitoring in progress w no signs of seizure\n activity. Pt continues on iv keppra and po lamictal. Bradycardic to\n 48-80 w sbp stable at > 95 systolic.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Lethargic, arousable to stimulation. Oriented x 3. Mae to command,\n lifts and holds all extremeties. Gag intact.\n Action:\n Taking clear liquids and meds po in high fowlers position. O2 sats\n stable on rm air.\n Response:\n Requires stimulation to become more fully awake. Tolerates po liquids\n well ,sitting in high fowlers position.\n Plan:\n High fowlers position when taking any po\ns to minimize risk aspiration.\n Monitor for partial airway obstruction, keep hob > 30-45 and continue\n to monitor sats.\n .H/O seizure, with status epilepticus\n Assessment:\n Neuro\n no seizure noted. Pserl at 3mm, lethargic, arousable to loud\n voice or stimulation, mae to command\n Action:\n Continuous eeg monitor in place. Receiving keppra iv and lamotrigine as\n ordered.\n Response:\n Lethargic, neuro exam otherwise wnl, no signs of seizure activity.\n Plan:\n Cont to monitor for seizure activity. Neuro vs q2h.\n"
},
{
"category": "Physician ",
"chartdate": "2154-12-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651640,
"text": "SICU\n HPI:\n 18 year-old man with a PMH of seizures p/w multiple seizures in context\n of recent GI illness\n Chief complaint:\n seizure\n PMHx:\n *seizures as above *numerous ear surgeries due to difficult drainage\n of his ears resulting in frequent ear infections\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:08 PM\n EXTUBATION - At 12:12 PM\n Post operative day:\n HD3\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 AM\n Famotidine (Pepcid) - 07:45 PM\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: 37.8\nC (100.1\n T current: 37\nC (98.6\n HR: 53 (52 - 96) bpm\n BP: 108/50(64) {96/40(53) - 141/84(102)} mmHg\n RR: 14 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 59.2 kg (admission): 55 kg\n Total In:\n 2,521 mL\n 509 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 2,281 mL\n 509 mL\n Blood products:\n Total out:\n 2,530 mL\n 510 mL\n Urine:\n 2,530 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n -9 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///24/\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 Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 199 K/uL\n 11.7 g/dL\n 105 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 32.8 %\n 7.3 K/uL\n [image002.jpg]\n 02:52 AM\n 03:06 AM\n WBC\n 12.3\n 7.3\n Hct\n 33.4\n 32.8\n Plt\n 205\n 199\n Creatinine\n 1.1\n 1.1\n Glucose\n 93\n 105\n Other labs: PT / PTT / INR:14.7/41.8/1.3, Ca:9.2 mg/dL, Mg:1.9 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), .H/O SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: 18 year-old man with a PMH of seizures p/w\n multiple seizures in context of recent GI illness\n Neurologic: Seizure: on lamictal 200'', added keppra 1000'', continuous\n EEG monitoring. Pt more awake now, but has slowed speech w/ some\n slurring, no recent seizures\n Cardiovascular: HD stable\n Pulmonary: stable post extubation, room air\n Gastrointestinal / Abdomen: diet advanced\n Nutrition: diet advanced\n Renal: Foley, Adequate UO, no issues\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: p/w GI inf. f/u stool cultures\n Lines / Tubes / Drains: d/c Foley\n Wounds:\n Imaging: EEG monitoring\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:52 PM\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: Transfer to floor\n Total time spent: 26 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 651641,
"text": ".H/O seizure, with status epilepticus\n Assessment:\n a&ox3, moving all extremities. Speech slow though clear. PERRL 3-4 mm.\n Neurologically intact though speech slow, slurred and delayed, per pt.\n Action:\n cont EEG monitoring. Frequent neuro checks.\n Response:\n NSS. Remains hemodynamically intact. MAE well. Tolerating reg diet\n well.\n Plan:\n Continue to closely monitor neuro signs and EEG. Provide comfort and\n support. Foley to be discontinued prior to transfer.\n"
},
{
"category": "Physician ",
"chartdate": "2154-12-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651617,
"text": "SICU\n HPI:\n 18 year-old man with a PMH of seizures p/w multiple seizures in context\n of recent GI illness\n Chief complaint:\n seizure\n PMHx:\n *seizures as above *numerous ear surgeries due to difficult drainage\n of his ears resulting in frequent ear infections\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:08 PM\n EXTUBATION - At 12:12 PM\n Post operative day:\n HD3\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:51 AM\n Famotidine (Pepcid) - 07:45 PM\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: 37.8\nC (100.1\n T current: 37\nC (98.6\n HR: 53 (52 - 96) bpm\n BP: 108/50(64) {96/40(53) - 141/84(102)} mmHg\n RR: 14 (14 - 20) insp/min\n SPO2: 99%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 59.2 kg (admission): 55 kg\n Total In:\n 2,521 mL\n 509 mL\n PO:\n 240 mL\n Tube feeding:\n IV Fluid:\n 2,281 mL\n 509 mL\n Blood products:\n Total out:\n 2,530 mL\n 510 mL\n Urine:\n 2,530 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n -9 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 99%\n ABG: ///24/\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 Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 199 K/uL\n 11.7 g/dL\n 105 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 110 mEq/L\n 142 mEq/L\n 32.8 %\n 7.3 K/uL\n [image002.jpg]\n 02:52 AM\n 03:06 AM\n WBC\n 12.3\n 7.3\n Hct\n 33.4\n 32.8\n Plt\n 205\n 199\n Creatinine\n 1.1\n 1.1\n Glucose\n 93\n 105\n Other labs: PT / PTT / INR:14.7/41.8/1.3, Ca:9.2 mg/dL, Mg:1.9 mg/dL,\n PO4:4.1 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), .H/O SEIZURE, WITH STATUS EPILEPTICUS\n Assessment and Plan: 18 year-old man with a PMH of seizures p/w\n multiple seizures in context of recent GI illness\n Neurologic: Seizure: on lamictal 200'', added keppra 1000'', continuous\n EEG monitoring. Pt more awake now, but has slowed speech w/ some\n slurring\n Cardiovascular: allow to autoregulate\n Pulmonary: stable post extubation\n Gastrointestinal / Abdomen: diet advanced\n Nutrition: diet advanced\n Renal: Foley, Adequate UO, no issues\n Hematology: stable\n Endocrine: RISS\n Infectious Disease: p/w GI inf. f/u stool cultures\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:52 PM\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: Transfer to floor\n Total time spent: 26 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651365,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt was intubated from OSH for airway protection d/t seizure\n Action:\n Remains on CPAP/PS, no vent changes overnight, on propofol gtt ,\n reduced the dose to 30mcg/kg/min\n Response:\n Pt is comfortable, sedated well, Good O 2sat, LS clear.\n Plan:\n Cont monitoring, pulm hygiene, wean & extubate in the morning if no\n more sz.\n .H/O seizure, with status epilepticus\n Assessment:\n Pt with h/o witnessed seizure x7, sz disorder diagnosed 3 yrs back,\n Action:\n Pt on continuous EEG monitoring, propofol gtt, neuro checks q2h.\n Response:\n No sz activities noted, propofol reduced to 30mcg.PERL, with drawing\n all extremities to pain when off sedation, not following any commands.\n Plan:\n Neuro checks q2h, cont EEG monitoring.\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651423,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt was intubated from OSH for airway protection d/t seizure\n Action:\n Remains on CPAP/PS, no vent changes overnight, on propofol gtt ,\n reduced the dose to 40mcg/kg/min\n Response:\n Pt is comfortable, sedated well, Good O 2sat, LS clear.\n Plan:\n Cont monitoring, pulm hygiene, wean & extubate in the morning if no\n more sz.\n .H/O seizure, with status epilepticus\n Assessment:\n Pt with h/o witnessed seizure x7, sz disorder diagnosed 3 yrs back,\n Action:\n Pt on continuous EEG monitoring, propofol gtt, neuro checks q2h.\n Response:\n No sz activities noted, propofol reduced to 40mcg.PERL, with drawing\n all extremities to pain when off sedation, not following any commands.\n Plan:\n Neuro checks q2h, cont EEG monitoring.\n"
},
{
"category": "Physician ",
"chartdate": "2154-12-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651436,
"text": "SICU\n HPI:\n The pt is an 18 year-old man with a PMH of seizures (either primary\n generalized or secondary generalized) who was transfered after having\n had multiple seizures earlier today. These occur in the context of a\n recent GI infection and possible decreased absorption of lamictal. He\n is currently seizure free. His work-up has shown a significant\n leukocytosis and anion gap which has improved on repeat labs here. He\n most likely has had seizrues due to infection and decreased medication.\n We will admit him for further monitoring and treatment and extubate\n once stable.\n Chief complaint:\n continued seizure activity\n PMHx:\n PMHx: *seizures as above *numerous ear surgeries due to difficult\n drainage of his ears resulting in frequent ear infections\n .\n MEDS: lamictal 150''\n .\n ALL: PCN\n .\n SOCIAL: - EtOH, - Tobacco, - recreational drug use\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Chlorhexidine Gluconate 0.12% Oral\n Rinse 5. Famotidine 6. Heparin\n 7. Insulin 8. LaMOTrigine 9. LeVETiracetam 10. Lorazepam 11. Magnesium\n Sulfate 12. Potassium Chloride\n 13. Potassium Chloride 14. Propofol 15. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 05:30 PM\n EVENTS:\n : admitted to SICU for continued ventilatory management given\n multiple episodes of status epilepticus\n Post operative day:\n EVENTS:\n : admitted to SICU for continued ventilatory management given\n multiple episodes of status epilepticus\n Allergies:\n Penicillins\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 04:01 AM\n Other medications:\n Flowsheet Data as of 08:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.1\nC (98.8\n HR: 95 (66 - 98) bpm\n BP: 139/82(102) {104/53(68) - 145/101(109)} mmHg\n RR: 19 (12 - 23) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 59 kg (admission): 55 kg\n Total In:\n 655 mL\n 863 mL\n PO:\n Tube feeding:\n IV Fluid:\n 655 mL\n 863 mL\n Blood products:\n Total out:\n 960 mL\n 830 mL\n Urine:\n 960 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -305 mL\n 33 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 450) mL\n Vt (Spontaneous): 435 (435 - 500) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 36\n PIP: 10 cmH2O\n SPO2: 100%\n ABG: ///23/\n Ve: 7 L/min\n Physical Examination\n General Appearance: No acute distress, Well nourished\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, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 205 K/uL\n 12.5 g/dL\n 93 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 12 mg/dL\n 111 mEq/L\n 141 mEq/L\n 33.4 %\n 12.3 K/uL\n [image002.jpg]\n 02:52 AM\n WBC\n 12.3\n Hct\n 33.4\n Plt\n 205\n Creatinine\n 1.1\n Glucose\n 93\n Other labs: Ca:8.8 mg/dL, Mg:2.2 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n Assessment and Plan: HPI:The pt is an 18 year-old man with a PMH of\n seizures (either primary generalized or secondary generalized) who was\n transfered after having had multiple seizures earlier today. These\n occur in the context of a recent GI infection and possible decreased\n absorption of lamictal. He is currently seizure free. His work-up has\n shown a significant leukocytosis and anion gap which has improved on\n repeat labs here. He most likely has had seizrues due to infection and\n decreased medication. We will admit him for further monitoring and\n treatment and extubate once stable.\n Neurologic: no seizures now. lamictal 200'', keppra 1000'', EEG\n monitoring, ativan for seizures, ativan\n Cardiovascular: hemodynamically stable\n Pulmonary: (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen:. NPO, protonix\n Nutrition: NPO, regular diet after extubation\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: possible viral enteritis. f/u stool cx . Check\n cultures. Afebrile. Improving leukocytosis.\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging: f/u EEG\n Fluids: NS\n Consults: Neurology\n Billing Diagnosis: Seizure, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 05:52 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2154-12-15 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651412,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 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: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments/Plan\n Pt remains intubated, minimally vent supported. No changes made\n overnight. RSBI=36 this am. See flowsheet for further pt data. Will\n follow.\n 06:22\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651341,
"text": "Patient admitted via Ed, having been transferred from hospital.\n Today patient had 4 witnessed seizures, at home. At hospital\n patient had a further 3 seizures, patient intubated to protect airway\n and transferred to . Patient\n sedated with Propofol at 90mcgs. When sedation stopped to assess,\n patient would not open eyes and would not follow commands, became very\n agitated, Tachycardic. Perrla. Mae strong.\n Iv fluids Ns 70cc hrly, urine output adequate.\n Lungs clear, soft non-tender, bs noted. Patient on cpap tolerating\n well.\n Patient on continuous EEG monitoring for seizure activity.\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 651549,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Lethargic, arousable to stimulation. Oriented x 3. Mae to command,\n lifts and holds all extremeties. Gag intact.\n Action:\n Taking clear liquids and meds po in high fowlers position. O2 sats\n stable on rm air.\n Response:\n Requires stimulation to become more fully awake. Tolerates po liquids\n well sitting in high fowlers position.\n Plan:\n High fowlers position when taking any po\ns to minimize risk aspiration.\n Monitor for partial airway obstruction, keep hob > 30-45 and continue\n to monitor sats.\n .H/O seizure, with status epilepticus\n Assessment:\n Neuro\n no seizure noted. Pserl at 3mm, lethargic, arousable to loud\n voice or stimulation, mae to command\n Action:\n Continuous eeg monitor in place. Receiving keppra iv and lamotrigine as\n ordered.\n Response:\n Lethargic, neuro exam otherwise wnl, no signs of seizure activity.\n Plan:\n Cont to monitor for seizure activity. Neuro vs q2h.\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 651550,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Lethargic, arousable to stimulation. Oriented x 3. Mae to command,\n lifts and holds all extremeties. Gag intact.\n Action:\n Taking clear liquids and meds po in high fowlers position. O2 sats\n stable on rm air.\n Response:\n Requires stimulation to become more fully awake. Tolerates po liquids\n well sitting in high fowlers position.\n Plan:\n High fowlers position when taking any po\ns to minimize risk aspiration.\n Monitor for partial airway obstruction, keep hob > 30-45 and continue\n to monitor sats.\n .H/O seizure, with status epilepticus\n Assessment:\n Neuro\n no seizure noted. Pserl at 3mm, lethargic, arousable to loud\n voice or stimulation, mae to command\n Action:\n Continuous eeg monitor in place. Receiving keppra iv and lamotrigine as\n ordered.\n Response:\n Lethargic, neuro exam otherwise wnl, no signs of seizure activity.\n Plan:\n Cont to monitor for seizure activity. Neuro vs q2h.\n"
},
{
"category": "Nursing",
"chartdate": "2154-12-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 651551,
"text": "The pt is an 18 year-old man with a PMH of seizures (either primary\n generalized or secondary generalized) who was transfered after having\n had multiple seizures earlier . These occur in the context of a\n recent GI infection and possible decreased absorption of lamictal. He\n is currently seizure free. His work-up has shown a significant\n leukocytosis and anion gap which has improved on repeat labs here. Pt\n adm to sicu intubated overnight and extubated on at 12pm w/o\n incident. Continuous eeg monitoring in progress w no signs of seizure\n activity. Pt continues on iv keppra and po lamictal.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Lethargic, arousable to stimulation. Oriented x 3. Mae to command,\n lifts and holds all extremeties. Gag intact.\n Action:\n Taking clear liquids and meds po in high fowlers position. O2 sats\n stable on rm air.\n Response:\n Requires stimulation to become more fully awake. Tolerates po liquids\n well sitting in high fowlers position.\n Plan:\n High fowlers position when taking any po\ns to minimize risk aspiration.\n Monitor for partial airway obstruction, keep hob > 30-45 and continue\n to monitor sats.\n .H/O seizure, with status epilepticus\n Assessment:\n Neuro\n no seizure noted. Pserl at 3mm, lethargic, arousable to loud\n voice or stimulation, mae to command\n Action:\n Continuous eeg monitor in place. Receiving keppra iv and lamotrigine as\n ordered.\n Response:\n Lethargic, neuro exam otherwise wnl, no signs of seizure activity.\n Plan:\n Cont to monitor for seizure activity. Neuro vs q2h.\n"
}
] |
822 | 191,344 | 1. Altered mental status: The patient was admitted to the MICU with AMS and elevated WBC count likely related to UTI and bacteremia. His multiple decubitus ulcers were also a potential source, but his blood grew E coli and Plastics felt the wounds were clean. The patient improved on Zosyn and linezolid while in the MICU. Other possible etiologies of the patient's AMS include overdose and neurologic etiology. Head CT was negative on admission and tox screen was positive only for benzodiazepines, which he is taking as an outpatient. The patient's mental status improved dramatically with treatment for his infection and remained at baseline. 2. UTI: The patient had an elevated WBC count and had a urine sample which grew pan-sensitive E coli. His blood cultures were also positive for E coli. Given a concern for infected decubitus ulcers as well, he was treated with both Zosyn and linezolid in the MICU with improvement in his clinical status. Platics did not feel that his ulcers were infected. On transfer to the floor, the patient's linezolid was discontinued and his Zosyn was continued. Follow-up cultures were negative. 3. Recurrent fevers: pt began spiking temps up to 103 even though UTI has resolved. CT pelvis was performed and showed osteo, specifically increased osteo (comp to ) in much of pelvis (ischial tuberocity; inf pubic rami); also new soft tissue ulcers and L hip effusion in close proximity w/ sq infection. consulted ortho for washout and L hip tap. consulted ID. no involvement of spine on the scan. daily survailence cxs showed no growth. s/p IR guided tap of L hip : cxs negative, so no urgency for immediate washout. Came up with the following plan: d/c pt on abxs (flagyl and cefpodoxime). Plan splastics surgery on by Dr. . Pt will also be seen in clinic. 4. Decubitus ulcers: The patient has a long history of MRSA infection of his decubitous wound. Plastics saw him in the ED and felt that his wound was not actively infected and recommended a CT pelvis when pt more stable. The patient had a Kinair bed for decreased sacral pressure and wound dressing changes with iodoform gauze per Plastics. He is scheduled for a flap procedure by Dr. on . Dressing changes to be continued as outpt. . 4. ARF: The patient was admitted with a creatinine of 3.3, over his baseline around , suggesting acute on chronic kidney disease. Likely due to prerenal azotemia in the setting of infection as patient appeared dry and his creatinine improved to his baseline with IVF resuscitation. His sevelamer was continued. . 5. Elevated INR: The patient was admitted with INR of 4, significantly higher than baseline. Repeat measurements were around 1.3. Not DIC as other coags and fibrinogen are normal. . 6. Dysphagia: Mother has reported problems with swallowing over the last several days. MICU RN reports pt aspirating water. All resolved by time of d/c. able to tolerate regular diet. . 7. Anion gap metabolic acidosis: due to infection. resolved. . 8. H/o seizure disorder: Continue keppra per outpt regimen . 9. Pain: The patient has chronic pain due to osteomyelitis and sacral decubitus ulcers. His pain medications were held given his mental status but were restarted when his mental status improved. | A compression deformity of T12 is present. Limited imaging through the lower pelvis shows normal appearing bowel. FINDINGS: AP PELVIS: This examination is markedly limited by exposure and positioning. The diffuse irregularity of the left hip contours suggests synovial proliferation or fibrosis. There is a new soft tissue defect with a sinus tract along the right posterior soft tissues, at the level of the lumbosacral junction. COMPARISON: Prior plain films dated and and prior pelvic CT dated and . Intra-articular positioning was confirmed by small injection of Conray. IMPRESSION: AP chest compared to : Right internal jugular line projects over the expected course to the SVC. Mediastinal fullness in the lower paratracheal regions extending to the thoracic inlet has been present since at least , probably fat deposition, alternatively longstanding stable adenopathy. There is a new moderate sized left hip effusion and septic arthritis may be present. Made NPO except for meds. Subcutaneous gas is seen tracking from the right ischial tuberosity ulcer inferiorly and laterally to the region of the right lesser trochanter. FINDINGS: The heart size and mediastinal contours are within normal limits. Irregularity of the left hip joint capsule suggesting synovial proliferation and/or fibrosis. New sinus tract in the right posterior pelvic soft tissues. IMPRESSION: Right IJ line in satisfactory position, no pneumothorax. Degenerative changes are seen in the sacroiliac joints bilaterally. Neuro: Lethargic. The inferior aspect of spinal hardware is seen. TECHNIQUE: Non-contrast CT scan of the pelvis was performed using 1.25 mm collimation. The ischial tuberosities are sclerotic and markedly irregular. The previously demonstrated destructive changes in the inferior pubic rami bilaterally are poorly visualized. During this interval, there has been significant progression of the osteomyelitis involving the ischial tuberosities and inferior pubic rami bilaterally. Destructive and sclerotic changes involving the left iliac bone are unchanged from . Findings were discussed with Dr. from orthopedics. Osteomyelitis would be much less likely. CHEST: The tip of the right IJ line lies in the lower SVC. Bolus as necessary to maintain urinary output. TECHNIQUE: AP pelvis and two views of low thoracic and upper lumbar spine. The destructive changes previously demonstrated within the inferior pubic ramus are therefore incompletely evaluated. The balloon appears to be positioned rather low, possibly in the prostatic urethra. Osteomyelitis in this region would be less likely. There is gas and abnormal soft tissue extending from the left decubitus ulcer towards the left hip joint and a left hip joint effusion is seen. TECHNIQUE: Axial non-contrast MDCT images were obtained through the head. FINDINGS: Two large soft tissue ulcers are noted extending into the ischial tuberosities and containing packing material. The left hip was prepped and draped in sterile fashion. LOW THORACIC AND UPPER LUMBAR SPINE, TWO VIEWS: There are bilateral rods with pedicle screws and laminar hooks extending from L2 and L1 to the lower thoracic spine, including T9 through T11. This is concerning for septic joint 3. The needle was withdrawn, and a bandage was placed over the puncture site. 11:23 AM CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # Reason: r.o sacral osteomyelitis Admitting Diagnosis: WOUND INFECTION FINAL ADDENDUM NON-CONTRAST CT SCAN OF THE PELVIS ADDENDUM: Comparison was made to a prior CT scan of the abdomen and pelvis dated . Markedly irregular and sclerosis of the ischial tuberosities bilaterally with large decubitus ulcers extending directly to the underlying bone. We are to pack small tunnelled areas with iodoform and the larger areas with NSS wet-dry. d/c PO meds or crush as pt appears to aspirate with each sip of water. These findings can be compatible with prior surgery. (Over) 11:23 AM CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # Reason: r.o sacral osteomyelitis Admitting Diagnosis: WOUND INFECTION FINAL REPORT (Cont) IMPRESSION: 1. There is persistent marked narrowing of the hip joints bilaterally. IMPRESSION: Stable radiographic appearance of the chest. Linear atelectasis at the base of the right lung is more pronounced today than it was on , but probably of no clinical significance. 1% lidocaine was used for local anesthesia. Spinal rods are noted. Irregularity and bony defect in the left iliac bone. HISTORY: New right central venous line. Clinical correlation is suggested. Left hip aspiration requested to assess for septic arthritis. Technically successful left hip aspiration. There is limited visualization of the inferior pubic rami, although this is likely largely technical in nature. However, given the clincial history, underlying osteomyelitis would be difficult to exclude and is likely present 2. TECHNIQUE: Single AP portable upright chest. Afebrile.C/V: HR 90's to 120's and sinus. The osseous structures appear unchanged with bilateral fixation rods in stable configuration. if pt should be taking PO meds. IMPRESSION: The examination is limited due to technique. The bowel gas pattern appears unremarkable. The paranasal sinuses are well aerated. Visualization of the posterior soft tissues is limited due to exposure. These changes can be compatible with prior surgery, however, underlying osteomyelitis would be difficult to excluded and is most likely present. Subcutaneous gas is seen tracking laterally from the left ischial tuberosity ulcer into the soft tissues of the left buttock and in close proximity to the left hip joint. | 8 | [
{
"category": "Radiology",
"chartdate": "2176-09-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 879797,
"text": " 3:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, effusion, edema, ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with altered mental status and cough\n REASON FOR THIS EXAMINATION:\n eval for pna, effusion, edema, ptx\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Altered mental status and cough, evaluate for pneumonia,\n effusion, edema or pneumothorax.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: The heart size and mediastinal contours are within normal limits.\n The lungs are clear, without focal consolidation, pleural effusion, or\n pneumothorax. The osseous structures appear unchanged with bilateral fixation\n rods in stable configuration.\n\n IMPRESSION: Stable radiographic appearance of the chest. No acute\n cardiopulmonary abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-29 00:00:00.000",
"description": "CT PELVIS ORTHO W/O C",
"row_id": 879885,
"text": " 11:23 AM\n CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # \n Reason: r.o sacral osteomyelitis\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n FINAL ADDENDUM\n NON-CONTRAST CT SCAN OF THE PELVIS\n\n ADDENDUM: Comparison was made to a prior CT scan of the abdomen and pelvis\n dated . During this interval, there has been significant progression of\n the osteomyelitis involving the ischial tuberosities and inferior pubic rami\n bilaterally. The soft tissue ulcerations have also increased in size and\n number.\n\n Findings were discussed with Dr. from orthopedics.\n\n\n\n 11:23 AM\n CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # \n Reason: r.o sacral osteomyelitis\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with uti, multiple decub ulcers, presents to mICU in septic\n shock\n REASON FOR THIS EXAMINATION:\n r.o sacral osteomyelitis\n CONTRAINDICATIONS for IV CONTRAST:\n cri\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE PELVIS WITHOUT CONTRAST DATED \n\n CLINICAL HISTORY: 30-year-old man with UTI, multiple decubitus ulcers,\n presents to medical ICU in septic shock, rule out sacral osteomyelitis.\n\n TECHNIQUE: Non-contrast CT scan of the pelvis was performed using 1.25 mm\n collimation. Images were reformatted and evaluated in the coronal and\n sagittal planes. No IV contrast was administered.\n\n COMPARISON: Prior plain films dated and and prior pelvic CT\n dated and .\n\n FINDINGS: Two large soft tissue ulcers are noted extending into the ischial\n tuberosities and containing packing material. The ischial tuberosities are\n sclerotic and markedly irregular. These changes can be compatible with prior\n surgery, however, underlying osteomyelitis would be difficult to excluded and\n is most likely present. These changes are new when compared to the prior CT\n studies.\n\n Subcutaneous gas is seen tracking laterally from the left ischial tuberosity\n ulcer into the soft tissues of the left buttock and in close proximity to the\n left hip joint. The gas continues to extend superiorly. There is a new\n moderate sized left hip effusion and septic arthritis may be present.\n\n Destructive and sclerotic changes involving the left iliac bone are unchanged\n from . These changes are likely sequelae of prior surgery, such as\n bone graft donor site. Osteomyelitis in this region would be less likely.\n Degenerative changes are seen in the sacroiliac joints bilaterally.\n\n There is a new soft tissue defect with a sinus tract along the right posterior\n soft tissues, at the level of the lumbosacral junction. Subcutaneous gas is\n seen tracking from the right ischial tuberosity ulcer inferiorly and laterally\n to the region of the right lesser trochanter. There is no hip effusion on the\n right.\n\n Limited imaging through the lower pelvis shows normal appearing bowel. There\n is a Foley catheter within bladder. The balloon appears to be positioned\n rather low, possibly in the prostatic urethra. Clinical correlation is\n suggested. The inferior aspect of spinal hardware is seen.\n (Over)\n\n 11:23 AM\n CT PELVIS ORTHO W/O C; CT RECONSTRUCTION Clip # \n Reason: r.o sacral osteomyelitis\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Markedly irregular and sclerosis of the ischial tuberosities bilaterally\n with large decubitus ulcers extending directly to the underlying bone. These\n findings can be compatible with prior surgery. However, given the clincial\n history, underlying osteomyelitis would be difficult to exclude and is likely\n present\n\n 2. There is gas and abnormal soft tissue extending from the left decubitus\n ulcer towards the left hip joint and a left hip joint effusion is seen. This\n is concerning for septic joint\n\n 3. New sinus tract in the right posterior pelvic soft tissues.\n\n 4. Irregularity and bony defect in the left iliac bone. Likely a bone graft\n donor site. Osteomyelitis would be much less likely.\n\n Findings were discussed with Dr. at approximately 3 p.m. on this day.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-28 00:00:00.000",
"description": "LUMBO-SACRAL SPINE (AP & LAT)",
"row_id": 879801,
"text": " 4:30 PM\n LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: eval for bony involvement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with chronic decub ulcers\n REASON FOR THIS EXAMINATION:\n eval for bony involvement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chronic decubitus ulcers, evaluate for osseous involvement.\n\n COMPARISON: .\n\n TECHNIQUE: AP pelvis and two views of low thoracic and upper lumbar spine.\n\n FINDINGS:\n\n AP PELVIS: This examination is markedly limited by exposure and positioning.\n There is limited visualization of the inferior pubic rami, although this is\n likely largely technical in nature. The destructive changes previously\n demonstrated within the inferior pubic ramus are therefore incompletely\n evaluated. There is persistent marked narrowing of the hip joints\n bilaterally. The bowel gas pattern appears unremarkable.\n\n LOW THORACIC AND UPPER LUMBAR SPINE, TWO VIEWS: There are bilateral\n rods with pedicle screws and laminar hooks extending from L2 and L1\n to the lower thoracic spine, including T9 through T11. A compression\n deformity of T12 is present. Visualization of the posterior soft tissues is\n limited due to exposure. No definite gas-containing regions are identified\n within the soft tissues. There are no definite areas of osseous destruction,\n although visualization of the posterior elements is limited due to technique.\n\n IMPRESSION: The examination is limited due to technique. The previously\n demonstrated destructive changes in the inferior pubic rami bilaterally are\n poorly visualized. No definite new areas of osteomyelitis are identified.\n\n If further evaluation is of clinical interest, a CT may be helpful.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-02 00:00:00.000",
"description": "L INJ/ASO MAJOR JT W/FLUORO LEFT",
"row_id": 880292,
"text": " 3:35 PM\n INJ/ASO MAJOR JT W/FLUORO LEFT Clip # \n Reason: L hip aspiration\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with pelvic osteo and L hip fluid collection\n REASON FOR THIS EXAMINATION:\n L hip aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old man with pelvic osteomyelitis and left hip fluid\n collection. Left hip aspiration requested to assess for septic arthritis.\n\n RADIOLOGISTS: Dr. and Dr. . Dr. , the attending\n radiologist, was present for the entire procedure.\n\n DESCRIPTION OF PROCEDURE: The procedure, its indications, risk, benefits, and\n alternatives were discussed with the patient. Written informed consent was\n obtained. The patient was placed supine on the fluoroscopy table. The left\n hip was prepped and draped in sterile fashion. 1% lidocaine was used for\n local anesthesia. Under fluoroscopic guidance, a 20-gauge spinal needle was\n placed into the left hip joint at several sites. Intra-articular positioning\n was confirmed by small injection of Conray. The diffuse irregularity of the\n left hip contours suggests synovial proliferation or fibrosis.\n\n Approximately 2 cc of slightly bloody fluid was aspirated and sent to the lab\n for culture. Insufficient quantity of fluid was attained in order to sent\n for a cell count. The needle was withdrawn, and a bandage was placed over the\n puncture site. There were no immediate complications, and the patient\n tolerated the procedure well.\n\n IMPRESSION:\n 1. Technically successful left hip aspiration. Aspirate sent to lab for\n culture.\n 2. Irregularity of the left hip joint capsule suggesting synovial\n proliferation and/or fibrosis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 879817,
"text": " 7:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH or mass effect\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with sepsis and INR of 4.0\n REASON FOR THIS EXAMINATION:\n eval for ICH or mass effect\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, INR of 4.0.\n\n COMPARISONS: .\n\n TECHNIQUE: Axial non-contrast MDCT images were obtained through the head.\n\n CT HEAD WITHOUT IV CONTRAST: There is no evidence of intracranial hemorrhage,\n hydrocephalus, shift of normally midline structures or edema. The -white\n matter differentiation is intact. The paranasal sinuses are well aerated.\n\n IMPRESSION: No evidence of intracranial hemorrhage or edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-09-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 879814,
"text": " 7:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval for ptx, line placement\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p R CVL placement\n REASON FOR THIS EXAMINATION:\n eval for ptx, line placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Right line placed, check for position, exclude\n pneumothorax.\n\n CHEST: The tip of the right IJ line lies in the lower SVC. There is no\n evidence of a pneumothorax. The lung fields are clear.\n\n Spinal rods are noted.\n\n IMPRESSION: Right IJ line in satisfactory position, no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 880105,
"text": " 11:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p R CVL placement, now with new fevers\n\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1147 A.M. .\n\n HISTORY: New right central venous line. Fever.\n\n IMPRESSION: AP chest compared to :\n\n Right internal jugular line projects over the expected course to the SVC.\n Mediastinal fullness in the lower paratracheal regions extending to the\n thoracic inlet has been present since at least , probably fat deposition,\n alternatively longstanding stable adenopathy. Linear atelectasis at the base\n of the right lung is more pronounced today than it was on , but\n probably of no clinical significance. There is no pneumonia or pleural\n effusion. Heart is normal size.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-09-29 00:00:00.000",
"description": "Report",
"row_id": 1272456,
"text": "Neuro: Lethargic. Mother in on admission. States that pt is normally very sarcastic at baseline, known to throw items at staff and holler obsenities. Pt has refused to be turned, does not hold still for lab draws. Still lethargic, difficult to understand as pt mumbles responses. All pain meds and benzo's d/c'd to allow pt to wake fully. At home pt takes oxycontin and percocet.\n\nResp: Pt satting 99-100% RA. Lungs clear. Pt aspirating water while taking pills. Made NPO except for meds. ? if pt should be taking PO meds. Afebrile.\n\nC/V: HR 90's to 120's and sinus. BP 90-120's/40-50's. No ectopy noted.\n\nGU/GI: Foley patent, draining clear yellow urine. Pt is 4.4 L + since admission.\n\nReceived 2L NSS in EW, 1L NSS at 2230, 1L D5W w/150meq sodium bicarb at 0030 and 0245. Received 4gm mag sulfate at 0215.\n\nSkin: Pt has multiple small tunnelling decubiti on which he is scheduled to have surgically repaired next month. Plastics saw him in the EW last evening. We are to pack small tunnelled areas with iodoform and the larger areas with NSS wet-dry. Areas packed on admission to MICU but ABD's covering them had come off in the sheets. Pt has refused to turn for dressing change. Will attempt again this AM now that pt has slept well through the night.\n\n Social: Pt lives with mother who is primary caregiver.\n\nPt has TLCL R IJ that infuses well but unable to draw from any port this am for labs. Intern aware. She plans to attempt an arterial stick for labs later this morning.\n\nPlan: Follow labs closely when available. Repleat lytes as ordered. Bolus as necessary to maintain urinary output. ? d/c PO meds or crush as pt appears to aspirate with each sip of water. Encourage pt to lie on his side and place on air bed when available. Dsg change Q24 hours.\n"
}
] |
23,016 | 189,107 | 1. Cardiac. Integrilin was started in the catheterization lab and she was continued on this for 18 hours after cardiac cath. Aspirin and Plavix were given. She should continue on Plavix for one month. Lipids were checked and were found to be slightly elevated with total cholesterol of 209, triglycerides 296, HDL 32, LDL 118. Therefore, a statin should be considered in the future. We did not initiate one here because of elevated LFTs. We implicated the myocardial infarct as the reason for her transaminitis. We also initiated beta blocker therapy, initially Lopressor 12.5 mg p.o. b.i.d. We tried to increase it to 25 mg p.o. b.i.d., but her blood pressure dropped. Therefore, she will be discharged on 12.5 mg p.o. b.i.d. This can be increased as an outpatient if her blood pressure allows. In terms of heart function, we performed echocardiogram which showed an ejection fraction of 35% to 40% with basal inferoseptal mid-inferoseptal and basal inferior hypokinesis, mid-inferior akinesis, basal inferolateral and mid-inferolateral hypokinesis and inferior apical akinesis. Right ventricle appeared normal. There was trace AI, mild MR, 3+ TR and physiologic PR. There was no effusion. In light of her depressed ejection fraction and elevated filling pressures on right heart catheterization, we felt an ACE inhibitor would be warranted. However, her blood pressure did not allow this. If her blood pressure improves as an outpatient, then an ACE inhibitor should certainly be considered. Of note, she had no significant ectopy following her myocardial infarction. 2. Pulmonary. Patient had no signs or symptoms of CHF. 3. Renal. Patient had normal renal function, although she did have a rise in BUN that we felt consistent with her GI bleed (see below). 4. Hematology. Although patient's hematocrit was 36 on admission, it decreased to 22 over the first 48 hours of her hospitalization. Examination of the groin access site for cardiac catheterization revealed no hematoma and no bruit. She had heme positive stool, but it was not melanotic nor did she have bright red blood per rectum. However, BUN doubled from 23 to 41 over 24 hours consistent with GI bleed. Abdominal CAT scan was performed that ruled out retroperitoneal hematoma. There was a small groin hematoma seen, but this was not large enough to account for the 14 point drop in hematocrit. Therefore, we assumed most of the blood loss was GI in origin and we transfused her two units of packed red blood cells with increase in hematocrit to 29. This remained stable and we continued to check hematocrit every 12 hours. It was recommended that she have colonoscopy as an outpatient. She has never had colonoscopy before. 5. Endocrine. We gave the patient stress dose steroids and tapered this to her basal cortisone requirement of 12.5 mg p.o. b.i.d. We also continued Synthroid at her home dose. 6. Genitourinary. We continued patient on Ditropan. 7. Prophylaxis. Patient received Protonix as GI prophylaxis and heparin subcutaneous. 8. Neurology. Patient had extremely poor short and long term memory and at one point and at one point was acutely confused and found to be very disoriented. However, this was transient and resolved spontaneously. We were assured by the patient's family that her mental status was at baseline. 9. Disposition. Patient was seen by physical therapy and found to be safe for discharge home. This was planned for . Final medication list will be dictated in a discharge summary addendum. However, at this time it seems likely that the only addition to her medication regimen will be aspirin, Plavix for 30 days 75 mg p.o. q.d. and Lopressor 12.5 mg p.o. b.i.d. Followup should be with her primary care physician, . . She should be seen by her cardiologist in approximately four weeks. , M.D. Dictated By: MEDQUIST36 D: 18:02 T: 18:40 JOB#: | Since the previous tracing of there is now a regular supraventricularrhythm without visible P waves, most probably a junctional rhythm. Overall left ventricular systolic function is moderatelydepressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -hypokinetic; basal inferior - hypokinetic; mid inferior - akinetic; basalinferolateral - hypokinetic; mid inferolateral - hypokinetic; inferior apex -akinetic;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) are mildly thickened. Myocardial infarction.Height: (in) 61Weight (lb): 130BSA (m2): 1.57 m2BP (mm Hg): 101/58Status: InpatientDate/Time: at 10:39Test: 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. CT ABDOMEN WITHOUT IV CONTRAST: There is a moderate-sized right-sided pleural effusion. Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is moderate regionalleft ventricular systolic dysfunction. Moderate tosevere [3+] tricuspid regurgitation is seen.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. There is an appendicolith but a non-enlarged or inflamed appendix. lung exam suggestive of chf although pt denies any subjective c/o sob. There is moderate regional left ventricularsystolic dysfunction. Trace aortic regurgitation is seen. ST segment elevations have resolved in the inferolateralleads with slight T wave flattening now in these leads. Resting regional wall motion abnormalitiesinclude severe hypokinesis-akinesis of the inferior septum, inferior wall andposterolateral wall of the left ventricle. The aortic valve leaflets (3) are mildlythickened. CT PELVIS AFTER IV CONTRAST: There is some stranding around the femoral vessels on the right. The left ventricularinflow pattern suggests impaired relaxation. Left ventricular wall thicknesses arenormal. in the ew, ekg changes were suggestive of a posterior mi, and the pt was sent to cath. Overall left ventricular systolicfunction is moderately depressed. Theleft ventricular inflow pattern suggests impaired relaxation.TRICUSPID VALVE: The tricuspid valve is not well visualized. FINAL REPORT CT OF THE ABDOMEN AND PELVIS WITHOUT IV CONTRAST FROM AT 20:10. TECHNIQUE: Helically-acquired CT images were obtained from the lung bases through the pubic symphysis without the administration of IV or oral contrast. (Over) 7:13 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Please eval for retroperitoneal bleed. 7:13 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Please eval for retroperitoneal bleed. anticipate transfer to the floor tomarrow followed by a day stay in house.pmh: small cell lung ca s/p chemo/xrt ~12yrs ago; pituitary tumor d/t brain mets s/p xrt; ischemic left parietal cva in 7/00 treated w/tpa which led to an ugib (no residual motor deficits noted); s/p tia in '; ?htnnkdareview of systemsrespiratory-> pt arrived wearing a nrb mask but was quickly weaned to 2 liters o2 via a cannula and maintaining sats >96%. the pt did undergo angioplasty and a stent was placed in the lcx which was completely occluded. A small hypodensity likely to be a cyst is seen within the right kidney. pt course in the cath lab was c/b transient periods of hypotension and bradycardia which were treated w/dopamine and atropine. PATIENT/TEST INFORMATION:Indication: Left ventricular function. this memory loss is apparently nothing new according to her husband.gi-> abd is soft, nontender, nondistended w/+bs. IMPRESSION: 1) Small hematoma tracking along the femoral vessels on the right. The left ventricular cavity size is normal. Right-sided chest leads do not show injury current.TRACING #2 Non-obstructing calculi are seen within the left kidney. ST segmentelevations are noted in leads II, III, aVF and V6 with ST segment depressionsin leads VI-V3. pt may start a cardiac diet in the morning.gu-> foley remains patent and intact. Right ventricular chamber size andfree wall motion are normal. The leftventricular cavity size is normal. denies c/o sob or difficulty breathing. Trace aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. REASON FOR THIS EXAMINATION: Please eval for retroperitoneal bleed. There is excretion of IV contrast seen within the gallbladder. she has been hemodynamically stable overnoc although she developed frequent vea last evening. plan will be to obtain an echo in the am to determine if the pt will also need an ace inhibitor.neuro-> pt is a&o x3, pleasant an cooperative w/her care. A fibroid is seen within the uterus and the adnexa are not clearly visualized. Some contrast material is seen within the large intestine, though I see no recent barium study. she received lasix iv x1 overnoc.heme-> hct stable @34 w/o evidence of any active bleeding.id-> tmax 99.6 orally w/no wbc.access-> #18g angios are located in either antecubsocial-> pt's husband and dtr were in briefly last noc and were able to speak w/the ccu team prior to going home. The abnormalities arenon-specific.TRACING #4 Moderate to severe [3+] tricuspidregurgitation is seen. Sinus tachycardia. she was repleted w/k+/mg++/ca++ with improvement in the frequency of the ectopy. pt is taking po liqs w/o incident. The tracing is consistent with an acute inferolateral process.TRACING #1 INDICATION: 14-point hematocrit drop since cardiac catheterization. Pearl, denies any chest pain or pressure.CV: Nsr-st no ectopy noted, bp 110/70, hr 80-90.Resp: nrm on at 15 l sat at 100% to titrate down.right groin pulse palp no edema, groin dsg d&I no drainage noted. in addition, she was started on plavix overnoc. lung exam notable for bilateral rales, and the pt eventually received lasix w/a good response.cardiac-> as noted above, the pt is to continue on integrelin until 9am today. The spleen and pancreas are normal. 2) There is no retroperitoneal hematoma. | 8 | [
{
"category": "Radiology",
"chartdate": "2132-08-01 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 762313,
"text": " 7:13 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please eval for retroperitoneal bleed.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with MI s/p cardiac cath/stent has had Hct drop from 36 to 22\n since admission. 9 point drop over last 24 hrs. No BRBPR or hematemesis.\n Asymptomatic.\n REASON FOR THIS EXAMINATION:\n Please eval for retroperitoneal bleed.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITHOUT IV CONTRAST FROM AT 20:10.\n\n INDICATION: 14-point hematocrit drop since cardiac catheterization. No\n clinical signs of a bowel source.\n\n TECHNIQUE: Helically-acquired CT images were obtained from the lung bases\n through the pubic symphysis without the administration of IV or oral contrast.\n No prior study is available for comparison.\n\n CT ABDOMEN WITHOUT IV CONTRAST: There is a moderate-sized right-sided pleural\n effusion. There is some dependent atelectasis and a bullous change within the\n left lower lobe. The liver is normal. There is excretion of IV contrast seen\n within the gallbladder. The spleen and pancreas are normal. There is no\n enlarged adenopathy within the mesentery or retroperitoneum. Calcifications\n are seen along the aortoiliac vessels. Non-obstructing calculi are seen\n within the left kidney. A small hypodensity likely to be a cyst is seen\n within the right kidney.\n\n There is no free air or free fluid within the abdomen.\n\n CT PELVIS AFTER IV CONTRAST:\n\n There is some stranding around the femoral vessels on the right.\n\n There is an appendicolith but a non-enlarged or inflamed appendix. A fibroid\n is seen within the uterus and the adnexa are not clearly visualized. Some\n contrast material is seen within the large intestine, though I see no recent\n barium study.\n\n No suspicious lytic or blastic lesions are seen within the osseous structures.\n\n IMPRESSION:\n\n 1) Small hematoma tracking along the femoral vessels on the right. This\n amount of stranding is unlikely to account for a 14-point hematocrit drop.\n\n 2) There is no retroperitoneal hematoma.\n\n These results were discussed with the Medicine house staff.\n (Over)\n\n 7:13 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please eval for retroperitoneal bleed.\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 1563216,
"text": "1800. Pt admitted from cath lab, right fem groin was pulled upon admission to micu. bleeding at site.\n Neuro: alert and oriented to person place and time. Pearl, denies any chest pain or pressure.\nCV: Nsr-st no ectopy noted, bp 110/70, hr 80-90.\nResp: nrm on at 15 l sat at 100% to titrate down.\nright groin pulse palp no edema, groin dsg d&I no drainage noted. to keep right leg straight until 0030.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-07-31 00:00:00.000",
"description": "Report",
"row_id": 1563217,
"text": "pmicu nsg admission/progress note\n\n\n briefly, the pt is a 62 woman w/an extensive pmh but no prior h/o heart disease who presented to the ew yesterday morning with c/o n/v and cp during her aerobic exercise. the pt's husband called ems, and the pt was brought to the ew. in the ew, ekg changes were suggestive of a posterior mi, and the pt was sent to cath. the pt did undergo angioplasty and a stent was placed in the lcx which was completely occluded. pt course in the cath lab was c/b transient periods of hypotension and bradycardia which were treated w/dopamine and atropine. integrelin was started in the cath lab and will continue until the morning. the pt's femeral sheath was removed w/o incident shortly after her arrival to the micu. she currently denies c/o n/v or chest pain and is resting comfortably. anticipate transfer to the floor tomarrow followed by a day stay in house.\n\npmh: small cell lung ca s/p chemo/xrt ~12yrs ago; pituitary tumor d/t brain mets s/p xrt; ischemic left parietal cva in 7/00 treated w/tpa which led to an ugib (no residual motor deficits noted); s/p tia in '; ?htn\n\nnkda\n\nreview of systems\n\nrespiratory-> pt arrived wearing a nrb mask but was quickly weaned to 2 liters o2 via a cannula and maintaining sats >96%. denies c/o sob or difficulty breathing. lung exam notable for bilateral rales, and the pt eventually received lasix w/a good response.\n\ncardiac-> as noted above, the pt is to continue on integrelin until 9am today. in addition, she was started on plavix overnoc. she has been hemodynamically stable overnoc although she developed frequent vea last evening. she was repleted w/k+/mg++/ca++ with improvement in the frequency of the ectopy. she was also started on lopressor and received a total of 25mg po; despite this, her hr remains in the 80's, nsr w/sbp 120-130's. plan will be to obtain an echo in the am to determine if the pt will also need an ace inhibitor.\n\nneuro-> pt is a&o x3, pleasant an cooperative w/her care. no motor deficits were noted on exam although the pt clearly has some memory deficits (ie she was unable to recall her med list at home or give an accurate description of events that brought her to the hospital). this memory loss is apparently nothing new according to her husband.\n\ngi-> abd is soft, nontender, nondistended w/+bs. pt is taking po liqs w/o incident. pt may start a cardiac diet in the morning.\n\ngu-> foley remains patent and intact. she received ivf in the cath lab and completed yesterday more than 1 liter tfb positive. lung exam suggestive of chf although pt denies any subjective c/o sob. she received lasix iv x1 overnoc.\n\nheme-> hct stable @34 w/o evidence of any active bleeding.\n\nid-> tmax 99.6 orally w/no wbc.\n\naccess-> #18g angios are located in either antecub\n\nsocial-> pt's husband and dtr were in briefly last noc and were able to speak w/the ccu team prior to going home.\n"
},
{
"category": "Echo",
"chartdate": "2132-07-31 00:00:00.000",
"description": "Report",
"row_id": 68163,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 61\nWeight (lb): 130\nBSA (m2): 1.57 m2\nBP (mm Hg): 101/58\nStatus: Inpatient\nDate/Time: at 10:39\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. There is moderate regional left ventricular\nsystolic dysfunction. Overall left ventricular systolic function is moderately\ndepressed.\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 - akinetic; basal\ninferolateral - hypokinetic; mid inferolateral - hypokinetic; inferior apex -\nakinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. The tips of the\npapillary muscles are calcified. Mild (1+) mitral regurgitation is seen. The\nleft ventricular inflow pattern suggests impaired relaxation.\n\nTRICUSPID VALVE: The tricuspid valve is not well visualized. Moderate to\nsevere [3+] tricuspid regurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. There is moderate regional\nleft ventricular systolic dysfunction. Overall left ventricular systolic\nfunction is moderately depressed. Resting regional wall motion abnormalities\ninclude severe hypokinesis-akinesis of the inferior septum, inferior wall and\nposterolateral wall of the left ventricle. Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened. Trace aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular\ninflow pattern suggests impaired relaxation. Moderate to severe [3+] tricuspid\nregurgitation is seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 149504,
"text": "Sinus tachycardia. Since earlier this date the rhythm is again sinus and the\nrate is more rapid. ST segment elevations have resolved in the inferolateral\nleads with slight T wave flattening now in these leads. The abnormalities are\nnon-specific.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 149505,
"text": "Junctional rhythm. No significant change from earlier this date.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 149506,
"text": "Right-sided chest leads do not show injury current.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2132-07-30 00:00:00.000",
"description": "Report",
"row_id": 149507,
"text": "Since the previous tracing of there is now a regular supraventricular\nrhythm without visible P waves, most probably a junctional rhythm. ST segment\nelevations are noted in leads II, III, aVF and V6 with ST segment depressions\nin leads VI-V3. The tracing is consistent with an acute inferolateral process.\nTRACING #1\n\n"
}
] |
52,505 | 174,107 | ASSESSMENT/PLAN: This is a 63 yo M with Hep C cirrhosis c/b HCC invading the portal vein s/p TACE and RFA who presents from clinic with evidence of recent upper GIB concerning for variceal bleed. | IMPRESSION: Endotracheal tube in proper position. Unchanged dense calcifications within the liver reflect prior chemoembolization. REASON FOR THIS EXAMINATION: eval ETT position FINAL REPORT INDICATION: Status post variceal bleed. Evaluate endotracheal tube placement. The cardiomediastinal silhouette is normal. FINDINGS: An endotracheal tube ends approximately 4 cm from the carina. COMPARISONS: Chest radiograph, . The lungs are clear without consolidation or edema. There is no pleural effusion or pneumothorax. | 1 | [
{
"category": "Radiology",
"chartdate": "2145-12-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223623,
"text": " 12:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT position\n Admitting Diagnosis: LIVER CANCER;?ESOPHAGEAL VARICIES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with variceal bleed s/p intubation for EGD.\n REASON FOR THIS EXAMINATION:\n eval ETT position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post variceal bleed. Evaluate endotracheal tube\n placement.\n\n COMPARISONS: Chest radiograph, .\n\n FINDINGS: An endotracheal tube ends approximately 4 cm from the carina. The\n lungs are clear without consolidation or edema. There is no pleural effusion\n or pneumothorax. The cardiomediastinal silhouette is normal. Unchanged dense\n calcifications within the liver reflect prior chemoembolization.\n\n IMPRESSION: Endotracheal tube in proper position.\n\n\n"
}
] |
70,456 | 151,314 | Patient was worked up pre-operatively in the ususal manner. He was brought to the operating room on with Dr and underwent four-vessel coronary artery bypass grafting. Please see operative note for further details. Post-operatively he was admitted to the CVICU for invasive hemodynamic monitoring. His drips were weaned and he was extubated by post-op day 1. On post-op day 2 he was transferred to the step down floor for further care. Physical therapy was consulted to work on strength and conditioning. On post-op day 3 the patient went into rapid atrial fibrillation and was treates with Iv lopressor and amiodarone. Coumadin was started. He converted to sinus rhythm on the morning of POD 5. He continued to progress and was cleared for discharge to home on POD 6. | No MS. Eccentric MR jet.Moderate (2+) MR. to the eccentric MR jet, its severity may beunderestimated (Coanda effect).TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Normal ascending aortadiameter. Normal descending aorta diameter. Moderate (2+) MR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - body habitus. No AR.MITRAL VALVE: Mild mitral annular calcification. There is probabaly mild to moderate (+)mitral regurgitation is seen. Moderate (2+) mitral regurgitation is seen. Thereis moderate mitral regurgitation. Mild to moderate (+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Normal aortic arch diameter. Resting tachycardia(HR>100bpm).Conclusions:The left atrium is dilated. Normal interatrial septum. Mild resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated aortic sinus.AORTIC VALVE: Aortic valve not well seen. Brief ST episode with HR ^120s. MT and left CT to sxn- min-mod amt serosang drg-no leak/crepitus. Thereis no pericardial effusion.IMPRESSION: Hyperdynamic LV with a small cavity and a mild resting LVOTobstruction (due to hyperdynamic function rather than LV hypertrophy). No VSD.RIGHT VENTRICLE: Normal RV systolic function.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Hemodynamically stable on low dose neo for bp support after volume. Hemodynamically stable on low dose neo for bp support after volume. PATIENT/TEST INFORMATION:Indication: Intra-op TEE for CABGHeight: (in) 68Weight (lb): 174BSA (m2): 1.93 m2BP (mm Hg): 124/74HR (bpm): 70Status: InpatientDate/Time: at 10:13Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. The cardiomediastinal silhouette is within normal limits. There are simpleatheroma in the descending thoracic aorta.5. VF-VT coming off pump defib and converted to SR. Extubated 2100hr Mild hypotension, NEO gtt, IV fluid boluses. There is mild heterogeneous plaque in the proximal ICA bilaterally. The left ventricular cavity is unusually small.There is a mild resting left ventricular outflow tract obstruction. Valvular heart disease.Height: (in) 68Weight (lb): 183BSA (m2): 1.97 m2BP (mm Hg): 153/60HR (bpm): 77Status: InpatientDate/Time: at 13:43Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. recovered quickly with , commence precedex & reattempt later.occasional multiifocal pvcs & 1 self limited episode of vt noted with committent hypokalemia. recovered quickly with , commence precedex & reattempt later.occasional multiifocal pvcs & 1 self limited episode of vt noted with committent hypokalemia. IMPRESSION: Tubes removed, no pneumothorax. The mediastinal and left chest tube have been removed. Evaluate for AI , LV functionHeight: (in) 68Weight (lb): 195BSA (m2): 2.02 m2BP (mm Hg): 124/51HR (bpm): 105Status: InpatientDate/Time: at 15:30Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Small LV cavity. generalize edema. generalize edema. generalize edema. generalize edema. Brief ST episode with HR ^120s. Brief ST episode with HR ^120s. Brief ST episode with HR ^120s. Brief ST episode with HR ^120s. IMPRESSION: AP chest compared to preop study: Normal postoperative appearance following median sternotomy. post T->preserved biventricular function,dynamic mr + with optimization of hemosynamics(beta blockade,afterload support) vt/vf off pump->defib->nsr. post T->preserved biventricular function,dynamic mr + with optimization of hemosynamics(beta blockade,afterload support) vt/vf off pump->defib->nsr. post T->preserved biventricular function,dynamic mr + with optimization of hemosynamics(beta blockade,afterload support) vt/vf off pump->defib->nsr. post T->preserved biventricular function,dynamic mr + with optimization of hemosynamics(beta blockade,afterload support) vt/vf off pump->defib->nsr. Mild left mid lung atelectasis. : 76M s/p CABGx4(LIMA-LAD,SVG-,SVG-OM,SVG-PDA)-- post T->preserved biventricular function,dynamic mr EF 55%--VT/VF off pump required defib to NSR, fluid/Neo gtt for hemodynamic support. : 76M s/p CABGx4(LIMA-LAD,SVG-,SVG-OM,SVG-PDA)-- post T->preserved biventricular function,dynamic mr EF 55%--VT/VF off pump required defib to NSR, fluid/Neo gtt for hemodynamic support. : 76M s/p CABGx4(LIMA-LAD,SVG-,SVG-OM,SVG-PDA)-- post T->preserved biventricular function,dynamic mr EF 55%--VT/VF off pump required defib to NSR, fluid/Neo gtt for hemodynamic support. good cough Plan: Monitor HR/BP. good cough Plan: Monitor HR/BP. good cough Plan: Monitor HR/BP. good cough Plan: Monitor HR/BP. Rate pain level Action: Medicated with percocet 2tabs and ketorolac iv. Rate pain level Action: Medicated with percocet 2tabs and ketorolac iv. Rate pain level Action: Medicated with percocet 2tabs and ketorolac iv. Rate pain level Action: Medicated with percocet 2tabs and ketorolac iv. Morphine Sulfate 17. Last fs 145 at 0930->received 2riss Response: HR remains 70s-80s. Last fs 145 at 0930->received 2riss Response: HR remains 70s-80s. mild with sbp 120-140/60-80 which worsened with sbp 80-90/40/50.at these pressures mr was +. mild with sbp 120-140/60-80 which worsened with sbp 80-90/40/50.at these pressures mr was +. mild with sbp 120-140/60-80 which worsened with sbp 80-90/40/50.at these pressures mr was +. mild with sbp 120-140/60-80 which worsened with sbp 80-90/40/50.at these pressures mr was +. FS 145 at 0930->received 2riss Team updated and eval patient in am Response: HR remains 70s-80s. FS 145 at 0930->received 2riss Team updated and eval patient in am Response: HR remains 70s-80s. | 23 | [
{
"category": "Nursing",
"chartdate": "2153-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549895,
"text": "76y/o M CABG4 on . VF-VT coming off pump defib and converted to\n SR. Extubated 2100hr\n Mild hypotension, NEO gtt, IV fluid boluses. Insulin gtt overnight.\n Pain controlled with IV morphine 1-2mg PRN and Percocet PO. A&O.\n Afebrile. MAE\ns, steady progress overnight. Complies with CDB and\n sternal splinting. Weaned off pressors, SR 80\ns with occ PVC. Asleep\n at intervals. Transitioned this am from Insulin gtt. De-line and\n advance for transfer to stepdown.\n Hypotension (not Shock)\n Assessment:\n SBP 85-90mmHg\n Action:\n NEO gtt, IV fluid boluses\n Response:\n Improved SBP overnight, weaned off pressor. Stable SBP towards am\n Plan:\n De-line and advance for transfer to stepdown\n Pain control (acute pain, chronic pain)\n Assessment:\n Rated Incisional pain \n Action:\n Morphine Iv PRN. Percocet PO this am\n Response:\n Good analgesia provided with med intervention. Complies with CDB\n exercises\n Plan:\n Continue assessing for pain and document intervention accordigly\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549858,
"text": "Hemodynamically stable on low dose neo for bp support after volume.\n Failed wean attempt x 2 with severe agitation,kicking,thrashing in the\n bed with hypotension into the 70\ns & fall in svo2 into the high\n 30\ns-40\ns.not making eye contact or following commands. recovered\n quickly with , commence precedex & reattempt\n later.occasional multiifocal pvc\ns & 1 self limited episode of vt noted\n with committent hypokalemia. Lytes repleted as recorded, will continue\n to evaluate for vea with a low threshold for amiodarone if needed.\n Family in,questions answered.see flow sheet.\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 549864,
"text": "Hemodynamically stable on low dose neo for bp support after volume.\n Failed wean attempt x 2 with severe agitation,kicking,thrashing in the\n bed with hypotension into the 70\ns & fall in svo2 into the high\n 30\ns-40\ns.not making eye contact or following commands. recovered\n quickly with , commence precedex & reattempt\n later.occasional multiifocal pvc\ns & 1 self limited episode of vt noted\n with committent hypokalemia. Lytes repleted as recorded, will continue\n to evaluate for vea with a low threshold for amiodarone if needed.\n Family in,questions answered.see flow sheet.\n ------ Protected Section ------\n Precedex started allowing rapid extubation. c/o severe sternal pain at\n rest with poor resp. effort & splinting with drop in svo2 into the 50\n & spo2 into the low 90\ns. morphine given with little relief,toradol\n added with improved comfort & rise in svo2,spo2. vea\n continued.multifocal with occasional couplets. Discussed with\n team,persistent hypokalemia treated,amiodarone x 1 & additional\n magnesium given with significant improvement.pacer occasionally\n missensing despite settimg adjustments,changed to off mode. Plan\n probable transition to floor in a.m.\n ------ Protected Section Addendum Entered By: , RN\n on: 22:05 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-11-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 549853,
"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:\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Plan for extubation when ready\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt received from OR s/p CABG and is currently vented PSV 5/5 tol well\n with stable Vt. Will cont with vent support and extubated when ready.\n"
},
{
"category": "Echo",
"chartdate": "2153-11-28 00:00:00.000",
"description": "Report",
"row_id": 86395,
"text": "PATIENT/TEST INFORMATION:\nIndication: Recent CABG. Chest pain, widened pulse pressure. Evaluate for AI , LV function\nHeight: (in) 68\nWeight (lb): 195\nBSA (m2): 2.02 m2\nBP (mm Hg): 124/51\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 15:30\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: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Small LV cavity. Mild resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Aortic valve not well seen. No AS. No AR.\n\nMITRAL VALVE: Mitral valve leaflets not well seen. Moderate (2+) MR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - body habitus. Resting tachycardia\n(HR>100bpm).\n\nConclusions:\nThe left atrium is dilated. The left ventricular cavity is unusually small.\nThere is a mild resting left ventricular outflow tract obstruction. Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmildly dilated at the sinus level. The aortic valve is not well seen. There is\nno aortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are not well seen. Moderate (2+) mitral regurgitation is seen. There\nis no pericardial effusion.\n\nIMPRESSION: Hyperdynamic LV with a small cavity and a mild resting LVOT\nobstruction (due to hyperdynamic function rather than LV hypertrophy). There\nis moderate mitral regurgitation. Aortic valve is not well seen but there is\nno stenosis or significant regurgitation.\n\nCompared with the prior study (images reviewed) of , image quality\nis not as good. The limited findings are similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2153-11-26 00:00:00.000",
"description": "Report",
"row_id": 86396,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for CABG\nHeight: (in) 68\nWeight (lb): 174\nBSA (m2): 1.93 m2\nBP (mm Hg): 124/74\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:13\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic\narch. Normal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mild mitral annular calcification. No MS. Eccentric MR jet.\nModerate (2+) MR. to the eccentric MR jet, its severity may be\nunderestimated (Coanda effect).\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was 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. See Conclusions for post-bypass data The\npost-bypass study was performed while the patient was receiving vasoactive\ninfusions (see Conclusions for listing of medications).\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler.\n2. Overall left ventricular systolic function is normal (LVEF>55%).\n3. Right ventricular chamber size and free wall motion are normal.\n4. There are complex (>4mm) atheroma in the aortic arch. There are simple\natheroma in the descending thoracic aorta.\n5. There are three aortic valve leaflets. There is no aortic valve stenosis.\nNo aortic regurgitation is seen.\n6. An eccentric, anterior directed jet of Moderate (2 -3 +) mitral\nregurgitation is seen. Due to the eccentric nature of the regurgitant jet, its\nseverity may be significantly underestimated (Coanda effect). Mild is seen\nat high pressures ( 120-140/ 60-80 mm of Hg), which worsens to moderate at\nlower pressures ( 80-90/40-50 mm of Hg). At these pressure MR worsens to +.\n\nDr. was notified in person of the results.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving vasoactive\ninfusions including phenylephrine and is in sinus rhythm.\n1. Biventricular function is preserved.\n2. MR and + with medical optimization of hemodynamics ( beta\nblockade, After load support)\n3. Aortic contours appear intact post decannulation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2153-11-21 00:00:00.000",
"description": "Report",
"row_id": 86397,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Preoperative assessment. Valvular heart disease.\nHeight: (in) 68\nWeight (lb): 183\nBSA (m2): 1.97 m2\nBP (mm Hg): 153/60\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 13:43\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with >55% decrease\nduring respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nSuboptimal image quality. The left atrium is normal in size. No atrial septal\ndefect is seen by 2D or color Doppler. The estimated right atrial pressure is\n0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global\nsystolic function are normal (LVEF >55%). There is no ventricular septal\ndefect. RV with normal free wall contractility. The aortic valve leaflets (3)\nare mildly thickened but aortic stenosis is not present. The mitral valve\nleaflets are mildly thickened. There is probabaly mild to moderate (+)\nmitral regurgitation is seen. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-11-21 00:00:00.000",
"description": "P CAROTID SERIES COMPLETE PORT",
"row_id": 1053017,
"text": " 12:03 PM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: Assess for sign. disease. Preop CABG\n Admitting Diagnosis: SHORTNESS OF BREATH\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with h/o LT hemispheric TIA in past when severely HTNive\n REASON FOR THIS EXAMINATION:\n Assess for sign. disease. Preop CABG\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: TIA.\n\n FINDINGS: Duplex evaluation was performed of bilateral carotid arteries.\n There is mild heterogeneous plaque in the proximal ICA bilaterally.\n\n On the right, peak velocities are 78, 75, and 113 cm/sec in the ICA, CCA, and\n ECA respectively. This is consistent with less than 40% stenosis.\n\n On the left, peak velocities are 116, 75 and 87 cm/sec in the ICA, CCA, and\n ECA respectively. This is consistent with 40-59% stenosis.\n\n There is antegrade vertebral flow bilaterally.\n\n IMPRESSION: Less than 40% right ICA stenosis. 40-59% left ICA stenosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-12-01 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1054620,
"text": " 11:44 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for pneumo, collections, etc\n Admitting Diagnosis: SHORTNESS OF BREATH\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p cabg with dyspnea\n REASON FOR THIS EXAMINATION:\n please eval for pneumo, collections, etc\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post CABG with dyspnea.\n\n CHEST\n\n Cardiac size is upper limits of normal, evidence of prior CABG. No failure is\n seen. Mild blunting of both costophrenic angles is present and some\n atelectasis at both bases is seen. There is no evidence of pneumothorax.\n\n IMPRESSION: No failure, no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1054159,
"text": " 6:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax s/p chest tube removal\n Admitting Diagnosis: SHORTNESS OF BREATH\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n WET READ: GWp WED 8:57 PM\n 3 chest tubes, Swan, ETT and OGT out. No PTX GWlms\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Chest tube removed, evaluate for pneumothorax.\n\n The mediastinal and left chest tube have been removed. No evidence for\n pneumothorax is seen, the lung fields appear clear. No failure seen.\n Swan-Ganz and endotracheal tube have also been removed.\n\n IMPRESSION: Tubes removed, no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-11-23 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1053230,
"text": " 10:50 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: SHORTNESS OF BREATH\\CATH\n Admitting Diagnosis: SHORTNESS OF BREATH\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with 3vd awaiting CABG\n REASON FOR THIS EXAMINATION:\n please assesss for infiltrate\n ______________________________________________________________________________\n WET READ: JKSd FRI 12:26 PM\n Flattening of diaphragms and increased AP diameter consistent with\n hyperinflation of lungs. Otherwise, lungs clear. No acute intrathoracic\n process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man with three-vessel disease awaiting CABG. Please\n assess for infiltrates.\n\n COMPARISON: None.\n\n TECHNIQUE: PA and lateral views of the chest.\n\n FINDINGS: The lungs appear clear bilaterally with no evidence of pneumonia.\n There is some flattening of the diaphragms with a slightly increased AP\n diameter suggestive of emphysema. A right cardiophrenic density is most\n likely epicardial fat. The cardiomediastinal silhouette is within normal\n limits. The visualized portions of the thoracic spine demonstrate\n degenerative changes. Note is made of cervical spine hardware and surgical\n clips in the left upper and the right lower lobes.\n\n IMPRESSION: No evidence of pneumonia. Flattened diaphragms and increase in\n the AP diameter of the chest, compatible with emphysema.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 549925,
"text": "Patient with significant pmh for hypertension and sob ongoing for more\n >15 years, TIA.\n : s/p CABG x4, VT/VF off pump required defib to NSR, fluid/Neo\n gtt for hemodynamic support. Extubated. Delined in am\n POD #1.\n Coronary artery bypass graft (CABG)\n Assessment:\n Received patient in NSR 80s, no ectopties. Brief ST episode with HR\n ^120s. NBP sbp 100s-110s/30s given map mid 50s-marginal 60s. Received\n Lasix 20mg at 0600->diuresis sufficient huo. Skin w/d. 2+pp.\n generalize edema. MT and left CT to sxn- min-mod amt serosang drg-no\n leak/crepitus. Hct 27.\n Vancomycin x4 doses. c/o Pain\n Action:\n Started Lopressor 25mg po\n Control pain\n Teach IS and encourage DBC. Oob to chair. Start eating\n jello this am\n Received 10units lantus/regular riss by night shift\n Rn\ntransitioned to sc . Last fs 145 at 0930->received 2riss\n Response:\n HR remains 70s-80s. SBP 100s/map mid 50s. pain relief. IS ^750ml.\n good cough\n Plan:\n Monitor HR/BP. Pulmonary hygiene. ^activity and diet as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o of sternal wound pain and Ct site pain. Described as\nsharp\n and constant\n at rest and worst with dbc/moving. Rate pain level \n Action:\n Medicated with percocet 2tabs and ketorolac iv. Reposition\n Response:\n Improved. Pain level now \n Plan:\n Control pain above regimen.\n"
},
{
"category": "Physician ",
"chartdate": "2153-11-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 549931,
"text": "CVICU\n HPI:\n HD7\n POD 1\n 76M s/p CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)\n EF 55% Cr 1.0 Wt 79.4K\n PMH: HTN, Prostate CA-s/p XRT/seed implant, Bursitis, R rotator cuff,\n C5-6 fusion, Lumbar laminectomy\n : Amlopidine 10', Avapro 500', Lisinopril 40', Lopressor SR 400',\n Crestor 10', Flomax 0.4', ASA 81'\n Current medications:\n Acetaminophen 4. Aspirin 8. Furosemide 9. HYDROmorphone (Dilaudid) 10.\n Insulin 11. Ketorolac 14. Metoprolol 16. Morphine Sulfate 17.\n Oxycodone-Acetaminophen 19. Ranitidine 20. Vancomycin\n 24 Hour Events:\n OR RECEIVED - At 01:05 PM\n INVASIVE VENTILATION - START 01:05 PM\n INTUBATION - At 01:10 PM\n from OR intubated\n NASAL SWAB - At 01:25 PM\n EKG - At 01:30 PM\n ARTERIAL LINE - START 02:07 PM\n CORDIS/INTRODUCER - START 02:08 PM\n CCO PAC - START 02:08 PM\n INVASIVE VENTILATION - STOP 08:42 PM\n EXTUBATION - At 08:51 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:04 PM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 05:37 PM\n Insulin - Regular - 07:54 PM\n Morphine Sulfate - 05:00 AM\n Furosemide (Lasix) - 06:17 AM\n Other medications:\n Flowsheet Data as of 10:53 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: 78 (78 - 95) bpm\n BP: 108/36(53) {101/36(53) - 113/49(61)} mmHg\n RR: 16 (12 - 23) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 9 (3 - 13) mmHg\n PAP: (26 mmHg) / (16 mmHg)\n CO/CI (Fick): (5.8 L/min) / (3 L/min/m2)\n CO/CI (CCO): (7.7 L/min) / (3.7 L/min/m2)\n SvO2: 66%\n Mixed Venous O2% sat: 84 - 84\n Total In:\n 5,602 mL\n 117 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,602 mL\n 117 mL\n Blood products:\n Total out:\n 1,985 mL\n 1,125 mL\n Urine:\n 1,465 mL\n 735 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,617 mL\n -1,008 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 543 (321 - 543) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 11 cmH2O\n Plateau: 16 cmH2O\n SPO2: 99%\n ABG: 7.42/38/165/28/0\n Ve: 10.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 224 K/uL\n 9.8 g/dL\n 82 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 103 mEq/L\n 135 mEq/L\n 27.1 %\n 14.0 K/uL\n [image002.jpg]\n 11:02 AM\n 11:31 AM\n 12:05 PM\n 12:11 PM\n 01:26 PM\n 01:48 PM\n 04:56 PM\n 08:07 PM\n 08:40 PM\n 04:01 AM\n WBC\n 11.9\n 18.4\n 14.0\n Hct\n 25\n 25\n 23.9\n 28\n 30.1\n 27.2\n 27.1\n Plt\n \n Creatinine\n 0.9\n 1.0\n TCO2\n 29\n 31\n 29\n 26\n 25\n Glucose\n 151\n 158\n 169\n 124\n 108\n 120\n 82\n Other labs: PT / PTT / INR:15.7/40.2/1.4, Fibrinogen:224 mg/dL, Lactic\n Acid:1.7 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG), HYPOTENSION (NOT SHOCK), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan:\n Neurologic: Percocet and Toradol for pain\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor\n Pulmonary: IS, Extubated this AM; PT/OOB\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO\n Hematology: Mod anemia --> cont to follow\n Endocrine: RISS with Lantus\n Infectious Disease: periop Vanco\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 10:25 AM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-11-27 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 549932,
"text": "CVICU\n , CC7C-0797-01 76 \n , R.\n Allergies: NKDA\n Resident: , <\n Last Updated by , on @ 2222 Patient location\n when updated: CC7C-0797-01\n HD7\n POD 1\n 76M s/p CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)\n EF 55% Cr 1.0 Wt 79.4K\n PMHx:\n PMH: HTN, Prostate CA-s/p XRT/seed implant, Bursitis, R rotator cuff,\n C5-6 fusion, Lumbar laminectomy\n : Amlopidine 10', Avapro 500', Lisinopril 40', Lopressor SR 400',\n Crestor 10', Flomax 0.4', ASA 81'\n Current medications:\n Aspirin EC Docusate Sodium Furosemide HYDROmorphone (Dilaudid)\n Insulin Ketorolac Metoclopramide\n Metoprolol Tartrate Morphine Sulfate Oxycodone-Acetaminophen\n Ranitidine Vancomycin\n 24 Hour Events:\n OR RECEIVED - At 01:05 PM\n INVASIVE VENTILATION - START 01:05 PM\n INTUBATION - At 01:10 PM\n from OR intubated\n NASAL SWAB - At 01:25 PM\n EKG - At 01:30 PM\n ARTERIAL LINE - START 02:07 PM\nCORDIS/INTRODUCER - START 02:08 PM\n CCO PAC - START 02:08 PM\n INVASIVE VENTILATION - STOP 08:42 PM\n EXTUBATION - At 08:51 PM\n 24 hour events: Surgery/extubated-hemodynamically stable\n Post operative day:\n POD1\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:04 PM\n Other ICU medications:\n Ranitidine (Prophylaxis) - 05:37 PM\n Insulin - Regular - 07:54 PM\n Morphine Sulfate - 05:00 AM\n Furosemide (Lasix) - 06:17 AM\n Flowsheet Data as of 10:54 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: 78 (78 - 95) bpm\n BP: 108/36(53) {101/36(53) - 113/49(61)} mmHg\n RR: 16 (12 - 23) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 9 (3 - 13) mmHg\n PAP: (26 mmHg) / (16 mmHg)\n CO/CI (Fick): (5.8 L/min) / (3 L/min/m2)\n CO/CI (CCO): (7.7 L/min) / (3.5 L/min/m2)\n SvO2: 66%\n Mixed Venous O2% sat: 84 - 84\n Total In:\n 5,602 mL\n 118 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,602 mL\n 118 mL\n Blood products:\n Total out:\n 1,985 mL\n 1,125 mL\n Urine:\n 1,465 mL\n 735 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 3,617 mL\n -1,007 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n SPO2: 99%\n ABG: 7.42/38/165/28/0\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, hypoactive BS\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 224 K/uL\n 9.8 g/dL\n 82 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 4.4 mEq/L\n 16 mg/dL\n 103 mEq/L\n 135 mEq/L\n 27.1 %\n 14.0 K/uL\n [image002.jpg]\n 11:02 AM\n 11:31 AM\n 12:05 PM\n 12:11 PM\n 01:26 PM\n 01:48 PM\n 04:56 PM\n 08:07 PM\n 08:40 PM\n 04:01 AM\n WBC\n 11.9\n 18.4\n 14.0\n Hct\n 25\n 25\n 23.9\n 28\n 30.1\n 27.2\n 27.1\n Plt\n \n Creatinine\n 0.9\n 1.0\n TCO2\n 29\n 31\n 29\n 26\n 25\n Glucose\n 151\n 158\n 169\n 124\n 108\n 120\n 82\n Other labs: PT / PTT / INR:15.7/40.2/1.4, Fibrinogen:224 mg/dL, Lactic\n Acid:1.7 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG), HYPOTENSION (NOT SHOCK), PAIN\n CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 76yo man s/p cabg. hemodynamically stable and\n doing well post-operatively\n Neurologic: Pain controlled, dilaudia and toradol\n Cardiovascular: Aspirin, Beta-blocker, Statins, resume Bblocker and\n statin\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, start diuretics\n Hematology: stable hct\n Endocrine: Insulin drip, covert to lantus and RISS\n Infectious Disease: no active issues\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires, rt IJ cordis\n Wounds: Dry dressings\n Fluids: KVO\n ICU Care\n Nutrition: ADAT\n Glycemic Control: Insulin infusion, Comments: convert to lantus/RISS\n Lines: 20 Gauge - 10:25 AM\n Prophylaxis:\n DVT: ambulate\n Stress ulcer: H2 blocker\n Comments: OOB ambulate today\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 549936,
"text": "Patient with significant pmh for hypertension and sob ongoing for more\n >15 years, TIA.\n : 76M s/p CABGx4(LIMA-LAD,SVG-,SVG-OM,SVG-PDA)\n EF 55% Cr 1.0, VT/VF off pump required defib to NSR, fluid/Neo gtt for\n hemodynamic support. Extubated. Delined in am\n POD #1.\n Wt 79.4K\n Coronary artery bypass graft (CABG)\n Assessment:\n Received patient in NSR 80s, no ectopties. Brief ST episode with HR\n ^120s. NBP sbp 100s-110s/30s given map mid 50s-marginal 60s. Received\n Lasix 20mg at 0600->diuresis sufficient huo. Skin w/d. 2+pp.\n generalize edema. MT and left CT to sxn- min-mod amt serosang drg-no\n leak/crepitus. Hct 27.\n Vancomycin x4 doses. c/o Pain\n Action:\n Started Lopressor 25mg po\n Control pain\n Teach IS and encourage DBC. Oob to chair. Start eating\n jello this am\n Received 10units lantus/regular riss by night shift\n Rn\ntransitioned to sc . Last fs 145 at 0930->received 2riss\n Response:\n HR remains 70s-80s. SBP 100s/map mid 50s. pain relief. IS ^750ml.\n good cough\n Plan:\n Monitor HR/BP. Pulmonary hygiene. ^activity and diet as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o of sternal wound pain and Ct site pain. Described as\nsharp\n and constant\n at rest and worst with dbc/moving. Rate pain level \n Action:\n Medicated with percocet 2tabs and ketorolac iv. Reposition\n Response:\n Improved. Pain level now \n Plan:\n Control pain above regimen.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n SHORTNESS OF BREATH CATH\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 79.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemai,bursitis,c5-6 fusion,lumbar\n laminectomy,hx tia's- pre op nics-> < 40% on rt.,40-60% left,,prostate\n ca s/p xrt,radioactive seeds,known cad with progressive cp,doe,+\n ett.cath->3 vd,severe diastolic dysfunction with lvedp ~ 29,ef 50-60%\n with 1-2+ mr.\n Surgery / Procedure and date: c x 4 lima->lad,vg->,,pda\n pre T->complex atheroma asc. aorta.+ mr ,severeity may be\n underestimated. mild with sbp 120-140/60-80 which worsened with sbp\n 80-90/40/50.at these pressures mr was +. post T->preserved\n biventricular function,dynamic mr + with optimization of\n hemosynamics(beta blockade,afterload support) vt/vf off\n pump->defib->nsr.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:39\n Temperature:\n 98.4\n Arterial BP:\n S:105\n D:41\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 529 mL\n 24h total out:\n 1,225 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n No\n Temporary atrial sensitivity threshold:\n 0.4 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 2.5 mV\n Temporary ventricular sensitivity setting:\n 1 mV\n Temporary ventricular stimulation threshold :\n 9 mA\n Temporary ventricular stimulation setting :\n 18 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:01 AM\n Potassium:\n 4.4 mEq/L\n 04:01 AM\n Chloride:\n 103 mEq/L\n 04:01 AM\n CO2:\n 28 mEq/L\n 04:01 AM\n BUN:\n 16 mg/dL\n 04:01 AM\n Creatinine:\n 1.0 mg/dL\n 04:01 AM\n Glucose:\n 82 mg/dL\n 04:01 AM\n Hematocrit:\n 27.1 %\n 04:01 AM\n Finger Stick Glucose:\n 145\n 11:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 549937,
"text": "Patient with significant pmh for hypertension and sob ongoing for more\n >15 years, TIA.\n : 76M s/p CABGx4(LIMA-LAD,SVG-,SVG-OM,SVG-PDA)-- post\n T->preserved biventricular function,dynamic mr \n EF 55%--VT/VF off pump required defib to NSR, fluid/Neo gtt for\n hemodynamic support. Extubated. Delined in am\n POD #1.\n Coronary artery bypass graft (CABG)\n Assessment:\n Received patient in NSR 80s, no ectopties. Brief ST episode with HR\n ^120s. NBP sbp 100s-110s/30s given map mid 50s-marginal 60s. Received\n Lasix 20mg at 0600->diuresis sufficient huo. Skin w/d. 2+pp.\n generalize edema. MT and left CT to sxn- min-mod amt serosang drg-no\n leak/crepitus. Hct 27.\n Vancomycin x4 doses. c/o Pain\n Action:\n Started Lopressor 25mg po\n Control pain\n Teach IS and encourage DBC. Oob to chair. Start eating\n jello this am\n Received 10units lantus/regular riss by night shift\n Rn\ntransitioned to sc . Last fs 145 at 0930->received 2riss\n Response:\n HR remains 70s-80s. SBP 100s/map mid 50s. pain relief. IS ^750ml.\n good cough\n Plan:\n Monitor HR/BP. Pulmonary hygiene. ^activity and diet as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o of sternal wound pain and Ct site pain. Described as\nsharp\n and constant\n at rest and worst with dbc/moving. Rate pain level \n Action:\n Medicated with percocet 2tabs and ketorolac iv. Reposition\n Response:\n Improved. Pain level now \n Plan:\n Control pain above regimen.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n SHORTNESS OF BREATH CATH\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 79.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemai,bursitis,c5-6 fusion,lumbar\n laminectomy,hx tia's- pre op nics-> < 40% on rt.,40-60% left,,prostate\n ca s/p xrt,radioactive seeds,known cad with progressive cp,doe,+\n ett.cath->3 vd,severe diastolic dysfunction with lvedp ~ 29,ef 50-60%\n with 1-2+ mr.\n Surgery / Procedure and date: c x 4 lima->lad,vg->,,pda\n pre T->complex atheroma asc. aorta.+ mr ,severeity may be\n underestimated. mild with sbp 120-140/60-80 which worsened with sbp\n 80-90/40/50.at these pressures mr was +. post T->preserved\n biventricular function,dynamic mr + with optimization of\n hemosynamics(beta blockade,afterload support) vt/vf off\n pump->defib->nsr.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:39\n Temperature:\n 98.4\n Arterial BP:\n S:105\n D:41\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 529 mL\n 24h total out:\n 1,225 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n No\n Temporary atrial sensitivity threshold:\n 0.4 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 2.5 mV\n Temporary ventricular sensitivity setting:\n 1 mV\n Temporary ventricular stimulation threshold :\n 9 mA\n Temporary ventricular stimulation setting :\n 18 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:01 AM\n Potassium:\n 4.4 mEq/L\n 04:01 AM\n Chloride:\n 103 mEq/L\n 04:01 AM\n CO2:\n 28 mEq/L\n 04:01 AM\n BUN:\n 16 mg/dL\n 04:01 AM\n Creatinine:\n 1.0 mg/dL\n 04:01 AM\n Glucose:\n 82 mg/dL\n 04:01 AM\n Hematocrit:\n 27.1 %\n 04:01 AM\n Finger Stick Glucose:\n 145\n 11:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 549939,
"text": "Patient with significant pmh for hypertension and sob ongoing for more\n >15 years, TIA.\n : 76M s/p CABGx4(LIMA-LAD,SVG-,SVG-OM,SVG-PDA)-- post\n T->preserved biventricular function,dynamic mr \n EF 55%--VT/VF off pump required defib to NSR, fluid/Neo gtt for\n hemodynamic support. Extubated. Delined in am\n POD #1.\n Coronary artery bypass graft (CABG)\n Assessment:\n Received patient in NSR 80s, no ectopties. Brief ST episode with HR\n ^120s. NBP sbp 100s-110s/30s given map mid 50s-marginal 60s. Received\n Lasix 20mg at 0600->diuresis sufficient huo. Skin w/d. 2+pp.\n generalize edema. MT and left CT to sxn- min-mod amt serosang drg-no\n leak/crepitus. Hct 27.\n Vancomycin x4 doses. c/o Pain\n Action:\n Started Lopressor 25mg po\n Control pain\n Teach IS and encourage DBC. Oob to chair. Start eating\n jello this am\n Received 10units lantus/regular riss by night shift\n Rn\ntransitioned to sc . FS 145 at 0930->received 2riss\n Team updated and eval patient in am\n Response:\n HR remains 70s-80s. SBP 100s/map mid 50s. pain relief. IS ^750ml.\n good cough\n Plan:\n Monitor HR/BP. Pulmonary hygiene. ^activity and diet as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o of sternal wound pain and Ct site pain. Described as\nsharp\n and constant\n at rest and worst with dbc/moving. Rate pain level \n Action:\n Medicated with percocet 2tabs and ketorolac iv. Reposition\n Response:\n Improved. Pain level now \n Plan:\n Control pain above regimen.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n SHORTNESS OF BREATH CATH\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 79.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemai,bursitis,c5-6 fusion,lumbar\n laminectomy,hx tia's- pre op nics-> < 40% on rt.,40-60% left,,prostate\n ca s/p xrt,radioactive seeds,known cad with progressive cp,doe,+\n ett.cath->3 vd,severe diastolic dysfunction with lvedp ~ 29,ef 50-60%\n with 1-2+ mr.\n Surgery / Procedure and date: c x 4 lima->lad,vg->,,pda\n pre T->complex atheroma asc. aorta.+ mr ,severeity may be\n underestimated. mild with sbp 120-140/60-80 which worsened with sbp\n 80-90/40/50.at these pressures mr was +. post T->preserved\n biventricular function,dynamic mr + with optimization of\n hemosynamics(beta blockade,afterload support) vt/vf off\n pump->defib->nsr.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:39\n Temperature:\n 98.4\n Arterial BP:\n S:105\n D:41\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 529 mL\n 24h total out:\n 1,225 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n No\n Temporary atrial sensitivity threshold:\n 0.4 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 2.5 mV\n Temporary ventricular sensitivity setting:\n 1 mV\n Temporary ventricular stimulation threshold :\n 9 mA\n Temporary ventricular stimulation setting :\n 18 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:01 AM\n Potassium:\n 4.4 mEq/L\n 04:01 AM\n Chloride:\n 103 mEq/L\n 04:01 AM\n CO2:\n 28 mEq/L\n 04:01 AM\n BUN:\n 16 mg/dL\n 04:01 AM\n Creatinine:\n 1.0 mg/dL\n 04:01 AM\n Glucose:\n 82 mg/dL\n 04:01 AM\n Hematocrit:\n 27.1 %\n 04:01 AM\n Finger Stick Glucose:\n 145\n 11:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2153-11-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 549943,
"text": "Patient with significant pmh for hypertension and sob ongoing for more\n >15 years, TIA.\n : 76M s/p CABGx4(LIMA-LAD,SVG-,SVG-OM,SVG-PDA)-- post\n T->preserved biventricular function,dynamic mr \n EF 55%--VT/VF off pump required defib to NSR, fluid/Neo gtt for\n hemodynamic support. Extubated. Delined in am\n POD #1.\n Coronary artery bypass graft (CABG)\n Assessment:\n Received patient in NSR 80s, no ectopties. Brief ST episode with HR\n ^120s. NBP sbp 100s-110s/30s given map mid 50s-marginal 60s. Received\n Lasix 20mg at 0600->diuresis sufficient huo. Skin w/d. 2+pp.\n generalize edema. MT and left CT to sxn- min-mod amt serosang drg-no\n leak/crepitus. Hct 27.\n Vancomycin x4 doses. c/o Pain\n Action:\n Started Lopressor 25mg po\n Control pain\n Teach IS and encourage DBC. Oob to chair. Start eating\n jello this am\n Received 10units lantus/regular riss by night shift\n Rn\ntransitioned to sc . FS 145 at 0930->received 2riss\n Team updated and eval patient in am\n Response:\n HR remains 70s-80s. SBP 100s/map mid 50s. pain relief. IS ^750ml.\n good cough\n Plan:\n Monitor HR/BP. Pulmonary hygiene. ^activity and diet as tolerated.\n support\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient c/o of sternal wound pain and Ct site pain. Described as\nsharp\n and constant\n at rest and worst with dbc/moving. Rate pain level \n Action:\n Medicated with percocet 2tabs and ketorolac iv. Reposition\n Response:\n Improved. Pain level now \n Plan:\n Control pain above regimen.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n SHORTNESS OF BREATH CATH\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 79.4 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemai,bursitis,c5-6 fusion,lumbar\n laminectomy,hx tia's- pre op nics-> < 40% on rt.,40-60% left,,prostate\n ca s/p xrt,radioactive seeds,known cad with progressive cp,doe,+\n ett.cath->3 vd,severe diastolic dysfunction with lvedp ~ 29,ef 50-60%\n with 1-2+ mr.\n Surgery / Procedure and date: c x 4 lima->lad,vg->,,pda\n pre T->complex atheroma asc. aorta.+ mr ,severeity may be\n underestimated. mild with sbp 120-140/60-80 which worsened with sbp\n 80-90/40/50.at these pressures mr was +. post T->preserved\n biventricular function,dynamic mr + with optimization of\n hemosynamics(beta blockade,afterload support) vt/vf off\n pump->defib->nsr.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:39\n Temperature:\n 98.4\n Arterial BP:\n S:105\n D:41\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 79 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 529 mL\n 24h total out:\n 1,225 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n No\n Temporary atrial sensitivity threshold:\n 0.4 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 2.5 mV\n Temporary ventricular sensitivity setting:\n 1 mV\n Temporary ventricular stimulation threshold :\n 9 mA\n Temporary ventricular stimulation setting :\n 18 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:01 AM\n Potassium:\n 4.4 mEq/L\n 04:01 AM\n Chloride:\n 103 mEq/L\n 04:01 AM\n CO2:\n 28 mEq/L\n 04:01 AM\n BUN:\n 16 mg/dL\n 04:01 AM\n Creatinine:\n 1.0 mg/dL\n 04:01 AM\n Glucose:\n 82 mg/dL\n 04:01 AM\n Hematocrit:\n 27.1 %\n 04:01 AM\n Finger Stick Glucose:\n 145\n 11:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Radiology",
"chartdate": "2153-11-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1053644,
"text": " 1:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: SHORTNESS OF BREATH\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD s/p CABG. Please page at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:33 P.M., ON \n\n HISTORY: Status post CABG.\n\n IMPRESSION: AP chest compared to preop study:\n\n Normal postoperative appearance following median sternotomy. Mild left mid\n lung atelectasis. No pneumothorax, pleural effusion or mediastinal widening.\n Heart size normal. ET tube, Swan-Ganz catheter and nasogastric tube are in\n standard placements.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2153-12-02 00:00:00.000",
"description": "Report",
"row_id": 241866,
"text": "Sinus rhythm. P-R interval is 200 milliseconds. Non-specific ST segment\nflattening in the lateral leads. Compared to the previous tracing of \nthe ST segment flattening is slightly more pronounced consistent with, but not\ndiagnostic of ischemia.\n\n"
},
{
"category": "ECG",
"chartdate": "2153-11-26 00:00:00.000",
"description": "Report",
"row_id": 241867,
"text": "Sinus rhythm. A-V conduction delay. Compared to the previous tracing\nof the rate has increased. The P-R interval is slightly longer.\nOtherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2153-11-21 00:00:00.000",
"description": "Report",
"row_id": 241868,
"text": "Sinus rhythm. Normal ECG. Compared to the previous tracing no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2153-11-21 00:00:00.000",
"description": "Report",
"row_id": 241869,
"text": "Normal sinus rhythm. Normal ECG. No previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
8,535 | 183,861 | IMPRESSION: No pneumothorax, status post CABG with satisfactory postoperative status. Rule out pneumothorax. The right jugular SG catheter terminates in the right main PA. POST-OPD: PT S/P CABG X 3 TODAY- LIMA TO LAD, SVG TO OM, DIAG- TOL WELL, OR UNEVENTFULL TO CSRU ON EPI/NEO.PROPOFOL, INTUBATED, 1 L PL CT, 1 MED CT. FOLET IN PLACE.PT AWOKEN AND EXTUBATED WITHOUT INCIDENT,PT REVERSED, PROPOFOL TO OFF NEO TO OFF- EPI TO OFF- STARTED LOW DOSE NTG.NEURO; PT WOKE SLIGHTLY AGITATED-EASILY CALMED WITH REASSURANCE. Right bundle-branch block.Diffuse non-diagnostic repolarization abnormalities. PA AND LATERAL CHEST: Heart size, mediastinal contours, and pulmonary vasculature are within normal limits. Decreased appetite.FEN: K+, Ca++, Mg++ repleted doing.GU: U/O qs. N+V treated with reglan then zofran with good effect. Patchy atelectasis is seen at the lung bases. Patchy atelectasis is seen at the lung bases. Also, the PR segment is elevatedin lead aVR and depressed in the lateral leads. FINAL REPORT INDICATION: CABG and chest tube removal. updateD: pt POD #1 from CAbg x 3, progressing well- sbp & hr elevated- started po lopressor- with some - pt oob to chair, intermttently c/o nausea appears to be sensitive to motion- nayusea resolves without tx- pt encouraged to take db thru nose and relax. The tracing suggests prior inferior myocardial infarctionwith superimposed anterolateral ischemic and/or pericarditic process. The heart and mediastinum are within normal limits. Lasix given this a.m.Pulses palpable, BLE warm, left ace wrap on.RESP: LS intermittently wheezy, coarse, diminished. Inferior myocardial infarction. Post chest tube removal. Compared to theprevious tracing of lasteral and mid-precordial ST segment elevation ismore prominent, consistent with ongoing evolution of lateral ischemiaand/or pericarditis. bun/creat wnl.inc: intact.discomfort: pt c/o more pain in left chest area- ? There are evidence of pericardial effusions or pleural effusions. The left chest tube and mediastinal drain are in place. FINDINGS: The cardiac and mediastinal contours are unchanged. IMPRESSION: Satisfactory postoperative status S/P CABG. Inparticular, focal lateral pericarditis is to be considered. O2, CT, etc. Patient is status post CABG and median sternotomy. AP UPRIGHT CHEST: Compared with one day prior, the left-sided chest tube and right central venous catheter has been removed. Refused Percocet d/t c/o it making him nauseous; MSO4 4mg IV given with apparent relief. The ET tube has been removed. Sinus tachycardia. The patient is status post CABG and mediasternotomy. Pt c/o of pain, given MSO4 with effect. assoc with l pl ct-pt responds to po percocet better than mso4 for relief of pain.plan: give po lopressor, eval response- d/c left pl ct in am.transfer to floor in am. Small mediastinal lymph nodes. LUNG MASS ON PRE-OP CHEST. COMPARISON: Chest radiograph . The airways are patent to the level of the segmental bronchi bilaterally. Pt cont without BM. The cardiac and mediastinal contours are unchanged. PALP PEDAL PULSES BILAT- LEFT WEAKER THEN RIGHT. There are sternotomy wires. Lungs are course but CTA, encourabed to cough and deep breathe. 9:59 AM CT CHEST W/O CONTRAST Clip # Reason: Q. abd soft, bs present. Hemodynamically pt is stable, no gtts, CO/CI wnl. Incomplete right bundle-branch block. updateD: u/o noted to be down, hr >100 consistently with adeq sbp- cvp 10A: pt tx with 500ns bolus Pt using MDIs ? C/O pain d/t left pleural CT, pain around incision. There is mild blunting of the left costophrenic angle. Zofran and Reglan given. ABD SOFT, BS ABSENT. 2) Bilateral lower lobe atelectasis. 8:33 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for infiltrate, effusion, PTX. TECHNIQUE: Multiple helically-acquired axial images were obtained from the chest without the administration of intravenous contrast. COUGHING WITHOUT RAISING.GI: OGT IN PLACE POST-OP DRAINING BILIOUS MATERIAL. The visualized portion of the upper abdomen is unremarkable except for a small splenule. PT WITH 1 A WIRE, 1 SKIN AND 2 VENT WIRES- SENSING ACCURATELY BUT AT TIMES FIRING WHEN NOT NECESSARY- THUS PACER TURNED TO OFF FOR SAFETY REASON (SPIKE ON T WWAVE)RESP: PT WEANED AND EXTUBATED, PLACED ON 4L NP WITH SAT >99%, BS CLEAR SLIGHTLY DIM IN BASES. ST segmentelevation in leads I, II, aVL, aVF and V2-V6 with T wave inversion inleads III, aVF and the mid-precordial leads. infiltrate FINAL REPORT HISTORY: 79 y/o status post CABG. There is bilateral lower lobe atelectasis. The patient has been extubated and the right jugular venous catheter has been changed to a Podis sheath. A nasogastric tube terminates in the stomach. The right lung is better aerated. MAE, ORIENTED X 3, WHEN PT FALLS WAKES DISORIENTED-EASILY REORIENTED. CARAFATE GIVEN PRIOR TO REMOVAL WITH EXTUBATION. 3:02 PM CHEST (PA & LAT) Clip # Reason: ? SHift NoteNeurologically pt is intact, MAE to command. Pt declined further narc's d/t their making him nauseous, began to demand to have CT and O2 removed immediately.CV: NSR, rare PVC; occ brief ST to 110-118 when anxious or coughing, spurts last < 10sec. | 14 | [
{
"category": "Radiology",
"chartdate": "2146-03-17 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 816542,
"text": " 8:51 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: r/o active disease processes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with left main CAD for CABG surgery \n REASON FOR THIS EXAMINATION:\n r/o active disease processes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest film prior to coronary artery bypass surgery.\n\n PA AND LATERAL CHEST: Heart size, mediastinal contours, and pulmonary\n vasculature are within normal limits. There are no pleural effusions. No\n consolidations are present. Within the left apex is a 7 mm nodular opacity\n which is adjacent to the left first anterior rib tip. There are no pleural\n effusions. Osseous structures are unremarkable.\n\n IMPRESSION: 7 mm nodular opacity in left upper lung, adjacent to left anterior\n first rib. Although this may represent asymmetrical degenerative changes in\n the first rib, further imaging with either CT scan or 15 degree shallow\n oblique films are reccommended to exclude a neoplastic nodule. No CHF or\n pneumonia.\n\n Findings were discussed with Dr. at 8:00 am on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-03-18 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 816620,
"text": " 9:59 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Q. LUNG MASS ON PRE-OP CHEST.\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with severe 3VCAD, found to have lung mass on preop CXR. Needs\n to be further evaluated before CABG\n REASON FOR THIS EXAMINATION:\n assess lung nodule\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 79-year-old with lung mass seen on preop chest x-ray.\n\n TECHNIQUE: Multiple helically-acquired axial images were obtained from the\n chest without the administration of intravenous contrast.\n\n COMPARISON: Chest radiograph .\n\n On lung windows, there are no parenchymal nodules, consolidations or masses.\n There is no evidence for active inflammation. The airways are patent to the\n level of the segmental bronchi bilaterally.\n\n On soft tissue windows, there are multiple small mediastinal lymph nodes, the\n largest lymph node is in the prevascular region and measures 9 mm. There is\n no axillary or significant hilar lymph adenopathy. There are evidence of\n pericardial effusions or pleural effusions. The heart, pericardium and great\n vessels are unremarkable.\n\n The visualized portion of the upper abdomen is unremarkable except for a small\n splenule.\n\n On bone windows, there are degenerative changes but no suspicious lesions.\n\n IMPRESSION:\n 1. No nodules or masses.\n 2. Small mediastinal lymph nodes. These lymph nodes, however, are of unclear\n etiology and unclear clinical significance. If clinically indicated, a\n followup is recommended in months.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-03-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 816860,
"text": " 8:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrate, effusion, PTX.\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p CABG. Post chest tube removal.\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrate, effusion, PTX.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CABG and chest tube removal.\n\n AP UPRIGHT CHEST: Compared with one day prior, the left-sided chest tube and\n right central venous catheter has been removed. There is persistent\n atelectasis of the lingula but no focal infiltrates or vascular congestion.\n The cardiac and mediastinal contours are unchanged. No pneumothorax.\n\n IMPRESSION: No pneumonia, cardiac failure, or pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-03-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 817127,
"text": " 3:02 PM\n CHEST (PA & LAT) Clip # \n Reason: ? infiltrate\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n ? infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79 y/o status post CABG.\n\n COMPARISON: \n\n PA AND LATERAL CHEST: The cardiac silhouette is enlarged and there is\n evidence of prior cardiac surgery. There are sternotomy wires. The right\n lung is better aerated. There is bilateral lower lobe atelectasis. There is\n mild blunting of the left costophrenic angle. The pulmonary vasculature is\n normal.\n\n IMPRESSION:\n\n 1) Cardiomegaly.\n 2) Bilateral lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-03-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 816746,
"text": " 12:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ro ptx\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with\n REASON FOR THIS EXAMINATION:\n ro ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79 y/o man with CABG. Rule out pneumothorax.\n\n COMMENT: Portable AP radiograph of the chest is reviewed and compared with\n the previous study of .\n\n Patient is status post CABG and median sternotomy. The tip of the\n endotracheal tube is identified 3 cm above the carina. The right jugular SG\n catheter terminates in the right main PA. The left chest tube and mediastinal\n drain are in place. A nasogastric tube terminates in the stomach.\n\n Patchy atelectasis is seen at the lung bases. The lungs are clear otherwise.\n The heart and mediastinum are within normal limits. No pneumothorax is seen.\n\n IMPRESSION: Satisfactory postoperative status S/P CABG.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-03-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 817033,
"text": " 6:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Patient now bleeding from sternal wound.\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n Patient now bleeding from sternal wound.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post CABG, bleeding from sternal wound.\n\n Portable upright frontal radiograph. Comparison is made to and .\n\n FINDINGS: The cardiac and mediastinal contours are unchanged. There is\n increasing opacification in the lingular area. The right lung is clear. The\n pulmonary vasculature is normal. There is no pneumothorax or\n pneumomediastinum. Sternal wires are intact.\n\n IMPRESSION: Increasing lingular opacification consistent with developing\n focal consolidation or persistent lingular atelectasis. No congestive heart\n failure or pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2146-03-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 816797,
"text": " 1:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Asses lung volumes\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n Asses lung volumes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 79-year-old man with status post CABG.\n\n COMMENT: Portable AP radiograph chest is reviewed, and compared to the\n previous study of yesterday. The patient is status post CABG and\n mediasternotomy. The patient has been extubated and the right jugular venous\n catheter has been changed to a Podis sheath. No pneumothorax is seen. The\n chest tube remains in place. The ET tube has been removed. The lung volume\n is small. Patchy atelectasis is seen at the lung bases. The heart is normal\n in size. There is no evidence of congestive heart failure.\n\n IMPRESSION: No pneumothorax, status post CABG with satisfactory postoperative\n status.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-21 00:00:00.000",
"description": "Report",
"row_id": 186537,
"text": "Sinus rhythm, rate 91. Incomplete right bundle-branch block. ST segment\nelevation in leads I, II, aVL, aVF and V2-V6 with T wave inversion in\nleads III, aVF and the mid-precordial leads. Also, the PR segment is elevated\nin lead aVR and depressed in the lateral leads. There are Q waves in\nleads III and aVF. The tracing suggests prior inferior myocardial infarction\nwith superimposed anterolateral ischemic and/or pericarditic process. In\nparticular, focal lateral pericarditis is to be considered. Compared to the\nprevious tracing of lasteral and mid-precordial ST segment elevation is\nmore prominent, consistent with ongoing evolution of lateral ischemia\nand/or pericarditis.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-20 00:00:00.000",
"description": "Report",
"row_id": 186538,
"text": "Sinus tachycardia. Inferior myocardial infarction. Right bundle-branch block.\nDiffuse non-diagnostic repolarization abnormalities. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-21 00:00:00.000",
"description": "Report",
"row_id": 1375405,
"text": "Nursing Progress Note\n 1900->0730\n\nS/O\n\nNEURO: A&O x3, MAE. C/O pain d/t left pleural CT, pain around incision. Refused Percocet d/t c/o it making him nauseous; MSO4 4mg IV given with apparent relief. Pt declined further narc's d/t their making him nauseous, began to demand to have CT and O2 removed immediately.\n\nCV: NSR, rare PVC; occ brief ST to 110-118 when anxious or coughing, spurts last < 10sec. Hypertensive when awake and agitated -> Lopressor dose increased. Lasix given this a.m.\nPulses palpable, BLE warm, left ace wrap on.\n\nRESP: LS intermittently wheezy, coarse, diminished. CPT and repsoitioning, deep breathing and coughing done. Pt using MDIs ? excessively, ? contribuitng to nausea, ? beneficial to increasing PO's.\nCrackles noted in right lower lung fields this a.m., clear elsewhere; Lasix 20mg IVP guven.\n\nGI: Freq c/o nausea d/t multiple sources, e.g. O2, CT, etc. Discussed health care options, impact of constant negative comments on his health. Zofran and Reglan given. Pt cont without BM. Decreased appetite.\n\nFEN: K+, Ca++, Mg++ repleted doing.\n\nGU: U/O qs. Lasix 20mg IV this am with 370mL in 1st hr.\n\nPSYCHOSOC: Issues and interventions as noted above.\n\nA/P\n\nDeline (a-line and cordis) as approprite and ordered.\nDiscuss with team re: pulling CT.\nContinue support, continue having patient be fully invovlved with his care and options.\nContinue current care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-19 00:00:00.000",
"description": "Report",
"row_id": 1375401,
"text": "POST-OP\nD: PT S/P CABG X 3 TODAY- LIMA TO LAD, SVG TO OM, DIAG- TOL WELL, OR UNEVENTFULL TO CSRU ON EPI/NEO.PROPOFOL, INTUBATED, 1 L PL CT, 1 MED CT. FOLET IN PLACE.\nPT AWOKEN AND EXTUBATED WITHOUT INCIDENT,PT REVERSED, PROPOFOL TO OFF NEO TO OFF- EPI TO OFF- STARTED LOW DOSE NTG.\nNEURO; PT WOKE SLIGHTLY AGITATED-EASILY CALMED WITH REASSURANCE. MAE, ORIENTED X 3, WHEN PT FALLS WAKES DISORIENTED-EASILY REORIENTED. FOLLOWS COMMANDS.\n\nCARDIAC; PT IN NSR INITIALLY RATES 70 UP TO 90'S- VOLUME GIVEN, SBP >100= ABLE TO WEAN NEO AND EPI WITH ADEQ SBP/MAP AND CO/CI. IN FACT STARTED IV NTG FOR ELEVATED SBP AND MAP>90. PALP PEDAL PULSES BILAT- LEFT WEAKER THEN RIGHT.\n PT WITH 1 A WIRE, 1 SKIN AND 2 VENT WIRES- SENSING ACCURATELY BUT AT TIMES FIRING WHEN NOT NECESSARY- THUS PACER TURNED TO OFF FOR SAFETY REASON (SPIKE ON T WWAVE)\n\nRESP: PT WEANED AND EXTUBATED, PLACED ON 4L NP WITH SAT >99%, BS CLEAR SLIGHTLY DIM IN BASES. COUGHING WITHOUT RAISING.\n\nGI: OGT IN PLACE POST-OP DRAINING BILIOUS MATERIAL. CARAFATE GIVEN PRIOR TO REMOVAL WITH EXTUBATION. ABD SOFT, BS ABSENT. PT C/O NAUSEA X 1 GIVEN REGLAN WITH RELIEF.\n\nGU; U/O EXCELLENT- CLEAR YELLOW URINE.\n\nPAIN; PT C/O PERSISTENT PAIN IN LEFT CHEST- MED WITH MSO4 2MG AMTS Q 15MIN WITH FAIR PT THEN GIVEN PERCOCET 2 TABS PO WITH BETTER RELIEF.\n\nDRSG: REMAIN INTAVCT, MIDLINE CHEST WITH SMALL AMT SANG DRAINAGE WH/ HAS NOT INC SINCE IMMED POST OP. ACE WRAP SECURE ON LEFT LEG.\n\nPLAN: PROGRESS DIET, ACTIVITY AS TOL, PEROCET FOR PAIN, ? NEED FOR SWAN PT OOB TO CHAIR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-19 00:00:00.000",
"description": "Report",
"row_id": 1375402,
"text": "update\nD: u/o noted to be down, hr >100 consistently with adeq sbp- cvp 10\nA: pt tx with 500ns bolus\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-20 00:00:00.000",
"description": "Report",
"row_id": 1375403,
"text": "SHift Note\nNeurologically pt is intact, MAE to command. Hemodynamically pt is stable, no gtts, CO/CI wnl. Lungs are course but CTA, encourabed to cough and deep breathe. U/O qs. Pt c/o of pain, given MSO4 with effect. N+V treated with reglan then zofran with good effect. See flowsheet for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2146-03-20 00:00:00.000",
"description": "Report",
"row_id": 1375404,
"text": "update\nD: pt POD #1 from CAbg x 3, progressing well- sbp & hr elevated- started po lopressor- with some - pt oob to chair, intermttently c/o nausea appears to be sensitive to motion- nayusea resolves without tx- pt encouraged to take db thru nose and relax. plan cont po lopressor give total 25mg po tonight- eval response.\ncardiac: pt in nsr - st, sbp 120-150/60- po lopressor given- ? need for higher doses. palp pedal pulses bilat.\nresp: pt weaned to 2l np with sat >96%, bs clear Coughing without raising.\ngi: pt with \"sensitive stomach\" appears to be easily nauseated with change in position. encouraged to take db thru mouth and relax- pills given, nausea does not correspond to percocet doses. abd soft, bs present. pt tol sips well, appetite fair.\ngu: lasix begun with good response. bun/creat wnl.\ninc: intact.\ndiscomfort: pt c/o more pain in left chest area- ? assoc with l pl ct-pt responds to po percocet better than mso4 for relief of pain.\n\nplan: give po lopressor, eval response- d/c left pl ct in am.\ntransfer to floor in am.\n"
}
] |
|
8,332 | 109,308 | Patient is admitted to the Intensive Care Unit in the context of hypotension, metabolic acidosis. This was believed to be due to an overwhelming infection and he was volume resuscitated. However, continuing volume resuscitation, probably led to worsening of his congestive heart failure. His creatinine continued to rise leading to a value of 3.0. He was eventually extubated, and was able to maintain decent oxygenation. On the night of , the patient developed new episodes of hypotension. At the same time, his sputum was growing Staphylococcus aureus. He was on broad-spectrum antibiotics throughout hospital stay including Vancomycin, ceftazidime, levofloxacin, and Flagyl. Patient initially responded to dopamine, but as the day progressed and particularly , he had continuous episodes of hypotension not responding to IV fluids. He was started on dopamine as well as norepinephrine with very minimal effect. At this point, he suffered an asystolic arrest, and despite resuscitative efforts, he expired around 10 a.m. on . DR., 12-981 Dictated By: MEDQUIST36 D: 13:43 T: 09:13 JOB#: | Right ventricular systolic functionappears depressed.AORTA: The aortic root is normal in diameter. Right ventricular systolicfunction appears depressed. CT PELVIS W/O CONTRAST: There appears to be mild wall thickening of the distal descending and probably the sigmoid colon though distention is poor in the sigmoid. There is moderatepulmonary artery systolic hypertension. Finally, not is made of right sided pleural calcifications in adjacent areas of scarring. IMPRESSION: New right internal jugular line tip at the mid-to-upper SVC, without evidence of pneumothorax. Bilateral pleural effusions, right greater than left are unchanged. Scattered calcifications are noted in the aorta. There are focal calcificationsin the aortic root.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic. Left ventricular function.Height: (in) 64Weight (lb): 122BSA (m2): 1.59 m2BP (mm Hg): 140/74Status: InpatientDate/Time: at 13:52Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. The aortic valve leaflets (3) are mildly thickenedbut not stenotic. Persistent bilateral pleural effusions and slight vascular congestion. There are a few small non- pathologically enlarged pretracheal and right paratracheal lymph nodes. There is no pericardial effusion.Impression: severe left ventricular contractile dysfunction consistent withmultiple vessel coronary disease; moderate-to-severe mitral regurgitation 3) Moderate right and small left pleural effusions. 4) Stable bilateral pleural effusions with slight increase in right lower lobe consolidative atelectasis. The tricuspid valve leaflets are mildlythickened. The right lung base is obscured. Prominent right pleural effusion and atelectasis. There is a dual chamber pacemaker and right internal jugular line in situ with positions unchanged from prior examination. There are stable small to moderate bilateral pleural effusions, left greater than right with associated atelectasis which is more confluent at the right base. CLINICAL INDICATION: Firm abdomen and hypotension. 2) New moderate gastric distention. Moderate[2+] tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. IMPRESSION: Bilateral pleural effusions likely related to either fluid overload or cardiac decompinsation. Moderate to severe(3+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The right pleural effusion and right lower lobe +/- middle lobe atelectasis are again noted. No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. A nonobstructed bowel gas pattern is visualized. There is nomitral valve prolapse. There is moderate pulmonary arterysystolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation. IMPRESSION: Right pleural effusion and lower lobe and partial right middle lobe atelectasis/collapse. There is vascular congestion and bilateral pleural effusions. There is mild bilateral upper lobe venous with diversion but no frank pulmonary edema. There is an area of confluent opacity in the right lower lung zone and right mid lung zone with associated signs of volume loss. The endotracheal tube has been removed. Stable appearance of the right pleural effusion and right lower lobe and right middle lobe atelectasis. Stool came back C-diiff +. GI ASPIRATES AND STOOL WERE BOTH OB-. + bowel sds. GI ASPIRATES OB+. Remains oliguric. AM RSBI 120.GI/GU: ABD FIRM WITH HYPOACTIVE BS. OGT IN PLACE, CLAMPED WITH MINIMAL CLEAR ASPIRATES. ?dilutional. STOOL FROM +CDIFF. AM ABG 7.34/35/159/20. Foley cath in place w/scant urine at this time. AM ABG 7.33/39/150/21. RESIDUAL MEDICATION FROM INTUBATION. Isordil held. CONTINUES ON FLAGYL, LEVO, CEFTAZ, AND VANCO. PATIENT IS NPO.ID: TMAX 98.0 WITH WBC 10.2. AM LYTES PER CAREVUE.ID: TMAX 97.3 WITH WBC 10.2, UNCHANGED. pr.on cpap with ps, normal range abg, will attempt to wean ps as tol. PERIPHERAL EDEMA PERSISTS. BS clear upper, ronchi lower zones. CT OF ABD SHOWED CDIFF COLITIS AND SQ FREE AIR OVER LLQ. DOUDERM TO COCCYX. Lasix given prior to extubation w/ minimal response. ABG 7.27/41/214/20. Antibiotics dc'd except for flagyl. HAS ONE SET BLD CX'S PENDING AS WELL AS STOOL FOR CDIFF. Await bumex reponse, start natracor prn per team.ID/GI- afebrile, no c/o pain, worsening GI s/s. NGT IN PLACE. Gd ABG. LS CLEAR WITH BIBASILAR COARSE RHONCHI. ID: on flaygl, vanco, and Levo Temp max 98. MONITOR U/O AND CRE. readicat asp. ON CEFTAZ, LEVOFLOXCIN, FLAGYL. Arrived here intubated and on low dose Dopa with gd BP. Plan to tranfuse. pt.admitted from for resp.fail., remains on ac ventilation, abg remains acidotic, ? BS coarse through out with some wheezes. TOLERATING ISORDIL AND HYDRALAZINE WITH SBP DROPPING IN THE 120'S FOR A SHORT TIME. PULSES BY DOPPLER. Hydral and Isordil attempting to be increased on hold. HCT 27, YESTERDAY AM 39.3 ?DILUTIONAL. stridor. Spec sent.T max 99.5 po. Nods head appropriatly. Clinical correlation issuggested. AM RSBI 47, ON SBT AT THIS TIME.GI/GU: ABD FIRM/FLAT WITH HYPERACTIVE BS. ATTEMPTING TO OBTAIN URINE CX'S.SKIN: DUODERN TO COCCYX INTACT. This am he had MS changes w/low BP and PH 7.17. Afebrile. Unable to assess at this time though RN report he has eschar on heels. BLBS diminished but clear. Probable ventricular premature beats. REMAINS OFF PRESSORS WITH BP 131-150/45-54. Ventricular paced rhythm - atrial mechanism is uncertain.Since the previous tracing of the same date paced rhjythm is seen.TRACING #2 SKIN FRAGILE, MANY ECCHYMOTIC/RED AREAS.ACCESS: #18 PIV, RIGHT ART LINE, RIJ CL.SOCIAL/DISPO: FULL CODE. , RRT MSICU NSG ADMIT NOTEPlease see Careview and Nsg Admit Note for further details.80 yo admitted to ,, form rehab w/ n/v diarrhea and low BP. BLD AND URINE STILL PENDING.SKIN: FRAGILE OVER ARMS. MAG NOTED TO BE 1.2 THIS AM WILL NOTIFY MD ORDERS. COLLAGENASE AND DSD APPLIED. RIGHT PUPIL 3MM AND BRISK LEFT IS SURGICAL. back post scan.Hct 27 this am from 39. Resp Care: Pt remains on vent,at the start of shift he was on A/Chowever he was changed to CPAP/PS and that is what he is on at this time,tol well.B/S coarse rhonchi sx'd for mod amt thick yellow.Plan is to continue to wean as tol. nsg update1800 BP dropped to 70s sys. | 30 | [
{
"category": "Radiology",
"chartdate": "2197-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802400,
"text": " 6:47 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: comparison with prior film from today; evaluate for worsenin\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CAD, pacemaker, ischemic cardiomyopathy with EF 30% with\n worsening sob.\n REASON FOR THIS EXAMINATION:\n comparison with prior film from today; evaluate for worsening CHF;\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Evaluate for worsening heart failure.\n\n PORTABLE AP CHEST: Comparison is made to previous films from .\n\n Positions of pacemaker and central lines are unchanged from prior\n examination. There are bilateral pleural effusions and mild upper lobe venous\n blood diversion with appearances essentially unchanged from prior examination\n three hours previously. No new infiltrate identified.\n\n IMPRESSION: No change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-10 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 802650,
"text": " 2:02 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: assess for abscess, intraabdominal source of infection, unde\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CAD s/p CABG, pacemaker, ischemic cardiomyopathy (EF\n 20-30%), chronic renal insuff, recent R hip surgery with 5 day history of\n bloody diarrhea (C Diff positive), n/v., now septic, source unclear.\n REASON FOR THIS EXAMINATION:\n assess for abscess, intraabdominal source of infection, underlying pneumonia.\n Please do NOT use contrast\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bloody diarrhea, nausea, vomiting and sepsis. Source unclear.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung apices to the\n pubic symphysis with oral contrast only. Intravenous contrast was not used\n due to renal insufficiency.\n\n COMPARISONS: CT abdomen and pelvis .\n\n CT CHEST W/O CONTRAST: The heart is enlarged but unchanged from the prior\n study. There is no pleural effusion. Multiple metallic artifacts are noted\n about the pericardium representing surgical staples and pacing wires.\n Scattered calcifications are noted in the aorta. There are a few small non-\n pathologically enlarged pretracheal and right paratracheal lymph nodes. There\n are also prominent bilateral axillary lymph nodes which do not meet CT\n criteria for pathologic enlargement. The pulmonary parenchyma is notable for\n multiple scattered foci of ground glass opacification throughout both lungs,\n right greater than left. There are stable small to moderate bilateral pleural\n effusions, left greater than right with associated atelectasis which is more\n confluent at the right base.\n\n CT ABDOMEN W/O CONTRAST: The liver, gallbladder, spleen, pancreas, adrenal\n glands, and kidneys are unremarkable, though evaluation is limited without\n intravenous contrast. There is no change from the prior study. There is\n slight interval increase in the degree of abdominal ascites. The contrast\n opacified loops of bowel in the abdomen are unremarkable. There is no\n intraperitoneal free air and no lymphadenopathy.\n\n CT PELVIS W/O CONTRAST: There appears to be mild wall thickening of the\n distal descending and probably the sigmoid colon though distention is poor in\n the sigmoid. There is slight increase in pelvic peritoneal free fluid. There\n is no lymphadenopathy. There are pockets of free air within the subcutaneous\n soft tissues overlying the left lower quadrant. The structures of the deep\n pelvis are partially obscured by the right hip prosthesis.\n\n There is diffuse increase in opacification of the subcutaneous soft tissues\n (Over)\n\n 2:02 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: assess for abscess, intraabdominal source of infection, unde\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consistent with anasarca. Degenerative changes are noted in the lumbar spine.\n No suspicious lytic or sclerotic osseous lesions are seen.\n\n IMPRESSION:\n\n 1) Air pockets in the subcutaneous fat overlying the left lower quadrant. The\n differential diagnosis includes iatrogenic causes vs. infectious causes and\n necrotizing fasciitis cannot be excluded. Clinical correlation is required.\n 2) Thickening of the wall of the distal descending colon and probably the\n sigmoid colon. The differentiation diagnosis includes infectious and\n inflammatory causes.\n 3) Scattered ground glass opacities involving both lungs, right greater than\n left. This is somewhat nonspecific, however, is likely related to infectious\n vs. inflammatory process.\n 4) Stable bilateral pleural effusions with slight increase in right lower lobe\n consolidative atelectasis.\n 5) Slight interval decrease in mild to moderate ascites.\n 6) Anasarca.\n 7) No evidence of abscess in the abdomen or pelvis although the study is\n somewhat limited without intravenous contrast.\n 8) Findings were immediately conveyed to the requesting physician . \n at approximately 4;10 P.M. on date of study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-09 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 802584,
"text": " 4:10 PM\n PORTABLE ABDOMEN Clip # \n Reason: s/p ngt placement. confirm placement. do stat.\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with c. diff, firm abdomen, hypotension.\n\n REASON FOR THIS EXAMINATION:\n s/p ngt placement. confirm placement. do stat.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN .\n\n CLINICAL INDICATION: Nasogastric tube placement.\n\n A nasogastric tube is in place and terminates in the proximal stomach. The\n bowel gas pattern is unremarkable. The imaged portion of the lower chest\n demonstrates a right pleural effusion and areas of increased opacity in the\n retrocardiac region of both lower lobes, right greater than left.\n\n IMPRESSION: Nasogastric tube terminates in the proximal stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802798,
"text": " 7:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate, effusions, pulm edema\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CAD, pacemaker, ischemic cardiomyopathy with EF 30%\n intubated for change in MS/acidosis, now extubated.\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate, effusions, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post pacemaker & extubation. SOB.\n\n AP portable chest radiograph. Comparison with that of . This\n study was presumably taken semierect. The endotracheal tube has been removed.\n The cardiac silhouette is enlarged. There is vascular congestion and bilateral\n pleural effusions. Multiple tubes and catheters are in a satisfactory position\n and unchanged.\n\n IMPRESSION: Allowing for technical differences, there is little overall\n change. Persistent bilateral pleural effusions and slight vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-04 00:00:00.000",
"description": "B FOOT AP,LAT & OBL BILAT",
"row_id": 802025,
"text": " 1:46 PM\n FOOT AP,LAT & OBL BILAT Clip # \n Reason: pt with bilateral foot pain and increased breakdown on heels\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CAD, pacemaker, cardiomyopathy, CRI, recent R hip surgery\n admitted for n/v, also with bilateral foot pain, heel necrosis.\n REASON FOR THIS EXAMINATION:\n pt with bilateral foot pain and increased breakdown on heels and toes; evaluate\n for fracture, gouty changes, abcess, osteo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral foot pain, increased breakdown on heel.\n\n COMPARISON: None.\n\n FINDINGS: Bilateral feet, AP, lateral and oblique views show evidence of\n osteopenia and vascular calcification throughout. No signs of fractures. No\n signs of osseous lytic or sclerotic lesions. The joint spaces are preserved.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-09 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 802562,
"text": " 12:47 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please evaluate for free air\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with c. diff, firm abdomen, hypotension.\n REASON FOR THIS EXAMINATION:\n Please evaluate for free air\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN .\n\n CLINICAL INDICATION: Firm abdomen and hypotension. Evaluate for free air.\n\n No definite free intraperitoneal air is identified, though please note that\n supine radiographs are relatively insensitive for detecting this finding.\n Additional upright or lateral decubitus view would be necessary for this\n purpose. A nonobstructed bowel gas pattern is visualized. Note is made of\n extensive degenerative changes in the spine as well as evidence of a prior\n right hip replacement.\n\n IMPRESSION: No evidence of free intraperitoneal air, but additional upright\n or left lateral decubitus view of the abdomen would be necessary to fully\n exclude this possibility.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-05 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 802168,
"text": " 3:36 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: pt with bloody diarrhea, nausea and vomiting; please evaluat\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CAD s/p CABG, pacemaker, ischemic cardiomyopathy (EF\n 20-30%), chronic renal insuff, recent R hip surgery with 5 day history of\n bloody diarrhea, n/v.\n REASON FOR THIS EXAMINATION:\n pt with bloody diarrhea, nausea and vomiting; please evaluate for abcess,\n colitis, infectious process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bloody diarrhea, nausea and vomiting, history of chronic renal\n insufficiency and CAD.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Helically-acquired contiguous axial images were obtained from the\n lung bases to the pubic symphysis without intravenous contrast secondary to\n the patient's history of chronic renal insufficiency.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized lung bases demonstrate\n bilateral pleural effusions with adjacent atelectasis. The liver,\n gallbladder, spleen, kidneys, adrenals and pancreas are unremarkable on this\n limited non-contrast CT examination. There is a moderate amount of ascites.\n There are extensive atherosclerotic calcifications. There is no mesenteric or\n retroperitoneal adenopathy. The intraabdominal loops of large and small bowel\n are unremarkable. There is no free air.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: There is extensive artifact secondary\n to patient's hip prosthesis. There is free fluid within the pelvis. There\n are extensive diverticula without evidence of associated stranding or\n diverticulitis. There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions. The\n patient is again noted to have a right hip prosthesis.\n\n IMPRESSION:\n\n 1) Bilateral pleural effusions with associated atelectasis.\n\n 2) Ascites and free pelvic fluid which may be secondary to the patient's\n history of cardiomyopathy.\n\n 3) No evidence for abscess or colitis.\n\n\n (Over)\n\n 3:36 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: pt with bloody diarrhea, nausea and vomiting; please evaluat\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802563,
"text": " 12:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for worsening chf, or infiltrate\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CAD, pacemaker, ischemic cardiomyopathy with EF 30% with\n worsening sob.\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening chf, or infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Worsening shortness of breath. Cardiomyopathy.\n\n COMPARISON: Previous study of 2 days earlier.\n\n CHEST, PORTABLE: A right internal jugular vascular catheter is present, the\n catheter tip is quite dense suggesting the catheter may be coiled at its tip\n or that it could potentially be going posterior into the azygous vein. A ICD\n remains in satisfactory position. The heart is upper limits of normal in size.\n There is upper zone vascular redistribution and bilateral perihilar haziness.\n There is an area of confluent opacity in the right lower lung zone and right\n mid lung zone with associated signs of volume loss. There is improving\n increased opacity in the left retrocardiac region. A small left pleural\n effusion is decreased in size in the interval and moderate size right pleural\n effusion is unchanged. Finally, not is made of right sided pleural\n calcifications in adjacent areas of scarring.\n\n IMPRESSION:\n\n 1) Persistent congestive heart failure.\n 2) Confluent right lower lobe opacity with associated volume loss, most likely\n due to atelectasis. Underlying infection in this region cannot be excluded.\n 3) Moderate right and small left pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 802390,
"text": " 3:14 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for infiltrate, PNA; new crackles on lung exam, sho\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with with CAD, pacemaker, ischemic cardiomyopathy with EF 30%,\n CRI admitted for n/v/ bloody diarrhea, now with worsening sob and crackles on\n lung exam. Evaluate for PNA, infiltrate, CHF\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, PNA; new crackles on lung exam, shortness of breath\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Worsening SOB and crackles on lung examination. Evaluate for\n infiltrate or heart failure.\n\n PA AND LATERAL CHEST: Comparison is made to previous films from .\n\n FINDINGS: Status post sternotomy. There is a dual chamber pacemaker and\n right internal jugular line in situ with positions unchanged from prior\n examination. There has been interval worsening of the right sided effusion and\n development of a new left sided effusion, from the prior examination. There is\n mild bilateral upper lobe venous with diversion but no frank pulmonary edema.\n\n IMPRESSION: Bilateral pleural effusions likely related to either fluid\n overload or cardiac decompinsation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 802845,
"text": " 9:17 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess for obstruction. perf\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with c. diff, firm abdomen, hypotension and concern for bowel\n ischemia.\n REASON FOR THIS EXAMINATION:\n assess for obstruction. perf\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: C. difficile colitis with hypertension and abdominal rigidity.\n\n Single supine film. Left flank is not included on film. NG tube is in proximal\n stomach. There is some retained contrast in the right colon. No evidence for\n intestinal obstruction or toxic megacolon. No obvious free intraperitoneal gas\n in the supine film. S/P right hip hemiarthroplasty.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802591,
"text": " 6:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ETT placement\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CAD, pacemaker, ischemic cardiomyopathy with EF 30%\n with respiratory failure, s/p placement of ETT\n REASON FOR THIS EXAMINATION:\n assess ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endotracheal tube placement in patient with respiratory failure.\n\n An endotracheal tube has been placed and is in satisfactory position. A right\n internal jugular vascular catheter and ICD remain in place and are unchanged\n in position. There is a pattern of congestive heart failure with development\n of perihilar edema in the interval. Bilateral pleural effusions, right greater\n than left are unchanged. Right lower lobe atelectatic changes are also stable.\n Left retrocardiac opacity has worsened in the interval. There is moderate\n gastric distention new in the interval.\n\n IMPRESSION:\n\n 1) Worsening congestive heart failure pattern.\n 2) New moderate gastric distention.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 802846,
"text": " 9:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess R IJ position\n Admitting Diagnosis: DEHYDRATION,SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with CAD, pacemaker, ischemic cardiomyopathy with EF 30%\n intubated for change in MS/acidosis, now extubated.\n REASON FOR THIS EXAMINATION:\n assess R IJ position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right IJ insertion.\n\n AP PORTABLE CHEST RADIOGRAPH: Comparison with exam of . Right IJ line\n is in the mid SVC. The NG tip and dual chamber pacer lines are poorly\n visualized. There are bilateral pleural effusions, with right greater than\n left. The right lung base is obscured. A consolidation within this region\n cannot be excluded.\n\n IMPRESSION: Little interval change. Prominent right pleural effusion and\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801921,
"text": " 1:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with h/o cri, here with n/v/d, bloody stool\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nausea, vomiting and diarrhea. Patient with chronic renal\n insufficiency.\n\n CHEST, AP PORTABLE RADIOGRAPH: There are no comparison studies. The heart\n size is grossly unremarkable. The patient is status post median sternotomy\n and dual-lead pacemaker tips over the right atrium and ventricle. There is a\n small right pleural effusion, which tracks up towards the right minor fissure.\n Atelectasis/collapse in the right lower lobe and partially in the right\n middle lobe. The soft tissues are remarkable only for a metallic stent in the\n left neck.\n\n IMPRESSION: Right pleural effusion and lower lobe and partial right middle\n lobe atelectasis/collapse.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-09-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 801928,
"text": " 3:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: look for line placement, pneumo, etc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p central line\n REASON FOR THIS EXAMINATION:\n look for line placement, pneumo, etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post central line placement, evaluate for pneumothorax and\n positioning.\n\n COMPARISON: Same-day radiograph at 14:05.\n\n CHEST, AP RADIOGRAPH: The cardiomediastinal and hilar contours are stable in\n appearance in a patient status post median sternotomy, CABG and dual-lead\n pacemaker insertion. The right pleural effusion and right lower lobe +/-\n middle lobe atelectasis are again noted. There is a new right IJ central\n venous line with tip in the mid-to-upper SVC. No evidence of pneumothorax.\n The osseous structures are unremarkable.\n\n IMPRESSION: New right internal jugular line tip at the mid-to-upper SVC,\n without evidence of pneumothorax. Stable appearance of the right pleural\n effusion and right lower lobe and right middle lobe atelectasis.\n\n"
},
{
"category": "Echo",
"chartdate": "2197-09-04 00:00:00.000",
"description": "Report",
"row_id": 75662,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 122\nBSA (m2): 1.59 m2\nBP (mm Hg): 140/74\nStatus: Inpatient\nDate/Time: at 13:52\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 moderately dilated.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is moderately dilated. Overall left ventricular systolic\nfunction is severely depressed. There is no resting left ventricular outflow\ntract obstruction.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root.\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. Moderate\n[2+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. The main\npulmonary artery and its branches are normal. No color Doppler evidence for a\npatent ductus arteriosus is visualized.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The right atrium is moderately dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nmoderately dilated. Overall left ventricular systolic function is severely\ndepressed (ejection fraction 20-30 percent) secondary to extensive apical\ndyskinesis, and severe hypokinesis of the inferior, posterior, and lateral\nwalls; there is relative sparing of the basal segment of the anterior free\nwall. Right ventricular chamber size is normal. Right ventricular systolic\nfunction appears depressed. The aortic valve leaflets (3) are mildly thickened\nbut not stenotic. No aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. There is no mitral valve prolapse. Moderate to severe\n(3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly\nthickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nImpression: severe left ventricular contractile dysfunction consistent with\nmultiple vessel coronary disease; moderate-to-severe mitral regurgitation\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-09 00:00:00.000",
"description": "Report",
"row_id": 1372526,
"text": "MSICU NSG ADMIT NOTE\n\nPlease see Careview and Nsg Admit Note for further details.\n\n80 yo admitted to ,, form rehab w/ n/v diarrhea and low BP. Treated with IVFs and broadspectrum antibiotics. Stool came back C-diiff +. Antibiotics dc'd except for flagyl. This am he had MS changes w/low BP and PH 7.17. Arrived here intubated and on low dose Dopa with gd BP. Foley cath in place w/scant urine at this time. HR V-paced. Afebrile. Given 1L D5W w/150 bicarb over 1hr. Plan to give 2nd liter at 150cc/hr after. MD to insert art line and send ABG. Pt is spanish speaking but per chart understands English well though would not follow commands. 2 dgts and a granddaughter in. Granddaughter translated. Appear to be poor historians. Bil multi podus boots on. Feet wrapped in kerlix. Unable to assess at this time though RN report he has eschar on heels. Please see her note for recommendations for foot care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-12 00:00:00.000",
"description": "Report",
"row_id": 1372537,
"text": "MICU/SICU Event/Expiration\nAt approximately 0745 pt was noted to have worsening hypotension so a Dopamine gtt was restarted at 2.5 mcg/kg/min and titrated up to the maximum of 20 mcg/kg/min over the course of 15 minutes. Since pt had little to no response to dopamine a bolus of 250cc NS was given and repeated for a total of 500cc. Pt was ventricular paced with a rate ~100-110, with frequent polymorphic PVC's and occasional runs of nonsustained VT. A Levophed gtt was started and quickly titrated up to maximum dose of 0.3 mcg/kg/min while the dopamine gtt was titrated down in an effort to reduce tachycardia and VEA. At 0920 pt's rate was noted to have dropped to the 40's with a significant drop in ABP. Pt was found unresponsive and anpneic with an escape rhythm of ~45. A cardiac arrest was called and CPR was initiated. The arrest was terminated at 0935 by Dr. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-10 00:00:00.000",
"description": "Report",
"row_id": 1372527,
"text": "pt.admitted from for resp.fail., remains on ac ventilation, abg remains acidotic, ? wean on days.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-10 00:00:00.000",
"description": "Report",
"row_id": 1372528,
"text": "MSICU NPN 7P-7A\nNEURO: PATIENT INITIALLY DIFFICULT TP AROUSE, GRIMACED AND MOVED EXTREMITIES TO PAIN. WOULD NOT OPEN EYES OR FOLLOW COMMANDS. ? RESIDUAL MEDICATION FROM INTUBATION. BY 2200 PATIENT ALERT WITH EYES OPEN AND FOLLOWING COMMANDS. MAE WITH PURPOSE. INDICATING THAT HE WAS HAVING PAIN AT COCCYX SITE WHERE DUODERM IS. RIGHT PUPIL 3MM AND BRISK, LEFT W/CATARACT SURGERY. SLEPT WELL AND WAS EASILY AROUSED TO VOICE THIS AM. FENT/VERSED ORDERED FOR SEDATION ON VENT BUT PATIENT WAS APPROPIATE AND GTTS NOT STARTED.\n\nCARDAIC: HR 79-93 VPACED WITH RARE PVC'S. RECEIVED ON DOPA @4MCG ABLE TO WEAN OFF WITHOUT DIFFICULTY. BP 124-145/41-50. PULSES BY DOPPLER. HCT 27, YESTERDAY AM 39.3 ?DILUTIONAL. NO OVERT BLEEDING NOTED. GI ASPIRATES OB+. INR 2.3 UP FROM 1.9 YESTERDAY AM.\n\nRESP: RECEIVED ON AC 500X16 60% +5PEEP. ABG 7.27/41/214/20. DECREASED FIO2 TO 40% AND INCREASED RR TO 18. BREATHING RESP OVER VENT. SATS 100%. LS COARSE T/O TO CLEAR ON LEFT AND COARSE WITH BASILAR CRACKLES ON RIGHT. LAVAGED AND SXTED ONCE FOR THICK TAN SPUTUM. AM ABG 7.33/39/150/21. AM RSBI 120.\n\nGI/GU: ABD FIRM WITH HYPOACTIVE BS. NO STOOL. NGT IN PLACE. MINIMAL U/O AMBER AND CLEAR. MD AWARE OF OUTPUT. CRE UNCHANGED FROM YESTERDAY @2.8.\n\nFEN: RECEIVED 1L BOLUS ON 150MEQ BICARB PRIOR TO SHIFT AND ANOTHER 1L @150CC/HR. CURRENTLY NO IVF INFUSING. CVP MEASURE THIS AM WAS 17-19. PATIENT WITH PERIPHERAL EDEMA. IONIZED CA 1.05 REPLETED WITH 2 GMS OF CA GLUCONATE, AM LEVEL IS 1.08. MAG NOTED TO BE 1.2 THIS AM WILL NOTIFY MD ORDERS. PATIENT IS NPO.\n\nID: TMAX 98.0 WITH WBC 10.2. YEST DIFF SHOWED 26% BANDS. ON CEFTAZ, LEVOFLOXCIN, FLAGYL. VANOC WAS ORDERED BUT NOT CLEARED BY PHARMACY, MD AWARE. NEXT DOSE DUE TOMORROW AND WILL CHECK LEVEL TOMORROW AM. HAS ONE SET BLD CX'S PENDING AS WELL AS STOOL FOR CDIFF. STOOL FROM +CDIFF. ON CONTACT PRECAUTIONS. UNABLE TO OBTAIN ADEQUATE SPUTUM SAMPLE AS PATEINT NEEDED MUCH LAVAGE TO CLEAR SPUTUM. ATTEMPTING TO OBTAIN URINE CX'S.\n\nSKIN: DUODERN TO COCCYX INTACT. BILAT HEELS WITH ESCHAR AND PINKISH AREA THAT HAVE ALREADY BEEN DEBRIDED. COLLAGENASE AND DSD APPLIED. MPS BOOTS IN PLACE. PETECHIA TO RIGHT INNER THIGH. SKIN FRAGILE, MANY ECCHYMOTIC/RED AREAS.\n\nACCESS: #18 PIV, RIGHT ART LINE, RIJ CL.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY OVERNOC. CONTINUE TO WEAN VENT, FOLLOW UP ON CX'S AND REPLETE LYTES AS NEEDED. MONITOR U/O AND CRE. QUIAC STOOLS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-10 00:00:00.000",
"description": "Report",
"row_id": 1372529,
"text": "MSICU NPN 0700-1900\n\nEasily aroused. Nods head appropriatly. Follows some commands, ?some language barrier. No sedation this shift. Sleeping when undisturbed.\n\nAbd firm. + bowel sds. 800cc readicat,for ct scan,tol well. Mod stool ~4hrs later. Min. readicat asp. back post scan.\n\nHct 27 this am from 39. ?dilutional. Plan to tranfuse. At present MD unable to locate family for consent.\n\nSwitched to PSV 15 and 5 PEEP. Gd ABG. Appears comfortable. Suct for mod amts thick-tenacious purulent-looking sputum. Spec sent.\n\nT max 99.5 po.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-10 00:00:00.000",
"description": "Report",
"row_id": 1372530,
"text": "Resp Care: Pt remains on vent,at the start of shift he was on A/C\nhowever he was changed to CPAP/PS and that is what he is on at this time,tol well.B/S coarse rhonchi sx'd for mod amt thick yellow.Plan is to continue to wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-10 00:00:00.000",
"description": "Report",
"row_id": 1372531,
"text": "nsg update\n1800 BP dropped to 70s sys. Pt alert at this time. Given 250cc NS IVB and turned from R side onto back. BP improved before IVB finished. Isordil held. No problem. Remains oliguric.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-11 00:00:00.000",
"description": "Report",
"row_id": 1372532,
"text": "pr.on cpap with ps, normal range abg, will attempt to wean ps as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-11 00:00:00.000",
"description": "Report",
"row_id": 1372533,
"text": "MSICU NPN 7P-7A\nNEURO: PATIENT ALERT AND FOLLOWING COMMANDS. MOVING ALL EXTREMITIES. DENIES PAIN BUT GRIMACES WHEN RIGHT ARM IS MOVED. RIGHT PUPIL 3MM AND BRISK LEFT IS SURGICAL. RESTRAINED FOR SAFETY OF TUBES. SLEPT WELL, BEHAVIOR APRROPIATE WHEN AWAKE, NO NEED FOR SEDATION ON VENT.\n\nCARDAIC: HR 95-103 VPACED WITH OCCASIONAL PVC'S. REMAINS OFF PRESSORS WITH BP 131-150/45-54. TOLERATING ISORDIL AND HYDRALAZINE WITH SBP DROPPING IN THE 120'S FOR A SHORT TIME. RECEIVED ONE UNIT PC'S FOR HCT OF 27 LAST NOC. HCT ONLY BUMPED TO 28.4 AND NO OVERT SIGNS OF BLEEDING. GI ASPIRATES AND STOOL WERE BOTH OB-. PLTS 133 DOWN FROM 160. INR 2.0 DOWN FROM 2.3 S/P ONE DOSE OF VIT K YESTERDAY. PULSES BY DOPPLER.\n\nRESP: RECEIVED ON CPAP 15/+5 30% AND SUBSEQUENTLY DECREASED PS TO 12. HAS MANTAINED TV 400-600 WITH RR 11-24 AND SATS 98-100%. AM ABG 7.34/35/159/20. LS CLEAR WITH BIBASILAR COARSE RHONCHI. SXTED FOR THICK TAN SPUTUM. CT LUNGS SHOWED PNA POSSIBLY ASPIRATION AND BILAT PLEURAL EFFUSIONS. AM RSBI 47, ON SBT AT THIS TIME.\n\nGI/GU: ABD FIRM/FLAT WITH HYPERACTIVE BS. MUSHROOM CATH IN PLACE DRAINING GREEN LIQUID STOOL BUT PATIENT ALSO STOOLING AROUND CATH LGE X2. OGT IN PLACE, CLAMPED WITH MINIMAL CLEAR ASPIRATES. MINIMAL U/O 8-17CC/HR YELLOW AND CLEAR CRE UNCHANGED @2.8.\n\nFEN: NO FLUID INFUSING, VOLUME COMIMG FROM ABX, BLOOD AND REPLETIONS. REMAINS NPO. PERIPHERAL EDEMA PERSISTS. AM LYTES PER CAREVUE.\n\nID: TMAX 97.3 WITH WBC 10.2, UNCHANGED. LACTATE 1.0 DOWN FROM 2.3 YESTERDAY. ON CONTACT PRECAUTIONS FOR CDIFF. CONTINUES ON FLAGYL, LEVO, CEFTAZ, AND VANCO. CT OF ABD SHOWED CDIFF COLITIS AND SQ FREE AIR OVER LLQ. SURGERY CONSULTED AND BELIEVE IT IS NOT NECROTIZING FASCIAITIS AS PATIENT CLINICAL PICTURE IS STABLE. THEY WILL CONTINUE TO MONITOR. SPUTUM FROM WITH GRAM+ COCCI. BLD AND URINE STILL PENDING.\n\nSKIN: FRAGILE OVER ARMS. RIGHT ARM WEEPING COPIOUS AMOUNTS OF SEROUS DRNG. BILAT HEELS WITH ESCHAR, TREATED WITH COLLAGENASE AND DSD. MPS BOOTS IN PLACE. DOUDERM TO COCCYX. PETECHIA UNCHANGED ON RIGHT INNER THIGH.\n\nACCESS: PIV X1, RIGHT ART LINE, RIJ CL.\n\nSOCIAL/DISPO: FULL CODE. SOME RELATIVES VISITING AT START OF SHIFT. DID NOT ASK QUESTIONS. PLAN IS TO CONTINUE TO WEAN VENT, IF UNABLE TO EXTUBATE TODAY SHOULD CONSIDER STARTING TUBE FEEDS...FOLLOW HCT AND PLT LEVELS AND TRANSFUSE AS NEEDED...F/U ON PENDING CX'S CONTINUE ABX AS ORDERED...SURGERY TO FOLLOW CLOSELY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-11 00:00:00.000",
"description": "Report",
"row_id": 1372534,
"text": "Respiratory Care Note\nPatient extubated without any problems. stridor. BLBS diminished but clear. SaO2 100%. Placed on a cool aerosol 40%. Will try mask ventilation if respiratory status diminishes.\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-11 00:00:00.000",
"description": "Report",
"row_id": 1372535,
"text": "M/SICU Nursing Porgress Note-\nNeuro-\nAlert& oriented x2, answering questions approp in Spanish, FC, MAE. No sedation given all day.\nREsp-\nOn vent this am w/ rsbi of 47, w/ sbt on .30/5/0/rr18-20/sat 99%. Lasix given prior to extubation w/ minimal response. Extubated w/o complication @ 1300 to .40 face tent, rr 18, sat 99%. Productive strong cough of tan secretions, mod amt, w/ yankauer assist. BS clear upper, ronchi lower zones. No distinct crackles heard.\nMIn output to lasix, bumex 1mg given @ 1740, awaiting response.\nCV-\nCHF (ef= ~15-20%)-ARF (Cr 2.8-baseline.7)\nBP 140-110/45-50, HR Vpaced@100. Episode of low BP to 70/ @ 1600 immediately afterbeing turned on Left side and increased dose Isordil 20mg PO given. Dopa 10m/k/m started and quickly weaned to off over 50 min. Now SBP 125/35. Isordil and hydralazine d/c, will restart prn/ stable BP.\nLasix 40 mg given prior to extubation @12n, w/ u/o 18-20cc/hr.\nI=1065/O=227; bumex given 1mg givne @ 1740, awaiting response.\n\nGI-C diff colitis\n+ BS, NT,no pain to deep palpation, no rebound, soft-distended. Small amt of green liquid stool, minimal leakage around rectal tube at present. Afebrile on vanco, flagyl, levo, ceftaz.\nSkin-\nHeel lesions remain unchanged, dsgs in place. Coccyx- duoderm, rash on thighs- petechia- unchanged\n\nEthics/ Medical Decisions-\n MD, interperter, daughter-, pt and this RN in room discussing current medical status, goals w/ renal and chf, and uncertain outcome. Introduction and explanation of what measures would be carried out should pt require aggressive treatment s/p extubation and uncertainty of pt response d/t worsening status of renal and cardiac function. GI/ID status explained as stable. Pt lethargic during most of discussion but answered appropriately to directed, simple, specific questions. Daughter will discuss w/ sister and patient and offer feedback on proxy and code status issues over next few days.\nA/P-\nNeuro- lethargic, but alert to answer questions, follow commands\nREsp- Extubated w/o compl, good sat on .40 face tent, BS congested.\nCardiac- failure unresponsive to lasix, and possibley bumex. Episode of low BP this pm, Dopa on x50 min. Hydral and Isordil attempting to be increased on hold. Await bumex reponse, start natracor prn per team.\nID/GI- afebrile, no c/o pain, worsening GI s/s. Cont antibx.\nEthics- Issues discussed w/ ICU Care Team, daughter and patient w/ Spanish interperter.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-09-12 00:00:00.000",
"description": "Report",
"row_id": 1372536,
"text": "S/MICU Nursing Progress Note\n S/O: Pt remains extubated and tolerating well. RR 20-26 on 40% face tent nemb, congested cough, able to cough to back of throat, use of yankeur by staff, encouraging deep breath and cough. BS coarse through out with some wheezes. O2 sat remained 95-98%\n BP stable, restarted hydralzine and isodil, 5am dose of hydralzine held as BP down to 112(parameters are to hold for <120) Bumex given x 1 at 2200 with only minimal results. Now urine output down to 15cc/hr.\n NPO at present, abd soft nontender, stool, green liquid to mucousy, mushroom catheter in place need to change to rectal bag. Coccyx and scrotum reddened. on precautions as is C-diff +\n Pt opening eyes and nodding yes to questions, only speaks spanish so not been able to fully assess MS, follows commands through gestures. MAE.\n ID: on flaygl, vanco, and Levo Temp max 98.\n PLan: family discussing code status issues, worsen urine output.\n"
},
{
"category": "ECG",
"chartdate": "2197-09-09 00:00:00.000",
"description": "Report",
"row_id": 193720,
"text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2197-09-03 00:00:00.000",
"description": "Report",
"row_id": 193721,
"text": "Baseline artifact. Ventricular paced rhythm - atrial mechanism is uncertain.\nSince the previous tracing of the same date paced rhjythm is seen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2197-09-03 00:00:00.000",
"description": "Report",
"row_id": 193722,
"text": "Wide complex tachycardia - mechanism is uncertain - consider ventricular\ntachycardia. Probable ventricular premature beats. Clinical correlation is\nsuggested. No previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
58,526 | 100,001 | 35 yo F with HTN & poorly controlled type I DM, c/b neuropathy, gastroparesis, nephropathy ?????? CKD, retinopathy presents with DKA and hypertension SBP to 200s. . # Diabetic ketoacidosis: Patient controls diabetes at home with Humalog SS and long acting Levemir. Sugars at home recently have been in 250s. In the ED, glucose was 466. UA was +ve for ketones ?????? corrected to 200s, but rose again to 300s. She was treated with an insulin drip which was transitioned to subq when she tolerated POs. Her electrolytes were repleted and she received aggressive volume resuscitation. saw her and gave sliding scale recommendations which were implemented. No source for DKA found, beleived to be gastroparesis. Nausea managed with ativan, compazine, and promethazine. She was discharged on her home Insulin and sliding scale with instructions to follow-up with . | No pulmonary edema. FINDINGS: As compared to the previous radiograph, there is no relevant change. No pleural effusions. No evidence of pneumonia or other pathological abnormalities. Normal size of the cardiac silhouette. COMPARISON: . | 1 | [
{
"category": "Radiology",
"chartdate": "2117-09-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1206584,
"text": " 11:12 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with vomiting\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Vomiting, evaluation for infiltrates.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. No evidence of pneumonia or other pathological abnormalities. No\n pleural effusions. No pulmonary edema. Normal size of the cardiac\n silhouette.\n\n\n"
}
] |
24,868 | 196,654 | Hospital Course: 20 M with PMH paraplegia s/p MVA , being transferred from to floor for resolving septic shock from MRSA bacteremia, ARDS, RLL MRSA/Pseudomonas pna, +influenza B. . ## RLL PNA (MRSA / Pseudomonas / GBS / ), +influenza B: Patient had been found down and unresponsive and was brought to Hospital, where Urine cx was positive for Klebsiella, (not albicans). sputum cx was positive for MRSA, beta hemolytic Strep B, (not albicans). A blood cx was positive for MRSA. He was antigen positive for influenza B and negative for influenza A. The patient was transferred to , where in the ED, the patient was intubated, was found to have purulent sputum, was on dopamine briefly for hypotension. The patient was admitted to from to . . In the , the patient was on Vanc/Unasyn for MRSA pna and bacteremia. It was thought that the Strep and were likely colonizing organisms. Antibiotics were changed to Vanc/Levo/Flagyl due to cephalosporin allergy, an increase in serum eosinophils, and to help treat a Klebsiella positive UTI. This regimen was again changed to Vanc/Zosyn/Flagyl for T103.7 spike on hospital day 3, changed again to Vanc/Meropenem for Pseudomonas in bronchial washings on . Blood cultures at were all negative. In the , he was maintained on an inexsufflator TID with suctioning. The inexsufflator exerted alternating positive and negative pressure with breathing, to help eject mucus from bronchi. . The patient was extubated on and did well in the . He was transferred to the floor on . The patient was continued on Vancomycin 1.5 IV Q8H for MRSA for a total 14 day course (start , end ) and Meropenem 1g Q8H (for ventilator-associated pna for Pseudomonal coverage) for a total 10 day course (start , end ). It was difficult to get the patient therapeutic on Vancomycin. The patient was weaned down to a 6L O2 requirement in the , and on the floor was continually weaned down from 6L O2 to room air for the last 2 days before discharge. . On the floor, the patient was triggered for desaturation to the 80's due to mucus plugging. The inexsufflator was the primary aid in recovering his saturations, and after ejection of much mucus, patient's saturations returned to 90s on 6L. As long as patient required > 2L O2, patient was maintained on inexsufflator to TID. On the last 3 days before discharge, patient no longer required inexsufflator. . CTA Chest showed ARDS, small RLL PE, mediastinal/hilar LAD. Placed on heparin drip for PE, started Coumadin . Transaminitis was thought to be due to shock liver (hypotension in ED) and followed. Patient was transferred to the floor on for resolving septic shock. . ## MRSA septic shock: On at Hospital, the patient was found to have a blood culture positive for MRSA. At , he was hypotensive and required dopamine for proper perfusion. The patient was on Vancomycin 1.5 IV Q8H for MRSA for a total 14 day course (start , end ) and Meropenem 1g Q8H (for ventilator-associated pna for Pseudomonal coverage) for a total 10 day course (start , end ). Meds were administered through a picc in his L arm (placed ). The patient has a history of IV drug use, and could not be discharged with a picc line in place, and was kept in house for the last few days of Vancomycin administration. A TTE was negative for endocarditis, and blood cultures at were all negative. . ## Transaminitis: The patient had a transaminitis thought to be due to shock liver from brief hypotension in the ED. A CT showed fatty liver, likely from a combination of alcohol and IVDU. . ## RLE DVT / RLL PE: The patient was found to have a RLL PE and ARDS on CTA Chest while in the . On the floor, the patient was triggered for acute desaturation. CTA Chest at that time did not show another PE, and desaturation and tachycardia was attributed to mucus plugging. Patient was started on heparin gtt in the and once therapeutic to INR 2.0 to 3.0, was maintained on Coumadin 5 mg PO QHS to be followed as an outpatient. Heme recommended a 6 month treatment on Coumadin for this paraplegic patient. . ## Reactive thrombocytosis: On the floor, the patient had plts up to 1130. Heme recommended no treatment, that aspirin was not required, and to continue to treat the cause of inflammation. The patient's plts continued to trend down for the last 2 days before discharge, to the 900's. . ## Sacral skin breakdown and L ankle ulcer: The patient had multiple areas of skin breakdown in the sacral area, and had a L ankle ulcer. He was kept on a -air mattress and had dry sterile dressing with saline wash to TID. The sacral skin breakdown improved greatly during his admission, and the L ankle ulcer remained stable. . ## Insomnia: Patient had episodes of insomnia during admission. He was maintained on Valium and Ambien, but had tried Trazodone, Xanax and Haldol with periodic improvement. . ## Paraplegia: Patient has chronic LE discomfort, and was maintained on Baclofen and Neurontin per his home regimen. He was not given percocet or vicodin during his stay. . ## Illicit drug use: Patient was found to have +tox screen for opiates, benzos, cannabinoids. Patient was not allowed to leave with a picc line in L arm due to history of IVDU. The picc had been placed on . Patient was counseled on drug addiction and abuse, as well as consequences of using such drugs with overlying pneumonia and paraplegic disposition. . ## Disposition: Family meeting agreement was that patient return to father's basement, where there is no handicap capability. It is an unfinished basement, not humidified, but patient was staunchly insistent on returning there, and refused any rehab facility despite communication over several days. He stated that he had not done well in a rehab in the past, and had had a long stay at rehab, and that he did not wish to return there again for now. Patient was at mother's home which was built to be entirely handicap capable, but patient had gotten into a fight with one of his mother's children, and he was not allowed back into his mother's house. Patient was discharged with inexsufflator therapy, and was told to use when he sensed mucus buildup or if he developed a cough. | SOME DEPENDENT EDEMA TO EXTS NOTED.GI/GU: + BS NOTED. FEBRILE AS STATED TO 103.6 RECTALLY. Pt was intubated for hypoxic resp failulre. c-diff.id: continues with low grade temp 99 -100 range. WILL RECHECK ABG WITH AM LABS.GI/GU: ABD OBESE, SOFT + BOWEL SOUNDS. Initiated albuterol, atrovent and flovent MDI's. CHEST PT DONE BILATERALLY ~ Q3H. FEBRILE THIS AM TO 101.8AX. AFTER CXR=RESTART ON TF'INGS. BS'S-RHONCHI THROUGHOUT. MONITOR TEMP Q4H, BLD CX PRN TEMP > 101. SATS HAVE IMRPOVED.GI: NGT D/C'ED AND OGT PLACED. FOLEY IN PLACE W/ ADEQUATE UO.SKIN: DUODERM TO LEFT BUTTOCK DECUB AREA IN PLACE. GIVEN 1 L NS BOLUS W/ GOOD EFFECT. W/ ABG 7.41/36/121/24 (ON FI02.60%). 2+ pitting edema lower exts.GI - Abd soft and obese. fi02 weaned with good abg. STILL NEEDS SPUTUM CX SAMPLE. hypoxia d/t worsening ARDS. Hypoactive BS. + 2 GENERALIZED EDEMA. + 2 GENERALIZED EDEMA. MIN AMT OF SECRETION VIA ETT. ABG SENT 7.38/48/74/29. PT DENIES PAIN.CV: TMAX 98.3 AXILLARY. NGT IN PLACE W/ TF'ING AT 30CC/HR W/ MIN RESIDUALS. TF RESIDUAL MINIMAL AND TF ADVANCED TO 60CC/HR. DECREASED COUGH/GAG + CORNEALS + EOMS.CV: PT RUNNING LOW GRADE TEMPS 100.4 TREATED WITH TYLENOL 650 MG REPEAT TEMP 100.4 MD MADE AWARE. CVP 13-14.ENDOC: K+ REPLETED. BP 86-129/48-69. DECREASED COUGH/GAG + CORNEALS + EOMS. ABG @0300 shows slight respiratory acidosis. + contact and droplet precautions. PERLA.PULM: LUNG W/ RHONCHI THROUGHOUT. + EOMS + CORNEALS. LS rhoncherous. PTT AT 1200 WAS SUB-THERAPEUTIC. need for antianxiety .Resp - Pt remains orally intubated. Pt transf to for further mgt. REMOVING NRB OFTEN D/T "CLAUSTRAPHOBIA." aline drsg in am. LEFT HEAL WITH OLD HEALED DECUB OTA, OLD HEALED SACRAL DECUB OTA. PO2 BY ABG 62-74, PCO2 WNL. K 3.8 Mg 1.8 - to be replete with 20 meq kcl iv and 2 gms magso4 iv.ID - Max temp 100.3 po. addendumPT IS ON A HEPARIN GTT AT 3350U/HR PTT WAS THERAPEUTIC THIS AM. SEE CAREVUE FOR Q1H VS, Q4H ASSESSMENTS. Mg 1.7 - repleted with 2 gms magso4 iv, Mg level now 2.4.ID - + Contact and droplet precautions. + dopplerable pulses except for PT . 2+ pitting edema lower exts.GI - Abd soft and obese. GI prophylaxis - lansaprazole. Given albuterol/atrovent inhalers. SX FOR MINIMAL SECRETIONS VIA ETT. Respiratory CarePt bronched this morning for small to moderate amounts of this white secreations. Hypoactive BS. CHEST PT DONE BY RT.GI/GU: ABD SOFT, OBESE. Lytes checked @ 1600 as pt auto-diuresing: K+3.9, Mg 2.0, ionized calcium 1.08. Changed to versed and fentanyl iv. Unasyn 3 gms iv q 6hrs for klebisiella uti. Sinus rhythmNormal ECGSince previous tracing of , sinus tachycardia and ST-T wave changes nowabsent Last abg shows improved oxygenation, normal limits. PUPILS EQUAL/REACTIVE BILAT, DECREASED COUGH/GAG. Abd obese/distended and soft with hypoactive bowel snds. Initially ventilated on AC 650 x 18 x 12 70% - ABG 7.44/34/81/0/24. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Heparin qtts unchanged @ 3350u/hr, with PTT within goal range @ 75.6.GI: TF of Promote with fiber cont via OGT @ goal 80ml/hr with scant residuals. + 1 GENERALIZED EDEMA PEDAL PULSES BY DOPPLER ONLY. CHEST XRAY ORDERED. Respiratory CareRemains intubated and ventilated on a/c 450 * 28 20 of peep. Improved aeration noted. Review of Systems and Nsg Progress NoteNeuro - Pt initially sedated on 65mcgs/kg/min propofol. Nursing note Addendum:PT TEMP 101.0 ORALLY, MD NOTIFIED. Inhalers given as ordered. PRESENTLY ON A/C 28/450/60%/16 .SX FOR SM AMT THICK YELLOW /WHITE SECRETIONS.STRONG COUGH.LUNGS REMAIN COARSE ,DUE FOR BRONCH TODAY.C/V: BECAME TACHYCARDIC INTO 150'S ST, TREATED FOR TEMP OF 101 AX W/ 1 GM TYLENOL, CVP WAS 16-17, BP 90'S-100'S. Heparin gtt remains at 3350 units/hr, PTT due this eve.Resp: Remains intubated on vent in AC mode 450/28/50/18; peep and fiO2 weaned from 60% and peep 20 with f/u abg's of 7.43/78/29/3; lung sounds are coarse throughout, diminished lower lobes; suctioned q 2-3hrs for moderate amounts white sputum; respiratory mechanics tested by RT to find best position for pt regarding respiratory muscles > no significant difference between lying flat or upright so pt maintained in semi-fowlers positon; ET tube rotated to L side of mouth and retaped; pt pushed out oral airway with tongue but seems to be cooperating so far by not biting the tube.GI: Abdomen softly distended, +BS, NT; TF of promote with fiber at goal of 80/hr; 10-50cc residuals. Small-to-moderate right pleural effusion is again demonstrated. The right subclavian IV catheter terminates at the cavoatrial junction. ET tube and right subclavian catheter are in standard placements and a nasogastric tube passes below the gastroesophageal junction and out of view. Right subclavian central line tip over lower SVC. This is associated with diffuse perihilar haziness. worsening pna FINAL REPORT PORTABLE CHEST. Left PIC catheter tip projects over the superior cavoatrial junction. Unchanged mediastinal and hilar lymphadenopathy. Moderate interstitial edema, left lower lobe opacity, small-to-moderate right pleural effusion are unchanged. The visualized portions of the paranasal sinuses, are normally aerated. Persistent perihilar edema. IMPRESSION: Stable pulmonary edema. The previously identified areas of mediastinal and hilar lymphadenopathy are unchanged. The cardiac silhouette is at the upper limits of normal. Findings consistent with a small pulmonary embolism to the artery to the right lower lobe given limitations of this study. Allowing for this, there is a small filling defect demonstrated within the lumen of the pulmonary artery to the right lower lobe. Prominence of upper zone pulmonary vasculature is noted. FINAL REPORT PORTABLE CHEST, : COMPARISON: . Findings consistent with volume overload or congestive heart failure. atelectasis and/or small effusion at right base, not fully evaluated here. Evaluation of the lungs demonstrates dense bilateral dependent consolidations. Mediastinal and hilar lymphadenopathy. An endotracheal tube remains in place, with the tip currently terminating approximately 6.5 cm above the carina. The heart, pericardium, and great vessels are within normal limits. The heart, pericardium, and great vessels are within normal limits. INDICATION: Respiratory failure. An endotracheal tube is present, with the tip terminating in the region of the superior aspect of the clavicles with the neck in apparently flexed position. FINDINGS: There are prominent interstitial markings, which are unchanged from the prior exam. | 57 | [
{
"category": "Nursing/other",
"chartdate": "2178-11-10 00:00:00.000",
"description": "Report",
"row_id": 1585549,
"text": "MICU/SICU NURSING NOTE 7P-7A:\n\nSEE CAREVUE FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT REMAINS SEDATED ON FENTANYL @ 200MCG/HOUR AND VERSED @ 15 MG/HOUR. PT OPENS EYES TO VOICE, INTERMITENTLY FOLLOWS COMMANDS. NODS HEAD APPROPRIATELY TO QUESTIONS. PUPILS EQUAL/SLUGGISHLY REACTIVE. DECREASED COUGH/GAG + CORNEALS + EOMS. PT BECAME AGITATED WITH TURN AND PAD CHANGE, BP INCREASED & PIP INCREASED TO 40S. PT WITH VERSED 4 MG IV AND FENTANYL 50 MCG WITH GOOD RESULTS.\n\nCV: AFEBRILE. HR 75-90 NSR NO ECTOPY. BP LABILE 75-105/46-70 MD AWARE OF DECREASED BP, TOLERATING LOW BPS AS LONG AS URINE OUTPUT REMAINS ADEQUATE. + 2 GENERALIZED EDEMA. CVP 13-18. HEPARIN GTT @ 3100 UNITS/HOUR LAST PTT 92.7 @ MIDNIGHT (GOAL PTT 60-100). WILL RECHECK @ 0600 WITH AM LABS.\n\nPULM: PT REMAINS INTUBATED VENT SETTINGS CHANGED TO AC-28 60% TV 450 PEEP 20 (RR INCREASED, FIO2 DECREASED) ABG ON THOSE SETTINGS 7.37/45/92/27. SATS 94-98% LUNGS COARSE T/O SUCTIONING SMALL THICK WHITE SECRETIONS.\n\nGI/GU: ABD SOFT, DISTENDED WITH HYPOACTIVE BOWEL SOUNDS. TUBE FEEDS @ 40 CC/HOUR (GOAL 80 CC/HOUR) INFUSING THROUGH OGT. MINIMAL RESIDUAL NOTED. - BM OVERNIGHT. FOLEY DRAINING CLEAR/YELLOW URINE EXCELLENT URINE OUTPUT.\n\nPLAN: CONT ANTIBIOTICS, WEAN VENT AS TOLERATED FOLLOW ABGS, FOLLOW LABS REPLETE AS NEEDED, ECHO WITH BUBBLE STUDY @ 0900 , FOLLOW CULTURES, CONT HEPARIN GTT FOLLOW PTT AND ADJUST PER PROTOCOL, ADVANCE TUBEFEEDS AS TOLERATED, WILL CONT TO MONITOR.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-10 00:00:00.000",
"description": "Report",
"row_id": 1585550,
"text": "Respiratory Care\nRemains intubated and ventilated on a/c 28 * 450 60% + 20 peep. Breath sounds coarse with expir wheezes. Getting albuterol/atrovent and flovent inhalers in line with vent. Suctioned for thick white sputum. Plan to place esoophageal balloon later today to check pulmonary pressures/ideal peep.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-10 00:00:00.000",
"description": "Report",
"row_id": 1585551,
"text": "npn\npt remains sedated on fentanyl at 200mcg and versed at 15mg. in am pt alert, responding to commands, trying to mouth words, pt tongueing ett and ogt(which he has been able to dislodged) perrla 2mm, pt had to be with both versed and fent due to 2 uncontrollable coughing episodes with turning and following tte. pt has been quiet most of day, able to arouse, opeining eyes, trying to mouth words around ett, does not consistently follow commands,\n\npain: pt grimacing with turning, see above.\n\ncad hr 80 to 90's sr no ectopy noted, abp 90 to 100 systolic, occassional dampening of alilne which is due to pt turning and change in wrist position. aline drsg in am. heparin gtt increased to 3350 units/hr due to ptt at 1230pm 59.5, no bolus was given . md notified. next ptt due at . TTE did not show any shunting of blood flow\n\nresp ls coarse, vent settings changed to acx28xtv 450 peep 20 fio2 50% 1700 abg 7.41/47/80. pt suctioned for small to scant amts. of yellowy thick secretions. pt has moderate amts oforal secretions, especially behind bite block. *** sat mid to high 90's\n\ngu: pt autodiuresing, uo 100 to 400cc/hr, still +2liters for los, pt has yeast infection in groain area , tx with nystatin powder.\n\ngi: bs+ PT HAS HAD ONE LIQUID BROWN STOOL IN AM. TF RESIDUAL MINIMAL AND TF ADVANCED TO 60CC/HR. PT NEEDS TO BE ON DAILY BOWEL REGIME FOR PARAPLEGICS, continues of flagyl for ? c-diff.\n\nid: continues with low grade temp 99 -100 range. vanco dosing changed see , trough due in a.m. prostate checked for possible inflammation which was negative\n\nskin: drsg toe area, scant drainage, pt has been on rotation mattress all day tolerating well.\n\nsocial: mother and friend visited, father called and updated.\n\nplan: ptt due at , vanco trough in am, continue to wean vent as tolerated, ? aggressive chest pt, cont to monitor vs, labs, advance tf as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-11 00:00:00.000",
"description": "Report",
"row_id": 1585552,
"text": "MICU/SICU NURSING NOTE 7P-7A:\n\nSEE CAREVUE FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT REMAINS SEDATED ON FENTANYL @ 200 MCG/HOUR AND VERSED @ 15 MG/HOUR. PT ALERT, NODS HEAD TO QUESTIONS. INCONSISTENTLY FOLLOWS COMMANDS. PUPILS EQUAL/REACTIVE BILAT. DECREASED COUGH/GAG + CORNEALS + EOMS.\n\nCV: PT RUNNING LOW GRADE TEMPS 100.4 TREATED WITH TYLENOL 650 MG REPEAT TEMP 100.4 MD MADE AWARE. HR 80-100 SR NO ECTOPY. BP 86-129/48-69. + 2 GENERALIZED EDEMA. HEPARIN GTT @ 3350 UNITS/HOUR. LAST PTT = 67.4 (GOAL 60-100).\n\nPULM: RECEIVED PT ON 28 50% TV 450 PEEP 20 SATS 92-94 % PT DESATURATED TO 88% AFTER A TURN AND PAD CHANGE. ABG SENT 7.38/48/74/29. AS NIGHT PROGRESSED PT PULSE OX DECREASED TO 90-91% ABG THIS AM 7.43/44/61/30 MD MADE AWARE. FIO2 INCREASED TO 60% WILL SEND REPEAT ABG. LUNGS COARSE T/O. SX SMALL THICK WHITE SECRETIONS FROM ETT AND LARGE ORAL SECRETIONS.\n\nGI/GU: ABD SOFT, DISTENDED, NONTENDER + BOWEL SOUNDS. TF @ 70 CC/HOUR (GOAL 80CC/HOUR) MINIMAL RESIDUAL NOTED. PT HAD LARGE BM SOFT, BROWN STOOL. PT WITH FOLEY, AUTODIURESING. UO 120-400CC/HOUR.\n\nSKIN: PT ON ROTATION MATTRESS, TOLERATING WELL. R GREATER TOE WITH INGROWN TOENAIL W-->D DSG IN PLACE, DRAINING SMALL SEROSANG DRAINAGE. LEFT HEAL WITH OLD HEALED DECUB OTA, OLD HEALED SACRAL DECUB OTA. GROIN WITH YEAST RASH, MICONAZOLE POWDER APPLIED.\n\nPLAN: CONT ANTIBIOTICS, FOLLOW CULTURES, WEAN VENT AS TOLERATED, ADVANCE TUBEFEEDS AS TOLERATED, CONT HEPARIN GTT (MONITOR PTT, CONT SEDATION WILL CONT TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-14 00:00:00.000",
"description": "Report",
"row_id": 1585568,
"text": "NPN 0700-1900\n\nNeuro: A&O X3 but increasing delerium as day wore on. Hallucinating, restless and agitated in afternoon/evening; given haldol 2.5mg x2 with little effect; speech is clear, moves arms freely.\n\nCV: HR 93-110, ocassional PVC; ABP 85-121/47-68; 2+ peripheral edema, peripheral pulses difficult to palpate, + by doppler; continues on heparin gtt at 3100 units/hr, PTT at noon 92.\n\nResp: Recieved on 100% NRB and NC @ 4L; weaned to cool neb face tent at 100% O2 with abg's 7.43/41/82/2/28; O2 sats 88-97%, lung sounds coarse, diminished L base; has congested cough but much difficulty mobilizing secretions due to a weak cough> given chest PT and MDI's.\n\nGI: Advanced to full liquids but only requesting gatorade which his Dad brought in; abdomen is obese, +BS, had 1 small soft BM; says he is hungry but desats when face mask off so taking sips of gatorade only.\n\nGU: Foley catheter draining 60-450cc/hr clear yellow urine; fluid status is -2500cc since midnight, -6L LOS.\n\nID: Tmax 99.8 po; remains on merepenem and vanco, needs vanco trough with next dose.\n\nAccess: A-line and R subclavian; PICC evaluation planned for tomorrow with goal of d/c'ing above lines when picc in.\nPlan: monitor resp status, pulmonary toilet, OOB to w/c when family brings chair in, chest PT, or nebs, continue abx; haldol prn restlessness, agitation; monitor temp, wbc's; hep gtt per protocol.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-15 00:00:00.000",
"description": "Report",
"row_id": 1585569,
"text": "MICU/SICU NURSING NOTE 7P-7A:\n\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT ALERT ORIENTED X EASILY REORIENTED TO TIME. RECEIVED PT RESTLESS IN BED, REPORTING ANXIETY. TREATED WITH ATIVAN 2MG IV WITH LITTLE RELIEF. MD MADE AWARE, ADDITIONAL 2 MG IV GIVEN WITH GOOD RESULTS. PT NOW RECEIVE ATIVAN 1-6 MG IV Q 4 HOURS PRN. PUPILS EQUAL/REACTIVE. + EOMS + CORNEALS. DECREASED COUGH AND GAG REFLEXES. MOVES ARMS FREELY AND FOLLOWS SIMPLE COMMANDS WITH UPPER EXTREMITIES. COMMUNICATES NEEDS WITH CLEAR SPEECH. PT DENIES PAIN.\n\nCV: TMAX 98.3 AXILLARY. HR 80-110 SR NO ECTOPY. BP 85-126/54-76. + 2 GENERALIZED EDEMA PEDAL PULSES DIFFICULT TO PALPATE BILAT (+1/+1). HEPARIN GTT REMAINS @ 3100 UNITS/HOUR. LAST PTT = 76.4 (GOAL 60-100). K = 3.8 PT GIVEN POTASSIUM 40 MEQ IVP REPLETION, WILL RECHECK LYTES WITH AM LABS. VANCO TROUGH = 18.7 MD AWARE.\n\nPULM: RECEIVED PT ON COOL NEB FACE MASK 100% FIO2, SATS 91-95%. PT AWOKE FROM SLEEP AND TOOK MASK OFF STATING \" THIS I NOT MY MASK, I WANT THE OTHER MASK. PLEASE DON'T DO THIS TO ME.\" PT GIVEN EMOTIONAL SUPPORT AND AN EXPLANATION WAS GIVEN TO PATIENT THAT IT WAS THE SAME MASK. PT CONTINUED TO REFUSE TO WEAR THE MASK DESATSURATED TO 84% ON RA. RT AND MD CALLED TO BEDSIDE. PT PLACED ON 4 L NC AND CONT COOL NEB VIA FACE TENT. PT DOING WELL FOR SEVERAL HOURS AND THEN BEGAN DESATURATING TO 86-87%. RR 20-25 ABG SENT 7.50/20/54/16 MD MADE AWARE. LUNGS COARSE T/O. PT WITH VERY WEAK COUGH UNABLE TO CLEAR SECRETIONS. NT SUCTIONED FOR MOD THICK TAN SECRETIONS. RT HELPED PT QUAD COUGH AND PT EXPECTORATED SMALL TAN SECRETIONS. PT GIVEN NEBULIZER AND NC INCREASED TO 6 L. SATS CURRENTLY 90-94% LAST ABG 7.44/27/68/19. WILL MONITOR RESP STATUS AND GIVE NEBS Q 2 HOURS AS NEEDED. AGGRESSIVE PULMONARY TOILET. WILL RECHECK ABG WITH AM LABS.\n\nGI/GU: ABD OBESE, SOFT + BOWEL SOUNDS. - N/V. PT TOLERATING CLEAR LIQUIDS AND PILLS WITHOUT DIFFICULTY. - BM OVERNIGHT. FOLEY DRAINING CLEAR/YELLOW URINE. PT UO 100-400CC/HOUR.\n\nPLAN: PICC EVAL IN AM, PULMONARY TOILET, NEBS AS NEEDED, HALDOL AND ATIVAN FOR DELIRIUM/ANXIETY, CONT ANTIBIOTICS, FOLLOW LABS AND REPLETE AS NEEDED, WOUND CARE, CONT HEPARIN GTT FOLLOW PTT, MONITOR RESP STATUS AND FOLLOW ABGS, WILL CONT TO MONITOR.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-15 00:00:00.000",
"description": "Report",
"row_id": 1585570,
"text": "RESPIRATORY CARE:\n\nFollowing pt for bronchodilator rx's and pulmonary toilet. Pt starting desaturating overnoc, difficulty clearing secretions. BS's coarse rhonchi, few scattered wheezes. Administered Albuterol and Atrovent nebs Q2, switched oxygen to high flow neb at 95%. NTS for thick white/yellow secretions, and assisted pt in quad coughing. Pt's pulm status became more stable overnight, maintaining oxygenation. See flowsheet for further pt data. Will plan to follow with nebs and aggressive pulm toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-15 00:00:00.000",
"description": "Report",
"row_id": 1585571,
"text": "NPN 0700-1900\n\nNeuro: A&O X3, behavior appropriate, no hallucinations, less restless and agitated; ativan d/c'd, po xanax started.\n\nCV: ABP 84-98/49-61, NBP 97-117/41-59; HR 95-110, SR/ST no ectopy; 1+ peripheral edema; pt is with negative fluid status of 1600cc since mn. Heparin gtt remains at 3100 units/hr but was off for 2 hrs for line placement so rebolused and restarted at 3100 at 1400, PTT due at .\n\nResp: Weaned to O2@6L with O2sats 90-97%; arterial line d/c'd; using cough assist machine from RT with fair results-> expectorating small to moderate amts of thick tan sputum; lung sounds remain coarse throughout, diminished lower lobes; chest PT done and nebs q 6 hrs. Pt not OOB today b/c he needs a w/c with seatbelt which family did not bring in yet; turned frequently in triadyne bed.\n\nGI: Abdomen soft, obese, +BS; eating house diet, has excellent apetite; incontinent 1 small loose stool.\n\nGU: Foley intact draining 90-360cc clear yellow urine; fluid status is negative 7700cc LOS.\n\nID: Tmax 100.4 po, Tcurrent 98.2 po; a-line and R central line d/c'd and R brachial double lumen PICC inserted; both catheter tip lines sent for culture; remains on merepenem and vanco.\n\nPlan: Monitor resp status, continue aggressive pulmonary toilet, monitor temp, follow cultures, wbc's; heparin gtt per protocol; monitor lytes, replete prn.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-08 00:00:00.000",
"description": "Report",
"row_id": 1585542,
"text": "Addendum - PTT 36.4 - pt bolused with 4800 units of heparin and drip increased to 1900units/hr. Needs PTT rechecked at 1100. Phos 1.9. Pt repleted with an additional 20 meq kcl IV(total 80 meq) and given 2 pkts neutrophos via NGT. Nasopharyngeal aspirate also sent for viral cx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-08 00:00:00.000",
"description": "Report",
"row_id": 1585543,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. Vent Vt changed to 550cc and RR increased to 22, Peep to 15. Pt has good ventilation but oxygenation remains an issue. Nasal aspirate obtained this 0625.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-08 00:00:00.000",
"description": "Report",
"row_id": 1585544,
"text": "M/SICU NPN FOR 7A-7P: FULL CODE NKDA\n\n DROPLET/CONTACT PRECAUTIONS FOR INFLUENZA B AND MRSA\n\n PLEASE SEE FLOWSHEET FOR MORE DETAILS\n\nEVENTS: SPIKED TEMP TO 103.6 RECTALLY. COOLING BLANKET PLACED. BLOOD CX'S X 2, AND URINE CX SENT. STILL NEEDS SPUTUM CX SAMPLE. CHEST X-RAY REDONE THIS AFTERNOON. RUQ ABD ULTRASOUND DONE AT BEDSIDE. CVP TRANSDUCED W/ 17-19. PTT AT 1200 WAS SUB-THERAPEUTIC. GIVEN 4800 UNIT BOLUS W/ HEPARIN DRIP INCREASED TO 2400UNITS/HR. NEXT PTT DUE AT . MIN. VENT CHANGED AS NOTED. CT/A RESULTS FROM OSH () WAS NEGATIVE FOR PE.\n\nNEURO: LIGHTLY SEDATED ON FENTANYL AND VERSED GTTS. OPENS EYES TO VOICE. ABLE TO NOD HEAD APPROPRIATELY TO Y/N QUESTIONS. MOVES ARMS PURPOSEFULLY TO ETT WHEN UNTIED. BILAT SOFT WRIST RESTRAINTS REMAIN IN PLACE. PERLA.\n\nPULM: LUNG W/ RHONCHI THROUGHOUT. PORT. CHEST X-RAY DONE THIS AFTERNOON. MIN AMT OF SECRETION VIA ETT. ETT REPOSITION/RE-TAPED AND PLACED TO 24CM AT LIP PER DR. REQUEST. REMAINS ON A/C 22 X 550, FIO2 .50%. W/ ABG 7.41/36/121/24 (ON FI02.60%). O2 SATS 91-95%. OVERBREATHING VENT THROUGHOUT THE DAY BY AT LEAST 3 BREATHS.\n\nCV: NSR W/ NO ECTOPY. BP DIPPED TO MAP 55 EARLY THIS AM. GIVEN 1 L NS BOLUS W/ GOOD EFFECT. BP VIA R RAD. A-LINE 93/51 - 101/54. FEBRILE AS STATED TO 103.6 RECTALLY. MIN EFFECT FROM LIQUID TYLENOL. COOLING BLANKET IN PLACE. BLOOD CX'S X 2 DRAWN FROM LINES DUE TO POOR PERIPHERIAL VENOUS ACCESS. SOME DEPENDENT EDEMA TO EXTS NOTED.\n\nGI/GU: + BS NOTED. ABD IS OBESE, SOFT, NT. NGT IN PLACE W/ TF'ING AT 30CC/HR W/ MIN RESIDUALS. NO BM TODAY. FOLEY IN PLACE W/ ADEQUATE UO.\n\nSKIN: DUODERM TO LEFT BUTTOCK DECUB AREA IN PLACE. LEFT HEEL HEALING DECUB. ELEVATED OFF BED AND OTA. GENERALIZED UPPER BODY RASH NOTED (NOT NEW PER OSH RECORDS). MICU TEAM IS AWARE AND WILL CONT. TO MONITOR.\n\nANTBX/LABS: LACTATE 2.5, PLACED ON TRIPLE ANTIBIOTICS VANCOMYCIN, FLAGLY, AND LEVAQUIN. IONIZED CALCIUM 1.05 (REPLTED).\n\nSOCIAL: MOTHER AND FATHER IN TODAY AT SEPARATE TIMES AND UPDATED SEPARATELY BY MICU INTERN. FATHER AND MOTHER DIVORCED, BUT BOTH INVOLVED IN SON'S CARE.\n\nPLAN: CONT. W/ CURRENT PLAN OF CARE. MONITOR PER PROTOCOL. REPLETE ELECTROLYTES AS NEEDED. WEAN VENT AS TOLERATED. CONSULT SKIN CARE RN IN AM. SOCIAL WORK CONSULT FOR FAMILY.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-09 00:00:00.000",
"description": "Report",
"row_id": 1585545,
"text": "7p to 7a Micu Porgress Note\n\nOverview of Events - pt with worsening hypoxia - very poor activity tolerance - pt desats to 87% and becomes hypotensive to 80 systolic. Requiring 100 % 02 for ~ 30 mins to recooperate. BP has returned to baseline without fluid boluses or pressors.\n\nNeuro - Alert, intermittently follows commands. Upper exts with purpposeful movement. Pt very tearful and appears frightened at times. Fentanyl infusing at 200mcgs/hr and versed increased to 10 mg/hr. ? need for antianxiety .\n\nResp - Pt remains orally intubated. See careview for vent adjustments and ABGs. Pt requring max vent support of 100% fio2 and 20 peep to maintain 02 sat of 90%. TV has been maintained at 550, goal is low TV's in lieu of evidence of ARDS. RR set at 22 - pt overbreathing vent by 3-5 breaths. Most recent vent setting - AC 550 x 22 x 20 x 90% - ABG 7.34/48/73/8/27. LS rhoncherous. Endotrach sx for scant to no secretions. Copious oral secretions. Bite block reinserted as pt biting on ETT decreasing volumes. Needs sputum sample sent for cx when available. MDI's also utilized with minimal improvment. ? hypoxia d/t worsening ARDS. Pt sched for c-xray at 0600.\n\nC-V - HR 77-92 SR, no ectopy. ABP 90-110/60s except during periods of agitation when SBP falls to 80. As per above hypotension resolves without intervention. Pt with DVT. PTT subtherapeutic throughout the night despite being bolused with heparin and drip increased. Currently heparin drip is infusing at 2900units/hr. MD notified - to continue infusion and recheck PTT at 1000 - ? pt with antiheparin antigen. Hct 34.6 - no evidence of hematuria or GIB. 2+ pitting edema lower exts.\n\nGI - Abd soft and obese. Hypoactive BS. Tube feeding changed to promote with fiber which infused via NGT until 4am. Tube feedings are on hold as pt has been passing copious amts soft to loose brown guiac neg stool. LFTs remain elevated. U/s yest reportedly neg.\n\nF/E - TFB + ~ 2750 ccs. Urine output 60-240ccs/hr via foley. CVP 16-21. K 3.8 Mg 1.8 - to be replete with 20 meq kcl iv and 2 gms magso4 iv.\n\nID - Max temp 100.3 po. WBC pend. + contact and droplet precautions. + MRSA + influenza B. + klebvsiella in urine. Pt currently being rx's with vanco, levaquin and flagyl.\n\nSkin - Macular rash over upper torso unchanged in appearance. Heel decubs open to air . L gluteal decub reportedly 2 years old, covered with duoderm but then removed and left open to air as pt soiling duoderm. Sm amt serous exudate noted on R great toe toenail excision - wet to dry dssg applied qd. Pt needs big boy bed and skin care consult.\n\nSocial - Mother called last eve. States she will be in to visit today. Family needs social work consult to help cope with pts illness.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-09 00:00:00.000",
"description": "Report",
"row_id": 1585546,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and fully ventilated on AC settings. Pt has had an increased need for higher FiO2 during the noc. FiO2 increased to 90%, Peep 20. PaO2=73. ABG @0300 shows slight respiratory acidosis. Progressively through the last 24 hours pt has trended down towards acidosis. BLBS are coarse with crackles. Initiated albuterol, atrovent and flovent MDI's. Plan: ? Esophageal balloon, attempt to decrease FiO2 requirements.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-09 00:00:00.000",
"description": "Report",
"row_id": 1585547,
"text": "RESP: CT SCAN + FOR SMALL PE. FIO2 REQUIREMENT IS DECREASING. ABG'S SLIGHTLY IMPROVED. TV DROPPED TO 450. AND FIO2 TO 65%. ABG'S TO BE DONE ON THESE SETTING. SUCTIONED FOR SMALL WHITE TO LGHT TAN SECRETIONS. BS'S-RHONCHI THROUGHOUT. SATS HAVE IMRPOVED.\nGI: NGT D/C'ED AND OGT PLACED. AFTER CXR=RESTART ON TF'INGS. NO FURTHER STOOL.\nRENAL: AUTODIURESING.\nNEURO: ON VERSED AND FENT. NOT ADEQUATELY SEDATED AND VERSED INCREASED TO 15MG/HR. OPENS EYES, ANSWERING QUESTIONS BY NODDING.\nCV: LABILE BP FROM 80'S TO 100'S. NOT REQUIRING PRESSORS. CVP 13-14.\nENDOC: K+ REPLETED. WILL NEED TO CHECK LATER IF HE CONTINUES TO AUTODIURESE.\nID: ANTIBIOTICS CHANGED. FEBRILE THIS AM TO 101.8AX. COOLING BLANKET ON, BUT LAST COUPLE OF HOURS PT'S TEMP HAS DECREASED AND REMAINED THERE. UNABLE TO CHANGED LINE OVER A WIRE D/T NO PERIPH ACCESS. HO'S AWARE. SPUTUM CX SENT THIS AM. OTHER CX'S HAVE BEEN NEG SO FAR.\nSKIN INTEGRITY: NO NEW DECUBS. VISIBLE.\nSOCIAL: MOTHER INTO VISIT AND VISIBLY UPSET AND CRYING.\nPLAN: CARDIAC ECHO WITH BUBBLE STUDY TOMORROW AT 9AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-09 00:00:00.000",
"description": "Report",
"row_id": 1585548,
"text": "resp care\npt remains intubated/vented/sedated. tidal vol. reduced to 450cc\nfor lung protection. fi02 weaned with good abg. cxr worsening. transported to\nand from cta without incident. results pending. continue to wean\no2 and then peep as tolerated. see flowsheet for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 1585565,
"text": "MICU NPN\nNEURO: PT. ON FENTANYL AND VERSED MOST OF THE DAY, WAS EXTUBATED AT 1700 AND SEDATION WAS THEN SHUT OFF. AELRT AND ORIENTATED X3.\n\nRESP: BROCHOSCOPY DONE THIS AM, SAMPLES WERE SENT OFF TO LAB. EXTUBATED THIS AFTERNOON, IN 100% NON-REBREATHER AT THIS PRESENT TIME, SATS 90-92%, ABLE TO COUGH UP SECREATIONS.\n\nCV: HR AND BP STABLE SEE CAREVUE FOR DETAILS. A-LINE REMAINS IN PT, SITE IS UNREMARKABLE. 40 MG OF IV LASIX GIVEN PT. D\n\nGI: MUSHROOM CATH IN PLACE DUE TO LOOSE STOOL, TUBE FEEDS OFF OGT OUT. TAKING IN ICE CHIPS WELL.\n\nGU: FOLEY IN PLACE, DRAINING LARGE AMTS. OF CLEAR YELLOW/LIGHT YELLOW URINE.\n\nSOCIAL: MOTHE RIN TO VISIT TODAY.\n\nPLAN: CONTINUE IV ABX. AGGRESSIVE PULMONARY TOILET.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 1585566,
"text": "addendum\nPT IS ON A HEPARIN GTT AT 3350U/HR PTT WAS THERAPEUTIC THIS AM. PT. ALSO IS BECOMING VERY AGITATED WANTED TO SIGN HIMSELF OUT TONIGHT, TEAM WAS ABLE TO TALK PT. INTO STAYING THE NIGHT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-14 00:00:00.000",
"description": "Report",
"row_id": 1585567,
"text": "NEURO: ALERT, ORIENTED X 3 MOST OF THE TIME BUT OCCASIONALLY DISORIENTED TO PLACE. \"EVERYTIME I WAKE UP I'M IN A DIFFERENT PLACE.\" \" I WANT TO BE ON THE .\" OCCASIONALLY GETS ANGRY ABOUT NOT BEING LEFT ALONE TO SLEEP. REMOVING NRB OFTEN D/T \"CLAUSTRAPHOBIA.\" NO PAIN MEDS OR SEDATIVES GIVEN.\n\nPULM: 5L N/C AND 100% NRB WITH SATS 90-96%, DESATS RAPIDLY TO 75% WITH NRB OFF. PO2 BY ABG 62-74, PCO2 WNL. PARADOXICAL RESPIRATORY PATTERN, WORSE WHEN AWAKE AND ANXIOUS. BREATHES BETTER WITH AT 15 DEGRESS D/T LARGE ABDOMEN. LUNGS EXTREMELY COARSE R SIDE, LUL LESS COARSE, LLL DIMINISHED. CHEST PT DONE BILATERALLY ~ Q3H. PT HAS POOR COUGH D/T PARAPLEGIA, LIFTS ARMS ABOVE HEAD TO COUGH, HITS ABDOMEN WITH BOTH HAND TO ASSIST WITH COUGHING. SXING SMALL TO MOD AMTS THIN WHITE-TAN SECRETIONS FROM MOUTH WITH YANKAUR. T MAX 100.1, WBC UP TO 32K. MEREPENEM AND VANCO CONTINUE.\n\nCV: NSR TO SINUS TACH WITHOUT ECTOPY. BP LABILE AT TIMES, SBP 77-140 BY R RADIAL ALINE, GOOD WAVE FORM FROM ALINE, CUFF BP CORRELATES. SEE CAREVUE FOR Q1H VS, Q4H ASSESSMENTS. K 3.7 REPLETED WITH 30MEQ KCL PO, PT REFUSED TO TAKE LAST 10MEQ KCL ORDERED D/T SOB WITH DRINKING. PALPABLE DP PULSES BILATERALLY. COLOR SOMEWHAT PALE. H&H STABLE. PTT 111 AT 2300, GTT DECREASED TO 3100 UNITS/HR PER SLIDING SCALE.\n\nGI: TAKING CLEAR LIQUIDS WELL EXCEPT CAUSES INCREASED SOB. SMALL AMTS SOFT BROWN STOOL AROUND MUSHROOM CATHETER, CATHETER DC'D. ABDOMEN OBESE, SOFT, + BS.\n\nGU: FOLEY TO CD DRAINING LARGE QUANTITIES LIGHT YELLOW URINE 170-500CC/HR.\n\nSOCIAL: NO VISITORS OR PHONE CALLS.\n\nPLAN: VERY AGGRESSIVE PULM HYGIENE Q1-2H. OOB TO CHAIR IN AM. CONTINUE IV ANTIBIOTICS. MONITOR TEMP Q4H, BLD CX PRN TEMP > 101. MAINTAIN ALINE UNITL MORE STABLE RESPIRATORY STATUS. EMOTIONAL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-08 00:00:00.000",
"description": "Report",
"row_id": 1585540,
"text": "Micu Acceptance Note\n\n20 yo male with hx of quadraplegia s/p mva transf from Hosp with resp failure, ? ARDS, bactermemia and radpid antigen + influenza B. Pt was admitted to HFH on after being found down at home, unresp and tachypneic. Per report, pt had told his father that he had been experiencing sob, fever and cough. It was also noted by VNA that he had purulent discharge from his indwelling foley catheter. Pt was intubated for hypoxic resp failulre. Admit tox screen was positive for opiates, benzos and cannabinoids. Cultures were positive for MRSA in blood and sputum, Group B strep in sputum, in sputum and urine and klebsiella PNA in urine. He tested antigen + for influenza B and neg for influenza A. Pt's course was complicated by hypotension for which he was treated with dopamine. Dopamine was weaned off prior to transfer. Pt was also anticoagulated wih lovenox for likely RLE DVT on u/s. CTA was neg for PE. Pt transf to for further mgt. Pt is FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-08 00:00:00.000",
"description": "Report",
"row_id": 1585541,
"text": "Review of Systems and Nsg Progress Note\n\nNeuro - Pt initially sedated on 65mcgs/kg/min propofol. Arousable only to painful stimuli. Changed to versed and fentanyl iv. During transition pt agitated, nodding affirmatively when asked if he was experiencing any pain, unable to identify source. Bolused with 100mcgs fentanyl and drip titrated up to 100mcgs/hr. Versed also titrated up - currently infusing at 8mg/hr. Pt opening eyes spont, not following commands, localizes pain. Pt is paraplegic, has purposeful movement upper exts. Also medicated with baclofen and neurontin.\n\nResp - Pt orally intubated and maintained on AC. Initially ventilated on AC 650 x 18 x 12 70% - ABG 7.44/34/81/0/24. Changed to AC 550 x 22 x 15 70% - most recent ABG 7.46/36/79/1/26. Goal TV 550-600.RR 23-25. 02 sat 92-94%. LS rhoncerous, no wheezing noted. Sx for scant amt thin white secretions.\n\nC-V - HR 90-100 SR, no ectopy noted. ABP 90-110/50-60. Remains off pressors. Pt with reported DVT - Heparin infusing at 1400 units/hr, no bolus administerd. Goal PTT 60-100. Am PTT pend. Hct 33.8. + dopplerable pulses except for PT . 2+ pitting edema lower exts.\n\nGI - Abd soft and obese. Hypoactive BS. No stool. Promote infusing via NGT at 20ccs/hr. Goal 60ccs/hr. Minimal residuals. GI prophylaxis - lansaprazole. + transaminitis - LTFs elevated. ? RUQ u/s to be done.\n\nF/E - Urine output 35-110ccs/hr via foley. K 3.2 - given 40 meq kcl iv with repeat K 3.5, now receiving an additional 20 meq kcl iv. Mg 1.7 - repleted with 2 gms magso4 iv, Mg level now 2.4.\n\nID - + Contact and droplet precautions. As per above, + MRSA sputum, + influenza A. Max temp 101 po. WBC 17.9. MRSA covered with vancomycin 1500mg iv q 12hrs. Unasyn 3 gms iv q 6hrs for klebisiella uti. Vanco trough 6.6 last eve.\n\nSkin - Pt s/p partial excision of R great toenail. No exudate noted, wet to dry dssg applied. L heel decub open to air. Duoderm applied to L gluteal decub. Skin care RN should be consulted. + yeast in groin area - miconazole powder applied.\n\nAccess - R radial aline, RSCL\n\nSocial - Mother called for update on pts condition. States she and pts brother will be in to visit him today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-12 00:00:00.000",
"description": "Report",
"row_id": 1585561,
"text": "Nursing Progress Note 0700-1900\nReview of Systems:\nNeuro: Sedation unchanged from Versed 13.5mg/hr, Fentanyl 180mcq/hr. Pt wakens easily, follows comands consistantly. Good strength in upper extremeties, bilat wrist restraints in place for safety. Occas belligerant/angry, mouthing that he wants to go home. He asked his mother to reorient him, and at one point mouthed, \"Who are you?\" to her. Denies pain. Pt on Triadyne bed with scheduled turning STS.\n\nResp: pt on vent settings AC 50%/28 X 450/+18 with ABG 7.41/46/73. Peep decreased from 18->16->14, however ABG on 14peep 7.44/43/59. Peep returned to 16 with other settings remaining constant. Pt without SRR. No further cuff leak with cap in place. CXR done X 2 with results pndg. Lung snds coarse/rhonchorous with intermit exp wheezes on left. Suctionned Q2-4hrs for mod amts thick, white secretions. Pt with strong cough, gag impaired.\n\nCV: HR 87-101SR with rare PVC's. BP 98/53-117/61. Lytes checked @ 1600 as pt auto-diuresing: K+3.9, Mg 2.0, ionized calcium 1.08. Heparin qtts unchanged @ 3350u/hr, with PTT within goal range @ 75.6.\n\nGI: TF of Promote with fiber cont via OGT @ goal 80ml/hr with scant residuals. Abd obese/distended and soft with hypoactive bowel snds. Pt had one med brown, guaiac neg, formed BM. Spec sent for c-diff.\n\nGU: Pt auto-diuresing with output 180-500ml/hr of light yellow urine. Fluid balance MN->1700 -870ml, with LOS balance +600ml.\n\nID: Tmax 101.7po. Pt pan-cultured with 2 sets bld cxs including fungal sent, as well as sputum cx and stool for c-diff. Pt rec'd tylenol 650mg via OGT @ 1400.\n\nSkin: R great toe with DSD intact. Heels/coccyx intact post old pressure wnds.\n\nSocial: Mother visited in am, father in pm. Both supportive, anxious re pt's condition.\n\nPlan: Repeat ABG on peep 16. Repeat Tylenol @ 1800. Bronchoscopy to be done tomorrow. Cont aggressive pulm toilet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 1585562,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse rhonchi improve with suct sm =>mod loose off white sput. Pt in NARD on current vent settings. MDI given as per order. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 1585563,
"text": "NPN 1900 -0700\n\nNEURO: LIGHTLY SEDATED ON FENT AND VERSED. DECREASED VERSED TO 10MG/HR HYPOTENSION. FENTYNAL UNCAHANGED @ 180MCG/HR.PT MOVES BOTH ARMS CAN LIFT AND HOLD, POOR FINE MOTOR DOES NOT MOVE FINGERS.\n\nRESP:EPISODES W/ SAT DROPPING DOWN TO 88-90, INCREASED FIO2 TO 60%, UNSUCCESSFUL IN DECREASING PEEP. PRESENTLY ON A/C 28/450/60%/16 .SX FOR SM AMT THICK YELLOW /WHITE SECRETIONS.STRONG COUGH.LUNGS REMAIN COARSE ,DUE FOR BRONCH TODAY.\n\nC/V: BECAME TACHYCARDIC INTO 150'S ST, TREATED FOR TEMP OF 101 AX W/ 1 GM TYLENOL, CVP WAS 16-17, BP 90'S-100'S. GAVE 2.5 LOPRESSOR WHICH BROUGHT HR DOWN TO 1TEENS. LOWERED VERSED TO 10MG FROM 13MG TO ALLEVIATE HYPOTENSION. BP AND HR RETURNED TO BASELINE .HEPRIN @ 3350 AM PTT PENDING.\n\nF/E/N: CONT TO AUTO DIURESE 150-250 HR .TF STOPPED FOR BRONCH TODAY, NO STOOL OVER NOC.\n\nPLAN: BRONC TODAY, MONITOR HEMODYNAMICS,ALTERNATE TYLENOL AND MOTRIN FOR TEMP.CONT AB TX\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 1585564,
"text": "Respiratory Care\nPt bronched this morning for small to moderate amounts of this white secreations. Improved aeration noted. MDI's given as ordered. Placed on CPAP/PSV with possible late shift intubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-12 00:00:00.000",
"description": "Report",
"row_id": 1585557,
"text": "Nursing Assessment Note 1900-0700\nNEURO: Pt lightly sedated on versed @ 13.5 mg/hour and fentanyl @ 180mcg/hour, pt easily arousable to verbal stimuli and mouths words and can answer yes or no questions, pt is a paraplegic and has bilat wrist restraints on as he is trying to reach for his ETT when awake, PERL, pt denies dizziness at this time\n\nCV: Pt's vss, febrile to 99.7, then 99.4, pt denies pain at this time, but does keep asking when the tube can come out, Pt is nsr/st without ectopy, pt has right radial A-line, waveform is sharp and wnl, and pt has right subclavian TLC, with NS @ KVO, versed @ 13.5 cc/hour and fentanyl @ 18 cc/hour, pt also on heparin drip @ 3350 units/hour or 33.5 cc/hour, last ptt at was theraputic, next ptt due with am labs, skin is pink, warm, and dry, pp + & =, with +1 - +2 edema, pt's right foot dsg is clean, dry, and intact, pt on special bed with automatic turn setting on\n\nRESP: Pt's lung sounds reveal rhonci in upper lobes, with exp whez & diminished in bases, rhonci will clear with suctioning, pt on A/C rate-28, TV-450, peep-18, Fio2-50%, pt suctioned for small amount thick white sputum, pt continued to try and tounge out ETT and tape came off twice, so pt had ETT taped to lower lip and pt has not been able to loosen tape, pt also seems to have persistent cuff leak, requiring 1-2 cc's air q 1 hour, I applied a cap to end of cuff and no further leaking has been noted in almost 2 hours\n\nGI: Pt's bowel sounds are positive, but hypoactive with softly distended abd, pt has ogt, placement confrimed via air bolus, tube feeding of promote with fiber @ 80 cc/hour (goal) infusing well without problems, pt's residual was 10 cc's at and 60 cc's at midnight, pt has had no stool at this time\n\nGU: Pt's foley draining clear yellow urine qs\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-12 00:00:00.000",
"description": "Report",
"row_id": 1585558,
"text": "Addendum Note\nPt had one episode where he coughed forcefully and disconnected self from vent, Pt sats decreased to 90-91% & pt reconnected to vent within 20-30 seconds and Fio2 transiently increased to 100% and pt sats returned to baseline within 1-2 mins\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-12 00:00:00.000",
"description": "Report",
"row_id": 1585559,
"text": "Respiratory Care\nRemains intubated and ventilated on a/c 450 x 28 +18 50%, last abgs within normal limits. Breath sounds coarse and rhonchorous. Given albuterol/atrovent inhalers. Suctioned for lots of thick white sputum.ET tube needed retaping x 2 but now seems more secure taped to bottom lip. ?cuff leak although has been stable past few hours.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-12 00:00:00.000",
"description": "Report",
"row_id": 1585560,
"text": "Respiratory Care\nPt slowly weaning peep per flowsheet. Suction small to moderate amounts of thick white secreations. Breath sounds equal/coarse. Bronchodilators administered as ordered. Possible bronchoscopy tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-11 00:00:00.000",
"description": "Report",
"row_id": 1585553,
"text": "Respiratory Care\nRemains intubated and ventilated on a/c 450 * 28 20 of peep. FIO2 increased back up to 60 due to desaturation last evening Breath sounds are coarse, suctioning thick white sputum. Inhalers given as ordered. Last abg shows improved oxygenation, normal limits.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-11 00:00:00.000",
"description": "Report",
"row_id": 1585554,
"text": "Nursing note Addendum:\n\nPT TEMP 101.0 ORALLY, MD NOTIFIED. ANOTHER DOSE TYLENOL 650 MG GIVEN, BLOOD CULTURES X 2 SETS DRAWN FROM ALINE AND SUBCLAVIAN LINE. URINE CULTURE SENT. CHEST XRAY ORDERED. PT AM PTT THERAPEUTIC @ 63.6. ABG ON FIO2 60% 7.45/45/72/32. PT HAD COUGHING EPISODE AND POPPED OFF THE VENTILATOR. PT RECONNECTED TO VENT IN LESS THAN 60 SECONDS. SINCE THIS EPISODE, PT DESATURATING TO MID 80S. PLACED ON 100% FIO2 FOR 2 MINUTES AND SATS INCREASED TO 90-91%. SX FOR MINIMAL SECRETIONS VIA ETT. MD MADE AWARE. RT INCREASED FIO2 TO 100% AND WILL WEAN AS TOLERATED. WILL CONT TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-11 00:00:00.000",
"description": "Report",
"row_id": 1585555,
"text": "NPN 0700-1900\n\nEvents/General: Sedation weaned 10% and vent settings decreased to 50% fiO2 and 18peep (from 20).\nNeuro: Lightly sedated on fentanyl 180mcg/midazolam 13.5mg which was decreased from 200mcg/15mg; now has haldol prn ordered for agitation; dozing frequently but easily awakened and opens eyes spontaneously; follows commands, moves UE, attempts to communicate by mouthing words.\nCV: ABP 91-112/47-63 with maps 61-78, HR 89-105, SR/ST no ectopy noted; CVP 19-20; + pitting edema of extremities which is lessening due to autodiuresing. Heparin gtt remains at 3350 units/hr, PTT due this eve.\nResp: Remains intubated on vent in AC mode 450/28/50/18; peep and fiO2 weaned from 60% and peep 20 with f/u abg's of 7.43/78/29/3; lung sounds are coarse throughout, diminished lower lobes; suctioned q 2-3hrs for moderate amounts white sputum; respiratory mechanics tested by RT to find best position for pt regarding respiratory muscles > no significant difference between lying flat or upright so pt maintained in semi-fowlers positon; ET tube rotated to L side of mouth and retaped; pt pushed out oral airway with tongue but seems to be cooperating so far by not biting the tube.\nGI: Abdomen softly distended, +BS, NT; TF of promote with fiber at goal of 80/hr; 10-50cc residuals. Incontinent 1 small loose light brown stool.\nGU: Foley catheter draining 100-450cc/hr clear yellow urine; pt is autodiuresing; fluid status is -280cc since midnight, +1700 LOS.\nID: Tmax 101 po, pan cultured this am; remains on Zosyn and vanco; vanco trough done. Droplet precautions d/c'd due to negative influenza culture; remains on contact precautions for MRSA.\nSkin: Dressing D&I R toe; remains on triadyne bed with rotation off.\nPlan: Wean sedation and vent as tolerated, suction prn, continue abx, MDI's, check abg's with changes; monitor fluid electrolyte status; monitor hemodynamic status, temp, wbc's; continue TF as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-11 00:00:00.000",
"description": "Report",
"row_id": 1585556,
"text": "resp. care\npt. remains intubated/vented/lightly sedated. very much\nawake and nods to questions. o2 weaned back to 50% and\npeep to 18 with acceptable abg. sx'ing white sputum. bite\nblock removed and pt. now not biting on ett. continue slow\npeep wean by 2cm. see flowsheet for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-16 00:00:00.000",
"description": "Report",
"row_id": 1585572,
"text": "MICU/SICU NURSING NOTE 7P-7A:\n\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT GIVEN XANAX 2 MG,AMBIEN 10 MG AND VALIUM 10 MG TO ASSIST WITH SLEEP PER PATIENT REQUEST. PT REMAINED RESTLESS THROUGHOUT NIGHT, DOSING OFF AND ON. PT TEARFUL AT TIMES. \" I DON'T WANT TO BE HERE ANYMORE, I'M READY TO GO HOME. I WANT SOMEONE TO STAY WITH ME.\" PT GIVEN EMOTIONAL SUPPORT. PUPILS EQUAL/REACTIVE BILAT, DECREASED COUGH/GAG. PT DENIES PAIN.\n\nCV: TMAX 99.1 HR 80-115 SR-ST NO ECTOPY. BP 90-127/40-60. + 1 GENERALIZED EDEMA PEDAL PULSES BY DOPPLER ONLY. HEPARIN GTT @ 3100 UNITS/HOUR PTT @ 2100 WAS 65.5 (GOAL 60-100).\n\nPULM: PT REMAINS ON 6 L NC SATS 91-98%. LUNGS COARSE DECREASED @ BASES. PT USING WITH RT, EXPECTORATING SMALL THICK TAN SECRETIONS. CHEST PT DONE BY RT.\n\nGI/GU: ABD SOFT, OBESE. + BOWEL SOUNDS TOLERATING HOUSE DIET WITHOUT DIFFICULTY. NO BM OVERNIGHT. PT , FOLEY DRAINING CLEAR YELLOW URINE 100-400CC/HOUR.\n\nPLAN: CONT ANTIBIOTICS, PULMONARY TOILET, MONITOR PULMONARY STATUS, FOLLOW LABS AND CULTURES, CONT HEPARIN GTT FOLLOW PTT, SOCIAL SERVICE CONSULT, EMOTIONAL SUPPORT, WILL CONT TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-16 00:00:00.000",
"description": "Report",
"row_id": 1585573,
"text": "RESPIRATORY CARE:\n\nFollowing pt for pulmonary hygiene and prn bronchodilator tx's. Pt has improved since last night, requiring only nasal cannula to maintain good SaO2's(mid to high 90's). Using inexsufflator through the night with good results, clearing thick white secretions. BS's remain coarse, with scattered exp wheezes. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-16 00:00:00.000",
"description": "Report",
"row_id": 1585574,
"text": "Resp Care\n\nPt continues on 6L NC with spo2 in the mid to low 90s. BS dim-slightly course at times. PT using cough assist device Tx well-MIE'ed x2 this shift for 6-8 breaths per cycle. Pt expectorating small to mod amts of thick white secretions following use. WIll cont to follow.\n"
},
{
"category": "Echo",
"chartdate": "2178-11-10 00:00:00.000",
"description": "Report",
"row_id": 75436,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 207\nBSA (m2): 2.12 m2\nBP (mm Hg): 102/57\nHR (bpm): 71\nStatus: Inpatient\nDate/Time: at 10:29\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nAgitated saline contrast study was performed with injection of 4 injections at\nrest. There was no evidence of intracardiac shunt although images were\ntechncially suboptimal.\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is borderline pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2178-11-17 00:00:00.000",
"description": "Report",
"row_id": 197043,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , sinus tachycardia and ST-T wave changes now\nabsent\n\n"
},
{
"category": "ECG",
"chartdate": "2178-11-12 00:00:00.000",
"description": "Report",
"row_id": 197280,
"text": "Baseline artifact. Sinus tachycardia. Diffuse non-specific ST-T wave changes.\nCompared to the previous tracing tachycardia is new.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-17 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 887514,
"text": " 3:12 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Need CTA Chest to assess if there are new PE (known RLL PE)\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 M, paraplegic, hypoxic resp distress, known RLL PE, on heparin/coumadin,\n with acute desat and more prominent S1Q3T3 on EKG\n REASON FOR THIS EXAMINATION:\n Need CTA Chest to assess if there are new PE (known RLL PE)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Paraplegic, hypoxic, respiratory distress, known right lower lobe\n PE.\n\n Comparison is made to the prior CT scan dated .\n\n TECHNIQUE: Multidetector CT scanning of the chest was performed following\n intravenous administration of 150 cc of Optiray contrast. Multiplanar\n reconstructions were also obtained.\n\n FINDINGS: The examination is again somewhat limited due to patient body\n habitus and arm position. There is a persistent filling defect in the\n pulmonary artery to the right lower lobe consistent with the previously\n described pulmonary embolism. This is not significantly changed. No new\n areas of embolism are identified. The previously identified areas of\n mediastinal and hilar lymphadenopathy are unchanged. The patient is status\n post extubation. The airways remain patent to the segmental level bilaterally\n with note of some retained secretions within the trachea. The heart,\n pericardium, and great vessels are within normal limits. There has been\n interval placement of a left-sided PICC line with the tip terminating in the\n distal SVC. Evaluation of the lungs again demonstrates bilateral dependent\n consolidations, which have improved slightly compared to the prior study,\n particularly in the right lower lobe. There is again demonstrated apparent\n more diffuse ground-glass and patchy opacities, although evaluation is\n somewhat limited due to expiratory phase of scanning. There is no pleural or\n pericardial effusion. The limited visualized portions of the upper abdomen\n are remarkable for hypoattenuation of the liver consistent with fatty\n infiltration.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions.\n\n CT RECONSTRUCTIONS: The above findings were confirmed with multiplanar\n reconstructions.\n\n IMPRESSION:\n\n 1. No new areas of embolism identified. Persistent small pulmonary embolism\n to the artery to the right lower lobe.\n\n 2. Bilateral dependent consolidations, which are slightly improved compared\n (Over)\n\n 3:12 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Need CTA Chest to assess if there are new PE (known RLL PE)\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to the prior study, particularly in the right lower lobe.\n\n 3. Unchanged mediastinal and hilar lymphadenopathy.\n\n 4. Retained secretions in the trachea.\n\n 4. Fatty infiltration of the liver.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886343,
"text": " 4:43 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please confirm OGT placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, intubated,\n w/MRSA in sputum now s/p OGT placement\n REASON FOR THIS EXAMINATION:\n please confirm OGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old man with hypoxia. OG tube placement.\n\n COMPARISON: Eleven hours earlier.\n\n CHEST AP: The tip of the feeding tube is in the stomach with the side port\n just below the GE junction.. There is unchanged appearance for mild pulmonary\n edema. Heart size, mediastinal and hilar contours are unremarkable. No areas\n of consolidation are visualized. The tip of the right-sided central line is in\n the right atrium.\n\n IMPRESSION: Stable pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886872,
"text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening disease\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, intubated,\n w/MRSA in sputum, persistent fevers\n REASON FOR THIS EXAMINATION:\n ? worsening disease\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxic respiratory failure and persistent fevers.\n\n PORTABLE AP CHEST: As compared to , endotracheal tube and\n right subclavian central venous catheter remain in stable, satisfactory\n position. The tip of the nasogastric tube cannot be detected beyond the\n distal esophagus due to technique. Moderate interstitial edema, left lower\n lobe opacity, small-to-moderate right pleural effusion are unchanged.\n\n IMPRESSION: No significant interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 888026,
"text": " 11:57 PM\n PORTABLE ABDOMEN Clip # \n Reason: ? constipation\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with h/o of quadraplegia s/p MVA , being transferred from\n to floor for resolving septic shock from MRSA bacteremia, ARDS, RLL\n MRSA/Pseudamonas pna, +influenza B now complaining of abdominal discomfort.\n REASON FOR THIS EXAMINATION:\n ? constipation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, TWO VIEWS, DATED :\n\n CLINICAL HISTORY: 20-year-old male with history of quadriplegia with\n influenza B, now complaining of abdominal discomfort, qustion constipation.\n\n FINDINGS: Comparison is made to prior examination dated . A single\n supine abdominal examination was obtained. There is no evidence for dilated\n bowel or obstruction. No significant amount of stool is identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 887170,
"text": " 12:25 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: picc placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, now\n with picc\n REASON FOR THIS EXAMINATION:\n picc placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxic respiratory failure, assess PICC placement.\n\n chest, 1 vw\n\n A PICC line is present. The tip overlies the right atrium. It should be\n retracted approximately 4.6 cm to lie at the SVC/RA junction. Pleural\n and parenchymal findings are otherwise essentially unchanged. No pneumothorax\n is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-15 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 887153,
"text": " 11:21 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: picc placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, now\n with picc\n REASON FOR THIS EXAMINATION:\n picc placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC line placement. Hypoxic respiratory failure.\n\n chest, single vw\n\n Compared with earlier the same day, a new left PICC line is present. However,\n the PICC line extends cephalad out of the chest into the neck, extending\n beyond this film. Again seen is left lower lobe collapse and/or\n consolidation. There is new opacity at the right base, likely representing an\n element of consolidation, with new prominence of the right hilum.\n\n IMPRESSION:\n 1. Left PICC line extending into neck and should be replaced.\n\n 2. Continued left lower lobe collapse and/or consolidation.\n\n 3. New opacity right base, likely representing atelectasis - - new compared\n with .\n\n Findings called to , at 11:51 a.m. on Sunday, .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-08 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 886187,
"text": " 3:41 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: rule out acalculous cholecystitis\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with quadriplegia, presents with hypoxemic resp failure \n PNA, now with elevated LFTs, alk phos and rising bili.\n REASON FOR THIS EXAMINATION:\n rule out acalculous cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of quadriplegia with hypoxemia, now with elevated LFTs\n and alk phos, evaluate for a acalculous cholecystitis.\n\n COMPARISON: CT scan from .\n\n LIMITED RIGHT UPPER QUADRANT ULTRASOUND: The study was limited secondary to\n the patient's large body habitus and inability to turn sideways. The\n gallbladder wall was not distended, and demonstrated no intraluminal stones or\n material. There was no gallbladder wall edema or pericholecystic fluid.\n There is no intrahepatic ductal dilatation. The liver demonstrated no focal\n mass lesions. The common bile duct and pancreas were obscured by overlying\n bowel gas, and were not completely visualized.\n\n IMPRESSION: The gallbladder was normal in appearance, without any associated\n intrahepatic ductal dilatation. There is limited evaluation of the CBD\n secondary to overlying bowel gas. The results were discussed with the\n covering house staff immediately after the study was performed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886122,
"text": " 9:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for infiltrate, evaluate ETT and line placement.\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, intubated, w/\n MRSA in sputum, also +fluB\n REASON FOR THIS EXAMINATION:\n Evaluate for infiltrate, evaluate ETT and line placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST .\n\n CLINICAL INDICATION: Respiratory failure. MRSA.\n\n There is poor visualization of the lines and tubes due to body habitus and\n technique of the exam. An endotracheal tube is present, with the tip\n terminating in the region of the superior aspect of the clavicles with the\n neck in apparently flexed position. Nasogastric tube and right subclavian\n vascular catheters are present, but their tips are not well visualized due to\n the factors listed above. The heart is mildly enlarged and there is upper\n zone vascular redistribution as well as widening of the vascular pedicle.\n This is associated with diffuse perihilar haziness. More confluent opacities\n are seen at the lung bases, right greater than left.\n\n IMPRESSION:\n 1. Endotracheal tube is slightly proximal in location particularly given\n flexed position of the patient's neck. This could be advanced several\n centimeters from more optimal placement as communicated to the clinical\n service caring for the patient.\n 2. Findings consistent with volume overload or congestive heart failure.\n 3. Asymmetrical basilar consolidation raises concern for underlying pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887038,
"text": " 7:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening pna\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure,\n intubated, w/MRSA in sputum, persistent fevers\n REASON FOR THIS EXAMINATION:\n ? worsening pna\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST.\n\n There is comparison from .\n\n CLINICAL HISTORY: Fevers, question pneumonia.\n\n FINDINGS: There are prominent interstitial markings, which are unchanged from\n the prior exam. There is no pleural effusion or pneumothorax. The cardiac\n silhouette is at the upper limits of normal. Since the prior exam the patient\n has been extubated and the nasogastric tube has been removed. There is a\n right central venous catheter with its tip in the region of the SVC/right\n atrium.\n\n IMPRESSION: No focal consolidation. There are persistent prominent\n interstitial markings, which may be related to prior episodes of pulmonary\n edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886583,
"text": " 7:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for increasing infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, intubated,\n w/MRSA in sputum, persistent fevers\n REASON FOR THIS EXAMINATION:\n please eval for increasing infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW, PORTABLE.\n\n INDICATION: 20-year-old man with hypoxic respiratory failure.\n\n COMMENTS: Portable supine AP radiograph of the chest is reviewed, and\n compared with the previous study of .\n\n The previously identified pulmonary edema has been slightly improving. There\n is increased right lower lobe opacity indicating pneumonia versus atelectasis.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. The\n right subclavian IV catheter terminates at the cavoatrial junction. The heart\n is normal in size. No pneumothorax is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887252,
"text": " 6:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for improvement in infiltrates\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, now extubated\n REASON FOR THIS EXAMINATION:\n please eval for improvement in infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:21 A.M, .\n\n HISTORY: Left pleural effusion.\n\n IMPRESSION: AP chest compared to and 30:\n\n Bibasilar atelectasis has improved slightly. Mild pulmonary edema persists,\n and there has been a significant increase in volume of moderate-sized left\n pleural effusion and development of progressive consolidation in the left\n perihilar as well as infrahilar left lung that could be due to asymmetric\n edema or worsening of pneumonia. Tip of a left PIC catheter projects over the\n superior cavoatrial junction. Heart is top normal size. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-09 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 886265,
"text": " 11:13 AM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: r/o PE\n Admitting Diagnosis: PNEUMONIA\n Field of view: 42 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with hypoxic respiratory failure and known DVT on heparin drip\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, respiratory failure, known DVT, on heparin drip.\n\n No prior studies are available for comparison.\n\n TECHNIQUE: Multidetector CT scanning of the chest was performed following\n intravenous administration of 150 cc of Optiray contrast through the patient's\n central line. Multiplanar reconstructions were also obtained.\n\n FINDINGS: The study is somewhat limited due to the patient's body habitus and\n injection through a central line. Allowing for this, there is a small filling\n defect demonstrated within the lumen of the pulmonary artery to the right\n lower lobe. This is best appreciated on series 2, images 80 and 81. The\n remaining pulmonary arteries demonstrate no other filling defects. There is\n an endotracheal tube, NG tube, and right subclavian central venous catheter in\n satisfactory position. The heart, pericardium, and great vessels are within\n normal limits. There are enlarged mediastinal and hilar lymph nodes. These\n include a prevascular lymph node measuring 1.5 cm in short axis and a right\n hilar lymph node measuring up to 1.5 cm in short axis as well. The airways\n remain patent to the segmental level bilaterally.\n\n Evaluation of the lungs demonstrates dense bilateral dependent consolidations.\n There are bilateral more scattered patchy areas of consolidation as well.\n There are diffuse bilateral ground-glass opacities. There is also bilateral\n thickening of the interlobular septa. There are trace effusions. Two\n adjacent small cysts are noted within the right upper lobe, the largest of\n which measures approximately 1 cm on series 2, image 115.\n\n The limited visualized portions of the upper abdomen are unremarkable.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions.\n\n CT RECONSTRUCTIONS: The above findings were confirmed with coronal and\n sagittal reformations.\n\n IMPRESSION:\n 1. Findings consistent with a small pulmonary embolism to the artery to the\n right lower lobe given limitations of this study.\n\n 2. Bilateral dependent consolidations.\n\n (Over)\n\n 11:13 AM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: r/o PE\n Admitting Diagnosis: PNEUMONIA\n Field of view: 42 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Diffuse ground-glass opacities and thickened interlobular septae\n consistent with pulmonary edema or ARDS.\n\n 4. Mediastinal and hilar lymphadenopathy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 887996,
"text": " 4:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for foci or masses or edema\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 yo M paraplegic with MRSA bacteremia, MRSA pna, with 20/800 vision loss\n REASON FOR THIS EXAMINATION:\n Eval for foci or masses or edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 20-year-old male paraplegic with visual loss. Evaluate for foci\n of masses or edema.\n\n TECHNIQUE: CT of the head without IV contrast.\n\n COMPARISONS: Made to .\n\n FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect,\n shift of normally midline structures, major vascular territorial infarcts. The\n -white matter differentiation is preserved. The density values of the\n brain parenchyma are within normal limits. The ventricles are of normal size.\n\n The imaging of the posterior fossa is limited due to hardware from occipital\n cervical fusion. No suspicious lytic bony lesions are seen. The visualized\n portions of the paranasal sinuses, are normally aerated. There is\n opacification of mastoid cells bilaterally due to fluid.\n\n IMPRESSION:\n 1. No evidence of acute intracranial pathology.\n 2. Opacification of bilateral mastoid air cells.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886768,
"text": " 10:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening disease\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure,\n intubated, w/MRSA in sputum, persistent fevers\n REASON FOR THIS EXAMINATION:\n ? worsening disease\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: MRSA in sputum. Persistent fevers.\n\n Endotracheal tube, central venous catheter, and nasogastric tube remain in\n place. The tip of the central venous catheter projects just below the\n cavoatrial junction on the current study. Cardiac and mediastinal contours\n are stable, and there is evidence of vascular engorgement and perihilar\n haziness. Slightly more confluent areas of opacification in the lower lobes,\n right greater than left are again demonstrated, with interval improvement. The\n degree of perihilar haziness is also slightly improved. Small-to-moderate\n right pleural effusion is again demonstrated.\n\n IMPRESSION:\n 1. Further improvement in degree of pulmonary edema.\n\n 2. Improving more confluent opacities in the lower lobes, right lower lobe\n greater than left, which could be due to dependent edema with asymmetric\n distribution, but underlying pneumonia is not excluded, particularly in the\n right lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887132,
"text": " 5:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?improving infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure,\n intubated, w/MRSA in sputum, persistent fevers\n REASON FOR THIS EXAMINATION:\n ?improving infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Persistent fevers, question improving infiltrate.\n\n CHEST, SINGLE AP VIEW.\n\n Lordotic positioning. Also, the lower portion of the chest is excluded from\n this film.\n\n There is a upper zone redistribution and diffuse vascular blurring raising the\n question of CHF. Limited assessment for effusion or consolidation due to\n exclusion of the diaphragms. Allowing for this, there does appear to be\n retrocardiac density, consistent with left lower lobe collapse and/or\n consolidation, similar to that seen on the film from one day earlier. ?\n atelectasis and/or small effusion at right base, not fully evaluated here.\n Right subclavian central line tip over lower SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886216,
"text": " 5:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA? effusions?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, intubated, w/\n MRSA in sputum, also +fluB\n REASON FOR THIS EXAMINATION:\n PNA? effusions?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:51 A.M., \n\n HISTORY: Hypoxic respiratory failure. MRSA in sputum.\n\n IMPRESSION: AP chest compared to and 23rd.\n\n Mild pulmonary edema is new and may be partly responsible for the increasing\n volume of consolidation in the right lower lobe due to pneumonia, but\n worsening infection may also be at work. Heart is normal size. Small right\n pleural effusion is new or newly apparent. ET tube and right subclavian\n catheter are in standard placements and a nasogastric tube passes below the\n gastroesophageal junction and out of view.\n\n No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887410,
"text": " 7:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? infiltrate or pulmonary congestion\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, now extubated\n with desat this am.\n REASON FOR THIS EXAMINATION:\n ? infiltrate or pulmonary congestion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:21 A.M.\n\n HISTORY: Respiratory failure.\n\n IMPRESSION: AP chest compared to :\n\n Right lower lobe atelectasis is minimally improved but still severe.\n Asymmetric interstitial pulmonary edema, favoring the left lung is unchanged.\n The heart is top normal size. There is no appreciable pleural effusion. Left\n PIC catheter tip projects over the superior cavoatrial junction. No\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887352,
"text": " 4:18 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: upright, eval effusions upright\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, now extubated\n\n REASON FOR THIS EXAMINATION:\n upright, eval effusions upright\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 20-year-old man transferred from outside hospital with hypoxic\n respiratory failure, now extubated. Evaluate effusions.\n\n COMPARISON: Multiple radiographs, most recent dated , at 6:21\n a.m.\n\n PORTABLE CHEST: Cardiac, mediastinal, and hilar contours are stable. There\n are low lung volumes on the exam, and the exam is slightly limited by motion.\n Prominence of upper zone pulmonary vasculature is noted. Bilateral lower lobe\n opacities are consistent with atelectasis. No definite pleural effusions are\n identified. Left-sided PICC is again noted with the tip in SVC. Osseous and\n soft tissue structures are unremarkable.\n\n IMPRESSION: Bilateral lower lobe atelectasis. Improving perihilar edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886183,
"text": " 2:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: spiked temp to 103.6, with PNA, on vent, worsened PNA?\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man transfered from OSH with hypoxic resp failure, intubated, w/\n MRSA in sputum, also +fluB\n REASON FOR THIS EXAMINATION:\n spiked temp to 103.6, with PNA, on vent, worsened PNA?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, :\n\n COMPARISON: .\n\n INDICATION: Respiratory failure. Spiking temperatures.\n\n An endotracheal tube remains in place, with the tip currently terminating\n approximately 6.5 cm above the carina. A central venous catheter remains in\n satisfactory position. The cardiac silhouette is enlarged and there is\n persistent vascular engorgement and perihilar haziness. More confluent\n alveolar opacities at the bases show slight interval improvement in the\n interval.\n\n IMPRESSION:\n\n 1. Endotracheal tube tip slightly proximal and could be advanced 1-2 cm for\n more optimal placement.\n\n 2. Persistent perihilar edema.\n\n 3. Slight improvement in more confluent basilar opacities, which may reflect\n dependent edema or other superimposed process such as aspiration or pneumonia.\n\n\n"
}
] |
32,775 | 128,184 | Patient was transferred to from on . He was admitted to the MICU with R abdominal & flank pain with extensive erythema and induration of the soft tissues. ID was consulted. He was started on linezolid, meropenem, and caspofungin. A prednisone taper was planned. He was continued on Lovenox. Overnight, he deteriorated. Surgery was consulted for necrotizing fasciitis. He was taken emergently to the OR for radical debridement with step incisions in the abdominal wall fascia & musculature on . He remained intubated, sedated, and went to the SICU postoperatively, where he required levophed to maintain his BP. On , he returned to the OR for repeat debridement and additional step incisions. A VAC was placed and required changes q3days. Overnight, he was stable without pressor requirement, but remained intubated and sedated. His cultures grew Citrobacter, which was appropriately covered by meropenem. He remained on linezolid and caspo empirically for C.albicans and GNC in L knee cultures from NEBH. Tube feeds were started on . Urology was consulted for scrotal edema and retracted penis. Ultrasound demonstrated symmetric blood flow and was negative for evidence of necrotizing fasciitis. On Ortho was consulted for h/o septic joint. A knee aspirate was performed; the culture was negative. Chronic Pain was consulted and recommended methadone, increased pregabalin and Ativan gtt to wean down fentanyl gtt. A CT torso performed on did not demonstrate significant change in the intraabdominal fluid collections. On , he went to the OR for tracheostomy, further I&D with drainage of periappendiceal abscess, and placement of cecostomy tube. A swab grew VRE, non albicans , and S. aureus. A CT torso performed on failed to demonstrate oral contrast extravasation (i.e. enterocutaneous fistula). Two pigtail drains were placed into his intraabdominal fluid collections with CT-guidance. The fluid drained grew Citrobacter. Ativan gtt was weaned off. Propofol was weaned off the following day. He remained on fentanyl gtt. Trach collar trials were tried daily. On , he underwent CT-guided placement of 2 additional drains as well as upsizing of one previously placed drain. Fluid culture grew Citrobacter, again appropriately covered by meropenem. A nonocclusive thrombus was found in the R popliteal vein-mid R SFV. He was started on heparin gtt. On , a Passy-Muir valve was placed. A PICC was placed on . On , his antibiotics were changed to tigecycline and caspo. PT was consulted. On , an IVC filter was placed. He was then placed on Lovenox; heparin gtt was stopped. Plastics was consulted and recommended b/l LE STSG. On , a CT abd demonstrated decreased size of the L subphrenic fluid collection and no significant new or 3 drained collection. He was transferred to the floor. On , he went to the OR with Plastics for debridement, scar excision, and meshed skin graft. Regular diet was started on ; he tolerated it well. His last JP drain was d/c'd on . He returned to the OR with Plastics on for removal of bolster. His skin graft was viable. The wound VAC was replaced with DuoDerm gel & Xeroform. Coumadin was started on . His PCA was d/c'd and he was transitioned to PO Dilaudid with IV Dilaudid prn breakthrough pain. Antibiotics were d/c'd on as per ID recommendations. OT was consulted. On , his cecostomy tube migrated out. Ostomy RNs were consulted and an appliance was afixed. He was decannulated without respiratory difficulty on . He refused d/c Foley throughout his hospital course secondary to difficulty with physical mobility. He also requires a great deal of encouragement to get out of bed to chair, where he sits for >3 hours/day. His pain is controlled on PO and IV Dilaudid. His PICC line is being left in place as per his request for IV Dilaudid administration. The risk for line infection has been explained to him, and he requests to keep it nevertheless. | The catheter was removed and the tract was dilated. Respiratory Care NotePt received on trach mask with cuff deflated and PMV in placed. The position of the catheter tip was confirmed by the aspiration of purulent material. The position of the catheter tip was confirmed by the aspiration of purulent material. The tip of the catheter was confirmed by the aspiration of very thick purulent material. ABDOMEN: A subtle stable 2 cm hypodensity in the right hepatic lobe (3, 26) was first visualized on and appears to have a tubular component. CONT ICU PLAN OF CARE. Albuterol/Atrovent nebs x 1 at pt's request. Thereafter, CT guidance was utilized to localize the perisplenic fluid collection. TECHNIQUE: Multidetector helical scanning of the chest, abdomen and pelvis was performed following the administration of oral and 130 cc of IV Optiray contrast. Utilizing CT guidance, and the catheter was secured. COMPARISON: CT torso of and chest radiograph of . To cath lab for ivc filter d/t right popliteal dvt. Rectal tube replaced in OR but oozing around still. SICU NN: SEE CAREVUE FOR SPECIFICS. SICU NN: SEE CAREVUE FOR SPECIFICS. current care, nebs prn FS q1hr (see CareVue for results). DP/PT pulses dopplerable. NGT TO LCWS. HCT stable and lytes repleted post. See CareVue for ABG results. Weaning ativan and to wean off gtt and to prn if able MD . of fem line, MD tried to resite. TRACH TO VENT. CONDITION UPDATEVSS. NGT to LCS draining bilious. Pt with anasarca. DRAINS TO LCWS. NSR, SBP 140s-160, general anascara, pulses via doppler. WEANED OFF. Hypothermic 94 post op and bair hugger on temporarily. (+) bowel sounds. L knee cx (+) MRSA and . Nebulizer tx given as ordered. PMV off for , place back on when pt wakes up. Plan: Wean sedation and vent as tolerated. IR tommorrow for ?peg placement and fluid collection drg?. Afebrile. AFEBRILE. AFEBRILE. Afebrile. AFEBRILE. PERRLA. Cuff pressure WNL. Bariair called, order placed.ID: Conts to be febrile ^ 102.4, BC X 1 off RIJ drawn, started back on previous antibx. foley patent and draining adequate hourly outputs. +RADIAL,FEMORAL,POPITEAL,PT AND DP X2.PULM: #8 PORTEX TRACH,SITE WNL AND TRACH CARE DONE. PASSE-MUIR VALVE IMPLACE AND TOLERATING WELL.GI: TOLERATING TF AT GOAL VIA NGT. AUTODIURESING WELL, LGE AMTS HUO. TITRATE SUPPLEMETNAL OXYGEN AS TOLERATED. HEPARIN GTT STARTED FOR RLE DVT. HR 90S-110S, NSR/ST, LOPRESSOR GIVEN AS ORDERED. EXTREMITES COOL.RESP: TRACH COLLAR ALL SHIFT, PASSY-MUIR VALVE IN PLACE. CONT GEN ABD PAIN, USING PCA W/MIN EFFECT PER PT. care NotePt followed this shift for Albuterol and Atrovent nebs Q6. RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACHIN PLACE. COVERAGE PER RISS.IVL'S: L-CVL LINE SITE WNL AND DRESSING INTACT. ATIVAN GIVEN PRN. WOKE UP SHORTLY AFTER SEDATION CEASED, REMAINS ON TRACH COLLAR, WELL. NPNPt recieved with RLQ abd leaking moderate am't of stool. VAC dsg to wall suction. MD AND MD AWARE LINE CONCERNS. Resp. Status Update:Data;Pt. CONT W/GEN EDEMA, MULTI WND DRAINS PATENT, FLUSHED AS ORDERED.PLAN: CONT HEMODYNAMIC MGMT, RESP SUPPORT/TRACH . PTT: 26.9,MD AWARE. Metoprolol IV q6hr ordered. K repleted and Lopressor IV started ATC. PCA pump Dilaudid. Repeat HCT stable post blood. Received alb/atr nebs. MRSA/VRE RECTAL SWAB DONE AND SENT. DP/PT pulses dopplerable. PPP.RESP: Pt trached. Briefly placed back on vent for drsg . New vac drsg by primary team. IN AM FOR CLEANING OF WD..KEEP COMF.. RIGHT RAD ALINE PLACED BY ANESTHESIA. NGT inserted and confirmed on XRAY. Updated by RN. Follow up result of CXR. resp. PROCEDURE AND ANESTHESIA CONSENT SIGNED BY PT. LACTATE SENT 3.0. nebs given. carept. Monitor incision on LLE. Pt follws commands. Plan:suction pt q4 hrs to maintain patent airway. PERRL.CV: NSR. Focus: Status UpdateData:Pt alert and oriented x3. STATUSD:ADMITTED FROM O.R. Bilateral small tears ischeal area also left open to air(L 1x1, R 2x1).Plan;Continue current plan of care. BS CTAB. Abd dsg taken down, assessed by urology, repacked and intact. PERRLA. tolerating trach mask with pmv on. brieflyback on vent for sedation for dressing changes. CC/CC replacement beggining with intial output of 2L and bolused with LR anc continuing to replace with LR. Hypoactive bs present.GU: foley draining adequate amts. care note - Pt. K+ 3.4 repleted.Resp: LS coarse to clear/diminished. F/U w/ CT results. WEAN SEDATION AND VENT AS TOLERATES. serous drainage to suction. Replete K+, as indicated by orders. Lungs are clear to coarse and weaned to cPap. LS clear/diminished. Abd vac dsg and to wall sxn, draining serosang. condition updatePlease see carevue for specifics.Neuro: Sedated on ppf, fentynal, and ativan gtt's. condition updatePlease see carevue for specifics.Neuro: Sedated with ppf/fentynal. 5 JPs patent and draining minimal fluid. Nebs given as ordered. peripheral pulses dopplerable. LS clear and diminished. serous drainage. resp. Resp. BS clear bilaterally and diminished at lung bases. Drains as previously mentioned. ABG this am resp acidosis.HR-ST.Temp 100.1. LUNGS CLEAR, DIMINISHED AT BASES (DIFFICULT TO ASCULATE LL LOBE D/T DRAINS TO WALL SUCTION). Suctioned for sm thk white. Respiratory CarePt remains intuabted (#7.5 ETT 23 @lip) and on vent support. Last ABG was WNL with good oxygenation. BS CTA bilaterally w/ exception of bases which sound diminished. care note - Pt. care note - Pt. RECIEVING PRN DILAUDID AND ATIVAN AS NEEDED. ADVANCE TF AS TOLERATES. Vent dc'd. MAG: 1.9 AND PHOS: 2.4, BOTH REPLETED.INTEG: SKIN WDI.ENDO: FS QID. ?DVT in LE. RESP SUPPORT, NEBS AS NEEDED. Resp. Resp. +RADIAL,FEMORAL,POPITEAL,PT AND DP X2. FS: 82-126.IVL'S: L-MULTI LUNEN SC-SITE WNL AND DRESSING CDI.ID: LOW GRADE TEMPS. SCHEDULED NEBS GIVEN.GI: TOLERATING TF'S AT GOAL WITH MINIMAL RESIDULAS. Respiratory carePt seen for trach check. PCA FOR PAIN MGMT. fdg restarted impact w/ fiber-resid 110cc. CVL REMAINS IN, PT IN FOR URGENT PICC EVAL. REPEAT PTT: 26.4, MD AWARE. FFP GIVEN. Drain care. RESP CARE: Pt remains trached/on vent on settings per carevue. PT UPDATE STATUSN: Pt A & O x3. SBP: 107-121/50-63. Compared to priortracing ST-T wave changes are now present. Sinus rhythm. MIN RESIDUAL. REPLETE LYTES AS NEEDED. +COUGH. TITRATE SUPPLEMENTAL OXYGEN AS TOLERATED. residual. PPP. dsg intact-drains patent-irriig w/ n/s 10cc.t. RR: . AGGRESSIVE PULM HYGIENE. SURVAILLENCE LABS PRN. Tm 100.6, CONT MULTI ANTBX. | 108 | [
{
"category": "Radiology",
"chartdate": "2200-09-03 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 982016,
"text": " 10:30 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate for pleural effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with necrotizing fasciitis, hx seronegative arthritis, s/p b/l\n hip replacements, left knee replacement\n REASON FOR THIS EXAMINATION:\n evaluate for pleural effusion\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Necrotizing fasciitis, status post extensive abdominal wall\n debridement, history of seronegative arthritis; evaluate for pleural effusion.\n\n COMPARISON: CT torso of and chest radiograph of .\n\n TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis were obtained\n following the administration of oral and intravenous Optiray contrast.\n Coronal and sagittal reformatted images were obtained.\n\n CT OF THE CHEST WITH IV CONTRAST: An endotracheal tube terminates above the\n carina and a NG tube terminates in the stomach. There are small bilateral\n pleural effusions, and air bronchograms at both lung bases, indicating\n associated atelectasis. Also noted are multiple right-sided healed rib\n fractures. The right lung exhibits significant external compression by the\n underlying perihepatic fluid collection. The heart, pericardium, and great\n vessels are unremarkable. There is no mediastinal or hilar lymphadenopathy.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Several very large intra-abdominal\n fluid collections are unchanged from the prior study. Specifically, the\n perihepatic fluid collection measures 16 x 11 cm and is causing considerable\n compression of the overlying the right lung. The midline abdominal fluid\n collection measures 13 x 11 cm, and the perisplenic fluid collection measures\n approximately 9 x 5 cm. These again measure simple fluid density.\n\n There has been interval extensive debridement of the right anterior abdominal\n wall from the mid chest to the pubic symphysis. Packing material is evident\n in several intra-abdominal sites. The liver, spleen, kidneys, and adrenal\n glands are unremarkable. Oral contrast material is seen in nondilated loops\n of small and large bowel to the rectum. There are no pathologically enlarged\n mesenteric or retroperitoneal lymph nodes.\n\n CT PELVIS WITH IV CONTRAST: Again, metallic artifact from bilateral hip\n replacements degrades visualization of the pelvis. The sigmoid colon and\n rectum appear normal.\n\n IMPRESSION:\n\n 1. Small bilateral pleural effusions with associated atelectasis.\n (Over)\n\n 10:30 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate for pleural effusion\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. No significant change in intraabdominal fluid collections.\n\n 3. Extensive debridement of right anterior abdominal wall with associated\n packing material.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-09-08 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 982611,
"text": " 10:27 AM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT PERITINEAL DRAIN EXCLUDING APPENDICEALClip # \n -59 DISTINCT PROCEDURAL SERVICE; CT ABSCESS CATH CHANGE\n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE\n CT GUIDANCE DRAINAGE; -59 DISTINCT PROCEDURAL SERVICE\n CT CHANGE PERCUTANEOUS TUBE; CT ABDOMEN W/CONTRAST\n CT PELVIS W/CONTRAST\n Reason: Assess for fluid collection and **drain collection if found*\n Admitting Diagnosis: SEPSIS\n Field of view: 55 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Abd CT scan there with cystic fluid collections in spleen and throughout\n abdomen\n REASON FOR THIS EXAMINATION:\n Assess for fluid collection and **drain collection if found**\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple fluid collections within the abdomen and pelvis.\n\n COMPARISONS: CT of the abdomen and pelvis dated and CT of the torso\n dated .\n\n PROCEDURE: MDCT images from the lung bases through the ischial tuberosities\n were obtained with 130 cc of nonanionic intravenous contrast and oral contrast\n which was administered through a nasogastric tube. Multiplanar reformations\n were essential to interpretation.\n\n LOWER CHEST: Small bilateral pleural effusions (right greater than left) are\n stable and associated with moderate lower lobe atelectasis. A nasogastric\n tube terminates in the body of the stomach.\n\n ABDOMEN: A subtle stable 2 cm hypodensity in the right hepatic lobe (3, 26)\n was first visualized on and appears to have a tubular component.\n\n Four dominant fluid collections are again visualized. A right\n subphrenic/perihepatic collection contains a pigtail catheter in appropriate\n position and has markedly decreased in size, measuring 7 x 1.7 cm, compared to\n 10.4 x 8.2 cm on the prior study. A midline subphrenic collection measures\n 12.8 x 8.1 cm, compared to 13.3 x 10.1 cm on the prior study. A pigtail\n catheter is seen along the anterior margin of the collection. A left\n subphrenic/perisplenic collection appears to have two components, the larger\n measuring 10.0 x 3.3 cm, compared to 11.9 x 4.5 cm. A left lower quadrant\n collection (3, 61) measures 16.6 x 6.2 cm, compared to 15.5 x 5.5 cm on the\n prior study.\n\n There is mild mass effect upon the spleen by the perisplenic collection. There\n is a stable moderate peripancreatic fat stranding, with a stable 2.5 x 1.2 cm\n collection abutting the distal pancreatic body (3, 45). There is no bowel\n dilatation, free fluid or pathologic lymph node enlargement within the abdomen\n or pelvis. Scattered subcentimeter in short axis retroperitoneal lymph nodes\n are similar in appearance when compared to previous studies.\n (Over)\n\n 10:27 AM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT PERITINEAL DRAIN EXCLUDING APPENDICEALClip # \n -59 DISTINCT PROCEDURAL SERVICE; CT ABSCESS CATH CHANGE\n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE\n CT GUIDANCE DRAINAGE; -59 DISTINCT PROCEDURAL SERVICE\n CT CHANGE PERCUTANEOUS TUBE; CT ABDOMEN W/CONTRAST\n CT PELVIS W/CONTRAST\n Reason: Assess for fluid collection and **drain collection if found*\n Admitting Diagnosis: SEPSIS\n Field of view: 55 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is persistent absence of the right anterior and lateral abdominal\n subcutaneous fat, with associated mesh. A cecostomy tube is noted. There is\n a small amount of free intraperitoneal air in the location of the subcutaneous\n defect. Note is also made of slightly amorphous hyperdensity suggestive of\n oral contrast tracking along the right lateral subcutaneous fat, without an\n obvious tract.\n\n The soft tissue defect extends into the perineum and scrotum and is associated\n with a moderate amount of interspersed air. Evaluation of the pelvis is\n severely limited by streak artifact from bilateral hip prostheses. A Foley\n catheter is present and there is a small amount of nondependent air in the\n bladder. There is apparent mild expansion and intraluminal hypodensity of the\n right common femoral vein, which persists on multiple images. There is\n diffuse stranding of the subcutaneous fat, compatible with anasarca.\n\n OSSEOUS STRUCTURES: The right posterolateral ninth and tenth ribs demonstrate\n fractures with associated callus formation.\n\n The primary team requested drainage of the remaining dominant fluid\n collections and after explaining potential risks and benefits of the procedure\n to the patient's mother, written informed consent was obtained over the\n telephone. The patient's intensive care unit nurse was there to administer\n the appropriate medication for pain control and sedation with continuous\n monitoring.\n\n Attention was first directed to the midline subphrenic collection. The skin\n surrounding the drain was prepared and draped in the usual sterile fashion.\n The pigtail was released and using CT guidance, 0.035 wire was\n advanced through the catheter. The catheter was removed and the tract was\n dilated. A 12- French catheter was then placed over the wire. Utilizing CT\n guidance, and the catheter was secured. The tip of the catheter was confirmed\n by the aspiration of very thick purulent material.\n\n The left lower quadrant collection was then localized utilizing CT guidance.\n The overlying skin was marked, prepared and draped in the usual sterile\n fashion. 1% lidocaine was injected into the skin and subcutaneous tissues for\n local anesthesia. Thereafter, an 18-gauge needle was advanced into the\n collection using CT guidance. wire was advanced through the needle\n and the needle was removed. The tract was dilated and a 10-French catheter\n (Over)\n\n 10:27 AM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT PERITINEAL DRAIN EXCLUDING APPENDICEALClip # \n -59 DISTINCT PROCEDURAL SERVICE; CT ABSCESS CATH CHANGE\n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE\n CT GUIDANCE DRAINAGE; -59 DISTINCT PROCEDURAL SERVICE\n CT CHANGE PERCUTANEOUS TUBE; CT ABDOMEN W/CONTRAST\n CT PELVIS W/CONTRAST\n Reason: Assess for fluid collection and **drain collection if found*\n Admitting Diagnosis: SEPSIS\n Field of view: 55 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n was placed into the collection. The position of the catheter tip was\n confirmed by the aspiration of purulent material. The catheter was then\n secured.\n\n Thereafter, CT guidance was utilized to localize the perisplenic fluid\n collection. The overlying skin was marked, prepared and draped in the usual\n sterile fashion. 1% lidocaine was injected into the skin and subcutaneous\n tissues for local anesthesia. Thereafter, utilizing CT guidance, an 18-gauge\n needle was inserted into the collection and using the Seldinger\n technique, and an 8- French catheter was placed into the collection. The\n position of the catheter tip was confirmed by the aspiration of purulent\n material. The catheter was then secured.\n\n In all cases, adequate hemostasis was achieved and the patient tolerated the\n procedure, without immediate complication. Dr. was an active\n participant in the entire procedure.\n\n IMPRESSION:\n 1. Patient status post upsizing of the catheter in a midline subphrenic\n collection and placement of two additional catheters in left lower quadrant\n and a perisplenic collections, without complication.\n 2. Significant interval decrease in the size of the right subphrenic fluid\n collection.\n 3. Persistent peripancreatic fat stranding, which may be secondary to\n pancreatitis. Correlation with laboratory values is recommended.\n 4. A focal hepatic hypodensity cannot be definitively characterized on this\n study. However, given its rapid appearance and somewhat tubular\n configuration, portal vein thrombus should be considered. An abscess would be\n less likely.\n 5. Suggestion of expansion and luminal hypodensity in the right common\n femoral vein. A deep vein thrombus cannot be excluded and ultrasound\n correlation is recommended.\n 6. Suspicion for oral contrast tracking along the right lateral abdominal\n subcutaneous tissues. Although no definite tract is visualized, an\n enterocutaneous fistula cannot be excluded.\n\n Finding of the equivocal right common femoral vein filling defect was conveyed\n to Dr. by at approximately 5:30 p.m. on .\n\n\n (Over)\n\n 10:27 AM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT PERITINEAL DRAIN EXCLUDING APPENDICEALClip # \n -59 DISTINCT PROCEDURAL SERVICE; CT ABSCESS CATH CHANGE\n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE\n CT GUIDANCE DRAINAGE; -59 DISTINCT PROCEDURAL SERVICE\n CT CHANGE PERCUTANEOUS TUBE; CT ABDOMEN W/CONTRAST\n CT PELVIS W/CONTRAST\n Reason: Assess for fluid collection and **drain collection if found*\n Admitting Diagnosis: SEPSIS\n Field of view: 55 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-28 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 981230,
"text": " 12:45 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please assess for evidence of residual pneumonia, consolidat\n Admitting Diagnosis: SEPSIS\n Field of view: 50 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with persistant fevers s/p treatment for septic left knee -\n pneumonia, history of perforated gastric ulcer, now w/reported liver cysts,\n pancreatic cysts and ? other fluid collections in the abdomen\n REASON FOR THIS EXAMINATION:\n please assess for evidence of residual pneumonia, consolidation in the lungs,\n fluid collections / abscess in the abdomen and/or pelvis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:44 AM\n Large perihepatic, peripancreatic and perisplenic psuedocyst-type fluid\n collections with no appreciable surrounding stranding or rim enhancement. Very\n limited view of the right flank due to artifact from large body habitus. There\n is however a lot of subQ fat stranding in this area. Difficult to assess this\n area for subQ fluid collection (can better reassess with proper positioning in\n the scanner). Small bowel ileus. RLL consolidation vs pna. RUL smaller amt of\n airspace dz--similar differential.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old man with persistent fevers after treatment for septic\n left knee and history of perforated gastric ulcer. Recent transfer from\n Hospital where other imaging studies were performed. The patient now\n has rapidly expanding infection involving the right anterior abdomen.\n\n No prior examinations are available for comparison.\n\n TECHNIQUE: Multidetector helical scanning of the chest, abdomen and pelvis\n was performed following the administration of oral and 130 cc of IV Optiray\n contrast. Coronal and sagittal reformats were displayed.\n\n CT OF THE CHEST: Right internal jugular line terminates in the distal SVC.\n The heart, pericardium and great vessels are normal. There is no mediastinal,\n hilar or axillary lymphadenopathy. Respiratory motion degrades evaluation of\n the lungs. There are small bilateral pleural effusions. Ground-glass opacity\n in the right upper lung zone measuring approximately 2.2 x 1.5 cm is\n concerning for infection. Additionally, at the right lung base, there is an\n enhancing area of airspace opacity, which may represent atelectasis or\n consolidation. There is no evidence of central pulmonary embolism.\n\n CT OF THE ABDOMEN: This portion of the exam is extremely degraded by artifact\n from the patient's large body habitus. There are multiple fluid collections\n throughout the abdomen, which likely measures simple fluid density though\n attenuation measurements are degraded by the artifact. There is a large\n subphrenic collection measuring 17 x 12 mm in the axial plane, and additional\n smaller collections abutting the left lobe of the liver, spleen, within the\n right paracolic gutter, in the left anterior mesentery, and right lower\n (Over)\n\n 12:45 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please assess for evidence of residual pneumonia, consolidat\n Admitting Diagnosis: SEPSIS\n Field of view: 50 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n quadrant. The collection in the right lower quadrant appears to involve the\n fascia and there is additional fluid collection and edema within the soft\n tissues adjacent to the fascia. These findings are concerning for necrotizing\n infection. The pancreas enhances homogeneously though there is a small fluid\n collection posterior to the tail of the pancreas measuring approximately 4.6 x\n 2.3 cm in the axial plane. The gallbladder is distended measuring 4 cm in\n diameter, however, there is no apparent wall thickening. The liver, spleen,\n adrenal glands, kidneys are normal. Multiple loops of dilated small and large\n bowel are seen, likely due to an ileus. There is no evidence of bowel wall\n thickening, pneumatosis, or portal venous gas. No free air. The aorta is of\n normal caliber. No pathologically enlarged mesenteric or retroperitoneal\n lymph nodes.\n\n CT OF THE PELVIS: Bilateral hip replacement and resultant metallic artifact\n degrade visualization of the majority of the pelvis. A Foley catheter is\n noted within the bladder. The sigmoid colon and rectum appear normal.\n\n BONE WINDOWS: There are no bone findings of malignancy. Vertebral body\n heights are maintained with no areas of lysis to suggest osteomyelitis.\n\n There is diffuse anasarca and as mentioned previously significant subcutaneous\n fat stranding within the right anterior abdomen.\n\n IMPRESSION:\n 1. Multiple intra-abdominal fluid collections which appear cystic in quality.\n Though the majority of them are remote from the pancreas, pancreatic\n pseudocysts remain in the differential. The fluid collection in the right\n lower quadrant is infiltrating the fascia and associated with significant\n subcutaneous edema and stranding, concerning for necrotizing infection of the\n fascia in this locale.\n 2. Dilated loops of bowel likely due to an ileus. No wall thickening or\n pneumatosis.\n 3. Right lower lobe consolidation versus atelectasis. Additional focus of\n airspace opacity in the right upper lobe is concerning for infection.\n\n Limited scan due to patient's body habitus and positioning within the scanner.\n For more detailed evaluation of the right lower abdomen in the region of the\n patient's clinical rapidly spreading infection, the patient could be\n positioned in the scanner to avoid artifact in this region if clinically\n indicated. These findings were discussed with Dr. from the\n surgical team at 10:00 a.m. on .\n\n (Over)\n\n 12:45 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please assess for evidence of residual pneumonia, consolidat\n Admitting Diagnosis: SEPSIS\n Field of view: 50 Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-09-05 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 982295,
"text": " 10:23 AM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT PERITINEAL DRAIN EXCLUDING APPENDICEALClip # \n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE\n CT GUIDANCE DRAINAGE; -59 DISTINCT PROCEDURAL SERVICE\n Reason: Please give oral contrast to eval for enterocutaneous fistul\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old man with abd CT scan there with cystic fluid collections in spleen\n and throughout abdomen.\n REASON FOR THIS EXAMINATION:\n Please give oral contrast to eval for enterocutaneous fistula and drain fluid\n collection. ****Please send fluid for stain and culture****\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT-GUIDED DRAINAGE.\n\n CLINICAL HISTORY: 32-year-old man with cystic fluid collections throughout\n the abdomen. Please drain fluid collections and send for culture and stain.\n\n After the risks and benefits of the procedure were explained and an informed\n consent obtained from the patient's mother over the phone, timeout was\n completed verifying three patient identifiers.\n\n Preliminary axial CT images obtained through the abdomen without contrast\n again demonstrate multiple fluid collections as seen on the recent contrast-\n enhanced CT. After discussion with the surgical team, a consensus was reached\n to place catheters and aspirate two largest fluid collections, one of which is\n situated between the lateral edge of the left hepatic lobe and the stomach and\n the second is at the dome of the liver.\n\n Initially, drainage of the left-sided collection was performed.\n\n The skin was marked, prepped and draped in standard sterile fashion.\n Approximately 10 cc of lidocaine was used for local anesthesia.\n\n Additional conscious sedation was not administered as the patient was\n intubated and was on fentanyl and propofol drip and was continuously\n monitored by an ICU nurse for the duration of the procedure.\n\n An 8 French catheter was placed into the left-sided fluid collection\n using CT fluoroscopy for guidance. After appropriate catheter position was\n confirmed, approximately 20 cc of whitish/cloudy fluid was aspirated and sent\n for culture and stain.\n\n Following this, drainage of the fluid collection at the dome of the liver was\n performed. The skin again was marked, cleaned and prepped in standard sterile\n fashion. Approximately 10 cc of lidocaine was used for local anesthesia. An\n 8 French catheter was placed into the fluid collection using CT\n fluoroscopy for guidance. After appropriate position was confirmed with CT\n images, approximately 900 cc of purulent fluid was aspirated and sent for\n culture and stain.\n (Over)\n\n 10:23 AM\n CT PERITINEAL DRAIN EXCLUDING APPENDICEAL; CT PERITINEAL DRAIN EXCLUDING APPENDICEALClip # \n -59 DISTINCT PROCEDURAL SERVICE; CT GUIDANCE DRAINAGE\n CT GUIDANCE DRAINAGE; -59 DISTINCT PROCEDURAL SERVICE\n Reason: Please give oral contrast to eval for enterocutaneous fistul\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Both catheters were secured with percutaneous skin fasteners. The right-sided\n drainage catheter was also sutured to the skin.\n\n The patient tolerated procedure well. No immediate complications occurred.\n Management and skin care for and drains was discussed with the ICU intern upon\n completion of the procedure.\n\n Post-procedure CT images through the abdomen demonstrates satisfactory\n position of both the drainage catheters in both fluid collections. There has\n been marked decrease in size of the right-sided collection at the dome of the\n liver. Both catheters were connected to drainage bags and left to open\n drainage.\n\n Dr. , radiology attending, was present and actively participated\n throughout the procedure.\n\n IMPRESSION: Successful CT-guided placement of pigtail catheters in two\n largest fluid collections in upper abdomen. Samples from both fluid\n collections sent for culture and stain.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-12 00:00:00.000",
"description": "Report",
"row_id": 1676627,
"text": "NPn\nPlease see carevue for further details\nalert oriented. moves upper extremities well. follows commands consistently. Dilaudid PCA .5/6/5 mg with mod relief. PERRL 3 mm briskly reactive.\nBLSCTA even unlabored. PMV on. TM at 100% with sats 98-100. RR 12-20.\nTravelled to CT for ct guided drainage of abd collection. changed pigtail #3 over a wire for a larger lumen catheter and drained approximately 450 ccs of viscous yellow/white drainage. Tolerated procedure fairly well with additional Fentanyl and Ativan given for pain and anxiety. Dr. present for most of the procedure.\nTF on hold until after CT. Infusing at 120. Cecostomy with large amoutns of thick soft brown stool. Multiple pigtail drains. See carevue for specifics re: amount and color. Foley draining clear yellow urine adq amounts. Tmax 100.7 R uppermost drain to wall suction with thick stool drainage. Dr. aware and will assess. Hep gtt increased to 2400 units/hr. PTT goal 60-80. Currently 41-46. Team aware. large abd dressing to wall suction with mod amounts of serosang drainage.\nPLAN: Continue to closely monitor hemodynamics, pain, respiratory status d/t additional pain medication during CT, drainage/output- ? convert pigtails to JPs, provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-12 00:00:00.000",
"description": "Report",
"row_id": 1676628,
"text": "Adendum: Pigtail drains x 4 changed over to JP suction bulbs. Pt sleeping soundly after CT/sedation but wakes easily to stimuli and is oriented x3. Central line tip sent for culture, physical assessment unchanged. No communication from family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-13 00:00:00.000",
"description": "Report",
"row_id": 1676629,
"text": "CONDITION UPDATE\nVSS STABLE. AFEBRILE. A/OX3. O2SAT HIGH 90'S TO 100% ON CURRENT TRACH MASK SETTINGS. LUNGS CLEAR THROUGHOUT, DIMINISHED RBASE. DENIES SOB. EARLIER IN THE SHIFT, PT USING PASSE MUIR VALVB W/O DIFFICULTY. ABD OBESE - VAC DRSG . MULT DRAINS TO JP SUCTION - SEE FLOWSHEETS FOR DETAILS. U/O QS VIA FOLEY. MOD AMT OF STOOL OUT X1. CONT ON PCA FOR PAIN MANAGEMENT W/ EFFECT.\nCONT CURRENT ICU CARE AND TREATMENTS. PAIN MANAGEMENT. PT TEACHING AND SUPPOURT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-13 00:00:00.000",
"description": "Report",
"row_id": 1676630,
"text": "NURSING NOTE\nHeparin drip at 2200units/hr, repeat PTT sent at 1800.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-13 00:00:00.000",
"description": "Report",
"row_id": 1676631,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n\nPT A&OX3, MAES. PT C/O ABD PAIN, DILAUDID PCA 0.5/6/5 W/MOD EFFECT PER PT. HR 90S-120S, NSR ST, SBP 160S-130. HEPARIN DRIP CONT AT 2000UNITS/HR, PTT>150 THIS EVE, HCT 25.1. TRACH COLLAR WELL, LUNGS CLEAR TO COARSE, DIMINISHED AT BASES. SUCTIONED FOR SM AMTS THICK YELLOW SECRETIONS. ABD DRAIN REPLACED BY DR., DRNG SEROSANG FLUID TO WALL SXN, PLAN FOR FULL DSG CHANGE . MULTI JP'S PATENT, FLUSHED AS ORDERED. TF AT 120CC/HR, MIN RESIDUAL, ADEQUATE HUO VIA FOLEY. CONT GEN EDEMA, PALP PP, NO NEW BREAKDOWN NOTED. FAMILY IN TO VISIT.\n\nPLAN: CONT HEMODYNAMIC MONITORING, RESP SUPPORT/TRACH COLLAR. PAIN MGMT/PCA, SKIN/WND CARE, PLAN FOR FULL DSG CHANGE AM. CONT ICU PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-14 00:00:00.000",
"description": "Report",
"row_id": 1676632,
"text": "Respiratory Care:\nPt with #8 portex trach on 50 % aerosol mask. PMV off at 2 am, and tolerated well. Planning on dressing change approx. 0930, will place back on vent at that time for procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-16 00:00:00.000",
"description": "Report",
"row_id": 1676643,
"text": "Neuro: alert and oriented x 3,REPL, move BUE and BLE, follows commends. Remains on PCA Dilaudid for abd pain with good relief.\n\nResp: upper lungs sounds clear with inspiration and slight wheeze with expiration, suctioned once for pt comfort with return of small amount thick white sputum.\n\nCardio/Hemo : NSR, no ectopy , no murmurs, HR: 80-90 bpm, remain on heparin drip for DVT prophylaxis,Ptt in theraputic range.\n\nGI: House diet, calorie count, BS present in all quadrants. Cecostomy draining thick brown stool in small quantity.\n\nGU: Foley to gravity, urine clear yellow between 100 and 300cc/hr.\n\nSkin: normal skin color, warm, consistant with the pt background, primary team planned vac dressing change - .\n\nPlan :NPO in the am for dressing change scheduled for 11am. calories count through . Follow lytes prn in setting of brisk UO, daily ptt. PT consult increase activities as tolerated. Keep pt/family up to date on poc.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-16 00:00:00.000",
"description": "Report",
"row_id": 1676644,
"text": "I agree with nurses note and poc as written by student nurse above. RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-17 00:00:00.000",
"description": "Report",
"row_id": 1676645,
"text": "CONDITION UPDATE\nVSS. AFEBRILE. A/OX3. USING PASSE MUIR VALVE MAJORITY OF SHIFT. MIN SUCTIONING FOR THICK, WHITE SPUTUM. DENIES SOB. LUNGS CLEAR, DIMINISHED AT BASES. SATS ACCEPTABLE ON TRACH COLLAR. ABD W/ EXTENSIVE OPEN WOUND. NPO POST MIDNIGHT FOR DEBRIDEMENT AND DRSG IN THE AM. OTHERWISE TOLERATING PO'S. U/O LARGE VIA FOLEY. SMALL AMT OF LIQUID BROWN STOOL OUT CECOSTOMY. ATIVAN X1 FOR ANXIETY W/ EFFECT.\nCONT TO MONITOR FOR INFECTION. PAIN MANAGEMENT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-17 00:00:00.000",
"description": "Report",
"row_id": 1676646,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nAfebrile. Alert and orientated. Continues on heparin gtt and dilaudid pca. Hep gtt decreased to 2400u/hr PTT 90. VAC dressing changed at bedside and pt back on vent for procedure with fent/neo/prop gtts by anesthesia. Multiple doses of dilaudid ivp for post procedures pain8-10 out of 10. Pt off vent and back on trach collar at 50%. To cath lab for ivc filter d/t right popliteal dvt. Plan: Emotional support and pain management. Please refer to carevue for all details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-17 00:00:00.000",
"description": "Report",
"row_id": 1676647,
"text": "Respiratory Care Note\nPt received on trach mask with cuff deflated and PMV in placed. BS diminished bilaterally with slight increase in aeration after nebs. Pt given aerosol nebs with Albuterol and Atrovent x2. Pt's cuff inflated and PMV removed at 11:10a. Pt placed on ventilator AC 50% 550 x 14 +5cm peep during wound dressing change secondary to sedation. Pt weaned to PSV after 40min and quickly weaned to trach once pt awakened from sedation. Cuff deflated and PMV in place once again. Plan to continue on trach mask as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-21 00:00:00.000",
"description": "Report",
"row_id": 1676656,
"text": "Focus: Status Update\nData:\nSee carevue flowsheet for details of care.\n\nPatient alert and oriented x3. Moving all extremities, legs weak. Pain well controlled with Dilaudid PCA. Ativan prn at pt. request.\n\nLungs clear bilaterally. Passe-muir valve off overnight and cuff inflated. Continues on trach collar at 50% with normal sats.\n\nAbdominal wound with vac dressing . JP'sx4 without drainage.\n\nPlan:\nOOB to chair. Next dressing change on . ?Transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-21 00:00:00.000",
"description": "Report",
"row_id": 1676657,
"text": "Resp Care\nPt remains trached on 50% TM. PMV taken off during sleep/ cuff up. BS clear throughout. Pt suctioned for scant thick white secretions. Prn nebs given x 1. See CareVue flowsheet for details.\nPlan: Place pt back on PMV/ cuff down in a.m., ? transfer to floors.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-21 00:00:00.000",
"description": "Report",
"row_id": 1676658,
"text": "BS essentially CTAB. Wearing PMV whole shift. Albuterol/Atrovent nebs x 1 at pt's request. Also suctioned x 1 per patient yielding minuscule amount thick white mucus.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-21 00:00:00.000",
"description": "Report",
"row_id": 1676659,
"text": "CONDITION UPDATE\nVSS. AFEBRILE. ALERT AND ORIENTED X3. CONT ON DILAUDID PCA FOR PAIN MANAGEMENT. ADMITS TO ACCEPTABLE PAIN LEVEL. NO C/O SOB. PASSE MUIR ON THROUGHOUT SHIFT. MIN SUCTIONING FOR SCANT WHITE, THICK SPUTUM. LUNGS CLEAR THROUGHOUT. O2 SAT ACCEPTABLE ON TRACH MASK. VAC DRESSING TO ABD. LG AMT OF REDDISH BROWN DRAINAGE OUT VAC DRESSING. MIN DRAINAGE OUT JP'S. SOFT, FORMED STOOL X1. U/O QS.\nATIVAN PRN FOR ANXIETY.\nMONTOR FOR S/S OF INFECTION. PAIN MANAGEMENT. PT TEACHING AND SUPPORT. CONT CURRENT ICU CARE AND ASSESSMENTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-22 00:00:00.000",
"description": "Report",
"row_id": 1676660,
"text": "Resp Care\nPt remains trached on 50% Trach collar. BS clear and diminished bilaterally at bases. Pt suctioned for scant thick white secretions. Nebulizer tx given as ordered. PMV off for , place back on when pt wakes up. See Carevue flowsheet for details.\nPlan: Cont. current care, nebs prn\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-22 00:00:00.000",
"description": "Report",
"row_id": 1676661,
"text": "Focus: Status Update\nData;\nPatient stable overnight. Slept without passe-muir valve and cuff inflated. Adequate pain control as pt able to sleep. Ativan Prn at pt. request.\n\nLungs clear bilaterally. Continues on trach collar at 50%.\n\nVac dressing with tan/brownish drainage. Due to be changed this am.\n\nPlan;\nDressing change today. Transfer to floor?\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 1676566,
"text": "MICU NPN\n32yo with extensive pmhx. Briefly, past med hx includes ankylosing spondylitis arthritis dx ', s/p bil TKR, s/p bil THR, L tibial oseotomy, L4-L5 laminectomy due to disc herniation from auto accident, anemia, MRSA, peptic ulcer with ? perf, anabolic steroid abuse.\n Admitted with septic L knee. He had washout with spacer exchange and patellectomy. L knee cx (+) MRSA and . He has had multiple fevers/^ WBC > multiple antibx coverages. PICC line grew (+) citrobacter freundii, line was dc'd. CT scan of abd showed multiple perioneal, RP, intrahepatic, pancreatic and pelvic cysts, unclear if infected. TTE was (-) for vegetations also r'd out for PE by CT scan. He has cont to have fevers throughout his stay but has cont to attempt rehab with ^^ amts of pain meds. On had ^^ WBC with hypotension requiring pressors ( of note, also low hct transfused with with PRBC's). NEBH felt that cysts needed aspiration/bx to tx fevers therefore transferred to MICU for further management.\n Pt admitted at 2045, lethargic and oriented x 2 (unsure of month ) as night progressed more oriented and less lethargic. Of note, he was on multiple pain meds at NEBH including SR morphine, IR morphine,clonazepam,\nand percocet. Has rec'd morphine 2mg x 2 for c/o r sided abd pain and has been able to go to sleep but when awaken for care states that pain conts to be , rec'd morphine SR 100mg at 5am, able to sleep. He is able to MAE, lower extrems more difficult to move than upper. Is requesting to have trapeze on bed in order to have ^ mobility. Bariair called, order placed.\nID: Conts to be febrile ^ 102.4, BC X 1 off RIJ drawn, started back on previous antibx. MRSA nasal swab also sent, need rectal swab for MRSA. Given tylenol 650 x 2 with slight decrease in temp. WBC down from 40 to 20. Pt down for Xray of knee/hip. Limited study due to pt unable to fit on table, awaiting results.\nCV: Hr elevated 110-130's st with no vea noted. BP 100-130's. Held 6am lopessor due to bp 109/49 with map 64. On sq heparin awaiting pneumo boots (ordered). CVP upper teens.\nResp: Lungs are clear throughout, diminished aeration. O2 at 4lnp with sats in the mid to upper 90's. No cough/sputum production. Unable to tolerate lying flat for extended periods of time. While in CT scan decreased sat to upper80's while lying flat requiring FM at 10l with sats in upper 90's. Pt very uncomfortable during scan due to SOB from lying flat.\nGI/GU: Abd extremely obese. (+) bowel sounds. Had small greenish liquid bm sent for c-diff. TPN @ 60cc/hr was dc'd at 1am. Has been NPO except for meds and few ice chips for ? procedure in am. Foley drng adequate amts of clear yellow urine. Initially thought Creat 1.7 therefore briefly on bicarb gtt prior to CT scan with contrast but repeat creat .9 therefore bicarb gtt dc'd as well as mucomyst. Went for CT scan (unable to scan in ew due to size, must be scanned on )of abd which revealed multiple pseudo\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 1676567,
"text": "MICU NPN\n(Continued)\ncyst fluid collection on liver, pancreas and spleen. R flank area also thought to have area of fluid with possible infection. Also has a small bowel ileus and RLL consolidation vs PNA.\nSkin: L knee with steri strips intact. Incision well approx no redness/ drainage noted. Has 3+ generalized pitting edema. Extreme weeping from R lateral aspect of abd. Softsorb placed as well as pink pad. R lower underside of calf also with excoriated area with small amt of weeping, softsorb to this area also. Stage 2 ulcer noted on under panus, aquacel placed. Buttocks with excoriation from previous loose stools, cleansed and left open to air. Scrotum extremely edematous/firm. Placed on Bariair bed with turn assist placed on. Pt turned for back care but very resistant with turning due to ^^ pain with movement.\nA: sepsis with ? cause> has multiple fluid filled cysts on liver/pancreas and spleen, also R flank possible source\n total body anasarca\nP: maintain NPO status for possible procedure today\n follow hemodynamics cautious with lopressor due to ^^ wbc/fever\n pneumo boots when available may start lovenox (on at NEBH)\n skin care consult\n cont with bariair bed and turning\n cont to provide emotional support\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-30 00:00:00.000",
"description": "Report",
"row_id": 1676574,
"text": "SICU NPN\nS-Sedated and intubated.\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\n\nO-Remains on Propofol and Fentanyl. Withdraws to pain. Does not follow commands. VSS during and post OR case. Further debridement done towards left groin area. Receiving 2uPRBCs during case. HCT stable and lytes repleted post. Remains on AC, FiO2 increased to 60% for PaO2 60. Anticipate weaning towards AM. Foley with large amounts of sediment. Flushed with great difficulty. Aspirating cluster of sediment. Flushed several times during shift. Foley currently free flowing and flushing without difficulty. HUO adequate. Out OR receiving 2L of LR boluses for low UOs and drainage losses. Continue 1/2cc per cc replacement. NGT to LCS draining bilious. NPO. Afebrile. Insulin infusion resumed post OR.\n\nA/P: s/p debridement for necrotizing fasciatitis, doing well overnight.\nContinue to monitor\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-30 00:00:00.000",
"description": "Report",
"row_id": 1676575,
"text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. FIO2 on 60% no RSBI done. Sedated with fentanyl and propofol. Suctioned for mod amts thick white secretions. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-30 00:00:00.000",
"description": "Report",
"row_id": 1676576,
"text": "STATUS\nD: AFEBRILE..VSS REMAINS ON INSULIN/FENTANYL/PROPOFOL GTT'S..SEDATED BUT AROUSABLE..MOVES ALL EXTREM'S BUT DOESN'T FOLLOW COMMANDS\nA: ABD WD DRAINING COPIOUS AMT SEROUS..BLANCHING OF LF ABD & RT LEG UNCHANGED..VERY EDEMATOUS EXTREM'S..INITALLY REPLETING 1/2CC/CC NOW OFF..HUO'S DOWN ALITTLE AT 50-70CC/H..NO VENT CHANGES..SUCTIONED FOR SM AMT THICK TAN/WHITE\nR: STABLE\nP: CONTINUE MONITOR BS'S Q2H & ADJUST GTT ACCORDINGLY..FENT & PROPOFOL FOR COMFORT..ABD DSG TO BE CHANGED AT BEDSIDE IN AM..CLOSELY MONITOR I&O CALL FOR DROPPING HUO'S..LABS PER HO\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-30 00:00:00.000",
"description": "Report",
"row_id": 1676577,
"text": "Respiratory Care\nPatient received on AC 650x20 8 PEEP 60%, with left side of the abdomen open, covered with some kind of plastic device, breath sounds essentially clear, somewhat diminished, suctioned intermittently for small amounts of thick white secretion, is on Fentanyl, Propofol, Insulin, SPO2 ranged 96 to 100, WBC 20.7, Hb 8.9, was afebrile and into normal sinus rhythm whole shift, the chest still being drained, extremities are very edematous, will stay intubated for further chest debridements.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-30 00:00:00.000",
"description": "Report",
"row_id": 1676578,
"text": "Nursing note 1500-1900\nNo significant events.\n\nCont on fentanyl & propofol gtts. Lightened briefly & opened eyes spontaneously & followed all commands, nodded \"yes\" to pain, ppf increased. NSR, SBP 140s-160, general anascara, pulses via doppler. No vent changes. NGT to LCS, GI drain large seronsang, abd dressing intact. Foley draining dark, clear yellow urine. Scrotal ultrasound done. Blood sugar 70 so insulin gtt turned off. Subsequent BS 97 and 95. Family by bedside and updated on POC.\n\nPlan: Cont with POC overnoc, monitor dressing, monitor blood sugars q hour until > 100 then start gtt. Check skin frequently, specifically back and sacrum. Provide emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-31 00:00:00.000",
"description": "Report",
"row_id": 1676579,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt sedated on Ppf and fentanyl gtt. PERRLA. Pt opens eyes to voice/ painful stimulus. Moves extremities to nailbed pressure. When Ppf gtt off, pt squeezes RN's hands, moves toes, opens eyes and mouth to command. Pt can lift/hold BUE. Bilateral wrist restraints applied to prevent pt from pulling out ETT, IV lines, dsg, foley catheter. All siderails up d/t bed rotation on. Pt with +gag/cough reflex. When asked if in pain, pt shook head \"no.\" No grimacing noted. Afebrile. HR 60s-80s (NSR; no ectopy noted). ABP 120-150s/60s-80s. CVP 10-17. Pt with anasarca. DP/PT pulses dopplerable. LR @ 200cc/hr. Calcium and potassium repleted. stockings on BLE. Venodyne boot on RLE. Lungs clear. Pt suctioned for small amount thick, white secretions. CMV: 60%, Vt 650 x 20, PEEP 8. RR 20. See CareVue for ABG results. Strong cough. Mouth care performed per VAP prevention protocol. HOB >/= 30 degrees. Abdomen open; bowel sound absent. Replete with fiber @ 10cc/hr infusing via NGT; minimal residual noted. Per Dr. , not advance TF rate. NGT flushed with 30mL water q4hr as ordered. No bowel movement this shift. Insulin gtt continued; following insulin scale (target BG 80-110). FS q1hr (see CareVue for results). Foley intact with clear, yellow urine. UO 45-320 cc/hr. Urology service following pt. Allevyn on coccyx clean, dry, intact. LLE with steri-strips clean, dry, intact. Abdomen open with packing intact; copious amount serosanguinous output (connected to medium wall suction). Abd dsg to be changed today. Right upper leg pink (edematous); no drainage noted. mother and grandmother visited; updated by RN on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Wean vent setting as tolerated. Continue Ppf and fentanyl gtt for sedation. Check FS q1hr while on insulin gtt. Follow insulin scale; target BG 80-110. Abd dsg to be changed today. ?OR early this week. Continue to monitor output from abdominal wound. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-31 00:00:00.000",
"description": "Report",
"row_id": 1676580,
"text": "Addendum to NPN:\nUS of scrotum (from ) showed symmetric Doppler flow within the testes bilaterally. Marked skin thickening within the scrotum. No focal collections identified per US report.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-04 00:00:00.000",
"description": "Report",
"row_id": 1676595,
"text": "Resp Care Note\nReceived pt on PSV 5/5 with Vt of 800-1.0 and RR 10-15. Later RR dropped, PaCo2^63, placed back on AC 16/650/+5/40%. Breath sounds with coarse crackles in bilat upper lobes. Suctioning small amounts of white secretions.\nPlan: OR today for trach and peg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-04 00:00:00.000",
"description": "Report",
"row_id": 1676596,
"text": "SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT SEDATED ON ATIVAN, PROPOFOL, AND FENTANYL DRIPS. MAE EQUALLY AND SPONTANEOUSLY. PERRL. ET TO VENT, RETURNED TO ASSIST CONTROL SECONDARY TO RR OF 5 AND INCREASED CO2. PLAN IS FOR TRACH TODAY. MINIMAL WHITE THIN SECRETIONS. RSR/ST ON LOPRESSOR ATC. AFEBRILE. BP WNL, ALINE DAMPENED AT TIMES. CATHETER IN PLACE (SIX LUMENS, THREE LARGER GUAGE AND THREE TYPICAL CENTRAL LINE LUMENS ALL FROM ONE HUB). ANASARCA. TUBE FEEDS HELD AT MIDNIGHT FOR OR TODAY. INSULIN GTT AS PROTOCOL. WEANED OFF. ABD OPEN WITH IOBAN DRESSING AND PACKING. DRAINS TO LCWS. FLEXISEAL PLACED FOR LIQUID BROWN STOOL. FOLEY WITH GOOD URINE OUTPUT. LEFT KNEE WITH STERISTRIPS. FENTANYL GTT FOR PAIN. PLAN: OR TODAY FOR TRACH, PEG, DEBRIDEMENT OF ABD WOUND AND POSSIBLE REMOVAL OF ONE TESTICLE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-04 00:00:00.000",
"description": "Report",
"row_id": 1676597,
"text": "Respiratory Care\nPt was trached today in OR (#8.0 Portex cuffed). Pt remains on vent support, no vent changes were made. Lung sounds were clear t/o. Suctioned for sm-mod thk white blood tinged secretions. No ABGs were drawn, pt needs new A-Line, ? of fem line, MD tried to resite. Care plan is to continue to wean as tol, ? of PSV if tol. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-04 00:00:00.000",
"description": "Report",
"row_id": 1676598,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nTo OR for abdominal washout and debridement as well as a trach. Pt returned unreversed, vented on AC, and with 3 drains: 2 to wall suction with Y adapter and one near a fistula to gravity. Rectal tube replaced in OR but oozing around still. Pt remains sedated on prop/ativan/fentanyl. Weaning ativan and to wean off gtt and to prn if able MD . Hypothermic 94 post op and bair hugger on temporarily. Current temp 98 and bair hugger is off. Lungs are clear and sats good with trach. Aline unable to draw and with fling. Attempt at rewire failed. Attempt to resite on left also unsuccessful and per primary team no fem stick and no aline at this time. Will follow pleth for now and draw abg's when necessary. NSR, slightly tachy since arrival from OR 90s-104. NIBP 104-115/40s. UO adequate and clear yellow. Pt's family updated and in to visit. Plan: Wean sedation and vent as tolerated. IR tommorrow for ?peg placement and fluid collection drg?. ID consulted. Please refer to carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-05 00:00:00.000",
"description": "Report",
"row_id": 1676599,
"text": "SICU NN: SEE CAREVUE FOR SPECIFICS. SEDATED ON PROPOFOL, ATIVAN AND FENTANYL DRIPS. TRACH TO VENT. RSR. AFEBRILE. CVL INTACT. ANASARCA. TPN STARTER BAG. NGT TO LCWS. ABD OPEN WITH YELLOW TRANSPARANT DSG. YELLOW DRAIN TO GRAVITY. CLEAR DRAIN X 2 TO WALL SUCTION. BOWEL SOUNDS PRESENT. FOLEY ADEQUATE OUTPUT. MOTHER VISITED LAST PM. PLAN: IR TOMORROW FOR PEG AND FLUID DRAINAGE FROM ABDOMEN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-05 00:00:00.000",
"description": "Report",
"row_id": 1676600,
"text": "Resp Care Note\nPt on AC overnight 16/650/+5/40%. # 8.0 portex patent and secure. Cuff pressure WNL. Suctioned thick tan secretions early in shift, now more thick white. RSBI 40.\nPlan: Wean to PSV as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-07 00:00:00.000",
"description": "Report",
"row_id": 1676610,
"text": "condition update\nplease see carevue for specifics.\n\nalert and oriented. able to mouth words and write for communication. MAE. afebrile. sr. HR 80's 114. pt tachy when trying to communicate w/ his family. CVP 11-16. Fentanyl gtt infusing, PRN dilauded d/c'd and dilauded pca started. Fentanyl gtt being weaned since clonidine and pca started. Pt receives tid clonidine and ativan q 4 hours. pt placed on trach collar via T piece this am and has tolerated all shift. Became anxious when mother notified him that he has been breathing on his own. LS CTA. Pt constantly wanting to be sxn'd via trach, but only scant amts of clear sputum sxn'd. TF increased to goal. foley patent and draining adequate hourly outputs. Pigtail drains flushed and are to gravity. Abdominal dressing to be changed .\n\nPlan: continue w/ current plan of care per sicu team. Fentanyl gtt/ dilauded PCA for pain mgmt. clonidine/ ativan for anxiety. Pulmonary toilet. Continue trach collar as tolerated. TF for nutrition. CT for CT guided drainage of abdominal abcess . Abdominal dressing change also . Continue IV abx. RISS for bs coverage. Continue to provide emotional support to pt and his family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-08 00:00:00.000",
"description": "Report",
"row_id": 1676611,
"text": "NURSING PROGRESS NOTE\n\nPLEASE SEE CAREVUE FOR SPECIFICS\n\nNEURO: A&Ox3. Mouthing words, writing on clipboard as needed. Cooperative in care. Constistantly in pain, majority in abdomen. Attempting to wean off Fentanyl drip, currently at 125mcg/hr, recieving Methadone and PCA of which when pt awake constantly hitting pain button (Pt aware that PCA has lock out). Pt knows that if recieves too much pain med it hinders breathing but continues to request additional pain control stating that d/t disease, has high tolerance; requested pain service comes back in am to reevaluate pain control, Dr aware. Pt also with c/o anxiety, recieving Clonadine as well as PRN ativan w/effect.\n\nRESP: Tolerated TPEAS 50% FiO2 overnight, sat'ing 100%. Lungs clear, diminished at bases. Suctioning for scant clear thin secretions.\n\nCV: SBP 120-150, NSR HR 70-90s, tachycardic into 110s with increased stimulation. No viewed ectopy.\n\nGI/ENDO: Open abdomen w/drains to LCWS. Tolerating goal TF at 120cc/hr, min residuals. No BM. + BS. FBS treated per RISS requiring min coverage.\n\nGU: Foley patent draining >80cc cyu.\n\nSKIN: Multiple drains, see flowsheet for specifics.\n\nSOCIAL: Mother and grandmother visit for early evening.\n\nPLAN OF CARE: Monitor pain, anxiety and resp status. Goal to wean off Fent, Pain Service involvement needed. CT today for drainage. HO aware of above, will call with any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-09 00:00:00.000",
"description": "Report",
"row_id": 1676617,
"text": "RESPIRATORY CARE: PT REMAINS W/ AN 8.0 PORTEX TRACH\nIN PLACE. CHANGED BACK FROM THE AC MODE TO A TRACH COLLAR\nEARLIER TODAY. APPEARS COMFORTABLE W/ A RR 14-18 BPM\nAND AN SPO2 95-98 %. WILL C/W TRACH COLLAR .50 AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-09 00:00:00.000",
"description": "Report",
"row_id": 1676618,
"text": "NURSING PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS\n\nNEURO: A+OX3. MOUTHING WORDS TO MAKE NEEDS KNOWN. PERRLA,BRISK. MAE WITH SRONG PURPOSEFUL MOVEMENT. +GAG/COUGH. FENTANYL GTT TITRATED TO OFF. DILAIDID PCA INCREASED WITH GOOD EFFECT. CONTINUES ON CLONIDINE PATCH AND METHADONE WITH GOOD EFFECT. ATIVAN X1 FOR ANXIETY WITH GOOD EFFECT.\n\nCARDIAC: NSR-ST. HR: 83-115. SBP: 104-121/40-71. HEPARIN GTT STARTED FOR RLE DVT. 5000 UNIT BOLUS GIVEN AND HEPARIN AT 700 UNITS PER HR. PTT: 26.9,MD AWARE. GOAL PTT BETWEEN 60-80. +RADIAL,FEMORAL,POPITEAL,PT AND DP X2.\n\nPULM: #8 PORTEX TRACH,SITE WNL AND TRACH CARE DONE. TOLERATING 50% HUMIDIFIED TRACH COLLAR. POX: 96-100%. RR: . LS: R+LUL COARSE,DIMINISHED BIBASILAR. SX FOR MODERAMTS OF THICK YELLOW/BLD TINGED SPUTUM. ENCOURAGED . PASSE-MUIR VALVE IMPLACE AND TOLERATING WELL.\n\nGI: TOLERATING TF AT GOAL VIA NGT. RESIDUALS OF 80-100CC. ABD:OPEN, +BSX4,S,TENDER. MULTIPLE PIGTAIL DRAINS INTACT-SEE CAREVUE FOR FURTHER DETAILS.\n\nGU: FOLEY WITH QS URINE.\n\nENDO: FS QID. COVERAGE PER RISS.\n\nIVL'S: L-CVL LINE SITE WNL AND DRESSING INTACT. MD AND MD AWARE LINE CONCERNS. PLAN CHANGE LINE ON .\n\nPSYCH/SOCIAL: MOTHER PHONED AND CONDITION UPDATE GIVEN. MOTHER PLANS TO VISIT TONIGHT.\n\nPLAN: MONITOR HEMODYNAMICS. TITRATE HEPARIN GTT FOR GOAL PTT BETWEEN 60-80. AGGRESSIVE PULM HYGIENE. TITRATE SUPPLEMETNAL OXYGEN AS TOLERATED. ENCOURAGE PT . SURVAILLENCE LABS PRN. PAIN/ANXIETY MANAGEMENT. AGGRESSIVE SKIN CARE. MONITOR TF RESIDUALS AND FOR BM. PROVIDE SUPPORTIVE CARE TO PT AND FAMILY.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-11 00:00:00.000",
"description": "Report",
"row_id": 1676624,
"text": "Respiratory Care:\n\nPt remain on TC cool mist o/n, PMV removed. We are sxtn for small amt of thick tan secretions, active strong cough. Nebs PRN given o/n. Plan: bedsibe vs OR dressing change, & keep confortable. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-11 00:00:00.000",
"description": "Report",
"row_id": 1676625,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n\nPT A&O X3, VERBALIZES NEEDS VIA TRACH W/PASSY-MUIR VALVE. CONT GEN ABD PAIN, USING PCA W/MIN EFFECT PER PT. ATIVAN GIVEN PRN. PT W/PROPOFOL & FENTANYL, VENTED FOR LGE ABD DSG CHANGE X1.5 HRS. WOKE UP SHORTLY AFTER SEDATION CEASED, REMAINS ON TRACH COLLAR, WELL. HR 90S-110S, NSR/ST, LOPRESSOR GIVEN AS ORDERED. PTT REMAINS SUBTHERAPUETIC-31, HEPARIN INCREASED TO 2000UNITS/HR. LUNGS COARSE, SUCTIONED FOR MIN THICK YELLOW SECRETIONS. +GAG, STRONG COUGH, NEBS AS NEEDED. TF REMAINS OFF, ?RE-START THIS PM. AUTODIURESING WELL, LGE AMTS HUO. CONT W/GEN EDEMA, MULTI WND DRAINS PATENT, FLUSHED AS ORDERED.\n\nPLAN: CONT HEMODYNAMIC MGMT, RESP SUPPORT/TRACH . PAIN MGMT/APS FOR PCA CHANGES. DRAIN/WND CARE, FAMILY/EMOTIONAL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-12 00:00:00.000",
"description": "Report",
"row_id": 1676626,
"text": "NSG.PROGRESS NOTES:\nSEE FLOW SHEET FOR SPECIFIC:\n\nNEURO: PATIENT ALERT AND ORIENTED X3,UE NORMAL STRENGTH,LE MOVES ON BED,C/O LOT OF PAIN ABD EARLY SHIFT CHRONIC PAIN SERVICE CONTACETD AND DILAUDID PCA INCREASED TO 0.5MG/6MIN/5MG 1 HR LIMIT WITH GOOD EFFECT,ATIVAN HELD AS PATIENT SLEPT WELL ON & OFF (EVEN THOGH HE WAS ASKING FOR ATIVAN).\n\nCV: NSR-ST.HR: 108-120,NO ECTOPY NOTED,SBP 100-135,IVF KVO.HEPARIN INCREASED TO 2200 WITH AM PTT DUE NEXT PTT AT 1000,DENIES CP OR DISCOMFORT,WEAK PP DUE TO EDEMA,++ EDEMA.\n\nRESP; REMAINS ON TRACH COLLAR,SXN COPIOUS SECRETION.LS CLEAR W/EXP WHEEZES AND DIMINISHED AT BASES,NEBS GIVEN.STRONG PRODUCTIVE COUGH.\n\nGI: ABD OBESE OPEN WITH VAC DRESSING SS DRAIN,+BS,TF RESTARTED AND TOLERATING WELL.CECOSTOMY TUBE DRAINING LIQ STOOL.\n\nGU: FOLEY CATH PATENT WITH YELLOW CLEAR URINE,30-45ML/HR,DR. AWARE,OKAY AS PATEINT AUTO DIURESED DURING DAY AND -4.9 FOR WHOLE DAY.\n\nID: AFEBRILE,ON ANBX,WBC 26.9.\n\nENDO: BLD SUG Q6H,WNL.\n\nACT: TURNED AND POSITION CHANGED PATIENT VERY RELECTANT TO CHANGE POSITION.\n\nSOCIAL: PATIENTS MOTHER CALLED DURING NIGHT AND TALKED TO PATIENT TROUGH TEL.\n\nPLAN; CONT MONITORING,PULM HYGIENE,PAIN CONTROL,WOUND AND DRAIN CARE,SUPPORT TO PATIENT AND FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-15 00:00:00.000",
"description": "Report",
"row_id": 1676638,
"text": "Resp. care Note\nPt followed this shift for Albuterol and Atrovent nebs Q6. BS with decreased aeration. Ambued and sxn for thick tannish secretions. PMV on all shift. 50% aerosol trache mask in place. Cont as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-15 00:00:00.000",
"description": "Report",
"row_id": 1676639,
"text": "See data, MD notes/orders\n\nNeuro: A&O x 3\n\nCV: Hemodynamically stable, SR/no ectopy, sbp 115/59.\n\nPulm: Trach mask/passe muire valve. Lungs clear bilaterally, 02 sat 100%.\n\nGU: Uo>100cc/hr clear yellow.\n\nGI: NGT dc/d, pt swallowing without difficulty, regular diet ordered.\n Cecumostomy draining brown liquid stool to gravity.\n\nEndo: Ssc with regular insulin.\n\nSkin: Surfaces grossly , vac dressing clean and dry, JP drains per I/O sheet.\n\nSoc: Mother and Grandmother in to visit.\n\nP: Monitor pain level, prn anxiolytics. Calorie count x 3 days. ?PT consult and increase in acitivity - OOB. Keep family up to date on poc. Consider transfer out of ICU when medically appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-16 00:00:00.000",
"description": "Report",
"row_id": 1676640,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with Portex 8.0 DIC trach tube. On 50% cool aerosol. PMV on until 0100. Sxn for thick white secretions. Inflated cuff and placed inner cannula for night. Plan to put PMV back on this AM. Tolerates PMV and vocalizes well.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-16 00:00:00.000",
"description": "Report",
"row_id": 1676641,
"text": "cv: hr 98-67msr no ectopy.bp 129-102/72-51.\n\ngi: taking liquids without difficulty. cecostomy tube draining brown liquid 120 cc over night.pt to take diet today and calorie count to be done for 3 days.\n\ngu: foley draining clear yellow urine in adequate amounts.\n\nresp: tolerated passe muir valve until ~ 0100... resp ts given and passe muir valve removed overnight. valve tolerated very well by pt.suctioned 3 times overnight for very small amounts of clear.\n\nmental status: alaert oriented calm and cooperative. pt requested ativan 2 mg iv times 2 with good effect. pt slept.\n\nPain: pt maintained at a comfortable level with dilaudid pca. c/o discomfort with turning but pt premedicates with pca and tolerates the movement.\n\nintegumentary; vac dressing to continuous suction.4 drains draining minimal amounts of drainage, serosanguinous(#1and#4) serous(#2) duoderm on coccyx. pt also has a abrasion, pink on r upper posterior thigh miconazole powder applied and barrier cream. abdomen dressing .\n\nlabs: endo glucose 86 and 69 no coverage required.mag+ 1.9 2 grams mag. K= 3.8 kcl 20 meq.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-16 00:00:00.000",
"description": "Report",
"row_id": 1676642,
"text": "Respiratory Care\nPt remains trached (#8.0 Portex) and on trach collar. Pt continues to wear PMV t/o shift. Lung sounds had slight exp wheezes t/o. Suctioned for sm thk yellow. Nebs given with good effect. No ABGs drawn. Trach site stable, sutures remain in place. Care plan is to continue current therapy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-19 00:00:00.000",
"description": "Report",
"row_id": 1676650,
"text": "Status Update:\nData;\nPt. alert and oriented x3. Moving upper extremities well but very weakly moving lower extremities. Multipodus splints ordered for foot drop prevention but pt. declines to wear them most of the time. He continues on Bariair bed but declines to lay on his side. Adequate pain control with PCA Dilaudid.\n\nLungs clear bilaterally. Pass-muir valve removed overnight and cuff inflated. Required ET suctioning x2 overnight for scant secretions, otherwise has strong cough. Trach collar at 50%.\n\nVery healthy appetite with large volume of fluid intake. Low glucose overnight to 74 treated with juice.\n\nAbdominal vac dressing , next scheduled change on per primary team. Plastics involved. No output per JP drains, vac dsg with serosang drainage.\n\nPlan:\nContinue current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-19 00:00:00.000",
"description": "Report",
"row_id": 1676651,
"text": "Respiratory Care:\nPatient had PMV removed for the night, and received 2 nebulizer treatments (see CareVue).\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-19 00:00:00.000",
"description": "Report",
"row_id": 1676652,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: ALERT, ORIENTED X3, FOLLOWING COMMANDS. APPEARS MORE COMFORTABLE THAN LAST WEEK WITH MINIMAL USE OF PCA.\nCV: AFEBRILE. VSS. EXTREMITES COOL.\nRESP: TRACH COLLAR ALL SHIFT, PASSY-MUIR VALVE IN PLACE. BS CLEAR. COUGHING WITHOUT RAISING\nGI: ABD OPEN WITH VAC DRESSING IN PLACE. REGULAR DIET WELL\nGU: CLEAR YELLOW URINE IN GOOD AMTS\nENDO: NO SLIDING SCALE INSULIN REQUIRED\nACTIVITY: SAT ON SIDE OF BED WITH PT, OOB TO CHAIR FOR 2 HRS VIA HOVER LIFT= REQUESTED TO GO BACK TO BED AFTER 1 HR BUT ENCOURAGED TO STAY UP.\nA/P: CONT TO MONITOR HEMODYANMICS, INCREASE ACTIVITY AS TOLERATED, ENCOURAGE PO INTAKE, DRESSING CHANGE FOR EARLY NEXT WEEK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-14 00:00:00.000",
"description": "Report",
"row_id": 1676633,
"text": "NPN\nPt recieved with RLQ abd leaking moderate am't of stool. Dr and he notified primary team. Decision to reinforce the area until the am made and entire abd dsg will be changed in the am.\nPTT>150 repeated perip stick and PTT was 26 so heparin gtt restarted at 2200. PTT 33 at 0200. Dr and no changes made, ? if heprin will be turned off at 0700 for 0930 dsg change.\nAnxiety treated with ativan 2mg IVP with relief.\nPain tolerable per pt with current settings.\nPasse muir valve on most of eve, Thick tan mucous plug obtained whem pt suction after passe muir removed for the noc.\nPt tolerating TFs FS impact with benefit at 120ml/hr.\nSkin area behinf left knee OTA, gaping hole noted, no drg.\nDuoderm to coccyx.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-20 00:00:00.000",
"description": "Report",
"row_id": 1676653,
"text": "Please see carevue for specifics:\n\nNeuro: Pt alert and orient x 3, follows commands, using Passe muir valve until midnight, removed and cuff inflated over night,Pt states pain and is controled well with PCA, Dilaudid.\n\nCV: Afebrile, NSR , HR 70s-80s, BP 100s-120s\n\nGI: Pt tolerates reg diet\n\nGU: pt is putting out 100 cc an hour, pt remains neg\n\nResp: lateral lung sounds clear throughout , cough and gag \n\nSkin: stage 2 ulcers located on the pt coccyx and upper things with in his folds, vesta was placed on the wounds.\n\nPlan: monitor skin for future breakdown, monitor pt's pain level, next abd dressing change schedule for monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-20 00:00:00.000",
"description": "Report",
"row_id": 1676654,
"text": "NPN\nPlease see carevue for further details\nalert, oriented x3. speech clear. trach collar, PMV on for most of the day. Dilaudid PCA .5/6/5 with mod effect. Ativan given x2. OOB to chair this afternoon. Encouraging active participation with care. BLSCTA dim at bases. HR 80s SBP 100-120s. + BS x4 abd firm nd. VAC dsg to wall suction. multiple JPs with min amounts of purulent/white drainage. FOley draining clear yellow urine adq amounts. cecostomy draining brown soft stool. small BM x1 this shift. afebrile. IV ABX continues. reg diet well. PLAN: Dressing change planned for Monday. Continue to closely monitor hemodynamics, skin integrity, pain, encourage activity, provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-20 00:00:00.000",
"description": "Report",
"row_id": 1676655,
"text": "BS CTAB. Albuterol nebs x 2 at patient's request. Also suxtioned per patient - very small amount thick white mucus.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-14 00:00:00.000",
"description": "Report",
"row_id": 1676634,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Alert and oriented. Coop with care. Pt follws commands. Dilaudid PCA for pain control.\nCV: AFebrile despite rising WBC's. Pt SBP stable. Hr-NSR no noted ectopy. Pt tolerating 1.5hr drsg with prop gtt at 100mcgs/kg/min and fent. Anesthesia at bedside for procedure. Pt stable throughout. Abd wall vascular in appearance. New vac drsg by primary team. Pt tolerated procedure well. New mushroom cath placed for cecostomy. 4JP's . Heparin cont at 2200 units\nResp: Remains on trach mask. Tolerating well. Briefly placed back on vent for drsg . Otherwise resp status unchanged.\nGI/GU: Abd distended. Prior to dsg change leaking large amts of stool from cecostomy site. Foley patent drng clear yellow urine.\nID: Mult abx rising WBC's.\nPlan: Cont with current plan of care. ? possible trnf to floor. ? changing wall sxn to vac machine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-14 00:00:00.000",
"description": "Report",
"row_id": 1676635,
"text": "resp. care\npt. tolerating trach mask with pmv on. nebs given. briefly\nback on vent for sedation for dressing changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-15 00:00:00.000",
"description": "Report",
"row_id": 1676636,
"text": "NPN\nNeuro:\nCV:VSS SBP dipping into the high 90's when pt asleep, Fluid balace stable positive 190ml, wgt stable, SR 70's, no ectopics. afeb. Plan:Continue to monitor.\nResp:Pt tolerating passe muir valve however mucous plugging noted after it is on awhile and pt likes to keep it on for long periods. Plan:suction pt q4 hrs to maintain patent airway. Neb treatments given by resp therapist.\nGI:Pt tolerating TFs at 120ml/hr, no residuals, PPIs, stool output from cecostomy tube has decreased.\nGU:Foley patent adeq u/o.\nEndocrine BSs treated per sliding scale no coverage required overnoc blood sugars WNL.\nVAC drains to wall suction drg serosang drg in large am'ts HCT stable at 26. Abd dsg clean and dry.\nPsychsocial: mother and grandmother at bedside until 8pm. Pt concerned with his body image with all the \"scaring.\" he anticipates.\nPt also expressed his dislike of being so dependant on others for his care. Reassurance and coping strategies discussed.\nPlan:Continue plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-15 00:00:00.000",
"description": "Report",
"row_id": 1676637,
"text": "Respiratory Care:\nPt remains trached #8 portex. Was on PMV till 0200, then taken off. Suctioned for thick tan pluggy secretions. **Pt should be hyperinflated with ambu, and suctioned periodically during day, when he has the PMV on. Aerosol trach mask on 50%. Received alb/atr nebs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-18 00:00:00.000",
"description": "Report",
"row_id": 1676648,
"text": "Focus: Status Update\nData:\nPt alert and oriented x3. Moves lower extremities in bed but weak to lift, lifting and holding upper extremities well. Pain better controlled overnight with PCA use only. Ativan given x2 at pt. request due to anxiety.\n\nLungs clear bilaterally. Maintaining sats 98-100% with 50% trach collar overnight and on and off while awake and using passe-muir valve.\n\nAbdominal incision with vac dressing , next change due Monday. Moderate amounts of light serosang drainage. Continues to wall sx.\n\nSmall 1x.5 stage II pressure sore on coccyx. Duoderm removed due to wrinkling and left open to air. Pt. remains on bariair mattress. Bilateral small tears ischeal area also left open to air(L 1x1, R 2x1).\n\nPlan;\nContinue current plan of care. Provide close pain assessment and management. Wound dressing change Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-31 00:00:00.000",
"description": "Report",
"row_id": 1676581,
"text": "resp care\nPt currently on a/c 650x16 50% 8peep with peak/plat 35/25. Suct for sml amts of thick white sput. BS coarse bil.ABg continue to show a resp/met alkalosis. Will cont to follow and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-18 00:00:00.000",
"description": "Report",
"row_id": 1676649,
"text": "focus update note\nafebrile, heart rate 80s NSR, no ectopy, on lopressor po, sbp 100-110/40-50s\n\nresp; pt lung sounds are clear on 50% trach mask, passey muir valve on all day, pt exhibits no difficulty with swallowing , o2sat 100% consistently\n\ngi/gi: foley catheter draining amber clear urine, >100cc hr, bowel movement via cecotomy, pt eating 100% of meal today, on calorie count, dietary evaluated pt today, no tube feedings needed at this time per the dietician.\n\nmobility: physical therapy here today to sit pt at edge of bed and attempt to get oob to chair, large bair chair ordered and air matress for transfer.\n\nneuro; pt alert oriented x 3, flat affect, not talkative, but appropriate follows commands consistently, able to lift and hold upper extremities and moves lower extremities on bed. ativan 1 mg iv given for anxiety prior to getting pt up with physical therapy.\n\nskin: vac dressing , vac dressing draining large amount serosang drainage, jps to suction, bed on rotate most of day, multipodus boots on pt and compression boots restarted per ICU team, pt started on lovenox for prophalxis from dvt, s/p ivc filter.\n\npain: dilaudid pca, pt requiring less pain medication today, also takes methadone po, tylenol d/ced and pt continues on pregalbalin and clonidine patch, pt to have another pain consult.\n\nplan: pain consult, continue with physical therapy, encourage mobility, continue with skin care, continue with calorie count, await plastics - for surgical flap, and next wound dressing change on monday with anesthesia at bedside\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-22 00:00:00.000",
"description": "Report",
"row_id": 1676662,
"text": "Condition Update\nPT STATUS UPDATE:\n\nVAC dressing change today @ 1430. Please see anesthesia record for specifics. Pt started on Precedex and Propofol. Put back on vent. HR 80s. NSR, no ectopy. BP dropped to 90s/50s and Propofol titrated down. Procedure finished by 1545, pt tolerated well. Both Precedex and Propofol shut off by 1550. Pt awake and alert by 1630, able to follow commands. BP 100s/50s. Pt left on vent following due to low RR.\n\nN: Pt A&O x3. MAE. Following all commands. Pain issues. PCA pump Dilaudid. See carevue for settings. Anxiety issues. Ativan PRN.\n\nCV: HR 80s. NSR, no ectopy. SBPs 100-120s. PPP.\n\nRESP: Pt trached. LS clear throughout. Passe-muir valve in for most of day. Put on vent AC for dressing change. Pt back on CPAP with PS, 5 and 5, after procedure.\n\nGI: 4 JPs-- 3 on /LLQ, 1 RUQ-- putting out minimal light brown fluid. Abd wound appeared pink amd granulating as per team. 3 penrose drains changed and new vac dsg applied to wall suction. +BS. Small BM.\n\nGU: Foley draining adequate amounts of clear, yellow urine.\n\nENDO: ISS for blood sugar control. Pt can be both hypo and hyperglycemic. Fixing low sugars with glass of juice.\n\nPLAN: Transfer to floor ?\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-22 00:00:00.000",
"description": "Report",
"row_id": 1676663,
"text": "Respiratory care\nPt had dressing change this afternoon required vent, pt with periods of apnea on cpap. Plan to wean to trach collar when pt wakes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 1676568,
"text": "MICU NSG 7A-1500\nRESP--PT CONTS ON 4L NC, DENIES SOB, LUNGS WITH DIMINSHED BS IN BASES. VBG SENT, PLEASE SEE CAREVIEW FOR RESULTS.\n\nCV--PT REMAINS IN ST 120-130, NO ECTOPY NOTED. BP 110-130/. LACTATE SENT 3.0. PT WITH ERYTHEMA FROM LEVEL OF AXILLA TO KNEE ON RIGHT SIDE, GROIN AREA ON LEFT. RIGHT SIDE OF ABD WITH 2CMX2CM BLISTER WEEPING MOD AMOUNT PURULENT DRG, TEAM AWARE, CX SWAB SENT FROM SITE. NEEDS FLUID/FUNGAL CX'S SENT FROM TISSUE. IN TO EVAL AND DECISION MADE FOR PT TO GO TO OR FOR DEBRIDEMENT. ~12PM PT TURNED AND NOTED TO HAVE COPIOUS WEEPING FROM BLISTER AREA, NEW SITES NOTED AND NEW 6CMX6CM BLACK/PURPLE AREA ON FLANK, PT WITH OTHER BLISTERING AREAS ON BACK/FLANK, APPEAR LIKE FLUID/PUS FILLED STRETCH MARKS. BACK TO EVAL, SENT TO OR AT 1400. PT WITH ACTIVE CLOT IN B, COAGS, CHEM 7 CBC SENT. PROCEDURE AND ANESTHESIA CONSENT SIGNED BY PT. RIGHT RAD ALINE PLACED BY ANESTHESIA. COCCYX WITH REDDENED YEAST LIKE RASH, ANTIFUNGAL POWDER APPLIED. MRSA/VRE RECTAL SWAB DONE AND SENT. BLD CX X1 SENT.\n\nNEURO--PT SLEEPING IN NAPS. C/O BURNING ABD PAIN. MED WITH MS CONTIN 100MG PO AND TOTAL OF MORPHINE 8MG IV WITH MIN RESUCTION IN PAIN. TEAM AWARE, PLANS TO INC PO MS CONTIN PRIOR TO BEING SENT TO OR. LEFT LEG REMAINS IN IMMOBILIZER BOOT, STERI STRIP INCISION LINE C/D/I.\n\nGI--PT NPO EXCEPT FOR MEDS. ABD OBESE, SKIN AS DESCRIBED ABOVE. GOOD BS IN ALL 4 QUADS. PT WITH ABD PAIN AS DESCRIBED ABOVE. FS 127, NO COVERAGE PER SS.\n\nGU--FOLEY CATH IN PLACE, DRAINING CLEAR YELLOW URINE 50-100CC/HR.\n\n MOTHER IN TO VISIT. HCP FORM SIGNED. PT ABLE TO SPEAK WITH MOTHER RE; CODE STATUS WISHES, PT WOULD LIKE TO BE FULL CODE. MOTHER SPOKE WITH MEDICAL AND TEAM, AND IS WAITING IN WAITING AREA TILL PROCEDURE DONE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 1676569,
"text": "Respiratory Care\nPatient admitted from the OR and placed on Full mechanical ventilation. Bilateral breath sounds diminished throughout. Settings documented in Carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 1676570,
"text": "STATUS\nD:ADMITTED FROM O.R. S/P EXPLOR LAP FOR NECROTIZING FASCITIS..OPEN ABD PACKED..OOZING COPIOUS SEROUS SANG..ON LEVO & PROPOFOL GTT'S..NOT REVERSED..MP SVT 200'S>>ADENOSINE 6MGM X1>> REVERSED TO ST 120-110 NO DROP IN BP DURING SVT BUT DROPPED DOWN WHEN REVERSED..LEVO GTT RESTARTED & INCREASED TO 0.1MGM..KEEP SBP >90/\nA: STABLIZING\nP: TO O.R. IN AM FOR CLEANING OF WD..KEEP COMF..\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-29 00:00:00.000",
"description": "Report",
"row_id": 1676571,
"text": "SICU NPN:\nS-Sedated and intubated\n\nSEE CAREVUE FOR ALL OBECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-Sedated on Propofol infusion. Pupils equal and reactive to light, 3mm bilaterally. Grimacing with suctioning. Started on Fentanyl infusion at 150mcgs/hr. Not following commands with no noted movement. Levophed weaned to 0.3mcg/kg/min where remains, unsuccesful at weaning in order to keep MAP > 60. Noted wide pulse pressures when BPs low, systolic pressures, 90-100s and diastolic pressures, 20-30s and MAPs low 50s. HR 90-100s, ST. Few burst of SVT with rate into the 160s but non-sustaining. K repleted and Lopressor IV started ATC. Since no further episode. Pulses dopplerable bilaterally. Grossly edematous throughout. Remains on AC with FiO2 weaned to 40%. ABGs improving with vent changes made on prior shift. Morning ABG with metabolic alkalosis. HUO adequate. Maitenance fluid continues at 200cc/hr. CVP 10-12. Aboomen open with copious amounts serosanguinous drainage. Drainage placed to LCWS with approval of Dr. and Dr. . Since placed to wall suction pt with > 5Ls. CC/CC replacement beggining with intial output of 2L and bolused with LR anc continuing to replace with LR. Also noted with further extension of redness to LLQ and RLE. Area warm to touch. Primary team resident visualizing and SICU resident aware. Plans to move OR case up to early this AM. NGT inserted and confirmed on XRAY. Repeat HCT stable post blood. AM HCT pending. Low grade temps overnight. Continuing triple antibiotics. Wound culture GS with PMN, GNR, GPC. Blood cultures pending from , Cdiff(-) from , and viral studies pending. Insulin infusion started for glucose in the 170s, since on infusion glucoses < 150. Mother, aunts and sister into visit during the evening. Updated by RN. Will return this morning.\n\nA/P: 32 year old male POD #1, s/p envolved debridement of peritoneal cavity for necrotizing fasciatis now low dose pressor and CC/CC replacement for copius drainage of wound. Stable overnight with plans to return to OR this AM.\nContinue CC/CC replacement\nKeep comfortable on Fentanyl infusion\nHourly FS while on Insulin infusion. Following guidelines\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-31 00:00:00.000",
"description": "Report",
"row_id": 1676582,
"text": "Respiratory Care\nPatient received on AC 650x16 50% 8 PEEP, breath sounds revealed bilaterally clear,diminished, suctioned for small thick while secretions, WBC 16.7, was 20.7 yesterday, was afebrile, into normal sinus rhythm whole shift, was hypertensive a few times, is on Propofol, Fentanyl, Insulin, Abdominal dressing redone today by doctors,no ABGs drawn during shift nor vent changes made, will continue to receive mechanical ventilatory support and close monitoring.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-31 00:00:00.000",
"description": "Report",
"row_id": 1676583,
"text": "Nursing progress note\nSee Carevue for specifics\n\nNeuro: pt cont on ppf & fent gtts, but will rouse to voice and follow simple commands, nodding appropriately to questions. MAE, withdraws/localizes pain. PERRL.\n\nCV: NSR. 1200 lopressor dose held d/t hr in low 60s s/p fentanyl for dsg change. SBP elevated in 160s-170s. MD aware, pt kvo'd, SBP now 150s. K repleted.\n\nResp: No vent changes. Sxn'd x 1 for minimal secretions.\n\nGI: TF advanced to 20cc/hr. Abd open but hypoactive BS.\n\nGU: Foley draining large amounts of cyu.\n\nSkin: Still flushed but not as diaphoretic. Abd dsg taken down, assessed by urology, repacked and intact. New drain tubing placed & cont to drain copious amounts of serosang fluid.\n\nEndo: insluin gtt cont. BS 90-153.\n\nSocial: Pt tearful at times while mother at bedside. Pt responds well to calm, positive support and being kept informed.\n\nPlan: Cont to monitor VSS, BS and pain needs. Monitor abdominal dsg and drain. Assess skin frequently. Keep patient up to date on plan of care and provide positive feedback frequently.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-01 00:00:00.000",
"description": "Report",
"row_id": 1676584,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt sedated on Ppf and fentanyl gtt. Easily arousable to voice. PERRLA. Moves all extremities. Follows commands. Nods/shakes head to questions appropriately. Pt denies having any pain; no grimacing noted. +gag/cough reflex. Afebrile. HR 60s-80s (NSR; no ectopy noted). ABP 120s-160s/50s-80s. Metoprolol IV q6hr ordered. CVP 11-18. Pt with anasarca; +4 pedal edema. Teds on BLE and venodyne boot on RLE. DP/PT pulses dopplerable. IVF @ KVO. A-line and central line dsg changed. Pressure tubings also changed. Lungs clear; diminished at bases. Pt with strong cough. Suctioned for small amount thick, white secretions. CMV: 50%, Vt 650 x 16, PEEP 8. O2 sat 100%. Mouth care performed per VAP prevention protocol (see CareVue) and head of bed >/= 30 degrees. CXR ordered for 5AM. Abdomen open; hypoactive bowel sounds. Replete with fiber @ 20cc/hr via NGT; no residual noted. NGT flushed with 30mL water q4hr as ordered. No bowel movement this shift. Insulin gtt continued; following insulin scale (target BG 80-110). FS q1hr while on insulin gtt. Foley intact with clear, yellow urine. UO 100-240cc/hr. Urology service following pt. Abdomen open; packing intact (connected to medium wall suction). Copious amount of serosang drainage from abdomen. Left lower leg with steri-strips intact. Scant amount of serous drainage noted from left knee incision; covered with 2x2 gauze and paper tape. RLE and left side of abdomen pink; no drainage noted. Allevyn on coccyx intact. Allevyn is due to be changed today. Pt on BariAir bed; bed rotation on. mom and grandmother visited; updated by RN on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Monitor neuro and respiratory status. Fentanyl and Ppf gtt for sedation; wean as tolerated. Wean vent setting as tolerated. Follow up result of CXR. FS q1hr while on insulin gtt; follow insulin scale (target BG 80-110). Monitor output from abdominal wound. Monitor incision on LLE. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-01 00:00:00.000",
"description": "Report",
"row_id": 1676585,
"text": "resp care\nPt remained on a/c 650x16 50%8peep with peak/plat 28/24. BS coarse. Suct for sml amt of loose white sput. RSBI done this am=32.Morning abg acceptable. Will cont to follow and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-01 00:00:00.000",
"description": "Report",
"row_id": 1676586,
"text": "STATUS\nD: MORE AWAKE FOLLOWS COMMANDS MOUTHING WORDS & NODDING APPROPRIATELY REMAINS ON INSULIN/PROPOFOL/FENT GTT'S..C/O ABD PAIN\nA: FENT GTT INCREASED TO 350MGM & PROPOFOL TO 80MCG WITH SOME IMPROVEMENT IN PAIN MANAGEMENT..INSULIN GTT DOWN TO 1U..TRIPLE LUMIN INSERTED IN PA PORT OF VA CATH WITH SOME DIFFICULTY..X_RAY OK..VENT CHANGES SEE FLOW SHEET.. SUCTIONED FOR SM AMT THICK WHITE..ABD DRAINING COPIOUS AMT SEROUS.. ADQUATE HUO'S\nR: STABLE\nP: CONTINUE TO MONITOR Q2H BS'S & AJUST INSULIN GTT PER PROTOCOL.. VENT CHANGES/LABS PER HO..INCREASE FENT GTT & PROPOFOL GTT TO KEEP PT COMFORTABLE..MONITOR I&O CLOSELY\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-01 00:00:00.000",
"description": "Report",
"row_id": 1676587,
"text": "Respiratory Care\nPt remains intuabted (#7.5 ETT 23 @lip) and on vent support. Vent changes were A/C to PSV and FiO2 from 0.5 to 0.4. Lung sounds were clear t/o. Suctioned for sm thk white. Last ABG was WNL with good oxygenation. Care plan is to continue current therapy and follow ventilation status due to sedation, adjust as needed. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-23 00:00:00.000",
"description": "Report",
"row_id": 1676664,
"text": "Nursing progress note\nSee Carevue for specifics\n\nNeuro: A & O x 3. MAE, follows all commands. Frequent c/o of pain and requesting pain medicine. 2 mg dilaudid x 2 given with minimal effect. Fentanyl given and dilaudid PCA dose increased to .75 (6.2 mg/hr). Positive effect on pain but resulted in apnea, desat and hypotension. Decision to have pain service consult tomorrow.\n\nCV: NSR, no ectopy noted. NBP mostly WNL with exception to hypotensive episodes s/p pain med.\n\nResp: Trache mask. LS clear/diminished. Sat 100%. Strong cough. Sxn'd for scant secretions. RT following closely and administering nebs PRN.\n\nGI: House diet. Unable to assess bowel sounds d/t open abdomen. No stool this shift. Abd vac dsg and to wall sxn, draining serosang. 5 JPs patent and draining minimal fluid. See Carevue for specific data.\n\nGU: Foley draining adequate clear yellow urine.\n\nSocial: Mother called.\n\nPlan: Order pain service consult for day shift. Cont to monitor resp status closely. Provide emotional support.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-23 00:00:00.000",
"description": "Report",
"row_id": 1676665,
"text": "Resp Care\nPt received on mechanical ventilation. Pt taken off vent at 8p.m. and placed 50% trach mask. BS clear bilaterally and diminished at lung bases. Pt suctioned for scant thick white secretions. Nebs given as ordered. See CareVue for details and specifics.\nPlan: Cont current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-29 00:00:00.000",
"description": "Report",
"row_id": 1676572,
"text": "Resp Care Note, Pt weaned down FI02 per ABG with good results. ABG this am resp acidosis.HR-ST.Temp 100.1. Sedated with fentanyl and propofol. No spont resp @ this time.Getting levophed and fluid bolus. To OR today for further exam of L side of abd. Will cont to monitor resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-29 00:00:00.000",
"description": "Report",
"row_id": 1676573,
"text": "STATUS\nD: FEBRILE 101..REMAINS ON PROPOFOL/INSULIN & FENT GTT'S..WILL WAKE TO STIMULI & MOVES ALL EXTREM'S\nA: REPLACING ABD DRAINAGE 1/2CC/CC WITH LR..CONTINUES WITH LGE AMT SEROUS SANG DRAINAGE..VA CATH PLACED LF SUBCL & RT IJ LINE DC'D & TIP SENT FOR CULT..NG DRAINING SM AMT BILIOUS..HUO GOOD ALL DAY BUT DROPPED TO 15CC AWARE..ABD & BOTH LEGS WARM BLANCH TO TOUCH..HO AWARE\nR: CRITICAL\nP: TO O.R. @ 1900 FOR MORE DEBRIDING & WASHING OUT OF WD..MONITOR HUO'S..FREQ BS'S & ADJUST GTT AS NEEDED\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-02 00:00:00.000",
"description": "Report",
"row_id": 1676588,
"text": "condition update\nPlease see carevue for specifics.\nNeuro: Sedated with ppf/fentynal. PPF/fent. gtt's titrated up briefly overnight as pt was tachy, appeared anxious and was complaining of pain. Pt arouses to vioce, follows commands, nods appropriately. Pupils equal and briskly reactive.\nCV: Tachy to 120, receive 1 liter LR bolus with good effect. Abd. wound draining copious amts. serous drainage. BP stable. Peripheral pulses palpable. K+ 3.4 repleted.\nResp: LS coarse to clear/diminished. Suctioned for small amts. thick white sputum. Peep weaned to 5. Abg's acceptable.\nGI: TF increased to 50cc/hr, minimal residual. Abd. is open and packed, draining copious amts. serous drainage to suction. No bm.\nGU: foley draining adequate amts. clear yellow urine.\nendo: insulin gtt titrated to keep bs <120.\nSkin: small opening in fold near cocycx, new alevyn applied.\nSocial: mother and grandmother visiting at bedside last evening, updated by rn.\nPlan: Abd. dsg change and debridement at the bedside today, pain management, titrate insulin gtt, monitor hr, advance TF as tolerted, emotional support to patient/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-02 00:00:00.000",
"description": "Report",
"row_id": 1676589,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated on spontaneous ventilation. We weaned PEEP from 8 to 5 cmH20. RSBI done 14. Bs are dim coarse. We are sxtn routinely for small amt of thick white secretions from ETT. Plan: keep conforttable. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-02 00:00:00.000",
"description": "Report",
"row_id": 1676590,
"text": "Respiratory Care\nPt remains intubated (#7.5 ETT 23@lip) and on vent support. Vent changes were PSV to A/C for sedation to dressing change. Pt has remained on A/C t/o shift. Lung sounds were clear t/o. Suctioned for scant-sm thk white. No ABGs were drawn. Care plan is to wean as tol, change back to PSV when ready. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-05 00:00:00.000",
"description": "Report",
"row_id": 1676601,
"text": "Nursing Note 7a-7P:\nNursing Assessment:\n\nCt guided drainage of abdomenal fluid collections. 600cc drained in CT of purulent pinkinsh/cloudy foul-smelling drg from R abdomen and small amt purulent yellowish drg from left abdomen. Cultures sent. Another 350cc from right to follow and 30cc from left. Drains placed in OR yesterday: 2 to y connector to wall suction with 1200 cc out for shift and drain to gravity near colon fistula with no drg despite flushes per orders. Following the guided drg in Ct pt given contrast via ngt and to return to CT for abdomen/colon fistula images.\n\nPt sedated on fent/prop with prn ativan (gtt discontinued) for procedures. Awake and anxious when lightened and follows commands/mouthing words.\n\ntmax 99. Lungs are clear to coarse and weaned to cPap. Suctioned for thick white secretions in mod amounts. Abdomen open with gauze packing. Drains as previously mentioned. No tube feeds at this time. NGT to LCWS with bilious output. TPN as ordered. HR NSR 80-110 (elevated with anxiety). SBP 110-140s. UO adequate via foley cath.\n\nPlan: CT at 5pm. Cont to monitor all drain outputs and flush according to orders. Wean sedation and vent as able following CT and medicate for anxiety with prn ativan. Cont antibiotics. Emotional support for pt and family. mother and grandmother at bedside. Monitor sugars and treat with sliding scale: insulin gtt is currently off.\n\nPlease refer to carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-05 00:00:00.000",
"description": "Report",
"row_id": 1676602,
"text": "Resp. care note - Pt. remaines trached and vented, transffered to CT and back to SICUA x 2 without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-06 00:00:00.000",
"description": "Report",
"row_id": 1676603,
"text": "RESP CARE: Pt remains trached/on vent on settings per carevue. Lungs coarse bilat. Sxd small amounts thick white sputum. RSBI-12. ? trach collar trial today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-06 00:00:00.000",
"description": "Report",
"row_id": 1676604,
"text": "NURSING PROGRESS NOTE\nPLEASE SEE CAREVUE FOR SPECIFICS\n\nNEURO: ALERT ON PROPOFOL. FOLLOWS COMMANDS, MAE. MOUTHING WORDS. C/O GENERALIZED AND ABDOMINAL PAIN, CONT ON FENT DRIP RECIEVING DILAUDID PRN W/EFFECT. NO ATIVAN GIVEN FOR ANXIETY AS PT SLEPT MOST OF NIGHT.\n\nRESP: CONT ON CPAP 40% FI02. SAT'S 98-100%. LUNGS CLEAR, DIMINISHED AT BASES (DIFFICULT TO ASCULATE LL LOBE D/T DRAINS TO WALL SUCTION). PRODUCTIVE COUGH SUCTIONING SMALL TAN/WHITE THICK SECRETIONS.\n\nCV: SBP 110-130, CVP 8-12, HR 70-90 NO VIEWED ECTOPY. HR INCREASES TO 100-110S WITH STIMULATION AND WHILE TALKING TO FAMILY. RECIEVING 2.5MG LOPRESSOR W/EFFECT. ELECTROLYTES REPLETED.\n\nGI/ENDO: ABDOMEN OPEN, DRAINS TO LCWS. NGT TO LCWS DRAINING SMALL TAN/BILIOUS. NPO. ? RESTART TF TODAY. TPN RUNNING AT GOAL. REMAINS OFF INSULIN DRIP, CHECKING FBS EVERY 6 HOURS TREATED PER RISS REQUIRING MINIMAL COVERAGE.\n\nGU: FOLEY PATENT DRAINING >30CC CYU HOURLY.\n\nSKIN: MULTIPLE DRAINS, FOLLOW ORDERS FOR PIGTAIL DRAIN FLUSHES MONITORING OUTPUT. SMALL LACERATION ON COCCYX, PINK, BARRIER CREAM APPLIED.\n\nSOCIAL: PTS MOTHER AND GRANDMOTHER IN FOR BEGINNING OF SHIFT AS WELL AS FRIEND .\n\nPLAN OF CARE: FOLLOW AND TREAT LABS AS NEEDED. MONITOR PAIN AND ANXIETY. WEAN SEDATION AND VENT AS TOLERATES. MONITOR DRAIN OUTPUT FLUSHING AS ORDERED. HO AWARE OF ABOVE, WILL CALL WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-03 00:00:00.000",
"description": "Report",
"row_id": 1676591,
"text": "condition update\nPlease see carevue for specifics.\nNeuro: Sedated on ppf, fentynal, and ativan gtt's. Wake up done (ppf off for 15min) and pt was alert, following commands, and nodding appropriately, moving all extremities. Pupils equal and reactive.\nCV: NSR mainly 70's-80's, sbp stable. peripheral pulses dopplerable. Generalized +4 edema.\nResp: Continues on a.c., no vent. changes made. Suctioned for minimal thick white secretions. LS clear and diminished. Abg's acceptable.\nGI: TF advanced, tolerating well. No BM. Abd. is open, packed and to wall suction draining copious amtts. brown serous drainage. Hypoactive bs present.\nGU: foley draining adequate amts. clear yellow urine.\nendo: insulin gtt titrated though bs elevated 150's-170's.\nPlan: pain management, titrate insulin gtt to keep bs <120, abd. CT today, pulmonary toileting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-03 00:00:00.000",
"description": "Report",
"row_id": 1676592,
"text": "RESP CARE: Pt remains intubated/on vent on AC 650/16/.4/5 PEEP. Pt sedated, not breathing over set rate. ABGs 7.43/46/105/32/4. Lungs coarse rhonchi, sxd mod amts thick white sputum. No RSBI due to absence of spont. resp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-03 00:00:00.000",
"description": "Report",
"row_id": 1676593,
"text": "NPN: Review of Systems\nNeuro: Pt is currently sedated w/ propofol and ativan, and receiving fentanyl for pain control. When proofol stopped, Pt's eyes opened to voice and he nodded to questions. Nodded yes when asked if uncomfortable. 100mcg fentanyl boluses given w/ activities such as turning, suctioning, mouthcare.. Propofol initially infusing at 60mcg/kg/min. After CT,started titrating propofol down and increasing ativan as needed. Currently on 30mcg/kg/min propofol and ativan increased to 2.5mg/hr from 2.0mg/hr. Appears comfortable. Breathing unlabored, HR at baseline.\n\nResp: Changed from AC to CPAP; 5PEEP/ % PS. RR mid teens w/ tidal volumes >600. F/U ABG=7.35/49/108 and 28/0. BS CTA bilaterally w/ exception of bases which sound diminished. Suctioning small amt of thick white secretions.\n\nCV: SR. No ectopy. HR 80s-90s and MAP 60-70s. Skin warm. DP pulses weakly palpable bilateraly. Pt had received 40meq KCl for K=3.1. F/U K+=3.4. C++=1.1. Mg++=2.2.\n\nGI: Abdominal dressing intact. Serous/ tea colored thin fluid in drain #1. Output=1700 this shift for total since MN=2500cc. Scant amt of serous drainage in drain #2. Abdominal CT done after 900cc Ready CAT. pending. Tubefeedings at goal rate of 100cc/hr. No residual and no bowel movement this shift.\n\nEndo: Regular insulin drip being titrated to achieve blood sugar <150. Currently on 4 units/hr.\n\nGU: Urine is clear yellow via foley. Please see careview for i/o. BUN/Cr=10/0.4.\n\nID: Afebrile. Continues on antibiotics. WBC=20.6K from 24.2k\n\nSkin: Excoriated wound present on nare where NGT is inserted. Wound approx. 0.5cm circular. No drainage. NGT taped away from site. Continues on rotation therapy via BAricair bed. Allevyn dressing intact on coccyx. Left knee incision OTA. Steristrips intact. Scant drainage.\n\nSocial: mother called. Informed that CT was done, and there is the possibility that Pt will go to the OR for washout/dressing change.\n\nA: Hemodynamic and pulmonary status has been stable. Tolerated decrease in propofol.\n\nP: Decrease propofol and increase ativan as tolerated. Continue to check glucose q1hr + titrate insulin drip accordingly. Replete K+, as indicated by orders. F/U w/ CT results. ? OR for abdominal washout. ? dobhoff to prevent further skin breakdown on nare.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-03 00:00:00.000",
"description": "Report",
"row_id": 1676594,
"text": "Respiratory Care:\nPt remains orally intubated and vented. Pt weaned to PS 5. Follow up ABG showed acid base within normal with hyperoxemia. Lung sounds clear. Suctioned for scant thick white secretions. Traveled to and from CT without incident. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-06 00:00:00.000",
"description": "Report",
"row_id": 1676605,
"text": "Nursing note (0700-1900) 15:45\n\nEvents:\nDressing change.\nTrach trial.\n\n\nNeuro.\nPt with severe pain to abdominal area, Fentanyl increased to 500mcg/hr, requires dilauded also. Was started on PO methadone, aim is to be able to wean down fent.\nPt very anxious at times, given ativan with good effect.\nPropofol stopped at 1500.\n\nResp.\nPt attempted on trach mask, but paniced and needed the vent after a few seconds, pt is on %/TV 900-1500. SpO2 98-100%. LS clear to UL's, diminished LL's.\n\nCVS.\nPt in NSR at 80-90, becomes tachy with family present, small response to Lopressor.\nBP 130-150.\n\nGI/GU.\nTF's restarted at 15:00 at 40cc/hr, to be increased by 20cc/hr Q4 to goal rate of 120cc/hr. Hypoactive BS with no BM as yet this shift.\nFoley patent for good ampounts of clear yellow urine.\n\nSkin.\nFasciotomy dressing changed by team at bedside, team state it is looking better, they may try a vac dressing next time.\nAll pressure areas intact at present.\n\nSocial.\nVisited by various members of family through the day, all aware of current condition.\n\nPlan.\nAdvance TF's.\nPain control.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-06 00:00:00.000",
"description": "Report",
"row_id": 1676606,
"text": "Resp. care note - Pt. remaines trached, weaned to TM, unable to tol, placed back on the vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-08 00:00:00.000",
"description": "Report",
"row_id": 1676612,
"text": "RESP CARE: Pt remains trached/on 35% TC all shift. 02 sats 99-100%.Sxd mod amts thick clear/white sputum. Lungs few rhonchi bilat, dim bibasilar. Vent dc'd. No periods of apnea noted this shift/no evidence of drops in 02 sats. Will continue to follow per airway protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-08 00:00:00.000",
"description": "Report",
"row_id": 1676613,
"text": "RESPIRATORY CARE: PT W/ AN 8.0 PORTEX TRACH IN PLACE.\nCHANGED FROM A TRACH COLLAR .50 TO THE AC MODE AS PER CV\nFOR A CT GUIDED DRAIN PLACEMENT PROCEDURE. STABLE DURING\nTRANSPORT. SX FOR YELLOW SPUTUM. HAD A VACC DRESSING\nPLACED AND REQUIRED SEDATION SO PT TO REMAIN ON THE AC\nMODE OVERNIGHT/ POSSIBLY TO THE OR IN THE AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-08 00:00:00.000",
"description": "Report",
"row_id": 1676614,
"text": "PT UPDATE\n STATUS\nN: Pt A & O x3. Follows commands and able to move all extremities. Weak BLE. Pt on 40mcg/kg/min Propofol.\n\nCV: HR 80-90s. NBP 130's/50's. PPP. Skin warm and dry. Pt can get hypertensive in times of stress. SBP max 170s during CT. Treated with 4mg Ativan. ?DVT in LE. Ultrasound at the bedside .\n\nRESP: on trach collar this am, doing well. Speech and swallow consulted for placement of passy-muir valve. This was deferred until tomorrow due to patient's 3 hr. CT scan and subsequent dressing change, requiring restarting of propofol and increasing fentanyl as needed for pain control (see flow sheet). Will keep patient on CPAP over night on minimal sedation, evaluate trach collar in am, slight change that patient could go to OR for further debriedment.\n\nGI: To CT this pm for guided drainage and placement of 2 additional pigtail drains (currently with total of 4). LUQ pigtail replaced with larger bore cath. 3 hr procedure, tolerated fairly well, required propofol and fentanyl with occ. bolus doses of fentanyl. Dressing changed after CT by Dr. and . Multiple areas of communication under abd. fascia--packed with kerlix. Vac dressing placed over wound,suction cath placed then blue steril cloth placed over these and stapled in place. Ioban dressing over this with 120mmHG\nwall suction to contain drainage. Currently intact. No leaking noted.\nwill restart tube feeds at previous rate, letting primary team know if stool like drainage noted from wound.\n\nGU: Foley draining clear, yellow urine.\n\nPlan: Monitor signs of worsening infection/ vitals. Drain care. Pain control--dilaudid PCA dose increased per pain service, currently being held as patient on higher doses of propofol and fentanyl. Patient and Family support for anxiety issues.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-09 00:00:00.000",
"description": "Report",
"row_id": 1676615,
"text": "Resp: pt on a/c 10/800/5/50%. Pt has #8 portex. BS are coarse to clear and suctioning for small to moderate thick yellow secretions. No changes or abg's this shift (no aline). No rsbi due to no resps. Plan to continue present settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-09 00:00:00.000",
"description": "Report",
"row_id": 1676616,
"text": "vss. sb/p 100-95 held 0600 dose lopressor. lightly sedated on ppf and fentanyl and using dilaudid pca liberally also requesting ativan\nx2. slept in long naps.\nabd. dsg intact-drains patent-irriig w/ n/s 10cc.\nt. fdg restarted impact w/ fiber-resid 110cc. no stool from rectum-\nsmall amt thick brown stool from cecostomy tube.\npt rested o/n on cmv switch to cpap.to wean to trach collar today as tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-07 00:00:00.000",
"description": "Report",
"row_id": 1676607,
"text": "NURSING PROGRESS NOTE\n\nPLEASE SEE CAREVUE FOR SPECIFICS\n\nNEURO: ALERT. FOLLOWS COMMANDS, MAE. PUPILS BRISK AND REACTIVE. PT W/CONTINUOUS C/O PAIN. WEANING OFF FENTANYL DRIP, INTRODUCING METHADONE. RECIEVING PRN DILAUDID AND ATIVAN AS NEEDED. DR AWARE OF PTS PAIN ISSUE, PAIN SERVICE IS INVOLVED, WILL MEET W/TEAM TODAY TO REASSESS PTS PAIN CONTROL.\n\nCV: SBP 130-150. NSR HR 70-90, TACHYCARDIC REACHING 110 W/INCREASED STIMULATION.\n\nRESP: CURRENTLY ON CPAP/PS 5/10/40%, HAD RESTED OVERNIGHT ON MMV. LUNGS CLEAR, DIMINISHED AT BASES. PRODUCTIVE COUGH SUCTIONING SMALL CLEAR THICK SECRETIONS. SAT'S 98-100%.\n\nGI/ENDO: OPEN ABDOMEN W/DRAINS TO LCWS. + BS. NO BM. TF RUNNING AT 80CC CURRENTLY, GOAL 120CC TO INCREASE IN 20CC INCRIMENTS. MIN RESIDUAL. FBS TREATED PER RISS REQUIRING MIN COVERAGE.\n\nGU: FOLEY PATENT DRAINING >30CC CYU.\n\nSKIN: MULITPLE DRAINS, OPEN ABDOMEN, L KNEE STAY SUTURES. SEE FLOWSHEET FOR SPECIFICS.\n\nSOCIAL: PTS MOTHER AND GRANDMOTHER IN FOR BEGINNING OF SHIFT.\n\nPLAN OF CARE: PAIN SERVICE INVOLVEMENT TO REASSESS PAIN CONTROL. ADVANCE TF AS TOLERATES. MONITOR PAIN AND ANXIETY. FOLLOW AND TREAT LABS AS NEEDED. ? TRACH MASK TRIAL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-07 00:00:00.000",
"description": "Report",
"row_id": 1676608,
"text": "RESP CARE: Pt remains trached/on vent on settings per carevue. Pt changed from CPAP/PSV to MMV with low set MV 6.5 liters, .40/PEEP 5/PS 5. This was change was made because pt has prolonged apneic periods following administration of pain medications. MD aware. Lungs coarse. Sxd mod amts thick white sputum. AM RSBI-18.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-07 00:00:00.000",
"description": "Report",
"row_id": 1676609,
"text": "Resp. care note - Pt. remaines trached weaned to 50% TPEICE, tol ok at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-10 00:00:00.000",
"description": "Report",
"row_id": 1676619,
"text": "Respiratory Care:\n\nPt followed trach in place, on 50% FI02 TC. We removed PMV last evening. We sxtn as needed for small to mod thick white, active strong cough. Plan: vent left on St-by for ?dressing changes or CT. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-10 00:00:00.000",
"description": "Report",
"row_id": 1676620,
"text": "vss, cvp 7-4. urine output 60-100cc c/y/u.\nheparin presently @ 1000units/hr.\npt able to communicate needs-tolerateing trach collar/passe-muir valve\nabd. dsg intact-drains/pigtail irrig w/ 10cc n/s-all patent and draining. cecostomy tube dgre thick brown stool.\ntolerating t fdg via ngt w/ min. residual. no stool from rectum.\npt in constant pain-using pca dilaudid liiberally. requesting ativan x2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-10 00:00:00.000",
"description": "Report",
"row_id": 1676621,
"text": "Respiratory care\nPt seen for trach check. Pt wearing PMV cuff down. Vent on standby for dressing change.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-10 00:00:00.000",
"description": "Report",
"row_id": 1676622,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n\n PT ALERT & ORIENTED, MAES, FOLLOWS COMMANDS. CONT HAVING PAIN ISSUES, C/O GEN ABD PAIN ON DILAUDID PCA 0.37/6/3.7, APS INVOLVED. HR 80S-110S, NSR/ST, SBP 100S-130S, CVP 6-10. CVL REMAINS IN, PT IN FOR URGENT PICC EVAL. HEPARIN DRIP UP TO 1200UNITS/HR, PTT REMAINS LOW-33.9, WRITTEN FOR 1UNIT FFP. PT /TRACH COLLAR ALL DAY, SUCTIONED FOR MIN THICK, WHITE SECRETIONS. LUNGS COARSE, WHEEZES AT BASES, NEBS WRITTEN. PLAN FOR ABD DSG IN OR , LGE AMT SEROSANG DRNG TO WALL SXN. TF AT 120CC/HR, MIN RESIDUALS. Tm 100.6, CONT MULTI ANTBX. FAMILY VERY SUPPORTIVE.\n\nPLAN: CONT HEMODYNAMIC MONITORING, HEPARIN DRIP/FFP FOR LOW PTT. RESP SUPPORT, NEBS AS NEEDED. PCA FOR PAIN MGMT. OR FOR DSG CHANGE, ?PICC IN IR VS. BEDSIDE. REPLETE LYTES AS NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-09-11 00:00:00.000",
"description": "Report",
"row_id": 1676623,
"text": "NURSING PROGRESS NOTE\nNURSING PROGRESS NOTE: SEE CAREVUE FOR OBJECTIVE DATA AND TRENDS.\n\nNEURO: A+OX3. ABLE TO VERBALIZE NEEDS. PERRLA,BRISK, MAE. +COUGH. C/O ABD PAIN AND FEELING ANXIOUS. CONTINUES ON DILAUDID PCA/METHADONE/ATIVAN WITH GOOD EFFECT.\n\nCARDIAC: HCT-27.2. NSR-ST. HR: 91-110. SBP: 107-121/50-63. FFP GIVEN. REPEAT PTT: 26.4, MD AWARE. HEPRAIN GTT INCREASED TO 1400 UNITS PER HOUR. +RADIAL,FEMORAL,POPITEAL,PT AND DP X2. COMPRESSION STOCKINGS ON.\n\nPULM: TACHED ON 50% HUMIDIFIED TRACH COLLAR. POX: 98-100%. RR: . LS: COARSE WITH OCC I/E WHEEZES. +STRONG PRODUCTIVE COUGH OF THICK BROWN SPUTUM. ENCOURAGED . SCHEDULED NEBS GIVEN.\n\nGI: TOLERATING TF'S AT GOAL WITH MINIMAL RESIDULAS. ABD:OPEN,DRESSING AND DRAINGES INTACT (SEE CAREVUE FOR FURTHER DETAILS). DENIES FLATUS AND NO BM PR.\n\nGU: FOLEY WITH QS . HUO: 80-300. MAG: 1.9 AND PHOS: 2.4, BOTH REPLETED.\n\nINTEG: SKIN WDI.\n\nENDO: FS QID. FS: 82-126.\n\nIVL'S: L-MULTI LUNEN SC-SITE WNL AND DRESSING CDI.\n\nID: LOW GRADE TEMPS. WBC: DOWN TO 19.9. CONTINUES ON LINZOLID, MEROPENEM AND CASPOFUNGIN.\n\nPSYCH/SOCIAL: MOTHER AND GRANDMOTHER IN TO VISIT AND UPDATED REGARDING POC.\n\nPLAN: MONITOR HEMODYNAMICS. TITRATE HEPARIN GTT FOR GOAL PTT OF 60-80. AGGRESSIVE PULM HYGIENE. TITRATE SUPPLEMENTAL OXYGEN AS TOLERATED. SURVAILLENCE LABS PRN. PAIN/ANXIETY MANAGEMENT. REPOSITION Q2 WITH AGGRESSIVE SKIN CARE. PROVIDE SUPPORTIVE CARE TO PTAND FAMILY. PLAN: BEDSIDE VS OR DRESSING CHANGE TODAY.\n"
},
{
"category": "ECG",
"chartdate": "2200-08-27 00:00:00.000",
"description": "Report",
"row_id": 134292,
"text": "Sinus tachycardia. Low QRS voltage in limb leads. Non-diagnostic\nrepolarization abnormalities. No previous tracing available for comparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2200-09-09 00:00:00.000",
"description": "Report",
"row_id": 134290,
"text": "Technically difficult study\nSinus tachycardia\nNormal ECG except for rate\nSince previous tracing of , heart rate faster, increased voltage\n\n"
},
{
"category": "ECG",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 134291,
"text": "Sinus rhythm. Low limb lead voltage. Compared to the prior tracing\nof the rate has slowed. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2200-10-02 00:00:00.000",
"description": "Report",
"row_id": 134248,
"text": "Sinus tachycardia. Diffuse non-specific ST-T wave changes. Compared to prior\ntracing ST-T wave changes are now present.\n\n"
}
] |
93,307 | 152,763 | The patient was brought to the operating room on where the patient underwent Aortic valve replacement with a size #23-mm St. tissue valve. Coronary artery bypass graft x 3: Left internal mammary artery to left anterior descending artery, and saphenous vein grafts to diagonal and obtuse marginal arteries. Endoscopic harvesting of the long saphenous vein. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. On she developed right sided upper extremity paralysis and right lower extremity weakness. A head CT was negative. Head MRI revealed mult. subacute watershed infarcts with possible ischemic and embolic origin. Neurology was consulted. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight.The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. US for RUE swelling was negative for DVT. She went into postoperative A Fib that initially converted to SR on amiodarone. POD#8 she had several episodes of paroxysmal afib and anticoagulation with Coumadin was started per Dr.. She was evaluated for speech and swallow. By the time of discharge on POD #8 the patient was ambulating with assist, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to rehab in , Ma. in good condition with appropriate follow up instructions. | There is no pericardial effusion.IMPRESSION: Small LV cavity size with hyperdynamic LV systolic function.Consequently the mitral valve and chordae are pulled towards the septum duringsystole and a moderate mid-cavitary gradient develops. Normal aortic arch diameter.Normal descending aorta diameter. There is a moderate resting left ventricular outflowtract obstruction. Normal ascending aorta diameter. Right ventricular chamber size and free wall motion arenormal. Moderate PA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. COMPARISON: non-contrast head CT. Moderate resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal descending aorta diameter.AORTIC VALVE: Aortic valve not well seen. There is mild symmetric left ventricularhypertrophy. swan-ganz catheter removed, but right IJ cordis remains in palce. There is moderate pulmonary artery systolichypertension. Mildto moderate (+) mitral regurgitation is seen. RIGHT UPPER EXTREMITY VENOUS ULTRASOUND COMPARISON: None. Minimal pulmonary edema. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Cannot exclude myocardial ischemia. Trivial mitral regurgitationis seen. bilateral chest tubes stable. Sinus rhythm with modest A-V conduction delay. Mild vascular engorgement is unchanged. Moderatemitral annular calcification. IMPRESSION: Post-CABG changes with no acute cardiopulmonary abnormality. Swan-Ganz catheter and bilateral chest tubes are in unchanged position. IMPRESSION: No DVT in the right upper extremity. Moderate pulmonary arterysystolic hypertension. Moderate (2+) aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. Normal hilar and mediastinal structures. The patient continues to be in minimal interstitial edema. somewhat improved left basilar aeration with residual atlectesls. Simple atheroma in descending aorta.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. IMPRESSION: Status post chest tube removal with no pneumothorax. Suboptimal image quality as the patient wasdifficult to position. Moderate cardiomegaly. vetricular size appears normal. Remaining vessels demonstrated normal flow, compressibility and augmentation. Cannot exclude myocardial ischemia or possiblehyperkalemia. Mild to moderate mitral regurgitation. Mild to moderate(+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Left lower lobe opacity is unchanged, most likely representing a combination of atelectasis and pleural effusion, but no appreciable increased since the prior study has been demonstrated. Trace aortic regurgitation is seen. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/globalsystolic function (LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Moderate (2+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild-to-moderate underlying atherosclerosis with no evidence of large vessel occlusion within the head or neck. Left ventricular function. Diffuse ST-T waveabnormalities. Normal regional LVsystolic function. Right ventricular function.Height: (in) 62Weight (lb): 209BSA (m2): 1.95 m2BP (mm Hg): 100/51HR (bpm): 91Status: InpatientDate/Time: at 11:03Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PATIENT/TEST INFORMATION:Indication: CABG, ASBP (mm Hg): 110/60HR (bpm): 72Status: InpatientDate/Time: at 15:47Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA. There may be minimal improvement of the left basilar opacification, with stable cardiomegaly. Mild atelectasis is in the left base. The cardiomediastinal and hilar silhouettes are stable. the neck MRA severely motion limited, but no definate filling defects or narrowing. FINAL REPORT INDICATION: Right upper extremity swelling. The left ventricular cavity is unusually small. Regional leftventricular wall motion is normal. The most superior aspect of the cervical internal carotid and vertebral arteries are not included on the study. Swan-Ganz catheter has been removed with a right IJ sheath in place. mild cardiomegaly, stable. During systole, thereis flow into the apical LV seen (due to obstruction). FINDINGS: As compared to the previous radiograph, the monitoring and support devices are in unchanged position. No atrial septal defect is seen by 2D or colorDoppler.There is mild symmetric left ventricular hypertrophy with normal cavity sizeand regional/global systolic function (LVEF>55%).Right ventricular chamber size and free wall motion are normal. Biatrial dilatation. The mediastinal and hilar contours are stable. PORTABLE CHEST RADIOGRAPH: A right-sided PICC line is in unchanged position. Significant aorticstenosis cannot be excluded due to increased LVOT velocities and poor shortaxis images. Consider inferior myocardialinfarction of indeterminate age, although is non-diagnostic. Anterior mediastinal wires appear intact. restricted diffusion in the left basal ganglia and possibly extending into the anterior limb of the internal capsule. The visible paranasal sinuses and mastoid air cells are well aerated. Mild to moderate[+] TR. A catheter or pacing wireis seen in the RA and extending into the RV.LEFT VENTRICLE: Mild symmetric LVH. MRA of the neck without contrast. Inferior wall myocardial infarction with ST-T wave configurationsuggesting acute process. The ventricles and sulci are normal in size and configuration. The right chest tube is in place. Regions of mild irregularity, particularly of the right M1 segments, likely reflects underlying atherosclerosis. Multiple anterior mediastinal wires appear intact. Thepatient appears to be in sinus rhythm. There is slight interval worsening of left lower lobe atelectasis. Chest tubes are stable with no evidence of pneumothorax. Mildly increasing retrocardiac atelectasis. Suboptimal image quality - bandages,defibrillator pads or electrodes. There is systolic anterior motion of the mitral valve leaflets. Clinical correlation issuggested. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Suboptimal image quality - body habitus.Conclusions:The left atrium is elongated. Trace AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. There are low lung volumes. There are low lung volumes. There is no appreciable interval increase in pleural effusion. TECHNIQUE: MDCT images were acquired through the head without contrast. Moderate irregularity of the proximal internal carotids, left greater than right, likely reflects underlying atherosclerosis. FINDINGS: Color and -scale son of bilateral subclavian vessels and right-sided internal jugular, axillary, cephalic, basilic and brachial vessels were performed. FINDINGS: No acute intracranial hemorrhage, large vascular territory infarct, shift of midline structures or mass effect is present. | 15 | [
{
"category": "Radiology",
"chartdate": "2107-06-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1189957,
"text": " 3:55 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with CABG/AVR\n REASON FOR THIS EXAMINATION:\n FAST TRACK EARLY EXTUBATION CARDIAC SURGERY\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CABG/AVR.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH, SUPINE: ETT ends approximately 5.5 cm above the\n carina. Multiple anterior mediastinal wires appear intact. A Swan-Ganz\n catheter tip terminates in the left pulmonary artery. A nasogastric tube tip\n is in the proximal stomach.\n\n A pleural catheter is noted overlying the right lower chest. Another chest\n catheter is seen overlying the left chest.\n\n There are low lung volumes. Bilateral atelectases are more prominent at the\n bases. There is no pleural effusion. The cardiomediastinal and hilar\n silhouettes are stable.\n\n IMPRESSION: Post-CABG changes with no acute cardiopulmonary abnormality.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190054,
"text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pleural effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: CABG, evaluation for pleural effusion.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. The tip of the Swan-Ganz catheter has been\n re-positioned. There is no evidence of pneumothorax. Mildly increasing\n retrocardiac atelectasis. Moderate cardiomegaly. Normal hilar and\n mediastinal structures. Minimal pulmonary edema. No focal parenchymal\n opacity suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190571,
"text": " 1:21 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG and chest tube removal.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: A right-sided PICC line is in unchanged position.\n Anterior mediastinal wires appear intact. Status post chest tube removal.\n\n There are low lung volumes. There is no pneumothorax. Mild atelectasis is in\n the left base. The cardiac size is enlarged, stable from prior study. The\n mediastinal and hilar contours are stable.\n\n IMPRESSION: Status post chest tube removal with no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190498,
"text": " 7:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG, to assess for change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Continued enlargement of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190318,
"text": " 8:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p cabg with dropping hct\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with CABG with dropping\n hematocrit.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The ET tube tip is relatively high, at the level of upper margins of the\n clavicular heads, 6.5 cm above the carina. Swan-Ganz catheter and bilateral\n chest tubes are in unchanged position. Left lower lobe opacity is unchanged,\n most likely representing a combination of atelectasis and pleural effusion,\n but no appreciable increased since the prior study has been demonstrated. No\n pneumothorax is seen. Mild vascular engorgement is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1190359,
"text": " 3:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for embolic event/ bleed\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p cabg with no right upper extremity movement\n REASON FOR THIS EXAMINATION:\n eval for embolic event/ bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman status post CABG with no right upper extremity\n movement. Evaluate for embolic event.\n\n COMPARISON: No relevant comparisons available.\n\n TECHNIQUE: MDCT images were acquired through the head without contrast. Bone\n kernel reconstructions and multiplanar reformations were obtained and\n reviewed. Motion degraded images were repeated, but the patient continued to\n move.\n\n FINDINGS:\n\n No acute intracranial hemorrhage, large vascular territory infarct, shift of\n midline structures or mass effect is present. The ventricles and sulci are\n normal in size and configuration. The visible paranasal sinuses and mastoid\n air cells are well aerated.\n\n IMPRESSION:\n\n No acute intracranial process.\n\n final attending comment: there is a subtle hypodensity in the left\n cerebellum.Recommend either follow up CT or MRI for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-12 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 1190445,
"text": " 1:22 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST\n Reason: NO RT EXT MOVEMENT POST CABG\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with no right upper extremity movement s/p cabg/avr\n REASON FOR THIS EXAMINATION:\n eval for embolic event\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw SUN 6:56 PM\n extensive relatively symmetric cortical subacute infarction involving\n bifrontal and bilateral parietal and occipital lobes in a predominately\n watershed distribution between the ACA/MCA and MCA/PCA territories\n respectively. deep white matter subacute infarcts in the right posterior\n centrum ovale. symmetric restricted foci of diffusion in the brainstem\n (402:14). findings all concerning for hypotensive infarction in the setting\n of recent CABG/bypass.\n\n restricted diffusion in the left basal ganglia and possibly extending into the\n anterior limb of the internal capsule. multifocal areas of subacute infarction\n in the left cerebellum. while the COW angiogram appears normal within the\n limits of this motion degraded study, these findings raise the possibility of\n embolic infarcts. the neck MRA severely motion limited, but no definate\n filling defects or narrowing.\n\n no areas of hemorrhage. vetricular size appears normal. extensive small\n periventricular white matter changes, likely due to hypertensive changes.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: MRI brain, MRA head without gadolinium. MRA of the neck without\n contrast.\n\n TECHNIQUE: Multiplanar, multisequence MRI of the brain was performed without\n gadolinium. Three dimensional time-of-flight MRA of the head was also\n performed without gadolinium. Multiplanar reformatted images were provided.\n Time-of-flight MRA of the neck was also performed including all but the most\n superior aspect of the neck\n\n REASON FOR THIS EXAMINATION: s/p cabg/avr eval for embolic event.\n\n COMPARISON: non-contrast head CT.\n\n FINDINGS:\n\n There are extensive subacute infarcts, predominantly in a watershed\n distribution, involving the cortex and peripheral white matter bilaterally\n between the ACA, MCA and PCA territories. In addition, there are subacute\n left cerebellar hemisphere infarcts which may relate to the AICA/PICA\n watershed. Underlying emboli are also possible. There is also some\n involvement of the more central matter, particularly the left caudate.\n (Over)\n\n 1:22 PM\n MR HEAD W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n MRA BRAIN W/O CONTRAST; MRA NECK W/O CONTRAST\n Reason: NO RT EXT MOVEMENT POST CABG\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is no hemorrhage. Edematous changes within the affected gyri create\n effacement of adjacent sulci. There is no evidence of hydrocephalus. There\n is no significant midline shift. There is mild mucosal reaction of the\n paranasal sinuses with fluid and secretions partially visualized in the\n pharynx. The patient is status post bilateral lens surgery.\n\n MRA HEAD:\n\n There is no evidence of large vessel occlusion. Regions of mild irregularity,\n particularly of the right M1 segments, likely reflects underlying\n atherosclerosis.\n\n MRA OF THE NECK:\n\n The time-of-flight MRA of the neck is somewhat limited by motion artifact.\n The vertebral, common and internal carotid arteries are patent over their\n visualized course. Moderate irregularity of the proximal internal carotids,\n left greater than right, likely reflects underlying atherosclerosis. The\n degree of luminal narrowing is difficult to quantify given motion artifact and\n other technical limitations. The most superior aspect of the cervical\n internal carotid and vertebral arteries are not included on the study.\n\n IMPRESSION:\n\n 1. Extensive bilateral predominantly cortical watershed infarcts, subacute,\n with no evidence of hemorrhage. There are likely underlying embolic infarcts\n as well, particularly within the left cerebellar hemisphere.\n\n 2. Mild-to-moderate underlying atherosclerosis with no evidence of large\n vessel occlusion within the head or neck. Degree of luminal narrowing of the\n proximal cervical internal carotid arteries is difficult to quantify secondary\n to motion and other artifacts. If warranted, ultrasound, CTA neck or\n contrast-enhanced MRA neck would better quantify the degree of luminal\n narrowing.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1190136,
"text": " 8:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p CABG w/droping HCT r/o effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/droping HCT r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after CABG with dropping\n hematocrit.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier.\n\n The ET tube tip is 5 cm above the carina. The Swan-Ganz catheter tip is at\n the level of the right ventricle outflow tract. The right chest tube is in\n place. There is no pneumothorax. There is no appreciable interval increase\n in pleural effusion. There is slight interval worsening of left lower lobe\n atelectasis. The patient continues to be in minimal interstitial edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-12 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1190466,
"text": " 4:57 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl picc 50cm iv \n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with picc\n REASON FOR THIS EXAMINATION:\n r dl picc 50cm iv \n ______________________________________________________________________________\n WET READ: JMGw SUN 5:24 PM\n right picc tip in the upper/mid SVC. swan-ganz catheter removed, but right IJ\n cordis remains in palce. bilateral chest tubes stable. ETT at level of\n clavicles 5.2cm from carina. somewhat improved left basilar aeration with\n residual atlectesls. mild cardiomegaly, stable. no ptx.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: PICC placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n right subclavian PICC line that extends to the upper portion of the SVC.\n Swan-Ganz catheter has been removed with a right IJ sheath in place. Chest\n tubes are stable with no evidence of pneumothorax. ET tube is at the level of\n the clavicles, approximately 5 cm above the carina. There may be minimal\n improvement of the left basilar opacification, with stable cardiomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-15 00:00:00.000",
"description": "UNILAT UP EXT VEINS US",
"row_id": 1190831,
"text": ", CSURG CSRU 10:57 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: eval for DVT\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with right upper extremity swelling\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT in the right upper extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-06-15 00:00:00.000",
"description": "UNILAT UP EXT VEINS US",
"row_id": 1190830,
"text": " 10:57 AM\n UNILAT UP EXT VEINS US Clip # \n Reason: eval for DVT\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT WITH AVR /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with right upper extremity swelling\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 4:00 PM\n PFI: No DVT in the right upper extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right upper extremity swelling. Evaluate for DVT.\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND\n\n COMPARISON: None.\n\n FINDINGS: Color and -scale son of bilateral subclavian vessels and\n right-sided internal jugular, axillary, cephalic, basilic and brachial vessels\n were performed. Symmetric waveforms were seen within the subclavian veins.\n Remaining vessels demonstrated normal flow, compressibility and augmentation.\n\n IMPRESSION: No DVT in the right upper extremity.\n\n"
},
{
"category": "Echo",
"chartdate": "2107-06-09 00:00:00.000",
"description": "Report",
"row_id": 91433,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Right ventricular function.\nHeight: (in) 62\nWeight (lb): 209\nBSA (m2): 1.95 m2\nBP (mm Hg): 100/51\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 11:03\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire\nis seen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. Moderate resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal descending aorta diameter.\n\nAORTIC VALVE: Aortic valve not well seen. Cannot exclude AS. Trace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Moderate\nmitral annular calcification. of mitral valve leaflets. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor subcostal views. Suboptimal image quality - bandages,\ndefibrillator pads or electrodes. Suboptimal image quality as the patient was\ndifficult to position. Suboptimal image quality - body habitus.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is unusually small. Regional left\nventricular wall motion is normal. Left ventricular systolic function is\nhyperdynamic (EF>75%). There is a moderate resting left ventricular outflow\ntract obstruction. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve is not well seen. The study is inadequate to exclude\nsignificant aortic valve stenosis. Trace aortic regurgitation is seen. The\nmitral valve leaflets are moderately thickened. There is no mitral valve\nprolapse. There is systolic anterior motion of the mitral valve leaflets. Mild\nto moderate (+) mitral regurgitation is seen. The tricuspid valve leaflets\nare mildly thickened. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Small LV cavity size with hyperdynamic LV systolic function.\nConsequently the mitral valve and chordae are pulled towards the septum during\nsystole and a moderate mid-cavitary gradient develops. During systole, there\nis flow into the apical LV seen (due to obstruction). Significant aortic\nstenosis cannot be excluded due to increased LVOT velocities and poor short\naxis images. Mild to moderate mitral regurgitation. Moderate pulmonary artery\nsystolic hypertension. Biatrial dilatation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2107-06-08 00:00:00.000",
"description": "Report",
"row_id": 91434,
"text": "PATIENT/TEST INFORMATION:\nIndication: CABG, AS\nBP (mm Hg): 110/60\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 15:47\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Normal aortic arch diameter.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS\n(area 0.8-1.0cm2). Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\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.\nThere is mild symmetric left ventricular hypertrophy with normal cavity size\nand regional/global systolic function (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal. There are\nsimple atheroma in the descending thoracic aorta. The aortic valve leaflets\nare severely thickened/deformed. There is severe aortic valve stenosis (valve\narea 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen. There is no pericardial effusion. Dr. was notified in person\nof the results on Mrs. before surgery incision.\n\nPOST_Bypass:\nPreserved biventricular systolic function.\nLVEF 55%.\nThe bioprosthesis in the aortic position is stable, functioning well with mean\ngradient < 10mm of Hg.\nIntact thoracic aorta.\nMinimal MR .\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-06-08 00:00:00.000",
"description": "Report",
"row_id": 258015,
"text": "Sinus rhythm. Inferior wall myocardial infarction with ST-T wave configuration\nsuggesting acute process. Right precordial lead ST-T wave changes with\nprominent/peaked T waves. Cannot exclude myocardial ischemia or possible\nhyperkalemia. Clinical correlation is suggested. Since the previous tracing of\nsame date further ST-T wave changes are now present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2107-06-08 00:00:00.000",
"description": "Report",
"row_id": 258016,
"text": "Sinus rhythm with modest A-V conduction delay. Consider inferior myocardial\ninfarction of indeterminate age, although is non-diagnostic. Diffuse ST-T wave\nabnormalities. Cannot exclude myocardial ischemia. Clinical correlation is\nsuggested. Since the previous tracing of the rate is faster, change in\ninferior lead QRS configuration raises the consideration of possible inferior\nmyocardial infarction, limb lead QRS voltage is less prominent and further\nST-T wave abnormalities are present.\nTRACING #1\n\n"
}
] |
19,373 | 121,302 | The patient was admitted intubated from an OSH. The patient required persistent ventilator support. His vent settings were changed for ARDS treatment, specifically pressure control with reduced tidal volumes (goal 450), reduced driving pressure (goal 14). The patient required high FiO2 (60%) to maintain his oxygen pressure. He was continued on high dose steroids. The patient's IV access from the outside hospital was removed and the patient underwent right IJ line placement as well A-Line placement. . The hospital course was complicated by a pneumothorax. It is unknown if the pneumothorax was due to prior trauma (the patient had a pneumothorax at the OSH prior to admission), a complication from central line placement or volu/ trauma from mechanical ventilation. The patient underwent chest tube placement with successful reduction of his pneumothorax. The patient had a persistent air leak from the right sided chest tube. The patient required large doses of sedation and continued to have dyssynchrony from the vent. The patient failed a trial of APRV. Ultimately the patient showed no improvements in his respiratory status. Upon dicussion with the family it became clear that the patient's wish was to never be ventilator dependent for any protracted period of time (by the family's account, the patient specifically stated a desire for no mechanical ventilation beyond 2 days). In accordance with the patient's stated wishes prior to intubation as well as the family's wishes, the patient was extubated on . He expired within 2 hours of extubation. . Of note, the patient had 1+ GNR on gram stain of his sputum and out of concern for a possible ventilator-associate pneumonia he was started on broad spectrum antibiotics. Ultimately sputum cultures grew only oropharyngeal flora. In addition, the patient grew coag negative staph - a likely contaminent - in 1 out of 4 bottles of blood from his A-line. | Intial abg 730/66/93 on 100% decreased to .8will continue support as ordered. Old R CT site w/dsd.Accompanied by 2sons and 1 dgt. New aline placed by md's.RESP: lungs coarse throughout. Not responding to commands.On 100% FiO2 he was placed on a/c 30 w/occ spont RR 3-5. updated on pt's condition & POC.A/P; Acceptable ABg's on present vent settings. R IJ placed and L SC dc'd. Nursing Note: 0700-1900 DNR/DNI, NKDANeuro: pt remains sedated versed gtt 15mg/hr, fentanyl gtt 300mcs/hr. Plan to recheck Plp and wean vent as tol. pos gag reflex, imparied cough reflex noted.Resp: remains intubated 8.0 ETT, PCV vent setting, set rate 30, set insp pressure 27, FI02 0.60, PEEP 12. MICU EAST NPN 0700-1900Please see flowsheet for further details...Initially arousable and nodding head appropriately on Fentanyl gtt at 100mcg/hr and Verse gtt at 5mg/hr. Pt tube retaped. Oral care done Q4 hrs.T-max 100.3 PO. Cont fent & versed gtts. On protonix and started on reglan. ABG 7.30 66 93 w/Oximeter 99%. Repeat K 4.5.On fent & versed gtts. Resp Care,Pt. Morning abg improved at 7.36/64/81GI/GU: abd soft, distended, obese, + bs, no bm. last sugar 315. Over breathing vent requiring IVB 2mg Ativan w/effect. Only changes made overnight were fio2 decreased and I time adjusted. Nursing Progress Note 1900-0800 hours:** Full code** allergy: nkda** access: left radial aline, right ij tlcIn brief: Pt tx'd here from Hosp. crepitus palpated unchanged from prior assessment.CV: HR 80-90 SR no ectopy, ABP 111-140/45-60. placed on ards net protocol weaned tidal vol. Updated by this RN and MDs. intubated #. SpO2 low 90s. Pt tolerating changes well with last ABG showing compensated respiratory acidosis and PaO2=81, Spo2=93%. CVP 7-10, tmax 100.3. some extremity edema noted, pos distal pulses.GU: foley intact, UO 100-130cc/hr clear yellow.GI: pos bowel sounds, abd soft, sm brown BM noted. Respiratory CarePt remains intubated with multiple vent changes made this shift. right sided chest tube remains intact to -20 suction, dressing D/I, minimal sanguanous drainage <10cc. Endotracheal tube terminates approximately 3.6 cm from the carina and there is stable appearance to right-sided central venous catheter and orogastric tube, whose distal tip is not visualized on current radiograph. IMPRESSION: AP chest compared to and 15: Residual right pneumothorax if any is minuscule, apical pleural tube in place. ETTube terminates in right mainstem bronchus. Right lung pneumothorax has essentially resolved, apical pleural tube still in place. IMPRESSION: Moderate right-sided pneumothorax with probable developing pneumomediastinum. Endotracheal tube terminates approximately 4 cm from the carina and there is stable position to right-sided internal jugular venous catheter. IMPRESSION: Interval removal of right subclavian central venous catheter. Fine reticular pattern throughout the lungs - can be seen with NSIP, UIP hypersensivity pneumonitis. Fine reticular pattern throughout the lungs - can be seen with NSIP, UIP hypersensivity pneumonitis. Additionally, there are linear lucencies projecting over the right upper mediastinum and left heart border which may represent a developing mild pneumomediastinum. Right pneumothorax if any is small, at the base of the right lung. CT ANGIOGRAM CHEST: An ETTube terminated in the right main stem bronchus. SUPINE PORTABLE CHEST RADIOGRAPH FINDINGS: There has been interval development of a moderate sized right-sided pneumothorax with grossly unchanged diffuse airspace opacities, likely progressed since examination of unclear etiology. Diffuse pulmonary findings bilaterally, of undetermined etiology. Right internal jugular central venous catheter remains with its tip in the SVC. HISTORY: Right pneumothorax. FINAL REPORT COMPARISON: AP semi-upright portable chest x-ray dated . ET tube, right internal jugular line are in standard placements respectively. Chest CT has been ordered. Pneumomediastinum and subcutaneous emphysema in the right chest wall and neck are stable. Grossly unchanged diffuse airspace opacities likely represents underlying chronic interstitial lung disease with superimposed edema, infection, or rapidly evolving alveolitis. IMPRESSION: Interval placement of right internal jugular central venous catheter. There is a right-sided subclavian line with its tip projected over the expected location of the distal SVC. crepitus palpated on right side up to neck.CV: HR 80-102 sinus rhythm, no ectopy. No AS.MITRAL VALVE: No MR.TRICUSPID VALVE: Mild [1+] TR. Also noted to have slight intermittent airleak this am from chest tube-level of 1. intermittent air leak noted, minimal <15cc sanguanous drainage noted. pupils 1mm/1mm reactive to light.Resp: remains intubated 8.0 ETT, PCV setting, set rate 30, insp pressure 27, Fio2 0.60, PEEP 12. sats 92-100. some vent dysynchrony noted. 1+ edema noted. Sats 89-94%GI/GU: abd soft, distended, + bs, tol tf's of nutren pulm at goal of 60cc/hr, minimal residuals. MDI's given as ordered, sx for minimal white thick. Moderatepulmonary hypertension.A technically limited study. Nsg.Notes 1900hrs-0700hrs.Admitted on with bilateral pneumonia,interstitial lung disease for ventillatory support.Events:Continued on PCV ventillation,high sedated.hourly blood sugar and on insulin infusion.Remained with stable vital signs during the shift.Neuro:sedated well,no response to call or painful stimuli, GCS 3.Pupils 1mm size and brisk reacting to light.positive gag reflex and negative cough reflex.Resp:On ventillator,PCV mode ,RR 30,Fio2 60%,PEEP 12.Suctioned small thick white secretions.Breath sounds coarse,dimished on base,Rt.ICD dressing dry and intact,no oozing noted.connected to low suction,slight air leak,draining very minimally.crepitus on right side neck presentCVS:HR 75-88/Min,NST,no cetopics present.BP 12-140/50-70 mm of Hg,peripheral pulse easily palpable,arterial line and CVP line in situ.GU/GI: Abdomen soft,bowel sounds present,on feed Nutren renal 30ml/hr increased as per protocol,and water300ml q4h,bowel not opened this shift.urine output adequate on foleys catheter,>100ml/hr,clear ,yellow urine.I/O adequateIntegu:Skin intact,on Triadyne bed on rotation q2h,all nursing care and sponge given.T max 100.1IV Access:Lt.radial artery and Rt:IJV,both site looks clean dressing intact.CVP site dessing changed,both lines patent and monitoring.Social:Family supported,Co-operative,,DNRPlan:Continue ventillation and present treatment,provide family support ,follow up sodium level and check for water whether to continue or not,monitor blood sugar and titrate insulin according to that.well sedate to control tachypoenia. Nursing Note: 0700-1900 NKDANeuro: pt remains heavily sedated versed drip 15mg/hr, fentanyl drip 300mcs/hr r/t vent synchrony. Valvular heart disease.Height: (in) 70Weight (lb): 260BSA (m2): 2.34 m2BP (mm Hg): 121/64HR (bpm): 93Status: InpatientDate/Time: at 15:54Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. | 41 | [
{
"category": "Nursing/other",
"chartdate": "2158-06-25 00:00:00.000",
"description": "Report",
"row_id": 1517964,
"text": "MICU EAST NPN 0700-1900\n\nPlease see flowsheet for further details...\n\nInitially arousable and nodding head appropriately on Fentanyl gtt at 100mcg/hr and Verse gtt at 5mg/hr. Denies uncomfortable breathing. Rarely overbreathing vent. With procedures and stimulations spont RR increased so sedation increased. Plan to maintain as more procedures planned for this eve.\n\nPCV weaned to 18 PEEP DP 20 RR 30 FiO2 55% TVs 400s-500s w/MV ~14L. O2 sats ~90% w/goal >88%. ABG pnd. Suctioned for mod amt thick white-clear sputum. Plan for Rotoprone bed tomorrow (ordered).\n\nT max 100.4 po. R IJ placed and L SC dc'd. Tip sent for culture and temp down to 99.4 this eve.\n\nUO adequate. Currently ~900cc neg since midnight. No stool. Colace given x1. TFs at 30cc/hr w/goal 60cc/hr. Tol well w/min residuals.\n\nChildren in most of day. Updated by this RN and MDs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-25 00:00:00.000",
"description": "Report",
"row_id": 1517965,
"text": "Respiratory Care\nPt recieved on pcv with dp of 28 able to wean driving pressure to 20, fio2 wean to 55. Pt had eso. balloon placed with difficulty, Ptpexp =5\nPtpinsp= 28.5, Deadspace = 30% . Pt had tube retaped. Pt more comfortable on vent. Plan to recheck Plp and wean vent as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-26 00:00:00.000",
"description": "Report",
"row_id": 1517966,
"text": "Resp Care\nPt remains intubated on PCV. I time shortened to .8 seconds and FiO2 weaned to 50%. Pt tolerating changes well with last ABG showing compensated respiratory acidosis and PaO2=81, Spo2=93%. Esphogeal balloon values obtained showing very similar results as previous numbers, please see pt chart for specific values. BS coarse and diminished bilaterally. Suctioned for scant thick clear/white secretions. Pt tube retaped. MDI's given as ordered. RSBI not completed due to PEEP >10. See CareVue for details and specifics.\nPlan: Pt to be place in prone positioning in \"Rotoprone\" bed this morning. Wean vent settings as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-26 00:00:00.000",
"description": "Report",
"row_id": 1517967,
"text": "Nursing Progress Note 1900-0800 hours:\n** Full code\n\n** allergy: nkda\n\n** access: left radial aline, right ij tlc\n\nIn brief: Pt tx'd here from Hosp. for management of on-going pulmonary failure, PNA, vent dependence and worsening interstitial lung dx.\n\nNEURO: pt is sedate on fent and versed gtts. Does not follow commands. Withdraws to pain. pearl at 2mm/brisk. +cough/gag. No spotaneous movements.\n\nCARDIAC: NSR-ST with occasional pvc's. HR 75-94. SBP 98-130/50-70. hct stable/threshold 21. New aline placed by md's.\n\nRESP: lungs coarse throughout. intubated #. Only changes made overnight were fio2 decreased and I time adjusted. Settings: 50%/tv 400-530/ rate 30/DP 20/p 18 with MY around 14. Bolused with fent/versed so RT could obtain esoph balloon numbers. Also bolused prior to turns and bath for ? discoordinance with vent. Scant to small thick yellow secretions via ett. Tube rotated & changed. Pt to be placed on rotoprone bed this am. MICU team decision to make this change on 'days' with more people available for assistance. Sats >88%. Placed on 100% prior to turning-tol well. right side with s/p old chest tube dsg site-c, d and intact-no crepitus; almost healed. Morning abg improved at 7.36/64/81\n\nGI/GU: abd soft, distended, obese, + bs, no bm. Nutren started after confirmation of tube by md-at 30cc/hr (goal of 60cc/hr) however, turned off at 4a due to plan for prone this am. Pt's FT is NOT post pyloric-will need to reassess this for proning purposes. On protonix and started on reglan. Foley with clear, yellow uop at 35-100cc/hr. Neg for LOS.\n\nENDO: fs q 6 hours with s.s. as ordered. last sugar 315. Had only received 1/2 dose of longer acting per dayshift to tf's being off.\n\nSKIN: s/p chest tube dressing c,d and intact. no other breakdown.\n\nID: t max 100.3 overnight. WBC 10.2 . Has already received course of abx-not on any right now-will consider if spikes and/or has infectious source.\n\nDISPO: -full code in micu\n -prone on rotoprone\n -abg's/vent changes as needed\n -cont med regimen and icu POC\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-26 00:00:00.000",
"description": "Report",
"row_id": 1517968,
"text": " 4 ICU NPN 0700-1900\nCont on PCV. ABG on 55%, PEEP 16, IP 36, VT 446-508- 97/62/7.33/34/3.\nPEEP decreased to 15. BS coarse. Minimal secretions. Sats currently running 91-92%. R chest tube placed for pneumothorax. Small amt bloody drainage noted from chest tube. Dsg D&I.Crepitus noted around chest tube insertion site. Intersn aware. Decision not to place pt on RotoProne bed. Cont on steroids. Oral care done Q4 hrs.\nT-max 100.3 PO. WBC 10.\nReceived lasix 20 mg this afternoon. Negative fld balance LOS 1330,negative approx 400 cc's since MN.\nTF advanced to 40 cc's hr via peditube. On reglan. Positive BS.\n SBP 118-120's. HR 70's to low 100's. cardiac echp done to assess wall, valve function. results pnd. Potasium 5.5. Received k-exelate 30 gms via NGT X1. No stool. Repeat K 4.5.\nOn fent & versed gtts. Sedation increased after receiving several 50 mcg boluses of fentanyl for increased workof breathing. Fent at 200 mcg hr & midaz & 7 mg hr with improvement in resp status. This AM pt able to nod & shake head to yes, no questions. Occas wiill follow simple commands. Sedated and not following commands at present.\nInsulin gtt started for persistent hyperglycemia. Gtt titrated to max of 10 units hr. Presently on 5 units hr. BS 160.\nSons & dtr in to visit throughout the day. updated on pt's condition & POC.\nA/P; Acceptable ABg's on present vent settings. Maintain sats >89%, VT ~450 cc's. Cont fent & versed gtts. Assess MS.\nAdvance Tf as tol to goal 60 cc hr.\nTitrate insulin gtt 100-150.\nSupport to family.\nFollow potassium\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-24 00:00:00.000",
"description": "Report",
"row_id": 1517960,
"text": "MICU EAST NSG ADMIT NOTE 1600-1900\n\n\nSEE FHPA/FLOWSHEET FOR FURTHER DETAILS..\n\n67 yo man, w/ h/o transferred from OSH vented on high settings w/interstitial lung disease s/p intitial admit for bilat pneumonia. Arrived w/Propofol gtt at 45mcgs/kg. Over breathing vent requiring IVB 2mg Ativan w/effect. Not responding to commands.\n\nOn 100% FiO2 he was placed on a/c 30 w/occ spont RR 3-5. TV 500 decreased to 400 d/t high PIPs and PEEP ^. ABG 7.30 66 93 w/Oximeter 99%. Plan to lower FiO2. Suct sm amt yellow sputum sent for C&S G/S.\n\nAfebrile on admit.\n\nR SC and R rad art line in place. Normotensive w/HR 60s NSR.\n\nSkin intact. Old R CT site w/dsd.\n\nAccompanied by 2sons and 1 dgt. Pt is a widow.\n\nPlan to follow ABGs and attempt to lower FiO2 as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-24 00:00:00.000",
"description": "Report",
"row_id": 1517961,
"text": "Respiratory care\nPt recieved from outside hospital Intubated with 8.0 et taped at 23cm\npt on a/c vent heated curcuit, measured to 71in. placed on ards net protocol weaned tidal vol. from 500 to 400cc rate increased from 12 to 30, peep from 12 to 15cm, pip on arrival 56 decreased to 37, plateu pressure from 52 to 32. Intial abg 730/66/93 on 100% decreased to .8\nwill continue support as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-25 00:00:00.000",
"description": "Report",
"row_id": 1517962,
"text": "MICU NPN\nNEURO: SEDATED WITH FENTANYL 100MCG/HR AND VERSED 5MG. IS EASILY AROUSABLE WHEN SEDATION IS LIGHTEN UP, OPENS EYES TO VOICE AND SHOOK HEAD YES/NO WHEN QUESTIONS WHEN ASK.\n\nRESP: RESP. THERAPIST ATTEMPTED TO PLACED ESOPHGEAL BALLOON WITH NO SUCCESS, PT. HAS SOME OLD BLOOD IN MOUTH DUE TO TRAUMA OF TRYING TO PLACE BALLOON. NUMEROUS VENT CHANGES MADE DURING THE NIGHT AS WELL AS BLOOD GASES PLEASE SEE CAREVUE FOR THIS INFORMATION, PRESENTLY VENT SETTINGS ARE AS FOLLOWS PCV WITH ASSIST, RATE OF 30, FIO2 60%, TV 440, PEEP OF 18. TEAM IS SATISFIED WITH SATS OF 88 AND ABOVE.\n\nCV: HR AND BP STABLE HAS ONE EPISODE OF HYPERTENSION WHEN SEDATION WAS CHANGED FROM PROPOFOL TO FENT/VERSED AN RECEIVED 500CC BOLUS OF NS AND RESPONF WELL. HAD CTA OF CHEST LAST NIGHT WHICH IS NEG. FOR PE.\n\nGI: NUTREN TUBE FEED STARTED AT 10CC/HR WITH GOAL OF 60CC/HR TOLERATING. NO BM.\n\nGU: FOLEY IN PLACE, U/O 50-200CC/HR YELLOW/PINK URINE WITH SEDIMENT.\n\nACCESS: #20G PIV WAS PLACED IN LEFT UPPER ARM FOR CT CONTRAST. RIGHT TRIPLE LUMEN CENTRAL CATH.\n\nSKIN: NEW DSG APPLIED TO OLD CHEST TUBE SITE, SITE CLEAN AND DRY NO DRAINAGE.\n\nSOCIAL: VERY SUPPORTIVE CHILDREN, UPDATED ON PT'S PLAN FOR LAST NIGHT, CONSENTS WERE SIGNED AND WILL BE IN TODAY.\n\nPLAN: CONTINUE WITH PRESENT PLAN, SUPPORT FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-25 00:00:00.000",
"description": "Report",
"row_id": 1517963,
"text": "Respiratory Care\nPt remains intubated with multiple vent changes made this shift. Different vent modes attempted including APRV, however pt did not tolerate with poor ABG, low pao2 and increased agitation (BP^). Pt then placed on PCV with Pinsp=46 and currently remains on those settings. ABG in PCV shows compensated respiratory acidosis with good oxygenation. FIO2 then weaned to 60% ABG pending on current O2 settings. SpO2=90%- team accepting Spo2 >88%. Esophogeal balloon attempted, however was unable to place. Pt to CT for chest scan and returned without incident. BS coarse and diminished at lung bases. Suctioning for scant thick white secretions. See CareVue for details and specifics.\nPlan: Wean O2, PEEP and pressure control settings as tolerated. ? esoph. balloon attempt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-29 00:00:00.000",
"description": "Report",
"row_id": 1517982,
"text": "Nursing Note: 0700-1900 DNR/DNI, NKDA\n\nNeuro: pt remains sedated versed gtt 15mg/hr, fentanyl gtt 300mcs/hr. no purposeful movements noted, pupils 1mm/1mm brisk, no grimacing noted. pos gag reflex, imparied cough reflex noted.\n\nResp: remains intubated 8.0 ETT, PCV vent setting, set rate 30, set insp pressure 27, FI02 0.60, PEEP 12. RR 30-34. sats 90-95. no vent changes made today. LS coarse upper, diminished lower, sm thick tan suctioned, no further ABGs to be ordered unless adverse resp changes noted. right sided chest tube remains intact to -20 suction, dressing D/I, minimal sanguanous drainage <10cc. crepitus palpated unchanged from prior assessment.\n\nCV: HR 80-90 SR no ectopy, ABP 111-140/45-60. CVP 7-10, tmax 100.3. some extremity edema noted, pos distal pulses.\n\nGU: foley intact, UO 100-130cc/hr clear yellow.\n\nGI: pos bowel sounds, abd soft, sm brown BM noted. nutren renal @ goal of 40/hr via doboff tube.\n\nEndo: insulin drip continues, hourly blood glucose checks, see careview.\n\nIV: right IJ TLC remains intact, left radial aline remains intact.\n\nID: WBC 9.4, cont vanco and zosyn. blood cultures drawn r/t ?line infection, sputum cult sent.\n\nSkin: no active skin breakdown noted, pt turned and fully bathed today. pt on 40 degree side to side rotation therapy.\n\nSocial: pts son expressed that they wish to pursue CMO status and possible withdrawl from vent tomorrow. social worker aware and has notified clergy, team made aware and in contact with family. referral made to NE organ bank today and they will conduct chart review and speak with family if potential donor. pt had several other family members visit today, family updated on POC.\n\nPlan:\n- continue to monitor level of sedation and possible pain for proper comfort and pain relief.\n- cont to monitor resp status, vitals.\n- cont hourly fingersticks r/t insulin gtt.\n- cont to provide emotional support to family and provide updates as appropriate.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-29 00:00:00.000",
"description": "Report",
"row_id": 1517983,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. No vent changes made this shift. Continues on PCV w/ Pinsp = 27 PEEP +12, driving pressure = 15. Suctioned for small amount of thick tan secretions, spec sent to lab for culture/gram stain. SpO2 low 90s. Vt ~400, occasionally triggers vent up to rate ~34. MDI given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-29 00:00:00.000",
"description": "Report",
"row_id": 1517984,
"text": "Respiratory Therapy addendum\n\nPt extubated to CMO at 1840. Family at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-29 00:00:00.000",
"description": "Report",
"row_id": 1517985,
"text": "Nursing Note:\n\npts family arrived this PM and verbalized that they wished to make pt tonight and not wait until tomorrow. medical team made aware and clergy visited at family request for sacrament of sick. MD feedings held, holding all PO meds, stopped insulin drip, and presently continuing versed and fentanyl drips, titrated to ensure pt comfort, no grimacing or increase in vitals noted. continuing to provide emotion support to family, assessment ongoing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-28 00:00:00.000",
"description": "Report",
"row_id": 1517976,
"text": "Resp Care,\nPt. remains intubated and sedated overnoc on PCV. Fio2 increased to 60% this shift, ABG acceptable. Suctioned no sputum. MDI's as ordered. RSBI not done due to peep level. Maintain current vent settings, see carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-28 00:00:00.000",
"description": "Report",
"row_id": 1517977,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Continues on PCV w/ Pinsp = 27 PEEP +12, driving pressure = 15cm. Briefly trialed on APRV w/ settings per resp flowsheet, but ABG 7.29/80; switched back to PCV. ABG slightly improved. SpO2 90s. MAP = 18. Rarely overbreathing vent rate of 30. No secretions. MDIs given as ordered. See resp flowsheet for specifics.\n\nPlan: maintain support\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961240,
"text": " 7:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for ET tube placement\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with R PTX s/p CT placement, now moved from bed to bed\n\n REASON FOR THIS EXAMINATION:\n assess for ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest x-ray portable AP.\n\n INDICATION: 67-year-old male with a history right pneumothorax status post\n chest tube placement. Assess for ET tube placement.\n\n COMPARISONS: at 6:50 a.m.\n\n FINDINGS: An endotracheal tube remains in good position approximately 4-5 cm\n above the carina. No pneumothorax is present. Subcutaneous emphysema in the\n right neck, thoracoabdominal wall and pneumomediastinum are slightly increased\n compared to the previous examination. Diffuse interstitial pulmonary\n abnormality is again present and chronic in appearance. No pleural effusion.\n\n IMPRESSION: Endotracheal tube in good position. Increasing subcutaneous\n emphysema, particularly within the soft tissues of the left neck compared to\n , examination from 12 hours prior. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 960923,
"text": " 5:31 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Check for Right IJ line placement following removal of right\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, intubated.\n\n REASON FOR THIS EXAMINATION:\n Check for Right IJ line placement following removal of right subclavian\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia. Line placement.\n\n Single portable radiograph of the chest demonstrates interval removal of the\n right subclavian central venous catheters seen on chest radiograph obtained\n earlier the same day. Right internal jugular central venous catheter remains\n with its tip in the SVC. The remaining support lines are unchanged. The\n nasogastric tube courses off the inferior aspect of the imaged field of view.\n Again seen is increased airspace opacities superimposed on an abnormal\n interstitial pattern. Cardiomediastinal contours are unchanged. Trachea is\n midline. No effusion is identified. No consolidation is evident.\n\n IMPRESSION:\n\n Interval removal of right subclavian central venous catheter. No\n pneumothorax.\n\n Increased airspace opacities superimposed on an abnormal interstitial pattern.\n Diagnostic considerations include pulmonary edema in the setting of\n interstitial disease. Pneumonia is not excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960990,
"text": " 11:03 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate change in R Pneumothorax\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, intubated. High driving pressures, ARDS,\n h/o R sided PTX that resolved ().\n REASON FOR THIS EXAMINATION:\n evaluate change in R Pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Reevaluation of right-sided pneumothorax, probable ARDS, prior\n biopsies noting acute interstitial pneumonitis.\n\n Comparison is made to most recent radiograph dated .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH:\n\n FINDINGS: Moderate right-sided pneumothorax persists, evaluation for change\n in size is limited due to supine technique on most recent film, but this\n could potentially be enlarging. Additionally, there are linear lucencies\n projecting over the right upper mediastinum and left heart border which may\n represent a developing mild pneumomediastinum. Endotracheal tube terminates\n approximately 5 cm from the carina and tip of Dobbhoff feeding tube most\n likely just past the GE junction. Diffuse parenchymal disease is not\n significantly changed.\n\n IMPRESSION:\n\n Moderate right-sided pneumothorax with probable developing pneumomediastinum.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961110,
"text": " 6:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u interstitial lung dx status, s/p chest tube for PTX\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with\n REASON FOR THIS EXAMINATION:\n f/u interstitial lung dx status, s/p chest tube for PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:30 A.M., \n\n HISTORY: Interstitial lung disease. Chest tube for pneumothorax.\n\n IMPRESSION: AP chest compared to through 14:\n\n There is no appreciable right pneumothorax, apical pleural tube in place.\n Subcutaneous emphysema in the right neck and thoracoabdominal wall and\n pneumomediastinum are increasing, which may reflect chest tube dysfunction.\n Clinical assessment recommended. Diffuse interstitial pulmonary abnormality\n is chronic. Heart size normal. No appreciable pleural effusion. ET tube,\n right internal jugular line are in standard placements respectively. Feeding\n tube passes into the stomach and out of view.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961273,
"text": " 5:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with R PTX s/p CT placement\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 3:59 A.M. ON .\n\n HISTORY: Right pneumothorax. Assess chest tube placement.\n\n IMPRESSION: AP chest compared to and 15:\n\n Residual right pneumothorax if any is minuscule, apical pleural tube in place.\n No appreciable right pleural effusion. Pneumomediastinum and subcutaneous\n emphysema in the right chest wall and neck are stable. Mediastinal vascular\n engorgement has progressed since , suggesting that there may be a\n component of acute pulmonary edema as well as diffuse interstitial pulmonary\n abnormality. Right jugular line tip projects over the lateral aspect of the\n mediastinum and could be in a small vein such as the right internal mammary\n since it lies lateral to a right subclavian line that was present on \n and more conclusively in the SVC. Tip of the endotracheal tube, with the chin\n not flexed, is as close as 2 cm to the carina, 1-2 cm below optimal placement.\n Feeding tube ends in the upper stomach. Dr. was paged to report\n these findings at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960819,
"text": " 4:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ET tube placement\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, intubated.\n REASON FOR THIS EXAMINATION:\n assess for ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Pneumonia.\n\n A single AP view of the chest is obtained at 15:16 hours. No prior\n films are available for comparison. The patient is intubated with the tip of\n the ET tube approximately 4.8 cm above the carina. There is a right-sided\n subclavian line with its tip projected over the expected location of the\n distal SVC. There is a diffuse increase in the interstitial markings\n bilaterally with some patchy diffuse airspace opacities. No large pleural\n effusions are identified. There is no evidence of pneumothorax. Nasogastric\n tube is present with its tip just in the gastric fundus.\n\n IMPRESSION:\n\n No prior films. Diffuse pulmonary findings bilaterally, of undetermined\n etiology. Findings may represent pulmonary edema or diffuse infection. Chest\n CT has been ordered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961008,
"text": " 12:51 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess interval change\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with R PTX s/p CT placement\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:50 A.M. \n\n HISTORY: 60-year-old man with pneumothorax after chest tube placement.\n\n IMPRESSION: AP chest compared to through 14 at 10:17 a.m.:\n\n Right lung apex is excluded from the examination. Right lung pneumothorax has\n essentially resolved, apical pleural tube still in place. Diffuse\n infiltrative pulmonary abnormality has worsened to the point of confluence\n since consistent with component of pulmonary edema. ET tube,\n nasogastric tube, right supraclavicular line are in standard placements. Right\n pneumothorax if any is small, at the base of the right lung. The heart is top\n normal size. The mediastinal veins are markedly dilated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960860,
"text": " 5:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, intubated.\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia.\n\n Single portable radiograph of the chest again demonstrates the right\n subclavian central venous catheter with its tip in the SVC. Again seen is a\n diffuse increased airspace opacity involving both lungs. The right\n costophrenic ankle is excluded. There may be mild interval improvement of\n right mid lung opacity when compared with . No effusion is seen.\n Tracheostomy tube is present with its tip located 3 cm above the level of the\n carina. A superimposed linear interstitial abnormality is better assessed on\n recent CT examination.\n\n IMPRESSION:\n\n Support lines in place.\n\n Abnormal linear interstitial pattern with superimposed airspace opacity\n involving the bilateral lungs diffusely. Diagnostic considerations include\n pulmonary edema in the setting of interstitial disease. Pneumonia is not\n entirely excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961452,
"text": " 6:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with acute interstitial pneumonia, intubated, now with R PTX\n s/p CT placement\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old man with pathologically diagnosed acute interstitial\n pneumonia status post spontaneous _____ barotrauma, right-sided pneumothorax.\n Assess for interval change.\n\n Comparison is made to most recent radiograph dated .\n\n SEMI-UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n No residual right-sided pneumothorax is identified and there is unchanged\n appearance to diffuse parenchymal opacities consistent with AIP. Endotracheal\n tube terminates approximately 3.6 cm from the carina and there is stable\n appearance to right-sided central venous catheter and orogastric tube, whose\n distal tip is not visualized on current radiograph. No evidence of\n superimposed pneumonia or frank pulmonary edema and subcutaneous emphysema has\n decreased in the interval.\n\n IMPRESSION:\n Unchanged findings of AIP without residual pneumothorax. Decreased\n subcutaneous emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 960907,
"text": " 1:58 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: assess for line placement\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, intubated.\n\n REASON FOR THIS EXAMINATION:\n assess for line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia. Intubated.\n\n Single portable radiograph of the chest demonstrates interval placement of a\n right internal jugular central venous catheter. Catheter tip is in the SVC.\n No pneumothorax. The remaining support lines are unchanged. The distal\n nasogastric tube courses off the inferior aspect of the imaged field of view.\n Increased opacities involving the bilateral lungs again represents an abnormal\n interstitial pattern with superimposed airspace opacities. Lung volumes are\n normal. Trachea is midline.\n\n IMPRESSION:\n\n Interval placement of right internal jugular central venous catheter.\n Catheter tip is in the SVC. No pneumothorax.\n\n Abnormal interstitial pattern with superimposed airspace opacities. The\n findings represent pulmonary edema in the setting of interstitial disease.\n Finding is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-24 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 960831,
"text": " 7:28 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for underlying and changing chronic vs acute idiopa\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with distant prior history of smoking, who presented with\n suddenly worsening DOE, found to have patchy b/l pulmonary opacities, that\n slightly improved with ABX, now with ventilator dependence, and peristent\n hypoxia/ARDS\n REASON FOR THIS EXAMINATION:\n evaluate for underlying and changing chronic vs acute idiopathic pulmonary\n disease with HIGH RESOLUTION and RECONSTRUCTIONS, also perform contrast CTA to\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn SUN 5:09 AM\n 1. No PE.\n 2. Fine reticular pattern throughout the lungs - can be seen with NSIP, UIP\n hypersensivity pneumonitis. Diffuse GGO has a broad differential including\n pulmonary edema and infection.\n 3. Mild paraseptal emphysema.\n WET READ VERSION #1 MMBn SUN 12:06 AM\n 1. No PE.\n 2. Fine reticular pattern throughout the lungs - can be seen with NSIP, UIP\n hypersensivity pneumonitis. Diffuse GGO has a broad differential including\n pulmonary edema and infection.\n 3. Mild paraseptal emphysema.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: AP semi-upright portable chest x-ray dated .\n\n TECHNIQUE: MDCT imaging of the chest was performed following the\n administration of 90 cc of intravenous Optiray. Coronal and sagittal\n reformatted images were obtained.\n\n CT ANGIOGRAM CHEST: An ETTube terminated in the right main stem bronchus.\n There are no filling defects within the pulmonary artery, proximal, or distal\n branches to suggest the presence of a pulmonary embolism. The heart,\n pericardium, and great vessels are normal in appearance. There is no pleural\n or pericardial effusion. Scattered mediastinal lymph nodes are not\n pathologically enlarged. The largest prevascular lymph node measures 7 mm in\n short-axis diameter. Bilateral hilar lymph nodes measure up to 10 mm on the\n right and 12 mm on the left. On lung windows, paraseptal emphysema in both\n lung apices is consistent with patient's history of smoking. There is a\n diffuse, coarse reticular pattern throughout the lung with mild tractional\n bronchiectasis. Underlying ground-glass opacities are also seen diffusely\n within the lungs. The airways are patent to the level of the subsegmental\n bronchi bilaterally.\n\n Limited imaging of the upper abdomen is not sufficient for diagnosis. Other\n than a small calcified gallstone in the gallbladder fundus, the upper abdomen\n (Over)\n\n 7:28 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for underlying and changing chronic vs acute idiopa\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is unremarkable.\n\n There are no lesions concerning for malignancy within the imaged bones.\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n\n 2. ETTube terminates in right mainstem bronchus.\n\n 3. Fine reticular pattern diffusely within the lungs with tractional\n bronchiectasis and ground-glass opacity. The differential diagnosis for this\n appearance is borad, but includes NSIP, UIP, hypersensitivity pneumonitis or\n sarcoid. Ground- glass opacities have a broad differential, including\n pulmonary edema and infection.\n\n 4. Mild paraseptal emphysema in bilateral lung apices consistent with\n patient's history of smoking.\n\n 5. Gallstone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960947,
"text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, intubated.\n\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: 67-year-old man with probable pneumonia, intubated, assess for\n interval change.\n\n Comparison made to prior radiographs dating back to and\n prior CTA chest dated .\n\n SUPINE PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n\n There has been interval development of a moderate sized right-sided\n pneumothorax with grossly unchanged diffuse airspace opacities, likely\n progressed since examination of unclear etiology. Endotracheal\n tube terminates approximately 4 cm from the carina and there is stable\n position to right-sided internal jugular venous catheter. Mild atelectasis at\n the right base maybe slightly increased.\n\n IMPRESSION:\n\n 1. New moderate sized right-sided pneumothorax.\n\n 2. Grossly unchanged diffuse airspace opacities likely represents underlying\n chronic interstitial lung disease with superimposed edema, infection, or\n rapidly evolving alveolitis.\n\n D/W Dr. at approximately 10:00 a.m..\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-06-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960930,
"text": " 7:44 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? position of feeding tube\n Admitting Diagnosis: INTERSTITIAL LUNG DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pneumonia, intubated.\n\n REASON FOR THIS EXAMINATION:\n ? position of feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia.\n\n Single portable radiograph of the epigastrium demonstrates the distal aspect\n of the feeding tube. Feeding tube tip is at the level of GE junction.\n Feeding tube should be advanced. Assessment of the cardiomediastinal contours\n and the pulmonary parenchyma is limited by respiratory motion. Endotracheal\n tube and right internal jugular central venous catheter tips remain similar in\n appearance to that seen on the chest radiograph obtained earlier the same day.\n\n IMPRESSION:\n\n Feeding tube with its tip at the level of the GE junction. The feeding tube\n should be advanced.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-28 00:00:00.000",
"description": "Report",
"row_id": 1517978,
"text": "Nursing Note: 0700-1900 NKDA\n\nNeuro: pt remains heavily sedated versed drip 15mg/hr, fentanyl drip 300mcs/hr r/t vent synchrony. no purposeful movement noted, no grimacing. pupils 1mm/1mm reactive to light.\n\nResp: remains intubated 8.0 ETT, PCV setting, set rate 30, insp pressure 27, Fio2 0.60, PEEP 12. sats 92-100. some vent dysynchrony noted. LS coarse upper, diminished lower. APRV trial done this AM, ABG on APRV 7.29/80/80/7, switched back to PCV. last ABG since back on PCV = 7.31/74/74/6. minimal secretions, via RRT. chest tube remains intact, suction= -20. dressing D/I. intermittent air leak noted, minimal <15cc sanguanous drainage noted. crepitus palpated on right side up to neck.\n\nCV: HR 80-102 sinus rhythm, no ectopy. ABP 100-125/40-50, MAP 60-75. temp 99.5-100.6. 650mg tylenol po given. pos distal pulses.\n\nGU/Endo: foley cath remains intact, UO >100cc/hr clear yellow. inuslin drip running presently @ 10 units/hr, titrating as neccesary.\n\nGI: tube feeding changed to nutren renal and restarted r/t increased mg level. TF currently @ 10/hr via doboff tube. pos bowel sounds, abdomen soft. no BM. senna and colace given PO, bisacodyl supp given.\n\nSkin: pt turned and washed at 1500, skin appeared to be D/I, no active breakdown noted. pt on triadyne bed on rotation therapy (40 degrees side to side) tolerating well.\n\nIV: r IJ TLC intact, left radial aline intact and working well.\n\nSocial: family meeting held today with pts two sons, medical team, social worker, RN. pts sons verbalized that pt. stated prior to intubation that he would not want mechanical ventilation for more than a few days. pt made DNR/DNI during meeting (orders being placed at present), and tentative plan for withdrawl of vent support and CMO status when other family has had abilty to visit.\n\nPlan:\ncontinue to monitor pts resp status, vitals, labs (Na Level)\n\ncontinue to provide emotional support and updates on POC to pts family.\n\ncontinue to monitor for potential for pain and adequate sedation level.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-28 00:00:00.000",
"description": "Report",
"row_id": 1517979,
"text": "correction: chest tube on right side\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-29 00:00:00.000",
"description": "Report",
"row_id": 1517980,
"text": "Nsg.Notes 1900hrs-0700hrs.\nAdmitted on with bilateral pneumonia,interstitial lung disease for ventillatory support.\n\nEvents:Continued on PCV ventillation,high sedated.hourly blood sugar and on insulin infusion.Remained with stable vital signs during the shift.\n\nNeuro:sedated well,no response to call or painful stimuli, GCS 3.Pupils 1mm size and brisk reacting to light.positive gag reflex and negative cough reflex.\n\nResp:On ventillator,PCV mode ,RR 30,Fio2 60%,PEEP 12.Suctioned small thick white secretions.Breath sounds coarse,dimished on base,Rt.ICD dressing dry and intact,no oozing noted.connected to low suction,slight air leak,draining very minimally.crepitus on right side neck present\n\nCVS:HR 75-88/Min,NST,no cetopics present.BP 12-140/50-70 mm of Hg,peripheral pulse easily palpable,arterial line and CVP line in situ.\n\nGU/GI: Abdomen soft,bowel sounds present,on feed Nutren renal 30ml/hr increased as per protocol,and water300ml q4h,bowel not opened this shift.urine output adequate on foleys catheter,>100ml/hr,clear ,yellow urine.I/O adequate\n\nIntegu:Skin intact,on Triadyne bed on rotation q2h,all nursing care and sponge given.T max 100.1\n\nIV Access:Lt.radial artery and Rt:IJV,both site looks clean dressing intact.CVP site dessing changed,both lines patent and monitoring.\n\nSocial:Family supported,Co-operative,,DNR\n\nPlan:Continue ventillation and present treatment,provide family support ,follow up sodium level and check for water whether to continue or not,monitor blood sugar and titrate insulin according to that.well sedate to control tachypoenia.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-29 00:00:00.000",
"description": "Report",
"row_id": 1517981,
"text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support of PCV. No vent changes overnight. BS vesicular W occasional crackles. Sx for scant to no secretions. ABG reveals partially compensated respiratory acidosis. No RSBI D/T peep of 12 and FiO2 .6. Please see carevue for specifics. Plan: family meeting today. Continue ventilatory support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-26 00:00:00.000",
"description": "Report",
"row_id": 1517969,
"text": "Respiratory Care\nPt remains intubated weaned on peep from 18cm to 15 throughout the day., Fio2 remains at 50%. Pt did not have eso. balloon measurements done due to chest tube insertion for pneumo. RUL . Pt had sedation issues overbreathing the vent after tube placement, increased sedation. Plan to obtain balloon readings in early pm. Will continue to wean Ip and fio2 as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-27 00:00:00.000",
"description": "Report",
"row_id": 1517970,
"text": "Nursing Progress Note 1900-0700 hours:\n** full code\n\n** allergy: nkda\n\n** access: left rad aline, right ij tlc\n\nIn brief: Pt tx'd here from Hosp. for management of on-going pulmonary failure, PNA, vent dependence and worseing interstitial lung dx.\n\nNEURO: Pt sedate on fent and versed gtts; both increased overnight due to ? discoordinance with vent although appearing sedate otherwise. No following of commands, no spot movement, not withdrawing to painful stimuli. md did not want pt to be overbreathing vent more than 1 or 2 breaths. pearl at 2mm/brisk. Impaired cough and gag iwth ^ sedation.\n\nCARDIAC: NSR-ST with rare pvc's, HR 66-93. SBP 100-130/48-64. CVP 7-14. Free water order for ^ sodium-am lab pending.\n\nRESP: intubated with settings: 45%/pc with rate 30/ tv range 380-530/ p 14, minute volumes of . Weaned this shift from 50% fio2 to 45% and peep of 15 to peep of 14-also increased DP. Lungs with some rhonchi-clear upper lobes. Chest tube in place with no crepitus, no leak; dsg changed-site wnl. RT did esop balloon numbers. ^ sedatives to facilitate better coordination w/ vent. Mult abg's-see carevue. Last abg 7.29/84/76. No episodes of acute desatting; tol turns with 100% o2 suction given. Minimal secretions. Sats 89-94%\n\nGI/GU: abd soft, distended, + bs, tol tf's of nutren pulm at goal of 60cc/hr, minimal residuals. On protonix and reglan. Foley with clear light yellow UOP at 35-475cc/hr (responded well to 40mg lasix. Currently neg 1400 for LOS, + 165 since midnight.\n\nENDO: on continuous insulin gtt-mor controlled.\n\nSKIN: new and old chest tube dressing sites on right chest. old site almost healed, new sight WNL. No other issue.\n\nID: t max 99.8. Had previously finished course of abx-will start again if spikes or new cx data.\n\npsychosocial: family in to visit on evenings-updated and support given. Will be back today.\n\nDISPO: -full code\n -cont with interventions necessary to support/correct\n interstitial lung dx.\n -sedate as appropriate to facilitate ventilation/oxygenation\n -cont med regimen and icu supportive care\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-27 00:00:00.000",
"description": "Report",
"row_id": 1517971,
"text": "Resp Care,\nPt. remains intubated and sedated on PCV overnoc. Fio2 weaned to 45% and peep decreased to 14 this shift, acceptable oxygenation. Worsening acidosis, DP increased to 24 this shift, VT remains high 400's. One episode of decreasing VT, suctioned and lavarged for small amount pale yellow sputum, VT increased. Vd/Vt 31%. RSBI not done due to peep 14cm. Cont. to wean Fio2 as tol. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-27 00:00:00.000",
"description": "Report",
"row_id": 1517972,
"text": "Nursing Note addendum:\nAm labs resulted-sodium level still high (in fact, unchanged) since yesterday despite addition of free water?? Also noted to have slight intermittent airleak this am from chest tube-level of 1.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-27 00:00:00.000",
"description": "Report",
"row_id": 1517973,
"text": "NPN 0700-1900\nEvents:\nRemains on PCV, attempting to decrease driving pressures d/t leak noted w/chest tube allowing for permissive hypercapnia, oyxgenation status tenuous.\n\nMoved to triadyne bed d/t sedation and oxygenation requirement needed for position changes and reddend coccyx.\n\nSons, and visited today, state that Mr. would not want to live with a tracheostomy and had only agreed to intubation for 2-3 days, family meeting arranged with Social Worker, .\n\nTemp spike to 100.1 PO, bld, urine, sputum cxs sent.\n\nNeuro: Remains heavily sedated on fentanyl 250mcg/hr and versed 10mg/hr. Does not respond to painful stim, no spontaneuous movement and had not overbreathed vent until this afternoon. Pupils pinpoint and briskly reactive to light. Haldol added to sedation regime to try to prevent increase in fent or versed, now 10mg PO TID. QTc .43-.45\nFebrile as above.\n\nResp: Multiple vent setting done to try to decrease driving pressures to allow for permissive hypercapnia, had not breathed over vent until noted spiking temp and now drop in O2 sats to 88%, bolused w/5mg versed x 2 and fentanyl 150mcg to stop overbreathing w/hope that O2 sats will increase. Tylenol for fever administered. Also moved patient to Triadyne bed by noon and noted lower tidal volumes w/right lung down, however better O2 sats w/right lung down. Rotation has been 40degree turn to right with zero hold time and centered for 2minutes then left turn 40degrees with 2minute hold. Rotation has been placed on hold @ 1800 w/drop in O2 sats to 87%, lavaged and suctioned w/scant amt return.\n\nCV: b/p 95-110/40-50s w/MAPs in 60s, with rotation there is variation in b/p, NBP taken to verify pressures. HR 60s this morning but as temp mounting noted increase in HR to 90s SR, no VEA noted. 1+ edema noted. f/b today +200 thus far.\n\nGI: ABD soft, BS+, appears to tolerate tube feeds @ goal 60cc/hr, continues w/free water boli via OGT as ordered for hypernatremia, waiting for 1630 Na+ results. No BM this shift. Cont on reglan.\n\nGU: foley patent, clr yellow urine in adequate amts. Urine lytes and cx sent.\n\nSocial: as above, sons expressing concerns that father would not want to be intubated prolonged period of time and not get a tracheostomy tube. Social services consulted to assist sons w/coping/decision making and family meeting arranged for tomorrow 1300. Discussed w/team who will inform Dr. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-27 00:00:00.000",
"description": "Report",
"row_id": 1517974,
"text": "Resp Care\nPt remains sedated, intubated, on PCV. Tol PCV well, able to wean D-Press, following abg's. Esophageal Balloon done, pts optimal peep is 12 @ this time. MDI's given as ordered, sx for minimal white thick. Plan to continue to wean vent as tol, maintain sedation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2158-06-28 00:00:00.000",
"description": "Report",
"row_id": 1517975,
"text": "Nsg.notes 1900hrs-0700hrs\n\n67yo admitted with H/o bilateral Pneumonia,Interstitial lung disease,transfered from for ventillation and further treatment due to hypoxia and ongoing respiratory failure.\n\nEvents:Continued on ventillator,with high sedation to maitain RR 32-35/Min as per resident,on infusion fentanyl and versed but received multiple bolus dose of Inj.Fentanyl and Inj.Versed for RR > 36/Min ( see care vue for more details)Titrated sedation according to RR and BP.Added inj.Halodol 5mg iv q4h.Spo2 89-92%Blood sugar monitored hourly ,on insulin drip,started on Inj.Vanco 1gm q12hrs and Inj.Piperacillin-Tazobactom 4.5gm stat and q6h for bacterial growth in sputum c/s\n\nNeuro:Well sedated,not responding to call or pain,pupils 1mm size and reacting to light.\n\nResp: On Ventillator ,mode PCV,RR 30/Min,PEEP 12,Fio2 60%Spo2 89% acceptable,RR to maintain than set rate as per Resident.Breath sounds clear,suctioned small white secretions ,Rt ICD ,air leak present,draining minimally,crepitus present on Rt upper chest and neck.\n\nCVS: HR 96-110/min,NSR,no ectopics,pedal pulse weak to palpate,BP 110-130/55-70 mm of Hg.Arterial line on Lt.Radial and CVP on Rt.IJV,CXR taken early in this shift.\n\nGI:Abd.soft,bowel sounds present,on feed Nutren pulmonary 60cc /hr and free water 300ml q4h for hypernatreamia.Tolerating feeds.bowel not opened.\n\nGU:On foleys catheter,urine output adequate,received 40mg Lasix IV this shift.\n\nIntegu:T max 100.5,Syp.Tyenlol 650mg given,skin intact.on Triadyne bed,position changed q2h.All Nsg.care given,sponge given.\n\nSocial:Visited by family,co operative,arranged family meeting today at 1pm,full code.\n\nIV access:Arterial line on Lt.radial,pressure kit and dressing changed ,site looks clean ,line patent.Rt.IJV patent,no redness,swelling or oozing noted.\n\nPLAN:To continue ventillation and sedation,to control blood sugar and sodium,family meeting at 1pm\n"
},
{
"category": "Echo",
"chartdate": "2158-06-26 00:00:00.000",
"description": "Report",
"row_id": 83405,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Left ventricular function. Valvular heart disease.\nHeight: (in) 70\nWeight (lb): 260\nBSA (m2): 2.34 m2\nBP (mm Hg): 121/64\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 15:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Aortic valve not well seen. No AS.\n\nMITRAL VALVE: No MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nOverall left ventricular systolic function appears normal (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 is not well seen. There is no aortic valve stenosis. No mitral\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Grossly preserved global biventricular systolic function. Moderate\npulmonary hypertension.\n\nA technically limited study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2158-06-27 00:00:00.000",
"description": "Report",
"row_id": 227515,
"text": "Normal sinus rhythm. ECG is within normal limits. No previous tracing available\nfor comparison.\n\n"
}
] |
7,230 | 197,850 | He was admitted for elective catheterization. This was complicated by dissection of the left main coronary artery. An intraaortic balloon was placed and multiple pressors were utilized. Ventricular tacchycardia, fibrillation occurred and DCCV was necessary. Emergency salvage bypass surgery was undertaken. Three vein grafts were performed and he weaned from bypass on epinephrine, Milrinone, neosynephrine and IABP counterpulsation were used to wean from bypass. He remained very stable with good hemodynamics. The IABP was weaned and removed on POD 1, followed by weaning of all pressors. he was extubated easily. On POD 2 he transferred to the floor, beta blockers were begun and diuresis begun. PT worked with him for mobilization and strength. Coumadin was resumed due to his history of embolic stroke and thrombophlebitis. | Extubated. Extubated. Extubated. Cordis removed. Cordis removed. Cordis removed. Cordis removed. Cordis removed. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. Emergently intubated. Secretions suctioned. Secretions suctioned. Secretions suctioned. PT to ambulate. Generalized edema. Generalized edema. Generalized edema. Generalized edema. Generalized edema. O2 weaned. Pt. Pt. Pt. Ca+ repleted. Ca+ repleted. Ca+ repleted. Weaned EPI to off. Weaned EPI to off. Weaned EPI to off. CO normal CI >2 on epi and milrinone. CO normal CI >2 on epi and milrinone. CO normal CI >2 on epi and milrinone. K+ repleted. K+ repleted. K+ repleted. Lasix given. Lasix given. Lasix given. Monitor CO/CI. Monitor CO/CI. Monitor CO/CI. Wean propofol. Wean propofol. Wean propofol. BP stables systolic. BP stables systolic. BP stables systolic. Chest tubes removed. Chest tubes removed. Chest tubes removed. Chest tubes removed. During cath, LM was dissected. Knowledge, Impaired 2. VSS. VSS. VSS. VSS. VSS. VSS. VSS. VSS. BS < 120. BS < 120. Remove chest tubes. D/C chest tubes. D/C chest tubes. D/C chest tubes. LS clear, diminished at bases. LS clear, diminished at bases. LS clear, diminished at bases. LS clear, diminished at bases. LS clear, diminished at bases. Foley removed. Foley removed. Foley removed. Foley removed. K+ Ca+ BS < 120. BS > 120. BS > 120. BS > 120. BS > 120. BS > 120. Intervention: n/a Other: Diagnosis: 1. BS remain > 120. BS remain > 120. BS remain > 120. MAE equally. MAE equally. MAE equally. MAE equally. MAE equally. Communicated with RN. soft, nd, BS present x4quads. soft, nd, BS present x4quads. soft, nd, BS present x4quads. soft, nd, BS present x4quads. soft, nd, BS present x4quads. Abd. Abd. Abd. Abd. Abd. Abd. Abd. Abd. R femoral line removed. R femoral line removed. R femoral line removed. R femoral line removed. R femoral line removed. Compression boots applied. Compression boots applied. Compression boots applied. Transfers, Impaired 4. soft, nd, BS hypoactive x4 quads. soft, nd, BS hypoactive x4 quads. soft, nd, BS hypoactive x4 quads. Monitor VS. Monitor VS. Monitor VS. K+ Ca+ pending. K+ Ca+ pending. IABP to 1:2. IABP to 1:2. IABP to 1:2. D/C swan. D/C swan. D/C swan. Milrinone turned off. Milrinone turned off. Milrinone turned off. Respiration / Gas Exchange, Impaired 3. Moist mucous membranes. Moist mucous membranes. Moist mucous membranes. Moist mucous membranes. Moist mucous membranes. Pedal Pulses auscultated by Doppler. Pedal Pulses auscultated by Doppler. Pedal Pulses auscultated by Doppler. Chest tubes patent, draining serosanguinous fluid. Chest tubes patent, draining serosanguinous fluid. Chest tubes patent, draining serosanguinous fluid. Last dose of vanco given. Last dose of vanco given. Last dose of vanco given. Last dose of vanco given. Last dose of vanco given. Extubated. Extubated. Extubated. Extubated. Cordis removed. Cordis removed. Cordis removed. Cordis removed. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. PERRL. Atorvastatin . Milrinone . Secretions suctioned. Secretions suctioned. Secretions suctioned. Secretions suctioned. Generalized edema. Generalized edema. Generalized edema. Generalized edema. PT to ambulate. Pt. Pt. Pt. Pt. Noduplicate was generated. Noduplicate was generated. Aspirin EC . O2 weaned. Weaned EPI to off. Weaned EPI to off. Weaned EPI to off. Weaned EPI to off. Ca+ repleted. Ca+ repleted. Ca+ repleted. Ca+ repleted. CO normal CI >2 on epi and milrinone. Lasix given. Lasix given. . Wean propofol. Wean propofol. Wean propofol. Wean propofol. Monitor CO/CI. Monitor CO/CI. Monitor CO/CI. Monitor CO/CI. Response: BP stables systolic. K+ repleted. K+ repleted. K+ repleted. K+ repleted. CO normal CI >2. CO normal CI >2. CO normal CI >2. Phenylephrine . VSS. VSS. VSS. VSS. VSS. VSS. VSS. VSS. BP stables systolic. BP stables systolic. BP stables systolic. Chest tubes removed. Chest tubes removed. Chest tubes removed. Chest tubes removed. BS < 120. Foley removed. Foley removed. Foley removed. Foley removed. LS clear, diminished at bases. LS clear, diminished at bases. LS clear, diminished at bases. LS clear, diminished at bases. BS > 120. BS > 120. BS > 120. BS > 120. K+ Ca+ BS < 120. K+ Ca+ BS < 120. K+ Ca+ BS < 120. D/C chest tubes. D/C chest tubes. D/C chest tubes. D/C chest tubes. Abd. Abd. Abd. Abd. Abd. Abd. Abd. Abd. Milk of Magnesia . BS remain > 120. BS remain > 120. BS remain > 120. MAE equally. MAE equally. MAE equally. MAE equally. soft, nd, BS present x4quads. soft, nd, BS present x4quads. soft, nd, BS present x4quads. soft, nd, BS present x4quads. Monitor VS. Monitor VS. Monitor VS. Monitor VS. K+ 3.7 Ca+1.1 BS >120. K+ 3.7 Ca+1.1 BS >120. K+ 3.7 Ca+1.1 BS >120. R femoral line removed. R femoral line removed. R femoral line removed. R femoral line removed. Milrinone turned off. Milrinone turned off. Milrinone turned off. Milrinone turned off. K+ Ca+ pending. D/C swan. D/C swan. D/C swan. D/C swan. IABP to 1:2. IABP to 1:2. IABP to 1:2. IABP to 1:2. soft, nd, BS hypoactive x4 quads. soft, nd, BS hypoactive x4 quads. soft, nd, BS hypoactive x4 quads. soft, nd, BS hypoactive x4 quads. Compression boots applied. Compression boots applied. Pedal Pulses auscultated by Doppler. Pedal Pulses auscultated by Doppler. Pedal Pulses auscultated by Doppler. Pedal Pulses auscultated by Doppler. Both ventricles were nearly akinetic. Moist mucous membranes. Moist mucous membranes. Moist mucous membranes. Moist mucous membranes. Sinus bradycardia. Last dose of vanco given. Last dose of vanco given. Last dose of vanco given. | 29 | [
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370281,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Strong productive cough. Pulse ox > 95%\n on 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 decreased to 2L nc.\n R femoral line removed. Cordis removed.\n 6 units regular insulin given per sliding scale.\n Breakfast given\ntoast and coffee.\n OOB in chair.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >95%.\n Tolerated breakfast well.\n Tolerated activity well\nchest tubes\n BS\n Plan:\n Pulmonary toileting.\n Position for comfort.\n Remove chest tubes.\n"
},
{
"category": "Rehab Services",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 370296,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 414.00 /\n Reason of referral: evaluate and treat\n History of Present Illness / Subjective Complaint: 71 y/o male adm \n for cardiac cath in setting of abnormal myocardial perfusion scan and\n coronary CTA. During cath, LM was dissected. Patient developed severe\n hypotension, tachycardia. Emergently intubated. Patient went into V\n tach and required defibrillation. s/p emergent salvage CABG x 3 with\n IABP placement on .\n Past Medical / Surgical History: hyperlipemia, embolic CVA, Right leg\n thrombus while skiing, Borderline anemia, Colon polyps,\n Appendectomy\n Medications: Nitroglycerin, Phenylephrine, Morphine,\n Oxycodone-Acetaminophen, Insulin, Metoprolol\n Radiology: CXR : Mild interstitial, patchy bibasilar retrocardiac\n atelectasis\n Labs:\n 27.9\n 10.4\n 152\n 5.6\n [image002.jpg]\n Other labs:\n Activity Orders: as tolerated\n Social / Occupational History: Owns a printing business\n Living Environment: Lives with wife and dtr, 2 level home, + railing on\n stairs\n Prior Functional Status / Activity Level: I PTA, exercises daily for\n 1.5 hours, no AD, no falls, I ADLs\n Objective Test\n Arousal / Attention / Cognition / Communication: Alert, pleasant,\n cooperative, asking appropriate questions, communicates well in english\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 77\n 121/61\n 96% 2L\n Rest\n /\n Sit\n 78\n 110/61\n Activity\n /\n Stand\n /\n Recovery\n 78\n 121/65\n 97% 2L\n Total distance walked: n/a\n Minutes:\n Pulmonary Status: Diminished BS throughout, IS = 500\n Integumentary / Vascular: Sternotomy with incision C/D/I, foley,\n external pacer wires, mediastinal chest tube to suction\n Sensory Integrity: intact to LT\n Pain / Limiting Symptoms: c/o LBP at rest but no incisional pain\n at rest; with activity, no c/o LBP, but c/o severe incisonal chest pain\n and pain at chest tube insertion site\n Posture: forward head, rounded shoulders, forward hip flexion\n Range of Motion\n Muscle Performance\n WFL\n B grasp strong, B elbow flex , B shoulder flex > \n B DF , B quads \n Motor Function: Moves all extremities in isolation\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Clarification:\n Rolling: Patient required verbal cues for technique, able to bend L\n knee on own and reach across body with L UE; required min A to complete\n roll\n Supine to sit: required min A to move B LE off bed, then required mod A\n to push up to sitting; did use B UE to assist in the push to sitting\n Sit to stand: required CG and verbal cues\n Pivot: Able to stand and take steps to chair with B UE support on\n therapist\n Ambulation: deferred RN request 2' first time OOB; although, pt was\n able to in place x 10 reps B\n Rolling:\n To right\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n HOB flat\n\n\n\n\n T\n\n Transfer:\n Stand-pivot\n\n\n T\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n n/a\n\n\n\n\n\n\n Stairs:\n n/a\n\n\n\n\n\n\n Balance: Seated: no LOB at EOB\n Standing: no LOB with B UE support on therapist\n Education / Communication: Educated patient as to role of PT, d/c plan,\n sternal precautions, importance of mobility and OOB, use of IS. Issued\n cardiac surgery packet.\n Communicated with RN.\n Intervention: n/a\n Other:\n Diagnosis:\n 1.\n Knowledge, Impaired\n 2.\n Respiration / Gas Exchange, Impaired\n 3.\n Transfers, Impaired\n 4.\n Gait, Impaired\n Clinical impression / Prognosis: 71 y/o male adm for cath c/b LM\n dissection requiring emergent CABG x 3 with IABP placement. Patient\n presents with above deficits consistent with cardiovascular pump\n dysfunction. Patient is mobilizing well. Anticipate that patient will\n be safe for d/c to home after additional visits. Patient would\n benefit from outpatient cardiac rehab after 6 weeks to maximize\n function and exercise tolerance. Patient has excellent rehab potential\n given high PLOF and high exercise tolerance PTA.\n Goals\n Time frame: 1 week\n 1.\n I sup to sit to stand\n 2.\n I ambulation w/o AD x 500'\n 3.\n I ascend/descend 1 FOS with rail\n 4.\n Stable HDR to all activity\n 5.\n O2 > 93% on RA with all activity\n 6.\n I state sternal precautions\n Anticipated Discharge: Home with Outpatient PT\n Treatment :\n Frequency / Duration: 1-3x/week x 1 week\n Transfer train, gait train without AD, stair training, monitor HDR,\n wean O2, DB/IS/PLB, patient education\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370299,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Strong productive cough. Pulse ox > 95%\n on 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 weaned.\n R femoral line removed. Cordis removed.\n Chest tubes removed.\n Foley removed.\n 6 units regular insulin given per sliding scale.\n Breakfast given\ntoast and coffee.\n OOB in chair.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >92% on RA.\n Tolerated breakfast well.\n Tolerated activity well.\n BS\n Plan:\n Pulmonary toileting.\n Position for comfort.\n Due to void @ .\n"
},
{
"category": "Physician ",
"chartdate": "2180-02-13 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 370300,
"text": "CVICU\n HPI:\n HD3\n POD 1\n 71M s/p emergent CABGx3 (SVG to LAD, SVG to Dx, SVG to OM) for\n dissected LT main \n EF: 53% Wt: 169 lbs Cr: 1.0 HgA1C:\n PMH: + stress test, CVA, heterozygote for PT gene, R leg thrombus,\n hyperlipidemia, anemia, colon polys, appy. + ETOH drinks/day\n : lipitor 10', coumadin 10\n Current medications:\n Acetaminophen, Aspirin EC, Atorvastatin, Captopril, Docusate Sodium,\n Furosemide, Insulin, Metoprolol Tartrate, Morphine Sulfate,\n Oxycodone-Acetaminophen, Ranitidine\n 24 Hour Events:\n 24 hour events: extubated,\n Weaned from Epi and milirone\n IABP removed\n ARTERIAL LINE - STOP 11:40 AM\n IABP LINE - STOP 11:40 AM\n EXTUBATION - At 03:30 PM\n INVASIVE VENTILATION - STOP 03:30 PM\n FEVER - 101.3\nC - 07:00 AM\n Post operative day:\n POD#2 - cabg x3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 08:00 AM\n Other medications:\n Flowsheet Data as of 12:18 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37\nC (98.6\n HR: 77 (64 - 78) bpm\n BP: 109/60(72) {109/60(72) - 128/69(79)} mmHg\n RR: 24 (0 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n CVP: 12 (11 - 16) mmHg\n PAP: (42 mmHg) / (19 mmHg)\n CO/CI (Thermodilution): (4.68 L/min) / (2.5 L/min/m2)\n SVR: 1,385 dynes*sec/cm5\n SV: 63 mL\n SVI: 33 mL/m2\n Total In:\n 1,234 mL\n 200 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,204 mL\n 200 mL\n Blood products:\n Total out:\n 3,400 mL\n 1,635 mL\n Urine:\n 2,685 mL\n 1,300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,166 mL\n -1,435 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: CPAP/PSV\n PS : 5 cmH2O\n PEEP: 5 cmH2O\n FiO2: 40%\n SPO2: 94%\n ABG: 7.37/36/102/28/0\n PaO2 / FiO2: 255\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), left EVH\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 152 K/uL\n 10.4 g/dL\n 167\n 1.0 mg/dL\n 28 mEq/L\n 4.7 mEq/L\n 14 mg/dL\n 107 mEq/L\n 140 mEq/L\n 27.9 %\n 5.6 K/uL\n [image002.jpg]\n 09:00 AM\n 10:00 AM\n 11:00 AM\n 12:00 PM\n 12:45 PM\n 01:30 PM\n 03:14 PM\n 06:00 PM\n 12:17 AM\n 08:00 AM\n WBC\n 5.6\n Hct\n 27.9\n Plt\n 152\n Creatinine\n 1.0\n TCO2\n 25\n Glucose\n 172\n 118\n 93\n 63\n 63\n 66\n 100\n 123\n 139\n 167\n Other labs: PT / PTT / INR:15.4/31.7/1.4, ALT / AST:67/359, Alk-Phos /\n T bili:43/0.8, Lactic Acid:1.9 mmol/L, Mg:2.1 mg/dL\n Microbiology: mrsa pending\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TRANSFERS,\n IMPAIRED, GAIT, IMPAIRED, .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, percocet prn\n effective\n Cardiovascular: Aspirin, Beta-blocker, Statins, left main dissection\n resulting cardiogenic shock requiring IABP and emergent OR, start\n captopril\n Pulmonary: IS, Discontinue chest tube(s), cough and deep breath, oob to\n chair increase ambulation\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, start lasix for diuresis with goal 1000-1500\n ml negative for 24 hours\n Hematology: stable anemia\n Endocrine: RISS, goal BG < 150\n Infectious Disease: vancomycin for periop antibiotics, no evidence of\n infection, no preop u/a - send\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires, dc foley/ct\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370193,
"text": ".H/O coronary artery bypass graft (CABG) S/P EMERGENT CABG X 3\n VESSELS FOR TORN LCA TO CVICU ON EPI/MIL/PRO/INSULIN/ STABLE ON\n ARRIVAL V/S COOL 36 UNRESPONSIVE\n NEURO PT REMAINS ON PROPOFOL FOR SEDATION NOT TO BE WEANED WILL\n OPEN EYES TO COMAND MOVES ALL EXTREMITY AT WILL OCC DOSE OF MSO4\n AND LARGER DOSE PROPOFOL WILL MOVE WITH VERBAL AS WELL AS TACTIAL\n STIMULATON TO BE MAINTAINED AT PRESENT RATE AND TYPE OF SEDATION\n HEART S1S2 NSR TO ST PR .16 QRS .08 QT WNL FOR AGE AND GENDER VSS\n ON EPI AND MIL MD REQUEST NOT TO BE WEANED AT THIS TIME CO/CI WNL\n PULSES POS 2 THRU OUT STRONG SOUNDS WEAK PULSES PACER WIRES WNL\n FUNCTIONS WELL DOUBLE A/LINE L/F FEM AREA BOTH TO MONITOR NOTE LEFT\n RADIAL DEVICE TO HOLD TO HEAL IN PLACED CLAMP ON SAO2 ON HAND TO CONT\n EVAL QUALIY OF CIRC IN EFFECTED HAND IABP IN PROGRESS TOL WELL NO\n ISSUES AT THIS TIME UNLOADING IN PROGRESS TOL WELL OCC TO FREQ PVC ALL\n ELECTROLYTES REPLACED SLOWLY\n RESP CLEAR OCC RHONCHI AT BASES ONLY CLEARS AFTER SUCTIONING ON\n CNV GOD PRESSURES NOTES LITTLE SPUTUM PRODUCTION NONE SOB REG RESP\n PATTERN WILL OVERBREATH VENT AT TIMES NO ISSUES AT THIS TIME\n GI POS B/S N/G SCANT NOTE SOME ORAL BLOODY DICHARGE\n PLAN MONITOR CLOSLY LEFT RADIAL CLAMP AND DISTAL CIRC SAO2 100\n GOOD PLETH ON HOME COMPUTER T/P CPT EMOTIOAL CARE IN PW\n WEAN AND WEAK AND CIC W\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370194,
"text": ".H/O coronary artery bypass graft (CABG) S/P EMERGENT CABG X 3\n VESSELS FOR TORN LCA TO CVICU ON EPI/MIL/PRO/INSULIN/ STABLE ON\n ARRIVAL V/S COOL 36 UNRESPONSIVE\n NEURO PT REMAINS ON PROPOFOL FOR SEDATION NOT TO BE WEANED WILL\n OPEN EYES TO COMAND MOVES ALL EXTREMITY AT WILL OCC DOSE OF MSO4\n AND LARGER DOSE PROPOFOL WILL MOVE WITH VERBAL AS WELL AS TACTIAL\n STIMULATON TO BE MAINTAINED AT PRESENT RATE AND TYPE OF SEDATION\n HEART S1S2 NSR TO ST PR .16 QRS .08 QT WNL FOR AGE AND GENDER VSS\n ON EPI AND MIL MD REQUEST NOT TO BE WEANED AT THIS TIME CO/CI WNL\n PULSES POS 2 THRU OUT STRONG SOUNDS WEAK PULSES PACER WIRES WNL\n FUNCTIONS WELL DOUBLE A/LINE L/F FEM AREA BOTH TO MONITOR NOTE LEFT\n RADIAL DEVICE TO HOLD TO HEAL IN PLACED CLAMP ON SAO2 ON HAND TO CONT\n EVAL QUALIY OF CIRC IN EFFECTED HAND IABP IN PROGRESS TOL WELL NO\n ISSUES AT THIS TIME UNLOADING IN PROGRESS TOL WELL OCC TO FREQ PVC ALL\n ELECTROLYTES REPLACED SLOWLY\n RESP CLEAR OCC RHONCHI AT BASES ONLY CLEARS AFTER SUCTIONING ON\n CNV GOD PRESSURES NOTES LITTLE SPUTUM PRODUCTION NONE SOB REG RESP\n PATTERN WILL OVERBREATH VENT AT TIMES NO ISSUES AT THIS TIME\n GI POS B/S N/G SCANT NOTE SOME ORAL BLOODY DICHARGE\n PLAN MONITOR CLOSLY LEFT RADIAL CLAMP AND DISTAL CIRC SAO2 100\n GOOD PLETH ON HOME COMPUTER T/P CPT EMOTIOAL CARE IN PW\n WEAN AND WEAK AND CIC W\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370245,
"text": ".H/O coronary artery bypass graft (CABG) NEURO PT REMAINS RELAXED A/O\n MILD STERNAL PAIN GOOD RESULTS PO PAIN MED SLEEPS SHORT PERIODS\n SPIRITS HIGH UNDERSTANDS AND HELPS WITH CARE GIVEN\n HEART S1S2\n DISTANT TONES NSR PR .16 QRS .04 QT WNL FOR SITUATION GENDER AND AGE\n PULSES FAIR EDEMA MILD IN NATURE VSS BP BORDERLINE HIGH LOPRESSOR\n USED GOOD EFFECTS PA CATH REMOVED MD WELL NORMALIZED V/S\n POST LOPRESSOR DOSES VSS\n GI PO WELL NO\n N/V AT THIS TIME POS B/S AND FLATUS\n RESP CLEAR\n NO SOB MILD O2 DEPENDENT NP 2L TO WELL\n PLAN\n SUPPORTIVE IN NATUR E CONT TO FOLLOW PLAN OF CARE\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370246,
"text": ".H/O coronary artery bypass graft (CABG) NEURO PT REMAINS RELAXED A/O\n MILD STERNAL PAIN GOOD RESULTS PO PAIN MED SLEEPS SHORT PERIODS\n SPIRITS HIGH UNDERSTANDS AND HELPS WITH CARE GIVEN\n HEART S1S2\n DISTANT TONES NSR PR .16 QRS .04 QT WNL FOR SITUATION GENDER AND AGE\n PULSES FAIR EDEMA MILD IN NATURE VSS BP BORDERLINE HIGH LOPRESSOR\n USED GOOD EFFECTS PA CATH REMOVED MD WELL NORMALIZED V/S\n POST LOPRESSOR DOSES VSS\n GI PO WELL NO\n N/V AT THIS TIME POS B/S AND FLATUS\n RESP CLEAR\n NO SOB MILD O2 DEPENDENT NP 2L TO WELL\n PLAN\n SUPPORTIVE IN NATUR E CONT TO FOLLOW PLAN OF CARE\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370247,
"text": ".H/O coronary artery bypass graft (CABG) NEURO PT REMAINS RELAXED A/O\n MILD STERNAL PAIN GOOD RESULTS PO PAIN MED SLEEPS SHORT PERIODS\n SPIRITS HIGH UNDERSTANDS AND HELPS WITH CARE GIVEN\n HEART S1S2\n DISTANT TONES NSR PR .16 QRS .04 QT WNL FOR SITUATION GENDER AND AGE\n PULSES FAIR EDEMA MILD IN NATURE VSS BP BORDERLINE HIGH LOPRESSOR\n USED GOOD EFFECTS PA CATH REMOVED MD WELL NORMALIZED V/S\n POST LOPRESSOR DOSES VSS\n GI PO WELL NO\n N/V AT THIS TIME POS B/S AND FLATUS\n RESP CLEAR\n NO SOB MILD O2 DEPENDENT NP 2L TO WELL\n PLAN\n SUPPORTIVE IN NATUR E CONT TO FOLLOW PLAN OF CARE\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370225,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. lightly sedated on propofol. Spontaneous movement and eye opening.\n Follows all commands. PERRL. Gag reflex intact.\n VSS. NSR with occasional recurrent PVC\ns. IABP in R femoral artery 1:1.\n CO normal CI >2 on epi and milrinone. Pedal Pulses auscultated by\n Doppler. Cap refill < 3 secs.\n Patient Intubated. Thick blood tinged secretions. LS clear slightly\n diminished at bases. Normal respiratory effort. O2 sats >97%. Chest\n tubes patent, draining serosanguinous fluid.\n Abd. soft, nd, BS hypoactive x4 quads. OG tube patent, draining\n bilious, blood tinged fluid.\n Foley patent, draining clear yellow urine to gravity.\n K+ 3.7 Ca+1.1\n BS >120 on insulin drip.\n Pain present, incisional.\n Action:\n Re orient client to time and place. Wean propofol.\n Monitor CO/CI. IABP to 1:2. Discontinued at 1130. Weaned EPI to off.\n Milrinone turned off.\n Secretions suctioned. Pt. Extubated. Face tent applied.\n Ice chips given.\n K+ repleted. Ca+ repleted.\n Insulin drip titrated and weaned off.\n Medicated with 2 percocet, 2mg IV push for pain.\n Response:\n Client A&Ox3. PERRL.\n BP stable\ns systolic. HR in 70\n LS remain clear, diminished at bases. O2 sats >95%.\n CO remains good >5 CI >2. Pedal Pulses present.\n Tolerated ice chips well.\n K+ Ca+ pending.\n BS < 120.\n Pain acceptable for client.\n Plan:\n Position for comfort.\n Monitor VS.\n Pulmonary toileting.\n D/C swan.\n D/C chest tubes.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370228,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. lightly sedated on propofol. Spontaneous movement and eye opening.\n Follows all commands. PERRL. Gag reflex intact.\n VSS. NSR with occasional recurrent PVC\ns. IABP in R femoral artery 1:1.\n CO normal CI >2 on epi and milrinone. Pedal Pulses auscultated by\n Doppler. Cap refill < 3 secs.\n Patient Intubated. Thick blood tinged secretions. LS clear slightly\n diminished at bases. Normal respiratory effort. O2 sats >97%. Chest\n tubes patent, draining serosanguinous fluid.\n Abd. soft, nd, BS hypoactive x4 quads. OG tube patent, draining\n bilious, blood tinged fluid.\n Foley patent, draining clear yellow urine to gravity.\n K+ 3.7 Ca+1.1\n BS >120 on insulin drip.\n Pain present, incisional.\n Action:\n Re orient client to time and place. Wean propofol.\n Monitor CO/CI. IABP to 1:2. Discontinued at 1130. Weaned EPI to off.\n Milrinone turned off.\n Secretions suctioned. Pt. Extubated. Face tent applied.\n Ice chips given.\n K+ repleted. Ca+ repleted.\n Insulin drip titrated and weaned off.\n Medicated with 2 percocet, 2mg IV push for pain.\n Response:\n Client A&Ox3. PERRL.\n BP stable\ns systolic. HR in 70\n LS remain clear, diminished at bases. O2 sats >95%.\n CO remains good >5 CI >2. Pedal Pulses present.\n Tolerated ice chips well.\n K+ Ca+ pending.\n BS < 120.\n Pain acceptable for client.\n Plan:\n Position for comfort.\n Monitor VS.\n Pulmonary toileting.\n D/C swan.\n D/C chest tubes.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370310,
"text": "Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN;SHORTNESS OF BREATH CATH\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 76.8 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia\n CV-PMH:\n Additional history: CHOL CVA NO RESIDUAL NOTE ON \n PERIOD OF DIZZINESS MRI DONE TO EVAL PAST CVA WITH NEW ONSET RESULTS\n NO EVENT OR BLEED REFERRED FOR CATH DONE LEFT MAIN DISSECTION AS A\n RESULT TRANSFER TO OR\n Surgery / Procedure and date: POST OP CABG X 3 WITH IABP\n EPI/NEO/MILRINONE/INSULIN/PROPOFOL\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:76\n Temperature:\n 98.6\n Arterial BP:\n S:129\n D:52\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 200 mL\n 24h total out:\n 2,135 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Ventricular Demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n No\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 1 mV\n Temporary ventricular sensitivity setting:\n .5 mV\n Temporary ventricular stimulation threshold :\n 7 mA\n Temporary ventricular stimulation setting :\n 14 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 12:17 AM\n Potassium:\n 4.7 mEq/L\n 12:17 AM\n Chloride:\n 107 mEq/L\n 12:17 AM\n CO2:\n 28 mEq/L\n 12:17 AM\n BUN:\n 14 mg/dL\n 12:17 AM\n Creatinine:\n 1.0 mg/dL\n 12:17 AM\n Glucose:\n 163\n 12:00 PM\n Hematocrit:\n 27.9 %\n 12:17 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: CVICU 797\n Transferred to: 6\n Date & time of Transfer: 1430\n .H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Weak productive cough. Pulse ox > 95% on\n 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 decreased to 2L nc.\n R femoral line removed. Cordis removed.\n Chest tubes removed.\n Foley removed. Lasix given.\n Breakfast given\ntoast and coffee.\n 6 units regular insulin given per sliding scale.\n OOB in chair.\n Compression boots applied.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >92% on 2L nc.\n Voided 300 at 1330.\n Tolerated breakfast well.\n Tolerated activity well.\n BS remain > 120.\n Plan:\n Pulmonary toileting.\n Position for comfort.\n Monitor, treat, support, d/c to home by end of week.\n PT to ambulate.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370223,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. lightly sedated on propofol. Spontaneous movement and eye opening.\n Follows all commands. PERRL. Gag reflex intact.\n VSS. NSR with occasional recurrent PVC\ns. IABP in R femoral artery 1:1.\n CO normal CI >2 on epi and milrinone. Pedal Pulses auscultated by\n Doppler. Cap refill < 3 secs.\n Patient Intubated. Thick blood tinged secretions. LS clear slightly\n diminished at bases. Normal respiratory effort. O2 sats >97%. Chest\n tubes patent, draining serosanguinous fluid.\n Abd. soft, nd, BS hypoactive x4 quads. OG tube patent, draining\n bilious, blood tinged fluid.\n Foley patent, draining clear yellow urine to gravity.\n K+ 3.7 Ca+1.1\n BS >120 on insulin drip.\n Pain present, incisional.\n Action:\n Re orient client to time and place. Wean propofol.\n Monitor CO/CI. IABP to 1:2. Discontinued at 1130. Weaned EPI to off.\n Milrinone turned off.\n Secretions suctioned. Pt. Extubated. Face tent applied.\n Ice chips given.\n K+ repleted. Ca+ repleted.\n Insulin drip titrated and weaned off.\n Medicated with 2 percocet, 2mg IV push for pain.\n Response:\n Client A&Ox3. PERRL.\n BP stable\ns systolic. HR in 70\n LS remain clear, diminished at bases. O2 sats >95%.\n CO remains good >5 CI >2. Pedal Pulses present.\n Tolerated ice chips well.\n K+ Ca+\n BS < 120.\n Pain acceptable for client.\n Plan:\n Position for comfort.\n Monitor VS.\n Pulmonary toileting.\n D/C swan.\n D/C chest tubes.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370303,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Strong productive cough. Pulse ox > 95%\n on 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 decreased to 2L nc.\n R femoral line removed. Cordis removed.\n Chest tubes removed.\n Foley removed. Lasix given.\n 6 units regular insulin given per sliding scale.\n Breakfast given\ntoast and coffee.\n OOB in chair.\n Compression boots applied.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >92% on 2L nc.\n Tolerated breakfast well.\n Tolerated activity well.\n BS remain > 120.\n Plan:\n Pulmonary toileting.\n Position for comfort.\n Due to void @ .\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370305,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Strong productive cough. Pulse ox > 95%\n on 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 decreased to 2L nc.\n R femoral line removed. Cordis removed.\n Chest tubes removed.\n Foley removed. Lasix given.\n Breakfast given\ntoast and coffee.\n 6 units regular insulin given per sliding scale.\n OOB in chair.\n Compression boots applied.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >92% on 2L nc.\n Voided at 1330.\n Tolerated breakfast well.\n Tolerated activity well.\n BS remain > 120.\n Plan:\n Pulmonary toileting.\n Position for comfort.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370312,
"text": "Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN;SHORTNESS OF BREATH CATH\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 76.8 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia\n CV-PMH:\n Additional history: CHOL CVA NO RESIDUAL NOTE ON \n PERIOD OF DIZZINESS MRI DONE TO EVAL PAST CVA WITH NEW ONSET RESULTS\n NO EVENT OR BLEED REFERRED FOR CATH DONE LEFT MAIN DISSECTION AS A\n RESULT TRANSFER TO OR\n Surgery / Procedure and date: POST OP CABG X 3 WITH IABP\n EPI/NEO/MILRINONE/INSULIN/PROPOFOL\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:76\n Temperature:\n 98.6\n Arterial BP:\n S:129\n D:52\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 200 mL\n 24h total out:\n 2,135 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Ventricular Demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n No\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 1 mV\n Temporary ventricular sensitivity setting:\n .5 mV\n Temporary ventricular stimulation threshold :\n 7 mA\n Temporary ventricular stimulation setting :\n 14 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 12:17 AM\n Potassium:\n 4.7 mEq/L\n 12:17 AM\n Chloride:\n 107 mEq/L\n 12:17 AM\n CO2:\n 28 mEq/L\n 12:17 AM\n BUN:\n 14 mg/dL\n 12:17 AM\n Creatinine:\n 1.0 mg/dL\n 12:17 AM\n Glucose:\n 163\n 12:00 PM\n Hematocrit:\n 27.9 %\n 12:17 AM\n Valuables / Signature\n Patient valuables: none\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: CVICU 797\n Transferred to: 6\n Date & time of Transfer: 1430\n .H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Weak productive cough. Pulse ox > 95% on\n 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 decreased to 2L nc.\n R femoral line removed. Cordis removed.\n Chest tubes removed.\n Foley removed. Lasix given.\n Breakfast given\ntoast and coffee.\n 6 units regular insulin given per sliding scale.\n OOB in chair.\n Compression boots applied.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >92% on 2L nc.\n Voided 300 at 1330.\n Tolerated breakfast well.\n Tolerated activity well.\n BS remain > 120.\n Plan:\n Pulmonary toileting.\n Position for comfort.\n Monitor, treat, support, d/c to home by end of week.\n PT to ambulate.\n ------ Protected Section ------\n Reviewed and agree w/above note\n ------ Protected Section Addendum Entered By: , RN\n on: 14:11 ------\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370222,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. lightly sedated on propofol. Spontaneous movement and eye opening.\n Follows all commands. PERRL. Gag reflex intact.\n VSS. NSR with occasional recurrent PVC\ns. IABP in R femoral artery 1:1.\n CO normal CI >2. Pedal Pulses auscultated by Doppler. Cap refill < 3\n secs.\n Patient Intubated. Thick blood tinged secretions. LS clear slightly\n diminished at bases. Normal respiratory effort. O2 sats >97%. Chest\n tubes patent, draining serosanguinous fluid.\n Abd. soft, nd, BS hypoactive x4 quads. OG tube patent, draining\n bilious, blood tinged fluid.\n Foley patent, draining clear yellow urine to gravity.\n K+ 3.7 Ca+1.1\n BS >120.\n Pain present, incisional.\n Action:\n Re orient client to time and place. Wean propofol.\n Monitor CO/CI. IABP to 1:2. Discontinued at 1130. Weaned EPI to off.\n Milrinone turned off.\n Secretions suctioned. Pt. Extubated. Face tent applied.\n Ice chips given.\n K+ repleted. Ca+ repleted.\n Insulin drip titrated to off.\n Medicated with 2 percocet, 2mg IV push for pain.\n Response:\n Client A&Ox3. PERRL.\n BP stable\ns systolic. HR in 70\n LS remain clear, diminished at bases. O2 sats >95%.\n CO remains good >5 CI >2. Pedal Pulses present.\n Tolerated ice chips well.\n K+ Ca+\n BS < 120.\n Pain acceptable for client.\n Plan:\n Position for comfort.\n Monitor VS.\n Pulmonary toileting.\n D/C swan.\n D/C chest tubes.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370301,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Strong productive cough. Pulse ox > 95%\n on 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 decreased to 2L nc.\n R femoral line removed. Cordis removed.\n Chest tubes removed.\n Foley removed.\n 6 units regular insulin given per sliding scale.\n Breakfast given\ntoast and coffee.\n OOB in chair.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >92% on 2L nc.\n Tolerated breakfast well.\n Tolerated activity well.\n BS remain > 120.\n Plan:\n Pulmonary toileting.\n Position for comfort.\n Due to void @ .\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370306,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Strong productive cough. Pulse ox > 95%\n on 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 decreased to 2L nc.\n R femoral line removed. Cordis removed.\n Chest tubes removed.\n Foley removed. Lasix given.\n Breakfast given\ntoast and coffee.\n 6 units regular insulin given per sliding scale.\n OOB in chair.\n Compression boots applied.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >92% on 2L nc.\n Voided 300 at 1330.\n Tolerated breakfast well.\n Tolerated activity well.\n BS remain > 120.\n Plan:\n Pulmonary toileting.\n Position for comfort.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 370298,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. A&Ox3. PERRL. MAE equally. Gag reflex intact.\n VSS. HR in the 70\ns, bp 120\n2 systolic. Cap refill < 3 secs. Pedal\n pulses present. Chest tubes draining serosanguinous fluid. Generalized\n edema.\n LS clear, diminished at bases. Strong productive cough. Pulse ox > 95%\n on 3L nc. Moist mucous membranes.\n Abd. soft, nd, BS present x4quads.\n Foley patent, draining clear, yellow urine.\n BS > 120.\n Action:\n Encourage incentive spirometry. O2 weaned.\n R femoral line removed. Cordis removed.\n Chest tubes removed.\n Foley removed.\n 6 units regular insulin given per sliding scale.\n Breakfast given\ntoast and coffee.\n OOB in chair.\n Last dose of vanco given.\n Educate about transfer.\n Response:\n VS remain stable.\n LS clear, O2 sats remain >92% on RA.\n Tolerated breakfast well.\n Tolerated activity well.\n BS\n Plan:\n Pulmonary toileting.\n Position for comfort.\n .\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370212,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. lightly sedated on propofol. Spontaneous movement and eye opening.\n Follows all commands. PERRL. Gag reflex intact.\n VSS. NSR with occasional recurrent PVC\ns. IABP in R femoral artery 1:1.\n CO normal CI >2. Pedal Pulses auscultated by Doppler. Cap refill < 3\n secs.\n Patient Intubated. Thick blood tinged secretions. LS clear slightly\n diminished at bases. Normal respiratory effort. O2 sats >97%. Chest\n tubes patent, draining serosanguinous fluid.\n Abd. soft, nd, BS hypoactive x4 quads. OG tube patent, draining\n bilious, blood tinged fluid.\n Foley patent, draining clear yellow urine to gravity.\n K+ 3.7 Ca+1.1\n BS >120.\n Pain present, incisional.\n Action:\n Re orient client to time and place. Wean propofol.\n Monitor CO/CI. IABP to 1:2. Discontinued at 1130. Weaned EPI to off.\n Milrinone turned off.\n Secretions suctioned. Pt. Extubated. Face tent applied.\n K+ repleted. Ca+ repleted.\n Insulin drip titrated to off.\n Medicated with 2 percocet.\n Response:\n BP stable\ns systolic. HR in 70\n LS remain clear, diminished at bases. O2 sats >95%.\n CO remains good >5 CI >2. Pedal Pulses present.\n K+ Ca+\n BS < 120.\n Pain acceptable for client.\n Plan:\n Position for comfort.\n Monitor VS.\n Pulmonary toileting.\n D/C swan.\n D/C chest tubes.\n"
},
{
"category": "Respiratory ",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 370201,
"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: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Physician ",
"chartdate": "2180-02-12 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 370206,
"text": "CVICU\n HPI:\n POD 1\n 71M s/p emergent CABGx3 (SVG to LAD, SVG to Dx, SVG to OM) for\n dissected LT main \n EF: 53% Wt: 169 lbs Cr: 1.0 HgA1C:\n PMH: + stress test, CVA, heterozygote for PT gene, R leg thrombus,\n hyperlipidemia, anemia, colon polys, appy. + ETOH drinks/day\n AH: lipitor 10', coumadin 10\n PLAN:\n keep intubated overnight, correct coagulapathy\n urrent medications:\n Acetaminophen4. Aspirin EC . Atorvastatin . Calcium Gluconate\n Chlorhexidine Gluconate 0.12% Oral Rinse Dextrose 50% Docusate Sodium\n Epinephrine HCl Glycopyrrolate . Influenza Virus Vaccine Insulin.\n Magnesium Sulfate Metoclopramide . Milk of Magnesia . Milrinone .\n Morphine Sulfate . Neostigmine Oxycodone-Acetaminophen . Phenylephrine\n . Pneumococcal Vac Polyvalent Ranitidine . Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 07:30 PM\n NOTE LINE DONE IN OR\n OR RECEIVED - At 07:50 PM\n ARTERIAL LINE - START 08:00 PM\n CORDIS/INTRODUCER - START 08:00 PM\n IABP LINE - START 08:00 PM\n INVASIVE VENTILATION - START 08:15 PM\n FEVER - 102.2\nC - 03:00 AM\n Post operative day:\n POD#1 - cabg x3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 AM\n Infusions:\n Epinephrine - 0.02 mcg/Kg/min\n Milrinone - 0.25 mcg/Kg/min\n Insulin - Regular - 6 units/hour\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Morphine Sulfate - 11:19 PM\n Insulin - Regular - 09:00 AM\n Other medications:\n Flowsheet Data as of 10:20 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: 85 (73 - 93) bpm\n BP: 103/62(82) {92/52(74) - 138/69(100)} mmHg\n RR: 0 (0 - 21) insp/min\n SPO2: 100%\n Height: 68 Inch\n CVP: 220 (9 - 220) mmHg\n PAP: (44 mmHg) / (19 mmHg)\n CO/CI (Thermodilution): (5.13 L/min) / (2.4 L/min/m2)\n SVR: 1,140 dynes*sec/cm5\n SV: 62 mL\n SVI: 32 mL/m2\n Total In:\n 525 mL\n 839 mL\n PO:\n Tube feeding:\n IV Fluid:\n 525 mL\n 839 mL\n Blood products:\n Total out:\n 4,220 mL\n 2,035 mL\n Urine:\n 3,745 mL\n 1,605 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,695 mL\n -1,196 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: SIMV/PSV/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 383 (83 - 383) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Neuromusc Block\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 100%\n ABG: 7.49/39/133/25/6\n Ve: 9.9 L/min\n PaO2 / FiO2: 332\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, x 1), Follows simple\n commands, Moves all extremities\n Labs / Radiology\n 251 K/uL\n 9.9 g/dL\n 118\n 0.9 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 106 mEq/L\n 142 mEq/L\n 29\n 4.3 K/uL\n [image002.jpg]\n 09:57 PM\n 11:00 PM\n 11:54 PM\n 12:09 AM\n 03:00 AM\n 04:49 AM\n 04:57 AM\n 08:00 AM\n 09:00 AM\n 10:00 AM\n WBC\n 6.5\n 4.3\n Hct\n 32\n 27.7\n 26.4\n 29\n Plt\n 283\n 251\n TCO2\n 34\n 31\n 31\n Glucose\n 63\n 88\n 117\n 137\n 119\n 140\n 172\n 118\n Other labs: PT / PTT / INR:15.1/32.4/1.3, Lactic Acid:1.9 mmol/L,\n Mg:2.2 mg/dL\n Assessment and Plan\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: Satble. plan to remove IABP, wean vent and\n pressures\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Statins\n Pulmonary: Extubate today, (Ventilator mode: CMV)\n Gastrointestinal / Abdomen:\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, OGT, ETT, Chest tube - pleural , Chest\n tube - mediastinal, Pacing wires\n Wounds: Dry dressings\n luids: Other\n ICU Care\n Glycemic Control:\n Arterial Line - 08:00 PM\n Cordis/Introducer - 08:00 PM\n IABP line - 08:00 PM\n 16 Gauge - 08:00 PM\n 20 Gauge - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370213,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. lightly sedated on propofol. Spontaneous movement and eye opening.\n Follows all commands. PERRL. Gag reflex intact.\n VSS. NSR with occasional recurrent PVC\ns. IABP in R femoral artery 1:1.\n CO normal CI >2. Pedal Pulses auscultated by Doppler. Cap refill < 3\n secs.\n Patient Intubated. Thick blood tinged secretions. LS clear slightly\n diminished at bases. Normal respiratory effort. O2 sats >97%. Chest\n tubes patent, draining serosanguinous fluid.\n Abd. soft, nd, BS hypoactive x4 quads. OG tube patent, draining\n bilious, blood tinged fluid.\n Foley patent, draining clear yellow urine to gravity.\n K+ 3.7 Ca+1.1\n BS >120.\n Pain present, incisional.\n Action:\n Re orient client to time and place. Wean propofol.\n Monitor CO/CI. IABP to 1:2. Discontinued at 1130. Weaned EPI to off.\n Milrinone turned off.\n Secretions suctioned. Pt. Extubated. Face tent applied.\n K+ repleted. Ca+ repleted.\n Insulin drip titrated to off.\n Medicated with 2 percocet, 2mg IV push for pain.\n Response:\n Client A&Ox3. PERRL.\n BP stable\ns systolic. HR in 70\n LS remain clear, diminished at bases. O2 sats >95%.\n CO remains good >5 CI >2. Pedal Pulses present.\n K+ Ca+\n BS < 120.\n Pain acceptable for client.\n Plan:\n Position for comfort.\n Monitor VS.\n Pulmonary toileting.\n D/C swan.\n D/C chest tubes.\n"
},
{
"category": "Nursing",
"chartdate": "2180-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 370272,
"text": ".H/O coronary artery bypass graft (CABG)\n Assessment:\n Pt. lightly sedated on propofol. Spontaneous movement and eye opening.\n Follows all commands. PERRL. Gag reflex intact.\n VSS. NSR with occasional recurrent PVC\ns. IABP in R femoral artery 1:1.\n CO normal CI >2 on epi and milrinone. Pedal Pulses auscultated by\n Doppler. Cap refill < 3 secs.\n Patient Intubated. Thick blood tinged secretions. LS clear slightly\n diminished at bases. Normal respiratory effort. O2 sats >97%. Chest\n tubes patent, draining serosanguinous fluid.\n Abd. soft, nd, BS hypoactive x4 quads. OG tube patent, draining\n bilious, blood tinged fluid.\n Foley patent, draining clear yellow urine to gravity.\n K+ 3.7 Ca+1.1\n BS >120 on insulin drip.\n Pain present, incisional.\n Action:\n Re orient client to time and place. Wean propofol.\n Monitor CO/CI. IABP to 1:2. Discontinued at 1130. Weaned EPI to off.\n Milrinone turned off.\n Secretions suctioned. Pt. Extubated. Face tent applied.\n Ice chips given.\n K+ repleted. Ca+ repleted.\n Insulin drip titrated and weaned off.\n Medicated with 2 percocet, 2mg IV push for pain.\n Response:\n Client A&Ox3. PERRL.\n BP stable\ns systolic. HR in 70\n LS remain clear, diminished at bases. O2 sats >95%.\n CO remains good >5 CI >2. Pedal Pulses present.\n Tolerated ice chips well.\n K+ Ca+ pending.\n BS < 120.\n Pain acceptable for client.\n Plan:\n Position for comfort.\n Monitor VS.\n Pulmonary toileting.\n D/C swan.\n D/C chest tubes.\n"
},
{
"category": "Echo",
"chartdate": "2180-02-14 00:00:00.000",
"description": "Report",
"row_id": 102552,
"text": "PATIENT/TEST INFORMATION:\nIndication: Emergency CABG\nStatus: Inpatient\nDate/Time: at 14:15\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\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\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 TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nThis was an emergency resuscitation brought from the cardiac cath lab directly\nto the OR to crash onto CPB. There was not enough time for a full exam\npre-bypass, but there was severe biventricular failure, with forward flow\nreally only provided by the IABP. Both ventricles were nearly akinetic. No\npericardial effusion.\n\nPost-bypass:\nNo spontaneous echo contrast is seen in the left atrial appendage. The\nascending, transverse and descending thoracic aorta are normal in diameter and\nfree of atherosclerotic plaque.. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nBiventricular systolic fxn is nearly normal, with EF 50 - 55%. Aorta intact.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2180-02-14 00:00:00.000",
"description": "Report",
"row_id": 102537,
"text": "PATIENT/TEST INFORMATION:\nIndication: x\nStatus: Inpatient\nDate/Time: at 10:38\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nGENERAL COMMENTS: A duplicate echocardiographic report was logged to this\npatient in error. No duplicate was generated.\n\nConclusions:\nA duplicate echocardiographic report was logged to this patient in error. No\nduplicate was generated.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2180-02-11 00:00:00.000",
"description": "Report",
"row_id": 102538,
"text": "PATIENT/TEST INFORMATION:\nIndication: .\nStatus: Inpatient\nDate/Time: at 10:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nGENERAL COMMENTS: A duplicate echocardiographic report was logged to this\npatient in error. No duplicate was generated.\n\nConclusions:\nA duplicate echocardiographic report was logged to this patient in error. No\nduplicate was generated.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2180-02-11 00:00:00.000",
"description": "Report",
"row_id": 293687,
"text": "Sinus bradycardia. Lateral T wave changes which are non-specific. Compared to\nthe previous tracing of there is no significant diagnostic change.\n\n"
}
] |
81,719 | 182,771 | This is a 88 yo M admitted for abdominal pain and hypotension, transferred to the unit for evaluation of new UGI bleed in setting of anticoagulation. # Hypotension/Shock. Felt initially to be hypovolemia in setting of GIB and poor po intake. He received IVF and blood (4 units total) and hcts remained stable. Patient also with poor CO (EF 25%) and some concern for cardiogenic shock so IVF given conservatively after initial boluses in ED. Patient then developed rapid AF and had MAPs in 40s. He was started on neosynephrine with good result. Digoxin was started as below and when patient remained in NSR BPs were in 110s/60s and the neo was turned off. In the setting of the hypotension he did develop ARF and ALF as noted below. After initiation of CVVH, hypotension continued and mental status deteriorated. Goals of care were transitioned to comfort measures after discussion with his family and he died less than 24 hours after CVVH was discontinued. Family and PCP were notified. Family declined autopsy. # Coffee ground emesis - Thought likely upper GI source in setting of therapeutic INR, ddx included PUD, ASA-induced gastritis, malignancy. Gi was consulted and wanted to perform EGD when INR< 2. He was given FFP and INR decreased however Hct remained stable after 2units pRBCs and he did not have further emesis so scope was deferred. Hct continued to remain stable and GI eventually decided to have EGD as o/p. He was on PPI gtt X 72 hours then transitioned to IV and later PO BID. His diet was advanced slowly. Coumadin and ASA were held. | - Treat AF as below with dig, beta blocker - Follow perfusion status with UOP, CvO2, lactate, liver function, mentation - Would give IVF cautiously if requires given CHF - If need to restart pressors, would use neo - Check repeat Hct later this am # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since dig loading. - Treat AF as below with dig, beta blocker - Follow perfusion status with UOP, CvO2, lactate, liver function, mentation - Would give IVF cautiously if requires given CHF - If need to restart pressors, would use neo - Check repeat Hct later this am # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since dig loading. Likely pre-renal given patient's fluid depleted clinical status - gentle IVF given EF - check UA and urine lytes - will hold on kayexelate pending procedure - recheck lytes in pm . Possible C/O today Atrial fibrillation (Afib) Assessment: Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2 hrs, BP stable, asymptomatic. - Treat AF as below with dig, beta blocker - If requires pressors, would resume neo - Follow perfusion status with UOP, CvO2, lactate, liver function, mentation - Would give IVF cautiously if requires given CHF # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since dig loading; current dig level 1.4. Required Neo overnight this AM is trending down slightly lactate stable. Required Neo overnight this AM is trending down slightly lactate stable. Possible C/O today Atrial fibrillation (Afib) Assessment: Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2 hrs, BP stable ,asymptomatic. Hypotension: resolving, off Neo, on Digoxin with stable level. - Treat AF as below with dig, beta blocker - If requires pressors, would resume neo - Follow perfusion status with UOP, CvO2, lactate, liver function, mentation - Would give IVF cautiously if requires given CHF # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since dig loading; dig level today 1.2. Likely pre-renal given patient's fluid depleted clinical status - gentle IVF given EF - check UA and urine lytes - will hold on kayexelate pending procedure - recheck lytes in pm . Renal to f/u and start HD if needed. Renal to f/u and start HD if needed. Possible C/O today Atrial fibrillation (Afib) Assessment: Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2 hrs, BP stable, asymptomatic. Possible C/O today Atrial fibrillation (Afib) Assessment: Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2 hrs, BP stable, asymptomatic. encephalopathy, titrate to 1 BM/day # Altered mental status: unclear cause, may be delirium from encephalopathy, uremia, hemodynamics; appears improved this am - cte to treat a-fib and ARF as indicated - lactulose as above - consider Haldol if QTc okay - minimizes lines/drains. Hypotension: resolving, off Neo, on Digoxin with stable level. - Decreased O2 sats -> CXR with retrocardiac opacity concerning for PNA. Anemia: DDX blood loss - HCT relatively stable maybe slow GI ooze. Likely pre-renal given patient's fluid depleted clinical status - gentle IVF given EF - check UA and urine lytes - will hold on kayexelate pending procedure - recheck lytes in pm . - Rx AF as below - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr - If requires pressors, would continue with neo - Follow perfusion status with UOP, LFTs, INR, mentation, skin exam, CvO2 # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since dig loading; current dig level 1.3. - Liberalize po fluid intake today - Monitor U/O - Wean pressor as tolerated # Demand Ischemia/Heart Failure: CPK trending down. Hypotension (not Shock) Assessment: Received multiple boluses of IVf d/t hypotension. - Rx AF as below - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr - If requires pressors, would continue with neo - Follow perfusion status with UOP, LFTs, INR, mentation, skin exam, CvO2 # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since dig loading; current dig level 1.3. - Rx AF as below - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr - If requires pressors, would continue with neo - Follow perfusion status with UOP, LFTs, INR, mentation, skin exam, CvO2 # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since dig loading; current dig level 1.3. EKGs old LBBB, initial troponins were neg. EKG done, Levophed stopped and neosynephrine started. EKG done, Levophed stopped and neosynephrine started. Pt hypotensive with MODs including ARF, r/I for MI with troponin 1.8, and shock liver. Pt hypotensive with MODs including ARF, r/I for MI with troponin 1.8, and shock liver. Pt hypotensive with MODs including ARF, r/I for MI with troponin 1.8, and shock liver. Pt hypotensive with MODs including ARF, r/I for MI with troponin 1.8, and shock liver. Pt was given 1L NS bolus, protonix bolus and transfered for MICU for further w/u and endoscopy. MS returned to baseline, and pt is A + O x . Plan: Cont w/ supp O2 in the setting of arrhythmia, hypotension, and AMS. EKG done, Levophed stopped and neosynephrine started. Repeat lytes sent, K 4.3 with out correction. Repeat lytes sent, K 4.3 with out correction. Repeat lytes sent, K 4.3 with out correction. Response: Repeat ABG on NRB 7.34/30/156. Response: Repeat ABG on NRB 7.34/30/156. Pt was given 1L NS bolus, protonix bolus and transfered for MICU for further w/u and endoscopy. Poss remove aline today Hypoxemia Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: - Rx AF as below - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr - If requires pressors, would continue with neo - Follow perfusion status with UOP, LFTs, INR, mentation, skin exam, CvO2 # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since dig loading; current dig level 1.3. | 198 | [
{
"category": "Nursing",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581661,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581753,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - Family agreed to temporary CVVH. If he clears from uremia, can\n re-address with patient desire for HD.\n - Renal: Attempted IJ dialysis catheter, but were unable to place it so\n Right femoral HD line was placed. Started on CVVH in evening after\n receiving 4 u FFP, SBP dropped to 80\ns briefly when CVVH paused for\n filter issue/change. A-line placed, neo restarted at 0.5 mcg/min.\n - Hct dropped this am from 34 ->28, repeat Hct this am\n - Will have to change dig dose per pharmacy for CVVH dosing. Get levels\n QOD until stable.\n - Liver: Said monitor Bili levels for more days and if still\n elevated -> redo RUQ U/S as he had sludge on his last exam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 75 (66 - 84) bpm\n BP: 104/45(66) {102/45(66) - 111/55(74)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 1,814 mL\n 910 mL\n PO:\n 260 mL\n TF:\n IVF:\n 428 mL\n 910 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 603 mL\n Urine:\n 905 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/27/117/18/-2\n Physical Examination\n Gen: Somnolent elderly man wearing bair-hugger\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB, no wheezes\n Abd: Soft, non-tender, non-distended, +bowel sounds\n Ext: Warm, well-perfused\n Neuro: Oriented to person only\n Labs / Radiology\n 159 K/uL\n 10.2 g/dL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 28.2 %\n 14.8 K/uL\n [image002.jpg]\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n Hct\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n Plt\n 59\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Concerning for hypovolemic etiology in setting of new\n Hct drop and fluid shifts in CVVH, also concerning for cardiogenic in\n this patient with acute on chronic CHF. Pressors restarted early this\n am. Mostly in sinus for most of past 24 hours. Transaminitis and\n lactate stabilizing, suggesting improved perfusion state however mental\n status significantly worse this am. CXR with increased opacities at\n bases bilaterally, possible pleural effusions.\n - Treat AF as below with dig, beta blocker\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n - Check repeat am Hct, transfuse if continues to drop\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Discussed with pharmacy. Will switch to daily digoxin dosing given\n dig level today.\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; had maroon colored stools\n 3 days ago and 2 bowel tarry bowel movements yesterday. Now with new\n Hct drop.\n - continue PO PPI\n - start bowel regimen with colace/senna\n - Repeat check Hct this am, transfuse for Hct <30\n - Will repeat the Hct later today.\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs,\n started CVVH yesterday. Bicarb d/c\ned now that on CVVH. need HD\n once more hemodynamically stable.\n - Monitor lytes\n - Monitor mental status\n - Liberalize po fluid intake\n - F/u renal recs\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n - CXR tomorrow morning.\n - d/c foley.\n - Continue to watch pt.\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. Bili\n mostly direct (19 direct, 22.5 total). abd U/S with no specific\n cholecystitis signs or biliary dilatation. Started on ursodiol and\n sarna for itching, could consider cholestyramine.\n - Trend LFTs, amylase, lipase\n - Per liver recs, will continue trending Tbili for next 48 hours, if no\n improvement will consider repeat RUQ u/s\n - MRCP/ERCP on hold pending increased patient stability\n - F/u liver recs\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # AMS: Confusion at night with non-focal neuro exam. have element\n of sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: Low sodium, renal diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 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"
},
{
"category": "Physician ",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581963,
"text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - dig dosing changed to qday while on CVVH, to be changed back when\n CVVH discontinued\n - repeat Hct improved at 32.7\n - neo weaned to off yesterday am with SBP's maintained in 110's-120's\n - renal: will change CVVH bath to avoid alkalosis\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 03:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 75 (62 - 83) bpm\n BP: 110/46(69) {82/40(54) - 136/68(85)} mmHg\n RR: 17 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 435 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 435 mL\n Blood products:\n Total out:\n 5,802 mL\n 185 mL\n Urine:\n 310 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 250 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.36/38/77\n Physical Examination\n Gen: Elderly man, somnolent, NAD\n HEENT: Sclera icteria, MMM\n CV: RRR, no m/r/g\n Lungs: CTAB, no w/r/r\n Abd: Soft, non-tender, non-distended, + bowel sounds\n Ext: 1+ edema in bilateral lower extremities, warm\n Neuro: Oriented to person only, does not answer questions appropriately\n Labs / Radiology\n 147\n 11.1\n 82\n 1.8 mg/dL\n 18\n 3.6 mEq/L\n 52\n 104\n 138 mEq/L\n 30.4\n 18.4 K/uL\n [image002.jpg]\n 07:30 PM\n 07:45 PM\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n WBC\n 14.8\n 17.1\n Hct\n 28.2\n 30.7\n 32.7\n Plt\n 159\n 181\n Cr\n 5.4\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n TCO2\n 19\n 21\n 19\n Glucose\n 75\n 63\n 68\n 64\n 80\n 79\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:9.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver.\n .\n # Hypotension: Concerning for hypovolemic etiology in setting of new\n Hct drop and fluid shifts in CVVH. Hct improved over the course of the\n day, however again slightly decreased this morning. Patient has also\n had significantly better perfusion over hospital course when in sinus\n instead of afib; appears to have been in afib throughout last 24\n hours. Pressors not restarted. Transaminitis, INR and lactate\n stabilizing, suggesting improved perfusion state however mental status\n significantly worse this am (difficult to interpret in setting of\n continued elevated BUN). CXR with increased opacities at bases\n bilaterally, possible pleural effusions. Patient afebrile and without\n growth on cultures but with WBC that continues to creep up, concerning\n for possible evolving septic picture.\n - Continue to follow Hct\n - Treat AF as below with dig, beta blocker\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n - If need to restart pressors, would use neo\n - Check repeat Hct later this am\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Discussed with pharmacy. Will switch to daily digoxin dosing given\n dig level today.\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; continues to have tarry\n black stool (several times yesterday). PO PPI changed to IV for\n difficulty swallowing. Bowel regimen held for several BM over the day.\n - hold bowel regimen with colace/senna\n - Repeat check Hct this am, transfuse for Hct <30\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs,\n started CVVH yesterday. Bicarb d/c\ned now that on CVVH. need HD\n once more hemodynamically stable.\n - Monitor lytes\n - Monitor mental status\n - Liberalize po fluid intake\n - F/u renal recs\n # Leukocytosis: Pt afebrile, but on CVVH. Cx without growth, c diff\n negative x 1, CXR without obvious infiltrate .\n - repeat blood, urine cx, repeat c.difff\n - Continue to trend WBC, temp.\n # AMS: Confusion at night with non-focal neuro exam. have element\n of sundowning + contribution from elevated BUN, possible evolving\n underlying infection given rise in leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising. abd U/S with\n no specific cholecystitis signs or biliary dilatation. Started on\n ursodiol and sarna for itching, could consider cholestyramine.\n - Trend LFTs, amylase, lipase\n - Per liver recs, will continue trending Tbili for next 24 hours, if no\n improvement will consider repeat RUQ u/s\n - MRCP/ERCP on hold pending increased patient stability\n - F/u liver recs\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed, neo as\n pressor to maintain MAP >65\n - Monitor on telemetry\n ICU Care\n Nutrition: Renal, heart-health\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), OK to intubate\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581750,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - Family agreed to temporary CVVH. If he clears from uremia, can\n re-address with patient desire for HD.\n - Renal: Attempted IJ dialysis catheter, but were unable to place it so\n Right femoral HD line was placed. Started on CVVH in evening after\n receiving 4 u FFP, SBP dropped to 80\ns briefly when CVVH paused for\n filter issue/change. A-line placed, neo restarted at 0.5 mcg/min.\n - Hct dropped this am from 34 ->28, repeat Hct this am\n - Will have to change dig dose per pharmacy for CVVH dosing. Get levels\n QOD until stable.\n - Liver: Said monitor Bili levels for more days and if still\n elevated -> redo RUQ U/S as he had sludge on his last exam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 75 (66 - 84) bpm\n BP: 104/45(66) {102/45(66) - 111/55(74)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 1,814 mL\n 910 mL\n PO:\n 260 mL\n TF:\n IVF:\n 428 mL\n 910 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 603 mL\n Urine:\n 905 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/27/117/18/-2\n Physical Examination\n Gen: Somnolent elderly man wearing bair-hugger\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB, no wheezes\n Abd: Soft, non-tender, non-distended, +bowel sounds\n Ext: Warm, well-perfused\n Neuro: Oriented to person only\n Labs / Radiology\n 159 K/uL\n 10.2 g/dL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 28.2 %\n 14.8 K/uL\n [image002.jpg]\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n Hct\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n Plt\n 59\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Concerning for hypovolemic etiology in setting of new\n Hct drop and fluid shifts in CVVH, also concerning for cardiogenic in\n this patient with acute on chronic CHF. Pressors restarted early this\n am. Mostly in sinus for most of past 24 hours. Transaminitis and\n lactate stabilizing, suggesting improved perfusion state however mental\n status significantly worse this am. CXR with increased opacities at\n bases bilaterally, possible pleural effusions.\n - Treat AF as below with dig, beta blocker\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n - Check repeat am Hct, transfuse if continues to drop\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Discussed with pharmacy. Keep same dig dose on CVVH.\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; had maroon colored stools\n 3 days ago and 2 bowel tarry bowel movements yesterday. Now with new\n Hct drop.\n - continue PO PPI\n - start bowel regimen with colace/senna\n - Repeat check Hct this am, transfuse for Hct <30\n - Will repeat the Hct later today.\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs,\n started CVVH yesterday. Bicarb d/c\ned now that on CVVH. need HD\n once more hemodynamically stable.\n - Monitor lytes\n - Monitor mental status\n - Liberalize po fluid intake\n - F/u renal recs\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n - CXR tomorrow morning.\n - d/c foley.\n - Continue to watch pt.\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. Bili\n mostly direct (19 direct, 22.5 total). abd U/S with no specific\n cholecystitis signs or biliary dilatation. Started on ursodiol and\n sarna for itching, could consider cholestyramine.\n - Trend LFTs, amylase, lipase\n - Per liver recs, will continue trending Tbili for next 48 hours, if no\n improvement will consider repeat RUQ u/s\n - MRCP/ERCP on hold pending increased patient stability\n - F/u liver recs\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # AMS: Confusion at night with non-focal neuro exam. have element\n of sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: Low sodium, renal diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 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"
},
{
"category": "Physician ",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581411,
"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 EKG - At 09:00 PM\n EKG - At 09:06 PM\n Afib w abberancy last PM\n 7.36/29/110 bicarb 17\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\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 11:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 119) bpm\n BP: 113/56(74) {86/41(60) - 130/73(87)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 367 mL\n PO:\n 970 mL\n 250 mL\n TF:\n IVF:\n 1,158 mL\n 117 mL\n Blood products:\n Total out:\n 820 mL\n 450 mL\n Urine:\n 820 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n -83 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.36/29/110/15/-7\n Physical Examination\n Gen: sitting in chair, NAD\n HEENT: dry o/p ++ icterus\n CV: RR\n Chest; fair air movement\n Abd: distended, +BS\n Ext: min edema\n Neuro: conversant but confused\n Labs / Radiology\n 11.8 g/dL\n 213 K/uL\n 101 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 144 mg/dL\n 109 mEq/L\n 142 mEq/L\n 34.1 %\n 16.8 K/uL\n [image002.jpg]\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n 16.8\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n Plt\n 18\n 213\n Cr\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 135\n 98\n 110\n 141\n 128\n 101\n Other labs: PT / PTT / INR:22.9/32.5/2.2, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:457/241, Alk Phos / T Bili:619/20.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.1 mg/dL, Mg++:2.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by intermittent AF c RVR.\n 1. Hypotension: resolving, off Neo, on Digoxin with stable level.\n Whereas yesterday he could not maintain BP to get OOB to chiar he is\n now doing so.\n 2. GIB: has been stable HCT, no further stools, PPI.\n 3. For , continue supportive care as above. Bblocker,\n 4. ARF: dense but Cr appears to have plateaued. UOP continues; hope to\n avoid HD as hemodynamics are optimized but need to follow closely Avoid\n all nehrotixins, renalally dose all meds, Nabicarn is a large salt load\n ask renal any alternatives.\n 5. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Had been discussion of ERCP to look\n but on hold for now. If not start to fall can re evaluate but no fevers\n ro other concerning signs.\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication:\n Code status: DNR (do not resuscitate) but OK to intubate\n Disposition :ICU\n Total time spent: 35\n be able to go to floor if BP stable\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581822,
"text": "Altered mental status (not Delirium)\n Assessment:\n +transaminitis, uremia, prob ICU delirium; increased\n confusion/disorientation\npt unable to maintain conversation; speech\n slurred/garbled at times, mouth dry; lethargic, closing eyes\n frequently; needing to repeat directions to assist with turns\n Action:\n Reorientated and reassurance provided; safety measures maintained\n Response:\n Easily redirected; making no attempts to get OOB; non-combative; making\n no attempts to interfere with lines/treatment; equal grasps/strength,\n PERL, smile symmetrical-no neuro deficits noted otherwise\n Plan:\n Cont to evaluate mental status; anticipate improvement in mental status\n as uremia and other existing factors improve; freq safety checks.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Started on CRRT last evening\n Action:\n Replacement fluid changed to B22K4; citrate d/c\nd; neo weaned; very\n positional right groin line; labs drawn\n Response:\n Min clots noted to filter since citrate d/c\nd; adequate SBP\ns; multiple\n flushes required to maintain patency of filter/line; access and return\n lines switched with improvement in flow; labs pnd. Improvement in\n BUN/Cr since intiation of CRRt. Cont to make some urine, 230cc this\n shift\n Plan:\n Cont with Crrt. Next labs due 0200hrs.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Hx melena stools; jaundiced; abdomen nontender to deep palpation\n Action:\n Colace given; senna held d/t (2) stools last evening; Hct repeated d/t\n Hct drop noted\n Response:\n Multiple formed tarry black stools, OB + today; no frank blood noted.\n Taking sips water w/ meds; min intake of pudding/ice cream offered.\n Repeat hct improved, am hct prob dilutional;\n Plan:\n Next hct in am. Cont to assess for s/s bleeding\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581959,
"text": "Chief Complaint: heart failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 04:47 PM\n Off Neo all night, but restarted this AM for hypotensive\n CVVH machine malfunction - off\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\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 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.8\nC (96.4\n HR: 75 (62 - 78) bpm\n BP: 84/38(55) {82/38(54) - 136/68(85)} mmHg\n RR: 18 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 914 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 914 mL\n Blood products:\n Total out:\n 5,802 mL\n 315 mL\n Urine:\n 310 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.36/38/77/18/-3\n Physical Examination\n Labs / Radiology\n 11.1 g/dL\n 147 K/uL\n 82 mg/dL\n 1.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 52 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.4 %\n 18.4 K/uL\n [image002.jpg]\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n 05:12 AM\n 05:13 AM\n WBC\n 14.8\n 17.1\n 18.4\n Hct\n 28.2\n 30.7\n 32.7\n 30.4\n Plt\n 159\n 181\n 147\n Cr\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n 1.8\n TCO2\n 21\n 19\n 22\n Glucose\n 63\n 68\n 64\n 80\n 79\n 82\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:251/272, Alk Phos / T Bili:697/23.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n 1. Hypotension: DDx lower circ volume when started on CVVH versus blood\n loss anemia. Required Neo overnight\n this AM is trending down slightly\n lactate stable.\n 2. ARF: started CVVH last PM but dropping BPs with it and initiated Neo\n to support, better this AM as awakens, trying to wean off Neo. Continue\n CVVH- goal ultrafiltration. Re Dose all meds.\n 3. Anemia: DDX blood loss from line, no physical evidence of RP bleed\n after fem line, CT if HCT drops\n 4. Leukocytosis: pan culturing, rule out C diff., follow up urine\n culture\n 5. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, has not required any pharma intervention and is usually\n redirectable.\n 6. GIB: no active bleeding at present\n bowel movement yesterday\n 7. For , continue supportive care as above. Bblocker, Dig,\n 8. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Liver saw yesterday and would repeat\n RUQ if rising in next few days\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\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": "2102-06-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 582162,
"text": "Chief Complaint: CHF, afib, ARF\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 08:05 AM\n picc and aline\n Pulled foley, truam, urology had to be consulted, 3 way irrigation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Phenylephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Metoprolol - 08:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 71 (62 - 137) bpm\n BP: 94/41(58) {72/31(44) - 147/69(98)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,807 mL\n 1,861 mL\n PO:\n 120 mL\n 30 mL\n TF:\n IVF:\n 2,687 mL\n 1,831 mL\n Blood products:\n Total out:\n 2,725 mL\n 2,512 mL\n Urine:\n 150 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 82 mL\n -651 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.47/20/109/14/-5\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.2 g/dL\n 138 K/uL\n 74 mg/dL\n 1.2 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 05:12 AM\n 05:13 AM\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n WBC\n 18.4\n 22.0\n 16.2\n Hct\n 30.4\n 33.7\n 31.7\n Plt\n 147\n 182\n 138\n Cr\n 1.8\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 22\n 18\n 19\n 15\n Glucose\n 82\n 91\n 83\n 76\n 74\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n LEUKOCYTOSIS\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 582163,
"text": "Chief Complaint: CHF, afib, ARF\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 08:05 AM\n picc and aline\n Pulled foley, truam, urology had to be consulted, 3 way irrigation\n Back in and out of Sfib\n dropped BP and needed Neo again\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Phenylephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Metoprolol - 08:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 71 (62 - 137) bpm\n BP: 94/41(58) {72/31(44) - 147/69(98)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,807 mL\n 1,861 mL\n PO:\n 120 mL\n 30 mL\n TF:\n IVF:\n 2,687 mL\n 1,831 mL\n Blood products:\n Total out:\n 2,725 mL\n 2,512 mL\n Urine:\n 150 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 82 mL\n -651 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.47/20/109/14/-5\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 11.2 g/dL\n 138 K/uL\n 74 mg/dL\n 1.2 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 05:12 AM\n 05:13 AM\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n WBC\n 18.4\n 22.0\n 16.2\n Hct\n 30.4\n 33.7\n 31.7\n Plt\n 147\n 182\n 138\n Cr\n 1.8\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 22\n 18\n 19\n 15\n Glucose\n 82\n 91\n 83\n 76\n 74\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n LEUKOCYTOSIS\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n 1. Hypotension: DDx overdiuresed, bowel ischemia, cardiac dysfunction.\n At this point he is on Neo again, but we need to discuss with son\n overall goals of cared as he is not able to be hemodynamically\n supported without vasopressors. Repeat SCVO2 and lactate.\n 2. ARF: CVVH- machine malfunctioning\n but he is on pressors even\n without CVVH so may not be able to go back on\n will assess as day\n progresses\n 3. Anemia: DDX blood loss - HCT relatively stable\n maybe slow GI\n ooze.\n 4. Leukocytosis: pan culturing, empiric Rx for C diff with Flagyl\n 5. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, overall trajectory is down and even with BUN 150 to 50 he is\n worse.\n 6. GIB: no active bleeding at present\n bowel movement yesterday\n 7. For , continue supportive care as above. Bblocker, Dig,\n check level\n 8. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Depending on goals could repeat RUQ if\n no change by tomm Friday or spikes, rising WBC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 582166,
"text": "Chief Complaint: CHF, afib, ARF\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 08:05 AM\n picc and aline\n Pulled foley, truam, urology had to be consulted, 3 way irrigation\n Back in and out of Sfib\n dropped BP and needed Neo again\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Phenylephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Metoprolol - 08:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 71 (62 - 137) bpm\n BP: 94/41(58) {72/31(44) - 147/69(98)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,807 mL\n 1,861 mL\n PO:\n 120 mL\n 30 mL\n TF:\n IVF:\n 2,687 mL\n 1,831 mL\n Blood products:\n Total out:\n 2,725 mL\n 2,512 mL\n Urine:\n 150 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 82 mL\n -651 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.47/20/109/14/-5\n Physical Examination\n Gen\n HEENT\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 11.2 g/dL\n 138 K/uL\n 74 mg/dL\n 1.2 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 05:12 AM\n 05:13 AM\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n WBC\n 18.4\n 22.0\n 16.2\n Hct\n 30.4\n 33.7\n 31.7\n Plt\n 147\n 182\n 138\n Cr\n 1.8\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 22\n 18\n 19\n 15\n Glucose\n 82\n 91\n 83\n 76\n 74\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n LEUKOCYTOSIS\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n 1. Hypotension: DDx overdiuresed, bowel ischemia, cardiac dysfunction.\n At this point he is on Neo again, but we need to discuss with son\n overall goals of cared as he is not able to be hemodynamically\n supported without vasopressors. Repeat SCVO2 and lactate.\n 2. ARF: CVVH- machine malfunctioning\n but he is on pressors even\n without CVVH so may not be able to go back on\n will assess as day\n progresses\n 3. Anemia: DDX blood loss - HCT relatively stable\n maybe slow GI\n ooze.\n 4. Leukocytosis: pan culturing, empiric Rx for C diff with Flagyl\n 5. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, overall trajectory is down and even with BUN 150 to 50 he is\n worse.\n 6. GIB: no active bleeding at present\n bowel movement yesterday\n 7. For , continue supportive care as above. Bblocker, Dig,\n check level\n 8. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Depending on goals could repeat RUQ if\n no change by tomm Friday or spikes, rising WBC\n ICU Care\n Nutrition: cannot take pos due to poor mental status\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication:\n Code status: DNR (do not resuscitate)\n We need another family meeting today- He is at a point where his goals\n of care shoukdl shift to comfort as he cannot tolerate CVVH, has likely\n bowel ischemia, Afib, CHFand severe mental status decline\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 582174,
"text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - dig dosing changed to qday while on CVVH, to be changed back when\n CVVH discontinued\n - repeat Hct improved at 32.7\n - neo weaned to off yesterday am with SBP's maintained in 110's-120's\n - renal: will change CVVH bath to avoid alkalosis\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 03:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 75 (62 - 83) bpm\n BP: 110/46(69) {82/40(54) - 136/68(85)} mmHg\n RR: 17 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 435 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 435 mL\n Blood products:\n Total out:\n 5,802 mL\n 185 mL\n Urine:\n 310 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 250 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.36/38/77\n Physical Examination\n Gen: Elderly man, somnolent, NAD\n HEENT: Sclera icteria, MMM\n CV: RRR, no m/r/g\n Lungs: CTAB, no w/r/r\n Abd: Soft, non-tender, non-distended, + bowel sounds\n Ext: 1+ edema in bilateral lower extremities, warm\n Neuro: Oriented to person only, does not answer questions appropriately\n Labs / Radiology\n 147\n 11.1\n 82\n 1.8 mg/dL\n 18\n 3.6 mEq/L\n 52\n 104\n 138 mEq/L\n 30.4\n 18.4 K/uL\n [image002.jpg]\n 07:30 PM\n 07:45 PM\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n WBC\n 14.8\n 17.1\n Hct\n 28.2\n 30.7\n 32.7\n Plt\n 159\n 181\n Cr\n 5.4\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n TCO2\n 19\n 21\n 19\n Glucose\n 75\n 63\n 68\n 64\n 80\n 79\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:9.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver.\n .\n # Hypotension: Concerning for hypovolemic etiology in setting of new\n Hct drop and fluid shifts in CVVH. Hct improved over the course of the\n day, however again slightly decreased this morning. Patient has also\n had significantly better perfusion over hospital course when in sinus\n instead of afib; appears to have been in afib throughout last 24\n hours. Pressors not restarted. Transaminitis, INR and lactate\n stabilizing, suggesting improved perfusion state however mental status\n significantly worse this am (difficult to interpret in setting of\n continued elevated BUN). CXR with increased opacities at bases\n bilaterally, possible pleural effusions. Patient afebrile and without\n growth on cultures but with WBC that continues to creep up, concerning\n for possible evolving septic picture.\n - Continue to follow Hct\n - Treat AF as below with dig, beta blocker\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n - If need to restart pressors, would use neo\n - Check repeat Hct later this am\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Discussed with pharmacy. Will switch to daily digoxin dosing given\n dig level today.\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; continues to have tarry\n black stool (several times yesterday). PO PPI changed to IV for\n difficulty swallowing. Bowel regimen held for several BM over the day.\n - hold bowel regimen with colace/senna\n - Repeat check Hct this am, transfuse for Hct <30\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs,\n started CVVH yesterday. Bicarb d/c\ned now that on CVVH. need HD\n once more hemodynamically stable.\n - Monitor lytes\n - Monitor mental status\n - Liberalize po fluid intake\n - F/u renal recs\n # Leukocytosis: Pt afebrile, but on CVVH. Cx without growth, c diff\n negative x 1, CXR without obvious infiltrate .\n - repeat blood, urine cx, repeat c.difff\n - Continue to trend WBC, temp.\n # AMS: Confusion at night with non-focal neuro exam. have element\n of sundowning + contribution from elevated BUN, possible evolving\n underlying infection given rise in leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising. abd U/S with\n no specific cholecystitis signs or biliary dilatation. Started on\n ursodiol and sarna for itching, could consider cholestyramine.\n - Trend LFTs, amylase, lipase\n - Per liver recs, will continue trending Tbili for next 24 hours, if no\n improvement will consider repeat RUQ u/s\n - MRCP/ERCP on hold pending increased patient stability\n - F/u liver recs\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed, neo as\n pressor to maintain MAP >65\n - Monitor on telemetry\n ICU Care\n Nutrition: Renal, heart-health\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), OK to intubate\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 582176,
"text": "TITLE:\n 24 Hour Events:\n - Family meeting: family unable to make definitive decisions re\n goal/CVVH, so decision is to continue with current therapy then meet\n again Friday\n - started IV flagyl empirically for c. diff\n - CVVH continued without interruption overnight with improvements in\n BUN/Cre, however mental status remains poor\n - Patient with several episodes of afib+ RVR (self-resolved), neo off\n since 2pm yesterday with intermittend fluid bolus producing SBP\ns in\n the 100\ns-110\n - RN replaced foley, small amount of bright red blood returned.\n Attempts at flushing failed to return any urine\n suspicion for clot.\n Foley pulled with removal of clot. 3-way foley placed and CBI started,\n urology consulted and recommended hand irrigation until good flow\n demonstrated (then could start CBI). Briefly hand irrigated, then\n stopped. In early am, urology able to evacuate clot from small\n contracted bladder\n -Urology to follow up on patient in afternoon.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.4\nC (95.7\n HR: 73 (69 - 89) bpm\n BP: 108/43(65) {82/37(53) - 147/69(98)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,807 mL\n 1,440 mL\n PO:\n 120 mL\n 30 mL\n TF:\n IVF:\n 2,687 mL\n 1,410 mL\n Blood products:\n Total out:\n 2,725 mL\n 1,867 mL\n Urine:\n 150 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 82 mL\n -426 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.47/20/109/14/-5\n Physical Examination\n Gen:\n HEENT:\n CV:\n Lungs:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 138 K/uL\n 11.2 g/dL\n 74 mg/dL\n 1.2 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 05:12 AM\n 05:13 AM\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n WBC\n 18.4\n 22.0\n 16.2\n Hct\n 30.4\n 33.7\n 31.7\n Plt\n 147\n 182\n 138\n Cr\n 1.8\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 22\n 18\n 19\n 15\n Glucose\n 82\n 91\n 83\n 76\n 74\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver.\n .\n # Hypotension: Concerning for cardiogenic etiology since patient has\n been intermittently in afib, also fluid shifts in CVVH .Hct\n stabilized. Transaminitis, INR and lactate stabilizing, suggesting\n improved perfusion state however mental status remains poor.\n - Recheck dig level today\n - Treat AF as below with dig, beta blocker\n - Continue to follow Hct\n - Would give IVF cautiously if requires given CHF\n - If need to restart pressors, would use neo for goal MAP >65\n - Follow perfusion status with CvO2, lactate, liver function, mentation\n # A-fib with RVR v. SVT with aberrancy: In afib again overnight after\n ~48 hours in sinus.\n - Rate control with metoprolol\n - Continue dig and recheck level today\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; continues to have tarry\n black stool. On IV PPI. Bowel regimen held for several BM over the\n day.\n - hold bowel regimen with colace/senna\n - Follow Hct, transfuse for Hct <30\n # Acute Renal Failure: On CVVH but mental status is persistently poor.\n Likely ATN due to hypotension per renal recs, started CVVH yesterday.\n Not stable enough for HD per renal note.\n - Family meeting friday\n - Monitor lytes\n - Monitor mental status\n - F/u renal recs\n # Leukocytosis: Pt afebrile, but on CVVH. WBC improved today on empiric\n flagyl for ?c. diff. and abdominal exam difficult to interpret. Cx\n without growth, c diff negative x 2.\n - follow cx\n - CXR in tomorrow am\n - Continue to trend WBC, temp.\n # AMS: Confusion initially only at night but patient now consistently\n confused, A+O x1. Initially thought to be due to uremia, however BUN\n much improved on CVVH and MS not improved. No obvious infectious\n source. Altered MS may represent end-organ hypoperfusion.\n - Continue leukocytosis w/u as above\n - manage hypotension as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising. abd U/S with\n no specific cholecystitis signs or biliary dilatation.\n - Trend LFTs, amylase, lipase\n - continue ursadiol, sarna\n - F/u liver recs, for Tbili persistently climbing (22\n 25), consider\n RUQ u/s\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed, neo as\n pressor to maintain MAP >65\n - recheck BNP\n - Monitor on telemetry\n ICU Care\n Nutrition: Cardiac, renal diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 582183,
"text": "TITLE:\n 24 Hour Events:\n - Family meeting: family unable to make definitive decisions re\n goal/CVVH, so decision is to continue with current therapy then meet\n again Friday\n - started IV flagyl empirically for c. diff\n - CVVH continued without interruption overnight with improvements in\n BUN/Cre, however mental status remains poor\n - Patient with several episodes of afib+ RVR (self-resolved), neo off\n since 2pm yesterday with intermittend fluid bolus producing SBP\ns in\n the 100\ns-110\n - RN replaced foley, small amount of bright red blood returned.\n Attempts at flushing failed to return any urine\n suspicion for clot.\n Foley pulled with removal of clot. 3-way foley placed and CBI started,\n urology consulted and recommended hand irrigation until good flow\n demonstrated (then could start CBI). Briefly hand irrigated, then\n stopped. In early am, urology able to evacuate clot from small\n contracted bladder\n -Urology to follow up on patient in afternoon.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.4\nC (95.7\n HR: 73 (69 - 89) bpm\n BP: 108/43(65) {82/37(53) - 147/69(98)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,807 mL\n 1,440 mL\n PO:\n 120 mL\n 30 mL\n TF:\n IVF:\n 2,687 mL\n 1,410 mL\n Blood products:\n Total out:\n 2,725 mL\n 1,867 mL\n Urine:\n 150 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 82 mL\n -426 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.47/20/109/14/-5\n Physical Examination\n Gen:\n HEENT:\n CV:\n Lungs:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 138 K/uL\n 11.2 g/dL\n 74 mg/dL\n 1.2 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 05:12 AM\n 05:13 AM\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n WBC\n 18.4\n 22.0\n 16.2\n Hct\n 30.4\n 33.7\n 31.7\n Plt\n 147\n 182\n 138\n Cr\n 1.8\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 22\n 18\n 19\n 15\n Glucose\n 82\n 91\n 83\n 76\n 74\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver.\n .\n # Hypotension: Concerning for cardiogenic etiology since patient has\n been intermittently in afib, also fluid shifts in CVVH .Hct\n stabilized. Transaminitis, INR and lactate stabilizing, suggesting\n improved perfusion state however mental status remains poor.\n - Recheck dig level today\n - Treat AF as below with dig, beta blocker\n - Continue to follow Hct\n - Would give IVF cautiously if requires given CHF\n - If need to restart pressors, would use neo for goal MAP >65\n - Follow perfusion status with CvO2, lactate, liver function, mentation\n # A-fib with RVR v. SVT with aberrancy: In afib again overnight after\n ~48 hours in sinus.\n - Rate control with metoprolol\n - Continue dig and recheck level today\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; continues to have tarry\n black stool. On IV PPI. Bowel regimen held for several BM over the\n day.\n - hold bowel regimen with colace/senna\n - Follow Hct, transfuse for Hct <30\n # Acute Renal Failure: On CVVH but mental status is persistently poor.\n Likely ATN due to hypotension per renal recs, started CVVH yesterday.\n Not stable enough for HD per renal note.\n - Family meeting friday\n - Monitor lytes\n - Monitor mental status\n - F/u renal recs\n # Leukocytosis: Pt afebrile, but on CVVH. WBC improved today on empiric\n flagyl for ?c. diff. and abdominal exam difficult to interpret. Cx\n without growth, c diff negative x 2.\n - follow cx\n - CXR in tomorrow am\n - Continue to trend WBC, temp.\n # AMS: Confusion initially only at night but patient now consistently\n confused, A+O x1. Initially thought to be due to uremia, however BUN\n much improved on CVVH and MS not improved. No obvious infectious\n source. Altered MS may represent end-organ hypoperfusion.\n - Continue leukocytosis w/u as above\n - manage hypotension as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising. abd U/S with\n no specific cholecystitis signs or biliary dilatation.\n - Trend LFTs, amylase, lipase\n - continue ursadiol, sarna\n - F/u liver recs, for Tbili persistently climbing (22\n 25), consider\n RUQ u/s\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed, neo as\n pressor to maintain MAP >65\n - recheck BNP\n - Monitor on telemetry\n ICU Care\n Nutrition: Cardiac, renal diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581936,
"text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - dig dosing changed to qday while on CVVH, to be changed back when\n CVVH discontinued\n - repeat Hct improved at 32.7\n - neo weaned to off yesterday am with SBP's maintained in 110's-120's\n - renal: will change CVVH bath to avoid alkalosis\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 03:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 75 (62 - 83) bpm\n BP: 110/46(69) {82/40(54) - 136/68(85)} mmHg\n RR: 17 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 435 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 435 mL\n Blood products:\n Total out:\n 5,802 mL\n 185 mL\n Urine:\n 310 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 250 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.43/28/94./17/-3\n Physical Examination\n Labs / Radiology\n 181 K/uL\n 11.0 g/dL\n 79 mg/dL\n 2.2 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 55 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.7 %\n 17.1 K/uL\n [image002.jpg]\n 07:30 PM\n 07:45 PM\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n WBC\n 14.8\n 17.1\n Hct\n 28.2\n 30.7\n 32.7\n Plt\n 159\n 181\n Cr\n 5.4\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n TCO2\n 19\n 21\n 19\n Glucose\n 75\n 63\n 68\n 64\n 80\n 79\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:9.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver.\n .\n # Hypotension: Concerning for hypovolemic etiology in setting of new\n Hct drop and fluid shifts in CVVH. Hct improved over the course of the\n day, however again slightly decreased this morning. Patient has also\n had significantly better perfusion over hospital course when in sinus\n instead of afib; appears to have been in afib throughout last 24\n hours. Pressors not restarted. Transaminitis, INR and lactate\n stabilizing, suggesting improved perfusion state however mental status\n significantly worse this am (difficult to interpret in setting of\n continued elevated BUN). CXR with increased opacities at bases\n bilaterally, possible pleural effusions. Patient afebrile and without\n growth on cultures but with WBC that continues to creep up, concerning\n for possible evolving septic picture.\n - Treat AF as below with dig, beta blocker\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n - If need to restart pressors, would use neo\n - Check repeat Hct later this am\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Discussed with pharmacy. Will switch to daily digoxin dosing given\n dig level today.\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; continues to have tarry\n black stool (several times yesterday). PO PPI changed to IV for\n difficulty swallowing. Bowel regimen held for several BM over the day.\n - hold bowel regimen with colace/senna\n - Repeat check Hct this am, transfuse for Hct <30\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs,\n started CVVH yesterday. Bicarb d/c\ned now that on CVVH. need HD\n once more hemodynamically stable.\n - Monitor lytes\n - Monitor mental status\n - Liberalize po fluid intake\n - F/u renal recs\n # Leukocytosis: Pt afebrile, but on CVVH. Cx without growth, c diff\n negative x 1, CXR without obvious infiltrate .\n - f/u Ucx, CXR, stool for C. diff.\n - Continue to trend WBC, temp.\n # AMS: Confusion at night with non-focal neuro exam. have element\n of sundowning + contribution from elevated BUN, possible evolving\n underlying infection given rise in leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising. abd U/S with\n no specific cholecystitis signs or biliary dilatation. Started on\n ursodiol and sarna for itching, could consider cholestyramine.\n - Trend LFTs, amylase, lipase\n - Per liver recs, will continue trending Tbili for next 24 hours, if no\n improvement will consider repeat RUQ u/s\n - MRCP/ERCP on hold pending increased patient stability\n - F/u liver recs\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed, neo as\n pressor to maintain MAP >65\n - Monitor on telemetry\n ICU Care\n Nutrition: Renal, heart-health\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), OK to intubate\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581939,
"text": "Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - dig dosing changed to qday while on CVVH, to be changed back when\n CVVH discontinued\n - repeat Hct improved at 32.7\n - neo weaned to off yesterday am with SBP's maintained in 110's-120's\n - renal: will change CVVH bath to avoid alkalosis\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 03:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 75 (62 - 83) bpm\n BP: 110/46(69) {82/40(54) - 136/68(85)} mmHg\n RR: 17 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 435 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 435 mL\n Blood products:\n Total out:\n 5,802 mL\n 185 mL\n Urine:\n 310 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 250 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.36/38/77\n Physical Examination\n Gen: Elderly man, somnolent, NAD\n HEENT: Sclera icteria, MMM\n CV: RRR, no m/r/g\n Lungs: CTAB, no w/r/r\n Abd: Soft, non-tender, non-distended, + bowel sounds\n Ext: 1+ edema in bilateral lower extremities, warm\n Neuro: Oriented to person only, does not answer questions appropriately\n Labs / Radiology\n 147\n 11.1\n 82\n 1.8 mg/dL\n 18\n 3.6 mEq/L\n 52\n 104\n 138 mEq/L\n 30.4\n 18.4 K/uL\n [image002.jpg]\n 07:30 PM\n 07:45 PM\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n WBC\n 14.8\n 17.1\n Hct\n 28.2\n 30.7\n 32.7\n Plt\n 159\n 181\n Cr\n 5.4\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n TCO2\n 19\n 21\n 19\n Glucose\n 75\n 63\n 68\n 64\n 80\n 79\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:9.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver.\n .\n # Hypotension: Concerning for hypovolemic etiology in setting of new\n Hct drop and fluid shifts in CVVH. Hct improved over the course of the\n day, however again slightly decreased this morning. Patient has also\n had significantly better perfusion over hospital course when in sinus\n instead of afib; appears to have been in afib throughout last 24\n hours. Pressors not restarted. Transaminitis, INR and lactate\n stabilizing, suggesting improved perfusion state however mental status\n significantly worse this am (difficult to interpret in setting of\n continued elevated BUN). CXR with increased opacities at bases\n bilaterally, possible pleural effusions. Patient afebrile and without\n growth on cultures but with WBC that continues to creep up, concerning\n for possible evolving septic picture.\n - Treat AF as below with dig, beta blocker\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n - If need to restart pressors, would use neo\n - Check repeat Hct later this am\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Discussed with pharmacy. Will switch to daily digoxin dosing given\n dig level today.\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; continues to have tarry\n black stool (several times yesterday). PO PPI changed to IV for\n difficulty swallowing. Bowel regimen held for several BM over the day.\n - hold bowel regimen with colace/senna\n - Repeat check Hct this am, transfuse for Hct <30\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs,\n started CVVH yesterday. Bicarb d/c\ned now that on CVVH. need HD\n once more hemodynamically stable.\n - Monitor lytes\n - Monitor mental status\n - Liberalize po fluid intake\n - F/u renal recs\n # Leukocytosis: Pt afebrile, but on CVVH. Cx without growth, c diff\n negative x 1, CXR without obvious infiltrate .\n - repeat blood, urine cx, repeat c.difff\n - Continue to trend WBC, temp.\n # AMS: Confusion at night with non-focal neuro exam. have element\n of sundowning + contribution from elevated BUN, possible evolving\n underlying infection given rise in leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising. abd U/S with\n no specific cholecystitis signs or biliary dilatation. Started on\n ursodiol and sarna for itching, could consider cholestyramine.\n - Trend LFTs, amylase, lipase\n - Per liver recs, will continue trending Tbili for next 24 hours, if no\n improvement will consider repeat RUQ u/s\n - MRCP/ERCP on hold pending increased patient stability\n - F/u liver recs\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed, neo as\n pressor to maintain MAP >65\n - Monitor on telemetry\n ICU Care\n Nutrition: Renal, heart-health\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), OK to intubate\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581962,
"text": "Chief Complaint: heart failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 04:47 PM\n Off Neo all night, but restarted this AM for hypotensive\n CVVH machine malfunction - off\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\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 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.8\nC (96.4\n HR: 75 (62 - 78) bpm\n BP: 84/38(55) {82/38(54) - 136/68(85)} mmHg\n RR: 18 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 914 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 914 mL\n Blood products:\n Total out:\n 5,802 mL\n 315 mL\n Urine:\n 310 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.36/38/77/18/-3\n Physical Examination\n Gen: lying in bed on CVVH\n CV: irreg irreg\n Chest: poor air movement\n Abd:soft + BS\n Ext: right groin line\n Labs / Radiology\n 11.1 g/dL\n 147 K/uL\n 82 mg/dL\n 1.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 52 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.4 %\n 18.4 K/uL\n [image002.jpg]\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n 05:12 AM\n 05:13 AM\n WBC\n 14.8\n 17.1\n 18.4\n Hct\n 28.2\n 30.7\n 32.7\n 30.4\n Plt\n 159\n 181\n 147\n Cr\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n 1.8\n TCO2\n 21\n 19\n 22\n Glucose\n 63\n 68\n 64\n 80\n 79\n 82\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:251/272, Alk Phos / T Bili:697/23.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n 1. Hypotension: DDx overdiuresed, bowel ischemia, cardiac dysfunction.\n At this point he is on Neo again, but we need to discuss with son\n overall goals of cared as he is not able to be hemodynamically\n supported without vasopressors.\n 2. ARF: CVVH- machine malfunctioning\n but he is on pressors even\n without CVVH so may not be able to go back on\n 3. Anemia: DDX blood loss -\n 4. Leukocytosis: pan culturing, empiric Rx for C diff with Flagyl\n 5. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, overall trajectory is down\n 6. GIB: no active bleeding at present\n bowel movement yesterday\n 7. For , continue supportive care as above. Bblocker, Dig,\n 8. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Liver saw yesterday and would repeat\n RUQ if rising in next few days\n ICU Care\n Nutrition: as able but poor mental status today\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: family meeting\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582266,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582267,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582268,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n Events: Family meeting held yesterday () and due to MSO and poor\n prognosis pt\ns status changed to CMO. Family grieving appropriately\n and asking appropriate questions.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581396,
"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 EKG - At 09:00 PM\n EKG - At 09:06 PM\n Afib w abberancy last PM\n 7.36/29/110 bicarb 17\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\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 11:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 119) bpm\n BP: 113/56(74) {86/41(60) - 130/73(87)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 367 mL\n PO:\n 970 mL\n 250 mL\n TF:\n IVF:\n 1,158 mL\n 117 mL\n Blood products:\n Total out:\n 820 mL\n 450 mL\n Urine:\n 820 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n -83 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.36/29/110/15/-7\n Physical Examination\n Labs / Radiology\n 11.8 g/dL\n 213 K/uL\n 101 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 144 mg/dL\n 109 mEq/L\n 142 mEq/L\n 34.1 %\n 16.8 K/uL\n [image002.jpg]\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n 16.8\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n Plt\n 18\n 213\n Cr\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 135\n 98\n 110\n 141\n 128\n 101\n Other labs: PT / PTT / INR:22.9/32.5/2.2, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:457/241, Alk Phos / T Bili:619/20.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.1 mg/dL, Mg++:2.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by AF c RVR.\n 1. Hypotension: Improving, off Neo, on Digoxin, but still hypotensive\n if stands or OOB\n 2. GIB had been stable but passed maroon stools yest thought stable\n HCT, PPI.\n 3. For , continue supportive care as above. Bblocker,\n 4. ARF is slightly better, UOP is up when in NSR; hope to avoid HD as\n hemodynamics are optimized.\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\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": "2102-06-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581398,
"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 EKG - At 09:00 PM\n EKG - At 09:06 PM\n Afib w abberancy last PM\n 7.36/29/110 bicarb 17\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\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 11:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 119) bpm\n BP: 113/56(74) {86/41(60) - 130/73(87)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 367 mL\n PO:\n 970 mL\n 250 mL\n TF:\n IVF:\n 1,158 mL\n 117 mL\n Blood products:\n Total out:\n 820 mL\n 450 mL\n Urine:\n 820 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n -83 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.36/29/110/15/-7\n Physical Examination\n Gen: sitting in bed, NAD\n HEENT: extremely dry o/p ++ icterus\n CV: RR\n Chest; fair air movement\n Abd: distended, +BS\n Ext: min edema\n Labs / Radiology\n 11.8 g/dL\n 213 K/uL\n 101 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 144 mg/dL\n 109 mEq/L\n 142 mEq/L\n 34.1 %\n 16.8 K/uL\n [image002.jpg]\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n 16.8\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n Plt\n 18\n 213\n Cr\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 135\n 98\n 110\n 141\n 128\n 101\n Other labs: PT / PTT / INR:22.9/32.5/2.2, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:457/241, Alk Phos / T Bili:619/20.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.1 mg/dL, Mg++:2.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by AF c RVR.\n 1. Hypotension: Improving, off Neo, on Digoxin, but still hypotensive\n if stands or OOB\n 2. GIB had been stable but passed maroon stools yest thought stable\n HCT, PPI.\n 3. For , continue supportive care as above. Bblocker,\n 4. ARF is slightly better, UOP is up when in NSR; hope to avoid HD as\n hemodynamics are optimized.\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\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": "2102-06-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581400,
"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 EKG - At 09:00 PM\n EKG - At 09:06 PM\n Afib w abberancy last PM\n 7.36/29/110 bicarb 17\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\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 11:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.5\nC (95.9\n HR: 70 (70 - 119) bpm\n BP: 113/56(74) {86/41(60) - 130/73(87)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 367 mL\n PO:\n 970 mL\n 250 mL\n TF:\n IVF:\n 1,158 mL\n 117 mL\n Blood products:\n Total out:\n 820 mL\n 450 mL\n Urine:\n 820 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n -83 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: 7.36/29/110/15/-7\n Physical Examination\n Gen: sitting in chair, NAD\n HEENT: extremely dry o/p ++ icterus\n CV: RR\n Chest; fair air movement\n Abd: distended, +BS\n Ext: min edema\n Neuro: conversant but confused\n Labs / Radiology\n 11.8 g/dL\n 213 K/uL\n 101 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 4.0 mEq/L\n 144 mg/dL\n 109 mEq/L\n 142 mEq/L\n 34.1 %\n 16.8 K/uL\n [image002.jpg]\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n 16.8\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n Plt\n 18\n 213\n Cr\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 135\n 98\n 110\n 141\n 128\n 101\n Other labs: PT / PTT / INR:22.9/32.5/2.2, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:457/241, Alk Phos / T Bili:619/20.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.1 mg/dL, Mg++:2.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by intermittent AF c RVR.\n 1. Hypotension: resolving, off Neo, on Digoxin with stable level.\n 2. GIB: had been stable but passed maroon stools yest thought stable\n HCT, PPI.\n 3. For , continue supportive care as above. Bblocker,\n 4. ARF is stable, UOP is up when in NSR; hope to avoid HD as\n hemodynamics are optimized.\n 5. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication:\n Code status: DNR (do not resuscitate) bur OK to intubate\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581401,
"text": "Chief Complaint:\n 24 Hour Events:\n - Renal: Cont bicarb. Creatinine increase likely hypotension but\n encouraged because euvolemic and still with good UOP.\n - Dry on exam so received two 500cc NS boluses\n - Called for slow VT with AMS. EKG showed same rhythm as before at rate\n 100bpm - LBBB with AFib. Neuro exam non-focal with delirium but\n otherwise no neurologic deficits. Lytes with low calcium (1.01). gave\n 2gm calcium. ABG with metabolic acidosis but nl PO2. Thought to be\n sundowning with no new arrhythmia.\n - Labs notable for TSH (0.17) and T4 (3) low\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.7\nC (96.3\n HR: 80 (74 - 119) bpm\n BP: 113/52(67) {86/27(40) - 127/72(82)} mmHg\n RR: 15 (13 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 254 mL\n PO:\n 970 mL\n 200 mL\n TF:\n IVF:\n 1,158 mL\n 54 mL\n Blood products:\n Total out:\n 820 mL\n 110 mL\n Urine:\n 820 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: 7.36/29/110/15/-7\n Physical Examination\n GEN: NAD\n HEENT: Jaundiced, sclericterus\n LUNGS: CTA b/l\n HEART: Regular\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 218 K/uL\n 12.3 g/dL\n 128 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 3.9 mEq/L\n 142 mg/dL\n 110 mEq/L\n 140 mEq/L\n 38\n 13.0 K/uL\n [image002.jpg]\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n Plt\n 18\n Cr\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 158\n 135\n 98\n 110\n 141\n 128\n Other labs: Ca++:8.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.8 mg/dL. TSH 0.17, T4\n 3. Dig 1.3.\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for GIB although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below with dig, beta blocker\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n - increase diet today and consider IVF cautiously given CHF if\n requires.\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Started metoprolol for rate control with stable pressures\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given GIB\n # Leukocytosis: Pt afebrile.\n - Check U/A, Ucx, stool for C. diff.\n - Consider CXR if spikes\n # GIB: Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower GIB. Hcts stable.\n - Check Hct QD\n - Transfuse for Hct <30\n - PPI IV BID ->change to PO today\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and beta blocker\n - Monitor on telemetry\n - consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Dry on exam yesterday with rise in Cr to 4.8 from 4 and decrease U/O\n - Cont bicarb per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n # Transaminitis: Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Consider ERCP in future if TBili does not resolve\n # Thyroid: Question of central hypothyroidism with low TSH and T4.\n - Consider checking free T4\n # AMS: Now resolved. Consider PT and OOB to chair today after IVF so\n less likely to have hypotension.\n ICU Care\n Nutrition: DM, Cardiac\n Glycemic Control: ISS\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI po bid\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok to intubate\n Disposition: Possible call out this PM if remain BP stable when OOB\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581404,
"text": "Chief Complaint:\n 24 Hour Events:\n - Renal: Creatinine increase likely hypotension but encouraged\n because euvolemic and still with good UOP. He did receive 500cc NS\n boluses x 2 as dry on exam.\n - Called for slow VT with AMS. EKG showed same rhythm as before at rate\n 100bpm - LBBB with AFib. Neuro exam non-focal with delirium but\n otherwise no neurologic deficits. Lytes with low calcium (1.01). gave\n 2gm calcium. ABG with metabolic acidosis but nl PO2. Thought to be\n sundowning with no new arrhythmia.\n - Labs notable for TSH (0.17) and T4 (3) low\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.7\nC (96.3\n HR: 80 (74 - 119) bpm\n BP: 113/52(67) {86/27(40) - 127/72(82)} mmHg\n RR: 15 (13 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 254 mL\n PO:\n 970 mL\n 200 mL\n TF:\n IVF:\n 1,158 mL\n 54 mL\n Blood products:\n Total out:\n 820 mL\n 110 mL\n Urine:\n 820 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: 7.36/29/110/15/-7\n Physical Examination\n GEN: NAD\n HEENT: Jaundiced, sclericterus\n LUNGS: CTA b/l\n HEART: Regular\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3 and conversant although less interative today\n Labs / Radiology\n 213 K/uL\n 11.8 g/dL\n 101 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 4 mEq/L\n 144 mg/dL\n 109 mEq/L\n 142 mEq/L\n 34.1\n 16.8 K/uL\n [image002.jpg]\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n Plt\n 18\n Cr\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 158\n 135\n 98\n 110\n 141\n 128\n Other labs: INR 2.2., Ca 9.1, Mg 2.6, P 4. ALT 457, AST 241, AP 619,\n Tbili 20.9. TSH 0.17, T4 3. Dig 1.4.\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Off pressors since 3am on . Had another episode of\n AF with RVR overnight but did not develop hypotension. Able to maintain\n BP while sitting up this AM, an improvement from yesterday.\n Transaminitis and UOP improving with nl lactate, suggesting improved\n perfusion state. Did have maroon colored stools on concerning for\n GIB but Hct stable.\n - Treat AF as below with dig, beta blocker\n - If requires pressors, would resume neo\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.4.\n - Continue metoprolol\n - Continue dig and follow levels\n - Monitor ECG, tele\n - If his HR increases, will try lopressor and neo if he requires\n pressors as above\n - No anticoagulation given GIB\n - F/u cards recs\n # Leukocytosis: Pt afebrile. Source unclear.\n - U/A, Ucx, stool for C. diff.\n - Consider CXR if spikes (occasional cough RN)\n # GIB: Admitted with coffee ground emesis but had maroon colored stools\n 2 days ago suggesting lower GIB. Hcts stable.\n - Check Hct daily\n - Transfuse for Hct <30\n - PPI IV BID ->change to PO today\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Cr curve flattening at 4.8, has some U/O.\n - Cont bicarb for now per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving although Tbili still rising; may lag. abd\n U/S with mildly improved gallbladder appearance with sludge and mild\n wall thickening; no specific cholecystitis signs or biliary dilatation.\n Started on ursodiol and sarna for itching.\n - Trend LFTs, amylase, lipase\n - Started sarna/ursodiol for itching; could consider cholestyramine\n - F/u liver recs; will ask Liver if Tbili elevation out of proportion\n to expectation with shock liver; consider ERCP in future if TBili does\n not resolve\n # Thyroid: Question of central hypothyroidism with low TSH and T4.\n - Checking free T4\n # AMS: Confusion at night with nonfocal neuro exam. have element of\n sundowning. Could also represent delirium in setting, ? underlying\n infection given rise in leukocytosis although afebrile\n - Leukocytosis w/u as above\n - OOB to chair\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: DM, Cardiac\n Glycemic Control: ISS\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI po bid\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok to intubate\n Disposition: Possible call out this PM if remain BP stable when OOB\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 582139,
"text": "TITLE:\n 24 Hour Events:\n - Family meeting: family unable to make definitive decisions re\n goal/CVVH, so decision is to continue with current therapy then meet\n again Friday\n - started IV flagyl empirically for c. diff\n - CVVH continued without interruption overnight with improvements in\n BUN/Cre, however mental status remains poor\n - Patient with several episodes of afib+ RVR (self-resolved), neo off\n since 2pm yesterday with intermittend fluid bolus producing SBP\ns in\n the 100\ns-110\n - RN replaced foley, small amount of bright red blood returned.\n Attempts at flushing failed to return any urine\n suspicion for clot.\n Foley pulled with removal of clot. 3-way foley placed and CBI started,\n urology consulted and recommended hand irrigation until good flow\n demonstrated (then could start CBI). Briefly hand irrigated, then\n stopped. In early am, urology able to evacuate clot from small\n contracted bladder\n -Urology to follow up on patient in afternoon.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.4\nC (95.7\n HR: 73 (69 - 89) bpm\n BP: 108/43(65) {82/37(53) - 147/69(98)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,807 mL\n 1,440 mL\n PO:\n 120 mL\n 30 mL\n TF:\n IVF:\n 2,687 mL\n 1,410 mL\n Blood products:\n Total out:\n 2,725 mL\n 1,867 mL\n Urine:\n 150 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 82 mL\n -426 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.47/20/109/14/-5\n Physical Examination\n Gen:\n HEENT:\n CV:\n Lungs:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 138 K/uL\n 11.2 g/dL\n 74 mg/dL\n 1.2 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 05:12 AM\n 05:13 AM\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n WBC\n 18.4\n 22.0\n 16.2\n Hct\n 30.4\n 33.7\n 31.7\n Plt\n 147\n 182\n 138\n Cr\n 1.8\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 22\n 18\n 19\n 15\n Glucose\n 82\n 91\n 83\n 76\n 74\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physician Surgical Progress Note",
"row_id": 582145,
"text": "TITLE:\n 24 Hour Events:\n - Family meeting: family unable to make definitive decisions re\n goal/CVVH, so decision is to continue with current therapy then meet\n again Friday\n - started IV flagyl empirically for c. diff\n - CVVH continued without interruption overnight with improvements in\n BUN/Cre, however mental status remains poor\n - Patient with several episodes of afib+ RVR (self-resolved), neo off\n since 2pm yesterday with intermittend fluid bolus producing SBP\ns in\n the 100\ns-110\n - RN replaced foley, small amount of bright red blood returned.\n Attempts at flushing failed to return any urine\n suspicion for clot.\n Foley pulled with removal of clot. 3-way foley placed and CBI started,\n urology consulted and recommended hand irrigation until good flow\n demonstrated (then could start CBI). Briefly hand irrigated, then\n stopped. In early am, urology able to evacuate clot from small\n contracted bladder\n -Urology to follow up on patient in afternoon.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 PM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.4\nC (95.7\n HR: 73 (69 - 89) bpm\n BP: 108/43(65) {82/37(53) - 147/69(98)} mmHg\n RR: 17 (13 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,807 mL\n 1,440 mL\n PO:\n 120 mL\n 30 mL\n TF:\n IVF:\n 2,687 mL\n 1,410 mL\n Blood products:\n Total out:\n 2,725 mL\n 1,867 mL\n Urine:\n 150 mL\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 82 mL\n -426 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.47/20/109/14/-5\n Physical Examination\n Gen:\n HEENT:\n CV:\n Lungs:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 138 K/uL\n 11.2 g/dL\n 74 mg/dL\n 1.2 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 05:12 AM\n 05:13 AM\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n WBC\n 18.4\n 22.0\n 16.2\n Hct\n 30.4\n 33.7\n 31.7\n Plt\n 147\n 182\n 138\n Cr\n 1.8\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 22\n 18\n 19\n 15\n Glucose\n 82\n 91\n 83\n 76\n 74\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver.\n .\n # Hypotension: Concerning for cardiogenic etiology since patient has\n been intermittently in afib, also fluid shifts in CVVH .Hct\n stabilized. Transaminitis, INR and lactate stabilizing, suggesting\n improved perfusion state however mental status remains poor.\n - Recheck dig level today\n - Treat AF as below with dig, beta blocker\n - Continue to follow Hct\n - Would give IVF cautiously if requires given CHF\n - If need to restart pressors, would use neo for goal MAP >65\n - Follow perfusion status with CvO2, lactate, liver function, mentation\n # A-fib with RVR v. SVT with aberrancy: In afib again overnight after\n ~48 hours in sinus.\n - Rate control with metoprolol\n - Continue dig and recheck level today\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; continues to have tarry\n black stool. On IV PPI. Bowel regimen held for several BM over the\n day.\n - hold bowel regimen with colace/senna\n - Follow Hct, transfuse for Hct <30\n # Acute Renal Failure: On CVVH but mental status is persistently poor.\n Likely ATN due to hypotension per renal recs, started CVVH yesterday.\n Not stable enough for HD per renal note.\n - Family meeting friday\n - Monitor lytes\n - Monitor mental status\n - F/u renal recs\n # Leukocytosis: Pt afebrile, but on CVVH. WBC improved today on empiric\n flagyl for ?c. diff. and abdominal exam difficult to interpret. Cx\n without growth, c diff negative x 2.\n - follow cx\n - CXR in tomorrow am\n - Continue to trend WBC, temp.\n # AMS: Confusion initially only at night but patient now consistently\n confused, A+O x1. Initially thought to be due to uremia, however BUN\n much improved on CVVH and MS not improved. No obvious infectious\n source. Altered MS may represent end-organ hypoperfusion.\n - Continue leukocytosis w/u as above\n - manage hypotension as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising. abd U/S with\n no specific cholecystitis signs or biliary dilatation.\n - Trend LFTs, amylase, lipase\n - continue ursadiol, sarna\n - F/u liver recs, for Tbili persistently climbing (22\n 25), consider\n RUQ u/s\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed, neo as\n pressor to maintain MAP >65\n - recheck BNP\n - Monitor on telemetry\n ICU Care\n Nutrition: Cardiac, renal diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581923,
"text": "Chief Complaint:\n 24 Hour Events:\n - dig dosing changed to qday while on CVVH, to be changed back when\n CVVH discontinued\n - repeat Hct improved at 32.7\n - neo weaned to off yesterday am with SBP's maintained in 110's-120's\n - renal: will change CVVH bath to avoid alkalosis\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 03:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 75 (62 - 83) bpm\n BP: 110/46(69) {82/40(54) - 136/68(85)} mmHg\n RR: 17 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 435 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 435 mL\n Blood products:\n Total out:\n 5,802 mL\n 185 mL\n Urine:\n 310 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 250 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.43/28/94./17/-3\n Physical Examination\n Labs / Radiology\n 181 K/uL\n 11.0 g/dL\n 79 mg/dL\n 2.2 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 55 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.7 %\n 17.1 K/uL\n [image002.jpg]\n 07:30 PM\n 07:45 PM\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n WBC\n 14.8\n 17.1\n Hct\n 28.2\n 30.7\n 32.7\n Plt\n 159\n 181\n Cr\n 5.4\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n TCO2\n 19\n 21\n 19\n Glucose\n 75\n 63\n 68\n 64\n 80\n 79\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:9.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n therapeutic INR, ddx includes PUD, ASA-induced gastritis, malignancy.\n - EGD to evaluate for active bleeding, will need reversal of\n anticoagulation prior to INR < 2.0, give 2 u FFP and repeat INR\n - has received 2 u pRBC now for decreased Hct, check Hct q6hr\n - continue PPI gtt\n - f/u GI recs\n - access = 3 PIV\n - hold ASA, coumadin\n .\n # Hypotension- Patient with poor CO (EF 25%) and clinically volume\n depleted. Increasing anion gap (12 -> 16) with lactate 2.2 further\n supports hypo-perfusion. Has received 2 L in ED and 1 L on floor, 2 u\n pRBC and 3 u FFP.\n - Gentle fluids given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - place a-line\n - continue monitoring on tele\n .\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.1 with K 5.7, no EKG changes. Likely pre-renal given patient's\n fluid depleted clinical status\n - gentle IVF given EF\n - check UA and urine lytes\n - will hold on kayexelate pending procedure\n - recheck lytes in pm\n .\n # Transaminitis/Abdominal pain- Possibly due to irritation caused by\n blood in abdomen, however components of history sound like biliary\n colic (transient pain in a band-like distribution, improved with\n belching and resolved within hours on arrival to ED). Does not sound\n like anginal equivalent, first two sets CE negative. LFT's with\n markedly elevated AST and ALT, hyperbilirubinemia (primarily\n conjugated) suggesting obstructive picture.\n - trend LFT's, amylase, lipase\n - RUQ u/s\n - continue ROMI\n .\n # Heart Failure- most recent EF 25% with severe hypokinesis. Has been\n anticoagulated to prevent intra-ventricular thrombus formation.\n Currently appears volume depleted, goal is to keep patient euvolemic.\n - volume repletion to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n - SvO2 and lactate wnl\n .\n #DM\n - hold glyburide while inpatient\n - RISS\n .\n # HTN\n - hold HCTZ, beta-blocker and ACE inhibitor in setting of GI bleed\n .\n # Nutrition: NPO for procedure\n .\n # Prophylaxis: pneumoboots, IV PPI\n ICU Care\n Nutrition: Renal, heart-health\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582045,
"text": "Hypotension (not Shock)\n Assessment:\n Off neo gtt in am; remained on dialysis thru yesterday with SBP\n 110-130\ns and able to tolerate removal of 900cc by 12MN; SBP in\n 90-100\ns on nights; progressively hypotensive in am\n Action:\n Bolused with 250cc NS for SBP 70-80\ns with HR 60-80\ns; coinciding with\n NIBP\n Response:\n Min response with bolus; started on phenylephrine gtt for large part of\n am; able to wean off by early afternoon\n Plan:\n Cont to monitor BP/HR; cont on low dose lopressor for HR control of\n afib; fluid goal\neven.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Issues overnight with CRRT machine resulting in break in CRRT cycle;\n remains hypotensive and not a candidate for HD; good response to CRRT\n as noted with decreased BUN/CR\n Action:\n Further issue with CRRT machine resulting in 3.5 hr loss of dialysis\n time; restarted for even goal; Renal attending spoke at length with\n daughter re: plans/prognosis\n Response:\n Tolerating CRRT; line flushing with ease. Requiring freq rescue line\n flushes resulting in pt being +800cc as of this writing\n Plan:\n Next protocol labs due 1800hrs. Attempt slow removal of fluid from\n rescue line accumulation. If pt does not tolerate removal of fluid,\n restart neo gtt and then resume removal of fluid for even goal. Cont\n with CRRT; re-eval plan in days. renal continues to follow\n Altered mental status (not Delirium)\n Assessment:\n Multifactoral issues as etiology for decreased mental status/lethargy;\n unresponsive with am team rounds.\n Action:\n Mental status closely monitored; cont to receive no\n sedatives/narcotics.\n Response:\n Pt more alert in late afternoon with family present; remains confused\n and orientated to person only. Appears less restless/apprehensive\n Plan:\n Cont to monitor mental status. Safety measures. Re-orient prn.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582132,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n Events Overnight: foley changed d/t new uti having been in place x 10\n days. Insertion was uneventful and initial output was a small amount of\n icteric appearing urine. A couple of hours later, pt was noted to have\n 10cc of grossly bloody output; the foley was subsequently irrigated\n with ~200cc ns for a much smaller amount of bloody return. The micu\n team was made aware and a larger 3-way foley was placed to initiate a\n cbi. Following insertion of the larger foley, the pt continued to have\n a poor return of instilled ns that was again grossly bloody but without\n clots. Urology was called and eventually came in to aggressively\n irrigate the foley for a moderate amount of clot. A cbi was started\n ~0430; there has been no discernable uop since the initiation of the\n cbi.\n Leukocytosis\n Assessment:\n Afebrile on CRRT. Remains on abx coverage for a new uti. WBC trending\n slightly downward today.\n Action:\n Foley changed out with above complication.\n Response:\n CBI infusing a moderate rate with a light pink output.\n Plan:\n Continue to monitor trend is wbc, repeat ua/cx when appropriate. Per\n urology, cbi may be d/c\nd when output is clear.\n Altered mental status (not Delirium)\n Assessment:\n No change in confused mental status although the pt has been more\n agitated and uncooperative this morning. He removed line dressings,\n oximeter probes, and was found pulling at the dialysis line. Motor\n function is unchanged.\n Action:\n After multiple attempts to reorient and redirect, wrist restraints were\n applied for the pt\ns own safety.\n Response:\n Pt is calmer but continues to be confused and restless.\n Plan:\n Follow mental status, reorient frequently. Remove restraints when pt is\n calmer.\n Hypotension (not Shock)\n Assessment:\n Pt has had several episodes af with rvr which resulted in transient\n periods of hypotension to sbp\ns 70\ns ~0630.\n Action:\n He received a total of 400cc ns in fluid boluses with improvement in hr\n and blood pressure. Neo drip is available at the bedside if needed.\n Response:\n Resolution of tachycardia with improvement in blood pressure.\n Plan:\n Monitor hemodynamic status closely. ?increasing beta blocker dosage for\n improved rate control.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT continued without interruption overnight. Uremia continues to\n improve despite lack of improvement in mental status. Pt also tolerated\n aggressive fluid removal to achieve an overall even fluid balance for\n the past 24 hours.\n Action:\n Pt received several fluid boluses for above mentioned hypotension\n essentially negating any fluid loss goals over the past 24 hours.\n Response:\n Hemodynamically stable at the present time. Uremia essentially\n resolved.\n Plan:\n Continue CRRT for the next 1-2 days as per discussion with the renal\n service and family. Pt remains too unstable to transition to HD at this\n time.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582369,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt asytolic at 950 am\n Action:\n Pt unresponsive, med with dilaudid 0.5mg iv prn for air hunger\n Pt asytolic at 950am for >1 minute. Team notified\n Family present in room\n Pt prounounced by Dr \n Response:\n Pt expired\n Plan:\n Pt expired, family notified\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582363,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt asytolic at 950 am\n Action:\n Pt unresponsive, med with dilaudid 0.5mg iv prn for air hunger\n Pt asytolic at 950am for >1 minute. Team notified\n Family present in room\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2102-06-30 00:00:00.000",
"description": "ICU Event Note",
"row_id": 582365,
"text": "Clinician: Resident\n Called by RN to assess patient as monitor displayed asystole at 9:50\n am. Patient non-responsive to sternal rub, no spontaneous movements, no\n heart tones or spontaneous respirations, no corneal reflex. Patient\n pronounced deceased at 9;50 am. Chief cause of death heart failure,\n antecedent causes of death renal failure and gastrointestinal bleeding.\n PCP notified, family and next of notified of death. No indication\n for medical examiner case.\n Total time spent: 15 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582109,
"text": "Leukocytosis\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582110,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n Leukocytosis\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 582336,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Family meeting: patient made CMO\n - a-line d/c\ned, pressors d/c\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Metoprolol - 08:45 AM\n Dextrose 50% - 10:15 AM\n Hydromorphone (Dilaudid) - 04:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 78 (62 - 137) bpm\n BP: 85/38(49) {54/20(28) - 95/71(76)} mmHg\n RR: 11 (9 - 24) insp/min\n SpO2: 94%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,430 mL\n 36 mL\n PO:\n 30 mL\n TF:\n IVF:\n 2,375 mL\n 36 mL\n Blood products:\n Total out:\n 3,702 mL\n 300 mL\n Urine:\n 1,110 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,272 mL\n -264 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: 7.46/24/107/16/-4\n Physical Examination\n Gen:\n HEENT:\n CV:\n Lungs:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 138 K/uL\n 11.2 g/dL\n 75 mg/dL\n 1.2 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 33 mg/dL\n 105 mEq/L\n 136 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n 11:39 AM\n 11:54 AM\n WBC\n 22.0\n 16.2\n Hct\n 33.7\n 31.7\n Plt\n 182\n 138\n Cr\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 18\n 19\n 15\n 18\n Glucose\n 91\n 83\n 76\n 74\n 75\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 582343,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Family meeting: patient made CMO\n - a-line d/c\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Metoprolol - 08:45 AM\n Dextrose 50% - 10:15 AM\n Hydromorphone (Dilaudid) - 04:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 78 (62 - 137) bpm\n BP: 85/38(49) {54/20(28) - 95/71(76)} mmHg\n RR: 11 (9 - 24) insp/min\n SpO2: 94%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,430 mL\n 36 mL\n PO:\n 30 mL\n TF:\n IVF:\n 2,375 mL\n 36 mL\n Blood products:\n Total out:\n 3,702 mL\n 300 mL\n Urine:\n 1,110 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,272 mL\n -264 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: 7.46/24/107/16/-4\n Physical Examination\n Gen: Snoring, elderly jaundiced man\n HEENT: Pupils pinpoint, dry MM\n CV: RRR, no murmurs\n Lungs: Poor air movement, coarse breath sounds\n Abd: faint bowel sounds, non-tender\n Ext: 1+ edema, warm\n Neuro: Does not arouse to voice\n Labs / Radiology\n No new labs today, yesterday\ns labs:\n 138 K/uL\n 11.2 g/dL\n 75 mg/dL\n 1.2 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 33 mg/dL\n 105 mEq/L\n 136 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n 11:39 AM\n 11:54 AM\n WBC\n 22.0\n 16.2\n Hct\n 33.7\n 31.7\n Plt\n 182\n 138\n Cr\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 18\n 19\n 15\n 18\n Glucose\n 91\n 83\n 76\n 74\n 75\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, acute on chronic CHF, ARF necessitating\n CVVH, shock liver. Patient made CMO yesterday.\n #Comfort\n - Dilaudid 0.5 mg q1hr:prn\n - Diphenhydramine, sarna for itching\n - Zofran prn for nausea\n # Hypotension: A-line d/c\ned, NBP\ns in 80\ns/40\ns. Pressors off since\n 1 pm yesterday, dig and beta-blockers also d/c\n # A-fib with RVR v. SVT with aberrancy: Has been intermittently in\n afib, all cardiac meds off.\n #Anemia: GI bleed\n - no new labs\n # Acute Renal Failure: CVVH d/c\n # Leukocytosis:\n - no new labs\n - c. diff negative, so d/c precautions\n # AMS: Patient somnolent, not arousing to voice\n - comfort as above\n # Transaminitis: No new labs\n - treat itching with diphenhydramine, sarna\n ICU Care\n Nutrition: Cardiac diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Prophylaxis:\n DVT: CMO\n Stress ulcer: CMO\n VAP: CMO\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition: callout to private room today\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582295,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n MICU course eventful for vasopressors intermittently and CRRT\n treatments.\n Events: Family meeting held yesterday () and due to MSO and poor\n prognosis pt\ns status changed to CMO. Family grieving appropriately\n and asking appropriate questions. Vigil at bedside by family all\n evening and into the early morning hours.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Arouses to verbal stimulation with eye opening, moving upper\n extremities, inconsisitently following commands during evening with\n increasing unresponsiveness, periods of restlessness, HR labile 50-110\n SR with bursts of Afib, freq. PVC\ns, BP= 55-95/40\ns, RR=, resp.\n status initially nonlabored and regular with progression to\n Cheynne- respirations, Sats 84-96% on room air. NS bladder\n irrigant infusing via 3-way Foley with hematuria still present.\n Action:\n Dilaudid IV PRN for comfort, restlessness, labored resp\n status----0.5mg x 4 doses, Dilaudid gtt held, Benadryl and Sarna lotion\n for pruritis, skin care, support offered to pt and family\n Response:\n Good response with 0.5 mg IV Dilaudid prn---no gtt necessary for\n comfort at this time, Good effect with IV Benadryl and topical Sarna\n lotion as pt not scratching as much and less restless, appears\n comfortable with no grimacing or moaning\n Plan:\n Continue CMO---start Dilaudid gtt if unable to get pt comfortable with\n prn Dilaudid, continue application of Sarna for pruritis. Family\n contact at home at 0315 for change in pt\ns condition as HR and\n breathing with increased freq. in irregularity and pt with apneic\n periods---pt\ns son arrived at 0345 and was updated on pt\n condition and is sitting at pt\ns bedside.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582296,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n MICU course eventful for vasopressors intermittently and CRRT\n treatments.\n Events: Family meeting held yesterday () and due to MSO and poor\n prognosis pt\ns status changed to CMO. Family grieving appropriately\n and asking appropriate questions. Vigil at bedside by family all\n evening and into the early morning hours.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Arouses to verbal stimulation with eye opening, moving upper\n extremities, inconsisitently following commands during evening with\n increasing unresponsiveness, periods of restlessness, HR labile 50-110\n SR with bursts of Afib, freq. PVC\ns, BP= 55-95/40\ns, RR=, resp.\n status initially nonlabored and regular with progression to\n Cheynne- respirations, Sats 84-96% on room air. NS bladder\n irrigant infusing via 3-way Foley with hematuria still present.\n Action:\n Dilaudid IV PRN for comfort, restlessness, labored resp\n status----0.5mg x 4 doses, Dilaudid gtt held, Benadryl and Sarna lotion\n for pruritis, skin care, support offered to pt and family\n Response:\n Good response with 0.5 mg IV Dilaudid prn---no gtt necessary for\n comfort at this time, Good effect with IV Benadryl and topical Sarna\n lotion as pt not scratching as much and less restless, appears\n comfortable with no grimacing or moaning\n Plan:\n Continue CMO---start Dilaudid gtt if unable to get pt comfortable with\n prn Dilaudid, continue application of Sarna for pruritis. Family\n contact at home at 0315 for change in pt\ns condition as HR and\n breathing with increased freq. in irregularity and pt with apneic\n periods---pt\ns son arrived at 0345 and was updated on pt\n condition and is sitting at pt\ns bedside.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581509,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be 20-30cc/hr. Renal evaluated yesterday, pt may require HD\n next week if renal fxn worsens.\n Action:\n Sent renal function with morning AM labs.\n Response:\n BUN 155(144) and Cr5.1(4.8)\n Plan:\n Closely monitor UOP. Follow up with renal regarding future plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt got more confused at night goes, pulling out gown and monitor wires,\n easily redirectable. Alert and oriented x2, lethargic. MAE, cont follow\n commands. Pt more confused when woken from a sleeping state. Denies\n any pain.\n Action:\n Frequent reorientation and emotional support. Provide calm and quiet\n environment and Bed alarm on.\n Response:\n Pt sleeping on and off.\n Plan:\n Provide frequent orientation. Emotional support. Possible C/O\n today\n Atrial fibrillation (Afib)\n Assessment:\n Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2\n hrs, BP stable, asymptomatic. On 2L sats 94-96%\n Action:\n Lopressor 12.5 mg TID given. . Pneumo boots in place.\n Response:\n Cont NSR to Afib. Dig level 2.1 with morning lab.\n Plan:\n Monitor rate and rhythm, cont lopressor\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581630,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n Events: Pt was initially c/o to the floor, however while awaiting\n transfer was seen by the renal team and per renal rec\ns was ordered to\n start CVVHD. R fem HD line placed at bedside, orders placed and pt will\n start CVVHD tonight.\n More confused & somnolent today & less directable. Oliguria persists\n with approx 20ml of sedimentated urine per hr. . Family cont to visit\n daily and kept up to date with pt status/POC. Catholic priest visited\n pt @ BS on \n Surveillance blood and urine cultures sent this am r/t leukocytosis.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Approx 20ml of sedimentated yellow urine output per hour today. AM Cr\n value trending up with a value of 5.1. Renal evaluated pt @ BS, pt may\n require HD if renal fxn worsens. The pt\ns FB is currently net\n postitive over nine liters for LOS. No obvious anasarca @ BS, mucous\n membranes appear dry. seen by renal this am.\n Action:\n Team holding additional fluid boluses @ this time given severe HF and\n very poor renal fxn. Ordered for CVVHD r/t ? labile b/p. Line placed\n at bedside as above.\n Response:\n Suboptimal urine output persists\n Plan:\n Cont to follow urine output trend, keep team up to date with I/O data.\n To start CVVHD this evening.\n Altered mental status (not Delirium)\n Assessment:\n Pt slightly more confused/encephalopathic, lethargic and less\n directable today despitestable BP values all shift. The pt has been\n essentially AAO times one to two for the past 2 days.(was AAOx3 at\n times on ). Pt more confused when woken from a sleeping state.\n Pt cont to follow commands consistently. No psychoactive agents admin\n to pt. No c/o pain or anxiety from pt today.\n Action:\n Pt freq re-oriented to person/place/time/care rationale to facilitate\n nl cognition. Pt engaged frequently, pt encouraged to express\n thoughts/feelings. Family members continue to visit and be supportive\n which has been encouraged. Bed alarm activated.\n Response:\n Pt MS cont to wax and wane.\n Plan:\n Cont to engage pt and re-orient freq. The team is considering whether\n the pt may be a suitable candidate for Zyprexa vs Haldol if problem\n persists/worsens.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours 6/21with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.2.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, cont digoxin/ BB as ordered. The pt is a DNR\n but not a DNI.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581498,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be 20-30cc/hr. Renal evaluated yesterday, pt may require HD\n next week if renal fxn worsens.\n Action:\n Sent renal function with morning AM labs.\n Response:\n BUN and Cr\n Plan:\n Closely monitor UOP. Follow up with renal regarding future plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt got more confused at night goes, pulling out gown and monitor wires,\n easily redirectable. Alert and oriented x2, lethargic. MAE, cont follow\n commands . Pt more confused when woken from a sleeping state. Denies\n any pain.\n Action:\n Frequent reorientation and emotional support. Provide calm and quiet\n environment and Bed alarm on.\n Response:\n Pt sleeping on and off.\n Plan:\n Provide frequent orientation. Emotional support.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours this AM with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.4.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, next Digoxin dose scheduled for @\n 08:00. The pt is a DNR but not a DNI.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581502,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be 20-30cc/hr. Renal evaluated yesterday, pt may require HD\n next week if renal fxn worsens.\n Action:\n Sent renal function with morning AM labs.\n Response:\n BUN and Cr\n Plan:\n Closely monitor UOP. Follow up with renal regarding future plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt got more confused at night goes, pulling out gown and monitor wires,\n easily redirectable. Alert and oriented x2, lethargic. MAE, cont follow\n commands . Pt more confused when woken from a sleeping state. Denies\n any pain.\n Action:\n Frequent reorientation and emotional support. Provide calm and quiet\n environment and Bed alarm on.\n Response:\n Pt sleeping on and off.\n Plan:\n Provide frequent orientation. Emotional support.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours this AM with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.4.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, next Digoxin dose scheduled for @\n 08:00. The pt is a DNR but not a DNI.\n Atrial fibrillation (Afib)\n Assessment:\n Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2\n hrs, BP stable ,asymptomatic. On 2L sats 94-96%\n Action:\n Lopressor 12.5 mg TID given at . Digoxin q other day. O2 weaned\n to 2 L NC. Pneumo boots in place.\n Response:\n Cont NSR to Afib.\n Plan:\n Monitor rate and rhythm, cont lopressor\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581505,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be 20-30cc/hr. Renal evaluated yesterday, pt may require HD\n next week if renal fxn worsens.\n Action:\n Sent renal function with morning AM labs.\n Response:\n BUN and Cr\n Plan:\n Closely monitor UOP. Follow up with renal regarding future plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt got more confused at night goes, pulling out gown and monitor wires,\n easily redirectable. Alert and oriented x2, lethargic. MAE, cont follow\n commands . Pt more confused when woken from a sleeping state. Denies\n any pain.\n Action:\n Frequent reorientation and emotional support. Provide calm and quiet\n environment and Bed alarm on.\n Response:\n Pt sleeping on and off.\n Plan:\n Provide frequent orientation. Emotional support. Possible C/O today\n Atrial fibrillation (Afib)\n Assessment:\n Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2\n hrs, BP stable ,asymptomatic. On 2L sats 94-96%\n Action:\n Lopressor 12.5 mg TID given at . Digoxin q other day. O2 weaned\n to 2 L NC. Pneumo boots in place.\n Response:\n Cont NSR to Afib.\n Plan:\n Monitor rate and rhythm, cont lopressor\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581687,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n Events: CRRT initiated last evening. Despite the addition of citrate,\n the initial filter clotted off ~0100. Treatment was resumed ~0330\n following placement of an arterial line and addition of a neo drip to\n support blood pressure.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n As noted above, CRRT initiated last evening clotted off after less than\n 4 hours and despite several rescue flushes. Blood was returned to pt\n manually. Creat level trending downward with CRRT. Continuous infusions\n of potassium and calcium titrated per CRRT sliding scales.\n Action:\n Following a discussion with the renal fellow, a citrate infusion was\n initiated early this morning and the blood flow rate was reduced to\n 150cc/hr. Pt is tolerating fluid removal @50cc/hr but has an overall\n positive fluid balance since initiation of CRRT due to frequent rescue\n flushes.\n Response:\n CRRT currently infusing with improved filter pressures.\n Plan:\n Monitor CRRT closely w/q6hr lab draws. Rescue flushes q4hrs to maintain\n patency of filter.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt had 2 small, black, ob+ stools overnight. Hct fell from 34 to 28\n this morning. Coags improved w/inr 1.6 s/p ffp infusion yesterday.\n Action:\n Unchanged; will repeat hct this morning w/scheduled blood draw.\n Response:\n Plan:\n Follow serial hct results; anticipate blood transfusion if needed.\n Hypotension (not Shock)\n Assessment:\n Arterial line placed earlier this morning and values were slightly\n higher than noninvasive results. Per discussion with the micu team,\n cardiology wants the pt to receive scheduled lopressor doses for rate\n control despite a relatively low blood pressure. Also of note, maps\n continued to fall below 60 during CRRT.\n Action:\n Neo drip restarted w/resumption of CRRT ~0330. pt is currently\n maintaining maps >60-65.\n Response:\n Improved blood pressure on low dose neo qtt.\n Plan:\n Monitor hemodynamic status closely. Titrate neo drip as needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt\ns speech pattern became notable more garbled and unintelligible as\n the shift progressed. He remains confused and oriented only to himself.\n He will follow simple commands to open his eyes and move his arms and\n legs.\n Action:\n Pt reoriented. MICU team feels that altered mental status is related to\n uremia only. Lactulose has been d/c\nd. LFT\nS continue to trend downward\n slowly.\n Response:\n Worsening confusion in the setting of progressive uremia.\n Plan:\n Monitor mental status and reorient as needed. Anticipate improvement in\n orientation and speech with CRRT treatment.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581771,
"text": "Chief Complaint: heart failure, renal failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n DIALYSIS CATHETER - START 05:43 PM\n ARTERIAL LINE - START 03:14 AM\n ARTERIAL LINE - STOP 03:17 AM\n Started CVVH overnight, droping BP, started neo to support CVVH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Phenylephrine - 0.3 mcg/Kg/min\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (96.9\n HR: 69 (65 - 84) bpm\n BP: 117/53(76) {96/45(66) - 117/61(76)} mmHg\n RR: 16 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 1,814 mL\n 1,909 mL\n PO:\n 260 mL\n 30 mL\n TF:\n IVF:\n 428 mL\n 1,879 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 1,498 mL\n Urine:\n 905 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 411 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.48/28/121/18/0\n Physical Examination\n Gen: lying in bed on CVVH\n CV: irreg irreg\n Chest: poor air movement\n Abd:soft + BS\n Ext: right groin line\n Labs / Radiology\n 11.0 g/dL\n 181 K/uL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.7 %\n 17.1 K/uL\n [image002.jpg]\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n 07:28 AM\n 07:35 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n 17.1\n Hct\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n 30.7\n Plt\n 59\n 181\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n 21\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n 1. Hypotension: DDx lower circ volume when started on CVVH versus blood\n loss anemia. Required Neo overnight\n this AM is trending down slightly\n lactate stable.\n 2. ARF: started CVVH last PM but dropping BPs with it and initiated Neo\n to support, better this AM as awakens, trying to wean off Neo. Continue\n CVVH- goal ultrafiltration. Re Dose all meds.\n 3. Anemia: DDX blood loss from line, no physical evidence of RP bleed\n after fem line, CT if HCT drops\n 4. Leukocytosis: pan culturing, rule out C diff., follow up urine\n culture\n 5. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, has not required any pharma intervention and is usually\n redirectable.\n 6. GIB: no active bleeding at present\n bowel movement yesterday\n 7. For , continue supportive care as above. Bblocker, Dig,\n 8. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Liver saw yesterday and would repeat\n RUQ if rising in next few days\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition: renal cardiac diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with son\n status: DNR (do not resuscitate)\n Disposition : ICU\n Total time spent: 40\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581433,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n UPDATE: Pt tol OOB to chair all AM with no BP issues. More confused &\n somnolent today & less directable. Oliguria persists with approx 20ml\n of sedimentated urine per hr. A-line d/c\ned. Family cont to visit\n daily and kept up to date with pt status/POC. Catholic priest visited\n pt @ BS.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Approx 20ml of sedimentated yellow urine output per hour today. AM Cr\n value remain elevated with a value of 4.8. Renal evaluated pt @ BS, pt\n may require HD next week if renal fxn worsens. The pt is currently net\n input 300ml today and is over nine liters input for LOS. No obvious\n anasarca @ BS, mucous membranes appear dry.\n Action:\n Team holding additional fluid boluses @ this time given severe HF and\n very poor renal fxn.\n Response:\n Suboptimal urine output today.\n Plan:\n Cont to follow urine output trend, keep team up to date with I/O data.\n Altered mental status (not Delirium)\n Assessment:\n Pt slightly more confused/encephalopathic, lethargic and less\n directable today despite improved BP values all shift. The pt has been\n essentially AAO times one to two today(not three as he was at times on\n ). Pt more confused when woken from a sleeping state. Pt cont to\n follow commands consistently. No psychoactive agents admin to pt. No\n c/o pain or anxiety from pt today.\n Action:\n Pt freq re-oriented to person/place/time/care rationale to facilitate\n nl cognition. Pt engaged frequently, pt encouraged to express\n thoughts/feelings. Family members continue to visit and be supportive\n which has been encouraged. Bed alarm activated.\n Response:\n Pt MS cont to wax and wane.\n Plan:\n Cont to engage pt and re-orient freq. The team is considering whether\n the pt may be a suitable candidate for Zyprexa vs Haldol if problem\n persists/worsens.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours this AM with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.4.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, next Digoxin dose scheduled for @\n 08:00. The pt is a DNR but not a DNI.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581484,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n UPDATE:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be 20-30cc/hr. Renal evaluated yesterday, pt may require HD\n next week if renal fxn worsens. The pt is currently net input 300ml\n today and is over nine liters input for LOS.\n Action:\n Team holding additional fluid boluses @ this time given severe HF and\n very poor renal fxn. Sent renal function with morning AM labs.\n Response:\n Plan:\n Closely monitor UOP. Follow up with renal regarding future plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt got more confused at night goes, easily redirect able. Alert and\n oriented x2, lethargic. MAE, cont follow commands consistently Pt more\n confused when woken from a sleeping state. Denies any pain.\n Action:\n Frequent reorientation and emotional support. Provide calm and quiet\n environment and Bed alarm on.\n Response:\n Pt sleeping on and off.\n Plan:\n Provide frequent orientation. Emotional support.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours this AM with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.4.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, next Digoxin dose scheduled for @\n 08:00. The pt is a DNR but not a DNI.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581668,
"text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 05:43 PM\n ARTERIAL LINE - START 03:14 AM\n ARTERIAL LINE - STOP 03:17 AM\n \n - Family agreed to temporary hemodialysis. If he clears from uremia,\n can re-address with patient desire for HD.\n - Renal: Attempted IJ dialysis catheter, but were unable to place it so\n Right femoral HD line was placed. Started on CVVH in evening.\n - Will have to change dig dose per pharmacy for CVVH dosing. Get levels\n QOD until stable.\n - Liver: Said monitor Bili levels for more days and if still\n elevated -> redo RUQ U/S as he had sludge on his last exam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 75 (66 - 84) bpm\n BP: 104/45(66) {102/45(66) - 111/55(74)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 1,814 mL\n 910 mL\n PO:\n 260 mL\n TF:\n IVF:\n 428 mL\n 910 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 603 mL\n Urine:\n 905 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/27/117/18/-2\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 159 K/uL\n 10.2 g/dL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 28.2 %\n 14.8 K/uL\n [image002.jpg]\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n Hct\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n Plt\n 59\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581669,
"text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 05:43 PM\n ARTERIAL LINE - START 03:14 AM\n ARTERIAL LINE - STOP 03:17 AM\n \n - Family agreed to temporary hemodialysis. If he clears from uremia,\n can re-address with patient desire for HD.\n - Renal: Attempted IJ dialysis catheter, but were unable to place it so\n Right femoral HD line was placed. Started on CVVH in evening.\n - Will have to change dig dose per pharmacy for CVVH dosing. Get levels\n QOD until stable.\n - Liver: Said monitor Bili levels for more days and if still\n elevated -> redo RUQ U/S as he had sludge on his last exam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 75 (66 - 84) bpm\n BP: 104/45(66) {102/45(66) - 111/55(74)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 1,814 mL\n 910 mL\n PO:\n 260 mL\n TF:\n IVF:\n 428 mL\n 910 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 603 mL\n Urine:\n 905 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/27/117/18/-2\n Physical Examination\n Gen: Sleeping, but easily arousable, answers to questions are somewhat\n delayed\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB\n Abd: Soft, non-distended with minimal RUQ tenderness\n Ext: Warm, well-perfused\n Labs / Radiology\n 159 K/uL\n 10.2 g/dL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 28.2 %\n 14.8 K/uL\n [image002.jpg]\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n Hct\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n Plt\n 59\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581671,
"text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 05:43 PM\n ARTERIAL LINE - START 03:14 AM\n ARTERIAL LINE - STOP 03:17 AM\n \n - Family agreed to temporary hemodialysis. If he clears from uremia,\n can re-address with patient desire for HD.\n - Renal: Attempted IJ dialysis catheter, but were unable to place it so\n Right femoral HD line was placed. Started on CVVH in evening.\n - Will have to change dig dose per pharmacy for CVVH dosing. Get levels\n QOD until stable.\n - Liver: Said monitor Bili levels for more days and if still\n elevated -> redo RUQ U/S as he had sludge on his last exam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 75 (66 - 84) bpm\n BP: 104/45(66) {102/45(66) - 111/55(74)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 1,814 mL\n 910 mL\n PO:\n 260 mL\n TF:\n IVF:\n 428 mL\n 910 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 603 mL\n Urine:\n 905 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/27/117/18/-2\n Physical Examination\n Gen: Sleeping, but easily arousable, answers to questions are somewhat\n delayed\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB\n Abd: Soft, non-distended with minimal RUQ tenderness\n Ext: Warm, well-perfused\n Labs / Radiology\n 159 K/uL\n 10.2 g/dL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 28.2 %\n 14.8 K/uL\n [image002.jpg]\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n Hct\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n Plt\n 59\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; dig level today 1.2.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Monitor ECG, tele\n - No anticoagulation given GIB\n - F/u cards recs\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Cr continues to climb (4.8 ->5.1), has some U/O.\n - Cont bicarb for now per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n - Discuss initiating HD with pt and family\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n - d/c foley\n # GIB: Admitted with coffee ground emesis but had maroon colored stools\n 2 days ago suggesting lower GIB. Hcts stable and has not stooled\n since.\n - continue PO PPI\n - start bowel regimen with colace/senna\n - Check Hct daily\n - Transfuse for Hct <30\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. abd\n U/S with mildly improved gallbladder appearance with sludge and mild\n wall thickening; no specific cholecystitis signs or biliary dilatation.\n Started on ursodiol and sarna for itching, could consider\n cholestyramine.\n - Trend LFTs, amylase, lipase\n - fractionate Bili\n - consider repeat RUQ U/S\n - tolerate MRCP now\n - F/u liver recs; consider ERCP in future if TBili does not resolve\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # Hypotension: Off pressors for >24 hrs. Appears to have been in sinus\n for most of past 24 hours with one episode of afib at 2am. Had SBP\n in high-80\ns/low-90\ns briefly this morning, now resolved. Over the\n weekend was not able to maintain BP whiel sitting up in chair.\n Transaminitis and UOP improving with nl lactate, suggesting improved\n perfusion state. Did have maroon colored stools on concerning for\n GIB but Hct stable.\n - Treat AF as below with dig, beta blocker\n - If requires pressors, would resume neo\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n # Thyroid: Question of central hypothyroidism with low TSH and T4,\n however free T4 nl.\n # AMS: Confusion at night with nonfocal neuro exam. have element of\n sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - HD discussion with pt and family as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581588,
"text": "Chief Complaint: ARF, CHF, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:22 PM\n URINE CULTURE - At 05:00 PM\n CALLED OUT\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 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 09:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 76 (67 - 81) bpm\n BP: 112/58(71) {82/45(55) - 124/78(85)} mmHg\n RR: 18 (13 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CO/CI (Fick): (8.2 L/min) / (4.3 L/min/m2)\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 957 mL\n 170 mL\n PO:\n 760 mL\n 170 mL\n TF:\n IVF:\n 197 mL\n Blood products:\n Total out:\n 865 mL\n 400 mL\n Urine:\n 865 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 92 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///15/\n Exam:\n Gen: sitting in bed, NAD, somnolent and confused when awake but will\n follow commands,\n HEENT: dry op\n CV: irreg irreg\n Chest: poor air movement\n Abd: no RUQ pain\n Ext: trace edema\n Labs / Radiology\n 12.0 g/dL\n 196 K/uL\n 87 mg/dL\n 5.1 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 155 mg/dL\n 110 mEq/L\n 143 mEq/L\n 34.2 %\n 17.6 K/uL\n [image002.jpg]\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n WBC\n 11.3\n 12.7\n 13.0\n 16.8\n 17.6\n Hct\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n Plt\n 13\n 196\n Cr\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n 5.1\n TCO2\n 15\n 17\n Glucose\n 98\n 110\n 141\n 128\n 101\n 87\n Other labs: PT / PTT / INR:22.5/32.9/2.1, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:373/257, Alk Phos / T Bili:663/22.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by intermittent AF c RVR.\n 1. Leukocytosis: pan culturing, rule out C diff., follow up urine\n culture\n 2. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, has not required any pharma intervention and is usually\n redirectable.\n 3. Hypotension: resolving, off Neo, on Digoxin with stable level.\n 4. GIB: has been stable HCT, no further stools, PPI.\n 5. For , continue supportive care as above. Bblocker, Dig,\n 6. ARF: dense but Cr appears to have plateaued. UOP continues; hope to\n avoid HD as hemodynamics are optimized but need to follow closely Avoid\n all nephrotoxins, renally dose all meds,\n 7. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Had been discussion of ERCP to look\n but on hold for now. Fractionate and call Hpetaology to clarify reimage\n US versus ERCP\n may not be needed just want to make sure we are all\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with son, HD has been approached\n Code status: DNR (do not resuscitate)\n Disposition : discuss with renal- if plan is for CVVH may need OICU for\n hemodynamic monitoring\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581147,
"text": "Chief Complaint: GI bleed, Afib w RVR\n I saw and examined the patient, and was physically present with the 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 Dig loaded yesterday - added metoprolol even though on low dose Neo\n DNR confirmed with familu (but short term intubation OK)\n Neo weaned off\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 110 (83 - 115) bpm\n BP: 106/61(76) {85/43(58) - 119/64(83)} mmHg\n RR: 22 (10 - 25) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 318 mL\n PO:\n 120 mL\n 290 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 415 mL\n Urine:\n 1,215 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///16/\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 218 K/uL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by AF c RVR. Will d/w cards re other\n options (procainamide?), continue dig to level for now. GIB had been\n stable but he is now passing maroon stools, will check serial HCT q8h\n today, transition back to PPI. For , continue supportive\n care as above. Shock liver / LFTs improving. ARF is slightly better,\n UOP is up when in NSR; hope to avoid HD as hemodynamics are optimized.\n Respiratory distress is stable, will wean oxygen as able. Will continue\n RISS for DM2. Above d/w family and patient at bedside. Remainder of\n plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: family meeting last PM\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": "2102-06-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581148,
"text": "Chief Complaint: GI bleed, Afib w RVR\n I saw and examined the patient, and was physically present with the 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 Dig loaded yesterday - added metoprolol even though on low dose Neo\n DNR confirmed with familu (but short term intubation OK)\n Neo weaned off at 3AM, tried to get OOB to chair and BP in 70s\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 110 (83 - 115) bpm\n BP: 106/61(76) {85/43(58) - 119/64(83)} mmHg\n RR: 22 (10 - 25) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 318 mL\n PO:\n 120 mL\n 290 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 415 mL\n Urine:\n 1,215 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///16/\n Physical Examination\n Gen: sitting in bed, NAD\n HEENT: extremely dry o/p ++ icterus\n CV: RR\n Chest; fair air movement\n Abd: distended, +BS\n Ext: min edema\n Labs / Radiology\n 12.3 g/dL\n 218 K/uL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by AF c RVR.\n 1. Hypotension: Improving, off Neo, on Digoxin,\n 2. GIB had been stable but passed maroon stools yest thought stable\n HCT, PPI.\n 3. For , continue supportive care as above. Bblocker,\n 4. ARF is slightly better, UOP is up when in NSR; hope to avoid HD as\n hemodynamics are optimized.\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition: advance diet\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: ppi\n Communication: family meeting last PM\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": "2102-06-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581722,
"text": "Chief Complaint: heart failure, renal failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n DIALYSIS CATHETER - START 05:43 PM\n ARTERIAL LINE - START 03:14 AM\n ARTERIAL LINE - STOP 03:17 AM\n Started CVVH overnight, droping BP, started neo to support CVVH\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 2 grams/hour\n Phenylephrine - 0.3 mcg/Kg/min\n KCl (CRRT) - 3 mEq./hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (96.9\n HR: 69 (65 - 84) bpm\n BP: 117/53(76) {96/45(66) - 117/61(76)} mmHg\n RR: 16 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 1,814 mL\n 1,909 mL\n PO:\n 260 mL\n 30 mL\n TF:\n IVF:\n 428 mL\n 1,879 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 1,498 mL\n Urine:\n 905 mL\n 105 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 411 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.48/28/121/18/0\n Physical Examination\n Gen: lying in bed on CVVH\n CV: irreg irreg\n Chest: poor air movement\n Abd:soft + BS\n Ext: right groin line\n Labs / Radiology\n 11.0 g/dL\n 181 K/uL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.7 %\n 17.1 K/uL\n [image002.jpg]\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n 07:28 AM\n 07:35 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n 17.1\n Hct\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n 30.7\n Plt\n 59\n 181\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n 21\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n 1. Hypotension: DDx lower circ volume when started on CVVH versus blood\n loss anemia. Required Neo overnight\n this AM is trending down slightly\n lactate stable.\n 2. ARF: started CVVH last PM but dropping BPs with it and initiated Neo\n to support, better this AM as awakens, trying to wean off Neo. Continue\n CVVH- goal ultrafiltration. Re Dose all meds.\n 3. Anemia: DDX blood loss from line, no physical evidence of RP bleed\n after fem line, CT if HCT drops\n 4. Leukocytosis: pan culturing, rule out C diff., follow up urine\n culture\n 5. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, has not required any pharma intervention and is usually\n redirectable.\n 6. GIB: no active bleeding at present\n bowel movement yesterday\n 7. For , continue supportive care as above. Bblocker, Dig,\n 8. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Liver saw yesterday and would repeat\n RUQ if rising.\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition: renal cardiac diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with son\n status: DNR (do not resuscitate)\n Disposition : ICU\n Total time spent: 40\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581724,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - Family agreed to temporary hemodialysis. If he clears from uremia,\n can re-address with patient desire for HD.\n - Renal: Attempted IJ dialysis catheter, but were unable to place it so\n Right femoral HD line was placed. Started on CVVH in evening after\n receiving 4 u FFP, SBP dropped to 80\ns briefly when CVVH paused for\n filter issue/change. A-line placed, neo restarted at 0.5 mcg/min.\n - Hct dropped this am from 34 ->28, repeat Hct this am\n - Will have to change dig dose per pharmacy for CVVH dosing. Get levels\n QOD until stable.\n - Liver: Said monitor Bili levels for more days and if still\n elevated -> redo RUQ U/S as he had sludge on his last exam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 75 (66 - 84) bpm\n BP: 104/45(66) {102/45(66) - 111/55(74)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 1,814 mL\n 910 mL\n PO:\n 260 mL\n TF:\n IVF:\n 428 mL\n 910 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 603 mL\n Urine:\n 905 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/27/117/18/-2\n Physical Examination\n Gen: Somnolent elderly man wearing bair-hugger\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB, no wheezes\n Abd: Soft, non-tender, non-distended, +bowel sounds\n Ext: Warm, well-perfused\n Neuro: Oriented to person only\n Labs / Radiology\n 159 K/uL\n 10.2 g/dL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 28.2 %\n 14.8 K/uL\n [image002.jpg]\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n Hct\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n Plt\n 59\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Concerning for hypovolemic etiology in setting of new\n Hct drop and fluid shifts in CVVH, also concerning for cardiogenic in\n this patient with acute on chronic CHF. Pressors restarted early this\n am. Mostly in sinus for most of past 24 hours. Transaminitis and\n lactate stabilizing, suggesting improved perfusion state however mental\n status significantly worse this am.\n - Treat AF as below with dig, beta blocker\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n - Check repeat am Hct, transfuse for if continues to drop\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Discussed with pharmacy. Keep same dig dose on CVVH.\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; had maroon colored stools\n 3 days ago and 2 bowel tarry bowel movements yesterday. Now with new\n Hct drop.\n - continue PO PPI\n - start bowel regimen with colace/senna\n - Repeat check Hct this am, transfuse for Hct <30\n - Will repeat the Hct later today.\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs,\n started CVVH yesterday. Bicarb d/c\ned now that on CVVH. need HD\n once more hemodynamically stable.\n - Monitor lytes\n - Monitor mental status\n - Liberalize po fluid intake\n - F/u renal recs\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n - CXR tomorrow morning.\n - d/c foley.\n - Continue to watch pt.\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. Bili\n mostly direct (19 direct, 22.5 total). abd U/S with no specific\n cholecystitis signs or biliary dilatation. Started on ursodiol and\n sarna for itching, could consider cholestyramine.\n - Trend LFTs, amylase, lipase\n - Per liver recs, will continue trending Tbili for next 48 hours, if no\n improvement will consider repeat RUQ u/s\n - MRCP/ERCP on hold pending increased patient stability\n - F/u liver recs\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # AMS: Confusion at night with non-focal neuro exam. have element\n of sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: Low sodium, renal diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 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"
},
{
"category": "Nursing",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581466,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n UPDATE:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be 20-30cc/hr. Renal evaluated yesterday, pt may require HD\n next week if renal fxn worsens. The pt is currently net input 300ml\n today and is over nine liters input for LOS.\n Action:\n Team holding additional fluid boluses @ this time given severe HF and\n very poor renal fxn. Sent renal function with morning AM labs.\n Response:\n Plan:\n Closely monitor UOP. Follow up with renal regarding future plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt got more confused at night goes,easily redirectable. Alert and\n oriented x2, lethargic. MAE, cont follow commands consistently Pt more\n confused when woken from a sleeping state. Denies any pain.\n Action:\n Pt freq re-oriented to person/place/time/care rationale to facilitate\n nl cognition. Pt engaged frequently, pt encouraged to express\n thoughts/feelings. Family members continue to visit and be supportive\n which has been encouraged. Bed alarm activated.\n Response:\n Pt sleeping comfortably.\n Plan:\n Cont to engage pt and re-orient freq. The team is considering whether\n the pt may be a suitable candidate for Zyprexa vs Haldol if problem\n persists/worsens.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours this AM with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.4.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, next Digoxin dose scheduled for @\n 08:00. The pt is a DNR but not a DNI.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581531,
"text": "TITLE:\n Chief Complaint: UGI bleed, hypotension\n 24 Hour Events:\n - Renal: need to initiate HD; discussed possibility with son. \n reevaluate tmrw.\n - Free T4 nl at 1.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (67 - 82) bpm\n BP: 93/65(72) {82/46(55) - 124/78(85)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CO/CI (Fick): (8.2 L/min) / (4.3 L/min/m2)\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 957 mL\n 50 mL\n PO:\n 760 mL\n 50 mL\n TF:\n IVF:\n 197 mL\n Blood products:\n Total out:\n 865 mL\n 280 mL\n Urine:\n 865 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 92 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///15/\n Physical Examination\n Labs / Radiology\n 196 K/uL\n 12.0 g/dL\n 87 mg/dL\n 5.1 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 155 mg/dL\n 110 mEq/L\n 143 mEq/L\n 34.2 %\n 17.6 K/uL\n [image002.jpg]\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n WBC\n 11.3\n 12.7\n 13.0\n 16.8\n 17.6\n Hct\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n Plt\n 13\n 196\n Cr\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n 5.1\n TCO2\n 15\n 17\n Glucose\n 98\n 110\n 141\n 128\n 101\n 87\n Other labs: PT / PTT / INR:22.5/32.9/2.1, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:373/257, Alk Phos / T Bili:663/22.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Off pressors for >24 hrs. Appears to have been in sinus\n for most of past 24 hours with one episode of afib at 2am. Had SBP\n in high-80\ns/low-90\ns briefly this morning, now resolved. Over the\n weekend was not able to maintain BP whiel sitting up in chair.\n Transaminitis and UOP improving with nl lactate, suggesting improved\n perfusion state. Did have maroon colored stools on concerning for\n GIB but Hct stable.\n - Treat AF as below with dig, beta blocker\n - If requires pressors, would resume neo\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; dig level today 1.2.\n - Continue metoprolol\n - Continue dig and follow levels\n - Monitor ECG, tele\n - If his HR increases, will try lopressor and neo if he requires\n pressors as above\n - No anticoagulation given GIB\n - F/u cards recs\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n # GIB: Admitted with coffee ground emesis but had maroon colored stools\n 2 days ago suggesting lower GIB. Hcts stable. Changed IV PPI to PO.\n - Check Hct daily\n - Transfuse for Hct <30\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Cr continues to climb (4.8 ->5.1), has some U/O.\n - Cont bicarb for now per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n - Discuss initiating HD with pt and family\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. abd\n U/S with mildly improved gallbladder appearance with sludge and mild\n wall thickening; no specific cholecystitis signs or biliary dilatation.\n Started on ursodiol and sarna for itching, could consider\n cholestyramine.\n - Trend LFTs, amylase, lipase\n - F/u liver recs; consider ERCP in future if TBili does not resolve\n # Thyroid: Question of central hypothyroidism with low TSH and T4,\n however free T4 nl.\n # AMS: Confusion at night with nonfocal neuro exam. have element of\n sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile\n - Continue leukocytosis w/u as above\n - HD discussion with pt and family as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: Regular, heart-healthy\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n Communication: Patient, patient\ns children\n Code status: DNR (do not resuscitate), OK to intubate\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581535,
"text": "TITLE:\n Chief Complaint: UGI bleed, hypotension\n 24 Hour Events:\n - Renal: need to initiate HD; discussed possibility with son. \n reevaluate tmrw.\n - Free T4 nl at 1.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (67 - 82) bpm\n BP: 93/65(72) {82/46(55) - 124/78(85)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CO/CI (Fick): (8.2 L/min) / (4.3 L/min/m2)\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 957 mL\n 50 mL\n PO:\n 760 mL\n 50 mL\n TF:\n IVF:\n 197 mL\n Blood products:\n Total out:\n 865 mL\n 280 mL\n Urine:\n 865 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 92 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///15/\n Physical Examination\n Gen: Sleeping, but easily arousable, answers to questions are somewhat\n delayed\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB\n Abd: Soft, non-distended with minimal RUQ tenderness\n Ext: Warm, well-perfused\n Labs / Radiology\n 196 K/uL\n 12.0 g/dL\n 87 mg/dL\n 5.1 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 155 mg/dL\n 110 mEq/L\n 143 mEq/L\n 34.2 %\n 17.6 K/uL\n [image002.jpg]\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n WBC\n 11.3\n 12.7\n 13.0\n 16.8\n 17.6\n Hct\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n Plt\n 13\n 196\n Cr\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n 5.1\n TCO2\n 15\n 17\n Glucose\n 98\n 110\n 141\n 128\n 101\n 87\n Other labs: PT / PTT / INR:22.5/32.9/2.1, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:373/257, Alk Phos / T Bili:663/22.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Off pressors for >24 hrs. Appears to have been in sinus\n for most of past 24 hours with one episode of afib at 2am. Had SBP\n in high-80\ns/low-90\ns briefly this morning, now resolved. Over the\n weekend was not able to maintain BP whiel sitting up in chair.\n Transaminitis and UOP improving with nl lactate, suggesting improved\n perfusion state. Did have maroon colored stools on concerning for\n GIB but Hct stable.\n - Treat AF as below with dig, beta blocker\n - If requires pressors, would resume neo\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; dig level today 1.2.\n - Continue metoprolol\n - Continue dig and follow levels\n - Monitor ECG, tele\n - If his HR increases, will try lopressor and neo if he requires\n pressors as above\n - No anticoagulation given GIB\n - F/u cards recs\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n # GIB: Admitted with coffee ground emesis but had maroon colored stools\n 2 days ago suggesting lower GIB. Hcts stable. Changed IV PPI to PO.\n - Check Hct daily\n - Transfuse for Hct <30\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Cr continues to climb (4.8 ->5.1), has some U/O.\n - Cont bicarb for now per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n - Discuss initiating HD with pt and family\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. abd\n U/S with mildly improved gallbladder appearance with sludge and mild\n wall thickening; no specific cholecystitis signs or biliary dilatation.\n Started on ursodiol and sarna for itching, could consider\n cholestyramine.\n - Trend LFTs, amylase, lipase\n - F/u liver recs; consider ERCP in future if TBili does not resolve\n # Thyroid: Question of central hypothyroidism with low TSH and T4,\n however free T4 nl.\n # AMS: Confusion at night with nonfocal neuro exam. have element of\n sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile\n - Continue leukocytosis w/u as above\n - HD discussion with pt and family as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: Regular, heart-healthy\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n Communication: Patient, patient\ns children\n Code status: DNR (do not resuscitate), OK to intubate\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581542,
"text": "TITLE:\n Chief Complaint: UGI bleed, hypotension\n 24 Hour Events:\n - Renal: need to initiate HD; discussed possibility with son. \n reevaluate today.\n - Free T4 nl at 1.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (67 - 82) bpm\n BP: 93/65(72) {82/46(55) - 124/78(85)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CO/CI (Fick): (8.2 L/min) / (4.3 L/min/m2)\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 957 mL\n 50 mL\n PO:\n 760 mL\n 50 mL\n TF:\n IVF:\n 197 mL\n Blood products:\n Total out:\n 865 mL\n 280 mL\n Urine:\n 865 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 92 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///15/\n Physical Examination\n Gen: Sleeping, but easily arousable, answers to questions are somewhat\n delayed\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB\n Abd: Soft, non-distended with minimal RUQ tenderness\n Ext: Warm, well-perfused\n Labs / Radiology\n 196 K/uL\n 12.0 g/dL\n 87 mg/dL\n 5.1 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 155 mg/dL\n 110 mEq/L\n 143 mEq/L\n 34.2 %\n 17.6 K/uL\n [image002.jpg]\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n WBC\n 11.3\n 12.7\n 13.0\n 16.8\n 17.6\n Hct\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n Plt\n 13\n 196\n Cr\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n 5.1\n TCO2\n 15\n 17\n Glucose\n 98\n 110\n 141\n 128\n 101\n 87\n Other labs: PT / PTT / INR:22.5/32.9/2.1, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:373/257, Alk Phos / T Bili:663/22.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Off pressors for >24 hrs. Appears to have been in sinus\n for most of past 24 hours with one episode of afib at 2am. Had SBP\n in high-80\ns/low-90\ns briefly this morning, now resolved. Over the\n weekend was not able to maintain BP whiel sitting up in chair.\n Transaminitis and UOP improving with nl lactate, suggesting improved\n perfusion state. Did have maroon colored stools on concerning for\n GIB but Hct stable.\n - Treat AF as below with dig, beta blocker\n - If requires pressors, would resume neo\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; dig level today 1.2.\n - Continue metoprolol\n - Continue dig and follow levels\n - Monitor ECG, tele\n - If his HR increases, will try lopressor and neo if he requires\n pressors as above\n - No anticoagulation given GIB\n - F/u cards recs\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n # GIB: Admitted with coffee ground emesis but had maroon colored stools\n 2 days ago suggesting lower GIB. Hcts stable. Changed IV PPI to PO.\n - Check Hct daily\n - Transfuse for Hct <30\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Cr continues to climb (4.8 ->5.1), has some U/O.\n - Cont bicarb for now per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n - Discuss initiating HD with pt and family\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. abd\n U/S with mildly improved gallbladder appearance with sludge and mild\n wall thickening; no specific cholecystitis signs or biliary dilatation.\n Started on ursodiol and sarna for itching, could consider\n cholestyramine.\n - Trend LFTs, amylase, lipase\n - F/u liver recs; consider ERCP in future if TBili does not resolve\n # Thyroid: Question of central hypothyroidism with low TSH and T4,\n however free T4 nl.\n # AMS: Confusion at night with nonfocal neuro exam. have element of\n sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile\n - Continue leukocytosis w/u as above\n - HD discussion with pt and family as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: Regular, heart-healthy\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n Communication: Patient, patient\ns children\n Code status: DNR (do not resuscitate), OK to intubate\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581561,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n UPDATE: Pt tol OOB to chair all AM with no BP issues. More confused &\n somnolent today & less directable. Oliguria persists with approx 20ml\n of sedimentated urine per hr. . Family cont to visit daily and kept\n up to date with pt status/POC. Catholic priest visited pt @ BS on\n \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Approx 20ml of sedimentated yellow urine output per hour today. AM Cr\n value trending up with a value of 5.1. Renal evaluated pt @ BS, pt may\n require HD if renal fxn worsens. The pt\ns FB is currently net\n postitive over nine liters for LOS. No obvious anasarca @ BS, mucous\n membranes appear dry.\n Action:\n Team holding additional fluid boluses @ this time given severe HF and\n very poor renal fxn.\n Response:\n Suboptimal urine output persists\n Plan:\n Cont to follow urine output trend, keep team up to date with I/O data.\n Renal to f/u and start HD if needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt slightly more confused/encephalopathic, lethargic and less\n directable today despite improved BP values all shift. The pt has been\n essentially AAO times one to two today(not three as he was at times on\n ). Pt more confused when woken from a sleeping state. Pt cont to\n follow commands consistently. No psychoactive agents admin to pt. No\n c/o pain or anxiety from pt today.\n Action:\n Pt freq re-oriented to person/place/time/care rationale to facilitate\n nl cognition. Pt engaged frequently, pt encouraged to express\n thoughts/feelings. Family members continue to visit and be supportive\n which has been encouraged. Bed alarm activated.\n Response:\n Pt MS cont to wax and wane.\n Plan:\n Cont to engage pt and re-orient freq. The team is considering whether\n the pt may be a suitable candidate for Zyprexa vs Haldol if problem\n persists/worsens.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours this AM with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.4.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, next Digoxin dose scheduled for @\n 08:00. The pt is a DNR but not a DNI.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581563,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n UPDATE: Pt tol OOB to chair all AM with no BP issues. More confused &\n somnolent today & less directable. Oliguria persists with approx 20ml\n of sedimentated urine per hr. . Family cont to visit daily and kept\n up to date with pt status/POC. Catholic priest visited pt @ BS on\n \n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Approx 20ml of sedimentated yellow urine output per hour today. AM Cr\n value trending up with a value of 5.1. Renal evaluated pt @ BS, pt may\n require HD if renal fxn worsens. The pt\ns FB is currently net\n postitive over nine liters for LOS. No obvious anasarca @ BS, mucous\n membranes appear dry.\n Action:\n Team holding additional fluid boluses @ this time given severe HF and\n very poor renal fxn.\n Response:\n Suboptimal urine output persists\n Plan:\n Cont to follow urine output trend, keep team up to date with I/O data.\n Renal to f/u and start HD if needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt slightly more confused/encephalopathic, lethargic and less\n directable today despitestable BP values all shift. The pt has been\n essentially AAO times one to two for the past 2 days.(was AAOx3 at\n times on ). Pt more confused when woken from a sleeping state.\n Pt cont to follow commands consistently. No psychoactive agents admin\n to pt. No c/o pain or anxiety from pt today.\n Action:\n Pt freq re-oriented to person/place/time/care rationale to facilitate\n nl cognition. Pt engaged frequently, pt encouraged to express\n thoughts/feelings. Family members continue to visit and be supportive\n which has been encouraged. Bed alarm activated.\n Response:\n Pt MS cont to wax and wane.\n Plan:\n Cont to engage pt and re-orient freq. The team is considering whether\n the pt may be a suitable candidate for Zyprexa vs Haldol if problem\n persists/worsens.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours 6/21with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.2.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, cont digoxin/ BB as ordered. The pt is a DNR\n but not a DNI.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 581565,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n UPDATE: Pt tol OOB to chair all AM with no BP issues. More confused &\n somnolent today & less directable. Oliguria persists with approx 20ml\n of sedimentated urine per hr. . Family cont to visit daily and kept\n up to date with pt status/POC. Catholic priest visited pt @ BS on\n \n Surveillance blood and urine cultures sent this am r/t leukocytosis.\n Foley cath removed MD.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Approx 20ml of sedimentated yellow urine output per hour today. AM Cr\n value trending up with a value of 5.1. Renal evaluated pt @ BS, pt may\n require HD if renal fxn worsens. The pt\ns FB is currently net\n postitive over nine liters for LOS. No obvious anasarca @ BS, mucous\n membranes appear dry.\n Action:\n Team holding additional fluid boluses @ this time given severe HF and\n very poor renal fxn.\n Response:\n Suboptimal urine output persists\n Plan:\n Cont to follow urine output trend, keep team up to date with I/O data.\n Renal to f/u and start HD if needed.\n Altered mental status (not Delirium)\n Assessment:\n Pt slightly more confused/encephalopathic, lethargic and less\n directable today despitestable BP values all shift. The pt has been\n essentially AAO times one to two for the past 2 days.(was AAOx3 at\n times on ). Pt more confused when woken from a sleeping state.\n Pt cont to follow commands consistently. No psychoactive agents admin\n to pt. No c/o pain or anxiety from pt today.\n Action:\n Pt freq re-oriented to person/place/time/care rationale to facilitate\n nl cognition. Pt engaged frequently, pt encouraged to express\n thoughts/feelings. Family members continue to visit and be supportive\n which has been encouraged. Bed alarm activated.\n Response:\n Pt MS cont to wax and wane.\n Plan:\n Cont to engage pt and re-orient freq. The team is considering whether\n the pt may be a suitable candidate for Zyprexa vs Haldol if problem\n persists/worsens.\n Hypotension (not Shock)\n Assessment:\n The pt has been in a NSR all shift with a HR in the 60-80\ns and\n consequently has remained normotensive all shift. Pt tol\n standing/pivoting/sitting into chair for approx four hours 6/21with\n excellent tol and no adverse hemodynamic issues. AM Dig level\n therapeutic with a value of 1.2.\n Action:\n The pt cont to receive BB TID on a timed schedule.\n Response:\n Pt remains hemodynamically stable.\n Plan:\n Cont to follow VS closely, cont digoxin/ BB as ordered. The pt is a DNR\n but not a DNI.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n Code status:\n DNR (do not resuscitate)\n Height:\n 70 Inch\n Admission weight:\n 73.1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin, GI Bleed\n CV-PMH: CAD, Hypertension, PVD\n Additional history: CAD s/p MI over a decade ago, PVD with bilateral\n carotid endarterectomies, BCC, Systolic HF with an EF 25-30% in ,\n with severe AK/HK on coumadin, BCC\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:39\n Temperature:\n 96.8\n Arterial BP:\n S:117\n D:59\n Respiratory rate:\n 15 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 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 170 mL\n 24h total out:\n 400 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:05 AM\n Potassium:\n 3.7 mEq/L\n 03:05 AM\n Chloride:\n 110 mEq/L\n 03:05 AM\n CO2:\n 15 mEq/L\n 03:05 AM\n BUN:\n 155 mg/dL\n 03:05 AM\n Creatinine:\n 5.1 mg/dL\n 03:05 AM\n Glucose:\n 87 mg/dL\n 03:05 AM\n Hematocrit:\n 34.2 %\n 03:05 AM\n Finger Stick Glucose:\n 104\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: MICU 684\n Transferred to: 214\n Date & time of Transfer: 11:00am\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581712,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - Family agreed to temporary hemodialysis. If he clears from uremia,\n can re-address with patient desire for HD.\n - Renal: Attempted IJ dialysis catheter, but were unable to place it so\n Right femoral HD line was placed. Started on CVVH in evening after\n receiving 4 u FFP, SBP dropped to 100\ns briefly when CVVH paused for\n filter issue/change. A-line placed, neo restarted at 0.5 mcg/min.\n - Hct dropped this am from 34 ->28, repeat Hct this am\n - Will have to change dig dose per pharmacy for CVVH dosing. Get levels\n QOD until stable.\n - Liver: Said monitor Bili levels for more days and if still\n elevated -> redo RUQ U/S as he had sludge on his last exam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 3 mEq./hour\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:33 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 35.7\nC (96.3\n HR: 75 (66 - 84) bpm\n BP: 104/45(66) {102/45(66) - 111/55(74)} mmHg\n RR: 15 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 1,814 mL\n 910 mL\n PO:\n 260 mL\n TF:\n IVF:\n 428 mL\n 910 mL\n Blood products:\n 1,126 mL\n Total out:\n 1,217 mL\n 603 mL\n Urine:\n 905 mL\n 75 mL\n NG:\n Stool:\n Drains:\n Balance:\n 597 mL\n 307 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.45/27/117/18/-2\n Physical Examination\n Gen: Somnolent elderly man wearing bair-hugger\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB, no wheezes\n Abd: Soft, non-tender, non-distended, +bowel sounds\n Ext: Warm, well-perfused\n Neuro: Oriented to person only\n Labs / Radiology\n 159 K/uL\n 10.2 g/dL\n 63 mg/dL\n 3.9 mg/dL\n 18 mEq/L\n 3.3 mEq/L\n 124 mg/dL\n 106 mEq/L\n 143 mEq/L\n 28.2 %\n 14.8 K/uL\n [image002.jpg]\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n 07:30 PM\n 07:45 PM\n 01:55 AM\n WBC\n 13.0\n 16.8\n 17.6\n 14.8\n Hct\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n 28.2\n Plt\n 59\n Cr\n 4.8\n 4.8\n 4.8\n 5.1\n 5.4\n 3.9\n TCO2\n 17\n 19\n Glucose\n 110\n 141\n 128\n 101\n 87\n 75\n 63\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:8.7 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Concerning for hypovolemic etiology in setting of new\n Hct drop and fluid shifts in CVVH, also concerning for cardiogenic in\n this patient with acute on chronic CHF. Pressors restarted early this\n am. Mostly in sinus for most of past 24 hours. Transaminitis and\n lactate stabilizing, suggesting improved perfusion state however mental\n status significantly worse this am.\n - Treat AF as below with dig, beta blocker\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n - Check repeat am Hct, transfuse for if continues to drop\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Confirm dig dosing during CVVH with pharmacy\n - Monitor ECG, tele\n - No anticoagulation given GIB, unstable Hct\n - F/u cards recs\n #Anemia: Admitted with coffee ground emesis; had maroon colored stools\n 3 days ago and 2 bowel tarry bowel movements yesterday. Now with new\n Hct drop.\n - continue PO PPI\n - start bowel regimen with colace/senna\n - Repeat check Hct this am, transfuse for Hct <30\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs,\n started CVVH yesterday. Bicarb d/c\ned now that on CVVH. need HD\n once more hemodynamically stable.\n - Monitor lytes\n - Monitor mental status\n - Liberalize po fluid intake\n - F/u renal recs\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n - d/c foley\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. Bili\n mostly direct (19 direct, 22.5 total). abd U/S with no specific\n cholecystitis signs or biliary dilatation. Started on ursodiol and\n sarna for itching, could consider cholestyramine.\n - Trend LFTs, amylase, lipase\n - Per liver recs, will continue trending Tbili for next 48 hours, if no\n improvement will consider repeat RUQ u/s\n - MRCP/ERCP on hold pending increased patient stability\n - F/u liver recs\n # Acute on Chronic CHF: BNP very elevated at >70K\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # AMS: Confusion at night with non-focal neuro exam. have element\n of sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - CVVH as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: Low sodium, renal diet\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 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"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581519,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be 20-30cc/hr. Renal evaluated yesterday, pt may require HD\n next week if renal fxn worsens.\n Action:\n Sent renal function with morning AM labs.\n Response:\n BUN 155(144) and Cr5.1 (4.8).\n Plan:\n Closely monitor UOP. Follow up with renal regarding future plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt got more confused at night goes, pulling at gown and monitor wires,\n easily redirectable. Alert and oriented x2, lethargic. MAE, cont follow\n commands. Pt more confused when woken from a sleeping state. Denies\n any pain.\n Action:\n Frequent reorientation and emotional support. Provide calm and quiet\n environment and Bed alarm on.\n Response:\n Pt sleeping on and off.\n Plan:\n Provide frequent orientation. Emotional support. Possible C/O\n today\n Atrial fibrillation (Afib)\n Assessment:\n Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2\n hrs, BP stable, asymptomatic. On 2L sats 94-96%\n Action:\n Lopressor 12.5 mg TID given. Pneumo boots in place.\n Response:\n Rhythm converted in to NSR. Dig level 2.1 and Venous O2- 77 with\n morning lab.\n Plan:\n Monitor rate and rhythm, cont lopressor\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581870,
"text": "Chief Complaint:\n 24 Hour Events:\n - dig dosing changed to qday while on CVVH, to be changed back when\n CVVH discontinued\n - repeat Hct improved at 32.7\n - neo weaned to off in am with SBP's maintained in 110's-120's\n - renal: will change CVVH bath to avoid alkalosis\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 03:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 35.6\nC (96\n HR: 75 (62 - 83) bpm\n BP: 110/46(69) {82/40(54) - 136/68(85)} mmHg\n RR: 17 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 435 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 435 mL\n Blood products:\n Total out:\n 5,802 mL\n 185 mL\n Urine:\n 310 mL\n 20 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 250 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.43/28/94./17/-3\n Physical Examination\n Labs / Radiology\n 181 K/uL\n 11.0 g/dL\n 79 mg/dL\n 2.2 mg/dL\n 17 mEq/L\n 3.6 mEq/L\n 55 mg/dL\n 105 mEq/L\n 138 mEq/L\n 32.7 %\n 17.1 K/uL\n [image002.jpg]\n 07:30 PM\n 07:45 PM\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n WBC\n 14.8\n 17.1\n Hct\n 28.2\n 30.7\n 32.7\n Plt\n 159\n 181\n Cr\n 5.4\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n TCO2\n 19\n 21\n 19\n Glucose\n 75\n 63\n 68\n 64\n 80\n 79\n Other labs: PT / PTT / INR:17.8/30.5/1.6, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:261/249, Alk Phos / T Bili:602/22.4,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:481 IU/L, Ca++:9.1 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n therapeutic INR, ddx includes PUD, ASA-induced gastritis, malignancy.\n - EGD to evaluate for active bleeding, will need reversal of\n anticoagulation prior to INR < 2.0, give 2 u FFP and repeat INR\n - has received 2 u pRBC now for decreased Hct, check Hct q6hr\n - continue PPI gtt\n - f/u GI recs\n - access = 3 PIV\n - hold ASA, coumadin\n .\n # Hypotension- Patient with poor CO (EF 25%) and clinically volume\n depleted. Increasing anion gap (12 -> 16) with lactate 2.2 further\n supports hypo-perfusion. Has received 2 L in ED and 1 L on floor, 2 u\n pRBC and 3 u FFP.\n - Gentle fluids given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - place a-line\n - continue monitoring on tele\n .\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.1 with K 5.7, no EKG changes. Likely pre-renal given patient's\n fluid depleted clinical status\n - gentle IVF given EF\n - check UA and urine lytes\n - will hold on kayexelate pending procedure\n - recheck lytes in pm\n .\n # Transaminitis/Abdominal pain- Possibly due to irritation caused by\n blood in abdomen, however components of history sound like biliary\n colic (transient pain in a band-like distribution, improved with\n belching and resolved within hours on arrival to ED). Does not sound\n like anginal equivalent, first two sets CE negative. LFT's with\n markedly elevated AST and ALT, hyperbilirubinemia (primarily\n conjugated) suggesting obstructive picture.\n - trend LFT's, amylase, lipase\n - RUQ u/s\n - continue ROMI\n .\n # Heart Failure- most recent EF 25% with severe hypokinesis. Has been\n anticoagulated to prevent intra-ventricular thrombus formation.\n Currently appears volume depleted, goal is to keep patient euvolemic.\n - volume repletion to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n - SvO2 and lactate wnl\n .\n #DM\n - hold glyburide while inpatient\n - RISS\n .\n # HTN\n - hold HCTZ, beta-blocker and ACE inhibitor in setting of GI bleed\n .\n # Nutrition: NPO for procedure\n .\n # Prophylaxis: pneumoboots, IV PPI\n .\n # Access: 3 PIVs\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT:\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581916,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n Events Overnight: Prismaflex machine stopped for weight changes\n requiring recalibration of scales ~0300. CRRT resumed at 0500. Please\n note that fluid balance is inaccurate as a result of scale imbalance.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n As noted above, CRRT treatment was interrupted for ~2 hours overnight.\n The lines remain reversed with improved patency of the dialysis line.\n He has tolerated a negative fluid balance although this is not\n reflected in the flowsheet d/t the scale imbalance.\n Action:\n Continues on CRRT.\n Response:\n Uremia slowly improving.\n Plan:\n Continue CRRT treatment for now although ?transition to HD if pt\n remains hemodynamically stable.\n Hypotension (not Shock)\n Assessment:\n Arterial blood pressures ranging 90-120\ns with maps >60. Transient\n hypotension w/sbp\ns dipping into the 80\ns noted when the pt falls\n asleep.\n Action:\n Pt stimulated when intermittently hypotensive.\n Response:\n Blood pressure improves significantly when pt is more awake.\n Plan:\n Continue to monitor hemodynamic status, expect fewer episodes of\n hypotension during the day.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt continues to pass small amouts of loose, black, ob+ stool. Hct ~30\n this morning.\n Action:\n Continue to monitor serial hct results. Held off on bowel meds\n overnight.\n Response:\n Unchanged.\n Plan:\n Follow serial hct results, guiac stool.\n Altered mental status (not Delirium)\n Assessment:\n Although the pt remains confused and nonverbal at times, he does appear\n to be more lucid this morning. He was able to name location and year.\n Speech was also more intelligible. No change in motor function.\n Action:\n Mental status assessed frequently and pt reoriented as needed.\n Response:\n More awake ?r/t slow improvement in uremia.\n Plan:\n Follow mental status, reorient as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581515,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP cont be 20-30cc/hr. Renal evaluated yesterday, pt may require HD\n next week if renal fxn worsens.\n Action:\n Sent renal function with morning AM labs.\n Response:\n BUN 155(144) and Cr5.1 (4.8).\n Plan:\n Closely monitor UOP. Follow up with renal regarding future plan.\n Altered mental status (not Delirium)\n Assessment:\n Pt got more confused at night goes, pulling out gown and monitor wires,\n easily redirectable. Alert and oriented x2, lethargic. MAE, cont follow\n commands. Pt more confused when woken from a sleeping state. Denies\n any pain.\n Action:\n Frequent reorientation and emotional support. Provide calm and quiet\n environment and Bed alarm on.\n Response:\n Pt sleeping on and off.\n Plan:\n Provide frequent orientation. Emotional support. Possible C/O\n today\n Atrial fibrillation (Afib)\n Assessment:\n Pt received NSR with HR 60-80 until 2300then pt flipped into LBBB for 2\n hrs, BP stable, asymptomatic. On 2L sats 94-96%\n Action:\n Lopressor 12.5 mg TID given. Pneumo boots in place.\n Response:\n Rhythm converted in to NSR. Dig level 2.1 and Venous O2 77 with\n morning lab.\n Plan:\n Monitor rate and rhythm, cont lopressor\n"
},
{
"category": "Nutrition",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 581798,
"text": "Diet Order: Low Na, renal, Heart healthy\n Pertinent Labs: Alb- K-3.3 PO4-3.8 BUN/Cr-124/3.9\n Patient\ns diet advanced to above on . Po intake has been poor-\n fair since. Would consider discontinuing renal diet restriction as\n lytes requiring supplementation on CVVH and this will increase food\n options. Will also send po supplements c/ meals in attempt to increase\n po intake. Will continue to follow and make additional recommendations\n prn. Please page c/?\ns #.\n"
},
{
"category": "Nutrition",
"chartdate": "2102-06-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 581799,
"text": "Diet Order: Low Na, renal, Heart healthy\n Pertinent Labs: Alb- K-3.3 PO4-3.8 BUN/Cr-124/3.9\n Patient\ns diet advanced to above on . Po intake has been poor-\n fair since. Would consider discontinuing renal diet restriction as\n lytes requiring supplementation on CVVH and this will increase food\n options. Will also send po supplements c/ meals in attempt to increase\n po intake. Will continue to follow and make additional recommendations\n prn. Please page c/?\ns #.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RD, \n on: 16:29 ------\n"
},
{
"category": "Nutrition",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 582032,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Ht: 69\"\n Wt: 73.1 Kg\n Diet: Renal/Cardiac/Low Sodium\n Patient's diet advanced to above . Patient initially c/ fair\n intake, but per discussion c/ RN has decreased c/ waxing/ mental\n status. Patient coughing c/ thin liquids, therefore RN not giving\n them-does well c/ soft solids-pudding, cream of wheat, etc. Hope is\n that mental status will improve c/ CVVH and patient will be able to\n increase po's. Would have swallow study once clearer given coughing\n c/ liquids. No need for renal or cardiac diet restrictions given poor\n po intake and lytes WNL. If po intake does not improve in next \n days, would consider feeding tube placement to prevent nutritional\n decline. Will follow-please page c/ ?'s #.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582225,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt alternating between afib and SR\n Action:\n Pt alternating between afib with hr 100-130 and sr 60-80\n Pt started on neo gtt and received lopressor 5mg iv x1 with fair effect\n Po digoxin changed to iv, received dose\n Family meeting held and decision made to change code status to \n This, RN, attending Dr , renal attending Dr , and SW\n present at meeting\n Neo gtt d/c\nd, no cpr, intub or , d/c\n Response:\n status\n Plan:\n d/c pressers\n prn dilaudid for pain/air hunger\n Altered mental status (not Delirium)\n Assessment:\n Pt min responsive\n Action:\n Pt lethargic, wrists restrained earlier in shift due to pulling at\n lines\n Pt confused with garbled speech, at times appears to be talking to\n people not there\n Impaired gag, appears to be having difficulty managing water from mouth\n care\n Pt scratching at torso, sarna lotion applied, receiving benedryl prn\n Response:\n Poor response to sarna and benedryl\n Worsening mental status\n Plan:\n Prn dilaudid for pain/discomfort\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT d/c\n Action:\n HD cath positional, freq alarms for high access pressure, due to\n coughing or movement\n Ports reversed with no improvement\n CRRT d/c\nd after family meeting when pt made \n Renal attending Dr involved in meeting\n 3way Foley with NS bladder irrigation continues\n Attempted to turn down rate, and urine became more red with need to\n manually irrigate cath for small clot, rate increased\n Response:\n CRRT d/c\n Still needing bladder irrigation\n Plan:\n NS bladder irrigation till hematuria resolves\n CRRT d/c\nd and not to resume\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Tarry stools\n Action:\n Pt noted to have dark tarry ob pos stools\n Team aware\n Response:\n Plan:\n No change in plans at this time\n Goals of care now comfort oriented\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582106,
"text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 582226,
"text": "Social Work:\n Attended family meeting with MICU team and pt\ns three children.\n Discussed goals of care and EOL issues. Daughter and two sons speak of\n how they have been preparing for this conversation and of their shared\n understanding that pt would want to focus on comfort at this time.\n Questions re his current condition were addressed. Reiterated SW\n availability for additional support after meeting, though family state\n they would prefer to be alone and support each other as needed. They\n appear to be coping effectively at this time. Please page with any\n questions or concerns.\n , LICSW, #\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 582288,
"text": "Chief Complaint:\n 24 Hour Events:\n ARTERIAL LINE - STOP 04:30 PM\n -RN replaced foley, small amount of bright red blood returned.\n Attempts at flushing failed to return any urine. Suspect clot\n retention. 3-way foley to be placed with CBI, if unsucessful will call\n Urology.\n -Upon removal of foley clot came out. On placement of 3-way foley was\n flushed and CBI initiated.\n -Urology returned page at . Recommended placing 22F 3-way\n catheter and hand irrigate to evacuate clots. Followed by CBI only\n after evident that there is good flow.\n -Unable to evacuate clot with hand irrigation\n -Informed Urology resident on call of inability to evacuate\n clots. Dr. on his way to evaluate Pt (0330)\n -0420 Urology able to evacuate clot from small contracted bladder\n -Urology to follow up on patient in afternoon.\n -changed pt to comfort measures only\n -arterial line d/c'ed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 12:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Metoprolol - 08:45 AM\n Dextrose 50% - 10:15 AM\n Hydromorphone (Dilaudid) - 04:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 84 (62 - 137) bpm\n BP: 71/34(41) {54/20(28) - 95/71(76)} mmHg\n RR: 15 (9 - 24) insp/min\n SpO2: 93%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,430 mL\n 26 mL\n PO:\n 30 mL\n TF:\n IVF:\n 2,375 mL\n 26 mL\n Blood products:\n Total out:\n 3,702 mL\n 100 mL\n Urine:\n 1,110 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,272 mL\n -74 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: 7.46/24/107/16/-4\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 138 K/uL\n 11.2 g/dL\n 75 mg/dL\n 1.2 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 33 mg/dL\n 105 mEq/L\n 136 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n 11:39 AM\n 11:54 AM\n WBC\n 22.0\n 16.2\n Hct\n 33.7\n 31.7\n Plt\n 182\n 138\n Cr\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 18\n 19\n 15\n 18\n Glucose\n 91\n 83\n 76\n 74\n 75\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES)\n LEUKOCYTOSIS\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581895,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581896,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582209,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt alternating between afib and SR\n Action:\n Pt alternating between afib with hr 100-130 and sr 60-80\n Pt started on neo gtt and received lopressor 5mg iv x1 with fair effect\n Po digoxin changed to iv, received dose\n Family meeting held and decision made to change code status to \n This,RN, attending Dr , renal attending Dr , and SW\n present at meeting\n Neo gtt d/c\nd, no cpr, intub or defib\n Response:\n status\n Plan:\n d/c pressors\n prn dilaudid for pain/air hunger\n Altered mental status (not Delirium)\n Assessment:\n Pt min responsive\n Action:\n Pt lethargic, wrists restrained earlier in shift due to pulling at\n lines\n Pt confused with garbled speech, at times appears to be talking to\n people not there\n Impaired gag, appears to be having difficulty managing water from mouth\n care\n Pt scratching at torso, sarna lotion applied, receiving benedryl prn\n Response:\n Poor response to sarna and benedryl\n Worsening mental status\n Plan:\n Prn dilaudid for pain/discomfort\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n CRRT d/c\n Action:\n HD cath postional, freq alarms for high access pressure, due to\n coughing or movement\n Ports reversed with no improvement\n CRRT d/c\nd after family meeting when pt made \n Renal attending Dr involved in meeting\n 3way foley with NS bladder irrigation continues\n Attempted to turn down rate, and urine became more red with need to\n manually irrigate cath for small clot, rate increased\n Response:\n CRRT d/c\n Still needing bladder irrigation\n Plan:\n NS bladder irrigation till hematuria resolves\n CRRT d/c\nd and not to resume\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Tarry stools\n Action:\n Pt noted to have dark tarry ob pos stools\n Team aware\n Response:\n Plan:\n No change in plans at this time\n Goals of care now comfort oriented\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581897,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581898,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581900,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Rehab Services",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 582205,
"text": "Spoke with nsg and patient has been made comfort measures only, no\n further acute PT needs, please re-consult if change in status.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581982,
"text": "Chief Complaint: heart failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - START 04:47 PM\n Off Neo all night, but restarted this AM for hypotensive\n CVVH machine malfunction - off\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Phenylephrine - 1.5 mcg/Kg/min\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 10:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.7\n Tcurrent: 35.8\nC (96.4\n HR: 75 (62 - 78) bpm\n BP: 84/38(55) {82/38(54) - 136/68(85)} mmHg\n RR: 18 (13 - 21) insp/min\n SpO2: 99%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n CO/CI (Fick): (3.5 L/min) / (1.8 L/min/m2)\n Mixed Venous O2% Sat: 54 - 71\n Total In:\n 4,895 mL\n 914 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,795 mL\n 914 mL\n Blood products:\n Total out:\n 5,802 mL\n 315 mL\n Urine:\n 310 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n -907 mL\n 599 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: 7.36/38/77/18/-3\n Physical Examination\n Gen: lying in bed , minimally responsive\n CV: irreg irreg\n Chest: poor air movement\n Abd:soft + BS\n Ext: right groin line\n Neuro: eyes open but not answering ?s or following commands, moving all\n extremities\n Labs / Radiology\n 11.1 g/dL\n 147 K/uL\n 82 mg/dL\n 1.8 mg/dL\n 18 mEq/L\n 3.6 mEq/L\n 52 mg/dL\n 104 mEq/L\n 138 mEq/L\n 30.4 %\n 18.4 K/uL\n [image002.jpg]\n 01:55 AM\n 07:28 AM\n 07:35 AM\n 12:38 PM\n 12:42 PM\n 06:10 PM\n 12:16 AM\n 12:17 AM\n 05:12 AM\n 05:13 AM\n WBC\n 14.8\n 17.1\n 18.4\n Hct\n 28.2\n 30.7\n 32.7\n 30.4\n Plt\n 159\n 181\n 147\n Cr\n 3.9\n 3.3\n 0.9\n 2.1\n 2.2\n 1.8\n TCO2\n 21\n 19\n 22\n Glucose\n 63\n 68\n 64\n 80\n 79\n 82\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:251/272, Alk Phos / T Bili:697/23.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n 1. Hypotension: DDx overdiuresed, bowel ischemia, cardiac dysfunction.\n At this point he is on Neo again, but we need to discuss with son\n overall goals of cared as he is not able to be hemodynamically\n supported without vasopressors. Repeat SCVO2 and lactate.\n 2. ARF: CVVH- machine malfunctioning\n but he is on pressors even\n without CVVH so may not be able to go back on\n will assess as day\n progresses\n 3. Anemia: DDX blood loss - HCT relatively stable\n maybe slow GI\n ooze.\n 4. Leukocytosis: pan culturing, empiric Rx for C diff with Flagyl\n 5. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, overall trajectory is down and even with BUN 150 to 50 he is\n worse.\n 6. GIB: no active bleeding at present\n bowel movement yesterday\n 7. For , continue supportive care as above. Bblocker, Dig,\n check level\n 8. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Depending on goals could repeat RUQ if\n no change by tomm Friday or spikes, rising WBC\n ICU Care\n Nutrition: as able but poor mental status today\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: family meeting to discuss goals of care, he continues\n to worsen, is pressor dependent and declining mental status\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": "2102-06-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581554,
"text": "Chief Complaint: ARF, CHF, hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:22 PM\n URINE CULTURE - At 05:00 PM\n CALLED OUT\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 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 09:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36\nC (96.8\n Tcurrent: 36\nC (96.8\n HR: 76 (67 - 81) bpm\n BP: 112/58(71) {82/45(55) - 124/78(85)} mmHg\n RR: 18 (13 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CO/CI (Fick): (8.2 L/min) / (4.3 L/min/m2)\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 957 mL\n 170 mL\n PO:\n 760 mL\n 170 mL\n TF:\n IVF:\n 197 mL\n Blood products:\n Total out:\n 865 mL\n 400 mL\n Urine:\n 865 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 92 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///15/\n Exam:\n Gen: sitting in bed, NAD, somnolent and confused when awake but will\n follow commands,\n HEENT: dry op\n CV: orreg orrge\n Chest: poor air movement\n Abd: no RUQ pain\n Ext: trace edema\n Labs / Radiology\n 12.0 g/dL\n 196 K/uL\n 87 mg/dL\n 5.1 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 155 mg/dL\n 110 mEq/L\n 143 mEq/L\n 34.2 %\n 17.6 K/uL\n [image002.jpg]\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n WBC\n 11.3\n 12.7\n 13.0\n 16.8\n 17.6\n Hct\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n Plt\n 13\n 196\n Cr\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n 5.1\n TCO2\n 15\n 17\n Glucose\n 98\n 110\n 141\n 128\n 101\n 87\n Other labs: PT / PTT / INR:22.5/32.9/2.1, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:373/257, Alk Phos / T Bili:663/22.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by intermittent AF c RVR.\n 1. Leukocytosis: pan culturing, rule out C diff., follow up urine\n culture\n 2. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, has not required any pharma intervention and is usually\n redirectable.\n 3. Hypotension: resolving, off Neo, on Digoxin with stable level.\n 4. GIB: has been stable HCT, no further stools, PPI.\n 5. For , continue supportive care as above. Bblocker, Dig,\n 6. ARF: dense but Cr appears to have plateaued. UOP continues; hope to\n avoid HD as hemodynamics are optimized but need to follow closely Avoid\n all nehrotixins, renalally dose all meds, Na bicarb is a large salt\n load\n ask renal any alternatives.\n 7. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Had been discussion of ERCP to look\n but on hold for now. Fractionate and call Hpetaology to clarify reimage\n US versus ERCP\n may not be needed just want to make sure we are all\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with son, HD has been approached\n Code status: DNR (do not resuscitate)\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-29 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 582186,
"text": "Chief Complaint: CHF, afib, ARF\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 08:05 AM\n picc and aline\n Pulled foley, truam, urology had to be consulted, 3 way irrigation\n Back in and out of Sfib\n dropped BP and needed Neo again\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 04:00 AM\n Infusions:\n Calcium Gluconate (CRRT) - 1.4 grams/hour\n KCl (CRRT) - 2 mEq./hour\n Phenylephrine - 0.4 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Metoprolol - 08:45 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 71 (62 - 137) bpm\n BP: 94/41(58) {72/31(44) - 147/69(98)} mmHg\n RR: 18 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: LBBB (Left Bundle Branch Block)\n Height: 70 Inch\n Total In:\n 2,807 mL\n 1,861 mL\n PO:\n 120 mL\n 30 mL\n TF:\n IVF:\n 2,687 mL\n 1,831 mL\n Blood products:\n Total out:\n 2,725 mL\n 2,512 mL\n Urine:\n 150 mL\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 82 mL\n -651 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\n ABG: 7.47/20/109/14/-5\n Physical Examination\n Gen lying in bed, min responsive\n HEENT op dry\n CV RR\n Chest poor air movement, BS bases\n Abd distended soft hypoactive BS\n Ext: right fem line\n Labs / Radiology\n 11.2 g/dL\n 138 K/uL\n 74 mg/dL\n 1.2 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 33 mg/dL\n 107 mEq/L\n 138 mEq/L\n 31.7 %\n 16.2 K/uL\n [image002.jpg]\n 05:12 AM\n 05:13 AM\n 12:27 PM\n 12:32 PM\n 06:15 PM\n 06:32 PM\n 12:00 AM\n 12:12 AM\n 05:15 AM\n 05:51 AM\n WBC\n 18.4\n 22.0\n 16.2\n Hct\n 30.4\n 33.7\n 31.7\n Plt\n 147\n 182\n 138\n Cr\n 1.8\n 1.8\n 1.5\n 1.2\n 1.2\n TCO2\n 22\n 18\n 19\n 15\n Glucose\n 82\n 91\n 83\n 76\n 74\n Other labs: PT / PTT / INR:19.9/35.8/1.8, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:236/257, Alk Phos / T Bili:749/25.8,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.8 mmol/L, Albumin:3.5\n g/dL, LDH:490 IU/L, Ca++:8.8 mg/dL, Mg++:2.2 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n LEUKOCYTOSIS\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n 1. Hypotension: DDx overdiuresed, bowel ischemia, cardiac dysfunction.\n At this point he is on Neo again, but we need to discuss with son\n overall goals of cared as he is not able to be hemodynamically\n supported without vasopressors. Repeat SCVO2 and lactate.\n 2. ARF: CVVH\n has not been successful either in terms of hemo\n 3. Anemia: DDX blood loss - HCT relatively stable\n maybe slow GI ooze\n versus ischemic bowel\n 4. Leukocytosis: pan culturing, empiric Rx for C diff with Flagyl\n 5. Mental Status: likely a combination of uremia, hyperbili, and ICU\n delirium, overall trajectory is down and even with BUN 150 to 50 he is\n worse.\n 6. For , continue supportive care as above. Bblocker, Dig,\n check level\n 7. Liver injury: presumed shock, LFTs coming down, bili continues to\n rise though starting to plateau. Depending on goals could repeat RUQ if\n no change by tomm Friday or spikes, rising WBC\n ICU Care\n Nutrition: cannot take pos due to poor mental status\n Glycemic Control:\n Lines:\n PICC Line - 03:00 PM\n Dialysis Catheter - 05:43 PM\n Arterial Line - 04:47 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication:\n Code status: DNR (do not resuscitate)\n We need another family meeting today- He is at a point where his goals\n of care shoukdl shift to comfort as he cannot tolerate CVVH, has likely\n bowel ischemia, Afib, CHFand severe mental status decline\n Disposition :ICU\n Total time spent: 35\n Addendum\n Family Meeting 30 min\n Met with all three children and Dr (primary nephrologist)\n Reviewed Mr overall multisystem organ failure (heart kidneys\n liver brain GItract) and that he has not been able to be sustained even\n with aggressive critical care. We will move to CMO and they are in\n agreement with this plan. They will be updating their mother who may or\n may ot come in tonight.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580908,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Converted to sinus with improved BP and UOP yesterday, briefly\n restarted on pressors for afib early this am\n - PICC placed; triple lumen pulled\n - Family meeting regarding code status\n - Started lactulose as no BM in setting of gastric bubble with NG tube\n out. Had large maroon colored BM this AM but Hct stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Insulin - Humalog - 10:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96\n HR: 91 (82 - 120) bpm\n BP: 127/60(86) {97/45(66) - 134/70(192)} mmHg\n RR: 24 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 12 (11 - 24)mmHg\n Total In:\n 1,315 mL\n 72 mL\n PO:\n 1,100 mL\n TF:\n IVF:\n 215 mL\n 72 mL\n Blood products:\n Total out:\n 940 mL\n 455 mL\n Urine:\n 940 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 375 mL\n -383 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///17/\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 230 K/uL\n 12.3 g/dL\n 98 mg/dL\n 4.0 mg/dL\n 17 mEq/L\n 3.8 mEq/L\n 137 mg/dL\n 109 mEq/L\n 143 mEq/L\n 34.9 %\n 12.7 K/uL\n [image002.jpg]\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n 11.3\n 12.7\n Hct\n 36.3\n 35.3\n 36.1\n 35.2\n 34.6\n 34.9\n Plt\n 190\n 226\n 238\n \n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n TCO2\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n 98\n Other labs: PT / PTT / INR:25.4/31.5/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:860/407, Alk Phos / T Bili:547/19.2,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Likely hypovolemic etiology due to poor forward flow vs\n volume depletion; appears to be improving now that patient has\n converted to sinus. Pressors briefly restarted overnight for\n tachycardia with systolic BP\ns in the 90\ns, currently being weaned.\n Transaminitis and UOP improving, suggesting improved perfusion state.\n - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n - Set 5 day course of Unasyn (to end on ) for possible septic\n source\n - PT consult\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig\n - Appreciate cards following\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Lactulose for ? encephalopathy, titrate to 1 BM/day\n # Altered mental status: unclear cause, may be delirium from\n encephalopathy, uremia, hemodynamics; appears improved this am\n - cte to treat a-fib and ARF as indicated\n - lactulose as above\n - consider Haldol if QTc okay\n - minimizes lines/drains.\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR. BM yesterday was maroon but not evidence of\n fresh blood. Hepatic injury may be contributing to coagulopathy with\n INR persistently high, now improving. PPI changed to . Tolerated a\n diet.\n - Hct stable since yesterday, checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Access = a-line, picc\n - Advance diet to full liquids\n - Consider DDAVP if further bleed for uremic plt per Renal\n - F/u GI recs\n - no anticoagulation\n - f/u INR\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr 4.0 down from\n 4.8. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: Clears, advance to full liquids\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI \n VAP:\n Comments:\n Communication: patient, patient\ns family\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580267,
"text": "TITLE:\n Chief Complaint: GI bleed\n 24 Hour Events:\n - Received Vit K 5mg po and 2 units FFP given elevated INR in setting\n of GIB.\n - Decreased O2 sats -> CXR with retrocardiac opacity concerning for\n PNA. Cipro changed to Augmentin to cover possible aspiration.\n - Repeat Hct stable: 36 -> 33.9 -> 35.7 -> 35.5\n - CK and trop still rising. TTE suboptimal; EF still 25% c/w\n multivessel CAD, 2+ MR PA systolic HTN increased since .\n - Liver: Rising LFTs likely shock liver. HIDA not indicated,\n consider MRCP.\n - INR increased to 5.3, given 5 mg vitamin K and 2 u FFP\n - Given 500cc for MAP <50s with only transient improvement. Started on\n dopamine gtt given EF 25% but stopped for tachy to 150s. A-line faulty\n but as SBP 80s with low U/O, CvO2 67, lactate 2.1 (CVP 12)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 106 (81 - 116) bpm\n BP: 64/36(47) {54/29(39) - 134/73(96)} mmHg\n RR: 28 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 14 (12 - 16)mmHg\n Total In:\n 3,227 mL\n 799 mL\n PO:\n TF:\n IVF:\n 2,531 mL\n 799 mL\n Blood products:\n 666 mL\n Total out:\n 738 mL\n 62 mL\n Urine:\n 738 mL\n 62 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 737 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: 7.32/31/95./17/-8\n PaO2 / FiO2: 137\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 190 K/uL\n 12.2 g/dL\n 190 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 4.8 mEq/L\n 90 mg/dL\n 110 mEq/L\n 142 mEq/L\n 36.3 %\n 13.3 K/uL\n [image002.jpg]\n 05:10 AM\n 05:15 AM\n 11:22 AM\n 12:54 PM\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n WBC\n 9.2\n 11.2\n 13.3\n Hct\n 36.0\n 33.9\n 35.7\n 35.5\n 36.3\n Plt\n \n Cr\n 3.1\n 3.0\n 3.6\n TropT\n 1.20\n 1.87\n TCO2\n 15\n 15\n 17\n 15\n 17\n Glucose\n 195\n 155\n 190\n Other labs: PT / PTT / INR:48.7/32.1/5.3, CK / CKMB /\n Troponin-T:705/39/1.87, ALT / AST:2415/3598, Alk Phos / T\n Bili:610/11.0, Amylase / Lipase:143/12, Lactic Acid:2.1 mmol/L,\n Albumin:3.5 g/dL, LDH:1337 IU/L, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n therapeutic INR, ddx includes PUD, ASA-induced gastritis, malignancy.\n - EGD to evaluate for active bleeding, will need reversal of\n anticoagulation prior to INR < 2.0, give 2 u FFP and repeat INR\n - has received 2 u pRBC now for decreased Hct, check Hct q6hr\n - continue PPI gtt\n - f/u GI recs\n - access = 3 PIV\n - hold ASA, coumadin\n .\n # Hypotension- Patient with poor CO (EF 25%) and clinically volume\n depleted. Increasing anion gap (12 -> 16) with lactate 2.2 further\n supports hypo-perfusion. Has received 2 L in ED and 1 L on floor, 2 u\n pRBC and 3 u FFP.\n - Gentle fluids given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - place a-line\n - continue monitoring on tele\n .\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.1 with K 5.7, no EKG changes. Likely pre-renal given patient's\n fluid depleted clinical status\n - gentle IVF given EF\n - check UA and urine lytes\n - will hold on kayexelate pending procedure\n - recheck lytes in pm\n .\n # Transaminitis/Abdominal pain- Possibly due to irritation caused by\n blood in abdomen, however components of history sound like biliary\n colic (transient pain in a band-like distribution, improved with\n belching and resolved within hours on arrival to ED). Does not sound\n like anginal equivalent, first two sets CE negative. LFT's with\n markedly elevated AST and ALT, hyperbilirubinemia (primarily\n conjugated) suggesting obstructive picture.\n - trend LFT's, amylase, lipase\n - RUQ u/s\n - continue ROMI\n .\n # Demand Ischemia/Heart Failure- CPK continues to rise. TTE yesterday\n reveals stable EF 25% with severe hypokinesis. Has been anticoagulated\n to prevent intra-ventricular thrombus formation. Current volume status\n - trend daily CK, CPK\n - volume repletion to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n .\n #DM\n - hold glyburide while inpatient\n - RISS\n .\n # HTN\n - hold HCTZ, beta-blocker and ACE inhibitor in setting of GI bleed\n .\n # Access: 2 PIV\ns, a-line, central line\n .\n # Code: full\n .\n # Communication: Patient , patient\ns wife\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581555,
"text": "TITLE:\n Chief Complaint: UGI bleed, hypotension\n 24 Hour Events:\n - Renal: need to initiate HD; discussed possibility with son. \n reevaluate today.\n - Free T4 nl at 1.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.4\nC (95.8\n HR: 80 (67 - 82) bpm\n BP: 93/65(72) {82/46(55) - 124/78(85)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CO/CI (Fick): (8.2 L/min) / (4.3 L/min/m2)\n Mixed Venous O2% Sat: 77 - 77\n Total In:\n 957 mL\n 50 mL\n PO:\n 760 mL\n 50 mL\n TF:\n IVF:\n 197 mL\n Blood products:\n Total out:\n 865 mL\n 280 mL\n Urine:\n 865 mL\n 280 mL\n NG:\n Stool:\n Drains:\n Balance:\n 92 mL\n -230 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///15/\n Physical Examination\n Gen: Sleeping, but easily arousable, answers to questions are somewhat\n delayed\n HEENT: MMM, sclera icteric\n CV: RRR, no murmurs\n Lungs: CTAB\n Abd: Soft, non-distended with minimal RUQ tenderness\n Ext: Warm, well-perfused\n Labs / Radiology\n 196 K/uL\n 12.0 g/dL\n 87 mg/dL\n 5.1 mg/dL\n 15 mEq/L\n 3.7 mEq/L\n 155 mg/dL\n 110 mEq/L\n 143 mEq/L\n 34.2 %\n 17.6 K/uL\n [image002.jpg]\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n 02:00 AM\n 03:05 AM\n WBC\n 11.3\n 12.7\n 13.0\n 16.8\n 17.6\n Hct\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n 34.1\n 34.2\n Plt\n 13\n 196\n Cr\n 4.8\n 4.0\n 4.8\n 4.8\n 4.8\n 5.1\n TCO2\n 15\n 17\n Glucose\n 98\n 110\n 141\n 128\n 101\n 87\n Other labs: PT / PTT / INR:22.5/32.9/2.1, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:373/257, Alk Phos / T Bili:663/22.5,\n Amylase / Lipase:143/12, Differential-Neuts:89.0 %, Band:1.0 %,\n Lymph:5.0 %, Mono:3.0 %, Eos:1.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:9.5 mg/dL, Mg++:2.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; dig level today 1.2.\n - Rate control with metoprolol\n - Continue dig and follow levels\n - Monitor ECG, tele\n - No anticoagulation given GIB\n - F/u cards recs\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Cr continues to climb (4.8 ->5.1), has some U/O.\n - Cont bicarb for now per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n - Discuss initiating HD with pt and family\n # Leukocytosis: Pt afebrile. Source unclear. UA with small leuk, 8 wbc,\n few bacteria\n - f/u Ucx, CXR, stool for C. diff.\n - d/c foley\n # GIB: Admitted with coffee ground emesis but had maroon colored stools\n 2 days ago suggesting lower GIB. Hcts stable and has not stooled\n since.\n - continue PO PPI\n - start bowel regimen with colace/senna\n - Check Hct daily\n - Transfuse for Hct <30\n # Transaminitis: Evaluated by Liver and thought likely shock liver with\n transaminitis improving, however Tbili still rising; may lag. abd\n U/S with mildly improved gallbladder appearance with sludge and mild\n wall thickening; no specific cholecystitis signs or biliary dilatation.\n Started on ursodiol and sarna for itching, could consider\n cholestyramine.\n - Trend LFTs, amylase, lipase\n - fractionate Bili\n - consider repeat RUQ U/S\n - tolerate MRCP now\n - F/u liver recs; consider ERCP in future if TBili does not resolve\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Cont dig and beta blocker; conservation IV fluids if needed\n - Monitor on telemetry\n - Consider d/c bicarb when renal function improves as high salt load\n # Hypotension: Off pressors for >24 hrs. Appears to have been in sinus\n for most of past 24 hours with one episode of afib at 2am. Had SBP\n in high-80\ns/low-90\ns briefly this morning, now resolved. Over the\n weekend was not able to maintain BP whiel sitting up in chair.\n Transaminitis and UOP improving with nl lactate, suggesting improved\n perfusion state. Did have maroon colored stools on concerning for\n GIB but Hct stable.\n - Treat AF as below with dig, beta blocker\n - If requires pressors, would resume neo\n - Follow perfusion status with UOP, CvO2, lactate, liver function,\n mentation\n - Would give IVF cautiously if requires given CHF\n # Thyroid: Question of central hypothyroidism with low TSH and T4,\n however free T4 nl.\n # AMS: Confusion at night with nonfocal neuro exam. have element of\n sundowning + contribution from persistently elevated BUN. Could also\n represent delirium in setting, ? underlying infection given rise in\n leukocytosis although afebrile.\n - Continue leukocytosis w/u as above\n - HD discussion with pt and family as above\n - Could consider low-dose antipsychotics if very agitated but no need\n for now\n ICU Care\n Nutrition: Regular, heart-healthy\n Lines:\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n Communication: Patient, patient\ns children\n Code status: DNR (do not resuscitate), OK to intubate\n Disposition: ICU, call out to floor\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581331,
"text": "Chief Complaint:\n 24 Hour Events:\n - Renal: Cont bicarb. Creatinine increase likely hypotension but\n encouraged because euvolemic and still with good UOP.\n - Dry on exam so received two 500cc NS boluses\n - Called for slow VT with AMS. EKG showed same rhythm as before at rate\n 100bpm - LBBB with AFib. Neuro exam non-focal with delirium but\n otherwise no neurologic deficits. Lytes with low calcium (1.01). gave\n 2gm calcium. ABG with metabolic acidosis but nl PO2. Thought to be\n sundowning with no new arrhythmia.\n - Both TSH (0.17) and T4 (3) low\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.7\nC (96.3\n HR: 80 (74 - 119) bpm\n BP: 113/52(67) {86/27(40) - 127/72(82)} mmHg\n RR: 15 (13 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 254 mL\n PO:\n 970 mL\n 200 mL\n TF:\n IVF:\n 1,158 mL\n 54 mL\n Blood products:\n Total out:\n 820 mL\n 110 mL\n Urine:\n 820 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: 7.36/29/110/15/-7\n Physical Examination\n GEN: NAD\n HEENT: Jaundice\n LUNGS: Crackles at bases\n HEART: Regular and tachycardic\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 218 K/uL\n 12.3 g/dL\n 128 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 3.9 mEq/L\n 142 mg/dL\n 110 mEq/L\n 140 mEq/L\n 38\n 13.0 K/uL\n [image002.jpg]\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n Plt\n 18\n Cr\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 158\n 135\n 98\n 110\n 141\n 128\n Other labs: Ca++:8.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.8 mg/dL. TSH 0.17, T4\n 3. Dig 1.3.\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for GIB although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below with dig\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n - increase diet today and consider IVF cautiously given CHF if\n requires.\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Started metoprolol for rate control with stable pressures\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given GIB\n # GIB: Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower GIB. Hcts stable.\n - Check Hct QD\n - Transfuse for Hct <30\n - PPI IV BID ->change to PO today\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and beta blocker\n - Monitor on telemetry\n - consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Dry on exam yesterday with rise in Cr to 4.8 from 4 and decrease U/O\n - Cont bicarb per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n # Transaminitis: Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Consider ERCP in future if TBili does not resolve\n # Thyroid: Question of central hypothyroidism with low TSH and T4.\n - Consider checking free T4\n # AMS: Now resolved. Consider PT and OOB to chair today after IVF so\n less likely to have hypotension.\n ICU Care\n Nutrition: DM, Cardiac\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok to intubate\n Disposition: ICU\n"
},
{
"category": "Echo",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Report",
"row_id": 65529,
"text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Hypotension. Elevated Cardiac Enzymes. Left ventricular function.\nHeight: (in) 70\nWeight (lb): 155\nBSA (m2): 1.87 m2\nBP (mm Hg): 93/50\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 12:18\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. Aneurysmal interatrial\nseptum.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate-severe\nregional left ventricular systolic dysfunction. No LV mass/thrombus. No\nresting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nakinetic; mid anteroseptal - akinetic; mid inferoseptal - akinetic; anterior\napex - akinetic; septal apex- akinetic; inferior apex - akinetic; apex -\nakinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Normal descending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Calcified tips of papillary muscles. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is mildly dilated. The interatrial septum is aneurysmal. Left\nventricular wall thicknesses and cavity size are normal. There is moderate to\nsevere regional left ventricular systolic dysfunction with near akinesis of\nthe distal 2/3rds of the ventricle (LVEF 25%). No aneurysm or thrombus is\nseen. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets are mildly thickened (?#). There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nmildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Normal left vevntricular cavity size\nwith extensive regional systolic dysfunction c/w multivessel CAD. Moderate\nmitral regurgitation. Mild pulmonary artery systolic hypertension.\nCompared with the report of the prior study (images unavailable for review) of\n, the severity of mitral regurgitation and the estimated pulmonary\nartery systolic pressure have increased. Left ventricular systolic function is\nsimilar.\n\nCLINICAL IMPLICATIONS:\nThe left ventricular ejection fraction is <40%, a threshold for which the\npatient may benefit from an ACEI or .\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Report",
"row_id": 139213,
"text": "Atrial fibrillation with a rapid ventricular response. Left bundle-branch\nblock. Since the previous tracing of atrial fibrillation and increase\nin rate have appeared. Otherwise, no apparent diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Report",
"row_id": 139214,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof the rhythm is now sinus.\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Report",
"row_id": 139215,
"text": "Compared to the previous tracing ventricular response rate to atrial\nfibrillation is reduced from 120 to 90. Left bundle-branch block persists.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Report",
"row_id": 139216,
"text": "Atrial fibrillation with a ventricular response rate of approximately 115\nand left bundle-branch block. Non-specific repolarization change. Compared to\nthe previous tracing of probably no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Report",
"row_id": 139217,
"text": "*** CONSIDER ACUTE ST ELEVATION MI ***\nProbable atrial fibrillation with rapid ventricular response\nLeft bundle branch block\nPossible inferior infarct - age undetermined\nLateral ST elevation\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Report",
"row_id": 139218,
"text": "*** CONSIDER ACUTE ST ELEVATION MI ***\nProbable atrial fibrillation with rapid ventricular response\nSinus rhythm with atrial ectopic activity\nLeft bundle branch block\nPossible inferior infarct - age undetermined\nLateral ST elevation\nSince previous tracing of the same date, both atrial fibrillation and sinus\nrhythm with atrial ectopic activity are seen\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Report",
"row_id": 139219,
"text": "Technically difficult study\n*** CONSIDER ACUTE ST ELEVATION MI ***\nSinus rhythm with atrial ectopic activity versus atrial fibrillation with rapid\nventricular response\nLeft bundle branch block\nPossible inferior infarct - age undetermined\nLateral ST elevation, CONSIDER ACUTE INFARCT\nSince previous tracing of , the heart rate is faster, irregular rhythm,\natrial ectopic activity or atrial fibrillation now present\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Report",
"row_id": 139220,
"text": "Sinus arrhythmia. Since the previous tracing of probably no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Report",
"row_id": 139221,
"text": "Sinus rhythm. Left axis deviation. Consider inferior myocardial infarction.\nLeft bundle-branch block. Since the previous tracing of the limb\nlead voltage has diminished.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2102-06-17 00:00:00.000",
"description": "Report",
"row_id": 139266,
"text": "Sinus rhythm. Left bundle-branch block. Compared to the previous tracing\nof no diagnostic change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085352,
"text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for interval change\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF, AFib w/ RVR, CVVH\n REASON FOR THIS EXAMINATION:\n please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: An 88-year-old male with CHF and atrial fibrillation, to assess for\n a cardiopulmonary process.\n\n TECHNIQUE: Single portable AP radiograph of the chest was performed.\n Comparison is made with prior radiograph dated .\n\n FINDINGS:\n\n The lungs are of relatively low volume. The cardiac silhouette remains\n enlarged. There is indistinctness to the pulmonary vasculature suggestive of\n early/mild CHF.\n\n CONCLUSION:\n\n Overall findings suggestive of mild/early CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-22 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1084477,
"text": " 3:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 51 cm Picc placed in right basilic vein, need Picc tip place\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 51 cm Picc placed in right basilic vein, need Picc tip placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 88 year old male with new right PICC placement.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST: A left internal jugular catheter terminating in the upper\n SVC is unchanged. A new right PICC terminating in the mid SVC is noted. The\n cardiomediastinal silhouette is unchanged. Stable increased opacity in the\n medial right lung apex is consistent with right substernal thyroid is better\n evaluated on CT neck. Minimally increased right upper lung opacity\n is new since hours prior. Bibasilar atelectasis is similar to 12 hours\n prior.\n\n IMPRESSION: Right PICC terminates in the mid SVC. Minimally increased right\n upper lung opacity may represent evolving infectious process or increasing\n atelectasis. Otherwise little change since hours prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085009,
"text": " 7:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with cardiogenic shock and renal failure now ? fluid overload.\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:57 \n\n HISTORY: Cardiogenic shock and renal failure. Possible fluid overload.\n\n IMPRESSION: AP chest compared to :\n\n Right perihilar opacification has worsened again since , and although\n it is impossible to exclude pneumonia, in the setting of persistent vascular\n engorgement this can also be explained by pulmonary edema. Heart size top\n normal. Pleural effusions are small, if any. No pneumothorax. Right-sided\n central venous line ends at the junction of the brachiocephalic veins. No\n pneumothorax.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580633,
"text": "This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n Code status: full code\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580234,
"text": "Hypoxemia\n Assessment:\n Increased oxygenation needs during days on ; received on NRB 10L;\n CXR-LLL infiltrate-begun on unasyn\n Action:\n Attempted to titrate oxygenation level and mode of delivery during\n course of night; enc C+DB\n Response:\n Maintaining o2 sats in low to mid 90\ns on NRB 8L; pt disliked face\n tent; desaturates to high 80\ns on RA; desats to low 90\ns with 6L nc and\n c/o nasal discomfort\n Plan:\n Titrate oxygen to maintain o2 sats in mid 90\ns or greater. Unasyn.\n Monitor via CXR.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB\n Action:\n Closely monitor. Other set of CPK\ns drawn this am\n Response:\n Labs pnd. Pt denies any SOB/CP /tightness\n Plan:\n Cont to closely monitor. Await labs.lBedrest. Pneumo boots.\n Hypotension (not Shock)\n Assessment:\n Received multiple boluses of IVf d/t hypotension.\n Action:\n Bp monitored by aline; AM labs indicates INR 5.2-resident notified\n Response:\n Dampened aline tracing; NIBP not coinciding with arterial line; NIBP\n with >10pt value higher; accepting MAP 60\ns via NIBP; BP tolerable\n thru the night. Increased ectopy noted, resident notified. Watch s/s\n bleeding\n Plan:\n Anticipate changing aline over wire. Cont to monitor BP. Consider\n reversing INR\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Borderline u/o over course of dayshift with no additional fluid boluses\n required\n Action:\n NIGHTS: Bolused with 1.25L NS for oliguria; trial of dopamine to\n improve u/o; catheter flushed to assess patency\n Response:\n Min response to boluses; u/o minimal and anuric at times. BUN/Cr\n increasing. Intolerant to dopamine-became increasingly tachycardic\n Plan:\n Obtain renal consult. Monitor u/o.\n Altered mental status (not Delirium)\n Assessment:\n Hypotensive, +UTI, +LLL infiltrate, +MI, patient in ICU,\n elderly\nincreased confusion and extreme restlessness noted thru shift;\n orientated to person, place, president. Awakens and pt req to be\n reorientated frequently; pulling at lines and attempting to get OOB\n Action:\n CLOSELY monitored throughout the night; reorientated frequently; pt\n spoke with wife beginning of shift, spirits good. Pt joking with staff\n in apparent effort to mask his confusion/disorientation\n Response:\n Remains confused/disorientated and restless\n Plan:\n Closely monitor pt. Consider restraints if pt pulling at lines. Bed\n alarm. Involve family. Reorientate prn\n"
},
{
"category": "Nutrition",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 580557,
"text": "Ht: 69\n (per patient)\n Admit Wt: 73.1 kg\n IBW: 72.6 kg/101%\n UBW: 72.6kg/100%\n BMI: 23.7\n Diet Order: clear liquids\n 88 year old male admitted with epigastric discomfort and transferred to\n ICU after vomiting blood and had hypotension and ARF. Patient reports\n good appetite and po intake PTA denies wt loss. Patient tolerated water\n this morning and is waiting for his lunch tray of clear liquids. Denies\n nausea and vomiting. Patient has been NPO and/or on unsupplemented\n clear liquid diet for 3 days. If patient's diet is not able to be\n advanced and tolerated, for nutrition support.\n Will continue to follow page with questions.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580680,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Got FFP with repeat INR 2.5, down from 5\n - Cards: Start dig 0.25 X 1 dose then 0.125 X 2 doses then check dig\n level\n - Liver: Start ursodiol\n - Renal: start bicarb. ?HRS\n - HR transiently into 150s with decreased BPs. Increased neo. Gave 5mg\n lopressor after neo increased with better rate control (although still\n occasional bursts of tachycardia), pressors off this morning\n - Pulled NGT, advanced diet to clears\n - PPI changed to IV BID\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36\nC (96.8\n HR: 104 (75 - 124) bpm\n BP: 123/69(87) {92/51(66) - 138/74(95)} mmHg\n RR: 25 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 14 (11 - 26)mmHg\n CO/CI (Fick): (5.2 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 2,446 mL\n 576 mL\n PO:\n 720 mL\n 480 mL\n TF:\n IVF:\n 1,212 mL\n 96 mL\n Blood products:\n 514 mL\n Total out:\n 720 mL\n 135 mL\n Urine:\n 720 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,726 mL\n 441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.37/25/78./15/-8\n Physical Examination\n Gen:\n HEENT:\n CV:\n Lungs:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 246 K/uL\n 12.3 g/dL\n 135 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.4 mEq/L\n 128 mg/dL\n 111 mEq/L\n 143 mEq/L\n 35.2 %\n 13.3 K/uL\n [image002.jpg]\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n Hct\n 35.5\n 36.3\n 35.3\n 36.1\n 35.2\n Plt\n 190\n 226\n 238\n 246\n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n TCO2\n 17\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n Other labs: PT / PTT / INR:29.4/30.6/2.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:1291/768, Alk Phos / T Bili:525/18.7,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Cardiogenic v. hypovolemic v. distributive. Was started\n on levophed yesterday but developed afib, switched to neo; afib\n terminated on its own without need to rate control.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to be able to wean neo with improvement in fluid status; goal\n MAP>60 and UOP >30 cc/hr\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo.\n - Appreciate cards recs\n - Monitor ECG, tele\n # Demand Ischemia/Heart Failure: CPK trending down. Very elevated BNP\n yesterday. TTE showed stable EF 25%.\n - Trend CK, CPK daily\n - Recheck BNP\n - Volume repletion and neo as above to goal MAP >60, UOP >30 cc/hr\n - Monitor on telemetry\n # Transaminitis- Likely shock liver with transaminitis improving. ERCP\n service consulted, however pt not felt likely to tolerate ERCP now and\n RUQ u/s was repeated showing slightly improved picture.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy. Hepatic injury may be contributing to coagulopathy with\n INR persistently high.\n - Hct stable since yesterday, decrease to daily checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Continue PPI gtt for 72 hours, then change to IV bid\n - Access 2 PIV, a-line, central line\n - D/c NGT, advance diet\n - Holding ASA, coumadin\n - Consider DDAVP if further bleed for uremic plt per Renal\n - Give FFP x 2 units\n - F/u GI recs\n - no anticoagulation\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre continues to\n climb. Urine without eos, + few granular casts. Urine lytes yesterday\n c/w pre-renal azotemia also likely from hypotension. UOP improved\n somewhat with pressors.\n - Liberalize po fluid intake today\n - Monitor U/O\n - Wean pressor as tolerated\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: Clears\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer:PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580437,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Since arrival to MICU patients course has been c/b UGIB requiring 2\n units PRBCs, Rec\nd mult. Units of FFP, and mult. Doses of PO and IV\n vitamin K for persistently high INR. Pt hypotensive with MODs\n including ARF, r/I for MI with troponin 1.8, and shock liver.\n Currently on levophed gtt and requiring 100& high flow oxygen.\n Hypoxemia\n Assessment:\n Received on high flow neb 100%. O2 sats 94-96%. LS-clear w/ diminished\n bases.\n Action:\n O2 changed to NC@ 5L.\n Response:\n O2 sats remained 94-95% on NC.\n Plan:\n Wean o2 as tolerated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB. BP 119-135/51-70. MAP 72-94. Continues on levophed gtt.\n Action:\n Levophed gtt titrated for MAP 70-80.\n Response:\n Denied chest pain/resp difficulty.\n Plan:\n Vitals monitored. Pneumo boots on. Wean levophed as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP continues to be low, ~20cc/hr.\n Action:\n UOP monitored.\n Response:\n No change in UOP.\n Plan:\n Monitor UOP.\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Pulled out NGT. Restless during the\n night. Pulling at IVs/tubes. Complained of feeling nervous.\n Action:\n Emotional support provided. Reoriented frequently. Bed alarm on.\n Response:\n No change in mental status.\n Plan:\n Monitor mental status. Reorient frequently.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 580780,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Got FFP with repeat INR 2.5, down from 5\n - Cards: Start dig 0.25 X 1 dose then 0.125 X 2 doses then check dig\n level\n - HR transiently into 150s with decreased BPs. Increased neo. Gave 5mg\n lopressor after neo increased with better rate control (although still\n occasional bursts of tachycardia), pressors off this morning\n - Increased O2 requirement (desat from 95% -> 89% on 3L) with ABG\n revealing metabolic acidosis, CXR with mild fluid overload, oxygen\n delivery increased (30% facemask + NC) o/n, now back down to 5L NC\n - more confused o/n\n - Pulled NGT, advanced diet to clears\n - PPI changed to IV BID\n - Liver: Start ursodiol\n - Renal: start bicarb\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36\nC (96.8\n HR: 104 (75 - 124) bpm\n BP: 123/69(87) {92/51(66) - 138/74(95)} mmHg\n RR: 25 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 14 (11 - 26)mmHg\n CO/CI (Fick): (5.2 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 2,446 mL\n 576 mL\n PO:\n 720 mL\n 480 mL\n TF:\n IVF:\n 1,212 mL\n 96 mL\n Blood products:\n 514 mL\n Total out:\n 720 mL\n 135 mL\n Urine:\n 720 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,726 mL\n 441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 5L\n SpO2: 94%\n ABG: 7.37/25/78./15/-8\n Physical Examination\n Gen: Awake elderly gentleman in NAD\n HEENT: sclera icteric, dry MM\n CV: RRR, no murmurs\n Lungs: bronchial breathsounds without crackles\n Abd: Soft, NT, ND, + bowel sounds, no RUQ tenderness\n Ext: Warm, well-perfused, no edema\n Neuro: A+Ox3, responds appropriately to questions\n Labs / Radiology\n 246 K/uL\n 12.3 g/dL\n 135 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.4 mEq/L\n 128 mg/dL\n 111 mEq/L\n 143 mEq/L\n 35.2 %\n 13.3 K/uL\n [image002.jpg]\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n Hct\n 35.5\n 36.3\n 35.3\n 36.1\n 35.2\n Plt\n 190\n 226\n 238\n 246\n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n TCO2\n 17\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n Other labs: PT / PTT / INR:29.4/30.6/2.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:1291/768, Alk Phos / T Bili:525/18.7,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n BNP - >\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Appears to be improving with CvO2 high 60\ns-low 70\n Cardiogenic v. hypovolemic v. distributive, with hypovolemic most\n likely. Was started on levophed intially but developed afib. Pressors\n off since this morning. ABG early this morning with gap metabolic\n acidosis further supports hypoperfused state.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to maintain pressors off; goal MAP>60 and UOP >30 cc/hr\n - If requires pressors, would choose neo\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n - Set 5 day course of Unasyn (to end on )\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo. Continues to have runs of afib. Lopressor x1 yesterday\n did not persistently slow rate. Cardiology recommended digoxin\n loading.\n - Continue dig loading with renal dosing\n - Appreciate cards following\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors.\n # Demand Ischemia/Heart Failure: CPK trending down. BNP increased from\n 40K -> 70K. TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol for possible biliary process.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Lactulose for ? encephalopathy\n # Altered mental status: unclear cause, may be delirium from\n encephalopathy, uremia, hemodynamics\n - cte to treat a-fib and ARF as indicated\n - give dose of lactulose\n - consider Haldol if QTc okay\n - minimizes lines/drains.\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR. Hepatic injury may be contributing to\n coagulopathy with INR persistently high, now improved with 2 u FFP.\n PPI changed to . Tolerated a diet.\n - Hct stable since yesterday, decrease to checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Access 2 PIV, a-line, central line\n - Consider DDAVP if further bleed for uremic plt per Renal\n - F/u GI recs\n - no anticoagulation\n - f/u INR\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr appears to have\n stabilized. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: ADAT\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer:PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 88M CAD, DCM (25%) c vent AK on coumadin, B\n CEA, UGIB, . Stable HCT. Loaded on digoxin, ongoing AF c RVR, off\n neo.\n Exam notable for Tm 97.5 BP 114/60 HR 70-120 RR 18 with sat 94 on 5LNC\n 7.37/25/78 CVP 14 CvO2 67. Pleasant, WD man, NAD. Clear BS B. RRR s1s2.\n Soft +BS. No edema. Labs notable for WBC 13K, HCT 35, K+ 4.4, Cr 4.2,\n INR 2.5. EKG LB3.\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by AF c RVR. Will d/w cards re other\n options (procainamide?), continue dig to level for now. Amio is not\n appealing given combination of tenuous pulmonary and hepatic function.\n For , continue supportive care as above. GIB is stable,\n serial HCT, PPI. Shock liver / LFTs improving. ARF is stable, UOP is up\n when in NSR; hope to avoid HD as hemodynamics are optimized.\n Respiratory distress is stable, will wean oxygen as able, and will\n continue antibiotics x5d for possible aspiration pneumonitis. Will\n continue RISS for DM2. Will try to place PICC. Above d/w family and\n patient at bedside. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:13 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580781,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Dig load completed\n Alternating between SR and afib\n Action:\n Dig load completed, dig level ordered for 1700\n Pt alternating between sr with hr 60-80\ns, and afib with hr 100-120, BP\n improved when in SR\n Pt with poor activity tolerance, hr inc to 120-130 with minimal\n activity, with drop in bp, pt remains on bed rest\n Remains off neosynephrine gtt\n PICC line placed, and tip placement confirmed, tlcl ordered for d/c\n Family meeting held to discuss pt\ns condition and plan of care. Family\n to discuss code status amongst themselves\n Response:\n Improved bp when in SR\n Plan:\n f/u dig level\n d/c tlcl\n neo gtt for hypotension\n remains on bed rest till activity tolerance improves\n Altered mental status (not Delirium)\n Assessment:\n Intermittently confused\n Action:\n Pt alternating between oriented x2 and confused\n Makes attempts at getting oob, but easily re-oriented\n Pulling at PIV on left arm this am, skin tear noted after pt pulled off\n tape around iv\n c/o\nitichiness\n saran lotion applied with little improvement\n Response:\n Intermittent confusion\n Plan:\n Saran lotion for pruritis\n Freq re-orientation\n Hypoxemia\n Assessment:\n Remains on nc 5l\n Action:\n Pt denies sob, but appears dyspnic with any activity\n Lungs with bibasilar crackles\n BNP from >70,000\n Response:\n Plan:\n Titrate o2 as tolerated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n u/o slowly improving\n Action:\n Creat 4.2 this am\n u/o 20-40ml/hr this shift, improves when in SR with better bp\n urine NA sent\n Response:\n Improved u/o when in SR\n Plan:\n Follow lytes, labs\n Urine NA with am labs\n Liver function abnormalities\n Assessment:\n LFT\ns stable\n Action:\n Pt jaundiced with icteric sclera\n INR 2.9 this am, plans for recheck this pm\n Tolerating clear liquid diet\n ? last bm\n Lactulose started\n Response:\n Stable liver function\n Plan:\n f/u pm coags\n lactulose as ordered\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580934,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Converted to sinus with improved BP and UOP yesterday, briefly\n restarted on pressors for afib early this am\n - PICC placed; triple lumen pulled\n - Family meeting regarding code status\n - Started lactulose as no BM in setting of gastric bubble with NG tube\n out. Had large maroon colored BM this AM but Hct stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Insulin - Humalog - 10:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96\n HR: 91 (82 - 120) bpm\n BP: 127/60(86) {97/45(66) - 134/70(192)} mmHg\n RR: 24 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 12 (11 - 24)mmHg\n Total In:\n 1,315 mL\n 72 mL\n PO:\n 1,100 mL\n TF:\n IVF:\n 215 mL\n 72 mL\n Blood products:\n Total out:\n 940 mL\n 455 mL\n Urine:\n 940 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 375 mL\n -383 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///17/\n Physical Examination\n GEN: NAD\n HEENT: Jaundice\n LUNGS: Crackles at bases\n HEART: Irregularly irregular and tachycardic\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 230 K/uL\n 12.3 g/dL\n 98 mg/dL\n 4.0 mg/dL\n 17 mEq/L\n 3.8 mEq/L\n 137 mg/dL\n 109 mEq/L\n 143 mEq/L\n 34.9 %\n 12.7 K/uL\n [image002.jpg]\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n 11.3\n 12.7\n Hct\n 36.3\n 35.3\n 36.1\n 35.2\n 34.6\n 34.9\n Plt\n 190\n 226\n 238\n \n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n TCO2\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n 98\n Other labs: PT / PTT / INR:25.4/31.5/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:860/407, Alk Phos / T Bili:547/19.2,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below\n - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given \n - Monitor ECG, tele\n # : Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower . Hcts stable.\n - Check Hct Q6H\n - Transfuse for Hct <30\n - Cls GI re: possibility of scope\n - PPI IV BID until source found as more likely LGIB but as came in with\n coffee ground emesis could be brisk UGIB\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n - consider D/C bicarb as large salt load\n - Cte dig as above\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr 4.0 down from\n 4.8. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs but will likely not continue for long given\n large sodium load with it.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Stop lactulose today give clear MS \n # AMS: Now resolved. Consider PT and OOB to chair today.\n ICU Care\n Nutrition: full liquids\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI IV\n Communication: patient, patient\ns family\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580516,
"text": "Chief Complaint: GI bleed\n 24 Hour Events:\n - Started on low dose levophed with goal of SBPs 120-130\n - Remains with marginal UOP 20-25 cc/hr\n - Renal rec: Repeat UA/lytes/Eos and give DDAVP if rebleeds for ?\n uremic platelets.\n - UA with 6-10 WBC, 20-30 RBC, and FeNa 0.8\n - Liver rec: ERCP consult who recommend repeat abd U/S ->\nMildly\n improved appearance of the gallbladder, containing sludge mixed with\n bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis\n - Weaned down on O2 overnight\n - Went into a-fib at 5 AM with rates to 120 and BPs down to 100s/60s.\n He was transitioned to Neo.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 0.6 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 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 102 (79 - 122) bpm\n BP: 113/64(82) {90/50(70) - 137/74(98)} mmHg\n RR: 19 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 15 (13 - 16)mmHg\n Total In:\n 1,915 mL\n 287 mL\n PO:\n TF:\n IVF:\n 1,335 mL\n 287 mL\n Blood products:\n 580 mL\n Total out:\n 385 mL\n 195 mL\n Urine:\n 385 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,530 mL\n 92 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.31/28/103/15/-10\n PaO2 / FiO2: 103\n Physical Examination\n General: Alert, mentating well, appears younger than stated age, face\n mask on\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 238 K/uL\n 12.7 g/dL\n 155 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 114 mg/dL\n 111 mEq/L\n 144 mEq/L\n 36.1 %\n 14.8 K/uL\n [image002.jpg]\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n WBC\n 13.3\n 14.0\n 14.8\n Hct\n 35.7\n 35.5\n 36.3\n 35.3\n 36.1\n Plt\n 190\n 226\n 238\n Cr\n 3.6\n 3.8\n 4.2\n TCO2\n 17\n 15\n 17\n 16\n 15\n Glucose\n 190\n 147\n 155\n Other labs: PT / PTT / INR:45.4/31.2/4.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:2055/, Alk Phos / T\n Bili:558/16.8, Amylase / Lipase:143/12, Differential-Neuts:85.9 %,\n Lymph:5.8 %, Mono:8.1 %, Eos:0.2 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy. Hepatic injury may be contributing to coagulopathy with\n INR persistently high.\n - defer EGD for now given cardiac ischemia, hypotension, coagulopathy\n - Hct stable since yesterday, increase to checks\n - continue PPI gtt for 72 hours (d/c at noon)\n - consider d/c NGT, advancing diet\n - f/u GI recs\n - access 2 PIV, a-line, central line\n - hold ASA, coumadin\n - Give IV vitamin K, consider additional \n # Hypotension- Patient is 6.5 L up over LOS. Was started on levophed\n yesterday but developed afib, switched to neo and afib terminated on\n its own without need to rate control.\n - goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - ECG this am\n - continue monitoring on tele\n # A-fib with RVR- likely due to levophed, changed to neo\n - monitor and EKG as above\n # Acute Renal Failure- Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre continues to\n climb. Urine without eos, + few granular casts. Urine lytes yesterday\n c/w pre-renal azotemia also likely from hypotension. UOP improved\n somewhat with pressors.\n - continue neo\n - per renal recs: consider DDAVP if further bleed for uremic plt,\n - gentle IVF given EF\n # Demand Ischemia/Heart Failure- CPK trending down. TTE yesterday\n reveals stable EF 25%.\n - trend CK, CPK\n - volume repletion and neo as above to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n # Transaminitis- Likely shock liver with transaminitis improving. ERCP\n service consulted, however pt not felt likely to tolerate ERCP now and\n RUQ u/s was repeated showing slightly improved picture.\n - f/u Liver recs\n - trend LFT's, amylase, lipase\n #DM\n - hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: NPO, consider advancing to clears today\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: patient, patient\ns wife\n status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580533,
"text": "Chief Complaint: GI bleed\n 24 Hour Events:\n - Started on low dose levophed with goal of SBPs 120-130. Went into\n a-fib at 5 AM with rates to 120 and BPs down to 100s/60s. He was\n transitioned to Neo.\n - Remains with marginal UOP 20-25 cc/hr. Renal recommended repeat\n UA/lytes/Eos: UA with 6-10 WBC, 20-30 RBC, FeNa 0.8, neg eos. To give\n DDAVP if rebleeds for ?uremic platelets\n - Liver recommended ERCP consult who recommend repeat abd U/S ->\nMildly improved appearance of the gallbladder, containing sludge mixed\n with bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis.\n - Weaned down on O2 overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 0.6 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 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 102 (79 - 122) bpm\n BP: 113/64(82) {90/50(70) - 137/74(98)} mmHg\n RR: 19 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 15 (13 - 16)mmHg\n Total In:\n 1,915 mL\n 287 mL\n PO:\n TF:\n IVF:\n 1,335 mL\n 287 mL\n Blood products:\n 580 mL\n Total out:\n 385 mL\n 195 mL\n Urine:\n 385 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,530 mL\n 92 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.31/28/103/15/-10\n PaO2 / FiO2: 103\n Physical Examination\n General: Alert, mentating well, appears younger than stated age, face\n mask on\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 238 K/uL\n 12.7 g/dL\n 155 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 114 mg/dL\n 111 mEq/L\n 144 mEq/L\n 36.1 %\n 14.8 K/uL\n [image002.jpg]\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n WBC\n 13.3\n 14.0\n 14.8\n Hct\n 35.7\n 35.5\n 36.3\n 35.3\n 36.1\n Plt\n 190\n 226\n 238\n Cr\n 3.6\n 3.8\n 4.2\n TCO2\n 17\n 15\n 17\n 16\n 15\n Glucose\n 190\n 147\n 155\n Other labs: PT / PTT / INR:45.4/31.2/4.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:2055/, Alk Phos / T\n Bili:558/16.8, Amylase / Lipase:143/12, Lactic Acid:1.5 mmol/L,\n LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL. Micro: No\n pending data.\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy. Hepatic injury may be contributing to coagulopathy with\n INR persistently high.\n - defer EGD for now given cardiac ischemia, hypotension, coagulopathy\n - Hct stable since yesterday, increase to checks\n - continue PPI gtt for 72 hours (d/c at noon)\n - consider d/c NGT, advancing diet\n - f/u GI recs\n - access 2 PIV, a-line, central line\n - hold ASA, coumadin\n - Give IV vitamin K, consider additional \n # Hypotension- Patient is 6.5 L up over LOS. Was started on levophed\n yesterday but developed afib, switched to neo and afib terminated on\n its own without need to rate control.\n - goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - ECG this am\n - continue monitoring on tele\n # A-fib with RVR- likely due to levophed, changed to neo\n - monitor and EKG as above\n # Acute Renal Failure- Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre continues to\n climb. Urine without eos, + few granular casts. Urine lytes yesterday\n c/w pre-renal azotemia also likely from hypotension. UOP improved\n somewhat with pressors.\n - continue neo\n - per renal recs: consider DDAVP if further bleed for uremic plt,\n - gentle IVF given EF\n # Demand Ischemia/Heart Failure- CPK trending down. TTE yesterday\n reveals stable EF 25%.\n - trend CK, CPK\n - volume repletion and neo as above to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n # Transaminitis- Likely shock liver with transaminitis improving. ERCP\n service consulted, however pt not felt likely to tolerate ERCP now and\n RUQ u/s was repeated showing slightly improved picture.\n - f/u Liver recs\n - trend LFT's, amylase, lipase\n #DM\n - hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: NPO, consider advancing to clears today\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: patient, patient\ns wife\n status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580536,
"text": "Chief Complaint: GI bleed\n 24 Hour Events:\n - Started on low dose levophed with goal of SBPs 120-130. Went into\n a-fib at 5 AM with rates to 120 and BPs down to 100s/60s. He was\n transitioned to Neo.\n - Remains with marginal UOP 20-25 cc/hr. Renal recommended repeat\n UA/lytes/Eos: UA with 6-10 WBC, 20-30 RBC, FeNa 0.8, neg eos. To give\n DDAVP if rebleeds for ?uremic platelets\n - Liver recommended ERCP consult who recommend repeat abd U/S ->\nMildly improved appearance of the gallbladder, containing sludge mixed\n with bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis.\n - Weaned down on O2 overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 0.6 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 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 102 (79 - 122) bpm\n BP: 113/64(82) {90/50(70) - 137/74(98)} mmHg\n RR: 19 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 15 (13 - 16)mmHg\n Total In:\n 1,915 mL\n 287 mL\n PO:\n TF:\n IVF:\n 1,335 mL\n 287 mL\n Blood products:\n 580 mL\n Total out:\n 385 mL\n 195 mL\n Urine:\n 385 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,530 mL\n 92 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.31/28/103/15/-10\n PaO2 / FiO2: 103\n Physical Examination\n General: Alert, mentating well, appears younger than stated age, face\n mask on\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Improved today - clear to auscultation bilaterally, no wheezes,\n rales, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 238 K/uL\n 12.7 g/dL\n 155 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 114 mg/dL\n 111 mEq/L\n 144 mEq/L\n 36.1 %\n 14.8 K/uL\n [image002.jpg]\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n WBC\n 13.3\n 14.0\n 14.8\n Hct\n 35.7\n 35.5\n 36.3\n 35.3\n 36.1\n Plt\n 190\n 226\n 238\n Cr\n 3.6\n 3.8\n 4.2\n TCO2\n 17\n 15\n 17\n 16\n 15\n Glucose\n 190\n 147\n 155\n Other labs: PT / PTT / INR:45.4/31.2/4.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:2055/, Alk Phos / T\n Bili:558/16.8, Amylase / Lipase:143/12, Lactic Acid:1.5 mmol/L,\n LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL. Micro: No\n pending data.\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy. Hepatic injury may be contributing to coagulopathy with\n INR persistently high.\n - Hct stable since yesterday, decrease to daily checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Continue PPI gtt for 72 hours, then change to IV bid\n - Access 2 PIV, a-line, central line\n - D/c NGT, advance diet\n - Holding ASA, coumadin\n - Consider DDAVP if further bleed for uremic plt per Renal\n - Give FFP x 2 units\n - F/u GI recs\n # Hypotension: Cardiogenic v. hypovolemic v. distributive. Was started\n on levophed yesterday but developed afib, switched to neo; afib\n terminated on its own without need to rate control.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to be able to wean neo with improvement in fluid status; goal\n MAP>60 and UOP >30 cc/hr\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo.\n - Appreciate cards recs\n - Monitor ECG, tele\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre continues to\n climb. Urine without eos, + few granular casts. Urine lytes yesterday\n c/w pre-renal azotemia also likely from hypotension. UOP improved\n somewhat with pressors.\n - Liberalize po fluid intake today\n - Monitor U/O\n - Wean pressor as tolerated\n # Demand Ischemia/Heart Failure: CPK trending down. Very elevated BNP\n yesterday. TTE showed stable EF 25%.\n - Trend CK, CPK daily\n - Recheck BNP\n - Volume repletion and neo as above to goal MAP >60, UOP >30 cc/hr\n - Monitor on telemetry\n - Anticoagulation on hold for now\n # Transaminitis- Likely shock liver with transaminitis improving. ERCP\n service consulted, however pt not felt likely to tolerate ERCP now and\n RUQ u/s was repeated showing slightly improved picture.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: D/c NGT, advance diet today\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: patient, patient\ns wife\n status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580659,
"text": "This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n Code status: full code\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Patient original admission was for UGIB. to super-therapeutic INR.\n INR yesterday morning 4.5. after 2u FFP it came down to 2.5. He started\n a clear liquid diet. He has tolerated the diet well. No bowel\n movement or vomiting noted. HCT 36.1,\n Action:\n Response:\n Plan:\n Hold ASA and coumadin, question DDAVP if bleeding noted. Monitor HCT\n and INR.\n Hypotension (not Shock)\n Assessment:\n He is on NEO at 0.8mcg/kg/min. now MAPS >70\ns. I did note, that when\n his heart rate increases. That his blood pressure will drop.\n Action:\n Continue the NEO at 0.8mcg.\n Response:\n MAPS >70\n Plan:\n Attempt to wean neo as tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n He is in AF with PVC noted. Heart rate went up to 170\n Action:\n He received metoprolol 5mg IV @.\n Response:\n Heart rate down to 78-120\n. He is also receiving a digoxin loading.\n Plan:\n Last dig loading is at 0900. please obtain dig level on @ 1700.\n Liver function abnormalities\n Assessment:\n All LFT are up.. He is slightly jaundiced in appearance. I did note\n that his tears were yellow. Both his fingers and toes are\n dusky(question poor circulation).\n Action:\n Ultra sounds on \n Response:\n Gallbladder containing sludge, with mild wall thickening\n Plan:\n Trend LFT\ns and\n Altered mental status (not Delirium)\n Assessment:\n He is a/ox2, and confused. I did note as the shift progressed he did\n awake during the night confused. He was scratching at his central line.\n Pulling ECG leads off.\n Action:\n Constant re-orientated needed. Soft wrist restraints placed loosely.\n Response:\n Continue with interference with treatment.\n Plan:\n I did obtain order for soft restraints.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n He is in AF on rate control medication. tropI trending down. TEE\n showed EF 25%.\n Action:\n Response:\n Plan:\n Holding ASA and coumadin.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 120 with Cr 4.4. Marginal urine out put noted.\n Action:\n Increased PO fluid intake.\n Response:\n No change at this time.\n Plan:\n Monitor urine out put..\n O2 sat drop down to 88-89%. On 5L NC. Lung sounds are bronchial bilat\n lower lobes and exp wheezing left upper lobe, diminished through out.\n RT in to evaluate him. He was placed on 50% face tent and NC was\n maintained at 5L. CXR done, ICU team stated. The CXR did appear to have\n mild amount of fluid overload. No lasix at this time 2/2 blood\n pressure. At this time his face tent is off, and he is sating at 95% on\n l NC. ABG\nS were drawn , also mixed venous drawn..\n 05:39\n"
},
{
"category": "Social Work",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 580770,
"text": "Social Work Initial Note:\n Family Information:\n Next of : , wife\n Health Proxy appointed: Yes - Copy of signed proxy form in medical\n record, , wife, is primary HCP: . Alternate HCP\n is daughter . alternate is son .\n Family Spokesperson designated: Symmons, daughter: h -\n , c - \n Communication or visitation restriction: none\n Patient Information:\n Previous living situation: Home w/ others\n wife and pt have been\n living on the of a two family home. Son lives\n upstairs on .\n Previous level of functioning: Independent\n Previous or other hospital admissions: /05 at \n Past psychiatric history: none\n Past addictions history: none\n Employment status: Retired firefighter\n Legal involvement: none\n Mandated Reporting Information: Agency: N/A\n Additional Information:\n Received referral from MICU RN to assess and support family coping and\n to offer resource assistance for pt's homebound wife. Reviewed chart\n and discussed with RN. Pt is an 88 y.o. married, Caucasian, Catholic\n man admitted to on with dx of epigastric discomfort and\n to rule out MI.\n SW met with pt\ns daughter individually this morning and then with\n daughter and two sons in family meeting with MICU attending and RN in\n afternoon. In meeting with daughter, she expresses her concern re pt\n condition and of how her mother will manage at home in the short term\n or indefinitely, as she fears he may die soon. She states pt has been\n providing personal care for his wife and maintaining the house up until\n his admission to the hospital. While he has been admitted, pt\ns three\n children are rotating caregiving among themselves for their mother, but\n daughter also asks for resources for professional home care. SW\n provided her with a list of home care agencies, Ethos Elder Services,\n and Elder Resources (case management). Provided emotional support for\n daughter as we discussed her anticipatory grief over the possibility of\n losing her father. She describes him lovingly as the center of the\n family.\n Then attended family meeting in afternoon with two other sons and\n discussed pt\ns current condition and goals of care. Met afterwards\n with daughter and son while son visited with pt for a\n while. and speak of how they feel they are in agreement with\n one another about goals of care but feel that may have more\n reservations about changing code status. They speak of wanting to talk\n this over together as a family with their mother tonight. also\n speaks of trying to figure out what makes sense in terms of pt\ns wife\n visiting pt in the hospital right now. She plans to talk about this\n openly with her mother one on one and be sure that she understands the\n nature of pt\ns condition. Informed daughter of SW\ns role and ongoing\n availability for additional emotional and resource support and provided\n SW contact info.\n Clergy Contact: None at this time, though daughter expresses an\n interest in meeting with Catholic priest in the future (denies interest\n in this today).\n Communication with Team:\n Primary Nurse: \n Attending: \n Plan / Follow up:\n Continuing issues to be addressed: Ongoing emotional support for\n pt/family as needed. SW will plan to touch base with family in the\n coming days to offer additional support. Please page with any\n questions or concerns.\n , LICSW, #\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581056,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in Afib, rate 88-117. Anticoagulation held d/t GIB, INR on\n 2.4. Pt A + O x , good pulses all extremities. Received pt in\n 5 L NC, Sp02 94-98%.\n Action:\n Lopressor 12.5 mg TID. Digoxin q other day. O2 weaned to 2 L NC.\n Pneumo boots in place.\n Response:\n MS unchanged, pt remains in Afib.\n Plan:\n Monitor rate and rhythm, cont medical mgt.\n Hypotension (not Shock)\n Assessment:\n Received pt on Neo 0.3 mcgkg/min. ABPs 87/43(58)\n 115/64(83).\n Waveform on R aline dampened.\n Action:\n Attempt to titrate pressor requirement, but Neo increased to 0.5 mcg to\n maintain MAP >65. Check NBP to ABP.\n Response:\n NBPs correlate w/ ABP when ABP properly positioned. Neo weaned back\n down to 0.3 mcg, turned off at 0330.\n Plan:\n Attempt to titrate pressors and maintain MAP >65 for organ perfusion.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley in place, UOP 20-50 ml/hr, icteric. Cre on 4.0.\n Action:\n Maintain BP for renal perfusion, encourage PO fluids.\n Response:\n UOP stable, Cre this AM 4.8.\n Plan:\n Cont to monitor, pt is DNR, unlikely that HD will be appropriate.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No BM this shift. Hct eve 34.1 and stable (baseline 37-39).\n Active clot at blood bank.\n Action:\n Protonix given, endoscopy not indicated at this time.\n Response:\n Pt is hemodynamically stable, AM Hct 36.\n Plan:\n Monitor Hct, monitor BMs.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580605,
"text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt R/I MI , Unable to start heparin gtt d/t hx recent GIB. No C/O\n chest pain or chest discomfort. BP 119-135/51-70. MAP 72-94. Continues\n on Neo at 0.5mics/kg/hr. On 5L NC sats 94-96%.\n Action:\n Neo titrated for MAP 70. Given 2gm calcium IV this morning..INR 4.2,\n given 2 units of FFP. Recycled Cardiac cycle. Pt cont go in and out to\n Afib, Asymptamatic, HR 70-145 back to SR. cardiology following, EKG\n done while he was going to Afib. Given 0.25 mg Dig at 1700.\n Response:\n INR down to 2.2 from 4.2.Denied chest pain/resp difficulty.\n Plan:\n Closely monitor HR,Cont rest of the Digoxin . Wean Neo and oxygen as\n tolerated, Goal Map > 70 and descent UOP.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP continues to be minimal 30-40cc/hr,BUN 114and Cr 4.2\n Action:\n UOP monitored. Lytes sent this evening..\n Response:\n UOP Cont to be borderline.. BUN 120 and Cr 4.4 this evening.\n Plan:\n Monitor UOP and renal function. Follow up with .\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Follow commands,able to help with\n turning. More confused during night\n Action:\n Reoriented frequently .Emotional support provided. Bed alarm on.\n Response:\n Pt looks more Alert .\n Plan:\n Monitor mental status. Reorient frequently.\n Atrial fibrillation (Afib)\n Assessment:\n Pt constantly going in and out frorm Afib with HR 70-145,\n Asymptamatic, No c/o Chest discomfort or pain. Received on Neo at 0.4\n mics/hr.\n Action:\n EKG done while on Afi.converted back to SR without any difficulty,\n Cardiology following\n Response:\n Dilt 0.25 mg given around 1700.Cont have Afib 70 120 without BP drop.\n Plan:\n Closley monitor HR,Cont dig as ordered. Lopressor if Hr persistently\n stays in 120-130. monitor lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580764,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Dig load completed\n Alternating between SR and afib\n Action:\n Dig load completed, dig level ordered for 1700\n Pt alternating between sr with hr 60-80\ns, and afib with hr 100-120, BP\n improved when in SR\n Pt with poor activity tolerance, hr inc to 120-130 with minimal\n activity, with drop in bp, pt remains on bedrest\n Remains off neosynephrine gtt\n PICC line placed, and tip placement confirmed, tlcl ordered for d/c\n Family meeting held to discuss pt\ns condition and plan of care. Family\n to discuss code status amongst themselves\n Response:\n Improved bp when in SR\n Plan:\n f/u dig level\n d/c tlcl\n neo gtt for hypotension\n remains on bedrest till activity tolerance improves\n Altered mental status (not Delirium)\n Assessment:\n Intermittently confused\n Action:\n Pt alternating between oriented x2 and confused\n Makes attempts at getting oob, but easily re-oriented\n Pulling at PIV on left arm this am, skin tear noted after pt pulled off\n tape around iv\n c/o\nitichiness\n saran lotion applied with little improvement\n Response:\n Intermittent confusion\n Plan:\n Saran lotion for pruritis\n Freq re-orientation\n Hypoxemia\n Assessment:\n Remains on nc 5l\n Action:\n Pt denies sob, but appears dyspnic with any activity\n Lungs with bibasilar crackles\n BNP from >70,000\n Response:\n Plan:\n Titrate o2 as tolerated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n u/o slowly improving\n Action:\n Creat 4.2 this am\n u/o 20-40ml/hr this shift, improves when in SR with better bp\n Response:\n Improved u/o when in SR\n Plan:\n Follow lytes, labs\n Liver function abnormalities\n Assessment:\n LFT\ns stable\n Action:\n Pt jaundiced with icteric sclera\n INR 2.9 this am, plans for recheck this pm\n Tolerating clear liquid diet\n ? last bm\n Lactulose started\n Response:\n Stable liver function\n Plan:\n f/u pm coags\n lactulose as ordered\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580980,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n In/out AFIB/NSR 90-120s, unable to anticoagulate due to GI bleed. HR\n up to 140 this AM. BP directly affected by HR, when pt in NSR or <100\n BP better 110-120 systolic.\n Action:\n Limited options given pt\ns multi-organ dysfunction. Received 5mg IV\n lopressor for HR in 140s. Cards following, suggested IV dig and PO\n lopressor to manage AFIB. On low dose neosynephrine to maintain MAP\n >65.\n Response:\n Little effect from IV lopressor during increased HR. Received one time\n dose IV dig this AM, to start standing dose tomorrow morning.\n Excellent response from PO lopressor, HR better controlled and able to\n decrease neo dose. UO also better with higher BP.\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with 2 maroon bowel movements this morning, grossly guic positive.\n Pt denies abdominal pain. Per past noted baseline HCT 37-39.\n Action:\n HCT checked at 1200, MDs aware of maroon stools. No active clot in\n blood bank.\n Response:\n 12PM HCT 33.7 from 34.9. No further bowel movements. New clot sent in\n case of need for blood.\n Plan:\n HCT to be rechecked this evening at . Monitor BMs.\n Code status changed to DNR, okay to intubate for respiratory distress.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580986,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n In/out AFIB/NSR 90-120s, unable to anticoagulate due to GI bleed. HR\n up to 140 this AM. BP directly affected by HR, when pt in NSR or <100\n BP better 110-120 systolic.\n Action:\n Limited options given pt\ns multi-organ dysfunction. Received 5mg IV\n lopressor for HR in 140s. Cards following, suggested IV dig and PO\n lopressor to manage AFIB. On low dose neosynephrine to maintain MAP\n >65.\n Response:\n Little effect from IV lopressor during increased HR. Received one time\n dose IV dig this AM, to start standing dose tomorrow morning.\n Excellent response from PO lopressor, HR better controlled and able to\n decrease neo dose. UO also better with higher BP.\n Plan:\n Continue IV dig and lopressor as ordered, titrate neo to MAP >65,\n monitor UO.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with 2 maroon bowel movements this morning, grossly guic positive.\n Pt denies abdominal pain. Per past noted baseline HCT 37-39.\n Action:\n HCT checked at 1200, MDs aware of maroon stools. No active clot in\n blood bank.\n Response:\n 12PM HCT 33.7 from 34.9. No further bowel movements. New clot sent in\n case of need for blood.\n Plan:\n HCT to be rechecked this evening at . Monitor BMs.\n Altered mental status (not Delirium)\n Assessment:\n Pt pleasant. Alert and oriented x 3. Occasionally confused asking for\n shoes, wanting to go\nfor a walk\n. Consistently following commands,\n cooperative with nursing care.\n Action:\n Re-oriented to time/situation as needed. Bed alarm on for pt safety.\n Family members at bedside throughout day.\n Response:\n MS waxing and , clear most of day, using call light\n appropriately.\n Plan:\n Orient as needed, maintain pt safety.\n Code status changed to DNR, okay to intubate for respiratory distress.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580966,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n In/out AFIB/NSR 90-120s, unable to anticoagulate due to GI bleed. Up\n to 140 this AM. BP directly affected by HR, when pt in NSR BP better\n 120-130 systolic.\n Action:\n Limited options given pt\ns multi-organ dysfunction. Received 5mg IV\n lopressor for HR in 140s. Cards following, suggested IV dig and PO\n lopressor. On low dose enosyne\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with 2 maroon bowel movements this morning, grossly guic positive.\n Pt denies abdominal pain. Per past noted baseline HCT 37-39.\n Action:\n HCT checked at 1200, MDs aware of maroon stools. No active clot in\n blood bank.\n Response:\n 12PM HCT 33.7 from 34.9. No further bowel movements. New clot sent in\n case of need for blood.\n Plan:\n HCT to be rechecked this evening at . Monitor BMs.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580970,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n In/out AFIB/NSR 90-120s, unable to anticoagulate due to GI bleed. Up\n to 140 this AM. BP directly affected by HR, when pt in NSR BP better\n 120-130 systolic.\n Action:\n Limited options given pt\ns multi-organ dysfunction. Received 5mg IV\n lopressor for HR in 140s. Cards following, suggested IV dig and PO\n lopressor. On low dose enosyne\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with 2 maroon bowel movements this morning, grossly guic positive.\n Pt denies abdominal pain. Per past noted baseline HCT 37-39.\n Action:\n HCT checked at 1200, MDs aware of maroon stools. No active clot in\n blood bank.\n Response:\n 12PM HCT 33.7 from 34.9. No further bowel movements. New clot sent in\n case of need for blood.\n Plan:\n HCT to be rechecked this evening at . Monitor BMs.\n Code status changed to DNR, okay to intubate for respiratory distress.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581239,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver).\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD s/p b/l\n endarterectomies, DM, severe systolic HF with EF 25% on Coumadin, CRI\n with baseline Cr value of 2.0.\n UPDATE: Fairly quiet day with pt maintained off IV Phenylephrine gtt.\n Pt unable to tol move OOB to chair with RVR/HR up to the 120\ns and\n consequent drop in SBP values to the 70\n BP improved once pt was\n returned to bed. Diet advanced today with good PO intake for lunch.\n Grandsons visited from out of town today. Catholic priest \n and will visit pt @ BS tomorrow. The pt remains a DNR only.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Liver function abnormalities\n Assessment:\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580827,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Since arrival to MICU patients course has been c/b UGIB requiring 2\n units PRBCs, Rec\nd mult. Units of FFP, and mult. Doses of PO and IV\n vitamin K for persistently high INR. Pt hypotensive with MODs\n including ARF, r/I for MI with troponin 1.8, and shock liver.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581112,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - determined that he does much better in sinus (minimal pressors and\n increase UOP)\n - Cards states all antiarrhythmics are contraindicated to renal\n failure and liver failure. Recommended continuing Dig and start\n metoprolol 12.5 mg TID. Titrate pressors as needed.\n - PM Hcts stable\n - Family re-addressed code status and he was made DNR, but okay to\n intubate if required.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 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 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 115 (83 - 130) bpm\n BP: 68/44(54) {68/43(54) - 128/64(85)} mmHg\n RR: 20 (10 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 78 mL\n PO:\n 120 mL\n 50 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 295 mL\n Urine:\n 1,215 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///16/\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 218 K/uL\n 12.3 g/dL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 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"
},
{
"category": "Physician ",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581113,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - determined that he does much better in sinus (minimal pressors and\n increase UOP)\n - Cards states all antiarrhythmics are contraindicated to renal\n failure and liver failure. Recommended continuing Dig and start\n metoprolol 12.5 mg TID. Titrate pressors as needed.\n - PM Hcts stable\n - Family re-addressed code status and he was made DNR, but okay to\n intubate if required.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 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 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 115 (83 - 130) bpm\n BP: 68/44(54) {68/43(54) - 128/64(85)} mmHg\n RR: 20 (10 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 78 mL\n PO:\n 120 mL\n 50 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 295 mL\n Urine:\n 1,215 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///16/\n Physical Examination\n GEN: NAD\n HEENT: Jaundice\n LUNGS: Crackles at bases\n HEART: Irregularly irregular and tachycardic\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 218 K/uL\n 12.3 g/dL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 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"
},
{
"category": "Physician ",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581115,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - determined that he does much better in sinus (minimal pressors and\n increase UOP)\n - Cards states all antiarrhythmics are contraindicated to renal\n failure and liver failure. Recommended continuing Dig and start\n metoprolol 12.5 mg TID. Titrate pressors as needed.\n - PM Hcts stable\n - Family re-addressed code status and he was made DNR, but okay to\n intubate if required.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 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 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 115 (83 - 130) bpm\n BP: 68/44(54) {68/43(54) - 128/64(85)} mmHg\n RR: 20 (10 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 78 mL\n PO:\n 120 mL\n 50 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 295 mL\n Urine:\n 1,215 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///16/\n Physical Examination\n GEN: NAD\n HEENT: Jaundice\n LUNGS: Crackles at bases\n HEART: Irregularly irregular and tachycardic\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 218 K/uL\n 12.3 g/dL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below\n - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given \n - Monitor ECG, tele\n # : Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower . Hcts stable.\n - Check Hct Q6H\n - Transfuse for Hct <30\n - Cls GI re: possibility of scope\n - PPI IV BID until source found as more likely LGIB but as came in with\n coffee ground emesis could be brisk UGIB\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n - consider D/C bicarb as large salt load\n - Cte dig as above\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr 4.0 down from\n 4.8. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs but will likely not continue for long given\n large sodium load with it.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Stop lactulose today give clear MS \n # AMS: Now resolved. Consider PT and OOB to chair today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 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"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580871,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Since arrival to MICU patients course has been c/b UGIB requiring 2\n units PRBCs, Rec\nd mult. Units of FFP, and mult. Doses of PO and IV\n vitamin K for persistently high INR. Pt hypotensive with MODs\n including ARF, r/I for MI with troponin 1.8, and shock liver.\n Team met with pts daughter and sons yesterday to discuss pts poor\n prognosis. Per family pt to be DNR/DNI, however when this was discussed\n with pt last night, he asked that it be readdressed today as he was too\n tired to talk about it. Pts daughter present at that time.\n Atrial fibrillation (Afib)\n Assessment:\n NSR in 80s-90s initially with adequate BP by aline. Converted to Afib\n 110s-130s with decrease in ABP to 78-84/40s, MAPs in 50s.\n Action:\n Neo gtt restarted for hypotension.\n Response:\n Afib continued for ~ 1 hr then converted back to NSR 80s-90s. No\n lopressor needed for rate control. Neo is being titrated off,\n Plan:\n Neo gtt for MAP>65. If Afib with RVR team will consider lopressor.\n Digoxin is being dosed per serum levels.\n Altered mental status (not Delirium)\n Assessment:\n A&O x 3, follows commands. MAE on bed. Afdter family left, pt asleep\n but restless, moving arms over head, scratching at skin on his arms.\n Oriented x 3 but also seems a little confused.\n Action:\n Bed alrms on, frequent checks on pt. Sarna lotion to skin\n Response:\n Slept well most of night. MS is very clear this AM, using call light\n appropriately.\n Plan:\n Monitor MS, bed alarm for safety.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP 40-80cc/hr clear yellow urine. Creatinine 4.0 this AM. UOP higher\n on neo gtt\n Action:\n Urine Na sent this AM\n Response:\n Improving UOP and creatinine\n Plan:\n Monitor UOP, lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581036,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in Afib, rate 88-117. Anticoagulation held d/t GIB, INR on\n 2.4. Pt A + O x , good pulses all extremities. Received pt in\n 5 L NC, Sp02 94-98%.\n Action:\n Lopressor 12.5 mg TID. Digoxin q other day. O2 weaned to 2 L NC.\n Pneumo boots in place.\n Response:\n MS unchanged, pt remains in Afib.\n Plan:\n Monitor rate and rhythm, cont medical mgt.\n Hypotension (not Shock)\n Assessment:\n Received pt on Neo 0.3 mcgkg/min. ABPs 87/43(58)\n 115/64(83).\n Waveform on R aline dampened.\n Action:\n Attempt to titrate pressor requirement, but Neo increased to 0.5 mcg to\n maintain MAP >65. Check NBP to ABP.\n Response:\n NBPs correlate w/ ABP when ABP properly positioned. Neo weaned back\n down to 0.3 mcg.\n Plan:\n Attmept to totrate pressors and maintain MAP >65 for organ perfusion.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley in place, UOP 20-50 ml/hr, concentrated, icteric. Cre on \n 4.0.\n Action:\n Maintain BP for renal perfusion, encourage PO fluids.\n Response:\n UOP stable, Cre this AM ()\n Plan:\n Cont to monitor, pt is DNR, unlikely that HD will be appropriate.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No BM this shift. Hct eve 34.1 and stable (baseline 37-39).\n Active clot at blood bank.\n Action:\n Protonix given, endoscopy not indicated at this time.\n Response:\n Pt is hemodynamically stable but still requiring vasopressor support.\n Plan:\n Monitor Hct, monitor BMs.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581128,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - determined that he does much better in sinus (minimal pressors and\n increase UOP)\n - Cards states all antiarrhythmics are contraindicated to renal\n failure and liver failure. Recommended continuing Dig and start\n metoprolol 12.5 mg TID. Titrate pressors as needed.\n - PM Hcts stable\n - Family re-addressed code status and he was made DNR, but okay to\n intubate if required.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 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 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 115 (83 - 130) bpm\n BP: 68/44(54) {68/43(54) - 128/64(85)} mmHg\n RR: 20 (10 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 78 mL\n PO:\n 120 mL\n 50 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 295 mL\n Urine:\n 1,215 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///16/\n Physical Examination\n GEN: NAD\n HEENT: Jaundice\n LUNGS: Crackles at bases\n HEART: Irregularly irregular and tachycardic\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 218 K/uL\n 12.3 g/dL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Ca: 8.6 Mg: 2.7 P: 4.2\n ALT: 626\n AP: 584\n Tbili: 19.9\n Alb:\n AST: 322\n LDH: 584\n Dbili:\n TProt:\n :\n Lip:\n PT: 24.7\n PTT: 34.8\n INR: 2.4\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below\n - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given \n - Monitor ECG, tele\n # : Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower . Hcts stable.\n - Check Hct Q6H\n - Transfuse for Hct <30\n - Cls GI re: possibility of scope\n - PPI IV BID until source found as more likely LGIB but as came in with\n coffee ground emesis could be brisk UGIB\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n - consider D/C bicarb as large salt load\n - Cte dig as above\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr 4.0 down from\n 4.8. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs but will likely not continue for long given\n large sodium load with it.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Stop lactulose today give clear MS \n # AMS: Now resolved. Consider PT and OOB to chair today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 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"
},
{
"category": "Physician ",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581146,
"text": "Chief Complaint: GI bleed, Afib w RVR\n I saw and examined the patient, and was physically present with the 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 Dig loaded yesterday - added metoprolol even though on low dose Neo\n DNR confirmed with familu (but short term intubation OK)\n Neo weaned off\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 110 (83 - 115) bpm\n BP: 106/61(76) {85/43(58) - 119/64(83)} mmHg\n RR: 22 (10 - 25) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 318 mL\n PO:\n 120 mL\n 290 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 415 mL\n Urine:\n 1,215 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///16/\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 218 K/uL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: family meeting last PM\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": "2102-06-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581149,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - determined that he does much better in sinus (minimal pressors and\n increase UOP)\n - Cards states all antiarrhythmics are contraindicated to renal\n failure and liver failure. Recommended continuing Dig and start\n metoprolol 12.5 mg TID. Titrate pressors as needed.\n - PM Hcts stable\n - Family re-addressed code status and he was made DNR, but okay to\n intubate if required.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 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 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 115 (83 - 130) bpm\n BP: 68/44(54) {68/43(54) - 128/64(85)} mmHg\n RR: 20 (10 - 28) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 78 mL\n PO:\n 120 mL\n 50 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 295 mL\n Urine:\n 1,215 mL\n 295 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -217 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///16/\n Physical Examination\n GEN: NAD\n HEENT: Jaundice\n LUNGS: Crackles at bases\n HEART: Regular and tachycardic\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 218 K/uL\n 12.3 g/dL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Ca: 8.6 Mg: 2.7 P: 4.2\n ALT: 626\n AP: 584\n Tbili: 19.9\n Alb:\n AST: 322\n LDH: 584\n Dbili:\n TProt:\n :\n Lip:\n PT: 24.7\n PTT: 34.8\n INR: 2.4\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for GIB although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below with dig\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n - increase diet today and consider IVF cautiously given CHF if\n requires.\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Started metoprolol for rate control with stable pressures\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given GIB\n # GIB: Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower GIB. Hcts stable.\n - Check Hct QD\n - Transfuse for Hct <30\n - PPI IV BID ->change to PO today\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and beta blocker\n - Monitor on telemetry\n - consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr 4.0 down from\n 4.8. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs but will likely not continue for long given\n large sodium load with it.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Consider ERCP in future if TBili does not resolve\n # AMS: Now resolved. Consider PT and OOB to chair today after IVF so\n less likely to have hypotension.\n ICU Care\n Nutrition: Advance diet today\n Glycemic Control: ISS\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI PO BID\n Communication: Comments: with patient and family\n Code status: DNR (do not resuscitate)\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 581172,
"text": "Chief Complaint: GI bleed, Afib w RVR\n I saw and examined the patient, and was physically present with the 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 Dig loaded yesterday - added metoprolol even though on low dose Neo\n DNR confirmed with family (but short term intubation OK)\n Neo weaned off at 3AM, tried to get OOB to chair and BP in 70s\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Metoprolol - 09:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 110 (83 - 115) bpm\n BP: 106/61(76) {85/43(58) - 119/64(83)} mmHg\n RR: 22 (10 - 25) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n Mixed Venous O2% Sat: 66 - 66\n Total In:\n 320 mL\n 318 mL\n PO:\n 120 mL\n 290 mL\n TF:\n IVF:\n 200 mL\n 28 mL\n Blood products:\n Total out:\n 1,215 mL\n 415 mL\n Urine:\n 1,215 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n -895 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///16/\n Physical Examination\n Gen: sitting in bed, NAD\n HEENT: extremely dry o/p ++ icterus\n CV: RR\n Chest; fair air movement\n Abd: distended, +BS\n Ext: min edema\n Labs / Radiology\n 12.3 g/dL\n 218 K/uL\n 110 mg/dL\n 4.8 mg/dL\n 16 mEq/L\n 4.2 mEq/L\n 140 mg/dL\n 107 mEq/L\n 141 mEq/L\n 36.0 %\n 13.0 K/uL\n [image002.jpg]\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n WBC\n 14.8\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 36.1\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n Plt\n 238\n 246\n 214\n 230\n 218\n Cr\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n TCO2\n 15\n 15\n Glucose\n 155\n 158\n 135\n 98\n 110\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, )\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by AF c RVR.\n 1. Hypotension: Improving, off Neo, on Digoxin, but still hypotensive\n if stands or OOB\n 2. GIB had been stable but passed maroon stools yest thought stable\n HCT, PPI.\n 3. For , continue supportive care as above. Bblocker,\n 4. ARF is slightly better, UOP is up when in NSR; hope to avoid HD as\n hemodynamics are optimized.\n Remainder of plan as outlined by housestaff\n ICU Care\n Nutrition: advance diet\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: ppi\n Communication: family meeting last PM\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580957,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with 2 maroon bowel movements this morning, grossly guic positive.\n Pt denies abdominal pain. Per past noted baseline HCT 37-39.\n Action:\n HCT checked at 1200, MDs aware of maroon stools. No active clot in\n blood bank.\n Response:\n 12PM HCT 33.7 from 34.9. No further bowel movements. New clot sent in\n case of need for blood.\n Plan:\n HCT to be rechecked this evening at . Monitor BMs.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581287,
"text": "Chief Complaint:\n 24 Hour Events:\n - Renal: cte bicarb. Creatinine inc likely hypotension but\n encouraged because euvolemic and still with good UOP. If GIB again\n consider DDAVP for uremic platelets.\n - Cards: No new recs.\n - TSH 0.17. Added on free T4 . . .\n - Was really dry on exam. got 2X 500mL NS boluses\n - Liver: no new recs\n - called for slow VT with AMS. EKG showed same rhythm as before at rate\n 100bpm - LBBB with AFib. Neuro exam non-focal with delirium but\n otherwise no neurologic deficits. Lytes with low calcium (1.01). gave\n 2gm calcium. ABG with metabolic acidosis but nl PO2. Likely sundowning\n plus same rhythm.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.7\nC (96.3\n HR: 80 (74 - 119) bpm\n BP: 113/52(67) {86/27(40) - 127/72(82)} mmHg\n RR: 15 (13 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 254 mL\n PO:\n 970 mL\n 200 mL\n TF:\n IVF:\n 1,158 mL\n 54 mL\n Blood products:\n Total out:\n 820 mL\n 110 mL\n Urine:\n 820 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: 7.36/29/110/15/-7\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 218 K/uL\n 12.3 g/dL\n 128 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 3.9 mEq/L\n 142 mg/dL\n 110 mEq/L\n 140 mEq/L\n 38\n 13.0 K/uL\n [image002.jpg]\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n Plt\n 18\n Cr\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 158\n 135\n 98\n 110\n 141\n 128\n Other labs: PT / PTT / INR:24.7/34.8/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:626/322, Alk Phos / T Bili:584/19.9,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.2 mmol/L, Albumin:3.5\n g/dL, LDH:584 IU/L, Ca++:8.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for GIB although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below with dig\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n - increase diet today and consider IVF cautiously given CHF if\n requires.\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Started metoprolol for rate control with stable pressures\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given GIB\n # GIB: Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower GIB. Hcts stable.\n - Check Hct QD\n - Transfuse for Hct <30\n - PPI IV BID ->change to PO today\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and beta blocker\n - Monitor on telemetry\n - consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr 4.0 down from\n 4.8. UOP improved somewhat over last 24 hours. Startedbicarb\n yesterday per renal recs but will likely not continue for long given\n large sodium load with it.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Consider ERCP in future if TBili does not resolve\n # AMS: Now resolved. Consider PT and OOB to chair today after IVF so\n less likely to have hypotension.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581023,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580216,
"text": "Hypoxemia\n Assessment:\n Increased oxygenation needs during days on ; received on NRB 10L;\n CXR-LLL infiltrate-begun on unasyn\n Action:\n Attempted to titrate oxygenation level and mode of delivery during\n course of night; enc C+DB\n Response:\n Maintaining o2 sats in low to mid 90\ns on NRB 8L; pt disliked face\n tent; desaturates to high 80\ns on RA; desats to low 90\ns with 6L nc and\n c/o nasal discomfort\n Plan:\n Titrate oxygen to maintain o2 sats in mid 90\ns or greater. Unasyn.\n Monitor via CXR.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB\n Action:\n Closely monitor. Other set of CPK\ns drawn this am\n Response:\n Labs pnd. Pt denies any SOB/CP /tightness\n Plan:\n Cont to closely monitor. Await labs.lBedrest. Pneumo boots.\n Hypotension (not Shock)\n Assessment:\n Received multiple boluses of IVf d/t hypotension.\n Action:\n Bp monitored by aline;\n Response:\n Dampened aline tracing; NIBP not coinciding with arterial line; NIBP\n with >10pt value higher; accepting MAP 60\ns via NIBP\n Plan:\n Anticipate changing aline over wire. Cont to monitor BP.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Borderline u/o over course of day; no additional fluid boluses required\n Action:\n Bolused with 1.25L NS for oliguria; trial of dopamine to improve u/o;\n cathter flushed to assess patency\n Response:\n Min response to boluses; u/o minimal and anuric at times. BUN/Cr\n increasing. Intolerant to dopamine-became increasingly tachycardic\n Plan:\n Obtain renal consult. Monitor u/o.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580215,
"text": "Hypoxemia\n Assessment:\n Increased oxygenation needs during days on ; received on NRB 10L;\n CXR-LLL infiltrate-begun on unasyn\n Action:\n Attempted to titrate oxygenation level and mode of delivery during\n course of night; enc C+DB\n Response:\n Maintaining o2 sats in low to mid 90\ns on NRB 8L; pt disliked face\n tent; desaturates to high 80\ns on RA; desats to low 90\ns with 6L nc and\n c/o nasal discomfort\n Plan:\n Titrate oxygen to maintain o2 sats in mid 90\ns or greater. Unasyn.\n Monitor via CXR.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB\n Action:\n Closely monitor. Other set of CPK\ns drawn this am\n Response:\n Labs pnd. Pt denies any SOB/CP /tightness\n Plan:\n Cont to closely monitor. Await labs.lBedrest. Pneumo boots.\n Hypotension (not Shock)\n Assessment:\n Received multiple boluses of IVf d/t hypotension.\n Action:\n Bp monitored by aline;\n Response:\n BP imp\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Cardiology Consult Note",
"row_id": 580390,
"text": "TITLE: Cardiology consult note\n History of Presenting Illness.\n 88-year-old man, with MMP consulted for management of shock with\n concern for cardiogenic etiology. Briefly, active medical issues\n include DM, CAD, h/o MI, cardiomyopathy with EF of 25%, HTN, HL, PVD.\n Pt was admitted with abd pain and nausea. Given SL nitro because\n it was thought that this was his anginal equivalent. EKGs old LBBB,\n initial troponins were neg. After SL nitro, BP dropped from 130s to 80s\n systolic but returned to the low 100s after 2L IVF. Subsequently,\n patient developed coffee ground hematemesis, with Hct dropping from 37\n to 27. He was admitted to the MICU. Per MICU records, SBP were noted to\n be in the 80-100 range on . The patient did not require pressors\n and continued to mentate well, but developed shock liver with\n transaminitis in the several thousand range, deranged INR, and acute on\n chronic renal failure.\n He has received PRBC tranfusions, with current Hct 35. Rpt echo showed\n EF of 25% essentially unchanged from prior. Biomarkers are mildly\n elevated (Trop 2, CK 700, MB 70). Primary team concerned abt\n cardiogenic shock because of continued hypotension despite volume\n resuscitation and hypoxemia. Current vitals are: SBP 90-100, HR 90s,\n afebrile.\n The MICU team is requesting a consult for the following questions:\n (1) Is this cardiogenic shock?\n (2) Would the patient benefit from dobutamine?\n Past Medical History:\n CAD, status post MI over a decade ago\n hypertension\n hyperlipidemia\n peripheral vascular disease with bilateral carotid endarterectomies\n BCC\n Cardiomyopathy, EF 25-30% in 04 w/ severe AK/HK (on coumadin)\n Review of Systems: Otherwise negative in detail.\n Medications at home\n EZETIMIBE [ZETIA] - 10 mg qd\n GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm\n HYDROCHLOROTHIAZIDE - 12.5 mg qd\n ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd\n METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd\n PRAVASTATIN [PRAVACHOL] - 40 mg qd\n QUINAPRIL - 40 mg qd\n WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth daily take\n one tab 4 days a week and taab on Tue, Th and Sat\n ASPIRIN - (OTC) - 81 mg qd\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D]\n MEDICATIONS IN ICU\n 1. Ampicillin-Sulbactam 3 g IV Q12H\n 2. Insulin SS\n 3. Norepinephrine 0.03-0.25 mcg/kg/min\n Allergies: NKDA\n .\n Social History:\n He is a retired fireman, lives in with his wife.\n Married 55 years. Grown children. No smoking. No alcohol consumption.\n .\n Family History:\n non-contributory\n .\n Physical Exam:\n Vitals: T: afebrile, BP:80-90/40-50 (off levophed), 100-120/60-70 (on\n low dose levophed), P:80-100, R: 20 O2: 95% on 2L NC, 87% RA\n General: Alert, mentating well, does not appear acutely ill\n HEENT: Sclera icteric, dry MM, oropharynx clear\n Neck: CVP 12\n Lungs: Clear to auscultation bilaterally, reduced BS bases.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: diffusely warm, 2+ pulses, no clubbing, cyanosis or edema\n .\n Labs:\n Hct 39\n WCC 6\n INR 3.1\n Cr 2.4\n BUN 48\n ALT normal\n1600\n2400\n AST normal\n2600\n3200\n LDH normal\n\n Tbil 0.4\n16.4\n CXR: no pulmonary edema\n .\n EKG: SR, LBBB (old) LAD\n Echo: EF 25%, unchanged from prior\n Assessment and Plan\n 88 year old man with cardiomyopathy EF 25% presenting with multiorgan\n failure (shock liver, acute on chronic renal failure) in the setting of\n upper GI bleed. The initial insult is most likely hypovolemic shock\n from GI bleed in a patient who is especially vulnerable to developing\n end organ ischemia due to low EF. This has resulted in shock liver and\n acute renal failure, and evolved into distributive shock (due to\n vasodilatation from shock liver). Cardiogenic shock seems unlikely as a\n primary etiology of end organ failure because of the lack of signs of\n left heart failure (no overt pulmonary edema, minimal O2 requirements,\n peripheral vasodilatation), brisk response to low dose levophed\n (suggesting distributive shock).\n Would suggest:\n - continued supportive management with levophed for BP\n support. I suspect hemodynamics will start to improve as his shock\n liver improves.\n - Dobutamine not indicated due to adequate response to\n levophed\n - If hemodynamic instability is encountered further, would\n suggest swan ganz catheter to guide pressor management. Otherwise, can\n hold off.\n - Maintain CVP 10-12.\n - Watch out for CHF/pulm edema d/t fluid overload.\n - Hypoxemia likely atelactasis +/- fluid overload.\n Incentive spirometry, encourage sitting up, nebulizers, avoid diuresing\n for now.\n - Agree with holding all cardiac meds for now (including ASA,\n beta blockers, ACEI) until stabilized.\n - Will staff with Dr .\n .\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581198,
"text": "TITLE: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver).\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD s/p b/l\n endarterectomies, DM, severe systolic HF with EF 25% on Coumadin, CRI\n with baseline Cr value of 2.0.\n UPDATE: Fairly quiet day with pt maintained off IV Phenylephrine gtt.\n Pt unable to tol move OOB to chair with RVR/HR up to the 120\ns and\n consequent drop in SBP values to the 70\n BP improved once pt was\n returned to bed. Diet advanced today with good PO intake for lunch.\n Grandsons visited from out of town today. Catholic priest \n and will visit pt @ BS tomorrow. The pt remains a DNR only.\n Hypotension (not Shock)\n Assessment:\n Pt with fairly stable MAP values in the 60-70\ns while on bed rest with\n hourly urine output of 20-50ml/hr via foley cath. Pt moved OOB to\n chair with good tol initially, unfortunately the pt afib evolved to RVR\n with HR up to the 120\ns and his SBP values dropped to the 70\ns with c/o\n lightheadedness.\n Action:\n Pt moved back to bed from chair, pt bolused with 500ml NS and pt\n encouraged to increase PO intake.\n Response:\n BP values improved once the pt was returned to bed with MAP\ns typically\n in the low 60\ns to 70\n Plan:\n Cont to follow both ABP & NBP values closely, will re-start IV\n Phenylephrine when/if MAP\ns drop below 60-65 and/or hourly urinary\n output goes below 30ml/hr.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal fxn numbers c/w ATN in setting of CRI with hourly urine output in\n the 20-50ml/hr range. Urine is icteric & concentrated. Dry mucous\n membranes noted and no peripheral edema. The pt is net input eight\n liters for LOS per metavision I&O data.\n Action:\n Pt bolused with 500ml NS this AM and pt encouraged to increase PO\n liquid intake.\n Response:\n Hourly urine output remains marginally adequate with 20-50ml/hr urine\n output.\n Plan:\n Cont to follow hourly urine output, pt may benefit from additional\n fluid challenges when/if urine output worsens.\n"
},
{
"category": "Rehab Services",
"chartdate": "2102-06-24 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 581206,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: GIB / 578.9\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 88 yo M p/w\n abdominal pain and hypotension, went to the icu with new UGIB, course\n complicated by hypotension, ARF, and shock liver.\n Past Medical / Surgical History: CAD s/p MI over 10 years ago, HTN,\n hyperlipidemia, PVD s/p B CEA, BCC, systolic HF/cardiomyopathy\n Medications: phenylephrine, ursodiol, metoprolol, digoxin\n Radiology: CXR - right upper lung opacity may represent evolving\n infectious process or increasing atelectasis\n Labs:\n 36.0\n 12.3\n 218\n 13.0\n [image002.jpg]\n Other labs:\n INR 2.4\n Activity Orders: OK for OOB MD\n Social / Occupational History: lives with family, wife is disabled\n Living Environment: lives in multi-level home\n Prior Functional Status / Activity Level: I pta, no DME\n Objective Test\n Arousal / Attention / Cognition / Communication: lethargic, awakens to\n voice but falls back to sleep easily. Increased arousal at edge of\n bed. Oriented to self only, perseverating on using the toilet and\n getting agitated with attempts at reorientation. Following simple\n commands with repetition.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 106\n 100/56\n 93% on 2.5L NC\n Sit\n /\n Activity\n 120\n 86/57\n 88% on 2.5L NC\n Stand\n /\n Recovery\n 84\n 107/62\n 95% on 2.5L NC\n Total distance walked: 0\n Minutes:\n Pulmonary Status: lungs diminished at bases, strong dry cough noted.\n On 2.5L via NC\n Integumentary / Vascular: jaundiced skin, R radial a-line, R PICC,\n foley, tele\n Sensory Integrity: appears grossly intact, patient unable to\n participate in sensation testing cognitive status\n Pain / Limiting Symptoms: denies pain\n Posture: mild kyphotic posture\n Range of Motion\n Muscle Performance\n B LE's WNL\n moves all extremeties agains gravity, pt unable to participate in\n strength testing cognitive status.\n Motor Function: no abnormal movement patterns\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to take several marching steps in place with min\n A x2. Mobility limited by bowel urgency. Denies lightheadedness\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n X2\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S/CG static/dynamic sitting at edge of bed, min A x2\n static/dynamic standing balance. no gross LOB with mobility.\n Education / Communication: PT and attempted\n re-orientation. Spoke with pt's family member re: baseline status.\n Communicated with nsg re: status\n Intervention:\n Other:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired endurance\n 3.\n Impaired balance\n 4.\n Impaired cognition\n Clinical impression / Prognosis: 88 yo M s/p UGIB p/w above impairments\n a/w deconditioing. Today he was most limited by altered cognitive\n status, therefore assessment of mobility possibly inaccurate at this\n time. He is below his baseline status, but given his baseline and even\n his function earlier in the day with nsg, would anticipate that he will\n be able to progress and return to independent level. If cognitive\n status and mobility status does not improve within the next several\n days, would receommend d/c to rehab. PT to re-assess once on the\n medical floor to determine appropriate d/c dispo.\n Goals\n Time frame: 1 week\n 1.\n Independent with all mobility\n 2.\n Ambulate >/= 200' with stable HDR\n 3.\n No LOB with mobility\n 4.\n Follows 100% of simple and complex commands\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x\n bed mobility, transfers, ambulation, balance, endurance, education,\n stairs, d/c planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Cardiology Consult Note",
"row_id": 580369,
"text": "TITLE: Cardiology consult note\n History of Presenting Illness.\n 88-year-old man, with MMP consulted for management of shock with\n concern for primarily cardiac etiology of shock. Briefly, active\n medical issues include DM, CAD, h/o MI, cardiomyopathy with EF of 25%,\n HTN, HL, PVD. Pt was admitted with abd pain. Given SL nitro\n because it was thought that this was his anginal equivalent. BP dropped\n from 130s to 80s systolic but returned to the low 100s after 2L IVF.\n Subsequently, patient developed coffee ground hematemesis, with Hct\n dropping from 37 to 27. He was never hemodynamically unstable, SBP was\n reportedly in the 90-100 range. However, pt developed shocked liver and\n ARF.\n He has received PRBC tranfusions, with current Hct 31. Rpt echo showed\n EF of 25% unchanged from prior. Biomarkers are mildly elevated. Pt has\n baseline SBP between 90-100, HR 90s, afebrile. Pt has a low level of O2\n requirement and never developed florid pulmonary edema.\n The MICU team are requesting a consult for the following questions:\n (1) Is this cardiogenic shock?\n (2) Would the patient benefit from dobutamine?\n Past Medical History:\n CAD, status post MI over a decade ago\n hypertension\n hyperlipidemia\n peripheral vascular disease with bilateral carotid endarterectomies\n BCC\n Cardiomyopathy, EF 25-30% in 04 w/ severe AK/HK (on coumadin)\n Medications at home\n EZETIMIBE [ZETIA] - 10 mg qd\n GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm\n HYDROCHLOROTHIAZIDE - 12.5 mg qd\n ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd\n METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd\n PRAVASTATIN [PRAVACHOL] - 40 mg qd\n QUINAPRIL - 40 mg qd\n WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth daily take\n one tab 4 days a week and taab on Tue, Th and Sat\n ASPIRIN - (OTC) - 81 mg qd\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D]\n MEDICATIONS IN ICU\n 1. Ampicillin-Sulbactam 3 g IV Q12H\n 2. Insulin SS\n 3. Norepinephrine 0.03-0.25 mcg/kg/min\n Allergies: NKDA\n .\n Social History:\n He is a retired fireman, lives in with his wife.\n Married 55 years. Grown children. No smoking. No alcohol consumption.\n .\n Family History:\n non-contributory\n .\n Physical Exam:\n Vitals: T: afebrile, BP:80-90/40-50 (off levophed), 100-120/60-70 (on\n low dose levophed), P:80-100, R: 20 O2: 97% on 2L NC\n General: Alert, mentating well, does not appear acutely ill, appears\n younger than stated age\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n .\n Labs:\n Hct 39\n WCC 6\n INR 3.1\n Cr 2.4\n BUN 48\n ALT normal\n1600\n2400\n AST normal\n2600\n3200\n LDH normal\n\n Tbil 0.4\n16.4\n CXR: no pulmonary edema\n .\n EKG: SR, LBBB (old) LAD, first degree AV block\n Echo: EF 25%, unchanged from prior\n Assessment and Plan\n 88 year old man with cardiomyopathy EF 25% presenting with multiorgan\n failure (shock liver, acute on chronic renal failure) in the setting of\n upper GI bleed. The initial insult is most likely hypovolemic shock\n from GI bleed in a patient who is especially vulnerable to developing\n end organ ischemia due to low EF. This has resulted in shock liver and\n acute renal failure and as a result of this, the picture has now turned\n into distributive shock (due to vasodilatation from shock liver).\n Cardiogenic shock seems unlikely as a primary etiology of end organ\n failure because of the lack of signs of left heart failure (no overt\n pulmonary edema, minimal O2 requirements), brisk response to low dose\n levophed (suggesting distributive shock).\n Would suggest:\n - continued supportive management with levophed for BP support\n - Dobutamine not indicated due to adequate response to\n levophed\n - If hemodynamic instability is encountered further, would\n suggest swan ganz catheter to guide pressor management\n - Maintain CVP 10-15.\n .\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580261,
"text": "TITLE:\n Chief Complaint: GI bleed\n 24 Hour Events:\n - Received Vit K 5mg po and 2 units FFP given elevated INR in setting\n of GIB.\n - Decreased O2 sats -> CXR with retrocardiac opacity concerning for\n PNA. Cipro changed to Augmentin to cover possible aspiration.\n - Repeat Hct stable: 36 -> 33.9 -> 35.7 -> 35.5\n - CK and trop still rising. TTE suboptimal; EF still 25% c/w\n multivessel CAD, 2+ MR PA systolic HTN increased since .\n - Liver: Rising LFTs likely shock liver. HIDA not indicated,\n consider MRCP.\n - Given 500cc for MAP <50s with only transient improvement. Started on\n dopamine gtt given EF 25% but stopped for tachy to 150s. A-line faulty\n but as SBP 80s with low U/O, CvO2 67, lactate 2.1 (CVP 12), given add'l\n 1L bolus.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 106 (81 - 116) bpm\n BP: 64/36(47) {54/29(39) - 134/73(96)} mmHg\n RR: 28 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 14 (12 - 16)mmHg\n Total In:\n 3,227 mL\n 799 mL\n PO:\n TF:\n IVF:\n 2,531 mL\n 799 mL\n Blood products:\n 666 mL\n Total out:\n 738 mL\n 62 mL\n Urine:\n 738 mL\n 62 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 737 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: 7.32/31/95./17/-8\n PaO2 / FiO2: 137\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 190 K/uL\n 12.2 g/dL\n 190 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 4.8 mEq/L\n 90 mg/dL\n 110 mEq/L\n 142 mEq/L\n 36.3 %\n 13.3 K/uL\n [image002.jpg]\n 05:10 AM\n 05:15 AM\n 11:22 AM\n 12:54 PM\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n WBC\n 9.2\n 11.2\n 13.3\n Hct\n 36.0\n 33.9\n 35.7\n 35.5\n 36.3\n Plt\n \n Cr\n 3.1\n 3.0\n 3.6\n TropT\n 1.20\n 1.87\n TCO2\n 15\n 15\n 17\n 15\n 17\n Glucose\n 195\n 155\n 190\n Other labs: PT / PTT / INR:48.7/32.1/5.3, CK / CKMB /\n Troponin-T:705/39/1.87, ALT / AST:2415/3598, Alk Phos / T\n Bili:610/11.0, Amylase / Lipase:143/12, Lactic Acid:2.1 mmol/L,\n Albumin:3.5 g/dL, LDH:1337 IU/L, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580476,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:44 PM\n \n - Started on low dose levaphed with goal of SBPs 120-130\n - Remains with marginal UOP 20-25 cc/hr\n - Renal rec: Repeat UA/lytes/Eos and give DDAVP if rebleeds for ?\n uremic platelets.\n - UA with 6-10 WBC, 20-30 RBC, and FeNa 0.8\n - Liver rec: ERCP consult who reced repeat abd U/S\n - Repeat U/S - Prelim read\n 1. Mildly improved appearance of the gallbladder, containing sludge\n mixed with bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis. Echogenic liver as previously seen. Right pleural\n effusion.\n - Weaned down on O2 overnight\n - Went into a-fib at 5 AM with rates to 120 and BPs down to 100s/60s.\n He was transitioned to Neo.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 0.6 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 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 102 (79 - 122) bpm\n BP: 113/64(82) {90/50(70) - 137/74(98)} mmHg\n RR: 19 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 15 (13 - 16)mmHg\n Total In:\n 1,915 mL\n 287 mL\n PO:\n TF:\n IVF:\n 1,335 mL\n 287 mL\n Blood products:\n 580 mL\n Total out:\n 385 mL\n 195 mL\n Urine:\n 385 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,530 mL\n 92 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.31/28/103/15/-10\n PaO2 / FiO2: 103\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 238 K/uL\n 12.7 g/dL\n 155 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 114 mg/dL\n 111 mEq/L\n 144 mEq/L\n 36.1 %\n 14.8 K/uL\n [image002.jpg]\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n WBC\n 13.3\n 14.0\n 14.8\n Hct\n 35.7\n 35.5\n 36.3\n 35.3\n 36.1\n Plt\n 190\n 226\n 238\n Cr\n 3.6\n 3.8\n 4.2\n TCO2\n 17\n 15\n 17\n 16\n 15\n Glucose\n 190\n 147\n 155\n Other labs: PT / PTT / INR:45.4/31.2/4.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:2055/, Alk Phos / T\n Bili:558/16.8, Amylase / Lipase:143/12, Differential-Neuts:85.9 %,\n Lymph:5.8 %, Mono:8.1 %, Eos:0.2 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580477,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:44 PM\n \n - Started on low dose levaphed with goal of SBPs 120-130\n - Remains with marginal UOP 20-25 cc/hr\n - Renal rec: Repeat UA/lytes/Eos and give DDAVP if rebleeds for ?\n uremic platelets.\n - UA with 6-10 WBC, 20-30 RBC, and FeNa 0.8\n - Liver rec: ERCP consult who reced repeat abd U/S\n - Repeat U/S - Prelim read\n 1. Mildly improved appearance of the gallbladder, containing sludge\n mixed with bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis. Echogenic liver as previously seen. Right pleural\n effusion.\n - Weaned down on O2 overnight\n - Went into a-fib at 5 AM with rates to 120 and BPs down to 100s/60s.\n He was transitioned to Neo.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 0.6 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 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 102 (79 - 122) bpm\n BP: 113/64(82) {90/50(70) - 137/74(98)} mmHg\n RR: 19 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 15 (13 - 16)mmHg\n Total In:\n 1,915 mL\n 287 mL\n PO:\n TF:\n IVF:\n 1,335 mL\n 287 mL\n Blood products:\n 580 mL\n Total out:\n 385 mL\n 195 mL\n Urine:\n 385 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,530 mL\n 92 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.31/28/103/15/-10\n PaO2 / FiO2: 103\n Physical Examination\n General: Alert, mentating well, appears younger than stated age, face\n mask on\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 238 K/uL\n 12.7 g/dL\n 155 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 114 mg/dL\n 111 mEq/L\n 144 mEq/L\n 36.1 %\n 14.8 K/uL\n [image002.jpg]\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n WBC\n 13.3\n 14.0\n 14.8\n Hct\n 35.7\n 35.5\n 36.3\n 35.3\n 36.1\n Plt\n 190\n 226\n 238\n Cr\n 3.6\n 3.8\n 4.2\n TCO2\n 17\n 15\n 17\n 16\n 15\n Glucose\n 190\n 147\n 155\n Other labs: PT / PTT / INR:45.4/31.2/4.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:2055/, Alk Phos / T\n Bili:558/16.8, Amylase / Lipase:143/12, Differential-Neuts:85.9 %,\n Lymph:5.8 %, Mono:8.1 %, Eos:0.2 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPOXEMIA\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n LIVER FUNCTION ABNORMALITIES\n GASTROINTESTINAL BLEED, UPPER (MELENA, GI BLEED, GIB)\n HYPOTENSION (NOT SHOCK)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580478,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 02:44 PM\n \n - Started on low dose levaphed with goal of SBPs 120-130\n - Remains with marginal UOP 20-25 cc/hr\n - Renal rec: Repeat UA/lytes/Eos and give DDAVP if rebleeds for ?\n uremic platelets.\n - UA with 6-10 WBC, 20-30 RBC, and FeNa 0.8\n - Liver rec: ERCP consult who reced repeat abd U/S\n - Repeat U/S - Prelim read\n 1. Mildly improved appearance of the gallbladder, containing sludge\n mixed with bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis. Echogenic liver as previously seen. Right pleural\n effusion.\n - Weaned down on O2 overnight\n - Went into a-fib at 5 AM with rates to 120 and BPs down to 100s/60s.\n He was transitioned to Neo.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 0.6 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 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 102 (79 - 122) bpm\n BP: 113/64(82) {90/50(70) - 137/74(98)} mmHg\n RR: 19 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 15 (13 - 16)mmHg\n Total In:\n 1,915 mL\n 287 mL\n PO:\n TF:\n IVF:\n 1,335 mL\n 287 mL\n Blood products:\n 580 mL\n Total out:\n 385 mL\n 195 mL\n Urine:\n 385 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,530 mL\n 92 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.31/28/103/15/-10\n PaO2 / FiO2: 103\n Physical Examination\n General: Alert, mentating well, appears younger than stated age, face\n mask on\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 238 K/uL\n 12.7 g/dL\n 155 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 114 mg/dL\n 111 mEq/L\n 144 mEq/L\n 36.1 %\n 14.8 K/uL\n [image002.jpg]\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n WBC\n 13.3\n 14.0\n 14.8\n Hct\n 35.7\n 35.5\n 36.3\n 35.3\n 36.1\n Plt\n 190\n 226\n 238\n Cr\n 3.6\n 3.8\n 4.2\n TCO2\n 17\n 15\n 17\n 16\n 15\n Glucose\n 190\n 147\n 155\n Other labs: PT / PTT / INR:45.4/31.2/4.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:2055/, Alk Phos / T\n Bili:558/16.8, Amylase / Lipase:143/12, Differential-Neuts:85.9 %,\n Lymph:5.8 %, Mono:8.1 %, Eos:0.2 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy.\n - defer EGD for now given cardiac ischemia, hypotension, coagulopathy\n - Hct stable since yesterday, increase to checks\n - continue PPI gtt for 72 hours\n - f/u GI recs\n - access 2 PIV, a-line, central line\n - hold ASA, coumadin\n - Hepatic injury may be contributing to coagulopathy. Consider vitamin\n K IV as long as HD stable.\n - Did receive FFP this am for coagulopathy and in setting of poor UOP\n for volume resusitation\n # Hypotension- Patient\ns exam difficult to interpret and unclear volume\n status but LOS balance positive 6L with poor but stable CO (EF 25%).\n FFP this am for coagulopathy as method of volume repletion but will\n favor holding further IVF because of CHF.\n - Did not tolerate dopamine. Consider levophed and hold further IVF\n given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - continue monitoring on tele\n # A-fib with RVR\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.6. Urine lytes c/w pre-renal azotemia likely from hypotension.\n - augment forward flow with levophed trial and FFP today as above\n - gentle IVF given EF\n - recheck lytes in pm\n # Demand Ischemia/Heart Failure- CPK continues to rise. TTE yesterday\n reveals stable EF 25%. Current volume status appeared slightly\n intravascularly depleted (MAP 73, UOP low but also new ARF) awaiting\n FFP. Dopa trial did not change UOP.\n - trend CK, CPK\n - volume repletion and levophed trial as above to goal MAP >60, UOP >30\n cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n # Transaminitis- Likely shock liver, however biliary process still\n possible. RUQ u/s equivocal for cholecystitis but exam not consistent\n with acute cholecystitis.\n - Cannot tolerate MRCP given ARF\n - trend LFT's, amylase, lipase\n #DM\n - hold glyburide while inpatient\n - RISS\n # Access: 2 PIV\ns, a-line, central line\n # Code: full\n # Communication: Patient , patient\ns wife\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 580386,
"text": "TITLE:\n Chief Complaint: GI bleed\n 24 Hour Events:\n - Received Vit K 5mg po and 2 units FFP given elevated INR in setting\n of GIB.\n - Decreased O2 sats -> CXR with retrocardiac opacity concerning for\n PNA. Cipro changed to Augmentin to cover possible aspiration.\n - Repeat Hct stable: 36 -> 33.9 -> 35.7 -> 35.5\n - CK and trop still rising. TTE suboptimal; EF still 25% c/w\n multivessel CAD, 2+ MR PA systolic HTN increased since .\n - Liver: Rising LFTs likely shock liver. HIDA not indicated,\n consider MRCP.\n - INR increased to 5.3, given 5 mg vitamin K and 2 u FFP\n - Given 500cc for MAP <50s with only transient improvement. Started on\n dopamine gtt given EF 25% but stopped for tachy to 150s. A-line faulty\n but as SBP 80s with UOP about 20 cc/hr, CvO2 67, lactate 2.1 (CVP 12)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 106 (81 - 116) bpm\n BP: 64/36(47) {54/29(39) - 134/73(96)} mmHg\n RR: 28 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 14 (12 - 16)mmHg\n Total In:\n 3,227 mL\n 799 mL\n PO:\n TF:\n IVF:\n 2,531 mL\n 799 mL\n Blood products:\n 666 mL\n Total out:\n 738 mL\n 62 mL\n Urine:\n 738 mL\n 62 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 737 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: 7.32/31/95./17/-8\n PaO2 / FiO2: 137\n Physical Examination\n General: Alert, mentating well, appears younger than stated age, face\n mask on\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 190 K/uL\n 12.2 g/dL\n 190 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 4.8 mEq/L\n 90 mg/dL\n 110 mEq/L\n 142 mEq/L\n 36.3 %\n 13.3 K/uL\n [image002.jpg]\n 05:10 AM\n 05:15 AM\n 11:22 AM\n 12:54 PM\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n WBC\n 9.2\n 11.2\n 13.3\n Hct\n 36.0\n 33.9\n 35.7\n 35.5\n 36.3\n Plt\n \n Cr\n 3.1\n 3.0\n 3.6\n TropT\n 1.20\n 1.87\n TCO2\n 15\n 15\n 17\n 15\n 17\n Glucose\n 195\n 155\n 190\n Other labs: PT / PTT / INR:48.7/32.1/5.3, CK / CKMB /\n Troponin-T:705/39/1.87, ALT / AST:2415/3598, Alk Phos / T\n Bili:610/11.0, Amylase / Lipase:143/12, Lactic Acid:2.1 mmol/L,\n Albumin:3.5 g/dL, LDH:1337 IU/L, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy.\n - defer EGD for now given cardiac ischemia, hypotension, coagulopathy\n - Hct stable since yesterday, increase to checks\n - continue PPI gtt for 72 hours\n - f/u GI recs\n - access 2 PIV, a-line, central line\n - hold ASA, coumadin\n - Hepatic injury may be contributing to coagulopathy. Consider vitamin\n K IV as long as HD stable.\n - Did receive FFP this am for coagulopathy and in setting of poor UOP\n for volume resusitation\n # Hypotension- Patient\ns exam difficult to interpret and unclear volume\n status but LOS balance positive 6L with poor but stable CO (EF 25%).\n FFP this am for coagulopathy as method of volume repletion but will\n favor holding further IVF because of CHF.\n - Did not tolerate dopamine. Consider levophed and hold further IVF\n given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - continue monitoring on tele\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.6. Urine lytes c/w pre-renal azotemia likely from hypotension.\n - augment forward flow with levophed trial and FFP today as above\n - gentle IVF given EF\n - recheck lytes in pm\n # Demand Ischemia/Heart Failure- CPK continues to rise. TTE yesterday\n reveals stable EF 25%. Current volume status appeared slightly\n intravascularly depleted (MAP 73, UOP low but also new ARF) awaiting\n FFP. Dopa trial did not change UOP.\n - trend CK, CPK\n - volume repletion and levophed trial as above to goal MAP >60, UOP >30\n cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n # Transaminitis- Likely shock liver, however biliary process still\n possible. RUQ u/s equivocal for cholecystitis but exam not consistent\n with acute cholecystitis.\n - Cannot tolerate MRCP given ARF\n - trend LFT's, amylase, lipase\n #DM\n - hold glyburide while inpatient\n - RISS\n # Access: 2 PIV\ns, a-line, central line\n # Code: full\n # Communication: Patient , patient\ns wife\n # Disposition: pending above\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI gtt\n Communication: Comments: Wife and patient\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 88M CAD, DCM (25%) c vent AK on coumadin, B\n CEA, UGIB, . Reversed coagulopathy, rising oxygen requirement,\n stable HCT. EF appears stable on echo. LFTs continue to rise.\n Hypotensive last PM, given fluids and dopa - developed tachycardia to\n 150s. UOP is low, lactate 2.1, CvO2 67%.\n Exam notable for Tm 98.6 BP 113/60 HR 80 RR 18 with sat 94 on 70%FM\n 7.32/31/95. Pleasant, WD man, NAD. Coarse BS B. RRR s1s2. Soft +BS.\n Trace edema. Labs notable for WBC 9K, HCT 36 (from 27 c 4 units\n PRBCs), K+ 5.0, Cr 3.1, WBC 13K, Cr 3.6, lactate 1.1, INR 5.3, TB 6,\n AST/ALT 1500-, AP 500. CXR with , EKG LB3.\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of episodic\n hypotension and cardiogenic shock. Will consult primary cardiologist\n and start levophed for inotropic support and close monitoring in MICU,\n including CVP and CvO2 monitoring. Agree with plan to manage GIB with\n IV PPI, NGT to LWS, and reversal of coagulopathy c FFP; will hold off\n on EGD for the moment. For , continue supportive care as\n above. For abnormal LFTs, will trend with volume resuscitation and\n pressor support, and consider MRCP as creatinine resolves. Similarly,\n ARF is progressive, will monitor with hemodynamic support, including\n volume and low dose levophed, while holding cardiac meds. Respiratory\n distress is stable, will wean oxygen as able, and will continue\n antibiotics for possible aspiration pneumonitis. Will continue RISS for\n DM2. Above d/w family and patient at bedside. Remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 05:17 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580472,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Since arrival to MICU patients course has been c/b UGIB requiring 2\n units PRBCs, Rec\nd mult. Units of FFP, and mult. Doses of PO and IV\n vitamin K for persistently high INR. Pt hypotensive with MODs\n including ARF, r/I for MI with troponin 1.8, and shock liver.\n Currently on levophed gtt and requiring 100& high flow oxygen.\n Hypoxemia\n Assessment:\n Received on high flow neb 100%. O2 sats 94-96%. LS-clear w/ diminished\n bases.\n Action:\n O2 changed to NC@ 5L.\n Response:\n O2 sats remained 94-95% on NC. WBC 14.8(14).\n Plan:\n Wean o2 as tolerated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB. BP 119-135/51-70. MAP 72-94. Continues on levophed gtt.\n Ica 1.01.\n Action:\n Levophed gtt titrated for MAP 70-80. Given 2gm calcium IV,\n Response:\n Denied chest pain/resp difficulty. INR 4.9(4.2). Ica 1.04, given 4gm\n calcium IV. CPK 409(705). ~0500, converted into a-fib w/ rate to\n 130\ns. EKG done, Levophed stopped and neosynephrine started.\n Converted back into SR.\n Plan:\n Vitals monitored. Pneumo boots on. Wean levophed as tolerated.\n Monitor lytes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP continues to be low, ~20cc/hr.\n Action:\n UOP monitored. Liver enzymes monitored.\n Response:\n No change in UOP. BUN 114(108).\n Plan:\n Monitor UOP.\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Pulled out NGT. Restless during the\n night. Pulling at IVs/tubes. Complained of feeling nervous.\n Action:\n Emotional support provided. Reoriented frequently. Bed alarm on.\n Response:\n No change in mental status.\n Plan:\n Monitor mental status. Reorient frequently.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580482,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Since arrival to MICU patients course has been c/b UGIB requiring 2\n units PRBCs, Rec\nd mult. Units of FFP, and mult. Doses of PO and IV\n vitamin K for persistently high INR. Pt hypotensive with MODs\n including ARF, r/I for MI with troponin 1.8, and shock liver.\n Hypoxemia\n Assessment:\n Received on high flow neb 100%. O2 sats 94-96%. LS-clear w/ diminished\n bases.\n Action:\n O2 changed to NC@ 5L.\n Response:\n O2 sats remained 94-95% on NC. WBC 14.8(14).\n Plan:\n Wean o2 as tolerated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB. BP 119-135/51-70. MAP 72-94. Continues on levophed gtt.\n Ica 1.01.\n Action:\n Levophed gtt titrated for MAP 70-80. Given 2gm calcium IV,\n Response:\n Denied chest pain/resp difficulty. INR 4.9(4.2). Ica 1.04, given 4gm\n calcium IV. CPK 409(705). ~0500, converted into a-fib w/ rate to\n 130\ns. EKG done, Levophed stopped and neosynephrine started.\n Converted back into SR.\n Plan:\n Vitals monitored. Pneumo boots on. Wean Neo as tolerated. Monitor\n lytes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP continues to be low, ~20cc/hr.\n Action:\n UOP monitored. Liver enzymes monitored.\n Response:\n No change in UOP. BUN 114(108). Creat 4.2(3.8).\n Plan:\n Monitor UOP.\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Pulled out NGT. Restless during the\n night. Pulling at IVs/tubes. Complained of feeling nervous.\n Action:\n Emotional support provided. Reoriented frequently. Bed alarm on.\n Response:\n No change in mental status.\n Plan:\n Monitor mental status. Reorient frequently.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580621,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Since arrival to MICU patients course has been c/b UGIB requiring 2\n units PRBCs, Rec\nd mult. Units of FFP, and mult. Doses of PO and IV\n vitamin K for persistently high INR. Pt hypotensive with MODs\n including ARF, r/I for MI with troponin 1.8, and shock liver.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt R/I MI , Unable to start heparin gtt d/t hx recent GIB. No C/O\n chest pain or chest discomfort. BP 119-135/51-70. MAP 72-94. Continues\n on Neo at 0.5mics/kg/hr. On 5L NC sats 94-96%.\n Action:\n Neo titrated for MAP 70. Given 2gm calcium IV this morning..INR 4.2,\n given 2 units of FFP. Recycled Cardiac cycle. Pt cont go in and out to\n Afib, Asymptamatic, HR 70-145 back to SR. cardiology following, EKG\n done while he was going to Afib. Given 0.25 mg Dig at 1700.\n Response:\n INR down to 2.2 from 4.2.Denied chest pain/resp difficulty.\n Plan:\n Closely monitor HR,Cont rest of the Digoxin . Wean Neo and oxygen as\n tolerated, Goal Map > 70 and descent UOP.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP continues to be minimal 30-40cc/hr,BUN 114and Cr 4.2\n Action:\n UOP monitored. Lytes sent this evening..\n Response:\n UOP Cont to be borderline.. BUN 120 and Cr 4.4 this evening.\n Plan:\n Monitor UOP and renal function. Follow up with .\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Follow commands,able to help with\n turning. More confused during night\n Action:\n Reoriented frequently .Emotional support provided. Bed alarm on.\n Response:\n Pt looks more Alert .\n Plan:\n Monitor mental status. Reorient frequently.\n Atrial fibrillation (Afib)\n Assessment:\n Pt constantly going in and out frorm Afib with HR 70-145,\n Asymptamatic, No c/o Chest discomfort or pain. Received on Neo at 0.4\n mics/hr.\n Action:\n EKG done while on Afi.converted back to SR without any difficulty,\n Cardiology following\n Response:\n Dilt 0.25 mg given around 1700.Cont have Afib 70 120 without BP drop.\n Plan:\n Closley monitor HR,Cont dig as ordered. Lopressor if Hr persistently\n stays in 120-130. monitor lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580634,
"text": "This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n Code status: full code\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Patient original admission was for UGIB. to super-therapeutic INR.\n INR yesterday morning 4.5. after 2u FFP it came down to 2.5. He started\n a clear liquid diet. He has tolerated the diet well. No bowel\n movement or vomiting noted. HCT 36.1,\n Action:\n Response:\n Plan:\n Hold ASA and coumadin, question DDAVP if bleeding noted. Monitor HCT\n and INR.\n Hypotension (not Shock)\n Assessment:\n He is on NEO at 0.8mcg/kg/min. now MAPS >70\ns. I did note, that when\n his heart rate increases. That his blood pressure will drop.\n Action:\n Continue the NEO at 0.8mcg.\n Response:\n MAPS >70\n Plan:\n Attempt to wean neo as tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n He is in AF with PVC noted. Heart rate went up to 170\n Action:\n He received metoprolol 5mg IV @.\n Response:\n Heart rate down to 78-120\n. He is also receiving a digoxin loading.\n Plan:\n Last dig loading is at 0900. please obtain dig level on @ 1700.\n Liver function abnormalities\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580635,
"text": "This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n Code status: full code\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Patient original admission was for UGIB. to super-therapeutic INR.\n INR yesterday morning 4.5. after 2u FFP it came down to 2.5. He started\n a clear liquid diet. He has tolerated the diet well. No bowel\n movement or vomiting noted. HCT 36.1,\n Action:\n Response:\n Plan:\n Hold ASA and coumadin, question DDAVP if bleeding noted. Monitor HCT\n and INR.\n Hypotension (not Shock)\n Assessment:\n He is on NEO at 0.8mcg/kg/min. now MAPS >70\ns. I did note, that when\n his heart rate increases. That his blood pressure will drop.\n Action:\n Continue the NEO at 0.8mcg.\n Response:\n MAPS >70\n Plan:\n Attempt to wean neo as tolerated.\n Atrial fibrillation (Afib)\n Assessment:\n He is in AF with PVC noted. Heart rate went up to 170\n Action:\n He received metoprolol 5mg IV @.\n Response:\n Heart rate down to 78-120\n. He is also receiving a digoxin loading.\n Plan:\n Last dig loading is at 0900. please obtain dig level on @ 1700.\n Liver function abnormalities\n Assessment:\n All LFT are up.. He is slightly jaundiced in appearance. I did note\n that his tears were yellow. Both his fingers and toes are\n dusky(question poor circulation).\n Action:\n Ultra sounds on \n Response:\n Gallbladder containing sludge, with mild wall thickening\n Plan:\n Trend LFT\ns and\n Altered mental status (not Delirium)\n Assessment:\n He is a/ox2, and confused. I did note as the shift progressed he did\n awake during the night confused. He was scratching at his central line.\n Pulling ECG leads off.\n Action:\n Constant re-orientated needed. Soft wrist restraints placed loosely.\n Response:\n Continue with interference with treatment.\n Plan:\n I did obtain order for soft restraints.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n He is in AF on rate control medication. tropI trending down. TEE\n showed EF 25%.\n Action:\n Response:\n Plan:\n Holding ASA and coumadin.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 120 with Cr 4.4. marginal urine out put noted.\n Action:\n Increased PO fluid intake.\n Response:\n No change at this time.\n Plan:\n Monitor urine out put..\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581337,
"text": "Called for slow VT with AMS. EKG showed same rhythm as before at rate\n 100bpm - LBBB with AFib. Neuro exam non-focal with delirium but\n otherwise no neurologic deficits. Lytes with low calcium (1.01). gave\n 2gm calcium. ABG with metabolic acidosis but nl PO2. Thought to be\n sundowning with no new arrhythmia.\n - Both TSH (0.17) and T4 (3) low\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 580570,
"text": "Chief Complaint: GI bleed\n 24 Hour Events:\n - Started on low dose levophed with goal of SBPs 120-130. Went into\n a-fib at 5 AM with rates to 120 and BPs down to 100s/60s. He was\n transitioned to Neo.\n - Remains with marginal UOP 20-25 cc/hr. Renal recommended repeat\n UA/lytes/Eos: UA with 6-10 WBC, 20-30 RBC, FeNa 0.8, neg eos. To give\n DDAVP if rebleeds for ?uremic platelets\n - Liver recommended ERCP consult who recommend repeat abd U/S ->\nMildly improved appearance of the gallbladder, containing sludge mixed\n with bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis.\n - Weaned down on O2 overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Phenylephrine - 0.6 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 06:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.1\nC (97\n HR: 102 (79 - 122) bpm\n BP: 113/64(82) {90/50(70) - 137/74(98)} mmHg\n RR: 19 (18 - 32) insp/min\n SpO2: 96%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 15 (13 - 16)mmHg\n Total In:\n 1,915 mL\n 287 mL\n PO:\n TF:\n IVF:\n 1,335 mL\n 287 mL\n Blood products:\n 580 mL\n Total out:\n 385 mL\n 195 mL\n Urine:\n 385 mL\n 195 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,530 mL\n 92 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: 7.31/28/103/15/-10\n PaO2 / FiO2: 103\n Physical Examination\n General: Alert, mentating well, appears younger than stated age, face\n mask on\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Improved today - clear to auscultation bilaterally, no wheezes,\n rales, rhonchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 238 K/uL\n 12.7 g/dL\n 155 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.7 mEq/L\n 114 mg/dL\n 111 mEq/L\n 144 mEq/L\n 36.1 %\n 14.8 K/uL\n [image002.jpg]\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n WBC\n 13.3\n 14.0\n 14.8\n Hct\n 35.7\n 35.5\n 36.3\n 35.3\n 36.1\n Plt\n 190\n 226\n 238\n Cr\n 3.6\n 3.8\n 4.2\n TCO2\n 17\n 15\n 17\n 16\n 15\n Glucose\n 190\n 147\n 155\n Other labs: PT / PTT / INR:45.4/31.2/4.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:2055/, Alk Phos / T\n Bili:558/16.8, Amylase / Lipase:143/12, Lactic Acid:1.5 mmol/L,\n LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.4 mg/dL, PO4:4.6 mg/dL. Micro: No\n pending data.\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy. Hepatic injury may be contributing to coagulopathy with\n INR persistently high.\n - Hct stable since yesterday, decrease to daily checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Continue PPI gtt for 72 hours, then change to IV bid\n - Access 2 PIV, a-line, central line\n - D/c NGT, advance diet\n - Holding ASA, coumadin\n - Consider DDAVP if further bleed for uremic plt per Renal\n - Give FFP x 2 units\n - F/u GI recs\n # Hypotension: Cardiogenic v. hypovolemic v. distributive. Was started\n on levophed yesterday but developed afib, switched to neo; afib\n terminated on its own without need to rate control.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to be able to wean neo with improvement in fluid status; goal\n MAP>60 and UOP >30 cc/hr\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo.\n - Appreciate cards recs\n - Monitor ECG, tele\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre continues to\n climb. Urine without eos, + few granular casts. Urine lytes yesterday\n c/w pre-renal azotemia also likely from hypotension. UOP improved\n somewhat with pressors.\n - Liberalize po fluid intake today\n - Monitor U/O\n - Wean pressor as tolerated\n # Demand Ischemia/Heart Failure: CPK trending down. Very elevated BNP\n yesterday. TTE showed stable EF 25%.\n - Trend CK, CPK daily\n - Recheck BNP\n - Volume repletion and neo as above to goal MAP >60, UOP >30 cc/hr\n - Monitor on telemetry\n - Anticoagulation on hold for now\n # Transaminitis- Likely shock liver with transaminitis improving. ERCP\n service consulted, however pt not felt likely to tolerate ERCP now and\n RUQ u/s was repeated showing slightly improved picture.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: D/c NGT, advance diet today\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: patient, patient\ns wife\n status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 88M CAD, DCM (25%) c vent AK on coumadin, B\n CEA, UGIB, . Stable HCT. On levo yesterday, c/b AF c RVR, no on\n neo.\n Exam notable for Tm 97.6 BP 104/60 HR 70-120 RR 18 with sat 94 on 4LNC\n 7.31/28/103 CVP 13 CvO2 pending. Pleasant, WD man, NAD. Clear BS B. RRR\n s1s2. Soft +BS. No edema. Labs notable for WBC 14K, HCT 36, K+ 4.7,\n Cr 4.2, WBC 14K, Cr 4.2, lactate 1.5, INR 5.3. EKG LB3.\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of episodic\n hypotension and resolving shock. Will check CvO2 and give volume in the\n form of FFP while advancing diet and trying to wean pressors. Agree\n with plan to manage GIB with change to IV PPI ; can also d/c NGT.\n For , continue supportive care as above. For abnormal LFTs,\n will trend with volume resuscitation and pressor support. Similarly,\n ARF is progressive, will monitor with hemodynamic support, including\n volume and low dose neo, while holding cardiac meds. Hope to avoid HD\n as hemodynamics are optimized. Respiratory distress is improving, will\n wean oxygen as able, and will continue antibiotics for possible\n aspiration pneumonitis. Will continue RISS for DM2. Above d/w family\n and patient at bedside. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:55 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Cardiology Consult Note",
"row_id": 580626,
"text": "TITLE: Cardiology consult note\n History of Presenting Illness.\n 88-year-old man, with MMP consulted for management of shock with\n concern for cardiogenic etiology. Briefly, active medical issues\n include DM, CAD, h/o MI, cardiomyopathy with EF of 25%, HTN, HL, PVD.\n Pt was admitted with abd pain and nausea. Given SL nitro because\n it was thought that this was his anginal equivalent. EKGs old LBBB,\n initial troponins were neg. After SL nitro, BP dropped from 130s to 80s\n systolic but returned to the low 100s after 2L IVF. Subsequently,\n patient developed coffee ground hematemesis, with Hct dropping from 37\n to 27. He was admitted to the MICU. Per MICU records, SBP were noted to\n be in the 80-100 range on . The patient did not require pressors\n and continued to mentate well, but developed shock liver with\n transaminitis in the several thousand range, deranged INR, and acute on\n chronic renal failure.\n He has received PRBC tranfusions, with current Hct 35. Rpt echo showed\n EF of 25% essentially unchanged from prior. Biomarkers are mildly\n elevated (Trop 2, CK 700, MB 70). Primary team concerned abt\n cardiogenic shock because of continued hypotension despite volume\n resuscitation and hypoxemia. Current vitals are: SBP 90-100, HR 90s,\n afebrile.\n The MICU team is requesting a consult for the following questions:\n (1) Is this cardiogenic shock?\n (2) Would the patient benefit from dobutamine?\n Past Medical History:\n CAD, status post MI over a decade ago\n hypertension\n hyperlipidemia\n peripheral vascular disease with bilateral carotid endarterectomies\n BCC\n Cardiomyopathy, EF 25-30% in 04 w/ severe AK/HK (on coumadin)\n Review of Systems: Otherwise negative in detail.\n Medications at home\n EZETIMIBE [ZETIA] - 10 mg qd\n GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm\n HYDROCHLOROTHIAZIDE - 12.5 mg qd\n ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd\n METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd\n PRAVASTATIN [PRAVACHOL] - 40 mg qd\n QUINAPRIL - 40 mg qd\n WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth daily take\n one tab 4 days a week and taab on Tue, Th and Sat\n ASPIRIN - (OTC) - 81 mg qd\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D]\n MEDICATIONS IN ICU\n 1. Ampicillin-Sulbactam 3 g IV Q12H\n 2. Insulin SS\n 3. Norepinephrine 0.03-0.25 mcg/kg/min\n Allergies: NKDA\n .\n Social History:\n He is a retired fireman, lives in with his wife.\n Married 55 years. Grown children. No smoking. No alcohol consumption.\n .\n Family History:\n non-contributory\n .\n Physical Exam:\n Vitals: T: afebrile, BP:80-90/40-50 (off levophed), 100-120/60-70 (on\n low dose levophed), P:80-100, R: 20 O2: 95% on 2L NC, 87% RA\n General: Alert, mentating well, does not appear acutely ill\n HEENT: Sclera icteric, dry MM, oropharynx clear\n Neck: CVP 12\n Lungs: Clear to auscultation bilaterally, reduced BS bases.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: diffusely warm, 2+ pulses, no clubbing, cyanosis or edema\n .\n Labs:\n Hct 39\n WCC 6\n INR 3.1\n Cr 2.4\n BUN 48\n ALT normal\n1600\n2400\n AST normal\n2600\n3200\n LDH normal\n\n Tbil 0.4\n16.4\n CXR: no pulmonary edema\n .\n EKG: SR, LBBB (old) LAD\n Echo: EF 25%, unchanged from prior\n Assessment and Plan\n 88 year old man with cardiomyopathy EF 25% presenting with multiorgan\n failure (shock liver, acute on chronic renal failure) in the setting of\n upper GI bleed. The initial insult is most likely hypovolemic shock\n from GI bleed in a patient who is especially vulnerable to developing\n end organ ischemia due to low EF. This has resulted in shock liver and\n acute renal failure, and evolved into distributive shock (due to\n vasodilatation from shock liver). Cardiogenic shock seems unlikely as a\n primary etiology of end organ failure because of the lack of signs of\n left heart failure (no overt pulmonary edema, minimal O2 requirements,\n peripheral vasodilatation), brisk response to low dose levophed\n (suggesting distributive shock).\n Would suggest:\n - continued supportive management with levophed for BP\n support. I suspect hemodynamics will start to improve as his shock\n liver improves.\n - Dobutamine not indicated due to adequate response to\n levophed\n - If hemodynamic instability is encountered further, would\n suggest swan ganz catheter to guide pressor management. Otherwise, can\n hold off.\n - Maintain CVP 10-12.\n - Watch out for CHF/pulm edema d/t fluid overload.\n - Hypoxemia likely atelactasis +/- fluid overload.\n Incentive spirometry, encourage sitting up, nebulizers, avoid diuresing\n for now.\n - Agree with holding all cardiac meds for now (including ASA,\n beta blockers, ACEI) until stabilized.\n - Will staff with Dr .\n .\n ------ Protected Section ------\n , M 88 \nDate: \nSigned by , MD, PHD on at 7:15 pm Affiliation: HMFP\n\nCARDIOLOGY CONSULT SERVICE\n====================================\nATTENDING STAFF NOTE\n====================================\nI saw and examined this patient today. I discussed this patient\nwith the cardiology fellow today and the housestaff team\ntoday and yesterday. I reviewed all of the notes since the\npatient's current admission to , and any available and\nrelevant external notes. I agree with the note of Dr. \n(hereafter termed \"index note\"), and would add the following\nremarks to its key portions:\nThe patient is an 88-year-old man, retired from the fire\ndepartment with Type 2\ndiabetes, CAD, status post MI over a decade ago, systolic CHF\nclass I/II, hypertension, hyperlipidemia, peripheral vascular\ndisease with bilateral\ncarotid endarterectomies admitted with abdominal pain and nausea.\nHe was given tng associated w/hypotension for which given fluids.\nHypotension persisted and hematemesis ensued. He has\nsubsequently stabilized on norepinehrine with ongoing hypoxia and\nnow rapid atrial fibrillation, acute on chronic renal\ninsufficiency, mixed hepatocellular + cholestatic LFT\nabnormalities.\nPast medical history, social history, family history, allergies,\nmedications. With exception of what was mentioned in the HPI,\nall other ROS negative.\nPhysical examination and other data are as outlined in the index\nnote, with any of my corrections or additions documented in the\nprinted chart. At noon bp 120/70, sr 80 and paf 100-140,\njaundiced, alert, oriented. Lungs:decr bs at bases w/egophony,\nupper zones clear. Cor: RR, JVP 12-15, I/VI holosys murmur llsb,\napex, p2? incr. Abd:bs active, mild distens. ext: tr edema\nImpression/Plan:\n================\n1. Hypotension\n2. Heart failure, acute on chronic systolic.\n3. CAD with troponin elevation in setting of 1,2, acute on\nchronic renal insufficiency, and mixed hepatocellular +\ncholestatic, hypoalbuminemia, anemia. ffp helpful here, see what\nrenal thinks about some diuresis. his usual jvp is low.\n4. PAF/flut w/baseline LBBB. rate control w/digoxin load over 2\ndays, and until off norepinephine, no amiodarone until lft\nimproved.\n5. Outpatient cardiology follow-up: me.\nThis impression and plan were discussed today with the patient,\nwho appeared to understand. All questions were answered to the\npatient's apparent satisfaction.\n ------ Protected Section Addendum Entered By: \n on: 19:35 ------\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580685,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Got FFP with repeat INR 2.5, down from 5\n - Cards: Start dig 0.25 X 1 dose then 0.125 X 2 doses then check dig\n level\n - HR transiently into 150s with decreased BPs. Increased neo. Gave 5mg\n lopressor after neo increased with better rate control (although still\n occasional bursts of tachycardia), pressors off this morning\n - Increased O2 requirement (30% facemask + NC) o/n with ABG revealing\n metabolic acidosis, now back down to 5L NC\n - Pulled NGT, advanced diet to clears\n - PPI changed to IV BID\n - Liver: Start ursodiol\n - Renal: start bicarb\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36\nC (96.8\n HR: 104 (75 - 124) bpm\n BP: 123/69(87) {92/51(66) - 138/74(95)} mmHg\n RR: 25 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 14 (11 - 26)mmHg\n CO/CI (Fick): (5.2 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 2,446 mL\n 576 mL\n PO:\n 720 mL\n 480 mL\n TF:\n IVF:\n 1,212 mL\n 96 mL\n Blood products:\n 514 mL\n Total out:\n 720 mL\n 135 mL\n Urine:\n 720 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,726 mL\n 441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.37/25/78./15/-8\n Physical Examination\n Gen:\n HEENT:\n CV:\n Lungs:\n Abd:\n Ext:\n Neuro:\n Labs / Radiology\n 246 K/uL\n 12.3 g/dL\n 135 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.4 mEq/L\n 128 mg/dL\n 111 mEq/L\n 143 mEq/L\n 35.2 %\n 13.3 K/uL\n [image002.jpg]\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n Hct\n 35.5\n 36.3\n 35.3\n 36.1\n 35.2\n Plt\n 190\n 226\n 238\n 246\n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n TCO2\n 17\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n Other labs: PT / PTT / INR:29.4/30.6/2.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:1291/768, Alk Phos / T Bili:525/18.7,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Cardiogenic v. hypovolemic v. distributive. Was started\n on levophed yesterday but developed afib, switched to neo; afib\n terminated on its own without need to rate control.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to be able to wean neo with improvement in fluid status; goal\n MAP>60 and UOP >30 cc/hr\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo.\n - Appreciate cards recs\n - Monitor ECG, tele\n # Demand Ischemia/Heart Failure: CPK trending down. Very elevated BNP\n yesterday. TTE showed stable EF 25%.\n - Trend CK, CPK daily\n - Recheck BNP\n - Volume repletion and neo as above to goal MAP >60, UOP >30 cc/hr\n - Monitor on telemetry\n # Transaminitis- Likely shock liver with transaminitis improving. ERCP\n service consulted, however pt not felt likely to tolerate ERCP now and\n RUQ u/s was repeated showing slightly improved picture.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy. Hepatic injury may be contributing to coagulopathy with\n INR persistently high.\n - Hct stable since yesterday, decrease to daily checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Continue PPI gtt for 72 hours, then change to IV bid\n - Access 2 PIV, a-line, central line\n - D/c NGT, advance diet\n - Holding ASA, coumadin\n - Consider DDAVP if further bleed for uremic plt per Renal\n - Give FFP x 2 units\n - F/u GI recs\n - no anticoagulation\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre continues to\n climb. Urine without eos, + few granular casts. Urine lytes yesterday\n c/w pre-renal azotemia also likely from hypotension. UOP improved\n somewhat with pressors.\n - Liberalize po fluid intake today\n - Monitor U/O\n - Wean pressor as tolerated\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: Clears\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer:PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580691,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Got FFP with repeat INR 2.5, down from 5\n - Cards: Start dig 0.25 X 1 dose then 0.125 X 2 doses then check dig\n level\n - HR transiently into 150s with decreased BPs. Increased neo. Gave 5mg\n lopressor after neo increased with better rate control (although still\n occasional bursts of tachycardia), pressors off this morning\n - Increased O2 requirement (desat from 95% -> 89% on 3L) with ABG\n revealing metabolic acidosis, CXR with mild fluid overload, oxygen\n delivery increased (30% facemask + NC) o/n, now back down to 5L NC\n - more confused o/n\n - Pulled NGT, advanced diet to clears\n - PPI changed to IV BID\n - Liver: Start ursodiol\n - Renal: start bicarb\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36\nC (96.8\n HR: 104 (75 - 124) bpm\n BP: 123/69(87) {92/51(66) - 138/74(95)} mmHg\n RR: 25 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 14 (11 - 26)mmHg\n CO/CI (Fick): (5.2 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 2,446 mL\n 576 mL\n PO:\n 720 mL\n 480 mL\n TF:\n IVF:\n 1,212 mL\n 96 mL\n Blood products:\n 514 mL\n Total out:\n 720 mL\n 135 mL\n Urine:\n 720 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,726 mL\n 441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.37/25/78./15/-8\n Physical Examination\n Gen: Awake elderly gentleman in NAD\n HEENT: sclera icteric, dry MM\n CV: RRR, no murmurs\n Lungs: bronchial breathsounds without crackles\n Abd: Soft, NT, ND, + bowel sounds, no RUQ tenderness\n Ext: Warm, well-perfused, no edema\n Neuro: A+Ox3, responds appropriately to questions\n Labs / Radiology\n 246 K/uL\n 12.3 g/dL\n 135 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.4 mEq/L\n 128 mg/dL\n 111 mEq/L\n 143 mEq/L\n 35.2 %\n 13.3 K/uL\n [image002.jpg]\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n Hct\n 35.5\n 36.3\n 35.3\n 36.1\n 35.2\n Plt\n 190\n 226\n 238\n 246\n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n TCO2\n 17\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n Other labs: PT / PTT / INR:29.4/30.6/2.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:1291/768, Alk Phos / T Bili:525/18.7,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Appears to be improving with CvO2 high 60\ns-low 70\n Cardiogenic v. hypovolemic v. distributive, with hypovolemic most\n likely. Was started on levophed intially but developed afib, switched\n to neo; afib terminated on its own without need to rate control.\n Pressors off since this morning.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to maintain pressors off; goal MAP>60 and UOP >30 cc/hr\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo. Continues to have runs of afib. Lopressor x1 yesterday\n did not persistently slow rate.\n - Continue dig loading with renal dosing\n - Appreciate cards following\n - Monitor ECG, tele\n # Demand Ischemia/Heart Failure: CPK trending down. Very elevated BNP\n yesterday. TTE showed stable EF 25%.\n - Trend CK, CPK daily\n - Recheck BNP\n - Volume repletion and neo as above to goal MAP >60, UOP >30 cc/hr\n - Monitor on telemetry\n # Transaminitis- Likely shock liver with transaminitis improving. ERCP\n service consulted, however pt not felt likely to tolerate ERCP now and\n RUQ u/s was repeated showing slightly improved picture. Started on\n ursadiol for biliary process.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR. Hepatic injury may be contributing to\n coagulopathy with INR persistently high, now improved with 2 u FFP.\n PPI changed to . Tolerated a diet.\n - Hct stable since yesterday, decrease to daily checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Access 2 PIV, a-line, central line\n - Consider DDAVP if further bleed for uremic plt per Renal\n - F/u GI recs\n - no anticoagulation\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre appears to have\n stabilized. UOP improved somewhat over last 24 hours.\n - Liberalize po fluid intake today\n - Monitor UOP\n # Metabolic acidosis: Likely due to hypoperfused state.\n - bicarb per renal recs\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: Clears\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer:PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580697,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Got FFP with repeat INR 2.5, down from 5\n - Cards: Start dig 0.25 X 1 dose then 0.125 X 2 doses then check dig\n level\n - HR transiently into 150s with decreased BPs. Increased neo. Gave 5mg\n lopressor after neo increased with better rate control (although still\n occasional bursts of tachycardia), pressors off this morning\n - Increased O2 requirement (desat from 95% -> 89% on 3L) with ABG\n revealing metabolic acidosis, CXR with mild fluid overload, oxygen\n delivery increased (30% facemask + NC) o/n, now back down to 5L NC\n - more confused o/n\n - Pulled NGT, advanced diet to clears\n - PPI changed to IV BID\n - Liver: Start ursodiol\n - Renal: start bicarb\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36\nC (96.8\n HR: 104 (75 - 124) bpm\n BP: 123/69(87) {92/51(66) - 138/74(95)} mmHg\n RR: 25 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 14 (11 - 26)mmHg\n CO/CI (Fick): (5.2 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 2,446 mL\n 576 mL\n PO:\n 720 mL\n 480 mL\n TF:\n IVF:\n 1,212 mL\n 96 mL\n Blood products:\n 514 mL\n Total out:\n 720 mL\n 135 mL\n Urine:\n 720 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,726 mL\n 441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: 7.37/25/78./15/-8\n Physical Examination\n Gen: Awake elderly gentleman in NAD\n HEENT: sclera icteric, dry MM\n CV: RRR, no murmurs\n Lungs: bronchial breathsounds without crackles\n Abd: Soft, NT, ND, + bowel sounds, no RUQ tenderness\n Ext: Warm, well-perfused, no edema\n Neuro: A+Ox3, responds appropriately to questions\n Labs / Radiology\n 246 K/uL\n 12.3 g/dL\n 135 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.4 mEq/L\n 128 mg/dL\n 111 mEq/L\n 143 mEq/L\n 35.2 %\n 13.3 K/uL\n [image002.jpg]\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n Hct\n 35.5\n 36.3\n 35.3\n 36.1\n 35.2\n Plt\n 190\n 226\n 238\n 246\n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n TCO2\n 17\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n Other labs: PT / PTT / INR:29.4/30.6/2.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:1291/768, Alk Phos / T Bili:525/18.7,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Appears to be improving with CvO2 high 60\ns-low 70\n Cardiogenic v. hypovolemic v. distributive, with hypovolemic most\n likely. Was started on levophed intially but developed afib, switched\n to neo; afib terminated on its own without need to rate control.\n Pressors off since this morning. ABG early this morning with gap\n metabolic acidosis further supports hypoperfused state.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to maintain pressors off; goal MAP>60 and UOP >30 cc/hr\n - If requires pressors, would choose neo\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo. Continues to have runs of afib. Lopressor x1 yesterday\n did not persistently slow rate.\n - Continue dig loading with renal dosing\n - Appreciate cards following\n - Monitor ECG, tele\n # Demand Ischemia/Heart Failure: CPK trending down. BNP increased from\n 40K -> 70K. TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol for possible biliary process.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR. Hepatic injury may be contributing to\n coagulopathy with INR persistently high, now improved with 2 u FFP.\n PPI changed to . Tolerated a diet.\n - Hct stable since yesterday, decrease to daily checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Access 2 PIV, a-line, central line\n - Consider DDAVP if further bleed for uremic plt per Renal\n - F/u GI recs\n - no anticoagulation\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre appears to have\n stabilized. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cre\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: Clears\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer:PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580449,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Since arrival to MICU patients course has been c/b UGIB requiring 2\n units PRBCs, Rec\nd mult. Units of FFP, and mult. Doses of PO and IV\n vitamin K for persistently high INR. Pt hypotensive with MODs\n including ARF, r/I for MI with troponin 1.8, and shock liver.\n Currently on levophed gtt and requiring 100& high flow oxygen.\n Hypoxemia\n Assessment:\n Received on high flow neb 100%. O2 sats 94-96%. LS-clear w/ diminished\n bases.\n Action:\n O2 changed to NC@ 5L.\n Response:\n O2 sats remained 94-95% on NC. WBC 14.8(14).\n Plan:\n Wean o2 as tolerated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB. BP 119-135/51-70. MAP 72-94. Continues on levophed gtt.\n Ica 1.01.\n Action:\n Levophed gtt titrated for MAP 70-80. Given 2gm calcium IV,\n Response:\n Denied chest pain/resp difficulty. INR 4.9(4.2). Ica 1.04, given 4gm\n calcium IV. CPK 409(705).\n Plan:\n Vitals monitored. Pneumo boots on. Wean levophed as tolerated.\n Monitor lytes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP continues to be low, ~20cc/hr.\n Action:\n UOP monitored. Liver enzymes monitored.\n Response:\n No change in UOP. BUN 114(108).\n Plan:\n Monitor UOP.\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Pulled out NGT. Restless during the\n night. Pulling at IVs/tubes. Complained of feeling nervous.\n Action:\n Emotional support provided. Reoriented frequently. Bed alarm on.\n Response:\n No change in mental status.\n Plan:\n Monitor mental status. Reorient frequently.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 582279,
"text": "The pt is an 88 yo man admitted with a gib. His micu course has\n been complicated by hypotension requiring pressor support, elevated\n lft\ns w/notable jaundice thought to be secondary to\nshock liver\n acute renal failure likely atn, s/p nstemi, and intermittent af w/rvr.\n MICU course eventful for vasopressors intermittently and CRRT\n treatments.\n Events: Family meeting held yesterday () and due to MSO and poor\n prognosis pt\ns status changed to CMO. Family grieving appropriately\n and asking appropriate questions. Vigil at bedside by family all\n evening and into the early morning hours.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Arouses to verbal stimulation with eye opening, moving upper\n extremities, inconsisitently following commands during evening with\n increasing unresponsiveness, periods of restlessness, HR labile 50-110\n SR with bursts of Afib, freq. PVC\ns, BP= 55-95/40\ns, RR=, resp.\n status initially nonlabored and regular with progression to\n Cheynne- respirations, Sats 84-96% on room air. NS bladder\n irrigant infusing via 3-way Foley with hematuria still present.\n Action:\n Dilaudid IV PRN for comfort, restlessness, labored resp\n status----0.5mg x 3 doses, Dilaudid gtt held, Benadryl and Sarna lotion\n for pruritis, skin care, support offered to pt and family\n Response:\n Good response with 0.5 mg IV Dilaudid prn---no gtt necessary for\n comfort at this time, Good effect with IV Benadryl and topical Sarna\n lotion as pt not scratching as much and less restless, appears\n comfortable with no grimacing or moaning\n Plan:\n Continue CMO---start Dilaudid gtt if unable to get pt comfortable with\n prn Dilaudid, continue application of Sarna for pruritis. Family\n contact at home at 0315 for change in pt\ns condition as HR and\n breathing with increased freq. in irregularity and pt with apneic\n periods.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 581332,
"text": "Chief Complaint:\n 24 Hour Events:\n - Renal: Cont bicarb. Creatinine increase likely hypotension but\n encouraged because euvolemic and still with good UOP.\n - Dry on exam so received two 500cc NS boluses\n - Called for slow VT with AMS. EKG showed same rhythm as before at rate\n 100bpm - LBBB with AFib. Neuro exam non-focal with delirium but\n otherwise no neurologic deficits. Lytes with low calcium (1.01). gave\n 2gm calcium. ABG with metabolic acidosis but nl PO2. Thought to be\n sundowning with no new arrhythmia.\n - Both TSH (0.17) and T4 (3) low\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.7\nC (96.3\n HR: 80 (74 - 119) bpm\n BP: 113/52(67) {86/27(40) - 127/72(82)} mmHg\n RR: 15 (13 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 2,128 mL\n 254 mL\n PO:\n 970 mL\n 200 mL\n TF:\n IVF:\n 1,158 mL\n 54 mL\n Blood products:\n Total out:\n 820 mL\n 110 mL\n Urine:\n 820 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,308 mL\n 144 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: 7.36/29/110/15/-7\n Physical Examination\n GEN: NAD\n HEENT: Jaundice\n LUNGS: Crackles at bases\n HEART: Regular and tachycardic\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 218 K/uL\n 12.3 g/dL\n 128 mg/dL\n 4.8 mg/dL\n 15 mEq/L\n 3.9 mEq/L\n 142 mg/dL\n 110 mEq/L\n 140 mEq/L\n 38\n 13.0 K/uL\n [image002.jpg]\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n 11:49 AM\n 08:00 PM\n 02:30 AM\n 08:52 PM\n 09:13 PM\n WBC\n 13.3\n 11.3\n 12.7\n 13.0\n Hct\n 35.2\n 34.6\n 34.9\n 33.7\n 34.1\n 36.0\n 38\n Plt\n 18\n Cr\n 4.4\n 4.2\n 4.8\n 4.0\n 4.8\n 4.8\n TCO2\n 15\n 17\n Glucose\n 158\n 135\n 98\n 110\n 141\n 128\n Other labs: Ca++:8.7 mg/dL, Mg++:2.7 mg/dL, PO4:3.8 mg/dL. TSH 0.17, T4\n 3. Dig 1.3.\n Assessment and Plan\n 88 yo M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for GIB although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below with dig\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n - increase diet today and consider IVF cautiously given CHF if\n requires.\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Started metoprolol for rate control with stable pressures\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given GIB\n # GIB: Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower GIB. Hcts stable.\n - Check Hct QD\n - Transfuse for Hct <30\n - PPI IV BID ->change to PO today\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and beta blocker\n - Monitor on telemetry\n - consider d/c bicarb when renal function improves as high salt load\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs.\n Dry on exam yesterday with rise in Cr to 4.8 from 4 and decrease U/O\n - Cont bicarb per renal recs\n - Monitor UOP and Cr\n - Liberalize po fluid intake\n - F/u renal recs\n # Transaminitis: Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Consider ERCP in future if TBili does not resolve\n # Thyroid: Question of central hypothyroidism with low TSH and T4.\n - Consider checking free T4\n # AMS: Now resolved. Consider PT and OOB to chair today after IVF so\n less likely to have hypotension.\n ICU Care\n Nutrition: DM, Cardiac\n Glycemic Control: ISS\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI po bid\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok to intubate\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581342,
"text": "HPI: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver).\n Neosynephrine gtt started for approx 48 hrs of BP support, goal MAPs\n >65. Neo off . Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP improved once pt was returned to bed. Diet advanced with good\n PO intake for lunch. Catholic priest and will visit pt @ BS\n . The pt remains a DNR only.\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD s/p b/l\n endarterectomies, DM, severe systolic HF with EF 25% on Coumadin, CRI\n with baseline Cr value of 2.0.\n EVENTS: Pt had 120 min incident of slow VT with AMS. EKG showed same\n rhythm as before at rate 100bpm - LBBB with AFib. Neuro exam non-focal\n with delirium but otherwise no neurologic deficits. Lytes with low\n calcium (1.01). gave 2gm calcium, other PM labs irremarkable. ABG with\n metabolic acidosis but normal PO2: 7.36/29/110. Thought to be\n sundowning with no new arrhythmia.\n S/p VT and Ca repletion, pt\ns HR returned to NSR w/ HR 70s-80s. MS\n returned to baseline, and pt is A + O x . Pt is afebrile, good\n pulses all extremities. Pt remains on NC 2 L for Sp02 94-98%. Pt\n tolerating water w/ meds w/o incident. A line no longer draws or\n flushes but remains in place to monitor ABPs which correlate w/ NBPs\n when positioned properly. Pt is normotensive w/ SBP 110s overnight.\n PLAN: Redraw labs this AM, monitor lytes.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581344,
"text": "HPI: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD s/p b/l\n endarterectomies, DM, severe systolic HF with EF 25% on Coumadin, CRI\n with baseline Cr value of 2.0.\n EVENTS: Pt had incident slow VT with AMS. EKG showed same rhythm as\n before at rate 100bpm - LBBB with AFib. Neuro exam non-focal with\n delirium but otherwise no neurologic deficits. Lytes with low calcium\n (1.01). gave 2gm calcium. ABG with metabolic acidosis but nl PO2.\n Likely sundowning plus same rhythm. Pt has sinced converted to NSR, HR\n 70-80. MS has returned to baseline. Pt is A + O x .\n Hypotension (not Shock)\n Assessment:\n ABP dampened, no longer draws or flushes. ABPs 95/41\n 121/62\n overnight. NBPs 90/54\n 122/55. Pt has weak pulses bilat lower\n extremities and good pulses bilat UEs. Pt is not febrile, last temp\n 95.9 .l\n Action:\n Encourage PO intake, cont to check NBPs to ABPs. KVO NS running 10\n ml/hr..\n Response:\n Pt is hemodynamically stable, HR 70-80s this AM. Neo gtt not needed at\n this time to maintain BP.\n Plan:\n Monitor. Poss remove aline today.\n Hypoxemia\n Assessment:\n Received pt on 2 L NC, Sp02 91-94%. Pt pulling off NC and Sp02 drops\n to <90%.\n Action:\n Reorient pt to NC. ABG at 2100 7.36/29/110.\n Response:\n Sp02 remains acceptable w/ supplemental O2.\n Plan:\n Cont w/ supp O2 in the setting of arrhythmia, hypotension, and AMS.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580278,
"text": "TITLE:\n Chief Complaint: GI bleed\n 24 Hour Events:\n - Received Vit K 5mg po and 2 units FFP given elevated INR in setting\n of GIB.\n - Decreased O2 sats -> CXR with retrocardiac opacity concerning for\n PNA. Cipro changed to Augmentin to cover possible aspiration.\n - Repeat Hct stable: 36 -> 33.9 -> 35.7 -> 35.5\n - CK and trop still rising. TTE suboptimal; EF still 25% c/w\n multivessel CAD, 2+ MR PA systolic HTN increased since .\n - Liver: Rising LFTs likely shock liver. HIDA not indicated,\n consider MRCP.\n - INR increased to 5.3, given 5 mg vitamin K and 2 u FFP\n - Given 500cc for MAP <50s with only transient improvement. Started on\n dopamine gtt given EF 25% but stopped for tachy to 150s. A-line faulty\n but as SBP 80s with UOP about 20 cc/hr, CvO2 67, lactate 2.1 (CVP 12)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 106 (81 - 116) bpm\n BP: 64/36(47) {54/29(39) - 134/73(96)} mmHg\n RR: 28 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 14 (12 - 16)mmHg\n Total In:\n 3,227 mL\n 799 mL\n PO:\n TF:\n IVF:\n 2,531 mL\n 799 mL\n Blood products:\n 666 mL\n Total out:\n 738 mL\n 62 mL\n Urine:\n 738 mL\n 62 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 737 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: 7.32/31/95./17/-8\n PaO2 / FiO2: 137\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 190 K/uL\n 12.2 g/dL\n 190 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 4.8 mEq/L\n 90 mg/dL\n 110 mEq/L\n 142 mEq/L\n 36.3 %\n 13.3 K/uL\n [image002.jpg]\n 05:10 AM\n 05:15 AM\n 11:22 AM\n 12:54 PM\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n WBC\n 9.2\n 11.2\n 13.3\n Hct\n 36.0\n 33.9\n 35.7\n 35.5\n 36.3\n Plt\n \n Cr\n 3.1\n 3.0\n 3.6\n TropT\n 1.20\n 1.87\n TCO2\n 15\n 15\n 17\n 15\n 17\n Glucose\n 195\n 155\n 190\n Other labs: PT / PTT / INR:48.7/32.1/5.3, CK / CKMB /\n Troponin-T:705/39/1.87, ALT / AST:2415/3598, Alk Phos / T\n Bili:610/11.0, Amylase / Lipase:143/12, Lactic Acid:2.1 mmol/L,\n Albumin:3.5 g/dL, LDH:1337 IU/L, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n therapeutic INR, ddx includes PUD, ASA-induced gastritis, malignancy.\n - defer EGD for now given cardiac ischemia, hypotension, coagulopathy\n - Hct stable since yesterday, continue q6hr checks\n - continue PPI gtt\n - f/u GI recs\n - access 2 PIV, a-line, central line\n - hold ASA, coumadin\n .\n # Demand Ischemia/Heart Failure- CPK continues to rise. TTE yesterday\n reveals stable EF 25% with severe hypokinesis. Current volume status\n appears slightly intravascularly depleted (MAP 73, UOP low but also new\n ARF).\n - trend CK, CPK\n - volume repletion to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n .\n # Increasing 02 requirement- New retrocardiac opacity suggests PNA.\n CXR does not suggest fluid overload/pulmonary edema\n - started on augmentin for possible aspiration\n - f/u am CXR for signs of pulmonary edema\n .\n # Hypotension- Patient clinically somewhat volume depleted with with\n poor but stable CO (EF 25%). Has received 500 cc fluid bolus with\n lactate persisting at in low 2\n - Gentle fluids given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - continue monitoring on tele\n .\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.1 with K 5.7, no EKG changes. Likely pre-renal given patient's\n fluid depleted clinical status\n - gentle IVF given EF\n - check UA and urine lytes\n - will hold on kayexelate pending procedure\n - recheck lytes in pm\n .\n # Transaminitis- Likely shock liver, however biliary process still\n possible. RUQ u/s equivocal for cholecystitis.\n - consider MRCP today, however Cre continues to rise\n - trend LFT's, amylase, lipase\n .\n #DM\n - hold glyburide while inpatient\n - RISS\n .\n # HTN\n - hold HCTZ, beta-blocker and ACE inhibitor in setting of GI bleed\n .\n # Access: 2 PIV\ns, a-line, central line\n .\n # Code: full\n .\n # Communication: Patient , patient\ns wife\n .\n # Disposition: pending above\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580602,
"text": "Hypoxemia\n Assessment:\n Received on %L NC sata 94-96%. LS-clear w/ diminished bases.\n Action:\n Oxygen down to 3L\n Response:\n O2 sats remained 94-95% on NC. WBC 14.8(14).\n Plan:\n Wean o2 as tolerated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt R/I MI , Unable to start heparin gtt d/t hx recent GIB. No C/O\n chest pain or chest discomfort. BP 119-135/51-70. MAP 72-94. Continues\n on Neo at 0.5mics/kg/hr. On 5L NC sats 94-96%.\n Action:\n Neo titrated for MAP 70. Given 2gm calcium IV this morning..INR 4.2,\n given 2 units of FFP. Recycled Cardiac cycle. Pt cont go in and out to\n Afib, Asymptamatic, HR 70-145 back to SR. cardiology following, EKG\n done while he was going to Afib. Given 0.25 mg Dig at 1700.\n Response:\n INR down to 2.2 from 4.2.Denied chest pain/resp difficulty.\n Plan:\n Closely monitor HR,Cont rest of the Digoxin . Wean Neo and oxygen as\n tolerated, Goal Map > 70 and descent UOP.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n .UOP continues to be minimal 30-40cc/hr,BUN and Cr\n Action:\n UOP monitored. Lytes sent this evening..\n Response:\n UOP Cont to be borderline.. BUN 120 and Cr 4.4 this evening.\n Plan:\n Monitor UOP and renal function. Follow up with .\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Pulled out NGT. Restless during the\n night. Pulling at IVs/tubes. Complained of feeling nervous.\n Action:\n Emotional support provided. Reoriented frequently. Bed alarm on.\n Response:\n No change in mental status.\n Plan:\n Monitor mental status. Reorient frequently.\n Atrial fibrillation (Afib)\n Assessment:\n Pt constantly going in and out frorm Afib with HR 70-145,\n Asymptamatic, No c/o Chest discomfort or pain. Received on Neo at 0.4\n mics/hr.\n Action:\n EKG done while on Afi.converted back to SR without any difficulty,\n Cardiology following\n Response:\n Dilt 0.25 mg given around 1700.Cont have Afib 70 120 without BP drop.\n Plan:\n Closley monitor HR,Cont dig as ordered. Lopressor if Hr persistently\n stays in 120-130. monitor lytes.\n"
},
{
"category": "General",
"chartdate": "2102-06-18 00:00:00.000",
"description": "MICU staff admission note",
"row_id": 579982,
"text": "TITLE: MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan.\n 88 yo M w/ DM and sig cardiac hx of systolic chf ef 25%, htn, and cad\n post MI yrs ago on coumadin for ventricular ak presented to ed\n yesterday with abd/epigastric pressure. In ED was AF and\n hemodynamically stable, 100% RA. Concerned for anginal equivalent and\n given asa and sl nitro with resultant transient hypotension which\n responded to 2 L IVF. CE neg. Was admitted to floor. This\n am nauseaus, hypotensive 80/palp, with bloody/brown coffee ground\n emesis. Hct 33-->27. Inr 3.1/ Started PPI ggt, IVFs, and transferred\n to MICU for further management of hypotension and GIB.\n PMH: DM, MI yrs ago, chf systolic ef 25%, htn, hyperlip, PVD post\n b/l cea\n SH, FH, ALL, MEDS reviewed, as in resident h and p.\n Exam: AF 98.6 BP 108/67 80 20 97% 2L\n alert M in NAD, JVP flat\n CTA with b/b rales\n RR distant, no m\n + bs, soft but distended, + hepatomegaly, no tenderness/ruq tenderness\n no edema\n Labs notable for WBC 8.7, HCT 33-->27 , K+5.7, Cr 3.1 (2.2b/l), abg\n 7.36/30/85 (2L), lactate 2.2\n EKGs reviewed--baseline LBBB, nsr, no clear ischemic changes\n CXR: ateletasis at l base, otherwise clear\n 88 yo M with DM and sig cardiac hx, sys chf with ef 25%, therapeutic on\n coumadin presents with hypotension in setting of UGIB.\n Issues include:\n * GIB\n * Hypotension\n * coagulopathy\n * ARF\n * hyperK\n * CHF, systolic\n * dm\n Agree with plan to manage GIB with reversal of coagulopathy (FFP)\n holding asa and coumadin. Transfuse prbc's, monitoring h/h Q 6. Keep\n NPO. PPI gtt. NGT placed (w/o BRB). Gi aware with plan to scope most\n likely in am tomorrow after stabilized from BP standpoint. Has 3 large\n bore PIVs but given intermittent hypotension and cardiac status with\n low ef, central access with cvp monitoring will be helpful to best\n optimize volume status. Hypotension most likely hypovolemia in pt\n with reduced ef. No evidence of active ischemia with 2 sets neg\n cardiac enzymes. BP has improved after fluid bolus and\n blood. Mentating well. Monitor resp status closely, follow cvp, svo2,\n lactate and urine output. Goal MAPS > 60 . ARF is likely prerenal\n and low flow state. Check urine lytes, u/a. HyperK is improving\n without acute ecg changes. Monitor serial lytes. Abd pain most likely\n related to epigastric issue with UGIB but with emesis also concern for\n possible biliary issue. Check LFTs and a/l. ICU: SSI, NPO, boots, 3\n PIV, place central line, a-line. Remainder of plan as outlined in\n resident note.\n Patient is critically ill\n Total time: 60 min\n Addendum:\n LFTs reveal a sig transaminitis 1600/2600 with elevated alk phos 432\n and t bili 2.1 ldh 1694\n Most concerning for shock liver given hypotension vs congestion\n (?r heart failure--less likely based on physical exam) or underlying\n hepatic injury. No evidence of rhabdo -ck NL. LFTs wnl a few days\n prior.\n Will trend, fractionate bili and send hemolysis labs given\n elevated ldh. Check ruq ultrasound.\n Additional 15 minutes crit care time in discussion/review.\n Addendum:\n L IJ placed under sterile conditions. Time out and pre-procedure\n verification performed. Consent obtained. I was present throuhgout the\n procedure. Pt tolerated well without immediate complications. CXR\n ordered and pending.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 579989,
"text": "Chief Complaint: GIB\n HPI:\n 88-year-old man, with diabetes, CAD, status post MI over a decade ago,\n hypertension, hyperlipidemia, peripheral vascular disease p/w abdominal\n tightness. It started around 730 pm when the pt was sitting watching\n TV. It resolved by itself within 5 mins. However it reappeared when the\n pt was in the ER and this time lasted abt 10 minutes. No\n SOB/dizzy/palps.\n .\n In the emergency department, initial vitals:98.2 66 132/80 18 100/ra.\n In the ED he recd ASA 325, SL NTG x 1, zofran x 1. Dropped SBP to 80s\n after SL NTG. Recd 2L IVF and SBP back to 110s. First set of enzymes\n was neg. CXR was WNL.\n .\n On the general medicine floor this am, he was found to have SBP\n 78/palp, felt nausea, vomited 400cc dark brown mixed w/ food.\n Gastoccult positive, guiac positive w. rectal exam of dark brown stool.\n Started PPI bolus and gtt. AM labs returned with HCT of 31.7 down from\n 33.7 after IVF, INR 3.1. GI aware. He also received 10mg po Vit K. VS\n at time of transfer BP 80-100 systolic, HR 70, afebrile, 98% on Ra.\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness,\n palpitations. Denied nausea, vomiting, diarrhea, constipation or\n abdominal pain. No recent change in bowel or bladder habits. No\n dysuria. Denied arthralgias or myalgias.\n Patient admitted from: \n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n At home\n EZETIMIBE [ZETIA] - 10 mg qd\n GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm\n HYDROCHLOROTHIAZIDE - 12.5 mg qd\n ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd\n METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd\n PRAVASTATIN [PRAVACHOL] - 40 mg qd\n QUINAPRIL - 40 mg qd\n WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth daily take\n one tab 4 days a week and taab on Tue, Th and Sat\n ASPIRIN - (OTC) - 81 mg qd\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other\n Provider) - Dosage uncertain\n .\n On transfer:\n Ezetimibe 10 mg PO DAILY\n Insulin SC (per Insulin Flowsheet) Sliding Scale\n Ondansetron 4 mg IV ONCE\n Pantoprazole 80 mg IV BOLUS plus 8 mg/hr IV DRIP\n Phytonadione 10 mg PO ONCE\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR\n Pravastatin 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n CAD, status post MI over a decade ago\n hypertension\n hyperlipidemia\n peripheral vascular disease with bilateral carotid endarterectomies\n BCC\n Systolic HF, EF 25-30% in 04 w/ severe AK/HK (on coumadin)\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is a retired fireman, lives in with his wife.\n Married 55 years. Grown children. No smoking. No alcohol consumption.\n Review of systems:\n Flowsheet Data as of 12:08 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: 36.2\nC (97.1\n HR: 96 (79 - 102) bpm\n BP: 105/64(78) {81/40(56) - 105/64(192)} mmHg\n RR: 22 (19 - 27) insp/min\n SpO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 12 (6 - 12)mmHg\n Total In:\n 3,311 mL\n 72 mL\n PO:\n TF:\n IVF:\n 1,328 mL\n 2 mL\n Blood products:\n 1,983 mL\n 70 mL\n Total out:\n 892 mL\n 25 mL\n Urine:\n 392 mL\n 25 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 2,419 mL\n 47 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.36/30/85./16/-6\n Physical Examination\n Vitals: T: 98.6 BP:108/57 P:87 R: 20 O2: 97% on 2L NC\n General: Alert, mentating well, does not appear acutely ill, appears\n younger than stated age\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 201 K/uL\n 10.9 g/dL\n 180 mg/dL\n 3.0 mg/dL\n 67 mg/dL\n 16 mEq/L\n 109 mEq/L\n 5.3 mEq/L\n 140 mEq/L\n 32.0 %\n 9.7 K/uL\n [image002.jpg]\n \n 2:33 A6/14/ 12:50 PM\n \n 10:20 P6/14/ 03:44 PM\n \n 1:20 P6/14/ 04:53 PM\n \n 11:50 P6/14/ 07:03 PM\n \n 1:20 A6/14/ 09:24 PM\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 8.9\n 11.4\n 9.7\n Hct\n 27.2\n 27.4\n 30.0\n 32.0\n Plt\n 230\n 226\n 201\n Cr\n 2.9\n 3.0\n TropT\n 0.01\n TC02\n 18\n Glucose\n 157\n 180\n Other labs: PT / PTT / INR:25.8/25.1/2.5, CK / CKMB /\n Troponin-T:73//0.01, ALT / AST:1468/2106, Alk Phos / T Bili:464/4.2,\n Amylase / Lipase:127/23, Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL,\n LDH:1413 IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR without acute change\n ECG: EKG: SR, LBBB (old) LAD, first degree AV block\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n therapeutic INR, ddx includes PUD, ASA-induced gastritis, malignancy.\n - EGD to evaluate for active bleeding, will need reversal of\n anticoagulation prior to INR < 2.0, give 2 u FFP and repeat INR\n - has received 2 u pRBC now for decreased Hct, check Hct q6hr\n - continue PPI gtt\n - f/u GI recs\n - access = 3 PIV\n - hold ASA, coumadin\n .\n # Hypotension- Patient with poor CO (EF 25%) and clinically volume\n depleted. Increasing anion gap (12 -> 16) with lactate 2.2 further\n supports hypo-perfusion. Has received 2 L in ED and 1 L on floor, 2 u\n pRBC and 3 u FFP.\n - Gentle fluids given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - place a-line\n - continue monitoring on tele\n .\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.1 with K 5.7, no EKG changes. Likely pre-renal given patient's\n fluid depleted clinical status\n - gentle IVF given EF\n - check UA and urine lytes\n - will hold on kayexelate pending procedure\n - recheck lytes in pm\n .\n # Transaminitis/Abdominal pain- Possibly due to irritation caused by\n blood in abdomen, however components of history sound like biliary\n colic (transient pain in a band-like distribution, improved with\n belching and resolved within hours on arrival to ED). Does not sound\n like anginal equivalent, first two sets CE negative. LFT's with\n markedly elevated AST and ALT, hyperbilirubinemia (primarily\n conjugated) suggesting obstructive picture.\n - trend LFT's, amylase, lipase\n - RUQ u/s\n - continue ROMI\n .\n # Heart Failure- most recent EF 25% with severe hypokinesis. Has been\n anticoagulated to prevent intra-ventricular thrombus formation.\n Currently appears volume depleted, goal is to keep patient euvolemic.\n - volume repletion to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n .\n #DM\n - hold glyburide while inpatient\n - RISS\n .\n # HTN\n - hold HCTZ, beta-blocker and ACE inhibitor in setting of GI bleed\n .\n # Nutrition: NPO for procedure\n .\n # Prophylaxis: pneumoboots, IV PPI\n .\n # Access: 3 PIVs\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\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": "Nursing",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580399,
"text": "Hypoxemia\n Assessment:\n Increased oxygenation needs during days on ; received on NRB 10L;\n CXR-LLL infiltrate-begun on unasyn\n Action:\n Pt c/o\ndry throat,\n changed to 100% high flow neb, enc C+DB\n Response:\n Maintaining o2 sats in low to mid 90\ns on high flow neb; desaturates to\n mid-high 80\ns on RA;\n Plan:\n Titrate oxygen to maintain o2 sats in mid 90\ns or greater. Unasyn.\n Monitor via CXR.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB. CK 700s, last troponin 1.8\n Action:\n Closely monitor. Tnd enzymes. Cardiac consult today, agrees with\n current poc, would consider swan-ganz catheter if pt becoming HD\n unstable. Daily EKG\n Response:\n Pt denies any SOB/CP /tightness, EKG unchanged.\n Plan:\n Cont to closely monitor. Await labs.lBedrest. Pneumo boots.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO low, 10-20cc/hr. BUN/Cr this AM 90/3.6. Rec\nd 1.25L NS o/n for\n oliguria with little to no effect. Also tried dopamine gtt o/n to\n increase UO, pt becoming extremely tachycardic 130s-140s-dc\nd dopamine\n gtt.\n Action:\n Placed patient on levophed gtt in hopes that SBP > 110 would improve\n UO. Renal consulted.\n Response:\n SBP on levophed ranging 120s-130s, UO remains low 20cc/hr. MD aware.\n Last BUN/Cr 108/3.8.\n Plan:\n f/u renal recs. Cont. levophed gtt, follow UO.\n Altered mental status (not Delirium)\n Assessment:\n +UTI, +LLL infiltrate, +MI, patient in ICU, elderly\nincreased confusion\n and extreme restlessness reported o/n; Pt more appropriate this shift,\n orientated to person, place, president.\n Action:\n CLOSELY monitored throughout the shift; spirits good. Pt joking with\n staff.\n Response:\n Pt calm and cooperative, MS seeming to have improved fm yesterday.\n Plan:\n Closely monitor pt. Bed alarm. Reorientate prn\n Liver function abnormalities\n Assessment:\n LFT elevated, Tbili this AM 11. Pt jaundiced.\n Action:\n Doppled liver u/s at bedside today. Tnding labs.\n Response:\n Liver enzymes remain elevated, liver following. Tbili this PM 16, MD\n aware.\n Plan:\n MRCP ordered, will hold off for now given patients impaired renal\n function. Cont. to tnd. Labs. F/u liver recs. require ERCP once\n patient is more HD stable.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580403,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Since arrival to MICU patients course has been c/b UGIB requiring 2\n units PRBCs, Rec\nd mult. Units of FFP, and mult. Doses of PO and IV\n vitamin K for persistently high INR. Pt hypotensive with MODs\n including ARF, r/I for MI with troponin 1.8, and shock liver.\n Currently on levophed gtt and requiring 100& high flow oxygen.\n Hypoxemia\n Assessment:\n Increased oxygenation needs during days on ; received on NRB 10L;\n CXR-LLL infiltrate-begun on unasyn\n Action:\n Pt c/o\ndry throat,\n changed to 100% high flow neb, enc C+DB\n Response:\n Maintaining o2 sats in low to mid 90\ns on high flow neb; desaturates to\n mid-high 80\ns on RA;\n Plan:\n Titrate oxygen to maintain o2 sats in mid 90\ns or greater. Unasyn.\n Monitor via CXR.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n R/I MI - pt voiced no complaints. Unable to start heparin gtt d/t\n hx recent GIB. CK 700s, last troponin 1.8\n Action:\n Closely monitor. Tnd enzymes. Cardiac consult today, agrees with\n current poc, would consider swan-ganz catheter if pt becoming HD\n unstable. Daily EKG\n Response:\n Pt denies any SOB/CP /tightness, EKG unchanged.\n Plan:\n Cont to closely monitor. Await labs.lBedrest. Pneumo boots.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UO low, 10-20cc/hr. BUN/Cr this AM 90/3.6. Rec\nd 1.25L NS o/n for\n oliguria with little to no effect. Also tried dopamine gtt o/n to\n increase UO, pt becoming extremely tachycardic 130s-140s-dc\nd dopamine\n gtt.\n Action:\n Placed patient on levophed gtt in hopes that SBP > 110 would improve\n UO. Renal consulted.\n Response:\n SBP on levophed ranging 120s-130s, UO remains low 20cc/hr. MD aware.\n Last BUN/Cr 108/3.8.\n Plan:\n f/u renal recs. Cont. levophed gtt, follow UO.\n Altered mental status (not Delirium)\n Assessment:\n +UTI, +LLL infiltrate, +MI, patient in ICU, elderly\nincreased confusion\n and extreme restlessness reported o/n; Pt more appropriate this shift,\n orientated to person, place, president.\n Action:\n CLOSELY monitored throughout the shift; spirits good. Pt joking with\n staff.\n Response:\n Pt calm and cooperative, MS seeming to have improved fm yesterday.\n Plan:\n Closely monitor pt. Bed alarm. Reorientate prn\n Liver function abnormalities\n Assessment:\n LFT elevated, Tbili this AM 11. Pt jaundiced. INR 5.3 this AM\n Action:\n Doppled liver u/s at bedside today. Tnding labs. Rec\nd 2 units FFP\n for INR 5.3, rec\nd 5mg iv vitamin K o/n.\n Response:\n Liver enzymes remain elevated, liver following. Tbili this PM 16, MD\n aware. INR 4.2\n Plan:\n MRCP ordered, will hold off for now given patients impaired renal\n function. Cont. to tnd. Labs. F/u liver recs. require ERCP once\n patient is more HD stable.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580301,
"text": "TITLE:\n Chief Complaint: GI bleed\n 24 Hour Events:\n - Received Vit K 5mg po and 2 units FFP given elevated INR in setting\n of GIB.\n - Decreased O2 sats -> CXR with retrocardiac opacity concerning for\n PNA. Cipro changed to Augmentin to cover possible aspiration.\n - Repeat Hct stable: 36 -> 33.9 -> 35.7 -> 35.5\n - CK and trop still rising. TTE suboptimal; EF still 25% c/w\n multivessel CAD, 2+ MR PA systolic HTN increased since .\n - Liver: Rising LFTs likely shock liver. HIDA not indicated,\n consider MRCP.\n - INR increased to 5.3, given 5 mg vitamin K and 2 u FFP\n - Given 500cc for MAP <50s with only transient improvement. Started on\n dopamine gtt given EF 25% but stopped for tachy to 150s. A-line faulty\n but as SBP 80s with UOP about 20 cc/hr, CvO2 67, lactate 2.1 (CVP 12)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 106 (81 - 116) bpm\n BP: 64/36(47) {54/29(39) - 134/73(96)} mmHg\n RR: 28 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 14 (12 - 16)mmHg\n Total In:\n 3,227 mL\n 799 mL\n PO:\n TF:\n IVF:\n 2,531 mL\n 799 mL\n Blood products:\n 666 mL\n Total out:\n 738 mL\n 62 mL\n Urine:\n 738 mL\n 62 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 737 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: 7.32/31/95./17/-8\n PaO2 / FiO2: 137\n Physical Examination\n GEN: Sitting up in bed in NAD\n HEENT: NC/AT anicteric sclera\n LUNGS:\n HEART:\n ABD:\n EXTREM:\n NEURO:\n Labs / Radiology\n 190 K/uL\n 12.2 g/dL\n 190 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 4.8 mEq/L\n 90 mg/dL\n 110 mEq/L\n 142 mEq/L\n 36.3 %\n 13.3 K/uL\n [image002.jpg]\n 05:10 AM\n 05:15 AM\n 11:22 AM\n 12:54 PM\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n WBC\n 9.2\n 11.2\n 13.3\n Hct\n 36.0\n 33.9\n 35.7\n 35.5\n 36.3\n Plt\n \n Cr\n 3.1\n 3.0\n 3.6\n TropT\n 1.20\n 1.87\n TCO2\n 15\n 15\n 17\n 15\n 17\n Glucose\n 195\n 155\n 190\n Other labs: PT / PTT / INR:48.7/32.1/5.3, CK / CKMB /\n Troponin-T:705/39/1.87, ALT / AST:2415/3598, Alk Phos / T\n Bili:610/11.0, Amylase / Lipase:143/12, Lactic Acid:2.1 mmol/L,\n Albumin:3.5 g/dL, LDH:1337 IU/L, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n therapeutic INR, ddx includes PUD, ASA-induced gastritis, malignancy.\n - defer EGD for now given cardiac ischemia, hypotension, coagulopathy\n - Hct stable since yesterday, continue q6hr checks\n - continue PPI gtt\n - f/u GI recs\n - access 2 PIV, a-line, central line\n - hold ASA, coumadin\n .\n # Demand Ischemia/Heart Failure- CPK continues to rise. TTE yesterday\n reveals stable EF 25% with severe hypokinesis. Current volume status\n appears slightly intravascularly depleted (MAP 73, UOP low but also new\n ARF).\n - trend CK, CPK\n - volume repletion to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n .\n # Increasing 02 requirement- New retrocardiac opacity suggests PNA.\n CXR does not suggest fluid overload/pulmonary edema\n - started on augmentin for possible aspiration\n - f/u am CXR for signs of pulmonary edema\n .\n # Hypotension- Patient clinically somewhat volume depleted with with\n poor but stable CO (EF 25%). Has received 500 cc fluid bolus with\n lactate persisting at in low 2\n - Gentle fluids given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - continue monitoring on tele\n .\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.1 with K 5.7, no EKG changes. Likely pre-renal given patient's\n fluid depleted clinical status\n - gentle IVF given EF\n - check UA and urine lytes\n - will hold on kayexelate pending procedure\n - recheck lytes in pm\n .\n # Transaminitis- Likely shock liver, however biliary process still\n possible. RUQ u/s equivocal for cholecystitis.\n - consider MRCP today, however Cre continues to rise\n - trend LFT's, amylase, lipase\n .\n #DM\n - hold glyburide while inpatient\n - RISS\n .\n # HTN\n - hold HCTZ, beta-blocker and ACE inhibitor in setting of GI bleed\n .\n # Access: 2 PIV\ns, a-line, central line\n .\n # Code: full\n .\n # Communication: Patient , patient\ns wife\n .\n # Disposition: pending above\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580307,
"text": "TITLE:\n Chief Complaint: GI bleed\n 24 Hour Events:\n - Received Vit K 5mg po and 2 units FFP given elevated INR in setting\n of GIB.\n - Decreased O2 sats -> CXR with retrocardiac opacity concerning for\n PNA. Cipro changed to Augmentin to cover possible aspiration.\n - Repeat Hct stable: 36 -> 33.9 -> 35.7 -> 35.5\n - CK and trop still rising. TTE suboptimal; EF still 25% c/w\n multivessel CAD, 2+ MR PA systolic HTN increased since .\n - Liver: Rising LFTs likely shock liver. HIDA not indicated,\n consider MRCP.\n - INR increased to 5.3, given 5 mg vitamin K and 2 u FFP\n - Given 500cc for MAP <50s with only transient improvement. Started on\n dopamine gtt given EF 25% but stopped for tachy to 150s. A-line faulty\n but as SBP 80s with UOP about 20 cc/hr, CvO2 67, lactate 2.1 (CVP 12)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.2\nC (97.2\n HR: 106 (81 - 116) bpm\n BP: 64/36(47) {54/29(39) - 134/73(96)} mmHg\n RR: 28 (20 - 32) insp/min\n SpO2: 93%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 14 (12 - 16)mmHg\n Total In:\n 3,227 mL\n 799 mL\n PO:\n TF:\n IVF:\n 2,531 mL\n 799 mL\n Blood products:\n 666 mL\n Total out:\n 738 mL\n 62 mL\n Urine:\n 738 mL\n 62 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,489 mL\n 737 mL\n Respiratory support\n O2 Delivery Device: Non-rebreather\n SpO2: 93%\n ABG: 7.32/31/95./17/-8\n PaO2 / FiO2: 137\n Physical Examination\n General: Alert, mentating well, appears younger than stated age, face\n mask on\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 190 K/uL\n 12.2 g/dL\n 190 mg/dL\n 3.6 mg/dL\n 17 mEq/L\n 4.8 mEq/L\n 90 mg/dL\n 110 mEq/L\n 142 mEq/L\n 36.3 %\n 13.3 K/uL\n [image002.jpg]\n 05:10 AM\n 05:15 AM\n 11:22 AM\n 12:54 PM\n 02:23 PM\n 04:52 PM\n 06:17 PM\n 10:23 PM\n 10:29 PM\n 01:26 AM\n WBC\n 9.2\n 11.2\n 13.3\n Hct\n 36.0\n 33.9\n 35.7\n 35.5\n 36.3\n Plt\n \n Cr\n 3.1\n 3.0\n 3.6\n TropT\n 1.20\n 1.87\n TCO2\n 15\n 15\n 17\n 15\n 17\n Glucose\n 195\n 155\n 190\n Other labs: PT / PTT / INR:48.7/32.1/5.3, CK / CKMB /\n Troponin-T:705/39/1.87, ALT / AST:2415/3598, Alk Phos / T\n Bili:610/11.0, Amylase / Lipase:143/12, Lactic Acid:2.1 mmol/L,\n Albumin:3.5 g/dL, LDH:1337 IU/L, Ca++:7.4 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.9 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n supra-therapeutic INR, ddx includes PUD, ASA-induced gastritis,\n malignancy.\n - defer EGD for now given cardiac ischemia, hypotension, coagulopathy\n - Hct stable since yesterday, increase to checks\n - continue PPI gtt for 72 hours\n - f/u GI recs\n - access 2 PIV, a-line, central line\n - hold ASA, coumadin\n - Hepatic injury may be contributing to coagulopathy. Consider vitamin\n K IV as long as HD stable.\n - Did receive FFP this am for coagulopathy and in setting of poor UOP\n for volume resusitation\n # Hypotension- Patient\ns exam difficult to interpret and unclear volume\n status but LOS balance positive 6L with poor but stable CO (EF 25%).\n FFP this am for coagulopathy as method of volume repletion but will\n favor holding further IVF because of CHF.\n - Did not tolerate dopamine. Consider levophed and hold further IVF\n given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - continue monitoring on tele\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.6. Urine lytes c/w pre-renal azotemia likely from hypotension.\n - augment forward flow with levophed trial and FFP today as above\n - gentle IVF given EF\n - recheck lytes in pm\n # Demand Ischemia/Heart Failure- CPK continues to rise. TTE yesterday\n reveals stable EF 25%. Current volume status appeared slightly\n intravascularly depleted (MAP 73, UOP low but also new ARF) awaiting\n FFP. Dopa trial did not change UOP.\n - trend CK, CPK\n - volume repletion and levophed trial as above to goal MAP >60, UOP >30\n cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n # Transaminitis- Likely shock liver, however biliary process still\n possible. RUQ u/s equivocal for cholecystitis but exam not consistent\n with acute cholecystitis.\n - Cannot tolerate MRCP given ARF\n - trend LFT's, amylase, lipase\n #DM\n - hold glyburide while inpatient\n - RISS\n # Access: 2 PIV\ns, a-line, central line\n # Code: full\n # Communication: Patient , patient\ns wife\n # Disposition: pending above\n ICU Care\n Nutrition: NPO\n Glycemic Control: ISS\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI gtt\n Communication: Comments: Wife and patient\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580023,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley catheter placed and exchanged soon after for leakage onto\n bed pad; BUN 63/Cr 2.9\n Action:\n Bolused with 2.5L of NS for hypotension/oliguria; urinalysis and urine\n cx sent; 2300labs drawn; catheter flushed to check patency\n Response:\n Minimal response with IVf boluses, u/o remains poor; urine cx pnd,\n urinalysis showing UTI; BUN/Cr continue to rise; catheter flushed with\n ease, clear return. Urine is amber, cloudy with sediment\n Plan:\n Monitor u/o. Consider pressors to improve u/o. Await am labs and urine\n cx data.\n Hypotension (not Shock)\n Assessment:\n Received pt with SBP 80/50-60\n Action:\n Bolused with 2.5L NS and 2 units PRBC for hypotension and mild\n tachycardia; CVP monitored; accuracy of aline checked against NIBp with\n right arm and right thigh\n Response:\n SBP increased to 110-120\ns/60\ns by early am; HR 80\ns, LBB, 1\nheart\n block; CVp increased from 6 to . Aline coinciding with NIBP\n Plan:\n Hypotension resolved presently. Cont to monitor via aline\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Received NGt to LIWS; previously had vomited large amts of coffee\n ground emesis\n Action:\n NGT to LIWS; monitored for s/s bleeding; serial hcts;\n Response:\n NGT drng clear with mild coffee ground specks\nclamped 0300hrs; no stool\n this shift; Hct stable with 5 point rise with 4 units PRBC\n Plan:\n Await am labs. Cont to monitor s/s bleeding ; GAS\n Liver function abnormalities\n Assessment:\n Elevated LFts noted\n Action:\n Repeat LFt drawn; US of abdomen\n Response:\n Tbili/Bili, amylase elevated. LFt\ns remain high. RUQ with some\n tenderness with deep palpation. US shows gallstones with\n thickening-suggesting HIDA scan\n Plan:\n Will prob obtain HIDA scan this am. Cont to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 579968,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Dispo: FULL code\n Allergies: NKDA\n Access: 3piv, RtRad/Aline\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with vomiting and 500cc CG emesis on floor, Rec\n protonix bolus on\n floor. Rec\nd pt with SBP 108/50. INR 3.1, Hct 30. Pt A&Ox3,\n pleasant.\n Action:\n Pt rec\nd a total of 3 units FFP, and 1 unit PRBCs this shift. Started\n on protonix gtt. Prepping pt for endoscopy, but emesis x1 with\n hurricaine spray administration- ~ 300cc CG emesis with subsequent\n hypotension, with SBP as low as 78. Given 3^rd unit FFP after this\n episode with good effect, A-line placed. EKG obtain during hypotensive\n episode, some ST depression noted, but otherwise unchanged. Troponin\n 0.01/ CK 73. NGT placed to LIS.\n Response:\n ABP ranging 90s-110s/50s-60s. Currently infusing 2^nd unit PRBCs for\n hct 27, repeat Hct prior to this unit sent. NGT with sm.-mod. Amounts\n of CG output drainage.\n Plan:\n Plan is to scope once HD stable. Cont. protonix gtt. Cont. NGT to\n LIS\n Hypotension (not Shock)\n Assessment:\n NBP ranging 78-110/39-55, ABP ranging 89-94/47-50, HR 90-110s SR/ST\n with no ectopy noted.\n Action:\n Rec\nd 3 units FFP, 2 unit PRBCs for bleed.\n Response:\n Labile BPs\n Plan:\n Serial Hcts, transfuse PRN, plan for endoscopy.\n Liver function abnormalities\n Assessment:\n AST 2624, ALT 1637, LDH 1694, Tbili 2.1\n Action:\n Repeat liver enzymes sent, liver/gallbladder U/S ordered\n Response:\n pnding\n Plan:\n Plan for abd. u/s tonight.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 64/3.1 on transfer to MICU. Rec\nd 1L NS bolus on floor for\n hypotension, likely r/t hypotension. On arrival, pt had noted voided\n since 0300. K 5.7\n Action:\n Foley catheter placed with 180cc uo returned immediately, UO currently\n very low\n only 10-15cc/hr, MD aware. Repeat lytes sent, K 5.5 with\n out correction. EKG unchanged.\n Response:\n Given mult. Blood products to correct bleeding, still with very little\n UO. K remains elevated 5.5, will not treat with kayexlate GIB and\n no EKG changes. Last Bun/Cr 63/2.9\n Plan:\n Cont. to monitor UO, currently placing , trend CVP, PRN fluid\n boluses if low. Pt with EF 25-30%. Cont. to trend labs.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580594,
"text": "Hypoxemia\n Assessment:\n Received on high flow neb 100%. O2 sats 94-96%. LS-clear w/ diminished\n bases.\n Action:\n O2 changed to NC@ 5L.\n Response:\n O2 sats remained 94-95% on NC. WBC 14.8(14).\n Plan:\n Wean o2 as tolerated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt R/I MI , Unable to start heparin gtt d/t hx recent GIB. No C/O\n chest pain or chest discomfort. BP 119-135/51-70. MAP 72-94. Continues\n on Neo at 0.5mics/kg/hr. On 5L NC sats 94-96%.\n Action:\n Neo titrated for MAP 70. Given 2gm calcium IV this morning..INR 4.2,\n given 2 units of FFP. Recycled Cardiac cycle. Pt cont go in and out to\n Afib, Asymptamatic, HR 70-145 cardiology following, EKG done while he\n was going to Afib. Given 0.25 mg Dig at 1700 .\n Response:\n INR down to 2.2 from 4.2.Denied chest pain/resp difficulty. INR\n 4.9(4.2). Ica 1.04, given 4gm calcium IV. CPK 409(705). ~0500,\n converted into a-fib w/ rate to 130\ns. EKG done, Levophed stopped and\n neosynephrine started. Converted back into SR.\n Plan:\n Vitals monitored. Pneumo boots on. Wean Neo as tolerated. Monitor\n lytes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP continues to be low, ~20cc/hr.\n Action:\n UOP monitored. Liver enzymes monitored.\n Response:\n No change in UOP. BUN 114(108). Creat 4.2(3.8).\n Plan:\n Monitor UOP.\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Pulled out NGT. Restless during the\n night. Pulling at IVs/tubes. Complained of feeling nervous.\n Action:\n Emotional support provided. Reoriented frequently. Bed alarm on.\n Response:\n No change in mental status.\n Plan:\n Monitor mental status. Reorient frequently.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580596,
"text": "Hypoxemia\n Assessment:\n Received on %L NC sata 94-96%. LS-clear w/ diminished bases.\n Action:\n Oxygen down to 3L\n Response:\n O2 sats remained 94-95% on NC. WBC 14.8(14).\n Plan:\n Wean o2 as tolerated.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Pt R/I MI , Unable to start heparin gtt d/t hx recent GIB. No C/O\n chest pain or chest discomfort. BP 119-135/51-70. MAP 72-94. Continues\n on Neo at 0.5mics/kg/hr. On 5L NC sats 94-96%.\n Action:\n Neo titrated for MAP 70. Given 2gm calcium IV this morning..INR 4.2,\n given 2 units of FFP. Recycled Cardiac cycle. Pt cont go in and out to\n Afib, Asymptamatic, HR 70-145 back to SR. cardiology following, EKG\n done while he was going to Afib. Given 0.25 mg Dig at 1700.\n Response:\n INR down to 2.2 from 4.2.Denied chest pain/resp difficulty.\n Plan:\n Closely monitor HR,Cont rest of the Digoxin Pneumo boots on. Wean Neo\n as tolerated. Monitor lytes.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n .UOP continues to be low, ~20cc/hr.\n Action:\n UOP monitored. Liver enzymes monitored.\n Response:\n No change in UOP. BUN 114(108). Creat 4.2(3.8).\n Plan:\n Monitor UOP.\n Altered mental status (not Delirium)\n Assessment:\n Alert, ox2-3. Confused at times. Pulled out NGT. Restless during the\n night. Pulling at IVs/tubes. Complained of feeling nervous.\n Action:\n Emotional support provided. Reoriented frequently. Bed alarm on.\n Response:\n No change in mental status.\n Plan:\n Monitor mental status. Reorient frequently.\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580720,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Got FFP with repeat INR 2.5, down from 5\n - Cards: Start dig 0.25 X 1 dose then 0.125 X 2 doses then check dig\n level\n - HR transiently into 150s with decreased BPs. Increased neo. Gave 5mg\n lopressor after neo increased with better rate control (although still\n occasional bursts of tachycardia), pressors off this morning\n - Increased O2 requirement (desat from 95% -> 89% on 3L) with ABG\n revealing metabolic acidosis, CXR with mild fluid overload, oxygen\n delivery increased (30% facemask + NC) o/n, now back down to 5L NC\n - more confused o/n\n - Pulled NGT, advanced diet to clears\n - PPI changed to IV BID\n - Liver: Start ursodiol\n - Renal: start bicarb\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36\nC (96.8\n HR: 104 (75 - 124) bpm\n BP: 123/69(87) {92/51(66) - 138/74(95)} mmHg\n RR: 25 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 14 (11 - 26)mmHg\n CO/CI (Fick): (5.2 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 2,446 mL\n 576 mL\n PO:\n 720 mL\n 480 mL\n TF:\n IVF:\n 1,212 mL\n 96 mL\n Blood products:\n 514 mL\n Total out:\n 720 mL\n 135 mL\n Urine:\n 720 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,726 mL\n 441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 5L\n SpO2: 94%\n ABG: 7.37/25/78./15/-8\n Physical Examination\n Gen: Awake elderly gentleman in NAD\n HEENT: sclera icteric, dry MM\n CV: RRR, no murmurs\n Lungs: bronchial breathsounds without crackles\n Abd: Soft, NT, ND, + bowel sounds, no RUQ tenderness\n Ext: Warm, well-perfused, no edema\n Neuro: A+Ox3, responds appropriately to questions\n Labs / Radiology\n 246 K/uL\n 12.3 g/dL\n 135 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.4 mEq/L\n 128 mg/dL\n 111 mEq/L\n 143 mEq/L\n 35.2 %\n 13.3 K/uL\n [image002.jpg]\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n Hct\n 35.5\n 36.3\n 35.3\n 36.1\n 35.2\n Plt\n 190\n 226\n 238\n 246\n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n TCO2\n 17\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n Other labs: PT / PTT / INR:29.4/30.6/2.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:1291/768, Alk Phos / T Bili:525/18.7,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n BNP - >\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Appears to be improving with CvO2 high 60\ns-low 70\n Cardiogenic v. hypovolemic v. distributive, with hypovolemic most\n likely. Was started on levophed intially but developed afib, switched\n to neo; afib terminated on its own without need to rate control.\n Pressors off since this morning. ABG early this morning with gap\n metabolic acidosis further supports hypoperfused state.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to maintain pressors off; goal MAP>60 and UOP >30 cc/hr\n - If requires pressors, would choose neo\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo. Continues to have runs of afib. Lopressor x1 yesterday\n did not persistently slow rate. Cardiology recommended digoxin\n loading.\n - Continue dig loading with renal dosing\n - Appreciate cards following\n - Monitor ECG, tele\n # Demand Ischemia/Heart Failure: CPK trending down. BNP increased from\n 40K -> 70K. TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol for possible biliary process.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR. Hepatic injury may be contributing to\n coagulopathy with INR persistently high, now improved with 2 u FFP.\n PPI changed to . Tolerated a diet.\n - Hct stable since yesterday, decrease to daily checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Access 2 PIV, a-line, central line\n - Consider DDAVP if further bleed for uremic plt per Renal\n - F/u GI recs\n - no anticoagulation\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cre appears to have\n stabilized. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cre\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: Clears\n Glycemic Control:\n Lines:\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer:PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 580723,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Got FFP with repeat INR 2.5, down from 5\n - Cards: Start dig 0.25 X 1 dose then 0.125 X 2 doses then check dig\n level\n - HR transiently into 150s with decreased BPs. Increased neo. Gave 5mg\n lopressor after neo increased with better rate control (although still\n occasional bursts of tachycardia), pressors off this morning\n - Increased O2 requirement (desat from 95% -> 89% on 3L) with ABG\n revealing metabolic acidosis, CXR with mild fluid overload, oxygen\n delivery increased (30% facemask + NC) o/n, now back down to 5L NC\n - more confused o/n\n - Pulled NGT, advanced diet to clears\n - PPI changed to IV BID\n - Liver: Start ursodiol\n - Renal: start bicarb\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 06:43 AM\n Ampicillin/Sulbactam (Unasyn) - 04:07 PM\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Infusions:\n Other ICU medications:\n Insulin - Humalog - 10:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 36\nC (96.8\n HR: 104 (75 - 124) bpm\n BP: 123/69(87) {92/51(66) - 138/74(95)} mmHg\n RR: 25 (17 - 34) insp/min\n SpO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 70 Inch\n CVP: 14 (11 - 26)mmHg\n CO/CI (Fick): (5.2 L/min) / (2.7 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 2,446 mL\n 576 mL\n PO:\n 720 mL\n 480 mL\n TF:\n IVF:\n 1,212 mL\n 96 mL\n Blood products:\n 514 mL\n Total out:\n 720 mL\n 135 mL\n Urine:\n 720 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,726 mL\n 441 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 5L\n SpO2: 94%\n ABG: 7.37/25/78./15/-8\n Physical Examination\n Gen: Awake elderly gentleman in NAD\n HEENT: sclera icteric, dry MM\n CV: RRR, no murmurs\n Lungs: bronchial breathsounds without crackles\n Abd: Soft, NT, ND, + bowel sounds, no RUQ tenderness\n Ext: Warm, well-perfused, no edema\n Neuro: A+Ox3, responds appropriately to questions\n Labs / Radiology\n 246 K/uL\n 12.3 g/dL\n 135 mg/dL\n 4.2 mg/dL\n 15 mEq/L\n 4.4 mEq/L\n 128 mg/dL\n 111 mEq/L\n 143 mEq/L\n 35.2 %\n 13.3 K/uL\n [image002.jpg]\n 10:23 PM\n 10:29 PM\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n Hct\n 35.5\n 36.3\n 35.3\n 36.1\n 35.2\n Plt\n 190\n 226\n 238\n 246\n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n TCO2\n 17\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n Other labs: PT / PTT / INR:29.4/30.6/2.9, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:1291/768, Alk Phos / T Bili:525/18.7,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.5 mg/dL, Mg++:2.6 mg/dL, PO4:4.2 mg/dL\n BNP - >\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Appears to be improving with CvO2 high 60\ns-low 70\n Cardiogenic v. hypovolemic v. distributive, with hypovolemic most\n likely. Was started on levophed intially but developed afib. Pressors\n off since this morning. ABG early this morning with gap metabolic\n acidosis further supports hypoperfused state.\n - Will receive volume with FFP; allow po fluid intake but caution in\n setting of EF 25%\n - Hope to maintain pressors off; goal MAP>60 and UOP >30 cc/hr\n - If requires pressors, would choose neo\n - Follow perfusion status clinically with UOP, mentation, skin exam,\n CvO2\n - Monitor ECG, tele\n - Set 5 day course of Unasyn (to end on )\n # A-fib with RVR v. SVT with aberrancy: Likely in setting of levophed,\n changed to neo. Continues to have runs of afib. Lopressor x1 yesterday\n did not persistently slow rate. Cardiology recommended digoxin\n loading.\n - Continue dig loading with renal dosing\n - Appreciate cards following\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors.\n # Demand Ischemia/Heart Failure: CPK trending down. BNP increased from\n 40K -> 70K. TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol for possible biliary process.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Lactulose for ? encephalopathy\n # Altered mental status: unclear cause, may be delirium from\n encephalopathy, uremia, hemodynamics\n - cte to treat a-fib and ARF as indicated\n - give dose of lactulose\n - consider Haldol if QTc okay\n - minimizes lines/drains.\n # Coffee ground emesis: Likely upper GI source in setting of\n supra-therapeutic INR. Hepatic injury may be contributing to\n coagulopathy with INR persistently high, now improved with 2 u FFP.\n PPI changed to . Tolerated a diet.\n - Hct stable since yesterday, decrease to checks\n - Defer EGD for now given stable Hct in setting of cardiac ischemia,\n hypotension, coagulopathy\n - Access 2 PIV, a-line, central line\n - Consider DDAVP if further bleed for uremic plt per Renal\n - F/u GI recs\n - no anticoagulation\n - f/u INR\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr appears to have\n stabilized. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n #DM\n - Hold glyburide while inpatient\n - RISS\n ICU Care\n Nutrition: ADAT\n Glycemic Control:\n Lines:\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer:PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580125,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Dispo: FULL code\n Allergies: NKDA\n Access: 3piv, RtRad/Aline\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Rec\n pt on protonix gtt. HD stable. Hct 36 this AM, INR 3.1 this\n AM.\n Action:\n Pt rec\nd a total of 2 units FFP, and 5mg PO vitamin K. Remains on\n protonix gtt. NGT to LIS with minimal CG output. Pt with dry heaves\n this AM, no output, rec\nd zofran x1 with good effect.\n Response:\n Remains HD stable. Last Hct 33.9, INR 2.1. No further c/o n/v.\n Plan:\n Cont. protonix gtt. Cont. NGT to LIS. GI following, f/u recs.\n Hypotension (not Shock)\n Assessment:\n ABP ranging 97-130s/48-73 HR 80s-90s 1^st degree AV block with rare\n PVCs noted.\n Action:\n HD stable this shift, no additional fluid needed. Did receive 2 units\n FFP as stated above for INR\n Response:\n HD stable currently\n Plan:\n Serial Hcts, transfuse PRN\n Liver function abnormalities\n Assessment:\n Elevated liver enzymes, cont. to trend up, Tbili 6.8 (fm 6.6 this AM).\n Abd u/s fm showing thickening, sludge, and gallstones. Original\n plan was for HIDA scan this AM to assess gallbladder.\n Action:\n Pt received CCK prior to HIDA scan, but HIDA scan dc\nd with new plan\n for MRCP. Repeat liver enzymes sent, liver consulted.\n Response:\n Liver enzymes cont. to rise.\n Plan:\n Plan for MRCP once BUN/Cr improves. f/u liver recs.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 76/3.1 this AM. CVP 12-13. UO ranging 15-40cc/hr. Urine\n amber/cloudy. + UA from . K this AM 5.0.\n Action:\n UO improved from yesterday. This afternoon, UO beginning to slow\n down. Repeat lytes sent, K 4.3 with out correction. EKG x 2,\n unchanged- with LBB, 1^st degree AV block.\n Response:\n K 4.3, BUN/Cr 73/3.0.\n Plan:\n Cont. to monitor UO, trend CVP with goal , PRN fluid boluses if\n low. Pt with EF 25-30%. Cont. to trend labs.\n Hypoxemia\n Assessment:\n Pt desating this AM to 88% on 2L nc.\n Action:\n Placed on 6L nc with stas 90%, then changed to 70% face tent. Pt\n tolerating 70% face tent well t/o the day, but felt uncomfortable then\n switched back to 6L nc sating 91-95%. No report of SOB/increased WOB\n noted. RR 20-30s. Around 1300, pt becoming confused, pulling at\n lines/tubes. ABG revealed 7.33/28/69. Pt was then placed on a NRB\n with sats 96-98%. CXR obtained.\n Response:\n Repeat ABG on NRB 7.34/30/156. CXR showing new left lower infiltrate\n Plan:\n Plan to cover for possible new ?asp. pna. require lasix for ?\n fluid overload in the setting of HF. BNP pnding\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Troponin 1.2. CK 552, Ck-MB 69 this AM fm 0.01. EKG unchanged, showing\n LBB, 1^st degree AV block\n Action:\n EKG obtained, unchanged. Repeat cardiac enzymes sent. Bedside Echo\n today.\n Response:\n Repeat troponin 1.86, CK 684, CK-MB 70\n Plan:\n f/u on echo results. Tnd enzymes.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580112,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Dispo: FULL code\n Allergies: NKDA\n Access: 3piv, RtRad/Aline\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Rec\n pt on protonix gtt. HD stable. Hct 36 this AM, INR 3.1 this\n AM.\n Action:\n Pt rec\nd a total of 2 units FFP, and 5mg PO vitamin K. Remains on\n protonix gtt. NGT to LIS with minimal CG output. Pt with dry heaves\n this AM, no output, rec\nd zofran x1 with good effect.\n Response:\n Remains HD stable. Last Hct 33.9, INR 2.1. No further c/o n/v.\n Plan:\n Cont. protonix gtt. Cont. NGT to LIS. GI following, f/u recs.\n Hypotension (not Shock)\n Assessment:\n ABP ranging 97-130s/48-73 HR 80s-90s 1^st degree AV block with rare\n PVCs noted.\n Action:\n HD stable this shift, no additional fluid needed.\n Response:\n HD stable currently\n Plan:\n Serial Hcts, transfuse PRN\n Liver function abnormalities\n Assessment:\n Elevated liver enzymes, cont. to trend up, Tbili 6.8 (fm 6.6 this AM).\n Abd u/s fm showing thickening, sludge, and gallstones. Original\n plan was for HIDA scan this AM to assess gallbladder.\n Action:\n Pt received CCK prior to HIDA scan, but HIDA scan dc\nd with new plan\n for MRCP. Repeat liver enzymes sent,\n Response:\n Liver enzymes cont. to rise.\n Plan:\n Plan for MRCP once BUN/Cr improves.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 76/3.1 this AM. CVP 12-13. UO ranging 15-40cc/hr. Urine\n amber/cloudy. + UA from . K this AM 5.0.\n Action:\n UO improved from yesterday. This afternoon, UO beginning to slow\n down. Repeat lytes sent, K 4.3 with out correction. EKG x 2,\n unchanged- with LBB, 1^st degree AV block.\n Response:\n K 4.3, BUN/Cr 73/3.0.\n Plan:\n Cont. to monitor UO, trend CVP with goal , PRN fluid boluses if\n low. Pt with EF 25-30%. Cont. to trend labs.\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580116,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Dispo: FULL code\n Allergies: NKDA\n Access: 3piv, RtRad/Aline\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Rec\n pt on protonix gtt. HD stable. Hct 36 this AM, INR 3.1 this\n AM.\n Action:\n Pt rec\nd a total of 2 units FFP, and 5mg PO vitamin K. Remains on\n protonix gtt. NGT to LIS with minimal CG output. Pt with dry heaves\n this AM, no output, rec\nd zofran x1 with good effect.\n Response:\n Remains HD stable. Last Hct 33.9, INR 2.1. No further c/o n/v.\n Plan:\n Cont. protonix gtt. Cont. NGT to LIS. GI following, f/u recs.\n Hypotension (not Shock)\n Assessment:\n ABP ranging 97-130s/48-73 HR 80s-90s 1^st degree AV block with rare\n PVCs noted.\n Action:\n HD stable this shift, no additional fluid needed.\n Response:\n HD stable currently\n Plan:\n Serial Hcts, transfuse PRN\n Liver function abnormalities\n Assessment:\n Elevated liver enzymes, cont. to trend up, Tbili 6.8 (fm 6.6 this AM).\n Abd u/s fm showing thickening, sludge, and gallstones. Original\n plan was for HIDA scan this AM to assess gallbladder.\n Action:\n Pt received CCK prior to HIDA scan, but HIDA scan dc\nd with new plan\n for MRCP. Repeat liver enzymes sent,\n Response:\n Liver enzymes cont. to rise.\n Plan:\n Plan for MRCP once BUN/Cr improves.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Cr 76/3.1 this AM. CVP 12-13. UO ranging 15-40cc/hr. Urine\n amber/cloudy. + UA from . K this AM 5.0.\n Action:\n UO improved from yesterday. This afternoon, UO beginning to slow\n down. Repeat lytes sent, K 4.3 with out correction. EKG x 2,\n unchanged- with LBB, 1^st degree AV block.\n Response:\n K 4.3, BUN/Cr 73/3.0.\n Plan:\n Cont. to monitor UO, trend CVP with goal , PRN fluid boluses if\n low. Pt with EF 25-30%. Cont. to trend labs.\n Hypoxemia\n Assessment:\n Pt desating this AM to 88% on 2L nc.\n Action:\n Placed on 6L nc with stas 90%, then changed to 70% face tent. Pt\n tolerating 70% face tent well t/o the day, but felt uncomfortable then\n switched back to 6L nc sating 91-95%. No report of SOB/increased WOB\n noted. RR 20-30s. Around 1300, pt becoming confused, pulling at\n lines/tubes. ABG revealed 7.33/28/69. Pt was then placed on a NRB\n with sats 96-98%. CXR obtained.\n Response:\n Repeat ABG on NRB 7.34/30/156. CXR showing new left lower infiltrate\n Plan:\n Plan to cover for possible new ?asp. pna. require lasix for ?\n fluid overload in the setting of HF. BNP pnding\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Troponin 1.2. CK 552, Ck-MB 69 this AM fm 0.01. EKG unchanged, showing\n LBB, 1^st degree AV block\n Action:\n EKG obtained, unchanged. Repeat cardiac enzymes sent\n Response:\n Repeat troponin 1.86, CK 684, CK-MB 70\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 580944,
"text": "88M admitted for abdominal pain and hypotension, transferred to the\n unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy. Received total 2 units PRBC for\n UGIB as well as FFP and PO/IV vitamin K for elevated INR. Hypotensive\n resulting in multi-organ dysfunction (ARF, MI, shock liver). Now\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD, DM, CHF with\n EF 25%.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Baseline 37-39\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-23 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 580948,
"text": "TITLE:\n Chief Complaint: GI bleed, hypotension\n 24 Hour Events:\n - Converted to sinus with improved BP and UOP yesterday, briefly\n restarted on pressors for afib early this am\n - PICC placed; triple lumen pulled\n - Family meeting regarding code status\n - Started lactulose as no BM in setting of gastric bubble with NG tube\n out. Had large maroon colored BM this AM but Hct stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 03:32 PM\n Vancomycin - 08:00 PM\n Ampicillin/Sulbactam (Unasyn) - 04:00 PM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Insulin - Humalog - 10:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96\n HR: 91 (82 - 120) bpm\n BP: 127/60(86) {97/45(66) - 134/70(192)} mmHg\n RR: 24 (15 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 12 (11 - 24)mmHg\n Total In:\n 1,315 mL\n 72 mL\n PO:\n 1,100 mL\n TF:\n IVF:\n 215 mL\n 72 mL\n Blood products:\n Total out:\n 940 mL\n 455 mL\n Urine:\n 940 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 375 mL\n -383 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///17/\n Physical Examination\n GEN: NAD\n HEENT: Jaundice\n LUNGS: Crackles at bases\n HEART: Irregularly irregular and tachycardic\n ABD: Soft. NT/ND\n EXTREM: No edema\n NEURO: A+OX3\n Labs / Radiology\n 230 K/uL\n 12.3 g/dL\n 98 mg/dL\n 4.0 mg/dL\n 17 mEq/L\n 3.8 mEq/L\n 137 mg/dL\n 109 mEq/L\n 143 mEq/L\n 34.9 %\n 12.7 K/uL\n [image002.jpg]\n 01:26 AM\n 02:24 PM\n 04:14 PM\n 02:56 AM\n 03:12 AM\n 02:53 PM\n 03:22 AM\n 04:02 AM\n 04:30 PM\n 03:30 AM\n WBC\n 13.3\n 14.0\n 14.8\n 13.3\n 11.3\n 12.7\n Hct\n 36.3\n 35.3\n 36.1\n 35.2\n 34.6\n 34.9\n Plt\n 190\n 226\n 238\n \n Cr\n 3.6\n 3.8\n 4.2\n 4.4\n 4.2\n 4.8\n 4.0\n TCO2\n 16\n 15\n 15\n Glucose\n 190\n 147\n 155\n 158\n 135\n 98\n Other labs: PT / PTT / INR:25.4/31.5/2.4, CK / CKMB /\n Troponin-T:409/14/1.87, ALT / AST:860/407, Alk Phos / T Bili:547/19.2,\n Amylase / Lipase:143/12, Differential-Neuts:88.0 %, Band:0.0 %,\n Lymph:7.0 %, Mono:5.0 %, Eos:0.0 %, Lactic Acid:1.5 mmol/L, Albumin:3.5\n g/dL, LDH:1150 IU/L, Ca++:8.9 mg/dL, Mg++:2.6 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation complicated by hypotension, ARF, and shock liver.\n # Hypotension: Improves when in NSR but ctes to have bouts of AF with\n RVR precipitating hypotension and necessitating neo. Now with maroon\n colored stools concerning for although Hct stable. Transaminitis\n and UOP improving, suggesting improved perfusion state.\n - Rx AF as below\n - wean neo as tolerated; goal MAP >60 and UOP> 30 cc/hr\n - If requires pressors, would continue with neo\n - Follow perfusion status with UOP, LFT\ns, INR, mentation, skin exam,\n CvO2\n # A-fib with RVR v. SVT with aberrancy: Has mostly been in sinus since\n dig loading; current dig level 1.3.\n - Continue dig and follow levels\n - Appreciate cards following\n - Monitor ECG, tele\n - if his HR increases, will try lopressor and neo if he requires\n pressors, as above\n - No anticoagulation given \n - Monitor ECG, tele\n # : Admitted with coffee ground emesis but now with maroon colored\n stools suggesting lower . Hcts stable.\n - Check Hct Q6H\n - Transfuse for Hct <30\n - Cls GI re: possibility of scope\n - PPI IV BID until source found as more likely LGIB but as came in with\n coffee ground emesis could be brisk UGIB\n # Acute on Chronic CHF: BNP continues to be elevated at >70K, however\n hemodynamics improved and recent TTE showed stable EF 25%.\n - Gentle volume repletion, dig and possible neo as above to goal MAP\n >60, UOP >30 cc/hr\n - Monitor on telemetry\n - consider D/C bicarb as large salt load\n - Cte dig as above\n # Acute Renal Failure: Likely ATN due to hypotension per renal recs, no\n need for renal replacement therapy at this time. Cr 4.0 down from\n 4.8. UOP improved somewhat over last 24 hours. Started bicarb\n yesterday per renal recs but will likely not continue for long given\n large sodium load with it.\n - Liberalize po fluid intake\n - f/u renal recs\n - Monitor UOP and Cr\n # Transaminitis- Likely shock liver with transaminitis improving, Tbili\n stable. Started on ursadiol and sarna for itching.\n - F/u Liver recs\n - Trend LFTs, amylase, lipase\n - Started sarna for itching\n - Stop lactulose today give clear MS \n # AMS: Now resolved. Consider PT and OOB to chair today.\n ICU Care\n Nutrition: full liquids\n Lines:\n Arterial Line - 03:39 PM\n PICC Line - 03:00 PM\n Prophylaxis:\n DVT: pboots\n Stress ulcer: PPI IV\n Communication: patient, patient\ns family\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 88M CAD, DCM (25%) c vent AK on coumadin, B\n CEA, UGIB, . Stable HCT. Loaded on digoxin, ongoing AF c RVR,\n back on neo. PICC placed.\n Exam notable for Tm 97.1 BP 90/50 HR 100-120 RR 24 with sat 93 on 5LNC.\n Pleasant, WD man, NAD. Clear BS B. RRR s1s2. Soft +BS. No edema. Labs\n notable for WBC 13K, HCT 35, K+ 4.4, Cr 3.8, INR 2.4, TB 19.\n Suspect much of this picture (ARF, shock liver, resp distress with\n elevated BNP, borderline BP) is the downstream effect of global\n hypoperfusion at this point driven by AF c RVR. Will d/w cards re other\n options (procainamide?), continue dig to level for now. had been\n stable but he is now passing maroon stools, will check serial HCT q8h\n today, transition back to PPI. For , continue supportive\n care as above. Shock liver / LFTs improving. ARF is slightly better,\n UOP is up when in NSR; hope to avoid HD as hemodynamics are optimized.\n Respiratory distress is stable, will wean oxygen as able. Will continue\n RISS for DM2. Above d/w family and patient at bedside. Remainder of\n plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 02:05 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 579944,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Rec\n protonix bolus on floor. Rec\nd pt with SBP 108/50. INR 3.1,\n Hct 30\n Action:\n Pt rec\nd a total of 3 units FFP, and 1 unit PRBCs this shift. Prepping\n pt for endoscopy, but emesis x1 with hurricaine spray administration-\n ~ 300cc CG emesis with subsequent hypotension, with SBP as low as 78.\n Given 3^rd unit FFPafter this episode with good effect, A-line placed.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581255,
"text": "HPI: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD s/p b/l\n endarterectomies, DM, severe systolic HF with EF 25% on Coumadin, CRI\n with baseline Cr value of 2.0.\n EVENTS:.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Liver function abnormalities\n Assessment:\n Action:\n Response:\n Plan:\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 581306,
"text": "HPI: 88M admitted for abdominal pain and hypotension, transferred to\n the unit for evaluation of new UGI bleed in setting of anticoagulation\n complicated by hypotension, ARF, and shock liver. Brought to ED \n by son with abdominal tightness, HD stable, received SL nitro and ASA\n then subsequently dropped BP to 80s, rebounded to 110s with 1L IVF.\n First set cardiac enzymes negative. Admitted to CC7 where pt vomited\n ~500cc coffee ground emesis, received IVF, started on protonix gtt and\n transferred to MICU for endoscopy but scope was never done. Received\n total 2 units PRBC for UGIB as well as FFP and PO/IV vitamin K for\n elevated INR. Hypotensive resulting in multi-organ dysfunction (ARF,\n MI, shock liver). Pt unable to tol move OOB to chair on d/t\n RVR/HR up to the 120\ns and consequent drop in SBP values to the 70\n BP. Improved once pt was returned to bed. Diet advanced with good PO\n intake. Grandsons visited from out of town today. Catholic priest\n and will visit pt on . The pt remains a DNR only.\n PMH: CAD s/p MI >10 tears ago, HTN, hyperlipidemia, PVD s/p b/l\n endarterectomies, DM, severe systolic HF with EF 25% on Coumadin, CRI\n with baseline Cr value of 2.0.\n EVENTS: Pt had incident slow VT with AMS. EKG showed same rhythm as\n before at rate 100bpm - LBBB with AFib. Neuro exam non-focal with\n delirium but otherwise no neurologic deficits. Lytes with low calcium\n (1.01). gave 2gm calcium. ABG with metabolic acidosis but nl PO2.\n Likely sundowning plus same rhythm. Pt has sinced converted to NSR, HR\n 70-80. MS has returned to baseline. Pt is A + O x .\n Hypotension (not Shock)\n Assessment:\n ABP dampened, no longer draws or flushes. ABPs 95/41\n 121/62\n overnight. NBPs 90/54\n 122/55. Pt has weak pulses bilat lower\n extremities and good pulses bilat UEs. Pt is not febrile, last temp\n 95.9 .l\n Action:\n Encourage PO intake, cont to check NBPs to ABPs. KVO NS running 10\n ml/hr..\n Response:\n Pt is hemodynamically stable, HR 70-80s this AM. Neo gtt not needed at\n this time to maintain BP.\n Plan:\n Monitor. Poss remove aline today\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2102-06-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 579951,
"text": "This is an 88yo male with a history sign. for CAD s/p MI over ten years\n ago, HTN, hyperlipidemia, PVD who presented to the ED with abdomenal\n \"tightness.\" In the , pt was HD stable, with SBP 132/80. He rec'd\n SL nitro, ASA, and zofran x1. He dropped his BP to the 80s s/p nitro\n and rec'd 1L NS with SBP back up to 110. Cardiac enzymes were neg, and\n the patient was admitted to CC7. This AM, pt vomited ~ 500cc CG\n emesis, hct 30. SBP ranging 70s-80s on floor. Pt was given 1L NS\n bolus, protonix bolus and transfered for MICU for further w/u and\n endoscopy.\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Pt with vomiting and 500cc CG emesis on floor, Rec\n protonix bolus on\n floor. Rec\nd pt with SBP 108/50. INR 3.1, Hct 30. Pt A&Ox3,\n pleasant.\n Action:\n Pt rec\nd a total of 3 units FFP, and 1 unit PRBCs this shift. Started\n on protonix gtt. Prepping pt for endoscopy, but emesis x1 with\n hurricaine spray administration- ~ 300cc CG emesis with subsequent\n hypotension, with SBP as low as 78. Given 3^rd unit FFP after this\n episode with good effect, A-line placed. EKG obtain during hypotensive\n episode, some ST depression noted, but otherwise unchanged. Troponin\n 0.01/ CK 73\n Response:\n ABP ranging 90s-110s/50s-60s. Hct 27 (taken while 1^st unit PRBCs\n infusing-Dr. aware).\n Plan:\n ? transfuse hct 27, awaiting recs/orders. Cont. protonix gtt.\n Hypotension (not Shock)\n Assessment:\n NBP ranging 78-110/39-55, ABP ranging 89-94/47-50, HR 90-110s SR/ST\n with no ectopy noted.\n Action:\n Rec\nd 3 units FFP, 1 unit PRBCs.\n Response:\n Labile BPs\n Plan:\n Serial Hcts, transfuse PRN, plan for endoscopy.\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1083722,
"text": " 4:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate NGT placement\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with upper GIB, s/p NGT placement.\n REASON FOR THIS EXAMINATION:\n please evaluate NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, ON \n\n HISTORY: Upper GI bleed, status post NG tube placement.\n\n FINDINGS: There is a new NG tube with tip coiled in the stomach. There is no\n focal infiltrate or effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1083633,
"text": " 9:42 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval for acute cardio-pulm process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with DM and CAD presenting with epigastric discomfort\n REASON FOR THIS EXAMINATION:\n please eval for acute cardio-pulm process\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, , AT 2142 HOURS\n\n HISTORY: Diabetes and coronary artery disease presenting with epigastric\n discomfort.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The lungs are clear without consolidation or edema. The\n mediastinum again demonstrates atherosclerotic disease of the aorta. The\n cardiac silhouette is within normal limits for size. No effusion or\n pneumothorax is noted. The osseous structures are grossly unremarkable.\n\n IMPRESSION: No acute pulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-19 00:00:00.000",
"description": "GALLBLADDER SCAN",
"row_id": 1083779,
"text": "GALLBLADDER SCAN Clip # \n Reason: 88 YR OLD MAN WITH RISING TOTAL BILIRUBIN,EQUIVOCAL RUQ USN, EVAL FOR CHOLECYSTITIS,GALLBLADDER OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n No isotopes administered on site.\n HISTORY: 88 year old male with elevated total bilirubin.\n\n DECISION: The patient was pretreated with 1.5 mcg Sincalide prior to the study\n due to a prolonged fasting state.\n\n INTERPRETATION: The study was cancelled by the ordering team (spoke with Dr.\n ) prior to the injection of radiotracer and no images were\n obtained. After consultation with the GI service, the medicine team felt that\n an MRCP would be a better study to evaluate the patient's symptoms.\n\n\n , M.D.\n , M.D. Approved: FRI 3:08 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1083735,
"text": " 6:22 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: CVL placement\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with hypotension/bleed\n REASON FOR THIS EXAMINATION:\n CVL placement\n ______________________________________________________________________________\n WET READ: JXKc SUN 9:06 PM\n Left IJ catheter tip in mid SVC. Lung volumes are low with bibasilar\n opacities, may reflect atelectasis. No pleural effusion or pneumothorax\n identified. -jkang\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:45 P.M., \n\n HISTORY: Hypotension and bleeding. New central venous line.\n\n IMPRESSION: AP chest compared to at 4:13 p.m.:\n\n Tip of the new left jugular line projects over the mid SVC. No pneumothorax,\n pleural effusion, or mediastinal widening. Heart size normal. New\n opacification right lung base is consistent with worsening atelectasis. Left\n lung grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085157,
"text": " 6:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? pneumo\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with s/p attempted RIJ line placement\n REASON FOR THIS EXAMINATION:\n ? pneumo\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Attempted right IJ placement, to evaluate for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, there are\n substantially lower lung volumes in a patient with elevated pulmonary venous\n pressure and bibasilar atelectatic change. Specifically, there is no evidence\n of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-18 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1083726,
"text": " 4:44 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ?cirrhosis, cholecystitis\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with UGIB and transaminitis and hyperbilirubinemia.\n REASON FOR THIS EXAMINATION:\n ?cirrhosis, cholecystitis\n ______________________________________________________________________________\n WET READ: ARHb SUN 8:45 PM\n Gallbladder filled with sludge, and likely small stones. Gallbladder wall\n thickening- equivocal for cholecystitis- consider HIDA for further\n evaluation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Upper GI bleed with transaminitis and hyperbilirubinemia.\n\n COMPARISON: None.\n\n FINDINGS: The liver is diffusely echogenic without focal lesion identified.\n There is no intrahepatic biliary ductal dilatation. The common bile duct is\n difficult to visualize. The gallbladder demonstrates wall thickening with\n sludge and likely several small stones. Son sign is\n negative. The spleen appears normal. The main portal vein demonstrates normal\n hepatopetal flow.\n\n IMPRESSION:\n 1. Gallbladder filled with sludge and stones with moderate wall thickening.\n The findings are equivocal for acute cholecystitis and if there is continued\n concern, consider HIDA scan for further evaluation.\n\n 2. Echogenic liver consistent with fatty infiltration. However, other forms of\n liver disease and more advanced liver disease (ie hepatic fibrosis/cirrhosis)\n are not exlcuded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1084345,
"text": " 4:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulm edema\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with shock liver, ATN, EF 25% with worsening hypoxia\n REASON FOR THIS EXAMINATION:\n ? pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: EF 25%, worsened hypoxia.\n\n Comparison is made with prior study of .\n\n Lung volumes are lower. Cardiomediastinal silhouette is unchanged. Bilateral\n bibasal opacities greater on the left side have increased on the left probably\n due to atelectasis and or aspiration. There is no pneumothorax. The left IJ\n catheter remains in place. NG tube has been removed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1083852,
"text": " 1:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for edema\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with CHF and increasing O2 requirement\n REASON FOR THIS EXAMINATION:\n eval for edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 1:49 P.M., :\n\n HISTORY: 88-year-old man with CHF and increasing hypoxia.\n\n IMPRESSION: AP chest compared to , 6:45 p.m.:\n\n Bilateral infrahilar opacification, left greater than right, which has\n worsened since is stable since , probably atelectasis,\n conceivably aspiration. Upper lungs clear. Heart size normal. No pulmonary\n edema. No appreciable pleural effusion or pneumothorax. Left jugular line\n tip projects over the junction of the brachiocephalic veins. Nasogastric tube\n ends in the upper stomach. Heart size top normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-20 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1084033,
"text": ", F. MED MICU 1:30 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ?ductal dilation\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with transaminitis and hyperbilirubinemia\n REASON FOR THIS EXAMINATION:\n ?ductal dilation\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Mildly improved appearance of the gallbladder, containing sludge mixed\n with bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis. Echogenic liver as previously seen. Right pleural effusion.\n\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Physician Resident/Attending Admission Note - MICU",
"row_id": 580108,
"text": "Chief Complaint: GIB\n HPI:\n 88-year-old man, with diabetes, CAD, status post MI over a decade ago,\n hypertension, hyperlipidemia, peripheral vascular disease p/w abdominal\n tightness. It started around 730 pm when the pt was sitting watching\n TV. It resolved by itself within 5 mins. However it reappeared when the\n pt was in the ER and this time lasted abt 10 minutes. No\n SOB/dizzy/palps.\n .\n In the emergency department, initial vitals:98.2 66 132/80 18 100/ra.\n In the ED he recd ASA 325, SL NTG x 1, zofran x 1. Dropped SBP to 80s\n after SL NTG. Recd 2L IVF and SBP back to 110s. First set of enzymes\n was neg. CXR was WNL.\n .\n On the general medicine floor this am, he was found to have SBP\n 78/palp, felt nausea, vomited 400cc dark brown mixed w/ food.\n Gastoccult positive, guiac positive w. rectal exam of dark brown stool.\n Started PPI bolus and gtt. AM labs returned with HCT of 31.7 down from\n 33.7 after IVF, INR 3.1. GI aware. He also received 10mg po Vit K. VS\n at time of transfer BP 80-100 systolic, HR 70, afebrile, 98% on Ra.\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness,\n palpitations. Denied nausea, vomiting, diarrhea, constipation or\n abdominal pain. No recent change in bowel or bladder habits. No\n dysuria. Denied arthralgias or myalgias.\n Patient admitted from: \n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n At home\n EZETIMIBE [ZETIA] - 10 mg qd\n GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm\n HYDROCHLOROTHIAZIDE - 12.5 mg qd\n ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd\n METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd\n PRAVASTATIN [PRAVACHOL] - 40 mg qd\n QUINAPRIL - 40 mg qd\n WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth daily take\n one tab 4 days a week and taab on Tue, Th and Sat\n ASPIRIN - (OTC) - 81 mg qd\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other\n Provider) - Dosage uncertain\n .\n On transfer:\n Ezetimibe 10 mg PO DAILY\n Insulin SC (per Insulin Flowsheet) Sliding Scale\n Ondansetron 4 mg IV ONCE\n Pantoprazole 80 mg IV BOLUS plus 8 mg/hr IV DRIP\n Phytonadione 10 mg PO ONCE\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR\n Pravastatin 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n CAD, status post MI over a decade ago\n hypertension\n hyperlipidemia\n peripheral vascular disease with bilateral carotid endarterectomies\n BCC\n Systolic HF, EF 25-30% in 04 w/ severe AK/HK (on coumadin)\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is a retired fireman, lives in with his wife.\n Married 55 years. Grown children. No smoking. No alcohol consumption.\n Review of systems:\n Flowsheet Data as of 12:08 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: 36.2\nC (97.1\n HR: 96 (79 - 102) bpm\n BP: 105/64(78) {81/40(56) - 105/64(192)} mmHg\n RR: 22 (19 - 27) insp/min\n SpO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 12 (6 - 12)mmHg\n Total In:\n 3,311 mL\n 72 mL\n PO:\n TF:\n IVF:\n 1,328 mL\n 2 mL\n Blood products:\n 1,983 mL\n 70 mL\n Total out:\n 892 mL\n 25 mL\n Urine:\n 392 mL\n 25 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 2,419 mL\n 47 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.36/30/85./16/-6\n Physical Examination\n Vitals: T: 98.6 BP:108/57 P:87 R: 20 O2: 97% on 2L NC\n General: Alert, mentating well, does not appear acutely ill, appears\n younger than stated age\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 201 K/uL\n 10.9 g/dL\n 180 mg/dL\n 3.0 mg/dL\n 67 mg/dL\n 16 mEq/L\n 109 mEq/L\n 5.3 mEq/L\n 140 mEq/L\n 32.0 %\n 9.7 K/uL\n [image002.jpg]\n \n 2:33 A6/14/ 12:50 PM\n \n 10:20 P6/14/ 03:44 PM\n \n 1:20 P6/14/ 04:53 PM\n \n 11:50 P6/14/ 07:03 PM\n \n 1:20 A6/14/ 09:24 PM\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 8.9\n 11.4\n 9.7\n Hct\n 27.2\n 27.4\n 30.0\n 32.0\n Plt\n 230\n 226\n 201\n Cr\n 2.9\n 3.0\n TropT\n 0.01\n TC02\n 18\n Glucose\n 157\n 180\n Other labs: PT / PTT / INR:25.8/25.1/2.5, CK / CKMB /\n Troponin-T:73//0.01, ALT / AST:1468/2106, Alk Phos / T Bili:464/4.2,\n Amylase / Lipase:127/23, Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL,\n LDH:1413 IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR without acute change\n ECG: EKG: SR, LBBB (old) LAD, first degree AV block\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n therapeutic INR, ddx includes PUD, ASA-induced gastritis, malignancy.\n - EGD to evaluate for active bleeding, will need reversal of\n anticoagulation prior to INR < 2.0, give 2 u FFP and repeat INR\n - has received 2 u pRBC now for decreased Hct, check Hct q6hr\n - continue PPI gtt\n - f/u GI recs\n - access = 3 PIV\n - hold ASA, coumadin\n .\n # Hypotension- Patient with poor CO (EF 25%) and clinically volume\n depleted. Increasing anion gap (12 -> 16) with lactate 2.2 further\n supports hypo-perfusion. Has received 2 L in ED and 1 L on floor, 2 u\n pRBC and 3 u FFP.\n - Gentle fluids given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - place a-line\n - continue monitoring on tele\n .\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.1 with K 5.7, no EKG changes. Likely pre-renal given patient's\n fluid depleted clinical status\n - gentle IVF given EF\n - check UA and urine lytes\n - will hold on kayexelate pending procedure\n - recheck lytes in pm\n .\n # Transaminitis/Abdominal pain- Possibly due to irritation caused by\n blood in abdomen, however components of history sound like biliary\n colic (transient pain in a band-like distribution, improved with\n belching and resolved within hours on arrival to ED). Does not sound\n like anginal equivalent, first two sets CE negative. LFT's with\n markedly elevated AST and ALT, hyperbilirubinemia (primarily\n conjugated) suggesting obstructive picture.\n - trend LFT's, amylase, lipase\n - RUQ u/s\n - continue ROMI\n .\n # Heart Failure- most recent EF 25% with severe hypokinesis. Has been\n anticoagulated to prevent intra-ventricular thrombus formation.\n Currently appears volume depleted, goal is to keep patient euvolemic.\n - volume repletion to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n .\n #DM\n - hold glyburide while inpatient\n - RISS\n .\n # HTN\n - hold HCTZ, beta-blocker and ACE inhibitor in setting of GI bleed\n .\n # Nutrition: NPO for procedure\n .\n # Prophylaxis: pneumoboots, IV PPI\n .\n # Access: 3 PIVs\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\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 ------ Protected Section ------\n Overnight events:\n - received 2 more PRBC and 1 FFP\n - troponins elevate out of proportion to renal failure\n - LFTs continue to rise\n Plan:\n GI Bleed: Attempted EGD, but became Hypotensive. Hct appears stable\n and minimal NG output\n - continue PPI gtt\n - L IJ and PIVs for access\n - hold coumadin and ASA\n - received 10 of Vit K -> will give 5 mg more\n - 2 U FFP with goal INR<2 today\n - Low intermittent wall suction to monitor for continued bleeding\n Hypotension: Has received 5U PRBC and 3 U FFP with stabilization of\n BPs.\n - FFP as above\n - goal CVP >10\n - monitor resp status with SaO2 and mixed venous sat\n Elevated CE: holding anticoagulation\n - ECHO today\n - trend Biomarkers\n Transaminitis: Has both elevated transaminitis and cholestatic picture.\n - HIDA scan\n - Liver consult\n ------ Protected Section Addendum Entered By: , MD\n on: 09:33 ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 88M CAD, DCM (25%) c vent AK on coumadin, B\n CEA, UGIB, .\n Exam notable for Tm 98.6 BP 113/60 HR 80 RR 18 with sat 94 on 70%FM.\n Pleasant, WD man, NAD. Coarse BS B. RRR s1s2. Soft +BS. Trace edema.\n Labs notable for WBC 9K, HCT 36 (from 27 c 4 units PRBCs), K+ 5.0,\n Cr 3.1, lactate 1.1, INR 3.1, TB 6, AST/ALT 1500-, AP 500. CXR with\n , EKG LB3.\n Agree with plan to manage GIB with IV PPI, NGT to LWS, reversal of\n coagulopathy and close monitoring in MICU, including CVP and CvO2\n monitoring. Will hold off on EGD for the moment. For , check\n echo today and d/w cards; need to hold off on ASA or heparin given GIB.\n For abnormal LFTs, will trend with volume resuscitation,\n hold statin and check HIDA given findings on RUQ USG. Will obtain liver\n consult and consider MRCP based on HIDA findings, but suspect this is a\n manifestation of global hypoperfusion, which has resolved. Similarly,\n ARF is new, will monitor with hemodynamic support while holding cardiac\n meds, treat UTI and follow labs. Will continue RISS for DM2. Remainder\n of plan as outlined above.\n Patient is critically ill\n Total time: 50 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:58 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2102-06-19 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 580076,
"text": "Chief Complaint: GIB\n HPI:\n 88-year-old man, with diabetes, CAD, status post MI over a decade ago,\n hypertension, hyperlipidemia, peripheral vascular disease p/w abdominal\n tightness. It started around 730 pm when the pt was sitting watching\n TV. It resolved by itself within 5 mins. However it reappeared when the\n pt was in the ER and this time lasted abt 10 minutes. No\n SOB/dizzy/palps.\n .\n In the emergency department, initial vitals:98.2 66 132/80 18 100/ra.\n In the ED he recd ASA 325, SL NTG x 1, zofran x 1. Dropped SBP to 80s\n after SL NTG. Recd 2L IVF and SBP back to 110s. First set of enzymes\n was neg. CXR was WNL.\n .\n On the general medicine floor this am, he was found to have SBP\n 78/palp, felt nausea, vomited 400cc dark brown mixed w/ food.\n Gastoccult positive, guiac positive w. rectal exam of dark brown stool.\n Started PPI bolus and gtt. AM labs returned with HCT of 31.7 down from\n 33.7 after IVF, INR 3.1. GI aware. He also received 10mg po Vit K. VS\n at time of transfer BP 80-100 systolic, HR 70, afebrile, 98% on Ra.\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denied\n cough, shortness of breath. Denied chest pain or tightness,\n palpitations. Denied nausea, vomiting, diarrhea, constipation or\n abdominal pain. No recent change in bowel or bladder habits. No\n dysuria. Denied arthralgias or myalgias.\n Patient admitted from: \n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Other medications:\n At home\n EZETIMIBE [ZETIA] - 10 mg qd\n GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm\n HYDROCHLOROTHIAZIDE - 12.5 mg qd\n ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd\n METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd\n PRAVASTATIN [PRAVACHOL] - 40 mg qd\n QUINAPRIL - 40 mg qd\n WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth daily take\n one tab 4 days a week and taab on Tue, Th and Sat\n ASPIRIN - (OTC) - 81 mg qd\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other\n Provider) - Dosage uncertain\n .\n On transfer:\n Ezetimibe 10 mg PO DAILY\n Insulin SC (per Insulin Flowsheet) Sliding Scale\n Ondansetron 4 mg IV ONCE\n Pantoprazole 80 mg IV BOLUS plus 8 mg/hr IV DRIP\n Phytonadione 10 mg PO ONCE\n Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR\n Pravastatin 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n CAD, status post MI over a decade ago\n hypertension\n hyperlipidemia\n peripheral vascular disease with bilateral carotid endarterectomies\n BCC\n Systolic HF, EF 25-30% in 04 w/ severe AK/HK (on coumadin)\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is a retired fireman, lives in with his wife.\n Married 55 years. Grown children. No smoking. No alcohol consumption.\n Review of systems:\n Flowsheet Data as of 12:08 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: 36.2\nC (97.1\n HR: 96 (79 - 102) bpm\n BP: 105/64(78) {81/40(56) - 105/64(192)} mmHg\n RR: 22 (19 - 27) insp/min\n SpO2: 95%\n Heart rhythm: 1st AV (First degree AV Block)\n Height: 70 Inch\n CVP: 12 (6 - 12)mmHg\n Total In:\n 3,311 mL\n 72 mL\n PO:\n TF:\n IVF:\n 1,328 mL\n 2 mL\n Blood products:\n 1,983 mL\n 70 mL\n Total out:\n 892 mL\n 25 mL\n Urine:\n 392 mL\n 25 mL\n NG:\n 500 mL\n Stool:\n Drains:\n Balance:\n 2,419 mL\n 47 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.36/30/85./16/-6\n Physical Examination\n Vitals: T: 98.6 BP:108/57 P:87 R: 20 O2: 97% on 2L NC\n General: Alert, mentating well, does not appear acutely ill, appears\n younger than stated age\n HEENT: Sclera anicteric, dry MM, oropharynx clear\n Neck: JVP not elevated\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 201 K/uL\n 10.9 g/dL\n 180 mg/dL\n 3.0 mg/dL\n 67 mg/dL\n 16 mEq/L\n 109 mEq/L\n 5.3 mEq/L\n 140 mEq/L\n 32.0 %\n 9.7 K/uL\n [image002.jpg]\n \n 2:33 A6/14/ 12:50 PM\n \n 10:20 P6/14/ 03:44 PM\n \n 1:20 P6/14/ 04:53 PM\n \n 11:50 P6/14/ 07:03 PM\n \n 1:20 A6/14/ 09:24 PM\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 8.9\n 11.4\n 9.7\n Hct\n 27.2\n 27.4\n 30.0\n 32.0\n Plt\n 230\n 226\n 201\n Cr\n 2.9\n 3.0\n TropT\n 0.01\n TC02\n 18\n Glucose\n 157\n 180\n Other labs: PT / PTT / INR:25.8/25.1/2.5, CK / CKMB /\n Troponin-T:73//0.01, ALT / AST:1468/2106, Alk Phos / T Bili:464/4.2,\n Amylase / Lipase:127/23, Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL,\n LDH:1413 IU/L, Ca++:8.0 mg/dL, Mg++:2.1 mg/dL, PO4:4.1 mg/dL\n Imaging: CXR without acute change\n ECG: EKG: SR, LBBB (old) LAD, first degree AV block\n Assessment and Plan\n This is a 88 yo M admitted for abdominal pain and hypotension,\n transferred to the unit for evaluation of new UGI bleed in setting of\n anticoagulation.\n .\n # Coffee ground emesis - Likely upper GI source in setting of\n therapeutic INR, ddx includes PUD, ASA-induced gastritis, malignancy.\n - EGD to evaluate for active bleeding, will need reversal of\n anticoagulation prior to INR < 2.0, give 2 u FFP and repeat INR\n - has received 2 u pRBC now for decreased Hct, check Hct q6hr\n - continue PPI gtt\n - f/u GI recs\n - access = 3 PIV\n - hold ASA, coumadin\n .\n # Hypotension- Patient with poor CO (EF 25%) and clinically volume\n depleted. Increasing anion gap (12 -> 16) with lactate 2.2 further\n supports hypo-perfusion. Has received 2 L in ED and 1 L on floor, 2 u\n pRBC and 3 u FFP.\n - Gentle fluids given poor EF, goal MAP>60 and UOP >30 cc/hr\n - follow perfusion status clinically with UOP, mentation, skin exam\n - place a-line\n - continue monitoring on tele\n .\n # Acute Renal Failure- Baseline Cre appears to be around 2.0, current\n Cre 3.1 with K 5.7, no EKG changes. Likely pre-renal given patient's\n fluid depleted clinical status\n - gentle IVF given EF\n - check UA and urine lytes\n - will hold on kayexelate pending procedure\n - recheck lytes in pm\n .\n # Transaminitis/Abdominal pain- Possibly due to irritation caused by\n blood in abdomen, however components of history sound like biliary\n colic (transient pain in a band-like distribution, improved with\n belching and resolved within hours on arrival to ED). Does not sound\n like anginal equivalent, first two sets CE negative. LFT's with\n markedly elevated AST and ALT, hyperbilirubinemia (primarily\n conjugated) suggesting obstructive picture.\n - trend LFT's, amylase, lipase\n - RUQ u/s\n - continue ROMI\n .\n # Heart Failure- most recent EF 25% with severe hypokinesis. Has been\n anticoagulated to prevent intra-ventricular thrombus formation.\n Currently appears volume depleted, goal is to keep patient euvolemic.\n - volume repletion to goal MAP >60, UOP >30 cc/hr\n - monitor on telemetry\n - anticoagulation on hold for now\n .\n #DM\n - hold glyburide while inpatient\n - RISS\n .\n # HTN\n - hold HCTZ, beta-blocker and ACE inhibitor in setting of GI bleed\n .\n # Nutrition: NPO for procedure\n .\n # Prophylaxis: pneumoboots, IV PPI\n .\n # Access: 3 PIVs\n .\n # Code: full\n .\n # Communication: Patient\n .\n # Disposition: pending above\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:12 PM\n 18 Gauge - 01:30 PM\n Arterial Line - 03:39 PM\n Multi Lumen - 06:20 PM\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 ------ Protected Section ------\n Overnight events:\n - received 2 more PRBC and 1 FFP\n - troponins elevate out of proportion to renal failure\n - LFTs continue to rise\n Plan:\n GI Bleed: Attempted EGD, but became Hypotensive. Hct appears stable\n and minimal NG output\n - continue PPI gtt\n - L IJ and PIVs for access\n - hold coumadin and ASA\n - received 10 of Vit K -> will give 5 mg more\n - 2 U FFP with goal INR<2 today\n - Low intermittent wall suction to monitor for continued bleeding\n Hypotension: Has received 5U PRBC and 3 U FFP with stabilization of\n BPs.\n - FFP as above\n - goal CVP >10\n - monitor resp status with SaO2 and mixed venous sat\n Elevated CE: holding anticoagulation\n - ECHO today\n - trend Biomarkers\n Transaminitis: Has both elevated transaminitis and cholestatic picture.\n - HIDA scan\n - Liver consult\n ------ Protected Section Addendum Entered By: , MD\n on: 09:33 ------\n"
},
{
"category": "Radiology",
"chartdate": "2102-06-20 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1084032,
"text": " 1:30 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ?ductal dilation\n Admitting Diagnosis: EPIGASTRIC DISCOMFORT/ RULE OUT MYOCARDIAL INFACTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with transaminitis and hyperbilirubinemia\n REASON FOR THIS EXAMINATION:\n ?ductal dilation\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): BMzb TUE 5:08 PM\n PFI:\n\n 1. Mildly improved appearance of the gallbladder, containing sludge mixed\n with bile, with mild wall thickening, 3.7 mm. No specific sign of\n cholecystitis. Echogenic liver as previously seen. Right pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Transaminitis and hyperbilirubinemia, previous ultrasound .\n\n FINDINGS: There is increased hepatic echogenicity. No focal lesion is seen.\n There is no intra- and extra-hepatic biliary ductal dilatation, with the\n proximal common duct measuring 5 mm. There is normal Doppler flow within the\n portal vein. The appearance of the gallbladder has mildly improved,\n containing sludge mixed with bile, with mild wall thickening measuring up to\n 3.7 mm. The spleen is normal, measuring 9.9 cm. No ascites is seen. A right\n pleural effusion is present.\n\n IMPRESSION:\n\n 1. Mildly improved appearance of the gallbladder, containing sludge, with\n mild wall thickening. No specific sign of cholecystitis or biliary\n dilatation.\n\n 2. Increased hepatic echogenicity as previously seen.\n\n 3. Right pleural effusion.\n\n"
}
] |
29,035 | 169,994 | Pleasant 66 yo female with MMP, hx of kidney liver failure, presented intially to the hospital with recurrent multi-drug resistant UTI, was transferred to the ICU for altered mental status and hypoxemia, electively intubated for LP and CT studies found to have gas pockets in her transplanted kidney. . # Emphysematous Pyelonephritis: She presented with UTI that had grown multidrug resistant klebsiella that was sensitive meropenem. She was started on meropenem. However she continued to spike fevers and her mental status was noted to be decreased from her baseline. She was later transferred to the MICU for AMS and hypoxia. There she underwent renal US and abd CT which showed gas in the collecting duct of her transplanted kidney. Urine cultures here did not grow any bacteria but did grow and she was started on Micafungin. After starting micafungin her fevers stopped and her mental status improved. She will be treated with a three week course of meropenem and micafungin. She will follow up with ID and urology for further management of her recurrent UTIs. She should have weekly Chem7, CBC w/ diff, ESR/CRP, ALT, AST, Tbili, and Alk Phos checked and all laboratory results should be faxed to Dr. at (. . #Hypoxia: During her admission she was noted to be hypoxic requiring non-rebreather. This was felt to be from pulmonary edema. She received IV lasix with improvement in her respiratory status. While she was continuing to spike fevers and had altered mental status she was briefly started on vancomycin in addition to the meropenem for possible aspiration PNA. She was also electively intubated to obtain head chest and abdominal CT. Sputum cultures were negative and the Vancomycin was stopped. She was extubated without complication. With improvement in her volume status she no longer needed oxygen during the day and only needed oxygen at night as she refuses her CPAP for sleep apnea. Volume status can be tenuous and she was discharged on torsemide 20mg . Home dose had been 40mg QAM, 20mg QPM but she was euvolemic at time of discharge. Close attention should be paid to volume status and diuretics increased as necessary. . # Acute Renal failure: While admitted she was noted to have elevation in her creatinine. Her diuretics were held though she later developed pulmonary edema. She was then diuresed with IV lasix. Her creatinine rose again during the diuresis but later returned to 1 which was actually below her recent baseline. Her torsemide was restarted and the dose was increased to her previous dose of 40mg in the morning and 20mg at night. . # Mental status: While admitted she had AMS. On admission she had been taking haldol, seroquel, aripiprazole, venlafaxine, and ativan as well as dilaudid for her hip pain. Haldol was continued but the rest of the medications were held per psychiatry recs. She also underwent an LP and head CT which were normal. With treatment of her UTI, holding her psychotropic medications and resolution of hypoxia her mental status returned to her baseline and her tremor resolved. She was restarted on her venlafaxine and ativan PRN but other medications were not restarted on discharge. . # Hx kidney/liver transplant: Her tacrolimus was increased to 1.5mg and prednisone was continued unchanged(7.5mg ) throughout this admission. Her MMF was stopped and was not restarted on discharge. Bactrim was continued. . # Hip Fracture: She recently had a hip fracture that was repaired by ortho in . She was taking dilaudid for pain when she was admitted but this was held in the setting of AMS. She was later changed to oxycodone as needed, which provided adequate pain control without mental status changes. She will need to go to rehab after this admission. She was continued on lovenox for DVT/PE prevention. Staples were removed . . # Diabetes: continued insulin sliding scale, glargine decreased to 15 unitsd QHS. This may need to be titrated up in the future. . # LUE Swelling: Pt. has known h/o chronic thrombus in LUE, s/p fistula in RUE so not usable for access. LUE was accessed for IR-guided PICC which was successfully placed. Pt. was noted to have LUE swelling at admission which persisted after PICC placement, non-tender, neurovascularly intact. US showed stable brachial vein thrombus, PICC in other brachial vein without thrombus, and new thrombus in mid portion of cephalic vein which is not a deep vein. Encouraged LUE elevation. . # HTN: Briefly held her amlodipine and torsemide though these were restarted later. she was persisitently hypertensive in the morning and her amlodipine was increased to 5 mg prior to discharge. This will need to be followed to confirm her BP improves. . CHRONIC ISSUES: . # HLD: Cont atorvastatin . # Hx afib: continued carvedilol, asa, and plavix. . # Hx seizures: Continued keppra, no seizures while inpatient. . # Hypothyroidism: Continued levothroxine. . # GERD: continued ppi. . # Gout: Colchicine and allopurinol were held in the setting of . Her allopurinol was restarted but her colchine was discontinued at discharge. . TRANSITIONAL ISSUES: #Antibiotics: She will need a total of three weeks of meropenem and micafungin. Her last day will be . She will follow up with infectious disease prior to this date. . #Recurrent UTIs: She has previously been on fosfomycin for prophylaxis but still developed this infection. She will need to follow up with urology and ID regarding prevention of future infections. . #Hip fracture: Duration of Lovenox must be determined per orthopedics that performed hip repair. . #Diabetes: Glargine may need to be increased if FSG persistently >180. . #Hypertension: She has been hypertensive particularly in the mornings during this admission. Her amlodipine was increased to 5 mg the day prior to discharge if she is persistently hypertensive she may need medication changes as directed by Dr. . . Please check weekly electrolytes with BUN/Cr, Tbili, ALT, AST, Alk Phos, CBC/w diff, ESR, and CRP. Please also check tacrolimus levels twice weekly as we have recently increased her dose. All laboratory results should be faxed to Dr. at ( and Dr. at ( . Please monitor blood sugars and titrate glargine insulin as needed to maintain FSG 140-180. . Please continue IV meropenem and micafungin through , last dose to be given that day then remove PICC line. | Chronic-appearing thrombus in one of three brachial veins, unchanged from . Pacemaker leads terminate in the expected location of right atrium and right ventricle. Transvenous right atrial and right ventricular pacer leads noted. Diastolic CHF. COMPARISON: Left upper extremity ultrasound . TECHNIQUE: Non-contrast CT head. Unchanged moderate pulmonary edema and pleural effusions. A catheter is seen in one brachial vein without adjacent thrombus. Stable mild edema and small bilateral pleural effusions. Dual-lead left-sided pacemaker with its leads terminating over the expected location of the right atrium and right ventricle respectively. ABCESS Admitting Diagnosis: URINARY TRACT INFECTION FINAL REPORT (Cont) myolipoma, which is unchanged from the prior study. There is a trace right-sided pleural effusion with compressive atelectasis and several air bronchograms. The cardiac silhouette is moderately enlarged but unchanged from the prior exam. CT OF THE PELVIS: A stable retroperitoneal hematoma along the left iliac crest measures 8.3 x 8.1 cm (previously 8.0 x 8.0 cm), which is unchanged. Endotracheal tube in proper position. An endotracheal tube is in place. The aorta is normal in caliber with calcifications of the aortic arch and descending thoracic aorta as well as the right brachiocephalic and left subclavian arteries. FINDINGS: A left PICC is somewhat obscured by the pacemaker, but appears to be coiled within the proximal brachiocephalic vein adjacent to the pacemaker wires. Aortic calcification is again noted. COMPARISON: CT head done on . TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet to the pubic symphysis without contrast. There are still small bilateral pleural effusions with adjacent mild atelectasis. The left internal jugular, subclavian, basilic, and two of three brachial veins show normal compressibility, flow and augmentation. A dual-lead left-sided pacer remains in place with its leads terminating over the expected location of the right atrium and right ventricle, respectively. Early cerebral edema cannot be completely excluded and assessment is somewhat limited. Stable mild pulmonary edema and small right pleural effusion. Stable pulmonary edema and bilateral pleural effusions are unchanged. Mildly prominent ventricles and extra-axial CSF spaces, likely relate to volume loss. Small bilateral pleural effusions are presumed. Small to moderate left-sided pleural effusion with compressive atelectasis and air bronchograms. Small stable bilateral pleural effusions are likely present. The heart is mildly enlarged without significant pericardial effusion. Evaluate endotracheal tube. Left internal jugular central line has its tip in the proximal superior vena cava. FINDINGS: Grayscale and color Doppler images of bilateral common femoral, right superficial femoral, deep femoral, popliteal and calf veins were obtained. Left transvenous pacemaker leads are in standard position in the right atrium and right ventricle. Tachypnea and hypoxemia. Mild pulmonary edema is unchanged from the prior study. Sinus rhythm with atrial sensing and ventricular pacing.Compared to the previous tracing of there is no significant change. Slightly hypodense appearance of the left caudate and left insular cortex is of equivocal significance. IMPRESSION: Stable mild pulmonary edema and small pleural effusions. Slightly hypodense appearance of the left insular cortex and left caudate is of equivocal significance. REASON FOR THIS EXAMINATION: any pneumothorax WET READ: WED 8:48 PM Stable pulmonary edema and bilateral pleural effusions are unchanged. Pacemaker leads are seen terminating in the right atrium and right ventricle. Interval reduction in lung volumes with likely stable mild pulmonary and interstitial edema. Mild mucosal thickening in the ethmoid air cells and fluid in the sphenoid sinus. Moderate enlargement of the cardiomediastinal silhouette is stable. Lungs are essentially clear except for minimal bibasilar opacities, right more than left. IMPRESSION: Uncomplicated ultrasound and fluoroscopy-guided placement of a 4 French 43 cm single-lumen PICC via the patent left brachial vein and with its tip in the mid-to-lower SVC. The gallbladder is surgically absent. Mild interstitial pulmonary edema. Post-surgical changes are seen in the right anterior pelvic wall. The heart remains mildly enlarged but unchanged. CT OF THE ABDOMEN: Evaluation of solid organs is limited without intravenous contrast. The proximal and distal portions of the cephalic vein are patent with normal flow. Nasogastric tube seen coursing below the diaphragm with the tip not identified. Non-occlusive thrombus in the mid portion of the left cephalic vein is new from but is otherwise age-indeterminant. The pacemaker wires are within the expected location in the right atrium and right ventricle. Small bilateral effusions are unchanged. A 0.018 wire was advanced through the needle and into the IVC after some effort in negotiating from the left subclavian vein into brachiocephalic vein. The patient is status post ORIF of the right hip with ossification of the adjacent soft tissues. COMPARISON: Chest radiograph . The heart remains mildly enlarged. FINDINGS: Examination is limited secondary to patient's condition with tremors. Interval improvement in aeration with improving mild pulmonary and interstitial edema. Correlation to CT abdomen and pelvis . IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity. Nasogastric tube courses below the diaphragm with the tip not identified. COMPARISONS: Chest radiograph . COMPARISONS: Chest radiograph . Interval placement of a left internal jugular central line with its tip in the upper-to-mid superior vena cava. A small to moderate nonhemorrhagic pleural effusion is noted in the left lung, also with significant compressive atelectasis and air bronchograms within the left lower lobe. The cardiomediastinal silhouette is mildly enlarged. The cardiomediastinal silhouette is mildly enlarged. Probable small layering right effusion. A nasogastric tube is seen terminating into the wall of the stomach without evidence of perforation. The pancreas is unchanged in appearance with a fluid collection adjacent to the tail measuring up to 2.6 cm and unchanged from the prior study. Left pectoral pacemaker device with leads in ra and rv. | 18 | [
{
"category": "Radiology",
"chartdate": "2156-02-19 00:00:00.000",
"description": "RENAL U.S. (PORTABLE)",
"row_id": 1223530,
"text": " 11:57 AM\n RENAL U.S. (PORTABLE) Clip # \n Reason: hydronephrosis? renal abscess?\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with recurrent UTI's, spiking fevers after 4 days of Abx\n coverage\n REASON FOR THIS EXAMINATION:\n hydronephrosis? renal abscess?\n ______________________________________________________________________________\n WET READ: 1:55 PM\n Right lower quadrant transplant kidney demonstrates shadowing echogenic\n material within the collecting system. Recent CT does not demonstrate\n calcification, thus, this likely represents air. Emphysematous pyelitis\n should be excluded.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n RENAL TRANSPLANT PORTABLE ULTRASOUND\n\n DATE: .\n\n Correlation to CT abdomen and pelvis .\n\n CLINICAL INDICATION: 66-year-old woman with recurrent UTIs, spiking fevers\n after 4 days of antibiotic coverage. Question hydronephrosis, question renal\n abscess.\n\n TECHNIQUE: Multiple son -scale images were obtained on a portable\n ultrasound unit of the right lower quadrant renal transplant. Select images\n were supplemented with color Doppler imaging.\n\n FINDINGS:\n\n Examination is limited secondary to patient's condition with tremors.\n\n The right lower quadrant renal transplant measures approximately 9.1 cm.\n There is no abscess, hydronephrosis, or perinephric fluid collection. Within\n the collecting system, echogenic material is present with posterior acoustic\n shadowing. On recent CT examination, there was no calcification in the\n collecting system. The ureter and bladder are not imaged.\n\n IMPRESSION:\n Echogenic shadowing material within the collecting system of the right lower\n quadrant transplanted kidney, suggestive of emphysematous pyelonephritis.\n There is no hydronephrosis or abscess. If the patient has not undergone\n recent instrumentation to account for air within the collecting system,\n emphysematous pyelitis should be considered. If further imaging is desired,\n CT would be recommended.\n\n Results were discussed with Dr. by Dr. via telephone on\n (Over)\n\n 11:57 AM\n RENAL U.S. (PORTABLE) Clip # \n Reason: hydronephrosis? renal abscess?\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n at 1345 hours.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223632,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement, infiltrates progression\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pleasant 66 yo female with MMP, hx of kidney liver failure, now presenting with\n recurrent multi-drug resistant UTI.\n REASON FOR THIS EXAMINATION:\n ET tube placement, infiltrates progression\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recurrent multidrug resistant UTI. Evaluate endotracheal tube.\n\n COMPARISON: Chest radiograph . Chest radiograph .\n\n FINDINGS: An endotracheal tube is approximately 3 cm from the carina. A\n feeding tube is in the stomach with the tip of of view. Pacemaker leads are\n in the standard position. Mild pulmonary edema is stable. There is no\n consolidation. Small pleural effusions are presumed but not obvious. There\n is no pneumothorax. Moderate enlargement of the cardiomediastinal silhouette\n is stable.\n\n IMPRESSION:\n Stable mild pulmonary edema and small pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223304,
"text": " 3:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion, infiltrate/ thanks\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with pmh liver and kidney transplant with acute dyspnea and\n hypoxia\n REASON FOR THIS EXAMINATION:\n effusion, infiltrate/ thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of liver and kidney transplant with acute dyspnea and\n hypoxia.\n\n COMPARISONS: Chest radiograph . Chest radiograph .\n\n FINDINGS: Again seen is hazy opacification of the bilateral lungs, most\n likely representing pulmonary edema, although may be infection, ARDS, or\n pulmonary hemorrhage. The cardiac silhouette is moderately enlarged and\n stable. Small bilateral effusions are unchanged. An opacification at the\n right base most likely represents atelectasis, although a developing infection\n cannot be excluded. There is no pneumothorax. Pacemaker electrodes are in\n standard position.\n\n IMPRESSION:\n 1. Unchanged moderate pulmonary edema and pleural effusions.\n 2. Probable right basilar atelectasis although developing pneumonia cannot be\n excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-19 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1223571,
"text": " 2:38 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: HX OF KIDNEY LIVER FAILURE ? GAS SEEN IN TRANSPLANT KIDNEY ? ABCESS\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n Interval study\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female status post liver and kidney transplant with\n multiple medical issues including recurrent UTIs, now spiking fevers after\n four days of antibiotics with worsening mentation and increasing creatinine,\n here to assess for new evidence of infection.\n\n COMPARISON: Same day renal son performed on and\n non-contrast CT of the abdomen and pelvis performed on .\n\n TECHNIQUE: MDCT-acquired axial images were obtained from the thoracic inlet\n to the pubic symphysis without contrast. Coronally and sagittally reformatted\n images were generated and reviewed.\n\n FINDINGS:\n\n CT OF THE CHEST: Two prominent lymph nodes measuring 8 mm in short axis are\n present in the left axilla but do not meet CT size criteria for\n lymphadenopathy. No pathologically enlarged lymph nodes are identified in the\n supraclavicular, right axillary, or mediastinal regions. An enlarged and\n calcified pericardial node measuring 9 mm is noted (2:31). The heart is\n mildly enlarged without significant pericardial effusion. Pacemaker leads are\n seen terminating in the right atrium and right ventricle. There is extensive\n calcification of the coronary arteries, aortic valve and mitral valve. The\n aorta is normal in caliber with calcifications of the aortic arch and\n descending thoracic aorta as well as the right brachiocephalic and left\n subclavian arteries. The great vessels are grossly patent. An endotracheal\n tube is in place. The central tracheobronchial tree is patent. There is a\n trace right-sided pleural effusion with compressive atelectasis and several\n air bronchograms. A small to moderate nonhemorrhagic pleural effusion is\n noted in the left lung, also with significant compressive atelectasis and air\n bronchograms within the left lower lobe. No pulmonary nodules or masses are\n present. A cardiac device is present in the left chest wall.\n\n CT OF THE ABDOMEN: Evaluation of solid organs is limited without intravenous\n contrast. The patient is status post orthotopic liver transplant with two\n stents noted within the hepatic arteries and suture material at the IVC. No\n gross liver abnormalities are identified. The gallbladder is surgically\n absent. No extra-hepatic biliary dilation is seen. The patient is status\n post splenectomy with ligation of the splenic artery. The pancreas is\n unchanged in appearance with a fluid collection adjacent to the tail measuring\n up to 2.6 cm and unchanged from the prior study. The left adrenal gland is\n unremarkable. The right adrenal gland contains a large 5.6 x 4.6 cm\n (Over)\n\n 2:38 PM\n CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: HX OF KIDNEY LIVER FAILURE ? GAS SEEN IN TRANSPLANT KIDNEY ? ABCESS\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n myolipoma, which is unchanged from the prior study. The bilateral native\n kidneys are atrophic.\n\n A nasogastric tube is seen terminating into the wall of the stomach without\n evidence of perforation. The intra-abdominal loops of small and large bowel\n are unremarkable without evidence of wall thickening, dilation, or\n obstruction. Multiple small aortocaval and para-aortic lymph nodes are noted,\n but none are pathologically enlarged by CT size criteria. No free air or\n ascites is present. There is extensive calcified atherosclerosis of the\n abdominal aorta.\n\n CT OF THE PELVIS: A stable retroperitoneal hematoma along the left iliac\n crest measures 8.3 x 8.1 cm (previously 8.0 x 8.0 cm), which is unchanged.\n The transplant kidney is located within the pelvis and contains air in the\n renal pelvis and ureter. There is no evidence of hydronephrosis in the\n transplanted kidney. There is no perinephric stranding. Post-surgical\n changes are seen in the right anterior pelvic wall. The rectum, sigmoid\n colon, and uterus are unremarkable. The urinary bladder is decompressed by a\n Foley catheter. There is no free pelvic fluid or inguinal lymphadenopathy.\n\n OSSEOUS STRUCTURES AND SOFT TISSUES: There is a 7.7 x 5.2 cm hematoma in the\n subcutaneous fat superficial to the right gluteus maximus, which appears\n slightly increased in size on coronal imaging from (previously 6.1\n cm).\n\n No suspicious lytic or sclerotic lesions are identified in the bone. The\n patient is status post ORIF of the right hip with ossification of the adjacent\n soft tissues. Degenerative changes are present in the bilateral sacroiliac\n joints.\n\n IMPRESSION:\n 1. No new focal fluid collection. Stable retroperitoneal hematoma in the\n left iliac fossa and slightly increased size of superficial hematoma adjacent\n to the right gluteus muscle both represent areas of possible infection.\n 2. Air within the collecting system of the right pelvic transplanted kidney\n may represent infection in the absence of recent instrumentation or reflux of\n air, but this finding is new from . CLINICAL CORRELATION IS ADVISED.\n 3. Small to moderate left-sided pleural effusion with compressive atelectasis\n and air bronchograms. Infection cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1223572,
"text": " 2:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: any masses\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo female with MMP, hx of kidney liver failure, now presenting with\n recurrent multi-drug resistant UTI.\n REASON FOR THIS EXAMINATION:\n any masses\n CONTRAINDICATIONS for IV CONTRAST:\n renal transplant\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Multiple medical problems, liver and kidney failure, to evaluate\n for any masses, prior to performing LP.\n\n COMPARISON: CT head done on .\n\n TECHNIQUE: Non-contrast CT head.\n\n FINDINGS:\n\n There is no acute intracranial hemorrhage, mass effect, shift of normally\n midline structures or hydrocephalus. Mildly prominent ventricles and\n extra-axial CSF spaces, likely relate to volume loss. Vascular calcifications\n and basal ganglial calcifications are noted. Slightly hypodense appearance of\n the left insular cortex and left caudate is of equivocal significance. Early\n cerebral edema cannot be completely excluded and assessment is somewhat\n limited.\n No suspicious lytic or sclerotic lesions are noted.\n Mild mucosal thickening is noted in the ethmoid air cells on both sides. The\n mastoid air cells are clear.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage or mass effect.\n\n 2. Mild mucosal thickening in the ethmoid air cells and fluid in the sphenoid\n sinus.\n\n 3. Slightly hypodense appearance of the left caudate and left insular cortex\n is of equivocal significance. Given the slightly noisy images, the component\n of cerebral edema cannot be completely excluded. Correlate clinically.\n\n Preliminary findings discussed with Dr. by Dr. on soon\n after the study by phone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223772,
"text": " 7:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval study for pulm edema\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with ? volume overload\n REASON FOR THIS EXAMINATION:\n interval study for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP UPRIGHT CHEST FILM AT 741\n\n CLINICAL INDICATION: 66-year-old with question volume overload, assess for\n pulmonary edema.\n\n Comparison is to prior study of at .\n\n A single portable upright chest film at 741 is submitted.\n\n IMPRESSION:\n\n 1. Dual-lead left-sided pacemaker with its leads terminating over the\n expected location of the right atrium and right ventricle respectively. Left\n internal jugular central line has its tip in the proximal superior vena cava.\n Endotracheal tube continues to have its tip approximately 3 cm above the\n carina. Nasogastric tube seen coursing below the diaphragm with the tip not\n identified.\n\n 2. The heart remains mildly enlarged but unchanged. Mediastinal contours are\n within normal limits. Interval improvement in aeration with improving mild\n pulmonary and interstitial edema. Probable small layering right effusion.\n More patchy opacity at the left base may reflect a combination of compressive\n atelectasis and effusion, although pneumonia cannot be entirely excluded.\n Clinical correlation is advised. No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-28 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 1224690,
"text": " 2:54 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: PT WITH WORSENING LUE, PLEASE R/O DVT\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with chronic vein clot in L brachial vein and now picc for\n UTI and worsening LUE\n REASON FOR THIS EXAMINATION:\n Please r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 66-year-old woman with chronic venous clot in the left\n brachial vein, now with PICC for UTI. The patient has worsening left upper\n extremity edema. Evaluate for DVT.\n\n COMPARISON: Left upper extremity ultrasound .\n\n FINDINGS: -scale and color Doppler son with spectral analysis of\n the bilateral subclavian veins, and the left internal jugular, axillary,\n brachial, basilic, and cephalic veins was performed.\n\n Again seen is chronic occlusive thrombus within one of three brachial veins,\n similar to the prior study. Non-occlusive thrombus in the mid portion of the\n left cephalic vein is new from but is age indeterminant. The\n proximal and distal portions of the cephalic vein are patent with normal flow.\n\n The left internal jugular, subclavian, basilic, and two of three brachial\n veins show normal compressibility, flow and augmentation. A catheter is seen\n in one brachial vein without adjacent thrombus.\n\n IMPRESSION:\n\n 1. Chronic-appearing thrombus in one of three brachial veins, unchanged from\n .\n\n 2. Non-occlusive thrombus in the mid portion of the left cephalic vein is new\n from but is otherwise age-indeterminant.\n\n Dr. discussed the findings with Dr. by phone at 4:10 p.m.\n on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223565,
"text": " 2:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: correct position of ET tube, and NG tube\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pleasant 66 yo female with MMP, hx of kidney liver failure, now presenting with\n recurrent multi-drug resistant UTI electively intubated to recieve CT abdomen\n REASON FOR THIS EXAMINATION:\n correct position of ET tube, and NG tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of kidney and liver failure with multidrug resistant UTI.\n New intubation.\n\n COMPARISONS: Chest radiograph .\n\n FINDINGS: An endotracheal tube ends approximately 3 cm from the carina. Mild\n pulmonary edema is unchanged from the prior study. Small stable bilateral\n pleural effusions are likely present. There is no consolidation or\n pneumothorax. The cardiac silhouette is moderately enlarged but unchanged\n from the prior exam. A pacemaker and its leads are in standard position.\n\n IMPRESSION:\n 1. Endotracheal tube in proper position.\n 2. Stable mild edema and small bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1223735,
"text": " 7:28 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Placement of new LIJ\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with pyelo; h/o renal tx\n REASON FOR THIS EXAMINATION:\n Placement of new LIJ\n ______________________________________________________________________________\n WET READ: 8:46 PM\n 1. Stable mild pulmonary edema and small right pleural effusion. Left\n costophrenic angle is not included in the field of view.\n 2. ETT tube 2.9 cm form the carina. Left pectoral pacemaker device with leads\n in ra and rv. ngt with side port in expected region of stomach.\n 3. New left ij line with tip in the expected region of upper SVC.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORT LINE PLACEMENT, AT 19:18\n\n CLINICAL INDICATION: 66-year-old with pyelo, history of renal transplant,\n placement of new left IJ.\n\n Comparison is made to the patient's prior study of at 4:17.\n\n A single portable supine chest film of at 7:35 p.m. is submitted.\n Left costophrenic angle is not entirely included on the study.\n\n IMPRESSION:\n 1. A dual-lead left-sided pacer remains in place with its leads terminating\n over the expected location of the right atrium and right ventricle,\n respectively. Interval placement of a left internal jugular central line with\n its tip in the upper-to-mid superior vena cava. Nasogastric tube courses\n below the diaphragm with the tip not identified. Endotracheal tube has its\n tip approximately 3 cm above the carina.\n\n 2. Interval reduction in lung volumes with likely stable mild pulmonary and\n interstitial edema. Possible small layering right effusion. The heart\n remains mildly enlarged. Mediastinal contours are difficult to assess but\n likely unchanged given marked patient rotation to the right on the current\n examination. Retrocardiac opacity may reflect compressive atelectasis in\n setting of effusion, although a pneumonia cannot be entirely excluded.\n Clinical correlation is advised. In a supine technique, pneumothorax cannot\n be adequately evaluated on the current examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-25 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 1224284,
"text": " 5:18 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC\n Admitting Diagnosis: URINARY TRACT INFECTION\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with renal trnasplant recurrent MDR UTI\n REASON FOR THIS EXAMINATION:\n Please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC PLACEMENT\n\n INDICATION: 66-year-old woman with renal transplant, recurrent UTI.\n\n OPERATORS: Drs. (fellow) and (attending\n physician).\n\n CONTRAST: None.\n\n SEDATION: None.\n\n PROCEDURE AND FINDINGS: Patient was placed supine on the imaging table in the\n interventional suite. Timeout was performed as per protocol.\n\n Under aseptic conditions and son guidance, a micropuncture needle was\n placed in the patent left brachial vein. Son images were printed\n prior to and following needle placement. A 0.018 wire was advanced through\n the needle and into the IVC after some effort in negotiating from the left\n subclavian vein into brachiocephalic vein. Needle was exchanged for a\n peel-away sheath. After appropriate measurements and removal of inner\n cannula, a 4 French 43 cm single-lumen PICC was placed over the wire. Sheath\n was peeled away. Wire was removed. Port was aspirated and flushed. Catheter\n was secured by StatLock. Site was appropriately dressed. Patient tolerated\n the procedure well and no immediate post-procedure complication was seen.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopy-guided placement of a 4\n French 43 cm single-lumen PICC via the patent left brachial vein and with its\n tip in the mid-to-lower SVC. It is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-14 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 1222844,
"text": " 9:31 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: RLE SWELLING, PLEASE EVAL OF DVT\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with recent hip surgery, now with RLE edema, cough, SOB with\n exertion\n REASON FOR THIS EXAMINATION:\n Please eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with recent hip surgery, now with right lower extremity\n edema, cough and shortness of breath with exertion. Assess for DVT.\n\n COMPARISONS: None available.\n\n FINDINGS:\n\n Grayscale and color Doppler images of bilateral common femoral, right\n superficial femoral, deep femoral, popliteal and calf veins were obtained.\n Normal flow, compressibility and augmentation is demonstrated throughout.\n\n IMPRESSION:\n\n No evidence of deep venous thrombosis in the right lower extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1222840,
"text": " 7:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for PNA\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with cough, low grade temp, admitted for UTI\n REASON FOR THIS EXAMINATION:\n Please evaluate for PNA\n ______________________________________________________________________________\n WET READ: SAT 8:37 PM\n Moderate cardiomegaly is increased compared to radiograph from . Mild\n interstitial pulmonary edema. No focal consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Cough and low-grade fever.\n\n Portable AP radiograph of the chest was compared to .\n\n Heart size is top normal. Mediastinum is stable. Lungs are essentially clear\n except for minimal bibasilar opacities, right more than left. The area on the\n right might reflect developing infectious process and it is new since the\n prior examination.\n\n Pacemaker leads terminate in the expected location of right atrium and right\n ventricle. Followup of the patient in four weeks after completion of\n antibiotic therapy is recommended for documentation of resolution of right\n most likely middle lobe infectious process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223341,
"text": " 10:10 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: any new infiltrates, progression of pulm edema\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo female with extensive PMH including renal/hepatic transplant in ,dchf\n on home 3L,presenting with tachypnea and hypoxemia\n REASON FOR THIS EXAMINATION:\n any new infiltrates, progression of pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:07 A.M., \n\n HISTORY: Renal and hepatic transplant. Diastolic CHF. Tachypnea and\n hypoxemia.\n\n IMPRESSION: AP chest compared to 3:29 a.m.:\n\n Moderately severe pulmonary edema has improved substantially since earlier in\n the day. Moderate cardiomegaly is stable. Small bilateral pleural effusions\n are presumed. No pneumothorax. Transvenous right atrial and right\n ventricular pacer leads noted. No endotracheal tube visible.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1223428,
"text": " 8:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: any pneumothorax\n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Pleasant 66 yo female with MMP, hx of kidney liver failure, now presenting with\n recurrent multi-drug resistant UTI.\n REASON FOR THIS EXAMINATION:\n any pneumothorax\n ______________________________________________________________________________\n WET READ: WED 8:48 PM\n Stable pulmonary edema and bilateral pleural effusions are unchanged. The\n cardiomediastinal silhouette\n is mildly enlarged.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Patient with recurrent multidrug resistant UTI and question\n pneumothorax.\n\n Comparison is made with prior study performed 5 hours earlier.\n\n Mild pulmonary edema has improved. Mild cardiomegaly is stable. Aeration of\n the lower lobes bilaterally has markedly improved. There are still small\n bilateral pleural effusions with adjacent mild atelectasis. Left transvenous\n pacemaker leads are in standard position in the right atrium and right\n ventricle.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1223376,
"text": " 2:07 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please check PICC tip left basilic 43 cm \n Admitting Diagnosis: URINARY TRACT INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with new line placement\n REASON FOR THIS EXAMINATION:\n please check PICC tip left basilic 43 cm \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate PICC placement.\n\n COMPARISONS: Chest radiograph, at 10 a.m. Chest radiograph,\n . Chest radiograph, .\n\n FINDINGS: A left PICC is somewhat obscured by the pacemaker, but appears to\n be coiled within the proximal brachiocephalic vein adjacent to the pacemaker\n wires. There is no pneumothorax. The pacemaker wires are within the expected\n location in the right atrium and right ventricle. Stable pulmonary edema and\n bilateral pleural effusions are unchanged. The cardiomediastinal silhouette\n is mildly enlarged. Aortic calcification is again noted.\n\n IMPRESSION: PICC coiled within the proximal brachiocephalic vein.\n\n Results were discussed with the IV team at 2:30 p.m. on via telephone\n by Dr. .\n\n"
},
{
"category": "ECG",
"chartdate": "2156-02-21 00:00:00.000",
"description": "Report",
"row_id": 166182,
"text": "Ventricular pacing and atrial sensing. Compared to the previous tracing\nof no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-02-18 00:00:00.000",
"description": "Report",
"row_id": 166183,
"text": "Ventricular pacing with probable atrial sensing. Compared to the previous\ntracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-02-18 00:00:00.000",
"description": "Report",
"row_id": 166184,
"text": "Artifact is present. Sinus rhythm with atrial sensing and ventricular pacing.\nCompared to the previous tracing of there is no significant change.\n\n"
}
] |
88,411 | 122,697 | Brief Course: Mr. is a 28yo male with PMH of bipolar disorder, depression and past suicide attempts who presented with clonidine overdose. He was intubated secondary to lethargy and need for airway protection and monitoring in the ICU. On HD #1, he was extubated and psychiatry was consulted. Pt was transferred to the medical floor while awaiting a psychiatric bed. . # Clonidine Overdose: As endorsed by the patient on admission. Tox screen negative for additional ingestion. Classic toxidrome associated with clonidine consists of central nervous system depression, bradycardia, hypotension, respiratory depression, and small pupil size. In the ED, patient noted to become increasingly lethargic with naloxene providing little effect. He was intubated and admitted to the MICU. Toxicology recommended supportive care with close monitoring of hemodynamics with plan for prn atropine/prn pressors. He was monitored on telemetry without hemodynamic instability. Once extubated, he was evaluated by psychiatry (as below). . # Bipolar disorder/Depression: Patient with h/o previous suicide attempts. Followed by psych at . Psych was consulted after extubation. Pt was placed on section 12 with a one to one sitter. He began to endorse thoughts of hurting/stabbing others and became somewhat agitated. Security was called to sit with the pt and he was placed in seclusion. Psychiatry recommended inpatient psychiatric hospitalization. . # Opiate Addiction: Previously addicted to heroin. Per family sober for last 6 months. Tox screen negative for opiates. As an outpatient on clonidine for cravings; last on suboxone ~2yrs prior. . # Hep C: Diagnosed 3yrs prior; transmission likely IVDU. Yet to undergo treatment. Per mother, HIV negative. Hepatitis serologies showed Hep C AB pos, Hep B AB pos but Hep B ag and core negative. . # Transitional Issues: -Continue to follow up with outpatient psychiatry once discharged from inpatient psychiatry and limit medications unless medically necessary | Normal sinus rhythm. Normal sinus rhythm. Normal tracing. Tracing is within normal limits. Cardiac and mediastinal contours are stable and within normal limits given portable technique. Tracing is normal and unchanged from tracing #1.TRACING #2 Since the previous tracing of there isprobably no significant change. Lung volumes remain relatively low with patchy opacity at the right base likely reflecting atelectasis. No pleural effusions. There is a perihilar fullness likely representing mild congestion related to resuscitation. IMPRESSION: 1. IMPRESSION: 1. Sinus rhythm. Mild central vascular congestion, may be secondary to resuscitation. Lines and tubes appropriate in position. FINDINGS: Single frontal view of the chest demonstrates an ET tube extending 2.9 cm above the carina. No previous tracingavailable for comparison.TRACING #1 The cardiac silhouette is prominent, accentuated by AP technique and low lung volume. An enteric tube traverses inferiorly out of view. There is no pneumothorax or large effusion. COMPARISON: None available. Question ET tube placement. 2. Aspiration or pneumonia would be less likely. Endotracheal tube continues to have its tip 2.5 cm above the carina. No evidence of pulmonary edema or pneumothorax. Comparison to prior study at 2248. A nasogastric tube is seen coursing below the diaphragm with the tip coiled within the stomach. A semi-upright portable chest film at 4 a.m. is submitted and compared to the prior study of at 2248. 10:46 PM CHEST (PORTABLE AP) Clip # Reason: {See Clinical Indication Field} MEDICAL CONDITION: History: 28M with clonidine overdoseClinical Question: evaluate ET tube placement REASON FOR THIS EXAMINATION: {See Clinical Indication Field} FINAL REPORT INDICATION: 28-year-old male with clonidine overdose. | 5 | [
{
"category": "Radiology",
"chartdate": "2188-01-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1228779,
"text": " 3:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for interval change\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old man with intubated\n REASON FOR THIS EXAMINATION:\n evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM AT 338\n\n INDICATION: 28-year-old intubated, evaluate for interval change.\n\n Comparison to prior study at 2248.\n\n A semi-upright portable chest film at 4 a.m. is submitted and\n compared to the prior study of at 2248.\n\n IMPRESSION:\n\n 1. Endotracheal tube continues to have its tip 2.5 cm above the carina. A\n nasogastric tube is seen coursing below the diaphragm with the tip coiled\n within the stomach. Lung volumes remain relatively low with patchy opacity at\n the right base likely reflecting atelectasis. Aspiration or pneumonia would\n be less likely. No evidence of pulmonary edema or pneumothorax. No pleural\n effusions. Cardiac and mediastinal contours are stable and within normal\n limits given portable technique.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2188-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1228768,
"text": " 10:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 28M with clonidine overdoseClinical Question: evaluate ET tube\n placement\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 28-year-old male with clonidine overdose. Question ET tube\n placement.\n\n COMPARISON: None available.\n\n FINDINGS: Single frontal view of the chest demonstrates an ET tube extending\n 2.9 cm above the carina. An enteric tube traverses inferiorly out of view.\n The cardiac silhouette is prominent, accentuated by AP technique and low lung\n volume. There is a perihilar fullness likely representing mild congestion\n related to resuscitation. There is no pneumothorax or large effusion.\n\n IMPRESSION:\n 1. Lines and tubes appropriate in position.\n 2. Mild central vascular congestion, may be secondary to resuscitation.\n\n"
},
{
"category": "ECG",
"chartdate": "2188-01-14 00:00:00.000",
"description": "Report",
"row_id": 246177,
"text": "Sinus rhythm. Normal tracing. Since the previous tracing of there is\nprobably no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2188-01-14 00:00:00.000",
"description": "Report",
"row_id": 246178,
"text": "Normal sinus rhythm. Tracing is normal and unchanged from tracing #1.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2188-01-13 00:00:00.000",
"description": "Report",
"row_id": 246179,
"text": "Normal sinus rhythm. Tracing is within normal limits. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
}
] |
73,043 | 166,944 | #. Respiratory distress: Patient was requiring 100% NRB to maintain O2 sat of 100% and had a temperature of 102 on presentation to the ED. He was briefly on BiPAP due to concern of flash pulmonary edema. BiPAP was subsequently stopped and he was changed to NRB. On admission to the MICU his symptoms were much improved and patient weaned down to 3L NC on arrival. This was thought to be multifactorial given BNP> with weight gain and CXR consistent with multifocal PNA as well as fever and cough. He was started on treatment for HCAP with Vanco/Zosyn/Cipro. His respiratory status continued to improve and he was transfered to the medical floor on HD2. He remained afebrile while on the floor and O2 was weaned off. His antibiotic regimen was changed to ceftazidime (with HD) and cipro (PO) due to ease of dosing and adequate coverage. Vancomycin was discontinued as the patient was found to be MRSA nasal swab (-). | Also, atrial prematurebeats are absent. Mild (1+) mitral regurgitationis seen. Mild(1+) aortic regurgitation is seen. Mild-moderateregional LV systolic dysfunction. There is mildsymmetric left ventricular hypertrophy. Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is elongated. The left ventricular cavity size isnormal. No VSD.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo; inferior apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There is mild to moderate regional left ventricular systolicdysfunction with severe inferior and infero-lateral hypokinesis. The mitral valve leaflets are mildlythickened. Mild tomoderate [+] TR. Ventricular ectopy is no longer evident andlateral repolarization abnormalities are less striking. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate mitralannular calcification. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , the LVEF andRVEF have improved. Mediastinal and hilar contours are unchanged. Within this limitation, mild cardiomegaly persists. There issubtle basal anterior and anteroseptal hypokinesis. Left ventricular hypertrophy.Cannot exclude anterior wall myocardial infarction of indeterminate age. Normal interatrial septum.No ASD by 2D or color Doppler. Mild thickening of mitral valve chordae. Compared to the previous tracing of normal sinus rhythm hasgiven way to sinus tachycardia. PORTABLE AP SUPINE RADIOGRAPH: The left cardiac border is obscured by an ill-defined opacity in the left mid-to-lower lung zone. No LV mass/thrombus. Normal LV cavity size. Normal IVC diameter (<2.1cm) with >55% decreaseduring respiration (estimated RA pressure (0-5mmHg).LEFT VENTRICLE: Mild symmetric LVH. Alternatively asymmetric edema or less likely pulmonary hemorrhage can explain this radiographic appearance. The pulmonaryartery systolic pressure could not be determined. No resting LVOTgradient. The aorta is calcified and tortuous again. No masses or thrombi areseen in the left ventricle. No MVP. There is no mitral valve prolapse. There may be an left pleural effusion. Sinus tachycardia with first degree A-V block. PATIENT/TEST INFORMATION:Indication: Evaluate Left Ventricular Function and Valvular AbnormalitiesHeight: (in) 69Weight (lb): 143BSA (m2): 1.79 m2BP (mm Hg): 156/78HR (bpm): 87Status: InpatientDate/Time: at 10:44Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No AS. Rightventricular chamber size and free wall motion are normal. There is no ventricular septal defect. No TS. The tricuspid valve leaflets are mildly thickened. Clinical correlation issuggested. There is no pneumothorax. No atrial septal defect is seen by 2D or colorDoppler. The estimated right atrial pressure is 0-5 mmHg. T wavepeaking in lead V3 consistent with hyperkalemia, hyperacute anterior myocardialischemia and/or left ventricular hypertrophy. overload, pna etc FINAL REPORT INDICATION: Shortness of breath, query overload, pneumonia. Bilateral diaphragmatic pleural calcification is probably due to asbestos exposure, or, less likely, other remote pleural insult. Regional LV dysfunction is now more evident. IMPRESSION: Multifocal airspace opacification is consistent with pneumonia in the appropriate clinical setting. COMPARISON: ; . 5:10 AM CHEST (PORTABLE AP) Clip # Reason: ? Airspace opacification is also seen in the right middle lobe. | 3 | [
{
"category": "Radiology",
"chartdate": "2152-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1139385,
"text": " 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? overload, pna etc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old man with sob\n REASON FOR THIS EXAMINATION:\n ? overload, pna etc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, query overload, pneumonia.\n\n COMPARISON: ; .\n\n PORTABLE AP SUPINE RADIOGRAPH: The left cardiac border is obscured by an\n ill-defined opacity in the left mid-to-lower lung zone. Within this\n limitation, mild cardiomegaly persists. The aorta is calcified and tortuous\n again. Mediastinal and hilar contours are unchanged. Airspace opacification\n is also seen in the right middle lobe. There may be an left pleural effusion.\n There is no pneumothorax.\n\n IMPRESSION: Multifocal airspace opacification is consistent with pneumonia in\n the appropriate clinical setting. Alternatively asymmetric edema or less\n likely pulmonary hemorrhage can explain this radiographic appearance.\n Bilateral diaphragmatic pleural calcification is probably due to asbestos\n exposure, or, less likely, other remote pleural insult.\n\n"
},
{
"category": "Echo",
"chartdate": "2152-06-27 00:00:00.000",
"description": "Report",
"row_id": 60522,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate Left Ventricular Function and Valvular Abnormalities\nHeight: (in) 69\nWeight (lb): 143\nBSA (m2): 1.79 m2\nBP (mm Hg): 156/78\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 10:44\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with >55% decrease\nduring respiration (estimated RA pressure (0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild-moderate\nregional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT\ngradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Indeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The estimated right atrial pressure is 0-5 mmHg. There is mild\nsymmetric left ventricular hypertrophy. The left ventricular cavity size is\nnormal. There is mild to moderate regional left ventricular systolic\ndysfunction with severe inferior and infero-lateral hypokinesis. There is\nsubtle basal anterior and anteroseptal hypokinesis. No masses or thrombi are\nseen in the left ventricle. There is no ventricular septal defect. Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Mild\n(1+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , the LVEF and\nRVEF have improved. Regional LV dysfunction is now more evident.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2152-06-26 00:00:00.000",
"description": "Report",
"row_id": 110775,
"text": "Sinus tachycardia with first degree A-V block. Left ventricular hypertrophy.\nCannot exclude anterior wall myocardial infarction of indeterminate age. T wave\npeaking in lead V3 consistent with hyperkalemia, hyperacute anterior myocardial\nischemia and/or left ventricular hypertrophy. Clinical correlation is\nsuggested. Compared to the previous tracing of normal sinus rhythm has\ngiven way to sinus tachycardia. Ventricular ectopy is no longer evident and\nlateral repolarization abnormalities are less striking. Also, atrial premature\nbeats are absent.\n\n"
}
] |
22,182 | 136,054 | This is a 70 yo F with HTN, DM2, Dementia, and ESRD on HD who presented with altered mental status. In the ED she was noted to be febrile, hypotensive, tachycardic and with a lactate in 7's, so code sepsis was initiated; the patient had R femoral central access obtained and received 1L NS, CTX 1gm, and vancomycin 1gm. She was also given 1gm tylenol and haldol 2.5mg x1 and was subsequently admitted to the MICU. Given her initial presentation, there was concern for sepsis; yet she had no leukocytosis or bandemia. Overdialysis was a possibility, since it was reported that the patient was dialyzed down 4 kg. Her hypotension, elevated lactate, and tachycardia could be attributed to hypoperfusion. She responded to 1L of IVF and had a normal heart rate and stable BP. There was no evidence of seizure activity. Her CXR was without infiltrate. She underwent LP, and showed no evidence of meningitis. Her antibiotics were stopped by the MICU team and she was transferred to the floor. On the floor her blood cultures came back with 1/2 bottles of coag neg staph, likely a skin contaminant. Vancomycin levels were checked and she received vancomycin at hemodialysis. CSF cultures remained negative. The patient is being discharged on a 10 day course of vancomycin, to be dosed at hemodialysis for vanco levels less than 15. . The patient's altered mental status was of unclear etiology. Upon review of OMR notes, patient has presented similarly in past. Prior work-up has been unrevealing (EEG: normal, CT: old infacts). Her behavior has been noted to have a diurnal pattern, with the patient being more conversive in the evenings and mute/not interactive in the mornings. Previously, neurology had been following the patient and thought her MS changes were toxic/metabolic insults. Head CT showed no acute changes. CSF was without infection. Her hypercalcemia may be contributing to her mental status. Per her family, the patient was close to baseline. . The patient's hypercalcemia was thought to be due to tertiary hyperparathyroidism. Her cinacalcet was continued. PTH, TSH, and Vit D studies were sent as well. . The renal team was made aware of patient. Her metabolic acidosis was thought to be related to uremia and dehydration. She was dialyzed on Monday. Her anti-hypertensives were held pre-HD. She was given a dose of vancomycin at HD and cultures were drawn. Nephrocaps and sevelamer were continued. . The patient was continued on her outpatient medications. She is not recommended to go home on two nitrates for her hypertension. The Bblocker and ACE may be titrated up to reduce the need for two nitrates (isordil and NG paste). | SR without ectopy. alert to self only and appears confused. No BM noted this shift.GU: FOley placed. Mild bronchiectatic changes are again identified. NPO except meds. No pain issues at this time.Resp: Pt. IMPRESSION: 1) Slightly motion limited study; allowing for this, no evidence of acute intracranial hemorrhage. appears to be anuric.Skin: Intact. Breath sounds clear, diminished in bases. The -white matter differentiation appears otherwise preserved. No active bleeding. was responsive but aphasic. Skin W+D. Osseous and soft tissue structures are stable with thoracolumbar dextroscoliosis again noted. Upon arrival she was hypotensive, tachycardic and had a temp of 101. No SOBCVS: Pt. BS + Pt. No cough. Pulmonary vasculature is unremarkable. Afebrile at this time.GI: Abd. NS KVOEndo: Pt. Pt. Pt. The lungs are clear without evidence of infiltrate. + Pulses. After dialysis pt. IMPRESSION: No evidence of pneumothorax. PORTABLE CHEST: Cardiac, mediastinal, and hilar contours are stable. The lungs are clear without evidence of infiltrates. There are no pleural effusions. remains stable to be called out to floor in am. Unable to obtain good waveform. TECHNIQUE: Axial MDCT images through the brain without IV contrast. If pt. At this time pt. IMPRESSION: No evidence of pneumonia or overt CHF. The aorta is calcified and tortuous. FINDINGS: The study is slightly motion limited at several levels. LP site with bandaid. SBP 98-140. soft. MAE. A liter of fluid was given which pt. COMPARISON: . Again, demonstrated are small chronic infarcts in the thalami bilaterally, the right internal capsule, the pons, and the cerebellum. MDs were unsuccessful so R groin line placed. COMPARISONS: Head CT of and brain MR of . 's mental status changed and she was brought to EW. Allowing for this, there is no evidence to suggest acute intracranial hemorrhage. There is periventricular white matter hypodensity consistent with chronic small vessel infarction. There is no evidence of pneumothorax or pleural effusion. Finally, there appears to be a chronic slit hemorrhage in the right lentiform nucleus. Progress Note 7p-7sEvents: This is a 70yo female with a PMH of IDDM, CRF on HD and cataracts. responded to and she was transferred to MICU for further monitoring.Neuro: Upon arrival pt. had dialysis today in which they removed 4L. Multiple chronic small vessel infarctions. L upper arm fistula with 2 dresings C+D+IR TL groin line remains with minimal bleeding. COMPARISON: at 4:32 p.m. PORTABLE CHEST: Cardiac, mediastinal, and hilar contours are stable. Follows commands consistently. If clinical suspcion remains high, MRI would be more senstitive. AM labs pending on Q6h accuchecks with SSI coverage if neededPlan: Continue to monitor hemodynamics closely. Sinus rhythmRight atrial abnormalityLeft ventricular hypertrophy with ST-T wave abnormalitiesProminent inferolateral Q waves - could be due to left ventricular hypertrophySince previous tracing of , right atrial abnormality present, QRSvoltages more prominent and ST-T wave changes now seen Sepsis protocol initiated and multiple attempts made to place subclavian precep cath. 2) Multiple remote infarcts and hemorrhage but no CT evidence to suggest acute major vascular territorial infarction. Bone windows demonstrate no evidence of acute fracture or other osseous abnormality. 4:54 PM CT HEAD W/O CONTRAST Clip # Reason: eval for ich MEDICAL CONDITION: 70 year old woman with altered mental status REASON FOR THIS EXAMINATION: eval for ich No contraindications for IV contrast WET READ: MGGb 6:17 PM No acute ICH. on 4L NC with sats 98-100%. 7:04 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: eval for ptx MEDICAL CONDITION: 70 year old woman post mult unsuccessful line attempts on right REASON FOR THIS EXAMINATION: eval for ptx FINAL REPORT HISTORY: 70-year-old woman status post multiple unsuccessful line attempts on the right. 250cc bolus given for MAP of 51 at 0200 with good effect. After a couple of hours she stated, "I am mad at you people and I don't talk when I am mad". WET READ VERSION #1 FINAL REPORT INDICATION: 70-year-old with acute mental status changes, evaluate for hemorrhage. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2102-12-23 00:00:00.000",
"description": "Report",
"row_id": 1552825,
"text": "Progress Note 7p-7s\nEvents: This is a 70yo female with a PMH of IDDM, CRF on HD and cataracts. Pt. had dialysis today in which they removed 4L. After dialysis pt.'s mental status changed and she was brought to EW. Upon arrival she was hypotensive, tachycardic and had a temp of 101. Sepsis protocol initiated and multiple attempts made to place subclavian precep cath. MDs were unsuccessful so R groin line placed. Unable to obtain good waveform. A liter of fluid was given which pt. responded to and she was transferred to MICU for further monitoring.\n\nNeuro: Upon arrival pt. was responsive but aphasic. After a couple of hours she stated, \"I am mad at you people and I don't talk when I am mad\". At this time pt. alert to self only and appears confused. MAE. Follows commands consistently. No pain issues at this time.\n\nResp: Pt. on 4L NC with sats 98-100%. Breath sounds clear, diminished in bases. No cough. No SOB\n\nCVS: Pt. SR without ectopy. SBP 98-140. 250cc bolus given for MAP of 51 at 0200 with good effect. Skin W+D. + Pulses. Afebrile at this time.\n\nGI: Abd. soft. BS + Pt. NPO except meds. No BM noted this shift.\n\nGU: FOley placed. Pt. appears to be anuric.\n\nSkin: Intact. LP site with bandaid. No active bleeding. L upper arm fistula with 2 dresings C+D+I\n\nR TL groin line remains with minimal bleeding. NS KVO\n\nEndo: Pt. on Q6h accuchecks with SSI coverage if needed\n\nPlan: Continue to monitor hemodynamics closely. If pt. remains stable to be called out to floor in am. AM labs pending\n"
},
{
"category": "ECG",
"chartdate": "2102-12-22 00:00:00.000",
"description": "Report",
"row_id": 126273,
"text": "Sinus rhythm\nRight atrial abnormality\nLeft ventricular hypertrophy with ST-T wave abnormalities\nProminent inferolateral Q waves - could be due to left ventricular hypertrophy\nSince previous tracing of , right atrial abnormality present, QRS\nvoltages more prominent and ST-T wave changes now seen\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 896940,
"text": " 7:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman post mult unsuccessful line attempts on right\n REASON FOR THIS EXAMINATION:\n eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old woman status post multiple unsuccessful line attempts on\n the right.\n\n COMPARISON: at 4:32 p.m.\n\n PORTABLE CHEST: Cardiac, mediastinal, and hilar contours are stable.\n The lungs are clear without evidence of infiltrate. There is no evidence of\n pneumothorax or pleural effusion.\n\n IMPRESSION: No evidence of pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 896924,
"text": " 4:54 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ich\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for ich\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MGGb 6:17 PM\n No acute ICH. Multiple chronic small vessel infarctions.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old with acute mental status changes, evaluate for\n hemorrhage.\n\n COMPARISONS: Head CT of and brain MR of .\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n FINDINGS: The study is slightly motion limited at several levels. Allowing for\n this, there is no evidence to suggest acute intracranial hemorrhage. There is\n periventricular white matter hypodensity consistent with chronic small vessel\n infarction. Again, demonstrated are small chronic infarcts in the thalami\n bilaterally, the right internal capsule, the pons, and the cerebellum.\n Finally, there appears to be a chronic slit hemorrhage in the right lentiform\n nucleus. The -white matter differentiation appears otherwise preserved.\n Bone windows demonstrate no evidence of acute fracture or other osseous\n abnormality.\n\n IMPRESSION:\n 1) Slightly motion limited study; allowing for this, no evidence of acute\n intracranial hemorrhage.\n 2) Multiple remote infarcts and hemorrhage but no CT evidence to suggest acute\n major vascular territorial infarction. If clinical suspcion remains high, MRI\n would be more senstitive.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 896922,
"text": " 4:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old woman with altered mental status.\n\n COMPARISON: .\n\n PORTABLE CHEST: Cardiac, mediastinal, and hilar contours are stable. The\n aorta is calcified and tortuous. Pulmonary vasculature is unremarkable. Mild\n bronchiectatic changes are again identified. The lungs are clear without\n evidence of infiltrates. There are no pleural effusions. Osseous and soft\n tissue structures are stable with thoracolumbar dextroscoliosis again noted.\n\n IMPRESSION: No evidence of pneumonia or overt CHF.\n\n\n"
}
] |
8,908 | 100,761 | The patient was brought to the cardiac critical care unit with continued atrial fibrillation while on a diltiazem IV drip. He was subsequently cardioverted with 2 rounds of 1 mg ibutilide given IV. He remained in normal sinus rhythm thereafter. The cause of his atrial fibrillation was considered to be a benign response to vagal trigger. Given the patient's age and lack of other cardiac medical history, anticoagulation and antiarrhythmic medications are not necessary at this time. The patient was scheduled for an outpatient echocardiogram to evaluate for occult structural disease and also will follow-up with a cardiologist as an outpatient. | EKG THEN SHOWED AFIB. RECEIVED IBUTILIDE 1 MG X2. BP STABLE 117-124/65-69. TRANSFERED TO CCU FOR IBUTILIDE TREATMENT.NEURO: PT. UPDATE PT. HR IN ED WAS 180, GIVEN ADENOSINE. ST-T wave configuration suggests in part earlyrepolarization pattern but clinical correlation is suggested. Advised about potientail of bleeding post heparin. REMAINS IN SR RATE 70, NO VEA. bOwel sounds heard.ACCESSS:- Peripheral lines removed, dressing inplace.SKIN:- Pressure areas inatct. Heparin gtt stopped as going home.NEURO:- A&O x3, moving all 4 limbs well. "O: PT. MOVING ALL EXTREMITIES, TURNS SELF IN BED.CV: ON ARRIVAL TO CCU HR 104 AFIB NO VEA NOTED. + BOWEL SOUNDS. Atrial fibrillation. ECHO SCHEDULED FOR MONDAY .RESP: LUNGS CLEAR, O2 AT 2L VIA NC. CONVERTED TO SR AFTER RECEIVING 2ND DOSE OF IBUTILIDE. NO SHORTNESS OF BREATH.GI: KEPT NPO EXCEPT FOR MEDS. DENIES C/O CP. TREATED WITH DILT 10 MG IV AND PO 30 MG. Not coughing/expectorting sputum.CV:- Moniotored in NSR rate 60-80bpm with no ectopics.No further episodes of afib/tachy. NO ETOH, NO TOBACCO/ILLICIT DRUGS.A/P: AFIB NOW IN SR AFTER IBUTILIDE INFUSION. CCU Progress Note 0700-1000RESP:- N/C removed as Sa02 100 on room air, RR 16 and regular, bilateral air entry heard to all lung fields. Since the previoustracing earlier this date the ventricular rate is slower.TRACING #2 SBP 110-120. NO BM OVERNIGHT. STARTED ON DILT GTT AND TRANSFERED TO 6. CONT ON DILT GTT AT 10 MG/HR. No previous tracingavailable for comparison.TRACING #1 ECHO ON MONDAY, FOLLOW PTT WHILE ON HEPARIN. Since theprevious tracing earlier this date the ventricular rate is slower and ST-T wavechanges are more evident.TRACING #3 Able to go home with out help. IS A 24 Y/O MALE ADMITTED FROM 6 (INITIALLY ADMITTED FROM ED) S/P NEAR SYNCOPAL EPISODE ASSICIATED WITH PALPITATIONS. Discharge planning advice given.GU:- Voiding using urinal, no problems.GI:- Not wanting any breakfast. HEPARIN GTT AT 1700 UNITS/HR. NURSING PROGRESS NOTES: "WILL I FEEL THE MEDICINE? Atrial fibrillation with a rapid ventricular response. Atrial fibrillation with a rapid ventricular response. AND FAMILY ON PLAN OF CARE PER CCU TEAM. Discharge advice also given re management of further episodes. NO CP. NS AT 150 CC/HR FOR 1 LITER.GU: VOIDING AMBER COLORED URINE.SKIN INTACT.SOCIAL: LIVES ALONE, RECENT COLLAGE GRAD, WORKING AT AS LIFEGUARD. No problems.FAMILY:- Mother called, spoke to and updated on plan to go home.PLAN:- Can go home, follow up instructions given. ALERT AND ORIENTED X3, PLEASANT AND COOPERATIVE. Abdomen soft and non tender. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2113-07-30 00:00:00.000",
"description": "Report",
"row_id": 1379863,
"text": "CCU Progress Note 0700-1000\nRESP:- N/C removed as Sa02 100 on room air, RR 16 and regular, bilateral air entry heard to all lung fields. Not coughing/expectorting sputum.\n\nCV:- Moniotored in NSR rate 60-80bpm with no ectopics.No further episodes of afib/tachy. SBP 110-120. Heparin gtt stopped as going home.\n\nNEURO:- A&O x3, moving all 4 limbs well. Discharge planning advice given.\n\nGU:- Voiding using urinal, no problems.\n\nGI:- Not wanting any breakfast. Abdomen soft and non tender. bOwel sounds heard.\n\nACCESSS:- Peripheral lines removed, dressing inplace.\n\nSKIN:- Pressure areas inatct. No problems.\n\nFAMILY:- Mother called, spoke to and updated on plan to go home.\n\nPLAN:- Can go home, follow up instructions given. Able to go home with out help. Advised about potientail of bleeding post heparin. Discharge advice also given re management of further episodes.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2113-07-30 00:00:00.000",
"description": "Report",
"row_id": 1379862,
"text": "NURSING PROGRESS NOTE\nS: \"WILL I FEEL THE MEDICINE?\"\n\nO: PT. IS A 24 Y/O MALE ADMITTED FROM 6 (INITIALLY ADMITTED FROM ED) S/P NEAR SYNCOPAL EPISODE ASSICIATED WITH PALPITATIONS. HR IN ED WAS 180, GIVEN ADENOSINE. EKG THEN SHOWED AFIB. TREATED WITH DILT 10 MG IV AND PO 30 MG. STARTED ON DILT GTT AND TRANSFERED TO 6. TRANSFERED TO CCU FOR IBUTILIDE TREATMENT.\n\nNEURO: PT. ALERT AND ORIENTED X3, PLEASANT AND COOPERATIVE. SOMEWHAT ANXIOUS ABOUT ADMISSION TO CCU DUE TO HEART ARRYTHMIAS. MOVING ALL EXTREMITIES, TURNS SELF IN BED.\n\nCV: ON ARRIVAL TO CCU HR 104 AFIB NO VEA NOTED. CONT ON DILT GTT AT 10 MG/HR. DENIES C/O CP. RECEIVED IBUTILIDE 1 MG X2. CONVERTED TO SR AFTER RECEIVING 2ND DOSE OF IBUTILIDE. REMAINS IN SR RATE 70, NO VEA. NO CP. BP STABLE 117-124/65-69. HEPARIN GTT AT 1700 UNITS/HR. ECHO SCHEDULED FOR MONDAY .\n\nRESP: LUNGS CLEAR, O2 AT 2L VIA NC. NO SHORTNESS OF BREATH.\n\nGI: KEPT NPO EXCEPT FOR MEDS. + BOWEL SOUNDS. NO BM OVERNIGHT. NS AT 150 CC/HR FOR 1 LITER.\n\nGU: VOIDING AMBER COLORED URINE.\n\nSKIN INTACT.\n\nSOCIAL: LIVES ALONE, RECENT COLLAGE GRAD, WORKING AT AS LIFEGUARD. NO ETOH, NO TOBACCO/ILLICIT DRUGS.\n\nA/P: AFIB NOW IN SR AFTER IBUTILIDE INFUSION. ECHO ON MONDAY, FOLLOW PTT WHILE ON HEPARIN. UPDATE PT. AND FAMILY ON PLAN OF CARE PER CCU TEAM.\n"
},
{
"category": "ECG",
"chartdate": "2113-07-29 00:00:00.000",
"description": "Report",
"row_id": 199706,
"text": "Atrial fibrillation. ST-T wave configuration suggests in part early\nrepolarization pattern but clinical correlation is suggested. Since the\nprevious tracing earlier this date the ventricular rate is slower and ST-T wave\nchanges are more evident.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2113-07-29 00:00:00.000",
"description": "Report",
"row_id": 199707,
"text": "Atrial fibrillation with a rapid ventricular response. Since the previous\ntracing earlier this date the ventricular rate is slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2113-07-29 00:00:00.000",
"description": "Report",
"row_id": 199943,
"text": "Atrial fibrillation with a rapid ventricular response. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
}
] |
23,219 | 162,986 | The patient was admitted on to the CSRU for close monitoring. Echo here revealed tamponade physiology and on HD#1 he underwent pericardiocentesis by Dr. and 500 cc of fluid was drained. The patient tolerated the procedure well and his symptoms resolved. An echo the following morning revealed reaccumulation of the fluid and Dr. of thoracic surgery was consulted. On he had a R VATS for a loculated pericardial effusion and tolerated the procedure well. On POD#2 the drain was d/c'd and on POD#3, the other drain was d/c'd. He grew out gm + rods from the pericardial fluid and he was evaluated by ID. He had a negative Lyme titer and stool samples sent. They felt no furhter treatment was needed. He was discharged to home in stable condition on POD#4. | hypo bsp. CT OF CHEST W/ CONTRAST DONE.FAMILY AT BESIDE.NO NEW ISSUES.ASSESS: STABLE VS THOUGH INCREASED EFFUSIONPLAN: MIN INV WINDOW . update/post-oppt s/p rt vats, pericardial window.return from OR s/p above. min serosang dng. +palp pp.Resp: lungs clear. pain level now to 1 when at rest. His echo showed a loculated pericardial effusion. abd sot. S/p pericardial window.Height: (in) 68Weight (lb): 211BSA (m2): 2.09 m2BP (mm Hg): 120/70HR (bpm): 60Status: InpatientDate/Time: at 12:00Test: TTE (Focused views)Doppler: Limited Doppler and no color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .RIGHT ATRIUM/INTERATRIAL SEPTUM: The IVC is normal in diameter withappropriate phasic respirator variation.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Normal aortic valve leaflets.MITRAL VALVE: Normal mitral valve leaflets.TRICUSPID VALVE: Normal PA systolic pressure.PERICARDIUM: Small to moderate pericardial effusion. re-admitted to today, s/p x3 on . Ocaasional cough.CV: In NSR. BP stable. had normal post-op course. tol po intake. oob to ch w/ min assist of 2. PATIENT AFEBRILE VSS, NO C/O PAIN. There is a small to moderatesized partially echo filled predominantly anterior pericardial effusion (1.3cmaround he basal right ventricle, 2.0cm anterior to the right atrium and distalright ventricle) without evidence for hemodynamic compromise.Compared with the prior study (images reviewed) of , the size of theeffusion is reduced, the IVC now demonstrates normal respiratory variation,and tamponade physiology is no longer suggested. Slightly elevated before meds. to have repeat echo in a.m NPO. OF SEROSANG FLUID. MD in, stripped tubes for 210cc. +bs, 2 loose bm's, guaiac neg. ppp, extrem warm bilat.gi: belly soft/nt/nd. No c/o sob.GI: Abd soft. Stress test was normal per pt. Will continue to monitor.Skin: Intact.Activity: Bedrest w/ commode priviledges.A: Stable.P: Await echo results and then remove pericardial drain pnd results. PT W/ CONT CARDIAC EFFUSION. pt. Pt. Pt. Pt. BP stable thru day. UPDATEPT AA0X3. ECHO showed a small effusion.GI: taking po, tolerated well. Start on ketorolac IM for comfort with good relief. nsr, no ectope noted, rate 60s. rt tube x2. CSRU NPN 7-11aNeuro: Alert and appropriate. ECHO in am for further eval. uop marginal. Pericardial drain to gravity with small amts serousang dng. pt pain level then to 10 / 10. mso4 iv w/ min effect. The estimatedpulmonary artery systolic pressure is normal. RA O2 sat stable. PLAN FOR THORACIC TO DO MIN INVASSIVE WINDOW . lungs coarse rt and fine crackles through left. Encouraged po fluids. SO in room much of afternoon.assess: stable post-op w/ pain control issue, now pain level to 1plan: pulm hygiene Flushed x1 without difficulty. VSS AS PER FLOWSHEET. remove drain later.Resp: BS diminished at lower lobes bilat, faint rales posteriorly left base. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. DRAIN IRRIGATE BY FELLOW THEN D/C. tol cardiac diet well, denies nausea. Moving around in bed independently.CV: bp labile. 2100, AWAKENED AT APPROX. Sgnificant, accentuated respiratoryvariation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.Conclusions:The left ventricular cavity size is normal. No aortic regurgitation isseen.7.The mitral valve leaflets are mildly thickened. Mild [1+] TR.PERICARDIUM: Large pericardial effusion. Normal ascending aorta diameter.Normal descending aorta diameter. Simple atheroma in descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets. Left ventricular systolic functionappears grossly preserved. Moderate pericardial effusion containing air, likley post- tapping. There is brief right atrial diastolic collapse. Normal RV systolic function.AORTA: Moderately dilated aortic arch.AORTIC VALVE: Mildly thickened aortic valve leaflets. The rightventricle is significantly compressed and there is right ventricular diastoliccollapse, consistent with impaired fillling/tamponade physiology. There are simple atheroma in the descending thoracic aorta.6.The aortic valve leaflets are mildly thickened. FINDINGS: The right chest tubes have been removed. Noaortic regurgitation is seen. No MR.TRICUSPID VALVE: Tricuspid valve not well visualized.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: Large pericardial effusion. Status post sternotomy, with prominent cardiomediastinal silhouette, elevated right hemidiaphragm, and patchy opacity right base. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The aortic arch is moderately dilated. Dilated IVC (>2.5 cm).LEFT VENTRICLE: Normal LV wall thickness. The pericardial effusion is moderate and contains scattered air likely related to previous drainage. Mild global RV free wall hypokinesis.AORTA: Focal calcifications in aortic root. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Question small right pleural effusion. A small right pleural effusion. There is mild global rightventricular free wall hypokinesis.5. Pericardial effusion.Height: (in) 68Weight (lb): 205BSA (m2): 2.07 m2BP (mm Hg): 126/60HR (bpm): 72Status: InpatientDate/Time: at 11:04Test: Portable 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: Normal LV cavity size.RIGHT VENTRICLE: Normal RV chamber size.MITRAL VALVE: Mildly thickened mitral valve leaflets.PERICARDIUM: Large pericardial effusion. Unchanged small retrocardiac atelectasis. IMPRESSION: Compared with , low lung volumes, probable new CHF. Right-sided chest tube present. Small left and tiny right pleural effusion. The right ventricular cavity is unusually small. The right ventricular cavity is unusually small. REASON FOR THIS EXAMINATION: eval post op FINAL REPORT INDICATION: Status post right VATS and pericardial window. CHEST, SINGLE AP VIEW, LORDOTIC POSITIONING: Status post sternotomy, with prominence of the cardiomediastinal silhouette. Low normal LVEF.RIGHT VENTRICLE: Small RV cavity. There is a small to moderate sized pericardial effusion. There is right ventricular compression. IMPRESSION: Mild bibasilar atelectasis and tiny bilateral pleural effusions, unchanged. Compared with , there is some increased retrocardiac opacity with interval obscuration of the left hemidiaphragm, probably with a small left pleural effusion. Clinicalcorrelation is recommended.Compared with the prior study (images reviewed) of , the pericardialeffusion appears larter. The right hemidiaphragm remains elevated with atelectasis in the adjacent right lower lobe. | 25 | [
{
"category": "Nursing/other",
"chartdate": "2175-07-12 00:00:00.000",
"description": "Report",
"row_id": 1565593,
"text": "7a-7p\nneuro: AAOx3, follows commands, moving all extremites\n\ncv: hr nsr, no ectopy, sbp stable(111-140), po zestril, norvasc, & lopressor\n\nresp: on room air, bs+ all lobes & clear, sat 95-97, rr 18-20, no resp distress noted, no c/o sob\n\ngi: npo for cath lab today, po colace held due to loose stool last noc, po protonix\n\ngu: foley patent, clear yellow urine, good uo\n\nother: bedsisde cardiac echo done this am, family called & updated on pt's condition, pt to cath lab @ 1600 for pericardial tap\n\nplan: continue to monitor pt in icu overnoc post procedure, tx to floor tomorrow if stable, possible OR if tap not successful\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-12 00:00:00.000",
"description": "Report",
"row_id": 1565594,
"text": "addendum\nreturned from cath lab @ 1815, 2 l np, AAOx3, bs+ all lobes & clear, vss, 500 cc's pericardial fluid removed, fluid sent for culture, 1.5 mg iv versed & 75 mics fentanyl given total for procedure, R groin sheath site c&d, no hematoma noted, pt with R leg straight x 4 hrs, distal pulses palpable, arterial & venous sheaths dc'd in cath lab @ 1750, may resume diet this pm, girlfriend in & updated on pt's condition, repeat bedside cardiac echo in am, pericardial drain in with drainage bag to gravity, no drainage noted, no bleeding noted from site\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-13 00:00:00.000",
"description": "Report",
"row_id": 1565595,
"text": "nursing progress note\n\nneuro: pt a+ox3, mae, following commands well, making needs known.\n\nresp: ls clear throughout, denies sob/distress since return from cath lab. o2 sats down to 90-92% when sleeping, nc o2 applied prn.\n\ncv: vss, afebrile. nsr, no ectope noted, rate 60s. c/o moderate pain to pericardial catheter site, catheter draining sm amts serosang drainage. cath site to right groin clean, no hematoma. ppp, extrem warm bilat.\n\ngi: belly soft/nt/nd. tol cardiac diet well, denies nausea. taking po fluids well.\n\ngu: foley patent clear yellow, volume drifting downward overnight, given fluid bolus 250cc x1 w/ good effect.\n\nid: afebrile.\n\nskin: pericardial drain site clean, slightly reddened, tender to touch. cardiology fellow in last evening to assess. old cabg incision healed.\n\nsocial: no family contact overnight.\n\na/p: s/p cardiac cath w/ pericardial effusion tap, drain left in place. pt c/o mild pain to drain area, percocet effective for relief. hemodynamics stable, pt denies any dyspnea, stating \"i cant believe how much better I feel than before the cath\". plan for transfer to floor today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-13 00:00:00.000",
"description": "Report",
"row_id": 1565596,
"text": "See and Carevue for complete documentation\nNeuro: Patient alert, oriented. Start on ketorolac IM for comfort with good relief. No percocet needed today. Denies pain. Remains on bedrest.\nResp: In RA with SATs >92%. BS clear and equal. Ocaasional cough.\nCV: In NSR. BP stable thru day. Slightly elevated before meds. Pericardial drain in place with scant amounts of s/s drainage (<5ml). Flushed x1 without difficulty. ECHO showed a small effusion.\nGI: taking po, tolerated well. Glucose elevated. No insulin as per due to patient length out from CABG.\nGU: Low urine output. Encouraged po fluids. DTV 8pm.\nSocial: Sig other into visit. Patient remains in good spirirts despite lack of progress, ICU stay.\nPlan: Continue cardiopulmonary monitoring. Keep drain in overnight, flush per protocol every 8 hours. ECHO in am for further eval.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-16 00:00:00.000",
"description": "Report",
"row_id": 1565602,
"text": "\n7 PM - 7 AM\nLOCULATED PERICARDIAL EFFUSION\nRIGHT VATS\nPERICARDIAL WINDOW ...\n\nCOMPLAINTS OF ^^ RIGHT CHEST TUBE SITE PAIN AT 0600.. REQUESTING CT REMOVAL..USING MS04 PCA FREQUENTLY THROUGHOUT THE NIGHT .. SEE FLOWSHEET FOR ATTEMPTS/INJECTIONS...\nCV HR 70-80'S SINUS ..SBP 100-110'S/60'S...VIA LEFT RADIAL ALINE\nRESP ON 5L NP .RR 22-24 ..SHALLOW ...CXS ON RIGHT ..COARSE LEFT BASE.. WEAK NON-PROD COUGH ...SEE FLOWSHEET FOR MOST RECENT ABG\nGI TOLERATING SIPS OF CLEAR LIQUIDS ..ABD SOFT ..DENIES FLATUS\nGU DIURESED WITH 20 MG IV LASIX....\nCT DSG INTACT ..MINIMAL OUTPUT UNTIL 0500 ..200 CC SEROUS ....\nA HYPOXIC FOLLOWING RIGHT VATS/PERICARDIAL WINDOW ..ALTHOUGH DENYING SOB .. SIGNIFICANT PAIN CONTROL ISSUES\nWOULD CONSIDER ^^ MS04 PCA\n^^ 02 DELIVERY\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-11 00:00:00.000",
"description": "Report",
"row_id": 1565591,
"text": "Pt. re-admitted to today, s/p x3 on . Pt. had normal post-op course. to home and feeling well; walking up to 3 miles. Noted that this was becoming more difficult. pt. having sob/DOE past 5 days. Had stress test yesterday and stated his complaints to the MD. Stress test was normal per pt. but he felt sob. His echo showed a loculated pericardial effusion. Chest CT done. Transferred here for further eval.\nAdmitted to CSRU: IV placed left hand, labs sent, EKG, PCXR, Foley placement attempted with difficulty requiring Lido gel and #16 foley placed by resident. Pt. to have repeat echo in a.m NPO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-12 00:00:00.000",
"description": "Report",
"row_id": 1565592,
"text": "11p-7a\n\nNeuro: alert + oriented x3. Denies pain. Moving around in bed independently.\n\nCV: bp labile. SR 70's. +palp pp.\n\nResp: lungs clear. Sats 95%/RA.\n\nGI/GU: NPO. +bs, 2 loose bm's, guaiac neg. Foley patent, urine yellow, qs.\n\nSkin: sternal incision healed.\n\nFamily: no contacts over night.\n\nPlan: cont to monitor hemodynamics/resp status.\nEcho this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-14 00:00:00.000",
"description": "Report",
"row_id": 1565597,
"text": "PATIENT NPO SINCE MN, SLEEPING SINCE APPROX. 2100, AWAKENED AT APPROX. 1AM TO CHECK TEMP, AT THIS TIME PATIENT VOIDED 180CC . PATIENT AFEBRILE VSS, NO C/O PAIN. PERICARDIAL CATHETER FLISHED AS ORDERED WITH OUT DIFFICULTY DRAINING SMALL AMT. OF SEROSANG FLUID. PLAN TO FLUSH AT 6AM, AND GIVE PATIENT TORADOL. PLAN TO DO TEE THIS AM EVALUATE , NEED WINDOW.. PATIENT ON BEDREST TIL CATHTER DCD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-14 00:00:00.000",
"description": "Report",
"row_id": 1565598,
"text": "CSRU NPN 7-11a\n\nNeuro: Alert and appropriate. MAE equally.\n\nCV: NSR with rate 60-70's. BP stable. Skin warm, dry. Pericardial drain to gravity with small amts serousang dng. Plan for TTE today and then ? remove drain later.\n\nResp: BS diminished at lower lobes bilat, faint rales posteriorly left base. RA O2 sat stable. No c/o sob.\n\nGI: Abd soft. NPO for echo.\n\nGU: Has not voided. NP. Order for flomax discontinued as pt not on pre op. Pt states he does not feel uncomfortable or that he cannot void. Will continue to monitor.\n\nSkin: Intact.\n\nActivity: Bedrest w/ commode priviledges.\n\nA: Stable.\n\nP: Await echo results and then remove pericardial drain pnd results. ? transfer to 2 later?\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-14 00:00:00.000",
"description": "Report",
"row_id": 1565599,
"text": " UPDATE\nPT AA0X3. VSS AS PER FLOWSHEET. PT W/ CONT CARDIAC EFFUSION. DRAIN IRRIGATE BY FELLOW THEN D/C. PLAN FOR THORACIC TO DO MIN INVASSIVE WINDOW . PT NOW TAKING PO AND OOB, TOL BOTH W/OUT INCIDENT. CT OF CHEST W/ CONTRAST DONE.\nFAMILY AT BESIDE.\nNO NEW ISSUES.\nASSESS: STABLE VS THOUGH INCREASED EFFUSION\nPLAN: MIN INV WINDOW .\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-15 00:00:00.000",
"description": "Report",
"row_id": 1565600,
"text": "nursing note (7p-7a): OR for minimally invasive pericardial window, pre-procedure sheet started still need consent\n\nneuro: a&ox3, mae's & follows commands, oob to chair, independent for adl's, slept most of night w/no complaints\n\nresp: lungs cta, no supplemental o2, sats>94% for shift\n\ncv: hemodynamically stable, hr 70's w/no ectopy, sbp> 110, kcl peripheral IV gtt started @ midnight @ 70cc/hr, type and screen sent\n\ngu/gi: NPO since midnight except for meds, voids in urinal, +bs/-bm,\n\nendo: ssri\n\ngoal/plan: to OR for pericardial window, consent needed by thoracic & anesthesia\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-07-15 00:00:00.000",
"description": "Report",
"row_id": 1565601,
"text": " update/post-op\npt s/p rt vats, pericardial window.\n\nreturn from OR s/p above. vss. uop marginal. ivf at 70cc/hr. nsr, no ect. rt tube x2. min serosang dng. MD in, stripped tubes for 210cc. pt pain level then to 10 / 10. mso4 iv w/ min effect. toradol 15 mg iv w/ only mod effect. PCA ordered and being used approp. pain level now to 1 when at rest. using IS to ~750cc. strong non-pro cough. lungs coarse rt and fine crackles through left. tol po intake. abd sot. hypo bsp. oob to ch w/ min assist of 2. SO in room much of afternoon.\nassess: stable post-op w/ pain control issue, now pain level to 1\nplan: pulm hygiene\n"
},
{
"category": "Echo",
"chartdate": "2175-07-17 00:00:00.000",
"description": "Report",
"row_id": 81239,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Pericarditis. S/p pericardial window.\nHeight: (in) 68\nWeight (lb): 211\nBSA (m2): 2.09 m2\nBP (mm Hg): 120/70\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 12:00\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\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The IVC is normal in diameter with\nappropriate phasic respirator variation.\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\nAORTIC VALVE: Normal aortic valve leaflets.\n\nMITRAL VALVE: Normal mitral valve leaflets.\n\nTRICUSPID VALVE: Normal PA systolic pressure.\n\nPERICARDIUM: Small to moderate pericardial effusion. No RV diastolic collapse.\nNo significant respiratory variation in mitral/tricuspid valve flows.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and systolic function are normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets appear structurally normal with good leaflet\nexcursion. The mitral valve leaflets are structurally normal. The estimated\npulmonary artery systolic pressure is normal. There is a small to moderate\nsized partially echo filled predominantly anterior pericardial effusion (1.3cm\naround he basal right ventricle, 2.0cm anterior to the right atrium and distal\nright ventricle) without evidence for hemodynamic compromise.\n\nCompared with the prior study (images reviewed) of , the size of the\neffusion is reduced, the IVC now demonstrates normal respiratory variation,\nand tamponade physiology is no longer suggested.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2175-07-15 00:00:00.000",
"description": "Report",
"row_id": 81139,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for evacuation of pericardial hematoma\nHeight: (in) 68\nWeight (lb): 210\nBSA (m2): 2.09 m2\nBP (mm Hg): 145/67\nHR (bpm): 61\nStatus: Inpatient\nDate/Time: at 09:42\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial\nseptum. No ASD by 2D or color Doppler. Dilated IVC (>2.5 cm).\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Low normal LVEF.\n\nRIGHT VENTRICLE: Small RV cavity. Mild global RV free wall hypokinesis.\n\nAORTA: Focal calcifications in aortic root. Normal ascending aorta diameter.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\n\nPERICARDIUM: Large pericardial effusion. Effusion echo dense, c/w blood,\ninflammation or other cellular elements. Effusion is loculated. Brief RA\ndiastolic collapse. RV diastolic collapse, c/w impaired fillling/tamponade\nphysiology.\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:\n1.No atrial septal defect is seen by 2D or color Doppler.\n\n2.The inferior vena cava and superior vena cava are dilated (>2.5 cm).\n\n3. Left ventricular wall thicknesses are normal. The left ventricular cavity\nis unusually small. Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is low normal (LVEF 50-55%).\n\n4. The right ventricular cavity is unusually small. There is mild global right\nventricular free wall hypokinesis.\n\n5. There are simple atheroma in the descending thoracic aorta.\n\n6.The aortic valve leaflets are mildly thickened. No aortic regurgitation is\nseen.\n\n7.The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\n8.The tricuspid valve leaflets are mildly thickened.\n\n9.There is a large pericardial effusion. The effusion is echo dense,\nconsistent with blood, inflammation or other cellular elements. The effusion\nappears loculated. There is brief right atrial diastolic collapse. There is\nright ventricular diastolic collapse, consistent with impaired\nfillling/tamponade physiology.\n\n10. Post evacuation the effusion size is reduced to 0.5 cm and the right\nventricular filling is much improved.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2175-07-14 00:00:00.000",
"description": "Report",
"row_id": 81240,
"text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery. Pericardial effusion.\nHeight: (in) 68\nWeight (lb): 205\nBSA (m2): 2.07 m2\nBP (mm Hg): 126/60\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 11:04\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: Normal LV cavity size.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nPERICARDIUM: Large pericardial effusion. Sgnificant, accentuated respiratory\nvariation in mitral/tricuspid valve inflows, c/w impaired ventricular filling.\n\nConclusions:\nThe left ventricular cavity size is normal. Left ventricular systolic function\nappears grossly preserved. Right ventricular chamber size is normal. The\nmitral valve leaflets are mildly thickened. There is a large pericardial\neffusion with diffuse stranding/organization/loculation. There is significant,\naccentuated respiratory variation in mitral valve inflows, consistent with\nimpaired ventricular filling. There is right ventricular compression. Clinical\ncorrelation is recommended.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion appears larter.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2175-07-13 00:00:00.000",
"description": "Report",
"row_id": 81262,
"text": "PATIENT/TEST INFORMATION:\nIndication: Serial effusion f/u 24 hrs s/p pericardiocentesis of 500cc .\nHeight: (in) 68\nWeight (lb): 205\nBSA (m2): 2.07 m2\nBP (mm Hg): 149/71\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 14:40\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no 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 cavity size.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPERICARDIUM: Small to moderate pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nConclusions:\n1. The left ventricular cavity size is normal.\n2. The aortic valve leaflets are mildly thickened. The mitral valve leaflets\nare mildly thickened.\n3. There is a small to moderate sized pericardial effusion. There are no\nechocardiographic signs of tamponade.\n4. Compared with the prior study (images reviewed) of , there is no\nsignificant change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2175-07-12 00:00:00.000",
"description": "Report",
"row_id": 81290,
"text": "PATIENT/TEST INFORMATION:\nIndication: S/P recent CABG . Evaluate effusion\nHeight: (in) 68\nWeight (lb): 205\nBSA (m2): 2.07 m2\nBP (mm Hg): 139/83\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 08:58\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Small RV cavity. Normal RV systolic function.\n\nAORTA: Moderately dilated aortic arch.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Large pericardial effusion. RV diastolic collapse, c/w impaired\nfillling/tamponade physiology.\n\nConclusions:\nThere is symmetric left ventricular hypertrophy. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). The right ventricular cavity is unusually small. Right ventricular\nsystolic function is normal. The aortic arch is moderately dilated. The aortic\nvalve leaflets are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nNo mitral regurgitation is seen. There is a large pericardial effusion that is\nsomewhat loculated (most prominent adjacent to the right ventricle). The right\nventricle is significantly compressed and there is right ventricular diastolic\ncollapse, consistent with impaired fillling/tamponade physiology. Clinical\ncorrelation recommended.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2175-07-12 00:00:00.000",
"description": "Report",
"row_id": 81263,
"text": "PATIENT/TEST INFORMATION:\nIndication: Focused imaging in the cath lab during tap and immediately after completion of 520cc tap.\nHeight: (in) 68\nWeight (lb): 205\nBSA (m2): 2.07 m2\nBP (mm Hg): 111/82\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 17:54\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPERICARDIUM: Large pericardial effusion.\n\nConclusions:\nThere was initially a large pericardial effusion adjacent to the right\nventricle (best appreciated on subcostal views) as noted earlier today. The\npericardiocentesis catheter was noted in the pericardial space. Following\npericardiocentesis of ~500 cc of fluid, there was minimal pericardial effusion\nnoted in subcostal views.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2175-07-11 00:00:00.000",
"description": "Report",
"row_id": 198069,
"text": "Sinus rhythm\nPoor R wave progression - is nonspecific and could be in part positional but\nconsider also prior anteroseptal myocardial infarction\nDiffuse nonspecific ST-T wave changes\nClinical correlation is suggested\nSince previous tracing of , inferior Q waves less prominent and ST-T\nwave changes present\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-07-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920153,
"text": " 1:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ptx?\n Admitting Diagnosis: CARDIAC TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old M s/p R. VATS, pericardial window, drainage of loculated\n pericardial effusion.\n REASON FOR THIS EXAMINATION:\n ptx?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right VATS pericardial window, drainage of loculated\n pericardial effusion, question pneumothorax.\n\n CHEST, SINGLE AP VIEW, LORDOTIC POSITIONING:\n\n Status post sternotomy, with prominence of the cardiomediastinal silhouette.\n Compared with , there is some increased retrocardiac opacity with\n interval obscuration of the left hemidiaphragm, probably with a small left\n pleural effusion. There is upper zone redistribution and diffuse vascular\n blurring, consistent with CHF. Question small right pleural effusion.\n\n Right IJ central line is present, tip over proximal SVC. No pneumothorax is\n detected.\n\n IMPRESSION: Compared with , low lung volumes, probable new CHF. New\n left lower lobe collapse and/or consolidation and small effusion. Question\n minimal subcutaneous emphysema at the right lower chest wall, but no\n pneumothorax identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-07-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 920525,
"text": " 1:43 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p drain removal, eval ptx\n Admitting Diagnosis: CARDIAC TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old M s/p R. VATS, pericardial window, drainage of loculated\n pericardial effusion.\n REASON FOR THIS EXAMINATION:\n s/p drain removal, eval ptx\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: S/P drain removal, evaluate pneumothorax. 65-year-old man\n S/P right VATS with pericardial window.\n\n Comparison is made with prior study performed a day before.\n\n FINDINGS: The right chest tubes have been removed. There is no pneumothorax.\n The right hemidiaphragm remains elevated with atelectasis in the adjacent\n right lower lobe. A small right pleural effusion. Unchanged small\n retrocardiac atelectasis. Persistent marked enlargement of the cardiac\n silhouette likely secondary to the patient's known pericardial effusion.\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-07-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 920350,
"text": " 9:45 AM\n CHEST (PA & LAT) Clip # \n Reason: eval post op\n Admitting Diagnosis: CARDIAC TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old M s/p R. VATS, pericardial window, drainage of loculated\n pericardial effusion.\n REASON FOR THIS EXAMINATION:\n eval post op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right VATS and pericardial window.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS OF THE CHEST: The patient is status post median\n sternotomy and CABG. There is persistent marked enlargement of the cardiac\n silhouette, likely secondary to the patient's known pericardial effusion.\n There is persistent elevation of the right hemidiaphragm with two right\n basilar chest tubes in place. Bibasilar atelectasis is present, right greater\n than left. Small bilateral pleural effusions are unchanged. There is no\n pneumothorax. Pulmonary vascularity is within normal limits.\n\n IMPRESSION:\n Mild bibasilar atelectasis and tiny bilateral pleural effusions, unchanged.\n Marked enlargement of the cardiac silhouette secondary to the patient's known\n pericardial effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920303,
"text": " 7:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: chest tubes to bulb sxn; assess interval change\n Admitting Diagnosis: CARDIAC TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p CABG\n\n REASON FOR THIS EXAMINATION:\n chest tubes to bulb sxn; assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: _____ chest tubes to bulb suction. Assess interval change.\n\n CHEST, SINGLE AP VIEW.\n\n Status post sternotomy, with prominent cardiomediastinal silhouette, elevated\n right hemidiaphragm, and patchy opacity right base. No CHF. Minimal blunting\n of right greater than left costophrenic angle, without other evidence of\n effusion. No pneumothorax detected. Right-sided chest tube present.\n\n Compared with , the right IJ sheath has been removed. Otherwise,\n possible interval improvement in CHF findings.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-07-14 00:00:00.000",
"description": "CT CHEST W&W/O C",
"row_id": 920055,
"text": " 4:03 PM\n CT CHEST W&W/O C Clip # \n Reason: please evaluate pericardial tamponade, pre-op for pericardia\n Admitting Diagnosis: CARDIAC TAMPONADE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with pericardial tamponade reaccumulation after tap\n REASON FOR THIS EXAMINATION:\n please evaluate pericardial tamponade, pre-op for pericardial window\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Susceptible pericardial tamponade in patient with\n known pericardial effusion after tap with history of CABG one month ago.\n\n COMPARISON: Chest radiograph from .\n\n TECHNIQUE: MDCT of chest before and after injection of 100 cc of IV contrast\n was obtained from the level of the thoracic inlet to the level of the\n upper abdomen.\n\n FINDINGS: The patient is status post median sternotomy with no evidence of\n sternal dehiscence or osteomyelitis. Mild fat stranding is demonstrated\n within the anterior chest wall and may represent postoperative sequela but\n infectious process cannot be ruled out.\n\n Multiple enlarged mediastinal lymph nodes involve all the stations being\n largest in the supracarinal, prevascular, and the left lower paratracheal\n areas measuring up to 1.8 cm.\n\n There are large bilateral hilar lymph nodes, the largest on the right,( series\n 7, image 32.)\n\n The heart is enlarged. At least two bypasses are visualized. The pericardial\n effusion is moderate and contains scattered air likely related to previous\n drainage. The density of this effusion is low, up to 8 Hounsfield units. There\n is a small left and tiny right pleural effusion, both also measuring low\n density of up to 4 Hounsfield units.\n\n The pulmonary windows demonstrate patent airways to the level of segmental\n bronchi. There are no pulmonary nodules or masses. The focal area of\n bronchiectasis in the medial basal segment of the right lower lobe just\n adjacent to the spine is most probably due to new osteophyte, fibrosis, and\n traction.\n\n The images of the upper abdomen demonstrate normal liver, spleen, gallbladder,\n and pancreas. There are no lytic or sclerotic lesions suspicious for\n malignancy.\n\n IMPRESSION:\n\n 1. Moderate pericardial effusion containing air, likley post- tapping.\n (Over)\n\n 4:03 PM\n CT CHEST W&W/O C Clip # \n Reason: please evaluate pericardial tamponade, pre-op for pericardia\n Admitting Diagnosis: CARDIAC TAMPONADE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Mediastinal lymphadenopathy of uncertain etiolgy, possibly reactive.\n\n 3. Small left and tiny right pleural effusion.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-07-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 919652,
"text": " 9:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG readmitted w/pericardial effusion\n Admitting Diagnosis: CARDIAC TAMPONADE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p CABG\n\n REASON FOR THIS EXAMINATION:\n s/p CABG readmitted w/pericardial effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of patient after CABG, readmitted with\n pericardial effusion.\n\n AP chest radiograph compared to and to .\n\n The patient is status post median sternotomy and CABG. The heart size is\n markedly enlarged in comparison to , which was done immediately\n postoperatively. The lungs are clear. There is no congestive heart failure\n or focal pulmonary infiltrates. There is no sizeable pleural effusion.\n\n IMPRESSION:\n 1. Markedly enlarged cardiac silhouette, likely due to known pericardial\n effusion.\n 2. No evidence of congestive heart failure.\n\n"
}
] |
21,745 | 115,254 | 87 year old female with a large hiatal and probable aspiration events, admitted with worsening shortness of breath, with imaging studies showing progression of her multifocal infiltrates. 1. Multifocal pneumonia and ? RML abscess: Pulmonary was consulted on admission, and she was placed on Ceftriaxone and Flagyl for coverage of probable multifocal aspiration pneumonia. Blood cultures drawn prior to initiation of antibiotics remained negative. Given concern over aspiration events, she was evaluated by speech and swallow, and a barium swallow was obtained on which revealed retention of contrast in the hernia without overt reflux. The study, however, was limited by poor patient compliance. On , she was noted to be more somnolent, with increasing oxygen requirement and a temperature to 101.7. Vancomycin was added for broader coverage. A CXR obtained at that time showed some pulmonary edema, and she was treated with Lasix diuresis. She, however, remained somnolent, and an ABG obtained the following morning showed 7.34/62/65. She was transferred to the MICU for further monitoring and management. She spontaneously improved, and did not require BiPAP. Her decompensation was ultimately attributed to anxiolytic administration. She was transferred back to the floor after 1 day in the ICU. While in the ICU, an echo was obtained, which showed preserved systolic function, evidence of diastolic dysfunction, and non-significant valvular disease. Note was made of thickened MV valve leaflets, non-specific, no obvious vegetation. On the floor, she was changed to Clindamycin. A repeat CT on showed "minimal improvement in extensive necrotizing pneumonia in the RUL, slight improvement in the LUL opacity, no change in the RLL consolidation. Note was also made of increasing right pleural effusion and new left pleural effusion.". Given these findings, a thoracentesis was entertained, and Coumadin was held in anticipation for this. A repeat CXR on , however, showed decreased effusions, and a bedside ultrasound performed by IP on showed insufficient fluid to tap. She continued to improve, eventually without oxygen requirement. She will complete a prolonged course of Clindamycin (5 additional weeks), and will follow-up in the Pulmonary clinic with Dr. . They will contact her with the appointment date and time. She is also scheduled for a repeat CT chest on at 1130. Lenght of antibiotic therapy will ultimately be dictated by clinical/radiographic resolution. Emphasis was placed on aspiration precautions, and eating small meals. 2. Paroxysmal atrial fibrillation: As noted above, her Coumadin was held in anticipation for a possible thoracentesis. She was given 2 doses of Vitamin K to expedite reversal of Warfarin therapy. She was started on Heparin IV when INR<2. Coumadin was eventually resumed at 5 mg daily (her out-patient dose) on , and she was placed on Lovenox (1mg/kg ) to brige until therapeutic INR (goal INR ). She remains on amiodarone. Please discontinue Lovenox when INR . 3. COPD: She was continued on Fluticasone and Combivent, with bronchodilator therapy via nebulizers as needed. 4. Hypertension: She was continued on Lisinopril 5 mg daily. Hydralazine was held in the hospital given good blood pressure control on the latter. If her blood pressure remains elevated, please consider addition of Hydralazine 25 mg PO QID (pre-hospital regimen). 5. Hyperthryoidism: She was continued on Methimazole 5 mg daily. | Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. Mild (1+) AR.MITRAL VALVE: Moderate mitral annular calcification. Normal ascending aorta diameter. Normal LV cavitysize. Minimal increase in ST-T waveabnormalities are present. Normalaortic arch diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. RR 25-32.CVS: Hemodynamically stable with heart rate in the 70's and B/P 130-140/syst.ID: Low grade temp of 100.2po. The aortic valve leaflets are mildlythickened. Left ventricular wall thicknesses and cavity sizeare normal. Physiologic TR.Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is dilated. Mild thickening of mitralvalve chordae. The left ventricular cavity size is normal. LV inflow pattern c/w impairedrelaxation.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Passed large, soft colored stool.F and E: Approximately even. The left ventricular inflow pattern suggestsimpaired relaxation. Theestimated pulmonary artery systolic pressure is normal. Right ventricular chambersize and free wall motion are normal. The mitral valve leafletsare mildly to moderately thickened. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. CXR~RML collapse,, pt with chronic CO2 retention.NEURO: pt not confused as on the floor, MS improved, with decrease in CO2 alert and oriented to name, place, date. Overall leftventricular systolic function is normal (LVEF>55%). No further sedatives given.RESP: Lungs with coarse breath sounds throughout with some expiratory wheezes. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 63Weight (lb): 200BSA (m2): 1.94 m2BP (mm Hg): 141/91HR (bpm): 85Status: InpatientDate/Time: at 10:48Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. no further sedation given - please holdCV: bp stable 110/40 HR 70-80's SR no vea noted. Mild (1+) MR. [Due to acoustic shadowing, the severity of MRmay be significantly UNDERestimated.] lungs w/ decreased breath sounds. The tricuspid valve leaflets are mildly thickened. Since the previous tracing of P wavesare less appreciated. Overall normal LVEF (>55%). Sats of 89-92% on 2.5L nasal cannula. UOP has decreased overnight.SKIN: Intact.SOCIAL: No contact with family overnight. on Amiodarone HCL, HydralazineGI: was NPO tolerating CV/heart healthy diet, tolerating po's, able to swallow pills, keep pt elevated. Slept only in brief naps after receiving trazadone at 2200. There is nopericardial effusion.The focal thickening of the mitral valve is not diagnostic for vegetation butcannot exclude.Compared to the prior study of , prior images were suboptimal forcomparison.NOTE: Report modified to include comparison with prior study and furthernotation re mitral valve thickening. Probable sinus rhythm, rate 94. tolerating some soft solids, passed small yellow stool ob negativeon colace, senna, psyllium. on vanco/flagyl/ceftriaxone for treatment of aspiration pneumonia.GI: Taking po fluids without difficulty. She completed her antibx. non-productive cough. Pt.has a vigorous, productive cough. resp therapy nebs q3-4 hrs. There is no aortic valvestenosis. MAE's, PEARL. transferred to 714. [Due to acoustic shadowing, the severity of mitral regurgitation may besignificantly UNDERestimated.] Aortic valve not wellseen. Pt. stable throughout the night.CNS: Alert, oriented and cooperative. CXR ~ worseing fluid overload, infiltrates bilat., given 1 mg po Ativan for anxiety, ABG~7.34/62/65 placed on 50% Venti mask, ABG 7.32/72/116 pt confused, transferred to MICU.PMH: restricitive lung disease, HTN, GERD, Afib, iron-deficiency anemia, SBO , hyperthyroid, appy, hiatal hernia, asp pneumonia.ALLERGIES: RANITIDINERESP: upon arrival to MICU pt placed on 2.5 l n/p O2 sats 91-92% rr~20-24 no sob, ABG repeat ~ 135/42/7.48 BIPAP not initiated. The aortic valve is not well seen. no ativan/ambien, micu 6 nursing/transfer notePlease refer to transfer note ; pt. sit upright after eating. No AS. here all day.PLAN: antibx, follow O2 sats, keep sats low 90's HOB elevated while eating. 10:30 am -11 pm npn87 y.o. MICU 6 Nursing Progress Note (2300-0700)Please see carevue for all objective data. on protonixGU: foley draining clear, yellow urine UO~50 cc/hrID: afebrile WBC 9.5 on Vanco, Flagyl, Ceftiaxone.SOCIAL: pt is a DNR/DNI lives in own home with help 24 hrs day. family in at bedside. stated was having weird dreams. The heart rate is faster. family very involved. one week prior to admit, she had increasing SOB- admitted to , on the floor, rr increased, O2 sats 80's, spiked temp, blood cx sent, Vanco started. 4 children. female with history of aspiration pneumonia, transferred to MICU from 7 with hypercarbic resp failure, and for initiation of BIPAPHPI: pt originally admitted to the medicine service on with a one week hx of progressive SOB. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2114-06-01 00:00:00.000",
"description": "Report",
"row_id": 1547521,
"text": "10:30 am -11 pm npn\n87 y.o. female with history of aspiration pneumonia, transferred to MICU from 7 with hypercarbic resp failure, and for initiation of BIPAP\n\nHPI: pt originally admitted to the medicine service on with a one week hx of progressive SOB. She was recently admitted to from for pneumonia and treated w/ Levo for 14 days. She completed her antibx. one week prior to admit, she had increasing SOB- admitted to , on the floor, rr increased, O2 sats 80's, spiked temp, blood cx sent, Vanco started. CXR ~ worseing fluid overload, infiltrates bilat., given 1 mg po Ativan for anxiety, ABG~7.34/62/65 placed on 50% Venti mask, ABG 7.32/72/116 pt confused, transferred to MICU.\n\nPMH: restricitive lung disease, HTN, GERD, Afib, iron-deficiency anemia, SBO , hyperthyroid, appy, hiatal hernia, asp pneumonia.\n\nALLERGIES: RANITIDINE\n\nRESP: upon arrival to MICU pt placed on 2.5 l n/p O2 sats 91-92% rr~20-24 no sob, ABG repeat ~ 135/42/7.48 BIPAP not initiated. lungs w/ decreased breath sounds. resp therapy nebs q3-4 hrs. non-productive cough. CXR~RML collapse,, pt with chronic CO2 retention.\n\nNEURO: pt not confused as on the floor, MS improved, with decrease in CO2 alert and oriented to name, place, date. stated was having weird dreams. family in at bedside. no further sedation given - please hold\n\nCV: bp stable 110/40 HR 70-80's SR no vea noted. on Amiodarone HCL, Hydralazine\n\nGI: was NPO tolerating CV/heart healthy diet, tolerating po's, able to swallow pills, keep pt elevated. sit upright after eating. tolerating some soft solids, passed small yellow stool ob negative\non colace, senna, psyllium. on protonix\n\nGU: foley draining clear, yellow urine UO~50 cc/hr\n\nID: afebrile WBC 9.5 on Vanco, Flagyl, Ceftiaxone.\n\nSOCIAL: pt is a DNR/DNI lives in own home with help 24 hrs day. family very involved. 4 children. here all day.\n\nPLAN: antibx, follow O2 sats, keep sats low 90's HOB elevated while eating. no ativan/ambien,\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-06-02 00:00:00.000",
"description": "Report",
"row_id": 1547522,
"text": "MICU 6 Nursing Progress Note (2300-0700)\n\nPlease see carevue for all objective data. Pt. stable throughout the night.\n\nCNS: Alert, oriented and cooperative. MAE's, PEARL. Slept only in brief naps after receiving trazadone at 2200. No further sedatives given.\n\nRESP: Lungs with coarse breath sounds throughout with some expiratory wheezes. Pt.has a vigorous, productive cough. Sats of 89-92% on 2.5L nasal cannula. RR 25-32.\n\nCVS: Hemodynamically stable with heart rate in the 70's and B/P 130-140/syst.\n\nID: Low grade temp of 100.2po. on vanco/flagyl/ceftriaxone for treatment of aspiration pneumonia.\n\nGI: Taking po fluids without difficulty. Passed large, soft colored stool.\n\nF and E: Approximately even. UOP has decreased overnight.\n\nSKIN: Intact.\n\nSOCIAL: No contact with family overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-06-02 00:00:00.000",
"description": "Report",
"row_id": 1547523,
"text": "micu 6 nursing/transfer note\nPlease refer to transfer note ; pt. transferred to 714.\n\n"
},
{
"category": "Echo",
"chartdate": "2114-06-02 00:00:00.000",
"description": "Report",
"row_id": 99919,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 63\nWeight (lb): 200\nBSA (m2): 1.94 m2\nBP (mm Hg): 141/91\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 10:48\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal LV cavity\nsize. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal\naortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Aortic valve not well\nseen. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Moderate mitral annular calcification. Mild thickening of mitral\nvalve chordae. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR\nmay be significantly UNDERestimated.] LV inflow pattern c/w impaired\nrelaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. Left ventricular wall thicknesses and cavity size\nare normal. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets are mildly\nthickened. The aortic valve is not well seen. There is no aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly to moderately thickened. Mild (1+) mitral regurgitation is seen.\n[Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] The left ventricular inflow pattern suggests\nimpaired relaxation. The tricuspid valve leaflets are mildly thickened. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion.\n\nThe focal thickening of the mitral valve is not diagnostic for vegetation but\ncannot exclude.\n\nCompared to the prior study of , prior images were suboptimal for\ncomparison.\n\nNOTE: Report modified to include comparison with prior study and further\nnotation re mitral valve thickening.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2114-06-01 00:00:00.000",
"description": "Report",
"row_id": 284184,
"text": "Probable sinus rhythm, rate 94. Since the previous tracing of P waves\nare less appreciated. The heart rate is faster. Minimal increase in ST-T wave\nabnormalities are present.\n\n"
}
] |
62,316 | 181,287 | 72 y/o female who underwent Right hepatic trisegmentectomy, cholecystectomy, intraoperative ultrasound, caudate lobe resection with Dr . She received At the time of surgery, the patient had a large mass in the right lobe of the liver extending into segment . By intraoperative ultrasound, it extended down to approximately the confluence of the right and left portal vein. It did not appear that there would be great deal of segment IVB left and its blood supply might be tenuous. It was then determined based on that information to proceed with a trisegmentectomy. The left lateral segment was free of disease. She had normal anatomy. Final pathology showed invasive adenocarcinoma (cholangiocarcinoma) Post operatively she was initially transferred to the SICU with a very labile BP ranging from 70 systolic to 160's. She had a hct drop to 24% and received RBC and cryo in the unit after receiving 5 units pRBCs, 2 u PLts and 2 U FFP while in surgery. She was extubated on . A PICC was placed which was removed the day of discharge. She was transferred to 10 on POD 3. She received 2 more units of pRBCs for a Hct of 26% after which time she remained completely stable. Aspirin was restarted on POD 3 and PLavix restarted on POD 7. Through the rest of the hospitalization she remained afebrile, diet was advanced with good tolerance but only fair appetite, regained bowel function and was working with physical therapy. The patient wsa screened for skilled nursing facility as she lives alone and family support was not assured. She received lasix while in house for lower extremity edema and hand puffiness. She was not discharged on lasix but should wear TEDS hose. | Normal ascending aorta diameter.Normal descending aorta diameter. Noaortic regurgitation is seen. A large inferior accessory right hepatic vein was noted incidentally. There is a trivial/physiologicpericardial effusion. Mild (1+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. A Swan-Ganz catheter appears to be in expected position. Mild mitral annularcalcification. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. PATIENT/TEST INFORMATION:Indication: Intraoperative TEE for hemodynamic instabilityStatus: InpatientDate/Time: at 15:31Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast in the body of the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.LEFT VENTRICLE: Small LV cavity. Normal regional LV systolic function.Hyperdynamic LVEF >75%.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Focal calcifications in aortic root. No PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. As compared to the previous image, there is worsening retrocardiac opacity and a newly appeared right basal density. FINAL REPORT CHEST RADIOGRAPH INDICATION: Central venous access line. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. ET tube and Swan-Ganz catheter in expected locations. Theleft ventricular cavity appears underfilled. Sinus rhythm with atrial premature beats. Left ventricular systolic function is hyperdynamic (EF>75%).Right ventricular chamber size and free wall motion are normal. No TEE related complications.Resting tachycardia (HR>100bpm). A surgical drain projects over the right hemidiaphragm. OG tube has its side port in the mid esophagus. OG tube has its side port in the mid esophagus. worsening retrocardiac opacity and new right basilar density. Demographics Day of intubation: Day of mechanical ventilation: 1 Ideal body weight: 52.2 None Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg Airway Airway Placement Data Known difficult intubation: Procedure location: Reason: Tube Type ETT: Position: 20 cm at teeth Route: Oral Type: Standard Size: 7mm Cuff Management: Vol/Press: Cuff pressure: 30 cmH2O Cuff volume: mL / Lung sounds RLL Lung Sounds: Clear RUL Lung Sounds: Clear LUL Lung Sounds: Clear LLL Lung Sounds: Clear Comments: Ventilation Assessment Level of breathing assistance: Continuous invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Assessment of breathing comfort: No response (sleeping / sedated) Non-invasive ventilation assessment: Invasive ventilation assessment: Trigger work assessment: Triggering synchronously Plan Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated Reason for continuing current ventilatory support: Sedated / Paralyzed Respiratory Care Shift Procedures An OG tube has its side port along the mid esophagus. There arecomplex (>4mm) atheroma in the descending thoracic aorta. Two small cysts were identified, one in segment II and the other laterally at the dome of the right lobe. The caudal aspect of the right lobe from the right portal vein trunk inferiorly is also free of tumor. The mass extends to within 1 cm of the origin of the left hepatic vein. The patient was undergeneral anesthesia throughout the procedure. Complex (>4mm) atheroma in the descendingthoracic aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Regional left ventricular wallmotion is normal. Anterior T wave abnormalities.Since the previous tracing of anterior T wave abnormalities are new.Clinical correlation is suggested. CHEST, PA AND LATERAL: There has been interval placement of an endotracheal tube with tip terminating approximately 5 cm above the carina. A large slightly hyperechoic mass was seen centrally in the right lobe in immediate contiguity and also deforming the origins of the middle and right hepatic veins. Midline staples are seen in the upper abdomen. No large pleural effusions. No large pleural effusions. The mass also extends into the caudate process of the right lobe, but segment I itself is free of tumor, as are segments II and III. Retrocardiac opacity may represent atelectasis versus infection. Final report findings reported to , M.D. Retrocardiac opacity with air-bronchogram may represent atelectasis or infection. No signs of other more distant hepatic tumor. , W. SICU-B 2:58 PM CHEST PORT. FINDINGS: The left PICC line projects over the cavoatrial junction with its tip. IMPRESSION: 1. 2:58 PM CHEST PORT. The cardiomediastinal silhouettes are unremarkable. 7:21 AM US INTRA-OP 30 MINS Clip # Reason: exp.lap., extended right hep lobectomy, IOUS MEDICAL CONDITION: right hepatic lesion REASON FOR THIS EXAMINATION: exp.lap., extended right hep lobectomy, IOUS FINAL REPORT INTRAOPERATIVE ULTRASOUND OF THE LIVER: CLINICAL INDICATION: Central right lobe hepatic mass for planned resection. | 7 | [
{
"category": "Radiology",
"chartdate": "2166-05-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1131573,
"text": " 2:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess swan position, ETT position\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with cholangioCA s/p trisegmentectomy\n REASON FOR THIS EXAMINATION:\n assess swan position, ETT position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:09 PM\n ET tube in proper position 5 cm above the carina. OG tube has its side port\n in the mid esophagus. Advancement by approximately 20 cm is recommended to\n achieve optimal positioning. No pneumothorax. No large pleural effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old female with cholangiocarcinoma status post\n trisegmentectomy, here for assessment of Swan positioning and ET tube\n positioning.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: There has been interval placement of an endotracheal\n tube with tip terminating approximately 5 cm above the carina. An OG tube has\n its side port along the mid esophagus. A Swan-Ganz catheter appears to be in\n expected position. A surgical drain projects over the right hemidiaphragm.\n Midline staples are seen in the upper abdomen. The cardiomediastinal\n silhouettes are unremarkable. Retrocardiac opacity with air-bronchogram may\n represent atelectasis or infection. There is no pneumothorax or significant\n pleural effusion.\n\n IMPRESSION:\n 1. ET tube and Swan-Ganz catheter in expected locations. OG tube needs to be\n advanced by about 20 cm for optimal positioning.\n\n 2. Retrocardiac opacity may represent atelectasis versus infection.\n\n Final report findings reported to , M.D. at the time of this\n dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-05-08 00:00:00.000",
"description": "US INTRA-OP 30 MINS",
"row_id": 1131483,
"text": " 7:21 AM\n US INTRA-OP 30 MINS Clip # \n Reason: exp.lap., extended right hep lobectomy, IOUS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n right hepatic lesion\n REASON FOR THIS EXAMINATION:\n exp.lap., extended right hep lobectomy, IOUS\n ______________________________________________________________________________\n FINAL REPORT\n INTRAOPERATIVE ULTRASOUND OF THE LIVER:\n\n CLINICAL INDICATION: Central right lobe hepatic mass for planned resection.\n\n High-resolution scans of the liver were performed intraoperatively. Two small\n cysts were identified, one in segment II and the other laterally at the dome\n of the right lobe. A large slightly hyperechoic mass was seen centrally in\n the right lobe in immediate contiguity and also deforming the origins of the\n middle and right hepatic veins. The mass extends to within 1 cm of the origin\n of the left hepatic vein. The mass also extends into the caudate process of\n the right lobe, but segment I itself is free of tumor, as are segments II and\n III. The caudal aspect of the right lobe from the right portal vein trunk\n inferiorly is also free of tumor. A large inferior accessory right hepatic\n vein was noted incidentally. There was no intrahepatic ductal dilatation.\n\n CONCLUSION: Large central right lobe mass primarily in segments VII and VIII\n and also extending into the medial segment of the left lobe as described. No\n signs of other more distant hepatic tumor.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-05-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1131863,
"text": " 9:29 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please read for right basilic PICC 49cmCarolyn #\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with need for central access\n REASON FOR THIS EXAMINATION:\n Please read for right basilic PICC 49cmCarolyn #\n ______________________________________________________________________________\n WET READ: JKSd SAT 10:05 PM\n left PICC ends at cavoatrial junction. worsening retrocardiac opacity and new\n right basilar density.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Central venous access line.\n\n FINDINGS: The left PICC line projects over the cavoatrial junction with its\n tip. As compared to the previous image, there is worsening retrocardiac\n opacity and a newly appeared right basal density. Short-term followup is\n recommended to exclude developing pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-05-08 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1131574,
"text": ", W. SICU-B 2:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess swan position, ETT position\n Admitting Diagnosis: LIVER MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with cholangioCA s/p trisegmentectomy\n REASON FOR THIS EXAMINATION:\n assess swan position, ETT position\n ______________________________________________________________________________\n PFI REPORT\n ET tube in proper position 5 cm above the carina. OG tube has its side port\n in the mid esophagus. Advancement by approximately 20 cm is recommended to\n achieve optimal positioning. No pneumothorax. No large pleural effusions.\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2166-05-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 534795,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 52.2 None\n Ideal tidal volume: 208.8 / 313.2 / 417.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n 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 Respiratory Care Shift Procedures\n"
},
{
"category": "Echo",
"chartdate": "2166-05-08 00:00:00.000",
"description": "Report",
"row_id": 87671,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for hemodynamic instability\nStatus: Inpatient\nDate/Time: at 15:31\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 in the body of the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Small LV cavity. Normal regional LV systolic function.\nHyperdynamic LVEF >75%.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Focal calcifications in aortic root. Normal ascending aorta diameter.\nNormal descending aorta diameter. Complex (>4mm) atheroma in the descending\nthoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No 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. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\nResting tachycardia (HR>100bpm). Results were personally reviewed with the MD\ncaring for the patient.\n\nConclusions:\nNo spontaneous echo contrast is seen in the body of the left atrium or left\natrial appendage. No atrial septal defect is seen by 2D or color Doppler. The\nleft ventricular cavity appears underfilled. Regional left ventricular wall\nmotion is normal. Left ventricular systolic function is hyperdynamic (EF>75%).\nRight ventricular chamber size and free wall motion are normal. There are\ncomplex (>4mm) atheroma in the descending thoracic aorta. 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 a trivial/physiologic\npericardial effusion. Dr. was notified in person of the results in the\noperating room at the time of the study.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2166-05-08 00:00:00.000",
"description": "Report",
"row_id": 223754,
"text": "Sinus rhythm with atrial premature beats. Anterior T wave abnormalities.\nSince the previous tracing of anterior T wave abnormalities are new.\nClinical correlation is suggested.\n\n"
}
] |
4,570 | 125,107 | The patient was admitted initially to the MICU where he was monitored overnight and was stable. He was called out to the the following day. 1. CARDIOVASCULAR: The patient remained on telemetry overnight and was first noted to have sinus pauses of greater than three seconds at a time and sinus bradycardia. The patient was ruled out for an acute myocardial infarction by cardiac enzymes and was evaluated by the EP service for question of sinus bradycardia and pauses causing syncope. An EP study was performed on and the patient was noted to have inducible ventricular tachycardia and was scheduled for an ICD the following morning. On the patient had an ICD with pacer capabilities placed without complications. Afterward the patient was noted to have a run of ventricular tachycardia of 27 beats which was asymptomatic. He had no further episodes of pauses or bradycardia once his beta blocker was discontinued. The patient was loaded on amiodarone and will be discharged on amiodarone. He will follow up with the EP service after discharge. The patient also underwent a repeat echocardiogram to rule out valvular abnormalities as the cause for his syncope. His echocardiogram showed left ventricular ejection fraction of 40%, mild AF, moderate AR, moderate to severe pulmonary hypertension, moderate mitral regurgitation, moderate tricuspid regurgitation, and some focal wall motion abnormalities. The patient also underwent repeat carotid ultrasound which showed right side with 40-59% stenosis which was unchanged from his prior study, and less than 40% stenosis. Hypertension - the patient had elevated blood pressures during his hospitalization. He was started on hydralazine 20 mg p.o. q.i.d., hydrochlorothiazide 25 mg p.o. q. day, and continued on his lisinopril at 40 mg p.o. q. day. Blood pressure was better controlled at that point. He will have his blood pressure checked as an outpatient. A home visiting nurse will help teach the patient how to check his blood pressure at home. 2. NEUROLOGIC: The patient was taken off Coumadin and reversed with vitamin K. He had no further episodes of bleeding and was felt stable by neurosurgery. The plan was to keep his INR less than 3 for at least seven days and then have his Coumadin restarted. This will be restarted as an outpatient. His neurologic examination remained completely normal. | There is mild regional left ventricularsystolic dysfunction.LV WALL MOTION: The following regional left ventricular wall motionabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -hypokinetic; basal inferior - hypokinetic; mid inferior - hypokinetic; theremaining left ventricular segments contract normally.RIGHT VENTRICLE: There is focal hypokinesis of the apical free wall of theright ventricle.AORTIC VALVE: The aortic valve leaflets are moderately thickened. Moderate (2+)aortic regurgitation is seen. Moderate (2+) aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild aortic valve stenosis. Mild to moderate(+) mitral regurgitation is seen.TRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The results were reviewed with the Cardiology Fellowinvolved with the patient's care.Conclusions:There is mild symmetric left ventricular hypertrophy with normal cavity size.There is mild regional left ventricular systolic dysfunction with focal severehypokinesis/akinesis of the basal half of the inferior septum and inferiorwalls. Moderate mitral andtricuspid regurgitation.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). Moderate[2+] tricuspid regurgitation is seen. There is focal hypokinesis of theapical free wall of the right ventricle. There is moderate pulmonary arterysystolic hypertension.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a moderate risk (prophylaxis recommended). There ismild aortic valve stenosis. Mild to moderate (+) mitral regurgitationis seen. There is moderateto severe pulmonary artery systolic hypertension.IMPRESSION: Focal left and right ventricular systolic dysfunction c/w CAD(proximal RCA disease). Atrial fibrillation with a controlled ventricular response. Mild aortic stenosis/moderate aortic regurgitation.Moderate to severe pulmonary artery hypertension. Mitral valve disease.Height: (in) 63Weight (lb): 135BSA (m2): 1.64 m2BP (mm Hg): 128/48HR (bpm): 65Status: InpatientDate/Time: at 10:29Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: GoodINTERPRETATION:Findings:LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. On the left, mild common carotid plaque is demonstrated. Maximal systolic velocities are 70, 129 and 65 cm/second in the right common carotid, right internal carotid and right external carotid arteries respectively. Flow in both vertebral arteries is antegrade. Small bilateral pleural effusions are present. The heart is at the upper limits of normal. Maximal systolic velocities are 61, 76 and 72 cm/second in the left CCA, ICA and ECA respectively. Ventricular response ismore irregular. FINAL REPORT CAROTID DUPLEX ULTRASOUND . The mitral valve leaflets are mildly thickenedbut without rheumatic deformity. Since the previous tracingof atrial fibrillation is no longer present. please evaluate carotid arteries for stenosis. On the right side, plaque formation is present in the right common carotid artery and in the proximal right internal carotid artery. PATIENT/TEST INFORMATION:Indication: Syncope. Aortic valve disease. The tricuspid valve leaflets are mildly thickened. A-V paced rhythm with ventricular pseudo-fusion. IMPRESSION: 40-59% right proximal internal carotid artery stenosis without significant change from examination. scale, color and Doppler son assessment of the carotid arteries and vertebral arteries were performed and compared with examination. The leftventricular cavity size is normal. IMPRESSION: ICD with distal tips projected over the RA and RV with pneumothorax. The left ICA/CCA ratio is 1.2. The ICA/CCA ratio on the right was 1.8. Less than 40% left internal carotid artery narrowing, not hemodynamically significant. The patient is status post CABG with sternal wires and surgical clips seen in place. The aortic valve leaflets aremoderately thickened. CHEST, 2 VIEWS: A left sided ICD is seen with distal tip projected over the RA and RV. The remaining walls contract well. Clinicaldecisions regarding the need for prophylaxis should be based on clinical andechocardiographic data. Clinical decisionsregarding the need for prophylaxis should be based on clinical andechocardiographic data. Since the previoustracing of is less organized and more rapid. REASON FOR THIS EXAMINATION: elderly gentleman with history of CEA and B carotid stenosis presents with SAH after syncope episode causing head trauma. INDICATION: Elderly gentleman with history of carotid endarterectomy and bilateral carotid stenosis presenting with subarachnoid hemorrhage after syncopal episode causing head trauma. Other features are as previously seen. Atrial pacing is present. 9:22 AM CAROTID DUPLEX US Clip # Reason: SYNCOPE MEDICAL CONDITION: 78 year old man with above. Essentially no change from examination. No consolidations or failure is present. 3:38 PM CHEST (PA & LAT) Clip # Reason: check placement of pacer MEDICAL CONDITION: 78 year old man with REASON FOR THIS EXAMINATION: check placement of pacer FINAL REPORT INDICATION: Check ICD placement. No spectral broadening demonstrated. | 5 | [
{
"category": "Echo",
"chartdate": "2189-07-28 00:00:00.000",
"description": "Report",
"row_id": 61498,
"text": "PATIENT/TEST INFORMATION:\nIndication: Syncope. Aortic valve disease. Mitral valve disease.\nHeight: (in) 63\nWeight (lb): 135\nBSA (m2): 1.64 m2\nBP (mm Hg): 128/48\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 10:29\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Good\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction.\n\nLV WALL MOTION: The following regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -\nhypokinetic; basal inferior - hypokinetic; mid inferior - hypokinetic; the\nremaining left ventricular segments contract normally.\n\nRIGHT VENTRICLE: There is focal hypokinesis of the apical free wall of the\nright ventricle.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is\nmild aortic valve stenosis. Moderate (2+) aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild to moderate\n(+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\n[2+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\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. The results were reviewed with the Cardiology Fellow\ninvolved with the patient's care.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy with normal cavity size.\nThere is mild regional left ventricular systolic dysfunction with focal severe\nhypokinesis/akinesis of the basal half of the inferior septum and inferior\nwalls. The remaining walls contract well. There is focal hypokinesis of the\napical free wall of the right ventricle. The aortic valve leaflets are\nmoderately thickened. There is mild aortic valve stenosis. Moderate (2+)\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened\nbut without rheumatic deformity. Mild to moderate (+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. There is moderate\nto severe pulmonary artery systolic hypertension.\n\nIMPRESSION: Focal left and right ventricular systolic dysfunction c/w CAD\n(proximal RCA disease). Mild aortic stenosis/moderate aortic regurgitation.\nModerate to severe pulmonary artery hypertension. Moderate mitral and\ntricuspid regurgitation.\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2189-07-30 00:00:00.000",
"description": "Report",
"row_id": 111119,
"text": "A-V paced rhythm with ventricular pseudo-fusion. Since the previous tracing\nof atrial fibrillation is no longer present. Atrial pacing is present.\n\n"
},
{
"category": "ECG",
"chartdate": "2189-07-26 00:00:00.000",
"description": "Report",
"row_id": 111120,
"text": "Atrial fibrillation with a controlled ventricular response. Since the previous\ntracing of is less organized and more rapid. Ventricular response is\nmore irregular. Other features are as previously seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-07-28 00:00:00.000",
"description": "CAROTID DUPLEX US",
"row_id": 739681,
"text": " 9:22 AM\n CAROTID DUPLEX US Clip # \n Reason: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with above.\n REASON FOR THIS EXAMINATION:\n elderly gentleman with history of CEA and B carotid stenosis presents with SAH\n after syncope episode causing head trauma. please evaluate carotid arteries\n for stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID DUPLEX ULTRASOUND .\n\n INDICATION: Elderly gentleman with history of carotid endarterectomy and\n bilateral carotid stenosis presenting with subarachnoid hemorrhage after\n syncopal episode causing head trauma.\n\n scale, color and Doppler son assessment of the carotid arteries\n and vertebral arteries were performed and compared with examination.\n On the right side, plaque formation is present in the right common carotid\n artery and in the proximal right internal carotid artery. Maximal systolic\n velocities are 70, 129 and 65 cm/second in the right common carotid, right\n internal carotid and right external carotid arteries respectively. The\n ICA/CCA ratio on the right was 1.8. No spectral broadening demonstrated.\n\n On the left, mild common carotid plaque is demonstrated. Maximal systolic\n velocities are 61, 76 and 72 cm/second in the left CCA, ICA and ECA\n respectively. Flow in both vertebral arteries is antegrade. The left ICA/CCA\n ratio is 1.2.\n\n IMPRESSION: 40-59% right proximal internal carotid artery stenosis without\n significant change from examination. Less than 40% left internal\n carotid artery narrowing, not hemodynamically significant. Essentially no\n change from examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-07-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 739721,
"text": " 3:38 PM\n CHEST (PA & LAT) Clip # \n Reason: check placement of pacer\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n check placement of pacer\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check ICD placement.\n\n CHEST, 2 VIEWS: A left sided ICD is seen with distal tip projected over the\n RA and RV. The heart is at the upper limits of normal. The patient is status\n post CABG with sternal wires and surgical clips seen in place. Small\n bilateral pleural effusions are present. No consolidations or failure is\n present. No pneumothorax is seen.\n\n IMPRESSION: ICD with distal tips projected over the RA and RV with\n pneumothorax.\n\n"
}
] |
75,534 | 159,636 | 52F HIV/AIDS admitted for encephalopathy and subdural hematoma after crack cocaine use, found to have subdural hematoma, myxedema coma, acute on chronic CRI, chronic systolic CHF, ruled out for TB and worked up for abnormal brain MRI signals before discharge to . . ACTIVE ISSUES: # Multifactorial Encephalopathy: Presented with acute changes in mental status in setting of recent history of crack/cocaine and medication non-compliance after discharge from . Etiology likely multifactorial including myxedema coma, drug effects/withdrawal, HIV encephalopathy, concussion in setting of recent fall, hypothyroidism, and hyponatremia. Hypothyroidism was treated with IV levothyroxine (see below). The patient had evidence for a small subdural hematoma, but this was unlikely to be contributing given the small size (Neurosurgery and Nueorlogy consulted). Other infectious work-up negative (I.D. Consulted) Patient underwent two LPs that revealed EBV in CSF but negative workup for primary CNS lymphoma. The patient was AOX3 at the time of discharge. . # Myxedema Coma: s/p thyroidectomry and radioiodine ablation for papillary thyroid cancer. Hx of non-compliant with her levothyroixine as her TSH was severely elevated (greater then assay). Endo consulted. Repleted with levothyroxine 100mcg daily. Adrenal insuficiency was investigated in setting of both hypothyrodism + hypoglycemia. stim test was negative, cortisol had appropriate increase 17-->33. Thyroglobulin test was negative, without signs of relapsed cancer. Pt's TSH improved during hospitalization from >100 to 63. -- Follow-up TSH within 4 weeks of discharge . # Multiple Cerebral Emboli: Pt complained of vertigo with both motion and when lying down. negative Epley . Neurology was consulted. 1st LP with lymphocytic pleocytosis with elevated protein that was thought most likely HIV neuro-cognitive disorder. CSF EBV PCR was positive. Pt's vertigo improved during the hospitalization and it was ultimately attributed to post-concussion vs phenytoin use vs thromboemoblic event with cerebellar involvement. MRI brain was performed which revealed possible thromboembolic event (multiple small acute-subacute infarcts crossing vascular territories) in addition to FLAIR hyperintensity along the splenium of the corpus callosum which might represent. 2nd LP ruled out Primary CNS lymphoma was negative. TTE was negative. TEE showed no intracardiac defects/asd and no valvular vegetations. --neurology recommends f/u MRI and Protein C,S and ATIII as outpatient. F/u in late . Will arrange MRI at the time as necessary. . # Acute on Chronic Kidnery: Unclear baseline Cr. Cr peaked at 7 and trended down until time of discharge. Renal US medical renal disease (echogenic kidneys bilaterally). DDx includes cocaine induced, systolic CHF exacerabation (see below) HIV related. The pt was diuresed with 80 PO lasix daily. Lasix was held for hyponatremia, and restarted at 40 mg PO qday for diuresis. Can be held for persistent hyponatremia or increased for fluid overload in the presence of acute worsening of heart failure. - f/u chem panel within 1 week of discharge. - f/u with outpatient Nephrologist . # Subdural Hematoma: Small subdural hematoma on CT (right parietal lobe).Stable on repeat CT. Neurosurgery consulted and recommended no intervetion. Provided phenytoin for seixure prophylaxis x 1 week. --follow up with neurosurgery to have repeat head CT. . # Epistaxis: Pt had epistaxis episode during hospitalization. Possibly recent cocaine use. Pt had HCT drop from 31-->18.8. Profuse bleeding possible complicated by uremic platelets. Her nose was packed and she was given nasal spray, Oxymetazoline. She was transfused 4 U PRBC and HCT stabalized. . # Hyponateremia: The patient's serum sodium dropped as low as 125. Hyponatremia was thought to be due to poor nutrition and poor PO intake coupled with SIADH due to pulmonary/intracranial issues. It improved after giving fluids, po food, and holding of Lasix. Stabalized at 128. Fluctuates to as low as 125. Patient non-complaint with urine electrolyte testing, IVF repelteition. Hyponatremia is a chronic issue and most likely not etiology of admission MS changes. Restarted on 40 mg po lasix for ICM, should recheck sodium. --recheck sodium within 5 days of discharge. | Mild (1+) mitral regurgitationis seen. Moderate [2+] TR.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Moderate tricuspid regurgitation. There is no pericardial effusion.IMPRESSION: Moderate global left ventricular hypokinesis. False LV tendon (normalvariant). Mild to moderateaortic and mitral regurgitation. Moderate tricuspidregurgitation.Dr. Moderate mitral regurgitation. Mild to moderate (+) AR.MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate(+) aortic regurgitation is seen. Moderate [2+]tricuspid regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Mild to moderate (+) aorticregurgitation is seen. Moderatelydepressed global left ventricular systolic function. Mild to moderate aorticregurgitation. Normal interatrial septum.No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild global RV free wall hypokinesis.AORTA: Normal aortic diameter at the sinus level. No latecontrast seen in left heart suggesting absence of intrapulmonary shunting.LEFT VENTRICLE: Moderate global LV hypokinesis. There is moderate pulmonary artery systolichypertension. Mild tomoderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Restingtachycardia (HR>100bpm).Conclusions:The left atrium is normal in size. The end-diastolic PR velocity is increased c/w PA diastolichypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: The patient appears to be in sinus rhythm. Mild to moderate(+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No LV mass/thrombus.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). Moderate [2+] TR.Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. The mitral valve leaflets are mildlythickened. Modest ST-T wave changes are non-specific. Modest ST-T wave changes are non-specific. Modest ST-T wave changes are non-specific. Moderate global LV hypokinesis. No late contrast is seenin the left heart (suggesting absence of intrapulmonary shunting). The aortic valve leaflets(3) are mildly thickened but aortic stenosis is not present. Since theprevious tracing of no significant change.TRACING #2 Moderate (2+) mitralregurgitation is seen. The ascending, transverse and descending thoracicaorta are normal in diameter and free of atherosclerotic plaque to 45 cm fromthe incisors. Regional left ventricular wall motion is normal. Mild spontaneous echo contrast is seen in thebody of the right atrium. Left ventricular wall thicknesses andcavity size are normal. Right ventricular chambersize is normal. Since the previous tracing of there isprobably no significant change.TRACING #1 Moderate (2+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Right ventricular chamber size andfree wall motion are normal. TheST-T waves are flat in lead II and there is new T wave inversion inleads III and aVF and biphasic to inverted T waves in leads V4-V5 withST-T wave flattening in lead V6. No resting LVOT gradient.RIGHT VENTRICLE: Normal RV chamber size. Normal regional LVsystolic function. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Since the previoustracing of same date there is probably no significant change. The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion. The mitral valve leaflets are structurally normal. No intracardiac source of embolismidentified.Compared with the prior study (images reviewed) of , the severity ofvalvular regurgitation and pulmonary hypertension have increased. with normal free wall contractility. Delayed R wave progression isnon-diagnostic but cannot exclude possible prior anterior wall myocardialinfarction. The estimatedcardiac index is borderline low (2.0-2.5L/min/m2). Left anterior fascicular block. Nomass or vegetation is seen on the mitral valve. Moderate to severepulmonary hypertension. There is no mitral valve prolapse. Estimated cardiac index isborderline low (2.0-2.5L/min/m2). No LV mass/thrombus. Assess for intracardiac source of thromboembolism.Height: (in) 65Weight (lb): 140BSA (m2): 1.70 m2BP (mm Hg): 142/99HR (bpm): 91Status: InpatientDate/Time: at 10:50Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA. Thereis moderate global left ventricular hypokinesis (LVEF = 30 %). There isno pericardial effusion.IMPRESSION: No intracardiac source of thromboembolism identified. Delayed R waveprogression is non-diagnostic but cannot exclude possible prior anterior wallmyocardial infarction. Delayed R waveprogression is non-diagnostic but cannot exclude possible prior anterior wallmyocardial infarction. No PS.Significant PR. Prior anteroseptal myocardial infarction.Compared to the previous tracing of the rate has decreased. Regular narrow complex tachycardia may be sinus but consider also atrialtachycardia, probable left anterior fascicular block. All four pulmonary veins notidentified.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body ofthe RA. Consider left anterior fascicular block. No ASDor PFO by 2D, color Doppler or saline contrast with maneuvers. No TEE related complications.Contrast study was performed with 3 iv injections of 8 ccs of agitated normalsaline, at rest, with cough and post-Valsalva maneuver. Right atrial appendage ejection velocity is good(>20 cm/s). No mass orvegetation on tricuspid valve. Regular narrow complex tachycardia may be sinus but consider also atrialtachycardia. No masses orthrombi are seen in the left ventricle. Clinical correlation issuggested. No thrombus is seen in the right atrial appendage No atrial septaldefect or patent foramen ovale is seen by 2D, color Doppler or saline contrastwith maneuvers (patient intermittenty cooperative). Left axis deviation. Left axis deviation. No MVP. Sinus rhythm. The tricuspid valve leaflets are mildly thickened. These findings suggest inferolateralischemia, in the context of QS deflections in leads V1-V2. PATIENT/TEST INFORMATION:Indication: Cocaine induced CMY now with multiple small strokes.Height: (in) 64Weight (lb): 145BSA (m2): 1.71 m2BP (mm Hg): 148/113HR (bpm): 107Status: InpatientDate/Time: at 14:09Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No masses or vegetations onaortic valve. Leftventricular function has deteriorated. Good (>20 cm/s) LAA ejection velocity. No AS. No AS. Sinus tachycardia. Good RAA ejection velocity (>20cm/s). Delayed precordialR wave transition. No thrombus in the RAA. Baseline artifact. Significant pulmonic regurgitation is seen. Clinicalcorrelation is suggested. No masses or vegetations are seen on the aortic valve.There is no aortic valve stenosis. Compared to the previous tracing of the rate hasincreased and the ST-T wave abnormalities previously recorded in leads V4-V5appear to be resolved, although there is variation in precordial lead placementand these changes may represent pseudonormalization. | 7 | [
{
"category": "Echo",
"chartdate": "2141-02-02 00:00:00.000",
"description": "Report",
"row_id": 99339,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Assess for intracardiac source of thromboembolism.\nHeight: (in) 65\nWeight (lb): 140\nBSA (m2): 1.70 m2\nBP (mm Hg): 142/99\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 10:50\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins not\nidentified.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body of\nthe RA. Good RAA ejection velocity (>20cm/s). No thrombus in the RAA. No ASD\nor PFO by 2D, color Doppler or saline contrast with maneuvers. No late\ncontrast seen in left heart suggesting absence of intrapulmonary shunting.\n\nLEFT VENTRICLE: Moderate global LV hypokinesis. No LV mass/thrombus.\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 masses or vegetations on\naortic valve. No AS. Mild to moderate (+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Moderate (2+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No mass or\nvegetation on tricuspid valve. Moderate [2+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. The posterior pharynx was anesthetized\nwith 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given as an\nantisialogogue prior to TEE probe insertion. No TEE related complications.\nContrast study was performed with 3 iv injections of 8 ccs of agitated normal\nsaline, at rest, with cough and post-Valsalva maneuver. Echocardiographic\nresults were reviewed by telephone with the houseofficer caring for the\npatient.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium or left atrial appendage. Mild spontaneous echo contrast is seen in the\nbody of the right atrium. Right atrial appendage ejection velocity is good\n(>20 cm/s). No thrombus is seen in the right atrial appendage No atrial septal\ndefect or patent foramen ovale is seen by 2D, color Doppler or saline contrast\nwith maneuvers (patient intermittenty cooperative). No late contrast is seen\nin the left heart (suggesting absence of intrapulmonary shunting). There is\nmoderate global left ventricular hypokinesis (LVEF = 30 %). No masses or\nthrombi are seen in the left ventricle. Right ventricular chamber size and\nfree wall motion are normal. The ascending, transverse and descending thoracic\naorta are normal in diameter and free of atherosclerotic plaque to 45 cm from\nthe incisors. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. No masses or vegetations are seen on the aortic valve.\nThere is no aortic valve stenosis. Mild to moderate (+) aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal. No\nmass or vegetation is seen on the mitral valve. Moderate (2+) mitral\nregurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is\nno pericardial effusion.\n\nIMPRESSION: No intracardiac source of thromboembolism identified. Moderately\ndepressed global left ventricular systolic function. Mild to moderate aortic\nregurgitation. Moderate mitral regurgitation. Moderate tricuspid\nregurgitation.\n\nDr. was notified of the results by e-mail on at 11 a.m.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2141-01-25 00:00:00.000",
"description": "Report",
"row_id": 99340,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cocaine induced CMY now with multiple small strokes.\nHeight: (in) 64\nWeight (lb): 145\nBSA (m2): 1.71 m2\nBP (mm Hg): 148/113\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 14:09\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD or PFO by 2D, color Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Moderate global LV hypokinesis. Estimated cardiac index is\nborderline low (2.0-2.5L/min/m2). No LV mass/thrombus. False LV tendon (normal\nvariant). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to\nmoderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS.\nSignificant PR. The end-diastolic PR velocity is increased c/w PA diastolic\nhypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting\ntachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. Regional left ventricular wall motion is normal. There\nis moderate global left ventricular hypokinesis (LVEF = 30 %). The estimated\ncardiac index is borderline low (2.0-2.5L/min/m2). Right ventricular chamber\nsize is normal. with normal free wall contractility. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. Mild to moderate\n(+) aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. Significant pulmonic regurgitation is seen. The end-diastolic\npulmonic regurgitation velocity is increased suggesting pulmonary artery\ndiastolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Moderate global left ventricular hypokinesis. Moderate to severe\npulmonary hypertension. Moderate tricuspid regurgitation. Mild to moderate\naortic and mitral regurgitation. No intracardiac source of embolism\nidentified.\n\nCompared with the prior study (images reviewed) of , the severity of\nvalvular regurgitation and pulmonary hypertension have increased. Left\nventricular function has deteriorated.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2141-01-17 00:00:00.000",
"description": "Report",
"row_id": 278246,
"text": "Regular narrow complex tachycardia may be sinus but consider also atrial\ntachycardia, probable left anterior fascicular block. Delayed R wave\nprogression is non-diagnostic but cannot exclude possible prior anterior wall\nmyocardial infarction. Modest ST-T wave changes are non-specific. Since the\nprevious tracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2141-01-14 00:00:00.000",
"description": "Report",
"row_id": 278247,
"text": "Regular narrow complex tachycardia may be sinus but consider also atrial\ntachycardia. Consider left anterior fascicular block. Delayed R wave\nprogression is non-diagnostic but cannot exclude possible prior anterior wall\nmyocardial infarction. Modest ST-T wave changes are non-specific. Clinical\ncorrelation is suggested. Since the previous tracing of there is\nprobably no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2141-01-12 00:00:00.000",
"description": "Report",
"row_id": 278248,
"text": "Sinus tachycardia. Baseline artifact. Left axis deviation. Delayed precordial\nR wave transition. Compared to the previous tracing of the rate has\nincreased and the ST-T wave abnormalities previously recorded in leads V4-V5\nappear to be resolved, although there is variation in precordial lead placement\nand these changes may represent pseudonormalization. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-01-11 00:00:00.000",
"description": "Report",
"row_id": 278249,
"text": "Sinus rhythm. Left axis deviation. Prior anteroseptal myocardial infarction.\nCompared to the previous tracing of the rate has decreased. The\nST-T waves are flat in lead II and there is new T wave inversion in\nleads III and aVF and biphasic to inverted T waves in leads V4-V5 with\nST-T wave flattening in lead V6. These findings suggest inferolateral\nischemia, in the context of QS deflections in leads V1-V2. Followup and\nclinical correlation are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-01-17 00:00:00.000",
"description": "Report",
"row_id": 278245,
"text": "The rhythm may be sinus tachycardia but consider also possible atrial\ntachycardia. Left anterior fascicular block. Delayed R wave progression is\nnon-diagnostic but cannot exclude possible prior anterior wall myocardial\ninfarction. Modest ST-T wave changes are non-specific. Since the previous\ntracing of same date there is probably no significant change.\n\n"
}
] |
49,872 | 137,056 | IMPRESSION: 86F with a PMH significant for CAD (s/p CABG , PCI with stenting of the LAD in ), ischemic cardiomyopathy (EF 30-35%), DM, HTN, HLD, CKD stage IV-V (baseline creatinine 3.5-4) who presented to with complaints of nausea and emesis found to have acute CHF exacberation with resulting acute respiratory failure requiring MICU admission for worsening acute respiratory failure, complicated by NSTEMI with medical management, initiation of hemodiayslis complicated by left femoral pseudoaneurysm vs. fistula who is hemodynamically stable. . # CORONARIES - The patient had a prior CABG in with (LIMA -> proximal LAD, SVG -> distal LAD, SVG -> OM2 and OM3) and is status-post PCI in (DES to proximal LAD) with a persantine MIBI in which showed his old LAD infarct and areas of ischemia in the distribution of the PDA and OM. This admission, the patient was admitted to the MICU on with concerns of acute respiratory failure precipitated by acute CHF exacerbation and volume overload. In that setting, the patient developed evidence of NSTEMI with Troponins peaking at 3.62 (CK-MB 70) in light of her renal dysfunction with some intermittent chest pain. Given these findings, she was medically optimized at that time with Aspirin 325 mg PO, we continued her statin, dosed her beta- and started a heparin gtt (this was intermittently on/off given concerns for a femoral left pseudoaneurysm, as noted below). The patient underwent cardiac catheterization via radial artery access on , where she had a distal RCA lesion, which by itself was not felt to be a culprit lesion and the patient also had stenosis about the area where one of her LIMA to LAD bypasses was. The cath was only diagnostic in that no interventions on the coronaries were performed at that time, and at the same time it was discovered that the patient had irregularities of the bilateral femoral arteries on informal angiography. We continued medical optimization as listed above, added Plavix 75 mg PO daily given the delay in catheterization and titrated her beta-. We trended her EKG findings, monitored her for chest pain, and trended her Troponins and CK-MB for resolution of her NSTEMI concerns. . # PUMP (ACUTE CHF EXACERBATION)- The patient had her last 2D-Echo in which showed symmetric LVH, moderate regional LV systolic dysfunction with moderate global hypokinesis and akinesis of the distal anterior septum and apex and an LVEF of 30-35%. There was also evidence of mild to moderate (+) mitral regurgitation. There was moderate pulmonary artery systolic hypertension. As noted above, the patient initially presented to the ED with nausea for several days and evidence of acute renal insufficiency. On , she saw her PCP who felt that the nausea was secondary to diuretics and her Metolazone and Lasix were decreased (or held?). Since then, her nausea persisted and her appetite became suppressed - but she was able to keep her medications down. In the ED () her VS 97.2 124/47 24 97% 2L NC. A CXR showed pulmonary congestion. She was admitted to the Medicine service on . Of note, the patient was recently discharged from after an admission for acute CHF exacerbation (). At that time, Torsemide 100 mg was changed to Lasix 200 mg PO BID with 5 mg of Metolazone to augment his loop diuretic. Her creatinine baseline is around 3.8-4.0. On the Medicine service, the patient's nausea improved intially and then worsened, responding to intermittent Zofran IV. She was seen by Nephrology who opted for conservative management initially. Her diuretics were held and her BUN trended from 181 -> 167, with a creatinine of 5.2 -> 5.0. Because there was not significant improvement and her symptoms were worsening, the plan was for HD line placement in IR on the day of transfer to the ICU. At some point in the night prior to transfer the patient woke up dyspneic and was placed on 4L NC. At 7:30 AM she became more acutely dyspneic and was satting 89% 4L NC and which improved to 96% on a NRB. She was tachypneic at a rate in the 40s. She was given Lasix 100 mg IV and put out 700 cc in the first hour, but remained dyspneic. There was concern for aspiration vs. MI vs. fluid overload. A CXR showed diffuse pulmonary edema, and it was difficult to assess whether an underlying apiration or consolidation was present. Nephrology then recommended placement of an emergent dialysis line so the patient was transferred to the MICU on . At time of transfer, her dyspnea had improved, but she remained on a non-rebreather. In the MICU, on , the patient was preparing for HD line placement per Nephrology recommendations, Metolazone and Lasix were continued. HD initiated on (-500 cc) and she tolerated this well and her oxygen requirement resolved. She was weaned to 2L NC before transferring to the floor on . We continued medical optimization of her CHF regimen (held off on ACEI/ given her renal issues) including Metoprolol, Imdur, a CCB and monitored her with daily weights, monitored her I/Os and aimed for a goal of even to negative 1L daily. We performed aggressive electrolyte optimization and monitored her via telemetry. . # RHYTHM - The patient presented in sinus rhythm appearing on telemetry and EKGs with no history of dysrrhythmias. We performed aggressive electrolyte optimization and monitored her via telemetry. . # ACUTE ON CHRONIC RENAL INSUFFICIENCY (HEMODIALYSIS) - On , she saw her PCP who felt that the nausea was secondary to diuretics and her Metolazone and Lasix were decreased (or held?). Since then, her nausea persisted and her appetite became suppressed - but she was able to keep her medications down. Of note, the patient was recently discharged from after an admission for acute CHF exacerbation (). At that time, Torsemide 100 mg was changed to Lasix 200 mg PO BID with 5 mg of Metolazone to augment his loop diuretic. Her creatinine baseline is around 3.8-4.0. On the Medicine service, the patient's nausea improved intially and then worsened, responding to intermittent Zofran IV. She was seen by Nephrology who opted for conservative management initially. Her diuretics were held and her BUN trended from 181 -> 167, with a creatinine of 5.2 -> 5.0. Because there was not significant improvement and her symptoms were worsening, the plan was for HD line placement in IR on the day of transfer to the ICU. At some point in the night prior to transfer the patient woke up dyspneic and was placed on 4L NC. Nephrology then recommended placement of an emergent dialysis line so the patient was transferred to the MICU on . At time of transfer, her dyspnea had improved, but she remained on a non-rebreather. In the MICU, on , the patient was preparing for HD line placement per Nephrology recommendations, Metolazone and Lasix were continued. HD initiated on (-500 cc) and she tolerated this well and her oxygen requirement resolved. She was weaned to 2L NC before transferring to the floor on (a temporary right IJ was placed for this purpose). We monitored her phosphorus, provided Nephrocaps and continued her on dialysis. She was making minimal urine at the time of floor transfer. We avoided nephrotoxins and renally dosed all medications. A permanent HD-line was tunneled on without issue and she will continue on outpatient hemodialysis. (Tuberculin testing negative , in OMR). The dialysis social worker will contact the rehab facility to arrange outpatient dialysis. . # LEFT FEMORAL PSEUDOANEURYSM VS. FISTULA - After bilateral attempts at cannulation of the femoral artery for HD-access, the patient subsequently developed a large partially thrombosed left femoral pseudoaneurysm (6-cm) which may have progressed to an AV-distula based on imaging. She underwent thrombin injection without avail and a repeat at thrombin injection which was again unsuccessful. Vascular surgery was consulted and following with plan for surgical repair pending stabilization of her cardiac issues. Serial ultrasound imaging was performed which showed the left PSA was stable. Her bilateral serial pulse exams were stable and we monitored her groins. Vascular surgery operatively repaired this PSA via an open, primary approach on without issue, she tolerated this well. She will follow up with vascular surgery as an outpatient. . # DYSPNEA, PULMONARY EDEMA - As noted above, the patient initially presented with acute respiratory failure in the setting of an acute CHF exacerbation with a new oxygen requirement which was weaned from NRB -> 4L to 2L via NC with initiation of hemodialysis and diuresis. A CXR showed bilateral effusions and she had no evidence of infiltrate on imaging (with no cough or URI symptoms). We continued aggressive volume control with hemodialysis, provided oxygen supplementation with plan to wean, and maintained her on albuterol and ipratroprium nebs as needed with pulse oximetry monitoring and incentive spirometry. . # NORMOCYTIC ANEMIA - The patient presented with baseline chronic renal insufficiency-induced normocytic anemia with HCT in the 30-32% range with Epopoeitin injections monthly. Upon MICU transfer she required 5 units of packed red cells during for a HCT of 24-25% which responded appropriately. The patient's hematocrit was trended closely and our transfusion goal was to a HCT > 26% given her significant CAD. . # INSULIN-DEPENDENT DIABETES MELLITUS - The patient was admitted on Humulin 70/30, 20 units before breakfast and 26 units before dinner, as a home regimen. The patient was given half her standing NPH at the time of transfer (blood glucose in the 250-300 mg/dL range) until she resumed her diet. The patient was continued on an insulin sliding scale as well with Q6 hour blood glucose monitoring. . # HYPERTENSION - The patient was continued on her home blood pressure regimen; with a goal BP < 130/80 mmHg. Her cardiac medications were optimized this admission. . # HYPERLIPIDEMIA - Her home Simvastatin 40 mg PO daily was changed to atorvastatin. . # GOUT - The patient recently completed a course of Prednisone on her last admission for gout flare and thus we continued her home Allopurinol medication (renally dosed). . # REACTIVE AIRWAY DISEASE - We continued her home Albuterol and Flovent medications; albuterol and ipatropium nebs were dosed as needed. . TRANSITION OF CARE ISSUES: 1. Patient was discharged to a rehab facility 2. The dialysis caseworker will follow-up with the rehab facility regarding outpatient dialysis. 3. The patient will f/u with Dr. from vascular surgery 4. The patient remained full code throughout this hospitalization | Left bundle-branch block.Compared to the previous tracing of sinus bradycardia is new. Borderline first degree A-V block. Sinus rhythm. Sinus rhythm. Compared to theprevious tracing of the same date tachycardia is no longer present.TRACING #2 Left bundle-branch block. Left bundle-branch block. Sinus bradycardia. Theventricular premature beat is absent. Ventricular ectopy. Compared to the previous tracing of tachycardia is new.TRACING #1 Probable ventricular tachycardia, although cannot exclude supraventriculartachycardia with underlying left bundle-branch block. Compared to the previous tracing of no change. P-R interval prolongation210 milliseconds. | 4 | [
{
"category": "ECG",
"chartdate": "2160-10-09 00:00:00.000",
"description": "Report",
"row_id": 308571,
"text": "Sinus rhythm. Ventricular ectopy. Left bundle-branch block. Compared to the\nprevious tracing of the same date tachycardia is no longer present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2160-10-09 00:00:00.000",
"description": "Report",
"row_id": 308572,
"text": "Probable ventricular tachycardia, although cannot exclude supraventricular\ntachycardia with underlying left bundle-branch block. Clinical correlation\nis suggested. Compared to the previous tracing of tachycardia is new.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2160-10-05 00:00:00.000",
"description": "Report",
"row_id": 308573,
"text": "Sinus rhythm. Left bundle-branch block. P-R interval prolongation\n210 milliseconds. Compared to the previous tracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2160-10-15 00:00:00.000",
"description": "Report",
"row_id": 308570,
"text": "Sinus bradycardia. Borderline first degree A-V block. Left bundle-branch block.\nCompared to the previous tracing of sinus bradycardia is new. The\nventricular premature beat is absent.\n\n"
}
] |
52,260 | 157,479 | 65 year old man with coronary artery disease and stenting in the distal LAD, mechanical AVR, and CVA x4 on warfarin complicated by frequent hemorrhagic gastritis (also has known gastric AVM and colon diverticulosis) who presented to the ED with hypotension during outpatient regular blood transfusion. He was at high risk for GI bleeding given his history and anticoagulation with warfarin despite decreased therapeutic goal to INR = . His most likely source of bleeding was from upper GI tract given his history of hemorrhagic gastritis and gastric AVM. He had a recent colonoscopy in that showed diverticulosis, which can also potentially bleed. His INR was 2.6 on admission. He was treated with pantoprazole IV then PO. From to , he received a total of 7 units of PRBC transfusion for continually dropping hematocrit. After much discussion with GI, Cardiology, and the patient, the decision was made to pursue EGD with possible use of argon-plasma coagulator. Coumadin stopped and INR allowed to drift down to 1.5. EGD performed on revealing angioectasia. Argon-plasma coagulator treatment was applied. Heparin gtt started after the EGD and Coumadin started the day after the procedure. For the 72 hours following the procedure, the patient's HCT remained stable even while the PTT was in or above the therapeutic range. Dr. , the patient's cardiologist said it was okay to stop heparin once the INR was close to the therapeutic range. Specifically, INR 1.6 was okay for heparin to be stopped. The reason is that clot formation on a prosthetic valve in the aortic position is relatively low. The patient was discharged home with slightly subtherapeutic INR with instructions to continue taking warfarin only for anticoagulation. The patient does have borderline hypotension and SBP in the outpatient setting is usually 100-120. He was initially euvolemic on exam but CXR showed some edema and bilateral pleural effusions. We continued on atorvastatin but initially held metoprolol and diuretics in the setting of borderline hypotension. He then developed some dyspnea and chest pain. Repeat EKG showed old unchanged posterior, inferior and lateral q waves and cardiac enzymes were normal. Repeat CXR showed increased moderate bilateral pleural effusions with persistent mild pulmonary edema. Extra doses of Lasix were used. He was then restarted on his home dose of torsemide. He continued to have edema but was not actively diuresed until after his bleeding was controlled. He is off aspirin but can restart if chest pain. However, currently the patient's more acute and life threatening probelm is bleeding, and he is already on coumadin for his aortic valve, which should offer some but not ideal protection against recurrent MI. He then developed shoulder pain consistent with calcific tendenitis/capsulitis. He had severe tenderness and an X ray confirmed calcific tendonitis. He was seen by orthopedics who stated this was either tendonitis or arthritis and he was developing frozen shoulder so he was treated with steroid injection which over time in conjunction w/ po oxycodone improved his symptoms. He should follow up in shoulder clinic in weeks post discharge. | Inferior myocardial infarction ofindeterminate age. Diffuse non-diagnostic repolarization abnormalities.Compared to the previous tracing of right bundle-branch block is nolonger evident. | 1 | [
{
"category": "ECG",
"chartdate": "2166-05-14 00:00:00.000",
"description": "Report",
"row_id": 289355,
"text": "Sinus rhythm with top normal P-R interval, approximately 200 milliseconds.\nVentricular premature depolarizations. Inferior myocardial infarction of\nindeterminate age. Diffuse non-diagnostic repolarization abnormalities.\nCompared to the previous tracing of right bundle-branch block is no\nlonger evident.\n\n"
}
] |
4,688 | 150,090 | Thus, the patient at this time was admitted to for surgical treatment of this likely mass in the tail of the pancreas. CTA showed pancreatic tail mass that had been increasing in size near the tail of the pancreas. The plan at this time was for likely distal pancreatectomy and possible splenectomy. Patient was prepared properly in the preoperative period and was noted to be of small risk for this procedure. Laboratory values were within normal limits at this time, and the patient was brought to the operating room for distal pancreatectomy and splenectomy. After extensive lysis of adhesions in the operating room, the splenic artery was suture ligated. The pancreas and splenic vein were divided with a TA stapler and oversewn and the specimen was removed. Patient tolerated the procedure well. Estimated blood loss was 800 cc and he received no transfusions. He was extubated and eventually brought to the floor. He received a total of three doses of Kefzol in the perioperative period and received beta blockers both pre and postoperatively. Patient was hypertensive postoperatively and on postoperative day number two, became tachycardic to the 120s. EKG showed ST depression in leads V2 through V5. CK's were elevated as was his troponin. He was started on aspirin and transferred to a monitored setting for better management of his heart rate and blood pressure with IV beta blockers and nitroglycerin. Cardiology was consulted and played an integral part in his management. His CK's were trending down. It was felt that he had completed a cardiac event and catheterization was delayed. On postoperative day four, he became agitated, tachypneic, and had decreasing oxygen saturations on 100 percent FIO2. He was intubated and a CTA was negative for pulmonary embolism, but there was evidence of pneumonia and CHF. He was treated with empiric antibiotics and Lasix, and his respiratory status improved. Two days later he began having diarrhea and was found to have a Clostridium difficile infection. He was treated with p.o. and p.r. Vancomycin as he had an allergy to Flagyl. He remained intubated over the next five days, where he had fevers and an elevated white blood cell count. Sputum cultures grew out MRSA and he was treated with a course of IV Vancomycin. He was extubated for a short amount of time, but then became agitated, tachypneic, tachycardic despite esmolol drip with elevated blood pressure. CK's and troponins again became elevated and he was begun on Heparin. Repeat echocardiogram showed new anterior wall motion abnormalities and he was taken for cardiac catheterization. His catheterization showed a right dominant system with 100 percent occlusion of his right coronary artery and 80 percent stenosis of his left main coronary artery, which was stented. He was continued on Plavix and aspirin postcatheterization and then was eventually extubated. He then improved from a respiratory standpoint and was getting physical therapy on the floor, and was noted to be progressing well during this time. Apparently, he will likely be discharged to rehabilitation. During this time on the floor, patient was also noted to have symptoms of depression and anxiety, and Psychiatry was consulted. Psychiatry suggestions at this time were to discharge imipramine and to decrease his mirtazapine dose from 30 mg q.d. to 7.5 mg q.h.s. These two medications were implicated by Psychiatry to be possibly causing some anticholinergic symptoms in this patient. Psychiatry's recommendations were followed, and the above stated adjustments were made. On , the patient was noted to be stable and to have vital signs within normal limits. On physical exam, to be in no apparent distress. To be comfortable. His heart is regular rate and rhythm with no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. His abdomen is nondistended with normoactive bowel sounds and to be nontender throughout with a well-healing wound without drainage or erythema. Patient's activity level at this time also seem to be improving as he had been noted to be walking 3-5x/day in the days leading up to his discharge with his spirits seeming to be improved. On the day of discharge, patient had been noted to be now tolerating a full diet for a period of two days. Patient at this time also received his immunizations against pneumococcal, Hemophilus influenza B, and the meningococcal vaccine. | ABG confirmed hypoxemia. EKG performed @ BS, ST depression noted. Sputum C + S and stool sent for c-diff. Pulm: Worsening pna and confirmed of ETT on cxr. R IJ cath site noted w/ purulent drainage when dc'd. Moderately withdrawn to plan of care r/t exhaution verbally stating. Dilaudid PCA with adequate pain control, new cartridge up. Levofloxacin continues for presumed pna. Stable shift with max temp 102.4, recultured MD order. SICU team to bedside--pt started on NGT and esmolol gtt changed to labetalol with moderate improvement in HR (130's to 100's). Pt alt MS managed on floor managed c freq dosing of ativan/dilaudid. 1500 hct down somewhat--pt with active clot in bb. Stat labs sent @ 18:00, results notable for low K now being repleted c 20MEQ KCL IV via R IJ TLC. Reposition frequently, observe R heal pressure ulcer. Vanco enema held this AM d/t sleep state. SX FOR TAN SPUTUM.ALBUTEROL MDI GIVEN. CXR DONE THIS AM.CVS; TMAX 99.4 PO NSR 80 BP 130-140/60. LS coarse on arrival t/o, but cleared significantly with suctioning.C-V: Cath findings/intervention as above. good, redressed, scant brwn from JP. other skin intact.ACCESS: cordis/swan ganz cath in right IJ. sedated well with Propafol 250 mcq/hr and dilaudid IVP q 2 hr mgm. of COPD.,BS without wheezes, essent. Ordered for Albuterol MDI, has Hx. stopped, labs sent, HO aware and to see pt. clonidine patch on yest. on recheck of residuals pt. NGT clamped post meds. RSBI completed this AM on PSV=0, Peep=0, ATC on=22. On return he was quickly weaned of the NTG; Esmolol remains at 150mcg. Hct, plt's, INR stable. Q6hr Hct ordered and stable x1. POST EXTUBATION ABG ACCEPTIBLE WILL PULL ALINE.CVS. Sputum cx positive MRSA, Cdiff pos. PTT decreasing off heparin.GI: Belly benign with hypoactive BS. Wean off NTG maintaining SBP 130's. Hands cyanotic and cool bilaterally ( aware); + pulses, ? Monitor LS as rhonchi are new post extubation. patient has bilateral femoral bruitsResp: Vent settings unchanged. There has been resolution of a right pleural effusion following thoracentesis. IMPRESSION: Small right apical pneumothorax following thoracentesis. IMPRESSION: Resolution of small right apical pneumothorax. FLATTENED TRACE BUT RE-REVIWED BY CARDIOLOGY TRACING SATISFACTORY CVP @ SVR RAISED/C.I/O REDUCED CARDIOLOGY AWARE ? There is a new small right apical pneumothorax present. CLINICAL INDICATION: Status post right thoracentesis. IMPRESSION: Decreased right apical pneumothorax. Denies difficulty in breathing PM Cxry for R pnuemo f/u. Thorocentesis today w/ 1200cc removed and small R apex lobe pnuemothorax.N: Lightly sedated weaned propofol from 30mcq to 15mcq d/t brief hypotension s/p thorocentisis. Moderate oral secretions sx'd Q2hr. The previously noted right apical pneumothorax is no longer visualized. IMPRESSION: Previously reported right greater saphenous vein and right popliteal vein thrombi not identified. Resolution of right pleural effusion. scale and Doppler son of the bilateral common femoral, superficial femoral, and popliteal veins demonstrates normal flow, compressibility, wave forms and augmentation. There is faint opacity in the right lower lobe, which can represent edema vs. layering small effusion. IMPRESSION: Normalization of previous CHF, regression of right lower atelectasis, unchanged positions of central venous line and NG tube. RESPIRATORY CARE: PT W/ 8.0 ORAL ETT IN PLACE.CHANGED BACK TO SIMV MODE 12/650/.40/5/PS 10AS PER CAREVUE. BP returned to baseline after Lopressor. FINDINGS: There has been interval removal of the ET tube. Attempt weaning esmolol if PO Atenolol absorbed maintaining HR <100. MAE ad lib.CV/Pulm: MP remains ST-NSR--Lopressor 20mg IV prn given x1 for HR 110's with HR decreased to 90's. In comparison with the next previous supine examination of the position of the right jugular approach central venous line and the NG tube is unchanged. R groin cath site WNL, R DP/PT pulses difficult to doppler post cath, foot now warm and dry post earlier assessment when extremity cool, MDs aware. Vanco enemas resumed. TPN 62.5cc/hr, Propofol 10mcq/kg/min, Esmolol 150mcq/kg/min, CVP 12-18. GI consult.GU: UOP approximately 100cc/hr without diuretics.Skin: See flow sheet, new R wrist abrasion. One unit PRBC given, TF resumed, cont'd with Vanco enemas q6h however started stooling at 1615-->copious amts liq stool. Again seen are an endotracheal tube, NG tube, and left subclavian central venous line, the positions of which are unchanged. Overall left ventricular systolic functionis mildly depressed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.MITRAL VALVE: The mitral valve leaflets are structurally normal. Overall left ventricular systolic function is mildlydepressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -hypokinetic; basal inferoseptal - hypokinetic; mid inferoseptal - hypokinetic;septal apex - hypokinetic;RIGHT VENTRICLE: The right ventricular wall thickness is normal. There is mildglobal right ventricular free wall hypokinesis.AORTIC VALVE: No aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild regionalleft ventricular systolic dysfunction. Mild (1+) mitralregurgitation is seen.PERICARDIUM: There is no pericardial effusion.Conclusions:1. Mild (1+) mitral regurgitation is seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: The rhythm appears to be atrial fibrillation. There is a small pericardial effusion.Compared to the prior study of (tape reviewed), there is a newanterior septum, anterior wall and apical wall motion abnormality. Sinus tachycardiaPremature ventricular contractionsST junctional depression is nonspecificLow QRS voltages in limb leadsSince previous tracing of , anterior ST-T wave abnormalities lessmarked, and ventricular arrhythmia seen Sinus tachycardiaProlonged Q-Tc intervalExtensive ST-T changes suggest myocardial injury/ischemiaLow QRS voltages in limb leadsSince previous tracing of , anterior ST-T wave abnormalities less markedand ventricular premature complexes seen Sinus tachycardiaPremature ventricular contractionsSupraventricular extrasystolesAnterior ST-T changes suggest myocardial injury/ischemiaLow QRS voltages in limb leadsSince previous tracing of , no significant change Sinus tachycardiaST junctional depression in leads V2-V4 is nonspecificLow QRS voltages in limb leadsSince last ECG, sinus tachycardia, shorter PR interval, ST segment depression,ventricular premature complex absent Sinus tachycardiaPossible right ventricular hypertrophyLateral ST-T changes suggest myocardial injury/ischemiaLow QRS voltages in limb leadsSince previous tracing of , the rhythm is no longer atrial fibrillationand ST-T wave abnormalities more marked Sinus rhythmAnt/septal+lateral ST-T changes suggest myocardial injury/ischemiaLow QRS voltages in limb leadsSince previous tracing of , no significant change AnterolateralST-T wave abnormalities suggest ischemia. Poor R wave progression - cannot rule out septal infarct.Non-specific anterolateral ST-T wave changes may be due to myocardial ischemia.Low QRS voltages in limb leads Compared to the previous tracing there areventricular premature beats, the rate is faster and there is loss of R wavein leads I and aVL.TRACING #1 | 116 | [
{
"category": "Nursing/other",
"chartdate": "2125-08-12 00:00:00.000",
"description": "Report",
"row_id": 1323441,
"text": "RESPIRATORY CARE: PT W/ 8.0 ORAL ETT\nFOR IMPENDING RESPIRATORY FAILURE AND PULMONARY\nTOILET/BRONCHOSCOPY FOR A PNA. PLACED ON SIMV 14\nAS PER CAREVUE. ABG C/W A MILD METABOLIC ACIDOSIS\nWHICH IS PARTIALLY COMPENSATED FOR AND STABLE\nOXYGENATION. FIO2 DECREASED TO .40. SX FOR TAN SPUTUM.\nALBUTEROL MDI GIVEN. WILL C/W CURRENT SETTINGS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-13 00:00:00.000",
"description": "Report",
"row_id": 1323442,
"text": "events: transfused one unit PRBC for hct <30, cpk still trending up, diltiazem changed to esmolol in hopes of achieving control of HR in the 60's but not achieved--vancomycin enemas discussed with intern and held due to put's elevated heart rate and desire to avoid additional stress while enzymes have not yet peaked\n\nneuro: well sedated on propofol at 40 mctg/kg/min but requires a lot of extra propofol in boluses for any procedures; moves all fours to command, denies pain when questioned\n\ncardiovascular: heart rate in mid-80's to mid-100's all night despite diltiazem drip up to 15 mg/hr, then changed to esmolol at 200 mcg/kg/min with boluses of 2.5 mg lopressor IV, repeated once, which still failed to lower HR below 90--BP generally stable during this night although nitro drip decreased to one cc/hr to achieve this--frequent PVC's although electrolytes wnl\n\npulmonary: continues to have large amounts of thick tan sputum; good spo2 all night on current settings as rrt note\n\nGI: nasal sump tube clamped for meds, minimal stooling this shift\n\nGU: qs clear amber urine via foley\n\nstatus and plan: full code, contact precautions, prioritize goals and continue efforts to lower heart rate and implement other post_MI care\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-13 00:00:00.000",
"description": "Report",
"row_id": 1323443,
"text": "Shift Summary\nDay 13 s/p spleenectomy& distal pancreatectomy. Day 2 reintubation for increased pnuemonia and cardiac ischemia. Bedside echo done today with progressive worsening EF, for cardiac cath this evening.\n\nN: Lightly sedated on Propofol at 40mcq/kg/min. Responds to verbal questions, appears more sedated this evening. Occasional twitching noted receiving nuerotin PO. Generalized weaknesss througout all extremeties equal bilaterally. Left eye blindness OD 4mm OS 3mm react to light briskly.\n\nCV: Esmolol drip weaned off and then restarted d/t c/o chest pain and probable progressing ischemia. Ntg drip titrated up for c/o chest pain this afternoon, weaned slighlty to maintain MAP 65-70. Pos sys murmur. telemetry with EKG changes during c/o CP, occasional PVC's. Fentanyl for c/o CP given d/t MSO4 allergy, denies c/o CP last five hours with Ntg drip therapeutic. Heparin drip initiated with new onset CP. Peripheral pulses difficult to palpate, trace anasarca. Fluid balance positive. L SC QLC intact with all ports infusing IVF's. New L FA INT inserteed. L Aline nonfunctional, left in place for cath over wire insertion, possibly this , MD aware.\n\nR: Reintubated tolerating SIMV 50% 18bpm LS continue course bilateral upper lobes, diminshed bilateral lower, suctioned Q4hr for small amount thick yellow. Sats maintained >95% per pulse ox.\n\nGI: NPO except meds. NGT R nares, [patent flushed, no s/s of GIB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-13 00:00:00.000",
"description": "Report",
"row_id": 1323444,
"text": "RESPIRATORY CARE: PT W/ 8.0 ORAL ETT IN PLACE.\nREMAINS ON THE SIMV MODE AS PER CAREVUE W/ A\nSTABLE ABG. SX FOR YELLOW. ALBUTEROL MDI GIVEN.\nGOING TO CARDIAC CATH LAB A BIT LATER. WILL C/W\nCURRENT SETTINGS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-18 00:00:00.000",
"description": "Report",
"row_id": 1323462,
"text": "Shift Summary\nContinues with unstable respiratory status. s/p speenectomy and distal pancreatectomy day 18. Third time reintubated today after 2day extubation.\n\nN: Disoriented this am x3. Inappropriate words throughout the day continuing to digress with pulse ox indicating dropping sats. ABG confirmed hypoxemia. Able to move all extremeties and assist with repositioning until respiratory status decompensated. Lightly sedation on 5cq/kg/min propofol weaned d/t borderline hypotension.\n\nCV: Atenolol dosage increased again to 150mg maintaining therapeutic borderline hypotensive BP. Telemetry without ectopy. No edema. Pedal pulse by doppler only. Left toes darkened with slow capilllary reflex.\n\nR: Continuing disorientation, brief diaphoresis, poor ABGs led to third reintubation today. Down for chest CT preliminary noted for increased pulmonary fluid bilaterally. Repeat ABG pending. Suctioned for copious amounts thick white/ye11ow secretions. Lung sounds continue coarse througout the clearing slightly with sxing.\n\nGI: Tube feeding resumed to 30cc/hr post intubation, residuals <10cc throughout the day. Rectal tube remains with liquid stool and vanco enemas Q6 repeat cdiff specimen sent. BS + x4. Abd soft with wound well approximated healing with steri strips in place.\n\nGU: Foley with approximaetly 80cc/hr out clear yellow x1 Lasix 10mg IVP.\n\nSkin: R Buttocks with small abrasion healing. Abd. wound as above.\n\nWife up to date on events of the day, back to hotel for the night.\n\nGood pulmonary toiletry d/t copious secretions, monitor ABG adjust ventilator settings per repeat ABG results pending. Cardiac labs pending ordered d/t earlier respiratory decompensation r/o ischemic event.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-10 00:00:00.000",
"description": "Report",
"row_id": 1323435,
"text": "events: central line changed over wire last evening. fever to 102.2 orally this AM so blood cultures added to AM labs.\n\nneuro: continues confused but cooperative. moves all fours well to command. restraints in place due to pt frequently removing oxygen and desatting into 80's or below.\n\ncardiovascular: rhythm sinus without block or ectopy, BP elevated in the middle of the night, did not respond to IV lopressor but did eventually respond to IV labetolol boluses, targeting systolic BP in the 140's\n\npulmonary: continues eupneic on nasal o2, with good spo2 in 90's when sat signal satisfactory; lungs diminished with poor inspiratory effort; has fair cough effort but does not raise and expectorate sputum.\n\nGI: nasal sump in place, tolerating meds and basal rate TF with problem; one moderate size liquid stool. TPN continues with good glucose control by insulin\n\nGU: qs clear amber urine via foley\n\nskin: generally intact; abdominal incision seems to be healing well, JP drain removed last evening by dr.\n\nstatus and plan: full code, contact precautions, adjust meds for better BP control\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-10 00:00:00.000",
"description": "Report",
"row_id": 1323436,
"text": "Shift Summary\nContinues unstable post op day 10 for pancreatectomy and spleenectomy. Stable shift with max temp 102.4, recultured MD order. R IJ QLC dc'd, cx'd and inserted new QLC L SC.\n\nN: Appears calm throughout the day. COnfused to sequence of events at times, reorients easily. Moderately withdrawn to plan of care r/t exhaution verbally stating. Pupils unequal wife states pt with L eye blindness. Generalized equal weakness all extremities, PT unable to meet needs d/t c/o weakness and nausea. PROM completed RN. Slightly HOH.\n\nR: Remains on 3L per NC throughout the day w/ sats >95% per pulse ox. LS with scattered rhonchi and diminished bases unchanged. Need encouragement w/ C&DB. RR regual and unlabored.\n\nCV: BP stablizing with ongoing increased PO Lopressor and IV Labetolol coverage to maintain pressure SBP 130-150's. L Radial a-line w/ dampened waveform approximately 20mmHg > cuff pressure. L SC QLC per Cxray in with all new tubing up. TPN continues. Dilaudid PCA with adequate pain control, new cartridge up. + Sys murmur. Pedal pulse weak bilaterally. No edema noted.\n\nGI: R nares NGT. Tolerating Criticare TF at 50cc/hr,rate to increase Q4 w/ max 80cc next increase at 200hrs w/ residual checked holding for residuals >150. BS + x4. Rectal tube dc'd and rectal pouch placed for continued liquid stool. Stool Cdiff positive tx'ing w/ PO vanco. LLQ JP puncture site w/ scant drainage. Abdominal staples intact wound well approximated and healing.\n\nGU: Foley w/ approximately 100cc/hr UOP clear yellow/\n\nSkin: New stage I pressure ulcer to R heal, frequent repositioning continues, with allother skinn integrity intact.\n\nID: Fever of unknown etiology, cx's pending. R IJ cath site noted w/ purulent drainage when dc'd. Still need sputum specimen, unable to induce.\n\nPlan; Maintain BP control. Encourage C&DB. Cover fever w/ tylenol. Obtain sputum specimen for cx. Reposition frequently, observe R heal pressure ulcer. Titrate TF to goal rate 80cc/hr monitor residual Q4hr. SSI coverage increased d/t increaesed FSG.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-11 00:00:00.000",
"description": "Report",
"row_id": 1323437,
"text": "neuro: confused at times but cooperative and relaxed\n\ncardiovascular: BP under better control this night, requiring only two prn doses of labetolol; rhythm sinus without block or ectopy\n\npulmonary: fair cough effort, does not consistently raise and expectorate sputum but eupneic and well-saturated on 3 liters nasal o2\n\nGI: tolerating goal rate of criticare HN with minimal residual; rectal bag in place with no significant output this night\n\nGU: qs clear amber urine via foley\n\nskin: generally intact except for incision, seems to be healing well;\n\nlabs: glucoses high this night requiring 10 units of RISS; others unremarkable\n\nID: tmax this night 101.8, cultures pending\n\nstatus and plan: full code, contact precautions, continue to monitor response to BP meds\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-11 00:00:00.000",
"description": "Report",
"row_id": 1323438,
"text": "MICU NPN 0700-:\n WBC count continues to climb to current level of 38--pt currently prepping for abd CT scan to r/o additional source of white count (presumed c-diff infection). Blood pressure control also remains an issue--PO lopressor transitioned to IV since enteral absorption in question.\n\n Neuro: Pt sleeping in frequent naps throughout day. When awake, pt a + o X 3, somewhat difficult to understand (hoarse voice) but conversant and cooperative. Pt pivoted oobtc X 1 hours with 2 assist. He tollerated movement well but was c/o extreme fatique after 1 hour. Dilaudid pca pump continues--pt showing good understanding and can use well--see carevue for exact doses/attempts. Pt states pain is well controlled.\n\n CV: Low grade temps. Sputum C + S and stool sent for c-diff. Pt in NSR, rate 80's. BP goal 140-160. On IV lopressor (with prn labatelol), SBP in 150's. Aline dampened, cuff pressures obtained. Equal in both arms. 1500 hct down somewhat--pt with active clot in bb. ? transfusion to keep hct > 30. 1 L NS hydration and mucomyst started to help protect pts kidneys with IV contrast.\n\n Pulm: Pt with incredibly weak cough despite aggressive pulm toilet. CPT done q 4 hours, IS q 1 hour. Alb inhalers with spacer. Pt expectorated occasional thick tenacious tan sputum. Lung sounds course. Levofloxacin continues for presumed pna.\n\n GI: TF d/c'd per surgery gold. TPN to continue. Residuals high in any event. Pt c/o diffuse abd pain that is worse in RUQ. FICC bag draining mod amts liquid brown stool. Pt recieving 3 bottles PO contrast for CT scan over 3 hours.\n\n GU: Foley to CD, uop excellent. Pt currently + 1500 cc for the day--will monitor fluid status closely as pt at risk for CHF (especially with hydration).\n\n Endo: RISS increased to q 4 hour coverage. FS down somewhat after d/c of tubefeeds.\n\n Skin: Pt repositioned per carevue. Heels elevated off bed. Full bath done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-12 00:00:00.000",
"description": "Report",
"row_id": 1323439,
"text": "neuro: continues very confused and voicing a lot of violent ideation (\"she could be killed two or three different ways\" \"i hate him, i'm going to kick his face\"); anxious and delirious but cooperative\n\ncardiovascular: more tachycardic than usual despite two increases in his lopressor dosage; 12-lead EKG this AM comparable to most recent in chart; occasional PVC's; BP under good control in 130-150 range; very difficult to find a digit with a good spo2 signal tonight; extremities cool to touch but not clammy or diaphoretic\n\npulmonary: cough effort weak, tolerated chest PT fairly well but does not cough effectively and does not raise or expectorate sputum; abg's show a decreasing trend of PaO2 despite increasing nasal o2; lungs essentially clear but does wheeze slightly with exertion\n\nGI: sump clamped, taking meds only; one small light brown diarrhea stool around mushroom\n\nGU: qs clear amber urine via foley\n\nskin: abdominal incision intact with staples; heel lesion intact, but pt keeps bending his legs and kicking leg pillow out of the bed\n\nlabs: wbc, BUN/creat worse; lytes wnl, glucoses well controlled\n\nstatus and plan: full code, contact isolation, CT scan report pending, continue post-MI care with heart rate control, pulmonary hygiene\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-12 00:00:00.000",
"description": "Report",
"row_id": 1323440,
"text": "MICU NPN 0700-:\n Events: Pt extremely diaphoretic, tachycardic and agitated this am. Pt confused and difficult to understand. EKG and ABG done. SICU team to bedside--pt started on NGT and esmolol gtt changed to labetalol with moderate improvement in HR (130's to 100's). Pt also found to have temp of 103 rectally. Pan cultures sent. Pt improved somewhat with tylenol, but continued to have mod resp distress through morning. CXR showed worsening pna--pt intubated for bronch and to decrease heart strain.\n\n Neuro: Pt c/o generalized pain throughout morning, but unable to articulate where pain was. denying chest pain. + effect with PCA. After intubation, PCA d/c'd and pt started on propofol. PRN dilaudid ordered--pt presently denying pain. Will administer narcotics as needed. On 25 mcg/kg/min propofol, pt arouses easily and follows commands . Bilat soft wrist restraints maintained for pt safety while intubated.\n\n CV: Tmax 103. Urine, 2 sets BC and sputum (post intubation) sent. After tylenol, HR decreasing significantly. Currently pt off labatelol and NTG due to post intubation hypotension. Pt started on levophed (low dose) to keep SBP > 100. After levo weaned off (and BP stable), plan is to restart NTG and diltiazem for rate control. Hct dropping slowly--1 u prbc infusing now without s/sx of rxn. Post transfusion hct should be checked this evening. Cardiac enzymes continue to climb--at 1030am CPK 434/65. Troponin pending. Plan to continue cycling enzymes until they begin trending down.\n\n Pulm: Worsening pna and confirmed of ETT on cxr. Pulmonary evaluatin pt now for bronch this afternoon. Lungs course throughout. Secretions incredibly thick and minimal amts removed with inline suctioning.\n\n GI: Pt NPO, plan for vanco enema/PO vanco/cholystyramine to treat persistant c-diff colitis. Abd tender with palpation. Mushroom catheter draining small amts golden liquid stool.\n\n GU: Of note, UOP dramatically down with SBP 90's. Now BP in 110-120 range and UOP much improved. 10 mg IV lasix attempted for ? pulm edema, but no response. MD aware. No further diuresis. Mucomyst dose # administered (last dose due tonight).\n\n Skin: Sacrum reddened but intact. Heels red.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-04 00:00:00.000",
"description": "Report",
"row_id": 1323412,
"text": "Nursing Progress/Transfer Admit Note.\n\nThis is a 57 yr old male admitted to on c recurrent pancreatitis c questionable pancreatic mass. Pt sent to OR that day for a distal pancreatectomy & splenectomy. Pt OR proc s complications. Pt sent to CC6 where he developed diaphoresis, N/V, MS changes and began ruling in for an MI. Pt transferred to 2 where his MS to delirium, confusion, agitation requiring 4 point restraints and a 1:1 sitter. Pt was found to r/i for AMI on 2. On a head CT was negative for changes. Pt alt MS managed on floor managed c freq dosing of ativan/dilaudid. Pt transfused c 2 units of PRBC's today on floor and became tachypneic, SOB, desatted, hyperdynamic and unresponsive on a 100% NRB. 17:15 ABG values are as follows: 7.33-42-62. Pt transferred to MICU-A @ 18:00 for emergent intubation which was executed s diff. A no 8# ETT is now in place, a CXR was performed to assess ETT placement, results are currently pending. EKG performed @ BS, ST depression noted. Propofol gtt in place and currently infusing @ 40mcg/kg/min c no agitation @ this time and SBP in the 110-130 range (HR also down to the 100's). A 10mg IV Lopressor dose was given @ 18:40 for tachycardia. Pt to go for a Chest CT to r/o PE this evening. Pt wife/dtr visited pt, kept up to date c /pt status. Stat labs sent @ 18:00, results notable for low K now being repleted c 20MEQ KCL IV via R IJ TLC. Foley cath in place, draining clear yellow urine. The pt is a Full Code. Univ isolation precautions in place. Multiple drug allergies noted, including; Morphine Sulfate, Ibuprofen, PCN, Zestril, Skellaxin, Percocet, Flagyl, and Leptin.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-04 00:00:00.000",
"description": "Report",
"row_id": 1323413,
"text": "addendum:\n\nAdmit note for wrong patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-05 00:00:00.000",
"description": "Report",
"row_id": 1323414,
"text": "Resp: pt on a/c 14/500/+5/100%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral coarse sounds. Suctioned for moderate amounts of white thick secretions. Transport to CTScan. Positive for RLL pneumonia, bilateral pleural effusions but negative for PE. Decreasd fio2 to 50%. AM ABG's 7.42/34/185/23. RSBI=135. No further changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-21 00:00:00.000",
"description": "Report",
"row_id": 1323468,
"text": "SHift Summary\nDay 21 s/p spleenectomy, distal pancreatectomy. Day 8 s/p MI. Day 1 post extubation after three intubations. See ICU updat tool. +MRSA sputum + cdiff. Stable but wakeful night.\n\nN: Frequent requests for \"antianxiety meds\" Frequent emotional support offered. Verbalizing hostile feelings regarding wifes . with Left eye blindness. Moves all extremeties well. Mostly A&Ox4, reorients easily to sequence of events and time.\n\nCV: Telemetry stable NSR, denies c/o CP or discomfort throughout the night. L brachial ALine intact with good wave form correlating with cuff. No edema. L SC TLC with small amount drainage toaite. Pedal pulses doppled bilaterally.\n\nR: Tolerating extubation with continued coarse bilateral lung sounds, strong occasionally productive cough. Pulse ox remains >95% on 5L per NC.\n\nGI/GU: Nepro TF to goal rate at 35cc/hr with scant residual. Rectal tube remains with green liquid stool, second cdiff specimen sent. Vanco enema held this AM d/t sleep state. UOP adequate for intake approximately 60cc/hr per foley.\n\nSkin: Abdominal wound well approxiameted and healing. New perineal/scrotal rash noted compared to yesterday assessemnt, denies pain/itching.\n\nPlan. Maintain strong pulmonary toiletry as pt has been reintubated x3 d/t increasing plueral effusions post extubation. Maintain aline as pt is difficult to stick. Hx/o poor ABGs have not always coorelated with a poor clinical picture. Encourage up to chair with PT. Tolerated up to chair x1 well. ?PO intake vs PEG tube. Frequent emotional support and TLC d/t chronic hx/o anxiety.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-21 00:00:00.000",
"description": "Report",
"row_id": 1323469,
"text": "NPN 0700-1900\nNEURO; AOOX2 MAE TO COMMAND TEARFUL AT TIMES LESS ANXIOUS,NO HALDOL GIVEN TODAY GIVEN DILAUDID 1MG PO X2 WITH GOOD EFFECT.\n\nRESP;LUNGS COARSE DIMINISHED AT BASES PRODUCTIVE COUGH OF THICK CREAMY SECRETIONS SATS 95-97% ON 2L FIO2 RR24-30 NO SOB . CXR DONE THIS AM.\n\nCVS; TMAX 99.4 PO NSR 80 BP 130-140/60. REQUIRED 10 MG LOPRESSOR I.V BOLUS THIS AM . FOR BP 161/79 WITH GOOD EFFECT. BRACHIAL ALINE D/C'D THIS AM.\n\nGU MIN AMOUNTS WNL CLEAR YELLOW URINE VIA FOLEY\n\nGI; CONTINUES T/F NEPRO AT GOAL ASKING TO EAT MANAGED ICE CHIPS HAVE ASKED TEAM IF PT TRY PO DURING DAY AWAITING ASNWER. CONTINUES TO PASS MOD AMOUNTS GREEN TO GOLDEN STOOL VIA RECTAL TUBE IN EXCESS OF VANCO ENEMA RETURN. BS ON RISS\n\nINTEGRUM SKIN CONTINU ES TO IMPROVE. AMBULATED TO CHAIR X2 WITH 2 PERSON ASSIST,S/B PT REHAB EVALUATION INITIATED,\n\nWIFE I AT BEDSIDE MOST OF DAY HAVE ASKED LISW TO SEE PT AND WIFE FOR EMOTIONAL SUPPORT.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-09 00:00:00.000",
"description": "Report",
"row_id": 1323431,
"text": "npn 7p-7a (see also careview flownotes for objective data)\n\ndx: s/p pancreatic surgery\n r/i for MI \n\nneuro:\npt w/ oriented interactions at beginning of shift, some confusion overnight; moves all extremities, weak; PERL:\n\nc-v:\npt weaned off Esmolol yest aft/ee, turned off at approx 18:00; IV lopressor also changed to po, 18:00 first dose of PO rte;\nreceived pt w/ sbp 160's-170's; b/p continued to increase despite increase in ntg gtt; IV lopressor given at approx 21:50 d/t continued htn, MD up to see pt, ordered labetelol gtt, started, pt w/ good response; however pt already developed c.p., unit EKG obtained, FIO2 in mist mask increased; labs obtained (including cardiac enzymes) at 22:00; pt given dilaudid for c.p. (allergy to MSO4); at finally more comfortable at about 23:00; labetelol decreased from max 2 mg, down to 0.5 mg, however pt's b/p started to rise again in the early morning, therefore increased again;\n\nresp:\nABG showed good response to increased FIO2 via face mask;\n\ng-i:\nremains NPO at this time; TF's criticare HN started as ordered;\nalso on TPN;\n\nendo:\non RISS, FS 22:00 required insulin coverage;\n\ng-u:\nurine output adequate via patent foley; somewhat diuretic affect after IV levofloxin;\n\nskin:\nfull bedbath received; no breakdown in coccyx area;\n\nPLAN:\nA.M. labs\n 1) re-cycle cardiac enzyes, set #2 due about 05:30 a.m.;\nhtn control\nDo not force pre-mature of weaning from b/p meds\nLevo for pna\nProtonix, hep SQ;\ntransfuse for hct <30\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-09 00:00:00.000",
"description": "Report",
"row_id": 1323432,
"text": "npn 06:15 addendum:\n\nTube Feed residual checked at 06:00, 80 cc dark opque return, pt had only recieved 40 cc's clear amber colored tube feed (criticare);\n\nJ-P drain at left abdominal surgical site with tiny amt (approx 5 cc) darkish opaque drainage;\n\nRecieved RISS for FS 241 as ordered.\n\nPt remains somewhat confused this a.m., eyes open, resting somewhat quietly at 06:15.\n\nLabetelol gtt back up to 2 mg/min, d/t htn. Given resid described above, ? adequacy of absorption NG administration of anti-hypertensives.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-09 00:00:00.000",
"description": "Report",
"row_id": 1323433,
"text": "06:45\n\nnew order for a.m. ABG received, specimen sent to lab 06:35.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-09 00:00:00.000",
"description": "Report",
"row_id": 1323434,
"text": "NPN;0700-1900;\n\nNEURO; AOOX2-3 ABLE TO KEEP TRACK OF EVERYTHING BUT DAY AND YEAR.\nMAE TO COMMAND, DIFFICULT TO UNDRESTAND AT TIMES ESPECIALLY WHEN WAKENS FROM SLEEP. NO HALDOL GIVEN TODAY.\n\nRESP; LUNGS DIMINISHED ENCOURAGED TO DEEP BREATH AND COUGH, GIVEN COUGH PILLOW TO SPLINT WOUND .WEANED FROM TENT MASK TO 6L N/C RR 16-20.SATS 96-100%.\n\nCVS; TMAX 101.7 PO BLOOD CULTURES DRAWN GIVEN TYLENOL T 100.6PO\nTEPID SPONGED HR 85-95.SBP MAINTAINED AROUND 145/ WEANED OF NITRO AND LABETOLOL DRIPS BY 1500 . GIVEN LOPRESSOR 5MGS I.V FOR SBP CONSISTENTLY IN THE 16O-165. GOAL SBP<,140.-\n\nPAIN; GIVEN 2 MGS DILAUDID WITH FAIR RESPONSE STARTED ON DILAIUDID PCA WITH GOOD EFFECT PAIN - NO PAIN NEEDS REMINDER TO PUSH BUTTON OCCASSIONALLY..\n\nGU; ADEQUATE URINE OUTPUT VIA FOLEY.\n\nGI; POS BS POS FLATUS, NO STOOL. HIGH RESIDUAL 60-120 MLS PINK COFFE GROUND . SERVICE AWARE ON PROTONIX CONTINUE WITH 10 MLS/HR BELLY SOFT.\n\nWOUNDS; OTA PINK WITH STAPLES NO DRAINAGE.. JP DRAINING MIN AMOUNTS.\n\nWIFE AT BEDSIDE MOST OF DAY,\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-04 00:00:00.000",
"description": "Report",
"row_id": 1323411,
"text": "NPN 1700-1900\n\nevents: pt admitted to MICU A for GI bleed after being transfered to ED from rehab after multiple complaints of CP (relieved by SL NTG). In ED, hct was 22, down from 32 during recent OP visit on , guiac positive and lavaged for BRB. Pt received 3 units RBC's and 1 unit FFP's before arriving in MICU A\n\nneuro: A&Ox3, groggy when he wakes but easily reoriented; MAE's, follows commands, c/o CP only\n\ncv: c/o CP and rc'd ntg SL with good relief, HR 60-80's, A-fib with occassional PVC's, SBP 160-180's (HO aware) and received 5mg IV Lopressor with minimal effect, +pp, continue to monitor serial HCT's (next due after 4th unit) and cardiac enzymes (due at midnight)\n\nresp: LS crackles throughout with some inspiratory/expiratory wheezing in L lobe, Sats 95-100% on 4L via NC, RR 14-18\n\ngi: npo, +bs, abd soft/distended/NT\n\ngu: u/o WNL, clear and light yellow\n\ninteg: cool/dry/intact\n\nid: afebrile\n\nsocial: wife and sister-in law in to visit and very supportive\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-20 00:00:00.000",
"description": "Report",
"row_id": 1323466,
"text": "neuro: remains sedated on propofol 20 mcg/kg/min\n\ncardiovascular: rhythm stable, BP stable on current therapy; atenolol held for one dose due to brief episode of hypotension which occurred when propofol titrated up to accomplish CXR last evening; skin and extremities well perfused\n\npulmonary: stable and eupneic on current vent settings; moderate amounts of thick pale yellow to tan sputum\n\nGI: tf on hold pending evaluation for extubation; vancomycin enemas continue, tolerated well but with very little stool excreted, only enema returned\n\nGU: qs clear amber urine; lasix order to be re-evaluated due to above-noted hypotensive episode\n\nskin: generally intact with well-healing abdominal incision; other skin breaks healing\n\nlines: CVP transduced, new left brachial arterial line inserted last evening\n\nstatus and plan: full code, contact isolation, consider extubation, promote diet and activity if indicated\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-07 00:00:00.000",
"description": "Report",
"row_id": 1323424,
"text": "Progress Note: 7P-7A\n\nCondition Stable but guarded at present, Post Distal pancreatectomy and spleenectomy complicated by MI and Resp Failure.\n\nNeuro: Patient will spontaneously open eyes, but only obeyed commands one time (wiggled toes). Sedated with Propofol right now at 60 mcgs, increased to keep BP down. Medicated with hydromorphine 2 mg X 2 (, 2330) and it works well for his BP. PERRLA, 3mm, brisk.\n\nCV: When medicated with dilaudid BP drops to 116-120,otherwise he sits in 130's HR is now 86-88, has decreased with temp. Patient has been afbrile since MN. CVP 6-7. PAS/PAD 33-36/24-27. Wedge 13. 0200 lasix held as pateint belived to be dry and is -1200 for past 24 hours\nDrips: Esmolol@ 125 mcg/kg/min\n NTG 0.6 mcg/kg/min\n Heparin @ 1600 units/hr. PTT drawn 1 hour earlier since patient had blood in GI residuals.....Was sub-therapeutic at 47.9. Will draw PTT at 0600.\n Potassium of 3.9 replaced with 40 MEq\n Magnesium 1.7 replaced with 2 grams\n CK 234 at 2200\n\nNote Swan is at 58cm, tracing adequate, wedging without difficulty, ?documentation error. Grion prep done for ? cath. patient has bilateral femoral bruits\n\nResp: Vent settings unchanged. PSV 5, Peep:5 O2 40%. has not needed suctioning, Sats excellent.\n\nGU: Lasix held at 0200 as ordered. Patient in Negative 1200 balence. Goal is for equal balence per 24 hours. Currently in small +. Average output since mn 45-60 ml/hr. Urine green from propofol.\n\nGI: Feeds off since MN for possible cardiac cath today (pending blood cultures). Residuals were 270. Discarded 180 of this. + Guaiac. to continue heparin at present. Covered with 2 units Regular insulin at mn for BS 145\n\n\nAM labs pending at present. Pending cultures. Sputum negative\n\nPlan: Cardiac cath when cultures negative, Continue ABX. BP control\n\n , RN\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-07 00:00:00.000",
"description": "Report",
"row_id": 1323425,
"text": "Respiratory Care Note:\n\n\nPt remain orally intubated and sedated on minimal PSV with No vent changes done. Routine suctioning done for smalla mt of white thick sputum. We adm Albuterool MDI with No changes in BS LPEW R>L. ETT retaped without incident. Plan: Continue recent ICU monitoring and look out for agitation episode, ? elective ext.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-07 00:00:00.000",
"description": "Report",
"row_id": 1323426,
"text": "Resp care\nPt remains on unchanged vent settings. ABG's show well oxygenated/ventilated. BS ess. clear. Sx sm thick white secretions. Plan to ext. tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-07 00:00:00.000",
"description": "Report",
"row_id": 1323427,
"text": "NURSING NOTE 0700HRS - 1700HRS\n\nEVENTS - REMAINED SEDATED/ WEAN ESMOLOL/NITRO DRIP, NO CATH AT PRESENT - P/O MEDS RE-INTRODUCED ANTI ANXIETY MEDS COMMENCED - PLAN TO EXTUBATE TOMORROW - TPN COMMENCED\n\n\nNEURO - CONTINUES SEDATED ON PROPOFOL X1 DOSE OF ANALGEIA GIVEN OCCASSIONALLY OPENING EYES BUT NO LIMB MOVEMENT NOT FOLLOWING COMMANDS - PUPILS EQUAL /RECATIVE - CLONIDINE PATCH COMMENCED TO HELP WITH ANXIETY ? TO COMMENCE OTHER MEDS IN PREP FOR ATTEMPTED EXTUBATION TOMORROW\n\n\n\nRESP - ABG STABLE SUCTIONED MINIMAL AMOUNT SATS >98% - LUNGS CONTINUE TO SOUND DIMINSHED\n\n\nCVS - B/P MAP MAINTAINED AT /AROUND 80 MAP AND NITRO TITRATED TO OBTAIN - THIS PM LASARTIN COMMENCED TO HELP CONTROL B/P IN ORDER TO WEAN NITRO {ALTHOUGH ? ABSORPTION OF MEDS , SEE BELOW} ORAL BBLOCKER ASLO COMMENCED IN ORDER TO WEAN ESMOLOL, DRIP WEANED TO 75MCGS/KG - HR 82-87 MINIMAL PACS\nREVIWED BY CARDIOLOGY EKG PERFORMED STABLE EJECTION FRACTION - PA PRESSURES STABLE/CVP 9-11 - CARDIAC ENZYMES STABLE CONTINUE TO CYCLE - NO CATH TODAY AS CARDIOLOGYS VIEW IS THAT PREVIOUS CARDIAC EVENT COMPLETED AND THEREFORE NO NEED FOR EMERGENT CATH - TO BE DONE AT LATER DATE\nHEPARIN TO CONTINUE AT PRESENT - THERAPEUTIC THIS AM, FOR CHECK THIS EVE\nCHEM 7 STABLE - CAL REPLACE - FOR CHECK HCT @ 1800HRS [STABLE THIS AM], AS BLOOD PREVIUOSLY IN G/I RESIDUALS\nAFEBRILE AB'S CONTINUE - POSITIVE TO C DIFF ORAL VANC COMMENCED\nBLOOD SUGARS STABLE\n\n\nG/I - C DIF FROM PREVIOUS SAMPLE VANC COMMENCED - NO BOWEL MOTION , AFTER MUCH DISCUSSION REGLAN COMMENCED TO HELP WITH HIGH RESIDULAS >100 - TUBE FEEDS RE-COMMENCED THIS PM, TO CONTINUE TO OBSERVE RESIDULAS - AND TPN COMMENCED THIS EVE\n\nG/U - LASIX D/C OUTPUT 40-60CC/HR - POS BALANCE - URINE LOOKS GREEN, TEAM AWARE AND SAMPLE SENT\n\nSKIN - INTACT\n\nLINES - ? FOR SWANN REMOVAL TOMORROW/ CHANGE TO CENTRAL LINE - X1 NEW PERIPHERAL INSERTED\n\n\nSOCIAL - FAMILY VISIT AWARE OF PLAN FOR TODAY\n\n\nPLAN - WEAN IV MEDS TODAY , INTRODUCE ORAL - OBSERVE FEEDING REIDUALS - TX FOR C DIF - ANTI ANXIETY MEDS WEAN TOMORROW\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-08 00:00:00.000",
"description": "Report",
"row_id": 1323428,
"text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and ventilated on CPAP 5/5/.40. RSBI completed this AM on PSV=0, Peep=0, ATC on=22. Tolerated well. No signs of distress noted, just agitated at times.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-08 00:00:00.000",
"description": "Report",
"row_id": 1323429,
"text": "NPN 1900 to 0730\nNEURO: Pt. sedated well with Propafol 250 mcq/hr and dilaudid IVP q 2 hr mgm. increase SBP reflective of increase anxiety/pain and responds well to adequate control. Opens eye, look frighteded, not follow commands , to pain stim. grimaces.\n\nCV: able to wean esmolol gtt and nitro gtt off with adequate sedation/analgesia in place, HT unremarkable, sbp 120-140, urine qs, peripheral pulses intact, skin warm dry, no edema, afebrile. HR sinus without ectopy/ CMS intact.\n\nRESP: pt. on CPAP 40% rr 8-12 dependant on level of sedation/rest level. suction for scant thin white secretions. oral clear. mod. lung fields clear to bases. slightly diminished bil. abg acceptable on current sets. goal to provide adequat sedation and work to extubate today. pt. gets very anxious on prev attempts, clonidine patch on chest wall\n\nGI: abd soft, appears non tender, NG residuals drk brwn trace + gastrocult early in pm. TF suspended. on recheck of residuals pt. found to have BRB from NG. HEPARIN gtt. stopped, labs sent, HO aware and to see pt. lavage with NS 2 liters still some BRB although majority in grossly + drk brwn. no stool. BT present. Pt. remains on low to mod cont suction. cont to have brwn ng drainage\n\nGU: urine brwn green qs per foley, clear.\n\nEndo: BS coverage for 192, 4 units insulin at 0000.\n\nSKIN: abd incision approximated without drainage, staples intact. JP site drains slight light brwn drainage, drsg , site . good, redressed, scant brwn from JP. other skin intact.\n\nACCESS: cordis/swan ganz cath in right IJ. dc PIV right hand, started new 18 g in right upper arm. art line good wave slight positional. PA line wave form good. wedge with 1 cc.\n\nSocial: pt. has hx of anxiety. to date been unsuccessful with extubation seconday to anxiety. clonidine patch on yest. will cont. to support pt. anxiety with med. education and reassurance.\n\nLABS: H/H slight decrease at 30, platelets adequate, 0630 am labs drawn and pending.\n\nPlan: Cont. monitor CV status, resp status, GI status, labs, Hemodynamics. Provide adequate pain/sedation pre and post extubation. DC TF, HEparin gtt and reeval based on GI. repeat labs pending. Provide emotional support to pt. and family. Provide ongoing resp. support and wound care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-08 00:00:00.000",
"description": "Report",
"row_id": 1323430,
"text": "Shift Summary\nDay 8 s/p pancreatectomy, spleenectomy. Stable day extubated 1530hr without event to 70% face mask. Esmolol weaned to off, unable to wean NTG d/t continued HTN. Continues with c/o chronic pain. Receiving heavy doses of pain narcatics Dilaudid, Percocet for Pancreatits prehospitalization. Dilaudid 2mg slow IVP given for generalized pain with minimal relief. Haldol 5mg IVP give for anxiety with good relief.\n\nN: A&O x3, confused at times to time and place, reorients easily. Most expresses unhappiness r/t continued pain and frustration with overall health status. Requires continued observation and emotioanl support d/t anxiety and agitation. OD 3mm reacts sluggish, OS 4mm reacts briskly. Generalized weakness.\n\nCV: PA line with cordis dc'd to cath over wire QLC to R IJ. Line site leaking d/t dilated site. MD with no pnuemo per CXRay. Pos murmur. Peripheal pulses equal. INT to L H and R AC patent and WNL. Telemetry without ectopy HR up ST 100's post extubation r/t increased anxiety.\n\nR: Scattered coarse rhonchi noted throughout bilateral lobes post extubation, requires encouraged C&DB. Not cooperative with care at this time d/t agitation r/t pain. Plan for incentive spirometry when pt cooperative. Sats >95% on 70 face shield. Tolerating extubation well.\n\nGI/GU: Abdominal wound well approximated with stales intact. JP to bulb sx remains, surgical team with plan to dc, orders not writted. BS + x4, No BM, Denies N/V. NGT clamped post meds. Plan to restart tube feeds, holding for increased residuals. Tube feeds off throughout the day d/t GIB, MDs aware. Q6hr Hct ordered and stable x1. NGT with continued coffee ground, lavage with no s/s active bleeding. Urine output adequate for intake. Hx/o birth with one kidney, no hx/o renal insufficiency.\n\nSkin: As above Abdominal wound intact, site without drainage, healing well post op day 8.\n\nPlaN: Maintain pain control. Wean off NTG maintaining SBP 130's. TPN restarted monitor FSG with SSI coverage as needed. TF to be restarted. Watch for s/s of new GIB, HCt Q6hr. Monitor LS as rhonchi are new post extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-20 00:00:00.000",
"description": "Report",
"row_id": 1323467,
"text": "npn 0700-1900;\nsub; i am depressed give me something for anxiety. give me something to put me to sleep.\n\nneuro;AOOX2 MAE TO COMMAND CONFUSED AND AGITATED AROUND 3 30 PM GIVEN 5 MGS HALDOL FOR AGITATION AND TYLENOL PO FOR PAIN SETTLED AND SLEPT UNTIIL 6PM ASKING FOR SOMETHING TO KEEP HIM ASLEEP /NEEDS PSYCHE CONSULT AS PT HAS HISTORY OF DEPRESSION.\n\nRESP; WEANED OFF PROPOFOL AND SUCCESSFULLY EXTUBATED. TO 50 % FACE TENT WEANED TO 6L N/C AT 6 PM. POST EXTUBATION ABG ACCEPTIBLE WILL PULL ALINE.\n\nCVS. T MAX 99 PO NSR WITH ISCO PVC'S K 5.3-5.2 BP STABLE GIVEN 100MGS OF ATENOLOL INSTEAD 150MGS. BP STABLE 110-140/75. QTC .41.\n\nGU; DIURESIS GREATER THAN 60 MLS/HR CLEAR YELLOW URINE. VIA FOLEY.\n\nGI; NPO FOR EXTUBATION BELLY SOFT POS BS SMALLAMOUNT OF GOLDEN. LIQUID STOOL. BS ON RISS.\n\nPAIN CONTROLLED WITH DILAUDID 2 MGS PO IN AM AND TYLENOL PO IN AFTERNOON. AS GAVE HALDOL FOR AGITATION AS DIFFICUTLT TO TELL WHETHER INPAIIN OR CONFUSED. WITH GOOD EFFECT.\n\nINTEGRUM SKIN ISSUES RESOVING,\n\nSOC; WIFE AT BEDSIDE AND UPDATED WITH PTS CURRENT CONDITION.\nA/P STABLE DAY CONTINUE WITH PULMONARY TOILET.\nCONTROL AGITATION WITH HALDOL AS TOLERATED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-19 00:00:00.000",
"description": "Report",
"row_id": 1323463,
"text": "neuro: continues well sedated on propofol, titrated up to 30 mcg/kg/min to promote sleep and BP tolerated this well\n\ncardiovascular: rhythm has been sinus with very little ectopy tonight, BP stable despite propofol, peripheral perfusion of skin and extremities is much improved\n\npulmonary: suctioned for moderate to large amounts of thick tan to pale yellow sputum; spo2 generally in high 90's when signal obtainable; current vent settings as RRT note\n\nGI: continues to tolerate tf at ordered max rate of 30 with minimal residuals; minimal stool output except return of vancomycin enena\n\nlabs: wbc improved despite fever; chemistries pending\n\nskin: generally improved, with skin breaks healing\n\nstatus and plan: full code, contact precautions, continue treatment of infections and other supportive care\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-19 00:00:00.000",
"description": "Report",
"row_id": 1323464,
"text": "Resp Therapy\nPt remains and on full vent support. Changed from CMV to SIMV +PSV. Thorocentesis performed for 550cc of clear fluid. Post procedure CXR showed small right apical pneumothorax. Repeat CXR ordered for later this PM. See resp flowsheet for any further vent data. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-05 00:00:00.000",
"description": "Report",
"row_id": 1323417,
"text": "ADDENDUM - PTT SUB THEARPETIC THIS AM THEREFORE BOLUS AND RATE INCREASED , REMAINED SUB THERAPEUTIC THIS PM, AWAIT TEAMS DECISION RE : INCREASE [ AIM FOR RANGE OF PTT 50-60]\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-05 00:00:00.000",
"description": "Report",
"row_id": 1323418,
"text": "Resp. Care Note\nPt remains intubated and vented on current settings PSV 12 peep 5 and 40%. Pt changed from AC to PSV this shift, good ABG. Ordered for Albuterol MDI, has Hx. of COPD.,BS without wheezes, essent. clear. Need sputum for culture, no secretions sxn so far. Cont current settings, eval tomorrow for readiness to wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-06 00:00:00.000",
"description": "Report",
"row_id": 1323419,
"text": "Respiratory Care Note:\n\nPt received on PSV and sedated. We decreased IPS from 12 to 10 cmH20 and tol well, comfirmed by ABG. We are sxtn small amt of yel-tan secretions from ETT. He is reveiving Alb MDI PRN, given once. BS Clear bil, occ coarse BBS. Plan: Continue weaning IPS as tol and planned elective extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-06 00:00:00.000",
"description": "Report",
"row_id": 1323420,
"text": "P-MICU NPN 7p-7a\nSystems Review:\n\nCV: Cardiac enzymes con't to be drawn q6h. CPK this am 344, up from 202! Troponin has not yet peaked. VS have remained stable. Receiving lopressor and hydralazine for BP and rate control. NTG weaned to off earlier in shift. Pt has received K+ replacement for K+ of 3.3. AM results 3.8.\n\nResp: Suctioned mult times for thick tan secretions. LS clear to coarse, improving after suctioning. PSV decreased to 10 from 12 with good ABG. RSBI: 35 this am. Placed on breathing trial and currently on 5 PSV and 5 peep. STV's 500's+.\n\nGI: High aspirates con't. TF's have not been reinitiated. F/U in am re: possible reglan po. +BS, +flattus. Large liquid BM OB-.\n\nGU: Received lasix per order, excellent response. Fluid balance negative by 1700cc's by midnight last night.\n\nSocial: Wife has called and been updated.\n\nNeuro: Propafol infusing with good effect. Received hydromorphone 2mg times 2. PERRLA ~3mm.\n\nID: Temp 99.5 basically all night. No temp spike. WBC up this am to 28.9 (from 20.7)\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-13 00:00:00.000",
"description": "Report",
"row_id": 1323445,
"text": "Shift Summary cont..\nGI: BS+ X4. c/o mild abdominal pain this afternoon, medicated with fentanyl IVP. Rectal tube remains in place no BM. Cdiff positive, pending repeat cultures tx'd with Vanco enema changed to IV vanco today. Abdominal wound well approximated with staple intact. JP puncture site RLQ healing well.\n\nGU: Receiving Lasix 10mg good urine output approximately 150cc/hr.\n\nSkin: Right heal pressure ulcer improving, healing well. Sacaral area slighlty reddened otherwise skin intact.\n\nID: Continues with low grade fever temp max 99F. Sputum cx positive MRSA, Cdiff pos. stool. Vanco IV initiated, pipercillan dc'd.\n\nPlan: Down for cardiac cath post ischemia progressing this afternoon. Bilateral Pedal pulses difficult to palpate prior to cath. Left Radial A-line nonfunctional, Pending new aline , 1400 ABG not drawn, MD informed. Heparin drip not therapeutic prior to cath. Insulin drip with Q1hr FSG per protocol maintaining BS 100-130 range. First set Cardiac enzymes 3 of 3 completed. f/ with MD regarding second set. post cath. Monitor s/s of GIB as pt has hx/o GIB with heparin drip on.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-14 00:00:00.000",
"description": "Report",
"row_id": 1323446,
"text": "NPN 1900-0700:\n\nEvents: Pt returned from Cath Lab at 2130 in stable condition. Findings: 3VD, including left main stem artery. Since pt not a surgical candidate, he underwent balloon angioplasty and stenting of left main stem. Heparin was D/C'd in lab and he was started on Plavix. He has remained very stale post-procedure.\n\nNEURO: Pt sedated on Propofol; dose increased from 40 to 80 mcg in the lab, and he required further increase to 100mcg on arrival back to unit for agitation. Since then he has been weaned down to 70mcg, with occasional twitching activity (not new). Pupils equal and sluggish. No spontaneous movement of extremities observed except twitching.\nRESP: Remains on same vent settings of SIMV .5/650/14/ with PEEP 5 and PSV 10. Occasional breaths over set rate. Suctioned on return from lab for large amount thick tan secretions; otherwise no sxn needed. LS coarse on arrival t/o, but cleared significantly with suctioning.\nC-V: Cath findings/intervention as above. On return he was quickly weaned of the NTG; Esmolol remains at 150mcg. BP stable, 90's-120's, rising gradually overnight. Post-procedure EKG done and placed in blue book. HR 80's, NSR, rare PVC's. Trop 4.27; CK's steady, but MB cont's to rise (13.9 this AM). Lytes WNL. Got first dose of Plavix in lab, and will continue on ASA. No need for Heparin. Hands cyanotic and cool bilaterally ( aware); + pulses, ? if new. On return from lab unable to doppler and pedal pulses except left DP. Feet equally cool; R great toe cyanotic, normal color otherwise on both LE's. Right femoral arterial and venous sheaths intact, sites clean and dry without evidence of hematoma. Cardiology fellow notified of findings, up to see patient. Sheath pulled by Dr without complication. Pt has remained flat in bed with right leg straight all night (restrictions on movement lifted at 0700). No change in extremities, and groin site remains without evidence of infection or hematoma.\nID: Afebrile, WBC stable. Cont's on IV Vanco, which has been changed to q24 hours based on levels. PO Vanco resumed.\nHEME: No evidence of bleeding. Hct, plt's, INR stable. PTT decreasing off heparin.\nGI: Belly benign with hypoactive BS. No stool overnight; tolerating meds via OGT.\nGU: Foley draining clear yellow urine. BUN/creat elevated but stable. Lasix D/C'd for now; pt has recieved first of 2 scheduled doses of Mucomyst. Hydration of .45NS for a total of 1500cc's being given.\nENDO: FSBS 67 on return from lab. Insulin gtt turned off, and sugars have remained <130 all night.\nSKIN: Abdominal incision clean dry, with intact staples.\nACCESS: Multiple unsuccessful attempts at a-line; quad lumen intact.\nSOCIAL: wife updated by Interventional Cardiologist Dr . She went back to the hotel and called for update later.\n\nA: stable post-cath\n\nP: continue to closely monitor hemodynamics, EKG, groin site, extremities; needs one more dose of mucomyst; complete hydration as ordered. Wea\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-14 00:00:00.000",
"description": "Report",
"row_id": 1323447,
"text": "(Continued)\nn sedation to keep patient comfortable and safe on vent. Continue to follow temps; abx as ordered. Assess for worsening renal failure; monitor closely for bleeding. Continue to support family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-14 00:00:00.000",
"description": "Report",
"row_id": 1323448,
"text": "Resp. Care Note\nPt remains and vented on settings as charted on resp flowsheet. Pt changed from AC mode to PSV 12 peep 5 and 50%. TV 500-600 and RR 20's for minute vent. of 13-14L. Sxn for thick white secretions, Albuteol MDI Q vent check. BS decreased bilat. No ABG's, no a-line. Cont current support, assess for PSV wean in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-19 00:00:00.000",
"description": "Report",
"row_id": 1323465,
"text": "Shift Summary\nDay 19 s/p spleenectomy, distal pancreatectomy. Day 2 reintubation x3. Thorocentesis today w/ 1200cc removed and small R apex lobe pnuemothorax.\n\nN: Lightly sedated weaned propofol from 30mcq to 15mcq d/t brief hypotension s/p thorocentisis. Expresses needs with yes/no appropriate answers. Medicated x2 with dilaudid 2mg s/p thorocentisis for c/o back pain. L eye blindness. Equal strength generalized weakness throughout bilaterally.\n\nCV: Telemetry in NSR with rare PVC throuhgout the day. Denies c/o CP or discomfort. BP normotensive maintained with increased Atenolol day 2. s/p brief hypotension 85/50 post thorocentesis resolved without tx. Pedal pulses continue by doppler only bilateral feet with improved vascular noted r/t warmth and improved color compared to .\n\nR: Tolerating current vent setting changed to IMV this AM. ABG for , not for aline d/t probable extubation and difficult stick. LS continue coarse with large copious thick white secretions per ETT sx'd 3hr. Moderate oral secretions sx'd Q2hr. Denies difficulty in breathing PM Cxry for R pnuemo f/u. Sats >95% per pulse ox throughut the day.\n\nGI: Tube feeds increased with Impact to 60cc/hr now at goal rate with minimal residuals. TPN not reordereds. Vanco enemas cont with minimal stool out per mushroom cath. BS+ x4 with no c/o abd pain, soft and nondistended.\n\nGU: UOP adequate with scheduled Lasix 20mg q12h.\n\nSkin: Intact with healing buttocks abrasion and abdominal wound.\n\nID: WBC cont downward trend. Borderline temp consistent. Plueral thorocentesis fluid clear. no s/s of crrent infection. Repeat cdiff pending.\n\nPlan: Encourage rest/sleep this evening, possible extubation tommorrow. CXry f/u for R pnuemo this evening. Frequent ETT and Oral sx'ing. Check TF residuals Q4 with new goal rate at 60cc/hr and frequent FSG levels borderline hypoglycemic prior to TPN being dc'd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-06 00:00:00.000",
"description": "Report",
"row_id": 1323421,
"text": "\nPT MAINTAINED ON PSV VENTILATION AND TOL. WELL WITH SEDATION, PT UNMANAGEABLE WITHOUT IT. SX FOR SM AMTS. MEDS GIVEN. VITALS STABLE, ECHO PLANNED FOR TODAY, WITH CATH LAB AT SOME LATER TIME. WHITE CT. AND FEBRILE. WIFE IN VISITING. PLAN IS TO CONT ON SAME PSV VENTILATION WITH HOPES OF EXTUBATION IF PT. TOL. BEING OF OF HIGH LEVELS OF SEDATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-06 00:00:00.000",
"description": "Report",
"row_id": 1323422,
"text": "NURSING NOTE 0700HRS - 1700HRS\n\n\n\nEVENTS - FAILED ATTEMPT TO EXTUBATE DUE TO AGITATION THEREFORE RE-SEDATED - ECHO/EKG CONTINUED CYCLING OF CARDIAC ENZYMES - FEBRILE BLOOD CULTURES TAKEN\n\n\nNEURO - RECEIVED SEDATED ON PRORPOFOL EASILY WAKENED BUT NOT FOLLOWING COMMANDS - DECISION BY TEAM TO WAKE-UP PATIENT TO ASSESS PROPERLY - SEDATION STOPPED PATIENT VERY AGITATED MOVING ALL 4 LIMBS NOT FOLLOWING COMMANDS FOR SAFETY OF PATIENT RE-SEDATED - X1 DOSE OF HYDRO-MORPH THIS PM ? IN PAIN ACCORDING TO VITALS - WIFE SAYS NORMALLY VERY ANXIOUS AND ON ANTI-ANXIETY MEDS AND WAS VERY AGITATED/CONFUSED POST PANCREATECTOMY - PATIENT CONTINUES ON PROPOFOL THIS PM - ICU/SURGICAL TEAM AWARE OF AGITATION ISSUE AND WILL FOLLOW\n\n\nRESP - ICU TEAM WISHED TO ATTEMPT TO EXTUBATE THIS AM - BUT DUE TO AGITATION TV DECRESAED TO 400 SATS TO 94% RES RATE ^30 - THEREFORE NO FURTHER ATTEMPT TO EXTUBATE TODAY - WHEN SETTLED SATS >98% T.V @ 500-550 RR @ 150-18 SUCTIONED OCCASSIONALLY FOR WHITE SECRETIONS - PRESENT SETTINGS 40% - REVIEWED BY SURGICAL TEAM THIS NOT FOR EXTUBATION THIS AT PRESENT\n\n\nCVS - AIM FOR B/P MAP @ 80, CONTROLLED PRESENTLY WITH NITRO [PREVIOUSLY HYDARALAZINE NOW D/C]\nAIM HR <100 CONTROLLED PRESENTLY WITH ESMOLOL CURRENTLY @ 125MCGS/KG - CONTINUES WITH FREQUENT PAC'S\n CARDIOLOGY REVIEW ECHO/EKG PERFORMED - CARDIAC ENZYMES CYCLED - TEAM AWARE OF SLIGHT RAISE THIS AM [1PM LABS DRAWN - ERROR AS NOT FOR THIS PATIENT] REPWATED AGAIN AT 1700HRS AWAIT RESULT - FOR CARDIAC CATH TOMORROW\nBORDERLINE TEMP [RAISED WBC] BLOOD CULTURES TAKEN\n\nK REPLACE THIS PM/OBSERVE\nHEPARIN INFUSSION INCREASED TO 1400U/HR - RE-CHECK @ 1700HRS AWAIT RESULT\nPA PRESSURES SYSTOLIC 25-35 [REDUCED WITH LOWER MAP] - WEDGE @ - ? FLATTENED TRACE BUT RE-REVIWED BY CARDIOLOGY TRACING SATISFACTORY CVP @ \nSVR RAISED/C.I/O REDUCED CARDIOLOGY AWARE ?? REPEAT THERMODILUTION THIS PM\n\n\nG/I - NO BOWEL MOTION [ SAMPLE SENT PREVIOUSLY] - NEPRO FEEDS PREVIOUSLY HELD HIGH RESIDULS - RE-COMMENCED TODAY BUT HELD GAIN IN VIEW OF POSSIBLE ECTUBATION - REGIME REVIWED BY DIETTION THIS PM TO COMMENCE CRITICARE @ 10CC/HR BUT IS NPO FROM 12 MN FOR CATH TOMORROW\n\n\nG/U - CONTINUE IN NEGATIVE BALANCE - LASIX AS ORDERED [DESPITE TEAM AWARE OF NEG BALANCE AND CVP READINGS] - NOW REDUCED DOSE AS ONGOING TACHCARDIA ?RELATED TO DEHYDRATION [AS PER CARDIOLOGY] - AIM NOW FOR THE REMAINDER OF THE DAY TO BE EVEN BALANCE BY 12.MN\n\n\nSKIN - INTACT - WOUND RE-DRESSED NO OUTPUT FROM J.P\n\nLINES - PATENT\n\nSOCIAL - WIFE AWARE OF POSSIBLE CATH TOMORROW - WILL CALL AGAIN THIS EVE\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-06 00:00:00.000",
"description": "Report",
"row_id": 1323423,
"text": "ADDENDUM - PLAN- KEEP INTUBATED/SEDATED [AS PER SURGEONS] ESMOLOL FOR HR CONTROL NITRO FOR B/P CONTROL - NPO FROM 12MN FOR CARDIAC CATH TOMORROW\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-23 00:00:00.000",
"description": "Report",
"row_id": 1323472,
"text": "npn 7p-7a (see also careview flownotes for objective data)\n\ndx: s/p pancreatic surgery; resp failure; cardiac stent;\n\nneuro:\nremains confused, oriented to person; verbalizations understandable, though confused; complained of feeling anxious last eve, given haldol prn as ordered with good effect; pt rested quietly following;\n this a.m. pt trying to get out of bed, c/o not being able to breath, though O2 sat 98-100%; lung sounds unremarkable, remains somewhat diminished in Rt lower lobe; given 1/2 dose ordered haldol at approx 06:45 to help assess if pt's complaints were coping, or respiratory;\n\nc-v:\nno c/o chest pain overnight; rare PVC's seen via cardiac monitor; hrt rate mostly in 80's-90's; recieving hep SQ to prevent blood clots; pt also on plavix; SCD's in use;\n\nresp:\nlungs clear upper, somewhat dimished lower, esp rt lower lobe;\nO2 sat 99-100% RA much of this 12 hours; 99-100% this a.m. on 2 l n.c.;\n\ng-i:\nremains on triple routes of Vanco, IV, PO, PR; pt does not hold PR enema, ?absorption;\n pt on Nepro FS at 35 cc/hr; Nutrition c/s recommends Ultracal, with goal of 60 ml/hr;\n small amt stool, liquid green, likely diluted w/ Vanco enema;\n\ng-u:\nurine output decreased over this night; surgery c/s 1st thought fluid bolus would be useful, then changed their mind;\n\nskin:\nabd'l incision w/ steri-strips, c/d/i; abd soft;\n\nPLAN:\n1) follow assessment re pt's complaints\n2) check if K+ supplement desired (check creatinine)\n3) follow toleration of tube feeds; check w/ team regarding Nutrition's recommendations\n4) FS's w/ SS coverage\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-23 00:00:00.000",
"description": "Report",
"row_id": 1323473,
"text": "0700-1500\nsee transfer note\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-23 00:00:00.000",
"description": "Report",
"row_id": 1323474,
"text": "Nursing Progess Note 1500-1900\nPt has bed on 10, awaiting room vacation before being transfered. Has remained hemodynamically stable throughout the day. tolerating RA w/ spo2 98-100%, no SOB or distress. BP 140-150's systolic. anxious in bed, fidgeting. appears depressed w/ flat affect. denies pain. tolerating small amounts of clear liquid. NGT remains in place for overnoc TF's (10pm-8am, Nepro at 35cc/hr), and PO meds. SC TLC remains patent and intact. wife at bedside. transfer not done. FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-05 00:00:00.000",
"description": "Report",
"row_id": 1323415,
"text": "P-MICU NPN 7p-7p\nEvents: CAT Scan, Swan floated.\n\nSystems Review:\n\nCV: Cordis placed prior to CT scan. After scan a swan was floated, all numbers were fairly normal. PAP 43-47/16-20, CVP 7-10, PCWP 10-13\nC.O. Fick 6.7, SVR 1290. BP 120's-140's/. Receiving hydralazine and lopressor per orders. HR has been in the high 90's to low 100's. APC's and occ PVC's noted. Pt did experience a few runs of VT during the swan placement. K 3.0. Heparin gtt initiated at 3am, at 800u/hr, received 1000 unit bolus. CT of chest and abdomen, preliminary showed no PE. CPK's con't to be cycled. Next draw at 8am. Levels on the decline. Last CK 547 down from 925. Cont's on IV NTG.\n\nResp: LS coarse bilat, suctioned mult times for thick yellowish secretions. Vent settings: A/C 14/500/+5/50% with ABG 7.42/34/185/23\nCT showed bilat pleural effusions and RUL pnx.\n\nID: WBC 20.5. Receiving IV levofloxacin q24h. Low grade temp of 99.4po\n\nNeuro: Calm and sedate on propafol 40 mcg/kg/min.\n\nSocial: Wife and daughter involved. last eve for update. They are at an area hotel. Phon number in the room.\n\nGI: NGT in place. NPO per orders. +BS, + flattus.\n\nGU: Adequate amts of urine via foley cath.\n\nSkin: Abdominal dressing intact, no drainage noted.\n\nEndo: FS being monitored. No insulin required per SS protocol.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-05 00:00:00.000",
"description": "Report",
"row_id": 1323416,
"text": "NURSING NOTE 0700HRS - 16.30HRS\n\n\n\n\nNEURO - SEDATED ON PROPOFOL X1 DOSE OF HYDRO-MORPH THIS AM AS ? IN PAIN/UNCOMFORTABLE AS RR^ AT 25 AND B/P CLIMBING - SETTLED WELL AFTER THIS AND HAS REMAINED SETTLED SINCE - MINIMAL RESPONSE TO PAINFUL STIMULI /PUPILS EQUAL RECATIVE TO LIGHT - ARM RESTRAINTS INSITU - TO CONTINUE WITH CURRENT SEDATION REGIME\n\n\n\nRESP - SWITCHED TO P/S AT 12 THIS AM PCO2 LOW DUE TO RESP RATE MID 20'S IMPROVED POST ANALGESIA - SATS >98% AND REPEAT GAS STABLE - NO SECRETIONS ON CHEST ,REQUIRES SPUTUM - PRESENTLY ON 40% P/S 12 PEEP @ 5 - TV @ 520-600 - NO EPISODES OF RESP DISTRESS\nNOW PERSCRIBED MDI'S AS KNOWN COPD\n\nCVS - NITRO SWITCHED OF AS SYSTIC <13O THIS AM , MAINTAINED 110-140 ON HYDRALAZINE AND METOPROLOL\nH/R 95-105 MAINTAINED / CONTROLLED ON METOPROLOL/CONTINUES WITH PAC'S\nK, MAG REPLACED\nAFEBRILE - TO BE CULTERED IF > 101 - AB' CONTINUE\nPAP - 42-50/STABLE - WEDGE @ 10. CVP @ - ASK TO PERFORM THERMODILUTION THIS AM, TEAMS AWARE OF RESULT OF C/O/CI/SVR\nBLOOD SUGARS STABLE AS PER S/S\nEKG PERFORMED REVIWED BY CARDIOLOGY FOR CATH AT SOME POINT - ? RESP DISTRESS RELATED TO FLASH PULMONARY OEDEMA\n\nG/I - FEED NEPRO COMMENCED AT 10CC/HR - APPEARS TO BE TOLLERATING - BOWEL SOUNDS PRESENT - NO BOWEL MOTION TODAY - CAN NOW HAVE P/O MEDS\n\nGU - LASIX NOW PERSCRIBED B/D AIM FOR 1-2L NEG BY 12MN - PASSING GOOD AMOUNTS OF URINE\n\nSKIN - DRESSING DRY/ INTACT - NO OUTPUT FROM J.P - PRESSURE AREAS INTACT\n\nLINES - REMAINS WITH SWANN /ART LINE - PATENT\n\nSOCIAL - WIFE VISITED SPOKE WITH SURGICAL TEAM AWARE OF CONDITION/PLAN\n\n\nPLAN - CONTINUE PRESENT REGIME / PCARDIAC CATH AT SOME POINT\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-18 00:00:00.000",
"description": "Report",
"row_id": 1323461,
"text": "an early abg = 7.39/47/56 on 6l/mn and rr=40's did not prevent him from being reintubated .he was then placed on cmv 500x12x100%x5 and\nabg of 7.44/42/355/29.changed to cmv 600x12x501%x5.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-22 00:00:00.000",
"description": "Report",
"row_id": 1323470,
"text": "pmicu npn 7p-7a\n\n pt was oriented to person and place only. he was frequently confused, despite reorientation, but also appeared to be less anxious overnoc. there were no attempts to get oob although he remained on 1:1 observation through the noc.\n\nrespiratory-> pt c/o feeling sob but did not appear to be in any distress. rr teens-20's, nonlabored. he is maintaining sats >98% on 4l nasal cannula.\n\ncardiac-> hemodynamically stable w/hr 70-80's, sr w/rare pvc's. sbp ranging 120-130's.\n\nneuro-> mae x4 w/equal strength. perrl @3mm. he is confused but easily follows simple commands. no periods of agitation or restlessness noted.\n\ngi-> abd soft, nontender w/+bs. pt is tolerating tube feedings at goal rate, and his diet was also advanced to clear liqs. he had some italian ice w/o incident. receiving vanco po/iv/and rectally for c.diff infection.\n\ngu-> uop >30cc/hr. the pt is tfb negative ~250cc since mn.\n\nid-> tmax 100 orally, receiving abx coverage for c. diff infection.\n\nendo-> pt received rissc x2 overnoc for fs 133-160.\n\naccess-> left sc triple lumen is patent and intact.\n\ndispo-> anticipate transfer to the floor later today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-22 00:00:00.000",
"description": "Report",
"row_id": 1323471,
"text": "Micu Nursing Progress Notes\nNeuro: Pt is alert and oriented to person but he knows he is in a hospital not sure of the name, and off and on to the city. He has been OOB to the chair with the use of a walker. He is steady with the walker and able to take a few steps. He has not been anxious but has been demanding with his needs. His wife seems to feed into his demands. He has been demanding to get OOB he would attempt it on his own. 1:1 sitters ordered to keep him safe.\n\nCardiac: B/P 120-130/70's, HR 70-80's.\n\nGI: rectal mushroom taken out in preparation for possible D/C to rehab tomorrow. Rectal bag applied to help collect from the vanco enemas. He continues to have small amount of liquid brown stool. His diet has been advanced to full liquids and he has been able to eat small amounts of full liquids.\n\nGu: foley draining clear yellow urine U/O 30-50cc/hr\n\nResp: His FiO2 has been weaned down to 2l NC with O2 sats of 99-100%. Breath sounds clear.\n\nSocial: here most of the day asking multiple question. She seems to be a very nervous person. He has been accepted at a Rehab facility but there was no bed available today but may have one tomorrow.\n\nPt is called out of the unit but there are no floor beds available.\n\nPlan: keep pt safe with sitter. Possible D/C to rehab tomorrow.\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 837242,
"text": " 3:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI s/p b/l\n thoracentesis -- with small R apical pneumothorax\n REASON FOR THIS EXAMINATION:\n eval ptx\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Reevaluate right pneumothorax.\n\n PORTABLE AP CHEST, : Compared to .\n\n The previously noted right apical pneumothorax is no longer visualized. A\n left subclavian vascular catheter and nasogastric tube remain in satisfactory\n position. Cardiac and mediastinal contours are stable. A small right pleural\n effusion is unchanged. There is resolving discoid atelectasis in the left\n lung base.\n\n IMPRESSION: Resolution of small right apical pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-15 00:00:00.000",
"description": "P ABDOMEN (SUPINE & ERECT) PORT",
"row_id": 836292,
"text": " 11:33 AM\n ABDOMEN (SUPINE & ERECT) PORT Clip # \n Reason: assess for colonic distention\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with Cdiff with rising wbc\n REASON FOR THIS EXAMINATION:\n assess for colonic distention\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN 2 VIEWS:\n\n HISTORY: C. difficile colitis with increasing white blood cell count.\n\n Gas and retained contrast are present in the colon. NG tube is in fundus of\n stomach. No free intraperitoneal gas. No evidence for megacolon. Surgical\n clips are present in the right upper quadrant s/p cholecystectomy.\n\n IMPRESSION: No evidence for megacolon or free intraperitoneal gas. Incidental\n note of left basal atelectasis and possible small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-20 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 836840,
"text": " 12:12 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: eval for changes from thrombus seen on past doppler study\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p distal pancreatectomy & splenectomy with PVD, MIx2, s/p\n cath c/o pain at R leg\n REASON FOR THIS EXAMINATION:\n eval for changes from thrombus seen on past doppler study\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up thrombi seen by prior ultrasound dated .\n\n scale and Doppler son of the bilateral common femoral, superficial\n femoral, and popliteal veins demonstrates normal flow, compressibility, wave\n forms and augmentation. No deep venous thrombosis is identified. The\n previously reported thrombi in the proximal right greater saphenous vein and\n in the right popliteal vein are no longer identified.\n\n IMPRESSION: Previously reported right greater saphenous vein and right\n popliteal vein thrombi not identified. No new deep venous thrombosis\n identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836748,
"text": " 1:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX, evaluate effusion.\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty;\n s/p R thoracentecis\n REASON FOR THIS EXAMINATION:\n r/o PTX, evaluate effusion.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, : Compared to previous study of .\n\n CLINICAL INDICATION: Status post right thoracentesis.\n\n There has been resolution of a right pleural effusion following thoracentesis.\n There is a new small right apical pneumothorax present. A left pleural\n effusion is unchanged in the interval. The right lung is clear except for a\n small focal opacity above the level of the minor fissure. The left lung\n demonstrates a retrocardiac opacity adjacent to the effusion.\n\n IMPRESSION: Small right apical pneumothorax following thoracentesis.\n Resolution of right pleural effusion.\n\n No significant change in left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836779,
"text": " 9:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess R pneumothorax\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, s/p bilateral\n thoracentesis - R pneumothorax on CXR\n REASON FOR THIS EXAMINATION:\n reassess R pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57 year old man status post distal pancreatectomy, bilateral\n thoracentesis, right pneumothorax.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n Comparison is made with the previous chest radiograph taken earlier on the\n same day, .\n\n FINDINGS: The right apical pneumothorax has slightly increased in size\n compared to the previous study.\n\n The left subclavian line and ETT remains unchanged compared to the previous\n study. NGT is coursing down below the left diaphragm.\n\n The heart is normal in size.\n\n Again note is made of plate-like atelectasis in the left lower lobe. There is\n faint opacity in the right lower lobe, which can represent edema vs. layering\n small effusion. Otherwise the lungs are clear. No evidence of pneumonia.\n\n IMPRESSION: Decreased right apical pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-18 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 836661,
"text": " 4:49 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: ACUTE RESP FAILURE,EVAL FOR PE\n Admitting Diagnosis: PANCREATIC MASS/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute resp failure; s/p splenectomy w/ plts 1,000,000;\n s/p 2 post op MIs\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with acute respiratory failure status-post\n splenectomy with platelets 1,000,000; status-post 2 post-operative MI's.\n Evaluate for PE.\n\n TECHNIQUE: Multislice images of the chest were acquired from the aortic arch\n to the highest point of the diaphragm, in an inferior to superior direction.\n\n COMPARISON: No studies are available for comparison.\n\n MULTIPLANAR REFORMATS: Multiplanar reformats were used to further evaluate.\n\n An ET tube is in-situ. Its tip lies well above the carina, but it does appear\n to lay against the right lateral tracheal wall.\n\n There are extensive bilateral pleural effusions wtih compressive atelectasis\n present.\n\n There is extensive background centrilobular and paraseptal emphysema. Motion\n artifact secondary to breathing is present on the study, and only a poor-to-\n moderate quality study was obtained.\n\n There is no evidence of pulmonary embolism to the 3rd order vessels. A distal\n pulmonary embolism cannot be ruled-out.\n\n An NG tube is in good position. A central venous access catheter in-situ,\n with its tip in the SVC. Multiple axillary and mediastinal lymph nodes are\n present.\n\n CONCLUSION\n\n 1. Poor-to-moderate quality study.\n 2. No evidence of central pulmonary embolism.\n 3. Large bilateral pleural effusions with atelectasis.\n 4. ET tube appears placed against the right tracheal wall.\n 5. Post-surgical changes are identified in the left upper quadrant consistent\n with a history of splenectomy.\n\n\n\n (Over)\n\n 4:49 PM\n CTA CHEST W&W/O C &RECONS; CT 150CC NONIONIC CONTRAST Clip # \n Reason: ACUTE RESP FAILURE,EVAL FOR PE\n Admitting Diagnosis: PANCREATIC MASS/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836376,
"text": " 6:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for new infiltrates\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp\n difficulty\n REASON FOR THIS EXAMINATION:\n eval for new infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old man with S/P distal pancreatectomy. Respiratory\n difficulty. Evaluate for new infiltrates.\n\n TECHNIQUE: Portable AP chest radiograph. The comparison is made with a\n previous chest radiograph dated .\n\n Findings:\n The endotracheal tube is terminating 6 cm above the carina. The central\n venous line is terminating in SVC. There is no pneumothorax. The heart is\n normal in size. There are bilateral effusions, slightly increased compared to\n the previous study. No consolidation is noted.\n\n IMPRESSION: Increased bilateral pleural effusion. No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836927,
"text": " 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: access for interval change in effusions\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI s/p b/l\n thoracentesis -- with small R apical pneumothorax\n REASON FOR THIS EXAMINATION:\n access for interval change in effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Right apical pneumothorax.\n\n PORTABLE AP CHEST: Comparison is made to the prior study from . Again\n seen are a left subclavian central venous line with the tip in the proximal\n SVC, and an NG tube with the tip in the stomach. The patient has been\n extubated. The small right apical pneumothorax is again identified, and\n appears slightly larger, although the patient is more upright on the current\n study, differences could be due to differences in technique. There are likely\n small bilateral pleural effusions. There is evolving opacity in the right\n upper lobe laterally, which could be due to pneumonia in the correct clinical\n contex. There is worsening left lower lobe atelectasis. Osseous structures\n are unchanged.\n\n IMPRESSION:\n\n 1. Lines and tubes as above. Extubation.\n 2. Small right apical pneumothorax, slightly larger than on prior study, but\n observed difference could be due to differences in position.\n 3. Increasing opacity in the right upper lobe, which could represent\n pneumonia in the correct clinical contex. Small bilateral effusions.\n 4. Worsening left lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836754,
"text": " 2:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o LEFT PTX, eval effusion\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp\n difficulty; s/p LEFT thoracentecis\n REASON FOR THIS EXAMINATION:\n r/o LEFT PTX, eval effusion\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST:\n\n INDICATION: S/P distal pancreatectomy. Postoperative myocardial infarction\n with respiratory difficulty. S/P left thoracentesis. R/O pneumothorax.\n\n FINDINGS: A single AP upright image. Comparison study taken 2 hours earlier.\n The ETT and the left subclavian central line remain well positioned. The NG\n line tip is in the fundus of the stomach. The heart and pulmonary vessels are\n unremarkable. There is some linear atelectasis at the left base posteriorly,\n improved since the previous examination. A very small right apical\n pneumothorax is again noted, not significantly changed.\n\n IMPRESSION: A right apical pneumothorax is unchanged. There is improvement of\n the left basal atelectasis. No other significant abnormalities are identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836494,
"text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess chf\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty\n\n REASON FOR THIS EXAMINATION:\n reassess chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Reassess CHF.\n\n PORTABLE AP CHEST X-RAY: Comparison made to study from . Again seen\n are ET tube, left-sided central venous catheter, and NG tube, which are all\n unchanged in position from previous exam. Bilateral effusions are again seen.\n No change is noted in the prominence of the pulmonary vasculature or heart\n size. No pneumothorax is seen. No consolidation is seen.\n\n IMPRESSION: No interval change from previous exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836639,
"text": " 12:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf, pneumonia\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty;\n acutely SOB now\n REASON FOR THIS EXAMINATION:\n eval for chf, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Shortness of breath.\n\n COMPARISON: Comparison is made to prior study of .\n\n FINDINGS: There has been interval removal of the ET tube. The NG tube and\n left subclavian line are unchanged. There is increased, hazy bilateral\n vasculature with increased bilateral pleural effusions and slight increase in\n alveolar filling pattern bilaterally consistent with increased fluid overload.\n An underlying infectious etiology cannot be excluded. The pleural effusions\n have increased. There is continued dense opacification of the retrocardiac\n region consistent with volume loss/effusion/infiltrate.\n\n IMPRESSION: Worsening CHF. An underlying infectious etiology cannot be\n totally excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836647,
"text": " 2:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ETT placement\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty;\n acutely SOB now\n REASON FOR THIS EXAMINATION:\n eval for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Shortness of breath. Check ET tube.\n\n CHEST, SINGLE VIEW AP:\n\n FINDINGS: Compared to the film from earlier the same day, there is a new ET\n tube with tip in good location. The left subclavian line tip is unchanged.\n There continues to be bilateral pleural effusions. Retrocardiac density could\n be due to volume loss/effusion/infiltrate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-16 00:00:00.000",
"description": "RP UNILAT LOWER EXT VEINS RIGHT PORT",
"row_id": 836411,
"text": " 10:59 AM\n UNILAT LOWER EXT VEINS RIGHT PORT Clip # \n Reason: R LEG PAIN, QUESTION DVT\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p distal pancreatectomy & splenectomy with PVD, MIx2, s/p\n cath c/o pain at R leg\n REASON FOR THIS EXAMINATION:\n r/op dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 57-year-old male with right leg pain. Evaluate for DVT.\n\n FINDINGS: This examination is technically limited due to the patient's\n surgeries and overlying edema. There is an arterial graft in place within the\n right common femoral artery. This graft appears patent. Thrombus is\n identified within the greater saphenous vein approximately 1 cm from the\n common femoral vein. There is evidence of normal compressibility, wave form,\n and color flow within the right common femoral vein, and superficial femoral\n vein. There is possible chronic non-occlusive thrombus within the right\n popliteal vein.\n\n IMPRESSION:\n 1. Technically limited study shows possible chronic thrombus within the right\n popliteal vein as well as thrombus of inderminate age within the greater\n saphenous vein approximately 1 cm from the common femoral vein.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-16 00:00:00.000",
"description": "Report",
"row_id": 1323453,
"text": " \"B\" Nsg Progress Note:\n\nPt with pancreatitis,s/p distal pancreatectomy and splenectomy,Postop +AMI,metal status changes and hypoxia postop,.\n\nCVS: T101.2-99.1, Pan cultured, tylenol given. HR=79-102 NSR no ectopy noted. IV Esmolol weaning at 50mcg/kg/min ,atenolol started yesterday, IV Lopressor prn for goal HR=60-80.SBP=98-148. IV TPN at 62.5cc/h. IV Propofol at 10mcg until ready for extubation in am. Pt becomes anxious and shakes head back and forth at times. PT and DP pulses located with doppler bilaterally. Feet warm and pink.\n\nNeuro: MAE, Pupils =+, No deficits noted. Pt became belligerent during night, given IV Haldol as ordered with good effect. Follows commands if he wants to, but is able to. Wrist restraints on due to pt grabbing for endotube at times, CSM hands good.\n\nSkin: Staples removed by surgical intern on abdomenal incision, which is clean,dry and intact. Abrasions on buttock and arm healing-pink, no drainage, pink area on heel intact. Lot of edema of arms noted. One peripheral IV site with good blood return and no rednessnoted.\n\nGI: +BS. TF criticare at 30cc/h goal but being held in am for probable extubation. IV TPN as noted. Small flecks of brown stool after enema but no significant stool.\n\nGU: U/O=100-160cc/h\n\nResp: On Vent: 50% FIO2 PSV+CPAP with TV>500. Sats=97-100%. Lung sounds coarse and diminished at bases. Suctioned frequently for large amt thick white sputum.\n\nPlan: Extubate today. Wean off Esmolol drip.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-16 00:00:00.000",
"description": "Report",
"row_id": 1323454,
"text": "0700-1900 NPN\nSee carevue for subjective/objective data.\nEvents of day: Weaning this AM, getting ready to extubate when pt became extremely anxious, HR, RR and BP elevated--required ativan for anxiety. Did not extubate due to sedation; pt back on IMV for now. Plan is to rest overnoc and reattempt in AM. One unit PRBC given, TF resumed, cont'd with Vanco enemas q6h however started stooling at 1615-->copious amts liq stool. Ultrasound done to r/o DVT (neg).\n\nNeuro: Currently A+Ox2. Nodding yes and no, cooperative. MAE ad lib.\n\nCV/Pulm: MP remains ST-NSR--Lopressor 20mg IV prn given x1 for HR 110's with HR decreased to 90's. BP returned to baseline after Lopressor. Propofol off in anticipation of extubation then restarted when pt placed back on IMV. Esmolol remains off. One unit PRBC currently infusing without evidence of adverse reaction--will check CBC 1-2h after completed. L TLC in place--unable to draw off of CVP line although flushes easily; unable to draw off or flush second port. Third port patent. Remains vented at this time with coarse breath sound bil--plan to attempt to extubate in AM. Sputum for C+S and gm stain sent.\n\nGI/GU: TF restarted via NGT at 10ml/hr with no residuals. One huge liq BM this afternoon--FIB applied. Cont with Vanco enemas q6h although unable to administer at 1600 as pt actively stooling. Lasix 20mg IV given at 1200 with brisk response--cont to have u/o of >50ml/hr at this time.\n\nID: Tmax=100.7 PO. WBC=33.0. No change in abx. Sputum sent as noted above.\n\nPsychosocial/Plan: Emotional support given to pt and fam. Rest on vent overnoc and reattempt to extubate in AM. Rpt labs after PRBC completed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-15 00:00:00.000",
"description": "Report",
"row_id": 1323450,
"text": "NPN 1900-0700:\n\nOverall pt has had a very stable night. Please see Carevue for all objective data.\n\nNEURO: Pt is lightly sedated on Propofol which has been weaned to 20mcg/kg/min. He arouses to voice, follows commands, nods/shakes head appropriately, and MAE. PERRL. Sleeps when left alone; no agitation at all. Pt has recieved Fentanyl 25mcg q2 hours and has denied pain all night.\nRESP: Remains on PS 12/PEEP 5/ 50% with RR 20-24, adequate TV's and MV. Suctioned q4 hours for thick white-pale yellow secretions. No ABG drawn, since he has no a-line.\nC-V: HR has been 95-102 all night, NSR with occasional PVC's. Esmolol gtt remains at 150mcg; he has been started on IV Lopressor q4 hours RTC, which has been increased several times with no effect. SICU resident aware of lack of response. BP stable 120's-130's/60's-70's. No c/o CP or associated cardiac symptoms. Right femoral site is without evidence of infection or hematoma; dressing D&I. Feet are now warm, normal in color, with all pulses dopplerable (though left PT is inconsistent). Labs pending.\nID: Low-grade temp all night; given Tylenol X 2. WBC pending. Cont's on IV and PO Vanco with trough level due prior to 12PM IV dose.\nHEME: No evidence of bleeding; labs pending.\nGU: Brisk U/O cont's without diuresis.\nGI: Tolerating Criticare TF's at 10cc/hr plus meds with residuals of <40cc's. Belly benign with active BS; no stool.\nENDO: Sugars 160's on SSI.\n\nA: very stable night hemodynamically, though no progress with HR; low-grade temp\n\nP: continue meds as ordered with goal HR 65-75; hopefully will extubate today; vanco level before 1200 dose; follow temps and give Tylenol prn; follow up with AM labs and replete lytes as needed; ? advance TF's. Continue support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-15 00:00:00.000",
"description": "Report",
"row_id": 1323451,
"text": "Shift Summary\nDay 15 s/p spleenectomy & distal pancreatctomy. Day 4 reintubation with unsuccessful weaning today. Day 2 s/p cardiac cath with L carotid stent . Contact isolation for Cdiff and MRSA sputum.\n Review of Systems\nN: Lightly sedated on 10mcq/kg/min propofol and scheduled Fentanyl 25mcq Q2hr for pain. Denies c/o pain throughout the day. PERRLA with left eye blindness. Generalized increased weakness to all extremeites compared to my assesssment . Responds appropriately to yes/no questions.\n\nCV: L SC QLC day 5. TPN 62.5cc/hr, Propofol 10mcq/kg/min, Esmolol 150mcq/kg/min, CVP 12-18. L FA INT day 2 w/ KVO NS. Telemetry wit occassional PVC SR -ST. Wean Esmolol as HR lowers with Atenolol PO started 1400hr. Pedal pulses dopppled. R groin cath site WNL, R DP/PT pulses difficult to doppler post cath, foot now warm and dry post earlier assessment when extremity cool, MDs aware. Denies c/o chest pain. BP stable, lower this evening SBP 110-150. Bilateral arm 2+ pitting edema new within last 48hrs, cardiology MD aware.\n\nR: Attempted weaning with RR up, ABG Pa02 down 70's, copious secretions, will attempt extubation tomorrow. Lung sounds course bilateral upper clearing with suction. Pulse ox remains 98% throughout day.\n\nGI: Tube feedings on hold most of day with plans for extubation. Restarted at 1400hr. Residuals <40cc. BS + X4. No BM. Vanco enemas resumed. KUB indicating residual abdominal contrast with concern for PO med absorption, ? GI consult.\n\nGU: UOP approximately 100cc/hr without diuretics.\n\nSkin: See flow sheet, new R wrist abrasion. R foot pressure sore healing well. R buttocks abrasion healing. cath puncture site healing. LLQ abdominal JP puncture site healing. Abdominal staples intact with well aproximatd wound.\n\nPlan: F/U with ID regarding rising WBC 33, MDs aware. Attempt weaning esmolol if PO Atenolol absorbed maintaining HR <100. Maintain comfort with scheduled fentanyl. Encourage rest maintaining strict pulomonary toiletry with plans for possible extubation tomorrow, hold TF's in AM. Document any BM, ? concern for + cdiff stool and no BM x3dy, vanco enemas to continue per ID.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-15 00:00:00.000",
"description": "Report",
"row_id": 1323452,
"text": "Resp. Care Note\nPt remains and vented on settings as per resp flowsheet. Pt placed in PSV 5 peep 5 this morning in anticipation of extubation. After several hours RR up to 28-30 and Pt maintaining minute vent of 14L. Pt also with increase in thick yellow secretions today. ABG on was 7.32/42/71/23/-4. Placed back on PSV 12 and pt appeared more comfortable with RR coming down to 22. Repeat ABG good and further vent adjustments made, see flowsheet. cont vent support, re-eval in AM for readiness to wean.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-14 00:00:00.000",
"description": "Report",
"row_id": 1323449,
"text": "Micu Nursing Progress Notes\nNeuro: Pt was on Propofol at 70 mcg/kg/hr and was slowly weaned off to 30 mcg/kg/hr during the day. By 11am he started to breath on his own, by 1500 he started to respond to his family, he was given fentanyl 25mcg IVP to help with his known pain and the propofol weaned to the present 30 mcg/kg/hr. The fentanyl can be given PRN 25-50 mcg q2h. He seems to be comfortable, but does respond to pain.\n\nCardiac: B/P has been stable 120-130/80, HR 100-105. The esmolol has remained at 150 mcg/kg/min. He was started on lopressor 25mg PO which had no response to his HR. The order was changed to IV due to ? absorption. Pulses in his feet are now dopplerable, his right great toe was bright red this am and then turned pink, his feet remain cool to the touch.\n\nResp: Vent changed to PSV at 12n after he began to breath on his own. RR 24-28, TV 550-600, FiO2 50%, unable to obtain an ABG, there was one more attempt to start an A-line but it failed. Suctioning whitish thick secretions q3-4h.\n\nGI: Continues to have hypoactive bowel sounds, residuals at 12n following medication administration was >60cc, at 1600 it was 40cc so tube feedings of criticacare was started at 10cc/hr. No stool. He continues on TPN.\n\nEndo: His BS slowly increase over the morning off insulin gtt to 175 by 12n. He was started on a SS insulin and was given 2u at 12n. 1600 his BS was 151.\n\nGU: Hydration IV 1/2 NS at 100cc/hr finished at 1300. His U/O started to increase at 11am to 200cc/hr and increased to over 300cc/hr for 2-3 hrs. He how about 150cc/hr. He was given his last dose of mucomyst at 1800.\n\nSocial: Wife and multiple other family members in to visit. Around 1600 he started to respond appropriately to them. Multiple questions asked and answered.\n\nPlan: Continue to wean vent as possible, give fentanyl q2h to keep his pain free, wean propofol when possible, with the IV lopressor wean esmolol when possible.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-17 00:00:00.000",
"description": "Report",
"row_id": 1323459,
"text": "Micu Nursing Progress Notes\nResp: Pt on PSV 5/Peep 5, FiO2 40%. Pt alert and mouthing \" when am I going to get this tube out so I can talk?\" MD's up at 9am and pt was extubated at 9am. He was placed on a 40% face tent for about 1hr with O2 sats 100%. He was found without the mask at 11am with sats 98% so left on room air. He was coughing up large plugs of clear secretion. ~13 his sats dropped to 88% so he was placed on 2l NC. His O2 sat is hard to obtain and can range from 91-99%. RR 18-20.\n\nCardiac: B/P 120-130/70, HR 80's. His atenolol was increased to 125mg with first dose given at 8am. He was given 20mg lasix with an excellent response. Labs sent at 1500 to monitor K+.\n\nGU: foley draining clear yellow urine. He had 1300cc out in 2h following the lasix with 200cc/hr in the hours following.\n\nGI: (+) Bowel sounds. NGT left in place when ETT was pulled. The tube feedings were restarted with impact with fiber increased to 30cc/hr by 12n. He continues on the vanco PR as oredered. He had 225 cc in liquid stool with the enema.\n\nPain: Pt C/O lower abd pain this am and was given dilaudid 1mg PO. This afternoon he C/O feeling really bad so he was given a one time dose of fentanyl 50mcd and dilaudid 2mg PO with good pain relief.\n\nNeuro: Pt alert and oriented x1-2, he thought we were in . OOB to the chair by 2person piviot for 2h before he tired.\n\nLines: 4lumen catheter was changed over a wire to a triple lumen catheter without difficulty.\n\nID: afebrile today with temp 99.0-99.3, antibotics unchanged.\n\nSocial: in to visit most of the day, she was very pleased with the extubation.\n\nPlan: continue to monitor resp status over night with possible C/O in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-18 00:00:00.000",
"description": "Report",
"row_id": 1323460,
"text": "neuro: remains confused but cooperative; has mumbled inappropriate content all night long.\n\ncardiovascular: continues tachycardic. responded to total of 30 mg of lopressor IV last night with HR in 90's and BP 160's over 90's. skin seems very poorly perfused this AM with cool, moist feel, mottled appearance of skin, and very poor sat signal.\n\npulmonary: somewhat tachypneic and occasionally labored. weak cough effort and does not raise or expectorate sputum.\n\nGI: impact with fiber at 30 ml/hr, no residual; vancomycin enemas tolerated well but no other stool output except return of enema.\n\nGU: qs clear amber urine per foley\n\nskin; generally intact, abdominal incision well-approximated with steristrips\n\nstatus and plan: full code, progress diet toward goals, consider removal of NG tube for trial of normal PO intake\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-16 00:00:00.000",
"description": "Report",
"row_id": 1323455,
"text": "ADDENDUM TO ABOVE NOTE\nDuring initial assessment at 0800 unable to doppler either DP or PT's both feet, both feet cold to touch, pale. SICU team in, also unable to doppler pulses. Feet warmed with blankets and socks-->very faint intermittent questinable doppler pulses R DP, faint doppler pulses L DP. Ultrasound done as noted to confirm patency of graft--per tech graft remains patent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-16 00:00:00.000",
"description": "Report",
"row_id": 1323456,
"text": "RESPIRATORY CARE: PT W/ 8.0 ORAL ETT IN PLACE.\nCHANGED BACK TO SIMV MODE 12/650/.40/5/PS 10\nAS PER CAREVUE. PRIOR ABG ON PS 5 STABLE. SX\nFOR THICK YELLOW SPUTUM. ALBUTEROL MDI GIVEN.\nEXTUBATION ON HOLD UNTIL AM DUE TO ANXIETY\nAND TACHYPNEA EARLIER THIS AM. APPEARS MORE\nCOMFORTABLE NOW. WILL CHANGE TO PS 5 AT 4 AM\nAMD GET ABG/RSBI AND HOPEFULLY EXTUBATE AT\n7 AM ROUNDS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-17 00:00:00.000",
"description": "Report",
"row_id": 1323457,
"text": "Pt is expected to be extubated this A.M. . Plan is to get ABG this A.M. and ext on rounds if indicated. Pt sx for copious amts of loose pale yellow secretions overnight. ABG may be difficult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2125-08-17 00:00:00.000",
"description": "Report",
"row_id": 1323458,
"text": "Nsg Progress Note 1900-0700\n\nCV - Pt had 2 readings of a K of 7.6 and then 7.9. Pt asymptomatic and no obvious reason for increase but given insulin 10u, 1 amp D50 and 1 amp NaHCO3. Femoral stick for labs done and K came back at 4.3. TPN does interfere with labs drawn from other lines of the SC line so TPN must be shut off and line flushed before labs are drawn. Pt also recieved MgSO4 and CaGluc. Labs are WNL this am. HR 80-90's with occ PVC's. One triplet noted at 8pm but no further mult ectopy noted overnight. BP elevated - required increased propofol and lopressor- BP better. Pt febrile most of the night - he is down to 99.3 po at 6am. IVF continues at KVO with TPN infusing at 62cc/hr.\n\nResp - Pt changed to CPAP at 3am in preparation for extubation this morning. BS continue course bilat and suctioning mod to large amt white frothy secretions q 1-2 hours. Mod amt oral secretions - appears to be decreasing this morning.\n\nGI - TF's held after midnight in preparation for extubation this am. Abd soft and non distended. Min stool overnight - FIB still intact.\nDid receive vanco enema through the FIB and pt tolerated procedure well.\n\nGU - Continues with diuresis - cl yellow urine.\n\nNeuro - Able to wean propofol slowly over the course of the night. Does require some sedation for procedures but appears to be quite calm and cooperative this morning. Plan is to NOT mention the extubation until just before taking the ETT out. Pt moves all extremities. PERL. Nods to questions but does not attempt to speak at this point.\n\nEndocrine - BS high just after D50 given but readjusted on its own and pt has not required any insulin coverage.\n\nVascular - feet much warmer and pinker this morning. Left foot is warmer than the right but both are improved. Still difficult to palpate pulses though.\n\nSocial - no contact from family overnight.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835771,
"text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess for infiltrate, effusion\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty\n REASON FOR THIS EXAMINATION:\n reassess for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post distal pancreatectomy, post operative MI, respiratory\n difficulties. Reassess infiltrate and/or effusions.\n\n FINDINGS: AP single views (2 exposures) were obtained with patient in sitting\n upright position. In comparison with the next previous supine examination of\n the position of the right jugular approach central venous line and the\n NG tube is unchanged. The heart is moderately enlarged and the thoracic aorta\n is somewhat widened and elongated but there is no evidence of pulmonary\n vascular congestion. No acute parenchymal infiltrates are seen. Density on\n the right base including blunting of the pleural sinus is most consistent with\n some pleural effusion or possible atelectasis but in comparison with the\n previous study no new abnormalities have occurred.\n\n IMPRESSION: Normalization of previous CHF, regression of right lower\n atelectasis, unchanged positions of central venous line and NG tube. Presence\n of cutaneous surgical clips in upper abdomen consistent with recent surgery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835175,
"text": " 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pulm edema\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, RIJ CVL\n\n REASON FOR THIS EXAMINATION:\n r/o pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57 y/o man with status post distal pancreatectomy. Right jugular\n vein catheter placement.\n\n TECHNIQUE: Portable AP chest radiograph. Comparison is made with the\n previous chest radiograph dated .\n\n FINDINGS: The tip of the intravenous catheter is in the SVC. There is no\n pneumothorax.\n\n The heart is mildly enlarged. The pulmonary vasculature is slightly increased\n in the upper lung zone. There are increased interstitial markings in\n bilateral lungs, which is more prominent on the right. There is patchy\n opacity in the right lung base, representing effusion and atelectasis. There\n is slightly increased patchy opacity in the right middle lung zone, which\n suggests the possibility of pneumonia.\n\n There are surgical staples in the soft tissue overlying the upper abdomen.\n\n IMPRESSION: Increased interstitial markings representing pulmonary edema,\n associated with small pleural effusion on the right. Increased opacity in the\n right middle lung zone, which raises the possibility of pneumonia. The tip of\n the central venous line is in the SVC. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835182,
"text": " 6:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ett placement\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, RIJ CVL\n\n REASON FOR THIS EXAMINATION:\n check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 18:23:\n\n INDICATION: ETT placement.\n\n FINDINGS: ETT has been placed with the tip 4.5 cm above the carina. The\n right CVL remains in place vs. - no ptx.\n\n Compared to the prior study there is increased interstitial markings and\n slight enlargement of the heart. The pulmonary vascular markings also appear\n somewhat more prominent. Increasing density is seen in the right mid lung\n field and follow up films should pay attention to this location for possible\n developing consolidation.\n\n The aorta is tortuous and calcified and the hilar contours are normal.\n\n IMPRESSION:\n\n ETT placement satisfactory.\n\n No ptx.\n\n New pattern of CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836794,
"text": " 5:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: reassess R pneumo; reassess for pleural effusion\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI s/p b/l thoracentesis\n -- with small R apical pneumothorax\n REASON FOR THIS EXAMINATION:\n reassess R pneumo; reassess for pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-ERECT CHEST:\n\n Compared to previous study of .\n\n CLINICAL INDICATION: Reevaluate pneumothorax.\n\n Again demonstrated is a right apical pneumothorax. Hyperlucency overlying the\n right lung base suggesting more significant basilar component of the\n pneumothorax. These findings are unchanged. Various lines and tubes remain\n remain in place. Cardiac and mediastinal contours are within normal limits.\n There is resolving atelectasis at the left base with minimal discoid\n atelectasis remaining.\n\n IMPRESSION:\n\n No significant change in right pneumothorax which is likely moderate in size\n considering the basilar component.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835845,
"text": " 3:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: new left CVL\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty\n\n REASON FOR THIS EXAMINATION:\n new left CVL\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate placement of a left sided central venous line.\n\n PORTABLE AP CHEST X-RAY: Comparison is made to study of the same day\n approximately nine hours earlier. There has been interval placement of a left\n subclavian central venous line catheter, with the tip visualized in the mid\n SVC. A right IJ central venous line catheter is seen with the tip in the\n proximal SVC and remains unchanged in position. NG tube is again visualized in\n unchanged position. No pneumothorax is seen. There has been no other acute\n interval change. Heart size and mediastinal contours are unchanged.\n\n IMPRESSION: Interval placement of left sided subclavian central venous line\n catheter with tip in mid SVC. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 836052,
"text": " 10:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sob, RL infiltrate, access for interval change\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty\n\n REASON FOR THIS EXAMINATION:\n sob, RL infiltrate, access for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post distal pancreatectomy, respiratory difficulty.\n\n PORTABLE SEMI-UPRIGHT AP CHEST: Comparison is made to . Again seen\n are an endotracheal tube, NG tube, and left subclavian central venous line,\n the positions of which are unchanged. Note is made that the endotracheal tube\n cuff appears slightly inflated. There is rather marked improvement in the\n appearance of the right upper lobe opacity. There are bilateral pleural\n effusions. The right effusion is small and unchanged. The left effusion is\n moderate, and has increased since the prior study. There is no overt CHF.\n\n IMPRESSION:\n 1) Endotracheal tube cuff overinflated.\n 2) Rapid improvement in right upper lobe opacity. The rapidity of improvement\n suggests either asymmetrical pulmonary edema or aspiration.\n 3) Increasing left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 835003,
"text": " 11:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with MS changes, HTN to SBP 200\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypertension, mental status changes. Evaluate for intracranial\n hemorrhage.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: None.\n\n NONCONTRAST HEAD CT: Portions of the study are limited by patient motion.\n There is no acute intra or extraaxial hemorrhage, hydrocephalus, or shift of\n normally midline structures. Note is made of widening of the extraaxial space\n anterior to the left cerebellar hemisphere. This could be due to an arachnoid\n cyst or epidermoid tumor. Osseous and extracranial soft tissue structures are\n unremarkable. The visualized paranasal sinuses are clear.\n\n IMPRESSION:\n 1) No acute intracranial hemorrhage.\n 2) Widened extraaxial space anterior to left cerebellar hemisphere could be\n due to arachnoid cyst or epidermoid tumor, MR imaging would\n be helpful for further evaluation, as clinically indicated.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835439,
"text": " 11:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: t spike and wbc: 25.8, ?PNA\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, RIJ CVL\n\n REASON FOR THIS EXAMINATION:\n t spike and wbc: 25.8, ?PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post distal pancreatectomy, right IJ central venous line\n placement. Now with temperature spike. Question pneumonia.\n\n PORTABLE AP CHEST X-RAY: Comparison is made to study from . The ET\n tube is again visualized with the tip approximately 4 cm above the carina, and\n the balloon slightly hyperinflated. A right sided Swan-Ganz catheter is again\n seen, with the tip in the distal lower lobar branch of the right pulmonary\n artery. NG tube is again seen with the tip in the gastric body. No opacities\n are noted in the lung fields. There has been interval improvment in the\n congestive heart failure since the previous study. There is also noted\n improvement in atelectasis. The heart size remains unchanged. A surgical\n drain is noted in the left upper quadrant, and remains unchanged from the\n previous exam.\n\n IMPRESSION: No evidence of pneumonia. Right sided Swan-Ganz catheter tip\n advanced distally. Dr. paged to convey results.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-04 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 835194,
"text": " 9:32 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please r/o PE\n Admitting Diagnosis: PANCREATIC MASS/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with acute resp failure\n REASON FOR THIS EXAMINATION:\n please r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n INDICATION: Acute respiratory failure. Status post surgery with distal\n pancreatectomy and splenectomy. Worsening condition.\n\n TECHNIQUE: Noncontrast low-dose images of the chest were performed. Contrast\n enhanced images of the chest following rapid bolus administration of 150 cc of\n IV Optiray were also performed. Images of the chest were reconstructed in\n sagittal and coronal planes. In addition, contrast enhanced images of the\n abodmen and pelvis were performed.\n\n IV CONTRAST: Nonionic IV Optiray contrast was used for rapid bolus\n administration.\n\n CT CHEST W/O&W CONTRAST: No pulmonary embolism is identified from the main\n pulmonary arterial trunk to the subsegmental pulmonary arterial vessels\n bilaterally. There are bilateral moderate pleural effusions with associated\n dependent and compressive atelectasis. Patchy consolidation is seen within\n the posterior aspect of the right upper lobe. There is diffuse ground glass\n opacity throughout the lungs superimposed upon changes of emphysema, most\n severe in the upper lobes. There is atherosclerotic disease of the thoracic\n aorta, but the heart, pericardium, and great vessels are otherwise\n unremarkable. An ET tube is seen in the mid trachea. An NG tube courses\n through the esophagus and ends with tip in the stomach. There is a single\n enlarged mediastinal lymph node in precarinal location measuring 1.1 cm in\n short axis diameter, likely reactive in nature.\n\n CT ABDOMEN WITH CONTRAST: At the site of recent surgery in the post surgical\n bed posterior to the fundus of the stomach and anterior to the superior\n portion of the left kidney, there is an area of post surgical fluid and soft\n tissue change. This area is continuous with enlargement of the left adrenal\n gland, which may be related to this change or rather may be a separate process\n of adrenal hemorrhage. The liver, remaining pancreas, stomach, right adrenal\n gland, and bowel loops are unremarkable. The right kidney is markedly\n atrophied, likely from atherosclerotic stenosis of the renal artery. Note is\n made of a right renal simple cyst. The left kidney is normal in appearance\n and enhances and excretes contrast promptly and symmetrically. The patient is\n status post cholecystectomy. Surgical skin staples are seen overlying the mid\n abdomen, and soft tissue changes in the anterior subcutaneous soft tissues is\n (Over)\n\n 9:32 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please r/o PE\n Admitting Diagnosis: PANCREATIC MASS/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consistent with recent surgery. The patient is status post aorto-biiliac\n stent graft. Marked atherosclerotic disease of the abdominal aorta and its\n major branches is noted. The abdominal aorta is mildly aneurysmal measuring\n 2.9 cm. There is no free fluid or free air. There is aneurysmal dilatation of\n the common iliac arteries bilaterally. The right measures 1.6 cm and the left\n 1.7 cm. A surgical drain is seen entering the abdomen on the left with tip\n located posterior to the fundus of the stomach.\n\n CT PELVIS WITH CONTRAST: Pelvic bowel loops are normal. The bladder and\n distal ureters are unremarkable. A Foley catheter is seen within the bladder.\n No free fluid or masses. There are bilateral common femoral artery\n aneurysms, the right measuring 2.2 cm and the left 1.8 cm.\n\n Bone windows show no suspicious lytic or blastic lesions.\n\n CORONAL AND SAGITTAL RECONSTRUCTIONS OF THE THORAX: Images reconstructed in\n sagittal and coronal planes show no pulmonary embolism or\n dilatation/dissection of the thoracic aorta.\n\n IMPRESSION:\n 1) Consolidation within posterior aspect of the right upper lobe consistent\n with pneumonia.\n\n 2) Diffuse ground glass opacity superimposed on underlying emphysema.\n Bilateral effusions with dependent and associated compressive bibasilar\n atelectasis. Findings are consistent with pulmonary edema.\n\n 3) No pulmonary embolism identified.\n\n 4) Post surgical fluid and changes seen in the post surgical bed. No\n drainable collection identified.\n\n 5) Enlargement of left adrenal gland adjacent to and contiguous with post\n surgical changes. The findings may relate to the latter, but isolated\n hemorrhage of the adrenal gland is also a consideration.\n\n 6) Diffuse atherosclerotic disease of the aorta status post aortobiiliac stent\n graft. There is minimal aneurysmal dilatation of the abdominal aorta and\n common iliac arteries. Bilateral common femoral artery aneurysms are also\n noted.\n\n 7) Severely atrophic right kidney, likely secondary to atherosclerotic disease\n of the renal artery.\n\n (Over)\n\n 9:32 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please r/o PE\n Admitting Diagnosis: PANCREATIC MASS/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835208,
"text": " 6:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: swan placement\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, RIJ CVL\n\n REASON FOR THIS EXAMINATION:\n swan placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 6:31 A.M.:\n\n INDICATION: Right IJ central venous line.\n\n FINDINGS: When compared with the examination from one day earlier, a right\n internal jugular Swan-Ganz catheter has been placed, and the tip projects over\n the right pulmonary artery. An ETT has also been placed, with the tip just\n below the clavicles. The tip of the feeding tube is seen projecting over the\n gastric fundus. There remains retrocardiac opacification as before,\n suggestive of atelectasis or consolidation. Mild opacities are seen in the\n right hilar area as before. The heart size is grossly within normal limits.\n There is no evidence of pneumothorax.\n\n IMPRESSION:\n 1) Satisfactory position of ETT, NGT, and Swan-Ganz catheter.\n 2) Stable left lower lobe opacities. Slightly improved aeration of the right\n lung base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835591,
"text": " 5:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval postion of TLC\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, s/p guidewire change of\n PA line to TLC\n REASON FOR THIS EXAMINATION:\n eval postion of TLC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57 year-old-man status post distal pancreatectomy and change of PA\n catheter to triple lumen.\n\n COMPARISON: .\n\n CHEST, AP: The right IJ CVL tip is at the SVC. No pneumothorax. The NGT and\n left upper quadrant drain are in unchanged position. The cardiac,\n mediastinal, and hilar contours are stable in appearance. There is bibasilar\n atelectasis and small bilateral pleural effusions. The osseous and soft\n tissue structures are unremarkable.\n\n IMPRESSION: Right IJ CVL tip at SVC. No pneumothorax. Small bilateral\n pleural effusions and bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835192,
"text": " 8:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pneumothorax, line placement, and ngt placem\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, RIJ CVL\n\n REASON FOR THIS EXAMINATION:\n please eval for pneumothorax, line placement, and ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 21:03:\n\n INDICATION: Line placements.\n\n COMPARISON: at 17:08.\n\n FINDINGS:\n\n Compared to the prior study a right central venous line has been removed and\n there is no ptx. A NGT has been placed and its tip is coiled in the left\n upper quadrant, probably in the fundus of the stomach. Another radiopaque\n catheter is visualized coursing from the left and curving upon itself in the\n left upper quadrant. This is similar to the prior study.\n\n Finally the patient was apparently intubated since the prior study with the\n tip of the ETT 5.7 cm above the carina.\n\n No new consolidations are seen. There is some haziness overlying the left\n lung base suggesting some pleural fluid layering out. There is a slight\n increased prominence to the upper lobe pulmonary vasculature and this suggests\n worsening in fluid status.\n\n IMPRESSION:\n\n No ptx. Lines and tubes as described above.\n\n Worsening fluid status.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835745,
"text": " 10:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of R IJ quad lumen catheter\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, s/p guidewire change TLC\n to QLC\n REASON FOR THIS EXAMINATION:\n placement of R IJ quad lumen catheter\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Triple lumen catheter change over wire.\n\n PORTABLE AP CHEST: Comparison is made with a study from . The right\n internal jugular central venous line tip is in the proximal SVC. No\n pneumothorax was seen. The NG tube is unchanged in appearance. There has\n been progressive bilateral lower lobe atelectasis.\n\n IMPRESSION:\n 1. Right internal juguarl central venous line tip in proximal SVC. No\n pneumothorax.\n 2. Improved CHF. Progression in bilateral lower lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-07-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 834669,
"text": " 1:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, RIJ CVL\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57 y/o man status post distal pancreatectomy and right IJ CVL\n placement.\n\n CHEST, AP: Right IJ CVL tip is at the SVC. There is no pneumothorax. NG\n tube tip is within the stomach. Cardiac, mediastinal and hilar contours are\n within normal limits. Pulmonary vasculature is normal. There is mild right\n lower lobe atelectasis. The lungs are otherwise clear. There are no pleural\n effusions. Surgical staples and drain are noted in the upper abdomen.\n Osseous and soft tissue structures are otherwise unremarkable.\n\n IMPRESSION: Right IJ CVL tip at the SVC. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835956,
"text": " 9:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: leukocytosis...r/o pneumonia\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty\n\n REASON FOR THIS EXAMINATION:\n leukocytosis...r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post distal pancreatectomy, post MI. Respiratory\n difficult. Leukocytosis, r/o pneumonia.\n\n PORTABLE AP CHEST: Lordotic positioning.\n\n There is mild cardiomegaly with unfolded aorta. There are increased\n interstitial markings, with bibasilar confluent opacity and apparent bilateral\n small pleural effusions. Findings are compatible with CHF. Underlying\n pneumonic infiltrate cannot be entirely excluded. NG tube tip is at the\n underlying fundus. The side port is not identified due to underpenetration.\n Left subclavian central line is present, tip over mid SVC. No pneumothorax.\n Compared with , the CHF findings are new.\n\n IMPRESSION: New CHF with alveolar edema and small bilateral pleural effusions.\n Abdominal staples noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 835970,
"text": " 1:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement\n Admitting Diagnosis: PANCREATIC MASS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy, postop MI, resp difficulty\n\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/P distal pancreatectomy. Postop MI. ETT placement for respiratory\n difficulty.\n\n chest, single ap view\n\n Compared with earlier the same day, an ETT has been placed. The tip lies in\n satisfactory position approximately 5 cm above the carina. Again seen is an NG\n tube, with tip over fundus. Side port also overlies the fundus. A left\n subclavian central line is present, tip over proximal SVC, unchanged.\n\n There is a small to moderate right pleural effusion. There is mild diffuse\n vascular blurring raising the question of a small degree of fluid overload.\n More confluent opacity seen in the right mid zone at the level of the carina.\n There is increased retrocardiac density, consistent with left lower lobe\n collapse and/or consolidation unchanged. ?vague nodular opacity in the left\n upper zone -- on the exam from earlier today it was seen between the third and\n fourth posterior ribs and is in a similar position on today's exam. No free\n air is detected beneath the diaphragm. Abdominal staples, skin staples and\n bowel contrast noted.\n\n IMPRESSION:\n\n 1) Interval placement of ETT, with tip in satisfactory position above the\n carina.\n\n 2) Right sided effusion unchanged. More apparent opacity in the right mid\n zone. Probable small degree of fluid overload.\n\n 3) ?nodular opacity left upper zone. See comment. There is no obvious\n correlate on the recent chest CT from suggesting this represents an\n artifact.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-08-11 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 835912,
"text": " 5:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: C diff colitis, need to access for viability of colon\n Admitting Diagnosis: PANCREATIC MASS/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p distal pancreatectomy/splenectomy now w/ respiratory\n failure.\n REASON FOR THIS EXAMINATION:\n C diff colitis, need to access for viability of colon\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old status-post distal pancreatectomy and splenectomy. C-\n diff colitis.\n\n TECHNIQUE: Helically acquired axial imaging of the abdomen and pelvis with\n oral and intravenous contrast. Coronal and sagittal reformatting.\n\n CONTRAST: Oral and 150 cc Optiray intravenously. Nonionic contrast was\n administered due to patient debility.\n\n COMPARISON: .\n\n CT ABDOMEN with contrast: Bilateral pleural effusions with compressive\n atelectasis have decreased. Post-operative changes compatible with\n splenectomy and distal pancreatectomy are again noted. The stranding and\n obscuration of some of the fat planes in the left upper quadrant is most\n likely post-operative. No discrete fluid collection or abscess is identified.\n Cholecystectomy is again noted. The liver and remaining proximal pancreas are\n unremarkable. Thickening of the left adrenal gland is again noted. The\n atrophic right kidney and normal appearning left kidney are unchanged.\n Intestines are unremarkable. There is no thickening of the colon to suggest\n colitis. There is no abnormal bowel loop dilatation. Abdominal aortic\n atherosclerotic disease remains similar in appearance.\n\n CT PELVIS with contrast: The aorto-biiliac grafts are again noted. Small\n aneurysms at the distal anastomoses remain similar in appearance. The pelvic\n viscera are unremarkable. No pelvic mass or free fluid is revealed.\n\n CT RECONSTRUCTIONS: Coronal and sagittal reformatting performed for\n additional assessment of the gastrointestinal tract fails to reveal any\n abnormal bowel wall thickening or bowel loop dilatation.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n\n IMPRESSION\n\n 1. No radiographic evidence of colitis.\n\n 2. Post-operative changes compatible with splenectomy and distal\n (Over)\n\n 5:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: C diff colitis, need to access for viability of colon\n Admitting Diagnosis: PANCREATIC MASS/SDA\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n pancreatectomy.\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-08-20 00:00:00.000",
"description": "Report",
"row_id": 76191,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 62\nWeight (lb): 142\nBSA (m2): 1.65 m2\nBP (mm Hg): 136/79\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 12:38\nTest: Portable TTE (Focused views)\nDoppler: Color doppler only\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. There is severe regional left ventricular\nsystolic dysfunction. Overall left ventricular systolic function is severely\ndepressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: mid anterior - akinetic; mid anteroseptal - akinetic;\nbasal inferior - hypokinetic; mid inferior - hypokinetic; basal inferolateral\n- hypokinetic; mid inferolateral - hypokinetic; anterior apex - akinetic;\nseptal apex- akinetic; inferior apex - hypokinetic; apex - akinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. There is severe regional left ventricular systolic\ndysfunction. Overall left ventricular systolic function is severely depressed.\nResting regional wall motion abnormalities include mid and distal anterior\nseptal and apical akinesis with inferior akinesis with inferolateral\nhypokinesis.\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.\n5.The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n6.There is no pericardial effusion.\n\nCompared to the previous study of , there are no new wall motion\nabnormalities. However the heart rate had decreased, the MR is less, and the\nnormally functioning basal segments are no longer hyperdynamic.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-08-06 00:00:00.000",
"description": "Report",
"row_id": 76192,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Myocardial infarction.\nHeight: (in) 65\nWeight (lb): 142\nBSA (m2): 1.71 m2\nBP (mm Hg): 136/78\nHR (bpm): 100\nStatus: Inpatient\nDate/Time: at 14:31\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is 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 is mildly dilated. There is mild regional left ventricular\nsystolic dysfunction. Overall left ventricular systolic function is mildly\ndepressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -\nhypokinetic; basal inferoseptal - hypokinetic; mid inferoseptal - hypokinetic;\nseptal apex - hypokinetic;\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. Right ventricular systolic function\nappears depressed.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated. There is mild regional\nleft ventricular systolic dysfunction. Overall left ventricular systolic\nfunction is mildly depressed. Resting regional wall motion abnormalities\ninclude inferolateral, inferoseptal walls . Right ventricular chamber size is\nnormal. Right ventricular systolic function appears depressed. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild\n(1+) mitral regurgitation is seen. There is no pericardial effusion. Thereis\nan echogenic density in sthe right ventricle consistent with a pulmonary\ncatheter.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof, the EF is unchanged though the inferoseptal wall was not previously\nmentioned as bieng hypokinetic.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-08-13 00:00:00.000",
"description": "Report",
"row_id": 76270,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction. Left ventricular function.\nHeight: (in) 62\nWeight (lb): 142\nBSA (m2): 1.65 m2\nBP (mm Hg): 150/82\nHR (bpm): 124\nStatus: Inpatient\nDate/Time: at 13:11\nTest: Portable TTE (Focused views)\nDoppler: Limited doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: There is moderate regional left ventricular systolic\ndysfunction.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. There is mild\nglobal right ventricular free wall hypokinesis.\n\nAORTIC VALVE: No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen.\n\nPERICARDIUM: There is a small pericardial effusion.\n\nConclusions:\nThere is moderate regional left ventricular systolic dysfunction (ejection\nfraction 30%). There is akinesis of the inferior wall and inferior septum. The\nmid and distal anterior septum and anterior wall are hypokinetic. The apex is\nakinetic. Right ventricular chamber size is normal. There is mild global right\nventricular free wall hypokinesis. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is\nseen. There is a small pericardial effusion.\n\nCompared to the prior study of (tape reviewed), there is a new\nanterior septum, anterior wall and apical wall motion abnormality. The left\nventricular systolic function has decreased.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-08-02 00:00:00.000",
"description": "Report",
"row_id": 76271,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 65\nWeight (lb): 142\nBSA (m2): 1.71 m2\nBP (mm Hg): 172/101\nHR (bpm): 120\nStatus: Inpatient\nDate/Time: at 17:27\nTest: Portable TTE (Focused views)\nDoppler: Limited doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\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 mildly depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is no\nsignificant mitral stenosis. Mild (1+) mitral regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Emergency\nstudy.\n\nConclusions:\nLeft ventricular wall thicknesses are normal. The left ventricular cavity size\nis normal. Overall left ventricular systolic function is mildly depressed\n(ejection fraction 40-50 percent) secondary to hypokinesis of the basal\nsegment of the inferior free wall and posterior wall; the apex was not\noptimally visualized, and may be hypokinetic as well. Right ventricular\nchamber size and free wall motion are normal. The mitral valve leaflets are\nstructurally normal. There is no mitral valve prolapse. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-14 00:00:00.000",
"description": "Report",
"row_id": 188379,
"text": "Sinus rhythm. Low limb lead voltage is non-specific. Anterolateral ST-T wave\nabnormalities - cannot exclude ischemia. Clinical correlation is suggested.\nSince the previous tracing of probably no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-13 00:00:00.000",
"description": "Report",
"row_id": 188380,
"text": "Sinus rhythm. Atrial premature beats. Low limb lead voltage is non-specific.\nAnterolateral ST-T wave abnormalities - clinical correlation is suggested for\npossible ischemia. Since the previous tracing earlier this date sinus\ntachycardia is absent and atrial ectopy is seen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-13 00:00:00.000",
"description": "Report",
"row_id": 188381,
"text": "Sinus tachycardia. Low limb lead voltage is non-specific. Anterolateral\nST-T wave abnormalities suggest ischemia. Clinical correlation is suggested.\nSince the previous tracing earlier this date the sinus tachycardia rate has\nincreased.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-13 00:00:00.000",
"description": "Report",
"row_id": 188382,
"text": "Sinus tachycardia\nPossible right ventricular hypertrophy\nLateral ST-T changes suggest myocardial injury/ischemia\nLow QRS voltages in limb leads\nSince previous tracing of , the rhythm is no longer atrial fibrillation\nand ST-T wave abnormalities more marked\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-18 00:00:00.000",
"description": "Report",
"row_id": 188376,
"text": "Sinus rhythm. First degree A-V block. Probable left atrial abnormality.\nAnterolateral ST-T wave abnormality - cannot rule out myocardial ischemia. Low\nQRS voltage in the limb leads. Compared to the previous tracing of \nventricular ectopies are absent and anterolateral ST-T wave abnormalities\npersist and are improved. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-16 00:00:00.000",
"description": "Report",
"row_id": 188377,
"text": "Sinus tachycardia\nProlonged Q-Tc interval\nExtensive ST-T changes suggest myocardial injury/ischemia\nLow QRS voltages in limb leads\nSince previous tracing of , anterior ST-T wave abnormalities less marked\nand ventricular premature complexes seen\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-14 00:00:00.000",
"description": "Report",
"row_id": 188378,
"text": "Sinus rhythm. Low limb lead voltage is non-specific. Anterolateral ST-T wave\nabnormalities - cannot exclude ischemia. Clinical correlation is suggested.\nSince the previous tracing earlier this date no significant change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-12 00:00:00.000",
"description": "Report",
"row_id": 188383,
"text": "Probable sinus rhythm with atrial premature complex\nExtensive ST-T changes may be due to myocardial ischemia\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in limb leads\nST-T wave abnormalities\nBaseline artifact makes rhythm interpretation difficult\nSince previous tracing of , and ventricular premature complex not seen\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-12 00:00:00.000",
"description": "Report",
"row_id": 188615,
"text": "Sinus tachycardia\nPremature ventricular contractions\nST junctional depression is nonspecific\nLow QRS voltages in limb leads\nSince previous tracing of , anterior ST-T wave abnormalities less\nmarked, and ventricular arrhythmia seen\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-08 00:00:00.000",
"description": "Report",
"row_id": 188616,
"text": "Sinus rhythm\nAnt/septal+lateral ST-T changes suggest myocardial injury/ischemia\nLow QRS voltages in limb leads\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-07 00:00:00.000",
"description": "Report",
"row_id": 188617,
"text": "Sinus rhythm. Compared to the previous tracing of the rate has slowed,\nthere are continued ST segment depressions in leads I, aVL and V3-V6\nconsistent with recent or ongoing anterolateral ischemic process, atrial ectopy\nis absent and the rate has slowed. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-06 00:00:00.000",
"description": "Report",
"row_id": 188618,
"text": "Sinus tachycardia\nPremature ventricular contractions\nSupraventricular extrasystoles\nAnterior ST-T changes suggest myocardial injury/ischemia\nLow QRS voltages in limb leads\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-05 00:00:00.000",
"description": "Report",
"row_id": 188619,
"text": "Sinus rhythm and occasional atrial ectopy. Low limb lead voltage. ST segment\ndepressions in leads V2-V6 that is now downsloping and more prominent as\ncompared to the previous tracing of , consistent with evolving\nanterolateral ischemic process. Rule out myocardial infarction. Followup and\nclinical correlation are suggested including the finding of low limb lead\nvoltage.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-04 00:00:00.000",
"description": "Report",
"row_id": 188620,
"text": "Sinus tachycardia. ST junctional depression is non-specific. Repolarization\nchanges may be partly due to rate. Low QRS voltages in limb leads. Loss\nof R wave in leads I and aVL. Compared to the previous tracing atrial premature\nbeats and ventricular premature beats are absent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-04 00:00:00.000",
"description": "Report",
"row_id": 188621,
"text": "Sinus tachycardia with atrial premature beats. Premature ventricular\ncontractions. Poor R wave progression - cannot rule out septal infarct.\nNon-specific anterolateral ST-T wave changes may be due to myocardial ischemia.\nLow QRS voltages in limb leads Compared to the previous tracing there are\nventricular premature beats, the rate is faster and there is loss of R wave\nin leads I and aVL.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-03 00:00:00.000",
"description": "Report",
"row_id": 188622,
"text": "Sinus tachycardia with atrial premature complex\nPoor R wave progression\nAnterolateral ST-T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince previous tracing of , anterior ST-T wave abnormalities present\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-02 00:00:00.000",
"description": "Report",
"row_id": 188623,
"text": "Sinus tachycardia with atrial premature complex\nPoor R wave progression\nAnt/septal+lateral ST changes suggest myocardial injury/ischemia\nLow QRS voltages in limb leads\nSince previous tracing of , ST-T wave abnormalities more marked\n\n"
},
{
"category": "ECG",
"chartdate": "2125-08-02 00:00:00.000",
"description": "Report",
"row_id": 188624,
"text": "Sinus tachycardia\nST junctional depression in leads V2-V4 is nonspecific\nLow QRS voltages in limb leads\nSince last ECG, sinus tachycardia, shorter PR interval, ST segment depression,\nventricular premature complex absent\n\n"
}
] |
4,353 | 143,248 | Perivascular/respiratory: The patient was initially treated with C-Pap. She required only small amounts of oxygen and was weaned to room air by the end of the first day. She has had apnea of prematurity, treated with caffeine. There has never been evidence of a patent ductus arteriosus. Blood pressure has been normal throughout her hospital stay. | Settles easliy. NNP aware.A;Feedstolerated. P:Repeat bili in AM. LSclear/=. A: Gestationally appropriate. BLS c/=, mildsc/ic retractions. P: Continue tomonitor. MAE, AFOSF,PFOSF. Respiratory O: Pt. A: Pt. A: Pt. Skin w/o leisons. Tolerating well. is stable inRA. LSclear and equal. IV out this am. Infantbecomes apneic then desats. O: Pt. Abd exam isunremarkable, v/s, heme neg. Independentw/cares. Mild IC/SC rtx. Temps stable in off iso. Abd benign. A&A w/cares. AGA. Report called to . LS cl/=. NoA/B's so far this shift. Plan to check in am. Comfortable apeparing.Wt 1365 down 173. Bili sent.8.4/0.3. and active withcares. A: &P check results in the AM. Two spells thus far this shift, onerequiring mild stim. RR stable. today11.5/0.4. Due for bili lab. tolerates. P: Cont to support dev needs. Updated at bedside. Mild SC/ICretractions. MAEW. Will hold on IVF for now as advancing on feeds this am.Single photorx. AG20cm. 1 desat thus far today. REmains in RA. A: Tolerating feeds. P:Cont to monitor for AOP. P: Continue with plan with possibility of advancing feedstoday. Parents in. NeonatologyDoing well. A; AGA P; cont devsupport.#6. A: CBC benign. mildly jaundiced, under double lights,Todays bili11.5/0.4,NNP Aware.A; Mildly jaundiced,P;cont double lightsas advised. P: Continue w/current feeding plan. Consent is signed and in the chart. Neonatology Fellow PNPE: Gen- ,responsive in isoletteHEENT- AF s/f, facial jaundiceResp- CTAB with mild retractionsCV- RRR without murmur, normal pulsesAbd- soft, NT/ND with active BSSkin- decreased jaundicePlan:1. UOP4.2cc/kgx12h. Lytes in good range.feed adavancement to continue as tolerated.Under dbl photorx for bili in 11 range. Cont to edu andupdate family.5. Neonatology Fellow PNPE: Gen- , vigorous in isoletteHEENT- SF s/f, jaundiceRep- CTAB with mild retractionsCV- RRR without murmurAbd- soft NT/ND with active BSSkin- jaundice to abdPlan:1. TF at 70 cc/k/d. NeonatologyRemains in RA. Eye inplace. remains in servo-controlisolette, nested w/ stable temps. WIll follow.Active . Remains in R air, BBS clear, equal, mild subcostal/intercostal retractions present, desats to 55%, Hrate 122,stim, needed blow by,occassional desats to low 80's QSRfollowing periodic breathing.On Caffine, periodic breathingnoted.A;desat needed blow by to recover x1.P; cont tomonitor resp status.#3. MildI/S retractions. A- Adequatehydration P- Check bili result. Tolincreased volume today with stable abd, min. PN to be started.Temp stable on warm,er.On ampi/gent for 48 h r/o. NPO due to resp status.P. Min asp. received Amp and GentP. Labs noted and PN adjusted accordingly. IV resited this am. A/P: Contto monitor bili. P: Check bili on . They mentioned that they may be interested intransfer back to when stableP. NNP informed. Appropriate to add Fe supps when feeds reach initial goal. Maintained temp. Initially placed on nasal prong CPAP. O: Temp stable nested in isolette. Plan to transfer to isolette later today.#6Bili ruddy on adm. Hct 60.2. A- AGA Tol. Now in low flow NCO@2SIgnificant apnea overnight rxed with narcan given maternal receipt. 6 BiliNsg Note cont#4ParentParents here from L&d. Increase noted inspells. Discussed with NNP.P. Well perfused. Cont to advancefeeds as tol.4. Current PN + EN meeting recs for fat and vits. Rests well inbewteen cares.A/P: Cont to cluster cares. BBScl+=. Passing trace meconiumA/Goals:Tolerating IVF w/ good BS control. Mother updated on 'sprogress. Will wean from O2 low flow cannula this amWt 1335 down 10. A:Tolerating advancing feeds. Rnupdated Mom. P: Continue to keepinformed.#5 O: Temp stable in off isolette. Await BC results#2RespLungs clear. +bs. Tolerating PN with good BS control. Breath soundsclear and equal, mild retractions. Cont to support and keep informed.Infant currently in off isolette w/ double phototherapylights applied. pnea spells improved with NarcanP. TF to remain at 80 cc/k/d. RR 20-40's with mild IC/SC retractions. o- Temps stable on servo warmer. Bili to be sent. O: Under double phototherapy. Settles with hand containment at times. Neonatology Fellow PNPE: Gen- , awake in isoletteHEENT- AF S/F, mmmResp- CTAB with mild retractionsCV- RRR without murmur, normal pulsesAbd- soft, NT/ND with active BSno loopsSkin- Jaundice to abd under lightsPlan: Cont to advance feeds as tolerated, obs for spells. Cont phototxHUS todayTx to when ready Will start caffeine and monitor response.Wt NPO at prersent. Transitional stoolG-. MIn asp. Rn updatedparents. On admission, BPP , EFW 1395, and normal AFI. P: Check bili in am. UO 1.9cc/hryesterday. Temp 99.1R. D/stix stable. A/P: Cont to mointor wt,abd, and I&O's.4. A: NPO now. Infanttol well. KUB done. O: Temp stable nested in servo isolette. O: Temp stable nested in servo isolette. Labs ordered fortomorrow am. CPAp removed and placed in RA. IV resited in right footthis am. +bs. Received NPO. Intermittent spells on acffeine.Comfortable apeparing.Wt 1345 down 17. A:cont with desats P: cont to monitor#3 TF cont at 130cc/k/d. G1P0 to 1 mother. P: Continuephototherapy. Follow resp status A: Toleratingsmall feeds. D/stix 72. Report any biliousresidual, inc abd girth etc. of apneicepisodes with sucking. KUB nl. P: Cont to monitor bili. A/P: Cont to monitor respstatus.3. Voidingwell and passing meconium. Currently is getting 60cc/k/dBM and 70cc/k/d PN10/IL via PIV. bili pnd A: hyper bili P: contphototherapy ? O: UNder double phototherapy. A/P: Cont to monitortemp. Seeflow sheet. Breath soundsclear and equal, mild retractions. Mom had PTL on . NeonatologyDoing well. pt apneic and havingdesats to 60's. Rests well inbetween cares. Cont in low flow O2 per NC. Received BBO2 and dried and stim in DR. adm to NICU and placed on NPCPAP . A; Increasing bili. NPO. Rest of exam as expected for gestational age.Impression:1. Mild I/Sretractions. Mother was admitted to at that time. Discussed infant's residualsand plan. Lsclear and slightly diminished. A/P: Cont to monitor temp. A: Hyperbili. A/P: Contto monitor resp status.3. P:Continue to support development.#6 O: Placed under double phototherapy at 0700. 1 desat to 60's with apnea. REmains in RA. BM20 tol well via ngt at30cc/kg. Neonatology Fellow PNPE: Gen- , comfortable in isoletteHEENT- AF s/f, ruddy, jaundiceResp- CTAB with mild retractionsCV- RRR without murmur, normal pulsesAbd- soft, NT/ND with active BSSkin-jaundice to thighPlan:1. increase TF to 150 cc/kg/d, increase feeds to 80 cc/kg/d2. Abdomen issoft, intermittant, soft loops noted, non tender. Nsg Adm Note adm to NIC for prematurity. | 50 | [
{
"category": "Radiology",
"chartdate": "2164-09-03 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 835388,
"text": " 10:56 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: r/o rds\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with resp distress, prematurity.\n REASON FOR THIS EXAMINATION:\n r/o rds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n\n Supine view of the chest demonstrates normal lung volumes. There is hazy\n parenchymal density at both bases. This could represent residual fetal lung\n fluid, however infiltrate cannot be excluded. If symptoms persist a follow-up\n study is advised.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-09-07 00:00:00.000",
"description": "BABYGRAM AP ABD ONLY",
"row_id": 835846,
"text": " 4:15 PM\n BABYGRAM AP ABD ONLY Clip # \n Reason: bilious aspirate\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n prematurity, feeding intolerance\n REASON FOR THIS EXAMINATION:\n bilious aspirate\n ______________________________________________________________________________\n FINAL REPORT\n The bowel gas pattern is normal. There is no evidence of pneumatosis portal\n venous gas or free air. The feeding tube is in the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2164-09-10 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 836025,
"text": " 7:36 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: screen for IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity at 31 1/7 weeks\n REASON FOR THIS EXAMINATION:\n screen for IVH\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Premature infant being evaluated for intracranial hemorrhage.\n\n CRANIAL ULTRASOUND: Real-time scanning of the brain was performed through the\n anterior and mastoid fontanelles. The brain is normal in echogenicity and\n morphology. The pattern of sulcation is appropriate for the patient's\n prematurity. The ventricles are normal in size, and there is no evidence of\n intraventricular or intraparenchymal hemorrhage. The extraaxial fluid spaces\n are normal.\n\n IMPRESSION: Normal cranial ultrasound.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-06 00:00:00.000",
"description": "Report",
"row_id": 1736465,
"text": "NPNote\n\n\n#2. Remains in R air, BBS clear, equal, mild subcostal/\nintercostal retractions present, desats to 55%, Hrate 122,\nstim, needed blow by,occassional desats to low 80's QSR\nfollowing periodic breathing.On Caffine, periodic breathing\nnoted.A;desat needed blow by to recover x1.P; cont to\nmonitor resp status.\n\n#3. Todays weight=1365,down173gms,TF=110cc/kg/day, Feeds at\n30cc/kg/day,MBM20,PG fed, tolerated, IVF Pn D10 with lipids\ninfusing at 80cc/kg/day,PIV infusing well without any\nredness or swelling.D'stix 81,BS+, no loops, voided, stooled\nmec x1.Lytes today 140/5.3/102/21/22. NNP aware.A;Feeds\ntolerated. P: cont current nutrition plan, increase feeds\n10cc/kg/ at 4+4.\n\n#4. Parents visited, asking app questions. involved in care.\nA; loving P; cont update and teaching.\n\n#5..active with care, temp stable in a servo control\nisolette, nested in sheepskin, mae. A; AGA P; cont dev\nsupport.\n\n#6. mildly jaundiced, under double lights,Todays bili\n11.5/0.4,NNP Aware.A; Mildly jaundiced,P;cont double lights\nas advised.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-11 00:00:00.000",
"description": "Report",
"row_id": 1736488,
"text": "Nursing Note\n\n\nInfatn remains in RA, sats mainly >95% with occassional\nspells/desats all req mild stim. RR stable. BLS c/=, mild\nsc/ic retractions. P/COnt to observe for spells, desats.\n3. WT=1335g. TF=150cc/kg/d BM 20 via NGt. Enteral feeds at\n110cc/kg/d q4h, gavaged over 45min. Feeds increased at\n0100/1300. Infant's IV was d/c per order of NNP at ~0500\ndue to ? infiltrate. Site slighty puffy. Abd exam is\nunremarkable, v/s, heme neg. Min asp, no spits. UOP\n4.2cc/kgx12h. See flowsehet for additional details.\n4. Parents in. Updated at bedside. Dad .\nAsking quest. P/WIll visit at 1300. Cont to edu and\nupdate family.\n5. Temps stable in off iso. Nested on sheepskin with photo\nblinds on. Remains under single photo. Due for bili lab\n. AA with cares, sleeps well between. MAE, AFOSF,\nPFOSF. AGA. Sucks paci. P/Cont to monito dev milestones.\nCont to monitor bili.\nSee flowsheet for additional details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-11 00:00:00.000",
"description": "Report",
"row_id": 1736489,
"text": "Neonatology\nDoing well. REmains in RA. Intermiottent spells on caffeine. Comfortable apeparing.\n\nWt 1335 Tolerating feeds at 110 cc/k/d out of tf of 150 cc/k/d. IV out this am. Will hold on IVF for now as advancing on feeds this am.\n\nSingle photorx. Bili to be repeated in am.\n\nContinue as at present.\n\nParents interested to transfer to . be ready for transfer on Wednesday or Thursday\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-11 00:00:00.000",
"description": "Report",
"row_id": 1736490,
"text": "Neonatology Fellow PN\nPE: Gen- , vigorous in isolette\nHEENT- SF s/f, jaundice\nRep- CTAB with mild retractions\nCV- RRR without murmur\nAbd- soft NT/ND with active BS\nSkin- jaundice to abd\n\nPlan:\n1. Increase feeds to 150 cc/kg/d\n2. Am bili on lights\n3. Tx to when able, possible tomorrow\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-06 00:00:00.000",
"description": "Report",
"row_id": 1736466,
"text": "Neonatology\nRemains in RA. No spells. Comfortable apeparing.\n\nWt 1365 down 173. Feeds at 40 cc/k/d being tolerated. Abdomen benign. TF at 70 cc/k/d. WIll increase TF to 130 cc/k/d. Lytes in good range.\nfeed adavancement to continue as tolerated.\n\nUnder dbl photorx for bili in 11 range. WIll follow.\n\nActive . Skin w/o leisons. Moving all. 4. Nruo non-focal.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-06 00:00:00.000",
"description": "Report",
"row_id": 1736467,
"text": "PT/Rehab Services\n observed during afternoon cares and noted strengths, stress signals, and techniques for comfort (see bedside posted care plan). Initiated education regarding care plan and role of PT/OT with parents. Will continue to follow with parent education and developmental care as appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-06 00:00:00.000",
"description": "Report",
"row_id": 1736468,
"text": "Neonatology Fellow PN\nPE: Gen- ,responsive in isolette\nHEENT- AF s/f, facial jaundice\nResp- CTAB with mild retractions\nCV- RRR without murmur, normal pulses\nAbd- soft, NT/ND with active BS\nSkin- decreased jaundice\n\nPlan:\n1. Increase TF to 130 cc/kg/d\n2. Increase feeds to 60 cc/kg/d\n3. Continue phototx for bili 11.5, AM bili\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-11 00:00:00.000",
"description": "Report",
"row_id": 1736491,
"text": "NPN \n\n\n\n #2. Infant remains in RA. RR 40-60. LS cl/=. Mild SC/IC\nretractions. Sating 98-100%. 1 desat thus far today. No\nA/B's so far this shift. 7/in 24hrs. Conts on caffeine. P:\nCont to monitor for AOP.\n\n #3. Infant working up on feedings. Presently on TF 130cc/k\nBM 20(33cc pg'd over 40min). DS 103. Tol feeds well thus\nfar. Abd benign. Belly soft w/active BS, min asp, no spits,\nAG stable, voiding and passing sm amts meconium. P: Adv to\nfull feeds by 2100 and assess tolerance.\n\n #4. Mom in to visit and do cares at 1300. Independent\nw/cares. Updates on infant's progress given at the bedside.\nAsking questions. Both parents will be in at 2100 for\nkangaroo care. P: cont support, keep updated and educate.\n\n #5. Temp stable nested in sheepskin boundaries in off\nisolette. A&A w/cares. Settles easliy. Sleeps between cares.\nAFSO. MAEW. P: Cont to support dev needs.\n\n #6. Infant conts under single photo therapy. Eye in\nplace. She is ruddy jundiced. Passing sm amts mec stool. P:\nRepeat bili in AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-06 00:00:00.000",
"description": "Report",
"row_id": 1736469,
"text": "Nursing NICU Note\n\n\n#2. Respiratory O: Pt. remains in RA, O2 sats ~94-100%.\nRR ~30-50's, no increae work of breathing noted. LS\nclear/=. RR ~30-50's. She has mild SC retractions noted.\nNo A&B's noted this shift thus far. A: Pt. is stable in\nRA. P: Continue to monitor respiratory status. Monitor\nfor A&B's.\n\n#3. FEN O: TF advanced to 130cc/kg/d. Enteral feeds of\nBM20 @ 50cc/kg =13cc Q 4hrs, gavaged over 20 min, tolerated\nwell. IVF D10 PN and IL are infuseing @ 80cc/kg via a Left\nfoot PIV wothout incident. Abdomen is soft, pink, +BS, no\nloops/spits noted. Abdominal girth is 21-21.5cm. She is\nvoiding, no stool noted this shift thus far. A: Pt. is\ntolerateing current nutritional plan. P: Continue w/\ncurrent feeding plan. Plan to advance enteral feeds by\n10cc/kg as pt. tolerates. Monitor for s/s of\nintolerance.\n\n#4. Parents O: Parents in to visit for cares and\nthroughout the shift. They were udpated at bedside on pt's\ncurrent status and daily plan of care. Parents are active\nin cares, asking appropriate questions. A: Family is\nloving and involved. P: Continue to udpate, support and\neducate.\n\n#5. Growth/Development O: Pt. remains in servo-control\nisolette, nested w/ stable temps. She is and active\nw/ cares, sleeps well in between. Fontanelle soft/flat.\nShe loves to use her pacifier, brings hands to face. A:\nAGA P: Continue to provide environment approrpriate for\ngrowth and development.\n\n#6. O: Pt. remains ruddy/jaundiced. today\n11.5/0.4. A: Alteration in . P: Continue to\nmonitor. Plan to check in am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-12 00:00:00.000",
"description": "Report",
"row_id": 1736492,
"text": "NPN 1900-0700\n\n\nRESP: In RA. O2sat 97-100%. RR 30-60's. Mild IC/SC rtx. LS\nclear and equal. Two spells thus far this shift, one\nrequiring mild stim. On caffeine.\n\nFEN: wt=1390g (up 55g). TF=150cc/kg/d of BM20. Equals 38cc\nq4hrs, gavaged over 45min. Tolerating well. Abdomen soft,\n+BS, AG stable, no loops, no spits, voiding and stooling.\nD-stick 78. Lytes sent.\n\nParents: Both parents in with visitors for 2100 cares. Mom\ntook temp and changed diaper. Kangaroo'd infant ~90min.\nTolerated well. Dad signed consent for transfer to\n. Given frozen breastmilk to take home.\n\nDEV: Temp stable, nested in isolette. and active with\ncares. Sleeps well between.\n\nBili: On single phototherapy with eye shields on. Bili sent.\n8.4/0.3.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-12 00:00:00.000",
"description": "Report",
"row_id": 1736493,
"text": "Neonatololgy Fellow PN\nPE:Gen- sleeping, easily aroused in isolette\nHEENT- AF S/F\nResp- CTAB without distress\nCV- RRR without murmur, pulses normal\nAbd- soft, NT/ND with active BS\nSkin- decreased jaundice\n\nPlan:\nTransfer to today, tolerating full feeds gavage, will advance caloric intake, on RA. stop phototx today\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-12 00:00:00.000",
"description": "Report",
"row_id": 1736494,
"text": "NICU Transfer Note\n Girl is being transfered to for further care. Consent is signed and in the chart. Spoke with mother this am so she is aware of transfer. Report called to .\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-05 00:00:00.000",
"description": "Report",
"row_id": 1736460,
"text": "Nursing Progress Note\n\n\n1.O: remains on antibiotics for a 48hour r/o. Temp stable.\nActive and alert for cares.\n A: CBC benign.\n P: Continue with antibiotics. Continue to monitor for s&s\nof sepsis. Ckeck blood cultures in 48 hours.\n2.O: remains in room air with O2 sats high 90's-100. having\noccaisional desats to the 70's-80's after crying. Infant\nbecomes apneic then desats. Breath sounds clear and equal.\nMild IC/SC retractions noted. Color ruddy.\n A: Apnea due to prematurity.\n P: need caffeine for apneic spells. Monitor. Document\nall spells.\n3.O: Weight 1535gms up 15gms. Total fluids at 100cc/kg/d. IV\nat 80cc/kg and NG feeds at 20cc/kg. Gavaged q4h with BM or\npremie formula and tolerated well. Abdomen soft and flat. AG\n20cm. Voiding, nostools. DS 85. Lytes and bili sent at 0430\nand results pending.\n A: Tolerating feeds.\n P: Continue with plan with possibility of advancing feeds\ntoday. Monitor abdomen for feeding intolerance Monitor\nstooling and voiding.\n4.O: Mom and Dad came up form the 2400 feed. Mom took the\ntemp and was shown how to change the diaper. They asked\nappropriate questions.\n A: loving parents.\n P: Inform and support.\n5.O: Nested in a heated isolette on servo. Temp stable.\nActive and alert. Sucking on pacifier intermittently.\n A: Gestationally appropriate.\n P> Continue to monitor.\n6.O: Color ruddy. Remains on phototherapy with eyes covered.\nBili drawn and results pending.\n A: &P check results in the AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-05 00:00:00.000",
"description": "Report",
"row_id": 1736461,
"text": "Social Work\n\n\nMet briefly with parents yesterday, young couple somewhat overwhelmed with preterm delivery, but adjusting very appropriately.\nHad family meeting yesterday, given parent packet, also parking information. Will plan to assess supports, and how couple continue to adjust to nicu environment. be interested in when ready.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-05 00:00:00.000",
"description": "Report",
"row_id": 1736462,
"text": "Neonatology\nDoing well. REmains in RA. Intermittent desats and apnea. On caffeine.\n\nWt 1535 up 15.Tolerating efeds at 100 cc/k/d. Feeds at 20, being tolerated. ABdomen benbign Will increase TF to 110 cc/k/d and advance feed volume as tolerated today. Na 145.\n\nBili in 11 range this am. Dbl photorx added this am.\n\nAmp/Gent to be dced after 48 h if cx negative.\n\nContinue feeding advancement and monitoring of apnea.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-05 00:00:00.000",
"description": "Report",
"row_id": 1736463,
"text": "neonatology Fellow PN\nPE: Gen- alert, quiet in isolette, ruddy with jaundice\nHEENT- AF s/f, pink\nResp- CTAB without distress\nCV- RRR without murmur, pulses normal\nAbd- soft NT/ ND without loops\nSkin- ruddy, jaundice to thigh\n\nPlan:\n1. increase feeds to 40 cc/kg/day, total fluids to 110 cc/kg/d, check AM lytes\n2. Phototx, AM bili\n3. D/C abx with negative bcx and no s/s sepsis\n4. Obs for A/B on caffeine\n5. Discussed plans with parents at bedside\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-10 00:00:00.000",
"description": "Report",
"row_id": 1736486,
"text": "Clinical Nutrition\nO:\n~32 wk CGA BG on DOL 7.\nWt: 1335 g (-10)(~25th %ile); birth wt: 1520 g. Wt currently down ~12% from birth wt\nHC: 28 cm (~10th to 25th %ile); last: 27.5 cm\nLN: 41 cm (~25th to 50th %ile); last: 41 cm\nLabs noted\nNutrition: 150 cc/kg/day TF. Feeds currently @ 70 cc/kg/day BM 20, increasing 20 cc/kg/. Remainder of fluids as PN via PIV; projected intake for next 24 hrs from PN ~28 kcal/kg/day, ~1.8 g pro/kg/day and no lipids. From EN: ~60 kcal/kg/day, ~0.9 g pro/kg/day and ~3.4 g fat/kg/day. GIR from PN ~4.2 mg/kg/min.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating feeds so far without GI problems. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Current PN + EN meeting recs for fat and vits. Current PN + EN not meeting recs for kcals/pro/or minerals due to limitations of PIV. Expect feeds to be increased to initial goal of ~150 cc/kg/day BM 24 soon, when all nutrition recs will be met. Growth should improve as feeds reach initial goal. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-10 00:00:00.000",
"description": "Report",
"row_id": 1736487,
"text": "Nursing Progress Notes.\n\n\n#2 O: weaned to room air this morning over several\nhours. Sats remain in mid to high 90's. Breath sounds\nclear and equal, mild retractions. has had 6 desats\nand/or brady's as listed in carevue, all requiring\nstimulation. A: Weaned off oxygen. Increase noted in\nspells. P: Continue to monitor and provide support as\nrequired.\n#3 O: Total fluids remain at 150cc/kg/day. Feeds of BM 20\nadvanced to 90cc/kg/day at 1300. Feeds given every 4 hours\nover 40 min. No spits or large aspirates. Abdomen soft,\nbowel sounds active no loops, girth stable, voiding\n5.9cc/kg/hr, trace meconium passed. IV fluids of D10PN and\nIL infusing well via peripheral IV. IV resited this am. A:\nTolerating advancing feeds. P: Continue to advance feeds\n20cc/kg twice a day as tolerated.\n#4 O: Mother in to visit this morning and parents plan to\nvisit this evening to kangaroo. Mother updated on 's\nprogress. A: Involved family. P: Continue to keep\ninformed.\n#5 O: Temp stable in off isolette. is and\nactive with cares and slept fairly well between cares. She\nsucks her pacifier when offered. A; Appropriate for age.\nP: Continue to support development.\n#6 O: changed to single phototherapy this morning.\neyes clean and covered. A: Decreased to single phototherapy\ntoday. P: Check bili on .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736457,
"text": "Clinical Nutrition\nO:\n31 wk gestational age BG, AGA, now on DOL 1.\nBirth WT: 1520 g (~50th to 75th %Ile)\nHC: 27.5 cm (~10th to 25th %ile)\nLN: 41 cm (~50th %Ile)\nLabs due\nNutrition: 80 cc/kg/day TF. NPO, but plan to start EN today @20 cc/kg/day BM/SSC 20. Fluid currently @D10W via PIV, but plan to change remainder of volume after feeds deducted to PN starting tonight; projected intake for next 24 hrs from PN ~28 kcal/kg/day, ~1.8 g pro/kg/day. From EN: ~13 kcal/kg/day, ~0.2 to 0.4 g pro/kg/day, and ~0.8 g fat/kg/day. GIR from PN ~4.2 mg/kg/min.\nGI: Abdomen soft, faint bowel sounds. Passing trace meconium\n\nA/Goals:\nTolerating IVF w/ good BS control. PLan to start feeds and PN today and monitor closely for tolerance. Labs to be drawn today. PN will be supplemental to feeds only. INitial goal for feeds is ~150 cc/kg/day BM/SSC 24, providing ~120 kcal/kg/day and ~3.2 to 3.3 g pro/kg/day. Further increases in feeds as per growth and tolerance. Appropriate to add Fe 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": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736458,
"text": "Neonatology Fellow PN\nPE: Gen- alert, responsive, ruddy in open warmer\nHEENT- AF S/F, mmm\nResp- CTAB without distress, mild subcostal retractions\nCV- RRR without murmur\nAbd- soft, NT/ND, occ BS heard, no masses or loops\nSkin- very ruddy, no jaundice\n\nPlan:\n1. Obs on RA, load with caffeine for A/B spells and start maint.\n2. Increasing Na on lytes at 12 hours, increase IVF total to 100 cc/kg/day, recheck in 12 hours\n3. Start feeds at 20 cc/kg/day\n4. Talked with father, will meet with mother\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736459,
"text": "NPN\n\n\n#1Sepsis No change. Infant remains on antibiotics.\n#2Resp O- infant remains in room air with O2 sats above 92.\nRR 26-40. Lungs clear with mild retractions noted. Infant\nloaded with caffeine this am after desats to 49/with\napnea.A- 31 week infant with A+B's/immature breathing\npattern. P- continue to follow closely.\n#3F/N O- Infant had total fluids increased to 100cc/kg.\nLytes 143/5.6/109/15 Enteral feeds of BM/SC20 started at\n20cc/kg. D-stick 84. Infant voiding well. No stool passed.\nabdomen is soft with good bowel sounds. A- Adequate\nhydration P- Check bili result. Repeat lytes in 12 hours.\n#4Family Parents in to visit and updated at bedside by RN.\nMom and Dad both holding infant today, Infant tol. kangaroo\ncare well with Mom. Family meeting held and review of\nsystems done MD. Parent packet given to family. A- young\ncouple updated P- Teach and support as needed.\n#5 Dev. o- Temps stable on servo warmer. Infant active and\nalert at care times. A- AGA Tol. kangaroo care well.P-\n support dev.\n#6 Bili sent Result 6.1/.2/5.9 Team notified.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736451,
"text": "#1Sepsis\nMom with antibiotics. CBC and diff and BC sent. \nreceived Amp and Gent\nP. Await BC results\n#2Resp\nLungs clear. Initially placed on nasal prong CPAP. Cxr\nshowed overinflation. CPAP removed. placed in RA.\nHowever, had episodes of apnea with desat to 82-83,\nmostly after crying which would quickly respond to mild\nstim. Mother had received 1 hour PTD. At 0230, \nNNP Naracn .15mg given IM. has had no further desats.\nLungs clear. RR 20-40's with mild IC/SC retractions. has\nremained in nasal cannula 25cc flow with sat in high 90's\nA. pnea spells improved with Narcan\nP. Cont to monitor and document\n#3FEN\nBW 1.52. Initial dstick 54. NPO due to resp distress. IV\nplaced in L hand. D10W infusing at 80cc/kg or 5cc/hr. repeat\ndstick was 107. Abd soft. Bowel sounds heard. Void.\nA. NPO due to resp status.\nP. Cont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736452,
"text": "RESPIRATORY CARE NOTE\n @ 31 1/7wks vaginal delivery. Apgars 9 & 9 wt 1520 grams received blow by O2 in the DR. to the NICU placed on Prong CPAP 6 @ 2230 hrs FIO2 25%. CxR taken appears well expanded. CPAP decreased to 5 and @ 2345 was taken off CPAP. Placed on nasal cannula. was having some apnea. Narcan given at 0230 hrs. Mother received 1 hr prior to delivery. now in room air. Will cont to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736453,
"text": "6 Bili\n\nNsg Note cont\n#4Parent\nParents here from L&d. Parents updated on 's condition.\nInformed of apnea spells. Parents pleased is able to\nbreath on own. Parents updated to NICU routine. Mom plans to\nbreast feed. They mentioned that they may be interested in\ntransfer back to when stable\nP. Keep parents updated.\n#5dev\n nested on servo control warmer. Irritable at times.\nColor ruddy.\nP. Plan to transfer to isolette later today.\n#6Bili\n ruddy on adm. Hct 60.2. Discussed with NNP.\nP. Plan to check a bili at 12 hours of age.\n\nREVISIONS TO PATHWAY:\n\n 6 Bili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736454,
"text": "Nsg Addendum\n has had 2 additional apnea spells with desat to 83-84 since receiving Narcan. NNP informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736455,
"text": "Neonatology\nWeaned from CPAP last night. Now in low flow NCO@2\nSIgnificant apnea overnight rxed with narcan given maternal receipt. Spells decreased significantly foillowing this rx, but seem to be increasing again this am. Will start caffeine and monitor response.\n\nWt NPO at prersent. Will consider begin of feeds later in day when spells stabilized. Abdomen benign. BS in good range. TF to remain at 80 cc/k/d. PN to be started.\n\nTemp stable on warm,er.\n\nOn ampi/gent for 48 h r/o. CBC unremarkable.\n\nActive alert. Moving all 4.\n\nCOntinue as at present. EWvaluate response to rx of apnea and ability to begin feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736456,
"text": "Case Management Note\nChart has been reviewed. List of Early Intervention Programs and VNA's have been placed in chart. I will cont to follow & assist w/any d'c planning needs w/family & team inputs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-09 00:00:00.000",
"description": "Report",
"row_id": 1736482,
"text": "NPN\n\n\nInfant in NC Fi02 100% at 100cc flow. Sats mostly 97-100%\nbut infant noted for 2 episodes of apnea w/sats to 50's,\ncyanotic, requiring mod stim. HR only to low 100's. Has occ\nQSR drifts without color change as well. On caffeine. BBS\ncl+=. No murmur. Well perfused. Jaundiced. See flow sheet\nfor VS. Cont to monitor closely.\nTF 150cc/kg/day. Currently PIV PN D10 w/lipids at\n100cc/kg/day and ent feeds at 50cc/kg/day of plain MBM. Tol\nincreased volume today with stable abd, min. asp, no spits.\nOrdered to inc by 20cc/kg . Next inc due at 1am. Voiding\nas charted on flow sheet. Passed large trans. stool.\nCOnt with current plan Assess for feeding tol.\nParents in for 2 feedings. Mom gave kangaroo care at 1700.\nInfant tol well. Maintained temp. Mom pumping. Very good\nsupply. Explained status and parents verbalized\nunderstanding of plan. Cont to support and keep informed.\nInfant currently in off isolette w/ double phototherapy\nlights applied. Temp too warm w/ isolette on. Infant noted\nto be extremely irritable at times despite nesting and\nboundries. Settles with hand containment at times. Becomes\napneic when sucking on pacifier. INfant keeps lower\nextremities extended and raised when in prone position.\nConsult with PT/OT needed. Discussed positioning w/parents.\nInfant remains under double phototherapy w/ mask applied.\nWill have bili drawn tomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-10 00:00:00.000",
"description": "Report",
"row_id": 1736483,
"text": "NPN Nights\n\n\n2. O: Received pt on NC 100% 100CC flow. RR 30-50's. Mild\nI/S retractions. 2 desats to 60's with apnea requiring stim\nto recover. On Caffeine. A/P: Cont to closely monitor resp\nstatus.\n\n3. O: Wt 1335gms, down 10. TF 150cc/kg. Currently Pn D10 +IL\ninfusing well via PIV at 80cc/kg. BM20 tol via ngt at\n70cc/kg. Min asp. No spits. Voiding. Trace stool. +bs. A/P:\nCont to monitor wt, abd, and tol of feeds. Cont to advance\nfeeds as tol.\n\n4. O: Mom called X1. Mom asking appropriate questions. Rn\nupdated Mom. A/P: Cont to educate and support.\n\n5. O: Temp stable nested in isolette. and active with\ncares. Irritable with cares. Rests well inbewteen cares.\nA/P: Cont to cluster cares. Cont to monitor temp.\n\n6. O: Under double phototherapy. Eye shields on. TF\n150cc/kg. Voiding and stooling. Bili to be sent. A/P: Cont\nto monitor bili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-10 00:00:00.000",
"description": "Report",
"row_id": 1736484,
"text": "Neonatology Fellow PN\nPE: Gen- , awake in isolette\nHEENT- AF S/F, mmm\nResp- CTAB with mild retractions\nCV- RRR without murmur, normal pulses\nAbd- soft, NT/ND with active BSno loops\nSkin- Jaundice to abd under lights\n\nPlan: Cont to advance feeds as tolerated, obs for spells. Cont phototx\nHUS today\nTx to when ready\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-10 00:00:00.000",
"description": "Report",
"row_id": 1736485,
"text": "Neonatology\nDoing well. Intermittent desats. On caffeine.. Comfortable apeparing. Will wean from O2 low flow cannula this am\n\nWt 1335 down 10. Tolerating feeds at 70 cc/k/d out of TF 150 cc/k/d of 20 cal. Abdomen benign.\n\nBili in 9 range. Under photorx. Will follow.\n\n this am unremarkable.\n\nCOntinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-08 00:00:00.000",
"description": "Report",
"row_id": 1736478,
"text": "NPN\n\n\n2.Infant currently in NC FiO2 100%, 100cc flow. Sats mainly\nin mid 90's, see flow sheet for sats and VS. At this time\ninfant had 2 episodes of brief drop in sats to 70's with\ncolor change requiring mild stim but no increase in 02 flow.\nBBS cl +=. No murmur. Caffeine given IV this am d/t NPO\nstatus at that time.\nCont to monitor closely.\n3. Received NPO. At 0900, 0.6cc residual green bilious\nsecretions obtained. Abd soft, benign. A/G stable at 20cm.\nRestarted feeds at 1230 pm @30cc/kg. Parents aware of plan.\nPIV @ 120cc/kg/day currently D10W w/ NaCl until PN delivered\nfrom pharmacy. PN to go up this afternoon. Voiding qs. See\nflow sheet. Stool trace amts x2, liquid, unable to guaiac.\nCont to monitor feeding tol closely. Report any bilious\nresidual, inc abd girth etc. to TEAM for further eval.\nParents in for feeding at 1230. Discussed infant's residuals\nand plan. Discussed NICU protocol and preemie issues with\nrespect to feeding tolerance. Mom slightly in\ndiscussing infant. Reassured and support given. Dad\nsupportive. verbalized understanding of info given.\nWill return this eve. Dad gave kangaroo care x60min. Infant\ntol well. Mom pumping successfully. Reviewed storage rules\netc.\nInvolved parents. cont to support.\nInfant irritable at times. Nested on sheepskin. Prefers abd.\nOnly sucks on pacifier briefly to settle d/t hx. of apneic\nepisodes with sucking. Temp slightly unstable d/t\nenvironmental factors. On servo probe.\n6. Cont under double phototherapy lights. Labs ordered for\ntomorrow am. Mask secure.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-09 00:00:00.000",
"description": "Report",
"row_id": 1736479,
"text": "NPN Nights\n\n\n2. O: Received in NC 100% 100cc flow. RR 20-50's. Mild I/S\nretractions. 1 desat to 60's with apnea. Ls clear. A/P: Cont\nto monitor resp status.\n\n3. O: Wt 1345gms, up 15. TF 150cc/kg. Currently, PN D10 +Il\ninfusing well via PIV at 120cc/kg. BM20 tol well via ngt at\n30cc/kg. No spits. UO 4.6cc/kg yesterday. Transitional stool\nG-. AG 20cm. No spits. MIn asp. A/P: Cont to monitor wt,\nabd, and tol of feeds.\n\n4. O: Mom and Dad in at . MOm independent with cares.\nBoth parents asking appropriate questions. Rn updated\nparents. A/P: Cont to educate and support.\n\n5. O: Temp stable nested in servo isolette. Irritable with\ncares. MAE. A/P: Cont to monitor temp. Cont to cluster\ncares.\n\n6. O: UNder double phototherapy. Eye shields on. TF\n150cc/kg. Voiding and stooling. Bili obtained (see labs)A/P:\nCont to monitor bili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-09 00:00:00.000",
"description": "Report",
"row_id": 1736480,
"text": "Attending Note\nPhysical Exam\ngen well appearing slightly jaundiced\nlungs clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds no masses or distention\nExt warm well perfused with brisk cap refill\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-09 00:00:00.000",
"description": "Report",
"row_id": 1736481,
"text": "Attending Note\nDay of life 6 CGA 32 0/7\nin nasal cannula 100 cc of 100%\nRR 30-50 on caffeine sat 95-100%\nHR 160-170's BP 72/49 mean 58\nBili 12.5/0.4 on double photo\nNa 131 K 5.9 Cl 99 CO2 17\ngrams 1345 up 15 on 150 cc/kg/day pg adv 10 cc/kg/day eneral at 30 cc/kg/day BM 20 cal/oz\nsoft abdomen no loops\nUO 4.6 cc/kg/hr and large mec stool\nin isolette\n\nImp-stable\nwill wean nasal cannula as tolerated\nwill advance enteral 20 cc/kg/day\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-03 00:00:00.000",
"description": "Report",
"row_id": 1736448,
"text": "Neonatology Attending Admission Note\n\nInfant is a 31 week, 1520 gm female newborn who was admitted to the NICU for management of prematurity.\n\nInfant was born to a 24 y.o. G1P0 to 1 mother. Serologies: A+, antibody unknown, HepBsAg negative, RPR NR, RI. GBS screening unknown. Pregnancy uncomplicated until onset of preterm labor on . Mother was admitted to at that time. Mother given magnesium sulfate, ampicillin, and betamethasone (complete ). On admission, BPP , EFW 1395, and normal AFI. This evening with progressive preterm labor.\n\nSepsis risk factor review: prematurity, GBS unknown, no maternal fever, no prolonged rupture of membranes.\n\nMaternal anesthesia of Nubain at 1 hour prior to delivery. Vaginal delivery. Apgars 9,9. Infant shown to parents and then transported to NICU for continued care.\n\nPhysical Exam:\nWt 1520 gms = > 50%; L 41 cm = 50%; HC 27.5 cm = 25%\nVS per CareView\ncomplete exam noted on newborn examination form. Briefly, a preterm infant in moderate respiratory distress with retractions and fair aeration. Rest of exam as expected for gestational age.\n\nImpression:\n1. AGA preterm female\n2. Respiratory distress - at risk for RDS\n3. r/o sepsis - need to consider given resp symptoms, prematurity, and unknownn GBS status\n\nPlan:\n-- given current respiratory distress will start on CPAP. need to consider ventilation and surfactant delivery. Check CXR and monitor O2 sats and blood gases.\n-- monitor for the development of apnea of prematurity given age and recent nubain for maternal anesthesia\n-- monitor BPs with volume and vasopressors as needed\n-- NPO\n-- maintenance IVFs at 80 cc/k/day, D10w\n-- check CBC w diff and blood cx, begin broad spectrum of ampicillin and gentamicin with duration pending lab results and clinical course\n-- usual metabolic monitoring of lytes and bilirubin levels\n\nWill keep family updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736449,
"text": "1 Infant with Potential Sepsis\n2 Alt in Resp Status\n3 Alt In FEN\n4 Alt in Parent\n5 Alt in Dev\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Alt in Resp Status; added\n Start date: \n 3 Alt In FEN; added\n Start date: \n 4 Alt in Parent; added\n Start date: \n 5 Alt in Dev; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-04 00:00:00.000",
"description": "Report",
"row_id": 1736450,
"text": "Nsg Adm Note\n adm to NIC for prematurity. born at 31 1/7 weeks. Mom had PTL on . Mom adm and received Ampicillin, Mag Sulfate, and betamethasone. born with apgar 9and 9. Received BBO2 and dried and stim in DR. adm to NICU and placed on NPCPAP . CXR done and showed lungs overinflated. CPAp removed and placed in RA. Initial Dstick 54. Temp 99.1R. CBC,diff, BC sent. IV placed in L hand.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-07 00:00:00.000",
"description": "Report",
"row_id": 1736475,
"text": "Nursing Progress Notes.\n\n\n#2 O: remained in room air until 1900 when she was\nplaced in Nasal cannula oxygen 100%, 200cc flow for spells.\n has had 12 spells between 1000 and 1900, most needing\nmild stim, 1 needing bag and mask assistance. Breath sounds\nclear and equal, mild retractions. A: Increased spells\ntoday even on caffeine. P: Continue to monitor and provide\nsupport as required.\n#3 O: Total fluids increased to 150cc/kg/day. was on\nfeeds of 60cc/kg/day of BM20 until noon. She is now NPO for\nbilious aspirates, (1-2cc) and a bilious spit. Abdomen is\nsoft, intermittant, soft loops noted, non tender. Voiding\nwell and passing meconium. IV fluids of D10PN and IL\ninfusing well via peripheral IV. IV resited in right foot\nthis am. D/stix 72. KUB done. A: NPO now. P: Continue NPO\ntonight and reassess in AM.\n#4 O: Parents in to visit and hold this morning and\nstayed for the day. out to kangaroo with mother this\nmorning. Parents updated by fellow about sepsis evaluation\nand KUB. A: Involved family. P: Continue to keep informed.\n\n#5 O: warm at times due to phototherapy spot lights,\nlights adjusted accordingly and isolette weaned. \nremains and very active. A: Appropriate for age. P:\nContinue to support development.\n#6 O: continues under double phototherapy. eyes clean\nand covered. A: Bili remains elevated. P: Continue\nphototherapy. Check bili on Sunday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-08 00:00:00.000",
"description": "Report",
"row_id": 1736476,
"text": "NPN NIGHTS\n\n\n2. O: Received pt in NC 100% 25cc. pt apneic and having\ndesats to 60's. Flow increased to 100cc. No more desats. Ls\nclear and slightly diminished. A/P: Cont to monitor resp\nstatus.\n\n3. O: Wt 1330gms, down 15. Tf 150cc/kg of Pn D10 +Il\ninfusing well via pIV. NPO. No spits or asp. UO 1.9cc/hr\nyesterday. NO stool. +bs. AG 21cm. A/P: Cont to mointor wt,\nabd, and I&O's.\n\n4. No contact thus far this shift from parents.\n\n5. O: Temp stable nested in servo isolette. Irritable with\ncares. Rests well inbetween cares. A/P: Cont to monitor\ntemp. Cont to cluster cares.\n\n6. O: Under double photo. Eye shields on. TF 150cc/kg.\nVoiding. No stool. A: Hyperbili. P: Cont to monitor bili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-08 00:00:00.000",
"description": "Report",
"row_id": 1736477,
"text": "Newborn Med Attending\n\nDOL#5. Cont in low flow O2 per NC. Occ desats, on caffeine. AF flat, clear BS, no murmur, abd soft, MAE. WT=1330 down 15, on 150 cc/kg/d PN/IL due to bilious aspirate yest. KUB nl. Bili=11.5, on photoherapy.\nA/P: Infant with low level concerns for NEC or obstructive process, but no evidenc by exam or KUB. Consider re-starting feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-07 00:00:00.000",
"description": "Report",
"row_id": 1736470,
"text": "NPN\n\n\n#2 remains in rm air. RR 40-60, LS clear and equal. She\nhas had 2 desats this shift with apnea and color change. A:\ncont with desats P: cont to monitor\n#3 TF cont at 130cc/k/d. Currently is getting 60cc/k/d\nBM and 70cc/k/d PN10/IL via PIV. Abd soft, +BS, vdg/stlg qs,\nno loops or distention. She had one asp of 3.2cc otherwise,\nmin asp. Wt 1345 down 17 grams. A: tol feeds thusfar P: no\nchange at present\n#4 dad called early in shift. asking how was, this is\ntheir first night home since delivery. Parents plan to visit\ntomorrow. A: involved family P: cont to support.\n#5 temp stable in servo isolette. sucks some on pacifier,\ncalm with cares, sleeps between feeds. A: AGA P: cont to\nsupport development\n#6 remains under double phototherapy, with eyes covered.\ncolor cont ruddy/jaundice. bili pnd A: hyper bili P: cont\nphototherapy ? to single lights if bili lower.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-07 00:00:00.000",
"description": "Report",
"row_id": 1736471,
"text": "Neonatology\nParents interested in transfer to .\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-07 00:00:00.000",
"description": "Report",
"row_id": 1736472,
"text": "Neonatology\nDoing well. REmains in RA. Intermittent spells on acffeine.\nComfortable apeparing.\n\nWt 1345 down 17. Tolerating efeds at 130 cc/k/d of feeds at 60. Will increase TF to 150 cc/k/d and continue feed advancement.\nLytes in good range.\n\nBili in 11 range. Under photorx. Will continue to follow.\n\nContineu as at present.\n\n for next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-07 00:00:00.000",
"description": "Report",
"row_id": 1736473,
"text": "Neonatology Fellow PN\nPE: Gen- , comfortable in isolette\nHEENT- AF s/f, ruddy, jaundice\nResp- CTAB with mild retractions\nCV- RRR without murmur, normal pulses\nAbd- soft, NT/ND with active BS\nSkin-jaundice to thigh\n\nPlan:\n1. increase TF to 150 cc/kg/d, increase feeds to 80 cc/kg/d\n2. Cont phototx, bili, lytes in 2 days\n3. Follow resp status\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-07 00:00:00.000",
"description": "Report",
"row_id": 1736474,
"text": "Nursing Progress Notes.\nAddendum\nCBC and blood culture sent due to increase in spells and bilious spit and aspirates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2164-09-05 00:00:00.000",
"description": "Report",
"row_id": 1736464,
"text": "Nursing Progress Notes\n\n\n#1 O: 48 hour rule out sepsis complete. Cultures remain\nnegative to date. Antibiotics discontinues after noon dose.\n A: Cultures negative. P: Problem resolved.\n#2 O: Breath sounds clear and equal, mild retractions, 1\nspell required mild stim. A; Occasional spells. P:\nContinue to monitor and provide support as required.\n#3 O: Total fluids increased to 110cc/kg/day. Feeds of BM20\nto advance to 30cc/kg/day at 1600 feeding. Feeds given every\n4 hours over 15 min. No spits or large aspirates. Abdomen\nsoft, bowel sounds active, no loops, girth stable. Voiding\n4cc/kg/hr, no stool passed yet. IV fluids of D10PN infusing\nwell via peripheral IV. D/stix stable. A: Tolerating\nsmall feeds. P: Advance feeds 10cc/kg/ as tolerated.\n#4 O: Parents up to visit and hold this afternoon.\nFather took 's temp and changed . Mother held .\n A: Involved family. P: Continue to keep informed.\n#5 O: Temp stable in isolette on servo. is and\nactive with cares and slept well between cares. \ntolerated kangaroo care well. A; Appropriate for age. P:\nContinue to support development.\n#6 O: Placed under double phototherapy at 0700. Eyes clear\nand covered. A; Increasing bili. P: Check bili in am.\n\n\n"
}
] |
8,070 | 121,121 | Hypotension. The patient was admitted to the MICU for evaluation of hypotension. He was started on aggressive fluid resuscitation and dopamine drip for blood pressure management. Dopamine was eventually weaned off on the day following admission. stim test to evaluate for renal insufficiency was within normal limits. Due to concern for sepsis, the patient was started on antibiotics, although there was no evidence for an infection. White blood count was not elevated. The patient remained afebrile throughout the remainder of the hospitalization. Nitrate was within normal limits. Chest x-ray was clear. UA was negative. All blood and urine cultures were no growth today. Because of the very low suspicion for sepsis, all antibiotics were stopped on hospital day 3. With aggressive IV fluids, because the patient's blood pressure eventually improved back to baseline. At the time of discharge, the patient's outpatient blood pressure medications including lisinopril and metoprolol had not been started. The patient was advised to not take these medications until he was seen by his primary care physician as an outpatient in one to two weeks. Anemia. The patient was admitted with hematocrit of 26.9 from his baseline of 40. He was transfused four units on admission and his hematocrits stabilized at 33. Stools were guaiac negative and iron studies showed normal iron and low TIBC. Abdominal CT scan showed no leak or rupture of the abdominal aortic aneurysm and there was no retroperitoneal bleed. Hemolysis abs were negative. There was no evidence for DIC. Folate was within normal limits. B12 was found to be low and he was started on B12 supplements. Supplementation was initially through IM, but it was eventually switched to p.o. as an outpatient. It is believed that his vitamin B12 deficiency is due to the removal of his terminal ileum to make the neobladder. Now its concern that the patient may not be able to adequately absorb the p.o. vitamin B12, but his primary care physician will decide as an outpatient if he should be started vitamin B12 IM injections instead. The patient's hematocrit was stable at 33 at the time of discharge. Nonanion gap metabolic acidosis. The patient's ABG on admission was 7.14, 22, 138, and 8. Urine anion gap was positive. Acidosis improved with bicarbonate drip and volume resuscitation. Following discussion with urology, it was determined that neobladder obstruction was an important cause for his non anion gap metabolic acidosis. The mucosa of the ilium has a tendency to excrete bicarbonate. Since the patient neobladder had been obstructed for some time prior to presentation, the patient was likely excreting large amounts of bicarbonate into his urine. With the bicarbonate drip and fluid resuscitation, his bicarbonate improved closer to baseline. At the time of discharge, the patient's bicarbonate was 18. The patient's acidosis resolved slowly throughout the course of hospitalization. Acute renal failure. The patient was found to be in acute renal failure on hospital admission with creatinine of 2.3 from his baseline of 0.9. Renal ultrasound showed bilateral hydronephrosis, which immediately resolved following flushing of the Foley and removal of the mucous blood obstructing the neobladder outlets. The patient was also hydrated for hypotension, which may have led to some acute tubular necrosis in addition to obstructive renal failure. At the time of discharge, the patient's creatinine was 1.2. The patient was encouraged to drink plenty of fluids to maintain good oral hydration. Spinal stenosis. The patient had complaint of neck pain for several weeks prior to presentation. Due to concern for possible osteomyelitis or discitis as the source of infection leading to hypotension, a MRI without contrast was obtained. There was no evidence for osteomyelitis or discitis. However, he was found to have a severe cervical spine stenosis at several levels with cord impression. The C3-4 level showed moderate sized antral disc protrusion with spinal stenosis and compression of the spinal cord in C3 nerve roots. C4 side has mild disc bulge with mild compression of spinal cord and C4 nerve roots. C5-6 showed mild disc bulge with mild compression of the spinal cord and C5 nerve roots. C6-7 showed mild disc bulge with no evidence of compression. Neurosurgery was consulted regarding these findings. They felt that the spinal cord compression was not a neurosurgical emergency. They did not feel that steroids were indicated in this situation. Neurosurgery recommended a followup with Dr. as an outpatient. Neurological exam was nonfocal and the patient did not have any numbness, weakness, tingling, or incontinence. The patient was given a soft, cervical neck collar to wear at all times, except when he is sleeping. | creat trending down to 1.1 this am.Skin: dry but intact.Access: # 16 Right fa and #20 left fa.ID: afebrile, tmax 99.5. Pt voids normal however a foley was placed in EW. At the C6/7 level, a mild central disc protrusion is present, which mildly narrows the central canal, without compresison on the spinal cord. Left atrial abnormality.First degree A-V block. asymptomatic, EKG obtained, MD notified, evaluated pt. Overnoc he required a one time irrigation of 60cc sterile h2o with effect. Sinus rhythm with 1st degree A-V blockGeneralized low QRS voltagesSince previous tracing, low voltage is new Sinus rhythmPremature ventricular contractionsFirst degree A-V blockGeneralized low QRS voltagesSince last ECG, no significant change Pericardial effusionand/or hyerthyroidism is in the differential. Did have a brief episode of rigors resolved with warming pt up.CV: hct 26. pt transfused with 2 units PRBC's, no transfusion reaction noted. Trace edema in upper extrem.RESP: ls clear on RA.GI: Reg diet. Both neural foramina are norrowed and there appears to be mild compression upon both C5 nerve root sleeves. INDICATION: Anuric renal failuire. Otherwise, the bilateral hydronephrosis resolved. Nsg progress note 7p-7aPt had an uneventful noc.Neuro: A+O X3, c/o HA after MRI, medicated with tylenol 650mg po with effect. CTA OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: As before, there is a 3.6 x 4.3 cm infrarenal abdominal aortic aneurysm with evidence of mural thrombus formation. There is evidence of an ileal loop diversion of the right ureter. MRA OF THE CAROTID AND VERTEBRAL ARTERIES: There are mild atherosclerotic changes within the right internal carotid artery after the bifurcation. Repleted K & Ca K3.1 & Ionized Ca 1.08.Pt. Ph in EW 7.15.Arrived to MICU A+O X3, denied pain or SOB. Taking in adequate po's.GU: foley to gravity. Mg repleted overnoc, am Mg+ 2.6. Irrigated x1.Skin: intact.Heme: hct stable @ 33.3 this am. Of note pt had an abd CT whcih showed a known 4mm AAA, not leaking.Full code. Additionally, endplate signal anbormalities consistent with degenerative changes are noted at the C3/4, C5/6 levels. Sinus rhythm, rate 62 with occasional sinus pause. Delayed images through the abdomen and pelvis were subsequently obtained. some contamination from IVF's infusing distal to venipuncture. Lactate 1.0 Bun and creat 66/2.3. Pt states normal BM yesterday.GU: Pt with hx bladder ca of which he had an ileo-neobladder placed. Abd soft, + BS, + flatus. Am ph 7.38 via VBG. There remains mild dilatation of the upper pole of the left kidney. Both neural foramina are slightly narrowed without evidence of compression upon the nerve root sleeves. TECHNIQUE: Sagittal T1 & T2W images of the cervical spine were obtained, along with axial T1 & T2W images from the C3/4 through C7/T1 interspace without IV contrast. Note is made of non-obstructing left renal calculus seen in non-contrast study. There is narrowing of both neural foramina with mild compression upon both C6 nerve roots sleeves. A & O X3, +MAE, +PERRLA, obeying commands, intact gag & cough reflex.Resp: LS clear, diminished @ bases, nonproductive cough noted, denies SOB. ( of note he received 6100cc of fluid in EW) and had 2liters out). SBP in EW 60-70's, asymptomatic. clear yellow urine noted.Endo: Started on figner sticks QID, not requiring coverage per scale.ID: Afebrile, Levo changed to PO, remains on IV Vanco, Flagyl.Cortisol stem test performed per orders, dexamethasone & Cocyntropin given X1. Urinalysis sent this am. (Over) 12:21 AM MR CERVICAL SPINE Clip # Reason: assess for abscess Admitting Diagnosis: ACUTE RENAL FAILURE;TELEMETRY FINAL REPORT (Cont) Signal intensity of the spinal cord is normal. Abd soft, + BS. Pelvic loops of bowel are otherwise unremarkable. Celiac axis, SMA, and are patent. CT OF THE ABDOMEN WITH IV CONTRAST: There is a stable appearing tiny low attenuation focus within the right lobe of the liver laterally which is too small to characterize but which most likely represents a tiny cyst. The right CP angle is cut off from the image. There are slightly prominant pulmonry markings at the lung bases bilaterally. There is narrowing of both neural foramina with mild compression upon both C4 nerve root sleeves. Arrived to MICU on Dopamine 5mcg/kg/min and have since been able to titrate down to 2.5mcg with subsequent fluid replacement of D5W with 3amps bicarb. MR OF THE C-SPINE WITHOUT IV CONTRAST: The alignment of the component vertebrae is within normal limits without evidence of listhesis. +PP, +CSM.GI/GU: Abd. nsg progress note 7p-7aPt admitted from EW . Pan cx's in EW, pending. Foley patent, lrg. The urinary bladder appears grossly normal. IMPRESSION: Obstructed foley catheter. EKG today. transfused with 2 u PRBS, for Hct 25.1, post transfusion Hct 33. K+ also low @ 3.1 and glucose 400's, both repeat pending. (Over) 11:31 AM CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # Reason: eval for AAA Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) Occasional ventricular premature beat. CHEST, AP: The heart size, mediastinal and hilar contours are unremarkable. Left-sided earlyrepolarization. REASON FOR THIS EXAMINATION: r/o obstruction WET READ: AZm TUE 7:17 PM No stones, masses or hydronephrosis. | 11 | [
{
"category": "Radiology",
"chartdate": "2102-05-23 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 827749,
"text": " 2:20 PM\n RENAL U.S. PORT Clip # \n Reason: PT WITH ACUTE RENAL FAILURE, ANURIA, H/O BLADDER CANCER AND PROSTACYSTECOTMY AND NEOBLADDER, R/O OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with acute renal failure, anuria, h/o bladder cancer and\n prostacsytectomy and neo-bladder.\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n WET READ: AZm TUE 7:17 PM\n No stones, masses or hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Anuric renal failuire.\n\n RENAL ULTRASOUND: The right kidney measures 11.5 cm. The left kidney measures\n 11.4 cm. There is mild hydronephrosis in the right kidney and moderate hydro-\n nephrosis in the left kidney. The urinary bladder is distended. There are no\n stones or masses present.\n\n After the Foley catheter was flushed the obstruction was removed and the\n urinary baldder collapsed to normal size. There remains mild dilatation of the\n upper pole of the left kidney. Otherwise, the bilateral hydronephrosis\n resolved.\n\n IMPRESSION: Obstructed foley catheter.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-05-24 00:00:00.000",
"description": "Report",
"row_id": 1369676,
"text": "nsg progress note 7p-7a\nPt admitted from EW . Pt had presented to PCP's office with generalized complaints of \"not feeling himself\" for over 1.5 Months. Pt c/o of some neck pain but otherwise no C.P, SOB. He has stated that since his hernia repair ~ 1.5 months ago that he's had a decrease in appetite and has lost 15-20 lbs. C/o always being cold and unable to work a full day. SBP in EW 60-70's, asymptomatic. + rigors, afebrile. Lactate 1.0 Bun and creat 66/2.3. K+ 6.6 of which was tx'd with insulin, kaexelate and D50. Ph in EW 7.15.\n\nArrived to MICU A+O X3, denied pain or SOB. Did have a brief episode of rigors resolved with warming pt up.\n\nCV: hct 26. pt transfused with 2 units PRBC's, no transfusion reaction noted. Arrived to MICU on Dopamine 5mcg/kg/min and have since been able to titrate down to 2.5mcg with subsequent fluid replacement of D5W with 3amps bicarb. Pt currently receiving his second liter of such fluid. ( of note he received 6100cc of fluid in EW) and had 2liters out). Pt NSR with occ PVC, SBP 80's-120 MAPs 60-65. This am his HR is more bradycardic and had one episode of brady to 38 while pt was sleeping. Currently HR 58-66 while awake. Repeat HCT this am 25.1 however another repeat was sent since ? some contamination from IVF's infusing distal to venipuncture. K+ also low @ 3.1 and glucose 400's, both repeat pending. Fingerstick 195, team aware of all labs and are waiting to treat once repeat results. Pt to be written for sliding scale insulin coverage. Pt is not a known diabetic. Mg repleted overnoc, am Mg+ 2.6. Pedal pulses 3+, no edema.\n\nRESP: pt on RA sats 99%. ph in EW 7.14 and has been trending up over course of noc. See careview. Am ph 7.38 via VBG. LS clear t/o, cxr neg in EW.\n\nGI: clear liquid diet, tolerated well. Abd soft, + BS. No stool, + flatus. Pt states normal BM yesterday.\n\nGU: Pt with hx bladder ca of which he had an ileo-neobladder placed. Pt voids normal however a foley was placed in EW. Pt states a tendency to clog d/t high mucous in bowel. Pt self caths at home. Overnoc he required a one time irrigation of 60cc sterile h2o with effect. U/o > 200cc/hr, light yellow urine. Urinalysis sent this am. Pt has order to irrigate if u/o drops. creat trending down to 1.1 this am.\n\nSkin: dry but intact.\nAccess: # 16 Right fa and #20 left fa.\nID: afebrile, tmax 99.5. Pan cx's in EW, pending. WBC's WNL's. On prophylaxis Levo, vanco, and flagyl.\nPlan: F/u repeat am labs and replete K+ if needed also f/u glucose and hct. Pt being typed and crossed for more PRBC's if needed. Plan to place aline for labs and Bp monitoring since pt likely to stay on pressors. Start LR for IVF replacement as pt is responding to IVB's. Pt may also get a central line if continued need for pressors. EKG today. To go to MRI for cervial spine and MRA of neck. Of note pt had an abd CT whcih showed a known 4mm AAA, not leaking.\nFull code. WIfe and daughter in to visit last night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-05-24 00:00:00.000",
"description": "Report",
"row_id": 1369677,
"text": "Neuro intact, pt. A & O X3, +MAE, +PERRLA, obeying commands, intact gag & cough reflex.\nResp: LS clear, diminished @ bases, nonproductive cough noted, denies SOB. ABGs wnl.\nCV: Pt. denies CP or discomfort. HR 40s-70s, SR/SB freq. PVC, 1st. degree block. At 1730 HR droped to 40s, pt. asymptomatic, EKG obtained, MD notified, evaluated pt. BP 90s-130s/50s-60s, Dopa gtt stoped @ noon. Pt. transfused with 2 u PRBS, for Hct 25.1, post transfusion Hct 33. +PP, +CSM.\nGI/GU: Abd. soft, nondistended, +BS, no BM. Diet advanced to house, good appetite. Foley patent, lrg. amt. clear yellow urine noted.\nEndo: Started on figner sticks QID, not requiring coverage per scale.\nID: Afebrile, Levo changed to PO, remains on IV Vanco, Flagyl.\nCortisol stem test performed per orders, dexamethasone & Cocyntropin given X1. Repleted K & Ca K3.1 & Ionized Ca 1.08.\nPt. called out to floor on tele. Awaiting for MRI this eve.\nFamily called, updated on plan of care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2102-05-25 00:00:00.000",
"description": "Report",
"row_id": 1369678,
"text": "Nsg progress note 7p-7a\nPt had an uneventful noc.\nNeuro: A+O X3, c/o HA after MRI, medicated with tylenol 650mg po with effect. Ambien 5mg given for sleep with effect and xanax 0.5mg given prior to MRI.\n\nCV: NSR 1st degree av block and SB 48-60's, occ PVC. BP stable mostly SBP 120's while awke 90's while sleeping. 3+ pedal pulses. Trace edema in upper extrem.\n\nRESP: ls clear on RA.\nGI: Reg diet. Abd soft, + BS, + flatus. No stool. Taking in adequate po's.\n\nGU: foley to gravity. Output 40-80cc/hr, light yellow. Irrigated x1.\nSkin: intact.\nHeme: hct stable @ 33.3 this am. Electrolytes pending.\nPt went to MRI overnoc for cervical spine views and MRA. Report pending.\nID: Afebrile, WBC\"s wnl's. Cont on Vanco, flagyl and levofloxacin.\nPt called out to the floor awaiting bed. Transfer note complete. Full code. WIfe and daughter in to visit, updated on progress and plan of care.\n"
},
{
"category": "Radiology",
"chartdate": "2102-05-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 827724,
"text": " 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with rigors and hypotension\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Rigors and hypertension, evaluate for pneumonia.\n\n CHEST, AP: The heart size, mediastinal and hilar contours are unremarkable.\n There are slightly prominant pulmonry markings at the lung bases bilaterally.\n There is no pleural effusion on the left side. The right CP angle is cut off\n from the image. The surrounding soft tissue and osseous structures are\n unremarkable.\n\n IMPRESSION: Mildly prominent pulmonary markings at the bases. Follow up is\n recommended. The right costophrenic angle is not visualized and hence a\n scar and/or fluid in that region cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-05-23 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 827721,
"text": " 11:31 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: eval for AAA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with hypotension and ?pulsatile mass\n REASON FOR THIS EXAMINATION:\n eval for AAA\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CCqc TUE 11:55 AM\n stable AAA without leak\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 58 year old male with a history of an abdominal aortic\n aneurysm referred for evaluation of hypotension.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases through\n the aortic bifurcation prior to and following the administration of 150cc of\n Optiray. Non-ionic contrast was used due to the rapid bolus infusion required.\n Delayed images through the abdomen and pelvis were subsequently obtained.\n Multiplanar reformatted images were included.\n\n CTA OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: As before, there is a 3.6 x\n 4.3 cm infrarenal abdominal aortic aneurysm with evidence of mural thrombus\n formation. There is no evidence of rupture or leak. Celiac axis, SMA, and \n are patent. The iliac arteries are not involved. Both renal arteries are well\n visualized above the level of the aneurysm.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a stable appearing tiny low\n attenuation focus within the right lobe of the liver laterally which is too\n small to characterize but which most likely represents a tiny cyst. The\n gallbladder, spleen, pancreas, kidneys, and adrenal glands are normal. Note is\n made of non-obstructing left renal calculus seen in non-contrast study.\n Stomach and visualized loops of small and large bowel are unremarkable. No\n pathologically enlarged mesenteric or retroperitoneal lymph nodes are\n identified. There is no free fluid or air.\n\n CT OF THE PELVIS WITH IV CONTRAST: The patient has undergone retroperitoneal\n lymph node dissection and prostatectomy. The urinary bladder appears grossly\n normal. There is evidence of an ileal loop diversion of the right ureter.\n Pelvic loops of bowel are otherwise unremarkable. There is no free fluid.\n\n Bone windows: No suspicious lytic or blastic lesions are identified.\n\n CT RECONSTRUCTIONS: Multiplanar reformatted images were reviewed and confirm\n the above findings.\n\n IMPRESSION: Stable appearance of infrarenal AAA without evidence of leak or\n rupture.\n (Over)\n\n 11:31 AM\n CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # \n Reason: eval for AAA\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-05-25 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 827926,
"text": " 12:21 AM\n MR CERVICAL SPINE Clip # \n Reason: assess for abscess\n Admitting Diagnosis: ACUTE RENAL FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with infection, acidosis, recent surgery, and sevre neck pain.\n REASON FOR THIS EXAMINATION:\n assess for abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infection, acidosis, recent surgery, and severe neck pain.\n\n COMPARISON: None.\n\n TECHNIQUE: Sagittal T1 & T2W images of the cervical spine were obtained,\n along with axial T1 & T2W images from the C3/4 through C7/T1 interspace\n without IV contrast.\n\n MR OF THE C-SPINE WITHOUT IV CONTRAST:\n\n The alignment of the component vertebrae is within normal limits without\n evidence of listhesis. There is loss of intervertebral disc height at all\n cervical levels with evidence of disc desiccation. Additionally, endplate\n signal anbormalities consistent with degenerative changes are noted at the\n C3/4, C5/6 levels. There are no signal abnormalities within the discs or\n vertebral bodies to suggest osteomyelitis or discitis. The patient is noted\n to have congenitally shortened pedicles throughout all of the cervical\n vertebral levels.\n\n At the C3/4 level, there is a moderate-size central disc protrusion present\n causing severe spinal stenosis and compression of the spinal cord. There is\n narrowing of both neural foramina with mild compression upon both C4 nerve\n root sleeves.\n\n At the C4/5 level, there is a mild disc protrusion present, which causes\n moderate spinal stenosis and compression of the spinal cord. Both neural\n foramina are norrowed and there appears to be mild compression upon both C5\n nerve root sleeves.\n\n At the C5/6 level, there is a mild disc protrusion present causing moderate\n moderate spinal stenosis and mild compression upon the spinal cord. There is\n narrowing of both neural foramina with mild compression upon both C6 nerve\n roots sleeves.\n\n At the C6/7 level, a mild central disc protrusion is present, which mildly\n narrows the central canal, without compresison on the spinal cord. Both\n neural foramina are slightly narrowed without evidence of compression upon the\n nerve root sleeves.\n\n At the T1/2 level, there is no evidence of central canal stenosis, neural\n foraminal narrowing.\n\n (Over)\n\n 12:21 AM\n MR CERVICAL SPINE Clip # \n Reason: assess for abscess\n Admitting Diagnosis: ACUTE RENAL FAILURE;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Signal intensity of the spinal cord is normal. The foramen magnum and its\n contents are normal. No paraspinal abnormalities are identified.\n\n IMPRESSION: Severe degenerative changes within the cervical spine causing\n spinal stenosis and cord compression, most marked at the C3/4 level, with\n congenital spinal stenosis as well. IV contrast was not administered during\n the exam; however, there are no signal abnormalities within the discs or\n vertebrae to suggest the presence of osteomyelitis or discitis. We discussed\n these findings with Dr. at 11:30 on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2102-05-25 00:00:00.000",
"description": "MRA CAROTID/VERTEBRAL W/O CONTRAST",
"row_id": 827927,
"text": " 12:22 AM\n MRA CAROTID/VERTEBRAL W/O CONTRAST Clip # \n Reason: assess artery flow in neck, symptomatic on neck flexion, lig\n Admitting Diagnosis: ACUTE RENAL FAILURE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old man with\n REASON FOR THIS EXAMINATION:\n assess artery flow in neck, symptomatic on neck flexion, lightheadedness and\n dizziness\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Symptomatic light headedness and dizziness on neck flexion.\n\n COMPARISON: None.\n\n TECHNIQUE: 3D and 2D TOF imaging was performed of the arteries of the neck.\n Multiplanar reconstructions were obtained.\n\n MRA OF THE CAROTID AND VERTEBRAL ARTERIES: There are mild atherosclerotic\n changes within the right internal carotid artery after the bifurcation. There\n is probably not hemodynamically significant narrowing fo the vessel, but it is\n mildly narrowed at this level. No other abnormalities are identified within\n the carotids bilaterally. The vertebral artery flow is continuous throughout\n without evidence of abnormalities. No other abnormalities are identified\n within the neck.\n\n IMPRESSION: Mild atherosclerotic disease within the right internal carotid\n artery. No detectable abnormality of vertebral arterial flow.\n\n"
},
{
"category": "ECG",
"chartdate": "2102-05-24 00:00:00.000",
"description": "Report",
"row_id": 111997,
"text": "Sinus rhythm\nPremature ventricular contractions\nFirst degree A-V block\nGeneralized low QRS voltages\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2102-05-23 00:00:00.000",
"description": "Report",
"row_id": 111998,
"text": "Sinus rhythm with 1st degree A-V block\nGeneralized low QRS voltages\nSince previous tracing, low voltage is new\n\n"
},
{
"category": "ECG",
"chartdate": "2102-05-24 00:00:00.000",
"description": "Report",
"row_id": 111996,
"text": "Sinus rhythm, rate 62 with occasional sinus pause. Left atrial abnormality.\nFirst degree A-V block. Generalized low voltage. Left-sided early\nrepolarization. Occasional ventricular premature beat. Pericardial effusion\nand/or hyerthyroidism is in the differential. Compared to the previous tracing\nof no significant change.\n\n"
}
] |
2,196 | 125,458 | The patient was admitted to the surgical Intensive Care Unit for monitoring and rule out for subarachnoid hemorrhage. She had a CAT scan that showed no obvious subarachnoid blood, however, there was effacement of the frontal and anterior temporal and sulci on the right side. She was admitted for observation. She had a CTA and MRA and MRI which showed no evidence of aneurysm or AVM. She had a conventional angiogram which was also negative for any aneurysm or artery or venous malformation. She was transferred to the regular floor. She was monitored and treated with pain medication for her headache. She was discharged to home in stable condition on with Percocet for pain and follow-up with Dr. on . The patient was in stable condition at the time of discharge. , M.D. Dictated By: MEDQUIST36 D: 11:51 T: 13:09 JOB#: | FINDINGS: CT OF THE HEAD WITHOUT IV CONTRAST: Once again seen is some asymmetry of the temporal lobes with a small Sylvian fissure on the right when compared with the left. FINDINGS: In the cervical and thoracic region, vertebral bodies demonstrate normal signal. HEAD CT WITHOUT IV CONTRAST: There is high attenuation material identified along the convexities of the right anterior frontal lobe,and along left posterior frontal/parietal lobe, a finding concerning for subarachnoid hemorrhage. TECHNIQUE: CT of the head initially without IV contrast and afterwards with IV contrast per cerebral CTA protocol. CT OF THE NECK: The carotid arteries are within normal limits without evidence of dissection. TECHNIQUE: Contiguous axial images were obtained from the foramen magnum through the cranial vertex without the administration of IV contrast. RIGHT GROIN ANGIO SITE CLEAN & DRY, NO HEMATOMA NOTED.RESP: BBS CTA. PROCEDURE: Diagnostic cerebral angiogram. End of Shift SummaryPt hemodynamically stable. Views of the right vertebral artery were obtained at the right anterior oblique projection without catheterization of the right vertebral artery itself. It should be noted that MRA is not sensitive for aneurysms less than 4 mm in size, or for detection of a thrombosed aneurysm. 11:00 PM CT NECK W/CONT +RECONSTRUCTION; CT HEAD W/ CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: Pt in ER with positive LP and ? CTIC/SICU NPN:S/O: CC OF FRONTAL HAEDACHE. Pt NPO except meds. IMPRESSION: Mild degenerative changes in the cervical and lumbar region. An incidental hemangioma is visualized in T3 vertebral body. R GROIN ANGIO SITE WITH NO EVIDENCE OF BLEEDING. Here for frequent neuro checks and r/o SAH. Note is made that the left transverse sinus is not present, because of a congenital variant. PT INTACT NEURO STATUS. FINDINGS: Injection of the right common carotid artery reveals no evidence of stenosis or dissection or atherosclerosis. The right and left groin area was prepped and draped in the usual sterile fashion. From skull base to the conus, the spinal cord shows normal signal intensities without evidence of extrinsic compression or intrinsic signal abnormalities. However, using an injection with the cuff elevated in the right arm, I was able to visualize the right vertebral artery, which was seen to be free of any dissection or disease in its intracranial course. The ventricles appear symmetric and do not appear dilated. Injection of the right external carotid artery reveals no evidence of shunting or anomaly. FINAL REPORT ^ ^ ^INDICATION: Positive lumbar puncture for blood, ? Pt was taken to angio for diagnostic cerebral angiogram. MRV: The left transverse sinus is not visualized and this is most likely congenital in nature. Note neuro exam on flowsheet. POSTOPERATIVE DIAGNOSIS: No evidence of aneurysm or arteriovenous malformation. CEREBRAL CTA: There are no aneurysms or vascular malformations appreciated. In the lumbar region, mild disc degenerative changes are visualized at L5-S1 level with mild bulging. Local infiltration of the right groin using 1% lidocaine without epinephrine around the right common femoral artery. ADMITTED TO R/O SAH. CONT WITH MS04 AND DROPERIDOL PRN. (Over) 11:00 PM CT NECK W/CONT +RECONSTRUCTION; CT HEAD W/ CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: Pt in ER with positive LP and ? NPO, ADVANCE DIET AS TOLERATES TO REG.RENAL: VOIDING QS W/O DIFFICULTY.HEME: HCT 37.ID: T-MAX 99.6. SAH on CT, please do CTA head with reconstruction and CTA neck with reconstruction. However subarachnoid hemorrhage from other causes cannot be excluded. Pt able to use bedpan to void. Pt remains to c/o HA. However there is no significant mass effect and the ventricles are symmetrical. Injection of the right internal carotid artery reveals no evidence of intracranial aneurysm. Nsg Admit Note GU - pt voiding adequate amts via bedpan.skin intact.ID- temp max 100.0 po, no tylenol or abx since EW.Pain- med w/ MSO4 xs 2 w/ mild relief noted.A/P- plan per attending this AM , ? ANESTHESIA: Conscious sedation and local anesthesia of the right groin. ENDOVASCULAR SURGERY: None. There is tortuosity of the thoracic aorta. It shows a well-visualized right posterior communicating artery. There is asymmetry of the cerebral hemispheres in that there appears to be effacement of the sulci/ sylivian fissure on the right. We then catheterized the right subclavian artery and angiography was obtained. NAD.GI: +BS, ABD SOFT/NT/ND. The inner dilator and guide wire were removed and the sheath was sutured in place with 0 silk sutures. High attenuation material within the basal ganglia bilaterally is consistent with benign calcifications. TMAX 101.1A: STABLE S/P ANGIO BUT HEADACHE AND FEVER PERSIST.P: CONT TO MONITOR NVS AND HR/BP. There is no evidence of abnormal flow voids in the lumbar thecal sac or in the region of conus to indicate AVM. The catheter was then placed into the right common carotid artery, where angiographic views were obtained. pt in SR rate 70's , BP 110-130/65, extremities warm and dry, easily palpable pulses x;s 4.Resp - pt on RA w/ O2 sats 93-98%, BS's clear bilat, RR 16-22 nonlabored. TXED WITH MS04 AND DROPERIDOL WITH SOME RELIEF. Injection of the right subclavian artery reveals no evidence of stenosis or dissection in the subclavian artery. Initial head CT w/ ? Neuorologically intact. Face symetrical, tounge midline, all extremities w/ full strength, no pronator drift. Please correlate clinically. Meds: levoxyl, evista, clariten, glucosamine, effexor, prenate, has had advil, fioricet and mso4 for HA. IMPRESSION: No significant abnormality. Subarachnoid hemorrhage. CONT ON IVF AT 75CC/HR.VOIDED 600CC IN ANGIO AFTER CASE AND 500CC IN SICU.VS REMAIN STABLE. MRA OF THE CIRCLE OF : There is no definite evidence of aneurysm involving the anterior communicating artery, middle cerebral artery bifurcation, posterior communicating artery or of the basilar tip. pt NPO, abd soft nondistended. 2) There continues to be some asymmetry between the temporal lobes with the Sylvian fissure being diminuative in size on the right when compared to the left. | 12 | [
{
"category": "Nursing/other",
"chartdate": "2160-09-18 00:00:00.000",
"description": "Report",
"row_id": 1290495,
"text": "SICU/CTIC NURSING ADMIT NOTE\n Pt admitted to EW from PCP's office for cc of headache resistant to tx. Here for frequent neuro checks and r/o SAH. HA's began following two days of metrogel tx. Initial head CT w/ ? SAH, LP in EW w/ some pink fluid and slightly cloudy, pt also noted to be febriile in EW w/ temp up to 101.0 po.\n Other PMHx: Hypothyroid, asthma, hx sinus HA's, vitiligo, depression/panic disorder, genital herpes.\n Meds: levoxyl, evista, clariten, glucosamine, effexor, prenate, has had advil, fioricet and mso4 for HA.\n\n Pt had CT angio and MRI/MRA just prior to admission to the sicu/ctic at 1:30 am, CT results neg, MRI arterial portion neg w/ venous reconstructions and review by attending pending. ? angiogram today.\n\n Review of Systems\n pt alert and oriented times 3, PERL at 4mm, c/o HA starting in the back of her head yet now extending around to the frontal area, currently on scale of w/ 10 being the worst pain. Pt photophobic, yet currently denies nausea, dizziness, blurry or double vision. Face symetrical, tounge midline, all extremities w/ full strength, no pronator drift.\n pt in SR rate 70's , BP 110-130/65, extremities warm and dry, easily palpable pulses x;s 4.\nResp - pt on RA w/ O2 sats 93-98%, BS's clear bilat, RR 16-22 nonlabored.\n pt NPO, abd soft nondistended. no nausea /vomiting\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-09-18 00:00:00.000",
"description": "Report",
"row_id": 1290496,
"text": "Nsg Admit Note \nGU - pt voiding adequate amts via bedpan.\nskin intact.\nID- temp max 100.0 po, no tylenol or abx since EW.\nPain- med w/ MSO4 xs 2 w/ mild relief noted.\nA/P- plan per attending this AM , ? angio today vs. con't monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-09-18 00:00:00.000",
"description": "Report",
"row_id": 1290497,
"text": "End of Shift Summary\nPt hemodynamically stable. Neuorologically intact. Able to follow commands. A/A/Ox3. Answering questions approriately. Note neuro exam on flowsheet. VSS. No resp distress or difficulty breathing. Pt NPO except meds. Tolerated few pills and sips. Pt able to use bedpan to void. Pt remains to c/o HA. MSO4 given for pain. Pt was taken to angio for diagnostic cerebral angiogram. Consent signed prior to going with neuro HO. Family has been at bedside this shift. Questions answered. Spoke with SICU fellow. Support given. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-09-18 00:00:00.000",
"description": "Report",
"row_id": 1290498,
"text": "RSICU NPN\nO: PT RETURNED FROM ANGIO WITH CONT HEADACHE AND NAUSEA. TXED WITH MS04 AND DROPERIDOL WITH SOME RELIEF. R GROIN ANGIO SITE WITH NO EVIDENCE OF BLEEDING. PULSES PALPABLE. CONT ON IVF AT 75CC/HR.\nVOIDED 600CC IN ANGIO AFTER CASE AND 500CC IN SICU.\nVS REMAIN STABLE. TMAX 101.1\n\nA: STABLE S/P ANGIO BUT HEADACHE AND FEVER PERSIST.\n\nP: CONT TO MONITOR NVS AND HR/BP. MONITOR U/O FOR ADEQUATE CLEARANCE OF DYE. CONT WITH MS04 AND DROPERIDOL PRN. MONITOR R GROIN FOR BLEEDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-09-19 00:00:00.000",
"description": "Report",
"row_id": 1290499,
"text": "PT INTACT NEURO STATUS. MAE, FOLLOWS COMMANDS PERL. ARIENTED TIMES 3.\nVS STABLE SATS ON RA 92 TO 94 DROPPED TO 90 ONCE WHEN SOUND ASLEEP.\nSTRAIGHT CATHED FOR URINE CULTURE, ONE BLOOD CULTURE SET SENT.\n COMPL OF SEVERE HEADACHE. GIVEN IV MS THEN FOUND PT HAD BETTER EFFECT WITH SC MS. 4 MGS SC AT 12 AND 5AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2160-09-19 00:00:00.000",
"description": "Report",
"row_id": 1290500,
"text": "CTIC/SICU NPN:\nS/O: CC OF FRONTAL HAEDACHE. ADMITTED TO R/O SAH. REVIEW OF SYSTEMS:\nNEURO: A&Ox3. MAE'S. PERRLA. MSO4 SQ FOR PAIN W/ GOOD EFFECT. PT. PREFERS LYING FLAT ON SIDE W/ LIGHTS DOWN.\nCV: , CAREVUE FLOWSHEET. LR @ 75CC/HR VIA LEFT HAND PIV. RIGHT GROIN ANGIO SITE CLEAN & DRY, NO HEMATOMA NOTED.\nRESP: BBS CTA. R/A SATS@ 93-97%. NAD.\nGI: +BS, ABD SOFT/NT/ND. NPO, ADVANCE DIET AS TOLERATES TO REG.\nRENAL: VOIDING QS W/O DIFFICULTY.\nHEME: HCT 37.\nID: T-MAX 99.6. WBC 15.7\nSKIN: INTACT.\nSOCIAL: HUSBAND VISITING/SUPPORTIVE.\nA/P: STABLE, NEUROLOGICALLY INTACT. MRI OF SPINE THIS AFTERNOON. ADVANCE DIET TO REG. AND ACT. TO OOB AS TOLERATES. MONITOR PAIN CONTROL. TRANSFER TO FLOOR.\n"
},
{
"category": "Radiology",
"chartdate": "2160-09-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 741848,
"text": " 8:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate? CHF?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with a susp. SAH.\n REASON FOR THIS EXAMINATION:\n infiltrate? CHF?\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE FILM\n\n HISTORY: SAH and possible CHF.\n\n Heart size is normal. There is tortuosity of the thoracic aorta. No evidence\n for CHF. The lungs are clear. No previous films for comparison.\n\n IMPRESSION: No significant abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-09-17 00:00:00.000",
"description": "CT EMERGENCY HEAD W/O CONTRAST",
"row_id": 741826,
"text": " 5:23 PM\n CT EMERGENCY HEAD W/O CONTRAST Clip # \n Reason: eval for sah\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ha for 5 days, non-focal neuro exam. bloody csf on lp\n REASON FOR THIS EXAMINATION:\n eval for sah\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 58-year-old woman with headache for five days. Bloody CSF\n on LP.\n\n TECHNIQUE: Contiguous axial images were obtained from the foramen magnum\n through the cranial vertex without the administration of IV contrast.\n\n COMPARISONS: None.\n\n HEAD CT WITHOUT IV CONTRAST: There is high attenuation material identified\n along the convexities of the right anterior frontal lobe,and along left\n posterior frontal/parietal lobe, a finding concerning for subarachnoid\n hemorrhage. There is asymmetry of the cerebral hemispheres in that there\n appears to be effacement of the sulci/ sylivian fissure on the right. However\n there is no significant mass effect and the ventricles are symmetrical. There\n is asymmetry in the sylvian fissures. No signficant edema is identified. No\n large vascular territorial infarcts are seen. High attenuation material\n within the basal ganglia bilaterally is consistent with benign calcifications.\n The basal cisterns are patent. No gross abnormalities of the soft tissues,\n osseous structures or paranasal sinuses are detected.\n\n IMPRESSION:\n 1) High attenuation material along the right anterior frontal convexity and\n in the left posterior frontal region. This could be related to traumatic\n lumbar puncture performed prior to the CT scan. However subarachnoid\n hemorrhage from other causes cannot be excluded. Please correlate clinically.\n No edema identified. No shift of midline structures and no evidence of\n hydrocephalus.\n\n The results of this study were discussed with Dr. at the time of\n the exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-09-18 00:00:00.000",
"description": "3ED ORDER THOR/BRACHIOCEPHALIC",
"row_id": 741881,
"text": " 4:58 PM\n CAROT/CEREB Clip # \n Reason: 58 year old woman s/p 5 days severe headache, + LP in the ER\n Contrast: OPTIRAY Amt: 250\n ********************************* CPT Codes ********************************\n * 3ED ORDER /BRACHIOCEPHALIC 2ND ORDER /BRACHIOCEPHALIC *\n * -59 DISTINCT PROCEDURAL SERVICE 2ND ORDER /BRACHIOCEPHALIC *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD OR> /BRACHIO *\n * ADD'L 2ND/3RD OR> /BRACHIO CAROTID/CERVICAL/BILAT A-GRAM *\n * CAROTID/CEREBRAL BILAT A-GRAM VERT/CAROTID/CEREBRAL A-GRAM *\n * VERT/CAROTID/CEREBRAL A-GRAM EXT CAROTID UNILAT A -GRAM *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n * IV CONSCIOUTIOUS SEDATION PRO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with\n REASON FOR THIS EXAMINATION:\n 58 year old woman s/p 5 days severe headache, + LP in the ER need angio to r/o\n aneurysm\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PREOPERATIVE DIAGNOSIS: Headache and subarachoid hemorrhage.\n\n POSTOPERATIVE DIAGNOSIS: No evidence of aneurysm or arteriovenous\n malformation.\n\n PROCEDURE: Diagnostic cerebral angiogram.\n\n ANESTHESIA: Conscious sedation and local anesthesia of the right groin. The\n conscious sedation was provided with divided doses of Fentanyl and Versed by\n the nursing staff under supervision of the operator, with continuous\n hemodynamic monitoring during the entire procedure. Local infiltration of the\n right groin using 1% lidocaine without epinephrine around the right common\n femoral artery.\n\n INTRAVENOUS PROCEDURES: None.\n\n ENDOVASCULAR SURGERY: None.\n\n PROCEDURE IN DETAIL: The patient was brought into the Angiography Suite and\n placed on the table in the supine position. The right and left groin area was\n prepped and draped in the usual sterile fashion. A skin incision was made\n over the right common femoral artery and a 19-gauge single-wall needle was\n used to puncture the right common femoral artery. Upon the return of brisk\n arterial blood, a .035-inch guide wire was inserted through the needle\n into the common femoral artery and into the abdominal aorta under fluoroscopic\n guidance the needle was removed and a #5 French vascular sheath was inserted\n over the guide wire into the right common femoral artery.\n\n The inner dilator and guide wire were removed and the sheath was sutured in\n place with 0 silk sutures. The sheath was connected to a heparinized saline\n drip, infused throughout the entire procedure. A #5 French #2\n (Over)\n\n 4:58 PM\n CAROT/CEREB Clip # \n Reason: 58 year old woman s/p 5 days severe headache, + LP in the ER\n Contrast: OPTIRAY Amt: 250\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n angiographic catheter was inserted over the guide wire and advanced\n through the abdominal thoracic aorta under direct fluoroscopic guidance. The\n catheter was then placed into the right common carotid artery, where\n angiographic views were obtained. This was used to place the catheter in the\n right internal carotid artery where a number of angiographic views were\n obtained and the catheter was then placed in the right external carotid artery\n where an angiographic view was obtained in lateral projection. We then\n catheterized the right subclavian artery and angiography was obtained.\n The cuff was elevated with the catheter in the right subclavian artery. Views\n of the right vertebral artery were obtained at the right anterior oblique\n projection without catheterization of the right vertebral artery itself. The\n catheter aws placed in the left subclavian artery. With the catheter in the\n left subclavian artery, angiographic views were obtained of the left\n subclavian artery and this was used to catheterize the left vertebral artery,\n and multiple views were obtained of the left vertebral artery.\n\n The catheter was then placed into the left common carotid artery, where a\n number of angiographic runs were obtained.\n\n At this point, review of the films revealed no evidence of aneurysm and the\n catheter was withdrawn from the patient.\n\n FINDINGS:\n Injection of the right common carotid artery reveals no evidence of stenosis\n or dissection or atherosclerosis. Injection of the left common carotid artery\n also shows no evidence of disease or stenosis or anomaly.\n\n Injection of the right internal carotid artery reveals no evidence of\n intracranial aneurysm. It shows a well-visualized right posterior\n communicating artery. Injection of the right external carotid artery reveals\n no evidence of shunting or anomaly. Injection of the right subclavian artery\n reveals no evidence of stenosis or dissection in the subclavian artery.\n Because of the tortuosity of the origin of the right vertebral artery, this\n could not be catheterized. However, using an injection with the cuff elevated\n in the right arm, I was able to visualize the right vertebral artery, which\n was seen to be free of any dissection or disease in its intracranial course.\n\n Injection of the left subclavian artery reveals no evidence of disease or\n stenosis or anomaly.\n\n Injection of the left vertebral artery reveals no evidence of dissection or\n stenosis of the cervical segment and reveals no evidence of intracranial\n aneurysm or malformation.\n\n Injection of the left common carotid artery reveals no evidence of carotid\n disease or stenosis and also injection of the left internal carotid artery\n (Over)\n\n 4:58 PM\n CAROT/CEREB Clip # \n Reason: 58 year old woman s/p 5 days severe headache, + LP in the ER\n Contrast: OPTIRAY Amt: 250\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n reveals no evidence of intracranial aneurysm or malformation. Note is made\n that the left transverse sinus is not present, because of a congenital\n variant. As a result, the left internal jugular is significantly smaller than\n the right, which appears to drain the majority of the blood flow from the\n superior sagittal sinus, even when injecting the left internal carotid artery.\n\n IMPRESSION: No evidence of aneurysm or arteriovenous shunt or fistula.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-09-17 00:00:00.000",
"description": "CT NECK W/CONT +RECONSTRUCTION",
"row_id": 741837,
"text": " 11:00 PM\n CT NECK W/CONT +RECONSTRUCTION; CT HEAD W/ CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Pt in ER with positive LP and ? SAH on CT, please do CTA hea\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with r/o SAH\n REASON FOR THIS EXAMINATION:\n Pt in ER with positive LP and ? SAH on CT, please do CTA head with\n reconstruction and CTA neck with reconstruction. NOTE: Please do CTA before\n previously scheduled MRI/MRA.\n ______________________________________________________________________________\n FINAL REPORT\n ^\n ^\n ^INDICATION: Positive lumbar puncture for blood, ? subarachonid hemorrhage or\n CT, evaluate with CTA of head and neck.\n\n COMPARISON: CT from same day approximately 5hrs prior were used for\n comparison.\n\n TECHNIQUE: CT of the head initially without IV contrast and afterwards with IV\n contrast per cerebral CTA protocol. Multi planar reconstructions were\n performed. 120cc of Optiray was administered. Optiray was administered\n secondary to fast bolus. CTA was of the neck was additionally performed.\n\n FINDINGS:\n CT OF THE HEAD WITHOUT IV CONTRAST: Once again seen is some asymmetry of the\n temporal lobes with a small Sylvian fissure on the right when compared with\n the left. There is some increased density and effacement of sulci over the\n convexity consistent with subarachnoid hemorrhage. The ventricles appear\n symmetric and do not appear dilated. There are calcifications of the basal\n ganglia. No large territorial infarct is seen.\n\n BONE WINDOWS: No abnormalities are noted.\n\n CEREBRAL CTA: There are no aneurysms or vascular malformations appreciated.\n\n MULTI PLANAR RECONSTRUCTIONS: The Circle of appears unremarkable.\n\n CT OF THE NECK: The carotid arteries are within normal limits without evidence\n of dissection.\n\n IMPRESSION: 1) There is no evidence of aneurysm or vascular malformation.\n\n 2) There continues to be some asymmetry between the temporal lobes with the\n Sylvian fissure being diminuative in size on the right when compared to the\n left. This is non specific and may be congenital in nature. Additionally there\n continues to be some high density in the region of the frontal lobe which may\n be secondary to artifact and overlying bone. These results were discussed with\n the neurosurgical team.\n\n (Over)\n\n 11:00 PM\n CT NECK W/CONT +RECONSTRUCTION; CT HEAD W/ CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Pt in ER with positive LP and ? SAH on CT, please do CTA hea\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-09-18 00:00:00.000",
"description": "MR HEAD NEURO",
"row_id": 741838,
"text": " 12:03 AM\n MR HEAD NEURO; MR-ANGIO HEAD Clip # \n MR RECONSTRUCTION IMAGING; MR-ANGIO HEAD\n -59 DISTINCT PROCEDURAL SERVICE; -59 DISTINCT PROCEDURAL SERVICE\n Reason: mri/mra head with diffusion weighted images to eval sah vs b\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 58 year old woman with ha, bloody lp, blood on head ct.\n REASON FOR THIS EXAMINATION:\n mri/mra head with diffusion weighted images to eval sah vs bleeding vascular\n malformation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bloody LP. Subarachnoid hemorrhage.\n\n TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain including\n diffusion weighted images as well as MRA of the circle of and MRV were\n performed. 3D TOF images with reconstructions of the circle of were\n performed.\n\n BRAIN MRI: The acute subarachnoid hemorrhage is not appreciated on this MRI.\n There is continued evidence of effacement of the sulci on the right, as well\n as effacement of the right sylvian fissure. No mass is identified. No major\n vascular territorial infarct is seen. There is no hydrocephalus. There is no\n shift of normally midline structures.\n\n MRA OF THE CIRCLE OF : There is no definite evidence of aneurysm\n involving the anterior communicating artery, middle cerebral artery\n bifurcation, posterior communicating artery or of the basilar tip. It should\n be noted that MRA is not sensitive for aneurysms less than 4 mm in size, or\n for detection of a thrombosed aneurysm.\n\n MRV: The left transverse sinus is not visualized and this is most likely\n congenital in nature.\n\n IMPRESSION: Continued evidence of effacement of the sulci on the right as\n well as asymmetry of the sylvian fissure. Although there is no definite\n evidence of aneurysm involving the circle of , MR angiography is not\n sensitive for detection of aneurysms less than 4 mm or for the detection of\n thrombosed aneurysms. Therefore, further evaluation with a formal angiogram\n is recommended. This is discussed with the house staff caring for the patient\n on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2160-09-20 00:00:00.000",
"description": "MR THORACIC SPINE",
"row_id": 741957,
"text": " 12:06 AM\n MR THORACIC SPINE; MR L SPINE SCAN Clip # \n Reason: 58 year old woman s/p +LP for blood and negative angio for a\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE SPINAL CANAL.\n\n CLINICAL INFORMATION: Patient with subarachnoid hemorrhage and negative\n angio, for further evaluation.\n\n TECHNIQUE: T1- and T2-weighted sagittal images of the spinal canal were\n obtained.\n\n FINDINGS: In the cervical and thoracic region, vertebral bodies demonstrate\n normal signal. Mild disc bulging is seen at C5-6 and C6-7 levels.\n\n From skull base to the conus, the spinal cord shows normal signal intensities\n without evidence of extrinsic compression or intrinsic signal abnormalities.\n There is no evidence of abnormal flow voids around the spinal cord to indicate\n arteriovenous malformation.\n\n In the lumbar region, mild disc degenerative changes are visualized at L5-S1\n level with mild bulging. No evidence of spinal stenosis is seen. The conus\n is located at a normal level. There is no evidence of abnormal flow voids in\n the lumbar thecal sac or in the region of conus to indicate AVM.\n\n An incidental hemangioma is visualized in T3 vertebral body.\n\n IMPRESSION: Mild degenerative changes in the cervical and lumbar region. No\n evidence of extrinsic spinal cord compression or intrinsic spinal cord signal\n abnormalities. No evidence of abnormal flow voids within the spinal canal to\n indicate AVM on non-contrast MRI of the spinal canal.\n\n\n"
}
] |
24,428 | 133,668 | 71 yo man with h/o hyperlipidemia, HTN, CAD with IMI s/p 4v CABG (') presenting with dyspnea on exertion now s/p cath with clean grafts, severe pulmonary arterial hypertension, elevated wedge pressure and low CI. In the CCU, the pulmonary artery catheter was initially left in place to aid with diuresis, but was pulled on HD3 when the pressure tracings dampened. He was diuresed aggressively with lasix 40-80 mg IV with good UOP and resolution of his lower extremity edema and significant improvement in his DOE. He was also ruled out for an MI with cardiac enzymes x 2 with a flat troponin of 0.02. Telemetry showed frequent PVCs, but he was asymptomatic. His electrolytes were repleted as needed. A TTE showed dilatation of the LV with severe global hypokinesis and EF 20%. He was continued on aspirin 325 QD and started on coreg 6.25 mg , lisinopril 5 mg QD, zetia 10 mg QD (given previous muscle pains with statins), spironolactone 25 mg QD, digoxin 0.125 mg QD and lasix 80 mg QD. He will get his electrolytes and digoxin level checked at his PCP's office within 1 week to be followed up by his PCP's nurse. EP was consulted regarding placement of an ICD; however, the patient wanted to defer ICD placement during this hospitalization. EP recommended a repeat TTE (transthoracic echocardiogram) in months and follow-up with EP after the TTE. They also recommended checking a TSH, which was normal at 2.6, and a CRP, which was elevated at 27.1 to be followed-up by his outpatient cardiologist. | Pulmonary artery systolic hypertension.Height: (in) 71Weight (lb): 205BSA (m2): 2.13 m2BP (mm Hg): 122/77HR (bpm): 67Status: InpatientDate/Time: at 11:54Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. The right ventricular cavity is mildlydilated with moderate global free wall hypokinesis. ECHO done this am-> EF <20%, +MR, 1+TR, mild PA systolic HTN, please see ECHO report for further details.Resp: LS CTA, O2 sats 95-100% on 3 L n.c. Pt denies SOB.Neuro: Pt alert and oriented x 3, pleasant and cooperative with care. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a moderate risk (prophylaxis recommended). Moderate global RV free wallhypokinesis.AORTA: Normal aortic root diameter. 7:58 AM CHEST (PORTABLE AP) Clip # Reason: Evaluate location of PA catheter. v-bigeminy w/ frequent VEA, lytes pending, Hct stable. There is no pericardial effusion.IMPRESSION: Biventricular cavity enlargement with severe left ventricularsystolic dysfunction c/w multivessel CAD or other diffuse process.Mild-moderate mitral regurgitation. "O: Please see careview for VS and additional data.CV: Pt HR 57 SB to 77 NSR, rare to occ PVC's noted, ventricular bigmeny noted at times with HR 57-60's. Pt denies CP, bilateral pedal pulses palp/dopplerable, R groin site CDI. +400cc @ MN, now -400cc LOS.ID: afebrile, no abxSKIN: PA line and venous sheath RFV, soft, no ooze/hematoma noted. Trace AR.MITRAL VALVE: Normal mitral valve leaflets. REASON FOR THIS EXAMINATION: Eval for swan cath placement FINAL REPORT SINGLE VIEW CHEST INDICATION: Swan-Ganz catheter placement. Mildto moderate (+) mitral regurgitation is seen. Pulmonary artery systolic hypertension.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). Sinus rhythm with PVCsProlonged QT intervalInferior infarct - age undeterminedPoor R wave progressionSince previous tracing, no significant change Pt tol PO Metoprolol 12.5 mg. PA pulled , right groin site CDI. To start low dose lisinopril this am. Trace aorticregurgitation is seen. CCU NPN 7p-7aS: "I've slept fine..."O: please see admit note/carevue/ICU update for complete assessment dataEVENTS: arrived from cath lab NEURO: pleasant and cooperative w/ care, c/o "fatigue" in back muscles from prolonged period in same position, relieved w/ Percoset. Tracing noted again to be dampened shortly after adjustment, CCU Attending aware, CXR done- PA line pulled back by CCU Fellow- with adequate tracing, PAD's 20-21. Sinus arrhythmia with frequent multifocal PVCsInferior infarct - age undeterminedPoor R wave progressionSince previous tracing, no significant change FINDINGS: Single bedside semi-upright AP exam demonstrates Swan-Ganz catheter, looped within the right atrium, with tip overlying the left main pulmonary artery. Mild to moderate (+) MR.TRICUSPID VALVE: Mild [1+] TR. PA tracing dampened this am, CCU Team aware-line adjusted by CCU Fellow and Attending. "O: Please see careview for VS and additional data.CV: Pt HR 59 to 85 NSR, rare to occ PVC's. Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). FINAL REPORT CLINICAL HISTORY: Pulmonary artery catheter placed, check position. No LV mass/thrombus.RIGHT VENTRICLE: Mildly dilated RV cavity. There is mild pulmonaryartery systolic hypertension. Goal for pt to be negative 1-1.5 L at midnoc.ID: Pt afebrile, T max 98.6.A/P: 71 y/o male with CAD, CHF, volume overloaded-pt being diuresed with lasix. No focal neuro deficit.CV: HD stable, PAD ranging 20-30, responding well to diuresis w/ lasix 20mg. Monitor HR/rhythm and hemodynamics. No c/o CP, distal pulses palp.RESP: initially >96% on RA, down to 90% while sleeping, placed on 3l NC w/ effect. S/p myocardial infarction. Tolerating lopressor (decreased to 12.5 after brady into low 50s w/ 1st dose 25mg). No c/o SOBNeuro: Pt alert and oriented x 3. IMPRESSION: PA catheter in left chest. PATIENT/TEST INFORMATION:Indication: Left ventricular function. Left ventricular wall thicknesses arenormal. Continue to monitor HD status, rhythm, u/o and resp status. NBP 98-128/51-79. CO/CI cont depressed but improved w/ diuresis, O2 therapy, MvO2 64%(56). Continue to monitor hemodynamics-> rhythm, CO/CI, PADs, labs, u/o->? pull PA line this am, TTE to eval LVEF. Requires 2L NC when asleep to keep sats above 92%. Pt with minimal u/o this am, 40 mg IV lasix given at 1325-> 650 cc u/o over 3 hours-HO aware, afternoon BUN 22 (was 21), creatinine 1.3 (was 1.1)-lasix order held, to be reassesed at 1800. The heart remains enlarged, and mild CHF persists. owns glue manufacturing business, wife is retired RN, family very supportive, declining HCP at this time.A: 71yo w/ known CAD ^sx CHF/volume overload, s/p cath, no new CAD and grafts patent, w/ LV syst dysfxn and cardiogenic shock in setting of volume overload, responding to diuresis w/ lasix.P: f/u am labs, cont to monitor I/O, cont diuresis goal -500 to 1L. REASON FOR THIS EXAMINATION: Evaluate location of PA catheter. The aortic valve leaflets(3) are mildly thickened but aortic stenosis is not present. Pt negative 1.5L at midnoc.ID: Afebrile during shiftA/P: 71 yo male with CAD, CHF, volume overload, pt being diuresed with lasix. Pt tol 12.5 mg metoprolol and 2.5 mg lisinopril this am. NBP 82-139/39-80. Echocardiographic results were reviewed by telephonewith the houseofficer caring for the patient.Conclusions:The left atrium is moderately dilated. IMPRESSION: Swan-Ganz catheter looped within the right atrium. LSCTA bilaterally, no cough/sputum or c/o SOB/PND.GI: Tol PO meds w/ water and crackers, no c/o N/V/D/C. Normal LV wall thickness. Diet/lifestyle/med teaching to pt. Pt awaiting bed on floor.Written by NU SNCosigned by , RN | 8 | [
{
"category": "Nursing/other",
"chartdate": "2105-04-08 00:00:00.000",
"description": "Report",
"row_id": 1579974,
"text": "NPN 1900-0700\nS: \"Feels good to move around and sit up.\"\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 59 to 85 NSR, rare to occ PVC's. NBP 82-139/39-80. Pt tol PO Metoprolol 12.5 mg. PA pulled , right groin site CDI. Per TTE EF < 20%.\n\nResp: LS CTA, O2 sats 94%-100% on 2L NC. Requires 2L NC when asleep to keep sats above 92%. No c/o SOB\n\nNeuro: Pt alert and oriented x 3. Pleasant and cooperative with care. Pt asking appropriate questions regarding care. Pt sat up at the side of bed to eat dinner with no c/o pain or lightheadedness.\n\nGI/GU: Pt abd soft, +BS x 4. No stool this shift, pt ate dinner, No C/O of N/V. 40mg of IV Lasix given @ 2200. Pt negative 1.5L at midnoc.\n\nID: Afebrile during shift\n\nA/P: 71 yo male with CAD, CHF, volume overload, pt being diuresed with lasix. Continue to monitor HD status, rhythm, u/o and resp status. Continue to monitor activity tolerance. Continue with diet and med teaching. Pt awaiting bed on floor.\nWritten by NU SN\nCosigned by , RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-04-07 00:00:00.000",
"description": "Report",
"row_id": 1579972,
"text": "CCU NPN 7p-7a\nS: \"I've slept fine...\"\nO: please see admit note/carevue/ICU update for complete assessment data\nEVENTS: arrived from cath lab \nNEURO: pleasant and cooperative w/ care, c/o \"fatigue\" in back muscles from prolonged period in same position, relieved w/ Percoset. No focal neuro deficit.\n\nCV: HD stable, PAD ranging 20-30, responding well to diuresis w/ lasix 20mg. Tolerating lopressor (decreased to 12.5 after brady into low 50s w/ 1st dose 25mg). v-bigeminy w/ frequent VEA, lytes pending, Hct stable. CO/CI cont depressed but improved w/ diuresis, O2 therapy, MvO2 64%(56). No c/o CP, distal pulses palp.\n\nRESP: initially >96% on RA, down to 90% while sleeping, placed on 3l NC w/ effect. LSCTA bilaterally, no cough/sputum or c/o SOB/PND.\n\nGI: Tol PO meds w/ water and crackers, no c/o N/V/D/C. LBM .\n\nGU: refusing foley cath, attempted condom cath w/o success, now voiding w/ assistance in urinal. +400cc @ MN, now -400cc LOS.\n\nID: afebrile, no abx\n\nSKIN: PA line and venous sheath RFV, soft, no ooze/hematoma noted. PIV x1. PA line becoming increasingly dampened t/o shift. No breakdown noted.\n\nSOC: wife and son in to visit. Pt. owns glue manufacturing business, wife is retired RN, family very supportive, declining HCP at this time.\n\nA: 71yo w/ known CAD ^sx CHF/volume overload, s/p cath, no new CAD and grafts patent, w/ LV syst dysfxn and cardiogenic shock in setting of volume overload, responding to diuresis w/ lasix.\nP: f/u am labs, cont to monitor I/O, cont diuresis goal -500 to 1L. Monitor HR/rhythm and hemodynamics. ? pull PA line this am, TTE to eval LVEF. To start low dose lisinopril this am. Diet/lifestyle/med teaching to pt. and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-04-07 00:00:00.000",
"description": "Report",
"row_id": 1579973,
"text": "CCU NPN 0700-1900\nS: \"I'd like to be home for my birthday tomorrow.\"\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 57 SB to 77 NSR, rare to occ PVC's noted, ventricular bigmeny noted at times with HR 57-60's. NBP 98-128/51-79. Pt tol 12.5 mg metoprolol and 2.5 mg lisinopril this am. Pt denies CP, bilateral pedal pulses palp/dopplerable, R groin site CDI. PA tracing dampened this am, CCU Team aware-line adjusted by CCU Fellow and Attending. PAP tracing at noon with PAD's 36, MVO2 60 CO/CI 4.1/1.85. Tracing noted again to be dampened shortly after adjustment, CCU Attending aware, CXR done- PA line pulled back by CCU Fellow- with adequate tracing, PAD's 20-21. ECHO done this am-> EF <20%, +MR, 1+TR, mild PA systolic HTN, please see ECHO report for further details.\n\n\nResp: LS CTA, O2 sats 95-100% on 3 L n.c. Pt denies SOB.\n\nNeuro: Pt alert and oriented x 3, pleasant and cooperative with care. Pt asking appropriate questions regarding care. Pt MAE, denies pain.\n\nGI/GU: Pt abd soft, + BS x 4, no stool this shift, pt ate breakfast and lunch-pt tol, no N/V. Pt with minimal u/o this am, 40 mg IV lasix given at 1325-> 650 cc u/o over 3 hours-HO aware, afternoon BUN 22 (was 21), creatinine 1.3 (was 1.1)-lasix order held, to be reassesed at 1800. Pt negative approx 1L at 1600. Goal for pt to be negative 1-1.5 L at midnoc.\n\nID: Pt afebrile, T max 98.6.\n\nA/P: 71 y/o male with CAD, CHF, volume overloaded-pt being diuresed with lasix. Continue to monitor hemodynamics-> rhythm, CO/CI, PADs, labs, u/o->? lasix this eve, resp status. Continue to provide emotional support to pt, continue with diet/med teaching. Awaiting further POC per CCU Team.\n\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2105-04-07 00:00:00.000",
"description": "Report",
"row_id": 61933,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/p myocardial infarction. Pulmonary artery systolic hypertension.\nHeight: (in) 71\nWeight (lb): 205\nBSA (m2): 2.13 m2\nBP (mm Hg): 122/77\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 11:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness. Severely dilated LV cavity. Severe global LV\nhypokinesis. TVI E/e' >15, suggesting PCWP>18mmHg. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\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. Echocardiographic results were reviewed by telephone\nwith the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is severely dilated with severe global\nhypokinesis. Tissue velocity imaging E/e' is elevated (>15) suggesting\nincreased left ventricular filling pressure (PCWP>18mmHg). No masses or\nthrombi are seen in the left ventricle. The right ventricular cavity is mildly\ndilated with moderate global free wall hypokinesis. The aortic valve leaflets\n(3) are mildly thickened but aortic stenosis is not present. Trace aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal. Mild\nto moderate (+) mitral regurgitation is seen. There is mild pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Biventricular cavity enlargement with severe left ventricular\nsystolic dysfunction c/w multivessel CAD or other diffuse process.\nMild-moderate mitral regurgitation. Pulmonary artery systolic hypertension.\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": "ECG",
"chartdate": "2105-04-07 00:00:00.000",
"description": "Report",
"row_id": 111231,
"text": "Sinus rhythm with PVCs\nProlonged QT interval\nInferior infarct - age undetermined\nPoor R wave progression\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2105-04-06 00:00:00.000",
"description": "Report",
"row_id": 111232,
"text": "Sinus arrhythmia with frequent multifocal PVCs\nInferior infarct - age undetermined\nPoor R wave progression\nSince previous tracing, no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903485,
"text": " 1:31 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for swan cath placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with R PA catheter.\n\n REASON FOR THIS EXAMINATION:\n Eval for swan cath placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW CHEST\n\n INDICATION: Swan-Ganz catheter placement.\n\n COMPARISON: Earlier, same day at 7:58 a.m.\n\n FINDINGS: Single bedside semi-upright AP exam demonstrates Swan-Ganz\n catheter, looped within the right atrium, with tip overlying the left main\n pulmonary artery. The heart remains enlarged, and mild CHF persists. No\n pneumothorax is seen.\n\n IMPRESSION: Swan-Ganz catheter looped within the right atrium. Findings\n discussed by telephone with Dr. at 3:30 p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-04-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 903410,
"text": " 7:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate location of PA catheter.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with R PA catheter.\n REASON FOR THIS EXAMINATION:\n Evaluate location of PA catheter.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Pulmonary artery catheter placed, check position.\n\n CHEST:\n\n A catheter is seen extending up the IVC into the heart. The tip lies in an\n upper segmental branch of the left pulmonary artery.\n\n The heart is enlarged with evidence of previous CABG. No failure is seen.\n Neither costophrenic angle is identified.\n\n IMPRESSION: PA catheter in left chest.\n\n\n"
}
] |
23,966 | 167,345 | Patient was referred by his primary care doctor secondary to positive stress test and a history of angina. Cardiac performed on revealed a severe left main and occlusive right coronary artery disease. Ejection fraction 55%. Subsequent to the , the patient was admitted for revascularization procedure. The patient had CABG x4 performed on . Saphenous vein graft to posterior descending artery, saphenous vein graft to OM-2 and OM-1, to left anterior descending artery. Intraoperatively, the patient was transfused 4 units of fresh-frozen plasma and 2 units of packed red blood cells. Repeat hematocrit in the evening of postoperative day #0 was 22 prompting another transfusion of additional 2 units of packed red blood cells. Patient was extubated on postoperative day #0 and was maintained on a Neo drip for hemodynamics. Patient was transfused an additional 2 units of packed red blood cells. Postoperative day #2, the patient was maintained on A-pacing for blood pressure support. On postoperative day #3, the patient's Neo-Synephrine was weaned off with continued stable hemodynamics. The patient was subsequently transferred to the floor, with the chest tube intact. A small air leak was noted while on suction. After being placed to water-seal, the chest tube was without air leak. Patient was subsequently transferred to Far 2. On the floor, the patient had failure to void after having Foley discontinued. This was repeated again after 24 hours of having the Foley catheter. Subsequently, the patient was noted to be intermittently febrile. A urinalysis revealed positive for infection. Culture grew out greater than 100,000 Enterobacter aerogenes. The patient was treated for his urinary tract infection with levofloxacin. Patient did have intermittent bouts of sinus tachycardia and was found to be somewhat orthostatic. As a result, he was given only 12.5 mg of Lopressor q day. Postoperative day #8, the patient was begun on his Levaquin for urinary tract infection and was also found to be somewhat nauseated and vomited x1. The patient got a KUB which is normal. After having noticed the patient to be somewhat jaundiced, LFTs and bilirubin were sent out. Bilirubin was mildly elevated at 2.4. The patient's abdomen was soft, nontender, nondistended. Followup right upper quadrant ultrasound as well as LFTs and amylase and lipase revealed a drop in the bilirubin back to 1.7, and only mild elevation of the lipase. The patient continued to spike intermittent temperatures and had one more episode of difficulty voiding. Urology was consulted with this on the evening of postoperative day #8. They recommended leaving the Foley out for specified period of time, after which the patient should have the Foley replaced. The patient spontaneously voided during this time period, and subsequent to this had no difficulties with urination. Patient continued to have intermittent fevers until postoperative day 11 when he was discharged without significant fever for 24 hour period. He was discharged on po pain medications and adequate pain control, tolerating a regular diet, and having no anginal symptoms. Patient had no significant arrhythmias in his postoperative course other than occasional sinus tachycardia associated with activity. The patient had an ultrasound of the right upper quadrant for the possibility of acalculous cholecystitis which was normal. | CYU.ENDO: Fs covered with RISS.ASSESS: Stable on neo. FINDINGS: There is a median sternotomy and CABG. DISTAL LT. LEG DP AND PT'S POSITIVE BY DOPPLER AND CSM WNL.GI; BS PRESENT NO BM THIS SHIFT. Borderline first degree A-V block.Non-specific T wave abnormalities. BS DIMINISHED BIBASILAR.NO CT LEAK. RIGHT FEM DSG WITH SANGUINOUS DRAINAGE.DOPP PP. Tiny left apical pneumothorax. Titrated/ weaned iv ntg and neo. FINAL REPORT HISTORY: CABG, hypoxia. 2) Small left apical pneumothorax. RIGHT FEM SITE ECCHYMOTIC SOFT. Small right pleural effusion. FINDINGS: Single frontal view chest. CHEST TUBES DRAINING MINIMAL THIN SEROSANQ. Sinus rhythm and occasional ventricular ectopy. TECHNIQUE: Chest PA and lateral. Altered comfort r/t incision pain. Dsd changed.GU: Adequate urine output through foley. VERY FREQ. CHEST TUBES DRAINING SM AMT THIN SEROSANQ. IMPRESSION: Moderate-sized left pleural effusion. There is a small left apical pneumothorax. Lungs are clear but dim @ bases. The left apical pneumothorax has almost completely resolved in the interval. LT GROIN REMAINS ECCYMOTIC WITH LG SOFT HEMATOMA. DRAINAGE.CARDIOVAS; SR FREQ PVC'S BEGGINING OF SHIFT BUT AS NOC PROGRESSED THEY SEEMED TO BE ALOT LESS FREQ. Please note that the sternal wires are malaligned. Sinus rhythm with ventricular bigeminy. Sinus rhythm with ventricular bigeminy. Repleted ca, k, mg with effect. DSGS D+I. PT ON LOW DOSES OF NEO AND UNABLE TO WEAN WHEN TITRATED OFF PT DROPS MAP <60 REQUIRING NEO TO BE CONTINUED. There is blunting of the right CP angle secondary to a small pleural effusion. There has been interval CABG with left pleural effusion and left lower lobe atelectasis consistent with recent aspiration. IS WELL GOOD COUGH NOT RAISING. NTG off. Freq PVC's. There are nsowdiffuse ST-T wave abnormalities. Correlation with physical exam findings is suggested to exclude dehiscence. DISTAL PULSES PRESENT IN LT FOOT DP AND PT BY DOPPLER. A-V conduction delay. The pulmonary vessels are within normal limits. The pulmonary vessels are within normal limits. Normal abdominal ultrasound. DENIES ANY C/O'S OF SOB. Diffusenon-specific ST-T wave abnormalities. Otherwise, no apparent diagnostic interimchange. HCT 23PLAN: pain mgmt, wean neo, transfuse as needed. Status post CABG. TECHNIQUE: A single view of the chest. CI >3.0. HCT 26.2 HO AWARE.AMB WITH PT TOLERATED WELL. PT HAVING LG AMTS OF PVC'S AND POTASSIUM, CA, AND MG REPLACED WITHOUT EFFECT ON PVC'S. DRAINAGE BUT DOES DUMP MOD AMTS WITH SITTING UP OR GETTING UP OOB.CARDIOVAS; A-PACED 90 FOR SBP SUPPORT. ileus FINAL REPORT ABDOMEN TWO VIEWS. NBP 110. The aorta is of normal caliber throughout. Compared to the previous tracingof the frequency of ventricular ectopy has diminished. IMPRESSION: 1) Post operative changes. GU: GOOD UO. PT USING I.S. 7P-7A CSRU SHIFT SUMMARY;NEURO; ALERT, ORIENTED, FOLLOWS COMMANDS, AND MAE'S WELL. REASON FOR THIS EXAMINATION: Please rule out pulmonary edema. PT DENIES ANY C/O'S SOB. Patient with benign abdominal exam. NEURO: A+O, PLEASANT , FOLLOWS COMMANDS,MAE. COUGHING OCC. HCT 23. ALINE DC'D . Sinus rhythmFrequent ventricular ectopyPrior inferior infarctProminent voltage in leads l, aVL for left ventricular hypertrophyCompared with the ECG of , the lateral ST-T wave abnormalities are moreprominent, and ventricular ectopy has increasedOtherwise no diagnostic interim changeClinical correlation is suggested 7:53 PM CHEST (PA & LAT) Clip # Reason: Please rule out pulmonary edema. Oozy from hemovac site l groin. CSM WNL FOOT WARM.GI; BS HYPOACTIVE TAKING AND TOLERATING PO'S WITH NO C/O'S NAUSEA. WITHOUT DIFFICULTY PER PT. NO BM THIS SHIFT. UNDERLYING SB WITH DROP IN SBP. FINDINGS: The heart and mediastinum are normal in size. There is a left pleural effusion and atelectasis at the left lung base. Fairly good cough. 1:38 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: ? LT GROIN POSITIVE SOFT LG HEMATOMA WITH HEMAVAC AT LT GROIN DRAINING MINIMAL SANQ DRAINAGE BUT AROUND INSERTION SITE PT OOZING MOD AMT BLOODY DRAINAGE REQUIRING A DSD CHANGE DURING THE NOC. DR AWARE OF HEMATOMA AND IN TO ASSESS DURING THE NOC. A few gas-filled loops of small bowel in the left abdomen, nonspecific. PRESSURE DRESSING CDI AT LT GROIN AND HEMAVAC INTACT AND DRAINING BLOODY DRAINAGE. Has palpable pedal pulses.NEURO: A+Ox3, mae and following comands. USING HIS I.S. IMPRESSION: No evidence of cholecystitis. TAKING AND TOLERATING PO'S WELL WITH NO C/O'S NAUSEA.COMFORT; NO C/O'S DISCOMFORT ALL SHIFT EXCEPT STARTED C/O BACK DISCOMFORT AROUND 0430 AND PT GIVEN 2 PERCOCETS PO AND AWAITING EFFECT.PLAN; CONT TO MONITOR AND ASSESS AND TRANSFER TO 2 THIS AM. TRANSFER TO FLOOR-DC INTRODUCER.AS PER ORDERS. Given 2mg mso4 incrementally for pain with moderate effect.SKIN: Chest and leg incision dsd's are intact and dry. No free intraperitoneal gas. ACE WRAP TO LT LEG INTACT. IMPRESSION: No heart failure or pneumonia. IMPRESSION: No evidence for intestinal obstruction. Encourage to cough and deep breath and notify staff if having pain.CV: Bp labile initially. BUT DOESN'T APPEAR TO HAVE ALOT OF SECREATIONS. HCT SENT 22 TX WITH 2U PRBC'S. Comparison . PAIN: RECIEVED 2 PERCOCET X 2 FOR BACK AND INCISIONAL DISCOMFORT WITH GOOD EFFECT.A: STABLE AT PRESENTP:MONITOR COMFORT, HR AND RHYTHYM, SBP, DSGS, RIGHT FEM SITE, PP, I+O, LABS. ALTERED CARDIAC STATUSS; "I FEEL SO MUCH BETTER"O: CARDIAC: A PACED @ 90 TO SR 60'S-70'S WITH FREQUENT PVC'S. | 13 | [
{
"category": "Radiology",
"chartdate": "2181-01-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 780424,
"text": " 9:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n FINDINGS: Single frontal view chest. Comparison . There has been\n interval CABG with left pleural effusion and left lower lobe atelectasis\n consistent with recent aspiration. There is a small left apical pneumothorax.\n There is no congestive heart failure.\n\n IMPRESSION:\n 1) Post operative changes.\n\n 2) Small left apical pneumothorax.\n\n Please note that the sternal wires are malaligned. Correlation with physical\n exam findings is suggested to exclude dehiscence.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-01-08 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 781128,
"text": " 2:32 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: ABDOMINAL PAIN, RUQ PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p CABG x3, now with nausea, jaundice, elevated bilirubin,\n benign abdominal exam.\n REASON FOR THIS EXAMINATION:\n ? acalculous cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72 year old male status post CABG with nausea, jaundice, and\n elevated bilirubin. Patient with benign abdominal exam. Evaluate for\n acalculus cholecystitis.\n\n FINDINGS: There are no examinations available for comparison.\n\n The gallbladder is normal in appearance with no evidence of gallstones,\n sludge, gallbladder wall thickening, or pericholecystic fluid. The common\n duct is not dilated, measuring 4 mm in greatest dimension. The liver is\n normal in contour and echo texture, and no focal masses are identified within\n the liver. Both kidneys are normal in appearance, with no evidence of\n hydronephrosis, masses, or stones. The pancreas and spleen are unremarkable.\n The aorta is of normal caliber throughout.\n\n IMPRESSION: No evidence of cholecystitis. Normal abdominal ultrasound.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-01-05 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 780914,
"text": " 7:53 PM\n CHEST (PA & LAT) Clip # \n Reason: Please rule out pulmonary edema.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with cad s/p cabg with new oxygen requirement.\n REASON FOR THIS EXAMINATION:\n Please rule out pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG, hypoxia.\n\n TECHNIQUE: Chest PA and lateral.\n\n Comparison with prior study from .\n\n FINDINGS: There is a median sternotomy and CABG. The heart is stable in\n size. The aorta is unfolded. The pulmonary vessels are within normal limits.\n There is blunting of the right CP angle secondary to a small pleural\n effusion. There has been interval increase in the size of the left pleural\n effusion which is moderate in size. The left apical pneumothorax has almost\n completely resolved in the interval.\n\n IMPRESSION: Moderate-sized left pleural effusion. Tiny left apical\n pneumothorax. Small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2181-01-06 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 780958,
"text": " 1:38 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ? ileus\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p CABG x3, now with nausea/vomiting, poor bowel function.\n REASON FOR THIS EXAMINATION:\n ? ileus\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN TWO VIEWS.\n\n History of CABG with nausea, vomiting and diminished bowel movements.\n\n There are a few nondilated gas-filled loops of small bowel in the left\n abdomen. Gas is present throughout the colon and in the rectum. No free\n intraperitoneal gas. There is a left pleural effusion and atelectasis at the\n left lung base. Status post CABG.\n\n IMPRESSION: No evidence for intestinal obstruction. A few gas-filled loops\n of small bowel in the left abdomen, nonspecific.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2180-12-28 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 780197,
"text": " 7:28 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: ANGINA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with cad preop for cabg\n REASON FOR THIS EXAMINATION:\n preop cabg\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preop for CABG.\n\n TECHNIQUE: A single view of the chest.\n\n FINDINGS: The heart and mediastinum are normal in size. The pulmonary\n vessels are within normal limits. There are no consolidations, pleural\n effusions or pneumothoraces. The bones reveal degenerative changes in the\n spine.\n\n IMPRESSION: No heart failure or pneumonia.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-12-31 00:00:00.000",
"description": "Report",
"row_id": 1575190,
"text": "ALTERED CARDIAC STATUS\nS; \"I FEEL SO MUCH BETTER\"\nO: CARDIAC: A PACED @ 90 TO SR 60'S-70'S WITH FREQUENT PVC'S. K PENDING. SBP 140'S THEREFORE NEO OFF AT 1400. ALINE DC'D . NBP 110. DSGS D+I. RIGHT FEM DSG WITH SANGUINOUS DRAINAGE.DOPP PP. RIGHT FEM SITE ECCHYMOTIC SOFT. HCT 26.2 HO AWARE.AMB WITH PT TOLERATED WELL.\n RESP: O2 INCREASED TO 5 L NP DUE TO P02 69 ON 3.5L. O2 SATS PRESENTLY 99%. IS WELL GOOD COUGH NOT RAISING. BS DIMINISHED BIBASILAR.NO CT LEAK.\n NEURO: A+O, PLEASANT , FOLLOWS COMMANDS,MAE.\n GI: REFUSED DINNER, TAKING WATER, HYPOACTIVE BOWEL SOUNDS, DENIES NAUSEA.\n GU: GOOD UO.\n SOCIAL: FAMILY INTO VISIT.\n PAIN: RECIEVED 2 PERCOCET X 2 FOR BACK AND INCISIONAL DISCOMFORT WITH GOOD EFFECT.\nA: STABLE AT PRESENT\nP:MONITOR COMFORT, HR AND RHYTHYM, SBP, DSGS, RIGHT FEM SITE, PP, I+O, LABS. ? TRANSFER TO FLOOR-DC INTRODUCER.AS PER ORDERS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-01-01 00:00:00.000",
"description": "Report",
"row_id": 1575191,
"text": " 7P-7A CSRU SHIFT SUMMARY;\n\nNEURO; ALERT, ORIENTED, FOLLOWS COMMANDS, AND MAE'S WELL. SON IN AND VISITED THIS EVENING AND THEY WATCHED THE SUPERBOWL GAME TOGATHER. PT APPEARS TO BE IN BETTER SPIRITS THIS EVENING.\n\nRESP; LUNGS CLEAR DIM IN THE BASES. 02 SAT'S WNL ON 5L N/C. PT DENIES ANY C/O'S SOB. USING HIS I.S. VERY FREQ. COUGHING OCC. BUT DOESN'T APPEAR TO HAVE ALOT OF SECREATIONS. CHEST TUBES DRAINING MINIMAL THIN SEROSANQ. DRAINAGE.\n\nCARDIOVAS; SR FREQ PVC'S BEGGINING OF SHIFT BUT AS NOC PROGRESSED THEY SEEMED TO BE ALOT LESS FREQ. SBP WNL AND MAP >60 AND <90 OFF OF NEO ALL SHIFT. LT GROIN REMAINS ECCYMOTIC WITH LG SOFT HEMATOMA. PRESSURE DRESSING CDI AT LT GROIN AND HEMAVAC INTACT AND DRAINING BLOODY DRAINAGE. ACE WRAP TO LT LEG INTACT. DISTAL LT. LEG DP AND PT'S POSITIVE BY DOPPLER AND CSM WNL.\n\nGI; BS PRESENT NO BM THIS SHIFT. TAKING AND TOLERATING PO'S WELL WITH NO C/O'S NAUSEA.\n\nCOMFORT; NO C/O'S DISCOMFORT ALL SHIFT EXCEPT STARTED C/O BACK DISCOMFORT AROUND 0430 AND PT GIVEN 2 PERCOCETS PO AND AWAITING EFFECT.\n\nPLAN; CONT TO MONITOR AND ASSESS AND TRANSFER TO 2 THIS AM.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-12-29 00:00:00.000",
"description": "Report",
"row_id": 1575188,
"text": "RESP: Extubated @ 1745. Fairly good cough. No secretions. Lungs are clear but dim @ bases. SPO2 99% on 50% venti. Encourage to cough and deep breath and notify staff if having pain.\n\nCV: Bp labile initially. No obvious signs of bleeding. HCT 23. CI >3.0. Given 2L LR and 1000cc hespan. Titrated/ weaned iv ntg and neo. Bp stable on .5mcg/kg/min NEO. NTG off. A paced 80's. Freq PVC's. Underlying rhythm nsr 60's-70's. Repleted ca, k, mg with effect. Skin is warm and dry. Has palpable pedal pulses.\n\nNEURO: A+Ox3, mae and following comands. Given 2mg mso4 incrementally for pain with moderate effect.\n\nSKIN: Chest and leg incision dsd's are intact and dry. Oozy from hemovac site l groin. No signs of hematoma. Dsd changed.\n\nGU: Adequate urine output through foley. CYU.\n\nENDO: Fs covered with RISS.\n\nASSESS: Stable on neo. Altered comfort r/t incision pain. HCT 23\n\nPLAN: pain mgmt, wean neo, transfuse as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-12-31 00:00:00.000",
"description": "Report",
"row_id": 1575189,
"text": " 7P-7A CSRU SHIFT SUMMARY;\n\nNEURO; ALERT ORIENTED FOLLOWS COMMANDS AND MOVES ALL EXTREMITIES WELL. SLEPT POOR OVER NOC JUST WASN'T COMFORTABLE IN THE BED AND REFUSED TO TAKE PAIN MED TIL THIS AM FOR BACK PAIN. PT MED WITH 2 PERCOCETS PO AND APPEARS TO BE HELPING THE DISCOMFORT ACCORDING TO PATIENT.\n\nRESP; LUNGS CLEAR 02 SAT'S AND RR WNL ON 4L N/C. DENIES ANY C/O'S OF SOB. PT USING I.S. WITHOUT DIFFICULTY PER PT. CHEST TUBES DRAINING SM AMT THIN SEROSANQ. DRAINAGE BUT DOES DUMP MOD AMTS WITH SITTING UP OR GETTING UP OOB.\n\nCARDIOVAS; A-PACED 90 FOR SBP SUPPORT. UNDERLYING SB WITH DROP IN SBP. PT HAVING LG AMTS OF PVC'S AND POTASSIUM, CA, AND MG REPLACED WITHOUT EFFECT ON PVC'S. PT ON LOW DOSES OF NEO AND UNABLE TO WEAN WHEN TITRATED OFF PT DROPS MAP <60 REQUIRING NEO TO BE CONTINUED. LT GROIN POSITIVE SOFT LG HEMATOMA WITH HEMAVAC AT LT GROIN DRAINING MINIMAL SANQ DRAINAGE BUT AROUND INSERTION SITE PT OOZING MOD AMT BLOODY DRAINAGE REQUIRING A DSD CHANGE DURING THE NOC. DR AWARE OF HEMATOMA AND IN TO ASSESS DURING THE NOC. HCT SENT 22 TX WITH 2U PRBC'S. DISTAL PULSES PRESENT IN LT FOOT DP AND PT BY DOPPLER. CSM WNL FOOT WARM.\n\nGI; BS HYPOACTIVE TAKING AND TOLERATING PO'S WITH NO C/O'S NAUSEA. NO BM THIS SHIFT. PT ON COLACE PO BID.\n\nGU; URINE OP WNL.\n\nENDO; BLD SUGARS WNL DID NOT REQUIRE ANY INSULIN OVER NOC.\n\nPLAN; CONT TO MONITOR AND ASSESS. MONITOR HCT LYTES AND LT GROIN HEMATOMA. TRANSFER TO 2 WHEN ORDERD BY TEAM.\n"
},
{
"category": "ECG",
"chartdate": "2180-12-28 00:00:00.000",
"description": "Report",
"row_id": 167103,
"text": "Sinus rhythm\nFrequent ventricular ectopy\nPrior inferior infarct\nProminent voltage in leads l, aVL for left ventricular hypertrophy\nCompared with the ECG of , the lateral ST-T wave abnormalities are more\nprominent, and ventricular ectopy has increased\nOtherwise no diagnostic interim change\nClinical correlation is suggested\n\n"
},
{
"category": "ECG",
"chartdate": "2180-12-29 00:00:00.000",
"description": "Report",
"row_id": 167104,
"text": "Sinus rhythm and occasional ventricular ectopy. A-V conduction delay. Diffuse\nnon-specific ST-T wave abnormalities. Compared to the previous tracing\nof the frequency of ventricular ectopy has diminished. There are nsow\ndiffuse ST-T wave abnormalities. Otherwise, no apparent diagnostic interim\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-12-28 00:00:00.000",
"description": "Report",
"row_id": 167105,
"text": "Sinus rhythm with ventricular bigeminy. No change since earlier this date.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2180-12-28 00:00:00.000",
"description": "Report",
"row_id": 167106,
"text": "Sinus rhythm with ventricular bigeminy. Borderline first degree A-V block.\nNon-specific T wave abnormalities. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
44,156 | 181,689 | 63 yo retired neurologist with history of hypertension and osteoarthritis who presented for a left total knee replacement who was transferred to the for pain control and episodes of apnea and desaturations. He remained stable overnight and was transfered to the floor in stable condition. Epidural catheter was removed and he was started on lovenox and percocet. He continued to work with PT and will be d/c to home with services in stable condition. | pt closely for apnea. edu re: plan of care, discharge plan, role of PT, proper LLE positioning, post-op therex, current WB precautions Intervention: Other: Diagnosis: 1. Will start lovenox for DVT ppx this AM when off epidural pain regimen, until then will maintain pneumoboots on right. Will start lovenox for DVT ppx this AM when off epidural pain regimen, until then will maintain pneumoboots on right. Will start lovenox for DVT ppx this AM when off epidural pain regimen, until then will maintain pneumoboots on right. Pt p/w above impairments associated with practice pattern total joint arthroplasty. Pt p/w above impairments associated with practice pattern total joint arthroplasty. Ortho and Acute Pain Service following. Ortho and Acute Pain Service following. Ortho and Acute Pain Service following. Ortho and Acute Pain Service following. PPX: -DVT ppx with pneumoboots, lovenox once off epidural -Bowel regimen ppi, colace, senna, bisacodyl -Pain management with epidural, naproxen PRN . - Appreciate Pain Service recommendations - Pain controlled overnight with intrathecal dilaudid/bupivicaine combination, toradol and naproxen - f/u pain management recs this AM . - Appreciate Pain Service recommendations - Pain controlled overnight with intrathecal dilaudid/bupivicaine combination, toradol and naproxen - f/u pain management recs this AM . - Appreciate Pain Service recommendations - Pain controlled overnight with intrathecal dilaudid/bupivicaine combination, toradol and naproxen - f/u pain management recs this AM . He was changed to an epidural with bupivacaine only. He was changed to an epidural with bupivacaine only. Will start lovenox for DVT ppx when off epidural pain regimen, until then will maintain pneumoboots on right. We are reconsulting pain service. Education / Communication: re: plan of care, discharge plan, role of PT, proper LLE positioning, post-op therex, current WB precautions Intervention: Other: Diagnosis: 1. Knowledge deficit re: post surgical precautions. Knowledge deficit re: post surgical precautions. Functional Status: Activity Clarification I S CG Min Mod Max Gait, Locomotion: Pt amb 5 ft c BAC and CGA. Currently, the patient has adequate oxygenation on nasal cannula, and is no longer apneic. Clinical impression / Prognosis: Pt is a 63 yo M POD #1 L TKR. Clinical impression / Prognosis: Pt is a 63 yo M POD #1 L TKR. Apnea/desaturations: Likely secondary to large narcotic doses postoperatively. Overnight, the patient had adequate oxygenation on nasal cannula, and was no longer apneic. Overnight, the patient had adequate oxygenation on nasal cannula, and was no longer apneic. Overnight, the patient had adequate oxygenation on nasal cannula, and was no longer apneic. Plan: Cont with epidural. APNEA : Likely secondary to large narcotic doses postoperatively. APNEA : Likely secondary to large narcotic doses postoperatively. APNEA : Likely secondary to large narcotic doses postoperatively. Will use CPAP overnight as needed, will likely need CPAP as an outpatient. Attending Physician: , Referral date: Medical Diagnosis / ICD 9: L TKR / 715.96 Reason of referral: Eval and Treat History of Present Illness / Subjective Complaint: Pt is a 63 yo M, POD #1 LTKR. Attending Physician: , Referral date: Medical Diagnosis / ICD 9: L TKR / 715.96 Reason of referral: Eval and Treat History of Present Illness / Subjective Complaint: Pt is a 63 yo M, POD #1 LTKR. He is being transferred to the for monitoring and pain control. Pt able to advance LLE indep., decreased step length and cadence. EMERGENCY CONTACT: HCP, partner, . Functional Status: Activity Clarification I S CG Min Mod Max Gait, Locomotion: Pt amb 5 ft c Bilat. + reflexes, equal BL. ABDOMEN: NABS. Pt I HEP. PERRLA/EOMI. Pt able to advance LLE I. Pt decreased step length and cadence. Anticipate pt will progress to discharge home c PT in visits. Anticipate pt will progress to discharge home c PT in visits. 63 yo transferred from PACU for hypoxia in setting of narcotic admin for TNR. A surgical drain is noted. Response: By 2115 pt was and dozing. Hypertension: Patient's blood pressure is currently well controlled off medications. Hypertension: Patient's blood pressure is currently well controlled off medications. Hypertension: Patient's blood pressure is currently well controlled off medications. Hypertension: Patient's blood pressure is currently well controlled off medications. Pt performs HEPindep. Pt transferred from PACU to unit for hypoxia in setting of narcotic administration. Pt transferred from PACU to unit for hypoxia in setting of narcotic administration. Trace edema on right. Trace edema on right. ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:20 PM Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: ICU L TKR: POD 0. | 12 | [
{
"category": "Physician ",
"chartdate": "2110-11-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 713457,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 05:00 AM\n URINE CULTURE - At 05:00 AM\n FEVER - 101.7\nF - 01:54 AM\n Requested pain medication and received toradol and naproxen in addition\n to dilaudid through epidural. Fell asleep and had no apneic events or\n desaturations; did not require CPAP.\n Fever to 101.7 at 2 am. Cultures sent.\n This AM, patient reports\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.4\nC (99.3\n HR: 90 (90 - 110) bpm\n BP: 103/69(77) {90/61(71) - 120/78(87)} mmHg\n RR: 11 (11 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,460 mL\n 784 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 400 mL\n 544 mL\n Blood products:\n 2,700 mL\n Total out:\n 1,700 mL\n 350 mL\n Urine:\n 415 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,760 mL\n 434 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 3 L\n Ventilator mode: Standby\n Physical Examination\n Labs / Radiology\n 220 K/uL\n 11.2 g/dL\n 119 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 104 mEq/L\n 136 mEq/L\n 32.4 %\n 10.0 K/uL\n [image002.jpg]\n 04:52 AM\n WBC\n 10.0\n Hct\n 32.4\n Plt\n 220\n Cr\n 0.8\n Glucose\n 119\n Other labs: PT / PTT / INR:14.1/25.8/1.2, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n OBSTRUCTIVE SLEEP APNEA (OSA)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ARTHRITIS, OSTEO (OSTEOARTHRITIS, OA)\n HYPERTENSION, BENIGN\n ICU Care\n Nutrition: Regular cardiac diet\n Glycemic Control:\n Lines:\n 18 Gauge - 06:20 PM\n Prophylaxis:\n DVT: Lovenox to restart this AM\n Stress ulcer: PO PPI\n VAP:\n Comments: bowel regimen with senna, colace, bisacodyl, pain regimen\n with epidural, naproxen and toradol\n Communication: Comments:\n Code status: Full code\n Disposition: Call out to orthopedics team\n"
},
{
"category": "Physician ",
"chartdate": "2110-11-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 713460,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 05:00 AM\n URINE CULTURE - At 05:00 AM\n FEVER - 101.7\nF - 01:54 AM\n Requested pain medication and received toradol and naproxen in addition\n to dilaudid through epidural. Fell asleep and had no apneic events or\n desaturations; did not require CPAP.\n Fever to 101.7 at 2 am. Cultures sent.\n This AM, patient reports\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.4\nC (99.3\n HR: 90 (90 - 110) bpm\n BP: 103/69(77) {90/61(71) - 120/78(87)} mmHg\n RR: 11 (11 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,460 mL\n 784 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 400 mL\n 544 mL\n Blood products:\n 2,700 mL\n Total out:\n 1,700 mL\n 350 mL\n Urine:\n 415 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,760 mL\n 434 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 3 L\n Ventilator mode: Standby\n Physical Examination\n Labs / Radiology\n 220 K/uL\n 11.2 g/dL\n 119 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 104 mEq/L\n 136 mEq/L\n 32.4 %\n 10.0 K/uL\n [image002.jpg]\n 04:52 AM\n WBC\n 10.0\n Hct\n 32.4\n Plt\n 220\n Cr\n 0.8\n Glucose\n 119\n Other labs: PT / PTT / INR:14.1/25.8/1.2, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n 63 yo retired neurologist with history of hypertension and\n osteoarthritis is POD 1 of L transferred to the for pain\n control and episodes of apnea and desaturations.\n .\n APNEA : Likely secondary to large narcotic doses postoperatively.\n Overnight, the patient had adequate oxygenation on nasal cannula, and\n was no longer apneic. Given patient's body habitus and history of\n snoring/daytime sleepiness, he likely has sleep apnea. CPAP not\n required overnight, but patient would likely benefit from CPAP as an\n outpatient.\n - Hold additional systemic narcotics, epidural for pain control (see\n below)\n - Will use narcan only if patient has prolonged apnea\n - Wean supplemental oxygen\n .\n ORTHOPEDIC DEVICE INFECTION (HARDWARE INFECTION, PROSTHETIC JOINT,\n ORTHOPAEDIC)\n L TKR: POD 1. Ortho and Acute Pain Service following. Will\n continue post-op cefazolin for total of 3 doses. Weight bearing status\n per ortho, currently on bedrest. Will require PT consult eventually.\n Will start lovenox for DVT ppx this AM when off epidural pain regimen,\n until then will maintain pneumoboots on right.\n - Appreciate Pain Service recommendations\n - Pain controlled overnight with intrathecal dilaudid/bupivicaine\n combination, toradol and naproxen\n - f/u pain management recs this AM\n .\n #. Hypertension: Patient's blood pressure is currently well\n controlled off medications. Will restart home lisinopril 40mg in AM.\n .\n ICU Care\n Nutrition: Regular cardiac diet\n Glycemic Control:\n Lines:\n 18 Gauge - 06:20 PM\n Prophylaxis:\n DVT: Lovenox to restart this AM, pneumoboots until then\n Stress ulcer: PO PPI\n VAP:\n Comments: bowel regimen with senna, colace, bisacodyl, pain regimen\n with epidural, naproxen and toradol\n Communication: Comments: Partner and HCP, partner, \n \n Code status: Full code\n Disposition: Call out to orthopedics team\n"
},
{
"category": "Physician ",
"chartdate": "2110-11-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 713461,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 05:00 AM\n URINE CULTURE - At 05:00 AM\n FEVER - 101.7\nF - 01:54 AM\n Requested pain medication and received toradol and naproxen in addition\n to dilaudid through epidural. Fell asleep and had no apneic events or\n desaturations; did not require CPAP.\n Fever to 101.7 at 2 am. Cultures sent.\n This AM, patient reports feeling well. Pain this am . No other\n complaints, breathing comfortably. Fever/chills resolved this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.4\nC (99.3\n HR: 90 (90 - 110) bpm\n BP: 103/69(77) {90/61(71) - 120/78(87)} mmHg\n RR: 11 (11 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,460 mL\n 784 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 400 mL\n 544 mL\n Blood products:\n 2,700 mL\n Total out:\n 1,700 mL\n 350 mL\n Urine:\n 415 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,760 mL\n 434 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 3 L\n Ventilator mode: Standby\n Physical Examination\n Gen: well-appearing middle aged man, sitting up in bed, NAD\n HEENT: NCAT, PERRL, OP clear, MMM, neck supple\n CV: RRR, nl S1, S2, no m/r/g\n Pulm: CTAB\n Abd: soft, NT, ND, +BS\n Extrem: Left leg in large soft cast, right in pneumoboots. Trace edema\n on right. 2+ DP pulses b/l\n Labs / Radiology\n 220 K/uL\n 11.2 g/dL\n 119 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 104 mEq/L\n 136 mEq/L\n 32.4 %\n 10.0 K/uL\n [image002.jpg]\n 04:52 AM\n WBC\n 10.0\n Hct\n 32.4\n Plt\n 220\n Cr\n 0.8\n Glucose\n 119\n Other labs: PT / PTT / INR:14.1/25.8/1.2, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:3.1 mg/dL\n U/A neg\n Urine Cx pend\n Blood Cx pend\n No new imaging\n Assessment and Plan\n 63 yo retired neurologist with history of hypertension and\n osteoarthritis is POD 1 of L transferred to the for pain\n control and episodes of apnea and desaturations.\n .\n APNEA : Likely secondary to large narcotic doses postoperatively.\n Overnight, the patient had adequate oxygenation on nasal cannula, and\n was no longer apneic. Given patient's body habitus and history of\n snoring/daytime sleepiness, he likely has sleep apnea. CPAP not\n required overnight, but patient would likely benefit from CPAP as an\n outpatient.\n - Hold additional systemic narcotics, epidural for pain control (see\n below)\n - Will use narcan only if patient has prolonged apnea\n - Wean supplemental oxygen\n .\n ORTHOPEDIC DEVICE INFECTION (HARDWARE INFECTION, PROSTHETIC JOINT,\n ORTHOPAEDIC)\n L TKR: POD 1. Ortho and Acute Pain Service following. Will\n continue post-op cefazolin for total of 3 doses. Weight bearing status\n per ortho, currently on bedrest. Will require PT consult eventually.\n Will start lovenox for DVT ppx this AM when off epidural pain regimen,\n until then will maintain pneumoboots on right.\n - Appreciate Pain Service recommendations\n - Pain controlled overnight with intrathecal dilaudid/bupivicaine\n combination, toradol and naproxen\n - f/u pain management recs this AM\n .\n #. Hypertension: Patient's blood pressure is currently well\n controlled off medications. Will restart home lisinopril 40mg in AM.\n .\n ICU Care\n Nutrition: Regular cardiac diet\n Glycemic Control:\n Lines:\n 18 Gauge - 06:20 PM\n Prophylaxis:\n DVT: Lovenox to restart this AM, pneumoboots until then\n Stress ulcer: PO PPI\n VAP:\n Comments: bowel regimen with senna, colace, bisacodyl, pain regimen\n with epidural, naproxen and toradol\n Communication: Comments: Partner and HCP, partner, \n \n Code status: Full code\n Disposition: Call out to orthopedics team\n"
},
{
"category": "Physician ",
"chartdate": "2110-11-19 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 713467,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 05:00 AM\n URINE CULTURE - At 05:00 AM\n FEVER - 101.7\nF - 01:54 AM\n Requested pain medication and received toradol and naproxen in addition\n to dilaudid through epidural. Fell asleep and had no apneic events or\n desaturations; did not require CPAP.\n Fever to 101.7 at 2 am. Cultures sent.\n This AM, patient reports feeling well. Pain this am . No other\n complaints, breathing comfortably. Fever/chills resolved this morning.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 37.4\nC (99.3\n HR: 90 (90 - 110) bpm\n BP: 103/69(77) {90/61(71) - 120/78(87)} mmHg\n RR: 11 (11 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 3,460 mL\n 784 mL\n PO:\n 360 mL\n 240 mL\n TF:\n IVF:\n 400 mL\n 544 mL\n Blood products:\n 2,700 mL\n Total out:\n 1,700 mL\n 350 mL\n Urine:\n 415 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,760 mL\n 434 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 3 L\n Ventilator mode: Standby\n Physical Examination\n Gen: well-appearing middle aged man, sitting up in bed, NAD\n HEENT: NCAT, PERRL, OP clear, MMM, neck supple\n CV: RRR, nl S1, S2, no m/r/g\n Pulm: CTAB\n Abd: soft, NT, ND, +BS\n Extrem: Left leg in large soft cast, right in pneumoboots. Trace edema\n on right. 2+ DP pulses b/l\n Labs / Radiology\n 220 K/uL\n 11.2 g/dL\n 119 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 15 mg/dL\n 104 mEq/L\n 136 mEq/L\n 32.4 %\n 10.0 K/uL\n [image002.jpg]\n 04:52 AM\n WBC\n 10.0\n Hct\n 32.4\n Plt\n 220\n Cr\n 0.8\n Glucose\n 119\n Other labs: PT / PTT / INR:14.1/25.8/1.2, Ca++:7.9 mg/dL, Mg++:1.6\n mg/dL, PO4:3.1 mg/dL\n U/A neg\n Urine Cx pend\n Blood Cx pend\n No new imaging\n Assessment and Plan\n 63 yo retired neurologist with history of hypertension and\n osteoarthritis is POD 1 of L transferred to the for pain\n control and episodes of apnea and desaturations.\n .\n APNEA : Likely secondary to large narcotic doses postoperatively.\n Overnight, the patient had adequate oxygenation on nasal cannula, and\n was no longer apneic. Given patient's body habitus and history of\n snoring/daytime sleepiness, he likely has sleep apnea. CPAP not\n required overnight, but patient would likely benefit from CPAP as an\n outpatient.\n - Hold additional systemic narcotics, epidural for pain control (see\n below)\n - Will use narcan only if patient has prolonged apnea\n - Wean supplemental oxygen\n .\n ORTHOPEDIC DEVICE INFECTION (HARDWARE INFECTION, PROSTHETIC JOINT,\n ORTHOPAEDIC)\n L TKR: POD 1. Ortho and Acute Pain Service following. Will\n continue post-op cefazolin for total of 3 doses. Weight bearing status\n per ortho, currently on bedrest. Will require PT consult eventually.\n Will start lovenox for DVT ppx this AM when off epidural pain regimen,\n until then will maintain pneumoboots on right.\n - Appreciate Pain Service recommendations\n - Pain controlled overnight with intrathecal dilaudid/bupivicaine\n combination, toradol and naproxen\n - f/u pain management recs this AM\n .\n #. Hypertension: Patient's blood pressure is currently well\n controlled off medications. Will restart home lisinopril 40mg in AM.\n .\n ICU Care\n Nutrition: Regular cardiac diet\n Glycemic Control:\n Lines:\n 18 Gauge - 06:20 PM\n Prophylaxis:\n DVT: Lovenox to restart this AM, pneumoboots until then\n Stress ulcer: PO PPI\n VAP:\n Comments: bowel regimen with senna, colace, bisacodyl, pain regimen\n with epidural, naproxen and toradol\n Communication: Comments: Partner and HCP, partner, \n \n Code status: Full code\n Disposition: Call out to orthopedics team this AM\n"
},
{
"category": "Rehab Services",
"chartdate": "2110-11-19 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 713485,
"text": "Attending Physician: , \n Referral date: \n Medical Diagnosis / ICD 9: L TKR / 715.96\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: Pt is a 63 yo M, POD\n #1 LTKR. Pt transferred from PACU to unit for hypoxia in setting of\n narcotic administration.\n Past Medical / Surgical History: HTN, anklyosing spondylitis-fused SIJ\n B, obesity, childhood asthma, OA, R knee meniscal debridement, L knee\n meniscal debridement x 2, tonsillectomy\n Medications: Hydromorphine, ketorolac, magnesium sulfate,potassium\n chloride, enoxaparin sodium\n Radiology: Knee X-ray: Left total knee prosthesis in satisfactory\n position with expected post-surgical changes in the region.\n Labs:\n 32.4\n 11.2\n 220\n 10.0\n [image002.jpg]\n Other labs:\n Activity Orders: OOB w/assist, LLE WBAT\n Social / Occupational History: Retired neurologist, -tobacco, +ETOH,\n lives with partner, owns computer software company\n Living Environment: Lives in loft, elevator access\n Prior Functional Status / Activity Level: PTA I ADLs, h/o BAC use for\n amb for post surgical\n Objective Test\n Arousal / Attention / Cognition / Communication: A + O x 3. Follows\n 100% of complex commands. Communicates clearly and appropriately.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 88\n 112/64\n 28\n 95\n Rest\n 88\n 112/64\n 28\n 95\n Sit\n 116/70\n Activity\n 93\n /\n 22\n 98\n Stand\n 93\n /\n 22\n 98\n Recovery\n 90\n 117/63\n 24\n 98\n Total distance walked: 5 feet\n Minutes: 5 min\n Pulmonary Status: - cough, - SOB, nonlabored breathing\n Integumentary / Vascular: JP drain in place, LLE wrapped in ace\n bandages and padding/dressing, epidural in place, L arm PIV, LLE toes\n warm and well perfused.\n Sensory Integrity: - c/o numbness/tingling per pt, able to detect light\n touch LLE distal to bandages\n Pain / Limiting Symptoms: at rest L knee, with mobility\n Posture: Obesity, B hip external rotation existing previously\n Range of Motion\n Muscle Performance\n L knee flexion/ext = -16 to 60 Limited bandaging\n All other LE and UE joints B WFL through AROM and transfers\n L hip flex 3-/5, BUE and RLE appear > through function\n Motor Function: Able to advance LLE during gait, unable to move in\n isolation against gravity off bed.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt amb 5 ft c BAC and CGA. Pt able to advance LLE I.\n Pt decreased step length and cadence. Pt increased trunk\n flexion. Pt I with AC transfer hand to hand.\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n WBAT L LE\n\n\n\n T\n\n\n Ambulation:\n WBAT L LE\n\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: (-) LOB EOB seated I, (-) LOB during amb, static standing c\n BAC I balance.\n Education / Communication: re: plan of care, discharge plan, role of\n PT, proper LLE positioning, post-op therex, current WB precautions\n Intervention:\n Other:\n Diagnosis:\n 1.\n Knowledge deficit re: post surgical precautions.\n 4.\n Impaired mobility/gait.\n 2.\n Impaired L knee flexibility.\n 5.\n Impaired endurance/activity tolerance.\n 3.\n Impaired LLE strength.\n 6.\n Clinical impression / Prognosis: Pt is a 63 yo M POD #1 L TKR. Pt p/w\n above impairments associated with practice pattern total joint\n arthroplasty. Pt current status appears below baseline function. Pt\n would continue to benefit from further acute PT services. Anticipate pt\n will progress to discharge home c PT in visits. Expect pt to make\n full recovery to PLOF pt motivation, age, PLOF, and support at\n home.\n Goals\n Time frame: 1 week\n 1.\n Pt acknowledges role of mobility.\n 2.\n Pt L knee flexion 0-90 degrees.\n 3.\n Pt I HEP.\n 4.\n Pt I bed mobility.\n 5.\n Pt I sit to stand c AC.\n 6.\n Pt amb c BAC x 300ft I.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: Daily\n Transfer training, gait training with BAC, endurance training, daily\n therex and PROM, CPM use 3x daily as tolerated, balance training, pt ed\n re fall prevention.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Nursing",
"chartdate": "2110-11-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713446,
"text": "is a 63 yo male who was transferred from PACU for hypoxia in setting\n of narcotic admin for TNR. He likely has obstructive sleep apnea. He\n was becoming hypoxic to 50% and apnic after he was given narcotics.\n The PACU attempt mask ventilation but this was only partially\n successful. He was changed to an epidural with bupivacaine only. He\n achieved pain relief from epidural but pain has returned .\n Pain control (acute pain, chronic pain)\n Assessment:\n Last evening pt was comfortable for a while on the bupificane epidural.\n At approx pt c/o pain in the left knee inscision.\n Action:\n Epidural was changed to bupificane and dilaudid at 8mg hr. ice pack\n from pacu also placed on pt left knee. Pt was given a dose of toradol\n 15mg iv.\n Response:\n By 2115 pt was and dozing. Has not complained of pain for the\n remainder of the shift. No apnea noted.\n Plan:\n Cont with epidural. pt closely for apnea. Ice pack is poorly\n fitting as it is for a shoulder, possibly change to ice packs with\n ortho permission.\n Arthritis, osteo (osteoarthritis, OA)\n Assessment:\n OA in the left knee\n Action:\n Total knee replacement done yesterday. Pt came to micu to be monitored\n due to his reaction to lg amt of narcotics in the Pacu. Blood cultures\n and urine culture sent.\n Response:\n Pt did have a temp of 101.7 this am at 0100.\n Plan:\n No pillow under the knee. Ice pack. Monitor cultures and temps\n"
},
{
"category": "General",
"chartdate": "2110-11-18 00:00:00.000",
"description": "ICU Event Note",
"row_id": 713416,
"text": "Clinician: Attending\n Critical Care\n Present for the key portions of the resident's history and exam. 63 yo\n transferred from PACU for hypoxia in setting of narcotic admin for\n TNR. History of snoring and daytime sleepiness c/w obstructive sleep\n apnea. Attempt at mask ventilation only partially successful in PACU.\n He achieved pain relief from epidural but pain has returned . We\n are reconsulting pain service. If forced to use narcotics will initiate\n CPAP at 10-12 cmH2O to control SaO2. Would not use bilevel or PSV as I\n suspect that exacerbates resp instability.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2110-11-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 713417,
"text": "This is a 63 yo male who was transferred from PACU for hypoxia in\n setting of narcotic admin for TNR. He likely has obstructive sleep\n apnea. He was becoming hypoxic to 50% and apnic after he was given\n narcotics. The PACU attempt mask ventilation but this was only\n partially successful. He was changed to an epidural with bupivacaine\n only. He achieved pain relief from epidural but pain has returned\n .\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p TKR, pain is with the epidural running at 8cc/hr of\n .1%bipivacaine only, he started to lose the sensation from the ice\n between this nipple and mid abd\n Action:\n Pain service was consulted\n Response:\n Plan:\n Cont to follow pain service instructions\n Orthopedic device infection (hardware infection, prosthetic joint,\n orthopaedic)\n Assessment:\n Pt with total knee replacement on the L, draining sangious fluid into a\n drain, pos pedal pulses\n Action:\n His ankle only to be on a pillow, no CPM, no pillow under knee\n Response:\n Plan:\n Ortho following\n"
},
{
"category": "Physician ",
"chartdate": "2110-11-18 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 713418,
"text": "Chief Complaint: transfer for apnea\n HPI:\n 63 yo male with history of hypertension and osteoarthritis of the knees\n is POD 0 of left sided total knee replacement being transferred to \n for monitoring and pain control. Postoperatively, the patient was\n treated with large amounts of narcotics including diluadid PCA for pain\n control. After he received many doses of dilaudid, he was noted to\n have desaturations and episodes of apnea. The patient was placed on\n non-invasive ventilation with a back up rate given the 30 sec pauses.\n The patient denies a history of sleep apnea. When the patient was\n aroused, his rate and oxygen saturation returned to . The acute\n pain service was consulted who attempted 2 femoral nerve blocks, but\n failed to control his pain. The patient then had an epidural placed\n infusing bupivicaine with better pain control. He is being transferred\n to the for monitoring and pain control.\n .\n Currently, the patient reports better pain control, at a level of 4.\n Believes the pain is secondary to transfer in the bed. He feels as\n though his legs and back are not numb as they had been previously when\n the epidural was first placed. Otherwise, he denies cough, sputum\n production, excessive tiredness. He does report that he snores at\n night and feels tired in the afternoons at baseline.\n Patient admitted from: OR / PACU\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n HOME MEDICATIONS:\n Lisinopril\n Vicodin\n .\n MEDICATIONS ON TRANSFER:\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Bupivacaine 0.1% 1 mg/ml ED Infuse at 8-15 ml/hr\n Milk of Magnesia 30 ml PO BID:PRN\n CefazoLIN 2 gm IV Q8H first post-op dose administered 2 hours after\n entering PACU for a combined total of 3 doses\n Naproxen 500 mg PO BID Discontinue after 48 hours\n Docusate Sodium 100 mg PO BID\n Enoxaparin Sodium 30 mg SC Q12H Start: In am\n Pantoprazole 40 mg PO Q24H\n Senna 1 TAB PO BID:PRN Constipation\n Lisinopril 40 mg PO DAILY\n Past medical history:\n Family history:\n Social History:\n Hypertension\n Fused sacro-iliac joints bilaterally (HLA B27 positive) for mild\n anklylosing spondylitis\n Obesity\n Asthma as a child, has not required medications since then\n Osteoarthritis\n .\n Past Surgical History:\n Right meniscal debridement, ,\n left meniscal debridement in and ,\n tonsillectomy\n Non-contributory\n Occupation: Retired Neurologist, MD, PhD\n Drugs: denies\n Tobacco: denies\n Alcohol: two bottles of wine per week\n Other:\n Review of systems:\n Flowsheet Data as of 08:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 37.4\nC (99.4\n HR: 101 (94 - 101) bpm\n BP: 98/73(79) {98/71(79) - 120/73(84)} mmHg\n RR: 19 (13 - 19) insp/min\n SpO2: 100%\n Height: 68 Inch\n Total In:\n 3,060 mL\n PO:\n 360 mL\n TF:\n IVF:\n Blood products:\n 2,700 mL\n Total out:\n 0 mL\n 1,465 mL\n Urine:\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,595 mL\n Respiratory\n O2 Delivery Device: Bipap mask\n Ventilator mode: Standby\n Vt (Spontaneous): 1,109 (1,109 - 1,109) mL\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n SpO2: 100%\n Physical Examination\n BP=120/71 HR=94 RR=14 O2= 100% on 4L\n GENERAL: Pleasant, well appearing man in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP=flat\n LUNGS: CTAB, good air movement biaterally.\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: Left lower extremity wrapped, JP drain in place draining\n sanginous fluid, No edema or calf pain, 2+ dorsalis pedis/ posterior\n tibial pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation\n throughout. 5/5 strength throughout. + reflexes, equal BL. Normal\n coordination. Gait assessment deferred\n PSYCH: Listens and responds to questions appropriately, pleasant\n Labs / Radiology\n [image002.jpg]\n Left Knee X-ray: Satisfactory position of left knee TKR. Subcutaneous\n emphysema, soft tissue swelling around the left knee relate to recent\n surgery.\n .\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ORTHOPEDIC DEVICE INFECTION (HARDWARE INFECTION, PROSTHETIC JOINT,\n ORTHOPAEDIC)\n 63 yo retired neurologist with history of hypertension and\n osteoarthritis is POD 0 of L transferred to the for pain\n control and episodes of apnea and desaturations.\n .\n #. Apnea/desaturations: Likely secondary to large narcotic doses\n postoperatively. Currently, the patient has adequate oxygenation on\n nasal cannula, and is no longer apneic. Given patient's body habitus\n and history of snoring/daytime sleepiness, he likely has sleep apnea.\n Will use CPAP overnight as needed, will likely need CPAP as an\n outpatient.\n - Hold additional systemic narcotics, epidural for pain control (see\n below)\n - Monitor in the ICU overnight\n - Will use narcan only if patient has prolonged apnea\n - Will use CPAP as needed overnight\n - Wean supplemental oxygen\n .\n #. L TKR: POD 0. Ortho and Acute Pain Service following. Will\n continue post-op cefazolin for total of 3 doses. Weight bearing status\n per ortho, currently on bedrest. Will require PT consult eventually.\n Will start lovenox for DVT ppx when off epidural pain regimen, until\n then will maintain pneumoboots on right.\n - Appreciate Pain Service recommendations\n - Control pain with epidural overnight, will change to intrathecal\n dilaudid/bupivicaine combination for better control\n - Will use naproxen and/or tramadol for breakthrough pain overnight,\n avoid narcotics\n .\n #. Hypertension: Patient's blood pressure is currently well\n controlled off medications. Will restart home lisinopril 40mg in AM.\n .\n FEN: Heart Healthy Diet, replete lytes PRN\n .\n PPX:\n -DVT ppx with pneumoboots, lovenox once off epidural\n -Bowel regimen ppi, colace, senna, bisacodyl\n -Pain management with epidural, naproxen PRN\n .\n ACCESS: PIV's\n .\n CODE STATUS: Full\n .\n EMERGENCY CONTACT: HCP, partner, \n .\n DISPOSITION: ICU overnight, will likely call out to Ortho in AM\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:20 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": "2110-11-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 713499,
"text": "63 yo retired neurologist with history of hypertension and\n osteoarthritis is POD 1 of L transferred to the for pain\n control and episodes of apnea and desaturations.\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt with probable sleep apnea, has not been worked up.\n Did not require CPAP thru nite.\n 2l np with sats 94-96%..rr 20-30..\n Using incentive spirometer\n Action:\n Pt OOB to chair with help from PT\n further 02 required at this time..sats 95%\n Response:\n Tolerated well\n Plan:\n Continue to increase activity\n Discuss with pt possible work up for OSA\n Pain control (acute pain, chronic pain)\n Assessment:\n Continueing epidural per pain team\n Pt feels he is adequately medicated at this time.\n Using bivocain/dialuded at 8cc hr\n Pt c/o achyness, refuses further meds..\n Action:\n No change in epidural rate.\n Site dry with intact dsg\n Response:\n Comfortable with this dose.\n Plan:\n Per pain team, to dc epidural tomorrow.\n s/p TKR..day #1\n Left leg dsg intact. drain in place. 300cc output\n x24hrs..\n Seen and evaluated by PT..to follow.\n K and mag repleted.\n Pt tolerating solid food well.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LEFT KNEE OSTEOARTHRITIS/SDA\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 90.1 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: OA of the knees\n Surgery / Procedure and date: Left total knee replacement \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:124\n D:87\n Temperature:\n 101.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 26 insp/min\n Heart Rate:\n 102 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 0% %\n 24h total in:\n 2,043 mL\n 24h total out:\n 1,230 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:52 AM\n Potassium:\n 3.9 mEq/L\n 04:52 AM\n Chloride:\n 104 mEq/L\n 04:52 AM\n CO2:\n 26 mEq/L\n 04:52 AM\n BUN:\n 15 mg/dL\n 04:52 AM\n Creatinine:\n 0.8 mg/dL\n 04:52 AM\n Glucose:\n 119 mg/dL\n 04:52 AM\n Hematocrit:\n 32.4 %\n 04:52 AM\n Valuables / Signature\n Patient valuables: bags of clothes\n Other valuables: pt has computer and cell\n phone\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: 12r\n Date & time of Transfer: \n"
},
{
"category": "Rehab Services",
"chartdate": "2110-11-19 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 713500,
"text": "Attending Physician: , \n Referral date: \n Medical Diagnosis / ICD 9: L TKR / 715.96\n Reason of referral: Eval and Treat\n History of Present Illness / Subjective Complaint: Pt is a 63 yo M, POD\n #1 LTKR. Pt transferred from PACU to unit for hypoxia in setting of\n narcotic administration.\n Past Medical / Surgical History: HTN, anklyosing spondylitis-fused SIJ\n B, obesity, childhood asthma, OA, R knee meniscal debridement, L knee\n meniscal debridement x 2, tonsillectomy\n Medications: Hydromorphine, ketorolac, magnesium sulfate,potassium\n chloride, enoxaparin sodium\n Radiology: Knee X-ray: Left total knee prosthesis in satisfactory\n position with expected post-surgical changes in the region.\n Labs:\n 32.4\n 11.2\n 220\n 10.0\n [image002.jpg]\n Other labs:\n Activity Orders: OOB w/assist, LLE WBAT\n Social / Occupational History: Retired neurologist, -tobacco, +ETOH,\n lives with partner, owns computer software company\n Living Environment: Lives in loft, elevator access\n Prior Functional Status / Activity Level: PTA I ADLs, h/o Bilat. AC use\n Objective Test\n Arousal / Attention / Cognition / Communication: A + O x 3. Follows\n 100% of complex commands. Communicates clearly and appropriately.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 88\n 112/64\n 28\n 95\n Rest\n 88\n 112/64\n 28\n 95\n Sit\n 116/70\n Activity\n 93\n /\n 22\n 98\n Stand\n 93\n /\n 22\n 98\n Recovery\n 90\n 117/63\n 24\n 98\n Total distance walked: 5 feet\n Minutes: 5 min\n Pulmonary Status: - cough, - SOB, non-labored breathing\n Integumentary / Vascular: JP drain in place, LLE wrapped in ace\n bandages and padded dressing, epidural in place, L arm PIV, LLE toes\n warm and well perfused.\n Sensory Integrity: - c/o numbness/tingling per pt, able to detect light\n touch LLE distal to bandages\n Pain / Limiting Symptoms: at rest L knee, with mobility\n Posture: B hip external rotation\n Range of Motion\n Muscle Performance\n Bilat. UEs/LEs: WFL except L knee ext = -16 deg, flex: 60 deg\n limited bandaging\n Bilat. UEs and R LE appear > through function, L hip flex: 3-/5, L\n quad: 3-/5, L DF: \n Motor Function: Able to advance LLE during gait, unable to move in\n isolation against gravity off bed.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt amb 5 ft c Bilat. AC and CGA. Pt able to advance\n LLE indep., decreased step length and cadence. Pt increased\n trunk forward flexion.\n Rolling:\n\n\n\n T\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n T\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n WBAT L LE\n\n\n\n T\n\n\n Ambulation:\n WBAT L LE\n\n\n T\n\n\n\n Stairs:\n\n\n\n\n\n Balance: (-) LOB EOB seated I, (-) LOB during amb, static standing c\n Bilat. AC Indep.\n Education / Communication: Pt. edu re: plan of care, discharge plan,\n role of PT, proper LLE positioning, post-op therex, current WB\n precautions\n Intervention:\n Other:\n Diagnosis:\n 1.\n Knowledge deficit re: post surgical precautions.\n 4.\n Impaired mobility/gait.\n 2.\n Impaired L knee ROM\n 5.\n Impaired endurance/activity tolerance.\n 3.\n Impaired L LE strength.\n 6.\n Clinical impression / Prognosis: Pt is a 63 yo M POD #1 L TKR. Pt p/w\n above impairments associated with practice pattern total joint\n arthroplasty. Pt current status appears below baseline function. Pt\n would continue to benefit from further acute PT services. Anticipate pt\n will progress to discharge home c PT in visits. Expect pt to make\n full recovery to PLOF pt motivation, age, PLOF, and support at\n home.\n Goals\n Time frame: 1 week\n 1.\n L knee flexion 0-90 degrees\n 2.\n Pt indep. with bed mobility.\n 3.\n sit to stand indep.\n 4.\n Pt amb. 300ft with bilat. ACs. Indep.\n 5.\n Pt performs HEPindep.\n 6.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: Daily\n Transfer training, gait training with Bilat. AC, endurance training,\n daily therex and PROM, CPM use 3x daily as tolerated, balance training,\n pt ed re fall prevention.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Time: 11:30-12:20\n Written by , PT/S, , PT/S\n"
},
{
"category": "Radiology",
"chartdate": "2110-11-18 00:00:00.000",
"description": "LP KNEE (2 VIEWS) LEFT PORT",
"row_id": 1112316,
"text": " 11:25 AM\n KNEE (2 VIEWS) LEFT PORT Clip # \n Reason: post op film\n Admitting Diagnosis: LEFT KNEE OSTEOARTHRITIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with new knee\n REASON FOR THIS EXAMINATION:\n post op film\n ______________________________________________________________________________\n WET READ: KKgc TUE 3:49 PM\n Satisfactory position of left knee TKR. Subcutaneous emphysema, softtissue\n swelling around the left knee relate to recent surgery.\n ______________________________________________________________________________\n FINAL REPORT\n LEFT KNEE, TWO VIEWS\n\n INDICATION: Post-operative radiograph after left total knee replacement.\n\n FINDINGS: Two views of the left knee demonstrate total left knee prosthesis,\n in satisfactory position. No acute fractures are identified. A surgical drain\n is noted. The subcutaneous emphysema, soft tissue swelling and anterior skin\n staples relate to the recent surgery.\n\n IMPRESSION: Left total knee prosthesis in satisfactory position with expected\n post-surgical changes in the region.\n\n"
}
] |
16,929 | 189,309 | A right-sided chest tube remains in place, and there is a persistent small right apical and lateral pneumothorax, slightly decreased in the interval. A right-sided pneumothorax is present. A tiny lateral pneumothorax is again visualized at the apex of the lung. There is a new small right apical pneumothorax. Trace aorticregurgitation is seen. IMPRESSION: 1) New small right apical pneumothorax with chest tube in place. FINDINGS: There has been interval placement of an endotracheal tube, which terminates in the right main stem bronchus. 2) Slight decrease in right pneumothorax. There is now diffuse hazy opacity of both lungs suggestive of bilateral pleural effusions layering posteriorly on this supine film. 2) Right-sided pneumothorax. Small right pneumothorax with chest tube in place. Stable right pneumothorax with chest tube in place and stable diffuse pulmonary abnormalities. Mild (1+) mitral regurgitationis seen. A right-sided chest tube has been placed in the interval. There is prominence of the pulmonary vascularity and there remains a diffuse bilateral pattern of hazy and reticular pulmonary opacities. 2) Central venous catheter terminates in right atrium. There is persistent large pneumomediastinum and pneumopericardium, which is unchanged when compared to the prior study. Remains on Linezolid only.GI: Increased residuals of 240cc's at . PT CONTS IN SR 80-100'S WITH STABLE BP VIA ALINE THAT CORELLATES WITH CUFF. ABGs stable with oxygen deficit[a/A ratio .19 gradient 371] though able to wean FIO2 throughout noc. She was started on Levophed at 0.03mcg/kg/min with excellent effect. RIGHT ANT CT DSG SATURATED WITH SEROUS FLUID THIS, DSG CHANGED, SITE C/D/I WITHOUT REDDNESS. PT RECEIVED DOSE LACTULOSE X1. Nursing Summary:Neuro:PT remains on high dose fentanyl/versed gtts. She is tolerating increasing degrees and time of rotation to both left and right with no compromise in oxygenation and slight compromise of BP. PT REMAINS MIN RESPONSIVE, OTHER THAN IN RR WITH ANY STIMULATION, WHEN RR OVER 35 O2 SAT BEGINS TO TREND DOWN.GI--PT CONTS ON PROMOTE WITH FIBER AT GOAL 60CC. RIGHT ANT CT PLACED TO H2O SEAL X1.45 HOURS WITH GRADUAL INC IN RR AND DECREASE IN O2 SAT. CVP 10.ID: Remains on linezolid for VRE to cath tip/sputum/blood. Pt scheduled for TEE today.GI- Abd soft and mildly distended. BS clear to slightly course with minimal secretions noted. WBC unchnged at 15.5Skin - Coccyx remains slightly reddened but skin intact - barrier cream applied. BS 75-130 since (see careview). Abgs ok after pressure adjustments. Crepitus still present but diminishing, dressing D&I, small intermittent air leak.C-V: HR mostly 80's, NSR, up to 90's when uncomfortable. Neck and extremites are flaccid, does not f/c, absent gag, cough strong at times, impaired at times.RESP: Stable sats early evening with improved ABG on APRV: 7.42/41/93. Nursing Note (0700-1900hrs)Events:Tolerated further wean of vent and sedation. She tolerated this poorly, with desaturation to 80's immediately (turned to R), incraesed RR and HR, and vent dysynchrony. Fluconazole for +.GI/GU: Tol TF at goal, residuals improved since yesterday; receiving reglan. Crepitus to axillary area persists, though seems decreased from early in shift. PERRL, sluggish at times.RESP: Remains on APRV with P-high weaned to 26; other settings unchanged: P-low 12, FiO2 40%, pt's RR 17-34, TV's 340-400. Pt still has high fi02 requirement, was able to wean slightly. Turned once for bath, assessment; not moved since d/t intolerance.C-V: BP very labile, depending on level of sedation. BP has been stable off pressors, dropping transiently into 90's with turning. K 3.8 and is currently being repleted; other lytes WNL.ID: Low-grade temp, WBC up to 17.5 (15). PERRL, sluggish.RESP: Placed on 100% FiO2 for bedbath/turn. on sedation but still with resp efforts and dysynchronous. Hct dropping from 34.9 to 30.1 this am - MD aware.Resp - Orally intubated and vented on APRV mode. resp carePt remains intubated on APRV, ABG's WNL, oxygenation improving - Phigh & Plow decreased, tol well. the fentanyl and versed qtts were eventually increased as well d/t persistent hypertension and ^hr.gi-> abd is soft, distended w/hypoactive bs. 3% NaCl resumed; per renal, we are following Na frequently and adjusting accordingly.GI: Not being fed; minimal residuals from OGT. C-tube dssg site D+I.GI - Abd soft and sl distended. R ant CT to sxn with minimal sero-sanguinous drainage. Hct rose from 28.5 to 31.6 after receiving one unit PRBCs on previous shift.3+ palp peripheral pulses.GI - Abd soft and distended. On Vanco post VATS as well as levo.Gi/GU: ABd soft, distended; able to increase TF to 30 (goal 60cc/hr)--TF absorption quite dependent on timing of reglan. Received (2) IV NS fluid boluses for sBP down to 70's and CVP=10. Given lactulose and colace via NGT and dulcolax pr.F/E - TFB + ~2300ccs yest. ABG 7.44/46/66 early in shift; later, with adequate sedation and paralysis, improved to 7.44/44/80. she remains just slightly tfb positive since mn.id-> tmax 98.6 orally with a slightly rising wbc. Minor changes made to ventilator r/t i & e times. Dressing changed with petroleum gauze and elasoplast with resolution. Anxious with all care...medicated with 1 mg. Ativan....followed by periods of restlessness...Ativan now d/c'd. Given total of 1L LR bolus with transient improvement. Right CT placed after VAT in situ. Started on Albuterol Nebs Q3hr and Atrovent Nebs Q6hr. Ativan now d/c'd and all sedation held. abg with po2 117, pco2 40 and pH 7.45. On call to OR for vats.GI: Abd soft with positve bowel sounds, Large BM x1, guiac -, sample sent, NPO, blood sugars 224 at noon. Remains on A/C vent, weaned o2 to 80% Last abg 740/42/92/27/0. occas efforts at spont resps noted. Slightly hypotensive this am with sbp in 90's. pmicu nursing admit/progress 3p-7pplease see fhpa for specifics.pt is a lovely portugese woman admitted with resp distress.review of systemsCV-vs have been stable with hr in the 70's nsr and bp 100-120/ via nbp.RESP-wearing 100% nrb her sats have been >95%, pt is tachypneic though with rr 25-40 with anxiety, occasionally using accessory muscles.lungs are diminished at bases, ?crackles RUL. Sedated on propofol immediately post-intubation. PROPAFOL GTT ADDED, DUE TO SIG INC IN BP/HR WHEN STIMULATED, BP 240/120 DURING TURNING THIS AM. | 94 | [
{
"category": "Echo",
"chartdate": "2168-06-15 00:00:00.000",
"description": "Report",
"row_id": 79889,
"text": "PATIENT/TEST INFORMATION:\nIndication: r/o Endocarditis.\nBP (mm Hg): 190/80\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 15:04\nTest: Portable TEE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on\naortic valve. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral\nvalve. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. No vegetation/mass on pulmonic valve.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. No TEE related\ncomplications. The patient appears to be in sinus rhythm.\n\nConclusions:\nNo atrial septal defect is seen by 2D or color Doppler. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The 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. No masses or vegetations are seen on the aortic valve. Trace aortic\nregurgitation is seen. The mitral valve leaflets are structurally normal. No\nmass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\nis seen. No vegetation/mass is seen on the pulmonic valve. There is no\npericardial effusion.\n\nIMPRESSION: No echocardiographic evidence of endocarditis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 872860,
"text": " 11:33 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate new IJ line placement\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman s/p right IJ placement, old right subclavian to be pulled \n VRE sepsis\n REASON FOR THIS EXAMINATION:\n evaluate new IJ line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST OF .\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: New line placement.\n\n A new right internal jugular vascular catheter has been placed, terminating\n within the superior vena cava. Endotracheal tube, right subclavian vascular\n catheter, nasogastric tube, and right-sided chest tube remain in satisfactory\n position. Cardiac and mediastinal contours are stable. Extensive\n pneumomediastinum and subcutaneous emphysema persist, with interval worsening\n of the subcutaneous emphysema. The degree of subcutaneous emphysema limits\n the sensitivity of portable radiographs for detecting pneumothoraces. With\n this limitation in mind, no definite pneumothorax is evident. Diffuse\n bilateral pulmonary opacities persist. The diaphragm contours appear slightly\n more obscured compared to the previous study suggesting slight worsening of\n disease of the bases, and there are also probable small pleural effusions\n contributing to this appearance as well.\n\n IMPRESSION:\n 1. New right internal jugular vascular catheter terminates in the superior\n vena cava. No definite pneumothorax allowing for decreased sensitivity due to\n extensive degree of subcutaneous emphysema in this patient.\n 2. Diffuse lung disease with slight worsening at the lung bases. These\n findings are in keeping with the patient's history of acute interstitial\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872457,
"text": " 6:06 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD, right sided\n chest tube s/p VATS, now s/p R subclavian placement, readjustment after line\n appeared to be in left subclavian\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n INDICATION: Readjustment of right subclavian line.\n\n The right subclavian catheter continues to cross the midline into the left\n brachiocephalic and left subclavian veins. There has been interval worsening\n of pneumomediastinum and subcutaneous emphysema. A right apical pneumothorax\n is probably not significantly changed allowing for limited visualization of\n this region due to overlying extensive subcutaneous emphysema. Diffuse hazy\n and reticular pulmonary opacities are unchanged.\n\n IMPRESSION:\n 1. Persistent malpositioning of right subclavian catheter crossing the\n midline into the left brachiocephalic and subclavian veins.\n 2. Worsening pneumomediastinum and diffuse subcutaneous emphysema.\n 3. Stable right pneumothorax with chest tube in place and stable diffuse\n pulmonary abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-15 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 872645,
"text": " 11:37 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ptx and sub-Q air ? cadiac tampenade to pneumo mediastin\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxia, pulmonary infiltrates\n\n REASON FOR THIS EXAMINATION:\n ptx and sub-Q air ? cadiac tampenade to pneumo mediastinum\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia and pulmonary infiltrate query cardiac tamponade\n secondary to pneumomediastinum.\n\n COMPARISON: CT scan of .\n\n TECHNIQUE: Helical CT of the chest was performed without intravenous\n contrast.\n\n FINDINGS: No mediastinal or hilar lymphadenopathy is seen. Minimal\n pericardial effusion is seen. Examination of the soft tissue windows\n demonstrates extensive subcutaneous emphysema and extensive anterior\n pneumomediastinum. There is a 3.6 x 2.2 cm soft tissue swelling anterior to\n the rib in the left lower thoracic region. This probably represents a\n hematoma.\n\n The ET tube is 2 cm above the carina. The subclavian line is seen in the SVC.\n The intercostal drain tip is in the right upper lobe.\n\n Left-sided pleural effusion is seen which was not seen on the prior CT scan.\n\n Examination of the lung windows shows extensive bilateral ground-glass\n opacification which has increased compared to the prior CT of .\n The bilateral basilar consolidations have decreased compared to the prior CT.\n New left-sided pleural effusion is seen. The airways are patent up to the\n segmental bronchi.\n\n Examination of the upper abdomen demonstrates cholecystectomy surgical clips\n in the gallbladder fossa. The liver, spleen, pancreas, adrenals and\n visualized portions of the kidneys are unremarkable.\n\n The bone windows demonstrate pectus excavatum. No suspicious lytic or blastic\n lesions are seen in the bony skeleton.\n\n IMPRESSION:\n 1. Increased bilateral ground-glass opacification with minimal decrease in\n the bilateral basilar consolidation. New left-sided pleural effusion seen. The\n differential diagnosis for this is acute interstitial pneumonia, cryptogenic\n organizing pneumonia, diffuse infection and vasculitis.\n 2. Extensive subcutaneous emphysema and extensive anterior pneumomediastinum.\n 3. A 3.5-cm subcutaneous hematoma along the anterior left lower thoracic rib.\n (Over)\n\n 11:37 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ptx and sub-Q air ? cadiac tampenade to pneumo mediastin\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Pectus excavatum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871603,
"text": " 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypotension s/p VATS\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with oral/palmar rash, fever and hypoxemia of unclear\n etiology transferred from OSH with \"bibasilar infiltrates\".\n REASON FOR THIS EXAMINATION:\n hypotension s/p VATS\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Hypotension following VATS procedure.\n\n A right-sided chest tube remains in place. A previously noted right\n pneumothorax is not clearly visualized, but may be less visible due to supine\n rather than semi-upright positioning on the previous study. A right\n subclavian vascular catheter continues to terminate within the right atrium.\n An endotracheal tube remains in satisfactory position, and a nasogastric tube\n coils in the stomach. The lung volumes are low. Again demonstrated are\n multifocal patchy opacities with a peripheral predominance. There are\n apparent worsening opacities within the lung bases, although the low lung\n volumes limit comparison to some degree.\n\n IMPRESSION: Worsening patchy bibasilar opacities, which could represent\n progression of the patient's multifocal alveolar process or a superimposed\n abnormality such as aspiration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871520,
"text": " 12:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate ETT placement s/p intubation\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with oral/palmar rash, fever and hypoxemia of unclear\n etiology transferred from OSH with \"bibasilar infiltrates\".\n REASON FOR THIS EXAMINATION:\n Evaluate ETT placement s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Rash, fever and hypoxemia, evaluate ET tube placement.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: There has been interval placement of an endotracheal tube, which\n terminates in the right main stem bronchus. The heart size and mediastinal\n contours are unchanged. There are persistent bilateral patchy pulmonary\n opacities, with improved opacity in the left lower lobe and decreased\n elevation of the left hemidiaphragm. In addition, there is improved aeration\n of the right lung base. There is marked gaseous distention of the stomach.\n The osseous structures appear unremarkable.\n\n IMPRESSION:\n 1. Intubation of the right main stem bronchus. The endotracheal tube should\n be repositioned. A page was sent to at 3:00 p.m. to communicate\n this finding.\n\n 2. Bilateral patchy air space opacities, improved at the bases in comparison\n with the examination of one-day prior.\n\n 3. Gaseous distention of the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871427,
"text": " 6:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: status of bilateral infiltrates\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with oral/palmar rash, fever and hypoxemia of unclear\n etiology transferred from OSH with \"bibasilar infiltrates\".\n REASON FOR THIS EXAMINATION:\n status of bilateral infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n History of rash, fever and hypoxemia.\n\n No previous films for comparison. There are low lung volumes. Allowing for\n this, heart size is borderline. There are ill-defined patchy predominantly\n air space opacities in both lower zones with some elevation of the left\n hemidiaphragm. No pneumothorax. Surgical clips are present in the right\n upper abdomen, status post cholecystectomy.\n\n IMPRESSION: Bilateral predominantly lower zone patchy consolidation\n consistent with bilateral pneumonia. This is associated with some atelectasis\n at the left base. No previous films for comparison.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872721,
"text": " 3:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please valuate for change\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD, right sided\n chest tube s/p VATS, initial R subclavian line was in left subclavian, now\n s/p new stick in R subclavian, also had inadvertent arterial stick\n REASON FOR THIS EXAMINATION:\n Please valuate for change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with severe mediastinal emphysema and\n subcutaneous emphysema.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP single view of the chest.\n\n FINDINGS: The ET tube, chest tube, NG tube, right IJ central lines are in\n stable position. There is again noted severe subcutaneous emphysema, which\n limits the evaluation of this study. Allowing for the limitations caused by\n the subcutaneous emphysema, the lung fields are stable. There is again noted\n a pneumopericardium and pneumomediastinum.\n\n IMPRESSION: Severe subcutaneous emphysema, limits slightly the study.\n Allowing for this, pneumomediastinum, pneumopericardium, and the lung fields\n are grossly unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872752,
"text": " 9:22 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: interval change and chest tube position\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD, right sided\n chest tube s/p VATS, initial R subclavian line was in left subclavian, now\n s/p new stick in R subclavian, also had inadvertent arterial stick\n REASON FOR THIS EXAMINATION:\n interval change and chest tube position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old female with hypoxemia due to acute interstitial\n pneumonia. The patient is status post right subclavian central line\n placement.\n\n COMPARISON: Comparison is made to .\n\n TECHNIQUE: AP single view of the chest.\n\n FINDINGS: The ET tube, NG tube, right IJ central line, chest tube are in\n unchanged position. There is again noted severe subcutaneous and mediastinal\n emphysema. The examination of the lung fields is limited due to overlying\n subcutaneous emphysema.\n\n IMPRESSION: Allowing for the limitations of the study due to the severe\n subcutaneous emphysema, there is no significant change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871586,
"text": " 9:46 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p VATS\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with oral/palmar rash, fever and hypoxemia of unclear\n etiology transferred from OSH with \"bibasilar infiltrates\".\n REASON FOR THIS EXAMINATION:\n s/p VATS\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n COMPARISON: .\n\n INDICATION: Status post VATS procedure.\n\n A right-sided chest tube has been placed in the interval. There is a new\n small right apical pneumothorax. An endotracheal tube has been repositioned\n and is now in satisfactory position. A nasogastric tube is in place, coiling\n within the stomach, with associated resolution of previously present gastric\n distention. There is a new right subclavian vascular catheter terminating in\n the body of the right atrium. Cardiac and mediastinal contours are within\n normal limits. Multifocal patchy alveolar opacities are again demonstrated\n with a somewhat peripheral predominance.\n\n IMPRESSION: 1) New small right apical pneumothorax with chest tube in place.\n\n 2) Central venous catheter terminates in right atrium.\n\n 3) Persistent multifocal patchy predominantly peripheral opacities. Please\n see recent CT dictation for differential diagnosis and correlate with pending\n biopsy results.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 872466,
"text": " 9:40 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD, right sided\n chest tube s/p VATS, initial R subclavian line was in left subclavian, now s/p\n new stick in R subclavian, also had inadvertent arterial stick\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n \\CHEST PORTABLE LINE PLACEMENT\n\n INDICATION: Positioning of central line.\n\n COMPARISONS: Comparison is made to radiograph performed in the same day for\n approximately 4 hours earlier.\n\n TECHNIQUE: AP upright single view of the chest.\n\n FINDINGS: There is interval repositioning of the right IJ central line with\n the tip in the SVC. There is persistent large pneumomediastinum and\n pneumopericardium, which is unchanged when compared to the prior study. There\n is diffuse subcutaneous emphysema. The other line are unchanged.\n\n IMPRESSION:\n 1. The line is now in good position.\n 2. Diffuse pneumomediastinum and diffuse subcutaneous emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871772,
"text": " 3:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: asses resolution of ptx.\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with oral/palmar rash, fever and hypoxemia of unclear\n etiology transferred from OSH with \"bibasilar infiltrates\" s/p VATS wiht\n right sided chest tube.\n REASON FOR THIS EXAMINATION:\n asses resolution of ptx.\n ______________________________________________________________________________\n FINAL REPORT\n Chest tube, status post VATS. Following pneumothorax.\n\n COMPARISON: Film performed at 3:49 a.m. on .\n\n Tip of the endotracheal tube remains in good position 3.9 cm above the carina.\n A right-sided chest tube is in good position. Tip of a right subclavian line\n is in the right atrium. There is no pneumothorax. Compared to the prior\n study, there has been a slight increase in opacity in the left lower lobe.\n There is now diffuse hazy opacity of both lungs suggestive of bilateral\n pleural effusions layering posteriorly on this supine film. NG tube is coiled\n in the stomach. Tip projects beyond the edge of the film.\n\n IMPRESSION: Tubes and lines are in adequate position.\n\n No pneumothorax.\n\n Interval development of bilateral pleural effusions layering posteriorly and\n also increased left lower lobe opacity consistent with worsening atelectasis\n or consolidation.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872163,
"text": " 1:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: status of interstitial lung tissue s/p steriods and improvin\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD,\n right sided chest tube.\n REASON FOR THIS EXAMINATION:\n status of interstitial lung tissue s/p steriods and improving oxygenation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxemia of unclear etiology right-sided chest tube. Evaluate\n status of interstitial lung disease and improving oxygenation.\n\n COMPARISON: .\n\n TECHNIQUE: AP portable supine chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 5 cm from the\n carina. Nasogastric tube coils within the stomach with tip terminating below\n the borders of the radiograph. The heart size and mediastinal contours are\n unchanged. Right subclavian venous access catheter is again seen in unchanged\n position, with tip at the RA/SVC junction. A right-sided pneumothorax is\n present. This is slightly larger in size than that present at the time of\n prior x-ray dated . A right-sided chest tube remains in place.\n There is new subcutaneous emphysema at the right lateral chest wall. There is\n interval improvement in patchy bilateral pulmonary parenchymal opacities. No\n pleural effusion. The osseous structures appear unchanged.\n\n IMPRESSION:\n 1) Lines and tubes in stable position.\n 2) Right-sided pneumothorax. Subcutaneous emphysema within the right chest\n wall.\n 3) Interval improvement in patchy bilateral pulmonary parenchymal opacities.\n\n Results were called to the resident caring for the patient at the time of\n interpretation (3:45 p.m.).\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872295,
"text": " 5:09 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Worsening of Pneumothorax?\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD, right\n sided chest tube.\n REASON FOR THIS EXAMINATION:\n Worsening of Pneumothorax?\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Diffuse alveolar damage. Right pneumothorax.\n\n An endotracheal tube has been advanced in the interval and now terminates\n approximately a centimeter above the carina. A right-sided chest tube remains\n in place, and there is a persistent small right apical and lateral\n pneumothorax, slightly decreased in the interval. A right subclavian vascular\n catheter remains in place as well as a nasogastric tube. The lung volumes are\n low. Even accounting for this factor, there has been marked interval\n worsening of a diffuse bilateral alveolar process. Subcutaneous emphysema is\n seen in the right chest wall.\n\n IMPRESSION:\n 1) Marked worsening of diffuse bilateral alveolar process, which may\n represent progressive ARDS.\n 2) Slight decrease in right pneumothorax.\n 3) Low position of endotracheal tube, as communicated with clinical\n housestaff caring for the patient.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872357,
"text": " 12:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT placement; please have pt flat w/ head midline prio\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD, right sided chest\n tube\n REASON FOR THIS EXAMINATION:\n eval ETT placement; please have pt flat w/ head midline prior to obtaining film\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n COMPARISON: .\n\n INDICATION: Endotracheal tube assessment.\n\n An endotracheal tube has been repositioned in the interval and now terminates\n approximately 3.5 cm above the carina. A right subclavian vascular catheter\n terminates in the proximal right atrium and a nasogastric tube is coiled in\n the stomach. Cardiac and mediastinal contours are within normal limits for\n technique. There has been interval improvement in a bilateral diffuse\n alveolar pattern with residual hazy opacities remaining throughout both lungs.\n A right-sided chest tube remains in place. There is an unusually sharp\n appearance of the right hemidiaphragm, likely reflecting a basilar\n pneumothorax. A tiny lateral pneumothorax is again visualized at the apex of\n the lung.\n\n IMPRESSION:\n 1. Satisfactory position of endotracheal tube.\n 2. Marked improvement in diffuse bilateral alveolar process.\n 3. Small right pneumothorax with chest tube in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872447,
"text": " 4:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R subclavian line placement. ?pneumothorax (small pneumo\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD, right sided\n chest tube\n REASON FOR THIS EXAMINATION:\n s/p R subclavian line placement. ?pneumothorax (small pneumothorax at baseline)\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n INDICATION: Evaluate for pneumothorax.\n\n There is a new right subclavian vascular catheter, which is malpositioned,\n crossing the midline into the left brachiocephalic and subclavian veins.\n There has been interval increase in size of a right apical pneumothorax, most\n prominent medially. There has also been development of pneumomediastinum and\n worsening of subcutaneous emphysema, which is now present diffusely in the\n chest and neck.\n\n Endotracheal tube and right-sided chest tube remain in satisfactory position.\n A nasogastric tube continues to coil in the stomach. Cardiac silhouette is\n mildly enlarged but stable. There is prominence of the pulmonary vascularity\n and there remains a diffuse bilateral pattern of hazy and reticular pulmonary\n opacities.\n\n IMPRESSION:\n 1. Malpositioned right subclavian vascular catheter crossing the midline into\n the left brachiocephalic and subclavian veins.\n\n 2. Increased size of right pneumothorax, most prominent medially.\n\n 3. Development of pneumomediastinum and marked progression of subcutaneous\n emphysema.\n\n Observed findings have been communicated to the clinical service caring for\n the patient on the date of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872596,
"text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: fever workup\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxemia of unclear etiology and DAD, right sided\n chest tube s/p VATS, initial R subclavian line was in left subclavian, now s/p\n new stick in R subclavian, also had inadvertent arterial stick\n REASON FOR THIS EXAMINATION:\n fever workup\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure and hypotension.\n\n TECHNIQUE: AP supine single view of the chest.\n\n FINDINGS: There is a right subclavian central line with the tip in the SVC.\n There is again noted diffuse subcutaneous emphysema, mediastinal emphysema and\n pneumopericardium. No definite pneumothorax can be seen in the chest\n radiograph allowing for limitations due to the severe subcutaneous emphysema.\n It is significantly worse when compared to the prior study from .\n The cardiac silhouette is otherwise unchanged. The ET tube and NG tube remain\n in the same position. The left chest tube is in unchanged position.\n\n IMPRESSION: Significant worsening of pneumomediastinum, pneumopericardium and\n subcutaneous emphysema when compared to the prior study. This limits the\n evaluation of the lungs. Please review the report of the CT scan of the chest\n performed in the same day for details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-06-06 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 871552,
"text": " 3:34 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess lung parenchyma\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with hypoxia, pulmonary infiltrates\n REASON FOR THIS EXAMINATION:\n assess lung parenchyma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old female with hypoxia, lung infiltrates. The symptoms\n started beginning of and has been progressively worsening. The\n patient was admitted to outside hospital on . Today, the\n patient was transferred to and had to be intubated.\n\n COMPARISONS: Comparison is made to outside hospital CT scan performed on\n . The films are available to us at this time for\n interpretation.\n\n TECHNIQUE: 64-axial images of the chest were obtained without IV contrast.\n\n FINDINGS: There is an ET tube located approximately at the level of the\n carina. Recommend withdrawing the ET tube approximately 2 cm. There are no\n significant axillary or mediastinal lymph nodes. The heart, pericardium, and\n great vessels are unremarkable. There are no pleural effusions and no\n evidence of pneumothorax.\n\n Examination of the lung fields demonstrates multiple patchy areas of ground-\n glass opacity and areas of consolidation. Some of these abnormalities are\n located in peripheral distribution. These peripheral opacities are\n significantly worse than in the prior study performed three days earlier. The\n consolidations seen in the prior study in superior segment of the right lower\n lobe are now more confluent and are now predominantly ground glass. There is\n also a suggestion of organizing process with early fibrosis and traction\n bronchiectasis of the bronchus to the superior segment of the right lower\n lobe. This appears to be worse when compared to the prior study. There is\n incidental note of a calcified granuloma in the left lower lobe.\n\n Examination of the upper abdomen demonstrates cholecystectomy clips. There is\n also distention of the stomach. Examination of the bone windows demonstrates a\n pectus deformity, but no active abnormality.\n\n IMPRESSION:\n 1. Progressive diffuse ground-glass opacities and consolidation with\n predominantly peripheral distribution. The differential diagnosis of this CT\n pattern includes eosinophilic pneumonia, cryptogenic organizing pneumonia and\n vasculitis. By report, this patient received steroids at an outside hospital\n and has progressed despite that treatment. Given this history, atypical\n infection and acute interstitial pneumonia (AIP) should also be considered.\n 2. The ET tube tip is located at the level of the carina. Recommend\n withdrawing the ET tube approximately 2 cm. These findings were communicated\n (Over)\n\n 3:34 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: assess lung parenchyma\n Admitting Diagnosis: BILATERAL LUNG INFILTRATES\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n to Dr. at the time of interpretation.\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2168-06-07 00:00:00.000",
"description": "Report",
"row_id": 210693,
"text": "Sinus rhythm.\nEarly R wave progression\nAnterolateral T wave changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2168-06-06 00:00:00.000",
"description": "Report",
"row_id": 210694,
"text": "Sinus rhythm with early R wave progression\nLead(s) unsuitable for analysis: V1.\nAnterior T wave changes are nonspecific\nNo previous tracing\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-14 00:00:00.000",
"description": "Report",
"row_id": 1484336,
"text": "Resp Care\n\nPt remains intubated and switched from APRV to CMV this afternoon well thus far with ABG relatively unchanged from previous mode of ventilation. FIo2 weaned to 50% with spo2 94-95%. ABG pending on present settings. Pt continues to be slightly dysynchronous with ventilator with little air trapping noted. BS clear to slightly course with minimal secretions noted. Will cont with present plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-14 00:00:00.000",
"description": "Report",
"row_id": 1484337,
"text": "Nursing Summary:\n\nNeuro:PT remains on high dose fentanyl/versed gtts. NO spontaneous movement noted, impaired cough/no gag. Fentanyl weaned to 475mcg/hr(from 500). Goal to wean to 450mcg/hr(total decrease of 10% for day). Versed remains at 15mg/hr. Sedation had been weaned previously to 350/10 but increased again overnoc r/t desaturation episodes.\n\nPUlm: Vent mode changed from aprv to cmv/320/peep 12/rr 30 r/t pt asychronous at times with aprv. Initial abg following mode change essentially unchanged to previous. Attempted to wean fio2 this pm to 50% w/po2 decreasing to 72 from 97. Discussed with DR. to increase back to 60% for now. Suctioning scant amount of pale yellow secretions. Lungs coarse, diminished in right base. Rt CT remains @ 20cm suction. Small amt serosanguinous drainage. No air leak noted(pt has had intermittent air leak in past). Dressing CDI. Crepitus has extended on right chest, right jaw, midline and left chest. Team aware. PT had previously been unable to turn r/t instability. Pads changed this afternoon-desat to 91% with good recovery. Triadyne bed not turning at this time r/t pt previously did not tolerate. Tapering of steroids started today.\n\nCVS: VSS in SR/ST. Generalized edema continues. Pt off levo since . in right wrist very positional. Dressing changed x1 r/t dressing saturated and unable to aspirate blood initially. Now drawing blood. DR. aware of problems. Pt to have TEE r/o vegetation. Enlarged heart on CXR. CVP range 1-5(not treated r/t vss and adequate UO)\n\nGI: PT with absent bowel sounds this am, hypoactive this pm. Residuals 20-65 for shift. Mushroom cath in place. Abdomen soft, non distended. TF at goal. Insulin gtt titrated to FS-range 95-157. See careview for details.\n\nGU: UO adequate, appears to be autodiuresing clear yellow urine.\n\nSkin: Coccyx area slightly reddened. No breakdown noted. Barrier cream applied.\n\nID: PT on contact precautions for in blood/sputum/cath tip from -on linezolid.\n\nSocial: Husband at bedside throughout most of day. Updated frequently on poc and pt status. Husband with multiple, appropriate questions regarding wife's status. Questions answered. Support given by this rn and chaplain services.\n\nPlan: Continue to decrease sedation to goal 450mcg/hr. Attempt to wean versed slightly as well. Monitor CT site/crepitus. Follow abg's. ?attempt to wean fio2 again in am. Attempt to restart rotation of triadyne bed. Insulin gtt for glucose control. Support family as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-14 00:00:00.000",
"description": "Report",
"row_id": 1484338,
"text": "Nursing addendum:\n\nSurveillance cultures also sent today r/t no repeat since pos.blood cx's drawn. Pt also to be npo after midnight r/t TEE tomorrow. Attempted to resume turning @ 15degrees on tryadine bed. Pt started coughing and desat to 92%. Off for now-attempt later.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-17 00:00:00.000",
"description": "Report",
"row_id": 1484348,
"text": "Resp Care Note:\n\nPt cont intub with OETT /paralyzed and on mech vent as per Carevue. Lung sounds ess clear. MDI given as per order. ABGs stable with oxygen deficit[a/A ratio .19 gradient 371] though able to wean FIO2 throughout noc. Cont APRV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-17 00:00:00.000",
"description": "Report",
"row_id": 1484349,
"text": "NPN 1900-0700:\n\nEVENTS: Able to wean FiO2 to 60% with acceptable ABG's. Tolerating bed rotation. Afebrile. Low-dose levo gtt started; insulin gtt re-started.\n\nROS:\nNEURO: Pt and chemically paralyzed with no change in dosing. She remains flaccid and unresponsive with no spontaneous movement or initiation of breaths. PERRL, sluggish.\nRESP: Able to wean FiO2 to 60% with sats 94-96% and ABG of 7.40/45/72 (sat of 93% at the time); sats continue to trend up. She is tolerating increasing degrees and time of rotation to both left and right with no compromise in oxygenation and slight compromise of BP. LS unchanged. Steroid taper to be completed today. No attempts to sxn, as there were no obvious secretions. CT dressing found saturated with serous fluid and was changed; no further leakage. CT remains to 20cm sxn with minimal output. No air leak; SQ emphysema cont's to progress, involving entire chest, breasts, neck, lower jaw, and both arms.\nC-V: Fluid bolus X 1 for CVP 7-8 with increase to 10. HR 80's-90's, NSR, no ectopy; K+ WNL. BP initially acceptable, but dropped to 80's (MAP 50's) with turning for bath. BP did not improve when returned to her back. She was started on Levophed at 0.03mcg/kg/min with excellent effect. She remains on this same dose with MAP's primarily 60's. She has tolerated bed rotation with minimal drops in BP as long as pressor is on.\nID: Afebrile with decreasing WBC. Central line re-sited to RIJ and tip sent for cx. Remains on Linezolid only.\nGI: Increased residuals of 240cc's at . This was discarded and TF's restarted at redulced rate of 30cc/hr which she has tolerated very well. Rate increased to 45cc/hr at 0400 (goal 60). Liquid brown stool via mushroom catheter (found to be clogged at , therefore replaced).\nGU: Brisk UO of 240-500cc/hr all shift. BUN/creat down to 14/0.3. Urine osm of 204 (done for ? DI).\nENDO: FSBS increased to >300, therefore insulin gtt resumed with good effect.\nHEME: Hct down to 24.6 (repeat 24.8) this AM. Team aware, clot sent to BB, no orders to transfuse at this time. Stool is negative, and she is without signs of active bleeding. Plt's and INR WNL.\nSKIN: Noted to have small amount frank bleeding from hemorrhoid; area cleansed and covered with vaseline gauze. Barrier cream to slightly reddened buttocks (looks improved). She remains grossly edematous with fluid and SQ air, but skin is otherwise intact.\nACCESS: As above, central line re-sited; a-line occasionally dampened with SBP lower than NBP, though MAP's correlate fairly well.\nSOCIAL: Husband and dtr continue to be very involved, asking appropriate questions and clearly understanding how ill she is. They remain optimistic but realistic. Went home for the night, and dtr is due to call before 0700.\n\nA: improving ABG's and tolerance of movement\n\nP: Anticipate trial off Cisatracurium today with plan to resume it if not tolerated. Cont to wean FiO2 as able, then consider decreasing PEEP levels. Continue to rotate bed as\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-17 00:00:00.000",
"description": "Report",
"row_id": 1484350,
"text": "(Continued)\n tolerated, increasing degree of rotation and time as able. Would maintain current levels of sedation until she shows signs of readiness for initial steps of weaning. Levo gtt prn to facilitate turning. Increase TF's back to goal as able; titrate insulin gtt prn. F/U with team re: ? transfuse. Continue all suportive measures; info and support to family as we are doing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-17 00:00:00.000",
"description": "Report",
"row_id": 1484351,
"text": "MICU NPN 0700-1900\n\nEVENTS: Continue to tolerate FiO2 60%, tolerating bed in rotation mode, remains dependent on low dose levophed, attempt wean paralytic this am with desaturation to 91% and pAo2 to 65, cont paralytic\n\nREVIEW OF SYSTEMS:\n\nNEURO:heavily with 500mcg/hr fentanyl gtt and midaz 20mg/hr, trial of weaning paralysis after 1hr respiratory effort visible on vent, esat cisatracurium resumed.\n\nCV: HR 70-90 SR, no VEA, BP 98-112/ 50-60, MAP 65-85, CV , cont low dose levophed, extrem warm palpable pulses, grossly edematous\n\nRESP: remains intubated vented with APRV 32/11, RR38, TV 300-330, min vol 12L, last abg 7.47/42/83/31/6, breath sounds coarse upper, decreased lower, chest tube intact, dsg changed, +fluc, -leak, small amt ooze drainage from site, increasing crepitus upper chest, breasts, neck, jaw, bilat upper arms, completed IV steroid taper today\n\nGI: abd soft distended, hypoactive to absent bowel sounds, cont reglan and bowel regime, tube feed residuals 50-100cc, tube feeds decreased to 30cc/hr, small amt brown stool output\n\nHEME: hct 24 with 1 unit PRBCS\n\nGU: foley intact with clear yellow urine, 100-200cc/hr\n\nID: afebrile, wbc 13, cont linezolid for 14 days\n\nSOCIAL: husband at bedside throughout the day, many visitors here to support husband, from pastoral care meets with husband daily\n\nPLAN: cont supportive care, cont low dose levophed, map >65, cvp >, transfuse hct<28\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-17 00:00:00.000",
"description": "Report",
"row_id": 1484352,
"text": "Resp Care\nPt remains on APRV-parameters noted. Phigh weaned slowly to 30. ABG pending. Pt has improved PaO2, but no wean at this time. Breath sounds essentially clear. Suction for scant secretions. MDI x 3. Will continue mech vent and wean as .\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-18 00:00:00.000",
"description": "Report",
"row_id": 1484353,
"text": "Resp Care Note:\n\nPt cont intub with OETT /paralyzed and on mech vent as per Carevue. Lung sounds ess clear.MDI given as per order. Recent ABGs[last shift] demonstrated a trend upward for pH; vent adjusted to \"normalize pH\" with good result. SubQ air persists chest and neck now involving L eye. Would attempt to lower FIO2 as long as PaO2 > 75 can be maintained. Cont APRV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-15 00:00:00.000",
"description": "Report",
"row_id": 1484339,
"text": "Micu Progress Note 7p to 7a\n\nNeuro - Pt remains unresponsive and flaccid. Sedation weaned down to fentanyl infusing at 450mcgs/hr and versed at 13mg/hr.\n\nResp - Maintained on AC 320 x 30 x 12 60% overnight. 02 sats initially 93-94%. Attempted to use rotation device on triadyne bed but pt began to cough and desat to low 90's. Pt also desat'd to 85% when turned during bath despite being with 100%. Sats returned to 93-94% within mins and actually improved to 97-100% the rest of the night. ABG 7.46/44/96/32/6/ LS coarse, diminished at bases. Sx for scant amt thin watery secretions. Chest tube to 20cm sx draining ~40ccs serosanguinous fluid. No air leak. Crepitus noted in R jaw and R chest and appears to be extending into L jaw and chest. Pt increasingly edematous and its difficulty to ascertain if swelling is d/t edema or crepitus.\n\nC-V - HR 90's NSR, no ectopy noted. NBP 100-140/50's. A-line dampened and leaking, unable to obtain accurate ABP readings but able to obtain ABG's. CVP 4-6. Hct stable at 29.8. Pt scheduled for TEE today.\n\nGI- Abd soft and mildly distended. BS hypoactive to absent. TF held since MN for TEE. Passing sm amt brown liquid stool via mushroom catheter.\n\nF/E - Urine output averaging 120ccs/hr via foley. CVP 4-6. No FB given.\n\nID - + Contact precautions for . Rx with linezolid. Temp spike to 102 orally - pt pan cx'd (peripheral stick and BC from RSC line sent as well as urine and sputum). Rx with tylenol. WBC unchnged at 15.5\n\nSkin - Coccyx remains slightly reddened but skin intact - barrier cream applied. Oozed sm amt of blood from hemorrhoid.\n\nEndo - Insulin drip stopped when TF held. BS 75-130 since (see careview). On steroid taper.\n\nSocial - Family at bedside last eve.\n\nA+P - Continue to wean sedation slowly. TEE today. Monitor temp and follow-up on cx results. ? need for new placement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-15 00:00:00.000",
"description": "Report",
"row_id": 1484340,
"text": "Resp Care: Pt continues intubated and on ventilatory support with a/c maintaining acceptable abg; bs coarse, sxn sm amt white secretions, rx with mdi , cont full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-15 00:00:00.000",
"description": "Report",
"row_id": 1484341,
"text": "Addendum - BP dropped to 83/39 - pt receiving 500cc NS fluid bolus.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-13 00:00:00.000",
"description": "Report",
"row_id": 1484331,
"text": "MICU A NSG 7A-7PM\nRESP--PT CONTS ON APRV P HIGH 24 P LOW 10 50%. NO PLANS TO MAKE FURTHER VENT CHANGES THIS SHIFT. SX'D FOR MIN TO NON SECRETIONS VIA ETT. RIGHT ANT CT PLACED TO H2O SEAL X1.45 HOURS WITH GRADUAL INC IN RR AND DECREASE IN O2 SAT. TEAM AWARE AND PLACED BACK ON WALL SUCTION. CREPITUS NOTED IN UPPER CHEST NECK AND FACE, NO LONGER NOTED IN ABD, BREAST AND BACK. PT ON 100% FIO2 PRIOR TO MOVING/PROCEDURES WITH GOOD EFFECT. PT CONTS WITH POOR ACTIVITY TOLERANCE WITH DESATT TO 88-90% AND INC RR TO 40-45 BPM WITH ROTATION ON BED CARE OR TURNING TO RIGHT SIDE,SEEMS TO LEFT SIDE BETTER.\n\nCV--QUAD LUMEN LINE PLACED IN RIGHT SC. PER TEAM, LINE TIP IN LEFT SC VEIN, AND WILL NEED TO BE REPOSITIONED PRIOR TO USE. PT CONTS WITH , CONTS WITH DAMPENED WAVEFORM AT TIMES, BUT ABLE TO GET BLOOD WITH MIN DIFF. IV ABX CHANGED TO LINAZOLID.\n\nNEURO--PT CONTS ON IV FENT 400MC/HR AND VERSED 15MG IV GTT WITH BOLUS' FOR CARE. RECEIVED PROPAFOL 3CC FOR CENTRAL LINE INSERTION WITH GOOD EFFECT. PT REMAINS MIN RESPONSIVE, OTHER THAN IN RR WITH ANY STIMULATION, WHEN RR OVER 35 O2 SAT BEGINS TO TREND DOWN.\n\nGI--PT CONTS ON PROMOTE WITH FIBER AT GOAL 60CC. PT RECEIVED DOSE LACTULOSE X1. RECTAL MUSHROOM CATH CLOOGED AND LEAKING, SMALL AMOUNT ~100CC THIS AM AND THIS PM LARGE AMOUNT ~1000CC. TUBE REPLACED AND NOW DRAINING WELL. CONTS ON IV INSULIN GTT PLEASE SEE CAREVIEW FOR HOURLY FS AND GTT TITRATION.\n\nGU--U/O 40-100CC/HR VIA FOLEY.\n\nSOCIAL--FAMILY IN TO VISIT, UPDATED ON PT'S CONDITION AND PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-13 00:00:00.000",
"description": "Report",
"row_id": 1484332,
"text": "Resp Care\nPT remains intubated and vented on APRV with no changes made to parameter settings. Vt around 400-500cc and RR low 30s on present settings. BS essentially clear anteriorly with minimal secretions noted. Will cont with vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-14 00:00:00.000",
"description": "Report",
"row_id": 1484333,
"text": "Resp Care: Pt continues intubated and on ventilatory support with aprv, periods of increased rr 38-40 with desat > increased fio2 with improvement; bs diminished, combivent mdi/sxn thick tan secretions, will cont full support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-14 00:00:00.000",
"description": "Report",
"row_id": 1484334,
"text": "NPN 1900-0700:\n\nEVENTS: Required increase in sedation and FiO2. Not tolerating any movement.\n\nROS:\nNEURO: Remains on Versed 15mg/hr; Fentanyl increased to 500mcg/hr for intermittent tachypnea and vent dysynchrony with drop in MV, but with little effect. She remains flaccid and unresponsive, though any stimulation results in increased RR.\nRESP: Early evening sats 93-94%; placed on 100% for line placement (sats up to 95%), then returned to 50% when done; sats dropped to 92%. Soon after she was again placed on 100% for bath/turning (sats up to 97%). About 1 hours after we were done, FiO2 reduced again to 50%, but sats dropped to 91% and stayed there. ABG 7.42/48/63, therefore FiO2 increased to 60%. She remains on APRV with P-high 24, P-low 14, inverse ratio, FiO2 60%. First ABG after FiO2 was increased to 60% was 7.43/46/109. Later in shift she was having increased episodes of tachypnea to 36-42 with drop in MV. ABG at this time showed decrease in pO2 to 91, but otherwise essentially unchanged. She also demonstrates increased WOB with these episodes; team does not wish to intervent at this point. She's had minimal thick tan secretions, LS unchanged. CT to 20cm sxn with minimal drainage. Dsg D&I, no air leak observed. SQ emphysema has increased and progressed, now involving upper chest, neck, lower face, bilat shoulders and upper arms. Dropped sats during bath transiently, recovered quickly. After several more hours slight rotation of bed to L was attempted; she immediately became tachypneic, dysynchronous, hypoxic and tachycardic. Bed rotation turned off, and no further attempts were made.\nC-V: HR generally 80's-90's, except up to 100's during above episode. BP trending down overnight, but still acceptable. CVP 8-10. Lytes WNL.\nID: Low-grade temps, WBC down to 15.7. Linezolid initiated for VRE.\nGI: TF's at goal, belly benign, stooling via mushroom catheter.\nGU: Auto-diuresing, BUN/creat stable.\nENDO: Insulin gtt titrated prn.\nHEME: Hct stable, no evidence of bleeding.\nSKIN: Slight redness to buttocks, large hemorrhoids with slight bleeding in one spot.\nACCESS: New R SC MLC placed and comfirmed by CXR.\nSOCIAL: Family visiting during the evening, remain anxious and asking lots of questions. Info and reassurance provided, and they went home for the night.\n\nA: increased FiO2 and sedation needs\n\nP: ? if added sedation (possibly propofol) would decrease WOB; watch for evidence of new infection or sepsis; continue all supportive measures and support/info to family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-14 00:00:00.000",
"description": "Report",
"row_id": 1484335,
"text": "Nursing Note (0700-1100hrs)\n\nPt has remained stable and without changes for this short period of time. Neurologically, very on fent/versed; impaired cough, no gag reflex. No movement of limbs. No weaning attempted with last nights events. CV: Hemodynamically stable. A-line cont to ooze sm amt fluid/blood--dampened. Sm amt drng of lt s/s from R cl site. Resp: medical rounds for further discussion with respiratory on next step to take with pt intolerance to position changes and occasional drop in volumes with increased RR despite high level of sedation. GI/GU: Unable to auscultate bowel sounds however residuals are wnl for TF at 60cc/hr. Mushroom cath with sm amt liquid brown stool. Diuresising. CVP 10.ID: Remains on linezolid for VRE to cath tip/sputum/blood. Off vanco/gent/levo. Steroid taper. WBC stable. Afebrile. Social: Husband at bedside since 9:30am, discouraged with apparent setback in pt's status and prolonged illness.\n\nPlan: Cont with present care/goals. Await rounds to discuss future treatment plan and ?trach. Full code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-12 00:00:00.000",
"description": "Report",
"row_id": 1484325,
"text": "MICU A NSG 7A-7PM\nRESP--PT CONTS ON APRV P HIGH 24 P LOW 10 FIO2 WEANED TO 50%, PLEASE SEE CAREVIEW FOR ABG. RIGHT ANT CT DSG SATURATED WITH SEROUS FLUID THIS, DSG CHANGED, SITE C/D/I WITHOUT REDDNESS. CREPITUS NOTED TO BE MORE EXTENSIVE BREAST, AXILLA, ABD AND BACK AROUND DSG. CONTS WITH SMALL INTERMITTENT AIRLEAK IN PLEUR-EVAC SYSTEM. PT TURN FOR DSG CAHNGE THIS AM WITH PREOXYGENATION AND LITTLE CAHNGE IN O2 SAT, BUT LATER IN MORNING NOT TURN ASSIST MODE ON TRIADYNE BED. O2 WITH SX'ING OR MOVEMENT DROP TO 84-90%. PT NOTED TO HAVE SIG IMPROVEMENT IN 02 SATS WHEN HOB >30 DEGREES. PT HAD REPEAT CXR THIS AM TO ASSESS PLACEMENT OF ETT, PER TEAM, ETT ON CXR LOOKED TO BE 2-3CM TO FAR IN. ? PT'S HEAD IN CHIN TO CHEST POSTITON WHEN FILM TAKEN. REPEAT CXR SHOWS TUBE IN GOOD POSITION AND NO CHANGE TO BE MADE AT THIS TIME.\n\nCV--BLD CX DRAWN FROM TLCL POS FOR GRAM POS COCCI IN PAIRS AND CHAINS. TEAM AWARE AND PIV X2 PLACED AND TLCL REMOVED AND TIP SENT FOR CX. PLANS TO REPLACE LINE THIS EVE OR IN AM. PTCONTS WITH . PT CONTS IN SR 80-100'S WITH STABLE BP VIA ALINE THAT CORELLATES WITH CUFF. NO DIFF DRAWING FROM ALINE THIS SHIFT. DSG CAHNGED DUE TO SEROSANGUINOUS DRG ON DSG, NOTED TO HAVE SM SKIN TEAR AT INSERTION SITE.\n\nNEURO--CONTS ON FENT GTT AT 350MC/HR AND VERSED GTT AT 10MG/HR. PT RECEIVED BOLUS OF FENT 50MC AND VERSED 2MG IV FOR INC RR AND DYSYNCHRONOUS BREATHING WITH VENT WITH GOOD EFFECT.\n\nGI--PT CONTS ON PROMOTE WITH FIBER AT GOAL 60CC/HR WITH RESIDUALS 50-80CC. MIN STOOL FROM RECTAL TUBE THIS SHIFT. CONTS ON IV INSULIN GTT PLEASE SEE CAREVIEW FOR HOURLY FS AND GTT TITRATION.\n\nGU--CREAT REMAINS STABLE AT 0.6 THIS AM. U/O 45-100CC/HR.\n\nSOCIAL--HUSBAND AND DAUGHTER IN TO VISIT. UPDATED ON PT'S CONDITION AND PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-12 00:00:00.000",
"description": "Report",
"row_id": 1484326,
"text": "resp. care\npatient remains intubated/vented/. fi02 decreased\nwith acceptable abg. cxr shows worsening ptx with ett in\ngood postion. mdi's given. continue current vent. see careview\nfor more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-13 00:00:00.000",
"description": "Report",
"row_id": 1484327,
"text": "NPN 1900-0700:\n\nEVENTS: Another relatively stable night. Unable to tolerate bed rotation, and required increase in Fentanyl and Versed doses.\n\nROS:\nNEURO: Pt remains unresponsive and flaccid. Appeared comfortable during the evening, and tolerated bath/turning with bolus of each. At MN attempted gentle rotation of bed, which she tolerated poorly. Bed rotation was turned off, but she cont'd with increased RR to 36-40, dysynchrony w/vent, and increased airway pressures. She was bolused twice with Fentanyl and Versed and gtts increased to 400mcg/hr and 15mg/hr respectively before she settled down. She has remained comfortable on these doses the rest of the night. PERRL, sluggish.\nRESP: Placed on 100% FiO2 for bedbath/turn. She tolerated this activity with no desaturation or evidence of any discomfort (bolused with Fent and Versed prior to movement). She was stable all evening, therefore gentle rotation of bed was attempted at MN. She tolerated this poorly, with desaturation to 80's immediately (turned to R), incraesed RR and HR, and vent dysynchrony. Rotation was turned off, and sats recovered quickly (transiently on 100%). However, she remained out of synch and tachypneic, as above, until sedation was increased. Otherwise sats have been 95-97% all night. Current vent settings: APRV with P-high 24, P-low 10, FiO2 50%, RR 31-33. ABG this AM: 7.43/41/94. Suctioned twice for small amounts of thick tan, blood-tinged secretions. LS coarse t/o, diminished R base. CT to 20cm sxn draining minimal sero-sanguinous fluid. Crepitus still present but diminishing, dressing D&I, small intermittent air leak.\nC-V: HR mostly 80's, NSR, up to 90's when uncomfortable. Very little ectopy noted. K 3.8 and is currently being repleted; other lytes WNL.\nID: Low-grade temp, WBC up to 17.5 (15). Started on Gent for synergy w/Vanco to cover VAP (per ID). Vanco level 11.1 (HO aware).\nGI: Belly benign, minimal stool, given Lactulose X 2. Tolerating TF's at goal with residuals of 10-40cc; cont's on Reglan. ALT/AST/LDH continue to rise; hep serologies pending from yesterday.\nGU: UO 60-120cc/hr, clear yellow. BUN up again to 26 (23); creat stable at 0.6.\nENDO: Insulin requirements fairly stable, gtt titrated prn.\nHEME: Hct stable at 29, plt's WNL, no evidence fo active bleeding.\nSKIN: Buttocks slighty reddened, very slight bleeding from hemorrhoid noted. Barrier creams applied. Anasarca worse, but no other skin breakdown present.\nACCESS: PIV X 2 functioning well. A-line cont's to leak and is usually impossible to draw from (though I was able to get ABG this AM). Line very dampened at times, decent tracing at other times. Dampening does not seem related to position, indicating that there may be a clot or she is having spasms.\nSOCIAL: Husband, dtr and son-in-law here till about 10PM, then went home for the night. Questions answered as able, and they were reminded of the prolonged and uncertain course that is expected. They continue to indicate good understanding. I encourage\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-13 00:00:00.000",
"description": "Report",
"row_id": 1484328,
"text": "(Continued)\nd them to spend a little more time at home tending to housework, mowing lawn, etc; they understand that this will be a good time to do so, since she is in a relatively stable holding pattern, and agreed that it was necessary. Overall they seem to be coping better, though they can easily become anxious or tearful. They do need to be reminded frequently to let US worry about the details of her medical care, and not to focus on little things. They have responded well to consistency in care, verbal reassurance, constant updates, and periodic visits from priest and SW.\n\nA: increased sedation needed; intolerant of bed rotation.\n\nP: Pt needs new central line and a-line today; replete lytes prn; attempt bed rotation as able; continue all supportive measures as well as support to family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-13 00:00:00.000",
"description": "Report",
"row_id": 1484329,
"text": "resp care\nPt remains intubated #7.5 et tube, retaped 19@lip. Bil breath sounds, sx'd for sm thick tan secretions. Vent remains unchanged, pt on APRV, ABG's WNL. MDI given as ordered. Plan to continue to wean Phigh as .\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-13 00:00:00.000",
"description": "Report",
"row_id": 1484330,
"text": "MICU A NSG 7A-7PM\nADDENDUM PT WITH CX, SPUTUM AND TLCL CATH TIP ALL POS FOR VRE. PLACED ON CONTACT PRECAUTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-15 00:00:00.000",
"description": "Report",
"row_id": 1484342,
"text": "resp care\nremains intubated, received on ac mode, peep of 12/60%. peep weaned to 10 however pt has had frequent and persistant desaturations. presently on peep 12/100%. pt did travel to ctscan today, also had TEE during which she desated to 77%. on sedation but still with resp efforts and dysynchronous. team to reevaluate. not functional at this time. sxned sm amt brownish/old tinged sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-15 00:00:00.000",
"description": "Report",
"row_id": 1484343,
"text": "Nursing Note (0700-1900hrs)\n\nEvents: TEE negative for vegetation, norm LVF. CT negative for tamponade from SQ emphysema. Remainder of shift complicated with desaturation requiring increase in support/sedation.\n\nReview of systems:\nNeuro: Sedation decreased to 400 mcg/hr with 13mg/hr versed--pt moving head s-s and moving BLE's on bed; became increasingly dysynchronous w/vent requirng return to prior sedation level. Pt required significant boluses of versed and fent with am procedures (TEE/CT)-received total of 22mg versed/200mcg fent with TEE and 18mg versed/300mcg fent with CT. Prresently on 450mcg/hr fent and 13mg/hr versed. No spont movement, PERL, 2mm.\n\nCV: Remained in NSR 70-90's, no ectopy. Labile BP 89/50-170/70 depending on sedation/procedures. No boluses given, CVP 5-10. WBC 14.6. Hct 30.6, stable. Coags repeated, elevated PTT, low albumin.\nRepleted with 1 Gm magnesium.\n\nResp: Ls coarse upper lobes, diminished lower. Cardiothoracic in to eval CT, CXR shows proper positioning of CT. Remained on suction 20cm during transport to tests as well. Drained 90cc s/s drng, crepitus extending to LUE and left side of face/eyelids. FIO2 decreased to 60% and PEEP down to 10; increased support for tests; unable to return to prior settings. Presently at AC 100/320/30/12, SRR 1-4. aware of nonfunctioning a-line. To attempt wire exchange. Discolored area to RUE approx 1\" beyond , MD in to eval.\n\nGi/GU: TF reinitiated at 30cc/hr, . Regland ATC. Abd soft, distended; hypo BS. Adequate u/o.\n\nID: Afebrile. CX pnd from pan cx , linezolid. Contact . WBC essentially unchanged.\nEndo: Insulin gtt off; BS wnl with steroid taper.\n\nSocial: Husband and relatives at bedside thru shift. Asking multiple questions; anxious.\n\nPlan: Cont with slow wean of sedatives; daily wake up per Dr. . Keep MAP >60, Pao2 >70, u/o >30cc/hr. Reattempt vent wean am. Labs am. Prob need to restart SSI with recommendation of NPH per nutrition. Closely monitor RUE. A-line insertion. Emotional support to family. Await further cx. Full code. Contact .\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-16 00:00:00.000",
"description": "Report",
"row_id": 1484344,
"text": "attempt made to wean pt from 100% early in AM but she SpO2 dropped and FiO2 returned to 100%. Pt being sx'd for moderate amounts of secretions. No RSBI this AM due to pt's high FiO2 and PEEP requirements. Otherwise vent settings remained as acid/base status is stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-16 00:00:00.000",
"description": "Report",
"row_id": 1484345,
"text": "NPN 1900-0700:\n\nEVENTS: Overall deterioration in oxygenation continues despite minimal activity. Pt now paralyzed, on 100% FiO2, and has required 2 fluid boluses.\n\nROS:\nNEURO: Pt unresponsive, generally flaccid. Impaired cough, absent gag earlier; now paralyzed, therefore cough absent. Fentanyl has been increased to 500mcg/hr and Versed to 20mg/hr. PERRL, sluggish.\nRESP: Pt remains on CMV with TV 320, rate 30, PEEP 12. FiO2 initially 100% with sats mid-90's. ABG showed pO2 165 at 0020, therefore FiO2 decreased to 80%. Since then she has done poorly, with sats dropping to 89-91% with any coughing, movement, increase in RR. By late in shift just putting her MP boots on caused desat to 89% without recovery. Placed back on 100% at 0600. In an attempt to improve oxygenation by supressing cough and resp effort, she is now paralyzed on Ciasatracurium. This has required an increase in sedation, as her BP immediately shot up when bolus dose was given. Still sensitive to activity, but responds to bolus of fent/versed. CT to sxn with minimal sero-sanguinous drainage; - air leak. Crepitus extending across upper chest, breasts, down both arms, and into neck and face. Turned once for bath, assessment; not moved since d/t intolerance.\nC-V: BP very labile, depending on level of sedation. Early in shift given 500cc bolus X 2 for hypotension with fair effect. CVP increased from 8 to 10, and BP acceptable. However, UO also increased from 100cc/hr to 450cc/hr immediately after boluses were given. HR 90's-low 100's, SR/ST, no ectopy.\nID: Tmax 101.2; WBC stable at 14; given Tylenol X 2, gent added to linezolid.\nGI: Tolerating TF's at goal; passing liquid brown stool via mushroom.\nGU: UO 80-450cc/hr, clear yellow. BUN/creat WNL.\nENDO: FSBS acceptable on SSRI.\nHEME: no active issues\nSKIN: intact; reddened coccyx treated with barrier cream (only turned once).\nACCESS: ICU attending ultimately able to place L brachial a-line. LSC quad lumen in place.\nSOCIAL: family remains hopeful and anxious, aware of how ill she is.\n\nA: deterioration in pulmonary status\n\nP: currently considering proning pt as last option. ? if going back up on steroids may help. Continue to look for source of fever. Continue all aggressive measures for patient; continue to support family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-16 00:00:00.000",
"description": "Report",
"row_id": 1484346,
"text": "MICU NPN \n EVENTS: episodes of hypotension treated with IVF boluses, mode of ventilation changed to APRV, fio2 wean to 80%, cont to not tolerate turning or moving, subcutaneous emphysema increasing\n\nREVIEW OF SYSTEMS:\n\nNEURO: with fent 500mcg/hr, midaz 20mg/hr, paralyzed with cistracurium 0.13mg/kg/hr, no movement or initiation of breaths\n\nCV; HR 70-90 Sr, no VEA, labile Bp hypotension responsive to IVF boluses, total of 2.5L NS given. CVP 8-12, extrem warm palpable pulses, grossly edematous\n\nRESP; intubated, mode of ventilation changed to APRV fio2 wean to 80%, peep12, P high 32, P low 11, RR 38, min vol 12.2, good abgs, chest tube intac with sersang drainage, dsg D/I, increasing subcu air chest, shoulders, arms, team aware examined by resident and intern\n\nGI: abd soft distended hypoactive bowel sounds min residuals, small amt brown stool, cont bowel regime and gi motility agents. tube feeds promote with fiber at 60cc/hr\n\ngu: foley intact with clear yellow urine, brisk urine output after fluid boluses\n\nendo; blood sugars 150-260 Q4hr sliding scale coverage provided\n\nmobility: cont not tolerating any movement, turning, tactile stimulation, attempt bed rotation this eve with adequate paralysis and o2 sat 100% on 80% fio2, Bp to 70's, sat to 97%, with supine lying BP and bolus BP returned to baseline, and sat remains 98%\n\nsocial: husband at bedside all day, appropriately upset concerned for wife, many questions concerns about treatment, spoken to at length by intern and met briefly with attending . Met for extended time with from pastoral care\n\nPLAN: cont supportive care, fluid boluses for hypotension, ? addition of levophed, follow sat/abg, wean fio2 as tolerates, slowly advance bed to rotation mode as sat/BP tolerates, cont to support husband\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-16 00:00:00.000",
"description": "Report",
"row_id": 1484347,
"text": "Respiratory Care Note:\nPt remains intubated and on the ventilator. Pt switched to APRV due to poor abg results. Abgs ok after pressure adjustments. Pt still has high fi02 requirement, was able to wean slightly. Minimal suctioning required. Mdi's given. Plan: continue on current settings as long as patient's acid/base status remains stable. See careview for additional vent. settings and info.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-11 00:00:00.000",
"description": "Report",
"row_id": 1484321,
"text": "MICU A NSG 7A-7PM\nRESP--PT WITH AIR LEAK NOTED FROM RIGHT ANT CT AND WITH FINDINGS OF INC PTX ON RECENT CXR DECISION MADE BY TEAM TO CHANGE TO TO PCV IP 18 PEEP 12 RATE 33 WITH FIO2 INC TO 60% AS OF WRITING OF THIS NOTE, DUE TO FALL IN O2 SAT/PAO2. PT BREATHING BREATHES OVER VENT WITH TV 300-600CC. PLEASE SEE CAREVIEW FOR MULTIPLE ABG'S. RIGHT ANT CT CONTS TO WALL SUCTION WITH CREPITUS AROUND DSG IN BREAST AND TO BACK. AIR LEAK NOTED AS ABOVE. PT WITH POOR TOLERANCE TO ACTIVITY, NOT TOL TURNING OR ROTATION MODE ON BED.\n\nNEURO--NO CHANGES MADE IN SEDATION THIS SHIFT. CONTS ON FENT GTT AT 350MC/HR AND VERSED GTT AT 10MG/HR. PT HEAVILY , ARMS FLOPPY AND NOT OPENING EYES EVEN TO PAIN. PT DOES CONSISTENTLY BREATH OVER VENT, AT TIMES IS DYSYNCHRONOUS WITH VENT, ESPICALLY AFTER STIMULATION. PT THEN WILL SETTLE OUT WITHOUT INTERVENTION. PT CONTS ON TRIADYNE BED.\n\nCV--PT REMAINS IN SR 80-100 WITH RARE TO OCCAS PVC'S. BP 90-120'S/. PT REMAINS OFF VASOPRESSORS. CVP 6-10. HCT 26 THIS AM, CLOT SENT TO BLOOD BANK AND PT 1U PC'S. PT WITH .\n\nGI--CONTS ON PROMOTE WITH FIBER TF AT GOAL 60CC/HR WITH RESIDUALS 40-50CCS. RECTAL TUBE REMAINS IN PLACE DRAINING SMALL AMOUNTS LIQUID BROWN STOOL. CONTS ON INSULIN GTT, PLEASE SEE CAREVIEW FOR HOURLY FS AND GTT TITRATION.\n\nRENAL--CREAT REMAINS WNL. U/O 80-180CC/HR.\n\nSOCIAL--HUSBAND AT BEDSIDE MOST OF SHIFT, DAUGHTER IN TO VISIT. ALL ANXIOUS OVER PT'S CHANGES IN CONDITION. MET WITH ATTENDING FOR UPDATE ON PT CONDITION AND PLAN OF CARE AND UPDATED FREQ BY THIS RN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-12 00:00:00.000",
"description": "Report",
"row_id": 1484322,
"text": "Resp Care\nPt remains intubated on APRV, no changes made during shift, ABG WNL. BIl breath sounds w/ scattered rhonchi t/o. Pt sx'd for sm thick white blood tinged sputum. MDI's given as ordered. Plan to continue to wean FIO2 and Phigh slowly as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-12 00:00:00.000",
"description": "Report",
"row_id": 1484323,
"text": "NPN 1900-0700:\n\nEVENTS: Relatively stable night with improving ABG's.\n\nROS:\nNEURO: Remains heavily with Fentanyl and Versed doses unchanged. Neck and extremites are flaccid, does not f/c, absent gag, cough strong at times, impaired at times.\nRESP: Stable sats early evening with improved ABG on APRV: 7.42/41/93. She was placed on 100% FiO2 to facilitate turning, bathing, full assessment, which she tolerated reasonably well (sats dropped to low of 86% during turn but rebounded quickly). She was then returned to 60% for the rest of the night. After several hours her bed rotation mode was turned on at very minimal settings. She had no compromise in her oxygenation, but HR increased somewhat (possibly d/t slight rise in temp at the same time). After a few more hours rotation settings increased a bit, which she again is tolerating thus far. Vent settings unchanged: she remains on APRV .6 with P-high 24, P-low 10, RR low 30's. ABG this morning further improved at 7.41/41/129. CT to 20cm sxn cont's with intermittent slight air leak, 80cc's sero-sanguinous drainage for the shift. Crepitus to axillary area persists, though seems decreased from early in shift. CXR done at 5PM yesterday \"much worse\" per MICU team (formal not yet in computer). Started on decreased dose of steroids per Meduri Protocol.\nC-V: HR 70's during the evening, up to low 100's since MN. BP has been stable off pressors, dropping transiently into 90's with turning. CVP 8-10. K 3.7 this AM, currently being repleted with 40meq KCl; Ca/Mg/Phos added on to AM labs and are pending.\nID: Low-grade temp (max 100.3), WBC down a bit to 15. Cont's Vanco, Levoflox, Diflucan.\nGI: Cont's to tolerate TF's at goal. Small amt liquid brown stool, belly benign. LFT's added on to yesterday's AM labs showed increased ALT, AST, and Alk Phos compared to previous levels; not repeated today.\nGU: Cont's with adequate U/O of 30-120cc/hr. BUN up to 23 (18); creat stable at 0.6.\nHEME: Hct 28.6, up from 26.1 after 1 unit PRBC's. Plt's WNL, no evidence of active bleeding.\nENDO: Insulin requirements increased significantly despite decreased steroid dosing. Gtt titrated accordingly.\nSKIN: Buttocks slightly reddenned but actually improved despite inability to tolerate turning much of the past 24 hours. No other breakdown. Anasarca increasing, but no weeping noted.\nACCESS: R SC TLC site benign and catheter functioning well. R radial a-line oozing sero-sanguinous fluid at start of shift; new dressing with surgicell placed. After a few hours dressing again saturated and tracing very dampened. Line was changed over a wire by MICU team. Initially new catheter had excellent waveform and good blood return, but soon was difficult to draw from and had very poor tracing. Able to manipulate line a re-secure with steri-strips (has sutures too) for better tracing, but still difficult to draw from. MICU intern aware of ongoing problems with line (it was very difficult to place initially and site is only 2 days\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-12 00:00:00.000",
"description": "Report",
"row_id": 1484324,
"text": "(Continued)\n old).\nSOCIAL: Husband and dtr aware of events of the night; asking appropriate questions and demonstrating understanding of nature of illness and uncertain prognosis. The went home for the night about 10PM and dtr has called once (scheduled to call again just before 0700).\n\nA: improved oxygenation and tolerance of turning despite worsening CXR.\n\nP: continue ventilation as needed; consider decreasing FiO2; bed rotation as tolerated; titrate insulin prn; f/u on lytes, replete prn; continue all supportive measures; continue to inform and support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-10 00:00:00.000",
"description": "Report",
"row_id": 1484318,
"text": "Nursing Note (0700-1900hrs)\n\nEvents:Tolerated further wean of vent and sedation. +BM. Off pressor.\n\nReview of systems:\nNeuro: Remains very on Fent 350mcg/hr and versed 8mg/hr(down 20%). Intermittent episodes of hiccups, resolving without intervention. PERL,2mm,sluggish. No movement of limbs despite painful stimuli.\n\nCV: Off levophed at 9am; a-line nonfunctional, replaced in late afternoon. Remains in NSR 70-90's with rare PVC's. R TLCL site unremarkable. 2+edema to upper extremities. Coccyx sl pink, barrier cream applied. CVP 9-13, no boluses today. Phos/K repleted.\n\nResp: Weaned; presently at P hi 30, P lo 12, PEEP 16; improving Vt for 340-400's; RR 31-33, Fi02 40%. ABG 7.45/33/132. No secretions. Cont on vanco for post VATS, levo for ?VAP. CXR this afternoon. Fluconazole for +.\n\nGI/GU: Tol TF at goal, residuals improved since yesterday; receiving reglan. Two BM's, one for very large amt, OB neg. Adequate u/o.\n\nEndo: Insulin gtt titrated protocol. Improved BS, now trending down to 90's.\n\nID: WBC elevated. On high dose steroids, last dose . Low grade temp. Pan cx x2, last ; pnd.\n\nSocial: Family's spirits improved however verbalized understanding that pt's status remains critical despite improvement. Social and pastoral services continue w/daily visits. Spoke w/MD at length\n\nPlan: IV antibx to end this w/e. Cont to wean vent as tol. Titrate insulin gtt, steroids ending . Labs am; pm lytes pnd. Emotional support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-11 00:00:00.000",
"description": "Report",
"row_id": 1484319,
"text": "Resp Care\nPt remains intubated on APRV, Phigh weaned to 26, Pt tol well. ABG's WNL. Bil breath sounds, sx'd for scant secretions. MDI's given as ordered. Pt excluded from AM RSBI. Plan to continue to wean vent support as tol.+\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-11 00:00:00.000",
"description": "Report",
"row_id": 1484320,
"text": "NPN 1900-0700:\n\nEVENTS: Pt has had a very stable night; able to further wean P-high a bit to 26 with acceptable ABG's.\n\nROS:\nNEURO: Pt remains heavily on Versed 10mg/hr, Fentanyl 350mg/hr. Extremities are flaccid, no need for restraints. PERRL, sluggish at times.\nRESP: Remains on APRV with P-high weaned to 26; other settings unchanged: P-low 12, FiO2 40%, pt's RR 17-34, TV's 340-400. Sats 94-97%; ABG this AM 7.41/40/93. Minimal thin white secretions; LS coarse t/o. Pt had episode of hiccups causing transient increases in airway pressures, but minimal desaturations. During the evening her sats dropped to low 80's when turned for bed bath despite 100% FiO2; later in shift she tolerated turning better. She has also tolerated rotation of the Triadyne bed without any problems. R anterior CT remains to 20cm sxn with ~100cc's sero-sanguinous drainage for shift. She has intermittent crepitus above CT site (CXR from yesterday showed some increase in size of ptx with new SQ emphysema). No air leak detected.\nC-V: HR generally 90's, NSR, with occ PVC's. BP stable 90's-100's off Levophed; no need for fluid boluses. Given 40meq KCl overnight; lytes WNL this AM.\nID: Low-grade temp to 99.8 this AM; given 650mg Tylenol. WBC down a bit to 16.1; no new cx data; no changes in abx.\nGI: Tolerating TF's at goal of 60cc/hr with max residual of 50cc's. Passing liquid green stool; mushroom catheter inserted and draining well.\nGU: UO much improved, and she is now auto-diuresing. BUN/creat WNL.\nENDO: Insulin gtt titrated prn. FSBS generally quite stable except increase after Solumedrol dose.\nHEME: No evidence of bleeding. Hct down to 26.1 (30.1).\nSKIN: Intact; buttocks reddened; covered with barrier cream. Bed rotating, multi-podus boots in use.\nSOCIAL: Many family members in all evening; all went home except husband who spent night in waiting area. He reports that he was able to sleep for several hours. He is encouraged by her progress over the past couple of days, but clearly understands that her prognosis remains guarded at best. In general family seems to be adapting and coping much better to pt's illness.\n\nA: significant improvement in oxygenation and hemodynamics past 24-48 hours\n\nP: Continue SLOW wean of sedation and vent as tolerated. ? transfuse. Continue all supportive measures.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-08 00:00:00.000",
"description": "Report",
"row_id": 1484309,
"text": "NURSING ADDENDEM: FS INCREASED AFTER HIGH DOSE STEROID. 273 THIS PM-COVERED WITH SSI. MONITOR MORE FREQUENTLY AS NEED AN INSULIN GTT TO MANAGE GLUCOSE LEVELS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-08 00:00:00.000",
"description": "Report",
"row_id": 1484310,
"text": "\nPT MAINTAINED ON APRV VENTILATION AT 60% WITH STABLE VITALS AND IMPROVING OXYGENATION. LAST X-RAY SHOWING ARDS ALONG WITH PATHOLOGY REPORT OF LUNG BIOPSY. PT CONVERTED OVER TO APRV FOR WORSENING OXYGENATION AND COMPLIANCE. SPIKED TO 103 TODAY. MENTALLY PT IS . B.S. BILAT AND VERY DECREASED. PRONING WAS DISCUSSED BUT NEGOTATIONS TO LEAVE PT ROTATING ON TRIADYNE BED AND ALLOWING APRV SOME CLINICAL TIME TO WORK SEEMED A BETTER APPROACH. ESOPH. BALLOON ALSO DISCUSSED BUT PUT ON HOLD FOR NOW. LAST ABG SHOWED IMPROVING OXYGENATION WITH PROPER VENTILATION. PLAN IS TO CONT ON CURRENT MODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-09 00:00:00.000",
"description": "Report",
"row_id": 1484311,
"text": "MICU Nursing Note 1900-0700\nEvents: Pt with labile BP and HR all noc...requiring IV fluid boluses and continues on IV Levophed. HTN episodes thought to be due to anxiety and IV Versed gtt increased to 12 mg/hr. Tolerating APRV mode at 60% with slightly improved ABG's. Did not tolerate rotation mode on triadyne bed due to hemodynamic instability. Family stayed in waiting room all night.\n\nNeuro: Remains on IV Versed at 12 mg/hr and IV Fentanyl at 500 mcgs/hr. No spontaneous movement noted. Pupils 2mm and sluggish. Occas eyelid fluttering noted with increased stimulation in room. All extremities flaccid and no need for limb restraints.\n\nCardiac: Extremely labile BP all noc. Pt with many episodes of sBP down to 70's requiring increase in Levophed to a max of 0.09 mcgs/kg/min. Pt's BP very sensitive to any adjustment in Levophed and hypotension quickly resolves with levo titration...resulting in sBP up to 180-200's. Received (2) IV NS fluid boluses for sBP down to 70's and CVP=10. BP up and down all night ...with hypertension pt's HR down to 50's SB...with hypotension episodes pt HR 60-80 SR. Occas. PVC noted. Currently IV Levophed infusing at 0.05 mcg/kg/min. Left radial Aline site oozing blood---dsg changed. Good correlation of Aline to NBP. Right SC central line site C/D/I.\n\nID: Afebrile. WBC 11. Remains on IV Vanco and Levoflox. and IV Diflucan started last eve. Remains on high dose steroids.\n\nResp: Tolerating APRV mode at 60 % with Isp. time=1.5 secs. and Peep=16cm. TV=250-300's. MV=8-9.5. RR=32. Occasionally tachypneic to RR=40 with all suctioning and activity. Pt with episode of hiccups resulting in RR=40 until hiccups resolved. Lungs coarse throughout. ETtube suctioned for mod. amts. thick yellowish sputum. O2 Sats=96-98%, improving ABG's throughout night....7.39-41-87-26 at 4am. Right ant. Chest tube remains to 20 cm SX with 20 ml serosang drainage noted in pleurovac for shift. No crepitus and No air leak noted. Dsg D/I. Bronchospastic with deSat's while on rotation mode on bed---placed supine for night.\n\nGI: OGtube placement checked by auscultation. Tube feeds at 20ml/hr ...unable to increase rate due to occasional high residuals. Abd softly distended with hypoactive bowel sounds all quads. No BM.\n\nEndo: Pt with FS=300-390's during night. Covered on sliding scale.\n\nGU: Foley to CD draining large amts clear yellow urine..1.5liters/shift.\n\nSkin: Remains on triadyne bed...currently supine with pulsation mode but not on rotation at present time. Unable to turn pt off of her back due to labile BP's and deSats. Venodynes and multipodis boots on bilat LE. Partial bath admin. Oral and eye care completed.\n\nSocial: Pt's family---husband, daughter, and son-in-law spent night resting in family waiting room. Support and comfort measures offered to family. Family updated on pt's condition this am.\n\nPlan: Attempt rotation on triadyne bed this am if more hemodynamically stable. Continue sedation. ? Need for IV insulin\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-09 00:00:00.000",
"description": "Report",
"row_id": 1484312,
"text": "MICU Nursing Note 1900-0700\n(Continued)\ngtt to cover hyperglcyemia while on high dose steroids. Advance TF as tol. Attempt wean from Levophed. Continue maximum support of pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-09 00:00:00.000",
"description": "Report",
"row_id": 1484313,
"text": "Respiratory Care:\nPatient remains on APRV ventilatory support: P hi=34; Plo = 16; T hi = 1.5 secs; T lo = .4 secs; FIO2-60% (All settings remained unchanged overnight). Morning abg results revealed a normal acid-base balance with good oxygenation on the current settings.\n\nNo RSBI measured due to the instability of the patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-09 00:00:00.000",
"description": "Report",
"row_id": 1484314,
"text": "Nursing Note (0700-1900hrs)\n\nEvents: Blood pressure continues to be labile requiring very minimal amts of levophed gtt and two boluses. Sedation weaned by nearly 20%. Continues on APRV mode on ventilator with improved ABG's.\n\nReview of systems:\nNeuro: Impaired cough reflex and absent gag. No movement of limbs despite noxious stimuli. Sedation weaned by nearly 20%-fent at 450mcg/hr and versed 10mg/hr. Unstable to do neuro check w/sedatives temp off. PERL, 2mm.\n\nCV: Severly sensitive to levophed rate; attempted several times to d/c levophed however BP dropping to 60's with MAP 40-50's. Remained on 0.03-0.05 mcg/kg/min most of shift. A-line occ dampened, oozing s/s drng at times; able to draw bloods without difficulty. R SC TLCL site unremarkable. HR 80-90's, nsr. CVP 8- bolused x2 with 250cc NS thru course of day; CVP now 12. Goal 12. MAP goal >60. p-boots/sq hep. Coccyx sl pink, triadyne bed on rotation mode--tol very well today. Did not tolerate complete bed bath very well, hypotensive to 60's after bath complete however quick response w/min increase in levophed gtt.\n\nResp: LS coarse throughout, no secretions. R ant CT at 20cm suction, no leak/crepitus; drained 90cc s/s drng. Cont on APRV mode, FIo2 decreased to 40%--ABG 7.38/43/119 with 40%/P hi 34/Plow 16; RR 31-33 with Vt improved to 340-370's. Remains on fluconazole for +bronchial washings w/. On Vanco post VATS as well as levo.\n\nGi/GU: ABd soft, distended; able to increase TF to 30 (goal 60cc/hr)--TF absorption quite dependent on timing of reglan. Lactulose given x2, colace x1--no BM since Sunday. Hypoactive BS. Urine decreasing thru course of day, 2160cc since 12m. U/O marginal last couple hours.\n\nEndo: Begun on insulin gtt for cont BS 300-400cc; presently at 17.6u/hr with BS in 160's. Cont on hi-dose steroids.\n\nSocial: Family at bedside thru shift; anxious. Asking appropriate questions. Social services/pastoral services involved. Spoke w/MD and nursing through course of day. Outside visitors kept to a minimum of 5Min visits per family's request; phone number to room not to be given out per family--admitting notified.\n\nPlan: Remains critical and labile. Goal CVP 12, u/o >30cc/hr, and MAp >60. Cont to titrate vent as tolerated. IV antibx. Emotional support to family. Advance TF as tol for goal 60cc/hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-09 00:00:00.000",
"description": "Report",
"row_id": 1484315,
"text": "resp. care\npt. continue to be intubated/vented. fi02 weaned to 40%.\nmdi's given. if p02 continues to improve would wean p high\nvery slowly. see careview for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-10 00:00:00.000",
"description": "Report",
"row_id": 1484316,
"text": "7p to 7a Micu Progress Note\n\nEvents - pt continues to have very labile BP, unable to wean levophed off. HR also variable, at times inversely related to BP and not affected by stimulation or sedation. Oxygentation improving - no episodes of desaturation.\n\nNeuro - Remains with 450 mcgs/hr fentanyl and 10mg/hr versed. No spont movement observed. Exts flaccid. PERL. No gag or cough reflex noted.\n\nC-V - HR 80 -120 ST with rare pvcs. SBP 74-170. Levophed titrated to maintain MAP > 60, currently infusing at .02mcg/kg/min. 3+ palp periph pulses. CVP 9-12. No fluid boluses administered. Hct dropping from 34.9 to 30.1 this am - MD aware.\n\nResp - Orally intubated and vented on APRV mode. P high decreased to 32 and P low to 14 as well as peep to 14 on 40% fio2 - ABG 7.41/40/156/1/26. RR 21-32. 02 sat > 94%. TV's ~350. LS coarse to clear. Sx x 1 for thick tan secretions, otherwise no sputum obtained when sx. C-tube to 20cm sx draining 60ccs serosanguinous fluid. No creptitus. C-tube dssg site D+I.\n\nGI - Abd soft and sl distended. Hypoactive BS. TF advanced to 40ccs/hr via NGT. Max residual 60ccs. Rx with iv reglan. No stool. Given lactulose and colace via NGT and dulcolax pr.\n\nF/E - TFB + ~2300ccs yest. Urine output improving - output 25-225ccs/hr via foley. K 3.4 and Phos 1.4 this am - pt to receive k-phos iv when available from pharmacy.\n\nID - Max temp 100.7 po. WBC rising to 17.4 from 11.1. Pt pan cultured ( 2 sets BC, urine and sputum sent). No tylenol given as temp declined without intervention. Being rx with vanco, fluconazole and levaquin.\n\nAccess - L radial aline continues to bleed, dssg changed, waveform dampened but able to draw blood without difficulty. RIJ dssg D+I.\n\nEndo - Labile BS as pt receiving high doses of methylprednisone. FS 105-167. Insulin drip currently infusing at 18units/hr.\n\nSocial - Family at bedside during the evening. Stated they will return ~ 10 am today.\n\nA+P - Pt remains extremely labile. Continue slow wean from vent. Titrate levophed for MAP >60. Replete lytes prn. Advance TF as tolerated. Aggressive bowel regime.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-10 00:00:00.000",
"description": "Report",
"row_id": 1484317,
"text": "resp care\nPt remains intubated on APRV, ABG's WNL, oxygenation improving - Phigh & Plow decreased, tol well. Pt sx'd for minimal secretions. MDI's given as ordered, pt excluded from AM RSBI. Please see carevue for details. Plan to continue to wean PEEP slowly as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-18 00:00:00.000",
"description": "Report",
"row_id": 1484356,
"text": "MICU A NSG 7A-7PM\nADDENDUM--PT CONTS WITH FULLY DILATED EYES DUE TO DILATED EYE EXAM. FS DONE Q2 WNL, PLEASE SEE , PT REMAINS OFF INSULIN GTT AT THIS TIME. TF REMAIN OFF DUE TO CONT HIGH RESIDUALS. ABG'S IMPROVING, PLANS TO SEND NEXT AT 7PM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-18 00:00:00.000",
"description": "Report",
"row_id": 1484357,
"text": "Resp Care\nPt remains on APRV-parameters noted. Following turn, pt had decreased PaO2 and increased resp failure. Team aware and no vent changes at this time. ECMO discussed. Pt is slowly recovering. Suction for scant secretions, sample sent. MDI x 3. Will continue mech vent at this time. Following 7pm ABG, team to decide next coarse of action.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-19 00:00:00.000",
"description": "Report",
"row_id": 1484358,
"text": "Resp Care Note:\n\nPt cont intub with OETT /paralyzed and on mech vent as per Carevue. Lung sounds sl coarse suct sm loose off white sput. ABGs adequate though significant oxygen deficit persists and has worsened compared to yesterday [a/A ratio .13 gradient 534] though oxygen weaned from 1.0 to .85FIO2. Cont APRV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-20 00:00:00.000",
"description": "Report",
"row_id": 1484363,
"text": "Resp Care NOte:\n\nPt cont intub with OETT /paralyzed and on mech vent as per Carevue. Lung ess unchanged suct sm loose white sput. MDI given as ordered. ABGs show sl improvement; no vent changes required overnoc. Cont present regime.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-20 00:00:00.000",
"description": "Report",
"row_id": 1484364,
"text": "NPN 1900-0700:\n\nEVENTS: Pt required increasing amounts of fentanyl, versed, and cisatracurium to maintain sedation and paralysis. Not moved d/t tenuous status. Extensive discussions with family around code status.\n\nROS:\nNEURO: Early in shift pt had repeated episodes of hypertension for unclear reasons. Without another apparent cause, pain or discomfort was assumed and Fentanyl/Versed were increased accordingly to 750mch/hr and 30mg/hr respectively. She was also transiently on Propofol when she cont'd to become hypertensive on above doses. BP dropped to 60's on even low-dose Prop, therefore it was stopped. She has had no indication via VS of discomfort since. Cisatracurium also increased during the evening when she was making resp effort. R pupil 4mm, reactive; unable to open L eye to assess. No spontaneous movement.\nRESP: Sats 91-93%. No vent changes made. ABG 7.44/46/66 early in shift; later, with adequate sedation and paralysis, improved to 7.44/44/80. No need for suctioning; LS difficult to auscultate d/t SQ air. SQ emphysema significantly increased over past day, involving entire chest, breasts, axillae, neck, face (esp L side, L eye). R ant CT to sxn with minimal sero-sanguinous drainage. Some drainage from dressing on pad under pt, but unable to turn to assess.\nC-V: HR low-100's, ST, no VEA. BP has settled out in 80's (MAP 60's) by a-line, 120's by NBP after earlier instability.\nID: Temp >101 all night; given Tylenol X 3. WBC up to 18K, cont's on Linezolid.\nGU: UO 80-150cc/hr, BUN/creat 11/0.3. 3% NaCl resumed; per renal, we are following Na frequently and adjusting accordingly.\nGI: Not being fed; minimal residuals from OGT. Minimal stool viz mushroom catheter.\nHEME: Hct, plt stable; no evidence of bleeding.\nSKIN: Intact anterior; unable to turn to assess back/buttocks.\nACCESS: L brachial a-line lower than NBP but with good waveform and easy to draw from; RIJ MLC.\nSOCIAL: I had many discussions with husband, dtr, and other family members reviewing pt's extremely grim prognosis and centered around what they believe pt would want. They fully understand that we are out of options, and they do not want pt to suffer. Husband also articulated pt's past statements that she would not want to live if she could not be active and fully participate in life. He is, however, wrestling with the idea of \"pulling the plug\", asking \"how can I kill my wife?\" He was assured that her illness is what is killing her, not him. He then stated \"but God hasn't taken her yet\". He was reminded that \"God is trying very hard to take her, but we are not letting that happen\". After several hours and repeated discussions with this RN and his family, he has opted for DNR status to avoid the pain of a resuscitation attempt. He would like to continue as we are doing through the day today and will likely be ready to withdraw care this evening. He was offered the option of having a priest come in during the night but declined; he (and the rest of the family) will\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-20 00:00:00.000",
"description": "Report",
"row_id": 1484365,
"text": "(Continued)\n benefit from a visit today. All family members are close and mutually supportive of each other; they also have a network of supportive friends involved.\n\nA: increased sedation and paralytic doses required; pt now DNR\n\nP: continue supportive care, focusing on comfort. Involve priest again today and ? SW (though family has been much more receptive to priest). Family will likely be ready to withdraw care tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-20 00:00:00.000",
"description": "Report",
"row_id": 1484366,
"text": "Resp Care\nPt remains on APRV- parameters noted. Pt had drop in SpO2 into the 80s so increased FiO2 to 95%. Suction scant secretions. x 3. Will continue mech vent at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-20 00:00:00.000",
"description": "Report",
"row_id": 1484367,
"text": "MICU NPN 0700-1900\n\nEVENTS: remains DNR, cont current level of care, awaiting family decision for comfort care\n\nREVIEW OF SYSTEMS:\n\nNEURO: heavily with fent 700mcg/hr and midax 30mg/hr, remains paralyzed with cisatracurium 0.3mg/kg, unresponsive to all stim,\n\nRESP: remains intubated and vented with APRV mode of ventilation, fio2 increased to 95%, secondary to desating to 88-89%, right chect tube intact with -leak, +crepitus, small amt oozing from insertion site, breath sounds decreased throughout, crepitus on chest, abd, upper arms, face, eyes, needle decompression of sq air by Dr , bilat upper chest with #14g angios in place,\n\nGI: abd soft distended hypoactive to absent bowel sounds, copious mucusy stool obstructing mushroom catheter, catheter removed profuse watery diarrhea, mushroom cath replaced, NPO, except po meds\n\nGU: foley intact, UO 100-180cc/hr\n\nF/E: na 126, cont 3%sodium at 20cc/hr per renal recs\n\nSKIN: coccyx intact, not tolerating turning/manipulation secondary to oxygenation, cont triadyne bed, diffuse subcutaneous air chest,abd,arms, face\n\nSOCIAL: many family members at bedside throughout the day, daughter and husband here all day, social work avialable to them for additonal support, pastoral care provider met with this am and again this afternoon, family reluctant to actively cause her death, attempted to explain we were actively preventing her death with our aggressive contiued treatment. The family is hoping \"God takes her\" without having to stop any machines\n\nPLAN; continue supportive care, cont to support family\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-20 00:00:00.000",
"description": "Report",
"row_id": 1484368,
"text": "FINAL NURSING NOTE:\n\nAfter further discussion with RN, family elected comfort care and terminal extubation. Cisatracurium gtt was D/C'd; Morphine and Propofol gtts were initiated, and pt was extubated at 2220. Pt comfort ensured with gtts; RN present with pt at all times till she expired at 2230. Family elected to leave room and returned after pt expired; they are appropriately grieving and mutually supportive of each other. Family declined autopsy and took all belongings home.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-18 00:00:00.000",
"description": "Report",
"row_id": 1484354,
"text": "pmicu npn 7p-7a\n\n\n overall, the pt's oxygenation continued to trend downward overnoc despite an actual increase in saturation values. fio2 was eventually increased to 70% at 0630. also of note, the pt's sq emphysema became substantially worse, particularly in the chest, neck, and face. the left side of her head is more affected than the left.\n\nreview of systems\n\nrespiratory-> the pt remains paralyzed, intubated, and on aprv w/rr 34, tv ~330cc. last abg on an fio2 60% was 7.41/52/61/34. the fio2 was subsequently increased to 70%. also of note, the peak inspiratory time was increased earlier in the shift to reduce her rr and normalize her ph. she was no suctioned this shift.\n\ncardiac-> hr 80-90's, sr with rare pvc's. she was repleted x1 with ca gluconate. more hemodynamically stable. sbp 90-120's off of levophed.\n\nneuro-> pt was inadequately paralyzed and at change of shift\nand required boluses x2 of cisatracurium to achieve the desired effect. the fentanyl and versed qtts were eventually increased as well d/t persistent hypertension and ^hr.\n\ngi-> abd is soft, distended w/hypoactive bs. tube feedings were increased to 50cc/hr. residuals 10-30cc.\n\ngu-> uop 100-200cc/hr. she remains just slightly tfb positive since mn.\n\nid-> tmax 98.6 orally with a slightly rising wbc. remains on abx coverage for .\n\nendocrine-> pt is currently off of an insulin qtt for fs <100.\n\nsocial-> pt's dtr called this am and was updated on her condition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-19 00:00:00.000",
"description": "Report",
"row_id": 1484359,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Remains chemically paralyzed with cisatricurium infusing at .20mg/kg/h. with 480mcgs/hr fentanyl, 20mg/hr versed and 20mcgs/kg/min propofol. Pupils gradually becoming less dilated overnight (chemically dilated by opthomolgist)but sluggish to react. Train of 4 showed pt with 4 twitches to 40 mm amp x 3. Sedation not adjusted as pts resp status very tenuous.\n\nResp - Orally intubated and vented on APRV. Able to wean fio2 to 85 % with most recent ABG 7.35/57/70/33/3. Will repeat ABG ~5am as pt's pco2 is beginning to rise. RR 34-36, no spontaneous initition of breaths. TV's 285-291. 02 sat > 93%. LS coarse to bronchial. C-tube to 20 xm sx, no air leak. Dssg D+I. Drainage initially serous, now serosanguinous. Crepitus continues to increase extending throughout face, chest, arms, abd and genitalia. Less edema noted in OS. Pt sx for scant amt thick white sputum.\n\nC-V - HR 82-92 SR. ABP 100-130/60's. Remains off pressors. Hct rose from 28.5 to 31.6 after receiving one unit PRBCs on previous shift.\n3+ palp peripheral pulses.\n\nGI - Abd soft and distended. Hypoactive to absent BS. TF restarted but then held d/t residuals of 100ccs. Amino acid soln with electrolytes and D5 currently infusing via central line.Passing sm amt brown liquid stool via mushroom catheter.\n\nF/E - TFB + ~500ccs yest. Urine output averaging 100ccs/hr via foley catheter. Am lytes mod hemolyzed - repeat sample sent.\n\nID - Max temp 100 po. WBC unchanged at 15. rx with linezolid for .\n\nSocial - Family members at bedside throughout the evening, tearful when departing. Reinforced to family that short of ECHMO not much else can be done to improve pts pulm status and that ECHMO can have many associated complications.\n\nA+P - Continue to monitor resp status - serial ABGs. TPN as pt unable to absorb TF's. Emotional support to family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-19 00:00:00.000",
"description": "Report",
"row_id": 1484360,
"text": "Addendum - Na 121 Cl 87 - Md notified.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-19 00:00:00.000",
"description": "Report",
"row_id": 1484361,
"text": "resp care\nremains on APRV mode. very small changes made, abg slightly worse this morning, now slightly improved again. maintaining Ve approx 10 lpm. c/w large amt of subq emphysema. remains on paralytic/sedation. occas efforts at spont resps noted. c/w small manipulations of APRV for optimal oxygenation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-19 00:00:00.000",
"description": "Report",
"row_id": 1484362,
"text": "MICU A NURSING PROGRESS NOTE. 0700-1900\n SEE FOR OBJECTIVE DATA.\n\n Events: No changes in neuro status. Minor changes made to ventilator r/t i & e times. Multiple medication changes regarding concentrations and base fluid.\n\n Neuro: Remains paralyzed on cisatricurium at .24 mcg/kg/hr with train of four showing 4 twitches to 40 ma x 2 and 4 twitches to 50ma x 1. Propofol turned off this am per recc. of renal r/t sodium level. Remains on versed at 20 mg/hr and fentanyl at 480 mcg/kg/hr. Pupils 4 mm and sluggish. All medication drips have been changed to ns base and concentrated to maximum level per recc. of renal r/t hyponatremia.\n\n Respiratory: Lung sounds are difficult to auscultate anteriorly r/t tremendous amount of subcutaneous air present in chest and neck. Unable to auscultate posteriorly r/t tenuous nature of pts respiratory and hemodynamic status. Lungs sounds are coarse in upper fields, bilat, diminished in rt base, pleural friction rub lt base. Ventilator settings remain aprv .85/peep 12. Not initiating breaths, tv 270's to 320's. O2 saturation on 89-95% present ventilator settings. Chest tube rt ant. with no air leak, draining s/s fluid. Dressing is D/I but appears to have some drainage posteriorly. + crepitus across anterior chest,abd, neck and face. Reducable around orbits but is now reoccuring and is far greater than it was this am. Team aware of lg amt of subcutaneous air.\n\n CV: Sinus rhythm to sinus tachy with no ectopy noted, rate 70's to 100's. Abp low 80's to 110's systolic. site in lt bracheal wnl, waveform sharp and good blood draw. Rt ij site difficult to visualize r/t sq air. 3+ peripheral pulses. Na level this am down to 116. Treated with 3% sdium chloride this pm iv at 100c/hr. Last na 124, drip d/c'd and latest sodium level is pending.\n\n GI/GU: Abdomen softly distended with + bs. Mushroom catheter remains in place with minimal brown stool drainage. Ogt in good placement, clamped at present. Placed on suction and drained 300 cc green bilious drainage, team aware. Foley catheter patent and draining clear yellow urine 45-550cc/hr.\n\n ID: Remains on linezolid for . Temperature max. 101.8 oral, tx with 650 mg tylenol pr. Given 650mg tylenol per ngt this am.\n\n Social: Husband, daughter and multiple family memebers visiting throughout shift. Family informed of present condition on several occn by team and did meet with Dr this am. They were informed that pt is very ill and that we have no further options. Family understandbly upset and social services on call and priest on call called and both spoke with family. No changes or decisions made in pts code status or treatments.\n\n Plan: Continue to monitor lab values and treat as required. Maximize resp. fxn as possible. Minimal stimulation and movement. Emotional support for family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-18 00:00:00.000",
"description": "Report",
"row_id": 1484355,
"text": "MICU A NSG 7A-7PM\nRESP--PT CONTS ON APRV. P HIGH 30 P LOW 11, FIO2 INC TO 100% THIS AM FOR TURNING. PT TURN POORLY WITH O2 SAT DROPPING TO 80% WITH DROP IN HR FROM 80'S TO 50'S. HO IN TO EVAL. PT PLACED FLAT ON BACK TILL HR AND O2 SAT RECOVERED. PT VIA ETT X1 FOR SCANT SECRETIONS, SPEC FOR CX SENT. MULTIPLE ABG'S DRAWN, pH TRENDING DOWN WITH INC IN PCO2. PLEASE SEE CAREVIEW. CT TO BE CONSULTED FOR POSSIBLE ECMO THERAPY, UNKNOWN IF PT WILL BE CANDIDATE AT THIS TIME.\n\nNEURO--PT RECEIVED ON FENTAYL GTT 600MC/HR AND VERSED GTT 25MG/HR, CISATRACURIUM GTT 0.2MG/KG/MIN. TRAIN OF FOUR ATTEMPTED, BUT RESULTS VARIABLE, AT TIMES WILL ONLY GET 1 TWITCH TO 40MAMPS, AND OTHERS 4 TWITCHES. PROPAFOL GTT ADDED, DUE TO SIG INC IN BP/HR WHEN STIMULATED, BP 240/120 DURING TURNING THIS AM. PT VS MORE STABLE WITH FEWER CHANGES DURING CARE. FENT AND VERSED WEANED BY 20%.\n\nCV--EVENT WITH DROPPING HR THIS AM AS ABOVE, AND PT REMAINS OFF PRESSORS. PT CONTS WITH . CREPTIUS THROUGHOUT FACE, CHEST, BACK, ABD ARMS, AND NOTED IN GENITAL AREA. LEFT EYE SWOLLEN SHUT AND OPHTHOMOLOGY IN TO EXAMINE EYE. CURRENT PLAN IS TO CONT WITH LACRILUBE. HCT 28 THIS AM AND RECEIVING 1U PC'S. CALCIUM ADN MAGNESIUM REPLETED.\n\nGI--RECTAL TUBE CLOGGED THIS AM, AND PT WITH LG VOLUMES OF LIQUID BROWN STOOL. UNABLE TO PLACE RECTAL BAG DUE TO ENLARGED HEMEROIDS AND ERYTHEMETOUS SKIN ON COCCYX. RECTAL TUBE REPLACED. TF ON HOLD DUE TO HIGH RESIDUALS. TEAM AWARE AND ? WILL START TPN IN NEXT DAY IF CANNOT TF.\n\nGU--FOLEY CATH DRAINING CLEAR YELLOW URINE.\n\nSOCIAL--FAMILY MEETING HELD, POSSIBILITY OF ECMO DISCUSSED. HUSBAND AND DAUGHTER PRESENT. AWARE OF PT'S TENUOUS CONDITION AND TEARY EYED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-06 00:00:00.000",
"description": "Report",
"row_id": 1484300,
"text": "EVENTS: Pt electively intubated at 1300, Chest CT done, Aline placed, Currently on call to OR for VATS procedure.\n\nNeuro: Initially, pt A+Ox2, lethargic/tired with periods of restlessness, followed commands, MAE, PERRL, c/o some abd pain when coughing. Sedated on propofol immediately post-intubation. Changed to Versed/Fentanyl gtts upon return from CT. Current rates 4mg/hr versed. 50mcg/hr Fentanyl. Easily arousable with coughing fits when stimulated.\n\nResp: Lung sounds coarse in apices, diminished with fine crackles in bases. Intubated electively at 1300 prior to CT and Vats this evening. Initially tube in R brohchous so pulled back to 17cm. ABG7.40/42/97/27. Vent settings CMV 330x16/80%/8. Deep suctioning for very thick, bloody sputum (looks like tar)So thick it is difficult to suck through catheter. Chest CT results pending. On call to OR for vats.\n\nGI: Abd soft with positve bowel sounds, Large BM x1, guiac -, sample sent, NPO, blood sugars 224 at noon. covered with 4u ss insulin.\n\nGU: U/O approx 30-50cc/hr. yellow urine foley patent.\n\nDerm: Grossly intact, some small dried blisters on palms of hands reportedly much better than previous. PIV in R forearm patentx2. Coxxyx redenned covered with barrier cream and repositioned frequently.\n\nID: afebrile, abx on hold while cultures pending. Steroids on hold as well.\n\nSocial: Family very concerned with numerous questions. Husband will stay in hosp with her tonight.\n\nPlan: vats today, monitor resp status closely, follow cultures and CT results, sedate according to comfort, reassurance for family, Full Code.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-07 00:00:00.000",
"description": "Report",
"row_id": 1484301,
"text": "NPN 1900-0700:\n\nEVENTS: To OR for VATS; returned after uneventful procedure. Central line placed. Temp spike to 103+; cx'd. 7-pt hct drop; hypotensive to 70's requiring 2L IVF and blood to correct. Abx started.\n\nROS:\nNEURO: Pt required increase in Fentanyl and Versed to 150 and 6 respectively d/t grimacing and overbreathing vent on return from OR. Later doses were decreased with hypotensive episode to 50 and 2; she has tolerated the decrease and remains on these doses. MAE weakly, not to command. Opens eyes insonsistently to pain. Wrists restrained for safety.\nRESP: Remains on same vent settings as pre-op with ABG stable at 7.42/43/93. Sats 99-100%. Suctioned X 2 for thick blood-tinged secretions with clots. LS variable (see Carevue). R anterior CT to 20cm sxn; occasional air leak noted. Site oozing small amt blood (not through dressing though); per CT surgeon this is to be expected. No crepitus noted; ~100cc's sero-sanguinous drainage overnight.\nC-V: Hemodynamically stable for several hours post-op regardless of level of sedation. About 0245 BP dropped to low 70's for no apparent reason and did not come up with reduction in sedatives. Ultimately given total of 2L IVF as well as PRBC's with improvement. CVP has risen from 7 to 10. HR has been low 80's-low 90's all night, NSR, rare PVC's. All lytes borderline low; HO aware and will address this AM.\nID: Temp spike to 103.1; she was fully cultured, given Tylenol, and started on Vanco and Zosyn; also given single dose of Solumedrol.\nHEME: Hct down to 26.8 (33.7); no obvious source of blood loss. First of 2u PRBC's hanging, 2nd to follow.\nGI: Belly softly distended, hypoactive BS; no stool. OGT placed and confirmed by CXR.\nGU: UO decreased with lower BP; will follow; BUN/creat 23/0.6.\nENDO: Sugars stable; no need for insulin coverage.\nSKIN: Reddened coccyx; treated with barrier cream. Healing blisters on hands as previously documented.\nACCESS: Both PIV's outdated and pt w/poor IV access; RSC TLC placed and confirmed by CXR.\nSOCIAL: husband, dtr, and son-in-law here all evening; husband spent the night. They were updated several timed by the MD's. Husband would have preferred to stay in room, but ended up in the waiting room most of the night because of ongoing issues w/pt. He did come in to see her periodically and said he was sleeping OK out there. He appears overwhelmed with her illness and would likely benefit from SS consult. His dtr and son-in-law are very supportive as well, but they live over an hours from here and she is very pregnant with their first child. Husband lives even further away.\n\nA: very busy somewhat unstable night; awaiting further cx data.\n\nP: Follow temps; abx as ordered; await cx results; aim to keep CVP >10; levophed prn; complete blood tx; ? re-check hct; SS consult for family; set limits and encourage family to take care of themselves; ? if husband would take a room at the hotel.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-07 00:00:00.000",
"description": "Report",
"row_id": 1484302,
"text": "Events: Uneventful shift for Ms \n\nNeuro: Pt arousable to stimuli pupils 2mm and reactive. Following no commands, nonpurposeful movement, MAE, Versed boluses for agitation with care. Versed gtt at 3mg/hr Fentanyl at 50mcg/hr.\n\nResp: Lung sounds coarse in apices, crackles in RLL diminished in LLL. Vent on 60% O2 PEEP increased to 12 for PaO2 of 62 with increase to 123. However PaO2 back down to 60's when PEEP lowered to 10. Currently at 10 of peep and will monitor. Team preferring to raise FiO2 rather than PEEP as pt had recent surgery. Vt remains at 350, RR 16 pt is consistently overbreathing vent by 8-13 bpm. O2 sat mid to upper 90's. Pt does desaturate quickly during repositioning. Taking a longer period of time to recover as shift goes on. Wouldn't recommend repositioning unless necessary. CT drain found to have air leak at 1300. Dressing changed with petroleum gauze and elasoplast with resolution. No current air leak. Output total for this shift 63cc.\n\nCardiac: NSR on monitor. Slightly hypotensive this am with sbp in 90's. Ranging 90-120/50-80. HR 60's-70's without ectopy. Peripheral pulses easily palpable. No fluid boluses given this shift.\n\nHEME: HCT 35 after 2uprbc this am.\n\nGI: Abd soft/distended with active bowel sounds. OGT with + placement. To start Promote with fiber tonight. No BM this shift. Blood sugars unremarkable.\n\nGU: Voiding adequate amts of yellow urine via foley.\n\nID: Tmax 99.4 Zosyn and vancomycin D/C'd. Levofloxacin 750mg given x1.\n\nDerm: Grossly intact. Small dried blisters remain on palmar surfaces of hands largely unchanged. Coxxyx remains red covered with barrier cream and repositioned prn. TLC site benign. Aline site oozing dressing changed and reinforced. waveform remains sharp with easy blood return.\n\nSocial: Family in to visit. Many questions and very concerned. Pastor visited this afternoon. Family showing more confidence in ability of hosp staff to care for pt.\n\nPlan: Follow up on cultures and biopsy, monitor resp status closely, motitor CT output and for s/sx leakage. Begin tube feedings. Titrate sedation as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-07 00:00:00.000",
"description": "Report",
"row_id": 1484303,
"text": "Respiratory Care\n\n Pt continues on full ventilatory support. PaO2 in the 60's PEEP increased to+12 with an increase to 123 Team want's FI02 increased not PEEP. PEEP back to +10 with drop in Pa02. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-08 00:00:00.000",
"description": "Report",
"row_id": 1484304,
"text": "NPN 1900-0700:\n\n55YO female admitted with acute pulmonary process; unclear organizing cryptogenic pnx vs chemical pneumonitis vs ??????. Awaiting bx results for VATS.\n\nEVENTS: Increasingly difficult to oxygenate, requiring huge increase in sedation, max vent support.\n\nROS:\nNEURO: Recieved pt on Fentanyl 75mcg/hr and Versed 4mg/hr. Pt was arousable to any stimulation at start of shift, which caused immediate agitation and desaturation to 70's with slow recovery. When left alone level of sedation was adequate. Later in shift worsening pulmonary status necessitated huge increase in sedation to 500mcg/hr Fentanyl and 10mg/hr Versed. She is currently virtually unresponsive but still overbretahing vent a bit; PERRL. When less sedated she was able to MAE, but without purpose. No spontaneous movement since increase in sedation.\nRESP: Recieved on CMV .6/350/16/10 with sats in high 90's. Initially ABG unchanged from previous shift with po2 70. However she began to desat to low 90's in the setting of recieving total of 1L IVF for hypotension, and did not recover. ABG at this time showed pO2 56. FiO2 increased to 80% with improvement in sats for a couple of hours, but they again dropped to low 90's. pO2 found to be 54, and FiO2 was increased to 100%. She was noted to be increasingly tachypneic, with nasal flaring whenever she was even slightly awake. With increased sedation she looked more comfortable, but sats did not improve and pO2 was down to 49. Vent rate increased to 24 to more closely match what she was doing on her own (persistently breathing near 30), and she has settled out with RR ~26. LS unchanged all night (CTA upper, few scattered rhonchi, diminished lower), but she began to produce frothy white sputum. CXR showed near-complete white-out bilaterally, much worse than 24 hours previous. PEEP increased to 12 and she was given 20mg IV Lasix with about 800cc's out thus far. Sats have improved to high 90's, and her pO2 is now 161.\nC-V: HR mostly 80's-90's, NSR, with rare PVC's. Lytes low/low-normal. BP stable during the early evening, but dropped to mid-80's by late evening. CVP 8-10. Given total of 1L LR bolus with transient improvement. Needed Levophed for just a few minutes at this time. Later in shift, with increase in sedation coupled with diuresis, she again required Levo gtt at low dose to maintain BP. CVP now running . She is warm and well-perfused with excellent peripheral pulses.\nID: Afebrile, WBC stable at 10K, no abx, no steroids, no new cx data.\nHEME: Hct, plt, INR stable, no evidence of bleeding.\nGI: Belly benign, no stool. TF's increased to 30cc/hr and held there d/t increased residual of 50cc's.\nGU: BUN/creat WNL; U/O 50-70cc/hr until Lasix was given, and has put out ~800cc's since.\nENDO: Sugars stable, no insulin needed.\nSKIN: Unable to assess backside d/t inability to turn her safely.\nACCESS: Central line and a-line intact and functioning well.\nSOCIAL: Family much more at ease after visit with priest yesterday. Th\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-08 00:00:00.000",
"description": "Report",
"row_id": 1484305,
"text": "(Continued)\ne stayed till about 2200, had all questions answered, and went home for the night (including her husband). Pt's dtr called for update at 0630, and husband plans to return this AM.\n\nA: major deterioration in pulmonary status, likely due at least in part to fluid overload.\n\nP: diurese for now, supporting with pressors prn; ? PA catheter placement to guide treatment; await bx results; continue to support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-08 00:00:00.000",
"description": "Report",
"row_id": 1484306,
"text": "Respiratory Care:\nPatient's ventilator settings adjusted for increasing hypoxia, first with increasing FIO2 from 60% to 80% and maximized at 100%. Still having severe hypoxemia. SX'd for moderate amount of exudate. Received lasix. Patient's PEEP value then increased to 12 cm from 10 cm, and rr increased to 24. Repeat abg results determined a compensated mild respiratory acidemia with excellent oxygenation.\n\nNo RSBI measured due to the level of PEEP and the high FIO2 currently required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-08 00:00:00.000",
"description": "Report",
"row_id": 1484307,
"text": "Nursing Summary:\n\nNeuro: PT heavily sedated on 500mcg Fentanyl and 10mg/hr Versed gtts. PT still with cough when suctioning, no other responses. Pt continues with desats w/suctioning(98 to 91%) and spontaneous desaturation. Plan to keep heavily sedated for now due to pulmonary status. Restraints no longer needed r/t pt sedated-dc'd.\n\nPulmonary: VAT biopsy results came back late morning-DAD, ARDS. Prognosis poor. High dose steroids commenced this afternoon. PT initially on cmv 100%, peep 12, rr 24, tv 350. Able to wean fio2 to 60% until patient acutely decompensated-o2sats to 50's and suctioning copious amouts of yellow, frothy sputum. Dr. at bedside at this time. Recruitment method done with pt hypotensive transiently(levo increased at this time). Pt responded well to recruitment. Post event pt placed on fio2 100% w/peep 16-see careview for abg results. Initially discussed proning patient. After changing to triadyne bed, decided to try APRV mode and eval 30minutes after. Because patient stable with po2 124 following change, team decided to remain supine, utilize triadyne to turn patient and eval in am for possible proning at that time. Pt with permissive hypercapnia-abg to be drawn at 1800. Fio2 weaned to 80% and o2sats stable at 97%. TV 250-270,s, mv , itime 1.5sec. Right CT placed after VAT in situ. Dressing intact(changed ), no air leak-draining small amt serosanguinous to serous fluid.\n\nCVS: Levophed gtt increased this am(restarted overnoc). Pt's bp very labile this am-Given total of 1.25 L NS for goal cvp 10. Responded well to ivf and able to wean levo this afternoon. Currently @.05. Pt with generalized edema. Received 2units prbc yesterday-hct now stable. Pt has remained in sr/st throughout shift with rare pvc's. Mg 1.8 given 2gms, phos 2-given 15mmols kphos.\n\nGU/GI:UO adequate via foley. PT with increased residuals this am to 150mls. TF stopped and discussed on rounds. Reglan started. TF remained off r/t possible proning but restarted this pm @ 20ml/hr. Hypoactive BS. No bm.\n\nSkin: Unable to turn and assess skin r/t instability. To eval tonight if stable-bed changed to triadyne-increasing angle to goal 45degrees. Currently @ 25 degrees and pt tolerating so far.\n\nSocial: Meeting held with family this am when biopsy results in. PResent were pt's husband, daughter and son in law, Dr. and DR. and social work in attendance. Discussed biopsy results DAD/ARDS and prognosis very poor. PT with 80-90% mortality. Pt's family appropriately tearful. Support given. See SW note for further details.\n\nID: Pt spiked temp 103.4 this am-pan cultured and given tylenol pr x2 throughout day. Utilized ice packs as well. Temp current 99.4. Pt with from bronch culture-started on flucon-ID approval pending. Restarted on vanco this am. Also on levoquin qd. Blood cx's pending.\n\nPlan: Continue sedation. Monitor frequent abg's to assess oxygenation status and acidosis. Attempt advancing degree angle with triadyne\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-08 00:00:00.000",
"description": "Report",
"row_id": 1484308,
"text": "(Continued)\nbed to goal of 45 degrees. Wean levo as tolerated to keep map>65, sbp>90. Advance TF as tolerated to goal. Support family as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-05 00:00:00.000",
"description": "Report",
"row_id": 1484295,
"text": "pmicu nursing admit/progress 3p-7p\nplease see fhpa for specifics.pt is a lovely portugese woman admitted with resp distress.\nreview of systems\nCV-vs have been stable with hr in the 70's nsr and bp 100-120/ via nbp.\n\nRESP-wearing 100% nrb her sats have been >95%, pt is tachypneic though with rr 25-40 with anxiety, occasionally using accessory muscles.lungs are diminished at bases, ?crackles RUL. abg with po2 117, pco2 40 and pH 7.45. CXR were sent from OSH and repeat CXR done 6 pm here. pt more comfortable with HOB elevated.has a dry hacking cough\n\nGI-belly is softly distended and has positive bowel sounds. no stool since admission. picking at a low Na tray.needs a ppi.\n\nNEURO-is sleepy but easily arousable and understands english quite well. no c/o pain. is very anxious about procedures, especially abgs.she is oriented x 3 and cooperative, no restraints needed.\n\nF/E-voiding sufficient quantities of clear yellow urine.has dry mucous membranes and mild c/o thirst. many labs sent off at 6:15 pm.no ivf at this time.\n\nENDO-written for qid fingersticks\n\nSKIN-is grossly intact.has remnants of blistery rash, worst on hands.had a little rash on the eyes.\n\nID-looks flushed but temp max 97.9 po. wbc pnd. blood cultures x 1 with fungal isolator bottle sent.\n\nIV ACCESS-has 2 peripheral heplocks in\n\nSOCIAL-has devoted husband and daughter, son in law. family states that pt is very anxious and that it will be best for pt and staff if husband stays over to soothe pt and translate. she does seem better with him around.a cot was obtained for him\n\na-pt with unclear picture of resp distress and DOE of unknown etiology-? infectious vs allergic process, ? secondary to the chemical pesticides or other source. DOE complicated by anxiety\n\nP-will assess resp status and need for a-line.await lab results.check CXR results. keep family updated as to plans, procedures\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-06 00:00:00.000",
"description": "Report",
"row_id": 1484296,
"text": "Respiratory care:\nPatient is a 55 Y.O. F who was transferred from an OSH with hypoxemia and pulmonary infiltrates for possible lung biopsy. She is on 100% non-rebreather and 4LNC at this time. She is ordered and receiving Q3hr albuterol nebs and Q6hr atrovent nebs. Breathsounds are decreased. She has a dry tight sounding cough. Please see respiratory section of carevue for treatment data and times. Patient pulling off non-rebreather mask off. She is not oriented to place or time. Patient Rambling at times and difficult to understand. ABG this am 7.41/44/118 29 and 3. Continue bronchodilator therapy. Monitor respiratory status closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-06 00:00:00.000",
"description": "Report",
"row_id": 1484297,
"text": "MICU Nursing Note 1900-0700\nEvents: Episodes of resp distress following bronchospastic episodes with acute deSaturation to 85% on 100% NRB. Albuterol and Atrovent nebs initiated and FI02 increased to 100%NRB plus 4L NC. Anxious with all care...medicated with 1 mg. Ativan....followed by periods of restlessness...Ativan now d/c'd. NPO after MN for VATS procedure sometime this afternoon. Husband with pt all night offering support and assisting in communication.\n\nNeuro: Initially conversive and A+OX3 during early evening hours. Anxious with all care and unable to sleep...med with 0.5 mg po Ativan with no effect---repeated with 0.5 mg IV Ativan with pt resting in short naps. Currently restless and mildly confused requiring freq. reorientation and freq reminders to not remove 02 mask. Ativan now d/c'd and all sedation held. PEARL. Moving all extremities and following all commands.\n\nPain: C/O abd pain with all coughing episodes. Grabbing abd with repositioning and turning. MD aware and assessed pt. No pain meds ordered. Pt taught how to splint abd with all coughing episodes---needs reinforcement.\n\nCardiac: HR 60-70's SR with no ectopy noted. BP stable 98-120/50-60's. Denies CP.\n\nResp: Labored breathing...shallow and using accessory muscles...tachypeneic with RR= 24-34 and increases to 40 with all activity. Bilat upper lobe rales and diminished air exchange over bilat. bases. Nonprod. weak, dry cough noted. Episodes of bronchospasm with acute deSaturation...requiring 4L NC added to the 100% NRB. ABG unchanged from evenings: 7.41-44-118. Started on Albuterol Nebs Q3hr and Atrovent Nebs Q6hr. HOB >45 at all times.\nLimit pt's activity and provide freq rest periods with all care.\n\nGI: Abd softly distended with + hypoactive bowel sounds all quads. No BM. C/O abd pain with coughing episodes and splinting lower abd with hands. Episode of C/O abd pain without coughing---Resident assessed pt and no further complaints of pain noted. Taking liquids in small amts until MN and now NPO after MN for VATS procedure today.\n\nEndo: On IV steroids....fingersticks QID...less than 150 during night\n\nGU: Foley to CD draining clear yellow urine ...> 30ml/hr. UA and CX sent and UA WNL and CX pending. Urine sent for legionella and pending.\n\nSkin: warm, occasionally diaphoretic, pale with flushed face, small blisters noted on palms---pt says much improved over last few days.\nCoccyx reddened...cream applied.\n\nID: BL Cx's and Fungal Cx's obtained and sent. Tmax 98.4ax. Antibx currently on hold as per medical team's plan.\n\nSocial: Pt's daughter and husband met with MICU attending and were updated on POC. Husband stayed in room all night to support pt and assist with communication d/t pt's primary language of Portuguese. husband with soothing affect over pt. Support offered to pt and husband.\n\nPlan: To OR sometime this afternoon for VATS for open lung BX. Continue supportive measures. Continue Nebs and close monitoring of Resp status. D/C Ativan....? need for o\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-06 00:00:00.000",
"description": "Report",
"row_id": 1484298,
"text": "MICU Nursing Note 1900-0700\n(Continued)\nther anti-anxiety . Start gentle hydration while pt NPO for procedure. Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-06-06 00:00:00.000",
"description": "Report",
"row_id": 1484299,
"text": "Respiratory Care\nPt Intubated with 8.0 oral intubation without complications. intially taped at 22 cm at lip and repositioned to 17cm at lip. Pt transported to cat-scan for chest scan, without incident. Pt. suctioned for mod to copious amts of black brown thick plugs. Remains on A/C vent, weaned o2 to 80% Last abg 740/42/92/27/0. Pt to recieve albuterol mdi q3, awaiting atrovent mdi for q6 treatment. Pt awaitng or trip for VATS proceedure.\n"
}
] |
|
3,435 | 118,270 | 55 y.o. man with PMHx h/o significant for colon CA, EtOH abuse, type 1 DM now with DKA, multifocal pneumonia on levo/flagyl, possible CHF, hct drop with hypotension. In the he was placed on an insulin drip, IV PPI, and IV flagyl/unasyn for his bilateral pulmonary infiltrates. He was extubated on changed to levo/flagyl. Insulin and versed drips were stopped on in the afternoon. He was extubated at 3 pm and called out on . 1) resolving Diabetic Ketoacidosis: On admission to OSH, the patient had an ABG of 7.02/15/95/95% with a gap of close to 40 with ketones in his urine. The patient is known to Dr. at and was last on Lantus 12 units QHS and Humalog SSI 2-15 units in 9' records. He was not using his insulin for a week prior ot admission because he "felt sick". He was put on an insulin drip and transitioned to sc insulin, glargine 10 QHS and sliding scale. followed him in house and he was discharged on 10 of lantus with instructions to continue regardless. 2) Hypoxic Respiratory Failure - The patient was intubated during admission for respiratory failure. Ddx included PNA vs CHF. He had CXR with multilobar PNA, sputum culture with no growth. Blood cultures showed no growth. Possible CHF (Ef 70% in past, but had a LVOT gradient in ' with no AS and concentric LVH) as the patient was aggressively fluid resuscitated at the OSH, but his echo showed normal EF and no outflow obstruction. He was treated with levaquin and flagyl, and autodiuresed after extubation without lasix. 3) Anemia: The patient was having guaiac positive brown stool with no melena/hematemesis and found to have an acute drop in his Hct from 32 to 22 with aggressive IVF resuscitation at the OSH. His baseline Hct is 43 (1 year ago). The patient was transfused 2 units PRBC at the OSH; now Hct stable and no TF here. GI was consulted and EGD showed a gastric ulcer, grade 1 esophageal varices and duodenitis. He was continued on PPI. Colonoscopy with diverticulosis and no acute issues. He did not require further transfusion. 4) Blood pressure - He was initially hypotensive and received fluid but then became hyprrtensive and was started on lisinopril. 5) EtOH Withdrawal with seizure - The patient had GTC seizure at the OSH with a negative urine tox screen on presentation on but a history of heavy EtOH use and depression. He denied drinking in the 10 days per patient which corroborates with EtOh of 0 at OSH. He was put on a CIWA scale with ativan/valium and given folate, thiamine, agressive electrolyte repletion. He had a social work consult and eill receive social work services as an outpatient. His daughter will also help monitor him at home. 6) Transaminitis: rising LFTS; AST>>ALT--likely due to alcoholic hepatitis. Hepatitis serologies were negative and RUQ ultrasound showed fatty liver infiltration. 7) Thrombocytopenia baseline in around 60-80. Most likely etiology is alcholic liver disease. No intervention was necessary. 8) Depression: continued celexa | Mild (1+) MR.TRICUSPID VALVE: Physiologic TR.PERICARDIUM: Trivial/physiologic pericardial effusion.Conclusions:1. Normal RVsystolic function.AORTA: Normal aortic root diameter. Regional left ventricular wall motion is probably normal butthe images are not optimal and have limited views of the distal septum.Overall left ventricular systolic function is probably normal (LVEF>55%).3. Mild (1+) mitral regurgitation is seen.6.There is a trivial/physiologic pericardial effusion.To better evaluate the septum and overall LV function, would recommend aDefinity contrast echo. Right ventricular systolicfunction is normal.4.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. PATIENT/TEST INFORMATION:Indication: Congestive heart failure.Height: (in) 69Weight (lb): 135BSA (m2): 1.75 m2BP (mm Hg): 146/69HR (bpm): 80Status: InpatientDate/Time: at 13:13Test: 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: Normal LV wall thickness. The left ventricular cavitysize is normal. 5.The mitral valve leaflets are mildlythickened. Right ventricular chamber size is normal. Normal LV cavity size. Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV wall thickness. The right and left kidneys demonstrate normal echogenicity, without masses, stones, or hydronephrosis. Normal ascending aorta diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Left ventricular wall thicknesses are normal. The gallbladder is normal. Nursing Assessment Note 1900-0700NEURO: Pt a&o x3, pleasant and cooperative, pt moves all extremities well without deficit, perl, pt denies dizziness or lightheadednessCV: Pt's vss, febrile to 100.2, then 100.7 at midnight, pt has #18 and #22 in left hand, both patent and intact, pt has #20 in right hand, pt has right IJ TLC, with NS @ kvo x2, and right radial a-line, waveform is sharp and wnl, but is slightly positional with blood draws, if you place some traction on aline it will flow much better, pt is in nsr, with rare pvc's, skin is pale, warm, and very dry, with areas of psorasis all over body, PP + & =, without edema,RESP: Pt's lung sounds initially revealed crackles throughout in left lung and in right base, by midnight, pt had only crackles in bases, Pt on O2 @ 40% mist mask, with sats 94-96%, pt has slightly congested non-productive cough and denies SOBGI: Pt tol po intake well without N/V, bowel sounds are +, with soft abd, pt inc of large amount stool x2's, which were both OB +GU: Pt's foley draining clear yellow urine qsENDO: pt's blood sugar at 2200 was 187, covered with 2 units humalog and 12 units lantus, rechecked blood sugar at 0000 and was wnl The left atrium is normal in size.2. Normal RV chamber size. Respiratory Care:Pt. Suctioned for small amount of thick white secretions. There is a right IJ central line; tip is somewhat difficult to see but is probably at the SVC/RA junction. The spleen is not enlarged. Resp: pt from osh intubated with 7.0 ett, retaped and secured @ 23 lip, cuff pressure @ 21. CAUSE, GASTRIC LAVAGE NEG, GI CONSULTED AND IN VIEW OF BEING UNABLE TO OBTAIN CONSENT AT THAT TIME PLUS STABILITY OF PATIENT SCOPE TO BE DONE LATER DATE...RECEIVED TOTAL X2 UNITS PRBCS UNIT PLATLETS...FOR CHECK HCT/ HCT >27 PLATLETS >50...CHECK HCT Q6ENDO....BLOOD SUGARS STABLE, TO COMMENCE LONG ACTING REGIME WITH S/S THIS EVE WHEN EATING... AT PRESENT ONLY TAKING FLUIDS POST EXTUBATIONGI..... LAVAGE AS ABOVE, STOOLED X3 TODAY NO OBVIOUS BLOOD BUT IS GHAUIC POS... TO COMMENCE DIET THIS EVE... FOR LIVER U/S TOMORROWGU...GOOD URINE OUTPUT...AIM FOR EVENS /SLIGHTLY POS BALANCE, AT PRESENT POS BY 1.5L, TEAM AWARE, CONTINUE TO OBSERVESKIN...PSORRIOS EVIDENT OVER ENTIRE BODY, DOES NOT SEEM TO BOTHER PATIENT AT THIS TIME , HAVE ASKED TEAM TO REVIEW CREAMS REQUIRED TO TREAT.... Note that the sidehole of the NG tube appears to be in proximity to the GE junction. There is an ET tube with tip in good position, approximately 3.8 cm above the carina. AM ABG's 7.38/32/95/20. IMPRESSION: Echogenic liver consistent with fatty infiltration. The heart is not enlarged. Bs auscultated reveal bilateral crackles. There are patchy infiltrates in both lung bases as well the left mid/lower lung fields laterally. There is a nasogastric tube with tip in proximal stomach. NURSING NOTE 0700HRS 1600HRSEVENTS....TRANSFUSSED X2 UNITS PRBC'S, X1 UNIT PLATLETS, GASTRIC LAVAGE NEG, GI CONSULT NO SCOPE TODAY, EXTUBATED @ 14.30HRS, TO SWITCH TO LONG ACTING INSULIN THIS PMNEURO...VERSED SWITCHED OF FOR EXTUBATION, POST EXTUBATION LETHARGIC BUT ORIENTATED TO PERSON /PLACE, COMMUNCATING HIS NEEDS HELPING WITH CARE... CIWA SCALE NOW PERSCRIBED FOR ALCOHOL WITHDRAWL, AS OF YET NO0T REQUIREDRESP...SUCCESSFULLY EXTUBATED @ 14.30HRS...ON FACE TENT 40% SATS >95% SATISFACTORY ABG, COUGHING WITH ENCOURAGEMENT NOT EXPECTORATING ANTHING AT PRESENT [ PREVIOUSLY SUCTIONING THIN /YELLOW SECRETIONS]CVS....B/P STABLE 120-140 SYSTOLIC, HR 75-85 PBM NO PVC'S FOE ECHO TOMORROW, K REPLACE THIS AM....AFERILEHAEM.... Suboptimaltechnical quality, a focal LV wall motion abnormality cannot be fullyexcluded. Limited visualization of pancreas is unremarkable. It would appear its sidehole is in the region of the GE junction, such that this could be advanced several centimeters for better placement. Vent changes reflect initial abg (see careview) decreased rate to 12, fi02 to 40%. OTHERWISE PRESSURE AREAS INTACTLINES....PATENTSOCIAL...WIFE CALLED AM, DAUGHTER AM AND HAS BEEN UPDATED RE-CONDITION/PLANPLAN..HCT Q6 MAINTAIN HCT >27, PLATLETS >55...MONITOR RESP FUNCTION,BLOOD SUGARS, LIVER U/S AND ECHO TOMORROW IMPRESSION: 1) Tubes and catheters as described. There is no intra or extrahepatic ductal dilatation. ABDOMEN ULTRASOUND: The liver is diffusely echogenic consistent with fatty infiltration. The common bile duct measures 4 mm. 2) No CHF. Nursing Assessment Note -0700Pt is 55 y.o. 3) Multifocal infiltrates as described. Will continue full vent support and wean appropriately. PORTABLE CHEST: There are no prior studies for comparison. Appears to be doing well. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. Placed on a/c 16/500/+5/50%. No AS. The hila are somewhat prominent, although it is uncertain whether this reflects technique. | 10 | [
{
"category": "Echo",
"chartdate": "2148-04-29 00:00:00.000",
"description": "Report",
"row_id": 67740,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 69\nWeight (lb): 135\nBSA (m2): 1.75 m2\nBP (mm Hg): 146/69\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 13:13\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. 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 (1+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is probably normal but\nthe images are not optimal and have limited views of the distal septum.\nOverall left ventricular systolic function is probably normal (LVEF>55%).\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 and no aortic regurgitation. 5.The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen.\n6.There is a trivial/physiologic pericardial effusion.\n\nTo better evaluate the septum and overall LV function, would recommend a\nDefinity contrast echo.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-04-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 867150,
"text": " 9:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for infiltrates, pulmonary edema\n Admitting Diagnosis: DKA PNEUMONIA SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with bilateral pulmonary infiltrates at OSH and hypotension,\n ?CHF after IVF hydration\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrates, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral infiltrates at outside hospital, assess for CHF after\n IV hydration.\n\n PORTABLE CHEST: There are no prior studies for comparison. There is an ET\n tube with tip in good position, approximately 3.8 cm above the carina. There\n is a right IJ central line; tip is somewhat difficult to see but is probably\n at the SVC/RA junction. There is a nasogastric tube with tip in proximal\n stomach. It would appear its sidehole is in the region of the GE junction,\n such that this could be advanced several centimeters for better placement. The\n heart is not enlarged. The hila are somewhat prominent, although it is\n uncertain whether this reflects technique.\n\n There are patchy infiltrates in both lung bases as well the left mid/lower\n lung fields laterally. There is no evidence of CHF.\n\n IMPRESSION: 1) Tubes and catheters as described. Note that the sidehole of\n the NG tube appears to be in proximity to the GE junction. This could be\n advanced several centimeters for better placement.\n 2) No CHF.\n 3) Multifocal infiltrates as described.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-04-29 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 867348,
"text": " 3:04 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: assess for mass\n Admitting Diagnosis: DKA PNEUMONIA SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with transaminits likely alcohol\n\n REASON FOR THIS EXAMINATION:\n assess for mass\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Transaminitis, likely alcohol related.\n\n ABDOMEN ULTRASOUND: The liver is diffusely echogenic consistent with fatty\n infiltration. No focal masses are present. There is no intra or extrahepatic\n ductal dilatation. The common bile duct measures 4 mm. The gallbladder is\n normal. The spleen is not enlarged. The right and left kidneys demonstrate\n normal echogenicity, without masses, stones, or hydronephrosis. Limited\n visualization of pancreas is unremarkable.\n\n IMPRESSION:\n Echogenic liver consistent with fatty infiltration. Other forms of liver\n disease and more advanced liver disease including significant hepatic\n fibrosis/cirrhosis cannot be excluded on this study.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-04-28 00:00:00.000",
"description": "Report",
"row_id": 1306756,
"text": "Nursing Assessment Note -0700\nPt is 55 y.o. male who was originally admited to with acidosis and DKA, pt was found down on floor by daughter for unknown time, pt lives is separated from wife and lives alone, pt has poor hygine and is non-compliant with meds and treatments per daughter; pt has PMH of IDDM, ETOH with withdrawl seizures, depression, malignant polyps with resection, peripheral nueropathy, subdural hematoma, HTN, smoker\n\nOSH COURSE: pt had head ct, which was negative, cxr showed RML infiltrate, abg was 7.02/15/95/4, with a gap of ~40, insulin gtt started and sent to CCU, pt had tonic/clonic seizure at 0200 , was given ativan 2 mg IV, pt had no further seizures or treatment for seizures, pt had intermitten issues with hypotension requiring boluses, which pt responded to, pt had Right IJ TLC placed, and had Calcium, Potassium, and Phos repleated, code status was addressed with daughter, and pt was made a CPR , pt's hct dropped to 22, and was transfused with 2 units PRBC's, which improved hct to 25.1, then ~28 upon admission to 4, sometime around 1200 noon, pt began requiring increasing amounts of oxygen from 6 L V/NC to 70% mask, and at 1730 the decision was made to intubate pt, pt was alert, but confused before intubation, OGT was placed and pt was transferred to for further evaluation and treatment\n\nNEURO: Pt intubated and sedated on versed initially @ 1 mg/hour but increased to 2 mg/hr at 2200, pt also received 2 mg versed X 1 dose upon arrival for agitation, but pt easily arousable and tries to reach for ETT each time pt alert, PERL, Pt does not follow any commands, and has bilat wrist restraints on, sclera was reported to be slightly jaundiced, but I am unable to see any jaundice\n\nCV: Pt's vss, afebrile at 98.4 rectally, pt assessed for no pain using grimace scale, pt has #18 and #22 in left hand/wrist area, which are patent and intact, pt also has #20 in right wrist, pt has Right IJ TLC, and pt had right radial A-line placed by our team, although A-line is slightly positional, Skin is pale, warm, and very dry, pt has several areas of psoriasis with flaking skin, pt is in NSR, with rare PVC's\n\nRESP: Pt intubated with 7.0 ETT @ 23 cm lip , pt initially on A/C 16-500-5-50%, but after admit ABG, rate was decreased to 12, and Fio2 was decreased to 40%, lung sounds are coarse, but diminished in bases\n\nGI: Pt has OGT, placement confirmed via air bolus and Ph of ~6.0/7.0\n, bowel sounds are +, with soft abd\n\nGU: Pt's foley draining clear yellow urine qs\n\nENDO: Pt on Insulin drip initially at 1 Unit/hour, but was decreased to 0.5 units/hr for blood sugar of 85,\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-04-28 00:00:00.000",
"description": "Report",
"row_id": 1306757,
"text": "Resp: pt from osh intubated with 7.0 ett, retaped and secured @ 23 lip, cuff pressure @ 21. Placed on a/c 16/500/+5/50%. Bs auscultated reveal bilateral crackles. Suctioned for small amount of thick white secretions. Vent changes reflect initial abg (see careview) decreased rate to 12, fi02 to 40%. AM ABG's 7.38/32/95/20. Will continue full vent support and wean appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-04-28 00:00:00.000",
"description": "Report",
"row_id": 1306758,
"text": "Respiratory Care:\nPt. extubated to a 40% face tent. Appears to be doing well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-04-29 00:00:00.000",
"description": "Report",
"row_id": 1306761,
"text": "Nursing Assessment Note 1900-0700\nNEURO: Pt a&o x3, pleasant and cooperative, pt moves all extremities well without deficit, perl, pt denies dizziness or lightheadedness\n\nCV: Pt's vss, febrile to 100.2, then 100.7 at midnight, pt has #18 and #22 in left hand, both patent and intact, pt has #20 in right hand, pt has right IJ TLC, with NS @ kvo x2, and right radial a-line, waveform is sharp and wnl, but is slightly positional with blood draws, if you place some traction on aline it will flow much better, pt is in nsr, with rare pvc's, skin is pale, warm, and very dry, with areas of psorasis all over body, PP + & =, without edema,\n\nRESP: Pt's lung sounds initially revealed crackles throughout in left lung and in right base, by midnight, pt had only crackles in bases, Pt on O2 @ 40% mist mask, with sats 94-96%, pt has slightly congested non-productive cough and denies SOB\n\nGI: Pt tol po intake well without N/V, bowel sounds are +, with soft abd, pt inc of large amount stool x2's, which were both OB +\n\nGU: Pt's foley draining clear yellow urine qs\n\nENDO: pt's blood sugar at 2200 was 187, covered with 2 units humalog and 12 units lantus, rechecked blood sugar at 0000 and was wnl\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-04-28 00:00:00.000",
"description": "Report",
"row_id": 1306759,
"text": "NURSING NOTE 0700HRS 1600HRS\n\n\nEVENTS....TRANSFUSSED X2 UNITS PRBC'S, X1 UNIT PLATLETS, GASTRIC LAVAGE NEG, GI CONSULT NO SCOPE TODAY, EXTUBATED @ 14.30HRS, TO SWITCH TO LONG ACTING INSULIN THIS PM\n\n\n\nNEURO...VERSED SWITCHED OF FOR EXTUBATION, POST EXTUBATION LETHARGIC BUT ORIENTATED TO PERSON /PLACE, COMMUNCATING HIS NEEDS HELPING WITH CARE... CIWA SCALE NOW PERSCRIBED FOR ALCOHOL WITHDRAWL, AS OF YET NO0T REQUIRED\n\n\n\nRESP...SUCCESSFULLY EXTUBATED @ 14.30HRS...ON FACE TENT 40% SATS >95% SATISFACTORY ABG, COUGHING WITH ENCOURAGEMENT NOT EXPECTORATING ANTHING AT PRESENT [ PREVIOUSLY SUCTIONING THIN /YELLOW SECRETIONS]\n\n\n\nCVS....B/P STABLE 120-140 SYSTOLIC, HR 75-85 PBM NO PVC'S FOE ECHO TOMORROW, K REPLACE THIS AM....AFERILE\n\n\nHAEM.... RECEIVED WITH HCT @ 25 ? CAUSE, GASTRIC LAVAGE NEG, GI CONSULTED AND IN VIEW OF BEING UNABLE TO OBTAIN CONSENT AT THAT TIME PLUS STABILITY OF PATIENT SCOPE TO BE DONE LATER DATE...RECEIVED TOTAL X2 UNITS PRBCS UNIT PLATLETS...FOR CHECK HCT/ HCT >27 PLATLETS >50...CHECK HCT Q6\n\n\nENDO....BLOOD SUGARS STABLE, TO COMMENCE LONG ACTING REGIME WITH S/S THIS EVE WHEN EATING... AT PRESENT ONLY TAKING FLUIDS POST EXTUBATION\n\n\nGI..... LAVAGE AS ABOVE, STOOLED X3 TODAY NO OBVIOUS BLOOD BUT IS GHAUIC POS... TO COMMENCE DIET THIS EVE... FOR LIVER U/S TOMORROW\n\n\nGU...GOOD URINE OUTPUT...AIM FOR EVENS /SLIGHTLY POS BALANCE, AT PRESENT POS BY 1.5L, TEAM AWARE, CONTINUE TO OBSERVE\n\n\nSKIN...PSORRIOS EVIDENT OVER ENTIRE BODY, DOES NOT SEEM TO BOTHER PATIENT AT THIS TIME , HAVE ASKED TEAM TO REVIEW CREAMS REQUIRED TO TREAT.... OTHERWISE PRESSURE AREAS INTACT\n\n\nLINES....PATENT\n\n\nSOCIAL...WIFE CALLED AM, DAUGHTER AM AND HAS BEEN UPDATED RE-CONDITION/PLAN\n\n\n\nPLAN..HCT Q6 MAINTAIN HCT >27, PLATLETS >55...MONITOR RESP FUNCTION,BLOOD SUGARS, LIVER U/S AND ECHO TOMORROW\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-04-28 00:00:00.000",
"description": "Report",
"row_id": 1306760,
"text": "ADDENDUM...@ 1700HRS GOOD AMOUNT OF DIET TAKEN BY PATIENT AT THAT TIME RECEIVED X4 UNITS OF HUMALOG AND INSULIN DRIP STOPPED, TO OBSERVE BLOOD SUGARS CLOSELY FOR THE NEXT HOURS THEN TO COMMENCE LONG ACTING INSULIN THIS EVE PRIOR TO BED\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-04-29 00:00:00.000",
"description": "Report",
"row_id": 1306762,
"text": "ADDENDUM NOTE\nPT'S AM LABS CAME BACK AND K+ WAS 2.4, REPLEATED WITH 40 MEQ KCL PO, AND IS NOW RECEIVING THE FIRST OF 2 DOSES OF 20 MEQ KCL IV, PT'S MAG LEVEL WAS 1.1, REPLEATING WITH 4 GRAMS MAGNESIUM SULFATE IV, PHOS LEVEL WAS 1.0, PT 2 PACKETS NEUTRA-PHOS PO & IS AWAITING 30 MMOL K-PHOS FROM PHARMACY TO RUN AFTER POTASSIUM FINISHES, MD ALSO ORDERED TO REPEAT SOME LYTES AT 0900, PT'S BLOOD SUGAR AT 0600 WAS 62, PT ASYMPTOMATIC, BUT DID RECEIVE 240 CC' , REPEAT SUGAR AT 0700, PT HAS TOTAL OF 3 OB+ STOOLS ON MY SHIFT, HCT STABLE AND PT NPO OTHER THAN OJ HE DRANK WITH MEDS\n"
}
] |
59,496 | 158,272 | Patient is an 84 year old woman with history of valvular heart disease, traumatic SAH, DM2 and stroke presented with sudden onset shortness of breath and hypoxia with bilateral basilar infiltrates associated with nonspecific lateral ST-T changes w/o fever or sputum production. pt was found to be in heart failure and treated accordingly. There was also question of PNA, for which she rec'd antibiotics. . #. Acute Diastolic Heart Failure/Valvular Heart Disease Patient presented with Dig effect on EKG, with Dig level of 1.8. Patient continued on reduced dose of 0.125mg daily. Lasix drip was stared with fluids goals of .5 negative daily. Diuresis was achieved and the patient was discharged on Lasix 40mg . Diltiazam was stopped and replaced with Carvedilol, with good results. The pt was discharged on this Lasix Carvedilol combination after good diuresis and resolution of SOB. Patient required 30mEq KCl on average per day in setting of lasix and was therefore discharged on K-Dur supplementation with recommended CHM7 check at rehab one week after discharge. . #. Possible Pneumonia: Concern for possible Aspiration PNA. Patient's oxygen requirement improved dramatically with diuresis. Pt remained afebrile during course. Completed full 5 day course of Azithromycin. . . #. L sided Weakness - per report the patient has a history of CVA in with residual left sided weakness. Likely consistent with recrudescence of old deficits. Family, per nursing reports, feels that patient at her baseline. Patient remained at baseline. . #. CAD - Chest pain free on presentation, nonspecific ischemic ECG changes, likely dig effect. CE neg x 2. Aspirin and statin were continued and Digoxin was continued 125mg alternating with 250mcg QD. - Continue aspirin and statin . # AF: Pt. Well rate controlled. Not on warfarin given recent traumatic SAH in . Pt continued on Coreg and Digoxin. . # DM: Held Metformin and Glyburide, con't SSI. Resumed outpatient regimen on discharge. . #. Depression/Dementia: Stable. Continue outpatient regimen of fluoxetine and mirtazapine. . #. FEN: During recent hospitalization was evaluated by speech and , continue nectar thick liquids and ground consistency solids. Continue aspiration precautions and supervision during meals. Patient has been refusing POs intermittently. have to consider G tube in future. . #. Access: R midline, PIV . #. PPx: Continue outpatient omeprazole, heparin SC . #. Code: DNR/DNI status confirmed . #. Dispo: to rehab with f/u with Dr. in 4 weeks and recommended CHM7 check one week after discharge. . Medications on Admission: Aspirin 81 mg daily Docusate Sodium 100 mg Multivitamin daily Fluoxetine 20 mg daily Rosuvastatin 10 mg Tablet daily Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H Omeprazole 20 mg daily Metformin 1000mg Mirtazapine 15 mg Tablet QHS Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS Insulin Lispro sliding scale Digoxin 125 mcg and 250 mcg on alternating days Diltiazem HCl 60 mg Tablet PO QID Ipratropium Bromide neb q6 Acetazolamide 250 mg PO Q12H Lisinopril 5 mg DAILY (Daily). Lasix 40 mg Tablet daily Glyburide 5 mg Tablet daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Docusate Sodium Oral 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamins Oral 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): 125 mcg and 250mcg on alternating days. 11. Ipratropium Bromide 0.02 % Solution Sig: Inhalation Q6H (every 6 hours) as needed. 12. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP under 100. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for BP < 90 or HR < 50. 16. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Insulin Insulin Lispro Sliding Scale as per standard 18. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 19. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Extended Care Facility: Care Center - Discharge Diagnosis: Primary - Acute on Chronic diastolic heart failure - Hypertension Secondary - Aortic stenosis Discharge Condition: Afebrile, vitals stable. Discharge Instructions: You were hospitalized because you had shortness of breath. After a thorough work up, you were found to be in heart failure. As a result, fluid was removed from you and subsequently your shortness of breath improved. Weigh yourself every morning, MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction to 2.0 L. . Medications as recommended below. . Follow-up as recommended below. . Please return immediately for any chest pain, unremitting SOB or fever. Followup Instructions: Please follow up with Dr. within 4 weeks of discharge. You will need to call ( to set up this appointment. Completed by:[**2107-3-2** | ST-T wave changes in leads I, aVL and V5-V6.Possible anterior wall infarction of undetermined age. Non-specific ST-T wavechanges which may be related to ischemia. Compared to tracing #1 no diagnostic interval change. Compared tothe previous tracing of no diagnostic interval change other thansomewhat more prominent ST-T wave changes in leads I, aVL and V5-V6.TRACING #2 The patient continues toshow the pattern of anterior wall infarction of undetermined age. Clinical correlation is suggested.TRACING #1 Low voltage in the standard leads.Decreased R wave in leads V1-V3. | 2 | [
{
"category": "ECG",
"chartdate": "2107-02-24 00:00:00.000",
"description": "Report",
"row_id": 308930,
"text": "Compared to tracing #1 no diagnostic interval change. The patient continues to\nshow the pattern of anterior wall infarction of undetermined age. Compared to\nthe previous tracing of no diagnostic interval change other than\nsomewhat more prominent ST-T wave changes in leads I, aVL and V5-V6.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2107-02-23 00:00:00.000",
"description": "Report",
"row_id": 308931,
"text": "Atrial fibrillation at a rate of 65. Low voltage in the standard leads.\nDecreased R wave in leads V1-V3. ST-T wave changes in leads I, aVL and V5-V6.\nPossible anterior wall infarction of undetermined age. Non-specific ST-T wave\nchanges which may be related to ischemia. Clinical correlation is suggested.\nTRACING #1\n\n"
}
] |
1,611 | 168,370 | A/P 66YO f with anxiety/depression, chronic LBP on narcotics who presents with suspected narcotic overdose c/b hypotension and rhabdo leading to renal failure. 1) Respiratory - likely aspiration pneumonia and developed pulmonary edema in the ICU requiring lasix diuresis. - Cont Lev Flagyl for 14d for aspiration coverage - added vanco for possible MRSA, which was stopped after neg cultures -Pt titrated off suppl O2 and was breathing comfortably at time of discharge 2) Narcotic overdose- Pt is unreliable historian. Denies SI by ED report during admission. - Psych consult obtained. Felt that pt has impulsive tendencies, no evidence of homicidal/suicidal tendencies. have confusional/early dementia component that is limiting her ability to care for herself appropriately. Advised to DC sedating medications. -Social Work followed patient in house as well -No evidence of withdrawal 3) Hypotension- meds, hypovolemia - Normotensive during remainder of course. 4) Renal failure- creat peak: 3.9, pre-renal by labs on admission, ARF from hypotension/hypovolemia but also likely from rhabdo. Normal renal ultrasound . Creatinine improved to baseline. 5) Hematocrit drop- likely represents hemodilution; will follow, close to baseline. - guaiac trace positive then negative upon DC. - Hct stable 6) ORTHO: h/o T-L compression deformitties in spine on chronic pain meds. -S/p fall- No obvious signs of injury. CT head negative. -PT consult (pt can walk with walker) -Getting Tylenol #3 for pain with good effect 7) Abd Pain: Pt has h/o ampullary mass on ERCP, biopsy negative, h/o CCY/Appy, no evidence of obstruction on exam or KUB. C-diff neg x 1, pt tolerating POs. LFTs//Lip wnl. Since persistent CT Abd obtained: no evidence of acute pathology, RLL consolidation vs mass likle effect, likley in setting of PNA with bialteral pleural effusions. need dedicated Chest CT as an outpt once PNA is treated to evaluate perenchyma. -PPI, Maalox, daily LFTs were normal. 8) Proph: PPI, pneumoboots 9) CODE: FULL (per PCP) 10) COMM/Dispo: Mother ) , to Rehab | Stable left pleural effusion. Mild (1+) aorticregurgitation is seen.3. Mild (1+) mitralregurgitation is seen.4. pleural effusion, stable lt. pleural effusion, bilat lower lobes atelectasis. Moderate [2+] tricuspid regurgitation is seen. LS clear to diminished at bases. Persistent right upper lobe opacity, unchanged compared to the prior study. IS NOTED ON XRAY TO HAVE BILAT PLEURAL EFFUSIONS, AND SLIGHT CHF. Note is made of right upper lobe opacity, appears to be unchanged compared to the prior study. There is a somewhat atypical morphology to the left iliac crest, which is unchanged compared with 8/03 and likely relates to either developmental changes or old trauma. Mild CHF and emphysematous change. FINDINGS: Again, note is made of mild cardiomegaly. 3) Mild central biliary prominence. There is mild central biliary ductal dilatation. MAE's w/ discomfort.CV: HR 80's, NSR, Hypotensive most of shift, sbp 80's, multiple fluid boluses given w/ only temporary effect (sbp 90's). Guiac stools per orders.Remains NPO resp. CXR showed slight worsening CHF & rt. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.TRICUSPID VALVE: Moderate [2+] TR. DID HAVE EARLIER C/O CRAMPING WHICH EASED OFF AFTER MOD-LARGE FORMED GUAIC TRACE POSITIVE STOOL. BOWEL SOUNDS ARE HYPOACTIVE, WITH ABD. BUT, PRESENTLY THIS AREA HAS BEEN LEFT OTA. COMPARISON: Chest x-ray dated . IMPRESSION: Interval improvement in right upper lobe and right middle lobe patchy opacities. THIS WAS WEANED DOWN FROM 100%NRB. SINGLE PORTABLE AP UPRIGHT VIEW OF THE CHEST: Bilateral pleural effusions are again seen, this time, right greater than left. Portable exam. FINAL REPORT (REVISED) *ABNORMAL! NEUROLOGICALLY PT. Congestive heart failure, unchanged. The right IJ line has been withdrawn into the lower SVC. Since the prior study, there has been placement of a right subclavian line. LUNGS ARE CLEAR IN UPPER LOBES WHILE NOW DIMINISHED IN BOTH BASES. AFEBRILE DURING THIS HOSPITALIZATION. IMPRESSION: Probable modest improvement in right effusion, otherwise unchanged. Multiplanar reformatted images redemonstrate the above findings and are of grade 2. NO TRACE EDEMA NOTED AND PULSES ARE EASILY PALPABLE. REMAINS NPO AND HAS BEEN NOTED TO HAVE SOME DIFFICULTY SWALLOWING. IMPRESSION: Repositioning of the right subclavian CVP line, as described above. Pulmonary embolus.Height: (in) 61Weight (lb): 76BSA (m2): 1.25 m2BP (mm Hg): 92/45HR (bpm): 86Status: InpatientDate/Time: at 15:06Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). 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. DOES DESAT WHEN MAKE IS OFF. prior contusions). prior contusions). The spleen, pancreas, and adrenal glands are within normal limits. SINGLE PORTABLE AP VIEW OF THE CHEST: The right upper lobe opacity persists, although it is improved. IS NOTED TO MAE'S AND HAS REMAINED AFEBRILE DURING THIS SHIFT. Bilateral frontal encephalomalacia. FINISHED REPLETION OF POTASSIUM, MAG, AND PHOS. Slightly worsening cardiac failure and right pleural effusion. C/O back pain/lordosis, slightly relieved w/ change of position. HAS REMAINED AFEBRILE DURING THIS SHIFT. HAD LOW TEMP BUT IS WNL'S AT THIS TIME. IMPRESSION: 1. Healed right pubic ramus fracture. Neuro: Pt. Small pleural effusion is noted. Afebrile. There is associated compressive atelectasis. A right subclavian line has been replaced with a right internal jugular central venous line, with its tip in the SVC. IS NOTED TO MAE'S UNDER HER BASELINE STRENGTH. Bilateral lower lobe atelectasis. In AM pt. Compared with the findings of the prior study (tape reviewed) of ,the tricuspid regurgitation and the estimated pulmonary artery pressure haveincreased. PELVIS, SINGLE AP VIEW. These are unchanged from . REMAINS NPO AT THIS TIME, WITH BOWEL SOUNDS HYPO ACTIVE AND NO STOOL NOTED DURING THIS SHIFT. pna vs. CHF REASON FOR THIS EXAMINATION: ? Appearances are most consistent with cardiac failure, however. DOES EXHIBIT A NON PRODUCTIVE COUGH. Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Scattered vascular calcification and a Foley catheter are noted. Severe PA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Compared with the findings of the prior study, the estimatedpulmonary artery pressure has increased.Conclusions:1. HR 80s-100, SR to ST, no ectopy, CVP 7-12. Palpable pedal pulses bilat.GI/GU: Abd. Severe compression deformity at the T12 level is noted, as is mild anterior compression deformity at the L1 level. The bowel loops are normal in caliber. HAS TWO PIV WHICH REMAIN TO FUNCTION WELL AND WITH IVF INFUSING AS ORDERED. Repositioning of the right subclavian CVP line is recommended. Hypodensities are visualized in the frontal lobes bilaterally consistent with previous history of trauma, and consistent with remnants of prior contusions. REASON FOR THIS EXAMINATION: please r/o fracture FINAL REPORT HISTORY: S/Pfall, portable exam. INTERPRETATION: No acute intracranial abnormalities. Regional left ventricular wall motion is normal.2. The mediastinal contours are unchanged. HAS BEEN NSR-ST 80-103 WITH NO NOTED ECTOPY THROUGHOUT THIS SHIFT. There is a healed right pubic ramus fracture. Improved is the lateral right middle lobe opacity. The bifrontal hypodense regions may represent post-tramatic sequelae (e.g. The bifrontal hypodense regions may represent post-tramatic sequelae (e.g. NEURO PT. Bilateral pleural effusions, right greater than left are new in the interval. There is a moderate amount of retained fecal debris. CENTRAL LINE PLACED THIS AM WITH PLACEMENT VERIFIED BY XRAY. FINDINGS: White and matter differentiation is preserved. TECHNIQUE: Noncontrast-enhanced CT scan. 3:53 PM CHEST (PORTABLE AP) Clip # Reason: ? | 20 | [
{
"category": "Radiology",
"chartdate": "2109-04-24 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 862517,
"text": " 12:58 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: PERSISTANT ABD PAIN EVAL FOR ACUTE HEPATOBILIARY/BOWEL ABNORMALITIES.\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with narcotic overdose, prior abd surgeries, persistent\n abdominal pain, h/o ampullary mass, voluntary guarding on exam.\n REASON FOR THIS EXAMINATION:\n Please r/o any acute hepatobiliary/bowel abnormalities. Please use\n Gastrograffin as pt cannot tolerate barium\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Persistent abdominal pain. Narcotic overdose and prior abdominal\n surgery.\n\n COMPARISON: .\n\n TECHNIQUE: CT of the abdomen and pelvis with oral and intravenous contrast\n and multiplanar reformatted images.\n\n ABDOMEN WITH CONTRAST: There is new mass-like consolidation at the right lung\n base anteriorly. This was not visible on the prior study, but may not have\n been included on the exam. Bilateral pleural effusions, right greater than\n left are new in the interval. There is associated compressive atelectasis.\n There is no pericardial effusion.\n\n There is mild central biliary ductal dilatation. No focal liver abnormalities\n are appreciated. The spleen, pancreas, and adrenal glands are within normal\n limits. The gallbladder is not visualized. There are small low-density\n lesions within both kidneys, the largest located on the right measuring 1.6 cm\n in greatest dimension. These are likely simple cysts, but are too small to\n definitively characterize. There is no retroperitoneal lymphadenopathy. There\n is no free abdominal fluid. The bowel loops are normal in caliber.\n\n PELVIS WITH CONTRAST: Detailed evaluation of the pelvis is limited by streak\n artifact from the patient's right metallic hip prosthesis. The bladder is\n grossly unremarkable. There is a moderate amount of retained fecal debris. No\n inguinal or deep pelvic adenopathy is appreciated.\n\n BONE WINDOWS: There is partial sacralization of the L5 on the left. Severe\n compression deformity at the T12 level is noted, as is mild anterior\n compression deformity at the L1 level. These are unchanged from . There is a healed right pubic ramus fracture. Calcifications are\n present within the abdominal aorta.\n\n Multiplanar reformatted images redemonstrate the above findings and are of\n grade 2.\n\n IMPRESSION:\n (Over)\n\n 12:58 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: PERSISTANT ABD PAIN EVAL FOR ACUTE HEPATOBILIARY/BOWEL ABNORMALITIES.\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1) No explanation for abdominal pain identified.\n 2) Mass-like consolidation at the right lung base anteriorly with bilateral\n pleural effusions, right greater than left. Complete chest CT is recommended\n for further evaluation.\n 3) Mild central biliary prominence.\n 4) Compression fractures at T12 and L1. Healed right pubic ramus fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-17 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 861811,
"text": " 3:38 PM\n RENAL U.S. Clip # \n Reason: eval for obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with new onset renal failure\n REASON FOR THIS EXAMINATION:\n eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old female with new onset renal failure. Evaluate for\n obstruction.\n\n RENAL ULTRASOUND: The right kidney measures 9.8 cm. There is a 1.4 x 1.7 x 2\n cm cyst within the interpolar right kidney. Additionally, there is a 6-mm\n calcified stone at the lower pole. There is no evidence of hydronephrosis or\n obstruction. The left kidney measures 10.3 cm. There are no cysts or stones\n within the left kidney. Flow is seen to both kidneys. The bladder is empty.\n\n IMPRESSION: Simple cyst, and 6-mm calculus within right kidney. No evidence\n of hydronephrosis, or obstruction bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 861980,
"text": " 1:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o intrapulmonary process\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with high fever, and hypoxia\n\n REASON FOR THIS EXAMINATION:\n r/o intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old woman with fever and hypoxia.\n\n COMPARISON: .\n\n SINGLE PORTABLE AP UPRIGHT VIEW OF THE CHEST: Bilateral pleural effusions are\n again seen, this time, right greater than left. There is a persistent\n cardiomegaly with persistent increased pulmonary, vascular markings, which are\n slightly worse. A right subclavian line has been replaced with a right\n internal jugular central venous line, with its tip in the SVC. No\n pneumothorax is seen.\n\n IMPRESSION:\n 1. Slightly worsening cardiac failure and right pleural effusion.\n\n 2. Stable left pleural effusion.\n\n 3. Bilateral lower lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 862174,
"text": " 5:15 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for obstruction, free air.\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with acute onset of abd pain with +guarding and some\n diarrhea.\n REASON FOR THIS EXAMINATION:\n please eval for obstruction, free air.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acute onset of abdominal pain. Evaluate for obstruction or\n free air.\n\n ABDOMEN, SUPINE: The distribution of gas in the abdomen is unremarkable. No\n evidence of obstruction is seen. A catheter tip is seen within the pelvis.\n\n IMPRESSION: No evidence of obstruction. Free air difficult to exclude on\n supine film..\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 861910,
"text": " 1:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement, right subclavian\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement. This study was obtained at 13:24 hours.\n\n Comparison is made to prior study of 11:11 hours earlier the same day.\n\n Since the prior study, there has been placement of a right subclavian line.\n The tip is in the right internal jugular vein. No evidence of pneumothorax.\n Since the prior study, there has been worsening in the degree of bilateral\n pulmonary vascular congestion and bilateral pleural effusion associated\n compression atelectasis of the lower lobes. These are most likely indicative\n of worsening congestive heart failure.\n\n IMPRESSION: The tip of the right subclavian CVP line is in the distal\n internal right jugular vein.repositioning of the line is recommended.\n\n Worsening congestive heart failure.\n\n"
},
{
"category": "Echo",
"chartdate": "2109-04-19 00:00:00.000",
"description": "Report",
"row_id": 101905,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Pulmonary embolus.\nHeight: (in) 61\nWeight (lb): 76\nBSA (m2): 1.25 m2\nBP (mm Hg): 92/45\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 15:06\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Severe PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Compared with the findings of the prior study, the estimated\npulmonary artery pressure has increased.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The aortic valve leaflets are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n4. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary\nartery systolic hypertension.\n5. Compared with the findings of the prior study (tape reviewed) of ,\nthe tricuspid regurgitation and the estimated pulmonary artery pressure have\nincreased.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 861799,
"text": " 2:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with etoh abuse, fall, h/o SDH\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JK WED 3:42 PM\n No intracranial hemorrhage. No change from study.\n The bifrontal hypodense regions may represent post-tramatic sequelae (e.g.\n prior contusions).\n\n Note- extremely small portion of occipital bone outer table not included in\n scan- technical error. Was this the site of the head trauma?\n WET READ VERSION #1 JK WED 3:40 PM\n No intracranial hemorrhage. No change from study.\n The bifrontal hypodense regions may represent post-tramatic sequelae (e.g.\n prior contusions).\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n INDICATION: 66-year-old woman with alcoholism;status post fall. Evaluate for\n hemorrhage.\n\n TECHNIQUE: Noncontrast-enhanced CT scan.\n\n FINDINGS: White and matter differentiation is preserved. No\n intracranial hemorrhages or masses are visualized. Midline structures are\n normal in position. Hypodensities are visualized in the frontal lobes\n bilaterally consistent with previous history of trauma, and consistent with\n remnants of prior contusions. These findings were present on a prior CT scan,\n as well.\n\n No fractures are visualized but this study is slightly limited since a tiny\n portion of the outer table of the occipital bone was not fully included in the\n scan, which is a technical error. This area appears normal on the\n accompanying scout radiograph.\n\n INTERPRETATION: No acute intracranial abnormalities. No intracranial\n hemorrhage is identified. Bilateral frontal encephalomalacia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 861929,
"text": " 2:39 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please re-evaluate line placement\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with high fever, hypoxia, s/p fall after overdose and down\n for a long period of time. aspiration on right, new right subclavian line\n after pulled back\n REASON FOR THIS EXAMINATION:\n please re-evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 66-year-old with high fever and hypoxia, status post line placement.\n\n FINDINGS: This study was obtained at 15:10 hours and comparison is made to\n the prior study obtained earlier the same day at 13:24 hours. There has been\n repositioning of the right subclavian central venous line, however, the line\n is now only 2 cm into the internal jugular vein on the right side. No\n evidence of pneumothorax. Repositioning of the right subclavian CVP line is\n recommended. Bilateral pleural effusion and bilateral pulmonary vascular\n congestion most likely due to congestive heart failure are again noted. These\n findings have not changed since the prior study.\n\n IMPRESSION: Repositioning of the right subclavian CVP line, as described\n above.\n\n Congestive heart failure, unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 862173,
"text": " 5:15 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please evaluate for free abd air\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with acute diarrhea and abdominal pain.\n REASON FOR THIS EXAMINATION:\n please evaluate for free abd air\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Acute diarrhea and abdominal pain. Evaluate for free air.\n\n CHEST WITH UPPER ABDOMEN: No free air is seen under either hemidiaphragm.\n The appearances within the chest are unchanged since the prior film of 1 hour\n before.\n\n IMPRESSION: No free air under either hemidiaphragm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 861832,
"text": " 8:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? CHF\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with high fever, hypoxia\n REASON FOR THIS EXAMINATION:\n ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old woman with fever, hypoxia.\n\n COMPARISON: .\n\n SINGLE PORTABLE AP VIEW OF THE CHEST: The right upper lobe opacity persists,\n although it is improved. Improved is the lateral right middle lobe opacity.\n Otherwise, the cardiac, mediastinal, and hilar borders are not significantly\n changed. Soft tissue and osseous structures remain unchanged.\n\n IMPRESSION: Interval improvement in right upper lobe and right middle lobe\n patchy opacities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-18 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 861891,
"text": " 11:08 AM\n PELVIS (AP ONLY) PORT Clip # \n Reason: please r/o fracture\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman s/p fall. Portable exam.\n REASON FOR THIS EXAMINATION:\n please r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: S/Pfall, portable exam.\n\n PELVIS, SINGLE AP VIEW.\n\n No localizing history available. No dedicated proximal femur views obtained.\n In addition, the distal most portion of the right femoral prosthesis is not\n included here. Material overlies the pelvis, causing some artifactual lines\n across each iliac crest.\n\n Allowing for this, no displaced fracture is detected about the pelvic girdle\n or left or right proximal femur. Scattered vascular calcification and a Foley\n catheter are noted. There is a somewhat atypical morphology to the left iliac\n crest, which is unchanged compared with 8/03 and likely relates to either\n developmental changes or old trauma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 861888,
"text": " 10:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with high fever, hypoxia, s/p fall after overdose and down\n for a long period of time. ?aspiration\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old woman with high fever.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Chest x-ray dated .\n\n FINDINGS: Again, note is made of mild cardiomegaly. The mediastinal contours\n are unchanged. Note is made of new right lower lobe opacity, probably\n representing consolidation due to aspiration pneumonia or bacterial pneumonia.\n Also, note is made of increased opacity in the left lower lobe. Note is made\n of right upper lobe opacity, appears to be unchanged compared to the prior\n study. Note is made of mild congestive heart failure with mild emphysematous\n change. Small pleural effusion is noted.\n\n IMPRESSION: Consolidation in bilateral lower lobes, which may be due to\n aspiration or pneumonia. Persistent right upper lobe opacity, unchanged\n compared to the prior study. Mild CHF and emphysematous change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-04-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 862165,
"text": " 3:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? improvement in infiltrates after diuresis\n Admitting Diagnosis: MORPHINE OVERDOSE;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old woman with respiratory failure due to ? pna vs. CHF\n REASON FOR THIS EXAMINATION:\n ? improvement in infiltrates after diuresis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Respiratory failure. The patient is being diuresed;\n evaluate for improvement.\n\n CHEST: There may have been a modest reduction in the size of the right\n effusion, but otherwise, the interstitial is not significantly changed.\n Appearances are most consistent with cardiac failure, however. The right IJ\n line has been withdrawn into the lower SVC.\n\n IMPRESSION: Probable modest improvement in right effusion, otherwise\n unchanged.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2109-04-17 00:00:00.000",
"description": "Report",
"row_id": 291590,
"text": "Baseline artifact\nProbable sinus rhythm\nThere may be ST-T wave changes but baseline artifact makes assessment difficult\nSuggest repeat tracing\nSince previous tracing of , baseline artifact makes comparison difficult\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-04-19 00:00:00.000",
"description": "Report",
"row_id": 1282913,
"text": "Neuro: Pt. is A&Ox2, intermittently confused. Follows commands, cooperative. +MAE, pupils sluggishly reactive to light, equal bilat. C/o chronich back pain occasionally radiating to sides, medicated with Tylenol for HA with relief.\nResp: From NRB weaned to OFM 70%, sats high 90s when mask is on properly, desats to 70s-80s on RA. LS clear to diminished at bases. CXR showed slight worsening CHF & rt. pleural effusion, stable lt. pleural effusion, bilat lower lobes atelectasis. In AM pt. was coughing up blood tinged sputum, no more productive cough since. Needs sputum culture per orders.\nCV: Weaned off Dopa gtt and fluids with Bicarb. BP 100s-110s/40s-50s, Medicated with Lasix 20mg IVP with good diuresis (see careview for I&O). HR 80s-100, SR to ST, no ectopy, CVP 7-12. Palpable pedal pulses bilat.\nGI/GU: Abd. soft, nontender, +BS, no BM. Guiac stools per orders.Remains NPO resp. status, tolerating sips with pills. Foley patent, clear yellow urine out.\nID: Afebrile. WBC 5.6. Continues on Levoquin, Flagyl, started on Vanco IV.\nHct 25.5 from 24.3, ? dilutional.\nSkin: Area of redness noted in midback, lotion applied, pt. repositioned frequently. Upper arms and rt. knee abrasions noted, s/p fall at home.\nSOcial: Mother and facility called, updated on status, want to be notified of any changes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-04-20 00:00:00.000",
"description": "Report",
"row_id": 1282914,
"text": "PT. REMAINS AWAKE, ALERT, AND SLIGHTLY CONFUSED. PT. IS MUCH MORE AWARE OF HER SURROUNDINGS THIS SHIFT, AND AT TIMES HAS BEEN COMPLETELY APPROPRIATE. PT. IS STARTING TO C/O HER CHRONIC BACK PAIN AFTER THREE DAYS OF NOT COMPLAINING OF ANY PAIN OR DISCOMFORT. PT. HAS REMAINED AFEBRILE DURING THIS SHIFT. NEUROLOGICALLY PT. CONTINUES TO HAVE SLUGGISH PUPILS, BUT THEY REACT EQUALLY TO LIGHT. PT. IS NOTED TO MAE'S UNDER HER BASELINE STRENGTH. PT. HAS BEEN NSR-ST 80-103 WITH NO NOTED ECTOPY THROUGHOUT THIS SHIFT. B/P HAS BEEN WNL WITH MAP'S >60, WITHOUT SUPPORT. PT. HAD BEEN ON DOPAMINE WHICH WAS WEANED OFF YESTERDAY. PT. DID RECEIVE 1 UNIT OF YESTERDAY PT. HAS RECEIVED 20MG LASIX AND HAS DIURESISED >4 LITERS. CVP HAS BEEN BETWEEN WHEN CHECKED THROUGHOUT THIS SHIFT. NO TRACE EDEMA NOTED AND PULSES ARE EASILY PALPABLE. PT. FINISHED REPLETION OF POTASSIUM, MAG, AND PHOS. WITH AM LABS PENDING AT THIS TIME. PT'S RESP STATUS IS SLOWLY IMPROVING WITH LESS OF AN OXYGEN DEMAND, PRESENTLY PT. IS ON 70% HUMIDIFIED FACE TENT AND 2L/MIN VIA N/C. THIS WAS WEANED DOWN FROM 100%NRB. SATS HAVE BEEN >95% BUT PT. DOES DESAT WHEN MAKE IS OFF. PT. IS NOTED ON XRAY TO HAVE BILAT PLEURAL EFFUSIONS, AND SLIGHT CHF. PT. REMAINS NPO AND HAS BEEN NOTED TO HAVE SOME DIFFICULTY SWALLOWING. PT. SITTING UPRIGHT HAS BEEN TOLERATING ICE CHIPS WITHOUT INCIDENT. BOWEL SOUNDS ARE HYPOACTIVE, WITH ABD. SOFT AND NON TENDER. PT. DID HAVE EARLIER C/O CRAMPING WHICH EASED OFF AFTER MOD-LARGE FORMED GUAIC TRACE POSITIVE STOOL. FOLEY CATHETER REMAINS INTACT ABD HAS DUMPED >4 LITERS POST LASIX DOSE OF CLEAR, PALE YELLOW URINE. PT. HAS MULTIPLE ABRASIONS FROM FALL AT HOME AND ALSO, PT. IS NOTED TO SCRATCH MULTIPLE TIMES, WITH PT. STATING THAT SHE IS UNAWARE OF THIS. PT. ALSO HAS A 4CM AREA ON BACK WHICH HAS NOT CHANGED SINCE ADMISSION, THIS HAS BEEN CONSTANTLY ASSESSED FOR INTERVENTION. BUT, PRESENTLY THIS AREA HAS BEEN LEFT OTA. ALL LINES REMAIN SECURE, AND FUNCTIONING WELL. PT. REMAINS ON FLAGYL, VANCO, AND LEVOFLOXIN FOR POSSIBLE PNUEMONIA WITH WBC'S WNL, AND PT. AFEBRILE DURING THIS HOSPITALIZATION. PT. REMAINS A FULL CODE AT THIS TIME. WITH SOCIAL WORKER FROM HER ASSISTED CARE FACILITY CALLING DAILY ALONG WITH THE PT'S MOTHER FOR UPDATES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-04-18 00:00:00.000",
"description": "Report",
"row_id": 1282911,
"text": "NPN 07:00-19:00 MICU\n*Please refer to Carevue for additional patient information\n*Full Code\nIntern on call #\n\nROS:\nNeuro: Very confused throughout shift,intermittently follows simple commands, A/O x1 (self; at times able to state place/\"hospital\".) C/O back pain/lordosis, slightly relieved w/ change of position. Pupils remain 2mm, very sluggish. MAE's w/ discomfort.\n\nCV: HR 80's, NSR, Hypotensive most of shift, sbp 80's, multiple fluid boluses given w/ only temporary effect (sbp 90's). CVP 14 at 14:00,and patient requiring increase in supplemental O2 (was on 2L NC now on 5L NC, now 99% on 5 L).Dr. aware, team to come and evaluate patient. Afebrile. Continues getting fluid replacement w/ Na+Bicarb.\n\nResp: NC 5L, O2 sat's high 90's, LS clear upper, increase crackles at bases. Non-productive cough. CXR RLL infiltrate, MD.\n\nGI/GU: NPO, swabs w/ water. U/O down to 12ccx 1 hour (when patient not receiving fluid boluses), however now >30cc.\n\nID: Levofloxacin and Flagyl for coverage of Aspiration PNX.\n\nAccess: Multiple attempts to place central line. PIV x2 wnl.\n\nSocial: Mother called, updated on patient and plan of care.\n\nPlan: Monitor Resp status, Hypotension ?Pressors, Line placement ?RIJ.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-04-19 00:00:00.000",
"description": "Report",
"row_id": 1282912,
"text": "PT. REMAINS AWAKE ALERT AND CONTINUES TO BE CONFUSED. PT. IS NOTED TO MAE'S AND HAS REMAINED AFEBRILE DURING THIS SHIFT. PT. EXHIBITS NO FURTHER NEURO DEFICITS AT THIS TIME. PUPILS REMAIN SLUGGISH BUT REACTIVE TO LIGHT EQUALLY. PT. HAS BEEN IN A NSR IN THE 70-90'S WITH NO NOTED ECTOPY AT THIS TIME. B/P HAS REQUIRED SUPPORT OF DOPAMINE GTT AT 2.6 MCG TO MAINTAIN MAP'S IN THE 60'S. CENTRAL LINE PLACED THIS AM WITH PLACEMENT VERIFIED BY XRAY. PT'S AM LABS ARE PENDING. PT. LUNGS ARE CLEAR IN UPPER LOBES WHILE NOW DIMINISHED IN BOTH BASES. XRAY EXHIBITED RIGHT LOWER LOBE PNEUMONIA. PT. DOES EXHIBIT A NON PRODUCTIVE COUGH. PT'S RESP DEMAND HAS AGAIN INCREASED TO WHICH THE PT. REQUIRES 100% NRB TO MAINTAIN SATS >95% PT. REMAINS NPO AT THIS TIME, WITH BOWEL SOUNDS HYPO ACTIVE AND NO STOOL NOTED DURING THIS SHIFT. FOLEY CATHETER REMAINS INTACT AND CONTNIUES TO DRAIN >50CC CLEAR YELLOW URINE. SKIN IS LESS REDDENED THAN PAST 24HRS. PT. DOES HAVE A 4CM AREA ON LOWER BACK WHICH CONTNIUES TO BE CLOSE TO BREAKDOWN. PT. REMAINS TO POSITION HERSELF, AND TOLERATES THIS WELL. PT. REMAINS A FULL CODE AND WILL BE WEANED OFF DOPAMINE TODAY WHEN B/P ALLOWS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-04-18 00:00:00.000",
"description": "Report",
"row_id": 1282909,
"text": "\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-04-18 00:00:00.000",
"description": "Report",
"row_id": 1282910,
"text": "NEURO PT. REMAINS LETHARGIC BUT THIS AM EASILY AROUSES TO VERBAL STIMULI. PT. IS OREINTED TIMES 2 AND AS INAPPROPRIATE WITH COMMENTS MADE SHE HAS BEEN ABLE TO STATE HER PRESENT LOCATION, MONTH AND YEAR. PT. IS ABLE TO MAE'S AND WALKS WITH WALKER AT HOME. PT. HAD LOW TEMP BUT IS WNL'S AT THIS TIME. PT. IS A SECTION 12 AND WILL HAVE A SITTER AT ALL TIMES. PSYCH WILL ATTEMPT TO EVALUATE PT. THIS AM. PT. HAS BEEN NSR IN TEH 70-90'S WITH NO NOTED ECTOPY DURING THIS SHIFT. ENZYMES ARE ALL ELEVATED, AND THOUGHT TO BE IN RABDO. PER TEAM. B/P HAS BEEN LOW AT TIMES WITH ONE FLUID BOLUS FOR 250CC GIVEN WITH DESIRED EFFECTS REACHED. PT. HAD BEEN TRANSFERRED TO THE UNIT DUE TO B/P IN THE 70'S, AND HAD RECEIVED 2 LITERS ON THE FLOOR. PT'S LUNGS ARE CLEAR IN ALL LOBES AND HAS BEEN WEANED DOWN FROM A NRB TO 3L/MIN VIA NASAL CANNULA. SATS REMAIN >95% BUT DESATS FROM TIME TO TIME IF HER OXYGEN IS OFF. PT. REMAINS NPO AT THIS TIME, BUT TOLERATING ICE CHIPS. BOWEL SOUNDS ARE EASILY AUDIBLE WITH NO STOOL NOTED DURING THIS SHIFT. WE ARE TO GUAIC ALL STOOLS. FOLEY CATHETER WAS PLACE WITH AMPLE AMT'S OF CLEAR YELLOW NOTED. PT. HAS TWO PIV WHICH REMAIN TO FUNCTION WELL AND WITH IVF INFUSING AS ORDERED. SKIN IS BENIGN WITH NO NOTED BREAKDOWN AT THIS TIME. PT. IS REDDEDNED OVER MOST ALL HER PROMINECE. THESE AREAS HAVE BEEN PROVIDED FREQUENT SKIN CARE. PT. REMAINS A FULL CODE AT THIS TIME.\n"
}
] |
27,594 | 137,829 | GI BLEED: Pt had several days of coffee ground emesis before admission. Endoscopy on showed grade II esophagitis (thought to be the bleeding source) and portal hypertensive gastropathy. He required 3 units PRBCs during course with stable hematocrit following this. Patient was started on PPI and his hematocrit was closely monitored throughout his hospitalization. | R/o abd abcess, eval for PNA, r/o hematoma s/p fall, r/p pancreatic necrosis/pseudocyst No contraindications for IV contrast PFI REPORT 1. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 71Weight (lb): 176BSA (m2): 2.00 m2BP (mm Hg): 139/73HR (bpm): 85Status: InpatientDate/Time: at 12:05Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Dilated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Moderate symmetric LVH. The right middle lobe opacity is unchanged and may represent a focus of infection and/or atelectasis. FINAL REPORT CT ABDOMEN WITH AND WITHOUT CONTRAST. There is left greater than right fat-containing inguinal hernias. There is mild thickening of the distal esophagus consistent with patient's known esophagitis. Trace aortic regurgitation is seen. R/o abd abcess, eval for PNA, r/o hematoma s/p fall, r/p pancreatic necrosis/pseudocyst No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): 4:55 AM 1. R/o abd abcess, eval Admitting Diagnosis: UPPER GI BLEED Field of view: 36 Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) symmetrically and excrete contrast normally. Coarse echogenic liver consistent with patient's known prior liver disease. Normal ascending aortadiameter. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is dilated. ( , ) FINAL REPORT HISTORY: Cirrhosis with bacteremia of unknown source. 19:00-07:00NEURO:PT REMAINS LETHARGIC AND OX1.SPEECH GARBLED.C/O PAIN TO FOOT AND THROAT WHEN ASKED.REMAINS ON CIWA WITH SCORE <5.PULM:LS CLEAR WITH DIMINISHED BASE.ON 35% O2 VIA FT.CONTINUES TO HAVE HICCUPS.CVS:IN NSR.NBP WITHIN LIMITS.HAD 1 UNIT PLT FOR PLT COUNT OF 45 AND 1 UNITS PRBC FOR HCT OF 23.1.GI: OFT WITH POS BS.NO PR BLEED OR NAUSEA/VOMITIING.PT IS NPO FOR EGD AND WOULD NEED SPEECH AND SWALLOW AFTER THAT AS PT WAS CHOKING ON CUSTARD YESTERDAY.GU:FOLEY DRAINING 40-100CC OF CLEAR YELLOW URINE.ID:PT HAS BEEN FEBRILE TO 102.6,PAN CULTURED.PT GROWING GPC IN BLD.COVERED WITH VANC AND ZOSYN.PLAN:HCT AND PLT Q4HRS.F/U CULTURE DATA AND FOLLOW TEMP CURVE.EGD TODAY.SUPPORT FAMILY.ROUTINE ICU CARE. Gastrointestinal bleed, upper (Melena, GI Bleed, GIB) Assessment: No active bleeding seen since admission, hct down Action: Pt recvd. Gastrointestinal bleed, upper (Melena, GI Bleed, GIB) Assessment: No active bleeding seen since admission, hct down Action: Pt recvd. monitoring Gastrointestinal bleed, upper (Melena, GI Bleed, GIB) Assessment: No active bleeding seen since admission, hct down Action: Pt recvd. Clinician: Attending Critical Care Remains febrile w/o clear source - amylase and lipase mildly elevated, CXR worse now with clear process in lingula and LLL. The extensive left lower lobe consolidation is likely unchanged, questionable right perihilar consolidation is no longer apparent. of acute chole, also with worsening of L and R pneumonia and parapneumonic effusions Allergies: No Known Drug Allergies Last dose of Antibiotics: Piperacillin - 04:00 PM Vancomycin - 08:21 AM Piperacillin/Tazobactam (Zosyn) - 12:05 AM Infusions: Other ICU medications: Pantoprazole (Protonix) - 08:12 PM 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 05:31 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38.8C (101.8 Tcurrent: 38.8C (101.8 HR: 94 (67 - 95) bpm BP: 142/71(84) {113/59(72) - 142/83(96)} mmHg RR: 14 (12 - 17) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 81 kg (admission): 80.3 kg Height: 71 Inch Total In: 1,400 mL 155 mL PO: 450 mL TF: IVF: 950 mL 155 mL Blood products: Total out: 1,890 mL 370 mL Urine: 1,890 mL 370 mL NG: Stool: Drains: Balance: -490 mL -215 mL Respiratory support O2 Delivery Device: None SpO2: 91% ABG: ///27/ 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 62 K/uL 9.4 g/dL 82 mg/dL 0.7 mg/dL 27 mEq/L 4.0 mEq/L 7 mg/dL 99 mEq/L 134 mEq/L 27.1 % 4.8 K/uL [image002.jpg] 04:00 AM 08:32 AM 04:40 PM 09:30 PM 03:24 AM 09:28 AM 04:19 PM 03:36 AM 03:34 PM 02:32 AM WBC 5.2 5.6 4.8 4.8 Hct 26.5 24.9 24.9 27.4 23.1 28.6 27.6 26.4 28.8 27.1 Plt 45 60 61 53 62 Cr 0.7 0.7 0.6 0.7 Glucose 109 104 90 82 Other labs: PT / PTT / INR:16.1/29.2/1.4, ALT / AST:16/42, Alk Phos / T Bili:46/1.0, Amylase / Lipase:162/102, Albumin:2.8 g/dL, LDH:181 IU/L, Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL Assessment and Plan A/P: 52 yo male with h/o Hep C cirrhosis, ETOH abuse who presented with coffee ground emesis and MS changes. Gastrointestinal bleed, upper (Melena, GI Bleed, GIB) Assessment: No signs of gi bleed Action: 1500 hct sent Response: Hct stable @ 28 Plan: Dc to floor in am Altered mental status (not Delirium) Assessment: Pt slightly lethargic, responds slowly to commands, oriented x 3, needs to be reminded to do things(ex. Action: Pt encouraged to take in freq small amts clear liqs. Action: Pt encouraged to take in freq small amts clear liqs. Action: Pt encouraged to take in freq small amts clear liqs. Action: Pt encouraged to take in freq small amts clear liqs. The right middle lobe opacity is unchanged and may represent a focus of infection and/or atelectasis. Cont minimlal pain med as tolerated. Cont minimlal pain med as tolerated. Cont minimlal pain med as tolerated. Cont minimlal pain med as tolerated. Response: Pt now denies nausea. Response: Pt now denies nausea. Response: Pt now denies nausea. Response: Pt now denies nausea. -D/C CIWA scale -MVI, thiamine and folate -Restraints or 1:1 sitter if needed -Ativan prn PANCREATITIS, ACUTE-LFT abnl- Pt with mildly elevated amylase and lipase; has recent h/o pancreatitis. -D/C CIWA scale -MVI, thiamine and folate -Restraints or 1:1 sitter if needed -Ativan prn PANCREATITIS, ACUTE-LFT abnl- Pt with mildly elevated amylase and lipase; has recent h/o pancreatitis. Trivial mitral regurgitation is seen. -still with slow trend down in Hct, could be related to pancytopenia -also required platlets to keep >50 -Protonix IV BID per GI recs -start diet of clear and advance if tolerate, observe for aspiration and consult speech and swallow if suspected -q6 HCT and Platelet check; will transfuse for Hct <25, Platelets <50K -repeat CT abdomen notc/w hematoma as source AMS-Pt came in with disorientation and garbled speech considered to be from withdrawal vs acute intoxication now improving -per records was discharged with Benzos and narcotics likely accounting for AMS since he has not received any here and has cleared -may have contributed to aspriation -IF MS does not improve will consider lactulose -fall precautions PANCYTOPENIA-pt w history of chronic thrombocytopenia, now with infection but no spike in WBC, and anemia -confusing picture but may need to see heme as outpatient -could be related to ribavarin treatment in past ODYNOPHAGIA-patient came in w dry mucous memranes and poor oral hygiene, DDx inlcudes phayngitis vs GERD vs poor oral hygiene - improved mouth care, humidified air seems -can be attributed to esophagitis, improved on PPI -no pain meds for now as patient has a history of abuse ETOH Pt recently admitted for detox and currently denies ETOh use over past few weeks; however given strong h/o abuse will cover for possible withdrawal. | 44 | [
{
"category": "Nursing",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332492,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past.\n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.2, patient positive for MRSA in blood, c/o abd pain\n Action:\n Continue iv antibiotics, Tylenol pr,\n Response:\n Good response to Tylenol,\n Plan:\n Continue antibiotics, monitor temp curve/labs, F/U pending culture\n results, precaution contact\n Altered mental status (not Delirium)\n Assessment:\n Lethargic, easily arousable to speech/stimuli, confused, oriented x1-2,\n trying to oob /risk of fall, speech garbled\n Action:\n Continue reorient the patient, bilateral soft restraint, bed alarm on\n Response:\n MS unchanged, continue restraints,\n Plan:\n Monitor MS, fall precaution,\n Pancytopenia\n Assessment:\n Platelet -61, no obivious signs of bleeding,rt flank haematoma remains\n same\n Action:\n Continue monitor signs of bleeding, goal to keep platelet>50\n Response:\n Platelet >50, no bleeding\n Plan:\n Monitor labs, s/s bleeding/ continue monitor the haematoma\n Pancreatitis, acute\n Assessment:\n c/o abd pain, enzymes elevated\n Action:\n Continue antibiotics/\n Response:\n No acute issues\n Plan:\n Continue monitor enzymes / abd pain\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT 28.5, no signs of bleeding\n Action:\n Monitor hct ,\n Response:\n No bleeding, HCT stable\n Plan:\n Hct check , to keep Hct >25\n Alteration in Nutrition\n Assessment:\n NPO, aspiration precaution/ pancreatitis /MS change\n Action:\n Npo\n Response:\n Plan:\n ? Swallow eval/ if failed NGT or OEG\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332494,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past.\n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.2, patient positive for MRSA in blood, c/o abd pain\n Action:\n Continue iv antibiotics, Tylenol pr,\n Response:\n Good response to Tylenol,\n Plan:\n Continue antibiotics, monitor temp curve/labs, F/U pending culture\n results, precaution contact\n Altered mental status (not Delirium)\n Assessment:\n Lethargic, easily arousable to speech/stimuli, confused, oriented x1-2,\n trying to oob /risk of fall, speech garbled\n Action:\n Continue reorient the patient, bilateral soft restraint, bed alarm on\n Response:\n MS unchanged, continue restraints,\n Plan:\n Monitor MS, fall precaution,\n Pancytopenia\n Assessment:\n Platelet -61, no obvious signs of bleeding,rt flank haematoma remains\n same\n Action:\n Continue monitor signs of bleeding, goal to keep platelet>50\n Response:\n Platelet >50, no bleeding\n Plan:\n Monitor labs, s/s bleeding/ continue monitor the haematoma\n Pancreatitis, acute\n Assessment:\n c/o abd pain, enzymes elevated\n Action:\n Continue antibiotics/\n Response:\n No acute issues\n Plan:\n Continue monitor enzymes / abd pain\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n HCT 28.5, no signs of bleeding\n Action:\n Monitor hct ,\n Response:\n No bleeding, HCT stable\n Plan:\n Hct check , to keep Hct >25\n Alteration in Nutrition\n Assessment:\n NPO, aspiration precaution/ pancreatitis /MS change\n Action:\n Npo\n Response:\n Well hydrated, lytes stable\n Plan:\n ? Swallow eval/ if failed NGT or OEG\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-04 00:00:00.000",
"description": "Report",
"row_id": 1623367,
"text": "Nurse Progress Note 0700-1900\n\nEvents: Liver/GI following -plan for EGD when more alert. CIWA neg but cont lethargic throughout day-unable to take PO's. T spike 101.5-tx w/ tylenol. Transfused 1 unit PRBC- serial HCt. Total 2L IVF for dehydration/low UOP. See carevue for details.\n\nNeuro/Pain: Generally lethargic/sleeping-arousing to voice breiefly but needs additional stimuli to engaging in ansering questions. Oriented x 3 w/ slurred/garbeled/occ confused speach slowly. Unable to engage in conversation even w/ family present. MAE-following commands. Impaired gag/good cough-coughing when asked. Unable to sustain being alert to take PO's-nodding off. intermittently decribes \"just feel bad all over\", to throat/mouth pain \"dry and hurts to swallow\", and 1 x abd pain. CIWA 2 -no coverage needed. Fall/Asp precautions.\n\nResp: Resp rate regular resting in bed, sat 95-100% 2L NC -placed on humidified facetent for dry mucous memberanes-sat > 94%. Ls bilat upper lobes coarse in AM -clearing w/ coughing, clear to deminisshed @ bases. Occ coughing-thick white/swallowing secretions. RR 13-18.\n\nCV: HR 77-101 SR/ST rare PAC, PVC. BP 96-120/47-54 MAP 61-69. No edema noted.\n\nGI: + BS, no BM. NPO. Attempted custard-pt swallowing sm amt w/ continuous prompting-coughing up most 1/2 hr later.\n\nGU: Clear yellow concentrated urine via foley. UOP 10-110cc/hr. Pos 2251 until time stated, pos 2221 LOS.\n\nFEN/ENDO: IVF in bolus. NPO.\n\nHEME: Repete Hct 24.9- transfused 1 unit RBC- repete HCt 24.9- MD aware -goal 25. Plt >50.\n\nID: On IV Vanc IV Zosyn ? asp PNA. + BC. T spike 101.5 PO- treated w/ 1gm PR Tylenol.\n\nSkin: Bruising on R flank, R outer thigh -no change over shift. Turning in bed. NO breakdown in skin integrity noted. Heals elevated.\n\nSocial: Mult family members @ bedside throughout day. Family -wife updated pt condition, medications, procedure and POC. Full Code.\n\n\nPOC\n1. Cont monitor resp status, asp risk\n2. Serial HCT-transfuse <25\n3. Cont to monitor MS- plan from EGD when more alert/awake\n4. Cont IV ABX, monitor temp curve\n5. Cont all routine ICU care\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-05 00:00:00.000",
"description": "Report",
"row_id": 1623368,
"text": "19:00-07:00\n\nNEURO:PT REMAINS LETHARGIC AND OX1.SPEECH GARBLED.C/O PAIN TO FOOT AND THROAT WHEN ASKED.REMAINS ON CIWA WITH SCORE <5.\n\nPULM:LS CLEAR WITH DIMINISHED BASE.ON 35% O2 VIA FT.CONTINUES TO HAVE HICCUPS.\n\nCVS:IN NSR.NBP WITHIN LIMITS.HAD 1 UNIT PLT FOR PLT COUNT OF 45 AND 1 UNITS PRBC FOR HCT OF 23.1.\n\nGI: OFT WITH POS BS.NO PR BLEED OR NAUSEA/VOMITIING.PT IS NPO FOR EGD AND WOULD NEED SPEECH AND SWALLOW AFTER THAT AS PT WAS CHOKING ON CUSTARD YESTERDAY.\n\nGU:FOLEY DRAINING 40-100CC OF CLEAR YELLOW URINE.\n\nID:PT HAS BEEN FEBRILE TO 102.6,PAN CULTURED.PT GROWING GPC IN BLD.COVERED WITH VANC AND ZOSYN.\n\nPLAN:\nHCT AND PLT Q4HRS.\nF/U CULTURE DATA AND FOLLOW TEMP CURVE.\nEGD TODAY.\nSUPPORT FAMILY.\nROUTINE ICU CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2183-08-04 00:00:00.000",
"description": "Report",
"row_id": 1623366,
"text": "19:00-07:00\n\nTHIS IS A 52 YO M WITH HEP C CIRRHOSIS,ETOH ABUSE(DETOX ONE MONTH AGO).HAS BEEN HAVING COFFEE GROUND VOMIT FOR 1 WEEK.CAME TO HOSP LAST MONDAY WHERE HE HAD AN NG LAVAGE WHICH WAS NEG.HE WAS BROUGHT BACK TO HOSP FOR COFFEE GROUND VOMIT.GAVE HIM 1 UNIT PRBC AND 2.7LIT FLUID. TO .\n\nIN ED VITALS STABLE.HAD 1 UNIT PLTS FOT PLT COUNT OF 49.NG LAVAGE NEG.WHILE IN PT HAD AN UNWITNESSED FALL.CT /HEAD DONE WHICH WERE NEG.PT WAS TO MICU FOR FURTHER MANAGEMENT.\n\nNEURO:PT IS VERY LETHARGIC,OBEYING COMMANDS.SPEECH IS GARBLED.ORIENTED X1-2.ON CIWA SCALE AS PT HAS LONG STANDING H/O ETOH(ALTHOUGH PT DENIES ANY DRINKING IN PAST 1 WEEK AND FAMILY THINK SO EITHER).CIWA HAS BEEN <10.PT HAS BEEN TAKING PERCOCET AND VALIUM AT HOME(DOSE UNKNOWN).SERUM BENZOS POS.IF MENTAL STATUS CHANGE WILL CONSIDER NARCANE.\n\nPULM:LS CLEAR,ON 2LNCO2.HAS GOT STRONG COUGH.\n\nCVS:IN NSR WITH SBP WITHIN LIMITS.PT WAS GETTING 1ST UNIT OF PRBC WITH US,SPIKED TEMP TO 100.9.STOPPED BLD AND Q4HRS STABLE.TRANSFUSE IF DROPS <25.AND PLTS<50.\n\nGI: SOFT WITH POS BS.NO PR BLEED OR BM.NO MORE VOMITING OR NAUSEA.PT IS NPO FOR EGD TODAY.\n\nGU:FOLEY DRAINING GOOD URINE.\n\nID:TMAX 101.6.INITIALLY THOUGHT IT WAS RELATED TO BLD.BLD WAS D/CED.PAN CULTURED.COVERING FOR ASP PNA.HAD TYLENOL PR X1.\n\nSKIN:INTACT.BRUISE TO RT FLANK.\n\nPLAN:\nEGD AM.\nF/U CULTURE REPORT.\nCIWA SCALE.IF MS IMPROVE CONSIDER NARCANE.\n\n"
},
{
"category": "Echo",
"chartdate": "2183-08-05 00:00:00.000",
"description": "Report",
"row_id": 71662,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 71\nWeight (lb): 176\nBSA (m2): 2.00 m2\nBP (mm Hg): 139/73\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 12:05\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Dilated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Hyperdynamic\nLVEF >75%. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. There is moderate symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Left ventricular\nsystolic function is hyperdynamic (EF>75%). Right ventricular chamber size and\nfree wall motion are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion. Trace aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. Trivial mitral regurgitation is\nseen. There is borderline pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nNo vegetations seen (cannot definitively exclude).\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026113,
"text": " 2:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evbal for interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Hep C cirrohsis, etoh abuse, GPC bacteremia, unclear\n source, ? RML inflitrate\n REASON FOR THIS EXAMINATION:\n Evbal for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 10:53 AM\n Worsening left lower lobe consolidation highly suspicious for worsening\n pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with Gram-positive cocci\n bacteremia.\n\n Portable AP chest radiograph was compared to .\n\n There is interval significant increase in left lower lobe consolidation which\n appears to be progressing since and highly suspicious for\n developing left lower lobe pneumonia. The right middle lobe opacity is\n unchanged and may represent a focus of infection and/or atelectasis. The\n upper lungs are unremarkable. There is no evidence of failure. Small left\n pleural effusion cannot be excluded.\n\n Findings were discussed with Dr. over the phone by Dr. at\n the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026114,
"text": ", MED MICU 2:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evbal for interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Hep C cirrohsis, etoh abuse, GPC bacteremia, unclear\n source, ? RML inflitrate\n REASON FOR THIS EXAMINATION:\n Evbal for interval change\n ______________________________________________________________________________\n PFI REPORT\n Worsening left lower lobe consolidation highly suspicious for worsening\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-06 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1026278,
"text": " 4:24 PM\n CT ABD W&W/O C Clip # \n Reason: please eval with and without contrast. R/o abd abcess, eval\n Admitting Diagnosis: UPPER GI BLEED\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with with esophagitis, droping HCT, but not clearly GI souce,\n h/o pancreatitis, s/p recent fall, spiking fevers without clear source. please\n eval with and without contrast\n REASON FOR THIS EXAMINATION:\n please eval with and without contrast. R/o abd abcess, eval for PNA, r/o\n hematoma s/p fall, r/p pancreatic necrosis/pseudocyst\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:55 AM\n 1. No evidence of intra-abdominal hematoma.\n\n 2. Worsening pneumonia at the left lung base with new foci of infection at\n the right lung base and bilateral parapneumonic effusions.\n\n 3. Gallbladder wall edema and pericholecystic fluid in the setting of a\n gallstone raise concern for cholecystitis in the right clinical setting.\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN WITH AND WITHOUT CONTRAST.\n\n INDICATION: 52-year-old man with esophagitis, dropping hematocrit without\n clear GI source, history of pancreatitis, recent fall, now febrile. Evaluate\n for abdominal abscess or pneumonia.\n\n TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis were obtained\n without intravenous contrast, followed by images of the abdomen with 130 cc of\n Optiray. Coronal and sagittal reformats were performed.\n\n COMPARISON: .\n\n CT ABDOMEN: There are multiple small focal patchy opacities in the right lung\n base which are new from prior study. There has also been interval worsening\n of the left lower lobe pneumonia. There are new bilateral parapneumonic\n effusions, left greater than right. There is a small amount of adjacent\n atelectasis bilaterally.\n\n There is a fatty liver. The gallbladder is more distended with mild wall\n edema, pericholecystic fluid and and a gallstone within the gallbladder.\n There is hepatic hyperenhancement near the gallbladder fossa suggesting\n inflammation. There is mild thickening of the distal esophagus consistent with\n patient's known esophagitis. The pancreas and adrenals are normal. The\n spleen is normal with a tiny splenule. There are tiny renal stones\n bilaterally, all measuring less than 3 mm, without evidence of hydronephrosis.\n There is new dilation of extrahepatic bile ducts to 7-8 mm, but no\n intrahepatic or definite CHD dilation, making this likely from sphincter\n dysfunction, though early obstruction is possible. The kidneys enhance\n (Over)\n\n 4:24 PM\n CT ABD W&W/O C Clip # \n Reason: please eval with and without contrast. R/o abd abcess, eval\n Admitting Diagnosis: UPPER GI BLEED\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n symmetrically and excrete contrast normally. The intra- abdominal large and\n small bowel is normal. There is no retroperitoneal or mesenteric adenopathy.\n There is no free air or free fluid.\n\n CT PELVIS: There is trace free fluid in the pelvis. There is diverticulosis\n without evidence of diverticulitis. There is air in the bladder likely due to\n Foley placement. There is left greater than right fat-containing inguinal\n hernias.\n\n Bone windows. Mild degenerative change is again noted in the lumbar spine and\n hips.\n\n IMPRESSION:\n 1. No evidence of retroperitoneal hematoma.\n\n 2. Interval worsening of pneumonia with new areas of patchy opacity in the\n right lung base, worsening opacity in the left lung base and new bilateral\n parapneumonic effusions\n\n 3. Findings very concerning for acute cholecystitis, new since . Suggest\n surgical consult and possible HIDA scan for further evaluation.\n\n 4. New CBD dilation without CHD or extrahepatic dilation. This could be\n sphincter dysfunction though early obstruction is possible.\n\n Findings were discussed with Dr. on the evening of the study.\n Dr. discussed recommendation for surgical consult and CBD\n dilation with Dr. at 200 pm on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-06 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 1026279,
"text": ", MED MICU 4:24 PM\n CT ABD W&W/O C Clip # \n Reason: please eval with and without contrast. R/o abd abcess, eval\n Admitting Diagnosis: UPPER GI BLEED\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with with esophagitis, droping HCT, but not clearly GI souce,\n h/o pancreatitis, s/p recent fall, spiking fevers without clear source. please\n eval with and without contrast\n REASON FOR THIS EXAMINATION:\n please eval with and without contrast. R/o abd abcess, eval for PNA, r/o\n hematoma s/p fall, r/p pancreatic necrosis/pseudocyst\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. No evidence of intra-abdominal hematoma.\n\n 2. Worsening pneumonia at the left lung base with new foci of infection at\n the right lung base and bilateral parapneumonic effusions.\n\n 3. Gallbladder wall edema and pericholecystic fluid in the setting of a\n gallstone raise concern for cholecystitis in the right clinical setting.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026329,
"text": ", MED MICU 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Hep C cirrohsis, etoh abuse, ? RML inflitrate\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Limited film. Likely unchanged left lower lobe consolidation. No _____\n of right middle lobe consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1025705,
"text": ", MED MICU 5:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with coagulopathy, fell in ED\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n There is no intracranial hemorrhage or other acute intracranial abnormality.\n Mild mucosal thickening of the paranasal sinuses.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-03 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1025706,
"text": " 5:20 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: without contrast, eval for RP bleed\n Admitting Diagnosis: UPPER GI BLEED\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with coagulopathy, fell in ED has large back abrasion\n REASON FOR THIS EXAMINATION:\n without contrast, eval for RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CT TORSO WITHOUT IV CONTRAST\n\n HISTORY: 52-year-old male with coagulopathy, fell in ED, has large back\n abrasion. Assess for retroperitoneal bleed.\n\n 5-mm contiguous axial images from the thoracic inlet through the lesser\n trochanters without IV contrast were obtained. Coronal and sagittal\n reconstructions were included in this study. Correlation is made to a prior\n CT scan of the abdomen and pelvis dated .\n\n FINDINGS:\n\n CT THORAX WITHOUT IV CONTRAST: The visualized portion of the thyroid gland\n appears normal. Atherosclerotic disease is noted in the coronary arteries and\n aorta. No evidence of pericardial or pleural effusion. Incidental note is\n made of a bovine aortic arch. There are multiple subcentimeter mediastinal\n and hilar lymph nodes. Ground-glass opacities, predominantly peribronchial,\n in the right middle lobe medial segment raise concern for infection. Opacity\n in the left lower lobe more has the appearance of aspiration or atelectasis.\n\n CT ABDOMEN WITHOUT IV CONTRAST: There is no evidence of retroperitoneal\n hematoma.\n\n The lack of IV contrast limits the evaluation of the solid parenchymal organs.\n There are 2 sub cm hypoattenuating lesions in segment IV of the liver, which\n are too small to characterize. Gallstones are noted in the gallbladder. There\n is no evidence of fat stranding in the gallbladder fossa to suggest\n cholecystitis. The liver, pancreas, spleen, and adrenal glands appear normal.\n There is a 4-mm, nonobstructing renal stone in the lower pole of the left\n kidney, with another punctate left renal stone and multiple punctate right\n renal stones. No evidence of mesenteric, retroperitoneal or inguinal\n lymphadenopathy.\n\n Small bowel is unremarkable. There are scattered colonic diverticula. No\n evidence of diverticulitis. The appendix is visualized and is unremarkable.\n Atherosclerotic disease is noted in the abdominal aorta which is normal in\n caliber.\n\n CT PELVIS WITHOUT IV CONTRAST: There is a Foley catheter in the decompressed\n (Over)\n\n 5:20 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: without contrast, eval for RP bleed\n Admitting Diagnosis: UPPER GI BLEED\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n bladder. Prostate gland is unremarkable. No evidence of pelvic\n lymphadenopathy. There are left greater than right fat-containing inguinal\n hernias.\n\n BONE WINDOWS: Note is made of bilateral L5 spondylolysis with associated\n grade 1 anterolisthesis of L5 on S1. No suspicious osteolytic or osteoblastic\n lesions are identified. Mild degenerative changes are seen in the bilateral\n hip joints which are characterized by osteophyte formation and mild\n subchondral cystic change.\n\n IMPRESSION:\n 1. No retroperitoneal hematoma.\n\n 2. Nodular ground-glass peribronchial opacities in the right middle lobe\n riases concern for infection. Left lower lobe opacity more has the appearance\n of a small area of aspiration or atelectasis.\n\n 3. Nonobstructing 4 mm renal stone, lower pole of the left kidney with\n other punctate left and right renal calculi.\n\n 4. Colonic diverticulosis, without evidence of diverticulitis.\n\n 5. Cholelithiasis.\n\n These findings were discussed with Dr. , pager , at\n approximately 8:00 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025886,
"text": " 7:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, r/o PNA\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Hep C cirrohsis, etoh abuse, GPC bacteremia, unclear\n source, presistant hiccups, ? RML inflitrate\n REASON FOR THIS EXAMINATION:\n interval change, r/o PNA\n ______________________________________________________________________________\n WET READ: PXDb MON 7:57 PM\n Slight reduction in retrocardiac aeration could reflect atelectasis. No\n evidence of pneumonia. No other interval changes. ( , )\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis with bacteremia of unknown source.\n\n FINDINGS: In comparison with the study of , the patient has taken a\n somewhat poorer inspiration, which most likely accounts for the increased\n prominence of the transverse diameter of the heart. Opacification persists in\n the left basilar region. Although most likely representing atelectatic\n change, the possibility of supervening pneumonia can certainly not be\n excluded. A lateral view would be helpful for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-08 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1026613,
"text": " 9:15 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: son to look for cholecystitis\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with cirrhosis, pneumonia, and acute cholecystitis\n REASON FOR THIS EXAMINATION:\n son to look for cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Liver and gallbladder ultrasound.\n\n HISTORY: 52-year-old man with cirrhosis, pneumonia and acute cholecystitis.\n Perform right upper quadrant son to evaluate for cholecystitis.\n\n COMPARISONS: CT abdomen from . CT torso from .\n\n FINDINGS: The gallbladder is distended and filled with sludge and there is a\n probable stone within the fundus of the gallbladder. No definite impacted\n stones are identified within the neck or proximal cystic duct. The gallbladder\n wall is thickened and edematous and measures approximately 4 mm. This\n appearance is generally unchanged from the CT scan from . There\n is no pericholecystic fluid. The common bile duct measures approximately 5 mm.\n There is no son sign.\n\n The liver is diffusely coarsened and echogenic consistent with patient's known\n liver disease. There is no intrahepatic biliary dilatation. The main portal\n vein is patent with normal hepatopetal flow. The head and body of the\n pancreas appear normal; however, the tail is not well visualized due to\n overlying bowel gas. The spleen appears normal in echotexture, but is\n enlarged measuring 14.2 cm.\n\n IMPRESSION:\n\n 1. Son findings are consistent with cholecystitis given the distended\n gallbladder with wall edema. However, there is no son sign\n and appearance is little changed over two days since prior CT. Would recommend\n a HIDA scan to further evaluate gallbladder function. The gallbladder wall\n edema could also be due to the patient's underlying liver disease.\n\n 2. Coarse echogenic liver consistent with patient's known prior liver\n disease.\n\n The findings of this study were communicated with Dr. at\n approximately 10:30 AM on .\n\n\n (Over)\n\n 9:15 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: son to look for cholecystitis\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026328,
"text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Hep C cirrohsis, etoh abuse, ? RML inflitrate\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:40 AM\n PFI: Limited film. Likely unchanged left lower lobe consolidation. No _____\n of right middle lobe consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old with hep C cirrhosis, alcohol abuse, and question\n right middle lobe infiltrate.\n\n COMPARISON: One day prior.\n\n SINGLE SEMI-UPRIGHT BEDSIDE CHEST RADIOGRAPH: Respiratory motion severely\n limits evaluation. The extensive left lower lobe consolidation is likely\n unchanged, questionable right perihilar consolidation is no longer apparent.\n The upper lung zones remain clear. There is no pulmonary edema and no sizable\n effusion. The right costophrenic angle has been excluded. Cardiomediastinal\n silhouette is normal. Left scapular screw again noted.\n\n IMPRESSION: Limited film with respiratory motion. Likely unchanged left\n lower lobe consolidation. Right middle lobe opacity no longer apparent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025716,
"text": " 8:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate for pna\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with coffee ground emesis, cough\n REASON FOR THIS EXAMINATION:\n pls evaluate for pna\n ______________________________________________________________________________\n WET READ: CXWc SUN 10:48 PM\n No acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Coffee-ground emesis and cough, to evaluate for pneumonia.\n\n FINDINGS: No previous images. The cardiac silhouette is at the upper limits\n of normal in size. No vascular congestion, pleural effusion, or acute\n pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026595,
"text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Hep C cirrohsis, etoh abuse, ? RML inflitrate\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy FRI 12:49 PM\n PFI: Complete resolution of right infrahilar opacity. The left lower lung\n also appears improved. The previously seen opacity has decreased as now more\n linear strongly suggestive of atelectasis. There are no other acute changes.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and ETOH abuse, concern for evolution of right middle lobe\n infiltrate.\n\n COMPARISON: .\n\n FINDINGS: The right lung is now entirely clear. There is persistent left\n lower lobe opacity, although this appears improved from prior film. It now has\n a linear appearance more strongly suggestive of atelectasis. There is no\n appreciable effusion. The hilar and cardiomediastinal contours are normal\n without evidence for vascular congestion.\n\n IMPRESSION: Resolution of right infrahilar opacity. Improvement in left\n lower lobe opacity now strongly suggestive of atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026596,
"text": ", MED FA10 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Hep C cirrohsis, etoh abuse, ? RML inflitrate\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Complete resolution of right infrahilar opacity. The left lower lung\n also appears improved. The previously seen opacity has decreased as now more\n linear strongly suggestive of atelectasis. There are no other acute changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1025704,
"text": " 5:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with coagulopathy, fell in ED\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc SUN 8:36 PM\n There is no intracranial hemorrhage or other acute intracranial abnormality.\n Mild mucosal thickening of the paranasal sinuses.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man who fell in the emergency department, with\n history of coagulopathy.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass\n effect. Basilar cisterns are preserved, and the -white differentiation is\n preserved. Ventricles and sulci are normal in contour and configuration. There\n is no fracture. Mild mucosal thickening is present in both maxillary sinuses,\n and fluid density material is present in the left mastoid air cells\n and anteriorly within the ethmoid air cells. There may be a tiny air\n fluid level in the left maxillary sinus. Mastoid air cells, sphenoid and\n frontal sinuses are well aerated. Soft tissues are unremarkable.\n\n IMPRESSION: No acute intracranial abnormality, including no intracranial\n hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2183-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025914,
"text": " 3:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change, r/o PNA\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Hep C cirrhosis, UGIB, ? lung infiltrate on CT chest\n REASON FOR THIS EXAMINATION:\n interval change, r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Possible pneumonia on chest CT.\n\n FINDINGS: In comparison with the study of , there is again patchy\n opacification at the left base. Again, although this could represent\n atelectatic change, the possibility of pneumonia should be seriously\n considered. A lateral view would be helpful for further evaluation if the\n patient's condition permits.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2183-08-03 00:00:00.000",
"description": "Report",
"row_id": 176872,
"text": "Sinus rhythm. Normal tracing. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332408,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active bleeding seen since admission, hct down\n Action:\n Pt recvd. 1U PRBC @0500\n Response:\n Hct. After transfusion 28.3\n Plan:\n Cont. with Q6 HCT, transfuse for hct less than 25, plt less than 50.\n Bedside Endoscope done\nresults pending\n Fall(s)\n Assessment:\n Pt had an unwitnessed fall while in ED, rt flank hematoma noted/\n ecchymotic areas to rt leg\n Action:\n Head/Abd/Pelvis CT done\n Response:\n CT Scan negative\n Plan:\n Cont. to monitor area, assess need for pain medication if pain not\n relieved by repositioning\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.1, pt positive for MRSA in blood\n Action:\n Pt pan cultured secondary to elevated temps\n Response:\n Pt cont on IV Abx\n Plan:\n Cont. to monitor temps, cont with IV Abx treatments, follow up with\n pending cultures\n Bacteremia\n Assessment:\n Pt positive for\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332424,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active bleeding seen since admission, hct down\n Action:\n Pt recvd. 1U PRBC @0500\n Response:\n Hct. After transfusion 28.3\n Plan:\n Cont. with Q6 HCT, transfuse for hct less than 25, plt less than 50.\n Bedside Endoscope done\nshows esophagitis, no active bleeding\n Fall(s)\n Assessment:\n Pt had an unwitnessed fall while in ED, rt flank hematoma noted/\n ecchymotic areas to rt leg\n Action:\n Head/Abd/Pelvis CT done\n Response:\n CT Scan negative\n Plan:\n Cont. to monitor area, assess need for pain medication if pain not\n relieved by repositioning\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.1, pt positive for MRSA in blood\n Action:\n Pt pan cultured secondary to elevated temps\n Response:\n Pt cont on IV Abx\n Plan:\n Cont. to monitor temps, cont with IV Abx treatments, follow up with\n pending cultures\n Bacteremia\n Assessment:\n Pt positive for MRSA in blood\n Action:\n Pt on IV Zosyn, IV Vanc\n Response:\n Remains febrile\n Plan:\n Cont. to temp, f/u with pending cultures\n Altered mental status (not Delirium)\n Assessment:\n alert and oriented x2\n Action:\n Cont to orient to unit, redirection\n Response:\n Pt able to follow commands more consistently; speech garbled but able\n to make needs known\n Plan:\n If pt MS doesn\nt show significant improve ? LP\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332478,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past.\n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332442,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past\n \n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No active bleeding seen since admission, hct down\n Action:\n Pt recvd. 1U PRBC @0500\n Response:\n Hct. After transfusion 28.3\n Plan:\n Cont. with Q6 HCT, transfuse for hct less than 25, plt less than 50.\n Bedside Endoscope done\nshows Grade 2 esophagitis, mild portal\n hypertensive gastropathy\n Fall(s)\n Assessment:\n Pt had an unwitnessed fall while in ED, rt flank hematoma noted/\n ecchymotic areas to rt leg\n Action:\n Head/Abd/Pelvis CT done on admission\n Response:\n CT Scan negative\n Plan:\n Cont. to monitor area, assess need for pain medication if pain not\n relieved by repositioning\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 100.1, pt positive for MRSA in blood\n Action:\n Pt pan cultured secondary to elevated temps\n Response:\n Pt cont on IV Abx\n Plan:\n Cont. to monitor temps, cont with IV Abx treatments, follow up with\n pending cultures\n Bacteremia\n Assessment:\n Pt positive for MRSA in blood\n Action:\n Pt on IV Zosyn, IV Vanco\n Response:\n Remains febrile\n Plan:\n Cont. to temp, f/u with pending cultures\n Altered mental status (not Delirium)\n Assessment:\n alert and oriented x2\n Action:\n Cont to orient to unit, redirection if attempting to get out of bed\n Response:\n Pt able to follow commands more consistently; speech garbled but able\n to make needs known\n Plan:\n If pt MS doesn\nt show significant improvement ? LP\n"
},
{
"category": "General",
"chartdate": "2183-08-06 00:00:00.000",
"description": "ICU Event Note",
"row_id": 332580,
"text": "Clinician: Attending\n Critical Care\n Remains febrile w/o clear source - amylase and lipase mildly elevated,\n CXR worse now with clear process in lingula and LLL. His mental status\n is improving suggesting much of lethargy was due to benzos as\n suspected. BC results were an error so no clear explanation for\n presentation. Will try to obtain sputum today. Hct is drifting down\n w/o clear explanation from EGD so will check CT given recent trauma.\n Total time spent: 40 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332737,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:13 AM\n T 101.8\n URINE CULTURE - At 04:48 AM\n FEVER - 101.8\nF - 04:00 AM\n Pt had had hiccups all night\n CT abd now being read with ? of acute chole, also with worsening of L\n and R pneumonia and parapneumonic effusions\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:00 PM\n Vancomycin - 08:21 AM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 38.8\nC (101.8\n HR: 94 (67 - 95) bpm\n BP: 142/71(84) {113/59(72) - 142/83(96)} mmHg\n RR: 14 (12 - 17) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81 kg (admission): 80.3 kg\n Height: 71 Inch\n Total In:\n 1,400 mL\n 155 mL\n PO:\n 450 mL\n TF:\n IVF:\n 950 mL\n 155 mL\n Blood products:\n Total out:\n 1,890 mL\n 370 mL\n Urine:\n 1,890 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n -490 mL\n -215 mL\n Respiratory support\n O2 Delivery Device: None\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 62 K/uL\n 9.4 g/dL\n 82 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 99 mEq/L\n 134 mEq/L\n 27.1 %\n 4.8 K/uL\n [image002.jpg]\n 04:00 AM\n 08:32 AM\n 04:40 PM\n 09:30 PM\n 03:24 AM\n 09:28 AM\n 04:19 PM\n 03:36 AM\n 03:34 PM\n 02:32 AM\n WBC\n 5.2\n 5.6\n 4.8\n 4.8\n Hct\n 26.5\n 24.9\n 24.9\n 27.4\n 23.1\n 28.6\n 27.6\n 26.4\n 28.8\n 27.1\n Plt\n 45\n 60\n 61\n 53\n 62\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 109\n 104\n 90\n 82\n Other labs: PT / PTT / INR:16.1/29.2/1.4, ALT / AST:16/42, Alk Phos / T\n Bili:46/1.0, Amylase / Lipase:162/102, Albumin:2.8 g/dL, LDH:181 IU/L,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n A/P: 52 yo male with h/o Hep C cirrhosis, ETOH abuse who presented with\n coffee ground emesis and MS changes.\n GASTROINTESTINAL BLEED, UPPER/ANEMIA-pt presented with history of\n hematemasis and drop in hemocrit. However, etiology remains unclear\n especially with EGD yesterday that did not find upper GI source. Pt\n also has h/o diverticulosis but no BRBPR. Overnight had a drop in Hct\n from 28.6-26.4. be alternative source in setting of pancreatitis\n and fall in ED.\n -also required platlets to keep >50\n -Protonix IV BID per GI recs\n -start diet of clear and advance if tolerate, observe for aspiration\n and consult speech and swallow if suspected\n -q6 HCT and Platelet check; will transfuse for Hct <25, Platelets <50K\n -repeat CT abdomen with and without to find hematoma vs abscess\n FEVER-Pt still spiking fevers, likely due to pna that has progressed\n -continue broad spectrum abx with Vanc and Zosyn for picture c/w\n aspiration\n -TTE from yesterday-no vegetations, LVEF75%\n -CXR-as above shows progression of pneumonia in L base, will repeat\n CXR\n -f/u Urine culture\n -f/u sputum cultures-try to get induced sputum today\n -continue surveillence cultures\n -records from show history of pancreatitis on discharge days\n before admission here\n AMS-Pt came in with disorientation and garbled speech considered to\n be from withdrawal vs acute intoxication now improving\n -per records was discharged with Benzos and narcotics likely\n accounting for AMS since he has not received any here and has cleared\n -may have contributed to aspriation\n -IF MS does not improve will consider lactulose\n -fall precautions\n PANCYTOPENIA-pt w history of chronic thrombocytopenia, now with\n infection but no spike in WBC\n -confusing picture but may need to see heme as outpatient\n ODYNOPHAGIA-patient came in w dry mucous memranes and poor oral\n hygiene, DDx inlcudes phayngitis vs GERD vs poor oral hygiene\n - improved mouth care, humidified air seems\n -consider CT and then possibly ENT consult\n -no pain meds for now as patient has a history of abuse\n ETOH Pt recently admitted for detox and currently denies ETOh\n use over past few weeks; however given strong h/o abuse will cover for\n possible withdrawal.\n -D/C CIWA scale\n -MVI, thiamine and folate\n -Restraints or 1:1 sitter if needed\n -Ativan prn\n PANCREATITIS, ACUTE-LFT abnl- Pt with mildly elevated amylase and\n lipase; has recent h/o pancreatitis. Also wtih elevated AST thought not\n surprising given ETOH abuse h/o but all elevated levels of liver\n function trending down.\n -Monitor for now\n CONJUNCTIVITIS-pt had R eye red and purulent at admission, now\n resolved with erythromycin opthal solution\n -willl follow\n HEPATITIS C- Followed by Dr ; recently completed course of\n Ribavarin in IFN. Pt does not appear encephalopathic any more.\n -reportedly had cirrhosis, but does not look like it with HSM and no\n varices\n -Consider Lactulose if MS does not improve\nHTN- Hold home anti-HTNs for now given acute bleeding risk\n ICU Care\n Nutrition:\n Comments: Start on clears and advance as tolerated with caution for\n aspiration with MVI, thiamine and folate\n Glycemic Control:\n Lines:\n 16 Gauge - 12:00 PM\n 18 Gauge - 01:12 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332730,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:13 AM\n T 101.8\n URINE CULTURE - At 04:48 AM\n FEVER - 101.8\nF - 04:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:00 PM\n Vancomycin - 08:21 AM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 38.8\nC (101.8\n HR: 94 (67 - 95) bpm\n BP: 142/71(84) {113/59(72) - 142/83(96)} mmHg\n RR: 14 (12 - 17) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81 kg (admission): 80.3 kg\n Height: 71 Inch\n Total In:\n 1,400 mL\n 155 mL\n PO:\n 450 mL\n TF:\n IVF:\n 950 mL\n 155 mL\n Blood products:\n Total out:\n 1,890 mL\n 370 mL\n Urine:\n 1,890 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n -490 mL\n -215 mL\n Respiratory support\n O2 Delivery Device: None\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 62 K/uL\n 9.4 g/dL\n 82 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 99 mEq/L\n 134 mEq/L\n 27.1 %\n 4.8 K/uL\n [image002.jpg]\n 04:00 AM\n 08:32 AM\n 04:40 PM\n 09:30 PM\n 03:24 AM\n 09:28 AM\n 04:19 PM\n 03:36 AM\n 03:34 PM\n 02:32 AM\n WBC\n 5.2\n 5.6\n 4.8\n 4.8\n Hct\n 26.5\n 24.9\n 24.9\n 27.4\n 23.1\n 28.6\n 27.6\n 26.4\n 28.8\n 27.1\n Plt\n 45\n 60\n 61\n 53\n 62\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 109\n 104\n 90\n 82\n Other labs: PT / PTT / INR:16.1/29.2/1.4, ALT / AST:16/42, Alk Phos / T\n Bili:46/1.0, Amylase / Lipase:162/102, Albumin:2.8 g/dL, LDH:181 IU/L,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PANCYTOPENIA\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 12:00 PM\n 18 Gauge - 01:12 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": "2183-08-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332733,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:13 AM\n T 101.8\n URINE CULTURE - At 04:48 AM\n FEVER - 101.8\nF - 04:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:00 PM\n Vancomycin - 08:21 AM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 38.8\nC (101.8\n HR: 94 (67 - 95) bpm\n BP: 142/71(84) {113/59(72) - 142/83(96)} mmHg\n RR: 14 (12 - 17) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81 kg (admission): 80.3 kg\n Height: 71 Inch\n Total In:\n 1,400 mL\n 155 mL\n PO:\n 450 mL\n TF:\n IVF:\n 950 mL\n 155 mL\n Blood products:\n Total out:\n 1,890 mL\n 370 mL\n Urine:\n 1,890 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n -490 mL\n -215 mL\n Respiratory support\n O2 Delivery Device: None\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 62 K/uL\n 9.4 g/dL\n 82 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 99 mEq/L\n 134 mEq/L\n 27.1 %\n 4.8 K/uL\n [image002.jpg]\n 04:00 AM\n 08:32 AM\n 04:40 PM\n 09:30 PM\n 03:24 AM\n 09:28 AM\n 04:19 PM\n 03:36 AM\n 03:34 PM\n 02:32 AM\n WBC\n 5.2\n 5.6\n 4.8\n 4.8\n Hct\n 26.5\n 24.9\n 24.9\n 27.4\n 23.1\n 28.6\n 27.6\n 26.4\n 28.8\n 27.1\n Plt\n 45\n 60\n 61\n 53\n 62\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 109\n 104\n 90\n 82\n Other labs: PT / PTT / INR:16.1/29.2/1.4, ALT / AST:16/42, Alk Phos / T\n Bili:46/1.0, Amylase / Lipase:162/102, Albumin:2.8 g/dL, LDH:181 IU/L,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PANCYTOPENIA\n PANCREATITIS, ACUTE\n ICU Care\n Nutrition:\n Comments: Start on clears and advance as tolerated with caution for\n aspiration with MVI, thiamine and folate\n Glycemic Control:\n Lines:\n 16 Gauge - 12:00 PM\n 18 Gauge - 01:12 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332724,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No signs GI bleed, pm hct stable,\n Action:\n Continue monitor hct/platelet, transfuse HCT <25 and platelet <50, IV\n protonix\n Response:\n HCT stable, 27.1 and platelet 62 this AM, no bleeding\n Plan:\n Continue monitor HCT and Platelet, F/U ct abdomen\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spike to 101.8 this AM, CXR shows progression of PNA in lt base ,\n mildly elevated amylase and lipase\n Action:\n Repeated CXR in am, blood and urine culture sent, continue\n antibiotics, F/U culture results\n Response:\n Continue to have low grade temp and temp spike this AM\n Plan:\n F/u culture results/ CT abdomen and pelvis, continue monitor amylase\n and lipase, IV antibiotics\n Altered mental status (not Delirium)\n Assessment:\n Lethargic, oriented x2-3, following commands, garbled speech, fall\n precaution\n Action:\n Frequent reorientation, continue bed alarm, bed low and locked\n Response:\n MS unchanged\n Plan:\n Continue monitor/ reorientation/? Consider lactulose\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332481,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past.\n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.2,\n Action:\n Response:\n Plan:\n Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332482,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past.\n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max 101.2,\n Action:\n Response:\n Plan:\n Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332476,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past.\n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Bacteremia\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332611,
"text": "Chief Complaint: AMS\n 24 Hour Events:\n ENDOSCOPY - At 04:04 PM\n FEVER - 101.2\nF - 08:00 PM\n -EGD: no varices, grade 2 esphoagitis, localized gastric erosion c/w NG\n tube trama\n History obtained from Patient, Family / Friend\n Allergies:\n History obtained from Patient, Family / FriendNo Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:00 PM\n Vancomycin - 08:21 AM\n Piperacillin/Tazobactam (Zosyn) - 10:22 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Edema\n Respiratory: Cough\n Gastrointestinal: Abdominal pain, Constipation\n Heme / Lymph: Anemia\n Pain: Minimal\n Pain location: right side of chest\n Flowsheet Data as of 03:18 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.4\nC (99.4\n HR: 72 (67 - 92) bpm\n BP: 123/66(81) {112/47(68) - 140/83(96)} mmHg\n RR: 13 (11 - 21) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 71 Inch\n Total In:\n 1,420 mL\n 742 mL\n PO:\n TF:\n IVF:\n 430 mL\n 742 mL\n Blood products:\n Total out:\n 2,295 mL\n 700 mL\n Urine:\n 2,295 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -875 mL\n 42 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n SpO2: 94%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL, Conjunctiva pale\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : L\n base), (Breath Sounds: Crackles : , Bronchial: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): AAOx2, Movement: Not assessed, Tone: Normal\n Labs / Radiology\n 53 K/uL\n 9.0 g/dL\n 90 mg/dL\n 0.6 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 8 mg/dL\n 105 mEq/L\n 139 mEq/L\n 26.4 %\n 4.8 K/uL\n [image002.jpg]\n 06:32 PM\n 11:56 PM\n 04:00 AM\n 08:32 AM\n 04:40 PM\n 09:30 PM\n 03:24 AM\n 09:28 AM\n 04:19 PM\n 03:36 AM\n WBC\n 9.8\n 9.9\n 5.2\n 5.6\n 4.8\n Hct\n 26.0\n 25.6\n 26.5\n 24.9\n 24.9\n 27.4\n 23.1\n 28.6\n 27.6\n 26.4\n Plt\n 52\n 53\n 45\n 60\n 61\n 53\n Cr\n 0.8\n 0.7\n 0.7\n 0.7\n 0.6\n Glucose\n 107\n 99\n 109\n 104\n 90\n Other labs: PT / PTT / INR:16.0/31.7/1.4, ALT / AST:17/43, Alk Phos / T\n Bili:42/1.1, Amylase / Lipase:161/97, Albumin:2.8 g/dL, LDH:136 IU/L,\n Ca++:7.7 mg/dL, Mg++:2.0 mg/dL, PO4:3.6 mg/dL\n Fluid analysis / Other labs: Echo: The left atrium is dilated. There is\n moderate symmetric left ventricular hypertrophy. The left ventricular\n cavity size is normal. Left ventricular systolic function is\n hyperdynamic (EF>75%). Right ventricular chamber size and free wall\n motion are normal. The aortic valve leaflets (3) appear structurally\n normal with good leaflet excursion. Trace aortic regurgitation is seen.\n The mitral valve leaflets are mildly thickened. Trivial mitral\n regurgitation is seen. There is borderline pulmonary artery systolic\n hypertension. There is no pericardial effusion.\n No vegetations seen (cannot definitively exclude).\n Imaging: There is interval significant increase in left lower lobe\n consolidation which\n appears to be progressing since and highly suspicious\n for developing left lower lobe pneumonia. The right middle lobe opacity\n is unchanged and may represent a focus of infection and/or atelectasis.\n The upper lungs are unremarkable. There is no evidence of failure.\n Small left pleural effusion cannot be excluded.\n Microbiology: -lab error no positive BCx\n Assessment and Plan\n A/P: 52 yo male with h/o Hep C cirrhosis, ETOH abuse who presented with\n coffee ground emesis and MS changes.\n GASTROINTESTINAL BLEED, UPPER/ANEMIA-pt presented with history of\n hematemasis and drop in hemocrit. However, etiology remains unclear\n especially with EGD yesterday that did not find upper GI source. Pt\n also has h/o diverticulosis but no BRBPR. Overnight had a drop in Hct\n from 28.6-26.4. be alternative source in setting of pancreatitis\n and fall in ED.\n -also required platlets to keep >50\n -Protonix IV BID per GI recs\n -start diet of clear and advance if tolerate, observe for aspiration\n and consult speech and swallow if suspected\n -q6 HCT and Platelet check; will transfuse for Hct <25, Platelets <50K\n -repeat CT abdomen with and without to find hematoma vs abscess\n FEVER-Pt still spiking fevers, likely due to pna that has progressed\n -continue broad spectrum abx with Vanc and Zosyn for picture c/w\n aspiration\n -TTE from yesterday-no vegetations, LVEF75%\n -CXR-as above shows progression of pneumonia in L base, will repeat\n CXR\n -f/u Urine culture\n -f/u sputum cultures-try to get induced sputum today\n -continue surveillence cultures\n -records from show history of pancreatitis on discharge days\n before admission here\n AMS-Pt came in with disorientation and garbled speech considered to\n be from withdrawal vs acute intoxication now improving\n -per records was discharged with Benzos and narcotics likely\n accounting for AMS since he has not received any here and has cleared\n -may have contributed to aspriation\n -IF MS does not improve will consider lactulose\n -fall precautions\n PANCYTOPENIA-pt w history of chronic thrombocytopenia, now with\n infection but no spike in WBC\n -confusing picture but may need to see heme as outpatient\n ODYNOPHAGIA-patient came in w dry mucous memranes and poor oral\n hygiene, DDx inlcudes phayngitis vs GERD vs poor oral hygiene\n - improved mouth care, humidified air seems\n -consider CT and then possibly ENT consult\n -no pain meds for now as patient has a history of abuse\n ETOH Pt recently admitted for detox and currently denies ETOh\n use over past few weeks; however given strong h/o abuse will cover for\n possible withdrawal.\n -D/C CIWA scale\n -MVI, thiamine and folate\n -Restraints or 1:1 sitter if needed\n -Ativan prn\n PANCREATITIS, ACUTE-LFT abnl- Pt with mildly elevated amylase and\n lipase; has recent h/o pancreatitis. Also wtih elevated AST thought not\n surprising given ETOH abuse h/o but all elevated levels of liver\n function trending down.\n -Monitor for now\n CONJUNCTIVITIS-pt had R eye red and purulent at admission, now\n resolved with erythromycin opthal solution\n -willl follow\n HEPATITIS C- Followed by Dr ; recently completed course of\n Ribavarin in IFN. Pt does not appear encephalopathic any more.\n -reportedly had cirrhosis, but does not look like it with HSM and no\n varices\n -Consider Lactulose if MS does not improve\nHTN- Hold home anti-HTNs for now given acute bleeding risk\n ICU Care\n Nutrition:\n Comments: Start on clears and advance as tolerated with caution for\n aspiration with MVI, thiamine and folate\n Glycemic Control:\n Lines:\n 16 Gauge - 12:00 PM\n 18 Gauge - 01:12 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332704,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No signs GI bleed, pm hct stable,\n Action:\n Continue monitor hct/platelet, transfuse HCT <25 and platelet <50, IV\n protonix\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temp, CXR shows progression of PNA in lt base , mildly\n elevated amylase and lipase\n Action:\n Repeat CXR in am, continue antibiotics, F/U culture results\n Response:\n Continue to have low grade temp\n Plan:\n F/u culture results/ CT abdomen and pelvis, continue monitor amylase\n and lipase, IV antibiotics\n Altered mental status (not Delirium)\n Assessment:\n Lethargic, oriented x2-3, following commands, garbled speech, fall\n precaution\n Action:\n Frequent reorientation, continue bed alarm, bed low and locked\n Response:\n MS unchanged\n Plan:\n Continue monitor/ reorientation/? Consider lactulose\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332673,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n No signs of gi bleed\n Action:\n 1500 hct sent\n Response:\n Hct stable @ 28\n Plan:\n Dc to floor in am\n Altered mental status (not Delirium)\n Assessment:\n Pt slightly lethargic, responds slowly to commands, oriented x 3, needs\n to be reminded to do things(ex. ..not to get oob on own)\n Action:\n Reorient as needed, 3 side rails up, bed in low position, bed alarm on\n Response:\n Did not try to get oob, pt cooperative with care\n Plan:\n Continue to observe, maintain safety\n"
},
{
"category": "Physician ",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 332786,
"text": "Chief Complaint: coughing\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 04:13 AM\n T 101.8\n URINE CULTURE - At 04:48 AM\n FEVER - 101.8\nF - 04:00 AM\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:00 PM\n Vancomycin - 08:21 AM\n Piperacillin/Tazobactam (Zosyn) - 09:12 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:12 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Cough\n Gastrointestinal: Abdominal pain, No(t) Nausea\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: 38.8\nC (101.8\n Tcurrent: 37.2\nC (99\n HR: 87 (72 - 95) bpm\n BP: 111/69(74) {111/32(48) - 142/78(89)} mmHg\n RR: 17 (9 - 17) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81 kg (admission): 80.3 kg\n Height: 71 Inch\n Total In:\n 1,400 mL\n 370 mL\n PO:\n 450 mL\n 50 mL\n TF:\n IVF:\n 950 mL\n 320 mL\n Blood products:\n Total out:\n 1,890 mL\n 850 mL\n Urine:\n 1,890 mL\n 850 mL\n NG:\n Stool:\n Drains:\n Balance:\n -490 mL\n -480 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: No(t) Clear : , Crackles : L base, No(t) Wheezes : )\n Abdominal: Soft, Tender: mid-epigastric\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 62 K/uL\n 82 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 99 mEq/L\n 134 mEq/L\n 27.1 %\n 4.8 K/uL\n [image002.jpg]\n 04:00 AM\n 08:32 AM\n 04:40 PM\n 09:30 PM\n 03:24 AM\n 09:28 AM\n 04:19 PM\n 03:36 AM\n 03:34 PM\n 02:32 AM\n WBC\n 5.2\n 5.6\n 4.8\n 4.8\n Hct\n 26.5\n 24.9\n 24.9\n 27.4\n 23.1\n 28.6\n 27.6\n 26.4\n 28.8\n 27.1\n Plt\n 45\n 60\n 61\n 53\n 62\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 109\n 104\n 90\n 82\n Other labs: PT / PTT / INR:16.1/29.2/1.4, ALT / AST:16/42, Alk Phos / T\n Bili:46/1.0, Amylase / Lipase:162/102, Albumin:2.8 g/dL, LDH:181 IU/L,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n PNEUMONIA, ASPIRATION\n PANCYTOPENIA\n PANCREATITIS, ACUTE\n DM Type II\n Clinically he is improving - more alert, eating. Cough remains\n prominent and CXR and CT both show worsening LLL process with some\n spread to R base. Remains febrile but WBC is stable at ~5 w/o L shift\n and he clinically looks better. We are not covering atypicals so will\n start Levoquinb and d/c Zosyn. CT is somewhat concenring for\n developing cholecystitis and his amylase remains elevated. Need to\n monitor this closely but his exam shows no RUQ tenderness and LFT have\n been stable to improved\n ICU Care\n Nutrition:\n Comments: Full diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 12:00 PM\n 18 Gauge - 01:12 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 332801,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:13 AM\n T 101.8\n URINE CULTURE - At 04:48 AM\n FEVER - 101.8\nF - 04:00 AM\n Pt had had hiccups all night\n CT abd now being read with ? of acute chole, also with worsening of L\n and R pneumonia and parapneumonic effusions\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:00 PM\n Vancomycin - 08:21 AM\n Piperacillin/Tazobactam (Zosyn) - 12:05 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:12 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt says feeling pt, still with dry cough with deep\n inspiration\n Flowsheet Data as of 05:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.8\n Tcurrent: 38.8\nC (101.8\n HR: 94 (67 - 95) bpm\n BP: 142/71(84) {113/59(72) - 142/83(96)} mmHg\n RR: 14 (12 - 17) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 81 kg (admission): 80.3 kg\n Height: 71 Inch\n Total In:\n 1,400 mL\n 155 mL\n PO:\n 450 mL\n TF:\n IVF:\n 950 mL\n 155 mL\n Blood products:\n Total out:\n 1,890 mL\n 370 mL\n Urine:\n 1,890 mL\n 370 mL\n NG:\n Stool:\n Drains:\n Balance:\n -490 mL\n -215 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 91%\n ABG: ///27/\n Physical Examination\n Gen:NAD except with deep inhalation goes into coughing paroxysms\n CV: s1s2, RRR, no MRG, no ectopy\n Pulm: B/L crackles in bases\n Abd: +BS, mild tenderness diffusely with deep palpation, soft, nd\n Skin: WNL\n Neurologic: AAOx2\n Labs / Radiology\n 62 K/uL\n 9.4 g/dL\n 82 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 4.0 mEq/L\n 7 mg/dL\n 99 mEq/L\n 134 mEq/L\n 27.1 %\n 4.8 K/uL\n [image002.jpg]\n 04:00 AM\n 08:32 AM\n 04:40 PM\n 09:30 PM\n 03:24 AM\n 09:28 AM\n 04:19 PM\n 03:36 AM\n 03:34 PM\n 02:32 AM\n WBC\n 5.2\n 5.6\n 4.8\n 4.8\n Hct\n 26.5\n 24.9\n 24.9\n 27.4\n 23.1\n 28.6\n 27.6\n 26.4\n 28.8\n 27.1\n Plt\n 45\n 60\n 61\n 53\n 62\n Cr\n 0.7\n 0.7\n 0.6\n 0.7\n Glucose\n 109\n 104\n 90\n 82\n Other labs: PT / PTT / INR:16.1/29.2/1.4, ALT / AST:16/42, Alk Phos / T\n Bili:46/1.0, Amylase / Lipase:162/102, Albumin:2.8 g/dL, LDH:181 IU/L,\n Ca++:7.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.6 mg/dL\n CT abd \n Provisional Findings Impression: 4:55 AM\n 1. No evidence of intra-abdominal hematoma.\n 2. Worsening pneumonia at the left lung base with new foci of infection\n at\n the right lung base and bilateral parapneumonic effusions.\n 3. Gallbladder wall edema and pericholecystic fluid in the setting of a\n gallstone raise concern for cholecystitis in the right clinical\n setting.\n Sputum culture contaminated with oropharyngeal flora\n Assessment and Plan\n A/P: 52 yo male with h/o Hep C cirrhosis, ETOH abuse who presented with\n coffee ground emesis and MS changes.\n ASPIRATION PNEUMONIAFEVER-Pt still spiking fevers, likely due to pna\n that has progressed\n -change Abx to Levoquin picture c/w aspiration, irritation of diaphragm\n likely causing hiccups\n -TTE from yesterday-no vegetations, LVEF75%\n -CXR-as above shows progression of pneumonia in L base, will repeat\n CXR\n -CT abd show progression of B/L pneumonia\n -f/u Urine culture\n -f/u sputum cultures-try to get induced sputum today\n -continue surveillence cultures\n -records from show history of pancreatitis on discharge days\n before admission here\n ABDOMINAL PAIN-pt has h/o of pancreatitis with amylase/lipase\n trending down\n -will continue to monitor\n -no RUQ pain as CT Abd might suggest\n -mild diffuse tenderness on deep palpation\n GASTROINTESTINAL BLEED, UPPER/ANEMIA-pt presented with history of\n hematemasis and drop in hemocrit. However, etiology remains unclear\n especially with EGD yesterday that did not find upper GI source except\n esophagitis. Pt also has h/o diverticulosis but no BRBPR. Overnight\n had a drop in Hct from 28.6-27.1.\n -still with slow trend down in Hct, could be related to pancytopenia\n -also required platlets to keep >50\n -Protonix IV BID per GI recs\n -start diet of clear and advance if tolerate, observe for aspiration\n and consult speech and swallow if suspected\n -q6 HCT and Platelet check; will transfuse for Hct <25, Platelets <50K\n -repeat CT abdomen notc/w hematoma as source\n AMS-Pt came in with disorientation and garbled speech considered to\n be from withdrawal vs acute intoxication now improving\n -per records was discharged with Benzos and narcotics likely\n accounting for AMS since he has not received any here and has cleared\n -may have contributed to aspriation\n -IF MS does not improve will consider lactulose\n -fall precautions\n PANCYTOPENIA-pt w history of chronic thrombocytopenia, now with\n infection but no spike in WBC, and anemia\n -confusing picture but may need to see heme as outpatient\n -could be related to ribavarin treatment in past\n ODYNOPHAGIA-patient came in w dry mucous memranes and poor oral\n hygiene, DDx inlcudes phayngitis vs GERD vs poor oral hygiene\n - improved mouth care, humidified air seems\n -can be attributed to esophagitis, improved on PPI\n -no pain meds for now as patient has a history of abuse\n ETOH Pt recently admitted for detox and currently denies ETOh\n use over past few weeks; however given strong h/o abuse will cover for\n possible withdrawal.\n -D/C CIWA scale\n -MVI, thiamine and folate\n -Restraints or 1:1 sitter if needed\n -Ativan prn\n PANCREATITIS, ACUTE-LFT abnl- Pt with mildly elevated amylase and\n lipase; has recent h/o pancreatitis. Also wtih elevated AST thought not\n surprising given ETOH abuse h/o but all elevated levels of liver\n function trending down.\n -Monitor for now\n CONJUNCTIVITIS-pt had R eye red and purulent at admission, now\n resolved with erythromycin opthal solution\n -willl follow\n HEPATITIS C- Followed by Dr ; recently completed course of\n Ribavarin in IFN. Pt does not appear encephalopathic any more.\n -reportedly had cirrhosis, but does not look like it with HSM and no\n varices\n -Consider Lactulose if MS does not improve\nHTN- Hold home anti-HTNs for now given acute bleeding risk\n ICU Care\n Nutrition:\n Comments: Start on clears and advance as tolerated with caution for\n aspiration with MVI, thiamine and folate\n Glycemic Control:\n Lines:\n 16 Gauge - 12:00 PM\n 18 Gauge - 01:12 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:d/c to regular floor\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 332816,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past.\n \n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Clinically he is improving - more alert, eating. Cough remains\n prominent and CXR and CT both show worsening LLL process with some\n spread to R base. Remains febrile but WBC is stable at ~5 w/o L shift\n and he clinically looks better. We are not covering atypicals so will\n start Levoquinb and d/c Zosyn. CT is somewhat concenring for\n developing cholecystitis and his amylase remains elevated. Need to\n monitor this closely but his exam shows no RUQ tenderness and LFT have\n been stable to improved.\n Pneumonia, aspiration\n Assessment:\n Afebrile. O2 sat 94-98% on RA with RR 9-17 and regular. Lung snds clear\n in upper airways, diminished in bases. Pt with non-productive cough,\n C/O sore throat S/P scoping. No evidence aspiration with clear liqs,\n although pt with poor coordination/arm strength when drinking from cup\n and using spoon.\n Action:\n Pt remains on RA, encouraged to C&DB. Zosyn D/C\nd and pt started on\n Levofloxacin po. Eating ices to sooth sore throat. OOB to chair, pt in\n upright position especially when eating/drinking.\n Response:\n Deep breathing causes bronchospasm/dry cough. Sore throat relieved by\n ingestion of ices.\n Plan:\n Cont aspiration precautions, assisting pt as needed while coordination\n impaired. PT/OT consults ordered. Cont to monitor temp. Incentive\n spirometer as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains lethargic, occas dozing in chair. When awake, pt O X and\n appropriate in conversation. Follows commands consistently, although\n difficulty with hand coordination/strength per above. OOB to chair with\n assist of 2 tolerated well. Pt C/O RUQ pain assoc with deep breathing.\n Action:\n Pt freq reoriented to time/place. Repositioned, not requiring pain med\n @ this time.\n Response:\n Pt remains approp in conversation, polite. Pain tolerable to pt.\n Plan:\n Cont to assess MS, reorienting as necessary. Cont minimlal pain med as\n tolerated.\n Alteration in Nutrition\n Assessment:\n Abd soft with + BS. Pt on full liqs diet, taking small amts clear liqs.\n He reported transient mild nausea when he attempted to eat hot cereal.\n No BM since ? admit.\n Action:\n Pt encouraged to take in freq small amts clear liqs. Pt rec\nd standing\n dose colace in am.\n Response:\n Pt now denies nausea. No BM yet.\n Plan:\n Cont full liq diet, assessing for nausea. More aggressive bowel\n protocol if pt without BM.\n ------ Protected Section ------\n Demographics\n Attending MD:\n \n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n 71 Inch\n Admission weight:\n 80.3 kg\n Daily weight:\n 81 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact\n PMH: ETOH, GI Bleed, Hepatitis\n CV-PMH:\n Additional history: Cirrohsis, Narc Dependent, Anxiet, Gerd,\n Diverticulitis, Suicide Ideation ()\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:52\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 14 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,230 mL\n 24h total out:\n 1,145 mL\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 02:32 AM\n Potassium:\n 4.0 mEq/L\n 02:32 AM\n Chloride:\n 99 mEq/L\n 02:32 AM\n CO2:\n 27 mEq/L\n 02:32 AM\n BUN:\n 7 mg/dL\n 02:32 AM\n Creatinine:\n 0.7 mg/dL\n 02:32 AM\n Glucose:\n 82 mg/dL\n 02:32 AM\n Hematocrit:\n 27.1 %\n 02:32 AM\n Finger Stick Glucose:\n 105\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: MIcu 6\n Transferred to: 10\n Date & time of Transfer: 1600\n ------ Protected Section Addendum Entered By: , RN\n on: 15:03 ------\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 332701,
"text": "Gastrointestinal bleed, upper (Melena, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 332811,
"text": "Pneumonia, aspiration\n Assessment:\n Afebrile. O2 sat 94-98% on RA with RR 9-17 and regular. Lung snds clear\n in upper airways, diminished in bases. Pt with non-productive cough,\n C/O sore throat S/P scoping. No evidence aspiration with clear liqs,\n although pt with poor coordination/arm strength when drinking from cup\n and using spoon.\n Action:\n Pt remains on RA, encouraged to C&DB. Zosyn D/C\nd and pt started on\n Levofloxacin po. Eating ices to sooth sore throat. OOB to chair, pt in\n upright position especially when eating/drinking.\n Response:\n Deep breathing causes bronchospasm/dry cough. Sore throat relieved by\n ingestion of ices.\n Plan:\n Cont aspiration precautions, assisting pt as needed while coordination\n impaired. PT/OT consults ordered. Cont to monitor temp. Incentive\n spirometer as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains lethargic, occas dozing in chair. When awake, pt O X and\n appropriate in conversation. Follows commands consistently, although\n difficulty with hand coordination/strength per above. OOB to chair with\n assist of 2 tolerated well. Pt C/O RUQ pain assoc with deep breathing.\n Action:\n Pt freq reoriented to time/place. Repositioned, not requiring pain med\n @ this time.\n Response:\n Pt remains approp in conversation, polite. Pain tolerable to pt.\n Plan:\n Cont to assess MS, reorienting as necessary. Cont minimlal pain med as\n tolerated.\n Alteration in Nutrition\n Assessment:\n Abd soft with + BS. Pt on full liqs diet, taking small amts clear liqs.\n He reported transient mild nausea when he attempted to eat hot cereal.\n No BM since ? admit.\n Action:\n Pt encouraged to take in freq small amts clear liqs. Pt rec\nd standing\n dose colace in am.\n Response:\n Pt now denies nausea. No BM yet.\n Plan:\n Cont full liq diet, assessing for nausea. More aggressive bowel\n protocol if pt without BM.\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 332812,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past\n \n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Pneumonia, aspiration\n Assessment:\n Afebrile. O2 sat 94-98% on RA with RR 9-17 and regular. Lung snds clear\n in upper airways, diminished in bases. Pt with non-productive cough,\n C/O sore throat S/P scoping. No evidence aspiration with clear liqs,\n although pt with poor coordination/arm strength when drinking from cup\n and using spoon.\n Action:\n Pt remains on RA, encouraged to C&DB. Zosyn D/C\nd and pt started on\n Levofloxacin po. Eating ices to sooth sore throat. OOB to chair, pt in\n upright position especially when eating/drinking.\n Response:\n Deep breathing causes bronchospasm/dry cough. Sore throat relieved by\n ingestion of ices.\n Plan:\n Cont aspiration precautions, assisting pt as needed while coordination\n impaired. PT/OT consults ordered. Cont to monitor temp. Incentive\n spirometer as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains lethargic, occas dozing in chair. When awake, pt O X and\n appropriate in conversation. Follows commands consistently, although\n difficulty with hand coordination/strength per above. OOB to chair with\n assist of 2 tolerated well. Pt C/O RUQ pain assoc with deep breathing.\n Action:\n Pt freq reoriented to time/place. Repositioned, not requiring pain med\n @ this time.\n Response:\n Pt remains approp in conversation, polite. Pain tolerable to pt.\n Plan:\n Cont to assess MS, reorienting as necessary. Cont minimlal pain med as\n tolerated.\n Alteration in Nutrition\n Assessment:\n Abd soft with + BS. Pt on full liqs diet, taking small amts clear liqs.\n He reported transient mild nausea when he attempted to eat hot cereal.\n No BM since ? admit.\n Action:\n Pt encouraged to take in freq small amts clear liqs. Pt rec\nd standing\n dose colace in am.\n Response:\n Pt now denies nausea. No BM yet.\n Plan:\n Cont full liq diet, assessing for nausea. More aggressive bowel\n protocol if pt without BM.\n"
},
{
"category": "Nursing",
"chartdate": "2183-08-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 332814,
"text": "52yo male pt, with PMH Hep C+, ETOH, Cirrohsis, Narc dept. anxiety,\n GERD, Diverticulitis, multi ortho surgeries in the past.\n \n Pt found by wife at home s/p coffee ground emesis, brought to ED, Hct\n 24.9; gastric lavage negative; pt recvd 6pack plts; propable OD\n Valium/Xanax/Librium; pt sent to unit for cont. monitoring\n Clinically he is improving - more alert, eating. Cough remains\n prominent and CXR and CT both show worsening LLL process with some\n spread to R base. Remains febrile but WBC is stable at ~5 w/o L shift\n and he clinically looks better. We are not covering atypicals so will\n start Levoquinb and d/c Zosyn. CT is somewhat concenring for\n developing cholecystitis and his amylase remains elevated. Need to\n monitor this closely but his exam shows no RUQ tenderness and LFT have\n been stable to improved.\n Pneumonia, aspiration\n Assessment:\n Afebrile. O2 sat 94-98% on RA with RR 9-17 and regular. Lung snds clear\n in upper airways, diminished in bases. Pt with non-productive cough,\n C/O sore throat S/P scoping. No evidence aspiration with clear liqs,\n although pt with poor coordination/arm strength when drinking from cup\n and using spoon.\n Action:\n Pt remains on RA, encouraged to C&DB. Zosyn D/C\nd and pt started on\n Levofloxacin po. Eating ices to sooth sore throat. OOB to chair, pt in\n upright position especially when eating/drinking.\n Response:\n Deep breathing causes bronchospasm/dry cough. Sore throat relieved by\n ingestion of ices.\n Plan:\n Cont aspiration precautions, assisting pt as needed while coordination\n impaired. PT/OT consults ordered. Cont to monitor temp. Incentive\n spirometer as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Pt remains lethargic, occas dozing in chair. When awake, pt O X and\n appropriate in conversation. Follows commands consistently, although\n difficulty with hand coordination/strength per above. OOB to chair with\n assist of 2 tolerated well. Pt C/O RUQ pain assoc with deep breathing.\n Action:\n Pt freq reoriented to time/place. Repositioned, not requiring pain med\n @ this time.\n Response:\n Pt remains approp in conversation, polite. Pain tolerable to pt.\n Plan:\n Cont to assess MS, reorienting as necessary. Cont minimlal pain med as\n tolerated.\n Alteration in Nutrition\n Assessment:\n Abd soft with + BS. Pt on full liqs diet, taking small amts clear liqs.\n He reported transient mild nausea when he attempted to eat hot cereal.\n No BM since ? admit.\n Action:\n Pt encouraged to take in freq small amts clear liqs. Pt rec\nd standing\n dose colace in am.\n Response:\n Pt now denies nausea. No BM yet.\n Plan:\n Cont full liq diet, assessing for nausea. More aggressive bowel\n protocol if pt without BM.\n"
}
] |
12,721 | 196,005 | # Urosepsis: Patient presented with hypotension, fever, elevated WBC, + U/A, therefore diagnosed with urosepsis. Subsequently, blood cultures drawn at home prior to transfer to the hospital grew 1/4 bottles of gram negative rods (speication and sensitivities waiting). Initially in the emergency department, she was treated with vancomycin and flagyl, also received aggressive IVF hydration given her hypotension. She was initially placed in the ICU due to her sepsis picture. In the ICU, here antibiotics were changed to levofloxacin, which she remained on throughout the remainder of her hopital course. She had one additional fever spike, where flagyl was added (see below), but otherwise her WBC trended downward, and she was discharged on levofloxacin to complete a 14 day course of antibiotics to be completed on . . # Cardiac - Congestive heart failure: Ms. is without any known cardiac history. However, the day following her aggressive IVF hydration for her hypotension, she developed symptoms of congestive heart failure, including increased O2 requirement, crackles in her lung exam, bilateral lower extremity edema. Therefore, as her infectious clinical status and hypotension was resolved quickly, she was diuresed with lasix 20mg IV PRN, to which she had good urine output. She slowly improved with this regimen, but remained with some symptoms. An ECHO was not obtained as it was not going to change clinical managment. A low dose ACE I was added to her regimen. Her respiratory status and O2 requirement slowly improved. She was discharged with instructions to slowly diurese with lasix if needed (moniter renal function), continue ACE I and titrate up as able. . # Shortness of breath: The patient was successfully diuresed several liters after transitioning out of the ICU, as above. She likely will need further diuresis post discharge as well. She developed a cough on , and a repeat CXR showed a new focal consolidation in the LLL. While levaquin would likely cover this as well as the UTI, we added a 10 day course of PO flagyl to cover possible aspiration pna. Therefore she should complete a 14 day course of levofloxacin and 10 day course of flagyl, both completed on . . # Cardiac - Ischemia: Patient without known cardiac disease, but on admission, was noted to have positive cardiac enzymes (therefore she ruled in for NSTEMI), her ultimate CK peak was in the 600's. Enzymes initially trended down. However, the patient's troponin continued to rise and fall throughout hospital course, even though her CK continued to trend downward. This was thought due to the patient's congestive heart failure status as opposed to recurrent ischemic events. She was not symptomatic and was without EKG changes throughout the hospital course. Given her age, she was not an ideal cardiac catheterization candidate and instead she was treated medically with aspirin, plavix and beta blocker (metoprolol which was titrated up throughout hospital course). An ECHO was not obtained as it was not going to change management. As above, a low dose ACE I was added to her medication regimen prior to discharge. . # Cardiac - Rhythm: Patient had atrial fibrillation with HR 90's on initial presentation. No clear history of AFib, therefore ?new onset. Likely due to her presenting setting of infectious process/urosepsis. She quickly converted to normal sinus rhythm without intervention and initially remained in sinus rhythm. She was not started on anticoagulation in setting of a prior GI bleed. Her HR was in and out of atrial fibrillation throughout remainder of hospital course. She was started on beta blocker, as above, titrated up as needed for heart rate control. . # Mental status changes: Patient was noted to have mental status changes in early AM in the setting of an acute desaturation to 70's when took off her NC O2. Therefore, initially patient was treated with haldol 1mg IV x 1, wrist restraints and a 1:1 sitter. Upon resolution of her hypoxia, patient's mental status returned to baseline. Therefore these measures were discontinued. She was written for SL zyprexa PRN for additional agitation. . Patient's other medical issues remained stable throughout hospital course. | Atrial fibrillationConsider prior inferior myocardial infarctionModest nonspecific ST-T wave changesSince previous tracing of , atrial fibrillation now present and inferiorQ waves more prominent Small Q waves in lead aVF withST segment elevations. AM ekg and CXR ordered. Sinus rhythmBorderline low QRS voltage - is nonspecificModest nonspecific ST-T wave changesSince previous tracing of , atrial fibrillation now absent and inferiorQ waves less prominent Q waves in the inferiorleads consistent with prior inferior wall myocardial infarction. Sinus rhythmPossible prior inferior myocardial infarctionModest nonspecific ST-T wave changesSince previous tracing of the same date, inferior Q waves slightly moreprominent but may be no significant change QR complexes inlead III with minor ST segment elevations. Compared to the previoustracing of tachycardia has appeared as well as better definition ofinferior wall myocardial infarction and new evidence of anterior ischemia. Code status was discussed while pt in ED and sons reversed code status with some contingencies. Rare atrial premature beat.Transmural inferior wall myocardial infarction which appears to be acute.Anterior ischemia. Reciprocal ST segment depressions in lead aVL.Horizontal ST segment depressions in leads V2-V5. Pt was started on maintenance fluids and is making marginal urine-small bollus of 250cc was given with some effect. Pt was previously DNR/DNI at Rehab. Diffuse non-specific ST-T wavechanges. MICU resident called and made aware of above findings-requested fluid bollus be given but okay with waiting to give fluid until after read of CXR. Atrial ectopy. Compared to the previous tracing ST-T wave changes are less extensive. Pt encouraged to take some deep breaths with little effect. with any c hanges Sinus tachycardia. Sinus tachycardia. Please refer to MD's notes for clarification. Urine output also down to 4cc/hr-foley flushed with a little extra return but not a significant amt. There is alate transition which is probably normal. Nursing note (0700-1900) 1700.N.Pt is A+Ox3, no complaints of pain, able to assist in turns. addendumO2 sat down to 92% on 4L nc. LS coarse to UL's, diminished bases.CVS.HR 80-90's NSr with no ectopy seen, no evidence of A-Fib, repeat enzymes pending.BP 100-120/40-50, stable since this am.GI/GU.Pt NPO for present, +BS with no BM as yet.Foley initially with minimal UOP, improved with Lasix.Pt on Levofloxacin for UTI.Skin.No evidence of breakdown noted, pt is very active at baseline.Social.Visited by members of family through the day, updated as to POC.Dispo.Pt is now back to DNR/DNI per family and medics.Plan.Monitor resp status,monitor UOP.Pt is called out to floor, Tx orders and note written, awaiting bed. BP 80-90's (prn order to bollus for SBP<83/50). At this point pt is full code and in case of code situation family is to be called immediately to clarify extent of actions.PLAN: AM EKG/CXR Monitor for si/sx chest pain bollus for bp<83/50 cycle ck's Cont antibiotics for UTI Notify H.O. Denies any difficulty breathing. (am CXR done at 0400). Pt denied any chest pain. Low normal voltage in the limb leads. Pt is hard of hearing, but very pleasant, and in good mood.R.Pt with increased wheezes following fluid bolus this am, given 30mg lasix total, with improved O2 sats and no wheeze. AM labs pending at this time. + urine culture in ED was started on antibiotics. Admission NoteD: See carevue flowsheet for specifics Pt admitted from ED at 2300. Afebrile, HR 70's in afib which converted within a couple hours to NSR with rate 60-70's. Atrial fibrillation with rapid ventricular response. A/Ox3, HOH. Urine has been marginal all night. Awaiting further orders from MICU resident. Pt repositioned and sat upright in bed-lungs with crackles in the bases. Son's stayed with patient while in ED and went home as pt was being brought up to SICU. Lungs clear but sat's 91% O2 nc increased to 4L and O2 sats 95%. | 8 | [
{
"category": "ECG",
"chartdate": "2117-05-14 00:00:00.000",
"description": "Report",
"row_id": 260445,
"text": "Atrial fibrillation with rapid ventricular response. Q waves in the inferior\nleads consistent with prior inferior wall myocardial infarction. There is a\nlate transition which is probably normal. Diffuse non-specific ST-T wave\nchanges. Compared to the previous tracing ST-T wave changes are less extensive.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-05-13 00:00:00.000",
"description": "Report",
"row_id": 260446,
"text": "Sinus tachycardia. Low normal voltage in the limb leads. QR complexes in\nlead III with minor ST segment elevations. Small Q waves in lead aVF with\nST segment elevations. Reciprocal ST segment depressions in lead aVL.\nHorizontal ST segment depressions in leads V2-V5. Rare atrial premature beat.\nTransmural inferior wall myocardial infarction which appears to be acute.\nAnterior ischemia. Sinus tachycardia. Atrial ectopy. Compared to the previous\ntracing of tachycardia has appeared as well as better definition of\ninferior wall myocardial infarction and new evidence of anterior ischemia.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-05-12 00:00:00.000",
"description": "Report",
"row_id": 260447,
"text": "Sinus rhythm\nPossible prior inferior myocardial infarction\nModest nonspecific ST-T wave changes\nSince previous tracing of the same date, inferior Q waves slightly more\nprominent but may be no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2117-05-12 00:00:00.000",
"description": "Report",
"row_id": 260448,
"text": "Sinus rhythm\nBorderline low QRS voltage - is nonspecific\nModest nonspecific ST-T wave changes\nSince previous tracing of , atrial fibrillation now absent and inferior\nQ waves less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2117-05-11 00:00:00.000",
"description": "Report",
"row_id": 260449,
"text": "Atrial fibrillation\nConsider prior inferior myocardial infarction\nModest nonspecific ST-T wave changes\nSince previous tracing of , atrial fibrillation now present and inferior\nQ waves more prominent\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-12 00:00:00.000",
"description": "Report",
"row_id": 1428832,
"text": "Admission Note\nD: See carevue flowsheet for specifics\n Pt admitted from ED at 2300. A/Ox3, HOH. Afebrile, HR 70's in afib which converted within a couple hours to NSR with rate 60-70's. BP 80-90's (prn order to bollus for SBP<83/50). Pt denied any chest pain. Lungs clear but sat's 91% O2 nc increased to 4L and O2 sats 95%. Denies any difficulty breathing. Pt was started on maintenance fluids and is making marginal urine-small bollus of 250cc was given with some effect. + urine culture in ED was started on antibiotics. AM labs pending at this time. AM ekg and CXR ordered.\n Son's stayed with patient while in ED and went home as pt was being brought up to SICU. Pt was previously DNR/DNI at Rehab. Code status was discussed while pt in ED and sons reversed code status with some contingencies. Please refer to MD's notes for clarification. At this point pt is full code and in case of code situation family is to be called immediately to clarify extent of actions.\nPLAN:\n AM EKG/CXR\n Monitor for si/sx chest pain\n bollus for bp<83/50\n cycle ck's\n Cont antibiotics for UTI\n Notify H.O. with any c hanges\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-12 00:00:00.000",
"description": "Report",
"row_id": 1428833,
"text": "addendum\nO2 sat down to 92% on 4L nc. Pt encouraged to take some deep breaths with little effect. Urine output also down to 4cc/hr-foley flushed with a little extra return but not a significant amt. Urine has been marginal all night. Pt repositioned and sat upright in bed-lungs with crackles in the bases. MICU resident called and made aware of above findings-requested fluid bollus be given but okay with waiting to give fluid until after read of CXR. (am CXR done at 0400). Awaiting further orders from MICU resident. Pt currently in no resp distress and denies any chest pain/difficulty breathing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-12 00:00:00.000",
"description": "Report",
"row_id": 1428834,
"text": "Nursing note (0700-1900) 1700.\n\n\nN.\nPt is A+Ox3, no complaints of pain, able to assist in turns. Pt is hard of hearing, but very pleasant, and in good mood.\n\nR.\nPt with increased wheezes following fluid bolus this am, given 30mg lasix total, with improved O2 sats and no wheeze. LS coarse to UL's, diminished bases.\n\nCVS.\nHR 80-90's NSr with no ectopy seen, no evidence of A-Fib, repeat enzymes pending.\nBP 100-120/40-50, stable since this am.\n\nGI/GU.\nPt NPO for present, +BS with no BM as yet.\nFoley initially with minimal UOP, improved with Lasix.\nPt on Levofloxacin for UTI.\n\nSkin.\nNo evidence of breakdown noted, pt is very active at baseline.\n\nSocial.\nVisited by members of family through the day, updated as to POC.\n\nDispo.\nPt is now back to DNR/DNI per family and medics.\n\nPlan.\nMonitor resp status,\nmonitor UOP.\nPt is called out to floor, Tx orders and note written, awaiting bed.\n"
}
] |
83,203 | 149,759 | 74yo M admitted to Hospital with necrotizing pancreatitis. His course there was complicated by C diff and worsening renal failure. . # Pancreatitis:Acute necrotizing pancreatitis. The patient continued to have fever and abdominal distension upon transfer, although bladder pressures remained <30 cmH2O. CT abdomen at showed severe pancreatic necrosis, extensive stranding and fluid around the pancreas but no discrete drainable fluid collections. GI, General Surgery, Renal and ID consultation teams assisted in management. The hospital course was characterized by overall progressive clinical decline, with escalating mechanical ventilator requirement, hypoxemia, escalating vasopressor needs, progressive acidosis despite continue renal dialysis, rising lactic acidosis and rising WBC. Following daily updates with available family members, with continued overall clinical decline and lack of progress despite maximal medical MICU supportive measures, decision to move to focus on patient comfort. Upon discontinuation of vasopressors and dialysis, the patient quietly and peacefully passed away on at 4pm. The family (sister was notified and post mortem examation was declined. . # Fevers: Persistnet fevers attributed predominately to underlying acute pancreatitis, although several infectious sources also identified. Foley catheter tip with debris stuck in tip, GPCs and GNRs on gram stain. Also, CVL from OSH appeared erythematous at the entry site, although culture of that tip was negative. Pt has been treated for C diff (C Diff + on ). Cultures are NGTD. Pt not tolerating being off wall suction, so continuing IV Flagyl, bladder pressures remained elevated (26 this AM). Con't IV vanc given concern for catheter tip infection and small area of right foot concerning for cellulitis. Added cefepime to cover for gut and urinary sources, particularly given persisant fat stranding on CT. IV Flagyl will cover gut anaerobes. Patient was started on oral vanc on once residuals in gut had decreased given concern for untreated cdiff with rising leukocytosis. He was also started on Ticacyline and PR Vancomcyin when not taking orally because of significant ileus. . # Resp failure: ARDS not clearly documented from OSH. Pt now has gross volume overload likely compromising respiratory status. Restrictive physiology of abdominal distention is likely contributing. Pt may also benefit from diuresis to improve his mechanics. Pt was started on CVVH for fluid removal. . # Anemia: Possible sites of acute drop, either bleed in the belly or retroperitoneum vs. hemolysis. No RP bleed on CT, negative hemolysis workup. . # ARF: Worsening throughout his stay at Hospital. Worsening metabolic acidosis and volume overload; transferred here to initaite CVVH. Concern for a component of obstruction given debris in foley catheter tip, but no hydronephrosis on US and no improvement in Cr after foley changed. HD line placed and CVVH initiaed through . . # Trach with air leak: Per report, was a difficult dissection given neck habitus. Rigid bronch scope with switched trach (fenestrated replaced) on by IP. SubQ air improved. . # Hyperglycemia: Pt had been on insulin gtt at OSH, but covered with sliding scale here (glc in the 100s-200s). . # Kidney masses: Incidentally noted 3.3 x 2.4 cm exophytically arising lesion from the lower pole of the left kidney and 6.0 x 4.1 cm adrenal myelolipoma on the right seen on abd CT. these had also been noted on OSh imaging. | Complex exophytic left lower pole renal lesion and adjacent cystic lesion with calcification in the rim. Bilateral nonobstructive lower lobe collapse and pleural effusions, left greater than right, are present. The posterior membranous wall of the trachea is a generally displaced anteriorly. Anterior to this is a low-density exophytic lesion measuring 1.8 x 1.8 cm with calcification in the rim of the lesion. Partial mastoid pneumatization, with opacification of pneumatized portions. Again visualized is a stable-appearing loculated collection of fluid around the greater curvature of the stomach likely representing a developing pseudocyst. FINDINGS: CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY: There is a small left and moderate right pleural effusion. There is a colonic gas pattern with mild dilatation of the transverse colon that reaches a diameter of 8.2 cm and a paucity of air elsewhere in the abdomen. FINDINGS: Images of the right common femoral vein are obscured by an indwelling venous catheter. Limited views of the abdomen demonstrate ascites, anasarca, mesenteric fat stranding as well as right renal and adrenal lesions. Probably tracheobronchomalacia. At the level of the aortic arch the diameters are 22mm coronal and 9 mm sagittal (4:165), compatible with tracheomalacia. A non-distended portion of transverse colon demonstrates bowel wall thickening. Stable small right and moderate left pleural effusions and bibasilar atelectasis. Low-density corresponds to areas of necrosis demonstrated on prior contrast-enhanced examination. IMPRESSION: Mildly dilated transverse colon with a nonspecific bowel gas pattern. There is peripancreatic and mesenteric fat stranding, incompletely evaluated. Incidentally noted 6.0 x 4.1 cm right adrenal myelolipoma. Moderate-to-large amount of simple intra-abdominal ascites. Moderate-to-large amount of simple intra-abdominal ascites. A small right and moderate left pleural effusion. A small right and moderate left pleural effusion. A right common femoral venous catheter and left common femoral arterial catheter are present. PELVIS: A moderate amount of ascites is present in the pelvis. Small right and moderate left pleural effusion. Stable left greater than right pleural effusions and bibasilar consolidation and/or atelectasis. There are small right and moderate left pleural effusions. Moderate amount of simple intra-abdominal ascites. Extensive peri-pancreatic and mesenteric fat stranding incompletely visualized. Small left lower lobe subpleural nodule has decreased in size FINAL REPORT CT ABDOMEN AND PELVIS WITHOUT CONTRAST DATE: . However, exophytically arising from the lower pole of the left kidney, there is a 3.3 x 2.4 cm lesion that measures higher attenuation than simple fluid and demonstrates several punctate calcifications. Well circumscibed 4x6cm right adrenal mass with calcification and foci of necrosis concerning for neoplasm. Extensive atherosclerotic calcifications are present within the normal caliber aorta. There is a 6.0 x 4.1 cm well-marginated oval mass centered within the right adrenal gland that demonstrates both punctate calcifications and macroscopic fat compatible with an adrenal myelolipoma. There is unchanged evidence of a small left pleural effusion, combined to left retrocardiac atelectasis. Diffuse non-specific ST-T wave abnormalities.Compared to the previous tracing of supraventricular tachycardia isnew. FINDINGS: In comparison with study of , a malpositioned left central venous catheter has been removed. Stable small right and moderate left pleural effusions and bibasilar atelectasis. Stable small right and moderate left pleural effusions and bibasilar atelectasis. The right IJ catheter tip terminates in the low SVC. A central venous catheter terminates in the low SVC. Moderate left pleural effusion and bibasilar atelectasis are unchanged. Endotracheal tube terminates in appropriate position. The stomach and small bowel are relatively decompressed. Unchanged low lung volumes and moderate cardiomegaly. FINDINGS: As compared to the previous radiograph, the obviously malpositioned left central venous access line has not been removed. ABDOMEN: Moderate ascites is again seen throughout the abdomen. FINDINGS: As compared to the previous radiograph, there has been status after tracheostomy revision. Tracheostomy noted. On today's image, the pre-existing air bilaterally in the cervical soft tissues has almost completely resolved. PELVIS: The remainder of the bowel is decompressed. FINDINGS: Single AP view of the chest is unchanged from prior. No discrete rim-enhancing fluid collection is identified although a loculated collection of fluid about the greater curvature of the stomach is (Over) 3:49 PM CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # Reason: r/o abscess Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) consistent with a developing pseudocyst. Small bowel wall thickening is secondary to ascites. A stable loculated fluid collection about gastric greater curvature is suggestive of developing pseudocyst though does not appear organized at the present time. Confluent anterior syndesmophytes in the thoracic spine are consistent with DISH. Minor T wave abnormalities.Since the previous tracing of no significant change. The left central venous access line has been removed. FINDINGS: CHEST: Moderate left and small right pleural effusions are similar in size to . A trace of ascites is noted in the abdomen. Supraventricular tachycardia. The left adrenal gland is normal. Moderate ascites is unchanged. Moderate ascites is unchanged. Sinus rhythm at upper limits of normal rate. The pancreatic head enhances normally, but only minimal enhancing pancreatic tissue is seen in the body and tail, consistent with pancreatic necrosis. | 21 | [
{
"category": "Radiology",
"chartdate": "2163-09-30 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1204471,
"text": " 12:52 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: NEWLY PLACED TRACH. AIR LEAK, SUBCUT AIR ON EXAM. EVAL\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with newly placed trach. Air leak, subcutaneuous air on exam.\n REASON FOR THIS EXAMINATION:\n trach placement, needed for IP planning\n CONTRAINDICATIONS for IV CONTRAST:\n ARF, here for initiation of CVVH\n ______________________________________________________________________________\n WET READ: SJBj FRI 2:06 AM\n Extensive subcutaneous subcutaneous emphysema in the cheeks, neck, anterior\n wall and upper paraspinal musculature. Atelectatic basal right lower lobe and\n left lower lobe. Small right and moderate left effusion. Coronary calcs.\n Well circumscibed 4x6cm right adrenal mass with calcification and foci of\n necrosis concerning for neoplasm. Correlate with prior imaging and consider\n MRI when clinically stable. Extensive peri-pancreatic and mesenteric fat\n stranding incompletely visualized. Peri-hepatic ascities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with newly placed tracheostomy and subcutaneous\n emphysema on physical examination.\n\n TECHNIQUE: Multidetector helical CT scan of the chest was obtained without\n the administration of contrast. Axial reconstructions in standard and lung\n algorithms were performed. Coronal and sagittal reformations were prepared.\n\n COMPARISON: None available.\n\n FINDINGS: There is extensive subcutaneous emphysema tracking along the\n anterior pectoralis musculature and superior paraspinal musculature and\n extending through the cervical soft tissues to the face. A relatively small\n amount of pneumomediastinum is present (3:32). A tracheostomy tube enters\n below the cricoid cartilage. No obvious source of air leak is seen inferior\n to the tracheostomy tube. An esophageal catheter is in standard position.\n\n The posterior membranous wall of the trachea is a generally displaced\n anteriorly. At the level of the aortic arch the diameters are 22mm coronal and\n 9 mm sagittal (4:165), compatible with tracheomalacia. The left bronchus is\n also narrowed, 6 mm across.\n\n Bilateral nonobstructive lower lobe collapse and pleural effusions, left\n greater than right, are present.\n\n There are extensive vascular calcifications involving the left main coronary\n artery as well as the left anterior descending and circumflex arteries. No\n pericardial effusion is seen.\n\n Bone windows demonstrate remote left clavicle fracture.\n\n (Over)\n\n 12:52 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: NEWLY PLACED TRACH. AIR LEAK, SUBCUT AIR ON EXAM. EVAL\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n This study is not designed for evaluation below the diaphragm and only limited\n views of the upper abdomen are obtained. These, however, demonstrate ascites\n as well as irregular contour of the liver. There is peripancreatic and\n mesenteric fat stranding, incompletely evaluated. The right kidney contains a\n 4.9 x 3.6 cm irregular hyperdense lesion (2:88). Additionally, the right\n adrenal gland contains a lesion measuring approximately 6.1 x 4.1 cm (2:75)\n with calcifications and areas of fat, could represent myelolipoma, however\n incompletely evaluated. There is diffuse anasarca.\n\n IMPRESSION:\n 1. Extensive subcutaneous emphysema extending throughout the cervical soft\n tissues, superiorly to the face and inferiorly through the pectoralis and\n paraspinal musculature. Small amount of pneumomediastinum. Aside from the\n entry site of the tracheostomy, no obvious source for air leak is identified.\n 2. Probably tracheobronchomalacia.\n 3. Limited views of the abdomen demonstrate ascites, anasarca, mesenteric fat\n stranding as well as right renal and adrenal lesions. Further evaluation with\n dedicated abdominal imaging is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-01 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1204665,
"text": " 2:00 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: New line plcmt\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with respiratory failure, pancreatitis\n REASON FOR THIS EXAMINATION:\n New line plcmt\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory failure, pancreatitis, new line placement.\n\n COMPARISON: Portable chest x-ray from , 1:47 a.m.\n\n FINDINGS: The patient has received the new left-sided internal jugular vein.\n The line takes the wrong course and is currently displaced, most likely in the\n left subclavian vein (instead of crossing the midline and entering the\n superior vena cava). There is no evidence of complications such as\n pneumothorax. However, the line needs to be re-positioned. The referring\n physician . was paged for notification at the time of dictation, 2:50\n p.m., on .\n\n Otherwise, the radiograph is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-03 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1204878,
"text": " 1:09 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: FEVER R/O DVT\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man admitted from OSH for CVVH with persistent fever and wbc\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 74-year-old male admitted from outside hospital for CVVH with\n persistent fever. Request to evaluate for deep venous thrombosis.\n\n COMPARISON: No previous lower limb imaging is available for comparison.\n\n TECHNIQUE: Grayscale, color and spectral Doppler used to evaluate both lower\n extremities. This was a technically difficult portable examination due to\n marked lower limb swelling.\n\n FINDINGS: Images of the right common femoral vein are obscured by an\n indwelling venous catheter. The more distal right common femoral vein is\n compressible on color Doppler. The right superficial femoral, right popliteal\n and right calf veins also demonstrate compressibility, however grayscale\n images are nondiagnostic. The left superficial femoral vein compresses, along\n with the left popliteal and left calf veins. Again, -scale images are of\n nondiagnostic quality.\n\n IMPRESSION: Technically limited study due to patient body habitus and\n extensive lower limb edema. On the images obtained there is no evidence of\n thrombus in lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-01 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1204694,
"text": " 8:09 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for pseudocyst/infection if fluid present we\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pancreatitis and persistent fevers. Has ARF with cr 4.0\n REASON FOR THIS EXAMINATION:\n please evaluate for pseudocyst/infection if fluid present we will consider FNA\n in the future...\n CONTRAINDICATIONS for IV CONTRAST:\n cr 4.0\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc SUN 2:31 AM\n 1. No discrete drainable fluid collections are identified. Extensive\n stranding and fluid demonstrated in the region of the pancreas compatible with\n known clinical diagnosis of pancreatitis.\n\n 2. Moderate-to-large amount of simple intra-abdominal ascites.\n\n 3. A small right and moderate left pleural effusion. Bibasilar right greater\n than left atelectasis.\n\n 4. 3.3 x 2.4 cm exophytically arising lesion from the lower pole of the left\n kidney that measures slightly higher attenuation than simple fluid.\n Correlation with ultrasound or MRI on a non-emergent basis can be obtained as\n clinically indicated.\n\n 5. Incidentally noted 6.0 x 4.1 cm adrenal myelolipoma on the right.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male with pancreatitis and persistent fevers.\n Evaluate for focal fluid collections.\n\n EXAMINATION: CT of the abdomen and pelvis without intravenous contrast.\n\n COMPARISONS: Renal ultrasound from and CT of the chest from\n .\n\n TECHNIQUE: Helically acquired axial images were obtained from the lung bases\n to the pubic symphysis after the administration of oral contrast only.\n Intravenous contrast was deferred secondary to impaired renal function.\n Coronal and sagittal reformations are provided for review.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY:\n\n There is a small left and moderate right pleural effusion. There is\n associated bibasilar atelectasis with increasing right lower lobe atelectasis\n since . The visualized portion of the tracheobronchial tree is\n patent.\n (Over)\n\n 8:09 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for pseudocyst/infection if fluid present we\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is a moderate amount of simple fluid attenuation intra-abdominal\n ascites. The liver and spleen are unremarkable.\n\n There is a 6.0 x 4.1 cm well-marginated oval mass centered within the right\n adrenal gland that demonstrates both punctate calcifications and macroscopic\n fat compatible with an adrenal myelolipoma. The left adrenal gland is\n unremarkable. There are multiple scattered hypodensities and hyperdensities\n seen throughout both kidneys, likely representing a combination of simple and\n hyperdense cysts. However, exophytically arising from the lower pole of the\n left kidney, there is a 3.3 x 2.4 cm lesion that measures higher attenuation\n than simple fluid and demonstrates several punctate calcifications.\n\n In the region of the pancreas, there is extensive stranding and fluid\n compatible with clinically known diagnosis of pancreatitis. Portions of the\n pancreas demonstrate some heterogenity in the neck which either may represent\n interdigitated fluid or necrosis. There are no discrete loculated drainable\n fluid collections identified.\n\n The visualized portions of intra-abdominal small and large bowel are\n unremarkable. An enteric tube is demonstrated with tip terminating within the\n stomach. There is no evidence of obstruction. There is no intra-abdominal\n free air. There is no mesenteric or retroperitoneal lymphadenopathy.\n\n CT OF THE PELVIS WITH ORAL CONTRAST ONLY: A rectal catheter is demonstrated\n in place. The rectum and sigmoid colon are collapsed. The bladder is\n collapsed around a Foley catheter with air in the nondependent portion. There\n is no pelvic free fluid. There is no pelvic or inguinal lymphadenopathy.\n\n There is extensive atherosclerotic calcification demonstrated within the\n abdominal aorta and its major branches.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions.\n\n There is anterior osteophytic formation, spanning greater than four vertebral\n bodies compatible with DISH.\n\n IMPRESSION:\n\n 1. Within the limitations of non contrast administration, no discrete\n loculated drainable fluid collections are identified. Extensive stranding and\n fluid demonstrated in the region of the pancreas compatible with known\n clinical diagnosis of severe pancreatitis. Heterogeneity in the region of the\n pancreatic neck can either represent interdigitating fluid or necrosis.\n\n (Over)\n\n 8:09 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for pseudocyst/infection if fluid present we\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Moderate amount of simple intra-abdominal ascites.\n\n 3. Small right and moderate left pleural effusion. Bibasilar right greater\n than left atelectasis.\n\n 4. Multiple scattered renal lesions, some of which represent hyderdense\n cysts, though some demonstrate increased complexity such as a 3.3 x 2.4 cm\n exophytic lesion in the lower pole of the left kidney. This may represent a\n solid renal mass or a lesion with sequella from chronic hemorrhage.\n\n If prior imaging is not available elsewhere to demonstrate long term\n stability, characterization with contrast enhanced CT scan is recommended when\n clinically feasible. Alternatively, ultrasound may be considered, though this\n may be technically challenging given patient body habitus.\n\n 5. Incidentally noted 6.0 x 4.1 cm right adrenal myelolipoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-01 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1204695,
"text": ", A. MED MICU-7 8:09 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: please evaluate for pseudocyst/infection if fluid present we\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pancreatitis and persistent fevers. Has ARF with cr 4.0\n REASON FOR THIS EXAMINATION:\n please evaluate for pseudocyst/infection if fluid present we will consider FNA\n in the future...\n CONTRAINDICATIONS for IV CONTRAST:\n cr 4.0\n ______________________________________________________________________________\n PFI REPORT\n 1. No discrete drainable fluid collections are identified. Extensive\n stranding and fluid demonstrated in the region of the pancreas compatible with\n known clinical diagnosis of pancreatitis.\n\n 2. Moderate-to-large amount of simple intra-abdominal ascites.\n\n 3. A small right and moderate left pleural effusion. Bibasilar right greater\n than left atelectasis.\n\n 4. 3.3 x 2.4 cm exophytically arising lesion from the lower pole of the left\n kidney that measures slightly higher attenuation than simple fluid.\n Correlation with ultrasound or MRI on a non-emergent basis can be obtained as\n clinically indicated.\n\n 5. Incidentally noted 6.0 x 4.1 cm adrenal myelolipoma on the right.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1205365,
"text": " 5:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: POOR MS \n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with necrotizing pancreatitis, weaned off sedation, poor MS,\n like to for .\n REASON FOR THIS EXAMINATION:\n please for \n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:46 PM\n No acute intracranial process. sphenoid sinus disease. Partial\n mastoid pneumatization, with opacification of pneumatized portions. -s\n d/w Dr via phone\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with necrotizing pancreatitis, poor mental status\n after weaning sedation.\n\n TECHNIQUE: Contiguous axial MDCT data were acquired through the head without\n intravenous contrast.\n\n FINDINGS: No hemorrhage, large territorial infarction, edema, mass, or shift\n of normally midline structures is appreciated. The -white differentiation\n is preserved. Mild periventricular hypodensities are consistent with small\n vessel ischemic changes. Mucosal thickening is seen in the bilateral sphenoid\n sinuses. The mastoid air cells are partially pneumatized and are mostly fluid\n filled.\n\n IMPRESSION: No acute intracranial process. Findings were discussed with Dr.\n via phone at 7:45 p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-06 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1205366,
"text": " 5:57 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: for pancreatic pseudocyst and toxic megacolon vs. other\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with necrotizing pancreatitis, c. diff infection, weaned off\n sedation, poor MS, like to for toxic megacolon vs. pancreatitic\n pseudocyst.\n REASON FOR THIS EXAMINATION:\n for pancreatic pseudocyst and toxic megacolon vs. other pathology.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:33 PM\n No appreciable change since or \n\n 1. Findings consistent with necrotizing pancreatitis, with continued\n extensive peripancreatic inflammatory change. A stable loculated fluid\n collection about gastric greater curvature is suggesti12ve of developing\n pseudocyst though does not appear organized at the present time.\n 2. Stable small right and moderate left pleural effusions and bibasilar\n atelectasis. Moderate ascites is unchanged.\n 3. Complex exophytic left lower pole renal lesion which should be evaluated\n with MRI when patient is clinically stable.\n 4. Incidentally noted right adrenal myelolipoma which can be evaluated at\n time of follow up MRI or within 6 months.\n 5. Small left lower lobe subpleural nodule has decreased in size\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN AND PELVIS WITHOUT CONTRAST\n\n DATE: .\n\n Comparison made to CT , and renal ultrasound\n .\n\n CLINICAL HISTORY: 74-year-old man with necrotizing pancreatitis, C. diff\n infection, weaned off sedation, poor mental status, like to evaluate for toxic\n megacolon versus pancreatic pseudocyst.\n\n TECHNIQUE: MDCT axial images of the abdomen and pelvis were obtained without\n the use of intravenous contrast. Oral contrast was administered. Sagittal\n and coronal reformatted images were constructed.\n\n FINDINGS:\n\n ABDOMEN: There has been minimal interval improvement in basilar\n consolidations. The left pleural effusion measuring simple fluid is\n approximately stable in size. There is a small amount of pleural fluid on the\n right. A subpleural nodular opacity at the left base measuring approximately\n 5 mm is unchanged (2:4). There is also a 5 mm nodular opacity at the right\n base (2:3). This is adjacent to a linear strand of atelectasis. Extensive\n coronary artery calcifications are noted. There is no pericardial effusion.\n (Over)\n\n 5:57 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: for pancreatic pseudocyst and toxic megacolon vs. other\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The lack of intravenous contrast limits evaluation of the solid parenchymal\n organs. There is no evidence of toxic megacolon. Bowel loops are nondilated.\n A non-distended portion of transverse colon demonstrates bowel wall\n thickening. A gastric tube terminates in the distal body of the stomach.\n There is low attenuation of a portion of the head, the entire neck and body\n and a portion of the tail of the pancreas. Low-density corresponds to areas\n of necrosis demonstrated on prior contrast-enhanced examination. There is\n significant surrounding peripancreatic fat stranding extending along the\n anterior pararenal fascia, again greater on the left. There is also a\n moderate degree of ascites in the abdomen and pelvis which measures simple\n fluid. Again visualized is a stable-appearing loculated collection of fluid\n around the greater curvature of the stomach likely representing a developing\n pseudocyst. This measures approximately 10.9 x 4.4 x 6.6 cm in AP, transverse\n and craniocaudal dimensions respectively. There are no new obvious areas of\n loculated fluid collection.\n\n The liver, spleen, left adrenal gland and gallbladder have a grossly normal\n unenhanced appearance. The kidneys demonstrate multiple lesions bilaterally\n some of which represent simple cysts and some complicated cysts (hemorrhage or\n containing proteinaceous material). However, there is an exophytic lesion\n arising from the lower pole of the left kidney measuring 2.6 x 3.4 cm. This\n contains internal calcifications and measures 40 Hounsfield units. Anterior\n to this is a low-density exophytic lesion measuring 1.8 x 1.8 cm with\n calcification in the rim of the lesion. This measures near simple fluid in\n Hounsfield units. Again demonstrated is the 5.6 x 3.8 cm right adrenal gland\n lesion with areas of fat.\n\n There is no abdominal lymphadenopathy. Extensive atherosclerotic\n calcifications are present within the normal caliber aorta.\n\n PELVIS:\n\n A moderate amount of ascites is present in the pelvis. The bladder is\n decompressed with Foley catheter and contains air, likely from\n instrumentation. A rectal tube is in place. A right common femoral venous\n catheter and left common femoral arterial catheter are present. There is\n extensive anasarca in the subcutaneous tissues.\n\n OSSEOUS STRUCTURES: Degenerative changes are present in the thoracic spine\n and facet arthropathy is noted in the lower lumbar spine. There are no\n destructive osseous lesions.\n\n IMPRESSION:\n 1. Findings consistent with necrotizing pancreatitis with stable-appearing\n extensive peripancreatic inflammatory change. A stable loculated fluid\n (Over)\n\n 5:57 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: for pancreatic pseudocyst and toxic megacolon vs. other\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n collection adjacent to the greater curvature of the stomach is suggestive of\n developing pseudocyst.\n 2. Stable left greater than right pleural effusions and bibasilar\n consolidation and/or atelectasis.\n 3. Moderate ascites.\n 4. Complex exophytic left lower pole renal lesion and adjacent cystic lesion\n with calcification in the rim. These should be evaluated with MRI when\n patient is clinically stable as the left kidney is poorly visualized by\n ultrasound.\n 5. Incidentally noted probable right adrenal myelolipoma may also be assessed\n at time of MRI.\n 6. 5 mm lower lobe nodular opacities may relate to inflammatory changes and\n should be followed on subsequent imaging.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-29 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1204465,
"text": " 10:42 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: ileus? free air?\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with distented, tympanic abdomen\n REASON FOR THIS EXAMINATION:\n ileus? free air?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with distended tympanic abdomen. Please evaluate\n for ileus or free air.\n\n COMPARISON: Subsequent portable chest radiograph and chest CT.\n\n FINDINGS: Two supine limited views of the abdomen were obtained without\n visualization of the left flank, pelvic area or peridiaphragmatic regions.\n There is a colonic gas pattern with mild dilatation of the transverse colon\n that reaches a diameter of 8.2 cm and a paucity of air elsewhere in the\n abdomen. The tip of the NG tube is seen high within the abdomen though below\n the level of the diaphragm. An accompanying chest CT showed extensive\n peripancreatic stranding worrisome for pancreatitis, with extensive fluid in\n lesser sac which could relate to superior displacement of the stomach seen\n here.\n\n IMPRESSION: Mildly dilated transverse colon with a nonspecific bowel gas\n pattern. Overall, findings are suggestive of focal ileus in the setting of\n pancreatitis. This could be further evaluated with abdominal CT if clinically\n indicated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204466,
"text": " 10:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: diaphragm free air. Trach\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with trach, OSH transfer\n REASON FOR THIS EXAMINATION:\n diaphragm free air. Trach\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: The patient with recent tracheostomy and extensive\n subcutaneous emphysema.\n\n Extensive subcutaneous emphysema in the neck, supraclavicular regions and\n small pneumomediastinum is better seen in subsequent CT of the chest as well\n as collapse of the left lower lobe and almost complete collapse of the right\n lower lobe. There are small right and moderate left pleural effusions.\n Cardiac size is normal. There are low lung volumes. The NG tube is out of\n view below the diaphragm. Left IJ catheter tip is in the left brachiocephalic\n vein. Tracheostomy tube is in standard position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205246,
"text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval interval changes.\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with man on CVVH, intubated on vanco, cefepime, flagyl for FUO,\n on trach, please eval interval changes.\n REASON FOR THIS EXAMINATION:\n please eval interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old male on CVVH, intubated, on antibiotics for fever of\n unknown origin with tracheostomy. Evaluation for interval change.\n\n TECHNIQUE: Single frontal radiograph of the chest.\n\n COMPARISON: Multiple prior examinations, most recent dated .\n\n FINDINGS: Lung volumes remain low with moderate left pleural effusion and\n basilar atelectasis. No pneumothorax is seen. The cardiomediastinal\n silhouette is unchanged. Right-sided central catheter is unchanged with tip\n near the superior cavoatrial junction possibly within right atrium.\n Tracheostomy tube and esophageal catheter are unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205404,
"text": " 2:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with pancreatitis, trache in place\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 pancreatitis.\n\n Comparison is made with prior study performed a day earlier.\n\n Tracheostomy tube is in standard position. NG tube tip is out of view below\n the diaphragm. There are low lung volumes. Moderate left pleural effusion\n with left lower lobe atelectasis is unchanged. Cardiomediastinal contours are\n stable with cardiac size top normal and mildly widened mediastinum. The right\n IJ catheter tip is in unchanged position in the right atrium.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1204766,
"text": " 2:25 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: New HD line plcmt in RIJ\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with acute pancreatitis and renal failure\n REASON FOR THIS EXAMINATION:\n New HD line plcmt in RIJ\n ______________________________________________________________________________\n WET READ: JEKh SUN 9:04 PM\n 1. interval placement of R IJ line, tip in low SVC; other lines/tubes\n unchanged.\n 2. low lung volumes.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Acute pancreatitis, new central venous access line.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the obviously malpositioned\n left central venous access line has not been removed. A new right-sided\n internal jugular vein line has been inserted. The line is positioned too low\n and could be pulled back by approximately 4 cm. No relevant change. No\n evidence of complications, notably no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205553,
"text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval changes\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with intubation, like to eval interval chagnes\n REASON FOR THIS EXAMINATION:\n interval changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Intubation.\n\n Compared to the film from the prior day there is no significant interval\n change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204610,
"text": " 1:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with trach revision prior subq emphysema\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change, status post tracheostomy\n revision.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there has been status after\n tracheostomy revision. On today's image, the pre-existing air bilaterally in\n the cervical soft tissues has almost completely resolved. The left central\n venous access line has been removed. There is unchanged evidence of a small\n left pleural effusion, combined to left retrocardiac atelectasis. Unchanged\n low lung volumes and moderate cardiomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1204853,
"text": " 10:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new fever, elevated WBC\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man on CVVH, intubated on vanco, cefepime, flagyl for FUO\n REASON FOR THIS EXAMINATION:\n new fever, elevated WBC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: FUO with new fever.\n\n FINDINGS: In comparison with study of , a malpositioned left central\n venous catheter has been removed. The right jugular catheter again extends\n into the right atrium and should be pulled back approximately 4 cm. Hazy\n opacification on the left suggests pleural fluid and there may be mild\n fullness of pulmonary vessels, though this could merely be a reflection of the\n extremely low lung volumes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-03 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1204909,
"text": " 3:49 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: r/o abscess\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with FUO and climbing wbc admitted from OSH for CVVH\n REASON FOR THIS EXAMINATION:\n r/o abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SJBj MON 5:10 PM\n 1. Extensive peripancreatic stranding and pancreatic necrosis. No discrete\n drainable fluid collection is identified. Moderate ascites is unchanged.\n 2. Stable small right and moderate left pleural effusions and bibasilar\n atelectasis.\n 3. Complex exophytic left lower pole renal lesion which should be evaluated\n with MRI when patient is clinically stable.\n 4. Incidentally noted right adrenal myelolipoma which should be evaluated\n with 6 month MRI once patient is clinically stable.\n 5. Small left lower lobe subpleural nodule which should be evaluated on\n follow-up imaging.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with fever of unknown origin, climbing white\n blood cell count.\n\n COMPARISON: CT abdomen and pelvis, .\n\n TECHNIQUE: MDCT data were acquired through the chest, abdomen and pelvis\n after the administration of intravenous contrast. Images were displayed in\n multiple planes.\n\n FINDINGS:\n\n CHEST: Moderate left and small right pleural effusions are similar in size to\n . Moderate left and small right dependent atelectasis is also\n stable. No new consolidations are detected in either lung. An apparent 6mm\n subpleural nodule in the left lower lobe (2:24) could represent atelectasis\n but should be followed on subsequent imaging. The heart and great vessels are\n of normal caliber and appearance. Diffuse coronary artery calcifications are\n present. A central venous catheter terminates in the low SVC. Endotracheal\n tube terminates in appropriate position. No mediastinal, hilar or axillary\n adenopathy is present.\n\n ABDOMEN: Moderate ascites is again seen throughout the abdomen. Extensive\n peripancreatic stranding is visualized consistent with pancreatitis, with\n extension along the anterior pararenal fascia bilaterally, more markedly on\n the left. The pancreatic head enhances normally, but only minimal enhancing\n pancreatic tissue is seen in the body and tail, consistent with pancreatic\n necrosis. No discrete rim-enhancing fluid collection is identified although\n a loculated collection of fluid about the greater curvature of the stomach is\n (Over)\n\n 3:49 PM\n CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: r/o abscess\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consistent with a developing pseudocyst. The liver enhances homogeneously\n without focal lesions. No intra- or extra-hepatic biliary dilatation is\n present. The gallbladder is not distended. The spleen is normal. The left\n adrenal gland is normal. A 6 x 4 cm marginated oval mass centered within the\n right adrenal gland again demonstrates punctate calcifications and macroscopic\n fat compatible with an adrenal myelolipoma. Scattered hypodensities and\n hyperdensities are seen within both kidneys likely representing a combination\n of simple and hyperdense cyst. An exophytic lesion arising from the lower\n pole of the left kidney measures 3 x 2.4 cm, measures higher attenuation than\n simple fluid and demonstrates several punctate calcifications. No mesenteric\n or retroperitoneal adenopathy is present. The stomach and small bowel are\n relatively decompressed. Small bowel wall thickening is secondary to ascites.\n\n PELVIS: The remainder of the bowel is decompressed. A rectal tube has been\n inserted. The bladder is collapsed around a Foley catheter. Ascites\n continues into the pelvis and diffuse anasarca seen within the subcutaneous\n tissues.\n\n BONE WINDOWS: There are no concerning lytic or sclerotic lesions. Confluent\n anterior syndesmophytes in the thoracic spine are consistent with DISH.\n\n IMPRESSION:\n 1. Findings consistent with necrotizing pancreatitis, with continued\n extensive peripancreatic inflammatory change. A stable loculated fluid\n collection about gastric greater curvature is suggestive of developing\n pseudocyst though does not appear organized at the present time.\n 2. Stable small right and moderate left pleural effusions and bibasilar\n atelectasis. Moderate ascites is unchanged.\n 3. Complex exophytic left lower pole renal lesion which should be evaluated\n with MRI when patient is clinically stable.\n 4. Incidentally noted right adrenal myelolipoma which can be evaluated at\n time of follow up MRI or within 6 months.\n 5. Small left lower lobe subpleural nodule which should be evaluated on\n follow-up imaging.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-30 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 1204528,
"text": " 11:56 AM\n RENAL U.S. PORT Clip # \n Reason: hydronephrosis?\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with wrosening renal failure. Has a foley from OSH that looked\n obstruced when pulled. Now putting out sufficient urine.\n REASON FOR THIS EXAMINATION:\n hydronephrosis?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 74-year-old man with worsening renal failure, evaluate for\n hydronephrosis.\n\n COMPARISON: No previous renal ultrasound for comparison.\n\n Visualization of the right kidney is very limited due to the patient's body\n habitus and the patient's inability to turn. The right kidney measures about\n 10.3 cm in length and demonstrates no hydronephrosis. No gross renal mass can\n be visualized but imaging is extremely limited.\n\n Despite diligent effort imaging the left flank and the left pelvic area, the\n left kidney could not be visualized (although is known to be located in the\n left renal fossa from preceding chest CT).\n\n A trace of ascites is noted in the abdomen.\n\n IMPRESSION:\n 1. No hydronephrosis seen in the right kidney. The left kidney could not be\n visualized. Note is made that this is an extremely limited ultrasound due to\n the patient's body habitus and the patient's inability to position for the\n examination.\n\n 2. Trace of ascites. The marked peripancreatic stranding that was seen on\n prior CT was not evaluated with ultrasound.\n\n Abdominal CT could be obtained for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-10-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1205151,
"text": " 9:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval changes\n Admitting Diagnosis: PANCREATITIS;ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with hypoxia, eval interval changes\n REASON FOR THIS EXAMINATION:\n eval interval changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History hypoxia, evaluate interval changes.\n\n COMPARISON: .\n\n FINDINGS: Single AP view of the chest is unchanged from prior. Lung volumes\n remain low. The right IJ catheter tip terminates in the low SVC. An OG tube\n is seen extending over the esophagus and below the GE junction. Tracheostomy\n noted. Moderate left pleural effusion and bibasilar atelectasis are\n unchanged.\n\n IMPRESSION:\n No change from prior.\n\n"
},
{
"category": "ECG",
"chartdate": "2163-10-07 00:00:00.000",
"description": "Report",
"row_id": 249505,
"text": "Supraventricular tachycardia. Diffuse non-specific ST-T wave abnormalities.\nCompared to the previous tracing of supraventricular tachycardia is\nnew.\n\n"
},
{
"category": "ECG",
"chartdate": "2163-10-03 00:00:00.000",
"description": "Report",
"row_id": 249506,
"text": "Sinus rhythm at upper limits of normal rate. Minor T wave abnormalities.\nSince the previous tracing of no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2163-09-30 00:00:00.000",
"description": "Report",
"row_id": 249507,
"text": "Artifact is present. Sinus rhythm. Low voltage in the precordial leads.\nNo previous tracing available for comparison.\n\n"
}
] |
24,990 | 127,853 | The patient was admitted on and underwent cardiac cath which revealed: LMCA with distal taper and moderate calcification, diffuse disease and distal 90% lesion of the LAD, moderate disease of D1, 90% LCX lesion, and RCA has 90% lesion with heavy calcification. He had an echo which showed an EF of 25-30%, LAE, trace MR and trace TR. On he had a L carotid stent placed by Dr. and tolerated the procedure well. Dr. was consulted and on he had a CABGx3(LIMA->Diag, SVG->LAD and PDA). The cross clamp time was 58 mins., total bypass time was 71 mins. He tolerated the procedure well and was transferred to the CSRU on Epi., Neo., and Propofol in stable condition. He was extubated on POD#1 and also had his chest tubes d/c'd. He had high glucoses post op which stabilized and was transferred to the floor on POD#5. He passed a swallowing evaluation. He progressed slowly and was discharged to rehab in stable condition on POD#6. | There is predominantly hypoechoic plaque at the origin of the right ICA. REASON FOR THIS EXAMINATION: r/o PTX/Effusion FINAL REPORT PORTABLE CHEST OF COMPARISON: . IMPRESSION: AP chest compared to : ET tube and nasogastric tube, left pleural tube and Swan-Ganz catheter, and midline s have all been removed. FINDINGS: The greater saphenous veins are patent bilaterally. IMPRESSION: AP chest compared to and 26: Tip of a new right internal jugular line projects low over the right atrium, approximately 10 cm beyond the superior cavoatrial junction. GOOD DIURESIS AFTER IVP LASIX.ENDO: BS MONITORED PER PT SS. ABD DISTENDED, NT. EXTREMITIES W/D. Midline sternotomy wires and vertical staple line noted. Endotracheal tube terminates about 3 cm above the carina, Swan-Ganz catheter terminates in the proximal right pulmonary artery, and mediastinal s and left-sided chest tube are in place as well as a nasogastric tube, which terminates below the diaphragm. Right internal jugular vein line in right atrium, which should be retracted. Bilateral small posteriorly loculated pleural effusions. AFEBRILE.RESP: BILATERAL LSCTA. There has been interval median sternotomy and coronary artery bypass surgery. Vascular engorgement, perihilar haziness, and interstitial opacities are attributed to edema from either fluid overload or CHF. Peak systolic velocities on the right are 163, 52 and 177 cm per second for the ICA, CCA, and ECA respectively. 500-750.GI/GU: TOLERATES CLR LIQS, PO MEDS. Please note that though not provided within the history, this patient is apparently status post a left carotid stent placement. The ICA to CCA ratio is 3.1 on the right and less than 1 on the left. Patchy atelectasis is present in the retrocardiac portions of both lower lobes. IMPRESSION: Findings as stated above which indicate approximately 60-69% right ICA stenosis and no significant left ICA stenosis. +BS. +PERRL. +FLATUS. BP 110S-120S, MAPS >60-BP UP TO 140S WHEN AGITATED. However, bilateral posteriorly loculated pleural effusions are seen, small in size. HISTORY: Central line placed. MONITOR NEURO STATUS, REORIENT PRN. USES I.S. Chest tube discontinued. The heart, mediastinal and hilar contours are normal. There is antegrade flow involving both vertebral arteries. FOLEY TO GRAVITY-ADEQUATE HUO, CLR YELLOW. IMPRESSION: 1. CHEST, TWO VIEWS: Cardiac shadow has improved in size. Neuro: A&Ox3; MAE's, followed commands consistently; voiceed out needs; PERRL 3mmCV: Afebril; SR 80's; SBP dips to 80;s after AM lopressor, improved with putting pt flat in bed to 90's, AM hct 22.9, decreased from 24 in AM lab, 2 units PRBC's given per Dr , SBP improved to 100's-110's with transfusion; eaily palpable pulses x4; +3 edema on LE bilat, RLE more swollen than L, skin cool to touch, old fem a line site softResp: Lung sound clear, RA sat 94-97%; IS to ~500GI: Abd soft, +bowel sound; tolerating dietGU: Foley draining clear yellow urine, QSInteg: see carevue for detailsEndo: Cover per sliding scalePain: c/o discomfort in back when in chair, resolved with repositionSocial: Family in for visitPlan: monitor hemodynamics, resp status & labs; recheck hct post transfusion; pulm toilet; transfer to 2 when appropriate CXR done.GI/GU: Abd softly distended. PA aware of plt 90s, pt received plavix this am in CCU per anesthesia.Resp: LS clear- coarse. Trivial MR.TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Will recheck k.Resp: Lungs cl. + pitting edema to BLE. restart clonazapam. ?Restart depakote. L groin cd&I, pulses dopp. MAE but with 2-3+ edema-stiffCV: 95-100's SR-ST with occ couplets noted. D/c IVF after liter completes. Titrate neo as needed. Denies nausea or flatus.Endo: Restarted lantus at 1/2 preop dose-17u at hs. creat 1.4- baseline 1.3- u/o adeq with lasix . +hypoactive bs. Epi gtt at 0.03mcg/kg/min as ordered. PATIENT/TEST INFORMATION:Indication: Intra-op TEE for CABGStatus: InpatientDate/Time: at 09:41Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement. Creat 1.3.GI: Abd obese, slightly distended this am. Wean vent to extubate as pt tolerates. CXR for line placement with air in stomach. SBP labile, see carevue. Monitor resp. SVO2 >60, SVO2 dropped 55-60 after reversals given, PA aware fluid bolus given. (takes in eve pre op)Skin: Old draingage to chest dsg, d+i. To CSRU on epi, neo, propofol gtts. Cough fair to strong with prompting-minimal secretions.GU: Foley with uo 13-60cc/hr. Occassional sl disorientation.P: Continue antipyschotic meds as ordered. NaHCO3/mucomyst as ordered. On Risperidol, Clonopin started. See carevue for vent changes and abgs. See admission hx for details.Neuro: Received pt sedated on propofol. A left-to-right shunt across the interatrialseptum is seen at rest.2. CT/MT DSD-DI. Left ace d+i. Trace aortic regurgitation is seen.6. There is moderate global rightventricular free wall hypokinesis.4. Perrla.CV: Received async. Pt has glaucoma-needs eye gtts restarted. Restarted on depakote as well as risperidone and klonipin. Sinus rhythm with PVCsLeft axis deviationRBBB with left anterior fascicular blockNo previous tracing available for comparison left carotid stent placement, in CCU after stent placement. Diuresed fairly after lasix 20mg IV.GI: Abd obese,softly distended with hypo BS. On and off neo gtt. K 5.7 Lasix given iv x2. Marked left axis deviation.Right bundle-branch block with left anterior fascicular block. Trivial mitral regurgitation is seen.POST-BYPASS: For the post-bypass study, the patient was receiving epinephrinevasoactive infusions including phenylephrine1. Normal ascending aorta diameter. Reversed per protocol. CT w/ small amts of sang, drainage.GI/GU: Abd obese absent BS. Simple atheroma in descending aorta.AORTIC VALVE: No AS. Creat 1.4. Follow up c labs, Mucomyst x 1 dose. Mildly dilated LV cavity. palp pedal pulses--very diff to feel- + with doppler.resp: bs clear--dim in bases, this afternoon-pt sounded more "wheezy"- crackles noted bilat-ptgiven addtional dose of lasix with improvement.gi: abd distended, bs present yet infreq. On oral amiodarone and lopressor. Occassional wheezes noted with activity. Left-to-right shunt across the interatrialseptum at rest.LEFT VENTRICLE: Normal LV wall thickness. inc PM lantas-alter sliding scale.glu up to 170's today--tx with some iv bolus and sc doses--last 2 levels 107-126.neuro: pt lethargic, responds to commands, aware of person and place- needed reinforcement with time of day. | 26 | [
{
"category": "Radiology",
"chartdate": "2105-06-29 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 962066,
"text": " 7:01 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: HYPERTENSION;CORONARY ARTERY DISEASE;PERIPHERAL VASCULAR DISEASE;CHRONIC RENAL INSUFFICIENCY\\CARDIAC CATH/SDA\n Admitting Diagnosis: HYPERTENSION;CORONARY ARTERY DISEASE;PERIPHERAL VASCULAR DISEASE;CHRONIC RENAL INSUFFICIENCY\\CARDIAC CATH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with 3 vessel CAD, pre op for CABG\n REASON FOR THIS EXAMINATION:\n r/o pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 63-year-old man with three-vessel coronary artery disease, pre-\n operative chest x-ray.\n\n The heart, mediastinal and hilar contours are normal. The lungs are clear. No\n pleural effusion or pneumothorax is noted. Severe degenerative changes of\n thoracic vertebrae are noted.\n\n IMPRESSION: Unremarkable chest radiograph with no acute cardio-pulmonary\n process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-01 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 962353,
"text": " 3:09 PM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: vein mapping for CABG\n Admitting Diagnosis: HYPERTENSION;CORONARY ARTERY DISEASE;PERIPHERAL VASCULAR DISEASE;CHRONIC RENAL INSUFFICIENCY\\CARDIAC CATH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with 3VD, needs bilateral LE vein mapping in prep for cardiac\n bypass\n REASON FOR THIS EXAMINATION:\n vein mapping for CABG\n ______________________________________________________________________________\n FINAL REPORT\n VENOUS STUDY\n\n HISTORY: Vein mapping prior to cardiac bypass.\n\n FINDINGS: The greater saphenous veins are patent bilaterally. Please see\n digitized images on PACS for formal sequential measurements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-01 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 962279,
"text": " 10:43 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: Pls evaluate carotid arteries\n Admitting Diagnosis: HYPERTENSION;CORONARY ARTERY DISEASE;PERIPHERAL VASCULAR DISEASE;CHRONIC RENAL INSUFFICIENCY\\CARDIAC CATH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with bilateral bruit\n\n REASON FOR THIS EXAMINATION:\n Pls evaluate carotid arteries\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bilateral carotid bruit.\n\n FINDINGS: No prior studies for comparison. There is heterogeneous calcific\n plaque scattered throughout the left ICA and within the left ECA. There is\n predominantly hypoechoic plaque at the origin of the right ICA. Peak systolic\n velocities on the right are 163, 52 and 177 cm per second for the ICA, CCA,\n and ECA respectively. Similar values on the left are 85, 145 and 121 cm per\n second. The ICA to CCA ratio is 3.1 on the right and less than 1 on the left.\n There is antegrade flow involving both vertebral arteries.\n\n IMPRESSION: Findings as stated above which indicate approximately 60-69%\n right ICA stenosis and no significant left ICA stenosis. Please note that\n though not provided within the history, this patient is apparently status post\n a left carotid stent placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962770,
"text": " 1:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CT d/c'd R/O pneumo\n Admitting Diagnosis: HYPERTENSION;CORONARY ARTERY DISEASE;PERIPHERAL VASCULAR DISEASE;CHRONIC RENAL INSUFFICIENCY\\CARDIAC CATH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CAD s/p CABG x 3.\n REASON FOR THIS EXAMINATION:\n CT d/c'd R/O pneumo\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:47 P.M., \n\n HISTORY: Coronary artery disease status post CABG. Chest tube discontinued.\n\n IMPRESSION: AP chest compared to :\n\n ET tube and nasogastric tube, left pleural tube and Swan-Ganz catheter, and\n midline s have all been removed. Low lung volumes are stable. Some\n widening of the cardiomediastinal silhouette and pulmonary vascular\n engorgement suggest volume overload. There is also new severe gaseous\n distension of the stomach.\n\n Dr. was paged to report these findings at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962792,
"text": " 6:14 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Trauma line changed over to TLCLCheck placement\n Admitting Diagnosis: HYPERTENSION;CORONARY ARTERY DISEASE;PERIPHERAL VASCULAR DISEASE;CHRONIC RENAL INSUFFICIENCY\\CARDIAC CATH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CAD s/p CABG x 3.\n\n REASON FOR THIS EXAMINATION:\n Trauma line changed over to TLCLCheck placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:13 P.M. .\n\n HISTORY: Central line placed.\n\n IMPRESSION: AP chest compared to and 26:\n\n Tip of a new right internal jugular line projects low over the right atrium,\n approximately 10 cm beyond the superior cavoatrial junction. Severe gaseous\n distention of the stomach has not improved. Heart is top normal size. Given\n the severely low lung volumes, lungs are grossly clear and the postoperative\n caliber of the mediastinum is unremarkable. There is no pleural effusion or\n pneumothorax.\n\n Findings were discussed with Dr. at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-08 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 963213,
"text": " 11:40 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: HYPERTENSION;CORONARY ARTERY DISEASE;PERIPHERAL VASCULAR DISEASE;CHRONIC RENAL INSUFFICIENCY\\CARDIAC CATH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man s/po CABG\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CABG, effusion. Follow-up.\n\n CHEST, TWO VIEWS: Cardiac shadow has improved in size. Lung fields appear\n clear. However, bilateral posteriorly loculated pleural effusions are seen,\n small in size. Right internal jugular vein line is again identified in the\n right atrium, and should be retracted at least 5 cm to be at the cavoatrial\n junction. Midline sternotomy wires and vertical staple line noted.\n\n IMPRESSION:\n 1. Bilateral small posteriorly loculated pleural effusions.\n 2. Right internal jugular vein line in right atrium, which should be\n retracted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 962626,
"text": " 11:34 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: HYPERTENSION;CORONARY ARTERY DISEASE;PERIPHERAL VASCULAR DISEASE;CHRONIC RENAL INSUFFICIENCY\\CARDIAC CATH/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with CAD s/p CABG x 3. Please at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Status post coronary artery bypass surgery.\n\n There has been interval median sternotomy and coronary artery bypass surgery.\n Endotracheal tube terminates about 3 cm above the carina, Swan-Ganz catheter\n terminates in the proximal right pulmonary artery, and mediastinal s and\n left-sided chest tube are in place as well as a nasogastric tube, which\n terminates below the diaphragm.\n\n Cardiac and mediastinal contours are difficult to assess due to patient\n rotation. Vascular engorgement, perihilar haziness, and interstitial\n opacities are attributed to edema from either fluid overload or CHF. Patchy\n atelectasis is present in the retrocardiac portions of both lower lobes. No\n pneumothorax is identified on this supine view.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-06 00:00:00.000",
"description": "Report",
"row_id": 1588158,
"text": "Neuro: A&Ox3; MAE's, followed commands consistently; voiceed out needs; PERRL 3mm\n\nCV: Afebril; SR 80's; SBP dips to 80;s after AM lopressor, improved with putting pt flat in bed to 90's, AM hct 22.9, decreased from 24 in AM lab, 2 units PRBC's given per Dr , SBP improved to 100's-110's with transfusion; eaily palpable pulses x4; +3 edema on LE bilat, RLE more swollen than L, skin cool to touch, old fem a line site soft\n\nResp: Lung sound clear, RA sat 94-97%; IS to ~500\n\nGI: Abd soft, +bowel sound; tolerating diet\n\nGU: Foley draining clear yellow urine, QS\n\nInteg: see carevue for details\n\nEndo: Cover per sliding scale\n\nPain: c/o discomfort in back when in chair, resolved with reposition\n\nSocial: Family in for visit\n\nPlan: monitor hemodynamics, resp status & labs; recheck hct post transfusion; pulm toilet; transfer to 2 when appropriate\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-06 00:00:00.000",
"description": "Report",
"row_id": 1588159,
"text": "1900\npost transfusion hct sent, awaiting result\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-07 00:00:00.000",
"description": "Report",
"row_id": 1588160,
"text": "NEURO: PT A&OX3 COOPERATIVE, MAES, FOLLOWING COMMANDS FIRST HALF OF SHIFT. DENIES PAIN. +PERRL. PT THEN SUDDENLY BECAME AGITATED OVERNOC, YELLING OUT, INSISTS HE BE TAKEN TO . PT BELIEVES HE'S BEING HELD AGAINST HIS WILL AT A \"GAS STATION\" AND DEMANDS TO BE RELEASED. PT WOULD NOT ACCEPT EXPLANATIONS WHEN REASSURED OF DATE/TIME & PLACE, BECAME INCREASINGLY AGITATED DURING ANY ATTEMPT TO REORIENT-MD AWARE, IV HALDOL ORDERED X1.\n\nCV: SR 80S-90S, BRIEF ST DURING AGITATED PERIOD. NO ECTOPY. LYTES REPLETED. EPICARDIAL WIRES SECURED. BP 110S-120S, MAPS >60-BP UP TO 140S WHEN AGITATED. WEAK BUT PALPABLE PEDAL PULSES. EXTREMITIES W/D. AFEBRILE.\n\nRESP: BILATERAL LSCTA. O2SATS >96% ON 1L NC (PER PT . SATS REMAIN >96% WHEN NC REMOVED. RESP RATE 10S-20S. NO C/O SOB. COUGHING & RAISING SM AMTS THK WHITE SECRETIONS. USES I.S. 500-750.\n\nGI/GU: TOLERATES CLR LIQS, PO MEDS. NAS/ DIET TOLERATED WELL ON DAYS. +BS. NO C/O NAUSEA. ABD DISTENDED, NT. +FLATUS. NO BM. FOLEY TO GRAVITY-ADEQUATE HUO, CLR YELLOW. GOOD DIURESIS AFTER IVP LASIX.\n\nENDO: BS MONITORED PER PT SS. LANTUS @ HS GIVEN.\n\nSOCIAL: NO CALLS FROM FAMILY OVERNOC.\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS, LABS. PULM TOILET. MONITOR NEURO STATUS, REORIENT PRN. INCREASE ACTIVITY AS TOLERATED. TRANSFER TO 2.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-06 00:00:00.000",
"description": "Report",
"row_id": 1588155,
"text": "neuro: awake alert confused at times but does re-direct- more alert as night progressed- all meds given\nresp: enc to cdb- able to raise sputum- is still poor does not follow directions well with it- lsc to dim- sats good on 1ln/c- better since he started coughing-\ncv: nsr no ectopy- pulses good- lopressor held for b/p being low\ngi/gu: abd distended but bs present denies any discomfort- foley to gravity- uo good\nendo: hs dose of lantus increased no coverage given through shift\nplan: - cont plan of care\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-06 00:00:00.000",
"description": "Report",
"row_id": 1588156,
"text": "K: PT K THIS AM, CREAT 1.3--PT GIVEN LASIX 20MG WITH MOD DIURESIS--\nA: KCL 20 MEQ GIVEN IVPB\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-06 00:00:00.000",
"description": "Report",
"row_id": 1588157,
"text": "hypotension\nD: pt dropped sbp 70's/ post po lopressor-\nA: pt placed flat\nR: sbp 80's, pt hr 70's sr with 100% sat on 1L NP.\nA: pt given 250cc NS, Ho Aware\nR: sbp up to 90's/\nalso spoke with Ho concerning lopressor dose to 12.5 mg\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-05 00:00:00.000",
"description": "Report",
"row_id": 1588153,
"text": "NPN: S/P CABG X3 \n\nNeuro: Alert but sleeping off/on for @ 1 hr periods at time overnight. Much less anxious and more cooperative tonight. Follows commands. Oriented to hospital,surgery and self. Cont with difficulty with time of day and passing time but much improved. Occassionally calling out and rambling story-? dreaming. Restarted on depakote as well as risperidone and klonipin. MAE but with 2-3+ edema-stiff\nCV: 95-100's SR-ST with occ couplets noted. On oral amiodarone and lopressor. Stable BP 100-130's with ^ 140-150's with agitation. Ca repleted. K remains 4.8. Pedal pulses by doppler. Skin warm and dry.\nHct 24.2 this am.\nID: Tmax 99.5 orally. Cont on postop Vanco. WBC-9.6.\nResp: Lungs slightly dim in bases otherwise CTA. Occassional wheezes noted with activity. IS to 100cc only. Cough fair-prod small amts clear secretions. Sats 98-100%-weaned to 2l nc.\nGU: Foley to gd. UO>45cc/hr. Creat 1.4. Diuresed fairly after lasix 20mg IV.\nGI: Abd obese,softly distended with hypo BS. CXR for line placement with air in stomach. Metaclopromide 5mg IV given X2. Tolerating clears. Denies nausea or flatus.\nEndo: Restarted lantus at 1/2 preop dose-17u at hs. Glucoses 198-172-covered per sliding scale with regular insulin.\nComfort: Percocet 1 q 4 hours with good effect. C/o incisional chest pain with coughing and back pain.\nActivity: Turned side to side in bed. Remains on bedrest r/t R fem aline.\nIncisions: Sternum and CT with DSD-old drainage -D/I. L leg with ace wrap and multipodus boot.\nA: Stable -tolerating oral meds, good oxygenation. Occassional sl disorientation.\nP: Continue antipyschotic meds as ordered. Increase lopressor, replete lytes as needed. Discuss for ^ lasix dose for diuresis. DC R fem aline and get patient OOB to chair. Possible transfer to 2.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-05 00:00:00.000",
"description": "Report",
"row_id": 1588154,
"text": "update\nD: pt POD #2 from pt delined-presently has a triple lumen RIJ due to poor access. fem aline d/c today- pt lethargic- responses to commands, mae--weak- pt oob to chair- required to get back to bed. pt napping most of day--does wake when stimulated--keeps eyes closed most of the time. hct 24 this am- tx 1 PC hct up to 26. am lasix given with blood- pt more wheezy in afternoon, crackles bibasilar- pt given addtional lasix 20mg with improvement.\n\nPlan: minimize all narcotics or sedation--? hold clonazepam tonight.\nencourage DB&C- ?? transfer to floor in am--\n\nglu control must be adjusted-? inc PM lantas-alter sliding scale.\nglu up to 170's today--tx with some iv bolus and sc doses--last 2 levels 107-126.\n\nneuro: pt lethargic, responds to commands, aware of person and place- needed reinforcement with time of day. mae- weak. pupils equal-\npt needed asssitance with eating and required to get back into bed.\ncardiac: pt in nsr-80's sbp 99-105/40- did not inc lopressor today.\nextremtiies warm yet pale. palp pedal pulses--very diff to feel- + with doppler.\nresp: bs clear--dim in bases, this afternoon-pt sounded more \"wheezy\"- crackles noted bilat-ptgiven addtional dose of lasix with improvement.\ngi: abd distended, bs present yet infreq. pt tol po's well in small amts. ppi cont.\ngu: foley patent draining cl yellow urine. creat 1.4- baseline 1.3- u/o adeq with lasix .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-04 00:00:00.000",
"description": "Report",
"row_id": 1588152,
"text": "POD 1 cabg x3 Day 4 left carotid stent\n\nNeuro: Lethargic \"exhausted\" til ~2pm, then finally fell asleep (did not sleep last night). Knows he is at \"\" and knows \"\", still disoriented to time of day. Also rambles on about family/friends, difficult understand ends of sentences. Speech starts out loud and clear but tapers off, getting soft and difficult to understand. C/O neck pain , percocet given 1po x2 with little effect. Bipolar. On Risperidol, Clonopin started. Depakote not restarted yet. Pt to stay in bed per Dr d/t rt fem aline.\n\nCV: ST low 100's to SR 90 with lopressor 25mg po. PVC's. Amio gtt changed to po. SBP 100-130's. Aline rt groin. CO >4.5 CI >2.16 Swan d/c'd. RIJ cordis to be changed over to tlcl later today (poor access per iv team). K 5.7 Lasix given iv x2. Will recheck k.\n\nResp: Lungs cl. Using I/S to 250cc. Sats 100% on 2L nc.\nCT's pulled. CXR done.\n\nGI/GU: Abd softly distended. +hypoactive bs. Tolerating jello. Diet advanced but to ground (not many teeth, pt states cannot afford dentures). Diuresing with lasix via foley.\n\nEndo: BS decreasing on insulin gtt. Now @1 unit/hr with BS 102.\nTo start Lantus tomorrrow per Dr . (takes in eve pre op)\n\nSkin: Old draingage to chest dsg, d+i. Left ace d+i. Multipodus boot applied to left foot per Podiatry note for heel protection. Heel looks wnl. See flowsheet.\n\nSocial: no calls so far this shift.\n\nPlan: Change cordis to tlcl. Cont to monitor hemodynamics/resp status. Monitor K and bs, +other labs, treat prn. ?Restart depakote. Pain control. OOB tomorrow after d/c fem aline.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-30 00:00:00.000",
"description": "Report",
"row_id": 1588146,
"text": "CCU Nursing Admission Note 1530-1900\nAddendum: SBP in left arm 30-40 points lower than right arm. Cardiology fellow aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-30 00:00:00.000",
"description": "Report",
"row_id": 1588147,
"text": "CCU Nursing Admission Note 1530-1900\nSee FHPA for PMH and HPI. Briefly pt is a 63 yo male admitted to CCU from cath lab following stent placement to L internal carotid artery c/b hypotension.\n\nO: see CCU flow sheet for complete objective data\n\nCV: HR 77-90 NSR with occ PVC's. BP 101-121/50-60's by NBP, 15-30 points > by a-line. Neo @ 0.23 mcg/kg/min titrated to keep SBP >120, but turned to off shortly after admission d/t adequate BP. L femoral arterial sheath pulled @ 1700. Fellow informed of discrepancy between a-line and NBP--to titrate neo to keep SBP >100 by NBP (neo continues to be off). Left groin site clean. Old cath site (R groin), without bleeding. Pulses dopplerable--DP easily, PT faintly dopplerable bilaterally. Feet warm, deep pink color. Able to wiggle toes. Pt instructed on activity limitations post arterial sheath pull. Plan for CABG ? Friday.\n\nNeuro: no pronator drift, hand grasps equal. Pupils 4mm, equal, briskly reactive to light. Normal smile, normal shoulder shrugs, tongue midline. Normal strength in legs. Speech normal. Talks incessantly. Bed exit alarm turned to on d/t history of previous fall.\n\nGU: unable to get condom cath to stay on pt. Incont of urine. Pt. refuses foley catheter. Attempting to use urinal. Receiving NaHCO3 gtt as ordered, to be followed by 1/2 NS X 1500cc. Also needs 2 more doses of mucomyst.\n\nGI: Good appetite. Abdomen obese, +BS. No sliding scale insulin coverage needed.\n\nSkin: scabbed area on left knee and right elbow. States Left knee scab is d/t previous fall.\n\nAccess: 1 PIV, have asked IV team to attempt to place second IV line in case neo is needed.\n\nSocial: Pt. has called brother (HCP) to inform him of current status.\n\nA: BP within goal parameter off of neo. No neuro deficits by exam.\n\nP: continue to monitor BP/HR. Titrate neo as needed. Monitor neuro exam. Follow groin, distal pulses. NaHCO3/mucomyst as ordered. Pre-op teaching for CABG.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-01 00:00:00.000",
"description": "Report",
"row_id": 1588148,
"text": "Nursing Progress Note 1900-0700\nS: \"I need to stand up to pee and no I do not want a catheter put in!!\"\n\nO: Please see carevue for complete objective data.\n\nCV: HR 60-80's, NSR, ocas PVC's. SBP ranged from 80's when sleeping to 120's. On lopressor XL, no need for neo gtt. L groin cd&I, pulses dopp. Undergoing w/u for CABG-?poss friday .\n\nResp: Sats 99-100 on RA. Lungs clr, no c/o cough or SOB.\n\nGI/GU/Endo: Had small dinner, BS present, no stool. Incontinent of urine @ shift change, refused foley cath and unable to keep condom cath on. Voided 650cc via urinal when allowed to move post cath. Rec'd bicarb gtt for 6 hours after-now d/c'd. 1/2 NS @ 125cc/hr for 1500cc. BS in PM was 278, gave 4uH ins per ss and fixed dose of Lantus 34u.\n\nNeuro/Social: No apparent residual focal defects from CVA in past. See flowsheet for assessment. H/o bipolar disorder and anxiety, very particular about things, (ie food/drink) doing things his way, not compromising. Calm attitude most of evening, but became very agitated before bed, annoyed with equipment. Able to calm down after talking through it. OOB to stand to urinate, steady on feet. No calls or visitors.\n\nID/Access: Afebrile. IV team able to place second IV, 20G on Right side.\n\nA: 63 yo male s/p stent placement to L-ICA in prep for CABG, c/p hypotension in holding holding area, requiring transient transferred to CCU for monitoring.\n\nP: Cont to monitor hemodynamics, Neo if necessary for hypotension. Follow up c labs, Mucomyst x 1 dose. D/c IVF after liter completes. Emotionally support pt and family and keep updated on plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-01 00:00:00.000",
"description": "Report",
"row_id": 1588149,
"text": "SP L CAROTID STENT ,PRE OP FOR CABG FRIDAY OR NEXT WEEK.\n\nSR RARE PVS.SBP 114 IN BED TO SBP 81 WHEN OOB TO CHAIR .ASYMPTOMATIC .LOPRESSER ,RESPERIDOL,LASIX HELD AM FOR LOW BP .CHECK C HO FOR TONIGHTS DOSE .FLUID BOLLUS 250CC X 2 .CATH SITE C/D,NO BLEEDING.PEDALS BY DOPPLER .\n\nCRACKLES IN BASES ,SAT 99 RM AIR\n\nGOOD APPETITE.NO STOOL. NO SSI REQUIRED FOR BS\n\nSTANDS TO VOID,650CC\n\nPT IS BIPOLAR BUT COOPERATIVE.DENIES PAIN .\n\nPOSTURAL HYPOTENSION POST CAROTID STENT .\n\nINCREASE ACTIVITY AS TOL\nCHECK C HO CONCERNING MEDS ON HOLD FOR BP .\nMONITOR FLUID STATUS ,O2 SATS,BS POST FLUID BOLLUSES .\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-03 00:00:00.000",
"description": "Report",
"row_id": 1588150,
"text": "\nPt is a 63 year old male s/p cabg x3 lima-diag, svg-lad,svg-pda. left carotid stent placement, in CCU after stent placement. To CSRU on epi, neo, propofol gtts. AV paced via epicardial wires, underlying ventricular escape rhythm per anesthesia, received amio bolus, amio gtt. At 1700, underlying SR w/ BBB, occasional pvcs, PA assessed ekg. See admission hx for details.\n\nNeuro: Received pt sedated on propofol. Reversed per protocol. Pt following commands at 1715, squeezed bilat hands on command, wiggled toes on command. Nodding yes when asked if in pain, medicated w/ 2mg ivp morphine w/ effect. Perrla.\n\nCV: Received async. av paced via epicardial wires, underlying ventricular escape rhythm per anesthesia. DDD paced 100 (overriding own rhythm in 90s, see ekg taken at 1700. Pt own underlying at present time 85-90s SR w/ pvcs, BBB- PA aware. DDD paced at present time for hemodynamics, set as OR set pacer box, not checked d/t ectopy. SBP labile, see carevue. On and off neo gtt. Epi gtt at 0.03mcg/kg/min as ordered. CI 1.9-2.3, see carevue. PA aware of values. Multi fluid boluses for low CI increasing CI>2. SVO2 >60, SVO2 dropped 55-60 after reversals given, PA aware fluid bolus given. /18-20s. CVP 12-20, see carevue. + dopplerable pedal pulses. + pitting edema to BLE. PA aware of ACT 140, protamine 50mg iv as ordered. PA aware of plt 90s, pt received plavix this am in CCU per anesthesia.\n\nResp: LS clear- coarse. Suctioned for scant thick tan. Orally intubated, presently on CPAP 5peep/10PS RR 15-20s TV 500s FiO2 50%. See carevue for vent changes and abgs. CT w/ small amts of sang, drainage.\n\nGI/GU: Abd obese absent BS. Soft. OGT + placement draining small amts of bilious drainage. Foley draining adequate amt of clear yellow urine, see carevue.\n\nEndo: Gtt started per protocol.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Follow labs and treat as appropriate. Wean vent to extubate as pt tolerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-04 00:00:00.000",
"description": "Report",
"row_id": 1588151,
"text": "NPN: S/P CABG X3 \n\nNeuro: Alert and oriented X 2 most of time. Anxious then angry and demanding at times. Gets easily belligerent. Occassionally says something that makes you think he is confused but can tell you he is in hospital and had heart surgery. No concept of time of day or passing minutes. Follows commands but moving lower extremities minimally on own with lots of prompting. Very tight and stiff moving. Pt has glaucoma-needs eye gtts restarted. H/o Bipolar disorder-risperidol given.\nCV: Initially AV paced-changed to A demand set at 80 with intrinsic 100-110 ST without PVC's. Continues on amiodarone gtt at 0.5mg/min. Weaned off epi gtt with SVO2-71-60%. CI> 2.2. PAD 17-24. CVP 8-13. K 4.6-5.7. Pedal pulses by doppler-PT's difficult to find on L. L great toenail bluish colored. Tachycardia unresponsive to volume. R fem aline. cordis cont oozing small sanginous drainage.\nResp: Extubated without incident at 20pm to 50% OFT neb with good ABG's and sats>98%. CT's to suction-no airleak and minimal sang-serosang drainage. Cough fair to strong with prompting-minimal secretions.\nGU: Foley with uo 13-60cc/hr. Low uo treated with 500cc NS bolus. Creat 1.3.\nGI: Abd obese, slightly distended this am. Tolerating clears. Asking to eat/drink immediately after extubation. + belching. Denies nausea.\nPantoprazole given.\nEndo: On insulin gtt per CTS protocol. Off with drop to 55-Given 1/4 amp of D 50. See flowsheet.\nComfort: Medicated with Morphine 2-4 mg IV alternating with sc with some degree of comfort. Frequeuntly c/o pain and requesting medication.\nActivity: Bedrest. Turned side to side q 2 hours with max assit 2.\nIncisions: Sternum with old serosang drainage -DSD intact. CT/MT DSD-DI. L leg steristrips on lap sites groin,knee and ankle-Ace wrap changed.\nSkin: R elbow with black eschar surrounded by half dollar sized area of redness. R foot-nickel sized calloused yellow ulcer.\nA: Tolerating wean of epi with good CO/CI. Tachycardia.\nP: Bipolar disorder-resume preop meds-risperidol and depakote. ? restart clonazapam. Consider changing amiodarone to po, ^ K-continue to monitor,Follow creat. Pain management-change to percocet when tolerating po's. Poor peripheral access-? change to TL. Pulmonary hygiene.\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2105-07-03 00:00:00.000",
"description": "Report",
"row_id": 98878,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intra-op TEE for CABG\nStatus: Inpatient\nDate/Time: at 09:41\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous hypertrophy of the\ninteratrial septum. PFO is present. Left-to-right shunt across the interatrial\nseptum at rest.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Severe\nregional LV systolic dysfunction. Severely depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free wall\nhypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch.\nNormal descending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: No AS. Trace AR.\n\nMITRAL VALVE: No MS. Trivial MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. 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 The post-bypass study was performed while the patient was receiving\nvasoactive infusions (see Conclusions for listing of medications).\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is moderately dilated. A patent foramen ovale is present\nand surgeon was made aware. A left-to-right shunt across the interatrial\nseptum is seen at rest.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nis mildly dilated. There is severe regional left ventricular systolic\ndysfunction of the lateral, inferior and anterior apical walls and the\ninferior and lateral mid walls.. Overall left ventricular systolic function is\nseverely depressed.\n3. Right ventricular chamber size is normal. There is moderate global right\nventricular free wall hypokinesis.\n4. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta.\n5. There is no aortic valve stenosis. Trace aortic regurgitation is seen.\n6. Trivial mitral regurgitation is seen.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving epinephrine\nvasoactive infusions including phenylephrine\n1. Biventricular function is slightly improved.\n2. Aorta is intact post decannulation\n3. Other findings are unchanged\n\n\n"
},
{
"category": "ECG",
"chartdate": "2105-07-03 00:00:00.000",
"description": "Report",
"row_id": 279584,
"text": "Sinus rhythm. Premature ventricular contractions. Marked left axis deviation.\nRight bundle-branch block with left anterior fascicular block. Old inferior\nmyocardial infarction. QRS changes in leads V3-V4 - probably due to left\nventricular hypertrophy but consider anterior myocardial infarction. Low\nQRS voltages in precordial leads. Compared to the previous tracing of \nthere is more suggestion of inferior wall myocardial infarction.\n\n"
},
{
"category": "ECG",
"chartdate": "2105-07-07 00:00:00.000",
"description": "Report",
"row_id": 279585,
"text": "Sinus rhythm. Right bundle-branch block with left anterior fascicular block.\nST segment elevations in leads V2-V6, consider acute anterior myocardial\ninfarction. Compared to the previous tracing of the R wave is less\nprominent in lead II, ventricular premature beats are absent and ST segment\nelevation is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-29 00:00:00.000",
"description": "Report",
"row_id": 279586,
"text": "Sinus rhythm with PVCs\nLeft axis deviation\nRBBB with left anterior fascicular block\nNo previous tracing available for comparison\n\n"
}
] |
92,063 | 137,472 | FINDINGS: CTA HEAD: There is a less than 1 mm aneurysm versus infundibulum at the anterior communicating artery. TECHNIQUE: Non-contrast MDCT through the head with axial, coronal, sagittal reformations. The right ventricularcavity is mildly dilated with normal free wall contractility. There is mild symmetric leftventricular hypertrophy. There is moderate pulmonary artery systolichypertension. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion.Compared with the prior study (images reviewed) of , mitralregurgitation is now more prominent. Regionalleft ventricular wall motion is normal (although some views are suboptimal socannot exclude a small focal wall motion abnormality). At least moderate [2+]tricuspid regurgitation is seen. Moderate (2+) MR.TRICUSPID VALVE: Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is markedly dilated. [Intrinsic RV systolic function likely more depressed given the severity ofTR].AORTA: Normal aortic diameter at the sinus level. IMPRESSION: Tiny aneurysm versus infundibulum measuring less than 1 mm at the anterior communicating artery. Mildly dilated ascendingaorta.AORTIC VALVE: Mildly thickened aortic valve leaflets. Normal RV systolic function. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 63Weight (lb): 152BSA (m2): 1.72 m2BP (mm Hg): 128/62HR (bpm): 70Status: InpatientDate/Time: at 15:38Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Marked LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. The mitral valve leaflets are mildlythickened. Ventricles and sulci are mildly prominent and age appropriate. The mastoid air cells and middle ear cavities are well aerated. The ascending aorta is mildly dilated. Unchanged multilevel degenerative disease with mild grade 1 anterolisthesis of C5 on C6 and C7 on T1. Mild left periorbital soft tissue swelling. Slight anterolisthesis of C5 on C6 and C7 on T1 are likely unchanged from prior 10/. The left ventricular cavity size is normal. Multilevel degenerative changes are seen, most pronounced at C1-2 and C6-7 without canal narrowing. There is mild periventricular hypoattenuation consistent with sequelae of small vessel ischemic disease. Normal regional LVsystolic function. The aorticvalve leaflets are mildly thickened (?#). No resting LVOT gradient.RIGHT VENTRICLE: Mildly dilated RV cavity. The imaged paranasal sinuses and mastoid air cells are well aerated. Stable cardiomegaly. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is mild left periorbital soft tissue swelling without underlying fracture. COMPARISON: Head CT from . Normal LV cavity size. FINDINGS: Single AP portable view of the chest is obtained. Slight anterolisthesis of C5 on C6 and C7 on T1 are unchanged from the prior study. Minor calcifications of the cavernous intracranial carotid segments without evidence of a flow-limiting stenosis in the head or neck. COMPARISON: CT head . WET READ VERSION #1 FINAL REPORT NON-CONTRAST HEAD CT PERFORMED ON Comparison is made with a prior study from . FINDINGS: AP single view of the chest has been obtained with patient in sitting semi-upright position. Since the previous tracingof no significant change.TRACING #1 They comprise a right atrial appendage location, one electrode in the sinus portion of the right ventricle and third one entering the left coronary venous sinus and terminating in a location compatible with an obtuse marginal coronary vein. The electrodes are in similar position as on the preceding chest examination of . Theestimated right atrial pressure is 0-10mmHg. TECHNIQUE: MDCT images were acquired through the head without contrast. stroke or dissection or acute process. Increased IVC diameter (>2.1cm) with >55%decrease during respiration (estimated RA pressure (0-10mmHg).LEFT VENTRICLE: Mild symmetric LVH. A permanent pacer is present in left anterior axillary position, seen to be connected to three intracavitary electrodes. fracture, dislocation No contraindications for IV contrast WET READ: SHSf MON 3:00 PM 1. CLINICAL HISTORY: Found down, altered, seizure activity, on Coumadin, question ICH. The origin of vertebral arteries are patent. Cardiomegaly is stable. Overall leftventricular systolic function is normal (LVEF>55%). The right atrium is dilated. Appropriately positioned NG tube. COMPARISONS: CT C-spine, . ICH No contraindications for IV contrast WET READ: MXAk MON 3:27 PM No acute intracranial injury. WET READ VERSION #1 FINAL REPORT INDICATION: Found down, possible seizure, assess for fracture or dislocation. TECHNIQUE: MDCT-acquired axial images were obtained through the cervical spine without intravenous contrast. Bilateral pleural effusions account for the diffuse haze on the bases, blunting of the lateral pleural sinuses and obscuration of the diaphragmatic contours. Atrial fibrillation with ventricular paced rhythm. Atrial fibrillation with ventricular paced rhythm. FINDINGS: There is no acute fracture or subluxation. Pacer device and leads are unchanged. No acute fracture or subluxation 2. PA and lateral chest examination of , confirms by review the described electrode position. Bony calvarium appears intact. Motion degraded images were repeated to good effect. A focal hypodensity in the right internal capsule (2A:13) likely represents a chronic lacunar infarct. The imaged lung apices are clear. FINDINGS: No acute intracranial hemorrhage, CT evidence of a large vascular territory infarct, edema or mass effect is present. The ventricles and sulci are prominent, indicating cerebral atrophy. There is no aortic valve stenosis.Trace aortic regurgitation is seen. [Intrinsic rightventricular systolic function is likely more depressed given the severity oftricuspid regurgitation.] Observe that the patient has been extubated since the next preceding examination. WET READ VERSION #1 FINAL REPORT HISTORY: Altered mental status and seizure, intubated for airway protection ? | 9 | [
{
"category": "Radiology",
"chartdate": "2125-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1195878,
"text": " 2:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with altered ms,\n REASON FOR THIS EXAMINATION:\n post intubation\n ______________________________________________________________________________\n WET READ: SESHa MON 2:42 PM\n ETT at carina - please retract by at least 2-3 cm.\n NGT ok\n\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY PERFORMED ON :\n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: Altered mental status, post-intubation, assess tube\n position.\n\n FINDINGS: Single AP portable view of the chest is obtained. The endotracheal\n tube is seen with its tip at the level of the carina pointing towards the\n right main stem bronchus. Retraction by at least 2.5 cm is recommended. Low\n lung volumes limit evaluation. An NG tube courses into the left upper\n quadrant. Pacer device and leads are unchanged. Cardiomegaly is stable.\n Lungs appear clear.\n\n IMPRESSION: ET tube positioned at the carina and retraction by at least 2.5\n cm is recommended. Stable cardiomegaly. Appropriately positioned NG tube.\n Findings were posted and flagged to the ED dashboard at the time of this\n dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-07-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1196403,
"text": " 3:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulmonary edema\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with CHF, pulmonary HTN and seizures s/p recent extubation\n r/o PNA or pulm edema\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: 84-year-old female patient with CHF and pulmonary hypertension as\n well as seizures, status post recent extubation, evaluate for pneumonia or\n pulmonary edema.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. There is marked cardiac enlargement and the\n pulmonary vasculature appears congested with distended vessels and significant\n perivascular haze. Bilateral pleural effusions account for the diffuse haze\n on the bases, blunting of the lateral pleural sinuses and obscuration of the\n diaphragmatic contours. A permanent pacer is present in left anterior\n axillary position, seen to be connected to three intracavitary electrodes.\n They comprise a right atrial appendage location, one electrode in the sinus\n portion of the right ventricle and third one entering the left coronary venous\n sinus and terminating in a location compatible with an obtuse marginal\n coronary vein.\n\n The electrodes are in similar position as on the preceding chest examination\n of . PA and lateral chest examination of , confirms by\n review the described electrode position.\n\n IMPRESSION: Marked cardiomegaly in a patient with biventricular pacing,\n marked congestion with bilateral pleural effusions. The degree of CHF and\n pleural effusion has increased since the next preceding examination of , . Observe that the patient has been extubated since the next\n preceding examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-07-16 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1195880,
"text": " 2:23 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? fracture, dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with fall, loc, seizure\n REASON FOR THIS EXAMINATION:\n ? fracture, dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SHSf MON 3:00 PM\n 1. No acute fracture or subluxation\n 2. Multilevel dgenerative disease most pronounced at C6/7. Slight\n anterolisthesis of C5 on C6 and C7 on T1 are likely unchanged from prior\n 10/. In the setting of these findings if cord injury is suspected MRI can\n be obtained.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down, possible seizure, assess for fracture or dislocation.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the cervical\n spine without intravenous contrast. Coronal and sagittal reformations were\n prepared.\n\n COMPARISONS: CT C-spine, .\n\n FINDINGS: There is no acute fracture or subluxation. Slight anterolisthesis\n of C5 on C6 and C7 on T1 are unchanged from the prior study. Multilevel\n degenerative changes are seen, most pronounced at C1-2 and C6-7 without canal\n narrowing. Soft tissues of the neck are unremarkable. The imaged lung apices\n are clear.\n\n IMPRESSION:\n 1. No acute fracture or subluxation.\n 2. Unchanged multilevel degenerative disease with mild grade 1\n anterolisthesis of C5 on C6 and C7 on T1.\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-07-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1195975,
"text": " 10:03 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval change ie stroke\n Admitting Diagnosis: SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with transient episode of altered consciosness, weakness\n REASON FOR THIS EXAMINATION:\n eval for interval change ie stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf TUE 4:18 PM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with transient episode of altered consciousness\n and weakness, evaluate for interval change.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: MDCT images were acquired through the head without contrast.\n Motion degraded images were repeated to good effect.\n\n FINDINGS:\n\n No acute intracranial hemorrhage, CT evidence of a large vascular territory\n infarct, edema or mass effect is present. The ventricles and sulci are\n prominent, indicating cerebral atrophy. There is mild periventricular\n hypoattenuation consistent with sequelae of small vessel ischemic disease. A\n focal hypodensity in the right internal capsule (2A:13) likely represents a\n chronic lacunar infarct. The imaged paranasal sinuses and mastoid air cells\n are well aerated.\n\n IMPRESSION:\n\n No evidence of an acute intracranial process.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-07-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1195881,
"text": " 2:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with found down, altered, then seizure, on coumadin\n REASON FOR THIS EXAMINATION:\n ? ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MXAk MON 3:27 PM\n No acute intracranial injury.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT PERFORMED ON \n\n Comparison is made with a prior study from .\n\n CLINICAL HISTORY: Found down, altered, seizure activity, on Coumadin,\n question ICH.\n\n TECHNIQUE: Non-contrast MDCT through the head with axial, coronal, sagittal\n reformations. Motion artifact limits evaluation. Allowing for motion\n limitations, there is no acute intracranial hemorrhage, edema, shift of\n normally midline structures, or definite signs of acute major vascular\n territorial infarction. Ventricles and sulci are mildly prominent and age\n appropriate. Mucosal thickening is noted in the ethmoid sinuses. The mastoid\n air cells and middle ear cavities are well aerated. Bony calvarium appears\n intact. There is mild left periorbital soft tissue swelling without underlying\n fracture.\n\n IMPRESSION: No acute intracranial process. Mild left periorbital soft tissue\n swelling.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-07-16 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1195902,
"text": " 4:59 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ? dissection, aneurysm, stroke\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with altered mental status, then seizure, intubated for\n airway protection, concern for stroke\n REASON FOR THIS EXAMINATION:\n ? dissection, aneurysm, stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MXAk MON 7:22 PM\n No evidence of hemorrhage, acute disection, or thrombosis.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Altered mental status and seizure, intubated for airway protection ?\n stroke or dissection or acute process.\n\n TECHNIQUE: CTA head and neck with contrast including 3D post-processing for\n MIP reconstruction, volume rendering and curved reformations.\n\n COMPARISON: CT head .\n\n FINDINGS:\n\n CTA HEAD:\n\n There is a less than 1 mm aneurysm versus infundibulum at the anterior\n communicating artery. No other intracranial aneurysms are shown. There is no\n evidence of a flow-limiting stenosis.\n\n CTA NECK:\n\n The origin of arch vessels and vertebral arteries are patent without evidence\n of a flow-limiting stenosis. The origin of vertebral arteries are patent.\n\n IMPRESSION:\n\n Tiny aneurysm versus infundibulum measuring less than 1 mm at the anterior\n communicating artery. Minor calcifications of the cavernous intracranial\n carotid segments without evidence of a flow-limiting stenosis in the head or\n neck.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2125-07-17 00:00:00.000",
"description": "Report",
"row_id": 89441,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 63\nWeight (lb): 152\nBSA (m2): 1.72 m2\nBP (mm Hg): 128/62\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 15:38\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: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen\nin the RA and extending into the RV. Increased IVC diameter (>2.1cm) with >55%\ndecrease during respiration (estimated RA pressure (0-10mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n[Intrinsic RV systolic function likely more depressed given the severity of\nTR].\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is dilated. The\nestimated right atrial pressure is 0-10mmHg. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity size is normal. Regional\nleft ventricular wall motion is normal (although some views are suboptimal so\ncannot exclude a small focal wall motion abnormality). Overall left\nventricular systolic function is normal (LVEF>55%). The right ventricular\ncavity is mildly dilated with normal free wall contractility. [Intrinsic right\nventricular systolic function is likely more depressed given the severity of\ntricuspid regurgitation.] The ascending aorta is mildly dilated. The aortic\nvalve leaflets are mildly thickened (?#). There is no aortic valve stenosis.\nTrace aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Moderate (2+) mitral regurgitation is seen. At least moderate [2+]\ntricuspid regurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , mitral\nregurgitation is now more prominent. Estimated pulmonary artery systolic\npressure is now higher.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-07-16 00:00:00.000",
"description": "Report",
"row_id": 233088,
"text": "Atrial fibrillation with ventricular paced rhythm. Since the previous tracing\nof same date there is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-07-16 00:00:00.000",
"description": "Report",
"row_id": 233089,
"text": "Atrial fibrillation with ventricular paced rhythm. Since the previous tracing\nof no significant change.\nTRACING #1\n\n"
}
] |
|
257 | 179,006 | She was admitted to the Intensive Care Unit. She was monitored in the Intensive Care Unit. She had a repeat CAT scan which showed stable appearance of a left subdural hematoma. She also has a right subdural hematoma which was found to be stable as well. The patient was monitored in the Intensive Care Unit. Her blood pressure was kept under 150. She was restarted on her p.o. | DENIES NAUSEA.GU ADEQUATE U/O VIA FOLEY. Again seen are bilateral subdural hematomas adjacent to the frontal and parietal lobes, which appear unchanged in size in the interval. The previously described left occipital lobe resection appears unchanged. CT SCAN SHOWED BILATERAL SDH W/ SLIGHT L-R SHIFT, ?SOME OLD, SOME NEW. FINDINGS: Comparison is made with most recent prior noncontrast head CT dated . TECHNIQUE: Noncontrast CT of the head. TECHNIQUE: Non-contrast CT of the head. IMPRESSION: Stable appearance of the brain and subdural collections, compared with the previous examination of . REASON FOR THIS EXAMINATION: evaluate new v old SDH No contraindications for IV contrast WET READ: RKKR TUE 5:46 PM B/L SDH with mild L to R shift Old L occipital lobe resection Old lacunar infarcts FINAL REPORT INDICATION: Trauma. IMPRESSION: Stable appearance of the brain and subdural collections, compared to the previous study of . SON IS SPOKESPERSON.A: NEUROLOGICALLY STABLE S/P FALL.P: CONT TO MONITOR Q1HR NVS. REASON FOR THIS EXAMINATION: assess SDH No contraindications for IV contrast FINAL REPORT INDICATION: Status post fall with subdural hemorrhage, assess subdural hemorrhage. Pupils equal and reactive.CV: HR 60-70's SR no ectopy noted. CT SCAN SHOWED SDH, HIGH INR. Since the previous tracingof there are fewer atrial premature beats. Compared to the previoustracing of no diagnostic changes. Borderline P-R interval prolongation.Left ventricular hypertrophy. Sinus rhythm with atrial premature beats. Mild left-to-rightward shift. FINDINGS: Bilateral subdural collections are unchanged in size and configuration. BP 130/70.GI: NPO OVERNOC. Sinus rhythm with an atrial premature beat. First degree A-V conduction delay. REASON FOR THIS EXAMINATION: size of SDH No contraindications for IV contrast FINAL REPORT CT SCAN OF THE BRAIN: INDICATION: Follow-up subdural hematoma. Old lacunar infarctions, left greater than right, are appreciated within the internal capsules. TECHNIQUE: Axial non-contrast CT scans of the brain were obtained. STABLE HR 60'S-70'S NSR W/ APC'S. MAINTAIN NPO OVERNOC. HTN IN EW, STARTED LABETALOL GTT. Comparison is made to the previous study of . No new parenchymal attenuation abnormalities are seen. NO EVIDENCE OF BLEEDINGID: AFEBRILE.SKIN: SCATTERED OLD BRUISES. (SEE FHP FOR PMH)ROS:NEURO: A & O X3, MAE AND FOLLOWS COMMANDS. Bilateral moderate to large subdural hematomas. L EYE DROOP IS OLD FINDING BUT MORE EXAGGERATED RECENTLY.CV: HTN 160/80 AND RESTARTED LABETALOL NOW AT .5 MG/MIN. The imaged portions of the paranasal sinuses and mastoids are well aerated. NBP to be less than 130 systolic on IV lopressor and IV labetalol titrated as needed.Resp: Lungs clear NARD sats 96-98% on RAGU/GI: Foley with clear yellow urine. Neuro's remain unchanged. Sinus rhythm. SKIN INTACT.SH: PT LIVES W/ SONS. PT STATES SHE GOT UP W/OUT DIFFICULTY AND WENT BACK TO BED W/ C/O "FRONTAL PRESSURE BUT NO OTHER PROBLEMS". REPEAT CT SCAN IN AM. Abd soft npo no n/v.Heme: Received 2units FFP and Vit K for INR 1.6 rechecked INR 1.1.Skin: Grossly intact no breakdown noted.Social: Children home for the night.Plan: Repeat head CT today, monitor BP, monitor labs, cont to monitor and support. LABETOLOL PRN FOR BP CONTROL. IMPRESSION: 1. FINDINGS: There are bilateral subdural hematomas extending along both cerebral hemispheres with elements of serpiginous high density seen on the right, suggesting more recent blood products. Surgical defect with resection of the left occipital lobe. FOUND ON FLOOR BY SON IN AM ALERT AND ORIENTED. DENIES LOC. ARRIVED IN TSICU AT 10PM IN STABLE CONDITION. The acuity/ temporality of hemorrhage is difficult to assess without prior films for comparison. Patient is status post resection of her left occipital lobe with streak artifact emanating from this area related to metallic clips. The associated mass effect on the brain is stable. There is a mild left- to-rightward shift but likely overall greater mass effect than appreciated due to balance of forces of bilateral extraaxial collections. There is no change in the associated minimal mass effect. GIVEN VITAMIN K AND TRANSFERRED TO FOR FURTHER MANAGEMENT. PEARL. BROUGHT TO . Subdural hematoma on outside scan. There is continued extensive streak artifact associated with multiple metallic clips at the site of the craniotomy, which obscures soft tissue detail in this region. L eye remains closed, no change from admit. Bone windows show a craniotomy defect in the left occipital location. WIDOWED X 16YRS. No previous tracing available for comparison. There is no evidence of new hemorrhage. There is no evidence of new hemorrhage. This is obscuring a number of images in this area. Other features are aspreviously noted. 3. 2. 1:33 PM CT HEAD W/O CONTRAST Clip # Reason: ASSESS SDH.CONFUSION Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY MEDICAL CONDITION: 81 year old woman s/p fall with SDH. 4:15 PM CT HEAD W/O CONTRAST Clip # Reason: evaluate new v old SDH MEDICAL CONDITION: 81 year old woman s/p fall with ?SDH on OSH scan. | 8 | [
{
"category": "Radiology",
"chartdate": "2112-12-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 809914,
"text": " 8:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL, SIZE OF SDH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall with SDH.\n REASON FOR THIS EXAMINATION:\n size of SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN:\n\n INDICATION: Follow-up subdural hematoma.\n\n TECHNIQUE: Axial non-contrast CT scans of the brain were obtained.\n\n Comparison is made to the previous study of .\n\n FINDINGS: Bilateral subdural collections are unchanged in size and\n configuration. The associated mass effect on the brain is stable. No new\n parenchymal attenuation abnormalities are seen.\n\n There is no evidence of new hemorrhage.\n\n IMPRESSION: Stable appearance of the brain and subdural collections, compared\n to the previous study of .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-12-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 810061,
"text": " 1:33 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ASSESS SDH.CONFUSION\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall with SDH.\n\n REASON FOR THIS EXAMINATION:\n assess SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall with subdural hemorrhage, assess subdural\n hemorrhage.\n\n TECHNIQUE: Noncontrast CT of the head.\n\n FINDINGS: Comparison is made with most recent prior noncontrast head CT dated\n . Again seen are bilateral subdural hematomas adjacent to the\n frontal and parietal lobes, which appear unchanged in size in the interval.\n There is no evidence of new hemorrhage. There is no change in the associated\n minimal mass effect. The previously described left occipital lobe resection\n appears unchanged. There is continued extensive streak artifact associated\n with multiple metallic clips at the site of the craniotomy, which obscures\n soft tissue detail in this region.\n\n IMPRESSION: Stable appearance of the brain and subdural collections, compared\n with the previous examination of .\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-12-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 809858,
"text": " 4:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate new v old SDH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman s/p fall with ?SDH on OSH scan.\n REASON FOR THIS EXAMINATION:\n evaluate new v old SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RKKR TUE 5:46 PM\n B/L SDH with mild L to R shift\n Old L occipital lobe resection\n Old lacunar infarcts\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma. Subdural hematoma on outside scan.\n\n TECHNIQUE: Non-contrast CT of the head.\n\n FINDINGS: There are bilateral subdural hematomas extending along both\n cerebral hemispheres with elements of serpiginous high density seen on the\n right, suggesting more recent blood products. Comparison to outside scan\n would be helpful in determining evolution of hemorrhage. There is a mild left-\n to-rightward shift but likely overall greater mass effect than appreciated due\n to balance of forces of bilateral extraaxial collections.\n\n Old lacunar infarctions, left greater than right, are appreciated within the\n internal capsules. Patient is status post resection of her left occipital\n lobe with streak artifact emanating from this area related to metallic clips.\n This is obscuring a number of images in this area.\n\n Bone windows show a craniotomy defect in the left occipital location. The\n imaged portions of the paranasal sinuses and mastoids are well aerated.\n\n IMPRESSION:\n 1. Bilateral moderate to large subdural hematomas. The acuity/ temporality of\n hemorrhage is difficult to assess without prior films for comparison. Having\n these films for comparison would be helpful, if available.\n\n 2. Mild left-to-rightward shift.\n\n 3. Surgical defect with resection of the left occipital lobe.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-12-22 00:00:00.000",
"description": "Report",
"row_id": 196882,
"text": "Sinus rhythm. First degree A-V conduction delay. Compared to the previous\ntracing of no diagnostic changes.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-12-21 00:00:00.000",
"description": "Report",
"row_id": 196883,
"text": "Sinus rhythm with an atrial premature beat. Since the previous tracing\nof there are fewer atrial premature beats. Other features are as\npreviously noted.\n\n"
},
{
"category": "ECG",
"chartdate": "2112-12-20 00:00:00.000",
"description": "Report",
"row_id": 196884,
"text": "Sinus rhythm with atrial premature beats. Borderline P-R interval prolongation.\nLeft ventricular hypertrophy. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-12-20 00:00:00.000",
"description": "Report",
"row_id": 1263803,
"text": "TRAUMA SICU NSG ADMIT NOTE\nO: 81 Y/O FEMALE WHO APPARENTLY FELL 5 DAYS AGO AT HOME, UNWITNESSED. PT STATES SHE GOT UP W/OUT DIFFICULTY AND WENT BACK TO BED W/ C/O \"FRONTAL PRESSURE BUT NO OTHER PROBLEMS\". LAST NIGHT PT FELL AGAIN WHEN GETTING READY FOR BED AND WAS UNABLE TO GET UP. DENIES LOC. FOUND ON FLOOR BY SON IN AM ALERT AND ORIENTED. BROUGHT TO . CT SCAN SHOWED SDH, HIGH INR. GIVEN VITAMIN K AND TRANSFERRED TO FOR FURTHER MANAGEMENT. HTN IN EW, STARTED LABETALOL GTT. CT SCAN SHOWED BILATERAL SDH W/ SLIGHT L-R SHIFT, ?SOME OLD, SOME NEW. ARRIVED IN TSICU AT 10PM IN STABLE CONDITION.\n(SEE FHP FOR PMH)\n\nROS:\nNEURO: A & O X3, MAE AND FOLLOWS COMMANDS. PEARL. L EYE DROOP IS OLD FINDING BUT MORE EXAGGERATED RECENTLY.\n\nCV: HTN 160/80 AND RESTARTED LABETALOL NOW AT .5 MG/MIN. STABLE HR 60'S-70'S NSR W/ APC'S. BP 130/70.\n\nGI: NPO OVERNOC. DENIES NAUSEA.\n\nGU ADEQUATE U/O VIA FOLEY. IVF AT 75CC/HR.\n\nHEME: CLOT TO BLOOD BANK AND AWAITING FFP TO CORRECT INR. NO EVIDENCE OF BLEEDING\n\nID: AFEBRILE.\n\nSKIN: SCATTERED OLD BRUISES. SKIN INTACT.\n\nSH: PT LIVES W/ SONS. WIDOWED X 16YRS. SON IS SPOKESPERSON.\n\nA: NEUROLOGICALLY STABLE S/P FALL.\n\nP: CONT TO MONITOR Q1HR NVS. REPEAT CT SCAN IN AM. MAINTAIN NPO OVERNOC. LABETOLOL PRN FOR BP CONTROL.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-12-21 00:00:00.000",
"description": "Report",
"row_id": 1263804,
"text": "T/SICU RN Progress Note\nNeuro: Sleeping most of night, wakes confused at times though reorients quickly. Neuro's remain unchanged. L eye remains closed, no change from admit. Pupils equal and reactive.\n\nCV: HR 60-70's SR no ectopy noted. NBP to be less than 130 systolic on IV lopressor and IV labetalol titrated as needed.\n\nResp: Lungs clear NARD sats 96-98% on RA\n\nGU/GI: Foley with clear yellow urine. Abd soft npo no n/v.\n\nHeme: Received 2units FFP and Vit K for INR 1.6 rechecked INR 1.1.\n\nSkin: Grossly intact no breakdown noted.\n\nSocial: Children home for the night.\n\nPlan: Repeat head CT today, monitor BP, monitor labs, cont to monitor and support.\n"
}
] |
25,822 | 105,274 | 53 year old female with DM (s/p renal and pancreatic transplant, on immunosuppression, blindness in both eyes) who presented on with nuasea, vomiting, diarrhea, headache and fevers. Fever work was initiated including Blood, urine, and stool cultures along with CMV viral load were all sent. Abd US, CXR, CT sinuses, abd, pelvis all negative. Pateint remain febrile despite all initial culture returning negative except CMV viral load of 58,000 copies. On hospital day patient was transferred to SICU for shortness of breath, tachypneaa nd hypoxemia. Pateint was subsequqnetly started on albuterol nebullizer, continous face mask and serial CXR. An echocardiagram showed left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). A portable CXR showed mild interstitial edema with moderate cardiomegaly has increased as has mediastinal vascular engorgement indicating elevated central venous volume. A repeat on showed satisfactory nasogastric tube position, worsening congestive heart failure and persistent left lower lobe atelectasis. A bronchoavleaolar lavage showed increased secretions but no other significant findings. A CT chest showed 1.Mild-to-moderate CHF with cardiomegaly and bilateral pleural effusions with bibasilar patchy atelectasis. 2. Small pericardial effusion. 3. Somewhat nodular appearance within the ground glass opacity consistent with CMV pneumonitis. Radiographically, fungal infections and miliary tuberculosis are in the differential diagnosis. 4. Left lower lobe pneumonia. On urine culture was positive for yeast and antifungal treatement was started. repeat CMV viral load . Repeat urine culture along with sputum on showed yeast. After a ten day course in ICU pt returned to floor . Antifungal where discontinued per ID recommendation after urine culture showed no evidence of yeast. CMV viral load was 10,600. Patient pertinent issue on the floor was ongoing nausea which improved after several days of adjusting tube feeds and antiemetics treatment. After stable course on floor patient was prepared for discharge rehab with appropiate followup schedule. Today on , patient feels cofortable and awaiting rehab.Patient is a febrile, VSS. Patient will leave with a foley, TFs . Please make sure patient is on a ConAir bed for sensitivity of skin, and increase risk for break down skin. | RESPIRATORY CARE Pt hypotensive laid flat = destuated to 93/94 FI02 increased to .6 CV: Hr NSR and BP WNL. po2 87, pco2 20's p h 7.40. compensating for metab. abg 7.38/41/99.gi: abd soft, bs+ tf on hold for resid>150cc at 0100,0300, ? remains NPO.PAIN: deniesACCESS: arrives with 1 PIV, second PIV started in left antecub. ABG WNL, PREPARING FOR EXTUBATION NO CUFF LEAK NOTED, RETURNED BACK TO CMV AND VERSED RESTARTED ICU TEAM AWARE, LARENGEAL EDEMA NOTEDCV: NSR, CVP 0-4, MAP > 60, HYPOTHERMIC T 95.5 AX, BEIR HUGGER APPLIED, TEMP RETURNED BACK TO NORMAL THIS PMGI: HIGH TF RESIDUALS NOTED, NGT D/C, DOBHOFF PLACED AND VERIFIED BY CXR, NEPRO RESUMED @ 10/HRGU: MARGINAL HOURLY U/O, ICU TEAM AWAREA/P: CONTINUE TO UPDATE AND EDUCATE FAMILY, AWAITING PLAN OF CARE FROM ICU TEAM, HOB HIGH-, MONITOR AND TREAT LARENGEAL EDEMA ABG: 7.38/41/99 25 and 0. Metoprolol held. Abdomen soft and tube feeds restarted. CONDITION UPDATE:D/A: T MAX 98.3NEURO: PT ON PROPOFOL, EASILY AWOKEN, FOLLOWS COMMANDS. Lungs clear to diminished at the bases. Some slight upper airway congestionnoted, cleared after neb treatment and clearingthe paitnts nose of secretions. urine sent for ua.SKIN: intactENDO: bs 142, sliding scale in use. BS clear/diminished. admit note 0200-0700 NPNPt. bearing status, need set up and SBACV: hr 120sinus tach no ectopy, maps 120's on arrival, ? MN-0600 - 97 CC'S. hr 80-100, receiving lopressor 10 mgm q 4 hr IV, rec'd on nitro gtt, able to wean after lopressor. 02sats>98%.Gi/GU: Abd remains soft and distended. Pt given intermittent versed for anxiety/comfort over noc.CV: Pt afebrile over noc. SUCTIONED FOR MINIMAL AMOUNTS OF SECREATIONS. START REGLAN FOR GI MOTILITY. stool is HEM NEG. foley to gravity good uop today.no bm's noted.integ skin warm dry intact.1 unit prbc given post transfusion hct 29.plan pulm toilet/pain/ anxiety management. reglan,gu: uo to120cc/hr of clear yellow, pt 3liters negative los,am K+ 3.6 repleted with 20, creat/bun 4.0/71 wnl for pt baseline.id: afebrile, wbc 2.9 vanco trough due this am. D:Resp:Pt srable overnoc resp wise. DOPPLER STUDY .RESP: LS CLEAR TO COARSE TO WHEEZY. + PPP BILAT LE'S. Bactrim.NUTRITION: npo til am then restart TF probableSKIN: intact. + PULSES BILAT LE'S. iv ntg weaned to off. responsive to reposition and tylenol.ENDO: bs 120.s sliding scale in use. general edema dependant. NEBS AS NEEDED. addedumpt b/p decreased versed stop, hypotensive, hob flat, fio2 increased lr bolus given, DR. aware Cont on Reglan. Titrated as needed. general 2+ dependant edema. Repat Benadrlx1 for iching given per d.o.. VENT WEAN AS TOLERATED. Tolerating well. CONTINUE ABX AND IMMUNOSUPPRESENTS. Cont to wean as tolerated. surgicell on. BS CTAB. Cont with current plan of care. tegaderm on. PT was intubated this AM secondary to resp failure. PT EXTUBATED WITHOUT INCIDENT, NEBS TREATMENTS GIVEN. a bit of time to equilibrate after cough. enc pt to assume adl cares as much as possible with setup. LATEST ABG ON SAME VENT SETTINGS: 7.49, 35, 146, 27, 4, 99. POST EXTUBATION, PT X3, ASKING APPROPRIATE QUESTIONS. Pt acutely desaturated to low 90s with changes made accordingly on vent. surgicell to line site with good result min. Resp Care Addendum:Please disregard previous note. Resp Care Addendum:Please disregard previous note. pulm toilet, mobilize pt. Dr notified, Benadryl given as ordered with relief. pt. pt. pt. cont. cont. cont. po fluids. Addendum to above note. BS clear to course sxing for small amts of thick tan to white secretions. changed for mod serous.ACCESS: multilumen right shoulder patent, art line with good tracePAIN: deniesSOCIAL: no visits this pmPLAN: cont. PT IS ABLE TO TALK, HAS A STRONG COUGH.GI: TUBE FEEDS REMAIN ON HOLD AS PT'S RESP STATUS WARRENT RE-INTUBATION. to have some seeping from puncture sites, redressed with pressure drsg. + BS. WIll cont with vent support as needed. WIll cont with vent support as needed. WILL NOTIFY DR. .CV: HR 80'S NSR. SVO2 70'S, PCWP 16, CO ~7.0, CI 4.0, CVP POSITIONAL . Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH. UPRIGHT AP CHEST: The left subclavian line has been retracted, with the tip now in the SVC. A small pericardial effusion is identified. CT CHEST: There is moderate cardiomegaly. Small bilateral pleural effusions and small pericardial effusion. There is mild symmetric left ventricular hypertrophy. Diffuse mesenteric and retroperitoneal stranding and small amount of intra-abdominal free fluid which could be related to volume status. Cardiac, mediastinal, and hilar contours are unchanged, with mild cardiomegaly. Diffuse mesenteric and retroperitoneal stranding is identified as is a small amount of free fluid. Moderate PA systolic hypertension.PERICARDIUM: Small to moderate pericardial effusion. ET tube and Swan-Ganz catheter in standard placements. Normal ascending aorta diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. Normal RVsystolic function.AORTA: Normal aortic root diameter. PATIENT/TEST INFORMATION:Indication: Pericardial effusion. The patient's endotracheal tube is now at the level of the carina and possibly into the right main stem bronchus. Right subclavian Swan-Ganz catheter and nasogastric tube are seen. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Stomach and bowel loops are within normal limits. There is a mild to moderate sized pericardial effusion. Cholelithiasis. A vaginal pessary is in place. Sinus tachycardiaPoor R wave progression - possible anterior infarct or due to lead placementSince previous tracing of , no significant change There is moderate pulmonary artery systolic hypertension.7. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are small bilateral pleural effusions as well as pericardial effusion. Clinical correlation issuggested. There is, however, a single bubble of air seen in the region of the transplant pancreas. 12:29 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: please eval for abscess, collection, etc. CT ABDOMEN: Within the limits of this non-contrast study, the liver, gallbladder, native pancreas, spleen, adrenal glands, and atrophic native kidneys are stable. The new nasogastric tube terminates below the left hemidiaphragm in the expected location of the stomach. | 54 | [
{
"category": "Nursing/other",
"chartdate": "2105-01-07 00:00:00.000",
"description": "Report",
"row_id": 1598626,
"text": "admit note 0200-0700 NPN\nPt. admitted from floor with increasing SOB. Arrives via stretcher with staff, alert awake, rr 30's but able to speak word sentences with problem. Pt. is totally blind, able to read braille.\n\nNEURO: intact, mae, legally bling since childhood, able to read braille. did fx right ankle earlier this year. affects wt. bearing status, need set up and SBA\n\nCV: hr 120sinus tach no ectopy, maps 120's on arrival, ? anxiety, nausea complaint no emesis. tmax 102.5 oral, pp intact, skin dry, tylenol given. no c/o chest pain. will cycle enzymes, next due at 1000.\n\nRESP: clear to bases bil. , received on 100% mask, weaned to 50% face tent. non prod. cough, rr 30, able to speak in work sentences without prob. 50% face tent placed po2 60's pco2 24 ph 7.42. NPO pending possible intubation.\n\nGU/GI: #14 fr. 5 cc foley placed for return clear urine. lasix 20 mgm given for 500cc at 2 hrs. abd soft non tender, no stool, c/o nausea, given compazine with good result. urine sent for ua.\n\nSKIN: intact\n\nENDO: bs 142, sliding scale in use. no coverage at this time . remains NPO.\n\nPAIN: denies\n\nACCESS: arrives with 1 PIV, second PIV started in left antecub. may place multilument sometime today for assistance in determining fluid status.\n\nSOCIAL: sister staying with pt. Husband advised of change. is now health care proxy, paperwork done, copy to chart , copy to pt/family.\n\nPLAN: monitor resp. status, monitor VS, labs including metab. status, BS and cardiac enzymes. may place multilumen if condition warrants today to assist in measurement of fluid status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-08 00:00:00.000",
"description": "Report",
"row_id": 1598628,
"text": "1900-0700 NPN\nNEURO: intact. pt is legally blind since childhood, mae\n\nCV: tmax 101.5, responsive to tylenol. hr 80-100, receiving lopressor 10 mgm q 4 hr IV, rec'd on nitro gtt, able to wean after lopressor. trace dependant edema, pp intact, urine qs\n\nRESP: sats 99% on 80% high flow O2 mask. po2 87, pco2 20's p h 7.40. compensating for metab. problem. rr 32 with anxiety now 18-27. noted 6 pt drop in hct this am. stool is HEM NEG. non prod. cough, lungs clear to bases, no wheeze noted.\n\nGU/GI: foley qs light yellow urine, abd soft flat bt present. large brwn liquid stool early pm. HEM NEG. stool mushroom cath placed. no nausea noted. pt. taking and tol sips of water with meds and intermittantly.\n\nNUTRITION: npo except meds. may require intubation of no improvement in rr and or po2.\n\nENDO: sliding scale only in use. requires insulin pm and am\n\nSKIN: intact\n\nPAIN: denies\n\nACCESS: 2 PIV patent. set up for art line and multi lumen in room.\n\nSOCIAL: supported this pm by family and friends.\n\nPLAN: MRI (check list sent)to r/o infectious process, pulm. toilet and high flow o2. monitor labs and vs, respond to same.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-08 00:00:00.000",
"description": "Report",
"row_id": 1598629,
"text": "Events:\n\nC/O of SOB and anxiety, desats to 80s with FM off, Soa2 improve quickly with FM on, ativan .5 mg IV for anxiety/SOB with effect\nLS with bibasilar crackles repeat CXR \"wet\" per Dr. , lasix given\nHCT 20.8-1u PRBC stool quiac negative\nID-attempt to obtain induced sputum, pt with dry cough and c/o of n/v emesis 50cc, anzemet 12.5mg IV with relief of nausea, dry cough, no sputum currently\n\nNeuro-Lethargic, easily arouses to voice, MAEW and equal, pt legally blind, anxious at times\nCV-HS S1 S2 with II/VI SEM best heard LUSB, RRR, no VEA, CSM WNL, SCDS, heparin SQ for prophylaxis, NTG drip for SBP<160, lopressor ATC\nResp-LS bibasilar crackles clear upper lobes, Fio2 80%, CPT, IS, and CDB done\nAbd-NPO awaiting MRI, soft distended NT, +BS, liq stool out C-diff neg , BS covered with SS insulin\nRenal-CR 3.2, u/o >30cc/hr, lasix, lytes monitored, foley-CD\nID-Tmax overnight 102.3, cultures pending since , CMV + continues on ganciclovir, cont on bactrim IV, flagyl\nImmunosupression-Sirolimus and prednisone PO\n\nPsychosocial-patient request to speak with social worker , without husband present, pt describes husband as angry, volatile, and verbal aggressive, sister is spokesperson but per patient OK for husband to get info, husband currently taking notes on hospitilzation, patient and sister state they are not in agreement with his actions and note taking, patient describes being under stress regarding the marriage and working through potential divorce, emotional support provided and social work notified\n\nPlan-MRI, ativan PRN axiety, cont pulm toilet, will attempt to induce sputum, recheck HCT after PRBC, quiac stool, ?need to reculture if T spike, cont ABX, cont Lasix, and monitor for flash pulmonary edema\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-07 00:00:00.000",
"description": "Report",
"row_id": 1598627,
"text": "Update:\nSee careview for details...\nNeuro: Pt 3 ,MAE, generalized weakness, PT legally blind\n\nCV/Resp: VSS in AM, denies CP, no edema, good periph pulses, bedside ECHO done MP SR 80-90 no ectopy,lungs clear this am,sats 95% on OFM 50%, Pt traveled to VQ scan and US, increased anxiety noted with increased BP and HR and decreased sats, returned to SICU, Pt with sats 90% on NRB, SOB with labored resp 30-40, Lungs with crackles bilat and exp wheezes,BP 200/100 HR 120, MD notified, Pt given 20 IV lasix, 10 IV lopressor, BP remained elevated, NTG IV started, good diuresis from lasix, additional 20 IV lasix given Transplant MD, Labs drawn as ordered. BP 170's with NTG, RR decreased and less labored, 100% high flow O2 applied, sats 94% Pt appears in less distress.\n\nGI: Pt incont of lrg amts watery stool, ID aware, occasional nausea with dry heaves, no vomiting, pt NPO, abd soft, + BS\n\nGU: Pt cont to diurese clear yellow urine after lasix, UO adequate throughout shift\n\nSKIN: skin WD and intact, pt turned Q2hrs\n\nPlan: Monitor resp status for S/S CHF, monitor labs, UO\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-10 00:00:00.000",
"description": "Report",
"row_id": 1598637,
"text": "Addenddum\nTwo gold-colored rings removed from left ring finger to prevent further vonstriction from swelling. Both rings given to pts sister with pts permission.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-10 00:00:00.000",
"description": "Report",
"row_id": 1598638,
"text": "Respiratory Care\nPt continues to be orally intubated/ventilated at this time. BS: clear bilaterally. Suctioned for small amts of tan secretions. Pt currently on Propfol/morphine for pain. CXR: CMV pneumonitis L>R side. PEEP decreased from 10cm-8cm this am. O2 sats remain 98-100%. Will continue to closely monitor and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-10 00:00:00.000",
"description": "Report",
"row_id": 1598639,
"text": "neuro remains intubated with anxiety. On Propofol 50 mcg/kg/min.\nanxious when family in the room trying to spell out words etc.\nc/o generalized aches med with 2mg ivp mso4 q4h prn w good effect.\nmae to command.\ncv/resp nsr rate in the 60's. bp stable. elevated x 1 rx with hydralazine and lopressor. good effect. suctioned for minimal secretions. peep weaned to 8 and pt. tol this well w no desaturation.\nlungs are coarse and distant bilat.\ngi/gu ngt to suctioned but now tube feeds started this afternoon at 10cc/hr promote w fiber. foley to gravity good uop today.\nno bm's noted.\ninteg skin warm dry intact.\n1 unit prbc given post transfusion hct 29.\nplan pulm toilet/pain/ anxiety management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-11 00:00:00.000",
"description": "Report",
"row_id": 1598640,
"text": "CONDITION UPDATE:\nD/A: T MAX 98.3\n\nNEURO: PT ON PROPOFOL, EASILY AWOKEN, FOLLOWS COMMANDS. EASILY AGGITATED. INTERACTING WITH FAMILY.\n\nCV: HR 60'S NSR. ABP ~ 140/50. CVP ~ 2. FLUID BALANCE + 865 CC'S. MN-0600 - 97 CC'S. P BOOTS.\n\nRESP: LS COARSE. SUCTIONED FOR MINIMAL AMOUNTS OF SECREATIONS. PT ON AC, 50%, RR 14, 8 PEEP WITH ABG: 7.54, 28, 164, 25, 3. RR DECREASED TO 12 WITH ABG: 7.44, 34, 104, 24, 0.\n\nGI: TUBE FEEDS STOPPED DUE TO HIGH RESIDUALS. ABDOMEN LARGE, SOFTLY DISTENDED. NO STOOL.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSKIN: INTACT.\n\nSX: FAMILY VISITING OVERNIGHT.\n\nR: AFEBRILE, VENT WEAN IN PROGRESS, REQUIRING SEDATION.\n\nP: CONTINUE MONITORING VITALS, RESP STATUS, ABG'S. VENT WEAN AS TOLERATED. ? START REGLAN FOR GI MOTILITY. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-11 00:00:00.000",
"description": "Report",
"row_id": 1598641,
"text": "respiratory care\npt on the ventilator tol well changes made see respiratory page of care view for more information\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-12 00:00:00.000",
"description": "Report",
"row_id": 1598643,
"text": "npn\npt very anxious on eves, continually requesting to be moved or adjusted, repeatedly saying she needed to be suction with sats at 100% and scant secretions noted with suctioning done. Pt not settling down, daughter present in room - hovering despite being instructed that pt would not be able to rest if she cont. to address her every action. issue addressed with resident and nursing supervisor. pt's propofol gtt was increased to 100mcg/hr and family was requested to leave bedside so pt's anxiety could be better controlled.\n\nneuro: see above, pt alert, arousable with propofol now at 75mcg, seems to resting comfortably, will awaked to voice, nods head to yes and no questions follows commands and moves all exts. when propofol gtt decreased for rsbi pt uncontrollably coughing against vent and gtt restarted at 75mcg. ? anxiety med to help with wean.\n\ncad hr 60 to 50's rare pvc, abp 97/37 to 128/49, systolic to 150 to 160's when anxious, hct, 30.2, 30.4\n\nresp: cmvx12x450x50%fio2 with peep at 5, rsbi=38, stas 98%, ls coarse thru out, suctioned for scant amt. of thin secretions. abg 7.38/41/99.\n\ngi: abd soft, bs+ tf on hold for resid>150cc at 0100,0300, ? reglan,\n\ngu: uo to120cc/hr of clear yellow, pt 3liters negative los,am K+ 3.6 repleted with 20, creat/bun 4.0/71 wnl for pt baseline.\n\nid: afebrile, wbc 2.9 vanco trough due this am. and prograf level.\n\nsocial: family in waiting room\n\nplan: ? weaning of vent settings, ? starting reglan for cont high resid, cont to monitor vs, labs,\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-12 00:00:00.000",
"description": "Report",
"row_id": 1598644,
"text": "Respiratory care:\nPatient remains intubated and mechanically vented. Vent checked and alarms functioning. Peep weaned this eve from 10 to 5. RSBI this am 38. SBT not done as patient became agitated patting her belly and coughing. Current settings: A/C 450*12 50% and 5 peep. ABG: 7.38/41/99 25 and 0. BS are coarse. Please see respiratory section of carevue for further data.\nPlan: Continue mechanical ventilation. RSBI good this am. have problems weaning patient as she becomes agitated when awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-12 00:00:00.000",
"description": "Report",
"row_id": 1598645,
"text": "RESPIRATORY CARE: PT W/ A 7.5 ORAL ETT IN PLACE.\nAC MODE AS PER CV. PS/SBT PENDING. PROPOFOL CHANGED\nTO VERSED DRIP. SX FOR WHITE SPUTUM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-12 00:00:00.000",
"description": "Report",
"row_id": 1598646,
"text": "focus data update\nsee careview for details\n\nNEURO: SEDATION CHANGED FROM PROPOFOL TO VERSED PER TX TEAM, PT LIGHTLY SEDATED AROUSES TO VOICE, SEDATION TITRATED FOR PT TO BE ABLE TO TOL ETT, MAE'S, PERLA, NODDING APPRORIATELY TO QUESTIONS, FAMILY AT BEDSIDE, MORPHINE GIVEN FOR RESP DISTRESS\n\nRESP: VERSED SEDATION STOPPED, PT VENT SETTINGS CHANGED TO CPAP. ABG WNL, PREPARING FOR EXTUBATION NO CUFF LEAK NOTED, RETURNED BACK TO CMV AND VERSED RESTARTED ICU TEAM AWARE, LARENGEAL EDEMA NOTED\n\nCV: NSR, CVP 0-4, MAP > 60, HYPOTHERMIC T 95.5 AX, BEIR HUGGER APPLIED, TEMP RETURNED BACK TO NORMAL THIS PM\n\nGI: HIGH TF RESIDUALS NOTED, NGT D/C, DOBHOFF PLACED AND VERIFIED BY CXR, NEPRO RESUMED @ 10/HR\n\nGU: MARGINAL HOURLY U/O, ICU TEAM AWARE\n\nA/P: CONTINUE TO UPDATE AND EDUCATE FAMILY, AWAITING PLAN OF CARE FROM ICU TEAM, HOB HIGH-, MONITOR AND TREAT LARENGEAL EDEMA\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-12 00:00:00.000",
"description": "Report",
"row_id": 1598647,
"text": "RESPIRATORY CARE\n\n Pt hypotensive laid flat = destuated to 93/94 FI02 increased to .6\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-11 00:00:00.000",
"description": "Report",
"row_id": 1598642,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nPt awakens easily on propofol and follows all commands. Agitated only when trying to communicate with family. Medicated infreq for pain with morphine-good effect. Propofol for sedation on ETTtube.\nAfebrile. CV: Hr NSR and BP WNL. Metoprolol held. Lungs coarse and suctioned for thick yellow secretions. Vent changes as needed. RISBI for morning with plan for extubation within a few days? Abdomen soft and tube feeds restarted. ?to start on nepro instead of impact with fiber. Residuals to be checked q 4 hours. Family updated on patient's status and plan of care. Please refer to carevue for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-14 00:00:00.000",
"description": "Report",
"row_id": 1598653,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Pt arouses to voice follows commands appropriately and gestures/mouthing words to communicate. Pt given intermittent versed for anxiety/comfort over noc.\nCV: Pt afebrile over noc. BP stable requiring no further fluid bolus' over noc. Able to maintain BP. HR remains in NSR no noted ectopy. PAD's 14-20. PCWP 11-15 CVP 6-12 CO/CI:7-8/3-4. SVR wnl. Maint IVF going at 45cc/hr. U/O still marginal despite mult bolus' on days. Pt's weight up 5kgs since .\nResp: No vent changes made over noc. Pt with + cuff leak intermittently both teams made aware. Pt with strong productive cough. Pt sxn for brown thick oral secretions. Lungs clear to diminished at the bases. 02sats>98%.\nGi/GU: Abd remains soft and distended. Remains with no BM/flatus. TF adv to 40cc/hr pt tolerated well. TF stopped this am for possible extubation today. Foley patent drng yellow urine.\nEndo: RISS\nID: Remains on mult abx. Afebrile.\nSoc: Support family.\nPlan: Possible extubation today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-14 00:00:00.000",
"description": "Report",
"row_id": 1598654,
"text": "Respiratory Care 1900-0700\nPt remains orally intubated on minimal vent settings CPAP/PS 5/5. ABG this AM was within normal limits. Cuff Leak was present at times during shift. BS clear/diminished. Sx for thick brown secretions. RSBI this AM= 43.9. No changes made to vent throughout the night. Possible extubation today? See carevue for further questions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-14 00:00:00.000",
"description": "Report",
"row_id": 1598655,
"text": "Respiratory Care note: 2:15pm\n\n Pt extubated comfortably, tested for cuff leak prior.\nRR 18 to 20 bpm, oxygen saturation 100% on 100% cool\nmist. 2.5 mg albuterol unit dose given by neb.\npost extubation. Some slight upper airway congestion\nnoted, cleared after neb treatment and clearing\nthe paitnts nose of secretions. Able to wean o2 to\nfio2 of 50% with Spo2 of 98%.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-16 00:00:00.000",
"description": "Report",
"row_id": 1598662,
"text": "1900-0700 NPN\nNEURO: AOx3, anxiety at intervals, responds to coaching. mae\n\nCV: hr 80-90 sinus, cvp with good trace , pp intact x 4, mucous membranes dry, tongue appears edematous, gag intact, afebrile, faced has flushed appearance. sys 130-160 with activity. urine 30cc + hr. right arm edematous. bleeding at old and new subclavian sites. surgicell on. cont. to bleed through this night. requires drsg 2.\n\nRESP: sats mid 90's, switched to face tent 50% sats in mid 90's, takes pt. a bit of time to equilibrate after cough. weak cough, non productive, oral cavity dry, lips and tongue appear swollen. gag intact. lungs coarse to clear. no rales rr 18-40 with anxiety.\n\nGU/GI: foley yellow qs, abd rounded soft, bt present stool liquid brwn hem -. mushroom cath place for freq. loose stools. skin excoriated in perianal area. barrier creama and mycostatin powder on.\n\nPAIN: c/o some mild pain in right arm. responsive to reposition and tylenol.\n\nENDO: bs 120.s sliding scale in use. pt. npo. held pm insulin.\n\nID: ambisome dose interupted per HO. pt. started itching chest, arms and neck shortly after starting medication. benadryl given with good result. not febrile , no presence of rash during or after dosing. pt. cont. Bactrim.\n\nNUTRITION: npo til am then restart TF probable\n\nSKIN: intact. general 2+ dependant edema. noted redness in groin area. no rash noted.\n\nACCESS: multilumen cath in left shoulder. some bleeding at site and punture sites. surgicell to line site with good result min. bleed.\n\nSOCIAL : sister and visitors at bedside\n\nPLAN: cont. pulm toilet, mobilize pt. asap, skin care to prevent further breakdown., follow vs and cvp responding to abnorms. cont. antibiotics, restart tube feed today. dc nystatin and ambisome due to potential allergic reactions noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-16 00:00:00.000",
"description": "Report",
"row_id": 1598663,
"text": "focus data update\nsee careview for details\n\n\nNEURO: OOB TO CHAIR, A/O X3, REQUIRED FENTANYL FOR DOBHOFF PLACEMENT IN FLURO, PLEASANT, WORKING VERY HARD TOWARDS REHAB\n\nRESP: BS COARSE AND DIMINISHED AT BASES, USING ISN WITH GOOD TECHNIQUE, COUGH STRONGER,NON-PRODUCTIVE, O2 5L/M VIA NC\n\nCV: NSR, AFEBRILE, EXT'S REMAIN EDANOUS, A-LINE PATENT CVP O-8, LASIX 80 MG'S IVP\n\nGI: STOOL LIQ 500CC'S MUSHROOM CATH INSERTED, TF STARTED, DDOBHOFF POST-PYLORIC DONE INM FLURO\n\nGU: CRT DECREASED, HOURLY U/O ADEQUATE\n\nA/P: MONITOR HEMODYNAMIC STATUS, LYTES, CONTINUE IS, AND PULM TOILETS\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-17 00:00:00.000",
"description": "Report",
"row_id": 1598664,
"text": "1900-0700 NPN\nNEURO: intact\n\nCV: sinus to sinus tach, hct cont to drop, this am 27. urine marginal at 30cc average an hr. afebrile this shift. no itching. general edema dependant. K+ 3.5 team aware. awaiting orders\n\nGU/GI: foley amber qs, BT present, Cdiff sent, loose watery stools 500 cc.+., no cramping. no nausea , blood in oral cavity, cont. to have some seeping from puncture sites, redressed with pressure drsg. tol. po fluids. tf at goal 30cc hr\n\nENDO: bs 194 then 120 this am. sliding scale in use.\n\nSKIN: peri area improved with decreasing redness. puncture sites oozing subclavian bil. tegaderm on. changed for mod serous.\n\nACCESS: multilumen right shoulder patent, art line with good trace\n\nPAIN: denies\n\nSOCIAL: no visits this pm\n\nPLAN: cont. to mobilize and provide pulm toilet. enc pt to assume adl cares as much as possible with setup. replete potassium, consider blood products. support emotionally. transfer to floor pending today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-14 00:00:00.000",
"description": "Report",
"row_id": 1598656,
"text": "CONDITION UPDATE:\nD/A: T MAX 98.4\n\nNEURO: NO SEDATION OR PAIN MEDS GIVEN THIS SHIFT. PRIOR TO EXTUBATION, PT FOLLOWING COMMANDS AND NODDING HEAD. POST EXTUBATION, PT X3, ASKING APPROPRIATE QUESTIONS. DENIES PAIN. C/O OF \"RESTLESS LEGS\" AND WOULD LIKE MEDICATION FOR THAT. WILL NOTIFY DR. .\n\nCV: HR 80'S NSR. ABP ~ 132/50. PA ~ 28/12. SVO2 70'S, PCWP 16, CO ~7.0, CI 4.0, CVP POSITIONAL . FLUID BALANCE MN-1800 + 1 LITER. + PPP BILAT LE'S. RIGHT ARM MARKEDLY MORE EDEMATOUS THAN LEFT. SICU TEAM AWARE. ARM ELEVATED AT ALL TIMES, + PULSES. PT ON ASPIRIN AND P BOOTS FOR DVT PROPHYLAXIS. DISCUSSION TO RESTART HEPARIN SC, DETERMINED PT WHILE HIT (-) CLEARLY BECOMES SYMPTOMATIC ON HEPARIN, AND HEPARIN SC WAS NOT RESTARTED. ? DOPPLER STUDY .\n\nRESP: LS CLEAR TO COARSE TO WHEEZY. PT EXTUBATED WITH MINIMAL AIR LEAK AND DR. , RESPIRATORY, DR. , NURSING, AND EMERGENCY AIRWAY CART PRESENT. PT EXTUBATED WITHOUT INCIDENT, NEBS TREATMENTS GIVEN. CONTINUES TO HAVE \"TIGHT\" UPPER AIRWAY BREATH SOUNDS AND DIMINISHED BREATH SOUNDS IN BASES. ABG POST EXTUBATION ON 50% HIGH FLOW HUMIDIFIED MASK: 7.35, 38, 129, 22, -3. PT IS ABLE TO TALK, HAS A STRONG COUGH.\n\nGI: TUBE FEEDS REMAIN ON HOLD AS PT'S RESP STATUS WARRENT RE-INTUBATION. + BS. LOOSE STOOL X1, SENT FOR CDIFF.\n\nGU: FOLEY-BSD SELF D/ BY PT BY ACCIDENT. NEW FOLEY PLACED.\n\nSKIN: BACK, BUTTOCKS, HEELS ALL INTACT. GROIN AREA PINK, IMPROVING WITH CREAM AND MICONAZOLE POWDER.\n\nSX: SOCIAL WORKER INVOLVED, PT'S SISTERS AND DAUGHTER PRESENT, HUSBAND VISITING IN EVENING.\n\nR: EXTUBATED, RESP STATUS REMAINS TENUOUS.\n\nP: CONTINUE CURRENT CLOSE MONITORING AND MANAGEMENT. CONTINUE CLOSE MONITORING OF RESPIRATORY STATUS. NEBS AS NEEDED. CONTINUE TO FOLLOW CULTURE DATA, ADJUST ABX PER ID. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-15 00:00:00.000",
"description": "Report",
"row_id": 1598657,
"text": "Respiratory Care 1900-0700\nPt remains on 50% cool mist. BS coarse bilat. Neb tx given with 2.5mg Albuterol, Tolerated well with NARN. See carevue for further questions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-15 00:00:00.000",
"description": "Report",
"row_id": 1598658,
"text": "D:Resp:Pt srable overnoc resp wise. O2sats stable but desats as low as 90% with O2 off while brushing her teeth. Remains on O2 50% cool neb,\nBilateral breath sounds present diminished at bases with inspir and expir wheezing especially when pt awake and anxious. Wheezing sl imoroves with albuterol nebs. Cough strong nonproductive. resp normal, nonlabored. Pt tolerates being flat in bed for short times without desating.\nCV:SR to ST, no ectopics. HR increased to 90-100 as 0600 dose of metoprolol due. No CP. VSS.\nGI:postpyloric FT in place, clamped to protect airway from aspiration in newly extubated pt. Nausea x 1 treated with antiemetic with relief.\nTacolimus held last night due to increased level. See new order. Please see carevue for detailed data from last night>\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-15 00:00:00.000",
"description": "Report",
"row_id": 1598659,
"text": "Addendum to above note. With the 2400 dose of ambisome , pt w/i 15min c/o severe itching. No rash noted however pt very uncomfortable. Dr notified, Benadryl given as ordered with relief. Repat Benadrlx1 for iching given per d.o.. \n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-09 00:00:00.000",
"description": "Report",
"row_id": 1598630,
"text": "data: pt afebrile-temp max 99.4 overnight. hr 70-80's ns w/o ect.\nB/P 160-120/75-67 rec'ing lopressor 15mg iv q4hrs and ntg gtt 1mcg/kg/min to keep sb/p<160.\nurines 250-80cc/hr on lasix gtt titrated to 6mg /hr.\ntransfused 1upc for hct 21.7-post hct 23.1.\nresp- rr 20-26 coughing-non-productive. cs-clear w/ crackles in bases.\ncfm @ 100% o2sats 95-98%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-09 00:00:00.000",
"description": "Report",
"row_id": 1598631,
"text": "Resp Care\n\nPt admitted to ICU from PACU this am intubated and vented on full support with changes made accordingly. BS slightly course sxing for small to mod amts thick tan secretions. ETT secured/patent. WIll cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-09 00:00:00.000",
"description": "Report",
"row_id": 1598632,
"text": "Resp Care Addendum:\n\nPlease disregard previous note. Written on wrong pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-09 00:00:00.000",
"description": "Report",
"row_id": 1598633,
"text": "Resp Care Addendum:\n\nPlease disregard previous note. Written on wrong pt. PT was intubated this AM secondary to resp failure. Intubated via #7.5 ETT secured at 21cm at the lip with +ETCO@ and BLBS. BS clear to course sxing for small amts of thick tan to white secretions. Pt acutely desaturated to low 90s with changes made accordingly on vent. Transported to and from Ct scan for chest Ct without any incident. PT also bronched earlier and cultures sent to lab. WIll cont with vent support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-09 00:00:00.000",
"description": "Report",
"row_id": 1598634,
"text": "significant events: pt intubuted, bronchscopy and also had ct scan\n\nnuero: pt sedated on propofol. with propfol on pt does open her eyes to voice. pt does follow commands.\n\npain pt denies any c/o pain by nodding her head when asked if she was having any pain\n\npulm: this morning pt with 02sat 86-88% in 100% high flow oxygen. abg checked 7.46/34/50/25, dr. , dr. aware. pt intubated, inital on 100%, pt oxygen weaned down to 60%, most recent abg 7.46/34/110/25, dr. aware, fi02 decreased to 50% per dr. . suctioning pt for scant amt of bloody tinged sputum. pt had bronchscopy done today.\n\ncards: please see flow sheet for specfic. iv ntg weaned to off. sbp has been above 90, cvp 6-14. pt in sr, no vea noted. pt had chest ct done. lasix gtt d/c'd per dr. \n\ngi: pt npo.\n\ngu: u/o has been 7-20cc/hr dr. aware, dr. aware.\n\nheme: pt recieved one unit of blood. repeat hct 24.7 dr. aware, no treatment ordered.\n\ncoag: ptt91.6, pt 16.4, inr 1.6 d-dimer 2060, dr. aware, no treatment ordered.\n\nf/e: ionized ca 1.06 dr. aware pt recieved 2gm of calicum gluconate, repeat ica 1.09, dr. aware, no treatment ordered.\n\nid: temp 103, pt pancultured, pt started on aztronam\n\nline: right subclavin line placed cxr done. right subclavin line pulled back to dr. , dr. stated,\"line ok to use\"\n\nsocial: pt sisters and daughters and husband into see patient.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-10 00:00:00.000",
"description": "Report",
"row_id": 1598635,
"text": "CONDITION UPDATE:\nD/A: T MAX 99.9\n\nNEURO: PT ON PROPOFOL GTT, EASILY AWOKEN AND AGITATED. PT IS FRUSTRATED BY ETT. DOES NOT APPEAR TO BE IN PAIN AND NODS HEAD NO TO PAIN. PUPILS LARGE, NON REACTIVE, PT HAS BLIND SINCE CHILDHOOD. FOLLOWS ALL COMMANDS, MOVES ALL EXTREMITIES WITH PURPOSEFUL MOVEMENTS.\n\nCV: HR 70'S NSR, NO ECTOPY. ABP ~ 116/45 WITH MAPS > 60. NO NITRO OR PRESSORS. CVP 4-13. NO S+S OF EDEMA. + PULSES BILAT LE'S. P BOOTS FOR DVT PROPHYLAXIS. FLUID BALANCE MN-0500 + 330 CC'S, FLUID BALANCE FOR +800 CC'S.\n\nRESP: LS CLEAR TO COARSE WITH WHEEZES AT TIMES. SUCTIONED FOR NO SECREATIONS. ABG CONCERNING ON EARLY EVENING ON AC, 50%, 10 PEEP WITH ABG: 7.52, 33, 73, 23, 3, 96. PT REPOSITIONED TO RIGHT SIDE WITH NO VENT CHANGES MADE. LATER IN SHIFT ABG'S MONITORED AND IMPROVED. LATEST ABG ON SAME VENT SETTINGS: 7.49, 35, 146, 27, 4, 99. ETT RETAPED DUE TO PT COMPLAINING OF DISCOMFORT.\n\nGI: NPO. NGT - LCSW WITH MINIMAL OUTPUT. ABDOMEN IS SOFTLY DISTENDED. + BS.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE. NO LASIX GIVEN THIS SHIFT, A DOSE WAS GIVEN @ THE END OF THE PREVIOUS SHIFT WITH GOOD RESULTS.\n\nSX: PT SISTERS STAYED OVER NIGHT IN WAITING ROOM. VISITED A FEW TIMES OVER NIGHT.\n\nSKIN: INTACT\n\nR: REMAINS SLIGHTLY ALKALOTIC, SLOW VENT WEAN IN PROGRESS. RESPIRATORY STATUS REMAINS CONCERNING. WORSENING RENAL FUNCTION WITH ELEVATED BUN AND CREATININE.\n\nP: CONTINUE CURRENT CLOSE MONITORING AND MANAGEMENT OF VITALS, LABS, S+S OF BLEEDING. VENT WEAN AS TOLERATED. CONTINUE ABX AND IMMUNOSUPPRESENTS. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-10 00:00:00.000",
"description": "Report",
"row_id": 1598636,
"text": "Resp Care\nPt remains on MV in AC mode as documented on Careview. BBS-coarse with decreased aeration in bilt LL's. Sx'ed with no secretions retrieved. ABG with marked difference in pO2 and w/o vent changes when pt is turned. pO2 on left side 73/83 with pO2 on right side 177. Bag and mask at bedside. Alarms on and functioning. Continue to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-12 00:00:00.000",
"description": "Report",
"row_id": 1598648,
"text": "addedum\n\npt b/p decreased versed stop, hypotensive, hob flat, fio2 increased lr bolus given, DR. aware\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-13 00:00:00.000",
"description": "Report",
"row_id": 1598649,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Remains on versed gtt for sedation. Titrated as needed. Pt still arouses to voice, able to follow simple commands. MAE. Morphine given intermittently for pain.\nCV: Pt becoming more HTN over noc. Hydralazine given with short effect. Pt also with ^HR from 60's to 90's with HTN. Team aware. U/O remains marginal. decreasing slowly over noc. MD is aware and creatinine is now 4.3 from 4.0.\nResp: Remains with no cuff leak. RSBI 67. Placed on CPAP 5/5 this am. lungs remain clear/coarse at times diminished at the bases.\nGI/GU: TF increased to 30cc/hr. Tolerating well. Cont on Reglan. Abd remains soft with + BS and no BM over noc. Foley patent drng yellow urine.\nEndo: RISS requiring no coverage.\nID: Pt afebrile remains on Vanco.\nInteg: Skin intact.\nSoc: Supportive family. Family needs to have limits enforced by all staff.\nPlan: Cont to monitor respiratory status. Cont to wean as tolerated. Monitor pt for cuff leaks daily. Cont to monitor hemodynamics and follow up on increasing creatinine level. Cont with current plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-13 00:00:00.000",
"description": "Report",
"row_id": 1598650,
"text": "Respiratory Care Note:\n\n\nPt remain oorally intubated and sedated on vent support, until we switched early this morning to minimal PSV, tol so far with episode of agitation. WE have been monitoring cuff P occ t/o shift, No leak and cuff left deflated for hrs, even off vent and occluded ETT. BS are clear bil. Plan: Continue ICU monitor esp respiratory abd cuff leak. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-13 00:00:00.000",
"description": "Report",
"row_id": 1598651,
"text": "BS CTAB. Pt remains on CPAP 8/5 without distress. Still no cuff leak so no move has been made to extubate. ? steroids.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-13 00:00:00.000",
"description": "Report",
"row_id": 1598652,
"text": "see careview for details\nfocus data update\n\n\nNEURO:pt uresonsive @ 0800 post versed d/c, pupils non-reactive (blind), slowly arousable as day progressed, mae's minimally, opening eyes upon command, and finally following command, family education given r/t stimulization of pt, family understands and cooperative\n\nRESP: vent settings unchanged, larynx appears more edamenous, sx for thick old blood secretions, sputum sent for cx\n\nCV: hypotensive this am, cco cath inserted svo2 in 40's, pawp , multiple fluid bolus's given, pan cx'd, ext's edamanous, tmax 102.1\nhct stable, type & cross sent, flat in bed and supine most of day\n\nGI: abd soft non-tender, TF held r/t pt's positioning, tf resumeed this pm\n\nGU: Anagoric, renal team aware and increased crt\n\nA/P: Fluid bolus for pawp < 10, goal cvp >6, continue to aggressively monitor fluid volume status, continue to emmotionall and educationally support family and patient\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-15 00:00:00.000",
"description": "Report",
"row_id": 1598660,
"text": "resp care\nalbuterol neb ordered q6prn. given x2 this shift. bs are only slightly coarse at rest, harsh insp bs with deep breathing. sats stable on 50% high flow neb. rr teens to low 20's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-01-15 00:00:00.000",
"description": "Report",
"row_id": 1598661,
"text": "CONDITION UPDATE:\nD/A: T MAX 98.2\n\nNEURO: A+OX3, MAE'S. DENIES PAIN EXCEPT DURING CENTRAL LINE INSERTION, FOR WHICH PT RECEIVED FENTANYL WITH GOOD EFFECT.\n\nCV: HR 90'S NSR. ABP ~ 140/50. PA LINE D/C'D. NEW TLCL PLACED AT NEW SITE. CHEST X-RAY SHOWING LINE IN TOO FAR, DR. AWARE AND WILL PULL BACK. HEPARIN SC STARTED BY TRANSPLANT TEAM. HEPARIN FREE TLCL PLACED BY SICU TEAM IN CASE PT SHOWS S+S OF HIT WITH INITIATION OF HEPARIN.\n\nRESP: LS CLEAR TO COARSE, TO WHEEZY, RESPIRATORY ADMINISTERING ALBUTEROL NEBS. NON PRODUCTIVE COUGH. NO ABG THIS SHIFT. O2 SATS ~ 99% ON 50% HI FLOW HUMIDIFIED FACE MASK.\n\nGI: NPO. TUBE FEEDS REMAIN ON HOLD PER DR. , GO TO IR AND HAVE POST PYLORIC TUBE PLACED. + BS, NO NAUSEA, + LOOSE STOOL X1.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSKIN: GROIN/PERINEAL AREA HEALED, INTACT. BACK, BUTTOCKS, HEELS ALL INTACT.\n\nSOCIAL: SOCIAL WORKER INVOLVED WITH FAMILY ISSUES BETWEEN PT'S , PT AND SISTERS. ALL IN AGREEMENT THAT WHILE PT IS IN THE ICU, EVERYONE'S GOAL IS FOR TO GET BETTER, AND TO NOT DISRUPT HER RECOVERY WITH DISCUSSIONS ABOUT ONGOING MARITAL ISSUES AND DECISIONS THAT CAN BE MADE AT A LATER DATE WHEN PT IS OUT OF INTENSIVE CARE.\n\nR: VITAL SIGNS STABLE, RESPIRATORY STATUS REMAINS CONCERNING HOWEVER IMPROVED FROM YESTERDAY.\n\nP: CONTINUE TO MONITOR VITALS, LABS, RESPIRATORY STATUS. CONTINUE TO MONITOR URINE OUTPUT, RENAL STATUS. PT AND FAMILY SUPPORT.\n"
},
{
"category": "Echo",
"chartdate": "2105-01-07 00:00:00.000",
"description": "Report",
"row_id": 68415,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. ? Tamponade.\nHeight: (in) 65\nWeight (lb): 150\nBSA (m2): 1.75 m2\nBP (mm Hg): 144/52\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 11:59\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV\nsystolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Physiologic TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nNo echocardiographic signs of tamponade.\n\nConclusions:\n1. The left atrium is mildly dilated. The left atrium is elongated.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is normal (LVEF>55%).\n3. The aortic valve leaflets are mildly thickened. No aortic regurgitation is\nseen.\n5. The mitral valve leaflets are mildly thickened. No mitral regurgitation is\nseen.\n6. There is moderate pulmonary artery systolic hypertension.\n7. There is a mild to moderate sized pericardial effusion. The effusion\nappears circumferential. There are no echocardiographic signs of tamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2105-01-22 00:00:00.000",
"description": "Report",
"row_id": 148969,
"text": "Sinus tachycardia\nPoor R wave progression - possible anterior infarct or due to lead placement\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2105-01-19 00:00:00.000",
"description": "Report",
"row_id": 148970,
"text": "Sinus rhythm\nLeftward axis\nPossible anterior infarct - age undetermined\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2105-01-08 00:00:00.000",
"description": "Report",
"row_id": 148971,
"text": "Sinus rhythm\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2105-01-07 00:00:00.000",
"description": "Report",
"row_id": 148972,
"text": "Sinus rhythm. Borderline prolonged/upper limits of normal QTc interval is\nnon-specific and may be within normal limits. Since the previous tracing\nof the QRc interval appears somewhat shorter.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2105-01-06 00:00:00.000",
"description": "Report",
"row_id": 148973,
"text": "Sinus rhythm. Borderline prolonged QTc interval. Clinical correlation is\nsuggested. Since the previous tracing of QTc interval appears less\nprolonged but there may be no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2104-12-31 00:00:00.000",
"description": "Report",
"row_id": 148974,
"text": "Sinus rhythm. Prolonged QTc interval - clinical correlation is suggested. No\nprevious tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-01-21 00:00:00.000",
"description": "FLUOR GUID PLCT/REPLCT/REMOVE",
"row_id": 901736,
"text": " 7:26 AM\n PIC CHECK/REPO Clip # \n Reason: Please replace her PICC under IR guidance. The current PICC\n Admitting Diagnosis: ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with\n REASON FOR THIS EXAMINATION:\n Please replace her PICC under IR guidance. The current PICC went into the\n jugular vein.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 53-year-old woman with PICC line placed which is\n malpositioned, needs PICC line exchange.\n\n PROCEDURE/FINDINGS: The procedure was performed by Dr. and Dr.\n . Dr. , the attending radiologist was present and supervising\n throughout the procedure.\n\n The patient was placed supine on the angiographic table. The left arm and the\n preexisting PICC line were prepped and draped in the standard sterile fashion.\n 5 cc of 1% lidocaine was applied for local anesthesia. A 0.018 guide wire was\n placed through the preexisting PICC line with the tip in the superior vena\n cava under fluoroscopic guidance. The preexisting PICC line was removed. A 4-\n French peel-away sheath was placed over the wire. After the inner dilator was\n removed, a 52cm, single-lumen PICC line was placed over the wire under\n fluoroscopic guidance with the tip in the superior vena cava. The peel- away\n sheath and the wire were removed. The lumen was flushed and the line was\n secured with skin with StatLock.\n\n The patient tolerated the procedure well and there were no immediate\n complications.\n\n IMPRESSION: Successful exchange of a 52-cm, single-lumen PICC line in the\n left arm, with the tip in the superior vena cava. The line is ready to use.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-01-04 00:00:00.000",
"description": "CT PELVIS W/O CONTRAST",
"row_id": 899561,
"text": " 12:29 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for abscess, collection, etc. po contrast only\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p kidney & pancreas transplant w/ FUO\n REASON FOR THIS EXAMINATION:\n please eval for abscess, collection, etc. po contrast only\n CONTRAINDICATIONS for IV CONTRAST:\n elevated creatinine in renal transplant pt;elevated creatinine in renal transplant pt\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Renal and pancreatic transplant, fever.\n\n COMPARISON: .\n\n TECHNIQUE: Axial images through the abdomen and pelvis with oral contrast\n only. IV contrast was not administered due to elevated creatinine.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are small bilateral pleural\n effusions as well as pericardial effusion. There is bibasilar atelectasis.\n There are coronary artery calcifications.\n\n On this unenhanced scan, the liver, spleen, and adrenal glands are normal.\n Stones are seen within the gallbladder. Both native kidneys are atrophic.\n There are vascular calcifications within the abdomen. There is no free air or\n free fluid. There are a few air fluid levels within non-dilated loops of\n small bowel. Contrast is seen just reaching the cecum; most of the contrast\n remains in small bowel. The cecum also contains air-fluid levels. There is\n no lymphadenopathy.\n\n CT OF THE PELVIS WITHOUT CONTRAST: The transplant kidney is located in the\n right lower quadrant and is unchanged in appearance. There is a bulky fibroid\n uterus. A vaginal pessary is in place. The rectum and sigmoid colon are\n normal. The transplant pancreas is located in the left lower quadrant. This\n is mostly unchanged in appearance. There is, however, a single bubble of air\n seen in the region of the transplant pancreas. There is also air within the\n bladder. This correlates with the patient's recent Foley catheter and the\n surgical history of a loop of bowel attached to the bladder. There is no free\n fluid or lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lesions.\n\n IMPRESSION:\n 1. No evidence of an abscess or bowel obstruction.\n 2. Small bilateral pleural effusions and small pericardial effusion.\n 3. Cholelithiasis.\n 4. Stable appearance of the pancreas and renal transplants (given the above\n description). These findings were discussed with Dr. at 2am on\n .\n\n (Over)\n\n 12:29 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: please eval for abscess, collection, etc. po contrast only\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-01-13 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 900739,
"text": " 9:49 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line change r subclavian changed to cco swan\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53F s/ p kidney transplant with fever n/v and elevated Cr now intubated and\n c new CVL on R\n REASON FOR THIS EXAMINATION:\n line change r subclavian changed to cco swan\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:00 A.M. ON .\n\n HISTORY: Renal transplant and fever.\n\n IMPRESSION: AP chest compared to 7:08 a.m.:\n\n Moderately severe pulmonary edema has worsened slightly. Persistent\n mediastinal vascular engorgement suggest volume overload. ET tube and\n Swan-Ganz catheter in standard placements. A feeding tube passes into the\n stomach and out of view. No pneumothorax.\n\n Left lower lobe consolidation has been present since at least ,\n probably atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-01-08 00:00:00.000",
"description": "MR CONTRAST GADOLIN",
"row_id": 900188,
"text": " 4:08 PM\n MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please eval CNS involvement of CMV virus\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p pancrease and renal transplant, now with high CMV titer\n and neurological symptoms.\n REASON FOR THIS EXAMINATION:\n please eval CNS involvement of CMV virus\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE HEAD\n\n INDICATION: 53-year-old female with history of pancreas and renal transplant\n with a high CMV titer and neurologic symptoms.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain before and\n after administration of gadolinium.\n\n FINDINGS: This entire exam is severely limited due to excessive patient\n motion. There is no overt abnormal enhancement identified. With the\n exception of two tiny punctate T2 hyperintensities in the right cerebral white\n matter, there are no or white matter signal abnormalities. At least two\n tiny foci are nonspecific, but could represent the residua of old injury or\n microvascular ischemia.\n\n Incidentally, the left occipital appears larger than the right, likely a\n normal variant.\n\n IMPRESSION: Severely limited study due to excessive patient motion. No\n definite evidence of cerebritis, meningitis, or ependymitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-01-15 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 901071,
"text": " 2:32 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: New Left SC CVL and eval for interval change.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53F s/ p kidney transplant with fever n/v and elevated Cr, now extubated.\n REASON FOR THIS EXAMINATION:\n New Left SC CVL and eval for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: CV line placement.\n\n Left subclavian CV line is in the upper right atrium and suggests withdrawal\n for 3 cm. No pneumothorax. Distal end of feeding tube is in the antrum of the\n stomach. There is persistent pulmonary edema, pleural effusions and possible\n atelectasis/consolidation in the left lower lobe. Findings called by telephone\n to Dr. \n\n"
},
{
"category": "Radiology",
"chartdate": "2105-01-08 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 900170,
"text": " 2:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval NGT position. r/o infiltrate\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53F s/ p kidney transplant with fever n/v and elevated Cr\n\n REASON FOR THIS EXAMINATION:\n eval NGT position. r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement. Status post renal transplant with fever\n and elevated creatinine.\n\n COMPARISON: , at 4:50 a.m. prior to nasogastric tube\n placement.\n\n FINDINGS: AP semi-upright portable view of the chest. The new nasogastric\n tube terminates below the left hemidiaphragm in the expected location of the\n stomach. There is interval progression of pulmonary edema. A left lower lobe\n opacity is again noted, likely representing atelectasis.\n\n IMPRESSION:\n\n 1. Satisfactory nasogastric tube position.\n\n 2. Worsening congestive heart failure.\n\n 3. Persistent left lower lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-01-13 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 900832,
"text": " 11:23 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for signs of lymphoma/occult infection\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53F s/p CRT, with fevers & +EBV concerning for lymphoproliferative disorder\n REASON FOR THIS EXAMINATION:\n eval for signs of lymphoma/occult infection\n CONTRAINDICATIONS for IV CONTRAST:\n creat 4.3\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old woman status post renal transplant with fevers, EBV\n concerning for lymphoproliferative disorder. Evaluate for signs of lymphoma\n or occult infection.\n\n TECHNIQUE: Multidetector axial images of the chest, abdomen, and pelvis were\n obtained with oral contrast. No IV contrast was administered due to the\n patient's renal insufficiency. Coronal and sagittal reformatted images were\n obtained.\n\n CT CHEST: There is moderate cardiomegaly. A small pericardial effusion is\n identified. Aortic and coronary calcifications are identified. Right\n subclavian Swan-Ganz catheter and nasogastric tube are seen. The patient's\n endotracheal tube is now at the level of the carina and possibly into the\n right main stem bronchus. No mediastinal, hilar, or axillary lymphadenopathy\n is identified. There are small bilateral pleural effusions, greater on the\n right. Both lower lobes are consolidated. Scattered right nodular opacities,\n more prominent on the right again noted but appear slightly improved compared\n to prior examination.\n\n CT ABDOMEN: Within the limits of this non-contrast study, the liver,\n gallbladder, native pancreas, spleen, adrenal glands, and atrophic native\n kidneys are stable. Small calcifications are again noted in the gallbladder.\n Stomach and bowel loops are within normal limits. There is no mesenteric or\n retroperitoneal lymphadenopathy. Diffuse mesenteric and retroperitoneal\n stranding is identified as is a small amount of free fluid.\n\n CT PELVIS: Foley catheter and air are observed in the bladder. The uterus,\n adnexa, sigmoid colon, and rectum are stable. The transplant kidney and\n pancreas are unchanged in appearance. There is a small amount of free fluid.\n There is no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n Chronic left-sided lumbar transverse process fractures are again identified.\n\n IMPRESSION:\n 1. Bilateral lower lobe consolidations which could represent atelectasis\n versus pneumonia. The patchy ground-glass and nodular pulmonary opacities\n seen on chest CT of , appear slightly less prominent. Again\n (Over)\n\n 11:23 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for signs of lymphoma/occult infection\n Admitting Diagnosis: ABDOMINAL PAIN\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the differential includes CMV, TB, and fungal infection.\n\n 2. No lymphadenopathy identified in the chest, abdomen, and pelvis.\n\n 3. Diffuse mesenteric and retroperitoneal stranding and small amount of\n intra-abdominal free fluid which could be related to volume status.\n\n 4. Cholelithiasis without evidence of cholecystitis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-01-15 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 901101,
"text": " 7:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval L SC line, pulled back\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53F s/ p kidney transplant with fever n/v and elevated Cr, now extubated.\n\n REASON FOR THIS EXAMINATION:\n eval L SC line, pulled back\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Kidney transplant with fever, nausea, vomiting and elevated\n creatinine. Evaluate left subclavian central line, pulled back.\n\n COMPARISON: at 1445.\n\n UPRIGHT AP CHEST: The left subclavian line has been retracted, with the tip\n now in the SVC. A Dobbhoff tube remains in place, with the tip overlying the\n stomach, oriented toward the pylorus. Cardiac, mediastinal, and hilar\n contours are unchanged, with mild cardiomegaly. Congestive failure has\n improved since the exam of 1445. Small bilateral pleural effusions may be\n also slightly improved. No pneumothorax.\n\n IMPRESSION:\n 1. A satisfactorily positioned left subclavian central line.\n 2. Improved failure.\n\n\n"
}
] |
32,410 | 129,228 | The pt. was admitted to the CVICU and was fully cultured. He was continued on his Daptomycin and cardiology and ID were consulted. He had a TEE which revealed 4+MR, vegetations on the AV and MV, a paravalvular leak, and an aortic- with abscess. He had also had severe back pain and had a spine MRI which showed possible discitis at T4-T5 and a question of discitis osteomyelitis at L3-L4 and possible L1-L2. On he underwent Redo sternotomy, AVR(23 mm porcine)/MVR(29 mm porcine)/closure of aorto- . The cross clamp time was 170 mins. and total bypass 215 mins. He tolerated the procedure well and was transferred to the CV ICU on Nitro and Epi in stable condition. His renal function deteriorated and he became oliguric. CVVH was begun on POD 3 after a renal consultation. He was extubated, then re intubated on POD #1 after only 11 minutes extubated. He went into A Fib with hypotension on POD #2 and was cardioverted to SR. Bronchoscopy done POD #2 for secretions and RLL collapse. Chest tubes also removed. Cardioverted again unsuccessfully on POD #4 but was not hypotensive. Cardiology consulted. Repeat bronch done POD #5. He remained stable and off pressors. He was making some urine and CVVH was converted to HD. After the treatment the dialysis catheter was removed and dialysis not required subsequently He was cultured for sternal drainage on POD #6 and ID re consulted. He was extubated again on POD #7. Haldol was given for agitation. The lower end of the sternal incision was opened and cultured negative on POD #8. A PICC line was also placed. Meropenem was started for pseudomonas in the urine. Postoperatively he had severe confusion in the ICU which responded to Haldol and cleared over several days. He has remained intact and Haldol has been reduced. He was transferred to the floor on POD # 13, but transferred back to the CV ICU early on POD #14 for respiratory distress. A right chest tube was placed for a large effusion. IV heparin and low dose Coumadin were started. Continued diuresis for mild CHF was carried out. The CT was eventually removed. The sternal wound was sterile(on antibiotics for endocarditis)and a wound vac was placed on . The wound has remained clean and the vac is changed every three days. He has continued to make adequate urine and the renal function has remained stable. At this point he is ready for rehabilitation and will complete a 6 week course of Daptomycin. | Again there is a small pneumothorax in the axillary region and stable right pleural effusion with atelectatic change at the base. FINDINGS: The cardiac silhouette is enlarged and there are small bilateral pleural effusions, unchanged. Small amount of edema involving T4/5 intervertebral disk, a nonspecific finding. Right PICC has been placed and ends in the low superior vena cava. CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Small amount of perihepatic ascites is present. FINDINGS: The patient has been extubated, the nasogastric tube has been removed. The patient is status post median sternotomy, as before. There is a small amount of low attenuation fluid, adjacent to the sternum posteriorly, and contiguous with the pericardial space. Right PICC still ends in mid SVC. There is probable a small right pleural effusion. Mild pleural effusions are seen bilaterally. Right PICC ends in the low superior vena cava. Unchanged appearance of small bilateral pleural effusions and cardiomegaly. Right pleural effusion with adjacent atelectasis significantly decreased. Incidentally noted is a duodenal diverticulum. A small fat-containing left inguinal hernia is noted. There is persistent left apical pneumothorax, unchanged from the previous study. The right-sided chest tube has been removed. IMPRESSION: Unchanged evaluation of the thoracic spine with possible discitis at T4-T5. FINDINGS: There is a tiny left apical pneumothorax. Right PICC line ends low in the SVC. A radiopaque density is seen projecting over the mid cardiac region, unchanged. FINAL REPORT PORTABLE CHEST ON AT 11:17 INDICATION: Right PICC tip. Swan-Ganz catheter terminates in the right main pulmonary artery. persistent tiny left apical pneumothorax. Compared to the film from the prior day the right lung looks slightly worse and a new tiny left apical pneumothorax is visualized. There is consolidation bilaterally with volume loss/loculated fluid on the left and a right effusion with perihilar haze and patchy areas of consolidation on the right. Bilateral pleural fluid collections are noted. There continues to be a small right effusion with right lower lobe volume loss. FINAL REPORT MRI of the thoracic and lumbar spine without gadolinium. ogt to lwsx, scant clear dng. IV Daptomycin q48hrs. hypo bsp. Haldol am/pm orders halved. crrt cont w/ pt tol fluid removals. f/u renal fxn/status. Heparin gtt d/c'd this am. pt remain on daptomycin iv.cv; 1avb with pri 0.28. on po lopressor. REPLETED.PAIN- DENIESPLAN- MONITOR BUN/CR. ambien held this shift d/t confusion last noc. Mild (1+) paravalvular aortic regurgitation is seen. tol neg fluid balance.plan: weant to cpap for am. REORIENTED PRN. Desats with apneic episodes briefly. addendum npnresp: pmh=apnea. R pleural ct to sxn-no leak/crepitus-minimum drg-- dsd saturated with serosang -changed. pt still have bodily edemadous 2+pitting peripheral, skin w/d.resp: ls very diminish in bases, more on Rll. presently on MMV.gi/gu: abd soft. sporadic episodes of apnea w/ prior good abg on cpap. CONTIUE ON ABX FOR RISISNG WBC.ASSESS NBEURO STATUS-> RE-ORIENT PRN. NORMOTHERMIC. LS clear, pt coughing and DB well. HD to be done in am.Skin: Duoderm to bil elbows. (+) CSM. Mild paravalvular aortic regurgitation. HUO min (HD today). cont in afib, rate controlled. +++ SYSTOLIC MURMUR NOTED. ADMITTED TO OSH ON , BLD CX + VRE, NARES SWAB + MRSA, URNE CX + PSEUDOMONAS. Respiratory CarePt has known Hx of OSA. CT cont to drain mod amt serosang. MDIs & nebs ordered. wean vent, cont cvvh. ADMISSION CHEST XRAY DONE.RENAL: HX CRI SINCE . HX ANEMIA, CRI. Absent bowelsounds.Oliguric throughout this post-operative period. Pt found od , pt tachypneic, suspended.PT placed back on AC for bronch. Haldol ordered (AM & HS). sternum steristrips CDI, mediastinal chest tube site pink, scant serosang drainage dsd's changed. 2 sets V's, 1 set A's. CarePt receieved on AC intubated with a 7.5 ett. scant serous/serosanguinous DRG noted on assessment.PLAN: Under close monitoring for worsening pulm status and changes in mentation. dapto and meropenum. converted to sinus tach sever hours later, sbp remaining labile; on and off neo. ABDOMEN SOFLTY DISTENDED, + BOWEL SOUNDS. cpap+PS in eve, but pt with low volumes-->apneic periods so changed to cmv overnoc. occ wheezing heard. Off pressors.Resp: CPAP 5/0--abg good. In af briefly , hypotensive. MD Levrsen notified. dulcolax supp. picc in -> d/c tlc. now w/ attempt diuresis w/ lasix 100mg iv and diuril. Staple removed and deep cx obtained. OLD LINE D/CD AND TIP CULTURED. I/D ON DAPTOMYCIN /MEROPENEM PRESENTLY. PT REORIENTED BY RN PRN. incision as noted. NBP 120's-130's,MAP 70's-80's.Palpable DP/PT pulses bilat,warm csm and +1 LE edema bilat. clearing slightly overnoc. AFEBRILE, 1ST DEGREE AVBLOCK. Allevyn over coccyx. extubation, abd sogt. PROB: CVVHDO: FILTER CLOTTED OFF. CA, K AND CITRATE CONTINUE. Willing to try am dulcolax supp. distal inc packed w/ gauze.resp: wean to n/c 4 l. lungs clear, dim bases. ON ROUNDS TO REPEAT DOSE. NOTED LEFT SIDED WIPEOUT, SUNCTIONED RECRUITMENT BREATHS, CXR AT 1630 IMPROVED. cont abx. GU: ML UO /HR. RECEIVED HALDOL 1 MG WITH SOME EFFECT. abd soft, c/o needs to have a BM. Encouraged CDB and I.S. pt febrile at the time, self resolved. DOBHOFF TO BE PLACED THIS AM. ett rotated,small abrasion noted rt. PSV again but returned to rate for bronch. BS ronchi, clear with sx. sternum with steristrips CDI chest tube sites approximating, scant serosang drainage dsd's changed. Reoriented, Haldol Q am and pm. daptomycin and meropenem continue.GI/GU: minimal urine out via foley. Sinus rhythm with first degree A-V delay. change foley in am, continue CCVHD, wean from vent. CONT TO REMOVE FLUID AS PT TOLERATES. First degree A-V block. REORIENTED AS NEEDED. transient hypotension sbp 90's with re-initiation of cvvh. Sinus rhythm. Sinus rhythm. Sinus rhythm. PT CONTINUES ON CVVHD. RESP CARE NOTEPT CONTINUES ON PSV . HD d/c'd .Plan-? First degree A-V delay. First degree A-V delay. Right axis deviation. Right axis deviation. Last ABG 7.45/41/94/29/3. Per resident request pt placed back on PS. ABGS ADEQUATE, SET CURRENTLY PENDING. coccyx pink but unbroken,mduoderm applied. LEG IMMOBILIZER ON WITH IMPROVEMENT. BUN 30, CR 2.2. monitor lytes and abg, wean fio2 Rightaxis deviation. CHEST INCISION DRAINING LESS, DRESSING INTACT.NEURO: MAE, CALLING OUT CONTINUOUSLY AFTER EXTUBATION. | 113 | [
{
"category": "Radiology",
"chartdate": "2131-07-24 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1030355,
"text": ", W. CSURG CSRU 6:03 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: r/o infection - sternal drainage and inc wbc s/p mvr and avr\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p avr and mvr\n REASON FOR THIS EXAMINATION:\n r/o infection - sternal drainage and inc wbc s/p mvr and avr - no contrast do\n to renal failure please page if questions \n CONTRAINDICATIONS for IV CONTRAST:\n ATN\n ______________________________________________________________________________\n PFI REPORT\n 1. Small amount of low attenuation fluid adjacent to the sternum and tracking\n into the pericardial space. The pericardial catheter in place. Difficult to\n exclude infection without intravenous contrast, however, no thick-walled\n collection identified.\n\n 2. Presence of multifocal pneumonia and bilateral pleural effusions.\n\n 3. Findings consistent with pulmonary edema.\n\n 4. Pancreatic head lipoma.\n\n 5. Bilobed infrarenal aortic aneurysm, extending into the iliac vessels\n without evidence of rupture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-14 00:00:00.000",
"description": "MR THORACIC SPINE W/O CONTRAST",
"row_id": 1028172,
"text": " 5:23 PM\n MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: r/o septic emboli\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with VRE prosthetic valve endocarditis and back pain\n REASON FOR THIS EXAMINATION:\n r/o septic emboli\n CONTRAINDICATIONS for IV CONTRAST:\n creatinin =2.6\n\n Yes to Choyke questions.\n ______________________________________________________________________________\n WET READ: ARHb SAT 8:25 PM\n Limited evaluation without contrast. No obvious fluid collections and no\n abnormal signal. Lower cervical degenerative changes with posterior disk\n bulges which contact anterior and cause and canal stenosis. Small amount\n of edema involving T4/5 intervertebral disk, a nonspecific finding.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the thoracic spine.\n\n CLINICAL INFORMATION: Patient with heart prosthesis and bacteremia and back\n pain, question of osteomyelitis.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n thoracic spine were acquired.\n\n FINDINGS: Mild multilevel degenerative changes are identified. At T4-5,\n there is increased signal seen within the disc without abnormalities in the\n adjacent endplates. The patient did not receive contrast secondary to low\n EGFR of 25. This finding could be due to degenerative change or early focus\n of discitis.\n\n Degenerative changes are seen in the lower cervical region. Mild indentation\n on the spinal is seen by disc bulging. No abnormal spinal signal\n identified in the thoracic region.\n\n The T4-5 disc is not evaluated on axial images as patient was unable to\n continue. Mild pleural effusions are seen bilaterally.\n\n IMPRESSION: Subtle increased signal within the T4-5 disc could be due to\n degenerative change or early focus of discitis. Gadolinium-enhanced imaging\n would have helped but patient could not have gadolinium secondary to eGFR <\n 30. It is recommended that patient get repeat imaging of the whole spine to\n exclude focus in other part of the spine as well as additional focused images\n of T4-5 disc with axial images at that level. Following this, if the\n suspicion persists, gadolinium-enhanced images can be obtained following\n consent from the patient and nephrology consultation. Findings were discussed\n with Dr. at the time of interpretation of this study and were also\n discussed with Dr. .\n (Over)\n\n 5:23 PM\n MR THORACIC SPINE W/O CONTRAST Clip # \n Reason: r/o septic emboli\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032332,
"text": " 3:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p redo sternotomy/AVR/MVR\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to evaluate for pneumothorax.\n\n In comparison with the study of , there is no definite pneumothorax at this\n time.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029793,
"text": " 10:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate left side\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p aorta replacement\n REASON FOR THIS EXAMINATION:\n evaluate left side\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SUN 2:35 PM\n Right lower lobe consolidation has worsened, worrisome for pneumonia. Left\n lower lobe partial collapse is persistent with associated small left pleural\n effusion. Probable right pleural effusion. Swan-Ganz catheter tip is in the\n right pulmonary artery. ET tube is in standard position. NG tube tip is in\n the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: S/P aorta replacement, intubated patient.\n\n Comparison is made with multiple prior studies including .\n\n Right lower lobe consolidation has worsened, worrisome for pneumonia. Left\n lower lobe partial collapse is persistent with associated adjacent small left\n pleural effusion. There is probable a small right pleural effusion. ET tube\n is in standard position. Swan-Ganz catheter tip is in the main pulmonary\n artery. NG tube tip is in the stomach.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2131-08-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031815,
"text": " 11:06 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n s/p ct placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc WED 4:03 PM\n Since earlier today, right chest tube was installed. Right pleural effusion\n and adjacent atelectasis significantly decreased. Small pneumothorax along\n the axillary line is new. Right PICC line ends in mid SVC. No other change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n REASON FOR EXAM: Status post chest tube placement.\n\n Since earlier today, recent sternotomy was performed. Right chest tube was\n installed. Right pleural effusion with adjacent atelectasis significantly\n decreased. Small pneumothorax along the axillary line is new. No other\n change. Right PICC still ends in mid SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031816,
"text": ", W. CSURG CSRU 11:06 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p ct placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n s/p ct placement\n ______________________________________________________________________________\n PFI REPORT\n Since earlier today, right chest tube was installed. Right pleural effusion\n and adjacent atelectasis significantly decreased. Small pneumothorax along\n the axillary line is new. Right PICC line ends in mid SVC. No other change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031307,
"text": " 10:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate atelectasis\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate atelectasis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DJRX SUN 2:16 PM\n No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Evaluate atelectasis. PICC placement.\n\n One portable view. The right side of the chest is not entirely included.\n Bilateral pleural effusions and right lung consolidation are again\n demonstrated. The patient is status post median sternotomy, as before.\n Mediastinal structures are unchanged in appearance. A PICC line remains in\n place.\n\n IMPRESSION: Limited study demonstrating no significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031308,
"text": ", W. CSURG CSRU 10:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate atelectasis\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n evaluate atelectasis\n ______________________________________________________________________________\n PFI REPORT\n No significant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031997,
"text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check R effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n check R effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right effusion, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the right chest tube remains\n in place. Again there is a small pneumothorax in the axillary region and\n stable right pleural effusion with atelectatic change at the base. The\n remainder of the study is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1030764,
"text": " 4:28 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 52 cm long DL 5 Fr Vaxcel Picc placed in right brachial vein\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 52 cm long DL 5 Fr Vaxcel Picc placed in right brachial vein, need Picc tip\n placement\n ______________________________________________________________________________\n WET READ: 5:09 PM\n Right PICC ends in the low SVC.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 73-year-old man with PICC placement.\n\n COMPARISON: Multiple prior radiographs, most recent dated .\n\n FINDINGS: The patient has been extubated, the nasogastric tube has been\n removed. Right PICC has been placed and ends in the low superior vena cava.\n There is no significant change in the appearance of the consolidation,\n involving the right lung. The degree of moderate pulmonary edema,\n asymmetrically more prominent on the right, is stable. The left costophrenic\n angle is excluded from the field of view, the right small pleural effusion has\n not changed. The degree of cardiomegaly is stable. The appearance of the\n median sternotomy wire is unchanged compared to the prior studies. No\n pneumothorax.\n\n IMPRESSION:\n 1. Right PICC ends in the low superior vena cava.\n 2. No change in the appearance of right lung consolidation, degree of\n cardiomegaly, pulmonary edema, or right pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1030179,
"text": ", W. CSURG CSRU 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p AVR/MVR\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Increase in right basilar opacity concerning for pneumonia or hemorrhage.\n Otherwise unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1031736,
"text": " 12:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/pAVR/MVR w/acute onset tachypnea/hypoxia-r/o PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n s/pAVR/MVR w/acute onset tachypnea/hypoxia-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post AVR and MVR with new-onset tachypnea, to evaluate for\n pneumothorax.\n\n FINDINGS: In comparison with study of , there is again layering pleural\n effusion on the right that may be more prominent than on the previous study.\n Atelectatic change or consolidation is seen at the right base. The left lung\n remains relatively clear. Midline sternal sutures are intact.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1030178,
"text": " 7:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p AVR/MVR\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa TUE 2:27 PM\n Increase in right basilar opacity concerning for pneumonia or hemorrhage.\n Otherwise unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n COMPARISON: .\n\n HISTORY: Status post AVR and MVR.\n\n FINDINGS: The cardiac silhouette is enlarged and there are small bilateral\n pleural effusions, unchanged. The ET tube is approximately 2.2 cm above the\n carina, unchanged. Interval increase in right basilar consolidation is\n concerning for pneumonia or hemorrhage.\n\n IMPRESSION:\n 1. Interval increase in right basilar consolidation concerning for worsening\n pneumonia or possible hemorrhage.\n 2. Unchanged appearance of small bilateral pleural effusions and\n cardiomegaly.\n\n Findings discussed with via telephone.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-24 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1030354,
"text": " 6:03 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: r/o infection - sternal drainage and inc wbc s/p mvr and avr\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p avr and mvr\n REASON FOR THIS EXAMINATION:\n r/o infection - sternal drainage and inc wbc s/p mvr and avr - no contrast do\n to renal failure please page if questions \n CONTRAINDICATIONS for IV CONTRAST:\n ATN\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 11:00 PM\n 1. Small amount of low attenuation fluid adjacent to the sternum and tracking\n into the pericardial space. The pericardial catheter in place. Difficult to\n exclude infection without intravenous contrast, however, no thick-walled\n collection identified.\n\n 2. Presence of multifocal pneumonia and bilateral pleural effusions.\n\n 3. Findings consistent with pulmonary edema.\n\n 4. Pancreatic head lipoma.\n\n 5. Bilobed infrarenal aortic aneurysm, extending into the iliac vessels\n without evidence of rupture.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO WITHOUT INTRAVENOUS CONTRAST\n\n INDICATION: 73-year-old male status post aortic and mitral valve replacement.\n Presenting with sternal drainage and leukocytosis, rule out infection.\n\n COMPARISON: CT abdomen and pelvis dated .\n\n TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis were obtained\n without administration of intravenous contrast secondary to patient's renal\n insufficiency. Coronal and sagittal reformatted images were obtained and\n reviewed.\n\n CT CHEST WITHOUT INTRAVENOUS CONTRAST: The right thyroid lobe is enlarged,\n and heterogeneous, measuring 4.0 x 2.3 cm.\n\n Bilateral moderate nonhemorrhagic right greater than left pleural effusions\n are present. There is compression atelectasis bilaterally, as well as patchy\n consolidations in the right upper, right middle and right lower lobe. Small\n areas of consolidation are noted in the left lower lobe. There is\n interstitial septal thickening as well as perihilar ground-glass attenuation,\n consistent with pulmonary edema.\n\n Extensive coronary artery calcifications are noted. The patient is post-\n (Over)\n\n 6:03 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: r/o infection - sternal drainage and inc wbc s/p mvr and avr\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mitral and aortic valve replacement.\n\n There is a small pericardial effusion. There is a small amount of low\n attenuation fluid, adjacent to the sternum posteriorly, and contiguous with\n the pericardial space. The fluid is without well-defined borders, however,\n without IV contrast it is difficult to rule out a collection.\n\n Numerous small mediastinal lymph nodes are present, measuring up to 10 mm in\n the mediastinum. The airways are patent to the lobar levels bilaterally. The\n segmental airways are difficult to evaluate secondary to some image\n degradation by motion. Small amount of secretions are noted in the left main\n stem bronchus. The patient is intubated, and endotracheal tube ends 3.5 cm\n above the carina.\n\n CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Small amount of perihepatic ascites\n is present. Non-contrast evaluation of the liver, spleen, and kidneys is\n unremarkable. 10-mm right adrenal nodule is noted. Fatty lesion is seen\n again within the pancreatic head. Incidentally noted is a duodenal\n diverticulum. Patient is status post cholecystectomy.\n\n An IVC filter remains in place.\n\n Again seen is an infrarenal abdominal aortic aneurysm, previously identified\n and described on the CT of the abdomen of , with bilobed\n appearance and extension into the iliac vessels. There is no free\n retroperitoneal fluid or stranding to suggest rupture. There is no\n pathologically enlarged mesenteric or retroperitoneal lymph nodes.\n\n CT PELVIS WITHOUT INTRAVENOUS CONTRAST: Urinary bladder is collapsed around\n the Foley catheter. The prostate remains enlarged. There is trace free fluid\n in the pelvis. No pathologically enlarged lymph nodes.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions noted. The appearance\n of the osseous structures are unchanged from the most recent prior studies and\n demonstrates some degenerative changes in the lumbar spine.\n\n The patient is post-median sternotomy with sternotomy wires which appear\n intact as well as surgical skin staples. No evidence of osseous destruction\n about the sternum.\n\n IMPRESSION:\n 1. Small amount of low attenuation fluid just inferior to the sternum,\n tracking into the pericardial space, unable to rule out infection based on the\n non-contrast study, no thick-walled fluid collection is identified though.\n\n (Over)\n\n 6:03 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: r/o infection - sternal drainage and inc wbc s/p mvr and avr\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Bilateral pleural effusions and multifocal consolidations, most concerning\n for pneumonia.\n\n 3. Findings consistent with pulmonary edema.\n\n 4. Large bilobed infrarenal aortic aneurysm without evidence of rupture at\n this time.\n\n 5. Pancreatic head lipoma.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029794,
"text": ", W. CSURG CSRU 10:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate left side\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p aorta replacement\n REASON FOR THIS EXAMINATION:\n evaluate left side\n ______________________________________________________________________________\n PFI REPORT\n Right lower lobe consolidation has worsened, worrisome for pneumonia. Left\n lower lobe partial collapse is persistent with associated small left pleural\n effusion. Probable right pleural effusion. Swan-Ganz catheter tip is in the\n right pulmonary artery. ET tube is in standard position. NG tube tip is in\n the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1030067,
"text": " 3:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p avr mvr\n REASON FOR THIS EXAMINATION:\n s/p bronch\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc MON 5:09 PM\n PFI: Since yesterday, ETT tip is 2.7 cm above the carina. Nasogastric tube\n ends in the stomach. Swan-Ganz was removed. Left basilar aeration greatly\n improved. Right basilar consolidation, slightly decreased but right pleural\n effusion slightly increased.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP:\n\n REASON FOR EXAM: 73-year-old man with status post AVR, MVR and bronchoscopy.\n\n Since yesterday, ETT tip is 2.7 cm above the carina. Nasogastric tube\n tip ends in the stomach. Swan-Ganz catheter was removed. Sternotomy for AVR\n and MVR is unchanged.\n\n Left basilar aeration greatly improved. Right basilar consolidation slightly\n decreased, but right pleural effusion partly layering posteriorly, slightly\n increased.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-24 00:00:00.000",
"description": "LP UNILAT UP EXT VEINS US LEFT PORT",
"row_id": 1030277,
"text": " 1:04 PM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: r/o dvt - edema, previous picc in left arm\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p mvr, avr\n REASON FOR THIS EXAMINATION:\n r/o dvt - edema, previous picc in left arm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RGS TUE 6:02 PM\n No evidence of deep vein thrombosis in the left arm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with left arm edema and previous PICC line.\n\n COMPARISON: No previous exams for comparison.\n\n FINDINGS: -scale, color and Doppler son of the left IJ, subclavian,\n axillary, brachial, basilic and cephalic veins were performed. There is\n normal flow, compression and augmentation seen in all the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in the left arm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-24 00:00:00.000",
"description": "LP UNILAT UP EXT VEINS US LEFT PORT",
"row_id": 1030278,
"text": ", W. CSURG CSRU 1:04 PM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: r/o dvt - edema, previous picc in left arm\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p mvr, avr\n REASON FOR THIS EXAMINATION:\n r/o dvt - edema, previous picc in left arm\n ______________________________________________________________________________\n PFI REPORT\n No evidence of deep vein thrombosis in the left arm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1030068,
"text": ", W. CSURG CSRU 3:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p avr mvr\n REASON FOR THIS EXAMINATION:\n s/p bronch\n ______________________________________________________________________________\n PFI REPORT\n PFI: Since yesterday, ETT tip is 2.7 cm above the carina. Nasogastric tube\n ends in the stomach. Swan-Ganz was removed. Left basilar aeration greatly\n improved. Right basilar consolidation, slightly decreased but right pleural\n effusion slightly increased.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1032938,
"text": " 10:18 AM\n CHEST (PA & LAT) Clip # \n Reason: check R effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n check R effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf TUE 12:12 PM\n PFI: No change compared to the previous study.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old man with status post AVR, MVR. Follow up effusion.\n\n TECHNIQUE: PA and lateral views of the chest were obtained.\n\n COMPARISON: Chest x-ray from .\n\n FINDINGS: Compared with the chest x-ray from , there is no\n significant change. Again noted is bilateral opacification of the lungs, more\n prominent on the right. Again noted is bilateral pleural effusion, more\n prominent on the right. The right effusion is loculated. The cardiac\n silhouette is unchanged compared to the previous scan. The visualized soft\n tissue and osseous structures are unchanged compared to the previous study.\n The post-surgical changes appear unchanged compared to the previous study.\n There is persistent left apical pneumothorax, unchanged from the previous\n study.\n\n IMPRESSION: No significant change compared to the previous study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1032939,
"text": ", W. CSURG FA6A 10:18 AM\n CHEST (PA & LAT) Clip # \n Reason: check R effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n check R effusion\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change compared to the previous study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032833,
"text": " 5:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p avr, mvr\n REASON FOR THIS EXAMINATION:\n f/u effusion\n ______________________________________________________________________________\n WET READ: JXRl MON 6:16 PM\n increase in right effusion, airspace consolidation. persistent tiny left\n apical pneumothorax. -\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:57 P.M., \n\n HISTORY: Status post AVR and MVR:\n\n Moderate right pleural effusion increased, mild pulmonary edema, moderate\n cardiomegaly and mediastinal vascular engorgement stable. Right PICC line\n ends low in the SVC. Tiny if any left apical pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032366,
"text": " 7:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for pneumo s/p chest tube removal\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/predo/AVR/MVR\n REASON FOR THIS EXAMINATION:\n eval for pneumo s/p chest tube removal\n ______________________________________________________________________________\n WET READ: MRGe FRI 10:09 PM\n Small left apical pneumothorax. No other significant change since prior study\n at 16:30. D/W Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Evaluate for pneumonia status post chest tube.\n\n REFERENCE EXAM: at 14:30.\n\n FINDINGS: There is a tiny left apical pneumothorax. This was discussed with\n the house staff at the time the study was originally interpreted on . The\n right-sided chest tube has been removed. Right PICC line with tip in the\n right atrium is unchanged. There is consolidation bilaterally with volume\n loss/loculated fluid on the left and a right effusion with perihilar haze and\n patchy areas of consolidation on the right. Compared to the film from the\n prior day the right lung looks slightly worse and a new tiny left apical\n pneumothorax is visualized.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-08-04 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1032431,
"text": " 10:43 AM\n CHEST (SINGLE VIEW) Clip # \n Reason: Is CHF getting worse s/p AVR/MVR\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n Is CHF getting worse s/p AVR/MVR\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS ON \n\n HISTORY: CHF.\n\n FINDINGS: Two views AP semi-upright demonstrate loculated fluid and volume\n loss in the left lateral lung. The left apical pneumothorax is decreased in\n size. The right subclavian line with tip in the right atrium is unchanged.\n There continues to be a small right effusion with right lower lobe volume\n loss. There is pulmonary vascular redistribution, perihilar haze suggesting\n fluid overload. Compared to the film from the prior day there is no\n significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-15 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1028257,
"text": " 9:36 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o abscess\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with prosthetic aortic valve endocarditis and back pain\n REASON FOR THIS EXAMINATION:\n r/o abscess\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine=2.6\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe SUN 12:27 PM\n Markedly limited evaluation without IV contrast to assess for abscesses. No\n abnormal free fluid collections. Bilobed infrarenal aortic aneurysm.\n Comparison to prior imaging would be helpful to see if this is enlarging and\n may explain the patient's back pain. No findings to suggest leak/rupture.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Prosthetic aortic valve endocarditis and back pain. Evaluate for\n abscess.\n\n No priors are available.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis without contrast and with oral contrast. IV contrast was withheld due\n to renal function.\n\n CT OF THE ABDOMEN WITH ORAL CONTRAST ONLY: Please note that evaluation of the\n lung bases is limited due to respiratory motion. There is mild diffuse ground\n glass opacity as well as septal thickening and small bilateral simple pleural\n effusions, right greater than left, with adjacent compressive atelectasis.\n Mitral and aortic valve prostheses are noted.\n\n Non-contrast evaluation of the liver, spleen, adrenal glands, and kidneys is\n unremarkable. The pancreas body and tail are normal. A 10 x 14 mm fatty\n lesion is noted within the pancreatic head. The patient is status post\n cholecystectomy. An IVC filter is noted in place. Moderate to severe\n atherosclerotic disease is noted within the intra-abdominal aorta which\n displays aneurysmal dilatation of the infrarenal segment, which appears\n bilobed, the more superior segment measuring approximately 4.7 x 4.9 and the\n more inferior segment measuring approximately 5.5 x 5.6 cm. Extension into\n the common iliac vessels is noted, the left more than the right, with the left\n measuring approximately 3 x 3.4 cm approximately. No retroperitoneal\n stranding or free fluid is noted to suggest rupture. No free air, free fluid,\n or pathologically enlarged lymph nodes are identified.\n\n CT OF THE PELVIS WITH ORAL CONTRAST ONLY. Mild-to-moderate amount of stool is\n noted within the large bowel which appears otherwise unremarkable. The\n prostate is markedly enlarged measuring approximately 6.4 x 6.8 cm with\n hypertrophy of the median lobe which projects into the urinary bladder. No\n pathologically enlarged lymph nodes or free fluid is noted within the pelvic\n cavity. A small fat-containing left inguinal hernia is noted.\n (Over)\n\n 9:36 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o abscess\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: No malignant-appearing osseous lesions are identified.\n Multilevel degenerative changes are noted with Schmorl's node formation noted\n at L3-4 involving the superior endplate of L4. Osteoarthritic changes are\n noted within the hip joints bilaterally.\n\n IMPRESSION:\n 1. No abnormal free fluid collections. Please note the evaluation for solid\n organ abscesses is markedly limited by inability to give IV contrast. If high\n clinical suspicion, could consider evaluation with a tagged white cell scan.\n\n 2. Small bilateral pleural effusions with septal thickening and mild diffuse\n ground glass opacities of the lungs is most suggestive of underlying pulmonary\n edema/mild CHF.\n\n 3. Bilobed infrarenal aortic aneurysm as described above without evidence of\n rupture. The aneurysm does appear to extend into the proximal common iliacs.\n Comparison to prior outside imaging would be helpful to assess for any change\n in the size of this aneurysm which may explain the patient's back pain.\n\n 4. Marked prostatic hypertrophy.\n\n 5. Pancreatic head lipoma\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029248,
"text": " 4:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess left side collapse\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p reintubation\n REASON FOR THIS EXAMINATION:\n assess left side collapse\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post reintubation.\n\n FINDINGS: In comparison with study of earlier in this date, there is little\n overall change in the appearance of the heart and lungs. Opacification at the\n left base with some shift of the mediastinum to this side is consistent with\n volume loss, though there also is some pleural effusion at the base.\n\n Following reintubation, the tip of the endotracheal tube lies approximately\n 4.9 cm above the carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-15 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1028258,
"text": ", CSURG CSRU 9:36 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o abscess\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with prosthetic aortic valve endocarditis and back pain\n REASON FOR THIS EXAMINATION:\n r/o abscess\n CONTRAINDICATIONS for IV CONTRAST:\n creatinine=2.6\n ______________________________________________________________________________\n PFI REPORT\n Markedly limited evaluation without IV contrast to assess for abscesses. No\n abnormal free fluid collections. Bilobed infrarenal aortic aneurysm.\n Comparison to prior imaging would be helpful to see if this is enlarging and\n may explain the patient's back pain. No findings to suggest leak/rupture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1028277,
"text": " 11:05 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 57cm right picc. tip?\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n 57cm right picc. tip?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 1:54 PM\n PICC tip in SVC.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 11:17\n\n INDICATION: Right PICC tip.\n\n FINDINGS:\n\n Right PICC line is seen with the tip in the SVC. Current study shows some\n increased density at the lung bases with a hazy appearance suggesting pleural\n fluid layering out. Left CP angle is cut off from view. Followup recommended\n to see if there is any evolution to airspace disease.\n\n IMPRESSION: PICC tip in SVC. Likely effusions layering out - followup\n recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028026,
"text": " 8:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: endocarditis\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n endocarditis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NLHa SAT 12:14 PM\n STUDY: Portable chest x-ray.\n\n Sternotomy wires. IVC filter. Right upper quadrant clips. No acute\n findings.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL VIEWS OF THE CHEST\n\n There are no prior exams for comparison.\n\n There are sternotomy wires in place. There is an IVC filter. There are\n surgical clips in the right upper quadrant. The osseous structures are within\n normal limits. There is calcification in the aortic arch. The cardiac\n silhouette is mildly enlarged. There is no pulmonary infiltrate or vascular\n congestion.\n\n IMPRESSION: Sternotomy wires.\n\n IVC filter.\n\n Surgical clips in the right upper quadrant.\n\n No acute findings.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028027,
"text": ", W. CSURG CSRU 8:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: endocarditis\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n endocarditis\n ______________________________________________________________________________\n PFI REPORT\n STUDY: Portable chest x-ray.\n\n Sternotomy wires. IVC filter. Right upper quadrant clips. No acute\n findings.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-16 00:00:00.000",
"description": "PROSTATE U.S.",
"row_id": 1028505,
"text": ", W. CSURG CSRU 4:07 PM\n PROSTATE U.S. Clip # \n Reason: prostate abscess\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man preop double valve chronic UTI\n REASON FOR THIS EXAMINATION:\n prostate abscess\n ______________________________________________________________________________\n PFI REPORT\n Prostatic enlargement, predominantly involving the central gland, with\n prostatic volume of 170 cc and estimated predicted PSA of 20 without focal\n prostatic fluid collections or abscesses.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1029457,
"text": " 12:56 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p avr/mvr new hd catheter\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH:\n\n INDICATION: 73-year-old man, post-aortic and mitral valve replacement, with\n new hemodialysis catheter.\n\n COMPARISON: , 8:15 a.m.\n\n FINDINGS: Since the prior study, new dual lumen left subclavian venous\n catheter has been placed, but the tip is not clearly seen, and additional\n nonrotated radiograph would be helpful to better localize this device. There\n is no pneumothorax. No significant change in appearance of the chest since the\n recent prior study, including the rest of support devices, degree of\n cardiomegaly, and bibasilar opacities.\n\n Findings were discussed with at 2:45 p.m. on by\n Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1028278,
"text": ", CSURG CSRU 11:05 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 57cm right picc. tip?\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with\n REASON FOR THIS EXAMINATION:\n 57cm right picc. tip?\n ______________________________________________________________________________\n PFI REPORT\n PICC tip in SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029206,
"text": ", W. CSURG CSRU 2:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ett placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p avr/mvr reintubated\n REASON FOR THIS EXAMINATION:\n assess ett placement\n ______________________________________________________________________________\n PFI REPORT\n Left lung diffuse opacification likely secondary to effusion and collapse.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-16 00:00:00.000",
"description": "PROSTATE U.S.",
"row_id": 1028504,
"text": " 4:07 PM\n PROSTATE U.S. Clip # \n Reason: prostate abscess\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man preop double valve chronic UTI\n REASON FOR THIS EXAMINATION:\n prostate abscess\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb MON 7:31 PM\n Prostatic enlargement, predominantly involving the central gland, with\n prostatic volume of 170 cc and estimated predicted PSA of 20 without focal\n prostatic fluid collections or abscesses.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with chronic UTI, evaluate for prostate abscess.\n\n COMPARISON: CT abdomen and pelvis from .\n\n FINDINGS: Transrectal ultrasound evaluation of the prostate demonstrates\n enlargement of the central gland with a heterogeneous appearance, consistent\n with BPH. The peripheral zone is compressed by the enlarged central gland with\n no definite masses identified. The prostate measures 6.7 x 6.8 x 7.2 cm\n overall, corresponding to a prostatic volume of 170 cc and a predicted PSA of\n 20. Foley catheter in place. No focal abscesses or fluid collections in the\n prostatic or periprostatic region are noted.\n\n IMPRESSION:\n 1. No evidence of prostate abscess.\n 2. Prostatic enlargement corresponding to a prostatic volume of 170 cc with\n an estimated predicted PSA of 20.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-17 00:00:00.000",
"description": "MR THORACIC SPINE W/O CONTRAST",
"row_id": 1028601,
"text": " 8:41 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: spinal source of osteo\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n valve abscesses\n REASON FOR THIS EXAMINATION:\n spinal source of osteo\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb TUE 2:01 PM\n Findings concerning for discitis osteomyelitis at L3-L4 and L1-L2. Within\n limits of this unenhanced scan, no definite evidence for epidural abscess is\n seen.\n ______________________________________________________________________________\n FINAL REPORT\n MRI of the thoracic and lumbar spine without gadolinium. The study was\n limited by patient motion. Gadolinium could not be administered due to low\n eGFR.\n\n Multilevel degenerative changes of the cervical and thoracic spine are\n unchanged.\n The thoracic portion of the study again demonstrates questionable increased\n signal within the T4-T5 disc space which could be related to discitis.\n\n Evaluation of the lumbar spine demonstrates abnormal high signal within the\n L3-L4 disc space with edema in the adjacent endplates and destruction of the\n superior endplate of L4. Findings are highly concerning for discitis\n osteomyelitis. No definite evidence for epidural abscess is seen, although\n evaluation is limited due to lack of intravenous gadolinium. An additional\n focus of possible discitis osteomyelitis is seen at L1-L2.\n\n Bilateral pleural fluid collections are noted. There is a small left renal\n cyst.\n\n Again noted is an infrarenal aortic aneurysm which was better assessed on the\n CT abdomen and pelvis from .\n\n IMPRESSION:\n\n Unchanged evaluation of the thoracic spine with possible discitis at T4-T5.\n\n In the lumbar spine, there are findings highly concerning for discitis\n osteomyelitis at L3-L4 and possibly at L1-L2. Within limits of this\n unenhanced scan, no definite evidence for an epidural abscess is seen.\n\n Findings were discussed with .\n\n\n\n (Over)\n\n 8:41 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: spinal source of osteo\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1028936,
"text": " 3:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p Redo AVR, MVR\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AZB WED 6:56 PM\n _____ position of newly inserted monitoring and support devices, except for\n the endotracheal tube that could be slightly advanced.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Follow up.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the tip of a newly inserted\n chest tube is located 8 cm above the carina and could be slightly advanced. A\n newly inserted nasogastric tube has a normal course. The Swan-Ganz catheter\n is introduced over the right internal jugular vein, its tip projects over the\n outflow tract of the right ventricle. The pre-existing opacity in the right\n and the left lung bases has not substantially increased. There is no evidence\n of newly occurred parenchymal opacities. The cardiac silhouette is slightly\n smaller than before.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029205,
"text": " 2:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ett placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p avr/mvr reintubated\n REASON FOR THIS EXAMINATION:\n assess ett placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:03 PM\n Left lung diffuse opacification likely secondary to effusion and collapse.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMPARISON: .\n\n HISTORY: 73-year-old male status post AVR and MVR with reintubation.\n\n FINDINGS: ET tube is identified at approximately 5.6 cm above the carina.\n Swan-Ganz catheter terminates in the right main pulmonary artery. Multiple\n clips and sternotomy wires are noted. A radiopaque density is seen projecting\n over the mid cardiac region, unchanged. The right lung field is clear. There\n has been interval development of left pleural effusion and opacification of\n the left mid and lower lung fields, concerning for collapse, given volume\n loss. There is no evidence of pneumothorax.\n\n IMPRESSION: Interval development of left lung opacification with volume loss\n concerning for effusion and collapse.\n\n These findings were communicated to Dr. by telephone at 3:15\n p.m.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029358,
"text": " 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for collapse\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p avr/mvr- reintubated for collapse Leftnow on flow by\n REASON FOR THIS EXAMINATION:\n assess for collapse\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP.\n\n COMPARISON: .\n\n HISTORY: Assess for lobar collapse.\n\n FINDINGS: ETT is approximately 3.9 cm above the carina. A Swan-Ganz catheter\n is seen terminating in the right main pulmonary artery. There is increased\n pulmonary vasculature and interstitial opacities consistent with pulmonary\n edema, unchanged. Retrocardiac opacity and small left pleural effusion are\n unchanged.\n\n IMPRESSION: No significant change when compared to prior exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-17 00:00:00.000",
"description": "MR THORACIC SPINE W/O CONTRAST",
"row_id": 1028602,
"text": ", W. CSURG CSRU 8:41 AM\n MR THORACIC SPINE W/O CONTRAST; MR L SPINE W/O CONTRAST Clip # \n Reason: spinal source of osteo\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n valve abscesses\n REASON FOR THIS EXAMINATION:\n spinal source of osteo\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Findings concerning for discitis osteomyelitis at L3-L4 and L1-L2. Within\n limits of this unenhanced scan, no definite evidence for epidural abscess is\n seen.\n\n"
},
{
"category": "Echo",
"chartdate": "2131-07-18 00:00:00.000",
"description": "Report",
"row_id": 87251,
"text": "PATIENT/TEST INFORMATION:\nIndication: MVR/Re-do AVR with endocarditis\nStatus: Inpatient\nDate/Time: at 10:05\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\nRIGHT VENTRICLE: Mild global RV free wall hypokinesis.\n\nAORTA: Simple atheroma in ascending aorta. Simple atheroma in descending\naorta.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).\n\nMITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Severe (4+)\nMR.\n\nTRICUSPID VALVE: Moderate [2+] 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. 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-CPB:\nThere is a fistula between the aorta and the LA. It arises from the sinus of\nValsalva at the left cusp, tracks by the non-coronary cusp and enters the LA.\nNo spontaneous echo contrast is seen in the left atrial appendage.\nRV shows mild global free wall hypokinesis.\nThere are simple atheroma in the ascending aorta.\nThere are simple atheroma in the descending thoracic aorta.\nA bioprosthetic aortic valve prosthesis is present. The leaflets all move but\nare thickened. There is a peak gradient of 42 mmHg across it.\nThe mitral valve leaflets are severely thickened/deformed. Severe (4+) mitral\nregurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen.\nThere is no pericardial effusion.\n\nPost-CPB:\nThe patient is on an epinephrine infusion.\nThere is a well-seated and functioning mitral valve prosthesis. No leak, no\nMR.\nThere is a prothetic aortic valve, also well-seated and with no leak or AI.\nThe residual aortic valve mean gradient is 9 mmHg.\nRV systolic fxn is mildly depressed.\nLV systolic fxn is moderately depressed. EF remains 30 - 35%.\nAscending and descending aorta intact.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2131-07-14 00:00:00.000",
"description": "Report",
"row_id": 87252,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Prosthetic valve function.\nHeight: (in) 69\nWeight (lb): 230\nBSA (m2): 2.19 m2\nBP (mm Hg): 134/56\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 13:19\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Low normal LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo;\n\nRIGHT VENTRICLE: Borderline normal RV systolic function.\n\nAORTA: Simple atheroma in descending aorta.\n\nAORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Thickened AVR\nleaflets. Large vegetation on aortic valve. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Large vegetation on\nmitral valve. Severe (4+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. Local anesthesia was\nprovided by benzocaine topical spray. No TEE related complications. Results\nwere personally reviewed with the MD caring for the patient.\n\nConclusions:\nA bioprosthetic aortic valve prosthesis is present. The prosthetic aortic\nvalve leaflets are thickened. There are strand-like echodensities on the\naortic bioprosthesis (cine loop #28), most consistent with vegetations. In the\narea of the mitral-aortic valve fibrous continuity, at the posterior aspect of\nthe biopsrosthesis, there is an area of echolucency, almost certainly\nrepresenting a paravalvular abscess (cine loop #52). There is an aortic\nannulus-to-left atrium fistula, facilitated by the paravalvular abscess (cine\nloops #43-47). Mild (1+) paravalvular aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is a large vegetation (2.4 cm x 0.9\ncm) on the posterior mitral leaflet (cine loop #50) with probable perforation\nof the leaflet base. Severe (4+) mitral regurgitation is seen. No atrial\nseptal defect is seen by 2D or color Doppler. Overall left ventricular\nsystolic function is low normal (LVEF 50-55%). with mild hypokinesis of the\nanterior wall. There are atheroma in the descending thoracic aorta, which are\nubiqiutous, but not complex (<4 mm thickness).\n\nIMPRESSION: Endocarditis of the native mitral valve and bioprosthetic aortic\nvalve. Aortic annular abscess with annular-to-left atrial fistula.\nDegeneration of aortic valve biopsrosthesis out of proportion the age of\nprosthesis. Mild paravalvular aortic regurgitation. Severe mitral\nregurgitation. Mildly depressed LV systolic function.\n\nDr. was notified in person (and Dr. by phone) of the results on\n at 12:30 PM.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-07-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1028937,
"text": ", W. CSURG CSRU 3:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE;MITRAL REGURGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p Redo AVR, MVR\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n PFI REPORT\n _____ position of newly inserted monitoring and support devices, except for\n the endotracheal tube that could be slightly advanced.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-29 00:00:00.000",
"description": "Report",
"row_id": 1672681,
"text": "NEURO- ALERT/ORIENTED X . REORIENTED PRN. PLEASANT & COOPERATIVE WITH CARE. FOLLOWS ALL COMMANDS & ASSISTS WITH TURNING. HALDOL Q AM & QPM\n\nCV- REMAINS IN 1ST AVB WITH NO ECTOPY. BP STABLE. NORMOTHERMIC. COLD HANDS. (+) CSM. PALP. PEDAL PULSES.\n\n\nRESP- 1L NC. SATS 96-98%. LSC DIM @ BASES. I.S.UP TO 500. NO COUGH.\n\nGI- ABD SOFT. +BS. NO BM. SWALLOWS PO MEDS WITHOUT DIFFICULTY BUT DOES HAVE A SMALL COUGH AFTERWARDS.\n\nGU- FOLEY DRAINING 12-20CC/HR. CLEAR YELLOW URINE.BUN/CR RISING 40/2.5\n\nLABS-CAL.GLUC. REPLETED.\n\nPAIN- DENIES\n\nPLAN- MONITOR BUN/CR. U/O. CONTIUE ON ABX FOR RISISNG WBC.ASSESS NBEURO STATUS-> RE-ORIENT PRN. INCREASE DIET 7 ACTIVITY AS TOL. TRANSFER TO 6 WHEN MD APPROVED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-29 00:00:00.000",
"description": "Report",
"row_id": 1672682,
"text": "breath sounds diminished rt. > lt., more tachypneic with activity & talking,spo2 consistently 88-91%.increased coughing with tannish secretions.cxr->rt sided atelectasis vs infiltrate.activity increased,oob->chair x 2 & p.t. reconsulted.o2 increased to 2l with spo2 > 94%. minimal huo with sl. rise in bun & creat.lasix x 1 with increased diuresis,see flow sheet.appetite improving,requiring ssri for glucose management. allevyn intact on coccyx,surrounding area pink & yeasty appearing/criticaid with antfungal applied.family in,questions answered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-08-02 00:00:00.000",
"description": "Report",
"row_id": 1672689,
"text": "Neuro: Pt a+ox2 to self and date, not to place-easily reorient. pt on haldol po schedule. behavior appropriate, speech coherent. asking Rn appropriately, maex4 to command, no apparent deficit.\n\nid: afebrile. wbc trending down. pt remain on daptomycin iv.\n\ncv; 1avb with pri 0.28. on po lopressor. map >60, with sbp 100s-130s. no ectopies. ptt subtherapeutic, heparin ^ to 900units/hr. recieved coumadin po yesterday. pt still have bodily edemadous 2+pitting peripheral, skin w/d.\n\nresp: ls very diminish in bases, more on Rll. cta upper lobes. dry cough. sat maintain>96% on 4lnc. breathing even. R pleural ct to sxn-no leak/crepitus-minimum drg-- dsd saturated with serosang -changed. need reinforcement to use IS, dbc. pt IS ^ 500ml. MDI puff given.\n\nGI: Tol liquid overnoc, no difficulty swallow pill. abdoment soft/non-tender. +bs. colace.\nENDO: no coverage require\nGU: Bun & creatinine remained elevated! pt making fair huo with lasix via foley. renal follow.\nWound: per careview flowsheet.\nComfort: denies pain. provide support/tlc. no family call/visit overnoc.\niv: r picc intact\n\na/p: con't aggressive pulmonary hygiene. Need ^^ physical activity/diet. ? anticoagulant with heparin/coumadin. f/u renal fxn/status. follow up with ptt. con't provide support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 1672667,
"text": "Neuro:, , responds to verbal stimuli, follows commands.\n\nPain: denies pain. given versed for CT scan, fentanyl 100mcg/h for comfort. titrated to 75mcg/h-per team. grimaces with care and activities. c/o intermittent abdominal pain~1200-resolved without treatment, ct of abd done.\n\nCV: HR 60's-70's atrial fib/flutter, irregular ventricular response rate. Neo titrated 0.25-0.5 for bp 90's MAP's 60's. Pacemaker off, not tested, V-wires not capturing, A-wires not tested due to irregular Pwave frequency. ultrasound of Left arm negative for DVT. pulses palpable in all extremities. L hand fingertips slightly mottled, with good capillary refill, greatly improved from yesterday.\n\nresp: intubated. lung sounds clear in upper lobes, coarse in bases. suctioned for small amount of tan secretions.\n\nGI/GU: urine output minimal, foley cath not changed due to enlarged prostate, per c- team. bowel sounds present, flatus, no bowel movement. 900ml BariCAT given via OG tube for CT scan of abdomen.\n\nSkin: heels pink, waffle boots on. Coccyx dressed with duoderm, intact. sternum draining brown serosang fluid. changed frequently. duoderm applied to sternal edges due to skin irritation related to tape. Abrasions on elbows, cleaned with soap and water, duoderm applied. Left arm wrapped in kerlex.\n\nID: CT scan for large amount sternal drainage. daptomycin and meropenem continue. abd CT for c/o pain. urine-pos yeast.\n\nSocial: wife and daughter in to visit. questions answered regarding plan of care.\n\nAssessment: chest incision cont to drain brown drainage, ct scan results pending.\n\nPlan: ? extubate in am. continue fluid removal as tolerated with CVVHD. ? urology changing foley.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 1672668,
"text": "PROB: CVVHD\n\nO: CVVHD DISCONTINUED AT NOON FOR ACCESS ALARMS, PT MOVING LEGS. LEFT OFF UNTIL EVENING D/T CT OF CHEST AND ABD. RESTARTED AT 9:45PM, PORTS SWITCHED FOR ACCESS DIFFICULTY. PT GOAL OF AT LEAST 100CC/HR NEGATIVE PER TEAM. PT CONT ON CITRATE, KCL AND CA DRIPS.\nA: TOLERATING CVVHD\nP: NEGATIVE BALANCE AS TOLERATED\nMONITOR LYTES/ABGS/BS\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-25 00:00:00.000",
"description": "Report",
"row_id": 1672669,
"text": "cvicu npn\nneuro/pain: pt w/ episodes of aggitation. kicking feet on bed, pulling at , shaking head. discussed w/ team and fentanyl drip cont. perl. will follow some commands. resistant to physical care much of time. mae in bed.\n\ncv: vs as per flowsheet. cont in afib, rate controlled. on low dose neo, pt hypertensive at times. tol neg 100-150cc/hr.\n\nresp: lungs coarse bilat though clearing after sx. sx for large amts yellow secretions. vent changes made as noted. sporadic episodes of apnea w/ prior good abg on cpap. presently on MMV.\n\ngi/gu: abd soft. hypo bsp. ogt to lwsx, scant clear dng. no bm. scant uop via foley. crrt cont w/ pt tol fluid removals. calcium/kcl repletion iv as per crrt.\n\nid: afeb (on crrt). wbc down some to 17. abx cont. same foley r/t enlarge prostate.\n\nskin issues as per flowssheet.\n\nassess: stable noc w/ episodes of aggition as well as apnea. tol neg fluid balance.\n\nplan: weant to cpap for am. ? extubation today. maintain crrt as ordered, ? eval in rounds. ? urology in to chage foley.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-26 00:00:00.000",
"description": "Report",
"row_id": 1672675,
"text": "addendum npn\nresp: pmh=apnea. no full w/u completed pre-op. apnea noted, autoset cpap ordered and to be applied tonoc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-14 00:00:00.000",
"description": "Report",
"row_id": 1672626,
"text": "Neuro:Patient is alert/oriented x3. He answers questions appropritely\nand is cooperative and pleasant. He follows commands well,MAE,Perrl.\nTransfered to chair with 2 assists due to weak/unsteady gait.\nMedicated patient with 1 Percocet tab and Tylenol for c/o chronic back\npain with fair relief.\n\nCV:First degree AVB,PR .25, rare VEA. NBP normal,MAP 60's-70's.\nTEE done at bedside-> 4+MR/endocarditis/native MV and AVR vegetation/\nAO- and prosthetic valve abscess. No peripheral edema,\npalpable DP/PT pulses bilateral with warm csm.\n\nResp:Lungs clear bilat.+ nonproductive congested cough. Sats>95 on 2L\nNC.RR20's unlabored at rest but +DOE relieved by rest.\n\nID:T max 100.1,WBC 9. Patient seen by ID team->patient needs more scans to find abscess in body preferably before surgery.Blood cultures\n0n ->gram +cocciin pairs/chains in anaerobic bottle and surgucal\nand ID team made aware. Currently patient is receiving IV antibiotics.\n\nGU/GI:Patient voids dark amber urine in good amounts. Abdomen is soft,\nnontender and nondistended with positive bowel sounds. Had poor\nappetite.\n\nSocial: wife and daughter visited and updated by doctors.\n\nPlan:Monitor hemodynamics and for elevated temps. MRI of spine.\nPain management of chronic back pain.Fall risk precautions.\ncontact precautions for \n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-27 00:00:00.000",
"description": "Report",
"row_id": 1672676,
"text": "Neuro: Alert, plesantly confused. Orientated to person, knows he is in a hospital in , answers differently to year. Slept off and on, given 1mg PO haldol. Weak but MAE. Pupils equal and reactive.\n\nCV: Sinus rhythm, 70's with 1st degree AVB (PR 0.3). SBP 130's-150's, goal 140's. Left radial art line pulled out by pt. Afebrile. Generalized edema, warm extremities, weak but palpable pulses. Right PICC placed . Heparin gtt at 1000 units, next PTT to be drawn at 6am.\n\nResp: Lungs clear, dim at bases, good cough. 2L NC sat 95%.\n\nGI/GU: Abd soft, taking fluids last night. /Cardia diet. RISS per protocol. Foley in place, adequate urine output. Left fem dialysis cath. HD to be done in am.\n\nSkin: Duoderm to bil elbows. Waffles boots bil LE. Allovyen to coccyx, red with breakdown. Sternum incision open bottom packed wet to dry, moderate amount tan drainage. Wound vac to be placed today.\n\nPlan: HD this am. Wound vac to sternum. Increase PO intake/start nutrition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-27 00:00:00.000",
"description": "Report",
"row_id": 1672677,
"text": "RESPIRATORY CARE NOTE\n\nPatient did not wear CPAP during the night. Remains confused. No periods of desaturation duting the night. Will attempt autoset again tonight.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-27 00:00:00.000",
"description": "Report",
"row_id": 1672678,
"text": "NEURO: Pt has been oriented off and on throughout the shift. Occ speaks garbled nonsense, but for the most part is with it. Haldol am/pm orders halved. Pt denies pain. Up to chair @ 1700 after removal of groin line.\n\nCV: pt in 1st degree AVB all shitt 70s-90s with rare vent trigeminy & PVCs. Heparin gtt d/c'd this am. SBP dipped when while receiving HD this afternoon; given more fluid back. SBP has since been stable >110. Lopressor IV changed to PO, however not given while on HD. PP palpable. Wound vac applied to lower part of sternum where incision was open and draining. To be changed by team in 2 days.\n\nRESP: Sats >95% on 2L RA. Pt has OSA, CPAP machine on windowsill (pt does not tol). Desats with apneic episodes briefly. LS clear, pt coughing and DB well. Expectorates thick sputum.\n\nGI/GU: pt advanced diet today. Fed himself, and ate 45% of meal. Drinking more fluids and swallowing pills without difficulty. HUO min (HD today). HD drew off 1400 total. SBP dropped to 60s while receiving HD, pt given fluid to ^ SBP. Quinton cath D/C'd after dialysis by team.\n\nENDO: BS WNL.\n\nID: Afebrile, abx cont. Dudoderms & allevyns on skin breakdowns\n\nPLAN: monitor neuro status, VS, u/o & labs. ^ diet & activity as tol. ? possible transfer out to floor tomorrow. PT consult!!!\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-15 00:00:00.000",
"description": "Report",
"row_id": 1672627,
"text": "NEURO: alert, oriented, MAE to command, deconditioned. ambien held this shift d/t confusion last noc. turns self in bed with assist for equipment. pain in back treated with percocoet 1 tab and acetamin. with good result pt states he is comfortable rates pain .\nCV: sinus rhythm with 1st deg. AVB. sbp 120's-130's. skin warm and dry. peripheral pulses palp.\nRESP: lungs clear bilat. resps even, unlabored. sats 93-96% 2L nasal cannula. occasional non-productive cough.\nGI/GU: abd soft, +bowel sounds. tolerating house diet. ate of corn and rice, few bites of meat for dinner. good liquid intake. voids amber colored cloudy urine in urinal, output sufficient.\nID: afebrile. q 48 hour daptomycin. wound cx sent.\nSKIN: duoderm intact to bilat buttocks. back intact. RLE and LLE with scabbing, open blister with yellow drainage, cultures sent NS cleansed dressed with adaptic and kling. abdominal skinfold with abrasion. NS cleansed and tegaderm placed.\nLINES/ACCESS: PICC line ordered. IV team aware, to eval for bedside PICC placement.\nSOCIAL: daughter, son in law, granddaughters, wife in to visit in eve. asking appropriate questions\nA/P: continue to monitor cv, resp, wound care/skin care. OOB to chair. encourage PO intake. eval for PICC line placement and CT abdomen today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-17 00:00:00.000",
"description": "Report",
"row_id": 1672632,
"text": "CVICU NPN\nNeuro: A&Ox3, calm, cooperative with all care. MAE. PERRLA. OOB to chair x 1 person assist, tol well. Given 2 tab percocet for c/o back pain (newly dx spinal stenosis) this AM. Effective. Premedicated with 0.5 mg IV lorazepam prior to lumbar/thoracic MRI this AM to r/o spinal abscess. Add'l 0.5 mg given during MRI per d/t pt being very fidgety during scan; effective. Prelim findings concerning for discitis osteomyelitis.\n\nCV: SR HR 80s-90s with 1st degree AVB. No ectopy noted. SBP 110-140 via cuff. MAP > 60. Weakly palpable pedal pulses. Afebrile.\n\nResp: LS clear throughout on 4L NC, O2 sats > 93%. Noticed periods of apnea with desaturation to 80s, aware. Attempted Auto flow machine, but pt kept removing mask. Will retry at bedtime tonight. Pt noted to have hx of sleep apnea and per pt's wife had completed half of a sleep study test but d/t medical issues was not able to fully complete study.\n\nGI/GU: abd soft, NT, ND. (+) BS, (-) BM, (+) flatus. Tolerating clear liquids and heart healthy diet without n/v. BUN 2.8, Creat 61 this AM. Foley to gd with clear amber adequate HUO.\n\nEndo: RISS per CVICU protocol.\n\nID: urine culture results grew psedomonas aeruginosa; blood cultures grew gram positive cocci in pairs and chains. ID following. Will receive Cipro this afternoon. IV Daptomycin q48hrs. Contact precautions for MRSA in nares and in blood. White count this AM 12.4.\n\nSkin: Duoderm applied to bilat buttocks d/t stage 2 breakdown, heels pink and elevated on pillows. abrasion to lower abdomen with transparent dressing. No other skin breakdown noted.\n\nSocial: wife in to visit pt today; updated on POC. Asking appropriate questions re: surgery scheduled for tomorrow.\n\nPlan: monitor cardiopulmonary status. Pre op teaching. Monitor respiratory status overnight. Pre op shave and scrub. To OR tomorrow for double valve replacement and Bental procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-18 00:00:00.000",
"description": "Report",
"row_id": 1672633,
"text": "CVICU NPN 11p-7a:\nNEURO: Pt. A&Ox2-3. Periods of confusion but easily reorients. Found taking and leads off x3 overnight. No attempts to get oob. MAE equally in bed. Denies any pain. CV: Tmax 99.0. HR 90s-100s 1st degree AVB. BP stable. Picc line to R AC intact and patent. Am labs pending. Palp. pedal pulses bilat.\nRESP: Continues on 4L O2 with O2 Sat >93%. Continues to have periods of apnea with desaturation to 87% but within 10seconds rebounds back into 90s. LS clear-coarse and diminished at LLL. Strong productive cough.\nGI/GU: Abd. soft with positive bowel sounds. NPO since MN for OR this am. Foley draining amber urine with some sediment and u/o dropping off to 25cc/hr last hour- will address with MD.\nSKIN: Duoderms to buttocks intact. Repositioned side to side.\nPlan for OR this am for double valve replacement and Bental procedure- 1st case. Still needs anethesia consent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-18 00:00:00.000",
"description": "Report",
"row_id": 1672634,
"text": "Respiratory Care\nPt has known Hx of OSA. Pt refuse to wear autoset cpap. Pt is placed on 4lnc with spo2 ranging from 91%-1005. will continue to monitor for apneic and desaturation episodes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-18 00:00:00.000",
"description": "Report",
"row_id": 1672635,
"text": "respiratory care\npt was admitted to CVICU via OR intubated tol fairly well. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-18 00:00:00.000",
"description": "Report",
"row_id": 1672636,
"text": "Op Day MVR/AVR Ao fistulla repair\nNSR with long PR tonight. Remained on Epinephrine for hemodynamic support. EF reported to be in the 20s in the O.R. without Epi and >35% on Epi. Periods of hypotension with sbp to the 80s. All bloodpressures recorded from r radial arterial line. R femoral arterial line dampened and running about 20pts lower. 3 liters LR given tonight with immediate improvement of sbp/SVO2/CO when pad 25-30 and cvp >15. Hct to 26 tonight without evidence of bleeding via mediastinal and R pleural ct. 1 PRBC given (SVO2 to 64% just after blood). Plan on one addition unit of blood and to keep Hct >26 per Dr. .\n\nBreathsounds distant. Low paO2 on 100% FiO2. CXR reported to show ett ~8cm above the carina. ETT dropped 3cm as requested by Mark CourtneyNP. Improvement in ABG noted. Plan to keep intubated overnight. Plan to wean PEEP to and Fio2 to 40% as requested by Dr. . attempt vent wean after 0500 per Dr. .\n\nOGT draining bilious. Thick oral secretions noted. Oral cavity suctioned several times. Absent bowelsounds.\n\nOliguric throughout this post-operative period. Crt before surgery 3.0. Additional volume given tonight with continued poor hourly urine totals. Bladder scan done at 2230 and only 38cc in bladder! Foley catheter flushed as requested by Dr. and no clot or obstruction noted. Plan to monitor closely.\n\nOriginal sternal and mediastinal dsg on. Wafer dsg on coccyx. Coccyx red where dsg not intact. Ankles red. Waffle boots placed. Discussed ordering an air mattress with or without a percussion/rotation mechanism. Plan to assess pt's condition in A.M. to see if patient is a candidate for extubation.\n\nPt not allowed to wake tonight. Propofol on continuously. Some tongue movements with oral care and side to side turning.\n\nGlucose elevated. On insulin gtt. See flowsheet. Morphine given for possible incisional discomfort.\n\nWife and daughters in to visit and will return tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-14 00:00:00.000",
"description": "Report",
"row_id": 1672625,
"text": "73 Y/O ADMITTED VIA AMBULANCE(AIR FLIGHT TO HANSCOMB AIR FORCE BASE) FROM MEDICAL CENTER IN WITH BACTERIAL ENDOCARDITIS. HX AVR(BIOPROSTHETIC) IN COMPLICATED BY SEVERE CHF, ISCHEMIC CARDIOMYOPATHY. ADMITTED TO OSH ON , BLD CX + VRE, NARES SWAB + MRSA, URNE CX + PSEUDOMONAS. PROBLEMS WITH LOWER GI BLEED RX'D WITH PRBC. HX ANEMIA, CRI. TEE DONE AT OSH ON + FOR EXTENSIVE BIOPROSTHETIC AV RING ABSCESS EXTENDING DOWN TO MITRAL ANNULUS WITH MULTIPLE VEGETATIONS AND PARITAL DEHISCENCE OV VALVE, + MOBILE VEGETATION ON MITRAL VALVE WITH 4+ MITRAL REGURG. TRANSFERRED HERE UNDER DR SERVICE FOR PROBABLE SURGICAL REPAIR. CONTACT PRECAUTIONS.\n\nNEURO: A&O X 3 UPON ARRIVAL AT 1900. C/O LOWER BACK PAIN FROM \"MY SPINAL STENOSIS.\" PERCOCET 2 PO AT 2100 WITH RELIEF. VAGUE HISTORIAN. TALKS IN SLEEP, PULLING OFF CHEST, REMOVED SAT PROBE FROM FINGER. PLEASANT AND COOPERATIVE BUT SOMEWHAT DISORIENTED TO PLACE UPON AWAKENING. SIDE RAILS UP X 4, BED IN LOW/LOCKED POSITION, ALARM ON DURING NIGHT.\n\nCV: FIRST DEGREE AV BLOCK(PR 0.24) WITH RBBB(QRS 0.16), HR 78-88, NO ECTOPY NOTED. +++ SYSTOLIC MURMUR NOTED. NIBP R ARM WNL. PEDAL PULSES PALPATED. 1+ ANKLE EDMEA. # 20 IV IN L ARM ON ARRIVAL, PLACED AT OSH. # 20 INSYTE PLACED L WRIST BY VENOUS ACCESS. DIFFICULT ACCESS. T MAX 100.0 PO. WBC 9K. ON DAPTOMYCIN 600MG IV Q48, RECEIVED DOSE ON AT OSH. BLD CX DRAWN X 2 PERIPHERALLY. TROPONIN + AT 0.34, CPH 8. REPORTED TO PA . HX + TROPONIN'S AT OSH ? DUE TO RENAL DZ.\n\nPULM: RA SATS >95 % ON ARRIVAL. HX SLEEP APNEA, SATS DROP TO 75% WITH 20-30 SECOND PERIODS OF APNEA. POOR SLEEP. O2 ON VIA N/C AT 3L WHILE ASLEEP. LUNGS CLEAR. FREQUENT PRODUCTIVE(CLEAR-WHITE) COUGH, SPUTUM SENT AS PART OF PAN CX. ADMISSION CHEST XRAY DONE.\n\nRENAL: HX CRI SINCE . BUN 57/CREATINE 2.5 ON ADMISSION. VOIDING ~ 100CC AMBER COLORED URINE. UA SENT.\n\nENDO: NO HX DIABETES. BS 147 ON ADMIT, REPEAT AT 0300 125, NO RX AT THIS TIME.\n\nGI: HX LOWER GI BLEED AT OSH, RECEIVED PRBC X 3 AT OSH ON . HCT STABLE ON ADMIT TO . ABDOMEN SOFLTY DISTENDED, + BOWEL SOUNDS. LAST BM AT OSH. LDH ELEVATED, T BILI 1.7. ATE ON ARRIVAL, TAKING FLUIDS WELL.\n\nSKIN: PT HAS \"CELLULITIS\" OF LOWER EXTREMITIES. MULTIPLE RED AREAS OVER LEGS. RECEIVED WITH DUODERMS OVER L LOWER SHIN AREA AND R DORSUM OF FOOT. DSGS DOWN. SMALL OPEN AREAS WITH RED CIRCUMFERENCE CLEANSED WITH NS, DUODERM REAPPLIED.\n\nSOCIAL: WIFE, , IS SPOKEPERSON. WIFE IS STAYING WITH THEIR DAUGHTER, , IN .\n\nPLAN: CONTACT PRECAUTIONS. AWAIT BLD, SPUTUM AND RUNE CX RESULTS. DAPTOMYCIN Q48H DUE AT 1400 . FINISH SERIAL ENZYMES, LAST SET DUE AT 0900. SURGICAL W/U FOR REPAIR OF VALVES. CUT TO 1 PERCOCET FOR LOWER BACK PAIN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-08-01 00:00:00.000",
"description": "Report",
"row_id": 1672687,
"text": "TRANSFER NOTE 0500HR\n0130HR Readmitted to CVICU-B after c/o resp distress on , hypoxia, tachypnea and changes in mentation. Arrives on monitor stable and in no immediate distress. Vital signs are stable.\nNEURO: A&O x3 on admit; Following verbal commands, MAE's; speech is soft and verbal response is appropriate. At 0230 became combative, non compliant with care. Haldol 1mg given with good effect. This am pt is belligerent, impulsive; removing medical devices and refusing to cooperate with medical care. Reassurances given to pt. Falls asleep at intervals.\nPULM: LS are coarse bilaterally with insp-exp wheezes per auscultation. FT 40% currently; O2 sats 97%. Requires constant reinforcement and encouragement to comply with CDb exercises. received Nebs per RT.\nCV: Remains on SR 70-80 with 1deg AVB and BBB. SBP 130-140mmHg. Weak PP bilaterally and generalized edema +. Waffle boots and compression boots on. U/O 40-50cc/hr with minimal improvement in diuresis after Lasix dose. BUN/CREAT levels increasing this am.\nGI/GU: PO fluids. Denies N/V. Distant active BS 4 Q's. Reg diet cardiac healthy. Foly draining clear yellow urine in good amounts.\nINTEG: See Carevue documentation. VAC Dressing is patent, intact and no leaks are detected i system. scant serous/serosanguinous DRG noted on assessment.\nPLAN: Under close monitoring for worsening pulm status and changes in mentation. Monitor VS and pulse oxymetry.\n? Renal team consult/dialysis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-08-01 00:00:00.000",
"description": "Report",
"row_id": 1672688,
"text": "NEURO: Pt A&Ox3; dozing intermittently throughout shift. Haldol ordered (AM & HS). Pt cooperative and pleasant.\n\nCV: 1st degree AVB 70s-80s with no ectopy noted. Heparin gtt started @ 800 units/hr @ 1600. Coumadin 2mg given. Lopressor 25mg TID PO tol well. SBP 100s-140s. Wound vac remains on lower portion of sternum; draining scant serous fluid. PP palpable.\n\nRESP: Received pt on 70% open FT. team decided pt needed R pleural CT for effusion. Immediate output was 1500cc serosang drainage. CT cont to drain mod amt serosang. -airleak/crepitus. LS clear, dim in bases. occ wheezing heard. MDIs & nebs ordered. Weaned O2 to 4L NC, sats >95%. RR 20s-30s. Uses IS & CDB well. IS <500\n\nGI/GU: Pt eating small/mod amts of food; feeds self. + BS, -BM. abd soft, non-distended. HUO marginal. 40mg IV lasix orderd. Creat 3. Renal team would like urine lytes in AM .\n\nENDO: BS tx per CVICU protocol.\n\nID/ACCESS: Afebrile; daptomycin cont. PICC line clotted off this am, both ports. tPA administered by venous access team and both ports open and flushed (no clamps, so keep extension on ports so don't clot again).\n\nPLAN: Cont to monitor Vs, neuro status, resp status, CT drainage, u/o. Pulm toilet. Urine Lytes with AM labs. ^ activity. PT!!!\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-19 00:00:00.000",
"description": "Report",
"row_id": 1672637,
"text": "Neuro: sedated on prop, pupils equal and reactive to light, going by vitals for pain assessment levels.\n\nCardiac: 1st degree av block, no ectopy, svo2's in the 60's-going by fick for ci's, conts epi gtt, bp's wnls with epi gtt-no epi weaning this shift, cvp 12-15 range, dopplerable pedial pulses, skin cool and diaphoretic, afebrile, one unit prbc's given hct up to 32.\n\nResp: only wean on vent was from 60 to 50%, lungs are dim in bases, ct system to lwsxn with no air leak and draining small amount of serosang.\n\nSkin: chest with dsd with staples under dsd site changed for moderate serous and staples cdi, ct dsd is cdi, bilat hells with stage 1 breakdown-waffle boots are on, compressive sleeves are on, duoderm to coccyx is intact.\n\nGi/Gu: npo, og tube draing small to moderate billeous, abd is soft and nontender with hypoactive bowel sounds, on riss gtt, making low u/o, cri at baseline, k rising last k was 5.7 will resend again before change of shift.\n\nSocial: son called and updated.\n\nPlan: ? changing to air bed if not extubated today, ? starting cvvh, ? wean epi, monitor K levels.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-19 00:00:00.000",
"description": "Report",
"row_id": 1672638,
"text": " Care\nPt receieved on AC intubated with a 7.5 ett. BS clear and diminished basilar. Pt suctioned for minimal secretion. Ett tube advanced 3cm MD with better oxygenation. Please refer to carevue respiratory flow sheet for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-19 00:00:00.000",
"description": "Report",
"row_id": 1672639,
"text": "Respiratory Care\nPatient weaned top extubation, reintubated within fifteen minutes. Spontaeous respiratory rates approaching 40 bpm. Suctioned for copious amounts of thick yellow/green secreations orally. 8.0 ETT placed at 23cm lip. Breath sounds equal, coarse throughout.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-16 00:00:00.000",
"description": "Report",
"row_id": 1672630,
"text": "Neuro: pt. oriented to person and time, confused about which hospital he is in. Perrla. MAE\n\nPain: denies pain at rest rating at 0/10. experiences pain with repositioning , reporting that it quickly resolves back to 0. 2 percocet given @ 1600 for procedures.\n\nCardiovascular: HR 80's, bps in 110-120's first degree heart block (PR .27) with a bundle branch. pulses weakly palpable bilaterally.\n\nresp: O2 2L NC sats 96-100%. Lungs clear bilaterally. congested non-productive cough.\n\nGI/GU: bowel sounds present abdomen soft, lg. bowel movement. condom cath changed to indwelling foley per urology for urine retention r/t enlarged prostate.\n\nSkin: impaired, pink areas on both heals, and coccyx. heals wrapped with gauze and floated on pillows. aloevesta applied to coccyx and changed position frequently. small tear on lower abdomin, dressed with a clear dressing. right foot blister treated with adaptic. left ankle wrapped with sterile gauze, no drainage.\n\nSocial: wife in to visit. daughter coming in later. pt lives in fla came to for treatment, daughter lives here.\n\nID: continues on daptomycin dose increased to 800mg, given today. cipro started. rectal ultrasound done, preliminary results for abcess negative\n\nAssessment: continued ID, urology, and cardiac workup. surgery tentative for Wednesday.\n\nPLan: NPO for MRI, on hold for MRI. pulmonary toilet, continue ID workup. Urine culture pending. bloods cultures to be sent with am bloodwork\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-17 00:00:00.000",
"description": "Report",
"row_id": 1672631,
"text": "- Blood, MRSA- Nares, pending results from urine\n\nNeuro: Alert and orientated. Seems confused at times, more so at night, but reorientes well. Very , follows commands. MAE. PERRLA.\n\nCV: Sinus rhythm in 80's. Febrile last night, HR tachy, lows 100's. Given tylenol. Pan cultured in past, new set of blood cultures set this am. Daptamycin dose increased per ID. No edema. Pedal pulses palpable.\n\nResp: NC @ 2L, sats mid 90's. Lungs clear. Known sleep apnea, had some apenic events last night. ??Wears c-pap at home??\n\nGI/GU: Abd soft, good bowel sounds. Had some dinner last night, tolerated well. Foley in place, adequate urine output.\n\nSkin: Feet were both wrapped with kerlix, I took this off and left them open to air. There is one small open sore on the top of pt's right foot, and one on his left ankle. Heels are pinkish, elevated on pillows. Small skin tear on left arm covered with transparent. Red area on stomach covered with transparent. Coccyx red with stage 1 breakdown. Barrier cream applied. Pt able to move independently in bed, but was cued at times and repositioned by staff.\n\nPain: Has chronic back pain from newly diagnosed spinal stenosis. Before treatment plan was determinded for back pain, was hospitalized for endocarditis. Was taking tylenol and motrin at home. Having some new kindey issues due to motrin use.\n\nSocial: Daughter lives in , wife staying with daughter.\n\nPlan: Double valve with bental scheduled for Wednesday. MRI of spine today to r/o abcess.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-20 00:00:00.000",
"description": "Report",
"row_id": 1672643,
"text": "Neuro: pt lightly sedated, waken up in AM with propofol off, MAE's, nodding to questions appropriately and very agitated, resedated on propofol for comfort & ventilation, PERRL 3 mm brisk\n\nCV: Afebrile; a fib 80's in AM, cardioverted x1-> SR 60's, 1 deg AVB & BBB, A paced for hemodynamics support MD , elevated K, ca repleted, SBP 100's-140's when stimulated, palp pulses x4, CI by fick >2, PAD high 20's-low 30's, CVP mid teens; SvO2 60's when in SR, low 50's when in a fib\n\nResp: Lung sound clear, very dim @ L base in AM, with very thick secretion from L side, improved aeration after bronch, ABG on CPAP 5 PEEP ) PS 40 % FiO2 acceptable, not ready to extubate yet NP , put back on CPAP 5/5, 40% FiO2, with good ABG; CT draining minimal amt serousang drainage\n\nGI: Abd soft, non-tender, +BS, OGT to suction with bilious drainage\n\nGU: Foley to gravity, drianing clear yellow urine, UO 20-34 ml/hr, started ojn CRRT, goal -50 ml/hr\n\nInteg: See carevue\n\nEndo: No coverage needed\n\nID: meropenum & daptomycin dose changed\n\nSocial: Multiple family visited, updated by team\n\nPlan: cont to monitor hemodynamics, resp status, labs; cont CRRT, ?switched to HD when epi off; wean epi; wean vent as tol\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-20 00:00:00.000",
"description": "Report",
"row_id": 1672644,
"text": "Addendum:\non amio gtt for a fib, shut off gtt @ 0600\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-20 00:00:00.000",
"description": "Report",
"row_id": 1672645,
"text": "Respiratory Care:\nPt remians orally intubated and vented. Pt found od , pt tachypneic, suspended.PT placed back on AC for bronch. BAL obtained and sent to lab. Suctioned for moderate thick yellow secretions. Currently pt on PS 5, tolerating well. Plan is to and possibly extubate this weekend.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-21 00:00:00.000",
"description": "Report",
"row_id": 1672646,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated on minimal spontaneous ventilation. No vent changes done. done ~86. Bs are dim & clear bil. We are sxtn for small amt of thick tan secretions from ETT, cough present. Plan: ? repeat cxr/ might repeat bronchoscopy again & Continue present ICU monitoring. See Careview for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-21 00:00:00.000",
"description": "Report",
"row_id": 1672647,
"text": "Neuro: sedated on prop, pupils equal and reactive to light, does withdraw to pain stimuli, using grimace scale for pain evaluation.\n\nCardiac: 1st degree av block with no ectopy, was a-paced but bp's better in own rhythm and able to wean off epi gtt and svo2's improved in own rhythm, going by ficks for index all >2, svo2 all >60, palpible pedial pulses, +4 edema in extremities, hypothermic and bair hugger placed, skin warm and dry.\n\nResp: lungs dim in bases, no vent wean this shift, chest tubes d/c'd this shift.\n\nSkin: chest with dsd that is cdi, old ct dsd s cdi, coccyx is pink and is a stage 1, heels bilat are pink and stage 1, waffle boots and compressive sleeves are on.\n\nGi/Gu: npo, og tube to lwsxn with scant billeous drainage, abd is soft and obese, good bowel sounds, on riss, making 10-15/hr or u/o, continues cvvh with goal to make 50/hr negative.\n\nSocial: no calls or visits this shift.\n\nPlan: ? wean prop, ? wean vent, cont cvvh.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-22 00:00:00.000",
"description": "Report",
"row_id": 1672654,
"text": "breath sounds unchanged but character of sputum different from yest.,yellow tan in color,copious in volume requiring more frequent suctioning. repeat c & s sent. nystatin started for whitish coating on tongue-thrush vs peridex residue.hemodynamically stable in 1st degree avb,pr today a bit more prolonged @ .36. temp. wires function,pacer remains in vvi mode.swan removed,plan for potential resiting vs picc.tf's started via ogt,tol. well.cvvhd filter clotting more frequently,citrate dosing adjusted with no further issues. pfr increased & tolerated well. plan at least 1.5 liters negative for today.renal considering switch to hd if bp remains stable.urine remains scant,amber with sediment.propofol decreased,wakes with stimulation,nods occasionally to questions & mae x 4 to command. restless at times & c/o back pain(had back pain pre op on percocet),medicated with morphine with relief via nods.family in,questions answered. see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-22 00:00:00.000",
"description": "Report",
"row_id": 1672655,
"text": "Resp Care\nPt remains intubated on PSV, no vent changes, tol well. Sx for cop thick yellow. Plan to continue with current tx and secretion management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-23 00:00:00.000",
"description": "Report",
"row_id": 1672656,
"text": "NEURO: sedated on prop gtt in eve--> changed to fent gtt with versed pushes overnoc. opens eyes to voice, follows commands and nods to questions, MAE. PERRL. indicating pain, treated with fent boluses.\nCV: sinus with prolonged PR in eve-->afib 50's, not tolerating with sbp 70's. v paced with some improvement but epicardial wires starting to fail. 2 sets V's, 1 set A's. the capped set of v wires does not work. currently VVI 50. amio bolused and attempted cardioversion x2 shocks with no success. converted to sinus tach sever hours later, sbp remaining labile; on and off neo. weight down but still volume overloaded, cvvh running even d/t labile bp. peripheral pulses weak palp.\nRESP: remains orally intubated. cpap+PS in eve, but pt with low volumes-->apneic periods so changed to cmv overnoc. abg met. alk. lungs diminished bilat. suctioned for copious amounts yellow thick sputum.\nGI/GU: abd soft +bowel sounds tolerating tubefeeds. foley with scant cloudy amber urine. cvvhd goal -50/hour currently running even.\nENDO: cvicu RISS\nID: wbc increasing, slightly hypothermic. dapto and meropenum. surveillance blood cx sent. sputum pending.\nSKIN: coccyx and bilat heels with stage I, waffle boots on duoderm to coccyx, pt on airbed. sternum steristrips CDI, mediastinal chest tube site pink, scant serosang drainage dsd's changed. L forearm abrasion with scant serous drainage NS cleansed and aquacel/kling. weeping from IV/phlebotomy sites.\nA/P: continue to monitor, ?bronch, ?re-site trauma line, increase fluid removal as pt tolerates, pain control, skin and wound care, increase tubefeeds to goal. blood and sputum cx pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-23 00:00:00.000",
"description": "Report",
"row_id": 1672657,
"text": "RESP CARE: Pt recieved orally intubated with 8.0ETT/23 lip. Copious yellow secretion all noc. Placed on AC early in the shift due to drop in Vts/increased apnea episodes on PS. AM -38. Pt become hypotensive following cough during maneuver. Will place back on CPAP/PS as tol per team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-23 00:00:00.000",
"description": "Report",
"row_id": 1672661,
"text": "PROB: CVVHD\n\nO: FILTER CLOTTED OFF. FILTER CHANGED AND DIALYSIS SWITCHED OVER TO NEW LINE-R GROIN SITE. OLD LINE D/CD AND TIP CULTURED. LINE POSITIONAL AT TIMES, HIGH PRESSURE ALARMS ACTIVATED, IMPROVED WITH PULLING BACK SLIGHTLY ON LINE. LABS PER FLOW SHEET. CA, K AND CITRATE CONTINUE. CURRENTLY PULLING OFF APPROX 50CC/HR. FLOW RATES ON BLOOD FLOW ADJUSTED DURING EVE.\nA: TOLERATING CVVHD.\nP: CONT.\nGOAL NEG 50CC/HR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 1672662,
"text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated now on CPAP/PS settings. Changed to CPAP/PS 0430. Appears agitated and restless at times. completed on PS 5=62. Will wean CPAP/PS as tolerated.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 1672663,
"text": "Neuro: Lightly sedated on fent gtt, open eyes spontaneously, MAE's, following commands inconsistently, appeared agitated most of the time when awake, PERRL 2mm brisk\n\nCV: Afebrile; SR with 1st deg AVB 80's-90's, rare PAC's, SBP 90's-140's, on & off neo, currently weaned off after pt on CPAP, palp pulses x4, 2A 4V wires, A wires per previous shift, V wires capped set don't work, connected set don't capture; +2 general edema; Na 136\n\nResp: Lung sound clear, dim @ bases bilat; received vented on AC 40% FiO2, RR14, 5 PEEP, AM 62, switched to CPAP 40% FiO2, 8 PEEP, 12 PS, O2 sat 95-100%; suctioned with scant amt thick tan secretion\n\nGI: Abd softly distended, OGT placement checked, TF nutren renal via OGT @ goal 35 ml/hr, minimal residual\n\nGU: Foley draining minimal amt clear amber urine; on CRRT, goal -50 ml/hr, tolerating -100 ml/hr currently, see flowsheet for details\n\nInteg: Dusky fingers, improved from AM per day shift, see carevue for detail assessment\n\nEndo: Cover per sliding scale\n\nID: WBC trending up, cont on daptomycin & meropenum, +yeast in sputum cx, blood cx result pending; +/MRSA/pseudomonas\n\nSocial: No calls\n\nPain: Managed with fent gtt, required bolus with turns\n\nPlan: Monitor hemodynamics, resp status, labs; wean vent as tol' cont CRRT, ?HD vs CRRT if pt remains off pressor; f/u cx results; pain management\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 1672664,
"text": "Addendum:\nFoley needs to be changed\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 1672665,
"text": "Neuro: Fentanyl gtt off, intermittnely anxious. Responds to verbal instructions. Follows commands\nCV: HR 80-90's nsr with frequent pac's. In af briefly , hypotensive. COnverted spontaneously. Off pressors.\nResp: CPAP 5/0--abg good. Lungs dim. Irregular breathing pattern due to sedation.\nGI: TF off for ? extubation, abd sogt. No bm\nGU: UOP 5-10cc/hr. foley patent. CRRT running. Goal negative as much as possible. Averaging 100cc/negative.\nID: Pt with lg amount sternal drng, old blood/brown. Staple removed and deep cx obtained. Incision swabbed with betadine. ? CT of chest. WBC cont rise\nPlan: ? CT chest, extubation. Cont follow cx. Cont assess cardio/resp status. Provide emotional support\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-24 00:00:00.000",
"description": "Report",
"row_id": 1672666,
"text": "Resp Care\nPt remains intubated vent settined weaned to 5/0 this am abg wnl rr ranged from 20-40 with anxiety. Pt currently on psv 5/5 rr 20-30 vt 400-700. BLBS diminished. plan to travel to CT this afternoon for chest scan and continue on psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-26 00:00:00.000",
"description": "Report",
"row_id": 1672673,
"text": "AGITATION\nS: \"*&*, LET ME GET UP !!1 HELLO\"\nO: CARDIAC: A FIB WITH VENTRICULAR RESPONSE 80'S . HEPARIN DECREASED TO 950 UNITS DUE TO PTT 73. SBP REQUIRED 5 MG HYDRALAZINE X 2 DUE TO SBP >150. EXTREMITES WARM AND DRY. PALP PP. BROWN PURELENT DRAINAGE FROM DISTAL PORTION OF STERNAL INCISION, DR. AWARE.\n RESP: NONPRODUCTIVE COUGH, BS DIMINISHED BIBASILAR, CLEAR UPPER. OPEN FACE TENT AT 50% WITH O2 SATS> 95%.\n NEURO: CONFUSED, ORIENTED TO SELF ONLY. SWEARING MORE THAN NOT. YELLING OUT . WHEN PERFORMING CERTAIN TASKS PT WILL DO THE OPPOSITE OF WHAT IS ASKED. PT IS EXTREMELY STRONG AND WILL GRAB YOU AND NOT LET GO. PT REORIENTED BY RN PRN. PERL, GRASPS STRONG. MAE. RECEIVED HALDOL 1 MG WITH SOME EFFECT.\n GI: HAS REMAINED NPO? DOBHOFF TO BE PLACED THIS AM. ABD SOFT,NONTENDER, + BOWEL SOUNDS. NO STOOL.\n GU: ML UO /HR. WILL HAVE HD TODAY.\n ENDO: NO SSI REQUIRED THUS FAR.\n ID: ANTIOBIOTICS PER ID. AFEBRILE\n PAIN: DENIES PAIN.\n SOCIAL: I HAVE NOT SPOKEN TO ANY FAMILY MEMBERS THIS SHIFT.\nA: CONFUSED AND AGITATED. CONTINUES IN AF.\nP: MONITOR COMFORT, HR AND RYTHYM - MONITOR QT, SBP-LOPRESSOR AND HYDRALAZINE AS PER ORDERS, PP, RESP STATUS-PULM TOILET, NEURO STATUS-REORIENTE PRN, I+O- HD TODAY,LABS AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-26 00:00:00.000",
"description": "Report",
"row_id": 1672674,
"text": "cvicu npn\nneuro: confused in am. moaning out much of time. answers some questions. po haldol began, took good nap. now oriented to hospital, . cooperative to care.\n\ncv: vss as per flowsheet. nsr w/ 1st degree avb. hr 80's most of time. goal sbp 140's. cont heparin infusion, last PTT 38.5, heparin increase 1100 unit/hr. cont tan/.brown dng from distal inc. team and Dr assess. several more staples d/c by Dr. . distal inc packed w/ gauze.\n\nresp: wean to n/c 4 l. lungs clear, dim bases. occas non-pro cough.\n\ngi/gu: min uop. HD x 1hr (r/t sceduling).initial drop in sbp ~80 but improved spont. 500cc off. now w/ attempt diuresis w/ lasix 100mg iv and diuril. abd soft, c/o needs to have a BM. abd soft. bsp. dulcolax supp. med formed brown stool. given h20 this w/ team at beside-> tol well no S+S of aspiration. app poor this am, improved by the afternoon. took jello, sips of healthshake.\n\nid: afeb. cont abx. incision as noted. picc placed at bedside.\n\nskin: dime size open area on coccyx. allevyn changed. duoderm to elbows intact.\n\nsocial: wife at this afternoon and updated.\n\nassess: stable day. less confused post po haldol. tol o2 wean and po. heparin adjusted.\n\nplan: cont pulm toilet. picc in -> d/c tlc. enc po. monitor ptt. dsg change prn. sbp ~140.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-30 00:00:00.000",
"description": "Report",
"row_id": 1672683,
"text": "neuro: a+ox2, mae, follows commands, occasional attempts to get out of bed on own, but easily convinced to stay in bed\n\ncv: sr 80s w/ 1st degree avb & BBB, no ectopy seen, sbp 140s, wound vac to lower sternal incision continues to drain scant s/s secretions, afeb\n\nresp: right lung cta dim to base, left lung dim, 02 sats 89-95%, pt will desat to 89% while sleeping w/ nasal cannula because pt is mouth breather\n\ngi: abdomen soft, bowel sounds present, tolerating regular diet\n\ngu: foley to gravity draining clear amber urine in small amts\n\nassess: stable\n\nplan: increase activity, pulmonary toilet, transfer to 6\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-30 00:00:00.000",
"description": "Report",
"row_id": 1672684,
"text": "Neuro:Alert/oriented x3,MAE,PERRL. Consistantly follows commands and answers all questions appropriately. No c/o pain. Patient transfered to chair x1 1/2 hours with 3 assists due to weakness.\n\nCV: First degree AVB 70's-80's,no VEA. NBP 120's-130's,MAP 70's-80's.\nPalpable DP/PT pulses bilat,warm csm and +1 LE edema bilat. Wound\nvac to distal area of sternal incision->drained small amounts serous\ndrainage.\n\nResp:RR 20's-30's unlabored. Lungs are clear upper/lower lobes and sats >93. Patient uses IS with good inspiratory effort.\n\nID: Afebrile and receiving IV antibiotics.\n\nGU/GI: U/O 20-30ml/hr->IV Lasix 40mg x1 resulting in marginal increase to 40-50ml/hr. Urine is amber color. Abdomen is soft,nontender,\nnondistended and +bowel sounds.Patient has poor appetite.\nBUN/CR normal\n\nEndo:Fingersticks managed with SS insulin.\n\nSocial:wife/daughter visited and updated\n\nPlan:Pulmonary toileting. monitor U/O,goal is >30ml/hr and monitor BUN/CR. Fall risk precautions. ?transfer to 6\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-31 00:00:00.000",
"description": "Report",
"row_id": 1672685,
"text": "1900-0700HR NOTE\nNEURO: A&O x3. MAE's with good ROM. Following commands. Speech is clear and verbal response is appropriate. Denies Pain.\nPULM: LSC with diminished bases bilat. Rhonchii over bases auscultated early this am after c/o difficulty breathing. Breathing treatment given per RT. Lasix 40mg given. Haldol 1mg IV given with good resolution of symptoms. 2L NC O2 sat 98%. Encouraged CDB and I.S. use.\nComplies with sternal splinting, needs frequent reminder.\nCV: SR 1DAVB and BBB rate 80-90. HTN this HS SBP 140-150mmHg. Hydralazine given PRN. rsponding well. U/O 45-50cc/hr. Mildly improved diuresis with IV 40mg lasix. Palpable PP bilaterally, Venodyne boots on.\nGI/GU: tolerating PO fluids overnight, denies N/V. Active BS 4Q's. Attempted BM x2 this HS--unsuccessful. passing gas. Willing to try am dulcolax supp. Foley catheter draining clear amber colored urine.\nINTEG: Sternal wound with VAC DSD is patent, intact and no leaks were detected. Allevyn over coccyx. duoderm over elbows. Waffle boots and compression boots are on.\nPLAN: Continue with Pulmonary toilet and encourage to increase ADL's as tolerated. Possible transfer to stepdown this am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-31 00:00:00.000",
"description": "Report",
"row_id": 1672686,
"text": "NURSING PROGRESS NOTE CVICU B\nFOR NURSING PROGRESS NOTE, PLS REFER TO NURSING TRANSFER NOTE IN \"NURSING TRANSFER NOTE\" SECTION OF CAREVIEW. THANK YOU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-15 00:00:00.000",
"description": "Report",
"row_id": 1672628,
"text": "Neuro:alert/oriented x3,MAE,PERRL. Follows commands consistantly and\nanswers questions appropriately.Patient medicated with 2 percocet\ntabs x1 and Tylenol for c/o back pain with good relief.\nPatient scheduled for repeat MRI of complete spine especially lumbar\nregion to R/O osteomylitis pre-op.\n\nCV:First degree AVB 70's-80's,PR .25 and no vea. NBP 119-141,MAP>68.\nPalpable peripheral pulses in LE with warm csm.DR. \nrisk of surgery with patient and will speak to wife and daughter\non . HCT 30.8\n\nResp:Lungs are clear bilaterally,unlabored at rest but DOE. He has a\nnonproductive cough occassionally. RR 11-24,sat>94 on 2L NC.\n\nGU/GI: Patient voided sufficient amounts of dark amber urine. His\nabdomen is soft,nondistended and nontender. He had a large guiac neg\nBM x1. Tolerating meals well. Abdomenal/pelvic CT scan done-> infrarenal aortic aneurysm with mild extension to common iliacs L>R,\nenlarged prostate,small left inguinal hernia,OA both hips.\n\nID:Afebrile,WBC 9.9,patient receiving IV antibiotics every 48 HRS for\n in blood. Blood cultures ordered daily per ID team. U/A positive\nfor bacti and culture pending.PICC line placed in right arm and\nplacement verified by x-ray to use according to IV nurse.\n\nSocial:wife and daughter visited and updated by nurse.Dr. will\nspeak to wife/daughter on about plans for surgery.\n\nPlan:Monitor hemodynamics.MRI of spine on without contrast\ndue to renal insufficiency. Contact/fall risk precautions.Daily\nblood cultures per ID team\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-16 00:00:00.000",
"description": "Report",
"row_id": 1672629,
"text": "NEURO: pt confused, oriented only to person in eve. clearing slightly overnoc. MAE, follows commands. states no pain overnoc. over past two nights confusion noted when pt rec'd 2 tabs percocet, pt tolerates 1 tab and acetamin with no confusion; good pain relief.\nCV: in eve pt with sinus tach to 120's, stable BP. MD Levrsen notified. pt febrile at the time, self resolved. rest of shift sinus 80's-90's. sbp 100's-130. peripheral pulses palp. +pedal edema.\nRESP: lungs clear. resps even, unlabored at rest. sats acceptable on 2 L nasal cannula. occasional non productive cough\nGI/GU: abd soft +bowel sounds. poor apetite ate <25% of dinner, takes liquids well. cath placed d/t incontinence x2.pt voiding amber colored cloudy urine.\nID: peripheral blood cx sent. tmax 100.9 on daptomycin q 48 hours.\nSKIN: stage I to buttocks, bilat heels with duoderm. bilat LE's with open blisters draining serosang NS cleansed and dressed with adaptic and kling. skin is thin and friable/easily irritated.\nSOCIAL: no calls this shift\nA/P: continue to monitor cv, resp, fever curve. continue surveillance blood cx, to have MRI of spine today to eval for ?osteomyelitis, will require premeds/?fent during MRI for back pain. skin/wound care. OOB to chair, encourage PO's. needs nutrition consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-19 00:00:00.000",
"description": "Report",
"row_id": 1672640,
"text": "PATIENT AWAKENED INTIALLY NOT FOLLOWING COMMANDS, SEDATED FOR PAIN, PATIENT LESS AGITATED BUT NEEDS REASSURANCE EVEN STILL RESTLESS AT TIMES. BY 1330 READY TO EXTUBATE, GOOD CUFF LEAK.BOUGIE PLACED BY NP , WITH RESP AT BEDSIDE, RAISING LOTS OF ORAL SECRETIONS POSTEXTUBATION.PATIENT RESPONSIVE TALKING INTIALLY THEN SAO2 DROPPED INTO THE 80'S WITH SVO2 IN THE 50'S, ABG REVEALED NEED FOR REINTUBATION. 38ET PLACED AFTER PROPOFOL RESTARTED WITHOUT INCIDENT, INTIALLY IN RMAINSTEM PULLED BACK,CXR DONE FOR PLACEMENT.. NOTED LEFT SIDED WIPEOUT, SUNCTIONED RECRUITMENT BREATHS, CXR AT 1630 IMPROVED. PLAN ABG AT 1800.PATIENT SEDATED ON PROPOFOL, WITH INTERMITTENT MORPHINE IV BOLUSES. NOW SEDATED BUT PRIOR TO REINTUBATION MOVING ALL EXTREMITIES, ORIENTED TO SELF. AFEBRILE, 1ST DEGREE AVBLOCK. GOOD SVO2'S WITH GOOD CI BY FICK, PLAN TO WEAN EPI LATER TODAY, HAD BEEN INCREASED WITH REINTUBETION. GU RENALMDS FOLLOWING PATINE K ELEVATED WILL FOLLOW CLOSELY, U/O 15-30CC/HR, MINIMAL RESPONSE FROM LASIX THIS AM, WILLL ? ON ROUNDS TO REPEAT DOSE. GI PLAN TO DROP OGT, ON RANTIDINE. ENDOCRINE BS WNL, NO INSULIN DRIP. I/D ON DAPTOMYCIN /MEROPENEM PRESENTLY. VASCULAR PEDAL PULSES ALL DOPPERABLE. SKIN DUODERM ON RCHEEK, LEFT CHEEK REDDENED, CRITICAID APPLIED. FAMILY AT BEDSIDE FOR APPROX. 4HRS. AWARE OF PATIENT'S REINTUBATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-20 00:00:00.000",
"description": "Report",
"row_id": 1672641,
"text": "Respiratory Care:\n\nPt remain orally intubated & sedated, re-intubated during the day yesterday after 15 min, post elective extubation. wew ere able to wean to PSV, See careview. RSBI done ~40. We are sxtn for small amt of thick tan secretions. Plan: wean as tol & Continue present ICU monitoring. Will follow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-20 00:00:00.000",
"description": "Report",
"row_id": 1672642,
"text": "Neuro: Pt intubated/sedated, unable to assess orientation.\n\nCardiac: NSR-Afib HR 60's, BP wnl 120'3-140''s. Amioderone started with bolus and gtt to follow. On epi .02 mcgs. CT with serosanginous drainage wnl, no air leak. 2a2v wires attached to box. Box off. Wires tested. Atrial: Sensitivity @ 1.0, Threshold at 2.0, mA of 20 not capturing. Venticular: Sensitivity @ 1.5, threshold 3.0, mV of 5 with capture. K 5.9: kayexylate given, also 10 Reg insulin IV, 25 D50, 80 lasix.\n\nResp: LS dim with some crackles throughout. On propofol, weened from prop to 10 for , pt. did not tolerate well, prop back on at 20. Vent currently on CPAP (FiO2 40%, PEEP 5 psupport @ 8)\n\nSkin: Sternal incision with staples, edges well approximated, DSD CDI. CT site DSD CDI. Skin tear on coccyx criticaid applied, redened buttocks critcaid applied.\n\nGI/GU: Foley draining marginal amounts of concentrated yellow urine 25-40cc per hour. BS present, abd soft nontender\n\nPlan: continue w POC, wean from vent, monitor VS, IO, maintain immobilizers while intubated.\n\n RN\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-21 00:00:00.000",
"description": "Report",
"row_id": 1672648,
"text": "remains sedated on propofol,grimaces to pain with procedures,turning. morphine given for presumed incisional/back pain. extubation deferred due to volume overload,excessive secretions. breath sounds remain coarse & diminished L.> R.ps increased for increased wob with RR mid 30's with spont. tv's < 300 cc.remains in 1st degree avb,pr ~ .3. amiodarone off,no atrial ectopy noted. a & v wires sense & pace appropriately. generalized edema,weeping from all puncture sites.nutrition on m.d.sbp drifting into the 90's,svo2 into the low 60's with cvp < 10,pad < 22. plan to transfuse prbc when available.tol. cvvhdf removal @ ~ 50 cc/hr.will attempt to increase pfr after prbc's.wife updated via phone,see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-21 00:00:00.000",
"description": "Report",
"row_id": 1672649,
"text": "improved hemodynamics,will attempt more aggressive fluid removal as tolerated. aquacel applied to leaking iv sites. coccyx pink but unbroken,mduoderm applied. ett rotated,small abrasion noted rt. lip.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-21 00:00:00.000",
"description": "Report",
"row_id": 1672650,
"text": "Respiratory Care:\nPt remains orally intubated and vented. PS increased to 12, pt extremly tachypneic with Vt between 250 and 300 on 10 PS. Lung soudns clear. Suctioned for moderate thick yellow secretions. Plan is to wean as tolerated. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-21 00:00:00.000",
"description": "Report",
"row_id": 1672651,
"text": "attempted increased fluid removal,shortly thereafter returned to afib with vrr 40's-50's with hypotension & drop in svo2 to 36%. amiodarone given,lytes treated,v paced @ 80,prbc's ordered for hct < 28% with cvp < 10,pad ~20-24.pfr decreased to previous settings with slow increase in svo2. capped v wires tested,non functional.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-22 00:00:00.000",
"description": "Report",
"row_id": 1672652,
"text": "RESP CARE NOTE\nPT CONTINUES ON PSV . LAST ABG 7.47/44/76. FIO2 INCREASED TO 60. NO OTHER CHANGED MADE. PT CONTINUES ON CVVHD. PLAN CONTINUE PSV AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-22 00:00:00.000",
"description": "Report",
"row_id": 1672653,
"text": "NEURO: sedated on propofol gtt opens eyes to pain and localizes. pain assessed by grimace and vitals, treated with morphine. PERRL.\nCV: sinus rhythm with prolonged PR interval. sbp 100's-130. tolerating cvvd goal -50/hour. transient hypotension sbp 90's with re-initiation of cvvh. self resolved. total body edema, weeping from old IV/blood draw sites. pedal pulses by doppler.\nRESP: orally intubated. lungs diminished bilat. suctioned for thick yellow secretions. fio2 increased this AM for pao2 70's, no other vent changes overnoc.\nGI/GU: abd soft +bowel sounds OGT draining coffee grounds-->bilious drainage. foley with scant output abmer cloudy. cvvhd continues with citrate infusion.\nENDO: blood glucose wnl\nID: afebrile. surveillance cultures sent. dapto, meropenum.\nSKIN: stage I coccyx with duoderm intact, bilat heels with stage I waffle boots on. pt moved to kinair bed. sternum with steristrips CDI chest tube sites approximating, scant serosang drainage dsd's changed. L arm abrasion aquacel and dsd changed.\nA/P: continue to monitor, continue cvvhd to take off fluid, skincare, wound care ?nutrition. surveillance cultures q day. monitor lytes and abg, wean fio2\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-23 00:00:00.000",
"description": "Report",
"row_id": 1672658,
"text": "Neuro: nodding head, mae, following commands correctly, up on fent gtt for c/o pain.\n\nCardiac: nsr with occ strips that have pr ranging from .14 to > .2 -? 1st degree block, no ectopy, palpible pedial pulses, skin extremities cool and dry, afebrile, bed heater on, bilat groin lines placed for increasing wbc.\n\nResp: sxned for lots of yellow thick, will get bronch at 2pm and needs culture sent from bronch, did wean to cpap shortly and abg was good back to rate now will change back to cpap.\n\nSkin: bilat heels pink and both stage one, coccyx with duodem that is intact, chest dsd is cdi, chest tube dsds are cdi, compressive sleeves and waffle boots are on.\n\nGi/Gu: tolerating tf's at goal, low residuals, abd is soft round and nontender with good bowel sounds, on riss, conts cvvh-needs to be changed pre placement to groin, renal did increase dose of k in the replac and dial bags today, goal is to keep even with u/o, low 5/hr uo-urine culture sent.\n\nSocial: wife in to visit and updated.\n\nPlan: needs cultures from central line tips when pulled, needs blood cultures from new groin line, needs foley changed out, will be bronched in afternoon and have new a-line placed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-23 00:00:00.000",
"description": "Report",
"row_id": 1672659,
"text": "BS few coarse crackles. Suctioned for moderate amount thick white secretions. Tried on PSV but placed back on rate for line placement. PSV again but returned to rate for bronch. Bronch reveals moderate amount thick white mucus, R>L. Still sedated and on AC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-23 00:00:00.000",
"description": "Report",
"row_id": 1672660,
"text": "Neuro: , , responds to verbal commands and stimuli.\n\nPain: pt. denies pain, however, grimaces and fights staff with activity and care. Versed given for bronch and with turning in bed and care, with good response.\n\nCV: NSR, HR 90's 100's, Neo titrated to keep MAPs above 60's and SBP above 90. right hand fingertips dusky mid-day, improved throughout evening, currently warm and pink. pulses weakly palpable bilaterally in all extremities. V wires sense, do not capture. pt switched to A Demand with hr set at 60/min.\n\nResp: lung sounds clear in upper lobes, diminished bilaterally in bases. Sats 100%. Bronched for minimal secretions. ABG's metabolic alkalosis.\n\nSkin: dressings intact. R&L heels discolored, waffle boots on. Coccyx dressed with duoderm, intact. left arm bruised and swollen, anticub- elevated on pillow-no dressing.\n\nID: BC sent from new groin lines, discontinued left subclavian Quinton and right IJ trauma cordis, tips cultured. A-line switched to left radial. daptomycin and meropenem continue.\n\nGI/GU: minimal urine out via foley. bowel sounds present, no flatus or bowel movement. OG in place, minimal residuals, tube feeds @ goal 35cc/h, tubing changed. water fluid boluses held, na 132.\n\nEndo: followed per unit protocol. bs wnl.\n\nSocial: wife and daughter in to visit, questions answered regarding direction of care, and progress\n\nassessment: pt. requiring small amounts of Neo to maintain bp throughout shift.\n\nPlan: ? change foley in am, continue CCVHD, wean from vent. pulmonary toilet for diminished lung sounds.\ncont to monitor lytes/bs/wbc/abg's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-25 00:00:00.000",
"description": "Report",
"row_id": 1672670,
"text": "Respiratory note:\nPt received on PS, which changed later to AC due to fatigue and episoded of apnea. Per resident request pt placed back on PS. Pt appears to be agited at times. BS ronchi, clear with sx. Currently on MMV. Well tol. ?plan this am. =88. Last ABG 7.45/41/94/29/3. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-25 00:00:00.000",
"description": "Report",
"row_id": 1672671,
"text": "Resp Care\nPt weaned back to PSV 5/5 this am then extubated with MD present over cook cath. ABG drawn with cook inplace on 100% cool aerosol face tent WNL so cook cath was removed. fio2 weaned throughout shift pt currently on 50% cool aerosol satting 99%. Pt has strong productive cough of thick white/tan secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-25 00:00:00.000",
"description": "Report",
"row_id": 1672672,
"text": "PROB: CVVDH\n\nCV: CONT IN AFIB/FLUTTER, STARTED ON HEPARIN DRIP AT 15:00, NO BOLUS GIVEN. ATTEMPTED TO GIVE PO LOPRESSOR, PT SPITTING OUT MEDS. PACER WIRES D/CD. SITE CLEAN AND DRY, DRESSING CLEAN AND DRY, CHANGED X1. ALINE DAMPENED, BANGING ARMS FREQUENTLY DURING DAY.\n\nRESP: EXTUBATED THIS AM-DIFFICULT AIRWAY CART AT BEDSIDE, EXTUBATED OVER BOUGE CATHETER. ABGS ADEQUATE, SET CURRENTLY PENDING. C/R THICK TAN.\n\nGI: ABD SOFT DISTENDED, PASSING FLATUS. BOWEL SOUNDS PRESENT.\n\nGU: MARGINAL AMOUNTS AMBER URINE WITH SEDIMENT. PT C/O OF HAVING TO VOID, FOLEY IRRIGATED WITHOUT DIFFICULTY.\n\nID: WBC DOWN. ANTIBIOTICS CHANGED. CHEST INCISION DRAINING LESS, DRESSING INTACT.\n\nNEURO: MAE, CALLING OUT CONTINUOUSLY AFTER EXTUBATION. ARMS REMAIN IMMOBILIZED, PT PULLING AT LINES. R KNEE IMMOBILIZER ON, PT MOVING AND SETTING ACCESS ALARMS OFF. PT FOLLOWS COMMANDS, ANSWERS APPROPRIATELY.\nPT SPITTING OUT PAIN MED/LOPRESSOR, SWEARING. TEAM WANTS TO CONTINUE TO OBSERVE.\n\nSOCIAL: WIFE IN TO VISIT MOST OF DAY, UPDATED BY DR. .\n\nCVVHD: PT IN NEGATIVE BALANCE-APPROX 2L SINCE MIDNOC. TOLERATING FLUID REMOVALS OF 250CC/HR.\nACCESS ALARMS CONT GOING OFF, PT MOVING LEG, COUGHING ECT. LEG IMMOBILIZER ON WITH IMPROVEMENT. LYTES PENDING. CA, K, CITRATE INFUSING.\n\nASSESSMENT: PT SLIGHTLY CONFUSED, UNCCOOPERATIVE AT TIMES.\n\nPLAN: LABS PENDING.\nRECHECK PTT AT 9PM.\nPULM HYGIENE.\nCONT CVVHD UNTIL FILTER SHUTS DOWN, PT HAVE HEMO TOMORROW. CONT TO REMOVE FLUID AS PT TOLERATES.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-28 00:00:00.000",
"description": "Report",
"row_id": 1672679,
"text": "7P->7A\nNeuro-A&O X 3, and then x 2 on and off during the night. Pleasantly confused at times. Reoriented, Haldol Q am and pm. , 3mm->2mm. follows commands, helps move and turn.\n\nCV-1 AVB all night 70's->90's without ectopy. SBP110-140's/60-70's. Tolerating Lopressor 25mg po BID. T max 97.7o, HCT 27.7, WBC 11.6. Wound vac in place to lower half of sternal incision. Currently 50cc out since placed . Upper half looks good.\n\nResp-Lungs clear, 2L n/c O2 with sats in mid to high 90's. Good cough, bringing up sputum but swallowing it. Refused auto set CPAP tonight.\n\nGI/GU-tolerating po's well, glucose stable. Positive bowel sounds, no stool. Foley to gravity. Decreased UOP at beginning of shift, got 80mg IV lasix with a good response. BUN 30, CR 2.2. HD d/c'd .\n\nPlan-? Transfer to 6. Monitor neuro status, watch for s/s of infection. Watch UOP, BUN, Cr, and electrolytes. Increase his activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-07-28 00:00:00.000",
"description": "Report",
"row_id": 1672680,
"text": "NEURO: ORIENTED X 2, REORIENTS TO PLACE EASILY. MAE, FDING SELF. SLID OOB TO STRETCHER CHAIR X 1 HOUR-TOLERATED WELL. CONTINUES WITH PO HALDOL.\n\nCARDAIC: HEART RATE 1ST AV BLOCK WITHOUT ECTOPY. VAC DRESSING INTACT. PALPABLE PULSES.\n\nRESP: CS DIMINISHED IN BASES. CNR.\n\nGI: TOLERATING DIET WELL. + BOWEL SOUNDS.\n\nGU: FOLEY IN PLACE, PATENT FOR AMBER URINE ~15 QH. RENAL IN.\n\nENDO: FOLLWING INSULIN PROTOCOL.\n\nPAIN: DENIES.\n\nPLAN: MONITOR RENAL STATUS, FOLLOW BUN/CREAT. ^ ACTIVITY AS TOLERATED. REORIENTED AS NEEDED.\n"
},
{
"category": "ECG",
"chartdate": "2131-07-22 00:00:00.000",
"description": "Report",
"row_id": 222599,
"text": "Sinus rhythm with first degree A-V delay. Right axis deviation. Right\nbundle-branch block. Non-specific inferior ST-T wave changes. Compared to\ntracing #1 no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-07-21 00:00:00.000",
"description": "Report",
"row_id": 222600,
"text": "Sinus rhythm. First degree A-V delay. Right axis deviation. Right\nbundle-branch block. Diffuse ST-T wave changes. Compared to the previous\ntracing of the rate is substantially slower. The other findings are\nbroadly similar.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2131-07-18 00:00:00.000",
"description": "Report",
"row_id": 222601,
"text": "Probable sinus tachycardia with first degree A-V delay and atrial premature\ncomplexes\nRight bundle branch block\nRight axis deviation - may be left posterior fascicular block - possible right\nventricular overload or possible lateral myocardial infarct\nClinical correlation is suggested\nSince previous tracing of , sinus tachycardia, atrial ectopy, and\nfurther right axis deviation are now present\n\n"
},
{
"category": "ECG",
"chartdate": "2131-07-13 00:00:00.000",
"description": "Report",
"row_id": 222602,
"text": "Sinus rhythm. First degree A-V block. Possible left atrial abnormality.\nRight bundle-branch block. No previous tracing available for comparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-07-22 00:00:00.000",
"description": "Report",
"row_id": 222598,
"text": "Sinus rhythm. First degree A-V delay. Right bundle-branch block. Right\naxis deviation. Non-specific inferior ST-T wave changes which may be due\nto myocardial ischemia. Compared to tracing #2 no significant interim change.\nClinical correlation is suggested.\nTRACING #3\n\n"
}
] |
88,552 | 190,094 | Pt was admitted through the emergency for SAH on . She underwent a cerebral angiogram with coiling of a Right ACA aneurysm. She also underwent an emergent placment of an EVD. Nimodipine was started. Her exam improved after the EVD placement and a she was able to be extubated on . A CT Head was performed which also remained stable. On , Transcranial dopplers were done which were normal. Her exam remained stable. On , early morning she was less responsive and a CT head was performed which was stable. Her exam improved later that morning. She also has some desaturation and her CXR showed some bibasilar atelectasis. TCD was normal. On , she again was less responsive with no eye opening or followed commands. A CTA head was performed which showed no vasospasm. Her neuro checks had been Q 1hr for days, we changed it to Q 2hrs to help promote sleep. An EEG was ordered and still pending. Her EVD output remained 10-20 cc/hr. Her SBP was kept 95-220 without difficulty. In the evening, it was noted that her EVD slowed and no longer drained, her ICPs were in the mid 20's and she was hypertensive. The EVD was distally and proximally flushed with NS and the EVD then began to drain appropiately. Her ICPs normalized. On , her EEG showed left frontal discharges which was concerning for seizures. A load of Dilantin was given and Dilantin 100mg TID was started. She remained on Keppra 1000mg . In the evening she had some L arm shaking that was observed and self resolved within a few minutes, EEG was on. Her Keppra was then increased to mg . On Her exam remained unchanged and we continued to monitor her progress with transcranial dopplers which were negative for vasospasm. Her oxygenation had decreased on Friday eve and a CXR was performed which appeared stable, she was given Lasix 10mg x1. Her IV fluids were discontinued. She was given another EVD clamp trial which she failed. On , her EEG showed seizures and she was bolused with Dilantin. On , there was no further seizures on EEG but generally slower. She was bolused with Dilantin and her maintenance dose was increased to 250 mg . She had an Alcius catheter placed for fevers that were thought to be central in nature. On , CTA revealed mild vasospasm and we opted to press her. She did improve exam wise with this on . Her eyes were open and her left upper extremity motor function improved mildly as well. We contact the Neurology team for formal recommendations for seizure control. A rash was noted that was thought to be from her dilantin. It was held initially. The neurology team recommended restarting her dilantin and following her LFT's. On , her blood pressures have been labile and required two agents and a couple of boluses of albumin. Cardiac enzymes and a Cortisol level were obtained which were normal. Evaluation of her CTA revealed no evidence of vasospasm and she was taken off pressors on . EEG monitoring revealed sub-clinical seizures on the 27 th and 28th, she was bolused several times with dilantin and her dilantin level was increased on to 300 . She also underwent a clamping trial and failed on the 29th. The EVD was clamped for trial of removal. She tolerated 48 hours of this without issue. CT was negative for hydrocephalus. Her EVD was removed. The pt pulled out her NGT and was bright enough for bedside trial of oral intake, but will need a PEG placed on this hospitalization as her PO intake is not adequate to sustain her nutritional needs. PEG was placed on withought incident. The patient is being screened for a rehab facility and was given a bed for but the family refused placement as they wanted a different facility. On she was offered a bed at and she was discharged. | There is bilateral subarachnoid hemorrhage of decreasing density consistent with normal evolution. Evolving bilateral sulcal subarachnoid hemorrhage with stable intraventricular hemorrhage. Diffuse subarachnoid hemorrhage again visualized Right internal carotid artery arteriogram status post coiling shows that the aneurysm in the anterior cerebral artery is completely obliterated except for a small residual neck. Unchanged extensive bilateral sulcal subarachnoid hemorrhage. Decreased cisternal subarachnoid hemorrhage. Prominent right vertebral artery with hypoplastic left vertebral artery, stable from prior study. Prominent right vertebral artery with hypoplastic left vertebral artery, stable from prior study. Prominent right vertebral artery with hypoplastic left vertebral artery, stable from prior study. Stable intraventricular hemorrhage, ventricular size and position of intraventricular drain. Stable intraventricular hemorrhage, ventricular size and position of intraventricular drain. Stable right frontal parenchymal hemorrhage with slightly increased surrounding edema. Stable right frontal parenchymal hemorrhage with slightly increased surrounding edema. Mild bibasilar atelectatic changes with continued elevation of the right hemidiaphragmatic contour. There is a right frontal approach ventricular catheter terminating in the third ventricle, unchanged in position from prior study. Endotracheal tube has been removed. FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, superficial femoral, popliteal and tibial veins. Other findings (Over) 2:21 PM CTA HEAD W&W/O C & RECONS Clip # Reason: please eval bleed Contrast: OPTIRAY Amt: 70 FINAL REPORT (Cont) as described above including probable infundibulum at the origin of right posterior cerebral artery. FINDINGS: AP chest compared to through , 3:49 p.m.: Right subclavian multichannel catheter has been withdrawn to the level of the superior cavoatrial junction. There is a right frontal approach ventricular drain entering the frontal right with tip terminating along the left lateral margin of the upper third ventricle, as before. Stable right frontal parenchymal hemorrhage with slightly increased surrounding edema and stable associated mass effect. Eval bilateral lower extremities for DVT. Eval bilateral lower extremities for DVT. Left vertebral artery arteriogram shows the left vertebral artery to be hypoplastic predominantly supplying the left PICA. IMPRESSION: EU critical underwent cerebral angiography and coil embolization of a distal anterior cerebral artery aneurysm leaving a small residual at the neck. Physiologic mitral regurgitation is seen(within normal limits). There is edema surrounding this hematoma with compression of the frontal of the right lateral ventricle which is largely unchanged from prior study. Mildascending aortic dilation. A previously described right subclavian central venous line remains in unchanged position. There is a right frontal approach ventricular drain entering the frontal of the right lateral ventricle with the tip terminating along the left lateral margin of the upper third ventricle, unchanged in position from prior study. Stable subarachnoid hemorrhage, greater intraventricular hemorrhage. Mild symmetric left ventricularhypertrophy with hyperdynamic left ventricular function. Stable intraventricular hemorrhage, ventricular size and position of intraventricular drain. Unchanged extensive bilateral sulcal subarachnoid hemorrhage. There is mild symmetric left ventricularhypertrophy with normal cavity size. There is extensive but stable bilateral sulcal subarachnoid hemorrhage. Mildly dilated ascendingaorta. There is largely unchanged mass effect with stable leftward shift of the anterior falx. Mild mitral annularcalcification. There is a small amount of intraventricular hemorrhage, unchanged from prior study. COMPARISONS: CTA of the head with and without contrast and reformats from and CT of the head without contrast from . The right-sided subclavian catheter terminates with its tip in the distal SVC. IMPRESSION: Bilateral lower lobe atelectasis is unchanged. The (Over) 9:52 AM CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: CTA / CTP of brain please Admitting Diagnosis: SUBARACHNOID HEMORRHAGE Contrast: OPTIRAY Amt: 110 FINAL REPORT (Cont) ventricles are stable in size. Normal aortic arch diameter.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Cardiomediastinal shadow is normal. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Expected evolution of the right frontal intraparenchymal hemorrhage with stable surrounding edema and mass effect on the frontal of the right lateral ventricle. Expected evolution of the right frontal intraparenchymal hemorrhage with stable surrounding edema and mass effect on the frontal of the right lateral ventricle. Expected evolution of the right frontal intraparenchymal hemorrhage with stable surrounding edema and mass effect on the frontal of the right lateral ventricle. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Weight (lb): 162BP (mm Hg): 152/67HR (bpm): 65Status: InpatientDate/Time: at 13:31Test: Portable 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. | 30 | [
{
"category": "Radiology",
"chartdate": "2190-07-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1199806,
"text": " 5:39 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Alsius line placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with head bleed.\n REASON FOR THIS EXAMINATION:\n Alsius line placement\n ______________________________________________________________________________\n WET READ: PBec SUN 8:08 PM\n r central venous line with tip at cavoatrial jx. stable exam. Pbishop.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, \n\n HISTORY: Intracranial hemorrhage. Assess line placement.\n\n FINDINGS: AP chest compared to through , 3:49 p.m.:\n\n Right subclavian multichannel catheter has been withdrawn to the level of the\n superior cavoatrial junction. No pneumothorax, appreciable pleural effusion,\n or mediastinal widening. Mild cardiomegaly has improved. Feeding tube ends\n in the upper stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199018,
"text": " 11:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for fluid overload\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71F w/ SAH now w/ decreased O2 sats\n REASON FOR THIS EXAMINATION:\n Eval for fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To assess for fluid overload.\n\n FINDINGS: In comparison with the study of , the tip of the Dobbhoff tube\n is now in the body of the stomach. There is continued enlargement of the\n cardiac silhouette with fullness of pulmonary vessels consistent with elevated\n pulmonary venous pressure. Bibasilar atelectatic changes are again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198642,
"text": " 2:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman intubated\n REASON FOR THIS EXAMINATION:\n please eval tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with new intubation for position of tube.\n\n COMPARISON: None available.\n\n FINDINGS: Single portable chest radiograph was obtained. An endotracheal\n tube is visualized with the tip at approximately 2.9 cm from the carina. An\n NG tube is also visualized in the stomach with the tip not clearly visualized,\n however the distal sideport is clearly distal to the gastroesophageal\n junction. Otherwise, multiple overlying wires are visualized. The lungs are\n clear with no evidence of consolidation, pneumothorax, or effusion. The\n cardiomediastinal silhouette is within normal limits.\n\n IMPRESSION: Endotracheal tube is visualized with the tip at approximately 2.9\n cm from the carina. NG tube appears in the stomach. Otherwise, no acute\n cardiopulmonary process visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-03 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1198643,
"text": " 2:21 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: please eval bleed\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n please eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MDAg SAT 3:09 PM\n NECT: 2.5 x 3.0cm right frontal intraparenchymal hemorrhage with extensive\n subarachnoid hemorrhage. tiny amount of blood in the posterior of the\n right lateral ventricle. 3mm leftward shift of midline structures at level of\n IPH but otherwise no midline shift. pt intubated.\n CTA:\n 1. 3x3 mm aneurysm of the right anterior cerebral artery (3:117)\n 2. atherosclerotic calcification in left internal carotid artery (3:4) with\n less than 50% stenosis. calcified plaque in the cavernous carotid arteries\n bilaterally and right vertebral artery.\n 3. posterior communicating arteries not visualized.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with subarachnoid hemorrhage.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Following this, using departmental protocol, CT angiography of the head\n acquired.\n\n FINDINGS:\n\n CT HEAD: There is a right frontal intraparenchymal hemorrhage seen adjacent\n to the falx with surrounding edema. Diffuse subarachnoid hemorrhage\n identified in the basal cisterns along the sulci and interhemispheric fissure.\n There is mild-to-moderate ventriculomegaly with prominence of temporal \n indicating developing hydrocephalus.\n\n CT ANGIOGRAPHY HEAD: The CT angiography of the head demonstrates a 3.7 x 2.5\n mm aneurysm arising from the bifurcation of the anterior cerebral artery A2\n segment. The aneurysm points slightly to the left side. In addition, there\n is slight protuberance seen on the posterior aspect of the internal carotid\n artery near the right posterior communicating artery origin which could be due\n to a small infundibulum. No other definite aneurysms are identified. There\n is no vasospasm seen. No vascular occlusion is noted.\n\n IMPRESSION:\n 1. CT head demonstrates intraparenchymal hemorrhage in the right frontal\n region and diffuse subarachnoid hemorrhage with developing hydrocephalus.\n 2. Aneurysm at the bifurcation of right anterior cerebral artery A2 segment\n pointing towards the left side in the interhemispheric region. Other findings\n (Over)\n\n 2:21 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: please eval bleed\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n as described above including probable infundibulum at the origin of right\n posterior cerebral artery.\n\n COMMENT: This report is provided without the availability of 3D reformatted\n images. When these images are available, an addendum will be given to this\n report if additional information is obtained.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1199798,
"text": " 3:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement (Alsius)\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n line placement (Alsius)\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Central venous line placement.\n\n AP radiograph of the chest was reviewed in comparison to .\n\n The right subclavian line has been inserted with its tip in the right atrium\n and should be pulled back approximately 2.5 cm. The Dobbhoff tube tip is in\n the stomach. The heart size and mediastinum are unremarkable. There is no\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1198658,
"text": " 4:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Check EVD placement.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with large SAH. S/P EVD placement.\n REASON FOR THIS EXAMINATION:\n Check EVD placement.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with large subarachnoid hemorrhage status\n post EVD placement for EVD site.\n\n COMPARISON: Head CTA from at 14:40.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Multiplanar reformatted images were prepared.\n\n FINDINGS: Again visualized is a right frontal intraparenchymal hemorrhage\n adjacent to the falx with increased minimally in size in comparison to prior\n study from two hours ago, now measuring 3.2 x 2.6 cm compared to 2.7 x 2.3 cm\n previously. It is worth noting that the degree of mass effect has remained\n stable. Interval placement of a right frontal ventriculostomy with the\n catheter tip terminating in the third ventricle. Otherwise, there is no\n significant change in comparison to prior study with diffuse subarachnoid\n hemorrhage identified in the basal cisterns along the sulci in the\n interhemispheric fissure. Again visualized is mild-to-moderate\n ventriculomegaly with prominence of the temporal horns indicating developing\n hydrocephalus, but stable in comparison to prior study.\n\n IMPRESSION:\n 1. Interval placement of a right frontal ventriculostomy with the catheter\n tip terminating in the third ventricle.\n 2. Intraparenchymal hemorrhage in the right frontal region has minimally\n increased in size, has a stable mass effect. Diffuse subarachnoid hemorrhage\n again visualized\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-03 00:00:00.000",
"description": "EMBO TRANSCRANIAL",
"row_id": 1198659,
"text": " 4:41 PM\n CAROT/CEREB Clip # \n Reason: 71 year old woman with large aneurysmal subarachnoid hemorrh\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 157ML OPTI240, 43ML OPTI320\n ********************************* CPT Codes ********************************\n * EMBO TRANSCRANIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT -59 DISTINCT PROCEDURAL SERVICE *\n * CAROTID/CERVICAL UNILAT -59 DISTINCT PROCEDURAL SERVICE *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * TRANSCATH EMBO THERAPY *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with large aneurysmal subarachnoid hemorrhage. Cerebral\n angiography for coiling.\n REASON FOR THIS EXAMINATION:\n 71 year old woman with large aneurysmal subarachnoid hemorrhage. Cerebral\n angiography for coiling.\n ______________________________________________________________________________\n FINAL REPORT\n DATE OF SERVICE: .\n\n INDICATION: Patient presented with a subarachnoid hemorrhage and was found to\n have anterior cerebral artery aneurysm on the right side. She had an emergent\n ventriculostomy placed and she was brought for coiling of the aneurysm.\n\n PROCEDURE PERFORMED: Left common carotid artery arteriogram, left vertebral\n artery arteriogram, right vertebral artery arteriogram, right internal carotid\n artery arteriogram, right common femoral artery arteriogram and Angio-Seal\n closure of right common femoral artery puncture site.\n\n INTERVENTIONAL PROCEDURE PERFORMED: Coil embolization of right A2 aneurysm\n with Target coils.\n\n ATTENDING:\n ASSISTANT: .\n\n DETAILS OF THE PROCEDURE: The patient was brought to the angiography suite.\n General anesthesia was induced in the supine position. Following this, both\n groins were prepped and draped in a sterile fashion. Access was gained to the\n right common femoral artery using a Seldinger technique and a 6 French\n vascular sheath was placed in the right common femoral artery. Now we\n catheterized the above-mentioned vessels and AP, lateral filming was done.\n This revealed the aneurysm on the right anterior cerebral artery at the\n junction of the pericallosal and callosal marginal artery. We now exchanged\n out the 2 catheter for an Envoy 6 French catheter in the right\n internal carotid artery. Following this, the aneurysm was catheterized with\n (Over)\n\n 4:41 PM\n CAROT/CEREB Clip # \n Reason: 71 year old woman with large aneurysmal subarachnoid hemorrh\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 157ML OPTI240, 43ML OPTI320\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n an SL-10 microcatheter and a Synchro microwire. The aneurysm was coiled\n starting with a 3 mm 360 UltraSoft Target coil followed by a 2 mm coil of a\n similar configuration. Following this the aneurysm was obliterated except for\n a small residual neck. A right common femoral artery arteriogram was done and\n a 6 French Angio-Seal was used for closure of the right common femoral artery\n puncture site.\n\n FINDINGS: Left common carotid artery arteriogram shows filling of the left\n internal carotid artery along the cervical, petrous, cavernous and\n supraclinoid portion. The anterior and middle cerebral arteries fill well.\n There is no evidence of any other aneurysms on this injection.\n\n Left vertebral artery arteriogram shows the left vertebral artery to be\n hypoplastic predominantly supplying the left PICA. There is filling of the\n basilar system.\n\n Right vertebral artery arteriogram shows filling of the right vertebral artery\n and the basilar artery. Both the posterior cerebral arteries are well\n visualized with no evidence of aneurysms.\n\n Right internal carotid artery arteriogram shows that the anterior and middle\n cerebral artery fills well. There is a 4 mm into 3 mm aneurysm at the\n junction of the pericallosal and callosal marginal artery on the right side.\n\n Right internal carotid artery arteriogram status post coiling shows that the\n aneurysm in the anterior cerebral artery is completely obliterated except for\n a small residual neck.\n\n Right common femoral artery arteriogram shows a widely patent right common\n femoral artery.\n\n IMPRESSION: EU critical underwent cerebral angiography and coil\n embolization of a distal anterior cerebral artery aneurysm leaving a small\n residual at the neck. This was uneventful.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-12 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1199841,
"text": " 7:56 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: 71 year old woman with SAH and fever of unknown origin. Eval\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH and fever of unknown origin. Eval bilateral lower\n extremities for DVT.\n REASON FOR THIS EXAMINATION:\n 71 year old woman with SAH and fever of unknown origin. Eval bilateral lower\n extremities for DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 71-year-old female with SAH and fever of unknown origin,\n evaluate for DVT in either leg.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral\n common femoral, superficial femoral, popliteal and tibial veins. Normal flow,\n compression, and augmentation is seen in all the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-12 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1199847,
"text": " 8:13 AM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o vasospasm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with ruptured aneurysm, s/p coiling, post bleed day # 9. r/o\n vasospasm\n REASON FOR THIS EXAMINATION:\n r/o vasospasm\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RJab MON 2:19 PM\n 1. Stable right frontal parenchymal hemorrhage with slightly increased\n surrounding edema. Stable associated mass effect.\n\n 2. Evolving bilateral sulcal subarachnoid hemorrhage.\n\n 3. Stable intraventricular hemorrhage, ventricular size and position of\n intraventricular drain.\n\n 4. Increased transit time with decreased flow and decreased \n volume in the right frontal lobe inferior to the hematoma above the orbit\n consistent with ischemia with completed infarction.\n\n 5. Narrowing of the right A1 segment as compared to , and given\n the clinical setting, likely due to vasospasm.\n\n 6. Prominent right vertebral artery with hypoplastic left vertebral artery,\n stable from prior study.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with ruptured aneurysm status post coiling.\n Post-bleed day 9, rule out vasospasm.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. An axial perfusion CT run was performed during infusion of\n 110 cc of Optiray intravenous contrast. Subsequently, rapid axial imaging was\n performed from the aortic arch through the brain. Images were processed on a\n separate workstation with display of mean transit time, relative cerebral\n volume, and cerebral flow maps for the CT perfusion study and\n curved reformats, 3D volume-rendered images, and maximum maximum-intensity\n projection images for the CTA.\n\n COMPARISON: CTA of head with and without contrast from , CTA of\n the head with and without contrast from and CT head without\n contrast from .\n\n FINDINGS:\n\n CT HEAD: There is a large right frontal intraparenchymal hemorrhage, largely\n (Over)\n\n 8:13 AM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o vasospasm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n unchanged from prior study. Slightly increased vasogenic edema surrounding\n the parenchymal hemorrhage. There is largely unchanged mass effect with\n stable leftward shift of the anterior falx. There is now an area of\n hyperdensity at the corpus callosum (image 2:19), likely representing\n hemorrhage dissecting through the corpus callosum. There is bilateral\n subarachnoid hemorrhage of decreasing density consistent with normal\n evolution. There is unchanged intraventricular hemorrhage in the bilateral\n occipital horns and the bilateral atria. There is no in the third or\n fourth ventricles. There is a right frontal approach ventricular catheter\n terminating in the third ventricle, unchanged in position from prior study.\n There is a coil pack in the anterior interhemispheric fissure with streak\n artifact. The visualized portions of the paranasal sinuses and mastoid air\n cells are clear. Bony structures are unremarkable.\n\n CT PERFUSION: There is increased transit time in the right frontal lobe,\n inferior to the hematoma and above the orbit with decreased flow and low\n volume, representing ischemia with completed infarction.\n\n CTA HEAD: The intracranial carotid and vertebral arteries and their major\n branches are patent with no evidence of occlusion. There is narrowing of the\n right A1 segment of the right anterior cerebral artery as compared to , which based on clinical setting is likely due to vasospasm. The left\n vertebral artery is hypoplastic when compared to the right as demonstrated on\n prior studies. There is a coil present in the A2 segment of the right ACA.\n\n IMPRESSION:\n\n 1. Narrowing of the right A1 segment as compared to , likely due\n to vasospasm given the clinical setting.\n\n 2. Stable right frontal parenchymal hemorrhage with slightly increased\n surrounding edema and stable associated mass effect. Evolving bilateral sulcal\n subarachnoid hemorrhage with stable intraventricular hemorrhage.\n\n 3. Increased transit time with decreased flow and decreased \n volume in the right frontal lobe inferior to the hematoma and above the orbit\n consistent with ischemia with completed infarction.\n\n 4. Prominent right vertebral artery with hypoplastic left vertebral artery,\n stable from prior study.\n (Over)\n\n 8:13 AM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o vasospasm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-12 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1199848,
"text": ", J. NSURG SICU-B 8:13 AM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: r/o vasospasm\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with ruptured aneurysm, s/p coiling, post bleed day # 9. r/o\n vasospasm\n REASON FOR THIS EXAMINATION:\n r/o vasospasm\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Stable right frontal parenchymal hemorrhage with slightly increased\n surrounding edema. Stable associated mass effect.\n\n 2. Evolving bilateral sulcal subarachnoid hemorrhage.\n\n 3. Stable intraventricular hemorrhage, ventricular size and position of\n intraventricular drain.\n\n 4. Increased transit time with decreased flow and decreased \n volume in the right frontal lobe inferior to the hematoma above the orbit\n consistent with ischemia with completed infarction.\n\n 5. Narrowing of the right A1 segment as compared to , and given\n the clinical setting, likely due to vasospasm.\n\n 6. Prominent right vertebral artery with hypoplastic left vertebral artery,\n stable from prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199638,
"text": " 4:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute pulm process\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p angio for coiling of R ACA aneurysm\n REASON FOR THIS EXAMINATION:\n acute pulm process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after right AC aneurysm\n coiling.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n The NG tube tip is in the stomach. Heart size is normal. Mediastinum is\n normal. Lungs are essentially clear except for minimal bibasilar atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1198954,
"text": " 5:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: decreased mental status\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with sah, ruptured aneurysm\n REASON FOR THIS EXAMINATION:\n decreased mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): IPf TUE 6:48 AM\n No significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decreased mental status in a 71-year-old woman with subarachnoid\n hemorrhage and ruptured aneurysm.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n COMPARISON: CT head .\n\n FINDINGS: There is a similar appearance of the right frontal intraparenchymal\n hemorrhage, though surrounding edema has decreased in density, as expected\n over time. There is unchanged mild leftward shift of the anterior falx and\n unchanged partial effacement of the frontal of the right lateral\n ventricle. Extensive bilateral sulcal subarachnoid hemorrhage is unchanged,\n but there is less blood in the basal cisterns. There is a right frontal\n approach ventricular drain entering the frontal right with tip\n terminating along the left lateral margin of the upper third ventricle, as\n before. The ventricles are stable in size. There is unchanged blood in the\n occipital horns of the lateral ventricles, but blood is no longer present in\n the fourth ventricle. There is no blood in the third ventricle, as before.\n There is a coil pack in the anterior interhemispheric fissure with streak\n artifact.\n\n The imaged bones are unremarkable. A nasogastric tube is noted.\n\n IMPRESSION:\n 1. No significant interval change in size of right frontal parenchymal\n hemorrhage and associated mass effect.\n 2. Unchanged extensive bilateral sulcal subarachnoid hemorrhage. Decreased\n cisternal subarachnoid hemorrhage.\n 3. Stable hemorrhage in the lateral ventricles, but resolution of blood in\n the fourth ventricle. Stable ventricular size and stable position of the\n intraventricular drain.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1198955,
"text": ", J. NSURG SICU-B 5:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: decreased mental status\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with sah, ruptured aneurysm\n REASON FOR THIS EXAMINATION:\n decreased mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No significant interval change.\n DFDkq\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198743,
"text": " 3:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: DHT placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH. Decreased mental status.\n REASON FOR THIS EXAMINATION:\n DHT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: SAH with decreased mental status, for Dobbhoff placement.\n\n FINDINGS: In comparison with the study of , the Dobbhoff tube has been\n placed with its tip in the lower body of the stomach. Endotracheal tube has\n been removed. There is some fullness of pulmonary vessels suggesting elevated\n pulmonary venous pressure. Atelectatic changes are seen at both bases,\n especially in the retrocardiac region.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199201,
"text": " 12:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with recent IPH, more lethargic\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: IPH with lethargy.\n\n FINDINGS: In comparison with the study of , there are somewhat improved\n lung volumes. Cardiac silhouette remains enlarged within indistinctness of\n engorged pulmonary vessels consistent with elevated pulmonary venous pressure.\n Mild bibasilar atelectatic changes with continued elevation of the right\n hemidiaphragmatic contour. The opaque tip of the Dobbhoff tube is below the\n inferior level of the image.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199979,
"text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for fluid status\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with h/o SAH with fluid rescucitation\n REASON FOR THIS EXAMINATION:\n assess for fluid status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage with fluid resuscitation, to assess for\n the fluid status.\n\n TECHNIQUE: Semi-erect portable radiograph of the chest.\n\n Comparison was made with prior radiographs with most recent from .\n\n FINDINGS: The tip of the right central line is terminating into the right\n atrium. The feeding tube can be traced up to the stomach. Bilateral lung\n volumes are low, and as compared to the previous radiograph, ,\n there are no relevant changes. Linear basal atelectasIs are persisting and\n unchanged. Cardiomediastinal shadow is normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1198709,
"text": " 8:20 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for interval change, EVD placement, ventricular exten\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with atraumatic SAH\n REASON FOR THIS EXAMINATION:\n assess for interval change, EVD placement, ventricular extension, hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SJBj SUN 9:46 AM\n Increasing size of right frontal parenchymal hemorrhage with greater mass\n effect on falx and anterior of R ventricle. Stable subarachnoid\n hemorrhage, greater intraventricular hemorrhage. EVD in good location.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with subarachnoid hemorrhage status post\n endovascular coiling of a right distal anterior cerebral artery aneurysm last\n night, placement of EVD.\n\n COMPARISON: Cerebral angiography , 4 p.m. CT head , 4:45 p.m.\n\n TECHNIQUE: Contiguous MDCT data were acquired through the head without\n intravenous contrast.\n\n FINDINGS: A right frontal intraparenchymal hemorrhage has slightly increased\n in transverse dimension compared to prior study, now measuring 3.1 x 3.2 cm\n compared to 3.1 x 2.6 cm. The hemorrhage exerts increased mass effect on the\n adjacent falx and frontal of the right lateral ventricle. An external\n ventricular drain enters the frontal of the right lateral ventricle and\n the tip terminates appropriately in the third ventricle. Endovascular coils\n are seen in the midline of the frontal lobes at the site of coiling of a\n distal right ACA aneurysm. Diffuse subarachnoid hemorrhage is again seen\n along the frontal sulci, interhemispheric fissure and into the basilar\n cisterns. Intraventricular hemorrhage has increased with more blood seen\n layering in the posterior horns of the ventricles and deflection of the\n anterior falx from mass effect from the parenchymal hemorrhage. No\n significant shift of normally midline structures is seen.\n\n IMPRESSION:\n 1. Slight increase in size of right frontal parenchymal hemorrhage with\n increasing mass effect on adjacent structures.\n 2. Diffuse subarachnoid and increased intraventricular hemorrhage.\n 3. Interval coiling of right ACA aneurysm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198763,
"text": " 1:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Gastric tube placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman s/p coiling R ACA aneurysm .Patient removed prior DHT.\n REASON FOR THIS EXAMINATION:\n Gastric tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative, for Dobbhoff placement.\n\n FINDINGS: In comparison with the study of , the Dobbhoff tube has been\n pulled back slightly into the upper stomach. Little change in the appearance\n of the heart and lungs. Continued fullness of pulmonary vessel is consistent\n with elevated pulmonary venous pressure. Bibasilar atelectatic changes are\n again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1201254,
"text": " 12:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm NGT placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n confirm NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with subarachnoid hemorrhage, confirm NG tube\n placement.\n\n COMPARISON: Multiple chest radiographs, the latest from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume but clear. The cardiac silhouette is top normal.\n The mediastinal silhouette and hilar contours are normal. The right-sided\n subclavian catheter terminates with its tip in the distal SVC. An NG tube\n terminates with its tip in the stomach and the side port past the GE junction.\n\n IMPRESSION:\n\n Appropriate positioning of the NG tube. No acute intrathoracic process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199446,
"text": " 1:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for NGT placement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with h/o SAH\n REASON FOR THIS EXAMINATION:\n Assess for NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with history of subarachnoid hemorrhage.\n Assess for an NG tube placement.\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 linear atelectasis in the right mid lung\n and mild developing atelectasis in the left lower lobe. The cardiac\n silhouette is top normal. The mediastinal silhouette and hilar contours are\n normal. No pleural effusion or pneumothorax is present. An NG tube\n terminates with its tip in the stomach appropriately.\n\n IMPRESSION:\n\n NG tube terminates in the stomach. Mild bilateral lower lobe atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1201111,
"text": " 12:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please confirm placement of dobhof feeding tube\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with new feeding tube placed\n REASON FOR THIS EXAMINATION:\n please confirm placement of dobhof feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: A 71-year-old female patient with new feeding tube placed,\n confirm location of Dobbhoff tube.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. A Dobbhoff line is now seen and its tip\n reaches the upper portion of the stomach. As the more dense solid portion of\n the Dobbhoff line is still partially within the hiatal area, further\n advancement by at least a few centimeters is recommended. Chest findings when\n compared to the next preceding portable chest examination of \n demonstrate less marked pulmonary congestion. No new infiltrates, no pleural\n effusion, or pneumothorax. A previously described right subclavian central\n venous line remains in unchanged position.\n\n IMPRESSION: Dobbhoff line reaching the upper portion of the stomach. Further\n advancement is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-07 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1199166,
"text": " 9:52 AM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: CTA / CTP of brain please\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with aca aneurysm s/p coiling with altered mental status\n REASON FOR THIS EXAMINATION:\n CTA / CTP of brain please\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab WED 11:37 AM\n CT Head: Large amount of SAH and intraparenchymal with progressive\n edema. No evidence of new infarct\n CTA: No new occlusion or spasm. Right ACA is smaller in caliber than the Left\n ACA, unchanged from prior study. Reformats pending\n CTP: Abnormally prolonged transit time at site of right intraparenchymal\n hemorrhage. No additional areas of prolonged transit to suggest infarct.\n\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with ACA aneurysm, status post coiling with\n altered mental status.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. An axial perfusion CT run was performed during the\n infusion intravenous contrast. Subsequently, rapid axial imaging was\n performed through the brain for the CTA. Images were processed on a separate\n workstation with display of mean transit time, relative cerebral volume\n and cerebral flow maps for the CT perfusion study and curved reformats,\n 3D volume-rendered images and maximum intensity projection images for the CTA.\n\n COMPARISONS: CTA of the head with and without contrast and reformats from\n and CT of the head without contrast from .\n\n FINDINGS:\n\n CT HEAD: There is a large right frontal intraparenchymal hemorrhage,\n measuring approximately 3.6 x 3.4cm which is slightly increased from prior\n study when allowing for differences in section and positioning. There is\n increased edema surrounding the intraparenchymal hemorrhage when compared to\n prior study. There is largely unchanged mass effect with stable leftward\n shift of the anterior falx. There is extensive but stable bilateral sulcal\n subarachnoid hemorrhage. There is intraventricular hemorrhage in the\n occipital horns of the lateral ventricles bilaterally which is unchaged from\n prior study. There is no in the third or fourth ventricles. There is a\n right frontal approach ventricular drain entering the frontal of the\n right lateral ventricle with the tip terminating along the left lateral margin\n of the upper third ventricle, unchanged in position from prior study. The\n (Over)\n\n 9:52 AM\n CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: CTA / CTP of brain please\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ventricles are stable in size. There is a coil pack in the anterior\n interhemispheric fissure with streak artifact. The visualized portion of the\n paranasal sinuses, mastoid air cells and middle ear cavities are clear. Bony\n structures are unremarkable.\n\n CT PERFUSION: There is an abnormally prolonged transit time at the site of\n the right intraparenchymal hematoma but no other areas of prolonged transit\n time to suggest infarct. There is reduced flow and volume at the\n site of the right frontal intraparenchymal hemorrhage.\n\n HEAD CTA: The intracranial internal carotid arteries and their major branches\n are patent without evidence of occlusion. There is a prominent right\n vertebral artery with hypoplastic left vertebral artery but no evidence of\n occlusion. The vessels appear smooth, not beaded or narrowed. There is no\n evidence of vasospasm. The right and left ACA are similar in caliber. There\n is a coil present in the A2 segment of the right ACA.\n\n IMPRESSION:\n 1. Slight increase in size of right frontal parenchymal hemorrhage with\n increase in surrounding edema. Stable associated mass effect.\n 2. Unchanged extensive bilateral sulcal subarachnoid hemorrhage.\n 3. Stable intraventricular hemorrhage, ventricular size and position of\n intraventricular drain.\n 4. No evidence of new infarct, intracranial arterial occlusion or vasospasm.\n Coil in the A2 segment of the right ACA.\n 6. Prominent right vertebral artery with hypoplastic left vertebral artery.\n\n COMMENT: A preliminary interpretation to this effect was discussed with Ms.\n , N.P. (Neurosurgry service), in-person, at 1100H, .\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1201044,
"text": " 5:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evolution of injury\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH s/p coiling of R ACA\n REASON FOR THIS EXAMINATION:\n evolution of injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg TUE 7:24 AM\n PFI:\n\n Interval decrease in right frontal intraparenchymal hemorrhage and mass effect\n on the falx and lateral ventricles. Expected interval evolution of\n subarachnoid and intraventricular hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old female with subarachnoid hemorrhage status post\n coiling of right ACA.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without IV\n contrast.\n\n FINDINGS: An 18 x 17 mm focus of intraparenchymal hemorrhage in the right\n frontal lobe with significant surrounding vasogenic edema has decreased from\n 36 x 25 mm previously. There is associated mass effect on the right frontal\n , but overall the frontal horns appear more expanded than on the prior\n study. There is no shift of the normally midline structures. There has been\n expected interval evolution of subarachnoid hemorrhage in the bilateral\n frontal and parietal sulci. Blood products layering in the bilateral\n occipital horns has decreased compared to the prior examination. There is no\n new hemorrhage.\n\n A coil mass is noted in the expected region of the right anterior cerebral\n artery. A ventriculostomy catheter from a right frontal approach terminates\n in the left lateral ventricle.\n\n The visualized paranasal sinuses and mastoid air cells are well aerated.\n There is no suspicious lytic or sclerotic osseous lesion.\n\n IMPRESSION:\n\n 1. Marked interval decrease in right frontal intraparenchymal hemorrhage with\n decreased mass effect on the falx and lateral ventricles.\n\n 2. Expected interval evolution of bifrontal and biparietal subarachnoid\n hemorrhage.\n (Over)\n\n 5:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evolution of injury\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-20 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1201045,
"text": ", J. NSURG SICU-B 5:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evolution of injury\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH s/p coiling of R ACA\n REASON FOR THIS EXAMINATION:\n evolution of injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n Interval decrease in right frontal intraparenchymal hemorrhage and mass effect\n on the falx and lateral ventricles. Expected interval evolution of\n subarachnoid and intraventricular hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1200487,
"text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for interval change\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with h/o SAH\n REASON FOR THIS EXAMINATION:\n Please assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of subarachnoidal hemorrhage, assessment for interval\n change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. Increase in density of the right\n hemithorax is likely due to change in patient position. However, moderate\n cardiomegaly is still present. Minimal widening of the pulmonary vessels\n might indicate mild overhydration. No pleural effusions. No focal\n parenchymal opacity suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1201145,
"text": " 3:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Dubhoff advancement\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with stroke.\n REASON FOR THIS EXAMINATION:\n s/p Dubhoff advancement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 71-year-old female patient with stroke, status post Dobbhoff line\n placement, check position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Comparison is made with the next preceding\n similar study obtained three hours earlier during the same day. The\n previously described Dobbhoff line has been advanced further and is now well\n placed in the mid portion of the corpus of the stomach. No other interval\n changes are identified.\n\n IMPRESSION: Good location of Dobbhoff line after adjustment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-09 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1199576,
"text": " 4:18 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: acute pulm process\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with desat, tachypnea\n REASON FOR THIS EXAMINATION:\n acute pulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with desaturation and tachypnea, question acute\n process.\n\n COMPARISON: Chest radiograph from at 2:00 a.m.\n\n ONE VIEW OF THE CHEST:\n\n The lungs are low in volume and show bilateral lower lobe opacities. The\n cardiomediastinal silhouette and hilar contours are normal. No pleural\n effusion or pneumothorax is present. A Dobbhoff tube terminates in the\n stomach appropriately.\n\n IMPRESSION:\n\n Bilateral lower lobe atelectasis is unchanged. No new acute process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1201574,
"text": " 1:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Hydrocephalus\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH, s/p coiling, evd removed, evaluate for HCP\n REASON FOR THIS EXAMINATION:\n Hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RJab FRI 3:45 PM\n PFI:\n 1. Interval removal of the EVD with no significant change in ventricular\n size.\n 2. Expected evolution of the right frontal intraparenchymal hemorrhage with\n stable surrounding edema and mass effect on the frontal of the right\n lateral ventricle.\n 3. Expected evolution of subarachnoid hemorrhage with stable small amount of\n intraventricular hemorrhage in the occipital horns bilaterally.\n 4. Opacification of the mastoid air cells on the left, unchanged from prior\n study.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old woman with subarachnoid hemorrhage, status post\n coiling with recent removal of the EVD. Evaluate for hydrocephalus.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISONS: CT head without contrast from .\n\n FINDINGS: There has been recent removal of the right frontal approach EVD\n with no significant change in ventricular size. The intraparenchymal hematoma\n in the right frontal lobe has slightly decreased in density, consistent with\n expected evolution. There is edema surrounding this hematoma with compression\n of the frontal of the right lateral ventricle which is largely unchanged\n from prior study. There is overall decreased density of the subarachnoid\n hemorrhage, consistent with expected evolution. There is a small amount of\n intraventricular hemorrhage, unchanged from prior study. There is no evidence\n of new hemorrhage or infarction. There is no evidence of central herniation.\n There is a coil pack in expected region of the right anterior cerebral artery.\n The visualized portions of the paranasal sinuses are clear. There is mild\n opacification of the mastoid air cells on the left.\n\n IMPRESSION:\n 1. Interval removal of the EVD with no significant change in ventricular\n size.\n 2. Expected evolution of the right frontal intraparenchymal hemorrhage with\n stable surrounding edema and mass effect on the frontal of the right\n lateral ventricle.\n 3. Expected evolution of subarachnoid hemorrhage with stable small amount of\n intraventricular hemorrhage in the occipital horns bilaterally.\n (Over)\n\n 1:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Hydrocephalus\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-07-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1201575,
"text": ", J. NSURG FA11 1:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Hydrocephalus\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old woman with SAH, s/p coiling, evd removed, evaluate for HCP\n REASON FOR THIS EXAMINATION:\n Hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Interval removal of the EVD with no significant change in ventricular\n size.\n 2. Expected evolution of the right frontal intraparenchymal hemorrhage with\n stable surrounding edema and mass effect on the frontal of the right\n lateral ventricle.\n 3. Expected evolution of subarachnoid hemorrhage with stable small amount of\n intraventricular hemorrhage in the occipital horns bilaterally.\n 4. Opacification of the mastoid air cells on the left, unchanged from prior\n study.\n\n"
},
{
"category": "Echo",
"chartdate": "2190-07-14 00:00:00.000",
"description": "Report",
"row_id": 92068,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nWeight (lb): 162\nBP (mm Hg): 152/67\nHR (bpm): 65\nStatus: Inpatient\nDate/Time: at 13:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal regional LV\nsystolic function. Hyperdynamic LVEF >75%. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta. Normal aortic arch diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Borderline PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Very small pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Regional left ventricular wall motion is\nnormal. Left ventricular systolic function is hyperdynamic (EF>75%). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. 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. Physiologic mitral regurgitation is seen\n(within normal limits). There is borderline pulmonary artery systolic\nhypertension. There is a very small pericardial effusion. The effusion appears\ncircumferential. There are no echocardiographic signs of tamponade.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with hyperdynamic left ventricular function. Borderline pulmonary\nartery hypertension. Very small circumferential pericardial effusion. Mild\nascending aortic dilation.\n\n\n"
}
] |
85,143 | 180,486 | Pt was admitted in setting of ischemic Left foot w/ no DP or PT signals. Was taken emergently to endovascular suite for revascularization. 1. VASCULAR: Pt was brought to operating room and underwent Left lower extremity thrombectomy with 4 compartment leg fasciotomies. Post op able to Doppler posterior tibial and dorsalis pedis at her ankle. The muscle was slightly responsive in the posterior compartment but the anterior and lateral compartments had no response to the . See operative dictation for full details. While recovering in the pt lost signals in her right lower extremity, despite being on supra therapeutic heparin drip. She began to have pain in her right foot and the foot appeared mottled. Therefore, she was taken back to the operating room for right lower extremity thrombectomy with on table angiogram. Unable to revascularize R foot. Angiogram revealed severely diseased tibial vessels with loss of complete flow into her anterior tibial and posterior tibial artery. See operative dictation for details. After second operation not able to identify a signal in the R dorsalis pedis or anterior tibial artery or the posterior tibial artery at the ankle. A very faint peroneal signal was identified. 2. PULM: Pt was extubated after first and second procedure. Following the second procedure pt was noted to be somnolent in the . ABG was pH 6.66/pO2 269/pCO2 188 / bicarb 25. I was immediately re-intubated w/ improvement in ABG. In ICU, pt was initially supported on CMV, and transitioned to CPAP. Once was made , was extubated. 3. HEME: Post op from second operation hct 16.8. Was transfused aggressively. And maintained on a heparin drip. Platelets decreased from 189 to 61, so given the concern for HIT, heparin stopped and argatroban drip started (although was HIT ab negative). POD#1 hct was maintained at ~30 w/ minimal transfusion requirement, although overnight on the day prior to death hct feel to 18. Platelets fell to 27, and INR rose to 7.3 with PTT >150. Fibrinogen fell to 118, and fibrinogen degradation products increased to 10-40. Given concern from DIC was transfused aggressively w/ pRBCs, FFP, and platelets. 4. RENAL: pt's urine output decreased to less than 30cc/day, while creatinine rose to 2.9. Renal was consulted and felt that urine sediment consistent with ATN, possibly the result of intra-operative blood loss and hypotension as well as radiocontrast exposure. 5. CV: Did not require pressors. Hypotensive eposides treated w/ multiple colloid boluses. Was in afib with ventricular rates in the 100's, but held off on beta blockade for rate control given borderline pressures. 6. NEURO: Sedated with dexmedetomidine, analgesia with morphine. On POD#, given renal failure, DIC, persistent limb ischemia, and hemodynamics, had family meeting to discuss poor prognosis. Pt's daughter, , HCP, made decision to make pt . All support measures were stopped. Pt was extubated, and continued on low dose morphine for comfort. Expired short time later at 2:45 PM on . Daughter declined an autospy. | Mild (1+) aorticregurgitation is seen. Normal left ventricular cavitysize with preserved global and regional left ventricular systolic function.Mild aortic regurgitation. Atrial fibrillation with moderate ventricular response. Atrial fibrillation with moderate ventricular response. Severe PA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm). Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Low hematocrit and near respiratory arrest. The right ventricular cavity is moderately dilated with normalfree wall contractility. Abnormal septal motion/position consistent with RV pressure/volumeoverload.AORTA: No 2D or Doppler evidence of distal arch coarctation.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There isabnormal systolic and diastolic septal motion/position consistent with rightventricular pressure and volume overload. The aortic valve leaflets (3) aremildly thickened but aortic stenosis is not present. Right pleural effusion.Conclusions:The left atrium is elongated. PATIENT/TEST INFORMATION:Indication: Source of embolism.Height: (in) 66Weight (lb): 88BSA (m2): 1.41 m2BP (mm Hg): 123/63HR (bpm): 128Status: InpatientDate/Time: at 08:51Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. The intrarenal resistive indices in the right kidney are mildly elevated, ranging to 0.81. Normal IVCdiameter (<=2.1cm) with <50% decrease with sniff (estimated RA pressure (mmHg).LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Moderately dilated RV cavity. [Intrinsic right ventricular systolic function islikely more depressed given the severity of tricuspid regurgitation.] Normal RV systolic function. Moderate to severe [3+]tricuspid regurgitation is seen. Resistive indices within the left kidney interpolar region are about 0.6. Gross patency of renal arteries is confirmed bilaterally with no definite evidence of renal artery stenosis. There is mild increased echogenicity of the renal cortices bilaterally. The peak systolic velocity within the right main renal artery is about 77.8 cm/sec. There is no pericardial effusion.IMPRESSION: Right ventricular cavity enlargement with preserved free wallmotion. Endotracheal tube tip is approximately 4.6 cm from the carina and is appropriate. IMPRESSION: AP chest reviewed in the absence of prior chest imaging: Tip of the endotracheal tube is at the thoracic inlet, but the tube is angulated and the tip abuts the tracheal wall which may impede its function. Low limb lead voltage.No major change compared to previous tracing.TRACING #3 Low limb leadQRS voltage. Poor R wave progression. Moderate to severe[3+] TR. Heart is moderately enlarged. Borderline cardiomegaly is stable. Cardiomediastinal silhouette is normal. [Intrinsic RV systolic function likely more depressed given the severity ofTR]. Thetricuspid valve leaflets are mildly thickened. Some images demonstrating apparent lack of antegrade diastolic flow in the intrarenal and main renal arteries are noted, although this may be technical. Elevated resistive indices in right kidney (evaluation of left kidney (Over) 9:37 AM RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # US RENAL ARTERY DOPPLER Reason: bilateral Admitting Diagnosis: LEFT CFA CLOT FINAL REPORT (Cont) very limited), and echogenic kidneys, suggests medical renal disease and increased parenchymal resistance. As before, the endotracheal tube is sharply angled and the tip abuts the tracheal wall. FINDINGS: Following repositioning, tip of the left PICC line is approximately at mid/lower SVC. Visualization of the intrarenal arterial waveforms on the left are particularly limited. Atrial fibrillation. There is severe pulmonary artery systolichypertension. Grossly preserved color flow is demonstrated in both kidneys. Lungs are grossly clear. Lungs are grossly clear. Left ventricularwall thickness, cavity size and regional/global systolic function are normal(LVEF >55%). IMPRESSION: AP chest compared to : Tip of the new left PICC line projects over the upper right atrium and would need to be withdrawn between 5 and 6 cm to confidently move it into the lower third of the SVC. The mitral valve leaflets are mildly thickened. Stomach is severely distended with air, presumably a function of intubation attempts. Severe pulmonary artery hypertension. INDICATION: -year-old female with recent lower extremity thrombectomies with new-onset anuria. FINDINGS: The right kidney measures 8.6 cm in size and the left kidney measures 9.1 cm in size. Within the left mid kidney there is a 2.7 x 2.4 x 4.4 cm complex cystic lesion with internal septations/calcifications. Color Doppler and spectral waveform analysis is markedly limited by acoustic penetration and window, limiting visualization of the renal vessels. LINE PLACEMENT Clip # Reason: Newly placed 42cm left arm PICC.? There is preserved flow within the renal veins. PICc tip location REASON FOR THIS EXAMINATION: Newly placed 42cm left arm PICC.? The estimated right atrial pressure is 5-10 mmHg. Complex cystic lesion in the left kidney. The flow velocity within the main renal artery involving the left kidney is 23.1 cm/sec. No major change from previous tracing.TRACING #2 Markedly limited Doppler evaluation of the renal vessels due to technical factors limiting visualization. TECHNIQUE: Real-time grayscale images of the kidneys were obtained. Lungs are clear. IMPRESSION: 1. TECHNIQUE: Supine portable chest view was read in comparison with the most recent radiograph from , acquired 3-4 hours apart. No definite cardiac source of embolism identified. Now anuric/ATN REASON FOR THIS EXAMINATION: bilateral FINAL REPORT STUDY: Renal son with Doppler. | 8 | [
{
"category": "Echo",
"chartdate": "2201-04-13 00:00:00.000",
"description": "Report",
"row_id": 104449,
"text": "PATIENT/TEST INFORMATION:\nIndication: Source of embolism.\nHeight: (in) 66\nWeight (lb): 88\nBSA (m2): 1.41 m2\nBP (mm Hg): 123/63\nHR (bpm): 128\nStatus: Inpatient\nDate/Time: at 08:51\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. Normal IVC\ndiameter (<=2.1cm) with <50% decrease with sniff (estimated RA pressure (\nmmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV systolic function.\n[Intrinsic RV systolic function likely more depressed given the severity of\nTR]. Abnormal septal motion/position consistent with RV pressure/volume\noverload.\n\nAORTA: No 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe\n[3+] TR. Severe PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm). Right pleural effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. The estimated right atrial pressure is 5-10 mmHg. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). The right ventricular cavity is moderately dilated with normal\nfree wall contractility. [Intrinsic right ventricular systolic function is\nlikely more depressed given the severity of tricuspid regurgitation.] There is\nabnormal systolic and diastolic septal motion/position consistent with right\nventricular pressure and volume overload. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. The\ntricuspid valve leaflets are mildly thickened. Moderate to severe [3+]\ntricuspid regurgitation is seen. There is severe pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Right ventricular cavity enlargement with preserved free wall\nmotion. Severe pulmonary artery hypertension. Normal left ventricular cavity\nsize with preserved global and regional left ventricular systolic function.\nMild aortic regurgitation. No definite cardiac source of embolism identified.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2201-04-12 00:00:00.000",
"description": "Report",
"row_id": 306827,
"text": "Atrial fibrillation with moderate ventricular response. Low limb lead voltage.\nNo major change compared to previous tracing.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2201-04-12 00:00:00.000",
"description": "Report",
"row_id": 306828,
"text": "Atrial fibrillation with moderate ventricular response. Low limb lead\nQRS voltage. No major change from previous tracing.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2201-04-12 00:00:00.000",
"description": "Report",
"row_id": 306829,
"text": "Atrial fibrillation. Poor R wave progression. No previous tracing available\nfor comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-04-13 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1235213,
"text": " 9:37 AM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n US RENAL ARTERY DOPPLER\n Reason: bilateral\n Admitting Diagnosis: LEFT CFA CLOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with F w/ bilateral acute/chronic vascular occlusion s/p\n bilateral thrombectomy despite on heparin. Now anuric/ATN\n REASON FOR THIS EXAMINATION:\n bilateral\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Renal son with Doppler.\n\n INDICATION: -year-old female with recent lower extremity thrombectomies\n with new-onset anuria.\n\n COMPARISON: None.\n\n TECHNIQUE: Real-time grayscale images of the kidneys were obtained.\n\n Color Doppler and spectral waveform analysis of the renal vessels were also\n obtained and reviewed.\n\n FINDINGS: The right kidney measures 8.6 cm in size and the left kidney\n measures 9.1 cm in size. There is mild increased echogenicity of the renal\n cortices bilaterally. Within the left mid kidney there is a 2.7 x 2.4 x 4.4\n cm complex cystic lesion with internal septations/calcifications. There is no\n hydronephrosis or nephrolithiasis.\n\n The urinary bladder is collapsed with Foley in place.\n\n Color Doppler and spectral waveform analysis is markedly limited by acoustic\n penetration and window, limiting visualization of the renal vessels. Grossly\n preserved color flow is demonstrated in both kidneys.\n\n The intrarenal resistive indices in the right kidney are mildly elevated,\n ranging to 0.81. Some images demonstrating apparent lack of antegrade\n diastolic flow in the intrarenal and main renal arteries are noted, although\n this may be technical. The peak systolic velocity within the right main renal\n artery is about 77.8 cm/sec. Visualization of the intrarenal arterial\n waveforms on the left are particularly limited. Resistive indices within the\n left kidney interpolar region are about 0.6. The flow velocity within the\n main renal artery involving the left kidney is 23.1 cm/sec. There is\n preserved flow within the renal veins.\n\n IMPRESSION:\n 1. Markedly limited Doppler evaluation of the renal vessels due to technical\n factors limiting visualization. Gross patency of renal arteries is confirmed\n bilaterally with no definite evidence of renal artery stenosis.\n\n 2. Elevated resistive indices in right kidney (evaluation of left kidney\n (Over)\n\n 9:37 AM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n US RENAL ARTERY DOPPLER\n Reason: bilateral\n Admitting Diagnosis: LEFT CFA CLOT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n very limited), and echogenic kidneys, suggests medical renal disease and\n increased parenchymal resistance.\n\n 3. Complex cystic lesion in the left kidney. A followup son should be\n obtained in three months to assess stability.\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-04-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1235153,
"text": " 6:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET Tube placement\n Admitting Diagnosis: LEFT CFA CLOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p fasciotomy and thrombectomy with hct 13.8 and near\n respiratory arrest\n REASON FOR THIS EXAMINATION:\n ET Tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:55 P.M. \n\n HISTORY: -year-old woman after fasciotomy and thrombectomy. Low hematocrit\n and near respiratory arrest.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest imaging:\n\n Tip of the endotracheal tube is at the thoracic inlet, but the tube is\n angulated and the tip abuts the tracheal wall which may impede its function.\n No mediastinal widening, pneumothorax, or pleural effusion. Heart is\n moderately enlarged. Lungs are grossly clear. Stomach is severely distended\n with air, presumably a function of intubation attempts.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-04-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1235219,
"text": " 10:15 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: L brachial PICC\n Admitting Diagnosis: LEFT CFA CLOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with BLE fem \n REASON FOR THIS EXAMINATION:\n L brachial PICC\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Left-sided PICC line is repositioned, for evaluation.\n\n TECHNIQUE: Supine portable chest view was read in comparison with the most\n recent radiograph from , acquired 3-4 hours apart.\n\n FINDINGS:\n Following repositioning, tip of the left PICC line is approximately at\n mid/lower SVC. Lungs are clear. Endotracheal tube tip is approximately 4.6\n cm from the carina and is appropriate. Cardiomediastinal silhouette is normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2201-04-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1235199,
"text": " 8:44 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Newly placed 42cm left arm PICC.? PICC tip location.\n Admitting Diagnosis: LEFT CFA CLOT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with new left arm 42cm PICC. ? PICc tip location\n REASON FOR THIS EXAMINATION:\n Newly placed 42cm left arm PICC.? PICC tip location.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:30 A.M. \n\n HISTORY: A -year-old woman with a new left PICC.\n\n IMPRESSION: AP chest compared to :\n\n Tip of the new left PICC line projects over the upper right atrium and would\n need to be withdrawn between 5 and 6 cm to confidently move it into the lower\n third of the SVC. Borderline cardiomegaly is stable. Lungs are grossly\n clear. No pneumothorax. As before, the endotracheal tube is sharply angled\n and the tip abuts the tracheal wall. Clinical evaluation is recommended to\n see if a function is acceptable.\n\n\n"
}
] |
32,457 | 100,764 | 56 year old male s/p fall from ladder head injury and consequent occipital bone basilar skull fracture, subdural hematoma, subarachnoid hematoma, contra-coup injury and traumatic C3 disk herniation. . - : Head injury and loss of consciousness. Suffered an occipital bone basilar skull fracture, subdural hematoma, subarachnoid hematoma and contra-coup injury. He was intubated prior to arrival at and had bolt insertion on . His ICPs remained normal for 24 hours and his bolt was removed. He moved all extremities except his left arm, plain films of the arm were negative. CT imaging of his neck showed a large disc herniation at C3-C4 causing cord compression and he underwent anterior cervical discectomy and fusion on . Patient receiving tube feeds through NG tube, patient is unable to eat. He was transferred out of the Trauma ICU on at that time he started having significant fevers. . - : The patient started to have a fever on , although, did have low grade temperatures (100-100.4) intermittently during the hospitalization. Blood cultures were drawn (presumed from the line, not labeled) Coagulase negative Staphylococcus, two morphologies, was reported on . He was started on vancomycin and surveillance cultures were drawn. He remained febrile through when he developed tachypnea and snoring respirations. He was scanned from his neck to pelvis and no obvious source of infection was found. He was transferred to the MICU service on for treatment of his fevers and concerning respiratory status. Upon arrival to the MICU, pt had difficulty protecting his airway - most likely secondary to both tongue obstruction as well as post op prevertebral soft tissue edema with subsequent narrowing of the airway. Patient was treated with Vancomycin/Zosyn for Aspiration Pneumonia. Pt was electively intubated on . While intubated, pt only required pressure support and he was successfully extubated on . . - : Patient transferred to general medicine floor. Patient continued on IV antibiotics (Vancomycin and Zosyn) for aspiration pneumonia until . patient developed fever of 100.3. Blood culture, urine culture, CXR negative. X-ray of hardware in cervical spine no overt sign of infection. Patient's fever eventually resolved. Nutritional status on problem. failed bed-side speech evaluation and video study. PEG tube was placed for nutritional status, currently on tube feeds. Patient requires rehab for neurologic dysfunction. Patient awake and alert, but oriented only to name. Left upper extremity is completely flaccid. Patient unable to eat, dress, wash or perform any basic activities on his own. Unable to follow simple directions. Patient is only able to answer yes/no to very simple questions, unable to follow more complex questions. | stable, extubated s/p fall, tbi.Pt. Pt repleated with lytes(Ca gluc, KCl & Mag). ett retaped/positioned. Pepcid for prophylaxis. Venodynnes, palp pulses. Dilaudid 1mg IV given at a time with +effect. IV Cefazolin while bolt is in place. Palp pulses, venodyynes. Nodding yes to pain once overnoc. VAP care per protocol.GI/GU- Abd soft, + bs x 4. Propofol dc'd. Midazolam gtt for agitation; wean as tolerated. Repleated with lytes, nsr. Cont with midaz/dilaudid. mdi'sgiven. Run of vtach x 1, HO aware. LUE intermitently posturing (extension to withdrawal). Trace generalized edema. BS reveal some coarsness with exp wheeze, MDI's ordered alb. Mannitol, dilantin atc. Lifts and holds lower exts spont, RUE normal strength, able to localize crossing midline (purposeful), LUE with noted weakness. Localizing with rt (crossing midline), lower ext's able to lift and hold. was in the process of midaz gtt taper and precedex titration prior to extubation, now sedation is off. Fluids now at KVO. pco2 acceptable per dr. . Good response to dilaudid per vitals trend.CV: NSR with occasional PVCs. resp. resp. Continuation of previous note:GIGU:Abdomen soft, OGT to suction with scant bilious output. Pt has an a-line sutured in place, left radial, with sharp waveform and good distal perfusion. DP/PT pulses palpable. LS ctab. Sedated with versed/dilaudid. Norepinephrine infusion in place to maintain CPP >= 70mmHg.to be continued. carept. carept. MDI given as documented. Monitor u/o. Covering aware Pt sedated on propofol. SpO2 90s, MDIs given as documented. (2) Pt had self-limiting run of vtach. plan for possible extubation OR ?trach if extubation failed Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: T max 101 rectal Action: Pan cultured, po Tylenol given continue antibiotics Response: Plan: Cooling blanket, po meds/ continue antibiotics, F/U culture results Altered mental status (not Delirium) Assessment: Alert, unable to assess orientation d/t oral ETT, following commands inconsistently. Activity Intolerance Assessment: Action: Response: Plan: Electrolyte & fluid disorder, other Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Action: Response: Plan: Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Action: Response: Plan: Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: Action: Response: Plan: Activity Intolerance Assessment: Action: Response: Plan: Fevers: source unclear; diarrhea raises concern for C Diff; CT scan with fluid collection at wound but, per neurosurgery, it appears consistent with post-operative change - appreciate ID recs - cont empiric vanco and pip/tazo; d/c metronidazole as c.diff toxins neg - NGTD for blood and urine cultures; continue to follow - Sputum from showed hemophilus as well as GPC in pairs. Coagulopathy: likely nutritional - PO vitamin K ICU Care Nutrition: Glycemic Control: Lines: Midline - 02:00 PM 18 Gauge - 10:06 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Full code Disposition: plan for possible extubation OR ?trach if extubation failed Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: T max 101 rectal Action: Pan cultured, po Tylenol given continue antibiotics Response: Plan: Cooling blanket, po meds/ continue antibiotics, F/U culture results Altered mental status (not Delirium) Assessment: Alert, unable to assess orientation d/t oral ETT, following commands inconsistently. plan for possible extubation OR ?trach if extubation failed Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin) Assessment: T max 101 rectal Action: Pan cultured, po Tylenol given continue antibiotics Response: Plan: Cooling blanket, po meds/ continue antibiotics, F/U culture results Altered mental status (not Delirium) Assessment: Alert, unable to assess orientation d/t oral ETT, following commands inconsistently. ETtube suctioning, Lungs clear bilat upper lobes and diminished at bases, bites ETtube and Yankaur with suctioning attempts Action: CPT x 2, ETtube suctioning Q2hr, oral Suction Q2hr, maintained vent settings with Sats >98%, CXR done and pending, ABG to be sent Response: RR= 14-20, nonlabored on CPAP+PS, Sats good, Tolerating and requiring freq. ETtube suctioning, Lungs clear bilat upper lobes and diminished at bases, bites ETtube and Yankaur with suctioning attempts Action: CPT x 2, ETtube suctioning Q2hr, oral Suction Q2hr, maintained vent settings with Sats >98%, CXR done and pending, ABG to be sent Response: RR= 14-20, nonlabored on CPAP+PS, Sats good, Tolerating and requiring freq. Of note, he had a right subclavian CVL placed on and removed (tip culture negative to date). Of note, he had a right subclavian CVL placed on and removed (tip culture negative to date). Of note, he had a right subclavian CVL placed on and removed (tip culture negative to date). Of note, he had a right subclavian CVL placed on and removed (tip culture negative to date). Of note, he had a right subclavian CVL placed on and removed (tip culture negative to date). Of note, he had a right subclavian CVL placed on and removed (tip culture negative to date). | 78 | [
{
"category": "Nursing/other",
"chartdate": "2156-08-17 00:00:00.000",
"description": "Report",
"row_id": 1673164,
"text": "Resp: pt on a/c 14/600/5+/50%. Ett 7.5, taped @ 21 lip. Cuff pressures @ 21 cmh20. BS reveal some coarsness with exp wheeze, MDI's ordered alb. Pt has a period of vtach in beginning of shift with ^ in icp to 20's. Trip to CT scan with results unchanged. Repeat CT scan expected today. Vent changes to decrease fio2 to 40%, then following RSBI=62, weaned to psv 12/5/40%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-17 00:00:00.000",
"description": "Report",
"row_id": 1673165,
"text": "TSICU-NPN\nPlease see flowsheet for all real time documentation and assessments.\n\nNeuro: Intubated, responsive to voice, eyes open spontaneously, localizes to pain. Gag, cough, and corneal reflexes intact. Eyes equal, round and reactive to light. Right upper extremity has good strength, purposeful movement, soft limb immobilizer in place on right. Left upper extremity has extension to pain. BLE withdraw from pain and patient moves both legs in bed while awake. bolt removed after consistent ICP less than 20, removed at 1700. Mannitol discontinued. C-collar exchanged for a -J collar.\n\nPain: At 1400 pt. experienced increase in BP and HR while awake, restless in bed, appeared to calm with reorientation from Rn however vitals remained elevated. Given Fentanyl IVP with good response and trend in vitals.\n\nCV: NSR with occasional PVCs. ABP 110-150/60-80. Multilumen central line placed right subclavian. Peripherals removed. Pboots on.\n\nResp: Lung sounds coarse on the right this AM, suctioned for thick yellow, brown sputum with good response. Lungs clear bilaterally. SPO2 95-100% on FiO2 40, PEEP 5. PaCO2 47 on 12 PSV, no changes per Dr .\n\nENDo: RISS tightened today for closer control. Given 2 Units of Insulin this afternoon.\n\nGI: Pt. has positive flatus on bowel regimen. NO BM. Tube feeds increased from 25-45ml/hr after no residuals. OG tube intact.\n\nGU: Pt. foley catheter to gravity. Clear yellow urine output >100 ml/hr.\n\nWounds: Abrasion to upper back, no drainage, open to air. Bolt site sutured, open to air with no drainage.\n\nID: Tmax 100.4. To receive one further dose of ancef after bolt then d/c.\n\nSocial: Family aware of pts. hospital admission. Grown daughters are legal next of however they have agreed that pt's girlfriend of >25 years can receive information. No visitors today.\n\nPlan: Hourly neuro checks, monitor telemetry and vital signs, monitor for increased pain, decrease sedation as possible, suction as needed, continue to turn and reposition patient every 2 hours and as needed. Monitor for signs of infection, increase tube feeds per order, monitor I+Os, Plan for MRI tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-17 00:00:00.000",
"description": "Report",
"row_id": 1673166,
"text": "resp. care\npt. remains intubated/vented. ett retaped/positioned. mdi's\ngiven. to and from head ct without incident. no vent changes\nthis shift. pco2 acceptable per dr. . see flowsheet\nfor more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1673167,
"text": "Respiratory Care\nPt remains intubated on mechanical ventilation PS 12/5/40%. pt for moderate amounts of thick yellow secretions. Transported pt to MRI for head and cspine films not yet read. MDI's continued as ordered. Plan to continue mechanical ventilation until further notice and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1673168,
"text": "Nursing Progress Note 7pm-7am\n\nROS: See carevue for exact data\n\nEvents of the night: MRI 2200-2400 Head/Neck\n\n**MRI per report from MD /swelling to cord, ligament injury, traumatic disc bulge. Covering aware\n\n Pt sedated on propofol. Fentanyl for pain. Tolerated MRI with no difficulty. At best exam with propofol completely off pt will open eyes inconsistently to stimulus, followed commands x2 with rt hand. Localizing with rt (crossing midline), lower ext's able to lift and hold. LUE intermitently posturing (extension to withdrawal). Pupils brisk and equal at 3mm. Corneal, cough, gag all intact. No sz activity, dilantin ATC. Nodding yes to pain once overnoc. J on.\n\nCV/Hem: SR 70-80. BP for the most part <160. Range 120-140/60-70 except for neuro exams briefly to 150-160 syst till pt settles out. Following art line pressures. Occasional pvc. Venodynnes, palp pulses. Upper ext's warm to touch, lowers cool but all normal in color with adeq csm. Fluids now at KVO. 5pt hct drop ? dilutional from one time bolus overnoc for low u/o.\n\nResp: Pt remains on psupp 40%. Suctioning thick yellow secretions. ? trache and peg in future. Last gas 739/54/122/34 MD . LS clr, dim at bases. CXR this a.m.\n\nGi/Gu: Abd soft, hypoactive BS. TF via OGT off for MRI. Currently at 50/hr replete with fiber. H2o flushes 100 q6 hrs, may need to increase since sodium creeping up (145). Goal 70, residuals 10. u/o drifitng off after TF stopped earlier for MRI. Bolus given with effect.\n\nEndo: Tight sliding scale in place Bld sugars 120-150\n\nSkin: Abrasion to back\n\nLytes: Potassium repletion 40 meq\n\nID: Afebrile, anbx complete. WBC trending down from 14->12\n\nSoc: Confirmed with daughter over phone MRI checklist done with RN per MRI. Dtrs updated last noc prior to MRI.\n\nPlan: Follow up cspine films. Cont sedation and fentanyl for pain. Monitor neuro exam ? q2 from q1. Maintain BP <160. Cont TF to goal. Monitor u/o. Follow abg's. Monitor hct drop. Cont to monitor provide support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1673169,
"text": "Tsicu-NPN 0700-1500\nPlease see flowsheets for all real time documentation and assessments.\n\nNeuro: Intubated, on best neuro exam eyes open spontaneously, responds to voice, localizes to voice. Gag, cough, corneal reflexes intact. Pupils equal round reactive to light. Purposeful movements of right upper extremity, reaches for tube. RUE immobilized with soft limb immobilizer. Left upper extremity postures, extends with nailbed pressure. Able to lift and hold BLE independent. Propofol dc'd. Started on Versed IVP as needed for sedation.\n\nPain: Pt. nodded when awake that he has pain. Given Fentanyl in AM with good response and switched to Dilaudid after propofol dc'd this afternoon. Good response to dilaudid per vitals trend.\n\nCV: NSR with occasional PVCs. ABP 110-130/60-80. Strong pulses x4.\n\nResp: Clear lungsounds bilaterally. Thick yellow sputum suctioned often. Sats 95-100% on 40% FiO2, PEEP 5, PS decreased from 12 to 5 today.\n\nEndo: RISS Insulin given at 1000.\n\nGI: Tube feeds increased to 75 ml/hr. Flushes given every 6 hours as ordered. Bowel sounds present. Flatus but no BM.\n\nGU: Foley intact clear yellow urine.\n\nSocial: Family visiting today. Daughter consented to surgery verbal to Neurosurg on the phone and will be here today.\n\nPlan: Surgery on Friday, cspine precautions, keep intubated for surgery, monitor tele and vital signs, neuro checks every 4 hours, I+Os, medicate for pain and sedation when needed, monitor for signs of infection, suction as needed. Continue tube feeds and RISS. Safety and fall precautions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1673170,
"text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. Weaned to +5PSV/+5PEEP this shift w/ Vt ~500 RR ~14 maintaining Ve ~7L/M. SpO2 90s, ABG acceptable. ETT secure/patent, suctioned for moderate amounts of thick tan sputum. MDI given as documented. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-18 00:00:00.000",
"description": "Report",
"row_id": 1673171,
"text": "T/SICU Nursing 15-19\nSee carevue for detailed assessment. No neuro changes. Neurosurgery requests q1 pupil checks but q4 full neuro exams. Sedated with versed/dilaudid. Localizes to ett, follows commands inconsistently. No vent changes made and pt remains comfortable, resting until planned ACDF on Friday. Family visited and was awaiting neurosurgery to sign consent, however they did not come by. Plan con't current management and assessment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-19 00:00:00.000",
"description": "Report",
"row_id": 1673172,
"text": "Respiratory Care\nPt remained on mechanical ventilation in CPAP-PS 5/5. Weaned his FIO2 from 40% to 30%. Pt resting comfortably throughout the shift. MDI's continued as ordered. RSBI 21.6. Plan: Pt to remain on mechanical ventilation until Friday while going to the OR. Plan to extubate following procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-19 00:00:00.000",
"description": "Report",
"row_id": 1673173,
"text": "Nursing Progress Note 7p-7a\n\nRos: See carevue for exact data\n\nN: Pt sedated on midazolam and dilaudid for pain. Increased requirements noted for midazolam as the night continues due to increased agitation from ETT. Pt nodding yes and no appropriately. At times pt very inconsistent. At best exam pt arouses to voice, opens eyes, makes eye contact. Lifts and holds lower exts spont, RUE normal strength, able to localize crossing midline (purposeful), LUE with noted weakness. Intermitently extends to painful stim and other times rn sees pt pick arm off bed and relocate. Pupils brisk 2mm, occasionally Rt >LT by 1 mm. Dilantin ATC, Cspine collar. Pt going for ACDF on friday. Restraint only to RUE. Neuro exams q4 hrs, pupil exam q1.\nCV: SR occas PVC. BP goal <160. Following art line pressures correlating with occlusion pressure. At times pt very hyperdynamic with exams, self limiting but may need something for BP if pt doesnt settle out. Palp pulses, venodyynes. Fluids at KVO.\nResp: LS clr, dim at bases. Sats wnl. Fio2 decreased. Suctioning thick yellow secretions.\nGI: Pt stooling small amts last noc, guiac neg. TF at goal no residual.\nGu: u/o adeq.\nLytes: repleted as needed.\nSoc: No calls overnoc.\nPlan: Neuro q4/pupil checks q1. Cont with midaz/dilaudid. Pt may benefit more from versed drip. Cont TF, off a mn for procedure on fri. Cont to monitor and provide support. ? Repeat head CT today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-19 00:00:00.000",
"description": "Report",
"row_id": 1673174,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Neuro exam q4hr; pupil checks q1hr. Right pupil > left at times; pupils equal this afternoon (briskly reactive). Prior to midazolam gtt, pt followed commands inconsistently. Nodding head to questions. Moved all extremities to command. Midazolam gtt started for agitation. Pt sitting up in bed and attempting to pull at ETT, CVL, and A-line. Bilateral wrist restraints applied for immobilization. Midazolam gtt started at 2mg/hr, but increased to 4mg/hr d/t continued agitation. Pt also grimaces at times with turning/repositioning. Dilaudid 1mg IV given at a time with +effect. While on midazolam gtt, pt opens eyes to voice; lifts BUE to command and withdraws BLE to nailbed pressure. +gag/cough reflex. Tmax 99.4. HR 60-90s (NSR). Goal SBP <160. SBP 180-200s when agitated; SBP <160 when calm (see CareVue). Trace generalized edema. DP/PT pulses palpable. Venodyne boots on BLE. Lungs clear. CPAP 30%, PEEP 5, PS 5. Pt with very strong cough. Suctioned for copious amount thick yellow secretions. Abdomen softly distended with +bowel sound. TF at goal rate via OGT; stopped for 2hrs this morning d/t high residuals (Dr. aware). Dr. ordered metoclopramide 10mg per OGT qid. TF restarted at goal rate; check residuals q4h; flush OGT with 100cc water q6hr. No bowel movement this shift. FS q6hr; treated per regular insulin sliding scale. Foley intact with clear yellow urine. See CareVue for hourly urine output. No pressure sores noted. Abrasion on upper back pink; no drainage noted. -J collar on; collar care performed. Pt's daughter, , called and nephew visited. updated by RN on pt's condition and on plan of care.\n Plan: Monitor VS, I's and O's, labs. Neuro exam q4hr; pupil checks q1hr. Midazolam gtt for agitation; wean as tolerated. Dilaudid IV for pain. Keep SBP <160. Keep J collar on. OR tomorrow for fusion cervical anterior with disectomy C3-C4. NPO at midnight. Update pt and family on plan of care; provide emotional support. Continue ICU care and treatment.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-19 00:00:00.000",
"description": "Report",
"row_id": 1673175,
"text": "Respiratory Therapy\n\nPt remains orally intubated on PSV. No vent changes made this shift; continues on +5PSV/+5PEEP w/ Vt ~400s RR mid teens maintaining Ve ~8L/M. SpO2 90s, MDIs given as documented. ETT secure/patent, suctioned for moderate amounts of thick tan sputum. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-20 00:00:00.000",
"description": "Report",
"row_id": 1673176,
"text": "Nursing (1900-0700)\nEVENTS:\nPt. self-extubated without resp. compromise.\nSee flowsheet for assessment.\n\nPt. responsive to voice, following most simple commands. LUE noted to be significantly weaker than right, does not move it to command, but he has been noted to move left arm spontaneously and purposefully. Pt. wiggles toes to command and ?is attempting to lift legs off be to command. Pt. was in the process of midaz gtt taper and precedex titration prior to extubation, now sedation is off. Pupillary exam stable, hourly. SWR's replaced due to safety risk as pt. became restless, removing O2, etc. this early a.m.\n\nVSS at rest, but pt. becomes hypertensive with most stimulation. Pt. given dilaudid (?pain element) twice thus far with resolution. Antihypertensives d/w HO - have not been ordered thus far.\n\nPt. resting comfortably on FT with stable abg's as noted. Cough strong (spontaneously, not to command), swallows secretions.\n\nPt. presently NPO on IVF for OR this a.m. OGT was removed by pt.\n\nA/P: Pt. stable, extubated s/p fall, tbi.\nPt. to OR this a.m. for C3-4 fusion. Continue neuro/pupillary exams as ordered. Optimze comfort and safety.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-16 00:00:00.000",
"description": "Report",
"row_id": 1673160,
"text": "Nursing admission note.\nPlease refer to CareVue for specifics.\n\nPt is a 56 yr old man, transfer from Hosp NH today following a witnessed 8 foot fall off a ladder. Pt reportedly struck his head on a dumpster on his way down, had a period of unconsciousness. Into ED where CT head showed an occipital fracture extending into the carotid canal, a right subdural hematoma and a right subarachnoid hemorrhage. On arrival , pt had bolt placed. Best neuro exam in ED reported as no eye opening, but moving all 4 (right arm the greatest), semipurposefully.\n\nNEURO:\nPt unresponsive, no eye opening, at best has some spontaneous localization of the right arm towards the ETT, crossing midline. GCS E1V1tM5= 7t. Also coughs spontaneously and lifts head off bed. The left arm and legs withdraw from noxious stimuli but with severe weakness (move on bed only). His pupils are right marginally greater than left, both react briskly. bolt is in place with good waveform and ICPs with transient spikes to 28mmHg, promptly returning to baseline. A norepinephrine infusion was commenced to maintain CPP > 70mmHg. Pt remains on log roll precautions with a c-collar in place awaiting read of scans. No seizure activity noted. Dilantin load given.\n\nRESP:\nOrally intubated with 7.5 ETT @ 22cm lipline secured with tape and commercial bite block. Chest wall movement symmetrical. Breath sounds clear and equal. Mechanical vent AC 6ml/kg x 14/min with PEEP 5cmH20 Fi02 weaned to 50%, with PIPs < 20. Occasional spontaneous non-productive cough.\n\nCV:\nPt dry, pink, mottled knees, cool, with brisk cap refill and 2+ pulses. Monitoring in SR with occasional unifocal PVCs. Pt has an a-line sutured in place, left radial, with sharp waveform and good distal perfusion. IV x2 peripherals patent without signs of infiltration. Norepinephrine infusion in place to maintain CPP >= 70mmHg.\n\nto be continued.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-16 00:00:00.000",
"description": "Report",
"row_id": 1673161,
"text": "Continuation of previous note:\n\nGIGU:\nAbdomen soft, OGT to suction with scant bilious output. Foley patent and draining clear urine.\n\nENDO:\nCovered for blood glucose 133 per sliding scale regular insulin.\n\nID:\nCefazolin for bolt; afebrile.\n\nMSI:\nScattered superficial abrasions to back and left shoulder, bleeding controlled.\n\nPSYCHSOC:\nMultiple family members present. Spokesperson at this time is , pt's sister, phone or . girlfriend of 27 years is , number . Social work consulting.\n\nAssessment:\nSubarachnoid, dubdural hemorrhage following fall.\n\nPlan:\nMonitor neuro status.\nAssess need for analgesia.\nCPP> 70.\nSupport family.\nFollow plan of care.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-16 00:00:00.000",
"description": "Report",
"row_id": 1673162,
"text": "resp. care\npt. s/p fall with sdh/sah. fi02 weaned to 50%.\nsee flowsheet for more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2156-08-17 00:00:00.000",
"description": "Report",
"row_id": 1673163,
"text": "T/SICU Nursing Progress Note\n1900-0700\n\nPlease see Carevue for exact data.\n\nSignificant Events:\n(1) Traveled to CT for scan of head, TLS. (2) Pt had self-limiting run of vtach. Repleated with lytes, nsr. (3) ICP climbing overnoc >25 x 15 minutes. No repeat head CT, started on mannitol with + effect.\n\nROS:\nNeuro- Repeat head CT unchanged per Dr. . bolt in place, transduced. ICP ranging 13-28, CPP>70. Goal ICP <20 . PERRL 2mm/2mm, briskly reactive. Occasional rt pupil lgr than left by 1/2 mm. Corneals, cough and gag intact. Pt MAE, withdraws to nailbed pressure x all 4 extremities R>L. Does not follow commands, opened eyes to stimuli x 1. Neuro check q 1 hour. Mannitol, dilantin atc. Fentanyl for pain\n\nCV- HR 70-80's SR, BP 120-150/60-70's. Run of vtach x 1, HO aware. Pt repleated with lytes(Ca gluc, KCl & Mag). Levophed gtt to maintain CPP > 70, SBP high but no >160. Hct 38.9. +PP. UE warm pink, LE cool pale. L radial art line, PIV x 3. Compression boots for prophylaxis.\n\nResp- #7.5 ETT 21 @ teeth. Deep suctioned for small amounts thick yellow secretions. LS ctab. VAP care per protocol.\n\nGI/GU- Abd soft, + bs x 4. Pepcid for prophylaxis. OG tube to continuous low wall suction, small bilious output. Foley with ample cyu. bun 14, cr 0.7.\n\nID- wbc 14.9, tmax 99.7. Cefazolin q 8 hours while bolt is in place.\n\nEndo- RISS, coverage required.\n\nSkin- Multiple superficial abrasions to back, L shoulder and R forearm.\n\nSocial- Daughters in to visit this evening( and ). Did not know that father was hospitalized. Legally they are next of . Phone numbers in chart, SW to follow up with family in am. Emotional support offered.\n\nPlan- Cont neuro checks q 1 hour. Follow labs. Wean vent as tolerated. IV Cefazolin while bolt is in place. Needs central access for Levophed gtt. SW to f/u with family in am. Repeat head CT at some point today.\n"
},
{
"category": "ECG",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Report",
"row_id": 223823,
"text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block. Compared to\nthe previous tracing the rate is slower.\n\n"
},
{
"category": "ECG",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Report",
"row_id": 223824,
"text": "Baseline artifact\nSinus tachycardia with atrial premature complexes\nLeft anterior fascicular block\nNo previous tracing available for comparison\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411817,
"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:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n No changes made overnight, remains vent supported. See flowsheet for\n further pt data. Will follow.\n 06:42\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411997,
"text": "Activity Intolerance\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 411645,
"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 56 yo women with no known PMHx. Fell off a ladder on . Head trauma\n with basilar skull fracture, SDH, SAH, contre-coup injury intubated\n with ICP monitor that showed nl pressures, so it was DC'ed nex day.\n Was noted to have have LUE weakness. MRI showed C3-C4 diskul\n herniation, so went for diskectomy and anterior fusion on . Since\n then has had low-grade fevers. Yesterday had temp 102, ID consult rec.\n CT scan of neck due to ?fluid collection. blood cx with coag neg\n staph.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:30 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n No known medical history\n unknown\n Occupation: lives at home, construction worker\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Constitutional: Fever\n Eyes: No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Epistaxis\n Cardiovascular: No(t) Edema\n Respiratory: Dyspnea\n Gastrointestinal: No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Integumentary (skin): No(t) Rash\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Lymphadenopathy\n Neurologic: No(t) Seizure\n Psychiatric / Sleep: Delirious\n Allergy / Immunology: Immunocompromised\n Flowsheet Data as of 05:54 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.7\nC (103.4\n Tcurrent: 38.8\nC (101.8\n HR: 88 (88 - 105) bpm\n BP: 147/69(87) {147/69(87) - 174/87(109)} mmHg\n RR: 31 (27 - 35) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,041 mL\n PO:\n TF:\n IVF:\n 946 mL\n Blood products:\n Total out:\n 0 mL\n 924 mL\n Urine:\n 924 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 117 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 96%\n ABG: ////\n Physical Examination\n General Appearance: distressed\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: s/p\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Musculoskeletal: Unable to stand\n Skin: Warm, No(t) Rash:\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Noxious stimuli, Movement: Not assessed, Tone: Not assessed, LUE\n flaccid\n Labs / Radiology\n 413 K/uL\n 38.0%\n 115 mg/dL\n 0.7 mg/dL\n 20 mg/dL\n 25 mEq/L\n 114 mEq/L\n 3.7 mEq/L\n 150 mEq/L\n 14.4 K/uL\n [image002.jpg]\n 02:17 AM\n 11:17 AM\n 02:14 AM\n 02:27 AM\n 07:04 AM\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n WBC\n 12.4\n 10.6\n 13.4\n Hct\n 33.7\n 32.0\n 34.5\n Plt\n \n Cr\n 0.6\n 0.5\n 0.6\n TC02\n 26\n 30\n 34\n 33\n 32\n 35\n 33\n Glucose\n 123\n 159\n 113\n 112\n Other labs: PT / PTT / INR:/1.9, Lactic Acid:1.4 mmol/L, Albumin:3.6\n g/dL, Ca++:9.1 mg/dL, Mg++:1.8 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: No infiltrate\n CT bibalisar septal wall thickening\n Assessment and Plan\n Respiratory Distress: Tongue is flopping back into oropharynx and has\n poor management of oral secretions and likely aspirating. Will need to\n be intubated.\n NSG team feels it may take weeks\n for MS to recover in which case he will likely need tracheostomy.\n Poor MS: Due to traumatic brain injury, but there is a decent chance\n for significant recovery.\n Fevers: Unclear source. Could just be aspiration pneumonitis. Other\n possible sources include C. diff or wound infection. R/O C. diff.\n Hypernatremia: Likely hypovolemic. Replete free water and hydrate\n with LR.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines / Intubation:\n 20 Gauge - 04:51 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 50 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 412062,
"text": "Chief Complaint:\n 24 Hour Events:\n MIDLINE - START 02:00 PM\n BLOOD CULTURED - At 08:55 PM\n URINE CULTURE - At 08:56 PM\n BLOOD CULTURED - At 04:11 AM\n SPUTUM CULTURE - At 04:11 AM\n URINE CULTURE - At 04:11 AM\n FEVER - 101.1\nF - 08:00 AM\n Extubated yesterday. Did well. Was more alert and able to communicate\n with daughters and staff.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 05:46 AM\n Vancomycin - 07:44 PM\n Piperacillin/Tazobactam (Zosyn) - 11:39 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 02:40 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: 36.3\nC (97.4\n HR: 64 (61 - 75) bpm\n BP: 128/66(78) {113/59(73) - 146/77(94)} mmHg\n RR: 19 (18 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,185 mL\n 27 mL\n PO:\n TF:\n IVF:\n 940 mL\n 27 mL\n Blood products:\n Total out:\n 1,385 mL\n 50 mL\n Urine:\n 1,385 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -24 mL\n Respiratory support\n Extubated\n SpO2: 97%\n VBG: 7.42/48/28\n Physical Examination\n Gen: opens eyes spontaneously and to voice; inconsistently follow\n occasional simple commands\n Neck: Incision C,D,I. No induration or fluctuance\n Pulm: coarse bs bilat but improving\n CV: reg rhythm\n Neuro: grimaces to pain in left UE, moves/makes fist with RUE. Moves\n both feet, R>L.\n Labs / Radiology\n 464 K/uL\n 10.8 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.2 %\n 16.3 K/uL\n [image002.jpg]\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n 05:02 PM\n 04:00 AM\n 07:56 AM\n WBC\n 13.4\n 17.5\n 16.5\n 13.8\n Hct\n 34.5\n 32.9\n 30.4\n 32.0\n Plt\n 53\n Cr\n 0.6\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 31\n 32\n 32\n Glucose\n 113\n 112\n 129\n 146\n 175\n 162\n 117\n 110\n Other labs: PT / PTT / INR:15.4/31.1/1.4, Differential-Neuts:75.3 %,\n Lymph:16.9 %, Mono:2.2 %, Eos:4.7 %, Lactic Acid:0.9 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) who was transferred to the MICU for tachypnea\n and difficulty protecting airway in the setting of fevers of unclear\n etiology. Was intubated on ; extubated on .\n 1. Airway compromise: improved with oral airway, but unable to\n maintain patent airway due to mental status and was intubated on ;\n per neurosurgery, this may improve with time, but will likely be a slow\n improvement. Extubated successfully on \n - pulmonary toilet\n -doing well on NC\n 2. Tachypnea: resolved. Was likely due to fevers and aspiration; no\n evidence of pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo for one more day (last doses\n ); d/c\nd metronidazole as c.diff toxins neg\n - NGTD for blood and urine cultures; continue to follow\n - Sputum from showed hemophilus (beta lactam neg) as well as GPC\n in pairs. Culture from shows only GPC in pairs.\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: resolved . increased free H2O in tube feeds\n 6. Coagulopathy: likely nutritional, improving. INR 1.4\n - PO vitamin K\n ICU Care\n Nutrition: TF with goal 70mL/hour\n Glycemic Control:\n Lines:\n Midline - 02:00 PM\n 18 Gauge - 10:06 PM\n Prophylaxis:\n DVT: subq heparin; pneumo boots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to floor today\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 412063,
"text": "Mr. . is a 56 year old man with past medical history of HTN and\n Hyperlipidemia who originally presented to on following a\n fall from a ladder with subsequent occipital bone basilar skull\n fracture, subdural hematoma, subarachnoid hematoma and contra-coup\n brain injury. He was intubated prior to transfer to on ,\n and had an ICP Bolt monitor placed on (removed due to\n normal ICPs). His initial presentation was notable for left arm\n weakness found to be due to traumatic C3-C4 cervical disc herniation\n with resultant cord compression. He underwent anterior discectomy and\n fusion on and his post-operative course has been complicated by\n fevers of unclear source beginning on . Initial cultures\n revealed one out of four blood culture bottles growing\n coagulase-negative Staph, and he was put on vancomycin on .\n Right subclavian CVL placed on and removed (tip culture\n negative to date). He spiked a fever > yesterday prompting an ID\n consult.\n After stay in T/SICU he was transferred to 11 and there was noted\n to have increasing tachypnea and loud upper airway sounds prompting\n concern that he wasn\nt protecting his airway, so he is transferred to\n the MICU for further management and intubated shortly after MICU\n admission. Extubated .\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Noted to be swallowing and coughing. At times noted to have some\n difficulty clearing secretions and requires oral suction.\n Action:\n Nothing by mouth at this time. Nutrition via Dobhoff feeding tube L\n nare. Speech and swallow consult ordered. HOB 45 degrees or greater at\n all times. Oral suctioning as needed and frequent oral care.\n Response:\n Lung sounds remain clear, RR 12-20 unlabored, SATs 94-96% on room air.\n Plan:\n Await Speech and Swallow consult before giving anything by mouth.\n Continue HOB>45, frequent oral care, suctioning oral cavitiy as\n needed, and nutrition via Dobhoff.\n Altered mental status (not Delirium)\n Assessment:\n Patient has periods of alertness followed by periods of somnolence.\n Inconsistently follows commands and answers simple questions. Remains\n oriented x0 as unable to state own name when asked.\n Action:\n Monitoring neuro status, encourage verbal interaction with staff and\n family. Soft mitt to R hand to prevent removal of feeding tube.\n Response:\n Patient is more alert today, able to respond to simple questions.\n Continues to neglect L arm.\n Plan:\n Continue to monitor neuro status, encourage family interaction with\n patient during visits.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n S/P FALL\n Code status:\n Full code\n Height:\n Admission weight:\n 94 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Smoker\n CV-PMH: Hypertension\n Additional history: hyperlipidemia\n Surgery / Procedure and date: discectomy and fusion C3-C4.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:135\n D:62\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 66 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 8 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,445 mL\n 24h total out:\n 2,010 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 02:28 AM\n Potassium:\n 3.7 mEq/L\n 02:28 AM\n Chloride:\n 107 mEq/L\n 02:28 AM\n CO2:\n 28 mEq/L\n 02:28 AM\n BUN:\n 16 mg/dL\n 02:28 AM\n Creatinine:\n 0.7 mg/dL\n 02:28 AM\n Glucose:\n 109 mg/dL\n 02:28 AM\n Hematocrit:\n 32.2 %\n 02:28 AM\n Finger Stick Glucose:\n 110\n 10:00 PM\n Valuables / Signature\n Patient valuables: Glasses on patient\n Other valuables: none\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU-686\n Transferred to: \n Date & time of Transfer: 1800\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411718,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.6\nF - 08:00 PM\n -Intubated around 6pm for failure to protect airway (tongue seemed to\n occlude airway).\n - Did well and was transitioned to CPAP\n CTA/CT abd/pelvis: PRELIM READ\n No central pulmonary embolism. Distal branches are not well evaluated\n due to respiratory motion. No acute intra-abd process\n CT neck: PRELIM READ. Per neuro- changes are normal for post op period\n 1. 4-cm gas-containing collection in the right neck for which infection\n cannot be excluded.\n 2. Surgical changes related to ACDF. Soft tissue swelling involving the\n prevertebral and retropharyngeal soft tissues anterior to cervical\n fusion\n which may represent edema or phlegmonous change.\n 3. Prevertebral soft tissue edema at the level of the - and\n oropharynx with subsequent narrowing of the airway\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Metronidazole - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 38.1\nC (100.5\n HR: 76 (66 - 105) bpm\n BP: 135/76(90) {109/51(65) - 174/92(109)} mmHg\n RR: 18 (16 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,681 mL\n 980 mL\n PO:\n TF:\n 40 mL\n 208 mL\n IVF:\n 2,296 mL\n 272 mL\n Blood products:\n Total out:\n 1,164 mL\n 690 mL\n Urine:\n 1,164 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,517 mL\n 290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n PS : 5 cmH2O\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.44/45/125/28/6\n Ve: 9.5 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General: lying in bed, intubated\n HEENT: no icterus; pupils 2-3 mm equal and reactive\n Neck: 4 cm horizontal incision over right neck clean/dry/intact, though\n with moderate induration; no fluctuance\n Chest: loud expiratory ronchi with no wheezes or rales; strong cough\n CV: heart sounds obscured by ronchi; no murmur\n Neuro: not responding to voice; left fingers contracted with increased\n tone; no clonus of hands/feet; bilat upgoing toes\n Labs / Radiology\n 406 K/uL\n 11.1 g/dL\n 146 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 108 mEq/L\n 144 mEq/L\n 32.9 %\n 17.5 K/uL\n [image002.jpg]\n 02:27 AM\n 07:04 AM\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n WBC\n 10.6\n 13.4\n 17.5\n Hct\n 32.0\n 34.5\n 32.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.7\n TCO2\n 34\n 33\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n Other labs: PT / PTT / INR:13.4/29.2/1.1, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) now with tachypnea and difficulty protecting\n airway as well as fevers of unclear etiology.\n 1. Airway compromise: improves with oral airway, but unable to\n maintain patent airway due to mental status; per neurosurgery, this may\n improve with time, but will likely be a slow improvement\n - intubated to protect airway; ? need for tracheostomy\n - pulmonary toilet\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; add metronidazole for empiric C Diff\n therapy and check C Diff toxin\n - f/u micro\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: increase free H2O in tube feeds\n 6. Coagulopathy: likely nutritional\n - PO vitamin K\n ICU Care\n Nutrition:\n ProBalance (Full) - 10:00 PM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:51 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": "2156-08-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 411720,
"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 56 yo man s/p head trauma and spinal trauma after fall. C/B post-op\n fevers, respiratory failure.\n 24 Hour Events:\n BLOOD CULTURED - At 02:22 PM\n URINE CULTURE - At 02:22 PM\n EKG - At 03:05 PM\n INVASIVE VENTILATION - START 05:40 PM\n FEVER - 103.6\nF - 08:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Metronidazole - 06:00 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n protonix\n keppra\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 10:28 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 38.4\nC (101.2\n HR: 75 (66 - 105) bpm\n BP: 143/59(82) {109/51(65) - 174/92(109)} mmHg\n RR: 20 (16 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,681 mL\n 1,586 mL\n PO:\n TF:\n 40 mL\n 325 mL\n IVF:\n 2,296 mL\n 501 mL\n Blood products:\n Total out:\n 1,164 mL\n 830 mL\n Urine:\n 1,164 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,517 mL\n 756 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n PS : 5 cmH2O\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.44/45/125/28/6\n Ve: 13.5 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Lungs: Clear, no rhonchi\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Extremities: Right: Absent\n Skin: Not assessed\n Neurologic: Opens eyes to voice. No commands. Left arm flaccid.\n Labs / Radiology\n 11.1 g/dL\n 406 K/uL\n 146 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 108 mEq/L\n 144 mEq/L\n 32.9 %\n 17.5 K/uL\n [image002.jpg]\n 02:27 AM\n 07:04 AM\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n WBC\n 10.6\n 13.4\n 17.5\n Hct\n 32.0\n 34.5\n 32.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.7\n TCO2\n 34\n 33\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n Other labs: PT / PTT / INR:13.4/29.2/1.1, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: ?RLL infiltrate\n Microbiology: Sputum: 4+ GNRs and 2+ GPCs\n Assessment and Plan\n Respiratory failure: Poor MS, has received no sedation, but largely\n unresponsive, although by report he has followed commands\n intermittently.\n Will likely need trach and PEG.\n Fevers: ?RLL infitrate. Diarrhea has improved. Sputum with positive\n gram stain. Continue Vanco/Zosyn.\n If C. diff is negative, can d/c flagyl.\n F/E/N: TFs with free water bolus.\n ICU Care\n Nutrition:\n ProBalance (Full) - 10:00 PM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:51 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411729,
"text": "Altered mental status (not Delirium)\n Assessment:\n Pt inconsistent with following commands, early exam pt able to squeeze\n with his right hand, move his lower ext and lft hand, later assessed pt\n less responsive to commands . Pt responds to painful stimuli, localizes\n and withdraws, perla 2mm brisk, no seizure activity noted ; pt not on\n sedation at this time\n Action:\n pt assessed by neuro today, cont with keppra\n Response:\n No changes noted with pt, cont with periods of responsive to commands\n Plan:\n Cont to , cont antiseizure meds\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated for airway protection, CPAP 5/5 PS, LSC bilat; pt\n has impaired cough/gag reflex, CXR shows RLL pneu\n Action:\n Pt suct for thick yellow secretions, Cont on IV abs Tmax 101.2,\n Tylenol given as ordered\n Response:\n O2 Sats remain 98-100% pt tolerating turns with out Desats\n Plan:\n Cont to ABGS, suction as needed, discuss with family possible\n peg/trach\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt Tmax 101.2 today\n Action:\n Cont with cooling blanket, BC pending from ; Tylenol given as\n orderd; pt seen by ID today\n Response:\n T down 100.2\n Plan:\n Cont with IV Abs, medicate as needed for temps; if cultures come back\n negative ? LP\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411880,
"text": "Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411674,
"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: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Weaned down to 5/5. with good results.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done on =32.\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 ABG puncture (0230)\n Comments: Drawn from R radial artery without problem. test done\n bleeding controlled.\n Will cont to monitor resp status.\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411698,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.6\nF - 08:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Metronidazole - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 38.1\nC (100.5\n HR: 76 (66 - 105) bpm\n BP: 135/76(90) {109/51(65) - 174/92(109)} mmHg\n RR: 18 (16 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,681 mL\n 980 mL\n PO:\n TF:\n 40 mL\n 208 mL\n IVF:\n 2,296 mL\n 272 mL\n Blood products:\n Total out:\n 1,164 mL\n 690 mL\n Urine:\n 1,164 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,517 mL\n 290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n PS : 5 cmH2O\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.44/45/125/28/6\n Ve: 9.5 L/min\n PaO2 / FiO2: 313\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 406 K/uL\n 11.1 g/dL\n 146 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 108 mEq/L\n 144 mEq/L\n 32.9 %\n 17.5 K/uL\n [image002.jpg]\n 02:27 AM\n 07:04 AM\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n WBC\n 10.6\n 13.4\n 17.5\n Hct\n 32.0\n 34.5\n 32.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.7\n TCO2\n 34\n 33\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n Other labs: PT / PTT / INR:13.4/29.2/1.1, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n ProBalance (Full) - 10:00 PM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:51 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": "2156-08-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411699,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.6\nF - 08:00 PM\n -Intubated around 6pm for failure to protect airway (tongue seemed to\n occlude airway).\n - Did well and was transitioned to CPAP\n CTA/CT abd/pelvis: PRELIM READ\n No central pulmonary embolism. Distal branches are not well evaluated\n due to respiratory motion. No acute intra-abd process\n CT neck: PRELIM READ\n 1. 4-cm gas-containing collection in the right neck for which infection\n cannot be excluded.\n 2. Surgical changes related to ACDF. Soft tissue swelling involving the\n prevertebral and retropharyngeal soft tissues anterior to cervical\n fusion\n which may represent edema or phlegmonous change.\n 3. Prevertebral soft tissue edema at the level of the - and\n oropharynx with subsequent narrowing of the airway\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Metronidazole - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 38.1\nC (100.5\n HR: 76 (66 - 105) bpm\n BP: 135/76(90) {109/51(65) - 174/92(109)} mmHg\n RR: 18 (16 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,681 mL\n 980 mL\n PO:\n TF:\n 40 mL\n 208 mL\n IVF:\n 2,296 mL\n 272 mL\n Blood products:\n Total out:\n 1,164 mL\n 690 mL\n Urine:\n 1,164 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,517 mL\n 290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n PS : 5 cmH2O\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.44/45/125/28/6\n Ve: 9.5 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General: lying in bed with loud upper airway ronchi, improved when\n tongue held with tongue depressor\n HEENT: no icterus; pupils 3 mm equal and reactive\n Neck: 4 cm horizontal incision over right neck clean/dry/intact, though\n with moderate induration; no fluctuance\n Chest: loud expiratory ronchi with no wheezes or rales; strong cough\n CV: heart sounds obscured by ronchi; no murmur\n Abdomen: soft, nontender, nondistended, normal bowel sounds\n Neuro: not responding to voice or withdrawing to pain; right arm with\n purposeful movement and normal tone; left arm flaccid; 3+ patellar\n reflexes bilaterally (right slightly more than left)\n Skin: Not assessed\n Labs / Radiology\n 406 K/uL\n 11.1 g/dL\n 146 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 108 mEq/L\n 144 mEq/L\n 32.9 %\n 17.5 K/uL\n [image002.jpg]\n 02:27 AM\n 07:04 AM\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n WBC\n 10.6\n 13.4\n 17.5\n Hct\n 32.0\n 34.5\n 32.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.7\n TCO2\n 34\n 33\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n Other labs: PT / PTT / INR:13.4/29.2/1.1, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury now with tachypnea\n and difficulty protecting airway as well as fevers of unclear etiology.\n 1. Airway compromise: improves with oral airway, but unable to\n maintain patent airway due to mental status; per neurosurgery, this may\n improve with time, but will likely be a slow improvement\n - intubated to protect airway; ? need for tracheostomy\n - pulmonary toilet\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; add metronidazole for empiric C Diff\n therapy and check C Diff toxin\n - f/u micro\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: increase free H2O in tube feeds\n 6. Coagulopathy: likely nutritional\n - PO vitamin K\n ICU Care\n Nutrition:\n ProBalance (Full) - 10:00 PM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:51 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": "2156-08-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411701,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 103.6\nF - 08:00 PM\n -Intubated around 6pm for failure to protect airway (tongue seemed to\n occlude airway).\n - Did well and was transitioned to CPAP\n CTA/CT abd/pelvis: PRELIM READ\n No central pulmonary embolism. Distal branches are not well evaluated\n due to respiratory motion. No acute intra-abd process\n CT neck: PRELIM READ. Per neuro- changes are normal for post op period\n 1. 4-cm gas-containing collection in the right neck for which infection\n cannot be excluded.\n 2. Surgical changes related to ACDF. Soft tissue swelling involving the\n prevertebral and retropharyngeal soft tissues anterior to cervical\n fusion\n which may represent edema or phlegmonous change.\n 3. Prevertebral soft tissue edema at the level of the - and\n oropharynx with subsequent narrowing of the airway\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:00 AM\n Metronidazole - 06:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.8\nC (103.6\n Tcurrent: 38.1\nC (100.5\n HR: 76 (66 - 105) bpm\n BP: 135/76(90) {109/51(65) - 174/92(109)} mmHg\n RR: 18 (16 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,681 mL\n 980 mL\n PO:\n TF:\n 40 mL\n 208 mL\n IVF:\n 2,296 mL\n 272 mL\n Blood products:\n Total out:\n 1,164 mL\n 690 mL\n Urine:\n 1,164 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,517 mL\n 290 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n PS : 5 cmH2O\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 32\n PIP: 22 cmH2O\n SpO2: 100%\n ABG: 7.44/45/125/28/6\n Ve: 9.5 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General: lying in bed, intubated\n HEENT: no icterus; pupils 2-3 mm equal and reactive\n Neck: 4 cm horizontal incision over right neck clean/dry/intact, though\n with moderate induration; no fluctuance\n Chest: loud expiratory ronchi with no wheezes or rales; strong cough\n CV: heart sounds obscured by ronchi; no murmur\n Neuro: not responding to voice; left fingers contracted with increased\n tone; no clonus of hands/feet; bilat upgoing toes\n Labs / Radiology\n 406 K/uL\n 11.1 g/dL\n 146 mg/dL\n 0.7 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 108 mEq/L\n 144 mEq/L\n 32.9 %\n 17.5 K/uL\n [image002.jpg]\n 02:27 AM\n 07:04 AM\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n WBC\n 10.6\n 13.4\n 17.5\n Hct\n 32.0\n 34.5\n 32.9\n Plt\n \n Cr\n 0.5\n 0.6\n 0.7\n TCO2\n 34\n 33\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n Other labs: PT / PTT / INR:13.4/29.2/1.1, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.7 mg/dL, Mg++:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) now with tachypnea and difficulty protecting\n airway as well as fevers of unclear etiology.\n 1. Airway compromise: improves with oral airway, but unable to\n maintain patent airway due to mental status; per neurosurgery, this may\n improve with time, but will likely be a slow improvement\n - intubated to protect airway; ? need for tracheostomy\n - pulmonary toilet\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; add metronidazole for empiric C Diff\n therapy and check C Diff toxin\n - f/u micro\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: increase free H2O in tube feeds\n 6. Coagulopathy: likely nutritional\n - PO vitamin K\n ICU Care\n Nutrition:\n ProBalance (Full) - 10:00 PM 40 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 04:51 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": "2156-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411779,
"text": "Altered mental status (not Delirium)\n Assessment:\n Pt inconsistent with following commands, early exam pt able to squeeze\n with his right hand, move his lower ext and lft hand, later assessed pt\n less responsive to commands . Pt responds to painful stimuli, localizes\n and withdraws, perla 2mm brisk, no seizure activity noted ; pt not on\n sedation at this time\n Action:\n pt assessed by neuro today, cont with keppra\n Response:\n No changes noted with pt, cont with periods of responsive to commands\n Plan:\n Cont to , cont antiseizure meds\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt remains intubated for airway protection, CPAP 5/5 PS, LSC bilat; pt\n has impaired cough/gag reflex, CXR shows RLL pneu\n Action:\n Pt suct for thick yellow secretions, Cont on IV abs Tmax 101.2,\n Tylenol given as ordered\n Response:\n O2 Sats remain 98-100% pt tolerating turns with out Desats\n Plan:\n Cont to ABGS, suction as needed, discuss with family possible\n peg/trach\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt Tmax 101.2 today\n Action:\n Cont with cooling blanket, BC pending from ; Tylenol given as\n orderd; pt seen by ID today\n Response:\n T down 100.2\n Plan:\n Cont with IV Abs, medicate as needed for temps; if cultures come back\n negative ? LP\n Electrolyte & fluid disorder, other\n Assessment:\n K 5.8 @1700\n Action:\n Reported to team, EKG obtained, no changes seen; pt to receive dose of\n kayexalate\n Response:\n Plan:\n Cont to labs, vs\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411860,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 09:00 AM\n 101.1 at 8am\n Spoke with family- they are amenable to trach/peg. However, pt seems\n more alert and is responding to simple commands. attempt\n extubation later today.\n Cultures pending. C.diff x 2; blood,urine NGTD; sputum prelim GNR,\n GPC. On vanc/zosyn; will d/c flagyl today.\n Continues to be coagulopathic. INR today 1.9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:31 AM\n Metronidazole - 05:46 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 PM\n Heparin Sodium (Prophylaxis) - 05:46 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 65 (58 - 83) bpm\n BP: 124/61(74) {103/56(73) - 143/78(85)} mmHg\n RR: 20 (16 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,590 mL\n 1,184 mL\n PO:\n TF:\n 1,260 mL\n 493 mL\n IVF:\n 1,050 mL\n 171 mL\n Blood products:\n Total out:\n 2,265 mL\n 535 mL\n Urine:\n 2,265 mL\n 535 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,325 mL\n 649 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n SpO2: 98%\n ABG: ///31/\n Ve: 10.7 L/min\n Physical Examination\n Gen: awake, closes eyes in response to questions\n Neck: wound slightly erythematous, no drainage, incision C, D, I\n Ext: can squeeze with right fist, left arm flaccid with fingers flexed\n Lower Ext: very slight movement of RLE only.\n Labs / Radiology\n 363 K/uL\n 10.4 g/dL\n 162 mg/dL\n 0.5 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.4 %\n 16.5 K/uL\n [image002.jpg]\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n WBC\n 10.6\n 13.4\n 17.5\n 16.5\n Hct\n 32.0\n 34.5\n 32.9\n 30.4\n Plt\n 63\n Cr\n 0.5\n 0.6\n 0.7\n 0.5\n 0.5\n TCO2\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n 175\n 162\n Other labs: PT / PTT / INR:19.9/35.8/1.9, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) now with tachypnea and difficulty protecting\n airway as well as fevers of unclear etiology.\n 1. Airway compromise: improved with oral airway, but unable to\n maintain patent airway due to mental status and was intubated on ;\n per neurosurgery, this may improve with time, but will likely be a slow\n improvement. Can consider extubation today as pt is more alert and\n able to communicate. If cannot extubate may need tracheostomy.\n - pulmonary toilet\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; d/c metronidazole as c.diff toxins\n neg x 2\n - NGTD for blood and urine cultures; continue to follow\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: resolved . increased free H2O in tube feeds\n 6. Coagulopathy: likely nutritional\n - PO vitamin K\n ICU Care\n Nutrition:\n ProBalance (Full) - 07:43 PM 70 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 06:37 PM\n Prophylaxis:\n DVT: subq heparin; pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411873,
"text": "Demographics\n Day of mechanical ventilation: 3\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Clear / Thin\n Sputum source/amount: Suctioned / Copious\n Comments: Pt has copious amts of secretions; requiring frequent\n suctioning.\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt remains on PSV 5/5 throughout shift; tol well.\n Plan\n Next 24-48 hours: Possible extubation in a.m.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411965,
"text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411966,
"text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Activity Intolerance\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411967,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury. He was\n intubated prior to transfer to on , and had an ICP Bolt\n monitor placed on (removed due to normal ICPs). His\n initial presentation was notable for left arm weakness found to be due\n to traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . Right subclavian CVL placed on and\n removed (tip culture negative to date). He spiked a fever >\n yesterday prompting an ID consult.\n After stay in T/SICU he was transferred to 11 and there was noted\n to have increasing tachypnea and loud upper airway sounds prompting\n concern that he wasn\nt protecting his airway, so he is transferred to\n the MICU for further management and intubated shortly after MICU\n admission.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and opening eyes spontaneously. Pt inconsistently following\n commands. Sensation in all four extremities, minimal movement noted on\n pt\ns left side. PERL brisk, he tracks to movement in the room.\n Impaired gag, strong cough. Pt speaking, but occ speak is garbled and\n pt\ns conversation does not always make sense.\n Action:\n Q4hour neuro checks. Frequently reoriented. Family in to see pt today.\n Response:\n Pt smiling with family at bedside and was interacting with them,\n although he was not always making sense with his conversation.\n Plan:\n Continue to q4hour neuron checks. Reorient pt as needed.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt received intubated CPAP+PS with small to moderate amounts of thin\n clear secretions. ABG 7.45/45/90. Strong cough, impaired gag.\n Action:\n Chest PT x3. Pt extubated at 1230.\n Response:\n He has been clearing his own secretions, and has been observed\n swallowing his oral secretions with no evidence of aspiration. OOB to\n chair with complete help from Physical Therapy and maintaining sats 99%\n on 2L NC.\n Plan:\n Continue with supplemental O2. Encourage pt to deep breath and cough.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Activity Intolerance\n Assessment:\n Pt with minimal spontaneous movement noted on left side. RUE with\n normal strength and Right leg pt can lift and hold.\n Action:\n Pt repositioned frequently prior to extuabtion. PT met with pt and got\n him OOB to stretcher chair via slide board. Per PT, pt unable to sit\n on side of bed unsupported.\n Response:\n Pt tolerating chair well\n Plan:\n Continue with repositioning while is bed. Pt OOB to stretcher chair as\n he tolerates.\n"
},
{
"category": "Rehab Services",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Generic Note",
"row_id": 411970,
"text": "TITLE:\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411903,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Alert, intubated for airway protection and awaiting for extubation this\n am, copious amount of whitish thick secretion. ? slowly improving\n mental status after head injury\n Action:\n Frequent pul toilet,\n Response:\n Continue have secretion, slowly improving MS\n :\n ? plan for possible extubation OR ?trach if extubation failed\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 rectal\n Action:\n Pan cultured, po Tylenol given continue antibiotics\n Response:\n Plan:\n Cooling blanket, po meds/ continue antibiotics, F/U culture results\n Altered mental status (not Delirium)\n Assessment:\n Alert, unable to assess orientation d/t oral ETT, following commands\n inconsistently. Continue lt side weakness, lt arm flaccid, no seizure\n activity,\n Action:\n Neuro assessment q 4hrs,\n Response:\n Slowly improving mental status\n Plan:\n Neuro surgery following,\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Generic Note",
"row_id": 411682,
"text": "TITLE:\n Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Copious amts of oral & endotracheal secretions, Impaired gag, intact\n cough.\n Action:\n Oral & endotracheal suctioning done as needed. Fio2 reduced to 50%,\n ABG WNL. Mode changed to CPAP+ PS. & fio2 further reduced to 40 %\n in am.\n Response:\n Breathing well on PS. Maintaining sats 98 to 100 %\n Plan:\n Continue Aspiration precaution, pulmonary & oral hygiene .\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-Max 103.4 orally.\n Action:\n MD informed, pancultures not needed as this was done earlier during the\n day. Tylenol given, icepacks applied & started on cooling blanket.\n Continued iv on vanco, zosyn & po flagyl.\n Response:\n Temp reduced to 99.9 Rectally, patient was shivering for few minutes,\n Switched off cooling blanket. Restarted after ~ 1.5 hours as rectal\n temp ^ to 101.\n Plan:\n Will continue to monitor. To send stools for c-diff when available.\n Started on feeds with probalance @ 20 mls/hr(Probalance or HN fiber\n feeds as per Resident & intern, will continue with either of the feeds\n until nutrition consult) & increased to 40 mls/hr, Na was high ,\n reduced to 144 in am labs, continued on NS flush 200 mls q 4 hours.\n Nutrition consult ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Generic Note",
"row_id": 411683,
"text": "TITLE:\n Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Copious amts of oral & endotracheal secretions, Impaired gag, intact\n cough.\n Action:\n Oral & endotracheal suctioning done as needed. Fio2 reduced to 50%,\n ABG WNL. Mode changed to CPAP+ PS. & fio2 further reduced to 40 %\n in am.\n Response:\n Breathing well on PS. Maintaining sats 98 to 100 %\n Plan:\n Continue Aspiration precaution, pulmonary & oral hygiene .\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-Max 103.4 orally.\n Action:\n MD informed, pancultures not needed as this was done earlier during the\n day. Tylenol given, icepacks applied & started on cooling blanket.\n Continued iv on vanco, zosyn & po flagyl.\n Response:\n Temp reduced to 99.9 Rectally, patient was shivering for few minutes,\n Switched off cooling blanket. Restarted after ~ 1.5 hours as rectal\n temp ^ to 101.\n Plan:\n Will continue to monitor. To send stools for c-diff when available.\n Altered mental status (not Delirium)\n Assessment:\n Does not obey simple verbal commands, withdraws to pain, opens eye\n spontaneously at times, perla brisk 3mm.no seizure noted. Continues to\n have Left side weakness\n Action:\n Continued on Kepra. Not stared on sedation.\n Response:\n Continues, no changes noted in assessment throughout the shift.\n Plan:\n Continue monitoring, continue meds. Continue emotional support.\n Started on feeds with probalance @ 20 mls/hr(Probalance or HN fiber\n feeds as per Resident & intern, will continue with either of the feeds\n until nutrition consult) & increased to 40 mls/hr, Na was high ,\n reduced to 144 in am labs, continued on NS flush 200 mls q 4 hours.\n Started on po Potassium sliding scale & calcium gluconate s/s.\n Received total of 40 + 40 meq of Kcl. Calcium 2 grams given. Nutrition\n consult ordered.\n"
},
{
"category": "Nutrition",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 411854,
"text": "Objective\n Pertinent medications: noted\n Labs:\n Value\n Date\n Glucose\n 162 mg/dL\n 03:44 AM\n Glucose Finger Stick\n 124\n 10:00 PM\n BUN\n 15 mg/dL\n 03:44 AM\n Creatinine\n 0.5 mg/dL\n 03:44 AM\n Sodium\n 143 mEq/L\n 03:44 AM\n Potassium\n 3.3 mEq/L\n 03:44 AM\n Chloride\n 106 mEq/L\n 03:44 AM\n TCO2\n 31 mEq/L\n 03:44 AM\n Albumin\n 3.6 g/dL\n 02:14 AM\n Calcium non-ionized\n 8.6 mg/dL\n 03:44 AM\n Phosphorus\n 3.2 mg/dL\n 03:44 AM\n Ionized Calcium\n 1.16 mmol/L\n 03:18 AM\n Magnesium\n 2.1 mg/dL\n 03:44 AM\n Phenytoin (Dilantin)\n 8.3 ug/mL\n 02:06 AM\n Current diet order / nutrition support: Probalance @70mL/hr (\n kcals/90 gr aa) c/ 200mL H2O q 4 hr\n GI: Abd: soft/dist/+bs\n Assessment of Nutritional Status\n Specifics:\n 56 y/o male s/p fall c/ skull fx, multiple SDH\ns. Tx\nd to MICU \n hypoxia and decreased MS c/ subsequent intubation. Pt c/ fever of\n unknown etiology-w/u ongoing. Pt receiving TFs via NGT, which are\n infusing @ goal and meeting 100% estimated nutrition needs. BG\n elevated. Lyte repletions noted.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via TF\n Continue TF's @ goal\n Start RISS for BG's >150 mg/dL\n monitor and replete lytes prn as you are\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411936,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Alert, intubated for airway protection and awaiting for extubation this\n am, copious amount of whitish thick secretion. ? slowly improving\n mental status after head injury\n Action:\n Frequent pul toilet,\n Response:\n Continue have secretion, slowly improving MS\n :\n ? plan for possible extubation OR ?trach if extubation failed\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 rectal\n Action:\n Pan cultured, po Tylenol given continue antibiotics\n Response:\n Plan:\n Cooling blanket, po meds/ continue antibiotics, F/U culture results\n Altered mental status (not Delirium)\n Assessment:\n Alert, unable to assess orientation d/t oral ETT, following commands\n inconsistently. Continue lt side weakness, lt arm flaccid, no seizure\n activity,\n Action:\n Neuro assessment q 4hrs,\n Response:\n Slowly improving mental status\n Plan:\n Neuro surgery following,\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 412050,
"text": "Mr. . is a 56 year old man with past medical history of HTN and\n Hyperlipidemia who originally presented to on following a\n fall from a ladder with subsequent occipital bone basilar skull\n fracture, subdural hematoma, subarachnoid hematoma and contra-coup\n brain injury. He was intubated prior to transfer to on ,\n and had an ICP Bolt monitor placed on (removed due to\n normal ICPs). His initial presentation was notable for left arm\n weakness found to be due to traumatic C3-C4 cervical disc herniation\n with resultant cord compression. He underwent anterior discectomy and\n fusion on and his post-operative course has been complicated by\n fevers of unclear source beginning on . Initial cultures\n revealed one out of four blood culture bottles growing\n coagulase-negative Staph, and he was put on vancomycin on .\n Right subclavian CVL placed on and removed (tip culture\n negative to date). He spiked a fever > yesterday prompting an ID\n consult.\n After stay in T/SICU he was transferred to 11 and there was noted\n to have increasing tachypnea and loud upper airway sounds prompting\n concern that he wasn\nt protecting his airway, so he is transferred to\n the MICU for further management and intubated shortly after MICU\n admission. Extubated .\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Noted to be swallowing and coughing. At times noted to have some\n difficulty clearing secretions and requires oral suction.\n Action:\n Nothing by mouth at this time. Nutrition via Dobhoff feeding tube L\n nare. Speech and swallow consult ordered. HOB 45 degrees or greater at\n all times. Oral suctioning as needed and frequent oral care.\n Response:\n Lung sounds remain clear, RR 12-20 unlabored, SATs 94-96% on room air.\n Plan:\n Await Speech and Swallow consult before giving anything by mouth.\n Continue HOB>45, frequent oral care, suctioning oral cavitiy as\n needed, and nutrition via Dobhoff.\n Altered mental status (not Delirium)\n Assessment:\n Patient has periods of alertness followed by periods of somnolence.\n Inconsistently follows commands and answers simple questions. Remains\n oriented x0 as unable to state own name when asked.\n Action:\n Monitoring neuro status, encourage verbal interaction with staff and\n family. Soft mitt to R hand to prevent removal of feeding tube.\n Response:\n Patient is more alert today, able to respond to simple questions.\n Continues to neglect L arm.\n Plan:\n Continue to monitor neuro status, encourage family interaction with\n patient during visits.\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411758,
"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: ICU\n Reason: Re-intubation; Comments: intubated for airway protection\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 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 / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Tracheostomy planned\n Reason for continuing current ventilatory support: Pending procedure /\n OR\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Tolerating psv/cpap well, with small amts yellowish sputum. Awaiting\n trach placement for airway protection.\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411825,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 09:00 AM\n Spoke with family. will go ahead with trach/peg.\n Cultures pending.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:31 AM\n Metronidazole - 05:46 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 PM\n Heparin Sodium (Prophylaxis) - 05:46 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 65 (58 - 83) bpm\n BP: 124/61(74) {103/56(73) - 143/78(85)} mmHg\n RR: 20 (16 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,590 mL\n 1,184 mL\n PO:\n TF:\n 1,260 mL\n 493 mL\n IVF:\n 1,050 mL\n 171 mL\n Blood products:\n Total out:\n 2,265 mL\n 535 mL\n Urine:\n 2,265 mL\n 535 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,325 mL\n 649 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n SpO2: 98%\n ABG: ///31/\n Ve: 10.7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 363 K/uL\n 10.4 g/dL\n 162 mg/dL\n 0.5 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.4 %\n 16.5 K/uL\n [image002.jpg]\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n WBC\n 10.6\n 13.4\n 17.5\n 16.5\n Hct\n 32.0\n 34.5\n 32.9\n 30.4\n Plt\n 63\n Cr\n 0.5\n 0.6\n 0.7\n 0.5\n 0.5\n TCO2\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n 175\n 162\n Other labs: PT / PTT / INR:19.9/35.8/1.9, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n ProBalance (Full) - 07:43 PM 70 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 06:37 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": "2156-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411826,
"text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 101.2\nF - 09:00 AM\n Spoke with family. will go ahead with trach/peg.\n Cultures pending.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:31 AM\n Metronidazole - 05:46 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 PM\n Heparin Sodium (Prophylaxis) - 05:46 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 37.9\nC (100.2\n HR: 65 (58 - 83) bpm\n BP: 124/61(74) {103/56(73) - 143/78(85)} mmHg\n RR: 20 (16 - 21) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,590 mL\n 1,184 mL\n PO:\n TF:\n 1,260 mL\n 493 mL\n IVF:\n 1,050 mL\n 171 mL\n Blood products:\n Total out:\n 2,265 mL\n 535 mL\n Urine:\n 2,265 mL\n 535 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,325 mL\n 649 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n SpO2: 98%\n ABG: ///31/\n Ve: 10.7 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 363 K/uL\n 10.4 g/dL\n 162 mg/dL\n 0.5 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.4 %\n 16.5 K/uL\n [image002.jpg]\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n WBC\n 10.6\n 13.4\n 17.5\n 16.5\n Hct\n 32.0\n 34.5\n 32.9\n 30.4\n Plt\n 63\n Cr\n 0.5\n 0.6\n 0.7\n 0.5\n 0.5\n TCO2\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n 175\n 162\n Other labs: PT / PTT / INR:19.9/35.8/1.9, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) now with tachypnea and difficulty protecting\n airway as well as fevers of unclear etiology.\n 1. Airway compromise: improves with oral airway, but unable to\n maintain patent airway due to mental status; per neurosurgery, this may\n improve with time, but will likely be a slow improvement\n - intubated to protect airway; ? need for tracheostomy\n - pulmonary toilet\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; add metronidazole for empiric C Diff\n therapy and check C Diff toxin\n - f/u micro\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: increase free H2O in tube feeds\n 6. Coagulopathy: likely nutritional\n - PO vitamin K\n ICU Care\n Nutrition:\n ProBalance (Full) - 07:43 PM 70 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 06:37 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Generic Note",
"row_id": 411922,
"text": "TITLE:\n RESPIRATORY CARE:\n Pt remains intubated, vent supported. No changes made overnight. BS\n diminished, with some coarseness. Sxing large amounts white/yellow\n secretions. RSBI=89 this am. See flowsheet for further pt data. Will\n follow.\n 06:03\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 411948,
"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 56 yo man s/p head trauma, respiratory failures, fevers.\n 24 Hour Events:\n MIDLINE - START 02:00 PM\n BLOOD CULTURED - At 08:55 PM\n URINE CULTURE - At 08:56 PM\n BLOOD CULTURED - At 04:11 AM\n SPUTUM CULTURE - At 04:11 AM\n URINE CULTURE - At 04:11 AM\n FEVER - 101.1\nF - 08:00 AM\n MS continues to wax and wane\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 05:46 AM\n Piperacillin/Tazobactam (Zosyn) - 06:08 AM\n Vancomycin - 08:15 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:08 AM\n Other medications:\n protonix\n keppra\n chlorhex\n vitamin K\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:23 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.4\nC (97.5\n HR: 70 (60 - 78) bpm\n BP: 132/67(84) {96/55(72) - 152/91(104)} mmHg\n RR: 30 (19 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,634 mL\n 517 mL\n PO:\n TF:\n 888 mL\n IVF:\n 556 mL\n 422 mL\n Blood products:\n Total out:\n 2,920 mL\n 830 mL\n Urine:\n 2,920 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -286 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 330 (330 - 540) mL\n PS : 5 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 89\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.45/45/90./28/6\n Ve: 10.1 L/min\n PaO2 / FiO2: 225\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.7 g/dL\n 453 K/uL\n 110 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.0 %\n 13.8 K/uL\n [image002.jpg]\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n 05:02 PM\n 04:00 AM\n 07:56 AM\n WBC\n 13.4\n 17.5\n 16.5\n 13.8\n Hct\n 34.5\n 32.9\n 30.4\n 32.0\n Plt\n 53\n Cr\n 0.6\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 31\n 32\n 32\n Glucose\n 113\n 112\n 129\n 146\n 175\n 162\n 117\n 110\n Other labs: PT / PTT / INR:15.4/31.1/1.4, Differential-Neuts:75.3 %,\n Lymph:16.9 %, Mono:2.2 %, Eos:4.7 %, Lactic Acid:0.9 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Respiratory failure: Improved MS, still waxing and , but\n sometimes following commands. WIll try and extubate.\n Fevers: Continue antibiotics.\n Head trauma: Reasonable chance for recovery of MS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:00 PM\n 18 Gauge - 10:06 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 411952,
"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 56 yo man s/p head trauma, respiratory failures, fevers.\n 24 Hour Events:\n MIDLINE - START 02:00 PM\n BLOOD CULTURED - At 08:55 PM\n URINE CULTURE - At 08:56 PM\n BLOOD CULTURED - At 04:11 AM\n SPUTUM CULTURE - At 04:11 AM\n URINE CULTURE - At 04:11 AM\n FEVER - 101.1\nF - 08:00 AM\n MS continues to wax and wane\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 05:46 AM\n Piperacillin/Tazobactam (Zosyn) - 06:08 AM\n Vancomycin - 08:15 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:08 AM\n Other medications:\n protonix\n keppra\n chlorhex\n vitamin K\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:23 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 36.4\nC (97.5\n HR: 70 (60 - 78) bpm\n BP: 132/67(84) {96/55(72) - 152/91(104)} mmHg\n RR: 30 (19 - 30) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,634 mL\n 517 mL\n PO:\n TF:\n 888 mL\n IVF:\n 556 mL\n 422 mL\n Blood products:\n Total out:\n 2,920 mL\n 830 mL\n Urine:\n 2,920 mL\n 830 mL\n NG:\n Stool:\n Drains:\n Balance:\n -286 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 330 (330 - 540) mL\n PS : 5 cmH2O\n RR (Spontaneous): 31\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 89\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.45/45/90./28/6\n Ve: 10.1 L/min\n PaO2 / FiO2: 225\n Physical Examination\n Eyes / Conjunctiva: PERRL\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: )\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 10.7 g/dL\n 453 K/uL\n 110 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.0 %\n 13.8 K/uL\n [image002.jpg]\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n 05:02 PM\n 04:00 AM\n 07:56 AM\n WBC\n 13.4\n 17.5\n 16.5\n 13.8\n Hct\n 34.5\n 32.9\n 30.4\n 32.0\n Plt\n 53\n Cr\n 0.6\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 31\n 32\n 32\n Glucose\n 113\n 112\n 129\n 146\n 175\n 162\n 117\n 110\n Other labs: PT / PTT / INR:15.4/31.1/1.4, Differential-Neuts:75.3 %,\n Lymph:16.9 %, Mono:2.2 %, Eos:4.7 %, Lactic Acid:0.9 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n Respiratory failure: Improved MS, still waxing and , but\n sometimes following commands. WIll try and extubate.\n Fevers: Continue antibiotics.\n Head trauma: Reasonable chance for recovery of MS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:00 PM\n 18 Gauge - 10:06 PM\n Prophylaxis:\n DVT: SQ UF Heparin(Systemic anticoagulation: Other)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411958,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MIDLINE - START 02:00 PM\n BLOOD CULTURED - At 08:55 PM\n URINE CULTURE - At 08:56 PM\n BLOOD CULTURED - At 04:11 AM\n SPUTUM CULTURE - At 04:11 AM\n URINE CULTURE - At 04:11 AM\n FEVER - 101.1\nF - 08:00 AM\n Fever O/N - UCx, BCx and Sputum Cx sent. CXR done on rads rounds\n Mental status clearer - following some commands, opening eyes.\n Attempted to place PICC yesterday but IV coiled in axillae. Was pulled\n back and is ok to use as a midline.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole\n d/c \n Vancomycin - 08:56 AM\n Piperacillin/Tazobactam (Zosyn) - 12:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:26 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 36.4\nC (97.5\n HR: 72 (60 - 78) bpm\n BP: 134/64(79) {96/55(67) - 152/91(104)} mmHg\n RR: 23 (19 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,634 mL\n 61 mL\n PO:\n TF:\n 888 mL\n IVF:\n 556 mL\n 61 mL\n Blood products:\n Total out:\n 2,920 mL\n 245 mL\n Urine:\n 2,920 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n -286 mL\n -184 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 435 (386 - 540) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 89\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.45/45/90\n Ve: 6.8 L/min\n Physical Examination\n Gen: opens eyes spontaneously and to voice; able to follow occasional\n simple commands\n Neck: Incision C,D,I. No induration or fluctuance\n Pulm: coarse bs bilat but improving\n CV: reg rhythm\n Neuro: grimaces to pain in left UE, moves/makes fist with RUE. Moves\n both feet, R>L.\n Labs / Radiology\n 453 K/uL\n 10.7 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.0 %\n 13.8 K/uL\n [image002.jpg]\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n 05:02 PM\n 04:00 AM\n WBC\n 13.4\n 17.5\n 16.5\n 13.8\n Hct\n 34.5\n 32.9\n 30.4\n 32.0\n Plt\n 53\n Cr\n 0.6\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 35\n 33\n 31\n 32\n Glucose\n 113\n 112\n 129\n 146\n 175\n 162\n 117\n 110\n Other labs: PT / PTT / INR:15.4/31.1/1.4, Differential-Neuts:75.3 %,\n Lymph:16.9 %, Mono:2.2 %, Eos:4.7 %, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) now with tachypnea and difficulty protecting\n airway as well as fevers of unclear etiology.\n 1. Airway compromise: improved with oral airway, but unable to\n maintain patent airway due to mental status and was intubated on ;\n per neurosurgery, this may improve with time, but will likely be a slow\n improvement. Can consider extubation today as pt is more alert and\n able to communicate. If cannot extubate may need tracheostomy.\n - pulmonary toilet\n - An ABG this morning is reassuring for extubation\n 2. Tachypnea: resolved. Was likely due to fevers and aspiration; no\n evidence of pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; d/c metronidazole as c.diff toxins\n neg\n - NGTD for blood and urine cultures; continue to follow\n - Sputum from showed hemophilus as well as GPC in pairs. Culture\n from shows only GPC in pairs.\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: resolved . increased free H2O in tube feeds\n 6. Coagulopathy: likely nutritional, improving. INR 1.4\n - PO vitamin K\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:00 PM\n 18 Gauge - 10:06 PM\n Prophylaxis:\n DVT: sub q hep, pneumo boots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Generic Note",
"row_id": 412054,
"text": "Critical Care Staff Addendum\n 12:30p\n I saw and examined the patient with the ICU team; Dr. \ns note from\n today reflects my input. I would add/emphasize that he has done very\n well since his extubation yesterday. His mental status has improved\n substantially. He remains on empiric antibiotics for pneumonia, now on\n day 6 of 7. We will attempt to get a PICC line, restart tube feeds,\n and continue his antibiotics for another day. We will plan for a\n speech/swallow in the next day or two. He is ready for transfer to the\n floor. Other issues as per ICU team note.\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 411656,
"text": "Chief Complaint: tachypnea, fevers\n HPI:\n Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed ). His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:30 PM\n Other medications:\n - heparin 5000 units SC tid\n - bisacodyl\n - vancomycin 1000 mg IV q12h ( - )\n - piperacillin/tazobactam 4.5 grams q8h ( - )\n - pantoprazole 40 mg IV q24h\n - albuterol neb q6h prn\n - metoclopromide 10 mg PO qACHS\n - levetiracetam 500 mg (), then increase to 1000 mg \n Past medical history:\n Family history:\n Social History:\n Reportedly none\n Unable to obtain\n Occupation: construction worker\n Drugs: unknown\n Tobacco: unknown\n Alcohol: unknown\n Other:\n Review of systems:\n Psychiatric / Sleep: Delirious\n Flowsheet Data as of 07:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.7\nC (103.4\n Tcurrent: 38.8\nC (101.8\n HR: 81 (81 - 105) bpm\n BP: 147/77(94) {138/54(74) - 174/87(109)} mmHg\n RR: 18 (18 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,043 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n Blood products:\n Total out:\n 0 mL\n 954 mL\n Urine:\n 954 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,089 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CMV/ASSIST\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 22 cmH2O\n SpO2: 100%\n Ve: 13.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 413 K/uL\n 152 mg/dL\n 0.7\n 20 mg/dL\n 25 mEq/L\n 114 mEq/L\n 3.7 mEq/L\n 150 mEq/L\n 38.0 %\n 14.4 K/uL\n [image002.jpg] INR 1.9\n Venous lactate 1.4\n Ca 8.9, Mg 2.4, Phos 3.7\n Imaging:\n CXR: Lungs clear. Dobhoff below diaphragm.\n CT Neck (prelim):\n 4 cm gas-containing fluid collection in right neck for which infection\n cannot be excluded. Surgical changes related to ACDF. Soft tissue\n swelling involving the prevertebral and retropharyngeal soft tissues\n anterior to cervical fusion which may represent edema or phlegmonous\n change. Prevertebral soft tissue edema at the level of - and\n oropharynx with narrowing of the airway.\n CT angio chest (prelim): no PE\n CT abdomen/pelvis: pending\n ECG: ECG\n Assessment and Plan\n 56 year old man with severe traumatic brain injury now with tachypnea\n and difficulty protecting airway as well as fevers of unclear etiology.\n 1. Airway compromise: improves with oral airway, but unable to\n maintain patent airway due to mental status; per neurosurgery, this may\n improve with time, but will likely be a slow improvement\n - intubate to protect airway; ? need for tracheostomy\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; add metronidazole for empiric C Diff\n therapy and check C Diff toxin\n - f/u micro\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: increase free H2O in tube feeds\n ICU Care\n Nutrition: Tube feeds with free water boluses\n Lines: 20 Gauge - 04:51 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Communication: Family meeting held Comments: Daughter . \n (cell )\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 411657,
"text": "Chief Complaint: tachypnea, fevers\n HPI:\n Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management. Of note, he has also\n begun having large volume liquid stools.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:30 PM\n Other medications:\n - heparin 5000 units SC tid\n - bisacodyl\n - vancomycin 1000 mg IV q12h ( - )\n - piperacillin/tazobactam 4.5 grams q8h ( - )\n - pantoprazole 40 mg IV q24h\n - albuterol neb q6h prn\n - metoclopromide 10 mg PO qACHS\n - levetiracetam 500 mg (), then increase to 1000 mg \n Past medical history:\n Family history:\n Social History:\n Reportedly none\n Unable to obtain\n Occupation: construction worker\n Drugs: unknown\n Tobacco: unknown\n Alcohol: unknown\n Other:\n Review of systems:\n Psychiatric / Sleep: Delirious\n Flowsheet Data as of 07:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.7\nC (103.4\n Tcurrent: 38.8\nC (101.8\n HR: 81 (81 - 105) bpm\n BP: 147/77(94) {138/54(74) - 174/87(109)} mmHg\n RR: 18 (18 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,043 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n Blood products:\n Total out:\n 0 mL\n 954 mL\n Urine:\n 954 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,089 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CMV/ASSIST\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 22 cmH2O\n SpO2: 100%\n Ve: 13.8 L/min\n Physical Examination\n General: lying in bed with loud upper airway ronchi, improved when\n tongue held with tongue depressor\n HEENT: no icterus; pupils 3 mm equal and reactive\n Neck: 4 cm horizontal incision over right neck clean/dry/intact, though\n with moderate induration; no fluctuance\n Chest: loud expiratory ronchi with no wheezes or rales; strong cough\n CV: heart sounds obscured by ronchi; no murmur\n Abdomen: soft, nontender, nondistended, normal bowel sounds\n Extremities: warm, no edema, 2+ DP pulses\n Skin: no rashes or jaundice\n Neuro: not responding to voice or withdrawing to pain; right arm with\n purposeful movement and normal tone; left arm flaccid; 3+ patellar\n reflexes bilaterally (right slightly more than left)\n Skin: Not assessed\n Labs / Radiology\n 413 K/uL\n 152 mg/dL\n 0.7\n 20 mg/dL\n 25 mEq/L\n 114 mEq/L\n 3.7 mEq/L\n 150 mEq/L\n 38.0 %\n 14.4 K/uL\n [image002.jpg] INR 1.9\n Venous lactate 1.4\n Ca 8.9, Mg 2.4, Phos 3.7\n Imaging:\n CXR: Lungs clear. Dobhoff below diaphragm.\n CT Neck (prelim):\n 4 cm gas-containing fluid collection in right neck for which infection\n cannot be excluded. Surgical changes related to ACDF. Soft tissue\n swelling involving the prevertebral and retropharyngeal soft tissues\n anterior to cervical fusion which may represent edema or phlegmonous\n change. Prevertebral soft tissue edema at the level of - and\n oropharynx with narrowing of the airway.\n CT angio chest (prelim): no PE\n CT abdomen/pelvis: pending\n ECG: Sinus rhythm at 99 bpm with APBs. Left axis deviation. Normal\n intervals. No or T wave changes.\n Assessment and Plan\n 56 year old man with severe traumatic brain injury now with tachypnea\n and difficulty protecting airway as well as fevers of unclear etiology.\n 1. Airway compromise: improves with oral airway, but unable to\n maintain patent airway due to mental status; per neurosurgery, this may\n improve with time, but will likely be a slow improvement\n - intubate to protect airway; ? need for tracheostomy\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; add metronidazole for empiric C Diff\n therapy and check C Diff toxin\n - f/u micro\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: increase free H2O in tube feeds\n ICU Care\n Nutrition: Tube feeds with free water boluses\n Lines: 20 Gauge - 04:51 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Communication: Family meeting held Comments: Daughter . \n (cell )\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 411658,
"text": "Chief Complaint: tachypnea, fevers\n HPI:\n Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management. Of note, he has also\n begun having large volume liquid stools.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:30 PM\n Other medications:\n - heparin 5000 units SC tid\n - bisacodyl\n - vancomycin 1000 mg IV q12h ( - )\n - piperacillin/tazobactam 4.5 grams q8h ( - )\n - pantoprazole 40 mg IV q24h\n - albuterol neb q6h prn\n - metoclopromide 10 mg PO qACHS\n - levetiracetam 500 mg (), then increase to 1000 mg \n Past medical history:\n Family history:\n Social History:\n Reportedly none\n Unable to obtain\n Occupation: construction worker\n Drugs: unknown\n Tobacco: unknown\n Alcohol: unknown\n Other:\n Review of systems:\n Psychiatric / Sleep: Delirious\n Flowsheet Data as of 07:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.7\nC (103.4\n Tcurrent: 38.8\nC (101.8\n HR: 81 (81 - 105) bpm\n BP: 147/77(94) {138/54(74) - 174/87(109)} mmHg\n RR: 18 (18 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,043 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n Blood products:\n Total out:\n 0 mL\n 954 mL\n Urine:\n 954 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,089 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CMV/ASSIST\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 22 cmH2O\n SpO2: 100%\n Ve: 13.8 L/min\n Physical Examination\n General: lying in bed with loud upper airway ronchi, improved when\n tongue held with tongue depressor\n HEENT: no icterus; pupils 3 mm equal and reactive\n Neck: 4 cm horizontal incision over right neck clean/dry/intact, though\n with moderate induration; no fluctuance\n Chest: loud expiratory ronchi with no wheezes or rales; strong cough\n CV: heart sounds obscured by ronchi; no murmur\n Abdomen: soft, nontender, nondistended, normal bowel sounds\n Extremities: warm, no edema, 2+ DP pulses\n Skin: no rashes or jaundice\n Neuro: not responding to voice or withdrawing to pain; right arm with\n purposeful movement and normal tone; left arm flaccid; 3+ patellar\n reflexes bilaterally (right slightly more than left)\n Skin: Not assessed\n Labs / Radiology\n 413 K/uL\n 152 mg/dL\n 0.7\n 20 mg/dL\n 25 mEq/L\n 114 mEq/L\n 3.7 mEq/L\n 150 mEq/L\n 38.0 %\n 14.4 K/uL\n [image002.jpg] INR 1.9\n Venous lactate 1.4\n Ca 8.9, Mg 2.4, Phos 3.7\n Imaging:\n CXR: Lungs clear. Dobhoff below diaphragm.\n CT Neck (prelim):\n 4 cm gas-containing fluid collection in right neck for which infection\n cannot be excluded. Surgical changes related to ACDF. Soft tissue\n swelling involving the prevertebral and retropharyngeal soft tissues\n anterior to cervical fusion which may represent edema or phlegmonous\n change. Prevertebral soft tissue edema at the level of - and\n oropharynx with narrowing of the airway.\n CT angio chest (prelim): no PE\n CT abdomen/pelvis: pending\n ECG: Sinus rhythm at 99 bpm with APBs. Left axis deviation. Normal\n intervals. No or T wave changes.\n Assessment and Plan\n 56 year old man with severe traumatic brain injury now with tachypnea\n and difficulty protecting airway as well as fevers of unclear etiology.\n 1. Airway compromise: improves with oral airway, but unable to\n maintain patent airway due to mental status; per neurosurgery, this may\n improve with time, but will likely be a slow improvement\n - intubate to protect airway; ? need for tracheostomy\n - pulmonary toilet\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; add metronidazole for empiric C Diff\n therapy and check C Diff toxin\n - f/u micro\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n - f/u CT reports\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: increase free H2O in tube feeds\n 6. Coagulopathy: likely nutritional\n - PO vitamin K\n ICU Care\n Nutrition: Tube feeds with free water boluses\n Lines: 20 Gauge - 04:51 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer: ppi\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Communication: Family meeting held Comments: Daughter . \n (cell )\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 411852,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n FEVER - 101.2\nF - 09:00 AM\n Continued fevers\n History obtained from Interpreter\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:31 AM\n Metronidazole - 05:46 AM\n Vancomycin - 08:56 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:23 PM\n Heparin Sodium (Prophylaxis) - 05:46 AM\n Other medications:\n protonix\n keppra\n chlorhex\n vitamin K\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 12:06 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.6\nC (99.7\n HR: 71 (58 - 83) bpm\n BP: 147/68(85) {103/56(67) - 147/78(85)} mmHg\n RR: 22 (16 - 23) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,595 mL\n 2,076 mL\n PO:\n TF:\n 1,265 mL\n 838 mL\n IVF:\n 1,050 mL\n 418 mL\n Blood products:\n Total out:\n 2,265 mL\n 1,685 mL\n Urine:\n 2,265 mL\n 1,685 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,330 mL\n 391 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 452 (452 - 452) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 65\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///31/\n Ve: 11.9 L/min\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 : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Warm, No(t) Rash:\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, Following\n commands this morning. Not moving left arm or leg\n Labs / Radiology\n 10.4 g/dL\n 363 K/uL\n 162 mg/dL\n 0.5 mg/dL\n 31 mEq/L\n 3.3 mEq/L\n 15 mg/dL\n 106 mEq/L\n 143 mEq/L\n 30.4 %\n 16.5 K/uL\n [image002.jpg]\n 10:18 AM\n 01:17 AM\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n WBC\n 10.6\n 13.4\n 17.5\n 16.5\n Hct\n 32.0\n 34.5\n 32.9\n 30.4\n Plt\n 63\n Cr\n 0.5\n 0.6\n 0.7\n 0.5\n 0.5\n TCO2\n 32\n 35\n 33\n 31\n 32\n Glucose\n 159\n 113\n 112\n 129\n 146\n 175\n 162\n Other labs: PT / PTT / INR:19.9/35.8/1.9, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.1 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n Respiratory Failure: Is much more awake and alert today. Will try to\n extubate - is currently following commands and mouthing words.\n Fevers: Unclear source. on vanco/zosyn. Continue to follow up\n cultures.\n head trauma: Not moving left leg consistently, will let neurosurgery\n know.\n ICU Care\n Nutrition:\n ProBalance (Full) - 09:47 AM 70 mL/hour\n Glycemic Control:\n Lines:\n 18 Gauge - 06:37 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411918,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Alert, intubated for airway protection and awaiting for extubation this\n am, copious amount of whitish thick secretion. ? slowly improving\n mental status after head injury\n Action:\n Frequent pul toilet,\n Response:\n Continue have secretion, slowly improving MS\n :\n ? plan for possible extubation OR ?trach if extubation failed\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T max 101 rectal\n Action:\n Pan cultured, po Tylenol given continue antibiotics\n Response:\n Plan:\n Cooling blanket, po meds/ continue antibiotics, F/U culture results\n Altered mental status (not Delirium)\n Assessment:\n Alert, unable to assess orientation d/t oral ETT, following commands\n inconsistently. Continue lt side weakness, lt arm flaccid, no seizure\n activity,\n Action:\n Neuro assessment q 4hrs,\n Response:\n Slowly improving mental status\n Plan:\n Neuro surgery following,\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411925,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MIDLINE - START 02:00 PM\n BLOOD CULTURED - At 08:55 PM\n URINE CULTURE - At 08:56 PM\n BLOOD CULTURED - At 04:11 AM\n SPUTUM CULTURE - At 04:11 AM\n URINE CULTURE - At 04:11 AM\n FEVER - 101.1\nF - 08:00 AM\n Fever O/N - UCx, BCx and Sputum Cx sent. CXR done on rads rounds\n Mental status clearer - following some commands, opening eyes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 05:46 AM\n Vancomycin - 08:56 AM\n Piperacillin/Tazobactam (Zosyn) - 12:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:26 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 36.4\nC (97.5\n HR: 72 (60 - 78) bpm\n BP: 134/64(79) {96/55(67) - 152/91(104)} mmHg\n RR: 23 (19 - 27) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,634 mL\n 61 mL\n PO:\n TF:\n 888 mL\n IVF:\n 556 mL\n 61 mL\n Blood products:\n Total out:\n 2,920 mL\n 245 mL\n Urine:\n 2,920 mL\n 245 mL\n NG:\n Stool:\n Drains:\n Balance:\n -286 mL\n -184 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 435 (386 - 540) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 89\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: ///28/\n Ve: 6.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 453 K/uL\n 10.7 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.0 %\n 13.8 K/uL\n [image002.jpg]\n 01:20 AM\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n 05:02 PM\n 04:00 AM\n WBC\n 13.4\n 17.5\n 16.5\n 13.8\n Hct\n 34.5\n 32.9\n 30.4\n 32.0\n Plt\n 53\n Cr\n 0.6\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 35\n 33\n 31\n 32\n Glucose\n 113\n 112\n 129\n 146\n 175\n 162\n 117\n 110\n Other labs: PT / PTT / INR:15.4/31.1/1.4, Differential-Neuts:75.3 %,\n Lymph:16.9 %, Mono:2.2 %, Eos:4.7 %, Lactic Acid:1.1 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) now with tachypnea and difficulty protecting\n airway as well as fevers of unclear etiology.\n 1. Airway compromise: improved with oral airway, but unable to\n maintain patent airway due to mental status and was intubated on ;\n per neurosurgery, this may improve with time, but will likely be a slow\n improvement. Can consider extubation today as pt is more alert and\n able to communicate. If cannot extubate may need tracheostomy.\n - pulmonary toilet\n 2. Tachypnea: likely due to fevers and aspiration; no evidence of\n pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; d/c metronidazole as c.diff toxins\n neg x 2\n - NGTD for blood and urine cultures; continue to follow\n - consider LP to rule out CNS infection if fevers persist and workup\n remains unrevealing\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: resolved . increased free H2O in tube feeds\n 6. Coagulopathy: likely nutritional\n - PO vitamin K\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:00 PM\n 18 Gauge - 10:06 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": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411934,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury. He was\n intubated prior to transfer to on , and had an ICP Bolt\n monitor placed on (removed due to normal ICPs). His\n initial presentation was notable for left arm weakness found to be due\n to traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . Right subclavian CVL placed on and\n removed (tip culture negative to date). He spiked a fever >\n yesterday prompting an ID consult.\n After stay in T/SICU he was transferred to 11 and there was noted\n to have increasing tachypnea and loud upper airway sounds prompting\n concern that he wasn\nt protecting his airway, so he is transferred to\n the MICU for further management and intubated shortly after MICU\n admission.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt with K 5.8 yesterday, received Kayaxelate with repeat K 3.3. HR\n 60s-70s with occ PVC noted.\n Action:\n Pt given 20mEq KCL PO on this time.\n Response:\n Repeat K 3.7\n Plan:\n Continue to monitor electrolytes and telemetry.\n Altered mental status (not Delirium)\n Assessment:\n Pt is alert at times and is easily arousable to voice. He consistently\n follows commands on right side of body. Pt with some purposeful\n movement noted to left extremities, lower > upper. He does have\n sensation in all four extrems. PERL brisk.\n Action:\n MS assessed q4hour. ROM performed with pt especially in left side. Pt\n oriented frequently. Wrist restaints on to maintain patency of all\n lines.\n Response:\n MS appears to be improving, pt more alert than when first admitted to\n the unit.\n Plan:\n Continue to monitor MS. Reorient as needed.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP+PS which he has tolerated all day. RR 19-22, Sats\n 99-100%\n Action:\n Chest PT x3, pt frequently suctioned via ETT.\n Response:\n Moderate to large amounts of thin, clear secretions suctioned.\n Plan:\n Continue aggressive pulmonary toileting. ABG and ?extubation in AM.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt with rectal probe and febrile with Tmax 101.1 and Tcurrent 99.1.\n Action:\n Pt on and off cooling blanket as needed. 650mg Tylenol given. Pt on IV\n vanco and zosyn. Flagyl discontinued after stool (-) c.diff x2.\n Response:\n Pt\ns temp trending down while on cooling blanket and minimal effect of\n Tylenol. Blood cultures neg to date.\n Plan:\n Continue to monitor temp with rectal probe. Cooling blanket and Tylenol\n PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411935,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury. He was\n intubated prior to transfer to on , and had an ICP Bolt\n monitor placed on (removed due to normal ICPs). His\n initial presentation was notable for left arm weakness found to be due\n to traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . Right subclavian CVL placed on and\n removed (tip culture negative to date). He spiked a fever >\n yesterday prompting an ID consult.\n After stay in T/SICU he was transferred to 11 and there was noted\n to have increasing tachypnea and loud upper airway sounds prompting\n concern that he wasn\nt protecting his airway, so he is transferred to\n the MICU for further management and intubated shortly after MICU\n admission.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt with K 5.8 yesterday, received Kayaxelate with repeat K 3.3. HR\n 60s-70s with occ PVC noted.\n Action:\n Pt given 20mEq KCL PO on this time.\n Response:\n Repeat K 3.7\n Plan:\n Continue to monitor electrolytes and telemetry.\n Altered mental status (not Delirium)\n Assessment:\n Pt is alert at times and is easily arousable to voice. He consistently\n follows commands on right side of body. Pt with some purposeful\n movement noted to left extremities, lower > upper. He does have\n sensation in all four extrems. PERL brisk.\n Action:\n MS assessed q4hour. ROM performed with pt especially in left side. Pt\n oriented frequently. Wrist restaints on to maintain patency of all\n lines.\n Response:\n MS appears to be improving, pt more alert than when first admitted to\n the unit.\n Plan:\n Continue to monitor MS. Reorient as needed.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP+PS which he has tolerated all day. RR 19-22, Sats\n 99-100%\n Action:\n Chest PT x3, pt frequently suctioned via ETT.\n Response:\n Moderate to large amounts of thin, clear secretions suctioned.\n Plan:\n Continue aggressive pulmonary toileting. ABG and ?extubation in AM.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt with rectal probe and febrile with Tmax 101.1 and Tcurrent 99.1.\n Action:\n Pt on and off cooling blanket as needed. 650mg Tylenol given. Pt on IV\n vanco and zosyn. Flagyl discontinued after stool (-) c.diff x2.\n Response:\n Pt\ns temp trending down while on cooling blanket and minimal effect of\n Tylenol. Blood cultures neg to date.\n Plan:\n Continue to monitor temp with rectal probe. Cooling blanket and Tylenol\n PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Generic Note",
"row_id": 411661,
"text": "TITLE:\n Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management.\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-25 00:00:00.000",
"description": "Generic Note",
"row_id": 411662,
"text": "TITLE:\n Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Copius amts of oral & endotracheal secretions.\n Action:\n Oral & endotracheal suctioning done as needed. Fio2 reduced to 50%,\n ABG WNL. Mode changed to cpap+ PS.\n Response:\n Breathing well on PS. Maintaining sats\n Plan:\n Will repeat abg in am.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-Max 103.4 orally.\n Action:\n MD informed, pancultures not needed as this was done earlier during the\n day. Tylenol given, icepacks applied & started on cooling blanket.\n Response:\n Temp reduced to 99.9 Rectally, patient was shivering for few minutes,\n Switched off cooling blanket. Restarted after ~ 1.5 hours as rectal\n temp ^ to 101.\n Plan:\n Will continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411899,
"text": "Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412004,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury. He was\n intubated prior to transfer to on , and had an ICP Bolt\n monitor placed on (removed due to normal ICPs). His\n initial presentation was notable for left arm weakness found to be due\n to traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . Right subclavian CVL placed on and\n removed (tip culture negative to date). He spiked a fever >\n yesterday prompting an ID consult.\n After stay in T/SICU he was transferred to 11 and there was noted\n to have increasing tachypnea and loud upper airway sounds prompting\n concern that he wasn\nt protecting his airway, so he is transferred to\n the MICU for further management and intubated shortly after MICU\n admission.\n Events: No significant events overnight, haemodynamically stable,? call\n out to floors\n Altered mental status (not Delirium)\n Assessment:\n Tramautic brain injury following fall from ladder, more alert, unable\n to assess orientation, following commands inconsistently, sometimes no\n or very slow to follow commands. Lt arm no movement LLE moves on bed,\n speech garbled. PEARL 3mm, gag/cough intact. No seizure activity,\n continue on keppra\n Action:\n Neuron obs 4 hrs, reorientation,\n Response:\n MS waxing/, Non purposeful movements, following commands\n inconsistently, slowly improving MS\n :\n Monitor MS, continue on keppra\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Extubated, RR regular, cough and gag intact, able to swallow secretion\n Action:\n Encourage deep breathing and cough exercises, CPT\n Response:\n O2 sats 98-100% on 35% cool neb\n Plan:\n Continue monitor resp status, CPT and deep breathing and cough\n exercises as tolerated.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n A febrile all through out the shift\n Action:\n Continue antibiotics\n Response:\n A febrile,\n Plan:\n Tylenol prn, monitor labs, F/U culture results and continue antibiotics\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 411653,
"text": "Chief Complaint: tachypnea, fevers\n HPI:\n Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed ). His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 03:04 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:30 PM\n Other medications:\n - heparin 5000 units SC tid\n - bisacodyl\n - vancomycin 1000 mg IV q12h ( - )\n - piperacillin/tazobactam 4.5 grams q8h ( - )\n - pantoprazole 40 mg IV q24h\n - albuterol neb q6h prn\n - metoclopromide 10 mg PO qACHS\n - levetiracetam 500 mg (), then increase to 1000 mg \n Past medical history:\n Family history:\n Social History:\n Reportedly none\n Unable to obtain\n Occupation: construction worker\n Drugs: unknown\n Tobacco: unknown\n Alcohol: unknown\n Other:\n Review of systems:\n Psychiatric / Sleep: Delirious\n Flowsheet Data as of 07:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.7\nC (103.4\n Tcurrent: 38.8\nC (101.8\n HR: 81 (81 - 105) bpm\n BP: 147/77(94) {138/54(74) - 174/87(109)} mmHg\n RR: 18 (18 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,043 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n Blood products:\n Total out:\n 0 mL\n 954 mL\n Urine:\n 954 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,089 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CMV/ASSIST\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 35%\n PIP: 22 cmH2O\n SpO2: 100%\n Ve: 13.8 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 413 K/uL\n 152 mg/dL\n 0.7\n 20 mg/dL\n 25 mEq/L\n 114 mEq/L\n 3.7 mEq/L\n 150 mEq/L\n 38.0 %\n 14.4 K/uL\n [image002.jpg] INR 1.9\n Venous lactate 1.4\n Ca 8.9, Mg 2.4, Phos 3.7\n Imaging:\n CXR\n CT Neck\n CT angio chest\n CT abdomen/pelvis\n ECG: ECG\n Assessment and Plan\n 56 year old man with severe traumatic brain injury now with tachypnea\n and difficulty protecting airway as well as fevers of unclear etiology.\n 1. Airway compromise:\n 2. Tachypnea\n 3. Fevers\n 4. Traumatic brain injury\n 5. Hypernatremia\n ICU Care\n Nutrition: Tube feeds with free water boluses\n Lines: 20 Gauge - 04:51 PM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer:\n VAP: HOB elevation, Mouth care\n Need for restraints reviewed\n Communication: Family meeting held Comments: Daughter . \n (cell )\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411800,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Remains unchanged, inconsistently follows commands, moving all\n extremities---right side stronger then left, moving left hand up\n towards tubes---wrist restraint added to left wrist as well as right\n wrist, PEARL, easily arouseable all shift, withdraws to painful stimuli\n Action:\n Freq Neuro checks, reoriented prn, pt with restraint on right wrist to\n prevent pt from pulling at lines and tubes and restraint added to left\n wrist last night\n Response:\n Stable Neuro status at present, still inconsistent with alertness and\n ability to follow commands, left side remains weaker than right but\n able to move left are more than previous\n Plan:\n Continue to reorient, increase activity as tolerated, increase\n stimulation as tolerated, hold sedation\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 412000,
"text": "Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 412007,
"text": "Chief Complaint:\n 24 Hour Events:\n MIDLINE - START 02:00 PM\n BLOOD CULTURED - At 08:55 PM\n URINE CULTURE - At 08:56 PM\n BLOOD CULTURED - At 04:11 AM\n SPUTUM CULTURE - At 04:11 AM\n URINE CULTURE - At 04:11 AM\n FEVER - 101.1\nF - 08:00 AM\n Extubated yesterday. Did well. Was more alert and able to communicate\n with daughters and staff.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 05:46 AM\n Vancomycin - 07:44 PM\n Piperacillin/Tazobactam (Zosyn) - 11:39 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 02:40 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: 36.3\nC (97.4\n HR: 64 (61 - 75) bpm\n BP: 128/66(78) {113/59(73) - 146/77(94)} mmHg\n RR: 19 (18 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,185 mL\n 27 mL\n PO:\n TF:\n IVF:\n 940 mL\n 27 mL\n Blood products:\n Total out:\n 1,385 mL\n 50 mL\n Urine:\n 1,385 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -24 mL\n Respiratory support\n Extubated\n SpO2: 97%\n VBG: 7.42/48/28\n Physical Examination\n Gen: opens eyes spontaneously and to voice; inconsistently follow\n occasional simple commands\n Neck: Incision C,D,I. No induration or fluctuance\n Pulm: coarse bs bilat but improving\n CV: reg rhythm\n Neuro: grimaces to pain in left UE, moves/makes fist with RUE. Moves\n both feet, R>L.\n Labs / Radiology\n 464 K/uL\n 10.8 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.2 %\n 16.3 K/uL\n [image002.jpg]\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n 05:02 PM\n 04:00 AM\n 07:56 AM\n WBC\n 13.4\n 17.5\n 16.5\n 13.8\n Hct\n 34.5\n 32.9\n 30.4\n 32.0\n Plt\n 53\n Cr\n 0.6\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 31\n 32\n 32\n Glucose\n 113\n 112\n 129\n 146\n 175\n 162\n 117\n 110\n Other labs: PT / PTT / INR:15.4/31.1/1.4, Differential-Neuts:75.3 %,\n Lymph:16.9 %, Mono:2.2 %, Eos:4.7 %, Lactic Acid:0.9 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) who was transferred to the MICU for tachypnea\n and difficulty protecting airway in the setting of fevers of unclear\n etiology. Was intubated on ; extubated on .\n 1. Airway compromise: improved with oral airway, but unable to\n maintain patent airway due to mental status and was intubated on ;\n per neurosurgery, this may improve with time, but will likely be a slow\n improvement. Extubated successfully on \n - pulmonary toilet\n 2. Tachypnea: resolved. Was likely due to fevers and aspiration; no\n evidence of pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; d/c metronidazole as c.diff toxins\n neg\n - NGTD for blood and urine cultures; continue to follow\n - Sputum from showed hemophilus (beta lactam neg) as well as GPC\n in pairs. Culture from shows only GPC in pairs.\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: resolved . increased free H2O in tube feeds\n 6. Coagulopathy: likely nutritional, improving. INR 1.4 yesterday;\n pending today\n - PO vitamin K\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:00 PM\n 18 Gauge - 10:06 PM\n Prophylaxis:\n DVT: subq heparin; pneumo boots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411654,
"text": "56 year old male admitted after witnessed foot fall from ladder\n and hit head on dumpster while falling, +LOC, GCS 3 on site when EMS\n arrived, intubated in the field for airway protection. Head CT showed\n skull fracture and many SDH. Admitted to T/SICU and then to 11,\n neuro step-down. Pt on 11, when noticed to have increased RR and\n laborred and less responsive than he had been, although pt had not \n very responsive prior to today. ABG 7.44/44/85. Pt transferred to MICU\n 6 with hypoxia and for further management of care.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt with tachypneic, labored breathing on 35% cool neb face tent with RR\n 20s-30s and sats 95-98%. Congested cough. LS rhonchi bilat.\n Action:\n Chest PT done and attempted to get pt to cough, deep suctioned for\n small amounts of blood tinged secretions suctioned. Pt\ns breathing did\n become more labored, but never desatted. Pt intubated at 1800,\n AC/600x14/5peep.\n Response:\n Pt RR and Sats now WNL and pt looks much more comfortable since\n intubation.\n Plan:\n Continue to monitor resp status, suction as needed.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 103.6 rectally and pt very warm to touch.\n Action:\n Given fluid bolus 1500cc, 650mg Tylenol PO, pancultured\n Response:\n Pt temp down to 101.2 Rectally.\n Plan:\n Continue to trend temp, Tylenol PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411802,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Remains unchanged, inconsistently follows commands, moving all\n extremities---right side stronger then left, moving left hand up\n towards tubes---wrist restraint added to left wrist as well as right\n wrist, PEARL, easily arouseable all shift, withdraws to painful\n stimuli, no seizure activity\n Action:\n Freq Neuro checks, reoriented prn, pt with restraint on right wrist to\n prevent pt from pulling at lines and tubes and restraint added to left\n wrist last night\n Response:\n Stable Neuro status at present, still inconsistent with alertness and\n ability to follow commands, left side remains weaker than right but\n able to move left arm more than previous\n Plan:\n Continue to reorient, increase activity as tolerated, increase\n stimulation as tolerated, hold sedation, continue anti-seizure meds.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Tolerating CPAP+PS, Copious secretions requiring freq. ETtube\n suctioning, Lungs clear bilat upper lobes and diminished at bases,\n bites ETtube and Yankaur with suctioning attempts\n Action:\n CPT x 2, ETtube suctioning Q2hr, oral Suction Q2hr, maintained vent\n settings with Sats >98%, CXR done and pending, ABG to be sent\n Response:\n RR= 14-20, nonlabored on CPAP+PS, Sats good, Tolerating and requiring\n freq. pulmonary toiletting\n Plan:\n Continue aggressive pulmonary toileting, wean vent as tolerated,\n possible trach in near future d/t labile neuro\n status\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Fevers continue---? If neurological vs. infection?, Tmax= 100.7\n rectally\n Action:\n Remains on vanco, zosyn, and flagyl, WBC pending from this am, Tylenol\n for Temps, cooling blanket off since MN, stool sent for C.diff\n Response:\n Good response from Tylenol with pt afebrile for short period of time,\n no high temp spikes while off of cooling blanket\n Plan:\n Continue antibx as ordered, await culture results, If cultures neg then\n MICU team to proceed to LP, Tylenol and cooling blankets for high\n temps. Address with Neuro if temp is related to neuro injury. If\n needs long-term antibx therapy will need long-term IV access (ie: PICC)\n Electrolyte & fluid disorder, other\n Assessment:\n K= 5.8 , occasional PVC\ns noted\n Action:\n Kaexylate x 1 with pt stooling and K down to 3.6 with new K level\n pending\n Response:\n Good effect from kaexylate\n Plan:\n Continue to monitor fluid and electrolytes and replace prn\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411803,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury who is now\n transferred to the MICU with worsening tachypnea and fevers of unclear\n etiology. He was intubated prior to transfer to on , and\n had an ICP Bolt monitor placed on (removed due to normal\n ICPs); he received cefazolin while the Bolt was in place. His initial\n presentation was notable for left arm weakness found to be due to\n traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . He spiked a fever > yesterday prompting\n an ID consult.\n .\n Of note, he had a right subclavian CVL placed on and removed\n (tip culture negative to date).\n He was noted to have increasing tachypnea and loud upper airway sounds\n prompting concern that he wasn\nt protecting his airway, so he is\n transferred to the MICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Remains unchanged, inconsistently follows commands, moving all\n extremities---right side stronger then left, moving left hand up\n towards tubes---wrist restraint added to left wrist as well as right\n wrist, PEARL, easily arouseable all shift, withdraws to painful\n stimuli, no seizure activity\n Action:\n Freq Neuro checks, reoriented prn, pt with restraint on right wrist to\n prevent pt from pulling at lines and tubes and restraint added to left\n wrist last night\n Response:\n Stable Neuro status at present, still inconsistent with alertness and\n ability to follow commands, left side remains weaker than right but\n able to move left arm more than previous\n Plan:\n Continue to reorient, increase activity as tolerated, increase\n stimulation as tolerated, hold sedation, continue anti-seizure meds.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Tolerating CPAP+PS, Copious secretions requiring freq. ETtube\n suctioning, Lungs clear bilat upper lobes and diminished at bases,\n bites ETtube and Yankaur with suctioning attempts\n Action:\n CPT x 2, ETtube suctioning Q2hr, oral Suction Q2hr, maintained vent\n settings with Sats >98%, CXR done and pending, ABG to be sent\n Response:\n RR= 14-20, nonlabored on CPAP+PS, Sats good, Tolerating and requiring\n freq. pulmonary toiletting\n Plan:\n Continue aggressive pulmonary toileting, wean vent as tolerated,\n possible trach in near future d/t labile neuro\n status\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Fevers continue---? If neurological vs. infection?, Tmax= 100.7\n rectally\n Action:\n Remains on vanco, zosyn, and flagyl, WBC = 16.5 this am, Tylenol for\n Temps, cooling blanket off since MN, stool sent for C.diff\n Response:\n Good response from Tylenol with pt afebrile for short period of time,\n no high temp spikes while off of cooling blanket\n Plan:\n Continue antibx as ordered, await culture results, If cultures neg then\n MICU team to proceed to LP, Tylenol and cooling blankets for high\n temps. Address with Neuro if temp is related to neuro injury. If\n needs long-term antibx therapy will need long-term IV access (ie: PICC)\n Electrolyte & fluid disorder, other\n Assessment:\n K= 5.8 , occasional PVC\ns noted\n Action:\n Kaexylate x 1 with pt stooling and K down to 3.6 with new K level\n pending\n Response:\n Good effect from kaexylate\n Plan:\n Continue to monitor fluid and electrolytes and replace prn\n"
},
{
"category": "Physician ",
"chartdate": "2156-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411989,
"text": "Chief Complaint:\n 24 Hour Events:\n MIDLINE - START 02:00 PM\n BLOOD CULTURED - At 08:55 PM\n URINE CULTURE - At 08:56 PM\n BLOOD CULTURED - At 04:11 AM\n SPUTUM CULTURE - At 04:11 AM\n URINE CULTURE - At 04:11 AM\n FEVER - 101.1\nF - 08:00 AM\n Extubated yesterday. Did well. Was more alert and able to communicate\n with daughters and staff.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 05:46 AM\n Vancomycin - 07:44 PM\n Piperacillin/Tazobactam (Zosyn) - 11:39 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 02:40 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: 36.3\nC (97.4\n HR: 64 (61 - 75) bpm\n BP: 128/66(78) {113/59(73) - 146/77(94)} mmHg\n RR: 19 (18 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,185 mL\n 27 mL\n PO:\n TF:\n IVF:\n 940 mL\n 27 mL\n Blood products:\n Total out:\n 1,385 mL\n 50 mL\n Urine:\n 1,385 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -24 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 363 (330 - 435) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 89\n SpO2: 97%\n ABG: 7.45/45/90./28/6\n Ve: 9.6 L/min\n PaO2 / FiO2: 257\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 453 K/uL\n 10.7 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.0 %\n 13.8 K/uL\n [image002.jpg]\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n 05:02 PM\n 04:00 AM\n 07:56 AM\n WBC\n 13.4\n 17.5\n 16.5\n 13.8\n Hct\n 34.5\n 32.9\n 30.4\n 32.0\n Plt\n 53\n Cr\n 0.6\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 31\n 32\n 32\n Glucose\n 113\n 112\n 129\n 146\n 175\n 162\n 117\n 110\n Other labs: PT / PTT / INR:15.4/31.1/1.4, Differential-Neuts:75.3 %,\n Lymph:16.9 %, Mono:2.2 %, Eos:4.7 %, Lactic Acid:0.9 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:00 PM\n 18 Gauge - 10:06 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": "2156-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 411990,
"text": "Chief Complaint:\n 24 Hour Events:\n MIDLINE - START 02:00 PM\n BLOOD CULTURED - At 08:55 PM\n URINE CULTURE - At 08:56 PM\n BLOOD CULTURED - At 04:11 AM\n SPUTUM CULTURE - At 04:11 AM\n URINE CULTURE - At 04:11 AM\n FEVER - 101.1\nF - 08:00 AM\n Extubated yesterday. Did well. Was more alert and able to communicate\n with daughters and staff.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 05:46 AM\n Vancomycin - 07:44 PM\n Piperacillin/Tazobactam (Zosyn) - 11:39 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 02:40 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: 36.3\nC (97.4\n HR: 64 (61 - 75) bpm\n BP: 128/66(78) {113/59(73) - 146/77(94)} mmHg\n RR: 19 (18 - 30) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,185 mL\n 27 mL\n PO:\n TF:\n IVF:\n 940 mL\n 27 mL\n Blood products:\n Total out:\n 1,385 mL\n 50 mL\n Urine:\n 1,385 mL\n 50 mL\n NG:\n Stool:\n Drains:\n Balance:\n -200 mL\n -24 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 363 (330 - 435) mL\n PS : 5 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 89\n SpO2: 97%\n ABG: 7.45/45/90./28/6\n Ve: 9.6 L/min\n PaO2 / FiO2: 257\n Physical Examination\n Gen: opens eyes spontaneously and to voice; able to follow occasional\n simple commands\n Neck: Incision C,D,I. No induration or fluctuance\n Pulm: coarse bs bilat but improving\n CV: reg rhythm\n Neuro: grimaces to pain in left UE, moves/makes fist with RUE. Moves\n both feet, R>L.\n Labs / Radiology\n 453 K/uL\n 10.7 g/dL\n 110 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 16 mg/dL\n 107 mEq/L\n 145 mEq/L\n 32.0 %\n 13.8 K/uL\n [image002.jpg]\n 02:06 AM\n 02:21 AM\n 08:20 PM\n 03:18 AM\n 03:30 AM\n 04:03 PM\n 03:44 AM\n 05:02 PM\n 04:00 AM\n 07:56 AM\n WBC\n 13.4\n 17.5\n 16.5\n 13.8\n Hct\n 34.5\n 32.9\n 30.4\n 32.0\n Plt\n 53\n Cr\n 0.6\n 0.7\n 0.5\n 0.5\n 0.6\n 0.6\n TCO2\n 33\n 31\n 32\n 32\n Glucose\n 113\n 112\n 129\n 146\n 175\n 162\n 117\n 110\n Other labs: PT / PTT / INR:15.4/31.1/1.4, Differential-Neuts:75.3 %,\n Lymph:16.9 %, Mono:2.2 %, Eos:4.7 %, Lactic Acid:0.9 mmol/L,\n Albumin:3.6 g/dL, Ca++:8.6 mg/dL, Mg++:2.2 mg/dL, PO4:3.8 mg/dL\n Assessment and Plan\n 56 year old man with severe traumatic brain injury (left basilar skull\n fx w/ right SDH and SAH) now with tachypnea and difficulty protecting\n airway as well as fevers of unclear etiology.\n 1. Airway compromise: improved with oral airway, but unable to\n maintain patent airway due to mental status and was intubated on ;\n per neurosurgery, this may improve with time, but will likely be a slow\n improvement. Can consider extubation today as pt is more alert and\n able to communicate. If cannot extubate may need tracheostomy.\n - pulmonary toilet\n - An ABG this morning is reassuring for extubation\n 2. Tachypnea: resolved. Was likely due to fevers and aspiration; no\n evidence of pneumonitis/pneumonia on chest imaging; ABG wnl\n - fever control\n 3. Fevers: source unclear; diarrhea raises concern for C Diff; CT scan\n with fluid collection at wound but, per neurosurgery, it appears\n consistent with post-operative change\n - appreciate ID recs\n - cont empiric vanco and pip/tazo; d/c metronidazole as c.diff toxins\n neg\n - NGTD for blood and urine cultures; continue to follow\n - Sputum from showed hemophilus as well as GPC in pairs. Culture\n from shows only GPC in pairs.\n 4. Traumatic brain injury:\n - cont levetiracetam for seizure prophylaxis\n 5. Hypernatremia: resolved . increased free H2O in tube feeds\n 6. Coagulopathy: likely nutritional, improving. INR 1.4\n - PO vitamin K\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:00 PM\n 18 Gauge - 10:06 PM\n Prophylaxis:\n DVT: subq heparin; pneumo boots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411981,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury. He was\n intubated prior to transfer to on , and had an ICP Bolt\n monitor placed on (removed due to normal ICPs). His\n initial presentation was notable for left arm weakness found to be due\n to traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . Right subclavian CVL placed on and\n removed (tip culture negative to date). He spiked a fever >\n yesterday prompting an ID consult.\n After stay in T/SICU he was transferred to 11 and there was noted\n to have increasing tachypnea and loud upper airway sounds prompting\n concern that he wasn\nt protecting his airway, so he is transferred to\n the MICU for further management and intubated shortly after MICU\n admission.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and opening eyes spontaneously. Pt inconsistently following\n commands. Sensation in all four extremities, minimal movement noted on\n pt\ns left side. PERL brisk, he tracks to movement in the room.\n Impaired gag, strong cough. Pt speaking, but occ speak is garbled and\n pt\ns conversation does not always make sense.\n Action:\n Q4hour neuro checks. Frequently reoriented. Family in to see pt today.\n Response:\n Pt smiling with family at bedside and was interacting with them,\n although he was not always making sense with his conversation.\n Plan:\n Continue to q4hour neuron checks. Reorient pt as needed.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt received intubated CPAP+PS with small to moderate amounts of thin\n clear secretions. ABG 7.45/45/90. Strong cough, impaired gag.\n Action:\n Chest PT x3. Pt extubated at 1230.\n Response:\n He has been clearing his own secretions, and has been observed\n swallowing his oral secretions with no evidence of aspiration. OOB to\n chair with complete help from Physical Therapy and maintaining sats 99%\n on 2L NC.\n Plan:\n Continue with supplemental O2. Encourage pt to deep breath and cough.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 99.8 rectally.\n Action:\n Pt given 650mg PO Tylenol x1. Pt on IV vanco and zosyn.\n Response:\n Tcurrent 97.5 axillary.\n Plan:\n Continue with IV antibiotics, trend temp.\n Activity Intolerance\n Assessment:\n Pt with minimal spontaneous movement noted on left side. RUE with\n normal strength and Right leg pt can lift and hold.\n Action:\n Pt repositioned frequently prior to extuabtion. PT met with pt and got\n him OOB to stretcher chair via slide board. Per PT, pt unable to sit\n on side of bed unsupported.\n Response:\n Pt tolerating chair well.\n Plan:\n Continue with repositioning while is bed. Pt OOB to stretcher chair as\n he tolerates.\n"
},
{
"category": "Nursing",
"chartdate": "2156-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 411883,
"text": "Mr. . is a 56 year old man with no known past medical history\n who originally presented to on following a fall from a\n ladder with subsequent occipital bone basilar skull fracture, subdural\n hematoma, subarachnoid hematoma and contra-coup brain injury. He was\n intubated prior to transfer to on , and had an ICP Bolt\n monitor placed on (removed due to normal ICPs). His\n initial presentation was notable for left arm weakness found to be due\n to traumatic C3-C4 cervical disc herniation with resultant cord\n compression. He underwent anterior discectomy and fusion on \n and his post-operative course has been complicated by fevers of unclear\n source beginning on . Initial cultures revealed one out of four\n blood culture bottles growing coagulase-negative Staph, and he was put\n on vancomycin on . Right subclavian CVL placed on and\n removed (tip culture negative to date). He spiked a fever >\n yesterday prompting an ID consult.\n After stay in T/SICU he was transferred to 11 and there was noted\n to have increasing tachypnea and loud upper airway sounds prompting\n concern that he wasn\nt protecting his airway, so he is transferred to\n the MICU for further management and intubated shortly after MICU\n admission.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt with K 5.8 yesterday, received Kayaxelate with repeat K 3.3. HR\n 60s-70s with occ PVC noted.\n Action:\n Pt given 20mEq KCL PO on this time.\n Response:\n Repeat K\n Plan:\n Continue to monitor electrolytes and telemetry.\n Altered mental status (not Delirium)\n Assessment:\n Pt is alert at times and is easily arousable to voice. He consistently\n follows commands on right side of body. Pt with some purposeful\n movement noted to left extremities, lower > upper. He does have\n sensation in all four extrems. PERL brisk.\n Action:\n MS assessed q4hour. ROM performed with pt especially in left side. Pt\n oriented frequently. Wrist restaints on to maintain patency of all\n lines.\n Response:\n MS appears to be improving, pt more alert than when first admitted to\n the unit.\n Plan:\n Continue to monitor MS. Reorient as needed.\n Airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Pt intubated on CPAP+PS which he has tolerated all day. RR 19-22, Sats\n 99-100%\n Action:\n Chest PT x3, pt frequently suctioned via ETT.\n Response:\n Moderate to large amounts of thin, clear secretions suctioned.\n Plan:\n Continue aggressive pulmonary toileting. ABG and ?extubation in AM.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Pt with rectal probe and febrile with Tmax 101.1 and Tcurrent 99.1.\n Action:\n Pt on and off cooling blanket as needed. 650mg Tylenol given. Pt on IV\n vanco and zosyn. Flagyl discontinued after stool (-) c.diff x2.\n Response:\n Pt\ns temp trending down while on cooling blanket and minimal effect of\n Tylenol. Blood cultures neg to date.\n Plan:\n Continue to monitor temp with rectal probe. Cooling blanket and Tylenol\n PRN.\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-08-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411978,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n 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 / Moderate\n Plan\n Comments: Pt received on PSV 5/5 as noted\n pt tolerating well. BS\n rhonchi throughout which clears with suctioning. Pt has a positive\n cuff leak test. Pt extubated to cool aerosol without incident.\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-08-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 411648,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Elective\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type: Standard\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: 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 / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt intubated due to increased Respiratory distress. Pt unable to\n protect airway. No other changes noted.\n"
}
] |
13,289 | 165,604 | The patient was admitted on and taken to the operating room for takedown of her ileostomy and ileocolic anastomosis. She tolerated the procedure well with minimal blood loss and was transferred to the PACU and then the floor. While on the floor she began having fevers and tachycardia on POD 1. Blood cultures were sent with one bottle out of four returning positive for MRSA. She was transferred to the ICU for closer monitoring and fluid resucitation. She recovered three days later with respect to her tachycardia and was afebrile after 3 days of vancomycin. Back on the floor she was found to have an ileus with abdominal distension. We placed an NGT for decompression and kept her NPO. On POD 7 she was started on clears and was advanced to a regular diet over the next two days. We noted that her surgical wound was draining some serosanguinous fluid, so we opened up 3-4 staples and packed the wound with a wet to dry dressing. She was discharged with VNA for care of this wound as well as her ileostomy wounds on POD 10. | Again note is made of right-sided pleural effusion, markedly decreased compared to the prior chest X-ray. IMPRESSION: Marked decrease of the right-sided pleural effusion with possible underlying consolidation compared to the chest X-ray in Septmeber. c/o vague chest discomfort w/ respiration. There is a trace left-sided pleural effusion. Specifically, there is prominence of the transverse and splenic flexures of the colon, although these areas are no frankly dilated. The visualized abdominal vasculature appears patent. pt had ileostomy takedown and ileocolonic anastomosis. NO BS .INCISION C STAPLES ,TWO OPEN ARIAS TO THE SIDE PACKED C SALINE GAUZE .SM AMT SEROUS DRAINAGE .PAIN CONTROL C PCA .AMBULATED IN ROOM X3 C ASSIST OF 2 PEOPLEHUO 50 TO 100CC VIA FOLEY .ALERT,ORIENTED COOPERATIVE . SICU NPN addendumdsg changed, staples well approximated, d/i. Non-specific bowel gas pattern as described, more likely ileus than bowel obstructions. SICU NPNS: " I think the pain is better"O: see carevue for all objective datacv: HR 112-130 sr, no vea, bp 100-130/64-72, CVP 2-5.resp: SATS 96-100% on RA, RR 14-20. lung sounds coarse. Pt admitted to for Ileostomy take down. Free fluid in the abdomen, likely post-operative 4. Wet -> dry dsg done, DSD to staples incision. There is a right pleural effusion with associated atelectasis at the right base unchanged since the prior film of the same date. Lungs with scattered rhonchi. Midline incision intact with small amount of serosang drainage. Residual thymic tissue. Incidental note is made gaseous distention of the splenic flexure of the colon. hypoactive BS. Right subclavian CV line is distal SVC. There is anterior mediastinal soft tissue extending along the prevascular space, most consistent with residual thymic tissue given the patient's age. serosanguinous drainage. Skin staples are seen along the midline, as well as two defects along the right anterior abdomen consistent with prior ostomies. CT of chest neg for PE, + RLL pneumonia with LLlobe atelectasis.CV: S.Tachycardia without ectopy noted. Denies nausea.O. Pt developed ischemic bowel and an ileostomy/colostomy placed. A surgical anastomosis is noted in the right mid abdomen. K:3.6,Mg:1.7-repleated. CT PELVIS W/IV CONTRAST: There is an enlarged uterus with multiple large degenerated low attenuation fibroids. While on the floor the pt became febrile 102.6, tachycardic 140-150s and lethargic with severe abd tenderness-pt sent for stat ct chest and abd and transfered to CCU.Neuro: Pt lethargic, responds to verbal stimuli and responds appropriately to questions. Neuro a/o x3 mae fccvs HR 128-107 ST without ectopy K+ 3.6 tx with 40 meq kcl IV, mag 1.7 tx with 2 amp mag sulf, bp 113/76-135/83, hct 36.4 skin w+d pp+3Resp lungs cta diminished bases using incentive spirometer coughing attempting deep breathinggi abd tender incision clean staples in place scant lower third incision BS+ no stool, alt 8 ast 15, ldh 142, amylase 59, total bili .4. A Foley is present within the bladder along with air seen anteriorlly, likely within the bladder, consistent with recent manipulation. +pulses to lower ext, pneumatic boots on.GI/GU: Abd with diffuse tenderness to all quadrants, no perf or leak noted on CT scan. Finding consistent with right lower lobe pneumonia. 9:16 PM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: assess for PE Admitting Diagnosis: OSTOMY/SDA Field of view: 32 Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 31F POD 1 s/p takedown ileostomy with tachycardia (140's), hypoxia, not responsive to fluid, normal hematocrit REASON FOR THIS EXAMINATION: assess for PE No contraindications for IV contrast FINAL REPORT INDICATION: Post-operative day 1, status-post take-down ileostomy, with tachycardia, hypoxia, not responsive to fluid. There is an NG tube noted with the tip in the body of the stomach. (Over) 9:16 PM CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST Reason: assess for PE Admitting Diagnosis: OSTOMY/SDA Field of view: 32 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) IMPRESSION 1. SBP 120-140/70s, CVP 3-4, IV LR @ 150/hr with fluid boluses, max temp 102.6 pan cx and tylenol given. The rectum and sigmoid are collapsed. There is moderate dilatation of multiple small bowel loops, the largest approximately 4.7 cm. NGT to LIS draining clear fluid-minimal amounts. IMPRESSION: Lungs now grossly clear on this single AP film. There is extensive patchy and more confluent areas of consolidation in the right lower lobe with an associated small pleural effusion. d/c foley Pt has a hx of appendectomy in with multiple complications postoperatively. The bronchi are patent to the segmental level bilaterally. Note is made of a small amount of respiratory motion artifact. Curvilinear calcifications in the pelvis correlate with calcified fibroids seen on the prior CT scans. Skin staples overlie the midline of the lower abdomen/upper pelvis. Follows commands well and moves all ext weakly. No productive cough noted. Using PCA pump 1-2 mg mso4/hr, with some relief, needs encouragement to use regularly.gu: LR infusing 150cc/hr, uo >100cc/hr, currently ~ even.id: tm 99.8 orally, now 98.9. on levo, flagyl, vanco. surgery for exploration: source of sepsis. The bowel gas pattern is nonspecific. There is a moderate amount of free fluid distributed throughout the abdomen, without focal abscess identified. There is interval improvement in aeration in the right lung base. | 11 | [
{
"category": "Radiology",
"chartdate": "2103-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848618,
"text": " 2:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R sc Line pulled back\n Admitting Diagnosis: OSTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with s/p ileostomy takedown\n\n REASON FOR THIS EXAMINATION:\n R sc Line pulled back\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n History of ileostomy takedown.\n\n Right subclavian CV line is distal SVC. No pneumothorax. The heart size is\n normal. There is a right pleural effusion with associated atelectasis at the\n right base unchanged since the prior film of the same date.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-11-13 00:00:00.000",
"description": "CTA CHEST W&W/O C &RECONS",
"row_id": 848535,
"text": " 9:16 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: assess for PE\n Admitting Diagnosis: OSTOMY/SDA\n Field of view: 32 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31F POD 1 s/p takedown ileostomy with tachycardia (140's), hypoxia, not\n responsive to fluid, normal hematocrit\n REASON FOR THIS EXAMINATION:\n assess for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post-operative day 1, status-post take-down ileostomy, with\n tachycardia, hypoxia, not responsive to fluid.\n\n COMPARISON: There are no prior studies for comparison.\n\n TECHNIQUE: Multidetector CT scanning of the chest, abdomen, and pelvis was\n performed following administration of 150 cc of Optiray contrast. Noncontrast\n images through the chest were also obtained.\n\n CTA CHEST W/ & W/O IV CONTRAST: The pulmonary arteries demonstrate no filling\n defects to suggest pulmonary embolism. Note is made of a small amount of\n respiratory motion artifact. The heart, pericardium, and great vessels are\n unremarkable. There is anterior mediastinal soft tissue extending along\n the prevascular space, most consistent with residual thymic tissue given\n the patient's age. There is an NG tube noted with the tip in the body of the\n stomach. There is extensive patchy and more confluent areas of consolidation\n in the right lower lobe with an associated small pleural effusion. There is a\n trace left-sided pleural effusion. The left lung is otherwise clear. The\n bronchi are patent to the segmental level bilaterally. There are no\n pathologically enlarged areas of adenopathy.\n\n CT ABDOMEN W/IV CONTRAST: The liver, spleen, kidneys, adrenals, ureters,\n gallbladder, are unremarkable. Skin staples are seen along the midline, as\n well as two defects along the right anterior abdomen consistent with prior\n ostomies. There is a trace amount of free air, likely post-operative. There\n is a moderate amount of free fluid distributed throughout the abdomen,\n without focal abscess identified. A surgical anastomosis is noted in the right\n mid abdomen. The visualized loops of large and small bowel are not distended,\n but grossly unremarkable. The visualized abdominal vasculature appears patent.\n\n CT PELVIS W/IV CONTRAST: There is an enlarged uterus with multiple\n large degenerated low attenuation fibroids. A Foley is present within the\n bladder along with air seen anteriorlly, likely within the bladder, consistent\n with recent manipulation. The rectum and sigmoid are collapsed. There is a\n small amount of free pelvic fluid. There is no pelvic or inguinal\n lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions.\n (Over)\n\n 9:16 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: assess for PE\n Admitting Diagnosis: OSTOMY/SDA\n Field of view: 32 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION\n 1. Finding consistent with right lower lobe pneumonia.\n 2. No evidence of pulmonary embolism.\n 3. Free fluid in the abdomen, likely post-operative\n 4. No definite abnormalities in the bowel given lack of oral contrast.\n 5. Multiple large degenerated fibroids.\n 6. Residual thymic tissue.\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-11-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 848540,
"text": " 12:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumothorax\n Admitting Diagnosis: OSTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old woman with pneumothorax.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n The comparison is made with the prior chest radiograph dated .\n\n FINDINGS: Again note is made of right IJ line, terminating in the junction of\n SVC and right atrium. NG tube is terminating in the left upper quadrant. No\n evidence of pneumothorax is noted. The heart is normal in size, the\n mediastinal and hilar contours are within normal limit. Again note is made of\n right-sided pleural effusion, markedly decreased compared to the prior chest\n X-ray. No evidence of new consolidation is noted.\n\n IMPRESSION: Marked decrease of the right-sided pleural effusion with possible\n underlying consolidation compared to the chest X-ray in Septmeber. No evidence\n of pneumothorax on this chest radiograph. The precise evaluation and the\n discussion of the chest, please refer to the report of chest, abdomen, and\n pelvic CT taken .\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 849043,
"text": " 4:31 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: assess for effusions\n Admitting Diagnosis: OSTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with s/p ileostomy takedown\n\n REASON FOR THIS EXAMINATION:\n assess for effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Effusion follow up.\n\n PORTABLE CHEST: Comparison is made to film from four days earlier. The\n central line has been removed. The tip of the NG tube is in the stomach. The\n cardiac and mediastinal contours are stable. There is interval improvement in\n aeration in the right lung base. The lungs now appear clear. No definite\n effusion is seen on this single view. Incidental note is made gaseous\n distention of the splenic flexure of the colon.\n\n IMPRESSION: Lungs now grossly clear on this single AP film.\n\n"
},
{
"category": "ECG",
"chartdate": "2103-11-13 00:00:00.000",
"description": "Report",
"row_id": 105460,
"text": "Sinus tachycardia\nQ-Tc interval appears prolonged but is difficult to measure\nDiffuse nonspecific ST-T wave abnormalities\nClinical correlation is suggested for possible in part metabolic/drug effect\nSince previous tracing of , further ST-T wave changes present\n\n"
},
{
"category": "Radiology",
"chartdate": "2103-11-18 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 849046,
"text": " 6:52 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: assess for ileus, please perform as soon as possible\n Admitting Diagnosis: OSTOMY/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old woman with\n REASON FOR THIS EXAMINATION:\n assess for ileus, please perform as soon as possible\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal distention, assess for ileus.\n\n ABDOMINAL FILMS: There are no prior films for comparison. An NG tube tip is\n in the stomach. Surgical suture wires are present in the right mid-abdomen.\n Skin staples overlie the midline of the lower abdomen/upper pelvis.\n\n No soft tissue masses are seen. Curvilinear calcifications in the pelvis\n correlate with calcified fibroids seen on the prior CT scans.\n\n The bowel gas pattern is nonspecific. The abdomen is filled with multiple\n prominent air filled loops of large and small bowel. Specifically, there is\n prominence of the transverse and splenic flexures of the colon, although these\n areas are no frankly dilated. There is moderate dilatation of multiple small\n bowel loops, the largest approximately 4.7 cm. In view of the amount of large\n bowel air that is present, findings may reflect ileus. Upright view\n demonstrates numerous air fluid levels in both large and small bowel. Note\n that it does not allow assessment for free intraperitonal air.\n\n IMPRESSION: 1. Non-specific bowel gas pattern as described, more likely ileus\n than bowel obstructions. Follow up films may be obtained as clinically\n indicated.\n\n 2. Note that the upright view does not allow adequate assessment for free\n air.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-11-14 00:00:00.000",
"description": "Report",
"row_id": 1435715,
"text": "SICU NPN addendum\ndsg changed, staples well approximated, d/i. 2 incisions,each ~ 1.5 cm deep x 3cm wide, w/ sm amt. serosanguinous drainage. Wet -> dry dsg done, DSD to staples incision. Per team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-11-15 00:00:00.000",
"description": "Report",
"row_id": 1435716,
"text": "S. Will they take my foley or ngt out? Denies nausea.\nO. Neuro a/o x3 mae fc\ncvs HR 128-107 ST without ectopy K+ 3.6 tx with 40 meq kcl IV, mag 1.7 tx with 2 amp mag sulf, bp 113/76-135/83, hct 36.4 skin w+d pp+3\nResp lungs cta diminished bases using incentive spirometer coughing attempting deep breathing\ngi abd tender incision clean staples in place scant lower third incision BS+ no stool, alt 8 ast 15, ldh 142, amylase 59, total bili .4. NGT LCS bilious 250cc output\nPain on pca morphine 1mg q 6 lockout 10mg needs to be encouraged to use, pain , splinting taking 1-2mg q hr\nID anaerobic bld cx gm + cocci in clusters and pairs aerobic bottle still pnding temp max 101, wbc 13.2 on flagyl, levofloxacin and vanco, MRSA isolated nares\nGU on LR at 150cc qhr u/o > 30cc +1090 mn to 0600, bun 5 cr .6\naccess ltan 18g, multlumen rsc\na. s/p takedown and ileocolic anastomosis, episode fever tachycardia with +bld culture anaerobic gm + cocci in clusters and pairs, Rt pleural effusion atelectasis\np. encourage use pain med increase mobility and decrease splinting incentive spirometer 10x q hr oob to chair today\nawait sensitivities bld cx, antibx, monitor wbc, temp,\n? d/c foley\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-11-15 00:00:00.000",
"description": "Report",
"row_id": 1435717,
"text": "31 YR OLD SP APPENDECTOMY COMPLICATED BY ISCHEMIC BOWEL REQUIRING ILEOSTOMY ,NOW SP REVERSAL OF ILEOSTOMY MONDAY .PT SPIKED TEMP 102 WENESDAY , POS BLD CX .ON TRIPLE ANTIBX ,MUCH IMPROVED ,READY FOR TRANSFER .\n\nST 110,NO ECT.STABLE BP/CVP 0 TO 6 .ON SC HEPARIN ,PNEUMO BOOTS.K,MG REPLETED ,\n\nC/R THICK GREEN,DOES INSP WELL,BS DIMINISHED .SAT 99 RM AIR.\n\nNOT PASSING GAS ,NG DRAINING GREEN POS . NO BS .\n\nINCISION C STAPLES ,TWO OPEN ARIAS TO THE SIDE PACKED C SALINE GAUZE .SM AMT SEROUS DRAINAGE .PAIN CONTROL C PCA .AMBULATED IN ROOM X3 C ASSIST OF 2 PEOPLE\n\nHUO 50 TO 100CC VIA FOLEY .\n\nALERT,ORIENTED COOPERATIVE . HAS SUPPORTIVE FAMILY,7MO OLD DAUGHTER.\n\nSTABLE FOR TRANS\n\nINCREASE ACTIVITY AS TOL\n CONTINUE PCA\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-11-14 00:00:00.000",
"description": "Report",
"row_id": 1435713,
"text": "2200-0700\n\nReceived pt transfered from CC6 following CT scan of chest and abdomen. Pt admitted to for Ileostomy take down. Pt has a hx of appendectomy in with multiple complications postoperatively. Pt developed ischemic bowel and an ileostomy/colostomy placed. pt had ileostomy takedown and ileocolonic anastomosis. While on the floor the pt became febrile 102.6, tachycardic 140-150s and lethargic with severe abd tenderness-pt sent for stat ct chest and abd and transfered to CCU.\n\nNeuro: Pt lethargic, responds to verbal stimuli and responds appropriately to questions. Follows commands well and moves all ext weakly. No evidence of intercranial bleed. Pupils equal and brisk.\n\nResp: Pt received tachypnic with RR in 30s, O2sat 100%. Lungs with scattered rhonchi. No productive cough noted. Unable to acquire sputum sample at this time. No ABG for AM. CT of chest neg for PE, + RLL pneumonia with LLlobe atelectasis.\n\nCV: S.Tachycardia without ectopy noted. SBP 120-140/70s, CVP 3-4, IV LR @ 150/hr with fluid boluses, max temp 102.6 pan cx and tylenol given. HCT: 40.2, WBC: 15.1, pt started on Vanco/Levaflaxin/Flagyl IV. R SC line placed-confirmed on Xray that the line must be pulled back-awaiting surgery to complete procedure. PIV X1. K:3.6,Mg:1.7-repleated. +pulses to lower ext, pneumatic boots on.\n\nGI/GU: Abd with diffuse tenderness to all quadrants, no perf or leak noted on CT scan. Midline incision intact with small amount of serosang drainage. hypoactive BS. NGT to LIS draining clear fluid-minimal amounts. Morphine PCA in use for abd pain control: fair outcomes. Foley catheter intact draining lt yellow urine. UO>150cc/hr. Urine lytes and osomal sent.\n\nPlan: Re evaluate pt in AM ? surgery for exploration: source of sepsis. continue fluid resecitation. Continue IV antibiotic coverage.\n"
},
{
"category": "Nursing/other",
"chartdate": "2103-11-14 00:00:00.000",
"description": "Report",
"row_id": 1435714,
"text": "SICU NPN\nS: \" I think the pain is better\"\nO: see carevue for all objective data\ncv: HR 112-130 sr, no vea, bp 100-130/64-72, CVP 2-5.\nresp: SATS 96-100% on RA, RR 14-20. lung sounds coarse. No c/o SOB. c/o vague chest discomfort w/ respiration. CXR-> r pleural effusion\ngi: NGT to LIS, ~ 350cc bilious drainage this shift. Hypoactive BS.\nConstant abdominal tenderness although improving throughout shift. Using PCA pump 1-2 mg mso4/hr, with some relief, needs encouragement to use regularly.\ngu: LR infusing 150cc/hr, uo >100cc/hr, currently ~ even.\nid: tm 99.8 orally, now 98.9. on levo, flagyl, vanco. WBC 15, down from 19.\nms: very lethargic in am, more alert this afternoon. Oriented, cooperative w/ care.\nsocial: married w/ 7 month old daughter. sister called. Pt spoke to husband on phone, he will be in later this eve.\nA: Improving abdominal pain, decreased temp, wbc. continued sinus tachycardia, r pleural effusion.\nP: monitor rhythm, temp curve, abd pain.Encourage use of PCA for pain control. Continue LR at 150cc/hr, abx, emotional support to pt.\n"
}
] |
96,974 | 179,056 | # Sepsis: Patient presented from rehab for increasing SOB. Patient was recently discharged from and OSH for STEMI and was being treated for a Pneumonia with Levaquin and Flagyl. On arrival here, she was noted to have hypotension with CXR consistent with RML Pneumonia. She was started on pressors for blood pressure control. She was intubated to respiratory distress. She was started on Vanco/Zosyn initially for her Pneumonia and was switched to Vanco/Cefepime/Ciprofloxacin on the morning of for treatmed of health care associated pneumonia. She was weaned off of pressors. On , she was extubated and then reintubated the following day respiratory distress. Cardiology was consulted given recent history of STEMI with EF of 20% as CHF was thought to be contributing to her respiratory distress and difficulty with extubation. She was diuresed with Lasix gtt and re-extubated successfully on which was successful. She was transferred to the medical floor on . Upon transfer, she was continued on PO vanc. Patient remained afebrile but continued to have an elevated WBC. She was ruled out for C.diff x 3 and CXR improved daily. Shortness of breath also improved. Her BP's returned to limits and she remained hemodynamically stable. Upon discharge, patient was doing well. She was started on amiodarone at OSH but it was held while here given her hemodynamic status- we continued to hold it on discharge and will ask that her outpatient cardiologist re-evaluate giving her amiodarone. She was restarted on her home dose of lisinopril 5mg daily. Her beta-blocker was also restarted but, instead of Toprol XL 50mg daily, she was given metoprolol tartrate 12.5mg PO BID. Her aldactone was also held on discharge. Patient will have her cardiac medications re-evaluated once she see her outpatient cardiologist in weeks. | - F/U cultures - Continue vanc/cefepime/cipro (adjust doses based on improved creatinine) - D/c c. diff coverage given no stool output here - Genlte IVF + wean pressors # Hypoxemic respiratory failure: Likely PNA with superimposed asthma flare. #Hypoxemic respiratory failure s/p extubation this AM [] CPAP [] diuresis (goal I/O -2L+) [] ABG this PM #s/p STEMI, EF25% - cont ASA, plavix, statin - defer BB and ACEI today in setting of recent hypoTN and goal to diurese, will re-assess in AM #Increasing WBC (16). #Hypoxemic respiratory failure s/p extubation this AM [] CPAP [] diuresis (goal I/O -2L+) [] ABG this PM #s/p STEMI, EF25% - cont ASA, plavix, statin - defer BB and ACEI today in setting of recent hypoTN and goal to diurese, will re-assess in AM #Increasing WBC (16). Respiratory failure, acute (not ARDS/) Assessment: Received pt on NC 4L/min. Response: ABG 7.33 PcO2 47 and PO2 40 thought to be venous sample. #Hypoxemic respiratory failure s/p extubation yesterday. ASA, plavix, high dose atorvastatin - Hold BB, ACEI, and aldactone; restart when BP allows - Cardiology consult to evaluate for cardaic etiology of events last pm # Afib: Currently in sinus. ASA, plavix, high dose atorvastatin - Hold BB, ACEI, and aldactone; restart when BP allows - Cardiology consult to evaluate for cardaic etiology of events last pm # Afib: Currently in sinus. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. extubated Respiratory failure, acute (not ARDS/) Assessment: Received pt on NC 4L/min. - F/U cultures - Continue vanc/cefepime/cipro (adjust doses based on improved creatinine) - D/c c. diff coverage given no stool output here - Genlte IVF + wean pressors # Hypoxemic respiratory failure: Likely PNA with superimposed asthma flare. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. # Sepsis/Hypotension: Resolved. # Sepsis/Hypotension: Resolved. ASA, plavix, high dose atorvastatin - Hold BB, ACEI, aldactone, lasix # Afib: Currently in sinus. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated and vented on PS5/peep 5 Fio2 35%, O2 sats 96-99%, RR-18-24. - F/U cultures - Continue vanc/zosyn (adjust doses based on improved creatinine) - D/c c. diff coverage given no stool output here - Genlte IVF + wean pressors # Hypoxemic respiratory failure: Likely PNA with superimposed asthma flare. - F/U cultures - Continue vanc/cefepime/cipro (adjust doses based on improved creatinine) - D/c c. diff coverage given no stool output here - Genlte IVF + wean pressors # Hypoxemic respiratory failure: Likely PNA with superimposed asthma flare. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. - attempt to wean ventilation - completed course of steroids -continue MDIs # Diarrhea/Leukocytosis: resolved. - F/U cultures - SWITCH vanc/zosyn to vanco/cefepime/cipro - Trend CEs, serial EKGs - Obtain records from - Follow up final ECHO - favor neo over levophed given recent MI and acutely depressed EF. # Sepsis/Hypotension: Resolved. - hold amiodarone, BB as hypotensive - supratherapeutic . ?cardiogenicunable to place a A line,wbc 30.8 with ma labs(up from 20).weak radial pulses,DP pulses dopplerablecvp 10-12.lactate down 2.1. - hold amiodarone, BB as hypotensive - supratherapeutic # Coagulopathy: Was on coumadin for afib at . ASA, plavix, high dose atorvastatin - Hold BB, ACEI, aldactone, lasix # Afib: Currently in sinus. Shock, septic Assessment: Pt presented from rehab with sob,wbc up to 30,chest x ray with RLL pna, with hypotension cvp 10-14,cool and clammy skin, received the pt on neo , no loose bm,only csnt secretions via the ET tube Action: Attempted to wean neo,contd iv vanco/cipro/cefipime,po vanco for empiric c diff coverage, Response: Sbp mostly in low 100s,map in mid 60s,weaning becoming unsuccessful given drop in blood pressure to 90s, uop has been 30-60 cc/hr,cvp 10-14,skin is cool and diaphoretic, Plan: Goal MAP>60,titrate neo as needed,follow urine output closely, follow cx datas, Respiratory failure, acute (not ARDS/) Assessment: Kwown asthma with superimposed pneumonia,pt with low EF of 20% with recent extensive anterior wall MI,s/p intubation on ..received the pt on cpap/psv, 10/5peep,lung sounds with exp wheeze at times, Action: No vent changes overnight, contd fent/versed for sedation(midas 2mg/hr and fent 50mcg/hr)suctioned as needed,VAP prevention bundle,MDI by RT. - F/U cultures - SWITCH vanc/zosyn to vanco/cefepime/cipro - Trend CEs, serial EKGs - Obtain records from - Follow up final ECHO - favor neo over levophed given recent MI and acutely depressed EF. - hold amiodarone, BB as hypotensive - supratherapeutic # Coagulopathy: Was on coumadin for afib at . - hold amiodarone, BB as hypotensive - supratherapeutic # Coagulopathy: Was on coumadin for afib at . - hold amiodarone, BB as hypotensive - supratherapeutic # Coagulopathy: Was on coumadin for afib at . ASA, plavix, high dose atorvastatin - hold BB, ACEI, aldactone, lasix # Afib: Currently in sinus. ASA, plavix, high dose atorvastatin - Hold BB, ACEI, aldactone, lasix # Afib: Currently in sinus. Remaining right lung, and the left lung are well aerated. Given CVP=12, stable EKG, and serial CE trending down, favor sepsis over cardiogenic shock. Mild to moderate pulmonary edema, predominantly basal, has progressed. There is persisting bu t improved retrocardiac and right basilar opacity. WBC began trending back up, so Laxative order by MD stool to send for C-Diff culture. IMPRESSION: Stable bibasilar airspace opacities, bilateral pleural effusions, and mild pulmonary vascular congestion. Coronary artery disease (CAD, ischemic heart disease) Assessment: VS stable, BP 98-110/55-68, HR 70-80s SR with occasional PVC Cardiology following. Retrocardiac atelectasis persists. - trial of fluids in effor to wean pressors, will be cautious given acutely depressed LVEF # Hypoxemic respiratory failure / increased work of breathing: Likely PNA with some contributiion from astma given severe wheezing on exam. | 128 | [
{
"category": "Physician ",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497628,
"text": "Chief Complaint: respiratory failure, volume overload s/p NSTEMI\n HPI:\n 77F (recent large STEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt intubated for worsening respiratory distress,\n extubated\n then re-intubated on acute respiratory distress.\n 24 Hour Events:\n Extubated this AM to nasal cannula.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 03:39 PM\n Cefipime - 05:04 PM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\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 Flowsheet Data as of 05:51 PM\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: 35.9\nC (96.7\n HR: 98 (76 - 100) bpm\n BP: 125/65(90) {104/55(75) - 173/162(168)} mmHg\n RR: 18 (11 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,082 mL\n 1,373 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,032 mL\n 953 mL\n Blood products:\n Total out:\n 2,685 mL\n 2,410 mL\n Urine:\n 2,685 mL\n 2,410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,603 mL\n -1,037 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 400 (400 - 481) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 0 cmH2O\n FiO2: 35%\n RSBI: 40\n PIP: 11 cmH2O\n SpO2: 93%\n ABG: 7.45/46/125/31/7\n Ve: 9.5 L/min\n PaO2 / FiO2: 357\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.1 g/dL\n 410 K/uL\n 308 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 42 mg/dL\n 97 mEq/L\n 135 mEq/L\n 27.6 %\n 16.5 K/uL\n [image002.jpg]\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n WBC\n 11.7\n 13.1\n 16.5\n Hct\n 25.5\n 26.2\n 27.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 243\n 180\n 281\n 199\n 308\n Other labs: PT / PTT / INR:44.1/34.5/4.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 77F (recent large NSTEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt now re-extubated to nasal cannula with continued\n volume overload.\n #Hypoxemic respiratory failure s/p extubation this AM\n [] CPAP\n [] diuresis (goal I/O -2L+)\n [] ABG this PM\n #s/p STEMI, EF25%\n - cont ASA, plavix, statin\n - defer BB and ACEI today in setting of recent hypoTN and goal to\n diurese, will re-assess in AM\n #Increasing WBC (16). Etiology is unclear. PNA being treated, no focal\n source of infection. Steroids is a possible source.\n [] resend u/a and urine cx\n [] vanc level, increase vanc dosing in setting of improved ARF\n [] C Diff if stool\n -PNA: on vanc / cefepime / cipro (day 7 of 8)\n #Asthma: Completed solumedrol x5d today\n #Elevated INR 4.7 on coumadin (on cipro) (for low EF/AF)\n [] hold coumadin\n ICU Care\n Nutrition:\n Comments: NPO until able to assess swallowing post-extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent:\n ------ Protected Section ------\n I saw and examined this pt, and was physically present with the ICU\n team for the key portions of services provided. I agree with Dr. \n note, including assessment and plan. I would add; 77 yo female with\n recent STEMI req/ stent and IABP, admitted with acute respiratory\n failure from asthma/HAP. Extubated earlier this week, only to develop\n acute respiratory distress the evening afterwards requiring\n re-intubation. BNP of 25,000\n previously prevented from diuresing by\n marginal BP/pressor requirement. , BP improved and responding well to\n lasix gtt. Extubated this morning.\n Oxygen requirement now down to 2liters n.c.- however, it was similarly\n down before she last decompensated. Given that and the apparent degree\n of volume overload, will try pt on NIPPV/CPAP while we continue to\n diurese.\n Leukocytosis noted this morning, infectious source unclear. She has\n nearly completed her course of abx for HAP. Will pan culture.\n Pt is critically ill. Total time spent: 35 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 18:17 ------\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497636,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated, vent settings CPAP 5 / 5 / 35%. Lung sounds\n clear upper fields, diminished in bases. Lasix gtt at 3mg/hr.\n Action:\n SBT for 1hr, tolerated well. Extubated at 1030 to 35% face tent, weaned\n to 2L NC. Oriented x3.\n Response:\n Patient diuresed 1600cc over previous 24 hr period, currently has\n diuresed 1 liter this shift. SAT remain 96-98%. Patient asking for\n inhaler although she has already received dose and is not currently\n wheezing.\n Plan:\n Encourage cough and deep breathing. Emotional support for anxiety\n regarding\nallergies\n and desire to over-use inhaler. Monitor mental\n status, SAT, and lung sounds.\n Anxiety\n Assessment:\n Received on Fentanyl gtt @ 25mcg and Versed gtt @ 2mg/hr. Opening eyes\n spontaneously and banging on bedrail. Follows commands. Denies pain.\n Action:\n Fentanyl turned off 1 hour prior to extubation. Versed left on until\n last moment before extubation.\n Response:\n Patient comfortable, mildly anxious regarding breathing and\nallergies\n, at times breathes loudly using vocal cords and states this\n is\nwheezing\n. No wheezing heard when patient asked to take quiet, deep\n breaths.\n Plan:\n Monitor patient\ns mental status, anxiety level. Has PRN ativan if\n needed, but was a question whether patient had been overmedicated\n leading up to last intubation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occasional PVC\ns, K4.6.\n Cardiology following.\n Action:\n Continued Lasix drip at 3 mg/hr.\n Response:\n Excellent response to Lasix. Diuresed for approx 2.5 liters since\n yesterday.\n Plan:\n Monitor VS and assess response to Lasix gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497808,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Extubated: INVASIVE VENTILATION - STOP 10:43 AM\n BB and ACEI restarted O/N\n CPAP not tolerated O/N.\n Much stool o/n, started on empiric vanc PO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 07:58 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Lorazepam (Ativan) - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 89 (82 - 108) bpm\n BP: 137/75(101) {111/61(81) - 167/124(144)} mmHg\n RR: 17 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 609 mL\n PO:\n 300 mL\n 50 mL\n TF:\n IVF:\n 1,035 mL\n 559 mL\n Blood products:\n Total out:\n 3,090 mL\n 1,100 mL\n Urine:\n 3,090 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -491 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (389 - 583) mL\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 2.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 421 K/uL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 77F (recent large NSTEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt now re-extubated to nasal cannula with continued\n volume overload.\n #Hypoxemic respiratory failure s/p extubation yesterday. CXR improved,\n esp in lower fields c/w diuresis. On 2L NC\n --completed vanc /cefepime / cipro today (day 8 of 8), s/p steroids\n x5d.\n [] diuresis with lasix gtt (goal I/O -2L+), BUN/CR stable.\n #s/p STEMI, EF25%\n - cont ASA, plavix, statin, BB ACEI\n - diuresis as above\n #Afib: cont BB\n #Increasing WBC (16\n 21). Etiology is unclear. PNA being treated, no\n focal source of infection. Steroids is a possible source.\n --vanc / cefepime / cipro completed today\n --now on vanc PO until C Diff returns\n [] send C Diff, U/A + urine cx\n #Elevated INR 4.7\n 4.4 [] coumadin held\n #Deconditioning: PT c/s\n #Asthma: Completed solumedrol x5d yesterday\n ICU Care\n Nutrition: PO diet\n Glycemic Control : good glucose control\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: elevated INR\n Stress ulcer: n/a\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Callout to \n Total time spent: 30 mins\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497047,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Extubated and O2 weaned\n - Pressor weaned off\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:28 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:52 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:49 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: 35.6\nC (96\n HR: 94 (76 - 94) bpm\n BP: 101/57(68) {92/46(60) - 116/70(77)} mmHg\n RR: 18 (0 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 16 (7 - 20)mmHg\n Total In:\n 1,706 mL\n 450 mL\n PO:\n 350 mL\n 150 mL\n TF:\n IVF:\n 1,206 mL\n 300 mL\n Blood products:\n Total out:\n 1,440 mL\n 415 mL\n Urine:\n 1,440 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 266 mL\n 35 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 378 (378 - 495) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 5.3 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Bibasilar crackles R>L and diffuse\n wheezing : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: warm, no rashes\n Neurologic: Attentive, Responds to: voice, Movement: purposeful, Tone:\n Not assessed\n Labs / Radiology\n 9.3 g/dL\n 457 K/uL\n 182 mg/dL\n 1.2 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 46 mg/dL\n 109 mEq/L\n 141 mEq/L\n 28.3 %\n 16.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n 04:13 AM\n WBC\n 30.8\n 26.2\n 20.5\n 16.5\n Hct\n 29.0\n 29.1\n 28.1\n 28.3\n Plt\n 57\n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n 1.2\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n 182\n Other labs: PT / PTT / INR:25.7/31.5/2.5, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CXR - Improving infiltrates.\n Microbiology: No new culture data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HCAP PNA/asthma\n flare\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - Continue vanc/cefepime/cipro for 8 day course\n - Off pressors since this am\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Extubated . On RA.\n - Continue albuterol MDI\n - Steroids started for asthma flare\n Day \n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix and restart when BP allows\n # Afib: Currently in sinus.\n - Restart amiodarone, BB when BP allows\n - On coumadin\n #FEN: Bowel regimen. Full cardiac diet.\n ICU Care\n Nutrition:\n Comments: Cardiac diet.\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Transfer to floor.\n Total time spent: 20 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497054,
"text": "Chief Complaint:\n 24 Hour Events:\n - Extubated successfully yesterday am\n -Weaned off of neo at 4am. Was not diuresed overnight given borderling\n BPs.\n - given continued absence of diahrrea, d/c'ed empiric covg for CDIFF\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:28 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:52 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 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: 35.6\nC (96\n HR: 88 (76 - 94) bpm\n BP: 98/48(60) {92/46(60) - 116/70(77)} mmHg\n RR: 15 (0 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 16 (7 - 21)mmHg\n Total In:\n 1,706 mL\n 433 mL\n PO:\n 350 mL\n 150 mL\n TF:\n IVF:\n 1,206 mL\n 283 mL\n Blood products:\n Total out:\n 1,440 mL\n 415 mL\n Urine:\n 1,440 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 266 mL\n 18 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 378 (378 - 495) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 5.3 L/min\n Physical Examination\n Gen: Well appearing, NAD\n Neck: Supple, no LAD\n Lungs: Bronchial breath sounds at R base. Diffuse expiratory wheezes.\n CV: RRR. No murmurs.\n Abdomen: Soft, NT, ND. No masses. No rebound or guarding.\n Extremities: Warm, well perfused. No LE edema.\n Labs / Radiology\n 457 K/uL\n 9.3 g/dL\n 182 mg/dL\n 1.2 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 46 mg/dL\n 109 mEq/L\n 141 mEq/L\n 28.3 %\n 16.5 K/uL\n [image002.jpg]\n Culture data NGTD\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n 04:13 AM\n WBC\n 30.8\n 26.2\n 20.5\n 16.5\n Hct\n 29.0\n 29.1\n 28.1\n 28.3\n Plt\n 57\n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n 1.2\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n 182\n Other labs: PT / PTT / INR:25.7/31.5/2.5, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, now extubated and not requiring pressors.\n # Hypotension: Resolved. Thought to be secondary to distributive\n shock, o2 requirement, in the setting of RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - favor neo over levophed if needed given recent MI and acutely\n depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing:\n resolved. Likely PNA with some contributiion from asthma given\n severe wheezing on exam.\n - extubated, BIPAP if flashes\n - steroidsx 5 days, MDIs\nday 5 of 5\n # Diarrhea/Leukocytosis: resolved.\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix given just weaned off pressors this\n morning. Consider restarting BB in AM if BP tolerates.\n - favor neo over levophed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resumed\n coumadin\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: call out to Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 497616,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Pt weaned and extubated without complications\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497770,
"text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:43 AM\n - good UOP on lasix drip, continued\n - restarting ace-i and BB this AM\n - Pt very uncomfortable with CPAP\n - WBC rising to 20 from 10 in two days, stooling all night, started on\n po anco, cdiff sent\n - coumadin held as INR still supratherapeutic\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.2\nC (97.2\n HR: 89 (81 - 108) bpm\n BP: 137/75(101) {111/58(80) - 167/124(144)} mmHg\n RR: 17 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 346 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,035 mL\n 346 mL\n Blood products:\n Total out:\n 3,090 mL\n 920 mL\n Urine:\n 3,090 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -574 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (389 - 583) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 2.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 421 K/uL\n 9.4 g/dL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Microbiology: Urine culture negative\n 11/2 Blood culture x1 negative\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock.\n # Sepsis/Hypotension: Resolved. Thought to be secondary to\n distributive shock, o2 requirement, in the setting of RLL pneumonia\n poorly compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving, but now worsening again\n (cdiff vs steroids?)\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n CEs at that time negative. EKG unchanged from prior.\n -continue broad spectrum vanc, cipro, cefepime day 7 of 8 for HA pna;\n check vanco level in AM\n - day 5 of 5 of steroids for asthma\n -continue MDIs\n -lasix gtt with goal I/Os of -2L if BP tolerates\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, while aggressively diuresising, but resume\n ASAP\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n - f/u cardiology recs\n # Afib: Currently in sinus.\n - hold BB as as above, resume amio (although long half-life means she\n will be therapeutic for a while)\n - supratherapeutic on coumadin\nhold coumadin today\n # FEN: IVFs / replete lytes prn / NPO\n # PPX: H2RA, supratherapeutic inr, INCREASING bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497781,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:43 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 07:58 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Lorazepam (Ativan) - 07:58 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 89 (82 - 108) bpm\n BP: 137/75(101) {111/61(81) - 167/124(144)} mmHg\n RR: 17 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 609 mL\n PO:\n 300 mL\n 50 mL\n TF:\n IVF:\n 1,035 mL\n 559 mL\n Blood products:\n Total out:\n 3,090 mL\n 1,100 mL\n Urine:\n 3,090 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -491 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (389 - 583) mL\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 2.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.4 g/dL\n 421 K/uL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 77F (recent large NSTEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt now re-extubated to nasal cannula with continued\n volume overload.\n #Hypoxemic respiratory failure s/p extubation this AM\n [] CPAP\n [] diuresis (goal I/O -2L+)\n [] ABG this PM\n #s/p STEMI, EF25%\n - cont ASA, plavix, statin\n - defer BB and ACEI today in setting of recent hypoTN and goal to\n diurese, will re-assess in AM\n #Increasing WBC (16). Etiology is unclear. PNA being treated, no focal\n source of infection. Steroids is a possible source.\n [] resend u/a and urine cx\n [] vanc level, increase vanc dosing in setting of improved ARF\n [] C Diff if stool\n -PNA: on vanc / cefepime / cipro (day 7 of 8)\n #Asthma: Completed solumedrol x5d today\n #Elevated INR 4.7 on coumadin (on cipro) (for low EF/AF)\n [] hold coumadin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497818,
"text": "Chief Complaint: respiratory failure (improved), s/p MI\n HPI: 77F (recent large STEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt now re-extubated to nasal cannula with improvement\n in volume overload.\n 24 Hour Events:\n Extubated: INVASIVE VENTILATION - STOP 10:43 AM\n BB and ACEI restarted O/N\n CPAP not tolerated O/N.\n Much stool o/n, started on empiric vanc PO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 07:58 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Lorazepam (Ativan) - 07:58 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 89 (82 - 108) bpm\n BP: 137/75(101) {111/61(81) - 167/124(144)} mmHg\n RR: 17 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 609 mL\n PO:\n 300 mL\n 50 mL\n TF:\n IVF:\n 1,035 mL\n 559 mL\n Blood products:\n Total out:\n 3,090 mL\n 1,100 mL\n Urine:\n 3,090 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -491 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (389 - 583) mL\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 2.4 L/min\n Physical Examination\n Gen: A/Ox3, NAD\n HEENT: oropharynx clear\n Cor: RRR, no m/r/g\n Lung: bilateral coarse BS\n Abd: soft NT +BS\n Peripheral Vascular: (Right radial pulse: intact), (Left radial pulse:\n intact),\n Skin: Intact\n Neurologic: non-focal\n Labs / Radiology\n 9.4 g/dL\n 421 K/uL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 77F (recent large NSTEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt now re-extubated to nasal cannula with continued\n volume overload.\n #Hypoxemic respiratory failure s/p extubation yesterday. CXR improved,\n esp in lower fields c/w diuresis. On 2L NC\n --completed vanc /cefepime / cipro today (day 8 of 8), s/p steroids\n x5d.\n [] diuresis with lasix gtt (goal I/O -2L+), BUN/CR stable.\n #s/p STEMI, EF25%\n - cont ASA, plavix, statin, BB ACEI\n - diuresis as above\n #Afib: cont BB\n #Increasing WBC (16\n 21). Etiology is unclear. PNA being treated, no\n focal source of infection. Steroids is a possible source.\n --vanc / cefepime / cipro completed today\n --now on vanc PO until C Diff ab result returns\n [] send C Diff, U/A + urine cx\n #Elevated INR 4.7\n 4.4\n [] coumadin held\n #Deconditioning: PT c/s\n #Asthma: Completed solumedrol x5d yesterday\n ICU Care\n Nutrition: PO diet\n Glycemic Control : good glucose control\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: elevated INR\n Stress ulcer: n/a\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Callout to (Dao wished to be attd)\n Total time spent: 30 mins\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 497898,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on Bipap mask, apparently placed on at 0600 that\n morning. Patient requesting to have mask off. Lung sounds clear upper\n fields, diminished in bases. Lasix gtt at 3mg/hr.\n Action:\n Bipap D/C\nd at 0800, returned to 2L NC. Encouraged coughing and deep\n breathing. OOB to chair from 0800 to 1200.\n Response:\n Patient diuresing well. SAT remain 96-98%. Patient asking for inhaler\n although she has already received dose and is not currently wheezing.\n With encouragement, patient has a strong, effective cough.\n Plan:\n Encourage cough and deep breathing. Emotional support for anxiety\n regarding\nallergies\n and desire to over-use inhaler. Monitor mental\n status, SAT, and lung sounds.\n Anxiety\n Assessment:\n Patient has frequent anxiety, will fixate regarding her breathing, her\n bowels, or her heart.\n Action:\n Ativan 0.25mg IVP x1 for anxiety.\n Response:\n Patient comfortable, mildly anxious regarding breathing and\nallergies\n, at times breathes loudly using vocal cords and states this\n is\nwheezing\n. No wheezing heard when patient asked to take quiet, deep\n breaths. Responds well to verbal redirection.\n Plan:\n Monitor patient\ns mental status, anxiety level. Has PRN ativan if\n needed, but was a question whether patient had been overmedicated\n leading up to last intubation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occasional PVC\n Cardiology following.\n Action:\n Continued Lasix drip at 3 mg/hr.\n Response:\n Excellent response to Lasix, is now about 800cc volume negative for\n length of stay.\n Plan:\n Monitor VS and assess response to Lasix gtt. Check recommendations\n from Cardiology.\n Diarrhea\n Assessment:\n Patient was given Miralax x1 on due to no BM. Patient had multiple\n small loose stools throughout the night and was quite upset about this.\n (On patient was on oral vanco for suspected C-diff, but had no\n stools to send for culture. On oral vanco was D/C\nd. WBC began\n trending back up, so Laxative order by MD stool to send for\n C-Diff culture. On oral vanco re-started.)\n Action:\n Encouraged patient to order and eat breakfast and lunch, Zofran 4mg x1\n IV for c/o nausea. All laxatives and stool softeners held.\n Response:\n Tolerating diet well, but will not eat if not encouraged by staff as\n she thinks this will cause more diarrhea. Only 2 soft stools passed\n this shift.\n Plan:\n Loose stool resolving. Continue to order meals with patient and\n encourage her to eat. Has Zofran for nausea PRN.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 65 Inch\n Admission weight:\n 70 kg\n Daily weight:\n 72.1 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact, Droplet\n PMH: Asthma\n CV-PMH: Arrhythmias, CAD, Hypertension, MI\n Additional history: s/p stent at hospital,s/p recent STEMI,\n with cardiogenic shock requiring baloon pump...a fib...dm type 2\n Surgery / Procedure and date: s/p 3 vessel stent\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:80\n D:48\n Temperature:\n 97.5\n Arterial BP:\n S:125\n D:73\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 87 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 1,228 mL\n 24h total out:\n 1,655 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:10 AM\n Potassium:\n 4.0 mEq/L\n 04:10 AM\n Chloride:\n 97 mEq/L\n 04:10 AM\n CO2:\n 34 mEq/L\n 04:10 AM\n BUN:\n 41 mg/dL\n 04:10 AM\n Creatinine:\n 1.2 mg/dL\n 04:10 AM\n Glucose:\n 176 mg/dL\n 04:10 AM\n Hematocrit:\n 28.0 %\n 04:10 AM\n Finger Stick Glucose:\n 240\n 12:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU-788\n Transferred to: \n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497019,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Extubated and O2 weaned\n - Pressor weaned down to 1\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:28 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:52 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:49 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: 35.6\nC (96\n HR: 94 (76 - 94) bpm\n BP: 101/57(68) {92/46(60) - 116/70(77)} mmHg\n RR: 18 (0 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 16 (7 - 20)mmHg\n Total In:\n 1,706 mL\n 450 mL\n PO:\n 350 mL\n 150 mL\n TF:\n IVF:\n 1,206 mL\n 300 mL\n Blood products:\n Total out:\n 1,440 mL\n 415 mL\n Urine:\n 1,440 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 266 mL\n 35 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 378 (378 - 495) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 5.3 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (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 9.3 g/dL\n 457 K/uL\n 182 mg/dL\n 1.2 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 46 mg/dL\n 109 mEq/L\n 141 mEq/L\n 28.3 %\n 16.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n 04:13 AM\n WBC\n 30.8\n 26.2\n 20.5\n 16.5\n Hct\n 29.0\n 29.1\n 28.1\n 28.3\n Plt\n 57\n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n 1.2\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n 182\n Other labs: PT / PTT / INR:25.7/31.5/2.5, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CXR - Improving infiltrates.\n Microbiology: No new culture data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - F/U cultures\n - Continue vanc/cefepime/cipro (adjust doses based on improved\n creatinine)\n - D/c c. diff coverage given no stool output here\n - Genlte IVF + wean pressors\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Intubated .\n - Continue albuterol MDI\n - Steroids started for asthma flare\n - Extubate today\n - Wean O2 as tolerated and check ABG\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - Hold amiodarone, BB as hypotensive\n - Restart coumadin\n ICU Care\n Nutrition:\n Comments: Advance as tolerated\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 20 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497020,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Extubated and O2 weaned\n - Pressor weaned off\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:28 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:52 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:49 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: 35.6\nC (96\n HR: 94 (76 - 94) bpm\n BP: 101/57(68) {92/46(60) - 116/70(77)} mmHg\n RR: 18 (0 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 16 (7 - 20)mmHg\n Total In:\n 1,706 mL\n 450 mL\n PO:\n 350 mL\n 150 mL\n TF:\n IVF:\n 1,206 mL\n 300 mL\n Blood products:\n Total out:\n 1,440 mL\n 415 mL\n Urine:\n 1,440 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 266 mL\n 35 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 378 (378 - 495) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 5.3 L/min\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Bibasilar crackles R>L and diffuse\n wheezing : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.3 g/dL\n 457 K/uL\n 182 mg/dL\n 1.2 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 46 mg/dL\n 109 mEq/L\n 141 mEq/L\n 28.3 %\n 16.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n 04:13 AM\n WBC\n 30.8\n 26.2\n 20.5\n 16.5\n Hct\n 29.0\n 29.1\n 28.1\n 28.3\n Plt\n 57\n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n 1.2\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n 182\n Other labs: PT / PTT / INR:25.7/31.5/2.5, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Imaging: CXR - Improving infiltrates.\n Microbiology: No new culture data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - Continue vanc/cefepime/cipro\n - Off pressors since this am\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Extubated . On RA.\n - Continue albuterol MDI\n - Steroids started for asthma flare\n Day \n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix and restart when BP allows\n # Afib: Currently in sinus.\n - Restart amiodarone, BB when BP allows\n - On coumadin\n #FEN: Bowel regimen. Full cardiac diet.\n ICU Care\n Nutrition:\n Comments: Cardiac diet.\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Transfer to floor.\n Total time spent: 20 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497619,
"text": "Chief Complaint: respiratory failure, volume overload s/p NSTEMI\n HPI:\n 77F (recent large STEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt intubated for worsening respiratory distress,\n extubated\n then re-intubated on acute respiratory distress.\n 24 Hour Events:\n Extubated this AM to nasal cannula.\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Ciprofloxacin - 03:39 PM\n Cefipime - 05:04 PM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\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 Flowsheet Data as of 05:51 PM\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: 35.9\nC (96.7\n HR: 98 (76 - 100) bpm\n BP: 125/65(90) {104/55(75) - 173/162(168)} mmHg\n RR: 18 (11 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,082 mL\n 1,373 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,032 mL\n 953 mL\n Blood products:\n Total out:\n 2,685 mL\n 2,410 mL\n Urine:\n 2,685 mL\n 2,410 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,603 mL\n -1,037 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 400 (400 - 481) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 0 cmH2O\n FiO2: 35%\n RSBI: 40\n PIP: 11 cmH2O\n SpO2: 93%\n ABG: 7.45/46/125/31/7\n Ve: 9.5 L/min\n PaO2 / FiO2: 357\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.1 g/dL\n 410 K/uL\n 308 mg/dL\n 1.2 mg/dL\n 31 mEq/L\n 4.3 mEq/L\n 42 mg/dL\n 97 mEq/L\n 135 mEq/L\n 27.6 %\n 16.5 K/uL\n [image002.jpg]\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n WBC\n 11.7\n 13.1\n 16.5\n Hct\n 25.5\n 26.2\n 27.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 243\n 180\n 281\n 199\n 308\n Other labs: PT / PTT / INR:44.1/34.5/4.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:1.8 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 77F (recent large NSTEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt now re-extubated to nasal cannula with continued\n volume overload.\n #Hypoxemic respiratory failure s/p extubation this AM\n [] CPAP\n [] diuresis (goal I/O -2L+)\n [] ABG this PM\n #s/p STEMI, EF25%\n - cont ASA, plavix, statin\n - defer BB and ACEI today in setting of recent hypoTN and goal to\n diurese, will re-assess in AM\n #Increasing WBC (16). Etiology is unclear. PNA being treated, no focal\n source of infection. Steroids is a possible source.\n [] resend u/a and urine cx\n [] vanc level, increase vanc dosing in setting of improved ARF\n [] C Diff if stool\n -PNA: on vanc / cefepime / cipro (day 7 of 8)\n #Asthma: Completed solumedrol x5d today\n #Elevated INR 4.7 on coumadin (on cipro) (for low EF/AF)\n [] hold coumadin\n ICU Care\n Nutrition:\n Comments: NPO until able to assess swallowing post-extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497009,
"text": "Chief Complaint:\n 24 Hour Events:\n - Extubated successfully in am\n - still dependent on neo (small dose), unable to wean completely; held\n off on diuresis as CVP~12 on avg, BP borderline even on pressor\n - given continued absence of diahrrea, d/c'ed empiric covg for CDIFF\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:28 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:52 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 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: 35.6\nC (96\n HR: 88 (76 - 94) bpm\n BP: 98/48(60) {92/46(60) - 116/70(77)} mmHg\n RR: 15 (0 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 16 (7 - 21)mmHg\n Total In:\n 1,706 mL\n 433 mL\n PO:\n 350 mL\n 150 mL\n TF:\n IVF:\n 1,206 mL\n 283 mL\n Blood products:\n Total out:\n 1,440 mL\n 415 mL\n Urine:\n 1,440 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 266 mL\n 18 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 378 (378 - 495) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 5.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 457 K/uL\n 9.3 g/dL\n 182 mg/dL\n 1.2 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 46 mg/dL\n 109 mEq/L\n 141 mEq/L\n 28.3 %\n 16.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n 04:13 AM\n WBC\n 30.8\n 26.2\n 20.5\n 16.5\n Hct\n 29.0\n 29.1\n 28.1\n 28.3\n Plt\n 57\n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n 1.2\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n 182\n Other labs: PT / PTT / INR:25.7/31.5/2.5, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, in\n septic shock still requiring pressors. Intubated yesterday for\n increased work of breathing.\n # Hypotension: Given distributive shock, o2 requirement, and CXR\n infiltrate, this is most likely septic shock from RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - Trend CEs, serial EKGs with any major hemodynamic changes\n - favor neo over levophed given recent MI and acutely depressed EF.\n - trial of fluids in effor to wean pressors, will be cautious given\n acutely depressed LVEF\n # Hypoxemic respiratory failure / increased work of breathing: Likely\n PNA with some contributiion from asthma given severe wheezing on\n exam. .Tolerating SBT well this am.\n - extubate, BIPAP if flashes\n - steroidsx 5 days, MDIs\n # Diarrhea/Leukocytosis: d/c empiric CDIFF covg given lack of\n diahrrea. f/u cdiff tox x2 when stools\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI.\n - Serial CEs, EKGs for any hemodynamic changes\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n - favor neo over levophed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resumed\n coumadin yesterday\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497763,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on Lasix gtt at 3mg/hr. Received on 2 liters nasal\n cannula. Sating mid to high 90\n Action:\n Patient remained on lasix diuresed overnight, pressure remaining\n stable. Patient requesting inhalers frequently. Element of anxiety\n present, but redirected when explained that she is not wheezey.\n Response:\n Pt. trialed on BiPAP this am. Tolerating for now. To start on ACE and\n Beta-blocker this am when BiPAP is off.\n Plan:\n Encourage cough and deep breathing. Emotional support for anxiety\n regarding\nallergies\n and desire to over-use inhaler. Monitor mental\n status, SAT, and lung sounds. BiPAP as tolerated.\n Diarrhea\n Assessment:\n Patient stooling frequently overnight.\n Action:\n Stool sent for C-Diff.\n Response:\n WBC 21 this am.\n Plan:\n Patient started on PO Vanco. Follow up on C-Diff.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497764,
"text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:43 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.2\nC (97.2\n HR: 89 (81 - 108) bpm\n BP: 137/75(101) {111/58(80) - 167/124(144)} mmHg\n RR: 17 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 346 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,035 mL\n 346 mL\n Blood products:\n Total out:\n 3,090 mL\n 920 mL\n Urine:\n 3,090 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -574 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (389 - 583) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 2.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 421 K/uL\n 9.4 g/dL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Microbiology: Urine culture negative\n 11/2 Blood culture x1 negative\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, reintubated overnight.\n # Sepsis/Hypotension: Resolved. Thought to be secondary to\n distributive shock, o2 requirement, in the setting of RLL pneumonia\n poorly compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving, but now worsening again\n (cdiff vs steroids?)\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n CEs at that time negative. EKG unchanged from prior.\n -continue broad spectrum vanc, cipro, cefepime day 7 of 8 for HA pna;\n check vanco level in AM\n - day 5 of 5 of steroids for asthma\n -continue MDIs\n -lasix gtt with goal I/Os of -2L if BP tolerates\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, while aggressively diuresising, but resume\n ASAP\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n - f/u cardiology recs\n # Afib: Currently in sinus.\n - hold BB as as above, resume amio (although long half-life means she\n will be therapeutic for a while)\n - supratherapeutic on coumadin\nhold coumadin today\n # FEN: IVFs / replete lytes prn / NPO\n # PPX: H2RA, supratherapeutic inr, INCREASING bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496556,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Intubated for respiratory distress\n - On pressors\n - OSH records obtained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 02:44 PM\n Ciprofloxacin - 02:00 AM\n Vancomycin - 08:14 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:00 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: 78 (69 - 101) bpm\n BP: 100/56(67) {69/36(43) - 144/63(77)} mmHg\n RR: 11 (9 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 70 kg\n CVP: 14 (0 - 20)mmHg\n Total In:\n 1,619 mL\n 1,003 mL\n PO:\n TF:\n IVF:\n 1,559 mL\n 943 mL\n Blood products:\n Total out:\n 1,325 mL\n 310 mL\n Urine:\n 1,325 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 294 mL\n 693 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): 560 (370 - 560) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.32/44/99./23/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 198\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 522 K/uL\n 251 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 36 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.1 %\n 26.2 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n WBC\n 30.8\n 26.2\n Hct\n 29.0\n 29.1\n Plt\n 510\n 522\n Cr\n 1.6\n 1.4\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n Other labs: PT / PTT / INR:23.8/34.5/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.8 mg/dL\n Imaging: CXR - Persistent RML opacity. ET tube at 2.5 cm.\n Microbiology: No new micro data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl.\n - F/U cultures\n - Continue vanc/zosyn\n - Genlte IVF + wean pressors\n - Trend CEs, serial EKGs\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Now intubated.\n - Continue albuterol MDI\n - Steroids started for asthma flare\n - Wean PS as tolerated\n # Diarrhea: Pt reports 1 week of diarrhea. Could be C. diff, although\n unlikely given recent flagyl. Elevated WBC count today prompted\n initiation of PO vanc.\n - Check C. diff\n - Continue PO vanc\n will d/c if c. diff neg x 2\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Serial CEs, EKGs\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - Hold amiodarone, BB as hypotensive\n - Restart coumadin\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496993,
"text": "Chief Complaint:\n 24 Hour Events:\n - Etubated successfully in am\n - still dependent on neo (small dose), unable to wean completely; held\n off on diuresis as CVP~12 on avg, BP borderline even on pressor\n - given continued absence of diahrrea, d/c'ed empiric covg for CDIFF\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:28 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:52 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 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: 35.6\nC (96\n HR: 88 (76 - 94) bpm\n BP: 98/48(60) {92/46(60) - 116/70(77)} mmHg\n RR: 15 (0 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 16 (7 - 21)mmHg\n Total In:\n 1,706 mL\n 433 mL\n PO:\n 350 mL\n 150 mL\n TF:\n IVF:\n 1,206 mL\n 283 mL\n Blood products:\n Total out:\n 1,440 mL\n 415 mL\n Urine:\n 1,440 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 266 mL\n 18 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 378 (378 - 495) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 5.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 457 K/uL\n 9.3 g/dL\n 182 mg/dL\n 1.2 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 46 mg/dL\n 109 mEq/L\n 141 mEq/L\n 28.3 %\n 16.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n 04:13 AM\n WBC\n 30.8\n 26.2\n 20.5\n 16.5\n Hct\n 29.0\n 29.1\n 28.1\n 28.3\n Plt\n 57\n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n 1.2\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n 182\n Other labs: PT / PTT / INR:25.7/31.5/2.5, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 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": "2153-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496994,
"text": "Chief Complaint:\n 24 Hour Events:\n - Etubated successfully in am\n - still dependent on neo (small dose), unable to wean completely; held\n off on diuresis as CVP~12 on avg, BP borderline even on pressor\n - given continued absence of diahrrea, d/c'ed empiric covg for CDIFF\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:28 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 04:52 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:04 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: 35.6\nC (96\n HR: 88 (76 - 94) bpm\n BP: 98/48(60) {92/46(60) - 116/70(77)} mmHg\n RR: 15 (0 - 33) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 16 (7 - 21)mmHg\n Total In:\n 1,706 mL\n 433 mL\n PO:\n 350 mL\n 150 mL\n TF:\n IVF:\n 1,206 mL\n 283 mL\n Blood products:\n Total out:\n 1,440 mL\n 415 mL\n Urine:\n 1,440 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 266 mL\n 18 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 378 (378 - 495) mL\n PS : 5 cmH2O\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 6 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 5.3 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 457 K/uL\n 9.3 g/dL\n 182 mg/dL\n 1.2 mg/dL\n 26 mEq/L\n 5.0 mEq/L\n 46 mg/dL\n 109 mEq/L\n 141 mEq/L\n 28.3 %\n 16.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n 04:13 AM\n WBC\n 30.8\n 26.2\n 20.5\n 16.5\n Hct\n 29.0\n 29.1\n 28.1\n 28.3\n Plt\n 57\n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n 1.2\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n 182\n Other labs: PT / PTT / INR:25.7/31.5/2.5, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.5 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, in\n septic shock still requiring pressors. Intubated yesterday for\n increased work of breathing.\n # Hypotension: Given distributive shock, o2 requirement, and CXR\n infiltrate, this is most likely septic shock from RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - Trend CEs, serial EKGs with any major hemodynamic changes\n - favor neo over levophed given recent MI and acutely depressed EF.\n - trial of fluids in effor to wean pressors, will be cautious given\n acutely depressed LVEF\n # Hypoxemic respiratory failure / increased work of breathing: Likely\n PNA with some contributiion from asthma given severe wheezing on\n exam. .Tolerating SBT well this am.\n - extubate, BIPAP if flashes\n - steroidsx 5 days, MDIs\n # Diarrhea/Leukocytosis: d/c empiric CDIFF covg given lack of\n diahrrea. f/u cdiff tox x2 when stools\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI.\n - Serial CEs, EKGs for any hemodynamic changes\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n - favor neo over levophed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resumed\n coumadin yesterday\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497226,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Started shift w/ pt already being treated for anxiety w/ x2 PRN doses\n ativan IV w/ no effect, MDI\ns w/ no effect, EKG done, CXR done,\n appearing mottled, feeling cold and clammy to touch, changes in LOC,\n very labored breathing, desat to high 70\ns, ABG w/ PaO2 in 40\ns (MD\n thought to be venous), placed on bipap for short period w/ no relief.\n Action:\n Pt intubated at start of shift. 40mg IV lasix x1 given. A-line\n placed. CXR to confirm ETT placement. Multiple ABG\ns and vent setting\n changes. OGT placed before AM CXR.\n Response:\n Pt immediately improved following intubation; skin warmed, pale (not\n mottled), skin dry, no wheezing (w/o MDI\ns being given), LS clear upper\n and diminished lower, HR decreased from 130\ns to 80\ns, BP stable all\n night w/ MAP>65.\n Plan:\n MICU resident, fellow and attending in to see pt. Feel that\n deterioration in resp status is r/t anxiety. Plan is to obtain a CXR\n and try Haldol. Continue MDI\ns as ordered. Encourage CDB. NTS PRN.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497872,
"text": "Chief Complaint: respiratory failure (improved), s/p MI\n HPI: 77F (recent large STEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt now re-extubated to nasal cannula with improvement\n in volume overload.\n 24 Hour Events:\n Extubated: INVASIVE VENTILATION - STOP 10:43 AM\n BB and ACEI restarted O/N\n CPAP not tolerated O/N.\n Much stool o/n, started on empiric vanc PO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 07:58 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Lorazepam (Ativan) - 07:58 AM\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.8\nC (96.5\n HR: 89 (82 - 108) bpm\n BP: 137/75(101) {111/61(81) - 167/124(144)} mmHg\n RR: 17 (14 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 609 mL\n PO:\n 300 mL\n 50 mL\n TF:\n IVF:\n 1,035 mL\n 559 mL\n Blood products:\n Total out:\n 3,090 mL\n 1,100 mL\n Urine:\n 3,090 mL\n 1,100 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -491 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (389 - 583) mL\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 2.4 L/min\n Physical Examination\n Gen: A/Ox3, NAD\n HEENT: oropharynx clear\n Cor: RRR, no m/r/g\n Lung: bilateral coarse BS\n Abd: soft NT +BS\n Peripheral Vascular: (Right radial pulse: intact), (Left radial pulse:\n intact),\n Skin: Intact\n Neurologic: non-focal\n Labs / Radiology\n 9.4 g/dL\n 421 K/uL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Assessment and Plan\n 77F (recent large NSTEMI at OSH in past 2 weeks, s/p PCI to LAD c/b\n cardiogenic shock requiring IABP. Hospital course also c/b PNA. Pt\n presented with increasing SOB, diarrhea and was found to be hypotensive\n and hypoxemic. Pt now re-extubated to nasal cannula with continued\n volume overload.\n #Hypoxemic respiratory failure s/p extubation yesterday. CXR improved,\n esp in lower fields c/w diuresis. On 2L NC\n --completed vanc /cefepime / cipro today (day 8 of 8), s/p steroids\n x5d.\n [] diuresis with lasix gtt (goal I/O -2L+), BUN/CR stable.\n #s/p STEMI, EF25%\n - cont ASA, plavix, statin, BB ACEI\n - diuresis as above\n #Afib: cont BB\n #Increasing WBC (16\n 21). Etiology is unclear. PNA being treated, no\n focal source of infection. Steroids is a possible source.\n --vanc / cefepime / cipro completed today\n --now on vanc PO until C Diff ab result returns\n [] send C Diff, U/A + urine cx\n #Elevated INR 4.7\n 4.4\n [] coumadin held\n #Deconditioning: PT c/s\n #Asthma: Completed solumedrol x5d yesterday\n ICU Care\n Nutrition: PO diet\n Glycemic Control : good glucose control\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: elevated INR\n Stress ulcer: n/a\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : Callout to (Dao wished to be attd)\n Total time spent: 30 mins\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n She is doing well on a lasix infusion which will be titrated for\n clinical response as she transitions out of ICU later today. Cardiology\n staff to advise regarding long term management.\n Remainder of plan as outlined above.\n Patient is chronically ill\n Total time: 30 min\n _________\n , MD\n Division of Pulmonary, Critical Care and Sleep Medicine\n \n , KS-B23\n , \n ------ Protected Section Addendum Entered By: , MD\n on: 16:00 ------\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496728,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on MMV 50%/RR 12/PS 10/peep 5, OVb 2-8 bpm, sat\n 100%, LS rhoncies clear after suction.pt lightly sedated on Fentanyl\n and versed, arousable to voice, follows commnads\n Action:\n No vent changes overnight, remains lightly sedated\n Response:\n In the mornign versed decreased to 1mg/hr , pt more awake spont RR\n 20, temp 99.4 RSBI 49\n Plan:\n Cont to follow, there has been discussion to extubated tomorrow so do a\n RSBI in the am, cont abx\n Shock, septic\n Assessment:\n Remains on neo 2.5 mg/kg/min, SBP 90s-100s, temp 99.4\n Action:\n Decreased Neo to 2.3mcg/kg/min, BP dropped to 90\ns with Map58\n Response:\n Cont Neo at 2.5 mcg/kg/min, BP 100\ns with MAP>60, afebrile, WBC down to\n 29 from 26\n Plan:\n Cont to try and wean the neo, keep Map>60cont abx, f/u with clx\n Social: pt\ns daughter called, talked to RN. Pt\ns son-in-law updated by\n RN and MD\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497361,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Reintubated for respiratory distress\n - A line placed\n - Borderline BP after intubation, but resolved with 500cc NS\\\n - 20 beat run of VT after intubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 08:23 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 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 09:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 85 (70 - 125) bpm\n BP: 105/58(78) {91/51(66) - 124/69(92)} mmHg\n RR: 16 (10 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 554 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 554 mL\n Blood products:\n Total out:\n 1,780 mL\n 655 mL\n Urine:\n 1,780 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 475 (443 - 475) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/43/120/25/1\n Ve: 6.7 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (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: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 355 K/uL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n 0.60\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Worsening pulmonary edema.\n Microbiology: No new culture data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n # Hypoxemic respiratory failure: Initially PNA with superimposed\n asthma flare. Extubated . Developed acute respiratory distress\n 11/5pm requiring re-intubation for obtundation and mottled appearance.\n Unclear etiology (VBG 4.32/42 and sats in high 90s on 4L prior to\n obtundation), but likely due to volume status and large anxiety\n component. Now looks extubatable, but hesitant given unclear event\n that led to reintubation. Differential includes pulmonary edema,\n anxiety, oversedation with ativan, HAP, PE, and acute bronchspasm.\n - Continue albuterol MDI; on steroids for asthma flare\n Day \n - Lasix gtt to diuresis given borderline BP\n - Continue abx for HAP\n - Versed gtt for anxiety\n - LE dopplers to r/o DVT as PE is consideration for acute episode last\n pm\n - SBT today, RSBI 37\n Decrease PS 5/5 and plan to extubate tomorrow\n - Cardiology consult\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - Continue vanc/cefepime/cipro\n Day \n - Off pressors since am\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, and aldactone; restart when BP allows\n - Cardiology consult to evaluate for cardaic etiology of events last pm\n # Afib: Currently in sinus.\n - Restart amiodarone, BB when BP allows\n - On coumadin\n hold today\ns dose and decreease dose (INR 3.7)\n #FEN: Bowel regimen. NPO\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: Boots, Coumadin\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": "2153-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497760,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient received on Lasix gtt at 3mg/hr. Received on 2 liters nasal\n cannula. Sating mid to high 90\n Action:\n Patient remained on lasix diuresed overnight, pressure remaining\n stable. Patient requesting inhalers frequently. Element of anxiety\n present, but redirected when explained that she is not wheezey.\n Response:\n Pt. trialed on BiPAP this am. Tolerating for now. To start on ACE and\n Beta-blocker this am when BiPAP is off.\n Plan:\n Encourage cough and deep breathing. Emotional support for anxiety\n regarding\nallergies\n and desire to over-use inhaler. Monitor mental\n status, SAT, and lung sounds. BiPAP as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497762,
"text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:43 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.2\nC (97.2\n HR: 89 (81 - 108) bpm\n BP: 137/75(101) {111/58(80) - 167/124(144)} mmHg\n RR: 17 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 346 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,035 mL\n 346 mL\n Blood products:\n Total out:\n 3,090 mL\n 920 mL\n Urine:\n 3,090 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -574 mL\n Respiratory support\n O2 Delivery Device: Bipap mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 583 (389 - 583) mL\n PS : 5 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 10 cmH2O\n SpO2: 100%\n ABG: ///34/\n Ve: 2.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 421 K/uL\n 9.4 g/dL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg]\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Microbiology: Urine culture negative\n 11/2 Blood culture x1 negative\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496670,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496671,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on MMV\n Action:\n Place on MMV to insure a MV, fnet and versed were decrease to try and\n increase her RR, conts on abx\n Response:\n Not urge to breath, pneumonia\n Plan:\n Cont to follow, there has been discussion to extubated tomorrow so do a\n RSBI in the am, cont abx\n Shock, septic\n Assessment:\n Remains on neo 2.5 mg/kg/min, SBP 90s-100s, T max 100.2\n Action:\n Given a 500cc NS bolus to see if we could decrease the neo\n Response:\n No change in her BP or u/o with the fluid bolus, clx are neg to date\n Plan:\n Cont to try and wean the neo, cont abx, f/u woith clx\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496673,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated on MMV 50%/RR 12/PS 10/peep 5, OVb 2-8 bpm, sat\n 100%, LS rhoncies clear after suction.pt lightly sedated on Fentanyl\n and versed, arousable to voice, follows commnads\n Action:\n No vent changes overnight, remains lightly sedated\n Response:\n Not urge to breath, pneumonia, temp 99.4\n Plan:\n Cont to follow, there has been discussion to extubated tomorrow so do a\n RSBI in the am, cont abx\n Shock, septic\n Assessment:\n Remains on neo 2.5 mg/kg/min, SBP 90s-100s, temp 99.4\n Action:\n Decreased Neo to 2.3mcg/kg/min, BP dropped to 90\ns with Map58\n Response:\n Cont Neo at 2.5 mcg/kg/min, BP 100\ns with MAP>60\n Plan:\n Cont to try and wean the neo, keep Map>60cont abx, f/u woith clx\n Social: pt\ns daughter called, talked to RN. Pt\ns son-in-law updated by\n RN and MD\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497160,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on NC 4L/min. Lung sounds with expiratory wheezes\n throughout most of the day. Congested cough, pt not bringing up much\n for secretions. Sats throughout the day high 90\ns and pt able to wean\n to 2L NC. Denied SOB and no increased WOB noted throughout the day.\n This evening, pt noted to have increased WOB with RR 30\ns and sats\n hovering mid to low 90\ns on 2L NC. C/O feeling like she can\nt breathe.\n Diaphoretic. Squirmy in the bed and picking at tubes. Tachycardic to\n 120\ns and SBP 150\ns. Of note, pt is known to have hx of becoming very\n anxious.\n Action:\n MDI\ns given as ordered with little effect, so Atrovent neb given. NC\n increased to 4L. Pt given 0.25mg Ativan with little effect, so another\n 0.25mg of Ativan given. EKG obtained. MICU resident in to see ot and\n ABG drawn.\n Response:\n ABG 7.33 PcO2 47 and PO2 40\n thought to be venous sample. Pt\ns sats\n have improved to high 90\ns since increase in O2 and receiving neb\n treatment. Continues to be diaphoretic and picking at gown/wires. Noted\n to be mottling. Cont to c/o difficulty breathing. Remains tachycardic\n in the 120\ns. MICU team aware.\n Plan:\n MICU resident, fellow and attending in to see pt. Feel that\n deterioration in resp status is r/t anxiety. Plan is to obtain a CXR\n and try Haldol. Continue MDI\ns as ordered. Encourage CDB. NTS PRN.\n Anxiety\n Assessment:\n Pt known to become very anxious at baseline, at times to the point of\n hyperventilation per pt\ns daughter. This AM noted to become anxious,\n medicated with 0.25mg Ativan with good effect. Later in the shift, pt\n noted to become anxious again, picking at tubes/lines.\n Action:\n Medicated with 0.25mg Ativan at 1710 with little effect. Another 0.25mg\n Ativan given at 1800.\n Response:\n Cont to be anxious despite receiving a total of 0.5mg.\n Plan:\n Pt is noted to be very anxious at baseline. Ativan PRN for anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497342,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496842,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated on MMV 500 / 12 / 10 / 5 / 50%. Lightly\n sedated on Versed 1mg/hr and Fentanyl 25mcg/hr. Moves all extremities\n to command, able to hold head off pillow.\n Action:\n Vent weaned to CPAP 10 / 5, then SBT. Tolerated CPAP 0 / 5 for 30\n minutes. Extubated to 4 L NC at 1200.\n Sedation off.\n Response:\n SAT 99-100%. Lung sounds clear upper fields, crackles in bases\n bilaterally. Received alb/atr nebulizers tx. Immediately upon\n extubation.\n Plan:\n Encourage cough and deep breathing. Albuterol and Atrovent inhalers as\n ordered.\n Shock, septic\n Assessment:\n Received on neo 2.5 mcg/kg/min, SBP 90s-100s, MAP 61-70, temp 99.7.\n Action:\n Weaning Neo gtt with goal MAP>60. Vanco, Cipro, Cefepime IV as ordered.\n Response:\n Current Neo rate 1.5 mcg/kg/min. SBP>100, MAP=70. Temp 98 PO. WBC\n trending down, current 20.5.\n Plan:\n Wean Neo as tolerated to keep MAP>60. Continue IV antibiotics.\n Anxiety\n Assessment:\n Received patient on Versed gtt 1mg/hr. Patient nods\n she is\n anxious, indicated it was due to ETT. Per patient\ns daughter, patient\n is an extremely anxious person, to the point of hyperventilation,\n although she does not take any home anti anxiety meds.\n Action:\n Patient extubated today, Versed gtt off. Lorazepam 0.25mg IVP PRN for\n anxiety.\n Response:\n Lorazepam 0.25mg IV x1 for anxious behavior with good response.\n Plan:\n Medicate PRN and offer emotional support for patient\ns high anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497343,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Anxiety\n Assessment:\n Action:\n Response:\n Plan:\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nutrition",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 497344,
"text": "Subjective\n int/sedated, moving hands\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 70 kg\n 72.1 kg ( 08:00 AM)\n up due to fluid wt gained\n 25.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 123%\n 60 kg\n not available\n Diagnosis: PNEUMONIA\n PMHx:\n Asthma\n Hyperlipidemia\n Hypertension\n Coronary artery disease\n Diabetes mellitus type 2\n GERD\n Recent massive NSTEMI at OSH 10 days ago, s/p 3 stents\n Food allergies and intolerances: not available\n Pertinent medications: Fentanyl Citrate, Midazolam, Furosemide,\n Clopidogrel , Insulin SC, Ranitidine , CefePIME, Ciprofloxacin,\n MethylPREDNISolone, Vancomycin, Docusate Sodium, Furosemide, others\n noted\n Labs:\n Value\n Date\n Glucose\n 180 mg/dL\n 03:06 AM\n Glucose Finger Stick\n 191\n 12:00 PM\n BUN\n 50 mg/dL\n 03:06 AM\n Creatinine\n 1.2 mg/dL\n 03:06 AM\n Sodium\n 141 mEq/L\n 03:06 AM\n Potassium\n 4.8 mEq/L\n 03:06 AM\n Chloride\n 107 mEq/L\n 03:06 AM\n TCO2\n 25 mEq/L\n 03:06 AM\n PO2 (arterial)\n 120 mm Hg\n 02:12 AM\n PCO2 (arterial)\n 43 mm Hg\n 02:12 AM\n pH (arterial)\n 7.40 units\n 02:12 AM\n pH (urine)\n 5.0 units\n 07:20 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 02:12 AM\n Calcium non-ionized\n 7.9 mg/dL\n 03:06 AM\n Phosphorus\n 3.2 mg/dL\n 03:06 AM\n Ionized Calcium\n 1.13 mmol/L\n 10:35 PM\n Magnesium\n 2.2 mg/dL\n 03:06 AM\n Total Bilirubin\n 0.6 mg/dL\n 03:53 AM\n WBC\n 13.1 K/uL\n 03:06 AM\n Hgb\n 8.7 g/dL\n 03:06 AM\n Hematocrit\n 26.2 %\n 03:06 AM\n Current diet order / nutrition support: Regular; Cardiac/Heart healthy\n GI: Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: normal\n Assessment of Nutritional Status\n Patient at risk due to: NPO, desat-reintubation\n Estimated Nutritional Needs\n Calories: 1320-1500 (BEE x or / 22-25 cal/kg)\n Protein: 72-84 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 77 year old female presented from rehab with diarrhea, hypotension and\n respiratory distress progressing into acute respiratory failure- found\n to have PNA/asthma flare, patient extubated , and then reintubated\n yesterday due to respiratory distress. Consider tube feed as temporary\n nutrition support if unable to extubate by Monday.\n Medical Nutrition Therapy Plan - Recommend the Following\n Change diet to: NPO\n Tube feeding recommendations: Boost Glucose Control goal\n 55ml/hr (1400kcal/77g protein)\n Check chemistry 10 panel daily, replete prn\n Continue insulin sliding scale if serum glucose greater than\n 150 mg/dL\n Other: if has question\n .\n"
},
{
"category": "Nutrition",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 497345,
"text": "Subjective\n int/sedated, moving hands\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 165 cm\n 70 kg\n 72.1 kg ( 08:00 AM)\n up due to fluid wt gained\n 25.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 56.7 kg\n 123%\n 60 kg\n not available\n Diagnosis: PNEUMONIA\n PMHx:\n Asthma\n Hyperlipidemia\n Hypertension\n Coronary artery disease\n Diabetes mellitus type 2\n GERD\n Recent massive NSTEMI at OSH 10 days ago, s/p 3 stents\n Food allergies and intolerances: not available\n Pertinent medications: Fentanyl Citrate, Midazolam, Furosemide,\n Clopidogrel , Insulin SC, Ranitidine , CefePIME, Ciprofloxacin,\n MethylPREDNISolone, Vancomycin, Docusate Sodium, Furosemide, others\n noted\n Labs:\n Value\n Date\n Glucose\n 180 mg/dL\n 03:06 AM\n Glucose Finger Stick\n 191\n 12:00 PM\n BUN\n 50 mg/dL\n 03:06 AM\n Creatinine\n 1.2 mg/dL\n 03:06 AM\n Sodium\n 141 mEq/L\n 03:06 AM\n Potassium\n 4.8 mEq/L\n 03:06 AM\n Chloride\n 107 mEq/L\n 03:06 AM\n TCO2\n 25 mEq/L\n 03:06 AM\n PO2 (arterial)\n 120 mm Hg\n 02:12 AM\n PCO2 (arterial)\n 43 mm Hg\n 02:12 AM\n pH (arterial)\n 7.40 units\n 02:12 AM\n pH (urine)\n 5.0 units\n 07:20 PM\n CO2 (Calc) arterial\n 28 mEq/L\n 02:12 AM\n Calcium non-ionized\n 7.9 mg/dL\n 03:06 AM\n Phosphorus\n 3.2 mg/dL\n 03:06 AM\n Ionized Calcium\n 1.13 mmol/L\n 10:35 PM\n Magnesium\n 2.2 mg/dL\n 03:06 AM\n Total Bilirubin\n 0.6 mg/dL\n 03:53 AM\n WBC\n 13.1 K/uL\n 03:06 AM\n Hgb\n 8.7 g/dL\n 03:06 AM\n Hematocrit\n 26.2 %\n 03:06 AM\n Current diet order / nutrition support: Regular; Cardiac/Heart healthy\n GI: Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: normal\n Assessment of Nutritional Status\n Patient at risk due to: NPO, desat-reintubation\n Estimated Nutritional Needs\n Calories: 1320-1500 (BEE x or / 22-25 cal/kg)\n Protein: 72-84 (1.2-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 77 year old female presented from rehab with diarrhea, hypotension and\n respiratory distress progressing into acute respiratory failure- found\n to have PNA/asthma flare, patient extubated , and then reintubated\n yesterday due to respiratory distress. Consider tube feed as temporary\n nutrition support if unable to extubate by Monday.\n Medical Nutrition Therapy Plan - Recommend the Following\n Change diet to: NPO\n Tube feeding recommendations: Boost Glucose Control goal\n 55ml/hr (1400kcal/77g protein)\n Check chemistry 10 panel daily, replete prn\n Continue insulin sliding scale if serum glucose greater than\n 150 mg/dL\n Other: if has question\n .\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497346,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Reintubated for respiratory distress\n - A line placed\n - Borderline BP after intubation, but resolved with 500cc NS\\\n - 20 beat run of VT after intubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 08:23 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 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 09:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 85 (70 - 125) bpm\n BP: 105/58(78) {91/51(66) - 124/69(92)} mmHg\n RR: 16 (10 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 554 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 554 mL\n Blood products:\n Total out:\n 1,780 mL\n 655 mL\n Urine:\n 1,780 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 475 (443 - 475) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/43/120/25/1\n Ve: 6.7 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (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: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 355 K/uL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n 0.60\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Worsening pulmonary edema.\n Microbiology: No new culture data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n # Hypoxemic respiratory failure: Initially PNA with superimposed\n asthma flare. Extubated . Developed acute respiratory distress\n 11/5pm requiring re-intubation for obtundation and mottled appearance.\n Unclear etiology (VBG 4.32/42 and sats in high 90s on 4L prior to\n obtundation), but likely due to volume status and large anxiety\n component. Now looks extubatable, but hesitant given unclear event\n that led to reintubation. Differential includes pulmonary edema,\n anxiety, oversedation with ativan, HAP, PE, and acute bronchspasm.\n - Continue albuterol MDI; on steroids for asthma flare\n Day \n - Lasix gtt to diuresis given borderline BP\n - Continue abx for HAP\n - Versed gtt for anxiety\n - LE dopplers to r/o DVT as PE is consideration for acute episode last\n pm\n - SBT today, RSBI 37\n Decrease PS 5/5 and plan to extubate tomorrow\n - Cardiology consult\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - Continue vanc/cefepime/cipro\n Day \n - Off pressors since am\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, and aldactone; restart when BP allows\n - Cardiology consult to evaluate for cardaic etiology of events last pm\n # Afib: Currently in sinus.\n - Restart amiodarone, BB when BP allows\n - On coumadin\n hold today\ns dose and decreease dose (INR 3.7)\n #FEN: Bowel regimen. NPO\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: Boots, Coumadin\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": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497439,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n 1006 Bilat leg U/S obtained No DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. L/S clear\n to diminished @ bases. CXR showing mild Pulmonary edema. Last\n ABG-7.36/48/123\n Action:\n PS decreased to 5 Peep-5, FIO2 30%. Suctioning occ for small amts\n yellow secretions. Started on Lasix GTT @ 5mg/hr then decreased to\n 3mg/hr. On IV antibx\ns for PNX. Bilat leg U/S obtained\n Response:\n Tolerated vent changes, good response to Lasix Gtt. No DVT\ns noted.\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR.\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 1mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Versed Gtt increased to 2mg.\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with no ectopy. Cardiology\n Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497440,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. L/S clear\n to diminished with crackles @ bases.\n Action:\n No vent changes made,cont Lasix gtt, received on 2mg/hr, goal 100cc/hr\n Response:\n Increased lasix to 3mg/hr\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR.\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 2mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with no ectopy. Cardiology\n Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497441,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS5/peep 5 Fio2 35%, O2 sats 96-99%,\n RR-18-24. L/S clear to diminished with crackles @ bases.\n Action:\n No vent changes made,cont Lasix gtt, received on 2mg/hr, goal 100cc/hr\n Response:\n Increased lasix to 3mg/hr\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR.\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 2mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Cont fentanyl/versed\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occass PVC\ns, K4.0.\n Cardiology Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497443,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS5/peep 5 Fio2 35%, O2 sats 96-99%,\n RR-18-24. L/S clear to diminished with crackles @ bases.\n Action:\n No vent changes made,cont Lasix gtt, received on 2mg/hr, goal 100cc/hr\n Response:\n Increased lasix to 3mg/hr\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR.\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 2mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Cont fentanyl/versed\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occass PVC\ns, K4.6.\n Cardiology Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497518,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:15 AM\n bilat leg U/S\n Cardiology consulted. Agreed that CHF playing a role in her\n respiratory distress. Started Lasix gtt, diuresed well.\n LENIS negative\n Plan for extubation this morning if doing well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:23 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:32 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 07:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.8\nC (96.5\n HR: 81 (76 - 99) bpm\n BP: 113/58(80) {104/55(75) - 173/162(168)} mmHg\n RR: 15 (11 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,082 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,032 mL\n 322 mL\n Blood products:\n Total out:\n 2,685 mL\n 1,000 mL\n Urine:\n 2,685 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,603 mL\n -558 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 481 (400 - 481) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 40\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.45/46/125/29/7\n Ve: 5.3 L/min\n PaO2 / FiO2: 357\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 410 K/uL\n 9.1 g/dL\n 199 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 45 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.6 %\n 16.5 K/uL\n [image002.jpg]\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n WBC\n 11.7\n 13.1\n 16.5\n Hct\n 25.5\n 26.2\n 27.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n TropT\n 0.60\n TCO2\n 26\n 25\n 26\n 28\n 28\n 33\n Glucose\n 243\n 180\n 281\n 199\n Other labs: PT / PTT / INR:44.1/34.5/4.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.0 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497520,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:15 AM\n bilat leg U/S\n Cardiology consulted. Agreed that CHF playing a role in her\n respiratory distress. Started Lasix gtt, diuresed well.\n LENIS negative\n Plan for extubation this morning if doing well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:23 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:32 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 07:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.8\nC (96.5\n HR: 81 (76 - 99) bpm\n BP: 113/58(80) {104/55(75) - 173/162(168)} mmHg\n RR: 15 (11 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,082 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,032 mL\n 322 mL\n Blood products:\n Total out:\n 2,685 mL\n 1,000 mL\n Urine:\n 2,685 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,603 mL\n -558 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 481 (400 - 481) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 40\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.45/46/125/29/7\n Ve: 5.3 L/min\n PaO2 / FiO2: 357\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 410 K/uL\n 9.1 g/dL\n 199 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 45 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.6 %\n 16.5 K/uL\n [image002.jpg]\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n WBC\n 11.7\n 13.1\n 16.5\n Hct\n 25.5\n 26.2\n 27.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n TropT\n 0.60\n TCO2\n 26\n 25\n 26\n 28\n 28\n 33\n Glucose\n 243\n 180\n 281\n 199\n Other labs: PT / PTT / INR:44.1/34.5/4.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.0 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, reintubated overnight.\n # Hypotension: Resolved. Thought to be secondary to distributive\n shock, o2 requirement, in the setting of RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - favor neo over levophed if needed given recent MI and acutely\n depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n CEs at that time negative. EKG unchanged from prior. PE unlikely given\n supratherapeutic on coumadin.\n - attempt to wean ventilation\n -continue broad spectrum vanc, cipro, cefepime day 6 of 8 for HA pna\n - day 4 of 5 of steroids for asthma\n -continue MDIs\n -lasix gtt with goal I/Os of -1L if BP tolerates\n -cycle Ces\n -Cardiology consult to eval whether hypoxia cardiac etiology given\n recent STEMI\n -bilateral LENIs\nif negative, consider CTA tomorrow if continues to be\n hypoxic\n # Diarrhea/Leukocytosis: resolved.\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n yesterday evening after being intubated.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix given just weaned off pressors this\n morning. Consider restarting BB in AM if BP tolerates.\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n - f/u cardiology recs\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - supratherapeutic on coumadin\nhold coumadin today\n # FEN: IVFs / replete lytes prn / NPO\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496832,
"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 - On SBT this morning\n - Still on pressors, CVP in low teens\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 03:52 PM\n Ciprofloxacin - 02:25 AM\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\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 11:12 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: 76 (71 - 93) bpm\n BP: 102/49(61) {83/45(58) - 110/67(74)} mmHg\n RR: 16 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 17 (7 - 21)mmHg\n Total In:\n 2,349 mL\n 899 mL\n PO:\n TF:\n IVF:\n 2,199 mL\n 749 mL\n Blood products:\n Total out:\n 768 mL\n 670 mL\n Urine:\n 768 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,581 mL\n 229 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 378 (226 - 577) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 42\n PIP: 6 cmH2O\n SpO2: 98%\n ABG: ///25/\n Ve: 5.3 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: present), (Left radial pulse:\n present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear, fair air movement : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: normal turgor, no rashes\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.2 g/dL\n 556 K/uL\n 191 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 42 mg/dL\n 110 mEq/L\n 141 mEq/L\n 28.1 %\n 20.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n WBC\n 30.8\n 26.2\n 20.5\n Hct\n 29.0\n 29.1\n 28.1\n Plt\n \n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n Other labs: PT / PTT / INR:24.2/31.4/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Improving RLL consolidation, perhaps some resolution of\n atelectasis. Increased edema.\n Microbiology: Sputum culture negative, Urine culture negative, Blood\n pending\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - F/U cultures\n - Continue vanc/cefepime/cipro (adjust doses based on improved\n creatinine)\n - D/c c. diff coverage given no stool output here\n - Genlte IVF + wean pressors\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Intubated .\n - Continue albuterol MDI\n - Steroids started for asthma flare\n - Extubate today\n - Wean O2 as tolerated and check ABG\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - Hold amiodarone, BB as hypotensive\n - Restart coumadin\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496974,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on NC 3L, sat 98%, pt has wheezing, cont nebs. Follows\n commands, MAE . RR up to 36\n Action:\n Given nebs, cont NC.\n Response:\n SAT 99-100%. After nebs R down to 20\ns. around 0500 pt start c/o of\n SOB, difficulty breathing, , pt has non-productive congestive cough,\n chest PT done, given nebs.\n Plan:\n Encourage cough and deep breathing. Albuterol and Atrovent inhalers as\n ordered.\n Shock, septic\n Assessment:\n Received on neo 1mcg/kg/min, SBP 90s-100s, MAP 61-70, temp 99.7.\n Action:\n Weaning Neo gtt with goal MAP>60. Vanco, Cipro, Cefepime IV as ordered.\n Wean Neo to 0.8mcg/kg/min and then 0.6 mcg/kg/min\n Response:\n Current off NEO. SBP>100, MAP>60. Temp 986.7PO. WBC trending down,\n current\n Plan:\n Wean Neo as tolerated to keep MAP>60. Continue IV antibiotics.\n Anxiety\n Assessment:\n Pt saying she\ns anxious. Per patient\ns daughter, patient is an\n extremely anxious person, to the point of hyperventilation, although\n she does not take any home anti anxiety meds.\n Action:\n Given Ativen 0.25 iv\n Response:\n Lorazepam 0.25mg IV x2 for anxious behavior with good response.\n Plan:\n Medicate PRN and offer emotional support for patient\ns high anxiety.\n Cont Lorazepam 0.25mg IVP PRN for anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496980,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on NC 3L, sat 98%, pt has wheezing, cont nebs. Follows\n commands, MAE . RR up to 36\n Action:\n Given nebs, cont NC.\n Response:\n SAT 99-100%. After nebs R down to 20\ns. around 0500 pt start c/o of\n SOB, difficulty breathing, , pt has non-productive congestive cough,\n chest PT done, given nebs.\n Plan:\n Encourage cough and deep breathing. Albuterol and Atrovent inhalers as\n ordered. Cont follow resp status\n Shock, septic\n Assessment:\n Received on neo 1mcg/kg/min, SBP 90s-100s, MAP 61-70, temp 99.7.\n Action:\n Weaning Neo gtt with goal MAP>60. Vanco, Cipro, Cefepime IV as ordered.\n Wean Neo to 0.8mcg/kg/min and then 0.6 mcg/kg/min\n Response:\n Current off NEO. SBP>100, MAP>60. Temp 986.7PO. WBC trending down,\n current\n Plan:\n Wean Neo as tolerated to keep MAP>60. Continue IV antibiotics.\n Anxiety\n Assessment:\n Pt saying she\ns anxious. Per patient\ns daughter, patient is an\n extremely anxious person, to the point of hyperventilation, although\n she does not take any home anti anxiety meds.\n Action:\n Given Ativen 0.25 iv\n Response:\n Lorazepam 0.25mg IV x2 for anxious behavior with good response.\n Plan:\n Medicate PRN and offer emotional support for patient\ns high anxiety.\n Cont Lorazepam 0.25mg IVP PRN for anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497155,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on NC 4L/min. Lung sounds with expiratory wheezes\n throughout most of the day. Congested cough, pt not bringing up much\n for secretions. Sats throughout the day high 90\ns and pt able to wean\n to 2L NC. Denied SOB and no increased WOB noted throughout the day.\n This evening, pt noted to have increased WOB with RR 30\ns and sats\n hovering mid to low 90\ns on 2L NC. C/O feeling like she can\nt breathe.\n Diaphoretic. Squirmy in the bed and picking at tubes. Tachycardic to\n 120\ns and SBP 150\ns. Of note, pt is known to have hx of becoming very\n anxious.\n Action:\n MDI\ns given as ordered with little effect, so Atrovent neb given. NC\n increased to 4L. Pt given 0.25mg Ativan with little effect, so another\n 0.25mg of Ativan given. EKG obtained. MICU resident in to see ot and\n ABG drawn.\n Response:\n ABG 7.33 PcO2 47 and PO2 40\n thought to be venous sample. Pt\ns sats\n have improved to high 90\ns since increase in O2 and receiving neb\n treatment. Continues to be diaphoretic and picking at gown/wires. Cont\n to c/o difficulty breathing. Remains tachycardic in the 120\n Plan:\n MICU resident, fellow and attending in to see pt. Feel that\n deterioration in resp status is r/t anxiety. Plan is to obtain a CXR\n and try Haldol. Continue MDI\ns as ordered. Encourage CDB. NTS PRN.\n Anxiety\n Assessment:\n Pt known to become very anxious at baseline, at times to the point of\n hyperventilation per pt\ns daughter. This AM noted to become anxious,\n medicated with 0.25mg Ativan\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497409,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. L/S clear\n to diminished @ bases. CXR showing mild Pulmonary edema. Last\n ABG-7.36/48/123\n Action:\n PS decreased to 5 Peep-5, FIO2 30%. Suctioning occ for small amts\n yellow secretions. Started on Lasix GTT @ 5mg/hr then decreased to\n 3mg/hr. On IV antibx\ns for PNX. Bilat leg U/S obtained\n Response:\n Tolerated vent changes, good response to Lasix Gtt. No DVT\ns noted.\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR.\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 1mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Versed Gtt increased to 2mg.\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with no ectopy. Cardiology\n Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 497498,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason: Emergent (1st time)\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: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496906,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient . Lightly sedated on Versed 1mg/hr and Fentanyl\n 25mcg/hr. Moves all extremities to command, able to hold head off\n pillow.\n Action:\n Vent weaned to CPAP 10 / 5, then SBT. Tolerated CPAP 0 / 5 for 30\n minutes. Extubated to 4 L NC at 1200.\n Sedation off.\n Response:\n SAT 99-100%. Lung sounds clear upper fields, crackles in bases\n bilaterally. Received alb/atr nebulizers tx. Immediately upon\n extubation.\n Plan:\n Encourage cough and deep breathing. Albuterol and Atrovent inhalers as\n ordered.\n Shock, septic\n Assessment:\n Received on neo 2.5 mcg/kg/min, SBP 90s-100s, MAP 61-70, temp 99.7.\n Action:\n Weaning Neo gtt with goal MAP>60. Vanco, Cipro, Cefepime IV as ordered.\n Response:\n Current Neo rate 1.5 mcg/kg/min. SBP>100, MAP=70. Temp 98 PO. WBC\n trending down, current 20.5.\n Plan:\n Wean Neo as tolerated to keep MAP>60. Continue IV antibiotics.\n Anxiety\n Assessment:\n Received patient on Versed gtt 1mg/hr. Patient nods\n she is\n anxious, indicated it was due to ETT. Per patient\ns daughter, patient\n is an extremely anxious person, to the point of hyperventilation,\n although she does not take any home anti anxiety meds.\n Action:\n Patient extubated today, Versed gtt off. Lorazepam 0.25mg IVP PRN for\n anxiety.\n Response:\n Lorazepam 0.25mg IV x1 for anxious behavior with good response.\n Plan:\n Medicate PRN and offer emotional support for patient\ns high anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496907,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on NC 3L, sat 98%, pt has wheezing, cont nebs. Follows\n commands, MAE . RR up to 36\n Action:\n Given nebs, cont NC.\n Response:\n SAT 99-100%. After nebs R down to 20\n Plan:\n Encourage cough and deep breathing. Albuterol and Atrovent inhalers as\n ordered.\n Shock, septic\n Assessment:\n Received on neo 1mcg/kg/min, SBP 90s-100s, MAP 61-70, temp 99.7.\n Action:\n Weaning Neo gtt with goal MAP>60. Vanco, Cipro, Cefepime IV as ordered.\n Wean Neo to 0.8mcg/kg/min\n Response:\n Current Neo rate 0.5 mcg/kg/min. SBP>100, MAP>60. Temp 98 PO. WBC\n trending down, current\n Plan:\n Wean Neo as tolerated to keep MAP>60. Continue IV antibiotics.\n Anxiety\n Assessment:\n Pt saying she\ns anxious. Per patient\ns daughter, patient is an\n extremely anxious person, to the point of hyperventilation, although\n she does not take any home anti anxiety meds.\n Action:\n Given Ativen 0.25 iv\n Response:\n Lorazepam 0.25mg IV x1 for anxious behavior with good response.\n Plan:\n Medicate PRN and offer emotional support for patient\ns high anxiety.\n Cont Lorazepam 0.25mg IVP PRN for anxiety.\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 497211,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n 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 Comments: ETT pulled back after Post\n intubation CXR.\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: Nasotrachial Suction / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Was on full ventilatory support, able to transition to PSV/\n ABG WNL.\n Assessment of breathing comfort: No claim of dyspnea); Comments: AWAke\n & following comand/ sedation weaned.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (Low min. ventilation)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~34.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497315,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:15 PM -secondary to\n hypoxemia and respiratory distress\n ARTERIAL LINE - START 10:00 PM -placed\n -20 beat run of VT\n -hypotensive after intubation. Resolved with 500cc bolus.Did not\n require pressors\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 80 (70 - 125) bpm\n BP: 108/60(79) {91/51(66) - 124/69(92)} mmHg\n RR: 14 (10 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 269 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 269 mL\n Blood products:\n Total out:\n 1,780 mL\n 455 mL\n Urine:\n 1,780 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -186 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 443 (443 - 443) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/43/120/25/1\n Ve: 6.2 L/min\n PaO2 / FiO2: 343\n Physical Examination\n Gen: Intubated, sedated, NAD\n Neck: Supple, no LAD\n Lungs: Bronchial breath sounds at R base. Diffuse expiratory wheezes\n bilaterally.\n CV: RRR. No murmurs.\n Abdomen: Soft, NT, ND. No masses. No rebound or guarding.\n Extremities: Warm, well perfused. No LE edema.\n Labs / Radiology\n 355 K/uL\n 8.7 g/dL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg] All culture data is pending\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, reintubated overnight.\n # Hypotension: Resolved. Thought to be secondary to distributive\n shock, o2 requirement, in the setting of RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - favor neo over levophed if needed given recent MI and acutely\n depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n CEs at that time negative. EKG unchanged from prior. PE unlikely given\n supratherapeutic on coumadin.\n - attempt to wean ventilation\n -continue broad spectrum vanc, cipro, cefepime day 6 of 8 for HA pna\n - day 4 of 5 of steroids for asthma\n -continue MDIs\n -lasix gtt with goal I/Os of -1L if BP tolerates\n -cycle Ces\n -Cardiology consult to eval whether hypoxia cardiac etiology given\n recent STEMI\n -bilateral LENIs\nif negative, consider CTA tomorrow if continues to be\n hypoxic\n # Diarrhea/Leukocytosis: resolved.\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n yesterday evening after being intubated.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix given just weaned off pressors this\n morning. Consider restarting BB in AM if BP tolerates.\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n - f/u cardiology recs\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - supratherapeutic on coumadin\nhold coumadin today\n # FEN: IVFs / replete lytes prn / NPO\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497318,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:15 PM -secondary to\n hypoxemia and respiratory distress\n ARTERIAL LINE - START 10:00 PM -placed\n -20 beat run of VT\n -hypotensive after intubation. Resolved with 500cc bolus.Did not\n require pressors\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 80 (70 - 125) bpm\n BP: 108/60(79) {91/51(66) - 124/69(92)} mmHg\n RR: 14 (10 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 269 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 269 mL\n Blood products:\n Total out:\n 1,780 mL\n 455 mL\n Urine:\n 1,780 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -186 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 443 (443 - 443) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/43/120/25/1\n Ve: 6.2 L/min\n PaO2 / FiO2: 343\n Physical Examination\n Gen: Intubated, sedated, NAD\n Neck: Supple, no LAD\n Lungs: Bronchial breath sounds at R base. Diffuse expiratory wheezes\n bilaterally.\n CV: RRR. No murmurs.\n Abdomen: Soft, NT, ND. No masses. No rebound or guarding.\n Extremities: Warm, well perfused. No LE edema.\n Labs / Radiology\n 355 K/uL\n 8.7 g/dL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg] All culture data is pending\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, reintubated overnight.\n # Hypotension: Resolved. Thought to be secondary to distributive\n shock, o2 requirement, in the setting of RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - favor neo over levophed if needed given recent MI and acutely\n depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n CEs at that time negative. EKG unchanged from prior. PE unlikely given\n supratherapeutic on coumadin.\n - attempt to wean ventilation\n -continue broad spectrum vanc, cipro, cefepime day 6 of 8 for HA pna\n - day 4 of 5 of steroids for asthma\n -continue MDIs\n -lasix gtt with goal I/Os of -1L if BP tolerates\n -cycle Ces\n -Cardiology consult to eval whether hypoxia cardiac etiology given\n recent STEMI\n -bilateral LENIs\nif negative, consider CTA tomorrow if continues to be\n hypoxic\n # Diarrhea/Leukocytosis: resolved.\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n yesterday evening after being intubated.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix given just weaned off pressors this\n morning. Consider restarting BB in AM if BP tolerates.\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n - f/u cardiology recs\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - supratherapeutic on coumadin\nhold coumadin today\n # FEN: IVFs / replete lytes prn / NPO\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 497740,
"text": "Demographics\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum source/amount: / minimal\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Non-invasive ventilation assessment: Tolerated well\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Comments:\n Pt has unclear Hx of sleep apnea, needs study. Has Hx CHF /\n cardiogenic shock. Sleep attending wanted to assess value of NIV for\n this patient.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497852,
"text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:43 AM\n - good UOP on lasix drip, continued\n - restarting ace-i and BB this AM\n - Pt very uncomfortable with CPAP\n - WBC rising to 20 from 10 in two days, stooling all night, started on\n po Vanco, cdiff sent\n - coumadin held as INR still supratherapeutic\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.2\nC (97.2\n HR: 89 (81 - 108) bpm\n BP: 137/75(101) {111/58(80) - 167/124(144)} mmHg\n RR: 17 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 346 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,035 mL\n 346 mL\n Blood products:\n Total out:\n 3,090 mL\n 920 mL\n Urine:\n 3,090 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -574 mL\n Respiratory support\n 2L nasal cannula\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 421 K/uL\n 9.4 g/dL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg] No new culture data\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Microbiology: Urine culture negative\n 11/2 Blood culture x1 negative\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock.\n # Sepsis/Hypotension: Resolved. Thought to be secondary to\n distributive shock, o2 requirement, in the setting of RLL pneumonia\n poorly compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - Completed 8 day course of vanco/cefepime/cipro empirically for HAP\n # Hypoxemic respiratory failure / increased work of breathing:\n resolvied. Likely PNA, asthma, and ? fluid overload. CEs at that\n time negative. EKG unchanged from prior.\n -completed 8 days of broad spectrum vanc, cipro, cefepime for HA pna\n - completed 5 days of steroids for asthma\n -continue MDIs\n -lasix gtt with goal I/Os of -2L if BP tolerates\n -d/c non invasive ventilation as patient does not tolerate\n # leukocytosis: WBC 21.3, up from 13.1 two days prior. Patient having\n abdominal cramping, and stool output after broad spectrum abx.\n Afebrile.\n -continue po vanc empirically for C diff\n -send C diff\n -UA, Ucx, Blood cultures negative to date\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, while aggressively diuresising, but resume\n ASAP\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n - f/u cardiology recs\n # Afib: Currently in sinus.\n - hold BB as as above, resume amio (although long half-life means she\n will be therapeutic for a while)\n - supratherapeutic on coumadin\nhold coumadin today\n # FEN: IVFs / replete lytes prn / NPO\n # PPX: H2RA, supratherapeutic inr\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: call out to Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497853,
"text": "Chief Complaint: Shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 10:43 AM\n - good UOP on lasix drip, continued\n - restarting ace-i and BB this AM\n - Pt very uncomfortable with CPAP\n - WBC rising to 20 from 10 in two days, stooling all night, started on\n po Vanco, cdiff sent\n - coumadin held as INR still supratherapeutic\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 05:04 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 09:55 AM\n Fentanyl - 09:55 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.2\nC (97.2\n HR: 89 (81 - 108) bpm\n BP: 137/75(101) {111/58(80) - 167/124(144)} mmHg\n RR: 17 (12 - 24) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,455 mL\n 346 mL\n PO:\n 300 mL\n TF:\n IVF:\n 1,035 mL\n 346 mL\n Blood products:\n Total out:\n 3,090 mL\n 920 mL\n Urine:\n 3,090 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,635 mL\n -574 mL\n Respiratory support\n 2L nasal cannula\n Physical Examination\n Gen: Well appearing, NAD\n Neck: Supple, no LAD\n Lungs: Crackles at bases bilaterally.\n CV: RRR. No murmurs.\n Abdomen: Soft, NT, ND. No masses. No rebound or guarding.\n Extremities: Warm, well perfused. No LE edema.\n Labs / Radiology\n 421 K/uL\n 9.4 g/dL\n 176 mg/dL\n 1.2 mg/dL\n 34 mEq/L\n 4.0 mEq/L\n 41 mg/dL\n 97 mEq/L\n 139 mEq/L\n 28.0 %\n 21.3 K/uL\n [image002.jpg] No new culture data\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n 03:54 PM\n 04:10 AM\n WBC\n 13.1\n 16.5\n 21.3\n Hct\n 26.2\n 27.6\n 28.0\n Plt\n 355\n 410\n 421\n Cr\n 1.2\n 1.1\n 1.1\n 1.2\n 1.2\n TropT\n 0.60\n TCO2\n 25\n 26\n 28\n 28\n 33\n Glucose\n 180\n 281\n 199\n 308\n 176\n Other labs: PT / PTT / INR:42.0/34.8/4.4, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.6 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.0 mg/dL\n Microbiology: Urine culture negative\n 11/2 Blood culture x1 negative\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock.\n # Sepsis/Hypotension: Resolved. Thought to be secondary to\n distributive shock, o2 requirement, in the setting of RLL pneumonia\n poorly compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - Completed 8 day course of vanco/cefepime/cipro empirically for HAP\n # Hypoxemic respiratory failure / increased work of breathing:\n resolvied. Likely PNA, asthma, and ? fluid overload. CEs at that\n time negative. EKG unchanged from prior.\n -completed 8 days of broad spectrum vanc, cipro, cefepime for HA pna\n - completed 5 days of steroids for asthma\n -continue MDIs\n -lasix gtt with goal I/Os of -2L if BP tolerates\n -d/c non invasive ventilation as patient does not tolerate\n # leukocytosis: WBC 21.3, up from 13.1 two days prior. Patient having\n abdominal cramping, and stool output after broad spectrum abx.\n Afebrile.\n -continue po vanc empirically for C diff\n -send C diff\n -UA, Ucx, Blood cultures negative to date\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, while aggressively diuresising, but resume\n ASAP\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n - f/u cardiology recs\n # Afib: Currently in sinus.\n - hold BB as as above, resume amio (although long half-life means she\n will be therapeutic for a while)\n - supratherapeutic on coumadin\nhold coumadin today\n # FEN: IVFs / replete lytes prn / NPO\n # PPX: H2RA, supratherapeutic inr\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: call out to Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 497401,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 56.7 None\n Ideal tidal volume: 226.8 / 340.2 / 453.6 mL/kg\n 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 Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497487,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS5/peep 5 Fio2 35%, O2 sats 96-99%,\n RR-18-24. L/S clear to diminished with crackles @ bases.\n Action:\n No vent changes made,cont Lasix gtt, received on 2mg/hr, goal 100cc/hr\n Response:\n Increased lasix to 3mg/hr. pt neg 1600cc fro 24 hr\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR. Possible\n extubation\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 2mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Cont fentanyl/versed\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occass PVC\ns, K4.6.\n Cardiology Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n Overnight notes pt has had bloody urine, ?trauma. in the morning urine\n more clear.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496897,
"text": "Chief Complaint:\n 24 Hour Events:\n ET tube pulled back 1cm. Repeat CXR with ET tube 3.2 cm above carina\n Coumadin Restarted.\n Fentanyl and Versed weaned down but patient did not tolerate weaning of\n vent. Remains on PS with MMV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 03:52 PM\n Ciprofloxacin - 02:25 AM\n Vancomycin - 05:58 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Midazolam (Versed) - 1 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 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.6\nC (99.7\n HR: 82 (71 - 93) bpm\n BP: 95/47(58) {78/45(58) - 110/67(74)} mmHg\n RR: 13 (8 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 70 kg\n CVP: 12 (7 - 20)mmHg\n Total In:\n 2,349 mL\n 469 mL\n PO:\n TF:\n IVF:\n 2,199 mL\n 409 mL\n Blood products:\n Total out:\n 768 mL\n 390 mL\n Urine:\n 768 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,581 mL\n 79 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 567 (226 - 635) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 42\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 556 K/uL\n 9.2 g/dL\n 191 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 42 mg/dL\n 110 mEq/L\n 141 mEq/L\n 28.1 %\n 20.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n WBC\n 30.8\n 26.2\n 20.5\n Hct\n 29.0\n 29.1\n 28.1\n Plt\n \n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n Other labs: PT / PTT / INR:24.2/31.4/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, in\n septic shock still requiring pressors. Intubated yesterday for\n increased work of breathing.\n # Hypotension: Given distributive shock, o2 requirement, and CXR\n infiltrate, this is most likely septic shock from RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - Trend CEs, serial EKGs with any major hemodynamic changes\n - favor neo over levophed given recent MI and acutely depressed EF.\n - trial of fluids in effor to wean pressors, will be cautious given\n acutely depressed LVEF\n # Hypoxemic respiratory failure / increased work of breathing: Likely\n PNA with some contributiion from asthma given severe wheezing on\n exam. .Tolerating SBT well this am.\n - extubate, BIPAP if flashes\n - steroidsx 5 days, MDIs\n # Diarrhea/Leukocytosis: d/c empiric CDIFF covg given lack of\n diahrrea. f/u cdiff tox x2 when stools\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI.\n - Serial CEs, EKGs for any hemodynamic changes\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n - favor neo over levophed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resumed\n coumadin yesterday\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497201,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Started shift w/ pt already being treated for anxiety w/ x2 PRN doses\n ativan IV w/ no effect, EKG done, CXR done, appearing mottled, feeling\n cold and clammy to touch, changes in LOC, very labored breathing, desat\n to high 70\ns, ABG w/ PaO2 in 40\ns (MD\ns thought to be venous), placed\n on bipap for short period w/ no relief.\n Action:\n MDI\ns given as ordered with little effect, so Atrovent neb given. NC\n increased to 4L. Pt given 0.25mg Ativan with little effect, so another\n 0.25mg of Ativan given. EKG obtained. MICU resident in to see ot and\n ABG drawn.\n Response:\n ABG 7.33 PcO2 47 and PO2 40\n thought to be venous sample. Pt\ns sats\n have improved to high 90\ns since increase in O2 and receiving neb\n treatment. Continues to be diaphoretic and picking at gown/wires. Noted\n to be mottling. Cont to c/o difficulty breathing. Remains tachycardic\n in the 120\ns. MICU team aware.\n Plan:\n MICU resident, fellow and attending in to see pt. Feel that\n deterioration in resp status is r/t anxiety. Plan is to obtain a CXR\n and try Haldol. Continue MDI\ns as ordered. Encourage CDB. NTS PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497264,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Started shift w/ pt already being treated for anxiety w/ x2 PRN doses\n ativan IV w/ no effect, MDI\ns w/ no effect, EKG done, CXR done,\n appearing mottled, feeling cold and clammy to touch, changes in LOC,\n very labored breathing, desat to high 70\ns, ABG w/ PaO2 in 40\ns (MD\n thought to be venous), placed on bipap for short period w/ no relief.\n Action:\n Pt intubated at start of shift. 40mg IV lasix x1 given. A-line\n placed. CXR to confirm ETT placement. Multiple ABG\ns and vent setting\n changes. OGT placed before AM CXR.\n Response:\n Pt immediately improved following intubation; skin warmed, pale (not\n mottled), skin dry, no wheezing (w/o MDI\ns being given), LS clear upper\n and diminished lower, HR decreased from 130\ns to 80\ns, BP stable all\n night w/ MAP>65. Able to wean vent to Psup but pt having periods of\n apnea even with weaning sedation to fent 25mcg and versed 2mg/hr.\n ABG\ns wnl, apnea periods <30sec, became less frequent and pt recovering\n on own so left on Psup @ this time. Pt easily arousable, follows all\n commands, MAE (lift/hold), no c/o pain.\n Plan:\n f/u on CXR results from AM, cont to wean vent as tolerated, ?\n cardiogenic cause for resp failure but pt will likely remain intubated\n until cause is determined. Cont abx. Awaiting AM cxr results to\n confirm OGT placement.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Resp status at being of shift as per above. ? cardiac issues leading\n to resp failure.\n Action:\n Cardiac enzymes sent last evening post event and repeated w/ AM labs.\n Lytes wnl.\n Response:\n Card . neg, EKG from day shift prior to intubation showing no\n changes compared to previous, CK 84-73 (MB and trop from AM still\n pending). No c/o chest pain from pt.\n Plan:\n Monitor for EKG changes and signs of MI.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497267,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:15 PM -secondary to\n hypoxemia and respiratory distress\n ARTERIAL LINE - START 10:00 PM -placed\n -20 beat run of VT\n -hypotensive after intubation. Resolved with 500cc bolus.Did not\n require pressors\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 80 (70 - 125) bpm\n BP: 108/60(79) {91/51(66) - 124/69(92)} mmHg\n RR: 14 (10 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 269 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 269 mL\n Blood products:\n Total out:\n 1,780 mL\n 455 mL\n Urine:\n 1,780 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -186 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 443 (443 - 443) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/43/120/25/1\n Ve: 6.2 L/min\n PaO2 / FiO2: 343\n Physical Examination\n Gen: Intubated, sedated, NAD\n Neck: Supple, no LAD\n Lungs: Bronchial breath sounds at R base. Diffuse expiratory wheezes.\n CV: RRR. No murmurs.\n Abdomen: Soft, NT, ND. No masses. No rebound or guarding.\n Extremities: Warm, well perfused. No LE edema.\n Labs / Radiology\n 355 K/uL\n 8.7 g/dL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, reintubated overnight.\n # Hypotension: Resolved. Thought to be secondary to distributive\n shock, o2 requirement, in the setting of RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - favor neo over levophed if needed given recent MI and acutely\n depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n CEs at that time negative. EKG unchanged from prior.\n - attempt to wean ventilation\n - completed course of steroids\n -continue MDIs\n -consider trial of diuresis today, as pressure tolerates\n -cycle Ces\n -consider repeat echo\n # Diarrhea/Leukocytosis: resolved.\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n yesterday evening after being intubated. No further evants like that\n overnight.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix given just weaned off pressors this\n morning. Consider restarting BB in AM if BP tolerates.\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resumed\n coumadin\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497389,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. L/S clear\n to diminished @ bases. CXR showing mild Pulmonary edema. Last\n ABG-7.36/48/123\n Action:\n PS decreased to 5 Peep-5, FIO2 30%. Suctioning occ for small amts\n yellow secretions. Started on Lasix GTT @ 5mg/hr then decreased to\n 3mg/hr. On IV antibx\ns for PNX. Bilat leg U/S obtained\n Response:\n Tolerated vent changes, good response to Lasix Gtt. No DVT\ns noted.\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR.\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 1mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Versed Gtt increased to 2mg.\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with no ectopy. Cardiology\n Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497288,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Reintubated for respiratory distress\n - A line placed\n - Borderline BP after intubation, but resolved with 500cc NS\\\n - 20 beat run of VT after intubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 08:23 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 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 09:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 85 (70 - 125) bpm\n BP: 105/58(78) {91/51(66) - 124/69(92)} mmHg\n RR: 16 (10 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 554 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 554 mL\n Blood products:\n Total out:\n 1,780 mL\n 655 mL\n Urine:\n 1,780 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 475 (443 - 475) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/43/120/25/1\n Ve: 6.7 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (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: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 355 K/uL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n 0.60\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Worsening pulmonary edema.\n Microbiology: No new culture data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HCAP PNA/asthma\n flare\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - Continue vanc/cefepime/cipro for 8 day course\n - Off pressors since this am\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Extubated . On RA.\n - Continue albuterol MDI\n - Steroids started for asthma flare\n Day \n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix and restart when BP allows\n # Afib: Currently in sinus.\n - Restart amiodarone, BB when BP allows\n - On coumadin\n #FEN: Bowel regimen. Full cardiac diet.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497295,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Reintubated for respiratory distress\n - A line placed\n - Borderline BP after intubation, but resolved with 500cc NS\\\n - 20 beat run of VT after intubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 08:23 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 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 09:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 85 (70 - 125) bpm\n BP: 105/58(78) {91/51(66) - 124/69(92)} mmHg\n RR: 16 (10 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 554 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 554 mL\n Blood products:\n Total out:\n 1,780 mL\n 655 mL\n Urine:\n 1,780 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 475 (443 - 475) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/43/120/25/1\n Ve: 6.7 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (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: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 355 K/uL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n 0.60\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Worsening pulmonary edema.\n Microbiology: No new culture data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n # Hypoxemic respiratory failure: Initially PNA with superimposed\n asthma flare. Extubated . Developed acute respiratory distress\n 11/5pm requiring re-intubation for obtundation and mottled appearance.\n Unclear etiology (VBG 4.32/42 and sats in high 90s on 4L prior to\n obtundation), but likely due to volume status and large anxiety\n component. Now looks extubatable, but hesitant given unclear event\n that led to reintubation. Differential includes pulmonary edema,\n anxiety, oversedation with ativan, HAP, PE, and acute bronchspasm.\n - Continue albuterol MDI; on steroids for asthma flare\n Day \n - Lasix gtt to diuresis given borderline BP\n - Continue abx for HAP\n - Versed gtt for anxiety\n - LE dopplers to r/o DVT as PE is consideration for acute episode last\n pm\n - SBT today, RSBI 37\n Decrease PS 5/5 and possible extubation later\n based on results of above\n - Cardiology consult\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - Continue vanc/cefepime/cipro\n Day \n - Off pressors since am\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, and aldactone; restart when BP allows\n - Cardiology consult to evaluate for cardaic etiology of events last pm\n # Afib: Currently in sinus.\n - Restart amiodarone, BB when BP allows\n - On coumadin\n hold today\ns dose and decreease dose (INR 3.7)\n #FEN: Bowel regimen. NPO\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: Boots, Coumadin\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": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497386,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS, O2 sats 96-99%, RR-18-24. L/S clear\n to diminished @ bases. CXR showing mild Pulmonary edema. Last ABG-\n Action:\n PS decreased to 5 Peep-5, FIO2 30%. Suctioning occ for small amts\n yellow secretions. Started on Lasix GTT @ 5mg/hr then decreased to\n 3mg/hr. On IV antibx\ns for PNX. Bilat leg U/S obtained\n Response:\n Tolerated vent changes, good response to Lasix Gtt. No DVT\ns noted.\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR.\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 1mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Versed Gtt increased to 2mg.\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with no ectopy. Cardiology\n Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 497377,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Reintubated for respiratory distress\n - A line placed\n - Borderline BP after intubation, but resolved with 500cc NS\\\n - 20 beat run of VT after intubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Vancomycin - 08:23 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 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 09:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 85 (70 - 125) bpm\n BP: 105/58(78) {91/51(66) - 124/69(92)} mmHg\n RR: 16 (10 - 35) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 554 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 554 mL\n Blood products:\n Total out:\n 1,780 mL\n 655 mL\n Urine:\n 1,780 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -100 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 475 (443 - 475) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 98%\n ABG: 7.40/43/120/25/1\n Ve: 6.7 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (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: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 8.7 g/dL\n 355 K/uL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n 0.60\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Worsening pulmonary edema.\n Microbiology: No new culture data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n # Hypoxemic respiratory failure: Initially PNA with superimposed\n asthma flare. Extubated . Developed acute respiratory distress\n 11/5pm requiring re-intubation for obtundation and mottled appearance.\n Unclear etiology (VBG 4.32/42 and sats in high 90s on 4L prior to\n obtundation), but likely due to volume status and large anxiety\n component. Now looks extubatable, but hesitant given unclear event\n that led to reintubation. Differential includes pulmonary edema,\n anxiety, oversedation with ativan, HAP, PE, and acute bronchspasm.\n - Continue albuterol MDI; on steroids for asthma flare\n Day \n - Lasix gtt to diuresis given borderline BP\n - Continue abx for HAP\n - Versed gtt for anxiety\n - LE dopplers to r/o DVT as PE is consideration for acute episode last\n pm\n - SBT today, RSBI 37\n Decrease PS 5/5 and plan to extubate tomorrow\n - Cardiology consult\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - Continue vanc/cefepime/cipro\n Day \n - Off pressors since am\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, and aldactone; restart when BP allows\n - Cardiology consult to evaluate for cardaic etiology of events last pm\n # Afib: Currently in sinus.\n - Restart amiodarone, BB when BP allows\n - On coumadin\n hold today\ns dose and decreease dose (INR 3.7)\n #FEN: Bowel regimen. NPO\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: Boots, Coumadin\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 ------ Protected Section ------\n I saw and examined this pt, and was present with the ICU team for the\n relevant portions of services provided. I agree with Dr. \ns note\n as outlined above, and would add: 77 yo female with recent STEMI\n requiring IABP/stent, admitted with resp distress/acute respiratory\n failure from HAP and asthma flare. Extubated morning of well until\n yesterday evening. Preceding events prior to acute decompensation\n mostly notable for gradual sinus tachycardia and pt\ns complaints of\n breathlessness, though no change in oxygen requirement or PE.\n Reportedly with diffuse wheezing immediately pre-intubation, lung exam\n clear today. Serial CXR\ns mostly identify ongoing fluid overload though\n not especially different yesterday. Ventilator requirements were\n rapidly weaned and she currently looks comfortable on PSV.\n CXR is not suggestive of a new HAP, airway pathophysiology feasible but\n not highly c/w the improvt in lung exam, in the absence of additional\n intervention. Recent decompensation could be from volume overload as\n her borderline BP\ns have prevented us from diuresing her before.\n As pt finally off pressors, will begin lasix gtt to diurese, have\n cardiology consult team see her. Plan SBT early tomorrow with hopeful\n plans to extubate early in the day. If she can tolerate without this\n aggravating her anxiety, early NIPPV might be considered, either\n immediately following extubation or otherwise with ABG drawn later in\n the day.\n Pt is critically ill. Total time spent: 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:46 ------\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497478,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated and vented on PS5/peep 5 Fio2 35%, O2 sats 96-99%,\n RR-18-24. L/S clear to diminished with crackles @ bases.\n Action:\n No vent changes made,cont Lasix gtt, received on 2mg/hr, goal 100cc/hr\n Response:\n Increased lasix to 3mg/hr. pt neg 1600cc fro 24 hr\n Plan:\n Pulmonary toilet as needed, monitor O2 sats and ABG\ns, continue Lasix\n Gtt and monitor u/o to be 1L to 1.5L\ns neg today. QD CXR. Possible\n extubation\n Anxiety\n Assessment:\n On Fentanyl Gtt @ 25mcq a and Versed Gtt @ 2mg/hr. Able to open eyes\n is interactive and obey commands and MAE\ns. No acute anxiety and\n agitation noted, no c/o\ns pain.\n Action:\n Cont fentanyl/versed\n Response:\n Comfortable on Versed and Fentanyl Gtt\n Plan:\n Continue Gtt\ns and assess MS, and provide for comfort.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occass PVC\ns, K4.6.\n Cardiology Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n Overnight notes pt has had bloody urine, ?trauma. in the morning urine\n more clear.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496771,
"text": "Chief Complaint:\n 24 Hour Events:\n ET tube pulled back 1cm. Repeat CXR with ET tube 3.2 cm above carina\n Coumadin Restarted.\n Fentanyl and Versed weaned down but patient did not tolerate weaning of\n vent. Remains on PS with MMV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 03:52 PM\n Ciprofloxacin - 02:25 AM\n Vancomycin - 05:58 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Midazolam (Versed) - 1 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 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.6\nC (99.7\n HR: 82 (71 - 93) bpm\n BP: 95/47(58) {78/45(58) - 110/67(74)} mmHg\n RR: 13 (8 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 70 kg\n CVP: 12 (7 - 20)mmHg\n Total In:\n 2,349 mL\n 469 mL\n PO:\n TF:\n IVF:\n 2,199 mL\n 409 mL\n Blood products:\n Total out:\n 768 mL\n 390 mL\n Urine:\n 768 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,581 mL\n 79 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 567 (226 - 635) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 42\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 556 K/uL\n 9.2 g/dL\n 191 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 42 mg/dL\n 110 mEq/L\n 141 mEq/L\n 28.1 %\n 20.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n WBC\n 30.8\n 26.2\n 20.5\n Hct\n 29.0\n 29.1\n 28.1\n Plt\n \n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n Other labs: PT / PTT / INR:24.2/31.4/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 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": "2153-10-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496772,
"text": "Chief Complaint:\n 24 Hour Events:\n ET tube pulled back 1cm. Repeat CXR with ET tube 3.2 cm above carina\n Coumadin Restarted.\n Fentanyl and Versed weaned down but patient did not tolerate weaning of\n vent. Remains on PS with MMV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 03:52 PM\n Ciprofloxacin - 02:25 AM\n Vancomycin - 05:58 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Midazolam (Versed) - 1 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 07:29 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 37.6\nC (99.7\n HR: 82 (71 - 93) bpm\n BP: 95/47(58) {78/45(58) - 110/67(74)} mmHg\n RR: 13 (8 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 70 kg\n CVP: 12 (7 - 20)mmHg\n Total In:\n 2,349 mL\n 469 mL\n PO:\n TF:\n IVF:\n 2,199 mL\n 409 mL\n Blood products:\n Total out:\n 768 mL\n 390 mL\n Urine:\n 768 mL\n 390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,581 mL\n 79 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: MMV/PSV/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 567 (226 - 635) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 42\n PIP: 15 cmH2O\n SpO2: 100%\n ABG: ///25/\n Ve: 5.5 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 556 K/uL\n 9.2 g/dL\n 191 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 42 mg/dL\n 110 mEq/L\n 141 mEq/L\n 28.1 %\n 20.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n WBC\n 30.8\n 26.2\n 20.5\n Hct\n 29.0\n 29.1\n 28.1\n Plt\n \n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n Other labs: PT / PTT / INR:24.2/31.4/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, in\n septic shock still requiring pressors. Intubated yesterday for\n increased work of breathing.\n # Hypotension: Given distributive shock, o2 requirement, and CXR\n infiltrate, this is most likely septic shock from RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. CDIFF may also be contributing. Given CVP=12,\n stable EKG, and serial CE trending down, favor sepsis over cardiogenic\n shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - Trend CEs, serial EKGs with any major hemodynamic changes\n - favor neo over levophed given recent MI and acutely depressed EF.\n - trial of fluids in effor to wean pressors, will be cautious given\n acutely depressed LVEF\n # Hypoxemic respiratory failure / increased work of breathing: Likely\n PNA with some contributiion from astma given severe wheezing on\n exam. Other concern would be LV failure from ischemia, but arguing\n against this is CVP=12avg.\n - s/p intubation; A-LINE attempts failed, will trend serial ABGS and\n venous gases\n - will attempt to wean PSV from to , RSBI 28, goal extubate\n tomorrow if tolerates wean\n - steroidsx 5 days, MDIs\n # Diarrhea/Leukocytosis: Empiric CDIFF covg given marked leukocytosis\n with PO vanco. f/u cdiff tox x2\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI.\n - Serial CEs, EKGs for any hemodynamic changes\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n - favor neo over levophed as above; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resuming\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 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": "2153-10-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496803,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - On SBT this morning\n - Still on pressors, CVP in low teens\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 03:52 PM\n Ciprofloxacin - 02:25 AM\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\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 11:12 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: 76 (71 - 93) bpm\n BP: 102/49(61) {83/45(58) - 110/67(74)} mmHg\n RR: 16 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 17 (7 - 21)mmHg\n Total In:\n 2,349 mL\n 899 mL\n PO:\n TF:\n IVF:\n 2,199 mL\n 749 mL\n Blood products:\n Total out:\n 768 mL\n 670 mL\n Urine:\n 768 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,581 mL\n 229 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 378 (226 - 577) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 42\n PIP: 6 cmH2O\n SpO2: 98%\n ABG: ///25/\n Ve: 5.3 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 9.2 g/dL\n 556 K/uL\n 191 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 42 mg/dL\n 110 mEq/L\n 141 mEq/L\n 28.1 %\n 20.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n WBC\n 30.8\n 26.2\n 20.5\n Hct\n 29.0\n 29.1\n 28.1\n Plt\n \n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n Other labs: PT / PTT / INR:24.2/31.4/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Improving RLL consolidation, perhaps some resolution of\n atelectasis. Increased edema.\n Microbiology: Sputum culture negative, Urine culture negative, Blood\n pending\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl.\n - F/U cultures\n - Continue vanc/zosyn\n - Genlte IVF + wean pressors\n - Trend CEs, serial EKGs\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Now intubated.\n - Continue albuterol MDI\n - Steroids started for asthma flare\n - Wean PS as tolerated\n # Diarrhea: Pt reports 1 week of diarrhea. Could be C. diff, although\n unlikely given recent flagyl. Elevated WBC count yesterday prompted\n initiation of PO vanc.\n - Check C. diff\n - Continue PO vanc\n will d/c if c. diff neg x 2\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Serial CEs, EKGs\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - Hold amiodarone, BB as hypotensive\n - Restart coumadin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496804,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - On SBT this morning\n - Still on pressors, CVP in low teens\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 03:52 PM\n Ciprofloxacin - 02:25 AM\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\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 11:12 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: 76 (71 - 93) bpm\n BP: 102/49(61) {83/45(58) - 110/67(74)} mmHg\n RR: 16 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 17 (7 - 21)mmHg\n Total In:\n 2,349 mL\n 899 mL\n PO:\n TF:\n IVF:\n 2,199 mL\n 749 mL\n Blood products:\n Total out:\n 768 mL\n 670 mL\n Urine:\n 768 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,581 mL\n 229 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 378 (226 - 577) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 42\n PIP: 6 cmH2O\n SpO2: 98%\n ABG: ///25/\n Ve: 5.3 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 9.2 g/dL\n 556 K/uL\n 191 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 42 mg/dL\n 110 mEq/L\n 141 mEq/L\n 28.1 %\n 20.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n WBC\n 30.8\n 26.2\n 20.5\n Hct\n 29.0\n 29.1\n 28.1\n Plt\n \n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n Other labs: PT / PTT / INR:24.2/31.4/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Improving RLL consolidation, perhaps some resolution of\n atelectasis. Increased edema.\n Microbiology: Sputum culture negative, Urine culture negative, Blood\n pending\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - F/U cultures\n - Continue vanc/zosyn (adjust doses based on improved creatinine)\n - D/c c. diff coverage given no stool output here\n - Genlte IVF + wean pressors\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Intubated .\n - Continue albuterol MDI\n - Steroids started for asthma flare\n - Extubate today\n - Wean O2 as tolerated and check ABG\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - Hold amiodarone, BB as hypotensive\n - Restart coumadin\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496805,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - On SBT this morning\n - Still on pressors, CVP in low teens\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 03:52 PM\n Ciprofloxacin - 02:25 AM\n Vancomycin - 08:00 AM\n Infusions:\n Fentanyl - 25 mcg/hour\n Midazolam (Versed) - 1 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\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 11:12 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: 76 (71 - 93) bpm\n BP: 102/49(61) {83/45(58) - 110/67(74)} mmHg\n RR: 16 (8 - 18) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n CVP: 17 (7 - 21)mmHg\n Total In:\n 2,349 mL\n 899 mL\n PO:\n TF:\n IVF:\n 2,199 mL\n 749 mL\n Blood products:\n Total out:\n 768 mL\n 670 mL\n Urine:\n 768 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,581 mL\n 229 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 378 (226 - 577) mL\n PS : 5 cmH2O\n RR (Set): 12\n RR (Spontaneous): 27\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 42\n PIP: 6 cmH2O\n SpO2: 98%\n ABG: ///25/\n Ve: 5.3 L/min\n Physical Examination\n General Appearance: Well nourished, No acute distress, Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right 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 9.2 g/dL\n 556 K/uL\n 191 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 5.0 mEq/L\n 42 mg/dL\n 110 mEq/L\n 141 mEq/L\n 28.1 %\n 20.5 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n 04:16 AM\n WBC\n 30.8\n 26.2\n 20.5\n Hct\n 29.0\n 29.1\n 28.1\n Plt\n \n Cr\n 1.6\n 1.4\n 1.3\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n 191\n Other labs: PT / PTT / INR:24.2/31.4/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.3 mg/dL,\n PO4:3.2 mg/dL\n Imaging: CXR - Improving RLL consolidation, perhaps some resolution of\n atelectasis. Increased edema.\n Microbiology: Sputum culture negative, Urine culture negative, Blood\n pending\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI.\n - F/U cultures\n - Continue vanc/cefepime/cipro (adjust doses based on improved\n creatinine)\n - D/c c. diff coverage given no stool output here\n - Genlte IVF + wean pressors\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Intubated .\n - Continue albuterol MDI\n - Steroids started for asthma flare\n - Extubate today\n - Wean O2 as tolerated and check ABG\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - Hold amiodarone, BB as hypotensive\n - Restart coumadin\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497238,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic, was intubated.\n extubated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Started shift w/ pt already being treated for anxiety w/ x2 PRN doses\n ativan IV w/ no effect, MDI\ns w/ no effect, EKG done, CXR done,\n appearing mottled, feeling cold and clammy to touch, changes in LOC,\n very labored breathing, desat to high 70\ns, ABG w/ PaO2 in 40\ns (MD\n thought to be venous), placed on bipap for short period w/ no relief.\n Action:\n Pt intubated at start of shift. 40mg IV lasix x1 given. A-line\n placed. CXR to confirm ETT placement. Multiple ABG\ns and vent setting\n changes. OGT placed before AM CXR.\n Response:\n Pt immediately improved following intubation; skin warmed, pale (not\n mottled), skin dry, no wheezing (w/o MDI\ns being given), LS clear upper\n and diminished lower, HR decreased from 130\ns to 80\ns, BP stable all\n night w/ MAP>65. Able to wean vent to Psup but pt having periods of\n apnea even with weaning sedation to fent 25mcg and versed 2mg/hr.\n ABG\ns wnl, apnea periods <30sec, became less frequent and pt recovering\n on own so left on Psup @ this time. Pt easily arousable, follows all\n commands, MAE (lift/hold), no c/o pain.\n Plan:\n f/u on CXR results from AM, cont to wean vent as tolerated, ?\n cardiogenic cause for resp failure but pt will likely remain intubated\n until cause is determined. Cont abx. Awaiting AM cxr results to\n confirm OGT placement.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n Resp status at being of shift as per above. ? cardiac issues leading\n to resp failure.\n Action:\n Cardiac enzymes sent last evening post event and repeated w/ AM labs.\n Lytes wnl.\n Response:\n Card . neg, EKG from day shift prior to intubation showing no\n changes compared to previous, CK 84-73 (MB and trop from AM still\n pending). No c/o chest pain from pt.\n Plan:\n Monitor for EKG changes and signs of MI.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497239,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:15 PM -secondary to\n hypoxemia and respiratory distress\n ARTERIAL LINE - START 10:00 PM -placed\n -20 beat run of VT\n -hypotensive after intubation. Resolved with 500cc bolus.Did not\n require pressors\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 80 (70 - 125) bpm\n BP: 108/60(79) {91/51(66) - 124/69(92)} mmHg\n RR: 14 (10 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 269 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 269 mL\n Blood products:\n Total out:\n 1,780 mL\n 455 mL\n Urine:\n 1,780 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -186 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 443 (443 - 443) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/43/120/25/1\n Ve: 6.2 L/min\n PaO2 / FiO2: 343\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 355 K/uL\n 8.7 g/dL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497240,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:15 PM -secondary to\n hypoxemia and respiratory distress\n ARTERIAL LINE - START 10:00 PM -placed\n -20 beat run of VT\n -hypotensive after intubation. Resolved with 500cc bolus.Did not\n require pressors\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 80 (70 - 125) bpm\n BP: 108/60(79) {91/51(66) - 124/69(92)} mmHg\n RR: 14 (10 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 269 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 269 mL\n Blood products:\n Total out:\n 1,780 mL\n 455 mL\n Urine:\n 1,780 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -186 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 443 (443 - 443) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/43/120/25/1\n Ve: 6.2 L/min\n PaO2 / FiO2: 343\n Physical Examination\n Gen: Intubated, sedated, NAD\n Neck: Supple, no LAD\n Lungs: Bronchial breath sounds at R base. Diffuse expiratory wheezes.\n CV: RRR. No murmurs.\n Abdomen: Soft, NT, ND. No masses. No rebound or guarding.\n Extremities: Warm, well perfused. No LE edema.\n Labs / Radiology\n 355 K/uL\n 8.7 g/dL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497242,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:15 PM -secondary to\n hypoxemia and respiratory distress\n ARTERIAL LINE - START 10:00 PM -placed\n -20 beat run of VT\n -hypotensive after intubation. Resolved with 500cc bolus.Did not\n require pressors\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 80 (70 - 125) bpm\n BP: 108/60(79) {91/51(66) - 124/69(92)} mmHg\n RR: 14 (10 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 269 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 269 mL\n Blood products:\n Total out:\n 1,780 mL\n 455 mL\n Urine:\n 1,780 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -186 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 443 (443 - 443) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/43/120/25/1\n Ve: 6.2 L/min\n PaO2 / FiO2: 343\n Physical Examination\n Gen: Intubated, sedated, NAD\n Neck: Supple, no LAD\n Lungs: Bronchial breath sounds at R base. Diffuse expiratory wheezes.\n CV: RRR. No murmurs.\n Abdomen: Soft, NT, ND. No masses. No rebound or guarding.\n Extremities: Warm, well perfused. No LE edema.\n Labs / Radiology\n 355 K/uL\n 8.7 g/dL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, reintubated overnight.\n # Hypotension: Resolved. Thought to be secondary to distributive\n shock, o2 requirement, in the setting of RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - favor neo over levophed if needed given recent MI and acutely\n depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n - attempt to wean ventilation\n - completed course of steroids\n -continue MDIs\n # Diarrhea/Leukocytosis: resolved.\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix given just weaned off pressors this\n morning. Consider restarting BB in AM if BP tolerates.\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resumed\n coumadin\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: call out to Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497243,
"text": "Chief Complaint: shortness of breath\n 24 Hour Events:\n INVASIVE VENTILATION - START 07:15 PM -secondary to\n hypoxemia and respiratory distress\n ARTERIAL LINE - START 10:00 PM -placed\n -20 beat run of VT\n -hypotensive after intubation. Resolved with 500cc bolus.Did not\n require pressors\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Fentanyl - 25 mcg/hour\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 PM\n Furosemide (Lasix) - 08:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 35.9\nC (96.6\n HR: 80 (70 - 125) bpm\n BP: 108/60(79) {91/51(66) - 124/69(92)} mmHg\n RR: 14 (10 - 35) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Total In:\n 1,816 mL\n 269 mL\n PO:\n 150 mL\n TF:\n IVF:\n 1,666 mL\n 269 mL\n Blood products:\n Total out:\n 1,780 mL\n 455 mL\n Urine:\n 1,780 mL\n 455 mL\n NG:\n Stool:\n Drains:\n Balance:\n 36 mL\n -186 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 450 (450 - 500) mL\n Vt (Spontaneous): 443 (443 - 443) mL\n PS : 10 cmH2O\n RR (Set): 10\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 34\n PIP: 16 cmH2O\n Plateau: 17 cmH2O\n Compliance: 40.9 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/43/120/25/1\n Ve: 6.2 L/min\n PaO2 / FiO2: 343\n Physical Examination\n Gen: Intubated, sedated, NAD\n Neck: Supple, no LAD\n Lungs: Bronchial breath sounds at R base. Diffuse expiratory wheezes.\n CV: RRR. No murmurs.\n Abdomen: Soft, NT, ND. No masses. No rebound or guarding.\n Extremities: Warm, well perfused. No LE edema.\n Labs / Radiology\n 355 K/uL\n 8.7 g/dL\n 180 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 4.8 mEq/L\n 50 mg/dL\n 107 mEq/L\n 141 mEq/L\n 26.2 %\n 13.1 K/uL\n [image002.jpg]\n 04:54 AM\n 04:16 AM\n 04:13 AM\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n WBC\n 26.2\n 20.5\n 16.5\n 11.7\n 13.1\n Hct\n 29.1\n 28.1\n 28.3\n 25.5\n 26.2\n Plt\n 522\n 556\n 457\n 320\n 355\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n 1.2\n TropT\n 1.06\n TCO2\n 26\n 25\n 26\n 28\n 28\n Glucose\n 43\n 180\n Other labs: PT / PTT / INR:36.0/32.9/3.7, CK / CKMB /\n Troponin-T:73//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, reintubated overnight.\n # Hypotension: Resolved. Thought to be secondary to distributive\n shock, o2 requirement, in the setting of RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - favor neo over levophed if needed given recent MI and acutely\n depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n CEs at that time negative. EKG unchanged from prior.\n - attempt to wean ventilation\n - completed course of steroids\n -continue MDIs\n -consider trial of diuresis today, as pressure tolerates\n # Diarrhea/Leukocytosis: resolved.\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI.\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix given just weaned off pressors this\n morning. Consider restarting BB in AM if BP tolerates.\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resumed\n coumadin\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: call out to Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497574,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated, vent settings CPAP 5 / 5 / 35%. Lung sounds\n clear upper fields, diminished in bases. Lasix gtt at 3mg/hr.\n Action:\n SBT for 1hr, tolerated well. Extubated at 1030 to 35% face tent, weaned\n to 2L NC. Oriented x3.\n Response:\n Patient diuresed 1600cc over previous 24 hr period, currently has\n diuresed 1 liter this shift. SAT remain 96-98%. Patient asking for\n inhaler although she has already received dose and is not currently\n wheezing.\n Plan:\n Encourage cough and deep breathing. Emotional support for anxiety\n regarding\nallergies\n and desire to over-use inhaler. Monitor mental\n status, SAT, and lung sounds.\n Anxiety\n Assessment:\n Received on Fentanyl gtt @ 25mcg and Versed gtt @ 2mg/hr. Opening eyes\n spontaneously and banging on bedrail. Follows commands. Denies pain.\n Action:\n Fentanyl turned off 1 hour prior to extubation. Versed left on until\n last moment before extubation.\n Response:\n Patient comfortable, mildly anxious regarding breathing and\nallergies\n, at times breathes loudly using vocal cords and states this\n is\nwheezing\n. No wheezing heard when patient asked to take quiet, deep\n breaths.\n Plan:\n Monitor patient\ns mental status, anxiety level. Has PRN ativan if\n needed, but was a question if patient had been overmedicated leading up\n to last intubation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occass PVC\ns, K4.6.\n Cardiology Consult obtained. No c/o\ns apin.\n Action:\n Started on Lasix Gtt.\n Response:\n Excellent response to Lasix.\n Plan:\n Monitor VS\ns, and assess response to Lasix Gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 497575,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated, vent settings CPAP 5 / 5 / 35%. Lung sounds\n clear upper fields, diminished in bases. Lasix gtt at 3mg/hr.\n Action:\n SBT for 1hr, tolerated well. Extubated at 1030 to 35% face tent, weaned\n to 2L NC. Oriented x3.\n Response:\n Patient diuresed 1600cc over previous 24 hr period, currently has\n diuresed 1 liter this shift. SAT remain 96-98%. Patient asking for\n inhaler although she has already received dose and is not currently\n wheezing.\n Plan:\n Encourage cough and deep breathing. Emotional support for anxiety\n regarding\nallergies\n and desire to over-use inhaler. Monitor mental\n status, SAT, and lung sounds.\n Anxiety\n Assessment:\n Received on Fentanyl gtt @ 25mcg and Versed gtt @ 2mg/hr. Opening eyes\n spontaneously and banging on bedrail. Follows commands. Denies pain.\n Action:\n Fentanyl turned off 1 hour prior to extubation. Versed left on until\n last moment before extubation.\n Response:\n Patient comfortable, mildly anxious regarding breathing and\nallergies\n, at times breathes loudly using vocal cords and states this\n is\nwheezing\n. No wheezing heard when patient asked to take quiet, deep\n breaths.\n Plan:\n Monitor patient\ns mental status, anxiety level. Has PRN ativan if\n needed, but was a question whether patient had been overmedicated\n leading up to last intubation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occasional PVC\ns, K4.6.\n Cardiology following.\n Action:\n Continued Lasix drip at 3 mg/hr.\n Response:\n Excellent response to Lasix. Diuresed for approx 2.5 liters since\n yesterday.\n Plan:\n Monitor VS and assess response to Lasix gtt. Check recommendations\n from Cardiology.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 497649,
"text": "Chief Complaint:\n 24 Hour Events:\n ULTRASOUND - At 11:15 AM\n bilat leg U/S\n Cardiology consulted. Agreed that CHF playing a role in her\n respiratory distress. Started Lasix gtt, diuresed well.\n LENIS negative\n Plan for extubation this morning if doing well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:23 AM\n Cefipime - 04:00 PM\n Ciprofloxacin - 04:32 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Furosemide (Lasix) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 07:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.8\nC (96.5\n HR: 81 (76 - 99) bpm\n BP: 113/58(80) {104/55(75) - 173/162(168)} mmHg\n RR: 15 (11 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.1 kg (admission): 70 kg\n Height: 65 Inch\n Total In:\n 1,082 mL\n 442 mL\n PO:\n TF:\n IVF:\n 1,032 mL\n 322 mL\n Blood products:\n Total out:\n 2,685 mL\n 1,000 mL\n Urine:\n 2,685 mL\n 1,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,603 mL\n -558 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 481 (400 - 481) mL\n PS : 5 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 35%\n RSBI: 40\n PIP: 11 cmH2O\n SpO2: 100%\n ABG: 7.45/46/125/29/7\n Ve: 5.3 L/min\n PaO2 / FiO2: 357\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 410 K/uL\n 9.1 g/dL\n 199 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 45 mg/dL\n 103 mEq/L\n 138 mEq/L\n 27.6 %\n 16.5 K/uL\n [image002.jpg]\n 06:19 PM\n 09:37 PM\n 10:35 PM\n 11:48 PM\n 01:12 AM\n 02:12 AM\n 03:06 AM\n 05:57 PM\n 03:40 AM\n 06:21 AM\n WBC\n 11.7\n 13.1\n 16.5\n Hct\n 25.5\n 26.2\n 27.6\n Plt\n \n Cr\n 1.2\n 1.2\n 1.1\n 1.1\n TropT\n 0.60\n TCO2\n 26\n 25\n 26\n 28\n 28\n 33\n Glucose\n 243\n 180\n 281\n 199\n Other labs: PT / PTT / INR:44.1/34.5/4.7, CK / CKMB /\n Troponin-T:73//0.60, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:8.3 mg/dL, Mg++:2.0 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, with\n septic shock, reintubated overnight.\n # Sepsis/Hypotension: Resolved. Thought to be secondary to\n distributive shock, o2 requirement, in the setting of RLL pneumonia\n poorly compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. Given CVP=12, stable EKG, and serial CE\n trending down, strongly favor sepsis over cardiogenic shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving, but now worsening again\n (cdiff vs steroids?)\n # Hypoxemic respiratory failure / increased work of breathing:\n Decompensated overnight. Likely PNA, asthma, and ? fluid overload.\n CEs at that time negative. EKG unchanged from prior.\n -continue broad spectrum vanc, cipro, cefepime day 7 of 8 for HA pna;\n check vanco level in AM\n - day 5 of 5 of steroids for asthma\n -continue MDIs\n -lasix gtt with goal I/Os of -2L if BP tolerates\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI. Patient had 20 beat run of VT\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, while aggressively diuresising, but resume\n ASAP\n - favor neo over levophed if needed; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n - f/u cardiology recs\n # Afib: Currently in sinus.\n - hold BB as as above, resume amio (although long half-life means she\n will be therapeutic for a while)\n - supratherapeutic on coumadin\nhold coumadin today\n # FEN: IVFs / replete lytes prn / NPO\n # PPX: H2RA, supratherapeutic inr, INCREASING bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition: regular s/p extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Arterial Line - 10:00 PM\n Prophylaxis:\n DVT: therapeutic inr\n Stress ulcer: h2b\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:icu\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496347,
"text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 09:30 PM\n TRANSTHORACIC ECHO - At 10:00 PM\n - multiple failed a-line attmpts\n - started on levophed\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Infusions:\n Norepinephrine - 0.26 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 71 (65 - 75) bpm\n BP: 115/59(72) {78/37(56) - 116/68(77)} mmHg\n RR: 30 (24 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (8 - 11)mmHg\n Total In:\n 1,591 mL\n 434 mL\n PO:\n TF:\n IVF:\n 1,091 mL\n 434 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 140 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 59 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 510 K/uL\n 9.7 g/dL\n 206 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 30.8 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n WBC\n 30.8\n Hct\n 29.0\n Plt\n 510\n Cr\n 1.6\n 1.4\n TropT\n 1.93\n 1.48\n Glucose\n 230\n 206\n Other labs: PT / PTT / INR:45.1/44.5/4.8, CK / CKMB /\n Troponin-T:79//1.48, Lactic Acid:2.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB, found to be hypotensive.\n # Hypotension: This is mostly likely septic shock from RLL pneumonia\n in the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl. In\n addition, U/A is equivocal. As far as cardiogenic reasons for shock,\n EF is 20% on prelim ECHO read and reportedly stable per son-in-law.\n Unlikely to have restent thrombosis or second ACS event as CK, CK-MB\n are flat. Trop is likely coming down. Unfortuantely, there are no\n records from available yet. Patient may also be slightly\n volume depleted.\n - bcxs, ucx, sputum cx, c. diff\n - broaden coverage for HAP with vanc/zosyn\n - trend CEs, serial EKGs\n - obtain records from \n - follow up final ECHO\n - IVFs, difficult to have CVP goal given recent massive MI\n - cont. levophed\n - needs aline\n .\n # Diarrhea: Pt reports 1 week of diarrhea. Unlikely to be C. diff\n given co-treatment of levaquin with flagyl.\n - check c. diff\n - hold on c. diff treatment for now\n .\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just massive anterior MI.\n - serial CEs, EKGs\n - cont. ASA, plavix, high dose atorvastatin\n - hold BB, ACEI, aldactone, lasix\n .\n # Afib: Currently in sinus.\n - hold amiodarone, BB as hypotensive\n - supratherapeutic\n .\n # Coagulopathy: Was on coumadin for afib at . Only slight\n oozing at RIJ site and mild hemoptysis.\n - follow coags\n - vitamin K 10 mg IV\n - hold coumadin\n - FFP if actively bleeding\n .\n # Elevated Creatinine: Cr at was 1.5. Unclear what it was\n prior to that admission.\n - will get PCP records\n dose meds\n .\n # HTN:\n - hold antihypertensives\n .\n # Hyperlipidemia:\n - cont. atorvastatin\n # Asthma\n - cont. atrovent nebulizers\n - cont. Advair\n .\n # Diabetes mellitus type 2:\n - hold metformin while in house\n - ISS\n # GERD:\n - cont. zantac\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, hold heparin SQ until repeat coags return, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Echo",
"chartdate": "2153-10-21 00:00:00.000",
"description": "Report",
"row_id": 88293,
"text": "PATIENT/TEST INFORMATION:\nIndication: Myocardial infarction c/b cardiogenic shock, hypotension. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 140\nBSA (m2): 1.68 m2\nBP (mm Hg): 105/68\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 22:25\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter\n(<2.1cm) with >55% decrease during respiration (estimated RA pressure\n(0-5mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate-severe\nregional left ventricular systolic dysfunction. Apical LV aneurysm. No LV\nmass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- akinetic; mid anterior - akinetic; basal anteroseptal - hypo; mid\nanteroseptal - akinetic; basal inferoseptal - hypo; mid inferoseptal -\nakinetic; basal anterolateral - akinetic; mid anterolateral - hypo; anterior\napex - akinetic; septal apex- akinetic; lateral apex - akinetic; apex -\nakinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Small pericardial effusion. No RV diastolic collapse.\n\nGENERAL COMMENTS: Suboptimal image quality as the patient was difficult to\nposition. Suboptimal image quality - patient unable to cooperate. Emergency\nstudy performed by the cardiology fellow on call. Echocardiographic results\nwere reviewed with the houseofficer caring for the patient. Right pleural\neffusion.\nDr. was notified in person of the results on at 20:15.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is 0-5\nmmHg. Left ventricular wall thicknesses and cavity size are normal. There is\nmoderate to severe regional left ventricular systolic dysfunction with near\nakinesis of the septum and anterior walls, apex, and distal lateral wall. The\napex is mildly aneurysmal. The remaining segments contract normally (LVEF =\n25-30 %). No intraventricular thrombus is seen. Right ventricular chamber size\nand free wall motion 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. Moderate (2+) mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is a small pericardial effusion. No right ventricular diastolic collapse\nis seen.\n\nIMPRESSION: Extensive regional left ventricular systolic dysfunction c/w CAD.\nModerate mitral regurgitation. Mild pulmonary artery systolic hypertension.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2153-10-21 00:00:00.000",
"description": "Report",
"row_id": 234337,
"text": "Sinus rhythm. Findings are as outlined on previous tracing of the same date\nand are without significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2153-10-21 00:00:00.000",
"description": "Report",
"row_id": 234338,
"text": "Sinus rhythm. Findings are as outlined on previous tracing of the same date\nand are without significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2153-10-21 00:00:00.000",
"description": "Report",
"row_id": 234339,
"text": "Sinus rhythm. Low QRS voltage. Delayed R wave progression with late\nprecordial QRS transition. Modest ST-T wave changes. Findings raise\nconsideration of possible prior anterior myocardial infaraction of\nindeterminate age and/or possible chronic pulmonary disease. Clinical\ncorrelation is suggested. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-26 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1106385,
"text": " 9:32 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: EVAL FOR LOWER EXTREMITY DVT; PT WITH ACUTE RESPIRATORY FAILIURE\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with acute respiratory failure over night requiring\n intubation. concern for PE. please eval for LE DVT\n REASON FOR THIS EXAMINATION:\n eval for lower extremity DVT\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 77-year-old woman with acute respiratory failure overnight,\n requiring intubation. Concern for PE. Please evaluate for lower extremity\n DVT.\n\n FINDINGS: There are normal venous waveforms identified in both common femoral\n veins with respiratory variation.\n\n Both common femoral veins, superficial femoral veins, and popliteal veins\n compress well and augment well, and demonstrate no evidence of thrombosis.\n Both posterior tibial, and peroneal veins demonstrate flow, and compress\n completely.\n\n Incidental note is made of significant edema within the subcutaneous tissues\n of both lower limbs.\n\n CONCLUSION:\n 1. There is no ultrasound evidence of deep venous thrombosis of the lower\n extremities.\n 2. There is evidence of edema of the soft tissues of both lower limbs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1105903,
"text": " 5:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval Endotracheal tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman intubated in ICU, ET tube pulled back 1cm\n REASON FOR THIS EXAMINATION:\n eval Endotracheal tube placement\n ______________________________________________________________________________\n WET READ: JXRl TUE 5:19 PM\n ETT 3.2cm above carina. Unchanged rt IJ catheter. NG tube at least into\n stomach, beyond inferior aspect of image. Bilateral layering effusions. Mild\n interstitial edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ICU intubation, to check for ET tube placement.\n\n FINDINGS: In comparison with the earlier study of this date, the ET tube has\n been pulled back to approximately 3.2 cm above the carina. Right IJ catheter\n and nasogastric tube remain in place.\n\n IMPRESSION: Bilateral layering effusions with interstitial edema is again\n seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106659,
"text": " 4:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with CAP and CHF, s/p extubation\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change, status post extubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the patient has been\n extubated. The nasogastric tube has also been removed. Unchanged course and\n position of the right-sided central venous access line placed over the\n internal jugular vein.\n\n The left lung base is improved in ventilation as compared to the previous\n image, the left costophrenic sinus is now unfolded. The pre-existing\n retrocardiac atelectasis has decreased in severity. In the right lung, the\n pre-existing basal opacities with signs of peribronchial cuffing and minimal\n fluid marking of the minor fissure are unchanged in extent and severity.\n\n No newly occurred focal parenchymal opacities. Unchanged size of the cardiac\n silhouette. Moderate calcifications of the aortic wall.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496304,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. transferred to micu for further care.\n Shock, septic\n Assessment:\n Pt presented from rehab(discharged to rehab on from \n hosp) with sob,known h/o asthma,as per the pt she has intermittent sob\n which usually relieves with albuterol which is dsicontd since recent\n MI,pt was hypotensive to the ED to 80\ns(lowest noted was 67/47).. with\n normal mentation, HR 60-70\ns sinus, initial lactate was noted for\n 3.1,wbc 20, cvp 8-14,cxr with RT sided PNA,does have chronic cough(on\n Lisinopril)\nUA with positive nitrates. o/e cyst vs abcess on the back\n and left hand,no loose bm,\n Action:\n Receieved vanco+zozyn down in the ED,contd vanco 1gm and zozyn q6h,\n also on levophed currently at 0.24,Had bedside echo which shows EF\n 20%,contd 02 4l via the NC\nreceived 1L fluid bolus\n Response:\n Sbp 90-110\ns,map>60,hr 70\ns, uop 30-40cc/hr,but skin appears cool and\n clammy??cardiogenic\nunable to place a A line,wbc 30.8 with ma labs(up\n from 20)\n.weak radial pulses,DP pulses dopplerable\ncvp 10-12.lactate\n down 2.1.\n Plan:\n Goal MAP>60,titrate levo as needed,follow urine output closely, follow\n cx datas,\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n s/p recent STEMI (10days ago),currently denies any chest pain, but\n sob,initial troponin was 2.08 with flat CKmb,ekg with sinus rythum,INR\n 6.5 with slight oozing from the RT IJ site\n Action:\n Contd asa,plavix,lipitor,had bedside echo,telemonitoring,cycle cardiac\n enzymes,received 10mg vit k.\n Response:\n Trponin trending down with flat ck,more likely from previous\n MI,currently hypotensive on levophed,inr doen to 4.8,no s/s of active\n bleeding\n Plan:\n Will cont to monitor,cardiology is following the pt.follow final read\n on ECHO,follow enzymes and ekg.\n Anxiety\n Assessment:\n Pt was increasingly anxious,restless and agitated,\nstating she cannot\n berath ,wants albuterol inhaler and meanwhile she states her doctor\n told her she cannot have heart disease\npt got extremely agitated\n and trying to get OOB,pulling out wires,\n Action:\n Received ativan 0.5mg IVP,reassured the pt\n Response:\n Good response with ativan,pt slept through the night,co operative with\n care,much better this am.\n Plan:\n Contd to reassure the pt,ativan as needed for severe anxiety.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496553,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - Intubated for respiratory distress\n - On pressors\n - OSH records obtained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 02:44 PM\n Ciprofloxacin - 02:00 AM\n Vancomycin - 08:14 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:00 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: 78 (69 - 101) bpm\n BP: 100/56(67) {69/36(43) - 144/63(77)} mmHg\n RR: 11 (9 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 70 kg\n CVP: 14 (0 - 20)mmHg\n Total In:\n 1,619 mL\n 1,003 mL\n PO:\n TF:\n IVF:\n 1,559 mL\n 943 mL\n Blood products:\n Total out:\n 1,325 mL\n 310 mL\n Urine:\n 1,325 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 294 mL\n 693 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): 560 (370 - 560) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.32/44/99./23/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 198\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 522 K/uL\n 251 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 36 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.1 %\n 26.2 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n WBC\n 30.8\n 26.2\n Hct\n 29.0\n 29.1\n Plt\n 510\n 522\n Cr\n 1.6\n 1.4\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n Other labs: PT / PTT / INR:23.8/34.5/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.8 mg/dL\n Imaging: CXR - Persistent RML opacity. ET tube at 2.5 cm.\n Microbiology: No new micro data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl.\n Off pressors with CVP of 12.\n - F/U cultures\n - Continue vanc/zosyn\n - Trend CEs, serial EKGs\n - Obtain records from \n - Follow up final ECHO\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare.\n - Continue albuterol MDI (not tolerated nebs)\n - Steroids started for asthma flare\n - Pt intubated due to persistent resp distress and high WOB.\n Oxygenation adequate, will check ABG\n # Diarrhea: Pt reports 1 week of diarrhea. Could be C. diff, although\n unlikely given recent flagyl. Elevated WBC count today prompted\n initiation of PO vanc.\n - Check C. diff\n - Continue PO vanc\n will d/c if c. diff neg x 2\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Serial CEs, EKGs\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - hold amiodarone, BB as hypotensive\n - supratherapeutic\n # Coagulopathy: Was on coumadin for afib at . Only slight\n oozing at RIJ site and mild hemoptysis. Also with elevated PTT.\n - Follow coags\n - Check to see if on SQ heparin at rehab to explain elevated PTT\n - Hold coumadin\n - Check DIC labs\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 496411,
"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: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally clear, suctioned intermittently for moderate to small\n amounts of thick tan secretions, treated with Albuterol inhaler, weaned\n from AC to PSV, SPO2 remained upper 90s, will continues to be followed.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496540,
"text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:30 AM\n OSH info:\n Presented with CP\n Anterior septal STEMI, 3 stents placed to LAD\n PCWP of 35\n On levophed and dopamine at OSH\n Lactate of 4\n WBC 37.5 on -treated for CAP with levo, and flagyl for empiric C\n diff given diarrhea\n Still required 2.5 of neo overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 02:44 PM\n Ciprofloxacin - 02:00 AM\n Vancomycin - 05:46 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 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: 78 (69 - 101) bpm\n BP: 106/58(69) {69/36(43) - 144/68(85)} mmHg\n RR: 9 (9 - 37) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (0 - 20)mmHg\n Total In:\n 1,619 mL\n 709 mL\n PO:\n TF:\n IVF:\n 1,559 mL\n 649 mL\n Blood products:\n Total out:\n 1,325 mL\n 240 mL\n Urine:\n 1,325 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 294 mL\n 470 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): 560 (370 - 560) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.32/44/99./23/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 198\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 522 K/uL\n 9.4 g/dL\n 251 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 36 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.1 %\n 26.2 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n WBC\n 30.8\n 26.2\n Hct\n 29.0\n 29.1\n Plt\n 510\n 522\n Cr\n 1.6\n 1.4\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n Other labs: PT / PTT / INR:23.8/34.5/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 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": "2153-10-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496541,
"text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:30 AM\n OSH info:\n Presented with CP\n Anterior septal STEMI, 3 stents placed to LAD\n PCWP of 35\n On levophed and dopamine at OSH\n Lactate of 4\n WBC 37.5 on -treated for CAP with levo, and flagyl for empiric C\n diff given diarrhea\n Still required 2.5 of neo overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 02:44 PM\n Ciprofloxacin - 02:00 AM\n Vancomycin - 05:46 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 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: 78 (69 - 101) bpm\n BP: 106/58(69) {69/36(43) - 144/68(85)} mmHg\n RR: 9 (9 - 37) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (0 - 20)mmHg\n Total In:\n 1,619 mL\n 709 mL\n PO:\n TF:\n IVF:\n 1,559 mL\n 649 mL\n Blood products:\n Total out:\n 1,325 mL\n 240 mL\n Urine:\n 1,325 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 294 mL\n 470 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): 560 (370 - 560) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.32/44/99./23/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 198\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 522 K/uL\n 9.4 g/dL\n 251 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 36 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.1 %\n 26.2 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n WBC\n 30.8\n 26.2\n Hct\n 29.0\n 29.1\n Plt\n 510\n 522\n Cr\n 1.6\n 1.4\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n Other labs: PT / PTT / INR:23.8/34.5/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI (based on q-waves and severly depressed\n ef, record pending) at OSH 10 days ago, s/p 3 stents IABP x 3 days for\n cardiogenic shock; had pneumonia treated with flagyl and levaquin,\n presented from rehab with increasing SOB and diarrhea, in septic shock\n requiring pressors\n # Hypotension: Given distributive shock, o2 requirement, and CXR\n infiltrate, this is most likely septic shock from RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. CDIFF may also be contributing. Given CVP=12,\n stable EKG, and CE trending down, favor sepsis over cardiogenic shock,\n but will continue to rule out MI given worsened status this am.\n - F/U cultures\n - SWITCH vanc/zosyn to vanco/cefepime/cipro\n - Trend CEs, serial EKGs\n - Obtain records from \n - Follow up final ECHO\n - favor neo over levophed given recent MI and acutely depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing: Likely\n PNA with some contributiion from astma given severe wheezing on\n exam. Other concern would be LV failure from ischemia, but arguing\n against this is CVP=12avg.\n - s/p intubation; needs a-line\n - steroidsx 5 days, MDIs\n # Diarrhea: Empiric CDIFF covg given marked leukocytosis with PO\n vanco. f/u cdiff tox x2\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes trending down\n suggesting that ACS is not contributing. EKG relatively stable, some\n rate dependent ST depressions inferiorly.\n - Serial CEs, EKGs\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n - favor neo over levophed as above\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - supratherapeutic\n # Coagulopathy: Was on coumadin for afib at . Only slight\n oozing at RIJ site and mild hemoptysis. Also with elevated PTT.-\n Follow coags; hold coumadin, check DIC labs\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496477,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. transferred to micu for further care.\n Shock, septic\n Assessment:\n Pt presented from rehab(discharged to rehab on from \n hosp) with sob,known h/o asthma,as per the pt she has intermittent sob\n which usually relieves with albuterol which is dsicontd since recent\n MI,pt was hypotensive to the ED to 80\ns(lowest noted was 67/47).. with\n normal mentation, HR 60-70\ns sinus, initial lactate was noted for\n 3.1,wbc 20, cvp 8-14,cxr with RT sided PNA,does have chronic cough(on\n Lisinopril)\nUA with positive nitrates. o/e cyst vs abcess on the back\n and left hand,no loose bm, this am she was noted to have WBC OF 30. Pt\n was noted to have a ?? PNA on cxray.\n Action:\n This am pt was very anxious, c/o SOB, with rr in the 30\ns or above and\n nausea. Pt was cool, clammy and hypothermic with a temp of 95.9. Pt\n lower ext were noted to have increasing mottling throughout the\n morning. Pt was tachy into the high 90\ns low 100\ns. Pt was also\n becoming more lethargic. Pt had two EKG done which showed ?? slight\n changes, pt was switched from levopehd to neo to help control HR. pt\n was intubated for airway protection. Started on fent/versed, and cipro\n and cifepeme.\n Response:\n Sbp 90-110\ns,map>60,hr 70\ns, uop 30-40cc/hr,but skin appears cool and\n sweaty now??cardiogenic will have cards consulted\nunable to place a A\n line,wbc 30.8 with ma labs(up from 20)\n.weak radial pulses,DP pulses\n dopplerable\ncvp 10-12.lactate up 2.5.\n Plan:\n Goal MAP>60,titrate neo as needed,follow urine output closely, follow\n cx datas,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496479,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. transferred to micu for further care.\n Shock, septic\n Assessment:\n Pt presented from rehab with sob,wbc up to 30,chest x ray with RLL\n pna, with hypotension cvp 10-14,cool and clammy skin, received the pt\n on neo , no loose bm,only csnt secretions via the ET tube\n Action:\n Attempted to wean neo,contd iv vanco/cipro/cefipime,po vanco for\n empiric c diff coverage,\n Response:\n Sbp mostly in low 100\ns,map in mid 60\ns,weaning becoming unsuccessful\n given drop in blood pressure to 90\ns, uop has been 30-60 cc/hr,cvp\n 10-14,skin is cool and diaphoretic,\n Plan:\n Goal MAP>60,titrate neo as needed,follow urine output closely, follow\n cx datas,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Kwown asthma with superimposed pneumonia,pt with low EF of 20% with\n recent extensive anterior wall MI,s/p intubation on ..received the\n pt on cpap/psv, 10/5peep,lung sounds with exp wheeze at times,\n Action:\n No vent changes overnight, contd fent/versed for sedation(midas 2mg/hr\n and fent 50mcg/hr)\nsuctioned as needed,VAP prevention bundle,MDI by RT.\n Response:\n Satting 100%on the current settings,pt arousable to stimulation follows\n commands,\n Plan:\n Will cont to monitor the resp status,wean vent as tolerated,daily wake\n up,RSBI,wean sedation,follow sputum cx,cont abx for PNA\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496292,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. transferred to micu for further care.\n Shock, septic\n Assessment:\n Pt presented from rehab with sob,kwnon c/o asthma,as per the she has\n intermittent sob which usually relieves with albuterol which is\n dsicontd since recent MI,pt was hypotensive to the ED to 80\ns(lowest\n noted was 67/47).. with normal mentation, HR 60-70\ns sinus, initial\n lactate was noted for 3.1,wbc 20,000, cvp 8-14,cxr with RT sided\n PNA,does have chronic cough(on Lisinopril)\n Action:\n Receieved vanco+zozyn down in the ED,contd vanco 1gm and zozyn q6h,\n also on levophed currently at 0.24,Had bedside echo which shows EF\n 20%,contd 02 4l via the NC\n Response:\n Sbp 90-110\ns,map>60,hr 70\ns, uop 30-40cc/hr,but skin appears cool and\n clammy??cardiogenic\nunable to place a A line\n Plan:\n Goal MAP>60,titrate levo as needed,follow urine output closely, follow\n cx datas,\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n s/p recent STEMI (10days ago),currently denies any chest pain, but\n sob,initial troponin was 2.08 with flat CKmb,ekg with sinus rythum\n Action:\n Contd asa,plavix,lipitor,had bedside echo,telemonitoring,cycle cardiac\n enzymes\n Response:\n Trponin trending down with flat ck,more likely from previous\n MI,currently hypotensive on levophed\n Plan:\n Will cont to monitor,cardiology is following the pt.follow final read\n on ECHO\n Anxiety\n Assessment:\n Pt was increasingly anxious,restless and agitated,\nstating she cannot\n berath ,wants albuterol inhaler and meanwhile she states her doctor\n told her she cannot have heart disease\npt got extremely agaitated\n and trying to get OOB,pulling out wires,\n Action:\n Received ativan 0.5mg IVP,reassured the pt\n Response:\n Good response with ativan,pt slept through the night,co operative with\n care\n Plan:\n Contd to reassure the pt,ativan as needed for severe anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496293,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. transferred to micu for further care.\n Shock, septic\n Assessment:\n Pt presented from rehab with sob,kwnon c/o asthma,as per the she has\n intermittent sob which usually relieves with albuterol which is\n dsicontd since recent MI,pt was hypotensive to the ED to 80\ns(lowest\n noted was 67/47).. with normal mentation, HR 60-70\ns sinus, initial\n lactate was noted for 3.1,wbc 20,000, cvp 8-14,cxr with RT sided\n PNA,does have chronic cough(on Lisinopril)\n Action:\n Receieved vanco+zozyn down in the ED,contd vanco 1gm and zozyn q6h,\n also on levophed currently at 0.24,Had bedside echo which shows EF\n 20%,contd 02 4l via the NC\n Response:\n Sbp 90-110\ns,map>60,hr 70\ns, uop 30-40cc/hr,but skin appears cool and\n clammy??cardiogenic\nunable to place a A line\n Plan:\n Goal MAP>60,titrate levo as needed,follow urine output closely, follow\n cx datas,\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n s/p recent STEMI (10days ago),currently denies any chest pain, but\n sob,initial troponin was 2.08 with flat CKmb,ekg with sinus rythum,INR\n 6.5 with slight oozing from the RT IJ site\n Action:\n Contd asa,plavix,lipitor,had bedside echo,telemonitoring,cycle cardiac\n enzymes,received 10mg vit k.\n Response:\n Trponin trending down with flat ck,more likely from previous\n MI,currently hypotensive on levophed\n Plan:\n Will cont to monitor,cardiology is following the pt.follow final read\n on ECHO\n Anxiety\n Assessment:\n Pt was increasingly anxious,restless and agitated,\nstating she cannot\n berath ,wants albuterol inhaler and meanwhile she states her doctor\n told her she cannot have heart disease\npt got extremely agitated\n and trying to get OOB,pulling out wires,\n Action:\n Received ativan 0.5mg IVP,reassured the pt\n Response:\n Good response with ativan,pt slept through the night,co operative with\n care\n Plan:\n Contd to reassure the pt,ativan as needed for severe anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496528,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. transferred to micu for further care.\n Shock, septic\n Assessment:\n Pt presented from rehab with sob,wbc up to 30,chest x ray with RLL\n pna, with hypotension cvp 10-14,cool and clammy skin, received the pt\n on neo , no loose bm,only csnt secretions via the ET tube\n Action:\n Attempted to wean neo,contd iv vanco/cipro/cefipime,po vanco for\n empiric c diff coverage,\n Response:\n Sbp mostly in low 100\ns,map in mid 60\ns,weaning becoming unsuccessful\n given drop in blood pressure to 90\ns, uop has been 30-60 cc/hr,cvp\n 10-14,skin is cool but better,t max 99.7 in this shift,lactate\n 1.7,troponin trending down.\n Plan:\n Goal MAP>60,titrate neo as needed,follow urine output closely, follow\n cx datas,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Kwown asthma with superimposed pneumonia,pt with low EF of 20% with\n recent extensive anterior wall MI,s/p intubation on ..received the\n pt on cpap/psv, 10/5peep,lung sounds with exp wheeze at times,\n Action:\n No vent changes overnight, contd fent/versed for sedation(midas 3mg/hr\n and fent 50mcg/hr)\nsuctioned as needed,VAP prevention bundle,MDI by RT.\n Response:\n Satting 100%on the current settings,pt arousable to voice follows\n commands,\n Plan:\n Will cont to monitor the resp status,wean vent as tolerated,daily wake\n up,RSBI,wean sedation,follow sputum cx,cont abx for PNA.\n Social:multiple calls from family during this shift,updated by this RN\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 496514,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496278,
"text": "Chief Complaint: hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 77W recent NSTEMI requiring 3 stents . This was complicated by\n cadiogenic shock requiring balloon pump for 3 days. She was ultimately\n transferred to rehab.\n In rehab has experienced hemoptysis and persistent CP. Today dyspnea\n worsened and referred to ER. In ER she was hypotensive and CXR showed\n right pneumomonia. She was placed on levophed. An echo showed EF 20%.\n 24 Hour Events:\n History obtained from housestaff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.26 mcg/Kg/min\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 Cardiovascular: Chest pain\n Respiratory: Cough, hemoptysis\n Flowsheet Data as of 12:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 68 (68 - 75) bpm\n BP: 116/37(56) {78/37(56) - 116/68(77)} mmHg\n RR: 31 (25 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 10 (8 - 10)mmHg\n Total In:\n 1,591 mL\n PO:\n TF:\n IVF:\n 1,091 mL\n Blood products:\n Total out:\n 740 mL\n 0 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: 4 LPM\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : right)\n Abdominal: Soft\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, Clubbing\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 383\n 230 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 37 mg/dL\n 99 mEq/L\n 133 mEq/L\n 29\n 20\n [image002.jpg]\n 11:00 PM\n Cr\n 1.6\n TropT\n 1.93\n Glucose\n 230\n Other labs: CK / CKMB / Troponin-T:94//1.93, Lactic Acid:2.1 mmol/L,\n Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:4.5 mg/dL\n Imaging: CXR RML pna\n ECG: NSR 70, Q's\n Assessment and Plan\n pna - will treat for hospital acquired pna\n shock - suspect related to infection in setting of depressed EF, will\n continue levophed and gentle hydration\n coagulopahty - unclear cause, will give vitamin K\n renal insufficiency - follow\n recent MI, cardiomyopathy - cont ASA and plavix, hold\n anti-hypertensives\n DM - SSI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n 20 Gauge - 09:30 PM\n Prophylaxis:\n DVT: (coagulopathic)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 38 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496279,
"text": "Chief Complaint: hypotension\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 77W recent STEMI requiring 3 stents last week. This was complicated by\n cardiogenic shock requiring balloon pump for 3 days. She was ultimately\n transferred to rehab. She also developed a-fib and was started on amio\n and coumadin.\n In rehab she experienced hemoptysis and persistent CP. Today her\n dyspnea worsened and she was referred to the ER. In ER she was\n hypotensive and CXR showed right pneumomonia. She was placed on\n levophed. An echo showed EF 20%.\n History obtained from housestaff\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.26 mcg/Kg/min\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 Cardiovascular: Chest pain\n Respiratory: Cough, hemoptysis\n Flowsheet Data as of 12:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 68 (68 - 75) bpm\n BP: 116/37(56) {78/37(56) - 116/68(77)} mmHg\n RR: 31 (25 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 10 (8 - 10)mmHg\n Total In:\n 1,591 mL\n PO:\n TF:\n IVF:\n 1,091 mL\n Blood products:\n Total out:\n 740 mL\n 0 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: 4 LPM\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, mild resp distress\n Neck right IJ\n Cardiovascular: (S1: Normal), (S2: Normal)\n Lungs crackles anteriorly on right\n Abdominal: Soft, non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Neurologic: sleepy, arousable and oriented\n Labs / Radiology\n 383\n 230 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 4.6 mEq/L\n 37 mg/dL\n 99 mEq/L\n 133 mEq/L\n 29\n 20\n [image002.jpg]\n 11:00 PM\n Cr\n 1.6\n TropT\n 1.93\n Glucose\n 230\n Other labs: CK / CKMB / Troponin-T:94//1.93, Lactic Acid:2.1 mmol/L,\n Ca++:7.7 mg/dL, Mg++:1.9 mg/dL, PO4:4.5 mg/dL\n Imaging: CXR RML pna\n ECG: NSR 70, Q's\n Assessment and Plan\n pna - will treat for hospital acquired pna\n shock - suspect related to infection in setting of depressed EF, will\n continue levophed and gentle hydration\n coagulopahty\n presumably due to excess coumadin, will give vitamin K\n renal insufficiency - follow\n recent MI, cardiomyopathy - cont ASA and plavix, hold\n anti-hypertensives\n DM - SSI\n ICU Care\n Nutrition: NPO for now, may very well need CPAP or intubation\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n 20 Gauge - 09:30 PM\n Prophylaxis:\n DVT: (coagulopathic)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 38 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 496282,
"text": "Chief Complaint: SOB\n HPI:\n Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. Cardiology to perform formal ECHO when\n patient hits the floor.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Norepinephrine - 0.26 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Asthma\n Hyperlipidemia\n Hypertension\n Coronary artery disease\n Diabetes mellitus type 2\n GERD\n Father died with DM. Mother died with kidney disease.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt is divorced, has 2 children. Worked as a housewife. She\n smoked from -. No etoh or recreational drug use.\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: Cough, Dyspnea, Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, Diarrhea,\n No(t) Constipation\n Neurologic: No(t) Headache\n Flowsheet Data as of 01:40 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.6\nC (97.8\n HR: 68 (68 - 75) bpm\n BP: 107/46(63) {78/37(56) - 116/68(77)} mmHg\n RR: 32 (25 - 36) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 10 (8 - 10)mmHg\n Total In:\n 1,591 mL\n 55 mL\n PO:\n TF:\n IVF:\n 1,091 mL\n 55 mL\n Blood products:\n Total out:\n 740 mL\n 0 mL\n Urine:\n 140 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 55 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///22/\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, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Diminished), (Left radial\n pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse:\n Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n RLL)\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 230 mg/dL\n 1.6 mg/dL\n 37 mg/dL\n 22 mEq/L\n 99 mEq/L\n 4.6 mEq/L\n 133 mEq/L\n [image002.jpg]\n \n 2:33 A11/1/ 11:00 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Cr\n 1.6\n TropT\n 1.93\n Glucose\n 230\n Other labs: PT / PTT / INR:57.8/46.4/6.5, CK / CKMB /\n Troponin-T:94//1.93, Lactic Acid:2.1 mmol/L, Ca++:7.7 mg/dL, Mg++:1.9\n mg/dL, PO4:4.5 mg/dL\n Imaging: CXR: RLL pneumonia.\n Microbiology: BCx, UCx pending.\n ECG: EKG: NSR at 70 bpm. Large q waves in V1-V3. Diffuse TW\n flattening. No STEs.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB, found to be hypotensive.\n .\n # Hypotension: This is mostly likely septic shock from RLL pneumonia\n in the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl. In\n addition, U/A is equivocal. As far as cardiogenic reasons for shock,\n EF is 20% on prelim ECHO read and reportedly stable per son-in-law.\n Unlikely to have restent thrombosis or second ACS event as CK, CK-MB\n are flat. Trop is likely coming down. Unfortuantely, there are no\n records from available yet. Patient may also be slightly\n volume depleted.\n - bcxs, ucx, sputum cx, c. diff\n - broaden coverage for HAP with vanc/zosyn\n - trend CEs, serial EKGs\n - obtain records from \n - follow up final ECHO\n - IVFs, difficult to have CVP goal given recent massive MI\n - cont. levophed\n - needs aline\n .\n # Diarrhea: Pt reports 1 week of diarrhea. Unlikely to be C. diff\n given co-treatment of levaquin with flagyl.\n - check c. diff\n - hold on c. diff treatment for now\n .\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just massive anterior MI.\n - serial CEs, EKGs\n - cont. ASA, plavix, high dose atorvastatin\n - hold BB, ACEI, aldactone, lasix\n .\n # Afib: Currently in sinus.\n - hold amiodarone, BB as hypotensive\n - supratherapeutic\n .\n # Coagulopathy: Was on coumadin for afib at . Only slight\n oozing at RIJ site and mild hemoptysis.\n - follow coags\n - vitamin K 10 mg IV\n - hold coumadin\n - FFP if actively bleeding\n .\n # Elevated Creatinine: Cr at was 1.5. Unclear what it was\n prior to that admission.\n - will get PCP records\n dose meds\n .\n # HTN:\n - hold antihypertensives\n .\n # Hyperlipidemia:\n - cont. atorvastatin\n .\n # Asthma\n - cont. atrovent nebulizers\n - cont. Advair\n .\n # Diabetes mellitus type 2:\n - hold metformin while in house\n - ISS\n .\n # GERD:\n - cont. zantac\n .\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, hold heparin SQ until repeat coags return, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Comments: cardiac diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:30 PM\n 20 Gauge - 09:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Case Management ",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Initial Patient Assessment",
"row_id": 496660,
"text": "Case Management Initial Assessment\n The patient is a 77 yo female s/p recent STEMI at OSH 10 days ago, s/p\n 3 stents & IABP x 3 days for cardiogenic shock; had pneumonia treated\n with flagyl and levaquin, presented from rehab with increasing SOB and\n diarrhea, in septic shock still requiring pressors. Intubated yesterday\n for increased work of breathing.\n This nurse case manager spoke on the phone with the patient\ns daughter\n and in person in the ICU with her niece . expressed the\n desire to have as much time as possible to choose a post-acute care\n facility for her mother as she felt that she did not have adequate time\n to choose a facility when the patient was discharged form St. E\ns to\n of . This nurse case manager reassured that she\n will receive frequent updates during the discharge process giving her\n the opportunity to make an informed choice for her mother. The\n conversation with took place prior to her mother\ns intubation.\n The meeting with took place in the ICU approximately two hours\n after intubation. is a nurse and thought that and LTACH in the\n area would be a good location. She indicated that she would be\n talking with later in the day and would discuss facility options\n with her.\n Currently the patient is intubated, vented, sedated and requiring\n pressor support for her BPs. LTACH referrals are not appropriate at\n this time. This NCM will continue to follow for discharge planning\n needs. Please page any time for assistance.\n , RN, BSN\n MICU Service Case Manager\n Phone: 7-0306 Pager: \n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 496716,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Airway\n Airway Placement Data\n Known difficult intubation: No\n ETT:\n Position:20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\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: MMV 500x12/+5/.5/10 psv\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: Maintaining Vt 500 ml with Ve 5-6 L, sp02 99%\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 Bedside Procedures: RSBI 42\n Comments: Will wean support as tol.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496607,
"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 - Intubated for respiratory distress\n - On pressors\n - OSH records obtained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 02:44 PM\n Ciprofloxacin - 02:00 AM\n Vancomycin - 08:14 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:00 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: 78 (69 - 101) bpm\n BP: 100/56(67) {69/36(43) - 144/63(77)} mmHg\n RR: 11 (9 - 34) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 72.5 kg (admission): 70 kg\n CVP: 14 (0 - 20)mmHg\n Total In:\n 1,619 mL\n 1,003 mL\n PO:\n TF:\n IVF:\n 1,559 mL\n 943 mL\n Blood products:\n Total out:\n 1,325 mL\n 310 mL\n Urine:\n 1,325 mL\n 310 mL\n NG:\n Stool:\n Drains:\n Balance:\n 294 mL\n 693 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): 560 (370 - 560) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.32/44/99./23/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 198\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: present), (Left radial pulse:\n present), (Right DP pulsepresent), (Left DP pulse: present)\n Respiratory / Chest: (Breath Sounds: Clear : , prolonged expiratory\n phase)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: normal turgor, warm, no rashes\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 9.4 g/dL\n 522 K/uL\n 251 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 36 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.1 %\n 26.2 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n WBC\n 30.8\n 26.2\n Hct\n 29.0\n 29.1\n Plt\n 510\n 522\n Cr\n 1.6\n 1.4\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n Other labs: PT / PTT / INR:23.8/34.5/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.8 mg/dL\n Imaging: CXR - Persistent RML opacity. ET tube at 2.5 cm.\n Microbiology: No new micro data.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl.\n - F/U cultures\n - Continue vanc/zosyn\n - Genlte IVF + wean pressors\n - Trend CEs, serial EKGs\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare. Now intubated.\n - Continue albuterol MDI\n - Steroids started for asthma flare\n - Wean PS as tolerated\n # Diarrhea: Pt reports 1 week of diarrhea. Could be C. diff, although\n unlikely given recent flagyl. Elevated WBC count yesterday prompted\n initiation of PO vanc.\n - Check C. diff\n - Continue PO vanc\n will d/c if c. diff neg x 2\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Serial CEs, EKGs\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - Hold amiodarone, BB as hypotensive\n - Restart coumadin\n ICU Care\n Nutrition: NPO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 34 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 496715,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Airway\n Airway Placement Data\n Known difficult intubation: No\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Clear\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: MMV 500x12/+5/.5/10 psv\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: Maintaining Vt 500 ml with Ve 5-6 L, sp02 99%\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 Bedside Procedures: RSBI 42\n Comments: Will wean support as tol.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496381,
"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 - CL placed\n - TTE (bedside by fellow) - EF 20%\n - Pressors weaned off this am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Infusions:\n Norepinephrine - 0.26 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Asa, Plavix, Zantac, RISS, Atrovent nebs, Advair, Vanco 1gm q48,\n Atorvastatin, PO vanc\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Gastrointestinal: Nausea\n Flowsheet Data as of 09:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 71 (65 - 75) bpm\n BP: 115/59(72) {78/37(56) - 116/68(77)} mmHg\n RR: 30 (24 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (8 - 11)mmHg\n Total In:\n 1,591 mL\n 462 mL\n PO:\n TF:\n IVF:\n 1,091 mL\n 462 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 140 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezing R>L: ); fair air movement\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Cool with mottling of extremities\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 510 K/uL\n 206 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 30.8 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n WBC\n 30.8\n Hct\n 29.0\n Plt\n 510\n Cr\n 1.6\n 1.4\n TropT\n 1.93\n 1.48\n Glucose\n 230\n 206\n Other labs: PT / PTT / INR:45.1/44.5/4.8, CK / CKMB /\n Troponin-T:79//1.48, Lactic Acid:2.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:4.2 mg/dL\n Imaging: CXR - RML infiltrate\n Microbiology: Pending.\n EKG: Increased rate with some worsening inferior ST depressions\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: Multifactorial with septic shock from RLL pneumonia in\n the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl.\n Off pressors with CVP of 12.\n - F/U cultures\n - Continue vanc/zosyn\n - Trend CEs, serial EKGs\n - Obtain records from \n - Follow up final ECHO\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare.\n - Continue albuterol MDI (not tolerated nebs)\n - Steroids started for asthma flare\n - Pt intubated due to persistent resp distress and high WOB.\n Oxygenation adequate, will check ABG\n # Diarrhea: Pt reports 1 week of diarrhea. Could be C. diff, although\n unlikely given recent flagyl. Elevated WBC count today prompted\n initiation of PO vanc.\n - Check C. diff\n - Continue PO vanc\n will d/c if c. diff neg x 2\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Serial CEs, EKGs\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - hold amiodarone, BB as hypotensive\n - supratherapeutic\n # Coagulopathy: Was on coumadin for afib at . Only slight\n oozing at RIJ site and mild hemoptysis. Also with elevated PTT.\n - Follow coags\n - Check to see if on SQ heparin at rehab to explain elevated PTT\n - Hold coumadin\n - Check DIC labs\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496382,
"text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 09:30 PM\n TRANSTHORACIC ECHO - At 10:00 PM\n - multiple failed a-line attmpts\n - started on levophed overnight\n - during rounds, decompensated, did not tolearate weaning of levophed,\n switched to neo.\n -intubated during rounds for increased work of breathing; gas prior to\n intubation 7.34/41/74 with lactate 2.5\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Infusions:\n Norepinephrine - 0.26 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 71 (65 - 75) bpm\n BP: 115/59(72) {78/37(56) - 116/68(77)} mmHg\n RR: 30 (24 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (8 - 11)mmHg\n Total In:\n 1,591 mL\n 434 mL\n PO:\n TF:\n IVF:\n 1,091 mL\n 434 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 140 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 59 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 510 K/uL\n 9.7 g/dL\n 206 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 30.8 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n WBC\n 30.8\n Hct\n 29.0\n Plt\n 510\n Cr\n 1.6\n 1.4\n TropT\n 1.93\n 1.48\n Glucose\n 230\n 206\n Other labs: PT / PTT / INR:45.1/44.5/4.8, CK / CKMB /\n Troponin-T:79//1.48, Lactic Acid:2.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:4.2 mg/dL\n Assessment and Plan\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n Assessment and Plan\n 77 yo female s/p recent STEMI (based on q-waves and severly depressed\n ef, record pending) at OSH 10 days ago, s/p 3 stents IABP x 3 days for\n cardiogenic shock; had pneumonia treated with flagyl and levaquin,\n presented from rehab with increasing SOB and diarrhea, in septic shock\n requiring pressors\n # Hypotension: Given distributive shock, o2 requirement, and CXR\n infiltrate, this is most likely septic shock from RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. CDIFF may also be contributing. Given CVP=12,\n stable EKG, and CE trending down, favor sepsis over cardiogenic shock,\n but will continue to rule out MI given worsened status this am.\n - F/U cultures\n - SWITCH vanc/zosyn to vanco/cefepime/cipro\n - Trend CEs, serial EKGs\n - Obtain records from \n - Follow up final ECHO\n - favor neo over levophed given recent MI and acutely depressed EF.\n # Hypoxemic respiratory failure / increased work of breathing: Likely\n PNA with some contributiion from astma given severe wheezing on\n exam. Other concern would be LV failure from ischemia, but arguing\n against this is CVP=12avg.\n - s/p intubation; needs a-line\n - steroidsx 5 days, MDIs\n # Diarrhea: Empiric CDIFF covg given marked leukocytosis with PO\n vanco. f/u cdiff tox x2\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes trending down\n suggesting that ACS is not contributing. EKG relatively stable, some\n rate dependent ST depressions inferiorly.\n - Serial CEs, EKGs\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n - favor neo over levophed as above\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - supratherapeutic\n # Coagulopathy: Was on coumadin for afib at . Only slight\n oozing at RIJ site and mild hemoptysis. Also with elevated PTT.-\n Follow coags; hold coumadin, check DIC labs\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 496651,
"text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments: ETT pulled back per CXR.\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Exp Wheeze\n Secretions\n Sputum color / consistency: Brown / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Prolonged exhalation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Possible air trapping\n Plan\n Next 24-48 hours: Pt placed on MMV for low RR. Sedation decreased. Pt\n still has some bronchospasm and is being Rxd with\n solumedrol/bronchodilators.\n Comments:\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496445,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. transferred to micu for further care.\n Shock, septic\n Assessment:\n Pt presented from rehab(discharged to rehab on from \n hosp) with sob,known h/o asthma,as per the pt she has intermittent sob\n which usually relieves with albuterol which is dsicontd since recent\n MI,pt was hypotensive to the ED to 80\ns(lowest noted was 67/47).. with\n normal mentation, HR 60-70\ns sinus, initial lactate was noted for\n 3.1,wbc 20, cvp 8-14,cxr with RT sided PNA,does have chronic cough(on\n Lisinopril)\nUA with positive nitrates. o/e cyst vs abcess on the back\n and left hand,no loose bm, this am she was noted to have WBC OF 30. Pt\n was noted to have a ?? PNA on cxray.\n Action:\n This am pt was very anxious, c/o SOB, with rr in the 30\ns or above and\n nausea. Pt was cool, clammy and hypothermic with a temp of 95.9. Pt\n lower ext were noted to have increasing mottling throughout the\n morning. Pt was tachy into the high 90\ns low 100\ns. Pt was also\n becoming more lethargic. Pt had two EKG done which showed ?? slight\n changes, pt was switched from levopehd to neo to help control HR. pt\n was intubated for airway protection. Started on fent/versed, and cipro\n and cifepeme.\n Response:\n Sbp 90-110\ns,map>60,hr 70\ns, uop 30-40cc/hr,but skin appears cool and\n sweaty now??cardiogenic will have cards consulted\nunable to place a A\n line,wbc 30.8 with ma labs(up from 20)\n.weak radial pulses,DP pulses\n dopplerable\ncvp 10-12.lactate up 2.5.\n Plan:\n Goal MAP>60,titrate neo as needed,follow urine output closely, follow\n cx datas,\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n s/p recent STEMI (10days ago),currently denies any chest pain, but\n sob,initial troponin was 2.08 with flat CKmb,ekg with sinus rythum,INR\n now 2\n Action:\n Contd asa,plavix,lipitor,had bedside echo,telemonitoring,cycle cardiac\n enzymes,received 10mg vit k on admission to the ICU.\n Response:\n Trponin trending down with flat ck,more likely from previous\n MI,currently hypotensive on levophed,inr doen to 4.8,no s/s of active\n bleeding\n Plan:\n Will cont to monitor,cardiology is following the pt.follow final read\n on ECHO,follow enzymes and ekg.\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496354,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - CL placed\n - TTE (bedside by fellow) - EF 20%\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Infusions:\n Norepinephrine - 0.26 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Asa, Plavix, Zantac, RISS, Atrovent nebs, Advair, Vanco 1gm q48,\n Atorvastatin, PO vanc\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Gastrointestinal: Nausea\n Flowsheet Data as of 09:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 71 (65 - 75) bpm\n BP: 115/59(72) {78/37(56) - 116/68(77)} mmHg\n RR: 30 (24 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (8 - 11)mmHg\n Total In:\n 1,591 mL\n 462 mL\n PO:\n TF:\n IVF:\n 1,091 mL\n 462 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 140 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 510 K/uL\n 206 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 30.8 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n WBC\n 30.8\n Hct\n 29.0\n Plt\n 510\n Cr\n 1.6\n 1.4\n TropT\n 1.93\n 1.48\n Glucose\n 230\n 206\n Other labs: PT / PTT / INR:45.1/44.5/4.8, CK / CKMB /\n Troponin-T:79//1.48, Lactic Acid:2.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:4.2 mg/dL\n Imaging: CXR - RML infiltrate\n Microbiology: Pending.\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB, found to be hypotensive.\n # Hypotension: This is mostly likely septic shock from RLL pneumonia\n in the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl. In\n addition, U/A is equivocal. As far as cardiogenic reasons for shock,\n EF is 20% on prelim ECHO read and reportedly stable per son-in-law.\n Unlikely to have restent thrombosis or second ACS event as CK, CK-MB\n are flat. Trop is likely coming down. Unfortuantely, there are no\n records from available yet. Patient may also be slightly\n volume depleted.\n - bcxs, ucx, sputum cx, c. diff\n - broaden coverage for HAP with vanc/zosyn\n - trend CEs, serial EKGs\n - obtain records from \n - follow up final ECHO\n - IVFs, difficult to have CVP goal given recent massive MI\n - cont. levophed\n - needs aline\n # Diarrhea: Pt reports 1 week of diarrhea. Unlikely to be C. diff\n given co-treatment of levaquin with flagyl.\n - check c. diff\n - hold on c. diff treatment for now\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just massive anterior MI.\n - serial CEs, EKGs\n - cont. ASA, plavix, high dose atorvastatin\n - hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - hold amiodarone, BB as hypotensive\n - supratherapeutic\n # Coagulopathy: Was on coumadin for afib at . Only slight\n oozing at RIJ site and mild hemoptysis.\n - follow coags\n - vitamin K 10 mg IV\n - hold coumadin\n - FFP if actively bleeding\n # Elevated Creatinine: Cr at was 1.5. Unclear what it was\n prior to that admission.\n - will get PCP records\n dose meds\n # HTN:\n - hold antihypertensives\n # Hyperlipidemia:\n - cont. atorvastatin\n # Asthma\n - cont. atrovent nebulizers\n - cont. Advair\n # Diabetes mellitus type 2:\n - hold metformin while in house\n - ISS\n # GERD:\n - cont. zantac\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 25 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 496356,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n - CL placed\n - TTE (bedside by fellow) - EF 20%\n - Pressors weaned off this am\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Infusions:\n Norepinephrine - 0.26 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Asa, Plavix, Zantac, RISS, Atrovent nebs, Advair, Vanco 1gm q48,\n Atorvastatin, PO vanc\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Respiratory: Dyspnea\n Gastrointestinal: Nausea\n Flowsheet Data as of 09:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.4\nC (97.6\n HR: 71 (65 - 75) bpm\n BP: 115/59(72) {78/37(56) - 116/68(77)} mmHg\n RR: 30 (24 - 36) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 11 (8 - 11)mmHg\n Total In:\n 1,591 mL\n 462 mL\n PO:\n TF:\n IVF:\n 1,091 mL\n 462 mL\n Blood products:\n Total out:\n 740 mL\n 375 mL\n Urine:\n 140 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n 851 mL\n 87 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezing R>L: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 9.7 g/dL\n 510 K/uL\n 206 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 35 mg/dL\n 101 mEq/L\n 134 mEq/L\n 29.0 %\n 30.8 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n WBC\n 30.8\n Hct\n 29.0\n Plt\n 510\n Cr\n 1.6\n 1.4\n TropT\n 1.93\n 1.48\n Glucose\n 230\n 206\n Other labs: PT / PTT / INR:45.1/44.5/4.8, CK / CKMB /\n Troponin-T:79//1.48, Lactic Acid:2.1 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:4.2 mg/dL\n Imaging: CXR - RML infiltrate\n Microbiology: Pending.\n EKG: Increased rate with some worsening inferior ST depressions\n Assessment and Plan\n Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with increasing SOB and diarrhea, found to be\n hypotensive and hypoxemic.\n # Hypotension: This is mostly likely septic shock from RLL pneumonia\n in the setting of poor EF from recent massive NSTEMI. Pt is also\n reporting diarrhea and may have developed c. diff though on flagyl.\n Off pressors with CVP of 12.\n - F/U cultures\n - Continue vanc/zosyn\n - Trend CEs, serial EKGs\n - Obtain records from \n - Follow up final ECHO\n # Hypoxemic respiratory failure: Likely PNA with superimposed\n asthma flare.\n - Continue albuterol MDI (not tolerated nebs)\n - Start steroids\n - ABG\n # Diarrhea: Pt reports 1 week of diarrhea. Could be C. diff, although\n unlikely given recent flagyl. Elevated WBC count today prompted\n initiation of PO vanc.\n - Check C. diff\n - Continue PO vanc\n will d/c if c. diff neg x 2\n # CAD, s/p recent STEMI, now with EF 20%: EKG shows no acute ischemic\n changes, per Cardiology, just old massive anterior MI.\n - Serial CEs, EKGs\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n # Afib: Currently in sinus.\n - hold amiodarone, BB as hypotensive\n - supratherapeutic\n # Coagulopathy: Was on coumadin for afib at . Only slight\n oozing at RIJ site and mild hemoptysis. Also with elevated PTT.\n - Follow coags\n - Check to see if on SQ heparin at rehab to explain elevated PTT\n - Hold coumadin\n - Check DIC labs\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 25 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496324,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Pt reports that at rehab, every night she had chest tightness, rating\n , associated with heavy breathing and nausea. No diaphoresis. The\n discomfort would last all night, preventing her from sleeping. She\n states it's a different pain than her MI. She denied any f/c. She\n reports that she has a chronic cough, but is blood-tinged. Notablely,\n she has a cough with lisinopril, which she is currently on. At 3PM,\n she c/o SOB wtih wheezing. VS were 90/54, 72, 18, 97% on 2L O2, T 98.\n She was taken to the ED.\n .\n In the ED, initial BP 85/47. On exam, pt was using accessory muscles.\n A bedside ultrasound showed minimal pericardial effusion, no evidence\n of tamponade. CXR showed R-sided pneumonia. Pt received Vanc/zosyn\n and 1 L NS. RIJ placed. Initially she was on dopamine without much\n response and was switched to levophed, currently at 0.18. 70, 97/78,\n 18, 99% on 2 L. CVP 11-16. transferred to micu for further care.\n Shock, septic\n Assessment:\n Pt presented from rehab(discharged to rehab on from \n hosp) with sob,known h/o asthma,as per the pt she has intermittent sob\n which usually relieves with albuterol which is dsicontd since recent\n MI,pt was hypotensive to the ED to 80\ns(lowest noted was 67/47).. with\n normal mentation, HR 60-70\ns sinus, initial lactate was noted for\n 3.1,wbc 20, cvp 8-14,cxr with RT sided PNA,does have chronic cough(on\n Lisinopril)\nUA with positive nitrates. o/e cyst vs abcess on the back\n and left hand,no loose bm,\n Action:\n Receieved vanco+zozyn down in the ED,contd vanco 1gm and zozyn q6h,\n also on levophed currently at 0.24,Had bedside echo which shows EF\n 20%,contd 02 4l via the NC\nreceived 1L fluid bolus\n Response:\n Sbp 90-110\ns,map>60,hr 70\ns, uop 30-40cc/hr,but skin appears cool and\n clammy??cardiogenic\nunable to place a A line,wbc 30.8 with ma labs(up\n from 20)\n.weak radial pulses,DP pulses dopplerable\ncvp 10-12.lactate\n down 2.1.\n Plan:\n Goal MAP>60,titrate levo as needed,follow urine output closely, follow\n cx datas,\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n s/p recent STEMI (10days ago),currently denies any chest pain, but\n sob,initial troponin was 2.08 with flat CKmb,ekg with sinus rythum,INR\n 6.5 with slight oozing from the RT IJ site\n Action:\n Contd asa,plavix,lipitor,had bedside echo,telemonitoring,cycle cardiac\n enzymes,received 10mg vit k.\n Response:\n Trponin trending down with flat ck,more likely from previous\n MI,currently hypotensive on levophed,inr doen to 4.8,no s/s of active\n bleeding\n Plan:\n Will cont to monitor,cardiology is following the pt.follow final read\n on ECHO,follow enzymes and ekg.\n Anxiety\n Assessment:\n Pt was increasingly anxious,restless and agitated,\nstating she cannot\n berath ,wants albuterol inhaler and meanwhile she states her doctor\n told her she cannot have heart disease\npt got extremely agitated\n and trying to get OOB,pulling out wires,\n Action:\n Received ativan 0.5mg IVP,reassured the pt\n Response:\n Good response with ativan,pt slept through the night,co operative with\n care,much better this am.\n Plan:\n Contd to reassure the pt,ativan as needed for severe anxiety.\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496642,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on the vent she was initially on PSV but was only breathing\n ~ 10 BPM, her venous C02 was elevated, 02 SAT has been in the high\n 90s-100%, LS with rale in the L base, sx for dark tan plugs, T max\n 100.2\n Action:\n Place on MMV to insure a MV, fnet and versed were decrease to try and\n increase her RR, conts on abx\n Response:\n Not urge to breath, pneumonia\n Plan:\n Cont to follow, there has been discussion to extubated tomorrow so do a\n RSBI in the am, cont abx\n Shock, septic\n Assessment:\n Remains on neo 2.5 mg/kg/min, SBP 90s-100s, T max 100.2\n Action:\n Given a 500cc NS bolus to see if we could decrease the neo\n Response:\n No change in her BP or u/o with the fluid bolus\n Plan:\n Cont to try and wean the neo, cont abx, f/u woith clx\n"
},
{
"category": "Physician ",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 496588,
"text": "Chief Complaint: Respiratory distress\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:30 AM\n OSH info:\n --Presented with CP\n --Anterior septal STEMI, 3 stents placed to proximal LAD\n --PCWP of 35\n --On levophed and dopamine at OSH\n --Lactate of 4\n ***Taken back to cath lab at StE\ns with placement of IABP as proximal\n LAD flow only TIMI 2, cath also showing 90% circ lesion and midLAD,\n distal LAD 80% stenoses.\n --WBC 37.5 on -treated for CAP with levo, and flagyl for empiric\n C diff given diarrhea\n Still required 2.5 of neo overnight. No other major events.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:19 AM\n Cefipime - 02:44 PM\n Ciprofloxacin - 02:00 AM\n Vancomycin - 05:46 AM\n Infusions:\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Phenylephrine - 2.5 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:24 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: 78 (69 - 101) bpm\n BP: 106/58(69) {69/36(43) - 144/68(85)} mmHg\n RR: 9 (9 - 37) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 14 (0 - 20)mmHg\n Total In:\n 1,619 mL\n 709 mL\n PO:\n TF:\n IVF:\n 1,559 mL\n 649 mL\n Blood products:\n Total out:\n 1,325 mL\n 240 mL\n Urine:\n 1,325 mL\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 294 mL\n 470 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): 560 (370 - 560) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 16 cmH2O\n Plateau: 21 cmH2O\n SpO2: 100%\n ABG: 7.32/44/99./23/-3\n Ve: 5.8 L/min\n PaO2 / FiO2: 198\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 522 K/uL\n 9.4 g/dL\n 251 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.8 mEq/L\n 36 mg/dL\n 106 mEq/L\n 138 mEq/L\n 29.1 %\n 26.2 K/uL\n [image002.jpg]\n 11:00 PM\n 03:53 AM\n 09:54 AM\n 01:58 PM\n 02:20 PM\n 04:54 AM\n WBC\n 30.8\n 26.2\n Hct\n 29.0\n 29.1\n Plt\n 510\n 522\n Cr\n 1.6\n 1.4\n 1.3\n TropT\n 1.93\n 1.48\n 1.30\n 1.06\n TCO2\n 23\n 24\n Glucose\n 230\n 206\n 251\n Other labs: PT / PTT / INR:23.8/34.5/2.3, CK / CKMB /\n Troponin-T:77//1.06, Alk Phos / T Bili:/0.6, Fibrinogen:817 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:446 IU/L, Ca++:7.9 mg/dL, Mg++:2.1 mg/dL,\n PO4:3.8 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ANXIETY\n SHOCK, SEPTIC\n CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n 77 yo female s/p recent STEMI at OSH 10 days ago, s/p 3 stents & IABP x\n 3 days for cardiogenic shock; had pneumonia treated with flagyl and\n levaquin, presented from rehab with increasing SOB and diarrhea, in\n septic shock still requiring pressors. Intubated yesterday for\n increased work of breathing.\n # Hypotension: Given distributive shock, o2 requirement, and CXR\n infiltrate, this is most likely septic shock from RLL pneumonia poorly\n compensated in the setting of an acutely depressed EF s/p recent\n myocardial infarction. CDIFF may also be contributing. Given CVP=12,\n stable EKG, and serial CE trending down, favor sepsis over cardiogenic\n shock.\n - F/U cultures; no organisms seen on initial gram stain\n - vanco/cefepime/cipro; leukocytosis improving\n - Trend CEs, serial EKGs with any major hemodynamic changes\n - favor neo over levophed given recent MI and acutely depressed EF.\n - trial of fluids in effor to wean pressors, will be cautious given\n acutely depressed LVEF\n # Hypoxemic respiratory failure / increased work of breathing: Likely\n PNA with some contributiion from astma given severe wheezing on\n exam. Other concern would be LV failure from ischemia, but arguing\n against this is CVP=12avg.\n - s/p intubation; A-LINE attempts failed, will trend serial ABGS and\n venous gases\n - will attempt to wean PSV from to , RSBI 28, goal extubate\n tomorrow if tolerates wean\n - steroidsx 5 days, MDIs\n # Diarrhea/Leukocytosis: Empiric CDIFF covg given marked leukocytosis\n with PO vanco. f/u cdiff tox x2\n # CAD, s/p recent STEMI, now with EF 20%: Cardiac enzymes continually\n trending down suggesting that ACS is not contributing. EKG relatively\n stable, some rate dependent ST depressions inferiorly. Previously\n under the impression that pt had been completely re-vascularized, but\n it seems that there are 80% lesions in mid and distal LAD along with\n 90% circ lesion which have not been intervened upon as they were not\n felt to be cultprits in Acute MI.\n - Serial CEs, EKGs for any hemodynamic changes\n - Cont. ASA, plavix, high dose atorvastatin\n - Hold BB, ACEI, aldactone, lasix\n - favor neo over levophed as above; goal HR as close to 60 as feasible\n - given degree of akinesis/infarct, pt should maintain therapeutic INR\n and be bridged with heparin for INR<2 to prevent LV thrombus\n # Afib: Currently in sinus.\n - hold BB as hypotensive, resume amio soon (although long half-life\n means she will be therapeutic for a while)\n - therapeutic on coumadin but INR trending down rapidly; resuming\n # FEN: IVFs / replete lytes prn / cardiac diet\n # PPX: H2RA, supratherapeutic inr, bowel regimen\n # ACCESS: RIJ\n # CODE: FULL\n # CONTACT: Daughter and son-in-law cell\n , cell , home .\n # DISPO: ICU\n ICU Care\n Nutrition: npo\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer: h2b\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu, intubated\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 496643,
"text": "Patient is 77 yo female with PMHx sig. for recent massive STEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin. She was\n sent to rehab on and presents from rehab with increasing SOB.\n .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains on the vent she was initially on PSV but was only breathing\n ~ 10 BPM, her venous C02 was elevated, 02 SAT has been in the high\n 90s-100%, LS with rale in the L base, sx for dark tan plugs, T max\n 100.2\n Action:\n Place on MMV to insure a MV, fnet and versed were decrease to try and\n increase her RR, conts on abx\n Response:\n Not urge to breath, pneumonia\n Plan:\n Cont to follow, there has been discussion to extubated tomorrow so do a\n RSBI in the am, cont abx\n Shock, septic\n Assessment:\n Remains on neo 2.5 mg/kg/min, SBP 90s-100s, T max 100.2\n Action:\n Given a 500cc NS bolus to see if we could decrease the neo\n Response:\n No change in her BP or u/o with the fluid bolus, clx are neg to date\n Plan:\n Cont to try and wean the neo, cont abx, f/u woith clx\n"
},
{
"category": "Nursing",
"chartdate": "2153-10-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 497882,
"text": "Patient is 77 yo female with PMHx sig. for recent massive NSTEMI at OSH\n 10 days ago, s/p 3 stents complicated by cardiogenic shock requiring\n IABP x 3 days and pneumonia treated with flagyl and levaquin, who\n presents from rehab with diarrhea, hypotension and respiratory distress\n progressing into acute respiratory failure- dx\nd with HAP PNA/asthma\n flare. Extubated and doing well on 4 L NC until pm when she\n was reintubated.\n Developed acute respiratory distress 11/5pm requiring re-intubation\n for obtundation and mottled appearance. Unclear etiology (VBG 4.32/42\n and sats in high 90s on 4L prior to obtundation), but likely due to\n volume status and large anxiety component. Now looks extubatable, but\n hesitant given unclear event that led to reintubation. Differential\n includes pulmonary edema, anxiety, oversedation with ativan, HAP, PE,\n and acute bronchspasm.\n Bilat leg U/S obtained, no DVT\ns noted.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient on Bipap mask, apparently placed on at 0600 that\n morning. Patient requesting to have mask off. Lung sounds clear upper\n fields, diminished in bases. Lasix gtt at 3mg/hr.\n Action:\n Bipap D/C\nd at 0800, returned to 2L NC. Encouraged coughing and deep\n breathing. OOB to chair from 0800 to 1200.\n Response:\n Patient diuresing well. SAT remain 96-98%. Patient asking for inhaler\n although she has already received dose and is not currently wheezing.\n With encouragement, patient has a strong, effective cough.\n Plan:\n Encourage cough and deep breathing. Emotional support for anxiety\n regarding\nallergies\n and desire to over-use inhaler. Monitor mental\n status, SAT, and lung sounds.\n Anxiety\n Assessment:\n Patient has frequent anxiety, will fixate regarding her breathing, her\n bowels, or her heart.\n Action:\n Ativan 0.25mg IVP x1 for anxiety.\n Response:\n Patient comfortable, mildly anxious regarding breathing and\nallergies\n, at times breathes loudly using vocal cords and states this\n is\nwheezing\n. No wheezing heard when patient asked to take quiet, deep\n breaths. Responds well to verbal redirection.\n Plan:\n Monitor patient\ns mental status, anxiety level. Has PRN ativan if\n needed, but was a question whether patient had been overmedicated\n leading up to last intubation.\n Coronary artery disease (CAD, ischemic heart disease)\n Assessment:\n VS stable, BP 98-110/55-68, HR 70-80\ns SR with occasional PVC\n Cardiology following.\n Action:\n Continued Lasix drip at 3 mg/hr.\n Response:\n Excellent response to Lasix, is now about 800cc volume negative for\n length of stay.\n Plan:\n Monitor VS and assess response to Lasix gtt. Check recommendations\n from Cardiology.\n Diarrhea\n Assessment:\n Patient was given Miralax x1 on due to no BM. Patient had multiple\n small loose stools throughout the night and was quite upset about this.\n (On patient was on oral vanco for suspected C-diff, but had no\n stools to send for culture. On oral vanco was D/C\nd. WBC began\n trending back up, so Laxative order by MD stool to send for\n C-Diff culture. On oral vanco re-started.)\n Action:\n Encouraged patient to order and eat breakfast and lunch, Zofran 4mg x1\n IV for c/o nausea. All laxatives and stool softeners held.\n Response:\n Tolerating diet well, but will not eat if not encouraged by staff as\n she thinks this will cause more diarrhea. Only 2 soft stools passed\n this shift.\n Plan:\n Loose stool resolving. Continue to order meals with patient and\n encourage her to eat. Has Zofran for nausea PRN.\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1105956,
"text": " 2:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure.\n\n FINDINGS: In comparison with the study of , there is continued\n enlargement of the cardiac silhouette with pulmonary vascular congestion and\n bilateral pleural effusion with associated compressive atelectasis.\n Monitoring and support devices remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106319,
"text": " 7:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n WET READ: 8:02 PM\n low lung volumes. development of interstitial pulmonary edema. worsening\n right mid to lower lung and left retrocardic opacities from 3:55am.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress, to evaluate for change.\n\n FINDINGS: In comparison with the earlier study of this date, there are\n somewhat lower lung volumes. Interstitial pulmonary edema persists, somewhat\n worse on the right. Retrocardiac atelectasis persists. The costophrenic\n angles are more sharply seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106547,
"text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure.\n\n COMPARISON: .\n\n FINDINGS: The endotracheal tube, right IJ and NG tube are stable in position.\n No significant change in bibasilar airspace opacities and bilateral pleural\n effusions. Persistent mild vascular congestion. Cardiomediastinal silhouette\n is unchanged. No pneumothorax is seen.\n\n IMPRESSION: Stable bibasilar airspace opacities, bilateral pleural effusions,\n and mild pulmonary vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1105591,
"text": " 5:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with SOB\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old woman with shortness of breath.\n\n COMPARISON: None.\n\n SINGLE UPRIGHT VIEW OF THE CHEST AT 1700 HOURS: Lung volumes are low. There\n is increased opacity of the right middle lobe, abutting the horizontal\n fissure, worrisome for right middle lobe pneumonia. Remaining right lung, and\n the left lung are well aerated. There is likely atelectasis at the left lung\n base. No pleural effusions are present. There is no pneumothorax. The heart\n size is within normal limits. There is no hilar or mediastinal enlargement.\n Pulmonary vascularity is normal.\n\n IMPRESSION: Right middle lobe opacity concerning for pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1105666,
"text": " 11:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: et placement, interval change (tech already on floor)\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman s/p intubation\n REASON FOR THIS EXAMINATION:\n et placement, interval change (tech already on floor)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check ETT\n\n COMPARISON: at 17:15 and 18:20 hours.\n\n SINGLE AP UPRIGHT CHEST RADIOGRAPH: Endotracheal tube tip 1.4 cm above the\n carina, should be withdrawn 3.0 cm for standard positioning. A right internal\n jugular catheter ends at the superior cavoatrial junction. Mild to moderate\n pulmonary edema, predominantly basal, has progressed. Heart size is top\n normal. A small right pleural effusion is new. Left basilar atelectasis is\n mild The thoracic aorta is tortuous. Mediastinal contours are normal. A\n nasogastric tube courses through the stomach.\n\n IMPRESSION:\n\n 1. ET tube tip 1.5 cm from the carina, should be withdrawn 3.0 cm.\n\n 2. Mild-to-moderate cardiogenic pulmonary edema worsened.\n\n The findings were discussed with Dr. immediately after the study.\n\n The findings were discussed with Dr. immediately after the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-21 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1105596,
"text": " 6:21 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with new right central line placement\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old woman with new right central line placement.\n\n COMPARISON: Chest radiograph approximately one hour earlier.\n\n SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT 18:25 HOURS: A right internal\n jugular catheter terminates at the cavoatrial junction. Diffusely increased\n opacity of the right middle lobe is again noted. Since the prior exam, there\n are increased interstitial markings and the development of mild vascular\n fullness. The aorta is tortuous, and there may be a hiatal hernia.\n\n IMPRESSION: Right internal jugular catheter terminates at the cavoatrial\n junction without evidence of pneumothorax. Right middle lobe opacity\n persists. Interval increase in vascular fullness suggesting interim fluid\n overload.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106146,
"text": " 3:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n eval for 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 examination, there is a clear\n improvement. The patient has been extubated, the nasogastric tube has been\n removed. The ventilation of the lungs has improved. Pre-existing parenchymal\n opacities have decreased in extent. On today's radiograph, they are most\n obvious at the lung bases and in the retrocardiac lung areas. There is\n unchanged minimal cardiomegaly, but no evidence of pulmonary edema.\n Otherwise, no relevant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106358,
"text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with pneumonia / chf\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure.\n\n FINDINGS: In comparison with study of , the endotracheal tube tip has\n been pulled back to about 2.8 cm above the carina. There is bibasilar\n opacification with poor definition of the hemidiaphragms, consistent with\n atelectasis and layering effusion. Some elevation of pulmonary venous\n pressure is also seen.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106804,
"text": " 8:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with resp distress\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 77-year-old woman with respiratory distress. Evaluate for\n interval change.\n\n COMPARISON: ; .\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: Again seen is a right internal jugular\n catheter with tip projecting over the mid SVC. Heart size and mediastinal\n contours are unchanged. The aorta is mildly calcified and unfolded. There is\n persisting bu t improved retrocardiac and right basilar opacity. There are\n no large pleural effusion. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1106325,
"text": " 7:41 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ET tube placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with resp failure\n REASON FOR THIS EXAMINATION:\n eval for ET tube placement\n ______________________________________________________________________________\n WET READ: 8:04 PM\n ETT 1cm above carina. d/w Dr 8pm . persistent retrocardiac,\n right lung opacities, most dense in right mid to lower lung. layering right\n effusion.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Radiograph of earlier the same date.\n\n INDICATION: Endotracheal tube placement.\n\n FINDINGS: Endotracheal tube tip terminates about 1 cm above the carina, as\n communicated by phone with Dr. . There has been apparent shift in\n distribution of pulmonary edema which is now predominantly located on the\n right. There is otherwise no substantial short-interval change since the\n recent study of less than one hour earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2153-10-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1105781,
"text": " 3:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old woman with respiratory failure\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: Respiratory failure.\n\n Comparison is made with a prior study performed a day earlier.\n\n Mild pulmonary edema has improved. Cardiac size is top normal. There is mild\n bilateral pleural effusions, greater on the right side. Left lower lobe\n atelectasis has increased. Opacity in the right lower lobe is most likely\n atelectasis. Right IJ catheter, ET tube and NG tube remain in place.\n\n\n"
}
] |
29,540 | 198,242 | The patient was admitted to the ICU from the ER to the neurosurgical service. An EVD was placed for monitoring and prevention of hydrocephalus. Dilantin was started for seizure prophylaxis and nimodipine was started for vasospasm prophylaxis. He was maintained on nafcillin for the drain. An angiogram was obtained which showed a large AVM supplied by the L PCA draining into SS sinus, also supplied by L ACA As branches, no aneurysm noted. A post angio CT was stable. ON HD 2 his neurological exam was improving. He was also seen by the neurology consult service. On HD#3 the patient pulled out his own ET tube. His CVP was noted to range from with the EVD open at 20cm above the tragus. Arrangements were made for his transfer to under the care of Dr. for further management of his large AVM. | Status post placement of a right frontal ventricular shunt terminating within the right lateral ventricle with slightly decreased size of the ventricles. There is a right- sided ventricular shunt in place. Left common carotid artery. The visualized right and left external carotid arteries are within normal limits. nsg noteSEE FLOWSHEET FOR SPECIFICS.NEURO-REMAINS ON PROP GTT. Remains on Q 4hr nimodipine and nafcillin. Allowing for presumptive supine positioning, the cardiomediastinal silhouette and pulmonary vessels are likely within normal limits. Since the last exam, a ventricular shunt has been placed terminating within the right lateral ventricle via a right frontal approach. Remains afebrile, NGT draining scant between frequent meds via tube. worsening bleed/ ICP No contraindications for IV contrast FINAL REPORT HISTORY: Known large left intraparenchymal hemorrhage with associated AVM and worsening hiccups. The remainder of the visualized paranasal sinuses and mastoid air cells remain normally aerated. Left internal carotid artery. Skin w+d, ppp. Left vertebral artery. A right frontal scalp hematoma is present with tiny locules of air within the subcutaneous tissues around the ventricular shunt. Mild-to-moderate mucosal thickening involving the maxillary sinuses bilaterally with partially aerosolized secretions is again noted, with remaining paranasal sinuses and mastoid air cells appearing well aerated. Follows commands, sl R sided drift noted w/neuro exam. COMPARISON: With CT of . Left external carotid artery. Tol po meds w/sip after NGT removed during extubation. Right common carotid artery. Right vertebral artery. ABG WNL with hyperoxia. Right internal carotid artery. Fluid is noted within the right maxillary sinus. Although there is supply by the left anterior and middle cerebral arteries. Right external carotid artery. FINDINGS: The overall size of the large left parietal intraparenchymal hemorrhage is unchanged. CT repeated this am. The major draining vein, as noted by Dr. , appears to merge with the posterior aspect of the superior sagittal sinus. The tip of the apparently newly-placed ET tube is relatively low-lying, terminating some 2.3 cm proximal to the carina. The positioning and appearance of the right intraventricular drain is unchanged, as is the size of the lateral, third, and fourth ventricles from most recent exam. IV NAFCILLIN STARTED AND TO CONTINUE WHILE DRAIN IN.GI: NGT TO LWS, NO DRAINAGE, CLAMPED AFTER MEDS. sx'd for minimal secretions. Sinus rhythm. He indicated "large left occipital temporal intraparenchymal hematoma with surrounding edema. There is moderate right and milder left-sided temporal enlargement. STILL LISTED AS EU CRITICAL AT THIS TIME.NEURO: SHORTLY AFTER ARRIVAL ON SICU, HEAT CT DONE, LG FRONTAL/TEMPORAL BLEED CLEARLY VISUALIZED WITH BLOOD IN VENTRICLES ALSO. There is some lobulation of this nidus. SKIN W+D. REMAINS ON NIMODOPINE. Venous drainage is into the superior sagittal sinus. Cough/gag +. The CT angiogram confirms the presence of a large vascular malformation, which appears to be primarily of pial, rather than dural origin. Neo weaned to off shortly after self extubated. Drainage is mostly into the superior sagittal sinus. + COUGH. SBP maint >110, able to wean Neo slightly this pm. NEURO CHECKS. There is mild-to- moderate mucosal thickening involving the maxillary sinuses more marked on the right. The amount of edema surrounding the intraparenchymal hemorrhage is stable. The nidus of the vascular malformation is situated along the superior aspect of the hemorrhage. Clinicalcorrelation is suggested. The following vessels were selectively catheterized and arteriograms were performed from the following locations: 1. PRELIMINARY REPORT: Provided by Dr. . Pt has very strong cough and gag.Plan: wean to extubation after procedure. J point andST segment elevation through the lateral precordial leads. LIKELY TO ANGIO THIS AM. NGT TO LWS WITH BILIOUS DRG.GU-VOIDING VIA FOLEY ADEQ AMTS BROWNISH URINE.COMFORT-APPEARS COMFORTABLE.ENDO-SSRI. High-attenuation material is seen within the sulci, particularly along the left cerebral hemisphere, which may represent subarachnoid blood, although delayed enhancement from recent contrast study is possible. Through the needle, a 0.038 wire was introduced and the needle was taken out. VENTRICULOSTOMY DRAINING BLOODY CSF. CONCLUSION: Large pial-based arteriovenous malformation within the left parietal- occipital region. The amount of edema surrounding the intraparenchymal hemorrhage is stable, with maintenance of -white differentiation in remaining portions of the brain. The positioning and appearance of the right intraventricular drain is stable. The major vascular feeder appears to be the left posterior cerebral artery, although there may well be contribution from distal branches of the left anterior cerebral artery arising from the pericallosal division. SEDATED ON PROPOFOL, LIGHTENED UP X2 FOR NEURO EXAM. Neuro intact, MAEW, oriented x3 but forgets that he is in . Both groins were prepped and draped in their usual sterile fashion. BS clear + cough noted w/weak gag which is more pronounced this pm. PBOOTS ON.RESP-NO VENT CHANGES MADE OVER NOC. NON-CONTRAST HEAD CT: Large intraparenchymal hemorrhage in the left occipitoparietal lobe measures 5.0 x 2.0 cm and dissects into the left lateral ventricle. Endogastric tube should be advanced. Respiratory CarePt remains intubated on vent support. +PP. An endogastric tube reaches the gastric fundus with its side-port in the region of the cardia. Breath Sounds clear after sx with good aeration. +BS. BLBS fine rhonchi to clear, suctioned for scant thick yellow secretions. FINDINGS: There is a large arteriovenous malformation in the left parieto- occipital region. PERRL. Remains sedated on vent support PS 10/5x40% w/sats maint >97% t/o day. CONCLUSION: No interval change in the size of the left parietal intraparenchymal hematoma or intraventricular hemorrhage. Interval decrease in amount of intraventricular hemorrhage with degree of dilatation involving the temporal horns appearing stable from most recent exam but improved from patient's original CT examination prior to drain. Evaluate for worsening bleed or signs of increased intracranial pressure. NON-CONTRAST HEAD CT The overall size of the known left temporal-occipital intraparenchymal hemorrhage has displayed no interval change, with decreased blood noted within the ventricular system, especially anteriorly. | 14 | [
{
"category": "Radiology",
"chartdate": "2197-03-26 00:00:00.000",
"description": "SEL CATH 3RD ORDER THOR",
"row_id": 1009937,
"text": " 4:48 PM\n CAROT/CEREB Clip # \n Reason: AVM\n Contrast: OPTIRAY Amt: 325\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 BILAT 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 26 year old man with IPH w/ ventricular extension\n REASON FOR THIS EXAMINATION:\n AVM\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 26-year-old man with IPH with ventricular extension.\n\n CONSENT: Written informed consent was obtained prior to the procedure after\n explaining the risks, benefits, and alternative management of the procedure.\n\n TECHNIQUE: After obtaining informed consent, the patient was brought to the\n interventional neuroradiology suite and placed on the biplane table in supine\n position. A preprocedure time-out was performed using two patient\n identifiers. Both groins were prepped and draped in their usual sterile\n fashion. Access to the right common femoral artery was obtained using a 19\n gauge single wall needle under local anesthesia with 1% lidocaine mixed with\n sodium bicarbonate. Through the needle, a 0.038 wire was introduced\n and the needle was taken out. Over the wire, a 5 Fr vascular sheath was\n placed and connected to a saline infusion (mixed with heparin 500 units in 500\n cc of saline) with a continuous drip. Through the sheath, a 4 Fr Berenstein\n catheter was introduced and connected to a continuous saline infusion (with\n heparin mixture 1000 units of heparin in 1000 cc of saline). The following\n vessels were selectively catheterized and arteriograms were performed from the\n following locations:\n\n 1. Left vertebral artery.\n 2. Right vertebral artery.\n 3. Right internal carotid artery.\n 4. Right external carotid artery.\n 5. Right common carotid artery.\n 6. Left internal carotid artery.\n 7. Left common carotid artery.\n 8. Left external carotid artery.\n\n After review of the films, the catheter and sheath were withdrawn and pressure\n was applied on the groin until hemostasis was obtained. The procedure was\n uneventful and the patient tolerated the procedure well without immediate\n complications. The patient was sent to the floor with orders.\n (Over)\n\n 4:48 PM\n CAROT/CEREB Clip # \n Reason: AVM\n Contrast: OPTIRAY Amt: 325\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The attending neuroradiologist, Dr. , was present during the entire\n procedure.\n\n FINDINGS: There is a large arteriovenous malformation in the left parieto-\n occipital region. The arteriovenous malformation is mainly supplied by the\n left posterior cerebral artery. Although there is supply by the left anterior\n and middle cerebral arteries. Drainage is mostly into the superior sagittal\n sinus.\n\n Evaluation of the arteries of the circle of demonstrate no aneurysm.\n There is no high grade stenosis or occlusion identified. There is a right-\n sided ventricular shunt in place.\n\n The visualized right and left external carotid arteries are within normal\n limits.\n\n IMPRESSION:\n\n Large arteriovenous malformation in the left parieto-occipital region supplied\n by the anterior, middle and posterior cerebral arteries but mostly by the\n posterior cerebral artery. Venous drainage is into the superior sagittal\n sinus.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-03-26 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1009931,
"text": " 3:16 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: eval aneurysm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with ICH/SAH\n REASON FOR THIS EXAMINATION:\n eval aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRCi SUN 6:55 PM\n Large left occipitoparietal intraparechymal hematoma with surrounding edema.\n A large amount of intraparechymal hemorrage is present in the ventricular\n system which demonstrates some degree of hydrocephalus in the temporal horns.\n Source of bleed is a large dural AVM in the left occipital region with\n arterial source appearing to be the left PCA and a large draining vein to the\n superior saggital sinus possibly congenital vein of trolard.\n WET READ VERSION #1 JRCi SUN 6:00 PM\n ______________________________________________________________________________\n FINAL REPORT\n CT ANGIOGRAPHY OF THE HEAD\n\n HISTORY: CT angiography using a bolus enhancement technique.\n\n PRELIMINARY REPORT: Provided by Dr. . He indicated \"large left\n occipital temporal intraparenchymal hematoma with surrounding edema. A large\n amount of intraparenchymal hemorrhage is present in the ventricular system,\n which demonstrates some degree of hydrocephalus involving the temporal horns.\n The source of bleed is a large dural AVM in the left occipital region with\n arterial source appearing to be the left posterior cerebral artery and a large\n draining vein to the superior sagittal sinus, possibly a vein of Trolard.\"\n\n FINDINGS: The large left posterior temporal occipital hemorrhage, with\n extensive intraventricular hemorrhage is seen. There is moderate right and\n milder left-sided temporal enlargement. There is no shift of normally\n midline structures.\n\n The CT angiogram confirms the presence of a large vascular malformation, which\n appears to be primarily of pial, rather than dural origin. The major vascular\n feeder appears to be the left posterior cerebral artery, although there may\n well be contribution from distal branches of the left anterior cerebral artery\n arising from the pericallosal division. The nidus of the vascular\n malformation is situated along the superior aspect of the hemorrhage. There\n is some lobulation of this nidus. Certainly, an intranidal aneurysm cannot be\n entirely excluded on the basis of this non-selective study. The major\n draining vein, as noted by Dr. , appears to merge with the posterior\n aspect of the superior sagittal sinus. However, its very posterior location\n is not compatible with the designation of the vein of Trolard. No other\n definite vascular abnormalities are demonstrated.\n\n CONCLUSION: Large pial-based arteriovenous malformation within the left\n parietal- occipital region. Clearly, this malformation requires\n superselective angiography for complete mapping of its vascular supply, but\n (Over)\n\n 3:16 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: eval aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n especially for improved analysis of the nidus for the presence of potential\n intranidal aneurysms.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-03-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1009930,
"text": " 3:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ett\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with intubated\n REASON FOR THIS EXAMINATION:\n ett\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST DATED .\n\n HISTORY: 26-year-old man, intubated.\n\n FINDINGS: Single bedside AP examination labeled \"up\" but presumably supine\n (the marker is empty and, therefore, uninterpretable), with no\n comparisons on record. The tip of the apparently newly-placed ET tube is\n relatively low-lying, terminating some 2.3 cm proximal to the carina. An\n endogastric tube reaches the gastric fundus with its side-port in the region\n of the cardia. Allowing for presumptive supine positioning, the\n cardiomediastinal silhouette and pulmonary vessels are likely within normal\n limits. There is biapical pleural thickening, but no supine evidence of\n pleural effusion, and no focal airspace process.\n\n IMPRESSION: Limited study, with:\n 1. No definite acute airspace process.\n 2. Relatively low-lying ET tube, which should be partially withdrawn\n approximately 2 cm.\n 3. Endogastric tube should be advanced.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-03-27 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1010004,
"text": " 10:20 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: new hippus, ? worsening bleed/ ICP\n Admitting Diagnosis: STROKE;TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with large ICH\n REASON FOR THIS EXAMINATION:\n new hippus, ? worsening bleed/ ICP\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known large left intraparenchymal hemorrhage with associated AVM and\n worsening hiccups. Evaluate for worsening bleed or signs of increased\n intracranial pressure.\n\n Comparison is made to multiple prior CTs dated .\n\n NON-CONTRAST HEAD CT\n\n The overall size of the known left temporal-occipital intraparenchymal\n hemorrhage has displayed no interval change, with decreased blood noted within\n the ventricular system, especially anteriorly. The positioning and appearance\n of the right intraventricular drain is unchanged, as is the size of the\n lateral, third, and fourth ventricles from most recent exam. The amount of\n edema surrounding the intraparenchymal hemorrhage is stable, with maintenance\n of -white differentiation in remaining portions of the brain. No new\n regions of intraparenchymal hemorrhage are identified. No significant midline\n shift or signs of uncal herniation are noted. Soft tissues and osseous\n structures are unremarkable. Mild-to-moderate mucosal thickening involving the\n maxillary sinuses bilaterally with partially aerosolized secretions is again\n noted, with remaining paranasal sinuses and mastoid air cells appearing well\n aerated.\n\n IMPRESSION:\n\n 1. No interval change in size of left temporal-occipital intraparenchymal\n hematoma. No CT findings to suggest elevated/worsening intracranial pressure.\n\n 2. Interval decrease in amount of intraventricular hemorrhage with degree of\n dilatation involving the temporal horns appearing stable from most recent exam\n but improved from patient's original CT examination prior to drain.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-03-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1010174,
"text": " 1:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls eval interval change\n Admitting Diagnosis: STROKE;TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 25 year old man admitted with L SAH/IPH w/3mm shift, s/p diagnostic angio\n REASON FOR THIS EXAMINATION:\n pls eval interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 25-year-old male with left subarachnoid hemorrhage and\n intraventricular extension, to assess for interval change.\n\n TECHNIQUE: CT of the brain was performed without intravenous contrast.\n\n COMPARISON: With CT of .\n\n FINDINGS:\n\n The overall size of the large left parietal intraparenchymal hemorrhage is\n unchanged. The positioning and appearance of the right intraventricular drain\n is stable. The size of the lateral, third and fourth ventricles are stable,\n with no significant change in the extensive intraventricular blood. The amount\n of edema surrounding the intraparenchymal hemorrhage is stable. There are no\n new regions of intraparenchymal hemorrhage. There is no significant midline\n shift or signs of uncal herniation.\n\n Soft tissues and osseous structures are unremarkable. There is mild-to-\n moderate mucosal thickening involving the maxillary sinuses more marked on the\n right.\n\n CONCLUSION:\n\n No interval change in the size of the left parietal intraparenchymal hematoma\n or intraventricular hemorrhage. No CT findings to suggest elevated/worsening\n intracranial pressure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2197-03-26 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1009945,
"text": " 8:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: STROKE;TIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with ruptured AVM s/p angio\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 26-year-old male with ruptured AVM status post angio.\n Evaluate for interval change.\n\n COMPARISON: at 15:30.\n\n NON-CONTRAST HEAD CT: Large intraparenchymal hemorrhage in the left\n occipitoparietal lobe measures 5.0 x 2.0 cm and dissects into the left lateral\n ventricle. Blood is seen within both lateral, third and fourth ventricles.\n Compared to the prior exam, there is probably no significant change in the\n size of large intraparenchymal hemorrhage, allowing for different orientation\n of axial images.\n\n Since the last exam, a ventricular shunt has been placed terminating within\n the right lateral ventricle via a right frontal approach. Although direct\n comparison is difficult from prior exam given difference in orientation of the\n axial images, there is probably slight decrease in the degree of ventricular\n dilatation. High-attenuation material is seen within the sulci, particularly\n along the left cerebral hemisphere, which may represent subarachnoid blood,\n although delayed enhancement from recent contrast study is possible.\n\n There is no shift of normally midline structures. The -white matter\n differentiation is intact. Fluid is noted within the right maxillary sinus.\n The remainder of the visualized paranasal sinuses and mastoid air cells remain\n normally aerated. A right frontal scalp hematoma is present with tiny locules\n of air within the subcutaneous tissues around the ventricular shunt.\n\n IMPRESSION:\n 1. Large intraparenchymal hemorrhage centered within the left\n occipitoparietal lobe with blood dissecting into the lateral, third and fourth\n ventricles. Compared to prior exam, there is no significant change in the\n size of the intraparenchymal hematoma, although there may be slightly\n increased amount of blood within the ventricle.\n\n 2. Status post placement of a right frontal ventricular shunt terminating\n within the right lateral ventricle with slightly decreased size of the\n ventricles.\n (Over)\n\n 8:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: STROKE;TIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-03-28 00:00:00.000",
"description": "Report",
"row_id": 1645162,
"text": "nsg note\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-REMAINS ON PROP GTT. PERRL. OPENS EYES AT TIMES TO VOICE OR PAIN. DID FOLLOW SOME COMMANDS WHEN FAMILY HERE TO INTERPRET. WITHDRAWS ALL EXTREMITIES TO PAIN. DOES MOVE ALL EXTREMITIES AT TIMES SOMEWHAT PURPOSEFULLY ON BED. REMAINS ON NIMODOPINE. VENT DRAIN AT 20CM ABOVE TRAGUS, OPEN WITH BLOODY DRG. ICP <20. + COUGH. + GAG AT TIMES. ? TO ANGIO IN AM.\n\nCV-HR SINUS BRADY TO 40'S. ON SOME NEO TO KEEP SBP 110-140. SKIN W+D. +PP. PBOOTS ON.\n\nRESP-NO VENT CHANGES MADE OVER NOC. ABG ACCEPTABLE. LS COARSE. SXN FOR LG AMT THICK TAN/YELLOW SPUTUM.\n\nGI-AND SOFT/NT/ND. +BS. NGT TO LWS WITH BILIOUS DRG.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS BROWNISH URINE.\n\nCOMFORT-APPEARS COMFORTABLE.\n\nENDO-SSRI. NO COVERAGE NEEDED.\n\nID-AFEB. ON NAFACILLIN.\n\nSOCIAL-BROTHER IN TO VISIT BUT DOES NOT SPEAK ENGLISH. FAMILY FRIEND HERE TO INTERPRET. BROTHER UPDATED ON PT'S CONDITION. WILL NEED TO SPEAK WITH MD WITH SPANISH INTERPRETER.\n\nP-CON'T WITH CURRENT PLAN. NEURO CHECKS. LIKELY TO ANGIO THIS AM. SPANISH INTERPRETER.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-03-28 00:00:00.000",
"description": "Report",
"row_id": 1645163,
"text": "Respiratory Care\nPt remains intubated on vent support. Sx for large amounts thick tan secretions. Breath Sounds clear after sx with good aeration. No RSBI due to scheduled procedure later today. ABG WNL with hyperoxia. Pt has very strong cough and gag.\nPlan: wean to extubation after procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-03-28 00:00:00.000",
"description": "Report",
"row_id": 1645164,
"text": "Nursing progress Note\n Please see carevue for details of care. Pt extubated self prior to start of shift. Remains extubated on 60% face tent for moisture. Cough/gag +. Sats 98-100%, no sob/dyspnea. BS remain clear/dim. Neuro intact, MAEW, oriented x3 but forgets that he is in . Follows commands, sl R sided drift noted w/neuro exam. Remains on Q 4hr nimodipine and nafcillin. Vent drain intact, cont to drain bloody drainage, maint 20cmH2O above tragus. ICP remains <20. Neo weaned to off shortly after self extubated.\n Remains in SB to occas 40's, SBP remains >110 off neo. Skin w+d, ppp. Tol po meds w/sip after NGT removed during extubation. Foley cont to drain amber to pale yellow urine. BS remain wnl, no coverage needed.\n Med x2 for c/o H/A w/stated effect.\n\nPLAN: To be transfered to this pm for intervention, report to nurse and family notified by neuro team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-03-27 00:00:00.000",
"description": "Report",
"row_id": 1645158,
"text": "Resp Care\nPt maintained on mech ventilation, settings adjusted per blood gasses, see flow sheet. BLBS fine rhonchi to clear, suctioned for scant thick yellow secretions. AM RSBI 64, will cont to follow up\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-03-27 00:00:00.000",
"description": "Report",
"row_id": 1645159,
"text": "NURSING ADMISSION\nTHIS 26YR OLD MAN WAS ADMITTED TO SICU S/P ANGIO C/O DR . ANGIO NURSE RUPTURED AVM SEEN, NO INTERVENTION AT THIS TIME. PT ACTUAL NAME , OBTAINED FROM OUTSIDE HOSPITAL NOTES. STILL LISTED AS EU CRITICAL AT THIS TIME.\n\nNEURO: SHORTLY AFTER ARRIVAL ON SICU, HEAT CT DONE, LG FRONTAL/TEMPORAL BLEED CLEARLY VISUALIZED WITH BLOOD IN VENTRICLES ALSO. PUPILS EQUAL IN SIZE, 3-5MM, SLUGGISH AT FIRST, NOW BRISK. SEDATED ON PROPOFOL, LIGHTENED UP X2 FOR NEURO EXAM. WHEN LIGHTENED, MOVING ALL EXTREMITIES AND PURPOSEFULLY REACHING FOR ETT. NOT RESPONDING TO VERBAL STIMULI. COUGH STRONG BUT GAG AND CORNEAL REFLEXES ABSENT STILL. VENTRICULOSTOMY DRAINING BLOODY CSF. ICP 12-18.\n\nCV: HR 50'S ON ARRIVAL. BRADY DOWN AS LOW AS 38 AROUND 0300, DR AND NOTIFIED, CONTINUING TO MONITOR CLOSELY. DEVELOPED HYPOTENSION W/SBP IN 90'S RESULTING IN DROP IN CPP TO 40'S, NEO GTTS STARTED TO SUPPORT BP WITH GOOD EFFECT.\n\nRESP: PT INTUBATED, VENT SUPPORT A/C OVERNOC, CPAP THIS AM. SATS 100%. BREATH SOUNDS CLEAR BILATERALLY. NO SECRETIONS OBTAINED BY SXN.\n\nID: AFEBRILE. WBC 12.8 THIS AM. IV NAFCILLIN STARTED AND TO CONTINUE WHILE DRAIN IN.\n\nGI: NGT TO LWS, NO DRAINAGE, CLAMPED AFTER MEDS. SOFT, BOWEL SOUNDS PRESENT. NO BM.\n\nGU: URINE PINK VIA FOLEY CATH INITIALLY, CLEAR YELLOW THIS AM.\n\nSOCIAL: FRIEND WITH WHOM PT LIVES LAST NOC, RELIEVED BECAUSE HE HAD BEEN UNABLE TO OBTAIN ANY INFORMATION ON PT DUE TO \"EU CRITICAL STATUS\". PTS BROTHER IN IS AWARE OF PTS ADMISSION TO HOSPITAL. FRIEND ) STATES THAT SOMEONE WILL VISIT TODAY TO IDENTIFY PT AND FORMULATE PLAN OF CARE.\n\nPLAN: CONTINUE TO MONITOR DEGREE OF BRADYCARDIA. KEEP SBP 110-140. PROBABLE REPEAT CT SCAN AND POSSIBLE RETURN TO ANGIO THIS AM.\n\nPT MONITORED CONTINUOUSLY.\nDR IN CLOSE ICU ATTENDANCE.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-03-27 00:00:00.000",
"description": "Report",
"row_id": 1645160,
"text": "Nursing Progress Note\n Please see carevue for details of care. Remains sedated on vent support PS 10/5x40% w/sats maint >97% t/o day. Suctions for small thick white/yellow scretions, increased secretions noited this pm after turn and mouth care. and with coughing. BS clear + cough noted w/weak gag which is more pronounced this pm. PERL briskly but pupils constrict to light and redilate 1-2mm while still under light. Neuro aware. CT repeated this am. Opens eyes to command. MAEW, hands purposeful attempting to reach for tubes. Squeezing hands ands pushing feet to command today, nodding appropriately to questions. Vent drain intact, 20 cm/h2o above tragus draining bloody fluid.\n Remains in SB 40's-50's. SBP maint >110, able to wean Neo slightly this pm. Remains afebrile, NGT draining scant between frequent meds via tube. Foley draining amber urine.\n\nPLAN: Cont to monitor neuro status Q1hr, monitor HD status to maint SBP 110-140, wean Neo as able, possible return to Angio in am to attempt coiling of AVM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-03-27 00:00:00.000",
"description": "Report",
"row_id": 1645161,
"text": "pt remained on PSV through shift without incidence, he was transported to CT for head image in order for comparison. sx'd for minimal secretions. plan to be revaluated in AM rounds. plan to keep on PSV through PM shift.\n"
},
{
"category": "ECG",
"chartdate": "2197-03-26 00:00:00.000",
"description": "Report",
"row_id": 214624,
"text": "Sinus rhythm. Increased QRS voltage, probably normal for age. J point and\nST segment elevation through the lateral precordial leads. Clinical\ncorrelation is suggested.\n\n"
}
] |
51,847 | 193,505 | 80 yo male with history of Parkinson's disease, dementia, CAD, and CHF with EF 25% who presented for altered mental status found to have a UTI and an obstructing right mid ureteric stone with upstream hydronephroureter. His mental status improved with ceftriaxone treatment. | There is nondependent air and a Foley catheter in place, possibly related to recent instrumentation. Multilevel lower thoracic spondylosis is present. 0.035 stiff Amplatz wire was advanced through the outer sheath and into the right proximal ureter. Consider percutaneous nephrostomy placement. IMPRESSION: Uncomplicated right percutaneous nephrostomy catheter placement under ultrasound and fluoroscopic guidance. 0.018 nitinol wire was advanced through the needle and into the right proximal ureter. Right percutaneous nephrostomy tube catheter is in place. Trace free fluid is seen subjacent to the cecal tip. IMPRESSION: 8-mm right mid ureteral stone in similar position as prior CT. CT ABDOMEN: There is trace bibasilar dependent atelectasis. The outer sheath was advanced into the right proximal ureter while appropriately retaining the metallic stiffener. High-grade obstruction in the right proximal-to-mid ureter. 8-mm right mid ureteric obstructing stone with moderate upstream hydronephroureter, as well as urothelial hyperenhancement suggestive of pyelitis. Moderate atherosclerotic disease is present throughout the descending aorta extending into branching vessels. (Over) 3:56 PM CT ABD & PELVIS WITH CONTRAST Clip # Reason: eval for infectious process, ischemic gut Contrast: OMNIPAQUE Amt: 130 FINAL REPORT (Cont) There are bilateral renal cysts, some of which too small to fully characterize. TECHNIQUE: Single portable supine abdominal radiograph was provided. There is extensive periventricular and subcortical white matter hypoattenuation, compatible with a small vessel ischemic disease. Bilateral renal cysts. COMPARISONS: CT abdomen and pelvis from . Ventricles and sulci are prominent, compatible with age-related involution. CT PELVIS: The bladder is partially distended, but demonstrates urothelial hyperemia and mural thickening, likely reflecting presence of cystitis. FINDINGS: Single AP upright radiograph of the chest was obtained. The nephrograms are symmetric. FINDINGS: There is an 8-mm main ureteral stone seen on the right which appears to be similar in location as seen on the CT exam. Moderate stranding and free fluid is seen around the right kidney. Suprasellar and basilar cisterns are patent. Multivessel coronary arterial calcifications are noted, with concurrent aortic valve calcification. 9-mm pancreatic head cyst, statistically most likely to represent side branch IPMN, which could be followed by MRCP. Catheter was then flushed with saline, secured by 0 silk sutures and Flexi-Trak, and connected to an external bag. Paranasal sinuses and mastoid air cells are well aerated. Question infectious process or ischemic bowel. Initial scout fluoroscopy demonstrated contrast within the right renal collecting system and proximal ureter, likely from the previous CT study. Under aseptic conditions and son guidance, a 21-gauge hollow-bore needle was placed in the right renal lower pole posterior calix. There is a nonspecific bowel gas pattern with air in both the colon and small bowel. Heart is top normal in size with normal cardiomediastinal contours. There is moderate right hydronephroureter upstream of an 8-mm mid ureteric stone (2, 51). A small amount of sterile contrast material was injected to confirm position. The pancreas is diffusely atrophic and demonstrates a 9-mm cyst in the head. CONTRAST: Sterile 10 mL Optiray 320 in the right renal collecting system. There is also a suggestion of urothelial hyperenhancement upstream of the stone, suggestive of pyelitis. Retention pigtail loop was placed in the right renal pelvis. Globes are intact with bilateral lens replacement. Inner stiffener and wire were removed. Site was dressed in an (Over) 7:22 PM PERC NEPHROSTO Clip # Reason: relieve obstruction Admitting Diagnosis: SEPSIS Contrast: OPTIRAY Amt: 25 FINAL REPORT (Cont) appropriate fashion. There is significant fecal impaction within the rectum. Bladder thickening and urothelial hyperenhancement suggestive of concurrent cystitis. 9mm panc head cyst, statistically most likely to represent IPMN. No right hydroureteronephrosis. OTHER MEDICATION: IV 1 g ceftriaxone. Vascular calcifications are seen in the cavernous carotid arteries. Extensive age-related involution and small vessel ischemic disease. 7:22 PM PERC NEPHROSTO Clip # Reason: relieve obstruction Admitting Diagnosis: SEPSIS Contrast: OPTIRAY Amt: 25 ********************************* CPT Codes ******************************** * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN * **************************************************************************** MEDICAL CONDITION: 80 year old man with R sided obstructing stone, urosepsis REASON FOR THIS EXAMINATION: relieve obstruction FINAL REPORT RIGHT PERCUTANEOUS NEPHROSTOMY CATHETER PLACEMENT INDICATION: 80-year-old man with right-sided obstructing ureteral stone, urosepsis and fever. | 6 | [
{
"category": "Radiology",
"chartdate": "2141-06-25 00:00:00.000",
"description": "INTRO CATH RENAL PELVIS FOR DRAINAGE",
"row_id": 1245585,
"text": " 7:22 PM\n PERC NEPHROSTO Clip # \n Reason: relieve obstruction\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 25\n ********************************* CPT Codes ********************************\n * INTRO CATH RENAL PELVIS FOR DR INTRO CATH TO PELVIS FOR DRAIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with R sided obstructing stone, urosepsis\n REASON FOR THIS EXAMINATION:\n relieve obstruction\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT PERCUTANEOUS NEPHROSTOMY CATHETER PLACEMENT\n\n INDICATION: 80-year-old man with right-sided obstructing ureteral stone,\n urosepsis and fever.\n\n OPERATORS: Dr. (fellow) and Dr. \n (attending physician). Dr. was present throughout the procedure.\n\n CONTRAST: Sterile 10 mL Optiray 320 in the right renal collecting system.\n\n SEDATION/ANESTHESIA: General endotracheal anesthesia provided by the\n anesthesiologist.\n\n OTHER MEDICATION: IV 1 g ceftriaxone.\n\n PROCEDURE AND FINDINGS: Consent was obtained from the healthcare\n proxy after explaining the benefits, risks and alternatives. Patient was\n placed prone on the imaging table in the interventional suite. Timeout was\n performed as per protocol.\n\n Initial scout fluoroscopy demonstrated contrast within the right renal\n collecting system and proximal ureter, likely from the previous CT study.\n Limited grayscale son of the right kidney did not demonstrate\n hydronephrosis. Under aseptic conditions and son guidance, a 21-gauge\n hollow-bore needle was placed in the right renal lower pole posterior calix.\n 0.018 nitinol wire was advanced through the needle and into the right proximal\n ureter. After making an incision at the access site, needle was removed to\n place the AccuStick system. The outer sheath was advanced into the right\n proximal ureter while appropriately retaining the metallic stiffener. The\n wire, stiffener and inner sheath were removed. 0.035 stiff Amplatz wire was\n advanced through the outer sheath and into the right proximal ureter. The\n outer sheath was then removed to dilate the tract under fluoroscopy with an 8\n French dilator. Following this, an 8 French nephrostomy catheter was placed.\n Inner stiffener and wire were removed. Retention pigtail loop was placed in\n the right renal pelvis. String was withdrawn, locked and trimmed. A small\n amount of sterile contrast material was injected to confirm position.\n Catheter was then flushed with saline, secured by 0 silk sutures and\n Flexi-Trak, and connected to an external bag. Site was dressed in an\n (Over)\n\n 7:22 PM\n PERC NEPHROSTO Clip # \n Reason: relieve obstruction\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 25\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appropriate fashion. No immediate post-procedure complication was seen.\n\n IMPRESSION: Uncomplicated right percutaneous nephrostomy catheter placement\n under ultrasound and fluoroscopic guidance. No right hydroureteronephrosis.\n High-grade obstruction in the right proximal-to-mid ureter.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-06-25 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1245572,
"text": " 3:56 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for infectious process, ischemic gut\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 80M with fever, ams, clutching abdomen, elev lactate\n REASON FOR THIS EXAMINATION:\n eval for infectious process, ischemic gut\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd SUN 6:27 PM\n 8-mm obstructing right mid ureteric stone with upstream hydronephroureter.\n 9mm panc head cyst, statistically most likely to represent IPMN. consider\n outpt MRCP for further assessment.\n\n WET READ VERSION #1\n WET READ VERSION #2 YGd SUN 4:32 PM\n 8-mm obstructing right mid ureteric stone with upstream hydronephroureter.\n\n WET READ VERSION #3 YGd SUN 4:45 PM\n 9mm panc head cyst, statistically most likely to represent IPMN. consider\n outpt MRCP for further assessment.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male with fever, altered mental status and abdominal\n pain. Question infectious process or ischemic bowel.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT images were acquired from the lung bases through the pubic\n symphysis following administration of intravenous and oral contrast with\n multiplanar reformations.\n\n CT ABDOMEN: There is trace bibasilar dependent atelectasis. The heart is\n normal in size without pericardial effusion. Multivessel coronary arterial\n calcifications are noted, with concurrent aortic valve calcification.\n\n The liver demonstrates no focal lesion. The gallbladder, spleen, and adrenal\n glands appear unremarkable. The pancreas is diffusely atrophic and\n demonstrates a 9-mm cyst in the head. There is no pancreatic ductal\n dilatation.\n\n The nephrograms are symmetric. There is moderate right hydronephroureter\n upstream of an 8-mm mid ureteric stone (2, 51). There is also a suggestion of\n urothelial hyperenhancement upstream of the stone, suggestive of pyelitis.\n There is no left-sided renal obstruction. No additional stone is seen.\n Moderate stranding and free fluid is seen around the right kidney. Small and\n large bowel loops are normal in caliber. Trace free fluid is seen subjacent\n to the cecal tip. There is no intra-abdominal lymphadenopathy. Great vessels\n are patent. Moderate atherosclerotic disease is present throughout the\n descending aorta extending into branching vessels.\n (Over)\n\n 3:56 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: eval for infectious process, ischemic gut\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There are bilateral renal cysts, some of which too small to fully\n characterize.\n\n CT PELVIS: The bladder is partially distended, but demonstrates urothelial\n hyperemia and mural thickening, likely reflecting presence of cystitis. There\n is nondependent air and a Foley catheter in place, possibly related to recent\n instrumentation. The prostate gland appears enlarged to 5.9 cm. There is\n significant fecal impaction within the rectum. No inguinal or pelvic sidewall\n adenopathy.\n\n No focal concerning lesion. Multilevel lower thoracic spondylosis is present.\n\n IMPRESSION:\n 1. 8-mm right mid ureteric obstructing stone with moderate upstream\n hydronephroureter, as well as urothelial hyperenhancement suggestive of\n pyelitis. Consider percutaneous nephrostomy placement.\n 2. Bladder thickening and urothelial hyperenhancement suggestive of\n concurrent cystitis.\n 3. Bilateral renal cysts.\n 4. 9-mm pancreatic head cyst, statistically most likely to represent side\n branch IPMN, which could be followed by MRCP.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-06-27 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1245788,
"text": " 11:36 AM\n PORTABLE ABDOMEN Clip # \n Reason: evaluation for migration of renal stone\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with parkinsons, admitted with urosepsis, found to have\n obstructing renal stone, now s/p perc nephrostomy\n REASON FOR THIS EXAMINATION:\n evaluation for migration of renal stone\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with Parkinson's, admitted with urosepsis and\n have obstructing renal stone, status post percutaneous nephrostomy, evaluate\n for migration of renal stone.\n\n COMPARISONS: CT abdomen and pelvis from .\n\n TECHNIQUE: Single portable supine abdominal radiograph was provided.\n\n FINDINGS: There is an 8-mm main ureteral stone seen on the right which\n appears to be similar in location as seen on the CT exam. Right percutaneous\n nephrostomy tube catheter is in place. There is a nonspecific bowel gas\n pattern with air in both the colon and small bowel. There is no evidence of\n obstruction, ileus, or large amount of free air. There are degenerative\n changes in the lower lumbar spine.\n\n IMPRESSION: 8-mm right mid ureteral stone in similar position as prior CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-06-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1245563,
"text": " 2:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o infection, intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 80M with AMS.\n REASON FOR THIS EXAMINATION:\n r/o infection, intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: YGd SUN 4:22 PM\n no ICH or infarct. consider MR concern. age related involution\n and small vessel ischemic dz\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male with altered mental status. Question acute\n process.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous non-contrast axial images were acquired through the\n brain with multiplanar reformations.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift\n of normally midline structures. The -white matter differentiation is\n preserved. There is extensive periventricular and subcortical white matter\n hypoattenuation, compatible with a small vessel ischemic disease. Ventricles\n and sulci are prominent, compatible with age-related involution. Suprasellar\n and basilar cisterns are patent.\n\n Paranasal sinuses and mastoid air cells are well aerated. Vascular\n calcifications are seen in the cavernous carotid arteries. The middle ear\n structures are symmetric. Soft tissue density in bilateral external auditory\n canals likely represents cerumen. Globes are intact with bilateral lens\n replacement.\n\n IMPRESSION:\n 1. No acute intracranial process.\n 2. Extensive age-related involution and small vessel ischemic disease.\n 3. If there is clinical concern for ischemia, consider MRI if not\n contraindicated.\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2141-06-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1245560,
"text": " 1:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infection, intracranial bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 80M with AMS.\n REASON FOR THIS EXAMINATION:\n r/o infection, intracranial bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male with altered mental status. Assess for\n infectious process.\n\n COMPARISONS: None.\n\n FINDINGS: Single AP upright radiograph of the chest was obtained. The lungs\n are slightly lower in volume but clear. There is no pleural effusion or\n pneumothorax. Heart is top normal in size with normal cardiomediastinal\n contours.\n\n"
},
{
"category": "ECG",
"chartdate": "2141-06-25 00:00:00.000",
"description": "Report",
"row_id": 176414,
"text": "Normal sinus rhythm. The tracing is within normal limits. Compared to the\nprevious tracing of the heart rate has increased and baseline artifact\nis no longer seen.\n\n\n"
}
] |
22,771 | 100,830 | The patient underwent cardiac catheterization on which showed a left ventricular ejection fraction of 40%, with mild diffuse hypokinesis, a 60% to 70% distal left main occlusion, a 70% proximal left anterior descending artery occlusion, a 70% left circumflex occlusion, a 90% first obtuse marginal occlusion, 70% ostial right coronary artery occlusion. The patient was taken to the operating room on for a coronary artery bypass graft times four; left internal mammary artery to left anterior descending artery, left radial to posterior descending artery, saphenous vein graft to obtuse marginal, with a sequential graft to the first diagonal. Please see the Operative Note for further details. The patient was transferred to the Intensive Care Unit in stable condition. The patient was weaned and extubated from mechanical ventilation on the first postoperative night. The patient required some volume resuscitation as well as a Neo-Synephrine infusion to maintain an adequate blood pressure. On postoperative day one, the patient's hematocrit was noted to be 21.8. The patient was transfused 2 units of packed red blood cells. The patient was on an insulin infusion to maintain adequate blood glucose control. The patient remained in the Intensive Care Unit due to labile blood pressures. The patient required aggressive pulmonary toilet, and the patient was placed on her nocturnal CPAP settings which she tolerated well. On postoperative day three, the patient was transferred from the Intensive Care Unit to the floor in stable condition. The patient required some aggressive diuresis and aggressive pulmonary toilet. The patient began ambulating with Physical Therapy, and it was determined that the patient would need rehabilitation. The patient was intermittently complaining of shortness of breath which she stated was at her baseline. This shortness of breath was improved with diuresis and the use of nocturnal CPAP which she was on at home. The patient's chest tubes and epicardial pacing wires were discontinued without complications. A chest x-ray showed small bilateral pleural effusions as well as bilateral atelectasis. The patient was cleared for discharge on to a rehabilitation facility. | + ULNAR PULSE W NORMAL CSM & PLETH WAVE.MIN, CT OUTPUT.TOL. + ULNAR PULSE.H.O.AWARE. BS~CLEAR UPPER, DIMINISHED IN BASES. BP STABLE.+PP.RESP- LSC. IMPRESSION: Left moderate pleural effusion with adjacent atelectasis vs. consolidation. LABILE BP & HEMODYNAMICS W LOW FILLING PRESSURES,MIN. IMPRESSION: Mild prominence of the perihilar vasculature consistent with mild CHF. There is slight perihilar fullness. POS ULNAR PULSE. IMPRESSION: 1) Bibasilar atelectasis, left greater than right. UPDATED: PT S/P CABG, POST OP UNEVENTFUL- RESP STATUS BORDERLINE. Additional linear opacities in the perihilar regions are consistent with discoid atelectasis. There is cardiac enlargement, stable in degree. TOL CLEAR LIQUIDS WITHOUT NAUSEA.G.I.- LOW U/O. NEURO- ALERT/ORIENTED X 3.MAE WITH MUCH ENCOURAGEMENT.PT MOANS INTERMITTENTLY BUT DENIES PAIN.CV-NSR 70-75 RARE PVC.BP STABLE.RESP- LSC.DIMINISHED AT THE BASES. NEURO-LETHARGIC.AROUSABLE TO VOICE. ARM PAIN DESPITE ELEVATION,PERCS & TORADOL. IMPRESSION: Small left pleural effusion with associated left basilar atelectasis. CLEAR SPEECH.CV-APACED AT 80 WITH UNDRLYING RHYTHM NSR 60-65.PACER RATE TURNED DOWN TO 60 WITH RARE INNAPPROPRIATE SENSED BEAT. SCANT SPUTUM.G.I.-ABD OBESE/SOFT. Q-T interval prolongation is less striking, however, and the U waveshave resolved.TRACING #2 SSC REG INS. PT IS A MOUTH BREATHER.CPT DONE. BIPAP PLACED ON NOC.EXPECTORATE SMALL AMT THICK GREEN/YELLOW SPUTUM X 1.G.I.- ABD SOFT WITH HYPOACTIVE BS. The mediastinal and hilar contours are normal. There has been interval development of atelectatic changes in the retrocardiac regions, left greater than right. MEDIATED WITH PERCOCET WITH RELIEF.ENDO- INSULIN GTT DCD. TOL SIPS WELL. 1:51 PM CHEST (PA & LAT) Clip # Reason: please eval the L-effusion ? ADEQUATE U/O.ENDO~INSULIN GTT CURRENTLY @ 3 UNITS/HR.A/P~STABLE. CT IN PLACE.NEURO; PT LETHARGIC, YET EASILY ARROUSABLE. +FLATUS.G.U.-40MG IV LASIX A/O. ASSESS U/O. lobar collapse REASON FOR THIS EXAMINATION: please eval for layering of a left pleural effusion FINAL REPORT Single lateral decubitus film demonstrates free flowing left pleural effusion. REPLACE LABS PRN. TOL.CLEAR LIQUIDS. FOLLOWING NORMAL POST OP COURSE. Sinus bradycardia, rate 47. GOOD CSM. 2) Bilateral pleural effusions, small on the left, and small to moderate on the left. Minimal upper zone vascular redistribution is seen. RAISED SMALL AMT THIN WHITE, WHEEZY WITH ACTIVITY. There is a small left pleural effusion with associated atelectasis at the left base. 2L NC =98%. MAE, ORIENTED X 3, PLEASANT.CARDIAC: HR 60;S SR RARE PAC NOTED, BP DIPPED THIS AFTERNOON, HR 62- P PACED PT AT 80 WITH MA 14 TO OBTAIN FULL CAPTURE. ARM PAIN/NUMBNESS.ELEVATED ON PILLOW,DSG REMOVED. ANOTHER 20MG IVP LASIX WITH GOOOD RESULTS.PAIN- VERY LOW PAIN THRESHOLD. WILL GO ON BIPAP TONIGHT.CARDIAC; HR 60'S SP, HELD LOPRSSOR TODAY- SBP >100/ CONSISTENTLY, PALP PEDAL PULSES, EXTREMITIES WARM AND DRY.GU: PT RECIEVED LASIX 40MG IVP WITH MIN RESPONSE, INC TO 40MG IVP ., U/O .40CC THRU OUT DAY- WT UP AGAIN TODAY-GI: ABD SOFT, OBESE, NON TENDER, BS HYPOACTIVE, PT STATES SHE IS PASSING FLATUS. A left lung pleural effusion is seen with adjacent opacity consistent with atelectasis vs. consolidation. The heart is mildly enlarged but stable. DIMINISHED AT THE BASE. There is slight interval widening of the mediastinum, likely due to postoperative change. DROP IN SBP TO HIGH 80'S-90'S W SLIGHT DROP IN FILLING PRESSURES,HUO. CPAP-BIPAP TONIGHT.GI; ABD SOFT, OBESE, BS PRESNET, NO C/O APIN OR DISCOMFORT. CSM,PLETH WAVE REMAIN NORMAL. NEED TO RESTART.RESP: PT BS DIMINISHED THRU OUT, SAT 96% ON 2L NP- R/A SAT 84%- PT C AND DB WITH "MUCH" ENCOURAGEMENT!! PUPILS EQUAL 3CM AND RX TO LIGHT. Sinus rhythmConsider left atrial abnormalityLateral ST-T changes are nonspecific but may be due to myocardial ischemiaDelayed precordial QRS transitionP-R interval 0.13Since previous tracing of : sinus bradycardia absent UNDERLYING RHYTHM SINUS @ 70. PALP PEDAL PULSES, FEET AND HANDS COOL TO TOUVH.RESP: PT WEANED TO 4L NP WITH SAT 96%- RARE DIP TO 94 WHEN ASLEEP BUT UP IMMED WITHOUT TX. Q-T interval prolongation with mid-precordialU waves raising question of electrolyte abnormality. HCT DOWN TO 20-21 YESTERDAY- TX WITH 2 UNITS PC UP TO 27 THEREAFTER.NEURO: PT MAE, FOLLOWS COMMANDS, ORIENTED TO PERSON, PLACE WITH RE-ORIENTATION AND TIME IS "HAZZY". MED W/ TORADOL AND MSO4 2 MG W/ RELIEF.RESP~ON 5L & 50% MAINTAINING SATS OF 98%. Shortness of breath. UPDATED: PT S/P CABG- POST OP UNEVENTFUL EXTUBATED WITHOUT DIFFICULTY, HCT DOWN TRANSFUSED WITH 2 UNITS PC, OFF ALL DRIPS- ALINE REMAINS IN, SWAN D/C. NEED FOR INCREASED MA & SENSITIVITY ESP. The right lung is clear. SPONTANEOUSLY OPENS YES. Sinus bradycardia, rate 52. COMPARISON: . BEGAN PACING INNAPROPRIATELY. REQUIRES 2 ASSIST. C/O MID BACK DISCOMFORT AND LEFT ARM NUMBNESS. SBP UP TO 110/50 THEREAFTER. HAS DIFFICULTY MOVING LEGS,BUT IS STABLE WHEN STANDING.ENDO-GLUCOSE=156 COVERRD WITH SSCI.PLAN-OOB TO CHAIR. POS PAL PEDAL PULSES BILAT.NEURO~A&OX3. C/O LT. HESPAN GIVEN & RETURNED TO A PACING @ 88. Compared to the previous tracing generalizedrepolarization abnormalities persist, most marked in the lateral standardleads. CARDIAC~INITALLY A PACED @ 86. PACER TURNED OFF. ENCOURAGING CDB, TOL FAIRLY.GI/GU~TOL ICE CHIPS. CONTINUE TO MOM RESP STATUS. SC PER PROTOCOL.GLUCOSE LEVELS74-93.PLAN- OOB TO CHAIR. HAND COOL. 40MG IVP LASIX WITH GREAT RESULTS THEN DECLINGING DOWNARDS. PA AND LATERAL CHEST RADIOGRAPH: The heart is slightly enlarged. Sternotomy wires are seen which is consistent with prior cardiac surgery. MAE. MAE. 5LNC=98 100% . The right lung appears clear without evidence of pleural effusion, or consolidation. 35%OFM =98%. INCREASE AMBULATION. ? The lungs are clear. No previous tracingavailable for comparison.TRACING #1 SIDE. Degenerative changes are observed in the spine. WIMPERS/MOANS WITH ALL MOVEMENT. CHANGES IN HCT->VOLUME,A PACING (UNDERLYING SB 50'S)W EFFECT.WEANED & EXTUBATED W/O INCIDENT BUT ADD'L O2 ADDED FOR MAINTAIN SPO2 > 92% WHEN ASLEEP DUE TO MOUTH BREATHING.NEEDS MUCH PROMPTING & ENCOURAGEMENT TO PERFORM DEEP BREATHING & COUGHING BUT EFFORTS IMPROVED AFTER TORADOL & MSO4. | 15 | [
{
"category": "Radiology",
"chartdate": "2166-12-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 772968,
"text": " 1:51 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval the L-effusion ? atelectasis vs lobar collapse;\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with 3vd now s/p CABGx3 c/b post-op hypoxia\n\n REASON FOR THIS EXAMINATION:\n please eval the L-effusion ? atelectasis vs lobar collapse; Assess for volume\n overload, patient aggresively diuresed in the last 24 hours\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57 year old woman s/p CABG with hypoxia and left effusion.\n\n CHEST X-RAY, PA AND LATERAL: Comparison made to film of . A left\n lung pleural effusion is seen with adjacent opacity consistent with\n atelectasis vs. consolidation. No pneumothorax. The right lung appears clear\n without evidence of pleural effusion, or consolidation. Sternotomy wires are\n seen which is consistent with prior cardiac surgery. Cardiomegaly is\n demonstrated.\n\n IMPRESSION: Left moderate pleural effusion with adjacent atelectasis vs.\n consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-12-03 00:00:00.000",
"description": "P CHEST (LAT DECUB ONLY) PORT",
"row_id": 772897,
"text": " 9:24 PM\n CHEST (LAT DECUB ONLY) PORT Clip # \n Reason: please eval for layering of a left pleural effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with SOB, can't r/o a large effusion ve. lobar collapse\n REASON FOR THIS EXAMINATION:\n please eval for layering of a left pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n Single lateral decubitus film demonstrates free flowing left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-12-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 772759,
"text": " 11:57 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p cabg w/sob-r/o effusions/infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with 3vd\n\n REASON FOR THIS EXAMINATION:\n s/p cabg w/sob-r/o effusions/infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n Compared to previous study of 5 days earlier.\n\n INDICATION: S/P coronary artery bypass surgery. Shortness of breath.\n\n Since the previous study, the patient has undergone median sternotomy and\n coronary artery bypass surgery. There is slight interval widening of the\n mediastinum, likely due to postoperative change. The heart is mildly enlarged\n but stable. There has been interval development of atelectatic changes in the\n retrocardiac regions, left greater than right. Note is also made of small\n bilateral pleural effusions. Additional linear opacities in the perihilar\n regions are consistent with discoid atelectasis.\n\n Degenerative changes are observed in the spine.\n\n IMPRESSION:\n\n 1) Bibasilar atelectasis, left greater than right.\n\n 2) Bilateral pleural effusions, small on the left, and small to moderate on\n the left.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-12-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 772891,
"text": " 7:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for PTX, effusion, failure; pt is s/p CABG and i\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with new onset chest pain s/p CABG\n REASON FOR THIS EXAMINATION:\n please eval for PTX, effusion, failure; pt is s/p CABG and is having persistent\n SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: SOB.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT CHEST @ 6:30 p.m.: The patient is s/p median\n sternotomy and CABG. There is cardiac enlargement, stable in degree. There is\n a small left pleural effusion with associated atelectasis at the left base.\n Minimal upper zone vascular redistribution is seen. There is no overt\n pulmonary edema. The right lung is clear. No PTX.\n\n IMPRESSION: Small left pleural effusion with associated left basilar\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2166-11-27 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 772377,
"text": " 5:45 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: +ETT\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with 3vd\n REASON FOR THIS EXAMINATION:\n pre op cabg\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Three vessel disease pre-op CABG.\n\n PA AND LATERAL CHEST RADIOGRAPH: The heart is slightly enlarged. The\n mediastinal and hilar contours are normal. There is slight perihilar\n fullness. The lungs are clear. There are no pleural effusions. No\n pneumothorax. Osseous structures are unremarkable.\n\n IMPRESSION: Mild prominence of the perihilar vasculature consistent with mild\n CHF. No consolidations to suggest pneumonia.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-29 00:00:00.000",
"description": "Report",
"row_id": 1559088,
"text": "UPDATE\nD: PT S/P CABG- POST OP UNEVENTFUL EXTUBATED WITHOUT DIFFICULTY, HCT DOWN TRANSFUSED WITH 2 UNITS PC, OFF ALL DRIPS- ALINE REMAINS IN, SWAN D/C. CT IN PLACE.\nNEURO; PT LETHARGIC, YET EASILY ARROUSABLE. MAE, ORIENTED X 3, PLEASANT.\n\nCARDIAC: HR 60;S SR RARE PAC NOTED, BP DIPPED THIS AFTERNOON, HR 62- P PACED PT AT 80 WITH MA 14 TO OBTAIN FULL CAPTURE. SBP UP TO 110/50 THEREAFTER. PALP PEDAL PULSES, FEET AND HANDS COOL TO TOUVH.\n\nRESP: PT WEANED TO 4L NP WITH SAT 96%- RARE DIP TO 94 WHEN ASLEEP BUT UP IMMED WITHOUT TX. COUGHING WITHOUT RAISING, ATTEMPTED SPIRCARE WITH POOR RESULTS--\"JUST CAN;T GET IT\"- DB AND COUGING WITH MUCH ENCOURAGMENT. CPAP-BIPAP TONIGHT.\n\nGI; ABD SOFT, OBESE, BS PRESNET, NO C/O APIN OR DISCOMFORT. TOL SIPS WELL. NO APPETITE AT THIS TIME.\n\nGU: FOLEY INPLACE DRAINING YELLOW URINE APPROX 30C/HR. NO \"REAL\" RESPONSE TO LASIX POST PC- U/O UP TO 100 THEN BACK DOWN ALMOST IMMED. AT 1900 U/O 10CC- WILL WATCH AND SEE WHAT NEXT HOUR BRINGS.\n\nCOMFORT: PT C/O PAIN, ESP BACK PAIN RELIEVED WITH REPOSITIONING, PT MOVES WELL IN BED WITH SOME ENCOURAGEMENT. MED WITH TORADOL AND PEROCET WITH GOOD RELIEF OF PAIN, SHE WILL MOAN OCCAS BUT NOT ALWAYS DUE TO PAIN.\n\nENDOCRINE_ PT CONT ON IV INSULIN DRIP- TITRATE UP TO 5U/HR LAST GLU 88- CONT TO MONITOR CLOSELY. ? SWITICH OVER TO SC WHEN OBTAIN STABLE BS.\n\nHEM: PT HCT 23 THIS AM, REPEAT 21- 2 UNITS PC ORDERED, 1 UNIT UP INFUSED- POST LASIX GIVEN, JUST PRIOR TO ADM NEXT PC- HCT CHECKED OFF ABG- CAME BACK 20---2ND UNIT INFUSING- COMPLETE AT 18:30 WILL RECHECK HCT AT 19:30.\n\nPLAN: CPAP TONIGHT- MONIOTOR HCT , PT UP IN CHAIR- 2 PEROSN ASSIST IN- ? PT MORE COMFORTABLE UP IN CHAIR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-30 00:00:00.000",
"description": "Report",
"row_id": 1559089,
"text": "NEURO-LETHARGIC.AROUSABLE TO VOICE. SPONTANEOUSLY OPENS YES. FOLLOW COMMANDS. MAE. CLEAR SPEECH.\n\nCV-APACED AT 80 WITH UNDRLYING RHYTHM NSR 60-65.PACER RATE TURNED DOWN TO 60 WITH RARE INNAPPROPRIATE SENSED BEAT. BP STABLE.+PP.\n\nRESP- LSC. DIMINISHED AT THE BASE. 5LNC=98 100% . BIPAP PLACED ON NOC.EXPECTORATE SMALL AMT THICK GREEN/YELLOW SPUTUM X 1.\n\nG.I.- ABD SOFT WITH HYPOACTIVE BS. TOL CLEAR LIQUIDS WITHOUT NAUSEA.\n\nG.I.- LOW U/O. 40MG IVP LASIX WITH GREAT RESULTS THEN DECLINGING DOWNARDS. ANOTHER 20MG IVP LASIX WITH GOOOD RESULTS.\n\nPAIN- VERY LOW PAIN THRESHOLD. WIMPERS/MOANS WITH ALL MOVEMENT. MEDIATED WITH PERCOCET WITH RELIEF.\n\nENDO- INSULIN GTT DCD. SSC REG INS. SC PER PROTOCOL.GLUCOSE LEVELS74-93.\n\nPLAN- OOB TO CHAIR. ASSESS U/O. REPLACE LABS PRN.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-28 00:00:00.000",
"description": "Report",
"row_id": 1559085,
"text": "LABILE BP & HEMODYNAMICS W LOW FILLING PRESSURES,MIN. CHANGES IN HCT->VOLUME,A PACING (UNDERLYING SB 50'S)W EFFECT.WEANED & EXTUBATED W/O INCIDENT BUT ADD'L O2 ADDED FOR MAINTAIN SPO2 > 92% WHEN ASLEEP DUE TO MOUTH BREATHING.NEEDS MUCH PROMPTING & ENCOURAGEMENT TO PERFORM DEEP BREATHING & COUGHING BUT EFFORTS IMPROVED AFTER TORADOL & MSO4. C/O LT. ARM PAIN/NUMBNESS.ELEVATED ON PILLOW,DSG REMOVED. + ULNAR PULSE W NORMAL CSM & PLETH WAVE.MIN, CT OUTPUT.TOL. ICE CHIPS WELL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-28 00:00:00.000",
"description": "Report",
"row_id": 1559086,
"text": "CONTINUES TO COMPLAIN OF LT. ARM PAIN DESPITE ELEVATION,PERCS & TORADOL. CSM,PLETH WAVE REMAIN NORMAL. + ULNAR PULSE.H.O.AWARE. DROP IN SBP TO HIGH 80'S-90'S W SLIGHT DROP IN FILLING PRESSURES,HUO. HESPAN GIVEN & RETURNED TO A PACING @ 88. NEED FOR INCREASED MA & SENSITIVITY ESP. WHEN POSITIONED ON RT. SIDE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-29 00:00:00.000",
"description": "Report",
"row_id": 1559087,
"text": "CARDIAC~INITALLY A PACED @ 86. BEGAN PACING INNAPROPRIATELY. PACER TURNED OFF. UNDERLYING RHYTHM SINUS @ 70. CONT ON NITRO @ .5 UCG/KG/MIN FOR RADIAL ARTERY. POS ULNAR PULSE. HAND COOL. GOOD CSM. ON NEO @ .75 UCG/KG/MIN TO MAINTAIN MAPS:60-90. POS PAL PEDAL PULSES BILAT.\n\nNEURO~A&OX3. FC. MAE. C/O MID BACK DISCOMFORT AND LEFT ARM NUMBNESS. MED W/ TORADOL AND MSO4 2 MG W/ RELIEF.\n\nRESP~ON 5L & 50% MAINTAINING SATS OF 98%. RR: 16-18. BS~CLEAR UPPER, DIMINISHED IN BASES. ENCOURAGING CDB, TOL FAIRLY.\n\nGI/GU~TOL ICE CHIPS. ADEQUATE U/O.\n\nENDO~INSULIN GTT CURRENTLY @ 3 UNITS/HR.\n\nA/P~STABLE. FOLLOWING NORMAL POST OP COURSE. ENCOURAGE INS/ AND DEEP BREATHING EXERCISES. DELINE & OOB TO CHAIR. POSSIBLE TRANSFER TO 2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-11-30 00:00:00.000",
"description": "Report",
"row_id": 1559090,
"text": "UPDATE\nD: PT S/P CABG, POST OP UNEVENTFUL- RESP STATUS BORDERLINE. PT SLIGHTLY CONFUSED AT TIMES, DIFFICULT TO MOBILIZE DUE TO \"SIZE\" AND C/O LOWER BACK PAIN. HCT DOWN TO 20-21 YESTERDAY- TX WITH 2 UNITS PC UP TO 27 THEREAFTER.\n\nNEURO: PT MAE, FOLLOWS COMMANDS, ORIENTED TO PERSON, PLACE WITH RE-ORIENTATION AND TIME IS \"HAZZY\". PUPILS EQUAL 3CM AND RX TO LIGHT. PT REMAINS LETHARGIC, MOANING INTERMITTENTLY BUT OFTEN DENIES PAIN.\nPT ON PROZAC PRE-OP ? NEED TO RESTART.\n\nRESP: PT BS DIMINISHED THRU OUT, SAT 96% ON 2L NP- R/A SAT 84%- PT C AND DB WITH \"MUCH\" ENCOURAGEMENT!! RAISED SMALL AMT THIN WHITE, WHEEZY WITH ACTIVITY. WILL GO ON BIPAP TONIGHT.\n\nCARDIAC; HR 60'S SP, HELD LOPRSSOR TODAY- SBP >100/ CONSISTENTLY, PALP PEDAL PULSES, EXTREMITIES WARM AND DRY.\n\nGU: PT RECIEVED LASIX 40MG IVP WITH MIN RESPONSE, INC TO 40MG IVP ., U/O .40CC THRU OUT DAY- WT UP AGAIN TODAY-\n\nGI: ABD SOFT, OBESE, NON TENDER, BS HYPOACTIVE, PT STATES SHE IS PASSING FLATUS. TOL SIPS WELL-SMALL LUNCH THIS AFTERNOON, TOL WELL.\n\nSKIN: INTACT NO BREAKDOWN, DIAPHORETIC AT TIMES.\n\nACTIVITY: OOB TO CHAIR 2 PERSON ASSIST, MARCHED IN PLACE WITH PT AND TO AMB MORE THAN 4 STEPS. STANDS WELL, BUT DOES NOT SEEM TO GET FEET MOVING. PT WILL \n\nGLU- 215 TX PER SLIDING SCALE THEN DOWN TO 135.\n\nPLAN: RE-ORIENT AS NEEDED, RESP- BIPAP TONIGHT. CONSULT CASE MANAGEMENT FOR REHAB PLACEMENT, PT LIVES ALONE IN .\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-12-01 00:00:00.000",
"description": "Report",
"row_id": 1559091,
"text": "NEURO- ALERT/ORIENTED X 3.MAE WITH MUCH ENCOURAGEMENT.PT MOANS INTERMITTENTLY BUT DENIES PAIN.\n\nCV-NSR 70-75 RARE PVC.BP STABLE.\n\nRESP- LSC.DIMINISHED AT THE BASES. 2L NC =98%. DOE WITH SATS DECREASING TO 85%.5LNC=89%. 35%OFM =98%. PT IS A MOUTH BREATHER.\nCPT DONE. SCANT SPUTUM.\n\nG.I.-ABD OBESE/SOFT. TOL.CLEAR LIQUIDS. +FLATUS.\n\nG.U.-40MG IV LASIX A/O. DIURESED WELL FTERWARD.\n\nACTIVITY-OOB TO CHAIR FOR 3 HRS. REQUIRES 2 ASSIST. HAS DIFFICULTY MOVING LEGS,BUT IS STABLE WHEN STANDING.\n\nENDO-GLUCOSE=156 COVERRD WITH SSCI.\n\nPLAN-OOB TO CHAIR. INCREASE AMBULATION. INCREASE DIET. CONTINUE TO MOM RESP STATUS.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2166-11-27 00:00:00.000",
"description": "Report",
"row_id": 133020,
"text": "Sinus bradycardia, rate 52. Q-T interval prolongation with mid-precordial\nU waves raising question of electrolyte abnormality. No previous tracing\navailable for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2166-12-03 00:00:00.000",
"description": "Report",
"row_id": 132976,
"text": "Sinus rhythm\nConsider left atrial abnormality\nLateral ST-T changes are nonspecific but may be due to myocardial ischemia\nDelayed precordial QRS transition\nP-R interval 0.13\nSince previous tracing of : sinus bradycardia absent\n\n"
},
{
"category": "ECG",
"chartdate": "2166-11-28 00:00:00.000",
"description": "Report",
"row_id": 132977,
"text": "Sinus bradycardia, rate 47. Compared to the previous tracing generalized\nrepolarization abnormalities persist, most marked in the lateral standard\nleads. Q-T interval prolongation is less striking, however, and the U waves\nhave resolved.\nTRACING #2\n\n"
}
] |
9,186 | 183,829 | Impression: 85 year-old Italian-speaking male with multiple medical problems including Afib, chronic SDH, CHF, and dementia, admitted with AMS, left sided weakness, found on admission to have acute on chronic SDH by head CT, began seizing in the ED and transferred to the MICU on admission. LP was negative, urine and blood cultures were negative to date. CXR on admission negative. Infectious workup negative. Pt stabilized, extubated, and transferred to medical floor. His post-MICU admission course was complicated by several issues, which will be reviewed by problem. . 1. Apnea: Throughout this admission, the pt appeared to have Respirations, thought most likely secondary to his congestive heart failure with an ejection fraction of 25%. The patient demonstrated evidence of failure on exam with elevated JVP (decreased from jawline to mid-neck by discharge), peripheral and sacral edema, and bibasilar rales. His chest X-rays were consistent with volume overload and he was diuresed with both IV and po lasix. Initially, it was difficult to diurese the patient, given his agitation with foley catheters, condom catheters being placed. The pt would consistently pull the catheters out in setting of waxing and mental status. He spent 24 hours in the MICU ~3 weeks prior to discharge for an episode of desaturation in the setting of apnea/ respirations, volume overload. He was transferred out to the medical floor within 24 hours, with stabilization of O2 sats, s/p diuresis with IV lasix in MICU, and afterload reduction with valsartan. In the MICU, a foley catheter was successfully placed, and the patient was diuresed with improvement in neck veins, bibasilar rales, and his peripheral edema decreased to trace to 1+. We continued with his CHF management with diuresis with standing po lasix on the medical floor, with additional IV lasix as dictated by I/O to allow for the goal diuresis to be -500cc to -1L per day. This was tailored to his diet/oral intake/volume status. His other CHF management was outlined as below. . 2. Altered Mental Status, improving slowly: Throughout the course of this admission, the patient demonstrated waxing and agitation, delerium, and confusion. The reasons for agitation included his chronic SDH (which was found to be smaller on repeat head CTs, but still present, his sz prophylaxis w/phenytoin), ?infection, the unfamiliar environment, restraints, the Italian language barrier, and intermittent apnea with - respirations. He was noted to improve markedly with his family present. Of note, he also experienced day-night dissociation by staying up all night, then sleeping throughout the daytime. During this admission, the pt required intermittent wrist restraints, a 1:1 sitter, and required infrequent prn haldol IV. He was titrated off Seroquel to seroquel only in the evening, 25mg po. His AM Seroquel was weaned off, and he was much more awake during the day time. At discharge, he was still w/ intermittent agitation, pulling at his nasal cannula, PICC line (which he eventually pulled out), and striking RNs during episodes of agitation (infrequent, but did occur on a few occasions). At discharge, he was much improved from a mental status point of view. He was awake during most of the day, singing and talking in Italian, taking his medicines orally (he passed a bedside-swallow evaluation for soft solids) without aspiration, and walking with assistance and physical therapy. . 3. Oxygen requirement/hypoxia: He continued to have an oxygen requirement, stabilized on 3L nasal cannula during his stay on the medical . This was thought secondary to pulmonary edema and CHF, possibly worsening in setting of his intermittent bouts of RVR. Also with sedation intermittently, COPD with mild restrictive pattern FEV1 2.16 in , when his amio was discontinued (although pulm fibrosis not suspected). He was diuresed as above (see apnea), and his CHF and Afib were managed as above, and below, respectively. . 4. Atrial fibrillation with RVR: Pt was noted this admission to be in Atrial fibrillation, new onset. An echo on revealed the mass/vegetation on lead wire in right atrium. The pt was noted to have occasional bursts of RVR, and his rate control regimen was tailored and modified throughout his stay to achieve optimal control. At discharge, he will be continued on diltiazem po qid and metoprolol tid po. This regimen allows for his HR to be maintained in the 80s-90s with only infrequent HR to 120s-130s when agitated, up and walking around. His digoxin was continued. Part of the difficulty in getting his rate initially under control was related to missed doses of meds secondary to somnolence and inability to take po with his waxing and mental status. This had improved by discharge, and his meds could be crushed in applesauce or ice cream. His ICD was in place, did not fire this admission. After lenghthy discussion with Neurosurgery and the primary medicine team, it was decided not to anticoagulate this patient given his fall risk, and the continued presence of his subdural hematoma (smaller but still present). . 5. Fever with Mass/Vegetation on Pacer/ICD Lead Wire: On , the pt was found to have vegetation on pacer lead wire seen on echocardiogram in the setting of a fever (with other cx negative, neg CXR). IV Vancomycin and Ceftriaxone were initiated and continued for approximately 7 weeks, with repeat echocardiogram showing the same prior vegetation/mass, now smaller in size, but with another vegetation/mass on the lead wire. Of note, all blood cultures spanning 2 months have been negative. Although the mass may be a vegetation, it could also be a thrombus, given the pt's Atrial fibrillation. However, it could not be ruled out that the mass was not infectious. The pt had a positive MRSA screen. Electrophysiology was originally consulted and felt that removal of the hardware posed risks that would outweigh benefits. Infectious Disease was also consulted, and it was felt that the best course of action would be to treat through it with IV antibiotic therapy. After completing ~7 weeks of IV antibiotics, with the new echo finding of persistent mass/vegetation seen on prior study plus new mass/vegetation, it was decided between both the medicine and infectious disease teams to continue IV antibiotics (CTX/VANCO) and then transition the pt to po linezolid prior to discharge. Pt will be discharged on po linezolid, with q weekly CBC checks on the linezolid to monitor for marrow suppression, a possible side effect of the medication. His PCP was informed that the results will be faxed to him by VNA, who will draw the pt's labs. He has a follow up appointment with Dr. with Infectious Disease department, as well. . 6. Congestive Heart Failure/Coronary Artery Disease: He had an echo in that showed an EF of 20% and moderate to severe MR. Additional echocardiograms, with the most recent being demonstrated severe global left ventricular hypokinesis, mild (1+) aortic regurgitation, mild to moderate (+) mitral regurgitation, moderate [2+] tricuspid regurgitation with severe pulmonary artery systolic . For his heart failure, the patient was continued on a beta , po and IV lasix (see apnea above) and a statin. He was tried on an ACEI but it was discontinued for cough, and initial trial of resulted in hypotension. He was intermittently gently diuresed in an effort to improve his volume and respiratory status without creating hypotension. His was eventually re-initiated in MICU stay (3 weeks prior to discharge) with success, so valsartan was continued for afterload reduction. For his coronary artery disease, he is to be maintained on a beta , , statin, . . 7. Subdural Hematoma: Chronic right subdural hematoma with no significant subfalcine herniation, improving on CTs done during his stay. His most recent Head CT prior to discharge was , showing slight improvement in the small subacute subdural hematoma along the right hemispheric convexity, with no evidence of acute hemorrhage within the intra- or extra-axial space. Overall, a slight decrease in the SDH since the 19th, when a prior Head CT was done. Because the patient initially presented with tonic clonic seizures in the emergency deparment thought secondary to his SDH, Neurosurgery and the primary medicine teams decided on indefinite seizure prophylaxis with dilantin. Anticoagulation for his atrial fibrillation was also discussed at length with NSGY, and ultimately, the risk most likely outweighs the benefits given this pt's waxing and mental status and fall risk. His dilantin levels will need to be monitored as an outpatient with his primary care physician. . with NSGY should see the patient in outpatient follow up for interval head CT to follow improvement in his SDH. . 8. GERD: Stable and continued on famotidine. . 9. PPx: SC Heparin, PPI. . 10. FEN: The pt underwent a speech and swallow study and was found to tolerate a soft mechanical diet. He will tolerate his medications well if they are crushed and blended in applesauce or ice cream. . 9. Code status: FULL CODE, discussed with HCP and family | Mild (1+) aorticregurgitation is seen. Mild (1+) aortic regurgitation is seen. RV functiondepressed.AORTA: Normal aortic root diameter. The left ventricular cavity size is top normal/borderlinedilated. Stable subfalcine herniation. Normal ascending aorta diameter. Pt noted to be febrile to 101.8. There is mild (non-obstructive) focal hypertrophy of thebasal septum. +PP,GI: Abd soft +BS. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. There is mild symmetric left ventricularhypertrophy. Mildly thickened aortic valveleaflets. Small bilateral pleural effusions are again noted. There is persistent fullness and perivascular haze, consistent with mild interstitial edema. output adequate.Access: R Picc line, single lumen. There is a small pericardial effusion.Compared with the prior study (tape reviewed) of , the massasscoiated with the pacer wire appears similar. Productive cough.GI: Abd soft +BS. PT WEANED OFF NEO GTT. Mild mitralannular calcification. PT was witnessed to have apneic episode in setting of -stoke like breathing pattern. Focal calcifications in aortic root.Mildly dilated ascending aorta. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 68Weight (lb): 180BSA (m2): 1.96 m2BP (mm Hg): 120/64HR (bpm): 129Status: InpatientDate/Time: at 12:02Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Moderate LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. IMPRESSION: 1) Persistent right subdural hematoma. Mildlydilated aortic arch.AORTIC VALVE: Moderately thickened aortic valve leaflets. The tricuspid valve leaflets are mildly thickened.Moderate [2+] tricuspid regurgitation is seen. There is slight worsening of sulcal effacement over the right cerebral hemisphere and stable mild leftward subfalcine herniation. Sxn for small amt of clear secretions. Mildly dilated LV cavity. IMPRESSION: Interval worsening of moderate CHF and development of a left and possibly right pleural effusion. Severe PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR. Mild thickening of mitral valve chordae. Mild to moderate (+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. There is stable marked cardiac enlargement. Right ventricular systolicfunction appears depressed. FINAL REPORT INDICATIONS: Mental status changes, not moving left side, seizure. The aortic arch is mildly dilated. Atrial fibrillationLeft anterior fascicular blockPoor R wave progression with late precordial QRS transition - could be due inpart to left axis deviation/ left anterior fascicular block but also prioranterior myocardial infarctionModest nonspecific low amplitude inferolateral T wavesSince previous tracing of , ventricular ectopy absent L-R arm lead reversedAtrial fibrillationBorderline low QRS voltageLeft anterior fascicular blockPoor R wave progression with late precordial QRS transition - may be due inpart to left axis deviation/ left anterior fascicular block but consider alsoprior anterior myocardial infarctionSince previous tracing of , ventricular ectopy absent SlowR wave progression with possible prior anterior wall myocardial infarction.Non-specific ST-T wave changes. Atrial fibrillation with ventricular premature complexesLeft anterior fascicular blockPoor R wave progression with late precordial QRS transition - could be due inpart to left axis deviation/ left anterior fascicular block but to also prioranterior myocardial infarctionModest nonspecific low amplitude inferolateral T wavesSince previous tracing of , wide complex beats less frequent Atrial fibrillationLeft anterior fascicular blockPoor R wave progression with Late precordial QRS transition - could be due inpart to left axis deviation/ left anterior fascicular block but consider alsopriro anterior myocardial infarctionModest nonspecific low amplitude inferolateral T wavesSince previous tracing of same date, no significant change Atrial fibrillationLow QRS voltagePossible atrial premature complexPoor R wave progression with late precordial QRS transition - is nonspecificbut consider prior anterior myocardial infarctionSince previous tracing of the same date, probably no significant change Baseline artifactAtrial fibrillationLeft anterior fascicular blockModest nonspecific ST-T wave changesSince previous tracing of , probably no significant change Atrial fibrillation with rapid ventricular responseLow QRS voltages in limb leadsLeft axis deviation - probable left anterior fascicular blockPoor R wave progression with Late precordial QRS transition -could be due inpart to left anterior fascicular block but consider prior anterior myocardialinfarctionConsider chronic pulmonary diseaseClinical correlation is suggestedSince previous tracing of , no significant change Compared to the previous tracingof the ventricular response rate to atrial fibrillation is slower andthere is now evidence of occaional ventricular pacing. Atrial fibrillationLeft axis deviation - anterior fascicular blockPoor R wave progression, could be normal variant but consider possible oldanterior infarctLateral T wave changes are nonspecificRepolarization changes may be partly due to rhythmNo change from previous There is an unchanged subacute to chronic hypodensity in the right basal ganglia consistent with a striate artery territory infarct. NON-CONTRAST HEAD CT: Portions are limited by patient motion. FINDINGS: There is again noted small right subdural hematoma, which is unchanged when compared to the prior study. There is a small-to-moderate right pleural effusion, with layering, and underlying collapse and/or consolidation. Unchanged from the previous study, there is hypodensity in the left temporal fraction of the left middle cranial fossa consistent with an arachnoid cyst. IMPRESSION: Cardiomegaly, mild CHF, moderate right effusion, and bibasilar collapse and/or consolidation, essentially unchanged compared with . IMPRESSION: Slight decrease in size of the small subacute right subdural hematoma. There is evidence of failure with perihilar edema and blunting of both costophrenic angle. Again seen is moderately severe cardiomegaly, with a calcified aorta. Bilateral pleural effusions, left greater than right are unchanged. COMPARISON: Non-contrast head CT from . Interval removal of the nasogastric tube and ETT noted. INDICATION: Tachypnea and shortness of breath. Allowing for limitations, the appearance of the thin subacute right hemispheric subdural hematoma is unchanged. The indwelling wire was removed and a 0.018 guidewire was advanced to the level of the right subclavian vein. Degenerative changes of the thoracic spine noted. FINDINGS: Again seen is a small subdural fluid collection overlying the right cerebral hemisphere. There is again noted encephalomalacic changes in the right frontal region, which is unchanged when compared to the prior study. REASON FOR THIS EXAMINATION: right parietal SDH--smaller/ gone/ incr in size??? TECHNIQUE: Non-contrast head CT. TECHNIQUE: Non-contrast head CT. IMPRESSION: No change in right subdural hematoma. A right PICC line remains in place, terminating in the region of the right axilla, and an ICD remains in place with leads in the right ventricle. There are bilateral interstitial opacities, which appear slightly worsened than on the prior study. FINDINGS: There has been slight improvement in the small subacute subdural hematoma along the right hemispheric convexity. | 59 | [
{
"category": "Echo",
"chartdate": "2200-01-08 00:00:00.000",
"description": "Report",
"row_id": 76314,
"text": "PATIENT/TEST INFORMATION:\nIndication: F/U pacing wire vegetation, Afib, CHF.\nHeight: (in) 68\nWeight (lb): 180\nBSA (m2): 1.96 m2\nBP (mm Hg): 112/60\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:00\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A mass/thrombus\nassociated with a catheter/pacing wire in the RA or RV.\n\nLEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the basal septum.\nTop normal/borderline dilated LV cavity size. Severe global LV hypokinesis. No\nLV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly\ndilated aortic arch.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. No masses or\nvegetations on aortic valve. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on\nmitral valve. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\nSevere PA systolic hypertension.\n\nPERICARDIUM: Small pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is markedly dilated. A\nmass/thrombus (1.0 x 0.5 cm) associated with a catheter/pacing wire is seen in\nthe right atrium. There is second mobile echodensity seen in the RA atrium\nthat likely represent a Chiari network but cannot exclude a second\nvegetation/mass. There is mild (non-obstructive) focal hypertrophy of the\nbasal septum. The left ventricular cavity size is top normal/borderline\ndilated. There is severe global left ventricular hypokinesis. No masses or\nthrombi are seen in the left ventricle. Right ventricular chamber size and\nfree wall motion are normal. The aortic arch is mildly dilated. The aortic\nvalve leaflets are moderately thickened. No masses or vegetations are seen on\nthe aortic valve. There is no aortic valve stenosis. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. No mass\nor vegetation is seen on the mitral valve. Mild to moderate (+) mitral\nregurgitation is seen. The tricuspid valve leaflets are mildly thickened.\nModerate [2+] tricuspid regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. There is a small pericardial effusion.\n\nCompared with the prior study (tape reviewed) of , the mass\nasscoiated with the pacer wire appears similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2199-11-29 00:00:00.000",
"description": "Report",
"row_id": 76315,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 68\nWeight (lb): 180\nBSA (m2): 1.96 m2\nBP (mm Hg): 120/64\nHR (bpm): 129\nStatus: Inpatient\nDate/Time: at 12:02\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing\nwire is seen in the RA and extending into the RV. A mass/thrombus associated\nwith a catheter/pacing wire in the RA or RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Severely\ndepressed LVEF. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. RV function\ndepressed.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nMildly dilated ascending aorta. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Moderate to severe (3+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. Moderate [2+] TR. Severe 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\nConclusions:\nThe left atrium is moderately dilated. The right atrium is markedly dilated. A\nvegetation/thrombus associated with a pacing wire is seen in the right atrium;\nthis measures approximately 1.7 by 0.5 cm and is mobile/pedunculated, attached\nto the pacemaker by a thin stalk. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is mildly dilated. Overall left\nventricular systolic function is severely depressed (ejection fraction 20\npercent). The right ventricular cavity is dilated. Right ventricular systolic\nfunction appears depressed. The ascending aorta is mildly dilated. There are\nthree aortic valve leaflets. The aortic valve leaflets are mildly thickened.\nThere is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nModerate to severe (3+) mitral regurgitation is seen. The tricuspid valve\nleaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen.\nThere is severe pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of , the mitral regurgitation is increased; the left ventricular ejection\nfraction is significantly decreased. A moderate-sized vegetation/thrombus is\nnow seen attached to the pacemaker wire in the right atrium.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 889882,
"text": " 4:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? effusion/congestion/consolidation\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with afib, endocarditis, CHF with tachypnea and SOB, now\n with acute SOB\n REASON FOR THIS EXAMINATION:\n ? effusion/congestion/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Portable chest.\n\n Endocarditis, now with SOB.\n\n A single AP upright portable view of the chest obtained at 4:25 a.m. shows\n cardiomegaly and interstitial pulmonary edema. There are bilateral pleural\n effusions, left greater.\n\n Note is made of a dual-lead pacemaker with leads overlying the right\n ventricle. There is a right-sided PICC line with the tip at the region of the\n right axillary vein.\n\n Comparison is made to previous examination of .\n\n IMPRESSION: Congestive heart failure.\n\n DR. \n"
},
{
"category": "Nursing/other",
"chartdate": "2199-11-20 00:00:00.000",
"description": "Report",
"row_id": 1383555,
"text": "CONDITION UPDATE\nASSESSMENT:\nPLEASE SEE FLOWSHEET FOR DETAILS\n PT ALERT, BUT CONFUSED. FOLLOWING COMMANDS, SPONTANEOUS MOVEMENT PURPOSEFUL, MAE, R>L. OPENING EYES SPONTANEOUSLY, PUPILS EQUAL AND REACTIVE, CONVERSING WITH FAMILY DURING FAMILY VISIT. ITALIAN SPEAKING ONLY. RECIEVING DILANTIN IV, NO SIEZURE ACTIVITY NOTED.\n PT REMAINS ON 3L N/C TO MAINTAIN O2 SAT 98-100%. RESP EQUAL AND UNLABORED. LS CLEARTO COARSE AND DIMINISHED AT BASES. PT ABLE TO COUGH AND DEEP BREATH. C&R THICK WHITE SPUTUM.\n PT WEANED OFF NEO GTT. BP STABLE. SHORT BURSTS OF HR IN 140'S. ICU RESIDENT NOTIFIED, LOPRESSOR DOSE GIVEN WITH POS EFFECT. PT REMAINS IN AFIB WITH OCCATIONAL PVC'S. R FEM LINE, L RADIAL A LINE.\n NGT D/C'D, SWALLOW DONE, PT ABLE TO DRINK WITH MEDS. ABD REMAINS SOFT +BS.\n ADEQUATE AMOUNTS OF CLEAR YELLOW URINE VIA FOLEY CATHETER.\nPLAN:\n TRANSFER TO FLOOR , D/C FEM LINE, ADVANCE DIET AS TOL, MONITOR HR AND MAINTAIN HR AND BP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-11-20 00:00:00.000",
"description": "Report",
"row_id": 1383556,
"text": "NEURO; CONFUSED ALL SHIFT, AGITATED AND RESTLESS, ATTEMPTING TO CLIMB OOB, FAMILY MEMBERS IN AND STATE PT IS ALERT TO PERSON, AND IDENTIFIES THEM CORRECTLY BUT OTHERWISE IS CONFUSED, FREQUENTLY PULLING AT LINES, TUBES, ETC.\n\nRESPIR; LUNGS CLEAR, DIFFICULT TO ASSESS AT TIMES DUE TO PT CONTINUALLY TALKING, 02 SAT 100% ON N/C AT 3L/MIN\n\nCARDIOVASCULAR; HR 90'S AFIB, , PT HAS AICD, EXTREMITIES WARM AND DRY\n\nPLAN; TRANSFER OUT OF SICU WHEN BED AVAILABLE, PT WILL NEED SITTER\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-11-21 00:00:00.000",
"description": "Report",
"row_id": 1383557,
"text": "focus hemodynmics\ndata: neuro: speaks italien. very hard to understand. beomes agitated and attempts to climb oob. bed armed with hands restrained for safety issues. sitter at the bedside this am. perla #3 bilaterally. moves upper extremities off the bed. left left lifts and falls. family at the bedside and states his is confused to time and plaace.\n\nresp: o2 at 3 liters and coughing and expectorating thick tan sputum. at times pt spits sputum on the floor. breath sounds clear.\n\n cardiac: in afib amd k 3.4 k repleted with 40meq kcl po. tol po pills ok. lopressor po given and hr 80-90's. magnesium repleted.\n\ngU: foley patent and draining amber colored urine.\n\ngI abd soft and no stool. taking po's ok.\n\naaction: labs as ordered. will be transferred to floor when private room available. bed armed due to pt attempting to climbing out of the bed. neuro signs q2hrs. family updated.\n\nresp[onse: monitor closely.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-11-22 00:00:00.000",
"description": "Report",
"row_id": 1383558,
"text": "Nursing Note--B Shift\nPlease see Carevue for complete assessment\n\nNEURO: Alert and confused. At times, combative. PERRLA 3 and brisk. With family present, he was talking continuously. Family states he is talking mostly nonsense. Follows commands. MAE in bed.\n\nRESP: LSCTA. On 2L NC sat 94-98%.\n\nCARDIAC: Afebrile. HR 70-120's. Given Lopressor 5mg x1 for HR > 100. +PP,\n\nGI: Abd soft +BS. Tol hse diet. Good appetite. +flatus.\n\nGU: Foley intact draining <30cc/hr of dark amber urine. NS @50cc/hr started at .\n\nINTEG: Ecchymotic bruises on Left hip and Left upper thigh. Both areas have improved from several days ago. Skin CDI.\n\nPSYCH/SOCIAL: Very supportive family very involved with care. Will be d/c'd to floor with sitter secondary to impulsiveness and lack of safety awareness.\n\nPLAN: D/C to floor pending bed availability.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-01-05 00:00:00.000",
"description": "Report",
"row_id": 1383559,
"text": "MICU NURSING ADMIT NOTE:\n Pt is an 86 yr old male with complex PMH and recent hospital course summarized in FHPA who was admitted to MICU o/n d/t apneic episode/O2 desaturation/MS changes. PT was witnessed to have apneic episode in setting of -stoke like breathing pattern. His O2 sats dropped to 60's, and only slowly responded to 100% NRB. He was unable to be weaned from NRB and was somnolent, not responding to stimuli. Pt noted to be febrile to 101.8. He was cx'd. He recieved 10mg iv lorpessor for AF 120's with HR to 90's, and 20mg iv lasix for worsening chf, with 400cc's urine output. PT transferred to MICU for further care.\nREview of Systems:\nNeuro: pt initially withdawing to pain, but somnolent, not opening eyes. PERRLA. L side slightly less responsive than R side. This am, pt opening eyes to voice/stimuli. Attempting to converse with coworker, but voice weak. Pt attempting to pull off O2 this am, soft restraints applied for safety. On Dilantin for sz disorder.\nRESP: pt weaned from 100%nrb to venti mask 31%. abg: 7.43/53/88/36. LS with bibasilar rales. pt was initially snoring, so upper airways difficult to assess. Continues with stoke like breathing pattern. No apneic spells so far. RR varies from teens up to high 20's. O2 sat difficult to pick up at times, but 100% on current O2 concentration.\nCV: HR 90's AF, with occasional PvC's, occasional ventricular paced beats. bp 1teens. cardiac meds to be restarted once cxr confirms ngt placement.\nGI: ab soft, bs +, + flatus, no stool. ngt placed as pt has intermittenty been too somnolent to take meds over past 2 weeks, and o/n as well.\nID: tmax 100. remains on ceftriaxone/vanco. Flagyl added o/n. REceived first dose imipenum on cc7.. still needs ID approval for this. cx pending.\nFE: am lytes show mg, K+ wnl. needs calcium repletion. fsbs 68, team aware. plan to start tf's once ngt placement confirmed.\nGU: foley intact. output adequate.\nAccess: R Picc line, single lumen. flushes, does not draw back.\nSocial: family in, spoke with team and received update. aware of ngt placement, in agreement.\n A/P: 86 yr old male with complicated medical history, admit for further observation to MICU s/p apneic episode/desaturation/ms change. Fio2 weaned to 31% as noted, pt receiving new abx for temps spike o/n. pt more alert this am. ? start tf's today. cont emotional support to pt/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-11-19 00:00:00.000",
"description": "Report",
"row_id": 1383552,
"text": "CONDITION UPDATE\nASSESSMENT:\nSEE FLOWSHEET FOR SPECIFICS\n PT WAS ADMITTED TO ED @ VIA OSH. PT WAS TAKEN TO CT SCAN POST INTUBATION (SECONDARY TO LACK OF GAG REFLEX), OF WHICH PT SUSTAINED RUNS OF VTACH POST INTUBATION. CT SCAN SHOWED PERSISTENT SDH. PT ADMITTED TO SICU APPROX 1845. LIDO GTT @ 1MG/MIN, NEO GTT @ .5MCG/KG/MIN, AND VERSED GTT @ 4MG/HR.\n PT WITHDRAWS TO PAIN VIA NAILBED, BUT POSTURING IS NOTED IN LUE. PT DOES NOT FOLLOW COMMANDS, ITALIAN SPEAKING, DOES NOT OPEN EYES TO ANY STIMULI. PUPILS EQUAL AND REACTIVE. VERSED GTT WEANED OFF AND PPF GTT STARTED PER NEUROSURG TEAM. PPF GTT @ 20MCG/KG/MIN WITH ADEQUATE SEDATION. LP PERFORMED @ BEDSIDE UPON ARRIVAL TO ICU, SPECS SENT TO LAB FOR CX.\n PT REMAINS ON CMV 600X5. FIO2 WEANED DOWN FROM 100 TO 40. ABG'S IMPROVING. LS CLEAR TO COARSE BILAT. SUCTIONING PRN THICK YELLOW SECRETIONS WITH POS EFFECT.\n PT REMAINS IN AFIB WITH FREQUENT PVC'S. LIDO GTT REMAINS @ 1MG/MIN. NEO GTT TITRATED TO MAINTAIN SBP >100 & < 140. ALINE PLACED AT BEDSIDE UPON ARRIVAL TO ICU. PT HAS L FEM TLC AS WELL AS MULTIPLE PIV BUE.\n ABD SOFT, NGT TO LOW CONT SUCTION, DRAINING BILIOUS FLUID.\n ADEQUATE AMOUNTS OF CLEAR YELLOW URINE VIA FOLEY CATH.\n PT HAS LARGE ECCHYMOTIC AREA ON L HIP AND FLANK.\nPLAN:\n HEAD CT , TRY TO WEAN OFF NEO, MAINTAIN SBP, WEAN OFF VENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-11-19 00:00:00.000",
"description": "Report",
"row_id": 1383553,
"text": "Respiraotry care:\nPatient was received at the change of shift with a subdural hematoma. Intubated at OSH and placed on ventilatory support (A/C). ABG results on the present settings revealed a mild metabolic alkalemia with excellent oxygenation.\n\nRSBI = 76.3 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2199-11-19 00:00:00.000",
"description": "Report",
"row_id": 1383554,
"text": "Nursing Note--A Shift\nPlease see Carevue for complete assessment and specifics:\n\nNEURO: PERRLA 3 and brisk. +corneals, strong gag and strong cough. Understands Italian only. Follows simple commands, with lots of encouragement. Nods and shakes head to questions asked. Speech thick(post extubation). Move all ext on bed R>L. Right gaze preference. Bolus dose of 500mg Dilantin IV given.\n\nRESP: Extubated at 3:15pm. Sxn for small amt of clear secretions. LS coarse and diminished. Productive cough.\n\nGI: Abd soft +BS. NGT +placement. Will start Tube feeds later this evening.\n\nGU: Foley intact draining qs clear yellow urine.\n\nCARDIAC: T max 100.1. Cardiology consult today. Interogated ICD--stated ICD is working fine. SBP 98-125. Goal is >100 and <140 maintained with NEO gtt. Lido gtt d/c'd at 9am. +PP.\n\nINTEG: Ecchymotic areas on Left hip and Left outer thigh, family states they happened at Rehab. Skin CDI.\n\nPSYCH/SOCIAL: Very involved family very supportive and helpful with his care. Family members present at bedside today all spoke English/Italian and were very helpful with care and keeping him calm. Much more interactive with family present. Appears to recognize family members and reaches his hand out to touch them.\n\nPLAN: Possible Head CT later this evening, Wean Neo gtt, Start tube feeds, Frequent Neuro checks. Provide extra comfort and reassurance.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-01-05 00:00:00.000",
"description": "Report",
"row_id": 1383560,
"text": "NPN MICU- 7AM-7PM\nS/O: NEURO: PT was yelling and upset this AM, talking in Italian, son was called and explained to pt about the transfer pt did calm down somewhat. Son came in and has stayed all day, has been calm and sleeping on/off most of day but easily arousable and per son is oriented. Does have sitter ordered for evening and nights.\n\nC/V: BP down to 100-115/50, from 120-130's/60, HR also down from 90-100's A-fib with frequ PVC's and runs to 70-80's A-fib with only occ PVC's noted no further runs noted. Has rec'd C/V meds as ordered.\n\nREspir: Able to wean FIO2 from 40% venti-mask to 3L NP with O2 sats 95-99%, RR 16-20. L/S crackles @ bases, bilat. Occ having productive cough of thick tinged sputum, spec was sent for culture.\n\nGI: NGT placement was checked by C-Xray, in correct position is rec'ing meds as ordered. soft with +BS's. No stool noted. Is NPO, does not have a gag reflex is ordered for Speech and Swallowing study tomorrow.\n\nGU: U/O 50-60cc/hr Bun/CRE 22/1.1. Rec'd PO Lasix dose.\n\nID: Temp 98.6 PO max continues on triple IV antibx's. WBC-7.6. No new culture data back.\n\nSocial: Son in all day, and other family members in this evening, family has been updated on pt's condition.\n\nA/P: Continue to monitor Respir status follow O2 sats, check L/S frequ assess VS's, administer C/V meds. Attempt to keep as calm and comfortable as possible, sitters @ bedside as needed. Monitor temps continue IV antibx's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-01-06 00:00:00.000",
"description": "Report",
"row_id": 1383561,
"text": "Nursing progress note:\n\nNeuro: Pt. is alert or easily arousable, Italian-speaking only, seems to understand gestures,MAE. Pt. is restrained due to rreaching for NG tube although this may be due to wanting to scratch his nose rather than trying to pull at the tube. Unable to determine orientation.\n\nCV:HR 88-95,a-fib with occ to frequent PVCs,NBP 88-111/36-55. Pt. had one episode of systolic BP of 83, team notified and want a MAP>55 which pt. had maintained since then. Pt. has PICC in R AC which is patent but did not function for lab draws. Pt. was restarted on cardiac and BP meds, Valsartan held @ 0200 due to systolic BP hovering around 100.\n\nResp: RR 20-29, LS clear to upper lobes with crackles to bases. Pt. maintains 02 sats>93% on 2L NC and has no signs of resp distress.\n\nGI/GU: Pt. is NPO due to impaired gag reflex<NG tube in place but no nutrition orders written yet. No BM on shift, UO 32-130 ( increased after PO Lasix).\n\n: Pt. has RISS in place but glucose has been stable.\n\nSkin: Pt. has Duoderm on R forearm, abrasion,coccyx intact.\n\nSocial: Family and friends at bedside in afternoon,pt. sesemed to be rresponding appropriately to them.\n\nID:Pt. needs sputum culture but cough was non-productive through night. Team aware that resp does not induce sputum for routine cultures. Pt. has been afebrile.\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-26 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 885543,
"text": " 12:56 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval swallowing\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute on chronic subdural hematoma\n REASON FOR THIS EXAMINATION:\n eval swallowing\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old man with acute on chronic subdural hemorrhage.\n Evaluate swallowing.\n\n VIDEO OROPHARYNGEAL SWALLOW: An oral and pharyngeal swallowing\n videofluoroscopy was performed in collaboration with speech pathology. Solids\n and liquids of different consistencies were administered.\n\n This study shows some penetration with patient's ability to clear it\n spontaneously. No aspiration was demonstrated.\n\n Please refer to speech pathologist's report for detailed findings and\n recommendations.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 884443,
"text": " 1:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute on chronic SDH s/p intubation\n REASON FOR THIS EXAMINATION:\n post intubation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post intubation.\n\n An endotracheal tube is in satisfactory position, terminating approximately\n 3.5 cm above the carina. There is a malpositioned nasogastric tube, coursing\n through the airway to terminate within the right lower lobe. There is stable\n marked cardiac enlargement. Note is made of a bilateral interstitial pattern,\n shown to represent chronic interstitial lung disease on , chest\n CT. Additionally, at that time, a pericardial effusion was evident.\n\n IMPRESSION:\n 1. Malpositioned nasogastric tube, coursing through the airway into the right\n lower lobe. This finding has been communicated to Dr. by telephone on\n the date of the study.\n 2. Satisfactory placement of endotracheal tube.\n 3. Chronic diffuse interstitial lung disease.\n 4. Enlarged cardiac silhouette, in keeping with known pericardial effusion on\n prior chest CT.\n 5. Incomplete imaging of the left lung. Attention to this area on repeat\n radiograph following replacement of the nasogastric tube is suggested.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 885333,
"text": " 2:43 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate interval changes on subdural collection\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with right acute on chronic SDH now less responsiove\n REASON FOR THIS EXAMINATION:\n evaluate interval changes on subdural collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute and chronic right subdural hemorrhage, decreased\n responsiveness.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: Noncontrast head CT.\n\n HEAD CT WITHOUT IV CONTRAST: Again demonstrated is a heterogeneous subdural\n hematoma, which appears decreased in density since the prior examination,\n likely reflecting evolution of the hematoma. The collection appears\n relatively stable in size since the prior study. There is continued mild mass\n effect upon the adjacent right frontal and parietal lobes, however, the sulci\n are not as effaced as on the prior examination. No new areas of intracranial\n hemorrhage are identified. There is no appreciable shift of midline\n structures. The ventricles are stable in configuration without evidence for\n hydrocephalus.\n\n Again demonstrated is widening of the extra-axial space anterior to the left\n temporal tip, stable in the interval, and likely representing an arachnoid\n cyst. There is a stable focal area of low attenuation within the right\n frontal white matter, consistent with a remote infarction. Differentiation of\n the and white matter is otherwise preserved.\n\n Mucosal thickening is seen involving the right sphenoid sinus. Aerosolized\n mucus is also demonstrated within the left sphenoid sinus. Remaining\n visualized paranasal sinuses are clear. Surrounding osseous and soft tissue\n structures are unchanged. The patient is status post right frontal\n craniotomy.\n\n IMPRESSION:\n 1. No significant interval change in the size of the right subdural hematoma.\n There is no significant subfalcine herniation. The previously seen sulcal\n effacement over the right cerebral hemisphere appears less pronounced on the\n current examination.\n 2. No new intracranial hemorrhage or mass effect identified.\n\n DFDdp\n (Over)\n\n 2:43 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate interval changes on subdural collection\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 884456,
"text": " 2:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: mental status changes, not moving left side, seizing, eval f\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with\n REASON FOR THIS EXAMINATION:\n mental status changes, not moving left side, seizing, eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EEZ MON 3:57 PM\n large right subdural collection with heterogeneous density and mild subfalcine\n herniation, changed slightly in configuration; see full report. Questionable\n worsening of sulcal effacement over right cerebral hemisphere raising\n suspicion for increased intracranial pressure. Stable subfalcine herniation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Mental status changes, not moving left side, seizure.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: Head CT from .\n\n NONCONTRAST HEAD CT: The large subdural collection over the right cerebral\n hemisphere is again identified, and demonstrates heterogeneous attenuation\n with focal areas of more dense blood products anteriorly. Since the prior\n study, there has been an interval decrease in the attenuation values in the\n majority of the collection. The collection along the lateral aspect of the\n right temporal lobe and inferior parietal lobe may be slightly more wide than\n on the previous study, but the frontal area appears slightly thinner, and this\n could be due to shifting of blood products, but an interval rebleed cannot be\n completely excluded. There is slight worsening of sulcal effacement over the\n right cerebral hemisphere and stable mild leftward subfalcine herniation. No\n new extraaxial collections over the left cerebral hemisphere or evidence of\n subarachnoid hemorrhage. Widening of the extraaxial space anterior to the\n left temporal tip, which could reflect a small arachnoid cyst, is also\n unchanged. There are changes from prior right frontal craniotomy. There is\n mucosal thickening in the ethmoid air cells. Aerosolized mucus is present\n within the sphenoid sinus. Evaluation of the skull base is limited due to\n motion artifact.\n\n IMPRESSION:\n 1) Persistent right subdural hematoma. Slight change in configuration likely\n reflects dependent changes and reorganization over time.\n 2) Slight questionable worsening of sulcal effacement over the right cerebral\n hemisphere, raising suspicion for increased intracranial pressure.\n\n Results called to Dr. at 3:50 p.m. on .\n (Over)\n\n 2:40 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: mental status changes, not moving left side, seizing, eval f\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885331,
"text": " 1:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate, pneumonia, atelectasis,or any acute process.\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute on chronic SDH s/p intubation febrile with\n seizures in ED, now with tachypnea.\n REASON FOR THIS EXAMINATION:\n evaluate, pneumonia, atelectasis,or any acute process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chronic subdural hemorrhage status post intubation, now with\n tachypnea.\n\n PORTABLE AP CHEST: Comparison is made to study dated .\n\n FINDINGS: Dual chamber pacemaker leads and ICD devices are unchanged. There\n is pronounced polychamber cardiomegaly, unchanged. There is persistent\n fullness and perivascular haze, consistent with mild interstitial edema.\n Small bilateral pleural effusions are again noted.\n\n IMPRESSION: No significant interval change in markedly cardiomegaly and mild\n interstitial edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 885462,
"text": " 6:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o acute processes, pna,\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute on chronic SDH s/p intubation febrile with\n seizures in ED, now with tachypnea.\n REASON FOR THIS EXAMINATION:\n r/o acute processes, pna,\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old man with acute on chronic subdural hemorrhage status\n post intubation. Now with tachypnea.\n\n COMPARISON: at 1:47 a.m.\n\n PORTABLE CHEST: There is marked cardiomegaly. The aorta is calcified and\n tortuous. Compared to a prior exam, there has been interval worsening of the\n pulmonary edema and development of a left pleural effusion and possible small\n right pleural effusion. Osseous and soft tissue structures are stable.\n Pacemaker and ICD leads are unchanged.\n\n IMPRESSION: Interval worsening of moderate CHF and development of a left and\n possibly right pleural effusion.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-26 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 885510,
"text": " 9:59 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: r/o dvt - pt with temp - intermittent SOB\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p recent intubation for febrile seizures wtih acute on\n chronic SDH\n REASON FOR THIS EXAMINATION:\n r/o dvt - pt with temp - intermittent SOB\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old man with recent intubation for febrile seizures.\n Intermittent shortness of breath. Assess for DVT.\n\n COMPARISON: None.\n\n FINDINGS: Grayscale and color Doppler examination of the deep veins of both\n thighs and posterior knees demonstrate normal compressibility, color flow,\n respiratory variation, and augmentation. No sign of intraluminal thrombus.\n\n IMPRESSION: No DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-04 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 886689,
"text": " 7:31 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pls eval for infiltrate\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with Afib, CHF, ?endocarditis, spiking through broad-spectrum\n antibiotics\n REASON FOR THIS EXAMINATION:\n pls eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:54 P.M. ON :\n\n HISTORY: Atrial fibrillation and CHF. Possible endocarditis.\n\n IMPRESSION: AP chest compared to , and 24:\n\n Severe enlargement of the cardiac silhouette due to cardiomegaly and/or\n pericardial effusion is unchanged. Borderline interstitial edema in the right\n lung has improved since , stable since . Small right\n pleural effusion has increased. Transvenous right ventricular pacer and pacer\n defibrillator leads project over the expected courses to the right ventricular\n apex. Both leads are continuous to the left axillary pacemaker, but the\n connections of the leads are obscured.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 886281,
"text": " 12:51 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Pt had a right sided picc line placed and needs tip confirma\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with endocarditis who needs picc for 4 weeks of\n Vancomycin.\n REASON FOR THIS EXAMINATION:\n Pt had a right sided picc line placed and needs tip confirmation please page\n at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Endocarditis, status post PICC placement.\n\n COMPARISON: Radiograph dated .\n\n PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: There is interval placement of a\n right PICC that enters the right internal jugular vein with distal tip\n terminating above the upper margin of this film. A dual lead pacemaker/ICD\n device is again demonstrated with electrodes terminating near the right\n ventricular apex. There is stable cardiac enlargement. There are stable\n bilateral pleural effusions with perivascular haze and congestion consistent\n with CHF.\n\n IMPRESSION:\n 1) Right PICC entering the right internal jugular vein with distal tip\n terminating above the upper margin of this film. This was discussed with\n of the IV team at the time of interpretation of the study.\n 2) Continued CHF.\n\n"
},
{
"category": "ECG",
"chartdate": "2200-01-05 00:00:00.000",
"description": "Report",
"row_id": 185577,
"text": "L-R arm lead reversed\nAtrial fibrillation\nBorderline low QRS voltage\nLeft anterior fascicular block\nPoor R wave progression with late precordial QRS transition - may be due in\npart to left axis deviation/ left anterior fascicular block but consider also\nprior anterior myocardial infarction\nSince previous tracing of , ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2200-01-02 00:00:00.000",
"description": "Report",
"row_id": 185578,
"text": "Atrial fibrillation with a rapid ventricular response and frequent ventricular\nectopy. Left anterior fascicular block. Low limb lead voltage. Compared to the\nprevious tracing of the ventricular response has increased and\nventricular ectopy has appeared. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-28 00:00:00.000",
"description": "Report",
"row_id": 185579,
"text": "Atrial fibrillation with a controlled ventricular response. Low limb lead\nvoltage. Left anterior fascicular block. Compared to the previous tracing\nof no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-26 00:00:00.000",
"description": "Report",
"row_id": 185580,
"text": "Atrial fibrillation with a mean ventricular, rate 93. Left axis deviation. Left\nanterior fascicular block. Cannot exclude anterior myocardial infarction.\nDiffuse non-diagnostic repolarization abnormalities. Compared to the previous\ntracing of no major change is evident.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-17 00:00:00.000",
"description": "Report",
"row_id": 185581,
"text": "Atrial fibrillation\nLow QRS voltage\nPossible atrial premature complex\nPoor R wave progression with late precordial QRS transition - is nonspecific\nbut consider prior anterior myocardial infarction\nSince previous tracing of the same date, probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-12 00:00:00.000",
"description": "Report",
"row_id": 185584,
"text": "Atrial fibrillation with a controlled ventricular response, rate\napproximately 70-80. Occasional ventricular paced beat. Left anterior\nhemiblock. Low voltage in standard leads. Compared to the previous tracing\nof the ventricular response rate to atrial fibrillation is slower and\nthere is now evidence of occaional ventricular pacing.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-06 00:00:00.000",
"description": "Report",
"row_id": 185585,
"text": "Baseline artifact\nAtrial fibrillation with rapid ventricular response\nLeft anterior fascicular block\nPoor R wave progression with late precordial QRS transition - could be due in\npart to left anterior fascicular block but consider also prior anterior\nmyocardial infarction\nSince previous tracing of , ventricular rate increased\n\n"
},
{
"category": "ECG",
"chartdate": "2199-11-22 00:00:00.000",
"description": "Report",
"row_id": 185827,
"text": "Probable atrial fibrillation with rapid ventricular response\nA 4 beat run of a regular wide complex tachycardia probable non-sustained\nventricular tachycardia but cannot rule out atrial fibrillation with aberrant\nconduction\nLeft axis deviation - anterior fascicular block\nNo change from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-17 00:00:00.000",
"description": "Report",
"row_id": 185582,
"text": "Atrial fibrillation with a ventricular response rate approximately 100. Low\nvoltage in standard leads. Left axis deviation. Poor R wave progression.\nPossible old anterior myocardial infarction. Possible aberrant conduction. A\nseparate long rhythm strip showed atrial fibrillation with a rapid ventricular\nresponse and six beat ventricular tachycardia at rate approximately 150.\nCompared to the previous tracing of ventricular response rate is\nsomewhat more regular and somewhat faster. The supraventricular tachycardia and\naberrantly conducted beats are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-15 00:00:00.000",
"description": "Report",
"row_id": 185583,
"text": "Atrial fibrillation with a moderate ventricular response. Low limb lead\nvoltage. Left axis deviation. Possible left anterior fascicular block. Slow\nR wave progression with possible prior anterior wall myocardial infarction.\nNon-specific ST-T wave changes. Compared to the previous tracing of \nventricular response is minimally faster and intermittent ventricular pacing is\nnot seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-10 00:00:00.000",
"description": "Report",
"row_id": 185822,
"text": "Atrial fibrillation with rapid ventricular response\nLow QRS voltages in limb leads\nLeft axis deviation - probable left anterior fascicular block\nPoor R wave progression with Late precordial QRS transition -could be due in\npart to left anterior fascicular block but consider prior anterior myocardial\ninfarction\nConsider chronic pulmonary disease\nClinical correlation is suggested\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2199-12-01 00:00:00.000",
"description": "Report",
"row_id": 185823,
"text": "Atrial fibrillation\nLeft axis deviation - anterior fascicular block\nPoor R wave progression, could be normal variant but consider possible old\nanterior infarct\nLateral T wave changes are nonspecific\nRepolarization changes may be partly due to rhythm\nNo change from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2199-11-25 00:00:00.000",
"description": "Report",
"row_id": 185824,
"text": "Atrial fibrillation\nLeft anterior fascicular block\nPoor R wave progression with Late precordial QRS transition - could be due in\npart to left axis deviation/ left anterior fascicular block but consider also\npriro anterior myocardial infarction\nModest nonspecific low amplitude inferolateral T waves\nSince previous tracing of same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2199-11-25 00:00:00.000",
"description": "Report",
"row_id": 185825,
"text": "Atrial fibrillation\nLeft anterior fascicular block\nPoor R wave progression with late precordial QRS transition - could be due in\npart to left axis deviation/ left anterior fascicular block but also prior\nanterior myocardial infarction\nModest nonspecific low amplitude inferolateral T waves\nSince previous tracing of , ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2199-11-23 00:00:00.000",
"description": "Report",
"row_id": 185826,
"text": "Atrial fibrillation with ventricular premature complexes\nLeft anterior fascicular block\nPoor R wave progression with late precordial QRS transition - could be due in\npart to left axis deviation/ left anterior fascicular block but to also prior\nanterior myocardial infarction\nModest nonspecific low amplitude inferolateral T waves\nSince previous tracing of , wide complex beats less frequent\n\n"
},
{
"category": "ECG",
"chartdate": "2199-11-18 00:00:00.000",
"description": "Report",
"row_id": 185828,
"text": "Atrial fibrillation with 3-7 beat runs of a slightly irregular wide complex\ntachycardia, rate 170 - probable ventricular tachycardia\nSince previous tracing of the same date, runs of wide complex tachycardia now\npresent\n\n"
},
{
"category": "ECG",
"chartdate": "2199-11-18 00:00:00.000",
"description": "Report",
"row_id": 185829,
"text": "Baseline artifact\nAtrial fibrillation\nLeft anterior fascicular block\nModest nonspecific ST-T wave changes\nSince previous tracing of , probably no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 886493,
"text": " 2:33 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls eval for progress of SDH\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with chronic subdural hematoma, worsening mental status\n REASON FOR THIS EXAMINATION:\n pls eval for progress of SDH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Chronic subdural hematoma. Worsening mental status.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISONS: .\n\n NON-CONTRAST HEAD CT: Portions of the study are limited by patient motion.\n There is no change in the intermediate attenuation, moderately large right\n extra-axial fluid collection. A moderate-sized arachnoid cyst anterior to the\n left temporal tip is also unchanged. There is no evidence of acute\n hemorrhage, worsening ventricular dilatation, or other change from .\n\n IMPRESSION: No change in chronic right subdural hematoma. No evidence of new\n acute intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-02 00:00:00.000",
"description": "PERIPHERAL W/O PORT",
"row_id": 886299,
"text": " 1:54 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: please fix PICC placement\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man s/p PICC with end in IJ\n REASON FOR THIS EXAMINATION:\n please fix PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post PICC line placement, with catheter positioned in the\n right internal jugular vein. Please reposition PICC.\n\n RADIOLOGISTS: The procedure was performed by , with \n , the attending physician, and supervising the entire\n procedure.\n\n PROCEDURE AND FINDINGS: The patient was placed supine on the angiography\n table. The indwelling right PICC catheter and right arm were prepped and\n draped in the usual sterile fashion. Approximately 3 cc of 1% lidocaine was\n administered subcutaneously around the indwelling catheter. The indwelling\n wire was removed and a 0.018 guidewire was advanced to the level of the right\n subclavian vein. The indwelling catheter was removed over the wire, and a 4-\n French micropuncture sheath was placed. The tip of the guidewire was then\n positioned within the SVC under flouroscopic guidance, and a length of 46 cm\n was determined suitable. A 4-French single lumen 46 cm PICC line was then\n placed over the guidewire, with the tip positioned in the superior vena cava.\n The peel-away sheath was removed. The catheter was flushed and hep-locked. A\n StatLock and sterile dressing were applied. A final fluoroscopic spot image of\n the chest demonstrates the tip within the superior vena cava.\n\n COMPLICATIONS: There were no immediate complications.\n\n IMPRESSION: Preexisting right PICC catheter removed, and a 46 cm long, 4-\n French single lumen PICC was replaced, with the tip in the SVC. The line is\n ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-28 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 885859,
"text": " 3:25 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: assess interval change\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with SOB and CP\n\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Shortness of breath and chest pain.\n\n FINDINGS: AP single view with patient in semi-upright position has been\n obtained and is compared with a similar previous study of .\n Again marked enlargement of the heart shadow is noted. The position of the\n left-sided pacer connected to a dual electrode system is unchanged and both\n electrodes terminate in a position compatible with the right ventricular\n apical portion. There is no significant pulmonary vascular congestion. The\n large heart size accounts for the poor visibility of the left diaphragmatic\n contour. There is no conclusive evidence of pleural effusion on either side\n on this portable examination.\n\n The findings are similar to what existed on . The remarkable\n enlargement of the cardiac shadow and in particular the right heart border in\n relation to the pacer wires raises the suspicion of pericardial effusion at\n least to contribute to this cardiac enlargement. In comparison with the next\n previous study, there is no conclusive evidence for new parenchymal\n infiltrates and no pneumothorax can be identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887795,
"text": " 12:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for acute process\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with afib, endocarditis, CHF with CP and SOB, increased O2\n requirement.\n REASON FOR THIS EXAMINATION:\n pls eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:36 P.M. .\n\n HISTORY: Endocarditis.\n\n IMPRESSION: AP chest compared to :\n\n Mild pulmonary edema has improved but severe cardiomegaly is unchanged and\n small bilateral pleural effusions persist. Transvenous right ventricular\n pacer defibrillator and pacer leads project over their expected courses from\n the left axilla but connections to the left pectoral pacemaker are difficult\n to trace. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 886892,
"text": " 8:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for changes in subdural hematoma\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with subdural hematoma that was stable on last CT\n REASON FOR THIS EXAMINATION:\n evaluate for changes in subdural hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Subdural hematoma. Follow up.\n\n TECHNIQUE: Non-contrast PET CT.\n\n COMPARISON: Head CT from .\n\n NON-CONTRAST HEAD CT: Portions are limited by patient motion. Allowing for\n limitations, the appearance of the thin subacute right hemispheric subdural\n hematoma is unchanged. The arachnoid cyst in the middle temporal fossa is\n also stable. No new areas of hemorrhage are identified. The low-attenuation\n area near the caudate is also unchanged.\n\n IMPRESSION: No change in right subdural hematoma. No other change since\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886206,
"text": " 11:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o CHF\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with acute on chronic SDH s/p intubation febrile with\n seizures in ED, now with tachypnea, hypotension\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:27 P.M. ON .\n\n HISTORY: Shortness of breath and chest pain.\n\n Seizures. Rule out CHF.\n\n IMPRESSION: AP chest compared to and 20th:\n\n Mild pulmonary edema is new. Severe enlargement of the cardiac silhouette is\n stable. Small bilateral pleural effusions have increased. Transvenous right\n ventricular pacer and pacer defibrillator leads project over their expected\n courses. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886991,
"text": " 10:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for PNA worsening CHF\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with afib, endocarditis, CHF with increasing SOB and increase\n in O2 requirement.\n REASON FOR THIS EXAMINATION:\n evaluate for PNA worsening CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing shortness of breath and increased O2 requirement.\n\n chest, single ap vw\n\n Compared with and allowing for differences in positioning and\n technique, no definite change is identified. Again seen is moderately severe\n cardiomegaly, with a calcified aorta. There is borderline upper zone\n redistribution. There is a small-to-moderate right pleural effusion, with\n layering, and underlying collapse and/or consolidation. There is probably\n also some degree of collapse and/or consolidation at the left base. No gross\n left-sided effusion. No pneumothorax detected. Degenerative changes of the\n thoracic spine noted.\n\n IMPRESSION: Cardiomegaly, mild CHF, moderate right effusion, and bibasilar\n collapse and/or consolidation, essentially unchanged compared with .\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-04 00:00:00.000",
"description": "CHEST U.S.",
"row_id": 886692,
"text": " 7:47 PM\n CHEST U.S. Clip # \n Reason: FEVERS, EVAL ICD SITE FOR FLUID COLLECTION\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with Afib, CHF, w/ICD now spiking on broad spectrum abx\n REASON FOR THIS EXAMINATION:\n pls eval ICD site for fluid collection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of ICD placement with fever on antibiotics. Evaluate for\n fluid collection adjacent to the ICD site.\n\n FINDINGS: Targeted ultrasound examination over the region of the ICD device\n in the left chest demonstrated no abnormalities. Specifically, no focal fluid\n collections or masses were seen.\n\n IMPRESSION: No evidence for a focal fluid collection within the left chest\n wall.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-05 00:00:00.000",
"description": "B CT LOW EXT W/O C BILAT",
"row_id": 886735,
"text": " 8:10 AM\n CT LOW EXT W/O C BILAT Clip # \n Reason: bilateralpls eval for effusion, osteo\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with Afib, CHF, ?endocarditis, h/o b/l total knee replacements,\n now spiking fevers through broad spectrum coverage\n REASON FOR THIS EXAMINATION:\n bilateralpls eval for effusion, osteo\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: CT BOTH KNEES.\n\n HISTORY: Bilateral total knee replacement, now spiking fevers. Evaluate for\n effusion or osteomyelitis.\n\n CT BOTH KNEES: Axial images were obtained through both knees and subsequently\n surgical and coronal reformatted images were acquired. No intravenous\n contrast was utilized.\n\n FINDINGS: Both knees show total knee prostheses. There are bilateral small\n joint effusions. There is no evidence of loosening of the prostheses. Two\n focal radiolucent areas are noted beneath the left tibial tray likely\n due to particle disease. There is no periosteal reaction. The surroundings\n of tissues are unremarkable.\n\n IMPRESSION: Bilateral total knee prostheses without evidence of loosening.\n Small joint effusions. Suggestion of early particle disease about the left\n tibial component.\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2199-12-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 887639,
"text": " 1:42 PM\n CHEST (PA & LAT) Clip # \n Reason: pls eval for infiltrate\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with Afib, CHF, ?endocarditis, cough, aspiration risk\n REASON FOR THIS EXAMINATION:\n pls eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Atrial fibrillation, cough, aspiration risk, evaluate for\n infiltrates.\n\n CHEST:\n\n Comparison is made with the prior film from . The heart remains\n markedly enlarged with prominence of both ventricles. There is evidence of\n failure with perihilar edema and blunting of both costophrenic angle.\n\n When compared with the prior chest x-ray, the right effusion is smaller but\n the pulmonary plethora is still present.\n\n IMPRESSION: Continued failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-04 00:00:00.000",
"description": "RP HAND (AP, LAT & OBLIQUE) RIGHT PORT",
"row_id": 886690,
"text": " 7:31 PM\n HAND (AP, LAT & OBLIQUE) RIGHT PORT Clip # \n Reason: pls eval for effusion/osteo\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with Afib, CHF, ?endocarditis on abx, now with fever, swollen\n 3rd knuckle, and pain\n REASON FOR THIS EXAMINATION:\n pls eval for effusion/osteo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Third knuckle pain, evaluate for effusion, osteo.\n\n Comparison is made to the prior plain films of the wrist dated .\n\n FINDINGS: There are no fractures identified. No bony destructive changes are\n identified. There are again demonstrated degenerative changes seen most\n pronounced at the first CMC joint. In addition, osteophytes are again seen at\n the distal portions of the second and third metacarpals. There is slight\n radial subluxation of the proximal phalanges at the second and third MCP\n joints. Note is made of a small radiopaque foreign body projecting over the\n distal aspect of the second digit. Dense vascular calcifications are noted in\n the volar aspect of the wrist.\n\n IMPRESSION:\n 1. No evidence of fracture or radiographic evidence of osteomyelitis.\n 2. Degenerative changes most pronounced at the first CMC joint. These\n changes are most likely reflective of osteoarthritis. The differential\n diagnosis could also include hemochromatosis, particularly given the large\n osteophytes at the MCP joints.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-01-10 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 891557,
"text": " 9:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: right parietal SDH--smaller/ gone/ incr in size???\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 86 year old man with h/o right parietal SDH, came in with acute on\n chronic right SDH, evid of decr in size on last 2 CT scans and .\n Please eval for decr in size/or whether the SDH is still present, as we are\n considering restarting anticoagulation in this pt (h/o Afib with RVR).\n REASON FOR THIS EXAMINATION:\n right parietal SDH--smaller/ gone/ incr in size???\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of right parietal subdural hematoma, please evaluate for\n size, considering restarting anticoagulation.\n\n COMPARISON: Non-contrast head CT from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There has been slight improvement in the small subacute subdural\n hematoma along the right hemispheric convexity. There is no evidence of acute\n hemorrhage within the intra- or extra-axial space. There is no evidence of\n mass effect or shift of normally midline structures. The right sphenoid air\n cell has an air-fluid level as well as aerosolized mucus. No other changes\n are identified since the prior study of .\n\n IMPRESSION: Slight decrease in size of the small subacute right subdural\n hematoma. No evidence of acute intra- or extra-axial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-01-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 891648,
"text": " 10:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement. ???\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with afib, endocarditis, CHF with tachypnea and SOB,\n increased oxygen requirement, now s/p NGT placement\n REASON FOR THIS EXAMINATION:\n NGT placement. ???\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Portable chest single AP view.\n\n REASON FOR THE EXAM: NG tube placement.\n\n HISTORY: 85-year-old man with atrial fibrillation, endocarditis, CHF with\n tachypnea and SOB.\n\n FINDINGS: NG tube with distal tip in the stomach. Stable cardiomegaly.\n Bilateral pleural effusions and bilateral interstitial and alveolar\n infiltrates in both bases are unchanged. Right side peripheral IV line with\n distal tip at the level of the right axillary vein. There is no pneumothorax.\n\n IMPRESSION:\n 1. NG tube with distal tip in the stomach.\n\n 2. Unchanged interstitial and alveolar infiltrates.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-01-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890847,
"text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for NGT placement\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with afib, endocarditis, CHF with tachypnea and SOB,\n increased oxygen requirement, now s/p NGT placement\n REASON FOR THIS EXAMINATION:\n please evaluate for NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Atrial fibrillation, endocarditis, increased O2\n requirement, NGT placed, check position.\n\n Film is somewhat underpenetrated. The exact position of the nasogastric tube\n is difficult to assess. It can be seen through the mid esophageal region.\n Either it stops there or is lost in the overlying shadow. A more penetrated\n view will help determine its position.\n\n The heart remains enlarged. Bilateral interstitial alveolar opacities are\n again seen.\n\n IMPRESSION: Exact position of NG tube cannot be determined, possibly lies in\n the mid esophagus.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 888433,
"text": " 2:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for worsening CHF or infiltrate\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with afib, endocarditis, CHF with tachypnea and SOB\n REASON FOR THIS EXAMINATION:\n pls eval for worsening CHF or infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Atrial fibrillation, endocarditis, congestive heart failure, with\n tachypnea and shortness of breath.\n\n CHEST X-RAY, PORTABLE AP: Comparison made to prior study of .\n There is a left chest wall dual-lead pacemaker with two leads in the right\n ventricle. The cardiac silhouette is enlarged, but not appreciably changed in\n the interval. The lung volumes are low. There are bilateral interstitial\n opacities, which appear slightly worsened than on the prior study. A right-\n sided PICC catheter is present, with tip at the region of the right subclavian\n vein. This is unchanged from multiple prior studies.\n\n IMPRESSION:\n\n Worsened congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-01-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890829,
"text": " 11:28 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate or effusion.\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with afib, endocarditis, CHF with tachypnea and SOB, 5L\n oxygen requirement. With new fever.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate or effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Afib, endocarditis, new fever.\n\n CHEST: Since the prior film of the 25th, there has been no change in\n the position of the various lines. Cardiomegaly persists. Bilateral\n effusions and interstitial alveolar infiltrates are present in both bases.\n Appearances suggest were failure though a concomitant pneumonia, particularly\n in the left lower lobe cannot be excluded. Appearances are not significantly\n changed since the prior chest x-ray of the 25th.\n\n IMPRESSION: Failure with or without the presence of pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 889443,
"text": " 8:29 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for worsening SDH or acute stroke\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with h/o SDH and A fib not on anticoagulation, now more\n somnolent\n REASON FOR THIS EXAMINATION:\n please evaluate for worsening SDH or acute stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT ON \n\n HISTORY: Somnolence.\n\n TECHNIQUE: Non-contrast head CT. Comparison with previous study from , .\n\n FINDINGS: Again seen is a small subdural fluid collection overlying the right\n cerebral hemisphere. Compared to the previous study, it is significantly\n smaller in size.\n\n Unchanged from the previous study, there is hypodensity in the left temporal\n fraction of the left middle cranial fossa consistent with an arachnoid cyst.\n There is an unchanged subacute to chronic hypodensity in the right basal\n ganglia consistent with a striate artery territory infarct. There is no\n finding to suggest an acute infarct. The defect in right frontal bone is\n consistent with a burr hole. Again, noted is an air-fluid level in the right\n sphenoid sinus, likely representing an ongoing inflammatory process.\n\n IMPRESSION: Improvement in the right subdural hematoma. No evidence of an\n acute hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-12-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 889903,
"text": " 9:22 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: INCREASED SOMNOLENCE, ? INCREASE IN SDH\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with known chronic sub dural hematoma, s/p fall 2 days ago, now\n with increased somnolence\n REASON FOR THIS EXAMINATION:\n ? increase in SDH, ? new bleed, ? signs of stroke\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 85-year-old male with chronic subdural hematoma status post fall\n two days ago. Now with increased somnolence.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: CT of the head without IV contrast.\n\n FINDINGS: There is again noted small right subdural hematoma, which is\n unchanged when compared to the prior study. There is no significant mass\n effect associated with it. There is again noted encephalomalacic changes in\n the right frontal region, which is unchanged when compared to the prior study.\n There are no findings to suggest an acute infarct. Patient is status post\n burr hole in the right frontal region. The appearance of the post-surgical\n changes is unchanged when compared to the prior study. The ventricles are\n stable in size.\n\n There are severe calcifications of the left vertebral artery.\n\n IMPRESSION: Stable appearance of the head.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 890632,
"text": " 9:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF worsening?\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with afib, endocarditis, CHF with tachypnea and SOB, 5L\n oxygen requirement.\n REASON FOR THIS EXAMINATION:\n CHF worsening?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Tachypnea and shortness of breath. Question worsening CHF.\n\n Examination is limited by extensive respiratory motion. By report, the\n patient was unable to cooperate with standard breath-holding for the\n procedure. A right PICC line remains in place, terminating in the region of\n the right axilla, and an ICD remains in place with leads in the right\n ventricle. The heart is enlarged but stable. There is apparent worsening\n perihilar haziness on the right and improving perihilar haziness on the left.\n Bilateral pleural effusions, left greater than right are unchanged.\n\n IMPRESSION: Worsening right perihilar and improving left perihilar haziness,\n which may be due to shifting asymmetric pulmonary edema. It is difficult to\n exclude underlying aspiration or pneumonia in the right perihilar region.\n Followup radiographs are suggested.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-11-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 885172,
"text": " 1:51 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: HEAD BLEED;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with SOB and CP\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: SOB, chest pain to evaluate for pneumonia.\n\n FINDINGS: Frontal and lateral radiographs of the chest reveal two-lead\n cardiac pacemaker in situ and cardiomegaly. Bilateral small pleural effusions\n are noted. Prominent interstitial markings likely due to pulmonary venous\n congestion. No evidence of pneumonia. Interval removal of the nasogastric\n tube and ETT noted.\n\n IMPRESSION: Pulmonary venous congestion. Bilateral small pleural effusions.\n\n\n"
}
] |
17,161 | 197,735 | The pt. was admitted on and underwent AVR(27mm Mosaic porcine valve)/replacement of ascending aorta/hemiarch(28mm Gelweave graft). The cross clamp time was 90 mins. and circ arrest was 18 mins., total bypass time was 116 mins. She was transferred to the CSRU in stable condition on Propofol and was extubated on the post op night. Her chest tubes were d/c'd on POD#1 and she was transferred to the floor. Her epicardial pacing wires were d/c'd on POD#3 and she was discharged to home in stable condition on POD#4. | CHEST, PA AND LATERAL: There is stable postoperative appearance of the cardiac, mediastinal, and hilar contours. Descending aorta intact.Ascending aorta tube graft is noted. There are simple atheroma in the descendingthoracic aorta. Cardiac silhouette remains enlarged as there is mild superior mediastinal widening. no difficulty swallowingendo; no coverage require overnocgu: adequate huo via foleywound: sternal wound cdi. IMPRESSION: Stable tiny left pleural effusion. The patient is now status post median sternotomy. Simple atheroma in descending aorta.AORTIC VALVE: Bicuspid aortic valve. hemodynamically stable,ci > 2. volume given for transient drop in svo2 with brisk huo,low filling pressures with effect.bp controlled with ntg. hct stable. Good biventricular systolic fxn. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Mt and Pleural Ct to sang drg-min amt, no leak. Mediastinal drains, a nasogastric tube, endotracheal tube and pulmonary arterial line are now in place. see careview for filling pressures/svr. Tiny residual left pleural effusion is stable. peripheral 2+edema. Left ventricular wall thicknesses, systolicfunction and cavity size are normal. pain controlp; monitor hemod. There has been interval development of a small left pleural effusion. follow NBP per pa e nillson. Interval development of small left pleural effusion. provided with sternal splinting pillow,surgical bra intact. Tubes and line in place. Right ventricular chamber size and freewall motion are normal. extubated to np's without incident. IMPRESSION: Widening of the superior mediastinum consistent with recent surgery. Osseous and soft tissue structures are unchanged. breathing even. support givena: pod #1, fast tracking, stable csru. No MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: No PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Apatent foramen ovale is present. The ascending aorta is markedly dilated, with apreserved sino-tubular junction. The aortic valve is bicuspid. The patient was under generalanesthesia throughout the procedure. Valvular heart disease.Status: InpatientDate/Time: at 10:03Test: 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: PFO is present.LEFT VENTRICLE: Normal LV wall thicknesses 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: Markedly dilated ascending aorta. skin w&d, palpable pulses. started on nitro briefly for sbp >120. pt con' to receive postop cefazolincv; nsr no ectopies. pulm toilet. deline. UPPER RIGHT PORTABLE CHEST RADIOGRAPH There has been interval removal of endotracheal tube, orogastric tube, Swan- Ganz catheter, and mediastinal drain/chest tubes without evidence of pneumothorax. mix venous recal high 60s. 10:19 AM CHEST (PA & LAT) Clip # Reason: evaluate effusion Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\REPLACEMENT ASCENDING AORTA & HEMIARCH;? There is widening of the superior mediastinum consistent with recent surgery. LINE PLACEMENT Clip # Reason: patient still in OR, ETA to CSRU is approximately 1.5 - 2 ho Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\REPLACEMENT ASCENDING AORTA & HEMIARCH;? I certifyI was present in compliance with HCFA regulations. IMPRESSION: Status post removal of multiple lines and tubes without evidence of pneumothorax. bra. Sinus rhythmNonspecific ST-T abnormalitiesSince previous tracing of , further ST-T wave changes present COMPARISON: . Comparison with . There is no pericardialeffusion.Post-CPB: A well-seated and functioning aortic valve prosthesis is in place.No leak, no AI. Comparison is made to prior radiograph dated and . support no deficit. gas good. need reminder to use Is. Results were personally reviewed with theMD caring for the patient.Conclusions:Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. pain control. neuro: pt a+ox3. The lungs remain clear. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. One portable view. id: low grade temp. no distressgi: tol ice chip & cl liquid. 1:11 PM CHEST (PORTABLE AP) Clip # Reason: r/o ptx chest tube removal Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\REPLACEMENT ASCENDING AORTA & HEMIARCH;? c/o sternal incisional pain and back pain (chronic) rate -gave morphine sulfate iv/sc, ketorolac, iv & started on percocet po-(able to dbc and use is ^750ml, no distress) maex4 to command. pneumo boots for dvt proph per attending.resp: ls cta, diminish both bases. ci>2. weak cough. ^diet & act. dipped transient to 58 with repostion but rebound quickly to baseline. Congenital heart disease. reluctant to deep or cough due to pain.medicated with morphine,will re-evaluate effect. Pulmonary vasculature is unremarkable. No TEE relatedcomplications. The TEE probe was passed with assistance from theanesthesioology staff using a laryngoscope. coccyx and heels intactsocial: daughter and brother visit at hs->status updated. Other parameters as pre-bypass. 1:32 PM CHEST PORT. The mitral valve leaflets aremildly thickened. No mitral regurgitation is seen. sat >98% on 4lnc. daughters & mom in,questions answered. art line wavefrom distorted/dampeend-unable to draw blood. There is no evidence of pulmonary edema or focal infiltrates. AVR/SDA MEDICAL CONDITION: 42 year old woman with s/p AVR, Replacement of Ascending Aorta REASON FOR THIS EXAMINATION: r/o ptx chest tube removal FINAL REPORT HISTORY: 42-year-old female status post AVR and replacement of ascending aorta status post chest tube removal. | 7 | [
{
"category": "Radiology",
"chartdate": "2121-04-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 961988,
"text": " 10:19 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\REPLACEMENT ASCENDING AORTA & HEMIARCH;? AVR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman s/p AVR Asc AO\n REASON FOR THIS EXAMINATION:\n evaluate effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old woman status post AVR, ascending aorta replacement.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: There is stable postoperative appearance of the\n cardiac, mediastinal, and hilar contours. Pulmonary vasculature is\n unremarkable. Tiny residual left pleural effusion is stable. Osseous and\n soft tissue structures are unchanged.\n\n IMPRESSION: Stable tiny left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-04-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961674,
"text": " 1:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx chest tube removal\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\REPLACEMENT ASCENDING AORTA & HEMIARCH;? AVR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with s/p AVR, Replacement of Ascending Aorta\n\n REASON FOR THIS EXAMINATION:\n r/o ptx chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 42-year-old female status post AVR and replacement of ascending\n aorta status post chest tube removal.\n\n Comparison is made to prior radiograph dated and .\n\n UPPER RIGHT PORTABLE CHEST RADIOGRAPH\n\n There has been interval removal of endotracheal tube, orogastric tube, Swan-\n Ganz catheter, and mediastinal drain/chest tubes without evidence of\n pneumothorax. Cardiac silhouette remains enlarged as there is mild superior\n mediastinal widening. There is no evidence of pulmonary edema or focal\n infiltrates. There has been interval development of a small left pleural\n effusion.\n\n IMPRESSION:\n\n Status post removal of multiple lines and tubes without evidence of\n pneumothorax. Interval development of small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2121-04-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 961516,
"text": " 1:32 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: patient still in OR, ETA to CSRU is approximately 1.5 - 2 ho\n Admitting Diagnosis: ASCENDING AORTIC ANEURYSM\\REPLACEMENT ASCENDING AORTA & HEMIARCH;? AVR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old woman with s/p AVR, Replacement of Ascending Aorta\n REASON FOR THIS EXAMINATION:\n patient still in OR, ETA to CSRU is approximately 1.5 - 2 hours, please call\n ahead - if results are of concern, please ()\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Postop aortic stenosis.\n\n One portable view. Comparison with . The lungs remain clear. The\n patient is now status post median sternotomy. There is widening of the\n superior mediastinum consistent with recent surgery. Mediastinal drains, a\n nasogastric tube, endotracheal tube and pulmonary arterial line are now in\n place.\n\n IMPRESSION: Widening of the superior mediastinum consistent with recent\n surgery. Tubes and line in place.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2121-04-24 00:00:00.000",
"description": "Report",
"row_id": 81905,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congenital heart disease. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 10:03\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: PFO is present.\n\nLEFT VENTRICLE: Normal LV wall thicknesses 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: Markedly dilated ascending aorta. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: 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. 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. Results were personally reviewed with the\nMD caring for the patient.\n\nConclusions:\nPre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. A\npatent foramen ovale is present. Left ventricular wall thicknesses, systolic\nfunction and cavity size are normal. Right ventricular chamber size and free\nwall motion are normal. The ascending aorta is markedly dilated, with a\npreserved sino-tubular junction. There are simple atheroma in the descending\nthoracic aorta. The aortic valve is bicuspid. The mitral valve leaflets are\nmildly thickened. No mitral regurgitation is seen. There is no pericardial\neffusion.\n\nPost-CPB: A well-seated and functioning aortic valve prosthesis is in place.\nNo leak, no AI. Good biventricular systolic fxn. Descending aorta intact.\nAscending aorta tube graft is noted. Other parameters as pre-bypass.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2121-04-24 00:00:00.000",
"description": "Report",
"row_id": 207839,
"text": "Sinus rhythm\nNonspecific ST-T abnormalities\nSince previous tracing of , further ST-T wave changes present\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-04-24 00:00:00.000",
"description": "Report",
"row_id": 1487408,
"text": "hemodynamically stable,ci > 2. volume given for transient drop in svo2 with brisk huo,low filling pressures with effect.bp controlled with ntg. extubated to np's without incident. reluctant to deep or cough due to pain.medicated with morphine,will re-evaluate effect. provided with sternal splinting pillow,surgical bra intact. daughters & mom in,questions answered. family instructed to take patient's tongue ring home & advised against further piercings .family is very concerned tongue hole will close up.\n"
},
{
"category": "Nursing/other",
"chartdate": "2121-04-25 00:00:00.000",
"description": "Report",
"row_id": 1487409,
"text": "neuro: pt a+ox3. needy/frequently ask to turn/repostion and ice chips. c/o sternal incisional pain and back pain (chronic) rate -gave morphine sulfate iv/sc, ketorolac, iv & started on percocet po-(able to dbc and use is ^750ml, no distress) maex4 to command. no deficit. \u0013\n\nid: low grade temp. pt con' to receive postop cefazolin\n\ncv; nsr no ectopies. started on nitro briefly for sbp >120. art line wavefrom distorted/dampeend-unable to draw blood. follow NBP per pa e nillson. ci>2. mix venous recal high 60s. dipped transient to 58 with repostion but rebound quickly to baseline. see careview for filling pressures/svr. hct stable. Mt and Pleural Ct to sang drg-min amt, no leak. peripheral 2+edema. skin w&d, palpable pulses. pneumo boots for dvt proph per attending.\n\nresp: ls cta, diminish both bases. breathing even. need reminder to use Is. weak cough. sat >98% on 4lnc. gas good. no distress\n\ngi: tol ice chip & cl liquid. no difficulty swallowing\nendo; no coverage require overnoc\ngu: adequate huo via foley\nwound: sternal wound cdi. bra. coccyx and heels intact\nsocial: daughter and brother visit at hs->status updated. support given\n\na: pod #1, fast tracking, stable csru. pain control\np; monitor hemod. deline. pulm toilet. ^diet & act. pain control. (pt take vicodin at home for back pain). support\n"
}
] |
26,996 | 119,919 | Patient admitted for elevated glucose without evidence of DKA or anion gap. Patient was started on an insulin drip in the ED and continued on it in the ICU. She had no evidence of infection with normal UA and CXR. Upon arrival in the ICU, she was started on long acting insulin and given fluids. Her potassium and magnesium were repleted. Her glucose came down to 190's. Patient was discharged feeling well and tolerating normal diet without nausea or vomiting. | URINE CLEAR.NEURO: ALERT AND ORIENTATED.ENDO: BS'S STABLE. CHEST, PA AND LATERAL: The cardiac and mediastinal contours are within normal limits. O2 SATS 100% ON RA.GI; NO N/V. RSR' pattern inlead V1. N/V subsided.Arrived alert and in no acute distress. APPETITE GOOD.RENAL: VOIDING IN MOD-SM AMTS. No pain.CV: hemodynamically stable, HR 90s-100s, no ectopy.Resp: LS clear. RESP: BS'S CLEAR. Good sats on RA.GI: +BS, abd soft, nt. Also received Zofran x1. The pulmonary vasculature is within normal limits. am FS 150, no coverage given.Neuro: A&Ox3. went home early am, will return ~ 1130.Plan: Monitor FS. Insulin gtt d/c'd last eve, placed on SS and fixed NPH. Consider left atrial abnormality. PT. FS 274. GIVEN 2U REG SC FOR BS OF 157 AT NOONTIME.PLAN: PT. Currently speaking to ICU MD. Med soft, brown stool.GU: Urine amber, adequate. voiding in bedpan.Social: Mother remained c pt all noc. .45NS w/20MEQs KCl infusing at 200cc/hr.Gd O2sats on RA. Given 6u Humalog and gtt dc'd. Probable call out or . MICU EAST NSG ADMIT NOTE 1630-1900addendum.Mother arrived at 1900. speaks English well. There are no pleural effusions. The lungs are clear. Difficult to understand her speech at times but denied pain and followed commands.Arrived with Insulin gtt at 6u/hr. Afebrile.Mother did not accompany dgt to ICU.Plan to monitor FSs closely overnight. MICU EAST NSG ADMIT NOTE 1630-1900Please see flowsheet and FHPA for further info.28 yo woman with Down Syndrome and DM presented to ED w/ N/V and glucose >500 though no gap. IMPRESSION: No radiographic evidence of pneumonia. Treated with IVFs and an Insulin gtt. COMPARISONS: None. NPN 1900-070028 yo fe w Down Syndrome and DM, to ER w glucose >500 and N/V, given iv flds and insulin gtt. No previous tracing available for comparison. DISCHARGED WITH HER MOTHER AT 13:45PM. Sinus tachycardia. HAD LUNCH PRIOR TO DISCHARGE. Ate full dinner last eve, no n/v. Speech sometimes diff to understand. | 6 | [
{
"category": "Radiology",
"chartdate": "2128-09-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 983981,
"text": " 10:19 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for infection, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 28 year old woman with DM-I, down's syndrome, p/w nausea, vomiting, and\n hyperglycemia\n REASON FOR THIS EXAMINATION:\n assess for infection, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetes mellitus, Down syndrome, nausea, vomiting,\n hyperglycemia.\n\n COMPARISONS: None.\n\n CHEST, PA AND LATERAL: The cardiac and mediastinal contours are within normal\n limits. The lungs are clear. There are no pleural effusions. The pulmonary\n vasculature is within normal limits.\n\n IMPRESSION: No radiographic evidence of pneumonia.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-09-23 00:00:00.000",
"description": "Report",
"row_id": 1615154,
"text": "MICU EAST NSG ADMIT NOTE 1630-1900\n\nPlease see flowsheet and FHPA for further info.\n\n\n28 yo woman with Down Syndrome and DM presented to ED w/ N/V and glucose >500 though no gap. Treated with IVFs and an Insulin gtt. Also received Zofran x1. N/V subsided.\n\nArrived alert and in no acute distress. Difficult to understand her speech at times but denied pain and followed commands.\n\nArrived with Insulin gtt at 6u/hr. FS 274. Given 6u Humalog and gtt dc'd. .45NS w/20MEQs KCl infusing at 200cc/hr.\n\nGd O2sats on RA. Afebrile.\n\nMother did not accompany dgt to ICU.\n\nPlan to monitor FSs closely overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-09-23 00:00:00.000",
"description": "Report",
"row_id": 1615155,
"text": "MICU EAST NSG ADMIT NOTE 1630-1900\naddendum.\n\nMother arrived at 1900. speaks English well. Currently speaking to ICU MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-09-24 00:00:00.000",
"description": "Report",
"row_id": 1615156,
"text": "NPN 1900-0700\n28 yo fe w Down Syndrome and DM, to ER w glucose >500 and N/V, given iv flds and insulin gtt. Insulin gtt d/c'd last eve, placed on SS and fixed NPH. am FS 150, no coverage given.\n\nNeuro: A&Ox3. Speech sometimes diff to understand. No pain.\n\nCV: hemodynamically stable, HR 90s-100s, no ectopy.\n\nResp: LS clear. Good sats on RA.\n\nGI: +BS, abd soft, nt. Ate full dinner last eve, no n/v. Med soft, brown stool.\n\nGU: Urine amber, adequate.\u0013 voiding in bedpan.\n\nSocial: Mother remained c pt all noc. went home early am, will return ~ 1130.\n\nPlan: Monitor FS. Probable call out or .\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-09-24 00:00:00.000",
"description": "Report",
"row_id": 1615157,
"text": "RESP: BS'S CLEAR. O2 SATS 100% ON RA.\nGI; NO N/V. APPETITE GOOD.\nRENAL: VOIDING IN MOD-SM AMTS. URINE CLEAR.\nNEURO: ALERT AND ORIENTATED.\nENDO: BS'S STABLE. GIVEN 2U REG SC FOR BS OF 157 AT NOONTIME.\nPLAN: PT. DISCHARGED WITH HER MOTHER AT 13:45PM. PT. HAD LUNCH PRIOR TO DISCHARGE.\n"
},
{
"category": "ECG",
"chartdate": "2128-09-23 00:00:00.000",
"description": "Report",
"row_id": 208880,
"text": "Sinus tachycardia. Consider left atrial abnormality. RSR' pattern in\nlead V1. No previous tracing available for comparison.\n\n"
}
] |
28,270 | 138,355 | Patient arrived to the ER with T F, HR 66 BP 167/97 RR 18 SpO2 96%; EKG had NSR @68 bmp, axis -30, no abnormalities. She was given IVF and IV morphine for pain control. A CT scan of the head did not show any abnormalities. Lab values were remarkable for a creatinine of 10.6 from a baseline of ~3.8 at (from outside records). A CT of the abdomen showed atherosclerosis. Patient was admitted to the medicine floor and then triggered for nursing concern, difficulty breathing and AMS and was transfered to the MICU. . In the MICU all sedating medicines were held, pt had a CXR with cardiomegaly without any other acute process. She was hydrated. In the MICU patient required CPAP for ventilatory support. Nephrology was consulted for the need of hemodialysis. Patient had a right hemodialysis catheter put in place, but was never used. The AMS was most likely due to uremia and acute pre-renal renal failure, that improved with medical management with hydration. There was no evidence for infection or toxic process. Patient became acidotic, but improved as the creatinine trended down. 5 days after MICU admission the patient was transfered to the medicine floor. . In the medical floor, patient was encouraged to have liquids PO and diet was advanced slowly. Creatinine was followd and trend dow up to 5.0 upon discharge. HD line was removed. PT was consulted and cleared her to go home. . | # GERD: PPI . # GERD: PPI . Exam most consistent with delirum. Exam most consistent with delirum. Respiratory failure, acute (not ARDS/) Assessment: Received pt on BIPAP. Action: Allevyn dsg in place to RLE. Action: Allevyn dsg in place to RLE. Action: Allevyn dsg in place to RLE. Action: Allevyn dsg in place to RLE. Action: Allevyn dsg in place to RLE. Altered mental status: neg non con head CT. Altered mental status: neg non con head CT. CAD, and HTN who presents w/ altered mental status and ARF. CAD, and HTN who presents w/ altered mental status and ARF. CAD, and HTN who presents w/ altered mental status and ARF. # HTN: Metoprolol as above. # HTN: Metoprolol as above. Plan: Will need dialysis. Plan: Will need dialysis. Recent Rx with Remacaid. Recent Rx with Remacaid. Respiratory failure, acute (not ARDS/) Assessment: LS CTA. Respiratory failure, acute (not ARDS/) Assessment: LS CTA. Respiratory failure, acute (not ARDS/) Assessment: LS CTA. Respiratory failure, acute (not ARDS/) Assessment: LS CTA. Respiratory failure, acute (not ARDS/) Assessment: LS CTA. Hold CCB until pt's clinical direction more clear. Hold CCB until pt's clinical direction more clear. .H/O renal failure, acute (Acute renal failure, ARF) Assessment: BUN/CRE with slow improvement. .H/O renal failure, acute (Acute renal failure, ARF) Assessment: BUN/CRE with slow improvement. .H/O renal failure, acute (Acute renal failure, ARF) Assessment: BUN/CRE with slow improvement. .H/O renal failure, acute (Acute renal failure, ARF) Assessment: BUN/CRE with slow improvement. Plan: Mental status expected to clear with dialysis. Respiratory failure, acute (not ARDS/) Assessment: Received pt on BIPAP. Altered mental status: neg non con head CT. Respiratory failure, acute (not ARDS/) Assessment: Pts resp status is labored, Pt. Hyperkalemia (high Potassium, Hyperpotassemia) Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: .H/O renal failure, acute (Acute renal failure, ARF) Assessment: Action: Response: Plan: require HD line placement and HD if no improvement. require HD line placement and HD if no improvement. # HTN: Metoprolol as above. # HTN: Metoprolol as above. # HTN: Metoprolol as above. # HTN: Metoprolol as above. Hold CCB until pt's clinical direction more clear. Hold CCB until pt's clinical direction more clear. Hold CCB until pt's clinical direction more clear. Hold CCB until pt's clinical direction more clear. CAD, and HTN who presents w/ altered mental status and ARF. CAD, and HTN who presents w/ altered mental status and ARF. CAD, and HTN who presents w/ altered mental status and ARF. CAD, and HTN who presents w/ altered mental status and ARF. # GERD: PPI . Altered mental status (not Delirium) Assessment: Periods of alertness followed by lethargy and somnalance. Altered mental status (not Delirium) Assessment: Periods of alertness followed by lethargy and somnalance. Exam most consistent with delirum. Resp Distress: intermittent hypoxemia which resolves with waking. Respiratory failure, acute (not ARDS/) Assessment: Action: Response: Plan: .H/O acidosis, Metabolic Assessment: Action: Response: Plan: Impaired Skin Integrity Assessment: Action: Response: Plan: Altered mental status (not Delirium) Assessment: Action: Response: Plan: .H/O renal failure, acute (Acute renal failure, ARF) Assessment: Action: Response: Plan: Respiratory failure, acute (not ARDS/) Assessment: Received pt on BIPAP. Respiratory failure, acute (not ARDS/) Assessment: Received pt on BIPAP. Plan: Mental status expected to clear with dialysis. Plan: Mental status expected to clear with dialysis. Temporary hemodialysis catheter was requested. - appreciate renal input - check FeNa; consider emperic volume repletion with NS in interim - consider PO bicarb - abd/pelvis CT scan in AM - renally dose all meds; avoid nephrotoxins; exchange atenolol for metoprolol and hold Topamax as these are renally cleared . PFI REPORT Uncomplicated temporary hemodialysis catheter placement. FINDINGS: NON-CONTRAST CT OF THE ABDOMEN: There is bibasilar dependent atelectasis. IMPRESSION: Uncomplicated placement of a temporary hemodialysis catheter via the right internal jugular venous approach. Admitting Diagnosis: ACUTE RENAL FAILURE ********************************* CPT Codes ******************************** * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE * * US GUID FOR VAS. Admitting Diagnosis: ACUTE RENAL FAILURE FINAL REPORT (Cont) Plan: Will need dialysis. Plan: Will need dialysis. Plan: Will need dialysis. Plan: Will need dialysis. Altered mental status (not Delirium) Assessment: Pt noted to be lethargic, combative and tearful at times- may be d/t uremia. Altered mental status (not Delirium) Assessment: Pt noted to be lethargic, combative and tearful at times- may be d/t uremia. Hold CCB until pt's clinical direction more clear. - MS appears to be improving; could consider Narcan PRN - hold all sedating meds - check CXR . | 54 | [
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336841,
"text": "Chief Complaint: altered mental status\n HPI:\n Pt is a 52 y/o female w/ a hx of DM, HTN, ? CVA who is brought in by\n her son due to altered mental status. The patient receives all of her\n care at and is unable to answer questions. In the few days prior to\n presentation, patient has had nausea/vomiting/diarrhea and inability to\n tolerate POs. On the day of presentation, patient's son found patient\n confused, w/ poor concentration and perseveration, and was\n intermittently following commands and described by EMS as lethargic. No\n focal neurological deficits were noted otherwise. Patient has not had\n any fevers, neck stiffness, headaches, or blurred vision. She has\n standing narcotics on medication regimen, for unclear reasons. She has\n no history of trauma.\n In the ED, T97 HR 72 BP 176/61 O2 98% on RA. She was found to be in new\n ARF. She was given IVF and IV morphine for pain control, and admitted\n to medicine for further management.\n .H/O acidosis, Metabolic\n Assessment:\n PH improving, 7.31/44/40 (vbg).\n Action:\n Cont. to monitor. PM lytes planned. Renal following, no indication for\n HD at present.\n Response:\n Awaiting results/labs.\n Plan:\n Cont. to monitor.\n Impaired Skin Integrity\n Assessment:\n Bilat. lower extrem. venous stasis ulcers. Right leg ulcer with green,\n purulent drainage.\n Action:\n Allevyn dsg in place to RLE. LLE with Aquacel AG in place, cleansed w/\n NS, wrapped in cling. Wound care following.\n Response:\n Awaiting effect.\n Plan:\n Wound care cont. to follow. Awaiting effect.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS CTA. Sats wnl. No cough or sob noted. Occ. desats when sleeping.\n Action:\n Bipap at night for OSA.\n Response:\n Well tolerated, improved acidosis.\n Plan:\n require formal sleep study for insurance purposes, and for\n outpatient bipap machine.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Serum K+ 4.3.\n Action:\n HD line in place, however no indication for HD at this time per Renal.\n Response:\n Well tolerated.\n Plan:\n Cont. to monitor.\n Altered mental status (not Delirium)\n Assessment:\n MS labile, distrustful, anxious, and crying at times. Alert oriented\n x3 most of time, occ. confused.\n Action:\n Bicarb. Gtt completed. Plan for PM labs.\n Response:\n MS improving.\n Plan:\n Cont. to monitor.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/CRE with slow improvement.\n Action:\n Renal following. No plans for immediate HD, as felt is may limit any\n self preservation potential of the kidneys.\n Response:\n Slight improvement.\n Plan:\n Follow labs. Appreciate Renal reqs.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ACUTE RENAL FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 66.4 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: unable to obtain history\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:80\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,997 mL\n 24h total out:\n 1,470 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 05:26 AM\n Potassium:\n 4.3 mEq/L\n 05:26 AM\n Chloride:\n 110 mEq/L\n 05:26 AM\n CO2:\n 21 mEq/L\n 05:26 AM\n BUN:\n 79 mg/dL\n 05:26 AM\n Creatinine:\n 8.9 mg/dL\n 05:26 AM\n Glucose:\n 104 mg/dL\n 05:26 AM\n Hematocrit:\n 28.4 %\n 05:26 AM\n Finger Stick Glucose:\n 118\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336842,
"text": "Chief Complaint: altered mental status\n HPI:\n Pt is a 52 y/o female w/ a hx of DM, HTN, ? CVA who is brought in by\n her son due to altered mental status. The patient receives all of her\n care at and is unable to answer questions. In the few days prior to\n presentation, patient has had nausea/vomiting/diarrhea and inability to\n tolerate POs. On the day of presentation, patient's son found patient\n confused, w/ poor concentration and perseveration, and was\n intermittently following commands and described by EMS as lethargic. No\n focal neurological deficits were noted otherwise. Patient has not had\n any fevers, neck stiffness, headaches, or blurred vision. She has\n standing narcotics on medication regimen, for unclear reasons. She has\n no history of trauma.\n In the ED, T97 HR 72 BP 176/61 O2 98% on RA. She was found to be in new\n ARF. She was given IVF and IV morphine for pain control, and admitted\n to medicine for further management.\n .H/O acidosis, Metabolic\n Assessment:\n PH improving, 7.31/44/40 (vbg).\n Action:\n Cont. to monitor. PM lytes planned. Renal following, no indication for\n HD at present.\n Response:\n Awaiting results/labs.\n Plan:\n Cont. to monitor.\n Impaired Skin Integrity\n Assessment:\n Bilat. lower extrem. venous stasis ulcers. Right leg ulcer with green,\n purulent drainage.\n Action:\n Allevyn dsg in place to RLE. LLE with Aquacel AG in place, cleansed w/\n NS, wrapped in cling. Wound care following.\n Response:\n Awaiting effect.\n Plan:\n Wound care cont. to follow. Awaiting effect.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS CTA. Sats wnl. No cough or sob noted. Occ. desats when sleeping.\n Action:\n Bipap at night for OSA.\n Response:\n Well tolerated, improved acidosis.\n Plan:\n require formal sleep study for insurance purposes, and for\n outpatient bipap machine.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Serum K+ 4.3.\n Action:\n HD line in place, however no indication for HD at this time per Renal.\n Response:\n Well tolerated.\n Plan:\n Cont. to monitor.\n Altered mental status (not Delirium)\n Assessment:\n MS labile, distrustful, anxious, and crying at times. Alert oriented\n x3 most of time, occ. confused.\n Action:\n Bicarb. Gtt completed. Plan for PM labs.\n Response:\n MS improving.\n Plan:\n Cont. to monitor.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/CRE with slow improvement.\n Action:\n Renal following. No plans for immediate HD, as felt is may limit any\n self preservation potential of the kidneys.\n Response:\n Slight improvement.\n Plan:\n Follow labs. Appreciate Renal reqs.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ACUTE RENAL FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 66.4 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: unable to obtain history\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:80\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,997 mL\n 24h total out:\n 1,470 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 05:26 AM\n Potassium:\n 4.3 mEq/L\n 05:26 AM\n Chloride:\n 110 mEq/L\n 05:26 AM\n CO2:\n 21 mEq/L\n 05:26 AM\n BUN:\n 79 mg/dL\n 05:26 AM\n Creatinine:\n 8.9 mg/dL\n 05:26 AM\n Glucose:\n 104 mg/dL\n 05:26 AM\n Hematocrit:\n 28.4 %\n 05:26 AM\n Finger Stick Glucose:\n 118\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Respiratory ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 336660,
"text": "Pt placed on cpap of 8 cmh20 through Nasal mask for the night. Pt\n sleeping comfortably. Will continue to monitor.\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 336662,
"text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 03:00 PM\n IR placement\n Given D5W with 3 amps bicarb, good uop\n Refused PO hydral during day, persistently hypertensive, got 2 doses IV\n hydral, BPs still in 180-190s overnight. BB increased.\n Pt tolerated Bipap overnight.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 07:45 PM\n Heparin Sodium (Prophylaxis) - 10:54 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 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: 68 (66 - 79) bpm\n BP: 157/69(88) {157/67(88) - 200/124(168)} mmHg\n RR: 21 (6 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,037 mL\n 595 mL\n PO:\n 160 mL\n TF:\n IVF:\n 2,877 mL\n 595 mL\n Blood products:\n Total out:\n 3,065 mL\n 560 mL\n Urine:\n 3,065 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -28 mL\n 35 mL\n Respiratory support\n SpO2: 95%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 294 K/uL\n 9.2 g/dL\n 134 mg/dL\n 9.4 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 81 mg/dL\n 110 mEq/L\n 142 mEq/L\n 28.4 %\n 9.5 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n 10:37 AM\n 08:01 PM\n WBC\n 12.0\n 10.1\n 9.5\n Hct\n 31.7\n 30.6\n 28.4\n Plt\n 299\n 280\n 294\n Cr\n 10.6\n 10.3\n 9.7\n 9.4\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n 76\n 134\n Other labs: CK / CKMB / Troponin-T:73//0.07, Differential-Neuts:72.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:12.0 %, Eos:2.0 %, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:30 AM\n Dialysis Catheter - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336710,
"text": ".H/O acidosis, Metabolic\n Assessment:\n Metabolic Acidosis\n Action:\n Bicarb gtt (150MEQ in D5)\n Response:\n Improving PH\n Plan:\n Continue Bicarb gtt\n Impaired Skin Integrity\n Assessment:\n Bilateral lower ext. ulcers\n Action:\n Dressing changed as per skin care directives\n Response:\n Pt tolerated well. Bandage is clean, dry and intact.\n Plan:\n Continue daily dressing changes as per skin care directives.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on BIPAP.\n Action:\n Pt currently on RA.\n Response:\n NAD distress.\n Plan:\n Will continue BIPAP when sleeping.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n 5.3 K\n Action:\n Temporary dialysis line placed in IR\n Response:\n Pt tolerated well. Line is secure and patent.\n Plan:\n Will need dialysis. Continue to monitor lytes.\n Altered mental status (not Delirium)\n Assessment:\n Pt noted to be lethargic, combative and tearful at times- may be d/t\n uremia.\n Action:\n Maintain safety, reassure as needed.\n Response:\n Calmer when family is at bedside.\n Plan:\n Mental status expected to clear with dialysis.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Increasing BUN and Creatinine\n Action:\n Continue to monitor lytes. Renal consult\n Response:\n Continues to be in Renal failure.\n Plan:\n Will need dialysis.\n 52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED by EMS for altered mental status. Pt received\n all usual care at - on diversion. No records. Was in USOH until\n Saturday with diarrhea, Nausea, vomiting. Noted to be confused and\n repeating herself. Son found her with worsening mental status and\n called 911.\n In our ED creatinine was 10.\nAlso noted to have lower ext ulcers - ?\n pyoderma gangrenosum. Initially admitted to 7 but triggered for\n somnolence and tx to MICU for further management.\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336821,
"text": "Chief Complaint: altered mental status\n HPI:\n Pt is a 52 y/o female w/ a hx of DM, HTN, ? CVA who is brought in by\n her son due to altered mental status. The patient receives all of her\n care at and is unable to answer questions. In the few days prior to\n presentation, patient has had nausea/vomiting/diarrhea and inability to\n tolerate POs. On the day of presentation, patient's son found patient\n confused, w/ poor concentration and perseveration, and was\n intermittently following commands and described by EMS as lethargic. No\n focal neurological deficits were noted otherwise. Patient has not had\n any fevers, neck stiffness, headaches, or blurred vision. She has\n standing narcotics on medication regimen, for unclear reasons. She has\n no history of trauma.\n In the ED, T97 HR 72 BP 176/61 O2 98% on RA. She was found to be in new\n ARF. She was given IVF and IV morphine for pain control, and admitted\n to medicine for further management.\n .H/O acidosis, Metabolic\n Assessment:\n PH improving, 7.31/44/40 (vbg).\n Action:\n Cont. to monitor. PM lytes planned. Renal following, no indication for\n HD at present.\n Response:\n Awaiting results/labs.\n Plan:\n Cont. to monitor.\n Impaired Skin Integrity\n Assessment:\n Bilat. lower extrem. venous stasis ulcers. Right leg ulcer with green,\n purulent drainage.\n Action:\n Allevyn dsg in place to RLE. LLE with Aquacel AG in place, cleansed w/\n NS, wrapped in cling. Wound care following.\n Response:\n Awaiting effect.\n Plan:\n Wound care cont. to follow. Awaiting effect.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS CTA. Sats wnl. No cough or sob noted. Occ. desats when sleeping.\n Action:\n Bipap at night for OSA.\n Response:\n Well tolerated, improved acidosis.\n Plan:\n require formal sleep study for insurance purposes, and for\n outpatient bipap machine.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Serum K+ 4.3.\n Action:\n HD line in place, however no indication for HD at this time per Renal.\n Response:\n Well tolerated.\n Plan:\n Cont. to monitor.\n Altered mental status (not Delirium)\n Assessment:\n MS labile, distrustful, anxious, and crying at times. Alert oriented\n x3 most of time, occ. confused.\n Action:\n Bicarb. Gtt completed. Plan for PM labs.\n Response:\n MS improving.\n Plan:\n Cont. to monitor.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/CRE with slow improvement.\n Action:\n Renal following. No plans for immediate HD, as felt is may limit any\n self preservation potential of the kidneys.\n Response:\n Slight improvement.\n Plan:\n Follow labs. Appreciate Renal reqs.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n ACUTE RENAL FAILURE\n Code status:\n Full code\n Height:\n Admission weight:\n 66.4 kg\n Daily weight:\n Allergies/Reactions:\n Precautions: No Additional Precautions\n PMH: Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: unable to obtain history\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:99\n D:80\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 1,997 mL\n 24h total out:\n 1,470 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 05:26 AM\n Potassium:\n 4.3 mEq/L\n 05:26 AM\n Chloride:\n 110 mEq/L\n 05:26 AM\n CO2:\n 21 mEq/L\n 05:26 AM\n BUN:\n 79 mg/dL\n 05:26 AM\n Creatinine:\n 8.9 mg/dL\n 05:26 AM\n Glucose:\n 104 mg/dL\n 05:26 AM\n Hematocrit:\n 28.4 %\n 05:26 AM\n Finger Stick Glucose:\n 118\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336808,
"text": "Pt is a 52 y/o female w/ a hx of DM, HTN, ?CVA, who is brought in by\n her son\n .H/O acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 336813,
"text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 03:00 PM\n IR placement\n Given D5W with 3 amps bicarb, good uop\n Refused PO hydral during day, persistently hypertensive, got 2 doses IV\n hydral, BPs still in 180-190s overnight. BB increased.\n Pt tolerated Bipap overnight.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 07:45 PM\n Heparin Sodium (Prophylaxis) - 10:54 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 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: 68 (66 - 79) bpm\n BP: 157/69(88) {157/67(88) - 200/124(168)} mmHg\n RR: 21 (6 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,037 mL\n 595 mL\n PO:\n 160 mL\n TF:\n IVF:\n 2,877 mL\n 595 mL\n Blood products:\n Total out:\n 3,065 mL\n 560 mL\n Urine:\n 3,065 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -28 mL\n 35 mL\n Respiratory support\n SpO2: 95%\n ABG: ///18/\n Physical Examination\n GEN: Obese AA female, snoring loudly, opens eyes to name call, unable\n to answer questions\n HEENT: NCAT, EOMI, pin-point pupils, wide neck\n NECK: Supple, no LAD, no appreciable JVD\n CV: RRR, normal S1S2, 4/6 SEM, no rubs or gallops\n PULM: CTAB, no w/r/r, good air movement bilaterally\n ABD: Obese Soft, NTND, normoactive bowel sounds, no organomegaly, no\n abdominal bruit appreciated\n EXT: Warm and well perfused, full and symmetric distal pulses, no pedal\n edema. Legs bandaged.\n NEURO: EOMI, moves all 4 extremities upon request. Otherwise not\n cooperative with exam. 2+ patellar reflex. Downgoing toes b/l.\n Labs / Radiology\n 294 K/uL\n 9.2 g/dL\n 134 mg/dL\n 9.4 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 81 mg/dL\n 110 mEq/L\n 142 mEq/L\n 28.4 %\n 9.5 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n 10:37 AM\n 08:01 PM\n WBC\n 12.0\n 10.1\n 9.5\n Hct\n 31.7\n 30.6\n 28.4\n Plt\n 299\n 280\n 294\n Cr\n 10.6\n 10.3\n 9.7\n 9.4\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n 76\n 134\n Other labs: CK / CKMB / Troponin-T:73//0.07, Differential-Neuts:72.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:12.0 %, Eos:2.0 %, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n 52 y/o female w/ hx of CVA, DM, ? CAD, and HTN who presents w/ altered\n mental status and ARF.\n .\n # Altered Mental Status: Suspect most likely second to uremia from ARF.\n Currently no evidence to suggest infection or toxic process. MS is now\n slowly improving.\n - continue to hold all sedating meds\n - monitor renal function; currently slowly improving\n -appreciate renal input; given improvement, plan to defer HD for now\n .\n # Acute on chronic renal failure: Suspect acute worsening of underlying\n poor renal function likely due to pre-renal azotemia. Pt has continued\n to make adequate urine however her renal failure is not improving.\n - appreciate renal input; continue to defer HD at the present time\n - volume repletion PRN\n - abd/pelvis scan without evidence obstruction\n - renally dose all meds; avoid nephrotoxins; exchange atenolol for\n metoprolol and hold Topamax as these are renally cleared\n .\n # AG acidosis: Much improved; thought to be due to ARF. No evidence to\n support other cause such as lactic acidosis, ketoacidosis or toxin\n ingestion.\n - hold fluid hydration at present and allow pt to drink to thirst\n - continue to trend\n - currently no plans for HD as described above\n .\n # LE wounds/PG: Appreciate wound care consult. Continue to monitor.\n .\n # DM: Continue pt's home insulin (decrease dose) with ISS.\n .\n # CAD: Continue home ASA; transition atenolol to metoprolol.\n .\n # HTN: Transition metoprolol to labetalol today. Titrate up based on\n BP.\n .\n # GERD: PPI\n ICU Care\n Nutrition: PO diet\n Glycemic Control: sugars well controlled\n Lines:\n 20 Gauge - 03:30 AM\n Dialysis Catheter - 03:00 PM\n Prophylaxis:\n DVT: hep subq\n Stress ulcer: PPI\n Code status: Full code\n Disposition: c/o to floor today\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336814,
"text": "Chief Complaint: acute renal faiuliure delirium\n I saw and examined the patient, and was physically present with the 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 DIALYSIS CATHETER - START 03:00 PM\n IR placement\n Persistent good UOP\n Tolerated BIPAP well overnight\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 07:45 PM\n Heparin Sodium (Prophylaxis) - 05:57 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 63 (63 - 79) bpm\n BP: 180/89(113) {157/67(88) - 200/124(113)} mmHg\n RR: 21 (6 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,042 mL\n 1,117 mL\n PO:\n 160 mL\n 100 mL\n TF:\n IVF:\n 2,882 mL\n 1,017 mL\n Blood products:\n Total out:\n 3,065 mL\n 960 mL\n Urine:\n 3,065 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -23 mL\n 157 mL\n Respiratory support\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n Pt currently refuses exam\n She is in NAD\n she is oriented to and her family\n but then shortly after asking\n for people who work at \n Labs / Radiology\n 9.2 g/dL\n 298 K/uL\n 104 mg/dL\n 8.9 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 79 mg/dL\n 110 mEq/L\n 144 mEq/L\n 28.4 %\n 9.0 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n 10:37 AM\n 08:01 PM\n 05:26 AM\n WBC\n 12.0\n 10.1\n 9.5\n 9.0\n Hct\n 31.7\n 30.6\n 28.4\n 28.4\n Plt\n 299\n 280\n 294\n 298\n Cr\n 10.6\n 10.3\n 9.7\n 9.4\n 8.9\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n 76\n 134\n 104\n Other labs: CK / CKMB / Troponin-T:73//0.07, Differential-Neuts:72.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:12.0 %, Eos:2.0 %, Ca++:8.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan 52 yo female CVA, DM, CRI with Acute on chronic\n renal failure.\n 1)Renal: continues to have good UOP, today she has some improvement in\n Cr, BUN coming down, VBG shows improvement in acidosis\n albeit on\n continuous bicarb- discus with renal role of po bicitra. Discussed with\n renal team and they still would like to continue to hold off on HD for\n now\n will need to watch how she does as we stop resuscitation.\n 2) OSA: BIPAP at night auto titrate\n 3) Delirium: mixed with uremia, acidosis, and med effect. More alert,\n follow exam closely.\n 4) HTN: start po labetalol\n 4)DM-continue insulin, trend blood sugars\n 5)CV: continue lopressor, ASA\n 6)Wound care-wound care following\n ICU Care\n Nutrition: renal diet\n Glycemic Control: glargine and SSRI\n Lines:\n Dialysis Catheter - 03:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Communication: with family\n Code status: Full code\n Disposition : tx to floor\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336815,
"text": "Chief Complaint: altered mental status\n HPI:\n Pt is a 52 y/o female w/ a hx of DM, HTN, ? CVA who is brought in by\n her son due to altered mental status. The patient receives all of her\n care at and is unable to answer questions. In the few days prior to\n presentation, patient has had nausea/vomiting/diarrhea and inability to\n tolerate POs. On the day of presentation, patient's son found patient\n confused, w/ poor concentration and perseveration, and was\n intermittently following commands and described by EMS as lethargic. No\n focal neurological deficits were noted otherwise. Patient has not had\n any fevers, neck stiffness, headaches, or blurred vision. She has\n standing narcotics on medication regimen, for unclear reasons. She has\n no history of trauma.\n In the ED, T97 HR 72 BP 176/61 O2 98% on RA. She was found to be in new\n ARF. She was given IVF and IV morphine for pain control, and admitted\n to medicine for further management.\n .H/O acidosis, Metabolic\n Assessment:\n PH improving, 7.31/44/40 (vbg).\n Action:\n Cont. to monitor. PM lytes planned. Renal following, no indication for\n HD at present.\n Response:\n Awaiting results/labs.\n Plan:\n Cont. to monitor.\n Impaired Skin Integrity\n Assessment:\n Bilat. lower extrem. venous stasis ulcers. Right leg ulcer with green,\n purulent drainage.\n Action:\n Allevyn dsg in place to RLE. LLE with Aquacel AG in place, cleansed w/\n NS, wrapped in cling. Wound care following.\n Response:\n Awaiting effect.\n Plan:\n Wound care cont. to follow. Awaiting effect.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS CTA. Sats wnl. No cough or sob noted. Occ. desats when sleeping.\n Action:\n Bipap at night for OSA.\n Response:\n Well tolerated, improved acidosis.\n Plan:\n require formal sleep study for insurance purposes, and for\n outpatient bipap machine.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336817,
"text": "Chief Complaint: altered mental status\n HPI:\n Pt is a 52 y/o female w/ a hx of DM, HTN, ? CVA who is brought in by\n her son due to altered mental status. The patient receives all of her\n care at and is unable to answer questions. In the few days prior to\n presentation, patient has had nausea/vomiting/diarrhea and inability to\n tolerate POs. On the day of presentation, patient's son found patient\n confused, w/ poor concentration and perseveration, and was\n intermittently following commands and described by EMS as lethargic. No\n focal neurological deficits were noted otherwise. Patient has not had\n any fevers, neck stiffness, headaches, or blurred vision. She has\n standing narcotics on medication regimen, for unclear reasons. She has\n no history of trauma.\n In the ED, T97 HR 72 BP 176/61 O2 98% on RA. She was found to be in new\n ARF. She was given IVF and IV morphine for pain control, and admitted\n to medicine for further management.\n .H/O acidosis, Metabolic\n Assessment:\n PH improving, 7.31/44/40 (vbg).\n Action:\n Cont. to monitor. PM lytes planned. Renal following, no indication for\n HD at present.\n Response:\n Awaiting results/labs.\n Plan:\n Cont. to monitor.\n Impaired Skin Integrity\n Assessment:\n Bilat. lower extrem. venous stasis ulcers. Right leg ulcer with green,\n purulent drainage.\n Action:\n Allevyn dsg in place to RLE. LLE with Aquacel AG in place, cleansed w/\n NS, wrapped in cling. Wound care following.\n Response:\n Awaiting effect.\n Plan:\n Wound care cont. to follow. Awaiting effect.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS CTA. Sats wnl. No cough or sob noted. Occ. desats when sleeping.\n Action:\n Bipap at night for OSA.\n Response:\n Well tolerated, improved acidosis.\n Plan:\n require formal sleep study for insurance purposes, and for\n outpatient bipap machine.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Serum K+ 4.3.\n Action:\n HD line in place, however no indication for HD at this time per Renal.\n Response:\n Well tolerated.\n Plan:\n Cont. to monitor.\n Altered mental status (not Delirium)\n Assessment:\n MS labile, distrustful, anxious, and crying at times. Alert oriented\n x3 most of time, occ. confused.\n Action:\n Bicarb. Gtt completed. Plan for PM labs.\n Response:\n MS improving.\n Plan:\n Cont. to monitor.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/CRE with slow improvement.\n Action:\n Renal following. No plans for immediate HD, as felt is may limit any\n self preservation potential of the kidneys.\n Response:\n Slight improvement.\n Plan:\n Follow labs. Appreciate Renal reqs.\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 336138,
"text": "Chief Complaint: altered mental status\n HPI:\n Pt is a 52 y/o female w/ a hx of DM, HTN, ? CVA who is brought in by\n her son due to altered mental status. The patient receives all of her\n care at and is unable to answer questions. In the few days prior to\n presentation, patient has had nausea/vomiting/diahrea and inability to\n tolerate POs. On the day of presenation, patient's son found patient\n confused, w/ poor concentration and perseveration, and was\n intermitendly following commands and described by EMS as lethargic. No\n focal neurologic deficits were noted otherwise. Patient has not had any\n fevers, neck stiffnes, headaches, or blurred vision. She has standing\n narcotics on medication regimen, for unclear reasons. She has no\n history of trauma.\n In the ED, T97 HR 72 BP 176/61 O2 98% on RA. She was found to be in new\n ARF. She was given IVF and IV morphine for pain control, and admitted\n to medicine for further manegment.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Per report and based off medication list:\n - CAD\n - DM\n - CRI, baseline Cr around \n - pyoderma gangrenosum\n - HTN\n - CVA\n - GERD\n - ? seizure d/o\n Cannot obtain from patient\n Occupation: clerical work\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: Lives alone. Son involved in care.\n Review of systems:\n Cannot be obtained\n Flowsheet Data as of 04:37 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: 37.2\nC (98.9\n HR: 70 (70 - 73) bpm\n BP: 146/62(78) {146/62(78) - 151/63(80)} mmHg\n RR: 19 (15 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -330 mL\n Physical Examination\n VS: T 98.7 BP 154/64 P 72 RR 96 % RA\n GEN: Obese AA female, snoring loudly, opens eyes to name call, unable\n to answer questions\n HEENT: NCAT, EOMI, pin-point pupils, wide neck\n NECK: Supple, no LAD, no appreciable JVD\n CV: RRR, normal S1S2, no murmurs, rubs or gallops\n PULM: CTAB, no w/r/r, good air movement bilaterally\n ABD: Obese Soft, NTND, normoactive bowel sounds, no organomegaly, no\n abdominal bruit appreciated\n EXT: Warm and well perfused, full and symmetric distal pulses, no pedal\n edema. Legs bandaged.\n NEURO: EOMI, moves all 4 extremities upon request. Otherwise not\n cooperative with exam. 2+ patellar reflex. Downgoing toes b/l.\n Labs / Radiology\n NCHCT: No acute intracranial process.\n 338\n 82\n 10.7\n 89\n 15\n 107\n 5.7\n 140\n 33.3\n 8.7\n [image002.jpg]\n ECG: Physiologic left axis, normal sinus at 70bpm, Poor R wave\n progression across precordium, TWI in aVL and flattening in I.\n Assessment and Plan\n 52 y/o female w/ hx of CVA, DM, ? CAD, and HTN who presents w/ altered\n mental status and ARF.\n .\n # Altered Mental Status: Ddx includes uremia secondary to ARF versus\n toxin ingestion (i.e., narcotics). Currently no evidence to suggest\n infection, hypoglycemia.\n - MS appears to be improving; could consider Narcan PRN\n - hold all sedating meds\n .\n # Acute on chronic renal failure: Wide differential, including\n pre-renal, renal and renal etiologies. Pt may be pre-renal if she was\n taking poor POs for some period of time. Appears to be making\n reasonable urine outpt, thus obstruction is less likely but still\n possible.\n - appreciate renal input\n - check FeNa; consider emperic volume repletion in interim\n - renal ultrasound in AM\n - renally dose all meds; avoid nephrotoxins; exchange atenolol for\n metoprolol and hold Topamax as these are renally cleared\n .\n # AG acidosis: be seen in the setting of ARF. Delta/delta ratio is\n <1. No evidence to support other cause such as lactic acidosis,\n ketoacidosis or toxin ingestion.\n - fluid hydration as above; could consider bicarb administration if\n worsening acidosis\n - repeat labs in AM and trend change\n .\n # DM: Continue pt's home insulin with ISS.\n .\n # CAD: Continue home ASA; transition atenolol to metoprolol.\n .\n # HTN: Metoprolol as above. Hold CCB until pt's clinical direction more\n clear.\n .\n # GERD: PPI\n .\n # FEN: renal diet when not NPO\n # PPX: heparin SC, PPI\n # Dispo: pending workup\n # CODE: presumed Full\n # Comm: , , \n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT: hep subq\n Stress ulcer: PPI\n Code status: presumed full\n Disposition: MICU\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 336195,
"text": "Chief Complaint: acute renal failure and delirium, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED last PM by EMS for altered mental status. Pt\n received all usual care at - on dievrt. No records. Was in USOH\n until Saturday when diarrhea, Nausea, vomiting. Sunday and Monday\n confusion, repeating herself. Yesterday son and found aletered\n and called 911.\n In our ED creatinine was 10-noted to have lowerer ext ulcers - ?\n pyoderma gangrenosum. Given morphine - admitted to the 7 and\n triggered for somnelence and Tx to MICU for further management.\n Home Meds: Alb, amitriptyline, ASA, Crestor, Lantus, Neurontin,\n Oxycodone, Procoardia, Renegal, Topamax, Toprol XL, Tylenol, Meclizine\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Other medications:\n SC hep 5000 tid\n Metoprolol\n Folate\n SSRI\n Glargine\n ASA 81\n Renagel 80 tid\n Kayxylate\n Past medical history:\n Family history:\n Social History:\n DM\n HTN\n As valve 1.0\n Nephrolithiaisis\n neg CT Fe b \n Pyoderma gangrenosum- on remacaid\n CRI (3.9 to 4.6)\n Old CVA\n CAD - single vessel\n ? seizure disorder\n (trying to get records from )\n unable to obtain\n Occupation: clerk - out on disability\n Drugs: neg\n Tobacco: neg\n Alcohol: neg\n Other: lives alone, sister and son are involved in her care\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, 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 Flowsheet Data as of 08:55 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: 36.1\nC (97\n HR: 75 (70 - 76) bpm\n BP: 146/62(84) {145/49(71) - 151/63(84)} mmHg\n RR: 18 (15 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,200 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 671 mL\n Urine:\n 371 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 529 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///13/\n Physical Examination\n Eyes / Conjunctiva: pinpoint pupils\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal, No(t) Absent), (S2: Normal, No(t) Distant,\n No(t) Loud, No(t) Widely split , No(t) Fixed)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: No(t) Attentive, Responds to: Tactile stimuli, Movement:\n Not assessed, Tone: Not assessed, unable to cooperate with exam fully\n Labs / Radiology\n 299 K/uL\n 31.7 %\n 10.1 g/dL\n 71 mg/dL\n 10.6 mg/dL\n 88 mg/dL\n 13 mEq/L\n 112 mEq/L\n 5.9 mEq/L\n 142 mEq/L\n 12.0 K/uL\n [image002.jpg]\n 05:02 AM\n WBC\n 12.0\n Hct\n 31.7\n Plt\n 299\n Cr\n 10.6\n TropT\n 0.07\n Glucose\n 71\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.4 mg/dL, Mg++:2.3\n mg/dL, PO4:9.2 mg/dL\n ABG: 7.18/40/98 on on 2l lactate 0.8\n ECG: SR at 70, twi in l and flat in 1, poor r wave progression\n CXR: none done\n Non Contrast Abd CT: negative for obstructing stone or hydro\n Non Con Head CT: no acute bleed or shift\n UA: slight blood, otherwise no casts\n Assessment and Plan\n 52 yr old woman with DM, CAD< HTN, CRI presents with delirium and acute\n renal failure\n 1. ARF: acute on chronic and may have been precipitated by\n illness and dehydration, but was as high as 4.7 at recently. Bland\n sediment, CT scan neg for stone or hydro. FeNa 6%. Currently she is\n hyperkalemic, very elevated BUN and Cr. Given 1 unit saline, Could\n change to d5W and 3 Amps bicarb\n understanding however that her resp\n status is tenuous from an oxygenation and ventilation. Would replete\n po bicarb for now and trend.\n 2. Altered mental status: neg non con head CT. Exam most\n consistent with delirum. Likely due to uremia, acidosis, exacerbated\n by morphine and possible hypercarbia.\n 3. Resp Distress: intermittent hypoxemia which resolves with\n waking. She looks like she at least has OSA and may well have obesity\n hypoventilation. Last ABG Paco2 was 40\n and normal pH.\n 4. Pyoderma: get in touch with derm, consult wound care.\n Recent Rx with Remacaid.\n 5. AS: mod to severe\n careful with volume status\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: lantus (1/2 dose and ssri)\n Lines / Intubation:\n 20 Gauge - 03:30 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Communication: discussed with sister overnight and left message for\n son\n status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 336197,
"text": "Chief Complaint: altered mental status\n HPI:\n Pt is a 52 y/o female w/ a hx of DM, HTN, ? CVA who is brought in by\n her son due to altered mental status. The patient receives all of her\n care at and is unable to answer questions. In the few days prior to\n presentation, patient has had nausea/vomiting/diahrea and inability to\n tolerate POs. On the day of presenation, patient's son found patient\n confused, w/ poor concentration and perseveration, and was\n intermitendly following commands and described by EMS as lethargic. No\n focal neurologic deficits were noted otherwise. Patient has not had any\n fevers, neck stiffnes, headaches, or blurred vision. She has standing\n narcotics on medication regimen, for unclear reasons. She has no\n history of trauma.\n In the ED, T97 HR 72 BP 176/61 O2 98% on RA. She was found to be in new\n ARF. She was given IVF and IV morphine for pain control, and admitted\n to medicine for further manegment.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Per report and based off medication list:\n - CAD\n - DM\n - CRI, baseline Cr around \n - pyoderma gangrenosum\n - HTN\n - CVA\n - GERD\n - ? seizure d/o\n Cannot obtain from patient\n Occupation: clerical work\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: Lives alone. Son involved in care.\n Review of systems:\n Cannot be obtained\n Flowsheet Data as of 04:37 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: 37.2\nC (98.9\n HR: 70 (70 - 73) bpm\n BP: 146/62(78) {146/62(78) - 151/63(80)} mmHg\n RR: 19 (15 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -330 mL\n Physical Examination\n VS: T 98.7 BP 154/64 P 72 RR 96 % RA\n GEN: Obese AA female, snoring loudly, opens eyes to name call, unable\n to answer questions\n HEENT: NCAT, EOMI, pin-point pupils, wide neck\n NECK: Supple, no LAD, no appreciable JVD\n CV: RRR, normal S1S2, 4/6 SEM, no rubs or gallops\n PULM: CTAB, no w/r/r, good air movement bilaterally\n ABD: Obese Soft, NTND, normoactive bowel sounds, no organomegaly, no\n abdominal bruit appreciated\n EXT: Warm and well perfused, full and symmetric distal pulses, no pedal\n edema. Legs bandaged.\n NEURO: EOMI, moves all 4 extremities upon request. Otherwise not\n cooperative with exam. 2+ patellar reflex. Downgoing toes b/l.\n Labs / Radiology\n NCHCT: No acute intracranial process.\n 338\n 82\n 10.7\n 89\n 15\n 107\n 5.7\n 140\n 33.3\n 8.7\n [image002.jpg]\n ECG: Physiologic left axis, normal sinus at 70bpm, Poor R wave\n progression across precordium, TWI in aVL and flattening in I.\n Assessment and Plan\n 52 y/o female w/ hx of CVA, DM, ? CAD, and HTN who presents w/ altered\n mental status and ARF.\n .\n # Altered Mental Status: Ddx includes uremia secondary to ARF versus\n toxin ingestion (i.e., narcotics). Currently no evidence to suggest\n infection, hypoglycemia.\n - MS appears to be improving; could consider Narcan PRN\n - hold all sedating meds\n - check CXR\n .\n # Acute on chronic renal failure: Wide differential, including\n pre-renal, renal and renal etiologies. Pt may be pre-renal if she was\n taking poor POs for some period of time. Appears to be making\n reasonable urine outpt, thus obstruction is less likely but still\n possible.\n - appreciate renal input\n - check FeNa; consider emperic volume repletion with NS in interim\n - consider PO bicarb\n - abd/pelvis CT scan in AM\n - renally dose all meds; avoid nephrotoxins; exchange atenolol for\n metoprolol and hold Topamax as these are renally cleared\n .\n # AG acidosis: be seen in the setting of ARF. Delta/delta ratio is\n <1. No evidence to support other cause such as lactic acidosis,\n ketoacidosis or toxin ingestion.\n - fluid hydration as above; could consider bicarb administration if\n worsening acidosis\n - repeat labs in AM and trend change\n .\n # LE wounds/PG: Will touch base with pt\ns dermatologist. Wound care\n consult.\n .\n # DM: Continue pt's home insulin (decrease dose slightly) with ISS.\n .\n # CAD: Continue home ASA; transition atenolol to metoprolol.\n .\n # HTN: Metoprolol as above. Hold CCB until pt's clinical direction more\n clear.\n .\n # GERD: PPI\n .\n # FEN: renal diet when not NPO\n # PPX: heparin SC, PPI\n # Dispo: pending workup\n # CODE: presumed Full\n # Comm: , , \n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT: hep subq\n Stress ulcer: PPI\n Code status: presumed full\n Disposition: MICU\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336807,
"text": ".H/O acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336740,
"text": "Chief Complaint: acute renal faiuliure delirium\n I saw and examined the patient, and was physically present with the 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 DIALYSIS CATHETER - START 03:00 PM\n IR placement\n Persistent good UOP\n Tolerated BIPAP well overnight\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 07:45 PM\n Heparin Sodium (Prophylaxis) - 05:57 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 63 (63 - 79) bpm\n BP: 180/89(113) {157/67(88) - 200/124(113)} mmHg\n RR: 21 (6 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,042 mL\n 1,117 mL\n PO:\n 160 mL\n 100 mL\n TF:\n IVF:\n 2,882 mL\n 1,017 mL\n Blood products:\n Total out:\n 3,065 mL\n 960 mL\n Urine:\n 3,065 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -23 mL\n 157 mL\n Respiratory support\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n Overweight / 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: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal, No(t) Absent), (S2: Normal, Distant, No(t)\n Loud, No(t) Widely split , No(t) Fixed)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.2 g/dL\n 298 K/uL\n 104 mg/dL\n 8.9 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 79 mg/dL\n 110 mEq/L\n 144 mEq/L\n 28.4 %\n 9.0 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n 10:37 AM\n 08:01 PM\n 05:26 AM\n WBC\n 12.0\n 10.1\n 9.5\n 9.0\n Hct\n 31.7\n 30.6\n 28.4\n 28.4\n Plt\n 299\n 280\n 294\n 298\n Cr\n 10.6\n 10.3\n 9.7\n 9.4\n 8.9\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n 76\n 134\n 104\n Other labs: CK / CKMB / Troponin-T:73//0.07, Differential-Neuts:72.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:12.0 %, Eos:2.0 %, Ca++:8.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 03:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336743,
"text": "Chief Complaint: acute renal faiuliure delirium\n I saw and examined the patient, and was physically present with the 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 DIALYSIS CATHETER - START 03:00 PM\n IR placement\n Persistent good UOP\n Tolerated BIPAP well overnight\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 07:45 PM\n Heparin Sodium (Prophylaxis) - 05:57 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 63 (63 - 79) bpm\n BP: 180/89(113) {157/67(88) - 200/124(113)} mmHg\n RR: 21 (6 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,042 mL\n 1,117 mL\n PO:\n 160 mL\n 100 mL\n TF:\n IVF:\n 2,882 mL\n 1,017 mL\n Blood products:\n Total out:\n 3,065 mL\n 960 mL\n Urine:\n 3,065 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -23 mL\n 157 mL\n Respiratory support\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n Labs / Radiology\n 9.2 g/dL\n 298 K/uL\n 104 mg/dL\n 8.9 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 79 mg/dL\n 110 mEq/L\n 144 mEq/L\n 28.4 %\n 9.0 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n 10:37 AM\n 08:01 PM\n 05:26 AM\n WBC\n 12.0\n 10.1\n 9.5\n 9.0\n Hct\n 31.7\n 30.6\n 28.4\n 28.4\n Plt\n 299\n 280\n 294\n 298\n Cr\n 10.6\n 10.3\n 9.7\n 9.4\n 8.9\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n 76\n 134\n 104\n Other labs: CK / CKMB / Troponin-T:73//0.07, Differential-Neuts:72.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:12.0 %, Eos:2.0 %, Ca++:8.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan 52 yo female CVA, DM, CRI with Acute on chronic\n renal failure.\n 1)Renal: continues to have good UOP, today she has some improvement in\n Cr, BUN coming down, VBG shows improvement in acidosis\n albeit on\n continuous bicarb- discus with renal role of po bicitra\n 2) OSA: BIPAP at night auto titrate\n 3) Delirium: mixed with uremia, acidosis, and med effect. More alert,\n follow exam closely.\n 4) HTN: start po labetalol\n 4)DM-continue insulin, trend blood sugars\n 5)CV: continue lopressor, ASA\n 6)Wound care-wound care following\n ICU Care\n Nutrition: renal diet\n Glycemic Control: glargine and SSRI\n Lines:\n Dialysis Catheter - 03:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Communication: with family\n Code status: Full code\n Disposition : tx to floor\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 336171,
"text": "Chief Complaint: acute renal failure and delirium, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED last PM by EMS for altered mental status. Pt\n received all usual care at - on dievrt. No records. Was in USOH\n until Saturday when diarrhea, Nausea, vomiting. Sunday and Monday\n confusion, repeating herself. Yesterday son and found aletered\n and called 911.\n In our ED creatinine was 10-noted to have lowerer ext ulcers - ?\n pyoderma gangrenosum. Given morphine - admitted to the 7 and\n triggered for somnelence and Tx to MICU for further management.\n Home Meds: Alb, amitriptyline, ASA, Crestor, Lantus, Neurontin,\n Oxycodone, Procoardia, Renegal, Topamax, Toprol XL, Tylenol, Meclizine\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Other medications:\n SC hep 5000 tid\n Metoprolol\n Folate\n SSRI\n Glargine\n ASA 81\n Renagel 80 tid\n Kayxylate\n Past medical history:\n Family history:\n Social History:\n DM\n HTN\n As valve 1.0\n Nephrolithiaisis\n neg CT Fe b \n Pyoderma gangrenosum- on remacaid\n CRI (3.9 to 4.6)\n Old CVA\n CAD - single vessel\n ? seizure disorder\n (trying to get records from )\n unable to obtain\n Occupation: clerk - out on disability\n Drugs: neg\n Tobacco: neg\n Alcohol: neg\n Other: lives alone, sister and son are involved in her care\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, 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 Flowsheet Data as of 08:55 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: 36.1\nC (97\n HR: 75 (70 - 76) bpm\n BP: 146/62(84) {145/49(71) - 151/63(84)} mmHg\n RR: 18 (15 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,200 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 671 mL\n Urine:\n 371 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 529 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///13/\n Physical Examination\n Eyes / Conjunctiva: pinpoint pupils\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (S1: Normal, No(t) Absent), (S2: Normal, No(t) Distant,\n No(t) Loud, No(t) Widely split , No(t) Fixed)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles : , No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: Absent, Left: Absent\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm\n Neurologic: No(t) Attentive, Responds to: Tactile stimuli, Movement:\n Not assessed, Tone: Not assessed, unable to cooperate with exam fully\n Labs / Radiology\n 299 K/uL\n 31.7 %\n 10.1 g/dL\n 71 mg/dL\n 10.6 mg/dL\n 88 mg/dL\n 13 mEq/L\n 112 mEq/L\n 5.9 mEq/L\n 142 mEq/L\n 12.0 K/uL\n [image002.jpg]\n 05:02 AM\n WBC\n 12.0\n Hct\n 31.7\n Plt\n 299\n Cr\n 10.6\n TropT\n 0.07\n Glucose\n 71\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.4 mg/dL, Mg++:2.3\n mg/dL, PO4:9.2 mg/dL\n ABG: 7.18/40/98 on on 2l lactate 0.8\n ECG: SR at 70, twi in l and flat in 1, poor r wave progression\n CXR: none done\n Non Contrast Abd CT: negative for obstructing stone or hydro\n Non Con Head CT: no acute bleed or shift\n UA: slight blood, otherwise no casts\n Assessment and Plan\n 52 yr old woman with DM, CAD< HTN, CRI presents with delirium and acute\n renal failure\n 1. ARF: acute on chronic and may have been precipitated by\n illness and dehydration, but was as high as 4.7 at recently. Bland\n sediment, CT scan neg for stone or hydro. FeNa 6%. Currently she is\n hyperkalemic, very elevated BUN and Cr. Given 1 unit saline, Could\n change to d5W and 3 Amps bicarb\n understanding however that her resp\n status is tenuous from an oxygenation and ventilation. Would replete\n po bicarb for now and trend.\n 2. Altered mental status: neg non con head CT. Exam most\n consistent with delirum. Likely due to uremia, acidosis, exacerbated\n by morphine and possible hypercarbia.\n 3. Resp Distress: intermittent hypoxemia which resolves with\n waking. She looks like she at least has OSA and may well have obesity\n hypoventilation. Last ABG Paco2 was 40\n and normal pH.\n 4. Pyoderma: get in touch with derm, consult wound care.\n Recent Rx with Remacaid.\n 5. AS: mod to severe\n careful with volume status\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: lantus (1/2 dose and ssri)\n Lines / Intubation:\n 20 Gauge - 03:30 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Communication: discussed with sister overnight and left message for\n son\n status: Full code\n Disposition: ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 336525,
"text": "Chief Complaint:\n 24 Hour Events:\n -unable to place additional PIVs\n -mental status appeared acutely worse overnight\n -pt trialed on CPAP without significant change\n -pt treated with IV bicarb\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Heparin Sodium (Prophylaxis) - 06:25 AM\n Other medications:\n Changes to medical and family history:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 70 (67 - 75) bpm\n BP: 176/76(101) {135/59(80) - 183/88(149)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,160 mL\n 1,198 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,560 mL\n 1,198 mL\n Blood products:\n Total out:\n 1,891 mL\n 565 mL\n Urine:\n 1,591 mL\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 633 mL\n Respiratory support\n O2 Delivery Device: BiPaP FiO2 40%\n ABG: 7.20/40/88/16/-11\n Physical Examination\n GEN: Obese AA female, snoring loudly, opens eyes to name call, unable\n to answer questions\n HEENT: NCAT, EOMI, pin-point pupils, wide neck\n NECK: Supple, no LAD, no appreciable JVD\n CV: RRR, normal S1S2, 4/6 SEM, no rubs or gallops\n PULM: CTAB, no w/r/r, good air movement bilaterally\n ABD: Obese Soft, NTND, normoactive bowel sounds, no organomegaly, no\n abdominal bruit appreciated\n EXT: Warm and well perfused, full and symmetric distal pulses, no pedal\n edema. Legs bandaged.\n NEURO: EOMI, moves all 4 extremities upon request. Otherwise not\n cooperative with exam. 2+ patellar reflex. Downgoing toes b/l.\n Labs / Radiology\n 280 K/uL\n 9.5 g/dL\n 72 mg/dL\n 10.3 mg/dL\n 14 mEq/L\n 5.6 mEq/L\n 86 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.6 %\n 10.1 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n WBC\n 12.0\n 10.1\n Hct\n 31.7\n 30.6\n Plt\n 299\n 280\n Cr\n 10.6\n 10.3\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:8.9 mg/dL\n Assessment and Plan\n 52 y/o female w/ hx of CVA, DM, ? CAD, and HTN who presents w/ altered\n mental status and ARF.\n .\n # Altered Mental Status: Suspect most likely second to uremia from ARF.\n Currently no evidence to suggest infection or toxic process. MS has not\n yet improved however.\n - continue to hold all sedating meds\n - monitor renal function; d/w renal about probable HD today or tomorrow\n .\n # Acute on chronic renal failure: Suspect acute worsening of underlying\n poor renal function likely due to pre-renal azotemia. Pt has continued\n to make adequate urine however her renal failure is not improving.\n - appreciate renal input\n - pt to get temp HD cath today with HD to likely occur today or\n tomorrow\n - continue volume repletion with D5/bicarb\n - abd/pelvis scan without evidence obstruction\n - renally dose all meds; avoid nephrotoxins; exchange atenolol for\n metoprolol and hold Topamax as these are renally cleared\n .\n # AG acidosis: Thought to be due to ARF. Delta/delta ratio is <1. No\n evidence to support other cause such as lactic acidosis, ketoacidosis\n or toxin ingestion.\n - fluid hydration as above\n - plans for HD as above\n .\n # LE wounds/PG: Will touch base with pt\ns dermatologist. Wound care\n consult.\n .\n # DM: Continue pt's home insulin (decrease dose) with ISS.\n .\n # CAD: Continue home ASA; transition atenolol to metoprolol.\n .\n # HTN: Metoprolol as above. Hold CCB until pt's clinical direction more\n clear.\n .\n # GERD: PPI\n ICU Care\n Nutrition: PO diet\n Glycemic Control: sugars well controlled on ISS\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT: hep subq\n Stress ulcer: PO diet\n Communication: Comments:\n Code status: Full code\n Disposition: MICU\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 336526,
"text": "Chief Complaint:\n 24 Hour Events:\n -unable to place additional PIVs\n -mental status appeared acutely worse overnight\n -pt trialed on CPAP without significant change\n -pt treated with IV bicarb\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Heparin Sodium (Prophylaxis) - 06:25 AM\n Other medications:\n Changes to medical and family history:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 70 (67 - 75) bpm\n BP: 176/76(101) {135/59(80) - 183/88(149)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,160 mL\n 1,198 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,560 mL\n 1,198 mL\n Blood products:\n Total out:\n 1,891 mL\n 565 mL\n Urine:\n 1,591 mL\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 633 mL\n Respiratory support\n O2 Delivery Device: BiPaP FiO2 40%\n ABG: 7.20/40/88/16/-11\n Physical Examination\n GEN: Obese AA female, snoring loudly, opens eyes to name call, unable\n to answer questions\n HEENT: NCAT, EOMI, pin-point pupils, wide neck\n NECK: Supple, no LAD, no appreciable JVD\n CV: RRR, normal S1S2, 4/6 SEM, no rubs or gallops\n PULM: CTAB, no w/r/r, good air movement bilaterally\n ABD: Obese Soft, NTND, normoactive bowel sounds, no organomegaly, no\n abdominal bruit appreciated\n EXT: Warm and well perfused, full and symmetric distal pulses, no pedal\n edema. Legs bandaged.\n NEURO: EOMI, moves all 4 extremities upon request. Otherwise not\n cooperative with exam. 2+ patellar reflex. Downgoing toes b/l.\n Labs / Radiology\n 280 K/uL\n 9.5 g/dL\n 72 mg/dL\n 10.3 mg/dL\n 14 mEq/L\n 5.6 mEq/L\n 86 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.6 %\n 10.1 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n WBC\n 12.0\n 10.1\n Hct\n 31.7\n 30.6\n Plt\n 299\n 280\n Cr\n 10.6\n 10.3\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:8.9 mg/dL\n Assessment and Plan\n 52 y/o female w/ hx of CVA, DM, ? CAD, and HTN who presents w/ altered\n mental status and ARF.\n .\n # Altered Mental Status: Suspect most likely second to uremia from ARF.\n Currently no evidence to suggest infection or toxic process. MS has not\n yet improved however.\n - continue to hold all sedating meds\n - monitor renal function; d/w renal about probable HD today or tomorrow\n .\n # Acute on chronic renal failure: Suspect acute worsening of underlying\n poor renal function likely due to pre-renal azotemia. Pt has continued\n to make adequate urine however her renal failure is not improving.\n - appreciate renal input\n - pt to get temp HD cath today with HD to likely occur today or\n tomorrow\n - continue volume repletion with D5/bicarb\n - abd/pelvis scan without evidence obstruction\n - renally dose all meds; avoid nephrotoxins; exchange atenolol for\n metoprolol and hold Topamax as these are renally cleared\n .\n # AG acidosis: Thought to be due to ARF. Delta/delta ratio is <1. No\n evidence to support other cause such as lactic acidosis, ketoacidosis\n or toxin ingestion.\n - fluid hydration as above\n - plans for HD as above\n .\n # LE wounds/PG: Will touch base with pt\ns dermatologist. Wound care\n consult.\n .\n # DM: Continue pt's home insulin (decrease dose) with ISS.\n .\n # CAD: Continue home ASA; transition atenolol to metoprolol.\n .\n # HTN: Metoprolol as above. Hold CCB until pt's clinical direction more\n clear.\n .\n # GERD: PPI\n ICU Care\n Nutrition: PO diet\n Glycemic Control: sugars well controlled on ISS\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT: hep subq\n Stress ulcer: PO diet\n Communication: Comments:\n Code status: Full code\n Disposition: MICU\n ------ Protected Section ------\n Add hydralazine today for BP control.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:28 ------\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336536,
"text": ".H/O acidosis, Metabolic\n Assessment:\n Metabolic Acidosis\n Action:\n Bicarb gtt (150MEQ in D5)\n Response:\n Improving PH\n Plan:\n Continue Bicarb gtt\n Impaired Skin Integrity\n Assessment:\n Bilateral lower ext. ulcers\n Action:\n Dressing changed as per skin care directives\n Response:\n Pt tolerated well. Bandage is clean, dry and intact.\n Plan:\n Continue daily dressing changes as per skin care directives.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on BIPAP.\n Action:\n Pt currently on RA.\n Response:\n NAD distress.\n Plan:\n Will continue BIPAP when sleeping.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336469,
"text": "Chief Complaint: acute renal failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Failed attempts at PIV\n Failed attempts at\n Bicarb - 4 AMPS overnight\n ABG 7.17/40/73\n This AM- more awake, perserverating on answers with questions\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:25 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 71 (67 - 75) bpm\n BP: 166/75(168) {135/59(80) - 183/88(168)} mmHg\n RR: 18 (11 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,160 mL\n 1,588 mL\n PO:\n 600 mL\n 100 mL\n TF:\n IVF:\n 2,560 mL\n 1,488 mL\n Blood products:\n Total out:\n 1,891 mL\n 865 mL\n Urine:\n 1,591 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.17/42/117/14/-12\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 Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 280 K/uL\n 72 mg/dL\n 10.3 mg/dL\n 14 mEq/L\n 5.6 mEq/L\n 86 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.6 %\n 10.1 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n WBC\n 12.0\n 10.1\n Hct\n 31.7\n 30.6\n Plt\n 299\n 280\n Cr\n 10.6\n 10.3\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:8.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336716,
"text": "52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED by EMS for altered mental status. Pt received\n all usual care at - on diversion. No records. Was in USOH until\n Saturday with diarrhea, Nausea, vomiting. Noted to be confused and\n repeating herself. Son found her with worsening mental status and\n called 911.\n In our ED creatinine was 10.\nAlso noted to have lower ext ulcers - ?\n pyoderma gangrenosum. Initially admitted to 7 but triggered for\n somnolence and tx to MICU for further management\n Impaired Skin Integrity\n Assessment:\n Bilat lower leg dressings, which remain dry and intact at this time.\n Action:\n Follow wound care regime ordered byb team, including skin care nurse\n recommendations.\n Response:\n Dressings remain dry and intact.\n Plan:\n To follow regime ordered by team.\n Altered mental status (not Delirium)\n Assessment:\n Pt\ns affect changes from agitation and interfering with treatment like\n pulling at lines and tubes. To being tearful, and then pleasant.. Pt.\n remains confused throughout this shift.\n Action:\n Monitor pt. closely for any neuro changes.\n Response:\n Pt. has been pleasant throughout this shift. And only required bilat\n wrist restraints to maintain bipap mask on.\n Plan:\n To continue to monitor pt. closely for any neuro deficits.\n .H/O acidosis, Metabolic\n Assessment:\n Pt. bun and creat remain elevated and remains in metabolic acidosis.\n Action:\n Pt. placed on bipap mask and continues on bicarb gtt.\n Response:\n Am labs are pending this am. Pt. continues to become more clear and\n more alert.\n Plan:\n Monitor labs and neuro status closely.\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 336726,
"text": "Chief Complaint:\n 24 Hour Events:\n DIALYSIS CATHETER - START 03:00 PM\n IR placement\n Given D5W with 3 amps bicarb, good uop\n Refused PO hydral during day, persistently hypertensive, got 2 doses IV\n hydral, BPs still in 180-190s overnight. BB increased.\n Pt tolerated Bipap overnight.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 07:45 PM\n Heparin Sodium (Prophylaxis) - 10:54 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:58 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: 68 (66 - 79) bpm\n BP: 157/69(88) {157/67(88) - 200/124(168)} mmHg\n RR: 21 (6 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,037 mL\n 595 mL\n PO:\n 160 mL\n TF:\n IVF:\n 2,877 mL\n 595 mL\n Blood products:\n Total out:\n 3,065 mL\n 560 mL\n Urine:\n 3,065 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n -28 mL\n 35 mL\n Respiratory support\n SpO2: 95%\n ABG: ///18/\n Physical Examination\n GEN: Obese AA female, snoring loudly, opens eyes to name call, unable\n to answer questions\n HEENT: NCAT, EOMI, pin-point pupils, wide neck\n NECK: Supple, no LAD, no appreciable JVD\n CV: RRR, normal S1S2, 4/6 SEM, no rubs or gallops\n PULM: CTAB, no w/r/r, good air movement bilaterally\n ABD: Obese Soft, NTND, normoactive bowel sounds, no organomegaly, no\n abdominal bruit appreciated\n EXT: Warm and well perfused, full and symmetric distal pulses, no pedal\n edema. Legs bandaged.\n NEURO: EOMI, moves all 4 extremities upon request. Otherwise not\n cooperative with exam. 2+ patellar reflex. Downgoing toes b/l.\n Labs / Radiology\n 294 K/uL\n 9.2 g/dL\n 134 mg/dL\n 9.4 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 81 mg/dL\n 110 mEq/L\n 142 mEq/L\n 28.4 %\n 9.5 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n 10:37 AM\n 08:01 PM\n WBC\n 12.0\n 10.1\n 9.5\n Hct\n 31.7\n 30.6\n 28.4\n Plt\n 299\n 280\n 294\n Cr\n 10.6\n 10.3\n 9.7\n 9.4\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n 76\n 134\n Other labs: CK / CKMB / Troponin-T:73//0.07, Differential-Neuts:72.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:12.0 %, Eos:2.0 %, Ca++:8.0 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n 52 y/o female w/ hx of CVA, DM, ? CAD, and HTN who presents w/ altered\n mental status and ARF.\n .\n # Altered Mental Status: Suspect most likely second to uremia from ARF.\n Currently no evidence to suggest infection or toxic process. MS has not\n yet improved however.\n - continue to hold all sedating meds\n - monitor renal function; d/w renal about probable HD today or tomorrow\n .\n # Acute on chronic renal failure: Suspect acute worsening of underlying\n poor renal function likely due to pre-renal azotemia. Pt has continued\n to make adequate urine however her renal failure is not improving.\n - appreciate renal input\n - pt to get temp HD cath today with HD to likely occur today or\n tomorrow\n - continue volume repletion with D5/bicarb\n - abd/pelvis scan without evidence obstruction\n - renally dose all meds; avoid nephrotoxins; exchange atenolol for\n metoprolol and hold Topamax as these are renally cleared\n .\n # AG acidosis: Thought to be due to ARF. Delta/delta ratio is <1. No\n evidence to support other cause such as lactic acidosis, ketoacidosis\n or toxin ingestion.\n - fluid hydration as above\n - plans for HD as above\n .\n # LE wounds/PG: Will touch base with pt\ns dermatologist. Wound care\n consult.\n .\n # DM: Continue pt's home insulin (decrease dose) with ISS.\n .\n # CAD: Continue home ASA; transition atenolol to metoprolol.\n .\n # HTN: Metoprolol as above. Hold CCB until pt's clinical direction more\n clear.\n .\n # GERD: PPI\n ICU Care\n Nutrition: PO diet\n Glycemic Control: sugars well controlled\n Lines:\n 20 Gauge - 03:30 AM\n Dialysis Catheter - 03:00 PM\n Prophylaxis:\n DVT: hep subq\n Stress ulcer: PPI\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 336448,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Heparin Sodium (Prophylaxis) - 06:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 70 (67 - 75) bpm\n BP: 176/76(101) {135/59(80) - 183/88(149)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,160 mL\n 1,198 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,560 mL\n 1,198 mL\n Blood products:\n Total out:\n 1,891 mL\n 565 mL\n Urine:\n 1,591 mL\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 633 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.17/42/117/14/-12\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 280 K/uL\n 9.5 g/dL\n 72 mg/dL\n 10.3 mg/dL\n 14 mEq/L\n 5.6 mEq/L\n 86 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.6 %\n 10.1 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n WBC\n 12.0\n 10.1\n Hct\n 31.7\n 30.6\n Plt\n 299\n 280\n Cr\n 10.6\n 10.3\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:8.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336319,
"text": "52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED last PM by EMS for altered mental status. Pt\n received all usual care at - on dievrt. No records. Was in USOH\n until Saturday when diarrhea, Nausea, vomiting. Sunday and Monday\n confusion, repeating herself. Yesterday son and found aletered\n and called 911.\n In our ED creatinine was 10-noted to have lowerer ext ulcers - ?\n pyoderma gangrenosum. Given morphine - admitted to the 7 and\n triggered for somnelence and Tx to MICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Periods of alertness followed by lethargy and somnalance. When alert,\n able to state name, birth date and that she was in the hospital. Able\n to drink fluids and swallow pills without difficulty. Patient not\n cooperative with some care, becoming combative and fearful at times\n with turning and bathing.\n Action:\n No sedative meds given. Verbal reassurance provided.\n Response:\n Huge improvement when patient\ns sister arrived; much happier and more\n cooperative.\n Plan:\n Monitor mental status, avoid sedating meds. Continue to provide\n emotional support and reassurance with care.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN>80, creat>10. Patient\ns skin is very itchy. Mental status remains\n altered.\n Action:\n Decision made not to dialyse at this time. 500cc NS bolus IV followed\n by NS @ 150cc/hr for 1 liter.\n Response:\n UOP is slowly increasing.\n Plan:\n Continue to hydrate, follow lab values. require HD line placement\n and HD if no improvement.\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Critical Care Staff",
"row_id": 336327,
"text": "CRITICAL CARE STAFF\n 23:20\n Called to see patient for somnolence and acidosis.\n 52 y/o woman with severe CKD and pyoderma admitted with ARF. The\n evaluation is detailed in her medical record. At present on exam she\n is somnolent. She arouses to voice but when asleep has sleep apnea\n events. She is markedly obese.\n Her acidosis has persisted in spite of therapy so far. Blood gases\n show:\n 5:53p\n 10:33p\n pH\n 7.16\n pCO2\n 42\n pO2\n 100\n HCO3\n 16\n BaseXS\n -13\n\n\n pH\n 7.17\n pCO2\n 42\n pO2\n 117\n HCO3\n 16\n BaseXS\n -12\n BUN/Creatinine remain elevated at 86 / 10.3\n Has made almost 1600 cc of urine today.\n Labs\n 9.5 g/dL\n 280 K/uL\n 72 mg/dL\n 10.3 mg/dL\n 14 mEq/L\n 5.7 mEq/L\n 86 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.6 %\n 10.1 K/uL\n [image002.jpg]\n Urine tox was (+) for opiates.\n Assessment and Plan\n 52-year-old woman with very concerning triad of altered mental status,\n acidosis, and acute renal failure. Her acid-base status shows a\n metabolic acidosis that is partially anion gap and partially\n hyperchloremic. In addition, her respiratory compensation is less than\n expected for this degree of acidosis, though that may reflect chronic\n hypercarbia from obesity-hypoventilation syndrome.\n She is very tenuous. We will plan to treat along multiple potential\n pathways:\n 1) Give bicarbonate to treat non-gap component of acidosis.\n 2) Ask renal to comment on emergent dialysis\n 3) Trial of naloxone\n 4) Trial of positive pressure therapy. This will treat what is\n clearly sleep apnea (by bedside exam) and may help improve her\n respiratory compensation for the metabolic acidosis.\n 5) Try to obtain additional IV access\n We will try these over the next hour or two. Given her likely\n difficult airway, if they are ineffective we will proceed with\n semi-elective intubation unless we see improvement.\n Discussed with , RN, and RT.\n 60 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336103,
"text": "52 y/o female with PMH of HTN.DM,ARF admitted initially to 7 from\n home with c/o altered MS,pt is poor historian,transferred to MICU\n since pt was increasingly lethargic ,slow to respond,intermittently\n following commands,ABG 7.18/pco2 40/po2 90 lactae 0.8 On admission to\n MICU pt oriented to self,tearful pain on lower limbs? venous stasis\n ulcer,not panning to give any narcotics at this time in view of her\n altered MS.\n Altered mental status (not Delirium)\n Assessment:\n Oriented to self,slow to respond answering yes for all questions,pt\n poor historian,new to no records available CT head fronm ED was\n negative, pt is on narcotics at home ? overdose\n Action:\n Hold narcotics till further order\n Response:\n As MD pt more awake now,\n Plan:\n Narcan as needed,NPO for\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt in ARF unclear etiology did not have any HD foley catheter in\n draining\n Action:\n NS 1000 ml X 2 hrs\n Response:\n Plan:\n HD catheter insertion and possible HD if pt doesnot improve.CT abdomen\n and pelvis to R/O hydronephrosis\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336101,
"text": "52 y/o female with PMH of HTN.DM,ARF admitted initially to 7 from\n home with c/o altered MS,pt is poor historian,transferred to MICU\n since pt was increasingly lethargic ,slow to respond,intermittently\n following commands,ABG 7.18/pco2 40/po2 90 lactae 0.8 On admission to\n MICU pt oriented to self,tearful pain on lower limbs? venous stasis\n ulcer,not panning to give any narcotics at this time in view of her\n altered MS.\n Altered mental status (not Delirium)\n Assessment:\n Oriented to self,slow to respond answering yes for all questions,pt\n poor historian,new to no records available CT head fronm ED was\n negative, pt is on narcotics at home ? overdose\n Action:\n Hold narcotics till further order\n Response:\n As MD pt more awake now,\n Plan:\n Narcan as needed,NPO for\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt in ARF unclear etiology did not have any HD foley catheter in\n draining\n Action:\n Response:\n Plan:\n HD catheter insertion and possible HD if pt doesnot improve.\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 336102,
"text": "Chief Complaint: altered mental status\n HPI:\n Pt is a 52 y/o female w/ a hx of DM, HTN, ? CVA who is brought in by\n her son due to altered mental status. The patient receives all of her\n care at and is unable to answer questions. In the few days prior to\n presentation, patient has had nausea/vomiting/diahrea and inability to\n tolerate POs. On the day of presenation, patient's son found patient\n confused, w/ poor concentration and perseveration, and was\n intermitendly following commands and described by EMS as lethargic. No\n focal neurologic deficits were noted otherwise. Patient has not had any\n fevers, neck stiffnes, headaches, or blurred vision. She has standing\n narcotics on medication regimen, for unclear reasons. She has no\n history of trauma.\n In the ED, T97 HR 72 BP 176/61 O2 98% on RA. She was found to be in new\n ARF. She was given IVF and IV morphine for pain control, and admitted\n to medicine for further manegment.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Per report and based off medication list:\n - CAD\n - DM\n - CRI, baseline Cr around \n - pyoderma gangrenosum\n - HTN\n - CVA\n - GERD\n - ? seizure d/o\n Cannot obtain from patient\n Occupation: clerical work\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: Lives alone. Son involved in care.\n Review of systems:\n Cannot be obtained\n Flowsheet Data as of 04:37 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: 37.2\nC (98.9\n HR: 70 (70 - 73) bpm\n BP: 146/62(78) {146/62(78) - 151/63(80)} mmHg\n RR: 19 (15 - 19) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 330 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -330 mL\n Physical Examination\n VS: T 98.7 BP 154/64 P 72 RR 96 % RA\n GEN: Obese AA female, snoring loudly, opens eyes to name call, unable\n to answer questions\n HEENT: NCAT, EOMI, pin-point pupils, wide neck\n NECK: Supple, no LAD, no appreciable JVD\n CV: RRR, normal S1S2, no murmurs, rubs or gallops\n PULM: CTAB, no w/r/r, good air movement bilaterally\n ABD: Obese Soft, NTND, normoactive bowel sounds, no organomegaly, no\n abdominal bruit appreciated\n EXT: Warm and well perfused, full and symmetric distal pulses, no pedal\n edema. Legs bandaged.\n NEURO: EOMI, moves all 4 extremities upon request. Otherwise not\n cooperative with exam. 2+ patellar reflex. Downgoing toes b/l.\n Labs / Radiology\n NCHCT: No acute intracranial process.\n 338\n 82\n 10.7\n 89\n 15\n 107\n 5.7\n 140\n 33.3\n 8.7\n [image002.jpg]\n ECG: Physiologic left axis, normal sinus at 70bpm, Poor R wave\n progression across precordium, TWI in aVL and flattening in I.\n Assessment and Plan\n 52 y/o female w/ hx of CVA, DM, ? CAD, and HTN who presents w/ altered\n mental status and ARF.\n .\n # Altered Mental Status: Ddx includes uremia secondary to ARF versus\n toxin ingestion (i.e., narcotics). Currently no evidence to suggest\n infection, hypoglycemia.\n - MS appears to be improving; could consider Narcan PRN\n - hold all sedating meds\n .\n # Acute on chronic renal failure: Wide differential, including\n pre-renal, renal and renal etiologies. Pt may be pre-renal if she was\n taking poor POs for some period of time. Appears to be making\n reasonable urine outpt, thus obstruction is less likely but still\n possible.\n - appreciate renal input\n - check FeNa; consider emperic volume repletion in interim\n - renal ultrasound in AM\n - renally dose all meds; avoid nephrotoxins; exchange atenolol for\n metoprolol and hold Topamax as these are renally cleared\n .\n # AG acidosis: be seen in the setting of ARF. Delta/delta ratio is\n <1. No evidence to support other cause such as lactic acidosis,\n ketoacidosis or toxin ingestion.\n - fluid hydration as above; could consider bicarb administration if\n worsening acidosis\n - repeat labs in AM and trend change\n .\n # DM: Continue pt's home insulin with ISS.\n .\n # CAD: Continue home ASA; transition atenolol to metoprolol.\n .\n # HTN: Metoprolol as above. Hold CCB until pt's clinical direction more\n clear.\n .\n # GERD: PPI\n .\n # FEN: renal diet when not NPO\n # PPX: heparin SC, PPI\n # Dispo: pending workup\n # CODE: presumed Full\n # Comm: , , \n ICU Care\n Nutrition: NPO for now\n Glycemic Control:\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT: hep subq\n Stress ulcer: PPI\n Code status: presumed full\n Disposition: MICU\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 336241,
"text": "Chief Complaint: acute renal failure and delirium, hypoxemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED last PM by EMS for altered mental status. Pt\n received all usual care at - on dievrt. No records. Was in USOH\n until Saturday when diarrhea, Nausea, vomiting. Sunday and Monday\n confusion, repeating herself. Yesterday son and found aletered\n and called 911.\n In our ED creatinine was 10-noted to have lowerer ext ulcers - ?\n pyoderma gangrenosum. Given morphine - admitted to the 7 and\n triggered for somnelence and Tx to MICU for further management.\n Home Meds: Alb, amitriptyline, ASA, Crestor, Lantus, Neurontin,\n Oxycodone, Procoardia, Renegal, Topamax, Toprol XL, Tylenol, Meclizine\n Patient admitted from: \n History obtained from Family / Medical records\n Patient unable to provide history: Sedated\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Other medications:\n SC hep 5000 tid\n Metoprolol\n Folate\n SSRI\n Glargine\n ASA 81\n Renagel 80 tid\n Kayxylate\n Past medical history:\n Family history:\n Social History:\n DM\n HTN\n As valve 1.0\n Nephrolithiaisis\n neg CT Fe b \n Pyoderma gangrenosum- on remacaid\n CRI (3.9 to 4.6)\n Old CVA\n CAD - single vessel\n ? seizure disorder\n (trying to get records from )\n unable to obtain\n Occupation: clerk - out on disability\n Drugs: neg\n Tobacco: neg\n Alcohol: neg\n Other: lives alone, sister and son are involved in her care\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea, No(t)\n Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, 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 Flowsheet Data as of 08:55 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: 36.1\nC (97\n HR: 75 (70 - 76) bpm\n BP: 146/62(84) {145/49(71) - 151/63(84)} mmHg\n RR: 18 (15 - 23) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,200 mL\n PO:\n 200 mL\n TF:\n IVF:\n 1,000 mL\n Blood products:\n Total out:\n 0 mL\n 671 mL\n Urine:\n 371 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 529 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///13/\n Physical Examination\n Gen: when asleep overt OSA and forced end expiratory abd rounding, slow\n to waken, confused, perserverating.\n HEENT: pupils small but reactive: o/p clear, large tongue\n Neck: obese\n CV: RR 3/l sys murmur RUSB\n Chest: poor air movement no wheezes\n Abd: os=bese distened + BS\n Skin: large bilat thin deep ulcerations with good granulation tissue,\n no overt exudate\n Neurologic:somnolent, slow to arouse, does waken to painful stimuli\n then stays awake, will not answer any questions, mpvement purposeful in\n attempts to push examiners away from legs.\n Labs / Radiology\n 299 K/uL\n 31.7 %\n 10.1 g/dL\n 71 mg/dL\n 10.6 mg/dL\n 88 mg/dL\n 13 mEq/L\n 112 mEq/L\n 5.9 mEq/L\n 142 mEq/L\n 12.0 K/uL\n [image002.jpg]\n 05:02 AM\n WBC\n 12.0\n Hct\n 31.7\n Plt\n 299\n Cr\n 10.6\n TropT\n 0.07\n Glucose\n 71\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.4 mg/dL, Mg++:2.3\n mg/dL, PO4:9.2 mg/dL\n ABG: 7.18/40/98 on on 2l lactate 0.8\n ECG: SR at 70, twi in l and flat in 1, poor r wave progression\n CXR: none done\n Non Contrast Abd CT: negative for obstructing stone or hydro\n Non Con Head CT: no acute bleed or shift\n UA: slight blood, otherwise no casts\n Assessment and Plan\n 52 yr old woman with DM, CAD< HTN, CRI presents with delirium and acute\n renal failure\n 1. ARF: acute on chronic and may have been precipitated by\n illness and dehydration, but was as high as 4.7 at recently. Bland\n sediment, CT scan neg for stone or hydro. FeNa 6%. Currently she is\n hyperkalemic, very elevated BUN and Cr. Given 1 unit saline without\n change in Cr, Could change to d5W and 3 Amps bicarb\n understanding\n however that her resp status is tenuous from an oxygenation and\n ventilation but feel that it is unlikey she can avoid HD at this point.\n . Would replete po bicarb for now and trend. Discuss urgent HD with\n Renal team this AM>\n 2. Altered mental status: neg non con head CT. Exam most\n consistent with delirum. Likely due to uremia, acidosis, exacerbated\n by morphine and possible hypercarbia.\n 3. Resp Distress: intermittent hypoxemia which resolves with\n waking. She looks like she at least has OSA and may well have obesity\n hypoventilation. Last ABG Paco2 was 40\n and normal pH. Not\n compensating for her met acidosis. Will monitor status closely, now\n awake but may need NIPPV when sleeping.\n 4. Pyoderma: get in touch with derm, consult wound care.\n Recent Rx with Remacaid.\n 5. AS: mod to severe\n careful with volume status\n 6. remainder of issues as per housestaff notes\n reviewed and\n discussed\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: lantus (1/2 dose and ssri)\n Lines / Intubation:\n 20 Gauge - 03:30 AM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n Communication: Met with her son for 15 minutes today at bedside and\n reviewed her condition, discussed indications for HD, and he was\n amenable to stay at for now an dpossibel Tx to later when not\n ICU level of care\n Code status: Full code\n Disposition: ICU\n Total time spent: 80 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336318,
"text": "52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED last PM by EMS for altered mental status. Pt\n received all usual care at - on dievrt. No records. Was in USOH\n until Saturday when diarrhea, Nausea, vomiting. Sunday and Monday\n confusion, repeating herself. Yesterday son and found aletered\n and called 911.\n In our ED creatinine was 10-noted to have lowerer ext ulcers - ?\n pyoderma gangrenosum. Given morphine - admitted to the 7 and\n triggered for somnelence and Tx to MICU for further management.\n Altered mental status (not Delirium)\n Assessment:\n Periods of alertness followed by lethargy and somnalance. When alert,\n able to state name, birth date and that she was in the hospital. Able\n to drink fluids and swallow pills without difficulty. Patient not\n cooperative with some care, becoming combative and fearful at times\n with turning and bathing.\n Action:\n No sedative meds given. Verbal reassurance provided.\n Response:\n Huge improvement when patient\ns sister arrived; much happier and more\n cooperative.\n Plan:\n Monitor mental status, avoid sedating meds. Continue to provide\n emotional support and reassurance with care.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN>80, creat>10. Patient\ns skin is very itchy. Mental status remains\n altered.\n Action:\n Decision made not to dialyse at this time. 500cc NS bolus IV followed\n by NS @ 150cc/hr for 1 liter.\n Response:\n UOP is slowly increasing.\n Plan:\n Continue to hydrate, follow lab values. require HD line placement\n and HD if no improvement.\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336388,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336390,
"text": "52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED last PM by EMS for altered mental status. Pt\n received all usual care at - on dievrt. No records. Was in USOH\n until Saturday when diarrhea, Nausea, vomiting. Sunday and Monday\n confusion, repeating herself. Yesterday son and found aletered\n and called 911.\n In our ED creatinine was 10-noted to have lowerer ext ulcers - ?\n pyoderma gangrenosum. Given morphine - admitted to the 7 and\n triggered for somnelence and Tx to MICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 336393,
"text": "Lung sounds\n RLL Lung Sounds:\n RUL Lung Sounds:\n LUL Lung Sounds:\n LLL Lung Sounds:\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Pt presents in \ns position in bed. Sats 96-98 O2 via N/C @ 1 L\n .RN, Resident and attending at bedside. Pt responsive to loud verbal\n stimuli, responding in only 1 word answers. ABG @ 2230:\n 7.17/42/117/16.Acclimated well to FM, BiPAP initiated via medium full\n FM @ no O2 needed. Pt tolerated well. Reassessed, PS increased to\n 12 to decrease WOB with good effect. . Follow-up ABG reveals continued\n metabolic acidosis. 7.20/40/88/16. Pt made frequent eye contact,\n phonating more clearly still not in sentences. Continues to fall back\n to sleep when stimuli removed. Plan: hemodyalisis today. Suggest\n continuing BiPAP as needed. R/O sleep apnea. Please see flow sheet for\n specifics.\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336397,
"text": "52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED last PM by EMS for altered mental status. Pt\n received all usual care at - on dievrt. No records. Was in USOH\n until Saturday when diarrhea, Nausea, vomiting. Sunday and Monday\n confusion, repeating herself. Yesterday son and found aletered\n and called 911.\n In our ED creatinine was 10-noted to have lowerer ext ulcers - ?\n pyoderma gangrenosum. Given morphine - admitted to the 7 and\n triggered for somnelence and Tx to MICU for further management.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt\ns resp status is labored, Pt. is Kussmal\ns breathing.\n Action:\n ABG drawn\n Response:\n Bicarb gtt and Bipap inttated.\n Plan:\n Repeat gas, and plan for possible H.D. tomorrow.\n .H/O acidosis, Metabolic\n Assessment:\n PH 7.17, PCO2 42, Po2 117, Bicarb 16.\n Action:\n Bicarb gtt, Bipap.\n Response:\n PH 7.20 PCO2 40 PO2 88 Bicarb 16\n Plan:\n Continue bicarb gtt.\n Impaired Skin Integrity\n Assessment:\n Bilat leg dressings. Bilat leg ulcers.\n Action:\n Change dressing to learge ulcer qd, and to smaller healing ulcer qod.\n Refer to skin care nurse\n .\n Response:\n No change at present.\n Plan:\n Following strict regime as planned out by skin care nurse.\n Altered mental status (not Delirium)\n Assessment:\n Pt. was becoming increasing obtunded.\n Action:\n Bipap, bicarb gtt. and narcan one time push.\n Response:\n Pt. became more alert, but remained confused. Narcan had no noted\n response.\n Plan:\n Attempt to manage pt\ns metabolic acidosis.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN/Creat 86/10.3\n Action:\n Fluids, and discussion with MICU team regarding possible hemodialysis.\n Response:\n Awatiing phleb to draw am labs.\n Plan:\n For line placement and possible H.D.\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336541,
"text": ".H/O acidosis, Metabolic\n Assessment:\n Metabolic Acidosis\n Action:\n Bicarb gtt (150MEQ in D5)\n Response:\n Improving PH\n Plan:\n Continue Bicarb gtt\n Impaired Skin Integrity\n Assessment:\n Bilateral lower ext. ulcers\n Action:\n Dressing changed as per skin care directives\n Response:\n Pt tolerated well. Bandage is clean, dry and intact.\n Plan:\n Continue daily dressing changes as per skin care directives.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on BIPAP.\n Action:\n Pt currently on RA.\n Response:\n NAD distress.\n Plan:\n Will continue BIPAP when sleeping.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n 5.3 K\n Action:\n Temporary dialysis line placed in IR\n Response:\n Pt tolerated well. Line is secure and patent.\n Plan:\n Will need dialysis. Continue to monitor lytes.\n Altered mental status (not Delirium)\n Assessment:\n Pt noted to be lethargic, combative and tearful at times- may be d/t\n uremia.\n Action:\n Maintain safety, reassure as needed.\n Response:\n Calmer when family is at bedside.\n Plan:\n Mental status expected to clear with dialysis.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Increasing BUN and Creatinine\n Action:\n Continue to monitor lytes. Renal consult\n Response:\n Continues to be in Renal failure.\n Plan:\n Will need dialysis.\n 52 yr old woman with DM, HTN, CRI (cr ) and ? of CVA without\n deficits. Brought into ED by EMS for altered mental status. Pt received\n all usual care at - on diversion. No records. Was in USOH until\n Saturday with diarrhea, Nausea, vomiting. Noted to be confused and\n repeating herself. Son found her with worsening mental status and\n called 911.\n In our ED creatinine was 10.\nAlso noted to have lower ext ulcers - ?\n pyoderma gangrenosum. Initially admitted to 7 but triggered for\n somnolence and tx to MICU for further management.\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336539,
"text": ".H/O acidosis, Metabolic\n Assessment:\n Metabolic Acidosis\n Action:\n Bicarb gtt (150MEQ in D5)\n Response:\n Improving PH\n Plan:\n Continue Bicarb gtt\n Impaired Skin Integrity\n Assessment:\n Bilateral lower ext. ulcers\n Action:\n Dressing changed as per skin care directives\n Response:\n Pt tolerated well. Bandage is clean, dry and intact.\n Plan:\n Continue daily dressing changes as per skin care directives.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on BIPAP.\n Action:\n Pt currently on RA.\n Response:\n NAD distress.\n Plan:\n Will continue BIPAP when sleeping.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n 5.3 K\n Action:\n Temporary dialysis line placed in IR\n Response:\n Pt tolerated well. Line is secure and patent.\n Plan:\n Will need dialysis. Continue to monitor lytes.\n Altered mental status (not Delirium)\n Assessment:\n Pt noted to be lethargic, combative and tearful at times- may be d/t\n uremia.\n Action:\n Maintain safety, reassure as needed.\n Response:\n Calmer when family is at bedside.\n Plan:\n Mental status expected to clear with dialysis.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Increasing BUN and Creatinine\n Action:\n Continue to monitor lytes. Renal consult\n Response:\n Continues to be in Renal failure.\n Plan:\n Will need dialysis.\n"
},
{
"category": "Nursing",
"chartdate": "2187-07-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 336119,
"text": "52 y/o female with PMH of HTN.DM,ARF admitted initially to 7 from\n home with c/o altered MS,pt is poor historian,transferred to MICU\n since pt was increasingly lethargic ,slow to respond,intermittently\n following commands,ABG 7.18/pco2 40/po2 90 lactae 0.8 On admission to\n MICU pt oriented to self,tearful pain on lower limbs? venous stasis\n ulcer,not panning to give any narcotics at this time in view of her\n altered MS.\n Altered mental status (not Delirium)\n Assessment:\n Oriented to self,slow to respond answering yes for all questions,pt\n poor historian,new to no records available CT head fronm ED was\n negative, pt is on narcotics at home ? overdose.Haemodinamically\n remains satble breathing efforts are normal,sats are maintained 95-100\n % on RA.Pupils were pinpoint ,positive for opiates in urine from ED.\n Action:\n Hold narcotics till further order\n Response:\n As MD pt more awake now,\n Plan:\n Narcan as needed,NPO for possible procedures,attempted for NG tube\n insertion pt was resistant to the procedure,thus failed,Hold sedating\n meds.\n .H/O renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt in ARF unclear etiology did not have any HD foley catheter in\n draining\n Action:\n NS 1000 ml X 2 hrs?pre-renal\n Response:\n Hydration,will monitor closely\n Plan:\n HD catheter insertion and possible HD if pt doesnot improve.CT abdomen\n and pelvis to R/O hydronephrosis\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 336451,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:28 AM\n Heparin Sodium (Prophylaxis) - 06:25 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.3\nC (97.3\n HR: 70 (67 - 75) bpm\n BP: 176/76(101) {135/59(80) - 183/88(149)} mmHg\n RR: 19 (11 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,160 mL\n 1,198 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,560 mL\n 1,198 mL\n Blood products:\n Total out:\n 1,891 mL\n 565 mL\n Urine:\n 1,591 mL\n 565 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 633 mL\n Respiratory support\n O2 Delivery Device: BiPaP FiO2 40%\n ABG: 7.20/40/88/16/-11\n Physical Examination\n GEN: Obese AA female, snoring loudly, opens eyes to name call, unable\n to answer questions\n HEENT: NCAT, EOMI, pin-point pupils, wide neck\n NECK: Supple, no LAD, no appreciable JVD\n CV: RRR, normal S1S2, 4/6 SEM, no rubs or gallops\n PULM: CTAB, no w/r/r, good air movement bilaterally\n ABD: Obese Soft, NTND, normoactive bowel sounds, no organomegaly, no\n abdominal bruit appreciated\n EXT: Warm and well perfused, full and symmetric distal pulses, no pedal\n edema. Legs bandaged.\n NEURO: EOMI, moves all 4 extremities upon request. Otherwise not\n cooperative with exam. 2+ patellar reflex. Downgoing toes b/l.\n Labs / Radiology\n 280 K/uL\n 9.5 g/dL\n 72 mg/dL\n 10.3 mg/dL\n 14 mEq/L\n 5.6 mEq/L\n 86 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.6 %\n 10.1 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n WBC\n 12.0\n 10.1\n Hct\n 31.7\n 30.6\n Plt\n 299\n 280\n Cr\n 10.6\n 10.3\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:8.9 mg/dL\n Assessment and Plan\n 52 y/o female w/ hx of CVA, DM, ? CAD, and HTN who presents w/ altered\n mental status and ARF.\n .\n # Altered Mental Status: Ddx includes uremia secondary to ARF versus\n toxin ingestion (i.e., narcotics). Currently no evidence to suggest\n infection, hypoglycemia.\n - MS appears to be improving; could consider Narcan PRN\n - hold all sedating meds\n - check CXR\n .\n # Acute on chronic renal failure: Wide differential, including\n pre-renal, renal and renal etiologies. Pt may be pre-renal if she was\n taking poor POs for some period of time. Appears to be making\n reasonable urine outpt, thus obstruction is less likely but still\n possible.\n - appreciate renal input\n - check FeNa; consider emperic volume repletion with NS in interim\n - consider PO bicarb\n - abd/pelvis CT scan in AM\n - renally dose all meds; avoid nephrotoxins; exchange atenolol for\n metoprolol and hold Topamax as these are renally cleared\n .\n # AG acidosis: be seen in the setting of ARF. Delta/delta ratio is\n <1. No evidence to support other cause such as lactic acidosis,\n ketoacidosis or toxin ingestion.\n - fluid hydration as above; could consider bicarb administration if\n worsening acidosis\n - repeat labs in AM and trend change\n .\n # LE wounds/PG: Will touch base with pt\ns dermatologist. Wound care\n consult.\n .\n # DM: Continue pt's home insulin (decrease dose slightly) with ISS.\n .\n # CAD: Continue home ASA; transition atenolol to metoprolol.\n .\n # HTN: Metoprolol as above. Hold CCB until pt's clinical direction more\n clear.\n .\n # GERD: PPI\n ICU Care\n Nutrition: PO diet\n Glycemic Control: sugars well controlled on ISS\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT: hep subq\n Stress ulcer: PO diet\n Communication: Comments:\n Code status: Full code\n Disposition: MICU\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336516,
"text": "Chief Complaint: acute renal failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Failed attempts at PIV\n Failed attempts at\n Bicarb - 4 AMPS overnight\n ABG 7.17/40/73\n This AM- more awake, perserverating on answers with questions\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:25 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 71 (67 - 75) bpm\n BP: 166/75(168) {135/59(80) - 183/88(168)} mmHg\n RR: 18 (11 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,160 mL\n 1,588 mL\n PO:\n 600 mL\n 100 mL\n TF:\n IVF:\n 2,560 mL\n 1,488 mL\n Blood products:\n Total out:\n 1,891 mL\n 865 mL\n Urine:\n 1,591 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.17/42/117/14/-12\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 Skin: Not assessed\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.5 g/dL\n 280 K/uL\n 72 mg/dL\n 10.3 mg/dL\n 14 mEq/L\n 5.6 mEq/L\n 86 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.6 %\n 10.1 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n WBC\n 12.0\n 10.1\n Hct\n 31.7\n 30.6\n Plt\n 299\n 280\n Cr\n 10.6\n 10.3\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:8.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336523,
"text": "Chief Complaint: acute renal failure,\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Failed attempts at PIV\n Failed attempts at a line\n Bicarb - 4 AMPS overnight\n ABG 7.17/40/73\n This AM- more awake, perserverating on answers with questions\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:25 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 71 (67 - 75) bpm\n BP: 166/75(168) {135/59(80) - 183/88(168)} mmHg\n RR: 18 (11 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,160 mL\n 1,588 mL\n PO:\n 600 mL\n 100 mL\n TF:\n IVF:\n 2,560 mL\n 1,488 mL\n Blood products:\n Total out:\n 1,891 mL\n 865 mL\n Urine:\n 1,591 mL\n 865 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,269 mL\n 723 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.17/42/117/14/-12\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 Skin: leg wounds dressing CDI\n Neurologic: Follows simple commands, Responds to: Verbal stimuli but\n repeats answers, perserverates\n Labs / Radiology\n 9.5 g/dL\n 280 K/uL\n 72 mg/dL\n 10.3 mg/dL\n 14 mEq/L\n 5.6 mEq/L\n 86 mg/dL\n 111 mEq/L\n 141 mEq/L\n 30.6 %\n 10.1 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n WBC\n 12.0\n 10.1\n Hct\n 31.7\n 30.6\n Plt\n 299\n 280\n Cr\n 10.6\n 10.3\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n Other labs: CK / CKMB / Troponin-T:73//0.07, Ca++:8.2 mg/dL, Mg++:2.2\n mg/dL, PO4:8.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 52 yo female CVA, DM, CRI with Acute on chronic\n renal failure.\n 1)Renal: discussed indications for acute HD with Renal on\n rounds. He felt strongly that since she had received more fluid\n overnight we should check stat repeat Cr now and if worse proceed with\n HD but if sig better hold off another 24 hrs. We discussed that she is\n quite acidotic with limited respiratory reserve and consistently high\n K. Going to IR for line place,emt today\n 2) OSA: BIPAP at night auto titrate\n 3) Delirium: mixed with uremia, acidosis, and med effect. More alert,\n follow exam closely.\n 2)DM-continue insulin\n 3)CV: continue lopressor, ASA\n 4)Wound care-wound care following.\n 5)ICU:SC heprin\n 6)FEN: renal diet.\n ICU Care\n Nutrition: \n Glycemic Control: glargine plus SSRI\n Lines:\n 20 Gauge - 03:30 AM\n Prophylaxis:\n DVT: SQ hep\n Communication: with son\n status: Full code\n Disposition :ICU\n Total time spent: 45\n critically ill with acidosis, intermittent\n delirium and resp distress\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336741,
"text": "Chief Complaint: acute renal faiuliure delirium\n I saw and examined the patient, and was physically present with the 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 DIALYSIS CATHETER - START 03:00 PM\n IR placement\n Persistent good UOP\n Tolerated BIPAP well overnight\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 07:45 PM\n Heparin Sodium (Prophylaxis) - 05:57 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 63 (63 - 79) bpm\n BP: 180/89(113) {157/67(88) - 200/124(113)} mmHg\n RR: 21 (6 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,042 mL\n 1,117 mL\n PO:\n 160 mL\n 100 mL\n TF:\n IVF:\n 2,882 mL\n 1,017 mL\n Blood products:\n Total out:\n 3,065 mL\n 960 mL\n Urine:\n 3,065 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -23 mL\n 157 mL\n Respiratory support\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n Overweight / 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: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (S1: Normal, No(t) Absent), (S2: Normal, Distant, No(t)\n Loud, No(t) Widely split , No(t) Fixed)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.2 g/dL\n 298 K/uL\n 104 mg/dL\n 8.9 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 79 mg/dL\n 110 mEq/L\n 144 mEq/L\n 28.4 %\n 9.0 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n 10:37 AM\n 08:01 PM\n 05:26 AM\n WBC\n 12.0\n 10.1\n 9.5\n 9.0\n Hct\n 31.7\n 30.6\n 28.4\n 28.4\n Plt\n 299\n 280\n 294\n 298\n Cr\n 10.6\n 10.3\n 9.7\n 9.4\n 8.9\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n 76\n 134\n 104\n Other labs: CK / CKMB / Troponin-T:73//0.07, Differential-Neuts:72.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:12.0 %, Eos:2.0 %, Ca++:8.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan 52 yo female CVA, DM, CRI with Acute on chronic\n renal failure.\n 1)Renal: discussed indications for acute HD with Renal on\n rounds. He felt strongly that since she had received more fluid\n overnight we should check stat repeat Cr now and if worse proceed with\n HD but if sig better hold off another 24 hrs. We discussed that she is\n quite acidotic with limited respiratory reserve and consistently high\n K. Going to IR for line place,emt today\n 2) OSA: BIPAP at night auto titrate\n 3) Delirium: mixed with uremia, acidosis, and med effect. More alert,\n follow exam closely.\n 2)DM-continue insulin\n 3)CV: continue lopressor, ASA\n 4)Wound care-wound care following.\n 5)ICU:SC heprin\n 6)FEN: renal diet.\n ICU Care\n Nutrition: renal diet\n Glycemic Control:\n Lines:\n Dialysis Catheter - 03:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336745,
"text": "Chief Complaint: acute renal faiuliure delirium\n I saw and examined the patient, and was physically present with the 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 DIALYSIS CATHETER - START 03:00 PM\n IR placement\n Persistent good UOP\n Tolerated BIPAP well overnight\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Hydralazine - 07:45 PM\n Heparin Sodium (Prophylaxis) - 05:57 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.3\nC (99.1\n HR: 63 (63 - 79) bpm\n BP: 180/89(113) {157/67(88) - 200/124(113)} mmHg\n RR: 21 (6 - 27) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,042 mL\n 1,117 mL\n PO:\n 160 mL\n 100 mL\n TF:\n IVF:\n 2,882 mL\n 1,017 mL\n Blood products:\n Total out:\n 3,065 mL\n 960 mL\n Urine:\n 3,065 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -23 mL\n 157 mL\n Respiratory support\n SpO2: 95%\n ABG: ///21/\n Physical Examination\n Pt currently refuses exam\n She is in NAD\n she is oriented to and her family\n but then shortly after asking\n for people who work at \n Labs / Radiology\n 9.2 g/dL\n 298 K/uL\n 104 mg/dL\n 8.9 mg/dL\n 21 mEq/L\n 4.3 mEq/L\n 79 mg/dL\n 110 mEq/L\n 144 mEq/L\n 28.4 %\n 9.0 K/uL\n [image002.jpg]\n 05:02 AM\n 05:13 PM\n 10:33 PM\n 10:37 AM\n 08:01 PM\n 05:26 AM\n WBC\n 12.0\n 10.1\n 9.5\n 9.0\n Hct\n 31.7\n 30.6\n 28.4\n 28.4\n Plt\n 299\n 280\n 294\n 298\n Cr\n 10.6\n 10.3\n 9.7\n 9.4\n 8.9\n TropT\n 0.07\n TCO2\n 16\n Glucose\n 71\n 72\n 76\n 134\n 104\n Other labs: CK / CKMB / Troponin-T:73//0.07, Differential-Neuts:72.0 %,\n Band:0.0 %, Lymph:14.0 %, Mono:12.0 %, Eos:2.0 %, Ca++:8.1 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan 52 yo female CVA, DM, CRI with Acute on chronic\n renal failure.\n 1)Renal: continues to have good UOP, today she has some improvement in\n Cr, BUN coming down, VBG shows improvement in acidosis\n albeit on\n continuous bicarb- discus with renal role of po bicitra\n 2) OSA: BIPAP at night auto titrate\n 3) Delirium: mixed with uremia, acidosis, and med effect. More alert,\n follow exam closely.\n 4) HTN: start po labetalol\n 4)DM-continue insulin, trend blood sugars\n 5)CV: continue lopressor, ASA\n 6)Wound care-wound care following\n ICU Care\n Nutrition: renal diet\n Glycemic Control: glargine and SSRI\n Lines:\n Dialysis Catheter - 03:00 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Communication: with family\n Code status: Full code\n Disposition : tx to floor\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-26 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1029188,
"text": " 1:40 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place temp HD line w/ side port.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with progressive renal failure, needing HD temp line.\n REASON FOR THIS EXAMINATION:\n Please place temp HD line w/ side port.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:38 PM\n Uncomplicated temporary hemodialysis catheter placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old woman with renal failure. Temporary hemodialysis\n catheter was requested.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist who was present and supervising throughout.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient\n explaining the risks and benefits of the procedure, the patient was placed\n supine on the angiography table and the right neck was prepped and draped in\n standard sterile fashion. A pre-procedure timeout was performed. Using\n sterile technique and local anesthesia, the right internal jugular vein was\n accessed and a 0.018 guidewire was advanced through the needle into the SVC\n under fluoroscopic guidance. Hard copy ultrasound images were obtained\n before and after venous access documenting vessel patency. Needle was then\n exchanged for a micropuncture sheath. The wire and the inner dilator of the\n sheath were removed and a 0.035 wire was advanced through the catheter\n into the IVC under fluoroscopic guidance. The micropuncture sheath was removed\n and the tract was sequentially dilated with 8, 12 and 14- French dilators. A\n temporary hemodialysis catheter was advanced over the wire with the tip\n positioned in the right atrium under fluoroscopic guidance. The wire was\n removed and the lumens of the catheter were flushed, heplocked and capped. The\n catheter was secured to the skin with 0 silk sutures. A sterile dressing was\n applied.\n\n The patient tolerated the procedure well without immediate complications.\n Final fluoroscopic image of the chest demonstrates the tip of the catheter to\n be located within the right atrium.\n\n IMPRESSION: Uncomplicated placement of a temporary hemodialysis catheter via\n the right internal jugular venous approach. The catheter is ready for use.\n (Over)\n\n 1:40 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place temp HD line w/ side port.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-26 00:00:00.000",
"description": "NON-TUNNELED",
"row_id": 1029189,
"text": ", C. MED MICU-7 1:40 PM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place temp HD line w/ side port.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with progressive renal failure, needing HD temp line.\n REASON FOR THIS EXAMINATION:\n Please place temp HD line w/ side port.\n ______________________________________________________________________________\n PFI REPORT\n Uncomplicated temporary hemodialysis catheter placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1029526,
"text": " 7:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for edema, infiltrate, other acute process\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with CAD and CP\n REASON FOR THIS EXAMINATION:\n please eval for edema, infiltrate, other acute process\n ______________________________________________________________________________\n WET READ: SBNa FRI 8:22 PM\n Right sided central line terminating at cavoatrial jxn. otherwise no\n significant change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess pulmonary edema and right IJ catheter.\n\n Comparison is made with prior study .\n\n Supraclavicular right-sided central line tip is in the cavoatrial junction.\n No pneumothorax or pleural effusion. Cardiomegaly is stable. The lungs are\n clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-25 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1028818,
"text": " 5:45 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for evidence of renal stones, hydronephrosis\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with acute on chronic renal failure and h/o renal stones.\n REASON FOR THIS EXAMINATION:\n Please evaluate for evidence of renal stones, hydronephrosis.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXRl WED 4:24 PM\n 1. No renal or ureteral calculi and no hydronephrosis.\n 2. Small fat-containing umbilical hernia with associated subcutaneous\n inflammatory changes.\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST CT OF THE ABDOMEN AND PELVIS\n\n HISTORY: 52-year-old woman with acute on chronic renal failure and history of\n renal stones. Please evaluate for evidence of renal stones or hydronephrosis.\n\n COMPARISON: None.\n\n FINDINGS:\n\n NON-CONTRAST CT OF THE ABDOMEN: There is bibasilar dependent atelectasis.\n There are coronary artery calcifications.\n\n Evaluation of abdominal viscera for focal lesion is limited without the use of\n intravenous contrast. Within this limitation, the liver, spleen, pancreas are\n normal. The gallbladder is distended. The kidneys have a normal non-contrast\n CT appearance. There is no renal or ureteral stone or hydronephrosis. There\n is no free fluid within the abdomen or free air.\n\n There is a small fat-containing midline anterior abdominal wall hernia. This\n is best appreciated on the sagittal imaging (300B:35), and has associated\n subcutaneous stranding. The loops of small bowel and colon are normal in\n caliber, without evidence of obstruction. There is a small hiatal hernia.\n There are no pathologically enlarged mesenteric or retroperitoneal lymph\n nodes. There is significant vascular calcifications of the aorta and branch\n vessels.\n\n NON-CONTRAST CT OF THE PELVIS: The rectum is normal. There are multiple\n diverticula of the sigmoid colon. A Foley catheter lies within the bladder.\n Unenhanced appearance of the uterus is unremarkable. There is no free pelvic\n fluid.\n\n There are degenerative changes of the thoracolumbar spine, and bilateral pars\n defects at L5.\n\n (Over)\n\n 5:45 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for evidence of renal stones, hydronephrosis\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. No renal or ureteral calculi. No hydronephrosis.\n 2. Small fat-containing umbilical hernia with associated inflammatory change\n of the subcutaneous tissue.\n 3. Atherosclerotic vascular calcification.\n 4. Bilateral L5 pars defects.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-25 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1028819,
"text": ", C. MED MICU-7 5:45 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please evaluate for evidence of renal stones, hydronephrosis\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with acute on chronic renal failure and h/o renal stones.\n REASON FOR THIS EXAMINATION:\n Please evaluate for evidence of renal stones, hydronephrosis.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PFI REPORT\n 1. No renal or ureteral calculi and no hydronephrosis.\n 2. Small fat-containing umbilical hernia with associated subcutaneous\n inflammatory changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1028755,
"text": " 6:38 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed or mass leison\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old woman with change in mental status\n REASON FOR THIS EXAMINATION:\n ? bleed or mass leison\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc TUE 7:34 PM\n No acute process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old female with change in mental status, evaluate for bleed\n or mass lesion.\n\n No prior studies available for comparison.\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no intra- or extra-axial hemorrhage, edema, mass effect,\n shift of normally midline structures, or acute major vascular territorial\n infarction. Ventricles and sulci are normal in caliber and configuration.\n Visualized paranasal sinuses and mastoid air cells are well aerated. Osseous\n structures are unremarkable.\n\n IMPRESSION: No acute intracranial process.\n\n Findings posted to the ED dashboard at the time of interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-07-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028848,
"text": " 9:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? evidence fluid overload, pneumonia\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old woman with acute on chronic renal failure, new leukocytosis\n REASON FOR THIS EXAMINATION:\n ? evidence fluid overload, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:28 A.M., \n\n HISTORY: Acute and chronic renal failure. New white count. Assess volume\n overload.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Lungs are clear. Heart is enlarged, particularly left atrium. Mild\n mediastinal and pulmonary vascular engorgement suggests mild volume overload.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2187-07-27 00:00:00.000",
"description": "Report",
"row_id": 221170,
"text": "\n\n\n"
},
{
"category": "ECG",
"chartdate": "2187-07-29 00:00:00.000",
"description": "Report",
"row_id": 221171,
"text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy with\nrepolarization abnormalities. Delayed R wave progression and ST segment\nchanges in the anterior precordial leads may be due to ischemia or left\nventricular hypertrophy. Clinical correlation is suggested. Compared to the\nprevious tracing of there is no significant difference.\n\n"
},
{
"category": "ECG",
"chartdate": "2187-07-24 00:00:00.000",
"description": "Report",
"row_id": 221172,
"text": "Normal sinus rhythm. Q wave in lead III and small R wave in lead aVF.\nST-T wave change in leads I, II and aVL and V4-V6. J point elevation\nin leads V1-V2. Possible old anterior wall myocardial infarction.\nClinical correlation is suggested. No previous tracing available for\ncomparison.\n\n"
}
] |
5,727 | 138,942 | 61yo M with DM, ESRD on HD, AF, sCHF (EF 30%), and hyperthyroidism who presents from rehab with nausea and poor po intake found to be in AF with RVR. . # Atrial Fibrillation with RVR: Rates to 170s initially. Received 2L of fluids in the ED without improvement in HR. He was given dilt boluses in the ED followed by gtt and transferred to MICU. He had a transient hypotension to the 90s (SBP) in the setting of rate and dilt gtt, however his pressures improved with slowing his rate. He is not anticoagulated with coumadin given history of GIB; on full-dose . His rate slowed to the 80s-90s and he was taken off of the dilt gtt and started on Diltiazem 90mg Q6H. Had an admission 2 weeks ago where hyperthyroism / thyrotoxicosis was felt to be contributing to tachycardia. His TSH remained <0.02, and Endocrine was reconsulted (see below). His rate control improved with treatment of thyroid disease. He was able to be transtioned to diltiazem ER 360mg daily with good control of heart rate. His heart rates were in the 90s at the time of discharge. . # Amiodarone induced hyperthyroidism, likely type II. Endocrine consulted for management. Patient was started on methimazole 20mg as well as Prednisone 40mg for combined control of likely type 2 amiodarone induced hyperthyroidism. Patient's T4 was initially elevated at 15.9, but decreased over 6 days to 9.7. Additionally, his Free T4 and T3 also decreased during the hospitalization. His TSH remained suppressed. Patient was subjectively improved with these changes. His doses were slowly downtitrated to 20mg of methimazole and 20mg prednisone prior to discharge. Started on bactrim prophylaxis given prolonged course of prednisone. . # ESRD: Tues/Thurs/Sat HD. team notified of admission via email. Evaluated and maintained on his outpatient schedule. Cinacalcet was uptitrated. . # Chest pain: Initially complained of chest pain in the ED, resolved by the time of ICU transfer without recurrence. His troponin is elevated chronically in the setting of renal failure. No ST changes noted on ECG. He was continued on aspirin. No further chest pain. His home statin was discontinued out of concern for contribution to generalized muscular pain. . # Hypoglycemia: Hypoglycemic in the ED and during the first few days of his stay, likely in the setting of poor PO intake and lantus. Initially held home standing lantus and covered with humalog sliding scale coverage. Endocrinology assisted in the adjustment of his sliding scale and basal insulin. . # HTN: On diltiazem and lisinopril. The dose of lisinopril was reduced due to concerns of previous episodes of hyperkalemia. . # Myalgias: Improved with ambulation, likely related to position/deconditioning. Atorvastatin stopped given concern for statin induced rhabdo, although CK was normal. If myalgias don't improve, can consider restart of atorvastatin, although most recent LDL was 51. . # Hyperlipidemia: Atorvastatin held as above, consider restart as outpatient. . # Diabetes: Continued on glargine with sliding scale. Sliding scale uptitrated while in hospital, likely will need further titration. . #Foot pain: likely multifactorial, with component of neuropathy. However patient also described claudication symptoms. ABIs were obtained and were abnormal. Outpatient vascular surgery follow up arranged. # Transitional Issues - F/U with endocrinology, vascular surgery - T/Th/Sat - Consider restarting atorvastatin based on LDL/improvement of myalgias Medications on Admission: 325mg atorvastatin 20mg lisinopril 20mg cinacalcet 30mg Senna pantoprazole 40mg daily nephrocaps daily Neurontin 300mg daily methimazole 20mg tab daily dilt 30mg 5 tabs QID albuterol 2 puffs q6 PRN/albuterol nebs PRN sevelamer 4 tabs TIS with meals benadryl 25mg 1-2 tabs q8 PRN Lantus 16 units lispro sliding scale oxycodone-acetaminophen 5/325 | The Doppler waveform at the right popliteal, posterior tibial, and dorsalis pedis is monophasic. The Doppler waveform at the left popliteal artery is still triphasic with monophasic waveform at the posterior tibial artery and dorsalis pedis. Evaluate for DVT in the right lower extremity. Poor R wave progression.Non-specific ST-T wave changes. RSR' pattern in lead V1.Low limb lead voltage. Previously noted tiny right pleural effusion appears resolved. IMPRESSION: Moderate outflow disease on the right at the level of superficial femoral artery and posterior tibial artery and mild outflow obstruction at the level of left posterior tibial artery. Patchy opacities at lung bases are likely reflective of atelectasis. Since the previous tracingof the rate is slower.TRACING #1 pna FINAL REPORT INDICATION: Tachycardia. Mild pulmonary vascular congestion. PORTABLE UPRIGHT AP VIEW OF THE CHEST: There are low lung volumes. There appears to be mild pulmonary vascular congestion. TECHNIQUE: Doppler waveforms, pulse volume recordings, and segmental blood pressures were acquired in bilateral lower extremities at rest. IMPRESSION: No DVT in the right lower extremity. Borderline low limb leadvoltage. ST-T wave abnormalities. ST-T wave abnormalities. Low QRS voltage in the limb leads. RIGHT LOWER EXTREMITY VENOUS ULTRASOUND COMPARISON: , right lower extremity venous ultrasound. PFI REPORT PFI: No DVT in the right lower extremity. IMPRESSION: Low lung volumes with patchy opacities in the lung bases which may reflect atelectasis, though infection cannot be excluded. Since the previoustracing the rate slower.TRACING #2 PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 1:36 AM PFI: No DVT in the right lower extremity. Atrial fibrillation with controlled ventricular response. FINDINGS: Normal triphasic Doppler waveforms were acquired in the common femoral arteries bilaterally. Comparedto the previous tracing of rapid atrial flutter is present. REASON FOR THIS EXAMINATION: DVT in RLE? REASON FOR THIS EXAMINATION: DVT in RLE? FINDINGS: Color and grayscale son of bilateral common femoral and right-sided superficial femoral, popliteal, and calf veins were evaluated. The mediastinal and hilar contours are unchanged. Probable atrial flutter with 2:1 A-V conduction with an atrial rate ofabout 320 and a ventricular rate of about 160. The heart size remains moderately enlarged. Evaluation for peripheral arterial disease. The ABI index on the right 0.58 and ABI index on the left is 0.85. Vessels demonstrated normal flow, compressibility and augmentation. FINAL REPORT INDICATION: End-stage renal disease, refusing heparin shots and not ambulating now with pain in lower legs. Otherwise, findings are unchanged. 4:47 PM CHEST (PORTABLE AP) Clip # Reason: ? The pulse volume recordings are symmetrical. There are multilevel degenerative changes in the thoracic spine. COMPARISON: . Atrial fibrillation with rapid ventricular response. Atrial fibrillation with rapid ventricular response. Since the previous tracing of therate is faster. 11:29 PM UNILAT LOWER EXT VEINS RIGHT Clip # Reason: RT LEG PAIN R/O DVT Admitting Diagnosis: TACHYCARDIA MEDICAL CONDITION: 61 year old man with ESRD, refusing heparin shots and not ambulating, now with pain in lower legs. , D. MED FA5 11:29 PM UNILAT LOWER EXT VEINS RIGHT Clip # Reason: RT LEG PAIN R/O DVT Admitting Diagnosis: TACHYCARDIA MEDICAL CONDITION: 61 year old man with ESRD, refusing heparin shots and not ambulating, now with pain in lower legs. 9:03 AM ART EXT (REST ONLY) Clip # Reason: RIGHT FOOT PAIN Admitting Diagnosis: TACHYCARDIA MEDICAL CONDITION: 61 year old man with ESRD, hyperthyroidism, A fib, CHF, DMII, Hyperlipidemia with right painful foot. REASON FOR THIS EXAMINATION: Evaluate for PAD FINAL REPORT NON-INVASIVE ARTERIAL STUDY AT REST INDICATION: 61-year-old man with end-stage renal disease, hyperthyroidism, atrial fibrillation, congestive heart failure, diabetes mellitus, hyperlipidemia, with right painful foot. pna MEDICAL CONDITION: 61 year old man with tachycardia REASON FOR THIS EXAMINATION: ? No pneumothorax is demonstrated. | 8 | [
{
"category": "Radiology",
"chartdate": "2158-09-04 00:00:00.000",
"description": "ART EXT (REST ONLY)",
"row_id": 1203880,
"text": " 9:03 AM\n ART EXT (REST ONLY) Clip # \n Reason: RIGHT FOOT PAIN\n Admitting Diagnosis: TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ESRD, hyperthyroidism, A fib, CHF, DMII, Hyperlipidemia\n with right painful foot.\n REASON FOR THIS EXAMINATION:\n Evaluate for PAD\n ______________________________________________________________________________\n FINAL REPORT\n NON-INVASIVE ARTERIAL STUDY AT REST\n\n INDICATION: 61-year-old man with end-stage renal disease, hyperthyroidism,\n atrial fibrillation, congestive heart failure, diabetes mellitus,\n hyperlipidemia, with right painful foot. Evaluation for peripheral arterial\n disease.\n\n No studies available for comparison.\n\n TECHNIQUE: Doppler waveforms, pulse volume recordings, and segmental blood\n pressures were acquired in bilateral lower extremities at rest.\n\n FINDINGS: Normal triphasic Doppler waveforms were acquired in the common\n femoral arteries bilaterally. The Doppler waveform at the right popliteal,\n posterior tibial, and dorsalis pedis is monophasic. The Doppler waveform at\n the left popliteal artery is still triphasic with monophasic waveform at the\n posterior tibial artery and dorsalis pedis. The ABI index on the right 0.58\n and ABI index on the left is 0.85. The pulse volume recordings are\n symmetrical.\n\n IMPRESSION: Moderate outflow disease on the right at the level of superficial\n femoral artery and posterior tibial artery and mild outflow obstruction at the\n level of left posterior tibial artery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1203595,
"text": " 4:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with tachycardia\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tachycardia.\n\n COMPARISON: .\n\n PORTABLE UPRIGHT AP VIEW OF THE CHEST: There are low lung volumes. The heart\n size remains moderately enlarged. The mediastinal and hilar contours are\n unchanged. There appears to be mild pulmonary vascular congestion.\n Previously noted tiny right pleural effusion appears resolved. Patchy\n opacities at lung bases are likely reflective of atelectasis. No pneumothorax\n is demonstrated. There are multilevel degenerative changes in the thoracic\n spine.\n\n IMPRESSION: Low lung volumes with patchy opacities in the lung bases which\n may reflect atelectasis, though infection cannot be excluded. Mild pulmonary\n vascular congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-09-10 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 1204795,
"text": " 11:29 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: RT LEG PAIN R/O DVT\n Admitting Diagnosis: TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ESRD, refusing heparin shots and not ambulating, now with\n pain in lower legs.\n REASON FOR THIS EXAMINATION:\n DVT in RLE?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 1:36 AM\n PFI: No DVT in the right lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease, refusing heparin shots and not\n ambulating now with pain in lower legs. Evaluate for DVT in the right lower\n extremity.\n\n RIGHT LOWER EXTREMITY VENOUS ULTRASOUND\n\n COMPARISON: , right lower extremity venous ultrasound.\n\n FINDINGS: Color and grayscale son of bilateral common femoral and\n right-sided superficial femoral, popliteal, and calf veins were evaluated.\n Vessels demonstrated normal flow, compressibility and augmentation.\n\n IMPRESSION: No DVT in the right lower extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2158-09-10 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 1204796,
"text": ", D. MED FA5 11:29 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: RT LEG PAIN R/O DVT\n Admitting Diagnosis: TACHYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with ESRD, refusing heparin shots and not ambulating, now with\n pain in lower legs.\n REASON FOR THIS EXAMINATION:\n DVT in RLE?\n ______________________________________________________________________________\n PFI REPORT\n PFI: No DVT in the right lower extremity.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2158-09-05 00:00:00.000",
"description": "Report",
"row_id": 290083,
"text": "Atrial fibrillation with rapid ventricular response. Borderline low limb lead\nvoltage. ST-T wave abnormalities. Since the previous tracing of the\nrate is faster. Otherwise, findings are unchanged.\n\n"
},
{
"category": "ECG",
"chartdate": "2158-09-03 00:00:00.000",
"description": "Report",
"row_id": 290084,
"text": "Atrial fibrillation with controlled ventricular response. Since the previous\ntracing the rate slower.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2158-09-02 00:00:00.000",
"description": "Report",
"row_id": 290085,
"text": "Atrial fibrillation with rapid ventricular response. RSR' pattern in lead V1.\nLow limb lead voltage. ST-T wave abnormalities. Since the previous tracing\nof the rate is slower.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2158-09-01 00:00:00.000",
"description": "Report",
"row_id": 290086,
"text": "Probable atrial flutter with 2:1 A-V conduction with an atrial rate of\nabout 320 and a ventricular rate of about 160. Poor R wave progression.\nNon-specific ST-T wave changes. Low QRS voltage in the limb leads. Compared\nto the previous tracing of rapid atrial flutter is present.\n\n"
}
] |
99,783 | 174,582 | The patient was admitted to the hospital and brought to the operating room on where the patient underwent Bental with #29 mechanical aortic valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He was initially hypertensive and required a nicardipine gtt. He was started on lopressor and lasix. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. On POD#1 he transferred to the floor. Chest tubes and pacing wires were discontinued without complication. Post opertatively he was noted to have a new LBBB which has since resolved. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was started on anticoagulation therapy his goal INR 2.5-3.5. He was given the following Coumadin doses -5mg/7.5mg/7.5mg/7.5mg/5 mg with INR 2.5 at the time of discharge. By the time of discharge on POD# 5, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with visiting nurse services in good condition with appropriate follow up instructions. His first VNA INR draw is to be done . | Normal descending aorta diameter. Moderate (2+)aortic regurgitation is seen. Probable left ventricular hypertrophy.Left bundle-branch block, less marked compared to the previous tracingof . MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Moderately dilated ascendingaorta Moderately dilated aortic arch. Probable left ventricular hypertrophy.Left bundle-branch block is a similar finding to the previous tracingof . FINDINGS: As compared to the previous radiograph, there is unchanged evidence of a small left pleural effusion, better seen on the lateral than on the frontal radiograph. FINDINGS: AP single view of the chest has been obtained with patient in supine position. There is no aortic stenosis.The mitral valve appears structurally normal with trivial mitralregurgitation.Post-Bypass:The patient is in sinus ryhthm on a phenylephrine infusion.#29 St. Moderate (2+) AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. . Simpleatheroma in descending aorta.AORTIC VALVE: Bicuspid aortic valve. The ascending aortaand arch are moderately dilated. Mechanical Aortic Valve graft appears well seated. IMPRESSION: Satisfactory first post-operative chest findings status post Bentall procedure. Normal size of the cardiac silhouette. The aortic valve is bicuspid. There are noapparent peri-valvular leaks. Diaphragmatic contours and lateral pleural sinuses are free. Subsequently, there is a small amount of retrocardiac atelectasis. Otherwise,no apparent diagnostic interim change.TRACING #2 REASON FOR THIS EXAMINATION: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Sinus rhythm. Sinus rhythm. Sinus rhythm. The patient appears tobe in sinus rhythm. Valvular heart disease.Height: (in) 70Weight (lb): 196BSA (m2): 2.07 m2Status: InpatientDate/Time: at 09:03Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the LAA.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%).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: Moderately dilated aorta at sinus level. Washing jets are present.Normal left ventricular function - EF50-55%Trace MR remains.Remainder of exam is unchanged. No PS.Physiologic PR.GENERAL COMMENTS: Written informed consent was obtained from the patient. The patient was under general anesthesiathroughout the procedure. An ETT has been placed, seen to terminate in the trachea some 7 cm above the level of the carina. Hypertension. There are lower lung volumes with some atelectatic changes especially in the retrocardiac region. Results were personally reviewed with the MD caring forthe patient.Conclusions:Pre-Bypass:Left ventricular wall thickness, cavity size, and global systolic function arenormal (LVEF>55%).Right ventricular chamber size and free wall motion are normal.The aortic root is moderately dilated at the sinus level. Left bundle-branch block is again recorded. Clinical correlation is suggested.TRACING #1 Left axis deviation. Left axis deviation. There is no evidence of pneumothorax and both lungs are well aerated. The sternal wires and the valvular replacement are in constant position. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. A right internal jugular approach sheath carries a Swan-Ganz catheter, tip of which reaches the central portion of the pulmonary artery. I certify I was present incompliance with HCFA regulations. New row of midline sternotomy wires is observed as well as a metallic ring-shaped component of an aortic valve prosthesis. Left bundle-branch block, new as compared with previoustracing of . No pneumothorax. No pneumothorax. Heart size has not changed significantly in comparison with the pre-operative study. No TEE related complications. An NG tube reaches well below the diaphragm where it is curved up in the stomach. There are no interval diagnostic changes since that tracing. 1:46 PM CHEST PORT. No AS. No other relevant changes. Please page at with abnormalities. ATEE was performed in the location listed above. No evidence of pneumothorax. COMPARISON: . Two mediastinal drainage tubes have been placed from below. FINDINGS: In comparison with study of , all of the monitoring and support devices have been removed. Sinus rhythm with increase in rate as compared with previous tracingof . 11:34 AM CHEST (PA & LAT) Clip # Reason: evaluate for effusion Admitting Diagnosis: AORTIC INSUFFICIENCY\BENTAL PROCEDURE /SDA MEDICAL CONDITION: 42 year old man POD3 AVR (Mechanical) REASON FOR THIS EXAMINATION: evaluate for effusion FINAL REPORT CHEST RADIOGRAPH INDICATION: Evaluation for pleural effusion. LINE PLACEMENT Clip # Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o Admitting Diagnosis: AORTIC INSUFFICIENCY\BENTAL PROCEDURE /SDA MEDICAL CONDITION: 42 year old man s/p Bentall procedure. INDICATION: 42-year-old male patient status post Bentall procedure, first post-operative examination, on fast track extubation cardiac surgery protocol. | 8 | [
{
"category": "Echo",
"chartdate": "2125-09-13 00:00:00.000",
"description": "Report",
"row_id": 104134,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Hypertension. Valvular heart disease.\nHeight: (in) 70\nWeight (lb): 196\nBSA (m2): 2.07 m2\nStatus: Inpatient\nDate/Time: at 09:03\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\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aorta at sinus level. Moderately dilated ascending\naorta Moderately dilated aortic arch. Normal descending aorta diameter. Simple\natheroma in descending aorta.\n\nAORTIC VALVE: Bicuspid aortic valve. No AS. Moderate (2+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. . 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\nGENERAL COMMENTS: Written informed consent was obtained from the patient. A\nTEE was performed in the location listed above. I certify I was present in\ncompliance with HCFA regulations. The patient was under general anesthesia\nthroughout the procedure. No TEE related complications. The patient appears to\nbe in sinus rhythm. Results were personally reviewed with the MD caring for\nthe patient.\n\nConclusions:\nPre-Bypass:\nLeft ventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%).\nRight ventricular chamber size and free wall motion are normal.\nThe aortic root is moderately dilated at the sinus level. The ascending aorta\nand arch are moderately dilated. The aortic valve is bicuspid. Moderate (2+)\naortic regurgitation is seen. There is no aortic stenosis.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nPost-Bypass:\nThe patient is in sinus ryhthm on a phenylephrine infusion.\n#29 St. Mechanical Aortic Valve graft appears well seated. There are no\napparent peri-valvular leaks. Washing jets are present.\nNormal left ventricular function - EF50-55%\nTrace MR remains.\nRemainder of exam is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-09-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1251701,
"text": " 1:46 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o\n Admitting Diagnosis: AORTIC INSUFFICIENCY\\BENTAL PROCEDURE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p Bentall procedure. Please page at with\n abnormalities.\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, ?line placement, r/o PTX/Effusion\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 42-year-old male patient status post Bentall procedure, first\n post-operative examination, on fast track extubation cardiac surgery protocol.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. An ETT has been placed, seen to terminate in the trachea\n some 7 cm above the level of the carina. New row of midline sternotomy wires\n is observed as well as a metallic ring-shaped component of an aortic valve\n prosthesis. Heart size has not changed significantly in comparison with the\n pre-operative study. A right internal jugular approach sheath carries a\n Swan-Ganz catheter, tip of which reaches the central portion of the pulmonary\n artery. An NG tube reaches well below the diaphragm where it is curved up in\n the stomach. Two mediastinal drainage tubes have been placed from below.\n There is no evidence of pneumothorax and both lungs are well aerated.\n Diaphragmatic contours and lateral pleural sinuses are free.\n\n IMPRESSION: Satisfactory first post-operative chest findings status post\n Bentall procedure. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-09-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1252012,
"text": " 11:34 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for effusion\n Admitting Diagnosis: AORTIC INSUFFICIENCY\\BENTAL PROCEDURE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man POD3 AVR (Mechanical)\n REASON FOR THIS EXAMINATION:\n evaluate for effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pleural effusion.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is unchanged evidence\n of a small left pleural effusion, better seen on the lateral than on the\n frontal radiograph. Subsequently, there is a small amount of retrocardiac\n atelectasis. The sternal wires and the valvular replacement are in constant\n position. No pneumothorax. No other relevant changes. Normal size of the\n cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2125-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1251937,
"text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for PTX\n Admitting Diagnosis: AORTIC INSUFFICIENCY\\BENTAL PROCEDURE /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man POD2 Bental AVR CT removal\n REASON FOR THIS EXAMINATION:\n evaluate for PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal, to assess for pneumothorax.\n\n FINDINGS: In comparison with study of , all of the monitoring and support\n devices have been removed. No evidence of pneumothorax. There are lower lung\n volumes with some atelectatic changes especially in the retrocardiac region.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-09-13 00:00:00.000",
"description": "Report",
"row_id": 305595,
"text": "Sinus rhythm with increase in rate as compared with previous tracing\nof . Left bundle-branch block is again recorded. Otherwise,\nno apparent diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2125-09-16 00:00:00.000",
"description": "Report",
"row_id": 305592,
"text": "Sinus rhythm. Left axis deviation. Probable left ventricular hypertrophy.\nLeft bundle-branch block is a similar finding to the previous tracing\nof . There are no interval diagnostic changes since that tracing.\n\n"
},
{
"category": "ECG",
"chartdate": "2125-09-15 00:00:00.000",
"description": "Report",
"row_id": 305593,
"text": "Sinus rhythm. Left axis deviation. Probable left ventricular hypertrophy.\nLeft bundle-branch block, less marked compared to the previous tracing\nof .\n\n\n"
},
{
"category": "ECG",
"chartdate": "2125-09-13 00:00:00.000",
"description": "Report",
"row_id": 305594,
"text": "Sinus rhythm. Left bundle-branch block, new as compared with previous\ntracing of . Clinical correlation is suggested.\nTRACING #1\n\n"
}
] |
5,909 | 175,121 | Patient is a 55 year-old gentleman with history of DMI, pancreas/ transplant (failed), ESRD, CAD s/p multiple stents, CHF (EF 50-55%), Hep B/C who was initially admitted on for RLQ pain. Pt reported RLQ pain to be sharp ()and consistent exacerbated by movement. Pt reports similar pain in that resulted in colostomy for perforated colon. Pt reports intermittent episodes of chills since but denies F/N/V/BRBPR/diarrhea/constipation. CT negative for obstruction or appendicitis. Evaluated by transplant team but determine not to have any surgical issues. While on floor, patient became bradycardic to 30s, hypotensive to systolic 90s, and developed chest pain on . EKG revealed ventricular escape rhythm. EP was consulted and patient received pacer, placed in right cephalic vein. . # Cardiac = Rhythm: Patient received pacer . Unknown etiology of arrhythmia, most likely secondary to extensive CAD. Pt back on beta-blocker and amiodorone = PUMP: EF >60% per ECHO . Fluid overloaded per CXR and labs but dry on exam - dealt with via dialysis. = ISCHEMIA: Patient with chest pain in setting of bradycardia. Pt found to have elevated 0.20 trop, likely due to failure . # RLQ pain - unclear etiology. ruled out for appendicitis, perforation. pyelonephritis a possibility but no stranding related to either native or transplant kidneys. in d/w radiology, not clearly related to constipation as not impressive amts of stool. symptoms not c/w mesenteric/colonic ischemia and pt is guiac neg. possible infectious etiology, ? c.diff, but nl wbc so not high suspicion. Patient with history of abdominal pain in past- could be hepatic or splenic infarct vs. atypical chest pain. At this point pt describes that pain has decreased signficantly and now has a good appetite. - PRN Dilaudid for pain control - Check stim, could be related to adrenal insufficiency # ESRD s/p transplant - continued on HD, monitor electrolytes - HD M/W/F , this wk, pt received HD on Tuesday as well continue renagel/phoslo - increase phoslo to 3 pills TID, send PTH - check ionized calcium - pt found to be hyperkalemic with a potassium of 6 given 15 of kayexalate and 1 amp of bicarb. # ? ANEMIA - at goal - continue epo 10,000 - iron studies TIBC decreased at 216 ,Ferritin levels wnl at 315, TRF decreased at 166. # s/p transplant - can stop t-plant meds per transplant team (bactrim, prednisone) # DM - cont lantus and humalog SS | states sometimes it takes a day for effects to work.Abdomen soft , non-tender with BSX4.Skin: Pt. SEE TRANSFER NOTE FOR UPDATECV: Pt has cont in PMR HR 60-70 no VEA noted, pacer checked by cardiology and functioning fine. His initiall CT was neg so far. Slow junctional rhythm without change compared to the previous tracingof .TRACING #1 Order for one time dose of 1 mg obtained with good effect.CV: HR 60 AV paced with no ectopy. Medicated with 2mgDilaudid with negligible effect. He is without SSCPGI: pt with x4 BM (good rsp to kayexalate). His dsg over the site is D&I.Resp: pt with only crackles at bases and on RA his O2 sat was 98% so the O2 is now off.Neuro; pt remained fully A&O x3. He was given 1mg IVP MSO4 with min rsp. Previous cx have all been negGI: pt still with abd pain. to be dialyzed in am.Resp: RR 11-17, 02 sats >95% on RA.LS clear to upper lobes with dimished bases. Slow junctional rhythm without change compared to the previous tracingof .TRACING #2 He cont to c/o mild RLQ pain but no SSCP. K+ was 6.0 at beginning of shift, 1 amp bicarb and 15mg Kayexalate given. His pulses where all dopplerable and his VS remained stableafter the procedure. K+ still 6.0 from am . Some redness noted to area,MD aware, no interventions ordered.Pt. He reported that his RLQ pain was abating. His BP did not rsp to IVF and he is a HD pt. He has left sided weakness and is w/c bound at home.Heme: his hct and coags are WNLID: pt has been afebrile here. No c/o SOB.GI/GU:Pt. w/u still in progress but few rewsults available. He remained in CHB but was fully mentating so he was sent to MICU for monitoring til they could take him to EP lab for a permanent pacemaker.MICU Adm Course:CV: pt cont in CHB rate of 34-44, BP was 98/20. Eating well and abd pain almost goneGU: tol HD wellA/P:Will cont to monitor for proper function Asses pain control ?changing to po pills. His EKG is neg and fully paced, normal K+ is 6 for him prior to HDSocial:pt's wife and daughter in to visit, updated by MDs post procedure,A/P:Will follow closely s/p procedure, note pulses,check site and VS changes keep arm in sling, avoid excessive turning and check CXR in the am. did get night and day confused but was reoriented easily.pleasant,and cooperative,MAE,only c/o pain to pacemaker insertion site late in night. Atrial sensed and ventricular paced rhythm, new compared to the previoustracing of .TRACING #3 R arm is in sling due to pacemaker insertion and should remain in sling. Baseline artifactProbable junctional rhythmIntraventricular conduction delay witwh left axis deviation - probable in partleft anterior fascicular block and additional intraventricular conduction delayPoor R wave progression with late precordial QRS transition - could be due inpart to left axis deviation/ intraventricular conduction delay but consideralso prior anterior myocardial infarctionNonspecific ST-T wave changes with prolonged Q-Tc intervalClinical correlation is suggested for possible in part metabolc/drug effectSince previous tracing of , junctional rhythm and further left axisdeviation now present Team aware, nointerventions ordered. He has been adv to clr liqs but that's all He hasnot passed any stool while here. Skin on LE very dry, lotion applied.Social: Wife and daughter saw pt. His BP was 98-105/20's. His BS are being covered with SS insulin.GU: pt to have HD tomorrow. Insertion site haas DSD with Tegaderm with slight staining. Nsg Adm NoteMr is a 57yo man adm to MICU for close observation of new onset CHB prior to his pacemaker insertion.PMH:DM,CAD,CHF,MI's with stent placements,Hepatitis B&C, hypothyroidism,PVD,CVA,ESRD,failed renal& pancreatitis, diverticulitis with resectionsAll:?codeine and gentamycinMeds:numerous INC:Lantus, bactrium,renalgel,phospholo,synthroid,toprolPt intitially adm on to 7 with abd c/o pain. to be dialyzed in am and is scheduled for chest X-ray. He was found to have a HR of 34 CHB, with BP 100/. He recieved x1 dose of vanco post procedure at 6pm. Will probably get called out today. during day.Plan: Pt. NBP 90-100s/40-50's. No urine output, no BM even after Kayexalate. Nursing progress note:Neuro: Pt.is alert and oriented (pt. This am pt awoke to c/o CP and ^SOB. Asses for fluid overload, to have HD in the am Keep to clr liqs for now, note stool amts Cont to follow fever curve Asses for pain, medicate with dialudid if needed He did have a K+ of 6.0 at 6pm. NPN-MICUMr has done well. He was than sent to Cath Lab and returned at 5pm with a DDD-AV pacemaker set at 60. Pt. Pt. is on clear liquid diet. has 2 PIVs, both in R arm. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2182-10-29 00:00:00.000",
"description": "Report",
"row_id": 1339902,
"text": "Nursing progress note:\n\nNeuro: Pt.is alert and oriented (pt. did get night and day confused but was reoriented easily.pleasant,and cooperative,MAE,only c/o pain to pacemaker insertion site late in night. Medicated with 2mg\nDilaudid with negligible effect. Order for one time dose of 1 mg obtained with good effect.\n\nCV: HR 60 AV paced with no ectopy. Insertion site haas DSD with Tegaderm with slight staining. Some redness noted to area,MD aware, no interventions ordered.Pt. has 2 PIVs, both in R arm. R arm is in sling due to pacemaker insertion and should remain in sling. NBP 90-100s/40-50's. K+ was 6.0 at beginning of shift, 1 amp bicarb and 15mg Kayexalate given. K+ still 6.0 from am . Team aware, no\ninterventions ordered. Pt. to be dialyzed in am.\n\nResp: RR 11-17, 02 sats >95% on RA.LS clear to upper lobes with dimished bases. No c/o SOB.\n\nGI/GU:Pt. is on clear liquid diet. No urine output, no BM even after Kayexalate. Pt. states sometimes it takes a day for effects to work.Abdomen soft , non-tender with BSX4.\n\nSkin: Pt. missing toes and fingers. Skin on LE very dry, lotion applied.\n\nSocial: Wife and daughter saw pt. during day.\n\nPlan: Pt. to be dialyzed in am and is scheduled for chest X-ray. Will probably get called out today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-10-29 00:00:00.000",
"description": "Report",
"row_id": 1339903,
"text": "NPN-MICU\nMr has done well. SEE TRANSFER NOTE FOR UPDATE\nCV: Pt has cont in PMR HR 60-70 no VEA noted, pacer checked by cardiology and functioning fine. He is without SSCP\nGI: pt with x4 BM (good rsp to kayexalate). Eating well and abd pain almost gone\nGU: tol HD well\nA/P:Will cont to monitor for proper function\n Asses pain control ?changing to po pills.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-10-28 00:00:00.000",
"description": "Report",
"row_id": 1339901,
"text": "Nsg Adm Note\nMr is a 57yo man adm to MICU for close observation of new onset CHB prior to his pacemaker insertion.\nPMH:DM,CAD,CHF,MI's with stent placements,Hepatitis B&C, hypothyroidism,PVD,CVA,ESRD,failed renal& pancreatitis, diverticulitis with resections\nAll:?codeine and gentamycin\nMeds:numerous INC:Lantus, bactrium,renalgel,phospholo,synthroid,toprol\nPt intitially adm on to 7 with abd c/o pain. His initiall CT was neg so far. This am pt awoke to c/o CP and ^SOB. He was found to have a HR of 34 CHB, with BP 100/. His BP did not rsp to IVF and he is a HD pt. He remained in CHB but was fully mentating so he was sent to MICU for monitoring til they could take him to EP lab for a permanent pacemaker.\nMICU Adm Course:\nCV: pt cont in CHB rate of 34-44, BP was 98/20. He cont to c/o mild RLQ pain but no SSCP. He was given 1mg IVP MSO4 with min rsp. He was than sent to Cath Lab and returned at 5pm with a DDD-AV pacemaker set at 60. His BP was 98-105/20's. He reported that his RLQ pain was abating. His pulses where all dopplerable and his VS remained stable\nafter the procedure. His dsg over the site is D&I.\nResp: pt with only crackles at bases and on RA his O2 sat was 98% so the O2 is now off.\nNeuro; pt remained fully A&O x3. He has left sided weakness and is w/c bound at home.\nHeme: his hct and coags are WNL\nID: pt has been afebrile here. He recieved x1 dose of vanco post procedure at 6pm. Previous cx have all been neg\nGI: pt still with abd pain. He has been adv to clr liqs but that's all He hasnot passed any stool while here. w/u still in progress but few rewsults available. His BS are being covered with SS insulin.\nGU: pt to have HD tomorrow. He did have a K+ of 6.0 at 6pm. His EKG is neg and fully paced, normal K+ is 6 for him prior to HD\nSocial:pt's wife and daughter in to visit, updated by MDs post procedure,\nA/P:Will follow closely s/p procedure, note pulses,check site and VS changes keep arm in sling, avoid excessive turning and check CXR in the am.\n Asses for fluid overload, to have HD in the am\n Keep to clr liqs for now, note stool amts\n Cont to follow fever curve\n Asses for pain, medicate with dialudid if needed\n"
},
{
"category": "ECG",
"chartdate": "2182-10-28 00:00:00.000",
"description": "Report",
"row_id": 301966,
"text": "Baseline artifact\nProbable junctional rhythm\nIntraventricular conduction delay witwh left axis deviation - probable in part\nleft anterior fascicular block and additional intraventricular conduction delay\nPoor R wave progression with late precordial QRS transition - could be due in\npart to left axis deviation/ intraventricular conduction delay but consider\nalso prior anterior myocardial infarction\nNonspecific ST-T wave changes with prolonged Q-Tc interval\nClinical correlation is suggested for possible in part metabolc/drug effect\nSince previous tracing of , junctional rhythm and further left axis\ndeviation now present\n\n"
},
{
"category": "ECG",
"chartdate": "2182-10-29 00:00:00.000",
"description": "Report",
"row_id": 301963,
"text": "Atrial sensed and ventricular paced rhythm, new compared to the previous\ntracing of .\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2182-10-28 00:00:00.000",
"description": "Report",
"row_id": 301964,
"text": "Slow junctional rhythm without change compared to the previous tracing\nof .\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2182-10-28 00:00:00.000",
"description": "Report",
"row_id": 301965,
"text": "Slow junctional rhythm without change compared to the previous tracing\nof .\nTRACING #1\n\n"
}
] |
14,985 | 139,922 | 41 y/o male with known Type 1 Diabetes Mellitus presented with DKA. . # DKA/Diabetes Mellitus Type 1: Gap rapidly closed with insulin gtt and IV fluids. He was able to tolerate POs. D5 was discontinued and he was restarted on home insulin regimen. Electrolytes were repleted. Compliance with blood glucose fingersticks was reinforced. PCP next week. . # Non-Anion Gap Acidosis: Likely iatrogenic hyperchloremia from large amounts of NS; possibly though less likely compensation of a respiratory alkalosis resulting from overcompensation for the gap acidosis. Repleted with lactated ringers and bicarb normalized. . # Sinusitis: Likely viral. Completed 2 week course antibiotics. Resolving. No further acute issues. . # Rash: Resolved. Likely due to drug allergy, possibly from bactrim. . # HTN: BP well controlled on home meds (diovan 80 mg and norvasc 5 mg). . # Hypercholesterolemia: Continued lipitor. . # Tobacco abuse: He was interested in smoking cessation and the available options were discussed. He was provided with additional resources and strongly encouraged to follow-up with his PCP. | REPEAT BS AT NOON PRIOR TO DISCHARGE WAS 147.RENAL: VOIDING.NEURO: ALERT AND ORIENTATED-UP OOB IN CHAIR AND AMBULATING.CV: HEMODYNAMICALLY STABLE.SOCIAL: PT. pm glucose treated with riss and fixed dose of 12u nph. His gap has closed, he conts to require potasium and phosphate. Neuro Alert and oriented x 3 denies pain.Cv/resp nsr no ectopy BP check q2h. System Review: Cardiac: HR 80-90 NSR, No VEA, BP stable 110-130/70's recieving D5NS at 250cc/hr with 40mEq KCL changed to D5LR with 40mEq KCL at 250cc/hr. Had been on Bactrim for sinusistis. 64 this am OJ 120cc given as a precaution.voiding in urinal and toilet. Mg level 1.9 repleting with 3gm of Magnesuim sulfate. Phosphate at 0.7 receiving Kphosphate now. +smoker 1.5ppd smoker. RESP: BS'S CLEAR.GI: GOOD APPETITE.ENDOC: BS AT 8AM WAS 74-NPH GIVEN. Bm last eve.Independent with ADLS and hygiene.Integ no skin issues. Sliding scale changed to humalog w q4h glucose checks.insulin gtt dc'd yesterday afternoon.glucose down over night. ALLERGIES: bactrim? q1hr FS and titrate insulin accordingly. pt states slightly less reddened than yesterday. allergic rxn to Bactrim. left PIV infiltrated and dc'd.Pt is a 41 yearold diabetic admitted in DKA now since resolved.? Endocrine: anion gap intially 20 now is at 13 cont on insulin at 8units/hr weaned to 6units/hr for FS 115-119. IVF all dc'd. Otherwise, normal ECG. following Fs Q1hr. c/o to floor today PMH: HTN,hypercholestmia, DM on insulin at home, h/o of +PPD "86 treated for 9months. DISCHARGED. his rash is all gone. monitor anion gap. Chemistrys obtained last eve but am labs not yet drawn. anion gap initally 20 now is 13. His reg insulin gtt was up to a high of 12 units/hr and is currently at 4 units/hr. His blood sugars have been under better control since the D5LR was changed to LR. MICU Nursing Admission Note 41y/o gentleman intially presented to OSH with c/o SOB,N/V denies any diarrhea, and body rash. VSS, he has tolerated food and was given his 10 units of NPH this morning and will be given 12 at bedtime. NPNPt is alert and oriented x3, out of bed to the commode and to wash up. Now Working to get therapeutic insulin doses. Very difficult phelebotomy stick. GU: voiding well at bedside, no c/o GI; NPO except ice chips this morning. Respiratory: RR 14-20 CTA through out all lung fields. had not been taking his long acting insulin and has poor history for how he was medicating himself with the regular insulin presented in DKA. Sinus tachycardia. Treated with 5l NS and IV insulin at to and admitted to MICU. cough is nonproductive dry. Plan: follow labs this am. No previous tracing available forcomparison. Plan: ? The team will talk with him about quiting smoking. TO HOME. no stool, abd flat and non-tender. Skin: pt is flushed appearance, fine reddened rash on upper torso and upper arms. | 5 | [
{
"category": "ECG",
"chartdate": "2181-03-08 00:00:00.000",
"description": "Report",
"row_id": 296781,
"text": "Sinus tachycardia. Otherwise, normal ECG. No previous tracing available for\ncomparison.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-03-10 00:00:00.000",
"description": "Report",
"row_id": 1457302,
"text": "Neuro Alert and oriented x 3 denies pain.\n\nCv/resp nsr no ectopy BP check q2h. WNL room air clear lungs no distress.\n\nGI/GU Ate a very full dinner. pm glucose treated with riss and fixed dose of 12u nph. Sliding scale changed to humalog w q4h glucose checks.insulin gtt dc'd yesterday afternoon.\nglucose down over night. 64 this am OJ 120cc given as a precaution.\nvoiding in urinal and toilet. Bm last eve.\n\nIndependent with ADLS and hygiene.\n\nInteg no skin issues. left PIV infiltrated and dc'd.\n\nPt is a 41 yearold diabetic admitted in DKA now since resolved.? allergic rxn to Bactrim. Now Working to get therapeutic insulin doses. IVF all dc'd. Very difficult phelebotomy stick. Chemistrys obtained last eve but am labs not yet drawn. Plan: ? c/o to floor today\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-03-10 00:00:00.000",
"description": "Report",
"row_id": 1457303,
"text": "RESP: BS'S CLEAR.\nGI: GOOD APPETITE.\nENDOC: BS AT 8AM WAS 74-NPH GIVEN. REPEAT BS AT NOON PRIOR TO DISCHARGE WAS 147.\nRENAL: VOIDING.\nNEURO: ALERT AND ORIENTATED-UP OOB IN CHAIR AND AMBULATING.\nCV: HEMODYNAMICALLY STABLE.\nSOCIAL: PT. DISCHARGED. TO HOME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-03-09 00:00:00.000",
"description": "Report",
"row_id": 1457300,
"text": "MICU Nursing Admission Note\n 41y/o gentleman intially presented to OSH with c/o SOB,N/V denies any diarrhea, and body rash. Had been on Bactrim for sinusistis. had not been taking his long acting insulin and has poor history for how he was medicating himself with the regular insulin presented in DKA. Treated with 5l NS and IV insulin at to and admitted to MICU. anion gap initally 20 now is 13.\n ALLERGIES: bactrim?\n PMH: HTN,hypercholestmia, DM on insulin at home, h/o of +PPD \"86 treated for 9months. +smoker 1.5ppd smoker.\n System Review:\n Cardiac: HR 80-90 NSR, No VEA, BP stable 110-130/70's recieving D5NS at 250cc/hr with 40mEq KCL changed to D5LR with 40mEq KCL at 250cc/hr.\n Endocrine: anion gap intially 20 now is at 13 cont on insulin at 8units/hr weaned to 6units/hr for FS 115-119. Phosphate at 0.7 receiving Kphosphate now. Mg level 1.9 repleting with 3gm of Magnesuim sulfate. following Fs Q1hr.\n Respiratory: RR 14-20 CTA through out all lung fields. cough is nonproductive dry.\n GU: voiding well at bedside, no c/o\n GI; NPO except ice chips this morning. no stool, abd flat and non-tender.\n Skin: pt is flushed appearance, fine reddened rash on upper torso and upper arms. pt states slightly less reddened than yesterday.\n Plan: follow labs this am. monitor anion gap. q1hr FS and titrate insulin accordingly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2181-03-09 00:00:00.000",
"description": "Report",
"row_id": 1457301,
"text": "NPN\n\nPt is alert and oriented x3, out of bed to the commode and to wash up. VSS, he has tolerated food and was given his 10 units of NPH this morning and will be given 12 at bedtime. His reg insulin gtt was up to a high of 12 units/hr and is currently at 4 units/hr. His blood sugars have been under better control since the D5LR was changed to LR. His gap has closed, he conts to require potasium and phosphate. his rash is all gone. The team will talk with him about quiting smoking.\n"
}
] |
28,131 | 172,434 | He was admitted to the Trauma Service and underwent CT imaging which revealed lumbar spine fracture. He was maintained on log roll precautions and was fitted for a TLSO which will need to be worn at all times while out of bed. His pain was initially controlled with IV narcotics and he was later changed to Percocet. A bowel regimen was initiated. He failed a voiding trial and was evaluated by Urology who recommended Flomax 0.4 mg at HS and to leave Foley in place for another week then try another voiding trial at that time. Physical and Occupational therapy evaluated him and have recommended rehab after his acute hospital stay. | At L3 there is a tiny avulsion fracture of the right transverse process. PB's for prophylaxis.Access: PIV x2 wnl.Resp: LS clear, diminished at bases. MUSCULOSKELETAL: There is a nondisplaced fracture of the mid body of the sternum with a small presternal hematoma. There is a nondisplaced fracture at the spinous process of C6, with mild adjacent soft tissue swelling. There is a small linear hypoattenuating lesion in the spleen, (best seen on 2,66), without evidence of peri-splenic fluid. There is mild cerebral atrophy. Nondisplaced mid body fracture of the sternum. A tiny area of high signal at the posterior margin of the thecal sac at this level represents a fracture cleft within the lamina. injuries FINAL ADDENDUM ADDENDUM: 1. injuries No contraindications for IV contrast WET READ: CHgc FRI 1:49 PM C6- spinous process fracture. There are sigmoid diverticula. At L4 there is a fracture of the right transverse process (not L5 as stated in error on the preliminary report). Tiny avulsion fracture at the trv. There is severe, asymmetric left facet arthropathy from C3-6. TECHNIQUE: MDCT-acquired contiguous axial images of the head were obtained without IV contrast. IS up to 1750-2000cc's.GI- abd soft nondistended, bowel sounds present, pt on PPI, nausea times one yet resolved w/ no intervention. C6 spinous process fracture with minimal displacement. There is a small presternal hematoma. C+DB, IS use when able.GI: abd soft, NT/D, BS hypoactive, NPO. Sigmoid diverticulosis without diverticulitis. IMPRESSION: Fracture of L1 vertebra with minimal retropulsion but without compression of the conus or high-grade thecal sac compression. There is mild bibasilar dependent atelectasis. FINDINGS: There is a large left subgaleal hematoma posterior to the left frontal bone with a small rounded area of higher attenuation within it. Severe asymmetric facet arthropathy on the left from C3-6. Sensation intact throughout; pt c/p some numbness "along my spine", denies numbness or tingling to extremities. There is mild accentuation of the normal lordosis. TECHNIQUE: MDCT-acquired contiguous axial images of the neck were obtained without IV contrast. Mild increased signal is seen in the intraspinous ligaments at T12-L1 and L1-2 level indicating mild edema. FINDINGS: There is an acute fracture of L1 vertebra identified with mild retropulsion indenting the thecal sac with less than 25% narrowing of the canal at this level. FINDINGS: The study is limited for evaluation of subtle non-displaced fractures due to osteopenia. The fracture extends through the spinous process and posterior elements as seen on the CT. Comminuted fracture to body L1 and right sided pedicle and transverse process, with some impingement on the ventral canal at that level. Incidental note is made of vertebral artery calcifications. The distal spinal cord shows normal signal intensities on T2-weighted sagittal and axial images. Smaller ground glass in the right upper lobe which would be very atypical for contusion, more likely a small micro-aspiration or very early pneumonia. There is bilateral gynecomastia. pt on 2 l NP w/ RR 14-18 nonlabored, breath sounds clear bilaterally. PERL at 3-4mm bilateraly, denies HA just soreness around abrasion on top of head. At T12 there is a fracture of the inferior articulating facet and lamina on the right (with fracture fragment seen more distally on 2,74). (Over) 11:56 AM CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT CHEST W/CONTRAST Reason: ? injuries FINAL REPORT (Cont) At L1 there is a comminuted fracture of the vertebral body, with some retropulsion of fracture fragments, approximately 8 mm posteriorly, and indentation of the thecal sac. A subtle area of signal abnormality adjacent to the right psoas muscle at L3 level could be due to a small hematoma. Pt has equal sensation on legs and arms yet does report slight numbness on posterior right thigh and intermittant sense of "fulness" in lower abd. 99.5; no abxSKin: head lac irrigated and sutured by Dr. ; DSD intact. T12, L3 and L4 fractures as detailed above. Coronal and sagittal reformats were performed. Coronal and sagittal reformats were performed. There are marginal osteophytes in the lower cervical spine. AP PELVIS: There is a dense structure projecting over the right hemipelvis likely external which limits evaluation. Skin w+d. Correlation with abdominal CT recommended. There is a small area of ground glass in the right upper lobe. injuries MEDICAL CONDITION: fall from 2 stories REASON FOR THIS EXAMINATION: ? injuries MEDICAL CONDITION: fall from 2 stories REASON FOR THIS EXAMINATION: ? Con't NPO at this time.GU- marginal u/o despite IVF of d5 1/2 NS at 100cc's hr.Endo- BS 150, no coverage ordered.ID- T max 99.2 PO, no abx's.A/P- con't to monitor closely, follow neuro checks closely. It is unlikely a splenic injury; however, a tiny grade 1 laceration cannot be excluded. TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were acquired. bleed MEDICAL CONDITION: fall from 2 stories REASON FOR THIS EXAMINATION: ? 11:56 AM CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT CHEST W/CONTRAST Reason: ? 11:56 AM CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT CHEST W/CONTRAST Reason: ? | 7 | [
{
"category": "Nursing/other",
"chartdate": "2176-07-20 00:00:00.000",
"description": "Report",
"row_id": 1630003,
"text": "TSICU NPN 7p-7a\nEvents over night - MRI of lumbar spine completed. Neuro checks Q 1hr, stable over night. Pain control with PCA.\n\nROS\n\n pt alert and oriented, appropriate and cooperative. PERL at 3-4mm bilateraly, denies HA just soreness around abrasion on top of head. Pt moving all extremities w/ good strength, Right leg slightly limited when lifting off of the bed yet dorsi flexion and plantar flexion very strong. Pt has equal sensation on legs and arms yet does report slight numbness on posterior right thigh and intermittant sense of \"fulness\" in lower abd. Still reports feeling \"numb\" in his back area from lying flat as well. MRI done, awaiting formal read and ortho spine plans. Pt maintained on log roll precaution and J intact, collar care times one. Ativan 0.5mg IVP times one for sleep w/ mild results.\n\nCV- HR 70-80's sinus, no ectopy, BP from the 90- low 100's over 60-70. AM labs stable, easily palpable pedal pulses.\n\n pt on 2 l NP w/ RR 14-18 nonlabored, breath sounds clear bilaterally. IS up to 1750-2000cc's.\n\nGI- abd soft nondistended, bowel sounds present, pt on PPI, nausea times one yet resolved w/ no intervention. Con't NPO at this time.\n\nGU- marginal u/o despite IVF of d5 1/2 NS at 100cc's hr.\n\nEndo- BS 150, no coverage ordered.\n\nID- T max 99.2 PO, no abx's.\n\nA/P- con't to monitor closely, follow neuro checks closely. Plan per ortho spine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-07-19 00:00:00.000",
"description": "Report",
"row_id": 1630002,
"text": "T-SICU NPN/admission note\n\nNKDA\nUniversal precautions\nPMH: high cholesterol\nmeds: ASA 81mg, naproxen, temazepam\n\n73yo male s/p unwitnessed fall from roof 2 stories onto concrete. Pt found by neighbor confused, ?LOC. Pt alert and able to move all extremities, follow all commands.\nInjuries: head lac (irrigated and sutured upon arrival), C6 SP fx, comminuted fx to L1 and R sided pedicle and TP fx, L5 TP fx with some impingement on the ventral , evu lsion fx of L3 TP on R, ? lung contusion, fitted for TLSO in ER.\nROS:\nNeuro: A+Ox3, MAE's, follows commands consistently. Pupils equal and reactive. Sensation intact throughout; pt c/p some numbness \"along my spine\", denies numbness or tingling to extremities. Morphine pca initiated 1mg q6minutes with 10mg lockout prior to foley placement with scope and head sutures; pt states pain was initially an 8, now 5 with pca use. Cont. to reinforce importance of pain control. Plan for MRI, checklist faxed.\nCV: HR 70's SR, BP 120/80's. Skin w+d. Pedal pulses palpable. PB's for prophylaxis.\nAccess: PIV x2 wnl.\nResp: LS clear, diminished at bases. RR teens, O2sats 98%2Lnc. Enc. C+DB, IS use when able.\nGI: abd soft, NT/D, BS hypoactive, NPO. Denies feeling nauseated. No stool. Protonix for prophylaxis.\nGU: foley placed w/scope by urology (unable in ER d/t enlarged prostate) draining clear yellow urine. Plan to keep foley in for 1-2 weeks, see urology note.\nID: temp. 99.5; no abx\nSKin: head lac irrigated and sutured by Dr. ; DSD intact. Back/buttocks intact. Sm. abrasion noted to LUE, OTA.\nPsych/social: pt lives in with his wife, both live independently; they have 2 children. Wife home for night.\nA: 73yo male s/p fall, neurologically intact; awaiting MRI\nP: Monitor VS, I/O, labs, q1hr neuro checks. Awaiting MRI, maintain c-spine/logroll precautions. Cont. aggressive pulmonary hygiene/skin care. Cont. ongoing open communication, comfort and support to pt and family.\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-19 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 1018478,
"text": " 11:47 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: AP pelvis and AP chest.\n\n HISTORY: Trauma\n\n AP CHEST: Study is limited as the apices have been excluded from the image.\n There is no focal consolidation or large pleural effusions. Bony structures\n are grossly intact. Please correlate with the anticipated CT scan.\n\n AP PELVIS: There is a dense structure projecting over the right hemipelvis\n likely external which limits evaluation. No gross fractures or dislocations\n are visualized.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1018480,
"text": " 11:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n fall from 2 stories\n REASON FOR THIS EXAMINATION:\n ? bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CHgc FRI 12:13 PM\n No fracture or intracranial hemorrhage. Soft tissue swelling at the vertex.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n INDICATION: 73-year-old man fall from two-and-a-half stories, question bleed.\n\n TECHNIQUE: MDCT-acquired contiguous axial images of the head were obtained\n without IV contrast.\n\n COMPARISON: None available.\n\n FINDINGS: There is a large left subgaleal hematoma posterior to the left\n frontal bone with a small rounded area of higher attenuation within it. There\n is no intracranial hemorrhage or acute vascular territorial infarct. There is\n mild cerebral atrophy. There is no evidence of fracture. The paranasal\n sinuses and mastoid air cells are clear. Incidental note is made of vertebral\n artery calcifications.\n\n IMPRESSION: Large subgaleal hematoma in the posterior to the left frontal\n bone. No acute infarct or intracranial hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-19 00:00:00.000",
"description": "MR L SPINE W/O CONTRAST",
"row_id": 1018571,
"text": " 8:56 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: eval for lig injury\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with L-spine fxs\n REASON FOR THIS EXAMINATION:\n eval for lig injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the lumbar spine.\n\n CLINICAL INFORMATION: Patient with lumbar spine fracture, for further\n evaluation.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n lumbar spine were acquired. Correlation was made with the abdominal CT of\n .\n\n FINDINGS: There is an acute fracture of L1 vertebra identified with mild\n retropulsion indenting the thecal sac with less than 25% narrowing of the\n canal at this level. The fracture extends through the spinous process and\n posterior elements as seen on the CT. However, on MRI, no obvious marrow\n edema is seen in the spinous process. A tiny area of high signal at the\n posterior margin of the thecal sac at this level represents a fracture cleft\n within the lamina. There is no obvious disruption of the ligamentous\n structures identified. Mild increased signal is seen in the intraspinous\n ligaments at T12-L1 and L1-2 level indicating mild edema. Mild increased\n signal is seen also in the posterior subcutaneous fat from focal trauma.\n\n There is no evidence of marrow edema identified from L2 to L4 vertebral bodies\n to indicate fracture. The sacrum demonstrates high signal on T1- and T2-\n weighted images indicative of fatty marrow. This could be due to osteopenia\n or could be due to prior pelvic radiation. Clinical correlation recommended.\n\n The distal spinal cord shows normal signal intensities on T2-weighted sagittal\n and axial images. Subtle increased signal was suspected on inversion recovery\n images which could not be confirmed on axial T2-weighted images and therefore\n appears to be artifactual.\n\n The CT demonstrated fractures of the transverse processes of the lumbar\n vertebrae are not apparent on the MRI. A subtle area of signal abnormality\n adjacent to the right psoas muscle at L3 level could be due to a small\n hematoma. Correlation with abdominal CT recommended.\n\n IMPRESSION: Fracture of L1 vertebra with minimal retropulsion but without\n compression of the conus or high-grade thecal sac compression. There is less\n than 25% narrowing of the spinal canal seen at this level. There is mild\n increased signal is seen in the interspinous ligament but no obvious\n disruption of the ligamentous structures identified. No evidence of\n intraspinal hematoma seen. Other findings as described above.\n (Over)\n\n 8:56 PM\n MR L SPINE W/O CONTRAST Clip # \n Reason: eval for lig injury\n Admitting Diagnosis: BLUNT TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-19 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1018483,
"text": " 11:56 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n fall from 2 stories\n REASON FOR THIS EXAMINATION:\n ? injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CHgc FRI 1:49 PM\n C6- spinous process fracture.\n\n osteopenia/ multi-level DJD\n ______________________________________________________________________________\n FINAL REPORT\n CT C-SPINE WITHOUT CONTRAST\n\n INDICATION: 73-year-old man with fall from two-and-a-half stories, question\n injury.\n\n TECHNIQUE: MDCT-acquired contiguous axial images of the neck were obtained\n without IV contrast. Coronal and sagittal reformats were performed.\n\n COMPARISON: None available.\n\n FINDINGS: The study is limited for evaluation of subtle non-displaced\n fractures due to osteopenia. There is a nondisplaced fracture at the spinous\n process of C6, with mild adjacent soft tissue swelling. There is mild\n accentuation of the normal lordosis. There is severe, asymmetric left facet\n arthropathy from C3-6. There are marginal osteophytes in the lower cervical\n spine. There is a vaacuum disc phenomenon at C5-6. There is no significant\n prevertebral edema.\n\n IMPRESSION:\n 1. C6 spinous process fracture with minimal displacement.\n 2. Severe asymmetric facet arthropathy on the left from C3-6.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-07-19 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 1018484,
"text": " 11:56 AM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: ? injuries\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM:\n\n 1. 4-mm nodule in the middle lobe and 4-mm nodule in the right lower lobe.\n Rec. f/up at 12 months.\n 2. Bilateral rib fractures.\n\n\n 11:56 AM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: ? injuries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n fall from 2 stories\n REASON FOR THIS EXAMINATION:\n ? injuries\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: CHgc FRI 12:47 PM\n No acute intra-thoracic or intra-abdominal organ injury.\n Small areas of ground glass suggestive of lung contusions.\n\n Comminuted fracture to body L1 and right sided pedicle and transverse process,\n with some impingement on the ventral canal at that level.\n Tiny avulsion fracture at the trv. process of L3 on the right, and trv.\n process # at L5 on right.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n INDICATION: 73-year-old man with fall from two and a half stories, question\n injuries.\n\n TECHNIQUE: MDCT-acquired axial images of the chest, abdomen, and pelvis were\n obtained with IV contrast. Coronal and sagittal reformats were performed.\n\n COMPARISON: None available.\n\n FINDINGS: There is a 2-cm hypodensity in the left lobe of the thyroid as well\n as a more distal 9-mm hypodensity consistent with thyroid nodules.\n\n There is no evidence of acute aortic injury. There is a small area of ground\n glass in the right upper lobe. There is mild bibasilar dependent atelectasis.\n There is bilateral gynecomastia.\n\n The liver, gallbladder, and pancreas are normal. There is a small linear\n hypoattenuating lesion in the spleen, (best seen on 2,66), without evidence of\n peri-splenic fluid. It is unlikely a splenic injury; however, a tiny grade 1\n laceration cannot be excluded. The adrenals, kidneys, small and large bowel\n are normal. There is no free air or free fluid.\n\n The distal ureters and bladder are normal. There is no free fluid in the\n pelvis. There are sigmoid diverticula.\n\n MUSCULOSKELETAL: There is a nondisplaced fracture of the mid body of the\n sternum with a small presternal hematoma. There is an old healed posterior\n fracture of the twelfth rib on the right.\n\n At T12 there is a fracture of the inferior articulating facet and lamina on\n the right (with fracture fragment seen more distally on 2,74).\n (Over)\n\n 11:56 AM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT CHEST W/CONTRAST\n Reason: ? injuries\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n At L1 there is a comminuted fracture of the vertebral body, with some\n retropulsion of fracture fragments, approximately 8 mm posteriorly, and\n indentation of the thecal sac.\n\n At L3 there is a tiny avulsion fracture of the right transverse process.\n At L4 there is a fracture of the right transverse process (not L5 as stated\n in error on the preliminary report).\n\n IMPRESSION:\n 1. Severely comminuted compression fracture of the body of L1 with 8 mm\n retropulsion of posterior fracture fragment indenting on the thecal sac.\n\n 2. T12, L3 and L4 fractures as detailed above.\n\n 3. Nondisplaced mid body fracture of the sternum. There is a small\n presternal hematoma.\n\n 4. Small linear hypoattenuation in the spleen which is unlikely to be splenic\n injury, as there is no perisplenic fluid; however, a tiny grade 1 laceration\n cannot be entirely excluded.\n\n 5. Sigmoid diverticulosis without diverticulitis.\n\n 6. Smaller ground glass in the right upper lobe which would be very atypical\n for contusion, more likely a small micro-aspiration or very early pneumonia.\n\n Initial findings d/w Dr , subsequent acute findings posted to the ED\n dashboard shortly after completion of the study.\n\n"
}
] |
5,865 | 186,505 | 88 y.o. male with history of recurrent GIBs in the setting of known AVMs and diverticulosis, who presents with a chief complaint of hematochezia. . # LGIB: presented with hematochezia as above. Pt has a history of AVMs and diverticulosis. Pt was admitted to the intensive care unit where he was transfused 12 units of blood. Initially question/concern for perforation given CT findings & tender abdomen. Surgery was consulted, but eval and intervention refused by the patient. Tagged red cell scan confirmed sigmoid colon source: active bleeding seen there. Pt taken for angio, however, by that time, no bleeding was seen and no intervention was done. The bleeding stopped on its own. Empiric antibiotics were started for GI coverage. Hematocrit never dipped below 30, and remained stable (>40) when the bleeding stopped. . # Lymphadenopathy: Pt found to have progressive mesenteric lymphadenopathy on CT. Recommend follow up and possible biopsy as outpatient. . #h/o colon cancer. Pt closely followed by his outpatient gastroenterologist Dr. during this admission. Pt had concerning symptoms (weakness and long term weight loss) and CT scan with worsening mesenteric LAD and matting concerning for metastasis of his prior malignancy. Currently no plan for scope given recent significant bleed but may be reconsidered as outpatient. . # CAD: s/p stent (unsure of what kind) and not on Plavix/ASA. Currently without chest pain, SOB and EKG unremarkable. . # ARF: Creatinine to 1.7 on presentation, improved with IVF/PRBCs, supporting pre-renal/hypovolemia in the setting of GIB. Pt got bicarb and NAC following arteriogram. Creatinine stablalized. . # Cellulitis: Patient developed erythema and warmth of the foot near the first MTP joint. Concern for gout vs. cellulitis. He was started on vancomycin x 1 dose with some improvement. Full and currently painless joint ROM, unlikely to be septic arthritis. Given improvement with antibiotics, a course of dicloxacillin will be given. He has no MRSA risk factors or past history; therefore empiric vancomycin was not given but his foot should be reassessed daily to monitor for worsening which might suggest need for MRSA coverage. . # Hypertension: Blood pressure meds held initially given concern for potential hemodynamic instability with large GI bleed. These were gradually reintroduced as BP tolerated. He is currently on his home regimen with the exception of being on 50 mg daily of atenolol. His BP meds may need further titration at rehab. . # GERD. Continued PPI and sucralfate. . . Medications: All home medications were continued. New medications were as follows: Ciprofloxacin 750mg PO q12, Flagyl 500mg PO TID, Dicloxacillin 250mg PO q6. The flagyl and ciprofloxacin course will be completed on . The dicloxacillin will be completed on . | Peripheral edema noted lt<rt. Peripheral edema noted lt<rt. Peripheral edema noted lt<rt. # Code status: DNR/DNI/CMO ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 07:52 AM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Coagulopathy: likely consumptive and dilutional will give ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:00 PM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition : Total time spent: # Code status: DNR/DNI/CMO ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:00 PM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: # Code status: DNR/DNI/CMO ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:00 PM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:00 PM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: DNR/DNI Disposition: c/o to floor .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Pt still passing maroon stool , however pt hemodynamically stable thoughout this shift, hypothemic to 95.6 Action: Repeat hct 46, wbc count 19.6 inr 2.0 Response: Pt stable at present Plan: Status change, will medically manage, have added flagyl and cipro, to cover abd source, will transfuse if needed ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:00 PM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI / CMO Disposition : Remains in ICU. # Code status: DNR/DNI/CMO ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 07:52 AM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: Patient admitted from: ER History obtained from Medical records Allergies: No Known Drug Allergies Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Past .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB) Assessment: Action: Response: Plan: ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:00 PM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Compression Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Disposition :Floor, will have Dr. discuss disposition with them. Lines / Intubation: Peripheral IVs, 18 Gauge - 07:52 AM Prophylaxis: DVT: Boots, Stress ulcer: PPI, Code status: Full, Disposition: Remains in ICU. ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:00 PM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI / CMO Disposition : Remains in ICU. # Code status: DNR/DNI/CMO ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 07:52 AM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: Disposition: # ARF: Creatinine to 1.7 on presentation, improved with IVF/PRBCs, supporting pre-renal/hypovolemia in the setting of GIB. Coagulopathy: likely consumptive and dilutional will give ICU Care Nutrition: Glycemic Control: Lines: 18 Gauge - 06:00 PM Cordis/Introducer - 12:00 AM Prophylaxis: DVT: Boots Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition : Total time spent: Lines / Intubation: Peripheral IVs. 3)FEN: advance to clears, Replete lytes 4)Code: DNR/DNI 5)Dispo: floor. Holding anti-hypertensives / diuretics. Holding anti-hypertensives / diuretics. The SMA arteriogram demonstrated a somewhat irregular, and large jejunal branch artery which correlated to the irregular area in the region of the patients known mesenteric mass seen on the prior CT. Prophylaxis: DVT: Compression boots Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Disposition :Floor, will have Dr. discuss disposition with them. | 55 | [
{
"category": "Physician ",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337168,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient's Hct decreased to 33 from 35 despite getting 3 units of PRBCs.\n Additionally, SBP dropped transiently to 80s and he passed a large,\n frankly bloody BM. He was given one more unit of PRBCs and IR and GI\n were notified. Per that discussion, patient was taken for tagged RBC\n scan, where bleeding was found in the sigmoid colon. While undergoing\n bleeding scan, patient's BP continued to intermittently drop and he\n received a total of 2 more units of blood and 3 liters of NS with\n transient increases in BP, but continued hematochezia. He was then\n brought up to the ICU for placement of a cordis and received 6 more\n units of PRBCs, 2 bags of FFP, 1 bag of platelets and 4 liters of NS.\n The plan was for IR intervention once he became hemodynamically stable,\n but patient was then noted to suddenly develop acute abdominal pain,\n abdominal distention and high pitched bowel sounds, which were\n concerning for a perforation. Surgery was notified and came to examine\n the patient, but he refused examination, stating that he only wanted to\n be made comfortable. He continued to refuse surgery at this point and\n had previously been made DNR/DNI. KUB was deferred as was angiographic\n intervention, at the patient's request. He was given Morphine boluses\n for comfort and the family was notified so that they could be present\n with him. He was made CMO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:50 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 02:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 99 (62 - 99) bpm\n BP: 113/61(73) {62/42(47) - 154/123(109)} mmHg\n RR: 22 (13 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,754 mL\n 1,875 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,250 mL\n Blood products:\n 3,404 mL\n 1,875 mL\n Total out:\n 1,590 mL\n 0 mL\n Urine:\n 1,490 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 6,164 mL\n 1,875 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 112 K/uL\n 11.4 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 108 mEq/L\n 142 mEq/L\n 30.8 %\n 19.5 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n WBC\n 11.5\n 19.5\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n Plt\n 199\n 149\n 112\n Cr\n 1.2\n 0.9\n 0.9\n Glucose\n 107\n 119\n 93\n Other labs: PT / PTT / INR:14.6/30.4/1.3, Ca++:6.6 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n # GIB: Confirmed bleeding in the sigmoid colon. Patient is no longer\n amenable to angiography and was never agreeable to surgery and these\n are essentially the extent of his definitive treatment options. Patient\n required several PRBCs and IVF and though currently hemodynamically\n stable, thought to be due to temporary halt of bleeding, he is at risk\n for further bleeding. Per repeated conversation with patient, he is\n only interested in being made comfortable with no further intervention.\n Additionally, his respiratory status is tenuous s/p multiple PRBCs and\n IVF boluses, so additional resuscitation would likely result in\n pulmonary edema, which would require Lasix and this would only\n potentiate hypotension.\n - Comfort measures only; no labs, avoid blood products and IVF,\n Morphine PRN for abdominal pain\n - Appreciate IR, GI and surgical input thus far\n .\n # GERD\n - Continue PPI\n - Continue Sucralfate\n .\n # FEN\n - NPO\n - IVF\n - Correct/Replete electrolytes PRN\n .\n # PPx\n - Pneumoboots\n - PPI IV BID\n .\n # Communication: With patient\n .\n # Code status: DNR/DNI/CMO\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:52 AM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337339,
"text": "Chief Complaint:\n 24 Hour Events:\n CMO status reversed yesterday morning\n Hct stable, no further evidence of active bleeding\n CXR showed no free air under diaphragm\n Started on cipro/flagyl due to concern for microperforation, WBC\n decreased this am.\n Tolerating PO, oral meds restarted\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:42 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: 77 (70 - 84) bpm\n BP: 110/52(67) {91/40(51) - 125/67(76)} mmHg\n RR: 17 (9 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,466 mL\n 582 mL\n PO:\n 360 mL\n 480 mL\n TF:\n IVF:\n 231 mL\n 102 mL\n Blood products:\n 1,875 mL\n Total out:\n 2,190 mL\n 245 mL\n Urine:\n 1,590 mL\n 245 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 276 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 14.8 g/dL\n 74 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 112 mEq/L\n 142 mEq/L\n 43.3 %\n 13.1 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n Plt\n 199\n 149\n 112\n 115\n 116\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n Glucose\n 107\n 119\n 93\n 120\n 74\n Other labs: PT / PTT / INR:20.9/39.1/2.0, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:1.8 mg/dL\n Assessment and Plan\n # GIB: Confirmed bleeding in the sigmoid colon. Patient is no longer\n amenable to angiography and was never agreeable to surgery and these\n are essentially the extent of his definitive treatment options. Patient\n required several PRBCs and IVF and though currently hemodynamically\n stable, thought to be due to temporary halt of bleeding, he is at risk\n for further bleeding. Per repeated conversation with patient, he is\n only interested in being made comfortable with no further intervention.\n Additionally, his respiratory status is tenuous s/p multiple PRBCs and\n IVF boluses, so additional resuscitation would likely result in\n pulmonary edema, which would require Lasix and this would only\n potentiate hypotension.\n - Comfort measures only; no labs, avoid blood products and IVF,\n Morphine PRN for abdominal pain\n - Appreciate IR, GI and surgical input thus far\n - Discontinue unnecessary meds\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI/CMO\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 337354,
"text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n large GI bleed - had initially refused aggressive intervention\n 24 Hour Events:\n CMO status reversed\n HCT stable in 40\n Surgery still following\n COnitnues Cipro Flagyl for empiric civerage for perf\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 71 (70 - 84) bpm\n BP: 117/52(68) {91/40(51) - 125/67(76)} mmHg\n RR: 15 (9 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,466 mL\n 615 mL\n PO:\n 360 mL\n 480 mL\n TF:\n IVF:\n 231 mL\n 135 mL\n Blood products:\n 1,875 mL\n Total out:\n 2,190 mL\n 348 mL\n Urine:\n 1,590 mL\n 348 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 276 mL\n 267 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///24/\n Physical Examination\n Gen\n Neck\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 14.8 g/dL\n 116 K/uL\n 74 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 112 mEq/L\n 142 mEq/L\n 43.3 %\n 13.1 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n Plt\n 199\n 149\n 112\n 115\n 116\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n Glucose\n 107\n 119\n 93\n 120\n 74\n Other labs: PT / PTT / INR:20.9/39.1/2.0, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:1.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337362,
"text": "Chief Complaint:\n 88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf, now making\n excellent recovery with conservative management.\n 24 Hour Events:\n CMO status reversed yesterday morning\n Hct stable, no further evidence of active bleeding\n CXR showed no free air under diaphragm\n Started on cipro/flagyl due to concern for microperforation, WBC\n decreased this am.\n Tolerating PO, oral meds restarted\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 None SH: Pt lives with wife in , their son lives above\n them.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Reports some intermittent crampy abdominal pain. No SOB. Still having\n hematochezia in rectal tube.\n Flowsheet Data as of 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 77 (70 - 84) bpm\n BP: 110/52(67) {91/40(51) - 125/67(76)} mmHg\n RR: 17 (9 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,466 mL\n 582 mL\n PO:\n 360 mL\n 480 mL\n TF:\n IVF:\n 231 mL\n 102 mL\n Blood products:\n 1,875 mL\n Total out:\n 2,190 mL\n 245 mL\n Urine:\n 1,590 mL\n 245 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 276 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94% 3L\n ABG: ///24/\n Physical Examination\n General:\n HEENT:\n Neck:\n CV:\n Pulm:\n Abd:\n Ext: resolving upper extremity pitting edema\n Neuro: Incredible lucid, alert and oriented\n Labs / Radiology\n 116 K/uL\n 14.8 g/dL\n 74 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 112 mEq/L\n 142 mEq/L\n 43.3 %\n 13.1 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n Plt\n 199\n 149\n 112\n 115\n 116\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n Glucose\n 107\n 119\n 93\n 120\n 74\n Other labs: PT / PTT / INR:20.9/39.1/2.0, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:1.8 mg/dL\n Assessment and Plan\n # GIB: Confirmed bleeding in the sigmoid colon. Patient is no longer\n amenable to angiography and was never agreeable to surgery and these\n are essentially the extent of his definitive treatment options. Patient\n required several PRBCs and IVF and though currently hemodynamically\n stable, thought to be due to temporary halt of bleeding, he is at risk\n for further bleeding. Per repeated conversation with patient, he is\n only interested in being made comfortable with no further intervention.\n Additionally, his respiratory status is tenuous s/p multiple PRBCs and\n IVF boluses, so additional resuscitation would likely result in\n pulmonary edema, which would require Lasix and this would only\n potentiate hypotension.\n - Comfort measures only; no labs, avoid blood products and IVF,\n Morphine PRN for abdominal pain\n - Appreciate IR, GI and surgical input thus far\n - Discontinue unnecessary meds\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI/CMO\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337324,
"text": "Chief Complaint:\n 24 Hour Events:\n CMO status reversed yesterday morning\n Hct stable, no further evidence of active bleeding\n CXR showed no free air under diaphragm\n Started on cipro/flagyl due to concern for microperforation, WBC\n decreased this am.\n Tolerating PO, oral meds restarted\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:42 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: 77 (70 - 84) bpm\n BP: 110/52(67) {91/40(51) - 125/67(76)} mmHg\n RR: 17 (9 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,466 mL\n 582 mL\n PO:\n 360 mL\n 480 mL\n TF:\n IVF:\n 231 mL\n 102 mL\n Blood products:\n 1,875 mL\n Total out:\n 2,190 mL\n 245 mL\n Urine:\n 1,590 mL\n 245 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 276 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 116 K/uL\n 14.8 g/dL\n 74 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 112 mEq/L\n 142 mEq/L\n 43.3 %\n 13.1 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n Plt\n 199\n 149\n 112\n 115\n 116\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n Glucose\n 107\n 119\n 93\n 120\n 74\n Other labs: PT / PTT / INR:20.9/39.1/2.0, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:1.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337436,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf\n H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd soft non tender, non distended, positive for BS and flatus, maroon\n color stool in rectal bag however in much smaller amnt. Denies N/V.\n NPO. HCT 43.3 b/p 130\ns/60\ns Hr at 80\ns. U/O WNL.\n Action:\n Serial Hct, GI consult, rectal bag and foley d/c per Dr. ,\n started on clear liquid diet - tolerates it well, PO Vit K given, Ca\n repleted, protonix and carafate ASDIR\n Response:\n Hct- 44.3 no s/s of active bleeding, VSS\n Plan:\n Continue to monitor patient status, transfuse as needed, per Dr.\n (GI) if rebleeds angio to be performed. f/u GI and surgery\n recs\n Neuro: a/oX3 follows commands, moves all 4 extr. OOB to chair w/\n 2assist, unsteady gait.\n Resp: weaned off O2 sats on RA 93-95%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P 130\ns/60\ns hr at 80\ns SR w/o ectopy. Peripheral edema noted\n lt<rt. Peripheral pulses present. Denies CP or SOB\n GU: clear yellow urine via foley. At 1315 foley d/c per Dr ,\n voided 150cc.\n Skin: no skin impairment noted.\n IV access: 2 PIV\n patent. RT IJ\nCordis/Introducer - leave in for now\n while trending hct and developing long term plan for recurrent bleed\n Social: patient DNR/DNI. Family in to visit updated by RN and MD\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337431,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf\n H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd soft non tender, non distended, positive for BS and flatus, maroon\n color stool in rectal bag however in much smaller amnt. Denies N/V.\n NPO. HCT 43.3 b/p 130\ns/60\ns Hr at 80\ns. U/O WNL.\n Action:\n Serial Hct, GI consult, rectal bag and foley d/c per Dr. ,\n started on clear liquid diet - tolerates it well, PO Vit K given, Ca\n repleted, protonix and carafate ASDIR\n Response:\n Hct- ________\n Plan:\n Continue to monitor patient status, transfuse as needed, per Dr.\n (GI) if rebleeds angio to be performed. f/u GI and surgery\n recs\n Neuro: a/oX3 follows commands, moves all 4 extr. OOB to chair w/\n 2assist, unsteady gait.\n Resp: weaned off O2 sats on RA 93-95%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P 130\ns/60\ns hr at 80\ns SR w/o ectopy. Peripheral edema noted\n lt<rt. Peripheral pulses present. Denies CP or SOB\n GU: clear yellow urine via foley. At 1315 foley d/c per Dr .\n DTV at -2115. voided 150cc.\n Skin: no skin impairment noted.\n IV access: 2 PIV\n patent. RT IJ\nCordis/Introducer - leave in for now\n while trending hct and developing long term plan for recurrent bleed\n Social: patient DNR/DNI. Family in to visit updated by RN and MD\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337505,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. CMO status reversed to DNR/DNI per patient and his personal\n GI doctor.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Liquid, maroon stools x2. Abd soft w/hyperactive BS. Denies pain.\n Action:\n Monitoring hcts , quiac stools.\n Response:\n Plan:\n No surgery per patient, if rebleeds would go to angio. If Hct stable\n possible call out.\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 337651,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. Was made CMO per pt wishes over the weekend, however hct\n stabilized and remained hd stable so status reversed to DNR/DNI per\n patient and his personal GI doctor. At present, pt does not wish to\n have any surgical interventions should he rebleed, however will go to\n Angio.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Hct remains stable\n last checked at noon today and was 44.4. HD\n stable. No brbpr, occasionally passing black tarry/maroon stool.\n Action:\n Monitoring for s&s of active bleeding.\n Response:\n No signs of active bleeding.\n Plan:\n Monitor hct and for any other s&s of active bleeding. If pt\n rebleeds, will transfuse and go to Angio. No surgical interventions per\n pt wishes.\n"
},
{
"category": "General",
"chartdate": "2192-08-25 00:00:00.000",
"description": "ICU Event Note",
"row_id": 337097,
"text": "Clinician: Attending\n We placed a right IJ cordis for improved vascular access with ongoing\n profuse lower GI bleeding. Currently hemodynamically stable. Tagged\n red cell scan is positive for bleeding in the sigmoid colon. Currently\n working on getting him to angiography.\n After placing the line we had a long discussion with Dr. . He\n clearly stated that he in no way wanted to have surgery even if it\n meant that he would bleed to death. He is adament about this. He is\n willing to undergo angiography. He has also expressed that he would\n not want to be intubated or undergo CPR/shocks should he arrest. He is\n now DNR/DNI.\n Total time spent: 45 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337286,
"text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337402,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf\n H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd soft non tender, non distended, positive for BS and flatus, maroon\n color stool in rectal bag however in much smaller amnt. Denies N/V.\n NPO. HCT 43.3 b/p 130\ns/60\ns Hr at 80\ns. U/O WNL.\n Action:\n Serial Hct, GI consult, rectal bag and foley d/c per Dr. ,\n started on clear liquid diet - tolerates it well, PO Vit K given, Ca\n repleted, protonix and carafate ASDIR\n Response:\n Hct- ________\n Plan:\n Continue to monitor patient status, transfuse as needed, per Dr.\n (GI) if rebleeds angio to be performed. f/u GI and surgery\n recs\n Neuro: a/oX3 follows commands, moves all 4 extr. OOB to chair w/\n 2assist\n Resp: weaned off O2 sats on RA 93-95%. Bil LS clear diminished at the\n bases. RRR, unlabored breathing.\n Cardio: B/P 130\ns/60\ns hr at 80\ns SR w/o ectopy. Peripheral edema noted\n lt<rt. Peripheral pulses present. Denies CP or SOB\n GU: clear yellow urine via foley. At 1315 foley d/c per Dr .\n DTV at -2115.\n Skin: no skin impairment noted.\n IV access: 2 PIV\n patent. RT IJ\nCordis/Introducer - leave in for now\n while trending hct and developing long term plan for recurrent bleed\n Social: patient DNR/DNI. Family in to visit updated by RN and MD\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 337715,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. Was made CMO per pt wishes over the weekend, however hct\n stabilized and remained hd stable so status reversed to DNR/DNI per\n patient and his personal GI doctor. At present, pt does not wish to\n have any surgical interventions should he rebleed, however will go to\n Angio.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Hct remains stable\n last checked at noon today and was 44.4. HD\n stable. No brbpr, occasionally passing black tarry/maroon stool.\n Action:\n Monitoring for s&s of active bleeding.\n Response:\n No signs of active bleeding.\n Plan:\n Monitor hct and for any other s&s of active bleeding. If pt\n rebleeds, will transfuse and go to Angio. No surgical interventions per\n pt wishes.\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n LOWER GASTROINTESTINAL BLEED\n Code status:\n Height:\n 60 Inch\n Admission weight:\n 60.5 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: GI Bleed\n CV-PMH: CAD, Hypertension\n Additional history: sig hx of gi bleed for duodenal avms R\n hemicolectomy - colon ca\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:136\n D:60\n Temperature:\n 97.8\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 76 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 92% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,369 mL\n 24h total out:\n 1,450 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 03:59 AM\n Potassium:\n 3.7 mEq/L\n 12:20 PM\n Chloride:\n 108 mEq/L\n 03:59 AM\n CO2:\n 24 mEq/L\n 03:59 AM\n BUN:\n 19 mg/dL\n 03:59 AM\n Creatinine:\n 0.9 mg/dL\n 03:59 AM\n Glucose:\n 82 mg/dL\n 03:59 AM\n Hematocrit:\n 44.4 %\n 12:20 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: Micu 786\n Transferred to: CC716\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337287,
"text": "88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulitis, CAD s/p LAD stent admitted with LGIB. Initial\n evaluation revealed likely sigmoid colon bleed. Unfortunately, last\n night he had massive bleeding following a tagged RBC scan. He received\n a total of 12 units PRBC. This was followed by severe abdominal pain.\n He declined to have further interventions including angiography and\n surgery. He is now DNR/DNI/CMO and receiving morphine for his\n abdominal pain.\n 88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulitis, CAD s/p LAD stent admitted with LGIB. Initial\n evaluation revealed likely sigmoid colon bleed. Unfortunately, last\n night he had massive bleeding following a tagged RBC scan. He received\n a total of 12 units PRBC. This was followed by severe abdominal pain.\n He declined to have further interventions including angiography and\n surgery. He is now DNR/DNI/CMO and receiving morphine for his\n abdominal pain.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337288,
"text": "88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulitis, CAD s/p LAD stent admitted with LGIB. Initial\n evaluation revealed likely sigmoid colon bleed. Unfortunately, last\n night he had massive bleeding following a tagged RBC scan. He received\n a total of 12 units PRBC. This was followed by severe abdominal pain.\n He declined to have further interventions including angiography and\n surgery. He is now DNR/DNI/CMO and receiving morphine for his\n abdominal pain.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 337391,
"text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n large GI bleed - had initially refused aggressive intervention\n 24 Hour Events:\n CMO status reversed\n HCT stable in 40\n Surgery still following\n COnitnues Cipro Flagyl for empiric civerage for perf\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 71 (70 - 84) bpm\n BP: 117/52(68) {91/40(51) - 125/67(76)} mmHg\n RR: 15 (9 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,466 mL\n 615 mL\n PO:\n 360 mL\n 480 mL\n TF:\n IVF:\n 231 mL\n 135 mL\n Blood products:\n 1,875 mL\n Total out:\n 2,190 mL\n 348 mL\n Urine:\n 1,590 mL\n 348 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 276 mL\n 267 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///24/\n Physical Examination\n Gen\n Neck\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 14.8 g/dL\n 116 K/uL\n 74 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 112 mEq/L\n 142 mEq/L\n 43.3 %\n 13.1 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n Plt\n 199\n 149\n 112\n 115\n 116\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n Glucose\n 107\n 119\n 93\n 120\n 74\n Other labs: PT / PTT / INR:20.9/39.1/2.0, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:1.8 mg/dL\n Assessment and Plan\n Massive LGIB: currently holding HCt from 47 to 44 after 12 U PRBC\n intervention at site was done but he is now stabilizing. Will Call DR\n to follow up on potential interventions.\n Coagulopathy: likely consumptive and dilutional\n will give\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 337393,
"text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n large GI bleed - had initially refused aggressive intervention\n 24 Hour Events:\n CMO status reversed\n HCT stable in 40\n Surgery still following\n COnitnues Cipro Flagyl for empiric civerage for perf\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 71 (70 - 84) bpm\n BP: 117/52(68) {91/40(51) - 125/67(76)} mmHg\n RR: 15 (9 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,466 mL\n 615 mL\n PO:\n 360 mL\n 480 mL\n TF:\n IVF:\n 231 mL\n 135 mL\n Blood products:\n 1,875 mL\n Total out:\n 2,190 mL\n 348 mL\n Urine:\n 1,590 mL\n 348 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 276 mL\n 267 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///24/\n Physical Examination\n Gen: lying in bed, AND\n Neck: supple\n CV: RR\n Chest: good air movement, decreased BS at bases, no\n Abd: soft + BS\n Ext:\n Labs / Radiology\n 14.8 g/dL\n 116 K/uL\n 74 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 112 mEq/L\n 142 mEq/L\n 43.3 %\n 13.1 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n Plt\n 199\n 149\n 112\n 115\n 116\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n Glucose\n 107\n 119\n 93\n 120\n 74\n Other labs: PT / PTT / INR:20.9/39.1/2.0, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:1.8 mg/dL\n Assessment and Plan\n Massive LGIB: currently holding HCt from 47 to 44 after 12 U PRBC\n intervention at site was done but he is now stabilizing. Will Call Dr\n to follow up on potential interventions\n pt is clear he would\n refuse surgery and likely scope as well at this point. We will maintain\n cordis, tx to maintain HCt > 30, IV PPI.\n Coagulopathy: likely consumptive and dilutional\n will give oral Vit K\n and trend.\n Remoiander of issues as per housestaff notes\n discussed on rounds\n ICU Care\n Nutrition: slowly advance diet\n Glycemic Control: prn\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: ppi\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition : ICU\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337564,
"text": "Chief Complaint: 88 y/o M with severe LGIB, now with stable Hct\n 24 Hour Events:\n Hct remained stable at 44\n Per Dr. , pt. would not want surgery, if bleeds again go\n directly to angio\n Ca, Mg and phos repleted\n Given 5mg PO vitamin K\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 12:05 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 12:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 89 (62 - 89) bpm\n BP: 144/65(85) {107/32(56) - 161/67(107)} mmHg\n RR: 20 (14 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 272 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n 518 mL\n 272 mL\n Blood products:\n Total out:\n 1,178 mL\n 100 mL\n Urine:\n 1,078 mL\n 100 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General: A+O, NAD\n HEENT:MMdry\n Neck:Cordis in place\n CV:AS murmur, regular rate\n Pulm:CTAB\n Abd:mildly TTP, +BS\n Ext: resolving upper extremity pitting edema\n Neuro: Incredible lucid, alert and oriented\n Labs / Radiology\n 145 K/uL\n 14.9 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan: 88 y/o M with LGIB, HCT now stable\n # GIB: Has history of AVMs, CT abd confirmed sigmoid source, initially\n shown to have active extravasation concerning for perforation, had\n acute abdomen, surgery consulted, but eval and intervention refused by\n the patient. Pt received total of 12 units PRBCs. Had elevated WBC,\n now improving, not spiking fevers. Still with some melena but with\n stable HCT x 48 hours.\n -Continue to monitor HCT\n -PO vitamin K x 3 days for elevated INR in setting of massive\n transfusion\n -follow Ca in setting of transfusion, repleted yesterday\n -f/u GI recs, plan for angio if rebleeds as tagged red cell scan have\n not been helpful\n -continue abx for 7 day course, empiric GI coverage. Currently day \n of cipro/flagyl\n -Continue PPI\n #h/o colon cancer. Per Closely followed by his outpatient\n gastroenterologist Dr. who in following patient in house. Pt\n had concerning symptoms (weakness and long term weight loss) and CT\n scan with worsening mesenteric LAD and matting concerning for\n metastasis of his prior malignancy. Currently no plan for scope given\n recent significant bleed but may be reconsidered as outpatient.\n -discuss long term plan for mgmt of colon ca with Dr. \n goals of care with pt and family, he has already made it very\n clear he will not consider surgery or other very invasive measures.\n .\n #GERD: PPI\n #Hyperlipidemia. Statin\n #Hypertension. Hold home regimen in setting of GIB\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI, CMO status reversed.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337574,
"text": "Chief Complaint: 88 y/o M with severe LGIB, now with stable Hct\n 24 Hour Events:\n Hct remained stable at 44\n Per Dr. , pt. would not want surgery, if bleeds again go\n directly to angio\n Ca, Mg and phos repleted\n Given 5mg PO vitamin K\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 12:05 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 12:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 89 (62 - 89) bpm\n BP: 144/65(85) {107/32(56) - 161/67(107)} mmHg\n RR: 20 (14 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 272 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n 518 mL\n 272 mL\n Blood products:\n Total out:\n 1,178 mL\n 100 mL\n Urine:\n 1,078 mL\n 100 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General: A+O, NAD\n HEENT:MMdry\n Neck:Cordis in place\n CV:AS murmur, regular rate\n Pulm:CTAB\n Abd:mildly TTP, +BS\n Ext: resolving upper extremity pitting edema\n Neuro: Incredible lucid, alert and oriented\n Labs / Radiology\n 145 K/uL\n 14.9 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan: 88 y/o M with LGIB, HCT now stable\n # GIB: Has history of AVMs, CT abd confirmed sigmoid source, initially\n shown to have active extravasation concerning for perforation, had\n acute abdomen, surgery consulted, but eval and intervention refused by\n the patient. Pt received total of 12 units PRBCs. Had elevated WBC,\n now improving, not spiking fevers. Still with some melena but with\n stable HCT x 48 hours.\n -Continue to monitor HCT\n -PO vitamin K x 3 days for elevated INR in setting of massive\n transfusion\n -follow Ca in setting of transfusion, repleted yesterday\n -f/u GI recs, plan for angio if rebleeds as tagged red cell scan have\n not been helpful\n -continue abx for 7 day course, empiric GI coverage. Currently day \n of cipro/flagyl\n -Continue PPI\n #h/o colon cancer. Per Closely followed by his outpatient\n gastroenterologist Dr. who in following patient in house. Pt\n had concerning symptoms (weakness and long term weight loss) and CT\n scan with worsening mesenteric LAD and matting concerning for\n metastasis of his prior malignancy. Currently no plan for scope given\n recent significant bleed but may be reconsidered as outpatient.\n -discuss long term plan for mgmt of colon ca with Dr. \n goals of care with pt and family, he has already made it very\n clear he will not consider surgery or other very invasive measures.\n .\n #GERD: PPI\n #Hyperlipidemia. Statin\n #Hypertension. Hold home regimen in setting of GIB\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI, CMO status reversed.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: c/o to floor\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337575,
"text": "Chief Complaint: 88 y/o M with severe LGIB, now with stable Hct\n 24 Hour Events:\n Hct remained stable at 44\n Per Dr. , pt. would not want surgery, if bleeds again go\n directly to angio\n Ca, Mg and phos repleted\n Given 5mg PO vitamin K\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 12:05 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 12:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 89 (62 - 89) bpm\n BP: 144/65(85) {107/32(56) - 161/67(107)} mmHg\n RR: 20 (14 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 272 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n 518 mL\n 272 mL\n Blood products:\n Total out:\n 1,178 mL\n 100 mL\n Urine:\n 1,078 mL\n 100 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General: A+O, NAD\n HEENT:MMdry\n Neck:Cordis in place\n CV:AS murmur, regular rate\n Pulm:CTAB\n Abd:mildly TTP, +BS\n Ext: resolving upper extremity pitting edema\n Neuro: Incredible lucid, alert and oriented\n Labs / Radiology\n 145 K/uL\n 14.9 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n No new culture data\n Assessment and Plan: 88 y/o M with LGIB, HCT now stable\n # GIB: Has history of AVMs, CT abd confirmed sigmoid source, initially\n shown to have active extravasation concerning for perforation, had\n acute abdomen, surgery consulted, but eval and intervention refused by\n the patient. Pt received total of 12 units PRBCs. Had elevated WBC,\n now improving, not spiking fevers. Still with some melena but with\n stable HCT x 48 hours.\n -Continue to monitor HCT\n -PO vitamin K x 3 days for elevated INR in setting of massive\n transfusion\n -follow Ca in setting of transfusion, repleted yesterday\n -f/u GI recs, plan for angio if rebleeds as tagged red cell scan have\n not been helpful\n -continue abx for 7 day course, empiric GI coverage. Currently day \n of cipro/flagyl\n -Continue PPI\n #h/o colon cancer. Per Closely followed by his outpatient\n gastroenterologist Dr. who in following patient in house. Pt\n had concerning symptoms (weakness and long term weight loss) and CT\n scan with worsening mesenteric LAD and matting concerning for\n metastasis of his prior malignancy. Currently no plan for scope given\n recent significant bleed but may be reconsidered as outpatient.\n -Dr. following\n -Patient cont. to deny surgery as possibility\n .\n #GERD: PPI\n #Hyperlipidemia. Statin\n #Hypertension. Hold home regimen in setting of GIB\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI, CMO status reversed.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with pts wife\n status: DNR/DNI\n Disposition: c/o to floor\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Fellow Progress Note",
"row_id": 337587,
"text": "Chief Complaint:\n HPI: I saw and examined the patient, and was physically present with\n the ICU team for the key portions of the services provided. I agree\n with the note above, including the assessment and plan. I would\n emphasize and add the following points: Patient is an 88 yo male PMH\n significant for Multiple AVMs with 15 year history of recurrent GIB,\n CAD s/p Stent to LAD in , HOCM, Mod AS and remote hx of Colon\n cancer ( A) s/p R hemicolectomy in . Presented with massive\n GI bleed with contrast extravisation in area of sigmoid on CT scan.\n Received 12 Units PRBC over the weekend initially made CMO until\n bleeding resolved.\n 24 Hour Events:No events Hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 06:00 AM\n Other medications:\n Protonix 40 q 24\n Simvistatin\n Sulcrafate\n Detrol\n Flagy 500 tid\n Cipro 750Q12\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 35.9\nC (96.7\n HR: 77 (62 - 93) bpm\n BP: 138/98(108) {109/32(56) - 161/98(108)} mmHg\n RR: 18 (16 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 612 mL\n PO:\n 1,440 mL\n 300 mL\n TF:\n IVF:\n 518 mL\n 312 mL\n Blood products:\n Total out:\n 1,178 mL\n 200 mL\n Urine:\n 1,078 mL\n 200 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 412 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///24/\n Physical Examination\n exam today:Gen: A+O x 3 NAD, HEENT: wnl, Lungs: CTA bilaterally, CV:\n RRRs1s2 +SEM late peaking RUSB with A2 present. Abd:+BS, soft, NT,\n ND. Ext: 1+LE edema Skin: + cordis in neck CDI\n Labs / Radiology\n 14.9 g/dL\n 145 K/uL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan: Assessment and Plan: 88 yo male with massive GI\n bleed currently stabilized.\n 1)GI bleed: Will discuss future managment plans with patient and\n GI/surgery.\n -Will give Vit K for INR, continue Cipro/flagy for concern of micro\n perforation for 7 day course, hcts\n 2)CV: Restart Beta blocker. Would restart Beta blocker the HCTZ.\n 3)FEN: advance to clears, Replete lytes\n 4)Code: DNR/DNI\n 5)ICU: PPI, compression , d\nc cortis today.\n 6)Dispo: Pending stable Hcts> 24hrs.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT: Compression \n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :Floor, will have Dr. discuss disposition with\n them.\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337544,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. CMO status reversed to DNR/DNI per patient and his personal\n GI doctor.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Liquid, maroon stools x2. Abd soft w/hyperactive BS. Denies pain.\n Action:\n Monitoring hcts , quiac stools.\n Response:\n Hct stable @42.3\n Plan:\n No surgery per patient, if rebleeds would go to angio. If Hct stable\n possible call out.\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337554,
"text": "Chief Complaint: 88 y/o M with severe LGIB, now with stable Hct\n 24 Hour Events:\n Hct remained stable at 44\n Per Dr. , pt. would not want surgery, if bleeds again go\n directly to angio\n Ca, Mg and phos repleted\n Given 5mg PO vitamin K\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 12:05 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 12:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 89 (62 - 89) bpm\n BP: 144/65(85) {107/32(56) - 161/67(107)} mmHg\n RR: 20 (14 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 272 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n 518 mL\n 272 mL\n Blood products:\n Total out:\n 1,178 mL\n 100 mL\n Urine:\n 1,078 mL\n 100 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 145 K/uL\n 14.9 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337559,
"text": "Chief Complaint: 88 y/o M with severe LGIB, now with stable Hct\n 24 Hour Events:\n Hct remained stable at 44\n Per Dr. , pt. would not want surgery, if bleeds again go\n directly to angio\n Ca, Mg and phos repleted\n Given 5mg PO vitamin K\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 12:05 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 12:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 89 (62 - 89) bpm\n BP: 144/65(85) {107/32(56) - 161/67(107)} mmHg\n RR: 20 (14 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 272 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n 518 mL\n 272 mL\n Blood products:\n Total out:\n 1,178 mL\n 100 mL\n Urine:\n 1,078 mL\n 100 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 145 K/uL\n 14.9 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n # GIB: Has history of AVMs, CT abd confirmed sigmoid source, initially\n shown to have active extravasation concerning for perforation, had\n acute abdomen, surgery consulted, but eval and intervention refused by\n the patient. Pt received total of 12 units PRBCs, abd exam much\n improved, subsequent plain film imaging without evidence for free air.\n Had elevated WBC, now improving, not spiking fevers. Still with some\n hematochezia but with stable HCT x >24 hours > 40.\n -Continue to monitor HCT\n -PO vitamin K for elevated INR in setting of massive transfusion\n -replete Ca in setting of transfusion\n -f/u GI recs\n -f/u surgery recs\n -continue abx for 7 day course, empiric GI coverage.\n -Continue PPI\n #h/o colon cancer. Per the patient and his wife all of the patient\ns GI\n care has been organized by his gastroenterologist Dr. who is\n following closely. Pt had concerning symptoms (weakness and long term\n weight loss) and CT scan with worsening mesenteric LAD and matting\n concerning for metastasis of his prior malignancy.\n -discuss long term plan for mgmt of colon ca with Dr. \n goals of care with pt and family, he has already made it very\n clear he will not consider surgery or other very invasive measures.\n .\n #GERD: PPI\n #Hyperlipidemia. Statin\n #Hypertension. Hold home regimen in setting of GIB\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI, CMO status reversed.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 337696,
"text": "Chief Complaint: GI Bleed\n HPI: I saw and examined the patient, and was physically present with\n the ICU team for the key portions of the services provided. I agree\n with the note above, including the assessment and plan. I would\n emphasize and add the following points: Patient is an 88 yo male PMH\n significant for Multiple AVMs with 15 year history of recurrent GIB,\n CAD s/p Stent to LAD in , HOCM, Mod AS and remote hx of Colon\n cancer ( A) s/p R hemicolectomy in . Presented with massive\n GI bleed with contrast extravisation in area of sigmoid on CT scan.\n Received 12 Units PRBC over the weekend initially made CMO until\n bleeding resolved. Currently with no signs of active\n bleeding. Reports decreased edema but still has swelling in his hands,\n feet and scrotum.\n 24 Hour Events:No events Hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 06:00 AM\n Other medications:\n Protonix 40 q 24\n Simvistatin\n Sulcrafate\n Detrol\n Flagy 500 tid\n Cipro 750Q12\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: see HPI/24hr events\n Flowsheet Data as of 10:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 35.9\nC (96.7\n HR: 77 (62 - 93) bpm\n BP: 138/98(108) {109/32(56) - 161/98(108)} mmHg\n RR: 18 (16 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 612 mL\n PO:\n 1,440 mL\n 300 mL\n TF:\n IVF:\n 518 mL\n 312 mL\n Blood products:\n Total out:\n 1,178 mL\n 200 mL\n Urine:\n 1,078 mL\n 200 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 412 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///24/\n Physical Examination\n exam today:Gen: A+O x 3 NAD, HEENT: wnl, Lungs: CTA bilaterally, CV:\n RRRs1s2 +SEM late peaking RUSB with A2 present. Abd:+BS, soft, NT,\n ND. Ext: 1+LE edema Skin: + cordis in neck CDI\n Labs / Radiology\n 14.9 g/dL\n 145 K/uL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan: Assessment and Plan: 88 yo male with massive GI\n bleed currently stabilized.\n 1)GI bleed: Will discuss future management plans with patient and\n GI/surgery.\n -Will give Vit K x 3 days for elevated INR, continue Cipro/flagy for\n concern of micro perforation for 7 day course, hcts\n 2)CV: Would restart Beta blocker the HCTZ.\n 3)FEN: advance to clears, Replete lytes\n 4)Code: DNR/DNI\n 5)Dispo: floor.\n ICU Care\n Nutrition: advance diet\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM D\nc Today.\n Prophylaxis:\n DVT: Compression boots\n Stress ulcer: PPI\n Communication: with pt and wife Dr also stopped by to see how\n he was doing and agrred with plan as outlined\n Code status: DNR/DNI\n Disposition :Floor\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337195,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient's Hct decreased to 33 from 35 despite getting 3 units of PRBCs.\n Additionally, SBP dropped transiently to 80s and he passed a large,\n frankly bloody BM. He was given one more unit of PRBCs and IR and GI\n were notified. Per that discussion, patient was taken for tagged RBC\n scan, where bleeding was found in the sigmoid colon. While undergoing\n bleeding scan, patient's BP continued to intermittently drop and he\n received a total of 2 more units of blood and 3 liters of NS with\n transient increases in BP, but continued hematochezia. He was then\n brought up to the ICU for placement of a cordis and received 6 more\n units of PRBCs, 2 bags of FFP, 1 bag of platelets and 4 liters of NS.\n The plan was for IR intervention once he became hemodynamically stable,\n but patient was then noted to suddenly develop acute abdominal pain,\n abdominal distention and high pitched bowel sounds, which were\n concerning for a perforation. Surgery was notified and came to examine\n the patient, but he refused examination, stating that he only wanted to\n be made comfortable. He continued to refuse surgery at this point and\n had previously been made DNR/DNI. KUB was deferred as was angiographic\n intervention, at the patient's request. He was given Morphine boluses\n for comfort and the family was notified so that they could be present\n with him. He was made CMO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:50 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 02:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 99 (62 - 99) bpm\n BP: 113/61(73) {62/42(47) - 154/123(109)} mmHg\n RR: 22 (13 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,754 mL\n 1,875 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,250 mL\n Blood products:\n 3,404 mL\n 1,875 mL\n Total out:\n 1,590 mL\n 0 mL\n Urine:\n 1,490 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 6,164 mL\n 1,875 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: Sleepy and slow to respond\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n Radiation to the axilla\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: Rales and\n ronchi throughout\n Abdominal: Patient refusing exam\n Labs / Radiology\n 112 K/uL\n 11.4 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 108 mEq/L\n 142 mEq/L\n 30.8 %\n 19.5 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n WBC\n 11.5\n 19.5\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n Plt\n 199\n 149\n 112\n Cr\n 1.2\n 0.9\n 0.9\n Glucose\n 107\n 119\n 93\n Other labs: PT / PTT / INR:14.6/30.4/1.3, Ca++:6.6 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n # GIB: Confirmed bleeding in the sigmoid colon. Patient is no longer\n amenable to angiography and was never agreeable to surgery and these\n are essentially the extent of his definitive treatment options. Patient\n required several PRBCs and IVF and though currently hemodynamically\n stable, thought to be due to temporary halt of bleeding, he is at risk\n for further bleeding. Per repeated conversation with patient, he is\n only interested in being made comfortable with no further intervention.\n Additionally, his respiratory status is tenuous s/p multiple PRBCs and\n IVF boluses, so additional resuscitation would likely result in\n pulmonary edema, which would require Lasix and this would only\n potentiate hypotension.\n - Comfort measures only; no labs, avoid blood products and IVF,\n Morphine PRN for abdominal pain\n - Appreciate IR, GI and surgical input thus far\n - Discontinue unnecessary meds\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI/CMO\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:52 AM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 337211,
"text": "Chief Complaint: LGIB\n I saw and examined the patient, and was physically present with the 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 88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulitis, CAD s/p LAD stent admitted with LGIB. Initial\n evaluation revealed likely sigmoid colon bleed. Unfortunately, last\n night he had massive bleeding following a tagged RBC scan. He received\n a total of 12 units PRBC. This was followed by severe abdominal pain.\n He declined to have further interventions including angiography and\n surgery. He is now DNR/DNI/CMO and receiving morphine for his\n abdominal pain.\n 24 Hour Events:\n CORDIS/INTRODUCER - START 12:00 AM\n -As above.\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 Morphine Sulfate - 02:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35\nC (95\n HR: 74 (62 - 100) bpm\n BP: 99/55(67) {62/42(47) - 154/123(109)} mmHg\n RR: 13 (11 - 27) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,754 mL\n 1,887 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,250 mL\n 12 mL\n Blood products:\n 3,404 mL\n 1,875 mL\n Total out:\n 1,870 mL\n 1,420 mL\n Urine:\n 1,770 mL\n 920 mL\n NG:\n Stool:\n 100 mL\n 500 mL\n Drains:\n Balance:\n 5,884 mL\n 467 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 90%\n Physical Examination\n Deferred.\n Labs / Radiology\n 11.4 g/dL\n 112 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 108 mEq/L\n 142 mEq/L\n 30.8 %\n 19.5 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n WBC\n 11.5\n 19.5\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n Plt\n 199\n 149\n 112\n Cr\n 1.2\n 0.9\n 0.9\n Glucose\n 107\n 119\n 93\n Other labs: PT / PTT / INR:14.6/30.4/1.3, Ca++:6.6 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Microbiology: None.\n Assessment and Plan\n 88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulosis, CAD s/p LAD stent admitted with massive LGIB with\n likely sigmoid colon source. He likely suffered a perforation last\n night and opted for no further interventions, with a focus on his\n comfort. He is currently responsive and denies any pain. Will\n continue morphine boluses PRN for comfort. DC other medications and lab\n draws.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI / CMO\n Disposition : Remains in ICU.\n Total time spent:\n Addendum:\n Patient after conversation with Dr. (his primary GI\n specialist) agrees to blood draws and transfusions. Wishes to continue\n DNR/DNI, however does want to be treated for GIB. Abdominal exam much\n improved currently soft, nontender.\n CC 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337370,
"text": "Chief Complaint:\n 88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf, now making\n excellent recovery with conservative management.\n 24 Hour Events:\n CMO status reversed yesterday morning\n Hct stable, no further evidence of active bleeding\n CXR showed no free air under diaphragm\n Started on cipro/flagyl due to concern for microperforation, WBC\n decreased this am.\n Tolerating PO, oral meds restarted\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 None SH: Pt lives with wife in , their son lives above\n them.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Reports some intermittent crampy abdominal pain. No SOB. Still having\n hematochezia in rectal tube.\n Flowsheet Data as of 06:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 77 (70 - 84) bpm\n BP: 110/52(67) {91/40(51) - 125/67(76)} mmHg\n RR: 17 (9 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,466 mL\n 582 mL\n PO:\n 360 mL\n 480 mL\n TF:\n IVF:\n 231 mL\n 102 mL\n Blood products:\n 1,875 mL\n Total out:\n 2,190 mL\n 245 mL\n Urine:\n 1,590 mL\n 245 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 276 mL\n 337 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94% 3L\n ABG: ///24/\n Physical Examination\n General: A+O, NAD\n HEENT:MMdry\n Neck:Cordis in place\n CV:AS murmur, regular rate\n Pulm:CTAB\n Abd:mildly TTP, +BS\n Ext: resolving upper extremity pitting edema\n Neuro: Incredible lucid, alert and oriented\n Labs / Radiology\n 116 K/uL\n 14.8 g/dL\n 74 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 112 mEq/L\n 142 mEq/L\n 43.3 %\n 13.1 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n Plt\n 199\n 149\n 112\n 115\n 116\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n Glucose\n 107\n 119\n 93\n 120\n 74\n Other labs: PT / PTT / INR:20.9/39.1/2.0, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:1.8 mg/dL\n No new micro data\n Assessment and Plan\n # GIB: Has history of AVMs, CT abd confirmed sigmoid source, initially\n shown to have active extravasation concerning for perforation, had\n acute abdomen, surgery consulted, but eval and intervention refused by\n the patient. Pt received total of 12 units PRBCs, abd exam much\n improved, subsequent plain film imaging without evidence for free air.\n Had elevated WBC, now improving, not spiking fevers. Still with some\n hematochezia but with stable HCT x >24 hours > 40.\n -Continue to monitor HCT\n -PO vitamin K for elevated INR in setting of massive transfusion\n -replete Ca in setting of transfusion\n -f/u GI recs\n -f/u surgery recs\n -continue abx for 7 day course, empiric GI coverage.\n -Continue PPI\n #h/o colon cancer. Per the patient and his wife all of the patient\ns GI\n care has been organized by his gastroenterologist Dr. who is\n following closely. Pt had concerning symptoms (weakness and long term\n weight loss) and CT scan with worsening mesenteric LAD and matting\n concerning for metastasis of his prior malignancy.\n -discuss long term plan for mgmt of colon ca with Dr. \n goals of care with pt and family, he has already made it very\n clear he will not consider surgery or other very invasive measures.\n .\n #GERD: PPI\n #Hyperlipidemia. Statin\n #Hypertension. Hold home regimen in setting of GIB\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI, CMO status reversed.\n ICU Care\n Nutrition: Heart healthy diet\n Glycemic Control: well controlled\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM, leave in for now while\n trending hct and developing long term plan for recurrent bleed, would\n need 2 large bore peripheral IVs if removed.\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n VAP: not needed\n Comments:\n Communication: Comments: With pt, wife, PCP emailed, both sons.\n status: DNR/DNI\n Disposition: Call out to floor if hct stable this afternoon and\n family/Dr. on same page with plan.\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337462,
"text": ".H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337463,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337464,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. CMO status reversed to DNR/DNI per patient and his persomal\n GI doctor.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337465,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. CMO status reversed to DNR/DNI per patient and his persomal\n GI doctor.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337125,
"text": "Pt at Nuclear Med tonight with profuse BRBPR, pt received many blood\n products and liter boluses; approx 2330, pt experiencing acute abd\n pain, abd rigid and distended, thought to be bowel perf; pt refusing\n surgery and wanting ICU team to let him\ndie in peace\n, pt adamant\n about not wanting any further intervention; pt now CMO; family at\n bedside\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337676,
"text": "0700-1900\n 88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. Was made CMO per pt wishes over the weekend, however hct\n stabilized and remained hd stable so status reversed to DNR/DNI per\n patient and his personal GI doctor. At present, pt does not wish to\n have any surgical interventions should he rebleed, however will go to\n Angio. If necessary . Presently c/o to the floor awaiting a bed.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Hct remains stable\n last checked at noon today and was 44.4. HD\n stable. No brbpr, occasionally passing black tarry/maroon stool.\n Action:\n Monitoring for s&s of active bleeding.\n Response:\n No signs of active bleeding.\n Plan:\n Monitor hct and for any other s&s of active bleeding. If pt\n rebleeds, will transfuse and go to Angio. No surgical interventions per\n pt wishes.\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337532,
"text": "Chief Complaint: 88 y/o M with severe LGIB, now with stable Hct\n 24 Hour Events:\n Hct remained stable at 44\n Per Dr. , pt. would not want surgery, if bleeds again go\n directly to angio\n Ca, Mg and phos repleted\n Given 5mg PO vitamin K\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 12:05 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 12:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 89 (62 - 89) bpm\n BP: 144/65(85) {107/32(56) - 161/67(107)} mmHg\n RR: 20 (14 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 272 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n 518 mL\n 272 mL\n Blood products:\n Total out:\n 1,178 mL\n 100 mL\n Urine:\n 1,078 mL\n 100 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 145 K/uL\n 14.9 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337063,
"text": "HPI:\n 88 M PMH colon CA s/p hemicolectomy, small bowel AVMs, diverticulosis\n and CAD s/p LAD stent who presented with BRBPR that started last\n night. He reports having diarrhea last week without abdominal pain, F\n or C. His BM had normalized since then. He also reports three years\n of poor appetite and >20 lbs weight loss.\n In ED, he was found to have HCT 36% down from baseline 40% and\n continued to have profuse blood and clots from rectum. An abdominal CT\n scan demonstrated extravasation of contrast near the sigmoid colon.\n His blood pressure on presentation was 160 systolic and had decreased\n to 100 just prior to transfer to MICU. Here, he received 3 units\n PRBC. He was evaluated by GI and IR and taken for angiography this\n morning. Unfortunately, no bleeding was visualized at angiography and\n he was returned to the MICU.\n He currently complains of diffuse, mild abdominal tenderness and\n thirst. Denies CP, SOB, lightheadedness. No N/V. Has not used ASA /\n NSAIDs.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt continues to pass brbpr , c/o cramping given ,5 mg iv and became\n hypotensive post morphine\n Action:\n Pt went to ir this am however they were unable to find the site of\n bleeding, pt has started out with hct in ed of 39, dropped to 32 was\n given I unit of prbc\ns in the ed and I am now finishing 4 th unit\n prbcs, pt also given I liter ivf for low BP\n Response:\n Bp improved to low 100\n Plan:\n Plan to send pt to red tag study this afternoon, awaiting time of test\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337233,
"text": "HPI:\n 88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulitis, CAD s/p LAD stent admitted with LGIB. Initial\n evaluation revealed likely sigmoid colon bleed. Unfortunately, last\n night he had massive bleeding following a tagged RBC scan. He received\n a total of 12 units PRBC. This was followed by severe abdominal pain.\n He declined to have further interventions including angiography and\n surgery. He is now DNR/DNI/CMO and receiving morphine for his\n abdominal pain. Pt was seen later this afternoon by DR , who\n is pt\n GI Md, DR readdressed cmo status with patient, and at\n present cmo is resended pt will continue with medical management but is\n not interested in aggressive treatment, If pt should rebleed please\n call Dr. .\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt still passing maroon stool , however pt hemodynamically stable\n thoughout this shift, hypothemic to 95.6\n Action:\n Repeat hct 46, wbc count 19.6 inr 2.0\n Response:\n Pt stable at present\n Plan:\n Status change, will medically manage, have added flagyl and cipro,\n to cover abd source, will transfuse if needed\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337036,
"text": "HPI:\n 88 M PMH colon CA s/p hemicolectomy, small bowel AVMs, diverticulosis\n and CAD s/p LAD stent who presented with BRBPR that started last\n night. He reports having diarrhea last week without abdominal pain, F\n or C. His BM had normalized since then. He also reports three years\n of poor appetite and >20 lbs weight loss.\n In ED, he was found to have HCT 36% down from baseline 40% and\n continued to have profuse blood and clots from rectum. An abdominal CT\n scan demonstrated extravasation of contrast near the sigmoid colon.\n His blood pressure on presentation was 160 systolic and had decreased\n to 100 just prior to transfer to MICU. Here, he received 3 units\n PRBC. He was evaluated by GI and IR and taken for angiography this\n morning. Unfortunately, no bleeding was visualized at angiography and\n he was returned to the MICU.\n He currently complains of diffuse, mild abdominal tenderness and\n thirst. Denies CP, SOB, lightheadedness. No N/V. Has not used ASA /\n NSAIDs.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-25 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 337049,
"text": "Chief Complaint: BRBPR\n I saw and examined the patient, and was physically present with the ICU\n fellow Dr for key portions of the services provided. I agree with\n her note above, including assessment and plan.\n HPI:\n 88 M PMH colon CA s/p hemicolectomy, small bowel AVMs, diverticulosis\n and CAD s/p LAD stent who presented with BRBPR that started last\n night. He reports having diarrhea last week without abdominal pain, F\n or C. His BM had normalized since then. He also reports three years\n of poor appetite and >20 lbs weight loss.\n In ED, he was found to have HCT 36% down from baseline 40% and\n continued to have profuse blood and clots from rectum. An abdominal CT\n scan demonstrated extravasation of contrast near the sigmoid colon.\n His blood pressure on presentation was 160 systolic and had decreased\n to 100 just prior to transfer to MICU. Here, he received 3 units\n PRBC. He was evaluated by GI and IR and taken for angiography this\n morning. Unfortunately, no bleeding was visualized at angiography and\n he was returned to the MICU.\n He currently complains of diffuse, mild abdominal tenderness and\n thirst. Denies CP, SOB, lightheadedness. No N/V. Has not used ASA /\n NSAIDs.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Colon CA s/p hemicolectomy\n Small bowel AVMs\n Diverticulosis\n CAD s/p LAD stent \n Moderate AS\n Moderate MR\n HOCM\n HTN\n HL\n s/p CCY\n s/p L inguinal hernia repair\n s/p prostatectomy\n s/p arthroscopic knee surgery for torn meniscus\n Chronic low back pain\n Neuropathy RLE\n M - HTN. Stroke.\n F - Lung cancer.\n Occupation: Retired accountant.\n Drugs: None.\n Tobacco: Quit 35 years ago.\n Alcohol: None.\n Other: Married. From originally.\n Review of systems:\n Constitutional: Weight loss\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: NPO\n Gastrointestinal: Abdominal pain\n Musculoskeletal: Joint pain\n Flowsheet Data as of 12:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 69 (69 - 76) bpm\n BP: 97/54(63) {97/54(63) - 114/59(72)} mmHg\n RR: 16 (16 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 957 mL\n PO:\n TF:\n IVF:\n 582 mL\n Blood products:\n 375 mL\n Total out:\n 0 mL\n 850 mL\n Urine:\n 750 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 0 mL\n 107 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Dry mucous membranes\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), \n harsh systolic M\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Tender: diffuse, no g/r, Hypoactive BS\n Extremities: Right: Absent, Left: Absent\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed,\n Labs / Radiology\n 199 K/uL\n 35.4 %\n 12.5 g/dL\n 107 mg/dL\n 1.2 mg/dL\n 21 mg/dL\n 25 mEq/L\n 105 mEq/L\n 3.8 mEq/L\n 138 mEq/L\n 11.5 K/uL\n [image002.jpg]\n 08:37 AM\n WBC\n 11.5\n Hct\n 35.4\n Plt\n 199\n Cr\n 1.2\n Glucose\n 107\n Other labs: PT / PTT / INR:14.4/28.4/1.3, Ca++:7.3 mg/dL, Mg++:1.4\n mg/dL, PO4:2.9 mg/dL\n Imaging: Abdominal CT - Extravasation of contrast near sigmoid colon.\n No evidence of ischemia.\n Microbiology: None.\n ECG: SB 55 bpm. LAD. IVCD. NSCCT 12/.\n Assessment and Plan\n 88 M PMH colon CA s/p hemicolectomy, small bowel AVMs, diverticulosis,\n CAD s/p LAD stent, moderate AS / HOCM who is admitted with BRBPR likely\n secondary to a diverticular bleed in the sigmoid colon. He is\n hemodynamically stable. There is ongoing BRBPR with no evidence of\n bleeding by angiography.\n 1) Acute GIB\n 2 peripheral IVs. Serial HCT Q6H. Transfuse for\n HCT < 30%. IV PPI. Should he rebleed, we will obtain tagged RBC scan,\n followed by IR. We will also consult general surgery. Last platelet\n count and coags were normal. Warming blanket in place.\n 2) Cardiovascular\n Currently hemodynamically stable. Holding\n anti-hypertensives / diuretics. No antiplatelet therapy. Continue\n statin. At risk of pulmonary edema with AS/HOCM.\n 3) ARF\n Improved after blood transfusion. Received HCO3 for\n renal ppx. Will complete 4 doses NAC.\n ICU Care\n Nutrition: Ice chips only.\n Lines / Intubation: Peripheral IVs, 18 Gauge - 07:52 AM\n Prophylaxis: DVT: Boots, Stress ulcer: PPI, Code status: Full,\n Disposition: Remains in ICU.\n Total time spent: 33, remains critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 337105,
"text": "Chief Complaint: GIB\n HPI:\n 88 y.o. male with history of AVMs and diverticulosis who noted frank\n blood with a bowel movement yesterday. Patient denies chest pain,\n shortness of breath, palpitations, lightheadedness or syncope, F/C, N/V\n with this bleeding. He does however note diarrhea the week prior to\n presentation, but says that this diarrhea was short-lived (relieved\n with Immodium) and non-bloody. He also reports an approximate 20 lb.\n weight loss over the past 3 years. As mentioned, patient has a history\n of GIB with multiple hospitalizations and is s/p a remote right\n hemicolectomy in for colon cancer.\n .\n Patient presented to the ED where he was noted to have a Hct drop\n from 39 to 32 with a SBP drop from 167 to 100. A CTA abdomen showed\n extravasation of constrast from the sigmoid colon and patient was\n admitted to the MICU for further management. Upon arrival, he was\n rapidly given 3 units of PRBCs and taken to IR where an angiogram\n showed no bleeding. He was then brought back to the MICU for further\n observation, with the plan to involve GI and surgery and proceed to a\n tagged RBC scan if bleeding recurred.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1)Colon cancer ( A) s/p R hemicolectomy in \n 2)Multiple AVMs with 15 year history of recurrent GIB\n 3)CAD s/p stent to LAD in \n 4)Hypertrophic cardiomyopathy\n 5)HOCM\n 6)GERD\n 7)h/o jejunal lipoma in \n 8)Hypertension\n 9)Hyperlipidemia\n NC\n Occupation: Retired Accounant\n Drugs: Denies\n Tobacco: Former Smoker\n Alcohol: Denies\n Other:\n Review of systems:\n Constitutional: Weight loss\n Gastrointestinal: Abdominal pain, Diarrhea\n Flowsheet Data as of 02:17 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 99 (62 - 99) bpm\n BP: 113/61(73) {62/42(47) - 154/123(109)} mmHg\n RR: 22 (13 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,754 mL\n 1,875 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,250 mL\n Blood products:\n 3,404 mL\n 1,875 mL\n Total out:\n 1,590 mL\n 0 mL\n Urine:\n 1,490 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 6,164 mL\n 1,875 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),\n Radiation to the axilla\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Bowel sounds present, Tender: Diffusely without\n rebounding or guarding\n Rectal: Frankly bloody stool\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 112 K/uL\n 11.4 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 14 mg/dL\n 24 mEq/L\n 108 mEq/L\n 3.6 mEq/L\n 142 mEq/L\n 30.8 %\n 19.5 K/uL\n [image002.jpg]\n \n 2:33 A8/23/ 08:37 AM\n \n 10:20 P8/23/ 02:44 PM\n \n 1:20 P8/23/ 05:42 PM\n \n 11:50 P8/23/ 08:53 PM\n \n 1:20 A8/23/ 11:23 PM\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 11.5\n 19.5\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n Plt\n 199\n 149\n 112\n Cr\n 1.2\n 0.9\n 0.9\n Glucose\n 107\n 119\n 93\n Other labs: PT / PTT / INR:14.6/30.4/1.3, Ca++:6.6 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Imaging: CTA Abdomen ()\n 1. Active extravasation of contrast in the sigmoid colon, likely\n related to a diverticular bleed. An AVM is also possible in this\n patient with a history of duodenal AVM. These findings were discussed\n with Dr. and the interventional radiology team at\n the time of the exam.\n .\n 2. Slightly increasing size of mesenteric soft tissue masses with\n tethering of adjacent bowel loops. There are also new soft tissue\n masses elsewhere in the mesentery. These findings are nonspecific and\n may represent confluent lymphadenopathy related to lymphoma or other\n process, a primary mesenteric mass such as carcinoid or desmoid tumor,\n or mesenteric fibrosis. Biopsy may be beneficial as the process is\n progressive.\n ECG: Sinus bradycardia at approx 55, LAD, prolonged PR, widened QRS w/\n RBBB, Q waves in V1, V2, all unchanged from prior\n Assessment and Plan\n 88 y.o. male with history of recurrent GIBs in the setting of known\n AVMs and diverticulosis, who presents with a chief complaint of\n hematochezia.\n .\n # GIB: Hematochezia on exam in a patient with a history of AVMs and\n diverticulosis; likely a lower GIB, though could be a brisk UGIB,\n particularly given the relative drop in BP. GI and IR currently\n involved. Should this be a diverticular bleed, endoscopic intervention\n is very limited and therapy would be deferred to IR or surgery.\n - Tagged RBC scan; F/U IR recs\n - Serial Hcts and transfuse to Hct > 30 as he is actively bleeding\n - PPI IV BID, though less concerned for UGIB\n - Surgical consult\n - F/U GI recs\n - Hold all BP meds so as to avoid potentiating hypotension\n - Avoid anticoagulants; pt. not caogulopathic currently\n .\n # CAD: s/p stent (unsure of what kind) and not on Plavix/ASA. Currently\n without chest pain, SOB and EKG unremarkable.\n - Keep Hct > 30\n - Low threshold to cycle enzymes\n - Holding BB, Nitro; Continue statin\n .\n # ARF: Creatinine to 1.7 on presentation, improved with IVF/PRBCs,\n supporting pre-renal/hypovolemia in the setting of GIB. Concern however\n is for contrast-induced nephropathy, now that pt. is s/p arteriogram.\n - Continue bicarb and NAC\n .\n # GERD\n - Continue PPI\n - Continue Sucralfate\n .\n # FEN\n - NPO\n - IVF\n - Correct/Replete electrolytes PRN\n .\n # PPx\n - Pneumoboots\n - PPI IV BID\n .\n # Communication: With patient\n .\n # Code status: FULL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:52 AM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337108,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient's Hct decreased to 33 from 35 despite getting 3 units of PRBCs.\n Additionally, SBP dropped transiently to 80s and he passed a large,\n frankly bloody BM. He was given one more unit of PRBCs and IR and GI\n were notified. Per that discussion, patient was taken for tagged RBC\n scan, where bleeding was found in the sigmoid colon. While undergoing\n bleeding scan, patient's BP continued to intermittently drop and he\n received a total of 2 more units of blood and 3 liters of NS with\n transient increases in BP, but continued hematochezia. He was then\n brought up to the ICU for placement of a cordis and received 6 more\n units of PRBCs, 2 bags of FFP, 1 bag of platelets and 4 liters of NS.\n The plan was for IR intervention once he became hemodynamically stable,\n but patient was then noted to suddenly develop acute abdominal pain,\n abdominal distention and high pitched bowel sounds, which were\n concerning for a perforation. Surgery was notified and came to examine\n the patient, but he refused examination, stating that he only wanted to\n be made comfortable. He continued to refuse surgery at this point and\n had previously been made DNR/DNI. KUB was deferred as was angiographic\n intervention, at the patient's request. He was given Morphine boluses\n for comfort and the family was notified so that they could be present\n with him.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:50 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 02:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 99 (62 - 99) bpm\n BP: 113/61(73) {62/42(47) - 154/123(109)} mmHg\n RR: 22 (13 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,754 mL\n 1,875 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,250 mL\n Blood products:\n 3,404 mL\n 1,875 mL\n Total out:\n 1,590 mL\n 0 mL\n Urine:\n 1,490 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 6,164 mL\n 1,875 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 112 K/uL\n 11.4 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 108 mEq/L\n 142 mEq/L\n 30.8 %\n 19.5 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n WBC\n 11.5\n 19.5\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n Plt\n 199\n 149\n 112\n Cr\n 1.2\n 0.9\n 0.9\n Glucose\n 107\n 119\n 93\n Other labs: PT / PTT / INR:14.6/30.4/1.3, Ca++:6.6 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:52 AM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337290,
"text": "88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulitis, CAD s/p LAD stent admitted with LGIB. Initial\n evaluation revealed likely sigmoid colon bleed. Unfortunately, last\n night he had massive bleeding following a tagged RBC scan. He received\n a total of 12 units PRBC, 2 units FFP, 1 pack plts. This was followed\n by severe abdominal pain. He declined to have further interventions\n including angiography and surgery and status changed to CMO per patient\n wishes. During day shift , patient after conversation with Dr.\n (his primary GI specialist) agreed to blood draws and\n transfusions. Wishes to continue DNR/DNI, however does want to be\n treated for GIB. Again, pt wanting to\nfinish it\n and end his\n life, Dr. and to see pt today, family called and in\n to visit, pt no longer making statements re: wanting to die.\n H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Pt s/p massive LGIB, source sigmoid colon, refusing interventions\n Action:\n HCT checked, fecal bag in place\n Response:\n Sm amt maroon stools; HCT 47\n Plan:\n Follow HCT, if further bleeding occurs, contact Dr. \n"
},
{
"category": "Nursing",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 337400,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Abd soft non tender, non distended, positive for BS and flatus, maroon\n color stool in rectal bag however in much smaller amnt. Denies N/V.\n NPO. HCT 43.3 b/p 130\ns/60\ns Hr at 80\ns. U/O WNL.\n Action:\n Serial Hct, GI consult, rectal bag and foley d/c per Dr. ,\n started on clear liquid diet - tolerates it well,\n Response:\n Hct- ________\n Plan:\n Continue to monitor patient status, transfuse as needed, per Dr.\n (GI) if rebleeds angio to be performed.\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Fellow Progress Note",
"row_id": 337632,
"text": "Chief Complaint: GI Bleed\n HPI: I saw and examined the patient, and was physically present with\n the ICU team for the key portions of the services provided. I agree\n with the note above, including the assessment and plan. I would\n emphasize and add the following points: Patient is an 88 yo male PMH\n significant for Multiple AVMs with 15 year history of recurrent GIB,\n CAD s/p Stent to LAD in , HOCM, Mod AS and remote hx of Colon\n cancer ( A) s/p R hemicolectomy in . Presented with massive\n GI bleed with contrast extravisation in area of sigmoid on CT scan.\n Received 12 Units PRBC over the weekend initially made CMO until\n bleeding resolved. Currently with no signs of active\n bleeding. Reports decreased edema but still has swelling in his hands,\n feet and scrotum.\n 24 Hour Events:No events Hct stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 06:00 AM\n Other medications:\n Protonix 40 q 24\n Simvistatin\n Sulcrafate\n Detrol\n Flagy 500 tid\n Cipro 750Q12\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: see HPI/24hr events\n Flowsheet Data as of 10:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 35.9\nC (96.7\n HR: 77 (62 - 93) bpm\n BP: 138/98(108) {109/32(56) - 161/98(108)} mmHg\n RR: 18 (16 - 22) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 612 mL\n PO:\n 1,440 mL\n 300 mL\n TF:\n IVF:\n 518 mL\n 312 mL\n Blood products:\n Total out:\n 1,178 mL\n 200 mL\n Urine:\n 1,078 mL\n 200 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 412 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///24/\n Physical Examination\n exam today:Gen: A+O x 3 NAD, HEENT: wnl, Lungs: CTA bilaterally, CV:\n RRRs1s2 +SEM late peaking RUSB with A2 present. Abd:+BS, soft, NT,\n ND. Ext: 1+LE edema Skin: + cordis in neck CDI\n Labs / Radiology\n 14.9 g/dL\n 145 K/uL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan: Assessment and Plan: 88 yo male with massive GI\n bleed currently stabilized.\n 1)GI bleed: Will discuss future managment plans with patient and\n GI/surgery.\n -Will give Vit K x 3 days for elevated INR, continue Cipro/flagy for\n concern of micro perforation for 7 day course, hcts\n 2)CV: Would restart Beta blocker the HCTZ.\n 3)FEN: advance to clears, Replete lytes\n 4)Code: DNR/DNI\n 5)Dispo: floor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM D\nc Today.\n Prophylaxis:\n DVT: Compression boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :Floor, will have Dr. discuss disposition with\n them.\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 337641,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. Was made CMO per pt wishes over the weekend, however hct\n stabilized and remained hd stable so status reversed to DNR/DNI per\n patient and his personal GI doctor. At present, pt does not wish to\n have any surgical interventions should he rebleed, however will go to\n Angio.\n"
},
{
"category": "Nursing",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 337646,
"text": "88M with h/o colon cancer and AVMs with multiple GIBs admitted with\n massive LGIB, initially thought to have bowel perf. Received a total of\n 12 units of packed cells. Abx therapy started for ?microperf. Acute abd\n improved. Was made CMO per pt wishes over the weekend, however hct\n stabilized and remained hd stable so status reversed to DNR/DNI per\n patient and his personal GI doctor. At present, pt does not wish to\n have any surgical interventions should he rebleed, however will go to\n Angio.\n .H/O gastrointestinal bleed, lower (Hematochezia, BRBPR, GI Bleed, GIB)\n Assessment:\n Hct remains stable\n last checked at noon today and was 44.4. HD\n stable. No brbpr, joccasionally passing black tarry/maroon stool.\n Action:\n Monitoring for s&s of active bleeding.\n Response:\n No signs of active bleeding.\n Plan:\n Monitor hct and for any other s&s of active bleeding. If pt\n rebleeds, will go to IR and be transfused. No surgical interventions\n per pt wishes.\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-25 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 337030,
"text": "Chief Complaint: BRBPR\n I saw and examined the patient, and was physically present with the 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 88 M PMH colon CA s/p hemicolectomy, small bowel AVMs, diverticulosis\n and CAD s/p LAD stent who presented with BRBPR that started last\n night. He reports having diarrhea last week without abdominal pain, F\n or C. His BM had normalized since then. He also reports three years\n of poor appetite and >20 lbs weight loss.\n In ED, he was found to have HCT 36% down from baseline 40% and\n continued to have profuse blood and clots from rectum. An abdominal CT\n scan demonstrated extravasation of contrast near the sigmoid colon.\n His blood pressure on presentation was 160 systolic and had decreased\n to 100 just prior to transfer to MICU. Here, he received 3 units\n PRBC. He was evaluated by GI and IR and taken for angiography this\n morning. Unfortunately, no bleeding was visualized at angiography and\n he was returned to the MICU.\n He currently complains of diffuse, mild abdominal tenderness and\n thirst. Denies CP, SOB, lightheadedness. No N/V. Has not used ASA /\n NSAIDs.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Colon CA s/p hemicolectomy\n Small bowel AVMs\n Diverticulosis\n CAD s/p LAD stent \n Moderate AS\n Moderate MR\n HOCM\n HTN\n HL\n s/p CCY\n s/p L inguinal hernia repair\n s/p prostatectomy\n s/p arthroscopic knee surgery for torn meniscus\n Chronic low back pain\n Neuropathy RLE\n M - HTN. Stroke.\n F - Lung cancer.\n Occupation: Retired accountant.\n Drugs: None.\n Tobacco: Quit 35 years ago.\n Alcohol: None.\n Other: Married. From originaly.\n Review of systems:\n Constitutional: Weight loss\n Ear, Nose, Throat: Dry mouth\n Nutritional Support: NPO\n Gastrointestinal: Abdominal pain\n Musculoskeletal: Joint pain\n Flowsheet Data as of 12:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 69 (69 - 76) bpm\n BP: 97/54(63) {97/54(63) - 114/59(72)} mmHg\n RR: 16 (16 - 20) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 957 mL\n PO:\n TF:\n IVF:\n 582 mL\n Blood products:\n 375 mL\n Total out:\n 0 mL\n 850 mL\n Urine:\n 750 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 0 mL\n 107 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Dry mucous membranes\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), \n harsh systolic M\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Tender: diffuse, no g/r, Hypoactive BS\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 199 K/uL\n 35.4 %\n 12.5 g/dL\n 107 mg/dL\n 1.2 mg/dL\n 21 mg/dL\n 25 mEq/L\n 105 mEq/L\n 3.8 mEq/L\n 138 mEq/L\n 11.5 K/uL\n [image002.jpg]\n 08:37 AM\n WBC\n 11.5\n Hct\n 35.4\n Plt\n 199\n Cr\n 1.2\n Glucose\n 107\n Other labs: PT / PTT / INR:14.4/28.4/1.3, Ca++:7.3 mg/dL, Mg++:1.4\n mg/dL, PO4:2.9 mg/dL\n Imaging: Abdominal CT - Extravasation of contrast near sigmoid colon.\n No evidence of ischemia.\n Microbiology: None.\n ECG: SB 55 bpm. LAD. IVCD. NSCCT 12/.\n Assessment and Plan\n 88 M PMH colon CA s/p hemicolectomy, small bowel AVMs, diverticulosis,\n CAD s/p LAD stent, moderate AS / HOCM who is admitted with BRBPR likely\n secondary to a diverticular bleed in the sigmoid colon. He no longer\n appears to be actively bleeding and is hemodynamically stable.\n 1) GIB\n 2 peripheral IVs. Serial HCT Q6H. Transfuse for HCT <\n 30%. IV PPI. Should he rebleed, we will obtain tagged RBC scan,\n followed by IR. We will also consult general surgery. Last platelet\n count and coags were normal. Warming blanket in place.\n 2) Cardiovascular\n Currently hemodynamically stable. Holding\n anti-hypertensives / diuretics. No antiplatelet therapy. Continue\n statin.\n 3) ARF\n Improved after blood transfusion. Received HCO3 for\n renal ppx. Will complete 4 doses NAC.\n ICU Care\n Nutrition: Ice chips only.\n Glycemic Control: None.\n Lines / Intubation: Peripheral IVs.\n 18 Gauge - 07:52 AM\n Comments:\n Prophylaxis:\n DVT: Boots.\n Stress ulcer: PPI.\n VAP: N/A.\n Comments:\n Communication: Comments:\n Code status: Full.\n Disposition: Remains in ICU.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 337176,
"text": "Chief Complaint: LGIB\n I saw and examined the patient, and was physically present with the 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 88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulitis, CAD s/p LAD stent admitted with LGIB. Initial\n evaluation revealed likely sigmoid colon bleed. Unfortunately, last\n night he had massive bleeding following a tagged RBC scan. He received\n a total of 12 units PRBC. This was followed by severe abdominal pain.\n He declined to have further interventions including angiography and\n surgery. He is now DNR/DNI/CMO and receiving morphine for his\n abdominal pain.\n 24 Hour Events:\n CORDIS/INTRODUCER - START 12:00 AM\n -As above.\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 Morphine Sulfate - 02:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 35\nC (95\n HR: 74 (62 - 100) bpm\n BP: 99/55(67) {62/42(47) - 154/123(109)} mmHg\n RR: 13 (11 - 27) insp/min\n SpO2: 85%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,754 mL\n 1,887 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,250 mL\n 12 mL\n Blood products:\n 3,404 mL\n 1,875 mL\n Total out:\n 1,870 mL\n 1,420 mL\n Urine:\n 1,770 mL\n 920 mL\n NG:\n Stool:\n 100 mL\n 500 mL\n Drains:\n Balance:\n 5,884 mL\n 467 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 90%\n Physical Examination\n Deferred.\n Labs / Radiology\n 11.4 g/dL\n 112 K/uL\n 93 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 108 mEq/L\n 142 mEq/L\n 30.8 %\n 19.5 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n WBC\n 11.5\n 19.5\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n Plt\n 199\n 149\n 112\n Cr\n 1.2\n 0.9\n 0.9\n Glucose\n 107\n 119\n 93\n Other labs: PT / PTT / INR:14.6/30.4/1.3, Ca++:6.6 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Microbiology: None.\n Assessment and Plan\n 88 M PMH colon CA s/p hemicolectomy, multiple small bowel AVMs,\n diverticulosis, CAD s/p LAD stent admitted with massive LGIB with\n likely sigmoid colon source. He likely suffered a perforation last\n night and opted for no further interventions, with a focus on his\n comfort. He is currently responsive and denies any pain. Will\n continue morphine boluses PRN for comfort. DC other medications and lab\n draws.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI / CMO\n Disposition : Remains in ICU.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 337357,
"text": "Chief Complaint: GI bleed\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n large GI bleed - had initially refused aggressive intervention\n 24 Hour Events:\n CMO status reversed\n HCT stable in 40\n Surgery still following\n COnitnues Cipro Flagyl for empiric civerage for perf\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Metronidazole - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:00 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 36.3\nC (97.4\n HR: 71 (70 - 84) bpm\n BP: 117/52(68) {91/40(51) - 125/67(76)} mmHg\n RR: 15 (9 - 19) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 2,466 mL\n 615 mL\n PO:\n 360 mL\n 480 mL\n TF:\n IVF:\n 231 mL\n 135 mL\n Blood products:\n 1,875 mL\n Total out:\n 2,190 mL\n 348 mL\n Urine:\n 1,590 mL\n 348 mL\n NG:\n Stool:\n 500 mL\n Drains:\n Balance:\n 276 mL\n 267 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///24/\n Physical Examination\n Gen\n Neck\n CV\n Chest\n Abd\n Ext\n Labs / Radiology\n 14.8 g/dL\n 116 K/uL\n 74 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 112 mEq/L\n 142 mEq/L\n 43.3 %\n 13.1 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n Plt\n 199\n 149\n 112\n 115\n 116\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n Glucose\n 107\n 119\n 93\n 120\n 74\n Other labs: PT / PTT / INR:20.9/39.1/2.0, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Ca++:6.8 mg/dL, Mg++:1.7 mg/dL,\n PO4:1.8 mg/dL\n Assessment and Plan\n Massive LGIB: currently holding HCt from 47 to 44 after 12 U PRBC\n intervention at site was done but he is now stabilizing. Will Call DR\n to follow up on potential interventions.\n Coagulopathy: likely consumptive and dilutional\n will give\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337556,
"text": "Chief Complaint: 88 y/o M with severe LGIB, now with stable Hct\n 24 Hour Events:\n Hct remained stable at 44\n Per Dr. , pt. would not want surgery, if bleeds again go\n directly to angio\n Ca, Mg and phos repleted\n Given 5mg PO vitamin K\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 12:05 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 12:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 89 (62 - 89) bpm\n BP: 144/65(85) {107/32(56) - 161/67(107)} mmHg\n RR: 20 (14 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 272 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n 518 mL\n 272 mL\n Blood products:\n Total out:\n 1,178 mL\n 100 mL\n Urine:\n 1,078 mL\n 100 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 145 K/uL\n 14.9 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337586,
"text": "Chief Complaint: 88 y/o M with severe LGIB, now with stable Hct\n 24 Hour Events:\n Hct remained stable at 44\n Per Dr. , pt. would not want surgery, if bleeds again go\n directly to angio\n Ca, Mg and phos repleted\n Given 5mg PO vitamin K\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ciprofloxacin - 10:00 PM\n Metronidazole - 12:05 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 03:15 PM\n Pantoprazole (Protonix) - 05:38 PM\n Carafate (Sucralfate) - 12:05 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 89 (62 - 89) bpm\n BP: 144/65(85) {107/32(56) - 161/67(107)} mmHg\n RR: 20 (14 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 1,958 mL\n 272 mL\n PO:\n 1,440 mL\n TF:\n IVF:\n 518 mL\n 272 mL\n Blood products:\n Total out:\n 1,178 mL\n 100 mL\n Urine:\n 1,078 mL\n 100 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 780 mL\n 172 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General: A+O, NAD\n HEENT:MMdry\n Neck:Cordis in place\n CV:AS murmur, regular rate\n Pulm:CTAB\n Abd:mildly TTP, +BS\n Ext: resolving upper extremity pitting edema\n Neuro: Incredible lucid, alert and oriented\n Labs / Radiology\n 145 K/uL\n 14.9 g/dL\n 82 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 5.4 mEq/L\n 19 mg/dL\n 108 mEq/L\n 141 mEq/L\n 42.3 %\n 11.3 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n 12:06 PM\n 03:16 AM\n 05:01 PM\n 03:59 AM\n WBC\n 11.5\n 19.5\n 19.8\n 13.1\n 11.3\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n 46.0\n 43.3\n 44.3\n 42.3\n Plt\n 199\n 149\n 112\n 115\n 116\n 145\n Cr\n 1.2\n 0.9\n 0.9\n 0.9\n 1.0\n 0.9\n Glucose\n 107\n 119\n 93\n 120\n 74\n 82\n Other labs: PT / PTT / INR:14.3/39.1/1.2, Differential-Neuts:94.0 %,\n Lymph:2.5 %, Mono:3.4 %, Eos:0.1 %, Albumin:2.9 g/dL, Ca++:7.7 mg/dL,\n Mg++:1.8 mg/dL, PO4:5.3 mg/dL\n No new culture data\n Assessment and Plan: 88 y/o M with LGIB, HCT now stable\n # GIB: Has history of AVMs, CT abd confirmed sigmoid source, initially\n shown to have active extravasation concerning for perforation, had\n acute abdomen, surgery consulted, but eval and intervention refused by\n the patient. Pt received total of 12 units PRBCs. Had elevated WBC,\n now improving, not spiking fevers. Still with some melena but with\n stable HCT x 48 hours.\n -Continue to monitor HCT\n -PO vitamin K x 3 days for elevated INR in setting of massive\n transfusion\n -follow Ca in setting of transfusion, repleted yesterday\n -f/u GI recs, plan for angio if rebleeds as tagged red cell scan have\n not been helpful\n -continue abx for 7 day course, empiric GI coverage. Currently day \n of cipro/flagyl\n -Continue PPI\n #h/o colon cancer. Per Closely followed by his outpatient\n gastroenterologist Dr. who in following patient in house. Pt\n had concerning symptoms (weakness and long term weight loss) and CT\n scan with worsening mesenteric LAD and matting concerning for\n metastasis of his prior malignancy. Currently no plan for scope given\n recent significant bleed but may be reconsidered as outpatient.\n -Dr. following\n -Patient cont. to deny surgery as possibility\n .\n #GERD: PPI\n #Hyperlipidemia. Statin\n #Hypertension. Hold home regimen in setting of GIB, restart BB and HCTZ\n today given BP have been stable.\n .\n # Communication: With patient and family\n .\n # Code status: DNR/DNI, CMO status reversed.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 06:00 PM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: with pt. and wife\n status: DNR/DNI\n Disposition: c/o to floor\n"
},
{
"category": "Physician ",
"chartdate": "2192-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 337174,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient's Hct decreased to 33 from 35 despite getting 3 units of PRBCs.\n Additionally, SBP dropped transiently to 80s and he passed a large,\n frankly bloody BM. He was given one more unit of PRBCs and IR and GI\n were notified. Per that discussion, patient was taken for tagged RBC\n scan, where bleeding was found in the sigmoid colon. While undergoing\n bleeding scan, patient's BP continued to intermittently drop and he\n received a total of 2 more units of blood and 3 liters of NS with\n transient increases in BP, but continued hematochezia. He was then\n brought up to the ICU for placement of a cordis and received 6 more\n units of PRBCs, 2 bags of FFP, 1 bag of platelets and 4 liters of NS.\n The plan was for IR intervention once he became hemodynamically stable,\n but patient was then noted to suddenly develop acute abdominal pain,\n abdominal distention and high pitched bowel sounds, which were\n concerning for a perforation. Surgery was notified and came to examine\n the patient, but he refused examination, stating that he only wanted to\n be made comfortable. He continued to refuse surgery at this point and\n had previously been made DNR/DNI. KUB was deferred as was angiographic\n intervention, at the patient's request. He was given Morphine boluses\n for comfort and the family was notified so that they could be present\n with him. He was made CMO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 12:50 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 02:37 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 99 (62 - 99) bpm\n BP: 113/61(73) {62/42(47) - 154/123(109)} mmHg\n RR: 22 (13 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n 7,754 mL\n 1,875 mL\n PO:\n 100 mL\n TF:\n IVF:\n 4,250 mL\n Blood products:\n 3,404 mL\n 1,875 mL\n Total out:\n 1,590 mL\n 0 mL\n Urine:\n 1,490 mL\n NG:\n Stool:\n 100 mL\n Drains:\n Balance:\n 6,164 mL\n 1,875 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///24/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 112 K/uL\n 11.4 g/dL\n 93 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 14 mg/dL\n 108 mEq/L\n 142 mEq/L\n 30.8 %\n 19.5 K/uL\n [image002.jpg]\n 08:37 AM\n 02:44 PM\n 05:42 PM\n 08:53 PM\n 11:23 PM\n WBC\n 11.5\n 19.5\n Hct\n 35.4\n 33.2\n 33.0\n 37.5\n 30.8\n Plt\n 199\n 149\n 112\n Cr\n 1.2\n 0.9\n 0.9\n Glucose\n 107\n 119\n 93\n Other labs: PT / PTT / INR:14.6/30.4/1.3, Ca++:6.6 mg/dL, Mg++:1.9\n mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n # GIB: Confirmed bleeding in the sigmoid colon. Patient is no longer\n amenable to angiography and was never agreeable to surgery and these\n are essentially the extent of his definitive treatment options. Patient\n required several PRBCs and IVF and though currently hemodynamically\n stable, thought to be due to temporary halt of bleeding, he is at risk\n for further bleeding. Per repeated conversation with patient, he is\n only interested in being made comfortable with no further intervention.\n Additionally, his respiratory status is tenuous s/p multiple PRBCs and\n IVF boluses, so additional resuscitation would likely result in\n pulmonary edema, which would require Lasix and this would only\n potentiate hypotension.\n - Comfort measures only; no labs, avoid blood products and IVF,\n Morphine PRN for abdominal pain\n - Appreciate IR, GI and surgical input thus far\n .\n # GERD\n - Continue PPI\n - Continue Sucralfate\n .\n # FEN\n - NPO\n - IVF\n - Correct/Replete electrolytes PRN\n .\n # PPx\n - Pneumoboots\n - PPI IV BID\n .\n # Communication: With patient\n .\n # Code status: DNR/DNI/CMO\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 07:52 AM\n Cordis/Introducer - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2192-08-25 00:00:00.000",
"description": "EA 1ST ORDER ABD/PEL/LOWER EXT A-GRAM",
"row_id": 1029613,
"text": " 8:34 AM\n MESSENERTIC Clip # \n Reason: Please evaluate source of bleeding and tx if found.\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 172\n ********************************* CPT Codes ********************************\n * EA 1ST ORDER ABD/PEL/LOWER EXT EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with BRBPR\n REASON FOR THIS EXAMINATION:\n Please evaluate source of bleeding and tx if found.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 1:07 PM\n No site of active bleeding identified; no embolization performed. Discussed\n with Dr. .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 88-year-old male with bright red blood per rectum and history of\n duodenal AVM. Please evaluate source of bleeding and treat if found.\n\n COMPARISON: CTA mesenteric, and mesenteric angiogram \n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. with\n Dr. supervising. Dr. reviewed the procedure.\n\n PROCEDURE: Following explanation of the risks, benefits, and alternatives to\n the procedure, written informed consent was obtained. The patient was brought\n to the angiography table and placed supine. The right groin was prepped and\n draped in the standard sterile fashion. A preprocedure timeout was performed\n to confirm the patient's name, medical record number, date of birth, and\n nature of procedure to be performed.\n\n Using 1% lidocaine for local anesthetic and palpatory guidance, the right\n femoral artery was punctured, and a 0.035 wire was advanced into the\n abdominal aorta under fluoroscopic guidance. The needle was then exchanged\n for a vascular sheath. The sheath was connected to a continuous side arm\n flush. A 5 French SOS catheter was then advanced over the wire, and selective\n catheterization and angiography of the celiac, superior mesenteric, and\n inferior mesenteric arteries was performed.\n\n The celiac arteriogram was unremarkable. The SMA arteriogram demonstrated a\n somewhat irregular, and large jejunal branch artery which correlated to the\n irregular area in the region of the patients known mesenteric mass seen on the\n prior CT. This area appeared similiar to the mesenteric angiogram performed\n on and on the mesenteric CTA performed several hours prior; no active\n extravasation was identified from this site. The arteriogram demonstrates\n normal branches, with no arterial abnormality or active extravasation.\n (Over)\n\n 8:34 AM\n MESSENERTIC Clip # \n Reason: Please evaluate source of bleeding and tx if found.\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 172\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The patient's hemodynamic parameters were monitored during operative study and\n found to be satisfactory. The patient tolerated the procedure well. Following\n manual pressure application for hemostasis, a sterile dressing of Tegaderm was\n applied to the right groin at the puncture site.\n\n These findings were discussed with Dr. .\n\n IMPRESSION:\n\n 1. No site of active bleeding identified.\n\n 2. Normal celiac and arteriogram.\n\n 3. SMA arteriogram demonstrates a somewhat enlarged irregular jejunal branch\n correlating to the area of the patients known mesenteric mass seen on the\n prior CT and has a similar angiographic appearance to the exam performed on\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2192-08-25 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 1029614,
"text": ", C. MED MICU-7 8:34 AM\n MESSENERTIC Clip # \n Reason: Please evaluate source of bleeding and tx if found.\n Admitting Diagnosis: LOWER GASTROINTESTINAL BLEED\n Contrast: OPTIRAY Amt: 172\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 88 year old man with BRBPR\n REASON FOR THIS EXAMINATION:\n Please evaluate source of bleeding and tx if found.\n ______________________________________________________________________________\n PFI REPORT\n No site of active bleeding identified; no embolization performed. Discussed\n with Dr. .\n\n"
},
{
"category": "ECG",
"chartdate": "2192-08-24 00:00:00.000",
"description": "Report",
"row_id": 263226,
"text": "Sinus bradycardia. Borderline first degree A-V block. Left axis deviation\nwith left anterior fascicular block. Right bundle-branch block. Compared to\nthe previous tracing of ventricular premature beats are absent.\nOtherwise, multiple described abnormalities persist.\n\n"
}
] |
52,001 | 189,007 | This is a 48 yo man with alcohol dependance who was presented for elective right total hip replacement revision. His surgery was long and he was not able to be immediately exubated due to left lower lobe collapse. He also developed left lower lobe pneumonia (H.flu) treated with 8 days of iv unasyn. He was able to be extubated but then developed acute alcholol withdrawl, requiring valium and haldol. He then became delerious, likely due to hypernatremia, icu delerium, pain, infection, and difficulty clearing sedating medications with some component of alcoholic hepatitis. This delayed his ability to participate with PT. He required seroquel to help his delerium clear. He was lucid on , and insisted on discharge. He was evaluated by PT and OT and felt unsafe to go home. Despite this he was able to clearly state understanding of risks and benefits of going home and signed out against medical advice. His hospital course was complicated by hypertension, which was not known prior to admission. He was started on metoprolol and clonidine for this and discharged on metoprolol. He was noted to have atrial fibrillation with RVR while acutely ill with pneumonia and intubated, this converted and he remained in sinus. Given CHADS score he was not recommended to be on anticoagulation given acute surgery but should discuss this as an outpatient with his pcp. was treated with thiamine, folate, multivitamin given his alcohol dependance. He was arranged to have home lovenox for DVT prophylaxis, and VNA with PT. He was noted to have anemia and thrombocytopmenia, likely due to acute blood loss perioperatively with poor marrow response due to alcoholic suppression and consumption of platelets perioperatively that was improving on discharge. He should have repeat CXR with his PCP 1 month to ensure resolution of his pneumonia. | # Prophylaxis: lovenox in the AM, bowel regimen . # Prophylaxis: lovenox in the AM, bowel regimen . # Prophylaxis: lovenox in the AM, bowel regimen . - currenlty on vanc/unasyn, can consider or zosyn for pseudomonal coverage if spikes again - f/u BCx, bronch washings # s/p hip surgery: - f/u ortho recs - strict posterior hip precautions - abduction pillow btw legs - hob not greater than 90 ICU Care Nutrition: NPO, advance to regular as tolerated. - changed to vanc/unasyn, can consider or zosyn for pseudomonal coverage if spikes again - f/u BCx, bronch washings # s/p hip surgery: - ortho recs: unchanged today (see below) - start lovenox 30 in am - AP pelvis - strict posterior hip precautions - abduction pillow btw legs - hob not greater than 90 . Response: Remains Hypertensive to 190s Plan: Cont to monitor HTN, medicate for pain and CIWA as odered. Arousal, Attention, and Cognition, Impaired Assessment: Continues to be compative despite wrists restraints pull out iv this am very confused Action: CIWA scale q 1hr, 10 -20mg of iv valium, received 1 time dose of iv haldol Response: Still restless and confused Plan: Continue ciwa scale. Arousal, Attention, and Cognition, Impaired Assessment: Continues to be compative despite wrists restraints pull out iv this am very confused Action: CIWA scale q 1hr, 10 -20mg of iv valium, received 1 time dose of iv haldol Response: Still restless and confused Plan: Continue ciwa scale. Less agitated, follows simple commands, coarse bs, RR, soft, NT + BS, dep edema, RLE wound dressing c/d/i Labs notable for WBC 5.1K, HCT 27.1, 80, na 154, K+ 3.9 , Cr 1.0, Micro--sputum pneumo pna/h flu Primary issues remain: Agitation, etoh withdrawal, delirium, hypernatremia, resolving pna, recent fever spike, resolving ARF, post-op hip revision Agree with plan to continue broadened antibx coverage (vanco/zosyn, and has completed 6 days unasyn) for HAP given recent temp spike, pending final cx data. Response: Remains Hypertensive to 190s Plan: Cont to monitor HTN, medicate for pain and CIWA as odered. - 250cc q4h free water through tube feeds -will re-check Na this pm # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now CXR shows ?collapsed RLL. - 250cc q4h free water through tube feeds -will re-check Na this pm # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now CXR shows ?collapsed RLL. - 250cc q4h free water through tube feeds -will re-check Na this pm # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now CXR shows ?collapsed RLL. Less agitated, follows simple commands, coarse bs, RR, soft, NT + BS, trace dep edema, RLE wound dressing c/d/i Labs notable for WBC 5.5K, HCT 26, plts 85, na 154--> 147, K+ 3.6 , Cr 0.9, Micro--sputum h flu resis to unasyn, bl cxs pending CXR--small lung volumes, full hilar vessels Primary issues remain: Agitation, delirium, hypernatremia, resolving pna, recent fever spike, resolving ARF, post-op hip revision Agree with plan to resume unasyn to complete 8 day course (day 7). - 250cc q4h free water through tube feeds -will re-check Na this pm # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now CXR shows ?collapsed RLL. 48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware removal course c/b post-op resp failure, asp pna, and L lung collapse, arf,, a-fib / flutter, and etoh withdrawal, extubated Hypernatremia (high sodium) Assessment: Action: Response: Plan: Arousal, Attention, and Cognition, Impaired Assessment: Action: Response: Plan: Fentanyl/versed sedation weaned off. Fentanyl/versed sedation weaned off. Fentanyl/versed sedation weaned off. Fentanyl/versed sedation weaned off. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated, Vent PSV 10/8, FIO2 50% 02 sats 93-96%, RR 15-20, LS clear upper/diminished bases. Anticipated Discharge: Rehab Plan: Progress Ther Ex/ROM Asses stand pivot transfer Pt -dcd famotidine -will dc unasyn today after last dose -will check pm CBC # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now CXR shows ?collapsed RLL. -dcd famotidine -will dc unasyn today after last dose -will check pm CBC # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now CXR shows ?collapsed RLL. Pt was still tachy to the 140s and Diltiazem 10 mg IV x1 was given. Pt was still tachy to the 140s and Diltiazem 10 mg IV x1 was given. Pt was still tachy to the 140s and Diltiazem 10 mg IV x1 was given. Pt was still tachy to the 140s and Diltiazem 10 mg IV x1 was given. Pt was still tachy to the 140s and Diltiazem 10 mg IV x1 was given. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated, Vent PSV 10/8, FIO2 50% 02 sats 93-96%, RR 15-20, LS clear upper/diminished bases. FINAL REPORT REASON FOR EXAMINATION: Hypoxemia. Status post bronchoscopy. Since preoperative exam , the fixation device in the proximal right femur has been removed and a bipolar right hemiarthroplasty has been placed with normal positioning as seen on these limited images. -will check pm CBC # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now CXR shows ?collapsed RLL. Fentanyl/versed sedation weaned off. Minor bibasal atelectasis and moderate cardiomegaly without overt signs of pulmonary congestion is again noted. 8:38 AM CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # Reason: Please evaluate for worsening PNA. Partial opacification in mastoid air cells, which is present on the prior CT of . Impaired airway clearance Impaired ROM Clinical impression / Prognosis: Pt is 48M s/p R THA in the setting of R hip post-traumatic osteonecrosis, POD1, c/b respiratory acidosis and currently remains intubated and sedated. Pt being treated forhypernatremia, withdrawal/delirium and agitation,thrombocytopenia, hypoxemia (assumed to be HAP), and decreasedurine output. Past Medical / Surgical History: HTN, R hip fx s/p IM nail in Medications: morphine, acetaminophen, enoxaparin sodium, fentanyl citrate, midazolam Radiology: hip xray: report unavailable; & CXR: report unavailable Labs: 44.0 14.5 95 22.7 [image002.jpg] Other labs: pH: 7.25 pCO2: 47 pO2: 130 HCO3: 22 Activity Orders: activity as tolerated; PWB RLE; strict R posterior hip precautions; no active R hip abduction; hip abduction pillow in bed at all times; obtain R hip abduction brace Social / Occupational History: unable to obtain from chart, but assume I PTA Living Environment: unable to obtain from chart or pt Functional Status / Activity Level: amb with cane hip pain, + smoking Objective Test Arousal / Attention / Cognition / Communication: pt sedated, occasionally opening eyes with PROM R hip Hemodynamic Response Aerobic Capacity HR BP RR O[2 ]sat HR BP RR O[2] sat RPE Supine / Rest 106 128/70 16 94% CMV Sit / Activity / Stand / Recovery 108 101/50 20 95% CMV Total distance walked: 0ft Minutes: Pulmonary Status: pt currently intubated CMV, FiO2 50%, PEEP 8 per respiratory/NSG notes, pt being suctioned for secretions Integumentary / Vascular: arterial line, foley, 2 hip drains, endotracheal tube, dressing R hip (C,D,I) all extremities warm to touch, dorsalis pedal pulses 2+ BLE Sensory Integrity: unable to assess sedation, but pt opening eyes to PROM R hip Pain / Limiting Symptoms: unable to asses sedation Posture: pt received supine in bed, HOB elevated 30 degrees, hip abduction pillow in place, R hip ER Range of Motion Muscle Performance WFL t/o LE, deferred UE PROM restraints R hip abd: 16, flex: 90, IR: to neutral, ER: 20 unable to formally assess, but pt demonstrates spontaneous movement of all limbs with decreased sedation, movements limited by restraints Motor Function: unable to assess Functional Status: Activity Clarification I S CG Min Mod Max Gait, Locomotion: unable to assess functional mobility pt intubated and sedated Rolling: Supine / Sidelying to Sit: Transfer: Sit to Stand: Ambulation: Stairs: Balance: unable to assess functional mobility pt intubated and sedated Education / Communication: NSG: pt status, locked knee ext on bed controls, maintain R hip neutral position as able, will contact ortho resident/ R hip abduction brace , PA: paged about putting order for R hip abd brace for brace shop Intervention: PROM R hip x10 minutes Other: Diagnosis: Clinical impression / Prognosis: Pt is 48M s/p R THA in the setting of R hip post-traumatic osteonecrosis, POD1, c/b respiratory acidosis and currently remains intubated and sedated. | 162 | [
{
"category": "Nursing",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585560,
"text": "Pt. admitted to from OR last eve s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. OR course was complicated by\n hypovolemia, EBL 3,200cc. Pt. kept intubated overnight due to acidosis\n throughout case and swelling due to positioning in OR.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt. oliguric since admission to unit. This a.m. creat is 1.6. Pt.\n remains hemodynamically stable with cuff pressures running about 30mmHg\n higher than Aline pressures.\n Action:\n Pt. given one liter of LR last eve upon return of initial blood gas.\n Presently bicarb gtt infusing.\n Response:\n UO remains very poor. Base deficit still present, though lactate is\n decreasing. Hct 44.\n Plan:\n Follow lytes, etc. closely. Consider fluid resuscitation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt. with very diminished LLL. ABG revealed mixed acidosis.\n Action:\n Vent changes made per flowsheet. Pt. suctioned for copious secretions\n - for first 5-6 hrs in unit, pt. required suctioning every thirty\n minutes. CXR done, ETT advanced per H.O. CPT given concentrating on\n LLL. MDI\ns ordered. Sedation changed and titrated as documented for\n ventilator compliance. Pt. given boluses as noted.\n Response:\n CXR improved after two hours. ABG\ns are improving since last vent\n change, though drawn while bicarb gtt infusing. LLL moving more air,\n overall pulmonary assessment improved. Pt. continues to have\n breakthrough periods of agitation with stimulation and becomes\n dissynchronous, but less frequent.\n Plan:\n Continue pulmonary hygiene as appropriate. Monitor sedation level,\n goal . Follow blood gases closely and wean vent as\n indicated.\n ------ Protected Section ------\n Addendum: Pt. requiring increased analgesia overnight/this a.m. H.O.\n notified. Pain has been waking him up these past few hours and he is\n requiring fentanyl boluses for this, also before and/or after\n repositioning.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:33 ------\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585742,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:14 PM\n URINE CULTURE - At 08:41 PM\n BLOOD CULTURED - At 08:41 PM\n FEVER - 101.2\nF - 08:13 PM\n - bronched, cleaned out secretions, BAL\n - CXR with improvement\n - failed weaning from PS, needed increased sedation steadily overnight\n w/ versed 4 / fentanyl 200, serial ABGs remained unchanged CO2, with\n improved O2\n - spiked to 101, cultured, abx changed to vanc/unasyn\n - Cr 1.9 in afternoon, FeNa 0.05%, intrabd pressure < 15, U/A improved,\n no e/o ATN/AIN -> pre-renal, given 500cc NS bolus over 2 hrs twice\n overnight\n - increased resp secretions noted\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Vancomycin - 09:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:40 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 10:36 AM\n Famotidine (Pepcid) - 08:18 PM\n Enoxaparin (Lovenox) - 08:42 PM\n Midazolam (Versed) - 04:29 AM\n Fentanyl - 04:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.1\nC (100.6\n HR: 104 (98 - 117) bpm\n BP: 114/58(74) {76/45(55) - 131/72(89)} mmHg\n RR: 16 (9 - 25) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Bladder pressure: 14 (14 - 14) mmHg\n Total In:\n 3,687 mL\n 720 mL\n PO:\n TF:\n IVF:\n 3,687 mL\n 720 mL\n Blood products:\n Total out:\n 1,124 mL\n 326 mL\n Urine:\n 549 mL\n 211 mL\n NG:\n Stool:\n Drains:\n 575 mL\n 115 mL\n Balance:\n 2,563 mL\n 394 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 800 (700 - 800) mL\n Vt (Spontaneous): 743 (372 - 844) mL\n PS : 10 cmH2O\n RR (Set): 25\n RR (Spontaneous): 15\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 30\n PIP: 11 cmH2O\n Plateau: 23 cmH2O\n SpO2: 95%\n ABG: 7.32/51/95./23/0 //\n Ve: 11.1 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, drain with sanguinous drainage,\n bilateral 1+ pedal pulses, bilateral LE TEDS stockings, abductor pillow\n in place\n Labs / Radiology\n 94 K/uL\n 11.6 g/dL\n 143 mg/dL\n 2.3 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 38 mg/dL\n 105 mEq/L\n 139 mEq/L\n 34.3 %\n 21.1 K/uL\n [image002.jpg]\n 04:49 AM\n 09:09 AM\n 11:04 AM\n 02:56 PM\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n WBC\n 23.9\n 23.7\n 21.1\n Hct\n 39.1\n 36.8\n 34.3\n Plt\n 97\n 84\n 94\n Cr\n 2.2\n 1.9\n 2.3\n TCO2\n 25\n 29\n 26\n 27\n 29\n 28\n 27\n Glucose\n 138\n 137\n 143\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.2 mg/dL, Mg++:1.9 mg/dL, PO4:4.9 mg/dL\n 04:12a\n _______________________________________________________________________\n pH\n 7.32\n pCO2\n 51\n pO2\n 95\n HCO3\n 27\n BaseXS\n 0\n Type:Art; Intubated; Vent:Spontaneous; FiO2%:50; Rate:/16; TV:600;\n PEEP:8; Temp:38.1\n Lactate:1.7\n 8:44p\n _______________________________________________________________________\n pH\n 7.31\n pCO2\n 54\n pO2\n 94\n HCO3\n 28\n BaseXS\n 0\n Type:Art; Intubated; Vent:Spontaneous; FiO2%:50; Rate:/18; TV:400;\n PEEP:8; Temp:39.6\n Lactate:1.9\n \n 6:02p\n _______________________________________________________________________\n pH\n 7.30\n pCO2\n 56\n pO2\n 79\n HCO3\n 29\n BaseXS\n 0\n Type:Art; Intubated; Temp:39.0\n Lactate:1.6\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n .\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am.\n - monitor ABGs closely\n - CXR appears stable from yesterday afternoon, will repeat tomorrow AM\n - attempt to wean again today, can consider precedex if necessary given\n ETOH/percocet history\n - albuterol MDI q2 prn\n - aggressive suctioning and chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal, given 500cc NS bolus over 2 hrs twice overnight. UOP has\n not increased after IVF challenge, raising concern for ATN\n - cont to monitor UOP, have given 500cc at 5am\n - recheck afternoon lytes\n .\n # ID: spiked to 101 overnight. WBC trended down slightly to 21.\n - changed to vanc/unasyn\n - f/u BCx\n .\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - start lovenox 30 in am\n - AP pelvis\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Received 1L LR on arrival to\n the . Now improved to around 1.7\n - cont to monitor lactate\n - expect to improve with IVF\n .\n # FEN: IVF as above, replete electrolytes, NPO\n .\n # Prophylaxis: lovenox in the AM, bowel regimen\n .\n # Access: peripherals\n .\n # Code: full code\n .\n # Communication:\n .\n # Disposition: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Resident Progress Note",
"row_id": 585759,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:14 PM\n URINE CULTURE - At 08:41 PM\n BLOOD CULTURED - At 08:41 PM\n FEVER - 101.2\nF - 08:13 PM\n - bronched, cleaned out secretions, BAL\n - CXR with improvement\n - failed weaning from PS, needed increased sedation steadily overnight\n w/ versed 4 / fentanyl 200, serial ABGs remained unchanged CO2, with\n improved O2\n - spiked to 101, cultured, abx changed to vanc/unasyn\n - Cr 1.9 in afternoon, FeNa 0.05%, intrabd pressure < 15, U/A improved,\n no e/o ATN/AIN -> pre-renal, given 500cc NS bolus over 2 hrs twice\n overnight\n - increased resp secretions noted\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Vancomycin - 09:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:40 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 10:36 AM\n Famotidine (Pepcid) - 08:18 PM\n Enoxaparin (Lovenox) - 08:42 PM\n Midazolam (Versed) - 04:29 AM\n Fentanyl - 04:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.1\nC (100.6\n HR: 104 (98 - 117) bpm\n BP: 114/58(74) {76/45(55) - 131/72(89)} mmHg\n RR: 16 (9 - 25) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Bladder pressure: 14 (14 - 14) mmHg\n Total In:\n 3,687 mL\n 720 mL\n PO:\n TF:\n IVF:\n 3,687 mL\n 720 mL\n Blood products:\n Total out:\n 1,124 mL\n 326 mL\n Urine:\n 549 mL\n 211 mL\n NG:\n Stool:\n Drains:\n 575 mL\n 115 mL\n Balance:\n 2,563 mL\n 394 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 800 (700 - 800) mL\n Vt (Spontaneous): 743 (372 - 844) mL\n PS : 10 cmH2O\n RR (Set): 25\n RR (Spontaneous): 15\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 30\n PIP: 11 cmH2O\n Plateau: 23 cmH2O\n SpO2: 95%\n ABG: 7.32/51/95./23/0 //\n Ve: 11.1 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, drain with sanguinous drainage,\n bilateral 1+ pedal pulses, bilateral LE TEDS stockings, abductor pillow\n in place\n Labs / Radiology\n 94 K/uL\n 11.6 g/dL\n 143 mg/dL\n 2.3 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 38 mg/dL\n 105 mEq/L\n 139 mEq/L\n 34.3 %\n 21.1 K/uL\n [image002.jpg]\n 04:49 AM\n 09:09 AM\n 11:04 AM\n 02:56 PM\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n WBC\n 23.9\n 23.7\n 21.1\n Hct\n 39.1\n 36.8\n 34.3\n Plt\n 97\n 84\n 94\n Cr\n 2.2\n 1.9\n 2.3\n TCO2\n 25\n 29\n 26\n 27\n 29\n 28\n 27\n Glucose\n 138\n 137\n 143\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.2 mg/dL, Mg++:1.9 mg/dL, PO4:4.9 mg/dL\n 04:12a\n _______________________________________________________________________\n pH\n 7.32\n pCO2\n 51\n pO2\n 95\n HCO3\n 27\n BaseXS\n 0\n Type:Art; Intubated; Vent:Spontaneous; FiO2%:50; Rate:/16; TV:600;\n PEEP:8; Temp:38.1\n Lactate:1.7\n 8:44p\n _______________________________________________________________________\n pH\n 7.31\n pCO2\n 54\n pO2\n 94\n HCO3\n 28\n BaseXS\n 0\n Type:Art; Intubated; Vent:Spontaneous; FiO2%:50; Rate:/18; TV:400;\n PEEP:8; Temp:39.6\n Lactate:1.9\n \n 6:02p\n _______________________________________________________________________\n pH\n 7.30\n pCO2\n 56\n pO2\n 79\n HCO3\n 29\n BaseXS\n 0\n Type:Art; Intubated; Temp:39.0\n Lactate:1.6\n Micro:\n Bronch washings: 3+ PMN, 4+ GNR, 1+ GPR\n .\n Cx pending\n CXR: stable since last film yesterday afternoon after bronch\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n .\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Now on PS 5/5.\n - monitor ABGs closely / daily CXRs\n - attempt to wean again today with SBT, HOB elevated may help, can\n consider precedex if necessary given ETOH/percocet history\n - may need CIWA scale after extubation given h/o ETOH\n - albuterol MDI q2 prn\n - aggressive suctioning and chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal, given 500cc NS bolus over 2 hrs twice overnight. UOP has\n not increased after IVF challenge, raising concern for ATN.\n - cont to monitor UOP, have given 500cc at 5am\n - recheck afternoon lytes\n - can re-attempt fluid challenge after extubation\n .\n # ID: spiked to 101 overnight. WBC trended down slightly to 21. Sputum\n w/ GNR, GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washingsTITLE:\n .\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - start lovenox 30 in am\n - AP pelvis\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Received 1L LR on arrival to\n the . Now improved to around 1.7\n - cont to monitor lactate\n - expect to improve with IVF\n .\n # FEN: IVF as above, replete electrolytes, NPO\n .\n # Prophylaxis: lovenox in the AM, bowel regimen\n .\n # Access: peripherals\n .\n # Code: full code\n .\n # Communication:\n .\n # Disposition: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 585717,
"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: or\n Reason: Hip surgery\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 cmH2O\n Cuff volume: 10 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 / Moderate\n Comments/Plan\n Pt remains intubated, vent supported. No vent changes made overnight.\n RSBI=30 this am. Administering Albuterol MDI as ordered. See\n flowsheet for rx times and further pt data. Will follow.\n 06:23\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-22 00:00:00.000",
"description": "MICU Resident/Attending Progress Note",
"row_id": 585811,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:14 PM\n URINE CULTURE - At 08:41 PM\n BLOOD CULTURED - At 08:41 PM\n FEVER - 101.2\nF - 08:13 PM\n - bronched, cleaned out secretions, BAL\n - CXR with improvement\n - failed weaning from PS, needed increased sedation steadily overnight\n w/ versed 4 / fentanyl 200, serial ABGs remained unchanged CO2, with\n improved O2\n - spiked to 101, cultured, abx changed to vanc/unasyn\n - Cr 1.9 in afternoon, FeNa 0.05%, intrabd pressure < 15, U/A improved,\n no e/o ATN/AIN -> pre-renal, given 500cc NS bolus over 2 hrs twice\n overnight\n - increased resp secretions noted\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Vancomycin - 09:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:40 AM\n Infusions:\n Midazolam (Versed) - 4 mg/hour\n Fentanyl - 200 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 10:36 AM\n Famotidine (Pepcid) - 08:18 PM\n Enoxaparin (Lovenox) - 08:42 PM\n Midazolam (Versed) - 04:29 AM\n Fentanyl - 04:29 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.2\n Tcurrent: 38.1\nC (100.6\n HR: 104 (98 - 117) bpm\n BP: 114/58(74) {76/45(55) - 131/72(89)} mmHg\n RR: 16 (9 - 25) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Bladder pressure: 14 (14 - 14) mmHg\n Total In:\n 3,687 mL\n 720 mL\n PO:\n TF:\n IVF:\n 3,687 mL\n 720 mL\n Blood products:\n Total out:\n 1,124 mL\n 326 mL\n Urine:\n 549 mL\n 211 mL\n NG:\n Stool:\n Drains:\n 575 mL\n 115 mL\n Balance:\n 2,563 mL\n 394 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 800 (700 - 800) mL\n Vt (Spontaneous): 743 (372 - 844) mL\n PS : 10 cmH2O\n RR (Set): 25\n RR (Spontaneous): 15\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 30\n PIP: 11 cmH2O\n Plateau: 23 cmH2O\n SpO2: 95%\n ABG: 7.32/51/95./23/0 //\n Ve: 11.1 L/min\n PaO2 / FiO2: 190\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, drain with sanguinous drainage,\n bilateral 1+ pedal pulses, bilateral LE TEDS stockings, abductor pillow\n in place\n Labs / Radiology\n 94 K/uL\n 11.6 g/dL\n 143 mg/dL\n 2.3 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 38 mg/dL\n 105 mEq/L\n 139 mEq/L\n 34.3 %\n 21.1 K/uL\n [image002.jpg]\n 04:49 AM\n 09:09 AM\n 11:04 AM\n 02:56 PM\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n WBC\n 23.9\n 23.7\n 21.1\n Hct\n 39.1\n 36.8\n 34.3\n Plt\n 97\n 84\n 94\n Cr\n 2.2\n 1.9\n 2.3\n TCO2\n 25\n 29\n 26\n 27\n 29\n 28\n 27\n Glucose\n 138\n 137\n 143\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.2 mg/dL, Mg++:1.9 mg/dL, PO4:4.9 mg/dL\n 04:12a\n _______________________________________________________________________\n pH\n 7.32\n pCO2\n 51\n pO2\n 95\n HCO3\n 27\n BaseXS\n 0\n Type:Art; Intubated; Vent:Spontaneous; FiO2%:50; Rate:/16; TV:600;\n PEEP:8; Temp:38.1\n Lactate:1.7\n 8:44p\n _______________________________________________________________________\n pH\n 7.31\n pCO2\n 54\n pO2\n 94\n HCO3\n 28\n BaseXS\n 0\n Type:Art; Intubated; Vent:Spontaneous; FiO2%:50; Rate:/18; TV:400;\n PEEP:8; Temp:39.6\n Lactate:1.9\n \n 6:02p\n _______________________________________________________________________\n pH\n 7.30\n pCO2\n 56\n pO2\n 79\n HCO3\n 29\n BaseXS\n 0\n Type:Art; Intubated; Temp:39.0\n Lactate:1.6\n Micro:\n Bronch washings: 3+ PMN, 4+ GNR, 1+ GPR\n .\n Cx pending\n CXR: stable since last film yesterday afternoon after bronch\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n .\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Now on PS 5/5.\n - monitor ABGs closely / daily CXRs\n - attempt to wean again today with SBT, HOB elevated may help, can\n consider precedex if necessary given ETOH/percocet history\n - may need CIWA scale after extubation given h/o ETOH\n - albuterol MDI q2 prn\n - aggressive suctioning and chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal, given 500cc NS bolus over 2 hrs twice overnight. UOP has\n not increased after IVF challenge, raising concern for ATN.\n - cont to monitor UOP, have given 500cc at 5am\n - recheck afternoon lytes\n - can re-attempt fluid challenge after extubation\n .\n # ID: spiked to 101 overnight. WBC trended down slightly to 21. Sputum\n w/ GNR, GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washingsTITLE:\n .\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - start lovenox 30 in am\n - AP pelvis\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Received 1L LR on arrival to\n the . Now improved to around 1.7\n - cont to monitor lactate\n - expect to improve with IVF\n .\n # FEN: IVF as above, replete electrolytes, NPO\n .\n # Prophylaxis: lovenox in the AM, bowel regimen\n .\n # Access: peripherals\n .\n # Code: full code\n .\n # Communication:\n .\n # Disposition: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 48M s/p hip revision for AVN - 4h case, 3L\n EBL rx 2 PRBC, 1700 cell , transient neo. Remaied intubated o/n\n d/t fluid shifts and sedation. Bronch for LLL collapse with\n reexpansion. Failed SBT yesterday, creatinine rising, febrile to 101.0,\n started on vanco/unasyn.\n Exam notable for Tm 101.2 BP 110/54 HR 110 RR 18 with sat 95 on PSV\n 0.5 7.32/51/95 +3L/24h, +8L/LOS, UOP 30-40 cc/h IAP 14. WD man,\n NAD on vent. Follows simple commands. Coarse BS B. RRR s1s2. Soft +BS.\n RLE wound dressing intact. Distal pulses weak but present, unchanged\n per report. Labs notable for WBC 21K, HCT 34, K+ 5.0, Cr 2.3, lactate\n 1.7. CXR with resolving LLL atelectasis.\n Agree with plan to try to transition to PSV with SBT this AM as we wean\n down sedation; hope to extubate today. Will continue to treat likely\n LLL aspiration pneumonia with vanco and unasyn. Will hold off on\n further diuresis given ongoing elevation in creatinine, RD meds and\n optimize hemodynamics - probably still somewhat dry, recheck lytes\n while holding lasix. He is likely to require ongoing benzos given\n baseline alcohol dependence and narcotic analgesia for postop pain.\n Will check PM HCT given anemia. POC per ortho team. Lovenox for DVT\n prophylaxis. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 45 min\n ------ Protected Section Addendum Entered By: , MD\n on: 17:14 ------\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Generic Note",
"row_id": 585812,
"text": "TITLE:\n Rehab Services Dept\n P.T\n Followed up to treat patient. Spoke with RN\n and patient extubated. Patient has been measured for R hip abductor\n brace and to be delivered tomorrow so planned to instruct in bed\n therex. Upon receiving patient, patient restrained and A-line noted to\n be not accurately and pulled back from skin. Notified RN\n immediately and left room with RN present. Will f/u for further\n mobility evaluation once abductor brace arrives and continue with\n therex and ROM. Please call with questions. Thanks. Pager #\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585815,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale started today\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output has picked up slightly today 30-50cc/hr, am creatinine\n 2.3 1800 labs to be done\n Action:\n Labs pending\n Response:\n Depends on what 1800 creatinine is\n Plan:\n Closely monitor urine output/ lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Extubated this am tolerated well\n Action:\n Still has high o2 requirements, 15 L shovel plus 6 liters n/c does\n have sleep apnea and was place on autoset machine until he woke up and\n pulled it off along with his a-line. Medicated for pain with Morphine\n see metavision and started on CIWA scale\n Response:\n Less agitated after Valium, sats 96 %\n Plan:\n need to go back on autoset , need follow up with this\n sleep apnea follow ciwa scale for agitation\n Right hip dsg was changed today by Orthopedics and incison is clean and\n dry, 2 hemovacs in place see metavision for drainage amounts . Dsg is\n clean and dry per Ortho nursing can reinforce dsg if needed or change\n it\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 585657,
"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 Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments: small oral secretions\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: PSV trial.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: when sedation wear off.\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated; Comments: Will rest.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 585981,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous non-invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Auto-Set CPAP\n Assessment of breathing comfort: No response (sleeping / sedated)\n Pt has been on Auto-Set CPAP most of shift with 12Lpm O2. Pt minimally\n arousable, sedated for ?? withdrawal otherwise very agitated.\n Witnessed obstruction, tol cpap well.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585899,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pulled art line\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 748 (748 - 748) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve: 11 L/min\n PaO2 / FiO2: 164\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 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 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": "2182-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585900,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pulled art line\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool\n Ventilator mode: Standby\n Vt (Spontaneous): 748 (748 - 748) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 50%\n PIP: 11 cmH2O\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve: 11 L/min\n PaO2 / FiO2: 164\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 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n .\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Now on PS 5/5.\n - monitor ABGs closely / daily CXRs\n - attempt to wean again today with SBT, HOB elevated may help, can\n consider precedex if necessary given ETOH/percocet history\n - may need CIWA scale after extubation given h/o ETOH\n - albuterol MDI q2 prn\n - aggressive suctioning and chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal, given 500cc NS bolus over 2 hrs twice overnight. UOP has\n not increased after IVF challenge, raising concern for ATN.\n - cont to monitor UOP, have given 500cc at 5am\n - recheck afternoon lytes\n - can re-attempt fluid challenge after extubation\n .\n # ID: spiked to 101 overnight. WBC trended down slightly to 21. Sputum\n w/ GNR, GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - start lovenox 30 in am\n - AP pelvis\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Received 1L LR on arrival to\n the . Now improved to around 1.7\n - cont to monitor lactate\n - expect to improve with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 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": "2182-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585903,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pulled art line\n -agitated at times, pulled out IV, had to be restrained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: NRB\n Ventilator mode:\n Vt (Spontaneous):\n PS :\n RR: 17\n PEEP:\n FiO2: 50%\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve:\n PaO2 / FiO2:\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n UCx: (-)\n BCx: Pending\n 1:08 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n 2:32 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n CXR:\n R hip XR:\n The new right hip hemiarthroplasty is seen with normal positioning. No\n new\n fractures or dislocations are identified.\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n .\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Now on PS 5/5.\n - monitor ABGs closely / daily CXRs\n - attempt to wean again today with SBT, HOB elevated may help, can\n consider precedex if necessary given ETOH/percocet history\n - may need CIWA scale after extubation given h/o ETOH\n - albuterol MDI q2 prn\n - aggressive suctioning and chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal, given 500cc NS bolus over 2 hrs twice overnight. UOP has\n not increased after IVF challenge, raising concern for ATN.\n - cont to monitor UOP, have given 500cc at 5am\n - recheck afternoon lytes\n - can re-attempt fluid challenge after extubation\n .\n # ID: spiked to 101 overnight. WBC trended down slightly to 21. Sputum\n w/ GNR, GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - start lovenox 30 in am\n - AP pelvis\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Received 1L LR on arrival to\n the . Now improved to around 1.7\n - cont to monitor lactate\n - expect to improve with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Generic Note",
"row_id": 585870,
"text": "TITLE:\n RESPIRATORY CARE:\n Following pt for CPAP therapy. Administering CPAP via Autoset range\n with full face mask. Pt tolerated fairly well overnight,\n requiring large amts of sedation and pain meds to keep calm. CPAP\n removed @ approx. 5am for bath and Albuterol neb rx. Administered\n 2.5mg unit dose of Albuterol via face mask. See flowsheet for further\n pt data. Will follow.\n 04:56\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586050,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt with h/o OSA , on auto cpap overnight. Pt asleep.early shift Absent\n gag , wake up early am and responding to commands. LS diminished on\n base.\n Action:\n Continued with cpap , nebs as ordered. Sats 88 -90 sometimes ,\\\n Response:\n Sats maintained mostly low 90\ns ,but have times dropped to 88\ns ,LS\n diminished. Pt asleep, difficult to arouse till early am and then\n become agitated and restless.\n Plan:\n Continue with CPAP, wean O2 as tolerated.\n Arousal, Attention, and Cognition Impaired, ETOH.\n Assessment:\n Pt deep sleep,difficult to arouse, no s/s of withdrawal noted till\n early am Calm and quiet and slept well during the night. Agitated\n and restless by early am ,received 5 mg iv valium this shift .\n Action:\n Received 5mg iv valium this shift,totally he got > 110 mg valium and\n 16mg morphine from yesterday .\n Response:\n Restless and agitated at times.\n Plan:\n Continue with valium 5mg iv PRN with CIWA Scale q 2h.\n Rt leg OP site dressing looks clean and dry, abduction pillow in place.\n Bath given and change of position done. Hemovac # 1 & 2 draining very\n minimal ,emptied and documented.\n Pt\ns girlfriend and his son into visit yesterday evening , not happy\n with pt care, they wanted him to transfer to , icu team\n called surgery , both of them spoke with the family given all\n possible informations regarding pt care.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586051,
"text": "Chief Complaint: intubated post-op\n 24 Hour Events:\n - received 115mg valium, 16mg morphine and 5mg haldol over the course\n of the day.\n - patient's family came to visit last night and were aggitated. They\n talked to the ortho attending and this seemed to calmed them down.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 06:11 PM\n Vancomycin - 08:16 PM\n Bactrim (SMX/TMP) - 06:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 AM\n Diltiazem - 12:43 PM\n Morphine Sulfate - 01:41 PM\n Haloperidol (Haldol) - 01:43 PM\n Metoprolol - 04:30 AM\n Diazepam (Valium) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 95 (75 - 177) bpm\n BP: 152/62(83) {101/36(59) - 191/83(101)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.3 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 890 mL\n 1,068 mL\n PO:\n TF:\n IVF:\n 890 mL\n 1,068 mL\n Blood products:\n Total out:\n 2,130 mL\n 495 mL\n Urine:\n 1,810 mL\n 435 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 60 mL\n Balance:\n -1,240 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 85 K/uL\n 9.5 g/dL\n 127 mg/dL\n 1.5 mg/dL\n 28 mEq/L\n 7.0 mEq/L\n 66 mg/dL\n 112 mEq/L\n 145 mEq/L\n 28.6 %\n 9.3 K/uL\n [image002.jpg]\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n WBC\n 23.7\n 21.1\n 16.5\n 9.3\n Hct\n 36.8\n 34.3\n 30.0\n 28.6\n Plt\n 84\n 94\n 86\n 85\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n 1.5\n TCO2\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n 127\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586054,
"text": "Chief Complaint: intubated post-op\n 24 Hour Events:\n - received 115mg valium, 16mg morphine and 5mg haldol over the course\n of the day.\n - patient's family came to visit last night and were aggitated. They\n talked to the ortho attending and this seemed to calmed them down.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 06:11 PM\n Vancomycin - 08:16 PM\n Bactrim (SMX/TMP) - 06:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 AM\n Diltiazem - 12:43 PM\n Morphine Sulfate - 01:41 PM\n Haloperidol (Haldol) - 01:43 PM\n Metoprolol - 04:30 AM\n Diazepam (Valium) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 95 (75 - 177) bpm\n BP: 152/62(83) {101/36(59) - 191/83(101)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.3 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 890 mL\n 1,068 mL\n PO:\n TF:\n IVF:\n 890 mL\n 1,068 mL\n Blood products:\n Total out:\n 2,130 mL\n 495 mL\n Urine:\n 1,810 mL\n 435 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 60 mL\n Balance:\n -1,240 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 85 K/uL\n 9.5 g/dL\n 127 mg/dL\n 1.5 mg/dL\n 28 mEq/L\n 7.0 mEq/L\n 66 mg/dL\n 112 mEq/L\n 145 mEq/L\n 28.6 %\n 9.3 K/uL\n [image002.jpg]\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n WBC\n 23.7\n 21.1\n 16.5\n 9.3\n Hct\n 36.8\n 34.3\n 30.0\n 28.6\n Plt\n 84\n 94\n 86\n 85\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n 1.5\n TCO2\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n 127\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586081,
"text": "Chief Complaint: intubated post-op\n 24 Hour Events:\n - received 115mg valium, 16mg morphine and 5mg haldol over the course\n of the day.\n - patient's family came to visit last night and were aggitated. They\n talked to the ortho attending and this seemed to calmed them down.\n -ortho took out JP drains this am.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 06:11 PM\n Vancomycin - 08:16 PM\n Bactrim (SMX/TMP) - 06:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 AM\n Diltiazem - 12:43 PM\n Morphine Sulfate - 01:41 PM\n Haloperidol (Haldol) - 01:43 PM\n Metoprolol - 04:30 AM\n Diazepam (Valium) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 95 (75 - 177) bpm\n BP: 152/62(83) {101/36(59) - 191/83(101)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.3 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 890 mL\n 1,068 mL\n PO:\n TF:\n IVF:\n 890 mL\n 1,068 mL\n Blood products:\n Total out:\n 2,130 mL\n 495 mL\n Urine:\n 1,810 mL\n 435 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 60 mL\n Balance:\n -1,240 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress, on CPAP\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 85 K/uL\n 9.5 g/dL\n 133 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 5.1 mEq/L\n 68 mg/dL\n 111 mEq/L\n 146 mEq/L\n 28.6 %\n 9.3 K/uL\n [image002.jpg]\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n WBC\n 23.7\n 21.1\n 16.5\n 9.3\n Hct\n 36.8\n 34.3\n 30.0\n 28.6\n Plt\n 84\n 94\n 86\n 85\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n 1.5\n TCO2\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n 127\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on BiPAP.\n - albuterol MDI q2 prn\n - chest PT\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Current HR\n 100s-110s. BP was stable throughout.\n -cont metoprolol 5 mg iv q4h\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr trending down from 1.9\n yesterday to 1.4 today. Currently w/ good UOP ~70-80cc/hr\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 9.3 today. Sputum w/ GNR,\n GPR.\n - currenlty on vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition: NPO, advance to regular as tolerated.\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up,\n Comments:\n Communication: ICU consent signed Comments: Pt agitated at times,\n pulling on his lines. Had to be restrained, please cont restrains.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585806,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output has picked up slightly today 30-50cc/hr, am creatinine\n 2.3 1800 labs to be done\n Action:\n Labs pending\n Response:\n Depends on what 1800 creatinine is\n Plan:\n Closely monitor urine output/ lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Extubated this am tolerated well\n Action:\n Response:\n Post Bronch chest-xray was much improved pt is now on cpap 5/5\n Plan:\n See metavision for ABG results on , if gas is good pt may be\n extubated tonight, fent deecreased to 100mcg/hr and versed to 2mg\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585980,
"text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Continues to be compative despite wrists restraints pull out iv this\n am very confused\n Action:\n CIWA scale q 1hr, 10 -20mg of iv valium, received 1 time dose of iv\n haldol\n Response:\n Still restless and confused\n Plan:\n Continue ciwa scale. Consider adding standing dose of Haldol\n Atrial fibrillation (Afib)\n Assessment:\n This am pt. went into A-fib with HR to the 180\ns, mostly due to\n withdrawning because during this time pt. was hypertensive to the 180\n , and became very restless and diapheretic\n Action:\n Received Lopressor 5mg x3, then Dilt 10mg x2\n Response:\n Eventually broke rate and went back into nsr, but before that went into\n a-flutter\n Plan:\n Continue to monitor, pt. has a standing Lopressor order\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt has OSA while sleeping, sats down to 88% this am\n Action:\n Placed on autoset c-pap and has been on it most of the day\n Response:\n Sats have been in the mid 90\ns all day\n Plan:\n Continue to monitor OSA, pt will need follow up prior to going home\n Right hip dsg was changed today by nursing, site is clean and intact\n old dressing had moderate amt. of serous drainage on it, 2 hemovac are\n in place.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586065,
"text": "Chief Complaint: intubated post-op\n 24 Hour Events:\n - received 115mg valium, 16mg morphine and 5mg haldol over the course\n of the day.\n - patient's family came to visit last night and were aggitated. They\n talked to the ortho attending and this seemed to calmed them down.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 06:11 PM\n Vancomycin - 08:16 PM\n Bactrim (SMX/TMP) - 06:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 AM\n Diltiazem - 12:43 PM\n Morphine Sulfate - 01:41 PM\n Haloperidol (Haldol) - 01:43 PM\n Metoprolol - 04:30 AM\n Diazepam (Valium) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 95 (75 - 177) bpm\n BP: 152/62(83) {101/36(59) - 191/83(101)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.3 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 890 mL\n 1,068 mL\n PO:\n TF:\n IVF:\n 890 mL\n 1,068 mL\n Blood products:\n Total out:\n 2,130 mL\n 495 mL\n Urine:\n 1,810 mL\n 435 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 60 mL\n Balance:\n -1,240 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress, on CPAP\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 85 K/uL\n 9.5 g/dL\n 133 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 5.1 mEq/L\n 68 mg/dL\n 111 mEq/L\n 146 mEq/L\n 28.6 %\n 9.3 K/uL\n [image002.jpg]\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n WBC\n 23.7\n 21.1\n 16.5\n 9.3\n Hct\n 36.8\n 34.3\n 30.0\n 28.6\n Plt\n 84\n 94\n 86\n 85\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n 1.5\n TCO2\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n 127\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Current HR\n 100s-110s. BP was stable throughout.\n -cont metoprolol 5 mg iv q4h\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr trending down from 1.9\n yesterday to 1.4 today. Currently w/ good UOP ~70-80cc/hr\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 9.3 today. Sputum w/ GNR,\n GPR.\n - currenlty on vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586066,
"text": "Chief Complaint: intubated post-op\n 24 Hour Events:\n - received 115mg valium, 16mg morphine and 5mg haldol over the course\n of the day.\n - patient's family came to visit last night and were aggitated. They\n talked to the ortho attending and this seemed to calmed them down.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 06:11 PM\n Vancomycin - 08:16 PM\n Bactrim (SMX/TMP) - 06:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 AM\n Diltiazem - 12:43 PM\n Morphine Sulfate - 01:41 PM\n Haloperidol (Haldol) - 01:43 PM\n Metoprolol - 04:30 AM\n Diazepam (Valium) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 95 (75 - 177) bpm\n BP: 152/62(83) {101/36(59) - 191/83(101)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.3 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 890 mL\n 1,068 mL\n PO:\n TF:\n IVF:\n 890 mL\n 1,068 mL\n Blood products:\n Total out:\n 2,130 mL\n 495 mL\n Urine:\n 1,810 mL\n 435 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 60 mL\n Balance:\n -1,240 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress, on CPAP\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 85 K/uL\n 9.5 g/dL\n 133 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 5.1 mEq/L\n 68 mg/dL\n 111 mEq/L\n 146 mEq/L\n 28.6 %\n 9.3 K/uL\n [image002.jpg]\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n WBC\n 23.7\n 21.1\n 16.5\n 9.3\n Hct\n 36.8\n 34.3\n 30.0\n 28.6\n Plt\n 84\n 94\n 86\n 85\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n 1.5\n TCO2\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n 127\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Current HR\n 100s-110s. BP was stable throughout.\n -cont metoprolol 5 mg iv q4h\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr trending down from 1.9\n yesterday to 1.4 today. Currently w/ good UOP ~70-80cc/hr\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 9.3 today. Sputum w/ GNR,\n GPR.\n - currenlty on vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments: Pt agitated at times,\n pulling on his lines. Had to be restrained, please cont restrains.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586067,
"text": "Chief Complaint: intubated post-op\n 24 Hour Events:\n - received 115mg valium, 16mg morphine and 5mg haldol over the course\n of the day.\n - patient's family came to visit last night and were aggitated. They\n talked to the ortho attending and this seemed to calmed them down.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 06:11 PM\n Vancomycin - 08:16 PM\n Bactrim (SMX/TMP) - 06:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 AM\n Diltiazem - 12:43 PM\n Morphine Sulfate - 01:41 PM\n Haloperidol (Haldol) - 01:43 PM\n Metoprolol - 04:30 AM\n Diazepam (Valium) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 95 (75 - 177) bpm\n BP: 152/62(83) {101/36(59) - 191/83(101)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.3 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 890 mL\n 1,068 mL\n PO:\n TF:\n IVF:\n 890 mL\n 1,068 mL\n Blood products:\n Total out:\n 2,130 mL\n 495 mL\n Urine:\n 1,810 mL\n 435 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 60 mL\n Balance:\n -1,240 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress, on CPAP\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 85 K/uL\n 9.5 g/dL\n 133 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 5.1 mEq/L\n 68 mg/dL\n 111 mEq/L\n 146 mEq/L\n 28.6 %\n 9.3 K/uL\n [image002.jpg]\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n WBC\n 23.7\n 21.1\n 16.5\n 9.3\n Hct\n 36.8\n 34.3\n 30.0\n 28.6\n Plt\n 84\n 94\n 86\n 85\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n 1.5\n TCO2\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n 127\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Current HR\n 100s-110s. BP was stable throughout.\n -cont metoprolol 5 mg iv q4h\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr trending down from 1.9\n yesterday to 1.4 today. Currently w/ good UOP ~70-80cc/hr\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 9.3 today. Sputum w/ GNR,\n GPR.\n - currenlty on vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition: NPO, advance to regular as tolerated.\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments: Pt agitated at times,\n pulling on his lines. Had to be restrained, please cont restrains.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586071,
"text": "Chief Complaint: intubated post-op\n 24 Hour Events:\n - received 115mg valium, 16mg morphine and 5mg haldol over the course\n of the day.\n - patient's family came to visit last night and were aggitated. They\n talked to the ortho attending and this seemed to calmed them down.\n -ortho took out JP drains this am.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 06:11 PM\n Vancomycin - 08:16 PM\n Bactrim (SMX/TMP) - 06:35 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 AM\n Diltiazem - 12:43 PM\n Morphine Sulfate - 01:41 PM\n Haloperidol (Haldol) - 01:43 PM\n Metoprolol - 04:30 AM\n Diazepam (Valium) - 05:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 37\nC (98.6\n HR: 95 (75 - 177) bpm\n BP: 152/62(83) {101/36(59) - 191/83(101)} mmHg\n RR: 22 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 118.3 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 890 mL\n 1,068 mL\n PO:\n TF:\n IVF:\n 890 mL\n 1,068 mL\n Blood products:\n Total out:\n 2,130 mL\n 495 mL\n Urine:\n 1,810 mL\n 435 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 60 mL\n Balance:\n -1,240 mL\n 573 mL\n Respiratory support\n O2 Delivery Device: CPAP mask\n SpO2: 93%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress, on CPAP\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 85 K/uL\n 9.5 g/dL\n 133 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 5.1 mEq/L\n 68 mg/dL\n 111 mEq/L\n 146 mEq/L\n 28.6 %\n 9.3 K/uL\n [image002.jpg]\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n WBC\n 23.7\n 21.1\n 16.5\n 9.3\n Hct\n 36.8\n 34.3\n 30.0\n 28.6\n Plt\n 84\n 94\n 86\n 85\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n 1.5\n TCO2\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n 127\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Current HR\n 100s-110s. BP was stable throughout.\n -cont metoprolol 5 mg iv q4h\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr trending down from 1.9\n yesterday to 1.4 today. Currently w/ good UOP ~70-80cc/hr\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 9.3 today. Sputum w/ GNR,\n GPR.\n - currenlty on vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition: NPO, advance to regular as tolerated.\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments: Pt agitated at times,\n pulling on his lines. Had to be restrained, please cont restrains.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 586078,
"text": "Chief Complaint: respiratory failure\n S/P Hip Repair\n I saw and examined the patient, and was physically present with the 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 Extensive Family discussions held yesterday\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 06:11 PM\n Bactrim (SMX/TMP) - 06:35 AM\n Vancomycin - 08:26 AM\n Infusions:\n Other ICU medications:\n Diltiazem - 12:43 PM\n Morphine Sulfate - 01:41 PM\n Haloperidol (Haldol) - 01:43 PM\n Metoprolol - 04:30 AM\n Diazepam (Valium) - 05:15 AM\n Famotidine (Pepcid) - 08:00 AM\n Enoxaparin (Lovenox) - 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: Fatigue\n Cardiovascular: Tachycardia\n Flowsheet Data as of 10:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 103 (75 - 140) bpm\n BP: 158/76(96) {101/36(59) - 185/83(100)} mmHg\n RR: 21 (14 - 26) insp/min\n SpO2: 92%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 118.3 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 890 mL\n 1,352 mL\n PO:\n TF:\n IVF:\n 890 mL\n 1,352 mL\n Blood products:\n Total out:\n 2,130 mL\n 875 mL\n Urine:\n 1,810 mL\n 815 mL\n NG:\n Stool:\n Drains:\n 320 mL\n 60 mL\n Balance:\n -1,240 mL\n 477 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 92%\n ABG: ///30/\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender\n Extremities: Right hip in dressing, distal pulses in tact.\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Verbal stimuli, eyes mid-line,\n PEERL, no follow commands but does move all extremities to pain\n Labs / Radiology\n 9.5 g/dL\n 85 K/uL\n 133 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 5.1 mEq/L\n 68 mg/dL\n 111 mEq/L\n 146 mEq/L\n 28.6 %\n 9.3 K/uL\n [image002.jpg]\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n WBC\n 23.7\n 21.1\n 16.5\n 9.3\n Hct\n 36.8\n 34.3\n 30.0\n 28.6\n Plt\n 84\n 94\n 86\n 85\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n 1.5\n 1.4\n TCO2\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n 127\n 133\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.9 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n 48 yo male now admitted following total hip replacement with prolonged\n OR procedure and in the setting of significant EtOH abuse has had high\n requirement for benzodiazepine replacement. He has maintained stable\n respiratory status following extubation. He has had encouraging\n decreased in WBC count across time and despite continued high dosing of\n benzodiazepines he has maintained continued good capacity to maintain\n airway but still has limited gag reflex.\n 1)Respiratory Failure-Patient extubated at this time, persistent\n altered mental status\n -Continue suctioning\n -Utilize NIV as needed for respiratory supression\n -Continue with B-agonists as needed\n -OOB when possible\n 2)Altered Mental Status-This is clearly multi-factorial and driven by\n EtOH withdrawl and with benzo Rx needed.\n -Valium PRN\n -CIWA scale\n -Thiamine/Folate/MVI\n -Continue close examinations\n 3)Acute Renal Failure-Likely pre-renal\n -Renal dose all medications\n -Continue to follow Cr\n -IVF and urine lytes for any worsening\n -Goal I/O is even to negative across the day today.\n 4)Leukocytosis-Improving WBC count\n -Unasyn continuing and current Rx is directed at possible pulmonary\n source of infection but with mixed flora noted on bronchoscopy done in\n the setting of active infection.\n -Will continue with broad spectrum ABX until sensitivities noted and\n bronchoscopy finalized\n -Primary insult may well be aspiration noted around time of intubation.\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition: PO diet as tolerated with return of GAG reflex\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition : ICU\n Total time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586164,
"text": "Obstructive sleep apnea (OSA)\n Assessment:\n Received pt with 40% face tent, sats maintained mid 90\ns. pt with OSA.\n LS diminished on base. Congested.\n Action:\n CPAP overnight , nasopharyngeal suction done by RRT ,obtained moderate\n amount blood stained thick secertions.\n Response:\n LS more clear ,less congested after suction. Sats\n Plan:\n Atrial fibrillation (Afib),hypertension.\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585977,
"text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Continues to be compative despite wrists restraints pull out iv this\n am very confused\n Action:\n CIWA scale q 1hr, 10 -20mg of iv valium, received 1 time dose of iv\n haldol\n Response:\n Still restless and confused\n Plan:\n Continue ciwa scale. Consider adding standing dose of Haldol\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586143,
"text": "Obstructive sleep apnea (OSA)\n Assessment:\n CPAP removed this morning, off most of day, O2 3L nc to maintain sats\n >92% and then cool mist to loosen thick secretions.\n Action:\n CPAP placed when snorous\n Response:\n Cooperative w/CPAP machine.\n Plan:\n Cont w/pulm hygiene as below.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt arouses to voice, opens eyes to command and wiggles toes\n inconsistently. Speech slurred. Aware of own name and significant\n other. Disoriented to place and time. Absent to very poor gag reflex.\n NPO.\n Action:\n Reoriented PRN.\n Response:\n Pt confused, speech slurred and cantakerous.\n Plan:\n Cont to monitor mental status, reorient as necessary. Pt needs\n nutrition, attempted OGT placement however, unable to place.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt med x 2 for pain, pt often moaning and attempting to move in bed but\n when asked denies pain.\n Action:\n Med x 2 w/2mg morphine for pain\n Response:\n Somewhat responsive to pain med as evidenced by less moaning and\n grimacing.\n Plan:\n Assess for pain, medicate as ordered, assess effectiveness.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr trending down. Urine output ~100cc/hr.\n Action:\n Monitored urine output\n Response:\n Good urine output, may be auto diuresing.\n Plan:\n Cont to monitor labs and urine output as ordered.\n Range of Motion, Impaired\n Assessment:\n OOB to stretcher chair with slide board. Right hip brace applied for\n OOB. Ortho removed drains today. DSD to staple line.. Drain sites\n continued to ooz sero sang drainage, mod amt, dressing reinforced once.\n Action:\n OOB to stretcher chair, too confused to attempt to ambulate.\n Response:\n Returned to bed after one hour d/t HTN\n Plan:\n Cont to increase activity as tolerated. OOB to chair w/brace. apply\n 50% weight bearing to right leg. have 90 degree flex at hip and\n knee.\n Airway Clearance, Impaired\n Assessment:\n Pt w/poor cough and gag.\n Action:\n CPT q2-4hours to mobilize secretions, cool neb to loosen secretions\n Response:\n Suctioned w/yankauer for moderate amt thick blood tinged and dried old\n secretions. NTS for large amt thick purulent sputum, spec sent for cx\n Plan:\n Cont w/pulmonary toilet, CPAP for sleep, CPT to mobilze secretions, NTS\n PRN.\n Atrial fibrillation (Afib)\n Assessment:\n SR to ST, Hypertensive 208/100\n Action:\n Metoprolol increased to 10mg IV q4h.\n Response:\n Remains Hypertensive to 190s\n Plan:\n Cont to monitor HTN, medicate for pain and CIWA as odered.\n Pt\ns S.O., visited today. Continues to be upset with care.\n Believes that we should be giving medicines to wake patient up and that\n we are not giving him enough pain medicine. believes that he is\n going through narcotic withdrawal and she would like to get him out of\n here to a different hospital. I spoke at length about pt\ns pneumonia\n and probable withdrawal from ETOH but ETOH withdrawal only angers\n . Patient spoke with intern from ICU team. Pt\ns sister and\n b-i-l also visited, asked appropriate questions.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586153,
"text": "Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586159,
"text": "Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586160,
"text": "Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586226,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Airway Clearance, Impaired\n Assessment:\n Resp failure most likely secondary to hypoventilation due to lll\n collapse causing significant resp acidosis .\n pt continues to Have significant amt of secretions.Pt lethargic but\n arousable . inconsistently following simple commands. Rhoncherous bs\n bil on auscultation but diminished at the bases. Bal with hemoph influ\n + beta lactamase, strpt penumo with sensitivities pending. Pt on 40%\n face tent o2 with rr I nthe 20\ns and 02 sats >94%.\n Action:\n Ciwa scale done q 2 hrs. albuterol mdi\ns q 2 hrs prn as ordered. Reps\n status monitored closely. nasotracheally suctioned for sm to mod amts\n of thick tan/blood tinged sputum. Repeat sputum culture sent off to\n microbiology. Unasyn d/c\nd and now started on vancomycin and zosyn for\n antibiotic coverage.\n Response:\n Reps status but will need frequent nasotracheal suctioning and\n reps status monitoring.\n Plan:\n Continue with present antibiotic coverage. Montior resp status and wean\n ciwa scale as much as possible . will try to avoid medicating with\n valium unless absolutely necessary. Cpap during the noc. Goal for o2\n sats is > 90%\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with hx of etoh abuse . pt extremely lethargic but is arousable.\n Inconsistently following simple commands. No episodes of agitation but\n restless and attempting to pull out ngt and remove o2 sat. alert and\n oriented to person only. Ciwa scale <6. no evidence of\n n/v,hallucinations, tremors or diaphoresis. Pt\ns speech is slurred and\n he is unable to stay awake.\n Action:\n Pt now started on clonidine 0.2 mg po tid. Ciwa scale c hanged to q 4\n hrs. hemodynamcis followed closley.. No need for iv valium this shift.\n Mental status assess freq during the shift\n Response:\n Pt not agitated but remains restless and confused.\n Plan:\n Conitinue to assess ciwa scale q 4 hrs. medicate with clonidine as\n ordered. Medicate with iv valium if high ciwa scale\n s/p r hip replacement\n Assessment:\n R hip drsg on previous shift remains d&i. c/o mod amt of pain\n to r hip surgical site\n Action:\n Pt oob to stretcher /chair without difficulty. Abduction pillow in\n place between both legs. Pneumo boots remain in place. Medicated with\n morphine 2 mg ivp x 2\n Response:\n Tolerated activity well. Pain relieved with iv morphine\n Plan:\n Continue to assess surgical site to r hip. Keep abduction pillows\n between both legs. Awaiting assist of physical therapy. Medicate with\n iv morhine for any voiced c/o pain,.\n Hypertension\n Assessment:\n Hypertensive with sbp 160\ns to 200\ns even on q 4 hrs iv lopressor.hr\n 80-90\n Action:\n Hemodynamics followed closely. pt given 1 packet neutraphos for\n repletion. Iv lopressor changed to po doses. Also given 40 meq kcl to\n repelte k+ of 3.7\n Response:\n Still hypertensive\n Plan:\n Continue to follow hemodynamics. Clonidine being given to pt may also\n improve pt\ns bp\n Ngt remain in place to and placement confirmed by cxr. Pt\n receiving replete with fiber tube fdgs at 40cc\ns/jhr and will increase\n as tolerated to a goal rate of 80cc\ns/hr. na level this am=151 and pt\n also getting 200cc\ns free water via ngt q 4 hrs. pt\ns girlfriend\n in to visit with pt and was update on pt\ns medical progress by\n Dr. . Will continue with present medical management and keep\n family members well informed on a daily basis.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586237,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Airway Clearance, Impaired\n Assessment:\n Resp failure most likely secondary to hypoventilation due to lll\n collapse causing significant resp acidosis .\n pt continues to Have significant amt of secretions.Pt lethargic but\n arousable . inconsistently following simple commands. Rhoncherous bs\n bil on auscultation but diminished at the bases. Bal with hemoph influ\n + beta lactamase, strpt penumo with sensitivities pending. Pt on 40%\n face tent o2 with rr I nthe 20\ns and 02 sats >94%.\n Action:\n Ciwa scale done q 2 hrs. albuterol mdi\ns q 2 hrs prn as ordered. Reps\n status monitored closely. nasotracheally suctioned for sm to mod amts\n of thick tan/blood tinged sputum. Repeat sputum culture sent off to\n microbiology. Unasyn d/c\nd and now started on vancomycin and zosyn for\n antibiotic coverage.\n Response:\n Reps status but will need frequent nasotracheal suctioning and\n reps status monitoring.\n Plan:\n Continue with present antibiotic coverage. Montior resp status and wean\n ciwa scale as much as possible . will try to avoid medicating with\n valium unless absolutely necessary. Cpap during the noc. Goal for o2\n sats is > 90%\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with hx of etoh abuse . pt extremely lethargic but is arousable.\n Inconsistently following simple commands. No episodes of agitation but\n restless and attempting to pull out ngt and remove o2 sat. alert and\n oriented to person only. Ciwa scale <6. no evidence of\n n/v,hallucinations, tremors or diaphoresis. Pt\ns speech is slurred and\n he is unable to stay awake.\n Action:\n Pt now started on clonidine 0.2 mg po tid. Ciwa scale c hanged to q 4\n hrs. hemodynamcis followed closley.. No need for iv valium this shift.\n Mental status assess freq during the shift\n Response:\n Pt not agitated but remains restless and confused.\n Plan:\n Conitinue to assess ciwa scale q 4 hrs. medicate with clonidine as\n ordered. Medicate with iv valium if high ciwa scale\n s/p r hip replacement\n Assessment:\n R hip drsg on previous shift remains d&i. c/o mod amt of pain\n to r hip surgical site\n Action:\n Pt oob to stretcher /chair without difficulty. Abduction pillow in\n place between both legs. Pneumo boots remain in place. Medicated with\n morphine 2 mg ivp x 2\n Response:\n Tolerated activity well. Pain relieved with iv morphine\n Plan:\n Continue to assess surgical site to r hip. Keep abduction pillows\n between both legs. Awaiting assist of physical therapy. Medicate with\n iv morhine for any voiced c/o pain,.\n Hypertension\n Assessment:\n Hypertensive with sbp 160\ns to 200\ns even on q 4 hrs iv lopressor.hr\n 80-90\n Action:\n Hemodynamics followed closely. pt given 1 packet neutraphos for\n repletion. Iv lopressor changed to po doses. Also given 40 meq kcl to\n repelte k+ of 3.7\n Response:\n Still hypertensive\n Plan:\n Continue to follow hemodynamics. Clonidine being given to pt may also\n improve pt\ns bp\n Ngt remain in place to and placement confirmed by cxr. Pt\n receiving replete with fiber tube fdgs at 40cc\ns/jhr and will increase\n as tolerated to a goal rate of 80cc\ns/hr. na level this am=151 and pt\n also getting 200cc\ns free water via ngt q 4 hrs. pt\ns girlfriend\n in to visit with pt and was update on pt\ns medical progress by\n Dr. . Will continue with present medical management and keep\n family members well informed on a daily basis.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586209,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Airway Clearance, Impaired\n Assessment:\n Resp failure most likely secondary to hypoventilation due to lll\n collapsecausing significant resp acidosispt continues to Have\n significant amt of secretions.Pt lethargic but arousable .\n inconsistently following simple commands. Rhoncherous bs bil on\n auscultation but diminished at the bases. Bal with hemoph influ + beta\n lactamase, strpt penumo with sensitivities pending. Pt on 40% face tent\n o2 with rr I nthe 20\ns and\n Action:\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Ciwa scale done q 2 hrs. albuterol mdi q 2 hrs prn as ordered. Resp s\n tatus monitired closely. nasotracheal suctioned for mod amts of thic\n tan blood tinged sputum. Repeat sputum sent off to microbiology.\n Unnasyn d/c\nd and pt started on vancomycin and zosyn for antibiotic\n coverage.\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586212,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Airway Clearance, Impaired\n Assessment:\n Resp failure most likely secondary to hypoventilation due to lll\n collapsecausing significant resp acidosispt continues to Have\n significant amt of secretions.Pt lethargic but arousable .\n inconsistently following simple commands. Rhoncherous bs bil on\n auscultation but diminished at the bases. Bal with hemoph influ + beta\n lactamase, strpt penumo with sensitivities pending. Pt on 40% face tent\n o2 with rr I nthe 20\ns and 02 sats >94%.\n Action:\n Ciwa scale done q 2 hrs. albuterol mdi\ns q 2 hrs prn as ordered. Reps\n status monitored closely. nasotracheally suctioned for sm to mod amts\n of thick tan/blood tinged sputum. Repeat sputum cullture sent off to\n microbiology. Unasyn d/c\nd and now started on vancomycin and zosyn for\n antibiotic coverage.\n Response:\n Reps status but will need frequent nasotracheal suctioning and\n reps status monitoring.\n Plan:\n Continue with present antibiotic coverage. Montiore resp status and\n wean ciwa scale as much as possible . will try to avoid meidcating\n with valium unless absolutely necessary. Cpap during the noc.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with hx of etoh abuse . pt extremely lethargic but is arousable.\n Inconsistently following simple commands. No episodes of agitation but\n restless and attempting to pull out ngt and remove o2 sat. alert and\n oriented to person only. Ciwa scale <6. no evidence of\n n/v,hallucinations, tremors or diaphoresis. Pt\ns speech is slurred and\n he is unble to stay awake.\n Action:\n Pt now started on clonidine 0.2 mg po tid. Ciwa scale c hanged to q 4\n hrs. hemodynamcis followed closley.. No need for iv valium this shift.\n Mental status assess freq during the shift\n Response:\n Pt not agitated but remains restless and confused.\n Plan:\n Conitnue to assess ciwa scale q 4 hrs. medicate with clonidine as\n ordered. Medicate with iv valium if high ciwa scale\n Hypertension\n Assessment:\n Hypertensive with sbp 160\ns to 200\ns even on q 4 hrs iv lopressor.hr\n 80-90\n Action:\n Hemodynamics followed closely. pt given 1 packet neutraphos for\n repletion. Iv lopressor changed to po doses.\n Response:\n Still hypertensive\n Plan:\n Continue to follow hemodynamics. Clonidine being given to pt may also\n improve pt\ns bp\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586216,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Airway Clearance, Impaired\n Assessment:\n Resp failure most likely secondary to hypoventilation due to lll\n collapse causing significant resp acidosis .\n pt continues to Have significant amt of secretions.Pt lethargic but\n arousable . inconsistently following simple commands. Rhoncherous bs\n bil on auscultation but diminished at the bases. Bal with hemoph influ\n + beta lactamase, strpt penumo with sensitivities pending. Pt on 40%\n face tent o2 with rr I nthe 20\ns and 02 sats >94%.\n Action:\n Ciwa scale done q 2 hrs. albuterol mdi\ns q 2 hrs prn as ordered. Reps\n status monitored closely. nasotracheally suctioned for sm to mod amts\n of thick tan/blood tinged sputum. Repeat sputum culture sent off to\n microbiology. Unasyn d/c\nd and now started on vancomycin and zosyn for\n antibiotic coverage.\n Response:\n Reps status but will need frequent nasotracheal suctioning and\n reps status monitoring.\n Plan:\n Continue with present antibiotic coverage. Montior resp status and wean\n ciwa scale as much as possible . will try to avoid medicating with\n valium unless absolutely necessary. Cpap during the noc.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with hx of etoh abuse . pt extremely lethargic but is arousable.\n Inconsistently following simple commands. No episodes of agitation but\n restless and attempting to pull out ngt and remove o2 sat. alert and\n oriented to person only. Ciwa scale <6. no evidence of\n n/v,hallucinations, tremors or diaphoresis. Pt\ns speech is slurred and\n he is unable to stay awake.\n Action:\n Pt now started on clonidine 0.2 mg po tid. Ciwa scale c hanged to q 4\n hrs. hemodynamcis followed closley.. No need for iv valium this shift.\n Mental status assess freq during the shift\n Response:\n Pt not agitated but remains restless and confused.\n Plan:\n Conitinue to assess ciwa scale q 4 hrs. medicate with clonidine as\n ordered. Medicate with iv valium if high ciwa scale\n s/p r hip replacement\n Assessment:\n R hip drsg on previous shift remains d&i. c/o mod amt of pain\n to r hip surgical site\n Action:\n Pt oob to stretcher /chair without difficulty. Abduction pillow in\n place between both legs. Pneumo boots remain in place. Medicated with\n morphine 2 mg ivp x1\n Response:\n Tolerated activity well. Pain relieved with iv morphine\n Plan:\n Continue to assess surgical site to r hip. Keep abduction pillows\n between both legs. Awaiting assist of physical therapy. Medicate with\n iv morhine for any voiced c/o pain,.\n Hypertension\n Assessment:\n Hypertensive with sbp 160\ns to 200\ns even on q 4 hrs iv lopressor.hr\n 80-90\n Action:\n Hemodynamics followed closely. pt given 1 packet neutraphos for\n repletion. Iv lopressor changed to po doses.\n Response:\n Still hypertensive\n Plan:\n Continue to follow hemodynamics. Clonidine being given to pt may also\n improve pt\ns bp\n Ngt remain in place to and placement confirmed by cxr. Pt\n receiving replete with fiber tube fdgs at 40cc\ns/jhr and will increase\n as tolerated to a goal rate of 80cc\ns/hr. na level this am=151 and pt\n also getting 200cc\ns free water via ngt q 4 hrs. pt\ns girlfriend\n in to visit with pt and was update on pt\ns medical progress by\n Dr. . Will continue with present medical management and keep\n family members well informed on a daily basis.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586320,
"text": "Chief Complaint:\n 24 Hour Events:\n --changed CIWA to q3hr\n --Na=151-->154. Added 100 cc/hr of D5W IV to free water flushes. Also\n collected urine osmol, urine sodium\n --Did not use BiPAP last night since saturating well on shovel mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Vancomycin - 08:40 PM\n Piperacillin - 05:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:00 AM\n Enoxaparin (Lovenox) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.5\nC (99.5\n HR: 59 (59 - 93) bpm\n BP: 119/58(73) {119/58(73) - 210/109(168)} mmHg\n RR: 21 (18 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 2,943 mL\n 1,727 mL\n PO:\n TF:\n 631 mL\n 363 mL\n IVF:\n 1,513 mL\n 844 mL\n Blood products:\n Total out:\n 2,775 mL\n 300 mL\n Urine:\n 2,775 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 168 mL\n 1,427 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: Not assessed\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 117 mEq/L\n 154 mEq/L\n 27.2 %\n 5.1 K/uL\n [image002.jpg]\n 2:32 am SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.\n HEAVY GROWTH BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.\n STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.\n Note: For treatment of meningitis, penicillin G MIC breakpoints\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n |\nCEFTRIAXONE----------- 0.12 S\nERYTHROMYCIN---------- =>1 R\nLEVOFLOXACIN---------- 1 S\nPENICILLIN G---------- 0.25 S\nTETRACYCLINE---------- =>16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n Plt\n 86\n 85\n 83\n 80\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n TCO2\n 27\n 29\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - CIWA scale changed to q3h\n - cont clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont. 50 tid po lopressor\n -CIWA scale (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr. Achieved I/O goal yesterday of\n -1L.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt\ns Na is 153 today increased from 151.\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 586233,
"text": "Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Nasotrachial Suction / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n :\n Plan\n Continue with bronchodilator therapy, NTS as needed. Cough is stronger\n but still requiring suctioning for copious secretions. No need for cpap\n this shift.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586322,
"text": "Chief Complaint:\n 24 Hour Events:\n --changed CIWA to q3hr\n --Na=151-->154. Added 100 cc/hr of D5W IV to free water flushes. Also\n collected urine osmol, urine sodium\n --Did not use BiPAP last night since saturating well on shovel mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Vancomycin - 08:40 PM\n Piperacillin - 05:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:00 AM\n Enoxaparin (Lovenox) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.5\nC (99.5\n HR: 59 (59 - 93) bpm\n BP: 119/58(73) {119/58(73) - 210/109(168)} mmHg\n RR: 21 (18 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 2,943 mL\n 1,727 mL\n PO:\n TF:\n 631 mL\n 363 mL\n IVF:\n 1,513 mL\n 844 mL\n Blood products:\n Total out:\n 2,775 mL\n 300 mL\n Urine:\n 2,775 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 168 mL\n 1,427 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: Not assessed\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 117 mEq/L\n 154 mEq/L\n 27.2 %\n 5.1 K/uL\n [image002.jpg]\n 2:32 am SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.\n HEAVY GROWTH BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.\n STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.\n Note: For treatment of meningitis, penicillin G MIC breakpoints\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n |\nCEFTRIAXONE----------- 0.12 S\nERYTHROMYCIN---------- =>1 R\nLEVOFLOXACIN---------- 1 S\nPENICILLIN G---------- 0.25 S\nTETRACYCLINE---------- =>16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n Plt\n 86\n 85\n 83\n 80\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n TCO2\n 27\n 29\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - CIWA scale changed to q3h\n - cont clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont. 50 tid po lopressor\n -CIWA scale (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt\ns Na is 153 today increased from 151.\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586332,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib/flutter, and etoh withdrawal, extubated .\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n No evidence of DT\ns. CIWA . Sleeping most of the shift. Lethargic,\n arousable, FC. Oriented to person, knows he\ns in the hospital.\n Action:\n Response:\n Plan:\n Airway Clearance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Range of Motion, Impaired\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": "2182-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586334,
"text": "Chief Complaint:\n 24 Hour Events:\n --changed CIWA to q3hr\n --Na=151-->154. Added 100 cc/hr of D5W IV to free water flushes. Also\n collected urine osmol, urine sodium\n --Did not use BiPAP last night since saturating well on shovel mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Vancomycin - 08:40 PM\n Piperacillin - 05:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:00 AM\n Enoxaparin (Lovenox) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.5\nC (99.5\n HR: 59 (59 - 93) bpm\n BP: 119/58(73) {119/58(73) - 210/109(168)} mmHg\n RR: 21 (18 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 2,943 mL\n 1,727 mL\n PO:\n TF:\n 631 mL\n 363 mL\n IVF:\n 1,513 mL\n 844 mL\n Blood products:\n Total out:\n 2,775 mL\n 300 mL\n Urine:\n 2,775 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 168 mL\n 1,427 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: Not assessed\n Not assessed\n Labs / Radiology\n 80 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 117 mEq/L\n 154 mEq/L\n 27.2 %\n 5.1 K/uL\n [image002.jpg]\n 2:32 am SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.\n HEAVY GROWTH BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.\n STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.\n Note: For treatment of meningitis, penicillin G MIC breakpoints\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n |\nCEFTRIAXONE----------- 0.12 S\nERYTHROMYCIN---------- =>1 R\nLEVOFLOXACIN---------- 1 S\nPENICILLIN G---------- 0.25 S\nTETRACYCLINE---------- =>16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n Plt\n 86\n 85\n 83\n 80\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n TCO2\n 27\n 29\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - CIWA scale changed to q3h\n - cont clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont. 50 tid po lopressor\n -CIWA scale (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt\ns Na is 153 today increased from 151.\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 586337,
"text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, therapeutic exercise (AP, LAQ)\n Updated medical status: CXR : prominence of the pulmonary\n vasculature consistent with elevated pulmonary venous pressure.\n Enlargement of the cardiac silhouette persists with probable bibasilar\n atelectasis and effusion.\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n Tx2\n Supine/\n Sidelying to Sit:\n\n\n\n\n Tx2\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n Tx2\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 69\n 123/67\n 94% 40% FT\n Activity\n Sit\n 79\n 120/60\n Recovery\n Supine\n 64\n 141/67\n 100% 40% FT\n Total distance walked:\n Minutes:\n Gait: transfer: sit<>stand x2 max A x2 maintained standing 20 sec first\n attempted, second attempt pt inc forward flex and knee flex immediately\n returning sitting\n Balance: pt able to maintain sitting eob w/R UE support on bed rail,\n leans to R and ant as fatigues able to self correct w/VC, max A x2 for\n moblity as above\n Education / Communication: ed pt re: role of PT, , d/c planning,\n benefit of mobility\n Other:\n Cognition: A&O x2 person and hospital, tracts sound, follows about 75%\n single step commands, pt mumbling and difficult to understand may be\n attributed to not having dentures in. able to correctly identify \n color.\n Strength: pt able to activate shoulder flexion against gravity but\n complete less than 25% ROM.\n Integumentary: foley, NGT, B UE PIV, telemetry, dressing L hip min\n serous drainage, cont o2 and BP monitoriing.\n Lungs: wheezes throughout\n Assessment: Pt is 48yoM now POD 6 s/p R THA. course c/b respiratory\n failure, etoh withdrawl and Afib.Pt today with increased activity\n tolerance participating in sit<>stand and seated balance at EOB. Given\n pt prolonged sedation, bedrest postop, and current level of assist\n recommend rehab however if pt significantly progresses once mentations\n clears may progress to be safe for home w/PT. Will continue to follow\n to progress.\n Anticipated Discharge: Rehab\n Plan: Bed mobility, therex, ROM, gait training, transfer training, pt\n ed, d/c planning.\n Face time: 15:30-16:50\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586338,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib/flutter, and etoh withdrawal, extubated .\n Now on NP alt with face tent (for humidification), converted to NSR, no\n evidence of DT\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n No evidence of DT\ns. CIWA . Sleeping most of the shift. Lethargic,\n arousable, FC. Oriented to person, knows he\ns in the hospital. Speech\n garbled. S/ concerned about waxing & MS.\n Action:\n CIEWA assessment Q4 hrs. Orient PRN. Soft wrist restraints for safety.\n Bed alarm on. met with SO\n Response:\n MS & wanes from somnolence to arousable to voice and able to\n minimally interact with family\n Plan:\n CIWA Q4 hrs .Orinent PRN. Support to family. Reinforce waxing & \n MS is to be expected.\n Airway Clearance, Impaired\n Assessment:\n Impaired cough. Very impaired gag. Unable to clear secretions or\n adequately protect airway. Sats high 90\ns. NP with 40% face tent\n Action:\n Yankauer suctioned back of throat several X\ns. Receiving nebs\n Response:\n Mod to amts oral secretions at back of throat\n Plan:\n Encourage cough, DB, Subglottal suction PRN. Follow sats\n Range of Motion, Impaired\n Assessment:\n Stood at edge of bed with PT & R leg/leg brace. Also dangled at edge\n of bed. Nod amt serrous drainage from hip incision.\n Action:\n Physical therapy, dsg changed X2\n Response:\n Tol well. Too tired to get to chair\n Plan:\n PT to follow. Pt will get slde sheet to assist turning in bed. Brace\n when pt gets OOB to chair, wt bears. Abducter pillow between legs when\n in bed. No >90 hip flexion. Qd DSD changes & prn\n Pain control (acute pain, chronic pain)\n Assessment:\n Denies pain. Tol turning, dangling, wt bear at edge of bed.\n Action:\n On Tylenol TRC\n Response:\n Denies pain\n Plan:\n Ongoing assessment. Cont RTC Tylenol. Morphine sulfate PRN for break\n throuhj pain\n Receiving D5W for NA 153 X1 liter. TF advanced to goal 80 cc hr, Free\n water boluses increased to 250 cc Q 4 hrs.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586350,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib/flutter, and etoh withdrawal, extubated .\n Now on NP alt with face tent (for humidification), converted to NSR, no\n evidence of DT\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n No evidence of DT\ns. CIWA . Sleeping most of the shift. Lethargic,\n arousable, FC. Oriented to person, knows he\ns in the hospital. Speech\n garbled. S/ concerned about waxing & MS.\n Action:\n CIEWA assessment Q4 hrs. Orient PRN. Soft wrist restraints for safety.\n Bed alarm on. met with SO\n Response:\n MS & wanes from somnolence to arousable to voice and able to\n minimally interact with family\n Plan:\n CIWA Q4 hrs .Orinent PRN. Support to family.\n Airway Clearance, Impaired\n Assessment:\n Impaired cough. Very impaired gag. Unable to clear secretions or\n adequately protect airway. Sats high 90\ns. NP with 40% face tent\n Action:\n Yankauer suctioned back of throat several X\ns. Receiving nebs\n Response:\n Mod to amts oral secretions at back of throat\n Plan:\n Encourage cough, DB, Subglottal suction PRN. Follow sats\n Range of Motion, Impaired\n Assessment:\n Stood at edge of bed with PT & R leg/leg brace. Also dangled at edge\n of bed. Nod amt serrous drainage from hip incision.\n Action:\n Physical therapy, dsg changed X2\n Response:\n Tol well. Too tired to get to chair\n Plan:\n PT to follow. Pt will get slde sheet to assist turning in bed. Brace\n when pt gets OOB to chair, wt bears. Abducter pillow between legs when\n in bed. No >90 hip flexion. Qd DSD changes & prn\n Pain control (acute pain, chronic pain)\n Assessment:\n Denies pain. Tol turning, dangling, wt bear at edge of bed.\n Action:\n On Tylenol TRC\n Response:\n Denies pain\n Plan:\n Ongoing assessment. Cont RTC Tylenol. Morphine sulfate PRN for break\n throuhj pain\n Receiving D5W for NA 153 X1 liter. TF advanced to goal 80 cc hr, Free\n water boluses increased to 250 cc Q 4 hrs.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 586203,
"text": "Chief Complaint: Respiratory Failure\n EtOH Withdrawl\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n BLOOD CULTURED - At 04:13 AM\n NGT placed for tube feeds\n Continued high benzodiazepine requirements\n Polymicrobial cultures seen from BAL\n Recurrent fevers, tachycardia and hypertension\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 AM\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 08:04 PM\n Diazepam (Valium) - 05:07 AM\n Morphine Sulfate - 06:07 AM\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 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 Cardiovascular: Tachycardia\n Flowsheet Data as of 09:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 37.4\nC (99.4\n HR: 93 (79 - 110) bpm\n BP: 196/100(168) {162/55(81) - 208/113(168)} mmHg\n RR: 24 (17 - 33) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 1,801 mL\n 766 mL\n PO:\n TF:\n 131 mL\n IVF:\n 1,801 mL\n 434 mL\n Blood products:\n Total out:\n 2,855 mL\n 1,350 mL\n Urine:\n 2,795 mL\n 1,350 mL\n NG:\n Stool:\n Drains:\n 60 mL\n Balance:\n -1,054 mL\n -584 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 87%\n ABG: ///30/\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: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.9 g/dL\n 83 K/uL\n 136 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 48 mg/dL\n 116 mEq/L\n 151 mEq/L\n 26.9 %\n 5.8 K/uL\n [image002.jpg]\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n WBC\n 21.1\n 16.5\n 9.3\n 5.8\n Hct\n 34.3\n 30.0\n 28.6\n 26.9\n Plt\n 94\n 86\n 85\n 83\n Cr\n 2.3\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n TCO2\n 28\n 27\n 29\n 27\n Glucose\n 143\n 150\n 155\n 127\n 133\n 136\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:1.9 mg/dL\n Imaging: CXR--Right lower lobe collapse noted, NGT in\n esophagus--concerning for persistent pneumonia and collapse.\n Assessment and Plan\n 48 yo male s/p hip repair with post operative course complicated by\n significant EtOH withdrawl. This has been complicated by significant\n respiratory failure and with recurrent and persistent fevers likely\n attributable to both EtOH withdrawl and pneumonia resolution.\n Encouragingly patient has had capacity to maintain oxygenation at\n reasonable levels wtih FIO2=0.4\n 1)Hip Repair\ncompleted, pain controlled\n 2)EtOH Withdrawl-\n -valium 40mg in past 24 hours\n -Thiamine\n -Based upon examination this morning patient has decreased\n responsiveness and concern for excess sedation in the setting of\n continued autonomic activation\n -Clonidine for withdrawl\n -Valium to continue\n -Haldol as needed\n 3)Hypoxemia-\n -Pneumonia--Primary contributor to respiratory failure in addition to\n mental status. He has had S. Pneumoniae and H. Flu identified on\n initial cultures. We have concern for persistent active pneumonia with\n fever, sputum, hypoxemia.\n -will broaden to Vanco/Zosyn\n -Albuterol to continue as needed\n -Right Lower Lobe Collapse-\n -will need to actively participate in chest PT\n -In interim he needs NT suctioning\n -CXR in morning\n -Aspiration\nRaised as a concern\nwill very NGT placement\n -CXR this morning to confirm NGT placement and\n continue RX\n 4)Hypernatremia-\n 1.8 liters/d free water given over past 24 hours\n Is 5 liter free water deficit\nwill need to be replaced over next 24-36\n hours\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:30 AM 40 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Patient has had continued clinical\n worsening largely related to patient inability to clear significant\n pulmonary infection despite aggressive suctioning, ongoing refinement\n of antibiotics in discussion with infectious disease antibiotic\n approval service and moving patient from bed to chair to facilitate\n secretion clearance. Patient family upset at lack of rapid clinical\n improvement and will be in need of further support\n Code status: Full code\n Disposition : ICU\n Total time spent: 45\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586205,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Airway Clearance, Impaired\n Assessment:\n Pt lethargic but arousable . inconsistently following simple commands.\n Rhoncherpous bs bil on auscultation but diminished at the bases. Bal\n with hemoph\n Action:\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586316,
"text": "Chief Complaint:\n 24 Hour Events:\n --changed CIWA to q3hr\n --Na=151-->154. Added 100 cc/hr of D5W IV to free water flushes. Also\n collected urine osmol, urine sodium\n --Did not use BiPAP last night since saturating well on shovel mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Vancomycin - 08:40 PM\n Piperacillin - 05:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:00 AM\n Enoxaparin (Lovenox) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.5\nC (99.5\n HR: 59 (59 - 93) bpm\n BP: 119/58(73) {119/58(73) - 210/109(168)} mmHg\n RR: 21 (18 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 2,943 mL\n 1,727 mL\n PO:\n TF:\n 631 mL\n 363 mL\n IVF:\n 1,513 mL\n 844 mL\n Blood products:\n Total out:\n 2,775 mL\n 300 mL\n Urine:\n 2,775 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 168 mL\n 1,427 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\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 80 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 117 mEq/L\n 154 mEq/L\n 27.2 %\n 5.1 K/uL\n [image002.jpg]\n 2:32 am SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.\n HEAVY GROWTH BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.\n STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.\n Note: For treatment of meningitis, penicillin G MIC breakpoints\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n |\nCEFTRIAXONE----------- 0.12 S\nERYTHROMYCIN---------- =>1 R\nLEVOFLOXACIN---------- 1 S\nPENICILLIN G---------- 0.25 S\nTETRACYCLINE---------- =>16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n Plt\n 86\n 85\n 83\n 80\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n TCO2\n 27\n 29\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - CIWA scale changed to q3h\n - cont clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont. 50 tid po lopressor\n -CIWA scale (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr. Achieved I/O goal yesterday of\n -1L.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt\ns Na is 153 today increased from 151.\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586317,
"text": "Chief Complaint:\n 24 Hour Events:\n --changed CIWA to q3hr\n --Na=151-->154. Added 100 cc/hr of D5W IV to free water flushes. Also\n collected urine osmol, urine sodium\n --Did not use BiPAP last night since saturating well on shovel mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Vancomycin - 08:40 PM\n Piperacillin - 05:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:00 AM\n Enoxaparin (Lovenox) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.5\nC (99.5\n HR: 59 (59 - 93) bpm\n BP: 119/58(73) {119/58(73) - 210/109(168)} mmHg\n RR: 21 (18 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 2,943 mL\n 1,727 mL\n PO:\n TF:\n 631 mL\n 363 mL\n IVF:\n 1,513 mL\n 844 mL\n Blood products:\n Total out:\n 2,775 mL\n 300 mL\n Urine:\n 2,775 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 168 mL\n 1,427 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\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 80 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 117 mEq/L\n 154 mEq/L\n 27.2 %\n 5.1 K/uL\n [image002.jpg]\n 2:32 am SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.\n HEAVY GROWTH BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.\n STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.\n Note: For treatment of meningitis, penicillin G MIC breakpoints\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n |\nCEFTRIAXONE----------- 0.12 S\nERYTHROMYCIN---------- =>1 R\nLEVOFLOXACIN---------- 1 S\nPENICILLIN G---------- 0.25 S\nTETRACYCLINE---------- =>16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n Plt\n 86\n 85\n 83\n 80\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n TCO2\n 27\n 29\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - CIWA scale changed to q3h\n - cont clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont. 50 tid po lopressor\n -CIWA scale (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr. Achieved I/O goal yesterday of\n -1L.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt\ns Na is 153 today increased from 151.\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586318,
"text": "Chief Complaint:\n 24 Hour Events:\n --changed CIWA to q3hr\n --Na=151-->154. Added 100 cc/hr of D5W IV to free water flushes. Also\n collected urine osmol, urine sodium\n --Did not use BiPAP last night since saturating well on shovel mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Vancomycin - 08:40 PM\n Piperacillin - 05:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:00 AM\n Enoxaparin (Lovenox) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.5\nC (99.5\n HR: 59 (59 - 93) bpm\n BP: 119/58(73) {119/58(73) - 210/109(168)} mmHg\n RR: 21 (18 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 2,943 mL\n 1,727 mL\n PO:\n TF:\n 631 mL\n 363 mL\n IVF:\n 1,513 mL\n 844 mL\n Blood products:\n Total out:\n 2,775 mL\n 300 mL\n Urine:\n 2,775 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 168 mL\n 1,427 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\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 80 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 117 mEq/L\n 154 mEq/L\n 27.2 %\n 5.1 K/uL\n [image002.jpg]\n 2:32 am SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.\n HEAVY GROWTH BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.\n STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.\n Note: For treatment of meningitis, penicillin G MIC breakpoints\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n |\nCEFTRIAXONE----------- 0.12 S\nERYTHROMYCIN---------- =>1 R\nLEVOFLOXACIN---------- 1 S\nPENICILLIN G---------- 0.25 S\nTETRACYCLINE---------- =>16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n Plt\n 86\n 85\n 83\n 80\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n TCO2\n 27\n 29\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - CIWA scale changed to q3h\n - cont clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont. 50 tid po lopressor\n -CIWA scale (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr. Achieved I/O goal yesterday of\n -1L.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt\ns Na is 153 today increased from 151.\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586396,
"text": "Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt did not receive any valium for > 24hrs. initially he was quiet\n sleeping,but later on he become agitated ,climbing over the side\n rails,pulled out NGT and one peripheral iv.\n Action:\n Received 5 mg iv and additional 10mg iv valium for ciwa > 10 and\n 4mg morphine . CIWA Q4H and valium per ciwa q 4h.\n Response:\n After 15 valium he is calm and sleeping.\n Plan:\n Continue monitor with ciwa and valum as needed.\n Range of Motion, Impaired\n Assessment:\n Pt s/p hip surgery, dressing over the Rt hip .\n Action:\n Abduction pillow in between legs .dressing soaked with SSG drainage\n ,looks like from hemovac site ,staples clean and dry and intact. Change\n of dressing done.\n Response:\n Ongoing. need to try for weight bearing on Rt leg during the day\n time.\n Plan:\n Change of dressing as neede\n Hypernatremia (high sodium)\n Assessment:\n Pt with Na 154 from evening lab.\n Action:\n Pt was getting 250cc water q4h via NGT but he pulled out his NGT ,so\n he is not getting that now. IVF D5 100cc/hr x 2litres.\n Response:\n pending\n Plan:\n Reinsert NGT and continue with free water and tube feed, f/u with am\n labs.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "MICU attending PN",
"row_id": 586321,
"text": "TITLE:\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 48 yo m w/ HTN, OSA, etoh abuse, s/p total\n hip revision with hardware removal course c/b post-op resp failure, asp\n pna, and L lung collapse, arf,, a-fib/flutter, and etoh withdrawal,\n extubated .\n Exam notable for AF BP 100/60 HR 50-90 (NS) 96% (40% shovel).\n Less agitated, follows simple commands, coarse bs, RR, soft, NT + BS,\n dep edema, RLE wound dressing c/d/i\n Labs notable for WBC 5.1K, HCT 27.1, 80, na 154, K+ 3.9 , Cr 1.0,\n Micro--sputum pneumo pna/h flu\n Primary issues remain:\n Agitation, etoh withdrawal, delirium, hypernatremia, resolving pna,\n recent fever spike, resolving ARF, post-op hip revision\n Agree with plan to continue broadened antibx coverage (vanco/zosyn, and\n has completed 6 days unasyn) for HAP given recent temp spike, pending\n final cx data. Unclear etiology of recent temp as no obvious new\n infiltrate on cx, no change in O2 requirement and no leukocytosis. No\n diarrhea. Wound site clean with ortho following. No central lines.\n Would send u/a and cx to evaluate for other potential infectious\n sources. In terms of etoh withdrawal, continue valium per ciwa,\n clonidine, using haldpol prn. Agitation much improved with decreased\n valium requirements. In terms of hypernatremia, replete free water\n deficit following serial na. Post-op a-fib resolved remains in NSR.\n Continue lopressor. Additional post-op recs per ortho.\n Remainder of plan as outlined in resident note.\n ICU: PIVs, TFs, lovenox, PPI, Full code.\n Patient is critically ill\n Total time: 50 min\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586833,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Sodium level =142 this am\n Action:\n Pt given 250cc\ns free water boluses via ngt as ordered and electrolytes\n checked as ordered\n Response:\n Sodium level on the decline\n Plan:\n Continue to check lytes as ordered and adjust free water boluses as\n needed\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt experienced etoh withdrawal post op requiring large amts of iv\n valium. Pt\ns girlfriend very supportive to pt but questioning all\n sedatives given to pt. states that pt is not to receive any haldol\n because\n it drops hr\n. pt is avbel to state his name, name of the\n hospital and street name but then becomes extremely agitated stating he\ns getting out of here and going home. Pt has self d/c\nd the condom\n cath and once foley cath was reinserted he also disconnected the\n foley. Pt becomes verbally abusive using foul language and then falls\n off to sleep\n Action:\n Safe environment maintained. Bed alarm activated and bed locked and in\n low position. All rails up to prevent pt from climbing oob. Pt offered\n emotional support and told frequently the plan of care and that pt is\n not safe or ready to go home.\n Response:\n Episodes of agitation continue but pt has not received any valium since\n Monday. Pt\ns girlfriend at times able to quiet pt down.\n Plan:\n Continue to reorient pt to plan of care and treatment plan. Maintain\n safe pt environment and avoid medicating with haldol. Allow to\n remain at bedside when possible to help quiet pt and support him\n Alteration in Nutrition\n Assessment:\n Pt s/p extubation on with altered ms and s/p 3 failed\n extubations. Immedicately following extubation pt with impaired gag\n reflex. Failed 1^st speech and swallow study and was scheduled to have\n video speech and swallow study today but because of pt\ns body habitus\n study could not be done. Bedside eval done at bedside. After 1 st\n failed study pt had ngt placed via left nare and tube fdgs were\n started. Na today=142. pt passed 2 lg brown softs tools that were heme\n neg.\n Action:\n Bedside speech and swallow study done. Tube fdgs of replete with fiber\n continue at pt\ns goal rate of 80cc\ns/hr. electrolytes followed as\n ordered. pt was receiving 250cc\ns free water boluses via ngt q\n 4 hrs but that was dropped down to 100cc\ns q 4hrs b/cause na level is\n on the decline\n Response:\n Speech and swallow recs are as follows\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586834,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Sodium level =142 this am\n Action:\n Pt given 250cc\ns free water boluses via ngt as ordered and electrolytes\n checked as ordered\n Response:\n Sodium level on the decline\n Plan:\n Continue to check lytes as ordered and adjust free water boluses as\n needed\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt experienced etoh withdrawal post op requiring large amts of iv\n valium. Pt\ns girlfriend very supportive to pt but questioning all\n sedatives given to pt. states that pt is not to receive any haldol\n because\n it drops hr\n. pt is avbel to state his name, name of the\n hospital and street name but then becomes extremely agitated stating he\ns getting out of here and going home. Pt has self d/c\nd the condom\n cath and once foley cath was reinserted he also disconnected the\n foley. Pt becomes verbally abusive using foul language and then falls\n off to sleep\n Action:\n Safe environment maintained. Bed alarm activated and bed locked and in\n low position. All rails up to prevent pt from climbing oob. Pt offered\n emotional support and told frequently the plan of care and that pt is\n not safe or ready to go home.\n Response:\n Episodes of agitation continue but pt has not received any valium since\n Monday. Pt\ns girlfriend at times able to quiet pt down.\n Plan:\n Continue to reorient pt to plan of care and treatment plan. Maintain\n safe pt environment and avoid medicating with haldol. Allow to\n remain at bedside when possible to help quiet pt and support him\n Alteration in Nutrition\n Assessment:\n Pt s/p extubation on with altered ms and s/p 3 failed\n extubations. Immedicately following extubation pt with impaired gag\n reflex. Failed 1^st speech and swallow study and was scheduled to have\n video speech and swallow study today but because of pt\ns body habitus\n study could not be done. Bedside eval done at bedside. After 1 st\n failed study pt had ngt placed via left nare and tube fdgs were\n started. Na today=142. pt passed 2 lg brown softs tools that were heme\n neg.\n Action:\n Bedside speech and swallow study done. Tube fdgs of replete with fiber\n continue at pt\ns goal rate of 80cc\ns/hr. electrolytes followed as\n ordered. pt was receiving 250cc\ns free water boluses via ngt q\n 4 hrs but that was dropped down to 100cc\ns q 4hrs b/cause na level is\n on the decline\n Response:\n Tolerated bedside speech and swallow study without any evidence of\n aspiration.\n Plan:\n Po diet: nectar thick liqs and moist puree consistencies. 1:1\n supervision. Alternate bites with sips. Continue tube fdgs as primary\n means of nutrition,hydration and meds. Please wait to remove tube fdgs\n until pt is seen again by speech and swallow consult team. Maintain\n aspiratipn precautions.\n Refer to social workers progress note from regarding conversations\n with pt\ns \n"
},
{
"category": "General",
"chartdate": "2182-08-29 00:00:00.000",
"description": "MICU staff PN",
"row_id": 586835,
"text": "TITLE:\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 48 yo m w/ HTN, OSA, etoh abuse, s/p total\n hip revision with hardware removal c/b post-op resp failure, asp pna,\n and L lung collapse, arf,, a-fib / flutter, and etoh withdrawal,\n extubated . Remains intermittently agitated/delirius.\n Exam notable for AF BP 99-180/50-60 HR 60-80 RR 18 Sat 95% RA\n Remains confused but less agitated, following simple commands, coarse\n bs, RR, soft, NT + BS, trace dep edema, RLE wound dressing c/d/i\n Labs notable for WBC 6.5K, HCT 28, plts 96, na 142, Cr 0.8\n ICU delirium w/ intermittent agitation remains his primary issue. We\n are limiting narcotics and minimizing use of benzos. Will start daily\n Zyprexa. Attempt to optimize sleep wake schedule. His hypernatremia has\n resolved and we will adjust his free water dosing. He remains anemic\n but his hctis stable. He thrombocytopenic is at\n baseline. Post-op a-fib has resolved and he remains in NSR on\n lopressor. He has completed 8 days unasyn for h flu / strep asp pna.\n His WBC ct remains stable. Will d/c standing tylenol which could mask\n temp. Will continue nebs, chest PT to help with secretion clearance.\n Post-op recs per ortho. Will continue PT and advance diet per swallow\n evaluation.\n Remainder of plan as outlined in resident note.\n ICU: PIVs, TFs, lovenox, PPI, PT following, Full code.\n Stable for transfer to medicine\n Total time: 40 min\n Addendum\n I have spoken with pt\ns girlfriend/fiance and updated her to\n pt\ns condition. I have explained that oveall Mr is improving from\n the multiple post-operative problems he has had (resp failure, afib,\n ARF, pna, etoh withdrawal). His delirium remains a problem at\n this time, although he is slowly improving. He continues to work with\n PT. We are working towards his leaving the ICU but he is not yet ready\n to go home and lmay require rehab.\n has expressed concerns regarding his care and at times has been\n agitated and difficult towards the medical team. She is concerned\n about Mr \ns need to remain in the hospital and wishes to bring him\n home. She would like him to get PT at home rather than at an acute\n rehab facility. She also has stated to our team (doctors and nursing)\n that she\nwill not allow\n haldol or any mind-altering medications to be\n given. She does not want Tfs to continue but wants him to eat. She is\n the pts next of , but not his HCP.\n I have addressed her concerns. I have spoken with the Dr from\n ortho as well. Will ask for a psych consult to assist with management\n of delirium. Have spoken with patient relations and have suggested\n that may speak with them as well, though she declined. Pt is\n being transferred to the medicine floor and will continue to work with\n PT. Social work is following and assisting.\n Additional 60 minutes spent in discussions/family mtgs\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586137,
"text": "Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt arouses to voice, opens eyes to command and wiggles toes\n inconsistently. Speech slurred. Aware of own name and significant\n other. Disoriented to place and time\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt med x 2 for pain, pt often moaning and attempting to move in bed but\n when asked denies pain.\n Action:\n Med x 2 w/2mg morphine for pain\n Response:\n Somewhat responsive to pain med as evidenced by less moaning and\n grimacing.\n Plan:\n Assess for pain, medicate as ordered, assess effectiveness.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Range of Motion, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Airway Clearance, Impaired\n Assessment:\n Pt w/poor cough and gag.\n Action:\n CPT q2-4hours to mobilize secretions, cool neb to loosen secretions\n Response:\n Suctioned w/yankauer for moderate amt thick blood tinged and dried old\n secretions. NTS for large amt thick purulent sputum, spec sent for cx\n Plan:\n Cont w/pulmonary toilet, CPAP for sleep, CPT to mobilze secretions, NTS\n PRN.\n Atrial fibrillation (Afib)\n Assessment:\n SR to ST, Hypertensive 208/100\n Action:\n Metoprolol increased to 10mg IV q4h.\n Response:\n Remains Hypertensive to 190s\n Plan:\n Cont to monitor HTN, medicate for pain and CIWA as odered.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586190,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:13 AM\n - BP up to 200, HR in 110s, given 5, 10, and 10 of diazepam over the\n course of yesterday and night on top of CIWA / increased standing\n lopressor to 10 IV q4\n - NGT placed, TF started\n - BAL with hemoph influ +beta lactamase (amp resistant), s pneumo,\n sensitivities pending\n - spiked to 101, sent Bcx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 AM\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Enoxaparin (Lovenox) - 08:04 PM\n Metoprolol - 03:30 AM\n Diazepam (Valium) - 05:07 AM\n Morphine Sulfate - 06:07 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 38.3\nC (101\n HR: 84 (79 - 110) bpm\n BP: 163/78(99) {158/55(81) - 208/113(125)} mmHg\n RR: 28 (17 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 1,801 mL\n 401 mL\n PO:\n TF:\n 44 mL\n IVF:\n 1,801 mL\n 356 mL\n Blood products:\n Total out:\n 2,855 mL\n 1,030 mL\n Urine:\n 2,795 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n 60 mL\n Balance:\n -1,054 mL\n -629 mL\n Respiratory support\n O2 Delivery Device: Face tent, 40%\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General: Sedated, in no acute distress, on CPAP\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 83 K/uL\n 8.9 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 48 mg/dL\n 116 mEq/L\n 151 mEq/L\n 26.9 %\n 5.8 K/uL\n [image002.jpg]\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n WBC\n 21.1\n 16.5\n 9.3\n 5.8\n Hct\n 34.3\n 30.0\n 28.6\n 26.9\n Plt\n 94\n 86\n 85\n 83\n Cr\n 2.3\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n TCO2\n 28\n 27\n 29\n 27\n Glucose\n 143\n 150\n 155\n 127\n 133\n 136\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued. Sedation weaned.\n CO2 in low 50s, likely stable hypercapnia given smoking history.\n Successfully extubated yesterday currently on BiPAP.\n - wean from CIWA scale\n - albuterol MDI q2 prn\n - chest PT\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont metoprolol 10 mg iv q4h\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr. Achieved I/O goal yesterday of\n -1L.\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # Hypernatremia: pt had I/O goal yesterday of -1L. free water deficit\n is approx -5.5L.\n - 200cc q4h free water through tube feeds\n .\n # ID: Afebrile overnight. WBC trending down 5.8 today. Sputum w/ GNR,\n GPR. Unclear if due to infectious source or if withdrawals.\n - currenlty on vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n ICU Care\n Nutrition:\n NGT in place / Replete with Fiber (Full) - 04:30 AM 20\n mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586206,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Airway Clearance, Impaired\n Assessment:\n Resp failure most likely secondary to hypoventilation due to lll\n collapsecausing significant resp acidosispt continues to Have\n significant amt of secretions.Pt lethargic but arousable .\n inconsistently following simple commands. Rhoncherous bs bil on\n auscultation but diminished at the bases. Bal with hemoph influ + beta\n lactamase, strpt penumo with sensitivities pending. Pt on 40% face tent\n o2 with rr I nthe 20\ns and\n Action:\n Response:\n Plan:\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586207,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 04:13 AM\n - BP up to 200, HR in 110s, given 5, 10, and 10 of diazepam over the\n course of yesterday and night on top of CIWA / increased standing\n lopressor to 10 IV q4\n - NGT placed, TF started\n - BAL with hemoph influ +beta lactamase (amp resistant), s pneumo,\n sensitivities pending\n - spiked to 101, sent Bcx\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:26 AM\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Enoxaparin (Lovenox) - 08:04 PM\n Metoprolol - 03:30 AM\n Diazepam (Valium) - 05:07 AM\n Morphine Sulfate - 06:07 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.3\nC (101\n Tcurrent: 38.3\nC (101\n HR: 84 (79 - 110) bpm\n BP: 163/78(99) {158/55(81) - 208/113(125)} mmHg\n RR: 28 (17 - 33) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 1,801 mL\n 401 mL\n PO:\n TF:\n 44 mL\n IVF:\n 1,801 mL\n 356 mL\n Blood products:\n Total out:\n 2,855 mL\n 1,030 mL\n Urine:\n 2,795 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n 60 mL\n Balance:\n -1,054 mL\n -629 mL\n Respiratory support\n O2 Delivery Device: Face tent, 40%\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General: Sedated, in no acute distress, on CPAP\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 83 K/uL\n 8.9 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 48 mg/dL\n 116 mEq/L\n 151 mEq/L\n 26.9 %\n 5.8 K/uL\n [image002.jpg]\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n WBC\n 21.1\n 16.5\n 9.3\n 5.8\n Hct\n 34.3\n 30.0\n 28.6\n 26.9\n Plt\n 94\n 86\n 85\n 83\n Cr\n 2.3\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n TCO2\n 28\n 27\n 29\n 27\n Glucose\n 143\n 150\n 155\n 127\n 133\n 136\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:1.9 mg/dL\n CXR: NGT tip not directly visualized but thought to be at least at GE\n jxn, was then advanced 5cm and started TF 6 hrs later. Also, noted for\n new RLL collapse.\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt\n continues to spike at night, although WBC trending down now 5.8. BAL w/\n H. flu +beta lactamase (amp resistant), S. pneumo. There is also a\n component of resp depression and withdrawal contributing to hypoxemia.\n - will start vanc/zosyn for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - resend sputum\n - wean from CIWA scale today\n - start clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -transition to 50 tid po lopressor with IV bolus prn\n -CIWA scale wean (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr. Achieved I/O goal yesterday of\n -1L.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt had I/O goal yesterday of -1L. free water deficit\n is approx -5.5L.\n - 200cc q4h free water through tube feeds\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n ICU Care\n Nutrition:\n NGT in place / Replete with Fiber (Full) - 04:30 AM 20\n mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Nutrition",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 586302,
"text": "Objective\n Pertinent medications: FeSO4, thiamine, FA, pepcid, vancomycin.\n Labs:\n Value\n Date\n Glucose\n 150 mg/dL\n 04:02 AM\n BUN\n 34 mg/dL\n 04:02 AM\n Creatinine\n 1.0 mg/dL\n 04:02 AM\n Sodium\n 154 mEq/L\n 04:02 AM\n Potassium\n 3.9 mEq/L\n 04:02 AM\n Chloride\n 117 mEq/L\n 04:02 AM\n TCO2\n 28 mEq/L\n 04:02 AM\n PO2 (arterial)\n 81. mm Hg\n 01:38 PM\n PCO2 (arterial)\n 53 mm Hg\n 01:38 PM\n pH (arterial)\n 7.30 units\n 01:38 PM\n pH (urine)\n 5.0 units\n 05:54 PM\n CO2 (Calc) arterial\n 27 mEq/L\n 01:38 PM\n Albumin\n 2.8 g/dL\n 12:41 AM\n Calcium non-ionized\n 8.0 mg/dL\n 04:02 AM\n Phosphorus\n 3.2 mg/dL\n 04:02 AM\n Magnesium\n 2.9 mg/dL\n 04:02 AM\n WBC\n 5.1 K/uL\n 04:02 AM\n Hgb\n 8.9 g/dL\n 04:02 AM\n Hematocrit\n 27.2 %\n 04:02 AM\n Current diet order / nutrition support: NPO/Tube Feed: FS Replete with\n Fiber at goal 80mL/hour with 200mL water flushes q 4 hours.\n GI:\n Assessment of Nutritional Status/Plan:\n Specifics:\n Tolerating tube feed advancement with minimum residuals & currently at\n 60mL/hour. Hypernatremia with elevated BUN likely due to dehydration &\n team adjusting free water flushes PRN. Unsure etiology of elevated\n magnesium\nfollow trends closely, stable at 2.9 past 3 days. Continue\n with current tube feed advance to goal. Monitor & replete electrolytes\n PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586393,
"text": "Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt did not receive any valium for > 24hrs. initially he was quiet\n sleeping,but later on he become agitated ,climbing over the side\n rails,pulled out NGT and one peripheral iv.\n Action:\n Received 5 mg iv and additional 10mg iv valium for ciwa > 10 and\n 4mg morphine . CIWA Q4H and valium per ciwa q 4h.\n Response:\n After 15 valium he is calm and sleeping.\n Plan:\n Continue monitor with ciwa and valum as needed.\n Range of Motion, Impaired\n Assessment:\n Pt s/p hip surgery, dressing over the Rt hip .\n Action:\n Abduction pillow in between legs .dressing soaked with SSG drainage\n ,looks like from hemovac site ,staples clean and dry and intact. Change\n of dressing done.\n Response:\n Ongoing. need to try for weight bearing on Rt leg during the day\n time.\n Plan:\n Change of dressing as neede\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586397,
"text": "Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt did not receive any valium for > 24hrs. initially he was quiet\n sleeping,but later on he become agitated ,climbing over the side\n rails,pulled out NGT and one peripheral iv.\n Action:\n Received 5 mg iv and additional 10mg iv valium for ciwa > 10 and\n 4mg morphine . CIWA Q4H and valium per ciwa q 4h.\n Response:\n After 15 valium he is calm and sleeping.\n Plan:\n Continue monitor with ciwa and valum as needed.\n Range of Motion, Impaired\n Assessment:\n Pt s/p hip surgery, dressing over the Rt hip .\n Action:\n Abduction pillow in between legs .dressing soaked with SSG drainage\n ,looks like from hemovac site ,staples clean and dry and intact. Change\n of dressing done.\n Response:\n Ongoing. need to try for weight bearing on Rt leg during the day\n time.\n Plan:\n Change of dressing as neede\n Hypernatremia (high sodium)\n Assessment:\n Pt with Na 153 from evening lab.\n Action:\n Pt was getting 250cc water q4h via NGT but he pulled out his NGT ,so\n he is not getting that now. IVF D5 100cc/hr x 2litres.\n Response:\n pending\n Plan:\n Reinsert NGT and continue with free water and tube feed, f/u with am\n labs.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586515,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Known alcoholic pts post op period was complicated with alcolhol\n withdrawal requring valium,pt received 15 mg of valium and 4mg morphine\n for agitation, pulled out IV line/NG tube overnightwas on ciwa\n q4h,ciwa this am 11,pt alert and oreinted x2,drowsy,but obeys commands\n Action:\n Ciwa has been discontd,contd b/l soft wrist restraints,\n Response:\n Pt was lethargic most ly ut easliy arousable,family was here at\n bedside all most all the time,does try to pull the leg OOB at times and\n easily dedirectable,more awake and alert this PM.\n Plan:\n Will hold off valium for now,if pt gets agiatated will give haldol vs\n zydis(family doesn\nt want haldol),cont restraints\n Hypernatremia (high sodium)\n Assessment:\n NA with am labs 147 down from 153,receiving d5@200cc/hr,K 3.7\n Action:\n Discontd d5,restarted FT with free water bolus @250cc/hr,received kcl\n 40meq via NGt\n Response:\n Na with 5pm lab 145.\n Plan:\n Will follow the Na level ,adjust free water bolus as needed.\n Range of Motion, Impaired\n Assessment:\n s/p IM nail removal hemiarthoplasy on ,currently abd pillow\n Action:\n Contd posterior hip precautions,pain mgt with morphine,tunrned and\n repositioned q2h, PT\n Response:\n MAE+,rt hip with SS drainage dsg changed\n Plan:\n Will cont the hip precautions,monitor and change the dsg as\n needed,ortho/PT is following the pt\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on 40% face tent,sats mid 90\ns,ronchorous berath\n sounds,poor cough unable to expectorate secretions,BAL with H\n influenzae\n Action:\n Yaunker suction as need,abx changed to unasyn,o2 weaned to 35%\n Response:\n Aferbile,decresed o2 requirement\n Plan:\n Follow sats,chest PT, abx,suction,\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586582,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na=154\n147, Uosm=638, UNa=24. On D5W 200cc/hr, free water flushes\n increased to 250cc. Calculated free water deficit 4L.\n --received 15 mg Valium overnight, 4 mg morphine for aggitation and\n pulling at tubes and lines.\n BLOOD CULTURED - At 11:30 AM\n peripheral stick\n URINE CULTURE - At 11:46 AM\n BLOOD CULTURED - At 02:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Piperacillin - 05:00 AM\n Vancomycin - 08:27 PM\n Piperacillin/Tazobactam (Zosyn) - 03:49 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:45 AM\n Diazepam (Valium) - 03:15 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 06:09 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: 36.6\nC (97.8\n HR: 66 (59 - 82) bpm\n BP: 134/64(79) {119/58(73) - 170/105(100)} mmHg\n RR: 22 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 5,973 mL\n 1,267 mL\n PO:\n TF:\n 1,587 mL\n 240 mL\n IVF:\n 2,857 mL\n 777 mL\n Blood products:\n Total out:\n 1,670 mL\n 585 mL\n Urine:\n 1,670 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,303 mL\n 682 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\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 85 K/uL\n 8.4 g/dL\n 144 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 113 mEq/L\n 147 mEq/L\n 26.0 %\n 5.5 K/uL\n [image002.jpg]\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n Plt\n 86\n 85\n 83\n 80\n 85\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night).\n -will dc CIWA for now to re-assess pt\ns MS\n decrease morphine dosing to re-assess pt\ns MS\n zyprexa for his aggitation\n # Hypernatremia: pt\ns Na down to 147 from 153 w/ free water repletion.\n Calculated free water deficit was 4L (Na 153).\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn dc\nd, pt re-started on unasyn for the rest of his course\n (total 8 days)\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.9. Currently w/ good UOP ~70-80cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586583,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na=154\n147, Uosm=638, UNa=24. On D5W 200cc/hr, free water flushes\n increased to 250cc. Calculated free water deficit 4L.\n --received 15 mg Valium overnight, 4 mg morphine for aggitation and\n pulling at tubes and lines.\n BLOOD CULTURED - At 11:30 AM\n peripheral stick\n URINE CULTURE - At 11:46 AM\n BLOOD CULTURED - At 02:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Piperacillin - 05:00 AM\n Vancomycin - 08:27 PM\n Piperacillin/Tazobactam (Zosyn) - 03:49 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:45 AM\n Diazepam (Valium) - 03:15 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 06:09 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: 36.6\nC (97.8\n HR: 66 (59 - 82) bpm\n BP: 134/64(79) {119/58(73) - 170/105(100)} mmHg\n RR: 22 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 5,973 mL\n 1,267 mL\n PO:\n TF:\n 1,587 mL\n 240 mL\n IVF:\n 2,857 mL\n 777 mL\n Blood products:\n Total out:\n 1,670 mL\n 585 mL\n Urine:\n 1,670 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,303 mL\n 682 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\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 85 K/uL\n 8.4 g/dL\n 144 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 113 mEq/L\n 147 mEq/L\n 26.0 %\n 5.5 K/uL\n [image002.jpg]\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n Plt\n 86\n 85\n 83\n 80\n 85\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night).\n -will dc CIWA for now to re-assess pt\ns MS\n decrease morphine dosing to re-assess pt\ns MS\n start zyprexa for aggitation\n # Hypernatremia: pt\ns Na down to 147 from 153 w/ free water repletion.\n Calculated free water deficit was 4L (Na 153).\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn dc\nd, pt re-started on unasyn for the rest of his course\n (total 8 days)\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.9. Currently w/ good UOP ~70-80cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586585,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 AM\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 57 (57 - 71) bpm\n BP: 114/58(70) {114/58(70) - 166/96(108)} mmHg\n RR: 18 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,163 mL\n 1,329 mL\n PO:\n TF:\n 1,101 mL\n 560 mL\n IVF:\n 2,112 mL\n 270 mL\n Blood products:\n Total out:\n 1,965 mL\n 750 mL\n Urine:\n 1,965 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,198 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 56 K/uL\n 9.6 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.3 K/uL\n [image002.jpg]\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n Plt\n 86\n 85\n 83\n 80\n 85\n 56\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:43 AM 80 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 05:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586592,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na 145 yesterday evening, continued 250cc free h20 flushes through\n NGT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 AM\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 57 (57 - 71) bpm\n BP: 114/58(70) {114/58(70) - 166/96(108)} mmHg\n RR: 18 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,163 mL\n 1,329 mL\n PO:\n TF:\n 1,101 mL\n 560 mL\n IVF:\n 2,112 mL\n 270 mL\n Blood products:\n Total out:\n 1,965 mL\n 750 mL\n Urine:\n 1,965 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,198 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 56 K/uL\n 9.6 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.3 K/uL\n [image002.jpg]\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n Plt\n 86\n 85\n 83\n 80\n 85\n 56\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night).\n -will dc CIWA for now to re-assess pt\ns MS\n decrease morphine dosing to re-assess pt\ns MS\n start zyprexa for aggitation\n # Hypernatremia: pt\ns Na down to 147 from 153 w/ free water repletion.\n Calculated free water deficit was 4L (Na 153).\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn dc\nd, pt re-started on unasyn for the rest of his course\n (total 8 days)\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.9. Currently w/ good UOP ~70-80cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586285,
"text": "Chief Complaint:\n 24 Hour Events:\n --changed CIWA to q3hr\n --Na=151-->153. Added 100 cc/hr of D5W IV to free water flushes. Also\n collected urine osmol, urine sodium\n --Did not use CPAP last night since saturating well on shovel mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Vancomycin - 08:40 PM\n Piperacillin - 05:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:00 AM\n Enoxaparin (Lovenox) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.5\nC (99.5\n HR: 59 (59 - 93) bpm\n BP: 119/58(73) {119/58(73) - 210/109(168)} mmHg\n RR: 21 (18 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 2,943 mL\n 1,727 mL\n PO:\n TF:\n 631 mL\n 363 mL\n IVF:\n 1,513 mL\n 844 mL\n Blood products:\n Total out:\n 2,775 mL\n 300 mL\n Urine:\n 2,775 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 168 mL\n 1,427 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\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 80 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 117 mEq/L\n 154 mEq/L\n 27.2 %\n 5.1 K/uL\n [image002.jpg]\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n Plt\n 86\n 85\n 83\n 80\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n TCO2\n 27\n 29\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586286,
"text": "Chief Complaint:\n 24 Hour Events:\n --changed CIWA to q3hr\n --Na=151-->153. Added 100 cc/hr of D5W IV to free water flushes. Also\n collected urine osmol, urine sodium\n --Did not use CPAP last night since saturating well on shovel mask.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Vancomycin - 08:40 PM\n Piperacillin - 05:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Metoprolol - 08:00 AM\n Enoxaparin (Lovenox) - 08:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.5\nC (99.5\n HR: 59 (59 - 93) bpm\n BP: 119/58(73) {119/58(73) - 210/109(168)} mmHg\n RR: 21 (18 - 30) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 117.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 2,943 mL\n 1,727 mL\n PO:\n TF:\n 631 mL\n 363 mL\n IVF:\n 1,513 mL\n 844 mL\n Blood products:\n Total out:\n 2,775 mL\n 300 mL\n Urine:\n 2,775 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 168 mL\n 1,427 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 96%\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 80 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.9 mEq/L\n 34 mg/dL\n 117 mEq/L\n 154 mEq/L\n 27.2 %\n 5.1 K/uL\n [image002.jpg]\n 2:32 am SPUTUM Source: Endotracheal.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Final ):\n SPARSE GROWTH OROPHARYNGEAL FLORA.\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.\n HEAVY GROWTH BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.\n STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.\n Note: For treatment of meningitis, penicillin G MIC breakpoints\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n |\nCEFTRIAXONE----------- 0.12 S\nERYTHROMYCIN---------- =>1 R\nLEVOFLOXACIN---------- 1 S\nPENICILLIN G---------- 0.25 S\nTETRACYCLINE---------- =>16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n Plt\n 86\n 85\n 83\n 80\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n TCO2\n 27\n 29\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - CIWA scale changed to q3h\n - cont clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont. 50 tid po lopressor\n -CIWA scale (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr. Achieved I/O goal yesterday of\n -1L.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt\ns Na is 153 today increased from 151.\n - 200cc q4h free water through tube feeds\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586481,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Known alcoholic pts post op period was complicated with alcolhol\n withdrawal requring valium,pt received 15 mg of valium and 4mg morphine\n for agitation, pulled out IV line/NG tube overnightwas on ciwa\n q4h,ciwa this am 11,pt alert and oreinted x2,drowsy,but obeys commands\n Action:\n Ciwa has been discontd,contd b/l soft wrist restraints,\n Response:\n Pt was lethargic most ly ut easliy arousable,family was here at\n bedside all most all the time,does try to pull the leg OOB at times and\n easily dedirectable,\n Plan:\n Will hold off valium for now,if pt gets agiatated will give haldol vs\n zydis,cont restraints\n Hypernatremia (high sodium)\n Assessment:\n NA with am labs 147 down from 153,receiving d5@200cc/hr\n Action:\n Discontd d5,restarted FT with free water bolus @250cc/hr\n Response:\n pending\n Plan:\n Will follow the Na level ,adjust free water bolus,If Na creeping up\n will add D5\n Range of Motion, Impaired\n Assessment:\n s/p IM nail removal hemiarthoplasy on ,currently abd pillow\n Action:\n Contd posterior hip precautions,pain mgt with morphine,tunrned and\n repositioned q2h, PT\n Response:\n MAE+,rt hip dsg intact\n Plan:\n Will cont the hip precautions,monitor and change the dsg as\n needed,ortho/PT is following the pt\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on 40% face tent,sats mid 90\ns,ronchorous berath\n sounds,poor cough unable to expectorate secretions,BAL with H\n influenzae\n Action:\n Yaunker suction as need,contd IV vanco/zosyn,o2 weaned to 35%\n Response:\n Aferbile,stable o2 requirement,\n Plan:\n Follow sats,chest PT, abx,suction,\n"
},
{
"category": "General",
"chartdate": "2182-08-27 00:00:00.000",
"description": "MICU staff PN",
"row_id": 586498,
"text": "TITLE: MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 48 yo m w/ HTN, OSA, etoh abuse, s/p total\n hip revision with hardware removal course c/b post-op resp failure, asp\n pna, and L lung collapse, arf,, a-fib / flutter, and etoh withdrawal,\n extubated . Remains agitated intermittently.\n Exam notable for AF BP 130/64 HR 60-80 (NS) RR 20's 98% (40 %\n shovel).\n Less agitated, follows simple commands, coarse bs, RR, soft, NT + BS,\n trace dep edema, RLE wound dressing c/d/i\n Labs notable for WBC 5.5K, HCT 26, plts 85, na 154--> 147, K+ 3.6 ,\n Cr 0.9,\n Micro--sputum h flu resis to unasyn, bl cxs pending\n CXR--small lung volumes, full hilar vessels\n Primary issues remain:\n Agitation, delirium, hypernatremia, resolving pna, recent fever spike,\n resolving ARF, post-op hip revision\n Agree with plan to resume unasyn to complete 8 day course (day 7). Is\n liekly colonized with H flu. Has Af since recent spike 2 days ago\n with no new cx growth.. ICU delerium remains his primary issue, with\n multifactorial etiology including pain, electrolyte abnl\n (hypernatremia), post-op, meds/valium/narcotics and sundowning. His\n etoh withdrawal has been treated. Will minimize use of benzos.\n Zyprexa for agitation. Optimize electrolytes--his hypernatremia is\n improving with repletion of free water deficit following serial na.\n Treating infections. Follow abg to r/o co2 retention/nocturnal PAP.\n Optimize sleep wake schedule. Reorient. Anemia persists with no\n obvious bleeding source. Heme check stool. Post-op a-fib has\n resolved, remains in NSR. Continue lopressor. His ARF has resolved.\n Additional post-op recs per ortho.\n Remainder of plan as outlined in resident note.\n ICU: PIVs, TFs, lovenox, PPI, PT following, Full code.\n Patient is critically ill\n Total time: 40 min\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586507,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Known alcoholic pts post op period was complicated with alcolhol\n withdrawal requring valium,pt received 15 mg of valium and 4mg morphine\n for agitation, pulled out IV line/NG tube overnightwas on ciwa\n q4h,ciwa this am 11,pt alert and oreinted x2,drowsy,but obeys commands\n Action:\n Ciwa has been discontd,contd b/l soft wrist restraints,\n Response:\n Pt was lethargic most ly ut easliy arousable,family was here at\n bedside all most all the time,does try to pull the leg OOB at times and\n easily dedirectable,\n Plan:\n Will hold off valium for now,if pt gets agiatated will give haldol vs\n zydis,cont restraints\n Hypernatremia (high sodium)\n Assessment:\n NA with am labs 147 down from 153,receiving d5@200cc/hr,K 3.7\n Action:\n Discontd d5,restarted FT with free water bolus @250cc/hr,received kcl\n 40meq via NGt\n Response:\n Na with 5pm lab pending\n Plan:\n Will follow the Na level ,adjust free water bolus,If Na creeping up\n may need d5\n Range of Motion, Impaired\n Assessment:\n s/p IM nail removal hemiarthoplasy on ,currently abd pillow\n Action:\n Contd posterior hip precautions,pain mgt with morphine,tunrned and\n repositioned q2h, PT\n Response:\n MAE+,rt hip with SS drainage dsg changed\n Plan:\n Will cont the hip precautions,monitor and change the dsg as\n needed,ortho/PT is following the pt\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on 40% face tent,sats mid 90\ns,ronchorous berath\n sounds,poor cough unable to expectorate secretions,BAL with H\n influenzae\n Action:\n Yaunker suction as need,abx changed to unasyn,o2 weaned to 35%\n Response:\n Aferbile,decresed o2 requirement\n Plan:\n Follow sats,chest PT, abx,suction,\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586620,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na 145 yesterday evening, continued 250cc free h20 flushes through\n NGT\n --not agitated overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 AM\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 57 (57 - 71) bpm\n BP: 114/58(70) {114/58(70) - 166/96(108)} mmHg\n RR: 18 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,163 mL\n 1,329 mL\n PO:\n TF:\n 1,101 mL\n 560 mL\n IVF:\n 2,112 mL\n 270 mL\n Blood products:\n Total out:\n 1,965 mL\n 750 mL\n Urine:\n 1,965 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,198 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 56 K/uL\n 9.6 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.3 K/uL\n [image002.jpg]\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n Plt\n 86\n 85\n 83\n 80\n 85\n 56\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypernatremia: pt\ns Na is 148 today up from 145 last night.\n - cont 250cc q4h free water through tube feeds\n -will re-check Na this pm\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated yesterday,\n w/o medications.\n -cont morphine prn\n - consider zyprexa if agitated overnight\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 56 from 85 yesterday. Considering HIT (low\n suspicion as pt on lovenox) vs drug reaction.\n -will check pm CBC\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn dc\nd, pt re-started on unasyn for the rest of his course\n (total 8 days). Today is last day of abx will dc after last dose.\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~90-100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586831,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Sodium level =142 this am\n Action:\n Pt given 250cc\ns free water boluses via ngt as ordered and electrolytes\n checked as ordered\n Response:\n Sodium level on the decline\n Plan:\n Continue to check lytes as ordered and adjust free water boluses as\n needed\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt experienced etoh withdrawal post op requiring large amts of iv\n valium. Pt\ns girlfriend very supportive to pt but questioning all\n sedatives given to pt. states that pt is not to receive any haldol\n because\n it drops hr\n. pt is avbel to state his name, name of the\n hospital and street name but then becomes extremely agitated stating he\ns getting out of here and going home. Pt has self d/c\nd the condom\n cath and once foley cath was reinserted he also disconnected the\n foley. Pt becomes verbally abusive using foul language and then falls\n off to sleep\n Action:\n Safe environment maintained. Bed alarm activated and bed locked and in\n low position. All rails up to prevent pt from climbing oob. Pt offered\n emotional support and told frequently the plan of care and that pt is\n not safe or ready to go home.\n Response:\n Episodes of agitation continue but pt has not received any valium since\n Monday. Pt\ns girlfriend at times able to quiet pt down.\n Plan:\n Continue to reorient pt to plan of care and treatment plan. Maintain\n safe pt environment and avoid medicating with haldol. Allow to\n remain at bedside when possible to help quiet pt and support him\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586826,
"text": "Chief Complaint:\n 24 Hour Events:\n --Patient failed bedside swallow, but passed video swallow study\n --Patient not on oxygen. Able to sit on chair/walk in afternoon.\n --agitated, yet directable.\n --Patient's platelets stable at 96, Na=143.\n --hypertensive at night, so given metoprolol 5mg IV\n --patient more awake and alert this am, able to answer questions and\n follow commands.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 06:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 AM\n Metoprolol - 01:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 62 (60 - 80) bpm\n BP: 151/82(95) {99/62(77) - 180/90(137)} mmHg\n RR: 25 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,083 mL\n 546 mL\n PO:\n TF:\n 1,933 mL\n 477 mL\n IVF:\n 640 mL\n 69 mL\n Blood products:\n Total out:\n 1,870 mL\n 500 mL\n Urine:\n 1,870 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,213 mL\n 46 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General: arousable, in no acute distress, AOx2\n HEENT: Sclera anicteric, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: not assessed\n Labs / Radiology\n 96 K/uL\n 9.2 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 109 mEq/L\n 142 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n 03:41 PM\n 04:24 AM\n WBC\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n 6.9\n 6.5\n Hct\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n 27.9\n 28.1\n Plt\n 85\n 83\n 80\n 85\n 56\n 99\n 96\n Cr\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n 0.9\n 0.8\n Glucose\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n 115\n 143\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring. Subsequently developed PNA w left lower lobe\n colapse and EtOH withdrawal.\n #Hypertension: pt was hypertensive last night up to 180/81. Given 5mg\n metoprolol IV w/ good response. Now 151/82.\n -cont to moniotor BP closely\n # Hypernatremia: pt\ns Na is 142 today up from 143 yesterday.\n -will decrease free water through tube feeds to 100cc/hr\n -will re-check Na in the am\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated overnight but\n was agitated and threatening in the am. Received no meds.\n -cont morphine prn\n -consider zyprexa if still agitated and threatening.\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 96 from yesterday in the pm and 56 yesterday\n in the am. Considering HIT (low suspicion as pt on lovenox) vs drug\n reaction. Most likely lab error.\n -f/u CBCs\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia. Pt finished his course of antibiotics yesterday (8 days of\n Unasyn). Currently off O2 on RA sats ~95%.\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Will advance to purees today.\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: none\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to reg floor\n"
},
{
"category": "General",
"chartdate": "2182-08-27 00:00:00.000",
"description": "MICU staff PN",
"row_id": 586467,
"text": "TITLE: MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 48 yo m w/ HTN, OSA, etoh abuse, s/p total\n hip revision with hardware removal course c/b post-op resp failure, asp\n pna, and L lung collapse, arf,, a-fib / flutter, and etoh withdrawal,\n extubated . Remains agitated intermittently.\n Exam notable for AF BP 130/64 HR 60-80 (NS) RR 20's 98% (40 %\n shovel).\n Less agitated, follows simple commands, coarse bs, RR, soft, NT + BS,\n trace dep edema, RLE wound dressing c/d/i\n Labs notable for WBC 5.5K, HCT 26, plts 85, na 154--> 147, K+ 3.6 ,\n Cr 0.9,\n Micro--sputum h flu resis to unasyn, bl cxs pending\n CXR--small lung volumes, full hilar vessels\n Primary issues remain:\n Agitation, delirium, hypernatremia, resolving pna, recent fever spike,\n resolving ARF, post-op hip revision\n Agree with plan to continue broad antibx coverage with vanco/zosyn day\n given beta lactam producing H flu in sputum/bal. F/u cx\n sensitivities and taper accordingly. ICU delerium remains his primary\n issue, with multifactorial etiology including pain, electrolyte abnl\n (hypernatremia), post-op, meds/valium/narcotics and sundowning. His\n etoh withdrawal has been treated. Will minimize use of benzos.\n Zyprexa for agitation. Optimize electrolytes--his hypernatremia is\n improving with repletion of free water deficit following serial na.\n Treating infections. Follow abg to r/o co2 retention/nocturnal PAP.\n Optimize sleep wake schedule. Reorient. Anemia persists with no\n obvious bleeding source. Heme check stool. Post-op a-fib has\n resolved, remains in NSR. Continue lopressor. His ARF has resolved.\n Additional post-op recs per ortho.\n Remainder of plan as outlined in resident note.\n ICU: PIVs, TFs, lovenox, PPI, PT following, Full code.\n Patient is critically ill\n Total time: 40 min\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586666,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n NA with am labs 148 on q4h water flushes,tube feed replete with fiber\n running at goal.\n Action:\n Contd free water 250cc q4h,followed Na level \n Response:\n Na with 5pm lab 143\n Plan:\n Will follow the Na level ,adjust free water bolus as needed,\n Range of Motion, Impaired\n Assessment:\n s/p IM nail removal hemiarthoplasy on ,currently with abd\n pilllow,post op period complicated with delirium,\n Action:\n Contd posterior hip precautions,pain mgt with morphine,tunrned and\n repositioned as needed,Was OOB to the chair,abd pillow while in the\n bed,foly was removed\n Response:\n MAE+,rt hip with SS dsg intact on the rt leg,pt was able to take OOB\n with 2person assist,with leg brace on,tolertaed with out pain,pt voided\n in the urinal\n Plan:\n Will cont the hip precautions,monitor and change the dsg as\n needed,ortho/PT is following the pt,pain mgt with morphine,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on 35% face tent,sats mid 90\ns,ronchorous berath\n sounds,poor cough unable to expectorate secretions,BAL with H\n influenzae\n Action:\n Yaunker suction as need,abx changed to unasyn,o2 weaned to RA,chest PT\n as tolerated,OOB daily.pt had bed side speech elaluation\n Response:\n Pt contd have the congested cough,unable to expectorate the\n sputum,satting mid 90\ns on RA,finished the abx today.\n Plan:\n Follow sats,chest PT, abx,suction,daily OOB,vedio swallow evaluation in\n am,\n Altered mental status (Delirium)\n Assessment:\n Pt alert and oriented x1-2,follws commands:sub\n I wants to go home\n was agiatated this pm trying to pulling out the wires\n Action:\n Contd soft restraints,redirected the pt frequently,\n Response:\n Pt need firm limit seting at times,pt was not ready to get back to\n bed,currently sleeping,family at bedside ,inform the family member\n about providing calm and quiet environment\n Plan:\n Will con the restraints,plan t give zyprexis if worsended agitation\n Social:family was here most during the whole day\nGirlfriend wants to\n take him upstairs(floor) ,she wants to to have take out the feeding\n tube and started giving po\ns,also to remove the catheter,she does nt\n want to give him anything for the agiatation,but restraints is ok,as\n per her clonopin is ok,girlfriend seems realistic and understanding\n during the conversation but changes the mind repeat and the same\n question and concerns.Ortho attending/micu attending was able to talk\n to the pt/family,social worker is following the pt,All these concerns\n are discussed with Nurse manager( )\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586787,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586789,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586790,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586792,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Sodium level =142 this am\n Action:\n Pt given 250cc\ns free water boluses via ngt as ordered and electrolytes\n checked as ordered\n Response:\n Sodium level on the decline\n Plan:\n Continue to check lytes as ordered and adjust free water boluses as\n needed\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt experienced etoh withdrawal post op requiring large amts of iv\n valium. Pt\ns girlfriend very supportive to pt but questioning all\n sedatives given to pt. states that pt is not to receive any haldol\n because\n it drops hr\n. pt is avbel to state his name, name of the\n hospital and street name but then becomes extremely agitated stating he\ns getting out of here and going home. Pt has self d/c\nd the condom\n cath and once foley cath was reinserted he also disconnected the\n foley. Pt becomes verbally abusive using foul language and then falls\n off to sleep\n Action:\n Safe environment maintained. Bed alarm activated and bed locked and in\n low position. All rails up to prevent pt from climbing oob. Pt offered\n emotional support and told frequently the plan of care and that pt is\n not safe or ready to go home.\n Response:\n Episodes of agitation continue but pt has not received any valium since\n Monday. Pt\ns girlfriend at times able to quiet pt down.\n Plan:\n Continue to reorient pt to plan of care and treatment plan. Maintain\n safe pt environment and avoid medicating with haldol. Allow to\n remain at bedside when possible to help quiet pt and support him\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586791,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Sodium level =142 this am\n Action:\n Pt given 250cc\ns free water boluses via ngt as ordered and electrolytes\n checked as ordered\n Response:\n Sodium level on the decline\n Plan:\n Continue to check lytes as ordered and adjust free water boluses as\n needed\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt experienced etoh withdrawal post op requiring large amts of iv\n valium. Pt\ns girlfriend very supportive to pt but questioning all\n sedatives given to pt. states that pt is not to receive any haldol\n because\n it drops hr\n. pt is avbel to state his name, name of the\n hospital and street name but then becomes extremely agitated stating he\ns getting out of here and going home. Pt has self d/c\nd the condom\n cath and once foley cath was reinserted he also disconnected the\n foley. Pt becomes verbally abusive using foul language and then falls\n off to sleep\n Action:\n Safe environment maintained. Bed alarm activated and bed locked and in\n low position. All rails up to prevent pt from climbing oob. Pt offered\n emotional support and told frequently the plan of care and that pt is\n not safe or ready to go home.\n Response:\n Episodes of agitation continue but pt has not received any valium since\n Monday. Pt\ns girlfriend at times able to quiet pt down.\n Plan:\n Continue to reorient pt to plan of care and treatment plan. Maintain\n safe pt environment and avoid\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Social Work",
"chartdate": "2182-08-30 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 586937,
"text": "Family Information\n Next of : , \n Health Care Proxy appointed: - Info Provided\n Family Spokesperson designated: Girlfriend (; Cell :\n )\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Required assistance with care\n Previous or other hospital admissions: Mr. has had two\n admissions at , the first .\n Past psychiatric history: Unknown.\n Past addictions history: A note from 10. reports two six\n packs/weekend; it is suspected that he drinks more but there is no\n report or documentation to support his EtOH use.\n Employment status: Disable\n Legal involvement: Unknown\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Dr. admitted this 48 y/ to the\n following the removal of R femur intramedullary gamma nail and R\n hip hemiarthroplasty for R hip osteonecrosis stage III. This worker\n spoke briefly twice with pt's girlfriend, Ms. , to offer\n support and then a third time today in greater length in response to\n RN/MD concerns about her level of agitation re Mr. TX, increasing\n demands to make TX decisions (there is apparently no documentation of\n her status as his HCP), and her criticism of his medical care in the\n . When this SW was present, two doctors tried multiple to\n explain his medical status and respond to her concerns, but Ms. \n repeatedly interrupted telling them what she wanted and expected re\n medication, going to a medical floor, and PT. After meeting with the\n MDs, she told this worker that she\nhated doctors,\n illustratively\n reporting that her mo who died at 95, never saw a doctor and that her\n father, who at age 60 felt he should have a medical exam. He then came\n home with\nsix medications,\n with her winning the bet of a $100 that he\n would have at least three. Recently, Ms. saw a doctor for a cut\n on her hand, but previously had not seen a doctor in 20 years, which\n she attributes to her being a vegetarian, who also eats fish, and takes\n cod liver oil daily. In addition, she contacts a cousin who is a\n surgeon and other people whom she alleges are medically knowledgeable\n and they criticize, not having evaluated him, his medical care. Ms.\n is insisting on soon taking him home for rehab.\n Assessment: It is not clear if Ms. \ns level of agitation is\n affecting her cognition or if there are other explanations for her\n compromised judgment. She repeatedly asks the same questions already\n answered by healthcare team members, with this worker sensing that she\n is not able to integrate any of the responses. She has said that she\n would stay here\n24/7\n and hold his hands so that he would be less\n agitated and therefore would not pull out his lines, not being able to\n understand that his agitation/delirium is endogenous, not because he is\n lying in bed in restraints. It also appears to this SW that she\n frequently projects, at one point referring to Klonopin being a\n medication that is effective but unknowingly instead of referring to\n relaxing him she referred to herself.\n Communication with Team:\n Primary Nurse: \n Attending: \n Plan / Follow up:\n 1. This worker will continue to follow pt and his girlfriend when\n transferred to 12R to assess psychosocial functioning and offer\n support.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586746,
"text": "Chief Complaint:\n 24 Hour Events:\n --Patient failed bedside swallow. will go for video swallow today\n --Patient not on oxygen. Able to sit on chair/walk in afternoon.\n --agitated, yet directable.\n --Patient's platelets stable, Na=143.\n --hypertensive at night, so given metoprolol 5mg IV, MR1\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 06:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 AM\n Metoprolol - 01:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 62 (60 - 80) bpm\n BP: 151/82(95) {99/62(77) - 180/90(137)} mmHg\n RR: 25 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,083 mL\n 546 mL\n PO:\n TF:\n 1,933 mL\n 477 mL\n IVF:\n 640 mL\n 69 mL\n Blood products:\n Total out:\n 1,870 mL\n 500 mL\n Urine:\n 1,870 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,213 mL\n 46 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\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 96 K/uL\n 9.2 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 109 mEq/L\n 142 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n 03:41 PM\n 04:24 AM\n WBC\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n 6.9\n 6.5\n Hct\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n 27.9\n 28.1\n Plt\n 85\n 83\n 80\n 85\n 56\n 99\n 96\n Cr\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n 0.9\n 0.8\n Glucose\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n 115\n 143\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:10 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586748,
"text": "Chief Complaint:\n 24 Hour Events:\n --Patient failed bedside swallow. will go for video swallow today\n --Patient not on oxygen. Able to sit on chair/walk in afternoon.\n --agitated, yet directable.\n --Patient's platelets stable, Na=143.\n --hypertensive at night, so given metoprolol 5mg IV, MR1\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 06:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 AM\n Metoprolol - 01:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 62 (60 - 80) bpm\n BP: 151/82(95) {99/62(77) - 180/90(137)} mmHg\n RR: 25 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,083 mL\n 546 mL\n PO:\n TF:\n 1,933 mL\n 477 mL\n IVF:\n 640 mL\n 69 mL\n Blood products:\n Total out:\n 1,870 mL\n 500 mL\n Urine:\n 1,870 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,213 mL\n 46 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\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 96 K/uL\n 9.2 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 109 mEq/L\n 142 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n 03:41 PM\n 04:24 AM\n WBC\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n 6.9\n 6.5\n Hct\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n 27.9\n 28.1\n Plt\n 85\n 83\n 80\n 85\n 56\n 99\n 96\n Cr\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n 0.9\n 0.8\n Glucose\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n 115\n 143\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring. Subsequently developed PNA w left lower lobe\n colapse and withdrawal.\n #Hypertension: pt was hypertensive last night up to 180/81. Given 5mg\n metoprolol IV w/ good response. Now 151/82.\n -start ace vs increase bb\n -cont to moniotor BP closely\n # Hypernatremia: pt\ns Na is 142 today up from 143 yesterday.\n -dc 250cc q4h free water through tube feeds\n -will re-check Na this pm\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated yesterday,\n w/o medications.\n -cont morphine prn\n -consider zyprexa if agitated overnight\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 96 from yesterday in the pm and 56 yesterday\n in the am. Considering HIT (low suspicion as pt on lovenox) vs drug\n reaction.\n -will check pm CBC\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia. Pt finished his course of antibiotics yesterday (8 days of\n Unasyn).\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~90-100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: none\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586785,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586847,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n Sodium level =142 this am\n Action:\n Pt given 250cc\ns free water boluses via ngt as ordered and electrolytes\n checked as ordered\n Response:\n Sodium level on the decline\n Plan:\n Continue to check lytes as ordered and adjust free water boluses as\n needed\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt experienced etoh withdrawal post op requiring large amts of iv\n valium. Pt\ns girlfriend very supportive to pt but questioning all\n sedatives given to pt. states that pt is not to receive any haldol\n because\n it drops hr\n. pt is avbel to state his name, name of the\n hospital and street name but then becomes extremely agitated stating he\ns getting out of here and going home. Pt has self d/c\nd the condom\n cath and once foley cath was reinserted he also disconnected the\n foley. Pt becomes verbally abusive using foul language and then falls\n off to sleep\n Action:\n Safe environment maintained. Bed alarm activated and bed locked and in\n low position. All rails up to prevent pt from climbing oob. Pt offered\n emotional support and told frequently the plan of care and that pt is\n not safe or ready to go home.\n Response:\n Episodes of agitation continue but pt has not received any valium since\n Monday. Pt\ns girlfriend at times able to quiet pt down.\n Plan:\n Continue to reorient pt to plan of care and treatment plan. Maintain\n safe pt environment and avoid medicating with haldol. Allow to\n remain at bedside when possible to help quiet pt and support him\n Alteration in Nutrition\n Assessment:\n Pt s/p extubation on with altered ms and s/p 3 failed\n extubations. Immedicately following extubation pt with impaired gag\n reflex. Failed 1^st speech and swallow study and was scheduled to have\n video speech and swallow study today but because of pt\ns body habitus\n study could not be done. Bedside eval done at bedside. After 1 st\n failed study pt had ngt placed via left nare and tube fdgs were\n started. Na today=142. pt passed 2 lg brown softs tools that were heme\n neg.\n Action:\n Bedside speech and swallow study done. Tube fdgs of replete with fiber\n continue at pt\ns goal rate of 80cc\ns/hr. electrolytes followed as\n ordered. pt was receiving 250cc\ns free water boluses via ngt q\n 4 hrs but that was dropped down to 100cc\ns q 4hrs b/cause na level is\n on the decline\n Response:\n Tolerated bedside speech and swallow study without any evidence of\n aspiration.\n Plan:\n Po diet: nectar thick liqs and moist puree consistencies. 1:1\n supervision. Alternate bites with sips. Continue tube fdgs as primary\n means of nutrition,hydration and meds. Please wait to remove tube fdgs\n until pt is seen again by speech and swallow consult team. Maintain\n aspiratipn precautions.\n Refer to social workers progress note from regarding conversations\n with pt\ns \n Demographics\n Attending MD:\n \n Admit diagnosis:\n RIGHT HIP OA/SDA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 118 kg\n Daily weight:\n 126 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: ETOH, Smoker\n CV-PMH: Hypertension\n Additional history: Pt. is s/p FALL from roof in >>> severe right\n femur fracture. Pt. developed avascular and osteo necrosis of femur\n head, and chronic pain of right hip/groin, revised today.\n Surgery / Procedure and date: ' IM nailing s/p femur fracture\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:181\n D:78\n Temperature:\n 98.6\n Arterial BP:\n S:145\n D:72\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 84 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 10 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 2,639 mL\n 24h total out:\n 1,700 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 04:24 AM\n Potassium:\n 3.5 mEq/L\n 04:24 AM\n Chloride:\n 109 mEq/L\n 04:24 AM\n CO2:\n 28 mEq/L\n 04:24 AM\n BUN:\n 21 mg/dL\n 04:24 AM\n Creatinine:\n 0.8 mg/dL\n 04:24 AM\n Glucose:\n 143 mg/dL\n 04:24 AM\n Hematocrit:\n 28.1 %\n 04:24 AM\n Valuables / Signature\n Patient valuables: transferred with pt\n valuables: cell phone\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: 402\n Transferred to: 1164\n Date & time of Transfer: 1815\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586742,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n NA with am labs 148 on q4h water flushes,tube feed replete with fiber\n running at goal.\n Action:\n Contd free water 250cc q4h,followed Na level \n Response:\n Na with 5pm lab 143\n Plan:\n Will follow the Na level ,adjust free water bolus as needed,\n Range of Motion, Impaired\n Assessment:\n s/p IM nail removal hemiarthoplasy on ,currently with abd\n pilllow,post op period complicated with delirium,\n Action:\n Contd posterior hip precautions,pain mgt with morphine,tunrned and\n repositioned as needed,Was OOB to the chair,abd pillow while in the\n bed,foly was removed\n Response:\n MAE+,rt hip with SS dsg intact on the rt leg,pt was able to take OOB\n with 2person assist,with leg brace on,tolertaed with out pain,pt voided\n in the urinal\n Plan:\n Will cont the hip precautions,monitor and change the dsg as\n needed,ortho/PT is following the pt,pain mgt with morphine,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on 35% face tent,sats mid 90\ns,ronchorous berath\n sounds,poor cough unable to expectorate secretions,BAL with H\n influenzae\n Action:\n Yaunker suction as need,abx changed to unasyn,o2 weaned to RA,chest PT\n as tolerated,OOB daily.pt had bed side speech elaluation\n Response:\n Pt contd have the congested cough,unable to expectorate the\n sputum,satting mid 90\ns on RA,finished the abx today.\n Plan:\n Follow sats,chest PT, abx,suction,daily OOB,vedio swallow evaluation in\n am,\n Altered mental status (Delirium)\n Assessment:\n Pt alert and oriented x1-2,follws commands:sub\n I wants to go home\n was agiatated this pm trying to pulling out the wires\n Action:\n Contd soft restraints,redirected the pt frequently,\n Response:\n Pt need firm limit seting at times,pt was not ready to get back to\n bed,currently sleeping,family at bedside ,inform the family member\n about providing calm and quiet environment\n Plan:\n Will con the restraints,plan t give zyprexis if worsended agitation\n Social:family was here most during the whole day\nGirlfriend wants to\n take him upstairs(floor) ,she wants to to have take out the feeding\n tube and started giving po\ns,also to remove the catheter,she does nt\n want to give him anything for the agiatation,but restraints is ok,as\n per her clonopin is ok,girlfriend seems realistic and understanding\n during the conversation but changes the mind repeat and the same\n question and concerns.Ortho attending/micu attending was able to talk\n to the pt/family,social worker is following the pt,All these concerns\n are discussed with Nurse manager( )\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586178,
"text": "Obstructive sleep apnea (OSA)\n Assessment:\n Received pt with 40% face tent, sats maintained mid 90\ns. pt with OSA.\n LS diminished on base. Congested.\n Action:\n CPAP overnight , nasopharyngeal suction done by RRT ,obtained moderate\n amount blood stained thick secertions. Nebs as ordered.\n Response:\n LS more clear ,less congested after suction. Sats > 94% .back to face\n tent by 4am.\n Plan:\n Wean O2 as tolerated,CPAP during the night. Suction PRN.\n Hypertension.\n Assessment:\n Pt with BP 160-200 /70-98 mm of hg since yesterday. HR 70-100\ns,SR\nST,no PVC\ns noted.\n Action:\n Pt on lopressor 10mg q4h. team aware about persistent hypertension,\n per team hypertension may be due to agitation or it could be pain.\n Valium and morphine given as needed, lopressor due dose given\n Response:\n Pt remained on SBP > 180mm of hg most of the time,early am SBP down to\n 160\ns ,HR 70-80\ns with lopressor. Pt verbalize as no pain. Pt\n restless sometimes .slept well.\n Plan:\n Monitor BP further,may need to add additional doses of someother\n antihypertensive,team to discuss with am rounds.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586464,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na=154\n147, Uosm=638, UNa=24. On D5W 200cc/hr, free water flushes\n increased to 250cc. Calculated free water deficit 4L.\n --received 15 mg Valium overnight, 4 mg morphine for aggitation and\n pulling at tubes and lines.\n BLOOD CULTURED - At 11:30 AM\n peripheral stick\n URINE CULTURE - At 11:46 AM\n BLOOD CULTURED - At 02:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Piperacillin - 05:00 AM\n Vancomycin - 08:27 PM\n Piperacillin/Tazobactam (Zosyn) - 03:49 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:45 AM\n Diazepam (Valium) - 03:15 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 06:09 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: 36.6\nC (97.8\n HR: 66 (59 - 82) bpm\n BP: 134/64(79) {119/58(73) - 170/105(100)} mmHg\n RR: 22 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 5,973 mL\n 1,267 mL\n PO:\n TF:\n 1,587 mL\n 240 mL\n IVF:\n 2,857 mL\n 777 mL\n Blood products:\n Total out:\n 1,670 mL\n 585 mL\n Urine:\n 1,670 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,303 mL\n 682 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\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 85 K/uL\n 8.4 g/dL\n 144 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 113 mEq/L\n 147 mEq/L\n 26.0 %\n 5.5 K/uL\n [image002.jpg]\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n Plt\n 86\n 85\n 83\n 80\n 85\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night).\n -will dc CIWA for now to re-assess pt\ns MS\n decrease morphine dosing to re-assess pt\ns MS\n consider antipsychotics for his aggitation\n # Hypernatremia: pt\ns Na down to 147 from 153 w/ free water repletion.\n Calculated free water deficit was 4L (Na 153).\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.9. Currently w/ good UOP ~70-80cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586553,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Continues to be confused, orientated x . Managed to disconnect his\n foley\n Action:\n Ciwa has been discontd,contd b/l soft wrist restraints, has received\n no Valium or morphine overnight\n Response:\n Restless, able to swing left leg over siderail\n Plan:\n Continue to reorientated pt, keep safe\n Hypernatremia (high sodium)\n Assessment:\n Action:\n Discontd d5,restarted FT with free water bolus @250cc/hr,received kcl\n 40meq via NGt\n Response:\n Na with 5pm lab 145.\n Plan:\n Will follow the Na level ,adjust free water bolus as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586554,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Continues to be confused, orientated x . Managed to disconnect his\n foley\n Action:\n Ciwa has been discontd,contd b/l soft wrist restraints, has received\n no Valium or morphine overnight\n Response:\n Restless, able to swing left leg over siderail\n Plan:\n Continue to reorientated pt, keep safe\n Hypernatremia (high sodium)\n Assessment:\n Last Na+ was 145\n Action:\n Continues with free h20 boluses q 4hours\n Response:\n Am Na+ pending\n Plan:\n Continues to follow Na+ levels, adjust free h2o boluses as needed\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586417,
"text": "Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt did not receive any valium for > 24hrs. initially he was quiet\n sleeping,but later on he become agitated ,climbing over the side\n rails,pulled out NGT and one peripheral iv. Continued with face tent\n O2.\n Action:\n Received 5 mg iv and additional 10mg iv valium for ciwa > 10 and\n 4mg morphine . CIWA Q4H and valium per ciwa q 4h. VSS. Sats maintained\n > 95%\n Response:\n After 15 valium he is calm and sleeping.\n Plan:\n Continue monitor with ciwa and valum as needed.\n Range of Motion, Impaired\n Assessment:\n Pt s/p hip surgery, dressing over the Rt hip .\n Action:\n Abduction pillow in between legs .dressing soaked with SSG drainage\n ,looks like from hemovac site ,staples clean and dry and intact. Change\n of dressing done.\n Response:\n Ongoing. need to try for weight bearing on Rt leg during the day\n time.\n Plan:\n Change of dressing as needed\n Hypernatremia (high sodium)\n Assessment:\n Pt with Na 153 from evening lab.\n Action:\n Pt was getting 250cc water q4h via NGT but he pulled out his NGT ,so\n he is not getting that now. IVF D5 100cc/hr x 2litres.\n Response:\n Am lab Na 147.\n Plan:\n Reinsert NGT and continue with free water and tube feed, f/u with am\n labs.\n sump NGT inserted via Lt nare,CXR done ,waiting for read the\n report to confirm the position,may restart tube feed later.20G PIV\n inserted on Rt wrist.\n Bath given and position changed.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586422,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na=154\n147, Uosm=638, UNa=24. On D5W 200cc/hr, free water flushes\n increased to 250cc. Calculated free water deficit 4L.\n --received 15 mg Valium overnight, 4 mg morphine for aggitation and\n pulling at tubes and lines.\n BLOOD CULTURED - At 11:30 AM\n peripheral stick\n URINE CULTURE - At 11:46 AM\n BLOOD CULTURED - At 02:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Piperacillin - 05:00 AM\n Vancomycin - 08:27 PM\n Piperacillin/Tazobactam (Zosyn) - 03:49 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:45 AM\n Diazepam (Valium) - 03:15 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 06:09 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: 36.6\nC (97.8\n HR: 66 (59 - 82) bpm\n BP: 134/64(79) {119/58(73) - 170/105(100)} mmHg\n RR: 22 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 5,973 mL\n 1,267 mL\n PO:\n TF:\n 1,587 mL\n 240 mL\n IVF:\n 2,857 mL\n 777 mL\n Blood products:\n Total out:\n 1,670 mL\n 585 mL\n Urine:\n 1,670 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,303 mL\n 682 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\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 85 K/uL\n 8.4 g/dL\n 144 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 113 mEq/L\n 147 mEq/L\n 26.0 %\n 5.5 K/uL\n [image002.jpg]\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n Plt\n 86\n 85\n 83\n 80\n 85\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn (started ) for presumed HAP\n - repeat CXR today\n - deep suction / chest PT\n - CIWA scale changed to q3h\n - cont clonidine 0.4 daily, prn haldol\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s\n yesterday. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s, subsequently converted into atrial flutter w/ 2:1 block.\n Metoprolol 5 mg IV Q4H was started. Pt was still tachy to the 140s and\n Diltiazem 10 mg IV x1 was given w/ good response. Yesterday pt BPs in\n low 200s, with HRs in 110s, given CIWA and increased lopressor to 10\n q4.\n -cont. 50 tid po lopressor\n -CIWA scale (per above)\n -clonidine (per above)\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 1.0. Currently w/ good UOP ~70-80cc/hr.\n - cont to monitor UOP, Cr\n .\n # Hypernatremia: pt\ns Na is 153 today increased from 151.\n - 250cc q4h free water through tube feeds\n -will re-check Na this pm\n .\n # s/p hip surgery:\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 586646,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Comments: Alb nebs treated x2 as ordered and pt refused last schedule\n treatment at 4pm. BS clear to slightly rhonchourous with no minimal\n changes noted s/p txs. Pt wearing 35% cool aerosol with spo2 upper 90s.\n Will cont to follow as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586415,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:30 AM\n peripheral stick\n URINE CULTURE - At 11:46 AM\n BLOOD CULTURED - At 02:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 05:56 PM\n Bactrim (SMX/TMP) - 06:10 AM\n Piperacillin - 05:00 AM\n Vancomycin - 08:27 PM\n Piperacillin/Tazobactam (Zosyn) - 03:49 AM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 02:45 AM\n Diazepam (Valium) - 03:15 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 06:09 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: 36.6\nC (97.8\n HR: 66 (59 - 82) bpm\n BP: 134/64(79) {119/58(73) - 170/105(100)} mmHg\n RR: 22 (18 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 123.6 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 5,973 mL\n 1,267 mL\n PO:\n TF:\n 1,587 mL\n 240 mL\n IVF:\n 2,857 mL\n 777 mL\n Blood products:\n Total out:\n 1,670 mL\n 585 mL\n Urine:\n 1,670 mL\n 585 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,303 mL\n 682 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 98%\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 85 K/uL\n 8.4 g/dL\n 144 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 3.6 mEq/L\n 24 mg/dL\n 113 mEq/L\n 147 mEq/L\n 26.0 %\n 5.5 K/uL\n [image002.jpg]\n 01:38 PM\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n Plt\n 86\n 85\n 83\n 80\n 85\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n TCO2\n 27\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.6 mg/dL, Mg++:2.4 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 11:45 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 585537,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22cm at teeth\n Route:\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: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments/Plan\n Pt admitted to ICU s/p hip surgery, side lying for many hours.\n CXR=near white out on L. Difficult to ventilate, requiring high minute\n volume to maintain adequate ABGs. Administering Albuterol MDI Q4,\n little change noted on airway pressures. Of note, pt /Plat=\n 41/22. See flowsheet for further pt data. Will follow.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586634,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n Hypernatremia (high sodium)\n Assessment:\n NA with am labs 148 on q4h water flushes,\n Action:\n Contd free water 250cc q4h\n Response:\n Na with 5pm lab 145.\n Plan:\n Will follow the Na level ,adjust free water bolus as needed.\n Range of Motion, Impaired\n Assessment:\n s/p IM nail removal hemiarthoplasy on ,currently with abd\n pilllow,post op period complicated with delirium,\n Action:\n Contd posterior hip precautions,pain mgt with morphine,tunrned and\n repositioned as needed,Was OOB to the chair\n Response:\n MAE+,rt hip with SS drainage dsg changed,pt was able to take OOB with\n 2person assist,with leg brace on,tolertaed with out pain,\n Plan:\n Will cont the hip precautions,monitor and change the dsg as\n needed,ortho/PT is following the pt,\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt on 35% face tent,sats mid 90\ns,ronchorous berath\n sounds,poor cough unable to expectorate secretions,BAL with H\n influenzae\n Action:\n Yaunker suction as need,abx changed to unasyn,o2 weaned to RA,chest PT\n as tolerated,\n Response:\n Pt contd have the congested cough,unable to expectorate the\n sputum,satting mid 90\ns on RA,\n Plan:\n Follow sats,chest PT, abx,suction,daily OOB\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 586639,
"text": "Subjective:\n \"I am going home today\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for therapeutic exercise , patient education\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n C Rail\n\n\n\n T\n\n\n Supine/\n Sidelying to Sit:\n Bed Flat\n\n\n\n\n\n T\n Transfer:\n PWB R LE Squat Pivot\n\n\n\n\n T\n\n Sit to Stand:\n\n\n\n x\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 64\n 132/78\n 24\n 98 50% Shovel\n Activity\n Sit\n 72\n /\n 28\n 98% RA\n Recovery\n Sit\n 63\n 144/76\n 24\n 98% RA\n Total distance walked:\n Minutes:\n Gait: Transfer: Pt able to squat pivot transfer from bed to stretcher\n chair c ModA\n Balance: CTG at EOB c B UE support.\n Education / Communication: Pt RE Precautions\n c RN RE Pt Status\n : MS: Able to follow one step commands. Orientated to person only.\n 10Reps RLE Supine Ther Ex\n RN issued repositioning sheet\n Abduction Brace donned in supine c MaxA\n Assessment: Pt is a 48M s/p R THR c/b prolonged ICU stay p/w improved\n functional mobility today in the setting of improved cognition. Pt is\n making steady progress and will benefit from D/C to STR when medically\n stable.\n Anticipated Discharge: Rehab\n Plan: Progress Ther Ex/ROM\n Asses stand pivot transfer\n Pt \n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586712,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n To have video swallow test today.. Received 1 time lopressor 5 mg iv\n overnight for bp of 180\ns/90\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Much more clearer\n Action:\n Continue to redirect pt. aways from his tubes, wrists restraints cont.\n Girlfriend spent the night at his bedside\n Response:\n Easily redirected\n Plan:\n Continue to reorientated pt, keep safe, ? go to floor today\n Hypernatremia (high sodium)\n Assessment:\n Last Na+ was 145\n Action:\n Continues with free h20 boluses q 4hours\n Response:\n Am Na+ pending\n Plan:\n Continues to follow Na+ levels, adjust free h2o boluses as needed\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586713,
"text": "48 yo m w/ HTN, OSA, etoh abuse, s/p total hip revision with hardware\n removal course c/b post-op resp failure, asp pna, and L lung collapse,\n arf,, a-fib / flutter, and etoh withdrawal, extubated \n To have video swallow test today.. Received 1 time lopressor 5 mg iv\n overnight for bp of 180\ns/90\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Much more clearer\n Action:\n Continue to redirect pt. aways from his tubes, wrists restraints cont.\n Girlfriend spent the night at his bedside\n Response:\n Easily redirected\n Plan:\n Continue to reorientated pt, keep safe, ? go to floor today\n Hypernatremia (high sodium)\n Assessment:\n Last Na+ was 143\n Action:\n Continues with free h20 boluses q 4hours\n Response:\n Am Na+ pending\n Plan:\n Continues to follow Na+ levels, adjust free h2o boluses as needed\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 585535,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22cm at teeth\n Route:\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: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585536,
"text": "Pt. admitted to from OR last eve s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. OR course was complicated by\n hypovolemia, EBL 3,200cc. Pt. kept intubated overnight due to acidosis\n throughout case and swelling due to positioning in OR.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt. oliguric since admission to unit. This a.m. creat is 1.6. Pt.\n remains hemodynamically stable with cuff pressures running about 30mmHg\n higher than Aline pressures.\n Action:\n Pt. given one liter of LR last eve upon return of initial blood gas.\n Presently bicarb gtt infusing.\n Response:\n UO remains very poor. Base deficit still present, though lactate is\n decreasing. Hct 44.\n Plan:\n Follow lytes, etc. closely. Consider fluid resuscitation.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt. with very diminished LLL. ABG revealed mixed acidosis.\n Action:\n Vent changes made per flowsheet. Pt. suctioned for copious secretions\n - for first 5-6 hrs in unit, pt. required suctioning every thirty\n minutes. CXR done, ETT advanced per H.O. CPT given concentrating on\n LLL. MDI\ns ordered. Sedation changed and titrated as documented for\n ventilator compliance. Pt. given boluses as noted.\n Response:\n CXR improved after two hours. ABG\ns are improving since last vent\n change, though drawn while bicarb gtt infusing. LLL moving more air,\n overall pulmonary assessment improved. Pt. continues to have\n breakthrough periods of agitation with stimulation and becomes\n dissynchronous, but less frequent.\n Plan:\n Continue pulmonary hygiene as appropriate. Monitor sedation level,\n goal . Follow blood gases closely and wean vent as\n indicated.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586623,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na 145 yesterday evening, continued 250cc free h20 flushes through\n NGT\n --not agitated overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 AM\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 57 (57 - 71) bpm\n BP: 114/58(70) {114/58(70) - 166/96(108)} mmHg\n RR: 18 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,163 mL\n 1,329 mL\n PO:\n TF:\n 1,101 mL\n 560 mL\n IVF:\n 2,112 mL\n 270 mL\n Blood products:\n Total out:\n 1,965 mL\n 750 mL\n Urine:\n 1,965 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,198 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General: arousable, in no acute distress, AOx2\n HEENT: Sclera anicteric, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: not assessed\n Labs / Radiology\n 56 K/uL\n 9.6 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.3 K/uL\n [image002.jpg]\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n Plt\n 86\n 85\n 83\n 80\n 85\n 56\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypernatremia: pt\ns Na is 148 today up from 145 last night.\n - cont 250cc q4h free water through tube feeds\n -will re-check Na this pm\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated yesterday,\n w/o medications.\n -cont morphine prn\n - consider zyprexa if agitated overnight\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 56 from 85 yesterday. Considering HIT (low\n suspicion as pt on lovenox) vs drug reaction.\n -dc\nd famotidine\n -will dc unasyn today after last dose\n -will check pm CBC\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn dc\nd, pt re-started on unasyn for the rest of his course\n (total 8 days). Today is last day of abx will dc after last dose.\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~90-100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "General",
"chartdate": "2182-08-28 00:00:00.000",
"description": "MICU staff PN",
"row_id": 586625,
"text": "TITLE:\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 48 yo m w/ HTN, OSA, etoh abuse, s/p total\n hip revision with hardware removal course c/b post-op resp failure, asp\n pna, and L lung collapse, arf,, a-fib / flutter, and etoh withdrawal,\n extubated . Has been less agitated. Received no morphine, benzos\n overnight.\n Exam notable for AF BP 114/58 HR 50-70(NS) RR 18 Sat 97% (40 %\n shovel).\n Less agitated, follows simple commands and oriented to self and date,\n coarse bs, RR, soft, NT + BS, trace dep edema, RLE wound dressing c/d/i\n Labs notable for WBC 5.3K, HCT 30, plts 56, na 148, Cr 0.8\n CXR is a limited film very rotated, increased interstitial marking with\n basilar atelectasis and effusions, no change from prior\n Agree with plan to complete 8 day coarse of unasyn for strep/H flu asp\n pna. He remains AF with stable WBC ct and no additional cx growth.\n Continue nebs, chest pt, pulm toilet and mobilization. His ICU delirium\n is slowly improving. We are limiting narcotics and minimizing use of\n benzos. Zyprexa for agitation. Attempt to optimize sleep wake schedule.\n We continue to optimize his hypernatremia by repleting his free water\n deficit. He remains anemic but his hct is up today with no evidence of\n active bleeding. He is morethrombocytopenic. We have low clinical\n suspicion for HIT. Possibly med effect (unasyn, H2B). Will d/c H2B and\n monitor. Post-op a-fib has resolved and he remains in NSR on\n lopressor. Additional post-op recs per ortho. Will continue PT and\n obtain speech and swallow c/s. D/c foley catheter.\n Remainder of plan as outlined in resident note.\n ICU: PIVs, TFs, lovenox, PPI, PT following, Full code.\n Remain in ICU for close monitoring though approaching floor status\n Total time: 40 min\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Bedside Swallowing Evaluation",
"row_id": 586627,
"text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\n HISTORY:\n Thank you for referring this 48 year-old man admitted on for IM\n nail removal and bipolar R hip replacement. Procedure was prolonged\n and hospital course has been complicated by large volume blood loss,\n transferred to the . Pt being treated for hypernatremia,\n withdrawal/delirium and agitation, thrombocytopenia, hypoxemia (assumed\n to be HAP), and decreased urine output. He has been NPO throughout\n this admission with NGT feedings. Intubated from to . We\n were consulted today to evaluate pt's oral and pharyngeal swallow\n function given concern for poor gag reflex.\n PMH includes:\n R femur fracture with IM nailing , HTN (no meds), 2 ppd smoker, 6\n beer per day drinker\n EVALUATION:\n The examination was performed while the patient was seated upright in\n the bed in .\n Cognition, language, speech, voice:\n Pt awake, agitated. Oriented to self, place, and \"I dunno, the 20th...\n 21st... 22nd... whatever.\" Follows simple commands. Answers y/n and\n simple questions accurately. Language fluent with significant\n confusion and agitation, perseverative on going home tonight and \"never\n being in the hospital again!\" Speech and voice WNL.\n Teeth: edentulous, dentures present in room and attempted for today's\n evaluation but poorly fitting, putting pt at risk for choking given his\n AMS.\n Secretions: moderate thick white secretions in oral cavity. Also with\n wet/junky vocal quality and breath sounds prior to eval. Yankauer\n suction x2 before eval with mod-gross return of thick, white secretions\n from oropharynx.\n ORAL MOTOR EXAM:\n Face grossly symmetrical. Labial, lingual, and buccal strength, tone,\n and ROM were WNL. palatal elevation symmetrical. No gag on deep\n suctioning.\n SWALLOWING ASSESSMENT:\n Pt offered ice chips, thin liquid (tspn, straw, consecutive), and bites\n of puree. Oral phase grossly WFL for these limited consistencies\n without anterior spillover or oral cavity residue. Laryngeal elevation\n mildly reduced to palpation. Pt had coughing x3 with thin liquids and\n x1 with nectar thick liquids. Coughing typically was followed by\n wet/congested sounds and yankauer suctioning with more thick, white\n secretions from oropharynx.\n SUMMARY / IMPRESSION:\n Pt presents with intermittent coughing during brief PO trial today. In\n addition he has baseline congested cough and risk factors for silent\n aspiration including ETOH/smoking history and recent (though short)\n intubation. Given baseline congestion, results of bedside swallow\n evaluation are not fully reliable. Pt should undergo videoswallow\n study prior to PO intake to determine the safest diet. This can be\n performed tomorrow and pt should maintain NPO with NGT pending this\n evaluation.\n The Dysphagia Outcome Severity Scale (DOSS) rating will be deferred\n pending tomorrow's videoswallow study.\n RECOMMENDATIONS:\n 1. NPO pending videoswallow study.\n 2. Continue nutrition, hydration, and medication via alternative means.\n 3. Q4 oral care while NPO\n 4. Videoswallow study tomorrow\n These recommendations were shared with the patient, nurse and medical\n team.\n M.S., CCC-SLP\n Pager # \n Face time: 13:45-14:00\n Total time: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586628,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na 145 yesterday evening, continued 250cc free h20 flushes through\n NGT\n --not agitated overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 AM\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 57 (57 - 71) bpm\n BP: 114/58(70) {114/58(70) - 166/96(108)} mmHg\n RR: 18 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,163 mL\n 1,329 mL\n PO:\n TF:\n 1,101 mL\n 560 mL\n IVF:\n 2,112 mL\n 270 mL\n Blood products:\n Total out:\n 1,965 mL\n 750 mL\n Urine:\n 1,965 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,198 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General: arousable, in no acute distress, AOx2\n HEENT: Sclera anicteric, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: not assessed\n Labs / Radiology\n 56 K/uL\n 9.6 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.3 K/uL\n [image002.jpg]\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n Plt\n 86\n 85\n 83\n 80\n 85\n 56\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypernatremia: pt\ns Na is 148 today up from 145 last night.\n - cont 250cc q4h free water through tube feeds\n -will re-check Na this pm\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated yesterday,\n w/o medications.\n -cont morphine prn\n - consider zyprexa if agitated overnight\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 56 from 85 yesterday. Considering HIT (low\n suspicion as pt on lovenox) vs drug reaction.\n -dc\nd famotidine\n -will dc unasyn today after last dose\n -will check pm CBC\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn dc\nd, pt re-started on unasyn for the rest of his course\n (total 8 days). Today is last day of abx will dc after last dose.\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~90-100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n ------ Protected Section ------\n Error on assessment, patient was extubated\n ------ Protected Section Addendum Entered By: , MD\n on: 14:20 ------\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586629,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na 145 yesterday evening, continued 250cc free h20 flushes through\n NGT\n --not agitated overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 AM\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 57 (57 - 71) bpm\n BP: 114/58(70) {114/58(70) - 166/96(108)} mmHg\n RR: 18 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,163 mL\n 1,329 mL\n PO:\n TF:\n 1,101 mL\n 560 mL\n IVF:\n 2,112 mL\n 270 mL\n Blood products:\n Total out:\n 1,965 mL\n 750 mL\n Urine:\n 1,965 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,198 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General: arousable, in no acute distress, AOx2\n HEENT: Sclera anicteric, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: not assessed\n Labs / Radiology\n 56 K/uL\n 9.6 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.3 K/uL\n [image002.jpg]\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n Plt\n 86\n 85\n 83\n 80\n 85\n 56\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypernatremia: pt\ns Na is 148 today up from 145 last night.\n - cont 250cc q4h free water through tube feeds\n -will re-check Na this pm\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated yesterday,\n w/o medications.\n -cont morphine prn\n - consider zyprexa if agitated overnight\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 56 from 85 yesterday. Considering HIT (low\n suspicion as pt on lovenox) vs drug reaction.\n -dc\nd famotidine\n -will dc unasyn today after last dose\n -will check pm CBC\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn dc\nd, pt re-started on unasyn for the rest of his course\n (total 8 days). Today is last day of abx will dc after last dose.\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~90-100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n ------ Protected Section ------\n Error on assessment, patient was extubated\n ------ Protected Section Addendum Entered By: , MD\n on: 14:20 ------\n on .\n ------ Protected Section Addendum Entered By: , MD\n on: 14:23 ------\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585642,
"text": "Pt. admitted to from OR last eve s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. OR course was complicated by\n hypovolemia, EBL 3,200cc. Pt. kept intubated overnight due to acidosis\n throughout case and swelling due to positioning in OR.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output continues to be low, less than 30cc/hr. Last creat. Was\n 2.2 from 1.6, k + 5.2\n Action:\n Urine lytes sent, pt. receive bicard gtt. overnight, no bolused with 1\n liter of LR today, and received 10 mg of Lasix but still no improvement\n Response:\n UO poor, Lactacte is trending down, creat is trending up\n Plan:\n Closely monitor urine output/ lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues to be intubated, large amts. of think white/tan secreations\n Action:\n Pt. was bronched today, moderate amt. of thick plugs were removed,\n Response:\n Post Bronch chest-xray was much improved pt is now on cpap 5/5\n Plan:\n See metavision for ABG results on , if gas is good pt may be\n extubated tonight, fent deecreased to 100mcg/hr and versed to 2mg\n R hip dsg is dry and intact, pt. has 2 hemovac in the right hip #1\n hemovac is draining more than # 2 hemovac and team is aware. On\n lovenox profolactally. Abbductor pillow in place, was seen by PT this\n am and they did some ROM with him\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585697,
"text": "Overnight Events:\n Spiked temp to 101.2, blood and urine cultures sent, PR\n tylenol given. MD aware and changes made to abx regimen.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, Vent PSV 10/8, FIO2 50%\n 02 sats 93-96%, RR 15-20, LS clear upper/diminished bases.\n Copious amts white/thick secretions via ETT.\n Action:\n No vent changes overnight.\n ETT re-taped/repositioned w/ RRT.\n Continue to suction pt prn.\n Response:\n Continues to have moderate/copious amt secretions.\n Plan:\n Cont to wean vent settings as tolerated.\n Cont to suction pt prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 2.2 -> 1.9 w/ PM labs.\n UO 10-35cc/hr, clear amber.\n K 5.4 w/ PM labs.\n Bladder Pressure = 14\n Action:\n Received 500cc NS over 2 hrs x2 overnight.\n Response:\n No noted improvement in UO following IVF.\n No change in renal function.\n Plan:\n Cont to monitor pts urine output, renal function labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n On fentanyl and midazolam gtts.\n Pt opens eyes to voice, nodded head yes to pain.\n Facial grimacing and increase in HR/BP/RR noted with\n turning/repositioning.\n Action:\n Required increase and fentanyl/midaz gtts following multiple boluses\n for pain/agitation.\n Response:\n Pt appears more comfortable via grimace scale and vitals following\n increase in gtts.\n Plan:\n Cont to monitor pts pain level via non-verbal scales.\n Titrate sedation/analgesia to pts comfort/vent compliance.\n - dressing on right hip is D/I, hemovacs x 2 draining sm amt sanguanous\n drainage.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585692,
"text": "Overnight Events:\n Spiked temp to 101.2, blood and urine cultures sent, PR\n tylenol given. MD aware and changes made to abx regimen.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, Vent PSV 10/8, FIO2 50%\n 02 sats 93-96%, RR 15-20, LS clear upper/diminished bases.\n Copious amts white/thick secretions via ETT.\n Action:\n No vent changes overnight.\n ETT re-taped/repositioned w/ RRT.\n Continue to suction pt prn.\n Response:\n Continues to have moderate/copious amt secretions.\n Plan:\n Cont to wean vent settings as tolerated.\n Cont to suction pt prn.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 2.2 -> 1.9 w/ PM labs.\n UO 10-35cc/hr, clear amber.\n K 5.4 w/ PM labs.\n Bladder Pressure = 14\n Action:\n Received 500cc NS over 2 hrs overnight.\n Response:\n No noted improvement in UO following IVF.\n No change in renal function.\n Plan:\n Cont to monitor pts urine output, renal function labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n On fentanyl and midazolam gtts.\n Pt opens eyes to voice, nodded head yes to pain.\n Facial grimacing and increase in HR/BP/RR noted with\n turning/repositioning.\n Action:\n Required increase and fentanyl/midaz gtts following multiple boluses\n for pain/agitation.\n Response:\n Pt appears more comfortable via grimace scale and vitals following\n increase in gtts.\n Plan:\n Cont to monitor pts pain level via non-verbal scales.\n Titrate sedation/analgesia to pts comfort/vent compliance.\n - dressing on right hip is D/I, hemovacs x 2 draining sm amt sanguanous\n drainage.\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 585968,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pt pulled out arterial line\n -agitated at times, pulled out IV, had to be restrained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: NRB\n Ventilator mode:\n Vt (Spontaneous):\n PS :\n RR: 17\n PEEP:\n FiO2: 50%\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve:\n PaO2 / FiO2:\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n TSH: 0.33\n UCx: (-)\n BCx: Pending\n 1:08 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n 2:32 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n CXR:\n R hip XR:\n The new right hip hemiarthroplasty is seen with normal positioning. No\n new\n fractures or dislocations are identified.\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Atrial Fibrillation: Pt went into afib w/ up to the 180s at\n 1000 today. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s and went into atrial flutter w/ 2:1 block. Metoprolol 5\n mg IV Q4H was started. Pt was still tachy to the 140s and Diltiazem 10\n mg IV x1 was given. Current HR 110s-120s. BP was stable throughout.\n -cont metoprolol 5 mg iv q4h\n - will try to further control pt\ns a-flutter w/ diltiazem\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr trending down from 2.2\n yesterday to 1.9 today.\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 16.9 today. Sputum w/ GNR,\n GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Now improved to around 1.7 on\n .\n - expect to improve with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments: Pt agitated at times,\n pulling on his lines. Had to be restrained, please cont restrains.\n Code status: Full code\n Disposition: ICU\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 48M s/p hip revision for AVN c/b resp\n failure, aspiration pneumonia and ARF. Currently agitated and in AF c\n at 160, required 70mg valium overnight.\n Exam notable for Tm 100.1 BP 130/54 HR 110-180 RR 15-30 with sat 96\n on 05.FM. WD man, NAD on vent. Minimally responsive. Coarse BS B. RRR\n s1s2. Soft +BS. RLE wound dressing intact. Distal pulses weak but\n present, unchanged. Labs notable for WBC 16K, HCT 30, K+ 4.4, Cr 1.9.\n CXR with resolving LLL atelectasis.\n Current issues include AF c , ethanol withdrawal, aspiration\n pneumonia, OSA, and resolving ARF. For new postop AF , \n continue metoprolol IV and will start esmolol if BP unstable. Will\n check LENIs and TSH, but suspect that this driven by combination of\n pneumonia and withdrawal. If +DVT, would need retrievable filter. For\n ethanol withdrawal, continue valium per CIWA. Will continue to treat\n likely LLL aspiration pneumonia with vanco and unasyn x8d. ARF is\n resolving, will check vanco level and redose. POC per ortho team.\n Lovenox for DVT prophylaxis. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 45 min\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Physical Therapy Progress Note",
"row_id": 585970,
"text": "Subjective:\n Pt medicated c valium, responds to noxious stimulus\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for therapeutic exercise ( stretch LLE 3x15s), other: (R hip\n ROM (flexion, extension (laying supine), abduction))\n Updated medical status: WBC 16.5*, Hgb 10.1*, Hct 30.0*, Plt 86*; \n CXR: bibasilar opacities c/w atelectasis d/t discontinued mechanical\n ventilation, increased caliber upper lung vessels\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n N/A\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n N/A\n\n\n\n\n\n\n Transfer:\n N/A\n\n\n\n\n\n\n Sit to Stand:\n N/A\n\n\n\n\n\n\n Ambulation:\n N/A\n\n\n\n\n\n\n Stairs:\n N/A\n\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 96\n 101/50\n 97% BiPAP\n Activity\n Supine\n 133\n /\n Recovery\n Supine\n 118\n 114/67\n 96% BiPAP\n Total distance walked: 0\n Minutes:\n Gait: unable to assess pt sedation\n Balance: unable to assess pt sedation\n Education / Communication: c RN pre & post re: pt status\n Other: R hip ROM ~28 to 90 (assessment of extension limited by\n pliability of bed), able to actively flex R hip ~70* on verbal command\n Assessment: 48 y/o M continues to be sedated ETOH withdrawal &\n therefore lacks progress c acute PT. Pt currently well below PLOF,\n anticipate will make progress c acute PT when less sedated & able to\n actively participate in PT. Pt will likely require rehab upon D/C, but\n may be able to progress home c PT- will continue to assess when pt able\n to participate in PT.\n Anticipated Discharge: Rehab\n Plan: Pt ed, bed mob, transfer training, gait training, THA therex,\n assess functional mobility, ROM\n Face time: 12:55-13:10\n Written by: PT/s\n Co-signed by: , PT\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-21 00:00:00.000",
"description": "MICU Attending Progress Note",
"row_id": 585620,
"text": "TITLE: MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I would emphasize\n the following points: 48M s/p hip revision for AVN - 4h case, 3L EBL rx\n 2 PRBC, 1700 cell , transient neo. Remaied intubated o/n d/t fluid\n shifts and sedation.\n Exam notable for Tm 100.1 BP 100/54 HR 110 RR 18 with sat 99 on VAC\n 7.19/57/82 o/n, now 7.32/54/71. WD man, NAD on vent. Follows simple\n commands. Coarse BS B. RRR s1s2. Soft +BS. RLE wound dressing intact.\n Distal pulses weak but present, unchanged per report. Labs notable for\n WBC 22K, HCT 44, K+ 5.6, Cr 1.6, lactate 2.8. CXR with resolving LLL\n atelectasis.\n Agree with plan to try to transition to PSV as we wean down sedation.\n Barriers to extubation include sedation, likely volume overload and LLL\n atelectasis. Will bronch for LLL obstruction / BAL, wean sedation (may\n need dexmetetomidate if agitated) and initiate gentle diuresis. Will\n hold on abx for possible LLL pna until BAL returns. Lactic acidosis\n improving, will monitor leg, check CK and follow exam. Creatinine\n slightly elevated, thought baseline unclear, RD meds and optimize\n hemodynamics. He is likely to require ongoing benzos given baseline\n alcohol dependence in addition to narcotic analgesia for postop pain.\n POC per ortho team. Lovenox for DVT prophylaxis. Remainder of plan as\n outlined above.\n Patient is critically ill\n Total time: 45 min\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 585857,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt requiring pap for sleep apnea\n Action:\n applied pap , monitored sats over noc and adjusted fio2 accordingly\n Response:\n Maint sats low 90\n Plan:\n Off pap in Am and for neb tx, cont to monitor for s/s resp distress\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Combative, restless, pulling off gown and leads , swearing, presenting\n s/s detox\n Action:\n MD aware increased CIWA to Q 1 HR\n Response:\n Min intermittent response to valium\n Plan:\n Cont CIWA , re orient when able, provide safe environment, re assess\n needs PRN\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585949,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pt pulled out arterial line\n -agitated at times, pulled out IV, had to be restrained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: NRB\n Ventilator mode:\n Vt (Spontaneous):\n PS :\n RR: 17\n PEEP:\n FiO2: 50%\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve:\n PaO2 / FiO2:\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n TSH: 0.33\n UCx: (-)\n BCx: Pending\n 1:08 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n 2:32 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n CXR:\n R hip XR:\n The new right hip hemiarthroplasty is seen with normal positioning. No\n new\n fractures or dislocations are identified.\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s at\n 1000 today. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s and went into atrial flutter w/ 2:1 block. Metoprolol 5\n mg IV Q4H was started. Pt was still tachy to the 140s and Diltiazem 10\n mg IV x1 was given. Current HR 110s-120s. BP was stable throughout.\n -cont metoprolol 5 mg iv q4h\n - will try to further control pt\ns a-flutter w/ diltiazem\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr trending down from 2.2\n yesterday to 1.9 today.\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 16.9 today. Sputum w/ GNR,\n GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Now improved to around 1.7 on\n .\n - expect to improve with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments: Pt agitated at times,\n pulling on his lines. Had to be restrained, please cont restrains.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585941,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pt pulled out arterial line\n -agitated at times, pulled out IV, had to be restrained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: NRB\n Ventilator mode:\n Vt (Spontaneous):\n PS :\n RR: 17\n PEEP:\n FiO2: 50%\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve:\n PaO2 / FiO2:\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n UCx: (-)\n BCx: Pending\n 1:08 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n 2:32 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n CXR:\n R hip XR:\n The new right hip hemiarthroplasty is seen with normal positioning. No\n new\n fractures or dislocations are identified.\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n .\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Now on PS 5/5.\n - monitor ABGs closely / daily CXRs\n - attempt to wean again today with SBT, HOB elevated may help, can\n consider precedex if necessary given ETOH/percocet history\n - may need CIWA scale after extubation given h/o ETOH\n - albuterol MDI q2 prn\n - aggressive suctioning and chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal, given 500cc NS bolus over 2 hrs twice overnight. UOP has\n not increased after IVF challenge, raising concern for ATN.\n - cont to monitor UOP, have given 500cc at 5am\n - recheck afternoon lytes\n - can re-attempt fluid challenge after extubation\n .\n # ID: spiked to 101 overnight. WBC trended down slightly to 21. Sputum\n w/ GNR, GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - start lovenox 30 in am\n - AP pelvis\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Received 1L LR on arrival to\n the . Now improved to around 1.7\n - cont to monitor lactate\n - expect to improve with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 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": "2182-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585944,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pt pulled out arterial line\n -agitated at times, pulled out IV, had to be restrained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: NRB\n Ventilator mode:\n Vt (Spontaneous):\n PS :\n RR: 17\n PEEP:\n FiO2: 50%\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve:\n PaO2 / FiO2:\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n TSH: 0.33\n UCx: (-)\n BCx: Pending\n 1:08 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n 2:32 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n CXR:\n R hip XR:\n The new right hip hemiarthroplasty is seen with normal positioning. No\n new\n fractures or dislocations are identified.\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s at\n 1000 today. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s and went into atrial flutter w/ 2:1 block. Metoprolol 5\n mg IV Q4H was started. Pt was still tachy to the 140s and Diltiazem 10\n mg IV x1 was given. Current HR 110s-120s.\n -cont metoprolol 5 mg iv q4h\n - will try to further control pt\ns a-flutter w/ diltiazem\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns Cr trending down from 2.2 yesterday to 1.9 today.\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 16.9 today. Sputum w/ GNR,\n GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Now improved to around 1.7 on\n .\n - expect to improve with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 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": "2182-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585945,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pt pulled out arterial line\n -agitated at times, pulled out IV, had to be restrained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: NRB\n Ventilator mode:\n Vt (Spontaneous):\n PS :\n RR: 17\n PEEP:\n FiO2: 50%\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve:\n PaO2 / FiO2:\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n TSH: 0.33\n UCx: (-)\n BCx: Pending\n 1:08 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n 2:32 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n CXR:\n R hip XR:\n The new right hip hemiarthroplasty is seen with normal positioning. No\n new\n fractures or dislocations are identified.\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s at\n 1000 today. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s and went into atrial flutter w/ 2:1 block. Metoprolol 5\n mg IV Q4H was started. Pt was still tachy to the 140s and Diltiazem 10\n mg IV x1 was given. Current HR 110s-120s.\n -cont metoprolol 5 mg iv q4h\n - will try to further control pt\ns a-flutter w/ diltiazem\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns Cr trending down from 2.2 yesterday to 1.9 today.\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 16.9 today. Sputum w/ GNR,\n GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Now improved to around 1.7 on\n .\n - expect to improve with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 585946,
"text": "Chief Complaint:\n 24 Hour Events:\n \n - patient tolerated extubation well.\n - put on CIWA protocol with Valium, received 80mg overnight\n -on morphine for pain, received 12g overnight\n - patient could not be fitted for a brace due to sedation.\n - pt pulled out arterial line\n -agitated at times, pulled out IV, had to be restrained\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:27 PM\n Ampicillin/Sulbactam (Unasyn) - 05:42 PM\n Vancomycin - 08:08 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:41 AM\n Enoxaparin (Lovenox) - 07:41 AM\n Morphine Sulfate - 05:00 AM\n Diazepam (Valium) - 06:45 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:21 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: 37.2\nC (99\n HR: 104 (103 - 122) bpm\n BP: 183/74(101) {117/47(33) - 183/80(143)} mmHg\n RR: 17 (15 - 31) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 130.6 kg (admission): 118 kg\n Total In:\n 1,404 mL\n PO:\n TF:\n IVF:\n 1,404 mL\n Blood products:\n Total out:\n 1,196 mL\n 500 mL\n Urine:\n 896 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 300 mL\n 210 mL\n Balance:\n 208 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: NRB\n Ventilator mode:\n Vt (Spontaneous):\n PS :\n RR: 17\n PEEP:\n FiO2: 50%\n SpO2: 96%\n ABG: 7.30/53/81./25/0\n Ve:\n PaO2 / FiO2:\n Physical Examination\n General: Sedated, in no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, 2 JP drains in place w/ little\n drainage, bilateral 1+ pedal pulses, bilateral LE TEDS stockings,\n abductor pillow in place\n Neurologic: Not assessed\n Labs / Radiology\n 86 K/uL\n 10.1 g/dL\n 155 mg/dL\n 1.9 mg/dL\n 25 mEq/L\n 4.4 mEq/L\n 59 mg/dL\n 109 mEq/L\n 142 mEq/L\n 30.0 %\n 16.5 K/uL\n [image002.jpg]\n TSH: 0.33\n UCx: (-)\n BCx: Pending\n 1:08 pm BRONCHIAL WASHINGS\n GRAM STAIN (Final ):\n 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n 2:32 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.\n IN PAIRS AND CLUSTERS.\n 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).\n RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.\n CXR:\n R hip XR:\n The new right hip hemiarthroplasty is seen with normal positioning. No\n new\n fractures or dislocations are identified.\n 05:06 PM\n 06:02 PM\n 07:54 PM\n 08:44 PM\n 03:49 AM\n 04:12 AM\n 10:47 AM\n 01:38 PM\n 05:30 PM\n 04:53 AM\n WBC\n 23.7\n 21.1\n 16.5\n Hct\n 36.8\n 34.3\n 30.0\n Plt\n 84\n 94\n 86\n Cr\n 1.9\n 2.3\n 2.2\n 1.9\n TCO2\n 27\n 29\n 28\n 27\n 29\n 27\n Glucose\n 137\n 143\n 150\n 155\n Other labs: PT / PTT / INR:14.3/32.1/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:7.7 mg/dL, Mg++:2.2 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Atrial Fibrillation: Pt went into afib w/ RVR up to the 180s at\n 1000 today. Was given metoprolol IV 5 mg x 3 with partial response, HR\n down 140s and went into atrial flutter w/ 2:1 block. Metoprolol 5\n mg IV Q4H was started. Pt was still tachy to the 140s and Diltiazem 10\n mg IV x1 was given. Current HR 110s-120s.\n -cont metoprolol 5 mg iv q4h\n - will try to further control pt\ns a-flutter w/ diltiazem\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to LLL collapse causing a significant respiratory acidosis. This\n was most likely a result of the pt lying on his left side for many\n hours during the surgery, compounded by volume overload and increased\n pulmonary secretions. The secretions have continued, and sedation was\n increased fent 200 / versed 4 at 4am. CO2 in low 50s, likely stable\n hypercapnia given smoking history. Successfully extubated yesterday\n currently on CPAP.\n - monitor ABGs closely / daily CXRs\n - albuterol MDI q2 prn\n - chest PT\n - caution with further IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr trending down from 2.2\n yesterday to 1.9 today.\n - cont to monitor UOP\n - cont to monitor Cr\n .\n # ID: Afebrile overnight. WBC trending down 16.9 today. Sputum w/ GNR,\n GPR.\n - changed to vanc/unasyn, can consider or zosyn for pseudomonal\n coverage if spikes again\n - f/u BCx, bronch washings\n # s/p hip surgery:\n - ortho recs: unchanged today (see below)\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Now improved to around 1.7 on\n .\n - expect to improve with IVF\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments: Pt agitated at times,\n pulling on his lines. Had to be restrained, please cont restrains.\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586016,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Obstructive sleep apnea (OSA)\n Assessment:\n Pt with h/o OSA , on auto cpap overnight. Pt asleep. Absent gag. LS\n diminished on base.\n Action:\n Continued with cpap , nebs as ordered. Sats 88 -90 sometimes ,tried\n with 100% hiflow, but no change ,so back to CPAP.\n Response:\n Sats maintained mostly low 90\ns ,but have times dropped to 88\ns ,LS\n diminished. Pt asleep, difficult to arouse, noted moving Lt leg.\n Plan:\n Continue with CPAP, wean O2 as tolerated.\n Arousal, Attention, and Cognition Impaired, ETOH.\n Assessment:\n Pt deep sleep,difficult to arouse, no s/s of withdrawal noted. Calm and\n quiet and slept well during the night. No valium /haldol/ morphine\n required this shift.\n Action:\n Off sedations .\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586011,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, Ciwa\n scale q2h\n Obstructive sleep apnea (OSA)\n Assessment:\n Action:\n Response:\n Plan:\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 586013,
"text": "Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Ventilation Assessment\n Level of breathing assistance: Unassisted spontaneous breathing\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Pt remained on CPAP throughout the shift. Pt required 12L of O2 to keep\n saturation above 90%. Pt did have periods of desaturation but picked up\n rather quickly. Nebs given as ordered. Plan to continue CPAP as\n tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586179,
"text": "Obstructive sleep apnea (OSA)\n Assessment:\n Received pt with 40% face tent, sats maintained mid 90\ns. pt with OSA.\n LS diminished on base. Congested.\n Action:\n CPAP overnight , nasopharyngeal suction done by RRT ,obtained moderate\n amount blood stained thick secertions. Nebs as ordered.\n Response:\n LS more clear ,less congested after suction. Sats > 94% .back to face\n tent by 4am.\n Plan:\n Wean O2 as tolerated,CPAP during the night. Suction PRN.\n Hypertension.\n Assessment:\n Pt with BP 160-200 /70-98 mm of hg since yesterday. HR 70-100\ns,SR\nST,no PVC\ns noted.\n Action:\n Pt on lopressor 10mg q4h. team aware about persistent hypertension,\n per team hypertension may be due to agitation or it could be pain.\n Valium and morphine given as needed, lopressor due dose given\n Response:\n Pt remained on SBP > 180mm of hg most of the time,early am SBP down to\n 160\ns ,HR 70-80\ns with lopressor. Pt verbalize as no pain. Pt\n restless sometimes .slept well.\n Plan:\n Monitor BP further,may need to add additional doses of someother\n antihypertensive,team to discuss with am rounds.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with h/o ETOH withdrawal, agitated and restless sometimes. Eye opens\n to call, alert and oriented x 1, talking in small words ,otherwise\n moans most of the time .\n Action:\n CIWA scale q 2h, valium 5mg q2h if CIWA ? 10, given valium as needed.\n Morphine 2mg for pain control.\n Response:\n Restless but not combative. Following commands. Slept well during the\n shift.\n Plan:\n f/u with CIWA protocol 2hr and valium as needed.\n s/p hip surgery .\n Assessment:\n Rt hip surgical site dressing soaked with moderate amount\n serosanguinous drainage .\n Action:\n Site cleaned and new DSD dressing applied. Staples intact. Abduction\n pillow in place between the legs , pneumo boots on, stockings on.\n Response:\n Staples looks clean and intact.\n Plan:\n f/u with orthopedics. Change of dressing prn. Watch for drainage.\n Pt NPO since extubation,no po meds given ,impaired gag , NGT inserted\n via Lt nare and position confirmed with CXR . tube feed replete with\n fiber 20c/hr started,goal @ 80cc/hr.mat need to increase as he\n tolerates. Due PO meds given . am labs Na 151, may need to start with\n free water via NGT.\n Foley to gravity , UO adequate.\n Bath given and change of position and all hygienic needs attended.\n Tamx 101 . Tylenol due dose given . blood c/s 1 set sent with am labs.\n Continued with iv antibiotics.\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 586269,
"text": "Demographics\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Nasotrachial Suction / Copious\n Comments:\n Respiratory Care Shift Procedures\n Bedside Procedures: Patient has required NTS at times. Received\n albuterol nebulizer therapy Q4. Remained on open face mask instead of\n being placed on autoset. Maintained adequate SPO2 values throughout\n the night. Suggest D/C\ning the autoset order.\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 585836,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n 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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated; Comments: Pt elective extubated ~1100, to\n open face Tent Cool mist & NC.\n Try Auto set CPAP as tol!!!\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2182-08-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 586116,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 80.7 None\n Ideal tidal volume: 322.8 / 484.2 / 645.6 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Bloody / Plug\n Sputum source/amount: Nasotrachial Suction / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent non-invasive ventilation\n Visual assessment of breathing pattern: Active exhalations\n Assessment of breathing comfort: No response (sleeping / sedated)\n Bedside Procedures:\n nts (1645)\n Comments: autoset cpap on x1 hr for snoring. Pt unable to mobilize\n secretions effectively. Continue with pulmonary hygiene, cpap PRN.\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586272,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, CIWA\n being done q4hr.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Airway Clearance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2182-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 586276,
"text": "Pt. admitted to from OR evening s/p right THR revision and\n hardware removal\n he developed avascular and osteo necrosis causing\n chronic pain to right hip/groin. Pt has a history of ETOH abuse, CIWA\n being done q4hr.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA scale being done q4hr as patient received extremely lethargic\n without any visible signs of active withdrawal.\n Action:\n CIWA scale assessments done and documented. No medication for\n withdrawal administered over this shift.\n Response:\n Patient more awake at the end of the shift than previously. He is\n inconsistent with following simple commands. VSS remain within\n acceptable limits.\n Plan:\n Continue to assess for sign of withdrawal and treat as needed, follow\n lab trends.\n Airway Clearance, Impaired\n Assessment:\n Secondary to his lethargy patient is not effective clearing his airway.\n The option of BIPAP was considered but deferred overnight as he was\n able to maintain adequate oxygenation.\n Action:\n Head of bed kept greater than 30 degrees, suctioned orally frequently\n to aid in clearing secretions as he does have a productive cough. Mouth\n care done,\n Response:\n With improving cough, however he does have a weak gag. Maintaining O2\n saturations in the mid to lower 90\n Plan:\n CXR done this morning. To follow lab trends, continue antibiotic\n treatment as recommended.\n Pain control (acute pain, chronic pain)\n Assessment:\n On schedule Tylenol with prn morphine for pain. He is s/p THR.\n Action:\n No acute changes in vital signs noted. He denies pain when awake\n enough, however does wince with movement of the right affected leg.\n Being rolled with abductor pillow insitu to maintain hip alignment.\n Response:\n VSS\n Plan:\n Asses and treat pain as indicated.\n Dressing to the right hip soiled but intact. No new area of oozing\n noted and leg kept aligned with abductor pillow.\n Bilateral soft wrist restraints are on for patient safety, order\n written.\n Tube feeding increased this morning to 60cc/hr goal is 80. No residuals\n noted.\n Na has been increasing in spite of getting free water q4hr and D5W x\n 1000ml. Team aware.\n"
},
{
"category": "Nutrition",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 585921,
"text": "Subjective\n Patient NPO, agitated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 118 kg\n 130.6 kg ( 07:00 AM)\n 35.2\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 146\n 90\n Diagnosis: Right Hip OA\n PMH : s/p right femur fracture (), hypertension, etoh abuse\n Food allergies and intolerances: none noted\n Pertinent medications: multivitamin, ferrous sulfate, thiamin, folic\n acid, others noted\n Labs:\n Value\n Date\n Glucose\n 155 mg/dL\n 04:53 AM\n BUN\n 59 mg/dL\n 04:53 AM\n Creatinine\n 1.9 mg/dL\n 04:53 AM\n Sodium\n 142 mEq/L\n 04:53 AM\n Potassium\n 4.4 mEq/L\n 04:53 AM\n Chloride\n 109 mEq/L\n 04:53 AM\n TCO2\n 25 mEq/L\n 04:53 AM\n Albumin\n 2.8 g/dL\n 12:41 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:53 AM\n Phosphorus\n 3.5 mg/dL\n 04:53 AM\n Magnesium\n 2.2 mg/dL\n 04:53 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft/obese with positive 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: 1800-2250 (BEE x or / 20-25 cal/kg)\n Protein: 105-135 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n 48 year old male transferred to s/p hip replacement surgery c/b\n significant blood loss and respirator failure. Patient was extubated\n yesterday, but is now experiencing agitation likely d/t etoh\n withdrawal. If patient continues to be unable to take PO intake, may\n need to consider nutrition support. If needed, suggest tube feeding of\n Replete with Fiber at 80ml/hr x 24 hours to provide 1920kcal and 119g\n protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet when possible\n 2. If unable, consider tube feedings, will adjust based on fluid\n status and renal labs if needed.\n 3. Following\n 10:15 AM\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586621,
"text": "Chief Complaint:\n 24 Hour Events:\n --Na 145 yesterday evening, continued 250cc free h20 flushes through\n NGT\n --not agitated overnight\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 05:00 AM\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 05:00 AM\n Infusions:\n Other ICU medications:\n Enoxaparin (Lovenox) - 07:51 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 57 (57 - 71) bpm\n BP: 114/58(70) {114/58(70) - 166/96(108)} mmHg\n RR: 18 (18 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,163 mL\n 1,329 mL\n PO:\n TF:\n 1,101 mL\n 560 mL\n IVF:\n 2,112 mL\n 270 mL\n Blood products:\n Total out:\n 1,965 mL\n 750 mL\n Urine:\n 1,965 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,198 mL\n 579 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General: arousable, in no acute distress, AOx2\n HEENT: Sclera anicteric, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: not assessed\n Labs / Radiology\n 56 K/uL\n 9.6 g/dL\n 107 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 20 mg/dL\n 112 mEq/L\n 148 mEq/L\n 29.6 %\n 5.3 K/uL\n [image002.jpg]\n 05:30 PM\n 04:53 AM\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n WBC\n 16.5\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n Hct\n 30.0\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n Plt\n 86\n 85\n 83\n 80\n 85\n 56\n Cr\n 2.2\n 1.9\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n Glucose\n 150\n 155\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.0 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n # Hypernatremia: pt\ns Na is 148 today up from 145 last night.\n - cont 250cc q4h free water through tube feeds\n -will re-check Na this pm\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated yesterday,\n w/o medications.\n -cont morphine prn\n - consider zyprexa if agitated overnight\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 56 from 85 yesterday. Considering HIT (low\n suspicion as pt on lovenox) vs drug reaction.\n -will check pm CBC\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia.\n - vanc/zosyn dc\nd, pt re-started on unasyn for the rest of his course\n (total 8 days). Today is last day of abx will dc after last dose.\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~90-100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:12 AM 60 mL/hour\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "ECG",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Report",
"row_id": 201792,
"text": "Atrial flutter with 2:1 block. Since the previous tracing of the\nrhythm is more regular. Atrial activity is organized. Atrial flutter is now\npresent as opposed to atrial fibrillation.\n\n"
},
{
"category": "ECG",
"chartdate": "2182-08-23 00:00:00.000",
"description": "Report",
"row_id": 201793,
"text": "Atrial fibrillation with a rapid ventricular response. Non-specific\nST-T changes. Compared to the previous tracing of rapid atrial\nfibrillation and ST-T wave changes are now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2182-08-19 00:00:00.000",
"description": "Report",
"row_id": 201794,
"text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088662,
"text": " 2:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for inflation\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with lobar collapse s/p bronch for mucus plug\n REASON FOR THIS EXAMINATION:\n assess for inflation\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DMFj WED 5:30 PM\n Limited exam. Probable improved left lung aeration.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old male with lobar collapse. Status post bronchoscopy.\n\n A single supine portable AP chest radiograph is compared to at 00:17\n hours. Examination is markedly limited by motion. An endotracheal tube\n terminates 5 cm above the carina. There is slightly improved left lung\n aeration. The right lung is clear.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088542,
"text": " 12:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man intubated s/p advancement of ET tube.\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of ET tube placement.\n\n Portable AP chest radiograph was compared to prior study obtained on at 10:37 p.m.\n\n On the current study the ET tube tip is 5 cm above the carina. There is a\n slight improvement of the left lung aeration. The left perihilar opacity\n cannot be excluded and might be consistent with aspiration or atelectasis,\n although improvement since the prior study is seen. Attention on the\n subsequent studies to this area is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088663,
"text": ", ORTHO 2:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for inflation\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with lobar collapse s/p bronch for mucus plug\n REASON FOR THIS EXAMINATION:\n assess for inflation\n ______________________________________________________________________________\n PFI REPORT\n Limited exam. Probable improved left lung aeration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1089203,
"text": " 9:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with new NGT\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nasogastric tube placement.\n\n FINDINGS: In comparison with the study of , there has been placement of a\n nasogastric tube that appears to extend only to the upper stomach with the\n sidehole still in the distal esophagus. However, the precise tip of the tube\n is difficult to see due to underpenetration of the upper abdomen.\n\n There is poor definition of the right hemidiaphragm, suggesting pleural fluid\n and atelectasis in this region. Respiratory motion somewhat degrades the\n image.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1089515,
"text": " 5:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: to confirm NGT position\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with h/o ETOH ,S/P HIP SURGERY\n REASON FOR THIS EXAMINATION:\n to confirm NGT position\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP.\n\n REASON FOR EXAM: Confirm NG tube position. History of recent hip surgery.\n\n FINDINGS: The NG tube passes into the stomach.\n There has been a slight worsening of the upper lobe pulmonary venous\n congestion with perihilar edema and cardiomegaly. The right sided pleural\n effusion and bibasal atelectasis is stable. No pneumothorax or mass.\n\n Impression: Satisfactory appearence of the NG tube.Interval wordening of the\n pulmonary venous congestion and cardiomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-30 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1090122,
"text": " 8:38 AM\n CHEST (SINGLE VIEW); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate for worsening PNA.\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with previous LUL PNA now with delirium s/p fall.\n REASON FOR THIS EXAMINATION:\n Please evaluate for worsening PNA.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest PA and lateral.\n\n REASON FOR EXAM: 48-year-old man with previous left upper lobe pneumonia. New\n delirium.\n\n Findings: Since the previous CXR , there is subtle increased opacification in\n the left lower lobe which suggests early consolidation. Minor bibasal\n atelectasis and moderate cardiomegaly without overt signs of pulmonary\n congestion is again noted.\n\n IMPRESSION:\n\n Increased airspace opacification in the left lower lobe suggests early\n pneumonia. Bilateral lower lobe atelectasis and cardiomegaly is unchanged.\n\n A followup chest radiograph is recommended to ensure resolution following\n treatment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1090082,
"text": " 12:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please confirm placement.\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with h/o LLL lung collapse and PNA now s/p NGT placement.\n REASON FOR THIS EXAMINATION:\n Please confirm placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post left lower lobe collapse and pneumonia, status post\n nasogastric tube placement.\n\n COMPARISON: .\n\n FINDINGS: Normal course of the nasogastric tube, the tip of the tube projects\n in the middle to distal parts of the stomach. No evidence of complications,\n no pneumothorax. Moderate cardiomegaly without signs of overhydration.\n Elevation of the right hemidiaphragm. No evidence of focal parenchymal\n opacities suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1089715,
"text": " 3:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 48 year old man with hypoxemia.\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with hypoxemia.\n REASON FOR THIS EXAMINATION:\n 48 year old man with hypoxemia.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxemia.\n\n Portable AP chest radiograph was compared to obtained at 05:55\n a.m.\n\n The NG tube tip is below the diaphragm, not included in the field of view.\n The mediastinal contours are unremarkable. The cardiac size cannot be\n assessed since the lung bases and the cardiac base were not included in the\n field of view. The patient continues to be in vascular engorgement, which\n appears to be slightly progressed since the prior study. Bilateral pleural\n effusions are most likely present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-20 00:00:00.000",
"description": "P PELVIS (AP ONLY) PORT",
"row_id": 1088535,
"text": " 9:57 PM\n PELVIS (AP ONLY) PORT Clip # \n Reason: Component alignment\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p right THA\n REASON FOR THIS EXAMINATION:\n Component alignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right hemiarthroplasty.\n\n COMPARISON: Hip radiographs from and intraoperative radiographs from\n .\n\n Three intra/postopertive views of the right hip show hemiarthroplasty. The\n hardware appears in normal anatomic alignment. There is marked post fracture\n deformity of the proximal right femur. Two broken interlocking screws are\n seen in the distal right femur.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-20 00:00:00.000",
"description": "R FEMUR (AP & LAT) RIGHT",
"row_id": 1088512,
"text": " 5:09 PM\n FEMUR (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: HIP REVISION TOTAL RIGHT W/HARDWARE REMOVAL\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Revised total hip.\n\n Six intraoperative radiographs of the right hip. Since preoperative exam , the fixation device in the proximal right femur has been removed and a\n bipolar right hemiarthroplasty has been placed with normal positioning as seen\n on these limited images.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1089246,
"text": " 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 48 year old man with PNA, NG tube, and intubated\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with PNA, NG tube, and intubated\n REASON FOR THIS EXAMINATION:\n 48 year old man with PNA, NG tube, and intubated\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: NG tube placement.\n\n FINDINGS: In comparison with study of , there is little overall change.\n Again, there is some prominence of the pulmonary vasculature consistent with\n elevated pulmonary venous pressure. Enlargement of the cardiac silhouette\n persists with probable bibasilar atelectasis and effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-30 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1090117,
"text": " 8:36 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Please assss for cervical fracture.\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with delirium s/p fall.\n REASON FOR THIS EXAMINATION:\n Please assss for cervical fracture.\n CONTRAINDICATIONS for IV CONTRAST:\n RECENT ACUTE RENAL FAILURE\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JEKh FRI 11:21 AM\n PFI: No fracture or malalignment. Mild diffuse degenerative changes.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 48-year-old male with delirium status post fall, concern for\n cervical fracture.\n\n STUDY AND TECHNIQUE: Contiguous axial non-contrast images of the cervical\n spine were obtained. Sagittal and coronal reconstructions were obtained.\n Comparison study .\n\n FINDINGS: No disc, vertebral or paraspinal abnormalities seen. There is no\n sign of fracture abnormal alignment. Mild diffuse degenerative changes are\n noted throughout the cervical spine. Please correlate clinically. CT is not\n able to provide intrathecal detail comparable to MRI but the visualized\n outline of the thecal sac appears unremarkable.\n\n IMPRESSION:\n No fracture or malalignment. Mild diffuse degenerative changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1090090,
"text": " 3:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL, ETOH WITHDRAWAL, WORSENING DELIRIUM. ? ICH.\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p R hip replacement c/b EtOH withdrawal s/p fall tonight with\n worsening delirium.\n REASON FOR THIS EXAMINATION:\n Please evaluate for ICH.\n CONTRAINDICATIONS for IV CONTRAST:\n Not needed\n ______________________________________________________________________________\n WET READ: JKSd FRI 4:54 AM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man status post right hip replacement complicated by\n alcohol withdrawal. Status post fall tonight with worsening delirium. Please\n evaluate for intracranial hemorrhage.\n\n COMPARISON: CT of the head of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the head without\n contrast. Coronal and sagittal reformatted images were also displayed.\n\n FINDINGS: There is no acute intracranial hemorrhage, large areas of edema, or\n mass effect. There is no evidence of acute large vascular territory infarct.\n There is normal preservation of -white matter differentiation. The\n ventricles and sulci are normal in size and configuration.\n\n Visualized paranasal sinuses demonstrate slight mucosal thickening of the left\n maxillary sinus and sphenoid sinus. There is partial opacification of mastoid\n air cells, left greater than right. No fractures are identified.\n\n IMPRESSION: No acute intracranial process. Partial opacification in mastoid\n air cells, which is present on the prior CT of .\n\n ATTENDING NOTE: Slight hyperdensity of tentorium is symmetric and appear\n within normal limit.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-30 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1090118,
"text": ", J. MED 11R 8:36 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: Please assss for cervical fracture.\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with delirium s/p fall.\n REASON FOR THIS EXAMINATION:\n Please assss for cervical fracture.\n CONTRAINDICATIONS for IV CONTRAST:\n RECENT ACUTE RENAL FAILURE\n ______________________________________________________________________________\n PFI REPORT\n PFI: No fracture or malalignment. Mild diffuse degenerative changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-23 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1088960,
"text": " 9:41 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: DVT\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with new onset tachycardia, resp distress s/p R hip surgery\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: New onset tachycardia and respiratory distress, status\n post hip surgery.\n\n TECHNIQUE: Grayscale, color and duplex Doppler imaging of the lower\n extremities was performed. There are no prior studies for comparison.\n\n FINDINGS: The common femoral, distal greater saphenous, superficial femoral,\n popliteal, posterior tibial and peroneal veins are patent bilaterally, with\n normal flow, augmentation and compressibility.\n\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-22 00:00:00.000",
"description": "HIP 1 VIEW",
"row_id": 1088767,
"text": " 10:10 AM\n HIP 1 VIEW Clip # \n Reason: Component alignment\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p R THA with hardwre removal\n REASON FOR THIS EXAMINATION:\n Component alignment\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 48 year-old male with revision right hip hemiarthroplasty for\n broken hardware, AVN, and secondary osteoarthritis.\n\n TECHNIQUE: AP hip radiographs.\n\n COMPARISON: Intraoperative femur radiographs from .\n\n The new right hip hemiarthroplasty is seen with normal positioning. No new\n fractures or dislocations are identified.\n\n IMPRESSION: Revision right hip hemiarthroplasty.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088919,
"text": " 4:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated, assess for interval change\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with s/p total hip replacement, unable to be extubated post op\n REASON FOR THIS EXAMINATION:\n intubated, assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient after total hip replacement.\n\n Portable AP chest radiograph was compared to obtained 5:28 p.m.\n\n The patient is currently extubated. There is slight decrease in the lung\n volumes with development of bibasilar opacities most likely consistent with\n development of atelectasis due to termination of mechanical ventilation. There\n is also interval slight increase in the caliber of the vessels in particular\n in the upper lungs that might be consistent with increased venous return after\n termination of mechanical ventilation, but should be closely followed to\n document resolution and no further progression toward pulmonary edema. There\n is no appreciable pleural effusion. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088537,
"text": " 10:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p total hip revision, now intubated. Tube malplacement\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after total hip revision.\n\n Portable AP chest radiograph was compared to preoperative study that was\n obtained on .\n\n The ET tube tip is currently 6 cm above the carina. There is newly developed\n atelectasis in the left perihilar area with subsequent left mediastinal shift.\n Left pleural effusion cannot be excluded. Right lung is hyper-expanded most\n likely compensatory to the left atelectasis. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1088732,
"text": " 4:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p R hip surgery now w/consolidation\n REASON FOR THIS EXAMINATION:\n infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n Status post right hip surgery, suspicion of pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the image quality is\n improved. The tip of the endotracheal tube projects 3.5 cm above the carina.\n The lung volumes are normal, there is no evidence of pleural effusion. The\n size of the cardiac silhouette is also normal. Parts of the ventilation\n devices project over the left lower lung. The lungs however do overall\n display normal density, without evidence of focal increase in density\n suggestive of an infectious process. Minimal bilateral increase in diameter\n of the main pulmonary arteries.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-30 00:00:00.000",
"description": "R FEMUR (AP & LAT) RIGHT",
"row_id": 1090089,
"text": " 3:47 AM\n FEMUR (AP & LAT) RIGHT Clip # \n Reason: Please evaluate prosthesis.\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p R hip replacement s/p unwitnessed fall.\n REASON FOR THIS EXAMINATION:\n Please evaluate prosthesis.\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Right femur, two views, .\n\n HISTORY: 48-year-old man status post right hip replacement. Status post\n unwitnessed fall. Evaluate prosthesis.\n\n FINDINGS: There is a right revision hip prosthesis. No periprosthetic\n fractures are seen. There is again seen a prominent butterfly fragment within\n the superomedial soft tissues. There are several broken screw fragments in\n the right distal femoral diametaphysis. Joint space narrowing at the medial\n compartment of the knee is seen. There is a knee joint effusion.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-08-30 00:00:00.000",
"description": "PELVIS PORTABLE",
"row_id": 1090085,
"text": " 1:03 AM\n PELVIS PORTABLE Clip # \n Reason: Please evaluate prothesis placement.\n Admitting Diagnosis: RIGHT HIP OA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p R hip replacement and fall.\n REASON FOR THIS EXAMINATION:\n Please evaluate prothesis placement.\n ______________________________________________________________________________\n FINAL REPORT\n\n STUDY: Pelvis, .\n\n HISTORY: 48-year-old man status post right hip replacement and revision.\n\n FINDINGS: There is a right revision hemiarthroplasty. The distal tip of the\n femoral stem is not included in the field of view. There is a prominent\n medial proximal femoral butterfly fragment. Lateral surgical skin staples are\n present. Mild degenerative changes of the left hip are seen.\n\n\n\n\n\n"
},
{
"category": "Social Work",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 586818,
"text": "Family Information\n Next of : , \n Health Care Proxy appointed: - Info Provided\n Family Spokesperson designated: Girlfriend (; Cell :\n )\n Communication or visitation restriction: None\n Patient Information:\n Previous living situation: Home w/ others\n Previous level of functioning: Required assistance with care\n Previous or other hospital admissions: Mr. has had two\n admissions at , the first .\n Past psychiatric history: Unknown.\n Past addictions history: A note from 10. reports two six\n packs/weekend; it is suspected that he drinks more but there is no\n report or documentation to support his EtOH use.\n Employment status: Disable\n Legal involvement: Unknown\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Dr. admitted this 48 y/ to the\n following the removal of R femur intramedullary gamma nail and R\n hip hemiarthroplasty for R hip osteonecrosis stage III. This worker\n spoke briefly twice with pt's girlfriend, Ms. , to offer\n support and then a third time today in greater length in response to\n RN/MD concerns about her level of agitation re Mr. TX, increasing\n demands to make TX decisions (there is apparently no documentation of\n her status as his HCP), and her criticism of his medical care in the\n . When this SW was present, two doctors tried multiple to\n explain his medical status and respond to her concerns, but Ms. \n repeatedly interrupted telling them what she wanted and expected re\n medication, going to a medical floor, and PT. After meeting with the\n MDs, she told this worker that she\nhated doctors,\n illustratively\n reporting that her mo who died at 95, never saw a doctor and that her\n father, who at age 60 felt he should have a medical exam. He then came\n home with\nsix medications,\n with her winning the bet of a $100 that he\n would have at least three. Recently, Ms. saw a doctor for a cut\n on her hand, but previously had not seen a doctor in 20 years, which\n she attributes to her being a vegetarian, who also eats fish, and takes\n cod liver oil daily. In addition, she contacts a cousin who is a\n surgeon and other people whom she alleges are medically knowledgeable\n and they criticize, not having evaluated him, his medical care. Ms.\n is insisting on soon taking him home for rehab.\n Assessment: It is not clear if Ms. \ns level of agitation is\n affecting her cognition or if there are other reasons, but she\n repeatedly asks the same questions already answered by healthcare team\n members, with this worker sensing that she is not able to integrate any\n of the responses. She has said that she would stay here\n24/7\n and hold\n his hands so that he would not pull out his lines, not being able to\n understand that his agitation/delirium is endogenous, not because he is\n lying in bed in restraints.\n Communication with Team:\n Primary Nurse: \n Attending: \n Plan / Follow up:\n 1. This worker will continue to follow pt and his girlfriend when\n transferred to 12R to assess psychosocial functioning and offer\n support.\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 586821,
"text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: / 733.41\n Reason of referral:\n History of Present Illness / Subjective Complaint: 48m adm on \n for IM nail removal and bipolar R hip replacement. Procedure was\n prolonged and hospital course has been complicated by large volume\n blood loss, pneumonia with LLL collapse, transferred to the . Pt\n being treated for hypernatremia, ETOH withdrawal/delirium and\n agitation,thrombocytopenia, hypoxemia (assumed to be HAP), and\n decreased urine output.\n Past Medical / Surgical History: see initial eval\n Radiology: CXR vascular engorgement likely bilateral pleural\n effusions\n Labs:\n 28.1\n 9.2\n 96\n 6.5\n [image002.jpg]\n Other labs:\n Activity Orders: with strict posterior dislocation precautions,\n abduction pillow in bed, abductor brace for out of bed\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: alerts to stim,\n oriented to self, \"\" \"Immaculate Conception something\"\n \"Hospital\", \"\", agitated at times-- wanting to go home,\n unrealistic about current status. confused/delirious eg. patient said\n \"throw this cigarette out the window before she comes in\" \"I\nve been\n smoking in her all day\", \"Hand me the ball\", \"I can walk just fine\".\n Patient became very agitated after walking with PT and said he was\n going home. He said \"The first person that ties my hands down, I'm\n going to cold cock them\"\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 74\n 166/75\n 23\n 94% RA\n Rest\n /\n Sit\n 149/?\n Activity\n /\n Stand\n unable to get further vitals due to agitation\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: breathing pattern labored with activity\n Integumentary / Vascular: hip dressing CDI, LUE PIV, NGTube for\n feeding, indwelling foley cath\n Sensory Integrity: denies paresthesias, grossly intact to LT\n Pain / Limiting Symptoms: no c/o pain\n Range of Motion\n Muscle Performance\n R hip extension >0, flexion >90, abduction 0-10; bilateral UEs and LLE\n WFL\n R hip flexion 3-/5, knee extension , abd/add 2-/5, extension >3-/5,\n bilat UEs and LLE grossly WFL\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: rolls side to side using bedrail but requires modA to\n maintain dislocation precautions\n sup to sit with \n sit to stand with \n amb 50' with RW and -- flexed posture, slow cadence, small\n steps bilaterally, requiring constant cues for proper technique.\n quickly fatigued requiring frequent standing breaks leaning forearms on\n \n :\n\n\n\n\n T\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n na\n\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n T\n\n\n Stairs:\n na\n\n\n\n\n\n\n Balance: able to sit EOB unsupported; able to static stand with RW\n unsupported\n Education / Communication: Pt ed: role of PT, d/c; case discussed with\n RN and MD\n Also discussed patient status with his girlfriend \n Intervention: therex per hip handout (supine)\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Range of Motion, Impaired\n 3.\n Muscle Performance, Impaired\n 4.\n Impaired functional mobility\n 5.\n Impaired endurance\n 6.\n Clinical impression / Prognosis: 48m s/p R hip replacement c/b\n pneumonia and withdrawal p/w above impairments c/w joint arthroplasty\n and CNS dysfunction. Pt currently greatly limited by his mental status\n as he is confused and easily agitated with poor safety awareness and\n minimal acknowledgement of his current status. This places him at\n great safety risk. He is also very deconditioned from prolonged\n bedrest. Currently he is not safe to go home and is appropriate for\n d/c to rehab once stable. Feel he will progress well once delerium\n clears fully given very high baseline and good progress today.\n Goals\n Time frame: 1 week\n 1.\n sup to sit independent\n 2.\n maintain dislocation precautions with all mobility\n 3.\n sit to stand with supervision\n 4.\n ambulate 200' with CG and crutches \n 5.\n demonstrate good safety awareness at all times\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/week x1 week\n pt ed/family ed\n functional mobility/gait training with progressing to crutches\n therex\n endurance training\n d/c planning\n T Patient (unable due to delirium) agrees with the above goals and is\n willing to participate in the rehabilitation program.\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Bedside Swallow Evaluation",
"row_id": 586801,
"text": "TITLE: BEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for referring this 48 year-old man admitted on \nfor IM nail removal and bipolar R hip replacement. Procedure was\nprolonged and hospital course has been complicated by large\nvolume blood loss, transferred to the . Pt being treated for\nhypernatremia, withdrawal/delirium and agitation,\nthrombocytopenia, hypoxemia (assumed to be HAP), and decreased\nurine output. He has been NPO throughout this admission with NGT\nfeedings. Intubated from to . Patient was previously\nseen by our department on and recommended for NPO status.\nWe return today to reevaluate pt's oral and pharyngeal swallow\nfunction and r/o aspiration while eating and drinking.\nPMH includes:\nR femur fracture with IM nailing \nHTN (no meds)\n2 ppd smoker\n6 beer per day drinker\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed on .\nCognition, language, speech, voice:\nPatient was lethargic and kept eyes closed for today's\nevaluation. He was oriented to self and hospital, year with\nchoices. Patient followed most basic commands given cues and\nmodels. His speech was fluent. Patient noted with wet vocal\nquality at baseline.\nTeeth: top and bottom dentures in place for evaluation, top\ndentures were very loose\nSecretions: normal oral secretions, audible baseline secretions\nand productive cough\nORAL MOTOR EXAM:\nLabial and lingual ROM and strength were reduced. Tongue\nprotruded to midline. Palatal elevation was bilateral. Buccal\nstrength was WFL. Patient noted with functional, productive\nvolitional cough. Gag was absent.\nSWALLOWING ASSESSMENT:\nPO trials included ice chip, thin liquids (tsp, straw), nectar\nthick liquids (tsp, straw), and puree consistencies. Labial seal\nwas adequate for spoon and straw. Mastication was not observed\n limited PO trials. Anterior/ posterior transition was\ntimely. Oral residue was not remarkable. Laryngeal elevation\nwas adequate to palpation. Patient noted with increased wet\nvocal quality and throat clearing after puree consistencies\nfollowed by thin liuqids. O2 sats remained stable at 95-97%.\nPatient did not report feeling as though anything was stuck in\nhis throat or went down the wrong way.\nSUMMARY / IMPRESSION:\nPatient was lethargic and kept eyes closed during today's\nevaluation. He p/w s/sx of aspiration on thin liquids followed\nby puree consistencies as evidenced by coughing and increased wet\nvocal quality. No coughing/ throat clearing was noted with\nnectar thick liquids alone and nectar thick liquids followed by\npuree consistencies. Recommend PO diet of nectar thick liquids\nand MOIST puree consistencies (please add syrup/ butter to dry\npurees), with 1:1 supervision. Alternate bites and sips.\nRecommend patient continue tube feeds as primary means of\nnutrition, hydration, and medication. Please wait to remove tube\nfeeds until patient is seen again by our department and is more\nawake/ alert and MS is adequate for full PO intake.\nThis swallowing pattern correlates to a Dysphagia Outcome\nSeverity Scale (DOSS) rating of Level 3, Moderate Dysphagia.\nRECOMMENDATIONS:\n1. PO diet: nectar thick liquids and MOIST puree consistencies\n(please add syrup/ butter to dry purees)\n2. 1:1 supervision\n3. Alternate bites and sips\n4. Continue tube feeds as primary means of nutrition, hydration,\nand medication.\n5. Please wait to remove tube feeds until patient is seen again\nby our department and is more awake, alert and adequate for full\nPO intake.\n6. Q6 oral care\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , SLP/student\nPager # \n____________________________________\n , M.S., CCC-SLP\nPager # \nFace time: 9:05 - 9:25\nTotal time: 100 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586808,
"text": "Chief Complaint:\n 24 Hour Events:\n --Patient failed bedside swallow, but passed video swallow study\n --Patient not on oxygen. Able to sit on chair/walk in afternoon.\n --agitated, yet directable.\n --Patient's platelets stable at 96, Na=143.\n --hypertensive at night, so given metoprolol 5mg IV\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 06:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 AM\n Metoprolol - 01:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 62 (60 - 80) bpm\n BP: 151/82(95) {99/62(77) - 180/90(137)} mmHg\n RR: 25 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,083 mL\n 546 mL\n PO:\n TF:\n 1,933 mL\n 477 mL\n IVF:\n 640 mL\n 69 mL\n Blood products:\n Total out:\n 1,870 mL\n 500 mL\n Urine:\n 1,870 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,213 mL\n 46 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\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 96 K/uL\n 9.2 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 109 mEq/L\n 142 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n 03:41 PM\n 04:24 AM\n WBC\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n 6.9\n 6.5\n Hct\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n 27.9\n 28.1\n Plt\n 85\n 83\n 80\n 85\n 56\n 99\n 96\n Cr\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n 0.9\n 0.8\n Glucose\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n 115\n 143\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring. Subsequently developed PNA w left lower lobe\n colapse and EtOH withdrawal.\n #Hypertension: pt was hypertensive last night up to 180/81. Given 5mg\n metoprolol IV w/ good response. Now 151/82.\n -cont to moniotor BP closely\n # Hypernatremia: pt\ns Na is 142 today up from 143 yesterday.\n -will decrease free water through tube feeds to 100cc/hr\n -will re-check Na in the am\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated overnight but\n was agitated and threatening in the am. Received no meds.\n -cont morphine prn\n -consider zyprexa if still agitated and threatening.\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 96 from yesterday in the pm and 56 yesterday\n in the am. Considering HIT (low suspicion as pt on lovenox) vs drug\n reaction. Most likely lab error.\n -will check CBC in the PM\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia. Pt finished his course of antibiotics yesterday (8 days of\n Unasyn). Currently off O2 on RA sats ~95%.\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Will advance to purees today.\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: none\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 586809,
"text": "Chief Complaint:\n 24 Hour Events:\n --Patient failed bedside swallow, but passed video swallow study\n --Patient not on oxygen. Able to sit on chair/walk in afternoon.\n --agitated, yet directable.\n --Patient's platelets stable at 96, Na=143.\n --hypertensive at night, so given metoprolol 5mg IV\n --patient more awake and alert this am, able to answer questions and\n follow commands.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:33 AM\n Piperacillin/Tazobactam (Zosyn) - 12:43 PM\n Ampicillin/Sulbactam (Unasyn) - 06:00 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 09:00 AM\n Metoprolol - 01:36 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.2\nC (99\n HR: 62 (60 - 80) bpm\n BP: 151/82(95) {99/62(77) - 180/90(137)} mmHg\n RR: 25 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 126 kg (admission): 118 kg\n Height: 72 Inch\n Total In:\n 4,083 mL\n 546 mL\n PO:\n TF:\n 1,933 mL\n 477 mL\n IVF:\n 640 mL\n 69 mL\n Blood products:\n Total out:\n 1,870 mL\n 500 mL\n Urine:\n 1,870 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,213 mL\n 46 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 95%\n ABG: ///28/\n Physical Examination\n General: arousable, in no acute distress, AOx2\n HEENT: Sclera anicteric, MMM\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi.\n Exam limited patient sedated and restrained.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel present, no rebound\n tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral\n LE TEDS stockings, abductor pillow in place\n Neurologic: not assessed\n Labs / Radiology\n 96 K/uL\n 9.2 g/dL\n 143 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 21 mg/dL\n 109 mEq/L\n 142 mEq/L\n 28.1 %\n 6.5 K/uL\n [image002.jpg]\n 04:18 AM\n 06:00 AM\n 03:50 AM\n 04:55 PM\n 04:02 AM\n 02:28 PM\n 04:09 AM\n 04:04 AM\n 03:41 PM\n 04:24 AM\n WBC\n 9.3\n 5.8\n 5.1\n 5.5\n 5.3\n 6.9\n 6.5\n Hct\n 28.6\n 26.9\n 27.2\n 26.0\n 29.6\n 27.9\n 28.1\n Plt\n 85\n 83\n 80\n 85\n 56\n 99\n 96\n Cr\n 1.5\n 1.4\n 1.0\n 1.1\n 1.0\n 1.0\n 0.9\n 0.8\n 0.9\n 0.8\n Glucose\n 127\n 133\n 136\n 159\n 150\n 186\n 144\n 107\n 115\n 143\n Other labs: PT / PTT / INR:13.9/26.6/1.2, CK / CKMB /\n Troponin-T:7250//, Differential-Neuts:74.0 %, Band:8.0 %, Lymph:5.0 %,\n Mono:9.0 %, Eos:0.0 %, Lactic Acid:1.7 mmol/L, Albumin:2.8 g/dL,\n Ca++:8.1 mg/dL, Mg++:2.0 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERNATREMIA (HIGH SODIUM)\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n ATRIAL FIBRILLATION (AFIB)\n OBSTRUCTIVE SLEEP APNEA (OSA)\n AROUSAL, ATTENTION, AND COGNITION, IMPAIRED\n AIRWAY CLEARANCE, IMPAIRED\n MUSCLE PERFORMACE, IMPAIRED\n RANGE OF MOTION, IMPAIRED\n RESPIRATION / GAS EXCHANGE, IMPAIRED\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ACIDOSIS, RESPIRATORY\n ACIDOSIS, MIXED\n HYPOVOLEMIA (VOLUME DEPLETION - WITHOUT SHOCK)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring. Subsequently developed PNA w left lower lobe\n colapse and EtOH withdrawal.\n #Hypertension: pt was hypertensive last night up to 180/81. Given 5mg\n metoprolol IV w/ good response. Now 151/82.\n -cont to moniotor BP closely\n # Hypernatremia: pt\ns Na is 142 today up from 143 yesterday.\n -will decrease free water through tube feeds to 100cc/hr\n -will re-check Na in the am\n #Withdrawal/pain/delirum: Pt has received a large amount of valium for\n his CIWA and ranges from barely arousable to aggitation. Cosidering\n alternate causes for his delirum including hypernatremia, pain,\n sundowning (aggitation is mostly at night). Not agitated overnight but\n was agitated and threatening in the am. Received no meds.\n -cont morphine prn\n -consider zyprexa if still agitated and threatening.\n #Thrombocytopenia: Pt\ns platelet count has been decreasing steadily\n since admission. Today 96 from yesterday in the pm and 56 yesterday\n in the am. Considering HIT (low suspicion as pt on lovenox) vs drug\n reaction. Most likely lab error.\n -will check CBC in the PM\n # Hypoxemia: Likely secondary to HAP (initially LLL infiltrate), now\n CXR shows ?collapsed RLL. This was most likely a result of the pt lying\n on his left side for many hours during the surgery, compounded by\n volume overload and increased pulmonary secretions. The secretions have\n continued to be greenish and concerning. Fentanyl/versed sedation\n weaned off. CO2 in low 50s, likely stable hypercapnia given smoking\n history. Successfully extubated yesterday currently on BiPAP. Pt was\n afebrile overnight, although WBC trending down now 5.1. BAL w/ H. flu\n +beta lactamase (amp resistant), S. pneumo (Cx . above). There is\n also a component of resp depression and withdrawal contributing to\n hypoxemia. Pt finished his course of antibiotics yesterday (8 days of\n Unasyn). Currently off O2 on RA sats ~95%.\n - chest PT\n - albuterol MDI q2 prn\n .\n # Atrial Fibrillation: Pt stable w/ no more episodes of a-fib w/ RVR\n on current regimen.\n -cont. 50 tid po lopressor\n -clonidine 0.4 daily\n .\n # Decreased urine output: Concern for ATN vs pre-renal. Although\n Una<10, FeNa 0.05%, intrabd pressure < 15, U/A improved, no e/o ATN/AIN\n -> pre-renal. Pt\ns ATN now resolving, Cr steadily improving daily, now\n 0.8. Currently w/ good UOP ~100cc/hr.\n - cont to monitor UOP, Cr\n .\n # s/p hip surgery:\n -f/u PT\n - f/u ortho recs\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n ICU Care\n Nutrition:\n Will advance to purees today.\n Glycemic Control:\n Lines:\n 16 Gauge - 10:42 PM\n 20 Gauge - 09:56 AM\n Prophylaxis:\n DVT: lovenox\n Stress ulcer: none\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU level of care\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 585501,
"text": "Chief Complaint: intubated post-op\n HPI:\n Mr. is a 48 year-old man who is being transferred to the for\n monitoring after hip replacement surgery and hardware removal\n complicated by significant blood loss. The patient initially injured\n his hip after falling from a roof in . He suffered a right hip\n fracture at the time that was repaired with an IM nail. Recently, he\n developed R groin and hip pain, found to be due to AVN of the femoral\n head. Today he underwent a prolonged procedure involving removal of\n the IM nail and associated hardware followed by bipolar hip\n replacement. The procedure took over four hours. Pt had approximately\n 3L of blood loss. He received 1750cc of cell blood in the OR, 2\n units of pRBC, and 6L of colloid. He did require some neosynephrine\n during the procedure which was weaned prior to transfer.\n .\n On arrival to the , he is intubated and sedated.\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 Cefazolin - 12:45 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Morphine Sulfate - 11:45 PM\n Midazolam (Versed) - 12:20 AM\n Fentanyl - 12:20 AM\n Other medications:\n Percocet (up to 9 tabs daily)\n Past medical history:\n Family history:\n Social History:\n s/p R femur fracture with IM nailing in '\n Hypertension (not on medication)\n Non-contributory\n Occupation:\n Drugs:\n Tobacco: Smokes 2 packs per day.\n Alcohol: Drinks 6 beers per day.\n Other:\n Review of systems: Unable to obtain as pt is intubated and sedated.\n Flowsheet Data as of 01:47 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 116 (107 - 116) bpm\n BP: 148/71(89) {111/57(73) - 155/84(103)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,422 mL\n 132 mL\n PO:\n TF:\n IVF:\n 6,972 mL\n 132 mL\n Blood products:\n 2,450 mL\n Total out:\n 3,770 mL\n 5 mL\n Urine:\n 20 mL\n 5 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,652 mL\n 127 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 800 (700 - 800) mL\n RR (Set): 25\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.19/59/102//-6\n Ve: 10.7 L/min\n PaO2 / FiO2: 204\n Physical Examination\n Vitals: T: 99.5, BP: 113/57, P: 108, R: 20, O2: 95%\n Vent: Vt 700, rate 16, PEEP 5, FiO2 50%\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, drain with sanguinous drainage,\n bilateral 1+ pedal pulses, bilateral LE TEDS stockings, abductor pillow\n in place\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A7/14/ 11:26 PM\n \n 10:20 P7/15/ 12:41 AM\n \n 1:20 P7/15/ 12:54 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Other labs: Lactic Acid:3.7 mmol/L\n Fluid analysis / Other labs: ABG: 7.19/57/82\n Imaging: CXR: left lower lobe collapse with mediastinal shift to the\n left, possible left pleural effusion, no effusion on the right\n Assessment and Plan\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n .\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to left lower lobe collapse causing a significant respiratory\n acidosis. This was most likely a result of the pt lying on his left\n side for many hours during the surgery, compounded by volume overload\n and increased pulmonary secretions.\n - monitor ABGs closely\n - increase RR to improve ventilation\n - albuterol MDI q2 prn\n - aggressive suctioning and chest PT\n - caution with further IVF\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Received 1L LR on arrival to\n the .\n - cont to monitor lactate\n - expect to improve with IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. has not\n increased after IVF challenge, raising concern for ATN.\n - send UA, urine lytes\n - monitor BUN/Cr\n - cont to monitor , hold off on further boluses given adequate\n BP and concern for volume overload\n # s/p hip surgery:\n - check post-op hct\n - start lovenox 30 in am\n - ancef x 24h\n - AP pelvis\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # FEN: IVF as above, replete electrolytes, NPO\n .\n # Prophylaxis: lovenox in the AM, bowel regimen\n .\n # Access: peripherals\n .\n # Code: full code\n .\n # Communication:\n .\n # Disposition: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 585507,
"text": "Chief Complaint: intubated post-op\n HPI:\n Mr. is a 48 year-old man who is being transferred to the for\n monitoring after hip replacement surgery and hardware removal\n complicated by significant blood loss. The patient initially injured\n his hip after falling from a roof in . He suffered a right hip\n fracture at the time that was repaired with an IM nail. Recently, he\n developed R groin and hip pain, found to be due to AVN of the femoral\n head. Today he underwent a prolonged procedure involving removal of\n the IM nail and associated hardware followed by bipolar hip\n replacement. The procedure took over four hours. Pt had approximately\n 3L of blood loss. He received 1750cc of cell blood in the OR, 2\n units of pRBC, and 6L of colloid. He did require some neosynephrine\n during the procedure which was weaned prior to transfer.\n .\n On arrival to the , he is intubated and sedated.\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 Cefazolin - 12:45 AM\n Infusions:\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Morphine Sulfate - 11:45 PM\n Midazolam (Versed) - 12:20 AM\n Fentanyl - 12:20 AM\n Other medications:\n Percocet (up to 9 tabs daily)\n Past medical history:\n Family history:\n Social History:\n s/p R femur fracture with IM nailing in '\n Hypertension (not on medication)\n Non-contributory\n Occupation:\n Drugs:\n Tobacco: Smokes 2 packs per day.\n Alcohol: Drinks 6 beers per day.\n Other:\n Review of systems: Unable to obtain as pt is intubated and sedated.\n Flowsheet Data as of 01:47 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.5\nC (99.5\n HR: 116 (107 - 116) bpm\n BP: 148/71(89) {111/57(73) - 155/84(103)} mmHg\n RR: 30 (16 - 30) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 9,422 mL\n 132 mL\n PO:\n TF:\n IVF:\n 6,972 mL\n 132 mL\n Blood products:\n 2,450 mL\n Total out:\n 3,770 mL\n 5 mL\n Urine:\n 20 mL\n 5 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,652 mL\n 127 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 800 (700 - 800) mL\n RR (Set): 25\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 26 cmH2O\n SpO2: 96%\n ABG: 7.19/59/102//-6\n Ve: 10.7 L/min\n PaO2 / FiO2: 204\n Physical Examination\n Vitals: T: 99.5, BP: 113/57, P: 108, R: 20, O2: 95%\n Vent: Vt 700, rate 16, PEEP 5, FiO2 50%\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: R hip with dressing in place, drain with sanguinous drainage,\n bilateral 1+ pedal pulses, bilateral LE TEDS stockings, abductor pillow\n in place\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A7/14/ 11:26 PM\n \n 10:20 P7/15/ 12:41 AM\n \n 1:20 P7/15/ 12:54 AM\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Other labs: Lactic Acid:3.7 mmol/L\n Fluid analysis / Other labs: ABG: 7.19/57/82\n Imaging: CXR: left lower lobe collapse with mediastinal shift to the\n left, possible left pleural effusion, no effusion on the right\n Assessment and Plan\n This is a 48 year-old man s/p prolonged IM nail removal and bipolar R\n hip replacement complicated by large volume blood loss, transferred to\n the for monitoring still intubated.\n .\n # Respiratory failure: Likely secondary to alveolar hypoventilation\n due to left lower lobe collapse causing a significant respiratory\n acidosis. This was most likely a result of the pt lying on his left\n side for many hours during the surgery, compounded by volume overload\n and increased pulmonary secretions.\n - monitor ABGs closely\n - increase RR to improve ventilation\n - albuterol MDI q2 prn\n - aggressive suctioning and chest PT\n - caution with further IVF\n .\n # Elevated Lactate: Concern for hypoperfusion in the setting of\n significant volume loss during surgery. Received 1L LR on arrival to\n the .\n - cont to monitor lactate\n - expect to improve with IVF\n .\n # Decreased urine output: Concern for ATN vs pre-renal. has not\n increased after IVF challenge, raising concern for ATN.\n - send UA, urine lytes\n - monitor BUN/Cr\n - cont to monitor , hold off on further boluses given adequate\n BP and concern for volume overload\n # s/p hip surgery:\n - check post-op hct\n - start lovenox 30 in am\n - ancef x 24h\n - AP pelvis\n - strict posterior hip precautions\n - abduction pillow btw legs\n - hob not greater than 90\n .\n # FEN: IVF as above, replete electrolytes, NPO\n .\n # Prophylaxis: lovenox in the AM, bowel regimen\n .\n # Access: peripherals\n .\n # Code: full code\n .\n # Communication:\n .\n # Disposition: ICU level of care\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 10:30 PM\n 16 Gauge - 10:42 PM\n Prophylaxis:\n DVT: LMW Heparin\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n 48 yr man s/p hip replacement complicated by signif blood loss. Still\n intubated. Injured hip after fall. Avascular necrosis of hip\n complicating nail placement for fixation. Had estimated blood loss of 3\n liters replaced with 2500cc blood. Required 6 liters crystallloid as\n well. Required Neo during procedure but weaned before sending to .\n Decided to vent overnight because of large volume requirement.\n PMH + HBP.\n Opt Meds - Percocet\n Smokes 2PPD/ 6 Beers/day\n 95% on AC with 700/16 with 8 PEEP, 50% FiO2 with 7.19/57/82\n Obese, sedated, pupils pinpoint\n Lungs - coarse anteriorly\n Cor - distant\n Abdomen - obese, non-tender, BS active\n Extrem - bandaged r hip, present pedal pulses\n Not alert, sedated\n CXR - partial LLL collapse, partially re-expanded on current film.\n Impression:\n Respiratory Failure from Volume overload, Left partial collapse\n Suctioning aggressively, chest PT, follow ABG's,\n Sedation with propafol, fentanyl/versed boluses\n Mild metabolic acidosis from hypoperfusion with only mildly elevated\n lactate\n Tachycardic with no clear etiology......doubt sepsis, concerned about\n possible DT's (on versed currently)\n Appears to be adeqautely volume repleted\n Renal Insufficiency - check sediment, maybe ATN from hypoperfusion\n during prolonged procedure\n Hip Surgery management per surgery. Will follow Hct closely\n Remainder of details per HO note\n Time Spent: 45 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 02:23 ------\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 585590,
"text": "Attending Physician: , \n Referral date: \n Medical Diagnosis / ICD 9: osteonecrosis femoral head / 733.41\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: Pt is 48M admitted\n s/p removal of R hip IM nail and THA in the setting of R hip\n -traumatic osteonecrosis of the R femoral head. Pt s/p R femoral fx\n and IM nail placement in after fall from roof. Pt reporting\n increased pain over past couple of months in R lateral hip and groin\n area, not relieved by percocet. Pt OR course c/b hypovolemia\n (estimated blood loss 3200 cc) and acidosis; operative report currently\n unavailable for review. Pt currently intubated and sedated.\n Past Medical / Surgical History: HTN, R hip fx s/p IM nail in \n Medications: morphine, acetaminophen, enoxaparin sodium, fentanyl\n citrate, midazolam\n Radiology: hip xray: report unavailable; & CXR: report\n unavailable\n Labs:\n 44.0\n 14.5\n 95\n 22.7\n [image002.jpg]\n Other labs:\n pH: 7.25\n pCO2: 47\n pO2: 130\n HCO3: 22\n Activity Orders: activity as tolerated; PWB RLE; strict R posterior hip\n precautions; no active R hip abduction; hip abduction pillow in bed at\n all times; obtain R hip abduction brace\n Social / Occupational History: unable to obtain from chart, but assume\n I PTA\n Living Environment: unable to obtain from chart or pt\n Functional Status / Activity Level: amb with cane hip pain, +\n smoking\n Objective Test\n Arousal / Attention / Cognition / Communication: pt sedated,\n occasionally opening eyes with PROM R hip\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 106\n 128/70\n 16\n 94% CMV\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n 108\n 101/50\n 20\n 95% CMV\n Total distance walked: 0ft\n Minutes:\n Pulmonary Status: pt currently intubated CMV, FiO2 50%, PEEP 8\n per respiratory/NSG notes, pt being suctioned for secretions\n Integumentary / Vascular: arterial line, foley, 2 hip drains,\n endotracheal tube, dressing R hip (C,D,I)\n all extremities warm to touch, dorsalis pedal pulses 2+ BLE\n Sensory Integrity: unable to assess sedation, but pt opening eyes\n to PROM R hip\n Pain / Limiting Symptoms: unable to asses sedation\n Posture: pt received supine in bed, HOB elevated 30 degrees, hip\n abduction pillow in place, R hip ER\n Range of Motion\n Muscle Performance\n WFL t/o LE, deferred UE PROM restraints\n R hip abd: 16, flex: 90, IR: to neutral, ER: 20\n unable to formally assess, but pt demonstrates spontaneous movement of\n all limbs with decreased sedation, movements limited by restraints\n Motor Function: unable to assess\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: unable to assess functional mobility pt intubated\n and sedated\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: unable to assess functional mobility pt intubated and\n sedated\n Education / Communication: NSG: pt status, locked knee ext on bed\n controls, maintain R hip neutral position as able, will contact ortho\n resident/ R hip abduction brace\n , PA: paged about putting order for R hip abd brace for\n brace shop\n Intervention: PROM R hip x10 minutes\n Other:\n Diagnosis:\n Clinical impression / Prognosis: Pt is 48M s/p R THA in the setting of\n R hip post-traumatic osteonecrosis, POD1, c/b respiratory acidosis and\n currently remains intubated and sedated. Pt p/w above impairments c/w\n joint arthoplasty. Evaluation limited pt sedation, but anticipate\n pt will be able to return to I functioning without AD with PT\n intervention. PT will f/u daily for ROM while pt sedated and initiate\n functional mobility and therex when pt is appropriate.\n Goals\n Time frame: 1 week\n 1.\n tolerate daily ROM to limit of R posterior hip precautions\n 2.\n assess functional mobility\n 3.\n assess muscle performance\n 4.\n 5.\n 6.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: daily for 1 week\n ROM R hip\n assess functional mobility and muscle performance when pt appropriate\n pt/family ed\n D/C planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
},
{
"category": "Rehab Services",
"chartdate": "2182-08-21 00:00:00.000",
"description": "Physical Therapy Evaluation Note",
"row_id": 585591,
"text": "Attending Physician: , \n Referral date: \n Medical Diagnosis / ICD 9: osteonecrosis femoral head / 733.41\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: Pt is 48M admitted\n s/p removal of R hip IM nail and THA in the setting of R hip\n -traumatic osteonecrosis of the R femoral head. Pt s/p R femoral fx\n and IM nail placement in after fall from roof. Pt reporting\n increased pain over past couple of months in R lateral hip and groin\n area, not relieved by percocet. Pt OR course c/b hypovolemia\n (estimated blood loss 3200 cc) and acidosis; operative report currently\n unavailable for review. Pt currently intubated and sedated.\n Past Medical / Surgical History: HTN, R hip fx s/p IM nail in \n Medications: morphine, acetaminophen, enoxaparin sodium, fentanyl\n citrate, midazolam\n Radiology: hip xray: report unavailable; & CXR: report\n unavailable\n Labs:\n 44.0\n 14.5\n 95\n 22.7\n [image002.jpg]\n Other labs:\n pH: 7.25\n pCO2: 47\n pO2: 130\n HCO3: 22\n Activity Orders: activity as tolerated; PWB RLE; strict R posterior hip\n precautions; no active R hip abduction; hip abduction pillow in bed at\n all times; obtain R hip abduction brace\n Social / Occupational History: unable to obtain from chart, but assume\n I PTA\n Living Environment: unable to obtain from chart or pt\n Functional Status / Activity Level: amb with cane hip pain, +\n smoking\n Objective Test\n Arousal / Attention / Cognition / Communication: pt sedated,\n occasionally opening eyes with PROM R hip\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n 106\n 128/70\n 16\n 94% CMV\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n 108\n 101/50\n 20\n 95% CMV\n Total distance walked: 0ft\n Minutes:\n Pulmonary Status: pt currently intubated CMV, FiO2 50%, PEEP 8\n per respiratory/NSG notes, pt being suctioned for secretions\n Integumentary / Vascular: arterial line, foley, 2 hip drains,\n endotracheal tube, dressing R hip (C,D,I)\n all extremities warm to touch, dorsalis pedal pulses 2+ BLE\n Sensory Integrity: unable to assess sedation, but pt opening eyes\n to PROM R hip\n Pain / Limiting Symptoms: unable to asses sedation\n Posture: pt received supine in bed, HOB elevated 30 degrees, hip\n abduction pillow in place, R hip ER\n Range of Motion\n Muscle Performance\n WFL t/o LE, deferred UE PROM restraints\n R hip abd: 16, flex: 90, IR: to neutral, ER: 20\n unable to formally assess, but pt demonstrates spontaneous movement of\n all limbs with decreased sedation, movements limited by restraints\n Motor Function: unable to assess\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: unable to assess functional mobility pt intubated\n and sedated\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: unable to assess functional mobility pt intubated and\n sedated\n Education / Communication: NSG: pt status, locked knee ext on bed\n controls, maintain R hip neutral position as able, will contact ortho\n resident/ R hip abduction brace\n , PA: paged about putting order for R hip abd brace for\n brace shop\n Intervention: PROM R hip x10 minutes\n Other:\n Diagnosis:\n 1.\n 3.\n 5.\n Impaired arousal, attention and cognition\n Impaired muscle performance\n Impaired gas exchange\n 2.\n 4.\n Impaired airway clearance\n Impaired ROM\n Clinical impression / Prognosis: Pt is 48M s/p R THA in the setting of\n R hip post-traumatic osteonecrosis, POD1, c/b respiratory acidosis and\n currently remains intubated and sedated. Pt p/w above impairments c/w\n joint arthoplasty. Evaluation limited pt sedation, but anticipate\n pt will be able to return to I functioning without AD with PT\n intervention. PT will f/u daily for ROM while pt sedated and initiate\n functional mobility and therex when pt is appropriate.\n Goals\n Time frame: 1 week\n 1.\n tolerate daily ROM to limit of R posterior hip precautions\n 2.\n assess functional mobility\n 3.\n assess muscle performance\n 4.\n above with O2 sats >92% on RA\n 5.\n 6.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: daily for 1 week\n ROM R hip\n assess functional mobility and muscle performance when pt appropriate\n pt/family ed\n D/C planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n"
}
] |
3,649 | 139,020 | Patient was admitted to the ICU after surgical resection of small bowel obstruction and repair of incisional hernia. Patient was found to be bacteremic with VRE and treatment started with Linezolid after surgery on . Patient was admitted to the ICU and progressed without incidence, was extubated and transferred to the floor with exception of poor nutritional intake and continued bactermia treatment. Nutrition was consulted and has followed patient throughout course. He has been on TPN on/off since . Once on floor, patient became more encephalopathic and restraints were used prudently to control outbursts. Patient had resistant ascites which has been one of the hallmarks of his stay. Patient did hallucinate at times, had slurred speech, and patient was treated with rifaximen and lactulose. Patient care was supportive with concern for patient's resistant ascites and poor general nutritional status. Patient had PICC placed on for antibiotics. Patient has been seen by PT throughout stay. On , one of multiple paracentesis grew out albicans and eventually . He also had 1110 WBCs, 58% polys. Patient also found to have fungemia. Patient had been treated with Fluconazole but was switched to Caspofungin then eventually to Micafungin 100 qd secondary to pharmacy/ID recs due to better metabolism by liver and need for higher Caspo dose. Zosyn started for SBP treatment. Paracentesis on to 3200 WBC with 86% polys. Meropenam was started per ID in case of ESBL organisms and linezolid continued for VRE. Rifaxamin was d/c at this time. CXR showed Right sided pleural effusion as patient complaining of difficulty breathing. US-guided thoracentesis was going to be attempted but did not occur as patient did not allow procedure. Secondary to thrombocytopenia to 14, pt. was switched from linezolid to Daptomycin for VRE coverage and platelets have risen slowly and completed a full course of antibiotics with resolution of the VRE bacteremia. Mr. was transferred to the hepatorenal medicine service on for continued management of his medical problems. was continued on iv Micafungin per the ID team for a 15 day course until at which point he had another paracentesis, this time with no evidence of bacterial or fungal peritonitis (330 WBCs, 28% neutrophils). The next day, however, his peripheral white blood cell count began rising and his PICC line was pulled (and TPN discontinued) due to concern for a line infection, but the line tip culture showed no infection. He remained without any localizing signs/symptoms of infection, though his WBC continued rising. A CXR on showed a new RLL consolidation and he was started empirically on Zosyn for a nosocomial pneumonia, though his WBC continued rising. A thoracentesis of his parapneumonic effusion showed no empyema and he was switched to po levofloxacin and metronidazole, still with no improvement in his WBC. A perianal cyst (which had not been previously noted) ruptured on , though his WBC didn't drop with drainage of this cyst. On , his ascites was again tapped and he was noted to have >4000 WBCs (39% neutrophils). He was resumed on the Micafungin per ID recs. Cultures of this fluid grew albicans and C. . He was taken off the waiting list due to this fungal peritonitis, although it was planned to re-list him after the infection was cleared. He was therefore maintained on micafungin IV. In , his creatinine began to rise above his baseline of 1.2 and eventually as high as 2.7. He had not previously carried a diagnosis of hepatorenal syndrome but renal ultrasounds and urine electrolytes did not point to any other renal pathology. His creatinine did gradually respond to empiric therapy with octreotide and midodrine for hepatorenal syndrome. His malnutrition had become a growing concern leading to the initiation of TPN. Although his TPN was d/c'ed on due to a concern for a line infection, his appetite began to improve and he ws steadily consuming Boost supplements daily through mid-, when his mental status began to deteriorate due to a worsening of hepatic encephalopathy and poor oxygenation due to recurrent/enlarging pleural effusions and tense ascites and he could not protect his airway well enough to take a po diet. No source could be found for his persistent leukocytosis, however. Repeated imaging of the abdomen did not reveal any abscesses; imaging of the orthopaedic hardware in the R tibia did not suggest osteomyelitis. In mid- his encephalopathy became worse, making him confused and disoriented, and the abdomen was again imaged without diagnostic findings other than worsening ascites. A diagnostic paracentesis was performed with findings consistent with bacterial peritonitis on ; cultures of the peritoneal fluid grew Staph aureus. The next day blood cultures also grew Staph aureus and vancomycin was started but the patient became increasingly disoriented and lethargic. Arterial blood gases showed hypoxia and hypercapnia. A radio-labeled white blood cell scan was also performed at the time of the diagnostic paracentesis, since the patient??????s renal function contraindicated IV contrast dye, to look for abscesses; the only intensities on WBC scanning were in the lungs. He was transferred to the ICU for intubation and ventilatory support. The recurrent right pleural effusion was again tapped and culture of the fluid grew Staph aureus; a chest tube was placed to drain the infected fluid. Pressors were started to maintain his blood pressure. Despite these interventions to address his overwhelming Staph infection, his mental status did not improve; sedatives were stopped and there was no return of cognitive function. The family was advised of his poor prognosis and multisystem organ failure and they decided to pursue comfort measures only, since further interventions seemed only to prolong his suffering. He was extubated and transferred out of the ICU and back to the hepatorenal service on . His pain was controlled with narcotics as needed. He expired on . | Remains on VRE and MRSA Precautions, Lactate= 4.2. Remains in ARF prob d/t sepsis. On vanco per levels; flagyl, micafungin, and cefepime--emperically treating. PT WITH GENERALIZED +2 EDEMA.GI/GU: ABD LG, ACITIES. Nursing Note (0700-1900hrs)Events: Remains off levophed and propofol gtts. Remains intubated on AC, rate increased to 18 for resp acidosis with pos effect.GI: Abd soft, distended, absent bs. Resp Care: Pt continues intubated and on ventilatory support with a/c overnoc maintaining abg wnl; bs coarse, sxn thick clear secretions, rsbi this am 81, placed on sbt per protocol, will attempt wean to extubate. Bowels hypoactive and NGT with minimal out. Most recent abgs reveals hyperoxygenated mild. sbp greater than 100 and aline remains positional.resp: pt remains on 4l nc and breath sounds remain clear.gi: pt remain npo with hypoactive bowel sound.gu: urine output remains adequatea: ?transfer to floor today. SX'D Q3-4 FOR THICK TAN AND BLOOD TINGED SECCRETIONS.NEURO--PT REMAINS MIN RESPONSIVE. acidosis, RR increased.Bs:diminished R>L.Plan: wake , wean > extubate. OGT CONTS TO LIS, DRAINING BILIOUS AND ? FS SLIGHTLY ELEVATED, BEING COVERED WITH SSREG.RENAL--U/O VIA FOLEY CATH 10-20CC/HR. Resp CarePt. Cortrosyn levels. Await return of bowel function to begin lactulose/po meds. NGT PATENT, DRNG SM AMT CLEAR FLUID. A-line unremarkable, occ positional--coinciding with NIBP> Repeat labs at 1700hrs.Resp: LS ess coarse upper, diminished to bases. Recieved 2 units PRBC's for Hct <30, 2 units FFP and vit K for INR 1.9.Resp: LS clear bilat, diminished on R side, Chest x-ray showing whiteout on R side. Po pills on hold for now.GU)Very low U/O via foley catheter. ABD REMAINS DISTENDED SEC TO ASCITES.RENAL--PT WITH MIN URINE OUT. PATIENT/TEST INFORMATION:Indication: Endocarditis.Height: (in) 70Weight (lb): 232BSA (m2): 2.23 m2BP (mm Hg): 106/44HR (bpm): 90Status: InpatientDate/Time: at 14:00Test: 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.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). sx via pleurovac---dressing changed and D/I, No crepitus noted, No air leak, + fluctuation, Tube draining small amts serosanguinous.....significantly decreased amount over last 24-36 hours.GI: Remains NPO. +gag reflex; sluggish pupil response to light; otherwise nonresponsive to stimuli.CV: HR 80-90's, NSR; BP 90-100's with MAP >60 with levophed gtt; presently 0.1mcg/kg/min, was able to titrate down. Lactate increased to 4.2 this am.Skin: Lower abd reddened---unchanged as per report from MD, No breakdown noted. Not breathing enough on CPAP immediately back on assist. Lung sounds sl coarse suct sm=>mod th tan sput. There is a minimally increasedgradient consistent with minimal aortic valve stenosis. The morphology and severity of aortic regurgitation appearsimilar.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). TECHNIQUE: MDCT axial non-contrast images of the abdomen and pelvis were obtained with sagittal and coronal reformatted images. Normal sinus rhythm with low amplitude P waves and a P-R intervalof approximately 0.18. No creptius noted and chest tube with + fluctation and negative for air leak. Right heart border is obscured by the atelectasis and pleural effusion. CT CHEST WITHOUT CONTRAST: There is a moderate/large right pleural effusion with presumed associated atelectasis that is relatively unchanged from . CT OF THE ABDOMEN WITHOUT CONTRAST: There is a large right pleural effusion with a loculated component anterior to the major fissure, with near complete collapse of the visualized portions of the right lower lobe and and portions of the right middle lobe. Marked gastric distension with distention of duodenum and proximal jejunum. CT OF THE ABDOMEN WITHOUT IV CONTRAST: Large right pleural effusion with associated atelectasis is seen. Note is made of marked free fluid within the pelvis and edema within the subcutaneous fat. The right jugular IV catheter terminates in the superior vena cava. Hazy obscuration of the right hemithorax appears to be related to large layering pleural effusion. TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained without IV contrast secondary to elevated creatinine. 8:48 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: ASCITES, INCRE. Evaluation of the bowel is somewhat limited by ascites. BILATERAL FAT-CONTAINING INGUINAL HERNIAS. There is a small anterior wall defect containing ascites. Fat-containing inguinal hernias are identified bilaterally. Bullous changes are present in the apices, and there is minimal left basilar atelectasis. There is perihepatic ascites and free fluid seen within the abdomen, similar to prior study. The right pleural catheter is again noted. There is evidence of CHF, with bibasilar atelectasis and a small right pleural effusion. FINDINGS FOR CT OF THE ABDOMEN WITH CONTRAST: There is a large right pleural effusion and right lower lobe atelectasis, unchanged. New right IJ catheter and status post thoracentesis. There is almost complete removal of the previously seen right pleural effusion. There is slightly decreased hazy opacity of the right hemithorax, likely related to right thoracentesis. IMPRESSION: Grossly unchanged right lower lobe consolidation with some increase in pleural effusion. 2) Findings compatible with CHF with alveolar edema, bilateral effusions and left lower lobe collapse and/or consolidation. The endotracheal tube, nasogastric tube, and the right internal jugular central venous catheter have been removed. There has been interval development of a tiny left pleural effusion and left basilar atelectasis. SEMI-UPRIGHT AP CHEST: There is an endotracheal tube in place, with the tip approximately 6.7 cm from the carina. Then, a 0.018 guidewire was advanced through the needle and into the distal SVC under fluoroscopic guidance. Multiple fluid collections are demonstrated within the subcutaneous tissues in region of prior hernia repair, the largest of which measures 5.7 cm x 2.3 cm, unchanged. A right-sided IJ central venous catheter is in unchanged position with the tip projecting over the distal SVC. Again seen is cardiomegaly and mild prominence of the superior mediastinum, with enlarged pulmonary hila. The right lower lobe consolidation is grossly unchanged with some increase in pleural effusion better demonstrated on the lateral exam. | 77 | [
{
"category": "Nursing/other",
"chartdate": "2135-07-01 00:00:00.000",
"description": "Report",
"row_id": 1309088,
"text": "nsg.progress notes:\nsee flow sheet for specific:\nNeuro:AOX3,obeys commands,MAE,PRN morphine for pain,with good effect\nCV: NSR ,no ectopy,Ivf D5 in 0.45% NS 50ml/hr,BP WNL ,inj.lasix & spirolactone po with good effect,tranplant team wants to discuss with renal team regarding diuretics,\nResp: spont breath O2 4L via NC,LS clear, O2 sat WNL,coughs out clear sputum,ABG acidotic ,Dr. aware.\nGI: NPO,NGT to LCS clear drain.abd ascitis,no BS,no bm today.abd dressing dry& intact,with abd binder\nGU: foley cath draining amber coloured clear urine,adq amt(on Lasix BD).\nEndo : FS Q6H ,on SSRI.\nACT: bed fast: turned & positioned changed Q2H,made OOB today on chair for 2hrs.tolerated well,stable VSS.\nID: afebrile,linezolid added to treatment.\nSkin: gluteal wound 2x1 cm ,with bleeding mod amt,S/b Wound nurse ,adviced for dressing with aquacel& pad,change PRN.bed changed tp Barimax with ETS per her advice( pt says he had this wound prior adm. & was taking bath for the same)\nPlan: cont monitoring,pul.hygiene.wound care,lytes & coag profile,?follow up by renal team,? transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-07-02 00:00:00.000",
"description": "Report",
"row_id": 1309089,
"text": "condition update\nD: pt alert and oriented. follows commands. moves all extremities. pt medicated with 2mg of morphine with relief of shoulder pain.\ncardiac: nsr rate in the 90's. sbp 120/60's. cvp in the teens.\nresp: pt remains on 4l nc with of sat of 98%. breath sounds are clear and pt coughing with raising.\ngi: ngt patent and draining clear fluid. abd distended with ascities.\ngu: urine output remains adequate. foley is patent.\na: assess for pain and medicate as needed. ? transfer to floor today.\nr: morphine effective in relieving pain. vs remain stable. pt appears ready for transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-07-02 00:00:00.000",
"description": "Report",
"row_id": 1309090,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO:ALERT & ORIENTED X2-3, FOLLOWS COMMANDS, MAES, EASILY AGITATED. C/O ABD, BILAT SHLDR, RIGHT HAND PAIN-2MG MORPHINE GIVEN W/RELIEF.\n\nCVS:HR 90S-100S, NSR, SBP 90S-110S, A-LINE POSITIONAL, CVP 12-17. AFEBRILE, ALBUMIN GIVEN, CONT 20MG LASIX , HOLD SPIRINOLACTONE PER TRANSPLANT TEAM.\n\nRESP: O2 SATS >97% ON 4L N/C, LUNGS CLEAR, NARD.\n\nGI/GU: ABD DISTENDED, ABSENT BS, NO FLATUS-TRANSPLANT TEAM AWARE. CONT NPO. NGT PATENT, DRNG SM AMT CLEAR FLUID. HRLY U/O>35CC.\n\nINTEG: ABD DSGS C/D/I, JP X1 W/MIN AMT SEROSANG DRNG. COCCYX DUODERM INTACT. PT TURNED FREQUENTLY FOR SKIN CHECKS, NO NEW AREAS BREAKDOWN NOTED.\n\nPLAN: CONT DIURESIS W/LASIX, PAIN MGMT, NEURO ASSESSMENT, TRANSFER TO .\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-07-03 00:00:00.000",
"description": "Report",
"row_id": 1309091,
"text": "condition update\nD: pt alert and follows commands. medicated with morphine for pain with good relief. moves all extremities. oob to chair with assist of 2. did well and sat up for approx. 1.1/2 hrs. back to bed and sleeping in short naps.\ncardiac: nsr rate in the 990's. sbp greater than 100 and aline remains positional.\nresp: pt remains on 4l nc and breath sounds remain clear.\ngi: pt remain npo with hypoactive bowel sound.\ngu: urine output remains adequate\na: ?transfer to floor today. oob to chair.\nr: tolerated getting oob to the chair. morphine effective in relieving pain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-06-29 00:00:00.000",
"description": "Report",
"row_id": 1309082,
"text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowshhet. ABG's with improving met. acidosis. FiO2 decreased from 50-40% with sats 99%. No other vent changes made. Plan to cont vent support, eval for ability to wean in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-06-30 00:00:00.000",
"description": "Report",
"row_id": 1309083,
"text": "Resp Care: Pt continues intubated and on ventilatory support with a/c overnoc maintaining abg wnl; bs coarse, sxn thick clear secretions, rsbi this am 81, placed on sbt per protocol, will attempt wean to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-06-30 00:00:00.000",
"description": "Report",
"row_id": 1309084,
"text": "NURSING UPDATE\nCV: NSR. MAP>60. HUO CONSIST 20-25CC (20CC ACCEPTABLE AMOUNT PER TEAM). HCT DOWN TO 25.7 THIS AM. PLAN: TO BE TRANSFUSED WITH 1U PRBC'S, FOLLOWED BY LASIX, PRODUCT NOT READY AT THIS TIME.\n\nRESP: BREATH SOUNDS SLIGHTLY COARSE TO CLEAR WITH TRANSIENT INSP WHEEZE IN LUL. FAILED CPAP TRIAL DURING NOC DUE TO PERIODS OF APNEA UP TO 20SECONDS. TOLERATING CPAP THIS AM AT THIS TIME, PROPOFOL VERY LOW DOSE, PLAN: EXTUBATE ON ROUNDS.\n\nNEURO: SEDATED ON LOW DOSE PROPOFOL, WEANING OFF THIS AM. SLIGHTLY AGITATED WHEN AWAKE, BUT FOLLOWING COMMANDS, NODDING AND SHAKING HEAD APPROPRIATELY IN RESPONSE TO QUESTIONS.\n\nGI: BOWEL SOUNDS RETURNED, HYPOACTIVE AT THIS TIME. NGT DRAINING SLIGHTLY BILE TINGED CLEAR FLUID. JP DRAINING SMALL AMOUNT DARK RED BLOOD. ABDOMINAL INCISION CLEAN AND DRY, NO DRAINAGE.\n\nSKIN: PT HAS HEALING DECUBITUS ON LT SIDE OF COCCYX, CLEAN, GRANULATING, NO DRAINAGE. AQUACEL AND TEGADERM APPLIED AT THIS TIME. PLAN: TO BE ASSESSED BY WOUND CARE NURSE TODAY.\n\nPT MONITORED CLOSELY.\nDRS AND IN ATTENDANCE OVERNOC.\nSEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-06-30 00:00:00.000",
"description": "Report",
"row_id": 1309085,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nPt extubated this morning and currently on 4 liters nasal cannula sating 96% and with good abg's. Alert, orientated to person, place, and reorientated to time. Aware of his surgery and diagnosis. Pt's neice called and will be in to visit today. Lungs clear and strong productive. Bowels hypoactive and NGT with minimal out. Dressing intact and jp with only minimal serous out. Morphine ivp x 1 for pain with good effect. HR NSR to Sinus tachy 105, BP 90s-100 most of day and urine ouput inc. to 40-70cc/hr with lasix (following blood this morning). Will continue to monitor labs, uo, and provide emotional support. Please refer to carevue for all further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-06-30 00:00:00.000",
"description": "Report",
"row_id": 1309086,
"text": "Resp Care\nPt successfully extubated and now on nasal 4LPM. Maintaining good Sats, and normal RR. Had one Alb tx, clear Breath sounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-07-01 00:00:00.000",
"description": "Report",
"row_id": 1309087,
"text": "NURSING UPDATE\n UNEVENTFUL NIGHT. AFEBRILE AND NORMOTENSIVE, SLIGHT SINUS TACHY, NO ECTOPY. BREATH SOUNDS CLEAR, SATS 95-97% ON 4L O2 N/PRONGS.\n MORPHINE PRN FOR C/O ABDOMINAL PAIN WITH GOOD EFFECT, INCISION DRESSISNG DRY AND INTACT. BINDER ON, MORE MOBILE IN BED TURNING WITH MIN ASSIST, REQUESTING TO GET OUT OF BED TODAY.\n NPO, GLUCOSE STABLE, INSULIN COVERAGE NOT REQUIRED. ALBUMIN INFUSED AS ORDERED. HUO 30-60CC CLEAR AMBER, SPEC SENT FOR UREA AND CREATININE THIS AM.\n PT MONITORED CONTINUOUSLY. DR IN CLOSE ATTENDANCE OVERNOC. SEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-29 00:00:00.000",
"description": "Report",
"row_id": 1309108,
"text": "MICU 6 NSG 7A-7PM\nRESP--PT CONTS ON AC 22 600 PEEP 8 40%, BREATHING OVER SET RATE. SX'D Q3-4 FOR THICK TAN AND BLOOD TINGED SECCRETIONS.\n\nNEURO--PT REMAINS MIN RESPONSIVE. GRIMACES TO PAINFUL STIMULI AND OCCAS OPENS EYES. NO SPONT MOVEMENT NOTED. PT REMAINS OFF ALL SEDATIVES.\n\nCV--HR 80-90'S SR NO ECTOPY NOTED. BP VIA RIGHT RAD REMAINS STABLE. CONTS WITH (+) EDEMA IN LOWER EXTREMITES AND SCROTUM. RIGHT PIGTAIL PLEURAL CATH REMAINS IN PLACE, WITH SEROSANG DRG VIA TUBE 10-20CC/HR. DRESSING C/DI, NO CREPITUS PALPATED. PLEUR-EVAC CONTS TO LOW WALL SUCTION.\n\nGI--ABD DISTENDED DUE TO ASCITES, NO BOWEL SOUNDS AUSCULTATED. OGT CONTS TO LIS, DRAINING BILIOUS AND ? FECAL MATERIAL. OGT INTERMITTENTLY CLOGGING AND NEEDING FLUSHING. NO BM THIS SHIFT. TBILI UP TO ~10 TODAY, INR 4.7 THIS AM. FS SLIGHTLY ELEVATED, BEING COVERED WITH SSREG.\n\nRENAL--U/O VIA FOLEY CATH 10-20CC/HR. CREAT INC TO 3.4 TODAY.\n\n (PT'S HCP) FOR UPDATES ON PT'S CONDITION, SPOKE WITH THIS RN AND DR FROM HEPATOLOGY. PLANS ON COMING IN THIS EVENING WITH OTHER FAMILY MEMBERS, TO VISIT PT AND MEET WITH LIVER TEAM AND MICU TEAM. SIGNED HCP FORM OBTAINED FROM TRANSPLANT COORDINATOR AND PLACED IN CHART. IS LISTED AS HCP ON FORM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-29 00:00:00.000",
"description": "Report",
"row_id": 1309109,
"text": "Resp Care\nPt continues to be intubated on A/C. No vent changes made this shift. BS slightly course, suctioned for sm amt of thick tan secretions. plan at this time is to continue on current settings. Please refer to carevue for all vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-30 00:00:00.000",
"description": "Report",
"row_id": 1309110,
"text": "NURSING MICU NOTE 7P-7A\n\nPT'S FAMILY ARRIVED AT . MULTIPLE FAMILY MEMBERS SPOKE ON THE PHONE WITH DR.. FAMILY MEETING WITH DR.. PT WAS MADE CMO. PT EXTUBATED AT . FAMILY AT BEDSIDE THOUGHT OUT NIGHT.\n\nNEURO: EARLY IN SHIFT PT WOULD WITHDRAW TO PAIN, NO SPONTANEOUS MVT, NOT FOLLOWING COMMANDS. SINCE EXTUBATION PT HAS RECEIVED PRN MORPHINE IVP FOR TOTAL 8MG. PT IS ORDERED FOR MORPHINE GTT, BUT HAS NOT YET REQUIRIED IT. PT WILL OPEN EYES TO PAINFUL STIMULI.\n\nRESP: PT IS ON RA WITH O2 SATS 95-100%. LS COARSE, DIMINSHED IN RIGHT BASE. PT HAS NO GAG. RR 6-15.\n\nCV: HR 80-110 NSR. SBP 100-120'S. PT WITH GENERALIZED +2 EDEMA.\n\nGI/GU: ABD LG, ACITIES. NO BS. OGT LEFT IN PLACE POST EXTUBATION. DRAINING GREEN THICK BILE. OGT FLUSHED WITH 30CC WATER TO PREVENT CLOGGING. FOLEY INTACT DRAINING AMBER URINE WITH SEDIMENT.\n\nDISPO: PLAN IS FOR COMFORT. PT STILL APPEARS COMFORTABLE, VSS. TO ASSES COMFORT, START MORPHINE GTT WHEN NEEDED. PT'S FAMILY AND FRIENDS IN AND OUT THROUGH OUT NIGHT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-06-29 00:00:00.000",
"description": "Report",
"row_id": 1309079,
"text": "Resp Care\nPt. received from OR s/p liver transplant. AC mode. Ventilation increased d/t resp. acidosis. Most recent abgs reveals hyperoxygenated mild. resp. acidosis, RR increased.\nBs:diminished R>L.\nPlan: wake , wean > extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-06-29 00:00:00.000",
"description": "Report",
"row_id": 1309080,
"text": "Admission Note\nAssessment:\nPlease see carevue for details\n\nPt arrived from OR s/p small bowel resection and hernia repair. Pt still paralyzied, intubated and placed on AC, abg's showing resp acidosis, resolving with increasing rate on vent.\n\nNeuro: Pt placed on prop gtt once paralytic wore off. Pt able to open eyes to speech and follow command intermittently. Pupils equal and responsive. MAE, withdraws to pain. Recieved morphine 2mg IV x1 for pain with pos effect.\n\nCV: Remains in NSR, no ectopy noted. Hyperkalemic to 6.1, recieved calcium, dextrose, insulin, and sodium bicarb with pos response of K 3.4. EKG done, no changes noted MD . SBP wnl, afebrile. Palp dp/pt bilat. CVP elevated 18-20. D51/2NS @ 100cc/hr. Recieved 2 units PRBC's for Hct <30, 2 units FFP and vit K for INR 1.9.\n\nResp: LS clear bilat, diminished on R side, Chest x-ray showing whiteout on R side. Remains intubated on AC, rate increased to 18 for resp acidosis with pos effect.\n\nGI: Abd soft, distended, absent bs. NGT to LCS, requiring frequent flushing to maintain sumping. JP draining small amounts of sang drainage. ABD binder intact, dsd intact.\n\nGU: Adequate amounts of cloudy yellow urine via foley cath.\n\nID: ABX for MRSA/VRE\n\nPlan:\n Monitor frequent hct and INR, give PRBC's and FFP per team, wean to extubate, Monitor LFT's, Pain management, provide emotional support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-27 00:00:00.000",
"description": "Report",
"row_id": 1309100,
"text": "Nursing Note--Cotinued\n\nResp: Right pigtail CT draining straw blood tinged fluid, approx 200cc this shift. Dsg changed, no further bleeding, site unremarkable. No leakage noted, no crepitus. LS coarse upper fields, significantly decreased to bases. CXR of showed ETT requiring advancement; advanced to 21cm and rotated to right side; awaiting results of repeat CXR. Gm stain with +yeast, cx neg. No changes on vent, remains on AC with SRR of 1-3breaths/min.\n\nGI/GU: Abd with lg amt ascites, OGT to LIWS, 200cc this shift, bile; no s/s bleeding; remains on ocreotide SQ. No bowel sounds auscultated -- to hold on po meds of lactulose/midodrine/rifaximin--team aware. Hold on TPN for now. No stool this shift--need specimen for c-diff. Mucous membranes sl dry, moistened prn. Bleeding gums. Remains in ARF prob d/t sepsis. Making approx 20cc/hr, amber, clear. Urine cx neg. Renal following. No CVVHD per request of family.\n\nID: ID following. On vanco per levels; flagyl, micafungin, and cefepime--emperically treating. Afebrile, WBC sl improved.\n\nSocial: Multiple family members and friends visiting. and sister updated on pt's condition. DNR\n\nPlan: present level of vent/pressor support; draw labs and am. Cortrosyn levels. Goal MAP >60 and Hct >30. Consider TEE at later time; await pnd cx. ?Paracentesis for infected abdomen early this week. Emotional support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-27 00:00:00.000",
"description": "Report",
"row_id": 1309101,
"text": "Passively resting on current settings.patient has very poor gag reflex suctioned for copious amount of thick bloody secretion. metabolic acidosis most likely related to kidney failure.% Sat ok,(R) pigtail placement still draining sanguinous fluid.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-28 00:00:00.000",
"description": "Report",
"row_id": 1309102,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with only the rr increased from 20 to 22. Latest results determined a partially compensated metabolic acidemia with excellent oxygenation on the current settings.\n\nRSBI = 56.1 on 0-PEEP and 0-PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-28 00:00:00.000",
"description": "Report",
"row_id": 1309103,
"text": "MICU Nursing Note 1900-0700\nEvents: Initially sedated on 15mcg/kg/min of Propofol...Pt unresponsive to painful stimuli---propofol off since MN, Resp. Rate increased on vent to 22 with improved , Able to wean IV Levophed to 0.03 mcgs/kg/min and pt actually tolerated being off of Levophed for 30 minutes during night.\n\nNeuro: Pupils 3mm equal but sluggish, no spontaneous movement and extremities flaccid, no response to painful stimuli, Propofol shut off at MN with no sig. change, Pt is overbreathing vent , + gag, + cough reflex, MICU team aware.\n\nCardiac: HR= 90-110 SR/ST with rare PVC noted, Right radial Aline with good waveform and correlation to NBP, BP= 84-106/40's with MAPs= 50-70, IV Levophed titrated to 0.03 mcgs/kg/min, Pt tolerated being off of Levophed for 30 minutes and then BP 80's/40's with MAP <60 so placed back on Levophed, CVP= , Right IJ multilumen cath patent and site C/D/I.\n\nResp: Remains intubated , Lungs coarse and diminished at bilat bases, ETtube suctioned for very thick blood tinged sputum, 7.27-40-109 during evening----Pt's rate increased from 20 to 22 with = 7.31-31-138. Current vent settings 600-40%-AC=22 and Peep=8. Pt overbreathing vent by 1-5 breaths while off propofol, MV= , Sats 97-100%, RSBI this am= 56. Right posterior pigtail chestube to 20 cm sx. and draining straw colored fluid with occasional serosang. to pleurovac=220/shift. Chest tube dressing C/D/I and no crepitus noted, Positive fluctuation and no air leak at present time.\n\nGI: Abd with large amt ascities, No bowel sounds auscultated, No BM, Remains NPO, OGtube to LIWS draining bilious with brown sediment, no coffee grounds and no evidence of bright red blood.\n\nGU: Foley to CD draining scant amts amber urine 10-30ml/hr. BUN= 65 with Creatinine= 2.8 this am. CO2= 14-15.\n\nID: Temp spike with Tmax= 100.6---Blood and urine cultures sent. WBC this am = 14.9. Remains on VRE and MRSA Precautions, Lactate= 4.2. Started on IV Hydrocortisone last night, Continues on IV Micfungin, IV Flagyl, and IV Cefepime.\n\nEndo: fingersticks WNL--no coverage required.\n\nSkin: general anasarca unchanged, No skin breakdown noted, Lower abdomen remains reddened.\n\nHeme: Hct down to 27.5 this am, INR up to 4.0, Platelets= 50, Continues on SC Octreotide, minor bleeding of gums and suctioning blood tinged sputum from ETtube.\n\nSocial: Family members (sisters) in to visit during evening hours, called and was updated on pt's condition and plan of care.\n\nPlan: Monitor for bleeding, ? pot. need for transfusion of FFP or possible platelets, Attempt to wean off of IV Levophed today, Freq. Neuro Checks----? if needs to restart Lactulose, Aggressive pulmonary toiletting, Wean vent as tolerated---CPAP+PS trial today, ? TEE in future, ? Paracentesis this week. Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-28 00:00:00.000",
"description": "Report",
"row_id": 1309104,
"text": "Nursing Note (0700-1900hrs)\n\nEvents: Remains off levophed and propofol gtts. Noted to have fecal material draining from OGT this am--prob obstruction. Renal function declining. Prognosis grim.\n\nReview of systems:\nNeuro: Opening eyes to sternal rub since 10am; occ opening eyes with verbal stimuli. No spont movements. +gag/cough reflex, mod strong. PERL, 4mm, brisk. Unable to administer lactulose d/t prob obstruction/NPO.\n\nCV: Maintaining HR 90-100's, NSR with rare PVC's. Occasionally hypotensive with MAP's 58-59 however quickly rises with stimuli. CVP decreased to . Hct sl decreased with continued decline in plts; no transfusion at this time. Ascites; +3 pitting edema to ankles; arms/hands much improved with elevation. Draining lg amt serous fluid from small abrasion to left ear. Scrotal/penile edema much improved with scrotal sling.QLCL RIJ, PIV d/c'd. A-line unremarkable, occ positional--coinciding with NIBP> Repeat labs at 1700hrs.\n\nResp: LS ess coarse upper, diminished to bases. Left Ct with s/s drng; set at 20cm sx, no crepitus/leak. Continues with mod amts thick blood tinged thick tan sputum. ETT advanced 3cm per CXR in am; 24cm teeth/25 cm lip. SRR 1-4. on AC at same settings in order to better manage metabolic issues.\n\nGi/GU: NPO; OGT to LIWS with fecal material noted by appearance and odor. OGT drained >1L since 7am. Abd remains quite distended, large however less tympanic. BS absent. Decrease in hourly u/o since yesterday,; renal has signed off. BUN/Cr increasing. Bladder pressure 12. -700cc at the time of this writing.\n\nID: Afebrile. Last pan cx last noc. VRE/MRSA. Fungal peritonitis, asp pna. On cefepime, flagyl, and vanco by level--due for dose today, level 20. Lactate stable ~4.\n\nSocial: Mutlipe family members visiting; HCP has called twice and updated. Team would like to be paged when HCP arrives to discuss pt's further decline and ?decision to make CMO>\n\nPlan: to support hemodynamics; treat with antibx for multiple infections; cx pnd. with goals for MAP >60. Await return of bowel function to begin lactulose/po meds. ?paracentesis. DNR. Family mtg; emotional support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-28 00:00:00.000",
"description": "Report",
"row_id": 1309105,
"text": "Patient less sedated today gag reflex more apparent with bronchial hygien.Has poor renal function,metabolic acidosis.On precaution for VRE,MRSA.Suctioned for moderate amount of thik brown to bloody sputum will continue to follow as per protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-29 00:00:00.000",
"description": "Report",
"row_id": 1309106,
"text": "Resp Care Note:\n\nPt intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse suct sm=>mod th tan sput. ABGs metabolic acidosis with good oxygenation; no vent changes required overnoc. mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-29 00:00:00.000",
"description": "Report",
"row_id": 1309107,
"text": "MICU Nursing Note 1900-0700\nEvents: Remains off IV Levophed and IV Propofol, NO hypotensive episodes overnight, Remains unresponsive except to painful stimuli, Lactulose on hold d/t probable bowel obstruction.\n\nNeuro: No sedation x 30 hours---no spontaneous movement noted, extemities remain flaccid, responds to sternal rub, occasionally will open eyes with turning and repositioning, pupils 4mm bilat and brisk, + gag and + cough reflex, lactulose on hold d/t fecal material via OGtube.\n\nCardiac: HR= 88-100 SR/ST with occas. PVC noted, Right radial with good waveform and good correlation to , dressing changed x2 d/t oozing bloody, BP= 100-120/50-60's, IV Levophed off x 24 hours, Right IJ mulitlumen cath site C/D/I and all ports patent, CVP= \n\nResp: Remains intubated with no vent changes overnight. No vent weaning at present d/t metabolic acidosis, Lungs coarse bilat and diminished at bilat. bases, ETtube suctioned for mod. amts thick tan and occasionally blood tinged sputum, Oral suction for same, Current vent settings 600-40%-AC=22 and Peep=8. Overbreathing vent with stimulation with RR 1-4 breaths over....otherwise RR=22, MV=, Pips 25-30, Sats= 97-100%, and = 7.34-29-130-16. Right posterior pigtail Chest tube to 20 cm. sx via pleurovac---dressing changed and D/I, No crepitus noted, No air leak, + fluctuation, Tube draining small amts serosanguinous.....significantly decreased amount over last 24-36 hours.\n\nGI: Remains NPO. Abd with large amt of ascites, no bowel sounds, no flatus, OGtube placement checked by auscultation and to LIWS and draining large amts bilious with occasional flecks of brown fecal matter.\n\nGU: Foley to CD draining scant amts amber clear urine 5-20ml/hr. BUN increased to 80 this am with creatinine up to 3.4. Renal signed off yesterday.\n\nID: Afebrile, WBC down to 14.3. Lactate= 3.4 this am, Remains on VRE/MRSA precautions, Continues on IV Hydrocortisone, IV Micafungin, IV Flagyl, and IV Cefepime.\n\nEndo: fingersticks 150-160's---required sliding scale coverage for first time overnight.\n\nHeme: Hct stable this am at 28.7 . Platelets continue to decrease=48. INR up to 4.7. Continues on SC octreotide. No evidence of bleeding at present time.\n\nSkin: Left ear with abrasion and draining small amts serous, Right arm draining serous fluid from old puncture sites, Anasarca unchanged, Scrotal edema increased---continues with scrotal sling.\n\nSocial: Large amts of family visiting all evening at bedside. Family reports that they are not ready to initiate CMO measures at this time. Support offered. No phone calls overnight after family left at MN. Remains DNR.\n\nPlan: Wean vent as tolerated, ? Paracentesis this week and ? of TEE this week, Prognosis poor with worsening liver and renal failure, Continue aggressive pulmonary toiletting, ? of lactulose via enema?, Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-06-29 00:00:00.000",
"description": "Report",
"row_id": 1309081,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nNeuro: Propofol gtt cont for comfort and safety. Pt easily awakens and follows commands but often agitated, sitting up and reaching for tubes. Temp 95.1 oral this morning and bair-hugger applied with good effect. Had been off this late morning/early afternoon and current temp maintains at 98F. Pt's neice called for update and ?will be in tommorrow. Morphine for abdominal and leg pain with good effect.\n\nCV/GU: HR NSR 80s and SBP 100-120. Urine output 20-30cc /hr adn drk amber, cloudy. 2 units FFP for inr >1.5, currently still 1.5 with no further units ordered at this time. Albumin q8hr. 500cc NS bolus with resulting 30-35cc/hr urine output, second ordered later in afternoon, but d/c'd during transfusion by liver team. 350cc in. K 4.6. Pt c/o right leg pain. Venodyne boot on right leg removed and acceptable per liver team, pulses only dopplerable on right and palpable on left. Liver team evaluated and aware, post tib pulses stronger and popliteal palpable by team Toes warm to touch and wiggles to command. NO further c/o pain, if any futher complaints or concern will work up with ultrasound and vascular studies.\n\nGI: NGT to low cont wall suct, straw colored out abdomen distended with ascites and bowel sounds absent. Dressing intact adn JP with minimal serous out\n\nREsp: Lungs clear on left, diminished on right. Suctioned infreq. Not breathing enough on CPAP immediately back on assist. Gases improved and o2 decreased to 40%.\n\nPlan: wean to extubate in am, cont to monitor urine output, abg's, bp. PLease refer to carevue for details\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-26 00:00:00.000",
"description": "Report",
"row_id": 1309094,
"text": "7pm to 7am:\n\nPt adm to MICU with resp failure and was intubated following vomiting and aspiration in radiology.\n\nROS:\n\nNeuro)\nPt remains intubated (OETT) with propofol gtt for sedation with good effect. Pt will occ open eyes to voice, but does not follow any commands.\n\nCV)\nPt was found to be hypothermic (94.5) at 8pm and was placed on \"Bair hugger\" with good result,- temp is now 98.8 (o). Pt is in NSR-ST (90-104) with no ectopy noted. A-line placed last night and has a good wave form. SBP 96-120's with MAP>60. Levophed gtt started last night D/T SBP in the 70-80's after no effect from fluid bolus. Levophed gtt now at 0.04 mcg/kg/min. (been unable to wean off). Pt given 3 units of FFP last night inr of 6.2--> now 3.8. MD aware of hct drop to 22 (27), will cont to follow. Pt has gen edema with + pitting to lower ext's.\n\nID)\nWBC elevated at 20 (24). night 5.3-> now 3.8. Pt has sputum, urine and blood cx's . Vanco was d/c'd ? restart. TR this am. Pt remains on Cefepime IV. Pt will need a stool sample.\n\nResp)\nNo vent changes made over night. A/C mode at 50/600 x 20/8peep. with no changes at 7.30/38/100/19. pt was deep sx'd for sml amounts of green-yellow scretions in the beginning of the shift-> and now deep sx'd for sml amounts of yellow secretions. Pt had a thoracenthesis done and are going to have another one today (Factor 7 on hold for now!). LS coarse to upper resp area with decreased LS at bases.\n\nGI)\nAbd very dist/round and soft. BS (-) x 2min. OGT in place and to LWS with only scant amounts of green drainage. OGT will need some irrigation. No BM at this time. IVF at KVO. Nutrition c/s re TPN. Alb IV qd. Po pills on hold for now.\n\nGU)\nVery low U/O via foley catheter. Md aware and no treatments for , cont to eval.\n\nSOC)\n HCP called last night and updated.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-26 00:00:00.000",
"description": "Report",
"row_id": 1309095,
"text": "MICU NSG 7A-7PM\nRESP--PT REMAINS ORALLY INTUB VENT SETTINGS AC 20 600 PEEP 8 40%. PLEASE SEE CAREVIEW FOR 'S. SX'D Q2-4 FOR SCANT AMOUNTS OF THICK GREEN TINGED SECRETIONS VIA ETT. PLEURAL PIGTAIL CATH PLACED AT BEDSIDE, SO FAR HAS DRAINED ~2400CC SEROSANGUINOUS FLUID.\n\nCV--PT CONTS IN ST ~100-118, NO ECTOPY NOTED. REMAINS ON LEVOPHED GTT TITRATED FOR GOAL MAP ~60. PT RECEIVED TOTAL OF 6U FFP FOR INR REVERSAL PRIOR TO THORACENTESIS. PT WITH HCT TRENDING DOWN THIS AM, RECEIVED 2U PC'S. WILL HAVE HCT/COAGS/CHEM CHECKED THIS EVENING. CVP 7-13. CONTS WITH (+) EDEMA IN EXTREMITES. FAMILY IN TO VISIT, HCP MADE PT DNR, BUT WOULD LIKE TO CONT WITH CURRENT TREATMENT.\n\nGI--OGT TO LIS AND CLAMPED AT TIMES. PT WITH COFFEE GORUNDS, SM AMOUNTS BRB AND SMALL CLOTES NOTED FROM TUBE. NO BM THIS SHIFT, PT WILL NEED STOOL SPECS WHEN HE HAS BM. ABD REMAINS DISTENDED SEC TO ASCITES.\n\nRENAL--PT WITH MIN URINE OUT. RENAL CONSULTED, RENAL US DONE. FAMILY REF HD AT THIS TIME.\n\nNEURO--PT CONTS ON PROPAFOL GTT INC TO 30MC/KG/MIN FOR PROCEDURES. PT EYES TO PAIN, AND WITHDRAWS TO PAINFUL STIMULI.\n\nSOCIAL--HCP AND OTHER FAMILY MEMBERS IN TO VISIT, UPDATED ON PT'S CONDITION AND SPOKE WITH HOUSESTAFF.\n\nPLAN--PM LABS\n--NO HD AT THIS TIME\n--PT DNR, BUT CONT CURRENTL TREATMENT\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-26 00:00:00.000",
"description": "Report",
"row_id": 1309096,
"text": "Patient with hepatic failure remains on mechanical ventilation all day.Fluid on (L) side pleural pig tail placed.Draining sanguinous fluid.Patient constipated with poor urine output also.Ultra-sound done,bs clear diminished bilaterally. DNR suctioned for small amount of thick yellow secretion.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-27 00:00:00.000",
"description": "Report",
"row_id": 1309097,
"text": "Respiratory Care:\nPatient remains on A/C ventilatory support with no parameter changes made throughout the night. Morning results determined a partially compensated metabolic acidemia with very good oxygenation. SX'd for thick, even pluggy secretions. Active humidification added to the ventilator.\n\nNo RSBI measured due to hemodynamic instability.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-27 00:00:00.000",
"description": "Report",
"row_id": 1309098,
"text": "MICU Nursing Note 1900-0700\nEvents: Pt with 2 episodes of acute hypotension requiring increased dosages of IV Levophed and fluid boluses. Remains sedated and intubated. Transfused with 2 units pRBC's during night.\n\nNeuro: Sedated on IV Propofol at 30 mcgs/kg/min. Pt with no spontaneous movement and does not follow commands, withdraws to painful stimuli, PEARL, bilat soft wrist restraints to prevent from pulling at lines and tubes.\n\nCardiac: Pt with episodes of BP decrease to 60-70's/40-50's requiring IV Fluid boluses and IV Levophed increased from 0.13 mcgs/kg/min to 0.5 mcgs/kg/min for short periods and then able to titrate Levophed back after each event. Pt with HR= 80-90's SR ----HR will trend to 50-60's SB with hypotensive episodes. 1 episode of HR= 130's SVT self-limiting and broke without intervention. Occas. PVC's. Right IJ multilumen cath site C/D/I and all ports patent, Right radial Aline with good waveform and correlation to NBP. Hct= 24---received 2 units pRBC's during night with repeat Hct this am = 28.6. Platelets remain low at 61. CVP= . Levophed currently infusing at 0.13 mcgs/kg/min. K= 3.4 during evening---replaced with 20 mEq KCL with am level still .\n\nResp: Remains intubated with current vent settings 600-40%-AC20 and Peep=8 with Sats=97-100% and = 7.30-35-110-97. Lungs coarse bilat with RLL diminished. ETtube suctioned for thick green sputum with occasional small plugs. Right posterior pigtail chest tube to 20 cm. suction and draining 30-80ml/hr of serous drainage into pleurovac. No creptius noted and chest tube with + fluctation and negative for air leak. Dressing over chest tube with small amt old bloody.\n\nGI: OGtube placement checked by auscultation and remains to LIWS and draining 300ml/shift of green bilious drainage---no coffee grounds and no bright red blood noted during night. Abd remains large with ascites and with + hypoactive and distant bowel sounds. No BM.\n\nGU: Foley to CD draining amber clear urine in scant amts...0-22 ml/hr\n\nID: Tmax= 99.1 with WBC decreased today to 15.9. Remains on IV Micafungin, IV Cefepime, and IV Flagyl. Lactate increased to 4.2 this am.\n\nSkin: Lower abd reddened---unchanged as per report from MD, No breakdown noted. General anasarca continues.\n\nSocial: niece was contact by MICU resident and she was updated as to pt's condition following acute hypotensive episode last eve... niece called at MN and was updated as to pt's condition at that time. No other contact from family or friends during the night\n\nPlan: Attempt to wean IV Levophed as tolerated, MAP goal is 60, Monitor for evidence of bleeding and transfuse to keep HCT > 30, ? if need to transfuse platelets?, Bleeding precautions,Wean Sedation as tolerated, Aggressive pulmonary toiletting, Support pt and family, pt remains DNR at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-27 00:00:00.000",
"description": "Report",
"row_id": 1309099,
"text": "Nursing Note (0700-1900hrs)\n\nMr. to require pressor and vent support. A right sided pigtail CT placed for large pleural effusion. Received 4units PRBC and 6units FFP ; he has been stable this shift.\n\nReview of systems;\nNeuro: Received on 30 mcg/kg/min propofol, heavily sedated with min response to sternal rub; propofol decreased to 20mcg/kg/min with a small increase in his response to sternal rub. +gag reflex; sluggish pupil response to light; otherwise nonresponsive to stimuli.\n\nCV: HR 80-90's, NSR; BP 90-100's with MAP >60 with levophed gtt; presently 0.1mcg/kg/min, was able to titrate down. CVP 10-13. Repeat Hct 29.1, no further s/s bleeding. Continues with ascites and +3 edema to hands/feet. Blood cx pnd ; receiving vanco for MRSA with 8/17 blood cx. Repleted with 20meq KCL this am for hypokalemia.\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-25 00:00:00.000",
"description": "Report",
"row_id": 1309092,
"text": "RESPIRATORY CARE: PT INTUBATED FOR IMPENDING\nRESPIRATORY FAILURE AND AIRWAY PROTECTION TODAY.\nTX FROM 10 TO MICU 6. 7.5 ORAL ETT ADVANCED\nFROM 19-20 TO 22 LIP PER CXR/MD. .\n"
},
{
"category": "Nursing/other",
"chartdate": "2135-08-25 00:00:00.000",
"description": "Report",
"row_id": 1309093,
"text": "NURSING NOTE: 1300-1900 51 year old male with PMH positive for cirrhosis, Hep C, CRF, EGD grade 1 varices, S/P splenectomy from trauma, S/P addpendectomy, incisional hernia, Rt tib/fibfx s/p vehicular trauma . Patient was admitted to hospital on with Incisional hernia repair for incarcerated hernia. Complicated post/op by VRE bacteremia, ARF, MRSA, worsening encephalopathy. Patient no longer on transplant list due to fungal infection. Today patient vomited in radiology during a tagged WBC scan, led to aspiration and transfered to MICU for further management. Patient was intubated on arrival to MICU. Please see review of Systems:\nNEURO: Patient somulent on arrival before intubation. Currently on Propofol at 20mcg/hr with good effect. Occassional bolus during prcedures. PERRLA, MAEW, Upper extremities in soft wrist restraints for line and tube safty.\nC/V: NSR rate 80-90's, SBP 80-low 100's/ 40-50's.\nHEME: INR on floor=6.2, transfused with 3 units FFP.\nRESP: Intubated please see flow sheet for settings. Lung sounds with bilateral rhonchi. O2 Sat 98-100%. Suctioned thick green bile secretions. Thorocotomy done at bedside samples sent to lab results , CXR .\nGI: Abd firm and distended, positive bowel sounds. OGT placed 2700cc green bile out. no stools this shift.\nGU: Foley catheter placed with minimal dark amber output.\nID: Tmax 95.6 AX, Continues on ABX, Blood cultures, urine cultures, and sputum culture sent.\nLINES: Two PIV started, Right multilumen also started CXR results .\nSOCIAL: Niece and other friends visited and updated on patients plan of care.\nPLAN: Continue to monitor, Aline to be started this evening. Awaiting cultures.\n\n"
},
{
"category": "Echo",
"chartdate": "2135-08-01 00:00:00.000",
"description": "Report",
"row_id": 79276,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nHeight: (in) 70\nWeight (lb): 232\nBSA (m2): 2.23 m2\nBP (mm Hg): 106/44\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 14:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased\ngradient c/w minimal AS. Significant AR, but cannot be quantified.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Based on \nAHA endocarditis prophylaxis recommendations, the echo findings indicate a\nmoderate risk (prophylaxis recommended). Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data. Left\npleural effusion. Ascites.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Regional\nleft ventricular wall motion is normal. Right ventricular chamber size and\nfree wall motion are normal. The aortic root is moderately dilated. The aortic\nvalve leaflets (3) are mildly thickened. There is a minimally increased\ngradient consistent with minimal aortic valve stenosis. Significant aortic\nregurgitation is present, but cannot be quantified - ?mild. 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 no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar. The aortic valve is better defined on the current study and appears\nto be trileaflet. The morphology and severity of aortic regurgitation appear\nsimilar.\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": "ECG",
"chartdate": "2135-08-26 00:00:00.000",
"description": "Report",
"row_id": 191882,
"text": "Sinus rhythm. Modest low amplitude lateral T waves are non-specific and\nprobably within normal limits. Since the previous tracing of T wave\namplitude is lower, but there may be no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2135-07-24 00:00:00.000",
"description": "Report",
"row_id": 192118,
"text": "Sinus rhythm. Within normal limits. Compared to the previous tracing of \nno significant diagnostic change.\n\n"
},
{
"category": "ECG",
"chartdate": "2135-06-29 00:00:00.000",
"description": "Report",
"row_id": 192119,
"text": "Normal sinus rhythm with low amplitude P waves and a P-R interval\nof approximately 0.18. Compared to the previous tracing of no\ndiagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2135-06-28 00:00:00.000",
"description": "Report",
"row_id": 192120,
"text": "Sinus rhythm with low amplitude P waves and P-R interval at about 0.16 seconds.\nRrelatively low voltage diffusely. Compared to the previous tracing of \nthe heart rate is not as fast, without diagnostic change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-06-28 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 916670,
"text": " 6:47 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: please evaluate po contrast\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p drinking po contrast with failure to pass through the\n stomach\n REASON FOR THIS EXAMINATION:\n please evaluate po contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Contrast failed to pass through stomach. Evaluate contrast for\n CT scan.\n\n COMPARISON: .\n\n TWO VIEWS OF THE ABDOMEN.\n Dilute contrast is noted within the stomach. Again seen are dilated air-\n filled loops of small bowel, which appear smaller when compared to . Degenerative changes again noted within the spine.\n\n IMPRESSION: Dilute contrast only seen within the stomach. Persistent\n dilatation of small bowel with air-filled loops concerning for obstruction.\n Please refer to CT performed the same day for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-08 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 918190,
"text": " 1:32 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: swelling in arm following PICC placement 2 days ago\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p hernia reduction, POD 10\n REASON FOR THIS EXAMINATION:\n swelling in arm following PICC placement 2 days ago\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Duplex ultrasound of left upper extremity.\n\n INDICATION: The patient is status post PICC line insertion. Rule out DVT.\n\n TECHNIQUE: Grayscale, color flow and pulse wave Doppler insonation of the\n deep veins of the left upper extremity were performed using dynamic\n compression maneuvers where appropriate to assess for vessel patency.\n\n COMPARISON: There was a previous left sided duplex ultrasound performed in\n .\n\n REPORT:\n\n There is normal compressibility, augmentation, and respiratory variation where\n appropriate of the deep veins of left upper extremity. The PICC line is\n identified within the left basilic vein extending proximally into the left\n subclavian vein. No thrombus is identified in either of these veins and no\n thrombus or adherent thrombus is identified adjacent to the PICC line.\n\n CONCLUSION:\n\n Normal examination. No evidence of DVT.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-06-28 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 916766,
"text": " 3:15 PM\n CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN; CT PELVIS W/O CONTRAST\n -59 DISTINCT PROCEDURAL SERVICE; -77 BY DIFFERENT PHYSICIAN\n : already received contrast but ileus present, reimage with co\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hepC cirrhosis with varices, ascites, with 2d N/V/abd\n pain,\n REASON FOR THIS EXAMINATION:\n already received contrast but ileus present, reimage with contrast movemetn\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man with hepatitis C cirrhosis, varices, ascites with\n previous abdominal CT questioning strangulated bowel loop.\n\n COMPARISON: at 3:14 a.m.\n\n TECHNIQUE: MDCT axial non-contrast images of the abdomen and pelvis were\n obtained with sagittal and coronal reformatted images.\n\n CT ABDOMEN WITHOUT IV CONTRAST: Again seen is a large right-sided pleural\n effusion with associated atelectasis. There is no pericardial effusion. There\n is a diffusely nodular liver consistent with the patient's history of\n cirrhosis. The gallbladder is enlarged but there is no evidence of\n cholecystitis. There is perihepatic ascites and free fluid seen within the\n abdomen consistent with the prior study. Allowing for the lack of IV\n contrast, the adrenal glands, pancreas, and kidneys are unremarkable.\n\n Again seen are multiple varices in the anterior abdominal wall.\n\n Contrast is seen within the stomach and within loops of small bowel. Compared\n to the prior examination the contrast has progressed. There is an apparent\n transition point at a complex anterior abdominal wall defect. Several loops\n of bowel are seen to pass through this defect and one loop in particular has\n an appearance worrisome for strangulation with fluid seen surrounding it. Far\n superiorly there is a suggestion of extraluminal air. No contrast is seen in\n distally collapsed loops of small bowel.\n\n CT PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon, and bladder are\n unremarkable. Again seen is a small amount of free fluid within the pelvis\n consistent with ascites.\n\n BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic foci.\n\n Multiplanar reformatted images confirm the above findings.\n\n IMPRESSION: Limited examination secondary to lack of IV contrast. There are\n multiple dilated loops of small bowel consistent with SBO and an apparent\n transition point at an anterior wall defect. A single loop of bowel which has\n (Over)\n\n 3:15 PM\n CT ABDOMEN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN; CT PELVIS W/O CONTRAST\n -59 DISTINCT PROCEDURAL SERVICE; -77 BY DIFFERENT PHYSICIAN\n : already received contrast but ileus present, reimage with co\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n passed through this defect is concerning for incarcerated bowel.\n\n The findings were discussed with the surgical house staff officer at 8:15 p.m.\n on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-06-28 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 916654,
"text": " 2:39 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for causes of acute abd pain\n Field of view: 48\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hepC cirrhosis with varices, ascites, with 2d N/V/abd\n pain,\n REASON FOR THIS EXAMINATION:\n assess for causes of acute abd pain\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd TUE 7:04 AM\n again seen is anasarca, right pleural effusion, cirrhois, and ascites\n\n contrast only in stomach, limiting evaluation of bowel\n\n anterior abdominal wall defects again seen with bowel within, limited\n assessment secondary to lack of contrast (oral and iv)\n\n plan to rescan when oral contrast has passed further, d/w dr. 5am\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C, cirrhosis, ascites, nausea, vomiting, and abdominal\n pain.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were obtained\n without IV contrast secondary to elevated creatinine. Multiplanar reformatted\n images were also displayed.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: Large right pleural effusion with\n associated atelectasis is seen. There are also atelectatic changes in the\n left lung. Oral contrast is seen within the stomach. Evaluation of the\n abdomen is limited by lack of IV contrast; however there do appear to be\n distended loops of small bowel. Again seen are multiple varices in the\n anterior abdominal wall. Also, again seen is a complex anterior abdominal\n wall defect with several loops of bowel seen passing into these defects. One\n loop in particular, best seen on series 3, image 54 appears concerning for\n incarceration. Collapsed loops of distal bowel are noted, especially in the\n area of the terminal ileum. Findings are concerning for a small-bowel\n obstruction with an incarcerated loop of bowel.\n\n Again seen is a small nodular liver consistent with cirrhosis. There is\n perihepatic ascites and free fluid seen within the abdomen, similar to prior\n study. Allowing for limitations of the non-contrast study, the pancreas,\n adrenal glands, and kidneys appear unremarkable. Again seen is evidence of\n anasarca.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid, bladder appear\n unremarkable. Again seen is evidence of free fluid within the pelvis\n consistent with ascites.\n (Over)\n\n 2:39 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for causes of acute abd pain\n Field of view: 48\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n BONE WINDOWS: No suspicious lytic or blastic lesions are identified.\n\n Multiplanar reformatted images confirm the axial findings.\n\n IMPRESSION: Limited study secondary to lack of IV contrast, however, multiple\n dilated loops of small bowel are seen with decompressed distal bowel. There\n is a loop of bowel within the anterior wall defect concerning for incarcerated\n bowel. Findings consistent with small bowel obstrution with possible\n incarceration.\n\n Discussed with Dr. at 8:30 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-06-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 916815,
"text": " 2:46 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: POST op\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n REASON FOR THIS EXAMINATION:\n POST op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Postop.\n\n COMPARISON: .\n\n AP CHEST RADIOGRAPH.\n Endotracheal tube placement is standard. Nasogastric tube is coiled in the\n stomach. New right IJ line tip overlies the SVC.\n\n Large right pleural effusion and the cardiac and upper mediastinal diameters\n have increased since the prior study. Diagnostic considerations include\n superimposed hemothorax or extravasated fluid from the right central venous\n line. No pneumothorax. Left lung is clear.\n\n IMPRESSION: Increased large right pleural effusion, hemothorax, or\n extravasation of infusate. Findings were discussed with Dr. 7:45\n a.m., .\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-06-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 916663,
"text": " 6:47 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pleural effusion.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with SOB and ascites\n REASON FOR THIS EXAMINATION:\n r/o pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and ascites. Evaluate for effusion.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST RADIOGRAPHS\n\n Cardiac and mediastinal, hilar contours appear unchanged. There is a\n moderate-to-large right-sided pleural effusion. No focal consolidation is\n seen within lungs.\n\n IMPRESSION: Again seen is a moderate-to-large right-sided pleural effusion,\n slightly increased compared to .\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-13 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 918816,
"text": " 8:48 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ASCITES, INCRE. WBCOUNT\n Admitting Diagnosis: ABD PAIN\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hepC cirrhosis with varices, ascites, s/p ventral hernia\n repair, now s/p paracentesis today w/WBC 1110, likely SBP though question of\n possible leak/perf\n REASON FOR THIS EXAMINATION:\n Please rule out bowel perforation, abscess, with PO contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n 51-year-old male with hepatitis C, cirrhosis. Concern for bowel perforation.\n\n COMPARISON: CT abdomen and pelvis, .\n\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\n were obtained with oral but no IV contrast due to the patient's elevated\n creatinine. Coronal and sagittal reformatted images were also obtained.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The left lung base is clear. Again\n demonstrated at the visualized portion of the right lung base is a small\n pleural effusion and atelectasis of the right lower lobe. Evaluation of the\n solid abdominal organs is limited by the non-contrast technique. The liver is\n shrunken and nodular consistent with cirrhosis. The patient is status post\n splenectomy. The gallbladder is not well seen. The pancreas, adrenal glands\n and right kidney are unremarkable. There has been no change in the left\n kidney with at least two round hypodense lesions consistent with cysts.\n\n There remains a large amount of intraabdominal ascites. The appearance of the\n bowel is similar to . Again demonstrated are a few dilated loops\n of small bowel up to approximately 4.8 cm. There is no evidence of\n obstruction with oral contrast passing through to the rectum. There is\n generalized wall edema throughout the colon. No inflammatory stranding or\n mural gas is identified. There is no free intra- abdominal air.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, prostate gland, seminal\n vesicles and urinary bladder are unremarkable. Ascites tracks into the\n pelvis.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n identified.\n\n IMPRESSION:\n 1. No significant change in appearance of the abdomen and pelvis compared to\n .\n 2. No free intraabdominal air or other evidence of bowel perforation.\n 3. A few loops of mildly dilated small bowel but no evidence of bowel\n obstruction.\n 4. Cirrhotic liver with large amount of intraabdominal ascites.\n (Over)\n\n 8:48 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: ASCITES, INCRE. WBCOUNT\n Admitting Diagnosis: ABD PAIN\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5. Diffuse edema of colon may be secondary to liver failure and ascites.\n\n This was discussed with Dr. at 11 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-10 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 918438,
"text": " 10:29 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for perf w/PO contrast only. no IV contrast\n Admitting Diagnosis: ABD PAIN\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hepC cirrhosis with varices, ascites, s/p ventral\n hernia repair, now s/p paracentesis today w/WBC 1110, likely SBP though\n question of possible leak/perf\n REASON FOR THIS EXAMINATION:\n assess for perf w/PO contrast only. no IV contrast\n CONTRAINDICATIONS for IV CONTRAST:\n elevated Cr\n ______________________________________________________________________________\n FINAL REPORT\n 51-year-old male with hepatitis C, cirrhosis and ascites, now with concern for\n bowel perforation versus spontaneous bacterial peritonitis.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT continuously acquired axial images of the abdomen and pelvis\n were obtained with oral but no IV contrast at the ordering physician's\n request. Coronal and sagittal reformatted images were also obtained.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized lung bases demonstrate\n a moderate-to-large right pleural effusion with associated atelectasis of the\n right lower lobe. The left lung base is grossly clear. There are coronary\n artery calcifications. Evaluation of the abdomen is limited by the\n noncontrast technique. The liver is shrunken and nodular consistent with\n cirrhosis. The gallbladder is not well visualized. The patient is status\n post splenectomy. The pancreas, adrenal glands and right kidney are\n unremarkable. There are at least two round hypodense lesions of the left\n kidney which are consistent with simple cysts.\n\n There is a large amount of intra-abdominal ascites. Evaluation of the bowel\n is somewhat limited by ascites. The stomach is nondistended. There are a few\n loops of mildly dilated small bowel measuring up to 4.6 cm but no evidence of\n obstruction with oral contrast passing freely through normal caliber large\n bowel to the rectum. Patient is status post interval ventral hernia repair.\n There is generalized wall edema throughout the colon probably secondary to\n liver failure. No inflammatory stranding or mural gas is identified. There\n is no free intra-abdominal air.\n\n CT OF THE PELVIS WITHOUT IV CONTRAST: Oral contrast extends freely through to\n the rectum. The prostate, seminal vesicles, and urinary bladder are\n unremarkable. The pelvic loops of bowel are of normal caliber. Ascites\n tracks into the pelvis.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are\n identified.\n\n IMPRESSION:\n (Over)\n\n 10:29 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: assess for perf w/PO contrast only. no IV contrast\n Admitting Diagnosis: ABD PAIN\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. No free intra-abdominal air or other evidence of bowel perforation.\n\n 2. A few loops of mildly dilated small bowel up to 4.8 cm, however no\n evidence of obstruction with free passage of oral contrast through to the\n rectum.\n\n 3. Cirrhotic liver with a large amount of intra-abdominal ascites.\n\n 4. Status post interval ventral hernia repair.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-06-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916989,
"text": " 6:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: asses effusion\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with effusion\n s/p ex-lap, has R whiteout ** please do portable UPRIGHT **\n REASON FOR THIS EXAMINATION:\n asses effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of right pleural effusion.\n\n Portable AP upright chest radiograph compared to .\n\n FINDINGS: The ET tube tip is 5.8 cm above the carina. The right internal\n jugular line tip is in distal portion of superior vena cava. The NG tube tip\n is in the stomach. The right pleural effusion covers almost all of the right\n hemithorax, being grossly unchanged in comparison to the previous film. The\n left lower lung consolidation most probably due to atelectasis is also\n unchanged. There is no sizable left pleural effusion. There are no gross\n abnormalities in the left lung.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916841,
"text": " 8:06 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? NGt tip ? effusion vs consolidation** please do portable U\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with\n s/p ex-lap, has R whiteout ** please do portable UPRIGHT **\n REASON FOR THIS EXAMINATION:\n ? NGt tip ? effusion vs consolidation** please do portable UPRIGHT **\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ONE VIEW PORTABLE\n\n INDICATION: 51-year-old man with effusion and consolidation.\n\n COMMENTS: Portable semi-erect AP radiograph of the chest is reviewed, and\n compared with the previous study at 3:27 a.m.\n\n The tip of the endotracheal tube is identified at the thoracic inlet. A\n nasogastric tube courses towards the stomach. The right jugular IV catheter\n terminates in the superior vena cava. No pneumothorax is identified.\n\n There is continued mild congestive heart failure with cardiomegaly associated\n with large right pleural effusion. Atelectasis is seen in the right lung\n base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-24 00:00:00.000",
"description": "IN-111 WHITE BLOOD CELL STUDY",
"row_id": 924069,
"text": "IN-111 WHITE BLOOD CELL STUDY Clip # \n Reason: KNOWN CIRROHSIS, CANDIDIAL PERITONITIS, PERSISTENT WBC = 20 DESPITE ANTIFUNGAL THERAPY\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 455.0 uCi In-111 WBCs;\n History: 51yo many with candidial peritonitis ? occult infection / abscess\n\n REPORT:\n\n Following the injection of autologous white blood cells labeled with In-111,\n images of the whole body were obtained.\n\n These images show abnormal, heterogeneous, intense lung uptake with highest\n uptake in the left lower lobe and right lower lobe.\n\n Compared with the prior study of the lung uptake is new. Also the\n patient's liver is smaller and there is haziness in the abdomen consistent with\n cirrhosis and ascites.\n\n IMPRESSION: Abnormal, intense lung uptake worst in LLL and RLL.\n\n\n , M.D.\n , M.D. Approved: FRI 3:35 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-13 00:00:00.000",
"description": "MRI PELVIS W/O & W/CONTRAST",
"row_id": 922932,
"text": " 2:08 PM\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: ? intraabdominal abcessPLEASE PERFORM BOTH ABDOMEN AND PELVI\n Admitting Diagnosis: ABD PAIN\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, h/o VRE bactermiea, , candidemia, perirectal\n abscess on exam, increasing white counts\n REASON FOR THIS EXAMINATION:\n ? intraabdominal abcessPLEASE PERFORM BOTH ABDOMEN AND PELVIS STUDY to look for\n abcess\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 51-year-old gentleman with cirrhosis, VRE bacteremia,\n candidemia, and perirectal abscess on exam.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet. Dynamic volumetric images were acquired before, during, and\n following intravenous administration of 0.1 mmol/kg of gadolinium-DTPA.\n Subtraction images and reformatted images were created on an independent\n workstation.\n\n FINDINGS:\n\n A linear tract emerges from the anal verge at approximately the 6 o'clock\n position. At the anal verge, there is an associated adjacent 13 x 9 mm region\n of enhancement. T2-weighted images show hypointensity in the region of\n enhancement on T1-weighted images; therefore, this may represent fibrosis or\n early organization. No supralevator collections.\n\n Note is made of marked free fluid within the pelvis and edema within the\n subcutaneous fat.\n\n Fat-containing inguinal hernias are identified bilaterally.\n\n Subtraction images and 2- and 3-dimensional reformatted images were helpful in\n delineating pathology.\n\n IMPRESSIONS:\n 1. Linear tract with associated area of enhancement adjacent to the anal\n verge, at approximately the 6 o'clock position. No drainable fluid collection\n is present. Signal characteristics may represent early organization of\n inflammation.\n 2. Ascites and anasarca.\n\n\n\n (Over)\n\n 2:08 PM\n MRI PELVIS W/O & W/CONTRAST; MR CONTRAST GADOLIN Clip # \n MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS\n Reason: ? intraabdominal abcessPLEASE PERFORM BOTH ABDOMEN AND PELVI\n Admitting Diagnosis: ABD PAIN\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 924375,
"text": " 1:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ett and ogt placement\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, ascites w/ , elevated WBC of unclear\n etiology.\n REASON FOR THIS EXAMINATION:\n ett and ogt placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis and ascites with and elevated white blood count.\n Status post endotracheal tube and orogastric tube placement.\n\n A supine portable chest radiograph shows endotracheal tube in place with the\n tip positioned 6-1/2 cm above the carina. The tip and sidehole of the\n orogastric tube are both below the left hemidiaphragm. Hazy obscuration of\n the right hemithorax appears to be related to large layering pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-24 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 924259,
"text": " 3:03 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval for evidence of SBO - Upright portable abdomen\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51M ESLD, h/o incarcerated ventral hernia, candidal peritonitis, now acutely\n nausea and vomiting.\n REASON FOR THIS EXAMINATION:\n eval for evidence of SBO - Upright portable abdomen\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with end-stage liver disease presenting with\n nausea and vomiting.\n\n COMPARISON: .\n\n SUPINE ABDOMEN, FOUR VIEWS: A moderate pleural effusion is seen at the right\n lung base. Surgical clips project over the left upper abdominal quadrant.\n There is a paucity of bowel gas. A few nondistended loops of gas filled bowel\n are seen in the right lower abdominal quadrant. No definite free\n intraperitoneal air is seen on the supine views. Bulging of the flanks and\n displacement of the bowel from the peritoneal fat stripe suggest underlying\n ascites. Deformity of the left iliac bone may represent prior trauma.\n\n IMPRESSION: No definite underlying obstruction or free intraperitoneal air.\n Likely moderate ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-17 00:00:00.000",
"description": "R ANKLE/FOOT (AP, LAT & OBL) RIGHT",
"row_id": 923416,
"text": " 3:57 PM\n ANKLE/FOOT (AP, LAT & OBL) RIGHT Clip # \n Reason: rule out osteomyelitis of prosthetic hardware\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, history of VRE bacteremia, persistent WBC,\n suspect osteo of tibia hardware\n REASON FOR THIS EXAMINATION:\n rule out osteomyelitis of prosthetic hardware\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Bacteremia and previous tibial hardware. Assess osteomyelitis.\n\n These two exams consist of three views of the right ankle and distal\n tibia/fibula as well as three views of the right foot. There is marked\n generalized soft tissue swelling particularly on the dorsum of the foot.\n There are healed fracture deformities in the distal diaphysis of both the\n tibia and fibula with lateral tibial plate and screws. There is relatively\n smooth bridging cortical new bone present with slight irregularity posterior\n to the fibular fracture of doubtful significance and unchanged from . There is no evidence of loosening of the plate or screws. Ankle\n mortise congruent with the talus. The bones of the foot are intact.\n\n IMPRESSION: Soft tissue swelling. Sequelae of previous fractures. No\n evidence of osteomyelitis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 924118,
"text": " 12:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval consolidation, effusion\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, ascites w/ , elevated WBC of unclear\n etiology.\n REASON FOR THIS EXAMINATION:\n eval consolidation, effusion\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate effusion and consolidations. Patient 51-year-old\n man with cirrhosis, elevated white blood count\n\n Comparison is made with prior study dated .\n\n FINDINGS:\n Interval increase in size in the moderate right pleural effusion. There is\n right lower lobe atelectasis. There is no pneumothorax. Left PICC line with\n tip in the superior third of the SVC. Right heart border is obscured by the\n atelectasis and pleural effusion. Mediastinum is midline.\n\n IMPRESSION: Enlarging moderate right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-26 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 924535,
"text": " 2:56 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate pigtail position and rule out pneumothorax.\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p placement of right pleural\n pig tail\n REASON FOR THIS EXAMINATION:\n Please evaluate pigtail position and rule out pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 15:45 HOURS.\n\n A single AP upright view of the chest is obtained and compared with the prior\n radiograph of 03:49 of the same day. Right pleural effusion is again seen and\n is likely not significantly changed. Patient has had placement of a pigtail\n catheter which is visualized on the current film. There is no evidence of\n pneumothorax. Tubes and lines are essentially otherwise unchanged.\n\n IMPRESSION:\n\n Placement of right-sided pigtail catheter in the pleural space. No evidence\n of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-26 00:00:00.000",
"description": "P RENAL U.S. PORT",
"row_id": 924537,
"text": " 3:20 PM\n RENAL U.S. PORT Clip # \n Reason: Evaluate please for hydro or evidence of obstruction\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with renal failure.\n\n REASON FOR THIS EXAMINATION:\n Evaluate please for hydro or evidence of obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal failure.\n\n COMPARISON: CT scan obtained two days prior.\n\n FINDINGS: The left kidney measures 13.3 cm in length. The right kidney\n measures 12.9 cm in length. There is no hydronephrosis, stones, or masses\n identified. The bladder is collapsed with a Foley in place. A moderately\n large amount of ascites is again seen throughout the abdomen with note of\n multiple septations within the ascites fluid.\n\n IMPRESSION:\n 1. No evidence of hydronephrosis.\n 2. Persistent ascites contained multiple septations, possibly the\n sequela of SBP or multiple paracenteses.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-24 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 924240,
"text": " 11:43 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: r/u recurrent PNA\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, peritonitis, known RLL effusion, with\n new cough and increasing WBC\n REASON FOR THIS EXAMINATION:\n r/u recurrent PNA\n CONTRAINDICATIONS for IV CONTRAST:\n chronic renal failure/hepatorenal syndrome\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n REASON FOR EXAM: Question pneumonia in a 51-year-old man with cirrhosis,\n peritonitis, enlarged right pleural effusion.\n\n TECHNIQUE: Multidetector CT through the chest without oral or IV contrast. 5,\n 1.25 mm collimation images and coronal reformation images were reviewed.\n\n Comparison was made to prior study dated .\n\n FINDINGS: Mildly enlarging nonhemorrhagic layering right pleural effusion is\n responsible for relaxation atelectasis in the right lower lobe. There is no\n pneumonia. There is a new small pericardial effusion. Bullae in the apices\n are unchanged. The central airways are patent. Heavy calcification of the\n aortic valve could be hemodinamicaly significant. Heart size is normal.\n Aside from a stable, 11mm wide juxtacardiac node, there is no\n pathologic enlargment of mediastinal, hilar or axillary lymph nodes.\n\n A large volume of ascites persists. The liver is shrunken and nodular\n consistent with cirrhosis. The adrenal glands are unremarkable. There is a\n large fluid-filled distention of the stomach.\n\n There are no bone findings of malignancy.\n\n IMPRESSION: No pneumonia.\n\n Minimally enlarged, large right pleural effusion.\n\n Aortic valve calcification. Possible aortic stenosis.\n\n New small pericardial effusion.\n\n Persistent ascites. Cirrhosis.\n\n Severely distended stomach\n\n\n (Over)\n\n 11:43 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: r/u recurrent PNA\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-24 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 924285,
"text": " 5:58 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval sbo, perf, abscess\n Admitting Diagnosis: ABD PAIN\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, s/p incarcerated hernia repair and small\n bowel resection. Now with hospital-acquired pna, but WBC still increasing.\n (+) diffuse abdominal pain, now sbc\n REASON FOR THIS EXAMINATION:\n eval sbo, perf, abscess\n CONTRAINDICATIONS for IV CONTRAST:\n hepatorenal\n ______________________________________________________________________________\n WET READ: KMcd WED 11:51 PM\n VERY LIMITED STUDY DUE TO ABSENCE OF IV AND ORAL CONTRAST. MASSIVE ASCITES.\n LARGE RIGHT SIDED PLEURAL EFFUSION WITH COMPRESSIVE ATELECTASIS. NO EVIDENCE\n OF BOWEL OBSTRUCTION. NO FREE ABDOMINAL AIR. ABSCESS CANNOT BE EXCLUDED GIVEN\n THE MASSIVE ASCITES. BILATERAL FAT-CONTAINING INGUINAL HERNIAS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis with incarcerated hernia repair and small bowel\n resection, now with pneumonia and increasing leukocytosis, diffuse abdominal\n pain. Assess for obstruction, perforation or abscess.\n\n TECHNIQUE: MDCT-imaging of the abdomen and pelvis was performed without\n contrast.\n\n COMPARISON: Abdominal CT scan from .\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: There is a large right pleural effusion\n with a loculated component anterior to the major fissure, with near complete\n collapse of the visualized portions of the right lower lobe and and portions\n of the right middle lobe. A tiny left pleural effusion and associated left\n lower lobe and lingular atelectasis is also present. There is a large volume\n of ascites throughout the abdomen, which has increased since the prior study.\n There is no free intraperitoneal air or evidence of abscess collection. The\n liver is small and nodular. Note is made of massive gastric distention which\n extends into the duodenum and proximal jejunum, but smoothly tapers distally.\n No frank transition point is identified. The descending and sigmoid colon are\n largely collapsed. The pancreas, adrenal glands, and kidneys are unchanged\n since the prior study.\n\n CT OF THE PELVIS WITHOUT CONTRAST: There is a large amount of fluid in the\n pelvis. No pathologically enlarged inguinal or pelvic nodes are identified.\n Bladder is unremarkable.\n\n BONE WINDOWS: There is redemonstration of multiple old left rib fractures and\n left iliac fracture.\n\n IMPRESSION:\n 1. Marked increase in amount of ascites. Spontaneous bacterial peritonitis\n (Over)\n\n 5:58 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval sbo, perf, abscess\n Admitting Diagnosis: ABD PAIN\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n is of concern given the patient's clinical status.\n 2. Marked gastric distension with distention of duodenum and proximal\n jejunum. No frank transition point.\n 3. No evidence of intra-abdominal abscess.\n 4. Large right pleural effusion, with possible loculation anteriorly.\n\n Results describing the effusion, ascites, and lack of bowel obstruction/free\n air/abscess was discussed with Dr. on the evening this study was\n performed.\n\n Findings detailing the gastric distention were discussed with Dr. \n at 9:30 a.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-14 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 923035,
"text": " 10:57 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ?occult abcess/assess pneumonia and effusion seen on cxrayCa\n Admitting Diagnosis: ABD PAIN\n Field of view: 46\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hep c/alcoholic cirrhosis, unexplained leukocytosis\n REASON FOR THIS EXAMINATION:\n ?occult abcess/assess pneumonia and effusion seen on cxrayCannot get contrast\n due to renal failure.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AHPb MON 12:14 AM\n limited by no iv. there is a large right pleural effusion and an associated\n right lower lobe opacity (atelectasis most likely, but pna is possible).\n\n 5 x 2cm fluid collection in anterior subcutaneous tissue (likely ascites from\n anterior wall defect, but limited by no iv contrast and poor bowel\n opacification. there is abundant ascites in abd/pelvis with hallmarks of\n advanced cirrhosis. focal fluid collections cannot be excluded but not\n suspected.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Alcoholic cirrhosis with unexplained leukocytosis.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast axial CT imaging of the chest, abdomen and pelvis\n without contrast was reviewed. Coronal and sagittal reformats were obtained\n and reviewed.\n\n CT CHEST WITHOUT CONTRAST: There is a moderate/large right pleural effusion\n with presumed associated atelectasis that is relatively unchanged from . Bullous changes are present in the apices, and there is minimal left\n basilar atelectasis. Left subclavian central venous catheter tip terminates\n in the right atrium. Calcification is present within the mitral annulus. No\n pathologic adenopathy identified. Note of gynecomastia. A few small lymph\n nodes are present in the pericardial fat.\n\n CT ABDOMEN WITHOUT CONTRAST: The liver is shrunken and nodular, consistent\n with cirrhosis. Attenuation is decreased within the left hepatic lobe of\n unclear etiology. There is abundant ascites in the abdomen and pelvis,\n increased from . There is a small anterior wall defect containing\n ascites. Multiple collaterals are presentThe gallbladder, pancreas, adrenal\n glands, and right kidney are unremarkable. The patient is status post\n splenectomy. Low- density lesions in the left kidney are unchanged. There are\n a few mildly dilated small bowel loops, but unchanged if not slightly improved\n from . Bowel wall thickening is likely secondary to ascites.\n Numerous collaterals are present throughout the abdomen.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid is unchanged. Note of bilateral\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: ?occult abcess/assess pneumonia and effusion seen on cxrayCa\n Admitting Diagnosis: ABD PAIN\n Field of view: 46\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n fat-containing inguinal hernias. The distal ureters and bladder are normal.\n Ascites is present in the pelvis. Though evaluation for focal fluid\n collections is limited per non-contrast CT, no suspicious areas are\n identified.\n\n BONE WINDOWS: No suspicious lesions are identified. Note of multiple poorly\n healed previous left posterior rib fractures. There is a prior left iliac\n fracture.\n\n IMPRESSION: No marked interval change from with a large right\n pleural effusion and associated atelectasis, marked ascites, and hallmarks of\n advanced cirrhosis. Mildly dilated small bowel loops are unchanged.\n\n These findings were provided to the ED dashboard at the time of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 924286,
"text": " 5:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ENCEPHALOPATHY\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51M endstage liver failure, ?fall, encephalopathy.\n REASON FOR THIS EXAMINATION:\n eval for head bleed\n CONTRAINDICATIONS for IV CONTRAST:\n hepatorenal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver failure, possible fall, encephalopathy. Evaluate\n for head bleed.\n\n Comparison is made to .\n\n CT HEAD WITHOUT CONTRAST: The study is significantly limited due to patient\n motion artifact, despite repeat acquisitions. Within these limitations, no\n definite acute intracranial hemorrhage is seen. A small lacunar infarct in\n the posterior right thalamus is less conspicuous on today's scan. A focal\n lacunar area in the right cerebellar hemisphere is stable. No mass effect or\n shift of normally midline structures is seen. Paranasal sinuses and mastoid\n air cells are clear.\n\n IMPRESSION: Within the limitations of motion artifact, no definite evidence\n of acute intracranial hemorrhage or cerebral edema is seen. No significant\n interval change since .\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 924464,
"text": " 3:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change, incr effusion, chf\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, ascites w/ , elevated WBC of unclear\n etiology.\n REASON FOR THIS EXAMINATION:\n eval for interval change, incr effusion, chf\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:49 A.M., .\n\n HISTORY: Cirrhosis and ascites. Elevated white count.\n\n IMPRESSION: AP chest compared to through 17:\n\n Large right pleural effusion, which decreased during the day on is\n stable subsequently. There is no pneumothorax. Consolidation at the base of\n the right lung, most likely residual atelectasis. Vascular congestion in the\n lungs and mediastinum is unchanged. Heart size top normal. No pneumothorax.\n Endotracheal tube tip is in standard placement, cuff distends the tracheal\n diameter above the thoracic inlet. Tip of the right subclavian line projects\n over the mid SVC and a nasogastric tube ends in the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-25 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 924423,
"text": " 6:44 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new r ij and s/ , eval for placement and ptx\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, ascites w/ , elevated WBC of unclear\n etiology.\n REASON FOR THIS EXAMINATION:\n new r ij and s/ , eval for placement and ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis and ascites with . New right IJ catheter and\n status post thoracentesis. Evaluate placement and for pneumothorax.\n\n COMPARISON: at 13:23.\n\n SEMI-UPRIGHT AP CHEST: There is an endotracheal tube in place, with the tip\n approximately 6.7 cm from the carina. An orogastric tube remains in place.\n There is a new right internal jugular approach central venous catheter, with\n the tip overlying the mid to distal superior vena cava. The patient is\n slightly rotated toward the left. There is unchanged cardiac enlargement and\n the lung fields are not significantly changed. There is slightly decreased\n hazy opacity of the right hemithorax, likely related to right thoracentesis. A\n moderate-to-large amount of right pleural fluid persists, however. There is\n no evidence of a pneumothorax on this study.\n\n Impression: No evidence of pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 920400,
"text": " 2:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate/pna\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, resolving SBP, now with incr WBC.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate/pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of cirrhosis with leukocytosis.\n\n Left-sided PICC line has tip located at proximal SVC close to junction with\n left brachiocephalic vein. Allowing for technique, heart size is within\n normal limits. Since the previous study of , there has been a\n reduction in the size of the right pleural effusion. No definite new lung\n lesions in this single AP film. Specifically, no evidence for new pneumonia.\n Surgical clips are present in the left upper abdomen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-02 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 921459,
"text": " 6:02 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: INCR WBC PLEASE EVAL FOR DVT'S\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man w/ HepC/EtOH cirrhosis, recent fungemia and bacteremia now\n with incr WBC without definite source.\n REASON FOR THIS EXAMINATION:\n Please eval for DVTs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old man with hepatitis C and cirrhosis with recent\n fungemia and bacteremia, now with increasing white blood cell count. Evaluate\n for DVT.\n\n COMPARISON: Study from .\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: -scale and color Doppler son\n was performed of the right and left common femoral, superficial femoral, and\n popliteal veins. Normal flow, compressibility, augmentation, and waveforms\n are demonstrated. No intraluminal thrombus is identified.\n\n IMPRESSION: No DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-10 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 918380,
"text": " 12:12 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: needs area marked for paracentesis to be done today\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ESLD/cirrhosis for transplant, abd distension, n/v/abd\n pain, increased ascites on exam\n REASON FOR THIS EXAMINATION:\n needs area marked for paracentesis to be done today\n ______________________________________________________________________________\n WET READ: KMcd SUN 1:03 PM\n moderate amount of ascites. LLQ pocket marked for para.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease with cirrhosis for transplant. Abdominal\n distention. Nausea, vomiting, abdominal pain, increased ascites. Needs a\n mark for paracentesis to be done today.\n\n FINDINGS: All four quadrants were examined. There is a moderate amount of\n ascites. A pocket in the left lower quadrant was marked for paracentesis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-02 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 917324,
"text": " 9:35 AM\n RENAL U.S. Clip # \n Reason: Please assess for renal pathology\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with renal failure\n REASON FOR THIS EXAMINATION:\n Please assess for renal pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with renal failure. Assess for renal pathology.\n\n COMPARISON: CT abdomen and pelvis , ultrasound paracentesis , .\n\n RENAL ULTRASOUND:\n\n This exam is limited secondary to limited patient positioning. The right\n kidney measures 10.5 cm. The left kidney measures 12.3 cm. There is no\n evidence of hydronephrosis. No evidence of stones. Marked ascites is\n present. The liver is small and nodular consistent with cirrhosis.\n\n IMPRESSION:\n\n No evidence of hydronephrosis or stones. Marked ascites. Cirrhosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-05 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 917757,
"text": " 4:06 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place double lumen picc for TPN and ABx.\n Admitting Diagnosis: ABD PAIN\n Contrast: OPTIRAY Amt: 10\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 51 year old man with EtOH/HCV cirrhosis, s/p SB resection for incarcerated\n hernia. Needs long term nutrition.\n REASON FOR THIS EXAMINATION:\n Please place double lumen picc for TPN and ABx.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis, status post small bowel resection, needs long-term\n parenteral nutrition.\n\n FINDINGS: The patient was placed supine on the angiography table. Limited\n ultrasound examination was performed of the left forearm. Using ultrasound\n guidance, a left brachial vein was accessed using a 21-gauge needle. Hard\n copy ultrasound images were obtained before and after establishing access. A\n 0.018 guidewire was then advanced through the needle into the SVC under direct\n fluoroscopic guidance. Based on the markers of the guidewire, the PICC line\n was trimmed to a length of 41 cm. The needle was exchanged for introducer\n sheath and the PICC line was advanced through the sheath under direct\n fluoroscopic guidance with the tip terminating at the lower SVC. Peel-away\n sheath and wire were removed. The PICC line was aspirated, flushed, capped,\n and hep-locked. The line was secured using a StatLock device. There were no\n immediate post-procedure complications.\n\n RADIOLOGISTS: and . The attending radiologist, Dr. \n was present for the entire procedure.\n\n IMPRESSION: Successful placement of a dual-lumen, 4 French PICC via a left\n brachial vein with the tip terminating within the mid SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-13 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 918744,
"text": " 11:52 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate, assess right pleural effusion\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with SOB and ascites s/p small bowel resection with hernia\n repair\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, assess right pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post ventral hernia repair with shortness of breath.\n\n COMPARISON: .\n\n CHEST: AP upright and lateral views. Allowing for differences in patient\n positioning, the large right pleural effusion is not significantly changed.\n There is no left pleural effusion. The left lung is clear. The endotracheal\n tube, nasogastric tube, and the right internal jugular central venous catheter\n have been removed. There is no pneumothorax. The new left PICC terminates in\n the upper SVC.\n\n IMPRESSION: Large right pleural effusion, not significantly changed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-18 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 919413,
"text": " 1:50 PM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: PLEASE ASSES FOR DVT IN RLE, R>L\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p incisional hernia repair, small bowel resection POD 20\n REASON FOR THIS EXAMINATION:\n please assess for DVT in RLE\n ______________________________________________________________________________\n FINAL REPORT\n\n EXAMINATION: Right lower extremity venous Doppler, .\n\n COMPARISON: None.\n\n INDICATION: Status post incisional hernia repair and small bowel resection,\n evaluate for DVT in right lower extremity.\n\n FINDINGS: scale, color Doppler, and spectral waveform imaging of the\n right lower extremity deep venous system was performed. There is no evidence\n of intraluminal thrombus within the right common femoral, superficial femoral\n and popliteal veins. These veins demonstrate normal color flow and\n augmentation. Incidental note is made of ill-defined complex fluid collection\n in the popliteal region which most likely represents a ruptured cyst.\n\n IMPRESSION:\n 1. No evidence of deep venous thrombosis in the right lower extremity.\n 2. Ruptured cyst.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-29 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 920918,
"text": " 10:25 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please eval for intraabdominal source of infection\n Admitting Diagnosis: ABD PAIN\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, s/p incarcerated hernia repair and small bowel\n resection. Now with hospital-acquired pna, but WBC still increasing. (+)\n diffuse abdominal pain, no SBP.\n REASON FOR THIS EXAMINATION:\n Please eval for intraabdominal source of infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CT of the abdomen and pelvis dated \n\n COMPARISON: CT of the abdomen and pelvis dated .\n\n INDICATION: 51-year-old male with cirrhosis status post incarcerated hernia\n repair and small bowel resection, now with hospital-acquired pneumonia with\n increasing white count, diffuse abdominal pain, but no SBP. Please evaluate\n for intra-abdominal source of infection.\n\n TECHNIQUE: MDCT axial images are obtained through the abdomen and pelvis\n after the administration of IV and oral contrast. The clinical team was\n aware of the patient's creatinine of 1.7 and used hydration and bicarbonate\n solution before and after the exam to help prevent contrast nephropathy.\n\n FINDINGS FOR CT OF THE ABDOMEN WITH CONTRAST: There is a large right pleural\n effusion and right lower lobe atelectasis, unchanged. There has been interval\n development of a tiny left pleural effusion and left basilar atelectasis.\n\n Again seen is a shrunken liver with nodular contour consistent with cirrhosis.\n The gallbladder is present. The patient is status post splenectomy. The\n pancreas, adrenal glands, and right kidney are unremarkable. Again seen are\n two low density lesions involving the left kidney, the interpolar region and\n at the lower pole, consistent with renal cysts. There has been slight\n interval increase in quantity of ascites within the abdomen since the prior\n exam. Multiple fluid collections are demonstrated within the subcutaneous\n tissues in region of prior hernia repair, the largest of which measures 5.7 cm\n x 2.3 cm, unchanged. Multiple dilated loops of small bowel are seen, which\n have thickened wall, there is no evidence for obstruction since contrast is\n seen within colon. The bowel wall thickening is thickening is likely\n secondary to hypoalbuminemia. There has been interval resolution of the\n diffuse colonic thickening seen on the prior examination. Numerous porta\n splenic collateral vessels are demonstrated. The bones demonstrate no\n suspicious lesions.\n\n FINDINGS FOR CT OF THE PELVIS: There has been slight increase in amount of\n intrapelvic ascites. There has been interval resolution of the colonic wall\n thickening. There is no lymphadenopathy or free intraperitoneal gas.\n\n (Over)\n\n 10:25 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Please eval for intraabdominal source of infection\n Admitting Diagnosis: ABD PAIN\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONE WINDOWS: Multiple old left lower rib fractures are demonstrated. There\n is evidence of old trauma to the left ilium.\n\n\n IMPRESSION:\n 1) Cirrhosis with slight increase in intra-abdominal and intrapelvic ascites.\n Stable large right pleural effusion and right basilar atelectasis. New tiny\n left pleural effusion and left lower lobe atelectasis.\n\n 2) Dilated loops of small bowel without evidence of bowel obstruction. Small\n bowel wall thickening, likely secondary to low protein state.\n\n 3) Interval resolution of the diffuse colonic thickening.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 921076,
"text": " 5:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for pneumothorax (s/p thoracentesis)\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, resolving SBP, now with incr WBC. s/p\n thoracentesis\n REASON FOR THIS EXAMINATION:\n Please eval for pneumothorax (s/p thoracentesis)\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cirrhosis, status post thoracentesis, evaluate for\n pneumothorax.\n\n Small bilateral pleural effusions are present. Neither side shows a\n pneumothorax. No infiltrates are present.\n\n IMPRESSION: No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-07-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 920641,
"text": " 1:53 PM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for infiltrate/pneumonia\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, s/p bacteremia and fungemia, now with\n increasing WBC again.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate/pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 51-year-old man with cirrhosis status post bacteremia and\n fungemia, now with increasing white cell count.\n\n CHEST, AP AND LATERAL:\n\n Extensive opacification is seen within the right lower lung posteriorly. This\n is associated with right pleural effusion also. The lower lobe opacifications\n are new and probably represent pneumonic consolidation.\n\n Elsewhere, the lung fields appear clear.\n\n IMPRESSION: Persistent right effusion. New right lower lobe infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-19 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 923716,
"text": " 5:58 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: WITH DUPLEX PLEASE-ASSESS for PV thrombosis\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ESLD/cirrhosis for transplant, ascites with acute rise\n in t. bili.\n REASON FOR THIS EXAMINATION:\n WITH DUPLEX PLEASE-ASSESS for PV thrombosis\n ______________________________________________________________________________\n FINAL REPORT\n 51-year-old male with end-stage liver disease, cirrhosis, awaiting transplant\n with acute rise in bilirubin, and concern for portal vein thrombosis.\n\n LIVER ULTRASOUND WITH DOPPLER: The liver is shrunken and nodular with\n coarsened echogenicity consistent with cirrhosis. No definite focal hepatic\n lesion is identified. No intra- or extra-hepatic biliary ductal dilatation is\n identified. There is moderate amount of ascites around the liver. Doppler\n evaluation demonstrates appropriate directionality and waveform of the main,\n left and right portal veins as well as main, left and right hepatic arteries\n and main and right hepatic veins. The left hepatic vein is not identified,\n due to technical factors. The IVC is patent.\n\n IMPRESSION: No evidence of portal vein thrombosis. Severe cirrhosis with\n moderate ascites. Left hepatic vein not visualized due to technical factors,\n but all other vessels are accounted for with appropriate directionality and\n waveform.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 924687,
"text": " 3:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p malposition ET tube\n\n REASON FOR THIS EXAMINATION:\n ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, candidemia, MRSA sepsis, ET tube placement.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n The ET tube is in satisfactory position approximately 6.2 cm above the carina.\n An NG tube coils over the left upper quadrant, unchanged. The coil overlies\n the expected course of the left hemidiaphragm and there is no air seen and the\n fundus of the precise position is difficult to confirm radiographically. Right\n IJ central line present, tip over distal SVC, unchanged.\n\n Again seen is cardiomegaly and mild prominence of the superior mediastinum,\n with enlarged pulmonary hila. There is upper zone redistribution, diffuse\n vascular blurring, more confluent opacities at the bases, and small bilateral\n pleural effusions. There is left lower lobe collapse and/or consolidation.\n The right pleural catheter is again noted.\n\n IMPRESSION:\n\n 1) ET tube in satisfactory position. Lines and tubes as described. Clinical\n correlation regarding the NG tube is requested. While it probably does lie\n within the gastric fundus, it is difficult to confirm radiographically.\n\n 2) Findings compatible with CHF with alveolar edema, bilateral effusions and\n left lower lobe collapse and/or consolidation. Allowing for differences in\n technique, this appearance is similar to the film from one day earlier.\n\n 3) No pneumothorax detected.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 924569,
"text": " 8:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: patient with drop in pressures s/p pig tail placement in \n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p placement of right pleural\n pig tail\n REASON FOR THIS EXAMINATION:\n patient with drop in pressures s/p pig tail placement in chest. Eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis, candidemia, MRSA, sepsis, status post placement of\n right pleural pigtail. Drop in pressures after pigtail placement. Evaluate\n for pneumothorax.\n\n COMPARISONS: Radiograph obtained approximately four hours earlier.\n\n PORTABLE AP SUPINE RADIOGRAPH OF THE CHEST: An endotracheal tube is seen\n approximately 7 cm above the carina. The tip of the NG tube projects over the\n gastric fundus. A right-sided IJ central venous catheter is in unchanged\n position with the tip projecting over the distal SVC. A pigtail catheter is\n seen projecting over the right lower lung. There is almost complete removal\n of the previously seen right pleural effusion. No pneumothorax is seen. There\n is new bilateral hilar prominence and perihilar haziness. The cardiac\n silhouette appear stable.\n\n IMPRESSION: 1. No evidence of pneumothorax. 1. Successful drainage of a right-\n sided pleural effusion. 3. Evidence of new pulmonary vascular congestion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 922682,
"text": " 3:17 PM\n CHEST (PA & LAT) Clip # \n Reason: r/u pna\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with cirrhosis, candidal peritonitis, now with increasing WBC\n again.\n REASON FOR THIS EXAMINATION:\n r/u pna\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increased white blood cell in patient with known\n peritonitis.\n\n PA and lateral upright chest radiograph compared to the previous film from\n , and .\n\n The left PICC line was inserted in the meantime interval with its tip\n projecting over the inferior portion of superior vena cava. The heart size is\n normal. There is no mediastinal widening or shifting. The right lower lobe\n consolidation is grossly unchanged with some increase in pleural effusion\n better demonstrated on the lateral exam. The rest of the lungs are\n unremarkable. The healed fractures on the left are again demonstrated.\n\n IMPRESSION: Grossly unchanged right lower lobe consolidation with some\n increase in pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 924628,
"text": " 1:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls check ETT position after advancement\n Admitting Diagnosis: ABD PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 yo male w/cirrhosis, candidemia, MRSA sepsis s/p malposition ET tube\n REASON FOR THIS EXAMINATION:\n pls check ETT position after advancement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cirrhosis, candidemia MRSA sepsis, status post ET tube malposition,\n check ET tube position after advancement.\n\n CHEST, SINGLE AP VIEW.\n\n Lines and tubes are unchanged. The ET tube lies approximately 7 cm above the\n carina at the level of mid clavicle, overall similar to its appearance on the\n film from one day earlier. Radiographically, it is somewhat high but in\n overall satisfactory position. If clinically indicated, it could be advanced\n by 1-3 cm. The right IJ central line tip overlies the distal SVC unchanged.\n Of note, the NG tube is coiled in left upper quadrant and overlies the\n hemidiaphragm itself. I suspect this is within the gastric fundus, but this\n is difficult to confirm on these views.\n\n The pleural and parenchymal findings are unchanged. There is evidence of CHF,\n with bibasilar atelectasis and a small right pleural effusion. The left\n costophrenic angle is excluded from the film. No pneumothorax is detected.\n\n IMPRESSION:\n\n 1. ET tube position essentially unchanged compared with . See\n comment.\n\n 2. Right lung base chest tube, with small effusion, unchanged.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2135-08-10 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 922482,
"text": " 12:58 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Attempted PICC x2 by IV nurse. Please attempt via IR. In n\n Admitting Diagnosis: ABD PAIN\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 51 year old man with EtOH/HCV cirrhosis, awaiting transplant, with \n peritonitis, will need long-term IV antifungal therapy\n REASON FOR THIS EXAMINATION:\n Attempted PICC x2 by IV nurse. Please attempt via IR. In need of long term\n abx for fungal peritonitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: peritonitis, needing long-term IV antifungal therapy.\n\n PROCEDURE: This procedure was performed by Dr. , with Dr. , the\n attending physician, and supervising throughout. The patient was\n brought to the angiography suite and placed supine on the table. A\n preprocedure timeout was performed to confirm patient, site, and procedure.\n The left upper arm was prepped and draped in the usual sterile fashion. As no\n suitable veins were visible, ultrasound was used to identify the left brachial\n vein, which was patent and compressible. After administration of\n approximately 4 mL of 1% lidocaine for local anesthesia, a 21-gauge needle was\n introduced into the brachial vein using real time ultrasound guidance. Hard\n copy ultrasound images were obtained before and after venipuncture\n documenting vessel patency.\n\n Then, a 0.018 guidewire was advanced through the needle and into the distal\n SVC under fluoroscopic guidance. The needle was exchanged for a 4-French\n micropuncture sheath. Based on the markers on the guide wire, the PICC was\n trimmed to 45 cm, then after withdrawal of the inner dilator, advanced over\n the wire and into the distal SVC under fluoroscopic guidance. The peel-away\n sheath and wire were removed, the line flushed, capped, Hep-Locked, and stat-\n locked, and a final fluoroscopic image taken to demonstrate the tip of the\n catheter in the distal SVC. The patient tolerated the procedure well. There\n were no immediate complications.\n\n IMPRESSION: Successful placement of single lumen PICC in the distal SVC via\n the left brachial vein. Line is ready for use.\n\n\n"
}
] |
12,136 | 108,671 | 72 yo F with intramural hematoma of thoracic aorta. Hospital course by problem: . 1. Chronic TAA: Initially, surgical intervention was not felt to be indicated as it was a type B hematoma. Her BP was managed initially with labetolol and Nipride for goal SBP<140 and >100 given likely hx of chronic elevated BP and risk for hypoperfusion. She was ruled out for an acute MI. Her Hct dropped to 23.9 on and developed acute abdominal pain radiating to her back, so a CTA was repeated and showed possible large intramural hematoma in descending thoracic aneurysm. Vascular Surgery was notified and upon review of the scans w/ Radiology, felt the aneurysm was not significantly changed. We changed her antihypertensives and had good BP control with labetalol (changed to Toprol XL upon dispo), amlodipine, and valsartan. . 2. Intramural hematoma with penetrating ulcer: The etiology was unclear. Initially, the ulcer was thought atherosclerotic disease. However, the patient became febrile during her stay and rheum and ID were consulted. She had a negative workup for infectious cause. Her rheum workup was above and notable for positive , anti-CCP, and RF in the setting of an elevated ESR and CRP. An MRI was obtained and revealed a pattern which was not consistent with aortitis. Thus, her fever and inflammatory response was thought to be rheumatoid arthritis and the patient did not have an underlying aortitis. The patient was discharged with good blood pressure control and plans to return on for surgical intervention of her penetrating aortic ulcer. Additionally, we started atorvastatin for goal LDL<70 and for it's anti-inflammatory activity. She has VNA to assist with medication compliance as well as frequent blood pressure checks. . 3. Fevers: As above. The patient had intermittent fevers and confusions for approx 6 days in the middle of her stay. CSF analysis and head CT showed no pathology. ID workup was negative. The fever was thought inflammatory state. The mental status change was thought ICU delirium and it improved rapidly after she was transferred to the floor. . 4. CHF: EF>55% by ECHO. No evidence of heart failure on chest Xray. No shortness of breath and oxygen saturation in high 90's. We continued lasix low salt diet . 5. Hyponatremia: Labs were consistent with SIADH. The patient had resolution of her hyponatremia prior to discharge. . 6. Osteoporosis: All of her bone films mentioned severe osteopenia. We started the patient on alendronate, calcium, and vitamin D during her admission and continued it upon discharge. | Normalregional LV systolic function. Normal RVsystolic function.AORTA: Moderately dilated aortic root. Mildly dilated ascending aorta. The ascending aorta is mildlydilated. Mildlydilated aortic arch. Right ventricular systolicfunction is normal.4.The aortic root is moderately dilated. Left ventricular function.Height: (in) 68Weight (lb): 154BSA (m2): 1.83 m2BP (mm Hg): 133/62HR (bpm): 80Status: InpatientDate/Time: at 16:38Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Stable left common iliac artery aneurysm. Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.Conclusions:1. Theinteratrial septum is aneurysmal.2.Left ventricular wall thicknesses are normal. Aneurysmal interatrial septum.LEFT VENTRICLE: Normal LV wall thickness. A posterior penetrating ulcer is again noted at the level of the diaphragmatic hiatus, but unchanged in size and character. The glenohumeral and acromioclavicular articulations are within normal limits. Unchanged appearance of extensive Type B intramural hematoma from the subclavian artery origin to the upper abdominal aorta. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Mild mitral annularcalcification. Aneurysmal dilation of the left common iliac measuring 1.8 cm is unchanged. Stable 4-cm infrarenal abdominal aortic aneurysm. No aortic regurgitationis seen.6.The mitral valve leaflets are mildly thickened. 4-cm infrarenal abdominal aortic aneurysm is unchanged. Mild aneurysmal dilation of the left common iliac artery. The aortic arch is mildly dilated. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Left ventricular hypertrophy.Non-specific ST-T wave changes. The associated posterior penetrating ulcer at the diaphragmatic hiatus is stable. Intraabdominal large and small bowel are normal. Mildly dilated descending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Bilateral pleural effusions are unchanged from the prior study. WILL CONTINUE O OBERVEB/S STABLERESP..SATS @ 95% ON 2/ NC, NOT TOLERTAING N/C WITH AGITATION AT TIMES..GI/U..TAKEN SOME FLUIDS, MOUTH LOOKS DRY, NO BOWEL MOTION...FOLEY AS ABOVE, SO PRESENTLY OUT..NEG BALANCE AT MN, ...TO HAVE ONE REPLACED WHEN APPROPRIATE....SKIN..INTACT...LINES..PATENT...SOCIAL..DAUGHETER PHONED ASLT PM AND UPDATED..BUT NOT AWARE OF MENTAL STATUS OVERNIGHT...PLAN..FOLOW MS CLOSELY AND MEDICATE AS REQUIRED, MONITOR B/P AIM < 140 CT CHEST WITH CONTRAST: There has been no marked interval change from , , with again demonstrated type B intramural hematoma extending from the subclavian artery through the diaphragmatic hiatus into the upper abdomen proximal to the celiac axis. Good flow demonstrated within parenchymal branches of the mid and lower poles bilaterally, upper pole is not well visualized secondary to patient respiration. Easily palpable PT's bilaterally weakly palpable DP's right weaker than left.RESP: Lungs with bibasilar crackles otherwise CTA. A posterior penetrating ulcer is seen at the level of the diaphragmatic hiatus is again visualized. Stable appearance of the chest, abdomen and pelvis with type B intramural hematoma and associated penetrating ulcer. Tele SR 70's with a a significant first degree AV block. NPN (cont'd)RESP: Lungs with diminished breath sounds throughout. The descending thoracic aorta ismildly dilated.5.The aortic valve leaflets (3) are mildly thickened. TECHNIQUE: Non-contrast and contrast-enhanced axial CT imaging of the chest, abdomen and pelvis was reviewed. TECHNIQUE: CT of the chest without IV contrast. The heart and pericardium are otherwise unremarkable except for dense coronary artery calcifications. Hct, 4pm, stable, 31.1 Vascular cont to follow; aortic dissection is non-operable at this time; may consider stenting if unstable. A crit was drawn @ 2100 that did not bump appropriately.Pt ordered for a CT angio of her chest which was completed at 0300. MICU Nursing Progress Note 0700-1900Events - Pt's BP extremely labile, crit of 28.7 after 2 units PRBCs.Neuro - Pt A&Ox3, MAE, follows commands. ABP 120-160S/ TRENDS DOWN TO 90S WHILE PT ASLEEP/ 0200 LABETALOL DOSE HELD PER PARAMETER/ TEAM AWARE. goal for bp 120-130. hct 28.7 and this am 29.3, k+ 4.1 mg 1.8. AT OSH PT WAS FOUND TO HAVE B/P 240/120/ CT SUGGESTIVE OF ACUTE ON CHRONIC THORACIC ANEURYSM/ TRANSFERRED TO FOR FURTHER MANAGEMENT. Hct drop initially to 24.7(from 28) and pt received 1UPRBC without appropriate bump. LS clear and diminished at the bases.cv: 1 degree AVB (not a new finding). Hypertension now being managed with po meds. Hrt sounds S1S2 w/ systolic murmur. MICU UPDATE and transfer note:Foley and Right Rad A-line d/c'd this AM. No increase in size of hematoma on CT. Stools were initially guiac positive.PO labetolol was started and gtts were weaned off by . Ruled out for an MI per enzymes. has hx of HTN/CHF/hypercholesterolemia along with hx of thoracic aortic aneurysm.Treated with labetolol and nipride gtts (goal 100-140/syst). pt became nauseous this am at 0200 anzemet 12.5mg ivp given w/ good effect. was incontinent this AM until foley was replaced. Fluid goal is slightly negative to a half a liter negative.Skin: IntactAccess: 2 PIV, right radial A-line.Endo: BS QIDSocial: Family in to visit for much of shift, updated on patient's condition. R radial aline.gi/gu: Pt is now NPO for ? Breathing pattern regular and unlabored.CV - Pt is in first degree AVB. pt denied back and abdominal pain. Will cont to closely monitor.CV: Remains in 1st degree AV block, 60-70's. BP elevated early am d/t infiltrated IV upon assessment. Additionally noted on the current exam is marked delayed crescentic enhancement of the entire aortic wall in the region affected by the intramural hematoma, compatible with associated engorgement of (Over) 10:41 AM MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Please eval for evidence of aortitis. 10:41 AM MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # Reason: Please eval for evidence of aortitis. Colace and PRN Senna added to medications. PM crit 30.1 up from 29.3GI: Pt advanced to regular diet and tolerating well. pt c/o of head ache early this am at 0300 tylenol 650mg po given w/ good effect. | 28 | [
{
"category": "Echo",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 81920,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypertension. Left ventricular function.\nHeight: (in) 68\nWeight (lb): 154\nBSA (m2): 1.83 m2\nBP (mm Hg): 133/62\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 16:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dynamic interatrial\nseptum. Aneurysmal interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal\nregional LV systolic function. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV\nsystolic function.\n\nAORTA: Moderately dilated aortic root. Mildly dilated ascending aorta. Mildly\ndilated aortic arch. Mildly dilated descending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Physiologic\nTR. Indeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size. The left atrium is elongated. The\ninteratrial septum is aneurysmal.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Regional left ventricular wall motion is normal. Overall left\nventricular systolic function is normal (LVEF>55%).\n3.Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4.The aortic root is moderately dilated. The ascending aorta is mildly\ndilated. The aortic arch is mildly dilated. The descending thoracic aorta is\nmildly dilated.\n5.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\nis seen.\n6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation\nis seen.\n7.The pulmonary artery systolic pressure could not be determined.\n8.There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 208684,
"text": "Sinus rhythm. A-V conduction delay and A-V nodal Wenckebach. Diffuse\nnon-specific ST-T wave flattening.\n\n"
},
{
"category": "ECG",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 208685,
"text": "Sinus rhythm. A-V nodal Wenckebach block. Left ventricular hypertrophy.\nNon-specific ST-T wave changes. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-28 00:00:00.000",
"description": "R HUMERUS (AP & LAT) RIGHT",
"row_id": 932507,
"text": " 2:33 PM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT; HUMERUS (AP & LAT) RIGHTClip # \n Reason: r/o fx\n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with right shoulder pain s/p trauma\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT SHOULDER, FOUR VIEWS, RIGHT HUMERUS, TWO VIEWS, AT\n 14:02 HOURS.\n\n HISTORY: Status post trauma.\n\n COMPARISON: None.\n\n FINDINGS: There is severe global osteopenia. There is no fracture or\n dislocation. The glenohumeral and acromioclavicular articulations are within\n normal limits. The coracoclavicular interval is appropriate. The regional\n soft tissues of the upper arm are unremarkable. The visualized adjacent lung\n is clear.\n\n IMPRESSION: Severe diffuse osteopenia, likely secondary to osteoporosis.\n Given the severity of the osteopenia, the sensitivity is decreased for\n detecting subtle nondisplaced fracture.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-17 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 930919,
"text": " 5:12 AM\n CT CHEST W&W/O C ; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Eval for evidence of new disection. PLEASE DO WITH MMS \n Admitting Diagnosis: BACK PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with hx of thoracic aortic aneurysm with chest pain.\n REASON FOR THIS EXAMINATION:\n Eval for evidence of new disection. PLEASE DO WITH MMS PROTOCOL.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old with history of thoracic aortic aneurysm and chest\n pain. Assess for new dissection.\n\n TECHNIQUE: CT of the chest without IV contrast. CT of the chest, abdomen,\n and pelvis after the administration of 90 cc of Optiray. Coronal and sagittal\n reformatted images were obtained.\n\n COMPARISON: .\n\n CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: Again seen is extensive Type B\n intramural hematoma from the origin of the subclavian artery through the\n diaphragmatic hiatus and into the upper abdominal aorta proximal to the celiac\n axis. A posterior penetrating ulcer is seen at the level of the diaphragmatic\n hiatus is again visualized. These findings are unchanged. There is no new\n dissection. There is no pulmonary embolus. The lung fields demonstrate\n diffuse patchy areas of ground-glass opacification and mild septal thickening.\n There is a 5 mm nodule in the right lower lobe. There is no focal\n consolidation. The trachea and bronchi are patent to the segmental level.\n Bilateral pleural effusions are unchanged from the prior study. The heart and\n pericardium are unremarkable other than dense coronary calcifications in the\n right, left anterior descending, and circumflex arteries.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: There is a 3.3 x 4.1 cm cyst in the left\n lobe of liver. No other hepatic lesions are identified. There is vicarious\n excretion of contrast into the gallbladder. The spleen, pancreas, adrenals,\n and kidneys are normal. There is no free air or free fluid in the abdomen.\n There is no pathologic lymphadenopathy. Intraabdominal large and small bowel\n are normal. There is a 4 cm infrarenal abdominal aortic aneurysm.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid are unremarkable.\n There is a small amount of free fluid in the pelvis. The uterus is\n unremarkable. There is no lymphadenopathy. There is aneurysmal dilation of\n the left common iliac artery measuring 1.8 cm.\n\n Degenerative changes are seen throughout the thoracic and lumbar spine. Severe\n facet arthropathy are seen at the L4 and L5 levels. Soft tissues are\n unremarkable.\n\n Coronal and sagittal reformatted images confirm the above findings.\n (Over)\n\n 5:12 AM\n CT CHEST W&W/O C ; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Eval for evidence of new disection. PLEASE DO WITH MMS \n Admitting Diagnosis: BACK PAIN\n Field of view: 36 Contrast: OPTIRAY Amt: 110\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. Unchanged appearance of extensive Type B intramural hematoma from the\n subclavian artery origin to the upper abdominal aorta. The associated\n posterior penetrating ulcer at the diaphragmatic hiatus is stable. No new\n dissection.\n\n 2. Findings suggestive of congestive failure/volume overload with bilateral\n pleural effusions and septal thickening.\n\n 3. Four-cm infrarenal abdominal aortic aneurysm.\n\n 4. Mild aneurysmal dilation of the left common iliac artery.\n\n 5. Dense coronary vascular calcifications.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-16 00:00:00.000",
"description": "DISTINCT PROCEDURAL SERVICE",
"row_id": 930902,
"text": " 6:24 PM\n RENAL U.S.; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: Pls perform Doppler U/S to evaluate for RAST in pt with \n Admitting Diagnosis: BACK PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with thoracic aortic hematoma and HTN requiring IV drips to\n control.\n REASON FOR THIS EXAMINATION:\n Pls perform Doppler U/S to evaluate for RAST in pt with persistent HTN on\n nipride and labetolol drips.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old woman with thoracic aortic hematoma, hypertension.\n Evaluate for renal artery stenosis.\n\n COMPARISON: None.\n\n FINDINGS: Right kidney measures 10.4 cm. Left kidney measures 10.7 cm. No\n evidence of hydronephrosis or stones. Arterial upstrokes with diastolic flow\n are seen within the mid and lower pole parenchymal branches of both kidneys,\n with resistive indices ranging from 0.65 to 0.70. Upper pole branches are not\n definitely seen bilaterally. Study was somewhat limited by the patient's\n respirations. Arterial upstrokes with diastolic flow are seen within the\n renal arteries bilaterally, venous waveforms are identified within the renal\n veins bilaterally.\n\n IMPRESSION: Normal arterial and venous waveforms seen within the main renal\n arteries and veins bilaterally. Good flow demonstrated within parenchymal\n branches of the mid and lower poles bilaterally, upper pole is not well\n visualized secondary to patient respiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-11-23 00:00:00.000",
"description": "CTA ABD W&W/O C & RECONS",
"row_id": 931805,
"text": " 5:43 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS\n Reason: pt with chronic thoracic AAA / with penetrating ulcer\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with AAA\n REASON FOR THIS EXAMINATION:\n pt with chronic thoracic AAA / with penetrating ulcer\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AAA with penetrating ulcer.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast and contrast-enhanced axial CT imaging of the chest,\n abdomen and pelvis was reviewed.\n\n CT CHEST WITH CONTRAST: There has been no marked interval change from , , with again demonstrated type B intramural hematoma extending from\n the subclavian artery through the diaphragmatic hiatus into the upper abdomen\n proximal to the celiac axis. A posterior penetrating ulcer is again noted at\n the level of the diaphragmatic hiatus, but unchanged in size and character.\n The diffuse patchy areas of ground-glass opacification are again noted within\n the lungs with note of a 5-mm nodule in the right lower lobe. The heart and\n pericardium are otherwise unremarkable except for dense coronary artery\n calcifications.\n\n CT ABDOMEN WITH CONTRAST: A 4-cm cyst in the left lobe of the liver is\n unchanged. Gallbladder, pancreas, spleen, adrenals, and kidneys are\n unremarkable. There is no free air or free fluid. No pathologic adenopathy\n is identified. 4-cm infrarenal abdominal aortic aneurysm is unchanged.\n\n CT PELVIS WITH CONTRAST: The rectum, sigmoid, and remaining large bowel is\n unremarkable. The uterus and adnexa are only remarkable for a small calcified\n fibroid. No pathologic adenopathy is identified. Aneurysmal dilation of the\n left common iliac measuring 1.8 cm is unchanged.\n\n BONE WINDOWS: Degenerative changes are again seen throughout the thoracic and\n lumbar spine with prominent degenerative changes at L5-S1.\n\n IMPRESSION:\n 1. Stable appearance of the chest, abdomen and pelvis with type B intramural\n hematoma and associated penetrating ulcer.\n 2. Improving ground-glass opacities.\n 3. Stable 4-cm infrarenal abdominal aortic aneurysm.\n 4. Stable left common iliac artery aneurysm.\n (Over)\n\n 5:43 PM\n CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS Clip # \n CTA PELVIS W&W/O C & RECONS\n Reason: pt with chronic thoracic AAA / with penetrating ulcer\n Admitting Diagnosis: BACK PAIN\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-17 00:00:00.000",
"description": "Report",
"row_id": 1421827,
"text": "NPN (cont'd)\n\nRESP: Lungs with diminished breath sounds throughout. Sats of >96% on 2lnc.\n\nGI: Taking po's well. OOB to BSC, moderate amount of soft, brown, guiac negative stool.\n\nSKIN: Intact.\n\nID: Afebrile.\n\nSOCIAL: Daughter called and pt's sister visited.\n\nPLAN: Continue to follow B/P on increased po medications...goal 120-140/syst.\n Follow up on results of head CT.. check with HO re:medicating further with haldol if indicated\n ?transfer to floor if B/P stable tomorrow.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-18 00:00:00.000",
"description": "Report",
"row_id": 1421828,
"text": "NURSING NOTE 1900HRS - 0400HRS\n\n\nEVENTS...INCREASING AGITATION/HALLUCINATING/ANGRY OUTBURSTS REQUIRING PO/IV MEDS FOR CONTROL AS PATIENT DANGER TO SELF...PULLED OUT FOLEY, REPLACED THEN TAKEN OUT BY RN AS PATIENT KEPT PULLING AT CATHETER...SITTER REQUESTED...\n\n\n\nNEURO..INITLALLY REALTIVELY CALM ORIENTATED TO SELF....ZYPREXA GIVEN AS PATIENT STARTED TO BECOME RESTLESS..NO EFFECT, NO SLEEP THEREFORE SEROQUEL GIVEN WITH NO EFFECT..PATIENT INCREASINGLY AGITATED AND OBVIUOS THAT SHE WAS HALLUCINATING, PICKING AT LINES/POINTING AT THINGS IN THE ROOM... AND IN PARTICULAR FOLEY..PULLED OUT FOLEY THEN REPLACED BUT AGAIN KEPT ATTEMPTING TO PULL OUT FOLEY ? HALLUCINATING AT THIS POINT AND CALLING OUT ? ANGRY AT TRYING HER TO STOP HER FROM ATTEMPTING TO DO THIS...IV HALDOL GIVEN [ BUT CONCERN FOR QTC INTERVAL]..CONTINUED TO INCREASE WITH SYMPTOMS, PATIENT ATTEMPTING TO GET OOB..EVENTUALLY PUT PATIENT INTO CHAIR..SEEN AGAIN BY TEAM, LORAZAPAM ORDERED WITH SOME EFFECT,PRESENTLY PATIENT QUIETER BUT CONTINUES TO PULL AT LINES AND APPEARS TO BE TALKING TO SELF...SITTER ORDERED WILL CONTINUE TO FOLLOW CLOSELY.. NO COMPLAINST OF PAIN OVERNIGHT... HEAD CT NEGATIVE TO ACUTE EPISODE TAKEN LAST PM\n\n\nCVS...B/P CONTROLLED ON PO MEDS 130-140 SYSTOLIC..HR 70-75BPM 1ST DEGREE AV BLOCK..\nHCT STABLE LAST PM..K MG RELETED ASLT PM AS @ 3.6 AND 1.5.. ALL AM LABS PENDING...\nBORDERLINE TEMP @ 100. WILL CONTINUE O OBERVE\nB/S STABLE\n\n\nRESP..SATS @ 95% ON 2/ NC, NOT TOLERTAING N/C WITH AGITATION AT TIMES..\n\n\nGI/U..TAKEN SOME FLUIDS, MOUTH LOOKS DRY, NO BOWEL MOTION...FOLEY AS ABOVE, SO PRESENTLY OUT..NEG BALANCE AT MN, ...TO HAVE ONE REPLACED WHEN APPROPRIATE....\n\n\nSKIN..INTACT...\n\nLINES..PATENT...\n\n\nSOCIAL..DAUGHETER PHONED ASLT PM AND UPDATED..BUT NOT AWARE OF MENTAL STATUS OVERNIGHT...\n\n\n\nPLAN..FOLOW MS CLOSELY AND MEDICATE AS REQUIRED, MONITOR B/P AIM < 140\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-12 00:00:00.000",
"description": "Report",
"row_id": 1421813,
"text": "pt is a 73yo woman arrived via from OSH. pt had Chest ct at OSH and showed thoracic abd aneurism. Pts BP was >250. Pt was initiated on labetalol, nipride and received morphine and zofran for nausea at OSH ED. Pt on arrival to unit was on nipride 4mcg/kg/min, labetalol 2mg/min. Bp was 195/89. pt received 10mg of hydralazine. pt had a-line placed without difficulty. pt arrived with 3 perp IV's. labs were obtained, waiting results. pt appears A+Ox1 unable to give full assessment pt does not speak english. sbp goal 120's\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 1421814,
"text": "Nursing Progress Note 1900-0700\n\n72 year old female with a PMH of HTN, hypercholesterolemia, hx of thoracic aortic aneurysm, and ? CHF. She was transferred from an OSH for further management of an acute on chronic thoracic aortic dissection. Upon arrival she was on a nipride gtt and a labetolol gtt was started for management of her HTN. CT surgery was consulted and recommended medical RX at this time. CT from outside hosptial showing a Intramural hematoma of descending thoracic aorta.\n\nNeuro: A&Ox3 per family, patient is portugese creole speaking only. She is able to make her needs known by nonverbal cues. Good bed mobility moving all 4 extremities. Pt with c/o back pain at , given 2 mg morphine with good effect.\n\nCardio: Nipride & Labetalol gtt's weaned to off. Systolic BP down to high 90's briefly overnoc. Tele SR 70's with a a significant first degree AV block. PR. 28-.32. Easily palpable PT's bilaterally weakly palpable DP's right weaker than left.\n\nRESP: Lungs with bibasilar crackles otherwise CTA. RR 10-14. Sats 95-100 on 2LNC ABG at 1900 7.44/29/111.\n\nGI: Remains NPO, abdomen soft non tender. + BS in 4 quadrents. No BM this shift. Trace guiac positive by rectal exam. Pt had two episodes of N&V at & 2100 with small amounts of clear thick emesis. Treated with Zofran & Phenagran with good effect.\n\nRenal: UOP decreased with Drop in BP to under 110 systolically (down to 10-20 x 4 hrs) UOP increasing with rise in BP. Urine is clear yellow. 0100 BUN/CREAT 15/0.7\n\nFEN: Mag and K repleted AM labs pending. On sodium Bicarb at 100/hr for one liter D/T large dye load from CT at OSH.\n\nHeme: HCT 28 upon arrival down to 25.2 at 1 AM. AM HCT pending\n\nID: afebrile, no issues\n\nSkin: No issues\n\nSocial: Mutiple family members in to see patient including her sister, husband, , nephew and daughter. Daughter () is to be spokesperson and is HCP. and sister speak minimal english. Family oriented to ICU environment and housestaff reviewed disease process and POC.\n\nPlan:\n\n1. Blood pressure control Goal is SBP between 110 and 130.\n2. Repeat CT scan in 24-48 hours\n3. Monitor UOP, fluid balance\n4. Pain & Nausea meds PRN for patient comfort\n5. NPO ?restart of diet if patient remains stable\n6. Monitor resp status Re: H/O CHF\n7. Routine ICU care and monitoring\n8. Emotional support to patient and family\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 1421815,
"text": "NPN addendeum\n\nRN noticed pt to have irregular HR, EKG done. ? Afib house staff aware. BP stable. HR 70's. Will Continue to monitor\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-13 00:00:00.000",
"description": "Report",
"row_id": 1421816,
"text": "NURSING NOTE 0700HRS - 1600HRS\n\nPATIENT ADMIT FROM OSH ...HX OF THORACIC AORTIC ANUERYSM AND CHF...SHE WAS TRANSFERRED FROM OSH FOR FURTHER MANAGEMENT OF ACUTE BACK PAIN ASLTING FOR 12HRS..CT OVER THERE SUGGESTED ACUTE ON CHRONIC THORACIC AORTIC DISSECTION...PATIENT TRANSFERRED ON NIPRIDE/LABETOLOL FOR B/P > 200, FOR FURTHER MANAGEMENT AND CONSULT...\n\n\n\nEVENTS...OF IV MEDS THIS AM BUT NIPRIDE RE-COMMENCED PM FOR >> SYSTOLIC TO 150..PO MEDS COMMENCED FRO B/P CONTROL BUT D/C AS HR VARAIBLE [ SEE BELOW]...\nFOR MEDICAL MANAGEMENT AT PRESENT OF B/P CONTROL/DISSECTION NOT FOR SURGERY AS HIGH RISK...\nFOR REPEAT CT SCAN TOMORROW TO RE-ASSESS AREA OF CONCERN\n\n\n\nNEURO...DOES NOT OFFICIALLY SPEAK ENGLISH BUT UNDERSTANDS A LITTLE..FAMILY HAVE BEEN HERE TODAY AND HAVE HELPED IN UPDATING HERE AS TO CONDITION AND PLAN OF CARE...C/O BACK PAIN AND HAS RECEIVED IV MORPHINE WITH GOOD EFFECT TODAY...MOVEMENT OF ALL 4 LIMBS AND FEET WARM PULSES DOPPLER\n\n\nCVS...B/P WITHIN PARAMETERS THIS AM [ AIM 120-130 SYSTOLIC, NOT LESS THAN 120 BECAUSE U/O AFFECTED]...THIS PM , WITH STIMULTION AND FAMILY VISIT, BP > 140 THEREFORE NIPRIDE DRIP RE- COMMENCED AND PO BBLOCKER GIVEN , TITRATED UP TO 1.5 FOR CONTROL [ TEAM AWARE AND WILL REVIEW PO MEDS FOR CONTROL]...HR OVERNIGHT 1ST DEGREE AV BLOCK TO AF THIS AM BUT B/P NOT COMPROMISED AND RATE CONTROLLED @ 75, ECHO PERFORMED, C/E STABLE..THIS PM RIVERTED BACK TO 1ST DEGREE AV BLOCK, RATE 75 BUT WITH OCCASSIONAL PAUSE, TEAM AWARE AND NUMEROUS EKG'S TAKEN, IN VIEW OF THIS BBLOCKER D/C...AWAITING TEAM TO RE-REVIEW MEDS...\nAFEBRILE...B/S STABLE, WERE RAISED DURING THE NIGHT...\nHCT DROPPING TO 24.5 [ THRESHOLD 25] THEREORE IS PRESENTLY RECEIVING X1UPRBC... ? CAUSE OF HCT DROP [ Q6HRLY HCT]\n\n\nRESP...XR SHOWS MILD CHF..LUNGS SOUND CLEAR, FEW CRACKLES BASES..SATS @ 100% ON N/C...\n\n\nGI..TAKEN SOME PO DIET/FLUIDS PM, ADBO SOFT...TRACE GHUAIC POS LAST PM...\n\n\nGU..SATISFACTORY U/O , COMPLETED BICARB DRIP..GIVEN TO PROTECT KIDNEYS AS RECEIVED DYE LOAD YESTERDAY DURING CT...BUN/CREAT ..PM K @ 3.3 REPLETED WITH PO K\n\n\nSKIN..INTACT..\n\n\nLINES...X3 PERIPHERAL, ART LINE..\n\n\nPLAN..B/P CONTROL [ 120-130] WITH PO/IV MEDS...OBSERVE HR FOR FURTHER ARRYTHMIAS..AWAIT REPEAT CT TOMORROW...MONITOR HCT Q6 MAINTAIN >25]\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-17 00:00:00.000",
"description": "Report",
"row_id": 1421824,
"text": "NEURO...DAUGHTER SAID LAST PM THAT PATIENT HAD BEEN INTERMITTENTLY HALLUCINATING/CONFUSED /DISORIENTED OVER THE COURSE OF THE DAY..PATIENT SETTLED EARLY LAST PM THEN BECAME RESTLESS/AGITATED/HALLUCINATING [ PICKING AT SELF AND THE BED] AT APPROX 0100HRS...REFUSED PO HALDOL THEREFORE GIVEN IV DOSE OF 1MG TOTAL..BECAME CALMER THE PATIENT C/O LEFT SIDED CHEST PAIN, EKG TAKEN S/L NITRATE GIVEN BUT TOTAL 4 MGS MORPHINE TOOK THE PAIN AWAY...PRESENTLY PATIENT PAINFREE AND AWAITING REPEAT CT CHEST...\nUNDERSTANDS SOME ENGLISH, SPEAKS /CREOLE\n\n\n\nCVS...LABETOLOL DRIPS WEANED TO OF WITH INCRESAED DOSE OF PO MEDS...BUT WITH INCRESAING AGITATAION/PAIN B/P INCREASING TO > 140 [ AIM 120-140] THEREFORE LABETOLOL DRIP RE-COMMENCED FOR CONTROL AND BRIEFLT NIPRIDE..PRESENTLY CONTROLLED 2MGS/MIN LABETOLOL HR 65-67 AND B/P @ 130 SYSTOLIC...\nHCT HAS DROPPED FROM 31 TO 28.9 [ ? RELATED TO DISSECTION] HAS HAD PREVIUOS DROP AND REQUIRED BLOOD...FRESH CROSS MATCH SENT...ALL OTHER AM LABS STABLE\nAFEBRILE..B/S STABLE...\n\n\nRESP..IN VIEW OF NEW CHEST PAIN 2LN/S APPLIED SATS >95%\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-17 00:00:00.000",
"description": "Report",
"row_id": 1421825,
"text": "GI...TAKING ONLY SMALL AMOUNTS OF FOOD..FAMILY HAVE REQUESTED TO BRING FOOD IN [ ADVISED NO SALT]..NO BOWEL MOTION FOR 4 DAYS THEREFORE ON REGIME, SOFT WITH B/S..HCT AS ABOVE, NEED TO GHUAIC STOOL , PREVIUOSLY GHUAIC POS ? FOR GI TO BE INVOLVED AT SOME POINT...\n\n\nGU..RECEIVED 20MGS LASIX YESTERDAY FOR MILD CHF WITH GOOD RESPONSE [ NEG BALANCE]...BUT RECEIVED BOLUS BICARB DRIP PLUS INFUSSION NOW IN PROGRESS FOR PROTECTION OF KIDNEYS POST CT WITH CONTRAST...\n\n\nLINES..NEW PERIPHERAL SIGHTED, ART LINE POSTIONAL BUT DRAWS..\n\n\nSOCIAL..DAUGHTER SPEAKS VERY GOOD ENGLISH AND IS HCP..SHE VISITS DAILY\n\n\n\nCVS...HR IS FIRST DEGREE HB, HAS HAD PREVIUOS EPISODE OF AF [ FRIDAY]..HR HAS SLOWED WITH TRANSITIONING FROM IV TO PO LOPRESSOR..PRESENTLY @ 60 SINUS/1ST DEGREE AV BLOCK...LOPRESSOR PO IS TO BE GIVEN WITH PARAMETERS\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-17 00:00:00.000",
"description": "Report",
"row_id": 1421826,
"text": "MICU 6 Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data. Hypertension now being managed with po meds. Hct has been stable. Pt to head CT for increased confusion, agitation and paranoia.\n\nCNS: Pt. initially assessed at being alert and oriented x 3 via interpreter this AM x 2. She did make some statements about last night \"they were trying to give me too much medication\"...\"they stuck needles in me\" and seemed upset. When her daughter called and spoke to her later in the morning, daughter stated her mother was extremely confused, disoriented and angry. HO notified re:? further haldol. Pt. began to cry out, again appearing angry and distressed. Given .5mg haldol with good effect and was taken for head CT...awaiting results. She is cooperative now, yet still seems somewhat angry.\n\nCVS: Pt. denies any back or chest pain today. CTA from last night unchanged per report. B/P has ranged 120-140/syst, except for a brief increase to 170/ during IV placement. Currently receiving labetolol 300mg qid, narvasc 10mg qd and valsartan 80mg qd also started today. Heart rate in the mid 60's without VEA. Pt. received 20mg lasix IV and is 900cc negative at this writing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-15 00:00:00.000",
"description": "Report",
"row_id": 1421820,
"text": "MICU Nursing Progress Note 0700-1900\n\nEvents: Attempted to transition patient to PO Labetelol and off Nipride gtt with some success.\n\nNeuro: Pt alert and oriented x 3, OOB to chair for approximately 4 hours with an assist of two. Patient able to stand and pivot. Speaks some english but mostly communicates needs through family and gestures. No complaints of pain this shift.\n\nResp: Lungs clear, diminished at bases. No longer on O2. Sats remain above 95%.\n\nCV: HR 63-68, first degree AVB. Afebrile. Pt remains on Nipride gtt currently running at 0.3mcg/kg/min, Labetalol at 4mg/min as well as 300mg PO Labetalol. BP very labile throughout shift. MICU team goal during AM rounds was to wean off Nipride gtt. During shift able to decrease from 1mcg/kg/min to 0.5mcg/kg/min. Pt very sensitive to changes in gtt rate. Goal BP 130-140 systolic. PM crit 30.1 up from 29.3\n\nGI: Pt advanced to regular diet and tolerating well. No complaints of nausea this shift. Please note that family is bringing in food for patient and was made aware by nurse to make sure food from home is low sodium due to increased BP. Colace and PRN Senna added to medications. No stool this shift.\n\nGU: Foley patent and draining light yellow, clear urine. Given 20mg Lasix with good effect, diuresed approximately 1100cc. Fluid goal is slightly negative to a half a liter negative.\n\nSkin: Intact\n\nAccess: 2 PIV, right radial A-line.\n\nEndo: BS QID\n\nSocial: Family in to visit for much of shift, updated on patient's condition. Daughter (HCP) called and updated, will be in this evening.\n\nPlan: Continue to monitor BP and titrate accordingly, wean Nipride gtt as tolerated by patient. Patient/family teaching regarding BP control, importance of compliance to medication regimen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-16 00:00:00.000",
"description": "Report",
"row_id": 1421821,
"text": "cv: 72-60 1st degree avb. sbp 106-155/ attmpts to wean nipride to off. unable to get nipride off but did decrease to 0.1 mics/kg/min. goal sbp 130-140.\n\ngi: positive bowel sounds. abdomen soft. no stool.\n\ngu: foley draining clear yellow urine.uo 25-325cc/hr\n\nneuro: moves all extremities to commands. comprehends some english but responds in portuguese.\n\nintegumentary: skin intact.\n\nPain: pt c/o head ache ..medicated with tylenol 650 mg po and morphine 2 mg sc with good effect.pt slept.\n\nlabs: hct stable.see careview for all lab results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-16 00:00:00.000",
"description": "Report",
"row_id": 1421822,
"text": "Nursing Note (0700-1900hrs)\n\nPt cont to require IV nipride and labetalol to maintain SBP 130-140's;cont to increase po antihypertensives. Vasc following--feels aortic hematoma does not explain Hct drop. Prob from GI sources with hx of coffee ground emesis, sm amt and OB+stool on admit.\n\nReview of systems:\nNeuro: A&OX3 per family however appears sl disorientated upon awakening; mentioning to family that she is in her living room then realizes she is wrong; also seeing some ?shadows to daughter's face. Will cont to closely monitor.\n\nCV: Remains in 1st degree AV block, 60-70's. BP elevated early am d/t infiltrated IV upon assessment. Nipride gtt continues to be difficult to wean off completely despite low dose of 0.5mcg/kg/min at this time. Labetalol at 4mg/min. PO labetalol increased to 200mg QID. Amlodipine increased to 10mg. Has right radial aline which is accurate however unable to draw bloods from; site sl tender to touch however discomfort seems r/t position of catheter. PIV to left hand leaking as well, presently has #20 to LLA, site unremarkable. Access good. No ankle edema. Hct, 4pm, stable, 31.1 Vascular cont to follow; aortic dissection is non-operable at this time; may consider stenting if unstable. Mg and potassium repleted this am.\n\nResp; Sl crackles to bases. >95% on RA. Evidence of pulm edema on CXR on admit; given lasix 20mg with fair response; goal of -500 to 1L today.\nGi/GU: NAS/Low chol diet; appetite fair. Some bile/mucous emesis in afternoon--prob r/t po potassium. Abd NTND; complaining of some abd discomfort however pt states LBM 4 days ago; up to commode x2 without results. Senna increased to . Given dose this am. Foley patent for clear yellow urine. GAS.\n\nID: Afebrile. No s/s infection. WBC wnl.\n\nSocial: Daughter and ?sister visiting; updated on condition. Daughter reports that aunt and grandmother both had hx aneurysms that were repaired.\n\nPlan: Cont with wean of nipride gtt first then labetalol gtt as po's increased. Goal for <140. Hct's, GAS; repeat CTA tomorrow. Renal US tonight/tomorrow to assess for renal stenosis. Diuresis. Enc po's--senna this evening. Closely monitor mental status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-17 00:00:00.000",
"description": "Report",
"row_id": 1421823,
"text": "NURSING NOTE 1900HRS - 0500HRS\n\nADMIT FROM OSH WITH KNOWN AORTIC DISSECTION , BACK PAIN, CT SHOWED HAEMATOMA ON DISSCETION, NOT CANDIDATE FOR SURGERY [ VASC FOLLOWING] ..BUT BE CANDIDATE FOR STENTING IF PATIENT BECOMES UNSTABLE\n\n\nEVENTS....AGITATED/HALLUCINATING REQUIRED IV HALDOL/... EXPERIENCED SIGNIFICANT LEFT SIDED CHEST PAIN REQUIRING IV MORPHINE AND TO RE-START LABETOLOL DRIP FOR B/P > 140... HCT DROP TO 28.9... IN VIEW OF PAIN/HCT FOR URGENT CT TO REASSESS DISSECTION...\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-12-01 00:00:00.000",
"description": "MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WS",
"row_id": 932830,
"text": " 10:41 AM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please eval for evidence of aortitis.\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old woman with known thoracic aortic aneurysm with mural wall thrombus\n and ulcer.\n REASON FOR THIS EXAMINATION:\n Please eval for evidence of aortitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for aortitis.\n\n TECHNIQUE: Dedicated thoracic aorta imaging was performed on a 1.5 Tesla\n magnet, including dynamic 3D imaging obtained prior to, during, and after the\n intravenous administration of 0.1 millimole per kilogram of gadolinium-BOPTA.\n\n COMPARISON: Findings are compared with recent prior CT scan dated .\n\n Multiplanar 2D and 3D reformations as well as subtraction images were acquired\n on an independent workstation.\n\n FINDINGS: The abdominal aorta is not included in the current examination.\n\n There is circumferential high T1 signal within the wall of the descending\n aorta that begins after the takeoff of the left subclavian and progresses to\n the inferior most extent of the visualized descending aorta on these images.\n The ascending aorta is noted to be spared. Additionally, post- contrast\n imaging of the aorta demonstrates marked delayed crescentic enhancement of the\n vascular wall surrounding the descending aorta that is involved by this\n intramural hematoma. Findings are compatible with intramural hematoma with\n associated engorgement of the vaso vasorum. Lack of circumferential\n enhancement argues strongly against aortitis.\n There is no evidence for aortic dissection. Evaluation of the aortic hiatus\n again demonstrates a prominent focal penetrating ulcer of the thoracic aorta\n at this level.\n\n Evaluation of the remainder of the visualized viscera is unremarkable except\n for simple liver cyst. No pulmonary emboli are visualized. Scattered\n mediastinal lymphadenopathy is again seen, unchanged.\n\n Multiplanar 2D and 3D reformations as well as subtraction images were\n essential in demonstrating multiple perspectives for this dynamic series.\n\n IMPRESSION:\n\n 1. Again seen is an extensive type B intramural hematoma extending from the\n takeoff of the left subclavian artery through the entire visualized thoracic\n and upper abdominal aorta. Additionally noted on the current exam is marked\n delayed crescentic enhancement of the entire aortic wall in the region\n affected by the intramural hematoma, compatible with associated engorgement of\n (Over)\n\n 10:41 AM\n MRI CHEST/MEDIASTINUM W/O & W/CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please eval for evidence of aortitis.\n Admitting Diagnosis: BACK PAIN\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the vaso vasorum. Lack of circumferential enhancement argues strongly against\n aortitis.\n\n 2. Abdominal aortic aneurysm is not included in the images of this study and\n has not evaluated.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-15 00:00:00.000",
"description": "Report",
"row_id": 1421819,
"text": "Nursing progress notes\nReview of systems:\n\nNeuro: pt alert and oriented per familly (pt speaks creole and some english) she can communicate her needs by using hand gestures and little broken english. mae. pt c/o of head ache early this am at 0300 tylenol 650mg po given w/ good effect. pt denied back and abdominal pain. pt has slept most of shift.\n\nResp: pt ls clear w/ diminished bases o2 on at 2liters sats 99-100%\n\nCv: tele sr 62-80 pt on nipride gtt currently at 1.1mcq/kg/min and labetolol gtt at 4mg/min. her bld pressure has been labile throughout shift. micu resident aware and recommended that staff increase labetolol gtt instead of nipride gtt. goal for bp 120-130. hct 28.7 and this am 29.3, k+ 4.1 mg 1.8. Hrt sounds S1S2 w/ systolic murmur. pedal pulses +3 w/ post tibs +2. per vascular, pt may go to OR for bypass if acutely unstable and pt agrees, if pt remains and off of gtts she may go for a stent sometime this week.\n\nGI: pt is npo however had sips of water w/ meds. pt became nauseous this am at 0200 anzemet 12.5mg ivp given w/ good effect. \u0013no sx planned, pt should be able to take po today as tolerates. abd soft bs+ no stool this shift\n\ngU: foley draining 25-125cc/hr\n\nskin: intact\n\naccess: #14 rfa , #20 left hand , right radial aline, it is positional, but still corolates w/ nibp, however it does not draw bld back.\n\nsocial: daughter and pt's sister stayed until 2200 all questions answered. emotional support given.\n\ncode: full\n\nendo: bs 122 no insulin needed\n\nPlan:\n\ncont to draw q 4hr hcts\ntitrate nipride and labetolol gtts for sbp 120-130\nadminister ms/diludid for pain\nobtain diet order\ngive emotional support to family and pt\nmay need to rewire or resite aline.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-18 00:00:00.000",
"description": "Report",
"row_id": 1421829,
"text": "MICU 6 Nursing Progress Note (0700-\n\nMrs. is a 72 year old () speaking woman admitted from OSH with sudden onset of back pain, N/V, and HTN (240/120). Pt. has hx of HTN/CHF/hypercholesterolemia along with hx of thoracic aortic aneurysm.\nTreated with labetolol and nipride gtts (goal 100-140/syst). CTA with evidence of intramural hematoma in descending thoracic aorta without evidence of dissection. Not a surgical candidate as spinal circulation would be compromised. Ruled out for an MI per enzymes. Hct drop initially to 24.7(from 28) and pt received 1UPRBC without appropriate bump. No increase in size of hematoma on CT. Stools were initially guiac positive.\nPO labetolol was started and gtts were weaned off by . Pt also received another 2UPRBC's and Hct has been stable since. +CHF, treated with lasix. CT repeated early AM due to chest and back pain...no changes.\nRecent problems have included worsening mental status with hallucinations, agitation and delirium (negative head CT). Pt. did spike a temp to 101 rectally today. BC x 2 and urine cultures sent. Pt. received one dose of vanco and one dose of ceftriaxone. LP done. Sitter and family at the bedside.\n\nCNS: Pt. very confused as to time and place per family. She is hallucinating, pointing and \"picking\" at sheets, etc. She is able to follow simple commands and MAE's. Haldol ordered prn, but has not yet been given as she is much better with family and friends at the bedside. Wrist restraints were initially applied for safety and have been removed with family present.\n\nCVS: Blood pressure under good control on labetolol 300mg qid/norvasc and valsartan. SBP generally 110-140/. Heart rate in the 60's, NSR without VEA. Denies any chest pain or SOB.\n\nRESP: Sats of 98% on room air. Lungs with diminished breath sounds throughout. (difficulty in obtaining consistent sat due to agitation).\n\nID: T max of 101 rectally (?cause for MS changes). BC x 2, urine sent. CXR done along with LP. pt. also received vanco and ceftriaxone x 1. Given tylenol 650mg po also.\n\nF and E: Inaccurate I and O's as pt. was incontinent this AM until foley was replaced. To receive 500cc IVF post LP.\n\nRENAL: Clear, light yellow urine via foley.\n\nGI: Taking po's well, needs to be fed. (soft solids as she will not keep dentures in). Please hold senna and colace due to large, loose stools x 3.\n\nSKIN: Intact.\n\nLINES; ART line present, pt. also has 2 peripheral IV's.\n\nSOCIAL: Multiple family members in...very helpful with translation and in keeping pt. calm.\n\nPLAN: Follow mental status and maintain pt. safety.\n Follow B/P with goal SBP 100-140/.\n Follow for any evidence of bleeding.\n Follow up on LP, culture results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-18 00:00:00.000",
"description": "Report",
"row_id": 1421830,
"text": "Addendum: No fluids post LP due to evidence of volume overload on CXR. Surgery in to see pt. and spoke with daughter re:possibility of stenting procedure to aorta on Friday. Pt's daughter understands and is agreeable to procedure.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-19 00:00:00.000",
"description": "Report",
"row_id": 1421831,
"text": "NSG 7PM-7AM\nPLEASE REFER TO CAREVIEW FOR OTHER OBJECTIVE DATA.\n\n72 YR SPEAKING FEMALE WITH HX OF HTN, HYPERCHOLES, CHRONIC THORACIC AORTIC ANEURYSM, PRESENTS TO OSH WITH ACUTE ONSET OF BACK PAIN ASSOCIATED WITH N/V. AT OSH PT WAS FOUND TO HAVE B/P 240/120/ CT SUGGESTIVE OF ACUTE ON CHRONIC THORACIC ANEURYSM/ TRANSFERRED TO FOR FURTHER MANAGEMENT.\n\n REPORTED ACUTE ONSET OF AGITATION AND HALLUCINATIONS OF UNKNOWN ETIOLOGY ON / RECEIVED ZYPREXA, SEROQUEL, HALDOL. PT RECEIVED MILDLY AGITATED, CONFUSED, DISORIENTED TO TIME, PLACE. REORIENTED AND REASSURED PER STAFF AND FAMILY MEMBER. PRESENTLY PT ASLEEP/ HAS BEEN ASLEEP FOR MOST OF SHIFT. NO EPISODE OF ACUTE AGITATION, HALLUCINATIONS/ THOUGH, PT STILL CONFUSED AND DISORIENTED/ REQUIRES SITTER FOR 1:1 SUPERVISION.\n\nHEART RYTHM SINUS/ 1ST DEGREE AVBLOCK/ HR IN 70S NO ECTOPY. ABP 120-160S/ TRENDS DOWN TO 90S WHILE PT ASLEEP/ 0200 LABETALOL DOSE HELD PER PARAMETER/ TEAM AWARE. CHEST XRAY POS FOR PULM EDEMA/ REMAINS ON LASIX DAILY/ UOP 10-80CC/HR/ 24 HR FLUID BALANCE NEG 575ML AT MN/ WITH LOS POS 1092ML.\n PAN CX/ ANTBX ON . T.MAX: 101.7/ TYLENOL 650MG GIVEN THIS SHIFT. CURRENT T:98.9/ WBC:5.8. BLOOD, URINE, SPINAL FLUID CX PENDING. SPINAL FLUID GRAM STAIN SHOWS NO LEUKOCYTES.\nHEAD CT ON NEG FOR HEMORRHAGE/ CHEST CT POS FOR INTRAMURAL HEMATOMA FROM THE SUBCLAVIAN ARTERY.\n\nRESP EFFORT UNLABORED AND EVEN/ LUNG SOUNDS DIMINISHED THROUGHOUT/ SATO2 92-96% ON RA. NON PRODUCTIVE COUGH AT TIME/ UNABLE TO OBTAIN SPUTUM FOR CX.\n\nABD SOFT POS BS/ SMEAR LBM. SENNA AND COLACE HELD FOR REPORTED LBMS PER PREVIOUS SHIFT. TOLERATES PO/ NO N/V.\n\nFOLEY PATENT DRAINING CLEAR URINE.\n\nSKIN W/D/I. ENCOURAGED REPOS. LP SITE COVERED WITH BANDAID/ NO DRAINAGE. PIVX1/ ALINE INTACT.\n\nFAMILY VISITED/INVOLVED IN HELPING REORIENTATING AND REASSURING PT.\n\nFOLLOW MENT STATUS/ MAINTAIN SAFETY/REMAINS RESTRAINED.\nFOLLOW BP/MAINTAIN GOAL 100-140\nFOLLOW TEMP CURVE/ FOLLOW SF AND OTHER CX.\nCOLLECT SPUTUM FOR CX IF POSS.\nPOSS AORTIC STENTING ON FRIDAY\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-19 00:00:00.000",
"description": "Report",
"row_id": 1421832,
"text": "MICU UPDATE and transfer note:\n\nFoley and Right Rad A-line d/c'd this AM. Report given to , RN on VICU at 1545. PT. tx'd to VICU via wheelchair and telementry in stable condition at 1600.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-14 00:00:00.000",
"description": "Report",
"row_id": 1421817,
"text": "npn 1900-0700\n\n Mrs received a unit of blood that finished early yesterday evening. A crit was drawn @ 2100 that did not bump appropriately.Pt ordered for a CT angio of her chest which was completed at 0300. It showed a hematoma. During this period pt has become very unstable; her BP has been as high as 200/100. Nipride gtt is maxed at 10mcg/kg/min. Labetolol has been initiated at 2mg/min. Crit drawn at 0345 has dropped again to 23.9. Is typed and crossed for 4 units. EKG done. VAscular surgery is at the bedside evaluating the patient. MICU intern and resident at bedside and have spoken with the ICU overnight attending. *** Patient is having a lot of abdominal pain-- a new finding.*** She has received many doses of IV morphine since 0400 and they seem to have little effect.\n\nThis RN called pt daughter at 0410 and requested that she come in. She lives ~90 minutes away and is on her way here.\n\nneuro: Pt is speaking and seems to be oriented, she speaks some English. Is able to folllow commands and MAE on the bed.\n\nresp: 2L nc. LS clear and diminished at the bases.\n\ncv: 1 degree AVB (not a new finding). Hypertensive as described above. Labetolol and nipride gtts. Goal BP 130-140. Very difficult to achieve at this point. Dopplerable pedal pulses.\n\naccess: 3 piv. R radial aline.\n\ngi/gu: Pt is now NPO for ? surgery. Patent foley.\n\nSkin: No issues.\n\nEndo: BS QID.\n\nPlan: Vascular team is evalusting CT images, dtr is on her way in, transfuse with 2 units cells.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-11-14 00:00:00.000",
"description": "Report",
"row_id": 1421818,
"text": "MICU Nursing Progress Note 0700-1900\n\nEvents - Pt's BP extremely labile, crit of 28.7 after 2 units PRBCs.\n\nNeuro - Pt A&Ox3, MAE, follows commands. Complained of moderate/severe headache x2 (pain ranging about ). Given morphine and dilaudid for pain, which was relieved but pt did experience some nausea and vomiting. Consider asking team for Tylenol, pt appears to be sensitive to narcotics. No complaints of abdominal pain.\n\nResp - Pt on 2L NC. Lung sounds clear but diminished in bases. Breathing pattern regular and unlabored.\n\nCV - Pt is in first degree AVB. BP continues to be labile, ranging from 190-90/90-50. Goal BP systolic 130-140's. Pt very sensitive to movement and changes in gtt rate. Nipride currently running at 1mcg/kg/min, Labetalol at 2mg/min. Crit after 2 units PRBCs 28.7. Evaluated by Vascular Surgery team and was determined not to be a candidate for surgery at this time.\n\nGI - Pt still NPO, awaiting okay from MICU team to advance diet if surgery is not planned. Bowel sounds present. No stool this shift.\n\nGU - Foley patent and draining clear, yellow urine.\n\nSkin - Intact.\n\nEndo - BS QID.\n\nAccess - 2 PIV, one changed due to left AC infiltration.\n\nSocial - Daughter and extended family in with patient for most of shift. Updated on patient's condition by Dr. .\n\nPlan - Continue to monitor BP, hematocrit, any s/s of bleeding.\n"
}
] |
31,512 | 152,600 | At the time of admission, he was toxic appearing with a distended, diffusely tender abdomen. This worsened on repeat examination with signs of peritonitis. CT scan was concerning for internal hernia with concern for the integrity of the bowel as far as ischemia. He was brought to the operating room for laparotomy. The high risks were discussed at length with him. The operative findings included a frozen abdomen with a foreshortened and fibrotic mesentery. He had abdominal wall varices which required control and essentially an intra-abdominal cocoon lining which was unable to be initially entered. Some adhesions were able to be lysed as there was a dilated loop of bowel that was visualized superficially and given these findings as well as the ability to decompress the abdominal contents, the operation was stopped at that juncture and open abdomen was left with a dressing. He was brought back to the operating room over the next few days on several occasions for re-evaluation. Dr. assisted with the operation on . He was found to have a small piece of dead bowel which appeared to be terminal ileum and cecum and this had an associated perforation. The ends of the bowel were left stapled off. I was still unable to round the entirety of it and abdomen was left packed with drains. He continued to require intensive care unit care during this point-in-time. Subsequently, he was brought back to the operating room with leakage of bile. A tube ileostomy was created and again a VAC was placed. During this time, intensive care unit care continued. He continued to be fairly stable but in the intensive care unit setting. Given the extenuating circumstances of his abdomen and the inability to provide definitive care and management, our best case scenario was adequate drainage of the ileostomy; however, he was really unable to achieve any significant parenteral nutrition. Ultimately the patient's family as well as the patient were involved in making decisions regarding his care. He was able to be extubated and was awake during this time for these conversations. Social work and palliative care were also involved. He was maintained on CMO care in the intensive care unit because of his high nursing needs. He continued to have high drainage from his abdominal wounds. He was kept comfortable. The patient and family were in agreement that CMO was appropriate care and he was therefore kept there in the intensive care unit with comfort measures only until his death on . , M.D. Dictated By: MEDQUIST36 D: 14:46:54 T: 15:11:13 Job#: | Small-bowel obstruction with a coiled up loop of fecalized distal ileum with mild bowel wall thickening adjacent to collapsed loop of terminal ileum possibly at the site of transition point located in the right lower quadrant. There has been interval development of a coalescent opacity in the right upper lung, limited inferiorly by the minor fissure. This loop is located in the right lower quadrant and there is a relatively collapsed loop of terminal ileum adjacent to it (300b:32) and could likely reflect a transition point. Cardiomediastinal contours appear slightly wider, and there is new minimal perihilar edema. The side hole of the nasogastric tube remains just above the cardioesophageal junction. IMPRESSION: Radiopacity covering the lower abdomen and contrast in tubular structure overlying the right lower quadrant, both of uncertain clinical implication; please correlate clinically and with recent operative procedures. CHEST, SINGLE AP SUPINE VIEW A right subclavian central line is present -- the tip overlies the right atrium. FINDINGS: In comparison with study of , there is now diffuse bilateral pulmonary opacification that has a generally alveolar quality. There is contrast noted in the tubular structure in the right lower quadrant, perhaps bowel. Endotracheal tube has been removed. Right renal hypoattenuation lesions could represent parapelvic cysts or collecting system fullness, the early phase of scanning limits differentiation. Again seen is the right-sided hydronephrosis. interval change PFI REPORT ET tube terminates 8 cm above carina, and right subclavian catheter terminates in proximal right atrium. Peripheral pulses palpable.Resp: LS clear/diminished. Min spont mvmt noted. TPN cont infusing. JP x1 w/serosang drng. Vac dsg with serosang output. 2+ edema to LE. JP self sxn with serosang output. Adequate huo, concentrated. Plan to cont to monitor, transition from fent gtt and maintain saftey and comfort. NGT & wnd#2 to suction w/mod amts serous drng. LR bolus given with good effect, total 1L given. Resp support. Abd wound open with vac dsg intact. TPN infusing as ordered. Respiratory Care:Pt. Condition UpdatePt continues to receive CMO care. AM ABG 7.45/34/189/24. Abd with vac dsg intact. Hct 29.9. MDI given as per order. MDI given as per order. Monitor fluid balance/lytes, goal remains even. Condition updateSee careview for objective data/trends:Remains sedated on fentanyl and versed gtt. Albumin x's 3 doses started.Resp: LS clear/diminished. NPO, NGT to lws. Wnd/drain care. 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. Good u/o after lasix. NPN:Neuro: Arouses to voice throughout day-weaned off midaz and pt extubated. Continued MDI's as ordered. Post-op s/p ex-lap, wash-out and vac dsg placement.Neuro: Received from o.r. BP stable. not reversed, currently sedated with fent./versed. Cont IVAB. Creat .7. Foley draining adequate amounts cyu. Lungs ess CTA with crackles L base. Stable on vent. Jp to bulb suctioned and ileum draining to gravity. HR 90s-100s, NSR/ST-min ectopy noted, SBP 110s-120s. OR Mon/Tues. BS are clear with diminished bases. MD aware, pt resedated lightly on versed gtt and ativan given to maintain. AFEBRILE.NEURO: PT SEDATED. NPN (NOC):CV: PT HAS BEEN HEMODYNAMICALLY STABLE OVERNOC OFF PRESSORS.RESP: PT REMAINS INTUBATED. condition updatePlease see carevue for specifics.Neuro: Sedated with fentynal and versed gtt's. Fentanyl gtt remains for pain.CV:SR to ST associated wtih alertness. +pitting edema bil lower ext. Abg's acceptable.GI: NPO, TPN infusing. NGT is to lws and draining clear to bilious fluid. REPLETED W/ 20 MEQ'S IV KCL. 2+ edema noted to bilat LE. Abd wound to intermittent wall suction - small amounts sero-sang drng. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Plan: Keep pt comfortable; titrate gtts as needed. Team aware that not holding suction at times.GU:foley apatent amber adeq. JP to bulb drainage, resecured with tegaerm. Calcium, mag, and k repleted. Question if consistent enough to use as communication.CV:ST, rare PVC's, maintaining bp off pressors. Lactate stable at 1.2 Cont to monitor hemodynamics, resp status, fluid balance, q4 hct/plt and coags, s/sx etoh witdrawl. BP bolus on way to OR for BP sys 80's.RESP:remains on cmv with abg's wnl.GI:ngt to LWS drng billious. Occlusive pressure confirmed accuracy of a-line. Drainage from jp noted to be brownish opaque, Dr aware and into assess. antibiotics a/o. antibiotics a/o. Transfused with 1 unit prbc and 1 unit ffp, goals hct >28 INR >1.8. +pp/csm. Pt appears comfortable, pain well controlled with fenynal gtt.CV: Sinus 100's - 110's with occasional pvc's. PT/OT consulted.RESP:LS clear, diminished. Generalized edema noted, +DP/PT pulses. Initially frequent runs of bigeminy noted, electrolytes from AM stable. Midaz gtt weaned off and receiving prn ativan with good effect. BS DIMINISHED BIBASILAR,CLEAR UPPER. Dr (sicu) aware and into assess aswell. HCT and INR stable. Resp Care Note:Pt cont intub with OETT as per Carevue. Suctioned x1 for scant clear secretions. CXR done. Lungs coarse occasionally, clear with sxn. NO FURTHER OR/ WILL SPEAK WITH DR.A: STABLE AT PRESENT, ABD PAIN.P: MONITOR COMFORT-FENTANYL, HR AND RYTHYM, SBP, CVP, PP, TEMP, RESP STATUS-PULM TOILET, NEURO STATUS-REORIENTE PRN, I+O-CONTINUE TPN, LABS PENDING. Patient has peripheral pitting edema noted and pulses have remained palpable.R - Patient remains on mechanical ventilation via ETT this shift with adequate ABGs and sats greater than 98%. Right SC TLC intact with CVP monitored as above, CVP between . Lungs mostly coarse but clear after sxn. Asking appropriate questions.PLAN:wean versed as tolerated, ativan prn for sedation. VANCO LEVEL 10-RECEIVED VANCO+ZOSYN. Started on lopressor with good effect, currently SR HR 80-90's no ectopy noted. Given ativan with good effect, given haldol x 1 for questionable delirium with no effect. Continues on A/C ventilation w/ PIP = 18, SpO2 90s, Ve ~6-7L/M. nursing noteneuro: versed weaning with addition of ativan. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Right SC TLC noted to be within the right atrium, pulled by resident and PCXR confirmed correct placement, bigeminy noted to lessen but continue, electrolytes checked later in shift and replaced magnesium and calcium per sliding scale order. | 75 | [
{
"category": "Radiology",
"chartdate": "2150-07-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1024858,
"text": " 10:26 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? subclavian line in good position\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with subclavian line\n REASON FOR THIS EXAMINATION:\n ? subclavian line in good position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subclavian line placement.\n\n FINDINGS: In comparison with earlier study of this date, the tip of the\n subclavian line lies in the lower portion of the SVC. The heart and lungs are\n unchanged, as is the position of the other tubes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1026262,
"text": " 2:51 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: PICC placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n ISTORY: PICC placement.\n\n COMPARISON: .\n\n FINDINGS: A new left-sided PICC follows the expected course with tip in the\n mid SVC. A right subclavian catheter is in adequate position. The tip is also\n in the SVC. Nasogastric tube extends into the stomach, but the tip is not\n visualized. Endotracheal tube has been removed. Again noted are substantial\n pleural effusions layering posteriorly with apical capping. There has been\n interval development of a coalescent opacity in the right upper lung, limited\n inferiorly by the minor fissure. This is concerning for developing pneumonia.\n The cardiomediastinal contours are unchanged.\n\n IMPRESSION:\n 1. New left-sided PICC with tip in the mid SVC. Right subclavian catheter\n and nasogastric tubes in standard position. ET has been removed.\n 2. Increased bilateral pleural effusions, moderate to large on the right,\n moderate on the left.\n 3. New right upper lobe opacity, which may be due to aspiration or developing\n infectious pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026857,
"text": " 10:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SICU. increased O2 requirements\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n SICU. increased O2 requirements\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing oxygen requirement.\n\n FINDINGS: In comparison with study of , there is now diffuse bilateral\n pulmonary opacification that has a generally alveolar quality. Although much\n of this could represent asymmetric pulmonary edema, the possibility of\n superimposed pneumonia must be seriously considered.\n\n The endotracheal tube has been removed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025898,
"text": " 9:48 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check ng tube position\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n check ng tube position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For nasogastric tube position.\n\n FINDINGS: In comparison with earlier study of this date, there has been\n placement of a nasogastric tube that extends at least to the lower body of the\n stomach where it passes the lower margin of the film. Allowing for\n sub-optimal technique, there is probably little change in the appearance of\n the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1024439,
"text": " 11:32 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval R subclavian CVL placement\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man w/ cirrhosis s/p ex lap s/p CVL placement\n REASON FOR THIS EXAMINATION:\n eval R subclavian CVL placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CVL placement.\n\n CHEST, SINGLE AP VIEW. No previous chest x-rays on PACS record for comparison.\n\n Heart size is at the upper limits of normal. The aorta is minimally unfolded.\n No CHF, focal infiltrate, or effusion is identified.\n\n An ET tube is present, tip approximately 4.9 cm above the carina. An NG tube\n is present, tip overlying the gastric fundus. A right subclavian central line\n is present, tip over SVC/RA junction -- clinical correlation to assess for\n slight retraction is requested. No pneumothorax is detected.\n\n There is dense opacification of the right renal collecting system, with\n evidence of hydronephrosis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024807,
"text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB TUE 9:36 AM\n ET tube terminates 8 cm above carina, and right subclavian catheter terminates\n in proximal right atrium. New mild pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intubation.\n\n Endotracheal tube terminates 8 cm above the carina, and right subclavian\n catheter terminates in the right atrium, as communicated by telephone to Dr.\n . Cardiomediastinal contours appear slightly wider, and there is new\n minimal perihilar edema. No pleural effusion or pneumothorax is evident.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1024808,
"text": ", S. SICU-B 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n PFI REPORT\n ET tube terminates 8 cm above carina, and right subclavian catheter terminates\n in proximal right atrium. New mild pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025883,
"text": " 5:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for effusions, atelectasis, consolidation\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 cirrhotic w/SBO s/p ex-lap (); s/p segmental bowel resection, washout\n (); s/p repair of ileal vs. cecal perforation, tube ileostomy ()\n REASON FOR THIS EXAMINATION:\n evaluate for effusions, atelectasis, consolidation\n ______________________________________________________________________________\n WET READ: PXDb MON 7:51 PM\n Small layeing bilateral pleural effusions, retrocardiac atelectasis. No\n Pulmonary edema, NG tube side port at GE junction, advance by 10 cm. ET tube\n relatively high, terminating 7 cm above the clavicle, which could be due to\n hyperextension, Findings relating to NG tube DW Dr.. .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative, to evaluate for pneumonia or atelectasis.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again, there are bilateral layering pleural effusions with some\n retrocardiac atelectasis without definite pulmonary edema. The side hole of\n the nasogastric tube remains just above the cardioesophageal junction. The\n relatively high endotracheal tube tip is above the clavicles, but measures\n only 7 cm above the carina.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-13 00:00:00.000",
"description": "O ABD (SINGLE VIEW ONLY) IN O.R.",
"row_id": 1025872,
"text": " 3:47 PM\n ABD (SINGLE VIEW ONLY) IN O.R. Clip # \n Reason: ABDOMINAL WASHOUT\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 53-year-old male, evaluate for abdominal washout of\n questionable foreign body.\n\n EXAMINATION: Single frontal abdominal radiograph.\n\n COMPARISONS: Comparison to CT of the abdomen and pelvis from .\n\n FINDINGS: Correlation with clinical history indicates that patient is status\n post surgery with possible open abdomen. There is a nasogastric tube in\n place. There is a peritoneal drainage catheter noted. There is a\n large uniform radiopacity projecting over the abdominal lower quadrant and\n pelvis, of uncertain significance, requiring clinical correlation for\n interpretation. There is contrast noted in the tubular structure in the right\n lower quadrant, perhaps bowel. There is a paucity of gas noted in the abdomen.\n The visualized osseous and soft tissue structures are otherwise unremarkable.\n\n IMPRESSION: Radiopacity covering the lower abdomen and contrast in tubular\n structure overlying the right lower quadrant, both of uncertain clinical\n implication; please correlate clinically and with recent operative procedures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026406,
"text": " 10:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: position of trachea\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p wash out abdomen\n REASON FOR THIS EXAMINATION:\n position of trachea\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 3:33 PM\n PFI: Endotracheal tube 5 cm from the carina. Persistent bilateral pleural\n effusions, cardiomegaly, and pulmonary vasculature cephalization. No\n significant interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recently reintubated following abdominal washout.\n\n COMPARISON: .\n\n FINDINGS: The endotracheal tube terminates 5 cm from the carina. The\n nasogastric tube and right subclavian line are in adequate position. Again\n noted is marked bilateral veiled opacification, suggesting layering pleural\n effusions. Heart size remains enlarged with cephalization of pulmonary\n vasculature. There is no other significant interval change.\n\n IMPRESSION: Endotracheal tube 5 cm from the carina. Persistent bilateral\n layering pleural effusions, cardiomegaly, and cephalization of pulmonary\n vessels.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026407,
"text": ", S. SICU-B 10:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: position of trachea\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p wash out abdomen\n REASON FOR THIS EXAMINATION:\n position of trachea\n ______________________________________________________________________________\n PFI REPORT\n PFI: Endotracheal tube 5 cm from the carina. Persistent bilateral pleural\n effusions, cardiomegaly, and pulmonary vasculature cephalization. No\n significant interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-03 00:00:00.000",
"description": "P ABD COMPL INCLUDING LAT DECUB PORT",
"row_id": 1024359,
"text": " 4:58 PM\n ABD COMPL INCLUDING LAT DECUB PORT Clip # \n Reason: r/o air fluid levels\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with h/o sbo left ama now with distended firm tender abd\n REASON FOR THIS EXAMINATION:\n r/o air fluid levels\n ______________________________________________________________________________\n WET READ: FXKd FRI 5:29 PM\n GAS FILLED DISTENDED LOOPS OF BOWEL WITH MAXIMAL SMALL BOWEL DISTETION OF 45\n MM. GAS IS PRESENT IN THE COLON AND RECTUM\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with history of small-bowel obstruction, now with\n firm, tender abdomen, to rule out bowel obstruction.\n\n TECHNIQUE: Portable AP radiograph of the abdomen was performed.\n\n Comparison was made with examination of .\n\n FINDINGS:\n\n Gas-filled distended loops of small bowel are seen in the mid abdomen. There\n is gas also seen in the colon as well as the rectum. The maximally distended\n loop of small bowel measures 45 mm. There is no evidence of free air. Early\n bowel obstruction cannot be excluded.\n\n There are degenerative changes present at the hip joints.\n\n CONCLUSION:\n\n Multiple gas-filled loops of bowel are seen with the maximal diameter of a\n loop of bowel in the right abdomen measuring 45 mm. Early obstruction cannot\n be excluded. There is no free air.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-04 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1024460,
"text": " 3:09 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line adjustment (R subclavian)\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man cirrhosis s/p adjustment of CVL (line withrdrawn 2cm)\n REASON FOR THIS EXAMINATION:\n eval line adjustment (R subclavian)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Adjustment of CVL.\n\n CHEST, SINGLE AP SUPINE VIEW\n\n A right subclavian central line is present -- the tip overlies the right\n atrium. The ET tube and NG tube are grossly unchanged. No acute pulmonary\n process or pneumothorax is identified. Again seen is the right-sided\n hydronephrosis.\n\n The left paravertebral stripe is prominent, but unchanged -- the significance\n of this findin on a supine film is indeterminate. Attention to this finding on\n followup films is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1025699,
"text": " 4:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: preop CXR\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n preop CXR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Preop radiograph\n\n A single portable radiograph of the chest demonstrates no change in the\n support lines seen on . Cardiomediastinal contours are normal.\n There is a persistent left-sided pleural effusion. There is a new right-sided\n pleural effusion. No pneumothorax is evident. The trachea is midline.\n\n IMPRESSION:\n\n Bilateral pleural effusions. No consolidation. Support lines unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-03 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1024385,
"text": " 11:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cirrhosis and h/o partial sbo who left ama here with\n distended abd\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PXDb SAT 2:03 AM\n SBO with dilated bowel loops no passage of contrast beyond the distal ileum,\n fecalized loop of ileum in the deep pelvis, with bowel wall thickening, likely\n transition point in the right lower quadrant, could be due to internal hernia\n or adhesions in the setting of h/o exploratory laparascopy.\n\n DW with surgery team.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with cirrhosis and history of partial small-bowel\n obstruction who left AMA, he have a distended abdomen, rule out obstruction.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical CT acquisitions from lung bases to pubic symphysis after\n administration of intravenous and oral contrast. Multiplanar reformations\n generated.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases are clear without\n focal consolidations, pleural effusions or pneumothorax. There is a moderate-\n sized hiatal hernia with NG tube extending into the stomach. There is a large\n amount of intraperitoneal free fluid. Relative hypertrophy of the left\n hepatic lobe is incidentally noted with cirrhotic morphology of liver. The\n spleen is mildly enlarged measuring 13.7 cm. Right renal hypoattenuation\n lesions could represent parapelvic cysts or collecting system fullness, the\n early phase of scanning limits differentiation. Otherwise the kidneys,\n adrenals, pancreas are unremarkable.\n\n Multiple distended small bowel loops are noted. The contrast passes only up\n to proximal ileum with multiple distended ileal loops measuring up to 4 cm.\n Additionally, there is no passage of contrast into the terminal portion of\n ileum with of fecalization and mild bowel wall thickening (2:57). There is a\n coiled up mass of ileal loops which grossly measures 10.2 x 8.1 cm and the\n transition point is likely within this area. This loop is located in the\n right lower quadrant and there is a relatively collapsed loop of terminal\n ileum adjacent to it (300b:32) and could likely reflect a transition point.\n Overall, findings indicate a small-bowel obstruction possibly due to an\n internal hernia or adhesions considering patient's history of exploratory\n laparoscopy. The right sided colonic loops are mildly distended with no\n passage of contrast into the colon. The rectum and sigmoid colon on the other\n hand are unremarkable. There is fecal material throughout the colon.\n\n (Over)\n\n 11:16 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS: The bladder is collapsed with the Foley catheter. There is\n moderate amount of intrapelvic free fluid. As described above, coiled up loop\n of ileal loops with fecalization and possible transition point is noted in the\n right lower quadrant.\n\n OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions. The L5-\n S1 vertebral body demonstrates mild degenerative changes with osteophyte\n formation, loss of intervertebral disc space. A single sclerotic T12\n vertebral body focus could represent a bone island.\n\n IMPRESSION:\n\n 1. Small-bowel obstruction with a coiled up loop of fecalized distal ileum\n with mild bowel wall thickening adjacent to collapsed loop of terminal ileum\n possibly at the site of transition point located in the right lower quadrant.\n These could be result of internal hernia or adhesion in the setting of prior\n exploratory laparoscopy.\n\n 2. Right renal hypoattenuating lesions could represent parapevlic cysts or\n collecing system fullness. Early phase of imaging limits differentiation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-06 00:00:00.000",
"description": "Report",
"row_id": 1663872,
"text": "7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nPt remains sedated on propofol and fentanyl. Pt will open eyes and inconsistently perform weak hand grasps when propofol lightened. Pt's HR running 80s-90s in NSR, BP ranging 110s-120s/60s-70s. CVP 10-14. Pt remains ventilated on AC mode, 40% fio2, 400 X 14 and 5 PEEP, no vent changes made as patient planned for OR ?Monday to close abdomen. LS clear bilaterally and Pox 98-100%.\nAt start of shift pt's urine output low at 15cc X 1 hour. Foley has been positional and U/O increased to adequate amounts after pt. repositioned in bed.\nPt's abdomen remains open with dressing intact. Pt also has JP drain intact and connected to suction which is putting out red/brown drainage. Abdomen is firm. Bladder pressures have been 10. NGT also to LWS and puttting out moderae amounts of bilious fluid. Getting TPN for nutrition.\nPLAN: ?OR Monday to close abdomen. Follow GI assessment, bladder pressures every 4 hours.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-06 00:00:00.000",
"description": "Report",
"row_id": 1663873,
"text": "Respiratory Care\nPt remains on vent, on AC settings. Pt presents with clear lung sounds bilaterally, but diminished at the bases. Suctioned as noted. Pt is breathing breathes spontanously, although breathing pattern produces a \"breath stack\" sporadically, but none of these \"breath stack\" act negativly on ventilation. PT to remain on current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-06 00:00:00.000",
"description": "Report",
"row_id": 1663874,
"text": "nursing note\nPt to OR for small bowel resection, + pus and stool in abd. Pt left with open abd, betadine elastoplast covering. BP on arrival quickly dropped to 60 systolic, MD in to eval. IVF wide open, levo gtt started and titrated up to goal sbp >85 and MAP 60. 2 u PRBC given with 2 U FFP with plans to check HCT and coags q4hrs. Bairhugger on to warm, off with temp of 98.6. JP to LWS with dark brownish bloody drainage. NGT with icteric output. Fluc/vanco/zosyn started. placed on kinair bed, wound consult deferred until tomorrow. brother calling for updates, spoke with MD. Daughter who is estranged also called for update and possibly to visit. Uncle told to call duaghter for update.\nPLAN: cont abx a/o. wea levo ast olerated. fent/propofol for comfort and sedation wtih open abd. pulm toilet. kinair bed. wound consult. monitor bladder pressures. follow labs q4. family support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-06 00:00:00.000",
"description": "Report",
"row_id": 1663875,
"text": "Patient went to OR for bowel resection,pus and stool found in abdomen.Abdomen still opened with Kentukey patch on.Distended abdomen,sedated on full mechanical ventilation will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-07 00:00:00.000",
"description": "Report",
"row_id": 1663876,
"text": "Resp: pt on ac 16/500/+5/40%. Ett 7.5 taped @ 20 lip. BS are clear with diminished bases. Suctioned for scant amount of white secretions No changes noc. AM ABG pending (see careview) RSBI=31. Plan: Continue present settings, pt remains with open belly and return trip to OR in future.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-09 00:00:00.000",
"description": "Report",
"row_id": 1663887,
"text": "Resp: pt on a/c 12/500/+5/40%. Ett 7.5, 21 @ lip. BS are clear bilaterally. Suctioned for no/scant clear secretions. MDI's atrovent administered with no adverse reactions. AM ABG 7.45/34/189/24. RSBI=34 Plan: wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-09 00:00:00.000",
"description": "Report",
"row_id": 1663888,
"text": "Nursing Note\nPlease see carevue for details\n 1300-1900\n Pt remains sedated on Fentanyl at 75mcg/hr, Versed at 2mg/hr. Opens eyes and grimaces to painful stimuli, but does not follow commands. Min spont mvmt noted. PERRL, 3mm, brisk. HR 90s-100s, NSR/ST-min ectopy noted, SBP 110s-120s. CVP 5-8, BLE edema noted, fluid balance presently neg~100cc/24hr, ok per Dr.. Remains on CMV-500x12/40%, no vent changes made, overbreathing set rate of 12 by 3-7 breaths at times. Lungs clear, diminished at bases. ABD remains open, covered w/modified vac dsg. TPN cont infusing. NGT & wnd#2 to suction w/mod amts serous drng. JP x1 w/serosang drng. Ileal drain to gravity w/serous drainage w/sediment. Adequate huo, concentrated. Family in to visit, inquiring about HCP form, but inappropriate given pt current condition per Social Work.\n\n Plan: Cont hemodynamic monitoring, Fentanyl/Versed for comfort. Resp support. Monitor fluid balance/lytes, goal remains even. Wnd/drain care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-09 00:00:00.000",
"description": "Report",
"row_id": 1663889,
"text": "Respiratory Care\nPt remains on mechanical ventilation. No changes on this shift. Pt remains on CPAP-PS 12/5/40%. Last gas done at 1251 7.35/33/88/19/-6. Plan: No plan for extubation, continue mechanical ventilation as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-09 00:00:00.000",
"description": "Report",
"row_id": 1663890,
"text": "Respiratory Care\nPt remains on mechanical ventilation AC 500/12/5/40%. Continued MDI's as ordered. Last gas at 1610 7.44/35/196/25/0. Went to IR this afternoon for a dialysis catheter. Plan to continue mechanical ventilation as order.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-10 00:00:00.000",
"description": "Report",
"row_id": 1663891,
"text": "condition update\nPlease see carevue for details.\nNeuro: Sedated with fentyanl/versed, aroues to voice, does not follow commands. Some spontaneous nonpurposeful movements noted in the lower extremities, no movement noted in the upper extremities. Pupils equal and briskly reactive. Pain seems well controlled at 75mcg/hr fentynal.\nCv: Sinus 90's-100's, no ectopy. Sbp mainly 110's-120's. LR continues at 200cc's/hr. Peripheral pulses palpable.\nResp: LS clear/diminished. Remains mechancially ventilated on a/c, no vent. changes made. Suctioned for small amounts thick white sputum.\nGI: NPO, NGT to lws draining bilious drainage. Ileum drain to gravity draining brown liquid. Jp to bulb suction draining serosang drainage, jp to wall suction draining serosang as well. Abd. is open, packing intact. Bs absent.\nGU: Foley draining adequate amounts clear yellow urine.\nEndo: SSRI, bs 129 and 113.\nSocial: Brother called x's 1 for update.\nPlan: Monitor i/o status, pain management, ? social work consult, monitor hemodynamics, ? return to or.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-10 00:00:00.000",
"description": "Report",
"row_id": 1663892,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds dim bilat; mod th off white sput. MDI given as per order. ABGs stable; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-13 00:00:00.000",
"description": "Report",
"row_id": 1663906,
"text": "condition update\nPlease see carevue for details. Post-op s/p ex-lap, wash-out and vac dsg placement.\nNeuro: Received from o.r. not reversed, currently sedated with fent./versed. pt was alert or aroused to voice, intermittenly agitated attempted to tongue out e.t. tube, etc.. Pupils equal and briskly reactive.\nCV: Sinus 80's-100's, no ectopy. Requiring post-op levophed briefly for map>65. Lr continues at 75cc's/hr. Albumin x's 3 doses started.\nResp: LS clear/diminished. Suctioned for thick white sputum. No vent. changes made.\nGI: Open abdomen with vac dsg intact to 75mmhg suction. Jp to bulb suctioned and ileum draining to gravity. NPO, NGT to lws. TPN continues.\nGu: Foley draining adequate amounts clear amber urine.\nEndo: bs wnl.\nPlan: Wean fent./versed as tolerated, monitor hemodynamics, prn levophed to keep map >65, continue albumin x's 2 more doses, comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-14 00:00:00.000",
"description": "Report",
"row_id": 1663907,
"text": "Condition update\nSee careview for objective data/trends:\n\nRemains sedated on fentanyl and versed gtt. Intermitantly waking and becoming aggitated. +pain per patient, fentanyl gtt increased from 125 mcg fentanyl to 200 for most of night although currently decreased to 175. Able to wean down versed gtt with better pain control, currently at 1.5mg/hr. Arousable to voice, following commands intermitantly. Able to nod to answer questions, bil weak hand grasps and moves ble spontanously. Tmax 100.1. SR-ST, initially HR 90's although increasing overnight to 100-110. BP trending down with systolic down to 88-92. LR bolus given with good effect, total 1L given. CVP 4-7. Lungs coarse, tolerating CPAP 5/5 with good oxygenation/ventilation. Abd wound open with vac dsg intact. Mesh underneith vac dressing, per HO ok to sit hob up. TPN infusing for nutrition. Adequate u/o. JP self sxn with serosang output. Vac dsg with serosang output. NGT with yellow/bilous drainage. Ileum draing with brown/green clear drainage with sedement. Plan to cont to monitor hemodyanmics, resp status, pain managment and sedation, ?plan for extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-14 00:00:00.000",
"description": "Report",
"row_id": 1663908,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs stable; able to switch to PSV; currently on SBT doing well. Cont SBT; ? extub today\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-14 00:00:00.000",
"description": "Report",
"row_id": 1663909,
"text": "NPN:\n\nNeuro: Arouses to voice throughout day-weaned off midaz and pt extubated. Initially slightly confused. Now oriented to self and hospital but not consistent. Moves all extremities and follows commands consistently. Gets slightly agitated-wanting to get OOB and walk. Needs reorientation. ? pt inadvertently dc'd his aline. Ativan prn.\nSocial: Brother and daughter called and updated. Family referred to social worker- who will meet with brother and speak with daughter tomorrow.\nID: Tmax 99.9 orally-now 98.4. Pt c/o being cold and shivering/quivering. WBC 14.8. Vanco level 15.3-dose given this am. Cont on zosyn and fluconazole.\nCV: 95-110's SR-ST without VEA. Initially requiring levo to .03 to keep MAP>60-now off. Lopressor 5mg IV given X1. Palpable pedal pulses with 2-3+ pitting edema. CVP 6-11. Hct 29.9. Pneumoboots on.\nResp: Weaned and extubated at 1230pm to 40% OFT neb with sats>975. Now on 4l nc O2 with sat 98-99%. Lungs ess CTA with crackles L base. Cough fair-productive of small tan secretions.\nGU: Foley with amber colored UO>30cc/hr. Creat .7. Given lasix 10 mg IV X1.\nGI: Abdomen remains firm,round with wound VAC intact draining moderate serosang drainage. JP drain scant output. L ileal tube 300cc thick yellow green liquid with brown sediment. NPO with L nare NGT-100cc yellow bilious drainage. TPN at 63cc/hr. Rec 25% albumin q 6 hrs X4.\nEndocrine: Glucoses 122-135-no treatment needed.\nSkin: Coccyx with allevyn foam intact.\nComfort: Remains on fentanyl gtt weaned to 50 then ^ to 100 with c/o pain. Also started on methadone 5mg IV tid.\nActivity: Bedrest-turned side to side q 2 hrs with 2 assists. Multipodus boots removed this afternoon after pt awake and extubated.\nA: Extubated without difficulty. Stable BP off levo-cont with high volume need. Social work involved.\nP: NPO,TPN. Social work-? family meeting-assess patients awareness of illness. Cont IVAB. Ativan prn for agitation. ?decrease IVF. Discuss diuresis if remains off levo.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-15 00:00:00.000",
"description": "Report",
"row_id": 1663910,
"text": "Condition update\nSee careview for objective data/trends:\n\nAlert and oriented to person, place and summer although at mildy confused but reorients easily. Following commands and cooperative with care. Ativan prn for anxiety, fent gtt for pain with good effect. Afebrile. HR 90-100 SR-ST. BP stable. Lungs clear but diminished, tolerating room air with sats>94%. Abd with vac dsg intact. Good u/o after lasix. Hct down to 25.2 sicu and primary team aware. Plan to cont to monitor, transition from fent gtt and maintain saftey and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-21 00:00:00.000",
"description": "Report",
"row_id": 1663923,
"text": "NURSING UPDATE\n EARLY PM, PT GROANING WITH EACH EXHALATION, WIDE-EYED DURING CARE. WHEN ASKED IF IN PAIN PT \"YUP\" - ANALGESIA AND SEDATION INCREASED TO UPPER PARAMETER DOSAGE WITH GOOD EFFECT. PT SINCE OPENING EYES WHEN REPOSITIONED OR HYGIENE CARE DONE BUT NOT GROANING OR GRIMACING. VITAL SIGNS HAVE REMAINED ESSENTIALLY STABLE ALSO. CONTINUES TO DRAIN LG AMT OF BILIOUS DRAINAGE FROM ABDOMEN, SURGICAL RESIDENT INFORMED THIS NURSE VAC WOULD BE APPLIED THIS AM. ALL COMFORT AND HYGIENE CARE PROVIDED. PT APPEARS TO BE AT OPTIMAL COMFORT LEVEL AT THIS TIME.\nMONITORED CONTINUOUSLY. SEE CAREVUE FLOWSHEETS FOR DETAILED DATA.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-21 00:00:00.000",
"description": "Report",
"row_id": 1663924,
"text": "Condition Update\nPt continues to receive CMO care. Receiving fent/ativan gtts continuously along with tid methadone IV. Pt is not responding to any verbal/physical stimulation. RR 15-17 with periods of apnea. THis afternoon respirations with gasping noise so ativan gtt increased from 4 to 6mg/hr. No significant changes noted today in vital signs. O2 sats 60-70 on RA SBP 70-80's. HR 80-90 with no ectopy noted. brother called for update x2. No visitors today. Palliative care involved. No further input today. Current plan to keep patient in ICU for CMO.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-22 00:00:00.000",
"description": "Report",
"row_id": 1663925,
"text": "post-mortem nursing note\n Comfort measures maintained through shift, pt at optimal comfort status on fentanyl and ativan gtts. vital signs fairly unchanged until 0305, then quickly progressed to asystole. time of death 0307. family notified by dr .\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-05 00:00:00.000",
"description": "Report",
"row_id": 1663868,
"text": "7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO-Pt remains sedated on propofol/fentanyl drips. When propofol decreased to 20mcg/kg/min, pt. opened eyes to verbal stimulation and performed weak hand grasps on command. Pupils at 3mm bilaterally and reactive to light.\nCV/HEME-HR 80s-90s in NSR, no ectopy noted. Pt's BP has ranged 130's-140s/70s. CVP ranging . HCT this AM 23.6, Dr. aware of HCT but prior HCT 24.8 so no intervention done at present time.\nRESP-Pt remains intubated and ventilated on settings: AC mode, 40% fio2, 400 X 18, 5 PEEP. Settings unchanged over night. Pox has remained 98-100%. LS clear bilaterally, suctioned only minimally for scant amount of thick white secretions.\nGI-abdomen is open post-surgery. Abdomen is large, firm. Bladder pressures . Dressing intact to open surgical site and JP bulb drainaige continues to LIWS, putting out serosanquinous drainaige. NGT putting out small to moderate amounts of bilious fluid. Pt started on amino acid with dextrose \"quick mix\" bag this evening\nGU-foley putting out 30-40/hr of slightly amber colored urine.\nPLAN-monitor abdominal exams, blader pressures Q 4 hours. Continue IVF, sedation/pain med as needed with overall plan to return to OR ?Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-05 00:00:00.000",
"description": "Report",
"row_id": 1663869,
"text": "Respiratory Care:\nPt. remains intubated and on AC/18/400/40%/+5 no changes overnight, alarms on and working. Breath sounds decreased, suctioned for scant amounts of thick white secretions. RSBI 17. Continue current level of support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-05 00:00:00.000",
"description": "Report",
"row_id": 1663870,
"text": "Nursing Note\nPlease see carevue for details\n\nSedated on propofol - lightened dose x1 and pt opening eyes spontaneously and lifting bilateral LE off bed. On current dose, opens eyes occasionally to stimuli, but not lifting extremities and appears more comfortable. Fentanyl gtt for pain control. Tmax 100.0. HRRR. BP stable. 2+ edema to LE. LSCTA. Stable on vent. Abd with open wound - patch in place - draining moderate amounts foul-smelling, brick red fluid on LIS (SICU team aware). Bladder pressure . TPN infusing as ordered. No BS. Foley draining adequate amounts cyu. Duoderm to coccyx. Frequent turn and reposition. Brother in to visit and updated on POC.\n\nPlan: Monitor hct. Monitor abdomen closely for changes. OR Mon/Tues. Continue sedation/pain med gtts. Comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-05 00:00:00.000",
"description": "Report",
"row_id": 1663871,
"text": "patient passively resting on mechanical ventilation.Post exp lap abdomen still opened with Kentukey patch on.Compensated Blood gas on rate of 14.Following simple commands @ times will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-08 00:00:00.000",
"description": "Report",
"row_id": 1663883,
"text": "NPN (NOC):\n\nCV: PT HAS BEEN HEMODYNAMICALLY STABLE OVERNOC OFF PRESSORS.\n\nRESP: PT REMAINS INTUBATED. LATEST ABG: 185/30/7.44/21. VENT SETTINGS CHANGED TO 12X500X40%. PT HAS BEEN OVERBREATHING TO HIGH TEENS, LOW 20'S. WILL REPEAT ABG. BS'S CLEAR. SX'D FOR MINIMAL SECRETIONS. AFEBRILE.\n\nNEURO: PT SEDATED. FENTYNL DRIP INCREASED TO 100 MCG'S D/T OVERBREATHING W/O EFFECT. PT WILL OPEN EYES BUT NOT TRACK. DOES NOT FOLLOW COMMANDS, BUT I HAVE OCCASIONALLY NOTED SPONTANEOUS MOVEMENT W/ TURNING ETC. PERL.\n\nGI: ABD REMAINS OPEN. JP TO LCS PUT OUT 700 CC'S OF STRAW COLORED FLUID OVERNOC. NGT TP LCS PUT OUT 500 CC'S OG BILIOUS MATERIAL. TPN CONT.\n\nF/E: I&O BEGINNING TO RUN NEGATIVE OVERNOC. CVP'S . LE'S REMAIN VERY EDEMATOUS. UO VERY GOOD. REPLETED W/ 20 MEQ'S IV KCL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-08 00:00:00.000",
"description": "Report",
"row_id": 1663884,
"text": "Respiratory Care\nPt remains on mechanical ventilation AC 40%/500/12/5. Pt went to OR today to place drain in ileum. Abdomen still open. BS clear bilaterally. Sxn thick amounts of white secretions. MDI's continued as ordered. Plan: Continue mechanical ventilation and MDI's as ordered.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-08 00:00:00.000",
"description": "Report",
"row_id": 1663885,
"text": "nursing note\nNeuro:pt remains sedated on versed gtt, fentanyl for comfort. Pt squueze hands lightly, blinks eyes. Question if consistent enough to use as communication.\nCV:ST, rare PVC's, maintaining bp off pressors. BP bolus on way to OR for BP sys 80's.\nRESP:remains on cmv with abg's wnl.\nGI:ngt to LWS drng billious. JP to bulb suction in pelvis and JP to wound overlay to wall suction. PRe OR, stool leaking from wound. MD aware. Post OR, ileum drain to gravity and draining stool with bile.\nGU:foley patent amber to yellow urine.\nSKIN:allevyn intact. remains on kinair.\nSOCIAL:brother calling for update and spoke with MD post surgery. MD states brother would like patient to remains full code until ne speaks with rest of family. Brother made aware of poor prognosis.\n\nPLAN:Cont versed/fentanyl gtts. Levophed if MAP <60. await post-op labs. TPN. antibiotics a/o. await family decisions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-09 00:00:00.000",
"description": "Report",
"row_id": 1663886,
"text": "condition update\nPlease see carevue for specifics.\nNeuro: Sedated with fentynal and versed gtt's. Pt opens eyes to voice, does not follow commands or move extremities --> fentynal and versed weaned down - will continue to monitor. Bilater pupils equal and briskly reactive, +gag, impaired cough. Pt appears comfortable, pain well controlled with fenynal gtt.\nCV: Sinus 100's - 110's with occasional pvc's. Sbp mainly 100's 0- 120's. Peripheral pulses weakly palpable. Received 500cc LR bolus x's 1 as it was noted that wound vac output is large, urine is concentrated and pt is tachycardic. Hct 31 (up from 29). INR 1.7.\nResp: Ls clear/diminished, remains mechancially ventilated, no vent. changes were made, suctioned for nothing. 02 sat 100%. Abg's acceptable.\nGI: NPO, TPN infusing. Abd. is open, 'wound vac' (jp to wall suction) is draining large amounts serosang drainage, jp to bulb suction is draining mod. amounts serosang drainage. Ileum tube is draining brownish/bilious colored liquid to gravity. NGT is to lws and draining clear to bilious fluid. Bowel sounds are absent.\nGU: Foley draining adequate amounts clear amber urine.\nEndo: Sliding scale regular insulin prn.\nSocial: No phone calls/visitors this shift.\nPlan: Monitor hemodynamics, IVF and bolus's prn, replete electrolytes prn, monitor coags, pain management, comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-12 00:00:00.000",
"description": "Report",
"row_id": 1663902,
"text": "nursing note\nNeuro:pt remains sedated on versed and fentanyl. Attempted wean at evrsed gtt, pt opening eyes and following commands consistently, pt agitated and attempting to pull at ETT tube and sit up in bed. MD aware, pt resedated lightly on versed gtt and ativan given to maintain. Fentanyl gtt remains for pain.\nCV:SR to ST associated wtih alertness. neg 1600 thus far today. LR decreased, cvp adequate.\nRESP:LS coarse,thick white secretions. pre op cxr done.\nGI:abd remains packed with wound packing and overlay JP to wall suction draining copious amounts. JP to bulb drainage, resecured with tegaerm. Team aware that not holding suction at times.\nGU:foley apatent amber adeq. amounts.\nSKIN:allevyn intact. on kinair bed.\nSOCIAL:sw consulted for estranged daughter relationship. Daughter visibly upset by fathers health and last time they spoke they foiught. MD also emailed for family meeting at some point this week.\n\nPLAN:OR tomorrow for wash out and closure. fentanyl and versed for sedation/pain. prn ativan. antibiotics a/o. family support and meeting this week with sw consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-13 00:00:00.000",
"description": "Report",
"row_id": 1663903,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. Pt in NARD on current settings; no vent changes required overnoc. Cont mech vent support.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-13 00:00:00.000",
"description": "Report",
"row_id": 1663904,
"text": "7pm-7am Nursing Note\nSee CareVue for objetive data and trends:\n\nPt remains sedated on versed drip at 2mg/hr and fentanyl at 125 mcg/hr. Pt opens eyes to verbal stimuli through sedation, will follow commands inconsistantly. Performing weak hand grasps and pt moving BLE on bed spontaneously. , pt very agitated when sedation lightened.\nPt noted to have occasional fine tremors and pt given PRN ativan Q 3-4 hours. Pt's HR 70s-80s in NSR with no ectopy and BP 100-130s/60s-80s. Pt's BP noted to increase/decrease depending o level of sedation. Pt remains intubated and on vent settings: AC, 40% fio2, 500 X 12, 5 peep. LS clear to coarse and being suctioned for small amounts of thick white secretions. Pox has maintained 98-100%.\nPt with open abdomen and plan to return to OR today. JP drain to self suction and wound drain to suction putting out yellow colored output.\nTmax 99.8, wbc 7.0 today and pt continues Vancomycin, fluconazole and zosyn for coverage.\nPLAN-Pt planned for OR today for possible closure of abdomen. Follow VS, continue antibiotic coverage. Social work consulted to follow-up with family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-13 00:00:00.000",
"description": "Report",
"row_id": 1663905,
"text": "Respiratory therapy\npt received this morning on AC. bs clear but diminished. mdi given as ordered. no respiratory distress noted. plan to continue with current vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-16 00:00:00.000",
"description": "Report",
"row_id": 1663913,
"text": "Nursing progress note\nPt returned from OR @ 730am. Paralyzed, vented on prop and Neo. A-line in right radial, triple lumen CVL in RSC, dual lumen picc in LAC. 4 abd drains present w/ packingin place. Sbp 90's-100. Per Surgical team wash out only done. Not able to reconnect bowel or close abd. Unknown if they will be able to close abd. Dr spoke w/ brother on phone in am re: prognosis.\n\nPt started moving around by 10 am. Fent Gtt restarted @ 75mcg's. Goal is to wean Fent, by increasing methadone. Methadone increased in afternoon to 10 mg. Fent down to 50mcg's. Propofol off at noon. Pt more alert. Following commands. MAE on bed. Became restless attempting to sit up and talk over ETT. Ativan 1mg given with good effect, pt more calm.\nLs course to clear by afternoon w/ dim bases L > R. O2 sats 98-100%. Suctioning small amts thick tan sputum from ETT. Weaned to cpap+ps 5/5 per abg's. MV up to 18. Pt c/o pain. Fent bolus given and gtt increased to 75mcg's.\nMV back down to 8-10. By late afternoon pt extubated per SICU team, placed on 4l NC. 02 sats 100%.\nNeo weaned off by noon. SBP per a-line 100-110's. Occlusive pressure confirmed accuracy of a-line. Goal is to keep SBP >100 MAP >60. Hr 70-90's SR no ectopy seen. CVP 7-10 No IVF ordered per fluid balance.\nUrine output 30-100hr concentrated clear urine.\nAbd packed, dist, 4 drains present. No bs. Coccyx has allevyn dsg in place due to be changed . Cream applied to back and heels. TPN infusing.\nBrother called in to obtain phone #. He will be in this evening.\nEthics consult was placed regarding the family's capacity to understand the gravity of the situation\nPlan:\nContinue to monitor abd drains and dsg's for signs of stool leak.\nMonitor temp and resp status potential for sepsis.\nPossible OR tomorrow for washout.\nFamily meeting possibly @ noon tomorrow.\nEthics to be involved along with social services to help support family and pt.\nFent and ativan prn for breakthrough pain and restlessness.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-16 00:00:00.000",
"description": "Report",
"row_id": 1663914,
"text": "Respiratory Care:\nPt recieved from the OR this AM s/p bowel surgery. He has wakened nicely and over today and was weaned to extubation to a 4L/m NC. Presently doing well. HR = 90; bp = 119/64; RR = 18; O2 Sat = 100%\nHe remains critically ill with surgical issues, will watch over noc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-04 00:00:00.000",
"description": "Report",
"row_id": 1663867,
"text": "Nursing Note\nPlease see carevue for details\n\nPt sedated on propofol. Appears comfortable - receiving fentanyl drip for pain control. PERRL, 3mm bilat, briskly reactive. HRRR. BP stable. Bladder pressure 10. TLCL placed in right subclavian. 2+ edema noted to bilat LE. +pp/csm. Calcium, mag, and k repleted. Stable on vent. LSCTA. No gag/weak cough. Abdomen firm with open wound - patch. Abd wound to intermittent wall suction - small amounts sero-sang drng. No BS. NPO. NGT to LCS - draining small amounts bilious drng. Foley draining adequate amounts dark yellow urine. Decubitus (stage 3) noted to coccyx - duoderm placed and freq turn/reposition - skin care consult placed.\n\nPlan: Maintain pt comfort - keep sedated per team. Monitor bladder pressure q4hours. Monitor labs. Monitor open abdomen. Maintain skin integrity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-19 00:00:00.000",
"description": "Report",
"row_id": 1663920,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\n brother and mother in to visit this morning and to discuss code status with surgery team. MD covering for MD and met with the family. Family feels that pt would not want to return to the OR and would like to make the patient comfort measures only. Pt received large doses of ativan and fent/haldol overnight for agitation and again this morning requiring ativan and increase in fent gtt for attempts OOB/ yelling, pulling at tubes/drains in open abdomen. MD plan is to keep patient in icu today with fent gtt/ativan, etc as needed for comfort and agitation. VAC dressing will be placed on abdomen to contain drainage and tommorrow pt can be called out to the floor/ contact hospice care. Pt becoming very restless, attempting oob, yelling out, and crying mostly disorientated. Medicated with ativan for a total of 4 mg at this time and fent gtt increased periodically up to 200mcq /hr. Pt continued to cry and attempt oob and medicated with 1 mg haldol with good effect. Plan: cont fent gtt, ativan, haldol, methadone as needed and consider switching to morphine gtt if nto reaching adequate level of comfort for pt. emotional support for the patient and the family. Please see carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-20 00:00:00.000",
"description": "Report",
"row_id": 1663921,
"text": "Condition update\nVery aggitated this evening, crying and yelling out, attempting to sit up and pulling at abd dsg and tubes. Large hole ripped in dressing and small area bowel exposed, Gold surgery and SICU resident aware and dressing reinforced with transparent dressing. Fentanyl gtt increased and ativan gtt started after mult doses ivp ativan to keep pt calm/comfortable. Able to wean down fentanyl gtt after ativan started although cont to require high doses as pt crying out in pain and very aggitated when awake. Pt currently appears very comfortable. Cont with comfort care and provide support. No calls from family overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-20 00:00:00.000",
"description": "Report",
"row_id": 1663922,
"text": "Nursing Note 7a-7p:\nNursing aSsessment:\n\nPt is comfort measures only and remains sedated on fent gtt and ativan gtt. Increased/ fent bolus for turning d/t moaning and grimacing on turns. Gtts also increased for agonal breathing with good effect. Hospice care into evaluate as well as social work and case managment. All agree that pt is to remain in icu at this time d/t requirements of large amounts of sedation in order to keep comfortable. Reinforcing abdomen d/t large amounts of leakage and still awaiting surgery team to place vac dressing to contain drainage. Plan: Keep pt comfortable; titrate gtts as needed. Please see careuve. Pts brother called and updated by RN and spoke with social work as well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-17 00:00:00.000",
"description": "Report",
"row_id": 1663915,
"text": "condition update\nPlease see carevue for specifics.\nNeuro: Alert and oriented x's 2, remains confused but less so than the previous night. More cooperative with care, less agitated. Pain controlled with fentyanl gtt (which was titrated down to 50mcg/hr) and tid iv methadone. Pt sleeping most of the night.\nCV: sinus 80's-90's, no ectopy. Sbp mainly 90's-100's, lopressor held. Peripheral pulses palpable. Hct 23. K+ and Mag repleted x's 1.\nResp: LS clear/diminished, 02 sat 97% on 4 liters n.c. Pt has congested cough, coughing/deepbreathing encouraged.\nGI: NPO. NGT to lws draining bilious drainage. Ileum drain to gravity draining brown liquid stool. Jp to wall suction draining dark serosang drainage, Jp to bulb suction unable to hold suction, and drain #2 to gravity draining small amounts brown liquid. Abd. is packed, dsg is intact.\nGU: Foley draining adequate amounts clear amber urine.\nEndo: BS wnl.\nSocial: brother, sister in law and daughter at bedside visiting earlier in the evening, will return at 12noon today for possible family meeting.\nPlan: Pain management, wean fentynal as tolerated, monitor hemodynamics, encourage coughing and deep breathing, monitor drains' output, continue iv abx, comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-17 00:00:00.000",
"description": "Report",
"row_id": 1663916,
"text": "NEURO; A&OX3, FOLLOWS SIMPLE COMMANDS, C/O ABD DISCOMFORT WHEN REPOSITIONED, METHADONE DOSE INCREASED TO 12.5 MGM IV TID, PTMET WITH SOCIAL WORKER AND HIS BROTHER TODAY AND DISCUSSED HIS WISHES TO DECLINE FURTHER SURGERY, FAMILY IN AGREEMENT WITH PT PER SOCIAL WORKER, PT REMAINS ON FENT GTT AT 50 MCG/HR\n\nCARDIOVASCULAR; HR 90'S, SR, TEMP 99.6, TRIPLE LUMEN AND PIC LINE ACCESS,\n\nRESPIR; LUNGS CLEAR, 02 SAT 95%,\n\nWOUND; OPEN ABD WOUND, PACKED WITH STERILE LINEN PACKING, JP DRAIN TO SELF SX, DRAIN #2 TO LWSX-MODER BROWNISH DGE, ILEOS BAG TO DGE, SMALL AMT LIQUID DARK BROWN DGE,\n\nPLAN; BROTHER WILL BE IN TOMORROW AND WOULD LIKE TO TALK TO MD'S ON DR. SERVICE REGARDING PT'S WISHES TO DECLINE FURTHER SURGERY, AND ? OF ADDRESSNG FUTURE FEEDING ISSUES, ETC., HELP PT ATTAIN COMFORT AND REST, EMOTIONAL SUPPORT TO PT AND FAMILY\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-18 00:00:00.000",
"description": "Report",
"row_id": 1663917,
"text": "Condition update\nSee careview for objective data:\n\nAlert and oriented this evening but became very disoriented and aggitated at 2200, unable to redirect and pt pulling at lines and attempting to get oob, given 2 mg ativan with fair effect. Additional 1 mg ativan given overnight although pt remains calm he is confused and often disoriented. He is currently calm and cooperative. C/o intermitant pain but mostly comfortable on fent gtt, requires 25mcg bolus for repositioning. Tmax 100.4. SR HR 80-90 no ectopy. BP stable. LUngs clear but diminished. ABd remains packed with jp to wall sxn. Drainage from jp noted to be brownish opaque, Dr aware and into assess. Good u/o. Plan to cont to monitor neuro status, resp status, s/sx worsening infection, provide support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-07 00:00:00.000",
"description": "Report",
"row_id": 1663877,
"text": "Condition update\nSee careview for objective data/trends:\n\nInitially sedated on propofol with fentanyl gtt for pain managment. On current propofol and fentanyl gtt rates no withdrawl/grimice noted to painful stimuli. Propofol off at MN for neuro exam and although not withdrawing to nailbed +grimice to nailbed pressure x 4 extremities and noted to move ble spont. HR elevated when propofol off and noted to be tremulous, given 1 mg ativan for suspected etoh withdrawl. Attempted to maintain lower propofol gtt rate d/t increase in BP with decreased propofol rate although pt remained tachycardic. Midaz gtt initiated for sedation and propfol off and HR remains <100, normotensive off levophed, and no tremors noted. Afebrile. HR 90's with vent bigemeny noted this evening, resolved with 2 gm mag sulfate (previous mag 1.8) then no ectopy noted until 0200 and pt in and out of vent bigeminy. Lytes wnl, no repleation indicated. EKG and cardiac enzymes done. Dr and Dr aware. Given additional 1000cc LR bolus with minimal effect. CVP remains . BP remains stable with ectopy. Transfused with 1 unit prbc and 1 unit ffp, goals hct >28 INR >1.8. +pitting edema bil lower ext. Lungs clear but diminished. No vent changes made, cont on AC 40% 16x500 5 peep occasionally breathing over set rate. ABG good oxygenation/ventilation. Last ABG 7.4/39/207/0/25. Abd open, packed and covered with occlusive transparent dressing, JP to abd to wall sxn with large amt brown/bloody output. Ngt with icteric output. Bladder pressure 8. Adequate urine output. Tbili 3.8 this am, Dr and Dr aware, direct bili pending. Lactate stable at 1.2 Cont to monitor hemodynamics, resp status, fluid balance, q4 hct/plt and coags, s/sx etoh witdrawl. provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-07 00:00:00.000",
"description": "Report",
"row_id": 1663878,
"text": "Respiratory Care\nPt continues on mechanical ventilation. BS clear bilaterally. No changes made to ventilator settings. Atrovent MDI ordered and given in the afternoon. Plan: To continue mechanical ventilation and MDI's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-07 00:00:00.000",
"description": "Report",
"row_id": 1663879,
"text": "N - Patient neuro status changed since prior shift. Since propofol gtt discontinued and fentanyl gtt decreased patient will open his eyes to verbal stimuli and will move left lower extremity on bed. He does not follow commands but continuously would open eyes without tracking to verbal stimulation. PERRL at 4mm bilaterally with brisk response. Cough and gag intact, no hand grasp. Fentanyl and versed gtts for sedation and comfort.\n\nCV - HR has been continuously NSR throughout shift in the 80s to 90s. Initially frequent runs of bigeminy noted, electrolytes from AM stable. Right SC TLC noted to be within the right atrium, pulled by resident and PCXR confirmed correct placement, bigeminy noted to lessen but continue, electrolytes checked later in shift and replaced magnesium and calcium per sliding scale order. BP has been stable this shift, levophed has remained off this shift with SBP high 90s-low 100s with MAP well above 60mmHg. Patient has remained afebrile. Patient has peripheral pitting edema noted and pulses have remained palpable.\n\nR - Patient remains on mechanical ventilation via ETT this shift with adequate ABGs and sats greater than 98%. Patient has PMH of smoking for greater than 30 years, lung sounds initially contained inspiratory wheezes, combivent MDI q6h ordered and LS have remained clear and diminished in the bases. ETT suctioned for small thick white secretions. Pt remains in reverse trendelenberg.\n\nGI - Patient's abdomen remains open with ioband dressing and surgical towel intact. Bowel sounds are absent and abdomen is firmly distended. Wound has JP drain to medium wall suction with dark yellow transparent drainage noted in large amounts noted, NGT to LCWS with very similar drainage qualities in amounts documented. No BM this shift though hemorrhoids noted to be edematous.\n\nGU - Foley draining amber clear urine in amounts documented, noted to be marginal at times, overall greater than 30mL/hr. IVF of LR infusing at 125mL/hr.\n\nACCESS - Right radial arterial line has good waveform noted, good blood return, good distal CSM noted and good correlation with NIBP. Right SC TLC intact with CVP monitored as above, CVP between . Left wrist 16G placed this shift after old PIV expired.\n\nENDO - RSSI given for elevated blood glucose, continue to monitor every 6 hours as ordered.\n\nSKIN - Wound nurse in to eval patient. Noted to have stage III ulcer on coccyx, dressed with hydragel and allevyn dressing, plan to change dressing every 3 days with hydragel and allevyn. Skin otherwise noted to be edematous and frail, no further breakdown noted. Patient turned frequently and remains on kinair mattress to alleviate pressure points.\n\nP/S - Brother called earlier this shift and updated on plan of care and patient's condition, no visitors or other calls this shift. All aspects of patient's care have been explained to him prior to performing them.\n\nID - Antibiotics administered as ordered. WBC noted to be increased over the pa\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-07 00:00:00.000",
"description": "Report",
"row_id": 1663880,
"text": "(Continued)\nst shifts, afebrile, lactate 0.8.\n\nPLAN - continue to monitor VS frequently, monitor hct/platelets/coags q4h's and plan to replace blood with PRBCs if less than 28, plan on FFP if coags less than 1.8, frequent turning and kinair mattress, wound dressing changes, monitor abdominal qualities and continue NGT/JP to suction, plan to go to OR for ? closure/resection of bowel, fentanyl/versed for sedation/comfort, replace electrolytes, keep patient/family informed on plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-07 00:00:00.000",
"description": "Report",
"row_id": 1663881,
"text": "addendum: IVF changed to LR at 40/hr\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-08 00:00:00.000",
"description": "Report",
"row_id": 1663882,
"text": "Resp: pt on a/c 16/500/+5/40%. BS are clear bilaterally. Suctioned for scant amounts of white secretions. MDI's administered atr as ordered with no adverse reactions. AM ABG 7.44/30/185/21. Decreased rate to 12. RSBI=75. No further changes noted. Continue on present settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-11 00:00:00.000",
"description": "Report",
"row_id": 1663897,
"text": "nursing note\nneuro: versed weaning with addition of ativan. Pt opening eyes and periodically following commands. Moving all extrem spont on bed. Fentanyl gtt remains. low grad temps cont. Vanco held for trough 23. To be rechecked this eve.\nCV:SR to ST, no relief in tachycardia with fentanyl bolus. Lopresoor held secondary to borderline BP at noon.\nRESP:LS coarse to diminished. suctioned for thick white secretions.\nGI: NGT with bilious icteric output. JP with ascites looking output. Wound drain with copious amounts of yellow clear frothy output. Ileum drain remains to gravity with light brown output with specs of dark brown stool. abd remains open with packing intact.\nGU: foley patent draining amber output.\nSKIN: allevyn intact. multipodus boots on.\nSOCIAL:daughter in to visit and emotional. Asking appropriate questions.\n\nPLAN:wean versed as tolerated, ativan prn for sedation. fentanyl gtt for pain. abx a/o. Monitor I+O's, allow to get net negative if BP tolerates. ? OR for monday. skin/wound care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-11 00:00:00.000",
"description": "Report",
"row_id": 1663898,
"text": "Resp Care\nPt remains intubated on CMV, no vent changes. Sx small white thick. Plan to continue with current tx, ?? OR for Abd closure next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-12 00:00:00.000",
"description": "Report",
"row_id": 1663899,
"text": "Resp Care Note:\n\nPt cont intub with OETT as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs remain ess unchanged; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-12 00:00:00.000",
"description": "Report",
"row_id": 1663900,
"text": "Condition update\nSee careview for objective data:\n\nAlert overnight, following commands much more consistantly and nodding appropriotly to some questions. Midaz gtt weaned off and receiving prn ativan with good effect. Fent gtt increased d/t pt nodding yes to pain consistantly on exam early am. Tmax 100.6. ST HR 100, decreases breifly to 80's after lopressor dose. Frequency of dose increased with good effect. Lungs coarse occasionally, clear with sxn. No vent changes made, abg shows adequate oxygenation/ventilation. Abd remains open. No change in drain outputs. Adequate u/o. Plan to cont to monitor hemodynamics, resp status, drainage, plan for ?or monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-12 00:00:00.000",
"description": "Report",
"row_id": 1663901,
"text": "Respiratory Therapy\n\nPt remains orally intubated on full mechanical support. Continues on A/C ventilation w/ PIP = 18, SpO2 90s, Ve ~6-7L/M. ETT secure/patent. MDI given as documented. See resp flowsheet for specific vent settings/data.\n\nPlan: maintain support\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-18 00:00:00.000",
"description": "Report",
"row_id": 1663918,
"text": "ALTERED COMFORT\nS: \"IT HURTS RIGHT THERE\"\nO: CARDIAC: SR 80-70'S IV LOPRESSOR X1. SBP 100-130'S. EXTEMITIES WARM AND DRY. PALP PP. HCT 24.3. CVP <10. K TO BE RECHECKED.\n RESP: O2 @ 4 L NP WITH O2 SAT >95%. BS DIMINISHED BIBASILAR,CLEAR UPPER. NONPRODUCTIVE CONGESTED COUGH. INSTRUCTED ON USE OF HIS COUGH PILLOW.\n NEURO: EASILY AROUSABLE, ORIENTED TO SELF AND DATE , NOT PLACE THEREFORE REORIENTED PRN BY NURSE. PERL AND BRISK, GRASPS EQUAL AND FAIRLY STRONG , CAN LIFT LEGS OFF BED. FOLLOWS COMMANDS. CALM MOST OF DAY, SLIGHTLY ANXIOUS PRIOR TO DAUGHTER ARRIVING. RECEIVED .5 MG IV ATIVAN X 1 WITH GOOD EFFECT.\n GI: NGT + PLACEMENT DRAINING GOLD DRAINAGE 300 ML SO FAR. ABD OPEN ? CLOSE OR APPLY MESH . DRAINS DRAINING -PLEASE SEE I+O, ABSENT BOWEL SOUNDS, NO STOOL FROM RECTUM. TPN CONTINUES.\n GU: ADEQUATE UO- AMBER WITH SEDIMENT.\n ID: CULTURES PENDING, TEMP MAX 100.4. VANCO LEVEL 10-RECEIVED VANCO+ZOSYN.\n ENDO: HAS NOT REQUIRED SSI\n PAIN: CONTINUES ON FENTANYL AT 50 MCQ WITH .25 MCQ BOLUS X 4 PRIOR TO MOVING.\n SOCIAL: DAUGHTER INTO VISIT AND UPDATED. BROTHER TO ARRIVE TO DISCUSS PLAN ? NO FURTHER OR/ WILL SPEAK WITH DR.\nA: STABLE AT PRESENT, ABD PAIN.\nP: MONITOR COMFORT-FENTANYL, HR AND RYTHYM, SBP, CVP, PP, TEMP, RESP STATUS-PULM TOILET, NEURO STATUS-REORIENTE PRN, I+O-CONTINUE TPN, LABS PENDING. DISCUSSION RE: PLAN. AS PER ORDERS.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-19 00:00:00.000",
"description": "Report",
"row_id": 1663919,
"text": "Condition update\nSee careview for objective data and trends:\n\nDisoriented this evening and worseing overnight. Aggitated and at times combative attempting to hit staff and get oob. Given ativan with good effect, given haldol x 1 for questionable delirium with no effect. Fentanyl gtt increased to keep pt comfortable. Abd dsg no longer occlusive d/t movement and leaking bile from bottom dressing. SXN not working d/t non occlusive dsg. Dr (Gold ) up to assess. Attempted to reinforce with tegaderm but not sucessful. Hob at 15 and attempted to keep pt calm and still d/t open abd with non occlusive dsg. Dr (sicu) aware and into assess aswell. Awaiting surgery resident to speak with Dr re: plan for abd dsg as pt and family has expressed wishes to not return for additional surgeries as pt has poor prognosis. Currently hemodynamically stable, SR 80's, BP stable SBP 100-130's. Temp 101.2, pan cx. WBC stable at 8 this am. Increased o2 requirement overnight, Dr and Dr aware. ABG wnl. LUngs clear. CXR done. Good u/o. Awaiting surgery rounds for plan re: open admomen, cont to monitor hemodynamics, monitor abd drainage for s/sx stool, maintain saftey and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-10 00:00:00.000",
"description": "Report",
"row_id": 1663893,
"text": "please see carevue for details of care\n\npt intubated, sedated on 2 mg/hr midazolam. Daily wake up done, pt arouses to voice, does not follow commands. Moves all extremities spontaneously, does not withdrawl to pain, grimaces to nailbed pressure. Pupils 3-4mm equal and reactive. No signs/symptoms of pain, specifically no shaking, no agitation, no grimace, 75 mcg/hr fentanyl infusing as ordered. T max 99.9, HR 90s-100s, SR/ST, no ectopy. BP 120s-140s/60s-70s. Midazolam restarted at 1 mg/hr for HR remaining >100 and SBP 140s. Generalized edema noted, +DP/PT pulses. SCD boots in place. LR changed to LR with 20KCl, awaiting pharmacy delivery. Electrolytes repleted as ordered. Lungs CTA all lobes posteriorly, remains ventilated on AC 40% FiO2, rate 12, PEEP 5. O2 sat=100%. Suctioned x1 for scant clear secretions. Open abdomen with VAC dressing in place, draining large amounts of ascities appearing fluid. BS absent. L nare NG tube to LCS draining bilious fluid. Ileostomy tube to gravity, draining brown fluid. pt remains NPO, TPN infusing @ 64 cc/hr. Pelvic JP draining clear serosanginous fluid. Foley catheter draining approx 60 cc/hr clear amber urine. ABdominal dressing C/D/I. Stage III coccyx ulcer with allevyn dressing. Eye drops/eye lubricant applied q 4 hrs for dry eyes. Family at bedside, updated re: plan of care.\n\nPlan: continue to monitor hemodynamic status, monitor drains s/s infection, assess respiratory status, assess GI status, assess pain level, assess neuro status, maintain pt safety.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-10 00:00:00.000",
"description": "Report",
"row_id": 1663894,
"text": "Resp Care\nPt remains intubated on CMV, no vent changes. Sx for scant white. Plan to continue with current tx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-11 00:00:00.000",
"description": "Report",
"row_id": 1663895,
"text": "Condition update\nPlease see careview for objective data/trends:\n\nAlert initially this evening although not following commands. Moving all extremities spontanously. Pt nodding at times but infrequently but when attempting to communicate is appropriote. Sedation increased after pt attempted to push ETT out with tongue, currently well sedated on midaz and fent gtts. Appears comfortable. Tmax 100.3 ST HR 100-110 this evening with SBP 150's. Started on lopressor with good effect, currently SR HR 80-90's no ectopy noted. Remains normotensive. Lungs mostly coarse but clear after sxn. Remains on AC, no vent changes made. ABG WNL. Abd remains open and packed, covered with occlusive dressing. JP to wall sxn draining +ascities to intra abdominal space. JP to pelvic space draining clear serosang fluid. Ileum tube to gravity with clear amber fluid with some sedement draining. NGT draining light clear yellow fluid. Good u/o. HCT and INR stable. WBC down this am to 9. Plan to cont to monitor s/sx worsening infection, monitor hemodyamics and resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-11 00:00:00.000",
"description": "Report",
"row_id": 1663896,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th off white sput. MDI given as per order. ABGs stable; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-15 00:00:00.000",
"description": "Report",
"row_id": 1663911,
"text": "nursing note\nNeuro: Patient alert, confused to course of events with labile mood. Intermittent pain with turns, methadone increased and fentanyl weaned. After dose of increased methadone, patient appears more comfortable and sleepy. Easily arouses to voice. Less complaints of anxiousness after increase in methadone.\nCV:SR to ST, no ectopy. SBP WNL. remains on lopressor q4. PICC placed for long term TPN use. At this time, 3 ports needed so central line left in place. PT/OT consulted.\nRESP:LS clear, diminished. Weak non-prod cough. o2 sats down to 93% on RA when asleep.\nGI: NGT to wall suction drng yellow bilious drng with decrease in output.\nGU:foley patent dark amber icteric urine.\nSKIN: Wound team re-evaluated coccyx wound. duoderm gel with allevyn foam applied, wound healing. Bed changed to first step to facilitate OOB. Wound care signed off at this time.\nSOCIAL: Social work fooliwng and spoke with family re:long term plans of rehab and nursing home. Family expressing inability of patient to retun to home where he lives with his 84 year old mother. Patients also in to visit and spoke with sicial work.\n\nPLAN: Vac change thurs at bedside, OOB, mointor I+O's, wean fentanyl with increase in methadone. rehab screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2150-07-16 00:00:00.000",
"description": "Report",
"row_id": 1663912,
"text": "condition updated\nPlease see carevue for specifics.\nNeuro: Pt noted to be increasingly more confused throughout the night. Cooperative at times, agitated at other times. Pain controlled with fentynal gtt and methadone iv atc. Moves all extremities on the bed.\nCV: Sinus 90's-100's, no ectopy. Sbp 100's-140's. Peripheral pulses palpable. LR increased to 100cc's/hr. K+ and Mag repleted. Hct stable at 25.\nResp: LS clear/diminished. 02 sat dropped to 92, 4 liters n.c. applied and sat improved to 97%. Congested cough, pt not able raise sputum, coughing/deep breathing encouraged.\nGI: NGT to lws draining bilious drainage, ileum draining brownish fluid. JP with minimal serosang, and wound vac draining serous/light brownish drainage. It was noted roughly around midnight that wound vac white sponge was stained brown on right side. Dr. notified and at bedside to evaluate just before 1am. Brown fluid appearing like stool was noted to be also leaking outside dsg at ileum tube site and near jp, and also extending to right side of wound vac white sponge. Dr. was notifed per Dr. . Pt will be returning to o.r. at 0530 for re-exploration. Brother notified and spoke with Dr. over the phone.\nGu: Foley draining cloudy urine, dr. aware, u/a and culture sent. Urine output is adequate.\nEndo: No ssri coverage necessary.\nID: Temp spike 101.2 at midnight, urine and blood cultures obtained.\nPlan: Return to or for exploration, washout at 0530. Monitor hemodynamics, monitor neuro status, pain management comfort and support.\n"
},
{
"category": "ECG",
"chartdate": "2150-07-07 00:00:00.000",
"description": "Report",
"row_id": 221123,
"text": "Sinus tachycardia. No previous tracing available for comparison.\n\n"
}
] |
73,417 | 155,561 | Assessment and Plan: 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who presents with dyspnea and vomiting complicated by acute respiratory failure and septic shock. . # Dyspnea/respiratory failure: Admitted with worsening dyspnea on exertion, stable orthopnea. Became acutely SOB requiring intubation in the ED, likely due to metabolic acidosis with respiratory compensation leading to fatigue. Repeat CXR showed increased bilateral opacities suggesting pulmonary edema. Heart failure was considered her BNP elevation and history of orthopnea, although she has no known heart failure and ECHO was not particularly concerning for CHF ( dilated, LVEF > 55%). Viral DFA was negative, pneumonia was less likely in the absence of sputum and change in CXR. She has smoking history, but no wheezing or CO2 retention to suggest COPD. Ischemia was considered given report of chest pain, although EKG negative and cardiac markers negative. ABG showed good oxygenation and patient was switched to PSV 10/5 with FiO2 40%. Pt was stable on pressure support on the vent and sedation was weaned. SBTs starting with intention to extubate were unsuccesful (RR into the 40s, tachycardic), likely secondary to volume overload. She was diuresed with lasix and repeated almost daily SBTs continued to show elevated RR and tachycardia. RSBI was 156 on , but given that she is an elderly female with baseline tachypnea and small TVs, extubation was attempted on and was successful. She was quickly weaned down to 2L NC with O2 sats 95-100%. Of note, RSBI is not likely a good indication of this patients suitability for extubation given her baseline tachypnea and small TV and as she did very well s/p extubation with a pre-extubation RSBI of 156. . # Septic shock: Initial WBC with bandemia, elevated lactate, fever, tachycardia, and pressor requirement. Most likely biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. was done on and showed large amounts of sludge and a sludge ball obstructing flow in the CBD. Sludge ball/stone in CBD is approx 3 cm long, so a 5 cm 10 Fr pigtail stent was placed around the sludge ball to facilitate drainage until a definitive procedure can be attempted, now scheduled for . Blood cultures showed G positive rods and Clostridium species (not perfringens) in anaerobic culture bottles, but have not yet been speciated. She was started on broad spectrum antibiotics including Vanc and Zosyn on , then narrowed to Zosyn with G negative organisms in blood with plan for 14 day course. A PICC was placed on . Pressors were weaned starting and she has maintained her BP off pressors. Metoprolol was started on and uptitrated. . # Atrial fibrillation with RVR. She developed atrial fibrillation on . She was initially started on IV amiodarone with no good response. Her rate remained in 100-120's, and rate control was initiated with metoprolol and diltiazem on . On , diltiazem was discontinued and metoprolol was uptitrated. On , she spontaneously converted back to normal sinus rhythm. . # ARF: Likely related to sepsis (ATN), as well as hypovolemia from vomiting and diarrhea. Baseline creatinine 1.2-1.4. urine lytes: Fena: 0.2, FeUrea: 14.9%. She was rescuscitated with D5 1/2 NS with 3 amps of bicarb followed by NS PRN to maintain CVP > 10. Cr returned to baseline by . . # Anion gap acidosis: Most likely related to elevated lactate, initially 4.5 improved consistently with IVF, now 1.7. No history of ingestion and no clear offenders on med list. Glucose not c/w DKA, BUN not c/w uremia. . FEN: Pt was initially kept NPO then provided with full fibersource tube feeds at 30 ml/hr. In anticipation of extubation and question of whether she would be able to pass speech and swallow immediately, her OG tube was changed to an NG tube on . She was evaluated by speech and swallow and her diet changed to regular full, which she tolerated well. . She was called out of the ICU on . FLOOR COURSE: On the floor, she continued to do well. She spontaneously converted from atrial fibrillation back to NSR on . Her oxygen was weaned, and she was seen by physical therapy, who recommended rehab. The remainder of her blood pressure medications from home were held and should be re-added as an outpatient. She was discharged to rehab on in stable condition, not on oxygen, and tolerating PO. . On the floor, she was noted to have frequent stools (3-4 per day). Per her daughter, this is chronic and has been going on for months. A C. difficile study on was negative, and her abdominal exam is benign. This warrants further workup as an outpatient, and she was instructed to make an appointment to see her primary care doctor as an outpatient once discharged from rehab. | Improving Plan: Plan to diurese as pts hemodynamics tolerate. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Diltiazem d/c Response: Hr effectively controlled on with po diltiazem and lopressor. Diltiazem d/c Response: Hr effectively controlled on with po diltiazem and lopressor. Plan: Change back to pressure support in am, check RSBI, ?ready for extubation repeat RSBI~157 would like pt negative one liter. Plan: Plan to diurese as pts hemodynamics tolerate. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Tongue was at midline with functional strength and ROM.Palatal elevation and gag deferred.SWALLOWING ASSESSMENT:The pt was seen with thin liquids (tsp, straw, consecutive),purees and regular solids. The U/S showed sludge /sludge baland pt is s/p ERCP and stent. - Leukocytosis is resolvingwhite count almost normalized. Peripheral pulses are palpable; she has a right IJ TL CL with CVP monitoring. - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c vanc as GI infection not likely MRSA. - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c vanc as GI infection not likely MRSA. - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c vanc as GI infection not likely MRSA. - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c vanc as GI infection not likely MRSA. - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb less than 18 or LR if needs resuscitation to prevent further NG acidosis. - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb less than 18 or LR if needs resuscitation to prevent further NG acidosis. She was then transferred to the for further management Atrial fibrillation (Afib) Assessment: Pt remains in afib at a rate of 100-130s, BP has been stable Action: Her amnio was d/ced and lopressor was started Response: Tolerated the lopressor it seemed to lower her HR from the 120s to the 100s Plan: Titrate up the lopressor Respiratory failure, acute (not ARDS/) Assessment: Remains vented, lots of oral and ETT secretions, tachypnic to the 40s with VTs in the 300s Action: Unable to extubate today, to receive lasix this afternoon, restarted TF Response: Not yet ready for extubation Plan: Follow I&Os, lytes, cont to try to wean, cont pulm toilet - Hold sedation for now to optimize mental status prior to extubation - need to place a dobhoff prior to extubation as she may be an aspiration risk - CXR looks stable to slightly worsened this morning - family okay with re-intubation if patient fails extubation # Atrial Fibrillation: First occurred during SBT on , initially rates were in the 110s, then increased to the 130s. - Hold sedation for now to optimize mental status prior to extubation - need to place a dobhoff prior to extubation as she may be an aspiration risk - CXR looks stable to slightly worsened this morning - family okay with re-intubation if patient fails extubation # Atrial Fibrillation: First occurred during SBT on , initially rates were in the 110s, then increased to the 130s. - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb less than 18 or LR if needs resuscitation to prevent further NG acidosis. - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb less than 18 or LR if needs resuscitation to prevent further NG acidosis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. Initial sepsis secondary to biliary source given CBD dilation with sludge and obstructive LFTs in setting on known choledocholithiasis. - Leukocytosis is resolvingwhite count almost normalized. - Leukocytosis is resolvingwhite count almost normalized. Compared to the previous tracingof atrial fibrillation has resolved and right bundle-branch block isnew. neo being weaned to off as pts hemodynamics tolerate Response: Hr remains in afib tachy from 100-130s but hemodynamically stable Plan: Plan is to continue infusion of amioderon for 18 hrs and then will consider d/cing gtt. A right internal jugular line ends in the mid SVC. PFI REPORT Left PICC ends in upper superior vena cava. FINDINGS: Left PICC ends in the upper superior vena cava. The right internal jugular central venous catheter tip remains in the mid-to-lower SVC. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: 41cm left picc. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # Reason: 41cm left picc. PORTABLE UPRIGHT CHEST RADIOGRAPH: The study is degraded by respiratory motion. FINDINGS: As compared to the previous radiograph, an OG tube has been placed. The right internal jugular line ends in the mid superior vena cava. Peripheral wedge-shaped opacity in the left hemithorax obscuring the lateral pleural sulcus, which developed on , has been stable since 1:39 a.m. today consistent with pulmonary infarction, perhaps related to septic embolus or small loculated pleural fluid collection, also sometimes the result of pulmonary embolus. | 128 | [
{
"category": "Nutrition",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 702478,
"text": "Subjective\n Patient with n/v and poor appetite prior to admissoin, now intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 163 cm\n 79 kg\n 83.8 kg ( 04:00 AM)\n 31.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 54.4 kg\n 144%\n 61 kg\n kg\n %\n Diagnosis: sepsis\n PMHx: kidney cancer s/p cyberknife, choledocholelithiasis s/p ERCP\n (), dementia, B12 deficiency, HTN, ostoeporosis, CKD, grave's\n disease, follicular lymphoma of intestine (in remission), chronic\n diarrhea\n Food allergies and intolerances: none noted\n Pertinent medications: 30KPhos, amiodarone, versed, phenylephrine,\n others noted\n Labs:\n Value\n Date\n Glucose\n 91 mg/dL\n 04:18 AM\n Glucose Finger Stick\n 116\n 12:00 PM\n BUN\n 32 mg/dL\n 04:18 AM\n Creatinine\n 1.6 mg/dL\n 04:18 AM\n Sodium\n 140 mEq/L\n 04:18 AM\n Potassium\n 3.4 mEq/L\n 04:18 AM\n Chloride\n 108 mEq/L\n 04:18 AM\n TCO2\n 26 mEq/L\n 04:18 AM\n Calcium non-ionized\n 7.7 mg/dL\n 04:18 AM\n Phosphorus\n 1.7 mg/dL\n 04:18 AM\n Magnesium\n 2.4 mg/dL\n 04:18 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft with hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1200-1500 (BEE x or / 20-25 cal/kg)\n Protein: 60-80 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Specifics:\n 85 year old female with history of choledocholithiasis, renal CA, and\n dementia who presents with dyspnea and vomiting complicated by acute\n respiratory failure and septic shock likely secondary to biliary\n source. She is now s/p ERCP and stent. Patient unable to be extubated\n so consult received for tube feeding recommendations. Suggest goal of\n Fibersource HN at 50ml/hr x 24 hours to provide 1440kcal and 64g\n protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n Start Fibersource HN at 20ml/hr, advance by 20ml q6H to goal\n rate of 50ml/hr x 24 hours\n Monitor residuals q4H and hold tube feeding if greater than\n 200ml\n Will follow for possible extubation tomorrow\n 10:50 AM\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1260493,
"text": " 6:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube placement\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman intubated w effusion\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: Radiograph of earlier the same date.\n\n INDICATION: Nasogastric tube assessment.\n\n FINDINGS: Nasogastric tube courses below the diaphragm, with tip not included\n on the radiograph. Endotracheal tube tip terminates 2.5 cm above carina with\n neck in a flexed position. Persistent cardiomegaly. Probable unchanged left\n effusion and adjacent basilar atelectasis allowing for slight differences in\n patient positioning. Small right effusion unchanged.\n\n\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 701892,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n 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: /\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Received on vent support; overbreathing. Switch to PSV.\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI done ~79.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 701890,
"text": "Chief Complaint: Dyspnea and vomiting\n HPI:\n This is an 85yo F with a h/o choledocholithiasis, HTN, renal CA, and\n dementia who presented to today with dyspnea and vomiting. History\n is mainly taken from that visit note. The patient had onset of n/v\n yesterday after eating fried shrimp the prior day. She took \"nausea\n relief\" from CVS with improvement, although had anorexia. In addition,\n the patient has had dyspnea with minimal exertion associated with\n nonproductive cough and chronic orthopnea. She has also experienced\n weakness and 2 mild falls (no trauma or LOC). She has had diarrhea four\n to five times a day, although may have chronic diarrhea. Per family\n report, patient also had chest pain, although patient could not\n confirm. She had a fever of 100.9 at home that improved to 97.6. She\n was sent to the ED for eval.\n .\n In the ED, labs showed tbili 9.9 with transaminitis, anion gap\n acidosis, lactate 4.5, bandemia 18% of 4.8 and creat 2.6 from 1.3\n baseline. CXR was clear. Due to report of COPD history, she initially\n received combivent and methylprednisolone, as well as ASA and\n ceftriaxone. Once labs revealed a septic picture, she received vanc and\n pip-tazo. SBP was upper 80s to low 90s and a RIJ was placed and the\n patient received 3L IVF. While undergoing RUQ U/S, she became acutely\n dyspneic with new opacities on CXR. She was tiring on , was\n intubated and sedated. The U/S showed CBD 25mm and sludge/sludge ball\n and GI plans to take for ERCP in the am. Prior to transfer, vitals\n were: 101.3 119 118/103 25 99%. However, after signout, she was started\n on norepinephrine.\n .\n On the floor, the patient is intubated and sedated. She is unable to\n answer questions.\n Patient admitted from: ER\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 Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Home medications:\n ALENDRONATE [FOSAMAX] - 70 mg weekly\n AMLODIPINE [NORVASC] - 10 mg once a day\n CHLORTHALIDONE - 25 mg QAM\n CITALOPRAM - 20 mg at bedtime\n ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit monthly\n LISINOPRIL - 40 mg once a day\n MEMANTINE [NAMENDA] - 10 mg twice daily\n METOPROLOL SUCCINATE [TOPROL XL] - 100 mg once a day\n POTASSIUM CHLORIDE - 20 mEq twice a day\n ASCORBIC ACID [VITAMIN C] - (OTC) - 500 mg once a day\n CYANOCOBALAMIN - 1,000 mcg once a day\n MULTIVITAMINS WITH MINERALS - 1 capsule once a day\n Past medical history:\n Family history:\n Social History:\n Primary kidney CA s/p cyberknife\n Choledocholithiasis s/p ERCP with sphincterotomy in \n Dementia\n B12 deficiency\n Hypertension\n Osteoporosis\n CKD\n disease, s/p RAI\n Follicular lymphoma of the small intestine, in remission\n ?Chronic diarrhea\n unable to obtain.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Married, lives with husband in . Remote tobacco history\n (one-half pack per day for 20 years), no EtOH.\n Review of systems:\n Flowsheet Data as of 05:26 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 86 (85 - 97) bpm\n BP: 91/51(61) {86/49(58) - 91/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 64 mL\n PO:\n TF:\n IVF:\n 64 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -86 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 470 (470 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 15 cmH2O\n SpO2: 99%\n ABG: 7.31/37/133//-6\n Ve: 9 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Labs / Radiology\n 140\n 130\n 2.6\n 30\n 16\n 106\n 4.0\n 140\n 37.3\n 4.8\n [image002.jpg]\n N 71, Band 18\n \n 2:33 A10/14/ 02:51 AM\n \n 10:20 P10/14/ 04:57 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 TC02\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Imaging:\n CXR: Study is slightly limited due to patient motion. No gross evidence\n of pneumonia or congestive heart failure.\n .\n CXR (repeat, my read): Mildly increased diffuse fluffy bilateral\n opacities compared to prior film.\n .\n RUQ U/S (prelim): Difficult to compare across modalities. perhaps\n slight increase in size of common duct at liver margin, previously\n ~21mm, currently ~25 mm, in pt with chronic dilatation of intra- and\n extra-hepatic bile ducts. echogenic material seen in distal CBD,\n probably sludge/sludge ball. more focal stone-appearing filling defect\n seen on recent MR (measuring 2.5 cm in longest dimension) not seen.\n also distalmost CBD / panc head not well visualized. clinical\n correlation necessary, and if indicated, ERCP or MRCP could be\n performed for further assessment. no fluid in RUQ. no Rt hydro.\n ECG: sinus rhythm, no ischemic changes\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock.\n .\n # Dyspnea/respiratory failure: Has been having recently worsening\n dyspnea on exertion, stable orthopnea. Became acutely SOB requiring\n intubation in the ED. Repeat CXR shows increased bilateral opacities\n suggesting pulmonary edema. Heart failure is possible with her BNP\n elevation and history of orthopnea, although she has no known heart\n failure. Influenza another possibility given concurrent fever and dry\n cough. Pneumonia less likely as initial CXR was clear and there was no\n sputum. Has smoking history, but no wheezing or CO2 retention to\n suggest COPD. Would also consider ischemia given report of chest pain,\n although EKG reportedly negative and cardiac markers negative x1. ABG\n shows good oxygenation and patient has been switched to PSV 10/5 with\n FiO2 40%.\n - Cont PSV for now and wean as tolerated\n - R/o influenza\n - TTE in am to eval for heart failure\n - Repeat CXR in am\n - Cycle cardiac markers\n .\n # Septic shock: Suggested by bandemia, elevated lactate, fever,\n tachycardia, and pressor requirement. Most likely biliary source given\n CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. UA unremarkable and CXR does not suggest PNA.\n Blood cx obtained in ED. BP currently stable on norepinephrine.\n - Cont broad spectrum abx with vancomycin and pip-tazo\n - ERCP in am for biliary drainage\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx and add on urine cx\n - Cont IVF to keep CVP 8-12 mmHg and good UOP\n - Wean pressors as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n .\n # ARF: Likely related to sepsis, as well as hypovolemia from vomiting\n and diarrhea. Baseline creatinine 1.2-1.4. Expect improvement s/p\n fluids.\n - IVF\n - Urine lytes\n - Avoid nephrotoxins\n - Trend renal function\n .\n # Anion gap acidosis: Most likely related to elevated lactate, now\n improving with IVF. No history of ingestion and no clear offenders on\n med list. Glucose not c/w DKA, BUN not c/w uremia.\n - Cont IVF\n - Repeat lactate, lytes in am\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: not indicated\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Husband/HCP (), hter \n ()\n Code status: Full code (confirm with family in am)\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702013,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 03:45 AM\n Vent settings were changed to Pressure support and tolerating well\n ECHO this AM\n ERCP today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 79 (79 - 97) bpm\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 6 (6 - 7)mmHg\n Total In:\n 369 mL\n PO:\n TF:\n IVF:\n 369 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 219 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 451 (451 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.31/37/133//-6\n Ve: 9.3 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n TCO2\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock.\n .\n # Dyspnea/respiratory failure:\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\n trying to compensate by respiratory means\n Has been having recently worsening dyspnea on exertion, stable\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\n CXR shows increased bilateral opacities suggesting pulmonary edema.\n Heart failure is possible with her BNP elevation and history of\n orthopnea, although she has no known heart failure. Influenza another\n possibility, though less likely, given concurrent fever and dry cough.\n CXR was not concerning for pneumonia or fluid overload. Consider also\n ischemia given report of chest pain, although EKG reportedly negative\n and cardiac markers negative x2, so not likely ACS. ABG shows good\n oxygenation and patient has been switched to PSV 10/5 with FiO2 40%.\n PE less likely\n - Cont PSV for now and wean as tolerated\n - R/o influenza\n - f/u w TTE from this morning\n .\n # Septic shock:\n Bandemia and lactate improving, still febrile and requiring pressors.\n Sepsis likely secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\n other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo\n - ERCP today for biliary drainage\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n .\n # Anion gap acidosis:\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\n IVF.\n - Cont IVF per sepsis protocol\n - trend lactate\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\n - IVFs for CVP 10-12\n - f/u Urine lytes\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia\n Likely secondary to sepsis.\n - send DIC labs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: pneumoboots, subq heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband\n status: Full (Presumed)\n need to confirm w husband\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 85F a w/ renal ca, dementia,\n choledocolithiasis presents with n/v X 2 days, diarrhea, dyspnea, Fever\n 100.9. In ED CXR clear initially but intubated for ? evolving\n infiltrates and resp distress. RIJ CVL placed for hypotension with IVF\n given, levophed then started. Received vanco/zosyn Labs concerning for\n biliary sepsis with t bili 9.9, transaminitis, AGMA, lactate 4.5, 18%\n bandemia and cr 2.6. RUQ with dil cbd, sludge with ERCP consulted and\n plan for ERCP in am today.\n PE: BP: 90/50 HR90 RR 19 T: 100.8 98% ACV--> PS 12/5 40% Intubated,\n sedated, jaundiced, perrla, CTA, RR, soft + BS, non T at ruq, no edema\n LABS: wbc 25 (4.8), 19-->0 bands, hct 31.6, plt 93 (140), na 137, cr\n 2.4 (2.6), lactate 2.4 (4.5), t bili 6.4 (9.9), ast/alt decreasing, inr\n 1.3, 7.31/37/133, trop 0.02, BNP 5600, u/a neg\n ECG with NSR TWI 3, v1. no ST changes\n Imaging reviewed: cxr appears rotated, pulm vascular fullness, no focal\n infiltrate though would watch r mid zone for possible evolving asp pna\n A/P: Sepsis appears from biliary source/cholangitis, c/b arf and resp\n failure. Resp failure does not appear primary lung process, as CXR\n is rather unimpressive, but suspect in setting of met acidosis she\n fatigued. There is a component of mild demand ischemia by trop without\n frank ecg changes. Agree with plan to manage biliary sepsis with broad\n antibx (vanco, zosyn for now f/u cx data), plan for ercp today to\n relieve obstruction. She does not appear fully tanked from volume\n standpoint. Will continue aggressive IVF (LR given NG as well as AGMA)\n for cvp > 10, weaning pressor off, following u/o, trending lactate,\n lfts, a/l. Will continue current vent support as she is oxygenating\n well and appears comfortable on PS. Follow abgs closely for signs of\n fatigue noting her continued met acidosis. Evidence of mild demand\n ischemia in setting of septic picture--trop are flat and without\n progressive ecg changes. Volume may be an issue in setting of\n extubation. TTE will be helpful. . Her ARF likely vol repletion\n from sepsis, n/v and diarrhea. Aggressive fluids as above, send urine\n lytes. Thrombocytopenia likely in part dilutional and related to\n sepsis, also concerning for DIC. Send dic panel. Low suspicion for\n HIT. ICU prophy. Consider a-line placement if unable to wean off\n pressor. Remainder of plan as outlined in resident note. Need to\n confirm code status w/ family.\n Patient is critically ill\n Total time: 55 min.\n ------ Protected Section Addendum Entered By: , MD\n on: 02:11 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703511,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent on \n Atrial fibrillation (Afib)\n Assessment:\n Pt intubated on . resp failure initially thought to be due to her\n primary metabolic acidosis which caused her to hyperventilate to\n compensate and fatigued beoming acutely sob and requiring intubation in\n the ed.pt initially unable to wean vent secondary to fluid\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\n 20\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\n Action:\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\n liter. Pt successfully extubated on . ngt in place for tube fdgs\n infusing presently at 30cc\ns/hr until speech and swallow study is\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\n status and fluid balance followed closely. Physical therapy consulted\n to increase pt\ns level of activity and for resp toileting. Speech and\n swallow study completed at bedside\n Response:\n Reps status improved with aggressive diuresis. Pt passed speech and\n swallow study so diet advanced to reg low sodium diet\n Plan:\n Continue to monitor pt\ns resp status and increase pt\ns level of\n activity. Continue to follow fluid balance closely. Continue with resp\n toileting. Pt will benefit from incentive spirometry. Physical therapy\n to evaluate pt. maintain pt on aspiration precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\ns . k+\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\n Action:\n Pt receiving lopressor as ordered . Electrolytres repleted as per\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\n Response:\n Hr effectively controlled on with po diltiazem and lopressor.\n Plan:\n Continue lopressor as ordered. Continue to check electrolytes as\n ordered and replete as needed. Follow hemodynamics closely. If pt\n remains tachycardic in afib will increase dose of lopressor.\n"
},
{
"category": "General",
"chartdate": "2169-11-22 00:00:00.000",
"description": "ICU Event Note",
"row_id": 702001,
"text": "Clinician: Resident\n An Arterial line was placed in the left radial arterial under sterile\n technique without complication at 930 am. 25 mcg of fentanyl was given\n for increased sedation during the procedure.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 701982,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 03:45 AM\n Vent settings were changed to Pressure support and tolerating well\n ECHO this AM\n ERCP today\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 79 (79 - 97) bpm\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 6 (6 - 7)mmHg\n Total In:\n 369 mL\n PO:\n TF:\n IVF:\n 369 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 219 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 451 (451 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.31/37/133//-6\n Ve: 9.3 L/min\n PaO2 / FiO2: 332\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n TCO2\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock.\n .\n # Dyspnea/respiratory failure:\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\n trying to compensate by respiratory means\n Has been having recently worsening dyspnea on exertion, stable\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\n CXR shows increased bilateral opacities suggesting pulmonary edema.\n Heart failure is possible with her BNP elevation and history of\n orthopnea, although she has no known heart failure. Influenza another\n possibility, though less likely, given concurrent fever and dry cough.\n CXR was not concerning for pneumonia or fluid overload. Consider also\n ischemia given report of chest pain, although EKG reportedly negative\n and cardiac markers negative x2, so not likely ACS. ABG shows good\n oxygenation and patient has been switched to PSV 10/5 with FiO2 40%.\n PE less likely\n - Cont PSV for now and wean as tolerated\n - R/o influenza\n - f/u w TTE from this morning\n .\n # Septic shock:\n Bandemia and lactate improving, still febrile and requiring pressors.\n Sepsis likely secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\n other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo\n - ERCP today for biliary drainage\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n .\n # Anion gap acidosis:\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\n IVF.\n - Cont IVF per sepsis protocol\n - trend lactate\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\n - IVFs for CVP 10-12\n - f/u Urine lytes\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia\n Likely secondary to sepsis.\n - send DIC labs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: pneumoboots, subq heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband\n status: Full (Presumed)\n need to confirm w husband\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703365,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent. Respiratory failure initially thought to be due to\n metabolic acidosis which caused her to hyperventilate to compensate.\n She fatigued quickly becoming acutely SOB and required intubation on\n ^th. Since then, unable to wean vent because of pt being\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\n coming off peep becoming very tachypneic with low tidal volumes which\n is more concerning for difficulty with compliance then volume overload.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on humidified fact ten s/p extubation @ 40% FiO2. Pt\n tachypneic @ times 30-40\ns but appearing comfortable & settles out on\n own. O2 sat 97-100%. LS clear, diminished @ bases. MN fluid goal\n 1.5\n 2L. Mental status much improved. Pt following commands and actively\n participating in care. Pt requesting food throughout the night.\n Action:\n Pt titrated down to 2LNC. Cough improving O/N. Pt able to produce small\n amts of sputum and allow for suctioning. Q4hr mouthcare. (Dentures @\n bedside) Tubefeeds initiated @ 10cc hr (please see previous order)\n Response:\n Pt -1L @ MN. Improving\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal - 1.5\n 2L @\n this time. Cont to trend lab values and f/u on micro data. As discussed\n w/ daughter (HCP) pt will be reintubated in necessary (but remains DNR)\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n Pt did have 2 smears of stool overnight. Please monitor\n closely. Skin breakdown is of concern, amt of stool was not significant\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\n not benefit from fecal inc. bag)\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703414,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:22 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\n improved in terms of pulmonary vascular congestion, will trial\n extubation today since patient looks the best she has since admission\n - patient may need Bipap post extubation\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n .\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 90\ns with both medications\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month\n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703415,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on humidified fact tent s/p extubation @ 40% FiO2. Pt less\n tachypneic this evening 20\ns. O2 sat 97-100%. LS clear,\n diminished @ bases. MN fluid goal\n 1.5\n 2L. Mental status much\n improved. Pt following commands and actively participating in care. Pt\n requesting food throughout the night.\n Action:\n Pt titrated down to 2LNC. Cough improving O/N. Pt able to produce small\n amts of sputum and allow for suctioning @ beginning of shift. Q4hr\n mouthcare. (Dentures @ bedside) Tubefeeds initiated @ 10cc hr (please\n see previous order) Atrovent nebs Q6hrs.\n Response:\n Pt -1L @ MN. TF currently running @ 30cc/hr (goal 50cc/hr) Dry, NPC\n this AM.\n Plan:\n Cont to diurese w/ Lasix IVP if warranted. Net goal - 1.5\n 2L @ this\n time. Cont to trend lab values and f/u on micro data. As discussed w/\n daughter (HCP) pt will be reintubated if necessary (but remains DNR)\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in Afib; HR ranging from 90-100\ns. SBP 85-120\ns. Minimal\n ectopy noted. AM K 3.6, Mg 1.9\n Action:\n Pt currently on Lopressor 25mg NG TID & Diltiazem 30mg NG Q6hr. MN Dilt\n was held to low BP. Tolerated Lopressor (HR 90\ns) Magnesium 2gm IV\n & KCL 20mEq IV given this AM per sliding scale orders.\n Response:\n Pt has remained in Afib but rate has significantly improved w/\n administration of Lopressor & Dilt. HR ranging 80\n low 100\ns w/\n minimal ectopy.\n Plan:\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\n Diltiazem as warranted. Follow electrolyte status & replete as needed.\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n Pt did have 2 smears of stool overnight. Please monitor\n closely. Skin breakdown is of concern, amt of stool was not significant\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\n not benefit from fecal inc. bag)\n Will most likely be c/o to medical floor this AM\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703417,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. status post extubation, doing great, weaned down to 2LNC\n - will c/s speech and swallow prior to advancing diet as patient is\n having some difficulty controlling her oral secretions\n - still on dilt/lopressor, dilt seems to have better HR effects\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\n improved in terms of pulmonary vascular congestion, will trial\n extubation today since patient looks the best she has since admission\n - patient may need Bipap post extubation\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n .\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 90\ns with both medications\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month\n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703486,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent on \n Atrial fibrillation (Afib)\n Assessment:\n Pt intubated on . resp failure initially thought to be due to her\n primary metabolic acidosis which caused her to hyperventilate to\n compensate and fatigued beoming acutely sob and requiring intubation in\n the ed.pt initially unable to wean vent secondary to fluid\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\n 20\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\n Action:\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\n liter. Pt successfully extubated on . ngt in place for tube fdgs\n infusing presently at 30cc\ns/hr until speech and swallow study is\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\n status and fluid balance followed closely. Physical therapy consulted\n to increase pt\ns level of activity and for resp toileting. Speech and\n swallow study completed at bedside\n Response:\n Reps status improved with aggressive diuresis. Pt passed speech and\n swallow study so diet advanced to reg low sodium diet\n Plan:\n Continue to monitor pt\ns resp status and increase pt\ns level of\n activity. Continue to follow fluid balance closely. Continue with resp\n toileting. Pt will benefit from incentive spirometry. Physical therapy\n to evaluate pt. maintain pt on aspiration precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\ns . k+\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\n Action:\n Pt receiving lopressor as ordered . Electrolytres repleted as per\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\n Response:\n Hr effectively controlled on with po diltiazem and lopressor.\n Plan:\n Continue lopressor as ordered. Continue to check electrolytes as\n ordered and replete as needed. Follow hemodynamics closely. If pt\n remains tachycardic in afib will increase dose of lopressor.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 703488,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. status post extubation, doing great, weaned down to 2LNC\n - passed speech and swallow. Diet advanced to regular\n - still on dilt/lopressor, dilt seems to have better HR effects\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\n Does c/o hoarse voice\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: awake, responsive, follows commands\n HEENT: PERRL, MMM, NG tube in place\n Neck: RIJ in place\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload was seen on CXR. S/p\n extubation.\n - s/p extubation, satting well on 2L NC\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 110\ns with both medications. Some\n tachycardia likely related to intubation and agitation. Episodic BPs\n low on both agents.\n - d/c dilt and monitor BP/tachycardia\n - will need ongoing titration/o/p follow up\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month, scheduled \n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n 12:28\n ------ Protected Section ------\n Agree with excellent medical student note with the following addition:\n The patient was on long acting metoprolol at a dose of 100mg daily\n prior to admission. She would benefit from continuing the beta-blocker\n rather than the calcium channel blocker for coronary artery disease\n history. She will likely need to be titrated up on the metoprolol to\n at least her prior home dose but likely higher.\n The patient is doing well on 2L NC this AM and is ready to be\n transferred to the floor.\n She passed her speech and swallow study. Her NG tube will be pulled\n today, and her diet will be advanced.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:53 ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\n respiratory failure, AF c RVR improved with BBL / CCB. Diuresis\n ongoing, BNP 6K.\n Exam notable for Tm 99.8 BP 116/62 HR 95-105AF RR 12-37 with sat 100 on\n PSV 8/5, -2L / 24h. WD woman, alert, conversant. JVD flat. CTA B, \n at bases c few rales. Irreg s1s2. Soft +BS. 2+ edema. Labs notable for\n WBC 7K, HCT 26, K+ 3.6, Cr 1.4.\n Agree with plan to respiratory failure with CPT / upright positioning,\n PT eval, OOB, hold on lasix. OK to ADAT s/p S+S, d/c NGT. Cholangitis\n improving, will need 14d abx via PICC (day ). Over the long term,\n will need f/u ERCP for large nonobstructive stone - scheduled for\n . For AF c RVR, continue BBL, d/c CCB today, start ASA 81mg. ARF\n has resolved; baseline CRI. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 01:59 PM ------\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703475,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. status post extubation, doing great, weaned down to 2LNC\n - passed speech and swallow. Diet advanced to regular\n - still on dilt/lopressor, dilt seems to have better HR effects\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\n Does c/o hoarse voice\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: awake, responsive, follows commands\n HEENT: PERRL, MMM, NG tube in place\n Neck: RIJ in place\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload was seen on CXR. S/p\n extubation.\n - s/p extubation, satting well on 2L NC\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 110\ns with both medications. Some\n tachycardia likely related to intubation and agitation. Episodic BPs\n low on both agents.\n - d/c dilt and monitor BP/tachycardia\n - will need ongoing titration/o/p follow up\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month, scheduled \n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n 12:28\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703478,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. status post extubation, doing great, weaned down to 2LNC\n - passed speech and swallow. Diet advanced to regular\n - still on dilt/lopressor, dilt seems to have better HR effects\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:42 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies CP/SOB, nausea, vomiting, diarrhea, pain.\n Does c/o hoarse voice\n Flowsheet Data as of 05:57 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: 36.1\nC (97\n HR: 108 (87 - 111) bpm\n BP: 118/56(69) {82/35(45) - 129/82(86)} mmHg\n RR: 29 (25 - 36) insp/min\n SpO2: 93%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 892 mL\n 666 mL\n PO:\n TF:\n 10 mL\n 99 mL\n IVF:\n 642 mL\n 247 mL\n Blood products:\n Total out:\n 1,965 mL\n 260 mL\n Urine:\n 1,965 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,073 mL\n 406 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 310 (236 - 310) mL\n PS : 8 cmH2O\n RR (Spontaneous): 33\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 9 cmH2O\n SpO2: 93%\n ABG: 7.46/44/124/30/7\n Ve: 9.2 L/min\n PaO2 / FiO2: 354\n Physical Examination\n General: awake, responsive, follows commands\n HEENT: PERRL, MMM, NG tube in place\n Neck: RIJ in place\n Lungs: clear lungs anteriorly, no wheezes, rales, ronchi\n CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 206 K/uL\n 8.9 g/dL\n 78 mg/dL\n 1.4 mg/dL\n 30 mEq/L\n 3.6 mEq/L\n 26 mg/dL\n 99 mEq/L\n 139 mEq/L\n 26.6 %\n 7.3 K/uL\n [image002.jpg]\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n 07:32 AM\n 04:02 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n 7.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n 26.6\n Plt\n 48\n 60\n 84\n 131\n 174\n 206\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n 1.4\n TCO2\n 32\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n 78\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.3 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload was seen on CXR. S/p\n extubation.\n - s/p extubation, satting well on 2L NC\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 110\ns with both medications. Some\n tachycardia likely related to intubation and agitation. Episodic BPs\n low on both agents.\n - d/c dilt and monitor BP/tachycardia\n - will need ongoing titration/o/p follow up\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month, scheduled \n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:00 PM 30 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: transfer to floor\n 12:28\n ------ Protected Section ------\n Agree with excellent medical student note with the following addition:\n The patient was on long acting metoprolol at a dose of 100mg daily\n prior to admission. She would benefit from continuing the beta-blocker\n rather than the calcium channel blocker for coronary artery disease\n history. She will likely need to be titrated up on the metoprolol to\n at least her prior home dose but likely higher.\n The patient is doing well on 2L NC this AM and is ready to be\n transferred to the floor.\n She passed her speech and swallow study. Her NG tube will be pulled\n today, and her diet will be advanced.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:53 ------\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703536,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent on \n Atrial fibrillation (Afib)\n Assessment:\n Pt intubated on . resp failure initially thought to be due to her\n primary metabolic acidosis which caused her to hyperventilate to\n compensate and fatigued beoming acutely sob and requiring intubation in\n the ed.pt initially unable to wean vent secondary to fluid\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\n 20\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\n Action:\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\n liter. Pt successfully extubated on . ngt in place for tube fdgs\n infusing presently at 30cc\ns/hr until speech and swallow study is\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\n status and fluid balance followed closely. Physical therapy consulted\n to increase pt\ns level of activity and for resp toileting. Speech and\n swallow study completed at bedside\n Response:\n Reps status improved with aggressive diuresis. Pt passed speech and\n swallow study so diet advanced to reg low sodium diet\n Plan:\n Continue to monitor pt\ns resp status and increase pt\ns level of\n activity. Continue to follow fluid balance closely. Continue with resp\n toileting. Pt will benefit from incentive spirometry. Physical therapy\n to evaluate pt. maintain pt on aspiration precautions.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\ns . k+\n 3.6 and mg=1.9 occasionall sbp has dropped to < 90.\n Action:\n Pt receiving lopressor as ordered . Electrolytres repleted as per\n sliding scale. Hemodynamics followed closely. Diltiazem d/c\n Response:\n Hr effectively controlled on with po diltiazem and lopressor.\n Plan:\n Continue lopressor as ordered. Continue to check electrolytes as\n ordered and replete as needed. Follow hemodynamics closely. If pt\n remains tachycardic in afib will increase dose of lopressor.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703440,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. Pt is s/p\n ERCP w/ stent on \n Atrial fibrillation (Afib)\n Assessment:\n Pt intubated on . resp failure initially thought to be due to her\n primary metabolic acidosis which caused her to hyperventilate to\n compensate and fatigued beoming acutely sob and requiring intubation in\n the ed.pt initially unable to wean vent secondary to fluid\n resuscitation as fluid overload seen on cxr. On 2l/m nc wth rr in the\n 20\ns and o2 sats> 94%. Lungs cta but diminished at the bases.\n Action:\n Pt aggressively diuresed. With gaol for fluid balance to be neg>1\n liter. Pt successfully extubated on . ngt in place for tube fdgs\n infusing presently at 30cc\ns/hr until speech and swallow study is\n completed at bedside. Pt encouraged to cough and deep breathe. Resp\n status and fluid balance followed closely. Physical therapy consulted\n to increase pt\ns level of activity and for resp toileting.\n Response:\n Reps status improved with aggressive diuresis\n Plan:\n Continue to monitor pt\ns resp status and increase pt\ns level of\n activity. Continue to follow fluid balance closely. Await final\n recommendations of speech and swallow consult. Continue with resp\n toileting. Pt will benefit from incentive spirometry.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains in afib with hr ranging form 80-100 and sbp 86-110\ns . k+\n 3.6 and mg=1.9\n Action:\n Pt receiving lopressor and diltiazem as ordered. Electrolytres repleted\n as per sliding scale. Hemodynamics followed closely.\n Response:\n Hr effectively controlled on with po diltiazem and lopressor.\n Plan:\n Continue diltiazem and lopressor as ordered. Continue to check\n electrolytes as ordered and replete as needed. Follow hemodynamics\n closely.\n"
},
{
"category": "Nutrition",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 703461,
"text": "Subjective\n happy to pass S & S eval\n Objective\n Pertinent medications: Piperacillin-Tazobactam, Vancomycin, Heparin,\n others noted\n Labs:\n Value\n Date\n Glucose\n 78 mg/dL\n 04:02 AM\n Glucose Finger Stick\n 149\n 06:00 PM\n BUN\n 26 mg/dL\n 04:02 AM\n Creatinine\n 1.4 mg/dL\n 04:02 AM\n Sodium\n 139 mEq/L\n 04:02 AM\n Potassium\n 3.6 mEq/L\n 04:02 AM\n Chloride\n 99 mEq/L\n 04:02 AM\n TCO2\n 30 mEq/L\n 04:02 AM\n PO2 (arterial)\n 124 mm Hg\n 07:32 AM\n PCO2 (arterial)\n 44 mm Hg\n 07:32 AM\n pH (arterial)\n 7.46 units\n 07:32 AM\n pH (urine)\n 5.0 units\n 09:47 AM\n CO2 (Calc) arterial\n 32 mEq/L\n 07:32 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:02 AM\n Phosphorus\n 3.2 mg/dL\n 04:02 AM\n Magnesium\n 1.9 mg/dL\n 04:02 AM\n ALT\n 45 IU/L\n 04:54 AM\n Alkaline Phosphate\n 103 IU/L\n 04:15 AM\n AST\n 23 IU/L\n 04:54 AM\n Amylase\n 16 IU/L\n 07:35 AM\n Total Bilirubin\n 1.5 mg/dL\n 04:15 AM\n WBC\n 7.3 K/uL\n 04:02 AM\n Hgb\n 8.9 g/dL\n 04:02 AM\n Hematocrit\n 26.6 %\n 04:02 AM\n Current diet order / nutrition support: Regular; Cardiac/Heart healthy\n GI: NBS, smear stool x 2 last night\n SKIN: buttocks redden\n Assessment of Nutritional Status\n 85 year old female with h/o choledocholithiasis presented with dyspnea\n and vomiting complicated by acute respiratory failure and septic\n shock. Patient intubated and started on tube feed, tube feed off for\n extubation, patient extubated yesterday, and passed S & S evaluation\n this morning, per discussion with SLP, okay to diet advance, patient\n still has her NGT in place and tube feed is currently at 30ml/hr\n HN, MD just change POE diet to regular and tube feed order\n discontinued.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet is appropriate\n Multivitamin / Mineral supplement: daily\n Check chemistry 10 panel daily, replete prn\n will monitor po as tol\n if has question\n"
},
{
"category": "Rehab Services",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Bedside Swallow Evaluation",
"row_id": 703463,
"text": "TITLE:\nBEDSIDE SWALLOWING EVALUATION:\nHISTORY:\nThank you for consulting on this 85 y/o female with h/o\ncholedocholithiasis, HTN, renal ca and dementia admitted on\n with dyspnea and vomiting. Pt also with diarrhea and\nfever. CXR was initially clear but pt developed acute dyspnea\nwhile in U/S with new opacities suggestive of pulmonary edema on\nCXR and pt required intubation. The U/S showed sludge /sludge bal\nand pt is s/p ERCP and stent. Pt had difficulty weaning from the\nvent volume overload fluid resuscitation. Pt was\nextubated yesterday around noon and we were consulted to evaluate\nfor oral and pharyngeal dysphagia. She is currently NPO with NG\ntube in place.\nEVALUATION:\nThe examination was performed while the patient was seated\nupright in the bed in the .\nCognition, language, speech, voice:\nThe pt was awake, alert and oriented x 3 with fluent language.\nSpeech and voice were wfl and she was able to follow all basic\ncommands.\nTeeth: edentulous- full set of well fitting dentures put in place\nSecretions: wfl in the oral cavity\nORAL MOTOR EXAM:\nSymmetrical facial appearance with adequate lip seal and buccal\ntone. Tongue was at midline with functional strength and ROM.\nPalatal elevation and gag deferred.\nSWALLOWING ASSESSMENT:\nThe pt was seen with thin liquids (tsp, straw, consecutive),\npurees and regular solids. Pt with mild difficulty biting solids,\nbut mastication was functional without significant residue. Pt\nwithout overt coughing, throat clearing or changes in vocal\nquality and she denied the sensation of aspiration or pharyngeal\nresidue. O2 SATs remained greater than 98%. Laryngeal elevation\nwas timely and wfl to palpation.\nSUMMARY / IMPRESSION:\nThe pt had difficulty self feeding but tolerated thin liquids and\nregular solids without difficulty or signs of aspiration. She can\nbe advanced to a regular diet but will require assistance with\nsetting up her meals and feeding. Pills can be given whole with\nwater. If pt tolerates lunch well, we can remove the NG currently\nin place.\nThis swallowing pattern correlates to a Functional Oral Intake\nScale (FOIS) rating of 7.\nRECOMMENDATIONS:\n1. Suggest a PO diet of thin liquids and regular consistency\nsolids.\n2. Supervision during meals to assist with feeding.\n3. Meds whole with thin liquids.\n4. If pt tolerates lunch, suggest removing her NG tube.\nThese recommendations were shared with the patient, nurse and\nmedical team.\n____________________________________\n , M.S., CCC-SLP\nPager #\nFace time: 11:00-11:20\nTotal time: 60 minutes\n [BUTTON Input] (not implemented)_____\n 11:24\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 703530,
"text": "Demographics\n Attending MD:\n F.\n Admit diagnosis:\n SEPSIS\n Code status:\n DNR (do not resuscitate)\n Height:\n 64 Inch\n Admission weight:\n 83.8 kg\n Daily weight:\n 80 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: lymphoma, dementia.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:97\n D:64\n Temperature:\n 97\n Arterial BP:\n S:123\n D:69\n Respiratory rate:\n 37 insp/min\n Heart Rate:\n 101 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 1,930 mL\n 24h total out:\n 960 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 04:02 AM\n Potassium:\n 3.6 mEq/L\n 04:02 AM\n Chloride:\n 99 mEq/L\n 04:02 AM\n CO2:\n 30 mEq/L\n 04:02 AM\n BUN:\n 26 mg/dL\n 04:02 AM\n Creatinine:\n 1.4 mg/dL\n 04:02 AM\n Glucose:\n 78 mg/dL\n 04:02 AM\n Hematocrit:\n 26.6 %\n 04:02 AM\n Finger Stick Glucose:\n 149\n 06:00 PM\n Valuables / Signature\n Patient valuables: upper and lower dentures\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: yellow colored wedding band and yellow colored engagement ring\n with clear colored stones\n Transferred from:\n Transferred to: 408\n Date & time of Transfer: 1830\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 701925,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management.\n CNS: Patient is now sedated on midazolam at 3mg/hr and fentanyl at\n 50mcg/hr for pain management. Bilateral soft wrist restraints on to\n prevent treatment interference. Patient not able to open eyes or follow\n commands at this time but does grimace to painful stimuli.\n CVS: SR on the monitor with BP being maintained on Levophed at 0.2mkm\n to keep MAP greater than 65mmHg. Peripheral pulses are palpable; she\n has a right IJ TL CL with CVP monitoring. One peripheral IV to the\n right inner wrist.\n RESP: Currently the patient is on PSV with setting and maintaining\n adequate saturations in the upper 90\ns, in no obvious distress at the\n time of reporting.\n GI: Abdomen soft with bowel sounds, OGT placed and to be confirmed.\n GU: Foley with icteric colored urine, urine lytes to be collected.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 701955,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 03:45 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 79 (79 - 97) bpm\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 6 (6 - 7)mmHg\n Total In:\n 369 mL\n PO:\n TF:\n IVF:\n 369 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 219 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 451 (451 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.31/37/133//-6\n Ve: 9.3 L/min\n PaO2 / FiO2: 332\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 02:51 AM\n 04:57 AM\n TCO2\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock.\n .\n # Dyspnea/respiratory failure:\n Likely tachypnea secondary to metabolic acidosis; pt was tiring out\n trying to compensate by respiratory means\n Has been having recently worsening dyspnea on exertion, stable\n orthopnea. Became acutely SOB requiring intubation in the ED. Repeat\n CXR shows increased bilateral opacities suggesting pulmonary edema.\n Heart failure is possible with her BNP elevation and history of\n orthopnea, although she has no known heart failure. Influenza another\n possibility given concurrent fever and dry cough. Pneumonia less likely\n as initial CXR was clear and there was no sputum. Has smoking history,\n but no wheezing or CO2 retention to suggest COPD. Would also consider\n ischemia given report of chest pain, although EKG reportedly negative\n and cardiac markers negative x1. ABG shows good oxygenation and patient\n has been switched to PSV 10/5 with FiO2 40%.\n - Cont PSV for now and wean as tolerated\n - R/o influenza\n - TTE in am to eval for heart failure\n - Repeat CXR in am\n - Cycle cardiac markers\n .\n # Septic shock:\n Bandemia and lactate improving, still febrile and requiring pressors.\n Sepsis likely secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis. No\n other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo\n - ERCP today for biliary drainage\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n .\n # Anion gap acidosis:\n Most likely lactic acidosis secondary to sepsis. Also has a non-gap\n acidosis, likely from chronic diarrhea. Gap acidosis improving with\n IVF.\n - Cont IVF per sepsis protocol\n - trend lactate\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Baseline creatinine 1.2-1.4.\n - IVFs for CVP 10-12\n - f/u Urine lytes\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia\n Likely secondary to sepsis.\n - send DIC labs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 701936,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 03:45 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Midazolam (Versed) - 3 mg/hour\n Fentanyl - 50 mcg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:04 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.8\n Tcurrent: 38.2\nC (100.8\n HR: 79 (79 - 97) bpm\n BP: 94/51(62) {86/49(58) - 94/51(149)} mmHg\n RR: 19 (19 - 26) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 6 (6 - 7)mmHg\n Total In:\n 369 mL\n PO:\n TF:\n IVF:\n 369 mL\n Blood products:\n Total out:\n 0 mL\n 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 219 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 451 (451 - 470) mL\n PS : 12 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 79\n PIP: 17 cmH2O\n SpO2: 100%\n ABG: 7.31/37/133//-6\n Ve: 9.3 L/min\n PaO2 / FiO2: 332\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 02:51 AM\n 04:57 AM\n TCO2\n 18\n 20\n Other labs: Lactic Acid:2.4 mmol/L\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 701907,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management.\n CNS: Patient is now sedated on midazolam at 3mg/hr and fentanyl at\n 50mcg/hr for pain management. Bilateral soft wrist restraints on to\n prevent treatment interference. Patient not able to open eyes or follow\n commands at this time but does grimace to painful stimuli.\n CVS: SR on the monitor with BP being maintained on Levophed at 0.2mkm\n to keep MAP greater than 65mmHg. Peripheral pulses are palpable; she\n has a right IJ TL CL with CVP monitoring. One peripheral IV to the\n right inner wrist.\n RESP: Currently the patient is on PSV with setting and maintaining\n adequate saturations in the upper 90\ns, in no obvious distress at the\n time of reporting.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702052,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\n Action:\n Placed on A/C for ERCP.\n Response:\n Remains on AC as she received paralytic for ERCP and remains very\n sedated.\n Plan:\n Return PSV when spontaneous breathing returns. Turn off sedation in\n a.m. and do SBT for possible extubation.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\n WBC up to 25.\n Action:\n Received additional 2L IVBs.\n Response:\n UO increased to ~40cc/hr. CVP 13-15. Levophed weaned to\n 0.1mcg/kg/minute.\n Plan:\n Wean Levophed as tol. Follow CVP and UO. IVBs as per team.\n"
},
{
"category": "Echo",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Report",
"row_id": 79089,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypotension. Dyspnea.\nHeight: (in) 64\nWeight (lb): 185\nBSA (m2): 1.89 m2\nBP (mm Hg): 97/50\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 09:09\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is normal\n(>=2.5L/min/m2). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification.\nMild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). The\nestimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. Trace aortic regurgitation is\nseen. The mitral valve leaflets are structurally normal. Mild (1+) mitral\nregurgitation is seen. The estimated pulmonary artery systolic pressure is\nhigh normal. There is a trivial/physiologic pericardial effusion.\n\nCompared with the prior study (images reviewed) of , the left\nventricle is less dynamic, the velocity across the aortic valve is lower (now\nnormal), and the severity of tricuspid regurgitation and pulmonary artery\nsystolic pressure are lower.\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": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703050,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\n RR up to 34-36 pt volume overloaded, remains on 1 mg Versed IV\n gtt, with prn boluses of 0.5 mg\n Action:\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\n received 10 mg IVP Lasix at 9 pm with good response. Received repeat\n 20 mg IVP Lasix at 4:30 am.\n Response:\n Pt rested overnight on AC.\n Plan:\n Change back to pressure support in am, check RSBI, ?ready for\n extubation repeat RSBI~157 would like pt negative one liter.\n Continue Versed gtt\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in Afib, rate 115-130 bp 100/60\n Action:\n Lopressor increased to 25 mg per NGT tid, also received 2.5 mg IV\n Lopressor at 4:30 am\n Response:\n HR down to 107 Afib\n Plan:\n Continue to monitor HR, bp closely. Lopressor increased to tid (25\n mg)\n GI: OG tube removed, r nare NG tube inserted, confirmed by CXRAY,\n also pulled back bile, and air heard in stomach.\n ID: Afebrile, ERCP showed\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703161,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\ns. afib\n first occurred during sbt on / trialed lopressor 12.5 mg po on\n without affect.\n Action:\n Lopressor dose was increased to 25 mg pot id without any improvement in\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\n hr. hemodynamics followed closely.\n Response:\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\n was d/c\nd. sbp retruned to her baseline once esmalol gtt was d/c\n Plan:\n Continue to follow hemodynamics . Continue to check lytes as ordered\n and replete as needed. Pt now started on lopressor 25 mg pot id and\n diltiazem 30 mg po q 6hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp failure initially thought to be due to metabolic acidosis which\n caused her to hyperventilate to compensate and fatigued becoming\n acutely sob and requiring intubation on ^th.unable to wean\n vent because of pt being fluid overloaded secondary to fluid\n resusitiation. Pt having difficulty coming off peep becoming very\n tachypenic with low tidal volumes which is more concerning for\n difficulty with compliance then volume overload. Cxr c/w lll opacity\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\n tachypenic . lungs clear with crackles noted bil at the bases.\n Suctioned for sm amts of thick white sputum.\n Action:\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\n closely.\n Response:\n Vent settings unchanged. Cxr unchanged\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Will keep on cpap mode\n of ventilation overnoc. Plan is to call anesthesia in the am to change\n #7 ett to o #8 ett over the cook catheter. Once ett is changed will\n then check rsbi and do sbt. Will do bronchoscopy after that and then\n possible extubation with the plan to reintubate if pt fails extubation.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703162,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\ns. afib\n first occurred during sbt on / trialed lopressor 12.5 mg po on\n without affect.\n Action:\n Lopressor dose was increased to 25 mg pot id without any improvement in\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\n hr. hemodynamics followed closely.\n Response:\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\n was d/c\nd. sbp retruned to her baseline once esmalol gtt was d/c\n Plan:\n Continue to follow hemodynamics . Continue to check lytes as ordered\n and replete as needed. Pt now started on lopressor 25 mg pot id and\n diltiazem 30 mg po q 6hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp failure initially thought to be due to metabolic acidosis which\n caused her to hyperventilate to compensate and fatigued becoming\n acutely sob and requiring intubation on ^th.unable to wean\n vent because of pt being fluid overloaded secondary to fluid\n resusitiation. Pt having difficulty coming off peep becoming very\n tachypenic with low tidal volumes which is more concerning for\n difficulty with compliance then volume overload. Cxr c/w lll opacity\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\n tachypenic . lungs clear with crackles noted bil at the bases.\n Suctioned for sm amts of thick white sputum.\n Action:\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\n closely.\n Response:\n Vent settings unchanged. Cxr unchanged\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal for i&o is to\n be neg 1.5 to 2 liters Will keep on cpap mode of ventilation overnoc.\n Plan is to call anesthesia in the am to change #7 ett to o #8 ett over\n the cook catheter. Once ett is changed will then check rsbi and do sbt.\n Will do bronchoscopy after that and then possible extubation with the\n plan to reintubate if pt fails extubation.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 703163,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - diurese further today to help w possibility of extubation--> Net Goal\n -1.5-2L\n - consider risk of aspiration post-extubation due to mental status\n - NG tube placed\n - patient remains tachycardic so metoprolol was increased to 25mg TID\n - need to address possib of anticoagulation w family and PCP\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\n tolerate 20mg IV)\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\n at 9:30pm to rest, so that she can be ready, better rested for SBT\n tomorrow, esp after diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 04:27 PM\n Heparin Sodium (Prophylaxis) - 04:31 AM\n Furosemide (Lasix) - 04:39 AM\n Metoprolol - 04:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 116 (100 - 125) bpm\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\n RR: 23 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 9 (9 - 272)mmHg\n Total In:\n 2,091 mL\n 206 mL\n PO:\n TF:\n 1,506 mL\n IVF:\n 524 mL\n 206 mL\n Blood products:\n Total out:\n 2,125 mL\n 1,120 mL\n Urine:\n 2,125 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -34 mL\n -915 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): 324 (255 - 463) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 25 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: ///30/\n Ve: 7.1 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 131 K/uL\n 9.1 g/dL\n 109 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 103 mEq/L\n 142 mEq/L\n 27.4 %\n 12.2 K/uL\n [image002.jpg]\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n WBC\n 20.2\n 11.3\n 10.6\n 11.2\n 12.2\n Hct\n 30.7\n 29.7\n 29.3\n 27.9\n 27.4\n Plt\n 52\n 48\n 60\n 84\n 131\n Cr\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n TCO2\n 23\n 26\n 25\n Glucose\n 91\n 128\n 119\n 126\n 143\n 117\n 109\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.6 mg/dL\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\n Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n Imaging:\n Chest X-Ray at 2330 (my read): stable effusion/opacity and\n RLL patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\n having difficulty coming off PEEP, becomes very tachypneic and has low\n tidal volumes, which is more concerning for difficulty with compliance\n and volume overload. Additionally, patient with opacity and\n diaphragm pulled up on the left that has been noted on all x-rays\n during this admission, to better see the anatomy in the , \n bronch the patient this afternoon to look at the .\n - continue with net negative goal, if UOP decreases to less than\n 100cc/hr will give another dose of lasix and readdress possible\n extubation this afternoon.\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\n the 120\ns to 130\ns, so will trial an esmolol drip\n # Septic shock: resolving, patient off pressors, likely secondary to\n cholangitis and infected stone/sludge. ERCP showed significant pusand\n very large stone, she is s/p stent placement. Patient afebrile and\n white count stable. Lactate normal. Initial sepsis secondary to biliary\n source given CBD dilation with sludge and obstructive LFTs in setting\n on known choledocholithiasis.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 48 hours.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\n will place a PICC and pull central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\n to help with further diruesis\n - Monitor UOP\n - Check PM lytes\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition: Tube feeds held o/n for possible extubation, will hold this\n afternoon for possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM, will put patient in for a PICC today\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\n respiratory failure, AF c RVR. Failed SBT this AM, diuresis ongoing.\n Exam notable for Tm 99.2 BP HR 122/80 RR 12-37 with sat 100 on PSV 5/5.\n WD woman, follows intermittent commands. Coarse BS B. Irreg s1s2. Soft\n +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+ 3.9, Cr 1.3.\n Agree with plan to manage respiratory failure ongoing IV lasix for TBB\n negative, will check and trend CVP, continue upright positioning,\n bronch c pedi scope to assess prior to trial of extubation. Will\n f/u sputum cx. Cholangitis improving, will need 14d abx, f/u\n cultures, will change CVL to PICC for long-term IV abx. For AF c RVR,\n continue PO BBL c esmolol gtt, hold off on anticoagulation. ARF has\n resolved. Continue TFs for now. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:36 PM ------\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703233,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent. Respiratory failure initially thought to be due to\n metabolic acidosis which caused her to hyperventilate to compensate.\n She fatigued quickly becoming acutely SOB and required intubation on\n ^th. Since then, unable to wean vent because of pt being\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\n coming off peep becoming very tachypneic with low tidal volumes which\n is more concerning for difficulty with compliance then volume overload.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in Afib; HR ranging from 90-130\ns. SBP 85-120\ns. Afib first\n occurred during SBT on . Occasional PVC\ns noted.\n Action:\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\n 20mEq IV given last evening per sliding scale orders.\n Response:\n Pt has remained in Afib but rate has significantly improved w/\n administration of Lopressor & Dilt. HR ranging 80\n low 100\ns w/\n minimal ectopy.\n Plan:\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\n Diltiazem. Follow electrolyte status & replete as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\n 30-40\ns but appearing comfortable & settles out on own. LS clear,\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\n 1.5\n 2L. Mental status much improved. Pt following commands and\n actively participating in care. Remains restless @ times but is easily\n redirected.\n Action:\n Suctioning q2-4 hrs for thick/white sputum. Pt appears to be pooling\n large amts of secretions in the subglottal area. (concern for\n aspiration post extubation)\n Response:\n Pt -2L @ MN.\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal - 1.5\n 2L @\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\n exchange. If all goes as planned, pt will be extubated late morning. As\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\n remains DNR)\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n Pt did have 2 smears of stool overnight. Please monitor\n closely. Skin breakdown is of concern, amt of stool was not significant\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\n not benefit from fecal inc. bag)\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703328,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on PSV 40% 8/5. Sedated on midaz\n at 1mg/hr. B/L LS clear diminished at the bases. Tachypneic to high\n 20-30\n Action:\n Lasix 20mg X1 given prior to extubation, extubated.\n Response:\n No s/s of resp distress. Patient denies any SOB when asked. Sats at\n high 90\ns on face tent.\n Plan:\n Continue to monitor patient resp status\n Atrial fibrillation (Afib)\n Assessment:\n Known AFib. HR in 90-low 100\ns. B/P 90-110\ns occasionally when asleep\n b/p down to 80\ns. Peripheral pulses present.\n Action:\n Metoprolol at 25mg TID and Dilt 30mg QID\n Response:\n HR in the 90\n Plan:\n Continue to monitor patient hemodynamic status.\n Neuro: alert, follows commands.\n GI: abd soft non tented, positive for BS. NPO. Ngt for meds\n clamped.\n 3 x smear of golden loose stools during the shift.\n GU: clear yellow urine via foley. Lasix X1 given.\n Skin: reddened buttocks. Critic aid cream applied.\n Social: patient is a DNR. OK to re-intubate if needed. Family in to\n visit. Updated by RN and MD.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 703321,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - f/u VBG 7.48/42/78 in central venous, repeat ABG 7.46/44/124\n - BNP high 5525 c/w volume overload.\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid\n - PICC placed\n - Called micro lab: will try to speciate. will call in AM to confirm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:39 AM\n Heparin Sodium (Prophylaxis) - 04:51 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 99 (86 - 128) bpm\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\n RR: 28 (18 - 41) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 6 (2 - 6)mmHg\n Total In:\n 784 mL\n 256 mL\n PO:\n TF:\n IVF:\n 784 mL\n 196 mL\n Blood products:\n Total out:\n 2,885 mL\n 495 mL\n Urine:\n 2,885 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (260 - 404) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 154\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: ///29/\n Ve: 9.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 174 K/uL\n 9.2 g/dL\n 80 mg/dL\n 1.4 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 101 mEq/L\n 140 mEq/L\n 27.9 %\n 11.3 K/uL\n [image002.jpg]\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n Plt\n 48\n 60\n 84\n 131\n 174\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n TCO2\n 26\n 25\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n Other labs:\n Ca: 8.6, Mg: 2.2, Phos: 3.1\n Mircrobiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n ANAEROBIC GRAM NEGATIVE ROD(S).\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\n Radiology:\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\n vena cava. The patient remains intubated, with the endotracheal tube\n terminating 3.2 cm above the carina. The right internal jugular line\n ends in the mid superior vena cava. Left pleural effusion with\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\n consistent with pulmonary arterial hypertension. The right lung is\n clear. There is no pulmonary edema.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\n improved in terms of pulmonary vascular congestion, will trial\n extubation today since patient looks the best she has since admission\n - patient may need Bipap post extubation\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n .\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 90\ns with both medications\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month\n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition: Tube feeds on hold for possible extubation\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition:ICU\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\n respiratory failure, AF c RVR improved with BBL / CCB. Diuresis\n ongoing, BNP 6K.\n Exam notable for Tm 99.8 BP 116/62 HR 95-105AF RR 12-37 with sat 100 on\n PSV 8/5, -2L / 24h. WD woman, follows intermittent commands. Coarse BS\n B. Irreg s1s2. Soft +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+\n 4.1, Cr 1.4. CXR c ?LLL collapse.\n Agree with plan to manage respiratory failure ongoing IV lasix for TBB\n negative (20mg x1 now), will continue upright positioning, SBT and plan\n for trial of extubation. Cholangitis improving, will need 14d abx, f/u\n cultures, will change CVL to PICC for long-term IV abx. Over the long\n term, will need f/u ERCP for large nonobstructive stone. For AF c RVR,\n continue BBL/CCB, hold off on anticoagulation. ARF has resolved;\n baseline CRI. Hold TFs for extubation. Remainder of plan as outlined\n above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:44 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702096,
"text": "Demographics\n Day of mechanical ventilation: 1\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Known difficult intubation: No\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Placed on CMV for ERCP. Had been on 12 PSV in am.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Wean to PSV as soon as tolerated. Pt to ? extubate in\n am.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702352,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt was in NSR without ectopi at about 1030 patient had new onset Atrial\n Fibrillation. Patient was on spontaneous breathing trial did not appear\n to be in res p distress O2 SAT > 95. Patient remained on Levophed at\n 0.07mcg/kg/min with out changed in SBP. Patient Hr 110-120 and\n tolerated. Since 1500 HR up to 130-140 at times.. discussed with ICU\n team .\n Action:\n Patient placed back on ventilator. EKG done and read. Additional fluid\n was given and attempted to wean Levophed without success, labs sent.\n Changed Levophed for Phenylephrine. Levophed off phenylephrine @\n 1.5mcg/kg/.\n Response:\n Pt has remained in A Fibrillation. Hr 110-140. Unable to wean Levophed.\n At present Hr in high 120 to 130\ns slightly lower than on Levophed.\n Plan:\n Continue to monitor patient. Monitor the HR and sbp to evaluate if\n phenylephrine drip is tolerated better shown by decrease in hr.\n Continue to treat sepsis and monitor labs,\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702085,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\n Action:\n Placed on A/C for ERCP.\n Response:\n Remains on AC as she received paralytic for ERCP and remains very\n sedated.\n Plan:\n Return PSV when spontaneous breathing returns. Turn off sedation in\n a.m. and do SBT for possible extubation. Monitor O2sats.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\n WBC up to 25 from 4.8. Remains in metabolic acidosis. R/O\nd for\n influenza.\n Action:\n Received additional 2L IVBs.\n Response:\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\n 0.1mcg/kg/minute.\n Plan:\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\n requires more fluids for low CVP. Monitor sodium in light of multiple\n liters of NS. Consider LR.\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702162,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n 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 / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions; Comments: Pt remains stable on vent,\n with full ventilatory support. Pt has clear lung sounds, with minimal\n secretions. Pt showed strong RSBI trial of 54, showing good\n spontaneous respiratory effort. Pt to be tried on CPAP/PSV trial, and\n to be assessed by MD team for plan of care.\n BEDSIDE RSBI- 54\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702558,
"text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n 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 Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702083,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\n Action:\n Placed on A/C for ERCP.\n Response:\n Remains on AC as she received paralytic for ERCP and remains very\n sedated.\n Plan:\n Return PSV when spontaneous breathing returns. Turn off sedation in\n a.m. and do SBT for possible extubation. Monitor O2sats.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\n WBC up to 25 from 4.8. Remains in metabolic acidosis. R/O\nd for\n influenza.\n Action:\n Received additional 2L IVBs.\n Response:\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\n 0.1mcg/kg/minute.\n Plan:\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\n requires more fluids for low CVP. Monitor sodium in light of multiple\n liters of NS. Consider LR.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702291,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n SBT tried this AM and patient went into afib with RVR. Changed to AC\n for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR (OK to intubate)\n Disposition: ICU for now\n ------ Protected Section ------\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 85F a w/ renal ca, dementia,\n choledocolithiasis in w/ sepsis/shock from cholangitis s/p ERCP\n with stent placement yesterday. Required intermittent neo boluses\n peri-proceudre. Remains on levophed though titrating down. During SBT\n this am developed a-fib, asx with rates 100-115. Now back on ACV.\n PE: Tm 97.8 MAP 62-103 HR 60-80\n100-115 RR 19 Sat 97% on PS 10/5\n 40% rsbi 54\n Intubated, awake, NAD, follows commands, mildly jaundiced, perrla, CTA,\n RR, soft + BS, NT, no edema\n LABS: wbc 17, 4% bands, hct 31, plt 48, na 137, cr 2.1 (2.6),\n lactate 1.4 t bili, ast/alt decreasing, inr 1.1, fibrinogen 500,dd >\n \n ECG reviewed-->new a-fib\n TEE ef > 65%, 1+ MR\n Micro: bl gpr 1, others ngtd\n A/P: Sepsis from cholangitis c/b arf, resp failure and\n thrombocytopenia. Now with new a-fib.\n While a-fib temporally related to SBT, suspect component of increased\n myocardial excitability pressors as well as underlying sepsis\n contributing. She has no underlying lung process as cause of her\n intubation, which seemed mainly related to inability to compensate for\n metabolic acidosis. She has had lots of fluids, though and increased\n WOB during SBT could have contributed. Her TTE yesterday showed good\n bivent fx.\n Agree with plan to repeat CXR and abg, transition back to PSV. Her HR\n is not rapid and BP has not changed. Will check 12 lead and assess for\n ischemia. Continue IVF boluses for cvp and u/o and wean pressor,\n maintaining MAPS > 65. If develops RVR, consider changing pressor to\n neo and adding rate control. Monitor resp and hemodynamic status\n closely and consider repeat SBT later in afternoon. We continue to\n treat biliary sepsis with anitbx. Continue zosyn and can d/c vanco,\n following cx data. Infection parameters are improving with decreasing\n wbc and temp curve. Her cr is down slightly from admit but not at\n baseline. ARF is likely pre-renal + atn from sepsis/hypotension. U/o\n holding with boluses. She continues to have worsening thrombocytopenia.\n No recent heparin exposure to suggest HIT occurring so quiclky.\n Suspect this is infection response or medications. Will hold\n heparin products and monitor, following DIC labs, and keeping t and c.\n ICU prophy. A-line and CVL. DNR\n Remainder of plan as outlined in resident note.\n Patient is critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 02:11 PM ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702621,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 54.4\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\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 / Scant\n Ventilation Assessment\n Level of breathing assistance: PSV 12/5/,4\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: weaning PSV as tol\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: ABG drawn: mild resp alkalosis with good\n oxygenation; RSBI 157\n Comments: Will wean as tol.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702265,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n SBT tried this AM and patient went into afib with RVR. Changed to AC\n for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR (OK to intubate)\n Disposition: ICU for now\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702349,
"text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / None\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan is to wean to SBT before rounds in \n"
},
{
"category": "Physician ",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702269,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n SBT tried this AM and patient went into afib with RVR. Changed to AC\n for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR (OK to intubate)\n Disposition: ICU for now\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702270,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n SBT tried this AM and patient went into afib with RVR. Changed to AC\n for now.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR (OK to intubate)\n Disposition: ICU for now\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702404,
"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: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n 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: 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: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning, Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Cannot manage secretions;\n Comments: Pt remain on vent, with PSV settings. Pt was tried on RSBI\n trial but became tachypneic with an RR of over 35 bpm. Pt had clear\n lung sounds but with some blood tinge secretions being suctioned. Pt\n remains stable with good expiratory tidal volumes and ABG findings. Pt\n to continue current support and to be assessed by MD team for possible\n extubation.\n"
},
{
"category": "Nutrition",
"chartdate": "2169-11-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 702943,
"text": "Subjective\n Patient intubated\n Objective\n Pertinent medications: 2pkt Neutrophos,others noted\n Labs:\n Value\n Date\n Glucose\n 143 mg/dL\n 04:15 AM\n Glucose Finger Stick\n 149\n 06:00 PM\n BUN\n 24 mg/dL\n 04:15 AM\n Creatinine\n 1.3 mg/dL\n 04:15 AM\n Sodium\n 140 mEq/L\n 04:15 AM\n Potassium\n 3.9 mEq/L\n 04:15 AM\n Chloride\n 104 mEq/L\n 04:15 AM\n TCO2\n 30 mEq/L\n 04:15 AM\n Calcium non-ionized\n 8.0 mg/dL\n 04:54 AM\n Phosphorus\n 2.2 mg/dL\n 04:54 AM\n Magnesium\n 1.6 mg/dL\n 04:15 AM\n Current diet order / nutrition support: Fibersource HN at 50ml/hr x 24\n hours - provides 1440kcal and 64g protein\n GI: Abdomen soft with positive bowel sounds, +large stool\n Assessment of Nutritional Status\n Specifics:\n 85 year old female with history of choledocholithiasis, renal CA, and\n dementia who presents with dyspnea and vomiting complicated by acute\n respiratory failure and septic shock likely secondary to biliary\n source. She is now s/p ERCP and stent. Patient unable to be extubated\n over weekend so tube feedings have been restarted and are running at\n goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue with Fibersource HN at goal rate of 50ml/hr x 24\n hours\n Monitor residuals q4H and hold tube feeding if greater than\n 200ml\n Will follow for possible extubation\n 11:22 AM\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702547,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Atrial fibrillation (Afib)\n Assessment:\n Hr 100-130\ns afib with sbp ranging from 100-120\ns. k+3.4 and phos=1.7.\n afib first occurred during sbt on . pressors were then changed to\n neo in attempt to drop pt\ns hr but was unsuccessful. Pt was started on\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\n bp support\n Action:\n Pt repleted with 30mmol of kphos. Hemodynamics montitored closely.\n Amioderone gtt decreased to 0.5mg/min after 6 hrs of infusion at\n 1mg/min. neo being weaned to off as pt\ns hemodynamics tolerate\n Response:\n Hr remains in afib tachy from 100-130\ns but hemodynamically stable\n Plan:\n Plan is to continue infusion of amioderon for 18 hrs and then will\n consider d/c\ning gtt. Continue to follow hemodynamics and wean as\n tolerated to keep map> 60 and hourly uo > 30cc\ns/hr. check lytes as\n ordered and replete as needed\n Sepsis without organ dysfunction\n Assessment:\n Pt s/p ercp on . low grade temps but wbc up to 20.2 from yesterday\n count of 16.blood cultures from grew gm pos rods and gm neg rods.\n Septic shock most likely secondary to cholangitis and infected\n stone/sludge.with increase in wbc concern is for a new infection.\n Action:\n Fever curve followed closely. Pt receiving piperacillin as ordered.\n Awaiting final speciation of all culture data. Pan cultured today\n Response:\n Low grade temps and elevated wbc unchanged.\n Plan:\n Await results for all culture data. Administer antibiotics as ordered\n and follow fever curve.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt most likely became fatigued in the setting of metabolic acidosis\n and attempt to hyperventilate to compensate requiring her to be\n intubated. Placed pt on 40% cpap with 5 peep and ps of 5 . lungs\n essentially clear on auscultation. Suctioned for sm amts of thick tan\n sputum.cxr c/w fluid overload which is likely contributing to the\n difficulty in weaning her off the vent.once pt is weaned off pressors\n will then need diuresis and hopefully pt will start to mobilize fluid.\n Action:\n Vent weaned to 40%cpap with 5 peep and ps of 5. resp status monitored\n closely. Antibiotics administered as ordered. Reps toileting continues.\n Decision made not to extubate pt since she became tachypneic ,had lower\n tv\ns and appeared more uncomfortable. Versed gtt increased back up to\n 2mg/hr. vent changed back to ac mode of ventilation. Sputum for c&s\n sent off to microbiology. Ogt placed in order to start tube fdgs until\n pt is extubated.\n Response:\n Resting comfortably on ac mode after not tolerating decrease in vent\n settings.\n Plan:\n Check rsbi in the am and do sbt. Wean pressors to off if possible and\n then will diurese as needed . d/c tube fdgs at midnoc in the hope of\n extubating pt in the am. Continue to monitor pt\ns resp status and\n continue with resp toileting\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702944,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - will attempt to decrease sedation this evening and do an SBT, if she\n looks good will hold tube feeds, otherwise will continue feeds\n overnight\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\n then urine output was over 1L to the lasix\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\n MV and O2sats but RR in the 40's with small TV's. After about 15min\n became uncomfortable with increased WOB-->improved from prior, has more\n stamina, diuresis seems to be improving her respiratory status\n - per discussion with patient's family she can be reintubated if she\n fails extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:55 AM\n Furosemide (Lasix) - 06:14 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 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: 37.2\nC (99\n HR: 112 (106 - 129) bpm\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\n RR: 12 (12 - 37) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 733 mL\n 452 mL\n PO:\n TF:\n 202 mL\n 264 mL\n IVF:\n 531 mL\n 188 mL\n Blood products:\n Total out:\n 3,345 mL\n 765 mL\n Urine:\n 3,345 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,612 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 296 (241 - 304) mL\n PS : 12 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 166\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 8.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 84 K/uL\n 9.2 g/dL\n 143 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n WBC\n 15.3\n 20.2\n 11.3\n 10.6\n 11.2\n Hct\n 31.4\n 30.7\n 29.7\n 29.3\n 27.9\n Plt\n 59\n 46\n 52\n 48\n 60\n 84\n Cr\n 1.8\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 26\n 25\n Glucose\n 102\n 91\n 128\n 119\n 126\n 143\n Other labs:\n Mg: 1.6\n Alk Phos: 103, T. bili: 1.5\n PT: 12, INR: 1, PTT: 23.7\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n Imaging:\n Chest X-Ray (my read): slightly worsening left effusion and right\n basilar patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR.\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\n about 800 cc\ns in the evening so she was given 20mg IV lasix with a\n brisk urine output response. Will give another dose of lasix since she\n had her best SBT with the increased diuresis, hold tube feeds for now\n in case she is able to be extubated this afternoon. She will likely\n never have an excellent RSBI, but she will need to not tire and\n maintain her sats during her SBT.\n - Hold sedation for now to optimize mental status prior to extubation\n - need to place a dobhoff prior to extubation as she may be an\n aspiration risk\n - CXR looks stable to slightly worsened this morning\n - family okay with re-intubation if patient fails extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Increase metoprolol to 25mg and titrate up to good HR control as\n her BP tolerates\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count stable. Lactate\n normal. Initial sepsis secondary to biliary source given CBD dilation\n with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 24 hours.\n - Cont zosyn pending any further culture data; Day of zosyn.\n Day 1=. Will f/u cutlure data to see if we can narrow our\n coverage, if she needs to be continued on Zosyn will place a PICC and\n pull central line, may be able to transitioned to a po antibiotic\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n - f/u sputum culture\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to her baseline at 1.3 today.\n - Monitor UOP\n - Trend creatinine while diuresing\n - Check PM lytes\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Platelet count stable and increasing\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Heparin SQ, pneumo boots\n Stress ulcer: none while on feeds\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, is intubated, ok to be reintubated post extubation if\n necessary\n Disposition: ICU pending stabilization post extubation\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703001,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Afib 85-130, hr appears responsive to 25mg lopressor. b/p 90s-110/60s.\n Action:\n Lopressor for rate control, 10mg IV Lasix\n Response:\n Better rate control after Lopressor dose, gentler response to 10mg\n Lasix today than yesterday, no hypotension associated w/diuresis.\n Plan:\n Cont to monitor HR and response to meds.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, PSV 12/5, on 0/8 with increase in RR to 30s. LS:\n crackles t/o. Scant secretions via ETT.\n Action:\n Tube feeds off in anticipation of possible extubation. Sedation off 3\n hours w/improvement in mental status, able to nod, laugh and respond to\n family, currently on 1mg versed and receiving 25mcg bolus of fent PRN\n pain.\n Response:\n Not yet ready for extubation\n Plan:\n Tube feeds off at MN as ordered. Daily wake up to aid w/extubation.\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702708,
"text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Tube Type\n ETT:\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 Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: PSV level increased this morning; weaned to 10cm at approx.\n 1600; please see flowsheet for details.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702713,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on PS 10/5 RR 30\ns , grimacing, visibly uncomfortable\n Action:\n Bolused w/ midaz, put back to PS 12/5\n Response:\n Pt tolerated mech vent support, RR 20\ns TV 300\ns w/ MV \n Plan:\n Will not extubate today will re assess for am extuabtion\n Sepsis without organ dysfunction\n Assessment:\n Off pressors for 24 hrs, ~ 50cc hr, maintaining maps > 60, afebrile\n Action:\n Assessed hemodynamics , following VS\n Response:\n Pt remains off of pressors\n Plan:\n Cont Ab therapy , monitor hemodynamics\n Atrial fibrillation (Afib)\n Assessment:\n Continues in a-fib hr 1teens-130\n Action:\n Amiodorone gtt cont @ .5mg /min\n Response:\n ongoing\n Plan:\n Continue to monitor hr, may wean to po amiodorone\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702865,
"text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\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: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt continues on PSV as charted.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702919,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - will attempt to decrease sedation this evening and do an SBT, if she\n looks good will hold tube feeds, otherwise will continue feeds\n overnight\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\n then urine output was over 1L to the lasix\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\n MV and O2sats but RR in the 40's with small TV's. After about 15min\n became uncomfortable with increased WOB-->improved from prior, has more\n stamina, diuresis seems to be improving her respiratory status\n - per discussion with patient's family she can be reintubated if she\n fails extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:55 AM\n Furosemide (Lasix) - 06:14 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 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: 37.2\nC (99\n HR: 112 (106 - 129) bpm\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\n RR: 12 (12 - 37) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 733 mL\n 452 mL\n PO:\n TF:\n 202 mL\n 264 mL\n IVF:\n 531 mL\n 188 mL\n Blood products:\n Total out:\n 3,345 mL\n 765 mL\n Urine:\n 3,345 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,612 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 296 (241 - 304) mL\n PS : 12 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 166\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 8.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 84 K/uL\n 9.2 g/dL\n 143 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n WBC\n 15.3\n 20.2\n 11.3\n 10.6\n 11.2\n Hct\n 31.4\n 30.7\n 29.7\n 29.3\n 27.9\n Plt\n 59\n 46\n 52\n 48\n 60\n 84\n Cr\n 1.8\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 26\n 25\n Glucose\n 102\n 91\n 128\n 119\n 126\n 143\n Other labs:\n Mg: 1.6\n Alk Phos: 103, T. bili: 1.5\n PT: 12, INR: 1, PTT: 23.7\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n Imaging:\n Chest X-Ray (my read): slightly worsening left effusion and right\n basilar patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR.\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\n about 800 cc\ns in the evening so she was given 20mg IV lasix with a\n brisk urine output response\n - Wean down vent settings as much as possible, but having difficulty\n due to volume overload\n - CXR looks stable to slightly worsened this morning\n - family okay with re-intubation if patient fails extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Increase metoprolol to 25mg and titrate up to good HR control as\n her BP tolerates\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count stable. Lactate\n normal. Initial sepsis secondary to biliary source given CBD dilation\n with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for 24 hours, this morning with low grade temps.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: . Will f/u cutlure data to see if we can narrow our coverage,\n if she needs to be continued on Zosyn will place a PICC and pull\n central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n - will send sputum cx with new low grade temps, and slightly worsening\n chest x-ray\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to her baseline at 1.3 today.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Will restart SQ heparin as her platelet count has increased and the\n initial drop was not consistent with HIT\n - No signs of active bleeding\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Heparin SQ, pneumo boots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, is intubated\n Disposition: ICU\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 703058,
"text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Increase ventilatory support at night\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Pt initially tachypneic with rr>32. Placed on psv overnight to rest in\n preparation for possible extubation today. Mod amts of thick white\n sput. Weak cough and gag.\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702767,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 54.4\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: PSV 12/5/.4\n Visual assessment of breathing pattern: Occ tachypneic (RR> 35 b/min),\n baseline rr 30\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments: Maintaining Vt 3-400 ml with Ve 8-9 L, sp02 99-100%\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: RSBI 204; heated wire system added for humidity\n Comments: Slow PSV wean as tol.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703241,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent. Respiratory failure initially thought to be due to\n metabolic acidosis which caused her to hyperventilate to compensate.\n She fatigued quickly becoming acutely SOB and required intubation on\n ^th. Since then, unable to wean vent because of pt being\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\n coming off peep becoming very tachypneic with low tidal volumes which\n is more concerning for difficulty with compliance then volume overload.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in Afib; HR ranging from 90-130\ns. SBP 85-120\ns. Afib first\n occurred during SBT on . Occasional PVC\ns noted.\n Action:\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\n 20mEq IV given last evening per sliding scale orders.\n Response:\n Pt has remained in Afib but rate has significantly improved w/\n administration of Lopressor & Dilt. HR ranging 80\n low 100\ns w/\n minimal ectopy. Magnesium & K levels WNL this AM.\n Plan:\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\n Diltiazem. Follow electrolyte status & replete as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\n 30-40\ns but appearing comfortable & settles out on own. LS clear,\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\n 1.5\n 2L. Mental status much improved. Pt following commands and\n actively participating in care. Remains restless @ times but is easily\n redirected.\n Action:\n Suctioning q2-4 hrs for thick/white sputum. Pt appears to be pooling\n large amts of secretions in the subglottal area. (concern for\n aspiration post extubation)\n Response:\n Pt -2L @ MN. AM RSBI 154 (will complete SBT once ETT is exchanged & pt\n is bronched per Dr. \n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal - 1.5\n 2L @\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\n exchange. If all goes as planned, pt will be extubated late morning. As\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\n remains DNR)\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n Pt did have 2 smears of stool overnight. Please monitor\n closely. Skin breakdown is of concern, amt of stool was not significant\n enough for a Flexiseal. Buttocks reddened w/ erythema (would probably\n not benefit from fecal inc. bag)\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703052,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\n RR up to 34-36 pt volume overloaded, remains on 1 mg Versed IV\n gtt, with prn boluses of 0.5 mg suctioned for sm amts of thick white\n sputum. CXR volume overload ~ needs to be diuresed. CVP~12\n Action:\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\n received 10 mg IVP Lasix at 9 pm with good response. Received repeat\n 20 mg IVP Lasix at 4:30 am.\n Response:\n Pt rested overnight on AC. Pt continues to diurese\n Plan:\n Change back to pressure support in am, check RSBI, ?ready for\n extubation repeat RSBI~157 would like pt negative one liter.\n Continue Versed gtt continue with pulmonary toilet.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in Afib, rate 115-130 bp 100/60\n Action:\n Lopressor increased to 25 mg per NGT tid, also received 2.5 mg IV\n Lopressor at 4:30 am\n Response:\n HR down to 107 Afib\n Plan:\n Continue to monitor HR, bp closely. Lopressor increased to tid (25\n mg)\n GI: OG tube removed, r nare NG tube inserted, confirmed by CXRAY,\n also pulled back bile, and air heard in stomach. Passing loose stool.\n tube feedings off at 12 midnight (will try again today to extubate)\n ID: Afebrile, ERCP on showed significant pus and very large\n stone, pt is s/p stent placement. Pt remains on Zosyn\n NEURO: remains on 1 mg/hr IV Versed gtt opens eyes to command, pt\n agitated at times, moving around in bed, hands restrained for safety,\n pt putting hands on ETT.\n SOCIAL: pt is DNR, if gets extubated would be reintubated. Husband\n and 2 daughters in last evening.\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 703245,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: suctioned frequently\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Cannot manage\n secretions, Underlying illness not resolved\n Comments: Pt. remains intubated on IPS overnoc. Suctioned frequently\n for large amounts thick white sputum. Plan to change ET tube this am to\n a larger ET , bronchoscopy prior to extubation. RSBI 154 this am. RR\n 30\ns at baseline.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702849,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib at a rate of 100-130s, BP has been stable\n Action:\n Her amnio was d/ced and lopressor was started\n Response:\n Tolerated the lopressor\n it seemed to lower her HR from the 120s to\n the 100s\n Plan:\n Titrate up the lopressor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains vented, lots of oral and ETT secretions, tachypnic to the 40s\n with VTs in the 300s\n Action:\n Unable to extubate today, to receive lasix this afternoon, restarted TF\n Response:\n Not yet ready for extubation\n Plan:\n Follow I&Os, lytes, cont to try to wean, cont pulm toilet\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702189,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\n versed 3mg/hr.\n Action:\n Suctioned for small amount secretions. Blood gas in the am. Versed\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\n Response:\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/ .am\n RSBI 54 and tolerated well.\n Plan:\n Wean vent / sedations as tolerated further and for possible\n extubation today.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\nS on\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\n /BUN 37,elevated liver enzymes.\n Action:\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\n with NaHCo3 150 meq given for hydration and for PH 7.29 from the\n evening lab\n Response:\n SBP 85-90\ns when tried to titrate Levophed further .so continued on\n 0.07mics. urine output improved with fluid bolus.\n Plan:\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702188,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\n versed 3mg/hr.\n Action:\n Suctioned for small amount secretions. Blood gas in the am. Versed\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\n Response:\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/\n Plan:\n Wean vent / sedations as tolerated further.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\nS on\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\n /BUN 37,elevated liver enzymes.\n Action:\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\n with NaHCo3 150 meq given for hydration and for PH 7.1 from the\n evening lab\n Response:\n SBP 85-90\ns when tried to titrate Levophed further .so continued on\n 0.07mics. urine output improved with fluid bolus.\n Plan:\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702466,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early this morning\npatient very tahcypneic, unable to be\n extubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n URINE CULTURE (Final ): NO GROWTH.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - early this morning\npatient very tachypneic with lower tidal\n volumes, appeared very uncomfortable during short trial this morning,\n will transition back to A/C and then wean to PSV throughout the day\n -Chest x-ray appeared volume overloaded, which is likely contributing\n to the difficulty weaning her off the ventilator, when patient is able\n to be weaned off pressors will need diuresis. Hopefully patient will\n start to mobilize her extra fluid, however once off pressors if she is\n unable to, will give lasix as needed to help decrease the fluid in her\n lungs\n - Hopeful extubation tomorrow pending ability to diurese\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - With increasing leukocytosis concern for a new infection, will\n reculture blood, urine and sputum, also send a C.diff when patient has\n a bowel movement, if LFT\ns increase, will reimage RUQ due to concern\n for possible blockage of stent\n - Cont zosyn pending any further culture data; f/u speciation and\n sensitivities from prior blood cx\n - Trend CBC/diff, LFTs, especially in the setting on increasing\n leukocytosis, will add on Diff to AM labs\n - Follow up blood cx speciation , urine cx with no growth\n - Wean neo as tolerated by MAP >= 60 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\n baseline creatinine 1.2-1.4.\n - Titrate MAP to greater than 60, unless urine output decreases then\n will titrate to increased MAP\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 26 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: Will place OG tube for tube feeds today and turn them off at\n midnight for hopeful extubation tomorrow\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702596,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated , cpap/ps see metavision for vent settings, continues\n lightly sedated with versed 2mg.\n Action:\n Vent settings cpap/ps 10/5 fio2 40%\n Response:\n Am blood gas 7.46/34/27\n Plan:\n possible extubation today. tube feeds off since midnight\n Sepsis without organ dysfunction\n Assessment:\n s/p ERCP, was on pressors after procedure\n Action:\n Neo has been weaned\n Response:\n Maps greater than 60 , following NBP\nS, -a-line that was reinserted\n yesterday had fallen out\n Plan:\n Follow vs\n Atrial fibrillation (Afib)\n Assessment:\n Continues in a-fib hr 120-130\n Action:\n Amiodorone gtt is being cont. passed the 18hours\n Response:\n ongoing\n Plan:\n Continue to monitor hr, may wean to po amiodorone\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 702691,
"text": "TITLE:\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\n presents with septic shock and cholangitis, s/p ERCP with stent, and\n respiratory failure. Now with persistent vent requirements.\n 24 Hour Events:\n Arterial line came out.\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 PM\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unable to obtain, patient sedated and intubated.\n Flowsheet Data as of 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.2\nC (97.2\n HR: 128 (114 - 141) bpm\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\n RR: 23 (14 - 30) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 1,682 mL\n 311 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 310 mL\n Blood products:\n Total out:\n 2,045 mL\n 920 mL\n Urine:\n 2,045 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -609 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): 380 (308 - 528) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 16 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.9 L/min\n PaO2 / FiO2: 318\n Physical Examination\n Gen\nl: intubated, sedated\n HEENT: ETT in place, pupils constricted by equal and reactive\n Pulm: diminished, transmitted vent sounds, no wheezing, crackles at\n bases anteriorly\n CV: irregularly irregular, tachycardic, distant and no murmur\n appreciated, no gallop or rubs\n Abdomen: soft, no grimace to palpation, (+) bowel sounds\n Extremities: no edema\n Neurologic: responds to tactile stimuli, non-purposeful movement\n Labs / Radiology\n 9.8 g/dL\n 48 K/uL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory failure\n - now likely secondary to volume overload\n - goal TBB - 1 to -1.5L today and will give prn lasix\n - wean pressure support as tolerated, check CXR\n Septic shock\n - now off pressors, autodiuresing\n - on zosyn, day , leukocytosis improving\n - LFTs improving s/p stenting via ERCP\n - awaiting speciation/sensitivities from cultures\nAtrial fibrillation\n - on amiodarone drip, will continue for now\n - will calculate total dose today\n Thrombocytopenia\n - stable, no signs of active bleeding\n - very low suspicion for HIT\n - will restart SC heparin when plts >50K\n ICU Care\n Nutrition:\n Comments: restart TF as unlikely to be extubated today\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702692,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - amio gtt started in early AM yesterday--> slow progress\n - Neo stopped at 0000\n - OG + tube feeds today, NPO at midnight with hopes for extubation\n - increasing WBC, send sputum for cx, blood and urine cx;\n - if she starts to spike again, then add back Vancomycin\n - Gm+ and Gm- rods in blood in anaerobic bottle\n - Was on AC for most of day after SBT; switched to PS 12/5-- ABG:\n 7.46/34/127 (at 3:15am) RSBI: couldn\nt tolerate b/c tachypnea:\n UOP 50-180 cc/hour\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 141 (111 - 141) bpm\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\n RR: 25 (14 - 36) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 8 (8 - 8)mmHg\n Total In:\n 1,682 mL\n 197 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 196 mL\n Blood products:\n Total out:\n 2,045 mL\n 520 mL\n Urine:\n 2,045 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -322 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): 482 (308 - 528) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 17 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.1 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 9.8 g/dL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\n Unable to wean effectively; likely secondary to fluid resuscitation; as\n fluid overload is seen on CXR.\n - Monitor UOP as patient is auto-diuresing well. Check i/o\ns this\n evening with TBB 1-1.5 liters\n - Wean down vent settings as much as possible, will likely be more\n effective once\n - CXR today to make sure no other acute process is occuring\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Continue amio gtt as HR has improved, but she is still tachycardic in\n the low 100\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\n be improving.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: .\n - f/u speciation and sensitivities from prior blood cx\n - Trend CBC/diff, LFTs,\n - Follow up blood cx speciation , urine cx with no growth\n - no need for pressors now. Monitor maps > 65.\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\n of HIT as timing does not correlate since patient has not had a prior\n heparin exposure. Vancomycin may also be contributing to her\n thrombocytopenia\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 24 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: OG tube feeds\n Glycemic Control:\n Lines: ( no A-line for now: A line measurement were SBP \n points higher than cuff pressure)\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702693,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - amio gtt started in early AM yesterday--> slow progress\n - Neo stopped at 0000\n - OG + tube feeds today, NPO at midnight with hopes for extubation\n - increasing WBC, send sputum for cx, blood and urine cx;\n - if she starts to spike again, then add back Vancomycin\n - Gm+ and Gm- rods in blood in anaerobic bottle\n - Was on AC for most of day after SBT; switched to PS 12/5-- ABG:\n 7.46/34/127 (at 3:15am) RSBI: couldn\nt tolerate b/c tachypnea:\n UOP 50-180 cc/hour\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 141 (111 - 141) bpm\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\n RR: 25 (14 - 36) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 8 (8 - 8)mmHg\n Total In:\n 1,682 mL\n 197 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 196 mL\n Blood products:\n Total out:\n 2,045 mL\n 520 mL\n Urine:\n 2,045 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -322 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): 482 (308 - 528) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 17 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.1 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 9.8 g/dL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\n Unable to wean effectively; likely secondary to fluid resuscitation; as\n fluid overload is seen on CXR.\n - Monitor UOP as patient is auto-diuresing well. Check i/o\ns this\n evening with TBB 1-1.5 liters\n - Wean down vent settings as much as possible, will likely be more\n effective once\n - CXR today to make sure no other acute process is occuring\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Continue amio gtt as HR has improved, but she is still tachycardic in\n the low 100\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\n be improving.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: .\n - f/u speciation and sensitivities from prior blood cx\n - Trend CBC/diff, LFTs,\n - Follow up blood cx speciation , urine cx with no growth\n - no need for pressors now. Monitor maps > 65.\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\n of HIT as timing does not correlate since patient has not had a prior\n heparin exposure. Vancomycin may also be contributing to her\n thrombocytopenia\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 24 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: OG tube feeds\n Glycemic Control:\n Lines: ( no A-line for now: A line measurement were SBP \n points higher than cuff pressure)\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n ------ Protected Section ------\n Patient may need a PICC line tomorrow if sensitivities of cultures do\n not return. She may need a full 10 day course of zosyn.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:38 ------\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702762,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on PS 12/5 40%, rr 30\n Action:\n Sedation off at 2am for ? extubate this am , tube feeds off also\n Response:\n RSBI 204 this am\n Plan:\n Sedation turned back on at 520 due to pt\ns increased rr rate, plan to\n extubate should be reassed at rounds, if no extubation today tube feeds\n need to be restarted\n Sepsis without organ dysfunction\n Assessment:\n Off pressors for 24 hrs, ~ 50cc hr, maintaining maps > 60, afebrile\n Action:\n Assessed hemodynamics , following VS\n Response:\n Pt remains off of pressors\n Plan:\n Cont Ab therapy , monitor hemodynamics\n Atrial fibrillation (Afib)\n Assessment:\n Continues in a-fib hr 1teens-130\n Action:\n Amiodorone gtt cont @ .5mg /min\n Response:\n ongoing\n Plan:\n Continue to monitor hr, may wean to po amiodorone\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702316,
"text": "Sepsis without organ dysfunction\n Assessment:\n T max 99.2 oral. Remains on Levophed to maintain sbp > 90. Patient\n alert follows command denies abd pain c/o of mouth pain from ET.RIJ 3\n lumen patent CVP 6-13pt in A Fib. Low PLT\n Action:\n Attempted to wean Levophed without success. Fluid given a total of 2.5\n liters. Blood culture from aline and RIJ sent. Labs sent. Antibiotics\n as ordered. Heparin and vancomycin stopped\n Response:\n CVP up to from 6. Urine changed from amber to yellow. Initially\n able to wean Levophed but then sbp dropped x2 levophed at .07mcg. A\n Fib continues PLT still low.\n Plan:\n Monitor plt, gap and lytes treat as indicated. Monitor urine output.\n Monitor HR and rhythm.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient does not appear in any distress tolerating ET tube though asked\n for it to be removed calm and cooperative. Oxygen saturation\n consistently over 95. RR 20-40. Lungs clear. Sputum clear and thick. No\n fever. Large amt of oral secretions. AT about 1030 Attempted to wean in\n am patient tolerated CPAP and PS on spontaneous breathing trial patient\n did not appear distress o2 SAT >95 but rhythm changed to AFIB\n Action:\n Pt placed back on vent after rhythm changed several hours later placed\n back on CPAP with PS, oral suction frequently. BS checked. Mouth care\n given turned q3-4 hours\n Response:\n Patient tolerating CPAP with PS oxygenation is > 95 patient appears\n comfortable\n Plan:\n Monitor resp. status. wean if able tomorrow. ABG\ns as indicated.\n Monitor continuous O2 saturation. Suction as needed. Check results of\n cultures. Continue antibiotics.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 702677,
"text": "TITLE:\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\n presents with septic shock and cholangitis, s/p ERCP with stent, and\n respiratory failure. Now with persistent vent requirements.\n 24 Hour Events:\n Arterial line\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 PM\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.2\nC (97.2\n HR: 128 (114 - 141) bpm\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\n RR: 23 (14 - 30) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 1,682 mL\n 311 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 310 mL\n Blood products:\n Total out:\n 2,045 mL\n 920 mL\n Urine:\n 2,045 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -609 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): 380 (308 - 528) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 16 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.9 L/min\n PaO2 / FiO2: 318\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.8 g/dL\n 48 K/uL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory failure\n - now likely secondary to volume overload\n - goal TBB - 1 to -1.5L today and will give prn lasix\n - wean pressure support as tolerated, check CXR\n Septic shock\n - now off pressors, autodiuresing\n - on zosyn, day , leukocytosis improving\n - LFTs improving s/p stenting via ERCP\n - awaiting speciation/sensitivities from cultures\nAtrial fibrillation\n - on amiodarone drip, will continue for now\n Thrombocytopenia\n - stable, no signs of active bleeding\n - will restart SC heparin when\n ICU Care\n Nutrition:\n Comments: restart TF as unlikely to be extubated today\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702462,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early this morning for hopeful extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n URINE CULTURE (Final ): NO GROWTH.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - early this morning, discontinue sedation for hopeful extubation\n this morning\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - With increasing leukocytosis concern for a new infection, will\n reculture blood, urine and sputum, also send a C.diff when patient has\n a bowel movement, if LFT\ns increase, will reimage RUQ due to concern\n for possible blockage of stent\n - Cont zosyn pending any further culture data\n - Trend CBC/diff, LFTs, especially in the setting on increasing\n leukocytosis, will add on Diff to AM labs\n - Follow up blood cx speciation , urine cx with no growth\n - Wean neo as tolerated by MAP >= 60 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\n baseline creatinine 1.2-1.4.\n - Titrate MAP to greater than 60, unless urine output decreases then\n will titrate to increased MAP\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 26 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: Will place OG tube for tube feeds today and turn them off at\n midnight for hopeful extubation tomorrow\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702438,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early this morning for hopeful extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n URINE CULTURE (Final ): NO GROWTH.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - early this morning, discontinue sedation for hopeful extubation\n this morning\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont zosyn pending any further culture data\n - Trend CBC/diff, LFTs\n - Follow up blood cx speciation , urine cx with no growth\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean neo as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\n baseline creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in\n case she had lasix, FeUrea: 14.9%...\n - IVFs for CVP 10-12: patient bolused large volume of fluid yesterday\n with improvement in CVP to 12\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 26 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: NPO pending hopeful extubation this morning, can restart\n diet post extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-26 00:00:00.000",
"description": "MICU Fellow Note",
"row_id": 702825,
"text": "TITLE:\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\n found to have cholangitis, now s/p ERCP and stenting, with course\n complicated by respiratory failure.\n 24 Hour Events:\n Decreased sedation overnight but had increasing agitation, had\n increased RR and decreasing tidal volumes so re-sedated and left at PS\n .\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\n RR: 37 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 243 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 239 mL\n Blood products:\n Total out:\n 1,795 mL\n 965 mL\n Urine:\n 1,795 mL\n 965 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -722 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 304 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 18 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: ETT in place, slight icterus\n Pulm: diminished at the bases, transmitted vent sounds, no wheezing\n CV: irregularly irregular, soft SM, no rub or gallop\n Abdomen: soft, non-tender, non-distended, (+) bowel sounds\n Ext: no edema\n Skin: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 60 K/uL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory Failure\n - continues to do poorly with decreased support, possibly due to\n ongoing volume overload\n - will follow TBB as she is autodiuresing, goal TBB -1L\n - low suspicion for underlying pneumonia given improving infectious\n parameters and shock\n - will continue PS today, repeat lightening of sedation and SBT\n tomorrow morning\n Septic shock\n - s/p ERCP with cholangitis\n - called micro for speciation of organisms, narrow abx if able\n - shock resolved, creatinine improved\n - on day Zosyn\n Atrial fibrillation\n - continues to be tachycardic, though improved\n - can try low dose beta-blocker today if BP tolerates\n - consider d'c amiodarone if able to be on beta-blocker\n Acute renal failure\n - improved overall\n - some of urine output now may be post-ATN diuresis\n Thrombocytopenia\n - slightly improved, no evidence of bleeding\n - will restart sc heparin today\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\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: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-26 00:00:00.000",
"description": "MICU Fellow Note",
"row_id": 702834,
"text": "TITLE:\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\n found to have cholangitis, now s/p ERCP and stenting, with course\n complicated by respiratory failure.\n 24 Hour Events:\n Decreased sedation overnight but had increasing agitation, had\n increased RR and decreasing tidal volumes so re-sedated and left at PS\n .\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\n RR: 37 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 243 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 239 mL\n Blood products:\n Total out:\n 1,795 mL\n 965 mL\n Urine:\n 1,795 mL\n 965 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -722 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 304 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 18 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: intubated, sedated\n HEENT: ETT in place, slight icterus\n Pulm: diminished at the bases, transmitted vent sounds, no wheezing\n CV: irregularly irregular, soft SM, no rub or gallop\n Abdomen: soft, non-tender, non-distended, (+) bowel sounds\n Ext: no edema\n Skin: Not assessed\n Labs / Radiology\n 9.9 g/dL\n 60 K/uL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory Failure\n - continues to do poorly with decreased support, possibly due to\n ongoing volume overload\n - will follow TBB as she is autodiuresing, goal TBB -1L\n - low suspicion for underlying pneumonia given improving infectious\n parameters and shock\n - will continue PS today, repeat lightening of sedation and SBT\n tomorrow morning\n Septic shock\n - s/p ERCP with cholangitis\n - called micro for speciation of organisms, narrow abx if able\n - shock resolved, creatinine improved\n - on day Zosyn\n Atrial fibrillation\n - continues to be tachycardic, though improved\n - can try low dose beta-blocker today if BP tolerates\n - consider d'c amiodarone if able to be on beta-blocker\n Acute renal failure\n - improved overall\n - some of urine output now may be post-ATN diuresis\n Thrombocytopenia\n - slightly improved, no evidence of bleeding\n - will restart sc heparin today\n ICU Care\n Nutrition: TF\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\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: 30 minutes\n Patient is critically ill\n ------ Protected Section ------\n CRITICAL CARE\n 85 yo with dementia, RCC intubated for resp failure in setting of\n cholangitis. Vent PSV 12/5\n 99.0 112 106/87\n Sedated on ventilator\n Chest\n few mid insp crackles bilat\n CV 2/6 sem\n I&O neg over 1 L yesterday -0.6 L today\n WBC 10.6\n RSBI > 200\n Making some progress with diuresis, but she is some ways from\n extubation. Still > 4L pos LOS. Seems likely that weaning success will\n depend on getting her to dry weight. No known signif cardiac dysfxn\n but has long standing cardiomeg on CXR and I wonder if Echo is\n underestimating MR. CXR remarkable for signif pleaural process on L\n possibly related to pancreatitis but signif vol loss is evident. She\n also has signif emphysema on CXR. Will need aggressive care to\n liberate her from vent and she remains at signif risk for VAP so would\n like to get her off ASAP. Her dementia will also likely complicate\n weaning as she may well become agitated as we taper midazolam.\n Time spent 40 min\n Critically ill\n ------ Protected Section Addendum Entered By: , MD\n on: 15:59 ------\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702430,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with SBT so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early SBT this morning for hopeful extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%. Some hemodynamic instability\n during SBT, with afib on AC for now.\n - Attempt to change back to PSV for now and wean as tolerated; consider\n sbt once patient can tolerate no sedation\n - wean pressors as tolerated\n - goal to extubate patient today\n # Atrial Fibrillation: Appears to be first episode as no history of\n this in past. Likely exacerbated by SBT and being on levophed in the\n setting of infection. Hemodynamically stable for now with rates in the\n 110\n - EKG\n - If fast rate persists or if worsening hemodynamics, consider\n changing levophed to phenylephrine as to reduce beta agonist activity\n and worsen afib with RVR.\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with pip-tazo until sensitivies return; d/c\n vanc as GI infection not likely MRSA.\n - Trend CBC/diff, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely. Since fluids do not seem\n to correct very fast, likely a component of ATN as well.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function with PM chem. 10.\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC and repeat labs\n equivical; low suscipicion of HIT as timing does not correlate.\n Concerning as platelets continuing to decrease. Vancomycin/ may be a\n possibility as known to cause thrombocytopenia.\n - D/C vanc and heparin today\n - unlikely DIC at this point\n - No signs of active bleeding\n - Re-check cbc at 1500\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO pending hopeful extubation this morning\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703141,
"text": "R radial nerve damage from compression\n s/p TAH/USO 8 yrs ago, c/b need for 3 units PRBC due to bleeding\n at a ligation site\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703142,
"text": "R radial nerve damage from compression\n s/p TAH/USO 8 yrs ago, c/b need for 3 units PRBC due to bleeding\n at a ligation site\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 14:45 ------\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702643,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - amio gtt started in early AM yesterday--> slow progress\n - Neo stopped at 0000\n - OG + tube feeds today, NPO at midnight with hopes for extubation\n - increasing WBC, send sputum for cx, blood and urine cx;\n - if she starts to spike again, then add back Vancomycin\n - Gm+ and Gm- rods in blood in anaerobic bottle\n - Was on AC for most of day after ; switched to PS 12/5-- ABG:\n 7.46/34/127 (at 3:15am) RSBI: couldn\nt tolerate b/c tachypnea:\n UOP 50-180 cc/hour\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:15 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 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 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 37\nC (98.6\n HR: 141 (111 - 141) bpm\n BP: 109/60(64) {83/55(62) - 127/70(81)} mmHg\n RR: 25 (14 - 36) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 8 (8 - 8)mmHg\n Total In:\n 1,682 mL\n 197 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 196 mL\n Blood products:\n Total out:\n 2,045 mL\n 520 mL\n Urine:\n 2,045 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -322 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): 482 (308 - 528) mL\n PS : 10 cmH2O\n RR (Set): 0\n RR (Spontaneous): 24\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 17 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.1 L/min\n PaO2 / FiO2: 318\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 9.8 g/dL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - RSBI early this morning\npatient very tachypnei,\n -Chest x-ray appeared volume overloaded, which is likely contributing\n to the difficulty weaning her off the ventilator, when patient is able\n to be weaned off pressors will need diuresis. Hopefully patient will\n start to mobilize her extra fluid, however once off pressors if she is\n unable to, will give lasix as needed to help decrease the fluid in her\n lungs\n - Hopeful extubation today pending ability to diurese\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - With increasing leukocytosis concern for a new infection, will\n reculture blood, urine and sputum, also send a C.diff when patient has\n a bowel movement, if LFT\ns increase, will reimage RUQ due to concern\n for possible blockage of stent\n - Cont zosyn pending any further culture data; f/u speciation and\n sensitivities from prior blood cx\n - Trend CBC/diff, LFTs, especially in the setting on increasing\n leukocytosis, will add on Diff to AM labs\n - Follow up blood cx speciation , urine cx with no growth\n - Wean neo as tolerated by MAP >= 60 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.5 today,\n baseline creatinine 1.2-1.4.\n - Titrate MAP to greater than 60, unless urine output decreases then\n will titrate to increased MAP\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 24 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: OG tube feeds\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702884,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on PS 12/5 40%, rr 30\n Action:\n Sedation off last night at 8pm then rsbi was done to decide whether to\n shut tf off at midnight for possible am extubation\n Response:\n RSBI 166 last night will not extubate today\n Plan:\n Continue good pulmonary toileting, midaz. Was increased to 3mg/hr due\n to agitation\n Atrial fibrillation (Afib)\n Assessment:\n Afib conts with hr in the 120\n Action:\n Lopressor was increased to 25mg po tid\n Response:\n ongoing\n Plan:\n Continue to monitor hr, increase lopressor if needed if bp can tolerate\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702968,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Crackles\n LUL Lung Sounds: Crackles\n LLL Lung Sounds: Crackles\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: 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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on the vent changes made tol fairly well. See respiratory page of\n meta vision for more information.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703143,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703145,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\ns. afib\n first occurred during sbt on / trialed lopressor 12.5 mg po on\n without affect.\n Action:\n Lopressor dose was increased to 25 mg pot id without any improvement in\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\n hr. hemodynamics followed closely.\n Response:\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\n was d/c\nd. sbp retruned to her baseline once esmalol gtt was d/c\n Plan:\n Continue to follow hemodynamics . may need to restart po lopressor.\n Continue to check lytes as ordered and replete as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp failure initially thought to be due to metabolic acidosis which\n caused her to hyperventilate to compensate and fatigued becoming\n acutely sob and requiring intubation on ^th.unable to wean\n vent because of pt being fluid overloaded secondary to fluid\n resusitiation. Pt having difficulty coming off peep becoming very\n tachypenic with low tidal volumes which is more concerning for\n difficulty with compliance then volume overload. Cxr c/w lll opacity\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\n tachypenic . lungs clear with crackles noted bil at the bases.\n Suctioned for sm amts of thick white sputum.\n Action:\n Pt placed on 405 cpap with 5 peep and ps of 8.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703221,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent. Respiratory failure initially thought to be due to\n metabolic acidosis which caused her to hyperventilate to compensate.\n She fatigued quickly becoming acutely SOB and required intubation on\n ^th. Since then, unable to wean vent because of pt being\n fluid overloaded secondary to fluid resuscitation. Pt having difficulty\n coming off peep becoming very tachypneic with low tidal volumes which\n is more concerning for difficulty with compliance then volume overload.\n Atrial fibrillation (Afib)\n Assessment:\n Received pt in Afib; HR ranging from 90-130\ns. SBP 85-120\ns. Afib first\n occurred during SBT on . Occasional PVC\ns noted.\n Action:\n Lopressor 25mg NG TID. Diltiazem 30mg NG Q6hr. Magnesium 2gm IV & KCL\n 20mEq IV given last evening per sliding scale orders.\n Response:\n Pt has remained in Afib but rate has significantly improved w/\n administration of Lopressor & Dilt. HR ranging 80\n low 100\ns w/\n minimal ectopy.\n Plan:\n Cont to trend BP, HR & rhythm. Administer standing Lopressor &\n Diltiazem. Follow electrolyte status & replete as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on PSV 40% 8/5. O2 sat 98-100%. Pt tachypneic @ times\n 30-40\ns but appearing comfortable & settles out on own. LS clear,\n diminished @ bases. Fine crackles noted in BLL at times. MN fluid goal\n 1.5\n 2L.\n Action:\n Suctiong q2-4 hrs for thick/white sputum. Pt is pooling secretions @\n back of throat (concern for aspiration post extubation)\n Response:\n Pt -2L @ MN.\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal - 1.5\n 2L @\n this time. Plan is to call anesthesia in the am to change #7 ETT to #8\n ETT over the Cook catheter. Once ETT is changed, pt will be placed on\n SBT & RSBI will be obtained. team would like to bronch pt post ETT\n exchange. If all goes as planned, pt will be extubated late morning. As\n discussed w/ daughter (HCP) pt will be reintubated in necessary (but\n remains DNR)\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703025,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt remains intubated and vented on 40% 5 Peep, 12 pressure support.\n RR up to 34-36 pt volume overloaded,\n Action:\n Pt rested overnight on 40% AC TV 500 rate 14, 5 peep pt\n received 10 mg IVP Lasix at 9 pm with good response.\n Response:\n Pt able to sleep, appeared comfortable, rr 14-16\n Plan:\n Change back to pressure support in am, check RSBI, ?ready for\n extubation\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in Afib, rate 115-130 bp\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703308,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - f/u VBG 7.48/42/78 in central venous, repeat ABG 7.46/44/124\n - BNP high 5525 c/w volume overload.\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid\n - PICC placed\n - Called micro lab: will try to speciate. will call in AM to confirm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:39 AM\n Heparin Sodium (Prophylaxis) - 04:51 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 99 (86 - 128) bpm\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\n RR: 28 (18 - 41) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 6 (2 - 6)mmHg\n Total In:\n 784 mL\n 256 mL\n PO:\n TF:\n IVF:\n 784 mL\n 196 mL\n Blood products:\n Total out:\n 2,885 mL\n 495 mL\n Urine:\n 2,885 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (260 - 404) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 154\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: ///29/\n Ve: 9.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Labs / Radiology\n 174 K/uL\n 9.2 g/dL\n 80 mg/dL\n 1.4 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 101 mEq/L\n 140 mEq/L\n 27.9 %\n 11.3 K/uL\n [image002.jpg]\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n Plt\n 48\n 60\n 84\n 131\n 174\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n TCO2\n 26\n 25\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n Other labs:\n Ca: 8.6, Mg: 2.2, Phos: 3.1\n Mircrobiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n ANAEROBIC GRAM NEGATIVE ROD(S).\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\n Radiology:\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\n vena cava. The patient remains intubated, with the endotracheal tube\n terminating 3.2 cm above the carina. The right internal jugular line\n ends in the mid superior vena cava. Left pleural effusion with\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\n consistent with pulmonary arterial hypertension. The right lung is\n clear. There is no pulmonary edema.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. CXR looks\n improved in terms of pulmonary vascular congestion, will trial\n extubation today since patient looks the best she has since admission\n - patient may need Bipap post extubation\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n .\n # Atrial Fibrillation: Metoprolol at 25mg TID and Dilt 30mg QID for\n rate control, rate has been in the 90\ns with both medications\n # Septic shock: resolved from initial cholangitis source, patient off\n pressors, likely secondary to cholangitis and infected stone/sludge.\n ERCP showed significant pusand very large stone, she is s/p stent\n placement. Patient afebrile and white count stable. Lactate normal.\n Initial sepsis secondary to biliary source given CBD dilation with\n sludge and obstructive LFTs in setting on known choledocholithiasis.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. PICC placed, will complete a 14 day course of zosyn as the\n mircolab is currently unable to provide further speciation and she has\n been improving on zosyn\n - repeat ERCP in 1 month\n .\n # ARF: Improved, back to her baseline.\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition: Tube feeds on hold for possible extubation\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: family\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 702804,
"text": "TITLE:\n Chief Complaint: cholangitis, 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 85yo F with PMH dementia, renal cancer who presents with septic shock\n found to have cholangitis, now s/p ERCP and stenting, with course\n complicated by respiratory failure.\n 24 Hour Events:\n Decreased sedation overnight but had increasing agitation, had\n increased RR and decreasing tidal volumes so re-sedated and left at PS\n .\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 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 10:16 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: 120 (114 - 124) bpm\n BP: 97/67(73) {76/44(55) - 133/80(87)} mmHg\n RR: 37 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 243 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 239 mL\n Blood products:\n Total out:\n 1,795 mL\n 965 mL\n Urine:\n 1,795 mL\n 965 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -722 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 304 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 35\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 18 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 9.5 L/min\n Physical Examination\n General Appearance: intubated, sedated\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 9.9 g/dL\n 60 K/uL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory Failure\n - continues to do poorly with decreased support, possibly due to\n ongoing volume overload\n - will follow TBB as she is autodiuresing, goal TBB -1L\n - low suspicion for underlying pneumonia given improving infectious\n parameters and shock\n - will continue PS today, repeat lightening of sedation and SBT\n tomorrow morning\n Septic shock\n - s/p ERCP with cholangitis\n - called micro for speciation of organisms, narrow abx if able\n - shock resolved, creatinine improved\n - on day Zosyn\n Atrial fibrillation\n - continues to be tachycardic, though improved\n - can try low dose beta-blocker today if BP tolerates\n - consider d'c amiodarone if able to be on beta-blocker\n Acute renal failure\n - improved overall\n - some of urine output now may be post-ATN diuresis\n Thrombocytopenia\n - slightly improved, no evidence of bleeding\n - will restart sc heparin today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: Not indicated\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: 30 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702810,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Goal to decrease sedation overnight to help with extubation hopefully\n Sunday. Her barriers are sedation and fluid overload\n ---> on 2 mg versed...shut off for 2-3 hours and patient agitated\n pulling at tube and moving around. RSBI tried on her during her wakeful\n moment and it was 204..has been tachypnic to the 30's and if go down on\n PS tidal volumes decrease. Kept same pressure support . and turned\n versed back to 2 mg.\n - Goal TBB negative 1-1.5 liters. autodiuresing well, no lasix needed\n - CXR done that did not show much interval change.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 122 (114 - 131) bpm\n BP: 108/50(62) {88/44(55) - 133/80(87)} mmHg\n RR: 29 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 201 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 197 mL\n Blood products:\n Total out:\n 1,795 mL\n 745 mL\n Urine:\n 1,795 mL\n 745 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -544 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 403 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 17 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 60 K/uL\n 9.9 g/dL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\n Unable to wean effectively; likely secondary to fluid resuscitation; as\n fluid overload is seen on CXR.\n - Monitor UOP as patient is auto-diuresing well. Check i/o\ns this\n evening with TBB 1-1.5 liters, if not at goal will trial some lasix if\n her blood pressure can tolerate\n - Wean down vent settings as much as possible, but having difficulty\n due to volume overload\n - CXR tomorrow morning to evaluate for improvement in volume overload\n - will further clarify intubation status with family prior to\n extubation, to see if they would want her to be re-intubated if she has\n difficulty post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Patient has\n remained tachycardic on amio gtt, now that she is off pressors will\n trial a low dose beta blocker,\n - Metoprolol 5mg IV: monitor effect on HR and BP, has been on\n metoprolol at home\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized, has been\n afebrile for over 24hours\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: . Will f/u cutlure data to see if we can narrow our coverage,\n if she needs to be continued on Zosyn will place a PICC and pull\n central line\n - LFT\ns normalized, no longer need to trend daily\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Will restart SQ heparin as her platelet count has increased and the\n initial drop was not consistent with HIT\n - No signs of active bleeding\n ICU Care\n Nutrition: Was npo after midnight for possible extubation, but since\n she will not be extubated will restart tube feeds\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: pneumo boots, SQ heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, pt is intubated\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-27 00:00:00.000",
"description": "Physician Resident/Attending Progress Note - MICU",
"row_id": 702962,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - will attempt to decrease sedation this evening and do an SBT, if she\n looks good will hold tube feeds, otherwise will continue feeds\n overnight\n - patient only negative about 600cc's at 4pm, gave 20mg IV lasix and\n then urine output was over 1L to the lasix\n - RSBI at 9pm=166, then SBT lasted about 15min, she was maintaining her\n MV and O2sats but RR in the 40's with small TV's. After about 15min\n became uncomfortable with increased WOB-->improved from prior, has more\n stamina, diuresis seems to be improving her respiratory status\n - per discussion with patient's family she can be reintubated if she\n fails extubation\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:29 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:55 AM\n Furosemide (Lasix) - 06:14 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 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: 37.2\nC (99\n HR: 112 (106 - 129) bpm\n BP: 89/56(65) {89/51(65) - 144/103(111)} mmHg\n RR: 12 (12 - 37) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 733 mL\n 452 mL\n PO:\n TF:\n 202 mL\n 264 mL\n IVF:\n 531 mL\n 188 mL\n Blood products:\n Total out:\n 3,345 mL\n 765 mL\n Urine:\n 3,345 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,612 mL\n -313 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 296 (241 - 304) mL\n PS : 12 cmH2O\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 166\n PIP: 18 cmH2O\n SpO2: 100%\n ABG: ///30/\n Ve: 8.6 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 84 K/uL\n 9.2 g/dL\n 143 mg/dL\n 1.3 mg/dL\n 30 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 104 mEq/L\n 140 mEq/L\n 27.9 %\n 11.2 K/uL\n [image002.jpg]\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n WBC\n 15.3\n 20.2\n 11.3\n 10.6\n 11.2\n Hct\n 31.4\n 30.7\n 29.7\n 29.3\n 27.9\n Plt\n 59\n 46\n 52\n 48\n 60\n 84\n Cr\n 1.8\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 26\n 25\n Glucose\n 102\n 91\n 128\n 119\n 126\n 143\n Other labs:\n Mg: 1.6\n Alk Phos: 103, T. bili: 1.5\n PT: 12, INR: 1, PTT: 23.7\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n Imaging:\n Chest X-Ray (my read): slightly worsening left effusion and right\n basilar patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR.\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\n about 800 cc\ns in the evening so she was given 20mg IV lasix with a\n brisk urine output response. Will give another dose of lasix since she\n had her best SBT with the increased diuresis, hold tube feeds for now\n in case she is able to be extubated this afternoon. She will likely\n never have an excellent RSBI, but she will need to not tire and\n maintain her sats during her SBT.\n - Hold sedation for now to optimize mental status prior to extubation\n - need to place a dobhoff prior to extubation as she may be an\n aspiration risk\n - CXR looks stable to slightly worsened this morning\n - family okay with re-intubation if patient fails extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Increase metoprolol to 25mg and titrate up to good HR control as\n her BP tolerates\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count stable. Lactate\n normal. Initial sepsis secondary to biliary source given CBD dilation\n with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 24 hours.\n - Cont zosyn pending any further culture data; Day of zosyn.\n Day 1=. Will f/u cutlure data to see if we can narrow our\n coverage, if she needs to be continued on Zosyn will place a PICC and\n pull central line, may be able to transitioned to a po antibiotic\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n - f/u sputum culture\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to her baseline at 1.3 today.\n - Monitor UOP\n - Trend creatinine while diuresing\n - Check PM lytes\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Platelet count stable and increasing\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 11:56 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Heparin SQ, pneumo boots\n Stress ulcer: none while on feeds\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, is intubated, ok to be reintubated post extubation if\n necessary\n Disposition: ICU pending stabilization post extubation\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: 85F CBD stone c/b cholangitis, septic shock,\n respiratory failure, AF c RVR. Failed SBT last PM, diuresis ongoing.\n Exam notable for Tm 99.8 BP HR 116/50 RR 12-37 with sat 100 on PSV\n . WD woman, follows intermittent commands. Coarse BS B. Irreg s1s2.\n Soft +BS. 2+ edema. Labs notable for WBC 11K, HCT 27, K+ 3.9, Cr 1.3.\n Agree with plan to manage respiratory failure with IV lasix now for TBB\n negative, will check and trend CVP, continue upright positioning, and\n consider NGT placement prior to extubation. Cholangitis improving, will\n need 14d abx, f/u cultures, consider change CVL to PICC if she needs\n long-term IV abx. For AF c RVR, continue PO BBL, hold off on\n anticoagulation for now and d/w family / PCP\n appears to be at long\n term risk of falls based on prior history. ARF has resolved. Continue\n TFs for now. Remainder of plan as outlined above.\n Patient is critically ill\n Total time: 40 min\n ------ Protected Section Addendum Entered By: , MD\n on: 15:37 ------\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703140,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - diurese further today to help w possibility of extubation--> Net Goal\n -1.5-2L\n - consider risk of aspiration post-extubation due to mental status\n - NG tube placed\n - patient remains tachycardic so metoprolol was increased to 25mg TID\n - need to address possib of anticoagulation w family and PCP\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\n tolerate 20mg IV)\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\n at 9:30pm to rest, so that she can be ready, better rested for SBT\n tomorrow, esp after diuresis\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 04:27 PM\n Heparin Sodium (Prophylaxis) - 04:31 AM\n Furosemide (Lasix) - 04:39 AM\n Metoprolol - 04:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 116 (100 - 125) bpm\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\n RR: 23 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 9 (9 - 272)mmHg\n Total In:\n 2,091 mL\n 206 mL\n PO:\n TF:\n 1,506 mL\n IVF:\n 524 mL\n 206 mL\n Blood products:\n Total out:\n 2,125 mL\n 1,120 mL\n Urine:\n 2,125 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -34 mL\n -915 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): 324 (255 - 463) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 25 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: ///30/\n Ve: 7.1 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 131 K/uL\n 9.1 g/dL\n 109 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 103 mEq/L\n 142 mEq/L\n 27.4 %\n 12.2 K/uL\n [image002.jpg]\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n WBC\n 20.2\n 11.3\n 10.6\n 11.2\n 12.2\n Hct\n 30.7\n 29.7\n 29.3\n 27.9\n 27.4\n Plt\n 52\n 48\n 60\n 84\n 131\n Cr\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n TCO2\n 23\n 26\n 25\n Glucose\n 91\n 128\n 119\n 126\n 143\n 117\n 109\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.6 mg/dL\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\n Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n Imaging:\n Chest X-Ray at 2330 (my read): stable effusion/opacity and\n RLL patchy opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\n having difficulty coming off PEEP, becomes very tachypneic and has low\n tidal volumes, which is more concerning for difficulty with compliance\n and volume overload. Additionally, patient with opacity and\n diaphragm pulled up on the left that has been noted on all x-rays\n during this admission, to better see the anatomy in the , \n bronch the patient this afternoon to look at the .\n - continue with net negative goal, if UOP decreases to less than\n 100cc/hr will give another dose of lasix and readdress possible\n extubation this afternoon.\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\n the 120\ns to 130\ns, so will trial an esmolol drip\n # Septic shock: resolving, patient off pressors, likely secondary to\n cholangitis and infected stone/sludge. ERCP showed significant pusand\n very large stone, she is s/p stent placement. Patient afebrile and\n white count stable. Lactate normal. Initial sepsis secondary to biliary\n source given CBD dilation with sludge and obstructive LFTs in setting\n on known choledocholithiasis.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 48 hours.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\n will place a PICC and pull central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\n to help with further diruesis\n - Monitor UOP\n - Check PM lytes\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition: Tube feeds held o/n for possible extubation, will hold this\n afternoon for possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM, will put patient in for a PICC today\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702081,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n TVs 400s on PSV 12/5. Gd O2sats. Minimal secretions. On versed gtt at\n 3mg.hr and Fentanyl at 50mcgs/hr. CXR not showing infiltrates.\n Action:\n Placed on A/C for ERCP.\n Response:\n Remains on AC as she received paralytic for ERCP and remains very\n sedated.\n Plan:\n Return PSV when spontaneous breathing returns. Turn off sedation in\n a.m. and do SBT for possible extubation. Monitor O2sats.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. On Zosyn. Levophed at 0.2mcgs/kg/minute.CVP 8. UO < 20cc/hr.\n WBC up to 25. Remains in metabolic acidosis.\n Action:\n Received additional 2L IVBs.\n Response:\n UO increased to ~50cc/hr. CVP 13-15. Levophed weaned to\n 0.1mcg/kg/minute.\n Plan:\n Wean Levophed as tol. Follow CVP and UO. Consider bicarb gtt if she\n requires more fluids for low CVP.\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 702876,
"text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 54.\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: PSV 12/5/.4\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments: Maintaining Vt 2-300\ns with Ve8-10 L, sp02 99%\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: Attempted SBT x1: ~18 minutes with RR 40, appeared\n to have increased WOB, increased HR> back to PSV 12/5; RSBI 166\n Comments: Will cont slow PSV wean as tol.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703214,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Atrial fibrillation (Afib)\n Assessment:\n Pt remains in afib with hr ranging from 100-130\ns.sbp 92-120\ns. afib\n first occurred during sbt on / trialed lopressor 12.5 mg po on\n without affect.\n Action:\n Lopressor dose was increased to 25 mg pot id without any improvement in\n hr so esmalol gtt was initiated at 50mcg/kg/min in attempt to control\n hr. hemodynamics followed closely.\n Response:\n 20 min after esmalol gtt was started sbp dropped to 62 so esmalol gtt\n was d/c\nd. sbp retruned to her baseline once esmalol gtt was d/c\n Plan:\n Continue to follow hemodynamics . Continue to check lytes as ordered\n and replete as needed. Pt now started on lopressor 25 mg pot id and\n diltiazem 30 mg po q 6hrs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp failure initially thought to be due to metabolic acidosis which\n caused her to hyperventilate to compensate and fatigued becoming\n acutely sob and requiring intubation on ^th.unable to wean\n vent because of pt being fluid overloaded secondary to fluid\n resusitiation. Pt having difficulty coming off peep becoming very\n tachypenic with low tidal volumes which is more concerning for\n difficulty with compliance then volume overload. Cxr c/w lll opacity\n and diaphragm pulled up on left. Rsbi=176. pt placed on sbt and became\n tachypenic . lungs clear with crackles noted bil at the bases.\n Suctioned for sm amts of thick white sputum.\n Action:\n Pt placed on 40% cpap with 5 peep and ps of 8. resp status monitored\n closely.\n Response:\n Vent settings unchanged. Cxr unchanged\n Plan:\n Plan to diurese as pt\ns hemodynamics tolerate. Net goal for i&o is to\n be neg 1.5 to 2 liters Will keep on cpap mode of ventilation overnoc.\n Plan is to call anesthesia in the am to change #7 ett to o #8 ett over\n the cook catheter. Once ett is changed will then check rsbi and do sbt.\n Will do bronchoscopy after that and then possible extubation with the\n plan to reintubate if pt fails extubation.\n DNR (will reintubate if necessary)\n L DL PICC\n Family in to see pt and updated by this RN last evening\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702792,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Goal to decrease sedation overnight to help with extubation hopefully\n Sunday. Her barriers are sedation and fluid overload\n ---> on 2 mg versed...shut off for 2-3 hours and patient agitated\n pulling at tube and moving around. RSBI tried on her during her wakeful\n moment and it was 204..has been tachypnic to the 30's and if go down on\n PS tidal volumes decrease. Kept same pressure support . and turned\n versed back to 2 mg.\n - Goal TBB negative 1-1.5 liters. autodiuresing beautifully and have\n not given lasix as she is -840 cc at .\n - CXR done that did not show much interval change.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 2 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.8\nC (98.3\n Tcurrent: 36.8\nC (98.3\n HR: 122 (114 - 131) bpm\n BP: 108/50(62) {88/44(55) - 133/80(87)} mmHg\n RR: 29 (14 - 38) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 628 mL\n 201 mL\n PO:\n TF:\n 128 mL\n 4 mL\n IVF:\n 500 mL\n 197 mL\n Blood products:\n Total out:\n 1,795 mL\n 745 mL\n Urine:\n 1,795 mL\n 745 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,167 mL\n -544 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 403 (260 - 483) mL\n PS : 12 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 204\n PIP: 17 cmH2O\n SpO2: 99%\n ABG: ///26/\n Ve: 8 L/min\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 60 K/uL\n 9.9 g/dL\n 119 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 107 mEq/L\n 141 mEq/L\n 29.3 %\n 10.6 K/uL\n [image002.jpg]\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n 10.6\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n 29.3\n Plt\n 48\n 59\n 46\n 52\n 48\n 60\n Cr\n 2.1\n 1.8\n 1.6\n 1.5\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 266\n 102\n 91\n 128\n 119\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:99/1.9,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:2.2 mg/dL\nMicro: 12:38 pm SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n GPR anaerobic bottles\n GNR in\n anaerobic bottles\nPan cultured yesterday: NGTD\nRadiology: None today\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED.\n Unable to wean effectively; likely secondary to fluid resuscitation; as\n fluid overload is seen on CXR.\n - Monitor UOP as patient is auto-diuresing well. Check i/o\ns this\n evening with TBB 1-1.5 liters\n - Wean down vent settings as much as possible, will likely be more\n effective once\n - CXR today to make sure no other acute process is occuring\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Continue amio gtt as HR has improved, but she is still tachycardic in\n the low 100\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolveing, T max was yesterday at 1600; appears to\n be improving.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1: .\n - f/u speciation and sensitivities from prior blood cx\n - Trend CBC/diff, LFTs,\n - Follow up blood cx speciation , urine cx with no growth\n - no need for pressors now. Monitor maps > 65.\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr improving to 1.5 today, baseline creatinine 1.2-1.4.\n - Monitor UOP\n - Trend creatinine\n .\n #Thrombocytopenia Stable. Likely secondary to sepsis. Low suscipicion\n of HIT as timing does not correlate since patient has not had a prior\n heparin exposure. Vancomycin may also be contributing to her\n thrombocytopenia\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 24 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: Currently NPO for possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: pneumo boots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR, pt is intubated\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703083,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - diurese further today to help w possibility of extubation--> Net Goal\n -1.5-2L\n - consider risk of aspiration post-extubation due to mental status\n - NG tube? prior to extubation\n - consider changing her to PO Abx today\n - amio was stopped yesterday ; on metoprolol 25mg --> incr to\n TID\n - need to address possib of anticoagulation w family and PCP\n given lasix 10mg IV x2 (2pm and 9:30pm) -- (BPs in 90s wouldnt\n tolerate 20mg IV)\n - RR was in 30s on PS 12/5, so she was switched to AC Vt 500cc, PEEP 5\n at 9:30pm to rest, so that she can be ready, better rested for SBT\n tomorrow, esp after diuresis\n - SBT in the AM to figure out if she's ready to be extubated; can\n restart tube feeds in AM if not ready\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Fentanyl - 04:27 PM\n Heparin Sodium (Prophylaxis) - 04:31 AM\n Furosemide (Lasix) - 04:39 AM\n Metoprolol - 04:40 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 36.7\nC (98\n HR: 116 (100 - 125) bpm\n BP: 107/59(68) {86/45(56) - 122/86(97)} mmHg\n RR: 23 (12 - 36) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 9 (9 - 272)mmHg\n Total In:\n 2,091 mL\n 206 mL\n PO:\n TF:\n 1,506 mL\n IVF:\n 524 mL\n 206 mL\n Blood products:\n Total out:\n 2,125 mL\n 1,120 mL\n Urine:\n 2,125 mL\n 1,120 mL\n NG:\n Stool:\n Drains:\n Balance:\n -34 mL\n -915 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): 324 (255 - 463) mL\n PS : 12 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 25 cmH2O\n Plateau: 18 cmH2O\n Compliance: 38.5 cmH2O/mL\n SpO2: 100%\n ABG: ///30/\n Ve: 7.1 L/min\n Physical Examination\n General: Intubated, awake, responsive, follows some commands\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: coarse breath sounds bilateral anteriorly, no wheezes, rales,\n ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no LE edema, upper extremities\n R>L, + edema bilaterally\n Skin: somewhat jaundiced\n Labs / Radiology\n 131 K/uL\n 9.1 g/dL\n 109 mg/dL\n 1.5 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 22 mg/dL\n 103 mEq/L\n 142 mEq/L\n 27.4 %\n 12.2 K/uL\n [image002.jpg]\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n WBC\n 20.2\n 11.3\n 10.6\n 11.2\n 12.2\n Hct\n 30.7\n 29.7\n 29.3\n 27.9\n 27.4\n Plt\n 52\n 48\n 60\n 84\n 131\n Cr\n 1.6\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n TCO2\n 23\n 26\n 25\n Glucose\n 91\n 128\n 119\n 126\n 143\n 117\n 109\n Other labs: PT / PTT / INR:12.0/23.7/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:45/23, Alk Phos / T Bili:103/1.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:8.2 mg/dL, Mg++:1.8 mg/dL,\n PO4:2.6 mg/dL\n Microbiology:\nBlood Culture: Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n ANAEROBIC GRAM NEGATIVE ROD(S).\n 3:55 pm SPUTUM Site: ENDOTRACHEAL\n Source: Endotracheal.\n GRAM STAIN (Final ):\n PMNs and <10 epithelial cells/100X field.\n 2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE.\n Imaging:\n Chest X-Ray at 2330 (my read): stable LLL effusion and RLL patchy\n opacity\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR.\n - Net goal yesterday was -1 to 1.5L, patient was only net negative\n about 800 cc\ns in the evening so she was given 20mg IV lasix with a\n brisk urine output response. Will give another dose of lasix since she\n had her best SBT with the increased diuresis, hold tube feeds for now\n in case she is able to be extubated this afternoon. She will likely\n never have an excellent RSBI, but she will need to not tire and\n maintain her sats during her SBT.\n - Hold sedation for now to optimize mental status prior to extubation\n - need to place a dobhoff prior to extubation as she may be an\n aspiration risk\n - CXR looks stable to slightly worsened this morning\n - family okay with re-intubation if patient fails extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Increase metoprolol to 25mg and titrate up to good HR control as\n her BP tolerates\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count stable. Lactate\n normal. Initial sepsis secondary to biliary source given CBD dilation\n with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 24 hours.\n - Cont zosyn pending any further culture data; Day of zosyn.\n Day 1=. Will f/u cutlure data to see if we can narrow our\n coverage, if she needs to be continued on Zosyn will place a PICC and\n pull central line, may be able to transitioned to a po antibiotic\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n - f/u sputum culture\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to her baseline at 1.3 today.\n - Monitor UOP\n - Trend creatinine while diuresing\n - Check PM lytes\n .\n #Thrombocytopenia: Stable, and her platelet count is increasing. Likely\n secondary to sepsis.\n - Platelet count stable and increasing\n ICU Care\n Nutrition: Tube feeds held o/n for possible extubation\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703266,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:34 PM\n MULTI LUMEN - STOP 05:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:39 AM\n Heparin Sodium (Prophylaxis) - 04:51 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 99 (86 - 128) bpm\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\n RR: 28 (18 - 41) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 6 (2 - 6)mmHg\n Total In:\n 784 mL\n 256 mL\n PO:\n TF:\n IVF:\n 784 mL\n 196 mL\n Blood products:\n Total out:\n 2,885 mL\n 495 mL\n Urine:\n 2,885 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (260 - 404) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 154\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: ///29/\n Ve: 9.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 174 K/uL\n 9.2 g/dL\n 80 mg/dL\n 1.4 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 101 mEq/L\n 140 mEq/L\n 27.9 %\n 11.3 K/uL\n [image002.jpg]\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n Plt\n 48\n 60\n 84\n 131\n 174\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n TCO2\n 26\n 25\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n Other labs:\n Ca: 8.6, Mg: 2.2, Phos: 3.1\n Mircrobiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n ANAEROBIC GRAM NEGATIVE ROD(S).\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\n Radiology:\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\n vena cava. The patient remains intubated, with the endotracheal tube\n terminating 3.2 cm above the carina. The right internal jugular line\n ends in the mid superior vena cava. Left pleural effusion with\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\n consistent with pulmonary arterial hypertension. The right lung is\n clear. There is no pulmonary edema.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\n having difficulty coming off PEEP, becomes very tachypneic and has low\n tidal volumes, which is more concerning for difficulty with compliance\n and volume overload. Additionally, patient with opacity and\n diaphragm pulled up on the left that has been noted on all x-rays\n during this admission, to better see the anatomy in the , \n bronch the patient this afternoon to look at the .\n - continue with net negative goal, if UOP decreases to less than\n 100cc/hr will give another dose of lasix and readdress possible\n extubation this afternoon.\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\n the 120\ns to 130\ns, so will trial an esmolol drip\n # Septic shock: resolving, patient off pressors, likely secondary to\n cholangitis and infected stone/sludge. ERCP showed significant pusand\n very large stone, she is s/p stent placement. Patient afebrile and\n white count stable. Lactate normal. Initial sepsis secondary to biliary\n source given CBD dilation with sludge and obstructive LFTs in setting\n on known choledocholithiasis.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 48 hours.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\n will place a PICC and pull central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\n to help with further diruesis\n - Monitor UOP\n - Check PM lytes\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 703267,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - f/u VBG 7.48/42/78 in mixed venous, Very weird gas for venous...\n - BNP high 5525 c/w volume overload.\n - still intubated with plan to do bronch Wednesday and change out the\n ET tube to a bigger size\n - i/o's goal of 1.5 to 2 liters. at goal around midnight\n - esmolol gtt and d/c metoprolol: Patient got very hypotensive. Esmolol\n stopped: started dilt po 30 mg qid and metoprolol 25 po tid...will need\n to clean this up in rounds. not at maximum doses of either and both\n aren't working very well.\n - Upright rsbi to be done in early AM.\n - PICC placed\n - Called micro lab: will try to speciate. will call in AM to confirm\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 12:30 AM\n Infusions:\n Midazolam (Versed) - 1 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 08:39 AM\n Heparin Sodium (Prophylaxis) - 04:51 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (99\n HR: 99 (86 - 128) bpm\n BP: 99/54(64) {62/23(32) - 149/93(100)} mmHg\n RR: 28 (18 - 41) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 79.2 kg (admission): 83.8 kg\n Height: 64 Inch\n CVP: 6 (2 - 6)mmHg\n Total In:\n 784 mL\n 256 mL\n PO:\n TF:\n IVF:\n 784 mL\n 196 mL\n Blood products:\n Total out:\n 2,885 mL\n 495 mL\n Urine:\n 2,885 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,101 mL\n -239 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 260 (260 - 404) mL\n PS : 8 cmH2O\n RR (Spontaneous): 38\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 154\n PIP: 14 cmH2O\n SpO2: 99%\n ABG: ///29/\n Ve: 9.6 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 174 K/uL\n 9.2 g/dL\n 80 mg/dL\n 1.4 mg/dL\n 29 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 101 mEq/L\n 140 mEq/L\n 27.9 %\n 11.3 K/uL\n [image002.jpg]\n 04:37 AM\n 03:15 AM\n 04:02 AM\n 04:54 AM\n 09:30 PM\n 04:15 AM\n 03:55 PM\n 02:50 AM\n 05:17 PM\n 03:59 AM\n WBC\n 11.3\n 10.6\n 11.2\n 12.2\n 11.3\n Hct\n 29.7\n 29.3\n 27.9\n 27.4\n 27.9\n Plt\n 48\n 60\n 84\n 131\n 174\n Cr\n 1.5\n 1.5\n 1.4\n 1.3\n 1.4\n 1.5\n 1.4\n 1.4\n TCO2\n 26\n 25\n Glucose\n 128\n 119\n 126\n 143\n 117\n 109\n 98\n 80\n Other labs:\n Ca: 8.6, Mg: 2.2, Phos: 3.1\n Mircrobiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n ANAEROBIC GRAM POSITIVE ROD(S).\n NOT RESEMBLING CLOSTRIDIUM SPECIES.\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n ANAEROBIC GRAM NEGATIVE ROD(S).\n IDENTIFICATION PERFORMED ON CULTURE # 283-4126L .\n Anaerobic Bottle Gram Stain (Final ):\n GRAM POSITIVE ROD(S) AND GRAM NEGATIVE ROD(S)\n Radiology:\n Chest X-ray (): FINDINGS: Left PICC ends in the upper superior\n vena cava. The patient remains intubated, with the endotracheal tube\n terminating 3.2 cm above the carina. The right internal jugular line\n ends in the mid superior vena cava. Left pleural effusion with\n atelectasis have not changed. Pulmonary arteries are markedly enlarged,\n consistent with pulmonary arterial hypertension. The right lung is\n clear. There is no pulmonary edema.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure initially thought to be due\n to her primary metabolic acidosis, which caused her to hyperventilate\n to compensate and fatigued, becoming acutely SOB and requiring\n intubation in the ED. Unable to wean effectively; likely secondary to\n fluid resuscitation; as fluid overload is seen on CXR. Patient is\n having difficulty coming off PEEP, becomes very tachypneic and has low\n tidal volumes, which is more concerning for difficulty with compliance\n and volume overload. Additionally, patient with opacity and\n diaphragm pulled up on the left that has been noted on all x-rays\n during this admission, to better see the anatomy in the , \n bronch the patient this afternoon to look at the .\n - continue with net negative goal, if UOP decreases to less than\n 100cc/hr will give another dose of lasix and readdress possible\n extubation this afternoon.\n - Hold sedation for now to optimize mental status prior to extubation\n - NGT in place for meds/diet post extubation\n # Atrial Fibrillation: First occurred during SBT on , initially\n rates were in the 110\ns, then increased to the 130\ns. Trialed\n metoprolol 12.5mg PO yesterday, with some improvement in HR to the\n 100\ns and her BP tolerated it well.\n - Metoprolol increased to 25mg TID, but patient still tachycardic in\n the 120\ns to 130\ns, so will trial an esmolol drip\n # Septic shock: resolving, patient off pressors, likely secondary to\n cholangitis and infected stone/sludge. ERCP showed significant pusand\n very large stone, she is s/p stent placement. Patient afebrile and\n white count stable. Lactate normal. Initial sepsis secondary to biliary\n source given CBD dilation with sludge and obstructive LFTs in setting\n on known choledocholithiasis.\n - Leukocytosis is resolving\nwhite count almost normalized. Had been\n afebrile for over 48 hours.\n - Cont zosyn pending any further culture data; Day of zosyn. Day\n 1=. Will f/u cutlure data to see if we can narrow our coverage,\n will place a PICC and pull central line\n - plan for repeat ERCP in one month, after resolution of initial\n infection for stone break up and removal\n .\n # ARF: Improved, near baseline. Likely related to sepsis and\n intravascular volume depletion secondary to vomiting and diarrhea, also\n likely some component of ATN as her renal function has not improved as\n quickly with fluids as would be expected in a purely pre-renal picture.\n Cr back to near her baseline at 1.5 today, will tolerate a bump in Cr\n to help with further diruesis\n - Monitor UOP\n - Check PM lytes\n .\n #Thrombocytopenia: resolved\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:34 PM\n Prophylaxis:\n DVT: SQ Heparin, pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate), ok for re-intubation if patient\n fails extubation\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702212,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP today: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n lactate normalized to 1.4.\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some.\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%.\n - Cont PSV for now and wean as tolerated; consider sbt once patient can\n tolerate no sedation and no pressors\n - goal to extubate patient today\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo until\n sensitivies return\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC labs equivical; low\n suscipicion of HIT as timing does not correlate.\n - Concerning as platelets continuing to decrease. Vancomycin/Zosyn may\n be a possibility as known to cause thrombocytopenia.\n - Repeat DIC labs\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband\n status: DNR\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 703352,
"text": "85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to cholangitis. She is s/p\n ERCP and stent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient intubated and vented on PSV 40% 8/5. Sedated on midaz\n at 1mg/hr. B/L LS clear diminished at the bases. Tachypneic to high\n 20-30\n Action:\n Lasix 20mg X1 given prior to extubation, extubated.\n Response:\n No s/s of resp distress. Patient denies any SOB when asked. Sats at\n high 90\ns on face tent.\n Plan:\n Continue to monitor patient resp status\n Atrial fibrillation (Afib)\n Assessment:\n Known AFib. HR in 90-low 100\ns. B/P 90-110\ns occasionally when asleep\n b/p down to 80\ns. Peripheral pulses present.\n Action:\n Metoprolol at 25mg TID and Dilt 30mg QID\n Response:\n HR in the 90\n Plan:\n Continue to monitor patient hemodynamic status.\n Neuro: alert, follows commands.\n GI: abd soft non tented, positive for BS. NPO. Ngt for meds\n clamped.\n 3 x smear of golden loose stools during the shift.\n GU: clear yellow urine via foley. Lasix X1 given.\n Skin: reddened buttocks. Critic aid cream applied.\n Social: patient is a DNR. OK to re-intubate if needed. Family in to\n visit. Updated by RN and MD.\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702218,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - ERCP yesterday: . Pus was seen extruding from the major papilla . A\n single 2.5-3cm filling defect consistent witha stone or sludge ball\n that was causing partial obstruction was seen at the mid CBD. A 10FR\n by 5cm double pigtail biliary stent was placed successfully\n - low UOP overnight-> gave 1 liter D5W with 3 amps bicarb. uop picked\n up some. And bicarb improved\n - this AM: CVP was 7: gave 1 liter of LR\n - neo boluses and levophed on s/p ercp. trying to wean levophed.\n Currently on minimal sedation.\n Changed from AC to PS: doing well; trying to wean down all sedation and\n pressors:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:09 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 50 mcg/hour\n Norepinephrine - 0.08 mcg/Kg/min\n Other ICU medications:\n 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 06:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36\nC (96.8\n HR: 71 (61 - 79) bpm\n BP: 99/50(67) {94/42(62) - 144/76(103)} mmHg\n RR: 19 (8 - 23) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 8 (7 - 344)mmHg\n Total In:\n 3,664 mL\n 1,194 mL\n PO:\n TF:\n IVF:\n 3,664 mL\n 1,194 mL\n Blood products:\n Total out:\n 827 mL\n 330 mL\n Urine:\n 827 mL\n 330 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,837 mL\n 864 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): 446 (399 - 470) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 54\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 98%\n ABG: 7.38/38/124/22/-1\n Ve: 9 L/min\n PaO2 / FiO2: 310\n Physical Examination\n General: Intubated, sedated, not responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 48 K/uL\n 10.7 g/dL\n 266 mg/dL\n 2.1 mg/dL\n 22 mEq/L\n 3.5 mEq/L\n 37 mg/dL\n 105 mEq/L\n 137 mEq/L\n 30.8 %\n 17.8 K/uL\n [image002.jpg]\n 02:51 AM\n 04:57 AM\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n WBC\n 25.0\n 17.8\n Hct\n 31.6\n 30.8\n Plt\n 93\n 48\n Cr\n 2.4\n 2.1\n 2.1\n TropT\n 0.02\n TCO2\n 18\n 20\n 18\n 23\n Glucose\n 195\n 151\n 266\n Other labs: PT / PTT / INR:14.5//1.3, CK / CKMB /\n Troponin-T:408/7/0.02, ALT / AST:104 (138)/59 (96), Alk Phos / T\n Bili:70/4.5 (6.5), Amylase / Lipase:16/, Differential-Neuts:90.0 %,\n Band:4.0 % (18% -> 0 -> 4), Lymph:0.0 %, Mono:2.0 %, Eos:0.0 %,\n D-dimer: ng/mL, Fibrinogen:515 mg/dL, Lactic Acid:1.4 mmol/L,\n LDH:194 IU/L, Ca++:6.8 mg/dL, Mg++:2.0 mg/dL, PO4:3.1 mg/dL\n DIC panel: fibrinogen 515, FDP: 10-40; smear: occasional shistocytes;\n D-dimer: :\n DIC repeat panel:\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n +BCx: : anaerobic bottle: GPR\n Ucx and BCx pending\n Radiology: none\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but suspect in setting of\n met acidosis she fatigued. Has been having recently worsening dyspnea\n on exertion, stable orthopnea. Became acutely SOB requiring intubation\n in the ED. Heart failure is less likely as echo and CXR do not show any\n evidence of this. ABG shows good oxygenation and patient has been\n switched to PSV 10/5 with FiO2 40%.\n - Cont PSV for now and wean as tolerated; consider sbt once patient can\n tolerate no sedation and no pressors\n - goal to extubate patient today\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP yesterday showed significant pus and s/p stent\n placement. Patient afebrile and white count trending down. Lactate now\n normal. Initial sepsis likely secondary to biliary source given CBD\n dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - Cont broad spectrum abx with vancomycin and pip-tazo until\n sensitivies return\n - Trend CBC/diff, lactate, LFTs\n - Follow up blood cx , urine cx; GPR may be contamination, but will\n continue to cover broadly for now until further speciation.\n - Cont IVF to keep CVP 10-12 mmHg and good UOP\n - Wean norepinephrine as tolerated by MAP >= 65 mmHg\n - Check ScvO2\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea. Currently stable at 2.1; Baseline\n creatinine 1.2-1.4. - urine lytes: Fena: 0.2...pre-renal; in case she\n had lasix, FeUrea: 14.9%...pre-renal likely.\n - IVFs for CVP 10-12\n - Avoid nephrotoxins\n - Trend renal function\n .\n #Thrombocytopenia Likely secondary to sepsis. DIC labs equivical; low\n suscipicion of HIT as timing does not correlate.\n - Concerning as platelets continuing to decrease. Vancomycin/Zosyn may\n be a possibility as known to cause thrombocytopenia.\n - Repeat DIC labs\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Cont IVF per sepsis protocol; will give bicarb as needed for bicarb\n less than 18 or LR if needs resuscitation to prevent further NG\n acidosis.\n ICU Care\n Nutrition: NPO for now in expectation of extubation today\n Glycemic Control: None\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband\n status: DNR\n Disposition: ICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702517,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Atrial fibrillation (Afib)\n Assessment:\n Hr 100-130\ns afib with sbp ranging from 100-120\ns. k+3.4 and phos=1.7.\n afib first occurred during sbt on . pressors were then changed to\n neo in attempt to drop pt\ns hr but was unsuccessful. Pt was started on\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\n bp support\n Action:\n Pt repleted with 30mmol of kphos. Hemodynamics montitored closely.\n Amioderone gtt decreased to 0.5mg/min after 6 hrs of infusion at\n 1mg/min. neo being weaned to off as pt\ns hemodynamics tolerate\n Response:\n Hr remains in afib tachy from 100-130\ns but hemodynamically stable\n Plan:\n Plan is to continue infusion of amioderon for 18 hrs and then will\n consider d/c\ning gtt. Continue to follow hemodynamics and wean as\n tolerated to keep map> 60 and hourly uo > 30cc\ns/hr. check lytes as\n ordered and replete as needed\n Sepsis without organ dysfunction\n Assessment:\n Pt s/p ercp on . low grade temps but wbc up to 20.2 from yesterday\n count of 16.blood cultures from grew gm pos rods and gm neg rods.\n Septic shock most likely secondary to cholangitis and infected\n stone/sludge.with increase in wbc concern is for a new infection.\n Action:\n Fever curve followed closely. Pt receiving piperacillin as ordered.\n Awaiting final speciation of all culture data. Pan cultured today\n Response:\n Low grade temps and elevated wbc unchanged.\n Plan:\n Await results for all culture data. Administer antibiotics as ordered\n and follow fever curve.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt most likely became fatigued in the setting of metabolic acidosis\n and attempt to hyperventilate to compensate requiring her to be\n intubated. Placed pt on 40% cpap with 5 peep and ps of 5 . lungs\n essentially clear on auscultation. Suctioned for sm amts of thick tan\n sputum.cxr c/w fluid overload which is likely contributing to the\n difficulty in weaning her off the vent.once pt is weaned off pressors\n will then need diuresis and hopefully pt will start to mobilize fluid.\n Action:\n Vent weaned to 40%cpap with 5 peep and ps of 5. resp status monitored\n closely. Antibiotics administered as ordered. Reps toileting continues.\n Decision made not to extubate pt since she became tachypneic ,had lower\n tv\ns and appeared more uncomfortable. Versed gtt increased back up to\n 2mg/hr. vent changed back to ac mode of ventilation. Sputum for c&s\n sent off to microbiology. Ogt placed in order to start tube fdgs until\n pt is extubated.\n Response:\n Resting comfortably on ac mode after not tolerating decrease in vent\n settings.\n Plan:\n Check rsbi in the am and do sbt. Wean pressors to off if possible and\n then will diurese as needed . d/c tube fdgs at midnoc in the hope of\n extubating pt in the am. Continue to monitor pt\ns resp status and\n continue with resp toileting\n"
},
{
"category": "Respiratory ",
"chartdate": "2169-11-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 703202,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 54.4 None\n Ideal tidal volume: 217.6 / 326.4 / 435.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: Diminished\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Accessory muscle use,\n Tachypneic (RR> 35 b/min)\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 Intolerant of weaning attempts, Pending procedure / OR\n Respiratory Care Shift Procedures\n Planning to change tube size and bronch in am.\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702324,
"text": "Atrial fibrillation (Afib)\n Assessment:\n Pt was in NSR without ectopi at about 1030 patient had new onset Atrial\n Fibrillation. Patient was on spontaneous breathing trial did not appear\n to be in res p distress O2 SAT > 95. Patient remained on Levophed at\n 0.07mcg/kg/min with out changed in sbp. Patient Hr 110-120 and\n tolerated. Since 1500 HR up to 130-140 at times.\n Action:\n Patient placed back on ventilator. EKG done and read Additional fluid\n was given and attempted to wean Levophed without success, labs sent\n Response:\n Pt has remained in A Fibrillation. Hr 110-140. Unable to wean Levophed.\n Plan:\n Continue to monitor patient. Possibly changed patient to another\n pressor. Continue to treat sepsis and monitor labs,\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702396,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\n versed 3mg/hr.\n Action:\n Suctioned for small amount secretions. Blood gas in the am. Versed\n down to 2mg/hr for possible weaning.vent settings changed to CPAP+PS\n /40%/ PEEP 5/ PSV 10/ blood gas done in the am.\n Response:\n Easily arousable, stable during the shift.blood gas 7.38/ 38/124/ .am\n RSBI 54 and tolerated well.\n Plan:\n Wean vent / sedations as tolerated further and for possible\n extubation today.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\nS on\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr .am labs creat 2.1\n /BUN 37,elevated liver enzymes.\n Action:\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min\n initially , and later titrated down to 0.07mics/kg/mn .1000cc D5\n with NaHCo3 150 meq given for hydration and for PH 7.29 from the\n evening lab\n Response:\n SBP 85-90\ns when tried to titrate Levophed further .so continued on\n 0.07mics. urine output improved with fluid bolus.\n Plan:\n Hydrate and wean levo as tolerated. moniotr urine output / VSS .\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702398,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated , cpap/ps see metavision for vent settings\n Action:\n Weaning sedation lightened fentanyl gtt if off, versed at 2mg/hr easily\n arousable following commands\n Response:\n Am blood gas pending\n Plan:\n possible extubation today.\n Sepsis without organ dysfunction\n Assessment:\n s/p ERCP, switch from levophed to neo yesterday\n Action:\n Weaning neo as tolerated\n Response:\n SBP 85-90\ns neo is at 1mcg//min presently\n Plan:\n Wean neo as tolerated. moniotr urine output / VSS .\n Atrial fibrillation (Afib)\n Assessment:\n Continues in a-fib hr 120-130\n Action:\n 10mg of iv Dilt. given\n Response:\n Hr 10 110-118 for short period of time now back in 120\ns still in\n a-fib\n Plan:\n Continue to monitor patient. Monitor the HR, may start on amiodorone\n today\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702511,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Atrial fibrillation (Afib)\n Assessment:\n Hr 100-130\ns afib with sbp ranging from 100-120\ns. k+3.4 and phos=1.7.\n afib first occurred during sbt on . pressors were then changed to\n neo in attempt to drop pt\ns hr but was unsuccessful. Pt was started on\n amioderone gtt infusing at 1mg/min. continues on neosynephrine gtt for\n bp\n Action:\n Response:\n Plan:\n Sepsis without organ dysfunction\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-25 00:00:00.000",
"description": "Physician Attending/Fellow Progress Note - MICU",
"row_id": 702702,
"text": "TITLE:\n Chief Complaint: septic shock, 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 85yo F with pmh choledocholithiasis, dementia and renal cancer who\n presents with septic shock and cholangitis, s/p ERCP with stent, and\n respiratory failure. Now with persistent vent requirements.\n 24 Hour Events:\n Arterial line came out.\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:06 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Fentanyl - 05:00 PM\n Midazolam (Versed) - 08:11 AM\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unable to obtain, patient sedated and intubated.\n Flowsheet Data as of 11:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38\nC (100.4\n Tcurrent: 36.2\nC (97.2\n HR: 128 (114 - 141) bpm\n BP: 111/67(76) {83/54(62) - 127/70(81)} mmHg\n RR: 23 (14 - 30) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n Height: 64 Inch\n Total In:\n 1,682 mL\n 311 mL\n PO:\n TF:\n 73 mL\n 1 mL\n IVF:\n 1,610 mL\n 310 mL\n Blood products:\n Total out:\n 2,045 mL\n 920 mL\n Urine:\n 2,045 mL\n 920 mL\n NG:\n Stool:\n Drains:\n Balance:\n -363 mL\n -609 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): 380 (308 - 528) mL\n PS : 12 cmH2O\n RR (Set): 0\n RR (Spontaneous): 26\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 157\n PIP: 16 cmH2O\n Plateau: 20 cmH2O\n Compliance: 31.6 cmH2O/mL\n SpO2: 99%\n ABG: 7.46/34/127/24/1\n Ve: 9.9 L/min\n PaO2 / FiO2: 318\n Physical Examination\n Gen\nl: intubated, sedated\n HEENT: ETT in place, pupils constricted by equal and reactive\n Pulm: diminished, transmitted vent sounds, no wheezing, crackles at\n bases anteriorly\n CV: irregularly irregular, tachycardic, distant and no murmur\n appreciated, no gallop or rubs\n Abdomen: soft, no grimace to palpation, (+) bowel sounds\n Neurologic: responds to tactile stimuli, non-purposeful movement\n Labs / Radiology\n 9.8 g/dL\n 48 K/uL\n 128 mg/dL\n 1.5 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 29 mg/dL\n 107 mEq/L\n 140 mEq/L\n 29.7 %\n 11.3 K/uL\n [image002.jpg]\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n 03:15 AM\n 04:02 AM\n WBC\n 17.8\n 15.3\n 20.2\n 11.3\n Hct\n 30.8\n 31.4\n 30.7\n 29.7\n Plt\n 48\n 59\n 46\n 52\n 48\n Cr\n 2.1\n 2.1\n 1.8\n 1.6\n 1.5\n TropT\n 0.02\n TCO2\n 23\n 23\n 26\n 25\n Glucose\n 151\n 266\n 102\n 91\n 128\n Other labs: PT / PTT / INR:12.2/33.1/1.0, CK / CKMB /\n Troponin-T:269/8/0.02, ALT / AST:70/36, Alk Phos / T Bili:102/2.5,\n Amylase / Lipase:16/, Differential-Neuts:93.0 %, Band:0.0 %, Lymph:2.0\n %, Mono:4.0 %, Eos:0.0 %, D-dimer:3903 ng/mL, Fibrinogen:596 mg/dL,\n Lactic Acid:1.7 mmol/L, LDH:203 IU/L, Ca++:7.7 mg/dL, Mg++:2.2 mg/dL,\n PO4:2.2 mg/dL\n Assessment and Plan\n Respiratory failure\n - now likely secondary to volume overload\n - goal TBB - 1 to -1.5L today and will give prn lasix\n - wean pressure support as tolerated, check CXR\n Septic shock\n - now off pressors, autodiuresing\n - on zosyn, day , leukocytosis improving\n - LFTs improving s/p stenting via ERCP\n - awaiting speciation/sensitivities from cultures\nAtrial fibrillation\n - on amiodarone drip, will continue for now\n - will calculate total dose today\n Thrombocytopenia\n - stable, no signs of active bleeding\n - very low suspicion for HIT\n - will restart SC heparin when plts >50K\n ICU Care\n Nutrition:\n Comments: restart TF as unlikely to be extubated today\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Not indicated\n VAP: HOB elevation, Mouth care, Daily wake up\n Comments:\n Communication: Family meeting held , ICU consent signed\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 702128,
"text": "Patient presented to the ED from the doctor's office on with one\n day h/o SOB, coughing and near syncopal event. On arrival to the ED\n alert and aware and communicating verbally. Lab tests revealed elevated\n Liver enzymes and lactate. She was treated with 2-3l of IV fluids,\n vancomycin, zosyn and a central line placed poor access. She was\n then taken for an abdominal u/s where she was placed in a low lying\n position. She then got into respiratory difficulty which required\n intubation and sedation followed by pressor to maintain a perfusing\n pressure. She was then transferred to the for further management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated ,vented, AC /14/500/40% / sedated with fentanyl 50 and\n versed 3mg/hr.\n Action:\n Suctioned for small amount secretions. Blood gas in the am.\n Response:\n Easily arousable, stable during the shift. RSBI in the morning.\n Plan:\n Wean vent / sedations as tolerated further.\n Sepsis without organ dysfunction\n Assessment:\n Afebrile. pt s/p ERCP for dialated CBD with sludge .SBP 80 -100\nS on\n levophed 0.1mic/kg/min low urine output, 20-35cc/hr\n Action:\n Continued with iv zosyn q 8h. levophed increased to 0.12 mic/kg/min,\n tried to titrate to 0.1 later .1000cc D5 with NaHCo3 150 meq given for\n hydration and for PH 7.1\n Response:\n SBP 85-90\ns when tried to titrate levophed.so continued on 0.12mics.\n SBP >110-110 mm of hg.urine output improved with fluid bolus. Blood gas\n in the am.\n Plan:\n Hydrate and wean levo as tolerated.moniotr urine output / VSS .\n"
},
{
"category": "Physician ",
"chartdate": "2169-11-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 702505,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - pt. s/p ERCP with stent placement\n - patient became tachycardic with so changed back to A/C--> went\n into A.fib with RVR--> changed pressors to neo from levo hoping to help\n with tachycardia, with no change in tachycardia tried 10mg IV dilt,\n which dropped her BP into the 70's systolic and her HR decreased into\n the 110's. Her heart rate remained elevated in the 130\ns and she\n continued to have a pressor requirement, so she was started on\n amiodarone early this morning.\n - early this morning\npatient very tahcypneic, unable to be\n extubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 06:30 AM\n Piperacillin/Tazobactam (Zosyn) - 12:14 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Phenylephrine - 1 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Diltiazem - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.2\n Tcurrent: 37.3\nC (99.2\n HR: 133 (72 - 141) bpm\n BP: 102/56(73) {79/45(60) - 124/94(103)} mmHg\n RR: 31 (10 - 34) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 83.8 kg (admission): 83.8 kg\n CVP: 18 (0 - 325)mmHg\n Mixed Venous O2% Sat: 79 - 79\n Total In:\n 5,376 mL\n 285 mL\n PO:\n TF:\n IVF:\n 5,376 mL\n 285 mL\n Blood products:\n Total out:\n 1,320 mL\n 555 mL\n Urine:\n 1,320 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 4,056 mL\n -270 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): 317 (308 - 415) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35-had good tidal volumes though\n PIP: 15 cmH2O\n SpO2: 97%\n ABG: 7.41/39/98./26/0\n Ve: 8.8 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General: Intubated, awake, responsive\n HEENT: PERRL, MMM, ETT in place\n Neck: RIJ in place\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: warm, well perfused, 2+ pulses, no edema\n Skin: somewhat jaundiced\n Labs / Radiology\n 52 K/uL\n 10.5 g/dL\n 91 mg/dL\n 1.6 mg/dL\n 26 mEq/L\n 3.4 mEq/L\n 32 mg/dL\n 108 mEq/L\n 140 mEq/L\n 30.7 %\n 20.2 K/uL\n [image002.jpg]\n 07:35 AM\n 05:45 PM\n 05:50 PM\n 03:59 AM\n 05:12 AM\n 06:45 AM\n 03:25 PM\n 06:19 PM\n 04:18 AM\n 04:37 AM\n WBC\n 25.0\n 17.8\n 15.3\n 20.2\n Hct\n 31.6\n 30.8\n 31.4\n 30.7\n Plt\n 93\n 48\n 59\n 46\n 52\n Cr\n 2.4\n 2.1\n 2.1\n 1.8\n 1.6\n TropT\n 0.02\n 0.02\n TCO2\n 18\n 23\n 23\n 26\n Glucose\n 195\n 151\n 266\n 102\n 91\n Other labs:\n Ca: 7.7, Mg: 2.4, Phos: 1.7\n AST: 36, ALT: 70, AP: 102, LDH: 203, T. bili: 2.5\n PT: 12.2, INR: 1.0\n Microbiology:\n 11:55 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n GRAM NEGATIVE ROD(S).\n 11:58 pm BLOOD CULTURE X2.\n Blood Culture, Routine (Preliminary):\n GRAM POSITIVE RODS.\n URINE CULTURE (Final ): NO GROWTH.\n ERCP: The major papilla was intra-diverticular. Pus was seen extruding\n from the major papilla. An opening draining bile and pus consistent\n with a choledochoduodenal fistula was seen at the superior portion of\n the major papilla. Cannulation of the biliary duct was successful and\n deep with a sphincterotome using a free-hand technique. Contrast medium\n was injected resulting in complete opacification. A single 2.5-3cm\n filling defect consistent witha stone or sludge ball that was causing\n partial obstruction was seen at the mid CBD. A 10FR by 5cm double\n pigtail biliary stent was placed successfully using a Oasis 10FR stent\n introducer kit.\n Echo: The left atrium is mildly dilated. Left ventricular wall\n thickness, cavity size and regional/global systolic function are normal\n (LVEF >65%). The estimated cardiac index is normal (>=2.5L/min/m2).\n Right ventricular chamber size and free wall motion are normal. The\n aortic valve leaflets (3) are mildly thickened but aortic stenosis is\n not present. Trace aortic regurgitation is seen. The mitral valve\n leaflets are structurally normal. Mild (1+) mitral regurgitation is\n seen. The estimated pulmonary artery systolic pressure is high normal.\n There is a trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , the left\n ventricle is less dynamic, the velocity across the aortic valve is\n lower (now normal), and the severity of tricuspid regurgitation and\n pulmonary artery systolic pressure are lower.\n Assessment and Plan\n 85yo F with a h/o choledocholithiasis, HTN, renal CA, and dementia who\n presents with dyspnea and vomiting complicated by acute respiratory\n failure and septic shock likely secondary to biliary source. She is s/p\n ERCP and stent.\n .\n # Dyspnea/respiratory failure: Resp failure does not appear primary\n lung process, as CXR is rather unimpressive, but in the setting of her\n metabolic acidosis she was hyperventilating to compensate and\n fatigued. Becoming acutely SOB and requiring intubation in the ED. Has\n been doing well on the ventilator, had hoped to extubate her yesterday,\n however she went into A.fib with RVR during her , she was\n intially changed back to A/C, then transitioned back to PSV.\n - early this morning\npatient very tachypneic with lower tidal\n volumes, appeared very uncomfortable during short trial this morning,\n will transition back to A/C and then wean to PSV throughout the day\n -Chest x-ray appeared volume overloaded, which is likely contributing\n to the difficulty weaning her off the ventilator, when patient is able\n to be weaned off pressors will need diuresis. Hopefully patient will\n start to mobilize her extra fluid, however once off pressors if she is\n unable to, will give lasix as needed to help decrease the fluid in her\n lungs\n - Hopeful extubation tomorrow pending ability to diurese\n # Atrial Fibrillation: First occurred during on , initially\n rates were in the 110\ns, then increased to the 130\ns, pressor changed\n from levophed to neo without any effect, her BP dropped with IV dilt,\n so started amiodarone morning of due to continued pressor\n requirement\n - Monitor for improvement and hopeful d/c of amio once patient is\n extubated and off sedation\n # Septic shock: Likely secondary to cholangitis and infected\n stone/sludge. ERCP showed significant pusand very large stone, she is\n s/p stent placement. Patient afebrile and white count trending down.\n Lactate now normal. Initial sepsis likely secondary to biliary source\n given CBD dilation with sludge and obstructive LFTs in setting on known\n choledocholithiasis. No other source of infection found.\n - With increasing leukocytosis concern for a new infection, will\n reculture blood, urine and sputum, also send a C.diff when patient has\n a bowel movement, if LFT\ns increase, will reimage RUQ due to concern\n for possible blockage of stent\n - Cont zosyn pending any further culture data; f/u speciation and\n sensitivities from prior blood cx\n - Trend CBC/diff, LFTs, especially in the setting on increasing\n leukocytosis, will add on Diff to AM labs\n - Follow up blood cx speciation , urine cx with no growth\n - Wean neo as tolerated by MAP >= 60 mmHg\n # ARF: Likely related to sepsis and intravascular volume depletion\n secondary to vomiting and diarrhea, also likely some component of ATN\n as her renal function has not improved as quickly with fluids as would\n be expected in a purely pre-renal picture. Cr improving to 1.6 today,\n baseline creatinine 1.2-1.4.\n - Titrate MAP to greater than 60, unless urine output decreases then\n will titrate to increased MAP\n .\n #Thrombocytopenia Likely secondary to sepsis. Low suscipicion of HIT as\n timing does not correlate since patient has not had a prior heparin\n exposure. Vancomycin may also be contributing to her\n thrombocytopenia. Platelets slightly increased today.\n - Continue to hold vanc/heparin\n - No signs of active bleeding\n - Transfuse for less than 10,000 or 30,000 for procedure\n - If platelets remain stable or increase tomorrow would restart heparin\n as HIT is very unlikely\n # Mixed Anion gap (lactic acid)/Non-anion gap (NS and diarrhea)\n acidosis: Gap has closed. Lactate normalized.\n - Bicarb 26 today, extubation will be facilitated by resolution of\n acidosis.\n ICU Care\n Nutrition: Will place OG tube for tube feeds today and turn them off at\n midnight for hopeful extubation tomorrow\n Glycemic Control:\n Lines:\n Multi Lumen - 03:45 AM\n 20 Gauge - 03:45 AM\n Arterial Line - 10:32 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer:\n VAP: bundle\n Comments:\n Communication: Comments: Husband, (daughter) is HCP.\n status: DNR-is intubated\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n resident note, including the assessment and plan. I would emphasize and\n add the following points: 85F a w/ renal ca, dementia,\n choledocolithiasis in w/ sepsis/shock from cholangitis s/p ERCP\n with stent placement. She remains intubated, Course has been c/b\n continued pressor requirements and development of A-fib in setting of\n yesterday now on amio gtt for rate control.\n PE: Tm 99.2 BP 102/56 HR 72-141 RR 20's Sat 97% on PS 10/5 40%\n -->7.41/39/98%\n Intubated, more alert awake, NAD, follows commands, CTA ant, decreased\n bb, , tachy, soft + BS, NT, no ruq tenderness, no pedal edema\n LABS: wbc 20.2, hct 31, plt 52, na 140, cr 1.6 (2.6), lactate 1.7, t\n bili, ast/alt continue to decrease, inr 1.0,\n Micro: bl cx's--> gpr/gnr\n CXR-->w/ sm L effusion and prominent vascular markings\n A/P: Sepsis from cholangitis c/b arf, resp failure, thrombocytopenia.,\n and a-fib. Her WBC is rising. She failed this am, likely related\n to extra volume. She remains on pressors.\n Agree with plan to rest on ACV and trial back on PS later today as she\n tolerates following abg and clinical picture. Her MAPs are adequate and\n we should be able to titrate off pressor support. She remains on amio\n gtt/load for rate control. Her cr continues to improve toward her\n baseline CRI and her urine outpt is excellent. We hope she will\n continue to mobilize fluids, though once BP is stable off pressors, we\n may need diurese prior to and extubation. We continue to treat\n biliary sepsis with zosyn. Given her rising wbc ct, we are concerned\n for new infection. Her lfts are down and her abd exam benign, there is\n no diarrhea or new secretions and she remains AF. Her lines are just a\n few days old. We will repeat pan cxs, check for c diff, and f/u\n pending cx speciation /sensitivities. We keep a low threshold for\n broadened coverage in setting of temp spike or clinical decline. We\n continue to monitor her plts closely and suspect her thrombocytopenia\n is infection response or medications noting no recent heparin\n exposure to support early HIT. Will continue to hold heparin products\n and monitor, following DIC labs, and keeping t and c. A-line and CVL.\n DNR. Start TFs.\n Remainder of plan as outlined in resident note.\n Patient is critically ill\n Total time: 45 min.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:31 PM ------\n"
},
{
"category": "ECG",
"chartdate": "2169-12-01 00:00:00.000",
"description": "Report",
"row_id": 192914,
"text": "Baseline artifact. Normal sinus rhythm with atrial premature beat.\nIntraventricular conduction delay of right bundle-branch block morphology.\nNon-specific ST-T wave abnormalities. Compared to the previous tracing\nof atrial fibrillation has resolved and right bundle-branch block is\nnew. Clinical correlation and repeat tracing are suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-11-23 00:00:00.000",
"description": "Report",
"row_id": 192915,
"text": "Atrial fibrillation with rapid ventricular response. Low QRS voltage in the\nprecordial leads. Diffuse non-specific T wave flattening. Compared to the\nprevious tracing of atrial fibrillation is new. Decreased QRS voltage\nis now evident.\n\n"
},
{
"category": "ECG",
"chartdate": "2169-11-22 00:00:00.000",
"description": "Report",
"row_id": 192916,
"text": "Baseline artifact. Sinus rhythm. Since the previous tracing probably no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2169-11-21 00:00:00.000",
"description": "Report",
"row_id": 192917,
"text": "Sinus rhythm. Leftward axis. Since the previous tracing no significant\nchange.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2169-11-21 00:00:00.000",
"description": "Report",
"row_id": 192918,
"text": "Sinus rhythm. Since the previous tracing of the single beat showing a\nmore leftward axis and right bundle-branch block morphology is no longer\npresent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102526,
"text": " 9:52 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ?fluid overload\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with progressive dyspnea, intubated, septic\n REASON FOR THIS EXAMINATION:\n NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:22 A.M., \n\n HISTORY: Progressive dyspnea and sepsis.\n\n IMPRESSION: AP chest compared to and 14 through 1:09 a.m.\n\n Peripheral wedge-shaped opacity in the left hemithorax obscuring the lateral\n pleural sulcus, which developed on , has been stable since 1:39 a.m.\n today consistent with pulmonary infarction, perhaps related to septic embolus\n or small loculated pleural fluid collection, also sometimes the result of\n pulmonary embolus. Moderate cardiomegaly and enlargement of the pulmonary\n arteries are longstanding. ET tube in standard placement. Right jugular line\n ends in the low SVC, nasogastric tube passes into the stomach and out of view.\n New opacification at the right lung base may be due to mild edema in the\n setting of severe emphysema. No pneumothorax or appreciable layering pleural\n effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102456,
"text": " 7:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA, CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for PNA, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: Chest radiograph .\n\n UPRIGHT AP VIEW OF THE CHEST: Study is slightly limited due to patient\n motion. The cardiac, mediastinal, and hilar contours are stable, with\n unchanged enlargement of the pulmonary arteries, compatible with underlying\n hypertension. Prominent epicardial fat pad is again noted. The lungs are\n grossly clear without focal consolidation, pleural effusion or pneumothorax.\n There appears to be hyperinflation of the lungs, stable from prior.\n Degenerative changes are seen within the right shoulder. New surgical clips\n are also noted within the epigastric region. Multilevel degenerative changes\n are present in the thoracic spine.\n\n IMPRESSION: Study is slightly limited due to patient motion. No gross\n evidence of pneumonia or congestive heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102784,
"text": " 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with sepsis requiring intubation from a biliary source\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:40 PM\n PFI: Gradual increase in left now moderate pleural effusion with adjacent\n opacity, likely due to compression atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 85-year-old woman with sepsis, requiring intubation. Evaluate\n for interval change.\n\n COMPARISON: Several prior studies, most recent dated .\n\n FINDINGS: The patient remains intubated, with the endotracheal tube in a\n standard position. A nasogastric tube is not present. A right internal\n jugular line ends in the mid SVC. The heart remains mildly enlarged. There\n is a left-sided pleural effusion, slowly increasing over the period of days.\n There is adjacent density, probably due to compression atelectasis.\n\n The pulmonary arteries are enlarged, as before. There is no pneumothorax or\n frank pulmonary edema.\n\n IMPRESSION: Gradual increase in left now moderate pleural effusion with\n adjacent opacity, likely due to compression atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102470,
"text": " 11:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new central line\n REASON FOR THIS EXAMINATION:\n eval for line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with new central line placement.\n\n COMPARISON: Chest radiographs of and , 7:38 p.m.\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: A new right internal jugular central\n venous catheter tip is seen in the low SVC. No new pneumothorax, pleural\n effusion, or mediastinal widening is seen. Otherwise, the exam is unchanged,\n with evidence of pulmonary hypertension and top normal heart size.\n\n IMPRESSIONS: No evidence of CHF or consolidation.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-22 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1102472,
"text": " 12:16 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please eval liver/gb\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new transamionitis and jaundice\n REASON FOR THIS EXAMINATION:\n please eval liver/gb\n ______________________________________________________________________________\n WET READ: AGLc WED 1:37 AM\n difficult to compare across modalities. perhaps slight increase in size of\n common duct at liver margin, previously ~21mm, currently ~25 mm, in pt with\n chronic dilatation of intra- and extra-hepatic bile ducts. echogenic\n material seen in distal CBD, probably sludge/sludge ball. more focal stone-\n appearing filling defect seen on recent MR (measuring 2.5 cm in longest\n dimension) not seen. also distalmost CBD / panc head not well visualized.\n clinical correlation necessary, and if indicated, ERCP or MRCP could be\n performed for further assessment. no fluid in RUQ. no Rt hydro.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with acute onset of dyspnea and vomiting\n beginning yesterday, with near collapse today. No leukocytosis but total\n bilirubin of 9.9.\n\n COMPARISON: MR abdomen of , CT torso last performed on , and\n lap ultrasound performed of the kidneys on .\n\n RIGHT UPPER QUADRANT ULTRASOUND: The examination of the right upper quadrant\n was terminated prematurely due to patient respiratory difficulty towards the\n end of the exam.\n\n The liver parenchyma appears unremarkable. There is again dilatation of the\n extrahepatic bile ducts and central intrahepatic ducts, similar to that seen\n on MRI of 2 weeks prior. The common bile duct again has dilated and tortuous\n appearance, measuring up to 2.5 cm in diameter. Echogenic debris is seen\n within the distal common bile duct which is non-shadowing, probably\n representing sludge and/or stones. However, the distalmost CBD and pancreatic\n head is not well visualized.\n\n Limited views of the right kidney show no hydronephrosis. There is again\n echogenic appearance to the kidney with cortical thinning. The known lower\n pole renal mass is not assessed as the examination was terminated at this\n point.\n\n No ascites is seen in the visualized right upper quadrant.\n\n IMPRESSION: Dilatation of bile ducts, similar to that seen on recent MRI\n study performed 2 weeks ago. Again with sludge/stones seen in CBD, but\n distal most CBD and pancreatic head not well visualized. In this patient with\n clinical concern for ascending cholangitis,there are no imaging studies\n sensitive for this.\n (Over)\n\n 12:16 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please eval liver/gb\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102475,
"text": " 1:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess cardiopulm status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory distress\n REASON FOR THIS EXAMINATION:\n Please assess cardiopulm status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with respiratory distress.\n\n COMPARISON: Earlier same evening radiographs of at 07:38 p.m. and\n 11:19 p.m., as well as prior chest radiograph of and PET CT of .\n\n PORTABLE UPRIGHT CHEST RADIOGRAPH: The study is degraded by respiratory\n motion. Allowing for this, exam is unchanged from two hours prior, with no\n interval development of pneumothorax, pleural effusion, pulmonary edema or\n consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102984,
"text": " 3:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: OG tube placement, thanks\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory distress s/p OG tube placement\n REASON FOR THIS EXAMINATION:\n OG tube placement, thanks\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: OG tube placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, an OG tube has been placed.\n The tip of the tube projects over the distal parts of the stomach, the course\n of the tube is unremarkable. There is no evidence of complications, notably\n no pneumothorax. The other monitoring and support devices are in unchanged\n position. Overall unchanged appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-22 00:00:00.000",
"description": "ERCP BILIARY&PANCREAS BY GI UNIT",
"row_id": 1102642,
"text": " 11:03 PM\n ERCP BILIARY&PANCREAS BY GI UNIT Clip # \n Reason: please evaluate ERCP films from \n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with CBD stone, cholangitis. Post double pigtail stent\n placement.\n REASON FOR THIS EXAMINATION:\n please evaluate ERCP films from \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Common bile duct stone and cholangitis.\n\n COMPARISON: MR from .\n\n FINDINGS: 16 spot fluoroscopic images of the right upper quadrant from an\n ERCP obtained without a radiologist present. Images reveal scattered clips in\n the right upper quadrant. Thereafter, note is made of cannulation of the\n common bile ducts with consequent opacification of both the pancreatic and\n common bile ducts. Both ducts are dilated with pronounced dilation of the\n common bile duct as well as the intrahepatic biliary ducts. Final image\n reveals placement of a plastic stent traversing the common bile duct.\n\n IMPRESSION: Dilation of both the pancreatic and common bile ducts, similar to\n that depicted on comparison cross-sectional images. Further details are found\n on ERCP report dated .\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102476,
"text": " 1:40 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: tube placement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with recent ett for flash edema\n REASON FOR THIS EXAMINATION:\n tube placement?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 85-year-old female with recent intubation for flash edema.\n\n COMPARISON: Chest radiographs performed earlier on the same evening on\n at 07:38 p.m. and 11:19 p.m., as well as on at 01:12 a.m.\n\n PORTABLE SUPINE CHEST RADIOGRAPH: The patient is newly intubated, with the ET\n tube tip terminating 3.2 cm above the carina. The right internal jugular\n central venous catheter tip remains in the mid-to-lower SVC. Allowing for\n rotation of the patient, cardiomediastinal contours are unchanged. No supine\n evidence for large pneumothorax is seen. However, there is now increased\n dense consolidation in the left lateral cardiophrenic angle.\n\n IMPRESSIONS:\n 1. No flash pulmonary edema seen.\n 2. Newly apparent dense consolidation in left lateral costophrenic angle,\n concerning for pulmonary embolism with infarction in this patient with\n respiratory distress. This was discussed with Dr. from the\n Medicine service over the phone at 8 am.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103260,
"text": " 4:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate a change in lung fields.\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with acute resp failure on vent, cholangitis, please evaluate\n a change in lung fields.\n REASON FOR THIS EXAMINATION:\n please evaluate a change in lung fields.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for lung fields, cholangitis.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Moderate cardiomegaly with suspicion for left-sided pleural effusion\n on subsequent retrocardiac atelectasis. The monitoring and support devices\n are in unchanged position. The presence of minimal right-sided pleural\n effusion cannot be excluded. Slightly hyperlucent lung structure, consistent\n with the presence of pulmonary emphysema. No focal parenchymal opacities\n suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1103566,
"text": ", F. MED 2:44 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 41cm left picc. tip?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new picc.\n REASON FOR THIS EXAMINATION:\n 41cm left picc. tip?\n ______________________________________________________________________________\n PFI REPORT\n Left PICC ends in upper superior vena cava.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1103565,
"text": " 2:44 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 41cm left picc. tip?\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with new picc.\n REASON FOR THIS EXAMINATION:\n 41cm left picc. tip?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 4:46 PM\n Left PICC ends in upper superior vena cava.\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n INDICATION: 85-year-old woman with new PICC.\n\n COMPARISON: Multiple prior studies, most recent dated .\n\n FINDINGS: Left PICC ends in the upper superior vena cava. The patient\n remains intubated, with the endotracheal tube terminating 3.2 cm above the\n carina. The right internal jugular line ends in the mid superior vena cava.\n Left pleural effusion with atelectasis have not changed. Pulmonary arteries\n are markedly enlarged, consistent with pulmonary arterial hypertension. The\n right lung is clear. There is no pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1102785,
"text": ", S. MED 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for interval change\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with sepsis requiring intubation from a biliary source\n REASON FOR THIS EXAMINATION:\n Evaluate for interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Gradual increase in left now moderate pleural effusion with adjacent\n opacity, likely due to compression atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2169-11-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1103113,
"text": " 1:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for change in volume status\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old woman with respiratory failure and septic shock\n REASON FOR THIS EXAMINATION:\n Eval for change in volume status\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure and septic shock.\n\n Comparison is made with prior study performed a day earlier.\n\n Small right, moderate left pleural effusions associated with adjacent\n atelectasis are unchanged. The upper lobes are clear. Lines and tubes are in\n unchanged standard position. Cardiomediastinal contours are unchanged.\n\n\n"
}
] |
27,597 | 180,160 | 60 yo presents w/ dyspnea and peripheral edema, admitted initially to ICU as above with severe anemia, acute renal failure, pulmonary hemorrhage with w/u (as above) consistant with anca+ vasculitis - Wegner's Granulomatosis. Pt with prolonged hospitalization, tx with cytoxan, 7 rounds of plasamphoresis, steroids - pt with slow pulm course (as expected), multiple unit transfusion as noted above in the ICU - required only 2units on floor with h/h remaining stable while in-house. Pt with rare aspergillus on sputum, ID consulted - decision to treat with voriconazole for 3 mo (can truncate treatment course if LFTs increase with plan below). ID also with concern for latent TB - AFBx3 neg as checked prior to d/c - decision to treat with INH/vit b6, LFTs to be monitored as outpt, scheduled staggerred consultant appointments for each medical consultant to follow LFTs with voriconazole/INH plan as below. Consultant f/u as detailed in summary (Rheum, Renal, ID, ENT, and Pulmonary). <br> 1. Wegner's Granulomatosis -presented w/ pulm hemorrhage, severe anemia, and ARF. -Appreciated Rheum and Renal input -s/p 7 treatments of plasmapheresis, completed on . Per Renal, removed pheresis catheter on -Appreciate Rheum input, increased Cyclophosphamide to 125mg QD and prednisone to 50mg QD on - with plan for further changes per outpt, f/u time schedule per rheum and renal services -Dyspnea, cough improved and oxygen requirement stable, with cont need for pulm support (more at night time, though recently relatively stable), overall this will be a process with pt about his expected baseline at this point in his disease process - pulm f/u in 1 month, has VNA set upt and home for o2, nebs, pulm support -Renal function stable, Cr monitored. Continued to make good urine, foley discontnued. Appreciate Renal recs, plan for outpt f/u with Dr. , lytes stable at time of d/c. <br> 2. Hypoxia/Aspergillus infection/concern for tuberculosis. -Initially thought to be from Wegener's disease, and is likely main contributor. Pt significantly improved from initial presentation and continues to have stable oxygen requirement. Is afebrile wnl WBC but also immunosupressed, (WBC relatively stable at time of d/c - 4.9). -Treating w/ voriconazole given rare aspergillus growth in one sputum sample () given significant immunosuppression, plan for 4-6wk treatment course (has clinic f/u this month) -shorter course give neg galactomannan and rare cx initially along with INH/cytoxan regime as well. -Oxygen requirement stable, pt worked w PT w/o increased oxygen requirement. Appreciate pulm recs, but they do not think repeat bronchoscopy is necessary. Overall pt stable with treatment, but exam still with sig wheezing, at this point still with benefit from neb tx prn - has VNA set up for support here -PPD placed on is neg but given exposure to TB (father had tb) and immunosupression, result difficult to interpret, quantiferon study considered, though given difficulty with result interpretation - plan to treat if AFB neg x3 (3rd pending, have to resend due to poor sample , awaiting sample's results). Given this regime will need very close monitoring of LFTs, would appreciate consulting services to also monitor LFTs and to assist coordinating appts (staggering) to keep pt consistantly monitored along with pt's PCP (should be checked q2 wks for next wks. - d/c on INH 300mg qd and B6 25mg qd. -AFB neg x3 at time of d/c. -Pt will be treated for latent TB given hx of exposure to tb and being immunocompromised as above <br> 3. Possible Aspergillus infection - Sputum Cx showed rare Aspergillus. ID consulted given pt is immunosuppresed. Clinically pt was afebrile w/ nl WBC but given abn Chest and sinus CT finding (which can be seen either with Wegner's or aspergillous) and given the fact that pt will be immunosupressed longterm, pt was started on Voriconazole (LFTs wnl). (LFTs remain stable, will check monday again (hold tomorrow) -ENT initially consulted given abn sinus CT. They did rhinoscopy and cultures from nasal region, which have not shown aspergillous. -Discussed w ENT about ID's request for sinus sampling and they strongly feel that he does not have acute invasive sinusitis and will defer on sinus sampling -Per ID, repeated sputm cx and sputum from and neg for fungal cx. Nasal swab by ENT showing no fungal growth. -Serum galactomannan noted negative -Per ID recs, ppd placed given that pt will be on immunosupressives for a longtime, ppd placed on has been neg (no induration noted) -Treat with voriconazole for 4-6wks with possibility of shorter course if change in LFTs (with plan for INH to be held at that point till voriconazole tx completed) <br> 4. Anemia, disease and recent active and losses - combination of ACD and acute blood loss from pulm hemorrhage. S/p 2 units PRBC on as HCT was 18 w appropriate correction to 25. Continue FeSo4 and continue to monitor as outpt, H/H stable at time of d/c. <br> 5. Tachycardia, suprventricular- Pt noted to have Aflutter w/ 2:1 block since admission. Pt is asymptomatic during tachycardia and has no hx of it. Tachycardia exacerbation by pulm disease and deconditioning. TTE this admission showed EF 45-50% w trace MR/TR. TSH wnl. HR under good control w repletion of lytes and combination of metoprolol and diltiazem, will continue. PCP to /u and titrate as indicated, may return to sinus with improvements of pulm status, again to f/u. <br> 6. Longterm immunosupression -Bactrim SS MWF for PCP (changed from initial atorovoquone with renal fx more stable now) -Calcium/VitD and Fosamax for osteoporosis prophylaxis (CaCO3 increased past week to help with repletion) -PPI for ulcer prophylaxis . 7. Hyperglycemia -likely high dose prednisone. Since pt is going to be on longterm steroids and has persistent hyperglycemia,pt started on low dose glyburide on . BS improved, fluctuates, will continue current dose, with note pt will need this monitored once able to be weaned off steroids as outpt. VNA to check BS intermittantly, keep BS log for PCP to /u. <br> 8. Constipation - continue senna and dulcolax in addition to colace, pt instructed to take as needed prn. . FEN - Reg diet. . Code status - Full . Disposition - To home today now that AFB neg x3, with extensive home VNA set up with home 02, resp support long with prn nebs, and home PT along with close family support. Pt given instructions, with close f/u arranged. <br> | Chief Complaint: Respiratory distress, hypoxemia HPI: 24 Hour Events: Remains with high FiO2 requirment. Monitor I/O HEMATURIA -- concern for hemorrhagic cystitis A-FIB -- good rate control COntinue meds. If worsening will get U/A -On Sevelamer, for hyperphos. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Assessment and Plan Wegener's Granulomatosis RESPIRATORY DISTRESS -- slow improvement clincally and radiographically. Confirmed to have c-anca vasculitis. Confirmed to have c-anca vasculitis. Confirmed to have c-anca vasculitis. TITLE: Resp Care Note, Pt rxd with albuterol/ atrovent via mask. #Hypocalcemia: plasmapheresis (containing citrate) and to underlying renal failure -follow ionized Ca, more accurate given citrate used in pheresis. - treating underlying cause (likely Wegener's) - Foley in place , strict I&O, q8 lytes. - Albuterol nebs PRN - CXR daily - F/u on BAL results from OSH - Patient now tolerating PO, though still concern for respiratory status - treating treating the underlying disease (presumed Wegener's): -Plasmapheresis, dose yesterday (QOD) -Prednison po daily, -Cyclophosphamide-dose to be determined after c/s with rheum and renal. Plan: Continue to monitor VSS, ECG changes, continue on lopressor., monitor lytes and replete as needed Renal failure, acute (Acute renal failure, ARF) Assessment: U/O maintaining above 40cc/hr, reveived one unit of red cell yesterday Action: HCT trending up from 20.9 to 22.4 after blood, received cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior to Cytoxan Response: U/O remains wnl, BUN and creatinine trending down from 160 and 8.1 yesterday to 149 and 7.1 early this a.m Plan: Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21), cytoxan as ordered Respiratory failure, acute (not ARDS/) Assessment: Continues on O2 6 liters NC and supplemental O2, sats maintaining above 95%, desats when pt removes O2 in his sleep. If worsening will get U/A -On Sevelamer, for hyperphos. If worsening will get U/A -On Sevelamer, for hyperphos. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Most likely secondary to diffuse alveolar hemorrhage C-ANCA vasculitis - Continue supplemental O2 PRN. Plan: Tachycardia, Other Assessment: Pt remains in ST with hr ranging from Action: Response: Plan: Pt currently clinically tachypneic. RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual improvement. -EKG unchanged # Tachycardia: Aflutter on EKG, in and out of NSR this am. Pt currently clinically tachypneic. Pt currently clinically tachypneic. # LE edema: likely secondary to renal failure above. # LE edema: likely secondary to renal failure above. Assessment and Plan VASCULITIS -- Wegener's Granulomatosis. Marked upper lobe predominant paraseptal and centrilobular emphysema are present. (Over) 5:49 PM CT CHEST W/O CONTRAST Clip # Reason: interval change, worsening consolidations on CXR, compare w Admitting Diagnosis: VASCULITIS FINAL REPORT (Cont) The airways are patent to the level of lobar and segmental bronchi bilaterally except for right lower lobe with occlusion of the apical segment is noted, most liklely due to secretions. The right ventricular cavity is mildly dilated with mild globalfree wall hypokinesis. Mild (1+) aortic regurgitation is seen. Thereis mild regional left ventricular systolic dysfunction with septalhypokinesis. Mild (1+) mitral regurgitation is seen.There is mild pulmonary artery systolic hypertension. Diffuse bilateral consolidations with slight decrease in the right mid lung but are unchanged on the left. Diffuse bilateral consolidations with slight decrease in the right mid lung but are unchanged on the left. There is no pericardialeffusion.IMPRESSION: Mild hypokinesis of the septum along with abnormal septal motion.Mildly dilated and hypokinetic right ventricle. Mild regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basalanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; midinferoseptal - hypo; septal apex - hypo;RIGHT VENTRICLE: Mildly dilated RV cavity. In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. Pt currently clinically tachypneic. Cyclophosphamide was started after UOP was confirmed to be adequate. HYPOCALCEMIA -- iv replacement Rx, consider constant infusion. Heart-Tachycardic and regular rate suggested on initial exam Extremities--1+ bilateral lower extremity edema. Assessment and Plan 60 yom now with Pulmonary-Renal syndrome. Will await Renal and Rheum recs. Following hct and lytes Q8hr as ordered. Following hct and lytes Q8hr as ordered. Following hct and lytes Q8hr as ordered. U/A there--RBC's and granular casts documented. Plan is for plasmapharesis, K to be rechecked. Nephritic picture with RBC casts. He was given Solumedrol 1g IV x 1. On arrival here, pt appeared mildly tachypneic. Lung sounds RLL Lung Sounds: Crackles RUL Lung Sounds: Clear LUL Lung Sounds: Diminished LLL Lung Sounds: Crackles Comments: Plan Pt presently on 3 lpm n/c and ordered for nebs alb/atr. #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+ binder) -Replace Ca2+ (given 4g this am), check again this PM # Tachycardia: Aflutter on EKG. cystitis while on cytoxan) #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+ binder) -Replace Ca2+ (given 4g this am), -lytes q6hrs -EKG # Tachycardia: Aflutter on EKG. # LE edema: likely secondary to renal failure above. In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. HYPOCALCEMIA -- iv replacement Rx, consider constant infusion. DDx: Wegeners granulomatosis, MPA, Goodpasteurs, lupus, post-strep GN with DIC (less likely). Chief Complaint: Respiratory distress, hypoxemia HPI: 24 Hour Events: Remains with high FiO2 requirment. Monitor I/O HEMATURIA -- concern for hemorrhagic cystitis A-FIB -- good rate control COntinue meds. Pt underwent bronchoscopy on , and was found to have active low grade blood emanating from the RLL and LLL. Assessment and Plan 60 yom now with Pulmonary-Renal syndrome. # LE edema: likely secondary to renal failure above. # LE edema: likely secondary to renal failure above. | 152 | [
{
"category": "Physician ",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 335302,
"text": "Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n Continues to require supplimental oxygen, desaturates with activity.\n Tolerating net diuresis.\n Hemoptysis resolved.\n Overall, states to feel improved. Dysnpea improved. Able to sleep\n somewhat last PM (improvement).\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.4\n HR: 98 (86 - 128) bpm\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\n RR: 25 (11 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 560 mL\n PO:\n 980 mL\n 360 mL\n TF:\n IVF:\n 319 mL\n 200 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 960 mL\n Urine:\n 4,410 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///31/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 170 K/uL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Imaging: CXR () somewhat improved, esp. right lung field.\n Assessment and Plan\n Wegener's Granulomatosis\n RESPIRATORY DISTRESS -- slow improvement clincally and\n radiographically, although clinically best tody. Continue current\n management. Provide supplemental oxygen, monitor SaO2, maintain >90%.\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\n urine output. No indication for acute dialysis at this time.\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\n Continue steoids, cytoxan, plasmaphoresis (total 7 treatments)\n NUTRITIONAL SUPPORT\n encourage PO.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335452,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding.\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335453,
"text": "Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding.\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335455,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Labs obtained in a.m\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335456,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal parameters trending down\n Action:\n Diuresed this p.m with 20 lasix,\n Response:\n Good response to lasix, negative 770 by midnight\n Plan:\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335620,
"text": "Chief Complaint:\n 24 Hour Events:\n Patient desats to 85 when FM falls off\n Did well O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 108 (91 - 135) bpm\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\n RR: 19 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 190 mL\n PO:\n 1,220 mL\n 120 mL\n TF:\n IVF:\n 470 mL\n 70 mL\n Blood products:\n Total out:\n 2,465 mL\n 900 mL\n Urine:\n 2,465 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -710 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n Gen- NAD, Aox3\n CV- Tachy but reg rhythm, No M/R/G\n Pulm- Decreased breath sounds at bases, crackles to mid lung fields\n Abd- Soft, NT/ND, BS +\n Extr- No edema, Puleses 2+symmetric\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 335606,
"text": "Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n No new events.\n Revieved 1 U PRBC transfusion, tolerated well.\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 Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 122 (97 - 135) bpm\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 477 mL\n PO:\n 1,220 mL\n 360 mL\n TF:\n IVF:\n 470 mL\n 117 mL\n Blood products:\n Total out:\n 2,465 mL\n 1,540 mL\n Urine:\n 2,465 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -1,063 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.2 g/dL\n 200 K/uL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n Respiratory distress and acute renal failure --> Wegener's\n Granulomatosis\n RESPRIATORY DISTRESS -- gradual improvement. Monitor RR, SaO2,\n maintain >90%.\n RENAL FAILURE -- initial good recovery, with good urine output;\n however, now creatitine with minimal decline over past 2-3 days. \n be approaching new baseline. ultimately require dialysis.\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\n cytoxan & plasmaphoresis\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\n disease.\n FLUIDS -- desire net negative if tolerated by BP.\n NUTRITIONAL SUPPORT -- encourage PO.\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335622,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Hx. Of alveolar hemorrhage due to wegener\ns dz. Remain on O2 at 80%\n face tent and 6L NC. LS diminished. Congested non productive cough.\n Action:\n Nebs as ordered. Up to chair for good part of the day.\n Response:\n Tolerated being up well. Pt. coughed while up in a chair but no sputum.\n O2 sat stable >90%. Still will desat to 86% while eating or when mask\n of. CXR improving.\n Plan:\n Cont. current treatment.\n"
},
{
"category": "General",
"chartdate": "2199-07-15 00:00:00.000",
"description": "Generic Note",
"row_id": 335701,
"text": "TITLE: Resp Care Note, Pt rx\nd with albuterol/ atrovent via mask. BS\n wheezes. Improved after rx. Will cont to monitor resp status.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335681,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Plasma pheresis due tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\n during sleep)\n Action:\n Continues on O2, ( frequently reminded to keep O2 on)\n Response:\n Remains afebrile, no hemoptysis, slept well overnight\n Plan:\n Continue to monitor resp status, wean O2 as tolerated.\n"
},
{
"category": "General",
"chartdate": "2199-07-15 00:00:00.000",
"description": "ICU Event Note",
"row_id": 335778,
"text": "Clinician: Attending\n Critical Care\n Urine output remains good and we will try to maintain him negative\n again today. Creat is trending down still. Oxygen requirement remains\n high and he still has diffuse bilat infiltrates. Plan for\n plasmapheresis again today. He is feeling better but still is very\n fragile HR 140 simply with exam. Checking ECK before increasing beta\n blocker.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335781,
"text": "Chief Complaint: 60 year old male transferred from OSH with repiratory\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis. Kidney function improving steadily, no dialysis was\n needed. Respiratory status stable, continues to require facemask to\n keep 02 sats >90%, no signs of continued bleeding into lungs.\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\n hyperglycemia to steroid use.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar hemoorhave given improving\n respiratory status and no hemoptysis. .\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O, goal -1 liter today (has been\n , no lasix unless needed this pm)\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\n continue for at least one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Continued tachycardia, ? atrial vs. sinus.\n Hemodynamically stable. ECHO showed mild LV septal , \n 45-50%. Possibly secondary to large volume shifts (retaining total\n body fluid with renal failure, with large volume load putting stress on\n atria.)\n -EKG to eval for atrial tach vs. sinus tach. If sinus, will work up\n underlying cause. If atrial, will increase lopressor to 75mg po tid.\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been low in the morning and higher in the afternoon for the\n past 2 days despite no transfusion and no plasmapheresis. Variation\n may be due to lab variability, fluid shifts during the day, or another\n unknown cause. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336024,
"text": "60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily. On RISS and NPH Q am.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n VASCULITIS\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 68.4 kg\n Daily weight:\n 93.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ? emphysema\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:78\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 24h total in:\n 1,136 mL\n 24h total out:\n 2,220 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:05 AM\n Potassium:\n 3.6 mEq/L\n 04:05 AM\n Chloride:\n 103 mEq/L\n 04:05 AM\n CO2:\n 32 mEq/L\n 04:05 AM\n BUN:\n 135 mg/dL\n 04:05 AM\n Creatinine:\n 4.3 mg/dL\n 04:05 AM\n Glucose:\n 92 mg/dL\n 04:05 AM\n Hematocrit:\n 21.3 %\n 04:05 AM\n Finger Stick Glucose:\n 150\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n pherisis line in R IJ, Foley cath\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 412\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336032,
"text": "60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily. On RISS and NPH Q am. BS well\n controlled.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n VASCULITIS\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 68.4 kg\n Daily weight:\n 93.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ? emphysema\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:126\n D:78\n Temperature:\n 98.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 106 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 24h total in:\n 1,136 mL\n 24h total out:\n 2,220 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 04:05 AM\n Potassium:\n 3.6 mEq/L\n 04:05 AM\n Chloride:\n 103 mEq/L\n 04:05 AM\n CO2:\n 32 mEq/L\n 04:05 AM\n BUN:\n 135 mg/dL\n 04:05 AM\n Creatinine:\n 4.3 mg/dL\n 04:05 AM\n Glucose:\n 92 mg/dL\n 04:05 AM\n Hematocrit:\n 21.3 %\n 04:05 AM\n Finger Stick Glucose:\n 150\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n pherisis line in R IJ, Foley cath\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: none\n Transferred from: MICU 412\n Transferred to: 1173\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335921,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output.\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Improving.\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334315,
"text": ": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 335286,
"text": "Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n Continues to require supplimental oxygen, desaturates with activity.\n Tolerating net diuresis.\n Hemoptysis resolved.\n Overall, states to feel improved. Dysnpea improved. Able to sleep\n somewhat last PM (improvement).\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 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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.4\n HR: 98 (86 - 128) bpm\n BP: 140/81(96) {113/53(67) - 151/93(107)} mmHg\n RR: 25 (11 - 27) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 560 mL\n PO:\n 980 mL\n 360 mL\n TF:\n IVF:\n 319 mL\n 200 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 960 mL\n Urine:\n 4,410 mL\n 960 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\n ABG: ///31/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 170 K/uL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Imaging: CXR () somewhat improved, esp. right lung field.\n Assessment and Plan\n Wegener's Granulomatosis\n RESPIRATORY DISTRESS -- slow improvement clincally and\n radiographically. Continue current management.\n RENAL FAILURE -- continues gradual improvement. Monitor BUN, creat,\n urine output.\n PULMONARY-RENAL SYNDROME -- attributed to Wegener's.\n WEGENER'S GRANULOMATOSIS -- clinical response to current mangement.\n Continue steoids, cytoxan, plasmaphoresis\n NUTRITIONAL SUPPORT --\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335287,
"text": "Chief Complaint:\n 24 Hour Events:\n Did well. No hemoptysis.\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\n diuresis yesterday to goal -2L.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36\nC (96.8\n HR: 86 (86 - 116) bpm\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\n RR: 18 (14 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 340 mL\n PO:\n 980 mL\n 240 mL\n TF:\n IVF:\n 319 mL\n 100 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 470 mL\n Urine:\n 4,410 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 7.8 g/dL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\n the last 3 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500\n1L today. We will also watch\n his urine output and restart IVF if necessary to keep >100cc/hr\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Rate has been well controlled over the past 2 days.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately but his HCT is\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\n will not receive pheresis this weekend, so we can monitor to see if HCT\n stays stable.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 334432,
"text": "Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirment.\n Renal bx consistent with Wegener's Granulomatosis.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.9\nC (96.6\n HR: 99 (87 - 130) bpm\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\n RR: 21 (9 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,477 mL\n 2,103 mL\n PO:\n 60 mL\n TF:\n IVF:\n 2,102 mL\n 2,043 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 1,025 mL\n Urine:\n 1,360 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,117 mL\n 1,078 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 221 K/uL\n 94 mg/dL\n 7.2 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 149 mg/dL\n 105 mEq/L\n 145 mEq/L\n 22.7 %\n 9.0 K/uL\n [image002.jpg]\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n WBC\n 8.1\n 5.4\n 9.0\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n Plt\n 355\n 261\n 221\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n 94\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\n likey due to vasculitis. Radiographically without significant change,\n but hope to see improvement over next several days. Monitor RR, SaO2.\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\n improve.\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\n plts). Monitor Hct, transfuse to > 21\n WEGENER\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\n plasmaphoresis QOD.\n FLUIDS -- euvolemic. Monitor I/O\n HEMATURIA -- concern for hemorrhagic cystitis\n A-FIB -- good rate control COntinue meds. Monitor HR.\n NASAL CONGESTION -- possible related to Wegener's but more likely due\n to high flow O2. Symptomaatic relief.\n HYPOCALCEMIA -- repleted. Monitor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334434,
"text": "Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO. Received 1 unit PRBCs yesterday\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Gen: Sleeping in bed, NAD\n CV:tachy, irregular. No murmur\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\n Ext: 1+ pedal edema, no rash or petichiae\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR.\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\n appropriately to 1unit PRBCs so likely not currently bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Prednison po daily,\n -Cyclophosphamide-dose to be determined after c/s with rheum and\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\n far.\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: Monitoring for need for dialysis, has line in\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\n signs of platelet dysfunction yet, mental status ok. Renal will give\n his kidneys about 48 more hours to turn around before dialyzing. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -pink tinged urine, stable, but will send daily U/As.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiacc negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334532,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\n has episodes of tachycardia in the 130\ns, typically with exertion or\n desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows with NSR episodes, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.9, BUN 149\n Action:\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\n administration of cyclophosphamide (chemo)\n Response:\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\n since midnight.\n Plan:\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\n HD catheter, may have it . Administer mesna as ordered with chemo\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n weak cough. +1.6L positive. Patient would frequently remove face tent,\n thus dropping O2 sats.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\n 6L NC. Patient encouraged to cough and deep breathe.\n Response:\n Oxygenation has improved throughout the afternoon with patient\ns family\n at the bedside\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334311,
"text": ": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 6 liters NC and supplemental O2, sats maintaining above\n 95%, desats when pt removes O2 in his sleep. , Moist non productive\n cough remains, LS with rhonchi in both lower lobes more on R.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334923,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\n pull the O2 mask and cannula,desats to low 80,s when the mask is\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\n cough.\n Action:\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\n Cytoxan yesterday with mesna/IV as ordered by MD. 3^rd dose of mesna\n due at 1000,pt now only on FM with 80%,sats >97% when mask is on.\n Response:\n Pt was more comfortable last night, but continued to be uncomfortable\n with the mask\n Plan:\n Monitor resp status,meds as ordered,Titrate O2 as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335259,
"text": "Chief Complaint:\n 24 Hour Events:\n Did well. No hemoptysis.\n Transfused one unit and crit bumped appropriately (21.5-25). Continued\n diuresis yesterday to goal -2L.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36\nC (96.8\n HR: 86 (86 - 116) bpm\n BP: 113/62(74) {113/62(74) - 151/93(107)} mmHg\n RR: 18 (14 - 27) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,945 mL\n 340 mL\n PO:\n 980 mL\n 240 mL\n TF:\n IVF:\n 319 mL\n 100 mL\n Blood products:\n 646 mL\n Total out:\n 4,410 mL\n 470 mL\n Urine:\n 4,410 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,465 mL\n -130 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 7.8 g/dL\n 79 mg/dL\n 5.2 mg/dL\n 31 mEq/L\n 3.5 mEq/L\n 147 mg/dL\n 101 mEq/L\n 144 mEq/L\n 22.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n WBC\n 9.0\n 10.3\n 11.0\n 11.0\n Hct\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n Plt\n 221\n 211\n 185\n 170\n Cr\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n Glucose\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:6.2 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2L in the past 24 hours and -4L in the\n last 2 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500 today. We will also watch his\n urine output and restart IVF if necessary\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - Stable crit and no more hemoptysis so pulmonary bleeding unlikely,\n - HCTq12h to monitor for alveolar bleeding.\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n No baseline Crit available.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334307,
"text": ": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334406,
"text": "Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 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 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\n will give his kidneys about 48 more hours to turn around before\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\n been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334409,
"text": "Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required 6L 02 with 40%FIo\\02 facemask to keep 02 sat >90. Got\n pheresis yesterday, solumedrom and cyclophosphamide. No hematuria.\n Talked to renal about biopsy, c/w Wegners. Has been on IVF to keep uop\n >100, successfully. Tolerating PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Gen: Sleeping in bed, NAD\n CV:tachy, irregular. No murmur\n Pulm: Decreased BS with crackles at the bases. No cyanosis.\n Ext: 1+ pedal edema, no rash or petichiae\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 93-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7 down to 7.1. BUN peaked at 160 now,\n 149. No signs of platelet dysfunction yet, mental status ok. Renal\n will give his kidneys about 48 more hours to turn around before\n dialyzing. As a note, plasmapheresis in cases of severe Wegeners has\n been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334385,
"text": ": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx., undervent renal biopsy, awaiting results.\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334873,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334877,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n High requirements of O2 On 80% face mask and NC 6L,Pt continued to be\n pull the O2 mask and cannula,desats to low 80,s when the mask is\n off,otherwise maintained >95%.LS ins/exp wheeze dim at base.Breathing\n efforts are normal,denies any pain, SOB or discomfort.Strong productive\n cough.\n Action:\n Pt was diuresed with 40 mg lasix/IV,nebs per RT,frequent reinforcenment\n about the O2 therapy.Pt was given Ambien 5 mg at night .Did receive\n Cytoxan yesterday with mesna/IV as ordered by MD.\n Response:\n Pt was more comfortable last night,\n Plan:\n Monitor resp status,meds as ordered,\n"
},
{
"category": "General",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Generic Note",
"row_id": 335493,
"text": "TITLE: Resp Care Note, Pt given albuterol/atrovent nebs. BS rhonchi. 02\n remains on 80% high flow neb/nc 4lpm. Sat 95%. Pt stable . Will cont ot\n monitor resp status.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 334716,
"text": "Chief Complaint: Hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirement.\n HR varies from A-flutter to NRS.\n Coughing up sputum (swallowing), but more productive cough today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 98 (85 - 131) bpm\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\n RR: 18 (12 - 25) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 1,971 mL\n PO:\n 750 mL\n 160 mL\n TF:\n IVF:\n 3,736 mL\n 1,811 mL\n Blood products:\n Total out:\n 2,400 mL\n 1,235 mL\n Urine:\n 2,400 mL\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 736 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\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, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 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, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 211 K/uL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\n Possible component of pulmonary edema.\n HYPOXEMIA -- attributed to pulmonary infiltrates.\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\n steroids & cytoxan. Plasmaphoresis.\n RENAL FAILURE -- improving.\n NUTRIONAL SUPPORT -- PO\n HEMATURIA -- stable. Monitor.\n ANEMIA -- stable s/p transfusion\n HYPOCALCEMIA -- continue to replete\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 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: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 335036,
"text": "Chief Complaint: Respiratory distress, hypoxemia.\n HPI:\n 24 Hour Events:\n Experienced some hemoptysis yesterday PM.\n Appears much more comfortable today, less dyspneic.\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 Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\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, Hematuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\n RR: 26 (18 - 27) insp/min\n SpO2: 88%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 238 mL\n PO:\n 290 mL\n 120 mL\n TF:\n IVF:\n 2,214 mL\n 118 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 2,900 mL\n Urine:\n 3,010 mL\n 2,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -2,663 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 88%\n ABG: ///28/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.3 g/dL\n 185 K/uL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Wegener's Granulomatosis\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\n plasmaphoresis\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\n falling, urine output improving, responding to diuretics.\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\n escalation. Consider dDAVP. need dialysis if continues to\n NUTRITIONAL SUPPORT -- PO\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\n suppression. Transfuse to Hct >25\n FLUID -- continue net negative. Monitor I/O.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335533,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (96.9\n HR: 108 (91 - 135) bpm\n BP: 134/63(80) {116/62(74) - 151/85(97)} mmHg\n RR: 19 (11 - 26) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 190 mL\n PO:\n 1,220 mL\n 120 mL\n TF:\n IVF:\n 470 mL\n 70 mL\n Blood products:\n Total out:\n 2,465 mL\n 900 mL\n Urine:\n 2,465 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -710 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 8.2 g/dL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis. This morning he\n looks mor comfortable though CXR looks unchanged. This is likely due\n to 2 days of diuresis, as he is -2.5L in the past 24 hours and -6.5L in\n the last 3 days. Urine output remains high.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n -Will give lasix 40IV for goal of -500\n1L today. We will also watch\n his urine output and restart IVF if necessary to keep >100cc/hr\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n - If possible Will collect sputum to determine whether hemoptysis is\n tinged, bright red or just pink fronthy.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Albuterol nebs PRN\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 yesterday, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's)\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -received 4IV CA last night\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Rate has been well controlled over the past 2 days.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately but his HCT is\n down today. HCT is likely due to fluid shifts with plasmapheresis. He\n will not receive pheresis this weekend, so we can monitor to see if HCT\n stays stable.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 334695,
"text": "Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n Comments:\n Diet: low sodium/heart healthy/Renal.\n Reports no weight loss. Tolerating current diet, says he's hungry. Will\n continue to monitor po intake. Continue to monitor renal function and\n hydration.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335226,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Followed up with labs overnight.\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 335572,
"text": "Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n No new events.\n Revieved 1 U PRBC transfusion, tolerated well.\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 Furosemide (Lasix) - 06:10 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:08 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 122 (97 - 135) bpm\n BP: 126/85(92) {122/63(77) - 151/85(97)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,690 mL\n 477 mL\n PO:\n 1,220 mL\n 360 mL\n TF:\n IVF:\n 470 mL\n 117 mL\n Blood products:\n Total out:\n 2,465 mL\n 1,540 mL\n Urine:\n 2,465 mL\n 1,540 mL\n NG:\n Stool:\n Drains:\n Balance:\n -775 mL\n -1,063 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, Face tent\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 8.2 g/dL\n 200 K/uL\n 117 mg/dL\n 5.0 mg/dL\n 29 mEq/L\n 3.5 mEq/L\n 148 mg/dL\n 100 mEq/L\n 140 mEq/L\n 24.0 %\n 12.2 K/uL\n [image002.jpg]\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n Hct\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n Plt\n 00\n Cr\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n Glucose\n 144\n 208\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.7 mg/dL,\n Mg++:1.7 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n Respiratory distress and acute renal failure --> Wegener's\n Granulomatosis\n RESPRIATORY DISTRESS -- gradual improvement.\n RENAL FAILURE -- initial good recovery, with good urine output;\n however, now creatitine with minimal decline over past 2-3 days. \n be approaching new baseline. ultimately require dialysis.\n WEGENER'S GRANULOMATOSIS -- slow clinical response; continue steroids,\n cytoxan & plasmaphoresis\n TACHYCARDIA -- persistent. Attributed to hypoxemia and airspace\n disease.\n FLUIDS -- desire net negative if tolerated by BP.\n NUTRITIONAL SUPPORT -- encourage PO.\n ANEMIA -- ACD, no evidence for acute bleed. Monitor Hct.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333963,
"text": "Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335357,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\n to 86% when pt. sleeping and face tent away from Pt.\ns face.\n Action:\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\n in sputum. Nebs as ordered.\n Response:\n Pt. states he is feeling better. No hemoptisis this shift. CXR\n improving.\n Plan:\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335358,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with hx. Of alveolar hemorrhage. On 80% face tent O2 and\n additional 6L NC. Occ congested non-productive cough. Occ. Will desat\n to 86% when pt. sleeping and face tent away from Pt.\ns face.\n Action:\n Cont. on Atovaquone for PCP . Cont. with Nystatin s/s for\n in sputum. Nebs as ordered.\n Response:\n Pt. states he is feeling better. No hemoptisis this shift. CXR\n improving.\n Plan:\n Cont. current treatment. F/U sputum cx. Wean O2 as possible.\n Repleated Ca+ this shift per Ca+ SS.\n Repeat Hct. 26\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335733,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Plasma pheresis due tomorrow.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, continues on O2 6 liters NC and 60% face tent, non productive\n moist cough remains, desats 10 86-87% when off O2 ( takes it iff\n during sleep),\n Action:\n Continues on O2, ( frequently reminded to keep O2 on), xray chest done\n this a.m\n Response:\n Remains afebrile, no hemoptysis, slept well overnight\n Plan:\n Continue to monitor resp status, wean O2 as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335748,
"text": "Chief Complaint: 60 year old male transferred from OSH with repiratory\n distress alveolar hemmorhage(confirmed by bronch), acute renal failure\n and nephritic syndome. Confirmed to have c-anca vasculitis. Treated\n here with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis. Kidney function improving steadily, no dialysis was\n needed. Respiratory status stable, continues to require facemask to\n keep 02 sats >90%, no signs of continued bleeding into lungs.\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable. Diuresed 1.2\n liters yesterday, (autodiuresis). Put on standing dose of insulin,\n hyperglycemia to steroid use.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar hemoorhave given improving\n respiratory status and no hemoptysis. Continue to monitor with q12\n HCT.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos. Phos at high end of normal today, will\n continue for at least one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335872,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n U/O has been good.\n Plan:\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335873,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335874,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care at the onset, due\n to having no PCP (regular PCP had retired.) He finally presented for\n care when he could not put his shoes on in the a.m. due to pedal edema.\n Upon presentation to the OSH, pt complained of bilateral LE pain/edema.\n Pt reports that LE symptoms started in the feet, progressing to\n swelling of his legs to his knees over 3 weeks. He also noted a diffuse\n macular rash in the LE of the same distribution. He also complained of\n some SOB on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Vasculitis\n Assessment:\n Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output.\n Action:\n Pt had plasmapheresis treatment yesterday.\n Response:\n Improving.\n Plan:\n Pt has 2 more plasmapheresis treatments and should be done on Fri.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n BUN 136/CREAT 4.2, both cont to improve. U/O good.\n Action:\n Pt did receive lasix 40mg this evening.\n Response:\n U/O has been good. Goal was for pt to be 1L neg by midnight, pt was\n 775cc neg.\n Plan:\n Cont to monitor u/o and bun/creat. Attempt 1L neg by this midnight.\n Tachycardia, Other\n Assessment:\n Pt remains in ST with hr ranging from 100-120, no ectopy noted.\n Action:\n Pt is on metoprolol 75 mg tid.\n Response:\n Pending.\n Plan:\n Monitor hr. cont metoprolol and possibly increase dose to slow hr.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 336022,
"text": "60 year old male transferred from OSH with respiratory distress\n alveolar hemorrhage(confirmed by bronch), acute renal failure and\n nephritic syndome. Confirmed to have c-anca vasculitis. Treated here\n with cyclophosphamide, steroids (solumedrol, now prednisone) and\n plasmapheresis.\n Vasculitis\n Assessment:\n Pt. dx. With Wegener\ns granulomatosis.\n Action:\n Has been reciving plasmapherisis , steroids and cytoxin.\n Response:\n Two more treatments of plasmapherisis planed for Wed. and Fri.\n Plan:\n Remains stable.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n S/P alveolar hemorrhage. LS clear and very diminished at bases. O2 at\n 6L NC. Occ. Congested non-productive cough.\n Action:\n Cont. Atovaquone for PCP . OOB to chair today.\n Response:\n CXR improving. Pt. states breathing feels much better.\n Plan:\n Cont. to wean O2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n In Renal failure when admitted to MICU.\n Action:\n Monitoring. Encourage PO fluid intake.\n Response:\n BUN/creatnine 135/4.2 today. Pt. voiding in adequate amounts.\n Plan:\n Goal urine output -500 to 1L .\n On FS QID due to Prednisone daily.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334074,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - also treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily\n -Cyclophosphamide 140mg\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok.\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\n However, apart from pulmonary association, ddx for acute renal failure\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\n Also consider DIC.\n - Renal biopsy yesterday, awaiting results\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is eating, can D/C D5W.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am), check again this PM\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6, given HCT , likely need blood this pm.\n - Type and screen, cross-matched\n - Blood consent obtained\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 336013,
"text": "Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n EKG - At 12:02 PM\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\n Tolerated plasmaphoresis yesterday.\n Continues net diuresis, tolerated well.\n No further hemoptysis.\n Up in chair, excellent spirits. Appropriate. Joking with family.\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 Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, 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 10:38 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\n HR: 114 (100 - 142) bpm\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,534 mL\n 902 mL\n PO:\n 1,220 mL\n 750 mL\n TF:\n IVF:\n 314 mL\n 152 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,690 mL\n Urine:\n 2,565 mL\n 1,690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,031 mL\n -788 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///32/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 200 K/uL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\n Assessment and Plan\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\n steroids, cytoxan. Complete Plasmaphoresis course.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\n oxygen requirement.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\n improvement. Monitor. No acute indication for dialysis.\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\n Monitor.\n TACHYCARDIA -- improved. Monitor.\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\n Transfuse to Hct >21.\n HYPERGLYCEMIA -- contributed by high dose steroids. Monitor, use\n insullin to maintain <150.\n ICU Care\n Nutrition: PO\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335526,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 80% via face tent and 6 L/M NC, LS diminished with\n scattered crackles in lower lobes, afebrile, , desats to 85-87% when\n off O2( removes O2 during sleep)\n Action:\n Continues on Atavoquone for pcp prophylaxis and nystatin for thrush in\n sputum, pt requires repeated reinforcement for O2 compliance with\n understanding. Scheduled nebs given\n Response:\n Remains afebrile, no hemoptysis this shift,\n Plan:\n Continue to monitor hemodynamic status, follow up on culture reports.,\n continue with neb Rx, wean O2 as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal parameters trending down\n Action:\n Diuresed this p.m with 20 lasix,\n Response:\n Good response to lasix, negative 770 by midnight\n Plan:\n Plasmapheresis on Monday, diurese as needed , follow up with a.m labs\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335854,
"text": "Vasculitis\n Assessment:\n Tolerating pheresis. Hemodynamically stable.\n Action:\n Plasma pheresis this afternoon. Lopressor increased to 75mg d/t atrial\n tachycardia. Hct 23. pedal edema slowly decreasing. Slept in naps. Ssi\n for bs\ns. mg+ 1.6 and given 2mg mg+ ivpb. Good appetite.\n Response:\n Continues to improve. Good response to lopressor.\n Plan:\n Need to check ionized ca+ at 20pm. Pt. has a ss for his ca+ doses.\n Transfuse if hct drops below 21.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Able to tolerate np only.\n Action:\n Mask off. Presently on 5L np. . Non-productive cough. No hemoptysis. No\n c/o sob.\n Response:\n Sats 98-100%.\n Plan:\n Continue to wean o2.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Renal failure improving.\n Action:\n Creat 4.4. k+ 3.7. /20mg lasix ivp ordered/given by night nurse. Urine\n slightly pink-tinged this am, but not noted this pm. Patent dialysis\n catheter with port.\n Response:\n Autodiuresing.\n Plan:\n Plan for 1L negative.\n"
},
{
"category": "General",
"chartdate": "2199-07-16 00:00:00.000",
"description": "ICU Event Note",
"row_id": 335955,
"text": "Clinician: Attending\n Critical Care\n 42 yo woman paraplegic after MVA , recently discharged from\n hospital after \"pneumonia\" noted by PCA to be lethargic at home, SaO2\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\n somewhat confused but conversant. Still somewhat lethargic. We are\n continuing Narcan but would have some concern about methadone as\n explanation for her lethargy as no change in methadone dose for 6 weeks\n and not previously sedated by med. Would also have some concern about\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\n presentation. Not clear why she developed PNA. We are continuing O2,\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\n have PFTs before d/c.\n Total time spent: 35 minutes\n Patient is critically ill.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 08:08 ------\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335974,
"text": "Chief Complaint:\n 24 Hour Events:\n Continues with same 02 requirement. EKG yesterday revealed aflutter\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\n 100s all night.\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\n overnight.\n Followed by renal and rheum.\n EKG - At 12:02 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 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: 36.6\nC (97.8\n HR: 106 (100 - 142) bpm\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,530 mL\n 600 mL\n PO:\n 1,220 mL\n 500 mL\n TF:\n IVF:\n 310 mL\n 100 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,200 mL\n Urine:\n 2,565 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,036 mL\n -600 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 7.2 g/dL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Has been stable on 6L NC. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Wean 02 to keep sat >90%.\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\n hemoorhave given improving respiratory status and no hemoptysis.\n Probably due to plasmapheresis and fluid shifting. His respiratory\n status may be marginally helped by an increased HCT, but will check pm\n HCT and transfuse if <21.\n -Continue nystatin mouthwash for + sputum given his high dose\n steroids. Day \n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 yesterday, then tomorrow and Friday.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine continues to trend down, 4.3 this morning, BUN is\n also finally down to 135, and he has maintained good urine output. As\n a note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Foley in place , strict I&O,we have been diuresing him well, with ?\n liters off in the past 5 days. We will continue to diurese with goal\n -500cc to -1L, using Lasix 20 IV prn.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\n one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Received 4gIV overnight, will re-check PM ionized Calcium and replete\n as needed. On days when he has pheresis, ionized CA needs to be drawn\n 4 hours after the end of pheresis to be accurate.\n -on SS replacement.\n -EKGs have been unchanged.\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\n stable. ECHO showed mild LV septal , 45-50%. Possibly\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n -Increased lopressor to 75mg po tid yesterday. Will continue to\n monitor on tele. If needed, could start a second rate controlling\n .\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been variable over the weekend despite no transfusion.\n Variation may be due to lab variability, or to fluid shifts with\n plasmapheresis. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\n unit if <21.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units, well controlled.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n #Dispo: to floor if it is possible to do pheresis outside of the ICU.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335016,
"text": "Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \n C-ANCA vasculitis. This morning, he breathing more easily, with stable\n lung exam though his CXR looks unchanged. This is likely due to\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\n 2+ budding yeast on sputum, without signs of candidiasis on\n oropharyngeal exam.\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\n urine output and restart IVF if necessary. We will balance maintaining\n urine output >100/hr for bladder protection with not giving too much\n Lasix due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n -Start nystatin mouthwash\n -Send blood cultures for fungus (though highly unlikely given pt. is\n afebrile, stable, but he is on high dose immunosuppression)\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - Given hemoptysis and drop in crit, some concern for pulmonary\n bleeding, though respiratory status improving.\n - HCTq8h to monitor for alveolar bleeding.\n - Will collect sputum to determine whether hemoptysis is tinged, bright\n red or just pink fronthy.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN , some wheezing on exam today\n - CXR daily\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 4/7 today, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n ok. Urine is less pink that previously. Renal function has been\n steadily improving, likely as a response to Wegeners treatment. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - treating underlying cause (likely Wegener's).\n - Foley in place , strict I&O, q8 lytes.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: likely secondary to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n No baseline Crit available.\n -transfuse one unit this morning as HCT is trending down (21.6)\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative yesterday, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334319,
"text": ": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx., undervent renal biopsy, awaiting results.\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335938,
"text": "Chief Complaint:\n 24 Hour Events:\n Continues with same 02 requirement. EKG yesterday revealed aflutter\n with variable 2:1 and 3:1 conduction. Increased BB to 75 tid, HR low\n 100s all night.\n Reveived plasmapheresis yesterday, tolerated it well. Repleted Calcium\n overnight.\n Followed by renal and rheum.\n EKG - At 12:02 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:25 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: 36.6\nC (97.8\n HR: 106 (100 - 142) bpm\n BP: 107/62(73) {103/47(59) - 138/86(96)} mmHg\n RR: 12 (12 - 26) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,530 mL\n 600 mL\n PO:\n 1,220 mL\n 500 mL\n TF:\n IVF:\n 310 mL\n 100 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,200 mL\n Urine:\n 2,565 mL\n 1,200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,036 mL\n -600 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///32/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 200 K/uL\n 7.2 g/dL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 60% Fio2 face tent,\n 90-98%. Continues to desat to 80s when mask comes off. Most likely\n secondary to diffuse alveolar hemorrhage C-ANCA vasculitis. CXR\n shows interval improvement, patient appears to be responding to\n diuresis as well.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT decreased to 21.3 this morning, unlikely due to alveolar\n hemoorhave given improving respiratory status and no hemoptysis.\n Probably due to plasmapheresis, given with 50% albumin yesterday.\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Atrovent nebs PRN (albuterol nebs held due to tachycardia)\n - CXR daily\n -Plasmapheresis, dose 5/7 yesterday, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n - f/u Rheum recs\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine up to 4.3 from 4.0 yesterday, BUN down to 135, good\n urine output. As a note, plasmapheresis in cases of severe Wegeners\n has been shown to improve kidney outcomes, though not mortality.\n - Foley in place , strict I&O,we have been diuresing him well, with ?\n liters off in the past 5 days. His creatinine bumped a little bit this\n morning, probably we are at his dry weight and can back off on\n diuresis.\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A\n -On Sevelamer, for hyperphos. Phos 4.0, will continue for at least\n one more day.\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Continued tachycardia, atrial flutter. Hemodynamically\n stable. ECHO showed mild LV septal , 45-50%. Possibly\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n -Increased lopressor to 75mg po tid yesterday.\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n HCT have been low in the morning and higher in the afternoon for the\n past 2 days despite no transfusion and no plasmapheresis. Variation\n may be due to lab variability, fluid shifts during the day, or another\n unknown cause. Will monitor as long as he is hemodynamically stable.\n -qday HCT, transfuse if <21. 21.3 today, will check PM and transfuse 1\n unit.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n #Hyperglycemia- non-diabetic, likely high dose steroids.\n -SSI plus standing 3units, well controlled.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333940,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s\n Action:\n Conts on lopressor 50mg TID\n Response:\n Tolerating the lopressor, he did have short periods of a HR in the\n 1teens this afternoon\n Plan:\n Cont with the lopressor, follow VS\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat was 8.6 this morning and 8.0 this afternoon, u/o has been\n 40-50cc/hr\n Action:\n Pt had a renal biopsy this morning under US guidance, given 2 bagsof\n FFP for this, needed Ca gluc this evening as well. He is receiving D5W\n 100cc/hr for 1 liter for a Na of 150\n Response:\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\n Plan:\n Follow HCT\n due tonight, VS, renal bx results, no immediate plans for\n dialysis, follow labs, to receive cytoxan again tonight, 7 \n resourse nurse is aware and some will be down to give this\n he needs\n mesna before and after\n please see \n Respiratory failure, acute (not ARDS/)\n Assessment:\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\n has not been coughing up any blood\n Action:\n He is on scoop mask at 60-70% and this brings his 02 up to the mid 90s\n Response:\n Conts to require a high FI02\n Plan:\n Follow SATs cont to try to wean his FI02\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-15 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335723,
"text": "Chief Complaint:\n 24 Hour Events:\n Continued to desat when facemask off. otherwise, stable.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 117 (99 - 137) bpm\n BP: 117/79(88) {113/64(78) - 143/85(96)} mmHg\n RR: 24 (11 - 29) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,510 mL\n 304 mL\n PO:\n 1,340 mL\n 240 mL\n TF:\n IVF:\n 170 mL\n 64 mL\n Blood products:\n Total out:\n 2,800 mL\n 300 mL\n Urine:\n 2,800 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,290 mL\n 4 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 217 K/uL\n 7.8 g/dL\n 88 mg/dL\n 4.4 mg/dL\n 30 mEq/L\n 3.7 mEq/L\n 145 mg/dL\n 103 mEq/L\n 144 mEq/L\n 23.0 %\n 9.8 K/uL\n [image002.jpg]\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n WBC\n 10.3\n 11.0\n 11.0\n 12.2\n 9.8\n Hct\n 23.9\n 24.0\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n Plt\n 00\n 217\n Cr\n 6.5\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n Glucose\n 95\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.6 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n This is a 60 year-old male with a distant history of nephrolithiasis,\n no other chronic medical problems who presents with lower extremity\n edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 80% Fio2 facemask, 90-98%.\n Continues to desat to 80s when mask comes off. Most likely secondary\n to diffuse alveolar hemorrhage C-ANCA vasculitis\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - HCT down today, unlikely due to alveolar imprroving respiratory\n status, no hemoptysis. Continue to monitor\n -Continue nystatin mouthwash for + sputum, though no sign of\n thrush.\n - Albuterol nebs PRN\n - CXR daily\n -Plasmapheresis, dose 5/7 today, then W/F.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-125 po. Rheumatology will write for this. No MESNA\n needed, will give po H20 before dose\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. As a note,\n plasmapheresis in cases of severe Wegeners has been shown to improve\n kidney outcomes, though not mortality.\n - Foley in place , strict I&O,\n -pink tinged urine, improved. Will continue to monitor visually. If\n worsening will get U/A. It is also possible that his HCT is due to\n hemorrhagic cystitis given he is on cyclophosphamide, though he has no\n signs of increasing hematuria at present.\n -On Sevelamer, for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n # Tachycardia: Asymptomatic, rate increases when active/talking,\n normal when sleeping. ECHO showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # Anemia: Low HCT originally due to pulmonary hemorrhage, chronic\n inflammatory disease, renal failure, and diffuse alveolar hemorrhage.\n He received 1 unit yesterday and bumped appropriately.\n -q12 HCT, transfuse if <21\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative thus far, continue to check all stools.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2199-07-15 00:00:00.000",
"description": "ICU Event Note",
"row_id": 335851,
"text": "Clinician: Attending\n Critical Care\n 42 yo woman paraplegic after MVA , recently discharged from\n hospital after \"pneumonia\" noted by PCA to be lethargic at home, SaO2\n 90%. Brought to ED where SaO2 < 90%. MS responded to Narcanx 2. Now\n somewhat confused but conversant. Still somewhat lethargic. We are\n continuing Narcan but would have some concern about methadone as\n explanation for her lethargy as no change in methadone dose for 6 weeks\n and not previously sedated by med. Would also have some concern about\n dx of PNA on last adm as no substantial clearing, no leukocytosis on\n presentation. Not clear why she developed PNA. We are continuing O2,\n monitoring MS q1h, sending tox screen. Will repeat chest CT. Should\n have PFTs before d/c.\n Total time spent: 35 minutes\n Patient is critically ill.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335154,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Ionized Ca+ 0.96, repleted with 4 gms of calcium this shift.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Followed up with labs overnight.\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334317,
"text": ": This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt in atrial flutter when awake , rate in mid 130\ns, BP remaining\n stable at 130\ns systolic. When sleeping NSR, rate in 90\ns, Calcium\n level remains low , less than 1.1 ( ionized calcium)\n Action:\n Scheduled lopressor given ., repleted with a total of 8mg of calcium\n this shift\n Response:\n Positive effect to lopressor.\n Plan:\n Continue to monitor VSS, ECG changes, continue on lopressor., monitor\n lytes and replete as needed\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n U/O maintaining above 40cc/hr, reveived one unit of red cell\n yesterday\n Action:\n HCT trending up from 20.9 to 22.4 after blood, received\n cyclophosphomide 140 mg IV this shift, received Mesna 40 mg IV prior\n to Cytoxan\n Response:\n U/O remains wnl, BUN and creatinine trending down from 160 and 8.1\n yesterday to 149 and 7.1 early this a.m\n Plan:\n Monitor VSS, U/O, Cytoxan as ordered , monitor HCT ( goal is above 21),\n cytoxan as ordered\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Afebrile, Continues on O2 6 liters NC and supplemental O2, sats\n maintaining above 95%, desats when pt removes O2 in his sleep. , Moist\n non productive cough remains, LS diminished at bases\n Action:\n Continue with mepron\n Response:\n VSS stable, no resp distress noted\n Plan:\n Continue to monitor VSS, sats,\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 334996,
"text": "Chief Complaint: Respiratory distress, hypoxemia.\n HPI:\n 24 Hour Events:\n Experienced some hemoptysis yesterday PM.\n Appears much more comfortable today, less dyspneic.\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 Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze, Hemoptysis\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, Hematuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:01 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: 101 (76 - 130) bpm\n BP: 129/75(84) {107/61(51) - 145/91(98)} mmHg\n RR: 26 (18 - 27) insp/min\n SpO2: 88%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 238 mL\n PO:\n 290 mL\n 120 mL\n TF:\n IVF:\n 2,214 mL\n 118 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 2,900 mL\n Urine:\n 3,010 mL\n 2,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -2,663 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 88%\n ABG: ///28/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, Conjunctiva pale,\n No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, 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: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.3 g/dL\n 185 K/uL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Wegener's Granulomatosis\n PULMNARY-RENAL SYNDROME -- attributed to Wegener's\n WEGENER'S GRANULOMATOSIS -- + c-ANCA. Continue steroids & cytoxan,\n plasmaphoresis\n RENAL FAILURE -- Wegener's. Continues gradual improvement, creatinine\n falling, urine output improving, responding to diuretics.\n HEMOPTYSIS -- likley due to pulmonary hemorrhage. Monitor for\n escalation. Consider dDAVP. need dialysis if continues to\n NUTRITIONAL SUPPORT -- PO\n ANEMIA -- multifactorial. Pulmonary hemorrhage (stablle), bone marrow\n suppression. Transfuse to Hct >25\n FLUID -- continue net negative. Monitor I/O.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-16 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 335972,
"text": "Chief Complaint: Respiratory distress\n HPI:\n 24 Hour Events:\n EKG - At 12:02 PM\n Requiring lower FiO2 (6 L nc), maintaining SaO2 >90%.\n Tolerated plasmaphoresis yesterday.\n Continues net diuresis, tolerated well.\n No further hemoptysis.\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 Furosemide (Lasix) - 07:30 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, 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 10:38 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\n HR: 114 (100 - 142) bpm\n BP: 136/74(88) {91/44(55) - 138/86(96)} mmHg\n RR: 21 (12 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 93.3 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 1,534 mL\n 902 mL\n PO:\n 1,220 mL\n 750 mL\n TF:\n IVF:\n 314 mL\n 152 mL\n Blood products:\n Total out:\n 2,565 mL\n 1,690 mL\n Urine:\n 2,565 mL\n 1,690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,031 mL\n -788 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///32/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.2 g/dL\n 200 K/uL\n 92 mg/dL\n 4.3 mg/dL\n 32 mEq/L\n 3.6 mEq/L\n 135 mg/dL\n 103 mEq/L\n 145 mEq/L\n 21.3 %\n 8.4 K/uL\n [image002.jpg]\n 09:59 PM\n 04:37 AM\n 07:41 PM\n 05:22 AM\n 04:05 PM\n 04:00 AM\n 03:55 PM\n 04:07 AM\n 08:17 PM\n 04:05 AM\n WBC\n 11.0\n 11.0\n 12.2\n 9.8\n 8.4\n Hct\n 23.7\n 21.6\n 25.0\n 22.6\n 26.7\n 24.0\n 27.0\n 23.0\n 25.1\n 21.3\n Plt\n 185\n 170\n 200\n 217\n 200\n Cr\n 6.2\n 6.1\n 5.6\n 5.2\n 5.1\n 5.0\n 4.4\n 4.2\n 4.3\n Glucose\n 146\n 82\n 145\n 79\n 237\n 117\n 88\n 208\n 92\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.0 mg/dL\n Imaging: CXR () diffuse pulmonary infiltrates, but improving.\n Assessment and Plan\n VASCULITIS -- Wegener's Granulomatosis. Good response. Continue\n steroids, cytoxan. Complete Plasmaphoresis course.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/) -- Pulmonary-Renal\n syndrome; predominately alveolar hemorrhage. Improving. Reduced\n oxygen requirement.\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF) -- continue gradual\n improvement. Monitor. No acute indication for dialysis.\n HYPOCALCEMIA (LOW CALCIUM) -- replete, monitor ionized Ca++\n ATRIAL FLUTTER (AFLUTTER) -- acceptable rate control on lopressor.\n Monitor.\n TACHYCARDIA -- improved. Monitor.\n ANEMIA -- No further clinical evidence for bleeding, CXR improving.\n Transfuse to Hct >21.\n HYPERGLYCEMIA -- contributed by high dose steroids.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333556,
"text": "Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - Check TSH\n - Surface ECHO in a.m.\n - Will start Lopressor 12.5mg PO daily for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333557,
"text": "Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - F/u on TSH\n - Surface ECHO in a.m. today\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-22 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1030091,
"text": " 5:49 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: interval change, worsening consolidations on CXR, compare w\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegner's granulomatosis, pulm hemorrhage, ? aspergillous\n infection, on vori, w worsening dyspnea. On CXR consolidation in R mid lung\n appears worse, needs repeat NON-CONTRAST CHEST CT (renal failure) to evaluate\n the densities further\n REASON FOR THIS EXAMINATION:\n interval change, worsening consolidations on CXR, compare w previous Chest CT\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: ARHb MON 7:50 PM\n Widespread pulmonary abnormalities, including consolidation, ground glass\n change, and nodularity, persist and have worsened at the right lung base.\n Differential continues to include vasculitis/hemorrhage and infection,\n including Aspergillus. Persistent right apical lung nodules. Increased small\n to moderate right pleural effusion. Unchanged left effusion. No significant\n change in mediastinl/hilar adenopathy.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient's Wegener's granulomatosis,\n pulmonary hemorrhage and suspected aspergillus infection with worsening\n dyspnea.\n\n COMPARISON: Chest CT from .\n\n TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to\n upper abdomen with subsequent 1.25 and 5-mm collimation. Axial images\n reviewed in conjunction with coronal and sagittal reformats.\n\n FINDINGS:\n\n Multifocal mediastinal lymphadenopathy is unchanged with enlarged nodes\n present in multiple compartments. Within the left mediastinal lymph nodes\n measure up to 1.4 cm at the shortest access, within the left compartment is up\n to 1.5 cm. The additional conglomerate of the lymph nodes in the subcarinal\n lesion is up to 1.8 cm in diameter so grossly with no significant change since\n the prior study. The bilateral hila are diffusely enlarged with most likely\n present lymph nodes that are difficult to evaluate without injection of\n contrast. Calcifications in the right hilus suggest prior granulomatous\n exposure. There is most likely increase in the size of the right hilar lymph\n node, 2:32 currently 1.3 cm in diameter compared to 7 mm on the prior study.\n The patient is anemic giving the high density of the myocardium compared to\n the blood in the . Diffuse coronary calcifications are seen. There\n is no pericardial effusion. Bilateral pleural effusions are present, still\n small but slightly increased compared to the prior study.\n\n The imaged portion of the upper abdomen is grossly unremarkable with no\n appreciable change since the prior study.\n (Over)\n\n 5:49 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: interval change, worsening consolidations on CXR, compare w\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The airways are patent to the level of lobar and segmental bronchi bilaterally\n except for right lower lobe with occlusion of the apical segment is noted,\n most liklely due to secretions. Widespread pulmonary abnormality has\n slightly progressed since the recent study including areas of consolidation,\n ground- glass opacities and poorly defined nodules. The consolidations and\n ground glass are most pronounced in the mid and lower lungs, namely in the\n posterior segment of left upper lobe, lingula, and both lower lobes, right\n more than left. The previously demonstrated well defined perifissural nodule\n in the right lower lobe anteriorly is unchanged. Extensive bronchial impaction\n is present within the lower lobe bronchi. Marked upper lobe predominantly\n paraseptal and centrilobular emphysema is unchanged. Within the right apex, a\n 2 cm nodular opacity is identified containing calcification. Similar size\n spiculated opacity is seen in the left apex with less prominent spiculated\n appearance.\n\n No suspicious lytic or blastic lesions were demonstrated in the imaged portion\n of the skeleton.\n\n IMPRESSION:\n\n 1. Widespread pulmonary abnormalities including consolidation, ground glass\n in poorly defined lung nodules, slightly worse, but no new areas involved. As\n previously mentioned vasculitis and associated pulmonary hemorrhage are the\n primary diagnosis. Coexisting infection such as bacterial infection or\n aspergillosis cannot be excluded.\n\n 2. Spiculated right apical lesion raise concern for possible primary lung\n cancer especially on a patient with underlying emphysema. It is still\n potentially can be related to diffuse lung abnormalities thus three months\n followup chest CT is highly recommended.\n\n 3. Extensive intrathoracic lymphadenopathy: related to vasculitis and/or\n reactive to infection.\n\n 4. Slightly increased but still small bilateral pleural effusion in minimal\n amount of ascites.\n\n 5. Evidence of anemia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1030021,
"text": ", V. MED 11R 9:37 PM\n CHEST (PA & LAT) Clip # \n Reason: worsening dyspnea, eval for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\n interval change\n REASON FOR THIS EXAMINATION:\n worsening dyspnea, eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n Dense consolidation right mid and left mid lung zone. Improved aeration in\n lower lung zones.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1030020,
"text": " 9:37 PM\n CHEST (PA & LAT) Clip # \n Reason: worsening dyspnea, eval for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's granulomatosis, w worsening sob, eval for\n interval change\n REASON FOR THIS EXAMINATION:\n worsening dyspnea, eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SBNa MON 3:42 PM\n Dense consolidation right mid and left mid lung zone. Improved aeration in\n lower lung zones.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PA AND LATERAL\n\n COMPARISON: .\n\n HISTORY: Wegener's granulomatosis and aspergillosis.\n\n FINDINGS: There has been interval increase in dense consolidation in the\n right mid lung zone and left mid lung zone. The lung bases appear to have\n improved in aeration. Small bilateral pleural effusions are unchanged.\n Emphysematous changes particularly in the apices are noted.\n\n IMPRESSION: More dense consolidations seen in the right mid lung and left mid\n lung zones. Improved aeration in the bilateral lower lung zones.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026997,
"text": " 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary renal syndrome\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 9:49 AM\n PFI: Slight interval improvement in the left lung consolidations.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Interval change in a patient with renal failure.\n\n Portable AP chest radiograph was compared to the prior studies obtained on\n .\n\n There is overall slight improvement in the opacities of the left lung with no\n change in the right lower lung consolidation with again demonstrated more\n discrete nodular opacity. There is no pleural effusion. For precise\n characterization of the finding, further evaluation with chest CT might be\n appropriate as the differential diagnosis is broad, including widespread\n infection, hemorrhage or asymmetric edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026998,
"text": ", M. MED 6:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary renal syndrome\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Slight interval improvement in the left lung consolidations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1026946,
"text": " 6:32 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please assess dialysis line placement.\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with IJ dialysis line\n REASON FOR THIS EXAMINATION:\n Please assess dialysis line placement.\n ______________________________________________________________________________\n WET READ: SBNa SUN 7:06 PM\n Right IJ line terminates in upper SVC. Unchanged appearance of b/l diffuse\n opacites. No ptx.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the central venous catheter placement.\n\n Portable AP chest was compared to .\n\n The right internal jugular line catheter was inserted with its tip projecting\n at the level of the junction of brachiocephalic vein and superior SVC. The\n heart size is moderately enlarged but stable. There is also no change in the\n mediastinal contour. There is overall no change in the extensive parenchymal\n consolidation compared to the prior study. The differential diagnosis might\n include extensive infection, pulmonary edema in the presence of underlying\n emphysema or pulmonary hemorrhage, clinical correlation in comparison to the\n prior studies is required. Note is made of a more discrete rounded density in\n the right lower lung unchanged since the prior study, which might represent a\n part of a similar process or additional underlying abnormality. Scarring in\n the upper lung is unchanged. No appreciable pleural effusion is demonstrated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028387,
"text": " 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's.\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP:\n\n COMPARISON: One day prior.\n\n HISTORY: 50-year-old man with Wegner's, evaluate for any change.\n\n FINDINGS: There is slightly improved aeration of both lungs. Again seen is\n diffuse areas of consolidation, primarily in the right mid lung zone and left\n mid and lower lung zone. No new consolidations are identified. Biapical\n scarring is unchanged. Cardiomediastinal and hilar contours are unremarkable.\n A right-sided internal jugular catheter sheath is seen terminating in the\n upper SVC. There is no evidence of pneumothorax.\n\n IMPRESSION: Slightly improved aeration of both lungs. Persistent opacities\n seen primarily in the right mid and left mid to lower lung zones.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-17 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1028954,
"text": " 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\n sx\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB WED 7:17 PM\n Multifocal consolidation, ground-glass attenuation, and poorly defined\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\n lymphadenopathy, and a small amount of ascites.\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST, \n\n Comparison chest radiographs dating between and .\n\n INDICATION: Wegener's granulomatosis, pulmonary hemorrhage, and Aspergillus\n on recent sputum culture.\n\n TECHNIQUE: Volumetric, multidetector CT acquisition of the chest was\n performed without intravenous or oral contrast. Images are presented for\n display in the axial plane at 5-mm and 1.25-mm collimation. A series of\n multiplanar reformation images were also submitted for review.\n\n FINDINGS: Widespread pulmonary abnormalities are present, including areas of\n consolidation, ground-glass attenuation, and poorly defined nodules. The\n areas of consolidation and ground glass are most pronounced in the mid and\n lower lungs. In addition to poorly defined bronchovascular nodules, one well-\n defined perifissural nodule is identified in the right lower lobe anteriorly\n measuring 8 mm (227, 4A). Extensive bronchial impaction is present within the\n lower lobe bronchi, but the more central airways appear patent. Marked upper\n lobe predominant paraseptal and centrilobular emphysema are present. Within\n the right apex, a spiculated 2.1-cm diameter nodular opacity is identified\n (68, 4A) with an eccentric granuloma. Additional similar-sized spiculated\n opacity is identified higher in the right apex (52, 4A).\n\n Multifocal mediastinal lymphadenopathy is present, with enlarged nodes present\n in multiple compartments. Within the left mediastinum, lymph nodes measure up\n to 1.4 cm in short axis in the lower left paratracheal region and 1.5 cm in\n the left prevascular area. Additional conglomerate lymph nodes are seen in\n the subcarinal region measuring up to approximately 17 mm in short axis. There\n are likely bilateral hilar nodes present, difficult to measure in the absence\n (Over)\n\n 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of intravenous contrast. A few small calcified mediastinal and hilar nodes are\n also evident. No pericardial effusion is identified. Coronary artery\n calcifications are evident. Small dependent simple pleural effusions are\n present bilaterally.\n\n Exam was not tailored to evaluate the subdiaphragmatic region, but note is\n made of a small amount of ascites as well as nonspecific mesenteric stranding.\n Liver appears relatively hyperdense, possibly due to previous transfusions or\n amiodarone therapy.\n\n No suspicious lytic or blastic skeletal lesions are identified.\n\n IMPRESSION:\n 1. Widespread pulmonary abnormalities including consolidation, ground-glass,\n and poorly defined lung nodules. These could be due to the patient's known\n vasculitis with associated pulmonary hemorrhage, but coexisting Aspergillus\n infection is likely given the reported sputum culture results.\n 2. Spiculated right apical nodules raise the concern for possible primary\n lung cancer in this patient with underlying emphysema, but could potentially\n be related to the same process as the diffuse lung abnormalities. 3-month\n chest CT followup is suggested following appropriate therapy to ensure\n resolution.\n 3. Extensive intrathoracic lymphadenopathy, which may be due to Wegener's\n and/or reactive nodes from infection.\n 4. Small bilateral pleural effusions and a small amount of ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-17 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1028955,
"text": ", MED 11R 4:27 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: eval of this currently immunocompromised pt with rare asperg\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval of this currently immunocompromised pt with rare aspergillis and poor resp\n sx\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n PFI REPORT\n Multifocal consolidation, ground-glass attenuation, and poorly defined\n nodules, which may be due to pulmonary hemorrhage/vasculitis and/or\n Aspergillus infection. Bilateral pleural effusions, intrathoracic\n lymphadenopathy, and a small amount of ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027858,
"text": " 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for worsening infiltrates\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for worsening infiltrates\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 10:07 PM\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\n are unchanged. There is no residual pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMMENTS: 50-year-old man with Wegener and pulmonary hemorrhage.\n\n Since yesterday, bilateral dense consolidation in mid and lower lung zones are\n unchanged. There is no residual pulmonary edema. Pleural effusions, if any,\n are small. Heart size is top normal and unchanged. Right internal jugular\n sheath ends in right brachiocephalic vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027200,
"text": " 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: looking for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n looking for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 9:50 AM\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\n is unchanged. Right internal jugular is in good position. Left small pleural\n effusion is new with associated atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n COMMENTS: 60-year-old man with hypoxia. Interval change.\n\n Since , bilateral alveolar opacity with slightly nodular appearance\n is unchanged in this patient with pulmonary renal syndrome.\n\n Small left pleural effusion is new associated with new left lower lobe\n atelectasis. Right internal jugular catheter is in good position.\n\n Findings can be consistent with multifocal infection, bilateral hemorrhage or\n much less likely asymmetric pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028071,
"text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, effusions, edema\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with wegener's and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, effusions, edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NLHa SAT 1:28 PM\n Bilateral opacities unchanged. Right central venous catheter unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Portable chest x-ray performed at 0515 hours.\n\n Comparison is . There are bilateral opacities involving both lower and\n mid lung fields. The opacity on the left extends to involve the upper lung\n field. Compared to prior exam, there is increasing density in the right\n base. The cardiac silhouette is mildly enlarged.\n\n IMPRESSION: Increasing density in the right base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027201,
"text": ", M. MED 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: looking for interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with hypoxia\n REASON FOR THIS EXAMINATION:\n looking for interval change\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, bilateral alveolar opacity with slightly nodular appearance\n is unchanged. Right internal jugular is in good position. Left small pleural\n effusion is new with associated atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027613,
"text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for new infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for new infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:10 AM\n PFI: No change in the bilateral severe predominantly lower lobe opacification\n compared to the prior study.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with pulmonary hemorrhage.\n\n Portable AP chest radiograph was compared to obtained at\n 05:40.\n\n In the interim, there is overall no significant change in the bilateral severe\n predominantly lower lobe consolidations with some involvement of the upper\n lungs, left more than right, consistent with diffuse parenchymal hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027401,
"text": ", MED 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\n remains normal. Pleural effusion, if any, is small. Right jugular line is\n central. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028562,
"text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc TUE 10:21 AM\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\n bilateral consolidations with slight decrease in the right mid lung but are\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\n lesions on the right could be present but are hard to confirm due to\n underlying diffuse consolidation. Chest CT could further characterize lung\n opacities.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORTABLE AP\n\n REASON FOR EXAM: 60-year-old man with Wegener. Evaluate for interval change.\n\n Since yesterday, right internal jugular catheter still ends in upper SVC.\n Diffuse bilateral consolidation slightly decreased in the right mid lung but\n are unchanged on the left. Consolidation has a more heterogeneous appearance,\n could be due to underlying cavitary lesions hard to better define. Chest CT\n could further characterize lung opacities if clinically warranted.\n\n Biapical scarring is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028563,
"text": ", MED 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, right internal jugular catheter ends in upper SVC. Diffuse\n bilateral consolidations with slight decrease in the right mid lung but are\n unchanged on the left. Consolidation is more heterogeneous today. Cavitary\n lesions on the right could be present but are hard to confirm due to\n underlying diffuse consolidation. Chest CT could further characterize lung\n opacities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-08 00:00:00.000",
"description": "BX-NEEDLE KIDNEY BY NEPHROLOGIST",
"row_id": 1027056,
"text": " 10:49 AM\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: ? Gbm disease versus wegeners' granulomatosis\n Admitting Diagnosis: VASCULITIS\n ********************************* CPT Codes ********************************\n * BX-NEEDLE KIDNEY BY NEPHROLOGIST GUIDANCE/LOCALIZATION FOR NEEDLE BIO *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with glomerulonephritis and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n ? Gbm disease versus wegeners' granulomatosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Glomerulonephritis and pulmonary hemorrhage. Questionable GBM\n disease vs. Wegener's.\n\n FINDINGS: Ultrasound guidance was provided for renal biopsy performed by\n nephrology team. Five core biopsy samples were obtained from the lower pole\n of the left kidney. The patient tolerated the procedure well. No immediate\n complications occurred.\n\n IMPRESSION: Successful ultrasound-guided biopsy performed by the nephrology\n team.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-17 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 1028947,
"text": " 4:15 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval sinusus (asking for non-contrast study with ARF as belo\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man her with newly dx wegener's granulomatosis - with ARF, pulm\n hemmorhage - on cyclophosphamide, predinose, and phalsamphoresis - now with\n noted sputum cx noting rare aspergillis\n REASON FOR THIS EXAMINATION:\n eval sinusus (asking for non-contrast study with ARF as below)\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 60-year-old male with newly-diagnosed Wegener's\n granulomatosis with acute renal failure, pulmonary hemorrhage with sputum\n culture noting \"rare aspergillus.\"\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT-acquired axial images of the sinuses. Coronal\n reformatted images were obtained.\n\n FINDINGS: Extensive sinus disease is present with air-fluid levels in both\n maxillary sinuses. The left maxillary sinus is nearly-completely opacified and\n containing hyperdense secretions. The right maxillary, sphenoid and frontal\n sinuses show circumferential mucosal thickening. Dense secretions are also\n identified in the right nasal cavity.\n\n There is diffuse bony remodeling and permeation involving the ethmoid septae,\n maxillary sinus medial walls and ostiomeatal complexes, and the nasal\n turbinates, which in the absence of history or prior surgery, likely relate to\n Wegener's granulomatosis. However, the nasal septum and hard palate remain\n intact. There is no evidence of intracranial or orbital involvement. The\n mastoid air cells remain normally aerated.\n\n IMPRESSION:\n 1. Extensive pansinus soft tissue disease, most severely affecting the left\n maxillary sinus. Note is made of dense secretions in the left maxillary sinus\n and right nasal cavity which may simply represent chronically-inspissated\n secretions; however, fungal colonization (ie. with Aspergillus spp. and their\n metabolic byproducts) can have a similar appearance.\n 2. Extensive bony remodeling and permeation involving the sinuses and nasal\n turbinates which in the absence of prior surgery can be seen with Wegener's\n granulomatosis. The nasal septum remains intact.\n\n These findings were discussed with Dr. (primary hospitalist) at the\n time of interpretation, by Dr. . Evaluation by ENT Service, with\n possible diagnostic aspiration of the left maxillary contents, may be\n warranted.\n\n (Over)\n\n 4:15 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: eval sinusus (asking for non-contrast study with ARF as belo\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028225,
"text": ", MED 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n PFI REPORT\n Improved aeration of left mid lung zone.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-08 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 1027059,
"text": " 10:42 AM\n RENAL U.S. Clip # \n Reason: WITH GLOMERULONEPHRITIS\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Glomerulonephritis.\n\n COMPARISON: None.\n\n FINDINGS: The right kidney measures 12.4 cm and the left 12.8 cm. The renal\n parenchymal echogenicity is increased, bilaterally. There are no renal\n calculi or hydronephrosis. Small amount of fluid is seen adjacent to the\n right kidney. The bladder is not distended with a Foley catheter within,\n cannot be assessed accurately.\n\n IMPRESSION: Bilateral increased renal parenchymal echogenicity consistent\n with medical renal disease. Small amount of right perinephric free fluid.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027400,
"text": " 5:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PSS WED 3:06 PM\n Most severe pulmonary consolidation may have worsened slightly since . Component of volume overload is more evident today, though heart size\n remains normal. Pleural effusion, if any, is small. Right jugular line is\n central. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:40 A.M. ON \n\n HISTORY: Pulmonary hemorrhage.\n\n IMPRESSION: AP chest compared to through :\n\n Severe infiltrative pulmonary abnormality responsible for dense consolidation\n in the lower mid and lower lung zones since has not improved and may\n have worsened in the lung bases, now accompanied by progressive vascular\n congestion in the upper lung suggesting volume overload also responsible for\n mild increase in caliber of the azygos vein, although vascular engorgement is\n undoubtedly exaggerated by supine positioning. Pleural effusions, if any, are\n small. Heart size is top normal and unchanged. Right jugular introducer ends\n at the thoracic inlet. No other invasive support devices.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1026858,
"text": " 10:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for evidence of infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with evidence of diffuse alveolar hemorrhage on bronch and\n renal failure\n REASON FOR THIS EXAMINATION:\n please assess for evidence of infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Diffuse alveolar hemorrhage.\n\n FINDINGS: No previous images available. There is mild enlargement of the\n cardiac silhouette. Diffuse bilateral asymmetric alveolar opacifications\n involving almost all of both lungs. This would be consistent with diffuse\n alveolar hemorrhage as clinically suspected. Fibrocalcific changes in the\n apices are consistent with old granulomatous disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027859,
"text": ", MED 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for worsening infiltrates\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegeners and pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for worsening infiltrates\n ______________________________________________________________________________\n PFI REPORT\n Since yesterday, bilateral dense consolidations in mid and lower lung zones\n are unchanged. There is no residual pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028072,
"text": ", MED 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrates, effusions, edema\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with wegener's and cough\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrates, effusions, edema\n ______________________________________________________________________________\n PFI REPORT\n Bilateral opacities unchanged. Right central venous catheter unchanged.\n\n"
},
{
"category": "Echo",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Report",
"row_id": 87723,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. Valvular heart disease.\nHeight: (in) 69\nWeight (lb): 150\nBSA (m2): 1.83 m2\nBP (mm Hg): 112/56\nHR (bpm): 78\nStatus: Outpatient\nDate/Time: at 11:48\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of\nthe interatrial septum. No ASD by 2D or color Doppler.\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\nanteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid\ninferoseptal - hypo; septal apex - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis. Abnormal septal motion/position.\n\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. Left ventricular wall thicknesses and cavity size are normal. There\nis mild regional left ventricular systolic dysfunction with septal\nhypokinesis. The right ventricular cavity is mildly dilated with mild global\nfree wall hypokinesis. There is abnormal septal motion/position. The aortic\nroot is moderately dilated at the sinus level. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThere is mild pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Mild hypokinesis of the septum along with abnormal septal motion.\nMildly dilated and hypokinetic right ventricle. The interventricular septal\nmotion is abnormal and may be consistent with right ventricular volume\noverload. Mild mitral and tricuspid regurgitation. Dilated aortic sinus and\nascending aorta.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027614,
"text": ", MED 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for new infiltrate\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with pulmonary hemorrhage\n REASON FOR THIS EXAMINATION:\n Eval for new infiltrate\n ______________________________________________________________________________\n PFI REPORT\n PFI: No change in the bilateral severe predominantly lower lobe opacification\n compared to the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2199-07-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1028224,
"text": " 4:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval pulm change\n Admitting Diagnosis: VASCULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with Wegener's\n REASON FOR THIS EXAMINATION:\n interval pulm change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): NR SUN 9:18 AM\n Improved aeration of left mid lung zone.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 05:20\n\n INDICATION: Wegener's.\n\n COMPARISON: at 05:09\n\n FINDINGS:\n\n Compared to prior there is improved aeration of the left mid lung zone. The\n remainder of the study is unchanged with continued evidence of previously seen\n airspace disease. No PTX. Right CVL remains in place.\n\n IMPRESSION: Improved aeration of the left mid lung zone.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2199-07-21 00:00:00.000",
"description": "Report",
"row_id": 224051,
"text": "Atrial flutter with variable block. Non-specific repolarization abnormalities.\nIntraventricular conduction delay of right bundle-branch block type. Compared\nto the previous tracing of there is no significant difference.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-07-17 00:00:00.000",
"description": "Report",
"row_id": 224052,
"text": "Atrial flutter with rapid ventricular response. Right ventricular conduction\ndelay. Compared to the previous tracing of no diagnostic interim\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2199-07-15 00:00:00.000",
"description": "Report",
"row_id": 224053,
"text": "Atrial flutter\nModest right ventricular conduction delay\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Report",
"row_id": 224054,
"text": "Atrial flutter. Modest right ventricular conduction delay. Since the previous\ntracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Report",
"row_id": 224055,
"text": "Atrial flutter. Modest right ventricular conduction delay. Since the previous\ntracing of no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Report",
"row_id": 224056,
"text": "Atrial flutter with variable block. Incomplete right bundle-branch block.\nCompared to the previous tracing of A-V block is now irregular. The\nunderlying atrial rhythm continues to likely be counterclockwise flutter.\nThe other findings are similar.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2199-07-06 00:00:00.000",
"description": "Report",
"row_id": 224057,
"text": "Counterclockwise atrial flutter with 2:1 A-V block. Diffuse non-specific\nST-T wave changes likely secondary to rate. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 333538,
"text": "Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. Maculopapular rash resolved.\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333555,
"text": "Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333655,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in a-flutter (baseline since arrival to OSH per report). RVR\n to 130\ns. BP remains stable.\n Action:\n Monitoring HR, rhythm and hemodynamic status closely. Lopressor\n increased to 25mg PO TID.\n Response:\n HR better controlled on increased lopressor (110-115). Continues in\n a-flutter. BP remains stable.\n Plan:\n Continue to monitor cardiac and hemodynamic status closely. Continue\n lopressor as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333454,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\n Action:\n Observing u/o and labs. Will consult renal in am and follow\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\n start sevelamer in the am.\n Response:\n pending\n Plan:\n Renal will consult in the am. Will draw am labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\n Response:\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\n with crackles\n way up.\n Plan:\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\n monitor sao2 and provide o2 as needed.\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333642,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333643,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt admitted w/ pulmonary hemorrhage as above. RR high 20\ns, SpO2 low\n 90\ns trending down to 87 on 4L via NC.\n Action:\n FiO2 increased to 50% via hi-flow neb. Monitoring respiratory\n assessment closely. Following ABG as ordered. Encouraging C+DB\n exercises.\n Response:\n SpO2 remains >90% on FiO2 50% as above. RR remains 20-28, w/ some use\n of accessory muscles; however, pt able to speak in full sentences and\n reports breathing is\nbetter\n as compared to yesterday. ABG 7.31/37/67.\n Plan:\n Continue to monitor respiratory assessment closely. Follow ABG as\n ordered. Titrated FiO2 as ordered and indicated\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt presented to OSH w/ Creatanine >9.\n Action:\n Following labs as ordered. Monitoring fluid status closely. Pt given\n kayexalate X 2 doses since admission\n see . Renal fellow currently\n placing HD line.\n Response:\n K 4.8 down from 5.8, Creatanine remains elevated at 9.6. UOP remains\n 30-100ml/hr. Hct remains stable at 27.\n Plan:\n Awaiting CXR to confirm HD line placement. Plan for plasmapharesis\n tonight. Also plan to continue cytoxin /mesna. Anticipate starting HD\n in am. Following hct and lytes Q8hr as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333496,
"text": "Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 1\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: ///17/\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 513 K/uL\n 9.0 g/dL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333711,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx. Pt was adm on .\n Atrial flutter (Aflutter)\n Assessment:\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\n the high 120-130 range during plasmapharesis. B/P has remained stable\n 110/78-132/69.\n Action:\n Lopressor was increased to 50mg tid which was started last evening.\n Response:\n H/R is decreasing from the 100\ns to the 80-90range.\n Plan:\n Cont with tid lopressor. Monitor h/r and pattern.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\n Action:\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\n past 24 hours pt has had 2 doses of Kayexalate.\n Response:\n K+ is 4. U/O improving with urine more yellow. Last creat 8.5 with bun\n 147\n Plan:\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\n lungs have had crackles bil bases with the left lung more dim than the\n right..\n Action:\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\n evening and was given cytoxan after the plasmaphoresis. Pt is also\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\n Response:\n Sao2 drops to the high 80\ns while pt wears only the n/c. pt does not\n like to wear face mask and denies any sob.\n Plan:\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\n plasmaphoresis again on Tues.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 333805,
"text": "Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. MacPap rash resolving\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n MICU Attending Addendum\n Pt seen with fellow and examined. Met with pt and family to review\n situation. Would add and emphasize the following to Dr \ns notes.\n On exam\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\n alos right forearm.\n ABG 7.31/37/67\n BUN 147/ Cr 9.6\n CXR: diffsue bilateral interstitial and alveolar infiltrates\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\n and renal failure quite concerning for vasculitis.\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\n Role of plasmapheresis without clear diagnosis is challenging. Will\n consult with Renal collegues on possibility of a renal biopsy to aid in\n diagnosis. Additionally he is moving towards dialysis, need to closely\n watch K, renally dose all meds. His resp status is tenusous due to\n hypoxemia as well as met acidosis and uremic encephalopathy- may\n require intubation for support\n would likely favor this over NIPPV\n given likely duration.\n Discussed with son who is HCP and updated.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent: Critically Ill 50 min\n ------ Protected Section ------\n MICU Attending Addendum\n Updated note on events from . In the course of the afternoon, I\n spent over 2 hours working with both the renal consultation team and Dr\n and the Plasmapheresis team determining indication and timing of\n pheresis for possible anti GBM. We were able to update family, call in\n pheresis team, and place pheresis catheter all to facilitate. Pt with\n progressive hypoxemia and on NRB\n ongoing frequent labs to assess HCT,\n also borderline indication for HD due to progressive encephalopathy,\n boerdeline hyperK and acidosis.\n Time Spent 120 min\n ------ Protected Section Addendum Entered By: , MD\n on: 08:22 ------\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 333807,
"text": "Chief Complaint: Respiratory distress/hypoxemia\n HPI:\n 24 Hour Events:\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\n Renal consultation concurred with Pulmonary-Renal syndrome.\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\n anticipating 5 days of treatment. Remains on cortocosteroids.\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\n Denies increased dyspnea, but remains with oxygen requirement.\n History obtained from Patient\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.3\nC (95.5\n HR: 81 (81 - 133) bpm\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\n RR: 24 (22 - 29) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 186 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 186 mL\n Blood products:\n Total out:\n 1,330 mL\n 690 mL\n Urine:\n 1,330 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -504 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\n mildly disshevled\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 355 K/uL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\n predominantly basilar. Right IJ catheter position acceptable. No\n significant overall change compared to .\n Assessment and Plan\n 60 yom now with Pulmonary-Renal syndrome.\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\n diffuse infiltrates and oxygen requirement.\n HYPOXEMIA -- attributed to pulmonary infiltrates.\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\n SaO2.\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\n consult prepared to move to dialysis when indicated. Monitor urine\n output, BUN, Creatitine.\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\n Continue steroids and plasmaphoresis.\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\n FLUIDS -- limit iv fluids intake.\n HYPERPHOSPHATEMIA -- start phosphate binder.\n NUTRITION -- NPO pending evaluation\n ANEMIA -- progressive, attributed to underlying process, and possible\n contribution from RIJ central line placement. Transfuse to Hct >21.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 333895,
"text": "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 Comments:\n Pt currently on 6L NC. Pt ordered for albuterol and Atrovent nebs Q6.\n Nebs given as ordered and pt tolerated them well.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 333425,
"text": "Chief Complaint: Bilateral LE edema, SOB\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy.\n .\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptons started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n .\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\n noted as having mild wheezing and productive cough of white sputum.\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\n Occult blood stool negative. U/A significant for protein 400mg/dl,\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\n microscopy positive for RBCs, granular casts.\n .\n Pt was seen by Renal, who thought there might possibly be a\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\n .\n CXR on admission showed underlying COPD with diffuse bilateral\n pulmonary infiltrates.\n Pt underwent bronchoscopy on , and was found to have active low\n grade blood emanating from the RLL and LLL.\n .\n EKG on admission showed atrial flutter at 2:1 block rate 150.\n .\n On arrival here, pt appeared mildly tachypneic. He reported that LE\n edema had improved, and that pain had resolved in LE. He complained of\n only mild nausea recently without vomiting, and a productive cough.\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\n constipation, melena, hematochezia, chest pain, urinary\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\n no epistaxis. Last BM was yesterday, and was formed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 12:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 107 (107 - 122) bpm\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 48 mL\n PO:\n 230 mL\n TF:\n IVF:\n 48 mL\n Blood products:\n Total out:\n 475 mL\n 100 mL\n Urine:\n 125 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -52 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///16/\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 543 K/uL\n 219 mg/dL\n 9.7 mg/dL\n 144 mg/dL\n 16 mEq/L\n 107 mEq/L\n 6.2 mEq/L\n 143 mEq/L\n 31.0 %\n [image002.jpg]\n \n 2:33 A8/9/ 11:05 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 Hct\n 31.0\n Plt\n 543\n Cr\n 9.7\n Glucose\n 219\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\n mg/dL, PO4:9.6 mg/dL\n Assessment and Plan\n ABG: ///16/\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2199-07-07 00:00:00.000",
"description": "ICU Event Note",
"row_id": 333422,
"text": "Clinician: Attending\n 60 yo male without significant medical history now admit to OSA with\n lower extremity edema x 2 weeks. His presentation there was notable\n for severe acute renal failure and with diffuse alveolar infiltrates.\n The findings at the OSA were consistent with acute GN based upon review\n of the urine sediment. In addition, patient did have bronchoscopy\n revealing a strong suggestion of alveolar hemorrhage with sequential\n lavage showing persistent bloody fluid. There was no hemoptysis noted.\n U/A there--RBC's and granular casts documented.\n There he has had persistent renal failure and alveolar infiltrates and\n now with persistent tachycardia patient to ICU for further\n evaluation and care after solumedrol and cytoxan started at OSH.\n ROS-negative for sinusitis/sinus congestion\n Here patient has persistent sinus tachycardia noted,\n Exam notable for-->\n Patient comfortable by subjective description\n No JVD\n Lungs-Diffuse crackles bilaterally inferiorly and to mid lung zone.\n Heart-Tachycardic and regular rate suggested on initial exam\n Extremities--1+ bilateral lower extremity edema. Diffuse macular rash\n from foot to knee.\n Labs->\n Cr-9.6\n K-5.8\n HCO3-=18\n CXR->Patient with diffuse bilateral alveolar infiltrates--there is a\n suggestion of lower lobe distribution but with the complete absence of\n pleural effusions which is consistent with alveolar hemorrhage.\n ECG-Atrial Flutter seen with atrial rate at approx 300 bpm and\n ventricular rate of 125-150.\n In summary this is a 60 yo male with findings of acute renal failure\n with evidence of diffuse alveolar hemorrhage and active disease with\n ESR >140. No definative diagnostic procedure was preformed and serum\n testing, although sent, is all pending at this time. Patient did start\n Solumedrol and Cytoxan for empiric diagnosis of\n vasculitis with serologies pending. Goodpasteur's and Wegner's and\n microscopic polyangiitis and PAN all are on this list along with\n connective tissue disease.\n 1)Acute Renal Failure-\n -Significant concern for acute vasculitis\n -Given severity of dysfunction certainly intervention is desired in\n timely fashion\n -Would favor biopsy prior to intervention is patient remains stable\n enough to accept.\n -With Solumedrol and Cytoxan 1 dose given is challenging decision to\n consider hold of further treatment prior to biopsy.\n -Will consult renal for consideration of biopsy.\n -Given significant clinical decline and significant pulmonary\n distress--tachypnea and tachycardia--I would favor continuation of\n treatment already started given his subjective improvement over past 24\n hours. Although this will cloud the biopsy results his clinical status\n at this point in time is one that warrants intervention.\n -Continue Solumedrol 1g qd and Cytoxan to continue\n -Renal and Rheum to evaluate patient for aid in diagnosis and treatment\n -C3, C4, , Anti-GBM, ANCA all pending\n 2)Alevolar Hemorrhage--seen on OSH bronchoscopy, no biopsies performed\n -Continue with supportive care at this time\n -Will have to consider diagnostic procedure and consideration of renal\n biopsy may be highest yield\n -Attempt to maintain euvolemia as hydrostatic edema is of concern given\n signficiant volume overload but will be limited by renal failure and\n the distribution of infiltrates.\n 3)Atrial Flutter-\n Hold anticoagulation for bleeding risk\n Rate control as needed\n Will need TSH and ECHO in full evaluation\n 4)Anemia-\n Patient with reasonable stability with transfusion--may well be\n inadequate production with associated blood loss at this time--with the\n blood loss less active at this time.\n -F/u HCT\n -Monitor with OB for stool\n Total time spent: 45 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333661,
"text": "Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight, pt's O2 requirement increased from 3 to 4L to maintain sats\n in low 90s. HR stable in 100-120s in Aflutter. Received Kayexelate x 2\n for elevated K.\n EKG - At 10:48 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics: None\n Infusions: None\n Other ICU medications: Metoprolol 12.5mg PO bid (started this a.m.)\n Other medications:\n Changes to medical and family history: None\n Review of systems is unchanged from admission except as noted below\n Review of systems: None\n Flowsheet Data as of 06:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.4\nC (95.8\n HR: 109 (107 - 123) bpm\n BP: 110/74(81) {87/66(70) - 126/82(92)} mmHg\n RR: 26 (16 - 31) insp/min\n SpO2: 90%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 161 mL\n PO:\n 230 mL\n TF:\n IVF:\n 161 mL\n Blood products:\n Total out:\n 475 mL\n 415 mL\n Urine:\n 125 mL\n 415 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -255 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 90%\n Physical Examination\n Gen: alert, awake, sitting up in bed eating breakfast, mildly\n tachypneic, NAD\n HEENT: mm slightly dry, EOMI grossly, PERRL, NCAT, telangiectasias on\n malar area of face\n CV: RRR, no murmurs/rubs/gallops, S1 S2 present\n LUNGS: rhonchi over R lung fields posteriorly, crackles/rhonchi over L\n lung fields posteriorly\n ABD: soft, NTND, bs+, +hepatomegaly, no palpable splenomegaly\n EXT: 1+pitting edema LE bilaterally, diffuse macular rash from knees->\n (improved today, less erythematous), no cyanosis/ clubbing\n Labs / Radiology\n 213 mg/dL\n 147 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 107 mEq/L\n 5.5 mEq/L\n 144 mEq/L\n 7.4 K/uL\n 9.0 g/dL\n 26.6 %\n 513 K/uL\n [image002.jpg]\n Anion Gap = 20\n CXR Final: mild increase in cardiac sillouhette, diffuse bilateral\n symmetrical alveolar opacities, almost in all lung fields, consistent\n with diffuse alveolar hemorrhage; fibrocalficific changes in the apices\n consistent with old granulomatous disease\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL****\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - CXR\ns as needed\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8 for now\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - F/u on u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - F/u on TSH\n - Surface ECHO in a.m. today\n - Starting Lopressor 12.5mg PO bid this a.m. for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n Addendum\n Anti-GBM test sent to Specialty Laboratories, 1, #4 to\n connect to lab. They will run this particular study on Tuesday, ^th, and result may become available ^th-15^th.\n PGY-1\n ------ Protected Section Addendum Entered By: , MD\n on: 19:28 ------\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "ICU Event Note",
"row_id": 333670,
"text": "Clinician: Attending\n Patient seen and examined. Plasmapharesis initiated this evening.\n Appears to be tolerating it well with no new complaints. Currently BP\n 130/70, HR 134, sat 94-97% on full face mask. No respiratory distress.\n Fine crackles heard laterally but otherwise lungs are relatively clear.\n Plan is for plasmapharesis, K to be rechecked. If necessary to be\n dialysed, renal will consider tonight. Cytoxan to be redosed at 140 mg\n IV, weight based at ~2 mg/kg for 67 kg. On Solumedrol 1 gm q24h x 3\n days. 30 min of CC time spent with patient.\n Total time spent: 30 minutes\n Patient is critically ill.\n"
},
{
"category": "Respiratory ",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 333725,
"text": "Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Crackles\n Comments:\n Plan\n Pt presently on 3 lpm n/c and ordered for nebs alb/atr. Nebs\n administered as ordered with no adverse reactions.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 335004,
"text": "Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage \n C-ANCA vasculitis. This morning, he breathing more easily, with stable\n lung exam though his CXR looks unchanged. This is likely due to\n diuresis, as he is -2L in the past 24 hours. Per nursing, he has new\n hemoptysis, unlclear if it is pink tinged or w/frank blood. Also has\n 2+ budding yeast on sputum, without signs of candidiasis on\n oropharyngeal exam.\n -Will give lasix 40IV for goal of -1-2 L today. We will also watch his\n urine output and restart IVF if necessary. We will balance maintaining\n urine output >100/hr for bladder protection with not giving too much\n Lasix due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n His septum is intact this am. Will continue to check daily.\n -Start nystatin mouthwash\n -Send blood cultures for fungus (though highly unlikely given pt. is\n afebrile, stable, but he is on high dose immunosuppression)\n -CT of sinus has been recommended, but will not likely change\n management so we will not order it at this time.\n - HCTq8h to monitor for alveolar bleeding. Given\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335152,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 334768,
"text": "Chief Complaint: Hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirement.\n HR varies from A-flutter to NRS.\n Coughing up sputum (swallowing), but more productive cough today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, 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 12:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.1\nC (96.9\n HR: 98 (85 - 131) bpm\n BP: 136/89(100) {104/60(74) - 136/90(100)} mmHg\n RR: 18 (12 - 25) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 1,971 mL\n PO:\n 750 mL\n 160 mL\n TF:\n IVF:\n 3,736 mL\n 1,811 mL\n Blood products:\n Total out:\n 2,400 mL\n 1,235 mL\n Urine:\n 2,400 mL\n 1,235 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 736 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 94%\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, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : diffuse, No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: 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, No(t) Sedated,\n No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.8 g/dL\n 211 K/uL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:14.3/28.3/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Pulmonary-Renal Syndrome (Wegener's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to vasculitis. Monitor RR, SaO2.\n Possible component of pulmonary edema.\n HYPOXEMIA -- attributed to pulmonary infiltrates. Continue\n supplemental oxygen, monitor RR, SaO2.\n PULMONARY RENAL SYNDROME -- Wegener's Granulomatosis. Continue\n steroids & cytoxan. Plasmaphoresis.\n RENAL FAILURE -- improving. Monitor uo, BUN, creatinine.\n FLUIDS\n desire to allow net diuresis. Consider Lasix dose.\n NUTRIONAL SUPPORT -- PO\n HEMATURIA -- stable. Monitor.\n ANEMIA -- stable s/p transfusion.\n HYPOCALCEMIA -- continue to replete.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 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: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334958,
"text": "Chief Complaint:\n 24 Hour Events:\n Had plamaspheresis yesterday. Cyclophosphamide changed to po.\n Continued to desat into the 80s because his mask falls off, but remains\n >95% when it is on. We stopped fluids yesterday and he was given 3x 40\n IV lasix. Was only -300 at midnight, but since, he has been -1.8\n liters. Urine output before midnight=300cc/hr and after MN, continued\n to >300. Cough has been productive for 2 days, with blood tinge, sputum\n sent yesterday.\n HCT remained stable, repleted lytes\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 12:30 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.2\nC (97.2\n HR: 92 (76 - 130) bpm\n BP: 136/67(84) {104/60(51) - 145/91(100)} mmHg\n RR: 26 (12 - 27) insp/min\n SpO2: 89%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,660 mL\n 70 mL\n PO:\n 290 mL\n TF:\n IVF:\n 2,214 mL\n 70 mL\n Blood products:\n 156 mL\n Total out:\n 3,010 mL\n 1,900 mL\n Urine:\n 3,010 mL\n 1,900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -350 mL\n -1,830 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 89%\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 185 K/uL\n 7.3 g/dL\n 82 mg/dL\n 6.1 mg/dL\n 28 mEq/L\n 3.6 mEq/L\n 152 mg/dL\n 104 mEq/L\n 143 mEq/L\n 21.6 %\n 11.0 K/uL\n [image002.jpg]\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n 03:17 PM\n 09:59 PM\n 04:37 AM\n WBC\n 9.0\n 10.3\n 11.0\n Hct\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n 24.0\n 23.7\n 21.6\n Plt\n 221\n 211\n 185\n Cr\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n 6.2\n 6.1\n Glucose\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n 146\n 82\n Other labs: PT / PTT / INR:14.5/29.8/1.2, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.1 mg/dL,\n Mg++:1.9 mg/dL, PO4:6.9 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\n of breathing, with worsening lung exam and desating to the 70s without\n the facemask on. This is unlikely due to hemorrhage as his crit has\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\n and chest Xray appears to have signs of pulmonary edema, making volume\n overload the most likely cause of worsening pulmonary status.\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\n output >100/hr for bladder protection with not giving too much Lasix\n due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n Will examine his septum today as this could worsen his repiratory\n status and make him feel nasal congestion (which he has been\n complaining of)\n -CT of sinus has been recommended, will consider when patient more\n stable.\n - HCT has been stable, follow HCT q8h to monitor for alveolar\n bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335153,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on O2 face tent 80%, and 6 liters / min NC, remains afebrile,\n moist non productive cough remains, LS with rhonchi bilaterally. Pt\n continues to desat when off O2 ( removes O2 while sleeping on and off)\n Action:\n Scheduled neb given , nystatin swish given for yeast in sputum.\n Response:\n Good response to neb , Slept well with ambien.\n Plan:\n Continue to monitor VSS and follow sats closely.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n HCT 25 after red cell transfusion ( up from 21.6, goal is 21 for HCT),\n BUN and creatinine trending down from 152/6.1 to 147/ 5.6\n Action:\n Response:\n U/O wnl, continued to monitor renal parameters\n Plan:\n Plasma pheresis on Monday, monitor serial HCT , follow up on a.m labs.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334748,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Dx: Wegener\ns Granulomatosis confirmed by renal biopsy\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\n frequent episodes of tachycardia in the 130\ns, typically with exertion,\n stimulation and desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows to the 80-90\ns with rest, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered. Encourage rest periods\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.5, BUN 153\n Action:\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\n Creatinine is trending down. Hct drawn at 1530, results pending.\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\n with meals. Lunch held due to respiratory distress.\n Response:\n Labs to be drawn 4 hours after plasmaphoresis and tonight at 2200.\n Fluid balance remains positive. Good urine output response to lasix.\n Tolerated plasmaphoresis with episodes of tachycardia.\n Plan:\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\n total of 7 treatments via right IJ HD catheter. Administer mesna as\n ordered with chemo. Chemo to be given after plasmaphoresis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n strong productive cough. Patient\ns O2 requirements increasing\n throughout the day.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 95% and\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\n albuterol changed to prn (may be contributing to tachycardia). Afrin\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\n on.\n Response:\n Oxygenation remains labile. Desats with eating and removal the face\n tent. Recovery time longer each time he desats.\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\n sputum sample. Patient may need a sinus CT scan if stable. Administer\n neb treatments as ordered.\n Patient\ns family at bedside. Updated on plan of care.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334749,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\n edema, 2L fluids up. Did not receive cytoxan yesterday. Will receive\n it after pheresis today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Per rheumatology, C-anca is positive confirming\n the diagnosis of C-ANCA vasculitis. This morning, he is increased work\n of breathing, with worsening lung exam and desating to the 70s without\n the facemask on. This is unlikely due to hemorrhage as his crit has\n remained stable. He is 2L fluid up in 24 hours and 6L up for his LOS,\n and chest Xray appears to have signs of pulmonary edema, making volume\n overload the most likely cause of worsening pulmonary status.\n -will D/C fluids, try Lasix 40IV x1. We will balance maintaining urine\n output >100/hr for bladder protection with not giving too much Lasix\n due to renal failure.\n -Patients at Wegener\ns are at increased risk for septal perforation.\n Will examine his septum today as this could worsen his repiratory\n status and make him feel nasal congestion (which he has been\n complaining of)\n -CT of sinus has been recommended, will consider when patient more\n stable.\n - HCT has been stable, follow HCT q8h to monitor for alveolar\n bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient desats while eating, if he continues will make him NPO\n - treating the underlying disease-Wegeners:\n -Plasmapheresis, dose 3/7 today, will get tomorrow, then next MWF.\n -Prednisone 60mg po daily,\n -Cyclophosphamide-140 po. Rheumatology will write for this. Will give\n mesna for cystitis prophylaxis\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: C-ANCA vasculitis, confirmed with renal\n biopsy. Creatinine trending down, good urine output. BUN still high\n but not increasing, no signs of platelet dysfunction yet, mental status\n okAs a note, plasmapheresis in cases of severe Wegeners has been shown\n to improve kidney outcomes, though not mortality.\n - Renal biopsy: per renal, patient with cresenteric glomerulosclerosis\n but more cellular glomeruli than sclerotic giving hope for return on.\n Monitor for bleeding at site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. -, anti-GBM-, anti-DNA-, cryglobulins P,\n ANCA P.\n - Foley in place , strict I&O, q8 lytes .\n -pink tinged urine, stable. Urine has been tinged nephritic\n picture, but if worsening, concern for hemorrhagic cystitis. Will\n monitor for increasing blood in urine and can irrigate the bladder if\n hemorrhagic cystitis is suspected.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - on Atovaqone for PCP prophylaxis, avoiding Bactrim due to\n renal toxicity.\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 4gIV in last 24 hours.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n Waiting at least 4 hours after pheresis for accurate .\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG, in and out of NSR this am.\n Asymptomatic, rate well controlled overnight. ECHO showed mild LV\n septal , 45-50%. Likely secondary to large volume shifts\n (retaining total body fluid with renal failure, with large volume load\n putting stress on atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiac negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: Dialysis line in his neck, with pigtail.\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 335073,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis on\n plasmapheresis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt. with Wegener\ns granulocytosis with Hx. Of pulmonary hemorrhage per\n bronch at OSH. On 80% face tent and 6L NC. LS diminished. Occ congested\n non-productive cough. No hemoptesis this shift.\n Action:\n Plasmapherisis today. Cont. O2 for O2 sat >90%. HOB >45 degrees.\n Atrovent neb as ordered. Started on Nyastatin swish and spit for yeast\n in sputum cx on .\n Response:\n O2 sat 92-98%. Occ will desat to 86% when mask falls down or when\n eating.\n Plan:\n Cont. current treatment. Monitor resp. status and wean O2 as tolerated.\n F/u sputum cx.\n Plasmapherisis today. Nest treatment on Monday. Transfused today with\n one unit of PRBC for Hct. 21.6. Will need serial Hct. Checks starting\n after transfusion.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 334190,
"text": "Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Blood loss due to pulmonary hemorrhage and\n renal bx likely contributing. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 334197,
"text": "Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Crackles\n Comments:\n Pt currently on 6L NC. Nebs given as ordered with no adverse reaction.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333491,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt arrived from osh in arf. Urine amber and cloudy, output approx\n 50-75cc/hr. creat 9.7, bun 144. k+ 6.2, phos 9.6.\n Action:\n Observing u/o and labs. Will consult renal in am and follow\n recommendations. Pt received sodium polystyrene sulfonate 30gm po. Will\n start sevelamer in the am.\n Response:\n Pending. Creat 9.2 this am\n Plan:\n Renal will consult in the am. Will draw am labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Pt placed on 3L N/C, increased to 4L at 0400. pt had cxr done\n Response:\n Pt denies sob and states he is feeling better. Sao2 89-94%. Lungs still\n with crackles\n way up.\n Plan:\n Consult rheumatology in am. Pt also has an echo ordered. Cont to\n monitor sao2 and provide o2 as needed.\n Pt had a hct of 14 at osh and was transfused a total of 5 units of prbc\n prior to admission to micu. Hct 31. plts 543, inr 1.5.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333972,
"text": "This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n na.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333970,
"text": "This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334155,
"text": "Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\n for presumed Wegeners.\n 24 Hour Events:\n Continues to have increasing 02 requirement, on 6L and facemask to keep\n 02 >90%. Yesterday he had a renal biopsy, TTE, given d5W for\n hypernatremia and seen by rheumatology.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\n likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily (will change to prednisone tomorrow per\n rheumatology)\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok. BUN continues to increase, but BUN\n often stays elevated in acute renal failure after the kidneys have\n started to improve, also the patient is on high dose steroids which can\n increase BUN. As a note, plasmapheresis in cases of severe Wegeners\n has been shown to improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday, awaiting results. Monitor for bleeding at\n site given possible platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Will try to maintain\n 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim due to renal function, patient should be\n discharged on Atovaqone.\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is taking PO, D/C D5W.\n -if needed, restart fluids to maintain UOP 100cc/hr (to prevent hem.\n cystitis while on cytoxan)\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am),\n -lytes q6hrs\n -EKG\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT , give 1unit today\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334025,
"text": "This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n Na.\n Response:\n Phos still high,Na 141 this am.BUN and creatinine trending down.\n Plan:\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\n Hct this am 21.1.?for transfusion.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334369,
"text": "Chief Complaint: 60 yo male with pulmonary hemorrhage, ARF, anemia and\n renal biopsy c/w Wegeners.\n 24 Hour Events:\n O/N required ?? 02. Got pheresis yesterday, solumedrom and\n cyclophosphamide. No hematuria. Talked to renal about biopsy, c/w\n Wegners. Has been on IVF to keep uop >100, successfully. Tolerating\n PO.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:43 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36\nC (96.8\n HR: 99 (75 - 130) bpm\n BP: 115/68(78) {98/49(62) - 127/69(80)} mmHg\n RR: 20 (18 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,475 mL\n 650 mL\n PO:\n TF:\n IVF:\n 2,100 mL\n 650 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 260 mL\n Urine:\n 1,360 mL\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,115 mL\n 390 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 261 K/uL\n 6.9 g/dL\n 172 mg/dL\n 7.1 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 149 mg/dL\n 101 mEq/L\n 145 mEq/L\n 22.4 %\n 5.4 K/uL\n [image002.jpg]\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n WBC\n 8.1\n 5.4\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n Plt\n 355\n 261\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n TCO2\n 20\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.2 mg/dL,\n Mg++:2.2 mg/dL, PO4:8.1 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%. Most\n likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, but increased with 1unit yesterday.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Solumedrol 1g IV daily, will ask Rheumatology for recommended\n prednisone dose\n -Cyclophosphamide 140mg w/mesna for cystitis prophylaxis, has had 4\n doses thus far.\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6,up to 8.1 then back down to 7.1. BUN\n peaked at 160 now, 150. No signs of platelet dysfunction yet, mental\n status ok. Renal will give his kidneys about 48 more hours to turn\n around before dialyzing. As a note, plasmapheresis in cases of severe\n Wegeners has been shown to improve kidney outcomes, though not\n mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n yesterday with D51/2.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -given 6g IV Ca yesterday, plus more during pheresis\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - given HCT trend, gave 1 unit yesterday with improved HCT.\n - Type and screen, cross-matched\n - Blood consent obtained\n - Guaiac all stools\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334116,
"text": "Chief Complaint: 60 y/o male who presented with anemia, hypoxia,\n bilateral pulmonary hemmorhage and acute renal failure. Being treated\n for presumed Wegeners.\n 24 Hour Events:\n Continues to have increasing 02 requirement, on 6L and facemask to keep\n 02 >90%. Yesterday he had a renal biopsy, TTE, put on\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.6\nC (96.1\n HR: 89 (72 - 133) bpm\n BP: 106/59(69) {98/51(65) - 125/76(85)} mmHg\n RR: 23 (18 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 343 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 343 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 440 mL\n Urine:\n 1,405 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 261 K/uL\n 6.9 g/dL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L w/ humidification, 93-98%\n Most likely secondary to diffuse alveolar hemorrhage confirmed on\n bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. HCT continues to\n slowly drop, likely a slow bleed. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - also treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose today (QOD)\n -Solumedrol 1g IV daily\n -Cyclophosphamide 140mg\n # Acute renal failure: Monitoring for need for dialysis, has line just\n in case. Creatinine down to 7.6, BUN up to 155. No signs of platelet\n dysfunction yet, mental status ok.\n Ddx includes most likely pulmonary renal syndromes, such as Wegener's\n (granulomas), Goodpasture's, microscopic polyangiitis, lupus, PAN.\n BUN/Cr on was 126/9.6, K 5.8. Nephritic picture with RBC casts.\n However, apart from pulmonary association, ddx for acute renal failure\n with nephritis includes PSGN, lupus nephritis, etc. ESR elevated >140,\n consistent with an autoimmune disorder. Age-appropriate for Wegener's.\n Also consider DIC.\n - Renal biopsy yesterday, awaiting results\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, pending: , anti-GBM, anti-DNA, cryglobulins, ANCA, HepB\n serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place , strict I&O, q8 lytes\n -On Sevelamer, Amphagel (day ) for hyperphos\n - Avoid nephrotoxic agents\n #Hypernatremia:likely secondary to lack of access to water,on D5W NA+\n today 141, down from 150.\n -Now patient is eating, can D/C D5W.\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+ (given 4g this am), check again this PM\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6, given HCT , likely need blood this pm.\n - Type and screen, cross-matched\n - Blood consent obtained\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 334121,
"text": "Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333431,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Renal will consult in the am.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n In osh pt had a bronchoscopy which showed pulmonary hemorrhage. Bil\n lungs with crackles\n way up. Also some mild exp wheezes.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 333432,
"text": "Chief Complaint: Bilateral LE edema, SOB\n HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy.\n .\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptons started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n .\n In the ED, VS was tachycardic (126), afebrile (97F), BP 131/70. He was\n noted as having mild wheezing and productive cough of white sputum.\n Mental status was clear. Initial bloodwork showed K 5.6, BUN 130, Cr\n 9.6. Tp nml at 0.3. BNP elevated at 625. Urinary protein elevated at\n 2410. Hct was 14.1 on admission, up to 23 after transfusion of 5 units.\n Occult blood stool negative. U/A significant for protein 400mg/dl,\n blood 250mg/dl, bilirubin negative, nitrite/leukocyte negative. Urine\n microscopy positive for RBCs, granular casts.\n .\n Pt was seen by Renal, who thought there might possibly be a\n pulmonary-renal syndrome or vasculitis, with ESR>140. He was given\n Solumedrol 1g IV x 1. Cyclophosphamide was started after UOP was\n confirmed to be adequate. Work-up by Renal included C3/C4, ,\n anti-GBM, anti-DNA, cryglobulins, ANCA, HepB/C serology.\n .\n CXR on admission showed underlying COPD with diffuse bilateral\n pulmonary infiltrates.\n Pt underwent bronchoscopy on , and was found to have active low\n grade blood emanating from the RLL and LLL.\n .\n EKG on admission showed atrial flutter at 2:1 block rate 150.\n .\n On arrival here, pt appeared mildly tachypneic. He reported that LE\n edema had improved, and that pain had resolved in LE. He complained of\n only mild nausea recently without vomiting, and a productive cough.\n Otherwise denies sore throat, fevers, chills, abdominal pain, diarrhea,\n constipation, melena, hematochezia, chest pain, urinary\n frequency/urgency, dysuria, lightheadedness, vision changes, headache,\n no epistaxis. Last BM was yesterday, and was formed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home medications:\n NONE\n Allergies:\n NKDA\n Past medical history:\n Family history:\n Social History:\n ?Nephrolithiasis ()- blood found in urine after workup for lower\n abdominal pain, no stones passed, 24hr protein done whith was normal\n per pt.\n Finger laceration ()\n Mother passed from CVA in 80s. Father passed in 70s from unknown cause.\n Twin brother passed from MI, another brother with hx cardiac artery\n bypass graft. Denies family hx renal or pulmonary disease.\n Pt works full-time as a machine operator. Mostly stationary job.\n Divorced, college-age son lives with wife. Lives alone.\n Smoked 1-1/2 ppd until when he quit (possibly 50 pack year hx\n prior). Drinks ~2 drinks/day, and on social occasions. Denies other\n drug use.\n Review of systems: He complained of only mild nausea recently without\n vomiting, and a productive cough. Otherwise denies sore throat, fevers,\n chills, abdominal pain, diarrhea, constipation, melena, hematochezia,\n chest pain, urinary frequency/urgency, dysuria, lightheadedness, vision\n changes, headache, no epistaxis.\n Flowsheet Data as of 12:49 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.5\nC (95.9\n HR: 107 (107 - 122) bpm\n BP: 118/75(82) {87/66(70) - 123/82(90)} mmHg\n RR: 27 (16 - 27) insp/min\n SpO2: 91%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 48 mL\n PO:\n 230 mL\n TF:\n IVF:\n 48 mL\n Blood products:\n Total out:\n 475 mL\n 100 mL\n Urine:\n 125 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -52 mL\n Respiratory\n O2 Delivery Device: Nasal cannula 3L\n SpO2: 91%\n Physical Examination\n GEN: Thin, pale, mildly distressed, tachypneic\n HEENT: EOMI, PERRL, sclera anicteric, conjunctiva pale, no epistaxis or\n rhinorrhea, dry MM, OP Clear\n NECK: No JVD, carotid pulses brisk, no bruits, shotty anterior cervical\n lymphadenopathy, trachea midline\n COR: RRR, no M/G/R, normal S1 S2, radial pulses +2\n PULM: diffuse rhonchi/crackles bilaterally almost to apices\n ABD: Soft, NT, ND, +BS, +hepatomegaly (four finger-breaths below costal\n margin)\n EXT: +1pitting edema lower extremities bilaterally, no palpable cords,\n no cyanosis/clubbing, diffuse faint non-pruritic macular rash from feet\n -> knees\n NEURO: alert, oriented to person, place, and time. CN II\n XII grossly\n intact. Moves all 4 extremities. Strength 5/5 in upper and lower\n extremities. Patellar DTR +1. Plantar reflex downgoing. No gait\n disturbance. No cerebellar dysfunction.\n SKIN: Diffuse macular rash in LE bilaterally from feet -> kness,\n scattered telangiectasias in malar area of face\n Labs / Radiology\n 543 K/uL\n 219 mg/dL\n 9.7 mg/dL\n 144 mg/dL\n 16 mEq/L\n 107 mEq/L\n 6.2 mEq/L\n 143 mEq/L\n 31.0 %\n [image002.jpg]\n CXR : bilateral fluffy pulmonary infiltrates, costophrenic angles\n visible (pending read by radiology)\n EKG : similar to prior EKG from OSH, with atrial flutter\n predominantly in limb leads, rate 121\n \n 2:33 A8/9/ 11:05 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 Hct\n 31.0\n Plt\n 543\n Cr\n 9.7\n Glucose\n 219\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.8 mg/dL, Mg++:2.0\n mg/dL, PO4:9.6** mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n .\n Plan:\n .\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - Continue supplemental O2 PRN\n - Albuterol nebs PRN\n - Daily CXR's\n - Type and screen, cross match x 2 units; threshold to transfuse hct\n <21, unless clinically unstable\n - Blood consent\n - Consult Renal and Rheum in a.m.\n - Will hold off on resuming Cytoxan for now as unclear what dose pt\n actually got at OSH. Will await Renal and Rheum recs. Pt may eventually\n get renal biopsy\n - Will continue Solumedrol 1g IV daily\n - F/u on Renal serology and BAL results from OSH\n - Will check Crits q8\n .\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on discharge was 126/9.6, K 5.8. Fits\n nicely into pulm-renal picture above. Nephritic picture with RBC casts.\n Denies epistaxis. However, apart from pulmonary association, ddx for\n acute renal failure with nephritis includes PSGN, lupus nephritis, etc.\n ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's.\n - Re-check u/a, urine lytes, urine sediment\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Consult Renal here\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Start Sevelemer in a.m. with meals for elevated Phos.\n .\n # Tachycardia: ?Aflutter on EKG at OSH. Also present in several limb\n leads on admission EKG here. Currently asymptomatic with rate in 120s.\n Can be secondary to underlying structural heart disease. Also may be\n secondary to large volume shifts (retaining total body fluid with renal\n failure, with large volume load putting stress on atria.)\n - Check TSH\n - Surface ECHO in a.m.\n - Will start Lopressor 12.5mg PO daily for rate control.\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check Crits q8\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: Regular renal-cardiac diet for now. Will switch back to NPO if\n respiratory status worsens anticipating intubation. Will replete lytes\n PRN. Kayexelate x 1 for high K, Sevelamer in a.m. for high phos.\n .\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control: RISS\n Lines: 2 PIVs\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: Pantoprazole PO\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334007,
"text": "This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. It is most likely secondary to diffuse\n alveolar hemorrhage from vasculitis, particularly a pulmonary-renal\n syndrome.\n Atrial flutter (Aflutter)\n Assessment:\n Pt is in Aflutter with HR 80-140.HR >100 with movement and\n activities.But when resting and sleeping in 80\ns-90\ns.NBP within\n limits.No drop in BP with high HR.\n Action:\n Pt is on metoprolol for rate control.\n Response:\n HR in 80\ns 90\ns while at rest.\n Plan:\n Cont monitoring.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt is on nc o2 at 6lit plus shuffle mask for humidification.LS clear\n with diminished base.Pt has got strong productive cough.\n Action:\n Resp failure most likely due to vasculitis from renal-pulm syndrome.Pt\n is on high dose of steroids and had chemo.And pt is getting\n plasmapheresis every other day.\n Response:\n Pt is saturating >90% on the above setting.no c/o pain/SOB o/n.\n Plan:\n Cont monitoring resp status.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley draining 35-50cc/hr of clear yellow urine. Creatinine was 8.1\n yesterday.Pt has got elevated phos and sodium.Calcium 5.\n Action:\n Renal failure most likely due to vasculitis. Pt is getting treated by\n chemo. Pt is reciving phos binders and getting D5W 100cc/hr for high\n Na.\n Response:\n Phos still high,Na 141 thos am.\n Plan:\n Monitor lytes and replete as needed.Pt is for ? plasmapheresis today.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 334102,
"text": "Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Overall, no significant change in supplimental oxygen requirement.\n Overall, appears much more comfortable.\n Able to eat.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.1\n Tcurrent: 35.2\nC (95.4\n HR: 90 (72 - 133) bpm\n BP: 115/65(75) {98/51(65) - 125/76(84)} mmHg\n RR: 22 (19 - 26) insp/min\n SpO2: 94%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,462 mL\n 443 mL\n PO:\n TF:\n IVF:\n 1,905 mL\n 443 mL\n Blood products:\n 557 mL\n Total out:\n 1,405 mL\n 485 mL\n Urine:\n 1,405 mL\n 485 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,057 mL\n -42 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula, High flow neb\n SpO2: 94%\n ABG: ///21/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\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, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): Person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 6.9 g/dL\n 261 K/uL\n 223 mg/dL\n 7.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 155 mg/dL\n 101 mEq/L\n 141 mEq/L\n 21.1 %\n 5.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n WBC\n 7.4\n 8.1\n 5.4\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n Plt\n 543\n 513\n 355\n 261\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n 8.1\n 7.6\n TCO2\n 20\n Glucose\n 93\n 176\n 156\n 223\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.4 mg/dL,\n Mg++:1.7 mg/dL, PO4:10.0 mg/dL\n Imaging: CXR () diffuse bilateral infiltrates, predominantly\n bibasilar, unchanged.\n Assessment and Plan\n PULMONARY-RENAL SYNDROME -- probable Wegener's Granulomatosis vs. GBM\n Disease. Continue steroids & cytoxan, plasmaphoresis empirically.\n Await renal Bx results and serologies.\n RESPRIATORY DISTRESS -- diffuse parenchymal infiltrates, attributed to\n hemorrhage. No significant change. Monitor RR, SaO2, CXR.\n RENAL FAILURE -- non-oliguric; gradually improving creatitine. Monitor\n BUN, creatitine, UO.\n NUTRITIONAL SUPPORT -- advance PO.\n FLUIDS -- provide adequate urine output (cytoxan)\n HYPERGLYCEMIA -- promoted by steroids.\n A-FLUTTER -- good rate control. Continue meds.\n ANEMIA -- slow reduction. Transfuse to >21\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334581,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334584,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continusly pulling the mask off inspite of frequently remainding\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\n mask off,denies any SOB,pain or discomfort.\n Action:\n On nebs and steroids,FM 60 % and additional NC is on,frequent\n reinforcement needed about need for oxygen.\n Response:\n Pt strongly denies for any pain,SOB\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334644,
"text": "Chief Complaint:\n 24 Hour Events:\n Overnight on facemask 50%-60% with NC to maintain sats >90%. Often\n pulling off facemask, has to be reminded. Received 4g Calcium. In and\n out of a flutter and NSR, this am in NSR. Urine remains pink tinged,\n no change, UOP was 200cc/hr for last 24 hours. Increasing pedal\n edema, 2L fluids up.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Requiring 6L NC and 40% Fio2 facemask,\n 90-98%. Most likely secondary to diffuse alveolar hemorrhage confirmed\n on bronchoscopy . Vasculitis is suspected, particularly a\n pulmonary-renal syndrome (e.g. Wegener's (granulomas), Goodpasture's,\n microscopic polyangiitis, lupus, PAN) given associated acute renal\n failure. However, lower on the differential are ARDS, TRALI with\n bilateral pulmonary infiltrates on CXR.\n - follow HCT q8h to monitor for alveolar bleeding. HCT responded\n appropriately to 1unit PRBCs so likely not currently bleeding.\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Albuterol nebs PRN\n - CXR daily\n - F/u on BAL results from OSH\n - Patient now tolerating PO, though still concern for respiratory\n status\n - treating treating the underlying disease (presumed Wegener's):\n -Plasmapheresis, dose yesterday (QOD)\n -Prednison po daily,\n -Cyclophosphamide-dose to be determined after c/s with rheum and\n renal. Will give mesna for cystitis prophylaxis, has had 4 doses thus\n far.\n -affrin nasal spray day for nasal congestion\n # Acute renal failure: Monitoring for need for dialysis, has line in\n case. Creatinine down down to 7.1. BUN peaked at 160 now, 149. No\n signs of platelet dysfunction yet, mental status ok. Renal will give\n his kidneys about 48 more hours to turn around before dialyzing. As a\n note, plasmapheresis in cases of severe Wegeners has been shown to\n improve kidney outcomes, though not mortality.\n - Renal biopsy yesterday: per renal, patient with cresenteric\n glomerulosclerosis but more cellular glomeruli than sclerotic giving\n hope for return on. Monitor for bleeding at site given possible\n platelet dysfunction.\n - treating underlying cause (likely Wegener's).\n - F/u on pending renal labs from OSH -> C3/C4-negative, Hep C VL\n negative, Hep B negative. pending: , anti-GBM, anti-DNA,\n cryglobulins, ANCA.\n - Foley in place , strict I&O, q8 lytes . Requiring 1/2NS @ 150 to\n maintain 100cc/hr urine output for prevention of hemorrhagic cystitis.\n -pink tinged urine, stable, but will send daily U/As.\n -On Sevelamer, Amphagel (today is day ) for hyperphos\n - Avoid nephrotoxic agents\n - D/C Bactrim yesterday due to renal function, patient now on\n Atovaqone for PCP .\n #Hypernatremia:likely secondary to lack of access to water,resolved\n with D51/2.\n #Hypocalcemia: plasmapheresis (containing citrate) and to\n underlying renal failure\n -given 16 IV Ca in the last 24 hours, ionized Ca now WNL.\n -follow ionized Ca, more accurate given citrate used in pheresis.\n -on SS replacement.\n -EKG unchanged\n # Tachycardia: Aflutter on EKG. Asymptomatic, rate well controlled\n overnight. ECHO yesterday showed mild LV septal , \n 45-50%. Likely secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - Continue lopressor titrated up to 50 mg PO tid with good rate control\n (HR in 80s).\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q8\n - will transfuse for HCT<21 or symptomatic anemia\n - Type and screen, cross-matched\n - Blood consent obtained\n - Stool guaiacc negative today, continue to check.\n # FEN: Taking PO. Will replete lytes PRN.\n # Access: 2 PIVs\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n # Code: FULL, confirmed with pt with son present ()\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334799,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Dx: Wegener\ns Granulomatosis confirmed by renal biopsy\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. More\n frequent episodes of tachycardia in the 130\ns, typically with exertion,\n stimulation and desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows to the 80-90\ns with rest, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered. Encourage rest periods\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.5, BUN 153\n Action:\n Ionized calcium this am 0.97, replaced with 4gm Calcium gluconate.\n Creatinine is trending down. Hct drawn at 1530, result 24.\n Cyclophosphamide (chemo) changed to PO from IV. Mesna IV x3 doses with\n administration of PO cyclophosphamide (chemo). Lasix 40mg IV given, IVF\n discontinued. Plasmaphoresis (#3 of 7) done today at 1pm. Renagel given\n with meals. Lunch held due to respiratory distress.\n Response:\n Labs to be drawn 8pm (4 hours after plasmaphoresis) and tonight at 2200\n (check with team). Fluid balance remains positive. Good urine output\n response to lasix. Tolerated plasmaphoresis with episodes of\n tachycardia.\n Plan:\n Daily U/As, monitor labs/hct/ionized calcium q8 hrs. transfuse if hct\n less than 21. monitor urine output. Plasmaphoresis tomorrow for a\n total of 7 treatments via right IJ HD catheter. Administer mesna as\n ordered with chemo. Chemo to be given after plasmaphoresis.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n strong productive cough. Patient\ns O2 requirements increasing\n throughout the day.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 80% and\n 6L NC. Patient encouraged to cough and deep breathe. Need to obtain\n sputum sample, specimen cup at the bedside. Atrovent scheduled dose,\n albuterol changed to prn (may be contributing to tachycardia). Afrin\n and Ocean nasal spray at bedside. Patient encouraged to leave face tent\n on.\n Response:\n Oxygenation remains labile. Desats with eating and removal the face\n tent. Recovery time longer each time he desats. Left lung sounds better\n than this am.\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing, obtain a\n sputum sample. Patient may need a sinus CT scan if stable. Administer\n neb treatments as ordered.\n Patient\ns family at bedside. Updated on plan of care.\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-07 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 333590,
"text": "Chief Complaint: ARF, alveolar hemorrhage\n I saw and examined the patient, and was physically present with the 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 60 M PMH former tobacco use, nephrolithiasis transferred from after experiencing SOB, edema for 2-3 weeks. There he was\n found to have hct 14.1%, ARF with RBC ?casts and proteinuria, ESR > 140\n and alveolar hemorrhage on BAL. He was started on 1 g solumedrol and\n cytoxan 120 mg there. He was transferred for consideration of\n plasmapheresis.\n 24 Hour Events:\n EKG - At 10:48 PM\n -Tachycardic to low 100s with EKG concerning for A.flutter\n -Hyperkalemic requiring kayexalate\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 RISS\n Solumedrol 1 g daily\n Albuterol Q6H\n Atrovent Q6H\n Protonix\n Colace\n Lopressor 12.5 mg \n Renagel\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Respiratory: Cough, No hemoptysis\n Gastrointestinal: Nausea\n Genitourinary: Foley\n Integumentary (skin): Rash, Diffuse maculopapular\n Heme / Lymph: Anemia\n Flowsheet Data as of 09:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 35.5\nC (95.9\n Tcurrent: 35.3\nC (95.6\n HR: 109 (106 - 123) bpm\n BP: 140/88(99) {87/66(70) - 140/88(99)} mmHg\n RR: 30 (16 - 31) insp/min\n SpO2: 93%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 2,105 mL\n 426 mL\n PO:\n 230 mL\n 240 mL\n TF:\n IVF:\n 186 mL\n Blood products:\n Total out:\n 475 mL\n 495 mL\n Urine:\n 125 mL\n 495 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,630 mL\n -69 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n FiO2: 4 L\n SpO2: 91%\n Physical Examination\n General Appearance: No acute distress, Tachypneic\n Cardiovascular: (S1: Normal), (S2: No(t) Normal, Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Breath Sounds: Bilateral crackles. Rhonchorous:\n Bilateral )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: None.\n Skin: Few petechiae at feet. MacPap rash resolving\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 9.0 g/dL\n 513 K/uL\n 213 mg/dL\n 9.2 mg/dL\n 17 mEq/L\n 5.5 mEq/L\n 147 mg/dL\n 107 mEq/L\n 144 mEq/L\n 26.6 %\n 7.4 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n WBC\n 7.4\n Hct\n 31.0\n 26.6\n Plt\n 543\n 513\n Cr\n 9.7\n 9.2\n Glucose\n 219\n 213\n Other labs: PT / PTT / INR:16.6/30.0/1.5, Ca++:6.3 mg/dL, Mg++:2.0\n mg/dL, PO4:9.9 mg/dL\n Fluid analysis / Other labs: AG 20\n Imaging: CXR - Diffuse bilateral opacities with alveolar and\n interstitial components. Normal cardiomediastinal contours. Minimal\n bilateral costophrenic blunting.\n Microbiology: None.\n Assessment and Plan: 60 M admitted with pulmonary-renal syndrome. DDx:\n Wegener\ns granulomatosis, MPA, Goodpasteur\ns, lupus, post-strep GN with\n DIC (less likely). He is currently clinically stable and has been\n started on solumedrol and cytoxan.\n 1) Pulmonary-renal syndrome\n ANCA, anti-GBM, , anti-dsDNA,\n anti-Sm, anti-phospholipid Ab, C3, C4, cryoglobulins, hepatitis\n serologies pending. Will consult renal for cytoxan dosing,\n consideration of plasmapheresis and renal biopsy. Supplemental O2 as\n needed for SpO2 > 90%. Continue solumedrol 1 g daily.\n 2) Anemia\n Likely alveolar hemorrhage. Will rule out\n hemolysis. Trend Q8H until stable.\n 3) Renal failure\n No acute indication for RRT at this point.\n Does have an AG metabolic acidosis. Hyperkalemia currently\n controllable with medications. No EKG changes. Renagel. Follow\n electrolytes.\n 4) Atrial flutter\n Start low-dose beta-blockade. TSH pending.\n TTE pending.\n MICU Attending Addendum\n Pt seen with fellow and examined. Met with pt and family to review\n situation. Would add and emphasize the following to Dr \ns notes.\n On exam\n Somnelent, but arousable, RR bilayteral crackles, petchiae on feet and\n alos right forearm.\n ABG 7.31/37/67\n BUN 147/ Cr 9.6\n CXR: diffsue bilateral interstitial and alveolar infiltrates\n 60 yr old man with subacute lethargy x weeks tx from OSH with pulmonary\n and renal failure quite concerning for vasculitis.\n Agree with plan for empiric Rx with Solumedrol at 1 GM and Cytoxan.\n Role of plasmapheresis without clear diagnosis is challenging. Will\n consult with Renal collegues on possibility of a renal biopsy to aid in\n diagnosis. Additionally he is moving towards dialysis, need to closely\n watch K, renally dose all meds. His resp status is tenusous due to\n hypoxemia as well as met acidosis and uremic encephalopathy- may\n require intubation for support\n would likely favor this over NIPPV\n given likely duration.\n Discussed with son who is HCP and updated.\n ICU Care\n Nutrition: Renal, cardiac\n Glycemic Control: Regular insulin sliding scale\n Lines: Peripheral IVs\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: Protonix\n VAP: N/A\n Comments:\n Communication: Comments:\n Code status: Full code. Son, , is HCP.\n Disposition :Remains in ICU.\n Total time spent: Critically Ill 50 min\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334220,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s occationally going to\n the 120s-130s\n Action:\n Conts on lopressor 50mg TID\n Response:\n HR was fairly well controlled though does have episodes of tachycardia\n in the setting of eating or low SATs\n Plan:\n Cont with the lopressor, follow VS, replete lytes\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat remains high, it was 7.6 this morning and 8.0 this afternoon.\n Calcium conts to be low as well as mag\n Action:\n Received 4 gms of calcium this morning and had a repeat ionized Ca of\n .86, he is presently receiving another 4 gms of Ca and 2 gm of MgS04.\n He is also receiving NS at 100cc/hr to try and protect his bladder from\n the cytoxan, to receive cytoxan again tonight\n Response:\n Creat bumped this afternoon, u/o 70-30cc/hr, conts with low Ca with his\n pheresis\n Plan:\n Presently being pheresed, to get cytoxan tonight\n this needs to be\n arranged with the 7Feldberg nurses, follow ionized Ca, creat, f/u on\n the renal biopsy from yest.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS with rhonchi and wheezes, 02 SAT has improved today from yest with\n an 02 SAT ~ 93% on 6 L NC, he states that he feels a little better\n today. Occationally has a wet cough but not bringing anything up.\n Action:\n Tolerating a lower FI02\n Response:\n Plan:\n Cont to follow 02 requirements, decrease the FI02 as he tolerates,\n started on mepron for PCP prophylaxis\n the bactrim was d/ced due to\n his renal failure\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 334640,
"text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 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 06:27 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: 85 (85 - 131) bpm\n BP: 126/71(83) {103/49(63) - 136/90(100)} mmHg\n RR: 23 (9 - 25) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 4,486 mL\n 979 mL\n PO:\n 750 mL\n TF:\n IVF:\n 3,736 mL\n 979 mL\n Blood products:\n Total out:\n 2,400 mL\n 640 mL\n Urine:\n 2,400 mL\n 640 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,086 mL\n 339 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 99%\n ABG: ///23/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 211 K/uL\n 7.8 g/dL\n 95 mg/dL\n 6.5 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 153 mg/dL\n 103 mEq/L\n 142 mEq/L\n 23.9 %\n 10.3 K/uL\n [image002.jpg]\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n 01:54 PM\n 11:04 PM\n 05:08 AM\n WBC\n 5.4\n 9.0\n 10.3\n Hct\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n 25.5\n 23.9\n Plt\n 261\n 221\n 211\n Cr\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n 6.9\n 6.8\n 6.5\n Glucose\n 156\n 223\n 195\n 229\n 172\n 94\n 144\n 208\n 95\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:6.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334646,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt continuesly pulling the mask off inspite of frequently remainding\n him,LS are dim/crackles bibasilar,sats 92-95% desta to 85-88 when the\n mask off,denies any SOB,pain or discomfort.\n Action:\n On nebs and steroids,FM 60 % and additional NC is on,frequent\n reinforcement needed about need for oxygen.\n Response:\n Pt strongly denies for any pain,SOB but continued to be uncomfortable\n during night,MD was informed.No meds ordered at this time.\n Plan:\n Continue to monitor resp status,follow up AM lab results,bleeding time\n should be drawn by lab at AM.\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333752,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx. Pt was adm on .\n Atrial flutter (Aflutter)\n Assessment:\n HR has remained 94-133, a-flutter, no ectopy noted. HR noted to be in\n the high 120-130 range during plasmapharesis. B/P has remained stable\n 110/78-132/69.\n Action:\n Lopressor was increased to 50mg tid which was started last evening.\n Response:\n H/R is decreasing from the 100\ns to the 80-90range.\n Plan:\n Cont with tid lopressor. Monitor h/r and pattern.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt was adm from osh with creat >9, last evening creat 8.5. u/o steadily\n increasing to good amts. K+ is down from 5.8 to 4.0. Hct 24.4.\n Action:\n Pt had a HD line placed. Monitoring labs. Renal has consulted. In the\n past 24 hours pt has had 2 doses of Kayexalate. Will not repleat K+ of\n 3.9 this am as pt rises.\n Response:\n K+ is 4. U/O improving with urine more yellow. Creat 8.6/bun149 this\n am.\n Plan:\n Will draw am labs to monitor bun and creat and lytes. Renal will be in,\n pt may have HD depending on recommendations. Q8 hr hct and lytes.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt was adm with pulm hemorrhage from osh. Has not coughed up blood.\n lungs have had crackles bil bases with the left lung more dim than the\n right..\n Action:\n O2 has been weaned according to pt needs. pt had plasmaphoresis this\n evening and was given cytoxan after the plasmaphoresis. Pt is also\n getting solumedrol 1gm iv q24H x3 doses. (one more dose due )\n Response:\n Sao2 drops to the high 80\ns while pt wears only the n/c. pt does not\n like to wear face mask and denies any sob.\n Plan:\n Cont to monitor sao2 and provide o2 accordingly. Pt will have\n plasmaphoresis again on Tues.\n Hct 22.8 this am and team would like to discuss in rounds as to further\n transfusions. Team wants Hct drawn at 0800. pt will also receive\n calcium gluconate 4gm to replenish 5.9. Na+ 150. Phos 9.5\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 333876,
"text": "HPI: This is a 60 year-old male with distant hx ?nephrolithiasis who\n presents after transfer from OSH for LE edema/pain, SOB on exertion x\n 2-3weeks, found to be have acute renal failure, anemia, and pulmonary\n hemorrhage on bronchoscopy. Pt does have hx of emphasema but no other\n medical hx.\n Atrial flutter (Aflutter)\n Assessment:\n Pt remains in aflutter at a rate of 70s-low 100s\n Action:\n Conts on lopressor 50mg TID\n Response:\n Tolerating the lopressor, he did have short periods of a HR in the\n 1teens this afternoon\n Plan:\n Cont with the lopressor, follow VS\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Creat was 8.6 this morning, u/o has been 40-50cc/hr\n Action:\n Pt had a renal biopsy this morning under US guidance, receiving D5W\n 100cc/hr for 1 liter for a Na of 150\n Response:\n No bleeding at the site, VSS, given DDAVP when he came back to the unit\n Plan:\n Follow HCT, VS, renal bx results, no immediate plans for dialysis,\n follow labs\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Conts to desat to 87-88% on 6L NC, LS with rhonchi throughout, he\n states that he does not feel SOB with an 02 SAT in the upper 80s. he\n has not been coughing up any blood\n Action:\n He is on scoop mask at 60-70% and this brings his 02 up to 93-99%.\n Response:\n Conts to require a high FI02, he wants to eat but is NPO due to his\n tenuous resp status\n Plan:\n Follow SATs cont to try to wean his FI02\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 334483,
"text": "Chief Complaint: Respiratory distress, hypoxemia\n HPI:\n 24 Hour Events:\n Remains with high FiO2 requirment.\n Renal bx consistent with Wegener's Granulomatosis.\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Bactrim (SMX/TMP) - 10:03 PM\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: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, 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 11:34 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 35.9\nC (96.6\n HR: 99 (87 - 130) bpm\n BP: 118/72(83) {98/49(62) - 127/82(90)} mmHg\n RR: 21 (9 - 28) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.4 kg (admission): 68.4 kg\n Height: 69 Inch\n Total In:\n 2,477 mL\n 2,103 mL\n PO:\n 60 mL\n TF:\n IVF:\n 2,102 mL\n 2,043 mL\n Blood products:\n 375 mL\n Total out:\n 1,360 mL\n 1,025 mL\n Urine:\n 1,360 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,117 mL\n 1,078 mL\n Respiratory support\n O2 Delivery Device: Face tent\n SpO2: 93%\n ABG: ///25/\n Physical Examination\n General Appearance: No(t) Well nourished, No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : scattered, No(t) Bronchial:\n , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, date, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 221 K/uL\n 94 mg/dL\n 7.2 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 149 mg/dL\n 105 mEq/L\n 145 mEq/L\n 22.7 %\n 9.0 K/uL\n [image002.jpg]\n 11:04 PM\n 04:02 AM\n 08:13 AM\n 02:46 PM\n 09:30 PM\n 04:25 AM\n 01:17 PM\n 09:20 PM\n 01:30 AM\n 08:05 AM\n WBC\n 8.1\n 5.4\n 9.0\n Hct\n 24.4\n 22.8\n 22.6\n 22.0\n 21.9\n 21.1\n 20.9\n 22.7\n 22.4\n 22.7\n Plt\n 355\n 261\n 221\n Cr\n 8.5\n 8.6\n 8.1\n 7.6\n 8.1\n 7.4\n 7.1\n 7.2\n Glucose\n 293\n 176\n 156\n 223\n 195\n 229\n 172\n 94\n Other labs: PT / PTT / INR:16.0/27.9/1.4, Alk Phos / T Bili:/0.5,\n Differential-Neuts:94.1 %, Lymph:3.2 %, Mono:2.4 %, Eos:0.3 %, Lactic\n Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.1 mg/dL, PO4:7.7 mg/dL\n Assessment and Plan\n Pulmonary-Renal syndrome (Wegner's Granulomatosis)\n RESPIRATORY DISTRESS -- attributed to diffuse alveolar infiltrates,\n likey due to vasculitis. Radiographically without significant change,\n but hope to see improvement over next several days. Monitor RR, SaO2.\n RENAL FAILURE -- attributed to vasculitis. Continues to slowly\n improve.\n ANEMIA -- blood loss (alveolar hemorrhage, renal bx, dysfunctional\n plts). Monitor Hct, transfuse to > 21\n WEGENER\"S GRANULOMATOSIS -- steroids and cytoxan. Continue\n plasmaphoresis QOD.\n FLUIDS -- euvolemic. Monitor I/O\n HEMATURIA -- concern for hemorrhagic cystitis\n A-FIB -- good rate control COntinue meds. Monitor HR.\n NASAL CONGESTION -- possible related to Wegener's but more likely due\n to high flow O2. Symptomaatic relief.\n HYPOCALCEMIA -- repleted. Monitor.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: PPI\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 333854,
"text": "Chief Complaint: LE edema, SOB\n 24 Hour Events:\n Overnight the patient remained stable, but continuing to require O2 by\n NC and facemask. HR down to 80s with lopressor but remains in\n aflutter. This am patient only c/o hunger.\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\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 01:53 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: 35.2\nC (95.3\n HR: 94 (72 - 133) bpm\n BP: 109/58(70) {104/53(66) - 142/88(102)} mmHg\n RR: 25 (18 - 29) insp/min\n SpO2: 88%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 1,042 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 485 mL\n Blood products:\n 557 mL\n Total out:\n 1,330 mL\n 1,080 mL\n Urine:\n 1,330 mL\n 1,080 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -38 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 88%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No acute distress\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral, almost \n way up lungs posteriorly)\n Extremities: Right: 1+ pitting, Left: 1+ pitting,, diffuse rash below\n knees\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 355 K/uL\n 7.6 g/dL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Assessment and Plan\n Assessment: This is a 60 year-old male with a distant history of\n nephrolithiasis, no other chronic medical problems who presents with\n lower extremity edema and SOB.\n Plan:\n # Respiratory distress: Most likely secondary to diffuse alveolar\n hemorrhage confirmed on bronchoscopy . Vasculitis is suspected,\n particularly a pulmonary-renal syndrome (e.g. Wegener's (granulomas),\n Goodpasture's, microscopic polyangiitis, lupus, PAN) given associated\n acute renal failure. However, lower on the differential are ARDS, TRALI\n with bilateral pulmonary infiltrates on CXR. Pt currently clinically\n tachypneic. Received a dose of Cytoxan and Solumedrol at OSH, but\n unclear if Cytoxan was PO or IV, and if pt was dosed monthly or daily.\n - follow HCT q6h to monitor for alveolar bleeding. Concern given\n recent HCT drop. Transfusion threshold is HCT<21\n - Continue supplemental O2 PRN. Maintain O2 sat >90%.\n - Figure out exact 02 requirement (patient on facemask, not always\n wearing it)\n - Albuterol nebs PRN\n - repeat CXR\n - F/u on BAL results from OSH\n - Continue to keep patient NPO due to tentative respiratory status (and\n renal biopsy).\n (see t'ment plan for presumed Wegener's under acute renal failure)\n # Acute renal failure: Ddx includes most likely pulmonary renal\n syndromes, such as Wegener's (granulomas), Goodpasture's, microscopic\n polyangiitis, lupus, PAN. BUN/Cr on was 126/9.6, K 5.8. Nephritic\n picture with RBC casts. However, apart from pulmonary association, ddx\n for acute renal failure with nephritis includes PSGN, lupus nephritis,\n etc. ESR elevated >140, consistent with an autoimmune disorder.\n Age-appropriate for Wegener's. Also consider DIC.\n - Renal biopsy today, FFP on call due to INR 1.5\n - For presumed Wegeners, started Plasmapheresis (firs tt'ment last\n night, will be QOD x 5 treatments)\n - Continue Solumedrol 1g IV daily\n - F/u on pending renal labs from OSH -> C3/C4, , anti-GBM, anti-DNA,\n cryglobulins, ANCA, HepB/C serology\n - Will re-check renal labs above here as well (C3, C4, etc.)\n - Foley in place\n - Avoid nephrotoxic agents\n - Replete lytes PRN\n - Will check q8 lytes for now\n - Continue Sevelemer in a.m. with meals for elevated Phos.\n - Renal c/s recommends also starting Amphagel (phosphate binder) 30cc\n po tid for 2-3 days for elevated Phos.\n #Hypernatremia: NA+ today 150, up from 147, likely lack of access\n to free water\n -Replace w/ D5NS\n #Hypocalcemia: plasmapheresis (uses citrate which acts as Ca2+\n binder)\n -Replace Ca2+\n # Tachycardia: Aflutter on EKG. Until yesterday, was asymptomatic but\n rate in 120s. Can be secondary to underlying structural heart disease.\n Also may be secondary to large volume shifts (retaining total body\n fluid with renal failure, with large volume load putting stress on\n atria.)\n - F/u on TSH\n - TTE today\n - Lopressor titrated up to 50 mg PO tid with good rate control (HR in\n 80s).\n .\n # LE edema: likely secondary to renal failure above. Would hold off on\n diuresis given ARF.\n .\n # Anemia: likely secondary to pulmonary hemorrhage. Likely related to a\n combination of chronic inflammatory disease, renal failure, and diffuse\n alveolar hemorrhage. No baseline Crit available.\n - Check HCT q6\n - Type and screen, cross-matched\n - Blood consent obtained\n .\n # FEN: NPO for worsening respiratory status, anticipating intubation.\n Will replete lytes PRN.\n # Access: 2 PIVs\n .\n # PPx: Pneumoboots, Pantoprazole PO daily, RISS, bowel regimen\n .\n # Code: FULL, confirmed with pt with son present ()\n .\n # Dispo: ICU at least overnight for close monitoring of hemodynamic and\n pulmonary status.\n .\n # Comm: HCP , ; \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Case Management ",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 333828,
"text": "Insurance information\n Primary insurance: OOS PPO-NON MANAGED CARE\n Secondary insurance: SELF PAY\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services: None prior to admission\n DME / Home O[2]: None prior to admission\n Functional Status / Home / Family Assessment:\n Pt. Lives alone in . He is divorced . He has a son who\n lives with the patient's ex-wife. PTA he was working and independent\n with all ADL's\n Primary Contact(s): (son) \n Health Care Proxy: .\n Dialysis: No\n Referrals Recommended: Social Work, Physical Therapy\n Current plan: Undetermined\n Unclear what level of services will be required at discharge. Case\n Management will follow for DC needs.\n If VNA services needed can use:\n VNA of SE Mass - \n - \n Centrus Premier Home Care - \n Patient (s) to Discharge:\n Medically unstable\n Patient discussed with multidisciplinary team: No\n"
},
{
"category": "Physician ",
"chartdate": "2199-07-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 333866,
"text": "Chief Complaint: Respiratory distress/hypoxemia\n HPI:\n 24 Hour Events:\n EKG - At 02:00 PM\n DIALYSIS CATHETER - START 06:48 PM\n Renal consultation concurred with Pulmonary-Renal syndrome.\n Plasmaphoresis initiated last PM via newly placed dialysis catheter,\n anticipating 5 days of treatment. Remains on cortocosteroids.\n Remains non-oliguric. Renal biopsy recommended, and planned for today.\n Denies increased dyspnea, but remains with oxygen requirement.\n History obtained from Patient\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 PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 35.3\nC (95.5\n HR: 81 (81 - 133) bpm\n BP: 118/73(85) {104/53(66) - 142/88(102)} mmHg\n RR: 24 (22 - 29) insp/min\n SpO2: 97%\n Heart rhythm: A Flut (Atrial Flutter)\n Height: 59 Inch\n Total In:\n 902 mL\n 186 mL\n PO:\n 240 mL\n TF:\n IVF:\n 662 mL\n 186 mL\n Blood products:\n Total out:\n 1,330 mL\n 690 mL\n Urine:\n 1,330 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n -429 mL\n -504 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.31/37/67/22/-6\n PaO2 / FiO2: 134\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, Anxious, No(t) Diaphoretic,\n mildly disshevled\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , 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: 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, Oriented (to): person, place, time, Movement: Purposeful,\n No(t) Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.6 g/dL\n 355 K/uL\n 176 mg/dL\n 8.6 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 149 mg/dL\n 108 mEq/L\n 150 mEq/L\n 22.6 %\n 8.1 K/uL\n [image002.jpg]\n 11:05 PM\n 04:46 AM\n 12:46 PM\n 01:36 PM\n 11:04 PM\n 04:02 AM\n 08:13 AM\n WBC\n 7.4\n 8.1\n Hct\n 31.0\n 26.6\n 27.1\n 24.4\n 22.8\n 22.6\n Plt\n 543\n 513\n 355\n Cr\n 9.7\n 9.2\n 9.6\n 8.5\n 8.6\n TCO2\n 20\n Glucose\n 93\n 176\n Other labs: PT / PTT / INR:16.6/29.1/1.5, Alk Phos / T Bili:/0.5,\n Lactic Acid:1.9 mmol/L, Albumin:2.8 g/dL, LDH:153 IU/L, Ca++:5.9 mg/dL,\n Mg++:2.0 mg/dL, PO4:9.5 mg/dL\n Imaging: CXR: () diffuse bilateral alveolar infiltrates,\n predominantly basilar. Right IJ catheter position acceptable. No\n significant overall change compared to .\n Assessment and Plan\n 60 yom now with Pulmonary-Renal syndrome.\n RESPIRATORY DISTRESS -- attributed to acidemia (renal failure) and\n hypoxemia in setting of pulmonary infiltrates. Stable, but still with\n diffuse infiltrates and oxygen requirement.\n HYPOXEMIA -- attributed to pulmonary infiltrates. Monitor SaO2,\n supplimental O2 to maintain SaO2 >90%.\n PULMONARY INFILTRATES -- attributed to alveolar hemorrhage. Monotor\n SaO2.\n RENAL FAILURE -- acute, attributed to Pulmonary-Renal syndrome. Renal\n consult prepared to move to dialysis when indicated. Monitor urine\n output, BUN, Creatitine.\n PULMONARY-RENAL SYNDROME -- evaluation and diagnostics pending.\n Continue steroids and plasmaphoresis.\n HYPOCALCEMIA -- iv replacement Rx, consider constant infusion.\n FLUIDS -- limit iv fluids intake.\n HYPERPHOSPHATEMIA -- start phosphate binder.\n NUTRITION -- NPO pending evaluation\n ANEMIA -- progressive, attributed to underlying process, and possible\n contribution from RIJ central line placement. Transfuse to Hct >21.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:00 AM\n 18 Gauge - 08:32 AM\n Dialysis Catheter - 06:48 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 55 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2199-07-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 334546,
"text": "This is a 60 year-old male with distant hx nephrolithiasis who presents\n after transfer from OSH for LE edema/pain, SOB on exertion x 2-3weeks,\n found to be in acute renal failure, anemia, and pulmonary hemorrhage on\n bronchoscopy.\n OSH course:\n Though sx started 2-3 weeks ago, pt did not seek care until now due to\n having no PCP (regular PCP had retired.) He finally presented for care\n when he could not put his shoes on in the a.m. due to pedal edema. Upon\n presentation to the OSH, pt complained of bilateral LE pain/edema. Pt\n reports that LE symptoms started in the feet, progressing to swelling\n of his legs to his knees over 3 weeks. He also noted a diffuse macular\n rash in the LE of the same distribution. He also complained of some SOB\n on exertion and decreased appetite.\n Patient is being worked up for Wegener\ns Granulomatosis\n Atrial flutter (Aflutter)\n Assessment:\n Patient is in atrial flutter with episodes of normal sinus rhythm. Also\n has episodes of tachycardia in the 130\ns, typically with exertion or\n desats. BP within normal limits.\n Action:\n Tolerating metoprolol PO\n Response:\n Heart rate slows with NSR episodes, VS WNL\n Plan:\n Continue to monitor Heart rate/rhythm, administer metoprolol as\n ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Adequate urine output. Urine output is pink tinged. +2 pedal edema\n noted. Creatinine is 6.9, BUN 149\n Action:\n U/A sent off, 2pm labs sent. Ionized calcium 0.97, replaced with 4gm\n Calcium gluconate. Creatinine is trending down. Mesna IV x3 with\n administration of cyclophosphamide (chemo)\n Response:\n Labs to be drawn at 2200. adequate urine output, 1600cc fluid positive\n since midnight.\n Plan:\n Daily U/As, monitor labs,. Plasmaphoresis every other day via right IJ\n HD catheter, may have it . Administer mesna as ordered with chemo\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Coarse rhonchi and crackles noted, O2 sats labile throughout the day,\n weak cough. +1.6L positive. Patient would frequently remove face tent,\n thus dropping O2 sats.\n Action:\n O2 titrated accordingly. Face tent increased/decreased, now at 50% and\n 6L NC. Patient encouraged to cough and deep breathe. Neb treatments as\n ordered\n Response:\n Oxygenation has improved throughout the afternoon with patient\ns family\n at the bedside\n Plan:\n Continue to titrate O2, encourage deep breathing and coughing.\n"
}
] |
26,083 | 120,427 | A/P: 84 y/ with h/o HTN, severe MR, and transferred to the ICU for abdominal pain and rising lactate/wbc. Please HPI for details of admission prior to ICU: . 1. Abdominal pain- on transfer, ddx includes perforated viscus and mesenteric ischemia. recent CTA showed no evidence of AAA. possible gastritis/ulcer dz w/ high dose steroids and hospitalization. surgery following and KUB w/out evidence of colonic obstruction or free air. lactate continued to rise following ICU transfer, despite elevated CVP and lack of respiratory variation, both indicative of volume repletion. patient continued to have minimal abdominal pain but did have other signs of poor cardiac output including a mixed venous sat of 42%. on the day of the patient's demise, his lactate was 8.6. . . 2. crpytogenic organizing pna- seen on prior needle biopsy and some improvementon high dose steroids (radiographic). O2 sats stable on NC but significant desaturation with any activity. on in the process of being rolled, the patient became acutely SOB and subsequently became apneic. per his family's documented request, a Code was not called. he subsequently expired. . 3. pt /w baseline creatinine of ~1.4 but elevated to 2.7 on micu admission. renal ultrasound today w/out evidence of obstruction/hydronephrosis. continued to worsen in the setting of poor cardiac output. . 4. Severe MR: pt in the process of preparing for a MVR prior to this admission. major contributor to the patient's poor forward flow. . 5. Coagulopathy: Initially likely poor nutritional status but now concern for DIC in setting of mesenteric ischemia . | Just returned from abd CT ruling out ischemic bowel. The pt then became bradycardic, remained apneic c no BP measurable. CxR showing worsenig PNACaridac: SR with no ectopy since arrival. Sinus tachycardiaPossible left atrial abnormalityModest nonspecific ST-T wave changesSince previous tracing of , ventricular ectopy absent PO lopressor on hold as b/p is hypotensive 90's/30's. Sinus rhythmIndeterminate axisLow limb lead QRs voltagesModest right ventricular conduction delay patternFindings are nonspecific but clinical correlation is suggested for possiblechronic pulmonary diseaseSince previous tracing of , sinus tachycardia rate slower Nursing Progress Note.Pt functional status progressively worsened over the coarse of the day, pt code status subsequently changed from DNR -- CPR not indicated to full DNR/DNI by team this AM c likely CMO as status waranted. infectious process Admitting Diagnosis: SHORTNESS OF BREATH FINAL REPORT (Cont) Sinus tachycardiaSlight ST-T wave changes - are nonspecific and may be within normal limitsSince previous tracing of , right precordial ST-T wave changes slightlyless prominent Pt has severe mvr and was in process of workup for mitral valve repair when MD suggested he visit ED.GU: Abd soft with positive bowel sounds. Perihperal pulses weakly palpable.ID: Afebrile. Since the previous tracing of the rate isincreased and ventricular ectopy is new. (Over) 11:47 AM CT CHEST W/O CONTRAST Clip # Reason: ? Did have period where he had some confusion while hypotensive, but resolved after fluid boluses. B/P droping as low as 70's/20's prior to fluid boluses. chf.resp remains on 2to3 l nc, ls clear with crackles in bases in am to cracles thru out after line placemnt and receving 2 units of ffp. 11:47 AM CT CHEST W/O CONTRAST Clip # Reason: ? Moderate non-hemorrhagic layering left pleural effusion is new. Events: Bolused with 250cc NS x3 for low u/o and hypotension. Pt states breathing is easier than previous but rr remains tachypneic (30's) at times.Cardiac: SR with no ectopy throughout shift. Unfortunately, the pt became apneic following a routine position change, ETS was attempted but unsuccessful. Left perihilar consolidation is the most significant region of abnormality followed by the right lung base and these areas have not cleared. K+5.8 Phos 9.1 Mg 3.2 BUN 97 and Cr3.8Heme: HCT down to 25.8 (28.5) INR up to 2.3 (2.5) received 2uffp prior to TLC placement yesterday.Derm: Grossly intact. Some minimal presacral fluid and some minimal fluid in the pelvis of unknown etiology. Below the diaphragm, given that this is a non-contrast CT, note is made of a low-attenuation lesion measuring 11 mm in the dome of the liver which is unchanged when compared to the previous CT from . FINDINGS: A right internal jugular vein approach central venous line is present seen to terminate overlying the SVC at the level 2 cm below the carina. Left pleural effusion. UPRIGHT AP CHEST: No free air is visualized beneath the hemidiaphragm. Sigmoid diverticula. There is a left pleural effusion. Scarring right base and bilateral effusions. There is a possible tiny right pleural effusion. While the right pleural effusion has nearly resolved, the moderate left pleural effusion has not. CT OF PELVIS: Note is made of some sigmoid diverticula. The left pleural effusion appears slightly decreased. HISTORY: Dyspnea and tachycardia. Grayscale and Doppler son of the left and right common femoral, superficial femoral, and popliteal veins were performed. 2:41 AM PORTABLE ABDOMEN Clip # Reason: Signs of perforation? INDICATION: Right internal jugular central venous line placement. Signs of ischemia? Note is made of some coronary artery calcification. The lung bases reveal a small right pleural effusion and a moderate-sized left pleural effusion. A subcentimeter lesion is seen in segment VII and is unchanged. IMPRESSION: No free air beneath the hemidiaphragm is visualized. Right upper lobe patchy opacities are also again seen. There is some right- sided linear atelectasis. A granuloma is noted in the right base. Just anterior to the sacrum, note is also made of some minimal fluid. A subcentimeter lesion is seen in segment and is unchanged. Cardiac silhouette is slightly enlarged, and there is persistence of vascular engorgement in the superior mediastinum suggesting cardiac decompensation and/or volume overload. The sequence of changes suggests the persistence of asymmetric edema, and clearing of the inflammatory process in the right upper lobe and improvement, but persistence of what is likely the same process in the right lower lobe. Rule out hydronephrosis or other blockage. A Foley catheter is in the urinary bladder, which is decompressed. The appearances suggest failure with probable pneumonia. Comparison made to CTA of the abdomen dated . Some vascular calcification is noted in relation to the aorta. No contraindications for IV contrast FINAL REPORT CT ABDOMEN INDICATION: Cryptogenic pneumonia, acute renal failure, abdominal pain. This patient is status post cholecystectomy. | 22 | [
{
"category": "Nursing/other",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 1601651,
"text": "Pt is a 84 y/o who presented to our ED on recomendation from his PCP after CxR as outpt showed new infiltrate. Pt was being worked up for a mitral valve repair due to severe MVR. Admitted to 2 where sputum cx grew out yeast, urine also noted to be cloudy and was cultured . On floor pt was having increasing O2 requirements and some shortness of breath. Also, pt was having increasing abd pain ( on arrival to MICU). Lab values INR 2.3 K 6 WBC 24 Lactic Acid 5. CxR done showing worsening PNA and pt's urine output had diminished to 50cc for entire night shift. Decision made to tx to MICU for increased monitoring and treatment. ABD CT done to r/o ischemic bowel.\n\nNeuro: Pt a+ox3, following commands consistently. MAE, drowsy as he has not had sleep in >24hrs. C/O abd pain \n\nResp: lung sounds with crackles. O2 sats mid 90's on 2L via n/c. Breathing somewhat labored but pt reports no difficulty breathing. CxR showing worsenig PNA\n\nCaridac: SR with no ectopy since arrival. PO lopressor on hold as b/p is hypotensive 90's/30's. Pt has severe mvr and was in process of workup for mitral valve repair when MD suggested he visit ED.\n\nGU: Abd soft with positive bowel sounds. C/O pain. No bm in spite of enemas on floor. Just returned from abd CT ruling out ischemic bowel. Surgery following. NPO.\n\nGU: No urine output since arrival on MICU. Due for labs at 0800.\n\nDerm: Grossly intact. PIV x1 20G intact. Perihperal pulses weakly palpable.\n\nID: Afebrile. On IV zosyn.\n\nPlan: Follow up on abd Ct, to surgery if positive, Lytes at 0800, monitor fluid status, and hemodynamic status.\n\nGU\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-29 00:00:00.000",
"description": "Report",
"row_id": 1601654,
"text": "Nursing Progress Note.\n\nPt functional status progressively worsened over the coarse of the day, pt code status subsequently changed from DNR -- CPR not indicated to full DNR/DNI by team this AM c likely CMO as status waranted. Family members (wife, two , -in-law) @ BS all AM and kept up to date c POC/pt status throughout shift. IVP 0.5mg Morphine provided this afternoon times two for pt discomfort c fair affect noted. Unfortunately, the pt became apneic following a routine position change, ETS was attempted but unsuccessful. The pt then became bradycardic, remained apneic c no BP measurable. Team notified and pt declared deceased @ approx 16:05. Please see CareVue for additional pt care data/comments. Family notified of event, verbal and non-verbal support provided by team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 1601652,
"text": "npn\nevents central line placed, mri on hold until \n\nneuro:aox3, sleeping off and on, pt stating he is very tired.\npain: denies pain. exp. general discomfort from lying in bed. pain med given with line placement which pt tolerated well.\n\ncad hr sr 80 to 90's, nbp 80 systolic in am with two 250cc ns boluses given with nbp up to the 100 to 90's systolic , again dropped to the high 80's at 1730 to 1830 md aware, cvp 12 with some fluctuating noted to 18, pt given lasix 20 mg ivp at 1845 for ? chf.\n\nresp remains on 2to3 l nc, ls clear with crackles in bases in am to cracles thru out after line placemnt and receving 2 units of ffp. sats 91 to 975 rr teens to high 20 to bursts to 30 to 40's.\n\ngi: abd soft slight distended. bs+ no bm this shfit, no c/o abd pain, ? c/o nausea with md was ordered and given in afternoon. mri held at pt's request.\n\ngu: urine output increased to 10cc/hr after multiple boluses and antibiotics given. now 5cc/hr pt given lasix 20 mg ivp at 1845. last 6 pt given kayexlate po at 1600 awaiting results.\n\nendo: bs 108 to 172 las t bs not covered due to pooor po intake.\n\nid: afebrile, antibiotics given.\n\nplan: mri tomorrow am, cont to be full code, cont to moniotr vs, labs resp and fluid status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-08-29 00:00:00.000",
"description": "Report",
"row_id": 1601653,
"text": "Events: Bolused with 250cc NS x3 for low u/o and hypotension. Family in and decision made to change code status to CPR not indicated. Pt can be intubated if need be however.\n\nNeuro: A+Ox3 and following commnads. Did have period where he had some confusion while hypotensive, but resolved after fluid boluses. No complaints of pain this shift. Slept throughout shift but arousable to verbal stimuli.\n\nResp: Lung sounds with wheezes throughout and crackles in bases. O2 sats maintained in high 90's on 70% humidified O2 via face tent. Alb/atr nebs q4. Pt states breathing is easier than previous but rr remains tachypneic (30's) at times.\n\nCardiac: SR with no ectopy throughout shift. CVP 11-16. Bolused with total of 750cc NS to keep MAP's >60. B/P droping as low as 70's/20's prior to fluid boluses. B/P largely 90's/40's since midnight. Team has been reluctant to start pressors as pt has 4+MR.\n\nGI: Abd soft and nontender this shift. No c/o pain which had been yesterday. medicated with 0.5mg morphine prior to start of this shift. No BM this shift either. Pt may go for MRI later today to assess for ischemic bowel.\n\nGU: Pt given 20mg IV lasix, with no effect. Then 40mg IV lasix with similar results, then 80mg with approx 100cc's amber urine output. Renal is following. Pt's electrolytes remain increasingly out of balance. K+5.8 Phos 9.1 Mg 3.2 BUN 97 and Cr3.8\n\nHeme: HCT down to 25.8 (28.5) INR up to 2.3 (2.5) received 2uffp prior to TLC placement yesterday.\n\nDerm: Grossly intact. PIV x1 patent. TLC in RIJ placed yesterday patent with good blood return. Small hematoma at site unchanged.\n\nPlan: Family in today to meet with attending to discuss prognosis and plan of care, may go for MRI if decided to fully treat, Monitor lab data (?HD), monitor hemodynamic status, may start levophed if b/p cannot be maintained with small boluses. Pt is currently CPR not indicated but will be intubated if need be.\n"
},
{
"category": "ECG",
"chartdate": "2200-08-28 00:00:00.000",
"description": "Report",
"row_id": 197667,
"text": "Sinus rhythm\nIndeterminate axis\nLow limb lead QRs voltages\nModest right ventricular conduction delay pattern\nFindings are nonspecific but clinical correlation is suggested for possible\nchronic pulmonary disease\nSince previous tracing of , sinus tachycardia rate slower\n\n"
},
{
"category": "ECG",
"chartdate": "2200-08-26 00:00:00.000",
"description": "Report",
"row_id": 197668,
"text": "Sinus tachycardia\nSlight ST-T wave changes - are nonspecific and may be within normal limits\nSince previous tracing of , right precordial ST-T wave changes slightly\nless prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2200-08-25 00:00:00.000",
"description": "Report",
"row_id": 197669,
"text": "Sinus tachycardia\nPossible left atrial abnormality\nModest nonspecific ST-T wave changes\nSince previous tracing of , ventricular ectopy absent\n\n"
},
{
"category": "ECG",
"chartdate": "2200-08-22 00:00:00.000",
"description": "Report",
"row_id": 197670,
"text": "Sinus tachycardia with ventricular ectopy. Ventricular rate 114 beats per\nminute. P-R interval 0.16. Since the previous tracing of the rate is\nincreased and ventricular ectopy is new. No other diagnostic changes have\noccurred.\n\n"
},
{
"category": "ECG",
"chartdate": "2200-08-18 00:00:00.000",
"description": "Report",
"row_id": 197914,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 926604,
"text": " 9:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for progression of volume overload\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam\n REASON FOR THIS EXAMINATION:\n please evaluate for progression of volume overload\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:12 P.M., .\n\n HISTORY: Dyspnea and tachycardia.\n\n IMPRESSION: AP chest compared to through .\n\n There has been substantial improvement in pulmonary edema, particularly in the\n right lung. Left perihilar consolidation is the most significant region of\n abnormality followed by the right lung base and these areas have not cleared.\n Small bilateral pleural effusion has increased slightly on the left and\n decreased on the right. Heart is normal size. Mediastinal vascular\n engorgement is unchanged. Left-sided skinfold and overlying tubing should not\n be mistaken for pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-19 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 925836,
"text": " 11:47 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? infectious process\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with new oxygen requirement, previous COP on biopsy, hemoptysis\n following CT guided biopsy on .\n REASON FOR THIS EXAMINATION:\n ? infectious process\n CONTRAINDICATIONS for IV CONTRAST:\n increased creatinine\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n REASON FOR EXAM: 84-year-old man with increased oxygen with history of\n organizing pneumonia\n\n COMPARISON: Comparison is made with prior study dated .\n\n TECHNIQUE: Multidetector CT through the chest performed in full inspiration\n and expiration. 2.5 and 1.25 mm collimation images were reviewed.\n\n FINDINGS:\n Extensive peripheral consolidations in the apico- posterior segments of the\n left upper lobe, posterior segment of the right upper lobe and right basal\n posterior and lateral segments have worsened\n New bilateral apical ground-glass opacities, and increase in the interstitial\n abnormality with peribronchial infiltration that is continuous with the\n consolidations, are either worsening of the preexistingpneumonia\n or superimposed pulmonary edema.\n\n The airways are patent to segmental level. Multiple prevascular,\n paratracheal, and subcarinal lymph nodes have increased in number and size,\n for instance the largest in the left lower paratracheal region (2:53)\n measuring 11 mm, was 6 mm, and a 10 mm right lower paratracheal lymph node was\n 6 mm. Many of the paratracheal and right hilar lymph nodes are calcified.\n Moderate non-hemorrhagic layering left pleural effusion is new. A small amount\n of pleural effusion in the right side is loculated in the major fissure. There\n is no pericardial effusion. The LAD is mildly calcified; otherwise, the heart\n and great vessels are unremarkable.\n\n There are no bone findings of malignancy.\n\n In the upper abdomen, sub-cm hypodense lesions in the liver, too small to be\n characterized are likely cysts. Patient is post-cholecystectomy.\n\n IMPRESSION:\n\n 1. Worsening multifocal pneumonia, not hemorrhagic. Multifocal interstitial\n abnormalities are either progression of organizing pneumonia or edema.\n 2. New bilateral pleural effusions, larger in the left side.\n (Over)\n\n 11:47 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ? infectious process\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-28 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 927008,
"text": " 4:13 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: RIJ placement postprocedure\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pna, s/p RIJ placement\n REASON FOR THIS EXAMINATION:\n RIJ placement postprocedure\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Right internal jugular central venous line placement. History of\n cryptogenic pneumonia. Check for line position.\n\n FINDINGS: A right internal jugular vein approach central venous line is\n present seen to terminate overlying the SVC at the level 2 cm below the\n carina. No pneumothorax has developed, no other placement related\n complications are identified. Pulmonary and pleural abnormalities remain\n unchanged as described on previous study obtained 12 hours earlier during the\n same date.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-27 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 926885,
"text": " 9:15 PM\n PORTABLE ABDOMEN Clip # \n Reason: Signs of obstruction or perforation?\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with severe MR, BOOP and new diffuse abdominal pain with\n nausea.\n REASON FOR THIS EXAMINATION:\n Signs of obstruction or perforation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 84-year-old man with severe mitral regurgitation, BOOP, and\n abdominal pain.\n\n ABDOMEN, SINGLE SUPINE PORTABLE: No prior radiographs for comparison. The\n bowel gas pattern is unremarkable, without dilatation of the small or large\n bowel. There is stool in the ascending colon and rectum. Air is present\n within the rectum. There are cholecystectomy clips in the right upper\n quadrant.\n\n IMPRESSION: No evidence of obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 926300,
"text": " 9:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulmonary edema, effusion\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia\n REASON FOR THIS EXAMINATION:\n eval pulmonary edema, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dyspnea, tachycardia.\n\n CHEST AP:\n\n Comparison is made with the prior chest from . There has been an\n increase in the size of the left pleural effusion. Some clearing of the\n opacities in the left upper lobe is seen. Patchy opacities are seen in all\n other parts of the lung. The appearances suggest failure with probable\n pneumonia.\n\n IMPRESSION: Increasing left effusion, some clearing of left upper lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 926347,
"text": " 9:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? edema\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam.\n\n REASON FOR THIS EXAMINATION:\n ? edema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Dyspnea, tachypnea. Evaluate failure.\n\n Since the prior chest x-ray of , there has been an increase in the\n size of the right pleural effusion, which now extends towards the apex.\n\n The interstitial is also somewhat more pronounced. These findings\n indicate worsening failure.\n\n IMPRESSION: Worsening failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 926651,
"text": " 9:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? worsening failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with dyspnea, tachycardia, crackles on exam\n\n REASON FOR THIS EXAMINATION:\n ? worsening failure\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:43 A.M .\n\n HISTORY: Dyspnea and tachycardia. Question worsening failure.\n\n IMPRESSION: AP chest compared to through .\n\n Previous heterogeneous opacification in the right upper lobe has largely\n cleared over the past two weeks and pulmonary edema in the right lung has\n largely resolved since . There is persistent severe\n perihilar opacification in the left lung and a slowly resolving heterogeneous\n region of opacity at the right lung base.\n\n While the right pleural effusion has nearly resolved, the moderate left\n pleural effusion has not.\n\n The sequence of changes suggests the persistence of asymmetric edema, and\n clearing of the inflammatory process in the right upper lobe and improvement,\n but persistence of what is likely the same process in the right lower lobe.\n Pleural effusions are probably secondary to pulmonary pathology. Cardiac\n silhouette is slightly enlarged, and there is persistence of vascular\n engorgement in the superior mediastinum suggesting cardiac decompensation\n and/or volume overload.\n\n Left skinfold should not be mistaken for pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 925757,
"text": " 7:25 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with recent treatment for PNA\n REASON FOR THIS EXAMINATION:\n evaluate for pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of recent treatment for pneumonia.\n\n COMPARISON: Radiograph dated and CT scan dated and\n radiograph dated .\n\n PA AND LATERAL VIEWS OF THE CHEST: There is increased confluent opacity in\n the left upper lobe. The area of opacity in the right lower lobe appears\n increased compared to the previous exam, however, the most densely opacified\n area is slightly smaller. Right upper lobe patchy opacities are also again\n seen. There is no evidence of pneumothorax. There is a possible tiny right\n pleural effusion.\n\n IMPRESSION: Interval worsening of left upper lobe airspace opacity with\n possible interval increase in extent of opacity also in the right lower lobe.\n This may represent an infectious process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-28 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 926899,
"text": " 2:41 AM\n PORTABLE ABDOMEN Clip # \n Reason: Signs of perforation?\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pna, acute renal failure on high dose steroids\n with new abdominal pain.\n REASON FOR THIS EXAMINATION:\n Please do upright chest film. Signs of free air?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cryptogenic pneumonia and acute renal failure, now with 9 out of\n 10 abdominal pain. Evaluate for signs of free air.\n\n There are no prior studies for comparison.\n\n SUPINE ABDOMEN: There is no evidence of free air on the supine views. The\n bowel gas pattern is nonspecific, with air seen within non-dilated loops of\n small bowel and throughout the colon to the rectum. No evidence of\n obstruction. There are surgical clips in the right upper quadrant, likely\n related to cholecystectomy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 926900,
"text": " 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ABDOMINAL PAIN/ CHECK FOR FREE AIR// ALSO SOB\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Patient with BOOP who is short of breath. Also, 9 out of 10\n abdominal pain. Evaluate for free air.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: No free air is visualized beneath the hemidiaphragm. Air\n space opacity within the left upper lobe has slightly improved compared to\n . The right upper lobe and right lower lung appear not\n significantly changed in the interim. Cardiomegaly and the aortic contours\n are unchanged. The left pleural effusion appears slightly decreased. No\n pneumothorax.\n\n IMPRESSION: No free air beneath the hemidiaphragm is visualized. Improved\n left upper lobe parenchymal opacification.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-28 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 926901,
"text": " 5:31 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please do abdominal CT scan with PO contrast (renal failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with cryptogenic pneumonia, acute renal failure, new \n abdominal pain out of proportion to exam with elevated lactate.\n\n REASON FOR THIS EXAMINATION:\n Please do abdominal CT scan with PO contrast (renal failure precludes IV\n contrast). Signs of ischemia?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT ABDOMEN\n\n INDICATION: Cryptogenic pneumonia, acute renal failure, abdominal pain.\n\n FINDINGS:\n\n A CT of abdomen and pelvis was performed with axial images taken from the lung\n bases to the symphysis pubis.\n\n Oral contrast only was administered because of the patient's renal failure.\n\n Multiplanar reconstructions in the coronal and sagittal planes were obtained.\n\n The lung bases reveal a small right pleural effusion and a moderate-sized left\n pleural effusion. A granuloma is noted in the right base. There is some right-\n sided linear atelectasis.\n\n Note is made of some coronary artery calcification.\n\n Below the diaphragm, given that this is a non-contrast CT, note is made of a\n low-attenuation lesion measuring 11 mm in the dome of the liver which is\n unchanged when compared to the previous CT from .\n\n A subcentimeter lesion is seen in segment VII and is unchanged.\n\n A subcentimeter lesion is seen in segment and is unchanged.\n\n The fourth lesion which was identified on the previous study is difficult to\n visualize on this study due to artifact from overlying skin markers.\n\n This patient is status post cholecystectomy.\n\n The spleen, adrenals, kidneys and pancreas are normal.\n\n No evidence of any significant lymphadenopathy.\n\n Some vascular calcification is noted in relation to the aorta.\n (Over)\n\n 5:31 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Please do abdominal CT scan with PO contrast (renal failure\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The bowel where visualized is normal.\n\n CT OF PELVIS:\n\n Note is made of some sigmoid diverticula.\n\n The bladder is catheterized with a significant amount of air secondary to\n instrumentation.\n\n In the pelvis, a tiny amount of fluid is seen which measures approximately 2 x\n 1.3 cm. It is of unknown etiology.\n\n Just anterior to the sacrum, note is also made of some minimal fluid. Again,\n this is of unknown etiology.\n\n BONY WINDOWS:\n\n Note is made of degenerative change\n\n IMPRESSION:\n\n No evidence of any ischemic bowel given that this is a non-contrast CT.\n\n Multiple lesions in the liver which are unchanged.\n\n Some minimal presacral fluid and some minimal fluid in the pelvis of unknown\n etiology.\n\n Sigmoid diverticula.\n\n Scarring right base and bilateral effusions.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-27 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 926851,
"text": " 2:54 PM\n RENAL U.S. Clip # \n Reason: EVAL FOR HYDRONEPHROSIS OR OTHER BLOCKAGE\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with increasing creatinine with some urinary retention\n yesterday now s/p foley.\n REASON FOR THIS EXAMINATION:\n ? hydronephrosis or other blockage\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Renal ultrasound.\n\n CLINICAL HISTORY: 84-year-old man with increasing creatinine with some\n urinary retention yesterday. Now status post Foley. Rule out hydronephrosis\n or other blockage.\n\n FINDINGS: Renal ultrasound was performed on . No prior ultrasound\n studies available for comparison. Comparison made to CTA of the abdomen dated\n .\n\n The kidneys are normal in size, without evidence of hydronephrosis or solid\n renal masses. There is a small crystal in the renal cortex of the midpole of\n the left kidney. No perinephric fluid collections are seen.\n\n There is a left pleural effusion.\n\n A Foley catheter is in the urinary bladder, which is decompressed.\n\n IMPRESSION:\n 1. No evidence of hydronephrosis.\n 2. Left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-08-26 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 926681,
"text": " 12:48 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with hypoxia, tachypnea\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY ULTRASOUND\n\n HISTORY: 84-year-old male with hypoxia and tachypnea. Please evaluate for\n DVT.\n\n FINDINGS: No prior study is available for comparison. Grayscale and Doppler\n son of the left and right common femoral, superficial femoral, and\n popliteal veins were performed. Normal flow, augmentation, compressibility,\n and waveforms are demonstrated. Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of deep venous thrombosis in either lower extremity.\n\n\n"
}
] |
47,758 | 135,647 | 64 year old female admitted to the acute care service with dehydration, elevated creatinine, and leakage around the g-tube site. Upon admission, she was fluid resusitated and her electrolytes were repleted. A foley catheter was replaced in the gastro-cutaneoous fistula to decrease leakge. Despite placment of a larger tube, she continued to leak around the G-tube site and an additional was placed and she was maintained NPO. During her hospitalization, her creatinine slowly decreased and her fluid status improved. She was started on clear liquids with gradual advancement to a regular diet. She continued to leak gastric contents around the drain. Recommendations for skin care were outlined by the ostomy/wound nurse. She has been reluctant to participate in physical therapy, but they have provided daily visits. Her vital signs are stable and she is afebrile. Her electrolytes have normalized and her creatinine as decreased to 2.0. She is preparing for discharge to her daughter's home with VNA assistance. She will follow-up with the acute care service in 2 weeks. She can have her foley catheter removed at the rehab facility Medications on Admission: : simvastatin 20 qhs, citalopram 40', singulair 10 qhs, advair 250/50", proair prn , albuterol prn, protonix 40', mvi, oxycodone prn, ativan prn | Left retrocardiac opacity that is unchanged since the previous examination and is likely to represent atelectasis. Moderate cardiomegaly without overt pulmonary edema. FINDINGS: As compared to the previous radiograph, the left PICC line has been removed. Normal aspect of the hilar and mediastinal structures. Coexisting pneumonia however, cannot be excluded. No other focal parenchymal opacities. No pneumothorax. 3:52 AM CHEST (PORTABLE AP) Clip # Reason: please evaluate for consolidation. report of LLL opacity on OSH films FINAL REPORT CHEST RADIOGRAPH INDICATION: Renal failure, evaluation for consolidation, report of left lower lobe opacity from an outside hospital film. COMPARISON: . | 1 | [
{
"category": "Radiology",
"chartdate": "2124-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1200882,
"text": " 3:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for consolidation. report of LLL opacity on\n Admitting Diagnosis: RENAL FAILURE, GASTROCUTANEOUS FISTULA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with poor PO intake and renal failure\n REASON FOR THIS EXAMINATION:\n please evaluate for consolidation. report of LLL opacity on OSH films\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Renal failure, evaluation for consolidation, report of left lower\n lobe opacity from an outside hospital film.\n\n COMPARISON: .\n\n FINDINGS:\n\n As compared to the previous radiograph, the left PICC line has been removed.\n Moderate cardiomegaly without overt pulmonary edema. Left retrocardiac\n opacity that is unchanged since the previous examination and is likely to\n represent atelectasis. Coexisting pneumonia however, cannot be excluded. No\n other focal parenchymal opacities. Normal aspect of the hilar and mediastinal\n structures. No pneumothorax.\n\n\n"
}
] |
2,378 | 157,554 | # Pneumonia - On admission, pneumonia was felt less likely given lack of clear evidence on chest x-ray and low grade temperature. Treated for COPD exacerbation with Levaquin and high dose pulse steroids with plan for quick taper. Shortness of breath remained at baseline for 48 hours after admission. On hospitaly day 2, repeat chest x-ray obtained in setting of hypotension showed worsening RLL opacity and Vancomycin and Cefepime were started due to history of MRSA and Pseudomonnal pneumonia. On hospital day 3, patient complained of increased dyspnea, was not hypoxic. She was also persistently hypotensive unresponsive to fluids and was transferred to the ICU for further management. In the ICU a central line was placed and CVP monitoring revealed low values indicative of hypovolemia. She was resuscitated with IV fluids and her blood pressure was initially responsive. She was continued on IV Vancomycin, IV Cefepime and IV Levofloxacin for double coverage given her recent hospitalization and history of Pseudomonal pneumonia, and she completed an eight day course of these antibiotics. Her respiratory status improved slowly with decreased work of breathing. She required only minimal oxygen supplemenation intermittently. # Sepsis - Likely secondary to pneumonia and C. diff diagnosed on hospital day 1. Initially normotensive on admission, Mrs. was hypotensive to SBP 80's on hospital day 2 with adequate response to 2L fluid bolus. Anti-hypertensives held. On hospital day 3, patient became hypotensive to 70-80's with little improvement after 3.5L bolus. Due to persistant hypotension, transferred to ICU and continued Vancomycin and Cefepime for pneumonia as well as PO Vancomycin for C. Diff. In the ICU a central line was placed and CVP monitoring revealed low values indicative of hypovolemia. She was resuscitated with IV fluids and her blood pressure was initially responsive. Presumedly she was hypovolemic due to massive GI losses from C.diff. She was continued on IV boluses PRN. Although he blood pressure did not improve greatly and she remained modestly hypotensive with SBP 90s, on gentle diuresis was started given her history of diastolic CHF as well as anasarca from worsened hypoalbuminemia. She tolerated this well without worsening of her blood pressures. After completing an eight day course of antibiotics for pneumonia, the plan is to complete an additional 6 week taper of PO vancomycin for recurrent C. diff infection. Central line was pulled on day of discharge without complication. # C. Difficile - Patient was admitted with leukocytosis, diarrhea and low grade fevers. C. Diff assay was positive. Vancomycin PO and IV flagyl were started due to recurrent C. Diff infections. Diarrhea was monitored. As above, she was volume resuscitated. Her course appears to have been complicated by a protein losing enteropathy causing a worsening of hypoalbuminemia (3. --> 2.2 now). This has worsened her anasarca and made diuresis more difficult. Repeat KUBs, including one on day before discharge, showed no evidence of significant bowel dilation but did indicate ongoing gut edema. Plan to extend C.diff treatment (oral vancomycin) an additional 6 week taper after completion of her pneumonia antibiotics given recurrent, severe C. diff infection. | Moderate narrowing of right mainstem bronchus. Mild colonic wall thickening particularly in the right hemicolon is noted. A right IJ catheter terminates in superior vena cava. The bilateral lower lobe consolidations are unchanged noting some non-enhancing lung in the right lower lobe. Right upper lobe calcified granulomas are again noted. There is mild atelectasis at the right lung base. Normal sinus rhythm with ventricular premature beats. Mild degenerative changes are in the thoracic spine. A separate area of consolidation is in the right upper lobe in a perifissural distribution(4.140). FINDINGS: There is stable severe emphysema. Linear atelectasis is mild in the lower lobes bilaterally and partially due to a new nonhemorrhagic small right pleural effusion. Bibasilar opacity is larger on the right side are unchanged. A hiatal hernia is small. Heart and mediastinum are probably within normal limits. 4)New intraabdominal ascites and new small right pleural effusion. A right upper lobe calcified granuloma is redemonstrated. Moderate ascites. FINDINGS: Single abdomen radiograph compared to the prior study from demonstrates a dilated colonic segment. There is mild colonic wall thickening seen particularly along the right hemicolon consistent with known C. diff colitis. There is mild cardiomegaly. The right heart border is obscured by opacity in the right lower lung. Stable bilateral lower lobe consolidation. There is a slightly increasing right pleural effusion and new small left pleural effusion. There is a small left-sided pleural effusion with left lower lobe atelectasis. Centrilobular emphysema is worse in the upper lobes bilaterally and stable since the prior CT. No pathologically enlarged mediastinal or axillary lymph nodes by CT size criteria. IMPRESSION: Improved right lower lobe atelectasis. Scattered phleboliths are noted. Additionally, there is retrocardiac opacity. Right IJ catheter tip is in the mid SVC. Right IJ catheter tip is in the mid SVC. There is a hiatal hernia. Diffuse non-specific ST-T waveabnormalities. Left lower lobe opacity has minimally improved. There is moderate amount of ascites seen in the abdomen. The caliber of the aorta and pulmonary artery is normal. IMPRESSION: 1)Multifocal consolidation which has improved in the left lower lobe and is slightly worse in the right lower and upper lobes since recent conventional CXRs. Compared to the previous tracing of no change. Cardiomediastinal contours are unchanged. Right lower lobe consolidation is stable. Sinus tachycardia with ventricular premature beat. Multiple calcified granulomas are again noted. Decreased oxygen saturation and hypotension. H/o CHF, COPD. Sinus tachycardia. Opacities in the left lower lobe are unchanged. Mild cardiomegaly is stable. Mild cardiomegaly is stable. FINDINGS: The cardiomediastinal silhouette appears unremarkable. BIBASILAR OPACITIES STABLE. Delayed R wave progression with late precordial QRS transitionis non-specific but cannot exclude possible prior anterior myocardialinfarction. There is a left-sided femoral prosthesis partially imaged. Dependent secretions in the right main stem bronchus are new. Heart size normal. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Persistent hypotension. Very little change from the prior study. There is calcification at the mitral annulus. Opacities in the left lower lobe are stable. The heart size is normal with no pericardial effusion. The hila are normal appearing bilaterally. Poor R wave progressionin leads V1-V4 of uncertain significance. Consider left atrialabnormality. There is calcification of the mitral valve. Increasing right greater than left bilateral pleural effusions. The lungs are hyperinflated and there is relative lucency within the lung apices suggestive of underlying emphysema. REASON FOR THIS EXAMINATION: assess for PE No contraindications for IV contrast FINAL REPORT HISTORY: Chest pain, worsening O2 saturations and history of PE with subtherapeutic INR. Upper lung zones are clear. Since the previous tracingof ST-T wave changes appear less prominent but baseline artifacton both tracings makes comparison difficult. Right lower lobe opacity has improved consistent with improving atelectasis. IMPRESSION: Patchy bibasilar opacities which could reflect pneumonia or aspiration in the appropriate clinical setting. IMPRESSION: AP chest compared to : Right basal opacification has worsened, consistent with progressive pneumonia or atelectasis superimposed. 5-mm and 1.25-mm axial slices were acquired with coronal and sagittal reformats. Patient is status post left total hip arthroplasty. FINAL REPORT SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Assess line. Atherosclerotic plaque is moderately severe in the aortic arch and extends into the origin of the left common carotid and subclavian arteries. No frank dilatation of the small bowel identified. FINDINGS: Single portable chest radiograph is compared to the prior study from . FINDINGS: Consolidation in the left lower lobe has improved and is slightly worse in the right lower lobe since the recent chest radiographs over the preceeding week. Contrast is identified within the bladder. ST-T wave changes are non-specific. IMPRESSION: No dilated loops of small bowel. COMPARISON: Previous CT and most numerous recent chest radiographs. Although this examination was not designed for subdiaphragmatic evaluation, there is new intra-abdominal ascites and diffuse vascular calcification of the suprarenal aorta. IMPRESSION: 1. REASON FOR EXAM: Evaluate for pneumonia TECHNIQUE: MDCT chest was performed without IV contrast. Calcification is severe in the mitral annulus and moderately severe in the aortic valve and coronary arteries. HISTORY: C. diff infection. Multiple calcified granulomas are seen in the lungs. IMPRESSION: No evidence of obstruction. AS before this could represent pneumonia or aspiration. There are degenerative changes in the spine. STUDY: AP portable upright chest radiograph. Some air is present in the descending colon. Extensive vascular calcifications are noted. There are extensive atherosclerotic calcifications of the aorta and coronary arteries. FINDINGS: There are no dilated loops of small bowel to suggest obstruction. Multiplanar reformats were performed. NO PTX OR ADDITIONAL INTERVAL CHANGE. COMPARISON: CT of the abdomen and pelvis from . | 15 | [
{
"category": "Radiology",
"chartdate": "2142-07-18 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1137626,
"text": " 2:50 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for colonic distention\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with acute C. diff infection\n REASON FOR THIS EXAMINATION:\n eval for colonic distention\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN, FOUR VIEWS.\n\n COMPARISON: .\n\n HISTORY: C. diff infection.\n\n FINDINGS: There are no dilated loops of small bowel to suggest obstruction.\n There is no evidence of free air. There is mild colonic wall thickening seen\n particularly along the right hemicolon consistent with known C. diff colitis.\n Contrast is identified within the bladder. Scattered phleboliths are noted.\n Extensive vascular calcifications are noted. Patient is status post left\n total hip arthroplasty.\n\n IMPRESSION: No evidence of obstruction. Mild colonic wall thickening\n particularly in the right hemicolon is noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-16 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1137332,
"text": " 3:14 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: assess for PE\n Admitting Diagnosis: COPD EXACERBATION\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with right chest pain, worsening O2 saturations, history of\n PE and subtherapeutic INR.\n REASON FOR THIS EXAMINATION:\n assess for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain, worsening O2 saturations and history of PE with\n subtherapeutic INR.\n\n COMPARISON: .\n\n TECHNIQUE: CT of the chest was performed before and after administration of\n IV contrast. Multiplanar reformats were performed.\n\n FINDINGS:\n\n There is stable severe emphysema. The bilateral lower lobe consolidations are\n unchanged noting some non-enhancing lung in the right lower lobe. Moderate\n narrowing of right mainstem bronchus. There is a slightly increasing right\n pleural effusion and new small left pleural effusion. There is moderate\n amount of ascites seen in the abdomen. There are extensive atherosclerotic\n calcifications of the aorta and coronary arteries. Multiple calcified\n granulomas are seen in the lungs. There is no evidence of pulmonary embolism.\n There is mild cardiomegaly. There is a hiatal hernia.\n\n There are degenerative changes in the spine.\n\n\n IMPRESSION:\n 1. No evidence of pulmonary embolism.\n\n 2. Stable bilateral lower lobe consolidation.\n\n 3. Increasing right greater than left bilateral pleural effusions.\n\n 4. Moderate ascites.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-12 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1136684,
"text": " 9:10 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with sepsis, pulmonary disease\n REASON FOR THIS EXAMINATION:\n Evaluate pneumonia versus evolving lesion in right lower lobe\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT chest without contrast.\n\n REASON FOR EXAM: Evaluate for pneumonia\n\n TECHNIQUE: MDCT chest was performed without IV contrast. 5-mm and 1.25-mm\n axial slices were acquired with coronal and sagittal reformats.\n\n COMPARISON: Previous CT and most numerous recent chest\n radiographs.\n\n FINDINGS:\n\n Consolidation in the left lower lobe has improved and is slightly worse in the\n right lower lobe since the recent chest radiographs over the preceeding week.\n A separate area of consolidation is in the right upper lobe in a perifissural\n distribution(4.140). Dependent secretions in the right main stem bronchus are\n new. Linear atelectasis is mild in the lower lobes bilaterally and partially\n due to a new nonhemorrhagic small right pleural effusion. Several calcified\n granulomata are scattered throughout the lungs. Centrilobular emphysema is\n worse in the upper lobes bilaterally and stable since the prior CT.\n\n No pathologically enlarged mediastinal or axillary lymph nodes by CT size\n criteria. Atherosclerotic plaque is moderately severe in the aortic arch and\n extends into the origin of the left common carotid and subclavian arteries.\n The caliber of the aorta and pulmonary artery is normal. The heart size is\n normal with no pericardial effusion. Calcification is severe in the mitral\n annulus and moderately severe in the aortic valve and coronary arteries.\n\n Although this examination was not designed for subdiaphragmatic evaluation,\n there is new intra-abdominal ascites and diffuse vascular calcification of the\n suprarenal aorta. A hiatal hernia is small.\n\n No destructive or sclerotic bone lesions are concerning for malignancy.\n\n IMPRESSION:\n\n 1)Multifocal consolidation which has improved in the left lower lobe and is\n slightly worse in the right lower and upper lobes since recent conventional\n CXRs.\n\n 2)Moderately severe diffuse centrilobular emphysema\n (Over)\n\n 9:10 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Evaluate pneumonia versus evolving lesion in right lower lob\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 3)Diffuse atherosclerotic calcification in the coronary arteries, aorta, in\n the mitral annulus and aortic valve.\n\n 4)New intraabdominal ascites and new small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1136612,
"text": " 4:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Etiology of SOB\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with persisten hypotension, PNA and C.diff\n REASON FOR THIS EXAMINATION:\n Etiology of SOB\n ______________________________________________________________________________\n WET READ: MBue WED 7:28 PM\n NO SIGNIFICANT CHANGE. BIBASILAR OPACITIES STABLE.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Persistent hypotension.\n\n Comparison is made with prior study .\n\n Mild cardiomegaly is stable. There is calcification at the mitral annulus.\n Bibasilar opacity is larger on the right side are unchanged. This could be\n due to atelectasis and/or pneumonia. Right upper lobe calcified granulomas\n are again noted. There is no pneumothorax or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1136700,
"text": " 10:59 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess colon distension, other intraabdominal pathology\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with cdiff and abd distension, pna, hypotension\n REASON FOR THIS EXAMINATION:\n assess colon distension, other intraabdominal pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Woman with C. diff and abdominal distention.\n\n COMPARISON: CT of the abdomen and pelvis from .\n\n Single view of the abdomen shows no dilated loops of small or large bowel.\n Air is noted within the colon. The visible osseous structures are\n unremarkable. There is a left-sided femoral prosthesis partially imaged.\n\n IMPRESSION:\n\n No dilated loops of small bowel.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1137104,
"text": " 3:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent PNA, cdiff, some hypotension\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: Recent pneumonia, hypotension.\n\n FINDINGS:\n\n Single portable chest radiograph is compared to the prior study from\n . A right IJ catheter terminates in superior vena cava. There is a\n small left-sided pleural effusion with left lower lobe atelectasis. There is\n mild atelectasis at the right lung base. Heart and mediastinum are probably\n within normal limits. Upper lung zones are clear. Very little change from\n the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-14 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1137105,
"text": " 3:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: Colonic distension\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with recent PNA, cdiff, some hypotension\n REASON FOR THIS EXAMINATION:\n Colonic distension\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, \n\n CLINICAL INFORMATION: Chronic distention.\n\n FINDINGS:\n\n Single abdomen radiograph compared to the prior study from \n demonstrates a dilated colonic segment. No frank dilatation of the small\n bowel identified. Some air is present in the descending colon.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-09 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1136254,
"text": " 3:41 PM\n CHEST (PA & LAT) Clip # \n Reason: Assess for edema, infiltrate\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with COPD and hx of pneumonia.\n REASON FOR THIS EXAMINATION:\n Assess for edema, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: COPD and history of pneumonia.\n\n Comparison is made with prior study, .\n\n Cardiomediastinal contours are unchanged. Right lower lobe opacity has\n improved consistent with improving atelectasis. Opacities in the left lower\n lobe are unchanged. Multiple calcified granulomas are again noted. There is\n calcification of the mitral valve. There is no pneumothorax or pleural\n effusion. Mild degenerative changes are in the thoracic spine.\n\n IMPRESSION: Improved right lower lobe atelectasis. Opacities in the left\n lower lobe are stable. AS before this could represent pneumonia or\n aspiration.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1136043,
"text": " 9:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with dyspnea, fevers. H/o CHF, COPD.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 82-year-old female with dyspnea and fevers.\n\n STUDY: AP portable upright chest radiograph.\n\n COMPARISON: .\n\n FINDINGS: The cardiomediastinal silhouette appears unremarkable. The hila\n are normal appearing bilaterally. The right heart border is obscured by\n opacity in the right lower lung. Additionally, there is retrocardiac opacity.\n A right upper lobe calcified granuloma is redemonstrated. There is no evidence\n for large pleural effusion or pneumothorax. The lungs are hyperinflated and\n there is relative lucency within the lung apices suggestive of underlying\n emphysema.\n\n IMPRESSION: Patchy bibasilar opacities which could reflect pneumonia or\n aspiration in the appropriate clinical setting.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1136628,
"text": " 7:08 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with hypotension\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: MBue WED 11:21 PM\n RT CVC TERMINATING IN MID TO DISTAL SVC. NO PTX OR ADDITIONAL INTERVAL\n CHANGE.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study performed two hours earlier.\n\n Right IJ catheter tip is in the mid SVC. There is no pneumothorax. No other\n interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1136382,
"text": " 12:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna/interval change\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with COPD, recurrent pneumonia with decreased O2 sat and\n hypotension\n REASON FOR THIS EXAMINATION:\n eval for pna/interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:54 P.M. ON \n\n HISTORY: Recurrent pneumonia. Decreased oxygen saturation and hypotension.\n\n IMPRESSION: AP chest compared to :\n\n Right basal opacification has worsened, consistent with progressive pneumonia\n or atelectasis superimposed. There is no pulmonary edema or pleural effusion.\n Heart size normal. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1136666,
"text": " 6:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evidence of worsened pulmonary process\n Admitting Diagnosis: COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with pneumonia, sepsis\n REASON FOR THIS EXAMINATION:\n Evidence of worsened pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Pneumonia.\n\n Comparison is made with prior study performed the day earlier.\n\n Mild cardiomegaly is stable. Right IJ catheter tip is in the mid SVC. There\n is no pneumothorax. Left lower lobe opacity has minimally improved. Right\n lower lobe consolidation is stable.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-07-12 00:00:00.000",
"description": "Report",
"row_id": 111179,
"text": "Sinus tachycardia. Compared to the previous tracing of no change.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-07-11 00:00:00.000",
"description": "Report",
"row_id": 111180,
"text": "Sinus tachycardia with ventricular premature beat. Consider left atrial\nabnormality. Delayed R wave progression with late precordial QRS transition\nis non-specific but cannot exclude possible prior anterior myocardial\ninfarction. ST-T wave changes are non-specific. Since the previous tracing\nof ST-T wave changes appear less prominent but baseline artifact\non both tracings makes comparison difficult.\n\n"
},
{
"category": "ECG",
"chartdate": "2142-07-08 00:00:00.000",
"description": "Report",
"row_id": 111181,
"text": "Normal sinus rhythm with ventricular premature beats. Poor R wave progression\nin leads V1-V4 of uncertain significance. Diffuse non-specific ST-T wave\nabnormalities. Compared to the previous tracing of ventricular premature\nbeats are new and heart rate has increased.\n\n"
}
] |
28,386 | 186,255 | 81F EF 45% inf HK, afib/C, DVT, dm2, copd p/w rapid afib and in setting of rapid rate has angina and CHF . 1. Cardiac: a. Rhythm: Pt was in rapid afib on admission. Initially ther was poor rate control in house and the patient went to ICU. She was on atenolol 12.5 daily that uptitrated gradually and rate control improved. Pt's coumadin was held on admission for a supratherapeutic level, though it was restarted. . b. Coronaries: The patient did have anginal symptoms in the setting of rapid heart rate. There was no known h/o CAD, though there is EF 45% with inf HK which suggests CAD. The chest pain was likely related to the rapid afib. The ECG showed only non-specific changes. Enzymes showed trop t 0.03 with negative CK and MB. Pt was rate controlled as described and continued with aspirin, beta blocker, and statin. c. Pt presented in acute CHF with pulmonary edema. LVEF 45%. The patient was diuresed. She was continued on beta blocker and we started an ace inhibitor as well. 2. Confusion: Pt has h/o dementia and was hospitalized with mutliple sedatives and psych meds. Pt's sedating medications were held in house. Confusion resolved and patient oriented again to person, place, and time by hospital day 4. 3. Pleural effusions: There were bilateral, moderate on the left and small on the right. This is unlikely contributing to SOB. The plan was to diurese and treat CHF. . 4. Leukocytosis: Pt had WBC of 16 on admission, but this resolved over hospital course down to 11.1. Likely stress response. Pt is afebrile, UA is negative. CXR is c/w CHF. 5. Diabetes Mellitus Patient c/w metformin and SSI in-house. . Access - PIV . Prophylaxis: anticoagulated for afib, PPI, bowel regimen, per home regimen | Left ventricular function.Weight (lb): 180BP (mm Hg): 142/83HR (bpm): 93Status: InpatientDate/Time: at 15:01Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:Left pleural effusion is present.LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Trivial mitral regurgitation isseen. Mild regional LVsystolic dysfunction. left basilar opacity likele reflects compression atelectasis. Cover BS c RISS. There is mild regional left ventricularsystolic dysfunction with inferior hypokinesis. Haziness is noted in the right lung base which mauy reflect edema. -5oo @ mdght, -260 current.Id-afebrile.Endo-SSI, metformin PO. Left apices clear, base diminished. She had some expiratory wheezes, more on L than R and benefited from atrovent neb. There is mild symmetric left ventricular hypertrophy. Normal ascending aortadiameter.AORTIC VALVE: Mildly thickened aortic valve leaflets. She continues to receive atrovent nebs.GI: Pt has excellent apetite. PMHx significant for HTN, AFib, CHF, DVT, COPD, dementia, DM.N-a/ox1, however and cooperative c care. The mitral valve leaflets are mildlythickened. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Captopril 6.25mg as ordered-tolerated well.Resp-Nebs doesd Q4 c increased in diffuse I/E wheeze-improvement post nebs. INR elevated-holding coumadin. CXR shows failure and bilateraly pleural effusions. No echocardiographic signs oftamponade.Conclusions:The left atrium is mildly dilated. She c/o of constipation and colace was increased to . Pt is asymptomatic. Reorient pt as needed. Reorient pt as needed. RR wnl.GI-no difficulties c pills. Early dementia c anxiety-responds well to reoriention/reassurance. However Right LS diminished throughout > than Left. HR therafter 70s-80s c occasional PVC, SBP 115-130. piv x1. Mild [1+] TR.Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: Small pericardial effusion. Right axis deviation. Right axis deviation. Trivial MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Atrial fibrillation with slowing of the ventricular response as compared withtracing of . possible echo today to evaluate pump function.Resp-bilateral pleural effusions per cxray L>R. She did not aspirate with liquids or soft solids.ENDO: Blood sugars quite elevated. The estimatedpulmonary artery systolic pressure is normal. There is a small pericardialeffusion without tamponade. Bilateral pleural effusions are noted, left greater than right. CCU NSG NOTE: ALT IN CV/RESPS: "I feel so anxious. 81y.o female c COPD exacerbation admitted from Rehab. Normal LV cavity size. Bilateral pleural effusions, moderate on the left and small on the right with probable underlying mild congestive failure. She has very decreased BS bilaterally. CCU NSG NOTE: ALT IN RESP/CVS: "It bothers me that I'm confused".O: For complete VS see CCU flow sheet. 1 piv. SBP 120s-140s, pulses palpable. Diffuse non-specificST-T wave changes. Dosed colace plus senna. coumadin currently on hold c increased INR. Captopril was also added at 6.25mg tid with bp now in 120-130/70-80s.She was KCL replaced this am with repeat K+ pending.RESP: She has more audible breath sounds today, though some crackles were heard. HR is 70-90s afib, much better controlled with 25mg lopressor.She has occasional single pvcs. abd obese, +BS. Theaortic valve leaflets are mildly thickened. afebrile. Continues on ASA, statin. Perhaps dulcolax tab tonight.RENAL: Pt still has foley draining clear urine, now in small amts. The leftventricular cavity size is normal. WBC last trending down.Skin-intact.endo-pm BS 135, no coverage per sliding scale.social/dispo-supportive children. hr now in mid 80s with bp 171/82. f/u am labs (monitor hyponatremia 129/132). IMPRESSION: 1. RR wnl c some DOE. She was symptom free and transfered to CCU on MICU service for further care.ID: WBCs down to 10.3 (16.9). follows commands consistenly. pulses palpable. Requires soft diet (no teeth).GU-foley c adequate CYU. Monitor resp status and nebs as needed. transfer note complete. Normal IVC diameter (1.5-2.5cm) with <50%decrease during respiration (estimated RAP 11-15mmHg).LEFT VENTRICLE: Mild symmetric LVH. HO notified and she received 12.5mg. Possible increase in Lopressor as BP tolerates. Right ventricular chamber size and free wall motion are normal. Monitor BP c increased lopressor. Clinical correlation of theright axis deviation is suggested. I want to go home".O: For complete VS see CCU flow sheet.ID: PT remains afebrile with decreasing WBCs.CV: PT has no c/o of chest or neck discomfort. CYU.ID-bld/urine cxs pending. The tricuspid valve leaflets are mildly thickened. -BM.GU-dosed 10mg IV lasix for low UO c effect. PT consult was called.A: Some improvement in MS/continued 02 requirement/walking with assistP: Monitor bp with new and increased meds. Known COPD/heart failure history. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. She was transfered to EW where she c/o of chest pressure in addition to her other symptoms. She received lasix 20mg IV at 1130 with good response. HR was 120af with bp in 170/80s. She was treated with sl nitro X 3, solumedrol for supposed copd exacerbation, nebs and dose of levofloxacin. no coverage last night.skin-pressure areas intact.plan-transfer to 6. (baseline while here). No further ABX, cultures pending.CV: HR creeping up to 110-120af when pt received 12.5 lopressor at 11am. Last dosed Lasix @ 1130 (10-20mg).GI-+BS, -BM since admit. "O-see flowsheet/admit note for additional details. f/u am labs. Support pt and her fears of being in a new place. Sugars were 228 and 245 and she received 4 and 5u of regular insulin.MS: Pt initially was quite lethargic and oriented only X 1. Please note evaluation was limited due to portable technique and marked patient rotation. She becomes anxious about what is happening, but responds well to reassurance.A: Decreasing WBCs, imcomplete control with 12.5 lopressor,improved msP: Continue to reassure pt that she is safe, and review todays event. By 1800 her sugar was 129 and no further reg insulin was required.MS/ACTIVITY: Pt continues to be A & 0 X . Ck peak 104. Faint basalar crackles. She received lasix 20mg iv at 11am with fair diaresis. Clinical correlation of the rightaxis deviation is suggested.TRACING #2 in short pt 81y.o female admitted from rehab c CP, SOB, hypoxia COPD Exacerbation. "O-see flowsheet/transfer notes for details. Keep careful I & O. Keep careful I & O. She has strong non-productive cough.RENAL: Pt has foley draining clear urine. | 8 | [
{
"category": "Radiology",
"chartdate": "2184-10-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 983497,
"text": " 4:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with COPD, CHF, p/w chest pain and SOB.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest pain and shortness of breath. Known COPD/heart failure\n history.\n\n No prior exams are available.\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS: Patient is rotated to the left. Bilateral pleural effusions\n are noted, left greater than right. left basilar opacity likele reflects\n compression atelectasis. Haziness is noted in the right lung base which\n mauy reflect edema. Upper lobe lucency likely related to emphysema in\n this patient with known COPD. The heart appears enlarged. No evidence of\n pneumothorax.\n\n IMPRESSION:\n\n 1. Bilateral pleural effusions, moderate on the left and small on the right\n with probable underlying mild congestive failure.\n\n 2. Please note evaluation was limited due to portable technique and marked\n patient rotation. Dedicated PA and lateral radiographs would be helpful to\n further delineate.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-10-25 00:00:00.000",
"description": "Report",
"row_id": 1632702,
"text": "CCU NSG NOTE: ALT IN RESP/CV\nS: \"It bothers me that I'm confused\".\nO: For complete VS see CCU flow sheet. This 81y old Rehab resident with pmh of CHF, af on coumadin, htn, aodm, COPD, and mild dementia awoke ~0200 with SOB & jaw pain. Her 02 sat was 70% that increased to 92% on 3L NP. She was transfered to EW where she c/o of chest pressure in addition to her other symptoms. HR was 120af with bp in 170/80s. She was treated with sl nitro X 3, solumedrol for supposed copd exacerbation, nebs and dose of levofloxacin. She also received 2.5IV lopressor which brought her hr down to 80s and bp to 120s/70s. She was symptom free and transfered to CCU on MICU service for further care.\nID: WBCs down to 10.3 (16.9). No further ABX, cultures pending.\nCV: HR creeping up to 110-120af when pt received 12.5 lopressor at 11am. \rByy 600 hr up to 100-125 again. HO notified and she received 12.5mg. hr now in mid 80s with bp 171/82. No further meds ordered. Pt is asymptomatic. CKs are 104 down to 86 at noon. Troponin .01.\nRESP: RR 18 up to high 20s later in the day. She has very decreased BS bilaterally. CXR shows failure and bilateraly pleural effusions. She had some expiratory wheezes, more on L than R and benefited from atrovent neb. She is now sating 98% on 4L NP. She has strong non-productive cough.\nRENAL: Pt has foley draining clear urine. She received lasix 20mg IV at 1130 with good response. She is now 600cc neg for the day.\nGI: Pt has excellent apetite, but needs soft food as she has no teeth. Mental status is improving, but pt should still be monitored while eating as she does not attend well and may need to be prompted to swallow. She did not aspirate with liquids or soft solids.\nENDO: Blood sugars quite elevated. Pt did not receive po today. Sugars were 228 and 245 and she received 4 and 5u of regular insulin.\nMS: Pt initially was quite lethargic and oriented only X 1. She slept when left alone, but was easily rouseable. By the afternoon she was more awake and aware that she was confused. She could not recall events earlier in the day. She becomes anxious about what is happening, but responds well to reassurance.\nA: Decreasing WBCs, imcomplete control with 12.5 lopressor,improved ms\nP: Continue to reassure pt that she is safe, and review todays event. Keep careful I & O. Notify HO if HR jumps up again. Monitor finger sticks to better control sugars.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-10-27 00:00:00.000",
"description": "Report",
"row_id": 1632705,
"text": "CCU Nursing note\nS-\"I hope my family is ok. I don't know where I am.\"\nO-see flowsheet/transfer notes for details. 81y.o female c COPD exacerbation admitted from Rehab. C/O to floor, 6. Transfer when ready.\n\nN-a/ox1-2 during night. (baseline while here). Early dementia c anxiety-responds well to reoriention/reassurance. follows commands consistenly. OOB to chair last shift and ambulating in room c walker.\nDenies any pain.\n\nCV-Chronic afib. coumadin currently on hold c increased INR. HR 80s-110 responding to 25mg PO Lopressor. SBP 120s-140s, pulses palpable. 1 piv. Captopril 6.25mg as ordered-tolerated well.\n\nResp-Nebs doesd Q4 c increased in diffuse I/E wheeze-improvement post nebs. Faint basalar crackles. RR wnl c some DOE. Last dosed Lasix @ 1130 (10-20mg).\n\nGI-+BS, -BM since admit. Dosed colace plus senna. No difficulties swallowing pills/eating. however some times requires reminders to swallow. Requires soft diet (no teeth).\n\nGU-foley c adequate CYU. Fluid restriction 1500cc/day. -5oo @ mdght, -260 current.\n\nId-afebrile.\n\nEndo-SSI, metformin PO. no coverage last night.\n\nskin-pressure areas intact.\n\nplan-transfer to 6. Monitor resp status and nebs as needed. Possible increase in Lopressor as BP tolerates. Reorient pt as needed. transfer note complete.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-10-26 00:00:00.000",
"description": "Report",
"row_id": 1632703,
"text": "CCU Nursing note\nS-\"I don't know where I'm at. Is it the ? As long as my family knows I'm here.\"\nO-see flowsheet/admit note for additional details. in short pt 81y.o female admitted from rehab c CP, SOB, hypoxia COPD Exacerbation. PMHx significant for HTN, AFib, CHF, DVT, COPD, dementia, DM.\n\nN-a/ox1, however and cooperative c care. Anxious at times, Responds well to orientation and reassurance. Dosed 650mg tylenol @ HS for back discomfort c effect. bilateral strength equal, PERRL, no other focal deficits.\n\nCV-Lopressor increased to 25mg TID c better rate control in afib. HR therafter 70s-80s c occasional PVC, SBP 115-130. piv x1. pulses palpable. Continues on ASA, statin. Ck peak 104. INR elevated-holding coumadin. f/u am labs (monitor hyponatremia 129/132). possible echo today to evaluate pump function.\n\nResp-bilateral pleural effusions per cxray L>R. However Right LS diminished throughout > than Left. Left apices clear, base diminished. Continues on 4L NC 96-99%. RR wnl.\n\nGI-no difficulties c pills. abd obese, +BS. -BM.\nGU-dosed 10mg IV lasix for low UO c effect. CYU.\n\nID-bld/urine cxs pending. afebrile. WBC last trending down.\nSkin-intact.\n\nendo-pm BS 135, no coverage per sliding scale.\nsocial/dispo-supportive children. Full code. c/o to floor when bed available.\n\nplan-echo today? f/u am labs. Monitor BP c increased lopressor. Cover BS c RISS. Reorient pt as needed. bed low/locked c alarm on.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-10-26 00:00:00.000",
"description": "Report",
"row_id": 1632704,
"text": "CCU NSG NOTE: ALT IN CV/RESP\nS: \"I feel so anxious. I want to go home\".\nO: For complete VS see CCU flow sheet.\nID: PT remains afebrile with decreasing WBCs.\nCV: PT has no c/o of chest or neck discomfort. HR is 70-90s afib, much better controlled with 25mg lopressor.She has occasional single pvcs. Captopril was also added at 6.25mg tid with bp now in 120-130/70-80s.She was KCL replaced this am with repeat K+ pending.\nRESP: She has more audible breath sounds today, though some crackles were heard. She is now sating 95-96% on 2L NP. On RA she sats 89-91%. She continues to receive atrovent nebs.\nGI: Pt has excellent apetite. She c/o of constipation and colace was increased to . She has attempted bm multiple times, but has not been able to. Perhaps dulcolax tab tonight.\nRENAL: Pt still has foley draining clear urine, now in small amts. She received lasix 20mg iv at 11am with fair diaresis. She is presently negative ~500cc for the day and ~1 liter LOS.\nENDO: Finger stick at noon was 199 and she received 4u reg insulin for that. She had received metformin 1000mg at 11. By 1800 her sugar was 129 and no further reg insulin was required.\nMS/ACTIVITY: Pt continues to be A & 0 X . By the late afternoon she became anxious, after her family left feeling she was unsure of where she was. She was up in the chair and perhaps fatigued. Once back in bed she went to sleep. She took a walk with assist and did well. She walks with walker at rehab. PT consult was called.\nA: Some improvement in MS/continued 02 requirement/walking with assist\nP: Monitor bp with new and increased meds. Support pt and her fears of being in a new place. Keep careful I & O. Increase activity as tolerated.\n\n"
},
{
"category": "Echo",
"chartdate": "2184-10-25 00:00:00.000",
"description": "Report",
"row_id": 96031,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function.\nWeight (lb): 180\nBP (mm Hg): 142/83\nHR (bpm): 93\nStatus: Inpatient\nDate/Time: at 15:01\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLeft pleural effusion is present.\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler. Normal IVC diameter (1.5-2.5cm) with <50%\ndecrease during respiration (estimated RAP 11-15mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\nNormal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. There is mild regional left ventricular\nsystolic dysfunction with inferior hypokinesis. There is no ventricular septal\ndefect. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets are mildly thickened. There is no aortic valve stenosis.\nNo 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. The estimated\npulmonary artery systolic pressure is normal. There is a small pericardial\neffusion without tamponade.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2184-10-25 00:00:00.000",
"description": "Report",
"row_id": 260971,
"text": "Atrial fibrillation with slowing of the ventricular response as compared with\ntracing of . Right axis deviation. Clinical correlation of the right\naxis deviation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2184-10-25 00:00:00.000",
"description": "Report",
"row_id": 260972,
"text": "Atrial fibrillation with rapid ventricular response. Diffuse non-specific\nST-T wave changes. Right axis deviation. Clinical correlation of the\nright axis deviation is suggested. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
}
] |
60,653 | 181,064 | The pt is a 44 year-old left handed man with PMH significant for tobacco and alcohol abuse plus untreated HTN who presents as a transfer from Hospital for management of a right basal ganglia hemorrhage. Etiology of the hemorrhage is somewhat uncertain. HTN is likely given the history of untreated high blood pressures. Patient was initially admitted to Neuro ICU service with neurosurgery following. Overnight, he required frequent Valium for EtOH withdrawal (severe diaphoresis and tachycardia). Patient became more somnolent the next morning which may have been due to Vailum but repeat CT/CTA showed increased hemorrhage with midline shift 13~14mm to the left. Patient was emergently taken to OR per neurosurgery where he underwent right-sided frontotemporal craniotomy for decompression, evacuation, partial frontal lobe resection. He was successfully extubated the next mornind and repeat CT showed no new hemorrhage with stable midline shoft ~9mm to the left as was seen in post-operative imaging. He was continued on CIWA for EtOH withdrawal with tapering standing Ativan plus as needed Ativan. Also, given hemorhage and surgical evacuation, he was empirically loaded with phenytoic for seizure prophylaxis and was continued on 100mg TID for maintenance. He gradually became more arousable but remains L hemiplegic with some withdrawal of LLE to noxious stimuli but no movement on LUE even with noxious stimuli. He started to speak more on POD #3 but his speech remained heavily dysarthric. Since transfer to the neurology floor, his speech has continued to improve. In addition, his awareness regarding his left hemiparesis has improved. On the floor, he no longer needed the Ativan, and his anti-hypertensive medication doses were optimized. He has been evaluated by speech and swallow and is on the appropriate diet as follows: 1. Continue po diet of ground solids, nectar thick liquids. 2. PO meds: crushed in puree 3. 1:1 supervision with all PO. Maintain aspiration precautions including: a) feed only when awake/alert b) sit fully upright for all PO c) alternate bites and sips d) provide verbal cues to clear L side of oral cavity e) if presents with fatigue, cease meal. Consider 6 small meals instead of 3 large ones as needed. He has had a Regular Low sodium / Heart healthy Consistency: Ground; Nectar prethickened liquids Supplement: Ensure Pudding breakfast, lunch, dinner Crush po meds, give 6 small meals, and 1:1 supervision with meals on the Neurology Floor. He has been evaluated by PT and OT and he needs close supervision and appropriate precautions when he is mobilised due to his left hemiparesis and left sided neglect. | Phenytoin 23. Metoprolol Tartrate 19. Tylenol for HA per primary service. Metoprolol Tartrate 17. Metoprolol Tartrate 17. Metoprolol Tartrate 18. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. Subjective: Pt just extubated. Famotidine 7. Famotidine 7. Nicotine Patch 17. Nicotine Patch 17. Morphine Sulfate 18. Morphine Sulfate 18. Lorazepam 14. Lorazepam 14. Phenytoin 21. Phenytoin 21. Phenytoin 21. Phenytoin 21. Current medications: 1. Ativan atc and prn. Ativan atc and prn. Lorazepam 17. Phenytoin 20. Phenytoin 20. Action: Freq neuro checks. Action: Freq neuro checks. Action: Freq neuro checks. Famotidine 10. Famotidine 10. Famotidine 10. HTN. On Ativan atc. On Ativan atc. On Ativan atc. Nicotine Patch 19. Nicotine Patch 19. FoLIC Acid 11. Nicotine Patch 21. Has prn hydral and lopressor. Has prn hydral and lopressor. Has prn hydral and lopressor. Docusate Sodium 9. Docusate Sodium 9. Docusate Sodium 9. Docusate Sodium 6. Docusate Sodium 6. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Lorazepam 15. Lorazepam 15. Current medications: . Current medications: . Morphine Sulfate 20. Lisinopril 13. Lisinopril 13. HydrALAzine 11. HydrALAzine 11. Ondansetron 19. Ondansetron 19. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Remains on ativan atc. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Remains on ativan atc. Addictions consult. Addictions consult. Metoprolol Tartrate 16. Metoprolol Tartrate 16. Action: Ativan atc. Action: Ativan atc. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. TITLE: Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. .H/O respiratory failure, acute (not ARDS/) Assessment: Pt extubated today. Metoprolol Tartrate 19. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Nicotine Patch 17. Nicotine Patch 17. Metoprolol Tartrate 18. Has prn hydral and lopressor. Has prn hydral and lopressor. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt continues with ciwa scale. hydralazine prn. Morphine Sulfate 16. Morphine Sulfate 16. Right Basal Ganglia Hemorrhage Assessment: c/o constant R sided HA upon initial exam, +tremors/sweats- please see metavision for neuron and CIWA assessment. Morphine Sulfate 20. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Hourly CIWA scale 17-27 Action: Response: Plan: Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage Assessment: Action: Response: Plan: Nicotine Patch 21. Phenytoin 19. Phenytoin 19. Current medications: 1. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. .H/O alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt with etoh hx. Action: Freq neuro checks. Action: Freq neuro checks. Action: Freq neuro checks. Phenytoin 23. Ordered morphine 1mg IVB x1 dose. Ordered morphine 1mg IVB x1 dose. IV labetelol drip restarted with goal SBP 140-160. Lorazepam 14. Lorazepam 14. Addictions consult. Sodium Chloride 0.9% Flush 27. FINDINGS: Post-operative change of a right craniotomy status post evacuation of an intraparenchymal bleed is again noted. A small amount of residual hemorrhage and extensive pneumocephalus within the right basal ganglia is identified. Hypertension, benign Assessment: Sbp >160 Action: Lopressor dose changed to po. ( series 401b/7) (Over) 10:52 AM CTA HEAD W&W/O C & RECONS Clip # Reason: Hemorrhage follow-up Admitting Diagnosis: INTRACRANIAL HEMORRHAGE FINAL REPORT (Cont) There is evidence of scleral band, with ocular implant on the left side, unchanged. Subarachnoid hemorrhage (SAH) Assessment: Neuro assessment done q2hrs. Sinus rhythmProminent precordial lead QRS voltage suggests left ventricular hypertrophy butmay be nondiagnostic given ageModest nonspecific inferior ST-T wave changesNo previous tracing available for comparison FINAL REPORT HISTORY: Known intracranial hemorrhage. FINDINGS: Patient is status post right frontoparietal craniotomy with evacuation of putaminal and temporal lobe hematoma. A few small hypodense foci, noted in the left internal capsule, may represent perivascular spaces or chronic lacunar infarcts are unchanged. Interval decrease in right basal ganglia hemorrhage. This location is most suggestive of a hypertensive etiology, although underlying mass lesion/metastasis is not completely excluded. | 52 | [
{
"category": "Nursing",
"chartdate": "2186-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417678,
"text": "Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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": "2186-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417679,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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": "Physician ",
"chartdate": "2186-08-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417538,
"text": "SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\n ETOH abuse, h/o illicit drug use\n : none\n .\n Current medications:\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. FoLIC Acid 11. Heparin\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\n 17. Metoprolol Tartrate\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\n Ondansetron 22. Phenytoin 23. Potassium Chloride\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\n 27. Thiamine\n 24 Hour Events:\n TF placed and tF started yesterday\n Post operative day:\n POD#3 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:41 AM\n Lorazepam (Ativan) - 06:00 PM\n Famotidine (Pepcid) - 08:13 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Hydralazine - 02:14 AM\n Metoprolol - 06:18 AM\n Other medications:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.1\nC (100.5\n HR: 119 (86 - 119) bpm\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\n RR: 18 (9 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,828 mL\n 776 mL\n PO:\n Tube feeding:\n 190 mL\n 129 mL\n IV Fluid:\n 2,518 mL\n 647 mL\n Blood products:\n Total out:\n 2,735 mL\n 700 mL\n Urine:\n 2,735 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 93 mL\n 76 mL\n Respiratory support\n SPO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 220 K/uL\n 13.6 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 38.0 %\n 16.5 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n Plt\n 20\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\n to PO\n Cardiovascular: Lopressor 75 TID PO\n HYDRALAZYN prn\n Pulmonary: Stable\n Gastrointestinal / Abdomen: Advance to goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Lasix 20mg \n Hematology: Stable\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Nephrology\n Billing Diagnosis: Other: Basal ganglia Bleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417605,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Remains on ativan atc. Tachy at times and occ attempting to pull at\n lines, otherwise no s/s withdrawal noted.\n Action:\n Ativan atc, but dose decreased\n Response:\n No need for prn ativan and no s/s withdrawal noted\n Plan:\n Con\nt to monitor. Ativan atc and prn.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Opens eyes to stim . right pupil round and reactive. Left pupil at\n baseline. Follows commands on right. Moves right spont. No spont\n movement on left. Withdraws on left to pain. Oriented to person and\n president and month. Only says few words and speech grarbled.\n Action:\n Neuro checks.\n Response:\n Neuro status unchanged.\n Plan:\n Con\nt neuro checks\n"
},
{
"category": "Physician ",
"chartdate": "2186-08-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417181,
"text": "SICU\n HPI:\n 44yo male presented to an outside hospital with acute onset\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\n right cranimtomy hemmhorrage evacuation\n Chief complaint:\n acute onset left sided plegia\n PMHx:\n left eye injury-screwdriver with surgical correction with\n noted visula impairment since, ETOH abuse, prior hx on illicit\n drug use.\n Current medications:\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\n Acid/Multivitamin/Thiamine-1000mL NS\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\n 17. NiCARdipine 18. Ondansetron\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\n 25. Vancomycin\n 24 Hour Events:\n OR SENT - At 03:00 PM\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\n INTUBATION - At 03:15 PM\n intubated in OR\n INVASIVE VENTILATION - START 03:15 PM\n intubated in OR\n ARTERIAL LINE - START 03:30 PM\n OR RECEIVED - At 05:45 PM\n Post operative day:\n POD#1 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Gentamicin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Diazepam (Valium) - 11:00 AM\n Midazolam (Versed) - 06:05 PM\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.3\nC (97.4\n HR: 88 (73 - 95) bpm\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\n RR: 13 (12 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,980 mL\n 1,228 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,780 mL\n 1,228 mL\n Blood products:\n 200 mL\n Total out:\n 3,800 mL\n 435 mL\n Urine:\n 1,690 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 180 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SPO2: 100%\n ABG: 7.44/40/198/28/3\n Ve: 6.9 L/min\n PaO2 / FiO2: 495\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, No(t) Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\n Weakness)\n Labs / Radiology\n 251 K/uL\n 13.2 g/dL\n 168 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 105 mEq/L\n 142 mEq/L\n 37.6 %\n 18.7 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n WBC\n 9.7\n 18.7\n Hct\n 43.2\n 37.6\n Plt\n 231\n 251\n Creatinine\n 0.8\n 1.0\n TCO2\n 26\n 28\n Glucose\n 134\n 146\n 168\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 44yo male presented to an outside hospital with\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\n evacuation\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\n MEDAZOLEM,\n Cardiovascular: D/C Nocrdipine, Start Lopressor\n Pulmonary: Extubate today, Spontaneous breathing trial\n Gastrointestinal / Abdomen: assess Swallow\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable Ht\n Endocrine: RISS, Start RISS start at 120 mg/dl\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CT scan head today\n Fluids:\n Consults:\n Billing Diagnosis: Other: Left Side weakness\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2186-08-25 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417183,
"text": "SICU\n HPI:\n 44yo male presented to an outside hospital with acute onset\n left sided plegia. Head-26x49mm right basal ganglia hemmorhage s/p\n right cranimtomy hemmhorrage evacuation\n Chief complaint:\n acute onset left sided plegia\n PMHx:\n left eye injury-screwdriver with surgical correction with\n noted visula impairment since, ETOH abuse, prior hx on illicit\n drug use.\n Current medications:\n . 2. 3. 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium 9. Famotidine 10. Fentanyl Citrate 11. Folic\n Acid/Multivitamin/Thiamine-1000mL NS\n 12. Gentamicin 13. Heparin 14. Insulin 15. Midazolam 16. Nicotine Patch\n 17. NiCARdipine 18. Ondansetron\n 19. Phenytoin 20. Phenytoin 21. Potassium Chloride 22. Senna 23. Sodium\n Chloride 0.9% Flush 24. Sodium Chloride 0.9% Flush\n 25. Vancomycin\n 24 Hour Events:\n OR SENT - At 03:00 PM\n Emergently sent to OR. Verbal handoff given to OR nurse in person.\n INTUBATION - At 03:15 PM\n intubated in OR\n INVASIVE VENTILATION - START 03:15 PM\n intubated in OR\n ARTERIAL LINE - START 03:30 PM\n OR RECEIVED - At 05:45 PM\n Post operative day:\n POD#1 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Gentamicin - 04:00 AM\n Infusions:\n Midazolam (Versed) - 2 mg/hour\n Fentanyl - 25 mcg/hour\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Diazepam (Valium) - 11:00 AM\n Midazolam (Versed) - 06:05 PM\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.3\nC (99.2\n T current: 36.3\nC (97.4\n HR: 88 (73 - 95) bpm\n BP: 120/66(83) {117/61(79) - 158/97(118)} mmHg\n RR: 13 (12 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,980 mL\n 1,228 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,780 mL\n 1,228 mL\n Blood products:\n 200 mL\n Total out:\n 3,800 mL\n 435 mL\n Urine:\n 1,690 mL\n 435 mL\n NG:\n Stool:\n Drains:\n Balance:\n 180 mL\n 793 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SPO2: 100%\n ABG: 7.44/40/198/28/3\n Ve: 6.9 L/min\n PaO2 / FiO2: 495\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-distended, No(t) Non-tender\n Left Extremities: (Pulse - Dorsalis pedis: Present), (Pulse - Posterior\n tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: No(t) x 2, x 1), Follows simple\n commands, (Responds to: Verbal stimuli, Tactile stimuli), No(t) Moves\n all extremities, (RUE: No(t) Weakness), (LUE: Weakness), (LLE:\n Weakness)\n Labs / Radiology\n 251 K/uL\n 13.2 g/dL\n 168 mg/dL\n 1.0 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 105 mEq/L\n 142 mEq/L\n 37.6 %\n 18.7 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n WBC\n 9.7\n 18.7\n Hct\n 43.2\n 37.6\n Plt\n 231\n 251\n Creatinine\n 0.8\n 1.0\n TCO2\n 26\n 28\n Glucose\n 134\n 146\n 168\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n Assessment and Plan: 44yo male presented to an outside hospital with\n acute onset left sided plegia s/p right cranimtomy hemmhorrage\n evacuation\n Neurologic: Neuro checks Q: 1 hr, continue Dilantin 100mg TID, prn\n MEDAZOLEM,\n Cardiovascular: D/C Nocrdipine, Start Lopressor\n Pulmonary: Extubate today, Spontaneous breathing trial\n Gastrointestinal / Abdomen: assess Swallow\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: Stable Ht\n Endocrine: RISS, Start RISS start at 120 mg/dl\n Infectious Disease:\n Lines / Tubes / Drains: Foley, NGT\n Wounds:\n Imaging: CT scan head today\n Fluids:\n Consults:\n Billing Diagnosis: Other: Left Side weakness\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417730,
"text": "Subarachnoid hemorrhage (SAH)\n Assessment:\n Moves right arm and leg off the bed. No spontaneous movement in left\n arm or left leg. Opens eyes to stimuli. Right pupil equal and reactive.\n Left pupil non reactive due to prior eye trauma. Speech garbled and at\n times difficult to understand. Pt able to state name and year. Becomes\n confused to month and place. Pt able to stick tongue upon command and\n squeeze hand to command.\n Action:\n Neuro check q2hrs. ativan 0.5mg iv as ordered.\n Response:\n Neuron status stable\n Plan:\n Continue to monitor neuron status.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-28 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417733,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 70.5 kg\n Daily weight:\n 67.6 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Hypertension\n Additional history: He had been told he needed to control HTN but no\n follow up with this recomendation.\n ETOH abuse\n Surgery / Procedure and date: S/P Right craniotomy admitted to\n SICU-A 692\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:139\n D:89\n Temperature:\n 100.6\n Arterial BP:\n S:155\n D:89\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 35% %\n 24h total in:\n 164 mL\n 24h total out:\n 30 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 03:27 AM\n Potassium:\n 3.4 mEq/L\n 03:27 AM\n Chloride:\n 103 mEq/L\n 03:27 AM\n CO2:\n 23 mEq/L\n 03:27 AM\n BUN:\n 8 mg/dL\n 03:27 AM\n Creatinine:\n 0.7 mg/dL\n 03:27 AM\n Glucose:\n 94 mg/dL\n 03:27 AM\n Hematocrit:\n 38.0 %\n 03:27 AM\n Finger Stick Glucose:\n 147\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": "Physician ",
"chartdate": "2186-08-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417743,
"text": "SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\n Acid 8. Furosemide\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\n Lorazepam 15. Metoprolol Tartrate\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\n Ondansetron 20. Phenytoin 21. Potassium Chloride\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\n Sodium Chloride 0.9% Flush\n 26. Thiamine\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:48 AM\n Post operative day:\n POD#4 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:19 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 110 (94 - 125) bpm\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\n RR: 19 (18 - 26) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,758 mL\n 686 mL\n PO:\n Tube feeding:\n 1,218 mL\n 647 mL\n IV Fluid:\n 1,059 mL\n 39 mL\n Blood products:\n Total out:\n 3,148 mL\n 275 mL\n Urine:\n 3,148 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -390 mL\n 411 mL\n Respiratory support\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n No movement), (LLE: No movement)\n Labs / Radiology\n 266 K/uL\n 14.4 g/dL\n 142 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 101 mEq/L\n 138 mEq/L\n 39.4 %\n 12.9 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n 03:31 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n 12.9\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n 39.4\n Plt\n 20\n 266\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n 0.9\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n 142\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\n controlled\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\n Pulmonary: cont pulm toilet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: stable\n Lines:\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2186-08-28 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417745,
"text": "SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n Acetaminophen 4. Bisacodyl 5. Docusate Sodium 6. Famotidine 7. FoLIC\n Acid 8. Furosemide\n 9. Heparin 10. HydrALAzine 11. Insulin 12. Lisinopril 13. Lorazepam 14.\n Lorazepam 15. Metoprolol Tartrate\n 16. Metoprolol Tartrate 17. Morphine Sulfate 18. Nicotine Patch 19.\n Ondansetron 20. Phenytoin 21. Potassium Chloride\n 22. Potassium Chloride 23. Senna 24. Sodium Chloride 0.9% Flush 25.\n Sodium Chloride 0.9% Flush\n 26. Thiamine\n 24 Hour Events:\n ARTERIAL LINE - STOP 09:48 AM\n Post operative day:\n POD#4 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:19 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.7\nC (99.8\n HR: 110 (94 - 125) bpm\n BP: 113/58(72) {113/58(72) - 156/99(112)} mmHg\n RR: 19 (18 - 26) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,758 mL\n 686 mL\n PO:\n Tube feeding:\n 1,218 mL\n 647 mL\n IV Fluid:\n 1,059 mL\n 39 mL\n Blood products:\n Total out:\n 3,148 mL\n 275 mL\n Urine:\n 3,148 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -390 mL\n 411 mL\n Respiratory support\n SPO2: 96%\n ABG: ///27/\n Physical Examination\n General Appearance: No acute distress\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n No movement), (LLE: No movement)\n Labs / Radiology\n 266 K/uL\n 14.4 g/dL\n 142 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 18 mg/dL\n 101 mEq/L\n 138 mEq/L\n 39.4 %\n 12.9 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n 03:31 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n 12.9\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n 39.4\n Plt\n 20\n 266\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n 0.9\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n 142\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.8 mg/dL, Mg:2.4 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, Pain\n controlled\n Cardiovascular: Beta-blocker, increased metoprolol to 75 TID\n Pulmonary: cont pulm toilet\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Serial Hct, stable\n Endocrine: RISS\n Infectious Disease: stable\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:04 PM 80 mL/hour\n Glycemic Control: Regular insulin sliding scale, Comments: stable\n Lines:\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417634,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Remains on ativan atc. Tachy at times and occ attempting to pull at\n lines, otherwise no s/s withdrawal noted.\n Action:\n Ativan atc, but dose decreased\n Response:\n No need for prn ativan and no s/s withdrawal noted\n Plan:\n Con\nt to monitor. Ativan atc and prn.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Opens eyes to stim . right pupil round and reactive. Left pupil at\n baseline. Follows commands on right. Moves right spont. No spont\n movement on left. Withdraws on left to pain. Oriented to person and\n president and month at times. Only says few words and speech grarbled.\n Action:\n Neuro checks.\n Response:\n Neuro status unchanged.\n Plan:\n Con\nt neuro checks\n To tx to SDU when bed avail.\n"
},
{
"category": "Physician ",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 416935,
"text": "Chief Complaint: left leg weakness\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Labetalol - 2 mg/min\n Other ICU medications:\n Diazepam (Valium) - 01:13 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n HTN untreated, alcohol abuse, tobacco use, remote left eye penetrating\n injury\n Occupation: unemployed\n Drugs:\n Tobacco: +\n Alcohol: admits to alcohol abuse, last drink @ 1pm, avg 6\n drinks/day\n Other:\n Review of systems:\n Eyes: hx left eye injury, impaired vision\n Neurologic: Numbness / tingling, Headache\n Psychiatric / Sleep: Agitated\n Flowsheet Data as of 03:32 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: 35.6\nC (96.1\n HR: 80 (78 - 117) bpm\n BP: 123/94(100) {90/68(69) - 162/106(120)} mmHg\n RR: 18 (15 - 24) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 120 mL\n 135 mL\n PO:\n TF:\n IVF:\n 120 mL\n 135 mL\n Blood products:\n Total out:\n 800 mL\n 0 mL\n Urine:\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n 135 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, Anxious\n Eyes / Conjunctiva: right pupil reactive, left surgical pupil\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\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, Oriented (to): person,\n place. Motor 0/5 left side, right side. Sensory\n light touch,\n decreased on left.\n Labs / Radiology\n head CT:\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\n with\n mild mass effect but no midline shift, presumed to be Htn induced.\n [image002.jpg]\n Assessment and Plan\n ASSESSMENT/PLAN:\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\n hemorrhage, with left leg weakness, left neglect (unable to sense left\n arm without guidance of RUE), and LUE numbness.\n NEURO: neuro check q1hr; neurosurgery consult appreciated and to\n follow; MRI/MRA pending; STAT head CT for acute mental changes. Tylenol\n for HA per primary service. HOB >30 degrees.\n CV: Maintain SB 140-160, MAP <130.\n Pulm/Endo/Heme/Renal/ID: no issues\n GI/ABD/FEN: NPO until S/S eval\n ICU Care\n Nutrition:\n Comments: NPO except meds until S/S eval\n Glycemic Control:\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417048,
"text": "Subarachnoid hemorrhage (SAH)\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed- revealed increased bleed with NEW midline shift.\n Discussion re: elective intubation for airway protection between\n physicians- decided to wait temporarily. 50mg IV mannitol given at\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\n positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417049,
"text": "44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\n at 15:00.\n Right Basal Ganglia Hemorrhage\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed- revealed increased bleed with NEW midline shift.\n Discussion re: elective intubation for airway protection between\n physicians- decided to wait temporarily. 50mg IV mannitol given at\n 13:00 over 30minuntes to decrease ICP. HOB at 30 degrees. Head\n positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417802,
"text": "Hypertension, benign\n Assessment:\n Pt slightly hypertensive in 140s; tachycardic to 120s\n Action:\n Administered metoprolol\n Response:\n Patient tolerated dose, heart to 90s and BP 120s/80s\n Plan:\n Continue beta blockade, hydral PRN\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n At times patient appeared restless, diaphoretic though afebrile,\n tachycardic\n Action:\n Ativan, attempted to reduce stimuli in room\n Response:\n Patient settled; less diaphoretic, less restless\n Plan:\n Continue to monitor, administer ativan\n"
},
{
"category": "Physician ",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417012,
"text": "TSICU\n HPI:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm),\n untreated HTN presented to OSH with change in gait on left side after\n alcohol use. Pt noted difficulty moving left leg, left facial weakness,\n left sided numbness, and left facial droop. CT @ OSH --> right BG\n hemorrhage 3cm, transferred to for further care. On transfer EMS\n noted pt has \"worsening symptoms\" from the initial transport to OSH\n (same EMS team). @ repeat head CT showed right BG hemorrhage at\n 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n Chief complaint:\n CC: left sided weakness\n ISSUES:\n 1. Intracranial hemorrhage with left sided plegia/paresthesia.\n 2. HTN.\n 3. EtOH abuse\n PMHx:\n Current medications:\n 24 Hour Events:\n - labetalol gtt started in evening for SBP>160, goal per neuro\n MAP<130, SBP 140s-160s. Await MRI/MRA. Increased valium dose for\n tremors.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Diazepam (Valium) - 08:50 AM\n Other medications:\n Flowsheet Data as of 11:06 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: 36.3\nC (97.3\n HR: 85 (78 - 117) bpm\n BP: 137/89(102) {90/68(69) - 162/106(120)} mmHg\n RR: 20 (15 - 24) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 120 mL\n 346 mL\n PO:\n Tube feeding:\n IV Fluid:\n 120 mL\n 346 mL\n Blood products:\n Total out:\n 800 mL\n 270 mL\n Urine:\n 800 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n 76 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ///28/\n Physical Examination\n General Appearance: Somnolent\n HEENT: Left pupil dilated, Right Pupil Equal and reactive\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No(t) Weakness), (LUE: No movement), (RLE: No(t) Weakness), (LLE: No\n movement)\n Labs / Radiology\n 231 K/uL\n 15.2 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 9 mg/dL\n 102 mEq/L\n 141 mEq/L\n 43.2 %\n 9.7 K/uL\n [image002.jpg]\n 03:35 AM\n WBC\n 9.7\n Hct\n 43.2\n Plt\n 231\n Creatinine\n 0.8\n Glucose\n 134\n Other labs: PT / PTT / INR:13.2/30.9/1.1, Ca:9.2 mg/dL, Mg:2.2 mg/dL,\n PO4:3.3 mg/dL\n Imaging: head CT:\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging,\n with\n mild mass effect but no midline shift, presumed to be Htn induced.\n Assessment and Plan\n 44yo male w/ hx uncontrolled HTN now with right basal ganglia\n hemorrhage.\n Assessment and Plan:\n Neurologic: Neuro checks Q: 1 hr, f/u Head CT\n Cardiovascular: Labetalol gtt for SBP < 160 & MAP < 130 (PER PRIMARY\n TEAM REC'S) --> will clarify these goals after f/u head ct. Will need\n a-line.\n Pulmonary: need intubated.\n Gastrointestinal / Abdomen: Will need S&S eval --> will most likely\n need dobhoff and TF\n Nutrition: NPO\n Renal: Foley, Adequate UO\n Hematology: No issues\n Endocrine: RISS\n Infectious Disease: No issues\n Lines / Tubes / Drains: Foley, PIV; For a-line.\n Wounds: none\n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS), CVA\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:45 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Needs ICU consent\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2186-08-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 417129,
"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 Known difficult intubation: No\n Procedure location: OR\n Reason: Intubated for procedure\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Plan to switch to CPAP/PS and extubate this AM.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Plan for extubation today. RSBI completed on PS 5=28.\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Nutrition",
"chartdate": "2186-08-25 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 417253,
"text": "Subjective: Pt just extubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 70.5 kg\n 68.1 kg ( 12:00 AM)\n 22.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 97%\n Diagnosis: ICH\n PMH : poorly controlled HTN, ETOH abuse (12-18 beers/day), +tobacco,\n remote R eye injury c/ screw driver\n Food allergies and intolerances: NKFA\n Pertinent medications: Famotidine, Abx, Colace, Senna, Bisacodyl, HISS,\n NS c/ Thiamine, Folic Acid & Mvit, others noted\n Labs:\n Value\n Date\n Glucose\n 168 mg/dL\n 02:24 AM\n Glucose Finger Stick\n 167\n 10:00 AM\n BUN\n 9 mg/dL\n 02:24 AM\n Creatinine\n 1.0 mg/dL\n 02:24 AM\n Sodium\n 142 mEq/L\n 02:24 AM\n Potassium\n 3.2 mEq/L\n 01:37 PM\n Chloride\n 105 mEq/L\n 02:24 AM\n Albumin\n 4.0 g/dL\n 02:24 AM\n Calcium non-ionized\n 9.4 mg/dL\n 02:24 AM\n Phosphorus\n 3.7 mg/dL\n 02:24 AM\n Ionized Calcium\n 1.09 mmol/L\n 01:37 PM\n Magnesium\n 2.1 mg/dL\n 02:24 AM\n Current diet order / nutrition support: NPO\n GI: Soft, +BS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: chronic ETOH abuse, possible permanent AMS head\n bleed\n Estimated Nutritional Needs\n Calories: 1760-2115 (BEE x or / 25-30 cal/kg)\n Protein: 84-99 (1.2-1.4 g/kg)\n Fluid: team\n Estimation of previous intake: unknown, possibly inadequate\n Estimation of current intake: Inadequate\n Specifics: 44 y.o. M adm with R basal ganglia hemorrhage, POD #1 of\n crani & hematoma evacuation. Pt recently extubated and remains\n agitated and confused. If pt unable to take po\ns in the next 2-3days,\n rec place feeding tube for start of enteral nutrition. Will use admit\n wt for feeding wt. Noted K is low.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If pt\ns MS doesn\nt clear, rec evaluation by SLP.\n 2) If pt unsafe for po\ns, rec place FT and start TF with goal of\n Fibersource @ 65cc/hr (1872kcals, 84g protein).\n 3) Multivitamin / Mineral supplement: Mvit, 100mg Thiamine & 1mg\n Folic Acid given daily\n 4) Check chemistry 10 panel daily, relplete lytes as needed (namely\n K).\n Please page if ?\ns \n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416960,
"text": "44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\n +family history,. Father also alcoholic When admitted to OSH ETOH level\n 145. Pt still with strong smell of alcohol on breath admits to \n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\n through out the night, trying to get OOB, at times completely drenched\n with new tremors noted at 0300. Neuro med resident called. Pt\n required constant bedside safety observations. Pt is also heavy smoker\n 1-1.5 packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\n restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\n and quickly weaned off. Every 1hr neuro checks remain stable without\n much change. Pt does not suffer from neglect has he frequently rubs his\n left arm and tries to straighten his left hand. c/o right sided\n headache frequently rubbing right side of head. As stated\n above pt a developed lower leg tremor when awake lasting 10-20seconds\n then legs relax. Intermittent periods of clear speech and able to pick\n up left leg 3 inches off bed then fell back. MRI check sheet filled\n out and faxed to MRI.\n Action:\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\n dose. Did not receive because had received valium recently. Received\n Tylenol 650mg PR .\n Response:\n Headache is somewhat improved per patient.\n Plan:\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\n infusion for SBP >160 or MAP >130\n Scheduled for MRI today. Remove nicotine patch before scan. One time\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\n IVB right before scan.\n Continue to keep pt and family aware of POC as discussed in multi\n disciplinary rounds.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416961,
"text": "44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt is an unemployed carpenter who long h/o ETOH abuse not in AA with\n +family history,. Father also alcoholic When admitted to OSH ETOH level\n 145. Pt still with strong smell of alcohol on breath admits to \n beers a day. Hourly CIWA scores 20-27 becoming Increasingly restless\n through out the night, trying to get OOB, at times completely drenched\n with new tremors noted at 0300. Neuro med resident called. Pt\n required constant bedside safety observations. Pt is also heavy smoker\n 1-1.5 packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Transient decrease in restlessness for 45 minutes after valium 5mg IVB.\n However by am CIWA scale decreasing to 17 by 0500 and becoming less\n restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n SBP 110-150 at 0400 started Labetalol infusion for SBP 170 at 2mg/min\n and quickly weaned off. Every 1hr neuro checks remain stable without\n much change. Pt does not suffer from neglect has he frequently rubs his\n left arm and tries to straighten his left hand. c/o right sided\n headache frequently rubbing right side of head. As stated\n above pt a developed lower leg tremor when awake lasting 10-20seconds\n then legs relax. Intermittent periods of clear speech and able to pick\n up left leg 3 inches off bed then fell back. MRI check sheet filled\n out and faxed to MRI.\n Action:\n Neuro medical resident aware of tremors. Ordered morphine 1mg IVB x1\n dose. Did not receive because had received valium recently. Received\n Tylenol 650mg PR .\n Response:\n Headache is somewhat improved per patient.\n Plan:\n Continue to follow every one hour checks. HOB >30 degrees. Labetalol\n infusion for SBP >160 or MAP >130\n Scheduled for MRI today. Remove nicotine patch before scan. One time\n order for ativan 2mg IVB before pt transferred to MRI and another 1mg\n IVB right before scan.\n Continue to keep pt and family aware of POC as discussed in multi\n disciplinary rounds.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417294,
"text": "Subarachnoid hemorrhage (SAH)\n Assessment:\n - pt off sedation\n - arousable to voice but rarely opens eyes. Shows effort by\n raising eyebrows but eyes are swollen\n - R pupil 3mm and reactive, L eye dilated and unreactive due\n to traumatic injury with screwdriver in the past.\n - lifts and holds , squeeze hand when asked\n - wiggles toes and moves RLE on bed\n - no movement of LUE, does not respond to nail bed stimuli\n - will withdraw LLE to pain\n - dry sterile dressing on R side of head post craniotomy \n not yet removed\n - will cough with turning and stimulation, and secretions\n suctioned out\n - on nicardipine gtt sbp paramters <140\n - on fentanyl and versed\n - K 3.2\n - Ionized Ca 0.94\n Action:\n - cool tea bags applied over R eye\n - q1h neuro checks\n - turn and reposition to stimulate cough\n - Dilantin to prevent sz\n - Fentanyl, and versed gtts off\n - Morphine 2-4mg prn\n - Nicardipine gtt off spb parameter changed from <140 to <160\n - NS with 40meq KCL at 85ml/hr initiated\n - Keep HOB>30\n - Calcium gluconate 2gm given\n Response:\n - swelling of R eye reduced\n - unchanged neuro status\n - cough stimulated with turning\n - no sz activity noted\n - pt more arousable\n - pain adequately controlled assessed by changes in vital\n signs\n - sbps 135-153\n - awaiting K level\n - Ionized ca 1.09\n -\n Plan:\n - continue using cool tea bags to reduce swelling\n - q1h neuro checks\n - turn and reposition with chest pt frequently\n - continue antiseizure therapy\n - treat pain adequately with prn morphine\n - lopressor 10mg q4h\n - monitor sbps with parameter <160\n - monitor and treat hypokalemia and hypocalcemia\n - keep HOB >30\n -\n Respiratory (intubated in OR)\n Assessment:\n - On CMV adequate ABG levels\n - SPO2 98-100%\n - Minimal secretions\n Action:\n - Changed to CPAP, Spontaneous breathing trial, followed by\n Extubation at 1100\n - 3L nasal cannula\n Response:\n - ABG levels within normal limits\n - SPO2 98-100%\n - Lungs sound rhonchorous\n - Normal and regular respiratory pattern\n Plan:\n - Nasal cannula at 3L\n - Chest pt\n - Turn and reposition frequently\n - Encourage pt to cough and suction out secretions when\n necessary\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n - hx smoking\n - alcoholism; takes 12-18 beers/day\n - level elevated on admission to OSH\n Action:\n - monitored for s/s of DTs\n - banana bag given\n - nicotine patch on R arm\n Response:\n - no sz or tremors, or other signs of DTs noted\n - unable to fully assess for CIWA scale due to neurological\n deficits\n Plan:\n - continue to monitor and assess for s/s of DTs\n - continue with nicotine patch\n - assess swallow/gag and start feeding either PO or NG if\n failure to pass swallow\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417417,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-26 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417418,
"text": "Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Physician ",
"chartdate": "2186-08-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417371,
"text": "SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\n Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\n Morphine Sulfate 16. Nicotine Patch\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EXTUBATION - At 11:10 AM\n INVASIVE VENTILATION - STOP 11:10 AM\n intubated in OR\n Post operative day:\n POD#2 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Famotidine (Pepcid) - 08:01 PM\n Morphine Sulfate - 01:00 AM\n Hydralazine - 02:20 AM\n Insulin - Humalog - 02:30 AM\n Lorazepam (Ativan) - 03:09 AM\n Metoprolol - 04:03 AM\n Other medications:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.5\nC (99.5\n HR: 98 (78 - 104) bpm\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\n RR: 19 (13 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,000 mL\n 555 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,000 mL\n 555 mL\n Blood products:\n Total out:\n 2,115 mL\n 765 mL\n Urine:\n 2,115 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 885 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\n PC : 0 cmH2O\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SPO2: 98%\n ABG: 7.45/35/81./25/0\n Ve: 9.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n Weakness, No movement), (LLE: Weakness, No movement)\n Labs / Radiology\n 198 K/uL\n 13.1 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 101 mEq/L\n 136 mEq/L\n 36.1 %\n 16.2 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n WBC\n 9.7\n 18.7\n 16.2\n Hct\n 43.2\n 37.6\n 36.1\n Plt\n \n Creatinine\n 0.8\n 1.0\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\n pain\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\n ?withdrawl- 1 q6 ativan, will start PO metoprolol 50 tid\n Pulmonary: chest pt\n Gastrointestinal / Abdomen:\n Nutrition: dobhoff and will start tube feeding, thiamine/folate, banana\n bag\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS, start tube feeds\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417287,
"text": "Subarachnoid hemorrhage (SAH)\n Assessment:\n - pt off sedation\n - arousable to voice but rarely opens eyes. Shows effort by\n raising eyebrows but eyes are swollen\n - R pupil 3mm and reactive, L eye dilated and unreactive due\n to traumatic injury with screwdriver in the past.\n - lifts and holds , squeeze hand when asked\n - wiggles toes and moves RLE on bed\n - no movement of LUE, does not respond to nail bed stimuli\n - will withdraw LLE to pain\n - dry sterile dressing on R side of head post craniotomy \n not yet removed\n - will cough with turning and stimulation, and secretions\n suctioned out\n - on nicardipine gtt sbp paramters <140\n - on fentanyl and versed\n - K 3.2\n - Ionized Ca 0.94\n Action:\n - cool tea bags applied over R eye\n - q1h neuro checks\n - turn and reposition to stimulate cough\n - Dilantin to prevent sz\n - Fentanyl, and versed gtts off\n - Morphine 2-4mg prn\n - Nicardipine gtt off spb parameter changed from <140 to <160\n - NS with 40meq KCL at 85ml/hr initiated\n - Keep HOB>30\n - Calcium gluconate 2gm given\n Response:\n - swelling of R eye reduced\n - unchanged neuro status\n - cough stimulated with turning\n - no sz activity noted\n - pt more arousable\n - pain adequately controlled assessed by changes in vital\n signs\n - sbps 135-153\n - awaiting K level\n - Ionized ca 1.09\n -\n Plan:\n - continue using cool tea bags to reduce swelling\n - q1h neuro checks\n - turn and reposition with chest pt frequently\n - continue antiseizure therapy\n - treat pain adequately with prn morphine\n - lopressor 10mg q4h\n - monitor sbps with parameter <160\n - monitor and treat hypokalemia and hypocalcemia\n - keep HOB >30\n -\n Respiratory (intubated in OR)\n Assessment:\n - On CMV adequate ABG levels\n - SPO2 98-100%\n - Minimal secretions\n Action:\n - Changed to CPAP, Spontaneous breathing trial, followed by\n Extubation at 1100\n - 3L nasal cannula\n Response:\n - ABG levels within normal limits\n - SPO2 98-100%\n - Lungs sound rhonchorous\n - Normal and regular respiratory pattern\n Plan:\n - Nasal cannula at 3L\n - Chest pt\n - Turn and reposition frequently\n - Encourage pt to cough and suction out secretions when\n necessary\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n - hx smoking\n - alcoholism; takes 12-18 beers/day\n - level elevated on admission to OSH\n Action:\n - monitored for s/s of DTs\n - banana bag given\n - nicotine patch on R arm\n Response:\n - no sz or tremors, or other signs of DTs noted\n - unable to fully assess for CIWA scale due to neurological\n deficits\n Plan:\n - continue to monitor and assess for s/s of DTs\n - continue with nicotine patch\n - assess swallow/gag and start feeding either PO or NG if\n failure to pass swallow\n"
},
{
"category": "Physician ",
"chartdate": "2186-08-26 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417369,
"text": "SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n L eye injury-screwdriver s/p repair, residual visual impairment, ETOH\n abuse, h/o illicit drug use\n Current medications:\n 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5. Bisacodyl 6.\n Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. Folic Acid/Multivitamin/Thiamine-1000mL NS\n 11. HydrALAzine 12. Insulin 13. Lorazepam 14. Metoprolol Tartrate 15.\n Morphine Sulfate 16. Nicotine Patch\n 17. Ondansetron 18. Phenytoin 19. Potassium Chloride 20. Senna 21.\n Sodium Chloride 0.9% Flush 22. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n EXTUBATION - At 11:10 AM\n INVASIVE VENTILATION - STOP 11:10 AM\n intubated in OR\n Post operative day:\n POD#2 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Famotidine (Pepcid) - 08:01 PM\n Morphine Sulfate - 01:00 AM\n Hydralazine - 02:20 AM\n Insulin - Humalog - 02:30 AM\n Lorazepam (Ativan) - 03:09 AM\n Metoprolol - 04:03 AM\n Other medications:\n Flowsheet Data as of 06:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.8\n T current: 37.5\nC (99.5\n HR: 98 (78 - 104) bpm\n BP: 160/86(113) {120/65(83) - 164/88(116)} mmHg\n RR: 19 (13 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.1 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 3,000 mL\n 555 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,000 mL\n 555 mL\n Blood products:\n Total out:\n 2,115 mL\n 765 mL\n Urine:\n 2,115 mL\n 765 mL\n NG:\n Stool:\n Drains:\n Balance:\n 885 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: None\n Ventilator mode: Standby\n Vt (Spontaneous): 5,007 (679 - 5,007) mL\n PC : 0 cmH2O\n PS : 5 cmH2O\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 35%\n PIP: 0 cmH2O\n SPO2: 98%\n ABG: 7.45/35/81./25/0\n Ve: 9.3 L/min\n PaO2 / FiO2: 205\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Neurologic: Follows simple commands, No(t) Moves all extremities, (LUE:\n Weakness, No movement), (LLE: Weakness, No movement)\n Labs / Radiology\n 198 K/uL\n 13.1 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.4 mEq/L\n 5 mg/dL\n 101 mEq/L\n 136 mEq/L\n 36.1 %\n 16.2 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n WBC\n 9.7\n 18.7\n 16.2\n Hct\n 43.2\n 37.6\n 36.1\n Plt\n \n Creatinine\n 0.8\n 1.0\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.2 mg/dL, Mg:1.7 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n Assessment and Plan:\n Neurologic: Phenytoin - therapeutic, Pain controlled, morphiine for\n pain\n Cardiovascular: Beta-blocker, mild tachycardia and hypertensive\n ?withdrawel 1 q6 ativan, will start PO metoprolol 50 tid\n Pulmonary: chest pt\n Gastrointestinal / Abdomen:\n Nutrition: dobhoff and will start tube feeding, thiamine/folate bannana\n bag\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: NS, d/c nml saline start tube feeds\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2186-08-27 00:00:00.000",
"description": "Intensivist Note",
"row_id": 417534,
"text": "SICU\n HPI:\n 44M with L plegia, CT with 2.6 x 4.9 cm R BG hemorrhage, now s/p R\n craniotomy, evac \n Chief complaint:\n BG hemorrhage\n PMHx:\n PMH:L eye injury-screwdriver s/p repair, residual visual impairment,\n ETOH abuse, h/o illicit drug use\n : none\n .\n Current medications:\n 1. 2. 3. 40 mEq Potassium Chloride / 1000 mL NS 4. Acetaminophen 5.\n Bisacodyl 6. Calcium Gluconate\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium 9.\n Famotidine 10. FoLIC Acid 11. Heparin\n 12. HydrALAzine 13. Insulin 14. Lisinopril 15. Lorazepam 16. Lorazepam\n 17. Metoprolol Tartrate\n 18. Metoprolol Tartrate 19. Morphine Sulfate 20. Nicotine Patch 21.\n Ondansetron 22. Phenytoin 23. Potassium Chloride\n 24. Senna 25. Sodium Chloride 0.9% Flush 26. Sodium Chloride 0.9% Flush\n 27. Thiamine\n 24 Hour Events:\n TF placed and tF started yesterday\n Post operative day:\n POD#3 - S/P right crani\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:00 AM\n Gentamicin - 12:34 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:41 AM\n Lorazepam (Ativan) - 06:00 PM\n Famotidine (Pepcid) - 08:13 PM\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Hydralazine - 02:14 AM\n Metoprolol - 06:18 AM\n Other medications:\n Flowsheet Data as of 06:35 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.1\nC (100.5\n HR: 119 (86 - 119) bpm\n BP: 154/83(106) {148/74(99) - 168/91(118)} mmHg\n RR: 18 (9 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 67.6 kg (admission): 70.5 kg\n Height: 69 Inch\n Total In:\n 2,828 mL\n 776 mL\n PO:\n Tube feeding:\n 190 mL\n 129 mL\n IV Fluid:\n 2,518 mL\n 647 mL\n Blood products:\n Total out:\n 2,735 mL\n 700 mL\n Urine:\n 2,735 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 93 mL\n 76 mL\n Respiratory support\n SPO2: 96%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present)\n Neurologic: Follows simple commands, (Responds to: No(t) Verbal\n stimuli, Unresponsive), No(t) Moves all extremities, (RUE: Weakness),\n (LUE: No movement), (RLE: Weakness), (LLE: No movement)\n Labs / Radiology\n 220 K/uL\n 13.6 g/dL\n 94 mg/dL\n 0.7 mg/dL\n 23 mEq/L\n 3.4 mEq/L\n 8 mg/dL\n 103 mEq/L\n 138 mEq/L\n 38.0 %\n 16.5 K/uL\n [image002.jpg]\n 03:35 AM\n 03:40 PM\n 02:24 AM\n 02:33 AM\n 09:48 AM\n 01:37 PM\n 02:44 AM\n 06:00 AM\n 03:27 AM\n WBC\n 9.7\n 18.7\n 16.2\n 16.5\n Hct\n 43.2\n 37.6\n 36.1\n 38.0\n Plt\n 20\n Creatinine\n 0.8\n 1.0\n 0.7\n 0.7\n TCO2\n 26\n 28\n 22\n 25\n Glucose\n 134\n 146\n 168\n 135\n 118\n 94\n Other labs: PT / PTT / INR:12.0/25.4/1.0, Lactic Acid:2.0 mmol/L,\n Albumin:4.0 g/dL, Ca:9.0 mg/dL, Mg:2.0 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Assessment and Plan: 44M with L plegia, CT with 2.6 x 4.9 cm R BG\n hemorrhage, now s/p R craniotomy, evac \n Neurologic: Neuro checks Q: hr, Check Dilantin, watch out DT. switch\n to PO\n Cardiovascular: Lopressor 75 TID PO\n HYDRALAZYN prn\n Pulmonary: Stable\n Gastrointestinal / Abdomen: Adnance to goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, Lasix 20mg \n Hematology: Stable\n Endocrine:\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids:\n Consults: Nephrology\n Billing Diagnosis: Other: Basal ganglia Bleed\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:25 AM 20 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 03:30 PM\n 14 Gauge - 06:00 PM\n 18 Gauge - 12:15 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416951,
"text": "44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Hourly CIWA scale 17-27\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416945,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416946,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Subarachnoid hemorrhage (SAH) right basal ganglia hemorrhage\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417343,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt continues with ciwa scale. Pt more restless pulling off gown and\n pulling at foley and taking off oxygen. Neuro exam is unchanged hr up\n to 106 and sbp 160\ns/80\n Action:\n Ativan .5mg iv x2 for total of 1mg. pt less restless and sbp down to\n 158/70.\n Response:\n Pt less restless after Ativan.\n Plan:\n Continue with neuro checks and ciwa scale. Assess for Ativan as\n needed.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Neuro exam is unchanged. Pt follows commands on right side. Withdrawal\n on left foot, none on left arm. Right pupil is reactive to light. Rt\n eye is swollen. Pt opens eyes to name. Speech very soft and slightly\n garbled. Goal sbp less than 160. lopressor increased to 20mg q4 and\n hydralazine prn, given x2. Dr. aware of sbp greater than 160.\n does not want to restart nicardipine and increased lopressor.\n Action:\n Lopressor increased to 20mg. hydralazine prn. Continue with q1 neuro\n checks, ? repeat ct today.\n Response:\n Neuro is unchanged. Pt restless at times but responded to ativan\n Plan:\n Continue with neuro exam. Treat bp as needed. Continue with ciwa scale.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417346,
"text": ".H/O respiratory failure, acute (not ARDS/)\n Assessment:\n Pt extubated today. Pt resp rate 16-20. o2 sat on room air 98%. Breath\n sounds are clear and diminished in the bases. Pt coughing and\n swallowing.\n Action:\n Encourage pt to cough and deep breath.\n Response:\n Doing well extubated.\n Plan:\n Continue to cough and deep breathe. Frequent position changes.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417147,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt responds to name and stimulation with jerking movements, attempts\n to sit up, and tremulous motion of right side, less motion on left\n side. Pt does not nod or shake head to communicate, so assessment of\n hallucinations, pain, etc is difficult.\n Action:\n Midazolam and fentanyl drips started and titrated up as needed to\n control tremulous movement\n Response:\n Tremors are quieter, although still existent with medications at higher\n dosage. Midaz returned to 2 mg/hr from 4 mg/hr when he became more\n difficult to arouse. He is now arousable but with fewer tremors than\n before midazolam and fentanyl were started.\n Plan:\n Titrate drips as needed, monitor for increase tremors, seizures,\n increase in heart rate and bp.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Pt post op evacuation of SDH. Head dressing is dry and intact. Pt\n arouses to name, as above, follows commands with right side, but does\n not nod or shake his head when asked to do so. He is intubated on CMV ,\n sx for thick yellow secretios Right pupil is and reacts briskly.\n Left pupil is damaged from a screwdriver injury. Pt is sedated for\n onset of DT\ns, and responding more slowly with midazolam and fentanyl\n on.\n Action:\n Midazolam decreased to 2 mg when pt very slow to respond to name and\n stimulation\n Response:\n Pt responding again when name called.\n Plan:\n Continue with q 1 hour neuro checks to evaluate neuro status\n complicated by alcohol withdrawal.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417053,
"text": "44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n : Pt w/ change in hemodynamics/ neurologic status as below. Head\n CTA w/ worsening bleed. Given 50mg IV mannitol. Taken emergently to OR\n at 15:00.\n Right Basal Ganglia Hemorrhage\n Assessment:\n c/o constant R sided HA upon initial exam, +tremors/sweats-\n please see metavision for neuron and CIWA assessment. Initially, pt\n able to verbally communicate w/ slurred speech and follow\n conversation. At 1030 AM just prior to leaving unit for CTA, pt with\n BP 166/110, dramatic decrease in mental responsiveness- only\n grimacing/withdrawing to sternal rub. ?Decerebrate posturing to\n position changes.\n Action:\n TSICU and Neuro teams notified immediately of above and in to assess\n pt. IV labetelol drip restarted with goal SBP 140-160. Head CT to\n reassess bleed revealed increased bleed, cerebral edema, and NEW 1.3\n cm midline shift to left. Discussion re: elective intubation for\n airway protection between physicians- decided to wait temporarily.\n 50mg IV mannitol given at 13:00 over 30minuntes to decrease ICP. HOB at\n 30 degrees. Head positioned at midline.\n Response:\n BP within goal range on 2mg labetelol. About 200ml UOP after IV\n mannitol.\n Plan:\n Emergently to OR at 15:00 for likely ventriculostomy.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n CIWA >13 when alert. Pt verbalized feelings of agitation, shakiness,\n and R sided headache. Per chart, pt reports drinking 12-18 beers/day.\n Last drink prior to admission. ETOH 143 in ED.\n Action:\n Given 2.5mg valium x 2.\n Response:\n Temporary decrease in symptoms.\n Plan:\n Continue to monitor for signs/ sxs ETOH withdrawal. IV Valium as\n ordered. Addictions consult.\n"
},
{
"category": "Respiratory ",
"chartdate": "2186-08-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 417263,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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 CT\n without incident\n Bedside Procedures:\n Comments:\n Pt received intubated and vented on AC settings as charted. RSBI 28\n today. Placed on PSV 5 peep 5 with TV 500 and RR 12-16. Pt transported\n to CT scan and placed on SBT after transport. Pt extubated without\n incident and is currently on 3L NP and stable from resp standpoint.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-26 00:00:00.000",
"description": "Generic Note",
"row_id": 417428,
"text": "TITLE:\n Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain but otherwise sleeping most of day. Right pupil\n reactive, round. Left pupil unreactive and odd shaped at baseline.\n Moves right side purposefully and attempts to pull at tubes/lines.\n Withdraws on left to pain. No spont movement on left. Said name once,\n otherwise only groans occ. Follows commands on right inconsistently. No\n sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417495,
"text": ".H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt has a known history of drinking > 8-12 beers/day. Brother states ?\n more than 12 beers. Attempting to pull off bed clothes. Pt does not\n focus on you when speaking to him.\n Action:\n Ativan 1 mg iv q6hrs. nictone patch as ordered.\n Response:\n Pt is less agitated after the ativan iv.\n Plan:\n Continue with ativan iv and prn. Monitor closely.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Neuro assessment done q2hrs. strong hand grasp on right side and moves\n right leg off the bed. Withdraws to pain on left foot but no actual\n movement in left arm. Withdraws slightly to painful stimuli. Speech is\n garbled and pt very diffiulct to understand. Right pupil reactive to\n light and left eye no reaction due to old eye injury. Bp at times >\n 160. operative site on head intact with staples present and no drainage\n noted.\n Action:\n Neuro signs q2hrs. ? head ct today. Incision inspected\n Response:\n No neuro changes\n Plan:\n Cont with neuro exam.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 417497,
"text": "Hypertension, benign\n Assessment:\n Bp mostly > 160 shift\n Action:\n Lopresssor 50mg via tube given as ordered. Hydralazine 10mg iv given\n linsopril 5mg via tube given as ordered.\n Response:\n Bp < 160 for short time after meds given but quickly returns to > 160.\n Plan:\n Monitor closely.\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-27 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 417574,
"text": "Hypertension, benign\n Assessment:\n Sbp >160\n Action:\n Lopressor dose changed to po. Lisinopril started. Hydral given\n Response:\n Sbp now <160\n Plan:\n Keep sbp <160. monitor closely. Has prn hydral and lopressor.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt with etoh hx. On Ativan atc. Ciwa scale difficult to perform d/t\n neuro status.\n Action:\n Ativan atc.\n Response:\n No s/s DT at this time. get Ativan prn as well.\n Plan:\n Con\nt Ativan atc and monitor for s/s withdrawal.\n Subarachnoid hemorrhage (SAH)\n Assessment:\n Arouses to pain. Right pupil reactive, round. Left pupil unreactive and\n odd shaped at baseline. Moves right side purposefully and attempts to\n pull at tubes/lines. Withdraws on left to pain. No spont movement on\n left. Said name once, otherwise only groans occ. Follows commands on\n right inconsistently. No sz.\n Action:\n Freq neuro checks.\n Response:\n No neuro changes.\n Plan:\n Con\nt to monitor closely.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes:\n Wallet / Money:\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 416954,
"text": "44yom with h/o poorly controlled HTN, ETOH abuse and smoking in usual\n state of health until 1300 when developed acute onset of left\n sided weakness, unable to hold phone with mild headache. Called 911\n transferred to OSH 1430 serum alcohol level 143, BP 188/115, CTS +right\n basal ganglia hemorrhage. Transferred to BIDEW left side plegia without\n neglect, dysarthric BP 149/92 repeat CTS-increased in right basal\n ganglia bleed compared to OSH, mass effect without midline shift. Neuro\n surgical consult found no midline shift at his time presumed to be HTN\n induced. Pt was transferred to CCU under neuro med/ICU team-TSICU team.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n ETOH level 145 at OSH with strong smell of alcohol on breath, admits to\n 12-18 beers a day. Hourly CIWA scores 20-27 becoming Increasingly\n restless through out the night, trying to get OOB, at times completely\n drenched with new tremors noted at 0300. Pt required bedside safety\n observations. Neuro med resident called. Pt is also heavy smoker 1-1.5\n packs a day for 25years.\n Action:\n Treated with Valium 5-10mg IVB q4hrs and Nicotine patch placed at 0000\n right upper arm.\n Response:\n Initially only decrease in restlessness for 45 minutes after valium 5mg\n IVB. However by am CIWA scale decreasing to 17 by 0500 and becoming\n less restless.\n Plan:\n Continue to monitor CIWA scale q1hr until score < 12 Valium 5-10mg IVB\n q4hrs. Remove nicotine patch before MRI.\n Right basal ganglia hemorrhage\n Assessment:\n Every 1hr neuro checks remain stable without much change. As stated\n above pt developed lower leg tremors mostly when awake lasting\n 10-20seconds then muscle relaxes.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2186-08-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 417069,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 0\n Ideal body weight: 72.6 None\n Ideal tidal volume: 290.4 / 435.6 / 580.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\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 arrived from O.R. and taken to C.T. Plan to extubated when awake.\n"
},
{
"category": "Radiology",
"chartdate": "2186-09-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039777,
"text": ", NMED FA11 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Querying aspiration pneumonitis\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with left hemiparesis, s/p crani after an ICH\n REASON FOR THIS EXAMINATION:\n Querying aspiration pneumonitis\n ______________________________________________________________________________\n PFI REPORT\n No evidence of acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037849,
"text": " 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Dobhoff placemnet eval plse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Dobhoff placemnet eval plse\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRld SAT 5:06 PM\n Dobbhoff tube is in the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess Dobbhoff catheter.\n\n Dobbhoff tip is in the stomach. There is mild cardiomegaly. The lungs are\n clear. There is no pleural effusion.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2186-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1037850,
"text": ", H. NMED SICU-A 12:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Dobhoff placemnet eval plse\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n s/p Dobhoff placemnet eval plse\n ______________________________________________________________________________\n PFI REPORT\n Dobbhoff tube is in the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-09-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1039776,
"text": " 11:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Querying aspiration pneumonitis\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with left hemiparesis, s/p crani after an ICH\n REASON FOR THIS EXAMINATION:\n Querying aspiration pneumonitis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc MON 3:52 PM\n No evidence of acute cardiopulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Suspected aspiration pneumonia.\n\n Portable AP chest radiograph was compared to prior study from .\n\n The heart size is normal. Mediastinal position, contour and width are\n unremarkable. Lungs are clear. No pleural effusion or pneumothorax is\n present. Potential old rib fracture is seen on the left\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-08-24 00:00:00.000",
"description": "ORBITS (WATERS, CALDWELL & LAT)",
"row_id": 1037401,
"text": " 11:18 AM\n ORBITS (WATERS, & LAT) Clip # \n Reason: bilateral orbital xray to rule out metal pre-mri\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44yo left handed man w/ PMHx EtOH abuse (last drink @ 1pm), untreated HTN\n presented to OSH with change in gait on left side after alcohol use. Pt noted\n difficulty moving left leg, left facial weakness, left sided numbness, and left\n facial droop. CT @ OSH --> right BG hemorrhage 3cm, transferred to for\n further care. On transfer EMS noted pt has \"worsening symptoms\" from the\n initial transport to OSH (same EMS team). @ repeat head CT showed right\n BG hemorrhage at 4.7cm. Admit to ICU for BP control and neuro check q1hr.\n REASON FOR THIS EXAMINATION:\n bilateral orbital xray to rule out metal pre-mri\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Orbit series .\n\n HISTORY: 44-year-old man with facial droop and needs MRI. Evaluate for metal\n in orbits.\n\n FINDINGS: Comparison is made to the CT scan from .\n\n There are no radiopaque densities in the left orbital prosthesis. Visualized\n paranasal sinuses are within normal limits.\n\n IMPRESSION: No radiopaque densities within the orbits to exclude the patient\n from having MRI.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-08-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1037478,
"text": " 5:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hemorrhage\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 7:10 PM\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\n pneumocephalus and intraventricular hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST.\n\n COMPARISON: Nine hours prior.\n\n HISTORY: Evaluate for hemorrhage.\n\n FINDINGS: Patient is status post right frontoparietal craniotomy with\n evacuation of putaminal and temporal lobe hematoma. Extensive pneumocephalus\n is identified along the right cerebral convexity. There is a leftward shift of\n normally midline structures by approximately 10 mm, slightly decreased when\n compared to prior exam. Intraventricular hemorrhage in the right frontal \n of the lateral ventricle and bilateral posterior horns of the lateral\n ventricle is not significantly changed. A small amount of residual hemorrhage\n and extensive pneumocephalus within the right basal ganglia is identified.\n Dilated temporal horns, left greater than right, are unchanged. The basilar\n cisterns are patent.\n\n IMPRESSION: Patient status post craniotomy with evacuation of hematoma.\n Extensive pneumocephalus over the right cerebral hemisphere and within the\n right basal ganglia. Interval decrease in right basal ganglia hemorrhage.\n Persistent intraventricular hemorrhage and leftward shift of midline\n structures as described above.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-08-24 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1037479,
"text": ", H. NMED SICU-A 5:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for hemorrhage\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Leftward shift of approximately 10 mm, slightly decreased. Extensive\n pneumocephalus and intraventricular hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-08-24 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1037390,
"text": " 10:52 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Hemorrhage follow-up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with R basal ganglia hemorrhage\n REASON FOR THIS EXAMINATION:\n Hemorrhage follow-up\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:13 PM\n\n Moderate increas ein the right basal ganglia hematoma with new areas and new\n itnraventricular hemorrhage and mass effect and cerbral edema on the right.\n Patent major arteries; no abnormal vascularity around the hematoma- however,\n lesions within the hematoma are not assessed.\n d/w Dr. . by Dr. on at 2pm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 44-year-old male patient with right basal ganglial hemorrhage,\n followup.\n\n COMPARISON: CT of the head done on at 4:19 p.m.\n\n TECHNIQUE: Non-contrast CT of the head, followed by CT angiogram of the head\n with IV contrast was performed. Volume rendered and 2D MIP reformations of\n the major arteries were obtained.\n\n FINDINGS:\n\n NON-CONTRAST CT OF THE HEAD:\n\n There is interval moderate increase in the size of the right basal ganglia\n hematoma, 7.6x3.6cm in the AP and transverse dimensions with significant\n mass effect on the adjacent structures, along with cerebral edema on the right\n side. There is 1.3 cm shift of the midline structures to the left side, which\n is increased, which is new. Some of the new areas that have developed are\n less dense in attenuation representing active bleeding/ due to anemia. There\n is also extension of the hemorrhage into the right lateral ventricle as well\n as the third ventricle. A few small hypodense foci, noted in the left\n internal capsule, may represent perivascular spaces or chronic lacunar\n infarcts are unchanged. No osseous lytic or sclerotic lesions of concern are\n noted.\n\n CT ANGIOGRAM OF THE HEAD:\n\n The major intracranial arteries, of the anterior and posterior circulation are\n patent without flow limiting stenosis, occlusion, or aneurysm. No abnormal\n vascularity is noted surrounding the large right basal ganglial hematoma.\n However, the vascular lesion, located within the area of hematoma itself is\n not excluded on the present study. A small prominent vein int he right vertex\n can relate to a small developmental venous anomaly. ( series 401b/7)\n (Over)\n\n 10:52 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Hemorrhage follow-up\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is evidence of scleral band, with ocular implant on the left side,\n unchanged.\n\n IMPRESSION:\n\n 1. Moderate increase in the size of the right basal ganglial hematoma with\n new areas of hemorrhage, which are less dense than expected, raising the\n possibility of active bleeding, ? bleeding disorders/anemia.\n\n 2. Development of new intraventricular hemorrhage, in the right lateral\n ventricle and third ventricle.\n\n 3. Significant mass effect, with cerebral edema on the right side, with 1.3\n cm shift of the midline structures to the left side.\n\n 4. Patent major intracranial arteries. No obvious abnormal vascularity noted\n around the hematoma. However, the vascular lesion, within the hematoma itself\n cannot be excluded on the present study. To consider followup evaluation for\n vascular lesions after resolution of the hematoma. In addition,\n MRI/conventional angiogram or close followup CT head can be considered.\n\n Findings were discussed with Dr. . for Dr. on at 2 p.m.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-08-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1037566,
"text": " 8:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for interval change. Please this this am\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change. Please this this am\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 44-year-old with intracranial bleed status post surgery, please\n evaluate for change.\n\n COMPARISON: .\n\n FINDINGS: Post-operative change of a right craniotomy status post evacuation\n of an intraparenchymal bleed is again noted. There is decrease in the overall\n amount of pneumocephalus. The degree of mass effect and intracranial\n hemorrhage is not overall changed from prior study. The degree of\n intraventricular hemorrhage is also stable without evidence of hydrocephalus.\n Prominence of the left temporal is stable. The suprasellar cistern\n remains patent. Scleral band over the left orbit is grossly unchanged.\n\n IMPRESSION: Decrease in overall degree of post-operative pneumocephalus. No\n new hemorrhage is identified. Degree of mass effect appears little changed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-08-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1037261,
"text": " 4:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old man with know bleed\n REASON FOR THIS EXAMINATION:\n eval for progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JKPe WED 4:45 PM\n 26 x 49mm, rt basal ganglia hemmorhage increased from outside imaging, with\n mild mass effect but no midline shift, presumed to be Htn induced.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Known intracranial hemorrhage.\n\n NON-CONTRAST HEAD CT\n\n FINDINGS: Comparison is made to outside scan from same date. Again\n identified is slightly heterogeneous hyperdense hemorrhage predominantly\n centered within the right basal ganglia with mass effect on the posterior limb\n of the right-sided internal capsule and adjacent parenchyma including the\n right frontal . The hemorrhage appears to have increased in size from\n outside examination, currently measuring 2.6 x 4.9 cm with prior measurement\n at similar level of approximately 2.3 x 3.6 cm. No other regions of\n intraparenchymal or intraventricular hemorrhage are identified. There is no\n significant midline shift. -white matter differentiation is otherwise\n well preserved. An old lacunar-type infarct is noted within the left internal\n capsule anterior limb. An apparent left globe prosthesis is noted. No soft\n tissue irregularity is present. Mastoid air cells and paranasal sinuses are\n well aerated.\n\n IMPRESSION:\n\n Interval increase in size to right intraparenchymal basal ganglia hemorrhage\n which displays mild mass effect on the adjacent brain parenchyma and right\n frontal with no significant midline shift. This location is most\n suggestive of a hypertensive etiology, although underlying mass\n lesion/metastasis is not completely excluded.\n\n Further evaluation with dedicated contrast-enhanced MRI may be obtained once\n the hemorrhage partially resolved for further characterization.\n\n"
},
{
"category": "ECG",
"chartdate": "2186-08-23 00:00:00.000",
"description": "Report",
"row_id": 223395,
"text": "Sinus rhythm\nProminent precordial lead QRS voltage suggests left ventricular hypertrophy but\nmay be nondiagnostic given age\nModest nonspecific inferior ST-T wave changes\nNo previous tracing available for comparison\n\n"
}
] |
17,440 | 169,094 | 1. Cardiac: The patient is status post ventricular fibrillation arrest, likely secondary to ischemia given the EKG changes, with ST elevations in the inferior leads. The patient was taken for an emergent catheterization. Pressures in the catheterization laboratory revealed right ventricle 42/17, PA 42/19, wedge of 20, cardiac output 8.2, cardiac index 3.7, SVR 1112. The patient's catheterization revealed an right coronary artery with a proximal 70% diffuse, mid-90% diffuse; left main was normal. Left anterior descending showed a 40% D2 lesion. Mid-LAD had a 90% lesion. Distal circumflex had a 30% lesion. The mid-LAD 90% lesion was successfully percutaneous transluminal coronary angioplasty and stented. The patient transferred to the Cardiac Care Unit. In the Cardiac Care Unit the patient was continued on aspirin, Plavix, Integrilin for 18 hours, started on Lipitor. The patient's enzymes were cycled with a maximum CK of 1300, ruling positive troponin. However, CK's trended down to normal by the time of discharge. The patient also had an echocardiogram which showed an ejection fraction of 35 to 40% with multiple regional wall motion abnormalities. The patient was diuresed aggressively throughout his stay. The patient with a ventricular fibrillation arrest, was continued on Lidocaine drip until the following morning, however, at which point Lidocaine was discontinued. The patient remained on Telemetry without any evidence of ventricular tachycardia or ventricular fibrillation after his stent was placed, due to a Staphylococcus aureus blood infection. The patient will be overturned for a defibrillator placement after his antibiotic course is finished. The patient's Captopril and Lopressor were titrated up as tolerated; see final Medicine List. 2. Pulmonary: The patient initially intubated with left lower lobe collapse, question of aspiration. The patient was started on Levaquin and Flagyl for aspiration pneumonia with aggressive deep suctioning and chest Physical Therapy. The patient was able to extubated successfully on hospital day three. The patient maintained excellent saturations for the rest of his stay off the ventilation. While intubated, the patient had a bronchoscopy which showed evidence of left lower lobe secretions consistent with aspiration pneumonia. 3. Infectious Disease: The patient with likely aspiration event. He was started on intravenous Levaquin and Flagyl which was switched over to p.o. when tolerating. The patient to finish a ten day course of p.o. Levaquin and Flagyl. Methicillin resistant Staphylococcus aureus: The patient with four out of four positive blood cultures with Staphylococcus aureus. Final sensitivities showed that Staphylococcus aureus was resistant to Oxacillin but sensitive to Vancomycin. Given Methicillin resistant Staphylococcus aureus the patient was placed on contact precautions and will be discharged to complete a 14 day course of Vancomycin. The patient had a PICC placed prior to discharge. The patient is starting Vancomycin on , to continue until . 4. Endocrine: The patient with history of diabetes mellitus. Was put on an insulin drip initially and switched over to NPH and insulin sliding scale; to restart his oral medications, Avandia 4 mg with an insulin sliding scale for tight control. Avandia can be increased as tolerated. 5. Renal: The patient with initial creatinine of 1.3, which improved with fluid resuscitation and remained in the normal limits with diuresis. 6. Fluids, Electrolytes and Nutrition: The patient was initially NPO and was receiving tube feeds. However, after the patient was extubated, he was able to tolerate clears and advancing diet as tolerated. The patient will be discharged with a mechanical soft diet to be increased to a full diet as tolerated. 7. Orthopedics: The patient initially in a cervical spine collar status post fall. The patient had an x-ray which revealed no evidence of cervical spine fractures. Cervical spine was cleared, the collar was removed and the patient to resume full activities as tolerated. 8. Gastrointestinal: The patient continued on Protonix for GI prophylaxis. 9. Neurologic: The patient with a question of mental status changes given his four minutes of hypoxia. Initial CT scan showed questionable white matter changes consistent with possible early anoxic encephalopathy. However, after sedation was weaned and the patient was extubated, the patient's neurologically mental status was returned to per wife; however, the patient will need aggressive physical therapy to improve his strength and coordination prior to resuming full activities. | There is moderateregional left ventricular systolic dysfunction.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -hypokinetic; anterior apex - hypokinetic; septal apex - hypokinetic; inferiorapex - hypokinetic; apex - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter. Q waves in leads III and aVF suggest inferior myocardialinfarction. T wave flattening in leads III, aVF and V4-V6 suggestpossible inferolateral ischemia. The right cephalic vein is occluded with thrombus. Sinus rhythm- premature ventricular contractionsOld inferior infarctAnterior T wave changes are nonspecificRhythm strip shows normal sinus rhythmSince previous tracing, , ventricular premature complex seen There has been interval removal of the ET tube. AP PORTABLE UPRIGHT CHEST: The left costophrenic angle is excluded. 3) Nasogastric tube side port above the level of the diaphragm. REASON FOR THIS EXAMINATION: r/o infiltrate, worsening CHF FINAL REPORT INDICATIONS: V fib at rest. There is an NG tube with tip in the stomach and sideport just below the level of the diaphragm. RSR' pattern in leads V1-V2.ST segment depressions in the anterior leads suggest possible anteriorischemia. There is opacification of the left retrocardiac space. Evaluation of the mediastinum and lungs is somewhat limited secondary to the overlying trauma board, patient motion and a cardiac pacer seen overlying the left lateral/lower hemithorax. Replaced NG tube. Atelectasis and diffuse parenchymal opacification are seen at the right lower lobe and posterior right middle lobe, findings consistent with aspiration. Sinus tachycardia. The tip of a nasogastric tube is seen just distal to the GE junction, with the side port likely within the distal esophagus. Evaluate for abscess. The ascending aorta is mildly dilated. The mitral valve leaflets are mildlythickened. The left ventricular cavity size is normal.There is moderate regional left ventricular systolic dysfunction. There is persistent opacification of the left lower lobe with a small left pleural effusion. New pulmonary edema. The ST segment depressions in the anterior leads has resolved.TRACING #2 The nasogastric tube overlies the stomach but the side port is above the diaphragm. PATIENT/TEST INFORMATION:Indication: s/p VF arrest, LAD stent, hypotensionHeight: (in) 73Weight (lb): 209BSA (m2): 2.19 m2BP (mm Hg): 127/90HR (bpm): 101Status: InpatientDate/Time: at 11:34Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. Physiologicmitral regurgitation is seen (within normal limits).TRICUSPID VALVE: The tricuspid valve leaflets are normal.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is normal in size. Compared to tracing #1, the Q waves in the inferior leads are nowapparent. Nasogastric tube tip overlies the proximal stomach with the side port at the level of the diaphgram. and LMCA normal.ID: Febrile. remained 95-120/60-70 via r rad aline.tol lopressor later in am.r fem aline pulled. CPKs trending down.GI: Pt with minimal OG aspirates. NTG WEANED & DCED. Tolerating BB and ACEI titration. ADEQ SEDATION. Abd firm and distended with normoactive BS's. CV=HEMODY STABLE. CV=HEMODY STABLE. min aspirates. Am abg 105/36/7.42/24/0. GI=SELF DCED NGT. tol lopressor and captopril w/ ^'ing doses. good uop.id: on flagyl and levo for aspiration. CONTS ON REGLAN. paps 30s/.sm soft hematoma. lido dc'd this am. bp low this am and req 500ccns bolus this am to stabilize. Occ dry NPC.ID afebrile 99.7R WBC 6.9 on triple abx.GI- NGT replaced for meds and tube feedings. Keep pt negative.Start reglan. TOLERATING CAPTO/LOPRESSOR. advance tf as tol. cont w/ r fem venous/pa line. am K+ pnd. U/O adequate prior to low BP's. Fentanyl and Ativan weaned today. cont on levo and flagyl.neuro: ativan weaned down this am, pt became more active, mae with good strength but nonpurposeful. Resp. U/O adequate, > 40cc/hr.GI: Abd soft and distended with normoactive BS's. resp exam. NSR WO ECTO. Continue to advance as tolerated and guiac stools.ENDO: Insuling gtt decreased to 2u/hr. sxn'd for mod amt drk tan sputum. PERL R>L. Pt then transferred to ER where started on Lido gtt and given occasional Versed and Ativan. Tm 101.1 and Tc 99.6. Started on Reglan QID for ? Given AM dose of NPH.ID: Low grade temps. cont with cspine precautions. anoxia. lobe was found to be inflated and lavaged for mod purulent sputum.gi: abd soft, +bs. Recieved NS bolus total of 1.5L and BP recovering. FOLLOW BS-ADJUST/DC GTT AS INDICATED. residuals. FS ranging 187-267.Following FS q1h. ENDO=BL SUGARS TRENDING DOWN. remains +3l since admit. GI=TF @ 10ML/HR W MINIMAL RESIDUALS. cpt as tol. wean o2 as tol. will req eps, poss device prior to d/c. Tmax 102.6 rectal given Tylenol time two. Breathing unlabored overnoc. Abg's within normal limits. BS PRESENT. BREATH SOUNDS=COURSE THROUGHOUT. borderline oxygenation. Since 0300 pt somolent. home for eve now.a: bp stable s/p fluid this am. Resp Careremains intub/vented ac mode. LIMITED STM, NEEDING FREQUENT REMINDING/ RE ORIENTATION. +BS. Given Tylenol ATC. ADEQ UO. pt remains sedated currently on 1mg ativan/hr. BP when recieved from CL hypertensive. 4.77. right groin swan dc'd and tip sent for cx. was previously on oral .gu: foley. HR 88-110 NSR with occ isolated PVC's K+ 40meq KCL po x1 repeat 3.2. "O: MS: Lethargic and oriented to self and place. pulses 2+/ bilat.integrillin cont at 16cc/hr. 10.6/C.I. ABG: 88/35/7.45. Good abgs as per flow. cont w/ low grade temps. PERL. CO/CI/MV 3.0/1.67/57. to adding additional antihypertensive on board.RESP:LS course on left and clear on right. PAD 12-24 overnoc. Integ at 16mls at to dc at 2200.K and Mg repleted.NEURO: Sedated and intubated. ota. delayed gastric emptying. Draining CYU. Attempted to wean Nitro. Fentanyl further weaned to 65ugs. ccu npn 11p-7aS: intubated and sedatedO: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 70-80 NSR, no vea noted. | 39 | [
{
"category": "Echo",
"chartdate": "2144-04-09 00:00:00.000",
"description": "Report",
"row_id": 70951,
"text": "PATIENT/TEST INFORMATION:\nIndication: s/p VF arrest, LAD stent, hypotension\nHeight: (in) 73\nWeight (lb): 209\nBSA (m2): 2.19 m2\nBP (mm Hg): 127/90\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 11:34\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. 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. There is moderate\nregional left ventricular systolic dysfunction.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal anteroseptal - hypokinetic; mid anteroseptal -\nhypokinetic; anterior apex - hypokinetic; septal apex - hypokinetic; inferior\napex - hypokinetic; apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\nmitral regurgitation is seen (within normal limits).\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. The left ventricular cavity size is normal.\nThere is moderate regional left ventricular systolic dysfunction. Resting\nregional wall motion abnormalities include severe hypokinesis of the mid and\ndistal septum and apical segments. Right ventricular chamber size and free\nwall motion are normal. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are mildly thickened. The mitral valve leaflets are mildly\nthickened. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-08 00:00:00.000",
"description": "Report",
"row_id": 160019,
"text": "Normal sinus rhythm. Q waves in leads III and aVF suggest inferior myocardial\ninfarction. Compared to tracing #1, the Q waves in the inferior leads are now\napparent. The ST segment depressions in the anterior leads has resolved.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-08 00:00:00.000",
"description": "Report",
"row_id": 160020,
"text": "Sinus tachycardia. Low limb lead voltage. RSR' pattern in leads V1-V2.\nST segment depressions in the anterior leads suggest possible anterior\nischemia. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-15 00:00:00.000",
"description": "Report",
"row_id": 160013,
"text": "Sinus rhythm\nProbable old inferior infarct\nAnteroseptal T wave changes may be due to myocardial ischemia\nLow QRS voltages in precordial leads\nSince previous tracing, , no ventricular premature complex\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-14 00:00:00.000",
"description": "Report",
"row_id": 160014,
"text": "Sinus rhythm\n- premature ventricular contractions\nOld inferior infarct\nAnterior T wave changes are nonspecific\nRhythm strip shows normal sinus rhythm\nSince previous tracing, , ventricular premature complex seen\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-13 00:00:00.000",
"description": "Report",
"row_id": 160015,
"text": "Sinus rhythm\nPossible old inferior infarct\nSince previous tracing, , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-12 00:00:00.000",
"description": "Report",
"row_id": 160016,
"text": "Sinus rhythm, rate 77. Since the previous tracing of the heart rate has\nslowed somewhat. Technical artifacts are seen. Increased ST-T wave\nabnormalities are noted, particularly over the anterolateral leads.\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-09 00:00:00.000",
"description": "Report",
"row_id": 160017,
"text": "Normal sinus rhythm. T wave flattening in leads III, aVF and V4-V6 suggest\npossible inferolateral ischemia. Compared to tracing #3, the inferolateral\nT wave flattening is new.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2144-04-08 00:00:00.000",
"description": "Report",
"row_id": 160018,
"text": "Normal sinus rhythm. Compared to tracing #2, the Q waves in the inferior leads\nare no longer present.\nTRACING #2\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-09 00:00:00.000",
"description": "C-SPINE (PORTABLE)",
"row_id": 756196,
"text": " 2:38 PM\n C-SPINE (PORTABLE) Clip # \n Reason: please r/o fracture; please focus on c7/t1 as previuos films\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p vfib arrest and fall with head and face trauma\n REASON FOR THIS EXAMINATION:\n please r/o fracture; please focus on c7/t1 as previuos films missed this\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57 y/o man status post V-fib arrest and fall with head trauma.\n\n Single lateral swimmer's view of the cervical spine is read in conjunction\n with AP and lateral cervical spine from earlier the same day. The cervical\n spine is normal in alignment through C7 without evidence of fracture. C7-T1 is\n not adequately visualized.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 756136,
"text": " 11:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. ch\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest, now intubated and stable\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. check for ETT\n placement and PAC placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P pulmonary artery catheter placement and ventricular\n fibrillation arrest.\n\n COMPARISONS: .\n\n CHEST, SINGLE: The heart size is within the upper limits of normal. The\n mediastinal and hilar contours are stable in appearance. There is increased\n bilateral perihilar haziness and alveolar opacities. The left costophrenic\n angle has been excluded from this study. There is opacification of the left\n retrocardiac space. An endotracheal tube it is approximately 5 cm above the\n carina. The nasogastric tube tip distended below the field of view. The\n apparent Swan-Ganz catheter tip lies in the right ventricular outflow tract.\n The osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. New pulmonary edema.\n\n 2. Swan-Ganz catheter in right ventricular outflow tract.\n\n 3. Left lower lobe consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-08 00:00:00.000",
"description": "C-SPINE (PORTABLE)",
"row_id": 756137,
"text": " 11:44 PM\n C-SPINE (PORTABLE) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. Fo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Found down, in\n cervical collar, need to clear c-spine.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unconscious, evaluate cervical spine.\n\n AP AND LATERAL CERVICAL SPINE: Vertebral bodies C1 through C6 are visualized.\n There is normal alignment and vertebral body and disc heights. The\n prevertebral soft tissues cannot be evaluated due to intubation and NG tube\n placement. No fractures or dislocations identified. The frontal view is\n unremarkable.\n\n IMPRESSION: C1 through C6 in normal alignment without evidence of fracture.\n C7 is not visualized on the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 756164,
"text": " 8:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 57 y/o man intubated with PAC in place s/p v-fib arrest. As\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n 57 y/o man intubated with PAC in place s/p v-fib arrest. Assess for PAC\n placement, ETT placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: S/P V-fib arrest with pulmonary artery catheter and\n endotracheal tube placement.\n\n COMPARISONS: at \n\n CHEST, SINGLE: The cardiac, mediastinal and hilar contours are stable in\n appearance. There has been slight interval improvement in the perhilar and\n predominantly central pulmonary alveolar opacities. There is persistent\n opacification of the left lower lobe with a small left pleural effusion. The\n endotracheal tube tip is approximately 5 cm above the carina. The Swan-Ganz\n catheter tip is in the right ventricular outflow tract. Nasogastric tube tip\n overlies the proximal stomach with the side port at the level of the\n diaphgram. The soft tissue and osseous structures are unremarkable.\n\n IMPRESSION: Slight improvement in the pulmonary edema.\n\n Nasogastric tube side port at the level of the diaphragm, recommend advancing\n this by several cm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-08 00:00:00.000",
"description": "CHEST CTA WITH CONTRAST",
"row_id": 756122,
"text": " 7:52 PM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o pe\n Field of view: 47 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cardiac arrest, ? pe\n REASON FOR THIS EXAMINATION:\n r/o pe\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac arrest, ? of PE\n\n TECHNIQUE: Multiple axial images were obtained from the thoracic inlet from\n the lung basis after the administration of intravenous contrast.\n\n CONTRAST: 100cc of Optiray were administered due to the fast bolus\n requirements: There were no complications.\n\n CT CHEST WITH INTRAVENOUS CONTRAST: The heart and great vessels are grossly\n normal in appearance. No intraluminal filling defects are seen within the\n pulmonary circulation. An NG tube is seen passing into the esophagus. There\n is complete collapse of the left lower lobe. Atelectasis and diffuse\n parenchymal opacification are seen at the right lower lobe and posterior right\n middle lobe, findings consistent with aspiration. There is a high attenuation\n nodular density in the peripheral right middle lobe, which may represent a\n granuloma versus a small enhancing nodule. There are no pleural effusions. No\n pneumothoraces are identified. An ET tube is seen terminating in the trachea\n just below the thoracic inlet. A few scattered mediastinal lymph nodes do not\n meet CT criteria for pathologic enlargement.\n\n Multiplanar reformatted images confirm the above findings.\n\n The soft tissues and osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. No evidence of pulmonary embolism.\n 2. Total collapse of left lower lobe.\n 3. Multifocal areas of atelectasis and probable aspiration.\n 4. Nodule or granuloma of right middle lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 756351,
"text": " 4:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate NG placement before starting TF/PO meds\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 yo male a/w VF arrest, now extubated, replaced NGT. Need to start TF.\n REASON FOR THIS EXAMINATION:\n evaluate NG placement before starting TF/PO meds\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: V-fib arrest. Now extubated. Replaced NG tube. Assess NG tube\n placement before starting tube feeds.\n\n PORTABLE AP CHEST: Comparison . The patient is rotated. There has been\n interval removal of the ET tube. There is an NG tube with tip in the stomach\n and sideport just below the level of the diaphragm. The heart is enlarged.\n There are bilateral patchy alveolar opacities throughout the lungs, without\n significant change. This likely reflects edema, although multifocal infection\n could also have this appearance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 756245,
"text": " 10:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate ETT placement and lung parenchyma for state of CHF.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest.\n REASON FOR THIS EXAMINATION:\n Evaluate ETT placement and lung parenchyma for state of CHF.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate endotracheal tube placement and CHF.\n\n COMPARISON: .\n\n CHEST, PA AND LATERAL: Allowing for technique and patient rotation, the\n bilateral diffuse pulmonary alveolar opacities are unchanged. The\n cardiomediastinal and hilar contours are unremarkable. The endotracheal tube\n tip is approximately 8 cm above the carina. The nasogastric tube overlies the\n stomach but the side port is above the diaphragm. The soft-tissue and osseous\n structures are unremarkable.\n\n IMPRESSION:\n\n 1) High-lying endotracheal tube, terminating 8 cm above carina.\n\n 2) No significant change in CHF.\n\n 3) Nasogastric tube side port above the level of the diaphragm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 756469,
"text": " 2:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, worsening CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 yo male a/w VF arrest, ? aspiration, now extubated, spiking fevers on\n levo/flagyl. r/o worsening infiltrates.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, worsening CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: V fib at rest. Extubated and spiking fevers.\n\n COMPARISONS: .\n\n AP PORTABLE UPRIGHT CHEST: The left costophrenic angle is excluded. Lung\n volumes appear slightly improved and the left lung has nearly completely\n cleared in the interval. There is persistent, though lessened, patchy opacity\n in the right perihilar region compatible with resolving pneumonia. The NG\n tube may have been retracted in the interval and the side port is not well\n visualized and may sit above the GE junction. Cardiac and mediastinal\n contours are unchanged.\n\n IMPRESSION: Improving multifocal pneumonia. NG tube probable malpositioned.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-17 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 756781,
"text": " 1:34 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: pt had a left sided picc placed and needs tip confimation, p\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with s/p cardiac arrest, bacterimia who needs picc for iv\n vanco.\n REASON FOR THIS EXAMINATION:\n pt had a left sided picc placed and needs tip confimation, please page \n with wet, read,asap because they would like to d/c pt. to rehab., thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac arrest, PICC line placement.\n\n TECHNIQUE: Single view chest: This film is dated and it now\n comes to the radiology list for dictation. There has been a PICC line placed\n and is seen at the lower SVC. There is basilar atelectasis on the left.\n\n No pneumothorax is present.\n\n PICC line seen at the lower SVC. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-18 00:00:00.000",
"description": "R US EXTREMITY NONVASCULAR RIGHT",
"row_id": 756858,
"text": " 2:42 PM\n US EXTREMITY NONVASCULAR RIGHT Clip # \n Reason: SWOLLEN RED RT ANTECUB FOSSA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p VF arrest, with MRSA bacteremia likely 2' to infection in\n right anticubital fossa, ruled out abscess.\n REASON FOR THIS EXAMINATION:\n r/o abscesss in right antecubital fossa\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: MRSA bacteremia with infection in right antecubital fossa.\n Evaluate for abscess.\n\n Targeted scale, Doppler and color images were obtained within the\n antecubital fossa. There is no evidence of a discrete fluid collection. The\n right cephalic vein is occluded with thrombus. There is no evidence of\n Doppler flow.\n\n IMPRESSION:\n 1. No discrete fluid collection to suggest abscess formation. There are soft\n tissue changes consistent with cellulitis.\n 2. Thrombus within the superficial cephalic vein.\n\n These findings were directly communicated to the physician caring for the\n patient.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 756114,
"text": " 6:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with s/p out of hospital arrest, now intubated and stable\n REASON FOR THIS EXAMINATION:\n eval for tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post cardiac arrest, now intubated and stable. Evaluate tube\n placement.\n\n FINDINGS: The tip of the endotracheal tube is seen at the level of the\n thoracic inlet, approximately 7 cm above the carina. The tip of a nasogastric\n tube is seen just distal to the GE junction, with the side port likely within\n the distal esophagus. Evaluation of the mediastinum and lungs is somewhat\n limited secondary to the overlying trauma board, patient motion and a cardiac\n pacer seen overlying the left lateral/lower hemithorax. The cardiac and\n mediastinal contours appear within normal limits. There are no focal\n consolidations or pleural effusions. The visualized soft-tissue and osseous\n structures are unremarkable.\n\n IMPRESSION: Endotracheal tube can be further advanced, with the tip now\n approximately 7 cm above the carina. Nasogastric tube can also be advanced,\n as the side port is now within the distal esophagus.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2144-04-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 756117,
"text": " 7:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: s/p trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man s/p fall, with head trauma and bleeding\n REASON FOR THIS EXAMINATION:\n s/p trauma\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Head trauma.\n\n TECHNIQUE: Multiple axial images were obtained from the foramen magnum to the\n cranial vertex without intravenous contrast.\n\n FINDINGS: There is some streak artifact from the underlying stiffener board.\n No intraaxial or extraaxial fluid collections or hemorrhages are identified.\n There is no shift of the normally midline structures, or mass effect. The CSF\n spaces are normal. No definite sulcal effacement is seen.\n\n Some mucoperiosteal thickening is seen within the visualized portions of the\n ethmoid sinuses. The orbits, soft tissues and osseous structures of the head\n are unremarkable.\n\n IMPRESSION:\n\n 1. No evidence of acute intracranial hemorrhage.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-14 00:00:00.000",
"description": "Report",
"row_id": 1490840,
"text": "CCU NSG PROGRESS NOTE.\nO:NEURO=A&O X2. COOPERATIVE. APPROPRIATE. VERY WEAK-ALL EXTREMETIES.\n PULM=BREATH SOUNDS=DEMINISHED/CLEAR THROUGHOUT. SATS MID 90'S.\n CV=HEMODY STABLE. NTG WEANED & DCED. TOLERATING CAPTO/LOPRESSOR.\n GI=SELF DCED NGT. TOLERATING CL LIQ-ABLE TO TAKE PO MEDS.\n GU=FOLEY. ADEQ UO.\n ID=LOW GRADE T. R-ANTECUB NOTE TO REDDENED/WARM/HARD TO TOUCH-WO CO DISCOMFORT.\n LABS=AM SENT.\n\nA:IMPROVING.\n\nP:CALL-OUT. CONTIN PRESENT MED MANAGEMENT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-14 00:00:00.000",
"description": "Report",
"row_id": 1490841,
"text": "ccu nursing progress note\ns: i had a heart attack\no: pls see carevue flowsheet for complete vs/data/events.\npls see transfer note from for complete details.\nneuro: improving. not agitated or confused. ox , cooperative. has poor stm. haldol dc'd.\nremains weak in arms and legs req 2 person pivot/transfer. req assistance w/ feeding. also needs monitoring for aspiration but appears to be doing well with pills, jello, liquids when sitiing up.\ncv: hr 80-90s sr, bp 120-160/70. tol lopressor and captopril w/ ^'ing doses. not on antiarrhythmics. will req eps, poss device prior to d/c. no vea since admit.\nresp: ra sat 93-95%, rr 24-30. bs coarse/dim at bases.\ngi: tol diet, to advance. aspiration precautions. no stool.\nendo: covered per ss and nph. was previously on oral .\ngu: foley. good uop.\nid: on flagyl and levo for aspiration. cont w/ low grade temps. also has mild cellulitus at r antecub.\nsocial: married, 3 children. lives on . works for health care/home care co.\na: s/p arrest c/b anoxic brain injury and aspiration pneumonia. s/p stent to lad.\np: cont to follow rhythm, response to cardiac meds. resp exam. advance diet. follow bs. follow ms. pt and ot. may need rehab stay. support to pt and family. transfer to 2 when bed avail.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-09 00:00:00.000",
"description": "Report",
"row_id": 1490824,
"text": "Respiratory Care: Pt recieved from cath lab put on AC 750*16 100% 10 PEEP. Pt had likely aspirated pao2 was poor ( 83 on 100% and 10 peep). Pao2 improved( see careview) Fio2 weaned to 60%. EET advanced from 22 to 25 MD verbal order. Bs equal bilat. Will continue to follow and wean Fio2 as tollerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-09 00:00:00.000",
"description": "Report",
"row_id": 1490825,
"text": "CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\nHPI/CC: 57 year old male with limited medical history available found down , flat on face. According to friends he was feeling well during the day, no c/o nausea, CP, and SOB. Was then walking and suddenly collapsed, no convulsions noted. When EMT's arrived, police officer doing CPR and pt unconscious, pulseless, and agonal respirations and blood from mouth and nares. Pt shocked with 200J in AIVR without pulses. Intubated in field. Atropine given and pt in CHB with a ventricular rate of at 150. EKG in field showing changes in lateral leads. Pt then transferred to ER where started on Lido gtt and given occasional Versed and Ativan. Moving all extremeties and coughing while intubated. Prior to passing OGT pt vomitted large amount dark brown material and chunks of food. During assessment by house staff O2Sats marginal at 88-90% on 100% Fio2. Pt was suctioned numerous time for copious amounts of food particles from ETT. Pt then taken for Head CT which was (-) for intracranial hemmorhage but showing some white and matter.? anoxia. Chest CT also done in addition which was (-) for PE and showing LLL consolidation. Post pt taken for Cath.\n\nCATH LAB: Cath procedure performed without difficulty with the following findings. LHC: RA 26, PA, 42/19, PA 20, CO 8.19 and CI 3.65\nLAD mod calcified, 90% mid occlusion involving moderate DZ. LAD stented times two. TIMI flow of 3 prior to intervention and post. RCA with diffuse dz 70%. and LMCA normal.\n\nID: Febrile. Tmax 102.6 rectal given Tylenol time two. Last given at 0600. Called for cooling blanket. Levo and Flagyl started this AM\nWBC from MN labs down from admission to 3(11).\n\nCV: HR 100's to 110's with rare PVC's. Given total of 10mg of Lopressor in Cath Lab. Repeat doses given aroung MN of 5mg x two and 25mg PO. HR maintaining 88 to low 90's. In addition Lidocaine continuing at 2mg/hr. BP when recieved from CL hypertensive. Given Versed and Verc in transit to floor shortly after pt awakening. Given 2 of Ativan and 50 of Fentanyl and BP bottoming. Recieved NS bolus total of 1.5L and BP recovering. Since has been labile and recieving additional numerous boluses. SBP 80-90's with map > 65. A-V sheath in place with femoral swan at venous site. PAD 12-24 overnoc. Swan unable to wedge. Recv'd 20mg of Lasix post boluses and numbers repeated 1-2hours post. CO/CI/MV 3.0/1.67/57. ? validity of swan because could not visualize in . Femoral site with small ooze and no noted hematoma. Pulses palpable distal. Integ at 16mls at to dc at 2200.\nK and Mg repleted.\n\nNEURO: Sedated and intubated. Ativan at 2mg/hr. Currently unresponsive. Earlier durin night began to awake and moving right extremety only. PERL. 3mm bilaterally. Corneal reflex (+) in left eye only. Right pupil less sluggish than left. Not moving any extremeties.\nFentanyl gtt off due to labile BP's\n\nRESP: Current vent setting at AC 750 x 16 .50 and 7.5 PEEP. When recieved from CL suctioning for copious amounts\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-10 00:00:00.000",
"description": "Report",
"row_id": 1490829,
"text": "CCU NSG PROGRESS NOTE.\nO:NEURO=SEDATED W FENTANYL @ 50MCG & ATIVAN @ 1MG CONTIN W GD EFFECT. AROUSABLE, BUT DOES NOT FOLLOW COMMANDS. WHEN STIM MOVEMENT OF UPPER BODY-SHOULDERS, NECK, & HEAD-ONLY!.\n PULM=INTUBATED & VENTED W SETTINGS-AC/50%/750X16/+7.5 W AM ABG-7.50/31/71/25/1 W SATS 97-98. RR DECREASED FROM 16 TO 12. BREATH SOUNDS=COURSE THROUGHOUT. SX-SCANT THICK TAN/BROWN SECRETIONS.\n CV=HEMODY STABLE. NSR WO ECTO. MAPS 70-80'S. PADS 16-18. CKS SENT @ 0000 & 0500.\n GI=TF @ 10ML/HR W MINIMAL RESIDUALS. WO STOOL.\n ID=FOLEY. LASIX 80MG @ 0000 W EXCELLENT RESPONSE.\n ENDO=BL SUGARS TRENDING DOWN. INSULIN GTT DECREASED TO 1U/HR W BL SUGAR 102.\n MISC=COLLAR/NECK CARE DONE.\n LABS=AM SENT.\n\nA:COMFORTABLE THROUGHOUT NIGHT.\n\nP:CONTIN PRESENT MED RX. ADEQ SEDATION. INCREASE TF AS TOLERATED. FOLLOW BS-ADJUST/DC GTT AS INDICATED. CK AM LABS-REPLACE AS NEEDED.\nSUPPORT PT/FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-10 00:00:00.000",
"description": "Report",
"row_id": 1490830,
"text": "Resp Care\nremains intub/vented ac mode. resp alkalosis thus vent changed to rate 12 ...settings 750x12x.5/7.5 peep. borderline oxygenation. small amts secretions..orangey/brown. stable plateaus. ?increase peep. c/w vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-10 00:00:00.000",
"description": "Report",
"row_id": 1490831,
"text": "CCU NURSING PROGRESS NOTE 7A-3P\n\nNEURO: Pt sedated on fentanyl and ativan gtts. PERL 3mm. Pt intermittently able to open eyes and wiggle toes to command; no purposeful movements noted of upper extremities. Ativan gtt dc'd at 1pm. Will cont to assess neuro status for changes. C-spine collar in place.\n\nRESP: Intubated on AC 750x12 with peep weaned to 5 and Fio2 weaned to 40%. ABG: 88/35/7.45. Suctioned for minimal amt thin tan secretions.\nPlan is to begin weaning sedation today and based on neuro status, aiming for vent weaning/extubation tomorrow.\n\nCARDIAC: Hemodynamically stable. No VEA. C.O. 10.6/C.I. 4.77. right groin swan dc'd and tip sent for cx. Pt started on 12.5mg captopril TID. CPKs trending down.\n\nGI: Pt with minimal OG aspirates. Tube feeds advanced to 30cc/hr with goal rate of 80cc/hr. +BS. No stool this shift.\n\nGU: foley draining cloudy yellow urine with sediment. Pt is -1200cc at this time. No plans for further diuresis at this time.\n\nENDO: FS range 138-180. Conts on insulin gtt 1-3u/hr.\n\nID: afebrile all shift on RTC tylenol. Conts on IV abx for presumed aspiration pnx.\n\nACCESS; Right a-line and 3 peripheral IVs intact and working well.\n\nFAMILY: Pt's 2 daughters and wife in and out most of afternoon. Appear to be asking appropriate questions. Pt's oldest daughter, has agreed to be spokesperson for all phone calls. Cardiology fellow has spoken to family and informed them of pt's progress and present status.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-11 00:00:00.000",
"description": "Report",
"row_id": 1490832,
"text": "CCU Nursing Note 1500-2300: Vfib Arrest, Aspirat PNA\nID: Low grade temps. Recieving Tylenol ATC with fair effect and continues on IV Abx for aspiration PNA.\n\nMS: Sedated and intubated. Fentanyl and Ativan weaned today. Recieved at 1500 with Ativan off and Fentanyl at 75ugs. Fentanyl further weaned to 65ugs. Pt now flailing in bed. MAE's. Not obeying or following commands. Moving neck from side to side. Started on Propofol at 10ugs and increased to 20ugs with excellent effect.\n\nCV: VSS. transiently dropping BP to high 90's with sedation titration.\nHR 80's. NSR with no ectopy. SBP 99-mid 100's. Hypertensive when aroused. Right femoral site with small hematoma and slight ooze but has decreased further into night. Pulses palpable distal. Skin clamy and warm to touch.\n\nRESP: LS course with occasional rhoncerous sounds throughout. O2Sats high 90's. Vent settings at AC 750/12/50/5 PEEP. No ABGs' done this shift due to the prior being WNL. Suctioning for moderate to large amounts of thick dark tan sputum, ? food particles. During period of flaling pt found not to be recieving TV's. Resp notified and pt biting on tube. Sedation administerd.\n\nGU: Foley patent, intact and draining golden colored urine. Received pt with sediment on walls of the foley tubing but not draining urine with sediment. U/O adequate, > 40cc/hr.\n\nGI: Abd soft and distended with normoactive BS's. TF increased to 40cc/hr but shut off when pt found not to be recieving volumes and since have not been shut back on. When increased found to have residual of 10cc. OGT intact and in place. Passing flatus but no BM's this shift.\n\nENDO: Insulin gtt continues at 3u/hr. FS ordered Q1H but have been checking 1-3hrs. FS range from 120-140's. No adjustments made this shift.\n\nSKIN: Facial and knee lacerations open to air. Cleansed this shift with NS and applied bactroban to wounds. Upper back area where C-collar rested are red and open abrasions. No drainage. Cleansed with NS and left open to air.\n\nDISPO: 57 year-old man who is S/P VF arrest with a guestimated time out of 4 minutes prior to EMS intervention who had emergent PTCA and stented x two the LAD. Pt course then c/b aspiration pna where he remains vented and sedated.\n\nPLAN:\nTitrate sedation to keep pt comfortable\nPossible re-trial of weaning sedation in AM to assess MS further\nContinue BB and ACE as tolerated\nMonitor skin\nDiscuss possible anticoagulation\nContinue to monitor hemodynamics\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-11 00:00:00.000",
"description": "Report",
"row_id": 1490833,
"text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 750, A/C 12, Fio2 40%, and Peep 5. PAP/Plateau 22/19. Bs slightly coarse L Lung, R Lung clear. Sx'd/lavaged for sm amounts of thick tan sputum. Abg's within normal limits. Pt. remains sedated. ETT retaped at 26cm. No further changes made. Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-12 00:00:00.000",
"description": "Report",
"row_id": 1490836,
"text": "CCU Nursing Note 1900-0700: S/P VFib Arrest/ Aspir P\nSee carevue for VSS and all objective data:\nS: Pt moaning and groaning.\n\nID: Afebrile. Given Tylenol ATC. Continues on IV Flagyl and Levo.\n\nMS: Still not obeying and following commands. Moving head from side to side and moving all extremeties in bed. Opened eyes once during shift but not to command. Neck and limbs remain flacid while on Propofol. Propofol attempted to wean but pt very restless. Given Haldol 5mg at HS and QID ATC. Since 0300 pt somolent. Needed emotional support and positive re-inforcement.\n\nCV: NSR-ST. Hypertensive and tachycardic when restless. Given Captopril and Lopressor with good effect. Nitro off due to low BP. QT interval checked at 0.16. Since 0300 has been NSR, HR 70's and BP 120-130's. Continue to BB and ACE-I as needed.\n\n\nRESP: LS course. FM weaned to .50 Fio2. CPT. Deep oral suctioned for blood-tan colored sputum. O2Sats 97-99%. Breathing unlabored. Continue CPT and sx as needed.\n\nGU/GI: Urine outputs adequate, >/= 60cc/hr. TF restarted at 0400 at 30cc/hr. Prior to residual 5cc. No residual checked since started.\nLarge BM tonoc. Soft-paste like consistency, brown in color. Guiac not checked. Continue to advance as tolerated and guiac stools.\n\nENDO: Insuling gtt decreased to 2u/hr. FS ranging from 77-98. Continue to monitor FS.\n\nSKIN: Cut and bruises open to air. Healing well. Continue to monitor.\n\nSOCIAL: Family into visit earlier during shift. No phone call overnoc.\n\nDISPO: 57 year-old male who s/p vfib arrest who arrest was c/b aspiration pna. Intubated and now extubated with new concern post extubation of anoxia.\n\nContinue to monitor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-12 00:00:00.000",
"description": "Report",
"row_id": 1490837,
"text": "CCU Nursing Progress Note\nS-\"I have a little headache\"\nO-Neuro becoming more awake during the day. Following commands , . Talking to family and staff. Mumbling most of the time, speech is not clear but understandable. Propofol weaned and d/c'd and haldol increased to 5mg QID. Family with pt mst of time but occ restlessness treated with IV haldol prn.\nCV-VSS IV NTG restarted with SBP 170's but weaned to 40mcg when captopril increased to 50mg TID BP 124-138/58-70 HR 79-90 NSR\nResp-O2 weaned to 5l NP with O2 sats 96% ABG 7.45/38/55 but O2 sats improved to 99-100% later in the am. LS coarse Occ NPC.\nID temp 101 IV abx changed over to po flagyl and levo.\nGU-urine output improved 100cc/hr and received lasix 40mg IVB with transfusion.\nGI-NGT in place tube feeds on hold d/t high residuals which remained most of the day. Possibly start reglan for gastricparesis. Incontinent of moderate amt of soft brown stool OB+. HCT 28 receiving 2nd unit of PRBC over 4hrs.\nEndo- Insulin 2u/hr gtt d/c'd adn started NPH 10u FS 121-156\nSOcial-family all in and aware of POC. Happy pt is conversant.\nA/P-Continue to adjust meds as tolerated. Keep pt negative.\nStart reglan. Follow electrolytes closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-09 00:00:00.000",
"description": "Report",
"row_id": 1490826,
"text": "CCU Admission Note 1900-0700: VFIB Arrest, s/p stent\n(Continued)\nof food particles. Now not raising anything from ETT. ETT tube advanced 4cm by resp. ABG improved. LS course. O2Sat 99-100%\n\nGU/GI:Foley patent and intact. Draining CYU. U/O adequate prior to low BP's. Currently making 30-500cc/hr for past 2hrs. HO aware. Abd firm and distended with normoactive BS's. OGT in place.\n\nENDO: Insulin gtt at 4u/hr per sliding scale. FS ranging 187-267.\nFollowing FS q1h.\n\n: Collar in place. Cspine film done at bedside last night. No injuries noted.\nCollar in place until pt awake or till trauma team clears\n\nPLAN:\nPossible removal of swans\nIntegrillin to dc at 2200\nContinue to follow neuro status\nContinue to monitor\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-09 00:00:00.000",
"description": "Report",
"row_id": 1490827,
"text": "Resp. Note\nPt remains on AC 16/750/7.5/50% No changes made today. Bronchoscopy done-poss food/foreign body aspiration. No particles found. Pt was sx today for brownish secretions throughtout the day. Will cont support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-09 00:00:00.000",
"description": "Report",
"row_id": 1490828,
"text": "ccu nursing progress note\ns: orally intubated\no: pls see carevue flowsheet for complete vs/data/events\nid: low grade temp. wbc nml. cont on levo and flagyl.\nneuro: ativan weaned down this am, pt became more active, mae with good strength but nonpurposeful. not able to open eyes or follow commands, did appear to respond to stimuli. in afternoon pt underwent bronch req ^'d sedation w/ fent and ativan. pt remains sedated currently on 1mg ativan/hr. no evidence of sz activity.\ncv: in sr rate 75-90s sr, no vea. lido dc'd this am. bp low this am and req 500ccns bolus this am to stabilize. remained 95-120/60-70 via r rad aline.\ntol lopressor later in am.\nr fem aline pulled. cont w/ r fem venous/pa line. paps 30s/.\nsm soft hematoma. pulses 2+/ bilat.\nintegrillin cont at 16cc/hr. to complete at 11pm.\nck up 1300, mb 19. will cont to cycle.\nresp: cont on a/c 750 x16. 50% and 7.5 peep. sats >95%. sxn'd for mod amt drk tan sputum. bronch'd this afternoon to eval ?collapse for lll. lobe was found to be inflated and lavaged for mod purulent sputum.\ngi: abd soft, +bs. no stool. min aspirates. tf started via ogt, promote w/ fiber at 10cc/hr. awaiting nutrition consult to confirm and set goal.\ngu: uop 30-50cc/hr. remains +3l since admit. will dose w/ lasix this eve. cr 1.4.\nskin: abrasion on face/chin. ota. some bruising underarms.\nremains w collar. cspine film taken this afternoon. has yet to be cleared.\nsocial: wife and children in today. updated. home for eve now.\na: bp stable s/p fluid this am. rhythm stable. neuro improving.\np: cont to monitor cv and neuro status. wean o2 as tol. cpt as tol. cont with cspine precautions. advance tf as tol. monitor fever and await cultures. support to pt and family.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-11 00:00:00.000",
"description": "Report",
"row_id": 1490834,
"text": "ccu npn 11p-7a\nS: intubated and sedated\n\nO: Please see carevue for VS and objective data\n\nCVS: Hemodynamically stable with HR 70-80 NSR, no vea noted. K+ 3.6 repleted with 40meq po KCL. am K+ pnd. BP 107-150/50-60. Tolerated po Captopril and Lopressor.\n\nResp; Remains intubated and mechanically ventilated on A/C 750x12 40%/5 peep. Good abgs as per flow. Am abg 105/36/7.42/24/0. Suctioned q 3-4 hours for small-mod. amounts of tan sputum. Lungs coarse. Rare spont. breathe over vent. impaired gag and cough.\n\nID: low grade on IV Flaggyl and Levo.\n\nEndo: Regular Insulin drip titrated 3u-4u/hour for glucose ranges 118-192.\n\nGI:GU: TF Promote with fiber at 30cc/hour increased to 40cc/hour without sign. residuals. Abdomen soft and distended with active bowel sounds. No stool. Foley to drainage with dark yellow urine with sediment. I/O neg 700cc at MN, positive 400cc this am.\n\nNeuro: Remains sedated on IV Propofol, increased to 40mcg/kg/min. for restlessness. with good effect. MAE, moving head side to side. Not opening eyes or following commands. PERL R>L. 3mm. Soft hand restraints intact. Poor gag and weak cough.\n\nA: Hemodynamically stable s/p arrest. Remains sedated and intubated.\n\nP: Cont to assess hemodynamics. Cont aggressive pulmonary toileting. Sedation as needed. Cont. insulin drip with tube feedings. Assess neuro status. Comfort and emotional support to Pt. and family. Follow up with am labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-11 00:00:00.000",
"description": "Report",
"row_id": 1490835,
"text": "CCU Nursing PRogress Note\nS-Delirious\nO-Neuro weaned off propofol by 1030 and added haldol 5mg x2 1 hr apart for persistant delirium with good effect. ALthough when IV haldol wore off (4hours) aggitation returned 1400 and required low dose propofol for pt saftey. Started po haldol 2.5mg QID started at 1800. Still requiring prn Haldol 2.5-5mg IVB. MAE very strong arms requiring wrist restraints. Opening eyes but not focusing or following commands.\nCV- hypertensive 160-180 with aggitation requiring IV NTG 200-300mcg. Lopessor increased to 50mg TID and captopril increased to 37.5mg TID.\nPlan to increase with each dose until desired effect. HR 88-110 NSR with occ isolated PVC's K+ 40meq KCL po x1 repeat 3.2. Radial aline replaced over a wire d/t brisk bleeding at site.\nResp-Vent changed over to PS 15/PEEP 5 with spont VT 500-800 rr 20-28. PS/PEEP weaned down to 5/5 and quicikly extubated by 1200 to 100% neb with O2 sats 92-100% Last ABG 7.41/42/81 at 1630 on 100% face tent.\nLS coarse with occ exp wheeze. Occ dry NPC.\nID afebrile 99.7R WBC 6.9 on triple abx.\nGI- NGT replaced for meds and tube feedings. Initial asp bile but after extubation coffee grounds OB+. Soft brown BM OB+. HCT 27.5 receiving 1uPRBC over 4 hours. Protonix\nTube feeds stopped for extubation and to be restarted this evening.\nGU-foley draining amber colored urine. Received lasix 40mg IVB with ~1200cc diuresis.\nSKin- pressure sores from neck immobilizer neck, shoulder blades and head cleansed and left open to air\nSocial- family all in and very supportive. Understanding POC\nA/P-succ extubated, s/p AMI stent\nPRN haldol for excessive aggitation, plan to wean off propofol when possible. CT scan Monday if MS unchanged.\nLAsix 40mg IVB PRN for low urine output.\nFollow electrolytes closely\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-13 00:00:00.000",
"description": "Report",
"row_id": 1490838,
"text": "CCU Nursing Note 1900-700: Vfib arrest, Aspir PNA\nS: \"I need to go to bathroom, I need to get up.\"\nO: MS: Lethargic and oriented to self and place. Speech less garbled and voices needs appropriately. Obeying and following simple commands.\nRestless and agitated overnoc needing repeative cues. Sleeping in spurts. Given 5mg every 2hr since MN with limited effect.\n\nCV:VSS stable overnoc. Still remains moderately hypertensive. Attempted to wean Nitro. High as 100ugs currently at 60ugs. Tolerating BB and ACEI titration. ? to adding additional antihypertensive on board.\n\nRESP:LS course on left and clear on right. O2Satt 95-99%/5l NC. Occasionally O2Sat dropping to 90-91& increased to 5L at 033O and has since remained > 95%. Breathing unlabored overnoc. (+) cough but nonproductive and assisted blowing nose with old blood secretions. NC changed over to humidified air.\n\nGU/GI: Foley draining amber colored urine. Urine outputs fair, >50cc/hr. Abd soft and distended. Moderate BM, guiac (+) soft and brown in appearance. TF up at MN at 10cc/hr prior to residual 50cc residual of bilious. Started on Reglan QID for ? delayed gastric emptying. At 0400 residual less that 5cc and TF advance to 20cc/hr. Next residual check at 0800. Given ice H2O overnoc for comfort.\n\nENDO: FS QID. Overnoc FS 125 and 136. Given AM dose of NPH.\n\nID: Low grade temps. Tm 101.1 and Tc 99.6. Given Tylenol 650mg x 2. Last at 0400.\n\nHEME: HCT 35 this AM.\n\nA/P:\nConsider possible PT/OT consult as MS continues to improve\nContinue repeative cues and emotional support\nConsider adding additonal antihypertensive in addition to ACE and BB\nContinue to monitor pulmonary status continue to wean O2\nAdvance TF's as tolerated.\nPossible transfer to floor. Transfer note in blue book.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2144-04-13 00:00:00.000",
"description": "Report",
"row_id": 1490839,
"text": "CCU NURSING PROGRESS NOTE 3P- 11P\nS: WHEN CAN I GO HOME?\nO:\nCV: FOR A COMPLETE SET OF VS AND OBJECTIVE DATA PLEASE REFER TO CARE VUE FLOWSHEET. DENIES CP/ SOB WHEN ASKED. REMAINS IN SR , NO VEA NOTED. NITRO DECREASED TO 40 MCG AFTER 4 PM CATOPRIL DOSE. GIVEN LOPRESSOR DOSE EARLY AT 9 PM FOR HR OF 85 AND SBP 160. AWAITING RESULTS.\nRESP: LUNGS WITH CLEAR UPPER LOBES AND CKLS AT LOWER BASES. SATS 91 - 96%. CONTS ON 4L O2.\nGI/ GU: TF AT 20 CC/HOUR INITALLY. THEN RESIDUALS AT 8 PM NOTED TO BE >120. TF HELD AT PRESENT. PT IS ABLE TO SWALLOW PILLS WITH SIPS OF WATER. ? ABSORPTION. CONTS ON REGLAN. BS PRESENT. TWO SMALL SOFT GUIAC POS STOOLS NTED.\nMS: PT IS A&O TO PERSON AND PLACE. HE IS PLEASANT AND COOPERATIVE. LIMITED STM, NEEDING FREQUENT REMINDING/ RE ORIENTATION. DAUGHTERS IN ALL EVE. FAMILY VERY HELPFUL WITH CALMING/ REORIENTATION.\nA: APPEARS STABLE , BUT ? ABSORPTION OF MEDS OR NEED TO INCREASE DOSES, TRANSFER TO THE FLOOR\nP: CONT OT MONITOR, ? INCREASE DOSING OF LOPRESSOR/ CAROPRIL, AWAIT BED.\n"
}
] |
4,313 | 148,275 | 31 year-old male with ESRD on HD, DMI, HTN presented with hyperkalemia in context of missing hemodialysis. He was section 12. Initially went to MICU for HD, then transferred to floor for continued HD. Had return to MICU later in hospital course for more intensive HD treatment secondary to hypoxia and fluid overload. | During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. Pt unable/pt refuse and PO medication. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing HD. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. Lines: PIV Prophylaxis: DVT: hep SC Stress ulcer: h2 VAP: n/a Comments: Communication: Comments: Code status: presumed full Disposition: ICU overnight. During pt's most recent admission/ED visit pt reported LLE swelling, LENIS negative and pt was given IV ABX. Noaortic regurgitation is seen. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIs negative and pt was given unasyn. Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . Home regimen unclear at this time - Changed to , due to concern for edema - Continue amlodipine - Patient currently on metoprolol, no longer on atenolol . - Monitor for withdrawal # Anemia: Likely ACD. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. transferred to the MICU for hypoxia. # Hypertension: Continue outpt meds and uptitrate prn. During pt's most recent admission/ED visit pt reported LLE swelling, LENIS negative and pt was given IV ABX. Fragmentation of medial patella consistent with nondisplaced, comminuted fracture. FINAL REPORT HISTORY: Left lower extremity swelling. nonacute fracture vs post- traumatic heterotopic ossificaiton in adjoining medial retinaculum. IMPRESSION: 1) Findings consistent with medial tibial plateau fracture likely subcaute or chronic . Sinus rhythm with non-diagnostic repolarization abnormalities. There is an ossific fragment along the medial border of the patella, which appears well corticated, and which could represent a either fracture fragment or heterotopic ossification in the medial retinaculum. Sinus rhythm upper normal rateNormal ECGSince previous tracing of , ST-T wave abnormalities are less EXAMINATION: Unilateral left lower extremity DVT study. This again demonstrates a depressed medial tibial plateau fracture, similar to that seen on . FINDINGS: Grayscale and color Doppler son of the left common femoral, superficial femoral and popliteal veins were performed. Medial patellar fracture. 2) Ossicle along medial patella -- ? Compared to the previous tracing there is nosignificant change.TRACING #1 There is a small fracture through the medial aspect of the patella. Tibial and patellar fractures. Moderate joint effusion. Lateral T wave abnormalities. Compared to the previous tracing there is nosignificant change.TRACING #2 Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Depressed, impacted medial tibial plateau fracture which also extends to the intercondylar eminence and medial tibial spine. Clinical correlation and repeat tracing aresuggested. Possible subacute fracture along the medial patella. Compared to the previoustracing of lateral T wave abnormalities are new. Additionally, comminuted fractures of the medial and lateral tibial spines. The prior tracing was consistent with right atrial abnormality.Otherwise, no diagnostic interim change. Sinus rhythmNormal ECGSince previous tracing of , the heart rate is slower Delayed precordial R wave transition. Non-specific ST-T wave changes. Compared to the previoustracing of previous non-specific ST-T wave abnormalities have resolved.Otherwise, no important change. Compared to the previous tracing of no change.TRACING #1 There is evidence of diffuse vascular calcification. Please do delayed phase for better visualization of veins. | 60 | [
{
"category": "Social Work",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 373800,
"text": "SOCIAL WORK:\n SW met with pt, brother (cell ), and mother\n . Pt reviewing his history of betrayal of his family and\n stating his intention to follow recommendations and change his\n behaviors. He would like his care centralized at . Mother spoke\n of how pt has always been self-centered\npt agrees\nto the point of not\n respecting the rights of others. Brother enforced how he still and\n always will love his brother, but that he does not like their\n relationship right now. All agreed that pt will have to earn back\n their respect and trust through hard work and behavior change. While\n pt is stating he would like to change his ways, he still provides many\n excuses for his behaviors (e.g.\n I may have stolen the credit card, but\n I wasn\nt going to use it just yet.\n Mother, brother, and psychiatrist Dr. , and this writer met\n separately from pt. Family reviewed h/o behavior, including\ndeviant\n behavior dating back to pt\ns childhood, but erratic mood swings and\n bizarre behavior (e.g. walking around family home undressed) only in\n recent months. Brother reports he has seen intoxicated on\n etoh and MJ lately, and reports pt\ns substance abuse is real. Mother\n and brother state pt reports he has been\nsnorting dope\n lately, and\n that he does hang around with an addict friend, but they are unclear\n re: history of this. Family notes that while many themes of pt\n reports are true, he does make up some stories.\n After Dr. left, questions were placed re: guardianship and\n capacity\nlargely deferred to meeting next week. Reviewed pt\ns h/o poor\n self-esteem. While pt did not feel he could learn like his brothers,\n pt had been physically skilled when he was young\nplanned to be a boxer,\n played football until dx with DM. Perhaps part of pt\ns long-term plan\n could involve boxing to alleviate physical aggression if medically\n able. Perhaps he could relate to ex-gang members in reform programs.\n Clearly he needs extensive psychiatric support.\n Am following case and waiting to see what floor pt is called out to\n before arranging family meeting for next week. Please page me at \n with any questions/concerns.\n -, LICSW\n PM\n"
},
{
"category": "Physician ",
"chartdate": "2176-06-01 00:00:00.000",
"description": "Physician Attending/Resident Progress Note - MICU",
"row_id": 373124,
"text": "Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotic positioning.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n - On EKG this AM QTc was 450 ms\n ROS:\n Unable to obtain due to patient sedation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97% on room air\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Physical Examination\n GEN: Sedated and sleeping.\n HEENT: PERRL, oral mucosa moist\n NECK: no LAD, JVP flat\n PULM: CTAB with overlying son upper respiratory sounds\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\n ABD: BS+, soft, non-distended\n EXT: Left > right lower extremity edema with no differential warmth\n NEURO: Somnolent\n Labs from \n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n MICRO:\n URINE URINE CULTURE-PENDING NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n # Chronic renal failure-secondary to ESRD/DM:\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\n hyperkalemia, and hyperphosphatemia.\n - HD today in the ICU\n # Left lower extremity edema:\n Acute within last week. Patient denies pain with ambulation or knee\n joint manipulation. Has had two negative sets of lower-extremity\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\n other obstructive process to cause differential swelling. Patient was\n on antibiotics at presentation, but this is not entirely consistent\n with a cellulitis.\n - Consider pelvic venous imaging to rule out pelvic DVT\n # Psychiatric:\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\n have decided to section 12 pt. Psychiatry aware and suggests that the\n pt does not have capacity and the medical team should consider\n guardianship. had two episodes of threatening to leave hospital\n overnight requiring security to assist in giving patient chemical\n restraints (5 mg haldol and 2 mg lorazepam each episode)\n - Follow-up psychiatry recs\n - Will need 1:1 observation and cannot leave hospital\n # Increase in size of cardiac silhouette by CXR on :\n Was ruled out for pericardial effusion by ECHO. Most likely\n projectional artifact.\n # Hypertension:\n Continue outpt meds and uptitrate prn. HD this AM.\n - As mental status allows will add back on amlodipine, lisinopril,\n metoprolol, labetolol.\n - Will have to reeval outpt regimen\n # Diabetes mellitus type 1:\n Insulin 75/25 at half of home doses and conservative sliding scale\n insulin given that patient is taking little orally.\n # Reported ETOH:\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\n admission. No history of withdrawal symptoms.\n - Monitor for withdrawal\n # Anemia:\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\n today.\n - Epoetin at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n ------ Protected Section ------\n CRITICAL CARE ADDENDUM\n Mr. was seen, examined and evaluated with Dr. and the ICU\n team with whose detailed note above I agree. Mr. is a 31 yo man\n with psychiatric illness, DM I, ESRD on HD who was brought in Section\n 12 because he was not compliant with HD. Getting hemodialysis for\n hyperkalemia. Agitated overnight requiring benzodiazepines and haldol.\n Left leg is edematous and LENIS negative. Overnight, CXR w/?widened\n mediastinum - echo w/o abnormality - ?fat pad or positioning.\n Somnolent throughout the day and agitated over night - restrained by\n security and given haldol. QTc stable at 450.\n Currently somnolent, but arousable and answering questions with\n curses. HR 90, 166/75, Neg 5.4L yesterday. 97% RA, Lungs clear to\n auscultation. RRR w/o murmur. Abd benign. Thrill palpable UE. Left\n LE edematous - no labs today (await w/HD).\n Plan includes hemodialysis today. Continue to use haldol and\n benzodiazepines as needed for agitation and sedation. We are awaiting\n guardianship. Evaluate Left LE with ?pelvic vein imaging and will d/w\n dr . Agitation control. Needs 1:1 sitter. be called out if\n stable following HD today.\n , MD\n Critical Care Attending\n 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 11:04 ------\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373628,
"text": "HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt admitted to the micu from 2. on 100% non rebreather o2sat\n 92-99%. Creat 7.8\n Action:\n Hemodyiaylsis nurse in and dialysis begun at 0430 am.\n Response:\n Diaylysis intiated and tolerating . bp 160-170\ns. very cooperative;\n sitter at the bedside.\n Plan:\n Continue dialysis till 0830am. Check creat level in late am.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n K upon arrival to the unit .8 repeat 7.2.\n Action:\n Postassium level being monitored. Hemodyamics being monitored. Ekg\n monitored.\n Response:\n Dialysis being done and tolerating well\n Plan:\n Monitor potassium level closely.\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 373786,
"text": "Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 373791,
"text": "Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor, hopefully to 2\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 373792,
"text": "Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor, hopefully to 2\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: hyperlipedemia, diabetes type I on insulin end\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\n pressured,racing thoughts decreased sleep consistent with possible\n mania. lower left extremitiy swelling dopplerable. neg for clots.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:136\n D:113\n Temperature:\n 96.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,100 mL\n 24h total out:\n 5,000 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 10:30 AM\n Potassium:\n 4.8 mEq/L\n 10:30 AM\n Chloride:\n 95 mEq/L\n 10:30 AM\n CO2:\n 31 mEq/L\n 10:30 AM\n BUN:\n 28 mg/dL\n 10:30 AM\n Creatinine:\n 4.6 mg/dL\n 10:30 AM\n Glucose:\n 326 mg/dL\n 10:30 AM\n Hematocrit:\n 26.4 %\n 10:30 AM\n Finger Stick Glucose:\n 351\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Micu 687\n Transferred to:\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2176-06-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373106,
"text": "Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\n w/o complaint until 0500- awake, initially pleasant, engaging in\n conversation- allowed off monitors to wash self , @ 05:30 stating\n wanted to leave to go to dialysis- attempted to talk down pt, pt\n reviewing care and accepting Insulin but not PO anti-hypertensives-\n moderate agitation just persisting on leaving- security called and pt\n accepting IV chemical restraint- 5mg IVP Haldol, 2mg IV Ativan and\n lying down in bed. Pt unable/pt refuse and PO medication. Section 12-\n pt may not leave AMA.\n Impaired Health Maintenance\n Assessment:\n Pt stating\nI had dialysis yesterday, I need to go to my dialysis\n today\n, unable to review dialysis plans, pt focused on leaving\n hospital, refusing medications\n Action:\n Emotional support, reviewing POC\n Response:\n Attempting to leave x1\n Plan:\n not leave AMA, IV Haldol for restraint, reviewing POC ? social work\n and psych to follow up\n"
},
{
"category": "Physician ",
"chartdate": "2176-06-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 373109,
"text": "Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotically positioned.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GEN:\n HEENT:\n NECK:\n PULM:\n CARD:\n ABD:\n EXT:\n NEURO:\n Labs / Radiology\n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan\n IMPAIRED HEALTH MAINTENANCE\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:45 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": "2176-06-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 373111,
"text": "Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotically positioned.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n GEN:\n HEENT:\n NECK:\n PULM:\n CARD:\n ABD:\n EXT:\n NEURO:\n Labs / Radiology\n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373079,
"text": "Events: - Accepted pt s/p IV Haldol and IV Ativan for chemical\n restraint- pt C/O but needs sitter for section 12. Lethargic overnight\n w/o complaint until 0500- awake.\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 373784,
"text": "Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 372913,
"text": "Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui.\n Action:\n HD for / hrs at bedside.\n Response:\n Plan:\n Follow up with renal,,cont HD\n"
},
{
"category": "Physician ",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 372907,
"text": "Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n"
},
{
"category": "Physician ",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 372908,
"text": "Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n ------ Protected Section ------\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\n DVT. Will give unasyn for now for presumed cellulitis.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:50 ------\n"
},
{
"category": "Physician ",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 372911,
"text": "Chief Complaint: Nephrology: Dr. \n CC: section 12 for HD/hyperkalemia.\n HPI:\n Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn.\n .\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship. In addition, pt often states that he is\n taking drugs and drinking large quantities of ETOH and withdrawing in\n the hospital, but screens are negative.\n .\n In the , Pt refused kayexylate, EKG. Pt was given haldol 5mg IV and\n ativan 2mg IV. Renal fellow aware that pt is here and HD planned for\n tonight. EKG showing ?some peaked T's. No intervention for hyperkalemia\n given plan for HD.\n .\n Time Pain Temp HR BP RR Pox\n 17:43 9 99.6 106 192/92 18 100\n states drinking a liter of ETOH daily.\n Patient admitted from: ER\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 Other ICU medications:\n Other medications:\n Epogen 3,000 unit/mL Injection\n given in dialysis three times a day\n Lipitor 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj\n 10 units q am and 8 units q pm\n Sensipar 90 mg Tab\n 1 Tablet(s) by mouth daily\n FOSRENOL 1,000 mg Chewable Tab\n 1 Tablet(s) by mouth 4 times daily with meals and snack\n Lisinopril 40 mg Tab\n 1 Tablet(s) by mouth once a day\n Colace 100 mg Cap\n 1 Capsule(s) by mouth twice a day as needed as needed for constipation\n Amlodipine 5 mg Tab\n 1 Tablet(s) by mouth once a day\n PhosLo 667 mg Cap\n 2 Capsule(s) by mouth three times a day\n Labetalol 300 mg Tab\n 1 Tablet(s) by mouth three times a day\n Metoprolol SR 25 mg 24 hr Tab\n 1 Tablet(s) by mouth twice a day\n Nephrocaps 1 mg Cap\n 1 Capsule(s) by mouth once a day\n Past medical history:\n Family history:\n Social History:\n 1. Type I DM (diagnosed 13 years ago), managed by Dr. \n \n 2. ESRD: CKD stage 5 (on hemodialysis since ) T-T-S\n Recently, he has been mostly dialyzed in\n hospital, but usually gets his HD at in \n T,Th,Sat.\n 3. Diabetic retinopathy (diagnosed 2 years ago)\n 4. Diabetic neuropathy\n 5. Diabetic myonecrosis ()\n 6. Chronic ulcer at right foot\n 7. Hypertension\n 8.?psychiatric disorder-bipolar\n .\n Social History:\n Recent social situation complicated, in that patient used to\n live with his mother, but due to a disagreement, has moved out.\n His FH is significant for diabetes. His mother and his father\n are in the 50's both suffering from DMII. He has 2 sisters at\n the age of 20 and 26 both suffering from DMI. He has four\n brothers at the age of 16, 19, 28, and 30. His both older\n brothers suffer from DMI. All his grandparents had DM. Pt. says\n there is no h/o of heart disease, HTN, cancer or bleeding\n disorders in the family.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: worked as cleaner until 7 years ago. Since than he has been\n living on disability. He is living with his mother, his 16 y/o\n brother and his 26 y/o sister in a house in . He was\n recently asked to leave his older brother's house as result of\n stealing form the brother. The patient now reports being\n homeless for the last 48 hours.\n Review of systems: see above\n Flowsheet Data as of 12:44 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: 93 (93 - 97) bpm\n BP: 178/88(118) {178/88(118) - 178/88(118)} mmHg\n RR: 14 (13 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n gen-somnolent after sedation, arousable to painful stimuli, snoring.\n vitals-T. 96.9, HR 97, BP 178/88, RR 13, sat 96% on RA\n HEENT-PERRLA, EOMI, anicteric,MMM,\n neck-unable to assess for JVP, no LAD\n chest-b/l ae, transmitted upper airway noise, no wheezing/crackles\n heart-s1s2 RRR no m/r/g\n abd-+bs, soft, Nt, ND\n ext-LLE 3+pitting edema to mid-thigh with splotchy erythema. 2+DP/PT\n pulses. RLE trace edema, 2+pulses. No calf tenderness or cords.\n neuro-somnolent but moving all 4 extremities.\n Labs / Radiology see OMR.\n [image002.jpg]\n Imaging: KG-NSR @94, QRS 76, ?mild peaked T's. TWI AVL, V1 seen on\n prior EKG.\n .\n EKG-4/09Sinus rhythm. Baseline artifact. Delayed precordial R wave\n transition. The P wave morphology appears less prominent while the P\n wave axis remains rightward. The prior tracing was consistent with\n right atrial abnormality. Otherwise, no diagnostic interim change.\n Clinical correlation is suggested.\n .\n ECHO -The left atrium is mildly dilated. No atrial septal defect\n is seen by 2D or color Doppler. There is mild symmetric left\n ventricular hypertrophy with normal cavity size. Regional left\n ventricular wall motion is normal. Overall left ventricular systolic\n function is normal (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) appear\n structurally normal with good leaflet excursion. No masses or\n vegetations are seen on the aortic valve. There is no aortic valve\n stenosis. No aortic regurgitation is seen. The mitral valve leaflets\n are structurally normal. There is no mitral valve prolapse. No mass or\n vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation\n is seen. There is mild pulmonary artery systolic hypertension. No\n masses or vegetations are seen on the pulmonic valve, but cannot be\n fully excluded due to suboptimal image quality. There is no pericardial\n effusion.\n CXR\n LENI -IMPRESSION: No left leg DVT.\n Assessment and Plan\n A/P:Pt is a 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n .\n #chronic renal failure-secondary to ESRD/DM. On HD tue//sat. Pt\n again missed HD sessions.\n -renal aware\n -plan for HD tonight\n -monitor lytes\n -continue outpt calcium acetate, sensipar, lanthanum\n -u/a and Cx\n -consider renal u/s.\n .\n #hyperkalemia/hyperphosphatemia-Likely secondary to ESRD and missing\n HD.\n -plan for HD tonight\n -monitor lytes\n .\n #HTN-continue outpt meds and uptitrate prn. HD tonight.\n -amlodipine, lisinopril, metoprolol, labetolol.\n -will have to reeval outpt regimen\n .\n #DM1-continue outpt regimen 75/25. HISS. FS qid. DM diet.\n .\n #psychiatric-PT with persistent pattern of non-compliance with HD,\n leaving AMA. Outpt HD SW concerned re: psychiatric process such as\n bipolar d/o etc leading to non-compliance. Pt often states he drinks\n large quantities of ETOH and takes illicit substances, then withdraws,\n but all screens have been negative. At this time, SW and pt's outpt\n nephrologist have decided to section 12 pt. Psychiatry aware and\n suggests that the pt does not have capacity and the medical team should\n consider guardianship.\n - screens negative\n -SW consult\n -f/u psych recs.\n .\n #reported ETOH-pt states drinking 1L of ETOH daily. negative. Will\n monitor for signs of w/d.\n .\n #anemia-likely ACD. Pt's baseline 27-33. Pt at baseline.\n -epogen at HD\n .\n #FEN-renal/DM\n .\n #PPx-bowel regimen, Hep SC\n #access-HD fistula, pt refusing IV\n .\n #Code-presumed full\n #dispo-pending completion of HD session.\n ICU Care\n Nutrition: NPO for now\n Glycemic Control: HISS/ 75/25 at home.\n Lines: PIV\n Prophylaxis:\n DVT: hep SC\n Stress ulcer: h2\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: presumed full\n Disposition: ICU overnight.\n ------ Protected Section ------\n Pt also with LLE edema/erythema. S/P 2 lenis that were negative for\n DVT. Will give unasyn for now for presumed cellulitis.\n ------ Protected Section Addendum Entered By: , MD\n on: 00:50 ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points: receiving HD currently, psych evaluation and\n treatment of cellulitis as described above. Unable to obtain complete\n ROS due to altered mental status. Labs reviewed and notable for\n hyperkalemia but otherwise stable.\n ------ Protected Section Addendum Entered By: , MD\n on: 01:31 ------\n"
},
{
"category": "Nursing",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 372914,
"text": "Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n"
},
{
"category": "Nursing",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 372965,
"text": "Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\n of Dextrose foe hypoglycemia.\n"
},
{
"category": "Physician ",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 373000,
"text": "Chief Complaint: hyperkalemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 31 yo ESRD secondary to DM I on tranplant list. Presenting with\n hyperkalemia after missing HD. Was brought in ?unclear how. In ED was\n agitated. Was eval by psych who felt he did not have capacity to make\n decisions. Got 5mg haldol and 2mg of ativan. K was 6.4. refused\n kayexalate. Came to MICU for urgent HD. BP 192/92 sat 100% on RAn in\n ED. Overnight required D50x3 for hypoglycemia after getting dosed\n with SSI.\n 24 Hour Events:\n NASAL SWAB - At 12:14 AM\n MRSA screen\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 06:00 AM\n Hydralazine - 06:10 AM\n Other medications:\n nephrocaps\n calcium acetate\n norvasc\n lisinopril\n EPO\n lipitor\n pepcid\n hep s/q\n toprol\n labetolol\n lanthenum\n SSI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 87 (75 - 98) bpm\n BP: 162/81(99) {137/57(77) - 201/106(128)} mmHg\n RR: 13 (11 - 17) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n PO:\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 0 mL\n 2,500 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -2,400 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: 3+\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.6 g/dL\n 400 K/uL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n ECG: slightly peaked Tw\n Assessment and Plan\n RENAL FAILURE, END STAGE (END STAGE RENAL DISEASE, ESRD): Got\n emergent HD overnight. K now normalized.\n Section 12: will need psych admission after medical issues are cleared\n RLE: swelling and redness. Has had this for at least a few days with\n no worsening. No clear evidence of cellulitis,\n DM I: will start half dose NPH and cut back on sliding scale as he was\n hypoglycemic today.\n agitation: Currently sedated, but will need sitter and haldol prn.\n has right effusion in knee: will tap.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 12:45 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU can go to floor after HD\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 372960,
"text": "Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/106(128). Pt given 2 amps\n of Dextrose foe hypoglycemia.\n"
},
{
"category": "Nursing",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373062,
"text": "31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, dialyzed overnight upon admission to\n unit .5L removed.\n Received pt very lethargic, arousable only to simulation,\n unable to give most PO meds due to lethargy.\n Action:\n Dialyzed again this afternoon per renal orders, 3L removed.\n Pt becoming more arousable during dialysis, alert and\n oriented x 3, very talkative at times becoming agitated however easily\n redirected.\n Response:\n Pt tolerated dialysis well, SBP >100\n Received IV Ativan 1mg x 2 with some effect, also ordered\n for but did not receive any Haldol.\n Plan:\n Pt to have dialysis again tomorrow.\n PRN Ativan and Haldol as needed.\n Pt noted to have larger heart on CXR, MDs questioning pericardial\n effusion, bedside ECHO performed, results pending. Pt called out to\n floor, awaiting bed placement.\n"
},
{
"category": "Nursing",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 372955,
"text": "Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n Pt received 10 mg Hydralasinr for BP of 190/\n"
},
{
"category": "Physician ",
"chartdate": "2176-06-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 373120,
"text": "Chief Complaint: Section 12 due to non-compliance with dialysis\n 24 Hour Events:\n - Read of CXR concerning for pericardial effusion given enlarged\n cardiac silloutte. 17 cm. Older study 4 cm smaller. Originally thought\n more lordotic positioning.\n - Clinically without hypotension or tachycardia. JVP flat.\n - ECHO revealed no pericardial effusion and slight increase in left\n ventricular size since \n - Was somnolent throughout day and awoke brief during dialysis and was\n agitated and threatening leave briefly, received 1 mg lorazepam and\n subsequently slept for several hours.\n - Was sitting up eating at ~ and suddenly anounced that he was\n going to leave. Talked to several heathcare personnel and became\n escalated to the point that he required security to help restrain him\n in order to give 5 mg haldol IV and 2 mg lorazepam. Then slept until ~\n 0500 on when had repeat episode and could not be talked down and\n again security called and was restrained and given 5 mg IV haldol and 2\n mg IV lorazepam.\n - On EKG this AM QTc was 450 ms\n ROS:\n Unable to obtain due to patient sedation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin/Sulbactam (Unasyn) - 04:14 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 10:15 AM\n Insulin - Humalog - 05:00 AM\n Lorazepam (Ativan) - 05:30 AM\n Haloperidol (Haldol) - 05:30 AM\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: 37.4\nC (99.3\n Tcurrent: 36.4\nC (97.6\n HR: 87 (85 - 102) bpm\n BP: 175/75(97) {111/37(56) - 197/119(137)} mmHg\n RR: 12 (10 - 21) insp/min\n SpO2: 97% on room air\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 100 mL\n 280 mL\n PO:\n 180 mL\n TF:\n IVF:\n 100 mL\n 100 mL\n Blood products:\n Total out:\n 5,500 mL\n 0 mL\n Balance:\n -5,400 mL\n 280 mL\n Physical Examination\n GEN: Sedated and sleeping.\n HEENT: PERRL, oral mucosa moist\n NECK: no LAD, JVP flat\n PULM: CTAB with overlying son upper respiratory sounds\n CARD: RR, nl S1, nl S2, II/VI murmur at RUSB\n ABD: BS+, soft, non-distended\n EXT: Left > right lower extremity edema with no differential warmth\n NEURO: Somnolent\n Labs from \n 400 K/uL\n 10.6 g/dL\n 38 mg/dL\n 8.5 mg/dL\n 29 mEq/L\n 4.7 mEq/L\n 44 mg/dL\n 99 mEq/L\n 142 mEq/L\n 32.6 %\n 7.1 K/uL\n [image002.jpg]\n 06:07 AM\n WBC\n 7.1\n Hct\n 32.6\n Plt\n 400\n Cr\n 8.5\n Glucose\n 38\n Other labs: PT / PTT / INR:13.1/26.4/1.1, ALT / AST:29/26, Alk Phos / T\n Bili:109/0.4, Differential-Neuts:72.8 %, Lymph:16.9 %, Mono:4.3 %,\n Eos:5.6 %, Albumin:3.6 g/dL, LDH:321 IU/L, Ca++:8.1 mg/dL, Mg++:2.2\n mg/dL, PO4:5.9 mg/dL\n MICRO:\n URINE URINE CULTURE-PENDING NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n BLOOD CULTURE Blood Culture, Routine-FINAL NGTD\n Assessment and Plan:\n 31 y.o with h.o ESRD on HD, DM, HTN who presents again with\n hyperkalemia, now section 12.\n # Chronic renal failure-secondary to ESRD/DM:\n On HD tue//sat. Pt again missed HD sessions. Has hypertension,\n hyperkalemia, and hyperphosphatemia.\n - HD today in the ICU\n # Left lower extremity edema:\n Acute within last week. Patient denies pain with ambulation or knee\n joint manipulation. Has had two negative sets of lower-extremity\n dopplers to rule out DVT. Possible that patient has a pelvic DVT or\n other obstructive process to cause differential swelling. Patient was\n on antibiotics at presentation, but this is not entirely consistent\n with a cellulitis.\n - Consider pelvic venous imaging to rule out pelvic DVT\n # Psychiatric:\n Patient with persistent pattern of non-compliance with HD, leaving AMA.\n Outpt HD SW concerned re: psychiatric process such as bipolar d/o etc\n leading to non-compliance. At this time, SW and pt's outpt nephrologist\n have decided to section 12 pt. Psychiatry aware and suggests that the\n pt does not have capacity and the medical team should consider\n guardianship. had two episodes of threatening to leave hospital\n overnight requiring security to assist in giving patient chemical\n restraints (5 mg haldol and 2 mg lorazepam each episode)\n - Follow-up psychiatry recs\n - Will need 1:1 observation and cannot leave hospital\n # Increase in size of cardiac silhouette by CXR on :\n Was ruled out for pericardial effusion by ECHO. Most likely\n projectional artifact.\n # Hypertension:\n Continue outpt meds and uptitrate prn. HD this AM.\n - As mental status allows will add back on amlodipine, lisinopril,\n metoprolol, labetolol.\n - Will have to reeval outpt regimen\n # Diabetes mellitus type 1:\n Insulin 75/25 at half of home doses and conservative sliding scale\n insulin given that patient is taking little orally.\n # Reported ETOH:\n Patient states drinking 1L of ETOH daily. Tox negative for EtOH at\n admission. No history of withdrawal symptoms.\n - Monitor for withdrawal\n # Anemia:\n Likely ACD. Pt's baseline 27-33. Pt at baseline yesterday, will trend\n today.\n - Epoetin at HD\n ICU Care\n Nutrition: Renal, diabetic diet\n Glycemic Control: Minimal glargine dose and conservative humalog\n sliding scale\n Lines: PIV\n Prophylaxis:\n DVT: Heparin subcutaneous\n Stress ulcer: H2 blocker as home medication\n Communication: Working with psychiatry and liason in determining if\n guardianship should be obtained. Patient not competent to make own\n medical decisions at this time.\n Code status: Presumed FULL\n Disposition: Transfer to medical floor with 1:1 sitter. Patient may not\n leave hospital without psychiatric clearance. Likely discharge to\n psychiatric facility.\n"
},
{
"category": "General",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Generic Note",
"row_id": 373765,
"text": "TITLE: Critical Care\n Present for the key portions of the resident\ns history and exam. Agree\n substantially with assessment and plan as outlined. This am he is\n manic\n euphoric, pressured speech, flights of ideas. Denies SOB but\n oxygenation still not normal. Seems to be improving with aggressive\n dialysis but CXR being read as c/w pneumonic process. Needs CXR\n tomorrow and may need CT if he fails to clear but clinically this is\n CHF rather than infection.\n Time spent 30 min\n"
},
{
"category": "Physician ",
"chartdate": "2176-06-06 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 373601,
"text": "Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\n HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: not willing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n **Patient unable to provide. Per discharge summary on ...\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\n Sensipar 30mg Tablet, 1 Tablet PO once a day\n Lanthanum Oral\n .\n Medications on transfer:\n Haloperidol 1.5 mg PO Q 12H\n Acetaminophen 325-650 mg PO Q6H:PRN pain\n Haloperidol 2 mg IM ONCE\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\n Duration: 1 Doses Order date: @ 1614\n amlodipine 5 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Aspirin 325 mg PO DAILY\n Insulin SC (per Insulin Flowsheet)\n Atorvastatin 40 mg PO DAILY\n Insulin Regular 10 UNIT IV ONCE\n Monitor Q1H for 6 Order date: @ 0044\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Lanthanum 1000 mg PO QID\n Calcium Acetate 1334 mg PO TID W/MEALS\n Labetalol 300 mg PO TID\n Calcium Gluconate 2 g IV ONCE\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\n Cinacalcet 30 mg PO DAILY\n Multivitamins 1 TAB PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nephrocaps 1 CAP PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nicotine Patch 21 mg TD DAILY\n DiphenhydrAMINE 25 mg PO HS:PRN\n Senna 1 TAB PO BID:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Epoetin Alfa\n To be administered during dialysis and dosed according to the \n Epoetin Alfa P&T Guidelines.\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\n Famotidine 20 mg PO Q24H\n Thiamine 100 mg PO DAILY\n FoLIC Acid 1 mg PO DAILY\n Valsartan 160 mg PO DAILY\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\n d1= Order date: @ 0044\n Haloperidol 0.5 mg PO Q2H:PRN agitation\n MD if giving Order date: @ 1301\n Past medical history:\n Family history:\n Social History:\n Type I DM (diagnosed 13 years ago), managed by Dr. \n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \n Diabetic retinopathy (diagnosed 2 years ago)\n Diabetic neuropathy\n Diabetic myonecrosis ()\n Chronic ulcer at right foot\n Hypertension\n Concern for psychiatric disorder, possibly bipolar\n :\n Per reveiw of records, Type II diabetes mellitus in mother and father.\n Type I diabetes mellitus in sisters and brothers.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is followed by a social worker because of concern about his\n competence. Reported alcohol use, illicit drug use.\n Review of systems: ROS\n Flowsheet Data as of 03:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 92 (92 - 92) bpm\n BP: 169/75() {169/75() - 169/75()} mmHg\n RR: 5 (5 - 5) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 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: Non-rebreather\n Physical Examination\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\n +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\n ABG, and hypoxia.\n .\n Studies:\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \n 8:11, TWI is more pronounced and STE is unchanged.\n - TTE (): The left atrium is normal in size. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Left ventricular systolic function is hyperdynamic (EF\n 80%). There is no ventricular septal defect. Right ventricular chamber\n size and free wall motion are normal. There are focal calcifications in\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is mild mitral valve\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\n artery systolic pressure is normal. There is no pericardial effusion.\n There is an anterior space which most likely represents a fat pad.\n Compared with the findings of the prior study (images unavailable) of\n , the left ventricular wall thickening has progressed.\n - CXR 2V (): Final read pending\n - LENI (): No evidence of DVT of the left lower extremity.\n Assessment and Plan\n Assessment and plan:\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2176-06-06 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 373606,
"text": "Chief Complaint: Chief complaint: Transfer from floor for hypoxia/AMS.\n HPI:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was , during his previous admssion. His normal HD schedule is\n T/Th/Sat.\n .\n He was seen by psychiatry in the ED and admitted under section 12\n because he was not deemed competent to decline medical care. He\n received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .\n He was noted to have an enlarged heart shadow on his CXR concerning for\n effusion. TTE did not show evidence of effusion.\n .\n His left leg was noted to be bigger than his right. LENIs were negative\n x2. He was started on Unasyn give a concern for cellulitis. Of note, he\n remained afebrile and did not have a leukocytosis.\n .\n In addition to above management, in the MICU the patient also received\n 3amps D5 for hypoglycemia. He received doses of haldol, lorazepam and\n required security involvment for agitation on two separate occasions.\n .\n Today, pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco. Given pt's current respiratory status, the renal\n fellow made the decision the urgently dialyze the pt and he was\n therefore transferred to the MICU.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: not willing\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n **Patient unable to provide. Per discharge summary on ...\n Calcium Acetate 667mg, 2 Capsule PO TID W/MEALS\n Metoprolol Tartrate 25mg Tablet, 1 Tablet PO BID\n Simvastatin 40mg Tablet, 2 Tablet PO DAILY\n Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR\n Sensipar 30mg Tablet, 1 Tablet PO once a day\n Lanthanum Oral\n .\n Medications on transfer:\n Haloperidol 1.5 mg PO Q 12H\n Acetaminophen 325-650 mg PO Q6H:PRN pain\n Haloperidol 2 mg IM ONCE\n Albuterol 0.083% Neb Soln 1 NEB IH ONCE Haloperidol 2.5 mg IV ONCE\n Duration: 1 Doses Order date: @ 1614\n amlodipine 5 mg PO DAILY\n Heparin 5000 UNIT SC TID\n Aspirin 325 mg PO DAILY\n Insulin SC (per Insulin Flowsheet)\n Atorvastatin 40 mg PO DAILY\n Insulin Regular 10 UNIT IV ONCE\n Monitor Q1H for 6 Order date: @ 0044\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Lanthanum 1000 mg PO QID\n Calcium Acetate 1334 mg PO TID W/MEALS\n Labetalol 300 mg PO TID\n Calcium Gluconate 2 g IV ONCE\n Lorazepam 0.5-2 mg IV Q4H:PRN agitation\n Cinacalcet 30 mg PO DAILY\n Multivitamins 1 TAB PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nephrocaps 1 CAP PO DAILY\n Dextrose 50% 25 gm IV ONCE\n Nicotine Patch 21 mg TD DAILY\n DiphenhydrAMINE 25 mg PO HS:PRN\n Senna 1 TAB PO BID:PRN\n Docusate Sodium (Liquid) 100 mg PO BID\n Epoetin Alfa\n To be administered during dialysis and dosed according to the \n Epoetin Alfa P&T Guidelines.\n Sodium Polystyrene Sulfonate 30 gm PO ONCE\n Famotidine 20 mg PO Q24H\n Thiamine 100 mg PO DAILY\n FoLIC Acid 1 mg PO DAILY\n Valsartan 160 mg PO DAILY\n Furosemide 80 mg IV ONCE Duration: 1 Doses Order date: @ 0013\n Vancomycin 1000 mg IV X1 Duration: 1 Doses\n d1= Order date: @ 0044\n Haloperidol 0.5 mg PO Q2H:PRN agitation\n MD if giving Order date: @ 1301\n Past medical history:\n Family history:\n Social History:\n Type I DM (diagnosed 13 years ago), managed by Dr. \n ESRD, CKD stage 5 (on hemodialysis since ) T-Th-S at \n Diabetic retinopathy (diagnosed 2 years ago)\n Diabetic neuropathy\n Diabetic myonecrosis ()\n Chronic ulcer at right foot\n Hypertension\n Concern for psychiatric disorder, possibly bipolar\n :\n Per reveiw of records, Type II diabetes mellitus in mother and father.\n Type I diabetes mellitus in sisters and brothers.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: He is followed by a social worker because of concern about his\n competence. Reported alcohol use, illicit drug use.\n Review of systems: ROS\n Flowsheet Data as of 03:55 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.8\nC (100\n HR: 92 (92 - 92) bpm\n BP: 169/75() {169/75() - 169/75()} mmHg\n RR: 5 (5 - 5) insp/min\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 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: Non-rebreather\n Physical Examination\n T 100, BP 169/75, HR 92, RR 5, sat 97% RA.\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - By anterior auscultation-pt refused to sit up, CTA bilaterally\n +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Labs: see below, notable for K 6.8 on\n ABG, and hypoxia.\n .\n Studies:\n - EKG (, 17:37): Rate 96, NSR, normal axis, normal intervals,\n TWI I, aVL, V4-V6; no Q waves; STE V2-V3. Compared to EKG on \n 8:11, TWI is more pronounced and STE is unchanged.\n - TTE (): The left atrium is normal in size. There is moderate\n symmetric left ventricular hypertrophy. The left ventricular cavity is\n unusually small. Left ventricular systolic function is hyperdynamic (EF\n 80%). There is no ventricular septal defect. Right ventricular chamber\n size and free wall motion are normal. There are focal calcifications in\n the aortic arch. The aortic valve leaflets (3) are mildly thickened but\n aortic stenosis is not present. No aortic regurgitation is seen. The\n mitral valve leaflets are mildly thickened. There is mild mitral valve\n prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary\n artery systolic pressure is normal. There is no pericardial effusion.\n There is an anterior space which most likely represents a fat pad.\n Compared with the findings of the prior study (images unavailable) of\n , the left ventricular wall thickening has progressed.\n - CXR 2V (): Final read pending\n - LENI (): No evidence of DVT of the left lower extremity.\n Assessment and Plan\n Assessment and plan:\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n MICU ATTENDING ADDENDUM\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I agree with the\n note above, including the assessment and plan. I would emphasize and\n add the following points:\n Worsening hypoxemia this eve with new bilateral infiltrates\n presumption is that this represents pulmonary edema and he was\n transferred to ICU for urgent dialysis. He was placed on a 100% NRB\n facemask to maintain adequate saturations.\n Exam notable for Tm afebrile HR 94 BP 156/70 RR 19 with 97 sat on\n 100% NRB\n No distress\n HEENT unremarkable\n Neck supple\n Lungs crackles\n Her rrr\n Abd benign\n Extreme RUE fistula, mild LLE edema\n Labs notable for K+ 6.3 yesterday morning\n Imaging: CXR with new bilateral patchy infiltrates\n EKG with peaked T\n Problems: respiratory distress, hypoxemia, pulmonary edema, ESRD, LLE\n edema, hyperkalemia, DM\n Agree with plan for urgent HD, wean O2 as tolerates, will continue\n antibiotics and let floor team sort out LLE, continue current DM\n regimen\n Remainder of plan as outlined above.\n Patient is critically ill.\n Total time: 36 min\n ------ Protected Section Addendum Entered By: , MD\n on: 04:31 ------\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373673,
"text": " MD H+P:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Today\ns Events\n HD today, removed 4.9kilo\n L leg remains swollen and tender to touch\n CXR revealed pneumonia, received vanco X1\n Pt desatuating on RA to 70\ns, productive cough\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373676,
"text": " MD H+P:\n Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n Last night, pt was noted to be lethargic with RA sat of ~60%. Pt placed\n on NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Today\ns Events\n HD today, removed 4.9kilo\n L leg remains swollen and tender to touch\n CXR revealed pneumonia, received vanco X1\n Pt desatuating on RA to 70\ns, productive cough\n Mg level 1.7 and replaced w/ Magnesium Sulfate 4gm IV\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, non-compliant with medical care . K+ 6.8\n overnight with worsening resp distress and desaturation to the 70\n Action:\n Renal ordered HD overnight.\n Response:\n HD removed 4.9kilo\n Plan:\n Monitor fluid balance, pt is refusing to abide by fluid restriction.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Known non-compliance with medical regimen. ? untreated Bipolar\n disease. History of leaving AMA, pt is Currently under Section 12 and\n has 1:1 sitter and can NOT leave.\n Action:\n Pt is on Haldol and can receive PRN doses\n Response:\n Pt has been cooperative with care, 1:1 sitter\n Plan:\n Psych and SW attempting to get medical guardianship, meeting friday\n"
},
{
"category": "Physician ",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 373734,
"text": "24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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": "2176-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 373735,
"text": "24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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": "2176-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 373737,
"text": "24 Hour Events:\n -3.5L at O/N\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Pt\n sat's improved after being given 80mg IV lasix. Appears, pt last\n dialyzed . However, infection such as from PNA, ACS/cardiac\n etiology, medication effect from anti-psychotics, or other illicit\n substance could be involved. Other possibility to consider is PE.\n -bcx and ucx\n -cxr\n -urgent HD per renal fellow\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source. Improved slightly, but now\n stable. Had temp of 100.8 on .\n - initially abx were stoped, but now keflex restarted with fever,\n even though this would be a odd presentation of cellulitis\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - Repeat EKG, daily while haldol dose is adjusted\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 28.4\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on transfer. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: Section 12. Followed by psychiatry. ?bipolar\n disorder component. Poor compliance has been long standing issue. Per\n psych notes, has had \"agitation, pressured speech, loose and\n tangential, racing thoughts and decreased sleep consistent with\n possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:34 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": "2176-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 373742,
"text": "24 Hour Events:\n -3.5L O/N\n -No episodes of hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Bcx (): PND\n Bcx (): PND\n UCx (): Negative\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Renal\n following, given dialysis yesterday early AM, continues to be fluid\n overloaded. Will continue to diureses as per renal recommendations and\n fluid restrict (1L per day, 80mg lasix QD).\n -bcx and ucx\n -cxr\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source.\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: As per admission note, patient is Section 12.\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\n has been long standing issue. Per psych notes, has had \"agitation,\n pressured speech, loose and tangential, racing thoughts and decreased\n sleep consistent with possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor\n"
},
{
"category": "Physician ",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 373826,
"text": "24 Hour Events:\n -3.5L O/N\n -No episodes of hypotension\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37.1\nC (98.8\n HR: 88 (86 - 106) bpm\n BP: 151/74(92) {107/46(64) - 200/113(118)} mmHg\n RR: 18 (0 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 1,550 mL\n 180 mL\n PO:\n 1,450 mL\n 180 mL\n TF:\n IVF:\n 100 mL\n Blood products:\n Total out:\n 4,900 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -3,350 mL\n 180 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///30/\n Physical Examination\n General - Resting comfortably in bed, no acute distress. No audible\n wheezing, head nods and answers yes/no to questioning.\n HEENT - Sclera anicteric, dry mucous membranes\n Neck - Supple,\n Pulm - CTA bilaterally +expiratory wheezing, +wet crackles.\n CV - RRR, normal S1/S2; no murmurs, rubs, or gallops\n Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended\n Ext - Warm, well perfused, radial pulses 2+; DP and PT pulses 1+, equal\n bilaterally; LLE with swelling extending above knee, trace pitting\n edema to shin without obvious erythema\n Neuro - Moves all extremities; unable to do exam given somnolence\n Labs / Radiology\n 457 K/uL\n 8.3 g/dL\n 296 mg/dL\n 5.1 mg/dL\n 30 mEq/L\n 5.4 mEq/L\n 29 mg/dL\n 93 mEq/L\n 132 mEq/L\n 26.6 %\n 15.1 K/uL\n [image002.jpg]\n 03:53 AM\n 03:17 PM\n WBC\n 14.7\n 15.1\n Hct\n 27.6\n 26.6\n Plt\n 550\n 457\n Cr\n 7.8\n 5.1\n TropT\n 0.27\n Glucose\n 74\n 296\n Other labs: PT / PTT / INR:14.8/26.9/1.3, CK / CKMB /\n Troponin-T:157/3/0.27, ALT / AST:221/153, Alk Phos / T Bili:255/0.3,\n Differential-Neuts:84.8 %, Lymph:7.4 %, Mono:4.9 %, Eos:2.6 %,\n Albumin:3.2 g/dL, LDH:283 IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.9\n mg/dL\n Bcx (): PND\n Bcx (): PND\n UCx (): Negative\n Assessment and Plan\n 31M with ESRD on HD, DMI, HTN, hypercholesterolemia admitted via\n Section 12 for hyperkalemia in context of missed HD. Transferred to\n medicine service on for further management of lower extremity\n swelling and placement in psychiatric facility. transferred to the\n MICU for hypoxia.\n .\n #hypoxia-likely secondary to volume overload from renal failure. Renal\n following, given dialysis yesterday early AM, continues to be fluid\n overloaded. Will continue to diureses as per renal recommendations and\n fluid restrict (1L per day, 80mg lasix QD).\n -bcx and ucx\n -cxr\n -has had several LENI's that have been neg for PE.\n -tele\n -EKG\n -CE's.\n .\n #. Lower extremity swelling: Patient has clear asymmetry of lower\n extremities, L>R extending above knee. Lower extremity dopplers x2\n negative for clot. CT pelvis neg for clot. Has intermitent pain in leg.\n Differential diagnosis for unilateral extremity swelling includes\n thrombosis, obstruction of venous return by extravascular source,\n cellulitis. Patient is on calcium-channel blocker, but would expect\n bilateral edema if this were the source.\n - Continue DVT prophylaxis as below\n -vanco started by floor team.\n .\n #. TWI lateral leads: Changed from admission. I, aVL, V4-V6. Patient\n had perstantine MIBI stress test in which was normal but with\n suboptimal heart rate. Several risk factors for CAD. At time of writing\n this note, patient more responsive; denies chest pain, shortness of\n breath, palpitations, back pain.\n - Aspirin 325mg PO daily\n - cardiac enzymes- negative\n - Continue beta-blocker\n .\n #. ESRD: CKD secondary to diabetes mellitus, type I. On hemodialysis as\n outpatient, although missed sessions prior to admission to MICU.\n Previously evaluated for transplantation by Dr. . Still with\n hyperphosphatemia; improving. Hyperkalemia recurrent.\n - Continue HD per home regimen (T/Th/Sat)\n - Renal diet\n - Continue cinacalcet, lanthanum, calcium acetate, nephrocaps\n - Renal recs\n .\n #. Anemia: Baseline hematocrit 28-32. Currently hematocrit 26.\n Secondary to ESRD and likely anemia of chronic disease (iron studies\n last checked .\n - Continue Epo at HD\n - Guaiac stools\n .\n #. Hypertension: Blood pressure elevated on yesterday. Home regimen\n unclear at this time\n - Changed to , due to concern for edema\n - Continue amlodipine\n - Patient currently on metoprolol, no longer on atenolol\n .\n #. Diabetes mellitus, type I: Last A1c , 7.4%. Refuses AM insulin,\n so on , insulin changed to once a day lantus at night.\n - humalog SSI\n - QID fingersticks\n .\n #. Psychiatric history: As per admission note, patient is Section 12.\n Followed by psychiatry. ?bipolar disorder component. Poor compliance\n has been long standing issue. Per psych notes, has had \"agitation,\n pressured speech, loose and tangential, racing thoughts and decreased\n sleep consistent with possible mania.\"\n - One to one sitter\n - Per psych recs, Haldol and Ativan prn for agitation; decreased haldol\n dose given sedation with 5mg IV\n - follow QTc if giving frequent doses of Haldol\n - Code purple if tries to leave AMA\n - possible psychiatry admission after medically stable for\n \"stabilization of mood and behavior that might then allow for more\n optimal medical mgmt\"\n - Psychiatry recs\n - starting PO haldol 1mg, will start 1mg tomorrow, using 0.5mg\n extra doses as needed, will uptitrate standing dose\n .\n #. Hyperlipidemia:\n - Continue statin per home regimen\n .\n #. Increase in size of cardiac silhouette by CXR on : Concern for\n pericardial effusion ruled out with TTE.\n .\n #. FEN/GI:\n - Renal, diabetic diet\n - Replete lytes as needed\n .\n #. Prophylaxis:\n - DVT - Heparin SC TID\n - Bowel - As needed\n - PPI - Not indicated at this time\n .\n #access-AV fistula, PIV\n .\n #. Contact: does not wish for his medical care to be discussed\n with family members.\n .\n #. Code status: FULL CODE\n .\n #. Disposition: Patient may not leave hospital without psychiatric\n clearance. Likely discharge to psychiatric facility after medically\n stable.\n ICU Care\n Nutrition: DM/RENal\n Glycemic Control: HISS\n Lines:\n 20 Gauge - 03:34 AM\n Prophylaxis:\n DVT: h2, HSC\n Stress ulcer:\n VAP: n/a\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Floor\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373709,
"text": "Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Overnight Events\n L leg remains swollen and tender to touch\n Pt desatuating on RA to80\ns, productive cough\n Pt compliant with meds and no periods of agitation, remains\n on 1:1 sitter\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt with known ESRD, non-compliant with medical care prior to admit HD\n done , tol well.\n Action:\n 1000ml fluid restriction maintained.\n Response:\n Pt compliant with meds, and fluid restriction\n Plan:\n Monitor fluid balance, ?HD today\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Known non-compliance with medical regimen. ? untreated Bipolar\n disease. History of leaving AMA, pt is Currently under Section 12 and\n has 1:1 sitter and can NOT leave.\n Action:\n Pt is on Haldol and received PRN dose x1 a/o\n Response:\n Pt has been cooperative with care, 1:1 sitter\n Plan:\n Psych and SW attempting to get medical guardianship, meeting today\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 373809,
"text": "Mr. is a 31 year-old male initially admitted to the MICU \n for hyperkalemia. He has a long history of poor compliance with\n dialysis and medical care. He was sent to the ED after his nephrologist\n found he was hyperkalemic. His last dialysis session prior to admission\n was .. He was seen by psychiatry in the ED and admitted under\n section 12 because he was not deemed competent to decline medical care.\n He received haldol and ativan, and was sent to the MICU because of\n somnolence after receiving these meds. His K+ peaked at 6.4 and there\n was some concern for peaked T waves. He never accepted kayexalate but\n he has had two dialysis prior to transfer to the floor.\n .His left leg was noted to be bigger than his right. LENIs were\n negative x2. He was started on Unasyn give a concern for cellulitis. Of\n note, he remained afebrile and did not have a leukocytosis.\n .\n On , pt was noted to be lethargic with RA sat of ~60%. Pt placed on\n NRB where his sats increased to 90%, then 98% after 80mg IV lasix.\n Peaked T waves were noted on EKG and pt was given ca gluconate, 1amp\n dextrose. He was initially given keflex for LLE cellulitis, then\n changed to vanco(last dose 4/30 at 0200). Given pt's current\n respiratory status, the renal fellow made the decision the urgently\n dialyze the pt and he was therefore transferred to the MICU.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Pt\ns K+ has been dropping with dialysis.\n Action:\n last K+ level was 4.4 at 1030 \n Response:\n Pt responding to dialysis.\n Plan:\n Continue dialysis according to his schedule.\n .H/O renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Since admission to the MICU pt has been had two sessions of diaylsis\n Action:\n Last dialysis was today with the removal of 5l of fluid.\n Yesterday they also removed 5l of fluid\n Response:\n With the total removal of 10 liters of fluid in the last 2 days his O2\n requirement dropped from NRB to room air. O2 sats are 96-100%.\n Plan:\n Continue with fliud restriction, continue with dialysis treatments.\n Psychiatric Disease, Other (including Schizophrenia, Personality\n Disorders)\n Assessment:\n Pt has been very manic today, He is in a good mood, talking almost\n constantly day. The family meeting with social services and Psych was\n cancelled but an informal family meeting was held at 1500.\n Action:\n Haldol 1.5 mg continues to be given q12h\n Response:\n Behavior in control today.\n Plan:\n Pt called out to the floor,\n Demographics\n Attending MD:\n \n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH: Hypertension\n Additional history: hyperlipedemia, diabetes type I on insulin end\n stage renal disease, on hemo tue/thurs/ sat. psychiatric history\n section 12 patient has 1:1 sitter. pt becomes agitated speech is\n pressured,racing thoughts decreased sleep consistent with possible\n mania. lower left extremitiy swelling dopplerable. neg for clots.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:136\n D:113\n Temperature:\n 96.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 89 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 95% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 100% %\n 24h total in:\n 1,100 mL\n 24h total out:\n 5,000 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 10:30 AM\n Potassium:\n 4.8 mEq/L\n 10:30 AM\n Chloride:\n 95 mEq/L\n 10:30 AM\n CO2:\n 31 mEq/L\n 10:30 AM\n BUN:\n 28 mg/dL\n 10:30 AM\n Creatinine:\n 4.6 mg/dL\n 10:30 AM\n Glucose:\n 326 mg/dL\n 10:30 AM\n Hematocrit:\n 26.4 %\n 10:30 AM\n Finger Stick Glucose:\n 351\n 10:00 AM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Micu 687\n Transferred to: 201\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 372931,
"text": "Pt is a 31 y.o male with DM1, ESRD on HD, reportedly on the transplant\n list who presents again with hyperkalemia after missing HD. Pt\n reportedly not cooperative in the ED and agitated. Of note, pt has had\n several admissions for hyperkalemia/missing HD sessions and left the\n hospital AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIs negative and pt was\n given unasyn. In the , Pt refused kayexylate, EKG. Pt was given\n haldol 5mg IV and ativan 2mg IV. Renal fellow aware that pt is here and\n HD planned for tonight. EKG showing ?some peaked T's. No intervention\n for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW)was to\n section the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt w/h ESRD on HD, pt has fistula on his right hand positive for\n thrill and brui. K was 6.4 in the ED.\n Action:\n HD for / hrs at bedside.\n Response:\n Rmoved 2.5 L fluid with Dialysis. Will repeat his lab around 0600.\n Plan:\n Follow up with renal, cont HD Monitor lytes and treat accordingly. C/O\n If stable.\n"
},
{
"category": "Nursing",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373010,
"text": "31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 373152,
"text": "TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\n treatment. Unfortunately pt became agitated, angry and appeared\n threatening early this afternoon. Feelings validated and pt given\n ample time to voice his displeasure to no avail. Stat security called\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\n admin. Pt now more cooperative and is not agitated. Pt seems to last\n 8 to 12 hours between outbursts.\n Impaired Health Maintenance\n Assessment:\n As noted above, the pt was more or less cooperative with care this AM\n (though refused all AM meds). Unfortunately pt impulsively became\n angry/agitated/beligerant this afternoon requiring stat security @ BS.\n Stable QTi on EKG this AM. Soft wrist restraints in place. 1:1 Sitter\n @ BS.\n Action:\n With security @ BS and a supportive sitter whom the pt trusted the pt\n relented and allowed 5mg IVP Haldol to be admin @ BS.\n Response:\n Pt now more cooperative with no agitation issues @ this time.\n Plan:\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\n becoming acutely agitated. Follow serial EKG QTi as long as IV Haldol\n treatment in place.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt received his third HD in three days today. AM potassium value of\n 4.3 noted.\n Action:\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\n Response:\n Pt without significant issues surrounding HD treatment.\n Plan:\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\n for Mon vs Tues.\n Demographics: The pt is appearantly estranged from his mother and has\n issues with some of his siblings. Pt also appears to have issues of\n homelessness. Pt with multiple recent hospital admits s/p missed HD\n treatments with significant hyperkalemia.\n Attending MD:\n R.\n Admit diagnosis:\n HYPERKALEMIA\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 71.2 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH: Anemia, Diabetes - Insulin, Renal Failure, Smoker\n CV-PMH: Hypertension\n Additional history: Diabetic retinopathy. Anemia. Recent LLE swelling\n (Leni's negative times two). diabetic neuropathy\n Diabetic myonecrosis. Chronic ulcer right foot\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:155\n D:65\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 380 mL\n 24h total out:\n 1,200 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 10:05 AM\n Potassium:\n 4.8 mEq/L\n 10:05 AM\n Chloride:\n 96 mEq/L\n 10:05 AM\n CO2:\n 29 mEq/L\n 10:05 AM\n BUN:\n 29 mg/dL\n 10:05 AM\n Creatinine:\n 7.2 mg/dL\n 10:05 AM\n Glucose:\n 83 mg/dL\n 10:05 AM\n Hematocrit:\n 29.2 %\n 10:05 AM\n Finger Stick Glucose:\n 147\n 10:05 AM\n Valuables / Signature: All of the pts personal property (5 bags) have\n been moved to a holding area on CC2.\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6 West.\n Transferred to: 226\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2176-06-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 373149,
"text": "TITLE: 31M with DM1, ESRD on HD, reportedly on the transplant list who\n presents again with hyperkalemia after missing HD. Pt reportedly not\n cooperative in the ED and agitated. Of note, pt has had several\n admissions for hyperkalemia/missing HD sessions and left the hospital\n AMA including most recently on . During pt's most recent\n admission/ED visit pt reported LLE swelling, LENIS negative and pt was\n given IV ABX. In the , pt refused kayexylate. Pt was given haldol and\n ativan IV. Renal fellow aware that pt is here and HD planned for\n tonight. No intervention for hyperkalemia given plan for HD.\n Given pts multiple AMA's and noncompliance with HD and medical\n treatment, pt's outpt HD SW feels that pt has an underlying psychiatric\n disorder that makes him incompetent to make medical decisions.\n Therefore, plan (developed by outpt renal Dr. and SW) was to\n section 12 the pt for HD and psychiatric eval. Psychiatry saw pt in the\n ED, feels that he lacks competency and suggests that the medical team\n pursue legal guardianship.\n EVENTS: Pt had a fairly quiet AM with good tol of a 4 hour HD\n treatment. Unfortunately pt became agitated, angry and appeared\n threatening early this afternoon. Feelings validated and pt given\n ample time to voice his displeasure to no avail. Stat security called\n @ 14:30, pt finally calmed down and allowed 5mg IVP Haldol to be\n admin. Pt now more cooperative and is not agitated. Pt seems to last\n 8 to 12 hours between outbursts.\n Impaired Health Maintenance\n Assessment:\n As noted above, the pt more or less cooperative with care this AM.\n Unfortunately pt became angry/agitated/ beligerant this afternoon\n requiring stat security @ BS. Stable QTi on EKG this AM.\n Action:\n With security @ BS and a supportive sitter whom the pt trusted the pt\n relented and allowed 5mg IVP Haldol to be admin @ BS.\n Response:\n Pt now more cooperative with no agitation issues @ this time.\n Plan:\n Cont to provide IV Haldol, IV Ativan judiciously to prevent pt from\n becoming agitated. Follow serial EKG QTi as long as IV Haldol\n treatment in place.\n Renal failure, End stage (End stage renal disease, ESRD)\n Assessment:\n Pt received his third HD in three days today.\n Action:\n 1.2 liters of ultrafiltrate removed during four hour session @ BS.\n Response:\n Pt without significant issues surrounding HD treatment.\n Plan:\n Pt will likely get a HD holiday on Sunday with next HD treatment slated\n for Mon vs Tues.\n"
},
{
"category": "Echo",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Report",
"row_id": 83971,
"text": "PATIENT/TEST INFORMATION:\nIndication: Enlarged cardiac size on CXR. Evaluate for effusion\nHeight: (in) 69\nWeight (lb): 156\nBSA (m2): 1.86 m2\nBP (mm Hg): 128/66\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 16:46\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: Moderate symmetric LVH. Small LV cavity. Hyperdynamic LVEF\n>75%. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal aortic arch diameter. Focal calcifications in aortic arch.\nNo 2D or Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal\ntricuspid valve supporting structures. No TS. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: 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\nConclusions:\nThe left atrium is normal in size. There is moderate symmetric left\nventricular hypertrophy. The left ventricular cavity is unusually small. Left\nventricular systolic function is hyperdynamic (EF 80%). There is no\nventricular septal defect. Right ventricular chamber size and free wall motion\nare normal. There are focal calcifications in the aortic arch. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is mild mitral valve prolapse. Trivial mitral regurgitation is seen. The\nestimated pulmonary artery systolic pressure is normal. There is no\npericardial effusion. There is an anterior space which most likely represents\na fat pad.\n\nCompared with the findings of the prior study (images unavailable) of , the left ventricular wall thickening has progressed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1075959,
"text": " 12:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, edema\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with h/o DM and ESRD on HD who had desat to 60% on RA.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Diabetes mellitus, desaturation.\n\n FINDINGS: As compared to the previous radiograph, there is a newly appeared\n extensive opacity in the middle and basal parts of the right lung and in the\n retrocardiac lung areas. The opacity is of alveolar morphology, multiple\n subtle air bronchograms are seen. The opacities tend to spare in the\n uppermost parts of the lung. In the region of the right hilus, subtle\n peribronchial cuffing is seen. However, all other signs indicative of\n overhydration are missing. In the light, they are much more likely to\n represent pneumonia rather than edema.\n Unchanged size of the cardiac silhouette, unchanged mediastinal contours.\n\n was notified by telephone at the time of dictation and informed\n about the abnormalities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-08 00:00:00.000",
"description": "L KNEE (AP, LAT & OBLIQUE) LEFT",
"row_id": 1076429,
"text": " 10:24 PM\n KNEE (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: Any fracture or other left knee pathology evident on plain f\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with leg lower extremity swelling and new left knee pain.\n REASON FOR THIS EXAMINATION:\n Any fracture or other left knee pathology evident on plain film?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left lower extremity swelling. New left knee pain.\n\n LEFT KNEE, THREE VIEWS\n\n There is deformity and increased density in the right tibial plateau\n consistent with a tibial plateau fracture, with depression. There is a\n probable joint effusion. There is minimal spurring about the patella. There\n is an ossific fragment along the medial border of the patella, which appears\n well corticated, and which could represent a either fracture fragment or\n heterotopic ossification in the medial retinaculum. No dislocation is\n identified. Dense vascular calcification is noted.\n\n IMPRESSION:\n\n 1) Findings consistent with medial tibial plateau fracture likely subcaute or\n chronic .\n\n 2) Ossicle along medial patella -- ? nonacute fracture vs post- traumatic\n heterotopic ossificaiton in adjoining medial retinaculum. Possible subacute\n fracture along the medial patella.\n\n 3. Joint effusion.\n\n Findings discussed with covering house officer Dr. at\n approximately 13:18 p.m. on the day of the exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-08 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 1076405,
"text": " 4:59 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: LLE SWELLING EVAL FOR DVT\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with possible DVT, dialysis patient\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n WET READ: DLrc SAT 6:47 PM\n No evidence of left lower extremity DVT. Prominent lymph nodes in the left\n groin.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 31-year-old male with possible deep venous thrombus.\n Evaluate for deep venous thrombus.\n\n EXAMINATION: Unilateral left lower extremity DVT study.\n\n COMPARISONS: Comparison to ultrasound examination from .\n\n FINDINGS: Grayscale and color Doppler son of the left common femoral,\n superficial femoral and popliteal veins were performed. There is normal\n compressibility, flow, augmentation. There is symmetric respiratory\n variability in the right and left common femoral veins.\n\n IMPRESSION: No evidence of left lower extremity DVT.\n SESHa\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-10 00:00:00.000",
"description": "L CT LOW EXT W/O C LEFT",
"row_id": 1076744,
"text": " 6:12 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: to evaluate knee fracture\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with hx of ESRD on HD, now with knee injury 2 weeks ago, now\n with plain films showing tibial and patellar fractures.\n REASON FOR THIS EXAMINATION:\n to evaluate knee fracture\n CONTRAINDICATIONS for IV CONTRAST:\n ESRD\n ______________________________________________________________________________\n WET READ: CXWc MON 8:46 PM\n Impacted right medial tibial plateau fracture extending to the articular\n surface, with pleateau depression of approximately 8mm. Bony sclerosis\n consistent with subacute fracture. Tiny intra-articular bony fragment\n posteriorly. Additionally, comminuted fractures of the medial and lateral\n tibial spines. Moderate joint effusion. Fragmentation of medial patella\n consistent with nondisplaced, comminuted fracture. Extensive vascular\n calcifications.\n ______________________________________________________________________________\n FINAL REPORT\n CT OF LEFT KNEE\n\n INDICATION: Knee injury. Tibial and patellar fractures.\n\n TECHNIQUE: Non-contrast multidetector CT of the left knee was performed.\n Multiplanar reformations were carried out.\n\n COMPARISON: Radiograph of left knee .\n\n FINDINGS:\n\n There is an impacted fracture of the left medial tibial plateau with at least\n 5 mm of depression of the medial tibial plateau. Comminution is evident with\n small fracture fragments at the medial aspect of the medial plateau (series\n 500B, image 31). Extension of the fracture line into the intercondylar\n eminence and into the medial tibial spine is evident.\n\n The lateral tibial plateau is intact. The proximal tibial and fibular shafts\n are intact. The distal femur demonstrates no evidence of focal bone lesion or\n fracture.\n\n There is a small fracture through the medial aspect of the patella. The\n fracture is minimally displaced, with approximately 2 mm of medial\n displacement of the smaller medial component of the fracture.\n\n Assessment of the internal structures of the knee is limited on CT, but no\n gross ligament abnormality is demonstrated.\n\n There is a moderate to large knee joint effusion. There is evidence of\n diffuse vascular calcification. The bones appear demineralized.\n (Over)\n\n 6:12 PM\n CT LOW EXT W/O C LEFT Clip # \n Reason: to evaluate knee fracture\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Depressed, impacted medial tibial plateau fracture which also extends to\n the intercondylar eminence and medial tibial spine.\n 2. Medial patellar fracture.\n 3. Moderate to large knee joint effusion.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-11 00:00:00.000",
"description": "OL KNEE( (SINGLE VIEW) IN O.R. LEFT",
"row_id": 1076811,
"text": " 8:06 AM\n KNEE( (SINGLE VIEW) IN O.R. LEFT; LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. LEFTClip # \n Reason: ORIF LEFT TIBIAL PLATEAU FX\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Tibial plateau fracture.\n\n A single intraoperative fluoroscopic view of the left knee was obtained\n without a radiologist present. This again demonstrates a depressed medial\n tibial plateau fracture, similar to that seen on . For additional\n details, please consult the operative report.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-12 00:00:00.000",
"description": "Report",
"row_id": 209357,
"text": "Normal sinus rhythm. Lateral T wave abnormalities. Compared to the previous\ntracing of lateral T wave abnormalities are new. Some of these\nabnormalities have been seen on previous tracings but now they are increased\nin leads V5-V6.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-09 00:00:00.000",
"description": "Report",
"row_id": 209358,
"text": "Normal sinus rhythm. J point elevation consistent with normal early\nrepolarization. Otherwise, within normal limits. Compared to the previous\ntracing of previous non-specific ST-T wave abnormalities have resolved.\nOtherwise, no important change. Clinical correlation and repeat tracing are\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-06 00:00:00.000",
"description": "Report",
"row_id": 205615,
"text": "Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the\nprevious tracing of no major change.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-05 00:00:00.000",
"description": "Report",
"row_id": 205616,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , the heart rate is slower\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-04 00:00:00.000",
"description": "Report",
"row_id": 205617,
"text": "Sinus rhythm upper normal rate\nNormal ECG\nSince previous tracing of , ST-T wave abnormalities are less\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-01 00:00:00.000",
"description": "Report",
"row_id": 205618,
"text": "Sinus rhythm. Compared to the previous tracing of there is\nT wave inversion in lead I and more prominent T wave inversion in\nlead aVL as well as new T wave inversion in leads V4-V6. Active\nlateral ischemic process cannot be excluded. Followup and clinical correlation\nare suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-02 00:00:00.000",
"description": "Report",
"row_id": 205619,
"text": "Sinus rhythm. Compared to the previous tracing no change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Report",
"row_id": 205620,
"text": "Sinus rhythm. Compared to the previous tracing of no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2176-05-31 00:00:00.000",
"description": "Report",
"row_id": 205621,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2176-05-30 00:00:00.000",
"description": "Report",
"row_id": 205622,
"text": "Sinus rhythm. Normal tracing. Compared to the previous tracing there is no\nsignificant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2176-05-27 00:00:00.000",
"description": "Report",
"row_id": 205623,
"text": "Sinus rhythm. Baseline artifact. Delayed precordial R wave transition. The\nP wave morphology appears less prominent while the P wave axis remains\nrightward. The prior tracing was consistent with right atrial abnormality.\nOtherwise, no diagnostic interim change. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2176-06-07 00:00:00.000",
"description": "Report",
"row_id": 205614,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous\ntracing of ST-T wave changes are new.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-03 00:00:00.000",
"description": "CT PELVIS W&W/O C",
"row_id": 1075475,
"text": " 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with left lower extremity swelling, negative LENI, concern for\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\n better visualization of veins.\n REASON FOR THIS EXAMINATION:\n eval for venous thrombosis\n CONTRAINDICATIONS for IV CONTRAST:\n Has ESRD and will get dialyzed Tuesday.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AJy MON 8:10 PM\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\n Extensive vascular calcifications _____, likely reflecting the patient's\n history of diabetes. There is no acute pelvic pathology.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old male with left lower extremity swelling and negative\n LENI. Evaluate for proximal clot in the iliac veins or IVC. The patient has\n a history of hypertension, diabetes, and end-stage renal disease.\n\n COMPARISON: None available.\n\n TECHNIQUE: Contiguous axial images were obtained through the pelvis prior to\n and following administration of intravenous contrast, and three-minute delayed\n phase protocol. Multiplanar reformats were prepared and reviewed.\n\n FINDINGS: Within limits of non-contrast and delayed phase imaging, visualized\n portion of the liver, gallbladder, pancreas, and kidneys are normal. There is\n no evidence for biliary dilatation, cholelithiasis, or hydronephrosis.\n Visualized pelvic loops of small and large bowel are unremarkable. There is\n high-density material within the colon, likely reflecting magnesium-containing\n laxative or antacid use. There is no bowel distention or bowel wall\n thickening. There is no free fluid or free air. There is no lymphadenopathy\n appreciated.\n\n Vascular calcifications are noted in the pelvic vessels, greater than expected\n for a patient of this age, likely due to the patient's history of diabetes.\n There is normal appearance and opacification of the bilateral iliac veins and\n IVC, with no evidence for venous thrombosis.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n 1. No evidence for venous thrombosis in the bilateral iliac vessels or IVC.\n 2. Vascular calcifications, greater than expected for a patient of this age,\n likely reflecting history of diabetes.\n 3. Within the limits of non-contrast and delayed phase imaging, no acute\n pelvic pathology.\n (Over)\n\n 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-03 00:00:00.000",
"description": "CT PELVIS W&W/O C",
"row_id": 1075476,
"text": ", R. MED FA2 4:12 PM\n CT PELVIS W&W/O C Clip # \n Reason: eval for venous thrombosis\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with left lower extremity swelling, negative LENI, concern for\n clot. Has h/o HTN, IDDM, and ESRD on dialysis. Please do delayed phase for\n better visualization of veins.\n REASON FOR THIS EXAMINATION:\n eval for venous thrombosis\n CONTRAINDICATIONS for IV CONTRAST:\n Has ESRD and will get dialyzed Tuesday.\n ______________________________________________________________________________\n PFI REPORT\n PFI: Delayed phase imaging demonstrates normal opacification and appearance\n of the bilateral iliac veins and IVC, with no evidence for venous thrombosis.\n Extensive vascular calcifications _____, likely reflecting the patient's\n history of diabetes. There is no acute pelvic pathology.\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-05-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1074872,
"text": " 11:16 PM\n CHEST (PA & LAT) Clip # \n Reason: eval effusion, pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with hx esrd\n REASON FOR THIS EXAMINATION:\n eval effusion, pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 31-year-old with history of end-stage renal disease.\n\n COMPARISON: \n\n PA AND LATERAL RADIOGRAPHS OF THE CHEST: The lateral view is limited due to\n inability of the patient to raise her arms. The lungs are grossly clear. The\n cardiac silhouette is increasing in size, even despite the lordotic\n positioning of the film, raising the possibility of pericardial effusion in\n this end- stage renal disease patient. The mediastinal contours are normal.\n There is no effusion or pneumothorax.\n\n IMPRESSION: Enlarging cardiac silouette, raising the possibility of\n pericardial effusion.\n\n Dr. was paged with these findings at 11:30 AM on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1076037,
"text": " 9:52 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls eval for infiltrate, consolidation, effusion\n Admitting Diagnosis: HYPERKALEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 31 year old man with ESRD, hypoxia\n REASON FOR THIS EXAMINATION:\n pls eval for infiltrate, consolidation, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Followup.\n\n COMPARISON: .\n\n As compared to the previous radiograph, the lung volumes have increased.\n Despite the resulting overall decrease in lung parenchymal transparency,\n subtle areas of parenchymal opacities, notably in the left basal and\n retrocardiac areas and at the right lung bases persist, so that the suspicion\n of pneumonia cannot be discarded. No evidence of pleural effusions.\n Unchanged mediastinal contours. The size of the cardiac silhouette is smaller\n than before.\n\n\n"
}
] |
85,444 | 152,754 | 58 y/o male who is admitted from home for liver . He received a DCD liver and the patient was taken to the OR with Dr after a careful discussion with the patient. The patient tolerated the procedure without difficulty, and the procedure was undertaken without significant complication. The donor liver appeared well perfused at the end of the case. The patient received routine immunosuppression induction to include cellcept, solumedrol intra-op with taper and started prograf on the evening of POD 1. The patient did require multiple transfusions in the ICU per the bleeding pathway, but was never hemodynamically unstable as a result of his bleeding, and by POD his HCT had stabilized. The liver did very well in the post op period. LFTs declined daily and T bili was 2.3 at the time of DC. The remainder of his post operative course was unremarkable. He successfully demonstrated adequate knowledge of his medications and at the time of discharge was sent home on tacrolimus, cellcept and the remainder of his prednisone taper. He was sent home with VNA for lab draws and with plan for close follow up in the clinic. Medications on Admission: : Entacavir 1 mg daily, Tenofavir 300 mg daily, Furosemide 20 mg daily, Spironolactone 100 mg daily, Clotramazole 10 mg troche (intermittent use) | small right pleural effusion. Small right pleural effusion. There is a small right pleural effusion. New small left pleural effusion. Left anterior fascicular block. Unchanged minimal right basal atelectasis. Upper abdominal drains in place. No larger pleural effusions. NG tube is in nondistended stomach. Sinus rhythm with left anterior fascicular block. A Swan-Ganz catheter appears to end in the proximal right pulmonary artery. New small left pleural effusion is present. Hilar, mediastinal and cardiac silhouettes are stable. The right, middle, and left hepatic veins are patent with appropriate waveforms. Extreme right lateral abdomen not fully included on the images. Sinus rhythm. Right IJ catheter tip projects over cavoatrial junction. The main hepatic artery and intrahepatic right and left hepatic arteries are patent, with appropriate waveforms demonstrating sharp systolic upstroke and preserved flow through diastole. NG tube ends within the stomach. patent MHA, RHA, LHA with appropriate waveforms. Swan-Ganz catheter has been removed. FINDINGS: Right IJ tip projects over cavoatrial junction. Upper abdominal drains are in place. patent RHV, MHV, LHV with appropriate waveforms. The right and left portal veins are patent, with forward flow. IMPRESSION: 1. IMPRESSION: 1. Unchanged moderate cardiomegaly without overt pulmonary edema. FINDINGS: As compared to the previous radiograph, the patient has been extubated. Pleural surfaces are normal. Left axis deviation. IMPRESSION: AP chest compared to preoperative study, : ET tube, nasogastric tube, Swan-Ganz catheter, in standard placements. IMPRESSION: Needle driver not seen within the imaged abdomen. COMPARISONS: Chest x-ray from . Compared tothe previous tracing of there is no diagnostic change.TRACING #1 Heart size normal. IMPRESSION: No acute cardiopulmonary process. Intraoperative films. The main portal vein is patent, with forward flow. patent MPV, RPV, LPV with forward flow. Two abdominal drains within the right abdomen. PA AND LATERAL VIEW, CHEST: Lungs are clear. 10:03 PM ABDOMEN (SUPINE ONLY); CHEST (SINGLE VIEW) Clip # Reason: MISSING NEEDLE HOLDER. Hilar contours and heart size is normal. INTRA-OP FILMS. Compared to the previoustracing there is no diagnostic change.TRACING #2 Left retrocardiac opacity, which may represent atelectasis, pleural fluid or infection in the right clinical setting. Lungs clear. Endotracheal tube ends 2.5 cm above the carina. No pneumothorax. No pneumothorax. IJ line placement. Normal liver transplant ultrasound with patent hepatic vasculature. Lung volumes are low. No pneumothorax or pleural effusion. COMPARISON: . COMPARISON: . SUPINE ABDOMINAL RADIOGRAPHS AND RADIOGRAPH OF NEEDLE DRIVER: Image of the needle holder/driver indicates the appearance of the missing intra-operative foreign body. Turbulent flow in the main portal vein may be related to the surgical anastomosis, with no definite stenosis identified. Retrocardiac opacity silhouetting left hemidiaphragm may represent pleural fluid, atelectasis or infection in the right clinical setting. 2. 2. There is no pulmonary edema. Allowing for this limitation, there is no intra- or extra-hepatic biliary ductal dilation. 2:19 PM CHEST PORT. COMPARISON: None. The other monitoring and support devices are unchanged. 10:58 PM CHEST PORT. 3. Multiple skin staples overlie the abdomen. The common duct measures 2 mm. No needle driver is noted projected within the imaged abdominal cavity. No evidence of focal parenchymal opacity suggesting pneumonia. ET tube is 5 cm from the carina. turbulent flow in MPV may be due to surgical anastamosis. Turbulent flow in the main portal vein may be due to the surgical anastomosis. Admitting Diagnosis: PRE-OP LIVER TRANSPLANT FINAL REPORT INDICATION: 46-year-old man with missing needle holder. FINAL REPORT HISTORY: 46-year-old male, operative day #1, status post liver transplant. TRANSPLANT LIVER ULTRASOUND: Imaging of the transplanted liver is limited due to the skin bandage and inability of the patient to hold his breath. 4:19 AM CHEST (PORTABLE AP) Clip # Reason: interval change Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man POD1 liver tx REASON FOR THIS EXAMINATION: interval change FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post liver transplant, assessment for interval change. 9:50 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # Reason: liver transplant u/s, POD 1 Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man with new liver REASON FOR THIS EXAMINATION: liver transplant u/s, POD 1 WET READ: JXRl TUE 12:10 PM no intra or extrahepatic biliary ductal dilation. LINE PLACEMENT Clip # Reason: Please eval for appropriate line placement/PTX Admitting Diagnosis: PRE-OP LIVER TRANSPLANT MEDICAL CONDITION: 46 year old man with ESLD s/p liver transplant, with swan/cordis switched to triple lumen CVL REASON FOR THIS EXAMINATION: Please eval for appropriate line placement/PTX FINAL REPORT INDICATION: Patient is status post liver transplant. | 8 | [
{
"category": "Radiology",
"chartdate": "2184-08-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1151372,
"text": " 2:19 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please eval for appropriate line placement/PTX\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with ESLD s/p liver transplant, with swan/cordis switched to\n triple lumen CVL\n REASON FOR THIS EXAMINATION:\n Please eval for appropriate line placement/PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is status post liver transplant. IJ line placement.\n\n COMPARISONS: Chest x-ray from .\n\n FINDINGS:\n\n Right IJ tip projects over cavoatrial junction. No pneumothorax.\n\n New small left pleural effusion is present. Retrocardiac opacity silhouetting\n left hemidiaphragm may represent pleural fluid, atelectasis or infection in\n the right clinical setting. Hilar, mediastinal and cardiac silhouettes are\n stable.\n\n ET tube is 5 cm from the carina. NG tube is in nondistended stomach.\n Swan-Ganz catheter has been removed. Upper abdominal drains are in place.\n\n IMPRESSION:\n\n 1. Right IJ catheter tip projects over cavoatrial junction. No pneumothorax.\n\n 2. New small left pleural effusion.\n\n 3. Left retrocardiac opacity, which may represent atelectasis, pleural fluid\n or infection in the right clinical setting.\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-08-02 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1151181,
"text": " 1:11 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PRE-OP LIVER TRANSPLANT\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man here for liver transplant\n REASON FOR THIS EXAMINATION:\n assess cardiopulmonary status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver transplant and assess cardiopulmonary status.\n\n COMPARISON: .\n\n PA AND LATERAL VIEW, CHEST: Lungs are clear. Pleural surfaces are normal.\n Hilar contours and heart size is normal. There is no pulmonary edema.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-08-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1151473,
"text": " 4:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man POD1 liver tx\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post liver transplant, assessment for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n extubated. The other monitoring and support devices are unchanged. Unchanged\n minimal right basal atelectasis. Unchanged moderate cardiomegaly without\n overt pulmonary edema. No larger pleural effusions. No evidence of focal\n parenchymal opacity suggesting pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-08-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1151271,
"text": " 10:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: RIJ, swan, ETT line placement\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with s/p OLT with new lines\n REASON FOR THIS EXAMINATION:\n RIJ, swan, ETT line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, :06 P.M.\n\n HISTORY: Liver transplant.\n\n IMPRESSION: AP chest compared to preoperative study, :\n\n ET tube, nasogastric tube, Swan-Ganz catheter, in standard placements. Upper\n abdominal drains in place. Lungs clear. No pneumothorax or pleural effusion.\n Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-08-02 00:00:00.000",
"description": "ABDOMEN (SUPINE ONLY)",
"row_id": 1151270,
"text": " 10:03 PM\n ABDOMEN (SUPINE ONLY); CHEST (SINGLE VIEW) Clip # \n Reason: MISSING NEEDLE HOLDER. INTRA-OP FILMS.\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old man with missing needle holder. Intraoperative\n films.\n\n SUPINE ABDOMINAL RADIOGRAPHS AND RADIOGRAPH OF NEEDLE DRIVER: Image of the\n needle holder/driver indicates the appearance of the missing intra-operative\n foreign body. Extreme right lateral abdomen not fully included on the images.\n No needle driver is noted projected within the imaged abdominal cavity. NG\n tube ends within the stomach. A Swan-Ganz catheter appears to end in the\n proximal right pulmonary artery. Endotracheal tube ends 2.5 cm above the\n carina. Two abdominal drains within the right abdomen. Multiple skin staples\n overlie the abdomen. Lung volumes are low.\n\n IMPRESSION: Needle driver not seen within the imaged abdomen. Findings were\n discussed with Dr. at 10:15 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2184-08-03 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1151316,
"text": " 9:50 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT; DUPLEX DOPP ABD/PELClip # \n Reason: liver transplant u/s, POD 1\n Admitting Diagnosis: PRE-OP LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old man with new liver\n REASON FOR THIS EXAMINATION:\n liver transplant u/s, POD 1\n ______________________________________________________________________________\n WET READ: JXRl TUE 12:10 PM\n no intra or extrahepatic biliary ductal dilation. small right pleural\n effusion. patent MPV, RPV, LPV with forward flow. turbulent flow in MPV may\n be due to surgical anastamosis. patent RHV, MHV, LHV with appropriate\n waveforms. patent MHA, RHA, LHA with appropriate waveforms.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 46-year-old male, operative day #1, status post liver transplant.\n\n COMPARISON: None.\n\n TRANSPLANT LIVER ULTRASOUND: Imaging of the transplanted liver is limited due\n to the skin bandage and inability of the patient to hold his breath. Allowing\n for this limitation, there is no intra- or extra-hepatic biliary ductal\n dilation. The common duct measures 2 mm. There is a small right pleural\n effusion.\n\n The main portal vein is patent, with forward flow. Turbulent flow in the main\n portal vein may be due to the surgical anastomosis. The right and left portal\n veins are patent, with forward flow. The right, middle, and left hepatic\n veins are patent with appropriate waveforms. The main hepatic artery and\n intrahepatic right and left hepatic arteries are patent, with appropriate\n waveforms demonstrating sharp systolic upstroke and preserved flow through\n diastole.\n\n IMPRESSION:\n 1. Normal liver transplant ultrasound with patent hepatic vasculature.\n Turbulent flow in the main portal vein may be related to the surgical\n anastomosis, with no definite stenosis identified.\n 2. Small right pleural effusion.\n\n"
},
{
"category": "ECG",
"chartdate": "2184-08-03 00:00:00.000",
"description": "Report",
"row_id": 234952,
"text": "Sinus rhythm with left anterior fascicular block. Compared to the previous\ntracing there is no diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2184-08-02 00:00:00.000",
"description": "Report",
"row_id": 234953,
"text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block. Compared to\nthe previous tracing of there is no diagnostic change.\nTRACING #1\n\n"
}
] |
16,492 | 104,892 | Pt was admitted on for ecxision of Pancoast tumor in RUL. Pain control w/ epidrual is at T6/T7 14/5. She is split receiving both bupivicaine .1% thru epidural and dilaudid PCA because she has a wide incision on multiple dermatomes and a neck incision. She was supported w/ low dose neo while on epidural. Briefly intubated in ICU and, successfully extubated. POD#2 AFIB despite IV lopressor. Treated w/ IV amiodarone bolus, gtt, 2nd bolus and 2 doses of diltiazem. Pain control w/ Epidural- bupivicaine + Dil PCA. 2 chest tubes to suction. Activity OOB > chair, PT, IS. POD#3 Transition to po amiodarone w/ recurrent Afib alt w/ NSR. Re-bolused amiodarone iv and placed back on gtt. Lopressor cont po. CT 1&2 to water seal w/o ptx. Drainage #1<200cc and d/c w/o complication, #2 remained to w/s w/ moderate drainage. Incision anterior and posterior clean and dry, staples intact. POD#4-Amiod po started, lopressor ^50mgBID. Overnight pt had episodes of HR 40 SB-150 Afib, treated with IV lopresssor and Dilt IV with fair rate control. Cardiology consulted.Lopressor 'd 25 .NSR resumed during day. CT #2 d/c w/o complication. PT, IS, ambulation cont w/ high compliance. BS course, very good airation. Inhalers cont. Remains on L O2. Pt R/O'd for MI by enzymes and EKG. POD#5- Per Cardiology rec- Amiod 400 BIDpo; Epid d/c, PCA cont. Lovenox started for anticoagulation in setting of intermittent Afib post epidural d/c. Evidence of left antecubital phlebitis(red, swollen, min discomfort) at old IV site present, Keflex po x10 days started, warm soaks locally w/ small improvement. Chest tube drainge moderate from CT site. Dressing changed prn. POD#6-Remains NSR on Amiod ; PCA weaned, PO Dilaudid started w/ fair effect. Coumadin 5mg dose #1 @1800. Activity/IS compliance excellent. Staples removed and steri-strips applied. Incision- no erythema, small amount serous drainage superior posterior incision. BS course- good airation, inhalers cont. O2 weaned to off w/ good sat at rest and w/ ambulation- 95%RA. POD#7- Cont in NSR,Amiod 400BIDpo, lopresor increased to 50 , restart Imdur 30 mg (1/2 dose), lisinopril 2.5 mg ( daily dose); Coumadin 5mg dose #2 @1800, lovenox ocnt. Pain med changed to percocet w/ very good effect. BM- occurred. Plan for discharge in am POD#8. Discharge plans arranged for anticoagulation follow-up with: VNA for blood draw and post op nursing care, Cardiology clinic short term, then coumadin clinic as of . Follow-up appointments w/ , Cardiology made. PCP, NP, Cardiology NP and Cardiologist informed of plans.Discharge instructions, new medication regimen and instructions reviewed with patient POD#8-Patient discharged to home in stable condition in company of family. Discharge instructions given and reviewed w/ patient and family. | FINDINGS: There has been interval removal of two right apical chest tubes. IMPRESSION: Interval removal of right apical pleural drains. Respiratory CarePt.received from PACU,intubated BBS+diminished on right,and coarse t/o.Placed on vent. 2) Right apical and hilar densities and postoperative changes right lung. Two chest tubes remain in place in the right hemithorax, and there is a persistent right apical pneumothorax. Since the previoustracing of atrial fibrillation has reverted to sinus with atrialpremature beats. Again seen is a right apical and hilar mass, two right-sided chest tubes, and skin staples. There is stable appearance of a persistent right apical pneumothorax. IMPRESSION: Possible small right apical pneumothorax, which in retrospect is probably unchanged. PT REMAINS TACHYCARDIC TO 120- LOPRESSOR RESTARTED. Right chest tubes x2 to 20 cm suction with small air leak.GI - NPO. There is volume loss of the right hemithorax with persistent elevation of the right hemidiaphragm and mediastinal shift to the right. R CT x2 ot H20 seal w/ serous drainage. DR AWARE OF ABOVE.ENDO: SLIDING SCALE INCREASED TO REFLECT BS 140-210.A: NEO WEANED TO OFF, PROPOFOL WEANED OFF, WEANED AND EXTUBATED, EPIDURAL FOR PAIN CONTROL WITH GOOD RELIEFR: TOL EXTUBATION WELL, HEMODYNAMICALLY STABLE, ENCOURAGE PULM TOILET, OOB TO CHAIR IN AM neo gtt to maintain a map> 60, LR at 75cc/hr, epidural at T5 with bupivicaine only.currently, afebrile, heart rate 90s, lopressor held- pt on neo gtt to keep map > 60.resp: vented, lsc with intermittent wheezes, treated with albuterol/atrovent, chest tubes X 2pain: epidural, but pt has sensation at t5, above and below t5. Abdomen benign.GU - Adequate UOP via foley. SBP 120-150 POST-EXTUBATION.RESP: PT WEANED AND EXTUBATED. CT PATENT WITH + AIR LEAK, NO CREPITUS NOTED.GI: ABD SOFT, HYPOACTIVE BS. Respiratory CarePt.remains on full vent.support,sedated with propofol.BBS reveal some exp wheezes t/o treated with Albuterol and atrovent.Abg's adequate. FINDINGS: There remain 2 apical right-sided pleural drains in unchanged position. Right perihilar and paramediastinal opacities are unchanged and attributed to postoperative changes. There are post-surgical changes at the right apex including signs of volume loss of the right hemithorax with persistent elevation of the right hemidiaphragm and mediastinal shift to the right. There is stable postoperative volume loss. Peripheral pulses palpable.Resp - Lungs essentialy clear. Interval decrease in right lung opacity consistent with postsurgical atelectasis. Compared with earlier the same day, the ET tube has been retracted. +periph pulses, sl edema, extrems warm.Resp: on 5l n/p w/ 02 sat 95-98%. DILT IF RATE IS NOT CONTROLLED.R: RAPID RATE UNCONTROLLED BY LOPRESSOR, AMIODARONE GTT INFUSING WITH POOR RATE CONTROL, START DILT IF RATE UNCHANGED IN HR. On the right, there are skin staples and a right chest tube. Foley cath w/ dark, conc yellow uine.Skin: R CT, R flank incision, R neck incision intactPain: Bupivicaine epidural at 6cc/hr - intact. FINAL REPORT PORTABLE CHEST X-RAY , AT 19:06. condition updateD: PLEASE SEE CAREVUE FOR SPECIFICSNEURO: PROPOFOL WEANED TO OFF. A chest tube remains in place, terminating at the extreme right lung apex. PT HAD MULTIPLE SHORT RUNS OF SVT WITH STABLE BP ALL AM. Surgical changes at the right apex with associated volume loss of the right hemithorax. The right hemidiaphragm is elevated. CT DRESSING CHANGED FOR MOD AMT SEROSANG. There has been slight interval increase in patchy opacity at the right apex, which may be due to atelectasis or aspiration. There has been interval decrease in opacity of the remaining right lung consistent with postoperative atelectasis and surgical change. Pneumothorax effusion. Sinus rhythm with bigeminal atrial premature beats. D:Pt treated for rapid afib without response to amiodarone bolus and diltiazem. ET tube with tip over left proximal main stem bronchus. chest, single vw An ET tube is present. 4:06 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: now both chest tubes with leaks. BS DIMINSHED IN RIGHT BASES. 0600 Metoprolol given early, ectopy continued. INDICATION: Status post right lung cancer resection. Heart size and cardiomediastinal contours are stable given differences and patient rotation. The left lung is slightly overinflated, but grossly clear. HO notified, PRN metoprolol given, Mg repleted with good effect. EKG DONE= RAPID AFIB, AMIODARONE BOLUS STARTED AND PT PLACED ON GTT AT 1MG/MIN. CHEST, SINGLE AP VIEW: A tiny right apical pneumothorax may be present, but is not distinctly seen. MAE WITH EQUAL STRENGTHCV: T MAX 100.9- DR AWARE, NO CX ORDERED, NEO GTT WEANED TO OFF THIS AM. TECHNIQUE: A portable AP upright chest radiograph was obtained. The right lung base and the left lung are grossly clear. The left lung is grossly clear. There is atelectasis in both lungs, slightly more pronounced in the left lung. BY 1600, HR UP TO 120-140, REPEAT BOLUS GIVEN.RESP: BS COARSE. No significant change compared with the film from , except for interval removal of the ET tube. Please evaluate for pneumothorax. IMPRESSION: No change since the prior chest x-ray. COMPARISON: AP portable upright chest radiograph . CXR obtained late morning.GI/GU: abd soft/distended. The tip overlies the proximal left main stem bronchus and should be retracted. There is postoperative volume loss in the right hemithorax, and there is increasing pulmonary opacification within the right lung with relative sparing of the right lung base. Taking clear liqs well. No change in persistent right apical pneumothorax. INDICATION: Pancoast tumor excision. lopressor given with pt converting to SR rate 70-80.P:Manage meds for a-fib. There are surgical staples overlying the right upper hemithorax. 7:02 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: worsening pneumo? Sinus rhythm. Please assess for change in pneumothorax. (A subsequent film currently on PACs demonstrates retraction of the ETT to an appropriate position.) | 20 | [
{
"category": "ECG",
"chartdate": "2171-10-23 00:00:00.000",
"description": "Report",
"row_id": 137430,
"text": "Sinus rhythm with bigeminal atrial premature beats. Since the previous\ntracing of atrial fibrillation has reverted to sinus with atrial\npremature beats.\n\n"
},
{
"category": "ECG",
"chartdate": "2171-10-20 00:00:00.000",
"description": "Report",
"row_id": 137431,
"text": "Atrial fibrillation with a rapid ventricular response. Borderline low\nvoltage. Diffuse non-specific ST-T wave abnormalities. Compared to the previous\ntracing of rhythm is now atrial fibrillation and rate is faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2171-10-14 00:00:00.000",
"description": "Report",
"row_id": 137432,
"text": "Sinus rhythm. Findings are within normal limits. Compared to the previous\ntracing of no significant diagnostic change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887462,
"text": " 11:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ptx, interval change\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excisionw/ 2 CT in\n place, no leak at present leaks\n REASON FOR THIS EXAMINATION:\n eval for ptx, interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman with lung cancer status post resection of Pancoast\n tumor. Please assess for change in pneumothorax.\n\n TECHNIQUE: A portable AP upright chest radiograph was obtained.\n\n COMPARISON: AP portable upright chest radiograph .\n\n FINDINGS: There remain 2 apical right-sided pleural drains in unchanged\n position. There is stable appearance of a persistent right apical\n pneumothorax. There is volume loss of the right hemithorax with persistent\n elevation of the right hemidiaphragm and mediastinal shift to the right. There\n has been interval decrease in opacity of the remaining right lung consistent\n with postoperative atelectasis and surgical change. The left lung is grossly\n clear. There are surgical staples overlying the right upper hemithorax.\n\n IMPRESSION: 1. No change in persistent right apical pneumothorax.\n\n 2. Interval decrease in right lung opacity consistent with postsurgical\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887141,
"text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX, effusion\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n REASON FOR THIS EXAMINATION:\n PTX, effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung CA. Pneumothorax effusion.\n\n CHEST, SINGLE AP VIEW:\n\n A tiny right apical pneumothorax may be present, but is not distinctly seen.\n The appearances are not significantly different from the film obtained on\n . Again seen is a right apical and hilar mass, two right-sided chest\n tubes, and skin staples. Changes in the differences of the appearance of the\n right hemidiaphragm likely relate to lordotic positioning on today's films.\n\n Prominence of markings in the left upper zone is noted, of uncertain\n significance. Attention to this area and followup films is recommended. The\n left lung is otherwise clear, without chf, focal infiltrate, or effusion.\n\n IMPRESSION: Possible small right apical pneumothorax, which in retrospect is\n probably unchanged. No significant change compared with the film from\n , except for interval removal of the ET tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887351,
"text": " 4:06 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: now both chest tubes with leaks. R/o larger pneumo.\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\n leaks\n REASON FOR THIS EXAMINATION:\n now both chest tubes with leaks. R/o larger pneumo.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post excision of right Pancoast tumor leaking from\n chest tubes.\n\n CHEST AP: Since the prior chest x-ray, there has been no significant change.\n Two chest tubes are seen in the left apical region with associated rib\n resections. Left lung remains clear. The right perihilar opacification\n persists unchanged.\n\n IMPRESSION: No change since the prior chest x-ray.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887291,
"text": " 10:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change on water seal-eval for PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision\n\n REASON FOR THIS EXAMINATION:\n interval change on water seal-eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST OF \n\n COMPARISON: .\n\n INDICATION: Status post right lung cancer resection. Chest tube on\n water-seal.\n\n A chest tube remains in place, terminating at the extreme right lung apex. An\n apical pneumothorax on the right is not significantly changed allowing for\n technical differences between the studies. There is stable postoperative\n volume loss. There has been slight interval increase in patchy opacity at the\n right apex, which may be due to atelectasis or aspiration. Right perihilar\n and paramediastinal opacities are unchanged and attributed to postoperative\n changes. The left lung is slightly overinflated, but grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 887789,
"text": " 11:29 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA post CT pull\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old woman with lung cancer status post surgical resection.\n Please evaluate for pneumothorax.\n\n TECHNIQUE: PA and lateral views of the chest were obtained and compared to\n .\n\n FINDINGS: There has been interval removal of two right apical chest tubes.\n No definite pneumothorax identified. There are post-surgical changes at the\n right apex including signs of volume loss of the right hemithorax with\n persistent elevation of the right hemidiaphragm and mediastinal shift to the\n right. Again noted are multiple surgical rib defects at the right apex. The\n right lung base and the left lung are grossly clear. Heart size and\n cardiomediastinal contours are stable given differences and patient rotation.\n\n IMPRESSION: Interval removal of right apical pleural drains. No definite\n pneumothorax. Surgical changes at the right apex with associated volume loss\n of the right hemithorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886968,
"text": " 5:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PTX\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n REASON FOR THIS EXAMINATION:\n eval PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Lung CA, question pneumothorax.\n\n chest, single vw\n\n An ET tube is present. The tip overlies the proximal left main stem bronchus\n and should be retracted. The left lung is grossly clear, without CHF,\n infiltrate, or effusion. On the right, there are skin staples and a right\n chest tube. The right hemidiaphragm is elevated. There is increased opacity\n in the right upper zone, confluent with the hilum. The right base is grossly\n clear.\n\n IMPRESSION:\n\n 1. ET tube with tip over left proximal main stem bronchus. This should be\n retracted approximately 4.2 cm. (A subsequent film currently on PACs\n demonstrates retraction of the ETT to an appropriate position.)\n\n 2) Right apical and hilar densities and postoperative changes right lung.\n\n 3) No pneumothorax detected.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 886985,
"text": " 9:13 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA\n\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ET tube placement.\n\n CHEST, SINGLE AP VIEW SUPINE.\n\n Compared with earlier the same day, the ET tube has been retracted. The tip\n now lies in satisfactory position approximately 2.3 cm above the carina. There\n is atelectasis in both lungs, slightly more pronounced in the left lung.\n Otherwise, no significant change is detected.\n\n"
},
{
"category": "Radiology",
"chartdate": "2171-10-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 887366,
"text": " 7:02 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: worsening pneumo?\n Admitting Diagnosis: RIGHT LUNG CA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with lung CA s/p right pancoast tumor excision now new CT\n leaks\n REASON FOR THIS EXAMINATION:\n worsening pneumo?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY , AT 19:06.\n\n COMPARISON: Previous study of earlier the same date at 16:22.\n\n INDICATION: Pancoast tumor excision. Chest tube leak.\n\n Two chest tubes remain in place in the right hemithorax, and there is a\n persistent right apical pneumothorax. There is postoperative volume loss in\n the right hemithorax, and there is increasing pulmonary opacification within\n the right lung with relative sparing of the right lung base. This may\n represent worsening postoperative atelectasis, but is difficult to exclude\n superimposed process such as aspiration. Within the left lung, no confluent\n areas of consolidation or pleural effusion are observed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-18 00:00:00.000",
"description": "Report",
"row_id": 1477987,
"text": "Respiratory Care\nPt.received from PACU,intubated BBS+diminished on right,and coarse t/o.Placed on vent. as documented.See CareVue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-19 00:00:00.000",
"description": "Report",
"row_id": 1477988,
"text": "admit note\nplease see flowsheet for details. pt came from at 1800 to pacu s/p flex bronch, superclavicular scalene fat pad and lymph node disection, cervical mobilization of pancose tumor, right thoractomy, with right upper lobectomy and chest wall excision for right upper lobe mass. She came to SICU from pacu at 2300. at that time she was intubated, sedated on 30 mcq/kg/min propofol but able to nod head to questions and follow commands moving all extremities. neo gtt to maintain a map> 60, LR at 75cc/hr, epidural at T5 with bupivicaine only.\n\ncurrently, afebrile, heart rate 90s, lopressor held- pt on neo gtt to keep map > 60.\n\nresp: vented, lsc with intermittent wheezes, treated with albuterol/atrovent, chest tubes X 2\n\npain: epidural, but pt has sensation at t5, above and below t5. minimal c/o pain, 50 mcq fentanyl given during aline placement\n\nneuro: alert, following commands briskly, mae+, despite propofol gtt at 30 mcq/kg/min,\n\nsurgical dressings c/d/i\n\nplan: wean vent as tolerated, cont to control pain, chest tubes and epidural.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-19 00:00:00.000",
"description": "Report",
"row_id": 1477989,
"text": "Respiratory Care\nPt.remains on full vent.support,sedated with propofol.BBS reveal some exp wheezes t/o treated with Albuterol and atrovent.Abg's adequate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-19 00:00:00.000",
"description": "Report",
"row_id": 1477990,
"text": "Pt woke up well with a good RSBI,VC,NIF & air leak past deflated cuff\nwas extubated and placed on AFM 40% She has a good cough and is productive of thick yellow-green sputum\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-19 00:00:00.000",
"description": "Report",
"row_id": 1477991,
"text": "condition update\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: PROPOFOL WEANED TO OFF. PT IS ALERT, ORIENTED X3, COOPERATIVE, FOLLOWS COMMANDS. MAE WITH EQUAL STRENGTH\nCV: T MAX 100.9- DR AWARE, NO CX ORDERED, NEO GTT WEANED TO OFF THIS AM. PT REMAINS TACHYCARDIC TO 120- LOPRESSOR RESTARTED. SBP 120-150 POST-EXTUBATION.\nRESP: PT WEANED AND EXTUBATED. CURRENTLY ON NP AT 4LITERS WITH SAT 96%. BS DIMINSHED IN RIGHT BASES. COUGHING AND RAISING THICK YELLOW SECRETIONS. CHEST DRESSING DRY AND INTACT. CT DRESSING CHANGED FOR MOD AMT SEROSANG. CT PATENT WITH + AIR LEAK, NO CREPITUS NOTED.\nGI: ABD SOFT, HYPOACTIVE BS. NPO.\nGU: UO DRIFTING OFF THIS AFTERNOON. DR AND DR NOTIFIED. FOLEY THEN IRRIGATED AT 1730 WITH MOD AMT OF SEDIMENT REMOVED AND PT THEN DRAINED 200CC CLOUDY YELLOW URINE. DR AWARE OF ABOVE.\nENDO: SLIDING SCALE INCREASED TO REFLECT BS 140-210.\nA: NEO WEANED TO OFF, PROPOFOL WEANED OFF, WEANED AND EXTUBATED, EPIDURAL FOR PAIN CONTROL WITH GOOD RELIEF\nR: TOL EXTUBATION WELL, HEMODYNAMICALLY STABLE, ENCOURAGE PULM TOILET, OOB TO CHAIR IN AM\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-20 00:00:00.000",
"description": "Report",
"row_id": 1477992,
"text": "NSICU Nursing Progress Note\nNeuro - Pt x3. Able to make needs known.\n\nCV - SR to ST with occ PCVs, multifocal PVCs. Pt began having runs of SVT ~0530 AM. 0600 Metoprolol given early, ectopy continued. HO notified, PRN metoprolol given, Mg repleted with good effect. MBP 90's by arterial line. Peripheral pulses palpable.\n\nResp - Lungs essentialy clear. O2 sat > 96% on 4 L NC. Strong cough productive of thick yellow sputum. Right chest tubes x2 to 20 cm suction with small air leak.\n\nGI - NPO. Abdomen benign.\n\nGU - Adequate UOP via foley. Large amount sediment. Sent for UA, cx.\n\nEndo - Regular insulin per sliding scale.\n\nA - Increasing ectopy this AM, resolved with metoprolol, MgSO4.\n\nP - continue to monitor. Contsider tx to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-20 00:00:00.000",
"description": "Report",
"row_id": 1477993,
"text": "CONDITION UPDATE\nD: PLEASE SEE CAREVUE FOR SPECIFICS\nNEURO: ALERT AND ORIENTED X3. EPIDURAL AT 6CC/HR FOR PAIN, DILAUDID PCA ALSO STARTED THIS AFTERNOON.\nCV: AFEBRILE. PT HAD MULTIPLE SHORT RUNS OF SVT WITH STABLE BP ALL AM. AT 1145, PT WENT INTO SUSTAINED RAPID RHTHTYM WITH DROP IN BP TO 90. EKG DONE= RAPID AFIB, AMIODARONE BOLUS STARTED AND PT PLACED ON GTT AT 1MG/MIN. RATE DID DROP TO 110 FOR A SHORT WHILE. BY 1600, HR UP TO 120-140, REPEAT BOLUS GIVEN.\nRESP: BS COARSE. COUGHING AND RAISING COPIOUS AMTS OF THICK YELLOW-GREEN SPUTUM. CT TO WATER SEAL WITH SEROUS DRAINAGE.\nGI: TAKING CLEAR LIQUIDS SLOWLY, ABD SOFT AND NON-TENDER.\nGU: YELLOW URINE WITH SEDIMENT.\nA: OOB TO CHAIR WITH ASSISTANCE OF 2- TOL GOOD. RHYTHM MONITORED, AMIODARONE GTT STARTED, ? DILT IF RATE IS NOT CONTROLLED.\nR: RAPID RATE UNCONTROLLED BY LOPRESSOR, AMIODARONE GTT INFUSING WITH POOR RATE CONTROL, START DILT IF RATE UNCHANGED IN HR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-21 00:00:00.000",
"description": "Report",
"row_id": 1477994,
"text": "D:Pt treated for rapid afib without response to amiodarone bolus and diltiazem. lopressor given with pt converting to SR rate 70-80.\nP:Manage meds for a-fib.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-10-21 00:00:00.000",
"description": "Report",
"row_id": 1477995,
"text": "FULL CODE Universal precautions Allergy: codeine\n\n\nNeuro: AAOx3, MAEx4. OOB in chair at beginning of shift - BTB at 1200 - walks well - fairly steady on her feet, required minimal assistance.\n\nCV: HR=80-90s, NSR w/ rare to freq PVCs. Prior to am lopressor dose, HR up to 140-160 for a few seconds, then returned to 90-100s. Given 25mg lopressor po dose and additional 5mg IV - HR down to 50s for about 1hour, then has returned to 80s w/ no increase in HR and ectopy has signif decreased as well. Amiodarone gtt at .5mg/min. BP=120-130s/50-60s. +periph pulses, sl edema, extrems warm.\n\nResp: on 5l n/p w/ 02 sat 95-98%. Lungs coarse bilat, decreased in R fields. Excellent cough effort produding thick white secretions - using yankar to clear oral secretions. using IS 750-1000cc. R CT x2 ot H20 seal w/ serous drainage. CXR obtained late morning.\n\nGI/GU: abd soft/distended. +BS, no BM. Taking clear liqs well. Foley cath w/ dark, conc yellow uine.\n\nSkin: R CT, R flank incision, R neck incision intact\n\nPain: Bupivicaine epidural at 6cc/hr - intact. PCA Dialudid .12/6/1.2. Using well.\n\nID: T=98.9 no antibx.\n\nAccess: L piv x2.\n\nSocial: Sister and daughter-in-law visiting - Supportive.\n\nPlan: Tx to 2.\n"
}
] |
9,702 | 177,827 | The patient was left intubated post operation due to some concerns of hypotenstion. This resoled quickly and he was extubated. He was extubated by the AM of POD1. He did well postoperativly. He had epidural anesthesia, which provided good pain control. He was moved to the VICU on POD1. His diet was held until flatus was passed. His INR was revered with Vit K. A bleeding time was done to assess coagulation, which was normal. His swan catheter was changed to cvl on POD 3 due to stable cardiac function. In the OR, a stomach mass was found, so Dr. service was consulted, he will f/u as an outpt. He was found to have a weak left deltoid, and neurology was consulted. After extensive radiological study, no definate cause for his weakness was found, but it had almost complealty resolved by the time of discharge. Otherwise his diet advanced without incident and he did well from a PT persepective. He was d/c'ed on POD 7 on coumadin to be followed by his PCP. | MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES: FINDINGS: There is slight irregularity of the proximal basilar artery without evidence of high-grade stenosis. IMPRESSION: Mild irregularity of the proximal basilar artery. Finally, asymmetrical right apical predominantly pleural opacity is noted and is stable compared to the recent radiograph. There has been interval removal of an endotracheal tube and nasogastric tube. The vertebral bodies demonstrate decreased T1 signal throughout. The distal right vertebral artery appears to end in a PICA. As noted in the cervical spine, there is diffuse decreased T1 signal throughout the vertebral bodies. There is diffuse bilateral carotid calcification seen as well as calcification within the aorta. Also, a mild degree of compression atelectasis at the right lung base is noted unchanged. Decreased T1 signal in the thoracic spine as in the cervical spine. IMPRESSION: 1) Free intraperitoneal air, most likely related to recent abdominal surgery. There are arteriosclerotic changes involving thoracic aorta, left ventricular enlargement, and postoperative changes from prior sternotomy. FINDINGS: A right internal jugular catheter has been placed and terminates in the superior vena cava. 4) Asymmetrical right apical opacity. Decreased T1 signal throughout the cervical spine. FINDINGS: The exam is somewhat limited by patient motion. Small bilateral pleural effusions are present. There is a remote lacunar infarct in the anterior aspect of the right thalamus, as identified on the patient's CT scan. Ventricles and sulci are mildly prominent consistent with mild brain atrophy. Note is made of moderate calcifications of both internal carotid arteries. Free intraperitoneal air is noted within the abdomen. 2) Central venous catheter in good position with no pneumothorax. FINDINGS: CERVICAL SPINE: The visualization of the cervical spine is limited by motion. also had a thoracic epidural, pulled today. Low densities in the right caudate head, the anterior limbs of the internal capsule and the right thalamus are probably remote infarcts but there are no comparison studies. most likely asymmetrical pleural thickening but attention to this region on a dedicated PA and lateral chest radiograph is recommended when the patient's condition permits. 3) Vascular calcifications within the bilateral carotids and aorta. Mild elevation of the left hemidiaphragm is seen. There are small lacunar infarcts, either in the anterior putamina or the anterior limbs of the internal capsules bilaterally, also consistent with CT scan findings. This could be seen in hematopoietic or neoplastic disorders. This could be seen in hematopoietic or neoplastic disorders. Status post sternotomy. Cardiac and mediastinal contours are stable. THORACIC SPINE: There is motion artifact present. 2) Persistent free intraperitoneal air due to the recent abdominal surgery. TECHNIQUE: Axial and sagittal T1, T2 and inversion recovery images of the thoracic and cervical spine were obtained. Free intraperitoneal air under both hemidiaphragms again noted due to recent abdominal surgery. C-spine nontrauma: There is a 2-mm focus of density in the subcutaneous tissues of the anterior neck around the level of C6. TECHNIQUE: Non-contrast CT of the head was obtained without comparisons. There are bibasilar opacities predominantly in the retrocardiac region which have worsened in the interval, and there are also small pleural effusions, left greater than right. INDICATION: Patient with status post catheter placement. The visualized spinal cord is unremarkable. Evaluate for infarction. Evaluate for epidural hematoma. although T-spine is ordered and patient had a Thoracic epidural, it should be noted that his deficit is of the C5 root and thus this area should be included in the study please FINAL REPORT INDICATION: Left deltoid paralysis, history of thoracic epidural. Some asymmetrical thickening in the right apex is seen. The osseous and soft-tissue structures appear unremarkable. Postoperative changes in the abdomen. The visualized paranasal sinuses have a normal signal. CLINICAL INDICATION: Line change. Pt had screening form done recently, and had MR this AM REASON FOR THIS EXAMINATION: Please do diffusion sequences, this was not available at initial MRI FINAL REPORT CLINICAL INFORMATION: Isolated deltoid weakness. The tip is in the mid superior vena cava. REASON FOR THIS EXAMINATION: evaluate for epidural hematoma. Again, the changes appear to be chronic. IMPRESSION: 1) There has been improvement in the magnitude of the left lower lobe partial atelectasis. This is a nonspecific finding. Probable chronic interstitial lung change. IMPRESSION: No evidence of acute mass or hemorrhage. Swan-Ganz catheter is identified with its tip in the right pulmonary artery. REPORT: The patient is intubated. 2) Degenerative changes of the C-spine with anterolisthesis, disk space narrowing, and osteophytosis as described above. No evidence of acute infarction. Areas of severe calcification along the left vertebral artery are also seen. The ventricles, cisterns, and sulci are within normal limits. 3) The remainder of the lungs are clear at this time. Note that MRI with diffusion-weighted imaging is a more sensitive evaluation for infarction. FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of normally midline structures. There is probably free air present on the previous supine study as well but the distribution has changed related to the patient's current upright positioning. 3) Worsening bibasilar opacities predominantly in the retrocardiac area, most likely due to atelectasis, although aspiration should also be considered. Some midline sutures are identified in the abdomen, and there are some apparent bowel loops also seen. IMPRESSION: No evidence of intracranial hemorrhage or gross infarction. Extensive parenchymal lung disease is identified. Anterior osteophytes are seen on C6 and C7. | 7 | [
{
"category": "Radiology",
"chartdate": "2138-12-29 00:00:00.000",
"description": "C-SPINE NON-TRAUMA 2-3 VIEWS",
"row_id": 854973,
"text": " 10:20 PM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: eval prior to MRI of Cspine/Tspine\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with possible epidural bleed after epidural catheter removal\n with hx of metal imbedded in neck\n REASON FOR THIS EXAMINATION:\n eval prior to MRI of Cspine/Tspine\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 78-year-old man with possible epidural bleed after epidural\n catheter removal with history of metal imbedded in neck. Please evaluate neck\n for metal.\n\n C-spine nontrauma: There is a 2-mm focus of density in the subcutaneous\n tissues of the anterior neck around the level of C6. This may be a small\n piece of metal. No fractures are identified within the C-spine. There is\n grade I anterolisthesis of C5 on C6. There is disk space narrowing at C4-C5,\n C5-C6, and C6-C7. The most severe disk space narrowing is at C6-C7. Anterior\n osteophytes are seen on C6 and C7. There are increased interstitial markings\n within the lungs. There is diffuse bilateral carotid calcification seen as\n well as calcification within the aorta.\n\n IMPRESSION:\n\n 1) A 2-mm focus of density, likely metal in the subcutaneous tissues of the\n anterior neck.\n\n 2) Degenerative changes of the C-spine with anterolisthesis, disk space\n narrowing, and osteophytosis as described above.\n\n 3) Vascular calcifications within the bilateral carotids and aorta.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-30 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 855008,
"text": " 8:00 AM\n CHEST (PA & LAT) Clip # \n Reason: surveillance CXR\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p aorto-bifem bypass on \n REASON FOR THIS EXAMINATION:\n surveillance CXR\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 78-year-old status post aorto-bifem bypass. Evaluate the chest.\n\n FINDINGS:\n\n Comparison is made to the prior study of a day earlier. Free intraperitoneal\n air under both hemidiaphragms again noted due to recent abdominal surgery.\n The right IJ line is in place. The tip is in the mid superior vena cava.\n There is no evidence of pneumothorax. Minimal degree of partial atelectasis\n involving the left lower lobe is noted, which has improved since the prior\n study. Also, a mild degree of compression atelectasis at the right lung base\n is noted unchanged. The remainder of the lungs are clear. There are\n arteriosclerotic changes involving thoracic aorta, left ventricular\n enlargement, and postoperative changes from prior sternotomy.\n\n IMPRESSION:\n\n 1) There has been improvement in the magnitude of the left lower lobe partial\n atelectasis.\n\n 2) Persistent free intraperitoneal air due to the recent abdominal surgery.\n\n 3) The remainder of the lungs are clear at this time.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854900,
"text": " 11:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check central line placement\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p right IJ cordis to triple lumen change over guidwire\n\n REASON FOR THIS EXAMINATION:\n check central line placement\n ______________________________________________________________________________\n FINAL REPORT\n This is a portable upright chest that is dated .\n\n CLINICAL INDICATION: Line change.\n\n FINDINGS:\n\n A right internal jugular catheter has been placed and terminates in the\n superior vena cava. There has been interval removal of an endotracheal tube\n and nasogastric tube. There is no pneumothorax. Cardiac and mediastinal\n contours are stable. There are bibasilar opacities predominantly in the\n retrocardiac region which have worsened in the interval, and there are also\n small pleural effusions, left greater than right. Free intraperitoneal air is\n noted within the abdomen. There is probably free air present on the previous\n supine study as well but the distribution has changed related to the patient's\n current upright positioning. Finally, asymmetrical right apical predominantly\n pleural opacity is noted and is stable compared to the recent radiograph.\n\n IMPRESSION:\n\n 1) Free intraperitoneal air, most likely related to recent abdominal surgery.\n\n 2) Central venous catheter in good position with no pneumothorax.\n\n 3) Worsening bibasilar opacities predominantly in the retrocardiac area, most\n likely due to atelectasis, although aspiration should also be considered.\n\n 4) Asymmetrical right apical opacity. most likely asymmetrical pleural\n thickening but attention to this region on a dedicated PA and lateral chest\n radiograph is recommended when the patient's condition permits.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-30 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 854998,
"text": " 6:47 AM\n MR CERVICAL SPINE; MR THORACIC SPINE Clip # \n Reason: evaluate for epidural hematoma. although T-spine is ordered\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with vasculopath, s/p aortobifem, with new Left deltoid\n paralysis. also had a thoracic epidural, pulled today.\n REASON FOR THIS EXAMINATION:\n evaluate for epidural hematoma. although T-spine is ordered and patient had a\n Thoracic epidural, it should be noted that his deficit is of the C5 root and\n thus this area should be included in the study please\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left deltoid paralysis, history of thoracic epidural. Evaluate\n for epidural hematoma.\n\n TECHNIQUE: Axial and sagittal T1, T2 and inversion recovery images of the\n thoracic and cervical spine were obtained.\n\n FINDINGS:\n\n CERVICAL SPINE: The visualization of the cervical spine is limited by motion.\n There is no spinal cord or paraspinal pathology visualized. There is no disc\n herniation noted. There is no evidence of spinal stenosis or subluxation of\n the component vertebra. The vertebral bodies demonstrate decreased T1 signal\n throughout. Small bilateral pleural effusions are present.\n\n IMPRESSION:\n 1. Decreased T1 signal throughout the cervical spine. This could be seen in\n hematopoietic or neoplastic disorders.\n 2. No evidence of cord compression.\n\n THORACIC SPINE: There is motion artifact present. There is no disc, vertebral\n or intraspinal pathology visualized. There is no evidence of spinal stenosis\n or spondylolisthesis. The visualized spinal cord is unremarkable. As noted in\n the cervical spine, there is diffuse decreased T1 signal throughout the\n vertebral bodies.\n\n IMPRESSION:\n 1. Decreased T1 signal in the thoracic spine as in the cervical spine. This\n could be seen in hematopoietic or neoplastic disorders.\n 2. No evidence of spinal cord compression.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 854648,
"text": " 7:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PA cath placement\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with s/p AoBF\n REASON FOR THIS EXAMINATION:\n PA cath placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Patient with status post catheter placement. Evaluate.\n\n COMPARISON: No study available for comparison.\n\n REPORT: The patient is intubated. The T-tube lies 5.5 cm above the carina.\n Status post sternotomy. A LIMA graft has also been performed. Swan-Ganz\n catheter is identified with its tip in the right pulmonary artery. It could\n be retracted slightly. NG tube is seen coursing through the mediastinum with\n its tip in the region of the stomach. Mild elevation of the left\n hemidiaphragm is seen. No studies are available for comparison. Some midline\n sutures are identified in the abdomen, and there are some apparent bowel loops\n also seen.\n\n Extensive parenchymal lung disease is identified. This is mostly interstitial\n in nature, the changes are likely longstanding, though no studies available\n for comparison. Some asymmetrical thickening in the right apex is seen. This\n is a nonspecific finding. Again, the changes appear to be chronic.\n\n CONCLUSION:\n\n Good position of the line. Probable chronic interstitial lung change.\n Postoperative changes in the abdomen.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-31 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 855123,
"text": " 12:42 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Please do diffusion sequences, this was not available at ini\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with isolated deltoid weakness, ? stroke. Pt had screening\n form done recently, and had MR this AM\n REASON FOR THIS EXAMINATION:\n Please do diffusion sequences, this was not available at initial MRI\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Isolated deltoid weakness. ? stroke.\n\n MRI OF THE BRAIN:\n\n Exam compared to the patient's CT scan of .\n\n FINDINGS: The exam is somewhat limited by patient motion. There is a remote\n lacunar infarct in the anterior aspect of the right thalamus, as identified on\n the patient's CT scan. There are small lacunar infarcts, either in the\n anterior putamina or the anterior limbs of the internal capsules bilaterally,\n also consistent with CT scan findings. There is no evidence of abnormal\n diffusion to suggest the presence of acute infarction. There is no evidence\n of mass effect or hemorrhage. Ventricles and sulci are mildly prominent\n consistent with mild brain atrophy. The visualized paranasal sinuses have a\n normal signal.\n\n IMPRESSION: No evidence of acute mass or hemorrhage. No evidence of acute\n infarction.\n\n MRA OF THE CIRCLE OF AND ITS MAJOR TRIBUTARIES:\n\n FINDINGS: There is slight irregularity of the proximal basilar artery without\n evidence of high-grade stenosis. The distal right vertebral artery appears to\n end in a PICA. There is no evidence of aneurysm. There is no evidence of\n flow abnormality in the carotid circuits.\n\n IMPRESSION: Mild irregularity of the proximal basilar artery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2138-12-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 854957,
"text": " 5:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ACUTE ASYMMETRICAL LEFT UPPER EXTREMITY WEAKNESS, EVAL FOR INFARCT\n Admitting Diagnosis: ILIAC ARTERY STENOSIS/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with acut asymmetrical left upper extremity weakness\n REASON FOR THIS EXAMINATION:\n r/o infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute asymmetric upper extremity weakness. Evaluate for\n infarction.\n\n TECHNIQUE: Non-contrast CT of the head was obtained without comparisons.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of\n normally midline structures. The ventricles, cisterns, and sulci are within\n normal limits. -white matter differentiation is preserved. Low densities\n in the right caudate head, the anterior limbs of the internal capsule and\n the right thalamus are probably remote infarcts but there are no\n comparison studies. Note is made of moderate calcifications of both internal\n carotid arteries. Areas of severe calcification along the left vertebral\n artery are also seen. The osseous and soft-tissue structures appear\n unremarkable.\n\n IMPRESSION: No evidence of intracranial hemorrhage or gross infarction. Note\n that MRI with diffusion-weighted imaging is a more sensitive evaluation for\n infarction.\n\n"
}
] |
55,263 | 101,045 | Patient was admitted on for an electively planned left sided craniotomy for mass resection. He had an uneventfull post-operative course in which he stayed in PACU overnight then transferred to floor. He ambulated without difficulty, pain well controlled. Did have some nausea/vomiting on however well controlled with medication. On he tolerated PO intake and feeling well. He was evaluated by OT who recommended outpt treatment. Incisional site c/d/i and exam non-focal except for tingling in fingers with sl. dexterity deficits in which he will have OT follow-up. | Chief complaint: Left Brain Mas PMHx: Left brain mass Current medications: 1. IMPRESSION: Extra-axial enhancing mass, as described above, with stable surrounding edema and thin supratentorial pachymeningeal enhancement. Please have completed within 36hrs post-op No contraindications for IV contrast PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 10:27 AM Post-operative changes and expected post-operative findings are seen on MRI. Plan: Q1hr neuro checks. Please have completed within 36hrs post-op No contraindications for IV contrast PFI REPORT Post-operative changes and expected post-operative findings are seen on MRI. COMPARISON: CTA of the head with and without contrast, and MRI head (), . T1 axial and MP-RAGE sagittal images were obtained following gadolinium. A faint area of increased signal within the pons with subtle enhancement is consistent with an incidental capillary telangiectasia which is unchanged from previous study. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. Response: Neuro status remains stable Plan: MRI today, transfer to floor with q 4 hour neuro checks, continue decadron and Dilantin, p.t. FINDINGS: Since the previous MRI of the patient has undergone resection of left frontoparietal extra-axial mass. Initially evaluated at NWH CT/MRI + for Left parietal mass. IMPRESSION: Expected postoperative changes, with a small amount of pneumocephalus overlying the left frontal lobe, as well as tiny foci of pneumocephalus and postoperative hemorrhage within the surgical bed. Chest pain Assessment: Pt c/o left lung pain Pt nauseous Denies sob All vital signs stable Neurologically intact Action: Dr. notified Ekg done Cardiac enzymes sent Zofran given Protonix given Response: Pt verbalizes relief of pain and nausea Ekg normal Enzymes normal Plan: Continue to monitor Visualized paranasal sinuses and mastoid air cells are normally aerated. TB as child vs PNA (per Pt he said he meant PNA when giving his FHP) Surgery / Procedure and date: Left Crani for excision of mass Latest Vital Signs and I/O Non-invasive BP: S:127 D:69 Temperature: 99.1 Arterial BP: S:127 D:56 Respiratory rate: 23 insp/min Heart Rate: 88 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 98% % O2 flow: 1 L/min FiO2 set: 24h total in: 1,982 mL 24h total out: 685 mL Pertinent Lab Results: Sodium: 140 mEq/L 02:01 AM Potassium: 4.0 mEq/L 02:01 AM Chloride: 102 mEq/L 02:01 AM CO2: 30 mEq/L 02:01 AM BUN: 15 mg/dL 02:01 AM Creatinine: 1.0 mg/dL 02:01 AM Glucose: 116 mg/dL 02:01 AM Hematocrit: 40.4 % 02:01 AM Finger Stick Glucose: 127 10:00 AM Valuables / Signature Patient valuables: Other valuables: Clothes: Sent home with: Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: sicu a Transferred to: 1114 Date & time of Transfer: TB as child vs PNA (per Pt he said he meant PNA when giving his FHP) Surgery / Procedure and date: Left Crani for excision of mass Latest Vital Signs and I/O Non-invasive BP: S:127 D:69 Temperature: 99.1 Arterial BP: S:127 D:56 Respiratory rate: 23 insp/min Heart Rate: 88 bpm Heart rhythm: SR (Sinus Rhythm) O2 delivery device: None O2 saturation: 98% % O2 flow: 1 L/min FiO2 set: 24h total in: 1,982 mL 24h total out: 685 mL Pertinent Lab Results: Sodium: 140 mEq/L 02:01 AM Potassium: 4.0 mEq/L 02:01 AM Chloride: 102 mEq/L 02:01 AM CO2: 30 mEq/L 02:01 AM BUN: 15 mg/dL 02:01 AM Creatinine: 1.0 mg/dL 02:01 AM Glucose: 116 mg/dL 02:01 AM Hematocrit: 40.4 % 02:01 AM Finger Stick Glucose: 127 10:00 AM Valuables / Signature Patient valuables: Other valuables: Clothes: Sent home with: Wallet / Money: No money / wallet Cash / Credit cards sent home with: Jewelry: Transferred from: sicu a Transferred to: 1114 Date & time of Transfer: | 15 | [
{
"category": "Nursing",
"chartdate": "2161-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 420806,
"text": "63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n"
},
{
"category": "Physician ",
"chartdate": "2161-11-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 420789,
"text": "SICU\n HPI:\n 63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation.\n Chief complaint:\n Left Brain Mas\n PMHx:\n Left brain mass\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Bisacodyl 5. Dexamethasone 6.\n Docusate Sodium 7. Gentamicin\n 8. HYDROmorphone (Dilaudid) 9. Heparin 10. HydrALAzine 11. Influenza\n Virus Vaccine 12. Insulin 13. NiCARdipine\n 14. Ondansetron 15. Pantoprazole 16. Phenytoin 17. Sodium Chloride 0.9%\n Flush 18. Vancomycin\n 24 Hour Events:\n OR RECEIVED - At 05:00 PM\n ARTERIAL LINE - START 05:11 PM\n EKG - At 02:21 AM\n CHEST PAIN - At 02:21 AM\n FEVER - 209.1\nC - 05:41 PM\n Post operative day:\n POD#1 - S/P L Crani\n Allergies:\n Penicillins\n Unknown;\n Last dose of Antibiotics:\n Gentamicin - 05:57 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 02:31 AM\n Other medications:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 98.4\nC (209.1\n T current: 37.2\nC (98.9\n HR: 83 (73 - 106) bpm\n BP: 144/62(87) {111/48(66) - 156/62(87)} mmHg\n RR: 26 (8 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,622 mL\n 1,039 mL\n PO:\n 200 mL\n 100 mL\n Tube feeding:\n IV Fluid:\n 2,422 mL\n 939 mL\n Blood products:\n Total out:\n 4,070 mL\n 520 mL\n Urine:\n 1,470 mL\n 520 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,448 mL\n 519 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 98%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Murmur: Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: No(t) Present)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (RUE: Weakness)\n Labs / Radiology\n 316 K/uL\n 14.9 g/dL\n 116 mg/dL\n 1.0 mg/dL\n 30 mEq/L\n 4.0 mEq/L\n 15 mg/dL\n 102 mEq/L\n 140 mEq/L\n 40.4 %\n 20.7 K/uL\n [image002.jpg]\n 02:01 AM\n WBC\n 20.7\n Hct\n 40.4\n Plt\n 316\n Creatinine\n 1.0\n Troponin T\n <0.01\n Glucose\n 116\n Other labs: PT / PTT / INR:13.2/22.0/1.1, CK / CK-MB / Troponin\n T:31//<0.01, Albumin:3.7 g/dL, Ca:8.6 mg/dL, Mg:1.9 mg/dL, PO4:4.5\n mg/dL\n ECG: ECG --> no change from prior; SR with non-specific Q wave\n inferiorly.\n Assessment and Plan\n Assessment and Plan: 63M elective admission for crani who presented\n earlier in the week for ascending paraesthesia of the RUE.\n Neurologic: Neuro checks Q: 4 hr, Phenytoin - therapeutic, MRI of the\n head , check Albumin and Phenytoin\n Cardiovascular: Post op HTN --> weaned off nicardipine overnight to\n Keep SBP<140;\n Pulmonary: Chest PT, OOB; Phys therapy and occupational Therapy.\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, D/C Foley\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: Periop Vancomycin\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: MRI of the head\n Fluids: NS\n Consults: Neuro surgery, P.T., O.T.\n Billing Diagnosis: Post-op hypertension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:11 PM\n 18 Gauge - 05:13 PM\n 20 Gauge - 08:07 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 31 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 420740,
"text": "Above pt with 2month Hx of intermittent R hand numbness/tingling now\n presents with tingling extending up the medial aspect of the right arm\n to the right shoulder and neck. Initially evaluated at NWH CT/MRI +\n for Left parietal mass. Pt referred to to for further\n evaluation. Pt to OR for Left craniotomy of Left parietal lesion.\n Assessment: Pt arrived from OR extubated. Neuro intact. A+O X3. No\n noted Neuro deficits noted. Pt crani incision clean dry and\n intact. Goal SBP 100-140. Pt arrived with SBP 160\n Action: Pt given 10mg hydral on arrival X2 with little effect.\n Nicardipine gtt started. Pt with mild c/o pain given 2mg PO dilaudid.\n Response: SBP now 125-139 with nicardipine at 3mcgs. Pt with good\n relief from PO dilaudid.\n Plan: Q1hr neuro checks. Cont to maintain SBP within paramenter. CT\n scan tonight MRI within 36hrs post op. Cont with current plan of care.\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 420828,
"text": "63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n BRAIN TUMOR/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 81 kg\n Daily weight:\n 81.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Hx of central vision loss OS-Dx macular\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\n he meant PNA when giving his FHP)\n Surgery / Procedure and date: Left Crani for excision of mass\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:69\n Temperature:\n 99.1\n Arterial BP:\n S:127\n D:56\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 1,982 mL\n 24h total out:\n 685 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:01 AM\n Potassium:\n 4.0 mEq/L\n 02:01 AM\n Chloride:\n 102 mEq/L\n 02:01 AM\n CO2:\n 30 mEq/L\n 02:01 AM\n BUN:\n 15 mg/dL\n 02:01 AM\n Creatinine:\n 1.0 mg/dL\n 02:01 AM\n Glucose:\n 116 mg/dL\n 02:01 AM\n Hematocrit:\n 40.4 %\n 02:01 AM\n Finger Stick Glucose:\n 127\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu a\n Transferred to: 1114\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2161-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 420834,
"text": "63yo RHM with 2 month hx of intermittent R hand\n numbness/tingling, restricted to 4th and fifth digits. Today\n tingling extended up the medial aspect of the right arm to the R\n posterolateral aspect of the neck and ear. Therefore Pt went to\n ED where neuroimaging (MRI/CT) revealed a L\n parietal lesion. Pt xferred to for further evaluation. S/p left\n crani on .\n Note: Foley was d/c\nd at 0900, pt is dtv at 1700.\n Problem\n parietal brain tumor, s/p craniectomy\n Assessment:\n Alert and oriented x\ns 3, pleasant and cooperative. Pupils equal and\n briskly reactive. Normal strength in all extremities except right arm\n in which very mild weakness is noted. Pt also c/o of decreased\n sensation in right hand, sensation intact in all other extremities. Pt\n c/o of mild headache, treated with po Tylenol with good effect.\n Action:\n Q 2 hour neuro checks, Tylenol prn pain, Dilantin, decadron. Pt was\n oob to chair today, advanced to regular diet (tolerating).\n Response:\n Neuro status remains stable\n Plan:\n MRI today, transfer to floor with q 4 hour neuro checks, continue\n decadron and Dilantin, p.t. and o.t., oob to chair and ambulate, d/c\n planning.\n Demographics\n Attending MD:\n M.\n Admit diagnosis:\n BRAIN TUMOR/SDA\n Code status:\n Full code\n Height:\n Admission weight:\n 81 kg\n Daily weight:\n 81.5 kg\n Allergies/Reactions:\n Penicillins\n Unknown;\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Hx of central vision loss OS-Dx macular\n degeneration several years ago. ? TB as child vs PNA (per Pt he said\n he meant PNA when giving his FHP)\n Surgery / Procedure and date: Left Crani for excision of mass\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:69\n Temperature:\n 99.1\n Arterial BP:\n S:127\n D:56\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 88 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 98% %\n O2 flow:\n 1 L/min\n FiO2 set:\n 24h total in:\n 1,982 mL\n 24h total out:\n 685 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:01 AM\n Potassium:\n 4.0 mEq/L\n 02:01 AM\n Chloride:\n 102 mEq/L\n 02:01 AM\n CO2:\n 30 mEq/L\n 02:01 AM\n BUN:\n 15 mg/dL\n 02:01 AM\n Creatinine:\n 1.0 mg/dL\n 02:01 AM\n Glucose:\n 116 mg/dL\n 02:01 AM\n Hematocrit:\n 40.4 %\n 02:01 AM\n Finger Stick Glucose:\n 127\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: sicu a\n Transferred to: 1114\n Date & time of Transfer: \n"
},
{
"category": "Nursing",
"chartdate": "2161-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 420765,
"text": "Chest pain\n Assessment:\n Pt c/o left lung pain\n Pt nauseous\n Denies sob\n All vital signs stable\n Action:\n Dr. notified\n Ekg done\n Cardiac enzymes sent\n Zofran given\n Protonix given\n Response:\n Pt verbalizes relief of pain and nausea\n Ekg normal\n Enzymes normal\n Plan:\n Continue to monitor\n"
},
{
"category": "Nursing",
"chartdate": "2161-11-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 420767,
"text": "Chest pain\n Assessment:\n Pt c/o left lung pain\n Pt nauseous\n Denies sob\n All vital signs stable\n Neurologically intact\n Action:\n Dr. notified\n Ekg done\n Cardiac enzymes sent\n Zofran given\n Protonix given\n Response:\n Pt verbalizes relief of pain and nausea\n Ekg normal\n Enzymes normal\n Plan:\n Continue to monitor\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-11 00:00:00.000",
"description": "MR HEAD W/ CONTRAST",
"row_id": 1041347,
"text": " 5:25 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: Wand protocol for placement of markers for surgery immediate\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with brain tumor.\n REASON FOR THIS EXAMINATION:\n Wand protocol for placement of markers for surgery immediately after.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male patient with history of a mass.\n\n TECHNIQUE: MRI of the brain was performed with IV contrast as per\n departmental protocol.\n\n COMPARISON: CTA of the head with and without contrast, and MRI\n head (), . The CT demonstrates no\n calcification within the mass, and no reactive change in the overlying skull.\n\n FINDINGS:\n\n There is a 2.9 (TRV) x 2.8 (AP) x 2.3 cm (CC), well-defined and lobulated,\n heterogeneously-enhancing mass that is T2-isointense-to- matter and\n demonstrates restricted diffusion. The mass also demonstrates a broad-based\n attachment to the left parietal dura, and causes mild enlargement of the\n surrounding subarachnoid spaces and buckling of the subjacent matter and\n is, therefore, likely extra-axial. There is vasogenic edema involving the\n adjacent subcortical white matter of the occipital, parietal, and posterior\n frontal lobes including the left precentral gyrus, with mass effect on and\n effacement of the overlying gyri of the left parietal lobe, but no evidence\n for midline shift or herniation. Minimal mass effect on the atrium of the left\n lateral ventricle, but no hydrocephalus. There is diffuse but smooth and thin\n pachymeningeal enhancement in the supratentorial compartment, but no evidence\n for leptomeningeal or subependymal enhancement, and no other focus of abnormal\n enhancement is noted.\n\n The visualized portions of the orbits are within normal limits. The paranasal\n sinuses are clear. The major vascular flow voids are normal.\n\n IMPRESSION: Extra-axial enhancing mass, as described above, with stable\n surrounding edema and thin supratentorial pachymeningeal enhancement. Given\n the constellation of findings, particularly its signal, diffusion and\n enhancement characteristics, this mass likely represents a meningioma. Much\n more remote differential diagnostic considerations also include dural- based\n metastasis (eg. from prostate cancer, in this patient with known nodule),\n lymphoma or granulomatous disease (eg. sarcoidosis).\n (Over)\n\n 5:25 AM\n MR HEAD W/ CONTRAST Clip # \n Reason: Wand protocol for placement of markers for surgery immediate\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1041525,
"text": ", M. NSURG SICU-A 8:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulmonary process\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p craniectomy and chest pain\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n PFI REPORT\n No acute cardiopulmonary abnormalities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1041524,
"text": " 8:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulmonary process\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p craniectomy and chest pain\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:50 AM\n No acute cardiopulmonary abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Chest pain, S/P craniectomy.\n\n Cardiomediastinal contours are normal. The lungs are grossly clear aside from\n linear atelectasis in the left base. There is no pleural effusion or\n pneumothorax.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2161-11-12 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1041641,
"text": " 5:00 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual tumor burden. Please have compl\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for residual tumor burden. Please have completed within 36hrs\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN FRI 10:27 AM\n Post-operative changes and expected post-operative findings are seen on MRI.\n No residual enhancement. No acute infarct or mass effect.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient is status post surgery.\n\n TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion\n axial images of the brain were acquired. T1 axial and MP-RAGE sagittal images\n were obtained following gadolinium.\n\n FINDINGS: Since the previous MRI of the patient has undergone\n resection of left frontoparietal extra-axial mass. Small amount of blood\n products are seen in the region. The edema seen in the left frontoparietal\n region has unchanged. Following gadolinium subtle marginal enhancement is\n seen which appears to be due to vascular and meningeal enhancement. No\n definite nodular, extra-axial or intra-axial area of residual enhancement\n identified. There are no acute infarcts seen. There is no midline shift or\n hydrocephalus. A faint area of increased signal within the pons with subtle\n enhancement is consistent with an incidental capillary telangiectasia which is\n unchanged from previous study.\n\n IMPRESSION: Status post resection of left-sided frontoparietal extra-axial\n mass. Small amount of blood products are seen in the region with expected\n post-surgical changes. No definite residual enhancement is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-12 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1041642,
"text": ", M. NSURG SICU-A 5:00 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: please evaluate for residual tumor burden. Please have compl\n Admitting Diagnosis: BRAIN TUMOR/SDA\n Contrast: MAGNEVIST Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for residual tumor burden. Please have completed within 36hrs\n post-op\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Post-operative changes and expected post-operative findings are seen on MRI.\n No residual enhancement. No acute infarct or mass effect.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1041473,
"text": ", M. NSURG SICU-A 8:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post operative changes\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p left crainotomy\n REASON FOR THIS EXAMINATION:\n post operative changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\n No other short interval change, with residual vasogenic edema involving the\n left parietal lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2161-11-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1041472,
"text": " 8:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post operative changes\n Admitting Diagnosis: BRAIN TUMOR/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old man with s/p left crainotomy\n REASON FOR THIS EXAMINATION:\n post operative changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:10 AM\n Postoperative changes with pneumocephalus overlying the left frontal lobe, as\n well as the expected tiny foci of air and hemorrhage within the surgical bed.\n No other short interval change, with residual vasogenic edema involving the\n left parietal lobe.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 63-year-old male status post left craniotomy, evaluate for\n postoperative changes.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n FINDINGS: There are post-surgical changes following a left frontal and\n parietal craniotomy, with a small amount of expected pneumocephalus overlying\n the left frontal lobe, as well as a small amount of pneumocephalus and tiny\n foci of hemorrhage seen within the surgical bed. No additional foci of\n hemorrhage are identified. There continues to be a residual vasogenic edema\n predominantly involving the left parietal lobe. Minimal rightward shift of\n midline is unchanged from . There is no evidence for acute\n major vascular territorial infarction. The caliber of the ventricular system\n is unchanged without hydrocephalus. Visualized paranasal sinuses and mastoid\n air cells are normally aerated. Osseous structures reveal a craniotomy defect.\n\n IMPRESSION: Expected postoperative changes, with a small amount of\n pneumocephalus overlying the left frontal lobe, as well as tiny foci of\n pneumocephalus and postoperative hemorrhage within the surgical bed.\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2161-11-12 00:00:00.000",
"description": "Report",
"row_id": 221980,
"text": "Sinus rhythm\nEarly precordial QRS transition is nonspecific\nProlonged Q-Tc interval\nModest ST-T wave changes\nFindings are nonspecific but clinical correlation is suggested for possible in\npart drug/metabolic/electrolyte effect\nSince previous tracing of , QT-c interval appears prolonged but may be\nno significant change\n\n"
}
] |
70,561 | 117,086 | The patient is a 49 year old male with a history of severe scoliosis, restrictive lung disease, OSA, who presented to an OSH with worsening dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent tacheostomy placement, now transfered for evaluation of posterior wall erosion. | Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Assessment and Plan RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: Assessment and Plan RESPIRATORY FAILURE, ACUTE (NOT ARDS/) ICU Care Nutrition: Glycemic Control: Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: SQ UF Heparin Stress ulcer: PPI VAP: Comments: Communication: Comments: Code status: Full code Disposition: Will ask IP if we can change to non-adjustable trach as position of trach has moved overnight -speaking without using , keep off for now -decrease lasix to dosingPulmonary hypertension likely due to restrictive lung disease -continue lasix ADDENDUM Trach changed to 110mm, size 7. Will ask IP if we can change to non-adjustable trach as position of trach has moved overnight -speaking without using , keep off for now -decrease lasix to dosingPulmonary hypertension likely due to restrictive lung disease -continue lasix ICU Care Nutrition: regular diet Glycemic Control: RISS Lines: 22 Gauge - 01:41 PM Prophylaxis: DVT: heparin SQ Stress ulcer: Protonix VAP: Comments: Communication: Comments: Code status: full Disposition :Transfer to hospital after IP evaluates whether we should change to non-adjustable trach Total time spent: Demographics Day of intubation: Day of mechanical ventilation: 4 Ideal body weight: 0 None Ideal tidal volume: 0 / 0 / 0 mL/kg Airway Airway Placement Data Known difficult intubation: Procedure location: Reason: : Tracheostomy tube: Type: Adjustable Neck Flange Manufacturer: Size: 7.0mm PMV: Yes Cuff Management: Vol/Press: Cuff pressure: 25 cmH2O Cuff volume: mL / Airway problems: Comments: Lung sounds RLL Lung Sounds: Clear RUL Lung Sounds: Rhonchi LUL Lung Sounds: Rhonchi LLL Lung Sounds: Rhonchi Comments: Secretions Sputum color / consistency: Blood Tinged / Thick Sputum source/amount: Suctioned / Moderate Comments: Ventilation Assessment Level of breathing assistance: Intermittent invasive ventilation Visual assessment of breathing pattern: Normal quiet breathing Assessment of breathing comfort: No claim of dyspnea) Plan Next 24-48 hours: Reason for continuing current ventilatory support: Underlying illness not resolved Respiratory Care Shift Procedures Comments: Patient had been off the ventilator most of day on a 50% trach collar. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. Now status post tracheostomy placement with revision due to hypoxemia with trach blockage. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. A similar episode occured on , and a #7 Bavrona hyperflexible tracheostomy was placed. Reflux: - cont tx scoliosis 3. pain: - minimal, holding narcotic 4. pHTN: - cont lasix for diuresis Remainder of plan per resident note. Reflux: - cont tx scoliosis 3. pain: - minimal, holding narcotic 4. pHTN: - cont lasix for diuresis Remainder of plan per resident note. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Due to his severe scoliosis, and failed nasal intubation, and ENT was consulted for a semi-emergent tracheostomy. Demographics Day of intubation: Day of mechanical ventilation: 2 Ideal body weight: 0 None Ideal tidal volume: 0 / 0 / 0 mL/kg Airway Airway Placement Data Known difficult intubation: Tube Type Tracheostomy tube: Type: Cuffed, Adjustable Neck Flange Manufacturer: Size: 7.0mm PMV: Yes Cuff Management: Vol/Press: Cuff pressure: cmH2O Cuff volume: mL / Airway problems: Positional leak around cuff, adjustable trach advanced to 12 cm just below flange via bronchoscopic evaluation. | 38 | [
{
"category": "Physician ",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 615795,
"text": "Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 615616,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - bronched in morning by IP: supraglottic edema -> started PPI.\n occlusion of airway during expiration by posterior larynx ->\n tracheostomy tube was advanced by 1 cm with better airway patency\n established.\n - put on PS 10/5 while sleeping during day. overnight on vent from 12\n am to 4 am, then on trach collar\n - case mmgnt: should return to OSH vs begin screening for rehab\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 11:13 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.2\nC (98.9\n HR: 92 (71 - 115) bpm\n BP: 124/88(96) {103/62(71) - 150/123(126)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 720 mL\n PO:\n 720 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 3,820 mL\n 275 mL\n Urine:\n 3,820 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,100 mL\n -275 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 323 (323 - 325) mL\n PS : 10 cmH2O\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 99%\n ABG: ///41/\n Ve: 9.7 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 06:10 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"
},
{
"category": "Respiratory ",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 615755,
"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:\n Procedure location:\n Reason:\n :\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\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: 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: 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:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Comments: Patient had been off the ventilator most of day on a 50%\n trach collar. Good vocalization using the passy muir valve. Pt had\n periods of dyspnea relieved with suctioning and neb treatments. Pt and\n wife anxious about handling trach care when home but anxious to get\n started with rehab.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615756,
"text": "49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received the pt alert and sitting on the commode as chair. On trach\n mask.\n Action:\n Suctioned for blood tinged secretion, C/O chest pain around 0200 EKG\n done no changes and he claimed no more chest pain. Received ambien as\n per pt request, Cont PO lasix.\n Response:\n Pt passing 200 cc hr, lung sound less wet sounding\n Plan:\n Continue with lasix tid, nebs and suction as needed, plan to transfere\n back to osh tomorrow\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615840,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\n trach site doe have some old blood around trach.\n Action:\n Pt given 40 mg po lasix and albuternal neb x1 this am\n Response:\n Pt states breathing feels better, pt passing 300 cc hr urine\n Plan:\n To transfere to back to osh where he came from,\n Pt had bronch this afternoon, trach changed to #12 boviena, pt received\n 1 mg iv versed and 50 mcgs of iv Fentanyl for procedure, pt states this\n trach more comfortable, also not swelling above trach and bleeding in\n nasal area, pt to be transferred back to osh this afternoon.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615362,
"text": "The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615364,
"text": "The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\n comfortably in a chair. When in bed pt must lie flat and needs to be on\n full vent status. Lung sounds clear and rhonchorus but will clear once\n suctioned. O2 sat\ns in high 90\n Action:\n Once examined and assessed by resident pt got oob to chair with minimal\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\n mod amt\ns of thick bloody secretions,\n Response:\n Pt tolerated sitting in chair and maintained good o2 sat\ns on 40% trach\n collar. Pt able to eat some ice cream and drank some gingerale without\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\n and then got back to bed and placed on vent with originale settings. Pt\n slept for about 4hrs and when awoke c/o back pain again.\n Plan:\n plan for pt is to schedule him for a permanent trach.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615486,
"text": "hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP service consulted, to do FOB to assess trache and exclude\n posterior membrane erosion\n - npo for proc\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615358,
"text": "The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 615361,
"text": "Airway\n Tube Type\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Airway problems: Positional leak around cuff\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\n ventilatory support in supine position, due to severe scoliosis.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615357,
"text": "The patinet is a deaf 58 year old gentleman with a history of likely\n hypertensive dialated cardiomyopathy (EF 50%,) poorly controlled blood\n pressure, DM2, OSA, deaf and mute who presented to the ED with\n complains of sudden onset SOB. The patient has had prior\n hospitalizations for acute pulmonary edema in the setting of\n hypertensive urgency. He was seen by his PCP one day prior to\n presentation with complaints of 3 days of conjunctivitis and rhinorhea\n with a slight, non-productive cough, which was felt to be a viral\n syndrome, but he was prescribed erythromycin ointment.\n .\n On the day of presentation, the patient was waking and became markedly\n short of breath. EMS was activated, and the patient was placed on a\n NRB. On arrival to the ED, he was markedly hypertensive 242/110/ HR\n 106, and afebrile. The patient was placed on BIPAP, was started on a\n nitro gtt, given ASA 325mg, and was 100mg IV lasix, to which he put out\n 400cc of urine. Cardiology was consulted in the ED, but felt that\n given recent URI symptoms, a MICU admission would be more appropriate.\n The patient was admitted to the MICU for further management.\n .\n The patient denies any fevers/chills, abdominal pain, diahrea, or\n dysuria. He has not had any worsening LE swelling, orthopnea, or PND.\n He reports to be compliant with home medication regimen. He complaints\n of b/l chest pain currently, similar to prior chest pain. Worse with\n palpation and deep inspiration.\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 615827,
"text": "Chief Complaint: Trach occlusion\n I saw and examined the patient, and was physically present with the ICU\n resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan. PMH, SH, FH and ROS are\n unchanged from admission except where noted above.\n HPI: 49 yo man with severe scoliosis. Initially admitted to \n hospital with increasing dyspnea, with hypercarbic respiratory\n failure requiring semi-urgent tracheostomy. Transferred to for\n trach occlusion, now sp advancement of trach 1cm.\n 24 Hour Events:\n -no further issues with occlusion of tracheostomy\n - currently, on AC overnight and TCM with intermittent\n use of during the day\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lasix 40 IV TID\n Protonix\n ASA\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.8\n HR: 98 (79 - 103) bpm\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\n RR: 18 (16 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 930 mL\n PO:\n 790 mL\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Thin. Severe scoliosis.\n Peripheral 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: inspiratory and expiratory wheezing\n Extremities: 2+ symmetrical LE edema\n Skin: Not assessed\n Neurologic: alert and oriented x3\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: CXR:\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n -still has adjustable , doing well during the day and requires\n ventilator at night. Will ask IP if we can change to non-adjustable\n trach as position of trach has moved overnight\n -speaking without using , keep off for now\n -decrease lasix to dosing\nPulmonary hypertension likely due to restrictive lung disease\n -continue lasix\n ADDENDUM\n Trach changed to 110mm, size 7. Tip approximately 1cm above the\n carina. Uncomplicated. Severe subglottic edema noted. Pt indicated that\n he felt much more comfortable with the new trach in place. Doing well\n on trach collar for > 1 hour.\n ICU Care\n Nutrition: regular diet\n Glycemic Control: RISS\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: Protonix\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition :Transfer to hospital. F/U as outpatient with\n Interventional Pulmonary service, Dr .\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615690,
"text": "49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\n to clear secreations, lungs course\n Action:\n Pt given lasix this am and then lasix increased to tid\n Response:\n Pt passing 200 cc hr, lung sound less wet sounding\n Plan:\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\n tomorrow\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615680,
"text": "49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert on 50% shovel mask pt suctioned q3-4 hr from white\n to clear secreations, lungs course\n Action:\n Pt given lasix this am and then lasix increased to tid\n Response:\n Pt passing 200 cc hr, lung sound less wet\n Plan:\n Continue with lasix tid, nebs as needed, plan to transfere back to osh\n tomorrow\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615804,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt awake and alert, on 50% trach mask suctioned once this am for pink\n tinged sputum, sats,95% lung course throughout with some exp wheezing,\n trach site doe have some old blood around trach.\n Action:\n Pt given 40 mg po lasix and albuternal neb x1 this am\n Response:\n Pt states breathing feels better, pt passing 300 cc hr urine\n Plan:\n To transfere to back to osh where he came from,\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 615808,
"text": "Chief Complaint: 49 yo man with severe scoliosis. Initially admitted to\n hospital with increasing dyspnea, with hypercarbic\n respiratory failure requiring semi-urgent tracheostomy. Transferred to\n for trach occlusion, now sp advancement of trach 1cm.\n HPI:\n 24 Hour Events:\n -no further issues with occlusion of tracheostomy\n - currently, on AC overnight and TCM with intermittent\n use of during the day\n -lasix increased yesterday for volume overload on CXR, net out 3.6L\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lasix 40 IV TID\n Protonix\n ASA\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.6\nC (97.8\n HR: 98 (79 - 103) bpm\n BP: 104/65(74) {104/65(74) - 154/102(111)} mmHg\n RR: 18 (16 - 27) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 930 mL\n PO:\n 790 mL\n 930 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -400 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 97%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n General Appearance: Thin. Severe scoliosis.\n Peripheral 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: inspiratory and expiratory wheezing\n Extremities: 2+ symmetrical LE edema\n Skin: Not assessed\n Neurologic: alert and oriented x3\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: CXR:\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n -still has adjustable , doing well during the day and requires\n ventilator at night. Will ask IP if we can change to non-adjustable\n trach as position of trach has moved overnight\n -speaking without using , keep off for now\n -decrease lasix to dosing\nPulmonary hypertension likely due to restrictive lung disease\n -continue lasix\n ICU Care\n Nutrition: regular diet\n Glycemic Control: RISS\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer: Protonix\n VAP:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition :Transfer to hospital after IP evaluates whether we\n should change to non-adjustable trach\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 615809,
"text": "Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion, trach repositioned b IP.\n - continue vent settings over night, w/ valve during the day. Although\n pt can talk around valve, which may portend need for trach replacement.\n - discourange ambient use\n - will d/w IP switch to non-flexible valve\n - cont guafenisin and duoneb\n - reduce lasix to \n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 615794,
"text": "Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 615796,
"text": "Chief Complaint:\n 24 Hour Events:\n - attempted transfer back to ; no beds available so will call in\n AM, they will take him back there\n - c/o dyspnea in AM, increase po furosemide to TID with good effect\n - c/o in chest pain in the middle of the night, checked ECG, no acute\n changes. CP resolved on its own\n - did not use the vent overnight; only trach collar\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:50 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 07:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 100 (79 - 103) bpm\n BP: 119/77(85) {104/66(78) - 154/92(102)} mmHg\n RR: 26 (16 - 27) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 790 mL\n 450 mL\n PO:\n 790 mL\n 450 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 4,390 mL\n 1,330 mL\n Urine:\n 4,390 mL\n 1,330 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,600 mL\n -880 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 230 (230 - 439) mL\n PS : 10 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 12 cmH2O\n SpO2: 95%\n ABG: ////\n Ve: 6.4 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 308 K/uL\n 12.1 g/dL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Imaging: Lung volumes have decreased and opacification particularly in\n the right lung has increased since . Given the marked\n anatomic distortion of the chest precise diagnosis is difficult, but\n since there is vascular engorgement in the left lung I suspect cardiac\n decompensation is playing a role. There is also the suggestion of\n retained secretions in the bronchial tree, particularly the right.\n Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No\n pneumothorax is\n present.\n Assessment and Plan\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both\n restrictive lung process due to severe scoliosis with additonal OSA.\n Now status post tracheostomy placement with revision due to hypoxemia\n with trach blockage. Patient has been using trach valve during the day\n and CMV at night. Transfered for evaluation of posterior trach\n erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 01:41 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 615423,
"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 seen by interventional pulmonary\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n asa 81\n lasix 40 qday\n heparin 5000 tid\n albuterol\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 09:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 99 (76 - 112) bpm\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\n RR: 21 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 200 mL\n PO:\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 175 mL\n 795 mL\n Urine:\n 175 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n -175 mL\n -595 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 0 cmH2O\n SpO2: 95%\n ABG: ///45/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: Well nourished, scoliosis\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): ,\n Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 11.9 g/dL\n 277 K/uL\n 119 mg/dL\n 0.4 mg/dL\n 45 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 91 mEq/L\n 141 mEq/L\n 38.0 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n WBC\n 5.4\n Hct\n 38.0\n Plt\n 277\n Cr\n 0.4\n Glucose\n 119\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n 1./ hypercarbic respiratory failure:\n - IP service following\n - likely bronch this morning, with potential replacement of trach\n - will cont to follow\n - cont albuterol nebs as needed\n - npo for now\n 2. Reflux: cont scoliosis\n 3. pain: minimal, holding narcotic\n 4. pHTN: cont lasix for diuresis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition :ICU\n Total time spent: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615390,
"text": "The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt arrived to micu on vent 40% 400 x 14 +5peep, pt alert and oriented x\n 3 and is able to speak around trach. pt with bivonna #7 trach. pt has\n severe scoliosis/kyphosis. Pt is very hunched over but is able to sit\n comfortably in a chair. When in bed pt must lie flat and needs to be on\n full vent status. Lung sounds clear and rhonchorus but will clear once\n suctioned. O2 sat\ns in high 90\ns. will desat to low 90\ns when need to\n be sx\nd, afebrile. Foley cath with good urine output,\n Action:\n Once examined and assessed by resident pt got oob to chair with minimal\n assist. Once in chair pt placed to 40% trach collar. Pt suctioned for\n mod amt\ns of thick bloody secretions,\n Response:\n Pt tolerated sitting in chair and maintained good o2 sat\ns on 40% trach\n collar. Pt able to eat some ice cream and drank some gingerale without\n difficulty. Pt c/o some backpain and was then medicated with oxycodone\n and then got back to bed and placed on vent with originale settings. Pt\n slept for about 4hrs and when awoke c/o back pain again. Resident d/d\n oxycodone and ordered Tylenol. Pt received 650mg this am.\n Plan:\n plan for pt is to schedule him for a permanent trach. pt is currently\n npo.\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 615396,
"text": "Airway\n Tube Type\n Tracheostomy tube:\n Type: Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Airway problems: Positional leak around cuff\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent 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 Reason for continuing current ventilatory support: Patient needs\n ventilatory support in supine position, due to severe scoliosis.\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 615577,
"text": "Demographics\n Day of mechanical ventilation: 3\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: when off vent.\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Increase ventilatory support at night\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-01 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 615315,
"text": "Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. On\n presentation to the ED, the he was found to be hypoxemic (80s) and\n hypercapnic (ABG 7.29 / 89 / 83 / 42,) with episodes of bradycardia\n with 3-4 sec pauses, and was admitted to the ICU. He was started on\n BIPAP at night, with intermitent use during the day due to his severe\n hypercapnic respiratory failure, but did not have good tolerance of\n non-invasive ventilation. His respiratory status continud to worsen,\n and the patient was found somnolent and difficult to arouse at night.\n PCO2 was found during to be 130. Due to his severe scoliosis, and\n failed nasal intubation, and ENT was consulted for a semi-emergent\n tracheostomy. A #6 LTC cuffed Shiley trach was placed, but started on\n Passy-Muir valve during the day time. On , the patient occluded\n the tracheostomy with severe hypoxia, requiring CPR, but resolved with\n trach manipulation to restablish the airway. A similar episode occured\n on , and a #7 Bavrona hyperflexible tracheostomy was placed. He\n has remained on mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - IP vs. ENT c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE:\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-01 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 615316,
"text": "Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. Of note, he\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\n to the ICU. He was started on BIPAP at night, with intermitent use\n during the day due to his severe hypercapnic respiratory failure, but\n did not have good tolerance of non-invasive ventilation. His\n respiratory status continud to worsen, and the patient was found\n somnolent and difficult to arouse at night. PCO2 was found during to\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\n Shiley trach was placed, but started on Passy-Muir valve during the day\n time. On , the patient occluded the tracheostomy with severe\n hypoxia, requiring CPR, but resolved with trach manipulation to\n restablish the airway. A similar episode occured on , and a #7\n Bavrona hyperflexible tracheostomy was placed. He has remained on\n mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL CODE\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 615319,
"text": "Chief Complaint: CHIEF COMPLAINT: DOE\n REASON FOR MICU ADMISSION: Vent Dependent on trach\n HPI:\n The patinet is a 49 year old male with a history of sever scoliosis\n complicated by secondary restrictive lung disease (FEV 27% predicted,)\n OSA who presented to an OSH on with complaints of progressive\n dyspnea.\n .\n The patient has had worsening shortness of breath at rest over the last\n year. OSH records also indicate the patient dozing off throughotu the\n day, raising concerns of him falling alseep while driving. Of note, he\n has gained 30lbs in the last 2 yrs. On presentation to the ED, the he\n was found to be hypoxemic (80s) and hypercapnic (ABG 7.29 / 89 / 83 /\n 42,) with episodes of bradycardia with 3-4 sec pauses, and was admitted\n to the ICU. He was started on BIPAP at night, with intermitent use\n during the day due to his severe hypercapnic respiratory failure, but\n did not have good tolerance of non-invasive ventilation. His\n respiratory status continud to worsen, and the patient was found\n somnolent and difficult to arouse at night. PCO2 was found during to\n be 130. Due to his severe scoliosis, and failed nasal intubation, and\n ENT was consulted for a semi-emergent tracheostomy. A #6 LTC cuffed\n Shiley trach was placed, but started on Passy-Muir valve during the day\n time. On , the patient occluded the tracheostomy with severe\n hypoxia, requiring CPR, but resolved with trach manipulation to\n restablish the airway. A similar episode occured on , and a #7\n Bavrona hyperflexible tracheostomy was placed. He has remained on\n mechanic ventialation at night, AC, 400/14/5.\n .\n Per OSH records, there were concerns that the tracheostomy tube tip\n appeard to be eroding at the posterior wall of the trachea due to the\n patients baseline abnormal antatomy. The patient was transfered to\n for evaluation of a potential customized tracheostomy vs other\n intervention.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n ASA 81mg daily\n Lasix 80mg daily\n Rozerem PRN\n .\n Medications at Transfer-\n Ambien 5mg HS PRN\n Morphine 4-6mg q4h PRN pain\n Percocet tab q4H PRN pain\n Claritin 10mg daily\n Magnesium oxide 400mg \n DuoNeb PRN\n Protonix 40mg daily\n Lorazepam 45mg q4 PRN\n Colace 100mg \n Humibid 1200mg \n Lasix 40mg daily\n Arixtra 2.5mg daily\n ASA 81mg daily\n Past medical history:\n Family history:\n Social History:\n Severe scoliosis\n Prior pneumothoraces\n Restrictive Lung Disease\n Chronic respiroatyr failure\n Cholecystectomy\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: The patient is currently married, no alcohol, or tobacco. On\n disability due to scoliosis.\n Review of systems:\n Flowsheet Data as of 11:06 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n HR: 103 (101 - 103) bpm\n BP: 132/108(111) {132/108(111) - 132/108(111)} mmHg\n RR: 25 (20 - 25) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 36 cmH2O\n SpO2: 99%\n Ve: 4.9 L/min\n Physical Examination\n Trached, on trach mask, sitting in a chair\n Severe scoliosis, slgith erosis on neck from trach\n Abnormal resioatory movements\n Distant heart sounds, tachycardic, no m/r/g\n Abdominal ventral, soft, ntnd\n 1+ LE b/l\n Labs / Radiology\n [image002.jpg]\n Imaging: :\n Severe Scoliosis and deformity of the thorax obsuring detail regarding\n the right lung. Opacification of the right heithorax suggesting\n pulmonary consolidation and a large pleural effusion with pulmonary\n vascular congestion.\n .\n TTE: EF 70-75%, mPHTN w/ PAP 45-50, mild RV enlargement and reduced\n function.\n .\n EKG, sinus at 95, right axis deviation, e/o right heart strain.\n Assessment and Plan\n ASSESSMENT & PLAN:\n The patient is a 49 year old male with a history of severe scoliosis,\n restrictive lung disease, OSA, who presented to an OSH with worsening\n dyspnea, who developed hypercapnic respiratory failure w/ semi-emergent\n tacheostomy placement, now transfered for evaluation of posterior wall\n erosion.\n # Hypercapnic respiratory failure: likely secondary to both restrictive\n lung process due to severe scoliosis with additonal OSA. Now status\n post tracheostomy placement with revision due to hypoxemia with trach\n blockage. Patient has been using trach valve during the day and CMV at\n night. Transfered for evaluation of posterior trach erosion.\n - continue vent settings as per \n - discourange ambient use\n - IP c/s in am\n - cont guafenisin and duoneb\n - check baseline CXR here\n - encourage weight loss and ? pulm rehab on discharge.\n .\n # Severe Scoliosis:\n - cont protonix\n - tylenol for pain, holding narcotics from OSH as is not part of home\n regimen.\n .\n # RV failure: likely due to mod pHTN (45mmHg) in the setting of OSA.\n Mild reduced RV function.\n - cont home lasix\n - TEDS\n .\n # FEN: IVFs / replete lytes prn / soft diet with thin liquids\n # PPX: PPI, heparin SQ, bowel regimen\n # ACCESS: PIV\n # CODE: FULL CODE\n # CONTACT: The patients wife\n # DISPO: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n MICU Overnight Attending Coverage\n I saw and examined the patient with Dr. . The assessment and plan\n was discussed in detail.\n I would emphasize the following. 49 y.o. man with severe scoliosis,\n OSA, and 30 pound weight gain over past approximately two years with\n progressive dyspnea, hypercapneic and hypoxic respiratory failure\n requiring urgent tracheostomy at the outside hospital. Trach changes\n as noted above, using vent at night, off most of the day, minimal\n suctioning required except when trach first placed. Now concern for\n posterior tracheal erosion. No hemoptysis, minimizing suctioning.\n Appears comfortable on trach collar sitting straight up in chair.\n Severe scoliosis poor air movement on right, occ. crackle on left, no\n wheeze\n RRR, no murmurs\n + bipedal edema Erythema on right forearm, no cord/fluctulence\n Alert and oriented x 3 Ventral and umbilical hernia\n Hypercapneic/hypoxic respiratory failure secondary to restrictive lung\n disease in setting of severe scoliosis and OSA exacerbated in setting\n of significant weight gain. require customized trach, IP to\n evaluate in the morning. NPO after midnight. Minimize suctioning.\n Plan as noted above.\n Patient is critically ill given tenuous respiratory status\n Full code\n Time spent 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 00:32 ------\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615568,
"text": "49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Stable overnight, no issues\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615570,
"text": "49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Stable overnight, no issues\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"
},
{
"category": "Nutrition",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 615664,
"text": "Ht: unavailable to assess due to severe scolosis\n Wt: 89 kg\n Diet: Soft, thin liquids\n Labs: noted\n Abdomen: soft/distended, positive bowel sounds\n Potential for nutrition risk. Patient being monitored. Current\n intervention if any, listed below:\n 49 year old male with a history of severe scoliosis, restrictive lung\n disease, obstructive sleep apnea, who presented to an outside hosptial\n with worsening dyspnea, who developed hypercapnic respiratory failure\n w/ semi-emergent tacheostomy placement, now transfered for evaluation\n of posterior wall erosion. Now status post tracheostomy placement with\n revision due to hypoxemia with trach blockage.\n Tolerating soft diet, good appetite. Eats soft diet at home. Thinks\n his current weight is\nhigh\n, but stable recently. Per chart, patient\n with 30 lb weight gain x 2 years.\n Noted plan for transfer to .\n Will follow to check po\ns if remains in house, page if questions *\n PM\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 615648,
"text": "TITLE:\n Chief Complaint: respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -IP performed FOB, evaluation of trache\n -Ventilated overnight\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 Pantoprazole (Protonix) - 08:18 PM\n Heparin Sodium (Prophylaxis) - 07:50 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:19 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.3\nC (99.1\n HR: 92 (71 - 115) bpm\n BP: 128/80(87) {103/62(71) - 150/123(126)} mmHg\n RR: 20 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 720 mL\n 100 mL\n PO:\n 720 mL\n 100 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 3,820 mL\n 1,075 mL\n Urine:\n 3,820 mL\n 1,075 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,100 mL\n -975 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Spontaneous): 323 (323 - 325) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SpO2: 97%\n ABG: ///41/\n Ve: 9.7 L/min\n Physical Examination\n General Appearance: No acute distress, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic, trache 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: No(t) Symmetric), (Breath Sounds:\n Diminished: ), severe kyphoscoliosis\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.1 g/dL\n 308 K/uL\n 103 mg/dL\n 0.4 mg/dL\n 41 mEq/L\n 4.1 mEq/L\n 7 mg/dL\n 94 mEq/L\n 141 mEq/L\n 38.2 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n 04:45 AM\n WBC\n 5.4\n 5.4\n Hct\n 38.0\n 38.2\n Plt\n 277\n 308\n Cr\n 0.4\n 0.4\n Glucose\n 119\n 103\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:8.9 mg/dL, Mg++:2.2 mg/dL,\n PO4:3.6 mg/dL\n Assessment and Plan\n 1. hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP performed FOB/airway evaluation\n -no posterior membrane erosion\n -trache adjusted\n - nocturnal ventilation ongoing\n 2. Reflux:\n - cont tx scoliosis\n 3. pain:\n - minimal, holding narcotic\n 4. pHTN:\n - cont lasix for diuresis\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition :Transfer to other facility\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 615711,
"text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Airway\n Airway Placement Data\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt on and off Trach Collar .50 today using PMV occasionally\n for short periods of time.\n"
},
{
"category": "Case Management ",
"chartdate": "2156-12-03 00:00:00.000",
"description": "Case Management Continued Stay Review",
"row_id": 615657,
"text": "Planned Discharge Date: \n Insurance Update\n Primary insurance / reviewer:\n Hospital days authorized to:\n Current Discharge Plan: Hospital, NH\n Narrative / Plan (Multidisciplinary team):\n Case discussed w/ team. Pt with new trach/vented on CPAP at times,\n would need hospital level rehab not . Pt with NH medicaid only. No\n LTACs in NH. No NH medicaid contracts at LTACs in MA. Plan is for pt to\n return to Hospital. MICU team has made contact with \n Physician to start arranging for transfer back.\n"
},
{
"category": "Nursing",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 615494,
"text": "49 year old male with a history of severe scoliosis, restrictive lung\n disease, OSA, who presented to an OSH with worsening dyspnea, who\n developed hypercapnic respiratory failure w/ semi-emergent tracheostomy\n placement, now transferred for evaluation of posterior wall erosion.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt alert and oriented x 3 and is able to speak around trach. pt with\n bivonna #7. severe scoliosis/kyphosis. Pt is very hunched over but is\n able to sit comfortably in a chair. When in bed pt must lie flat and\n needs to be on full vent status. Lung sounds clear and rhonchorus with\n wheezes throughout, responds very well to neb treatments. Hands and\n feet puffy from recent weight gain and fluid. Here for IP consult\n Action:\n TEDS stockings applied. IP bronched pt this pm, advanced his \n trache to better spot. Pt w/ estrictive lung dz, exacerbated by recent\n signif. Wt gain, also scholiosis and OSA\n Response:\n Pt tolerated procedure well. No erosion noted of trache, some\n irritation though. PPI started for this. sitting in chair and\n maintained good o2 sat\ns on 40% trach collar. To fully supported on\n vent. Diet advanced back to his soft solids, tolerated well.\n Plan:\n plan for pt to hopefully be transferred back to Hospital\n tomorrow. He needs to go to rehab in NH and from a facility in NH d/t\n his Medicaid insurance\n"
},
{
"category": "Physician ",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 615453,
"text": "Chief Complaint:\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n 24 Hour Events:\n - seen by interventional pulmonary\n Allergies:\n No Known Drug Allergies\n Other medications:\n asa 81\n lasix 40 qday\n heparin 5000 tid\n albuterol\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 09:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.7\nC (98\n HR: 99 (76 - 112) bpm\n BP: 114/74(82) {99/60(71) - 135/108(111)} mmHg\n RR: 21 (14 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 200 mL\n PO:\n 200 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 175 mL\n 795 mL\n Urine:\n 175 mL\n 795 mL\n NG:\n Stool:\n Drains:\n Balance:\n -175 mL\n -595 mL\n Respiratory support\n O2 Delivery Device: Trach mask\n Ventilator mode: Standby\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Unstable Airway\n PIP: 0 cmH2O\n SpO2: 95%\n ABG: ///45/\n Ve: 4.2 L/min\n Physical Examination\n General Appearance: Well nourished, scoliosis\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: No(t) Normocephalic, Poor dentition\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: poor air mvmt on right\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Attentive\n Labs / Radiology\n 11.9 g/dL\n 277 K/uL\n 119 mg/dL\n 0.4 mg/dL\n 45 mEq/L\n 3.7 mEq/L\n 7 mg/dL\n 91 mEq/L\n 141 mEq/L\n 38.0 %\n 5.4 K/uL\n [image002.jpg]\n 12:26 AM\n WBC\n 5.4\n Hct\n 38.0\n Plt\n 277\n Cr\n 0.4\n Glucose\n 119\n Other labs: PT / PTT / INR:11.8//1.0, Ca++:9.0 mg/dL, Mg++:2.1 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n 1. hypercarbic respiratory failure:\n - restrictive lung disease in setting of severe scoliosis and OSA\n - likely exacerbated with recent significant weight gain\n - IP service consulted, to do FOB to assess trache and exclude\n posterior membrane erosion\n - npo for proc\n 2. Reflux:\n - cont tx scoliosis\n 3. pain:\n - minimal, holding narcotic\n 4. pHTN:\n - cont lasix for diuresis\n Remainder of plan per resident note.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:10 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin(Systemic anticoagulation: None)\n Stress ulcer:\n VAP: Mouth care\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition :ICU\n Total time spent:\n"
},
{
"category": "Respiratory ",
"chartdate": "2156-12-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 615454,
"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 Tube Type\n Tracheostomy tube:\n Type: Cuffed, Adjustable Neck Flange\n Manufacturer: \n Size: 7.0mm\n PMV: Yes\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems: Positional leak around cuff,\n adjustable trach advanced to 12 cm just below flange via bronchoscopic\n evaluation.\n Comments: deflated while off ventilator\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments: expriratory wheezes T/O clear after albuterol adm via\n nebulizer.\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Expectorated / None\n Ventilation Assessment\n Level of breathing assistance: Off ventilator during the day\n Visual assessment of breathing pattern: occasional dyspnea with\n increased congestion and expiratory wheezes, relieved with coughing and\n nebulized albuterol.\n Plan\n Next 24-48 hours: Increase ventilatory support at night; Comments:\n placed on ventilator at night for management of CO2\n Reason for continuing current ventilatory support:\n Bedside Procedures:\n Bronchoscopy (12:00)\n Comments:\n"
},
{
"category": "ECG",
"chartdate": "2156-12-04 00:00:00.000",
"description": "Report",
"row_id": 230766,
"text": "Sinus rhythm. Consider right atrial abnormality. Right axis deviation.\nProminent lateral lead Q waves. Findings raise consideration of possible\nright ventricular overload. Possible prior lateral myocardial infarction\nof left posterior fascicular block. Clinical correlation is suggested.\nNo previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1116684,
"text": " 9:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with trach c/o dyspnea.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 9:39 A.M. \n\n HISTORY: Tracheostomy. Complains of dyspnea.\n\n IMPRESSION: AP chest compared to :\n\n Lung volumes have decreased and opacification particularly in the right lung\n has increased since . Given the marked anatomic distortion of the\n chest precise diagnosis is difficult, but since there is vascular engorgement\n in the left lung I suspect cardiac decompensation is playing a role. There is\n also the suggestion of retained secretions in the bronchial tree, particularly\n the right. Right pleural effusion has probably developed and whether the\n right lower lung is atelectatic or consolidated is radiographically\n indeterminate, as is the extent of presumed cardiomegaly. No pneumothorax is\n present.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-12-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1116480,
"text": " 11:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls evaluate lung fields\n Admitting Diagnosis: SCOLIOSIS;RESPIRAORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old man with severe scoliosis s/p trach\n REASON FOR THIS EXAMINATION:\n pls evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Evaluate tracheostomy.\n\n The interpretation of this radiograph is very limited due to the severe\n scoliosis and deformity of the thoracic cage. Tracheostomy tube tip is 5.5 cm\n above the carina. Cardiomediastinal contours cannot be evaluated. There is\n no evident pneumothorax. If any, there is a small right pleural effusion.\n The main central pulmonary arteries appear to be enlarged. There are no prior\n studies available for comparison. The asymmetric increased density in the\n right hemithorax could be due to pleural effusion or lung opacities in the\n right lower lobe, I suspect that also is due to the deformity of the thoracic\n cage. If prior studies were available , comparison could be performed to\n assess new abnormality.\n\n"
}
] |
369 | 145,787 | Pt under went an unremarkable hospital course. Pt was tolerating a regular diet with good pain control on PO pain medications. Pt was ambulating on her own and working with physical therapy. On , pt's CXR showed R pleural effusion. Pt's O2 saturation were 95% on RA. On discharge, the pt was 6 kg over her pre operative weight and was DC'd on 1 week on lasix 40mg for continued diuresis. CXR pending. An addendum will be added regarding results. | BS DIMINISHED BIBASILAR COURSE UPPER CLEARS WITH SX. Since the previoustracing of atrial ectopy, right bundle-branch block and prolongedQTc interval are seen. REASON FOR THIS EXAMINATION: r/o PTX/Effusion/Tamponade. RX X 1 WITH REGLAN. The approximately 1 cm nodular opacity in the left lower lung zone periphery is again noted, which may represent loculated fluid vs. an unusual atelectatic pattern. is still in OR, please perfo Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT; ? EXTUBATED AT MIDNOC. The patient is status post AVR and median sternotomy. CALCIUM AND MAG REPLACED. IMPRESSION: Residual bilateral pleural effusions. Residual left lower lobe atelectasis. CSRU UPDATES/P AVR TISSUE VALVE. Atrial premature beats. Evaluate for pleural effusion. There are residual bilateral pleural effusions, with residual left lower lobe atelectasis. 1:46 PM CHEST (PORTABLE AP) Clip # Reason: r/o PTX/Effusion/Tamponade. MIN CT DRAINAGE. SBP LABILE 88- 130 PRESENTLY NIPRIDE @ .7 MCQ TO KEEP SBP 90-120.CI > 2.5. 11:31 AM CHEST (PA & LAT) Clip # Reason: re-eval right effusion Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT; ? NEO TITRATED OFF.NEURO: LETHARGIC. NEO ON TRANSIENTLY FOR LOW BP. Pt s/p AVR. Sinus rhythm. The right jugular Swan-Ganz catheter terminates in the right main PA. NIPRIDE OFF TRANSIENT NEO HOWEVER PRESENTLY OFF BOTH WITH SBP 100'S. There is bilateral lower lobe atelectasis. TMAX 37.7. ADDITONAL K AND CALCIUM GIVEN. DILAUDID FOR PAIN. CLINICAL INDICATION: Status post aortic valve replacement. FINDINGS: PA and lateral views of the chest show interval removal of the endotracheal tube and Swan-Ganz catheter. Mildly increased moderate right pleural effusion, with stable left pleural effusion. Unusual nodular opacity over left lower lung zone peripherally, possibly representing possibly loculated fluid vs. unusual pattern of atelectasis. C/O STIFFNESS LEFT ARM. Small left and moderate right pleural effusions are noted with slight worsening of the right effusion. Pt. Pt. VENT SETTINGS PER FLOW WITH GOOD ABG. Midline sternotomy wires and a prosthetic aortic valve are again seen. CI REMAINS > 2. ID: VANCO @ . Midline sternotomy wires and prosthestic aortic valve are seen. Stable small left pleural effusion and improving left lower lobe atelectasis. GIVEN 1L LR THROUGHOUT SHIFT. is still in OR, please perform when pt is in CSRU. NEURO: REVERSED AND AWOKE CALM, PERL, MAE, GRASPS STRONG AND EQUAL. IMPRESSION: 1. IMPRESSION: 1. AMIODARONE BOLUS AND GTT @ 1 MG DUE TO RUNS OF AF. DC CORDIS/SWAN. 10:49 AM CHEST (PRE-OP PA & LAT) Clip # Reason: r/o effusion Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT; ? Low limb lead voltage is non-specific.Right bundle-branch block. CURRENT O2 SETTINGS .7 O2 FACE TENT/ 4L NC. NEO CURRENTLY OFF. HCT 34. Cardiac and mediastinal contours are stable in the postoperative. COMPARISON: . COMPARISON: . S/P AVRO: CARDIAC: CONTINUES TO REQUIRE LR, SR 80'S PRESENTLY. ?TX TO FLOOR. See resp flowsheet for vent data. LS CLEAR, DECREASED IN THE BASES. Mediastinal drains are in place. 3:01 PM CHEST (PA & LAT) Clip # Reason: s/p chest tube removal-r/o PTX Admitting Diagnosis: AORTIC STENOSIS\AORTIC VALVE REPLACEMENT; ? FICK CO 3.86, THERMODILUTION 3.0. The patient is status post median sternotomy and aortic valve replacement procedure. An old compression fracture of a mid thoracic vertebra is again noted. FINDINGS: PA & lateral views of the chest show bilateral pleural effusions; the right appears somewhat greater, while the left is stable. Clinical correlation is suggested. Attention to this region on followup CXR is recommended. There are bibasilar atelectatic changes which have improved at the left base and are unchanged at the right lung base. An old compression fracture of a mid- thoracic vertebra is seen. HCT PENDING FEBRILE RECIEVED 650 MG TYLENOL PR. Finally, there is an apparent small nodular opacity in the periphery of the left lower lung zone, possibly due to an overlying structure external to the patient based on the lateral view findings. GI: OGT + PLACEMENT, CARAFATE X2, ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS. Slight increase in right pleural effusion, moderate in size. REQUIRING LR 2 L TO KEEP HR <100, CT MINIMAL DRAINAGE SINCE INITIAL 200ML, DSGS D+I. There is mild congestive heart failure with cardiomegaly and small bilateral pleural effusions. AS PER ORDERS. MAE. The tip of the endotracheal tube is identified 3 cm above the carina. 3. 2. 2. SX FOR A SMALL AMOUNT OF TAN SPUTUM. Prolonged QTc interval - cannot excludemetabolic/drug effect. HYPOACTIVE BS.GU: URINE OUTPUT HAS SLOWED OVN TO 30-40CC/HR.PLAN: OOB TO CHAIR. Respiratory TherapyPt remains orally intubated and on full vent support. SR 80-90'S. DENIES PAIN OR DISCOMFORT WHEN MOANING.CV: NSR 67. COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with the previous study of . Questionable nodular opacity in left lower lobe, possibly external to the patient. A nasogastric tube courses towards the stomach. | 9 | [
{
"category": "Radiology",
"chartdate": "2142-10-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839984,
"text": " 1:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perfo\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with AS/AI s/p AVR.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade. Pt. is still in OR, please perform when pt is in\n CSRU.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 75-year-old woman with status post AVR.\n\n COMMENTS: Portable AP radiograph of the chest is reviewed, and compared with\n the previous study of .\n\n The patient is status post AVR and median sternotomy. There is mild\n congestive heart failure with cardiomegaly and small bilateral pleural\n effusions. The right jugular Swan-Ganz catheter terminates in the right main\n PA. The tip of the endotracheal tube is identified 3 cm above the carina. A\n nasogastric tube courses towards the stomach. Mediastinal drains are in\n place. No pneumothorax is identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-10-15 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 840646,
"text": " 10:49 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: r/o effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n Compared to earlier study of , and .\n\n CLINICAL INDICATION: Status post aortic valve replacement. Evaluate for\n pleural effusion.\n\n The patient is status post median sternotomy and aortic valve replacement\n procedure. Cardiac and mediastinal contours are stable in the postoperative.\n There is no evidence of cardiac failure. There are bibasilar atelectatic\n changes which have improved at the left base and are unchanged at the right\n lung base. Small left and moderate right pleural effusions are noted with\n slight worsening of the right effusion. There is no evidence of pneumothorax.\n Finally, there is an apparent small nodular opacity in the periphery of the\n left lower lung zone, possibly due to an overlying structure external to the\n patient based on the lateral view findings.\n\n IMPRESSION:\n 1. Stable small left pleural effusion and improving left lower lobe\n atelectasis.\n 2. Slight increase in right pleural effusion, moderate in size.\n 3. Questionable nodular opacity in left lower lobe, possibly external to the\n patient. Repeat radiograph following removal of external EKG lead devices\n would be helpful to fully exclude a lung nodule.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-10-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 840798,
"text": " 11:31 AM\n CHEST (PA & LAT) Clip # \n Reason: re-eval right effusion\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n re-eval right effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative for aortic valve replacement.\n\n COMPARISON: .\n\n FINDINGS: PA & lateral views of the chest show bilateral pleural effusions;\n the right appears somewhat greater, while the left is stable. There is\n bilateral lower lobe atelectasis. The approximately 1 cm nodular opacity in\n the left lower lung zone periphery is again noted, which may represent\n loculated fluid vs. an unusual atelectatic pattern. It is also seen on the\n lateral radiograph and does not appear to be due to a structure external to\n the patient, as was considered on the prior report. Midline sternotomy wires\n and a prosthetic aortic valve are again seen. An old compression fracture of a\n mid thoracic vertebra is again noted.\n\n IMPRESSION: 1. Mildly increased moderate right pleural effusion, with stable\n left pleural effusion.\n\n 2. Unusual nodular opacity over left lower lung zone peripherally, possibly\n representing possibly loculated fluid vs. unusual pattern of atelectasis.\n Attention to this region on followup CXR is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-10-11 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 840223,
"text": " 3:01 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p chest tube removal-r/o PTX\n Admitting Diagnosis: AORTIC STENOSIS\\AORTIC VALVE REPLACEMENT; ? CABG/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with severe aortic stenosis, pre op for AVR\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic valve replacement.\n\n COMPARISON: .\n\n FINDINGS: PA and lateral views of the chest show interval removal of the\n endotracheal tube and Swan-Ganz catheter. There are residual bilateral\n pleural effusions, with residual left lower lobe atelectasis. There is no\n evidence of congestive heart failure. An old compression fracture of a mid-\n thoracic vertebra is seen. Midline sternotomy wires and prosthestic aortic\n valve are seen.\n\n IMPRESSION: Residual bilateral pleural effusions. Residual left lower lobe\n atelectasis.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2142-10-09 00:00:00.000",
"description": "Report",
"row_id": 134536,
"text": "Sinus rhythm. Atrial premature beats. Low limb lead voltage is non-specific.\nRight bundle-branch block. Prolonged QTc interval - cannot exclude\nmetabolic/drug effect. Clinical correlation is suggested. Since the previous\ntracing of atrial ectopy, right bundle-branch block and prolonged\nQTc interval are seen.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-10-09 00:00:00.000",
"description": "Report",
"row_id": 1265625,
"text": "S/P AVR\nO: CARDIAC: CONTINUES TO REQUIRE LR, SR 80'S PRESENTLY. AMIODARONE BOLUS AND GTT @ 1 MG DUE TO RUNS OF AF. NIPRIDE OFF TRANSIENT NEO HOWEVER PRESENTLY OFF BOTH WITH SBP 100'S. CI REMAINS > 2. HCT PENDING FEBRILE RECIEVED 650 MG TYLENOL PR. PAD'S LO TWENTIES WITH CVP 15. MIN CT DRAINAGE. ADDITONAL K AND CALCIUM GIVEN.\n RESP: FAILED CPAP WEAN TO ATTEMPT AGAIN, UNABLE TO LIFT HEAD OFF PILLOW. VENT SETTINGS PER FLOW WITH GOOD ABG. O2 SAT >97%. BS DIMINISHED BIBASILAR COURSE UPPER CLEARS WITH SX. SX FOR A SMALL AMOUNT OF TAN SPUTUM. NOT OVERBREATHING THE VENT. NO CHEST TUBE LEAK.\n NEURO: REVERSED AND AWOKE CALM, PERL, MAE, GRASPS STRONG AND EQUAL.\n GI: OGT + PLACEMENT, CARAFATE X2, ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS.\n GU: AUTODIURESED POST OP,\n ENDO: INSULIN GTT PRESENTLY AT 2 UNITS/HR.\n ID: VANCO @ .\n PAIN: RECIEVED .5 MG DILAUDID X 2 WITH GOOD EFFECT, DENIES PAIN AT PRESENT.\n SOCIAL: HUSBAND AND CHILDREN INTO VISIT AND UPDATED\nA: LARGE VOLUME REQUIREMENTS, AMIODARONE DUE TO INCREASED ATRIAL ACTIVITY,FEBRILE, FAILED INITIAL WEAN, LARGE DIURESIS.\nP: MONITOR COMFORT, HR AND RYTHYM-CONTINUE AMIODARONE, KEEP SBP BETWEEN 90-120, CI, CT DRAINAGE, RESP STATUS-WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS PENDING. AS PER ORDERS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-10-10 00:00:00.000",
"description": "Report",
"row_id": 1265626,
"text": "CSRU UPDATE\nS/P AVR TISSUE VALVE. EXTUBATED AT MIDNOC. NEO TITRATED OFF.\nNEURO: LETHARGIC. MAE. C/O STIFFNESS LEFT ARM. DILAUDID FOR PAIN. MOANING THROUGHOUT NIGHT. STATES IT \"MAKES ME FEEL BETTER TO MOAN.\" DENIES PAIN OR DISCOMFORT WHEN MOANING.\nCV: NSR 67. PLACED ON ADEMAND AT 80 TO INCREASE BP. TMAX 37.7. NEO ON TRANSIENTLY FOR LOW BP. GIVEN 1L LR THROUGHOUT SHIFT. NEO CURRENTLY OFF. FICK CO 3.86, THERMODILUTION 3.0. 3+ PEDAL PULSES.\nPULM: NEEDING A LOT OF ENCOURAGEMENT FOR COUGHING AND DEEP BREATHING. CURRENT O2 SETTINGS .7 O2 FACE TENT/ 4L NC. LS CLEAR, DECREASED IN THE BASES. ?START LASIX THIS AM.\nGI: CONTINUES ON INSULIN GTT AT 1U/HR. RX X 1 WITH REGLAN. HYPOACTIVE BS.\nGU: URINE OUTPUT HAS SLOWED OVN TO 30-40CC/HR.\nPLAN: OOB TO CHAIR. DC CORDIS/SWAN. ?TX TO FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-10-09 00:00:00.000",
"description": "Report",
"row_id": 1265623,
"text": "Respiratory Therapy\nPt remains orally intubated and on full vent support. Pt s/p AVR. See resp flowsheet for vent data. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-10-09 00:00:00.000",
"description": "Report",
"row_id": 1265624,
"text": "S/P AVR\nO: ARRIVED ON NTG AND NIPRIDE TO KEEP SBP <125 PER DR. , 200 ML CT. 80 MCQ OF PROPOFOL. SR 80-90'S.\n CARDIAC: SR WITH PAC'S NOTED, 6 BEAT RUN VT WITH K 4.5 HAD RECIEVED 40 MEQ KCL X 1. SBP LABILE 88- 130 PRESENTLY NIPRIDE @ .7 MCQ TO KEEP SBP 90-120.CI > 2.5. REQUIRING LR 2 L TO KEEP HR <100, CT MINIMAL DRAINAGE SINCE INITIAL 200ML, DSGS D+I. HCT 34. CALCIUM AND MAG REPLACED.\n"
}
] |
61,825 | 163,976 | The patinet is a 66 year old man with severe COPD, AAA and HTN who presented with right-sided chest pain and worsening shortness of breath, and was found the have a pulmonary embolus and pneumonia. | Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Trace aortic regurgitation is seen. Check sputum cx. - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . - ipratropium and albuterol nebs prn . Echo and LENIs today PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. CTA: Prelim RLL segmental PE. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. Pancreatic ductal dilation would recommend MRCP/ERCP. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. - ipratropium nebs and albuterol nebs . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . # Hyperlipidemia: - continue atorvostatin . Continue albuterol and atrovent nebs. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. #PE: Pt with RLL segmental PE with associated infarct. Treat with anticoagulation. Treat with anticoagulation. Treat with anticoagulation. Will eval area of hyperdensity seen on CTA with non-con abd CT. Will eval area of hyperdensity seen on CTA with non-con abd CT. Will eval area of hyperdensity seen on CTA with non-con abd CT. PE, PERINEPHRIC ABSCESS OTHER PATH Contrast: OPTIRAY Amt: 130 FINAL REPORT (Cont) enhancement. Echo and LENIs today PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. CTA with RLL segmental PE and RLL infarct. Check sputum cx. Cholelithiasis. Cholelithiasis. The aortic knob is calcified. Pancreatic ductal dilatation: Will need MRCP as outpt or when stabilized. Hepatic vasculature and portal vein are patent. Continue heparin drip PNA and leukocytosis: Unusual look to PNA with area of cavitation versus area of bullous emphysema. Correlation with endoscopy. Prior inferior myocardial infarction. Follow up CT as outpt to eval. The right posterior tibial and peroneal veins are patent. Coronal and sagittal reformats were performed. FINAL REPORT CT TORSO COMPARISON: and . Treat with anticoagulation. Treat with anticoagulation. Switch back to spiriva and prn albuterol inhaler when back to baseline. Rec: MRCP. Rec: MRCP. Rec: MRCP. Rec: MRCP. Continue albuterol and atrovent nebs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. Sputum with two GNRs. There is trace ascites. Severe emphysema is noted. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Got Vanco/Levoflox for PNA. Clinical concern for lower extremity DVT. IV contrast was administered. Reasonable to treat with Vanc/Cefepim/Levoflox given history of GNRs in sputum. 5:06 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? IMPRESSION:Hyperdensity noted on recent CTA torso is unchanged and likely corresponds to calcification. MRCP or ERCP should be performed. Sinus tachycardia. Would follow up CT. Strep PNA in sputum. Trace ascites. Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in sputum. Post-surgical changes from left lateral fusion hardware are present. Monitor Hct. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. LLL consolidation concerning for PNA. Sinus tachycardia with ventricular premature beats. COMPARISON: CT abdomen and ; ct chest . Prelim showing left DVT. Severe emphysema is demonstrated as well as nonspecific scarring at the right apex. There is mild pancreatic ductal prominence. Has LLL consolidation on CXR. There mild antral wall thickening and mucosal (Over) 5:06 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? | 34 | [
{
"category": "Nursing",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 619882,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\n heparin to 800units/hr\n Plan:\n Next PTT at 1200. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"
},
{
"category": "Physician ",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 619890,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\n use heparin gtt\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\n need repeat CT in 3 months to re-eval.\n -- LFT/lipase/amylase unremarkable\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 325 mL\n PO:\n TF:\n IVF:\n 361 mL\n 325 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n 225 K/uL\n 10.5 g/dL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\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:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 619896,
"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\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 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 619897,
"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\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 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\n sputum cx.\n COPD: seems stable, not need for steroids.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 619900,
"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen:\n HEENT:\n Neck:\n CV:\n Pulm:\n Abd:\n Extrem:\n Neuro:\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Cipro given history of GNRs in sputum. Check sputum\n cx\n COPD: seems stable, not need for steroids.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 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 Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 619901,
"text": "Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 11:05 PM\n -- CT-abd non-con AAA stable and no evidence of leak. Vascular: OK to\n use heparin gtt\n -- LLL pneumonia on CT-scan look like it adheres to pleura? will likely\n need repeat CT in 3 months to re-eval.\n -- LFT/lipase/amylase unremarkable\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Heparin Sodium - 06:21 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 325 mL\n PO:\n TF:\n IVF:\n 361 mL\n 325 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, mild expiratory\n wheeze\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n 225 K/uL\n 10.5 g/dL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PNEUMONIA, OTHER\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. The patient was\n started on a heparin gtt in the ED. ECG showed no evidence of RV\n strain, troponin wnl. Overnight pt did well on 3L NC and remains\n hemodynamically stable. Troponins have been flat. Pt with no recent\n surgerys, immobilization, known malignancy, family history of\n hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Start Coumadin 5mg; monitor INR\n - follow up TTE to evaluate for right heart strain\n - LENI pending\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - Continue Vanco/Cefepime and d/c cipro given negative urine legionella\n - sputum cx\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . There was mention of a hyperdensity seen on CTA\n and a non-contrast CT abdomen showed AAA stable Spoke with vascular\n surgery who felt there was no evidence of a leak.\n -Monitor Hct closely given heparin/coumadin\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.. LFTs wnl\n - f/u final CTA read\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\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:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 619902,
"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Albuterol nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen:\n HEENT:\n Neck:\n CV:\n Pulm:\n Abd:\n Extrem:\n Neuro:\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\n resolution since could also represent malignancy.\n Continue heparin drip. Start coumadin today. Echo and LENI\ns today\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignancy. Follow up CT as outpt to eval.\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\n sputum. Check sputum cx\n COPD: seems stable, not need for steroids. Continue albuterol and\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\n back to baseline.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon. Guaiac stools.\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\n awaiting final read. LFT\ns and /lipase normal. need MRCP as\n outpt.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n ICU Care\n Nutrition: regular diet\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: heparin gtt\n Code status: Full code\n Disposition : call out to floor\n Total time spent: 30 min\n"
},
{
"category": "Nursing",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 619977,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Patient started on Coumadin today. Given first dose of 5mg.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Monitor Hct.\n AAA increased in size from , but per MICU team is currently\n stable. Hct 34 at 12pm, stable from 33 with am labs. Patient needs\n bedside echo tomorrow.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n Demographics\n Attending MD:\n Admit diagnosis:\n Code status:\n Height:\n Admission weight:\n Daily weight:\n Allergies/Reactions:\n Precautions:\n PMH:\n CV-PMH:\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:\n D:\n Temperature:\n Arterial BP:\n S:\n D:\n Respiratory rate:\n Heart Rate:\n Heart rhythm:\n O2 delivery device:\n O2 saturation:\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n Pacer Data\n Pertinent Lab Results:\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Valuables / Signature\n Patient valuables: Clothes, shoes\n Other valuables:\n Clothes:\n Wallet / Money: Patient has wallet, but he sent his credit cards and\n cash to security. Wallet contains only ID card and other cards that\n are not credit cards.\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 7\n Transferred to: CC701\n Date & time of Transfer: 1800\n"
},
{
"category": "Nursing",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 619952,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs. Patient needs bedside echo.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n"
},
{
"category": "Nursing",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 619945,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L, good effect after percoset. Last PTT 49, increased\n heparin to 800units/hr\n Plan:\n Next PTT at 1200. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco.nebs ABD CT done\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"
},
{
"category": "Nursing",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 619951,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift. Nebs given.\n Response:\n Remains afebrile, continues to be tachynic with exertion, but O2\n requirement remains the same.\n Plan:\n Cont ABX. Encourage pulmonary toilet.\n"
},
{
"category": "Nursing",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 619828,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT at 1000\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2131-12-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 619817,
"text": "Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs q6 and albuterol\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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": "Physician ",
"chartdate": "2131-12-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 619818,
"text": "Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs q6 and albuterol\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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": "Physician ",
"chartdate": "2131-12-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 619819,
"text": "Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evalution\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium nebs and albuterol nebs\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs / replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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": "Physician ",
"chartdate": "2131-12-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 619821,
"text": "Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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": "Physician ",
"chartdate": "2131-12-29 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 619822,
"text": "Chief Complaint: CHIEF COMPLAINT: Pleuritic Right Chest Pain\n REASON FOR MICU ADMISSION: PE & Pneumonia\n HPI:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated for pneumonia/COPD\n exacerbation with levofloxacin and prednisone. His sputum culture grew\n 2 types of GNR that were not speciated. He was also discharged on\n after being intubated in the MICU for COPD exacerbation/pneumonia\n that eventually grew S. pneumonia and treated with levoflox.\n .\n The patient reports for the last for days he has been having worsening\n SOB, cough and sputum production. The patient also developed\n sharp/pleuritic right lower chest and flank pain. He states that the\n breathing and cough has worsened. Pt denied hemoptysis, fevers, chills,\n abdominal pain or N/V.\n .\n In the ED initial vital signs were 97.6 123 145/72 24 95% 3L. He\n underwent CTA that showed RLL segmental PE with associated RLL\n infarct. There was also a LLL consolidation concerning for pnuemonia.\n Additionally, his AAA had increased in size to 4.2x7.5cm without\n evidence of rupture. He was given Vancomycin/Levofloxacin for his\n pneumonia and started on a heparin gtt (guaiac negative). CE x1 were\n negative. Leukocytosis of 22.0 and lactate of 2.9. UA was negative. He\n was also given morphine 2mg x2 for pain. The patient continued to be\n tachycardic with rates 105-110, SBP stable ranging 120-140, and O2 sats\n 100% on 3L.\n .\n On the floor the patient is complaining of SOB and pleuritic right\n sided chest/flank pain. He denied fevers/chills.\n .\n Called by radiology regarding CTA . Pancreatic ductal dilation\n would recommend MRCP/ERCP. AAA has area of calification/hyperdensity\n likely represents thrombus, but would recommend non-con CT to better\n evaluated for possible leak.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n MEDICATIONS AT HOME:\n Bisacodyl 5 mg daily\n Senna 8.6 mg \n Docusate Sodium \n Albuterol Sulfate 0.63 mg/3 mL q6:prn\n Albuterol Sulfate 90 mcg/Actuation QID\n Allopurinol 150mg daily\n Cholecalciferol (Vitamin D3) 800U daily\n Oxycodone-Acetaminophen 5-325 mg 1-2tabs po q6\n Atorvastatin 10 mg daily\n Tiotropium Bromide 18 mcg Capsule daily\n Codeine-Guaifenesin q6prn\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n Hyperlipidemia\n Gout\n Osteoporosis, history of L1 burst fracture on chronic opioids for pain\n relief, l3 compresion fracture\n No history of CAD.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: History of EtOH abuse with beer, no history of illicit drug use.\n Long history of smoking >40 years of 2 ppd, currently smoking pack\n per day. Lives by himself, is on disability.\n Review of systems:\n Flowsheet Data as of 09:30 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 117 mL\n PO:\n TF:\n IVF:\n 117 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -183 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n Physical Examination\n GEN: NAD, tachypneic and purse lip breathing\n SKIN:No rashes or skin changes noted\n HEENT:10cm JVP, neck supple, No lymphadenopathy in cervical, posterior,\n or supraclavicular chains noted.\n CHEST: diminished breath sounds with poor air movement, no rhonchi or\n wheezes\n CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.\n ABDOMEN: s/nt/nd\n EXTREMITIES: no pedal edema bilaterally\n NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE ,\n and BLE both proximally and distally. No pronator drift. Reflexes\n were symmetric.\n Labs / Radiology\n [image002.jpg]\n STUDIES:\n ECG: sinus tach, normal axis, NI, PVC, flattened t-wave v5-v6, no\n significant change when compared to .\n .\n CTA: Prelim\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with\n air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x\n 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n .\n TTE \n The left atrium and right atrium are normal in cavity size. The\n estimated right atrial pressure is 0-5 mmHg. Left ventricular wall\n thickness, cavity size, and global systolic function are normal\n (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\n abnormality cannot be fully excluded. Right ventricular chamber size\n and free wall motion are normal. The aortic valve leaflets are mildly\n thickened (?#). There is no aortic valve stenosis. Trace aortic\n regurgitation is seen. The mitral valve appears structurally normal\n with trivial mitral regurgitation. The pulmonary artery systolic\n pressure could not be determined. There is no pericardial effusion.\n IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes\n with preserved global biventricular systolic function. Aortic valve\n sclerosis.\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE\n ASSESSMENT & PLAN:\n Mr. is a 66 year-old man with a history of COPD, AAA, and HTN,\n recently discharged on after being treated in the MICU for COPD\n exacerbation/pneumonia with levoflox and prednisone presents with PE\n and pneumonia.\n .\n #PE: Pt with RLL segmental PE with associated infarct. Pt with\n associated tacyhcardia, but stable blood pressure. He is maintaining\n his sats on 3L, but tachypneic. The patient was started on a heparin\n gtt in the ED. ECG showed no evidence of RV strain, troponin wnl.\n Pt with no recent surgerys, immobilization, known malignancy, family\n history of hypercoagulability.\n - Cont heparin gtt (active T&S and guaiac stools)\n - Cont Respiratory Support, stable on room air, but low threshold for\n intubation\n - Hemodynamics- currently not hypotensive. Initial management with IVF,\n but will limit given possibility of worsening RV failure. Maintain MAPS\n >65. Support with levophed if needed.\n - check BNP\n - trend troponin\n - order TTE to eval for right heart strain\n - LENI\n - ECG\n .\n #. Leukocytosis: Pt with LLL consolidation on CT scan concerning for\n infection. Likely cause of leukocytosis. Lactate 2.9. CT-torso on\n evidence of other acute pathology. UA negative Also, likely reactive\n component in the setting of PE and pulm infarct. Prior admission\n pt with GNR in sputum and also treated for S. pneumo on \n both treated with levoflox.\n - plan to treat pneumonia with Vanco/Cefepime/Cipro given likely HAP\n and to cover for legionella/ double coverage given GNR in last sputum\n - sputum cx\n - legionella antigen\n - f/u urine and blood cx\n - trend fever curve and WBC\n .\n #. AAA: Pt with increase in AAA since to 4.2 x 7.5cm, but stable\n from U/S on . Will eval area of hyperdensity seen on CTA with\n non-con abd CT. Spoke with vascular surgery and if non-con abd CT\n abnormal then will further assess patient.\n .\n #. Pancreatic Duct Dilation: Seen on CTA. The patient's right sided\n pain likely secondary to pulmonary infarct, however less likely could\n represent gallbladder/pancreatic pathology.\n - will check LFT and lipase/amylase\n - f/u final CTA read\n - consider MRCP for further evaluation if needed\n .\n #. COPD: Pt with 2 prior COPD exacerbations associated with pneumonia.\n Current tachypnea and SOB related to PE & pneumonia and not COPD\n exacerbation.\n - ipratropium and albuterol nebs prn\n .\n # Hyperlipidemia:\n - continue atorvostatin\n .\n #. Gout: Cont allopurinol\n .\n # FEN: IVFs prn/ replete lytes prn / regular diet\n # PPX: PPI, heparin gtt, bowel regimen\n # ACCESS: PIV\n # CODE: Full, discussed\n # CONTACT:\n # DISPOSITION:\n [ ] Floor pending further investigation\n [ ] Floor pending\n [ ] Stepdown / \n [x] ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\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": "Physician ",
"chartdate": "2131-12-29 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 619823,
"text": "Chief Complaint: Right sided pleuritic CP/ PE and PNA\n I saw and examined the patient, and was physically present with the 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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification.\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 09:26 PM\n Infusions:\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n COPD\n AAA\n HTN\n admitted to MICU for COPD exacerbation and PNA. Strep PNA in\n sputum.\n Meds:\n allopurinol\n atorvastatin\n albuterol/tiatropium\n vitamin D\n percocet\n cough suppressant\n noncontributory for PE\n Occupation:\n Drugs:\n Tobacco: long smoking history. - ppD currently\n Alcohol: h/o ETOH abuse - drinks few per night. No recent withdrawl\n Other: lives by self, on disability at home in apartment.\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: Chest pain\n Respiratory: Dyspnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea\n Genitourinary: No(t) Dysuria\n Endocrine: No(t) Hyperglycemia\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated\n Allergy / Immunology: No(t) Immunocompromised\n Pain: Moderate\n Flowsheet Data as of 10:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.5\nC (97.7\n HR: 108 (108 - 116) bpm\n BP: 107/56(69) {107/56(69) - 130/66(81)} mmHg\n RR: 25 (19 - 25) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 125 mL\n PO:\n TF:\n IVF:\n 125 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -175 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ////\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Diminished: b/l)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 221\n 39\n 141\n 0.8\n 10\n 26\n 93\n 3.6\n 133\n 22.0\n [image002.jpg]\n Other labs: Lactic Acid:2.9\n Fluid analysis / Other labs: negative U/A\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant.\n Continue heparin drip\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignacy. Would follow up CT. Reasonable to treat\n with Vanc/Cefepim/Levoflox given history of GNRs in sputum. Check\n sputum cx.\n COPD: seems stable, not need for steroids.\n Pancreatic ductal dilatation: Will need MRCP as outpt or when\n stabilized.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n Percocet for pain.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2131-12-29 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 619825,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT\n"
},
{
"category": "Nursing",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 619829,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n pt transfer from Ed with Heparin gtt 800unit/hr, c/o of r low chect\n pain and flank pain with cough and movemnt PTT 109\n Action:\n decreased Heparin to 700units/hr, given Percoset.\n Response:\n remaisn on NC 3L\n Plan:\n next PTT at 1000. Leni\ns in the morning.\n Pneumonia, other\n Assessment:\n Afebrile, upon arrival to unit tachypnic to high 20\ns mid 30\ns, sat\n 96-98%, on NC 3L.\n Action:\n Start on Cipro Iv, cefepime, cont Vanco. ABD CT done\n Response:\n Plan:\n Cont ABX, follow CT result.\n"
},
{
"category": "Physician ",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 619982,
"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 66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation. Rec: MRCP. Also wanted\n non-contrast CT to r/o possible leak versus calcification. Abd CT\n showed no leak\n 24 Hour Events:\n heparin gtt started for PE\n Stable overnight\n Allergies:\n Atenolol\n Wheezing;\n Ms Contin (Oral) (Morphine Sulfate)\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefepime - 09:26 PM\n Ciprofloxacin - 10:53 PM\n Vancomycin - 06:27 AM\n Heparin Sodium - 800 units/hour\n Atrovent nebs\n Albuterol nebs\n Allopirinol\n Lipitor\n Nicotine patch\n Vit D\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:52 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.8\nC (98.2\n Tcurrent: 36.1\nC (97\n HR: 83 (83 - 116) bpm\n BP: 93/51(61) {90/50(60) - 130/66(81)} mmHg\n RR: 17 (9 - 26) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 42.3 kg (admission): 42.3 kg\n Total In:\n 2,361 mL\n 335 mL\n PO:\n TF:\n IVF:\n 361 mL\n 335 mL\n Blood products:\n Total out:\n 1,100 mL\n 200 mL\n Urine:\n 500 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,261 mL\n 135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///27/\n Physical Examination\n Gen: alert, oriented, NAD\n HEENT: PERRL\n Neck:supple\n CV: S1S2 tachy\n Pulm: clear ant/lat\n Abd: soft, nt\n Extrem: no edema\n Labs / Radiology\n 10.5 g/dL\n 225 K/uL\n 130 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.4 mEq/L\n 7 mg/dL\n 104 mEq/L\n 137 mEq/L\n 33.1 %\n 15.1 K/uL\n [image002.jpg]\n 04:25 AM\n WBC\n 15.1\n Hct\n 33.1\n Plt\n 225\n Cr\n 0.6\n TropT\n <0.01\n Glucose\n 130\n Other labs: PT / PTT / INR:13.6/49.3/1.2, CK / CKMB /\n Troponin-T://<0.01, Differential-Neuts:89.0 %, Band:0.0 %, Lymph:2.0 %,\n Mono:8.0 %, Eos:0.0 %, Ca++:8.1 mg/dL, Mg++:1.4 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PULMONARY EMBOLISM (PE), ACUTE: RLL with associated infarct.\n Hemodynamically stable. Treat with anticoagulation. No clear\n preciptant. Should have repeat CT in weeks to eval LLL lesion for\n resolution since could also represent malignancy.\n Continue heparin drip. Start coumadin today. Echo and LENI\ns today\n PNA and leukocytosis: Unusual look to PNA with area of cavitation\n versus area of bullous emphysema. Await final read of Chest CT, but\n would worry about malignancy. Follow up CT as outpt to eval.\n Reasonable to treat with Vanc/Cefepime/Cipro given history of GNRs in\n sputum. Check sputum cx\n COPD: seems stable, not need for steroids. Continue albuterol and\n atrovent nebs. Switch back to spiriva and prn albuterol inhaler when\n back to baseline.\n Anemia: Hct down to 33 from 39. No evidence of bleeding on exam, but\n will watch carefully in light of anticoagulation. Recheck Hct this\n afternoon. Guaiac stools.\n Pancreatic ductal dilatation: Seen as incidental finding on CT, but\n awaiting final read. LFT\ns and /lipase normal. need MRCP as\n outpt.\n As per radiology: abd CT shows stable aneurysm compared to last CT.\n ICU Care\n Nutrition: regular diet\n Lines:\n 18 Gauge - 08:29 PM\n 20 Gauge - 08:30 PM\n Prophylaxis:\n DVT: heparin gtt\n Code status: Full code\n Disposition : call out to floor\n Total time spent: 30 min\n"
},
{
"category": "Nursing",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 619949,
"text": "66 yo man recent d/c on with PNA/COPD brief MICU stay on bipap tx\n with steroids and levoflox. Sputum with two GNRs. Presents now with 4\n days of SOB, cough, sputum, right sided CP. No hemoptysis. In ED HR\n 123, SBP 120s-140s. 95% on 3L. CTA with RLL segmental PE and RLL\n infarct. LLL consolidation concerning for PNA. AAA was increased in\n size compared to . Got Vanco/Levoflox for PNA. As per radiology\n there was also pancreatic ductal dilatation, possible needs\n MRCP/ERCP. Also wanted non-contrast CT to r/o possible leak versus\n calcification\n Pulmonary Embolism (PE), Acute\n Assessment:\n Patient received on Heparin gtt 800unit/hr. c/o of r low chest pain\n and flank pain with cough and movement. Patient tachypnic with\n movement/exertion.\n Action:\n PTT subtherapeutic at 12pm. Bolused with 900units Heparin and gtt\n increased to 900units/hr. Next PTT due at . Patient had LENI\n today. Prelim showing left DVT. Received 2 Percocet for pain\n associated with coughing.\n Response:\n Remains on NC 3L. Patient states he has relief from Percocets.\n Plan:\n Next PTT at . Continue Heparin gtt per protocol. Patient starting\n on Coumadin 5mg tonight. Monitor Hct. AAA increased in size from\n , but per MICU team is currently stable. Hct 34 at 12pm, stable\n from 33 with am labs.\n Pneumonia, other\n Assessment:\n Afebrile. WBC 15 down from 20. Patient with weak cough. Has LLL\n consolidation on CXR.\n Action:\n Patient with weak cough. Encouraged to cough up secretions and\n pulmonary toilet. Sputum sample sent this shift.\n Response:\n Remains afebrile, appeared comfortable, no SOB, RR 12-20.\n Plan:\n Cont ABX, follow CT result.\n"
},
{
"category": "ECG",
"chartdate": "2132-01-03 00:00:00.000",
"description": "Report",
"row_id": 252938,
"text": "Sinus tachycardia. Prior inferior myocardial infarction. Low limb lead\nvoltage. Non-specific inferolateral ST-T wave flattening. Compared to the\nprevious tracing of the rate has increased. The Q waves are more\nevident in the inferior leads. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2131-12-30 00:00:00.000",
"description": "Report",
"row_id": 252939,
"text": "Sinus rhythm. Baseline artifact. Non-specific ST-T wave changes. Compared to\ntracing #1 the rate has decreased and the ventricular premature beats are no\nlonger seen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2131-12-29 00:00:00.000",
"description": "Report",
"row_id": 252940,
"text": "Sinus tachycardia with ventricular premature beats. Non-specific ST-T wave\nchanges. Compared to the previous tracing of the ventricular premature\nbeats are new.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-29 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1120181,
"text": " 5:06 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with severe R lower chest wall TTP and flank TTP, sob\n REASON FOR THIS EXAMINATION:\n eval for PE, perineprhic abscess, other acute path\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SBNa SAT 6:44 PM\n RLL segmental PE. Likely pulm infarct in rll. Focal consolidation with air\n bronch in left lung concerning for infection. Abd aortic aneurysm 4.2 x 7.5\n cm increased since . gallstones. Debris in trachea, can't exclude\n underlying endobronchial lesion.\n ______________________________________________________________________________\n FINAL REPORT\n CT TORSO\n\n COMPARISON: and .\n\n HISTORY: Right lower chest wall tenderness to palpation, shortness of breath,\n evaluate for PE, perinephric abscess or other acute pathology.\n\n TECHNIQUE: MDCT axially acquired images through the chest, abdomen and pelvis\n were obtained. IV contrast was administered. Coronal and sagittal reformats\n were performed.\n\n FINDINGS: Within the right lower lobe segmental pulmonary artery, there are\n filling defects extending into the subsegmental branches. There is\n consolidation in the right lower lobe which may represent pulmonary infarct\n versus infection. There are severe emphysematous changes identified. In the\n left lower lobe (3A, 58) there is peripheral consolidation with the suggestion\n of an air bronchogram concerning for infection. There is no pleural or\n pericardial effusion. There is no axillary, hilar or mediastinal\n lymphadenopathy. Debris within the trachea is identified (3A, 10). While\n most of this appears aerosolized, underlying endobronchial lesion cannot be\n entirely excluded particularly within the right main stem bronchus (3A, 21).\n\n Atherosclerotic plaque is identified along the thoracic aorta and extending\n into the abdominal aorta.\n\n CT ABDOMEN: There is a large abdominal aortic aneurysm measuring\n approximately 4.2 x 4.0 x 7.5 cm. This has increased in size when compared to\n . More prominent hyperdensity along the periphery likely represents\n calcification (3b, 137). Streak artifact from the posterior spinal hardware\n slightly limits evaluation of the abdomen. Within this limitation, the\n spleen, kidneys, adrenal glands,and small bowel are unremarkable. The liver\n appears nodular. The gallbladder contains tiny gallstones. There is mild\n pancreatic ductal prominence. The commone bile duct is dilated, measuring up\n to 1.5 cm in diameter, new. There mild antral wall thickening and mucosal\n (Over)\n\n 5:06 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: R LOWER CHEST WALL TTP AND FLANK TTP SOB, ? PE, PERINEPHRIC ABSCESS OTHER PATH\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n enhancement. There is no mesenteric or retroperitoneal lymphadenopathy. There\n is no free fluid or free air.\n\n CT OF THE PELVIS: The bladder, rectum and sigmoid colon are unremarkable.\n The prostate contains coarse calcifications. There is no pelvic or inguinal\n lymphadenopathy.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions identified.\n Compression fracture of L3 is stable.\n\n IMPRESSION:\n 1. Right lower lobe segmental pulmonary artery embolus with possible right\n lower lobe pulmonary infarct vs infection.\n 2. Focal consolidation in the left lower lobe concerning for infection.\n 3. Debris within the trachea; while most appears aerosolized, underlying\n endobronchial lesion cannot be entirely excluded particularly within the right\n main stem bronchus.\n 5. Cholelithiasis. Dilated common bile duct and prominent pancreatic duct.\n MRCP or ERCP should be performed.\n 6. Infrarenal abdominal aortic aneurysm as described above, with interval\n increase in size when compared to .\n 7. Mild antral wall thickening and enhancement, may in part relate to\n underdistention or gastritis. Correlation with endoscopy.\n 8. New hyperdensity within the aortic aneurysm which is likely calcification.\n Noncontrast CT scan of this area is recommended to confirm.\n\n Findings were discussed with Dr. at approximately 6:40\n p.m. via telephone. Recommendations were conveyed to Dr. at 9 pm\n via telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120222,
"text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD presents with pneumonia and PE\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Pneumonia. Pulmonary embolism.\n\n FINDINGS: Ill-defined opacities at the right lung base have progressed since\n the recent chest radiograph, and correspond to an area of suspected hemorrhage\n and/or evolving infarction on recent CT in the setting of an adjacent\n pulmonary embolism. Poorly defined opacities in periphery of left lung base\n could be related to either pulmonary embolism or infection. Severe emphysema\n is demonstrated as well as nonspecific scarring at the right apex.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-29 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1120204,
"text": " 9:46 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\n hyperdensity radiology recommended non-contrast eval\n REASON FOR THIS EXAMINATION:\n eval AAA given radiology concern for hyperdensity seen on prior CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb SUN 12:35 AM\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\n torso, demonstrating the likely etiology to the mural calcification.\n 2. No other short-term interval changes.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, AAA, presents with PE, pneumonia. On the prior CTA\n performed earlier today, there was a questionable hyperdensity in the\n abdominal aorta, for further evaluation.\n\n TECHNIQUE: Non-contrast CT acquisition through the abdomen at the level of\n the kidneys with multiplanar reformations.\n\n FINDINGS: Focused evaluation was performed for assessing the region of\n interest in the abdominal aorta (2:19) at the site of the abdominal aortic\n aneurysm. The previously noted linear hyperdensity is again present on the\n non-contrast sequences (2:19, 25), unchanged, and therefore likely reflects\n calcification. Please refer to the concurrent CT for further details of the\n remainder of the findings.\n\n Residual contrast is seen in the kidneys from the prior study. Gallstones are\n present. Again is noted the calcified infrarenal abdominal aortic aneurysm\n measuring 4 x 4.2 cm. There is patchy opacity at the base of the right lung\n could represent atelectasis, aspiration, superimposed pneumonia cannot be\n excluded. Post-surgical changes from left lateral fusion hardware are\n present.\n\n IMPRESSION:Hyperdensity noted on recent CTA torso is unchanged and likely\n corresponds to calcification. No other short-term interval change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-29 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 1120205,
"text": ", A. MED MICU-7 9:46 PM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: F/U TO HYPERDENSITY SEEN ON PRIOR CTA\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with COPD, AAA presents with PE & pneumonia. AAA on CTA showed\n hyperdensity radiology recommended non-contrast eval\n REASON FOR THIS EXAMINATION:\n eval AAA given radiology concern for hyperdensity seen on prior CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Focused evaluation of the questionable hyperdensity noted on recent CTA\n torso, demonstrating the likely etiology to the mural calcification.\n 2. No other short-term interval changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-01-01 00:00:00.000",
"description": "MRCP (MR ABD W&W/OC)",
"row_id": 1120550,
"text": " 8:36 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\n Admitting Diagnosis: PULMONARY EMBOLIS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with PE, PNA, COPD, recent weight loss found to have dilated\n pancreatic duct on abdominal CT.\n REASON FOR THIS EXAMINATION:\n Please evaluate for causes of pancreatic duct dilatation, specifically\n malignancy.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRCP obtained .\n\n COMPARISON: CT abdomen and ; ct chest .\n\n HISTORY: A 66-year-old male with recent weight loss and dilated pancreatic\n duct on recent abdominal CT, evaluate for etiology.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5\n Tesla magnet, including dynamic 2D T1-weighted GRE images obtained prior to,\n during, and after the uneventful intravenous administration of 17 mL of\n Magnevist. Additionally, the patient drank a combination of Gastromark and\n Redicat.\n\n The study is limited secondary to poor breathhold and therefore non-breath\n hold 2D images were performed for the dynamic series rather than 3D images.\n\n FINDINGS:\n There is pleural thickening along the left lateral chest wall, seen on recent\n CT chest of , and consistent with pleural scarring/chronic changes.\n Additionally, soft tissue density in the right hilum correlates with\n lymphadenopathy per chest CT. Fibrotic changes are stable within the right\n lung base. There are small bilateral pleural effusions.\n\n The liver demonstrates a nodular contour, morphology consistent with\n cirrhosis. There is normal signal intensity. There is homogeneous post-\n contrast enhancement within the liver. No abnormal enhancing are noted within\n the liver. There is no intrahepatic biliary ductal dilatation. Hepatic\n vasculature and portal vein are patent. There is trace ascites.\n\n There is mild dilatation of the common bile duct, which tapers normally at the\n ampulla. Additionally, there is mild dilatation of the pancreatic duct, which\n is smooth and tapers normally to the level of the papilla. There is no\n obstructing lesion or abnormal enhancement identified.\n\n The pancreas, spleen, and adrenal glands are unremarkable in appearance.\n Kidneys demonstrate prompt and symmetric uptake and excretion of contrast.\n Gallstones are identified within the gallbladder. There is no pericholecystic\n fluid or GB wall edema.\n (Over)\n\n 8:36 AM\n MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please evaluate for causes of pancreatic duct dilatation, sp\n Admitting Diagnosis: PULMONARY EMBOLIS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is aneurysmal dilatation of the descending abdominal aorta, in an\n infrarenal distribution, measuring approximately 4.2 x 3.7 cm in dimension.\n This is stable in appearance when compared to the recent abdominal CT and has\n a large partially thrombosed lumen, again unchanged when compared to the\n recent CT.\n\n No enlarged intraabdominal lymphadenopathy is identified.\n\n Bone marrow signal is grossly unremarkable. Hardware is noted within the\n spine.\n\n Multiplanar 2D and 3D reformations provided multiple perspectives for the\n dynamic series.\n\n IMPRESSION:\n 1. Mild dilatation of the common bile duct and pancreatic duct which taper\n normally at the ampulla and are smooth in contour. This is most likely from\n papillary stenosis versus sphincter of Oddi dysfunction as no obstructing\n lesion is seen, however, a subtle lesion could be missed given limited\n evaluation secondary to patientinability to breath hold. If concern persists,\n ERCP could be performed for further evaluation.\n\n 2. Cirrhosis. Trace ascites.\n\n 3. Cholelithiasis.\n\n 4. Infrarenal abdominal aortic aneurysm, which is partially thrombosed, and\n unchanged in appearance when compared to the recent CT, and better evaluated\n on that CT.\n\n 5. Fibrosis at the right lung base with scarring involving the left lateral\n pleura as well as right hilar lymphadenopathy, findings unchanged from recent\n chest CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1120169,
"text": " 3:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with hx of copd recent pneumonia now right flank/?back pain\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, single AP upright portable view.\n\n CLINICAL INFORMATION: 56-year-old male with history of COPD and recent\n pneumonia, now with right flank and back pain.\n\n COMPARISON: .\n\n FINDINGS: The lungs again are hyperinflated with flattening of the diaphragms\n and prominence of the interstitial markings with relative lucency of the upper\n lobes, suggesting chronic obstructive pulmonary disease. Scattered\n parenchymal scarring is again noted, most pronounced in the bilateral apical\n region, right greater than left, where biapical thickening is seen. Mild\n opacities along the peripheral left lung base are without significant interval\n change to mildly decreased since the prior study. Interstitial opacities are\n seen along the right lung base. No discrete focal consolidation or pleural\n effusion is seen. The heart is not enlarged. The aortic knob is calcified.\n Partially visualized spinal metallic hardware is again noted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-30 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1120268,
"text": " 12:00 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE,EVAL FOR DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo M with COPD, AAA, presents with PE and pneumonia\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHfd SUN 2:33 PM\n IMPRESSION:\n\n Extensive thrombus within the left superficial femoral vein, popliteal vein\n and peroneal veins.\n\n No right lower extremity deep venous thrombosis.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: A 66-year-old male with COPD, abdominal aortic aneurysm, PE\n and pneumonia. Clinical concern for lower extremity DVT.\n\n TECHNIQUE: Grayscale and Doppler ultrasound images of bilateral lower\n extremity veins were obtained.\n\n FINDINGS: The left common and superficial femoral veins are thrombosed with\n clot extending into the left popliteal vein and peroneal veins. The clot is\n not entirely occlusive in the common femoral vein but its proximal extent is\n not delineated on this study. The left posterior tibial vein demonstrates\n normal color flow. The right common femoral, superficial femoral, popliteal\n veins demonstrate normal compression, flow, and augmentation. The right\n posterior tibial and peroneal veins are patent.\n\n IMPRESSION: Extensive thrombus within the left common and superficial\n femoral, popliteal and peroneal veins. No right lower extremity deep venous\n thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-30 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1120269,
"text": ", A. MED MICU-7 12:00 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: PE,EVAL FOR DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 yo M with COPD, AAA, presents with PE and pneumonia\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n PFI REPORT\n IMPRESSION:\n\n Extensive thrombus within the left superficial femoral vein, popliteal vein\n and peroneal veins.\n\n No right lower extremity deep venous thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2131-12-31 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1120388,
"text": " 10:13 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r picc 42cm\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 66 year old man with P/E\n REASON FOR THIS EXAMINATION:\n r picc 42cm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 66-year-old man with new right-sided PICC placement. Evaluate\n for PICC placement.\n\n COMPARISON: Multiple priors, the most recent portable AP chest radiograph\n ; CT chest, abdomen and pelvis .\n\n TECHNIQUE: Portable chest radiograph.\n\n FINDINGS: The cardiac, mediastinal and hila contours are normal and unchanged\n from . The right-sided PICC terminates at the cavoatrial\n junction. Lung opacity is worsened since . Worsened bibasilar\n opacities are noted compared to , worrisome for pneumonia.\n Severe emphysema is noted. Spinal hardware is unchanged compared to most\n recent priors.\n\n IMPRESSION:\n 1. Right-sided PICC line at the cavoatrial junction.\n 2. Worsening bibasilar opacities compared to , worrisome for\n pneumonia.\n 3. Severe emphysema, unchanged since prior.\n\n"
}
] |
16,436 | 140,997 | This is a 68-year-old female with morbid obesity, admitted for line sepsis, methicillin-resistant Staphylococcus aureus with a transient decrease in urinary output, and atrial fibrillation, now controlled, who is now re-admitted to the Medical Intensive Care Unit with an upper gastrointestinal bleed. There was blood seen in her lower esophagus by esophagogastroduodenoscopy with a large amount of clots and oozing red blood in the fundus. The patient was not able to protect airway herself, and she was do not intubate (per her sister who was her health care proxy). An nasogastric tube was placed, and the patient did not clear after 8 liters of fluid. A blood transfusion was initiated. The patient was given Protonix intravenously. Per, the Gastrointestinal Service, the patient was unable to be re-scoped without intubation. However, since she was refusing intubation because the patient wanted to be do not intubate even for temporary measures. The patient understood that this eliminated the possibility of gaining control of bleed via esophagogastroduodenoscopy. The Interventional Radiology Service was consulted, but they were unable to take the patient to angiography for possible embolization secondary to the patient's weight and difficulty in accessing groin and problems of ascites. The patient also received 2 units of fresh frozen plasma to correct coagulation. The team had a conversation with her sister regarding limited options at this point. We reiterated that esophagogastroduodenoscopy with intubation might be her last hope. The sister did understand the situation, but reported that the patient repeatedly expressed the desire to be do not resuscitate/do not intubate. Meanwhile, the patient was receiving blood transfusions and fluid resuscitation. The team was called at 6:30 in the morning by bedside and found the patient having no respirations. The patient subsequently passed away at that time. The patient was pronounced dead at 6:30 in the morning on . , M.D. Dictated By: MEDQUIST36 D: 13:50 T: 10:15 JOB#: | She has had a non productive cough.Cardiac: HR 68-78 SR with frequent PAC's. PT DOES HAVE CPAP AT THE BEDSIDE.CV: PT'S HR 80-90'S NSR WITH OCCASIONAL PAC'S AND SBP 110-130'S.GI: ABD TIGHT AND UNABLE TO AUSCULTATE BOWEL SOUNDS. No bowel sounds noted.G-U - Foley draining well, u/o approx 50cc/hr.Skin - + MRSA from old pic line. She was placed back on bipap and she immediately fell asleep with sats 94-96%. Began agonal breathing with decreased pulse Dr. pronounced pt dead at 1830. CALLING OUT TO PEOPLE NOT THERE AND MAKING STATEMENTS THAT ARE DIFFICULT TO UNDERSTAND OR INCOMPREHENSIBLE.RESP: PRESENTLY ON O2 AT 2L/M NC WITH O2 SATS>94%. MAX TEMP=99.2 AND WBC=19.9.SOCIAL PT'S SISTER IS AT BEDSIDE AND AWARE OF PRESENT SITUATION. EMS activated, found to be cyanotic, apneic. SISTER HAS BEEN UPDATED BY MEDICAL TEAM.REVIEW OF SYSTEMS:NEURO: PT AND IS ORIENTED TO PESON AND PLACE BUT STATES IT'S . Pmicu Nursing Progress NoteResp: Pt on biPap with nose mask but around 9am she took off the mask. INSP/EXP WHEEZES BIL BUT DIMINSIHED AT THE BASES. If she moves the NC at all her O2 sats drop very quickly to the 80's. Sinus rhythm - premature ventricular contractionsAnteroseptal infarct - age undeterminedInferior/lateral ST-T changes may be due to myocardial ischemiaGeneralized low QRS voltages PT NEEDS CL ACCESS.INTEGUMENTARY : SKIN VERY THIN WITH AREAS OF ABRASIONS- SKIN TEARS TO ARMS. PT VERY OBESE.ID: PT NOW WITH MRSA FROM OLD PICC SITE AND STAPH LLE CELLULITIS SWAB. Q waves in leads V1-V4 suggest previous anteriormyocardial infarction. She is allergic to Percocet.At , pt was felt to be septic, with acute on chronic renal failure. She was D/C'd , was doing well until when she was noted to have MS changes, fever to 105. Overnight , developed SVT to 160's, given Adenosine 6mg IV with brief response, additional 12mg IV with HR down to 100-120 ? She was ambu'd briefly, brought to , given IV Vanco, blood cx off PICC line grew Gm+ cocci, transferred to per pt/family request. Lungs with inspiratory and expiratory wheezing.GI- Passed small amount maroon stoolx 1. 7p to 7a Micu Progress NoteNeuro - Pt only responding to painful stimuli. update to the above note: pt not a candidate for ir intervention and pt continues with brb output from ogt.discussion held with pt's siste decision made for no further intervention and comfort measures only. BIL LOWER EXTREMTIY DRSGS D&I WITHOUT DRAINAGE. Given Ativan 1mg IV x2 overnight with fair effect, slept only in short naps Per pt's sister, this has been her baseline MS recentlyResp: Sats >95% on BiPAP mask with 3l O2 bled through, drop to 86% with mask off BS diminished throughoutCV: Given Lopressor 12.5mg PO, 2nd dose Digoxin IV (for total .25mg) with HR down to 70's SR with occasional-frequent PAC's. She had a recent prolonged hospitalization for CHF, bilat LE cellulitis, for which a PICC line was placed for home IV Lasix w/ VNA. IV fluid NS begun at 100ml/hr per medical residentGI: NPO except for meds with sips water + bowel sounds, no stool overnightGU: Approx 30ml/hr amber urine with sediment via Foley cath, has not increased with IV fluidsSkin: Dsgs intact at both LE's, no drainageSocial: sister at bedside until 2100, telephone update given this AM Pt remains DNR/DNI. Morphine drip being titrated. PT IS A DNR/DNI SO AFTER DISCUSSION WITH FAMILY PT WAS NOT INTUBATED. TRANSFUSED WITH 2 U FFP AND HCT UPON ARRIVAL=26.5. When asked if she's having pain, she says "No". Last rights administered yest pm by chaplain. PT WAS TO GI UNIT BUT UNABLE TO VISULAIZE SOURCE OF BLEEDING SO PT WAS THEN TO MICU FOR FURTHER MANAGEMENT. WETHER PT WILL GO TO IR FOR ANGIOGRAPHY AND POSSIBLE COIL PLACEMENTRENAL: ADEQUATE UO VIA FOLEY CATH WHICH IS AMBER IN COLOR.IV ACCESS: PT HAS 1 18G SL TO R LOWER ARM AND 20G IN L LOWER ARM. Became cyanotic and stopped breathing. Nursing Admission NotePt is a 60yr old woman with complex PMH: CAD, S/P MI '; CHF EF 25-35% last echo ; OSA chronic BiPAP since ; IDDM; Morbid Obesity; elevated cholesterol; Hx GI bleed. She was placed on 1.5L NC with O2 sats 90-92%. Arrived with HR 130's SVT with frequent PAC's, BP stable 120-130/ On her baseline BiPAP, her sats are 93-96% Sister at bedside. PT TO FLOOR LAST EVENING AFTER 24 HR STAY IN MICU FOR CONTROL OF SVT WITH ADENOSINE AND DIGOXIN. LLE cellulitus.Status - Pt is DNR/DNI and CMO. She has had 2 small smears of brown stool.GU: foley draining amber urine with U/O ~40cc/hr.Neuro: Pt oriented to person and place. The toe was cleaned with soap and water, antibotic ointment applied and DSD applied.Social: Her sister in to visit around 11am who helped with her orientation. chaplain at bedside and sacrament of the sick administered. OGT PLACED AND PT CONTINUOUSLY LAVAGED AND HAVE BEEN UNABLE TO CLEAR. Small non-diagnostic Q waves in leads III and aVF.Diffuse low QRS voltage. Addendum- At 1825 pt passing large amount of melanotic stool. admssion note to micu for gi bleedd: SEE ADMISSION NOTE FROM YESTERDAY FOR PT'S PMH AND ORIGINAL REASON FOR ADMISSION. 02 sat 92 - 97 on 4lnc. Adaptic was placed on both areas with some antibotic put on the left leg. The right area is almost healed ulcerated area. will start mso4 gtt and keep titrate to keep pt comfortable Given Vanco, Ceftaz, given fluid. Pt is transferred to MICU for further care. OCCASIONAL DRY NONPRODUCTIVE COUGH. Atrial fibrillation with rapid ventricular response of 123Old anterior myocardial infarctDiffuse ST-T abnormalitiesAbnormal ECG She tolerated the chair until 2pm when she wasd put back to bed with a total lift (10 people helped). Pulling off BiPAP mask, removing johhnie despite continuous reinforcement to not do this. OVERNOC ON CC7 PT HAD 5 EPISODES OF MELANOTIC STOOL AND THIS AM WAS HAVING BRB STOOL OUTPUT APPROXIMATELY EVERY 20 MIN. | 10 | [
{
"category": "ECG",
"chartdate": "2166-10-29 00:00:00.000",
"description": "Report",
"row_id": 246785,
"text": "Normal sinus rhythm. Q waves in leads V1-V4 suggest previous anterior\nmyocardial infarction. Small non-diagnostic Q waves in leads III and aVF.\nDiffuse low QRS voltage. Compared to the previous tracing of there has\nbeen no diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2166-10-28 00:00:00.000",
"description": "Report",
"row_id": 246786,
"text": "Sinus rhythm\n - premature ventricular contractions\nAnteroseptal infarct - age undetermined\nInferior/lateral ST-T changes may be due to myocardial ischemia\nGeneralized low QRS voltages\n\n"
},
{
"category": "ECG",
"chartdate": "2166-10-27 00:00:00.000",
"description": "Report",
"row_id": 246787,
"text": "Atrial fibrillation with rapid ventricular response of 123\nOld anterior myocardial infarct\nDiffuse ST-T abnormalities\nAbnormal ECG\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-10-28 00:00:00.000",
"description": "Report",
"row_id": 1477156,
"text": "Pmicu Nursing Progress Note\nResp: Pt on biPap with nose mask but around 9am she took off the mask. She was placed on 1.5L NC with O2 sats 90-92%. If she moves the NC at all her O2 sats drop very quickly to the 80's. She was put in the chair with 4 people helping her but she did not help very much. She tolerated the chair until 2pm when she wasd put back to bed with a total lift (10 people helped). She was placed back on bipap and she immediately fell asleep with sats 94-96%. She has had a non productive cough.\n\nCardiac: HR 68-78 SR with frequent PAC's. B/P 104-110/50's.\n\nGI: Pt has no appetite just drinking apple juice and water. She has had 2 small smears of brown stool.\n\nGU: foley draining amber urine with U/O ~40cc/hr.\n\nNeuro: Pt oriented to person and place. She occasionally will talk to people who are not in the room but quickly reoientes. She was able to stand to transfer to the chair but she was unable to turn into the chair.\n\nSkin: She has an area in the front of her tibias on both legs. The right area is almost healed ulcerated area. On the left the ulcerated area has several small ulcers, reddened around the whole area. Adaptic was placed on both areas with some antibotic put on the left leg. Also on her left great toe the toe nail was lifted up during the transfer to the chair and it started to bleed. The toe was cleaned with soap and water, antibotic ointment applied and DSD applied.\n\nSocial: Her sister in to visit around 11am who helped with her orientation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-10-29 00:00:00.000",
"description": "Report",
"row_id": 1477157,
"text": "admssion note to micu for gi bleed\nd: SEE ADMISSION NOTE FROM YESTERDAY FOR PT'S PMH AND ORIGINAL REASON FOR ADMISSION. PT TO FLOOR LAST EVENING AFTER 24 HR STAY IN MICU FOR CONTROL OF SVT WITH ADENOSINE AND DIGOXIN. OVERNOC ON CC7 PT HAD 5 EPISODES OF MELANOTIC STOOL AND THIS AM WAS HAVING BRB STOOL OUTPUT APPROXIMATELY EVERY 20 MIN. HCT THIS AM=28 AND VSS WERE STABLE WITH SBP 100-110. PT WAS TO GI UNIT BUT UNABLE TO VISULAIZE SOURCE OF BLEEDING SO PT WAS THEN TO MICU FOR FURTHER MANAGEMENT. PT IS A DNR/DNI SO AFTER DISCUSSION WITH FAMILY PT WAS NOT INTUBATED. OGT PLACED AND PT CONTINUOUSLY LAVAGED AND HAVE BEEN UNABLE TO CLEAR. TRANSFUSED WITH 2 U FFP AND HCT UPON ARRIVAL=26.5. SISTER HAS BEEN UPDATED BY MEDICAL TEAM.\n\nREVIEW OF SYSTEMS:\nNEURO: PT AND IS ORIENTED TO PESON AND PLACE BUT STATES IT'S . CALLING OUT TO PEOPLE NOT THERE AND MAKING STATEMENTS THAT ARE DIFFICULT TO UNDERSTAND OR INCOMPREHENSIBLE.\n\nRESP: PRESENTLY ON O2 AT 2L/M NC WITH O2 SATS>94%. OCCASIONAL DRY NONPRODUCTIVE COUGH. INSP/EXP WHEEZES BIL BUT DIMINSIHED AT THE BASES. PT DOES HAVE CPAP AT THE BEDSIDE.\n\nCV: PT'S HR 80-90'S NSR WITH OCCASIONAL PAC'S AND SBP 110-130'S.\n\nGI: ABD TIGHT AND UNABLE TO AUSCULTATE BOWEL SOUNDS. NO STOOL AT PRESENT. OGT IN PALCE WITH BRB OUTPUT AND WILL NEED TO TRANSFUSE BLOOD AS NEEDED. NO C/O N/V. ? WETHER PT WILL GO TO IR FOR ANGIOGRAPHY AND POSSIBLE COIL PLACEMENT\n\nRENAL: ADEQUATE UO VIA FOLEY CATH WHICH IS AMBER IN COLOR.\n\nIV ACCESS: PT HAS 1 18G SL TO R LOWER ARM AND 20G IN L LOWER ARM. PT NEEDS CL ACCESS.\n\nINTEGUMENTARY : SKIN VERY THIN WITH AREAS OF ABRASIONS- SKIN TEARS TO ARMS. BIL LOWER EXTREMTIY DRSGS D&I WITHOUT DRAINAGE. PT VERY OBESE.\n\nID: PT NOW WITH MRSA FROM OLD PICC SITE AND STAPH LLE CELLULITIS SWAB. MAX TEMP=99.2 AND WBC=19.9.\n\nSOCIAL PT'S SISTER IS AT BEDSIDE AND AWARE OF PRESENT SITUATION. WILL GET PHONE NUMBER WHERE SHE CAN BE REACHED.\n\nCODE STATUS : PT IS A DNR/DNI\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-10-29 00:00:00.000",
"description": "Report",
"row_id": 1477158,
"text": "update to the above note: pt not a candidate for ir intervention and pt continues with brb output from ogt.discussion held with pt's siste decision made for no further intervention and comfort measures only. chaplain at bedside and sacrament of the sick administered. will start mso4 gtt and keep titrate to keep pt comfortable\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-10-30 00:00:00.000",
"description": "Report",
"row_id": 1477159,
"text": "7p to 7a Micu Progress Note\n\nNeuro - Pt only responding to painful stimuli. No spontaneous eye opening. Morphine drip being titrated. Pt not restless, sleeping most of evening and night.\n\nResp - RR 12 - 20. 02 sat 92 - 97 on 4lnc. Lungs with inspiratory and expiratory wheezing.\n\nGI- Passed small amount maroon stoolx 1. No further drainage noted from og tube. No bowel sounds noted.\n\nG-U - Foley draining well, u/o approx 50cc/hr.\n\nSkin - + MRSA from old pic line. LLE cellulitus.\n\nStatus - Pt is DNR/DNI and CMO. Sister with pt constantly in room. Other family members visiting throughout the evening. Last rights administered yest pm by chaplain.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-10-30 00:00:00.000",
"description": "Report",
"row_id": 1477160,
"text": "Addendum- At 1825 pt passing large amount of melanotic stool. Became cyanotic and stopped breathing. Began agonal breathing with decreased pulse Dr. pronounced pt dead at 1830. Sister at bedside. Friends of sister called to come in.\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-10-28 00:00:00.000",
"description": "Report",
"row_id": 1477154,
"text": "Nursing Admission Note\nPt is a 60yr old woman with complex PMH: CAD, S/P MI '; CHF EF 25-35% last echo ; OSA chronic BiPAP since ; IDDM; Morbid Obesity; elevated cholesterol; Hx GI bleed. She had a recent prolonged hospitalization for CHF, bilat LE cellulitis, for which a PICC line was placed for home IV Lasix w/ VNA. She was D/C'd , was doing well until when she was noted to have MS changes, fever to 105. EMS activated, found to be cyanotic, apneic. She was ambu'd briefly, brought to , given IV Vanco, blood cx off PICC line grew Gm+ cocci, transferred to per pt/family request. She lives with her sister in . She is allergic to Percocet.\nAt , pt was felt to be septic, with acute on chronic renal failure. Given Vanco, Ceftaz, given fluid. Overnight , developed SVT to 160's, given Adenosine 6mg IV with brief response, additional 12mg IV with HR down to 100-120 ? Afib. Pt is transferred to MICU for further care. Arrived with HR 130's SVT with frequent PAC's, BP stable 120-130/ On her baseline BiPAP, her sats are 93-96%\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2166-10-28 00:00:00.000",
"description": "Report",
"row_id": 1477155,
"text": "Nursing Progres Note\nNeuro: Pt calling out for her sister, yelling \"!\" When asked if she's having pain, she says \"No\". Pulling off BiPAP mask, removing johhnie despite continuous reinforcement to not do this. Soft restraints on bilat. Given Ativan 1mg IV x2 overnight with fair effect, slept only in short naps Per pt's sister, this has been her baseline MS recently\nResp: Sats >95% on BiPAP mask with 3l O2 bled through, drop to 86% with mask off BS diminished throughout\nCV: Given Lopressor 12.5mg PO, 2nd dose Digoxin IV (for total .25mg) with HR down to 70's SR with occasional-frequent PAC's. SBP remains > 110. IV fluid NS begun at 100ml/hr per medical resident\nGI: NPO except for meds with sips water + bowel sounds, no stool overnight\nGU: Approx 30ml/hr amber urine with sediment via Foley cath, has not increased with IV fluids\nSkin: Dsgs intact at both LE's, no drainage\nSocial: sister at bedside until 2100, telephone update given this AM Pt remains DNR/DNI. ? call out to floor later this morning\n"
}
] |
29,867 | 138,500 | This is a 57 year old woman with history of CAD s/p MI and stent () presenting with BRBPR due to diverticulosis. Brief hospital course presented below by problem. . Briefly, this is a 57 year old female with history of MI s/p stent in on aspirin/plavix presented on with single episode of lower GI bleed. She had acute onset of lower abdominal cramping, then was incontinent of a large volume of bright red blood and diarrhea. The pain resolved after the BRBPR. She denied any other preceeding symptoms: fever, chills, chest pain, shortness of breath, nausea, preceeding diarrhea or constipation. In the ED she was hemodynamically stable with BP 107-113/71-83, HR 90s and her hematocrit was 38. She was given 1 liter Normal saline, NG lavage negative. The patient was evaluated by GI who recommended ICU monitoring for lower GI bleed. . In the ICU, patient was continued on her PPI, given IVF, kept NPO for EGD and colonoscopy. No ischemic changes on EKG. The patient's beta blocker was held to not mask tachycardia. She received 1 unit of PRBC. On , her tagged RBC scan was negative, her EGD was shown to be normal, and colonoscopy on showed diverticulosis as likely cause of GIB. Also showed multiple non-bleeding diverticula. During the whole hospital course, the patient was continued on asprin and plavix for recent drug eluting stent . She was also continued on her statin for hyperlipidemia. Patient's Hct remained stable after the colonoscopy and patient was transferred to the general medicine floor for continued care in the evening of . On the day of discharge, the patient tolerated regular diet, had no more episodes of bleeding, and had a stable hematocrit. Patient was discharged on all her home medications including restarting her coreg CR for hypertension. She will need follow up with her primary care physician, . , within 1-2 weeks of discharge from the hospital. Also, she will need follow up with a local GI specialist for a full screening colonoscopy with better prep in the future to look for polyps and other colonic morphology. | adequate amount.IVF's 1L of .9 done-no new orders for more fluid.Plan: follow hct's q 6 hours cont. BP 100's-1teens/70's, tmax 99.0 po.Resp: LS clear, o2 sat's high 90'sGI/GU: +bs, no bm since 8am, u/o wnl.Access: PIV x2, wnl.plan: hct 18:00, ?c/o to floor Repeat HCT down to 30.9. Received total of PRBC's 1unit, most recent Hct @1200 30.6. Golytley started for colonoscopy prep. No active bleeding since this am, next hct due at 18:00. 4mg zofran given with good effect.No BM yet.GU: voids on the commode. No edema + 3 pt/dp bilaterallyGI: On clear liquids, to start golytely this evening. Nursing Progress NOtereview of systems: 7p-11pSkin: intactNeuro: intact. WBC up with last labs. In the EW her HCT was stable at 36, a NG lavage was done which was negative. Needs U/A sent with next voidID: afebrile, + WBC needs blood cultures with next blood drawSkin: Intact no issuesFEN: getting NS x 1 liter.Heme: HCT 30.9, next HCT due at Social: Son drove down from VT, she lives in PA with daughter and her family works as a medical assistant and in medical researchPlan1. RR mid teensCardiac: Hemodynamically stable. Early precordial R wave transition.Non-diagnostic Q waves in leads II, III and aVF. NPN 07:00Please refer to Carevue for additional patient information*Full CodeShift Events: Las bm at ~8am, liquid/watery stool. Approved: TUE 4:32 PM RADLINE ; A radiology consult service. Red TAG study done this am, no active bldg found. clear liquid diet until midnight and then NPO. nsg notes contd....Pt had large after 0400hrs,total 900ml ( blood + urine) crit sent,report 26,informed team,vital signs stable ,HR 70's,so Dr ti draw next crit at 0800hrs and if it is less than 25 ,then will do further management. Tele SR 70-80's without ectopy. ls clear bilat and throughout.GI: abd soft, nondistended. next due @ 0200.Resp: RA with sats> 95%, RR wnl. GI BLEEDING STUDY Clip # Reason: CAD S/O DES ON ASPIRIN/PLAVIS PRESENTING W/ BRBPR S/ EPISODES FINAL REPORT RADIOPHARMECEUTICAL DATA: 15.5 mCi Tc-m RBC (); GI BLEEDING STUDY. Prep for colonoscopy2. sats 94-96 on RA. No further epiodes of BRBPR or stoolRenal: Voiding clear yellow via commode. with golytely another set of blood cx with next hct draw Colonoscopy done this afternoon, md's probable cause of bleed is Diverticulosis. HCT q 6 hours-stable. Denies painResp: Lungs CTA bilaterally, respirations even and unlabored. VSS, she was transferred to the MICU for an emergent EGD and closer montioring. ST-T wave flattening in lead I. T wave inversion in lead aVL.ST-T wave flattening in leads V5-V6. , M.D. one set of blood cultures and urine culture sent. Nsg.notes 2300-0700hrsAllergies:NKDAEvents: 57YO lady admitted on with H/O BRBPR ,On admission crit 36,susequently down to 30 ,but no PRB till midnight.had an episode of BRBPR at midnight,300ml,vital signs stable,crit sent-28.7,team aware,informed GI team,per GI team,if continuous bleeding and crit lower than 27.5,may need to do red tag study.had one more episode at 0230,100ml.crit at 4am.Neuro:alert and oriented well,having mild abdominal cramping,using commode, on feet.CVS:HR 70-90's,NSR,No ectopics noted,BP 85-110/55-70 mm of hg.crit Q4h.next draw at 0800hrs.bloos c/s 2nd sample sent.Resp:LS clear,Sats 93-95% on RA.gu/gi:Abdomen soft,BS present.had 2 maleana.voided,using commode,yellow clear urine.on oral liquids.for colonosopy today,colon preparation with golytely,drinking not very adequately.Integu:skin intact,mild redness on sacrum.afebrileIV access:18g PIV'S one on each hand.patent.social:calm and co operative.DNR,but she wish to intubate.Plan:serial crit,and follow up with results.watch for PR bleed,and monitor vital signs. + BS in 4 quadrents. VSS through MICU course. She is to be prepped tonight for a colonoscopy in AMNeuro: A&Ox3, OOB to commode with supervision. To hear preliminary results, prior to transcription, call the Radiology Listen Line . EGD was done which was negative (total of 75 mcg fentanyl 2 mg versed given for procedure). Serial HCTS3. FINDINGS: Following intravenous injection of autologous red blood cells labeled with technetium-m, blood flow and dynamic images of the abdomen were obtained for 120 minutes. Routine ICU monitoring and care Sinus rhythm. ?c/o to floor (patient does not have insurance and is very concerned regarding her "stay" in hospital) Family at bedside most of day, updated on plan of care.ROS:Neuro: a/o x3, very pleasant, no c/o pain,dizziness.CV: HR 80's, NSR, no ectopy. afebrile. IMPRESSION: No evidence of GI bleeding. No previous tracingavailable for comparison. pt has nausea after starting the prep. pt very cooperative and pleasantCV: VS stable. pt steady on feet. yellow, clear urine. The obtained images demonstrate no evidence of tracer extravasation. Nursing Progress Note 0700-1900This is a 57 year old female with a PMH of HTN, CAD (s/ 5 months ago) who was at a conference this am when she had sudden onset of abdominal cramping and then passed a large amount of BRBPR. | 7 | [
{
"category": "Radiology",
"chartdate": "2180-10-28 00:00:00.000",
"description": "GI BLEEDING STUDY",
"row_id": 978569,
"text": "GI BLEEDING STUDY Clip # \n Reason: CAD S/O DES ON ASPIRIN/PLAVIS PRESENTING W/ BRBPR S/ EPISODES\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMECEUTICAL DATA:\n 15.5 mCi Tc-m RBC ();\n GI BLEEDING STUDY.\n\n INDICATION: Bright red blood per rectum.\n\n FINDINGS: Following intravenous injection of autologous red blood cells labeled\n with technetium-m, blood flow and dynamic images of the abdomen were obtained\n for 120 minutes.\n\n The obtained images demonstrate no evidence of tracer extravasation.\n\n IMPRESSION: No evidence of GI bleeding.\n\n\n , M.D. Approved: TUE 4:32 PM\n\n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-28 00:00:00.000",
"description": "Report",
"row_id": 1648225,
"text": "nsg notes contd....\n\nPt had large after 0400hrs,total 900ml ( blood + urine) crit sent,report 26,informed team,vital signs stable ,HR 70's,so Dr ti draw next crit at 0800hrs and if it is less than 25 ,then will do further management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-28 00:00:00.000",
"description": "Report",
"row_id": 1648226,
"text": "NPN 07:00\nPlease refer to Carevue for additional patient information\n*Full Code\n\nShift Events: Las bm at ~8am, liquid/watery stool. Received total of PRBC's 1unit, most recent Hct @1200 30.6. Red TAG study done this am, no active bldg found. Colonoscopy done this afternoon, md's probable cause of bleed is Diverticulosis. No active bleeding since this am, next hct due at 18:00. ?c/o to floor (patient does not have insurance and is very concerned regarding her \"stay\" in hospital) Family at bedside most of day, updated on plan of care.\n\nROS:\nNeuro: a/o x3, very pleasant, no c/o pain,dizziness.\nCV: HR 80's, NSR, no ectopy. BP 100's-1teens/70's, tmax 99.0 po.\nResp: LS clear, o2 sat's high 90's\nGI/GU: +bs, no bm since 8am, u/o wnl.\nAccess: PIV x2, wnl.\nplan: hct 18:00, ?c/o to floor\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-27 00:00:00.000",
"description": "Report",
"row_id": 1648222,
"text": "Nursing Progress Note 0700-1900\n\nThis is a 57 year old female with a PMH of HTN, CAD (s/ 5 months ago) who was at a conference this am when she had sudden onset of abdominal cramping and then passed a large amount of BRBPR. In the EW her HCT was stable at 36, a NG lavage was done which was negative. VSS, she was transferred to the MICU for an emergent EGD and closer montioring. VSS through MICU course. Repeat HCT down to 30.9. EGD was done which was negative (total of 75 mcg fentanyl 2 mg versed given for procedure). She is to be prepped tonight for a colonoscopy in AM\n\nNeuro: A&Ox3, OOB to commode with supervision. Denies pain\n\nResp: Lungs CTA bilaterally, respirations even and unlabored. sats 94-96 on RA. RR mid teens\n\nCardiac: Hemodynamically stable. Tele SR 70-80's without ectopy. No edema + 3 pt/dp bilaterally\n\nGI: On clear liquids, to start golytely this evening. + BS in 4 quadrents. No further epiodes of BRBPR or stool\n\nRenal: Voiding clear yellow via commode. Needs U/A sent with next void\n\nID: afebrile, + WBC needs blood cultures with next blood draw\n\nSkin: Intact no issues\n\nFEN: getting NS x 1 liter.\n\nHeme: HCT 30.9, next HCT due at \n\nSocial: Son drove down from VT, she lives in PA with daughter and her family works as a medical assistant and in medical research\n\nPlan\n\n1. Prep for colonoscopy\n2. Serial HCTS\n3. Routine ICU monitoring and care\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-27 00:00:00.000",
"description": "Report",
"row_id": 1648223,
"text": "Nursing Progress NOte\nreview of systems: 7p-11p\n\nSkin: intact\n\nNeuro: intact. pt very cooperative and pleasant\n\nCV: VS stable. afebrile. WBC up with last labs. one set of blood cultures and urine culture sent. HCT q 6 hours-stable. next due @ 0200.\n\nResp: RA with sats> 95%, RR wnl. ls clear bilat and throughout.\n\nGI: abd soft, nondistended. clear liquid diet until midnight and then NPO. Golytley started for colonoscopy prep. pt has nausea after starting the prep. 4mg zofran given with good effect.No BM yet.\n\nGU: voids on the commode. pt steady on feet. yellow, clear urine. adequate amount.\n\nIVF's 1L of .9 done-no new orders for more fluid.\n\nPlan: follow hct's q 6 hours\n cont. with golytely\n another set of blood cx with next hct draw\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-10-28 00:00:00.000",
"description": "Report",
"row_id": 1648224,
"text": "Nsg.notes 2300-0700hrs\n\nAllergies:NKDA\n\nEvents: 57YO lady admitted on with H/O BRBPR ,On admission crit 36,susequently down to 30 ,but no PRB till midnight.had an episode of BRBPR at midnight,300ml,vital signs stable,crit sent-28.7,team aware,informed GI team,per GI team,if continuous bleeding and crit lower than 27.5,may need to do red tag study.had one more episode at 0230,100ml.crit at 4am.\n\nNeuro:alert and oriented well,having mild abdominal cramping,using commode, on feet.\n\nCVS:HR 70-90's,NSR,No ectopics noted,BP 85-110/55-70 mm of hg.crit Q4h.next draw at 0800hrs.bloos c/s 2nd sample sent.\n\nResp:LS clear,Sats 93-95% on RA.\n\ngu/gi:Abdomen soft,BS present.had 2 maleana.voided,using commode,yellow clear urine.on oral liquids.for colonosopy today,colon preparation with golytely,drinking not very adequately.\n\nIntegu:skin intact,mild redness on sacrum.afebrile\n\nIV access:18g PIV'S one on each hand.patent.\n\nsocial:calm and co operative.DNR,but she wish to intubate.\n\nPlan:serial crit,and follow up with results.watch for PR bleed,and monitor vital signs.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-10-27 00:00:00.000",
"description": "Report",
"row_id": 220411,
"text": "Sinus rhythm. ST-T wave flattening in lead I. T wave inversion in lead aVL.\nST-T wave flattening in leads V5-V6. Early precordial R wave transition.\nNon-diagnostic Q waves in leads II, III and aVF. No previous tracing\navailable for comparison.\n\n"
}
] |
14,666 | 136,758 | 1. Respiratory: The patient was on CPAP of 6 until day of life 3 at which point he transitioned to room air without any supplemental oxygen required after that point. Comfortable on room air at this time, with last bradycardiac spell at 7 p.m. on . The patient will complete a 5-day spell count at 5 p.m. on prior to discharge. 2. Cardiovascular: No issues, no murmur, no history of hypotension. 3. Fluids, electrolytes, nutrition: The patient initially on D10W, transitioned to full enteral feeds by day of life 4 and increased to 24 kilocalories on day of life 11 under which the patient has been undergoing adequate weight gain. At this time, he is on breast milk 24 supplemented with Similac powder. He is taking ad lib p.o. on top of breast feed. No gavage necessary. Discharge weight 2725g. 4. GI: Maximum bilirubin 12.3 on day of life 9, with phototherapy discontinued on day of life 11, with a rebound of 6.5. 5. Hematology: Initial hematocrit 51, white count 16, platelets 322. 6. Infectious disease: The patient is status post 48 hours of ampicillin and gentamicin during initial blood culture, which was negative. Since that time, the patient has had antibiotic ointment with Telfa dressing to the right foot for an IV infiltrate which was discontinued approximately 4 to 5 days before discharge with resolution of infiltrate and healing of skin. 7. Neurology: Not applicable. Sensory hearing screening was performed on with automated auditory brain-stem responses and the patient passed. 8. Ophthalmology: Not applicable. | Reb bili 10.6/0.2. Sm amtyellow/serous drainage noted. Tripleabx and tefla applied. Swaddled, withboundaries. #1RespLungs clear with mild sc retractions. G/D: Temps stable swaddled in off-isolette. G/D: Temps stable swaddled in off-isolette. BS clear and =; mild sc ret. MildSCR noted. MildSCR noted. to monitor resp. to monitor resp. TEMP STABLE IN AN OFFISOLETTE.#4PARENTMOM X 1 FOR AN UPDATE#6BILIBILI WAS 10.6/.2. A: Resolving P: Check biliMon. NNP INFORMED. Bili thisam was 9.6/0.3. mild subcostal retractions. Cl and = BS. Cl and = BS. Mild rtxns. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Mild retractions. Mild sc rtxns. Updated re statusand plan. Tol well. Tol well. Mild desats-sr. HR 130-140s. infant colorjaundiced. both helping changediaper and do temp. AGA. AGA. Infant breastfed well x 1. TF 100 BM/SC20. Infant isalert/active with cares. Infant isalert/active with cares. REMAINS SL JAUNDICED#7SKINDSG TO R FOOT CHANGED, AREA PINK AND CLEAN. TF 120 BM20/SC20. Tolerating feedingswell; abd exam benign, no spits, min asp. LC gave Momnipple . Infant is a&awith cares. Brady x1, needing mild stim torecover. Parents updated bythis R.N. Small amt of serous drainage noted on dsg x1from that area. Ferinsol and Multivit. Infant can be fiestyat times. LS cl/=.Mild SC retractions. Willalso settle with pacifier, containment and holding. Pedi is . Desitin applied todiaper area.A. Rest well inbetween cares. Stool heme neg. Abd benign, AG 26,V/S, mec stooling. Both held infanttoday. NPN Noc#1 Resp: RA, 30-60's, c/=, mild SC retrac. Updated on infant'scondition and plan of care by this RN. NPN discharge noteVSS, exam benign; see flowsheet for details. AGA.Tripple abx oint TID to right foot infiltrate. Both updated. NPN 0700-2. NPN#1 S. O. BBS cl/=. Abd soft, +, noloops. Will update pediatrician. Mom and this am. A: stable in RA P:Cont to monitor and providesupport as needed.#2: TF's ^'ed to 100cc/k/d. Infant passed trace mec stool. and active duringcares, resting well in between. Eagerbottler and breastfeeder. Fontssoft/flat. Follow wt and exam.#3: Temps stable in an air isolette. NPN Daysaddendum: Pt passed hearing screen. Min asp. A: Toleratingfeeds. P: Cont tosupport and update. Cont to receive BM24.A. Onesmall wet burp. updates given. #1RespLungs clear with mild retractions. On ad lib demand. V/S. sucking onpacifier. abd benign. Abd benign. Plan to recheck bili am. Passed hearing screen. A: AGA. Passing heme negative stool. Passing heme negative stool. MAE/AFOF.AGA. D/C OT. Abdomen round and softwith + BS. Placed in RA. Asking appropriatequestions. Feeding tube out. Tempsstable. BM24 with powder. Took 70cc this am and BF well while werevisiting. Pt day of spell count down. Cont. Discussed SIDS precautions and EI qualifications. Voiding and stooling normally (heme negative). Maturing breathing control. exambenign. Abd soft, active bowel sounds. P- Will cont to monitor resp status.#2 Pt ad lib demand. Sucks on pacifier. BS clear. voiding and stooling. Voiding and stooling. Abd. Benign abdomen. Appearscomfortable#2FENWt 2.615 up 30g. Rehab/OTMet at the bedside. Interested inbottling#4Parentno contact so far. P: Cont to support development.#4 O: Both in to visit. remainder of volume gavaged. P: Cont tomonitor bili status PRN. P: Cont to supp and update. Infant isjaundice. Cl and = BS. continue with currentplan of care. Respiratory CarePt cont on prong CPAP. Updatedat bedside by RN. Fio2 .24-.27. bs clear, rr 50-70 with mild retractions. +murmur. Lytes this am were143/4.6/108/22. CBG: 7.28/47/45/23/-4. A: Independent andappropriate w/cares. sucks vigorously onpacifier. A: AGA. BPP was . d/c photot and check reb bili in AM. AG 27. u/o1.2cc/kg/hr thus far. Infant bottled 52 cc @ 0900 cares w/remainingvolume gavaged. Plan to recheck bili in the am. Mild SC retractions. At delivery, twin A emerged with moderate tone and good cry, with Apgars . aga. AGA. AGA. mild subcostal retractions. BP 67/37, 47. 6.5/0.2 (reb). LS clear/equal, oximetry d/c'dthis morning. Infant GFR on arrival to NICU. CL and =. Tol well. Persistant grunting on CPAP, subcostal retractions. TF 150 BM24. TF 150 BM24. TF 150 BM24. sent this shiftpending. po/pg. Po/pg. PO/PG. Otherwise, AFSFO, oropharynx clear, NGT w/o breakdownCV - RRR, nl s1+s2 no murmurPULM - CTABABD - soft, NT, ND, no massEXT - wwp, R foot c/d/i, cr < 2 secNEURO - reactive, MAE in REsp status. Stable on CPAP cont to follow. ; P/Cont. REsp. O/Anitbiotics d/c. Restswell inbetween cares. Updates given. P/Cont. P/Cont. P/Cont. toleratingfeeds well. Murmur notedand reported to NNP. Updated by RN. Updated re status andplan. remains under neoblue lights with eye shieldsin place. Bili to be rechecked in am. BS clear and =, mild sc ret. NPN 07p-07aRESPRA, LS clear & equal with mild subc. BF well.uop and stool wnl, heme neg.abd wnl. NG d/c. noincreased wob noted. Wakes occassionally for cares. Abd benign. Triple antx ointment applied as ordered.Cont. A/Completion of 48hr r/O. BS active. Nospells so far this shift, last one on . Pt. Pt. Pt. Pt. mild subcostal retractions. Please refer toflowsheet. retractions. Abd exam benign, VQS, smyellow stool x2. VS stable.Alert & active with cares. Stable on CPAP cont to follow closely. Remains NPO.Intermittently sucking on pacifier.3. Occ sat drifts, one spell so far this shift,resolved with mild stim and increased 02. monitorPO/PG feeding tolerance & weight.G&DIn air isolette, temps stable. G/D: Temps stable swaddled in off-isolette. MildSCR noted. NPN DAYS#1 Pt received and cont in RA. updated re: pt spells and DCdate pushed back. A: Independent andappropriate w/cares. Lytes 135/4.0/19. LS C+=. mild subcostal retractions. Abd benign. Keeping NPO. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Pt voiding and stooling hemneg. CBG 7.28/47. NPN:RESP: RA. IV placed in R hand with D10W infusing, initial DS 47, after IVF infusing, DS 74. BBS =/clear. Voiding qs and stoolingheme neg. Bilirubin 1.7. SATSIMPROVED ON BELLY.#2 NPO. received infant in an offisolette. Infant isalert/active with cares. asking approp ques. A: AGA. FeS04. Lung sounds cl/= and mild SC retractions. minimal aspirates. Settlesvery well with pacifier and boundaries. to suppot developmentalneeds. LS sl coarse and diminished, color good, cont with GFR through shift. B.S. AGA. Lung sounds clear/=. Attempted to BFx 2 thus far - latched well. abd benign.all po feeds. ess. Independent withcares and handling infants. lung sounds clear andequal. LS ARE CLEAR,SLIGHTLY DIMINISHED. | 107 | [
{
"category": "Nursing/other",
"chartdate": "2197-12-16 00:00:00.000",
"description": "Report",
"row_id": 1884793,
"text": "Neonatology Attending\nDOL 7 / PMA 35-3/7 weeks\n\nRemains in room air with no distress. Occasional drifting saturations but no bradycardias.\n\nNo murmur.\n\nOff phototherapy with bilirubin 10.6 yesterday.\n\nWt 2385 (+35) on TFI 140 cc/kg/day BM20, tolerating well. Bottling up to of feeds. Voiding and stooling (guiac negative). Abd benign.\n\nTemp stable in off isolette.\n\nRIght foot infiltrate improved.\n\nA&P\n34-3/7 week GA infant with respiratory and feeding immaturity\n-Continue to await maturation of oral feeding skills and respiratory drive\n-Repeat bilirubin on Monday\n-No changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-16 00:00:00.000",
"description": "Report",
"row_id": 1884794,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 90%. Lung sounds clear/=. RR 30-50's. Mild\nSCR noted. No bradys noted. Occ drifts to high 80's noted.\nP: Cont. to monitor resp. status.\n\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempting to\nPO when awake and alert. Infant breastfed x 2 thus far -\nlatched well. Tolerating NGT feedings well; abd exam\nbenign, no spits ,min asp. Voiding qs and stooling heme\nneg. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/active with cares. Settles well in betwen cares.\nAppropriatley brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support developmental\nneeds.\n\n4. : Mom in for 2 set of cares today. Independent\nwith cares and handling. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved . P: Cont. to support and update\n.\n\n5. Bili: Rebound bili fri am was 10.6. Infant remains sl.\njaundiced. Will follow bili on mon am.\n\n6. Skin: Dressing changed no right foot infiltrate. Triple\nabx and tefla applied. No drainage, redness or swelling\nnoted. P: Cont. to monitor skin.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-17 00:00:00.000",
"description": "Report",
"row_id": 1884795,
"text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 96-99%.RR 30-60's.LS\nremain clear and equal with sc retractions.No A's and B's or\ndesats thus far.\n\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\nq 4 hrs gavaged over 45 min.Infant attempted to bottle with\nthe Playtex Nurser and took 25-44cc's.Appeared well\ncoordinated;remainder gavaged.Weight=2.410 up 25 grams.Abd\nsoft with pos bs,no loops or spits,minimal aspirates.Voiding\nand stooling heme negative.\n\nG/D:AF soft and flat.Alert and active with cares.Sleeping\nwell b/t.MAE.Bringing hands to face and mouth.Infant remains\nin off isolette;swaddled with nested boundaries.Temp.\nmaintained.\n\nParenting:Mom called x 1.Updated by this RN.Asking\nappropriate questions very loving and invested.\n\nBili:Infant cont's jaundice but well perfused.Stooling.To\nhave bili checked on .\n\nSkin:R foot appears pink with serous drainage on old\ndressing.Applied triple antibiotics;healing well.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-17 00:00:00.000",
"description": "Report",
"row_id": 1884796,
"text": "Neonatology Attending\n\nDOL 8 PMA 35 4/7 weeks\n\nStable in RA. No A/B.\n\nNo murmur. BP 78/33 mean 50\n\nOn 140 ml/kg/d BM 20 po/pg. Voiding. Stooling. Wt 2410 grams (up 25).\n\nR foot infiltrate being treated with triple antibiotics.\n\n in and up to date.\n\nA: Stable. No spells. Tolerating feeds and learning to po. Infiltrate healing.\n\nP: Monitor\n pos as tolerated\n Continue care for infiltrate\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-15 00:00:00.000",
"description": "Report",
"row_id": 1884789,
"text": "Nursing Progress note\n\n\n#1 Resp-- O: RR 30s-60s; HR 140s-160s; Sats 96-99. No\ndesats, no spells. BS clear and =; mild sc ret. Pink/jaund.\nNo murmer. A: Rare desats in RA P; Cont to monitor\nsats/vitals/spells\n\n#2 Nutrition-- O: Enteral feeds advanced to 140cc/kg/d= 60cc\nBM20 q4h. BF great x2 with good latch and suck 5-10 min-\nthen drowsy. Tol full volume after BF over 45 min. tol well-\nno spits, no asp. NG #5 placed in rt nare after baby pulled\ntube. Abd exam benign, AG 25cm, +BS. VQS, Yellow x2\nguiacneg. A: Stable, tol adv feeds with wt gain P: Monitor\ntol and growth\n\n#3 Development-- O: Alert and active with cares, social with\nmom. stable in off islolette. Swaddled, with\nboundaries. Hands to mouth. A: AGA P: Cont to support\ndevelopment\n\n#4 Parenting-- O: Mom in for 0900 and 1300 feeds.\nIndependent with babies, handling well. Updated re status\nand plan. Will be back for 1700 feed. A: Involved. loving P:\nCont to support and keep informed\n\n#6 ^Bili-- O: rebound bili stable off og photo Rx. Color sl\njaund, VQS, stooling, full feeds. A: Resolving P: Check bili\nMon. am\n\n#7 Skin-- O: Rt foot lesion drsg . Sm amt\nyellow/serous drainage noted. Area cleansed with sterile\nH2O, triple antibx ointment applied with Telpha and gauze\nwrap. A: Improving P: Monitor and change drsg \n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-15 00:00:00.000",
"description": "Report",
"row_id": 1884790,
"text": "Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl external male genit, no rash\nEXT - wwp, cr < 2, R foot wound c/d/i with normal granulation tissue and no pus or erythema\nNEURO - MAE, reactive\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-16 00:00:00.000",
"description": "Report",
"row_id": 1884791,
"text": "Nursing Progress Note 1900-0700\n\n\nResp:Infant remains in RA saturating 97-100%.RR 30-60's.LS\nremain clear and equal with sc retractions.No A's and B's\nthus far.Occ. will drift in sats to high 80's QSR.\n\nF/E/N:Infant cont's on TF 140cc's/kg/day.To rec.BM20 60cc's\nq 4 hrs gavaged over 45 min.Infant bottled x 2 with Playtex\nbottle and took 17-47cc the remainder gavaged.Weight=2.385\nup 35.Abd. soft with pos bs,no loops or spits,minimal\naspirates.Voiding and stooling heme negative.\n\nG/D:AF soft and flat.Alert and active with cares.Stirring\nprior to feeds.MAE.Bringing hands to face and mouth and\nintermitently sucking on pacifier.Infant remains in off\nisolette swaddled with nested boundaries.Temp. stable.\n\nParenting:No contact from so far.\n\nBili:Infant cont's slightly jaundice.To recheck Bili .\n\nSkin:R foot appears to be healing well.Cont's slightly pink\nwith healing tissue.No drainage or foul odor\npresent.Dressing changed per protocol.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-16 00:00:00.000",
"description": "Report",
"row_id": 1884792,
"text": "Neonatology NP note\nPE\nswaddled in open crib, cobedding with twin\nAFOf\nminimal subcostal retractions in room air, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-14 00:00:00.000",
"description": "Report",
"row_id": 1884786,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 93%. Lung sounds clear/=. RR 40-60's. Mild\nSCR noted. Few drifts to high 90s noted. No apnea noted\nthus far. P: Cont. to monitor resp. status.\n\n2. FEN: TF were increased to 120 cc/kg/day of BM/SC20.\nInfant is attempting to PO/breastfeed when awake and\ninterested. Infant breastfed well x 1. Tolerating feedings\nwell; abd exam benign, no spits, min asp. Voiding qs and\nstooling trans stools. P: Cont. to support nutritional\nneeds.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/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. Parents: Mom in for cares this shift. Independent with\ncares and handling infants. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved parents. P: Cont. to support and update\nparents.\n\n5. Bili: Single phototherapy was d/c'd at 1000. Bili this\nam was 9.6/0.3. Plan is to check rebound in am.\n\n6. Skin: Dressing was changed x 1. Tefla and gauze and\ntriple abx ointment placed on infiltrate. No drainage noted\nfrom site. P: Cont. to monitor and change dressings as\nordered.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-15 00:00:00.000",
"description": "Report",
"row_id": 1884787,
"text": "#1Resp\nLungs clear with mild sc retractions. Baby has had one spell\ntonight which required mild stim.RR 40-60 with sat in high\n90's.\nP. Cont to monitor\n#2FEN\nWt 2.35 up 25g. Baby cont to receive 150cc/kg BM20 52 cc q4.\nAbd round but soft active bowel sounds. Min asp No spits,\nSleepy at 2100 and feed gavaged. At 0130 awake and alert but\nnot that interested and took 15cc. At 0500, bottled 22.\\\nA. Tol feed and learnung to feed\nP> CONT TO MONITOR TOL TO FEEDS AS WELL AS WEIGHT GAIN AND\nFEED ABILITY\n#3DEV\nAWAKE AND ALERT WITH CARES BUT TIRES. TEMP STABLE IN AN OFF\nISOLETTE.\n#4PARENT\nMOM X 1 FOR AN UPDATE\n#6BILI\nBILI WAS 10.6/.2. NNP INFORMED. REMAINS SL JAUNDICED\n#7SKIN\nDSG TO R FOOT CHANGED, AREA PINK AND CLEAN. NO DRAINAGE.\nGOOD PERFUSION TO THE TOES. DIAPER AREA SL PINK. DESITIN\nAPPLIED\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-15 00:00:00.000",
"description": "Report",
"row_id": 1884788,
"text": "Neonatology Attending Note\nDay 6, PMA 35 2\n\nRA. RR40-60s. Mild sc rtxns. Cl and = BS. Mild desats-sr. HR 130-140s. BP 85/43, 56. Reb bili 10.6/0.2. Wt 2350, up 25. TF 120 BM20/SC20. PO/PG. Tol well. Nl voiding and stooling. Desitin to diaper dermatitis. In off isolette.\n\nA/P:\nGrowing preterm infant learning how to po feed. Adv TF to 140. Follow jaundice clinically, check another Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-14 00:00:00.000",
"description": "Report",
"row_id": 1884782,
"text": "npn 1900-0700\n\n\n1: resp\nremains in ra. one spell with breastfeeding, qsr, see flow\nsheet. rr 30-70's. mild subcostal retractions. no increased\nwob noted. sats 93-100%. lung sounds clear and equal.\nconitnue to monitor for changes in respiratory status.\n\n2; fen\ncurrent weight 2325gms down 50. total fluids remain at\n100cc/kilo/day of bm 20/sc 20. tolerating feeds well. no\nspits. minimal aspirates. voiding and stooling. abd soft\nwith no loops. girth stable. mom breastfed at 2100 and at\n0100, with first care infant latched on and took a few\nsucks, at 0100 care infant latched on and nursed well for\n5-10 minutes. continue to support mom with breastfeeding.\nfull gavage feed given following breastfeeding. continue\nwith current feeding plan.\n\n3: growth and development:\ntemps stable in an air heated isolette. alert and active\nwith cares. sleeps well inbetween. brings hands to face.\nsucks vigorously on pacier. irritable at times. unswaddled\nwith boundaries for phototherapy. continue with current\nfeeding plan.\n\n4; parenting\nmom and dad in for 2100 care. both involved with cares.\nloving and asking appropriate questions. both helping change\ndiaper and do temp. continue to support family while in the\nnicu environment.\n\n6: bili\ninfant remains under single phototherapy. eye shields in\nplace. bili drawn this shift 9.6/0.3/9.4. infant color\njaundiced. continue to monitor for change.\n\n7: skin:\ninfant with newborn rash. infant also with right foot lesion\n\nwith multiple small scabs and open area that is pink. small\namount of serous draingae noted on gauze. dressing changed\nand triple antibiotic ointment applied. no active bleeding\nand no edema noted. continue with dressing changes.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-14 00:00:00.000",
"description": "Report",
"row_id": 1884783,
"text": "Neonatology Attending Note\nDay 5, PMA 35 1\n\nRA. RR30-70s. Cl and = BS. Mild rtxns. Occass sat drifts. +2 A&Bs past 24h. HR 130-150s. No murmur.\n\nJaundice, Bili 9.6/0.3, under single photot.\n\nWt 2325, down 50. TF 100 BM/SC20. Tol well. Nl voiding and stooling. Tr mec.\n\nIn air isolette.\n\nA/P:\nCont to monitor mild AOP off caffeine. d/c photot and monitor bili levels in AM. Adv TF to 120.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-14 00:00:00.000",
"description": "Report",
"row_id": 1884784,
"text": "Exam Note\nGEN - asleep in isolette\nHEENT - AFSFO, oropharynx clear, nares patent\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl ext genit\nEXT - wwp, cr < 2s\nNEURO - reactive, MAE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-14 00:00:00.000",
"description": "Report",
"row_id": 1884785,
"text": "Exam Addendum\nEXT - RLE wound examined under bandage, c/d/i with appropriate eschar and no signs of infection.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884775,
"text": "Neonatology Attending\n\nDay 4 PMA 35 0/7 wks\n\nRemains in RA. RR 30-60s. Mild retractions. Had four bradycardia episodes over last 24 hours- one with feeding. No murmur. HR 120-160s. BP mean 56. Bilirubin 9/0.4 on phototherapy. Weight 2375g (-30). TF at 80 ml/kg/d. Now on full feeds BM/SC 20. Put to breast daily. Latched. Minimal aspirates. Stable girth. Passing heme negative stool. Stable temperature in air-controlled incubator. Foot infiltrate clean with crust. Treated with triple antibiotic and Telfa. Family meeting yesterday.\n\nDoing well overall with mild breathing control immaturity. Will continue to monitor. Increasing to 100 ml/kg/d today. Monitoring feeding tolerance. Will speak with family today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884776,
"text": "Lactation Consult\nMet w/ mom/babies this AM to assist w/ latch and assess milk supply. Infants are 4 day old 34 wks, 35 wks corrected today. Infant remains under single phototx and has an ng tube for feeds. Baby went to breast w/o nipple shield first and demonstrated difficulty in latching, and was then trialed w/ nipple shield and did very well. Baby had frequent audible swallows and milk in nipple shield, nursing X 10mins. He was then ng fed for full vol.\nReviewed risks and benefits of using a nipple shield w/ mother, emphasized need to pump 8-12X per 24hrs. Gave mom written material to assess 24 hr milk supply. Will follow this family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884777,
"text": "Social Work\n\nFamily meeting yesterday, parents doing well, many good questions. Will follow assess need for any additional support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884778,
"text": "Exam Note\nGEN - awake,alert\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl ext genit\nEXT - wwp, cr < 2\nNEURO - reactive, MAE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884779,
"text": "NPN 7a-7p\n\n\n#1: remains in RA, sating >/= 94%. Rare drift to high\n80's noted with QSR. Brady x1, needing mild stim to\nrecover. RR stable. BBS cl/=. Breathing with mild\nretractions. A: stable in RA P:Cont to monitor and provide\nsupport as needed.\n\n#2: TF's ^'ed to 100cc/k/d. Infant now receiving 43cc q4hrs\ngavaged over 50mins. D/S stable. No spits. Max asp 1.8cc\nslightly green tint. Fellow assessed. Abd soft, +, no\nloops. AG stable. Refed asp and cont'ed with feeds. Infant\nwent to breast x2 today. 1st attempt did well for ~10mins,\nmore consistent latch and suck. 2nd attempt infant was more\ninterested in snuggling with Mom. Latched briefly. Voiding\nqs. Stooled x2 heme negative. A: tol'ing feeds P:Cont to\nmonitor tol to feeds. Follow wt and exam.\n\n#3: Temps stable in an air isolette. Infant can be fiesty\nat times. Sleeps best when nested within boundaries. Will\nalso settle with pacifier, containment and holding. Fonts\nsoft/flat. Brings hands to face. Loves to kangaroo. MAE. A:\nAGA P:Cont to support dev needs.\n\n#4: Parents in for both cares thus far. Mom and\n this am. Better this afternoon. Mom has been d/c'ed\ntoday, but parents are staying in Parent Room overnight. Mom\nmet with LC this am and worked on breastfeeding. LC gave Mom\nnipple . See LC note for details. Parents\nparticipating in cares. Both updated. Both held infant\ntoday. A: Involved, loving family P:Cont to support and\neducate.\n\n#6: Jaundice. Tol'ing full feeds. Voiding and stooling.\nConts under single phototherapy with eye shields on. A:\nhyperbili P:Cont with phototherapy as ordered. Check bili\nlevel in am.\n\n#7: NB rash noted over trunk, face and extremities. Team\nassessed. Right foot noted to have several lesions on it.\nLesion on top of foot has opened pink center with scabbed\nyellow edges. Small amt of serous drainage noted on dsg x1\nfrom that area. No bleeding noted. No edema noted. Other\nscabs intact. Triple antibiotic ointment applied and covered\nwith Telfa dsg.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884780,
"text": "NPN 7a-7p cont'ed\n\n7 Skin:\n\n#7cont'ed: Team assessed lesions today. Foot warm to touch\nwith nml pulses. A: healing skin lesions P:Cont with dsg\nchange 3 times a day. Monitor.\n\nREVISIONS TO PATHWAY:\n\n 7 Skin:; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884781,
"text": "NICU Infant CPR Class Note\n\nO: Both parents present for infant CPR class at 1800. Watched video and demostration of infant CPR and relieving choking maneuvers by this RN. Both parents practiced on the manikin and were able to demonstrate proper techniques. Reviewed \"Back to Sleep\" brochure and gave to parents. Also gave CPR poster and handout. All questions answered. Both parents stated that they understood all teaching and had no further questions. Class concluded at 1900.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884769,
"text": "NPN 0700-1900\n\n\nResp: Infant received on CPAP 6 with FiO2 21%, weaned\ninfant to RA at 1130. SpO2 89-98%. RR 30s-60s. LS cl/=.\nMild SC retractions. 2 bradys thus far (see flowsheet for\ndetails). P: Cont to monitor resp status.\n\nFEN: TF increased today to 80cc/kg/day. D10W with 2&1\ninfusing at 20cc/kg/day via PIV in left hand without\nincidence. Enteral feeds increased to 60cc/kg/day of\nBM/SC20 = 26cc q4hrs. Plan to advance enteral feeds by\n15cc/kg/day . Will check DS at 1700. Abd soft, full,\n+BS, no loops. AG stable. 3.6 bilious asp at 0900, NNP\naware, discarded asp. No spits. Voiding (see flowsheet for\nu/o this shift). Lg mec stool x1. P: Cont to support\nnutritional needs.\n\nG/D: Temps stable, nested on servo warmer. Infant is a&a\nwith cares. Irritable at times. Appropriately brings hands\nto face and sucks pacifier to comfort self. AFSF. AGA.\nTripple abx oint TID to right foot infiltrate. P: Cont to\nsupport dev needs.\n\nSocial: Mom in for all cares today. Updated on infant's\ncondition and plan of care by this RN. Loving, invested\nparents. Asking appropriate questions. Family meeting\ntoday at 4pm. P: Cont to update & support NICU family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884770,
"text": "Family Meeting\nMet with parents in the family room today. Mother to be discharged home tomorrow. See family meeting checklist for issues discussed. Parents asked many questions that were answered to their apparent satisfaction. Seemed to have a good understanding of the issues. Pedi is .\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-26 00:00:00.000",
"description": "Report",
"row_id": 1884844,
"text": "1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\nequal, no retractions seen. No oximetry. Currently on spell\ncountdown, possible discharge tomorrow on day . Continue\nto monitor respiratory status.\n\n2. FEN-Infant is on adlib po demand schedule of BM 24 with\n powder. Infant bottling 45cc's this morning with Playtex\nnurser and breastfeeding with mom this afternoon. Eager\nbottler and breastfeeder. Abd soft. Voiding and stooling\nheme negative. No spits. Destitin applied to bottom with\neach diaper change. Continue to encourage po feeds.\n\n3. DEV-Infant has stable temperatures swaddled in OAC.\nWaking q3-3.5 hours to be feed. and active during\ncares, resting well in between. Continue to support\ndevelopmental needs.\n\n4. PARENT-Mom and dad in this afternoon. Loving towards\ninfant and independent with cares. Made pedi appt for \non Monday due to holiday. Excited for possible discharge\ntomorrow. Continue to educate and support .\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-26 00:00:00.000",
"description": "Report",
"row_id": 1884845,
"text": "NPN\n\n\nI have examined the infant and agree with the above note\nwritten by PCA.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-27 00:00:00.000",
"description": "Report",
"row_id": 1884846,
"text": "#2FEN\nWt 2.725 up 20g. Baby waking q4h to bottle. Bottled 70/75cc\nwith playtex bottle. Void and stooling. Stool heme neg. No\nspits. Abd soft, active bowel sounds. Desitin applied to\ndiaper area.\nA. Tol feed and gaining weight\nP. Cont to monitor tol to feed\n#3Dev\nTemp stable in an open crib. Waking for feeds\n#4Parent\nNo contact this shift\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-27 00:00:00.000",
"description": "Report",
"row_id": 1884847,
"text": "Neonatology Attending\n\nDay 18 PMA 37 0/7 WKS\n\nRemains in RA. RR 30-60s. Had 6.5 seconds heart rate drop seen on pneumocardiogram yesterday that was quickly self-resolved. No murmur. HR 140-170s. BP mean 46. Pink. Weight 2725g (+20). On BM 24 with formula powder. Took 124 ml/kg. Occasional choking with feeds. Benign abdomen. Passing heme negative stools. Waking every 4 hours. Passed hearing screen and car seat position study.\n\nDoing well overall. Feeding well and gaining weight. Heart rate drop not clinically significant so ready for discharge. Appointment with primary pediatrician on Monday. Discharge summary pending. Will update pediatrician.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-27 00:00:00.000",
"description": "Report",
"row_id": 1884848,
"text": "Exam Note\nGEN - NAD, active\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+S2, no M\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2 sec\nNEURO - MAE, reactive, +grasp/suck/moro,\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-27 00:00:00.000",
"description": "Report",
"row_id": 1884849,
"text": "NPN 0700-\n\n\n2. Infant on ad lib demand feeds of BM24 with powder.\nWaking Q3-4hr and taking 50cc and 80cc thus far. Bottles\nwith playtex fast flow nipple. Abdomen benign. Voiding and\nstooling; heme negative. Ferinsol and Multivit. given.\nTolerating all bottles without spits. Plan to D/C home this\nafternoon.\n\n3. Temp stable swaddled in open crib. Waking for feeds as\nnoted above. Rest well inbetween cares. MAE, brings hands\nto face and mouth. Suckles well on pacifier. AGA. To be\nd/c'd later today.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-27 00:00:00.000",
"description": "Report",
"row_id": 1884850,
"text": "NPN discharge note\nVSS, exam benign; see flowsheet for details. Reviewed NICU D/C instruction form with . Infant D/C home with in car seat. Breast milk given to .\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884763,
"text": "NPN\n\n#1 S. O. Received infant on a cpap of 6 with fio2 21% to\n23%. Breath sounds clear and equal with subcostal\nretractions noted. R.R.30's to 70's. O2 sats 94 to\n98%.There have been no a's or b's noted at this time. A.\nInfant with a hx of respiratory distress. P. Discuss with\nteam in the am regarding plan for trial off of cpap.\n\n#2 S. o. Weight down 45 grams. Voiding with 24 hour urine\noutput 1.6cc/kg/hr. Infant passed trace mec stool. Piv of\nd10w with lytes infusing well via left hand piv. Total\nfluids = 60cc/kg/day. Right foot infiltrate site pink/red\nwith no drainage noted.Right foot elevated. Infant had a\n1.4cc bilious aspirant at the 0100 care. Abdomen softly\ndistended with good bowel sounds and no loops. NNP\nnotified.Aspriant discarded. Feeds not advanced at that\ntime. A. ? bilious aspriant related to slow gastric\nmotility. P. Monitor closely. Assess for advancemnet on\nfeeds at the next care.\n\n#4 S. O. Parents in for the 2100 care. Parents updated by\nthis R.N. at the bedside. A. Loving parents. P. Support\nand keep updated.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884764,
"text": "5 ID\n\nREVISIONS TO PATHWAY:\n\n 5 ID; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884765,
"text": "Neonatology Note\n3 d.o\non CPAP + 6 this am and wean to RA now\n2 spells this am, self resolved.\nwt= 2405 gm -45\nTF at 60 ml/kg/d with IV and feeding at 45 ml/kg/d with EBM/SC 20, 2 aspirates noted\nvoiding(+), bm(+)\n141/6.4/110/21\nbili=9, under phototherapy\n\nA: twin #1, ex 34 wks GA, resolving RDS, hyperbilirubinemia, R foot infiltration resolving\nP: continue advancing feeding and monitor tolerance, monitor spell, f/u bilirubin\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884771,
"text": "NPN Noc\n\n\n#1 Resp: RA, 30-60's, c/=, mild SC retrac. No spells so far\nthis shift. P: Cont to monitor resp status.\n#2 FEN: TF=80cc/kg, infant currently on full feeds, BM/SC20.\nPo/pg feeding, infant took 14cc po x 1. Abd benign, AG 26,\nV/S, mec stooling. P: Cont to monitor FEN status.\n#3 G&d: Temp stable in air isolette, nested. Alert, active,\nand sl irritable with cares. Enjoys his pacifier, MAE, opens\neyes, AFSF. IV infiltrate to right foot, triple abx ointment\napplied and wrapped in sterile gauze. Area is sl swollen,\nsmall scabs surrounding small open area on top of foot. P:\nCont to monitor and support G&D, cont with triple abx to\nright foot breakdown.\n#4 Parents: Parents in for eve caretimes. Mom participated\nin cares, briefly held infant. Asking appropriate questions.\nP: cont to encourage parental calls and visits.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884772,
"text": "NPN Noc\n#6 Bili: Infant appears jaundiced, cont on single spotlight phototherapy. P: Cont phototherapy, will check bili on Thurs AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884773,
"text": "6 Alt in Bili\n\nREVISIONS TO PATHWAY:\n\n 6 Alt in Bili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-13 00:00:00.000",
"description": "Report",
"row_id": 1884774,
"text": "NNP Physical Exam\nPE: pink, AFOF, breath sounds clear/equal with easy WOB, no murmur, well perfused, abd soft, full, + bowel sounds, e tox rash, right foot wound from IV infiltrate with moist scab, does not look infected, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-25 00:00:00.000",
"description": "Report",
"row_id": 1884837,
"text": "NPN 0700-1500\n\n\n#2 O: Infant remains feeding ad lib amounts of BM24 made\nwith similac powder. Bottling 60cc's. Abdomen round and soft\nwith + BS. Voiding and stooling. No spits. A: Tolerating\nfeeds. P: Cont to monitor.\n\n#3 O: Maintaining temp in oac; cobedding with twin. Awake\nand with cares; sleeping well between. AFSF. Swaddled\nin blanket; brings hands to face for comfort and sucks on\npacifier. A: AGA. P: Cont to support development.\n\n#4 O: Both in to visit. Asking appropriate\nquestions. Reviewing d/c teaching for sibling. Mom\nbreastfeeding while here and pumping. Plan to take other\ninfant home this afternoon. A: Involved, loving. P: Cont to\nsupport and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-25 00:00:00.000",
"description": "Report",
"row_id": 1884838,
"text": "Rehab/OT\n\nMet at the bedside. Reviewed back to sleep protocol and activities birth through one worksheet. Discussed SIDS precautions and EI qualifications. No further in house needs. D/C OT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-25 00:00:00.000",
"description": "Report",
"row_id": 1884839,
"text": "Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no M\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2\nNEURO - MAE, reactive\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-26 00:00:00.000",
"description": "Report",
"row_id": 1884840,
"text": "Nursing Progress Note 1900-0700\n\n\nF/E/N:Infant cont's on Ad lib demand schedule waking q 4\nhrs.TF over 24 hrs 122cc's/kg/day.Infant bottling with a\nPlaytex nipple and taking 70-90cc's q time.Weight=2.705 up\n25 grams.Abd. soft with pos bs,no loops or spits.Voiding and\nstooling heme negative stool.\n\nG/D:AF soft and flat. and active with cares.Sleeping\nwell b/t.MAE.Bringing hands to face and mouth.Sucking\nintermitently on pacifier.Infant presently swaddled in open\ncrib.Temp. stable.\n\nParenting:Mom called x 1.Updated by this RN.Asking\nappropriate questions very loving and invested.Other twin at\nhome per mom and doing well.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884766,
"text": "NNP Physical Exam\nPE: exam this am while on CPAP. pink, jaundiced, AFOF, CPAP prongs in place, breath sounds clear/equal with easy WoB, no grunting, good air entry, no murmur, well perfusion, abd soft, non distended, non tender, active bowel sounds, IV infiltrate right foot with superficial scabs on dorsum of the foot, no redness or drainage, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884767,
"text": "NPN 0700-1900\nBili: Bili this am was 9.0/0.4, down from 9.6/0.3. Infant remains under single phototherapy wtih eye shields on. Plan to recheck bili am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884768,
"text": "Respiratory Care Note\nBbay Boy I was weaned from +6 to +5 prong CPAP this am and then was taken off CPAP at noon. Placed in RA. BS clear. RR 30's-60's. No bradys noted since he has been off CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-24 00:00:00.000",
"description": "Report",
"row_id": 1884832,
"text": "NPN Days\n\n\n#1 Pt has had no spells so far this shift. Pt day \nof spell count down. P- Will cont to monitor resp status.\n#2 Pt ad lib demand. BM24 with powder. all po\nfeeds. Took 70cc this am and BF well while were\nvisiting. abd benign. voiding and stooling. no spits. P-\nWill cont to monitor FEN.\n#3 G&D- Temp stable in open crib. cobedding with sibling.\n and active with cares. irritable at times. sucking on\npacifier. using playtex bottle with fast flow nipple to\nfeed. P- Will cont to monitor G&D.\n#4 Mom called x1 this am. updates given. Both\n visiting @1300. Participating in cares. feeding pt.\nDC teaching done with both re: carseat safety,\nfeeding, bowel and bladder, back to sleep. declined\ncirc. P- Will cont DC teaching.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-24 00:00:00.000",
"description": "Report",
"row_id": 1884833,
"text": "NPN Days\naddendum:\n Pt passed hearing screen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-24 00:00:00.000",
"description": "Report",
"row_id": 1884834,
"text": "Neonatology Attending\nDOL 15 / PMA 36-4/7 weeks\n\nIn room air with no apneas/bradycardias in 2 days.\n\nNo murmur. BP 68/41 (51).\n\nWt 2655 (+35) on ad lib with intake 119 fcc/kg/day BM24 in addition to breastfeeding well. Abd benign. Voiding and stooling normally (heme negative). On iron.\n\nTEmp stable in open crib. Hepatitis B immunization administered.\n\nA&P\n34-3/7 week GA infant with resolving respiratory immaturity\n-Continue to monitor until free of apnea/bradycardia for at least 5 days prior to discharge home\n-Discharge planning in progress\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-25 00:00:00.000",
"description": "Report",
"row_id": 1884835,
"text": "NPN/1900-0700\n\n\n#2 FEN: Wt 2680, ^25gms. Ad libe demand feeding, BM24.\nTaking all po's; bottled 149cc/k + breastfeeding this\nprevious 24hrs. Taking 60-80cc Q4hrs. No spits. Abd. exam\nbenign. V/S. Cont. to support nutritional needs.\n#3 DEVELOPMENT: Swaddled in oac; cobedding with twin. Temps\nstable. Active/ w/ cares; sleeps well b/t. Wakes on\nhis own Q3.5-4hrs to feeds. Sucks on pacifier. MAE/AFOF.\nAGA. Support developmental needs.\n#4 : visiting during the day shift; no\ncontact over .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-26 00:00:00.000",
"description": "Report",
"row_id": 1884841,
"text": "Neonatology Attending\n\nDay 17 PMA 36 wks\n\nRemains in RA. RR 50-70s. Clear breath sounds. Day without bradycardia. No murmur. HR 140-160s. BP mean 54. Weight 2705 g (+25). On ad lib demand. On BM 24 with formula powder. Benign abdomen. Passing heme negative stool. On iron. Waking for feeds. Stable temperature in open crib. Passed hearing screen and car seat study.\n\nDoing well overall. Will continue to monitor closely. Feeding well and gaining weight. Will be ready for discharge tomorrow if remains spell-free.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-26 00:00:00.000",
"description": "Report",
"row_id": 1884842,
"text": "Lactation Consult\nMet w/ family @ 1pm to assess infant latch. Baby latched on beautifully w/ nipple having frequent audible swallows and milk present in . Mom held infant by football hold and is pleased w/ feeding. plan to nurse infants at home following up w/ bottles of 24cal breast milk. Advised to monitor baby's voids and stools at home and assess for swallows at the breast.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-26 00:00:00.000",
"description": "Report",
"row_id": 1884843,
"text": "Exam Note\nGEN - NAD, active and \nHEENT - AFSFO, oropharynx clear\nCV - RRR, nl s1+s2, no M, fem pulses 2+ bilat\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash, stool present\nNEURO - MAE, reactive\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-25 00:00:00.000",
"description": "Report",
"row_id": 1884836,
"text": "Neonatology Attending\n\nDay 16 PMA 36 wks\n\nRemains in RA. RR 40-70s. Clear breath sounds. No bradycardia- day . No murmur. HR 150-160s. Pink. BP mean 59. Weight 2680g (+25). Ad lib BM 24 with formula powder. Taking 60-80 ml per feed- 149 ml/kg total- and breast feeding. Passing heme negative stool. Feeding tube out. No spits. Stable temperature in open crib. independent with care.\n\nDoing well overall. Maturing breathing control. Will continue to monitor closely. Needs 2 more days spell-free. Received hepatitis B vaccine. Passed hearing screen. Will speak with mother this morning.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-22 00:00:00.000",
"description": "Report",
"row_id": 1884819,
"text": "#1Resp\nLungs clear with mild retractions. No spells. Appears\ncomfortable\n#2FEN\nWt 2.615 up 30g. Baby has bottled entire volume at 2100 and\n0100. Abd soft, active bowel sounds. Void and stooling. One\nsmall wet burp. Min asp. Cont to receive BM24.\nA. Tol feed and gaining weight\nP. Cont to monitor tol to feeds as well as weight gain.\nEncourage po feed ability\n#3Dev\nWaking for feeds. Maintaining temp in crib. Interested in\nbottling\n#4Parent\nno contact so far.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-22 00:00:00.000",
"description": "Report",
"row_id": 1884820,
"text": "Cafe spot noted on R side of forehead.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-22 00:00:00.000",
"description": "Report",
"row_id": 1884821,
"text": "Neonatology Attending Note\nDay 13, PMA 36 2\n\nRA. RR40-60s. Mild intermittent sc retractions. No A&Bs. No murmur. HR 130-150s. BP 86/44, 56. Wt 2615, up 40 gms. TF 150 BM24. Just transitioned to all PO last night. Nl voiding and stooling. In open crib.\n\nA/P:\nGrowing preterm infant with improving PO skills. If continues to do well with PO feedings will plan for discharge Monday. PO feedings q other BF. Monitor weight with this suppl plan.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-22 00:00:00.000",
"description": "Report",
"row_id": 1884822,
"text": "Exam Note\nGEN - calm, NAD\nHEENT - AFSFO, oropharynx clear, NGT out of nose, nares intact\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no M\nGU - nl male ext genit, no rash\nEXT - wwp, cr < 2 sec, dorsum c/d/i\nNEURO - MAE, reactive\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-22 00:00:00.000",
"description": "Report",
"row_id": 1884823,
"text": "Case Management Note\nReferral called to Care Group VNA today (/fax ) and have made home visit for Wednesday . Team anticipates home d'c Monday . If this date needs to be chnaged, please call VNA to reschedule. All in agreement w/plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-09 00:00:00.000",
"description": "Report",
"row_id": 1884745,
"text": "Admission Note\nNeonatology Admission H&P\n\nBaby is a newborn 34 wk twin infant admitted to the NICU with prematurity and respiratory distress.\n\nHe was born at 12:30 am this morning as the 2575 gram product of a 34 wk twin gestation pregnancy to a 28 y.o. G1 P0-2 mother with . Prenatal labs included BT A+/Ab- and GBS unknown; remainder were unavailable at time of delivery but were reportedly negative. Pregnancy was IVF-assisted di/di twin gestation, and was reportedly unremarkable until when mother presented to PMD for evaluation of URI symptoms and was found to be hypertensive. She was sent to , and was also found to have proteinuria and elevated uric acid, consistent with preeclampsia. BPP was . With relatively advanced gestational age, delivery was recommended. Last EFW on was 2289; concordant growth was noted throughout pregnancy.\n\nFamily history and social history are otherwise non-contributory.\n\nInfant was born via c-section for twin gestation. At delivery, twin A emerged with moderate tone and good cry, with Apgars . He required blow-by oxygen for duskiness with gradual improvement, and was brought to NICU with moderate work of breathing noted.\n\nPhysical Exam:\nWt 2575 gm (75-90%) HC 32 cm (50-75%) L 48 cm (75-90%).\nVS: T 97.7, HR 160s, RR 50s, O2sat 80s in RA, 90s with O2, BP pending.\nGen: WD premature infant, moderate resp distress, active and vigorous, overall appearance consistent with EGA.\nSkin: warm, dry, pink with oxygen, no rash.\nHEENT: fontanelles soft and flat, ears/nares normal, palate intact with mildly high arch, +RR bilaterally.\nNeck: supple, no lesions.\nChest: coarse, poorly aerated, + g/f/r.\nCardiac: RRR, no m, femoral pulses 2+.\nAbdomen: soft, quiet BS, no mass, no HSM, 3VC.\nGU: normal male, testes palpable bilaterally, anus patent.\nExt: hips/back normal, no lesions.\nNeuro: appropriate tone, activity, intact moro/grasp.\n\nIMP: Newborn 34 wk twin, delivered secondary to maternal preeclampsia, currently with moderate respiratory distress likely secondary to RDS. Low risk of sepsis given circumstances of delivery.\n\nPLANS:\n- Admit NICU.\n- Monitor resp status closely, likely will need CPAP.\n- O2 as needed.\n- CXR, ABG if resp status worsens.\n- Consider intubation/surfactant if FiO2 high or worsening respiratory distress or hypercarbia.\n- Monitor hemodynamics.\n- NPO, maintenance IVF.\n- Periodic monitoring of dstiks, lytes, bilirubin.\n- CBC with diff, blood cx.\n- Low threshold for abx as pneumonia cannot be ruled out given respiratory distress.\n- Thermoregulatory support on warmer.\n\nParents updated in delivery room.\n\nPMD: , .\nOB: , delivered by .\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-09 00:00:00.000",
"description": "Report",
"row_id": 1884746,
"text": "Admission Note\nHep B: Maternal HBsAg resent. Will give HBV if results not available by 12 hrs of life.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-09 00:00:00.000",
"description": "Report",
"row_id": 1884747,
"text": "Respiratory Care\nSee attending and nursing admit notes for hx and further details. Infant GFR on arrival to NICU. Given facial CPAP then placed on prong CPAP 6. BS diminished. 02 req on CPAP 26-30%. CXR done to assess lung fields. Persistant grunting on CPAP, subcostal retractions. CBG: 7.28/47/45/23/-4. RR 30's-60's. Grunting significantly improved, presently intermittent. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-21 00:00:00.000",
"description": "Report",
"row_id": 1884813,
"text": "npn 1900-0700\n\n\n1: resp\nremains in ra. no spells and no dsats. lung sounds clear and\nequal. mild subcostal retractions. no increased wob noted.\nrr 40-70's. sats >97%. continue to monitor for changes in\nrespiratory status.\n\n2; fen\ncurrent weight 2560 gms up 20. total fluids remain at\n150cc/kilo/day of bm24 cals tolerating feeds well. no spits,\nminimal aspirates. voiding and stooling. stool hem negative.\n\nabd soft with no loops. infant continues on iron. infant\npo'd 20cc's at 2100 and then 50cc at 0100. infant waking\nfor both cares. remainder of volume gavaged. continue with\ncurrent feeding plan.\n\n3: growth and development\ntemps stable in an oac. alert and active with cares. sleeps\nwell inbetween. brings hands to face. sucks vigorously on\npacifier. wakes for feedings. aga. continue to monitor for\ndevelopmental milestones.\n\n4; \nno contact thus far this shift from \n\n6: \ninfant currently off of phototherapy. sent this shift\npending. continues to be jaundiced in color. continue to\nfollow .\n\n7: skin\ninfant continues on triple antibiotic ointment to right\nfoot. infant's right foot with scabbing from old infiltrate\nsite. no drainage or bleeding noted. continue with current\nplan of care.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-20 00:00:00.000",
"description": "Report",
"row_id": 1884809,
"text": "I have examined and agree with the above note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-20 00:00:00.000",
"description": "Report",
"row_id": 1884810,
"text": "Neonatology Attending Note\nDay 11, PMA 36\n\nRA. Cl and = BS. No A&Bs. +murmur. HR 140-160s. BP 67/37, 47. Under photot. Bili 6.5/0.2. Wt 2540, up 70. TF 150 BM24. PO/PG. Tol well. Nl voiding and stooling. In air isolette.\n\nA/P:\nGrowing preterm infant learning how to po feed. Will begin Fe. d/c photot and check reb bili in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-21 00:00:00.000",
"description": "Report",
"row_id": 1884814,
"text": "Neonatology Attending Note\nDay 12, PMA 36 1\n\nRA. RR40-70s. CL and =. No A&Bs. No murmur. HR 130-150s. BP 67/45, 53. 6.5/0.2 (reb). Wt 2560, up 20 gms. TF 150 BM24. po/pg. Nl voiding and stooling. On Fe. Co-beeding in open crib.\n\nA/P:\nGrowing preterm infant awaiting maturation of feeding abilities.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-21 00:00:00.000",
"description": "Report",
"row_id": 1884815,
"text": "PCA Progress Note \nI agree with the above PCA note and have assessed the pt. see flowsheet for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-21 00:00:00.000",
"description": "Report",
"row_id": 1884816,
"text": "PCA Progress Note \n\n\n#1 RESP: Infant remains in room air breathing 50-60s with\nmild subcostal retractions. LS clear/equal, oximetry d/c'd\nthis morning. No spells this shift. Breathing comfortably in\nroom air. Continue to monitor respiratory status.\n\n#2 FEN: TF 150cc/kg/day BM24. 64cc q4hours. Infant finished\nwhole bottle this morning, then breast fed with mom at \ncares and half volume bottle. Uses Playtex\nbottle/nipple. Abd benign, no loops, +BS. No spits, minimal\naspirates. Voiding and stooling heme neg. Tolerating feeds.\nContinue to encourage POs.\n\n#3 DEV: Stable temps swaddled cobedding with twin brother.\n and active with cares, sleeping well between and\noccasionally waking early. MAE. AFSF. Brings hands to face,\nenjoys pacifier. AGA. Continue to support developmental\nneeds.\n\n#4 SOC: Mom in for cares. Independent with son. Updated\nat bedside by RN. Asking appropriate questions. Loving\nfamily. Continue to update and support.\n\n#6 : Photo tx has been off since morning of 15th. \nfrom last night 6.5/0.3, remaining the same as the day\nbefore. Infant slightly jaundiced/well perfused. Continue to\nmonitor.\n\n#7 SKIN: Scab on right foot from IV infiltration healing\nwell. Triple antibiotic applied, then d/c'd this morning.\nContinue to monitor.\n\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-20 00:00:00.000",
"description": "Report",
"row_id": 1884811,
"text": "NPN 7a-7p\n\n\n#1 Resp: Infant in room air w/resp rate 40s-70s and sat\n97-100%. Lung sounds cl/= and mild SC retractions. No spells\nso far this shift. A: Infant stable in room air w/no spells.\nP: Cont to monitor.\n\n#2 FEN: TF 150 cc/kg of BM 24 (64 cc q4h gavaged over 50\nmin). Po/pg. Infant bottled 52 cc @ 0900 cares w/remaining\nvolume gavaged. BF well for 20 min @ 1300 cares and was\nsupplemented with half volume gavage. No spits, min asp.\nAbdomen round, pink, and soft w/active bowel sounds and no\nloops. Voiding and stooling heme neg. Now on iron. A: Infant\nimproving with po feedings and is well coordinated. P: Cont\nw/current plan and encourage po feedings as tol.\n\n#3 Dev: Received infant nested in air isolette. Infant now\nswaddled in an open crib, cobedding with brother. \nstable. Alert and active during cares and sleeps well in\nbetween. Wakes early for most feedings. Periods of quiet\nalert. A: AGA. P: Cont to supp dev needs.\n\n#4 : Mom in @ 1300 and was updated. Mom took temp,\nchanged diaper, and BF infant. A: Independent and\nappropriate w/cares. P: Cont to supp and update. Plan to\nprovide bath and teaching @ 1700 cares.\n\n#6 : Photo rx d/c @ 1030. A: Infant appears jaund. P:\nCont off photo rx and plan to check am.\n\n#7 Skin: Infant cont triple antibiotic ointment to scabbed\narea on R foot on old IV infiltrate site. No redness or\ndrainage noted.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-20 00:00:00.000",
"description": "Report",
"row_id": 1884812,
"text": "Exam Note\nGEN - calm, NAD\nHEENT - 15-20 blanchable erythematous macules 3-5mm in diameter on face, no excoriation or secondary infection, c/w erythema toxicum. Otherwise, AFSFO, oropharynx clear, NGT w/o breakdown\nCV - RRR, nl s1+s2 no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nEXT - wwp, R foot c/d/i, cr < 2 sec\nNEURO - reactive, MAE\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-11 00:00:00.000",
"description": "Report",
"row_id": 1884759,
"text": "NPN 0700-1900\n\n\nResp: Infant remains on CPAP 6, FiO2 24-27%. RR 30s-50s.\nLS cl/=. Mild SC retractions. No A's or B's thus far. P:\nCont to support/monitor resp status.\n\nFEN: TF 60cc/kg/day. D10 with 2Na & 1K infusing via left\nhand PIV at 30cc/kg/day. Right foot PIV infiltrated at 0900\nwith excoriated skin d/t tape noted; NNP aware & right foot\nelevated and left OTA. Enteral feeds started today at\n30cc/kg/day of BM/SC20 = 13cc q4hrs. Plan to increase\nenteral feeds by 15cc/kg/day at 1a &1p. DS 74 at 1100.\nAbd full, soft, +BS, no loops; no spits. AG 27. u/o\n1.2cc/kg/hr thus far. No stool. Lytes this am were\n143/4.6/108/22. P: Cont to support nutritional needs.\n\nG/D: Temps stable, nested on sheepskin with boundaries in\nplace on open warmer. Infant is a&a with cares. Irritable\nat times, settles well when left alone. Appropriately\nbrings hands to face & sucks pacifier to comfort self.\nAFSF. AGA. P: Cont to support dev needs.\n\nParents: Mom in for 0900 cares. Speaking lovingly to\ninfant. Updated on infant's condition and plan of care.\nAsking appropriate questions. P: Cont to update & support\nNICU family & plan for family meeting tomorrow at 4pm.\n\nID: IV abx d/c'd. Problem resolved at this time.\n\nBili: Bili this am was 9.6/0.3, up from 1.7/0.3 Infant\nplaced under phototherapy lights at 1130. Infant is\njaundice. Plan to recheck bili in the am. P: Cont to\nmonitor bili status PRN.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-11 00:00:00.000",
"description": "Report",
"row_id": 1884760,
"text": "NP NOTE\nPE: well developed preterm infant swaddled in open warmer. PInk, jaundiced in RA CPAP. Edematous.\nAFOF sutures approximated, eyes clear, puffy, nares patent with prongs in place, MMMP, white, frothy secretions\nChest is clear, fair exchaneg, mild SCR. Fair exchange, shallow.\nCV: RRR, no murmur, pulses+2=\nAbd: soft, active bs cord dry\nGU: testes ins crotum\nEXT: PIV in left hand, right foot edematous with IV infiltrate.\nNeuro: active, responsive. Flexed posture, good tone, symmetric reflexes.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-11 00:00:00.000",
"description": "Report",
"row_id": 1884761,
"text": "Respiratory Care\nPt cont on prong CPAP. Fio2 .24-.27. bs clear, rr 50-70 with mild retractions. On caffeine. No spells. Plan to support as needed. Consider trial off in near future. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-12 00:00:00.000",
"description": "Report",
"row_id": 1884762,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 21-24%. RR 30-70's Breath sounds are clear. Stable on CPAP cont to follow. Plan to wean off CPAP soon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-23 00:00:00.000",
"description": "Report",
"row_id": 1884827,
"text": "Neo Attending note\nday 14, now 36.3 wk pma\nwt 2620, up 5 gm.\nCV: no murmur, hr 150s, bp 63/40, 48j\nrespr: ra, rr 3040s, clear=bs, 1qsr brady with apnea / periodic breathing. Thus countdown restarts today = D 0/5.\nTF: 150 cc/kg/day. BM24 all po + BFx2 per day. BF well.\nuop and stool wnl, heme neg.\nabd wnl. 7.5 stable. no spits.\ntemp stable in crib. State Newborn screen sent. HepB immunization today.\nCar seat: wait until bradycardia have continued to improve.\nhearing screen pending, pending.\n\nassessment: due to brady/apnea/periodic breathing, infant will continue CVR monitoring with oximeter.\notherwise assement is as noted above.\nPlan: as noted above.\n\nPt evaluated and discussed with team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-19 00:00:00.000",
"description": "Report",
"row_id": 1884807,
"text": "1. RESP-Infant is in RA with RR 30-60's. Lungs are clear and\nequal, mild subcostal retractions seen. O2 sats are >97%. No\nspells so far this shift, last one on . Continue to\nmonitor respiratory status.\n\n2. FEN-TF=150cc/kg of BM/SC now 24 or 64cc q4hrs PO/PG.\nInfant offered bottle at 0900 care, bottled 18cc's using\nPlaytex bottles. Eager bottler at first but tires easily.\nMom put infant to breast at 1300, infant latched and\nbreastfed for about 10 minutes. Infant asleep for third care\nand mom was unable to put to breast. Full feed gavaged\nafterward over 50 minutes. Abd benign. Voiding and stooling\nheme negative. No spits. Minimal aspirates. Continue to\nencourage po feeds as tolerated by infant.\n\n3. DEV-Temperatures stable in air isolette under neoblue\nlight. Wakes occassionally for cares. Alert and active\nduring first two cares, asleep with last care. Continue to\nsupport developmental needs.\n\n4. PARENT-Mom in afternoon. Updated by RN. Loving towards\ninfant, independent with care. Continue to educate and\nsupport .\n\n6. BILI-Infant remains under neoblue with eye shields in\nplace and slighly jaundiced in color. Yesterdays bili was\n12.3 (0.3). Bili to be rechecked in am. Continue to monitor\nbili.\n\n7. SKIN-Infants right foot continues to heal, small scab\npresent. Triple antibiotic ointment applied as ordered by\nRN. Continue to monitor skin integrity.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-20 00:00:00.000",
"description": "Report",
"row_id": 1884808,
"text": "PCA Progress Note 1900-0700\n\n\n#1 RESP: Pt. remains in RA breathing in the 40-60s with\nmild subcostal retractions. Lung sounds cl+= bilaterally.\nNo episodes of apnea or bradycardia so far this shift. P:\nContinue to monitor respiratory status.\n\n#2 FEN: Weight: 2540g ^ 70g. Total fluids: 150cc/kg/d of\nBM/SC 24= 64cc Q4hrs PO/PG. Pt. was put to breast @ 2100\nwith +latch and good coordination for > 10minutes, full\nfeeding gavaged. Pt. took 20cc using the playtex nurser @\n0100. Abd soft and round, +BS, no loops. No spits.\nMinimal aspirates. Pt. is voiding, stooling heme neg. P:\nContinue to encourage po feedings as tolerated.\n\n#3 G&D: Temps stable nested in air isolette. Alert and\nactive during cares. Sometimes waking for feedings. Rests\nwell inbetween cares. MAE. AFSF. P: Continue to support\ndevelopmental needs.\n\n#4 Parenting: Mom and Dad in @ 2100. Mom independent with\ncares and breastfeeding. Mom called X 1. Very loving and\ninvolved. Updates given. P: Continue to support and update\nfamily.\n\n#6 BILI: Pt. remains under neoblue lights with eye shields\nin place. Pt. is sl jaundice. Stooling. Last bili:\n12.3/0.3. Bili was drawn this morning, results pending. P:\nContinue to monitor.\n\n#7 Skin: Scab noted on right foot. Healing, no drainage or\nredness noted. Triple antibiotic applied as ordered. P:\nContinue to monitor.\n\nPlease see flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-18 00:00:00.000",
"description": "Report",
"row_id": 1884802,
"text": "Exam Note\nGEN - alert, fussy in air crib under bili lights\nHEENT - AFSFO, oropharynx clear, eye covers intact, NGT w/o breakdown\nCV - RRR, nl s1+s2, no murmur\nABD - soft, NT, NT, no mass\nGU - nl ext genit, no rash\nEXT - wwp, cr < 2 sec\nNEURO - MAE< reactive\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-19 00:00:00.000",
"description": "Report",
"row_id": 1884803,
"text": "NPN 07p-07a\n\n\nRESP\nRA, LS clear & equal with mild subc. retractions. RR30-60's.\nNo spells or desats this shift thus far. Cont. monitor resp.\nstatus.\nFEN\nCurrent weight 2470g (^50). TF 150cc/kg/day, BM/SSC20.\nTolerating well. Gavaged q4hrs/bottled x1 this shift thus\nfar 20cc (coordinated, quickly tiring). BS active. Abd.\nsoft, round. Voiding, stooling heme negative. Cont. monitor\nPO/PG feeding tolerance & weight.\nG&D\nIn air isolette, temps stable. Nested. Alert & active with\ncares. Resting comfortably inbetween. Fontanels soft, flat.\nMAEs. PPPx4ext. Cont. monitor growth & developm. patterns.\n\nMOB updated over phone x1. Loving & caring. Cont. support &\neducate.\nBili\nCont. under neoblue bank, eye shields in place. VS stable.\nAlert & active with cares. Voiding, stooling. Cont. monitor\nfor changes.\nSkin\nCont. with scabbed area on right foot, no redness, drainage\nor swelling noted. Triple antx ointment applied as ordered.\nCont. monitor for changes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-19 00:00:00.000",
"description": "Report",
"row_id": 1884804,
"text": "Neonatology Attending\n\nAdvancing to 24 cals/oz feed. Will discontinue phototherapy.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-19 00:00:00.000",
"description": "Report",
"row_id": 1884805,
"text": "Neonatology Attending\n\nDay 10 PMA 35 wks\n\nRemains in RA. Clear breath sounds. No bradycardia. No murmur. BP mean 45. Weight 2470g (+50). TF at 150 ml/kg/d- BM/SC 20. Bottling 20-30ml per feed. Passing heme negative stool. Stable temperature in air-controlled incubator. Stable temperature.\n\nDoing well overall. Monitoring for apnea. Tolerating feeds well. Gaining weight well. Encouraging po feeds.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-19 00:00:00.000",
"description": "Report",
"row_id": 1884806,
"text": "I have examined baby boy I and agree with the above note written by , PCA.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-10 00:00:00.000",
"description": "Report",
"row_id": 1884754,
"text": "NPN Days\n\n\n#1 Resp: CPAP 6 26-32%. 40-80's with occ increased\ntachypnea, mild SC retrac, LS c/=, with intermittent\ngrunting noted. Occ sat drifts, one spell so far this shift,\nresolved with mild stim and increased 02. P: Cont to monitor\nresp status, will check CBG this eve.\n#2 FEN: TF=60cc/kg D10W infusing via PIV without diff. Abd\nbenign, infant cont to be NPO, V/S, mec stooling. P: COnt to\nmonitor FEN status, check lytes and bili in AM.\n#3 G&D: Temp stable on off warmer, swaddled. Alert and\nactive with cares, occ irritable, given sucrose. Sleeps well\nin between cares. P: Cont to monitor and support G&D.\n#4 Parents: Parents in for cares, participated where able.\nAsking appropriate questions, updated frequently by this RN.\nAppear very loving towards infant. P: Cont to encourage\nparental calls and visits.\n#5 ID: Temp stable, infant acting appropriately. Bld cx NTD,\non Amp and Gent. P: F/u with cxs, d/c'd abx at 48hrs.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-10 00:00:00.000",
"description": "Report",
"row_id": 1884755,
"text": "Respiratory Care Note\nInfant remains on NCPAP +6, 26-32% - BS sl. diminished, RR's 40's-70 with some intermittant grunting - no spells thus far - occasional saturation drifts - continue to monitor - blood gas this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-11 00:00:00.000",
"description": "Report",
"row_id": 1884756,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 23-32%. Breath sounds are clear. RR 40-80's occasional grunting. Stable on CPAP cont to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-11 00:00:00.000",
"description": "Report",
"row_id": 1884757,
"text": "Nursing NICU Note\n\n\n1. REsp. O/ Intermittent grunting noted. Remains on Nasal\nProng CPAP of 6, 21-30% primarily. Please refer to\nflowsheet. NO A/B noted. A/Alt. in REsp status. P/Cont. to\nmonitor resp status and intervene as needed. Murmur noted\nand reported to NNP. A/Resp status remains stable at this\ntime on CPAP. P/Cont. to monitor for evidence of resp\ndistress.\n\n2.F/N. O/ Tf remain at 60cc/k/d of IVF D10 with 2 NaCl/dl\nand 1meq KCL/dl via new PIV. Please refer to flowsheet for\nexaminations of pt from this shift. Remains NPO.\nIntermittently sucking on pacifier.\n\n3. G/D. O/TEmp remains stable swaddled on a warmer. AWake\nand alert at care times and sleeping well in between. A/Alt.\nin G/D. P/Cont. to support pt's growth and dev. needs.\n\n4. Parents. O/Parents into visit last night. Parents updated\non pt's status and plan of care. Father held infant\nswaddled. A/Parents are involved in pt's care.; P/Cont. to\nsupport and educate parents.\n\n5. ID. O/Anitbiotics d/c. NNP stated that she corrected lab\nerror. A/Completion of 48hr r/O. Cont. to monitor for s/s of\n infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-11 00:00:00.000",
"description": "Report",
"row_id": 1884758,
"text": "Neonatology Note\n2 d.o\non CPAP+6, RA-30%O2, no caffeine\nbili= 9.6\nwt= 2450 gm -50\nTF at 60 ml/kg/d, NPO\nvoiding(+), bm(+)\nlytes: 143/4.6/108/22\n\nA: twin #1, 34 wks GA, RDS, sepsis evaluation, hyperbilirubinemia\nP: monitor respiratory staus on CPAP, wean O2 as tolerated, start feeding, start phototherapy, f/u bili.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-22 00:00:00.000",
"description": "Report",
"row_id": 1884824,
"text": "Nursing Progress Note\n\n\n#1 Resp-- O: RA. No spells. HR 160s; HR 50s-60s. Color\npink/sl jaund. BS clear and =, mild sc ret. A: Day 4 of 5 P:\nCont to monitor vitals, document spells\n\n#2 Nutrition-- O: 150cc/kg/d= 65cc BM24- HMF d/c- powder\n4cal/oz started. Po fed well at 0900 taking 70cc., tol well.\nBF x20 min at 1300 well- no supplement after breast. wakeful\nfor long period after feed. NG d/c. Abd exam benign, VQS, sm\nyellow stool x2. Desitin to reddened butoocks (skin intact).\nOn iron. A: Adequate growth, all po x 24h. P: Cont to\nmonitor intake and growth. Plan to supplement BF every other\nBF session with bottle. Switch to pwder 4cal/oz. repeat\nPKU and in am.\n\n#3 Development-- O: and active, waking for feeds.\nHands to mouth, and sucking on pacifier. Temp stable,\nco-bedding with twin. All po feeds. Social with Mom. A: AGA\nP: Cont to support development; Hep B vaccine tonight\n\n#4 Parenting-- O: Mom in at 1300. Updated re status and\nplan. pleased with progress. Mom upset about baby taking\nfeeding by regular nipple overnight and prefers the Playtex\nNurser. Will bring in car seat ; will decide about\ncirc with dad by called, referral to Caregroup\nwith tentative visit next Wed. Mom to make pedi appt\ntentatively for next Tues with tentative discharge date Mon.\nA: Nearing discharge P: Cont to support and keep informed;\ncont discharge planning- car seat test ; Hep B,\nPKU, & over night.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-23 00:00:00.000",
"description": "Report",
"row_id": 1884825,
"text": "NNP Physical Exam\nAwake and . AFOF with good tone. Breaht sounds clear and equal on RA without retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded wiht active BS, no HSM or masses. Normal GU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-23 00:00:00.000",
"description": "Report",
"row_id": 1884826,
"text": "npn 1900-0700\n\n\n1: resp\nremains in ra. infant has had one spell thus far this shift.\ninfant brady was to 74, apneic, qsr. see flow sheet. lung\nsounds clear and equal. mild subcostal retractions. no\nincreased wob noted. rr 30-40's. continue to monitor for\nchanges in respiratory status.\n\n2; fen\ncurrent weight 2620gms up 5gms. total fluids remain at\n150cc/kilo/day of bm 24 cals with powder. tolerating\nfeeds well. taking all po feeds. infant taking 50cc at 2100\ncare and then 70 with 0100 care. infant tolerating feeds\nwell. no spits. abd soft with no loops. voiding and\nstooling. desitin applied to buttocks. using platex nurser.\ncontinue with current feeding plan.\n\n3: g/d\ntemps stable in an oac. co-bedded with brother. and\nactive with cares. sleeps well inbetween. brings hands to\nface. sucks vigorously on pacifier. wakes for feedings.\naga. continue to monitor for developmental milestones.\n\n4: \nno contact thus far this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-18 00:00:00.000",
"description": "Report",
"row_id": 1884799,
"text": "Neonatology Attending\n\nDay 9 PMA 35 wks\n\nRemains in RA. RR 30-50s. Sats 92-100%. Clear breath sounds. had one bradycardia episode over last 24 hours. No murmur. HR 130-160s. No murmur. BP mean 57. Bilirubin 12.3 (rebound) so palced back under phototherapy. Weight 2420g (+10). TF at 140 ml/kg/d- SC 20. Bottled one feed. Breast feeding for 5-10 minutes. No spits. Minimal aspirates. Stable temperature in air-controlled incubator. Family up to date.\n\nDoing well overall. Minimal respiratory immaturity. Will continue to monitor. Advancing feeds to 150 ml/kg/d. Exaggerated physiologic hyperbilirubinemia. Will continue on phototherapy.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-18 00:00:00.000",
"description": "Report",
"row_id": 1884800,
"text": "Social Work\n\n\nMet with mother while in visiting with babies today.\nMother feeling overwhelmed today. She states that she gets here in the morning and styas for the whole day as she wants to be here for all of the babies feedings.\nTalked with her about cutting back on the amount of time she is here each day, and the importance of having some time for her to rest and pump. Really encouraged her to only come in in early afternoon and she can stay until her husband comes in from work and then they can go home together.\nMother states that she has good supports, a lot of help from members of her church who have been bringing in dinners for them. Also a friend has been driving them in to the hospital each day, as the couple do not have a car they live closby in , but public transportation is not direct to the hospital.\nMother's sister will be visiting from over , and her mother in law will come in mid . All extended family members are in State.\nWill plan to check in with mother tomorrow, continue to encourage her to take car of herself and not to be spending the entire day at the hospital.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-18 00:00:00.000",
"description": "Report",
"row_id": 1884801,
"text": "NPN 7a-7p\n\n\n#1 Resp: Infant in room air w/resp rate 20s-50s and sat\n93-100%. Lung sounds cl/= and mild SC retractions. No spells\nso far this shift. A: Infant stable in room air w/no spells.\nP: Cont to monitor.\n\n#2 FEN: TF inc from 140 to 150 cc/kg of BM 20 (64 cc q4h\ngavaged over 50 min). Po/pg. Infant breast feeding w/Mom q\ncares and receiving full gavage volume. Infant BF for 5 min\n@ 0900 but was sleepy with weak suck. Infant awake and eager\nand breast fed for 10 min with good latch and suck @ 1300\ncares. No spits, min asp. Abdomen round, pink, and soft\nw/active bowel sounds and no loops. Voiding and stooling\nheme negative. A: Infant coordinated w/breast feeding when\nawake and eager. P: Cont w/current plan and encourage po\nfeedings as tol.\n\n#3 Dev: Infant nested in air isolette, temp stable. Alert\nand active during cares and sl irritable in between. Settles\nvery well with pacifier and boundaries. A: AGA. P: Cont to\nsupp dev needs.\n\n#4 : Mom in q cares and updated. Mom took temp,\nchanged diaper, and breast fed infant. A: Independent and\nappropriate w/cares. P: Cont to support and update.\n\n#6 Bili: Infant cont neoblue photo rx with eye shields for\nbili of 12.3/0.3 this am. A: Infant appears jaund. P: Cont\nphoto rx and check bili .\n\n#7 Skin: Triple antibiotic ointment applied to old\ninfiltrate/scabbed area on right foot @ 0900 cares.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-17 00:00:00.000",
"description": "Report",
"row_id": 1884797,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining his O2 sats\ngreater than 96%. Lung sounds clear/=. RR 30-50's. Mild\nSCR noted. No A's or B's noted. P: Cont. to monitor resp.\nstatus.\n\n2. FEN: TF remain at 140 cc/kg/day of Bm20. Attempted to BF\nx 2 thus far - latched well. Tolerating NGT feedings well;\nabd exam benign, no spits, min asp. Voiding qs and stooling\nheme neg. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable swaddled in off-isolette. Infant is\nalert/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 suppot developmental\nneeds. P: Cont. to support developmental needs.\n\n4. : in throughout day. Independent with\ncares and handling infants. Updated at bedside on infant's\ncondition and plan of care. Asking appropriate questions.\nLoving, involved . P: Cont. to support and update\n.\n\n5. Bili: Photo was d/c'd on thurs at 10 am for a bili of\n10.6. P: Repeat bili to be drawn in am.\n\n6. Skin - Rt foot infiltrate left open to air. Healing well\nwith triple abx ointment q 12 hours. No drainage, swelling,\nor redness noted. P: Cont. to monitor skin.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-18 00:00:00.000",
"description": "Report",
"row_id": 1884798,
"text": "npn 1900-0700\n\n\n1: resp\nremains in ra. no spells and no dsats. lung sounds clear and\nequal. mild subcostal retractions. no increased wob noted.\nrr 30-50's. sats .925. continue to monitor for changes in\nrespiratory status.\n\n2: fen\ncurrent weight 2420gms up 10. total fluids remain at\n140cc/kilo/day of bm 20 cals. tolerating feeds well. no\nspits. minimal aspirates. voiding and stooling. abd soft\nwith no loops. infant po'd 20cc at 0100. infant po fed based\non feeding cues. continue to encourage po feeds as\ntolerated.\n\n3: growth and development. received infant in an off\nisolette. infant currently co-bedding in a crib with\nsibbling. temps remain stable. alert and active with cares.\nsleeps well inbetween. brings hands to face. sucks\nvigorously on pacifier. brings hands to face. aga.continue\nto monitor for developmental milestones.\n\n6; bili\ninfant color slighlty jaundiced. infant currently off of\nphototherapy. rebound bili sent this shift. will continue to\nmonitor bili closely.\n\n7: skin\ninfant right foot old infiltrate sight with multiple small\nscabs. no drainage noted and no bleeding. triple antibiotic\nointment applied at 2100. continue to monitor for changes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-09 00:00:00.000",
"description": "Report",
"row_id": 1884748,
"text": "Admission Note\nBB admitted to NICU following C/S delivery for PIH. Infant emerged with good cry, dusky and retracting, requiring stim and BBO2 in DR. . on admission, GFR with RA SaO2 mid 80's, placed on CPAP 6 in 26-30% FiO2 to maintain SaO2 89-95. LS sl coarse and diminished, color good, cont with GFR through shift. Cap gas 7.27/45/47. No murmur audible, BP 75/35 mean 45. Labs sent for Bld cx and CBC, antibiotics begun. IV placed in R hand with D10W infusing, initial DS 47, after IVF infusing, DS 74. Abd benign, soft, round, +BS, has voided, no stool, NPO for now. Stable on open warmer, sl irritable with cares, little interest in pacifer. Dad visited briefly, told weights/measures and equipment explained, spoke softly with the babies. A: 34 week infant w/RDS P: cont CPAP/O2 as needed, maintain IVF NPO for now, cont antibiotics as ordered, monitor\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-09 00:00:00.000",
"description": "Report",
"row_id": 1884749,
"text": "Respiratory Care Note\nPt continues on Prong CPAP +6 FIO2 26-28%. B.S. ess. clear with good air entry. Mild retractions and grunting noted. Without apnea or bradys as of this note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-09 00:00:00.000",
"description": "Report",
"row_id": 1884750,
"text": "1 Alt in Resp\n2 Alt in FEN\n3 Alt in G&D\n4 Alt in Parenting\n5 ID\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in Resp; added\n Start date: \n 2 Alt in FEN; added\n Start date: \n 3 Alt in G&D; added\n Start date: \n 4 Alt in Parenting; added\n Start date: \n 5 ID; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-10 00:00:00.000",
"description": "Report",
"row_id": 1884751,
"text": "#1 PT CONT ON CPAP OF 6, MOSTLY 25-30% FI02. LS ARE CLEAR,\nSLIGHTLY DIMINISHED. RR 40-80 WITH OCC GRUNTING. SATS\nIMPROVED ON BELLY.\n#2 NPO. TF 60/KG D10W INFUSING WELL VIA PIV. WEIGHT DECREASE\n75GM. VOIDING AND STOOLING. DSTIX 113. BELLY FULL AND SOFT\nWITH ACTIVE BS.\n#3 TEMPS ARE STABLE NESTED ON SERVO WARMER. ALERT AND\nIRRITABLE.\n#4 DAD IN TO VISIT IN EVENING. DAD UPDATED AT BEDSIDE.\n#5 PT CONT ON AMP AND GENT AS ORDERED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-10 00:00:00.000",
"description": "Report",
"row_id": 1884752,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on Prong CPAP 6 FiO2 25-30%. Occasional grunting RR 40-80's. Breath sounds are clear. Stable on CPAP will cont to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-10 00:00:00.000",
"description": "Report",
"row_id": 1884753,
"text": "Neonatology Attending\n\nDay 1 PMA 34 wks\n\nRemains on CPAP 6 with fio2 0.28. RR 50-80s. Intermittent grunting. CBG 7.28/47. No apnea, bradycardia. No murmur. HR 130-160s. BP mean 47. Weight 2500g (-75). NPO. IV dextrose at 60 ml/kg/d. Blood glucose 103. Benign abdomen. Lytes 135/4.0/19. Bilirubin 1.7. Stable temperature on off warmer. Parents in earlier this morning. On ampicillin and gentamicin. Blood culture no growth.\n\nMild hyaline membrane disease. Will continue to monitor closely. Keeping NPO. Will continue to follow blood glucose. Ruling out on antibiotics.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-21 00:00:00.000",
"description": "Report",
"row_id": 1884817,
"text": "Exam Note\nGEN - , active\nHEENT - AFSFO, facial macules almost completely resolved from yesterday, oropharynx clear\nCV - RRR, nl s1+s2, no murmur\nPULM - CTAB\nABD - soft, NT, ND, no mass\nGU - nl male ext genit, no rash, stool present\nEXT - wwp, cr < 2\nNEURO - MAE, reactive\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-21 00:00:00.000",
"description": "Report",
"row_id": 1884818,
"text": "6 Alt in \n7 Skin:\n\nREVISIONS TO PATHWAY:\n\n 6 Alt in ; resolved\n 7 Skin:; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-23 00:00:00.000",
"description": "Report",
"row_id": 1884828,
"text": "NPN DAYS\n\n\n#1 Pt received and cont in RA. LS C+=. no spells so\nfar this shift. Pt day of spell count down. P- Will cont\nto monitor resp status.\n#2 FEN- TF=150cc/kg/d of BM24 with powder. abd benign.\nall po feeds. po 35-50cc +BFx2. Pt voiding and stooling hem\nneg. no spits. waking q2.5-4hrs. P- Will cont to monitor\nFEN.\n#3 G&D- Temp stable in open crib. cobedding with sibling.\n and active with cares. sucking on pacifier. P- Will\ncont to monitor G&D.\n#4 Mom and Dad visiting this shift. Loving and\ncaring towards pt. asking approp ques. updates given.\nhelping with cares. updated re: pt spells and DC\ndate pushed back. P- Will cont to support and educate\n.\nSee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-23 00:00:00.000",
"description": "Report",
"row_id": 1884829,
"text": "NPN DAYS\naddendum: Hep B immunization given @ 1800.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-24 00:00:00.000",
"description": "Report",
"row_id": 1884830,
"text": "NPN:\n\nRESP: RA. RR=40-50s w/SC retraction. BBS =/clear. Last A&B on ; day of brady count.\n\nCV: No murmur. HR=140-160. BP=68/41 (51). Color pink w/slight jaundice. Perfusion good.\n\nFEN: Wt=2655g (+ 35g). Ad Lib feeds of BM-24. Intake yesterday 119cc/kg/d + breast fdgs x 2. Bottled slowly x 1 for 10cc; 60cc taken well at following feeding. No spits. Abd benign. Voiding qs; small yellow stool. FeS04. Mother has appt w/lactation consultant on (13:00).\n\nG&D: CGA=36-4/7 wk. Temp stable in crib. Co-bedding w/sibling. Active and w/good tone. Swaddled and resting well. Discharge preparations in progress; hearing screen and carseat test need to be done.\n\nSOCIAL: Mother called x 1 for update.\n"
},
{
"category": "Nursing/other",
"chartdate": "2197-12-24 00:00:00.000",
"description": "Report",
"row_id": 1884831,
"text": "NNP ON-Call\nPhysical Exam\nGeneral: infant in open crib, room air,co-bedding with twin\nSkin; warm and dry; color pink/jaundiced; cafe spot on forehead\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds; cord healed\nExt: moving all\nneuro: appropriate tone and reflexes; alerts\n"
},
{
"category": "Radiology",
"chartdate": "2197-12-09 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 934419,
"text": " 1:36 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate for rds vs retained fetal lung fluid\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, on CPAP\n REASON FOR THIS EXAMINATION:\n evaluate for rds vs retained fetal lung fluid\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest x-ray.\n\n DATE OF EXAM: .\n\n TIME OF EXAM: 1:46.\n\n CLINICAL HISTORY: This is a newborn infant on day of life 1 with respiratory\n distress.\n\n FINDINGS: A single, portable view of the chest was obtained. I have no prior\n films available for comparison. The heart size is normal. The pulmonary\n vasculature is within range of normal limits. There is some increased\n interstitial fluid suggesting the diagnosis of TTN, perhaps with a component\n of mild hyaline membrane disease. There is no focal lung opacification.\n\n Abdominal situs is normal. The visualized bony structures are normal.\n\n\n"
}
] |
81,662 | 124,697 | 46 y/o w/ depression and prior suicide attempts and MAOI overdose/toxicity, presents after being found unresponsive concerning for medication overdose. | IMPRESSION: No acute intracranial abnormality. COMPARISON: CT head without contrast . The cardiomediastinal and hilar contours are normal. Minimal fluid is seen within the left mastoid air cell. The ventricles and sulci are normal in caliber and configuration. Sinustachycardia persists. No acute fractures are identified. Minimal hypodensity in the right frontal region suggests small vessel ischemic disease. No right pleural effusion or pneumothorax is seen. Non-specific ST-T wave changes.Compared to the previous tracing of no diagnostic interim change. TECHNIQUE: Contiguous axial images were acquired through the head without intravenous contrast. Endotracheal tube in good position. Lungs are clear with the previously noted infiltrate at the left lung base resolved. The basal cisterns are normal. Heart size and vascularity are normal. PORTABLE SEMI-ERECT CHEST RADIOGRAPH: Endotracheal tube is low in position terminating in the proximal left main bronchus. The imaged paranasal sinuses are clear. IMPRESSION: 1. IMPRESSION: 1. The -white matter differentiation is well preserved. The lung volumes are low, with bibasal opacities, could represent atelectasis or aspiration. FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses or mass effect. There is no evidence of pneumothorax. There is an NG tube passing beyond the stomach. Low lung volumes with bibasal opacities, could represent atelectasis or aspiration. Endotracheal tube in the proximal left main bronchus. An endotracheal tube is present with the tip at the T3 level. ICH No contraindications for IV contrast WET READ: KKgc SAT 5:55 PM No acute intracranial abnormality. No evidence for active cardiopulmonary disease. Sinus tachycardia. 2. 2. Sagittal and coronal reformats were generated and reviewed. Early R wave transition. 4:59 PM CT HEAD W/O CONTRAST Clip # Reason: ? The findings were discussed with Dr. on . ICH MEDICAL CONDITION: 46 year old woman unresponsive REASON FOR THIS EXAMINATION: ? WET READ VERSION #1 FINAL REPORT INDICATION: 46-year-old woman, unresponsive, to rule out intracranial hemorrhage. 3:16 PM CHEST (PORTABLE AP) Clip # Reason: please eval tube MEDICAL CONDITION: 46 year old woman unresponsive, intubated REASON FOR THIS EXAMINATION: please eval tube FINAL REPORT INDICATION: 46-year-old woman who is unresponsive and is intubated. 9:35 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please evaluate for ET tube placement Admitting Diagnosis: UNRESPONSIVE MEDICAL CONDITION: 46 year old woman presented unresponsive, s/p ET adjustment REASON FOR THIS EXAMINATION: please evaluate for ET tube placement FINAL REPORT PORTABLE CHEST HISTORY: Unresponsive, ET tube placement. | 4 | [
{
"category": "Radiology",
"chartdate": "2109-09-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210749,
"text": " 9:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please evaluate for ET tube placement\n Admitting Diagnosis: UNRESPONSIVE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman presented unresponsive, s/p ET adjustment\n REASON FOR THIS EXAMINATION:\n please evaluate for ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n HISTORY: Unresponsive, ET tube placement.\n\n COMPARISON: at 1524 hours.\n\n An endotracheal tube is present with the tip at the T3 level. There is an NG\n tube passing beyond the stomach. Heart size and vascularity are normal.\n Lungs are clear with the previously noted infiltrate at the left lung base\n resolved. There is no evidence of pneumothorax.\n\n IMPRESSION:\n 1. Endotracheal tube in good position.\n 2. No evidence for active cardiopulmonary disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1210729,
"text": " 4:59 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman unresponsive\n REASON FOR THIS EXAMINATION:\n ? ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc SAT 5:55 PM\n No acute intracranial abnormality.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old woman, unresponsive, to rule out intracranial\n hemorrhage.\n\n COMPARISON: CT head without contrast .\n\n TECHNIQUE: Contiguous axial images were acquired through the head without\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, edema, masses or\n mass effect. The -white matter differentiation is well preserved. The\n ventricles and sulci are normal in caliber and configuration. Minimal\n hypodensity in the right frontal region suggests small vessel ischemic\n disease. The basal cisterns are normal. No acute fractures are identified.\n The imaged paranasal sinuses are clear. Minimal fluid is seen within the left\n mastoid air cell.\n\n IMPRESSION: No acute intracranial abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-09-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1210716,
"text": " 3:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 46 year old woman unresponsive, intubated\n REASON FOR THIS EXAMINATION:\n please eval tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 46-year-old woman who is unresponsive and is intubated.\n\n PORTABLE SEMI-ERECT CHEST RADIOGRAPH: Endotracheal tube is low in position\n terminating in the proximal left main bronchus. The lung volumes are low,\n with bibasal opacities, could represent atelectasis or aspiration. The\n cardiomediastinal and hilar contours are normal. No right pleural effusion or\n pneumothorax is seen.\n\n IMPRESSION:\n 1. Endotracheal tube in the proximal left main bronchus. The findings were\n discussed with Dr. on .\n 2. Low lung volumes with bibasal opacities, could represent atelectasis or\n aspiration.\n\n"
},
{
"category": "ECG",
"chartdate": "2109-09-21 00:00:00.000",
"description": "Report",
"row_id": 164267,
"text": "Sinus tachycardia. Early R wave transition. Non-specific ST-T wave changes.\nCompared to the previous tracing of no diagnostic interim change. Sinus\ntachycardia persists.\n\n"
}
] |
3,018 | 160,704 | Patient admitted to the trauma service. Plastic Surgery was immediately consulted for his facial fractures; Ophthalmology was also consulted for his orbital fractures. He was taken to the operating room on by Plastics for repair of his facial fractures. He was prophylaxed with IV antibiotics for meningitis. Ophthalmology recommended follow up in Eye Clinic for his diabetic retinopathy. Neurosurgery was consulted for his head injuries and recommended repeat imaging and Dilantin. His Dilantin was weaned per recommendation by Neurosurgery starting on with a d/c date of . Diabetes was also consulted because of his elevated blood sugars. Patient started on 75/25 insulin . He has agreed to follow up in the Clinic after discharge. Because of his ETOH history patient was placed on CIWA protocol; there were no clinical signs of delirium tremors during his hospitalization. Physical and Occupational therapy were consulted. Social work consulted because of patient's home situation and his refusal of home services and complying with his medication regimen after his discharge; reportedly patient does not have a permanent home address and no family in this country or his home land of . Psychiatry was consulted to assess patient's capacity and felt that he did possess the capacity to make his health decisions. Pt. discharged to home. | Right subdural hematoma. RIght subdural hematoma. Stable appearance of tiny focus of probable intraparenchymal hemorrhage within the right temporal lobe. Again seen is a right subdural hematoma extending along the convexity, which appears approximately unchanged in size. There is proptosis of the right globe and intraorbital hematoma within the superolateral aspect of the right orbit. There is a moderate right subdural hematoma layering adjacent to the right frontoparietal convexity and extending inferiorly to the right temporal lobe. Subdural hemorrhage, right temporal lobe hemorrhage approx unchanged. Probable left subarachnoid hemorrhage. There is air within the right orbit, and along the superolateral aspect of the orbit, there is a hematoma displacing the extraocular muscles medially. Right frontal and parietal subgaleal hematoma. further access today.Resp: LS clear, diminished at bases; suctioned for sm. Marked gastric distention. Possible small focus of right temoral intraparenchymal hemorrhage. PB's for DVT prophylaxis. PB's for DVT prophylaxis. A right frontal fracture line extends anteriorly and inferiorly to the right frontal sinus, where there is marked comminution with displaced fragments involving the anterior and posterior walls of the frontal sinus. A small focus of hyperdensity along the medial aspect of the right frontal lobe likely represents a small amount of subarachnoid hemorrhage at this location. Note is made of heterogeneity within the clivus, a finding that may indicate clival hemangioma. Additional linear opacity within the right middle and right lower lobe laterally is consistent with scarring versus atelectasis. There is diffuse narrowing of the sulci of the right frontal and parietal lobes. The celiac trunk, superior mesenteric artery, and inferior mesenteric artery appear patent. Injuries: non-depressed R skull fx, traumatic R frontal parietal SDH/SAH with complex orbital/midface fx with sm. on ciwa scale (score ).Resp: LS clear, diminished at bases, denies shortness of breath or difficulty breathing. The appearance of a rounded focus of hemorrhage within the posterior aspect of the right temporal lobe, possibly representing an intraparenchymal hemorrhage, is stable. Right frontal and parietal scalp hematoma. There has been slight interval new hypodensity within the inferior right frontal lobe, which could be consistent with a contusion. TECHNIQUE: Non-contrast head CT. A large right frontal scalp hematoma appears approximately unchanged. The lateral ventricles are symmetric and nondilated, and the basilar cisterns appear patent. Additional tiny focus of hemorrhage within the right temporal lobe may represent subarachnoid or intraparenchymal hemorrhage. Within the right lobe of the liver anteriorly, there is a triangular area of hypodensity. The cardiac, mediastinal, and hilar contours are within normal limits. Proptosis of right globe with intraorbital hematoma on right. There is a punctate density superficially within the area of the right frontoparietal hemorrhage, which may possibly represent a foreign body versus structure on the surface of the patient. Respiratory Therapy60 y.o. Questionable subarachnoid hemorrhage within the left parietal region. Evaluate for solid organ injury. MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate a triangular area of hypodensity within the right lobe of the liver anteriorly. Right frontal skull fracture, displaced. There is a small amount of fluid and mucosal thickening within the left ethmoid air cells and left frontal sinus. Right subdural hematoma is approximately unchanged in size. There are comminuted fractures of the right zygomatic arch and of the anterior and lateral walls of the right maxillary sinus. R side of forehead/next to eye with sm. The visualized portions of the heart and pericardium appear unremarkable. Additional incidental finding of possibly left lung abnormality - please see report. Subarachnoid blood is again seen medially adjacent to the right frontal lobe. Note is made of a small amount of intraventricular hemorrhage which is seen layering in the left lateral ventricle slightly more conspicuous than the prior study. A rounded focus of hemorrhage within the posterior aspect of the right temporal lobe may represent a small focus of subarachnoid blood versus an intraparenchymal hemorrhage. unasyn as ordered.Skin: back/buttocks intact; R sided facial abrasion with sm. FINAL REPORT INDICATION: Facial trauma, found down. Wedge configuration of L1 vertebra, a finding that likely represents old trauma versus normal variant. There is an appearance of proptosis of the right globe, although no large retrobulbar hematoma is identified. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are dependent changes within the lower lobes bilaterally. Right inferior frontal lobe contusion is more apparent on the current study. Coronal and sagittal reformations are provided. FINDINGS: The previously identified right subdural hematoma is not significantly changed. Old right rib fracture and wedge configuration of L1 that could represent prior compression deformity or normal variant; see report. Lytes repleted.Endo: BS 132->195, covered per ss.ID: tmax 100.3; wbc 7.5,conts. Subarachnoid hemorrhage centered in the suprasellar cistern and involving the right frontal lobe inferolaterally and medially. There is decreased conspicuity of subarachnoid hemorrhage along the course of the right middle cerebral artery. There is soft tissue stranding and swelling within the right frontal scalp and preorbital soft tissues. There are multiple comminuted fractures involving the anterior and posterior walls of the right frontal sinus with posterior displacement of a fracture fragment into the intracranial space and with a tiny focus of pneumocephalus. There is an additional comminuted fracture of the posterior aspect of a right ethmoid air cell with displacement of a fracture fragment into the intracranial space. (+) ETOH Intubated in ED for deteriorating GCS. A right frontal skull fracture with triangular configuration demonstrates mild displacement. Kcl repleted.Endo: BS 216->covered per SS.ID; tmax 99.2; conts. IMPRESSION: Bibasilar linear atelectases. The prevertebral soft tissues appear unremarkable. In the setting of trauma, this could represent a hepatic laceration, although no perihepatic fluid collections are identified. There is degenerative change of the thoracolumbar and lumbosacral spine. Dilantin loaded in ER. Comminuted fracture of the anterior wall of the right orbit and of the right zygomatic arch. The ventricles are symmetric and nondilated. Questionable hyperdensity at the left insula is suggestive of possible subarachnoid hemorrhage. | 16 | [
{
"category": "ECG",
"chartdate": "2128-08-18 00:00:00.000",
"description": "Report",
"row_id": 209871,
"text": "Normal sinus rhythm. Tracing is within normal limits. No previous tracing\navailable for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-14 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 881656,
"text": " 4:10 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: r/o injueries\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man found btwen curb and car\n REASON FOR THIS EXAMINATION:\n r/o injueries\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall.\n\n COMPARISON: None.\n\n AP CHEST X-RAY: The cardiac silhouette, mediastinal, and hilar contours are\n normal. No pneumothorax is seen bilaterally on this supine radiograph. Both\n lungs are clear without consolidations or effusions. The surrounding soft\n tissue and osseous structures are unremarkable.\n\n AP PELVIS: Bilateral sacroiliac joints, pubic symphysis, and partially imaged\n bilateral hips are unremarkable. There is normal bony mineralization, without\n malalignment. The surrounding soft tissues are unremarkable.\n\n IMPRESSION: No evidence of intrathoracic or intrapelvic trauma.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 881657,
"text": " 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with found unresp btwn car and curb\n REASON FOR THIS EXAMINATION:\n r/o injur\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 5:22 PM\n Subarachnoid hemorrhage in basal cisterns and extending along right frontal\n and parietal lobes. RIght subdural hematoma. Possible small focus of right\n temoral intraparenchymal hemorrhage. Probable left subarachnoid hemorrhage.\n Multiple facial and skull fractures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: There is subarachnoid blood\n within the suprasellar cistern and lateral to the pons on the right, with\n extension to the Sylvian fissure and to the inferolateral aspect of the right\n frontal lobe. A small focus of hyperdensity along the medial aspect of the\n right frontal lobe likely represents a small amount of subarachnoid hemorrhage\n at this location.\n There is a moderate right subdural hematoma layering adjacent to the right\n frontoparietal convexity and extending inferiorly to the right temporal lobe.\n A rounded focus of hemorrhage within the posterior aspect of the right\n temporal lobe may represent a small focus of subarachnoid blood versus an\n intraparenchymal hemorrhage. Questionable hyperdensity at the left insula is\n suggestive of possible subarachnoid hemorrhage.\n\n The lateral ventricles are symmetric and nondilated, and the basilar cisterns\n appear patent. There is diffuse narrowing of the sulci of the right frontal\n and parietal lobes. There is no shift of normally midline structures. The\n - white differentiation appears preserved.\n\n Bone windows demonstrate numerous fractures of the skull and facial bones.\n There is a coronally oriented fracture extending through the right and left\n frontal bones originating near the vertex. A right frontal fracture line\n extends anteriorly and inferiorly to the right frontal sinus, where there is\n marked comminution with displaced fragments involving the anterior and\n posterior walls of the frontal sinus. There are multiple comminuted fractures\n of the roof of the orbit and of the right lamina papyracea. There are\n comminuted fractures of the right zygomatic arch and of the anterior and\n lateral walls of the right maxillary sinus. There is blood layering within\n the right maxillary sinus, ethmoid sinuses, and frontal sinus and air within\n the orbit. There is an appearance of proptosis of the right globe, although\n no large retrobulbar hematoma is identified. The mastoid air cells are\n (Over)\n\n 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n normally pneumatized. There is extensive soft tissue swelling and hematoma\n within the right frontal scalp. There is a punctate density superficially\n within the area of the right frontoparietal hemorrhage, which may possibly\n represent a foreign body versus structure on the surface of the patient.\n\n IMPRESSION:\n 1. Subarachnoid hemorrhage centered in the suprasellar cistern and involving\n the right frontal lobe inferolaterally and medially.\n 2. Right subdural hematoma.\n 3. Additional tiny focus of hemorrhage within the right temporal lobe may\n represent subarachnoid or intraparenchymal hemorrhage.\n 4. Questionable subarachnoid hemorrhage within the left parietal region.\n 5. Numerous comminuted facial and skull fractures.\n 6. Right frontal and parietal subgaleal hematoma.\n\n Facial fractures will be further assessed with facial bone CT of same date.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-14 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 881658,
"text": " 4:25 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with found unresp btwn car and curb\n REASON FOR THIS EXAMINATION:\n r/o injur\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 5:46 PM\n No fracture of cervical spine.\n Slight exaggeration of cervical lordosis may be positional. Please see\n dictated report for further recommendations. Additional incidental finding of\n possibly left lung abnormality - please see report.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found unresponsive between car and curb, evaluate for injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained through the cervical spine without\n intravenous contrast. Coronal and sagittal reformations are provided.\n\n CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: The cervical spine is\n imaged from C1 through the upper portion of T3. No fracture is identified in\n the cervical spine. There is multilevel degenerative change of the cervical\n spine with anterior osteophytosis, most prominent at C3-4, C5-6, and C6-7.\n There is slight exaggeration of the normal cervical lordosis that may be\n positional in nature. There is a suggestion of widening of the intervertebral\n disc spaces anteriorly, a finding that is predominantly diffuse to the C4-5\n through C6-7 intervertebral disc spaces. The prevertebral soft tissues appear\n unremarkable. The visualized outlines of the thecal sac demonstrate posterior\n probable disc bulges at C4-5 and C5-6 with indentation of the thecal sac. CT\n is limited in its ability to provide intrathecal detail.\n\n The visualized portions of the lung apices demonstrate emphysematous change.\n In addition, there is an ill-defined opacity at the left lung apex with\n irregular margins that is incompletely imaged. There are several small\n projections from the tracheal wall, which may represent adherent secretions.\n The mastoid air cells are normally pneumatized.\n\n IMPRESSION:\n 1. No fracture of the cervical spine.\n 2. Exaggeration of the cervical lordosis with diffuse widening of several\n intervertebral disc spaces anteriorly may be positional in nature. If there\n is clinical concern for ligamentous injury, MR is a more sensitive test.\n 3. Suggestion of disc bulges at C4-5 and C5-6. CT is limited in its\n evaluation of the spinal canal and its contents.\n 4. Emphysematous changes in the visualized portions of the lungs and\n additional irregular opacity at the left lung apex, a finding that may be\n further evaluated with dedicated chest CT once the patient is clinically able.\n\n (Over)\n\n 4:25 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/o injur\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-14 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 881659,
"text": " 4:28 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/out fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with facial trauma\n REASON FOR THIS EXAMINATION:\n r/out fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 6:54 PM\n Multiple facial and skull fractures. please see report.\n Proptosis of right globe with intraorbital hematoma on right.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Found down with facial trauma, evaluate fractures.\n\n COMPARISON: Head CT of same date.\n\n TECHNIQUE: Axial MDCT images were obtained through the facial bones. Coronal\n reformations are provided.\n\n CT OF THE FACIAL BONES WITHOUT INTRAVENOUS CONTRAST: There are numerous skull\n and facial fractures. A right frontal skull fracture with triangular\n configuration demonstrates mild displacement.\n\n There are multiple comminuted fractures involving the anterior and posterior\n walls of the right frontal sinus with posterior displacement of a fracture\n fragment into the intracranial space and with a tiny focus of pneumocephalus.\n There is an additional comminuted fracture of the posterior aspect of a right\n ethmoid air cell with displacement of a fracture fragment into the\n intracranial space.\n\n Additional comminuted fractures are present within the roof of the right orbit\n with displacement of a fracture fragment into the superior aspect of the right\n orbit. There is air within the right orbit, and along the superolateral\n aspect of the orbit, there is a hematoma displacing the extraocular muscles\n medially. The fracture fragments do not appear to impinge directly upon the\n optic nerve, although there is proptosis of the right globe.\n\n There are additional linear fractures of the lamina papyracea on the right.\n Comminuted fracture of the anterior wall of the right orbit and of the right\n zygomatic arch. There is blood layering within the right maxillary sinus,\n ethmoid sinuses, and frontal sinus. There is a small amount of fluid and\n mucosal thickening within the left ethmoid air cells and left frontal sinus.\n The left maxillary sinus is normally pneumatized and no fractures are\n identified within the left maxillary sinus or orbit. The mastoid air cells\n are normally pneumatized. Note is made of heterogeneity within the clivus, a\n finding that may indicate clival hemangioma. There is soft tissue stranding\n and swelling within the right frontal scalp and preorbital soft tissues.\n\n IMPRESSION:\n 1. Right frontal skull fracture, displaced.\n (Over)\n\n 4:28 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: r/out fx\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Extensive comminuted fractures of the right frontal sinus, maxillary\n sinus, orbit, and zygomatic arch.\n 3. There is proptosis of the right globe and intraorbital hematoma within the\n superolateral aspect of the right orbit.\n 4. There are displaced comminuted fracture fragments protruding into the\n right orbit without direct evidence of impingement upon the optic nerve.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-14 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 881660,
"text": " 4:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/out solid organ injury\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with facial trauma found down\n REASON FOR THIS EXAMINATION:\n r/out solid organ injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 6:09 PM\n Triangular hypodensity in right lobe of liver without perihepatic fluid\n collection could possibly represent small liver laceration versus other liver\n lesion.\n\n No fractures identified. Old right rib fracture and wedge configuration of L1\n that could represent prior compression deformity or normal variant; see\n report.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Facial trauma, found down. Evaluate for solid organ injury.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic\n symphysis following the administration of 150 cc of intravenous Optiray.\n Additional coronal and sagittal reformations are provided.\n\n CONTRAST: Intravenous non-ionic contrast was administered due to the rapid\n rate of bolus injection required for this examination.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are dependent changes\n within the lower lobes bilaterally. Additional linear opacity within the\n right middle and right lower lobe laterally is consistent with scarring versus\n atelectasis. The visualized portions of the heart and pericardium appear\n unremarkable. There is marked distension of the stomach containing air and\n fluid.\n\n Within the right lobe of the liver anteriorly, there is a triangular area of\n hypodensity. There is no perihepatic fluid collection at this location. There\n is an additional questionable hypodensity within the left lobe of the liver\n superiorly (series 2, image 9), possibly representing partial volume\n averaging. The spleen, pancreas, gallbladder, and adrenal glands appear\n unremarkable. There are no perinephric fluid collections. There are symmetric\n nephrograms bilaterally without evidence of masses or hydronephrosis in either\n kidney. The ureters are nondilated. The aorta is normal in caliber. The\n celiac trunk, superior mesenteric artery, and inferior mesenteric artery\n appear patent. The large and small bowel loops are normal in caliber. The\n appendix is normal. There is no free fluid and no free air within the\n abdomen.\n\n (Over)\n\n 4:29 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/out solid organ injury\n Field of view: 40 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder contains a Foley\n catheter and contrast. The bladder, distal ureters, prostate and seminal\n vesicles, rectum, and sigmoid colon appear unremarkable. There is no\n pathologic-appearing pelvic or inguinal lymphadenopathy. There is no free\n fluid and no free air within the pelvis.\n\n BONE WINDOWS: Bone windows demonstrate anterior wedge deformity of L1, a\n finding that is of uncertain significance. This could represent prior\n compression deformity versus normal variant. There is additional lucency\n within the superior endplates of T12 and L1 that is suggestive of Schmorl's\n node. There is degenerative change of the thoracolumbar and lumbosacral\n spine. There is deformity of the right iliac bone with sclerotic margins\n suggestive of prior trauma. No suspicious lytic or sclerotic osseous lesions\n are identified. There is an old healed right-sided rib fracture.\n\n MULTIPLANAR REFORMATS: Coronal and sagittal reformations demonstrate a\n triangular area of hypodensity within the right lobe of the liver anteriorly.\n\n IMPRESSION:\n 1. Triangular area of hypodensity in the right lobe of the liver. In the\n setting of trauma, this could represent a hepatic laceration, although no\n perihepatic fluid collections are identified. Additional questionable\n hypodense lesion in the left lobe of the liver may represent artifact.\n 2. Marked gastric distention.\n 3. Wedge configuration of L1 vertebra, a finding that likely represents old\n trauma versus normal variant. No acute fractures are identified.\n\n Results were called to the trauma resident caring for the patient at the time\n of interpretation.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 882768,
"text": " 10:34 AM\n CHEST (PA & LAT) Clip # \n Reason: consolidation?\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p repair for skull fracture, SAH, SDH now spiking fevers\n\n REASON FOR THIS EXAMINATION:\n consolidation?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of subarachnoid and subdural hemorrhages, fever.\n\n COMPARISON: Chest x-ray from .\n\n PA AND LATERAL CHEST RADIOGRAPHS: The lungs are clear. The cardiac,\n mediastinal, and hilar contours are within normal limits. Bilateral healed\n rib fractures are noted.\n\n IMPRESSION: No evidence of pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 881671,
"text": " 6:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: HEAD TRAUMA\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Head trauma.\n\n FINDINGS: There is an endotracheal tube with tip 3 cm above the carina. The\n lungs are clear without effusion. There is some pleural thickening or\n scarring in the right lateral lower lung. An NG tube is in the stomach.\n Despite the NG tube in the stomach, there is a large collection of air seen in\n the mid abdomen. Compared to the CT from a few hours earlier, this is seen to\n represent a markedly distended stomach. This finding was called to the floor\n at the time of the CT .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 881672,
"text": " 6:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression of bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ICH\n REASON FOR THIS EXAMINATION:\n eval for progression of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRSg SAT 7:46 PM\n Increase in subarachnoid hemorrhage with local mass effect (sulcal narrowing\n but no shift of normally midline structures).\n Subdural hemorrhage, right temporal lobe hemorrhage approx unchanged.\n No hydrocephalus\n Please see report\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage, evaluate for progression of bleed.\n\n COMPARISON: Same date at 16:19 hours.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: In comparison with the\n examination of several hours earlier, there is a similar extent of\n subarachnoid hemorrhage within the basilar cisterns as well as within the\n sulci of the right frontal, parietal, and temporal lobes. Again seen is a\n right subdural hematoma extending along the convexity, which appears\n approximately unchanged in size. The appearance of a rounded focus of\n hemorrhage within the posterior aspect of the right temporal lobe, possibly\n representing an intraparenchymal hemorrhage, is stable. The subarachnoid\n blood within the left parietal sulciappears stable overall. The ventricles\n are symmetric and nondilated. The ventricles appear unchanged in size in\n comparison with the previous examination. There is no shift of normally\n midline structures. The basilar cisterns are patent. Subarachnoid blood is\n again seen medially adjacent to the right frontal lobe. A large right frontal\n scalp hematoma appears approximately unchanged.\n\n Bone windows again disclose numerous facial and skull fractures. There is\n increased density within the right maxillary, ethmoid, and frontal sinuses.\n\n IMPRESSION:\n 1. Some redistribution in subarachnoid hemorrhage within the basilar\n cisterns, layering within the sulci of the right frontal, parietal, and\n temporal lobes, and within the sulci of the left parietal lobe. There is no\n definite increase in the amount of subarachnoid blood.\n 2. Right subdural hematoma is approximately unchanged in size.\n 3. Stable appearance of tiny focus of probable intraparenchymal hemorrhage\n within the right temporal lobe.\n 4. No hydrocephalus and no shift of normally midline structures.\n 5. Right frontal and parietal scalp hematoma.\n (Over)\n\n 6:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for progression of bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 6. Multiple facial fractures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 881720,
"text": " 10:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval bleed\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with SAH, SDH, intraparenchymal s/p trauma -- repeat head CT in\n AM\n REASON FOR THIS EXAMINATION:\n eval bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD\n\n INDICATION: Trauma, followup of hemorrhages.\n\n Comparison is made to the CT scan performed one day prior.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The previously identified right subdural hematoma is not\n significantly changed. There is again demonstrated bilateral areas of\n subarachnoid hemorrhage which is again seen layering in the interpeduncular\n cistern. Note is made of a small amount of intraventricular hemorrhage which\n is seen layering in the left lateral ventricle slightly more conspicuous than\n the prior study. There has been slight interval new hypodensity within the\n inferior right frontal lobe, which could be consistent with a contusion. There\n is decreased conspicuity of subarachnoid hemorrhage along the course of the\n right middle cerebral artery. The previously identified tiny focus of\n hemorrhage along the posterior aspect of the right temporal lobe is not\n significantly changed. No new areas of hemorrhage are identified. There is\n no shift of normally midline structures, mass effect or hydrocephalus. The\n previously described paranasal sinuses and osseous structures are not\n significantly changed with redemonstration of numerous facial and skull\n fractures.\n\n IMPRESSION: No new areas of hemorrhage identified. Right inferior frontal\n lobe contusion is more apparent on the current study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-08-18 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 882170,
"text": " 2:54 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: INTRACRANIAL BLEED\n Admitting Diagnosis: INTRACRANIAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man pre-op for for skull fracture, SAH, SDH.\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS PA AND LATERAL\n\n Preop subdural hematoma.\n\n Heart size is normal. Apart from bibasilar linear atelectases the lungs are\n clear. No pleural effusions and no pneumothorax.\n\n IMPRESSION: Bibasilar linear atelectases.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-08-15 00:00:00.000",
"description": "Report",
"row_id": 1301104,
"text": "T-SICU admission note -0700\n60yo male found down between 2 parked cars, +ETOH. Arrived in ER with GCS 13, decreased MS , intubated. Injuries: non-depressed R skull fx, traumatic R frontal parietal SDH/SAH with complex orbital/midface fx with sm. L SAH. ?Spanish speaking per chart; appears to understand some English over course of noc. A-line placed by HO. ER RN, ER SW was working on location family/next of ; no contact .\n:\nNeuro: Lightly sedated on propofol gtt; easily lightened for neuro exams (at times neuro exam consistent with propofol on). Pupils dilated in EW; initially both pupils 8mm, NR, slowly improving over noc, currently R5mm, L 4mm, reactive. +corneals, gag and cough. MAE's; follows commands when asked in Spanish by Dr. ; cont. to follow commands throughout night in few Spanish words with this RN (squeezes hands, wiggles toes, sticks out tongue, opens eyes). Dilantin loaded in ER. Logroll c/spine precautions maintained.\n\nCV: HR 70-80'sSR, BP 100-130's/50-60's. Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\nAccess: a-line placed last noc; PIV x2 wnl, ? further access today.\n\nResp: LS clear, diminished at bases; suctioned for sm. amts. blood tinged sputum. Suctioned for sm. amts. blood tinged oral secretions. See carevue for labs/resp. notes.\n\nGI: abd soft, BS hypoactive, no stool, NPO. OGT to LCWS for sm. amts. brown drainage. Protonix for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in adequate amts. Kcl repleted.\n\nEndo: BS 216->covered per SS.\n\nID; tmax 99.2; conts. unasyn as ordered.\n\nSkin: back/buttocks intact; R sided facial abrasion with sm. amt. sang. drainage. R eye with red/purple hematoma, +scleral edema; iced NS gauze applied .\n\npsych/social: no contact from family/next of ; follow up with SW today.\n\nA: pt found down +SAH/SDH, hemodynamically stable\n\nP: Monitor VS, I/O, labs, neuro checks. Follow up CT results, ?d/c logroll, repeat head CT, ? further access today. Follow up with SW regarding next of . Maintain sedation/comfort/support to pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-08-15 00:00:00.000",
"description": "Report",
"row_id": 1301105,
"text": "Respiratory Therapy\n60 y.o. M found down btwn 2 cars MOI unknown. (+) ETOH Intubated in ED for deteriorating GCS. Pt remains orally intubated on full ventilatory support at this time. BS clear Sx for sml amts thick blood tinged secretions. FiO2 weaned to .4. Plan: wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-08-15 00:00:00.000",
"description": "Report",
"row_id": 1301106,
"text": "T/SICU NPN: 0700-1900\nS:\n\nO: SYSTEM REVIEW:\n\nNEURO: FOLLOW UP HEAD CT THIS MORNING ALERT TO OPENS EYES TO VOICE\nORIENTED TO PERSON ONLY PT THINKS HE IS IN AND THE YEAR ABLE TO SPEAK ENGLISH SPEECH AT TIMES DIFFICULT TO UNDERSTAND D/T ACCENT AND LACK OF TEETH ANSWERS MOST QUESTIONS APPROPIATELY PUPILS REACTIVE TO LIGHT R=5MM WITH NO TO SLUGGISH REACTION L=4 WITH BRISK REACTION CORNEAL REFLEXES WEAKER ON RIGHT INTACT COUGH/GAG\nMAE WITH GOOD STRENGTH SPONTANEOUSLY AND TO COMMAND CONTINUES ON DILANTIN 100MG TID LEVEL 10.1 TODAY C-COLLAR INTACT AND REMAINS ON\nTLS CLEARED LOGROLL PRECAUTIONS D/C'D\n\nCVS: HR 70-80'S WITH NO>>RARE>>OFTEN UNIFOCAL PVC'S WITH COMPENSATORY PAUSE ELECTROLYTES REPLETED GOAL TO KEEP SBP < 140 RECEIVED TOTAL OF 5MG IV LABETOLOL X 3 SBP 120-130'S SKIN WARM/DRY PALPABLE PEDAL PULSES\n\nRESPIRATORY: SELF EXTUBATED TODAY AT 1440 RR 10-14 SAO2 100% ON 50% FACE TENT LUNGS CLEAR, DECREASED AT BASES NONPRODUCTIVE COUGH\n\nRENAL: FOLEY PATENT AND DRAINING CLEAR YELLOW URINE 10-200CC/HR\nNS AT 125CC/HR K+ 3.5 CURRENTLY RECEIVING TOTAL OF 40MEQ KCL OVER 5HRS FOR REPLETION MG++ 1.7 REPLETED WITH 2GMS MGSO4\nIVF TO CHANGE TO NS WITH 20MEQ KCL IV 125CC/HR\n\nGI: ABDOMEN: SOFT HYPOACTIVE BS REMAINS NPO ON IVF NO N/V ON PROTONIX OGT PULLED WITH EXTUBATION\n\nENDOCRINE: SS TIGHTENED 0800 179 COVERED WITH 6UNITS REGULAR INSULIN SQ 1400 FS 141 COVERED WITH 4UNITS OF REGULAR INSULIN\n\nHEME: CONTINUES ON PNEUMOBOOTS FOR DVT PROPHYALAXIS\n\nID: TMAX 99.6 ANTBX CHANGED TO FLAGYL/OXACILLIN/CEFTRIAXONE FOR OMF\n\nSKIN: BACK AND BUTTOCKS INTACT WITH NO REDNESS RIGHT EYE WITH ECCHYMOSIS SMALL ABRASION---PINK WITH NO OBVIOUS DRAINAGE SMALL RIGHT FRONTAL HEMATOMA\n\nCOMFORT: DENIES ANY PAIN\n\nPSYCHOSOCIAL: STATES LIVES ALONE IN NO FAMILY NEVER BEEN MARRIED WORKS PART-TIME AS LABORER ALTHOUGH UNABLE TO ELABORATE ABOUT JOB DENIES ANY PMH/PSH/MEDICATIONS STATES NO ALLERGIES\nADMITS TO ETOH USE--STATES THAT DRINKS A BOTTLE OF VODKA A DAY\n\nA: STABLE S/P HEAD INJURY\n\nP: CONTINUE TO MONITOR ABOVE PARAMETERS\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-08-16 00:00:00.000",
"description": "Report",
"row_id": 1301107,
"text": "T-SICU NPN 1900-0700\nSee carevue for specifics.\n:\nNeuro: Sleeping most of noc; arousable to voice, opens eyes spontaneously, MAE's, follows commands consistently. Oriented to self only; states he is in (also states this is where he lives); does not know date, remember incident, or that he is in hospital. +corneals,gag, and cough. R pupil 5mm, L pupil 4mm both reactive. C-collar in place. Conts. dilantin.\nCV: HR 60-70'sSR with occ. PVC's, BP 120-150's/60-70's. Started 100mg po labetalol last eve, SBP cont. 140-150's; additional 100mg po labetalol given, SBP now 130-140 (goal <140). Skin warm, dry. Pedal pulses palpable. PB's for DVT prophylaxis. Heme: hct 32.3\nAccess: R rad. a-line and PIV'x 2 wnl. conts. on ciwa scale (score ).\nResp: LS clear, diminished at bases, denies shortness of breath or difficulty breathing. O2sats 99-100% on 50% face tent which pt. continually removed, sats 98% ra. Enc. C+DB; pt with productive cough, swallowing secretions.\nGI: abd soft, NT/D, BS hypoactive, no stool. Tol sips water, denies n/v. Protonix for GI prophylaxis.\nGU: foley patent draining large amts. light yellow clear urine. Lytes repleted.\nEndo: BS 132->195, covered per ss.\nID: tmax 100.3; wbc 7.5,conts. cefazolin/flagyl/oxacillin as ordered.\nSkin: back/buttocks intact. R eye with red/purple hematoma, +scleral edema, eye gtt applied as ordered. R side of forehead/next to eye with sm. abrasion, OTA.\nPsych/social: pt states he lives alone, no family in area.\nA: labetolol po increased, hemodynamically stable with SBP<140; confusion conts.\nP: Monitor VS,I/O, labs, neuro checks, CIWA scale. Enc. pulmonary hygiene, increase po's as tolerated. Re-orient prn. Cont. ongoing comfort/support to pt. ?transfer to floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-08-16 00:00:00.000",
"description": "Report",
"row_id": 1301108,
"text": "See nursing transfer note.\n"
}
] |